For Dr. Stuart McGill, surgery should be the last resort.

In fact, for many patients who don’t properly address their pain, surgery is, at best, a temporary option. Consider this: following a disc hernia procedure, many patients, including those Dr. McGill sees, usually fall back into old habits and run the risk of re-injuring their damaged spine. “So you are going to have to change the way that you move [and] become more efficient in purposefully stimulating the adaption that you need in your body to become robust again,” he says.

The problem, Dr. McGill says, is that most orthopaedists don’t do a full exam of the whole patient to find the source of the pain. That can take two to three hours. 

“The assessment, if it's thorough enough, will always give you the answer,” says Dr. McGill. And that answer is rarely putting a patient under the knife. Other solutions, which can often include long-term therapies, will get to the source of the pain and lead to long-term healing “95% of the time,” he says.

Dr. McGill knows what he’s talking about: he has literally written the book on the mechanics of back pain, how to assess it, and published award-winning research on spine biomechanics. Also, as a distinguished Professor Emeritus at University of Waterloo, he is considered one of the world’s leading biomechanists.

On this episode of Back Talk Doc, Dr. McGill joined Dr. Lakhia with special guest Dr. John Lesher, MD, MPH, of Carolina Neurosurgery & Spine Associates to talk all about spine biomechanics: from the benefits of a technique experts refer to as “virtual surgery,” to the mechanics of strengthening exercises for back pain. 

Read the Full Show Notes on our website BackTalkDoc.com.



💡 Featured Expert 💡

Name: Dr. Stuart McGill, PhD

What he does: Dr. Stuart McGill is one of the world’s most renowned spine biomechanists. He is a distinguished Professor Emeritus of spine biomechanics at the University of Waterloo, where he published over 200 peer-reviewed papers and award-winning research in the field of low back biomechanics. He is also the author of several books, the most recent being Back Mechanic (2015).

Company: BackFitPro 

Words of wisdom: “The way to stay pain-free is, one day a week, rest. Don't do anything. That's the day that your body adapts. So all the stimulation that you've done all week long, let it adapt.”

Connect: Website | Twitter

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👉 If you enjoyed this episode of Back Talk Doc, check out our recent episode Back Pain Relief Through Posture and Movement, with Esther Gokhale.

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Back Talk Doc is brought to you by Carolina Neurosurgery & Spine Associates, with offices in North and South Carolina. To learn more about Dr. Lakhia and treatment options for back and spine issues, go to backtalkdoc.com. To schedule an appointment with Carolina Neurosurgery & Spine Associates, you can call us at 1-800-344-6716 or visit our website at carolinaneurosurgery.com.

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Welcome. You're listening to Back Talk Doc where you'll find answers to some of the most common questions about back pain and spine health brought to you by Carolina Neurosurgery & Spine Associates, where providing personalized, highly-skilled, and compassionate spine care has been our specialty for over 75 years. Now it's time to understand the cause of back pain and learn about options to get you back on track. Here's your Back Talk Doc, Dr. Sanjiv Lakhia.

When I started the podcast, Back Talk Doc, about two years ago, I had two goals in mind. First, obviously, I'm biased. I love where I work and I wanted to feature all the talents and services we offer at Carolina Neurosurgery & Spine Associates and, largely, I've done that. We've had great interviews with some of the best surgeons in the entire region in the country, talking about things like minimally-invasive spine surgery, spinal stenosis.

I've been able to interview many of my partners who are physiatrists as well, where we've talked about regenerative medicine, injections. We've had multiple episodes on the rehabilitative approach to back pain. So I've been very proud and pleased to offer that to all you listeners out there. My other goal though was to try and attract thought leaders in the space of spine care from across the country and the world.

Folks, I'm super excited today to say that we are accomplishing that goal in the moment. Today, I'd love to welcome to the show probably the world's most renowned back mechanic, spine biomechanist, Dr. Stuart McGill. Stu, welcome to the show.

Well, thanks so much, Sanjiv, and a good day to John as well.

Yes, and also my friend and colleague, Dr. John Lesher, is joining us for a conversation today. Originally, Stu, when we talked, we were kind of titling this show, Fact or Fiction Regarding Spine Care and Back Pain. But I have a feeling with three spine nerds like us, this could go in any direction. But I want to introduce you to the listeners. I'm not understating. You're literally a living legend in the field of back rehabilitation.

Particularly when I mentioned to the physical therapy team in our group, everyone was really pleased to hear that you volunteered some time to speak with us. But for those potential patients out there or just people who aren't familiar with you, I'm going to take a brief moment and kind of go over your background. Dr. McGill is a distinguished professor emeritus, spine biomechanics at the University of Waterloo.

He's a professor there for 30 years and explored low back mechanics, both intact humans, both normal and injured people, and harvested tissues where specific injuries are created and analyzed. He's been the author of many scientific journal papers, last I recall, almost 200 peer-review published articles, maybe more. He's mentored over 40 graduate students, and his work has received several international awards, including the Volvo Bioengineering Award for Low Back Pain Research in 1986 and, most recently, the Order of Canada.

As a consultant, he's provided expertise on low back injury to various government agencies, many corporations and legal firms, professional and international athletes and teams worldwide. Dr. McGill's regularly referred special patient cases from the international medical community for opinion. So folks, he's an expert. He's also an author, and I've been deep diving into his work. So the first one I have here is, with my green screen here how that's going to show up, Back Mechanic.

This is a fabulous book put together ... Actually, I wasn't aware of it until John mentioned it to me to take a look at for my own back, and it's been a wonderful resource. Other ones, Ultimate Back Fitness and Performance. Then I also have Low Back Disorders: Evidence-Based Prevention and Rehab. My physical therapy team provided that for me, so they are definitely heavy, heavy into your work. He sat on numerous editorial boards for journals, like the Journal of Spine, Clinical Biomechanics, and Journal of Applied Biomechanics.

Like I said, an author and he's also put together the book, Gift of Injury, which is a very, very interesting read. He is a married gentleman with two children and lives in Ontario and really just an authority in the world of back pain. Stu, did I leave anything out that you think people should know about you?

I was thinking of a very smart answer that you might have to censor, so we won't start off that way.

Okay. Fair enough, fair enough. But really, you've dedicated your life. This is your focus. It's so appreciated for those of us in clinical medicine, that there are people who have put in the work in the laboratory. One of the things on this podcast, I've been able to bring in all different types of angles and approaches to how you treat back pain, and what you really add in terms of value-add to the show is a scientific background on how you've literally investigated a lot of the thoughts about the way things should be and put evidence behind them or kind of disproven them.

