Dr. Stuart McGill: Build a Strong, Pain-Proof Back

Welcome to the Huberman Lab podcast, where we discuss science and science-based tools for everyday life. I'm Andrew Huberman, and I'm a professor of neurobiology and ophthalmology at Stanford School of Medicine.

My guest today is Dr. Stuart McGill. Dr. Stuart McGill is a distinguished professor of spine biomechanics at the University of Waterloo. As a professor for more than three decades, Dr. McGill has analyzed the spines of injured people as well as healthy people and developed methods to treat spine injuries and pain, as well as to improve spine biomechanics in anybody. He has authored more than 250 peer-reviewed research articles on these topics, making him a true world expert.

During today's episode, we discuss spine anatomy, as well as the common sources of back pain, and we discuss some of the controversies regarding the origins and different treatments for back pain. As you’ll quickly learn, there is no one specific source of back pain, nor is there one specific solution to back pain.

However, as Dr. McGill spells out very clearly, there are things that anyone and everyone can do in order to strengthen their back and reduce the amount of pain they may be experiencing. He explains some specific ways to self-diagnose your back pain, which of course is critical for understanding what specific things to do, as well as to avoid, in dealing with any pain and as it relates to applying in sport and in everyday life.

Dr. McGill and I also discuss several of the avid controversies within the field of back pain and the treatments for back pain. We talk about the so-called biopsychosocial model of pain, which points to the various sources that pain can arise from, everything from emotional to lack of sleep to specific locations in the spine, brain, and elsewhere in the body, and the ways those mesh together to give us what we call pain, as well as to direct us towards specific treatments for pain that tend to be especially effective.

Dr. McGill is a true encyclopedia on the topics of back physiology, anatomy, sources of back pain, and treatments for back pain. It’s truly a special opportunity to be able to learn from him in such immense detail and in such a clear and actionable way.

By the end of today's episode, you will have a quite thorough understanding of the anatomy and physiology of the back as it relates to a healthy back, to back pain, and of course, you'll have various remedies for dealing with back pain, preventing back pain, and for strengthening your back for all sorts of different kinds of movement—not just for exercise and sport, but also to move through your daily activities pain-free and with ease and mobility at any age.

Before we begin, I'd like to emphasize that this podcast is separate from my teaching and research roles at Stanford. It is, however, part of my desire and effort to bring zero-cost-to-consumer information about science and science-related tools to the general public. In keeping with that theme, I’d like to thank the sponsors of today’s podcast.

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And now for my discussion with Dr. Stuart McGill.

Dr. Stuart McGill, welcome.

Thank you, sir. Great to have you here. I'm a big fan of your work. I've watched a lot of your other content, read your books, and I'm excited to discuss today what makes for a really strong, resilient back, what causes back pain, and how to relieve it.

And perhaps the bigger issue is what all of that allows for in terms of mobility and functionality—not just in sport but in everyday life. So to kick things off, I’d like to ask a question that I think is on a lot of people's minds: Most people aren't thinking about their back unless they have pain. So what causes back pain?

You start with the easy questions. Let me give context before I define it as tightly as I can for you: Back pain is a symptom. So let’s just change the topic for a moment and talk about leg pain. Can you imagine asking someone, “Well, could you give me an exercise or a prevention strategy for leg pain?” Okay, so that sets the stage a little bit. We're talking about a symptom for which there are a hundred or more different pathways and mechanisms.

So we've got to have a fairly comprehensive assessment and understanding to focus on the type of back pain and then match an appropriate intervention. I was listening to your new podcast with Andy Galpin this morning, The Perform Podcast. He said, “I'm going to try and follow the three Is,” and it was, I think, “gather information, interpret the information, and then intervene.” So it's the same kind of deal here, and of course, that's a pan-medical condition, shall we say?

So with that context, I'm going to answer it like this: what causes back pain? Genetics loads the gun, exposure pulls the trigger, and then the psychosocial milieu around the individual influences how they respond to the pain. So there's a start. We can break it down into those three categories if you wish.

Sure. So when you say genetics load the gun, what comes to mind, because in my experience, I have a right shoulder that sits a little bit lower than my left shoulder unless I'm mindful of that. My dad has the same thing, and I can, you know, put an ankle on my other knee a bit more easily on one side versus the other. I tend to pronate one foot a little bit more than the other when I run.

These are subtle things. They don't necessarily result in back pain, but I'm guessing that a lot of that is either developmental, overuse, or particular sport. I'm regular footed. I skateboarded a bunch, so I push with my right foot; I kick a soccer ball with my right foot—those sorts of things. But let’s assume that genetics played some role, created some bias. If I were to tell you that, which I just did, would then your mind immediately go to a particular origin of that pain or perhaps even more importantly, a particular remedy to that pain? Or do we need to drill a little bit deeper and really understand more about what I do, what I don't do, if I'm more thin-set or heavily set at the level of bone structure?

You know, what are some of the other questions one would ask in the investigate category?

My thought would not go to one or the other, but it would go to both. I’d start that conversation with this analogy: Let's talk about breeds of dogs. We both love dogs. If I said to you we’re going to take two dogs, and we’re going to train them for the Greyhound track—one's a Greyhound, and one's a St. Bernard—how do you think you’re going to make out with the St. Bernard? No matter how you train it or condition it, it will never make it to performing on a Greyhound track. You're going to end up with a broken St. Bernard.

So there's a little bit of a start from a big perspective, but now let’s drill down and talk about spines. It’s interesting when you look at the basic anatomical structure of an individual; we just did that with dogs. Imagine if I took a thin willow branch. I could bend that willow branch back and forth over and over, and it wouldn't accumulate stress. But if I took that same willow branch and loaded it top to bottom like an I-beam, it would just bend and break.

So it supports bending cycles, but it doesn't support compression. Now, I'm going to change that willow branch into a thicker stick, and I bend the stick once, and it shatters. In other words, the thickness and radial diameter being larger means the stress is bigger in bending. However, let’s compress the same stick; it can bear tremendous compression.

So there's a very fast example on spines. There’s a fellow who has the world record in consecutive sit-ups—thousands of them. Given what I’ve just said, what’s your prediction? Do you think he has a big, strong fellow with a thick spine, or do you think he’s a very slender man with a willowy thin spine?

He's a willowy, bendy guy who can just keep bending up and down off the ground.

Bingo! Bingo, he has to be; there’s no option.

So there’s a start on the genetics. Not everybody can play offensive tackle, and not everybody can be a gymnast. Not everybody can simply tolerate sitting in a chair being a computer operator. That’s a very mundane example for you.

Could I ask you a question about the willow versus thicker trunk example? Can we look to torso thickness, wrist thickness, or ankle circumference as a way to assess ourselves as to whether or not we are likely to be more willowy or Redwood-like? I mean, it should be obvious just by looking at ourselves knowing ourselves, but for instance, I have a short torso. I'm kind of thick through the torso front to back; I always have been since I was a kid. My wrist circumference isn’t small, but isn't huge.

I had a bulldog Mastiff, and he would often look at me, and I knew in his mind he was thinking my wrists are really thick compared to yours, Andrew. I knew that’s what he was thinking. He had forearms like a longshoreman, and of course he had never done any work whatsoever. Actually, the primary goal of the bulldog is to do as little work as possible in life.

But I have friends who, you know, have thick knees; some have smaller joints, smaller ankles. Can we make some general assessments about our spine without imaging it by looking at some of these peripheral markers?

Absolutely! The knee width, the bi-iliac crest width (which is the width of your iliac crests), hip width are all surrogates to indicate general heaviness of the skeleton. So yes, that’s one good marker.

But there’s more to the story for genetics and how bendy a spine can be. The shape of the disc matters. So if you take, on average, a group of top golfers, you’ll notice that their spines—that the disc shape, if we were to cut through, which is a transverse scan on an MRI—are more ovoid. If you take someone who can bear a lot of compressive load, the discs look more like a lima bean, and that’s called a lima-con-shaped disc.

And of course, the discs are in repeating fashion throughout the spine top to bottom, correct?

And the discs are the soft tissue that allows for the mobility of the vertebrae, the bony segments.

Exactly. They are the joints, but they’re not a ball-and-socket joint. They’re actually a fabric of layer upon layer of collagen fibers, and we can talk about that as well.

What a beautiful adaptation, right? Take a bunch of bony—if you want to be able to bend a bone, you need to break it up into segments, kind of like beads on a necklace. And then in between those beads you put some pliable yet, I guess, a tissue that you can still compress.

So it's both pliable, and it can squeeze down and become more narrow in the vertical direction, and it can also squeeze down on one side or the other to some degree.

Yeah, we evolved discs, and there really is no other better architecture. People say, “Well, why don’t we have ball-and-socket joints in our spine?” And the reason is this: Can you imagine stacking five oranges one on top of the other, and then you could make them mobile by putting a ball-and-socket joint in between them? The amount of control that you would need on every single orange—you move one orange; you have to control all the others. It’s Mission Impossible.

I would do an experiment with students in my lectures. I would take four coffee cans and put a tennis ball between each coffee can, and then I would put a rope at the front and the back of each coffee can, and then one on the side. I had four students take those four ropes, and then I took another four students who had the ropes on the next coffee can and then the next coffee can, and then I would say, “Okay, group, flex the spine forward.”

So the students on the front would pull a little bit, but the guy on top had to pull more than the next coffee can, and then the next coffee can a little bit less. Vice versa, the people on the other side had to pay out the rope in sequence, and then I would say, “Okay, now let’s twist a little bit.” Anyway, you could imagine it was impossible to control.

And then I took out the tennis balls, and I put in what was a disc, a big round cylindrical piece of foam rubber. All of a sudden, that added stiffness. So now, because the body uses stiffness as the control parameter, now we’ve added control in that the foam rubber would create a buffer. And as the deviation in motion occurred, the foam rubber would add more resistance, so it was an automatic control.

And that’s what a shock absorber does on a car. It has an elastic element plus the damper, but it’s the elastic element. And we’re going to talk about stiffness and stability, I hope, that really creates the control. So that’s why we have evolved discs; it’s highly efficient.

I can bend the spine to tie my shoe, but if I have to carry home, these days, heavy shopping bags, I need stiffness of that flexible rod so it doesn’t collapse. Or years ago, I might have been carrying home an animal for dinner, and I needed those discs to provide the stiffness in a very economical way and in a way that didn’t create stress concentrations the way ball-and-socket joints would.

So that’s an evolutionary necessity. Also, when we look at spines, there are the column vertebrae with the intervening discs, but behind them, there are two more joints, and those are called facet joints, and they guide motion.

Those facet joints have a variety of angles. They can have open angles, which allow you to twist. So if you took a group of golfers, could you imagine if they had facet angles like this? You can’t twist. So facet angles that are too close together, basically a small angle, if the angle is oriented forward, you can’t twist.

And you won’t find, if you're dealing with a group of professional golfers, you’ll find that they all have open facet joints.

Is that genetic?

It's absolutely 100% genetic.

Now, interestingly enough, when you arch back, when the facet joints are oriented open as I’m describing, when you arch back, one pushes hard on the other like shingles on a roof. That stresses a bone called the pars bone, and gymnasts, for example, get a very typical fracture pattern called a spondylolysis, which is a fracture of that bone, and then the spine shifts a little bit at that joint.

I’m just finishing rehabbing a pro tennis player who had the same thing after they tried to have too much range of motion in their serve. The coach gave them excessive extension to try to put more miles an hour on the ball, but it didn’t suit the spine, and they ended up having a stress fracture.

I mean, is it fair to say that if we are naturally flexible—for instance, my sister can—her fingers can bend back really easily. Her shoulder extension, which I guess for people that aren't familiar with shoulder extension, you know, she can lean up against a railing with her back to the railing, the railing is just above lower back height, and she can put both hands on it parallel. So her arms are very close together to the torso.

And then, with feet about, I don’t know, a foot or two away from that bar, she can do a knee bend, and basically, her arms go back behind her. I happen to have a fair degree of shoulder, just natural shoulder extension ability. I’m not particularly flexible, quote unquote, but that’s just how I’m structured. I have some friends that can’t do that to save their life, right?

But I wouldn’t consider myself hyper-flexible. My sister is a bit more flexible; we’re related, obviously. So would people like her, or people that tend to be pretty flexible naturally, be wise to avoid certain activities if their goal is to remain pain-free? I mean, you talk about the St. Bernard running on the Greyhound track. You know, we all can enjoy things recreationally, but of course, we don’t want to injure ourselves.

So is somebody who’s naturally flexible—should they avoid certain sports and activities? Conversely, if somebody is naturally stiffer, thicker spine, thicker joints, should they avoid certain activities?

