How to Prevent and Treat Lower Back Pain with Steuart McGill

Added: Jan 29, 2024

In this podcast episode, Peter Attia welcomes guest Steuart McGill to discuss the anatomy of the human back and the mechanisms of lower back pain. The main goal of the discussion is to empower people by helping them understand the mechanisms of lower back pain and how to mitigate its causes.

Key takeaways


Understanding the anatomy and mechanisms of lower back pain is crucial for empowering individuals to mitigate its causes.


The 'Big Three' exercises (the modified curl up, side plank, and bird dog), which focus on core stability, are beneficial for managing back pain and promoting spinal health.


Individualized assessment and tailored exercise programs are essential for effectively managing back pain.


Lifestyle factors, such as posture, movement patterns, and avoiding prolonged sitting, play a significant role in spinal health.


Proper assessment and comprehensive training are vital for addressing back pain in the healthcare system.

Anatomy of the Spine

McGill begins by explaining the anatomy of the spine, which is a series of vertebrae forming a flexible rod that allows for movement and flexibility. He emphasizes the importance of the discs, which act as a fabric and provide efficiency in the dimensions of the human body. The discs contain a pressurized gel and are held together by concentric rings of collagen. McGill also discusses the facet joints, which guide motion and can become thicker and more gnarly-looking after a major disc injury.

Mechanism of Lower Back Pain

The discussion then delves into the mechanism of lower back pain, particularly related to disc injuries. McGill explains that a healthy disc does not contain nerves or vascular tissues. However, when the disc is damaged, vascular sprouts and nerves grow into the disc, leading to increased sensitivity and pain. He also demonstrates how the shape and thickness of the spine, as well as the orientation of facet joints, contribute to the vulnerability of certain areas, such as the interfaces between L4 and L5 or L5 and S1.

Stress and Strain

McGill clarifies the difference between stress and strain, using the example of applied load and deformation. He explains that when a force is applied to a structure, it deforms, and the behavior of biomaterials under different types of stress (tension, compression, shear, etc.) can lead to specific types of damage.

Concrete Example

To illustrate the concept, Attia and McGill use the example of concrete, which is strong in compression but weak in tension. They discuss how engineers use rebar to reinforce concrete and make it strong in both compression and tension, drawing parallels to the spine's ability to handle different types of loads.

Axial Load and Flexion/Extension

The conversation then shifts to the spine's ability to handle axial load and the impact of flexion and extension. McGill explains that the cervical spine is designed for flexibility, while the lumbar spine is built to handle large compressive loads. He emphasizes the sacrifice of mobility in the lumbar spine for the sake of stability and load-bearing capacity.

Prevalence of Lower Back Pain

While McGill does not provide specific statistics on the prevalence of acute lower back pain episodes, he emphasizes that chronic back pain is often a result of repeated insults and acute attacks on the back. He explains that chronic pain is characterized by changes in the brain and trauma, rather than a strong mechanical trigger.

The Big Three Exercises

Dr. McGill introduces the "Big Three" exercises, which are designed to improve core stability and proximal stiffness. These exercises include the modified curl up, side plank, and bird dog. He explains that these exercises are not only beneficial for athletes but also for individuals who are elderly or dealing with health issues. The modified curl up involves lifting the head, neck, and shoulders while maintaining abdominal contraction. The side plank is performed to strengthen the core muscles on one side of the body, while the bird dog exercise focuses on creating stability and disassociating ball and socket joint motion.

Assessment and Individualized Approach

Dr. McGill emphasizes the importance of individualized assessment when prescribing exercises. He explains that the Big Three exercises may not be suitable for everyone, and it is essential to understand a person's specific pain triggers and movement patterns before recommending these exercises. He shares a story about a patient who was told she had to leave her home due to her inability to get off the toilet safely. Through a simple demonstration and coaching, Dr. McGill was able to teach her proper movement patterns, allowing her to regain her independence and avoid leaving her home.

Performance and Longevity

The discussion also touches on the relationship between stability, performance, and longevity. Dr. McGill highlights the impact of stability on athletic performance, citing examples of elite athletes and their ability to generate force efficiently through proper stability and movement patterns. He emphasizes that stability is not only about performance but also about preventing injury and maintaining overall health and longevity.