It's very much appreciated because in the world of back pain, it can be a black box, I guess. We can go down pathways and not get the results we're looking for. I think the question I want to lead off with in our fact versus fiction ... Before we get into that, I want to let John. I think he's got a very good question, and we were talking about it before you came on, referencing how you made a decision to get into this clinical space. So John, I'll let you lead with that question as an opening question for Dr. McGill.

Sure. Thanks, Sanjiv. I was just basically really interested in how or was there a sentinel event or something that went on in your early career or life where you said, "Gosh, the studies that I'm doing and the research that I'm doing, I need to apply this directly more to patients to help in their assessment and then guide them through the rehab journey?" So I'm just curious, was there a spark that really got that going in your career?

Yes and no. This might surprise you. I never intended to become this clinician aberration that I am. I never intended to see patients. I was a scientist and started off in the laboratory just asking a simple question, how does the spine work? That was it. I would be invited to orthopedic meetings or neurology meetings, and the medics would approach me afterwards and say, "What you just showed in terms of mechanism is something that we haven't thought about. Would you see a patient with us that's being a bit difficult right now, a challenge for us?"

I said, "No, I'm not a clinician." And they said, "Don't worry. We are, but we would like you to come and see this patient and show us what you see." So that was the start of that and, very reluctantly, I went. But I realized not having gone through the traditional medical school training, although I took all the engineering courses and quite a number, obviously, medical anatomy and physiology and those kinds of things, but I hadn't been through the clinical realm.

In other words, here's how you conduct a back assessment and you have 15 minutes. And then in another 15, you're going to see the next patient. I didn't have any of that. So the next seminal event was the dean came to me and said, "I'd like you to start an experimental research clinic here at the university." Well, I wasn't familiar with the 15-minute model. I asked the question, "How long do I need to be with a patient to understand the mechanism of their pain, why they're in pain, what's missing?"

I decided I think I need two hours to see a patient to start that process. I have to listen to them and understand what are all the impediments that have prevented them from getting better with all of the other clinicians that they've seen, because if I don't deal with that right off the bat, I will fail, too. And then listening to their story, I would generate hypotheses. "Hmm. I think I could test that." I could test this and test this to prove and manipulate things and get insights into these various pathways.

And then I needed a little bit of time to try it with them. Can I immediately modulate their pain? Can I make it worse? Can I make it better and probe it? Do you know, John, after the first year ... By the way, when we started that, my medical colleagues said, "Two hours? What are you going to do with a patient for two hours?" By the end of the first year, we changed that to three hours.

I still, to this day, book three hours to see a patient to really understand the mechanism of their pain and get an understanding of how we're going to organize a strategy to address it. So those are two seminal events, I guess, to use your words. But never did I ever think 30 years ago I would be a clinician.

Great.

Wow. I mean that speaks to if someone as well-studied, researched as you, and you're speaking to a two to three-hour evaluation, I think that just really illustrates for people how complex things can be and, even more than that, how important it is to listen to someone's story when they come in with back pain versus a cookie cutter approach.

John and I do get 15 minutes to evaluate a patient and make a determination about how to positively influence their trajectory with their back. So what you do as a physician is we break up that two-hour evaluation over subsequent multiple visits and at least try and get the ball rolling in the positive direction. We're fortunate in our group. In the Carolinas, we have numerous physical therapists who are very well-educated.

A lot of them follow your teachings and your methods about evaluation and looking at spine triggers and things like that, so that's fantastic. Thank you for sharing that. I wasn't aware you kind of got pulled into it, whether you wanted to or not.

Right. Yeah.

Fantastic. All right. So today's topic, we're going to do fact versus fiction. I thought this was a great way to shape this. I did this sort of paradigm a few episodes ago with one of my partners about lumbar epidural injections. Going through your back mechanic books, dude, one thing I will say is you are not afraid to take a position, and I like that. I like that. Typically, I think the reason you're not afraid is because you've done the work. You've done the work and the research to back it up.

So the first question as we kind of hit this off is, and I'm going to try and go through some topics that are not necessarily hot topics, but there is some debate out there. There's going to be people who would conflict with what we may or may not say, but let's get right to it. Fact versus fiction number one, most back pain is a result of herniated lumbar discs.

I would say most back pain of the people who you are seeing in your clinic, and it's disabling pain-

Yes.

... sufficient to miss work, for example. I wouldn't say herniated discs, but I would say certainly the majority of them have disc disruption which changes the mechanics of the joint, offloads stress from some tissues onto others, and the rest of it. Sorry about that.

That's fine.

You can spot the professor. I know what you're thinking. But in any case, so disc derangement, I would say, is involved in the majority. But, Sanjiv, the assessment, if it's thorough enough, will always give you the answer. So if you were to start with what activities cause the pain and what activities take the pain away, and then let's just do a little bit of pattern recognition.

At the base level, if someone said to you, "Sitting at the computer for 20 minutes really ramps up my pain. But if I go for a fast walk for 15 minutes, my pain goes away." All right. There is a very discogenic type of pattern. But then the person comes in. The next one is 65 years of age, and they give you exactly the opposite pattern. They say, "Going for a walk for 15 minutes, I have to sit down to get back pain relief."

So we're out of the discogenic joint and stability phase, and now the joint is stiffened. It's got a bit gnarly with some arthritic bone growth and whatnot and more into the stenotic categories that you mentioned earlier. So those very simple patterns, putting them together, would you say that the disc is still part of the pain? Well, it might be, and it certainly was 30 years prior in that person's life. But now, their patterns have changed. So there you go.

We would then do provocative tests. We would apply loads and compression and sheer and bending and torsion, tension, and see what exacerbates their pain or takes their pain away. Specific postures, sit in a chair upright. Does this cause your pain? Let's say the person says no. Good, slouch. Oh yeah, there's my familiar pain and, not only that, my right great toe just started to buzz a little bit. All right. Well, we're starting to slice and dice down here.

So the next pass is to become actually tissue-specific. Let's load that particular tissue. Off camera, we were talking about spondylolisthesis, and not to preempt that discussion. But again, there's a pattern to those kinds of patients that we put together to come up not only an activity-based diagnosis and understanding of their pain mechanism, but now we get to actual tissues.

So anyway, that would be the mechanical approach that would lead us to understanding whether it is a disc herniation and what type or subcategory of herniation it is or are we far down the cascade?

Yeah, that's great. I started off with that question because I wanted people listening to get a little bit of insight into how you organize your evaluation. The other piece of it is we all know that there's a certain degree of degenerative disc changes that are associated with aging. You look at research studies that show a certain percentage of the population's going to have an "abnormal" MRI and may not have symptoms.