That’s a huge question, and there are many more variables to consider. But I will say that when we are rehabilitating an athlete or just a person to get back to work—they’re an occupational athlete—we take all of this into consideration.

So as you were describing your sister arching back, I know she has plump discs, discs that are full of fluid, to allow the mobility to take place in the disc. I also know that if we looked at an X-ray from the side, you know, the posterior spinous processes, if you run your thumb down the midline of a person’s back, you will feel the bumps of bone up the middle of the spine; those are the posterior spines. She will have a large space between each one when she’s standing upright.

So when she extends back, those spaces will come together, and eventually the spines what we call “kissing spines.” It takes me back to some of the old Russian techniques for bench press; they would bench press with a huge arch in their back. And then other people would say, “Oh, I’m going to try and mimic that particular bench press technique because it allows you to get much more force.”

So to latissimus dorsi a stiffer back, and you get a different force vector, and actually more effective force on the bar—they didn’t realize that when we work with a person who has a huge arch, they have big spaces between those spinous processes. And if you don’t have those big spaces, you are going to crush the interspinous ligaments, which naturally are between those spaces, and you will now fire off a whole set of new problems.

So what is a mechanical advantage for one person is a mechanical disadvantage for another. Do you follow?

So all of this matters. Going back to the discs being a fabric of layer upon layer of collagen strands, typically, the disc is about 80% type I collagen; that is the stiff strength collagen. About another 20% is elastic collagen, type II. But there's type III through X that bind those collagen fibers together; that's where there's a much greater degree of genetic variability.

So there are some people who can get away with doing many sit-ups. They have a slender spine, and they have the type of binding collagen that holds all those fibers together. But if I wanted to work these fibers of my shirt apart, get them to delaminate, I would create repeated stress-strain reversals. The resistance of that fabric depends on the stuff holding the fibers together.

So there will be binding fibers, and that’s where the genetic variance lies in many people.

So even there, the person’s resilience to repeatedly doing a bending drill is determined by your parents to some degree, both in the size and the collagen type three through ten makeup.

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Unless somebody is seeking to be a world-class athlete in something, in which case they should probably pay attention to their genetics and see whether or not it lines up well with a given sport—though there have been exceptions where people who were incredibly, uh, genetically biased toward not being able to perform well in a sport have nonetheless succeeded in performing at a world-class level—that those are exceedingly rare exceptions.

For most people who want to do things recreationally, like the heavier set person with a thicker spine who wants to golf, or do ballet, perhaps, or the thinner, willowy person who wants to get into powerlifting, for instance. Are there certain things that they should each consider and embrace as activities in order to make themselves more resilient, more pain resilient, and more apt to have higher performance?

For instance, would the willow person, so to speak, do well to build up some of the musculature around the spine to compensate for the thinness of that spine? And would the person with the heavier or thicker spine do well to encourage more pliability of their discs somehow?

The answer is yes, but it’s a very limited yes. So if I can set the stage and give some context here: every system in the body requires stress for optimal health. Think of the cardiovascular system, the musculoskeletal system, the endocrine system, even the psychological system—it needs stress to create adaptation for robustness. But you cannot cross what’s known as the tipping point. Because if you do, you start building cumulative trauma of some form, whether it’s emotional trauma psychologically or it’s cumulative stress at the tissue level, at the level of the cell.

So we have to talk about those tipping points. We've got to define where they are, try and expand them, adapt them, but don’t cross them.

So with that context, now we can talk about a person's suitability for the stresses on different parts of their body associated with different sports. We can talk about the rate at which the adaptation occurs, the amount of deloads and rest that are required—all of these things are genetically influenced.

The way that they perform the movement is going to move the stress concentration. Here’s an interesting demonstration for you: if you go to the Olympics and look at the podium winners of a javelin thrower, they look identical. Do you think the swimmers look like the javelin throwers? No, they don’t. But they look like each other.

But they look like each other. The people on the podium look very similar in structure.

Let me just give another very poignant example of that. Consider a sport that has three very separate demands of the athlete: consider a triathlete. The triathlete has to swim a certain distance, then they bike a certain distance, and then they run a certain distance.

Have you ever known a person who comes out of the lake or the pool, whatever it is, first, winning the triathlon? It doesn’t work that way. What suited them to be a fish fast in water—they have to be somewhat floppy in the ankles because they’re creating a fish’s fin, longer in the torso.

Consider a powerlifter performing a butterfly stroke; it wouldn’t look very pretty. Then they get on the bike, where they have to stiffen.

I don’t know if you know bike design. Well, I’m sure you do. You’re paying for stiffness of the frame. That’s what a really elite cyclist does.

So when a person pushes on the pedal, the frame doesn’t flex because that would be an energy leak. You pay for a very stiff frame so every ounce of force that you apply to the crank handle to propel you forward propels you forward instead of being wasted and bending the frame.

The same way, the cyclist will lock in on the bike. They’ll squeeze the saddle between their legs, lock into the bars, and lock their core down so that when they create power through the hips and through the legs, it's transferred to the power.

It isn’t transferred to bending their willowy body. That is very different from the neurology and the mechanics of a swimmer.

Now let’s run to the most efficient runners store and recover elastic energy in tuned springs. A wonderful book to read is “The Lost Art of Running” by Shane Benzie, who studied the Kenyan runners and how they store and recover elastic energy with each stride, almost the same way as a kangaroo would. A kangaroo is more efficient when it hops versus plodding along using eccentric-concentric muscle contractions.

So again, the polar opposite of a swimmer, it’s a very tuned stiffness. The most efficient runners for the third leg of the triathlon pre-stiffen; they have a pre-contraction of the muscle so when the foot hits the ground, they’re already storing the elastic elements and they get that back for free.

But if the springs were not tuned and they stretched away, their muscles just to be passive elements—which serves them very well in the swimming element—think of doing a pogo jump. So you’re just pogoing through the ankles.

Now if you had no tone in the leg, you just flop into the ground and you would have to use concentric-eccentric muscle contractions. But if you stiffened too much, you're now a piece of iron, and you won't be able to jump either, but you’ll get a beautiful resonance—a beautiful pogo—when you have the tuning just right.

So when a muscle contracts, it creates force; we all know this. But people don’t appreciate that you’re also tuning the stiffness. If I maximally contract my muscles, I can't move.

So athletes have to tune muscles if they're impacting athletes, but they also have to pulse and relax. Pulse—we're talking about Mike Tyson before the podcast today and the mechanics of how he pulses, and then he’s got to relax to get the closing velocity of the fist to the opponent.

And then when his fist hits the opponent, he turns to granite. It's just such an awesome experience to feel that a little bit. It’s one of the joys of my life working with elite athletes to feel their athleticism but then dissect it down as to how they do it.

So there's a lot in that, but that lesson from the triathlete really shows us how you can’t be good at everything. There’s always a trade-off with athleticism and the genetic part, and then, of course, the appropriate training to optimize and express that genetic gift through technique.

So some athletes are very loose, some athletes are very tight, some are very elastic. You won't hit a golf ball 330 yards if you're not an elastic athlete.

You’ll notice if you measure a golfer who can hit 330 yards—they don’t test very strong. They have a beautifully tuned elastic body; you can almost see it if you’ve worked with enough of them. There’s a smoothness to the muscle.

Underneath the skin is a fascial net. Someone who can throw a baseball 110, 115, 120 miles an hour will be the same, but now you have a very asymmetric elastic effect.

So, I know that you loathe and avoid generalizations, with good reason, but given that most people listening to or watching this are probably not aiming to become elite athletes—I know I’m certainly not—can we safely make at least one or two generalizations about what we each and all can do to try and avoid, let’s say, back pain and injury, by either diversifying our training or avoiding certain types of training?

For instance, let’s take the three major phenotypes, and this is obviously not how the world works—but the classic, you know, ectomorphic phenotype, very thin, very willowy, small joints, long and lean, you know, or the mesomorph, thicker, more muscular, and then the so-called endomorph, the more heavy set, maybe even carrying some extra body fat, etc. I don’t really know what’s under there; they could fall into either of the other two phenotypes.

I could imagine, based on everything that you’re saying, that a good rule of thumb would be to avoid the types of activities that are outside of your natural genetic propensity based on body type—at least in the extremes. Like if you're not very bendy, don’t do seven days a week of yoga, okay? But I could also imagine the opposite—which is, if you're not very bendy, do seven days of yoga because that’s going to allow you to become more bendy.

Or the person that is naturally shaped more like a shot putter, let’s say, the mesomorph or endomorph, and you could say, well, they’d be a great powerlifter. I mean, I knew kids like this in high school. In P.E. class they’re like, “Okay, weight training today.” None of us have done weight training, and then the kid lies down and, you know, pushes 315. You’re like, “Oh goodness, that’s wild.”

But maybe they shouldn’t be weight training if their goal is to be all around fit.

Which I think is the goal of most people: to be able to, you know, carry some luggage at the airport without having to stop every once in a while and suck for air, to be able to lean down and grab something out of a cabinet, you know, pick up a kid, do some hard labor in the yard, you know, move some logs and things like that—just be able to do stuff without getting injured, without being so sore in the following days that you feel like you need extensive rehabilitation.

So again, I know you like to avoid generalizations, but should we make it a point to train against our predisposition in order to offset the imbalances that would otherwise occur, or would we be wise to lean into our strengths and just not touch stuff that taps into our weaknesses?

I understand the question. The answer is I don’t know. But I know people will say, “Oh, this professor, he’s avoiding the question,” and I'm not going to do that. So I’m going to tell you how I find the answer, and it's through assessment.

I’m glad we’re getting back to back pain, by the way, because it’s my real cornerstone of my expertise. Our assessment is very comprehensive. It starts out by me simply asking the person, “Tell me your story.” Some people never tell me about their pain when I ask them to tell me their story; they will be telling me about their family life and the pressures that they have to still go to work because they have two kids in school or four kids in school, or they might tell me about the passions that they have or they might tell me about their goals.

So the goals are the beginning of answering your question, Andrew. We all know people who aren’t suited for a certain occupation or they aren't suited—or I'll take myself for example. I had a high school careers counselor tell my father, “Well, Miguel, he’s not really suited academically; he should go to trade school.” So I registered for plumbing school.

No, I just—RUBS—because clearly that’s not the way you went. Not that going to plumbing school would be a bad decision for some, but in your case, you went a very different direction.

I think I would have been okay as a plumber, sure. But anyway, my point in that is: what are the goals?

Then the assessment, I’m paying attention to the person’s learning style. How are we going to coach them? And then we get down to the details of their pain. What’s the nature of the pain? Is it when they get out of bed in the morning? Is it associated with a certain activity? Is it associated with certain motions, postures, or loads? And how does the pain change?

Does it start out on one side of the back, and then later in the day, it’s in the left glute, or does it go down to your right toes? All of these things are telling me about the stability of the pain; it’s giving me clues on what I’m going to assess.

Then we go and assess them, and it begins with what we call provocative testing. I’m purposefully provoking their pain. If I can provoke their pain, I’ve nailed the mechanic; if I can’t provoke it, it’s not mechanical.

Okay, well, that tells me something now. So now I’m starting to see—I know what their job is, I know what sport it is they want to do, I know enough about that job in sport that I know the physical demands, I know the psychological demands.

Do they have what's required of the job or sport? And then I test that. If it triggers their pain, we have a problem. So now we have to focus the training very specifically because people do not have infinite training capacity; they only have so much. And when you’re hurt, you have even less.

So we try and focus on things that are going to make a difference to enable them to have the ability to meet those specific demands that we’ve identified.

So do you see how it’s a long-winded answer? But I know how to get there to know how to train them.

So now that we’ve recognized the very specific nature of their pain pathway, and it may be something that’s going through the linkage. In other words, when they run—I could give you an example of if we put a group of Canadian hockey players on an elliptical trainer—they don’t do very well because, typical of the sport, the hockey players tend to get stiffer in the hips.

It’s the way they are. They skate a little bit flexed, and they carry heavy skates and heavy equipment down the legs; they get stiffer in the hips. When they go on the elliptical, their hips don’t have the range of motion, and their spine and pelvis gyrate with every rotation on the elliptical trainer.

The elliptical gives them back pain if they already have motion-triggered back pain. We take another group who has mobile hips; they do very well on elliptical trainers. The stress doesn’t go into their backs.

So now do you see why I know why one group does well with the elliptical, and the other group does not? I know why one group—if I give them a lateral shear test, which is basically a bear hug, I pull their pelvis towards me as I hook down their shoulder in my armpit.

So I’m shearing their spine laterally. If that triggers their pain—exactly. I had a pro hockey player the other day. I gave him the lateral shear test, and he had a right-sided flash of pain going around his right flank. It exactly replicated the pain. I just found with precision the mechanism.

