Review of The McGill 2 course: "Reducing pain and enhancing performance: The three hour back assessment."

I attended this course on 4th February at the Anglo-European College of Chiropractic in Bournemouth. I previously attended McGill 1 ('Building the ultimate back: from rehabilitation to performance') in Dublin in 2015.

To see the general description of Professor Stuart McGills courses and his books and publications go here. I assume by reading this blog you already know who he is.

Now, I'm not going to give the detail of the course, if you want that you can pay for the course yourself! But I will compare McGill 1 and 2, give a few insights and suggest whether it is worth you doing the course yourself if you are interested. Also, McGill doesn't let you take pictures of video either, so none of that here.

Anything in quotation marks is a quote from Stuart McGill unless otherwise stated.

McGill 2.

The course is one day, and split in two halves. The morning is lectures covering the theory, movement screening, imaging and examples from various research studies.

The afternoon is the practical going through various tests, movement screens, and practical recommendations in a clinical environment. In this case using Chiropractor plinths - which I must say are bizarre and not very good if you are not doing Chiropractic manipulations! Apparently McGill has presented at AECC on several occasions, so they should have known that the treatment tables they had were not going to be any good for the practical things we were doing.

Movement Screens.

McGill is quick to point out that he is not going to give you a simple system like an FMS to use. There is no simple screen or test with complicated back pain cases.

He covers his research into the FMS - which he also does on McGill 1. He probably spent more time on this in McGill 1.

There is an assumption that people on this course had done McGill 1, but it seemed most people hadn't. Most people on McGill 2 were Chiropractors (surprising eh, being at a Chiro school) whereas I would say at McGill 1 there were more athletic trainers.

In short, even though he has a lot of good things to say about Gray Cook and suggests any new trainer learns the FMS, this is not going to be enough for anyone trying to be a top notch clinician. In essence the FMS is a three chord punk song whereas the McGill assessment is "jazz".

For example, the overhead squat test in the FMS, which requires very good shoulder mobility to score a 3,  but "shoulder mobility is a gift from God!', not necessarily something you can change.

His approach is about "converging on a precise diagnosis".

This is where his scientific background comes in. You formulate your hypothesis, and then test it. For example, pain is coming from disc at L.4. Test it, if your wrong, go again.

You can read his books, get his DVDs and listen to podcasts with him in to garner most of what he covers in his seminars. However, there is that extra quality to seeing him in a real life situation. He has charisma, a wealth of knowledge and despite protestations that he is no clinician - obviously is gifted in this area as well as his ability to relate to people.

He has worked with so many different types of people from professional hockey, NFL, MMA, rugby, powerlifting, as well as every day people with everyday jobs with back pain that has been dismissed or misdiagnosed (or not diagnosed at all). He is normally the last resort, if you are seeing him, you are desperate and have seen 10 other experts; his approach has to work.

He brings all this into the lecture theatre, at his best when going off on tangents, citing a research study, talking about specific patients, answering questions - but genuinely listening and not afraid to give strong opinions and say "I don't know" when he doesn't.

For example, I asked him why people sit into their pain, it seems counter-intuitive that someone who is forward flexion intolerant would adopt that posture. He said he didn't know why people did it, but they do and we don't know why.

Or, a friend of mine who is in his 2nd year at Chiropractor school asked if McGill ever saw acute cases. He doesn't, by the time they reach him they are chronic. He said the acute cases are for the clinicians and manual therapists.

Context.

His approach is all about context. He gives the example of posture, no variability and too much variability in posture will result in injury, there is a "sweet spot" in the middle. However, in the weights room there should be zero variability (not in that everyone should squat or deadlift the same) but when you have found the best technique for you or a client, you should be fastidious with every rep.

He also gives examples of very good winning athletes with so called 'poor movement', are you going to change their posture when they are winning and not in pain? Of course not.

He also covered several studies in the morning session. Including one on firefighters and movement screening, and how some moved better with load and some moved worse with load. And studies on changing hip mobility, stretching,  and trying to change peoples lordotic spine curves.

Stop trying to fit a pentagon shaped peg into a square hole. Everyone is different.

Non specific back pain and imaging.

If  you really want to wind up Prof. McGill mention non specific back pain and general exercise recommendations.