The Role of Elite Athletes

Dr. McGill challenges the notion that working with elite athletes is irrelevant to the general population. He shares a powerful story about how lessons learned from elite weightlifters were applied to help an elderly woman regain her independence. He stresses the importance of learning from the best athletes in the world and applying those lessons to benefit individuals of all ages and abilities.

Importance of Understanding the Mechanism of Back Pain

Dr. McGill emphasizes the importance of understanding the mechanism of back pain in order to develop an effective treatment plan. He shares stories of patients who have experienced debilitating back pain and how a thorough assessment of the pain mechanism led to successful treatment outcomes. He also highlights the need for clinicians to have a deep understanding of biomechanics, psychology, neurology, and physiology in order to accurately assess and treat back pain.

Virtual Surgery as a Treatment Approach

Dr. McGill introduces the concept of "virtual surgery" as a treatment approach for certain back pain cases. He explains that for some patients, mimicking the forced rest that follows surgery can lead to pain relief and improved outcomes. By strategically desensitizing the pain mechanism and implementing mobility and stability exercises, patients can avoid surgery and achieve long-term relief.

Indications for Surgery

While virtual surgery may be effective for many patients, Dr. McGill acknowledges that there are cases where surgery is the best course of action. He mentions that surgery is often necessary for patients with heavy stenosis, spondylolisthesis, or traumatic injuries. In these cases, surgical intervention can provide the necessary relief and stability that cannot be achieved through conservative measures.

Challenges in the Current Healthcare System

Dr. McGill discusses the challenges within the current healthcare system, particularly the lack of a billing code for assessing back pain mechanisms. He emphasizes the need for clinicians to receive comprehensive training in assessing and treating back pain, regardless of their professional background. He also highlights the importance of identifying red flags and referring patients to the appropriate specialists when necessary.

Importance of Proper Assessment

Dr. McGill emphasizes the importance of a thorough assessment when dealing with back pain. He explains that there is no such thing as non-specific back pain and that a proper assessment is necessary to understand the specific causes and triggers of an individual's pain. He also discusses the need for self-tests and pattern recognition to identify activities that cause pain and those that provide relief.

Dr. McGill's Book "Back Mechanic"

Dr. McGill has written a book called "Back Mechanic," which serves as a guide for individuals dealing with back pain. He explains that he does not see patients until they have read the book, as it provides a framework for self-assessment and understanding of back pain triggers. The book includes self-tests, activities that cause pain, and strategies for managing and mitigating back pain.

The Role of Exercise in Managing Back Pain

Dr. McGill discusses the importance of exercise in managing back pain. He emphasizes the need for a strategic exercise program tailored to an individual's specific condition. He mentions the "Big Three" exercises, which focus on core stability, but also highlights the need for mobility exercises for those with different types of back pain. Dr. McGill also stresses the importance of avoiding activities that exacerbate pain and adopting a lifestyle that promotes spinal health.

The Impact of Lifestyle on Spinal Health

The conversation delves into the impact of lifestyle on spinal health. Dr. McGill shares examples of individuals with different lifestyles and their corresponding back pain triggers. He emphasizes the need for individuals to understand how their daily activities and movements affect their back health. He also discusses the importance of posture, movement patterns, and avoiding prolonged sitting to maintain spinal health.

Dr. McGill's Approach to Patient Care

Dr. McGill explains his approach to patient care, which involves a comprehensive assessment, self-tests, and tailored exercise programs. He also discusses the importance of finding the right healthcare provider who understands the complexities of back pain and can provide effective guidance and treatment. He mentions the certified and master clinicians who have been trained to assess and manage back pain based on his methods.

The Future of Spinal Health

The conversation concludes with a discussion about the future of spinal health. Dr. McGill shares his optimism about the potential for improved spinal health, especially for those who adopt a strategic exercise program and make lifestyle changes. He also expresses his confidence in the growing number of clinicians who have been trained to assess and manage back pain using his methods.


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