287 ‒ Lower back pain: causes, treatment, and prevention of lower back injuries and pain

ruticker 07.03.2025 7:25:28

Recognized text from YouScriptor channel Peter Attia MD

Recognized from a YouTube video by YouScriptor.com, For more details, follow the link 287 ‒ Lower back pain: causes, treatment, and prevention of lower back injuries and pain

Ultimately, what we're trying to do is to empower people by showing them they have the ability within themselves. They just need to understand the mechanism, and most of the time, they are able to mitigate the cause and then build a robust foundation. --- **Hey everyone, welcome to the Drive Podcast!** I'm your host, Peter AA. Hey, Stuart, thank you so much for joining me today. I wish we were doing this in person because there's so much I'd love to get into, but I have a feeling we're going to be able to do a pretty good job remotely. I get the sense that you're very well-versed at communicating your ideas in two dimensions rather than three. So anyway, great to make your acquaintance today. **Stuart:** Same here, Peter! I've been looking forward to this day for quite a long time. At some point, I'm going to thank you for writing your book. You are one of the few people on this planet who, A, I allowed, and B, I did change my behavior. So, thank you very much for that! Let's see where we go today. **Peter:** I don't want you to leave me hanging with that. I'm curious to know what it was. Were you a smoker who somehow stopped? No, I'm kidding! What was it? **Stuart:** Well, a couple of years ago, my family doctor right now is one of my former students. This may bring a smile to your face. I don't remember this, but apparently, when he was an undergrad, he asked me to write a letter of recommendation for medical school. I told him, "Of course, I'm going to write this because one day I'm going to need a good doc when I'm an old man." Well, wouldn't you know? Anyway, we did my blood work, and I was just on the edge of what the Cardiology Association is saying—meing a Crestor or Lipitor or something like that. This doc knows me well enough, and he said, "Let's run the experiment." So, we're doing it for three months. I'm living Peter AA's life, and then I love to work hard physically and finish it off with a beer, which, of course, six days out of seven, I'm denying myself of that. But long story short, I have my blood work done again in two weeks, and we'll see if this three-month experiment has paid off. He says, "No, it's in your genetics; you're not going to move the marker." But my sister says, "Oh no, you will." She did. So anyway, thanks and no thanks! But I think I'm sleeping a little bit better; I think I'm a little more mentally sharp, but we'll see over the next hour if that's true. **Peter:** Well, we can revisit this. I'll reserve the right to come back and say maybe you don't have to be quite as restrictive. I don't necessarily believe in denying all the pleasures of life, and I certainly don't deny them myself. There were some paragraphs in your book that just burned into my memory—the day you allowed yourself some French fries. I thought, "Oh, okay, I'm going to stay with a plan come H High!" But anyway, there you go. I'm going to start with a story, Stuart, because it's a story that some of the listeners might know, but you probably don't know in this level of detail, and it sets the stage for why this is a topic that is of great interest to me personally. By extension, I suspect that there are very few people who are going to listen to us today who can't relate to the subject at hand. The very abridged version of the story is: I grew up doing all sorts of really aggressive things and really took to powerlifting when I was probably 14. I found myself reasonably strong for a little scrawny kid, and between about the ages of 14 and 19, I really pushed. I couldn't bench press to save my life but seemed pretty strong in a squat and deadlift, and kind of ignored any claims my parents made that maybe I was doing a little too much. Truthfully and sadly, I had no formal instruction. There was no—you know, I was just watching the other grown men in the gym who were insanely powerful and sort of just trying to replicate what they were doing, but truthfully had no sense of what I was doing. Anyway, fast forward. I am 21 years old; I'm rowing at the time, so rowing crew. For the first time in my life, I experienced lower back pain, and this really rocked my world because I always thought that people who got lower back pain were people who did nothing. I never really thought someone who was as active as I was could get it. For about two weeks, Stuart, it completely disabled me. You know, I could sort of get around, but barely. Being a college student, I didn't really have any resources; I didn't know what to do. I was able to get to—this was actually, I think, during the summer, so I didn't have classes, but you know, I had to stop rowing. I remember that. Otherwise, I was able to work. It went away, and I thought everything was fine, and I never thought about it again until the summer three years later when I was 24 years old. I remember exactly where I was. I was in San Diego, riding my bike up the steepest hill in San Diego, which is a certain patch of a mountain called Mount Soledad. There's a section of this thing where you make a sharp right turn, and at that moment, it's about a 25-degree pitch, and I experienced this very sudden pain in my lower back. Like a typical idiot, I just kept on pushing and climbing to the top and finished my ride, but then went on to experience the exact same thing, Stuart. For two weeks, I was debilitated; couldn't do a thing other than sort of lay around and walk. But then it got better, and I kind of just forgot all about it. Then fast forward to the big one. I'm doing pattern recognition here. So the big one occurred in my third year of medical school. I'm now 27 years old, and the remarkable consistency of this is not lost on me. It is every three years—by the summer, the summer of '94, '97, and 2000. I'm riding my bike from class to the gym, and I get to the gym, hop off my bike to lock it up, and all of a sudden, I feel that same familiar, just horrible pain in my back. But this time, it's a little worse than the previous two bouts, and it was so bad that I did something I'd never done before, Stuart. I decided not to go into the gym. So I just slowly got back on the bike and limped my way back to my apartment and wasn't able to do anything other than just sort of lay in bed. I assumed I'd be fine the next morning, and I woke up the next morning and actually couldn't get out of bed. Luckily, my roommate and I each had separate phone lines, so I was able to call him from my room. So began a really painful journey over the next couple of weeks where the only place I could find relief was bent at 90° forward, where I would basically stand and bend over the nurses' station. By this point, I was doing my clinical rotations, and as every good gunning medical student knows, there was no way I was going to miss a