As I go along in my career, there were times where I feel like I might over-interpret that sort of information and, other times, under interpret it. What you're talking about, it sounds like, is you look at the whole person. As an osteopath, that's how we looked at things in medical school was looking at alignment and movement patterns and such, and then I kind of got away from it. We like to say we treat patients, not MRIs.

I think what you might be saying is that we treat patients, and we really understand their MRI and try and figure out mechanistically what's going on. John, is that kind of how you look at things, too, when you're doing your evaluation with people and interpreting their MRIs?

Yes. It's much more of a comprehensive approach. Just actually, Dr. McGill, I'm always impressed when I read or listen to some of your work on how you interpret MRIs and how you will pick up on things that are not at all discussed by the radiologist. But if you know the clinical background of their pain, the findings really give you a much colorful and comprehensive picture of what's going on.

Yes. Did you want to comment about that, John?

Just with regards to just, for example, Schmorl's nodes in certain parts of the spine or anterior aspects of the end plates really are not commonly discussed by radiologists, but then you listen to a person's history and they're a weightlifter who's loading their back repeatedly with heavy loads or they're in a manual labor task where they're doing a lot of forward flexion with a sledgehammer or heavy equipment. And then you're saying, "Well, gosh, there could be something there based on what you're doing regularly."

Yes. I get a little bit disturbed when I see a clinician and even before they've seen the patient walk in the door, they have the MRIs up on the screen and they've decided whether they're going to intervene. And yet, the sclerotic bone they might be seeing or the end plate fractures, in comes the world champion power lifter or the world's strongest man. Those sclerotic changes are adaptations to heavy load. It's a good thing.

Sanjiv, to your point talking about degenerative discs and you follow a person through their cascade, the more degenerated some people get, the less pain they have because the pain wasn't the degenerated disc. The pain was when the disc started to first lose its turgor. Now the person was getting micro movement. So if I could take, if I may, take a pelvis with three lumbar discs visible here, there's L5, L4, and L3. L3 and 5 are normal.

L4 has now started the degenerative cascade. It's lost its stiffness. Just like a knee that has strained knee ligaments, it's lost its stiffness. If you do a drawer test, you will get laxity, instability. So let's do the equivalent of a drawer test on a spine. L4, as I've already said, has lost its stiffness. I'm just going to apply a torque. Do you see where the majority of the motion is occurring? It's at the unstable joint. Now, on MR, it might look perfect.

You would never see that instability until you did an instability test or perhaps you could do some radiological stills, a full flexion, full extension, or whatever it happens to be. Look at the work that the facets are experiencing at that level of L4, L5, not at L4. So when you see the gnarly facets four or five years later at only one level, that was because of the micro movements that were occurring due to that original loss of disc turgor through injury or damage. None of that's visible on the MR.

Over time, that joint will get a little bit gristly and gnarly. So the radiologist is very concerned about a degenerative change at that level. In 10 years, the pain from that level, it's all gone. That's the worst-looking joint. We see this in whiplash patients, as well, through video fluoroscopy. The joint that looks normal, the person will take their neck through the range of motion and, all of a sudden, somewhere in the mid range, C5 on C6 might have a heavy sheer translation and the person goes, "Ugh," and then keeps on going. The pain was associated with a micro movement invisible on the MR.

Yeah. That's a great point. It's interesting. It occurs to me. Many of our neuro spine surgeons will have a suspicion or intuition that a patient has instability in their low back. From a insurance model, there's certain criteria you have to meet for the patient to be appropriately approved for the surgery. We have limitations. What you just illustrated, we can image in a sagittal plane and look for spinal instability.

We actually have one of the few groups that has a flex-ex MRI. But of course, you can do dynamic plane films, but that's just one plane of movement. Really, putting that model up on the screen was awesome. I mean it shows how micro movements can occur in any direction and be a pain trigger. Now, I know that jumping to lumbar fusion is probably not the first thing that comes to your mind, and it kind of feeds into my second fact versus fiction statement or question for you, Dr. McGill.

Fact versus fiction number two, most back pain is lifelong regardless of treatment.

Fiction, usually. It's very difficult for me to be absolute on anything, and I don't mean to avoid the question. But we're dealing with people, and that's the truth. So I'm going to say fiction, usually. When I ran the experimental clinic, we followed up with every patient that we ever saw in the history of the clinic. I don't know of another clinic in the world that has done that. Of course, we had failures.

But what we did do was we ran with the idea, there's no such thing as nonspecific pain. It's all very specific. When we subcategorized people, we would then, through the follow-up, learn who got better and who didn't. Did they comply? Did they do what we asked them to do? What was it that we gave them to do? Was there a match between that? What tests results did we have?

In other words, I can now better answer your question on, is the pain going to have the likelihood of being lifelong or not? One more statement, every patient that we saw at the experimental clinic was a failure. No one said, "Oh, I've got fresh back pain. We're going to go off to the experimental clinic." We got the people who'd already seen at least 10 different clinicians, and they had failed. So right now, their clinical success junction was zero.

That's where we're starting from. They have zero chance of getting better, and they are your lifelong patients. Would you believe that if they were told, "You've tried everything. You've been to the osteopath, the physio, the physiatrist. You've been to the pain clinic. You've done cognitive behavioral therapy, et cetera. You've done it all, and the last option for you is surgery."

If that was your subcategory and you followed the program that we gave to wind down your pain sensitivity through spine hygiene and moving with competency according to your triggers, et cetera, build a foundation to move with proximal stability and appropriate mobility throughout the linkage, et cetera, following the philosophy, in a two-year follow-up, 95% reported that they were glad that they never had the surgery. So there's a statistic there. That's an impressive one.

But now I can get into the less impressive categories. If a patient was categorized with flexion intolerance ... So remember the person just had the sitting test. They sit upright, and they say, "No, I don't really have any symptoms." Sit slouched. "Oh yeah. There are my symptoms." So there is a test for flexion intolerance. [inaudible 00:24:18] of them in the two-year follow-up reported excellent outcome, meaning that they needed no further intervention and they were happy with their lives. So that's less than half.

If the person was categorized with flexion plus compression intolerance, compression intolerance is a tough one because there's not too much rehab you can do in terms of adapting your tissues with a load stimulus. We're down to 33% within two years, chance of them saying, "I'm very fine with life." But if they had flexion and extension motion intolerance, they had a 80% success rate in saying that, "I had an excellent outcome. I don't need any further intervention."

So those were the people attending our clinic. Now I go into the athletic cases because, as you're aware, to this day, still our subspecialty, I suppose, is dealing with world-class athletes, people who push their bodies to the nth degree.