He is dismissive of the medical profession that gives this diagnosis (no one ever had non specific head pain and then was told to have surgery anyway to remove part of the head!) and also some radiologists and their inability to interpret an MRI.

In the morning session of McGill 2 he briefly covers medical imaging and differential diagnosis.

For example, MRI might show a disc bulge at L.2, but if all the symptoms show a problem with L.4, then surgery in L.2 is not going to do anything, even if the MRI shows 'abnormality' there.

In fact, he is very much certain that in 95% of cases that have been told they need surgery you can help them avoid it.

I think one of the other attendees used the phrase "Victim Of Medical Imaging Technology" - VOMIT. Haha. Yes imaging is a fantastic tool but know its limitations.

People giving general exercise recommendations like 'do yoga or pilates' is also lazy. Know the limitations of research where people are diagnosed with 'general back pain' and given 'general exercise'.

In terms of differential diagnosis, McGill interestingly says he has only come across two cases of piriformis syndrome - it is very rare. But, as anyone working in this field knows, people get told all the time they have piriformis syndrome and advised to drive a lacrosse ball into it.

Two interesting things McGill mentioned were spinal shock and neural resonance.

These were interesting, and I will have to think about them more from a neuroscience point of view. The neural resonance effect is when someone has a shuddering in a 8-10 Hz range before being able to do a movement like stand up. This appears to be coming from the Motor Cortex itself. This is easier to demonstrate than explain.

At this point he mentioned visualization and trying to lay down myelination and form new engrams (the software in the brain needs updating, the hardware is fine) of movement. This very much chimes with what I've  been reading recently in neuroscience, neuroplasticity and long term synaptic potentiation.

The assessment.

I think what he is trying to get across is how complete the assessment of the person in front of you has to be. From observing how they get out of their car, walk up the stairs, open the door, the look on their face, their complete history, how they sleep, how long they sleep, are they a type A or B personality and on and on.

He doesn't have a set assessment form. Every person is different.

You need to see how they move when fresh, when under stress, when under fatigue - 'break them down' and see what their movement does.

"What matters most to that person" is what you need to focus on.

Is it getting down on the floor and playing with their kids or returning to the NFL or running 10k? There is not one route.

When you have tested the hypothesis, and have a plan you then need to "coach movement not corrective exercise"

You should then "know the goal of the training programme and every single exercise."

The practical.

In the afternoon McGill then goes through the various practical assessments such as heel drop test, seated compression and things like neural flossing. All looking to identify if there is a stability problem, what are the triggers etc. Too many to mention here, with too many pearls of clinical wisdom.

But, I think if you hadn't read his books or watched his DVDs this section could be overwhelming. I would recommend familiarizing yourself with these before attending the course.

Yeah I'm the fan boy who bought the books when they originally came out over 10 years ago. I would read these or watch his assessment DVDs before attending the course. These are my books from 2002 and 2004, the latest editions contain  more recent research.

His assistant Joel (website for his facility here) covered the hip assessment, I believe he is an S&C coach.

By 6pm everyone was flagging and there was information overload. And left me with a couple of final thoughts on how to integrate all this information.

Three hour assessment.

In reality I don't think anyone in that room apart from McGill is going to go away and start doing three hour back assessments. However, I think everyone can take something away and make their approach more rigorous. We all get stuck in patterns, become a  bit lazy and default to certain ways of thinking , or diagnosis (if that's what you do).

Courses like this re-energise you.

McGill 1 or 2?

McGill 1 covered the research for the exercises more in depth and had a big practical element going through cat camels, bird dogs, side bridges, curl ups, glute exercises and more. Afterall McGill 1 is 2 days long.

If you are an athletic trainer, McGill 1 is the course to do. If don't have access to a therapy couch or your job doesn't allow hands on testing and assessment then there is not much you can practically take away from McGill 2.

From a clinician/ therapist point of view, McGill 2 is going to give you more assessment tools and some treatment options that can be done in a clinical setting and help the client can move better. But if you don't know the big 3 exercises, what a hip hinge is, and more, then it doesn't give you much to give your client to take away and do. For example, McGill mentioned the side bridge on the course and some peoples obsession with making it harder, but said that lifting a leg in a side bridge can double the spine load. If you don't know how to do the side bridge in the first place, this information may not be of use.