day of this. So I would drag myself into the hospital each day and somehow managed to get through this. The nurses took pity on me, and so did the residents, and they were injecting me full of Toradol. This went on for a month, and it got so bad that eventually the pain progressed from just being debilitating in my lower back to a nerve pain that felt like my foot was being skinned. It was interesting in that the pain in my lower back started to subside as it was replaced by the feeling of my left foot being skinned from the bottom. I'm not going to go into the more details of the story because it gets worse and worse before getting better, but needless to say, I have a graduate degree in back pain. There's a happy ending to this story, Stuart, which is after this particular bout, which occurred when I was 27 and took a year to resolve, I made it kind of a mission to figure out what was going on. I'm not suggesting that I have, but I know so much more now than I did then. Fortunately, anytime I've had back pain since then, it has been a very, very short-lived experience. I'll plant one last seed before we jump into this, just for both you and the listener, so that we can come back to it. If you were to look at an MRI of my spine today, you would ask yourself—maybe not you because you're so well-versed—but a reasonable person would look at an MRI of my spine today at the age of 50 and say, "How does he walk? This person must be in so much pain he doesn't know his name." Yet I can tell you, for the most part, I'm not at all. Occasionally, I get a little tight in my lower back musculature, but you know, I don't have radicular pain. I'm not limited in anything I do. Again, suggesting that the correlation between the image of my back on an MRI and my symptoms is pretty light. Okay, so with all that as a backdrop, the fact that you're smiling so much as I tell you this story tells me not that you're taking pleasure in my pain, but rather the familiarity of my story. **Stuart:** Exactly! I've been doing pattern recognition. There's only one thing that would account for the repeated acute episodes in the interim between each one. You were quite fine, then it shifted to a radicular pain, and now you're at the stage of your life where it's more an occasional grumpiness when you cross what we call the tipping point. So, if you did the pain go to your foot, Peter? **Peter:** Yes, it went to my toes. **Stuart:** Big toes or little toes? **Peter:** No, it was actually really interesting. It was a burning pain that felt like the bottom of the foot was being skinned. I should have shared one detail that might explain this: when I finally did have surgery, it turned out I had a free fragment that was about 5 cm long from the L5-S1 disc. So that free fragment had broken off. **Stuart:** Well, I was going to guess this for you, actually. I was going to ask you which foot, and did it? So the fifth root goes to your big toe. But anyway, you carry on. **Peter:** So basically, the really unbearable pain I was having presumably was because that free fragment was parked on the S1 nerve root. Even though it ended up taking two surgeries to get that out, and those surgeries ended up causing more damage that needed more repair, that turned into a journey of a thousand cuts. You know, I was on the road to recovery, but the radicular pain seemed to be directly a result of the S1 nerve root. **Stuart:** Right. Well, if you want me to react to that story a little bit, I'm smiling because you told me exactly what the pain mechanism was. I knew it was a disc with an open fissure, a disc bulge. It would be on the side of your foot pain. Was it right or left? **Peter:** It was left. **Stuart:** Okay, so you had a posterior left-sided biased open fissure disc bulge that would open and close as a function of the flexion postures—bending down to lock your bicycle. You just gave it to me every single time. And then you were able to vacuum that in. It lasted for a couple of weeks. Now you're in the unstable phase. So if you want, I can show and tell. If you want me to show you, do you want me to show you a couple of mechanisms? **Peter:** Yeah, in fact, what I was going to suggest even before we get into that, because I want to—this is exactly where I want to go, Stuart—is let's walk people through the anatomy of the back. Now, I understand that there are some people who are going to be listening to us, so whenever possible, do your best imagining somebody can't see us. But I think there's also going to be enough people watching on video, and we'll certainly refer people to the video, at least for this section, in addition to some diagrams. But let's really explain to people what this remarkable structure of the human back is—the stability, the flexibility, the mobility, the amount of nerves, muscles, and ligaments that are involved. You could almost argue it's a miracle we don't get more injured, even though the frequency with which we do is intense. Take us through the anatomy. **Stuart:** Right. I would almost argue the opposite, Peter. There was a television show that they were producing, asking various experts around the world, "If you got to re-engineer your particular area—me being the spine guy—and this thing, you know, they had a cardiac person, an endocrine system person, etc.—how would you re-engineer it and make it better?" Every expert said they couldn't; it was perfect. So everything in terms of systems in your body comes with a tradeoff, and there are rules that manage the tradeoff. So with that, I can start the anatomy. The spine is a series of vertebrae, as you know, forming a flexible rod. This allows us to dance and move and procreate, tie our shoes, and do all of these wonderful things. But at some point, you now say, "Are picking your child out of the crib?" You reach across the crib, gather your child, pull them in. If you had a flexible rod, consider a series of stacked oranges; it would fall apart. So you need a flexible rod that you can then stiffen to bear a load. You cannot push rope, but you can push stone, or in this case, an I-beam to bear load. So all of these things are necessary to have a functional spine. What else can I say? Let's look at the structure of the discs, which are the fabric. The disc actually forms the subcategory of a biological fabric. It's not a ball-and-socket joint. Could you imagine if we had vertebrae with ball-and-socket joints? You would need an enormous musculature around that flexible rod to control all the ball and sockets. You would need an enormous motor cortex to coordinate all of these. You would be so wide you couldn't walk; you couldn't run, etc. But we have this very slender torso because we have discs. Now, the stress-strain curve of a disc starts out with a little bit of a neutral zone in the neutral range, and as you approach the end range, the disc provides stiffness—a mechanical stop to motion. Fabulous! I didn't need all this complex musculature to do so. So the disc creates tremendous evolutionary efficiency in your spine. Let's see. Now, either end of the