I can name many world records players who are marquee players in your professional leagues, the NFL, the NBA, the UFC, the fight league, NHL hockey, who have now come back and are playing at previous levels or even better levels, proving that their pain and disability sufficient for them to lose millions of dollars in salary and all the rest of it, that they got back to set world records or play their professional sport again.

So it's not a lifelong sentence. But of course, it's context and case-specific. If you've been in a car wreck and heavily compromised and a surgeon has really had to be magical to get you back together, the chance that you're going to be back power lifting again is not very high. So of course, it's case-specific. But there's a little bit of, I hope, encouragement for listeners.

Yeah, exactly. I would say for those listeners out there, before you try and slam Dr. McGill or us for saying all back pain 100% of the time can be cured, I think what you're really trying to say is with a purposeful, systematic approach, most maybe nonmalignant back pain has an opportunity to improve. You've definitely done some research and data to document some outcomes which are encouraging.

But it does lead me to my next question. In terms of surgery, so fact versus fiction, back pain with radiculopathy, so for laymen, that's, let's say, pain radiating down your leg with some associated weakness, maybe you can't get your toes up, numbness, is a clear indication for surgery. I'll bring that specific question up because, in our world, in the medical spine world, that is, at least for physiatrists, that's when our alarm bell goes off and we're thinking much more about do we need to get our neurosurgical colleagues involved?

I know the devil's in the details, for sure. But John, you agree when you see a patient that comes in who has some motor weakness in their leg and it's associated with numbness and intractable pain, that your awareness level is a little bit higher about whether or not the patient needs surgery?

Yes, especially if it's progressing or moving pretty quickly.

So I want to get your thoughts, Dr. McGill, and this may not be ... I mean as all of these, these aren't black and white answers. There's a lot of context that needs to be involved and so forth. But we'd love to hear your thoughts on that type of situation.

Very rarely do we jump to that conclusion quickly. We almost always run an experiment, and the experiment is called virtual surgery. So we perform some tests and we create the radiation that you're describing, whether it's a numbness down a specific neural tract, whether it's mechanical crosstalk and tension from one nerve to another, or is it an open-fissure disc bulge? If it's an open-fissure disc bulge, no. Do virtual surgery first.

Prove to the patient that if they sit like this at the computer for four hours, chances are that pressure from that specific disc bulge on that specific nerve root is going to get worse and worse and worse. But if we teach them, well, maybe we have to do a hip exam. We learn from the hip exam that when they turn the pelvis, now I'm flexing the hips and they have an anatomy to their hip sockets that causes them to back off the hip impingement.

They're right back into the hydraulic pressure to increase the size of the disc bulge. Spread your knees apart. Get your feet underneath you. That took the pressure off the hips. Now I can sit in that position more comfortably. Now, every hour, stand up, reach for the ceiling. Twice a day, lay on your tummy for five minutes. Do not do a McKenzie prone push-up. Just lay and breathe and relax your back. Does that take the numbness out of your foot?

If they come back in a week and say, "Those radiating symptoms are starting to disappear," fabulous. Let's keep it going. So my point is, and I should say that this works very well for patients who, let's say, they are exercise addicts. Let me paint a picture here. A stay-at-home mom, two young kids, comes in and says, "I have to go to the gym every day and ride the elliptical for 45 minutes, otherwise, I'm stressed out and I'm going to murder my husband and my kids."

I'll say, "Good. Well, go have the surgery then. But you do realize that tomorrow, if you have the surgery, you're going to lay in bed. You're going to get up and go for a pee. You're going to go and lay down in bed again, and you're going to progressively reintegrate movements and all the rest of it. But if you go right back to the same patterns, you have a great chance of re-herniating. So you are going to have to change the way that you move, become more efficient in purposefully stimulating the adaption that you need in your body to become robust again. Why don't we do it now? Let's perform virtual surgery."

I'm very dramatic about it. I'll say, "I'm knighting you. There you are. You've had your virtual surgery. Now behave like a post-surgical patient." When I said that 95% figure, that's where that came from. Performing virtual surgery works 95% of the time if they fit the category of they haven't been traumatized. There's no heavy tissue damage from impact. Do you know what I mean? We're not dealing with anything that's a red flag.

Let me clarify. So when you're saying virtual surgery, are you essentially applying rest and gentle modification for a period of time?

I'm suggesting that they behave like a postsurgical patient starting now.

Okay.

So we show them the cause of their pain mechanically, and our assessment will show that and reveal it to them. Then we coach them on if this is how they get out of the chair and they have ... We'll just use that posterior open-fissure disc bulge subcategory of patient. If their first movement is into even more flexion to get out of the chair and no one showed them that if they spread their knees, get their feet underneath them, suck a little bit of air, lead with the chest, flex through the hips, and pull the hips through.

Now I've just stopped. I've arrested the hydraulic effort that causes the disc bulge to grow. Would you like to see another model of this? I can show you with precision, if you like.

Yes, that'd be fabulous because that's a big common mechanism of pain.

All right. These are all made by Dynamic Disc Designs, which I have no business relationship with. I will point that out. However, they have based a lot of these models on our work over the years that we've documented. So let's look into the disc from the top here. We see the nuclear gel and the collagenous fibers forming the fabric of the disc. It's not a ball-and-socket joint. It is actually a fabric.

Now, if I wanted to delaminate the fibers of my shirt, which is a fabric, I would create stress strain reversals back and forth, and the fibers would delaminate and create a tear. So the disc has to have some delamination so the fibers pull apart. And then the pressurized nucleus will work its way, under great pressure, through the delaminations. That's typically caused by a combination of flexion movement plus load.

If you just have flexion movement, no real issue. Belly dancers, for example, can do all kinds of gyrations, but they're not under load. They adapt a very mobile annulus and ground substance structure in the collagen fibers, but they don't herniate. But it's not the spine you want to put a lot of load on because of the laxity. In any case, I'm now going to show that there has been a delamination that's occurred.

This is exactly what you would see in a surgical case, bloody invagination growth of nerve endings and vascular structures along the delamination. So now we have a posterior lateral delamination and you can see it as a red mark at the end of my finger there. Now I'm going to squeeze the spine to simulate compression. I'm compressing the incompressible hydraulic fluid of the nucleus, and I'm going to allow it to flex forward.

Watch the fissured site. I'm going to squeeze, and I'm going to drive the hydraulic pressure posteriorly. Now you see the disc bulge. There is the nerve root. So now I can see when I put them into a all-fours position, I rock them back and now I'm going to pull her head down. I'm going to pull the nerve roots up. Watch this nerve root under my thumb. I pull it right into the offense. Do you see it moving right here?

