Hard Times for McKenzie Method, Low Back Pain

The McKenzie method for low back pain: a systematic review of the literature with a meta-analysis approach. Spine. 2006 Apr 20;31(9) Machado LA, de Souza Mv, Ferreira PH, Ferreira ML.

From the study:

“Eleven trials of mostly high quality were included. McKenzie reduced pain (weighted mean difference [WMD] on a 0- to 100-point scale, -4.16 points; 95% confidence interval, -7.12 to -1.20) and disability (WMD on a 0- to 100-point scale, -5.22 points; 95% confidence interval, -8.28 to -2.16) at 1 week follow-up when compared with passive therapy for acute LBP. When McKenzie was compared with advice to stay active, a reduction in disability favored advice (WMD on a 0- to 100-point scale, 3.85 points; 95% confidence interval, 0.30 to 7.39) at 12 weeks of follow-up.”

“When analyzing the results of individual trials, McKenzie was as effective as flexion exercise at 2 weeks for chronic pain.. … and marginally better than flexion exercise for acute pain at 8 weeks…”

“Delitto et al reported a large effect on acute disability… …favoring McKenzie when compared with flexion exercises after 5 days.”

“Two high-quality studies reporting on acute LBP compared McKenzie with advice to stay active… The pooled results in Figure 5 indicate a significant decrease in disability… … favoring advice to stay active at 12 weeks follow up.

“There is some evidence that the McKenzie method is more effective than passive therapy for acute LBP; however, the magnitude of the difference suggests the absence of clinically worthwhile effects.

 

My comments:

This is not exactly breaking news but McKenzie method of diagnosis and treatment of low back pain is still being taught to physical therapists and physical therapy patients still have to endure end range, and sometimes end range plus overpressure, spine extension, and to a lesser degree flexion stretches. Googling “Mckenzie method” will bring up a plethora of physical therapists touting Mckenzie method benefits and anecdotal reports of it being great. But what does the actual research say? Ehh, the reality seems a little less remarkable. The results of the above study (which was a meta-analysis that pooled the results of relevant research that went before it) are about what I would expect. Overall the researchers found the McKenzie method is perhaps slightly better than passive modalities (but not enough to matter), better than Williams’ lumbar flexion exercises, but slightly less effective than the simple advice to keep active. I’ve read McKenzie’s books so I have a pretty good grasp on his techniques and why I think they don’t work so well for the average low back pain sufferer.

I do agree with much of McKenzie’s observations that spine flexion happens too often and for too long for most people in activities of daily living, and I do agree that people should take steps to lessen spine flexion. I think this is why this study found McKenzie worked better than Williams flexion exercises but not much better than nothing at all. Williams flexion exercises were the standard McKenzie was reacting to when he came out with his method favoring spine extension in 1981. This is because once you remove any placebo and gate control effects of flexion stretches on pain, you are left with a motion that causes posterior displacement of nucleus material in the lumbar disc and stretch/creep to passive ligaments that are supposed to control spine motion. Thus flexion stretches over time decrease spine stability, increasing long term pain and disability. So I would say McKenzie is not as harmful as Williams spine flexion exercise.

In his books McKenzie likes to use the example of having a person hold their finger backwards at end range until it starts to hurt as analogous to what goes on in the discs during spine flexion, and that if you remove the stress on the finger and bend it the other way the pain goes away. The problem I think is that McKenzie goes too far the other way. The solution to pain injury in flexion is not hyperextension but just eliminating the flexion and returning the joint to a more neutral position. This works with both the finger and low back. I would not cure the finger joint pain from prolonged extension by bending it the other way as far as possible and holding it there, rather I would just remove the stress.

As this paper correctly asserts, McKenzie method should not be thought of as just extension exercise because McKenzie also teaches spine flexion stretches if the patient has an increase in symptoms with extension during his evaluation. I disagree with this as well, because posterior disc herniation caused by too much flexion during ADLs can be irritated with extension and still worsened in the long run with more flexion. Different spinal structures can also play a role in these symptoms’ presentation as well. For example, if one already has a collapsed disk at L5-S1 causing facet joint approximation and arthritis at that level, we would expect to see worsened symptoms with back extension. Flexion stretching in this case might unload the irritated facet joint and provide short term relief, but would be putting the discs above (T12 and L1-L4) at risk for flexion-related injury. A better method in this example (and in most cases of low back pain) would be teaching the patient to avoid both extremes in flexion and extension. This would serve two roles: lessening stress and pain on the posterior facet joints, while preventing further degeneration of the remaining vertebral discs.

Worth mentioning is that even with McKenzie’s more common extension-related treatment, he still teaches flexion exercises after pain is resolved, “to restore normal range of motion.” I disagree with this as well, since (as McKenzie rightfully surmises) daily activities still generally give people too much spine flexion. As such I think most don’t need any stretches in spine flexion but rather total body fitness, mobility around the peripheral joints, and motor control/postural awareness to maintain a neutral and pain free spine position during work, play and, rest.

As always, if you have any further questions or need for clarifications, please don’t hesitate to ask. Being aware that some of my blog ideas are contentious and occasionally a bit out of the field of my expertise, I encourage my readers to come forth with any questions/comments that are of interest or concern. Your comments are valued and welcomed.

Chad Reilly is a licensed physical therapist, located in North Phoenix, practicing science based medicine with treatment protocols unique and effective enough to proudly serve patients from Phoenix, Scottsdale, Mesa, Chandler, Tempe, Peoria, and Glendale.

 

Update: 12-1-15

This is currently my second most popular blog, and while I think it’s good stuff, I think my best material is written below in answer to comments and questions. Also this blog is a bit negative, being mostly about what doesn’t work, or at least what the above meta-analysis suggest doesn’t work very well. However, in answering questions below I wrote a great deal below about what I think does work. Much of which has been summarized in my low back pain info page. Also, I made an example low back pain workout video of what I would say is my stereotypical low back pain workout. I don’t start people off on all these exercises, but generally start with the standing rows, standing presses, and maybe add the hip in/out machine on day one. All performed 3 sets or 15 reps (easy, medium and hard weights) stopping immediately if there is any pain. If the person does well with those exercises on day one, I’ll add 1-2 exercises per day, until I get to what I think is a complete program. Some patients can’t do all the exercises, some do alternatives and some do extra, but the video program is my basic. The exercises themselves only make up about ⅓ of what it often takes to recover from low back pain. The other parts are improving static postures and motor control during active motions, the latter of which the exercises help teach. To help it all, unless a patient has an abdominal hernia, or a pacemaker, I almost ALWAYS perform electric muscle stimulation (EMS) to the abdominal and low back region to both decrease pain and improve core strength. This works especially well when patients can’t perform regular exercises intense enough to increase strength, and the lucky side effect is the harder you do EMS, generally the less pain you have after. 

188 thoughts on “Hard Times for McKenzie Method, Low Back Pain

  1. I have been diagnosed with a severe left foraminal narrowing at L5/S1…due to osteophyte complex with compression of
    the exiting L5 nerve root within the foramen.

    and I am contemplating the McKenzie method..but am now confused after reading your blog!! really do not want surgery, shots
    etc…but what can I do to avoid more injury??
    Thank you
    Eleanor Walmsley

    • Hi Eleanor,

      “Severe narrowing” AKA foraminal stenosis sounds like a bad case and this is a hard and likely inaccurate answer to give over the internet but I’ll do my best. While McKenzie method is usually associated with extension exercises, I would expect (according to McKenzie theory) in your case (based on your MRI findings which does not always match symptoms) a physical evaluation would find back extension and side bending to your left would be painful. So while McKenzie method is usually associated with extension exercises, in your case a trained McKenzie therapist would likely have you do a number of spine stretches in flexion (forward bending) and side bending right, in order to open up your left foramen. That’s according to the theory at least.

      Unfortunately in your case I see potential problems with McKenzie method of treatment. First is that in real life I find low back pain patients often have their pain exacerbated by partial and end range motions in all directions. In my experience, the McKenzie stretches are as likely as not to cause more pain, rather than relief in the short term, and with regards to low back pain I don’t for a second believe that you have to go through short term pain for long term relief. Effort yes, but not pain. The other problem is that if everything does fit the McKenzie model and forward bending and side bending right did give you short term relief at your L5-S1, that motion will increase stress at the lumbar discs which could lead to disc bulges and/or herniations farther up in the low back at perhaps L4-5.

      So for conservative treatment I think the best course is to increase strength and endurance of the core muscles while keeping the spine neutral/in its most pain free position. I would strengthen hip and leg muscles also while keeping the spine neutral. Also you should look at static sitting postures during the day, and motor control, with regards to how your spine is moving during dynamic activities, all of which is hard for me to convey over the internet. I get a lot of results with short term pain reduction and strengthening of the core muscles by using EMS if it is too painful to do regular core exercises. Usually though, I have my patients do both EMS and exercises.

      The problem with stenosis is that if it is too bad, even good exercises might not be tolerated very well. Injections are hit or miss, but when they work sometimes they work really well and can give enough pain relief that the right exercises will be tolerated. If the nerve is too compressed, surgery might be necessary; afterwards all the exercises, motor control, and postural adjustments would be imperative to prevent problems up the spine at the next couple levels. I hope that helps and let me know if you have any further questions as I like talking about this stuff. Unfortunately, there are a lot of limitations as to precise instructions I can give over the internet without having done a thorough evaluation and observing how you respond to each intervention.

      Chad Reilly, PT

  2. As someone who suffered with LBP for almost 3yrs straight due to a weightlifting injury I was at wits end until I found McKenzie’s method.

    It was an absolute life changing experience for me. I had been put through the PT mill by my PCP and blown off by them both. PCP wouldn’t order X-Ray or MRI (I know, I know they don’t always provide better outcomes – I heard that speach) citing insurance company BS. I was to the point that I was furious at the lack of evaluation and treatment I had been given by my PCP and three PTs. It was always the same, check hamstring flexibility, prescribe some stretches (almost all flexion), some core exercises and see me next week.

    And the outcome was always the same. More pain.

    As a lifetime athlete, I did not need ‘core strength’. Most of my workouts are/were on gymnastics rings and other bodyweight exercises. My core was/is not weak. There was an issue with the structure. After growing tired of all the BS I had endured with three three different PTs I subjected myself to, I scored on the fourth PT. She practiced the McKenzie method.

    What an absolute godsend. After the first eval and treatment I was pain free. Yes. After the first session I walked out of her office feeling no pain for the first time in almost 3yrs. I continued the full cycle and now live pain free with no LBP. I am able to deadlift, squat, surf (hyperextension to full flexion), and just enjoy life as I should have years prior. If my first PT had known about this and utilized the 5 minute eval I would have been ‘fixed’ years before. If I weren’t so happy from no longer having LBP I would throttle him.

    I now incorporate the methods into my regular routines and am careful about lumbar flexion and can hardly believe such a simple method has such profound results.

    I recommend every PT at least do the test to see if patient responds favorably – what’s there to lose? If they don’t respond well, then don’t prescribe McKenzie method. And, patients need to be their own best health advocate – it is the only thing that saved me. If you aren’t getting results with one practitioner, move on.

    Good luck!

    • Sam, thanks for your comments! You bring up a number of points I think are worth touching on.

      First– your doctor didn’t want to order x-rays or an MRI. X-rays are relatively inexpensive and don’t sound unreasonable, but MRIs for low back pain show a lot of false positives (spine abnormalities shown in otherwise normal subjects without pain). MRIs haven’t been shown to provide information that positively influences outcomes.