torso strategically is a ball-and-socket joint. The ball-and-socket joints of the hips and shoulders are designed to create power. Power is force times velocity. So if you were to watch a sprinter sprint, the extensor muscles explode like a hammer hitting a stone—a stiffened structure. If they hit rope, you—the hips would be some—you couldn't run anywhere. You can't even walk without sufficient stiffness in the core. So I can get into an interesting discussion of how stability works proximately to unleash and enable this distal athleticism. In terms of anatomy, we have a flexible disc that is a fabric that creates the advantage of the efficiency of your dimensions that I'm talking about. We're light, narrow in the waist; we can run, etc. The price that you pay, though, is being a structure of many collagen fibers. If, let's take my shirt, which is a fabric. If I wanted to delaminate the fibers, I would have to create stress-strain reversals back and forth, and slowly we would debond the fibers. This is what happens to people's discs. They debond the fibers with too much load and motion simultaneously, and this is what you must have done as a younger fellow. But the concentric rings of collagen that are held together with collagen type X—the binding substance—they hold a pressurized gel, which is this incompressible hydraulic fluid that creates the ball that gets pressurized. But it's always seeking the weakness in the wall. If you delaminate the collagen fibers, then the nucleus seeps through, and in some situations, the fibers are pulled together, and they create a fragment, as you described earlier. Or if it's an open fissure and contained underneath the posterior longitudinal ligament, there's a good chance it's going to get vacuumed back in, and off you go for another two or three years. I don't know how much well I can talk about the nerves, I suppose. If you have a disc bulge, there is the spinal cord centrally behind the vertebrae, and at each lumbar or spinal joint is a pair of nerve roots. Sorry, maybe one thing we can talk about before that, Stuart, is the other point of fixation, which are the facet joints. So if anteriorly this structure is bounded and the vertebral bodies are stuck together through their sharing of the discs, on the back we have these other joints that come from each of them called these facet joints. So, yeah, why don't you talk a little bit about that? **Stuart:** I don't know if you can see those, but the facet joints are guiding motion. So you can see as I'm flexing and extending and twisting this model spine, these are articular joints in the back that are guiding motion. What you will find if I look at your MRI at the level of the disc bulge, the facet joints will now be getting a little thicker, a bit more gnarly looking. Am I right? Because the facets almost always, two or three years after a major disc injury, they take much more load. As you think of air in your car tire, if you let a little air out of your car tire, it bulges on the road; it gets a bit sloppy to drive your car. You have to tune the pressure. This is exactly what happens with your body. So when you lose the controlling stiffness of the disc, you get more work performed on the facet joints, and they wear a little bit faster than the adjacent joints, and they grow thicker. Facet pain is very different from disc pain. It's more of an ache; it comes on a bit more slowly. If you have a wound-up facet joint, it can take two or three months to wind it down versus a disc that, as you described, you can wind down in a couple of weeks. But if I can show this as a model now, this disc is normal. This bottom disc, L5, is normal. L4 has been damaged. I'm just going to apply a torque to this spine. Do you see how the majority of the motion now is occurring at the joint that's lost stiffness? Think of it like a knee that has a damaged ACL ligament. It no longer has the guidance, and the rotation motion of the knee, which is normal, is now substituted with shearing motion. So shearing motion indicates it's the metric for instability. Now you can see the shearing instability, and now look at the work being performed by the facet joints at the level of the disc being damaged and losing stiffness. Now those will get grumpy, and they will wear a little bit faster if you continue with the behavior that you did prior to the injury. This cascade changes the rules a little bit. So initially, the goal was to create power in the shoulders and the hips and transfer it through a controlled spine. But now the game has changed a little bit. You're 50 years old; you will have a little bit of joint instability. It's more important now to create a muscular girdle around the joint that has lost a bit of stiffness, and for the next little while, do your core exercises, develop a bit more muscular control, arrest the shearing motions. By the time—but you and I are very similar, by the way. So I'm in my late 60s now; my pain is gone. The joint has become so stiff, it's—I can still do everything I want to do, but the joint itself has stiffened up. Professor Caldi Willis, the famous Canadian spine surgeon, wrote a book called *Managing Low Back Pain*, and he described very well the process that most of us go through—the instability and the very acute episodes that come every two or three years that are very debilitating to a muscular ache. You wake up in the morning on one side with this ache in your back, but if you push one heel away or put a pillow under your waist or something like that, you can get rid of the ache. And then if you live a little bit longer and behave by the new rules, you're back to—I don't have any back pain, and I can encourage that you will seek that relief as well. **Stuart:** Give us a sense of the prevalence of acute lower back pain episodes. So is it acute? Is an acute lower back pain episode defined as one that lasts up to some period of time, two weeks or something like that? **Peter:** No, I don't define it that way at all, and you'll be surprised. I'm not the guy who can give you those statistics. I don't worry about those sorts of things. All I worry about is the people who come here and ask for help with their back pain. So I'm not out there doing population studies to track incidents. And even having said that, when I used to study that as a younger scientist, what is back pain? What's an acute episode? Is it sufficient to be debilitating so you don't have to work? I was a professor; I could have an acute attack and go to work. If I was a construction worker, I couldn't. So even the definition of whether it was disabling or not gets lost. So I didn't really get into those statistics. But having said that, I don't categorize pain as being acute, lasting a certain period of time, and chronic, lasting a longer period of time. Because when we measure people here with back pain, very rarely do we find chronic back pain. It's almost always due to them repeatedly insulting their back with many acute attacks and offenses all day long. So they think they have chronic pain because it lingers. When we