Wow. Yeah.

And then I might straighten the leg and pull it the other way. So I can tell exactly whether that disc bulge is over hooking or under hooking the disc bulge. That will correlate almost all the time with the antalgic lean that you see in the disc herniation pattern. They will be leaning away, but it doesn't predict the side. It predicts whether the disc is under or over hooking the nerve root.

And then the neurodynamic tests, as you're migrating the spinal cord cranially and caudally, you will figure out, with great precision, a lot about that mechanic. Now, what's the antidote? Now we're going to squeeze the spine, but I'm not going to allow it to flex. In other words, I'm creating a equal hydraulic pressure on the wall of the annulus. Watch. The whole disc is going to squeeze down. Yes?

Yep.

Nothing comes out posteriorly. So it's as simple as if I had an orange seed, being Carolina boys. You're a little north of the orange groves. But anyway, you know what I mean.

Yeah.

If you squeeze an orange seed, and I want to squeeze it out that way, I had to bias the pressure and out it goes every single time. But I lock it in place as I drive the hydraulic pressure straight down through the middle. So it's hydraulics. If I can get out of the chair now not going into that flexion hydraulic pressure driver to the open fissure, but I ... You follow what I-

Yes.

... did in that coaching of the patient? Now pull the hips through. Typically, that person will say, "I get relief when I go for a walk. I get relief even when I carry my groceries." No kidding.

Yeah. I really love the cue you have for them to sniff. When you do that, you can feel some core activation there. Is that what you're trying to do?

Several things. People become so victimized, and they have despair from their pain. You know the person who comes into your office. No one comes in and say, "Hey, doc, I've got back pain." No, that's never an extensor proud pattern. It's defeated. They're beaten. "I've got back pain," feeding the flexion hydraulics to make the posterior fissure that I just showed you grow even more. Who owns the world? These are all just little psychological games that we'll play.

They'll say, "Well, what do you mean." Then I've said, "I've just shown you that you can now reduce the pressure. You can reduce the numbness of your feet by planking on the wall and allowing your hips to drift towards the wall. Now stand tall and you own the world. You're now in control. Swing your arms from the shoulders. Get a little bit of natural nerve flossing going." That sniff is a little bit of ... I own the world a little bit.

So that's the start of the psychological empowerment that they now have some control over their back pain. It also stacks the mass. So mechanically, we can palpate the person's erector spinae, and you'll find that they're taut. They're compressing chronically. Their back pain, they might have a compartment syndrome in the fascia with the muscle, just chronic muscular pain. When they move, it's a sharp pain. But then if we can get them to stack their mass, they can feel those muscles just shut down.

We didn't give them a dose of methocarbamol or muscle relaxants. We simply got them to stand. So the sniff might feed that posture as well. It does a lot of things. Your statement of it then activates the core muscles, which form a guy-wire system to stiffen the rod. So this micro movement that I showed you earlier, yes, we have a loss of control. The body uses stiffness and joint stiffness to control movement.

It has now lost its control, but we make up for that by adding a little bit of muscular bracing with the core muscles as you do very well. So do you see? The sniff does many things.

Yeah, this is great. I honestly don't even remember the question anymore. I'm just so engaged with what you're talking about. It's awesome. These models are phenomenal.

They are. They are so empowering for a patient to transition from, okay ... There's this movement in therapy now. Don't always tell the patient the truth. Keep encouraging them that their back isn't fragile. They're going to be okay. We don't do that. We show the person what their particular pain pathway is and then give them enough education or wherewithal that they can now control it and create the adaptations to get some robustness back.

Sanjiv, so many of them say, "Thank you. You're the first doc who hasn't treated us like a five-year-old." We get it.

Awesome.

The person might be a car mechanic. If I show them a lever arm or if I'm going to pull on a door, I'm going to pull a door and I'll say, "Did you ever play basketball in high school? Good. Show me a drop step. You're boxing out Shaq O'Neal." They know what a drop step is. Good. Grab the door. Now you're pulling the force vector right through your spine, but drop step. Take a step back. "Oh, Doc, I just opened up the heavy steel door for the first time without any back pain." They're a car mechanic. They understand mechanics.

Yeah. I'll just take a moment here to plug your Back Mechanic book. For those who want to pick up a copy, you also offer with the accompanying videos, which I did, and they're excellent. You go over a lot of these things. Dr. McGill's covering a lot of his concepts in a fairly quick manner right now, but if you want to take a deeper dive. We'll link to his books in the show notes for the podcast and the videos on YouTube.

You just touched a little bit on the core. I want to segue into this concept, fact versus fiction here, Dr. McGill. A strong core is more important than back and leg flexibility in preventing back injuries? Specifically, what I'm getting at with this question here, number one, is I want to open the door for you to discuss and share with people who aren't familiar with your big three. And then I also want your opinion on the idea of particularly the hamstrings, because a lot of people are told they have very tight hamstrings and that if your hamstrings are locked, it'll create a flexion moment about the L5-S1 disc when you try and hip hinge and you just can't do it.

So hamstrings stretching is an integral part of rehabilitative exercise programs for lower lumbar disc herniation. So it's a couple of points there that I want to pick your brain on.

Well, there's so much to unpack there. I'll try and be efficient. First, the assessment shows whether they have tight hamstrings or tight sciatic nerves mimicking and being perceived by the patient as a tight hamstring. I would say that more often than not, it is the tight nerve. Don't stretch a tight sciatic nerve. It will become even tighter. So here's a person who comes into the office and say, "Well, I've been working on my hamstrings. I've been stretching them for a year. I haven't gotten any better."

Oh, good. Let's do some neurodynamic testing on that nerve. The expertise that we put into a straight leg raise, we palpate the two heads of hamstrings. We raise the leg, and we feel where the muscles become engaged. But if they say, "Oh, no, I'm tight," and you can clearly palpate the muscles aren't tight yet. Now get your finger right up into the popliteal fossa and really play guitar strings on the sciatic nerve. They'll say, "Oh yeah. That's causing my back pain." "Son, you have a tight sciatic nerve. You do not have tight hamstrings, so please stop stretching them."

What we're going to do now is try some nerve mobilization once we've figured out what it is that's causing the tight nerve, whether it's a disc bulge or an arthritic bone spur, a Tarlov cyst or whatever the case may be. So there's a little bit of a start on the hamstrings. Now, the next thing is on the performance side. Do you think Michael Jordan has tight or loose hamstrings?

My guess is tight.