Okay, what’s the antidote? I put my fingers into his oblique muscles and said, “Push my fingers out.” And he did it too hard. He says, “Oh no, that hurts even more.” Okay, dial it back a bit. Tune what we’re trying to achieve here.

Fight me just a little bit. I repeated the formerly offensive test, and the symptom was gone.

So now I’m getting more precision on knowing what I need to do. He was doing the Poff press. The Poff press is a long lever exercise, so you take a load, usually with a cable or a band that’s held laterally, and you increase the length of the lever which you have to resist because it’s punching out from the body.

Yeah, you try and—it’s causing you to twist, but it also creates a tremendous shear load on your spine. That was triggering his pain. So we took out the Poff press, which for him right now is replicating his symptoms.

But if you're playing in the NHL, you should be able to do a Poff press, you follow?

Yeah, it’s a requirement of the rigors of professional hockey, but he can’t do it now, so this is informing the programming that we’re going to do.

So if somebody has pain in a given movement, say standing up after they sit for too long, right—a particular style of hip hinge, you know, deadlift or squat, or when they run, for instance—would it be wise for them to think about the exact movement that makes the pain the worst in the moment that they’re doing the movement, or afterwards? Because oftentimes pain will arrive after we engage in a certain activity, but during the activity, that pain is shut down, which by the way is an interesting phenomenon on its own right and might be worth some mention as to a couple of the reasons why that occurs.

We always think, oh, blood flow? It’s warm? But clearly, it’s more than that.

Yeah, for sure. So let’s say I have pain in my knee when I run—should I avoid running in that gait that causes pain and work around it?

It seems to me that would be the logical choice, right?

Every person that comes to us comes with back pain, so initially, we avoid it. We can have a neurological discussion if you like, we can have a biomechanical discussion, or we can have a psychological discussion. We can take it in the framework of any of those if we like.

If the pain is causing a sensitization, I’m going to use the example here of stubbing your toe. You stub your toe once. Okay, well, it hurts a bit, and the pain goes away fairly quickly.

But if every day you stubbed your toe, you would increase the sensitivity so that you don’t have to stub it anymore. All you have to do is lightly touch that sensitized toe, and you are going to have a maladaptive heightened response.

So if we keep creating pain on that toe, it will never get better. So we have to start a desensitization wind down, which is tissue-based, but it's also neurologically-based as well.

And because everyone comes to us with pain, we work very hard to hack our way around it. So let’s say sitting causes their pain. All right, we’ll find out that when we do a sitting test, if they sit slouched, that causes their pain. When they sit upright, their pain goes away.

So I will give them a lumbar support, which I’m just happy to use now. I had to sit on an airplane for five hours yesterday coming to see you, and this allows me to not get back pain on the airplane while I'm sitting because if I sit flexed for five hours, I will have a grumpy back, and I won't feel like when I get into the hotel to go for a walk.

Which is—and train a bit, because that’s what we have to do to create a stress below the tipping point to optimize health.

So it’s the same thing in putting together the program. First of all, know the cause and try and eliminate it. So we’ll teach them how to do spine hygiene.

We teach them how to hip hinge, how to squat, how to lunge, how to get to the floor, how to roll without twisting their spine into pain but using the ball and socket joints. We teach them how to do a baby's crawl, which eliminates the torso twisting, which in their current state will offend the sensitized pain trigger.

That must be humbling for adults to get down and do a baby crawl.

It’s humbling to take a world record holding athlete and humble them right back. I, as you know, I've had the current holder of the all-time record squat, Brian Carroll, and I—Brian and I have written a book together, so I can use his name.

What’s the squat record?

1,036 pounds, if you can believe that—down to parallel. Down to parallel. No other human has done that. That was four years ago now, and no one’s replicated it.

Does he wear one of those elastic lifting suits when he does that?

He does, yeah. So he’s putting on an exoskeleton of stiffness.

But I want to come back to how humbling it was to have someone who already held world records in squatting in two different weight categories, and I had to show them how to get off the toilet. But that’s another story.

We both laugh at this now, but that was what pain had done. Pain had corrupted his movement patterns and he forgot how to squat, but he held the world record. That’s how corruptive pain is to the neurological engram, and we can talk about inhibition and facilitation and all of the things.

I mean, I’d love to have that conversation because I know who I’m sitting with. The neural aspects are fascinating. When he does that incredible squat poundage, does he take the bar off a standard squat rack and then walk it back, or is it one of those ones where the bar is suspended from two hooks and then he takes it from there?

Yeah, so that particular lift was lifted off a monolith, where he didn’t have to walk it out, so he takes it off.

So it’s hanging from hooks.

Then the hooks away—the reason I ask is, it sounds like he’s optimized for one very specific movement and a couple of planes, and nothing else; because walking with a thousand-plus pounds on one shoulder is also a feat in itself.

Okay, shuffling backwards as it were. Alright, you’re not letting me off the hook, which is fine. So I’ve worked with competitors who compete in strongman, and they can carry and walk with 1,000 pounds on their shoulders.

It’s called the super yoke. Another client of ours who held the world Wilks score in the IPF (International Powerlifting Federation), where they do not lift out of a monolith—they take the bar off a squat rack and they have to step back—and that is, if you don’t have enough lateral strength and control in your torso, that’s when you become hurt. Not during the squat; it’s during the walkout.

So it’s a tremendous, it’s a very different feat of strength.

So best not be carrying a willow spine for that one; you want to be like a redwood.

Well, you want to be built like Blaine Sumner, who’s another one of our clients. I’ve worked with Blaine for quite a number of years.

I love the analogy to dog breeds. I love going to dog shows. I've only done it a few times—not to actually see the prancing around of the dogs. That doesn’t interest me at all.

The best part about a really excellent dog show is you go back behind the arena where all the different breeds reside. So you can see the lineup of the finest Irish wolfhounds, the finest English bulldogs, etc. You know, hundreds of different breeds, and you really get to see these genetic extremes—not just of structure but of temperament.

And you get to see the similarity in temperament of the bulldogs, and of course, there’s variation. Some of them are a bit more jolly; others more stoic. The terriers are magnificent in their own right.

And as you pointed out earlier, with respect to the podium, more similar to each other within breed than across breeds in terms of temperament. But there’s variation within breed.

The reason I bring this up, and the reason I bring this up now, is that if you look at the movement of those animals, even just the way they walk—whether or not they enjoy a flexion of the paw as they stride or whether or not they tend to stride differently.

I don’t have language for this; I'm not an expert in this, but I have a visual system that works, and I can see that they may move differently. They actually walk differently, even at the same pace.

And then you look at human beings—shorter, taller, medium, more lean, more heavy set—and it’s amazing that we don’t take this into consideration, that we all move very differently.

Even within species, but that we be into these groups. So when someone walks into your laboratory, as it were, your clinic, your laboratory—do you, are you paying attention to how they move into the room, irrespective of pain?

100%. We time the clients—I see one in the morning and one in the afternoon, and they’re three-hour appointments, so I know when they’re coming. I watch them get out of the car if I can, and that’s when the assessment starts.

But just to go back to the dogs, my sister is a vet; her husband’s a vet, and her daughter’s in vet training. So we have these conversations all the time. Do you know she’s already made an assessment of that dog on how it’s going to behave when she injects it or has to do a rectal exam or whatnot in what dog or breed?

And even in cats, which ones she’s going to muzzle, because she’s usually right on who’s going to get bit.

Yeah, and interestingly as well, it’s how the dog feeds off the owner, and she can look at the owner and usually determine how the dog is going to behave.

So talk about the psychosocial milieu around dog behavior.

Absolutely!

Going back to your question, when a person walks in, so I’ve had gold—have I had a gold medalist in sprints? Yes, I have from the Olympics. I’ve had a silver medalist; I’ve had just what every athlete that you can—and then a person walks in off the street, all with back pain.

In your mind’s eye, conjure up the image of a good sprinter. Do you think they have a flat lower back, or do you think they have a lot of lordosis, which is an extension hollow in their low back?

A sprinter?

Now, what will they have?

I recall seeing Michael Johnson sprinting very upright, yes.

So when I think upright, I think either flat lower back or a little bit of an arch in the lower back, you know, this kind of.

Yeah, he was 200 meters, wasn’t he? 200 and 400?

Well, I think he was a 200 and 400. He was—which is unusual. Someone could win gold in both.

Well, I’ll think of some of the sprinters now. The 100-meter men and women—they will find they have a lot more lordosis than the runners.

Yeah, they have a—and what that does, I’ll just explain the running mechanics here for a minute. If you’re running along, you have a center of mass. You have to bias the force under your feet behind the center of mass to propel you forward, because if it’s in front of the center of mass, you’re actually braking, which wouldn’t win you a gold medal.

So footfall has to occur behind the center of mass, and then you get a very brief period of time to create an extensor pulse and then recover the leg. If you can pre-tune the pelvis with a lot of lordosis in the spine, you get much more power development behind the center of mass through the extensor range.

If you have a flat back, it’s difficult. Now you’ve just shortened up the range that you can pulse into propulsive forces. A sprinter’s turn B—the body.

But you’ll notice it’s very difficult for a sprinter to kick high.

So you’ll, I look at these different forms in the combat athletes. If you look at someone who can kick high in a roundhouse, they will tend to have a flatter back.

So combat athletes tend to have a flatter back. Going back to the runners, you’ll notice that the Michael Johnsons and the more the runners with more distance have a flatter spine, they’re more upright, and they’re tuning that ability to store and recover elastic energy.

Where the sprinter, out of the blocks, it’s horsepower; it’s concentric and eccentric muscle pulsing. But anyway, there would be an example since you mentioned it with running—the style of running, the event—they’re not running isn’t running.

Running is very different. And again, look at the podium winners of the sprinters versus the 10,000 meters—very different architecture.

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I love where this conversation is going because there’s tremendous variation in body shape and form out there. And I’m certain that by now, everybody listening is starting to think about, “Oh, am I more likely to have a willowy spine, a thinner spine, or a thicker spine?”—the kind of pliability or, um, what you call vertical stacking resilience that one spine or the other would have.

And it brings me back to this question of what can we each and all do to try and create the strongest back as well as limit the propensity for pain, assuming we don’t have it yet.

Okay, so, um, I would say I’m kind of in the middle. I’m neither extremely lean, nor am I shaped like a, you know, like a kettlebell—somewhere in between.

So for me, I make it a point across my training week to include three resistance training sessions, three quote-unquote cardiovascular training sessions—one long, one medium, one short cardiovascular session. The lifting sessions are geared toward building or maintaining strength in a balanced way for me; everyone is going to have different requirements.

In other words, nothing is skewed toward one particular outcome like endurance or strength or power. And I think most people probably want something similar, because they’d like to be able to meet the various demands of life.

So I frame the question I’m about to ask that way because as people start to assess themselves, the question arises again: Should we try and compensate for our weaknesses by emphasizing a certain style of training a little bit more? And if so, what does that look like for the spine?

You said earlier, and I love this quote: “All systems in the body require stress for better health.”

Optimal health.

Thank you, for optimal health. So assuming that somebody has a thinner stature, they’re more bendy, would they be wise to build up the muscles of the core—not just the abdominals, but the obliques and the lower back muscles, you know, all around the spine—in order to give it more stability?

And would the person who has a thicker torso, thicker spine, thicker joints do well to emphasize some additional yoga training, um, some additional, um, anything that allows them to be more bendy?

I’m going to go back to the fact that they’re coming to me with pain. We are going to figure out through the thorough assessment what triggers their pain.

Most people it’s true don’t want ultimate performance. They’re not being paid $10 million to be able to throw a fastball or something like that; they want to enjoy life.

Let’s say they love golf. My job is to get them sufficiently robust and out of pain to go and play recreational golf. So it becomes a moot point now whether they have a willowy spine or not.

I will look at their basic golf swing. If I can divide that up just binary, some people are what we call twisters. They don’t have a lot of hip mobility, and they twist their spine, so it’s called the X factor in golf, and they store and recover elastic energy.

Again, it is an elastic athleticism. But the next person isn’t so much a twister; they’re a turner. They have what we call quick hips, so their hips turn, and their spines don’t sustain as much twist.

And then we measure—well, when they impact the ball, if they have a 100% violent lateral crunch and then we measure them and assess them, and that turns out to be their pain trigger, what we do is we don’t allow them to go to 100% in lateral crunch at impact. They go to 95%, and that just moves them off the tipping point, so they’re not stubbing their toe or slamming into the pain sensitizer.

Just stay off the desensitizer now, so backtracking a little bit but making sure that I’m doing that with purpose. You need to know what generates the pain in order to try and localize the pain.

It all comes back to the assessment. But then, the goal is not to repeat whatever creates the pain, correct?