show them a strategy or whatever the treatment happens to be to stop the insults that occur throughout the day, all of a sudden, their pain goes, and then they realize, "You know, I never did have chronic back pain." So chronic back pain to us is pain that is intransigent. and I appreciate your insights. To answer your question, yes, you would have likely benefited from some form of anti-inflammatory therapy. The inflammatory response that occurs when the nucleus pulposus of the disc extrudes is significant. It can lead to muscle spasms and a protective mechanism that locks the spine in place, which is what you experienced. In terms of what you would have seen on the MRIs over the years, you would have likely observed a gradual progression of changes in the disc structure. Initially, the discs would appear healthy, but as you continued to lift heavy weights without proper technique, you would have seen signs of degeneration starting to develop. This could include: 1. **Loss of hydration**: The discs may start to lose their water content, leading to decreased height and flexibility. 2. **Fissures and tears**: You would see the development of fissures in the annulus fibrosus, which is the outer layer of the disc. These fissures can lead to delamination, as you mentioned. 3. **Bulging**: Eventually, you might see bulging of the disc, particularly in the posterior direction, as the structural integrity of the disc is compromised. 4. **Inflammation**: When the nucleus pulposus extrudes, you would see signs of inflammation in the surrounding tissues, which could be indicative of nerve root irritation. The combination of these factors would culminate in the acute episode of pain you experienced at 21. The body’s response to the injury, particularly the inflammatory response, is what makes the pain so debilitating. As for the long-term implications, if you had continued to lift heavy weights without addressing the underlying issues, you could have faced chronic pain or recurrent episodes of back pain. However, with proper training, rehabilitation, and understanding of your body’s mechanics, many individuals can manage and mitigate these risks effectively. In summary, the interplay between mechanical loading, disc health, and the body’s inflammatory response is crucial in understanding back pain and injuries. Your experience is a classic example of how cumulative stress and improper mechanics can lead to significant issues in the spine. and I want you to try something different. I want you to think about your posture. I want you to engage your core, and I want you to use your legs to push yourself up. So, I guided her through the process, and slowly, she began to understand how to activate her muscles properly. As she stood up, there was a visible change in her demeanor. She was no longer defeated; she was empowered. I could see the spark in her eyes as she realized that she could control her body again. It was a small victory, but it was monumental for her. This experience reinforced for me the importance of stability and strength, not just for elite athletes but for everyone, especially as we age. The exercises we discussed earlier—the modified curl-up, side plank, and bird dog—are not just for performance; they are essential for maintaining independence and quality of life. **Modified Curl-Up**: This exercise helps to engage the core without putting excessive strain on the spine. It teaches proper alignment and muscle activation, which is crucial for everyday movements. **Side Plank**: This exercise strengthens the lateral core muscles, which are often neglected. A strong lateral core helps with stability during activities like walking, climbing stairs, and even sitting down. **Bird Dog**: This exercise promotes coordination and stability between the upper and lower body. It teaches the brain to control movement patterns, which is vital for preventing injuries during daily activities. These exercises should be part of everyone's routine, regardless of their fitness level. They help build a foundation of strength and stability that can prevent injuries and improve overall function. So, to wrap up, the goal is not just to perform better but to live better. By focusing on stability and strength, we can enhance our quality of life and maintain our independence as we age. --- **Peter:** Absolutely, Stuart. I think that’s a perfect note to end on. The takeaway here is that stability is key, not just for athletes but for everyone. Thank you for sharing your insights and expertise today. I look forward to our next conversation and hopefully getting together at your place in Gravenhurst! **Stuart:** Looking forward to it, Peter! Take care. the muscle activation patterns change. He was able to maintain tension and control, preventing that clunk from happening again. Over the next few sessions, we worked on building his awareness of his body mechanics and how to stabilize his spine during movements. **Stuart:** This experience highlighted the profound connection between the mind and body. Many patients with chronic pain often feel trapped in a cycle of fear and anxiety, which can exacerbate their physical symptoms. It's crucial for us as clinicians to address both the physical and psychological aspects of pain. **Peter:** Absolutely. The psychological trauma associated with chronic pain can be debilitating. Many patients feel hopeless, especially when they've been told their pain is "in their head." This can lead to a sense of isolation and despair. **Stuart:** Right. It's essential to validate their experiences and help them understand that pain is a complex interplay of physical, emotional, and psychological factors. Encouraging them to engage in movement, even if it's gentle, can help break that cycle. **Peter:** And education plays a significant role. Helping patients understand the mechanics of their bodies and the nature of their pain can empower them. When they realize that they have control over their movements and can influence their pain, it can be a game-changer. **Stuart:** Exactly. We need to teach them that pain doesn't always equate to damage. Just because they feel pain doesn't mean they're causing harm. This understanding can alleviate some of the fear that often accompanies movement. **Peter:** So, what strategies do you recommend for clinicians to help patients navigate this complex relationship between mind and body? **Stuart:** First, active listening is crucial. Allow patients to express their fears and frustrations without judgment. Then, provide them with clear, concise information about their condition. Use visual aids or demonstrations to help them understand the mechanics of their pain. Next, introduce them to gentle movement practices, such as yoga or tai chi, which can help them reconnect with their bodies in a safe way. Encourage them to set small, achievable goals to build confidence in their movement abilities. Lastly, consider incorporating mindfulness or relaxation techniques to help them manage anxiety and stress. This holistic approach can significantly improve their overall