McGill 1 cover more things you can do with athletes as well. He covers deadlifting technique, squat technique, neural drive and more. In McGill 2 he only briefly mentions the spate of end plate fractures from people deadlifting and broken pelvic rings from people going too heavy on unilateral leg work.

In someways, it might be better to have the courses the other way round.

We had more time on McGill 1, McGill 2 seemed like we were rushing through the tests and assessments in the afternoon. And these are subtle things, with nuance that take time to learn. In some ways trying to cram too much in can cause confusion and lack of clarity.

On McGill 1 we were given a pdf of all the lectures. On this course there was no pdf or printed copy of the slides provided. This would have been useful to have.

Questions.

Some of these questions have only occurred to me after the course, some I had on the day.

McGill 2 doesn't give you an exercise pathway as such. For example, someone has a underhook at L.3, does this change the way you do the cat camel or bird dog? Aren't you going to do the big three exercises regardless of outcome?

Why do some people sit into their pain?

Why do some people have "reversed perception" and constantly self manipulate, how can you stop them?

Does any professional team or facility have a robust screening/assessment process that has been shown to reduce injury and improve performance by individualizing programmes?

Would it be possible to see neural resonance traces on an EEG or fMRI?

As always courses like this always throw up more questions and more to learn.

As McGill says "It depends" and "We are playing Jazz here". Treat or train the person in front of you, adapt and freestyle as needed, but use science and logic as your guide.

Closing thoughts.

You could learn nearly all that is covered on the course from McGills books, DVDs and research publications.

But by going on the course, you learn something more. It gives you an insight into how to interact with clients and patients. You see the man in action and his thought process.

He has just retired and is winding down, so if this is your thing now is probably the time.

I believe AECC billed this as a more intimate course than McGill 1 but it seems there were as many people as McGill 1, with 50+ other people in the room.

But even if you only take away 1 or 2 new bits of information or a way of phrasing something or carrying yourself in front of client then it was worth it.

I preferred McGill 1 as a course, and from McGill 2 I enjoyed the morning lectures session the most. It has given me a list of research to follow up. But maybe that's just my bias of wanting to know more about the research and not being so clinic based.

Take home message - be better, know more.

Now should I do McGill 3?

So Many Mobility Exercises So Little Time. Which Ones Should You Do?

There are hundreds of mobility exercises, and some are better than others. With limited time, which ones should you do? Which ones will achieve the most in the time available? A quick straw poll amongst the trainer and coaches I know, revealed the following three to be our current favourites.

Of course, these aren't the only mobility exercises or drills we do and depending on your individual needs, injuries and goals there may be better choices for you. With that caveat in mind, here are three mobility exercises you or your clients should try.

Cat Camel



Why Should You Do This?

If like most people you spend much of your day sitting, or driving or stuck in one position your back gets glued up and stuck. The cat/ camel can provide some active flexibility for the back with minimal loading. It is often a starting point for people with back pain. It is proven to reduce the viscosity (makes it less glued up and reduces friction) in the spine & torso (McGill, 2002 & 2007). Before you work out or anytime during the day when you have been stuck in one position jump down and do some cat camels to get the back moving more efficiently. The beauty of the cat camel is just about everyone can do it

How To Do It

On all fours, hands under shoulders, knees under hips. Then get the whole spine to move up and down - neck, middle back and lower back. Note this is not a stretch, in the video above you can see Nathan starts with a very small range of movement. There should be no grimacing or pushing into the end part of the movement. You only need to do 6-10 of these to get the effect of reducing viscosity in the back, there is no need to do anymore.

What Can Go Wrong?

Some people, especially those who have had or do have back pain can find it very hard to move their spine. They think they are moving their back up and down but they are not, their spine has turned into a breeze block. Look for compensation in the arms and shoulder blades. It is possible for someone to have no spinal movement and literally be bending their arms and shrugging, this has no benefit.  The person who does this is going to need extra cuing and coaching.

Also some people with sciatica may find the flexion (arching up) part of the movement increases their symptoms (McGill, 2002), they need to reduce the movement. As always, all movement should be pain free, look out for the pain face and breath holding.