Perhaps what I’m hearing is the goal is to get near the proximity of the pain, but not go there—not generate the movement that that recreates the pain, but you know, take the movement as far as one can without creating the pain, and then think about where the instability or weakness or biomechanical failure is contributing to the pain.

Okay, so now I understand why, if I can just add one, I don’t want to interrupt, but this is a good juncture. Andrew, then we get into the volume of exposure.

So remember the tipping point: we can have somewhat of an offense to their former pain, but if we do it sparingly, that’s another key.

So it isn’t a matter of selecting the exercise sometimes as much as it is controlling the volume and then having a period of time off or a deload or whatnot.

So it may simply be, I’ve got an athlete that comes to mind right now. In fact, I got a—an email; it wasn’t an email; it was a WhatsApp message. Oh, I just won!

So she said, “An international tournament today,” and they play every day. But in getting her back, it was a matter of we have to do these things that were former pain triggers, but control the volume.

Uh, you can think of, again, combat athletes—jiu-jitsu requires a lot of spine mobility. And typically, jiu-jitsu athletes get pain when they use too much spine mobility.

What we do is we limit their training. In other words, they have the skill of jiu-jitsu, but they don’t need to push the end range every day because if they do, they’re in so much pain they can’t train.

So we back off the volume. And I could tell you stories about professional football players. They were their strongest when they were in college. Their bodies can't take the heavy strength training once they get into the NFL.

They don’t squat and deadlift what they used to. They’re limiting the depth; they’re pulling off blocks.

The game changes, and it’s not what people think!

And well, and there’s some wisdom to not pushing into pain and extremes all the time if the goal is to have a long arc of fitness or athletic career. A good friend of mine who’s very accomplished in the fitness community, he says one of the best ways to get and stay in excellent shape your entire life is to train consistently, train reasonably hard.

Can we talk about what his recommendation is?

I’d love your thoughts, but as best as one can to not get hurt. You know we forget about this; we hear so much about training consistently and pushing hard, but the not getting hurt part is key as well.

Here’s his suggestion on intensity: Can I share it with you and just get your thoughts?

Yeah, okay. I have a short attention span. Can I just add added value to that? Don’t get hurt; getting hurt is tremendously asymmetric.

Let me, uh, do you know the book by T.B. Nasim?

Oh, “Antifragile”?

Yeah. Oh, “Antifragile.” He quotes our work—he quotes my “Low Back Disorders” book as an example of antifragile medicine.

Interesting! Anyway, when you talk to, uh, T.B. in an economic sense, if I gave you $100 to invest, if you had a 50% gain, you’d end up with $150. If you had a 50% loss, you’d end up with $50.

It’s much more hurtful to lose $50 than the relative jolly you would get of gaining $50.

Yeah, there’s some neuroscience, certainly, some psychology to support that, right? In terms of how we reset our, um, kind of reinforcement threshold, right?

And so it is so asymmetric with injury training. If you push, it’s taking a risk.

You might gain a little bit in short-term resilience or short-term performance, but you have a chance of really screwing things up, and an injury is really asymmetrically harmful.

So when we work with people and athletes, we really try and avoid injury because of the asymmetry of the consequence. Injury is bad. That’s the first part that I wanted to say.

The second part is people train hard and they feel a muscle burn, and they talk about muscle, but they don’t talk about their joints. And the key to long life is don’t mess up your joints.

You can train hard and build muscle, but muscle is adaptive and resilient; joints are not so much. And if you start messing those up when you’re younger by training too hard, you’ll find that, “Oh, I was training at this intensity because I wanted to be strong when I’m 70 and 80,” they’ll find that no, their knees ache; they can’t get down on their knees anymore; they have to crawl up a chair or a wall.

It’s a very sad picture!

It is! Don’t mess up your joints. So that’s an overarching principle to, of which the spine is one, obviously. But that’s some wisdom with training intensely when you’re young.

Don’t base the outcome on muscle; think about the joints.

No, it’s excellent recommendations for everyone!

His suggestion, and by the way, this is not for competitive athletes—this is just for exercisers, if you will— is to make 85% of one’s workouts across the year at about 85% of maximal intensity and output.

So still constraining the total length of a session to whatever the goal of that session is, whether it’s resistance training or cardiovascular training, but to not go all out—to go at 85% of one’s subjective understanding of what all out on that day would be.

On that day!

To make 10% of one’s workouts across the year at somewhere between 90 to 95% intensity of what one could generate that day—again, 100% all out being subjective for that day. And then 5% or even less of their workouts all out—everything you could possibly give, quote unquote, leaving it all on the mat—whatever phrase one prefers.

And I like that recommendation because it keeps things in check. And it also creates an awareness of how intense one is training.

And it allows us to not let the great night’s sleep or the extra cup of coffee that we had or the great song that happens to be playing or the competitive spirit that’s arising because someone joined you that day or asked you to join a workout to take you into the domain of harming yourself.

In fact, I can look to the times when I’ve been injured training, and almost always it’s because somebody invited me to join their workout. And we got into a little bit of a competitive spirit.

And I’m not an ultra-competitive person, but you push yourself to 100% on that day, and two weeks later you’ve got something you’re dealing with, or two days later you’ve got something.

And you go, “God, was that really worth it?”

And I think unless one is a competitive athlete, and that’s competition day, it’s probably not worth it.

Right! Well, I’m very sympathetic to the overall sentiment of what you just described, but I think it’s much more individual than that.

You can take a younger person and drive them quite hard, as some trainers do, and they have success—a young person responds; they recover faster, etc. You try doing that to a 65-year-old, and you’ll find that they don’t recover as quickly. They need many more deload and rest days.

So if you go to 85%, you just committed to a five-day rest. Well, maybe that’s not wise. If you went to 50%, you only need one day of rest between. So do you see how you play and you optimize this?

And it’s like tapering—what we call tapering down an athlete. Or you know, in my life, I have seasons. Up until two years ago, I rode snowmobiles hard in the winter. Two years ago, I hit a rock at 100 miles an hour on a lake. I fractured my spine; you can spot the professor!

So that was my passion. I had to—so my training would start in August every year. I’d get into shape to ride sleds fairly aggressively. I couldn’t do it all year, Andrew; I’d become injured.

So I would have a cycle of three months getting ready, and then really have some fun.

But obviously, I don’t do that anymore. But my point in telling that story is, I need much more information than just, “Okay, 85%.”

You may get away with that when you’re 20 to 25; I don’t think you’re going to get away with that when you’re 50, as an example.

As we optimize performance in our clients, sometimes you’ve got to leave a lot of gas in the tank because you want to train every other day.

Uh, certainly if you do two days in a row at 85%, there’s no way!

So do you see what I mean? It depends on their age, their injury history, their genetics, and their body type, and all the rest of it.

What are we actually pushing to 85%? Is it a distance on a run? Is it a deadlift weight?

That’s pretty heavy!

Yeah, here I’m thinking about intensity, meaning, um, well, for resistance training, let’s say that one could complete six repetitions at a given weight, but if they had a gun to their head they could complete nine, right?

Well, then you’re doing six. Again, this is crude, crude calculations, right? But six, maybe seven, maybe cheating a little bit on that seventh repetition if it’s a run. And like for me, on Sundays, typically there’s a long, slow jog.

But the slow in that component is a little bit subjective.

So am I pushing a little bit harder than I’m comfortable, or am I hitting kind of a cruising pace?

Right, okay. So 85% of max intensity for me would be staying at cruising pace and occasionally bumping up the speed a little bit.

Okay.

But on all-out day, if it happens to be one, then it’s long quote unquote slow distance, but I’m trying to increase the speed of what I’m referring to as slow.

So again, this is all very objective, but we know on a given day whether or not we’re pushing past our comfort zone or not.

And I’m not somebody who relies heavily on heart rate monitors and things like that.

What I rely on is my consistency. This is the way that I’ve decided to stay in all-around shape for, you know, more than three decades. I feel like I’m in decent shape—I’m not a great athlete. I’ll never be the strongest person in the room or have the best endurance or the most speed or explosiveness, but I’m pretty sure I can keep up with most things pretty well, and I don’t have pain.

And I feel very grateful not to have pain, and I think it’s because I’ve adopted a stance of—I don’t want to call it moderation, but of modulation.

Well, I appreciate all that you’ve said. In my world, everyone has a back pain history. So it’s always, I just let the guy—it's the information that we gather from the assessment that guides our decision on how we’re going to, A, get them out of pain, build some base resilience, which is tuning their body, strategic mobility, strategic stability.

Now, if one thing we haven’t talked about is various types of pain and how yet that impacts on how we’re going to approach their programming for life.

You did a podcast with somebody—I can’t remember what their name was—but it was a pain podcast, and you were developing this idea that if the mechanism of their pain was really part of the changed engram; they were traumatized at the time of the event, or maybe it was a history of sexual abuse or whatever, but I can detect that person almost always.

I’ll start to put my hands on them to feel, “Oh, is there any allergy here?” and they recoil. That's an abused person. That’s a very characteristic response, so you start putting together some of these reactions, and you note that there’s something deeper than an injury to a part of their spine.

Yeah, we had Dr. Sean Mackey—that was it!

Yeah, Dr. Sean Mackey is our head of essentially the pain division at Stanford School of Medicine. He’s an MD, PhD, and he’s a big proponent of the biopsychosocial model of pain, which probably makes sense for us to discuss now.

As the name suggests, it incorporates psychological elements; it incorporates, of course, physiological elements, and it points to, as I recall, seven or more sort of paths to dealing with pain—some of which include thoughts about one’s emotional state, stress level, sleep.

I mean, all of these things clearly play a role in pain and rehabilitation from pain, right?

I love that podcast, by the way, because it’s so consistent with what we’ve found and what we do. If a person has—it was just a mechanical exceeding of their tipping point, and they now have some tissue damage, we address that by creating a strategy that they don’t move or load in a way to stress that, and we allow the injury to heal if we can.

And we should talk about whether the disc adapts or you have to manage it, but that’s another very interesting topic to get into. But nonetheless, we are tuning their body with strategic mobility and stability, giving them core exercise, unleashing their hips and shoulders, etc.

And we will have a reasonable level of success. And we know, by the way, what our success is because uniquely we follow up with every patient we see to know if we were successful or not.

But now we have that person—and I can think of many examples. Just to give a spectrum, perhaps the person was in a car accident—they survived, but the person beside them who might have been their mother died. So now they’re carrying a hell of a lot of emotional trauma, guilt trauma.

Maybe they nodded off at the time of the accident; they were driving. Tremendous psychological stress.

Maybe they were sexually abused or whatever; that rewires their brain. So now they come in, and the pain pattern doesn’t fit.

We do physical stressing of their various tissues, and the reactions change; they’re not what they should be. The way that their brain perceives the pain has been rewired.

If we give them the traditional approach of giving them more fitness and ability, it won't work. We can’t break through that maladaptive response.

We completely change. Now it might be just to desensitize—and you’ll laugh at this—we might get a feather and brush it over their back, and they say, “Oh yeah, that triggers my pain.”

Really?

Yes! Oh, and now I’m getting a headache.

Okay, so we have to come up with what they can do without triggering that maladaptive response, and then slowly desensitize it with repetition, never triggering pain, and then we expand that repertoire.

So you’ve heard of fibromyalgia, which is a little bit of a catchall term, but a flashing light—surprising someone—they’re walking down the street and someone comes out of a shop and surprises them somehow, and that triggers off this massive pain response.

We do that with very gentle love, doing the things that don’t cause pain and trying to slowly expand that engram into a pain-free one.

There are those in what’s called work hardening. It’s usually funded by insurance companies. So if you have intransigent back pain, we are now going to get you to do your job.

We start out with an hour a day. You’re a bricklayer; you’re going to lay bricks for an hour. Tomorrow you’re going to lay for an hour and a half. And occasionally they have some success, or they have some really miserable failures, and the person says, “I cannot do another day of bricklaying for four hours,” even though it’s only a portion of my job.

And so now they get kicked out of the program because they’re called a non-compliant. In other words, there’s something psychological wrong with them, and they’re shattered. Those are the people we see.

So these are, you know, talk about the biopsychosocial approach. I know I get labeled sometimes as the biomechanist, and I ignore all the psychosocial. But these are people who’ve never read our work, and they don’t know it.

So I really appreciate you bringing this up because I’m not often asked this perspective, but again, I know with your background you’ll appreciate all of this.

Yeah, surely the, you know, the nervous system is involved in generating movement and feedback from the muscles and proprioception. And, as you’re describing, the nervous system creates our sense of pain.

There’s an emotional component to it, as Dr. Mackey pointed out. And as you’re reinforcing, the neural circuits that control, quote unquote, pain or give rise to pain involve the confluence of all of these things at some level.

