What A Future Physical Therapist Learned From Dr. Stuart McGill: Part 1

By Jack Davis

Part 1: Introduction

This article is written to help understand the process of training designed to improve performance but also strengthen the back and limit pain and limitation. To write this article I have read the book Ultimate Back Fitness and Performance by Dr. Stuart McGill. Here at TrainSMART Personal Fitness, Dr. McGill has had an immeasurable impact. Owner Joe Fox has stated that Dr. McGill has had one of the biggest impacts on his career and practice. Dr. McGill is considered an expert in managing back pain and rehabilitation and is a leading authority in the realm of spine biomechanics. Dr. McGill is a professor of Spine Biomechanics at the University of Waterloo, Canada. In Dr. McGill’s 30+ year career,he has published hundreds of scientific articles along with a team of scientists and graduate students. Dr. McGill utilizes his research to help patients rehabilitate the worst cases of back pain/injury and has published several books and teaches his findings to others. Some other books by Dr. Stuart McGill include, but not limited to, Low Back Disorders: Evidence Based Prevention and Rehabilitation and Back Mechanic. If you are currently trying to manage back pain, I strongly recommend Back Mechanic as it provides lots of useful information for managing pain. After reading this article, you should have a better understanding of ways to train to avoid injury as well as ways to train with injury. Over Dr. McGill’s career, he has treated many people for back pain, ranging from normal people to world champion athletes.

The very first thing that must be addressed when designing a program is exercise dosage. For a painful or injured back, the exercise dose which will stimulate adaptation is extremely close to the dose which will cause harm. As patients progress in training and rehab the margin of safety increases. However, you must still proceed with caution to not aggravate any new injury. By using an appropriate load, injury risk can be minimized, and gains can be maximized. Load is typically thought of as the amount of weight used, but a better way to think of load is it is “the cumulative forces that are imposed on the tissues that result from daily activity and training sessions.”(pg. 10, McGill) When load exceeds one’s tolerance, injury and tissue damage occur. By following a well-designed program, one can continuously improve their tolerance and progressively increase load. While talking about load and tolerance, it is also necessary to discuss capacity. Capacity is the sum of all activities performed over a period of time, which can be looked at over a training session, a day, a week, etc. Capacity is important because everyone has a definitive capacity. A portion of your capacity is used with every activity performed and can even be wasted by poor posture! Capacity is an extremely important variable to observe especially during times of acute back pain, or during times of extreme pain/injury. Capacity can also be used to help guide workouts as well.

Example: A patient with low back pain has been training/rehabbing for 1 month and has seen improvements in pain and performance. However today they went golfing prior to their training session. That would greatly deplete their capacity and their training should reflect this and proceed with caution.

The other key to remember is a pain free, high performing back is extremely dependent on functional hips and core. With functional hips and core it will help to reduce stress placed on the spine and provide stability. By training hips and core it will allow force to be directed through the skeleton so weaker joints are not forced to absorb any energy, resulting in maximal force transmission. To accommodate for the factors described above Dr. McGill has developed a 5-stage program to rehab back pain and improve performance. The stages include ingraining motor patterns, stability, endurance, strength, and speed/power.

However, before we dive into McGill’s 5 stage approach, we must first discuss the core and lumbar stability. The core musculature acts as a stabilizer of the spine, and the importance of this cannot be stressed enough. The spine is essentially a column that bears and supports the weight of the body. The key difference between the spine and a normal weight bearing column is that the spine moves! There are nearly no structures that are both weight bearing and moving, and this is asked of the spine every day. The spine can twist, flex, bend, and extend, but is responsible for supporting the body as well. In a study performed on the spine of a cadaver (with no core stability provided), the lumbar spine buckles with only 20 pounds of compressive load. This is why building a strong and functional core is important. A functional core acts as a 3-D guy wire system which functions to stabilize the spine and transfer force and power through the hips, while minimizing force loss. This stiffness and stability is achieved by training the core musculature and co-contraction of these muscles to eliminate the micromovements which cause pain or tissue damage. This core stiffness is even more crucial for those with past injury, as injury results in more laxity. This increased laxity leads to more micromovements causing pain and tissue damage. If you are struggling to achieve a braced core, start with your elbow. Slightly bend the elbow then squeeze your arm tight, while maintaining the same position. Activate both flexors (biceps) and extensors (triceps) and feel the difference of arm position stiffness before and after this. Then use this new understanding of stiffness and work to a full contraction of core and feel the difference.