Yeah. But look at every leaper in the NBA. That's the spring that they jump off. I've measured quite a number of them. So be careful now how much you want to slacken off a hamstring. But let's go to the opposite end of the spectrum. There are those people with pathologically tight hamstrings, and they create the syndrome exactly as you describe. It is so tight. It bends the pelvis, which bosses the spine into flexion and stresses to the point where it is the cause of their back pain.

So again, the answer is, it depends. But the assessment always shows you the way forward on how to approach this perceived tight hamstring idea.

That's great. John, I want to let you jump in. I don't want to hog all of his attention. Do you have anything to offer on that or any questions that are coming to your mind?

No. As far as the assessment on that, I commonly see the same thing. It's, is this a muscle issue or is it a nerve issue? One of the things I was going to ... It kind of piggybacks onto the question is just flexibility. This is a generalization I'll see in my clinic. My female patients want to become more flexible where they need more stability, and it's my male patients who want to get stiffer or stronger where they may need a little bit more mobility. So Dr. McGill, I was just curious if you see patterns like that as well?

Absolutely. Yeah. You've been in the clinic. You spent your time. I see that. There are some people who say, "Well, okay, I'm going to go to yoga class to deal with my back pain." Now, it may be that some of the asanas in yoga are wonderful for them, but it may be that the very next one is creating more laxity when it's the micro movements that's causing their pain. What they're doing is they'll get a 20-minute jolly. They fired a stretched reflex. Feels good for 20 minutes.

But then an hour later, they've got the same feeling back. Oh, I think I better pull my knees to my chest again or whatever it happens to be. We'll say, "Stop all that. We're going to give you a replacing alternative. Every time you want to pull your knees to your chest, I suggest you lay on your tummy on the floor and take 10 deep breaths. Now tell me how you are after three days." You know what the result of that is.

Surprisingly to them, sometimes for the first time now they say, "I can sit a little bit longer before my toes go numb," or whatever the case may be. But tuning of the body to make it resilient, if the person is really training to be more mobile, terrific, great. They love going to the yoga studio and whatnot. I'm going to give a plug for a friend right now. I have a friend who's a yogi, Bernie Clark. Bernie Clark wrote a series of books. One was called Your Body, Your Yoga. Another one was called Your Spine, Your Yoga.

He guides the teachers and the students through self-assessments of their anatomy and their mechanics to determine how they're going to do certain yoga asanas, or poses, to create the desired effect of resilience and performance and not more pain. You follow the logic. People are all different, as you know. You look at the shape of hip sockets, which are, yes, you got them from your parents.

But if you look at the shape of hip sockets around the world and the incidence of orthopedic disease based on that hip socket, it follows haplogroups and genetic groups. For example, where's the highest rate of FAI in Caucasian Europe? It's the Celtic nations. It's the Irish and the Scots who have the highest rate of FAI. They've got the congenitally deepest hip sockets. Picking things up off the floor ... I'm not saying every Irishman has a deep hip socket. I'm not saying that at all. I'm just saying the population average.

What's the polar opposite in an orthopedic incidence sense of FAI and deep hip sockets? Well, it's the dysplastic hip, hip dysplasia. Where's the highest rate of hip dysplasia across Caucasian Europe? I'm not shocking about Asia because that has a different distribution of pools within it. The epicenter is Poland. The highest rate of hip dysplasia. Who has the shallowest hip sockets? It's the Poles. Where do the Olympic lifters come from, people who have to deep squat with weight over their head?

So you're starting to see form and function here a little bit. Now, I'm not saying every Pole has a dysplastic hip, not at all. I'm just saying it is evidence to link different characteristics of joints with function, tolerance, ability. So there are some people who are made for yoga, and they're not made to be on a power-lifting platform and vice versa. So now we get into recognizing these different types and feeding their bodies with the appropriate distribution of mobility and flexibility and stiffness and control and load bearing.

So if I took a spine, which if you took a spine out of you and we just had this osteo ligamentous spine and I put it on a table, it would collapse with about five pounds. That's all your spine will take. Now, this spine has some load-bearing ability because I've added stiffness. I've put a wire rod up the middle to give it compression. Now I'm going to take some compression away, and you see it collapses right away. So if I'm a wet noodle and a very flexible person and I have to carry 100 kilo in each hand and I don't create a very stiff controlling girdle or guy-wire system, my spine will buckle.

We've done experiments to prove that. But how many strong men, and I've worked with people who compete in World's Strongest Man, do you think they do sit-ups and spine mobility work? No. As you pointed out, they do stiffening exercise to get that flexible garden hose of a spine to bear tons of load. If I stacked up five oranges and put a book on the top, it would fly apart. But if I put guy-wires on all of those oranges, particularly on the end of toothpicks ... This was experiments that I used to do with students.

Those are called transverse processes, by the way, with vertebra. They create stability and bigger moment arms. It's called oiler stiffness, if you're an engineer. But that's the role of the abdominal muscles. So in the most mild forms, Sanjiv, we might sniff to activate those muscles and create more robustness for load. We might go through to muscular bracing. We might go all the way through to Valsalva maneuvers.

The person who dead lifts 1000 pounds will suck up about 70 to 80% of tidal volume in their lungs. And then they compress down with their pecs and lats, and they create a hydraulic pressurized cylinder to allow that spine to be now a rigid I-beam.

Wow.

Anyway, do you see how we really have to have a good conversation now as to what we're trying to engineer in this person's body and the distribution of stability and mobility? If I could take this one piece further now, we live in a linkage, this linkage with all of the joints. I'm going to ask you to wiggle your finger as fast as you can. Did you notice you had to stiff in your wrist? Because if you don't stiffen your wrist, you wiggle your finger as fast. So this is the law of the linkage.

In order to create distal athleticism, you had to create proximal stability. If I want to create a punch ... I'm going to train a offensive tackle now for the offensive line in the NFL, and they're going to box out the defensive players. If they train bench press, say, a pushing exercise. The pec major, the bench press muscle, is a uniarticular muscle crossing the shoulder joint. Distal to that joint, it creates the arm flexion, which is the desired athleticism.

But look what that same muscle does proximally. It attaches to the ribcage. It bends the ribcage. It's an energy leak. It's a performance de-evolution, if you want. So that same muscle on one side of the joint creates a desired action. On the other side, it creates a collapse. So I engineer that out in the linkage with proximal stability. I lock my core. Now 100% of that bench press muscle gets expressed as distal athleticism.

So now let's go to some of the world-class athletes. Well, I've measured some of the fighters who hit the hardest in this fight league, the UFC. The big strong fellas with big muscles, you would be surprised in that they probably don't hit the hardest because they push their punches. It's quite a slower motion versus the one who pulses muscles. They pulse and then relax to increase the closing velocity because strong muscles also have high stiffness. You have to let the muscle relax to let it go quickly.