well-being and help them regain control over their lives. **Peter:** That's a fantastic approach, Stuart. It's about creating a supportive environment where patients feel safe to explore their movement and regain their confidence. **Stuart:** Absolutely. And remember, every patient is unique. Tailoring your approach to their individual needs and experiences is key to helping them on their journey to recovery. --- **Peter:** Thank you for sharing your insights, Stuart. This conversation has been incredibly enlightening, and I hope it helps many people who are struggling with back pain. **Stuart:** Thank you, Peter. It's always a pleasure to discuss these important topics with you. Let's continue to advocate for better understanding and treatment of pain in all its forms. See him? I said, "We're there. Do it again. Hold on, keep control." He didn't clunk. Now, it took him about four months to wind down the ache, but he never had another clunk. Ten years later, he brought his daughter to me, and I saw her for back pain. He brought me a case of beer and said, "I did my one-year follow-up with you, but how have you been?" He replied, "Fabulous." I asked, "Did you ever get another episode?" He said, "Never had one." Now, some people will think that that's a fantastic, impossible story. After that one coaching class, we gave him, he was so coachable, and he got it. He understood. He was a mechanical mind. You know, he never had another acute episode ever. Think of a suicide case from the medical system—not having a sufficient evaluation procedure to really get at the mechanism of his pain. They defaulted and said, "We've tried everything with you; it's not working; therefore, the pain is in your head." Now, think of the psychological impact of that. To coach him, the key was to prove to him immediately that he had the ability; he just had to be shown how. It was a process of understanding the mechanism, giving him a strategy to address the mechanism, and that just empowered him. May I give you one more story? Absolutely. I was giving a lecture in England, and there was a fella off to the side, slumped down. If you get a clinical psychology textbook, the picture of depression is this: knees together, slowed down in that demeanor. Now, if you have a posterior disc bulge, that is not a good position to be in. So there we were, starting with clinical depression feeding a disc bulge—so they don't go together. He just sat there, and then in the break, he came over to me, very quietly spoken, and said, "I hear what you're saying. Do you have 30 seconds for me to tell you my story?" I said, "Sure." He said, "I used to be a police officer. I hurt my back. I went through the NHS system. They only gave me exercises that hurt me more. Finally, they gave me a pamphlet on how to live with your back pain." He said, "That book destroyed me." I asked, "What do you mean?" He replied, "I have to live the rest of my life with my back pain, and no one's ever touched me or shown me any of this." I said, "Oh." Then you'll remember that squat procedure we went through with the older woman that I described earlier. I simply showed him that, and he went back and sat down in the chair, nice and tall. At the end of the lecture, I went over to him and asked, "How's your pain?" He stood up and said, "It's gone," and he started to cry because he realized what the system had done to him. In the meantime, he lost his job, and he realized that he'd been stolen from. Those are his words: "They stole my career from me, giving me that book on how to live with my back pain. Why didn't anyone show me what my pain was like? You just did in 30 seconds." I've been watching this pattern for so many years; you could see it a mile away. Those are two stories to link the mechanics. Ultimately, what we're trying to do is empower people by showing them they have the ability within themselves. They just need to understand the mechanism, and most of the time, they are able to mitigate the cause and then build a robust foundation. So, I wrote *Back Mechanic*, and people would come. I started the experimental research clinic at the University of Waterloo. We were the only clinic—maybe you've heard of this, but I've never heard of another clinic where they follow up with every single patient they ever saw. We did a two-year follow-up with every single patient who came in, and we subcategorized them because we assessed everyone into the mechanism of their pain pathway. We gave them an appropriate exercise prescription, followed up to see if they even complied—because some people didn't—and then how they were doing after two years. If you were in the subcategory that everything had failed, and you've been told you need surgery, so you're at the end of the road—now you're a surgery case—in the two-year follow-up, following the plan that I just described for you with this thing called virtual surgery, 95% reported that they avoided surgery and were glad that they did. So that's my efficacy to the empowerment and psychology issue. I don't know if that answers your question. Sometimes I get a little bit—I try to create a logic flow. I hope that worked. What stands out to me the most in those stories, Stuart, is your consistent, adamant drive towards understanding the mechanism of the pain. It's a matter of breaking this down into a physics and biology problem. I guess my question is, which type of healthcare providers are most in line with that? Your training is in kinesiology, right? Yes, and I should back that up. There's a lot of mechanical engineering in there. But nonetheless, when we think of all the different practitioners that interact with patients who have lower back pain—ranging from neurosurgeons, orthopedic surgeons, chiropractors, physical therapists, kinesiologists—I mean, there are so many people. I never want to suggest that the profession determines the school of thought. I really think that individuals—there are great people and there are lousy people within all of those categories. But what are the characteristics that you see driving that type of search for a true mechanistic understanding of the pain? Because, I'll be honest with you, in all of my bouts of back misery, nobody ever explained to me what was going on. I mean, nobody said to me, "This is happening." Even as a medical student, yes, I could look at the MRI; I could see the fragment. It clearly had to come out, presumably, given that I was in such excruciating pain. It might have taken months for the thing to have been resorbed. But there wasn't a sort of, "We need to understand the why this is happening so that we're going to fix the underlying behavior that's causing it." That's the thing that strikes me as the most interesting of those stories. Is that, I guess, what my long-winded question is? Is that a function of the individual or of the school of training? Both. The elephant in the room here is that there is no billing code that exists for an assessment of back injury mechanism. You can't bill an insurance company and say, "Well, I assessed the person's back pain." When