Part 2: McGill's 5 Stage Approach

Stage 1: Ingrain Motor Patterns

Motor/motion patterns can have drastic effects on injury and performance and can even be altered by injury. Those with back problems often develop improper motor patterns which act as a detriment to recovery and performance. Improper motor patterns can also be the cause of injury. While training motor patterns there are 3 key stages. The cognitive stage is the stage where you are first learning a new movement. The motor stage is after having some experience with the movement and being able to perform consistently. The automatic stage is after mastering the movement and being able to do so without coaching.

Cognitive Stage

Individuals respond well to environmental/external cues
Visual and verbal cues more important than proprioceptive, however use of hands can help athlete learn movement
Continuous coaching is necessary until athlete is able to reach intended position independently

Motor Stage

Effective, consistent movement
Athletes able to identify their own mistakes
Proprioceptive feedback is more useful here compared to verbal/visual feedback
Consistently drill movement at home and practice to make automatic

Automatic Stage

End goal
Movement is second nature, able to perform independently

Movement patterns can be trained very differently depending on the person and, if done correctly, can be extremely beneficial.

With motor patterns it is also important to work on posture. Poor posture will decrease overall capacity and limit muscle performance. For example, a neck when flexed will slightly diminish the endurance of back extensors, while an extended neck severely impacts endurance of the back extensors. To correct posture, a simple test can be done independently.

Stand in your normal standing posture and place your hands on your low back and each side of your spine. Feel the muscles, do they feel relaxed? Do they feel tight like they are contracting? If they are relaxed, that means you are standing in good posture and you’re not wasting capacity with unnecessary muscle contraction. If they are tight and contracting, this means you are slouching. Extend the hips and stand taller until you discover the position these muscles relax, meaning your center of mass is directly over the lumbar spine to effectively support weight.

To ensure a neutral spine and reduce the risk of injury, the hip hinge motion is a critical movement pattern which is used in almost every activity/movement. A great exercise to drill the motor pattern of the hip hinge is a kneeling isolation hip hinge(see photo below). While kneeling, stay tall then drop the butt down to the heels. A bar/dowel can be used as well to ensure a neutral spine. The bar must remain intact with the 3 points of contact being back of head, thoracic spine, and the sacrum. If the bar loses contact, you moved through your spine not the hip. To progress, weight may be added with a barbell on top of the shoulders or an elastic band along the waist.

Another great exercise to train the standing hip hinge is the shortstop squat. It is called this because it mimics a common posture from baseball players. While standing tall, slide your hands down the front of your legs to above the knee, while moving the hips back. Then do the reverse, extend at the hips, and slide your hands up your legs.

A great exercise to train rotation using the hips and not twisting of the spine is the wall roll. It begins with a plank position against a wall. Brace the core and lock the ribs down to your pelvis. Then pivot about the feet and remove one arm from the wall, the key is to move the shoulders and hips together as one.

One more test that can be very beneficial and educational for athletes involves getting into a quadruped position. This test is done to determine optimal hip and foot width for the squat. The depth of the squat is largely due to the structure of our hip joints, and everyone has different hips. So begin on all fours, with knees together. Then rock back and take note of when spine lost the neutral position and rounded. Repeat this with the knees in a different position. By playing around and testing out new positions you can determine the placement which allows you to go the farthest without compromising a neutral spine.

Stage 2: Whole Body and Spine Stability

To build whole body stability, the first key part is balance. Proper balance ensures force is directed in the correct direction. Training balance requires relatively low volumes of work and is something that is best to do daily. There is also a very big difference between training static and dynamic balance, and to achieve elite balance you must train every aspect there is to balance. There are countless balance exercises and almost every movement can be designed to challenge balance. When developing a balance program, a progression list (seen below) can be used to provide continuous challenge while demanding new adaptations from the body.