And then when they hit the contact point, they have a second pulse of muscle. So it's boom, boom. They hit you with their whole body as it turns to stone. That characteristic of the muscle pulse is what is so important in this tuning of stability and mobility to create athleticism. Let's go to a running example. Usain Bolt, everyone knows that as a name. Do you think he did a lot of core stabilization work? You can look it up. His training program's on YouTube.

For sure.

He had to, because without creating proximal stiffness, when the hip muscles explode, the desired athleticism is to propel the femur through the extensor range. But those same muscles also connect to the pelvis. If those muscles aren't stiffened proximally, they just bend the spine. Oh, look out. I'm going to fire my glutes. Every time, he'd be doing this down the sprint track. So you engineer out all that proximal motion, make it stiff to get 100% of the power transfer to the distal side of the ball-and-socket joint, which is the hip and the shoulder.

So now it almost ties up our questions about hamstrings. It's no coincidence that our core, our spine has a ball-and-socket joint on either end, the only location in the body. I have a spine here from a whale. It's interesting when you look at the mammals in the oceans. They have a ball-and-socket joint in the big tail that drives the flukes. There's the ball, and there's the socket. But we don't have a ball-and-socket. We've evolved this, stiffened this.

Could you imagine if we had ball-and-socket joints? The muscles we would have to have controlling those ball-and-sockets up our torso, but the spine with discs give a defined stiffness. The neutral zone and the final stiffness of each joint allows us to have a slender spine and be athletic.

Yeah. It occurs to me, several years ago when I was doing martial arts, in our black belt training, the instructor, to break the boards, which were getting thicker and more complex, the teaching was never about the force with the hand. It was all about stability through the trunk, looseness, relaxation with the extremity until the very last moment with the rotation and then using the breath. There were guys who were much bigger than me, stronger, who couldn't do it.

And then there was people smaller than me, younger than me, kids who were accomplishing it with the same kind of mechanism. I'm wondering. I'm sitting here thinking if it's a similar concept to what you're describing about how you generate the power through core stability to get that distal explosion.

I never met Bruce Lee. I wish I did. His one-inch punch, now we did measure some accomplished athletes performing that. It is exactly as you just described, Sanjiv. So you would take a contact on, say, a device to measure the impact. And then you stiffen the core, and it's just a hip turn ... That's what is the one-inch punch. Now, when you put motion, pivot off the rear foot, put motion in and then boom, snap, with the appropriate muscular pulse at the end. `Now all hell and fury is unleashed. It's a one-inch punch plus.

But this is the hallmark of the great athletes. Again, I've measured so many of the great ones and, you know this, they don't test to be the strongest in the weight room or on the power lifting platform. They are the ones who can create muscular force. When we measure the timing of those, and sometimes it was six times faster than the graduate students who were members of our laboratory could produce, six times faster.

I talk to some strength and conditioning coaches and I point out, with some graphical data, why this person is so great. Then I say, "Okay, how many of you are training the speed of muscle?"

Well, look, this has been incredibly informative. I want to be respectful of your time and energy, but I won't let you off the hook without one last question that I know you've been asked during numerous interviews. But it's worth asking again because it's such an important concept. John, would you agree that in your clinic, probably the most common mechanism, from a history perspective, for people who hurt their back is bending over of some type?

Yes. Sure.

Yeah. So then that leads to the final fact versus fiction. People with back pain should avoid flexion or bending when they're lifting?

It depends. It's so context-specific. If the person has this open fissure that creates a disc bulge to grow and pinch the nerve root when they flex for a period of time sitting or they're gardening and pulling weeds with that method and that causes their symptoms to elevate, the answer is perform a hip hinge, which every good American should know baseball, the short stop posture. Carry the weight down the arms. Grab the knees hard and watch some of the movements now.

I'm going to tune my back. There's a flexed back. There's an extended back. I'm going to find the perfect resilience somewhere in the middle. And then I'm going to activate my lats and my pecs and, watch, I'm going to pop up. I just drifted my shoulders down away from my arms. Now I can grab a and pull my hips through. So I'm not bending the knees to lift. I'm pulling my hips through, which is an entirely different coaching instruction.

So I've bent over, but I didn't bend in a way that caused that open fissure to grow. I moved in a way to actually vacuum it in, so it was actual therapy. That would be to pick up my child. If I dropped my keys on the ground, I could sniff, turn this leg, stiffened to my body, into a baseball bat. I'm going to push the heel away and over I go. Pull my hip through. I bent over. I picked up the key off the floor. Did I flex? Well, I did. But I didn't cause the flexion stress on my back.

So that open-fissure disc bulge is consistent with the pattern of a person who trains at the gym with weights. The next client has never touched a weight. They are into yoga. They love flexibility. When you look at their discs, they're plump. They have lots of motion. When they bend forward, the compression side of the disc buckles because it's soft. It's compliant. Now they get a disc bulge anteriorly, not posteriorly.

In other words, bending forward through their spine takes their disc bulge away off the nerve root. So do you see how it depends? And it's so-

The devil's in the details. Yeah.

It is. I know people get on the internet and criticize, "Oh McGill, you don't like ..." I did a podcast with Martins Licis, who's the current world's strongest man and Aaron Horschig from Squat University. We did that about a month ago, and we went through the mechanics of the atlas stone lift. The atlas stone can be a 400-pound round ball of cement, and the athletes flex right over and pick up this 400-pound ball off the floor.

The chatter on the internet from people who have never measured these beasts who pick up these balls and they say, "Well, they're flexing their backs and they don't break their backs?" But again, the devil is in the details. The ball is between their feet. 400 pounds is less than half of their deadlift weight. So they're only picking up half of what they would normally pick up on a barbell. And then they pull the bar into their laps and they curl their spine around the stone. So their spine and their stone becomes one.

They do not have the hydraulic motion causing the delamination of the fibers. They just lock their spine in flexion. So that's all right for most people. Another thing that people don't realize, to get into some of the mechanics, Martins has double the moment arm of his back muscles than the three of us, meaning that if you look at the line of action of the extensor muscles that extend and pull the spine up, his are double the distance. He's got double the wrench handle.

So if he picks up 400 pounds, you realize there's only half the load transferred from the muscles onto his back than me. He picks up 400 pounds with half the weight on his back because he's got double the moment arm of his muscles. So muscle hypertrophy plays a huge role in this. I can go on and on with the nuances of why the answer is, it depends. Some people are confused over flexion. Well, flexion is a motion. It's a kinematic. But flexion is a torque. It's a kinetic.