And I appreciate that you’re willing to go into this biopsychosocial model of pain and acknowledge it, because I think all too often in this space of biomechanics and pain, and back pain in particular, people in some cases get labeled as only subscribing to one particular pattern of remedy or one particular framework, and that’s simply not true.

It’s just not true!

In fact, I’ll go so far as to say that

This when you're uh uh on a team getting a uh combat athlete ready. If they are neurologically explosive, you design the fight and the training that they pretty much have to win in the first round. If they don't win in the first round, they're going to gas out. The person who is uh preparing to compete against them is training to survive the first round and then come on in the second, so they're training endurance.

To compare those two different athletes from a psychological point of view, uh, and if you do it enough, I think you'll come to agree with me. You will notice that there is how you coach them. It has to be short consumable bites, and it’s not that they're any more or less intelligent; they get it. But you have to be on cue and choose your words. Be efficient. Do you see what I mean? The coaching style changes quite a bit.

Do you think that if somebody has pain, that they should have the capacity both to like lean into and push into the pain? Not exacerbate it, but to, you know, sit with it and feel it, as opposed to just avoiding it? How should people think about their own pain and how to work with it? That's the reason I'm asking. Right, it depends, and it's a dance.

I can give you some examples. One chapter in my back mechanic book is called… well, it’s about surgery and whether you should have surgery. We did this uh because, as you know, in our experimental clinic at the University, we followed up with every patient we ever saw. We would assess them and then we would subcategorize them into different bins.

If a person was told, “You've tried everything, you've been to the chiropractor, you've been to the physical therapist, the osteopath, you've had a surgical consult, uh, you've been to the psychologist, etc., and you failed every single one of them,” so basically you’ve been conditioned to fail. We tried a process called virtual surgery.

So I’m defining the group now: you've tried everything and you've been told the last thing for you is surgery. That's the subcategory of people that we're now going to talk about. I'll say fine, you can go and roll a dice and have surgery. Most of them don’t want it obviously, and I’ll say, “But what we're going to do is try virtual surgery.”

I make a bit of a production out of it. I anoint them like a knight. I touch them on the shoulder and I say, “That's your surgery,” and I'm looking into their eyes. Now I give them one of these, we're looking into each other's soul. Now you've had surgery; you're going to behave like you've had surgery. Tomorrow is your first post-surgical recovery day.

You're going to lay in bed, relax, get up for a pee every 2 or 3 hours, have short little shuffles. The next day we’ll add a little bit more, etc. We give you a post-surgical recovery program, a really good one, and then we start tuning the body strategically: stability, mobility, and eventually adding a little bit of endurance long before strength, and then getting the movement patterns, etc.

If the person was an exercise addict as well, so you can imagine the person who has the personality that you're describing. They tell me in the interview, “You know, I have to ride the elliptical for 40 minutes every day because if I don't, I'm going to murder my kids and my husband because that's my stress relief.” Oh my goodness! Not literally, but that's what they'll say, painting the picture that person—a treadmill, right?

Or exercise, okay? So they've won that negotiation with every previous clinician. Well, they're not going to win it with me because all I care about is outcome. My job is to get them better by whatever means. So I have to tame that. Surgery works in a lot of cases because it’s forced rest. Surgery for that exercise addict forces them to have rest and allows them to desensitize, so we fake it and we do it.

Now for the evidence, we followed up with every patient, and in a 2-year follow-up, 95% of those people who avoided surgery but did the virtual surgery were glad that they did. Yeah, that answers the question. It's uh follow the advice of the clinician, and it gets back to this issue of predisposition to move a certain way, to therefore avoid other forms of movement, to engage in certain activities but not other activities.

I realize that I'll get in trouble if I say, you know, 70% of the training that we do should be in line with our predisposition and 30% should be uh countercurrent to that, but I'm kind of veering towards numbers more or less like that, right? I mean we know, for instance, in the um machine learning algorithms that relate to learning in the nervous system that a rough, this is a rough estimate of difficulty should be about 15% of questions or challenges.

So these could be cognitive challenges or physical challenges; they should lead to failures—non-injurious failures—getting the answer wrong about 15% of the time tends to optimize learning across a number of different domains, okay? Like, is that true for everything? Is it true for language, math, dance? No, but it’s true for a lot of things.

That's an argument that's used a lot, and I, uh however, as I said, I've done the work and I've done the follow-up, and I have an opinion for a reason. We start out by giving them the tools to not have pain from a physical point of view. That's really important. From a psychological point of view, we've just empowered that person. They are now in control because they never had the tools.

A, they didn’t understand what the real mechanism of pain was, so they had no strategy to down-regulate it, if I'm a neuroscientist, or to desensitize it. But now they know with some precision what the moves, the loads, the activities are that cause their pain. They know the counterpoint points, what actually are beneficial for their pain, and they begin this life of having as little pain as possible.

Now I go back to uh the tipping point, and all systems need stress, but in the beginning, we cannot cross the tipping point. That's really the essence of your question: when do we start pushing them now to allow a little bit of pain? Some people start it way too early. We do not. We know where that tipping point is, and we keep building the training capacity of being pain-free until we have a margin of safety.

Now it's that margin of safety that we start to play with: can we expand the volume of training and get them ready to go back to work or to go back to their sport? Or maybe they just want to play recreational golf; we've talked about that. Eventually, we’re going to go to the point where we're butting up against the tipping point now.

Now we have another conversation. Remember what the goal is: how important is it for you to set a personal best in deadlift or to play 18 holes of golf 5 days a week? Would you settle for three? And now they’ve had a year of no pain; their life has changed. They’re mentally in a different place; they have their answer, and they converged on it themselves.

I'm not 18; I'm 55 years of age. I've got two young grandkids. I'm looking forward to playing golf with them when I'm 75. So do you see how when we bring them through that way, accepting a certain amount of pain—that's more of a younger person's outlook.

There are still some warriors left; a lot of us soften up as we get older. But, you know, I just think of my own journey. I trained heavy as a kid, and I remember my dad saying, “Why are you doing this? You're really shortening your athletic career!” Not that I had one, but, you know, he was right.

Now my training has totally changed, but I, as you know, I have no pain. I’m still fairly physical. Yeah, you're in great shape at 67—just remarkable shape. For those listening and not watching, I encourage you to take a look at the top card or the YouTube video. I mean, Stu moves around great and um, your posture is great, and you’re in awesome shape for any age, much less 67.

So that's a testament to your methods. Well, the point was it's okay to push when you're younger. You don't have the capacity to push. Now, if I go into pain, I'm in pain for a few days, not an hour. So you're cautious. Yeah, and older people will get to that point.

I'd like to ask you about Mill's big three. I know that, again, you loathe to impart generalizations on people, but at some point, you realized that people need something to do to work with in order to try and, quote unquote, pain-proof their back or reinforce their back.

So we did a video that included the big three. We'll provide a link to those in the show note captions where I perform the big three—probably not perfectly, admittedly. I should have invited you to critique my form, and we can always shoot another one of those, but I think it captures the big three well enough: the bird dog, the roll-up, and the side plank, right?

Designed to build strength and stability around the spine and to stave off back pain, or, in some cases, rehabilitate back pain. An enormous number of people wrote to us and commented how much the big three have helped them. So I just want to make sure that it's clear that despite the fact that you are appropriately reluctant to say that the big three is the solution to everything in terms of back pain for everyone, they have helped a large, large number of people avoid and, in some cases, rehabilitate back pain.

If you were to add a fourth exercise to the big three, what would it be? Depends on the assessment. Let's say somebody has a willowy spine and they want more spine stability. They want to be able to generate more spine rigidity for whatever purpose. What are their pain triggers? They have lower back pain on one side, and when they sit too long and then stand up, it feels like that side is locked up and there's some pain shooting down the leg.

Okay, so they've got mechanical back pain; they’ve got neurological involvement. If it's shooting down the leg, how old are they? Early 50s? Maybe in their 40s or older—a big range. So they will have some discogenic disorder. There’s a disorder of the joint, and it will be causing the nerve to react in such a way.

When they walk a bit, 10 or 15 minutes, they tend to feel better. Ah, okay, so they have a younger spine because discogenic disorders are more common among younger people, and sitting is the causative pathway. Going for a walk is the relieving pathway. But that will switch over when they get older, is that right?

Yeah, sitting becomes the relief, and walking then becomes the uh exacerbator of their pain. Well, again, I need to know with some precision what the pathway is, but if they have neurological parts, I need to know why—what makes them worse? So I might have them sit upright in a chair, grab the seat pan of the chair, and pull up.

I'm adding compression; does that cause more nerve radiation? If it does, they've got a little bit of compression intolerance. Okay, so now I have to choose an exercise that is not compressive by nature. If I move the nerve—so if I extend their leg at the same time and ask them to look up, it releases the whole spinal cord and all the nerve roots from above, and it pulls it from below.

In other words, it flosses it through. If that causes pain as they're doing it, they've got nerve friction. If they do it and it's tensile tension, then it's nerve tension. So these are very different mechanisms of their pain, and they require different approaches.

So do you see why I'm still hedging on that next exercise? It might be mobilizing the nerve; it might be giving them more thoracic spine extension through a thoracic. And now they've taken the load off when they sit and stand. So you can imagine standing, you can palpate your erector spinae muscles, and they might be relaxed. You poke your chin and those muscles come on.

But if the cramp was on one side and if it was muscular, that's probably not related to this. That’s still a very discogenic sign. There’s a bulge or there’s something off that’s mechanical that we will determine. I might just say walk more, but not in a single dose. Again, I've described all of this in back mechanic.

Instead of walking an hour in one dose, have three 20-minute walks. Walking for an hour increases the risk of getting pain; walking for 20 minutes guarantees you have no pain, so do it in three doses. You've just guaranteed success. So I might add another exercise, but I might program it very strategically as well.

What are your thoughts on um inversion tables and anti-gravity boots, um and things to deload the spine? Right, well, again, if you follow our work, we do uh de-loading of the spine through traction. It's usually applied by one of our trained clinicians, and the reason for that is let's take that younger person again, as you just described.

Maybe laying on their tummy, as they exhale, they allow the low back to sink into the table, increasing the lordosis, which is—we measured this in the lab. If they have a posterior disc bulge with an open fissure, which is probably one of the more common ones, that maneuver vacuums in the disc bulge. If that immediately reduces the pain down their leg, I would say, “Lay prone and have someone pull on your legs along the plane of the table, five or six pounds per leg.”

Now, the next person comes in and says, “Oh, that hurts.” Well, now we play what we call jazz. This is the art of therapy. I'm playing with how we're going to apply a twisting torque to their feet. No decompression table does all of this; it doesn't have the art. It’s more of a brutal hammer.

And to really get difficult people—remember, no one has back pain and says, “Oh, I think I'll go see Miguel.” It doesn't work that way. We only get the ones who've failed 10 previous attempts, every other treatment. No, we've got to know; we've got to have some skills here.

Well, I started doing the big three on the basis of your book, and it certainly has helped my lower right-side back pain that occasionally flares up. I also noticed I've gotten stronger in various lifts, but the most salient consequence has been when I run. I feel like my torso can um, uh stay more upright as I can kind of cycle my legs underneath me, like I'm pedaling on a bike, and I feel like I have endurance for days.

That's exactly what you should feel. You've improved the cylinder so the diaphragm pumps up and down inside the cylinder to allow you to lung ventilate. If you don't have that athletic diaphragm, you're entraining your abdominal muscles—the oblique muscles—to the breathing effort while you're running. It wears you out; it also compromises your spine.

So you need those muscles to form a girdle and hold it all together. Now I know enough of your history that I suspect you will have a little bit of a disc bulge. I do, yeah. I had a whole body scan for, just, you know, for fun, I guess; it’s the sort of thing I do for fun. And indeed, there's a—I think it's like an L3-L4 bulge on one side, which is fully consistent with the pattern of pain that I've had.

Right, and I've managed to avoid, for a number of years now, doing um cobra type poses, um these kinds of things. The cobra doesn't work for everybody, but it is a powerful vacuum in of certain types of disc bulges. So I'm glad it works for you and you've found it. It will work for some others or it will make the pain worse than some others, and there's tests for figuring that out.

I notice if I travel and it forces me to sit for long periods of time, and then the next day I train with any kind of hip hinge movement, it flares up again. Right, don't forget to use your Lumar on the airplane, right?

Yes, Dr. Mill gave me this little pillow; they call it the Lumar, that inflates to put in the lower back, and it’s um, it's a wonderful tool, right? Um, that gives you resilience for travel. If one didn't have access to that, um they could just roll up a towel and put it in their lower back?

