Monday 26 March 2018

The McGill Method - Common Misconceptions

In collaboration with Professor Emeritus Stuart McGill, PhD

                In the Fall of 2010, when I was a student at the University of Waterloo, I first met Dr. Stuart McGill. He was gracious enough to take the time out of his day to answer a few questions that I had from reading his book Low Back Disorders over that summer. Since then, Stu has been a great friend and has “had my back” ever since. Because of my friendship with Dr. McGill over the years I get asked a lot about his work and get dragged into various social media threads concerning him, his philosophy, and his methodology.
                Quite often, despite all the interviews and podcasts he’s been in recently (thanks to his book Gift Of Injury with Brian Carroll which I highly recommend), I find a lot of people misinterpret Dr. McGill’s work, teaching and principles & criticize what they don’t know. When people ask me about Stu’s work or pull me into an online thread I find myself more clarifying misinterpretations of his work than anything else. Yes there are some things Stu and I do differently but I would say 90%+ of our philosophy & methods are the same.
                In this article I will discuss some of the common misconceptions about Stuart McGill’s work

1) The McGill method ignores psychosocial factors

This is one of the biggest criticisms and misconceptions of the McGill method, particularly by some of my colleagues who are renowned for their knowledge in pain science & the biopsychosocial model.

What people forget is that some of Dr. McGill’s vast research on sports injury risk prediction has looked at psychosocial factors as a risk factor for injury.

McGill has also stated in his Back Mechanic book, and in various interviews, that he looks at the personality types and factors of his clients. Are they Type A personalities who are competitive, hard-driving, ambitious and sometimes push too hard or are they Type B personalities who are more lazy, sedentary & need to be motivated? McGill also looks at life stresses and contextual factors that may be affecting the person’s pain. His extensive interview and assessment process of a patient probes their past impediments to success, many of which involve social and psychological variables. He works to address these impediments with custom strategies for each person.

Side note from Eric: In addition to a McGill style assessment I like to have my patients fill out the Orebro Questionnaire (link here) before the assessment to try to “catch” any psychosocial factors or maladaptive beliefs that may be problematic and predispose someone to a higher likelihood of chronic pain.

2) NO Spinal flexion when using McGill’s principles

This is the other, if not bigger, main criticism and misconception of Stuart McGill’s principles.

One of the big principles of the McGill method is minimizing movements that worsen pain. Both Stu and I find that the vast majority of our patients don’t tolerate flexion very well. I find that, using a repeated movement style of assessment, all but maybe 1-2 of my patients in the last 2.5 years were made progressively worse with repeated spinal flexion. Towards that end it makes sense to give people alternative ways to move and do their ADLs that are preferably less painful.

When I hear (or read) comments like “McGill said never do a situp again” or “McGill said never flex your spine again” – that reflects a big misunderstanding & stereotype again. McGill is a fan of moving in a way that achieves the end goal in the most “biomechanically friendly” way. Towards that end he (and I) encourage hip hinging whenever possible but also understand that some tasks & some sports require spinal movement. Examples of common athletes McGill works with who do have to move their spines are
-          Rowers, MMA and jiu jitsu fighters, gymnasts, tennis players, and strongmen who have to flex & extend their spines in their respective sports
-          And powerlifters who extend during the bench press

For these athletes McGill recommends programming training in a way that provides enough training stimulus to build the required fitness for those sports, but also incorporates deloads & emphasizes joint sparing movement strategies to allow the spine to recover & build capacity for further sport-specific training. Once a spine has desensitized from pain, and adapted with appropriate rehab, then he trains protective stabilization within the movements and tasks for the athlete – these must include deviated postures. His record for restoring back pained athletes from virtually all of the professional sports and many Olympic sports is hard to beat.

3) The McGill method is all about core stiffening and “The McGill Big 3”

Many people I talk to think that McGill’s principles are all about bracing and doing lots of core exercises. As McGill often so eloquently says “it depends.”

The McGill methods works to isolate the movements, postures and loads that worsen an individuals’ pain – than it directs a strategy to address the cause. For example in Brian Carroll’s case, fractured vertebral bone had to be calloused during the rehabilitation phase prior to programming performance training. Many other medical experts failed to accomplish this.

During some of McGill’s tests; which are further described in his books Low Back Disorders, Back Mechanic, and Gift of Injury; McGill will get his patients to do the test without bracing and then with bracing. If bracing reduces symptoms during these tests than bracing and core exercises are emphasized. If bracing increases symptoms the emphasis shifts to relaxing the core musculature.

McGill has documented how tuning core stiffness reduces pain in some whereas other patients may require relaxation of the core musculature. He has measured how tuning stiffness increases performance variables such as enhanced load bearing and strength, strike speed and power in MMA athletes, to name just a few. This involves strategic muscle pulsing at the distal joints reinforced with proximal linkage core stiffness.

Too often I see patients that have mindlessly done core exercises without any critical thinking about why they are doing them or the effect its having on their symptoms.

4) McGill’s research is all done on pig spines

Another issue where I see people dismissing McGill’s work is to say he used animal spines to reach his conclusions. Perhaps they read a single paper. About 10 percent of his publications involved animal spines. Studying any medical condition needs animal models to control variables in a scientific experiment – testing fifty identical human spines is not feasible. But his observations were scaled and verified in humans. For example, the mechanisms he documented leading to disc herniation have been matched by many other scientific groups.