What kind of flexion are you talking about? So the golfer's lift and the short stop squat, those are kinetic flexion lifts, but not kinematic. So there's a lot of nuances that we have to get through here, too.

I appreciate that. Definitely wanted to give you a space to comment on that.

Yeah.

Well, it's been terrific. This has been extremely informative and really love your passion and how you've dedicated your whole life towards really understanding what's happening. For myself, I've learned I need to do a better straight leg raise. I certainly don't have the level of detail that you described there when evaluating patients. I know John is doing some of your training as well, as we look to up-level our game when we take care of patients.

Before I let you go, though, I always like to have my guests share a little bit about their daily routine, so to speak. I'm a bit of a health and wellness nut. So I always like to add things in and would love to hear just how you keep yourself healthy both mentally, physically, and enjoy your life.

Yeah. Well, I appreciate that question, Sanjiv, for a lot of reasons. I left the university five years ago. Primarily when I signed on to be a professor almost the better part of 40 years ago now, do you know computers weren't even invented? We didn't even have a computer in the lab 40 years ago. Everything was done on strip chart recorders and analog devices, et cetera. And then computers took over. And then towards the end, students would say, "Oh, can't I meet you on a virtual meeting on the computer for office hours? Do I actually have to get my body down to your office?"

You know how I teach. I teach with my hands and getting them to feel it. Let's go to a patient table. We're going to workshop this. I couldn't stand it, and my health was in decline, sitting at a computer. So I said, "I'm done now." I retired, and now I moved three hours north of the university so I can get a decent winter. I'm healthier now than I've been since I was in my 20s. I live what I call the biblical week. So here it is. There's seven days in a week. By the way, this is the foundation of the teachings of every single major religion, and that's why I call it the biblical week.

I do physical labor. I heat with wood. I chop my own firewood, shovel snow. All of these things are built into my daily routine. But two days a week, I do dedicated strength and power training, two days a week. I've had a lot of injuries. I've broken my neck. I've fractured ribs, really had some substantial ... broken my hip. In any case, I have to do some mobility. When I was 30, I didn't need any mobility. God gave it to me. But now I need strategic mobility.

So two days a week, I'm very strategic. I work on things that are a little bit stuck, my ribcage, my neck, my hip, et cetera. Two days a week, I work on cardiovascular, my ticker. So if I chop firewood, I just accomplished all three.

For sure.

So I get a free day. But if I don't, I will either go for a swim or a bike ride or a ski. I'll be in the clinic here, and I'll do some mobility work or some strength work if I haven't had that in. But the magic of it all, and the way to stay pain-free is one day a week is rest. Don't do anything. That's the day that your body adapts. So all the stimulation that you've done all week long, now let it adapt. The other thing, too, is say I am doing a heavy day on the chainsaw. I don't do two days in a row.

Then it's training or I'm a passionate snowmobiler. I never do two days in a row. So I feel fabulous. Anyway, the other thing is ... It's funny. People talk about weight and diets. I have a weight, and I weigh myself once a week. My target is 180 pounds. If I'm under 180, I can drink all the beer I want. I can eat chocolate. I can do whatever I like. If I'm 181, I don't do any of that. So what's my diet? Never cross 180.

That's great. Thank you for sharing that, a bit of almost a personal side to yourself about your routine and your rest day. I've shared with my listeners. I just graduated from the Andrew Weil Integrative Medicine two-year fellowship program.

Oh, nice.

We talk about the importance of mind, body, and soul. One other thing I would add. Just listening to you, you have a unique sense of humor, which I think really comes across in your actions. Terrific teacher. I can imagine being a student in the lab with you, and I'm sure John as well appreciates that. We can recognize that and honor that. So I want to thank you for your contributions to the spine field.

Those of us who are really down in the trenches, we lean on that type of research to help us improve the quality of life for our patients and, frankly, for ourselves. So John, anything you want to add for him before we let him get out of here and probably do something more important than talk to us?

Yeah. I just wanted to ask more on a lighter note, with regards to your mustache, have you ever gone full handlebar or Fu Manchu? We have to have a little bit of fun, right? Humor-

Yeah. You know what the logo for our company is? It's the mustache and glasses. My daughter, who's almost 30 now, but she would be maybe seven or eight years old. I've always had either a beard or some kind of facial hair. I never shaved. She said, "Dad, I've never seen you without a mustache." So I shaved it, and it was awful. I walked by the president of the university. He didn't know me. I mean I've known this guy for ... I see him every day. People didn't know who I was.

And then they would pick me up at the airport to do a lecture or something. Some graduate student would say, "Well, we were just told to look for the mustache and you'll know it when you see it." This was before the internet. Anyway, so I have to have the mustache for the logo. Yes, I have shaved a beard and left a big, long straggly handlebar. But I can tell you it's pure wife repellent, and I can only hold out a week or so. So I have to behave.

Thanks for sharing that. Thank you. This has been truly a privilege. It's been wonderful.

Women don't find this particularly attractive. I can tell you that.

You notice we're both clean shaven.

Yeah, yeah. Yeah. Well-

Yeah, no. It's been an honor. Thank you for your time. I hope we can, in some manner, stay in touch. When you're in the Carolinas, you definitely look us up. Would love to host you, introduce you to people in our group, and really give you more exposure for your teachings and the contributions that you've made. So thank you so much for your time. We really appreciate it, too.

Well, Sanjiv and John, thank you so much for your support of what we do and your passion in getting this out to helping the people who deserve it so much.

Yeah. We'll definitely link to your company's website, some of the books that you have, and educational materials for people. Please send me if you have any other contact information that you're comfortable putting in the show notes and things. We'll definitely add that for people to reach out if they want to get ahold of you.

Yeah. The best thing is the backfitpro.com website. By the way, if we have patients who are unable to get to you in the Carolinas, we do have a network of clinicians who are listed on our website. I hope to see one or both of you on that in the distant future. And then the website will feed some patients to you as well.

Terrific. All right, guys. I will let you go. Thank you both for your time today, and blessings for a great rest of the week for both of you.

And same to you. Bye-bye. All right.

Take care. Bye-bye.

Bye-bye.

Thank you for listening to this episode of Back Talk Doc brought to you by Carolina Neurosurgery & Spine Associates with offices in North and South Carolina. If you'd like to learn more about Dr. Lakhia and treatment options for back issues, go to backtalkdoc.com. We look forward to having you join us for more insights about back pain and spine health on the next episode of Back Talk Doc. Additional information is also available at carolinaneurosurgery.com.