Absolutely, yeah. Or sitting in a lecture, if they're a student, travel with it; sitting in a restaurant, people who go and say, “Oh my back's killing me after sitting in that booth in the restaurant,” you might get some funny looks, but you'll be the person still mobile and not complaining about your pain while everyone else is grunting.

I'm past the funny looks; I'm okay with that. That's an advanced neuroplasticity trick that comes with age. Yeah, I'm right there with you. I have a question about walking.

Yeah, um, these days we're hearing more and more about benefits of walking after meals, walking several times per day, blood sugar regulation. I think it's all wonderful. Anything that gets people moving in healthy ways, um I think is terrific. When it comes to walking, none of us want to be the person paying careful attention to our gait, especially when we're not in pain and things of that sort.

But if you were going to recommend a daily walk, is there a duration and speed that you think, you know, could be beneficial in terms of staving off back pain, um, just general posture, things of that sort? Are we talking about a brisk 5-minute walk or a brisk 20-minute walk, this kind of thing?

I'm with you 100% with the notion that walking is one of the most healthy things you can do. I get stuck a little bit when you want me to give numbers in a generic, broad application. Ranges are fine. If I saw the person and they have a back pain history, I would know—uh, should I just leave walking alone and tell them to walk? It's quite fine; that's not your problem, but we still want you to walk three or four times a day.

But I know what the question is, and you want some general rules on all of this. Don't walk to pain. So, if your tipping point is 40 minutes, you can't go in for a 40-minute walk. You've just guaranteed that you will be unsuccessful in having a pain-free day. But can you walk 20 minutes? Good. Walk 20 minutes three times a day; now you've got a full hour of pain-free walking guaranteed.

So it was the exposure and how you dosed it throughout the day. If the person has discogenic back pain, they will find that they don't like to stand in one position for very long, sit in one position for very long, or do any single activity for a long period of time.

So the key for their daily regimen is to keep changing posture. Something like a sit-stand desk at work would be a really good idea. But now the magic comes if they could sit for 20 minutes, stand for 30 minutes, and walk for 10. Now that was the magic dosing that allows them to do their job as a computer programmer or whatever it is where they're a slave to the computer; there's no option.

So there's an idea there. In my own life, it's a habit—I walk after every meal, I walk before I go to bed, and that's my time with my wife and my dog. It's our routine. Even when we travel in the winter, we drive south; we break up the drive and we do our walks, and it keeps us pain-free.

If I see, it doesn't matter who you are, if you sit all day, chances are you will cause pain. I can talk about damage, which is interesting. We've probably loaded more spines than any other laboratory in the world; I think that's a fair thing to say.

If we put a cadaveric spine—that is, what we call a virgin spine—in other words, it came from a young donor; it wasn’t traumatized, so there's no pre-existing cumulative damage to it. If you put it in a sitting posture, you cannot create new injury.

So if a person has never had back pain, and I can give you an example—you know the person; they're probably overweight and all they do is sit—it’s so unfair, they don't have any back pain, and then their colleague is much more fit; they go to the gym every day, they have back pain, and they think, “This is so unfair!” But what they didn’t realize is they are not training wisely at the gym.

They are probably going far too hard in a short period of time with too much intensity, and they're creating a little bit of microtrauma. So now they just made sitting painful. So do you see what I mean? You can’t injure the spine sitting if you have no pre-existing injury.

But if you have pre-existing delamination of the collagen, an old disc bulge, sitting for a long time will then make it painful. If ever there were two exercises that bring to mind notions of back strengthening and potentially back pain, it's the deadlift and the squat.

What are your thoughts on deadlifts and squats as a function of one’s age, one's perhaps phenotype, ecto, endo, or myomorph, or any other factors that would lead you to say, “Yes, deadlift,” “Endor squat!” “No, don’t deadlift,” “Endor squat!” “Or maybe you should deadlift and/or squat?” Okay, uh, those who know me know it could be any of those three options.

At the highest level, every exercise is a tool, and it's a tool to reach a specific goal. So in our world of limited capacity, when a person is fresh coming out of back pain or they're training to really achieve something physically, have they defined the goal and have they chosen the best tool to keep as much capacity as they can for training other things that really matter?

The deadlift is an extraordinary exercise, and as you know, I don’t know of anyone who's been involved with more world-class deadlifters than myself through the back pain relationship. So, you know, on one hand, I can say, “Well, I love the deadlift,” and on another hand, I can say, “I hate the deadlift.”

I can tell you, Andrew, that if you take the clients who ask for consults now, and they're under 30 years of age, I will say half of them will say in their interview with me, “It started with a deadlift.” So I would say that is getting onto the category of an epidemic, and yet I will still tell you, “I love the deadlift.”

So there are a lot of variables here—a lot of moving parts. The deadlift is a tremendously neurologically dense exercise, whether you're lifting a light weight or a heavy weight. I love these bodybuilding charts that say, “Oh, well, to do a deadlift, it lights up the erector spinae, the glutes, and the quads.”

Perhaps every single muscle of the body should be involved to a deadlift. Every single muscle; the full fascial complex will be tightened up to take the slack out to pull a bar from the ground. That's a good deadlift; that's what minimizes the risk of injury. And as you know, competitive deadlifters will actually put on an exoskeleton of even more fascial stiffness; it's called a lifting suit.

But not everybody, obviously, is in that category. Now, I'm going to talk about one of the most potent pathways to disc herniation. So we have the disc from an anatomical point of view. It's a gel core wrapped with layer upon layer of concentric layers of collagen fibers. In order to get a disc bulge or a disc herniation, they needed to delaminate, and the gel nucleus, when it’s pressurized under a heavy bend, will seek the weak spot between these fibers, work through the delamination, and create a disc bulge.

There's been several recent studies now that have done assay investigations of the harvested nucleus in disc surgery. More than half the time that harvested nucleus contains fragments of broken endplate. Broken endplate comes from excessive compression.

Then you go into the history of the person. Oh well, maybe they fell on ice and they piledrived their back—there's a candidate mechanism to create small fractured bits of endplate. But then they will say, “No, this whole discernation story—it started with a deadlift two years ago. My back got a bit tweaky after that. I kept deadlifting and whatnot,” and then they find the fragments of bone.

So more than half of that harvested nucleus shows evidence of an overload and compression. When you put that together with the history—and again, it's not the fault of the deadlift; it's the fault of the progression. There are some trainers who will take a person from an unfit state through to lifting in a deadlift twice their body weight in half a year.

When you look at the stimulus to bone growth, it takes a lot longer than half a year. And when you look at the characteristics of really successful deadlifters, they're not young men and women; they are people who've trained their body over many years to get that density of bone because that really is the weakest link in a deadlift as far as back injury goes.

So there's something to consider. First of all, um, let's go back to the back-pained person now. There are some people who do not perform an assessment and they say, “Oh, if you've got back pain, the symptom of back pain, do deadlifts.”

Well, hold on a second. One of the first things we do after we've assessed them is to try and get rid of the cause. That almost always involves teaching them how to bend at the hips and not stress and create concentrations in the spine.

It's called a hip hinge. Then we may put a load in their hands, and then we have to assess their hips to determine whether the hips have shallow sockets or deep sockets; in other words, what’s the hip range of motion that will allow you to pick a bar off the ground? There are many people who shouldn't be picking heavy bars off the ground.

When you look at the size of an Olympic— I call them cookies, but a 45-pound plate, I suppose—that was arbitrarily chosen. In fact, it was actually chosen that if someone dropped the bar on the ground, your head could fit between the bar and the ground. That was where that original size of the plate came from.

Is my understanding of it? People lifting alone quite often—is that why? Oh yeah, well there’s lots of YouTube videos of those injuries.

But anyway, yeah, that's something that I both encourage and discourage people from searching for, because it can scare you appropriately, but it can also be traumatizing to see. Right? So now, we've put together the idea of what anatomy do they have in the hips and where's the tipping point in picking something off the ground.

We may start to progress the hip hinge into a loaded situation. If the person doesn’t have compressive load triggers to their back pain pattern, I doubt we’ll be pulling a bar off the ground. Though we will elevate the bar and put it on blocks.

So if you come to Backfit Pro and you look at our rack that has 1300 lbs. available to lift if you wish, we pull off pins. In other words, we’re matching the height of the pole to their biomechanical optimum in the beginning. And then we have to decide, is the deadlift the best tool to get them to their goal?

You know, I did the podcast with Peter Attia, and Peter had a little section on the deadlift. He asked me the same question, but he just told me his personal story of conflict and whether he should be deadlifting. You know, he’s had a couple of spine surgeries as a younger man when none of us knew better in those days, I suppose.

And my answer was to him—and a lot of people took it—and we got a lot of blowback on this—that it was a generic answer for deadlifts. It wasn’t; it was an answer for him where I started to talk about, “Well, maybe for yourself, why don’t we walk backwards up a hill in a monster walk style?”

You will feel the quads burning. How many squats and deadlifts do you really need to do? Neurology comes into this. You walk backwards up a hill, say it’s about 50 yards; your quads are burning, then walk down to the bottom of the hill and walk forwards up the hill.

The brain says, “I’m perceiving exhausted quads; let’s go get the next in the hierarchy—your glutes.” It’s a fabulous stimulator to glutes. So there you go; I've just found a better tool for a person who has limited capacity.

The deadlift was not the way to go; they’re going to walk backwards up the hill, and then they’re going to walk forward and really uh feel tremendous exhaustion if that’s how they get their jollies.

And if that’s what we need in the athleticism to keep them going and building robustness. What are your thoughts on um glute ham raises? I'm a big fan of Nordic curls and glute ham raises for the posterior chain. To me, a glute ham raise—folks can look it up—is basically a deadlift into a leg curl, into a hamstring leg curl, except that your feet are, um, instead of being on the floor for the deadlift part, you’ve rotated yourself 90°, um, so that the feet are effectively at the wall.

Right, that and from the bottom position up to the parallel to floor position, that's more or less a dead deadlift, right? A stiff-legged or partially stiff-legged deadlift, and then the rest of the way is the Nordic curl or the leg curl. To me, that seems like almost the perfect exercise for the posterior chain, hamstrings, and glutes, which is why I do them regularly.

What are your thoughts about them for back strengthening and for people that are trying to avoid back pain, both in the present and in the future? It’s exactly the same answer that I gave you for deadlifts: A, it depends, and B, is it the best tool to reach the goal? That is an auxiliary exercise; it’s not a deadlift; it’s just challenging a part of the chain involved in the full chain that’s required for a deadlift.

If I go back to some of the criticism after that original deadlift statement, there were a lot of older fellas who were saying, “You know, I love the deadlift. When I stop deadlifting, my back pain actually increases, and deadlifting keeps the bogeyman away.” I get it; okay? That was the right tool for them.

But I can tell you about the characteristics of those people: they will be somewhat unidimensional in their athleticism. I will bet you dollars to donuts—actually donuts are getting more expensive now, so that’s a poor analogy that worked when I was a kid—but anyway, ask them to throw a football, ask them to swing a golf club.

I’ll bet you the ones who say deadlifts are good for their back pain won’t do well in either of those activities. So it’s a very unidimensional because they can’t generate that kind of twist and snap with the throwing of a football, for instance.

The stiffening up of the body precisely at the right moment and the relaxing of the arm, the flicking and spiraling. A deadlift is not a pulsing strength; it’s a grinding strength. Again, if you want neurology to adapt to create, you know—when again, I know people don’t like when I do this—but when I, I love athletic examples, and I learn so much because it’s like a car mechanic working on a McLaren and then a dump truck, which carries a heavy load, and then a Baja racer, which is incredibly endurable, because it shows you in terms of engineering and automotive technology what is possible.

So when you work with a great athlete, you learn what is humanly possible. So something like a deadlift teaches the nerves to carry electricity. When you measure a very good deadlift, it is an exhausting—but think of what it is: strength starts with this thought and now you have to densify that thought.

Then you have to densify the pulse train down through the nerves, and you've got to teach the nerves to carry that amount of electrical pulse, and you’ve got to teach the muscles to utilize it. So in terms of grinding strength capacity, a deadlift is pretty good, but does that have to do with most people with back pain?

A few years ago, the professional golf community, led by a few personalities, got into heavier lifting. Now this was rather odd. If you go back to the old days of Jack Nicklaus and Gary Player and Arnold Palmer, do you think they lifted heavy weights? And I think Arnold Palmer is still playing.

I mean, some of those guys back when were known for having a few alcoholic drinks plus smoking cigarettes on the course. But my point is, the more you deadlift, the less you will be able to throw a football and play golf.

So if your goal in life is to be generally able to enjoy a really diverse array of activities, be careful on the tools that you choose. So going back to the pro golfers of say 15 years ago, when a few of them got into Olympic lifting, which is heavy hip mobility down to the deep squat for the snatch and tremendous shoulder mobility and deadlifts, not one of them to my knowledge—and I know some of them intimately well—hit the ball further.

