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:
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.
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.
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.
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.
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 Revisiting the spinal flexion debate: prepare for doubt — Greg Lehman *Greg did his Master’s studies under McGill before going to chiro school.
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 Loading...
@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:
@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.
@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: Revisiting the spinal flexion debate: prepare for doubt — Greg Lehman). 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:
Stan Efferding and Blaine Summer:
Layne Norton:
(session with McGill)
(Recent squat session)
Jonnie Candito
(about how he dealt with injury)
(comeback meet)
Pete Rubish also credits a core routine including the Big 3 here…
and here:
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.
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.
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
You gave the example of homeopathy, so I thought you were implying placebo. If not placebo, is this what you mean?
“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.”
Luca,
Can you clarify specifically are you having trouble understanding? Citing the utilization of elite athletes is a slippery slope (Tom Brady anyone?). Professional athletes are by and large some of the worst references as to the efficacy of a treatment/product. I have had the pleasure of working with a fair number of professional athletes at the point (not because I’m special, but because I have been employed at two “prestigious” universities) and the vast majority of initial consult is just working through all of the beliefs they have been told through the years. I actually specifically follow two professional athletes as a means of staying up to date on what the treatment du jure is to know not what to do.
As to the McGill/placebo discussion I think part of the misunderstanding is related to what defines a “placebo.” The word itself is a paradox as something cannot be “inert” and “work” at the same time. This is why there has been a movement towards “contextual factors” which is much better phrasing. Now, if we take your prior quote:
“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 (contextual factors) alone.”
I’m more okay with the end of that sentence with that substitution but I want to go a little deeper. If these individuals think they “need” these exercises as part of their routine, what do you think may be their beliefs if we took away those three exercises? What do you think that they think may happen? I highly doubt the answer is “nothing.” This gets at the utility of the exercises, of which there is nothing special about the McGill 3 aside from it being named after someone. Any movement is going to cause some level of local, physiological change but a belief that a specific one is needed and others should be avoided is completely unwarranted.
McGill’s opinion that there is no such thing as nonspecific low back pain is completely antithetical to the current state of the literature. He also has a propensity for assigning “good/bad” to things that just “are.” There are no good or bad movements but only movements. Saying repeated flexion is going to cause endplate fractures is idiotic. If I do repeated curls, I cause muscle breakdown in my biceps, but my biceps adapts to that breakdown, why should bone be any different? Just because a transient change is seen in an isolated spine with repeated flexion does not mean that change is either good or bad. It fails to account for the adaptive process that comes downstream of that change.
This is the part I was having trouble with (if not beneficial for mechanistic reasons, and not due to placebo, either, then what do you think the probable reasons for the Big 3 “working” are?) @Austin_Baraki
Luca, it is difficult to satisfy your inquiry with a simple, clean and tidy answer. Everyone that has offered you a response has clearly articulated that we don’t have all the answers and that pain is complicated. Whereas McGill has sold you on an inaccurate and oversimplified narrative that appeals to your curiosity and desire to bank a concrete answer away in your fund of knowledge on a not so simple subject.
If you take a step back and let that sink in, you may appreciate how silly it is for one person to claim that performing 3 random exercises is the answer to all back pain complaints, essentially implying that all professionals in the field, past and present, are so incompetent and ill-informed that if they would just prescribe these 3 exercises, ALL pain and suffering would end, forever. Doesn’t that sound naive to you?
As far as I understand it, the McGill method is not limited to the Big 3 - rather, they are one the part of the approach that remains consistent for most (all?) patients, with the rest of being tailored to the patient’s specific pain triggers and other factors. But the narrative he proposes is certainly much neater and dichotomous than reality appears to be, as all of you have been patient enough to point out.
I would imagine that the reason why the mechanistic narrative appeals to me and others is that it gives an (illusory) sense of control. If I “know” that, as long as I avoid certain movements throughout the day and maintain perfect form (whatever that means) in the gym, my pain will improve, that gives me a degree of control over my pain. In my experience, this has simply translated into doing a little lunge or single-leg deadlift to pick up objects off the floor instead of flexing at the lumbar most of the time , maintaining “good” posture most of the time, progressing the big 3 a few times a week, and ensuring that I maintain proper form during my lifts. I am not too paranoid about rounding my lumbar every now and then - I just try not to if I can help it. I know this is not backed by evidence, but it seems to be working well in terms of my symptoms, hence my own bias.
It will be interesting to see whether this or my coping strategies change as I read more into the biopsychosocial model. At any rate, thanks again to everyone for your patience and happy holidays.