      As for your positive experience, I agree that flexion stretches are almost, if not always, a bad idea for low back pain. You say your core was strong already such that core strength and endurance training wouldn’t help much, which sounds right. And you later worked into squats and deadlifts, which if you perform them keeping the spine neutral you are using two of my favorite spine stabilization exercises. Though they are not part of McKenzie method, they should continue to serve you well.

      So the question is, why were your results so good, when research shows McKenzie method results in little to no benefit on average? I would speculate the reasons are several fold.

      You had low back pain that was exacerbated by flexion, which in accordance with McKenzie method should be treated with extension. A problem is that your first 3 physical therapists treated you with what sounds like Williams flexion exercises which I would agree, and research would suggest also, would only further exacerbate your back pain. They probably told you that the stretches sometimes feel bad at first to make you feel better later, which I agree is bunk. Hamstring stretches likely wouldn’t have any effect if you have a straight leg raise of at least 60 degrees anyway. If you had a background in gymnastics I would guess you are better than average. So it sounds like your first 3 therapists were actually causing harm with the circa 1930s Williams-based flexion exercises. That is what McKenzie was reacting against when he came out with his extension stretches, which compared to flexion stretches are probably a godsend to a lot of people with low back pain.

      You likely had a bulged disc or small disc herniation where at least 60% of your disc height was maintained at the time you started the McKenzie stretches. If you have seen my other blog, I talk about the McGill study where they tested repeated McKenzie type extension stretches on injured pig spines and found they did in fact reverse the posterior migration of the discs about half the time, and they tended to do so when the 60% of the disc height was retained. However if the discs were damaged to such a degree that less than 60% of disc height remained, then the McKenzie type stretches were ineffective at reversing the posterior migration of the disc nucleus.

      You had a strong core already and you later implemented core strengthening exercises on your own. Core strength and endurance exercises are lacking in the McKenzie program, but they weren’t as necessary for you as they are in a lot of people with low back pain. Plus, you later implemented your own exercises– squats and deadlifts– that probably do a lot more to stabilize the spine than typical “spine stabilization” exercises that are popular among a lot of physical therapists as they misguidedly focus on isolating the transverse abdominus and multifidus muscles.

      So it sounds like you were a square peg put into a square hole. The problems with McKenzie method seem to be when when low back pain sufferers have greater degrees of disc height loss, they don’t have sufficient core, hip and leg strength, and they have poor motor control, and that includes a great number of back pain sufferers who are not sufficiently helped with the McKenzie protocols. These problems were revealed in the meta analysis cited showing little to no overall effect. And unfortunately this likely describes patients like Eleanor who replied earlier who already has osteophytes and foraminal stenosis.

      Static posture is an important factor that McKenzie does address in his books. In my opinion though, his recommended lumbar supports are on the extreme side resulting in an extended rather than a neutral spine. Also, if a McKenzie evaluation reveals that your symptoms are exacerbated by extension, his protocol requires that you be treated with end range flexion stretches which are essentially identical to those advocated by Williams. All the same risks will apply with those flexion stretches. I think I mentioned in one of my blogs that I spoke with Stuart McGill by email after reading his study showing that repeated extension stretches sometimes helped reverse posterior disc nucleus migration. I asked him if that meant he was advocating those stretches? He said no because he thought repeated end range extension stretches might lead to facet joint irritation/arthritis. Instead, he advocated just laying prone propped up on one’s elbows at most and holding that position static for 10-15 minutes (as opposed to the McKenzie floppy push-up where you repeatedly extend all the way up on outstretched arms). This way, you would get the benefits of extension with regard to the discs without the repeated facet joint trauma. The last problem that I can think of is that of the McKenzie evaluation itself. While McGill’s paper indicates extension stretches may, at least initially, be beneficial for a number of people with low back pain, a recent study revealed that physical therapists trained in McKenzie evaluation methods don’t do a very good job of consistently determining which patients fall into which category of treatment.

      Thanks for your comments, if you have any more I would be happy to hear them. Recommended treatments for low back pain over the years have been complicated, convoluted and often contradictory. It’s only recently that spine biomechanics and causes of injury have been sorted out well enough to make some sense of the various treatments given and why some might work well and others might not. Unfortunately much of this knowledge came after McKenzie method treatments had already been codified, else (having read all of McKenzie’s books myself) I get the impression that he would have implemented the newer ideas.

      Chad Reilly, PT

  3. I’m a 49 year old male that has had chronic LBP for almost 20 years. And an avid cyclist. I’ve had Discectomies at L4/5 and L5/S1, advanced Facet arthritis on at least three levels, plus all the other “extras” that are included for fee, stenosis, nerve root compression etc… Prior to my last discectomy I sufferd “drop foot” for about a month. After the surgery my left leg and hip never really returned to normal. I don’t believe in PT, I’m stubborn and believe that if you go back to your regular routine things will work out. However, this time it was different because of the drop foot. I’d lost strength and mobility in my hip which turned into a disaster when I resumed my cycling. My gluteus medius was really weak and so cramps and Piriformis syndrome my best friend. I don’t think my left leg has fully recovered all it’s strength, my last surgery was Aug 2010, I hoped that my cycling would eventually help to strengthen my weaker left leg. It did to a small degree but I still feel weak in the leg so I asked for a referral for some PT. When I went in for in take the therapist had me do “cobra” push ups which I thought is harmful and painful for my facet disease. Therapist assured me all would be fine. It wasn’t. About two hours later I had some of the worst pain I’d ever experienced! Major sciatica and Piriformis pain. I talked with the attending PTA and he said my pain was caused by sitting when I got home. He recommended I avoid sitting and bending and to do ten cobra push ups every two to three hours. From my many years of LBP it sounds counter intuitive. I am scared to death to go back and have to endure those pain inducing push ups for fear it will exacerbate my facet condition and worsen my bulging discs at L2/3 and L3/4. Am I missing something, or will all the pain be worth it? The best relief I get from my facet pain is to bend over for a few seconds. But I’ve instructed not to bend over and to sleep on my stomach. I’ve had three facet RFA’s in the past three years but this last one hasn’t really worked as well as the others. I’m at my wits end here.

    • With the caveat that I haven’t evaluated you, seen your x-rays, or anything else, for the sake of discussion I’m willing to take everything you say at face value as it agrees with my general experience. So I’m going to tell you what I would do for one of my patients if they had symptoms similar to what you describe, but know that I could be wrong.

      Given your experience, I wouldn’t believe in physical therapy either, however your regular routine got you all the problems in the first place. I think a lot of people think degenerative disc disease is something that just happens but the science is really starting to show spine degeneration is cause and effect.

      I think it likely that being a cyclist contributed to your back pain because the most aerodynamic cycling posture is generally with the spine in full flexion, which is known to be a position that contributes to lumbar disc bulges and herniations. Once you start losing vertebral disk height due to the herniations, the facet joints impact each other sooner and harder often becoming arthritic. I have a cyclist I am treating now who has had 2 lumbar fusions before he came to me and his surgeon said he should have no problem returning to cycling after the second surgery, to which I responded the first surgery should have been a clue, and the second a bigger clue. In fact he worked really hard and was able to return to cycling but he had to compromise by riding with a less aerodynamic cycling position so he can keep his spine neutral to lessen future degeneration. Also it took a lot of core, hip and leg strength and endurance work to get him there and he had to get his hamstring range of motion better than normal.

      The subject of this blog is McKenzie Method of physical therapy, which while I am not a general fan of, it does not seem to be what you are getting. McKenzie is mostly associated with extension stretches as prescribed by your current therapist, but per McKenzie’s own books, if extension exacerbated your condition he would have you stop extension stretches and start doing flexion. I don’t think he would have you power through the cobra or floppy push up while it was increasing your pain. It sounds like you are aware that extension closes off the spinal canal so if you already have facet arthritis and vertebral/foraminal stenosis I would expect it would only increase pain, which you have apparently experienced. Contrary to what your PTA is saying, I would NOT expect it to get better. If it were me I would refuse to continue with that exercise, and I would be suspicious of anything else they might tell me.

      I would expect a true McKenzie Method practitioner to test you and notice extension exacerbates your pain, and would then prescribe you spine flexion stretches, which you say does relieve your pain. But here’s the rub, spine flexion stretches may increase space for the nerves but they cause further disc bulges, herniations and disc degeneration. If your L4-L5-S1 is already shot, the upper lumbar vertebra are next to go, which you report are already bulging. So given your history I think getting really good at maintaining a neutral spine, nigh all day long, is the best option you have and would minimize stress to both your discs and facet joints so long as the stenosis isn’t too advanced.

      If you were my patient I would most likely advise you to maintain a neutral spine when sitting with the use of lumbar supports (which can be as simple as a couple throw pillows on a couch). I would perhaps add a thin lumbar support to your car seat (but not so much as to push your spine into extension beyond neutral), and adjust the seat position so its close enough and upright enough that when your shoulders are back in the seat you can still rest your wrist over the top of the steering wheel. When cycling I would maybe suggest a higher handlebar position or to keep your elbows extended with perhaps some hamstring stretches if they are tight. I would advise maintaining a neutral spine during dynamic activities such that you bend over using your hips rather than at your waist/lumbar spine, and twist and rotate with your legs rather than through your waist/lumbar spine. The spine awareness during activity I think is best taught through various resistance exercise so it has the benefit of also increasing general strength and endurance. I think for your weaker left leg it would be good to do some progressive resistance exercise with machines, which aren’t as good for teaching spine motor awareness, but they make it easy for you to train one leg at a time so you know exactly how much catching up your weaker side has to do. Last I think the most intense core strength exercise is done with electric muscle stimulation, which if done properly not only increases muscle strength better than you can with curl ups or planks, but also does a real good job of acutely reducing back pain. I would think EMS applied to your weaker leg might help it catch up in strength and endurance faster as well. If tolerated I do think front and side planks/bridges are still a good exercise. For what it is worth I will sometimes have a patient do static stretch for maybe 10 minutes in prone on elbows at most, and only if it provides relief (in your case I would not expect it would) and never if it exacerbates pain. I never have my patients perform the cobra/floppy push up.

      While it sounds like the physical therapy you are getting now is inept, it’s hard to fully blame the therapist because PT schools are still teaching Williams (flexion stretching) and McKenzie (mostly Extension but sometimes flexion) approaches to back pain, neither of which take into account that spine stretching in flexion, extension, and twisting tend to cause spine pain and degeneration. Often when talking about spine stabilization exercises, therapists are referring to isolating the transverse abdominus and multifidus muscles, which I don’t think is effective either. The newer research is no secret and medical professionals who treat back pain not reading it, and professors not teaching it, is lazy at best. At worst, it makes people not trust the profession; and contributes to long term pain and disability when a patient is sent to therapy, it doesn’t work, and they are referred back to a surgeon or pain management specialist which if you are lucky surgery or drugs help for a bit but don’t solve the problem contributing to further degeneration of the spine, further surgeries, and eventually narcotics.

      I hope that helps and if you have any questions let me know. I have number of my favorite back and hip and leg exercises on my youtube channel that you might try, but I would stop or lower the intensity on any of them if they increase your pain. Back pain is not something that I ever tell my patients to continue to work through the pain with.

      If you have any more questions or I can further clarify anything don’t hesitate to ask.