Lastly, generally avoid any spine bending first thing in the morning when the back is at its stiffest and the discs have re-hydrated overnight. Otherwise, you can do this exercise any time of day.

Boot Strapper Squat




Why Should You Do This? 

I have found that this exercise is one of the quickest ways to improve someones squat depth and technique. I think Dan John probably invented it, but don't quote me on that.

There is something about the movement pattern that the body responds to. It could be because it combines a hip hinge/ deadlift movement with a squat movement. It could be because this is the way humans move when developing as babies, we generally pick weights up off the floor using a deadlift movement and when we learn to squat it is from a bottoms up position. As babies we crawl, then bear crawl and then get into a squat position and stand up.

Even if this movement has nothing to do with developmental kinesiology, it does work. I've seen clients who couldn't squat to anywhere near to parallel without knee collapse and loss of control, get to a below parallel good position squat after less than 10 repetitions of bootstrappers.

How To Do It

Grab a kettlebell by the horns, as in the video. There is something about the kettlebell shape and the way the weight pulls downwards that makes it conducive to this exercise.


Then drop into a squat position, there is a good chance you or your client will not be as mobile as Nathan is in the video clip above. Just drop as low as possible with good technique - neck neutral, lumbar spine neutral, knees pushing outwards. It's also best to do this barefoot, so you can see any compensation in the feet or ankles (trying to lift up or turn out excessively).The next stage is to push the kettlebell backwards low through your legs and push the hips up and back at the same time. You end up in a hip hinge, RDL position, again the spine is neutral, as is the neck (no cranking on the neck or looking up) and the knees are slightly bent, you should feel the tension in the hamstrings. And then slowly drop back into a squat and bring the kettlebell back up to the goblet squat position. The depth and quality of the squat should improve as you do the repetitions.

I have seen several video clips of people doing this exercise fast and for high reps, using it more as a conditioning exercise. I prefer to do it as in the video I filmed above, a smooth, controlled tempo, doing up to 10 repetitions as a mobility drill before a workout.

What Can Go Wrong?

This is one of those exercises that doesn't work well in a group training environment. You will demonstrate it, and then when you look around the class to see what people are actually doing you will cry.

Most common is for people to round their back, not hip hinge, crank their head forward and up and anything else you can think of that is wrong. Therefore, I would generally only do this exercise one to one with a client, that way you can correct and cue as needed.

Brettzel

As invented by Brett and Gray Cook. Hence, I have embedded their videos here as they can explain it better than me.



Most of your clients are going to look more like Brett Jones doing the exercise above. In other words, they are going to find the position hard and are going to need some props. Some might have good mobility like the video below with Gray Cook demonstrating with someone who has good mobility.



Why Should You Do This?

Did you not watch the videos above? This is going to work on your T-spine mobility, hip flexor/quad of the down leg and the lateral hip muscles of the top leg. Plus, you can work on your diaphragmatic breathing while holding the positions.

How To Do It

Like in the videos above! Most people are going to have to use some props under their knee and under their head, use whatever you have to hand, towels, yoga block, foam rollers.

What Can Go Wrong?

Some people will not be able to grab their lower leg and put it into a stretch position. In which case, a band or strap could be used, careful though, this causes some people to tense up and lose upper body positioning. These clients may be better off not trying to grab the lower leg; they should try a rib roll to begin with, just focusing on the T-spine and middle back.

Someone says they feel it in their lower back? Check the front knee/ leg position. Their hip might need more flexion and they may need that leg up on a prop to stop twist in the pelvis if they are tight in that area.

Also, look out for the pain face again. This might be a challenging mobility exercise, but you shouldn't be grimacing or holding your breath. Some people want to be martyrs and refuse to use props. Remind them this is not cheating, but actually making the movement better. No forcing, no bouncing into the movement and no pain!

Wrap Up

Try these if you haven't already done so. And if you have any mobility exercises or drills that you think are essential or should be in a program let me know.

References

McGill S (2002) Low Back Disorders: Evidence Based Prevention & Rehabilitation
McGill S (2007) Ultimate Back Fitness & Performance
Cook G & Jones B Kettlebells From The Ground Up DVD