Question for Dr. Feigenbaum re: McGill method

[Luca B.]

Hello Doc(s)!

I have been dealing with some minor sciatic pain on and off over the course of the past two years or so, and have been doing a fair amount of research on how to manage it. More recently, I have read McGill's Back Mechanic, and listened to several podcasts of McGill being interviewed on the subject. I have also been practicing the Big 3 protocol, and have benefited noticeably from it (placebo?).

On the other hand, your content has also been a great help in developing my attitude toward pain management, and I trust you guys to provide evidence-based information, so I was intrigued by Dr. Feigenbaum's negative assessment of the McGill method:

https://forum.barbellmedicine.com/forums/training-q-a-with-dr-jordan-feigenbaum-and-dr-austin-baraki/16198-is-weight-training-in-the-morning-safe

Would you be able to expand a little on why you see his approach as "ultimately harmful'? I'm genuinely curious.

Thank you in advance!!

[JHG]

From my understanding of Stu McGill’s protocol, he does not believe in the diagnosis of non-specific low back pain and contends that every case of back pain has a specific cause and that he can locate the cause whether it be muscular, discogenic, facetogenic or ligamentous in nature based on his interview and physical exam. He then determines that the spine is unstable through one of these aforementioned causes and thus requires stability through performing the “Big 3” exercises, which he established place low compressive and shear forces on the spine. So, essentially the same treatment protocol for whatever the exacting cause of back pain is. People will often feel better because exercise (of any nature) does have an analgesic effect, but the narrative offered by McGill is not accurate.

I think McGill’s work on spine biomechanics is excellent and that he is a very accomplished researcher, but he is not a clinician and this is obvious in his approach, as our understanding is that 90% of low back pain is non-specific (see attachment), and most exercises help diminish back pain, which will also resolve on its own. So, there is no single exercise protocol that is superior to another for the management of back pain.

The recommendation you will hear on here is to continue to train, and this is based on the aforementioned understanding of the natural history of non-specific back pain. The difference in the approach is that resistance exercise confers favourable musculoskeletal and metabolic adaptations that the “Big 3” don’t, while still providing analgesic effects and the reassurance that nothing is unstable, so continued physical activity and exercise is not harmful and will not worsen one’s condition.

I don’t mean to speak on behalf of the BBM crew, but I feel like we are all on the same page here, and that you would likely receive a similar response.

[Luca B.]

Hi JHG! Thank you so much for the in-depth explanation - this is exactly what I was looking for.

I'd like to put some thought into my response in view of what I know of the McGill method, having read his material. Unfortunately I'm too busy with work right now but will come back to the thread once I'm a bit more free, provided it doesn't get locked.

Thanks again.

[Michael Ray]

From my understanding of Stu McGill’s protocol, he does not believe in the diagnosis of non-specific low back pain and contends that every case of back pain has a specific cause and that he can locate the cause whether it be muscular, discogenic, facetogenic or ligamentous in nature based on his interview and physical exam. He then determines that the spine is unstable through one of these aforementioned causes and thus requires stability through performing the “Big 3” exercises, which he established place low compressive and shear forces on the spine. So, essentially the same treatment protocol for whatever the exacting cause of back pain is. People will often feel better because exercise (of any nature) does have an analgesic effect, but the narrative offered by McGill is not accurate.

I think McGill’s work on spine biomechanics is excellent and that he is a very accomplished researcher, but he is not a clinician and this is obvious in his approach, as our understanding is that 90% of low back pain is non-specific (see attachment), and most exercises help diminish back pain, which will also resolve on its own. So, there is no single exercise protocol that is superior to another for the management of back pain.

The recommendation you will hear on here is to continue to train, and this is based on the aforementioned understanding of the natural history of non-specific back pain. The difference in the approach is that resistance exercise confers favourable musculoskeletal and metabolic adaptations that the “Big 3” don’t, while still providing analgesic effects and the reassurance that nothing is unstable, so continued physical activity and exercise is not harmful and will not worsen one’s condition.

I don’t mean to speak on behalf of the BBM crew, but I feel like we are all on the same page here, and that you would likely receive a similar response.

I couldn't have said it better myself. McGill's narratives are typically not well supported in the research evidence and he appears rooted in the biomedical model.