  4. I appreciate reading your comments here. I’m someone for whom the McKenzie stretches don’t seem to work. I was given them to do, and while they haven’t radically increased my sciatica, I’m definitely no better, and could possibly be a bit worse. So I’m going to stop doing them. But your comments are the first I’ve encountered that suggest McKenzie is often ineffective. In my searching on the internet, it seems that his stretches are considered a miracle cure, so I was left feeling it was MY problem they didn’t work! Not a helpful feeling. Thanks.

  5. Back in December of 2014 I was referred to a local PT chain and after my intial visit I had the worst sciatica since my last sequestered discectomy in 2010. I’ve had two Discectomies L4-S1 fist one in 2004 and my second in 2010. The second, L4/L5 was a total sequestration and caused a few weeks of no feeling in my big toe which subsequently led to a poor gait and I’ve had lots of problems with my left Piriformis and gluteus medius ever since. I’m a 49 year old male and a very avid cyclist. I finally got a referral to PT and was excited about finally fixing the Piriformis problem. On my first visit the therapists assistant did not look at or even as to look at my MRI, she asked a few questions and then had me do a series of McKenzie exercises then sent me on my way. About 2 hours later I had severe sciatica in my left leg. I called the clinic and asked why this happened. I was told by the cheif therapist that the pain was because I sat down. What?!! I’ve been suffering with DDD, stenosis, Facet diease and all the goodies that accompany two missing disc’s for well over 10 years and with all the Dr’s and therapists I’ve seen while active duty Army never once did I have this much pain after a PT session. I was extremely afraid to go back to this PT using the McKenzie extensions, and I have not returned.
    Was it “normal” to have so much sciatica after that first visit using the McKenzies stretches? It feels very counter intuitive to do extension exersices for Facet Syndrome and Stenosis. What have I done wrong? I also read that a traumatic injury to your glutes can cause Piriformis Syndrome. And I had a very bad cycling fall back in 2003 that caused a VERY large hematoma on my left glute that required three surgeries and a six week hospital stay. So I’m guessing that this nasty accident is what’s causing my Piriformis Syndrome and maybe the weak gluteus medius. I’ve been advised by my PM Dr to NOT do any core exercises unless I’m hanging from a sling or chin up bar. This makes sense but I do not have access to a sling or chin up bar. And I know that a strong core is vital to good posture on the bike. I believe I’d be less fatigued and more comfortable cycling with a strong core. I used to do a lot of core work while in the Army and it did wonders in many aspects of my life.
    Should I stay away from the McKenzie method?

    • Hi Kenneth, I remember your history and believe I commented with you about your back and McKenzie method before. To answer your question, if I were you I would avoid McKenzie flexion and extension exercises. The spine extension stretches will likely irritate your facets and potentially be compromising nerves as they exit your vertebral canal, and flexion stretching would likely worsen disc degeneration at other levels. This is especially so you notice those stretches are worsening your symptoms. Per McKenzie’s books if extension increases pain and then flexion relieves it, you should do flexion stretches (and that’s what your current physical therapist seems to be missing). However, the flexion stretches along with being in prolonged spine flexion as a cyclist is likely contributing to your degenerative disc disease. I think you would be a lot better off working to improve your postures, increasing core and extremity strength all while maintaining a neutral spine (thus improving hip and spine motor control)

      I think I mentioned above somewhere that I love EMS (electrical muscle stimulation) circumferentially around the core with low back pain. If I take a 4 channel machine like the (EV-906), or my new favorite but more expensive Globus Genesy, and apply 2 channels to the abdominals, 1 channel to the obliques and 1 channel to the spine extensors. With the proper settings and 10 cm rubber carbon electrodes described here, I get considerable core strengthening with immediate pain reduction that continues to surprise me. In recent months, I’m starting to be more surprised if it doesn’t work.

      As for the diagnosis of “piriformis syndrome” a lot of people have pain in their posterior hip and numbness going down the leg and given your history and MRI report, I would suspect nerves are compressed in your lumbar spine rather than by your piriformis muscle. Piriformis syndrome is a pretty iffy diagnosis and in 15 years of treating low back pain I have made the diagnosis only a few times but looking back I don’t think that diagnosis was ever correct. And never once did stretching the piriformis muscle relieve pain in someone I thought had the piriformis syndrome. So I think piriformis syndrome is just back/radicular pain originating from the spine, with pain and/or numbness referring down the leg and not something that needs to be treated any differently than back pain in general.

      Anyway, I hope some of that helps and I’m happy to continue to answer any questions you have. However if you find yourself in the Phoenix area, I can probably teach you a lot more, a lot faster.

  6. As an orthopedic physical therapist, there’s a lot I could say in response to this blog. But to maintain a high level of discourse, might I just suggest investigating the most recently released JOSPT Clinical Practice Guidelines for low back pain (published in 2012, 6 years after your cited source).

    They recommended, with strong evidence, only 3 interventions:
    1) General Exercise
    2) Manipulation (for select populations as outlined by the clinical prediction rule)
    3) Repeated Movement Testing and Specific Exercise (ie, Mckenzie)

    Thanks for allowing me to throw my two cents into the ring!

    • Hi Ryan, thank you for your response. I’m familiar with the paper you cite, having read and highlighted it a couple years back. I don’t know if I would agree that any of those recommendations are in reality based on “strong evidence” and I have this to say about each:

      1) Regarding “general exercise,” what exactly do you mean? Are you implying that all exercises are the same, with running on a treadmill or riding a road bike being the same as crossfit, gymnastics or yoga? Personally I think exercise in general is more good than bad, but for back pain I think some exercise choices are clearly are better than others. Do you disagree? And doesn’t your (or their) first recommendation kind of contradict your/their third?

      2) If you were to think as a scientist, looking for cause and effect relationships, what’s manipulation going to do for someone with low back pain? Say a patient has a herniated disc, DDD, or stenosis; beyond psychology, or mild gait control theory effects from being touched, how could manipulation help any lumbar pathologies?

      3) How is repeated movement testing going to help someone with back pain? I agree that if flexion hurts a person, you shouldn’t have them do flexion, but is aggressive end range extension really going to help them? And if extension hurts a person, I agree you certainly shouldn’t do extension, but are end range flexion stretches really going to help them? Honestly how would that work? Before you answer, do note that the most recent cited source regarding Mckenzie method, in the very paper you are referring me to, IS the 2006 paper I reviewed in this blog. Specifically in the first paragraph on page A35 it says:

      “Machado et al (206) performed a systematic review and meta-analysis of 11 trials utilizing the McKenzie treatment approach. Short-term results demonstrated improved outcomes compared to passive treatments. Long-term follow-up at 12 weeks favored advice to remain active over McKenzie exercise, raising questions on the long-term clinical effectiveness of the McKenzie methods for management of patients with low back pain.”

      Thanks again for your comments, I do hope you will share more of your insights. Perhaps next time you will get a little more in depth than review summaries that aren’t necessarily supported by the text of the same article. TTFN

    • Hi again Ryan,

      I just thought I would respond more to your paper as I just did two more relevant blogs. Not related to McKenzie Method this time, but to your second point above regarding spine manipulation. It seems that meta-analyses for both acute low back pain and chronic low back pain found spinal manipulation/mobilization is little or no better than placebo. Which is particularly interesting admission since the primary author of both reviews is a chiropractor. Well designed exercise programs still work, as does avoiding damaging spine postures, so we can all be glad of that. Cheers

  7. Chad, you may find the research article below of interest where you are presently only exploring the sagittal plane and completely ignoring the lateral. It’s not your fault because years ago people started comparing Williams Flexion to McKenzie Extension where in reality they are comparing Flexion to Extension. If you remember from reading the McKenzie Text Books then you will remember Left verses Right rotation in flexion. If you compare Left and Right rotation in flexion without using them with side specific clinical reasoning then you would get much different results then it you utilized them specific to the side of the symptoms. Think of squeezing the disc by forward bending as squeezing it at 12 O’ Clock. Backward bending or extension would then be at 6 O’ Clock. Rotation in flexion while laying on the right side would be at 3 O’ Clock opposite to Rotation in flexion while laying on the left side would be at 9 O’ Clock. When patients like walking then they are telling you that they like the extension component of ambulation and would then like exercising at 6 O’ Clock. If they have increased symptoms during ambulation then they are telling you that they dislike extension indicating that they don’t like 6 O’ Clock. What are the other options: 12 O’ Clock for spinal stenosis, verses 3 O’ Clock or 9 O’ Clock for disc bulges that have turned lateral. You will find that the patients that have increased sciatica during ambulation will do well with rotation in flexion (reclining spinal twist in Yoga) while laying on their right side when they have right sciatica and rotation in flexion while laying on their left side when they have left sciatica. You are only thinking in 2 directions when in reality there are 4 to consider. Pick a single direction based on diagnosis and what happens to individual patients during ambulation and you will like what you find. Kind Regards, Steve

    Does it Matter Which Exercise?: A Randomized Control Trial of Exercise for Low Back Pain.

    Long, Audrey BScPT *; Donelson, Ron MD +; Fung, Tak PhD ++

    Spine. 29(23):2593-2602, December 1, 2004.

    [Randomized Trial]

    AN: 00007632-200412010-00002.

    • Hi Steve thanks for the reference, I read it with interest today because it wasn’t included in the meta-analysis I cited. I thought it was interesting, but when I googled it, I also found this criticism published soon afterwards in the NZ Journal of Physiotherapy with the following quotes taken from it:

      “For me the biggest design flaw they mention is the fact that the study was confounded by potentially unexplained variability due to the physiotherapist effect.”

      “Firstly, a more robust study would have employed assessors who were independent of the treatment provision, thereby ensuring treating physiotherapists were blinded to patients’ DP.”

      “I cannot agree with the authors’ comment that the physiotherapists were able to be equally enthusiastic and motivating regardless of the type of exercises they were prescribing. I find it very hard to believe that any physiotherapist, let alone one trained in the MDT approach, could be as enthusiastic and motivated to treat patients whom they knew were receiving not only unsubstantiated usual care exercises (the EBC group) but also those patients who were being given potentially detrimental exercises (the opposite direction group).”

      “The authors report a relatively high attrition rate for each of the EBC (32.8%) and opposite direction group (34.8%), whilst no one from the matched group left the study. This should not have been a problem since the authors chose ‘intention to treat’ analysis, but as outcome measurements for these patients were completed when they left the trial, i.e. before the end of the two-week study period, this becomes a more serious problem. In terms of research this is a major flaw since the natural history of LBP suggests many people will show natural recovery within a two to four week time frame (ACC guidelines, 2003). Thus the outcome data for these patients could unfavourably influence the overall outcome for these two groups, and might explain the difference between their results and those of the matched group. The authors do attempt to justify this decision to take outcome measurements early since it was deemed unethical to prevent these patients from going on to receive other treatment. It may therefore have been more appropriate to remove these cases from the final analysis.”

      “On first glance the results appear very exciting. However, having felt sympathetic towards the authors’ attempts to justify the design flaws my tolerance finally waned when I started to consider their statistical analysis.”

      The statistical analysis criticism is beyond my knowledge base, but the rest of the critic’s comments ring true to me. One thing not mentioned in the published criticism but that I noticed myself is that they didn’t mention much in the way of details about the various treatment programs. However, in what was described, I think I spotted what is another major potential confounder of the results of your paper in the 2nd paragraph on page 2595. The McKenzie group was instructed to “avoid activities and positions that increase intensity or radiation of symptoms” while the opposite and usual care groups were given advice in accordance with the biopsychosocial model of back pain to “minimize fear avoidance behavior.” If I am not mistaken the latter means teaching patients not be afraid to do what hurts them and to keep doing it. I have already offered criticism of the latter in another blog, and I think avoiding activities that cause low back pain is rather prudent.