Bilateral stance
Unilateral stance
Arms/legs as counterbalance
No arms
Eyes closed
Varied surface
Apparatus (unstable surface or smaller base of support)
Dynamic movement
Increased range of motion
Increased speed
Add reaction component
Add external kinesthetic stimulus

After training balance, it is time to develop lumbar stability and core strength/endurance. To do so the “Big 3” will be the most effective. The big 3 includes the Curl-Up, Side bridge, and Birddog. It is important to note that with these exercises, especially with the Curl-Up if there is neck pain. If there is neck pain, it may be helpful to place the tongue on the roof of the mouth behind the front teeth and push the tongue into the back of them. By doing so it activates the digastric muscles which provide more stability to the neck. For those with neck pain, it may also be beneficial to train some isometric exercises specifically to the neck. For these exercises, the head and neck will not move. Simply press the head into the hands which provides a resistive force. The different hand positions include hands on forehead, 1 hand on side of head, hands on back of head. Place tongue behind teeth to roof of mouth and drive head/neck into hand while not allowing movement with the hand. Hold this position and tension with contraction for 8-10 seconds, relax and repeat. After performing the Big 3 some progressions for core training include the dead bug, scissor side plank, rolling plank. Other ways to progress the core exercises would be to use a labile surface. With the use of labile forces it causes much greater co-contraction between the abdominal muscles. Dr. McGill performed a study with the use of EMG to determine the difference between the Curl-Up and one performed with the torso on a med ball, which showed a nearly 2x increase in muscle activation of rectus abdominis, and both internal/external obliques. During Dr. McGill’s research he has also found that maximum stability occurs at the beginning of expiration as it activates the obliques and transverse abdominus to expire air.

Stage 3: Endurance

At this stage of training, you have now developed some prerequisites for stability and have trained movement patterns. Now it is time to build up more endurance and be able to increase the amount of total volume tolerable. At this stage of training your total tolerance has increased and we are able to begin increasing the total load/volume . With building endurance, most people believe it should be for long durations and very fatiguing. However, we will be trying to build endurance without becoming fatigued. To do so we start with short isometric holds of about 7-8 seconds of the Big 3. This time duration has been determined to be the optimal length as time beyond this causes drastic losses in the amount of available oxygen to torso muscles. So to continue to build endurance while working within this timeframe we increase reps, rather than duration. Endurance of the core and back is extremely important as core endurance has been found to be one of the most crucial factors in determining low back health. Dr. McGill likes to use the “Russian Reverse Pyramid” for his core training. In the reverse pyramid model,it looks like doing 6 reps of exercise on each side, then 4 reps of exercise on each side, then 2 reps on each side then rest. During exercise, it is crucial that form is maintained, as it has been found that even just deviating the neck from neutral affects endurance times. Training core endurance is important, as it is what will maintain that stiffness and stability for long duration, and stiffness must be independent of breathing.

Before actual endurance training can be done, it is important to first breathe properly. To practice this we will do some “Crocodile breathing”, which is a form of diaphragmatic breathing performed in the prone position.

Lie on floor face down, with face in hands
Stiffen torso and push abdomen into floor
Breathe and think about pushing stomach more into floor, raising body away from floor

It is important to breathe through the diaphragm as the core functions together as a team and everything must be operating correctly.

With endurance training it is important to make the training specific to the demands which will be imposed onto the athlete in the demands of their sport. For example, many strength athletes are required to maintain a stiff torso while under asymmetric loads, a good exercise for this would be the suitcase carry.

Stage 4: Strength

The reason strength-oriented training takes place after endurance, stability, and motor control is because of how important it is to have a strong foundation. Maximal strength cannot be exerted if unstable or if force is being misdirected. That is why proper motor patterns must first be developed, then stabilized, and then must have adequate endurance to maintain that position. While training for strength, Dr. McGill recommends training in a style that involves short and explosive sets, while maintaining perfect form without fatigue. After a set of exercises you should feel facilitated, not fatigued. Dr. McGill also places a focus on training with dumbbells or kettlebells rather than a barbell. The reasoning for this is that very rarely are the hands moving together, and often are moving independent of each other. Therefore, training with free weights better mimics a sporting environment.

An approach that Dr. McGill likes to take while strength training is to also train motor unit activation. Training motor unit activation allows athletes to be able to activate maximal amounts of motor units during exercise. To train this Dr. McGill uses a method called the moveable fulcrum (shown in the video below). During this exercise, mental imagery is important and focus on contracting the targeted muscle. A great muscle group to use this technique for is the extensors of the back, which are important for stability and will help maintain a neutral spine. Although external weight may be used for this exercise, it is not important as the main focus is to simply feel the difference between muscle activation in different segments of the muscle. To perform this exercise a bench and pad are required. While laying down on the pad start with around chest height. Allow the back to bend and flex over it, then pull yourself up to neutral. Repeat this but move the pad down slightly. Only return yourself to a neutral position, and do not pass beyond.