I started the experimental research clinic, I set aside two hours to see a back pain person. I'm that guy; that's all I ever saw—two hours. My medical colleagues, who'd been through medical school training, which I had not—I'd only ever been a guest professor at a medical school, but I sure didn't graduate from one—said, "Two hours? What are you going to do for two hours?" Well, I've been spending 30 years figuring out how I'm going to test sheer tolerance to compression, pulling a nerve root one way, pulling it the other way. Is it flossing? Is it friction? Is it stuck? I'm probably, again, a handful of people in the world that would take cadaver spines and create the injuries so I knew how to measure them and what to look for in terms of the full pattern. That's the first political impediment to all of this: there's no billing code. Therefore, you're left with clinicians who are billing for a procedure that they've been trained to perform. If you have non-specific back pain, it's an absolute crapshoot whether a manipulation for mobility, an exercise prescription for stability, or just a movement tool—not to create a stress riser or a stress concentration on the tissue that is sensitized—will work. Where I've arrived at with all of this is that we have to train our own clinicians, and that's what I've been doing through BackFitPro. I do not care if you come from a chiropractic, physical therapy, coaching, training, physiatry, neurology, or radiology background. All I care about is that you have passion. We then have a 50-hour online course of me going through anatomy, physiology, neurology, psychology, biomechanics, etc., and then probably 100 subcategories of pain mechanisms. Then, how do you test for all of these? After all of that, we have three days together where we do hands-on skills training at a table. Again, there's no subcategory in the medical rubric that trains how to assess back pain from the perspective of biomechanics, psychology, neurology, physiology, etc. They don't exist. So that was my challenge. What's the name of that course? It's called The Summit Course, and you can read about it on backfitpro.com. A member of the lay public, because some of them are very savvy from taking it, however, the gatekeeper of all of this is there's a fairly extensive exam at the end. It is a written exam; there's a practical exam where the person must assess a real patient, usually online with one of our examiners. They have to come up with a written explanation of the pain pathway and then a program of what they're going to do with the person. They have to coach elements of it, so they have to see the coaching skill as well. That's sort of the gatekeeper at the end that I think would only be for clinicians. But that's the only way that I found possible. Having said that, I'm like you—I'm very agnostic in terms of preparation. There are fabulous chiropractors and the absolute opposite, fabulous therapists, fabulous professors, and terrible professors. It's just the way it is. But anyway, I don't know if that answers your question. No, that's a very interesting course. It's almost something I wonder—I’d love to figure out a way to make the time. So it's 50 hours online plus three days in person, is what it sounds like, correct? Let's talk about the cases where you think surgery is really the best course of action. Again, I think it should always be stated that surgery, without understanding how you got there and then making sure you correct it post-surgically, is not what we're talking about. It should always be assumed that you want to understand what got you there. But what are the indications in your mind for where a patient is better off getting a surgical procedure? We could talk about the different types—whether you think discectomy, fusion, etc.—versus when you think where you would take a contrarian approach, where many people would say yes to surgery, and you would say, "Let's push a little bit harder before." Wow, a lot of elements there. So I'll just start at the beginning and hope I can create a logic story. I did mention the follow-up that we did where 95% of people who were told they needed surgery, in fact, avoided it. What we did there was I anointed them and said, "There is your virtual surgery." This worked really well on people who I'll paint the picture of: let's take a stay-at-home mom with two young kids. Every day, she has to go to the gym and ride the elliptical for 20 minutes or do something else as a stress reliever; otherwise, she's going to murder her husband. You've heard that story before. I'll say, "Good, go get your surgery." Are you going to do that tomorrow? No, you are going to lay in bed. You're going to behave like a post-surgical person. You're going to get out of bed and go for a pee three times; that is your total workload tomorrow. Slowly, you're going to build yourself back in. In other words, surgery may work for you because it's forced rest. Now I'm going to give you a tool that will mimic the forced rest; it's called virtual surgery. Tomorrow, here's the plan; here's how you're going to behave. We are going to desensitize strategically the pain mechanism as we've measured it, and we're going to retune your body with strategic mobility and stability plus movement skill so we don't replicate the stress concentrations that caused your problem in the first place. Let's see how you are. If they can do that, 95% will avoid surgery. So there's my first little story for people in that category. Just to be clear, what are the patients who you would not offer that virtual surgery to? Give me an indication where you would say, "You know what? This is too pressing—obvious red flags." Before we see a patient, we don't take patients off the street. They always come through physician referral, so I'm hoping they've been checked for red flags. Do you know how many have not? Even though we state in the referral directions to the referring medic, we've had cases of aortic aneurism, lung embolism, cancerous tumors, metastasized issues—all sorts of things that somehow these poor people got through the system, and we were the ones that found it and saved their lives. I wish that wasn't the case, but all of those obviously are surgery cases, and they should never have come to us in the first place. So obvious red flags are number one. Number two is when the pattern doesn't fit. I was smiling when you were telling your original story only because it was such a familiar, spot-on pattern consistency. You fit the pattern; I knew exactly what it was. When the pattern doesn't fit, I'll say, "No, something's not right. I need you to go back to your doc." Here's the reason why: there is tenderness under your liver; we're not able to move that pain by moving stress concentrations around your spine. So it's not a nerve; it's nothing vertebral or facet. The pattern doesn't fit; it's something else. So there is a person where we refer back and say something needs further investigation. But now, the last part of your question was about the need or when we would say to a