      So I don’t see anything in this paper that sways me from the basic finding of my review paper, that McKenzie method, as a whole, is better than flexion stretch based programs (because flexion stretches are generally bad for your back) but is no better than advice to keep active. I would make the point, that I have made at least a few times above, that extension can help to reverse disc herniations if they have not gone too far and disc height is maintained, but I think aggressive end range extension, will eventually cause it’s own problems, namely facet joint irritation.

      You do, however, make a good point that McKenzie isn’t just flexion and extension, but that it also includes side glides, rotation and extension into right and left quartiles. However, I think they are neither here nor there because:

      A) McKenzie method of training (regardless of level) does a poor job of diagnosing which patient should go into what classification of problem, particularly for lateral shifts.

      B) The meta-analysis I cite above includes use of lateral shifts in diagnosis and treatment and there is still no evidence of worthwhile treatment effects.

      C) Lumbar discs generally bulge and herniate posterolaterally, and they almost never go forward or directly to the right or left such that I think the side glide or spine flexion is almost never going to reduce a bulged disc. If the person has bulged a disc posterolaterally I would expect extension, perhaps combined with lateral flexion to help reduce that prolapse about 45% of the time in accordance with McGill’s study on reversing disk protrusions, which did combine side bending forces for both the cause and reversal of disc prolapse. I would expect it possible that when a lateral glide appears to work by itself, it might be because flexion is causing pain, extension is causing pain, and a lateral glide is just doing little to no harm, so therefore feels best and is what the person did most recently when the pain lessened. Post hoc ergo propter hoc.

      D) You talk about spine rotation, but that’s a known spine irritant as well, with combined spine flexion and rotation being particularly pathological, such that I’m not going to put any of my patients through it in either evaluation or treatment.

      I have a few more thoughts, but that should be enough for now. What do you think?

  8. I suffered from a disk herniation on the L5-S1. With severe radiculopathy. It was mainly caused by several deadlift related injuries due to poor form and also a couple of weeks of sitting with poor posture. After a long recovery I tried the McKenzie exercise. The prone press up actually increased the pressure on the nerve and it caused a lot of pain. However the side glide improved my condition in a great deal. I no longer have any pain when walking and doing the Lassegue sign. Which gave me instant pain on my leg. Well the Press up still gives me small discomfort. So I surely agree you on that. I have several questions that I want to make.
    -I have been able to squat up to 200 pounds with no discomfort whatsoever. Taking good care on the form. Can I increase the weight on the long run? My doctor was very against it and advised me to “never squat ever again”. I have misleading pieces of information as you mentioned that squatting and deadlifting develop the erector muscles. But it seems counter intuitive as heavy squats, obviously increase the pressure on the injured disk. I am afraid I might injure myself worse being careless with squats.

    -Do herniated disks trully heal? Or they just become smaller with time that they don’t affect the nerve as bad? I have heard many different opinions on these. What is your take on this topic?

    -What is your opinion on exercises such as the famous Reverse Hyper popularized by Louie Simmons. I get that, in theory, they relieve pressure from the disk and they “hydrate” the disk when it loses water. That seems too good to be true. But I would like to know your opinion.

    -I am a judo and jiu jitsu grappler. But I havent trully trained in one year. I have some fears about re-injuring myself. Some positions on jiu jitsu are pretty awkard and sometimes you have to be explosive. Can someone with a damaged disk practice such activities?

    -I have become diligent on core training. I prefer the ab wheel rollout and now I can do 25 strict repetitions of standing ab wheel rollout. I could not do a single one pre-injury. That seems like disk herniation blasphemy. But usually when I have some back discomfort some repetitions of standing ab wheel rollouts kind of “pop” my spine and it feels good. Does that make sense on a physiological way?

    -I have few problems. Mainly I go without pain throughout the day except in the times I do the prone press up. However I feel there is just that 10% to 15% of herniation pressure that I would like to get rid off. Is that possible? Or it could be scar tissue pressuring the nerve? What can I do?

    -What is the role of flexibility on recovery?

    -I have been suffering of muscular issues on the middle of the back. IS that related to the height change of the disk? What can I do about it?

    -Will I have in some point of my life have to undergo a spinal fusion? What can I do to avoid it?

    These are many questions but your blog is priceless. and your knowledge for me is precious at this point of my life.

    • Hi Francis,

      Regarding increasing the weights on your squats, I honestly have no idea what level of weights your spine can safely take, and I’m pretty sure your doctor doesn’t either. Squats are one of my favorite low back rehabilitation exercises, but I am very strict with my low back pain patients. I insist that they keep their spine neutral throughout the movement, and that they stop or back down immediately if they have any increase in back pain, either during the exercise or afterwards. Even if back position is kept perfect, there may be some point where compressive loads during squats might irritate your back. With my patients I tell them I don’t know of any particular number with regards to how much they can or should lift, but when the weights start to get heavy, and I would say 200 lbs is getting there, I would tell them to be careful, move up slower rather than faster and follow their instincts. It has been my experience doing it that way, using a number of specific warm up sets, that none of my patients have had a major exacerbation of pain that way. Sometimes they will get to a weight level where they will start to feel minor to moderate increases in pain afterwards. At which point, if their technique was otherwise good, I tell them, that pain is likely their early warning system saying weights are getting too heavy, maybe. Sorry if that’s not particularly concrete but both physical therapy and strength and conditioning are a fuzzy science.

      As for the counterintuitive part regarding squats and deadlifts, with good technique both do increase disc pressure (compressive force), but discs generally handle compressive force reasonably (though not infinitely) well. On the contrary with spine flexion (like if you sit with bad posture or round your back at the bottom of a squat, or round during a deadlift) there is compression on the front, and tension on the rear most portion of the disc and if done too hard and/or too often, it may eventually cause the disc nucleus to track rearward and eventually squirt out the back (herniate) just like squishing the front half of a jelly donut, and just like what it sounds like you did to your L5-S1 disc. Also with end range spine flexion, the erector spinae muscles (active structures) tend to turn off, putting additional tensile stress on passive structures of the spine, that being posterior ligaments and discs, and allowing for increased shear stress/forward slippage of one vertebra upon another. So yes, you might injure yourself worse if you are careless with your squats. So if you are going to squat, don’t be careless, ever, same with deadlifts.

      Do the discs heal? Macrophages will eventually clean up the extruded disc material but I would expect the fissure through which that material escaped will never have fully normal strength. Also, when discs herniate you lose disc height, which as far as I know, once it’s gone it’s gone. So I would encourage you to not lose anymore.

      Regarding the reverse hyper, I have only done them with bodyweight and if you keep the spine neutral, I think they are fine. When I see people doing them on machines with weight on youtube it appears to me that they are flexing and extending their lumbar spines, which I expect would make things worse rather than better. Shear stresses with a reverse hyper appear opposite of what you would get flexing your spine on a squat or deadlift so it might not be as bad, but I can’t say for sure as I don’t regularly use them when rehabilitating my low back pain patients with resistance, and I am unaware of any studies looking at spine motion during reverse hypers. Once in a blue moon, if I know I have a patient with spondylolisthesis (forward slipping of one vertebra upon another) I will have my patients try them, without weight, on the end of a table and if they can do so pain free I will put it in their program. I’m pretty sure they don’t hydrate, but would rather dehydrate a disc.

      I think you can do judo and jujitsu, but you would be at elevated risk of hurting your back doing so. I don’t tell my patients what sports they can do or cannot do, I just tell them what I think the risks are, tell them what I think will help minimize those risks and let them make their own decisions. If you really feel your back getting hurt, I would recommend tapping out. Also I think you will be better able to tolerate the risks of martial arts if you increase the strength and endurance of your hips and core, and lessen spine stress during all hours that you are not in martial arts. An hour or two of high stress to the spine in judo or jujitsu will be much better tolerated if you haven’t been sitting all day slouched on a couch or in a bad chair. Google some video of spine researcher Stuart McGill doing work with mixed martial arts champions and you will get some ideas. “Stir the pot” is one of his favorite exercises with them.

      I think the ab wheel rollout is a great abdominal exercise, which shares some characteristics with the ‘stir the pot’ exercise that I mentioned above. With both you get strong abdominal contractions while you keep the spine neutral, which like in the squats and deadlifts with a neutral spine, helps to protect it. Unfortunately the same can not be said for a lot of other abdominal exercises. FYI, don’t think there is any abdominal exercise that’s remotely as effective at increasing abdominal strength as electric muscle stimulation (EMS), and EMS helps with pain as well. How cool is that?

      If I were you, I would never do a prone press up ever again. No way is a prone press up going to un-herniate your disc. That horse is already out of the barn. Given that you already have disc height loss, your facet joints are closer together than normal, such that a prone press up at this point is likely to increase the risk of facet joint irritation/arthritis. Rather, get the core strong and improve your spine awareness/motor control so you can avoid irritating ranges of motion, namely end range flexion, extension, rotation, and side bending.

      Flexible and strong hips and shoulders will let you do more activities with lesser range of motion at the spine thus protecting the spine, which is damaged from years of too much flexibility. The best stretch for the spine in my opinion is none.

      I wouldn’t expect your low back problems to have much directly to do with your middle back pain, but the same forces and stretches that hurt one, likely hurt the other. I would encourage you to maintain good neutral static postures throughout your spine, improve motor control about your spine during dynamic activities, and improve strength and endurance of your core. So pretty much, I would treat middle back pain, and even neck pain in much the same way as I treat low back pain.

      I would expect if you do all of the above you would have a very good chance of avoiding a spine fusion down the road.

      Good questions, let me know if you have anymore, but remember I haven’t evaluated you so I can really only speak in generalizations and what I do in the treatment of others. Hope that helps.

  9. Good job Francis using the lateral side glide in standing and then returning to the sagittal plane. Recovery of function is used to strengthen the scar withint the disc completing the healing process. It’s used in the final stages of all healing whether you are talking about muscle scar or disc scar. It prevents adhesions or what Robin McKenzie called the adherant nerve root.

  10. Thanks so much for your complete and elaborate answer. Such insightful and knowledgeable information is invaluable for me. I come from a country in which spine related issues are being treated with bed rest, medication and not much else. My neurosurgeon advised, completely prohibited squats. He stated “never to squat again, never ever” Because it would ruin my spine. A neurosurgeon. He advised for leg presses instead which, to my knowledge accentuate spinal flexion as you cannot really maintain a neutral spine in the bottom position. He is a quack. When I started losing control of my calf during the “recovery” I knew his advice was terribly wrong and I had to become proactive with my recovery. Squats only once irritated my back. I put 100 pounds on the bar. Which is a warmup set for me and it really messed me up. Now I don’t have any issues handling twice that weight. It Makes sense from an angular standpoint even. The pressure from the bar is compressing the spine and the posterior part of the disk is being pressed, That might be th reason why deadlifts injured me but never squats as the forces are completely opposite from eachother. I will stick to squats. I love them. But I don’t think I will be doing deadlifts anytime soon. I will abandon all prone press ups and concentrate on developing my core and lower back. I have been working on my hip flexibility as well. Thanks again for your response and again keep the good work. Valuable knowledge for people like me, who are miles and miles away from any reputable source regarding physical restoration is priceless. Thanks!!!

