In the area of prevention and treatment of lower back pain, Stuart McGill, PhD, is considered one of the world’s foremost experts. Known for his success with the most difficult cases, McGill is the go-to back specialist for NFL, MLB, NBA and UFC athletes and Olympic competitors in nearly every sport. Also among his clientele are celebrities, military personnel and Fortune 500 executives.
McGill is a professor at the University of Waterloo in Waterloo, Ontario. In the late 1980s he began receiving requests from sports teams to evaluate and design treatment protocols to help their athletes who were suffering from back problems. Upon successful treatment of many of these athletes, McGill’s reputation began to grow among orthopedic physicians and neurosurgeons. His work has been recognized by his academic colleagues, and he has received such awards as the Volvo Bioengineering Award for Low Back Pain Research.
McGill has written two books,
Low Back Disorders and
Ultimate Back Fitness and Performance, as well over 200 scientific papers on the healthy functioning and rehabilitation of the low back. He is an editorial board member for prestigious journals such as
SPINE, Journal of Applied Biomechanics and
Clinical Biomechanics. His speaking engagements and seminars attract a full spectrum of health professionals from all over the world.
The following exclusive interview provides a sampling of McGill’s expertise in the area of healthy back function, specifically as it relates to law enforcement professionals.
Q: What are some common causes of low back disorders in law enforcement professionals?
A: Whether it’s from driving in their vehicles or filling out paperwork, prolonged sitting is commonplace in the law enforcement profession. Excessive time spent in a seated position can disrupt normal back function and can damage the annulus of the disc, eventually leading to stiffness and pain, or worse. The lack of seat rigidity and lumbar support in the police cruiser can result in or exacerbate low back disorders. A lumbar support can aid in preserving the natural curve of the spine in a seated position, but this device needs to work with the items on a particular officer’s duty belt.
Q: Have you noticed any common postural imbalances among law enforcement professionals?
A: One that is unique to the profession is an altered gait pattern, with the right arm swinging outward to accommodate the firearm. We have noticed that even when our police officers are not wearing the duty belt, this characteristic arm swing is a habitual default gait pattern due to the amount of time spent in uniform. This altered pattern decreases quality of movement, and can trigger problems in the low back and hips.
Q: What specific challenges do you encounter with clients who have chronic back pain?
A: We can’t always create the conditions for rapid healing, as some of the tissues will take about 10 years to heal – that is the nature of some parts of the back that get injured, such as the vertebral end plate. However, quite often we can substantially reduce or eliminate the pain and symptoms.
Q: Generally speaking, what is your approach to rehabilitating an individual with low back pain?
A: Before we begin a treatment protocol, we conduct a thorough assessment. We need to determine the causes of pain and the cofactors associated with the pain or dysfunction. We conduct provocative testing to identify the motions, postures and loads that cause the pain and those that take the pain away. Then we show the individual how to eliminate their pain mechanism by altering the motions, postures and loads in activities of daily life in conjunction with the training program.
Obviously, the first step is to avoid or remove those motions, postures or loads that are causing the pain. Then we organize a four- or five-stage progressive protocol depending on the needs of the client. If they are a serious competitive athlete, they will incorporate the fifth stage, while most trainees may require only the first four stages. The five stages are as follows:
Stage I: Establish healthy movement engrams
Stage II: Establish a base fitness level and movement quality while enhancing low back stability and mobility at the ball and socket joints
Stage III: Build endurance
Stage IV: Increase strength
Stage V: Improve speed and power
Q: What is the focus of stage one?
A: Typically, in stage one we are trying to establish pain-free movement patterns that create a pain-free capacity to move. This is needed before any real training resumes. The trick is to make the movements, loads and activities that are pain-free the default patterns that the person will resort to during daily activities. For example, when a police officer sits in a cruiser for a few hours during a shift, their back may become sore or stiff. Due to this increased soreness, they may not be able to train effectively later in the day. In essence, they are robbing themselves of their capacity to conduct their rehabilitation program. In the case of sitting, breaking up the activity into intervals will help.
Q: Would you elaborate on how you improve back stability and mobility in stage two?
A: The core exercises have been designed to ensure stability but also to spare the spine from high loads; this way we can achieve much more muscular challenge without excessive spinal loads for a back that is recovering. A special consideration for this stage is the age of the officer. We have seen that roughly around the age of 50, the hip and shoulder joints can become stiff, disrupting the balance between mobility and stability. This compromises the ability for deep squats, heavy overhead work and sometimes bench pressing – in that case we modify or replace these loaded movements.
Q: How do you build endurance in stage three?
A: Training endurance follows a progression. In the beginning we want sufficient endurance to facilitate repeatable good-quality movements to spare the joints. We are looking to repeat optimal movement patterns over a series of successive repetitions. Oftentimes people get hurt when they break form during loaded movements; when they get tired, they overuse their backs instead of using their hips.
We performed a study on factory workers whose job it was to lift 75-pound chrome bumpers all day long. Of the 73 workers, 46 had no back problems; the remaining 27 exhibited chronic repeat bouts of disabling back pain but also had periods of no pain. Our measurements showed that on average those who had the repeated pain episodes had stronger backs but much less endurance in their back muscles; they also had stiffer hips. When they lifted, they used their backs, while the workers who did not have back pain used their hips to lift. So, the problem was that the workers with stronger backs had less endurance – although they lifted well for a few reps, they broke form and then became injured.
Q: Stage four focuses on developing strength, while stage five aims at increasing speed and power. Would you explain the difference?