But they ended up with sore knees and disc bulges essentially, really heavily compromising their careers. A few of them—and I've worked with quite a number of them—have now backed off that heavy lifting, and they have less pain, far more resilience, and I think they're going to be playing a lot longer for it.

So I know that’s going to create some controversy, but so be it. Well, that’s okay. I mean, I’ve gone on record saying that I’ll do—and genuinely do—heavy hack squats, hack machine squats, leg extensions, those kinds of things, alternatives that for me have just led to, you know, progressively more of what I’m looking for when training legs, um and back, of course, lower back.

And I do the glute ham raises, and I can do all of those without pain. Um, I don't know the last time I ever did a deadlift. I was never particularly strong in the deadlift, but if you’re telling me that avoiding deadlifts as I get older—heavy deadlifts that is—is going to help me avoid back and hip pain, then, you know, I’m all for avoiding heavy deadlifts.

If you want, first of all, I don’t put you in the category of high risk for osteoporosis, which is mineral loss from your bones through genetics and uh way under the tipping point in terms of load stimulation, so I’m not worried about that for you.

So if I was, that would justify a heavier loading regimen for now. But as alternatives, a rear leg elevated split squat—you can do it just with body weight—or consider this: interlace your fingers, put them behind your head, become a peacock, lift your chest up. Now do the split leg rear elevated squat like lunge squats, and you’re potentiating the erector spinae and the whole stabilizing mechanism by pushing up and resisting.

Do you see how I flare? Do I need to flare my elbows back? You can do, yeah. Okay, now do you see how that just stimulated your whole upper body? The more you push, and traps everything light up, right? You just lit up your whole erector spinae.

We did all of that without a heavy bar. You could do a goblet squat; hold it in front. Now the whole body takes a more upright stance. It’s more knee load if you want more knee load and less back and hip load. Or, you know, a back squat— you add more hip and low back load and you take some off the knees.

So you can band the knees; we can really play jazz on this to optimize the best variant to get optimal reward with minimal risk. And that will change as you recover from the back injury; it will change with age; it will change with other co-morbid issues would be another example.

Now you've added a balance challenge. As you get older, your risk will not be mitigated by deadlifts, because the biggest risk as you get older is falling. That will really change your life, as it does in many people. Do you have the agility and neural dexterity that when you stumble, can you get your foot out ahead of the center of mass, which is now ahead of the base of support, so you're going to fall?

You've got to get that quick! So it's hip power: quick, restrain the fall and really mitigate against catastrophe, which is that fall. So do you see how that changed?

But can I just finish off with one thing? I want to talk about deadlifts and capacity as well. And again, it’s a lesson that we learn from elite athletes. When we have an athlete whose goal is to set a world record, be it in deadlifting or squatting or whatever, they can’t train maximum deadlifts and squats two or three times a week.

It is just too exhausting, and the recovery period required between training sessions becomes so long that they actually lose the peak off the training progress. So we do it through auxiliary exercise. When I think of someone like Brian Carroll—you know, again, this is all sort of content validity types of arguments I get it.

But until someone produces a few more winners, I’m going to stick with the way our science has shown to go. If you train and really push—you know, you're talking about training at 85%, well, are you going to set the world record if you only train at 85%? Probably not. But if you go to 100%, you’ve got to take a couple of weeks off.

So instead, you do some auxiliaries like Brian used heavily, the belt squat machine, which you can really train hips, legs, etc. Tremendous power, but it doesn’t take or exhaust the whole upper body and back system, where you're not loading the spine or compressing the spine.

That’s right, because it—you just can’t do it. So if, do you see why, you know, it’s very difficult for me without knowing the person, knowing what the goals are, knowing what their future risks are? Is it a bone mineral density issue or is it their knees are getting a bit cranky now or whatever it is?

I have to choose the most efficient tools. Occasionally it’s a deadlift, but I also told you that right now there are too many young people influenced by social media who are trying to set, “Oh, I'm going to set personal bests in the deadlift,” not really knowing how to densify the neural drive, take out all the slack, so when they grip the bar, the final squeeze of the bar actually gets the bar moving.

They're breaking it from the floor with—they’re so stiff throughout their body, and they don’t know this yet. And they end up with a back injury, and those are long-lasting; they're hard to recover from. You talked about the so-called biblical training week. I love this; it’s something that I plan to adopt for myself.

It's not too far off from what I do now, but it's distinctly different enough that I'm excited, because it's going to require some psychological adaptation, physical adaptation. Tell me, what is the biblical training week and why is it so useful? It is the underlying philosophy of how I train now.

It wouldn’t have appealed to me when I was in my 20s and 30s. In those days, it was all about strength, power, looking good, impressive, etc. But, you know, my joints aren’t what they used to be. My training has evolved with my age. So the name training biblical training week came from the idea that every major religion has a Sabbath day—a day off.

And I, when I was a kid and working with my dad, you didn’t do any work on Sunday. That was his day of allowing all the cumulative work during the week to adapt and settle out. So it's a very wise thing to do.

There are six days to train. In its basic form, two days a week I strength train, two days a week I work on the things that are a bit sticky and not moving very well because I'm getting older and I have a few injuries. So those are the mobility days. Two days a week, I work on my ticker, my cardiovascular system: things to challenge my heart, etc.

There’s more caveats to all of this. I live in a rural setting most of the time. We heat our cabin; I live in most of the days of the week by wood, so I have to split firewood. If I split firewood, I’ve checked all the boxes.

It’s cardiovascular training; it’s mobility training; and it’s strength training, so it’s also a lot of power. So I’ve done my training for that particular day. But I wouldn’t split wood two days in a row; I wouldn’t strength train two days in a row; I wouldn’t mobility train two days in a row.

So that’s another caveat: don’t do the same thing two days in a row and allow this soreness to really develop into something. Another thing that suits me well is routine. I try and go to bed at the same time, get up at the same time, so those are the basic tenets of the biblical training week.

The components of each—you know, I’ve I’ve had some neck trauma, some shoulder trauma, I broke my hip, hip replaced. These are the things that I focus on for strategic mobility. The strength training is a little bit of bodybuilding, a little bit of strength and patternings—patterns of a squat, a lift, a lunge, a push, a pull, etc.

I don’t run because of my hips, but in the summertime, I will swim, kayak, canoe. But I’ll put a bit of beef into it, a bit of effort. I ride my bike. In the winter, I cross-country ski; shoveling snow is a big part of where I live, etc.

So those are the… oh, by the way, I do the big three six days out of seven, and I didn’t really discuss that of why they're essential. We didn’t invent those exercises, but we measured—we were one of the few groups in the world to actually measure spine stability in a quantitative way; doing the big three was the most efficient way to guarantee spine stability but spare the spine while you’re doing it.

Well, some people will say, “Well, why are you sparing your spine?” It allows me to have the capacity—the limited capacity to do other things, so why would I waste them all on core training? The other thing is we live in a linkage.

So the spine is a flexible rod; there’s no coincidence that either end of your core is a ball-and-socket joint—the shoulder and the hips. If I wanted to put you or an object—a heavy door, perhaps, at the University or at a shopping mall—say I could bench press 300 lbs.

Well, I can’t anymore, but say I could; the bench press muscle is the pec major. Let's look at the architecture of the pec major. The pec major crosses the shoulder joint distal to the shoulder joint to where it connects on the upper arm bone, the humerus.

The muscle contracts and creates the desired push, but proximal it connects to my rib cage. Look what it does: it collapses my torso into my shoulder, which is an energy leak; that is anti-push. But if I can use core control and core stiffness and lock down proximately, 100% of that muscle activity now goes distally to the athleticism.

So you may have heard the expression “a stronger core makes you stronger throughout your body.” Well, how does that work? I’ve just explained to you that when you create proximal control and stiffness, it directs the athleticism distally.

If you want to wiggle your finger quickly, you had to stiffen your wrist. If you want to wiggle your arm quickly, you had to stiffen your upper arm, etc. So the mother of all proximal stability is your core.

In exactly the same way, a heavy equipment operator using a backhoe, the first thing they do is they put down the stabilizers, which are posts that go into the ground and lift the tires off the ground to stabilize the tractor. So that now the arm can be the athlete pulling Earth.

Failure to stabilize, you’re just pulling the tractor around. So core stability is essential for ability and performance; it’s arresting all little micro movements. I mean, we’re all shrinking. You will notice this probably over the next decade; the discs height is now shrinking, and there’s going to be a little bit more micro-movement in the discs.

Is there anything that can be done to offset the shrinking? Not that I know of. People will ask with hanging or anti-gravity boots that, oh well, I've measured that. Yes, it will, it will increase disc height for 15 minutes.

And then gravity and the hydrostatic pressures will cause the fluid flow, and the fluid flow—there’s a little bit through laterally through the discs, but most of it comes through the end plates, so from the vertebral body into the nucleus of the disc. And you can draw fluid in under tension, but the hydrostatic pressure overrides the osmotic pressure in gravity, and then the discs lose all the fluid, so it’s a 15-minute effect.

I feel like every tissue in the body has been the target of an attempt to either restore its more youthful state or somehow augment its, I don't know, resilience over time. So these days we hear a lot about FDA-approved treatments using so-called platelet-rich plasma (PRP) injected into the knee, or PRP injected into an ovary, or PRP injected into whatever tissue it is that people are attempting to restore a youthful state to.

Is there any evidence for any compounds or injectable drugs that can restore the tensile strength and thickness to the discs? I haven’t seen any evidence of PRP doing so. Now, I didn’t condemn PRP throughout the body; I swear by it for, uh, stubborn muscle tears.

Interesting. In one example, uh, ball-and-socket articular joints—there’s no question, not all the time, but it can make a measurable difference, but not injected into the discs.

So I just need to give a little bit of context to this now. If we take someone’s disc who’s never been traumatized, so they’re a young person, uh, they can expose their spine to mobility, be it yoga or ballet or whatever, and they will probably increase the range of motion and mobility.

They can strength train and toughen the collagen in the endplate and build some bone, and in other words, they can do both, Andrew: they can increase the constituent strength of the various parts, and they can create mobility.

But once you have an injury to the disc and you lose a little bit of disc height, the world changes. It’s not so easy to adapt those full range of athletic abilities anymore. So now you’re forced to make a compromise.

Most people we can get them to do one or the other. They can maintain mobility to play golf after a disc injury or they want to pop up on a surfboard—that's their thing in life; they just want to be able to surf. I’ll say, “Good; we can manage. It’s no longer adapting; we can manage you to achieve that.”

But you're going to have to back off the deadlifts and some of the strength exposures because they will just further compromise the disc height of a damaged disc, and we can do the opposite. If you want to strength train and bear a load, you’re going to have to give up the mobility.

So that game, that dance with the devil, comes after the back injury. So I think the question was a little bit about adaptation. If you haven’t experienced disc damage yet, you have a lot more leeway to adapt your spine; after that, it becomes a game of management and encouraging an athletic ability.

You become a little bit more unidimensional, and if you want a little bit of everything, okay, but you have to be very modest. You just have to try and achieve sufficient mobility, sufficient strength to do whatever, to just to get through life. It’s a bit of a dance, so I don’t know if that gives a bit of a context? That’s perfect.

Yeah, uh, could you walk us through your biblical week training with some examples of what one could select from the buffet of training options? Right, um, okay. I can.

So let’s say today I’m going into our clinic gym and I will start with doing the big three. So I will do bird dogs, and I'm going to work on good form.

Then I’m going to put some dynamism into it. I don’t lift the leg so much; I push the heel away, and it really causes you to lock the core to create the proximal stability. Pushing the heel away really engages the glutes and hamstrings.

Then I draw small squares; I square out with the hand and foot down towards the midline and up. So now I'm creating a little bit of a disassociation through the ball and socket joints, which is what I want with the core control.

So that is translatable; we did an experiment with the Pensacola Fire Department, by the way, where those firefighters who were trained with a coach who explained why they were insisting on certain exercise forms. We measured them doing fire ground tasks before the training sessions—in other words, we measured them putting up a fire ladder, advancing a loaded fire hose, which is a tremendous reactive push, as you know; piking open an elevator door, chopping a hole in a burning roof.

Then half the group trained with this attention to exercise form and we explained the principles to them. The other half of the firefighters had trainers who were more like cheerleaders trying to get them to do more reps and encouraging them.

Both groups got fit, and then we measured them all again out on the fire ground. Remember, now we never trained them how to do the fire ground tasks. They went back to the fire ground; those who trained with the cheerleader types of, “Oh, just do more reps,” had more known injury markers.

Do you know valgus collapse of the knee is a very strong predictor of future risk of ACL injury, being one of them? So there would be an example of that.