    • Glad I could help Francis. I don’t know if I would go so far as to call your surgeon a quack, we all specialize so that none nobody knows everything and neurosurgeons usually don’t get a lot of training with regards to exercise. Plus it’s been a common meme to say squats are bad for your knees and bad for your back so he probably just heard that somewhere and repeated it. Plus it’s true that some people do hurt their backs doing squats. It’s just usually if they flex their spines during the motion, so it’s not the squats per se that damages the discs, but rather the repeated spine flexion under heavy load.

      As for leg press, yeah, if you go deep with both legs it puts a pretty strong flexion force through the spine. I still use leg presses sometimes but I get around the flexion by both adding a lumbar support, and by using one leg at a time. If the other leg is on the ground it helps anchor the pelvis, helping keep the spine neutral. I think leg presses are a fair rehabilitation exercise, and good if one leg is stronger than another and you want to bring one up, but if you are already doing squats, leg presses would be a step backwards not forwards. Lunges are usually good too, if you keep your torso erect.

      Also I wouldn’t necessarily write off deadlifts. Powerlifters usually do deadlifts with some degree of spine flexion (usually not full) so that they can get their hands lower without bending the hips and knees as much so they can lift more weight, which I think might be a bad exercise for you. But if you do conventional or sumo style deadlifts with the spine neutral and start out light, you might be able to do them pain free as well. With my back pain patients I try to progress almost all of them to doing Romanian Deadlifts (RDLs) which I like because they really strengthen the spine and hip extensors and teach one to bend at the hips while teaching the spine locked neutral, which is great motor control to have if you need to lift things during daily life. I teach my patients that if they can lift weights right, they can lift everything right.

  11. Dear Francis, I found this blog when I was doing a little research on Dr. Paul Williams. I had heard things about this particular Orthopedic surgeon and I wanted to be sure that I was correct in what I had heard about him; it appears that he first developed Williams flexion protocol just prior to WWII. This fellow believed in evolution and therefore he built all of his methodology on that premise and was terribly wrong. I’m a Christian and I belief that we should, “Test all things; hold fast what is good”, 1st Thessalonians 5:21 It sounds like your back has passed the test in your ability to squat 200# without any pain. Good job and feel free to live your life realizing that the recurrence of low back pain is common. Please don’t fall into the psychological fears that so many fall into when they have suffered an injury..

    However, you said that you had a herniated disc. I’m sorry but that doesn’t tell me very much because herniated just means bulging beyond it’s normal limits. There are bulging or herniated disc, herniated sequestered disc that hat broken through the outer wall of the annulus fibrosis, and finally the herniated sequestered disc. Chad seems to think that you had a herniated sequestered disc and when he was talking about macrophages which is translated “big eaters”. These big eaters can clean up sequestered disc material but it doesn’t sound to me like you had a sequestered disc by what you describe. It sounds like a bulging disc (outer wall intact) that took a turn laterally requiring the lateral side glide in standing. Robin McKenzie always treated the lumbar spine in lying with the single exception of the lateral shift patient that was listing to one side and then he quickly returned to the front to back (sagittal plane) after the lateral component was reduced. I know this for a fact because I communicated with him via email prior to his death a few years ago; God rest his soul. I’ve never communicated with Dr. Paul Williams who died prior to my becoming a PT in 1996.

    Shortly after I became a PT, I was struggling in treating my spine patients. My supervisor recommended that I take a McKenzie course stating, “In her 20 years of practice, it was the best course that she had ever taken!” I doubt that Chad has ever taken a McKenzie sourse but I completed the McKenzie International Diploma Programme in 2004. Well, it’s been 10 years and a lot of water has passed under the bridge. At the McKenzie International Conference in Baltimore 5 years ago, Stephen George PT, FAAOMPT presented what he called Predictors for spinal manipulation where he was performing rotation manipulation (twisting the back with a thrust) and was getting an 85% rapid recovery rate when the patients had 4 of 5 clinical predictors.I was impressed with the results and started to look for my own indicators using the McKenzie evaluation form.

    After 5 years, I’ve learned that when a patient has increased sciatica while walking, then they respond well to side specific rotation in flexion or what they call the reclining spinal twist (RST) in Yoga. I’m not an advocate of Yoga but I do appreciate some of the exercises that they use where the RST is the exercise that McKenzie used after he exhausted the sagittal plane using his hips off center technique as found in the “Treat Your Own Back” book that is in it’s 10th edition of print. I’d love to see the 11th edition include side specific rotation in flexion or the RST.

    We live in a world of evidence based medicine and as new evidence presents itself then we need to adapt to new information. Physical Therapists like Tim Flinn and Stephen George have shown great evidence for the utilization of rotation techniques using manual therapy. However, McKenzie always taught that it is empowering for patients to be able to control their own symptoms using the Centralization Phenomenon (CP) as a guide. I’ve told my patients for year, “I don’t care if it’s something that you do at home, at work, for recreation or even if it’s an exercise that I’ve shown you; If the pain goes further down your leg then it’s your body telling you to stop whatever you are doing even if it’s the exercise that I’ve shown you.” We know for a fact that if you compress the nerve roots as they exit your spine that you can have leg symptoms: pain, numbness or tingling. We also know that the more you compress the nerve root that the pain will go further and further down your leg. However, the opposite is also true, where when you decompress the nerve root that the pain will move back up out of your leg as the nerve root is decompressed. The secret to unlocking your pain is in symptoms location: further down the leg indicates nerve compression, movement out of the leg indicates nerve decompression. The secret to unlocking your pain is not in symptom location where often times the pain will increase higher up as it disappears down below. Many times I’ve had patients tell me that as their foot symptoms disappear that their calf symptoms increased. As their calf symptoms disappear then it when to the knee. As the knee pain disappear it when to the hamstring region, then the buttocks, then the back and then disappeared all together. My patients are always amazed when their leg symptoms turn off but quite honestly, I’m more surprised when patients fail to respond.

    The Long, Donelson study that I brought to the table shows that 40% of patients resolve all of their symptoms in the first 2 weeks and that nearly all of the others had some improvement. Less than 5% failed to respond at all and when the methodology is used correctly then nobody ever worsens. The other two categories showed that other methodology can at times have negative results but I NEVER HAD PATIENTS GET WORSE WHEN UNDER MY CARE! I didn’t mention my International Diploma earlier because quite honestly, I’d love to see other Physical Therapists grown in their understanding the Mechanical Design of the inter-vertebral disc to the point that they can be as successful as myself. I’ve reached the point in my career that Robin McKenzie reached in the 70’s where I am tired of helping patients one at at time and just want to help other Physical Therapists become better at their craft.

    Chad stated that these topics can be controversial. That’s understating the fact. There is too much pride and arrogance in the medical profession. There is too much bias for what we have always done in our clinics. We need to put aside all of our bias and difference and test all things using the Centralization Phenomenon as a guide. Chad, God made our bodies to forward bend, backward bend, side bend, twist and rotation. God doesn’t make mistakes but we as people sometimes perform bad techniques with dead lifts or lifting with a twist over and over. We can develop repetitive motion traumas to our disc from moving in any direction too much, backward bending included.

    • I don’t know what to tell you Steve. If I had spent thousands of dollars and a lot of hours becoming McKenzie certified that might cause me a fair degree cognitive dissonance about critical papers too, such that I’d feel inclined to defend McKenzie’s method in spite of overwhelming evidence that it isn’t particularly effective.

      I’m not going into detail but you have said a few things that make me think you may not be very well versed in the scientific method. A meta-analysis, like the one this blog is about, means they took all the McKenzie method studies they could find at the date it was written, I’m sure using a number of McKenzie certified therapist just like yourself, lumped them all together and gave a summary result, which I bolded at the very top of the blog. The results were better than Williams flexion exercise, but not even as good as advice to just keep active.

      The paper you cited is interesting, but has been criticized for a number of methodological and statistical errors raising questions about the reliability of their findings, not to mention the additional confounding variable I brought up. I don’t even doubt there overall findings that much, but it just appears they compared fair stretches and some generally good postural advice (which I think McKenzie is known for) to other treatments that amounted bad stretches and generally bad advice. However I don’t see anything in it that indicates McKenzie method is even as good advice to stay active. I’m sorry.

  12. This thread is very interesting for me. In my case what helped me was the side glide. Which is, in my uneducated opinion less agressive than the prone press up. In retrospective the prone press up never really helped. What has been helping me a great deal is core training, a lot of flexibility work and a lot of time. I have been squatting with no discomfort at all. However after a lot of months without weight training the DOMS is unbearable. God I missed that! I am thaknful for the replies regarding my particular case and the insightful topics discussed in this thread.
    I have been visiting a lot of other related threads and one that caught my attention was the one regarding the outcome of people that undergo disc surgery and the ones that prefer a conservative type of rehabilitation protocol.
    What is your personal take on that topic? The study was rather inconclusive as a lot of the subjects migrated from one type of treatment to the other.
    In my case I declined surgery as it seemed to be counter intuitive for true recovery and rehabilitation. It is regarded as a non invasive procedure. But what I saw in some surgery footage was far from non invasive. In your personal experience which one is more advisable for a regular person vs the stress that an athlete has to undergo?

    • It’s interesting that you say the slide glide is less aggressive than the press up, and kind of it is. Extension with or without lateral flexion has been shown to reverse disc protrusions, so long as 60% of the normal disc height is maintained, in laboratory conditions. I talked about the study that said so in my blog, Reversing Disc Protrusions, McKenzie Mostly Correct in Theory. I emailed one of researchers Stuart McGill asking if he was recommending prone press ups, given the findings in this study. He said not really, but kind of, because he thought the floppy pushup (what he calls the prone press up) was too aggressive (both in repetitions and in range of motion) and would would lead to facet joint irritation/arthritis so he recommended just laying prone with either the chin propped up on 2 fists as mild extension, or prone but propped up on elbows as moderate extension. Rather than repeating the extension for a number of reps to just lay there for a sustained 10-15 minutes or so to try and reverse the protrusions without the repeated impact on the facets joints of the spine. In your case if your disc height is less than 60% of normal I wouldn’t expect it to help, but otherwise it might be worth a try. McGill said he would stop doing it if it increased pain at all. So maybe some of what McKenzie method, as a whole, was missing is moderation. McGill said he was currently studying if the more moderate prone extension helped in real patients with back pain but was still collecting data. I have my back pain patients do it if they report it feels good, but not if they have any pain. Anecdotally it’s hard to tell how much it contributes to pain relief on top of all the other things I do.

      As for surgery, unless there is a significant loss in motor/sensory function from a nerve being impinged so bad that it may never recover, I’m generally against surgery. Certainly at least until I have a chance to try my program on a patient. If I recall my research correctly, surgery for a herniated disc is usually only needed if pain is immediately unbearable, as one year post surgery, outcomes in those who have surgery are no better off than those that do not. And surgery generally does not correct the real problem. It may excise the disc fragment, but the problem is what caused that disc herniation in the first place, which is typically repeated or sustained spine flexion due to poor motor control during daily activities and poor static postures. So surgery may remove the fragment and impinge a spinal nerve, but the remaining poor motor control and bad postures, if not corrected, will only lead to further disc bulges, herniations and DDD.

      Sometimes however I will see a patient that no matter what I do to treat them they continue to have sever pain and later MRIs in that case have often shown severe spinal stenosis or bone spurs. If after 8-12 weeks of rehabilitation in such cases if the patient is still having severe pain and not progressing at all, I may suggest looking into a spinal fusion or laminectomy. Almost always however such a patient is elderly or nearly so, so I wouldn’t put you in that camp. Hope that helps, TTFN.