[jade sperring]

Hey Michael, Luca B, its fantastic to see discussion and around the mcgill method happening. Ive been waiting for that top happen. Guys , there is a physio in Australia who has released this today, what are your thoughts . SIX REASONS WHY KEEPING A STRAIGHT BACK TO LIFT IS WRONG!

In 2009 I presented a poster at the Chartered Society of Physiotherapy Congress (UK) titled ‘Lifting: Are We teaching Our Patients The Wrong Thing?’.
In this recent article in The Telegraph in the UK (Nov 22 2018) it seems at last the wheel is turning, with various research teams (Curtin University in Western Australia and Aberdeen University) coming to the similar conclusions.
For several sound biomechanics reasons it is true that lifting with a straight back is not the way to go.
In fact, I believe the health and safety guidelines promulgated the world over are actually turning good backs into bad backs - and making bad backs worse!
As concluded by one group in the attached article (see below) lifting with back-straight-knees bent ‘is based on scant reliable evidence and may be inferior to the bent-back approach’.

SIX REASONS NOT TO LIFT WITH A STRAIGHT (ARCHED) BACK:

1. Un-loads the lumbar intervertebral discs and de-pressurises them
2. Directs weight the facet joints which are bony articulations not designed to be load-bearing
3. Puts the immensely strong ’mechanical strap’ ligamentous system on the slack
4. Puts both the deep spinal muscles and the long spinal muscles into inner range ’shortened’ position to act
5. It’d hard to pull your tummy in and generate stability of the core with an arched back
6. It’s clumsy and awkward to pick anything up with a straight back and knees bent

A STRAIGHT OR ARCHED BACK UNLOADS THE INTERVERTEBRAL DISC AND DEPRESSURISES IT
The intervertebral disc is the fluid filled fibro-elastic pillow situated between each load-bearing bony segments down the front of the spine. The disc is an ingenious mechanism, designed to give mobility under low load and stability at high load. You want stability under high load (lifting) because you do not want the spinal segments slipping askew and the spine coming undone. Indeed, you want none of the spinal segments moving even to the tiniest infinitesimal degree since this wrenches the spine when it least needs it and causes osteo-ligamentous damage – otherwise known as injury! To lift safely, you want each each intervertebral disc acting like a supremely efficient, fluid-primed hydraulic sac thrusting the spinal segments apart. The makes the spine whippy and strongly secure. You can only get this if you roll your upper-body weight forward over the lumbar spine by pulling your tummy in and bending the lower back. Conversely, arching your lower back takes the pressure off the discs and makes the lumbar segments more wobbly. Just what you don't want.

A STRAIGHT BACK PUTS LOAD THROUGH THE FACET JOINTS
The facet joints are situated at the back of the spine, flanking the spinal canal which houses the spinal-cord. Facet joints are formed where the bones of contiguous vertebrae slot together, bone against bone. In an ideal world, facets only take a small amount of glancing load because their main role is controlling excessive movement of the stacked vertebrae. Arching the back dramatically increases the pressures through these delicate joints. Lifting heavy weights while the lower back is arched massively compresses the cartilage buffer protecting the bone of the opposing facet surfaces. This is particularly significant if there is thinning of the disc at the problem level, so that the widely espoused norm of 'correct' lifting techniques - far from doing good - can mechanically inflame an already bad back.

A STRAIGHT BACK PUTS THE POSTERIOR LIGAMENTOUS LOCK OF THE SPINE ON THE SLACK
The entire back of the spine is clothed in a complex festoonery of immensely strong ligaments that hold the bony segments of the column together. The important thing about all ligaments is that they derive their tensile strength through being on the stretch. Quite simply, the more stretched they are the more powerfully taut they hold the spine. If you are lifting something heavy you want all your ligaments acting like steel cables between the bones, holding everything secure so that the trunk and spine muscles can bring about the lifting movement. Arching the back literally weakens the back by taking the tension out of the ligaments. It makes the spinal muscles have to work doubly hard to get the weight airborne.