person, "You're not our person; you need to see a surgeon." Surgeons, by the way, we see far too many post-surgical patients who went through—maybe the surgery was botched. When I see a horrible scar on the outside of the skin, I think, "Man, if that's the pride that the surgeon took on the outside, what carnage has gone on the inside?" Or sometimes it's a happenstance story; the nerve scarred in and adhered. That's rough, you know? Or the post-rehab was terrible. Here's a person who went to a fabulous surgeon, and the surgeon says, "Oh, go do PT; that's your rehab." The PT goes and gives them toe touches or something after they just had a micro-disc surgery, and guess what? They're re-injured again, and now we're seeing them. But when would we say, "No, you're not for us?" Here, the surgeons are at their best in cases of real heavy stenosis. So there's not much room in your neural canal; the facet joints are thick in behind. You've got encroachment from behind; you've got a calcified disc bulge coming from the front. A couple-level laminectomy to give the nerve some space—that really is when the surgeons are at their best. Some of the spondylopathies that we'll see in the neck—I think of a lead lawyer in the courtrooms. The judges would ask him, "Sir, are you drunk?" He said to us, "Well, when I stand, I start my presentation; I'm fine. But after two or three minutes, I'm losing my balance and falling over." The judges think he's drunk, and then we found it was a cervical spondylopathy that was also co-presenting with back pain, but no one had figured this out. So that was a surgery case, obviously. It's either post-trauma, and that one's obvious—they need a little bit of hardware to stabilize their spine. But it may also be spondylolisthesis; the sheer translation is just choking off the cauda equina or another nerve. It's best to recommend surgeons who we have really good luck with. In that situation, if the spondylolisthesis is significant enough, is the only treatment fusion? I'm going to say yes. There's no amount of stability you can generate in the paraspinous muscles, in the QL, in the psoas to compensate for that. I realize that, because you have to forgive me, I'm not an orthopedic surgeon, but I would assume that there's some threshold, right? One millimeter of spondylolisthesis might be tolerated, and at some level, they would say, "No, it's too unstable." No, I wouldn't agree with that, Peter. It's not the distance at all. You go with the assessment, and the evidence I offer there is we're coming down to the next Olympics now. I don't know how many Olympians and people who are tapering now for the Olympic trials we've had here over the past year, but this is every four years; we're inundated with these types of athletes. They come in pairs where we might have two young women who are competing for a place on the US Olympic team in gymnastics. Both have the same spondylolisthesis. One, we'll say, we need six months off here of gymnastics, and here's what we're going to do: we're going to do a heavy stabilization program. The next one says, "Oh no, we really got to make the trials; we're just going to keep going with gymnastics." I can almost predict with 100% accuracy who's going to make it. So I wouldn't say at all that we don't try a heavy exercise stability program regardless of the amount of slippage. I've done that with people trying to make the special forces in the US. You've got to do a speed setup test; you've got to do all of these things. "Oh, but you got a heavy spondylolisthesis? Okay, here is the program to try and get there. You might make it." Anyway, what about nerve pain? What about patients who are either having weakness, such as a foot drop, or significant pain, like the pain I had where it was... Okay, so yeah, take that away. We have them all the time, Peter. If I can get the nerve pain to move on the assessment, please don't have surgery. Let us have a try at it. Most of the time, they will be pleased. Wow, and what you're basically doing is playing with certain rules. Give me an example of some of those. Let's say your assessment comes out that this person who's having intermittent sciatic pain—and you do an assessment and you say, "Look, there is no doubt that you have a ruptured annulus here. You've got a protruding segment of disc, and it is clearly at times, depending on your activity, getting nearer to the nerve root. It's driving that sciatic pain." But during your assessment, I assume what you're getting at is through some of those positional things, such as laying the person on their front, manipulating the legs, getting the herniation to retreat into the annulus. If so, you're saying if you can demonstrate resolution under a changing movement pattern, that gives you enough confidence that this doesn't need to be removed surgically. Not resolution. Can I move the pain a little bit? Can I make it worse, and can I make it better? Now I'm starting to understand the variables that make it worse and make it better, and I play with those. I see—here's, and again, I'm trying not to sound boastful; I'm trying to be scientific here. There was a day not that long ago—I'm losing track of time; it was probably, well, it was the NHL playoffs, so there's our time marker. I just—I don't watch TV really, but for some dumb reason, it was Saturday. I flipped on the TV; it was the NHL playoffs, and I listened to the announcer say, "Oh, that's my patient." Then I saw the next player—my patient. Two of my patients are now in the NHL playoff series. A little bit later, I flipped over to TSN—what's the big professional tennis tour? I look at that; my patient. Then that night, the UFC comes on—there's my patient. So in one day, I see three different pro sports. Every single one of them had sciatica when they came to me. So that's some evidence that I can offer. Now, let's take—I remember one of those players in the NHL. If he fully flexed, he would stir up sciatic pain and increase the risk of a full-blown acute attack, as you know. You and I know very well. So we got him to move well. He played hockey mindful of a skating style that he didn't get too flexed up. We didn't allow him to tie his own skates. He said, "Tying my own skates really set my back up." I said, "Good." Now, NHL players are very particular about how they tie their skates, but they had one of the training staff tie his skates for him. Now, I know some people will laugh at that, but that was all part of the plan. viewership. The good news is that the body has an incredible capacity for healing and adaptation. If you can identify the patterns that lead to pain and address them proactively, you can significantly improve your quality of life. **Key Takeaways:** 1. **Understand Your Pain**: Recognize that pain is often a signal from your body. Keep a journal of activities that trigger pain and those that relieve it. This can help you identify patterns. 2. **Seek Professional Guidance**: If you're struggling with back pain, consult a healthcare professional who understands the mechanics of the spine. Look for someone who can assess your specific situation rather than relying solely on generalized advice. 