  13. Hi Chad, it’s the MDT Diplomate again to comment on your blog on the McKenzie Method. Franklin Covey in identifying the seven habits of highly effective people stated in the fifth habit, “Seek first to understand, then to be understood.” I’ve been spending the last several days running things discussed earlier through my mind over and over. Francis is easy to understand because I’m very much like him. Francis just wants to return to exercising like he once did having learned from the school of hard knocks. You gotta love a guy like Francis but then we are often drawn to people that think like ourselves.

    I’m 52 and I have a spondylolysis with a spondylolisthesis but I work out at Gold’s gym for 2 hours, 4 days a week. Last night I was working chest and triceps. I performed 9 sets of (hands in pronation) narrow grip push-down X 100# X 30 reps alternating immediately (no rest) with 10 sets of (hands in neutral) wide grip push-downs starting with 50# X 10 reps building each set building up to 90#. I then did dips for 30 min performing sets of 10 reps X sets every 45 seconds. I finished up my chest work-out with a Procor press machine: 3 sets using (6 X 45#) X 10 reps, dropping (2 X 45#) weights but adding (2 X 25#) X 10 reps, dropping (2 X 25#) but adding back (2 X 45#), dropping and adding again and again until there was only (1 X 45#) on each side; only rest during the drop sets was while changing the weights. Then I did cardio on the adaptive motion training cranked up to the highest setting for 30 minutes. When I do push-downs, I turn my core on like steel to stabilize my spondylolysis. I also perform a slight forward bed placing my pelvis in a posterior pelvic tilt to reduce the spondylolisthesis. I like push-downs because they produce a negative pressure in my spine and disc via Newton’s 3rd law of opposite forces. I do the same while performing dips where both exercises have a component of lumbar traction or unloading the spine. The Procor press machine is neutral against gravity in regards to loading my spine, so all is good in my paradigm of the spondylolisthesis with a spondylolisthesis. I only went into all of this detail because from listening to your words, you seem to be a weightlifting and core kinda guy and I can appreciate it because I’ve done if since I was 16 years old.

    One of the first things that we are taught in Physical Therapy school is to “Do no harm.” Chad, you remind me of “The watchman on the wall” as seen in the bible. In the Old Testament the watchman was always a prophet who warned people of impending doom unless they repented of their evil ways. In treating patients there are two sides of a coin. In treating the spine, one side of the coin is putting the body in the best environment for healing. You used McKenzie’s cut on the back of the knuckle and you warn people with posterior disc bulges of avoiding lumbar flexion. You warn people against slouching and point out their need to correct their posture. You warned Francis off of certain exercises and talked a lot about exercise. You even stated that you would NEVER twist the spine of a one of your patients. By the time you finished talking to Francis you had effectively warned him regarding exercises in all 4 directions that MDT Clinicians are trained to explore. We too agree that we shall do no harm and we use the Centralization Phenomenon as our guide.

    After studying your words, I’d like to make the following statement. The McKenzie Method is a Method. The McKenzie Method uses what I was talking about a moment ago regarding loading and unloading the spine while exercising. The McKenzie Method starts with small forces and depending on what happens to the patient’s symptoms, centralization or not, we will progress with greater forces. If small forces partially centralize a patient’s symptoms but doesn’t abolish them then we add greater and greater force until the symptoms are abolished. We use as little force as possible but as much as necessary to abolish the patient’s symptoms. I want you to notice that I haven’t talked about a single exercise but rather a methodology of force progressions. If you have read the McKenzie Text books then you understand these principals and the paradigm from which the McKenzie Method operates. When I click on your link regarding McKenzie books it takes me to his text books. May I please ask, did you read the Lumbar spine text book that is 732 pages long or did you read the “Treat Your Own Back” book that is 72 pages long? If you only read the 72 page book that I use in my clinic to show patients exercises and reinforce sitting posture then you are not seeing all of the methodology that is intended for Medical Professionals that treat patients. If you read the book intended for patients then I’d say that you understand about 10% of the McKenzie method. Perhaps a greater understanding of McKenzie’s methodology can be found in the other 90% of the McKenzie paradigm. Let’s say for a moment that you read the text book. If I read a text book on playing tennis, does that make me a tennis expert? What if I read 10 books on tennis, am I now a tennis expert. In order to prove that you are a tennis expert, you need to win some sort of championship. If you practiced playing tennis for years, using the principals that you learned in reading textbooks then you might actually become an expert. The McKenzie Institute International does just give MDT Diplomas away. You have to prove yourself and pass a test. You have to prove that you have a great understanding of the McKenzie Method and understand the paradigm.

    Next, you stated that you would never twist a patient, yet there has been research and evidence suggesting that there is benefit. Everyone has their theories about what is happening when patients twist or rotate the lumbar spine but nobody can ever prove absolutely what is actually occurring. The name of your blog is Absolute Physical Therapy and I’m guessing that you believe in absolutes but I’m sorry, sometimes we will never know what is truly happening. The human body is fearfully and wonderfully made and if you are not humbled by its complexity then I have to wonder about you. Sometimes you need to seek first to understand, then to be understood. Maybe you need a paradigm shift.

    I heard you talk about the jelly doughnut. Today I present to you the cinnamon roll. The laminae in the annulus fibrosis are like a roll of tape or a cinnamon roll that can be either rolled up going one direction or unrolled going the opposite. You might even call it a twist. The jelly doughnut works very well to explain an annular tear that is breaking through layer after layer of laminae. However, when the tear takes a lateral turn and the laminae start to split apart or delaminate it requires a different tool or method to squeeze the layers back together. That’s where side specific rotation in flexion or the reclining spinal twist comes into play. Twist one direction and the layers are squeezed back together but turn the wrong direction and the layers split further apart. You said that you would never twist a patient then you were only looking at the negative side of the coin once again. Do a paradigm shift and turn the coin over and look at it from a different perspective. Look at it from the perspective of “Wow, that turned off all of the pain and I just gotta wonder what was happening.” When you do that then you will be looking through the McKenzie Paradigm.

    McKenzie talked a lot about his patient Mr. Smith who when he accidentally performed a backward bend lying prone in extension for several minutes abolished all of his symptoms. McKenzie was perplexed by something that occurred opposite to what Williams the great Orthopedic Surgeon was teaching; he saw the opposite abolished all of the patient’s symptoms. McKenzie chose to think outside of the box and came up with a multidirectional approach to treating the back as shown in Long and Donelson’s study. You copied and pasted some negative thoughts from his competitors but you can never prove anything. It reminds me of Tom Brady and deflate-gate. If you love Tom Brady then he is innocent but if you hate him then it is the opposite. What is the evidence? The referees measured the pressure in the balls and it was below regulation. Who would benefit from the balls being deflated?

    You started a tread in an attempt to deflate the McKenzie Method. Why? I have a greater understanding of the McKenzie Method than you having practiced it for nearly 20 years. Who understands it better? If you are waiting for someone to prove things absolutely then you are in for a very long wait. I have but one recommendation for you. Look carefully at figures #1 and #4 on the Long and Donelson study and see if it matches what you are talking about in your introduction in this tread; it doesn’t. It matches Ponte et al who did a research study 30 years ago with poor methodology not having the knowledge and experience necessary to call themselves experts on the McKenzie Method or William’s Flexion for that matter. Why is it that those who don’t know always choose to teach about what they don’t know? If you don’t understand the reason for recovery of function and the force progressions that I stated in a few lines above then maybe you should take the time to read the entire text book and take McKenzie part A. Test all things and hold onto what is good. Erase your own bias and seek first to understand, then to be understood.

    Chad, you said to Francis, what are we going to do with this Steve guy? You are probably now saying, “This Steve guy just won’t shut up.” You do realize that out of all of us, I’m the expert concerning Mechanical Diagnosis and Therapy. Chad, sometimes you just gotta take a leap of faith. I’m not trying to convert you to becoming a MDT Clinician. I’m just trying to help you understand the McKenzie paradigm that you will never appreciate until you see the magic of directional preference. You talk a lot about directional vulnerability but that’s only one side of the coin. Each patient has a direction of preference as shown in the study that I submitted you. You just need to find each patients directional preference using the centralization phenomenon. There are only 3 directions for posterior disc bulges. There is only one for annular tears at 6 O’ Clock using the jelly doughnut tool and 2 at either 3 O’ Clock or 9 O’ Clock using the cinnamon roll tool. Jelly doughnuts like walking because of the extension but cinnamon rolls don’t like walking because the laminae are splitting further apart during ambulation. One looks at the good side of the coin, the other looks at the neg. Of all people, I thought that you would be the guy running with the ball using the negative as a guide. FYI: when someone says that the find the side glide in standing less aggressive then they are saying that they are a 3 or 9 O’ Clock and if the 6 O’ Clock extension is too aggressive, it’s only because they are not a 6 O’ Clock responder. Don’t be too aggressive. Use as little force as possible but as much as necessary until all of the symptoms have resolved, McKenzie Method 101.

    TTFN for now, I’ll be listening to your words, Steve

    • Hi again Steve, I have a number of comments but I don’t want to make any assumptions. How did you get you spondylolysis and spondylolisthesis? What kind of exercises do you do for your back, abdominal, hip and leg muscles? Do you really think the anulus is like a cinnamon roll? What way does it wind up, clockwise or counterclockwise?

      To answer your question, I read both the McKenzie’s short book and his long ones. I thought if you tore the books roughly in half and read the first part, it was pretty good advice.