A sagittal plane spine motion under load...every study that surveils groups who have to bend down through their spine and pick up more load has a much higher incidence. Bill Marris’s study showed 10 times the risk factor to having a disc injury if you do that.

So, I will then do side planks, rolling side planks. I will do a variety of abdominal exercises: the modified abdominal curl that you’re familiar with, and I’ll do some glute bridges.

Then I’ll do them one-legged, and I’ll get the arm involved and crossbody. I may put a kettlebell on my belly and do some hip thrusts, uh, that way, but a very mindful way. I’m focused on my brain, squeezing the glutes, pushing the feet away, etc.

Then I will probably stand up and do the strength patterns, so I’ll go over and do pushes. Now consider a push-up, which rather than me load heavy with a bench press or something like that, I’ll do push-ups. You know the clapping push-up?

Where you dynamically explode up, clap, and go down? I’ll do a variety of those, very dynamic power-generating pushes. Then I’ll do some pulls. I probably won’t do a row with a barbell, but I’ll do an inverted row, pulling on a TRX, pronated grip, pulling into a grip, power breathing and exploding, really trying to get some power into it.

Then I will go to, um, probably a split lunge—rear elevated foot, uh, squat lunge squat with the techniques that I showed you. Hands interlaced behind my head, peacocking high, pushing back, pulling forward, and now doing the lunge squat.

So that’s challenging my balance, the whole extensor chain, strength, etc. I might do some bilateral squats with my hips—I’ve broken my ankle; I do heel elevated squats usually with a banded knee.

Sometimes I just use my brain and try and spread the floor. Then I get into the auxiliaries. So I broke C4. Um, I have to, uh, yeah, not a good thing—playing football—hockey. Hockey, head down into the boards, classic.

Um, I can't really do shearing exercises where I push against resistance that will get my neck a bit cranky, so I take out the shear. I get tall; I push my tongue hard to the roof of my mouth and I grimace.

So now I’ve activated all the flexors, and I put my hands underneath, and I just push up isometrically, and I control. So there’s no shear anymore, but I’ve really started to build the flexor family.

Keep your neck strong; it’s important for me, yep. Now, put your chin poking, retract, now push up. You got it; that’s it! Push your tongue, yeah, don’t go crazy.

And add a little bit of endurance to that. I appreciate the neck work that you do, though, which I have a four-way neck machine, but I don’t require one. I’ve actually found that taking a platelying on and wrapping in a towel, lying on one side, making sure to hook my foot under the wrench and stabilize with my other hand on the ground, and then just gently doing repetitions.

Jeff Cavalier from ATHLEANX has a great set of videos on this where he really spells out the dangers of things like neck bridges. They can be done, but there’s a risk there that probably outweighs the potential benefits for most people.

Right, but every once in a while, I can’t help myself, and I do some bridges, yeah, because I really enjoy them. If you're at the University of Iowa, you're doing bridges for a good while, you're probably okay doing neck bridges.

Yeah, I get teased for saying this too often, but the value of having a strong neck is just, um, hard to overstate. You don't have to have a big neck, but a strong neck—for the sake of stabilizing the whole shoulder girdle—excuse me, during um pressing and pulling lifts, for posture, um, for, you know, feeling like your head is stably placed on your body.

Think of every pulling motion; where does it start? The trapezius originates off the neck. Stack that flagpole and really get those muscles ready to pull. It requires a stiff, strong neck, absolutely.

So every strong puller...yeah, my bulldog was alive; he had the larger neck in the house. But it's again, it's not about building size into the neck; it’s really that strength and stability, right? That I just think translates to so many things that are valuable.

Anyway, I'll finish out my strength routine with some more auxiliaries. People laugh at this; I call it sword play. The amount of athletic gain that we’ve achieved with swordplay, I take an iron bar like a, uh, you know, the old, uh, iron dumbbell weights. It’ll be an iron bar about that long, and I’ll put maybe a two-pound weight on the end and then I grab it and I do figure eights—over here, over here, over here, around there.

You wouldn’t believe I have professional hockey players in the NHL who say, “Wow, those figure eight sword plays my wrist shot, my slap shot have two, tennis players—I’ve never had such power and finesse off the racket,” because of that swordplay exercise.

Yeah, this is interesting. I love older exercise books, and recently I came across one called Heavy Hands. This must be from the 70s, and the entire book was centered around people being encouraged to carry some dumbbells during exercise—not all the time—and doing some lunges or walking uphill and getting the weights out from their body.

And um, I was kind of chuckling about it on the one hand, pun intended. But at the same time, you know, we know based on a number of really good studies using neuroimaging and functional scoring of neural system function as one ages, that the innervation of some of the distal muscles and the fine control of the fingers, you know, fingers and toes and foot, uh, toe spreading and things like that, um, even calf size and atrophy, um, are fairly reliable markers of the extent to which there’s been degeneration of the upper motor neuron pathways, um, other brain areas or not.

So the idea of keeping the nervous system and neuromuscular connectivity youthful by quote-unquote heavy hands, or maybe ankle weights, provided they're not going to induce injury, makes a lot of sense.

Weighing the most distal portion of our body in order to generate adaptations, I think is going to be something that returns to the kind of modern sphere of fitness and longevity.

May I give you a couple of comments? Please, that was fabulous! It’s so much fun when I see someone getting out of their car and walking up to the clinic door, and I can see the muscle wasting on their calf, and they'll say, “Oh, I have to get out my EMG nerve conduction velocity scores here.” I said, “Are you kidding me? You telling me the doc needed to do an EMG conduction velocity and all they had to do was look at your leg?”

We know exactly the nerve roots that are deficit because I know exactly what serves those muscles that have wasted. I mean, it's crazy how technology has made so many people oblivious to the signs that we all show.

That was my first comment, but the second one was, going back to the old time books, I collect a lot of those actually. I have quite a library of old time strength books from some from the 1800s—the old Inch book of strength, and oh, they're fabulous.

Indian clubs, are you familiar with Indian clubs? So it's a wooden club that looks like a bowling pin basically. But some of the old-style Indian clubs were this long. Well, there's a great manual strength athlete that not too many people have heard of, John Brookfield. He lives in North Carolina, Pinehurst, North Carolina.

In Pinehurst, there’s a sculpture—a very heavy steel—that John bent with his bare hands to make this sculpture, and yeah, he’ll take heavy rebar and bend it and, you know, put on strength shows with his hands. He’s fabulous, too, by the way.

He’s got a set of Indian clubs—I can hardly pick one up, but he just picks up this Indian club, and it was from some famous guy from the 1800s, and somehow he got the Indian clubs, and they’re about this long. But he can just get them and play swordplay with very heavy Indian clubs.

There’s actually, uh, a good friend of mine. He’s an Australian fellow, Andrew Lock—I don’t know if you’ve ever heard of Andrew Lock. Andrew has collected kettlebells and Indian clubs from the old-timers; he’s got quite a lovely collection in Melbourne, where he’s from in Australia.

But they’re wonderful exercises and none of these things require fancy equipment. One could imagine just grabbing a hold of some...either well, an iron bar. An iron bar, yeah.

I really think there's something to this loading of the distal limbs, um, cautiously, right? Properly, but there’s something there in terms of keeping the neural pathways healthy and alive, because we know they atrophy with age, and that explains in part the calf muscle atrophy, which, as you point out, is a well-known clinical marker for neurodegeneration.

Yeah, um, well, simply things—and you can certainly comment about this—I try and do things with my opposite hand. So today I’m just going to brush my teeth, comb my hair with my opposite hand. Now don't ask me to throw a ball, because I'm a...but you know, if I'm splitting firewood, okay, it's 10 reps this way, 10 reps that way, and that’s all in an attempt to keep my brain as movement competent and dextrous as possible.

Well, certainly when I resistance train, if I'm doing anything standing, I make it a point to stagger my stance, yes. Um, and at the same time, to make sure that my belly button is pointing forward so that I generate some anti-rotation effort, so that most of my abdominal work can be placed within the workout.

For other things, I do some pikes and some direct abdominal work as well in the roll-up and things of that sort that you've recommended. But I find that from a coordination standpoint, and especially from a balancing of the musculature and the strength on both sides of the body, this is extremely important.

And I know this because after years of skateboarding, where you push with one leg—that was when I was younger—boxing, I'm traditional stance as opposed to southpaw, you know, you start getting into all these imbalances, and it goes way beyond anything aesthetic.

I mean, the aesthetic stuff might concern certain people, but it was more the feeling that I could turn to my right very easily without pain, turning my left I felt stiff, and it was just an imbalance in um some of the muscles controlling, uh, anti-rotation.

So I think that weaving asymmetric stance, weaving um the requirement for symmetric balancing of the musculature on both sides of the midline just makes, you know, all the sense in the world to me, uh, especially if one is going to be a regular exerciser, which hopefully people are.

Well, if I can convince you to consider the biblical training week, all of that fits into your mobility days. Yeah, let's talk about those, because you talked about the strength days. What about the two days of mobility?

Well, given my history, I do thoracic spine extension. I do a little bit of neck work; hip mobility, but again I have a certain capacity there that I can’t, uh, overdrive.

And then, uh, once I’ve done the targeted ones, I just go through the motion of every joint and don’t add load. And then I will do the footwork. So with my background, I’ll do a little bit of shadow boxing. I’ll play, uh, traditional southpaw, um, etc.

If you could just repeat the cardiovascular days since it depends on the time of year. I really like to be outside. So if it's wintertime and I, for some reason, couldn’t go for a cross-country ski that day or whatnot, I will ride a stationary bike in the clinic.

I'd prefer not to, but I will. If it's summertime, I'm riding outside, and uh, I could kayak, swim, canoe—just go to the hills and walk with Tico, my dog, hard, and that might be my cardiovascular that day.

And going back to the genetics, which is how we started this podcast. Have you ever had your athletic panel done from a genetic base? In other words, they look at your genes and determine what you're genetically good at and what you're genetically horrible at.

Do you know that? I mean, I know a few things that I'm horrible at, but you haven’t had it tested genetically? No? Okay, I have, and they gave me a panel of 10 athleticism. Now, interestingly enough, if I didn't have my athletic panel and you just asked me to check am I good at this or am I bad at it and check somewhere in between, I would have got every single one 100% right.

Interesting, yeah. So I know my abilities and it aligns 100%. In other words, I’m ultra, which is the highest for grip strength—I’ve always known that. You know they’re a pair of hands, but if I got my hands on you in football, you weren’t getting, you know what I mean?

I’ve always had a very good grip strength. So genetically that came through was ultra. And the other thing I was ultra at was I can be quick for the first 35 milliseconds. Boom! If you want something done like that, I can usually pop it.

You know, when I was playing hockey, typically it’s a 45502 anaerobic blast and you sit down for 3 minutes. There are two more shifts and then the coach taps you on the helmet, and I’m still breathing heavily, and my two linemates—they’re ready to go again. I was terrible at recovering from an anaerobic blast.

Guess what? I’m the worst possible genetic category for recovery of heart rate, and I’ve worked with some of the best heart rate recovery people, and I'm hopeless at it. I have a feeling I'm naturally inclined to do endurance work, because once I start running distance, I can just run and run.

Then eventually it just feels like the stopping comes from, you know, I don't know, some nagging little injury or something like that, or pain, as opposed to anything stopping me from continuing to run, which is unfortunate, because I tend to like the shorter workout type stuff.

Right, it brings us back to what we were talking about earlier: try and do a balance of those, um, and everything in between. I love the biblical training week and given that currently I've been doing three days of resistance training total per week and three days of cardiovascular training—all it requires is shifting one each of those days toward mobility training, still taking the full day off each week.

Make sure you take that day off; you will be less painful with your joints. I predict when you’re going into your 60s and 70s and knock on wood, having a blast when you’re 80—that’s the plan.

And I’ve certainly had a blast today, Dr. McGill! This has been amazing. I mean, you’ve given us such a wealth of knowledge about the back, its anatomy, neurology, the sources of pain for those that have back pain, avenues to relieve back pain, avenues for people to stave off back pain, including the big three but not limited to the big three.

You also gave us a wonderful window into the precision with which you approach assessment. During the introduction and also in the show note captions, I mention and link to the many clinicians that you’ve trained all over the world so that if people want to try and access direct coaching and rehabilitation, they can do that.

I also really appreciate the books you’ve written, and we linked to that as well, um, Back Mechanic: the step-by-step Mill method to fix back pain. Please see the show note caption; also in the caption, you'll find a link to backfitpro.com, which is Dr. Mill's website, where he has links to specific practitioners you can work with if you're experiencing back pain.

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Thank you once again for joining me for today’s discussion with Dr. Stuart McGill. And last but certainly not least, thank you for your interest in science. [Music]