A STRAIGHT BACK PUTS BOTH SETS OF SPINAL MUSCLES AT A MECHANICAL DISADVANTAGE
Similarly, all muscles work at an advantage when they operate in a slightly stretched position (this is why you get a stronger grip with your fingers when you cock your wrist back). Putting the back into an arched position to lift makes it profoundly difficult for the back to generate strength. This is even more unkind for the back sufferer who has chronic protective tone of the lower back (we call this muscle spasm) which is very common when a back is bad (the back feels stiff). At a time when back comfort is only brought about by relaxing this unwanted clench, the back muscles have to generate a frenzy of contractile activity in order to lift even the slightest weight. Patients persevere, because this is the advice they are given, but trying to lift with an arch back simply makes backs more tense and more painful.

IT’S HARD TO GENERATE CORE STRENGTH WHEN THE BACK IS ARCHED
A critically important feature of lifting is using your abdominal muscles to pressurise your abdominal space (this is why professional weightlifters reinforce there abdominal pressure by cinching in their kidney belt). Pulling the tummy in naturally rounds the lower back and creates a pressurised airbag at the front of the spine which helps keep the segments secure. If you are trying to follow instructions to keep your back arched you make it very difficult to round your lower back and generate any supportive pressure at the front of your spine which makes it easier to lift. Having a bad back tends to make the deep abdominal muscles switch off, making it doubly difficult to recruit both abdominal and pelvic floor muscles in any effective way.

IT’S CLUMSY AND LABOURSOME TO LIFT WITH THE BACK STRAIGHT
It is the most natural thing in the world to bend over normally to pick something up (think of a new mother bending over the crib to pick up her baby). Conversely, trying to get down with your back straight and knees bent means that your knees will always get in the way. It feels supremely awkward and often actually hurts the back. The advice of the Health and Safety Executive in the UK to bend the knees so that the ‘thighs are parallel to the floor’ is ludicrous in its impossibility. Of course, if you are to try to lift an extremely heavy weight, such as a car or a boat, then you do jack your back straight and lift by straightening the knees. But for everyday weights bending normally is the way to go as. As you will read in this page of my website, it also gives the discs a drink! See https://www.simplebackpain.com/bendi...strengtheni…

https://www.simplebackpain.com/better-deadlifts-to-avoid-back-pain.html?fbclid=IwAR0Oe-1YKPHQSsLRu4UjD1-9Pd2-Hb54I3TrK1WOFBo741dy4DJUptfF-Cc

The Telegraph article: https://www.telegraph.co.uk/…/straig...nees-ad…/…

[Michael Ray]

jade sperring, meh. Lots of negative language ("bad back") in that piece and overall just conjecture that likely isn't helpful.

[Luca B.]

Apologies for coming back to this thread late. Thank you for your response as well, Michael.

Having gone over the chapters on exercise prescription in the Back Mechanic again, I have to agree that the protocol seems rather cookie-cutter, although McGill does recommend additions and/or modifications for specific conditions such as sciatica, kyphosis, scoliosis, stenosis and so forth.

Still, I would be curious to hear what the consensus is on these boards on the views expressed by McGill on the importance of spine hygiene (maintaining movement patterns and postures throughout the day that place the spine in a position that minimizes herniating forces), and, therefore, of endurance in the musculature supporting the spine (as opposed to strength).

I appreciate that most back pain is non-specific, but aren't certain movement patterns (notably loaded lumbar flexion) likely to result in injury and pain, regardless of whether the exact cause of pain can be determined through subsequent examination or imaging?

So by the same principle that squatting heavy loads in lumbar flexion is likely to result in injury and pain, wouldn't it make sense to avoid lumbar rounding in a myriad of mundane tasks (picking up objects from the floor, sitting, etc.), and to train core endurance to that end?

Not trying to argue - just trying to understand things better and clear my doubts as a lay person.

[JHG]

Hi Luca,

We still don’t fully know the answer to your question regarding loaded spinal flexion. Greg Lehman did a nice write up on this topic http://www.greglehman.ca/blog/2016/0...pare-for-doubt *Greg did his Master’s studies under McGill before going to chiro school.

Injury and pain are different. You can have injury without pain https://www.ncbi.nlm.nih.gov/pubmed/20227309, and pain without injury https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3281476/.

You’re asking good questions. Unfortunately we (everyone, including McGill) do not have all the answers. Evidence-based recommendations are made based on the probability that person X has condition Y, given their history and report, and we predict outcome Z based on the outcomes of research evidence of trials studying this problem.

Pain is complicated. I would recommend you read Michael’s article https://thelogicofrehab.com/2017/09/...ding-the-path/

[Luca B.]