  14. Hi Chad, I don’t just have a spondy, I have other things going on too. I developed a mild scoliosis as a teen complete with rib hump after a terrific crash on my bike jumping way up in the air; spectacular crash that took me 30 minutes to get up from the ground and no we didn’t wear helmets back then. No, I didn’t suffer a head injury then or ever (ha ha). This trauma occurred at a period of time during my life when I was growing a great deal and my theory is that it produced the scoliosis but not my spondy.
    True story: When I was in PT school and we were covering scoliosis, I volunteered to stand up in front of the entire class so that others could learn about my condition…sound familiar. So my class picks me apart for about one hour finding all great little tid-bits like when I forward flex, I have a rib hump on my right side, yada yada. So after an hour of being picked to pieces, I ask the bulk of my class and my teacher, “Now what?” I wanted to know what everyone was going to do about my scoliosis pain which during PT school was severe. Nobody had any answers.
    Then one day everything turned around, and I made it to McKenzie part B which was on the Cervical and Thoracic spine. If you ask about my dedication to the McKenzie Method it isn’t as a Clinician but rather as a patient. I spent only 10K going through the Diploma Programme and the greatest expense was how difficult it was to complete ( gave me my first grey hairs); Only 1 out of 4 who entered the programme the year I entered made it to the end successfully where everyone entering had passed the Credentialing exam prior to entering the Diploma Programme. 10 K is a drop in the bucket, where I just consider it to be continuing education cost of a PT. One of our DPT new graduates just came out owing 200K.
    You asked about what I do for my back and I’m assuming the spine but I’ll wait and I’ll tell you in a minute about latissimus dorsi and gluteus maximus and the crisscrossing stabilization that they provide for my spondy. However, I’ll tell you what abolished my constant thoracic pain first; it was thoracic extension exercises (I’m an extension responder there are lateral responders too). I told you that the McKenzie Method was a method. I learned the extension principal and took exercises like repeated extension in lying and performed it up to the thoracic vertebra that was producing my pain over and over. I took it to end range at that thoracic vertebra using REIL which wasn’t end range for the lumbar spine. I took the methodology that I learned on the lumbar spine and used it on my thoracic spine and it worked. I’ve worked on the McKenzie Method for nearly 20 years and I’ve seen many variations on McKenzie’s exercises by other MDT Clinicians and even patients. McKenzie was famous for the statement, “My patients taught me everything that I know.” McKenzie had is own paradigm of “Wow that just turned off all of the pain and I’ve gotta wonder what is happening.” Which came first, the chicken or the egg? Very often something turns off the pain and then we try and figure out why?
    I had my own patient who I call Mr. Love who took lumbar rotation in flexion and after I performed a rotation mobilization in flexion that turned off all of his pain, and he developed his own version where it rotated the spine from the bottom up like the mobilization verses from the top down like the exercise. He got such great relief from the mobilization which applied additional force in the direction that was improving his symptoms and developed his own exercise that worked wonderful. I use Mr. Love’s version of rotation in flexion all of the time now. McKenzie had his own Mr. Smith who was a sagittal plane responder (S in Smith for sagittal) and I had my own Mr. Love who was a lateral responder (L in Love for lateral). It’s a methodology where you look for patterns and then find ways of identifying them like what I was describing occurs during ambulation. It’s all mechanical and therefore, it’s repeatable again and again.
    On to my spondy: I don’t know what caused it just like so many of my patients. I ride mountain bikes and I’ve crashed and burned. I was a Class 5 white water kayaker and I’ve had my spills. I ski and I’ve had my yard sales. I’ve had my adventures and there are many things that could have caused my spondy. There is a general theory that extension is the most common cause of a fracture in the pars interarticularis. Somebody tackling a football player in the back is a good mechanism of injury. If you want to suggest that lumbar extension exercises caused my spondy then I have to tell you that my lumbar spine likes Mr. Love’s exercise and here’s why.
    I often describe the spondy as a door with three hinges. The top hinge and the bottom hinges are the facet joints and the middle hinge is the intervertebral disc. After removing the top and bottom hinges, when you open the door then there is a great deal of stress on the center hinge (disc) which can cause sheering forces. The door wants to twist and you need to control it as it swings open or the center hinge will become twisted or damaged. A spondylolisthesis is much more than just an unstable spinal fracture as the result of bilateral pars defects. A spondylolisthesis places great stresses on the intervertebral disc at the level of the fracture. As a result, I believe by faith without evidence that absolutely points to delamination occurring within the laminae that I’ve developed a lateral component to a posterior disc bulge. I’ve had the lateral shift phenomenon that required side specific side gliding in standing but most often when I start to get pain into my right buttocks, I simply perform rotation in flexion while lying on my left side and the symptoms are abolished. I use it PRN.
    I constantly use my core to stabilize my lumbar spine isometrically. By core here I’m talking about turning on my abdominal muscles. The analogy here is the spine is like a fence post in a post hole. If tighten the abdominal muscles then you place a firm rigid barrier in front of the spine and it’s like you filled the post hole with concrete. However, I also keep my lats and glutes strong where they form a crisscrossing pattern with the foci being the thoracolumbar fascia. If you look at the direction that the muscle fibers of the lats and the glutes are oriented then you will see that they make an X-shaped pattern. This can stabilize the lumbar spine via a crisscrossing forces. I use the adaptive motion trainer for my cardio because it reinforces this crisscrossing pattern and strengthens my lats as I pull and my glutes as I go into hip extension. I actually push and pull with my upper extremities just like when I would kayak with the paddle (punch and pull simultaneously). These are all positive things that I can do but then there are the negatives.
    I was once upon a time a long distance runner. There is too much extension in running so I cannot run unless it’s from a bear but in reality I’d be better off playing dead. However, I need the loading and unloading of the disc where it gets its nutrition by diffusion across the end plates which is facilitated by loading and unloading forces. The repetitive loading and unloading on the adaptive motion trainer gives me what I’ve lost now that I cannot run. I cannot perform a lot of your traditional core exercises where I have a recurrent posterior disc bulge with a lateral component that is reduced by side specific rotation in flexion PRN. I need to focus on abdominal isometrics.
    Another true story, I was taking McKenzie part C on clinical thinking in Tulsa where the instructor was treating someone with a spondy. This patient was actually an aerobics instructor at the hospitals wellness center. The aerobics instructor was in great shape stating that she never had her symptoms while teaching abs class. The instructor asked the class if we had any questions and I asked her, if you turn on your core, what happens to your symptoms that occur while walking. She stated that she didn’t understand the question. I said again, your core is very strong from teaching abs classes, what happens if you turn it on when you walk. The pretty blonde responded again, I don’t understand the question. I went on to explain to her the post hole theory and she stated, I’ve never done that. Sometimes we have the power within reach but we don’t know how to use it or we are afraid of what might happen.
    I believe in the philosophy that exercise is activity specific. Lance Armstrong rode bikes getting ready for the Tour. Michael Phelps swam getting ready for the Olympics. If you plan on using your abdominal core muscles isometrically all day long which I do then you had better strengthen them isometrically. Also, if you exercise your core isometrically all day long then they will become strong by regular constant use. The construction worker doesn’t need to go to the gym and exercise lifting weights after work because he’s been working hard all day long. I use my core isometrically all day long and as a result it is very strong in precisely the way that I need for it to be.
    However, sometimes I get tired. Dude, I’m 52 and I’m not the Class 5 kayaker that I once was 10 years ago. I gave up kayaking when I developed my spondy just like I had to give up running. I have tricks that I do when I get tired. When I’m tired of using my core to stabilize my spondy when I’m standing then I lean against the wall. When I lean with my back against the wall, my spondylolisthesis is stabilized and reduced. Heck, I’ve made it a habit and it works great. If I don’t have a wall to lean on and I’m having left buttock pain standing in church then I perform step standing with my left foot up on the seat of the lateral chair frame in front of me which produces a unilateral posterior pelvic tilt on that side. I like the tilt in space technique while sitting. You know the one that you got in trouble for when you were in school. I tilt my chair back against a wall which reduces the spondy once again as the pelvis goes into posterior pelvic tilt. As I’m typing this today, I’m using my core because the computer chair that I’m sitting has wheels. My core is my best friend and because we work together on stabilizing my spinal instability life is good.
    I could go on and on but this you give you some good ammo to shoot me down. I just don’t imagine that you want to help me as much as take the wind out of my sails. Take your best shot, I can see it coming. I don’t mind because I’m in as good of shape as I have ever been at 6’ 2”, 220#, I just cannot do certain things that I once was passionate about. Knock me down, I’ll get back up. If I have a character trait that serves me well as a PT, it’s that I don’t give up easily; tenacious as a terrier just like the private investigator McKenzie Milhone from the Sue Grafton novels.

  15. How do I attach a picture for your delamination question? Are you saying that you don’t believe that the laminae can delaminate or split apart?

  16. Chad, If you have a better analogy to use for the delamination of the disc than the cinnamon roll or roll of tape then I’d love to hear it. As you can see, I use a lot of analogies which helps people see things when I’m just trying to use words. In my office, I have Netter and a lot of other pictures. The annulus is concentric layers of laminae with fibers running at 65 degrees, who knew. They are circles until you develop a tear. Circles have no end until you develop a tear is at some location. Cinnamon rolls do have and end and therefore can split apart. You are trying to see everything at the macroscopic level like when you were talking about no evidence for lateral tears. I’m talking about the direction at the tip of the lesion. Is it pointing to 6 O’ Clock, 3 or 9 O’ Clock. Zoom in on the region of the lesion and look at it microscopically. Zoom in to where you no longer see a circle but lines running along an X-axis or Y-axis. Use a rifle scope and use the cross hairs like an X and Y axis. Zoom in on a region looking at a annular tear and tell me what you are seeing at that location where the scope only sees the laminae as lines rather than circles. Look at a tear as it goes from breaking through layer after layer of laminae to splitting apart the lamina rather than breaking through the next wall. It actually is protective against disc extrusion and sequestration of nuclear material. Which is better to delaminate one layer or break through all of the layers.
    Pull apart your spine model and look at your lumbar vertebra from the top. Look at the facet joint and how it creates a 1/4 circle. The facet joint has a convex and concave relationship between the vertebra above and below. Look at the vertebral body where the disc sits on top. They feed into each other looking like a clothes wringer. Look on the opposite side and look how they do a mirror image or the opposite. As you twist the disc above will be pushed posteriorly into the facet joint squeezing in on one side while unloading it on the opposite side. Its a clothes wringer effect that squeezes the laminae back together.
    Back in the day when I was kayaking we had straps the we would use to tie down our boats on the roof of my Explorer. After I rolled them up, I would twist them tighter until they were as small as I could get them to store them. Certain you have something in your life that you would roll up or twist together that brings the concept home. At one moment the layers are lose and the next they are tight together. One moment they are falling apart and then next they are held tight back together again.
    Sorry dude but that’s what I got. Its the shear hypothesis. Laminae can split apart but you can squeeze them together. I don’t know for a fact. Maybe Stephen George is right, maybe Tim Flinn is right. The only thing that all of us agree upon is that the pain turns off.
    TTFN, Steve

    • Steve you didn’t describe any core, hip or leg resistance exercise. Does that mean you don’t do any? Do you just cardio and abdominal bracing during ADLs? Also it sounds like you have back and leg pain. On a 0-10 scale could you say how much you hurt on average, at your best, and at your worst?

  17. I love you Chad. I cannot perform leg curls in prone because they bring my spine in extension; I perform leg curls in sitting along with knee extension in sitting. I cannot do squats because I gave myself a hernia a few years back and after getting it repaired then I decided that I didn’t need another one. There is a leg press machine that I like because I’m lying supine. I work legs after I finish with my Adaptive Motion trainer alternating days between calves and thighs. I cannot perform traditional core exercises because they increase my back pain.
    Numbers, wow you are the first to ever ask. During an exacerbation then they get up to around 5-6 but on average 2. I don’t have leg pain but rather a pinch in the buttocks. I manage it very well PRN with rotation in flexion and never allow it to get out of control. Pain in the butt is not an issue. I will live with LBP for the rest of my life but life is good and it’s not that bad. I know bad, I’ve seen bad and they cannot do anything remotely close to what I do everyday at the gym.

  18. hey one last thing. What are the general time frames related with the recovery of such an injury? I got injured 8 months ago but depending on the position I still get a bit of discomfort. Nowhere near the feeling I had when I got injured but still. I have heard that 12 months would be a sensible time to consider recovery. I am realistic about the expectations as this type of fiber cannot really heal as other types of tissue in the body but I would like to think that in a few months of strengthening and careful sitting I would get some improvement still. I know the science of rehabilitation and recovery is dependant on the individual. but still I would like to know if after 8 months my situation can still vary. WOuld it be the disk itself or the amount of muscle strengthening done and the increase of lower back musculature? Thanks again for your insightful information and the time you take responding.

    • Francis, if I recall correctly disc fragments in the vertebral canal are often gone upon MRI examination in 1 year, and maybe 6 months after they are first seen on MRI. I recently read a couple papers on sheep spines that were injured with puncture and concentric annular tears and were considered “healed” 6 months to a year after injury as well. The latter, however, was observed in sheep spines, and sheep being quadruped may not be subjected to the repeated and prolonged flexion forces of the spine that westerners get. For example, sheep don’t slouch at a computer or in a couch and watch TV, thus continuing to worsen initial injury like people often do. So in the best of circumstances, 6 months to a year later the disc may be “healed”, though I expect it would always be compromised somewhat. That said, with good strength and conditioning exercises, better spine motor control, avoidance of poor static postures, and EMS, I regularly see chronic pain eliminated in just a couple to a few weeks, sometimes in just a few visits. EMS to the core is no joke, and in my estimation it improved my outcomes 100% over just exercise/posture/motor control alone.