3. **Engage in Movement**: Incorporate exercises that promote both stability and mobility. The "Big Three" exercises—curl-ups, side planks, and bird dogs—are great for building core stability, but don't forget to include mobility work for your hips and spine. 4. **Limit Prolonged Sitting**: If you work at a desk, make it a habit to stand up and move around every hour. This can help prevent stiffness and maintain spinal health. 5. **Educate Yourself**: Resources like *Back Mechanic* can provide valuable insights into understanding your back pain and developing a personalized approach to managing it. 6. **Be Patient**: Healing takes time. Focus on gradual improvements and celebrate small victories along the way. By taking these steps, you can empower yourself to manage your back health effectively and reduce the risk of future pain. Remember, the journey to a healthier back is a marathon, not a sprint. I retired early. I retired when I was 60. I reached a stage where I realized what my job was. When I started as a professor in 1986, student meetings meant students came to see you, and we would get up and work through things in the laboratory and whatnot. Then the students started to migrate to this idea: "Oh, sir, could we have an online call for student hours?" No, you can't! You get down there! We’re going to work through this problem together. In other words, my job got turned into a sitting job, and it was killing me. I realized that my health was declining; my fitness was declining. I still walked to the university. I strategically bought a home right on the edge of campus so I would have a 20-minute walk to and from my office and laboratory. Still, I was declining. So, I walked away. I shut the door on my office. I said to the graduate students, "There are all my books; go take them to all the other professors. There’s my lab; go take it. I’m done." I just walked away, never thinking that anyone would ever ask me again because I wasn't producing new data anymore. I was sort of wrong on that estimate. But anyway, my point is, Peter, I'm healthier now than I ever was in the latter 15 years of my computerized work life. I hardly go on the computer; it's fabulous. I can talk about my life now if you want and what I do. But my point in all of that is things are going to get really better for you. They're not going to decline more. I've heard you say that, and I think, "Pete, come over with me, man. Spend a couple of days, and you’ll see how you're not on this decline as you think." Well, you just said something a moment ago that I was going to ask you about. So, at the risk of overwhelming you, because I know that there are going to be so many people listening to us who are going to say, "You know what? I am not happy with the assessment or lack thereof that I've received. I'm not happy with the care that I'm receiving with respect to my lower back injury. I need to go and see Dr. Mill." What is involved in arranging that type of consultation with you? And again, I feel awkward saying this, but that's why I wrote *Back Mechanic*. So, I don’t see anybody until they've read the book, and most of them say, "I don’t need to see you now." So, they've been through the self-assessment; they've got enough out of it. Now, if they're not getting enough out of it, on our website, backfitpro.com, we have two layers of clinicians. We have the certified clinicians who've taken that 50-hour course, gone through the hands-on skills training, and written the exam, but I've never worked with them personally. They are all there on a page. Then we have a different level called Master Clinicians. I have worked with every single one of those people and trained them. I've seen patients with them; they have my confidence now that I can send them any patient, and they will subcategorize them and know pretty well what to do with them. I continue to train those individuals. I seek out stars or people who have the passion and the skill, and I go to them and say, "Would you now study with me, and I’d like you to become one of our Master Clinicians?" So, that’s my answer to that conundrum. How many Master Clinicians are there in North America, Stuart? Not many. I don’t know—maybe a dozen, 15, something like that. But they're all identifiable on the website, which is backfitpro.com, correct? And the certified clinicians—that's growing all the time. There are maybe 30 or 40 of them. We add to that maybe one or two every couple of months. Anyway, I think people, in reading that book, it’s quite a quick read. It was a very difficult book to write, as you can imagine. I’ve written my medical textbooks for my medical colleagues; those are easy to write. You put in the references, you make your points, you show the strength of evidence, etc. But you can’t do that with the public. You have to give them enough of the truth to guide an effective strategy, but you can’t overwhelm them with jargon and all of that. So, that’s why those things are so difficult to write. But people tell me that *Back Mechanic*—in any case, I sent you a copy. I hope you got it. Not only got it, I greatly appreciated the inscription in it. Thank you! Ah, yeah, okay, that was special. In any case, that is my solution to that conundrum, and that’s why going to the internet, as you know, it’s the wild west. You can get screwed up as much as you can be helped. Well, Stuart, this has been a really enlightening discussion for me. Given how much I've thought about this topic, I think that says something. But it tells me that, more than anything else, a lot of people listening to this—which again, I think is a lot of people who can relate to what we're talking about personally—I think this offers more than just a glimmer of hope and also a set of resources that people can look to. I will take you up on this offer. The next time I'm in Toronto, we’ll make that trip up to Gravenhurst. Apologies for my poor Canadian geography; I always thought Gravenhurst was just outside of Toronto. I didn’t realize it was that far north. Yeah, Huntsville, Bracebridge, Gravenhurst—if you know that area, right in the heart of Muskoka. So, just from like Aurora, we’re talking like what, 90 minutes, two hours? We’d be a good hour north—no, about an hour and a half north of Aurora. Okay, yeah. All right, well, we’ll make that happen. I hope so, Peter. I’ve looked forward to this day ever since we scheduled it a couple of months ago. The leadership that you’ve provided is fabulous. I have spent many hours listening to your podcasts and getting wisdom from your guests. The level that you take all these issues to is just the foundation I need for a lot of the things that I think about. So, for all you do, thank you so much. The way you posed your questions today was not really typical, so I appreciate that very much. But again, thanks for all you do, and thank you for what you do because that’s where I’m learning today. **Stuart:** My pleasure!

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