Hi JHG,

That Lehman article is exactly I was looking for!

Thank you again for taking the time - just all the more reason to recommend BBM to everyone I know

[Michael Ray]

Apologies for coming back to this thread late. Thank you for your response as well, Michael.

Having gone over the chapters on exercise prescription in the Back Mechanic again, I have to agree that the protocol seems rather cookie-cutter, although McGill does recommend additions and/or modifications for specific conditions such as sciatica, kyphosis, scoliosis, stenosis and so forth.

Still, I would be curious to hear what the consensus is on these boards on the views expressed by McGill on the importance of spine hygiene (maintaining movement patterns and postures throughout the day that place the spine in a position that minimizes herniating forces), and, therefore, of endurance in the musculature supporting the spine (as opposed to strength).

I appreciate that most back pain is non-specific, but aren't certain movement patterns (notably loaded lumbar flexion) likely to result in injury and pain, regardless of whether the exact cause of pain can be determined through subsequent examination or imaging?

So by the same principle that squatting heavy loads in lumbar flexion is likely to result in injury and pain, wouldn't it make sense to avoid lumbar rounding in a myriad of mundane tasks (picking up objects from the floor, sitting, etc.), and to train core endurance to that end?

Not trying to argue - just trying to understand things better and clear my doubts as a lay person.

Luca B. myself, and more importantly the research evidence, is against the biomedical narratives McGill provides. Spinal hygiene / health / any other BS marketing term, is setting false expectations and isn't supported by research evidence. Posture, like movement, is variable and poorly linked to pain and "injury".

"I appreciate that most back pain is non-specific, but aren't certain movement patterns (notably loaded lumbar flexion) likely to result in injury and pain, regardless of whether the exact cause of pain can be determined through subsequent examination or imaging?" - No. I highly recommend listening to our latest podcast: https://www.youtube.com/watch?v=V43mSQEjZY8&t=2460s.

"So by the same principle that squatting heavy loads in lumbar flexion is likely to result in injury and pain, wouldn't it make sense to avoid lumbar rounding in a myriad of mundane tasks (picking up objects from the floor, sitting, etc.), and to train core endurance to that end?" - No and this mindset typically instills kinesiophobia (fear of movement) unnecessarily.

To echo JHG , we don't have evidence to make such fear-mongering statements to people regarding posture and movement. Instead, we do have evidence on the variability of posture and its poor link to symptoms:

The fall of the postural-structural-biomechanical model in manual and physical therapies: exemplified by lower back pain.

Analysis of cervical spine alignment in currently asymptomatic individuals: prevalence of kyphotic posture and its relationship with other spinopelvic parameters.

Text neck and neck pain in 18-21-year-old young adults.

How do we stand? Variations during repeated standing phases of asymptomatic subjects and low back pain patients.

Spinal curves and health: a systematic critical review of the epidemiological literature dealing with associations between sagittal spinal curves and health.

Comparing lumbo-pelvic kinematics in people with and without back pain: a systematic reviewand meta-analysis.

Does the sagittal alignment of the cervical spine have an impact on disk degeneration? Minimum10-year follow-up of asymptomatic volunteers.

The burden and determinants of neck pain in workers: results of the Bone and Joint Decade2000-2010 Task Force on Neck Pain and Its Associated Disorders.

Neck Posture Clusters and Their Association With Biopsychosocial Factors and Neck Pain in Australian Adolescents.

Is thoracic spine posture associated with shoulder pain, range of motion and function? A systematic review.

Is there a relationship between subacromial impingement syndrome and scapular orientation? A systematic review.


At some point, we will likely write a blog on the topic of posture for further clarification. Happy to discuss.

[Luca B.]

Michael Ray I've come back to this thread for the Lehman article and have only now seen your reply. I'll listen to the podcast, go through the articles and (probably) come back to discuss more. In the meantime, thanks for posting the wealth of resources above - it's much appreciated.

[Luca B.]

Michael Ray Hello again - I have listened to the podcast and had a look at the studies you posted. The data on the link between posture and pain is eye-opening, and it has given me food for thought with regard to the concept of spine hygiene in day-to-day activities. I'll be sure to dig more into the subject in the months to come.