A: Stage four specifically focuses on training multi-articular functional strength by training patterns of movement in squats, lunge, lift, push, pull, carry, and torsional buttress patterns. This ensures that strength is developed in a balanced way throughout the body linkage so that there are no weak links. Incidentally, our work with competitors in world-class strongman events has shown time and again how a strong core radiates strength outwards to more distal parts of the body linkage. Thus, abdominal bracing is emphasized in an effort to create greater stability and stiffness during loaded athletic and occupational movements. Bracing is taught in an upright unloaded position; then we progressively transfer this bracing to conventional and/or functional training methods. This is a foundational method of strength and injury prevention.
Once the foundation of strength has been achieved, stage five is optional, depending on the goals of the individual. Stage five may not be required for an office worker looking to alleviate back stress, but in our work with emergency task force squads and special-unit members, such as the Navy SEALS, we make sure this ability is well trained.
Q: What are your thoughts on neural inhibition of the surrounding musculature as a cause of low back pain?
A: Dr. Vladimir Janda theorized decades ago about neural inhibition of the gluteal musculature as a cause of pain. He referred to the syndrome as the “crossed pelvis syndrome.” I prefer the term “gluteal amnesia,” as back pain and hip pain inhibit the glutes. We recently proved this in a provoked pain study. The implication is that pain must be addressed first, and then the residual legacy of gluteal inhibition must be countered with a specific focus to reactivate the gluteal muscles into the motor patterns and then make them strong and endurable.
Q: What is your approach to tight hamstrings and piriformis syndrome as cofactors in low back pain?
A: We find after testing that quite often tight hamstrings are not the cause of low back pain but rather a result. We treat the back pain first, which then often unlocks the hamstrings. Further, hamstring tightness tends to be a neural response, such that stretching the hamstrings does not help over the long run. Of course there are exceptions.
Regarding piriformis syndrome, this pain in the lateral buttocks region is often seen as referred sciatica from an impinged lumbar root; it is not a muscle issue. We have found stretching the piriformis can further exacerbate the issue. Treatment of the low back by improving movement quality, increasing strength and endurance, and enhancing motor patterning is an effective treatment to alleviate these issues. I have only seen a couple of true piriformis cases, one being an international soccer player who was kicked in the buttock and truly had piriformis muscle pathology.
Q: Can genetics play a role in the potential for disc herniation?
A: Absolutely. For example, the shape of your spinal discs is mainly determined by genetics, and the shape of your disc can determine what type of herniation you may be more susceptible to. Those with a limaçon-shaped disc are more susceptible to focal disc herniations – these occur with repeated forward bending in the spine under load, not at the hips. Those with ovoid-shaped discs are more susceptible to diffuse disc herniations; these occur with repeated twisting.
Q: Is there any single “best” exercise you would recommend for law enforcement professionals dealing with chronic or acute low back pain?
A: There is no such thing as an ideal exercise for everybody – what works for one client may create a completely different set of circumstances for another. The best way to approach exercise selection for the treatment of low back pathology is to calculate the risk versus reward through a thorough assessment. For a law enforcement professional who has become intolerant to low-back flexion, the risks associated with a sit-up may far outweigh the rewards.
Q: Can you elaborate? There appears to be some debate and misunderstanding among trainers about your take on sit-ups and spinal flexion exercises.
A: In a fully flexed position with external load as seen in the sit-up exercise, the nucleus inside muscle fibers has the potential to breach the collagen fibers, leading to disc bulge or herniation. For the flexion-intolerant trainee, it is advisable to choose exercises with less movement but greater load challenge. For example, during the stir the pot gym-ball exercise, there is flexion moment (or challenge) without flexion movement. This combination protects the nucleus in those individuals who are intolerant to spinal flexion. But there are many cofactors here.
If a person is training with higher loads, they will find that sitting makes their back sore. If a person stops training, they will usually find that sitting for longer periods is more tolerable. What this shows is that flexion capacity is being used up in training. So those who are training with more intensity must back off on the flexion motion exercises. People who claim that sit-ups are universally OK do not understand the relationship that we have observed with many experiments through the years.
Q: What exercises have a high reward-to-risk ratio for the flexion-intolerant trainee?
A: Generally speaking, a program of several exercises is best – however, this is tailored to the individual. For example, the cat-camel from your hands and knees can be very beneficial for law enforcement professionals with low back stiffness because it is a gentle way to introduce tolerable spine motion. The prone plank optimizes low spine load on a resilient back posture with quite substantial abdominal muscle challenge. This abdominal muscle activation is driven to 100 percent with a walkout of the hands forward. The side bridge addresses the important lateral obliques and quadratus lumborum. The rotational plank to side bridge exercise is an excellent training approach for both rehabilitating low backs and increasing speed and rotational power – but here the rib cage is locked to the pelvis and the motion takes place about the hips. And, of course, the bird dog exercise is an excellent way to begin the back muscle progression before moving on to the upright movement patterns.
Q: Are there strongman exercises you would recommend for law enforcement?
A: Certain strongman exercises may not be appropriate for trainees suffering from chronic back pain, while others can be of great benefit. Asymmetrically loaded exercises – including suitcase carries, sandbag carries and keg carries – are the most effective approach for training the QL and co-contracting muscles associated with dynamic upright stability. The QL is an essential muscle for athletic walking, running and directional change.
Q: Thank you very much for your time and tremendous insight.
A: You are very welcome.