What people may not realize is that his clinical work with people with back pain formed the questions he probed with his scientific experiments. The lab and the clinic were closely linked. And the findings from probing different back pain mechanisms were then used to desensitize pain and restore a foundation for performance training. When he expresses an opinion there is a body of evidence to support it obtained from the lab and the clinic.

I hope this article clears up some misconceptions about the McGill method and gives you a greater appreciation of his work. As always, thanks for reading.

Saturday 10 March 2018

Random Thoughts February 2018 - The Relationship Between Strength & Pain, How I Recover From My Busy Life, The Importance Of Keeping Active Patients Exercising Through Rehab, And The Place Of Manual Therapy In Rehab

        I'm revamping my "Random Thoughts" series. Instead of my traditional short article series I will release a monthly article which will compile Facebook/Twitter posts and other unpublished thoughts I have on various topics on rehab & fitness that are worth mentioning but don't have enough material to make it worth dedicating a full article to.

With that here are my random thoughts from the past month....

The Relationship Between Strength & Pain

Sometimes a lack of strength can be relevant in pain – particularly when there’s a “mismatch” between a person’s demands and their physical capabilities, regardless of whether its before/after their pain started. And there is some research that does show lack of strength to be a risk factor for certain injuries/pain conditions.

That being said
1) The correlation between strength and many musculoskeletal pain conditions isn’t as strong as most people think
2) Many clinical studies have shown that changes in strength don’t always correlate with symptoms
3) Given what we know about the complexities of pain and the biopsychosocial model … to suggest all pain is due to weakness is reductionist & out of line with the evidence

How I Recover From My Busy Life Of Treating, Educating, And Lifting 

Given all my roles as a practicing physiotherapist, doing the occasional consultant, helping with 2 university curriculums, and training for powerlifting … some people ask me how I do it all and not burn out. Admittedly this took me a good year to “get right” after burning out in the past and it will be something I will continue to adjust.

My strategies have included

1) Proper nutrition

2) Proper sleep – around 7-8 hours a night. I aim to go to bed & get up at approximately the same time daily.

3) Adequate down time

I try to pencil in at least an hour of down time at the end of the day to decompress. This enables me to reset myself & sleep a lot better.

4) Time management

Last year I learned I can only run 1-2 areas of my life (ie career, lifting, family) hard at any one point in time (props to Will Kuenzel for teaching me that)… and I need some downtime. Towards that end I prioritize what I need to do, schedule it in my todoist app and my google calendar app, and also put in adequate down time.

It’s part of me realizing, as Stan Efferding said “that you can be good at anything but you can’t be good at everything” much to the chagrin of my hardheaded, Type A personality. In Brian Carroll’s 10/20/Life book he emphasizes having phases where you’re more focused on a meet vs time where you’re more focused on your external life.

5) Active recovery

I’m not a big fan of ice baths or saunas. My recovery approach consists of
-          Twice weekly foam rolling & self ART
-          Daily 10 minute walks as per the advice of Stan Efferding (I don’t do these 3x/day as he recommends due to scheduling but I do do them twice daily)
-          Daily performance of my knee rehab (knee extensions in sitting McKenzie style) and back rehab (McGill Big 3). Even though I’m painfree on a day to day basis I still believe in doing these for rehab & active recovery.

6) Stress management

Pretty much all of these count as stress managers. The only thing I would add is using a lot of positive self-talk to make sure my head is right when dealing with any situation I’m in. 

The Importance Of Keeping Active Patients Exercising Through Rehab

When athletic & physically active patients ask me "what do you think of me doing <insert exercise/activity here>" my answer, unless there are contraindications or unless they're clearly not ready for it, is "let's see how you do with it."

Quite often, more than not, many otherwise healthy & fit patients are capable of doing far more than they think but sometimes the fear of pain/injury holds them back.

Some may disagree with me - but I always believe in giving physically active patients (short of any contraindications) stuff that they can do ideally properly & painfree as it 
1) Gets them on my side - and makes me not look like the 10th person telling them to "just rest" or "never run/squat/deadlift etc again" 
2) Will likely benefit their pain, healing and mood through the benefits of well tolerated movement & general exercise and
3) Gets them to trust & believe in their bodies more
4) Gives them a means to maintain/improve fitness
5) Makes the rehab process feel less like boring rehab

The Place Of Manual Therapy In Rehab

Manual therapy has a place if a patient can't tolerate a full session of exercise/education due to
1) High irritability
2) Deconditioning - let's face it we've all had those patients that are toast after 1-2 simple exercises
3) Contraindications due to surgeries or medical conditions that prevent the patient from doing much (if any) exercise

Some would say "I'd rather only have a patient do 2 minutes of exercise than make them dependent on me." While I appreciate that idea - there's only so much education you can do in a session & expect a patient to retain effectively. If I was a patient, paid for a 30 minute session, and only got 5-10 minutes of therapy I'd be pretty POed. That's where the passive therapies have their place.

That said - the research and guidelines are really trying to push away from passive therapies & more to movement/exercise, education, and psychosocial therapies in the management of musculoskeletal pain and that's where the vast majority of our treatments should fall in.

How I've Adapted The McKenzie Method Over The Years

If someone were to ask me “what are the biggest influences on your therapy philosophy” they would be (in no particular order) ·  ...