On the other hand, I am going to have to side with Greg Lehman and stick with neutral in heavily loaded activities (see the part of the conclusion titled "Heavy Load Activities" here: http://www.greglehman.ca/blog/2016/0...pare-for-doubt). I have no trouble believing that a strong lifter's back will be fine after a rounded-back max attempt at a meet; I doubt the same would be the case if he or she were, for the sake of argument, to consistently take up the kind of scared-cat deadlifting seen that's ridiculed on YouTube (that is, moving the lumbar from major flexion to extension while moving the load) in all of his/her training sessions (with as heavy a weight as he/she can manage with such poor technique). But I fear I am already out of my depth here, as I have no background in either biomechanics or pain science.

Re: the McGill method, however, one thing that does not require *any* sort of background to notice is its endorsement by elite lifters. I know of several elite-level powerlifters who have either returned or are in the process of returning to competition after debilitating back injury, and credit McGill for it:

Brian Carroll:

https://www.youtube.com/watch?v=AJzvhipugYg

Stan Efferding and Blaine Summer:

https://www.youtube.com/watch?v=zF2EO9UGOS4

Layne Norton:

https://www.youtube.com/watch?v=r-e-3F6t110

(session with McGill)

https://www.youtube.com/watch?v=2SIHjDEhGvQ

(Recent squat session)

Jonnie Candito

https://www.youtube.com/watch?v=2c-fD-9enIw

(about how he dealt with injury)

https://www.youtube.com/watch?v=kQF_IS5hVLE

(comeback meet)

Pete Rubish also credits a core routine including the Big 3 here...

https://www.youtube.com/watch?v=UP1c_ap4GDM

and here:

https://www.youtube.com/watch?v=hQfYl4uB5MI

Finally, Chris Duffin also rates the McGill method and has had McGill on his podcast several times.

I'm sure there are more whom I don't know about.

If these people have benefited from the method, wouldn't it be fair to think that perhaps there *is* something to it? These guys are obviously not the sort to think that their bodies might break if they move them around, and I am not sure that you could take a top level athlete from severe pain and loss of performance back to elite competition on the strength of placebo alone.

[Austin Baraki]

We are not debating whether people have benefited from his guidance.

However, the keys are:
1) anecdote and uncontrolled observations are not reliable sources of data (see: When Logic Fails: Part 1 - Barbell Medicinehttps://www.barbellmedicine.com/when-logic-fails-1/ )
2) the observed outcome does not prove the proposed mechanism.

Do you know how many people swear by homeopathy? Do these people legitimately feel better? Yes. Does that prove their mechanistic understanding of homeopathy correct? Of course not.

At the current time, we do not see sufficient evidence to support McGill's mechanistic explanation for pain / back pain / injury, and the mechanisms by which his approach provides benefit (in other words, we think that when his approach "works", it is probably not for the reasons he suggests). Conversely, we see many ways by which his proposed mechanisms and narratives can cause harm.

[Luca B.]

Hi Austin Baraki , thanks for your reply.

I understand - I must be underestimating the magnitude of placebo and social narratives here. I simply find it hard to believe that there is no point at which the mechanistic explanation applies (apologies if I am misconstruing your stance here). Time to go do more reading

[Austin Baraki]

Yes, you are misconstruing our stance. I did not say that these observed responses are all placebo effects.

I think more reading would be wise.

[Luca B.]

You gave the example of homeopathy, so I thought you were implying placebo. If not placebo, is this what you mean?

https://www.bettermovement.org/blog/2015/review-of-greg-lehman-workshop-reconciling-biomechanics-with-pain-science

"For example, Greg doesn't believe that McGill's "big three" exercises reduce pain by making the core more stable. But he continues to prescribe them, because he believes they are a great "psychosocial" intervention. If you accept a heavy load through your back in a functional way, and it doesn't hurt, this may reduce perception of threat in the back. Further, if these exercises involve enough stress, they may stimulate local adaptations that could help reduce peripheral sensitivity to nociception."

Please help me understand.

[Austin Baraki]

I specifically addressed these ideas in the posts.

2) the observed outcome does not prove the proposed mechanism.

...

At the current time, we do not see sufficient evidence to support McGill's mechanistic explanation for pain / back pain / injury, and the mechanisms by which his approach provides benefit (in other words, we think that when his approach "works", it is probably not for the reasons he suggests).