  19. Francis, by definition your pain is chronic. If I had a cough for 6 months medical professionals would say that you have a chronic cough. Medical professionals label every patient that they treat because they want to get reimbursed for treatment. Every diagnosis has a code and there are thousands. 8 yearso ago I had a lateral shift like yourself and I know your pain. That was 8 years ago. I have an unstable spinal fracture that will never heal and I have chosen to live life. You only have one. I’ve made mistakes in life and I’ve paid for some and learned from others. You go on as best you can and live life being a little wiser. The difference between knowledge and wisdom is the difference between what we know and what we do. You know what you did wrong, just don’t make the same mistake again. Stay away from the mechanism of your old injury and you should do well. If your body doesn’t like an exercise then it will tell you. Listen carefully. I know my body very well and it talks to me every day. Sure with my unstable fracture it blows up on me out of the blue but I’m not going to give up living and let it win. Stay fit, live life. Love those around you.
    God bless, Steve

  20. Hi Chad, we need to bring things back around the topic of this tread. I’m going to ask a few rhetorical questions. Are you a member of the APTA? I’m not. Are you politically correct? I’m not. I’m no longer even a member of the McKenzie Institute USA even though I’d like to get the literature that comes along with being a member.
    Sometimes people try and manipulate us with words like politically correct. The political organization the APTA supports the political organization the McKenzie Institute USA. Stacy Lyon the head administrator for MIUSA is a good friend of mine and I just love her. However, Stacy has talked to me about the politics of the McKenzie Institute International and how MIUSA must answer to MII in all that they do.
    All of the PT schools in the USA are accredited by the APTA. When I graduated in 1996, I graduated with a bachelor’s degree. The APTA mandated that all schools would elevate their status to Masters Degrees by 2000 and Doctorate Degrees by 2010. I had a DPT student that I mentored last year that already owed $106K . She told me that her PT school was finished teaching her but that she had another year to pay tuition while she completed her last year of clinical rotations that were added onto my program to give her a doctorate degree. The APTA as a political organization has attempted to elevate the status of Physical Therapists but has only effectively increased the size of PT student loans.
    I work at the VAMC another political organization. I’ve been in the VA system for nearly 20 years. I didn’t have student loans when I graduated because the VA paid for my school tuition, books and gave me a stipend to live on while I was in school. The only catch was that I would own them 2 years when I graduated; that was over 18 years ago. I’m loyal to the VA because the VA helped me when I needed it while I was in school; I’m not even a Veteran. I’m loyal to the McKenzie Institute USA because the McKenzie Method helped with my pain; I’m not even a member.
    The VA got tired of false elevation of medical credentials a few years back and took the boarding of Physical Therapists from the local level to the regional level. There is a great big deal in the VA right now because nobody can get regionally boarded as a GS 12 clinical specialist. Physical Therapists are having a very difficult time across the country showing the VA that the new DPT deserves anymore recognition than my bachelor’s degree. I however, was able to convince the regional board that I am a Clinical Specialist. It took a lot of work and I had to show them with strong clinical reasoning why I was worthy of getting paid a little more. I am the only GS 12 Clinical Specialist at my VA but then I’m the only one in the entire state of Colorado that has completed the rigorous McKenzie Diploma Programme.
    In my lifetime, I’ve seen the medical community adopt some fancy words like Evidence Based Medicine. EBM is just like being politically correct. It’s someone trying to manipulate you with their words. The problem with medicine is that it’s so political and everyone is struggling for the power. Everyone wants more power and respect just like the APTA.
    Patients don’t care about power. They just want their pain turned off. I’ve had many patients in my clinic that have leg pain. They rate their pain on the scale from 0 to 10 and give me a number. My patients aren’t a number to me although I might tell them that they are a 6 O’ Clock responder. I’m not medically licensed to diagnose patients, so I’ve made my own way of describing the direction which centralizes their symptoms and it makes sense to my patients and that’s what matters the most. It’s not politically correct with the APTA, MII or MIUSA but my patients appreciate that I listen to their plight. They just want their pain turned off. Chad it you want evidence regarding directional preference then the only evidence that you will need is if a patient’s pain turns off or not. Do no harm and you will be coving half of the patients request when they enter your clinic. Turn off all of their pain and then you have covered the other half.
    Chad, I’ve had patients come into my clinic with all kinds of diagnosis and explanations from different medical providers regarding what is causing their symptoms. When doctors label them with another new diagnosis for the same condition they become frustrated and are given another label of personality disorder or antisocial behavior. Patients are frustrated and the just want for their pain to turn off. Just turn their pain off Chad, just turn it off. They don’t want a label they just want their pain turned off. Patients are tired of us medical professional all arguing over our turf. They just want their pain turned off.
    In the city where I live we have a fellow who is known at the EBM Orthopedic Surgeon. He sponsored a continuing education where a fellow had performed a meta-analysis of PT as a whole; he read all of the literature that had ever been done and came up with his conclusions. I attended the lecture and he effectively stated in the end that having looked at all of the evidence, PT doesn’t work. However, the EBM Orthopedic Surgeon has his own PT clinic. I don’t think that he bought what the other guy was saying.
    When I was in the Diploma Program, looked at all of the research on the McKenzie Method and saw that some was using good methodology and some was poorly done. Ponte et al was one of the worst yet that is the one that you have chosen to show the world. I have one final comment, “Everything gets ugly when you mix the good with the bad.
    Fight the good fight, run the good race, and God Bless, Steve

    • Steve, I don’t have time to respond to everything you said, but I wonder if in your case the repeated spine flexion/rotation and extension stretches you are doing might be what caused your vertebral fractures. I would expect all of that end range extension and rotation motion to pretty rough on a facet joint and flexion combined with rotation has been demonstrated to be particularly bad for the discs. Also, it sounds to me like your core is (understandably) undertrained relative to the rest of you. Such that maybe increasing the strength and endurance of your core, legs and hip muscles in a pain free manner (while maintaining a neutral spine) might help. Like Francis said earlier, I would be leery of leg presses. One of my early blogs was on a study that found weight training with machines (which might leave the core muscles relatively weak) to be associated with increased low back pain. Also, I think you should explore that EMS paper I cited above with regards to strengthening the core while reducing back pain. I know you like McKenzie, but he broke from conventional wisdom to come up with his own way, which I agree was better than Williams flexion exercises. Maybe it’s time for you to do likewise and break from McKenzie method for a while and see how it goes. If I’m not mistaken, Robin McKenzie developed his method in the 50’s and published it in the 80’s, which was a long time ago. I think it would be a mistake to ignore what’s come since, even if it goes against the McKenzie gospel, so to speak.

  21. Hey I’m getting one of those machines ASAP. Also last friday I got some accupuncture done and now my back feels awesome. Pain free even in hyperextension. I have been sitting correctly and avoiding the prone press up though.

  22. Hey my man. I read it and I believe that it must be placebo. However the last few days my back has been feeling as new. Today I squatted 225 lbs 3×3 and then some other posterior chain stuff. I feel no pressure even when I hiperextend my back. I don’t know, maybe is the fact that I have been sitting very correctly but something is going on and very rapidly.

    • Great to hear it! That all sounds right. I think people often do more damage to their backs with the way they sit than they do lifting, even if technique isn’t perfect. So, if you you remove the source of irritation the back can start feeling better in a hurry, and you can lift more. I’d still always be careful, listen to your body, and if you ever have pain, think about what you are doing then, or what you did earlier that might have caused it. It’s almost always because of something, and if you can remove those ‘somethings’, you should be pain free, with full function. Almost full function at least, because your back will probably never tolerate slouching like it did 10 years ago.

      I think that’s where Robin McKenzie got it right. His advice to avoid spine flexion during daily activities was pretty much spot on. I think he just went too far with his extension stretches, and then went back to Williams flexion stretches to restore lost range of motion when pain was eliminated. The latter parts never made any sense to me, but I can see what he was thinking at the time. Anyway I’m real happy to hear you are feeling better!

  23. One last thing. Sometimes i get a feeling in my lower back. Like a needle pinching sensation. Specially after i stretch the hamstrings. Its never severe and it only lasts some seconds. What could that be? Could i be re-herniating myself or something?

    • I generally tell my patients to avoid all pinching or sharp pains. I don’t mind a lactic acid burn or a muscle pump in the low back when working out, but otherwise I almost always (I hate to say always) consider all pain in the back as something to be avoided. Though pain when you feel it, should be learned from to figure out what caused it, which it sounds like you are doing.

      As for Hamstring Stretches and back pain; when most people do hamstring stretches, they either run out of hamstring range of motion or hip range of motion, and they keep pulling causing a “posterior pelvic tilt” where if they are laying on their back, they lose their normal lumbar lordosis (neutral spine position) and their low back flattens out against the ground, bed, or mat. Williams flexion stretches were all about posterior pelvic tilts so you will sometimes still hear therapist and fitness trainers advocate it. However posterior pelvic tilt is the positive name, the negative name is “spine flexion” which we already talked about as being the primary force that herniates the disc. The way not to flex the spine during hamstring stretches is to make sure the other (non-stretched) leg remains flat on the floor (leg straight NOT bent) to help anchor the pelvis neutral and prevent the spine from flattening. A folded towel under the low back might help as well, but once I establish normal enough hamstring range of motion I usually have my patients maintain and further improve it with RDLs so they can strengthen and work on motor control at the same time. If range of motion is full I don’t spend a lot of time stretches as I think they are too limiting and I can often get, and almost always maintain, full muscle and joint range of motion (of joints other than the spine) with my strength training exercises.

      So that would be my guess as to what’s happening. If hamstring stretches are causing a pinching feeling, you might be flexing your spine, and that probably isn’t doing your discs any good at all. So my advice would be to make sure your spine is staying absolutely neutral when stretching the hamstrings. An alternate explanation for your pain could be that there is some scar tissue preventing motion of the sciatic nerve where it exits the spine and that’s the source of the pain, thought I expect that is less likely, but it’s still a pain I would be cautious of and I would still want to keep the spine neutral during the stretches.

      Let me know if any of that sounds right or helps!

  24. Hey it’s me again! Just to let you know that since incorporating squats, heavy ab work, good mornings with high reps and sets and constant hanging from a pullup bar with some foam rolling (using a metal ball) has helped me a lot. The days after I train lower body with the use of everything mentioned are great, My back feels as new specially they day after I work out. Does this makes sense? I am increasing the strength of my lower back and I already feel the muscles growing.

    • Glad to hear you are doing well. I think the ab work is great so long as it’s isometric in nature. If for example you were doing a crunch machine or rotary torso machine I would expect they might eventually cause problems. Good mornings bending at the hip with the spine neutral should be good, and I think work pretty much the same as RDLs. I prefer the bar position of the RDLs cause you can just drop the bar or set it down by bending your knees if you run into trouble vs having the bar on your shoulders which makes both more difficult. Hanging always seemed like a good idea to me, but honestly I have never seen it make a noticeable difference in anyone’s back pain. Foam rolling I think is a fad, same with using a ball, but I expect is benign as far as your back is concerned. But fitness writers need something to write about so some years back they made up the foam roll thing, now it’s lacrosse balls, dry needling, voodoo floss, or whatever. All of which reminds me of something Art Dreshler said in his book the The Weightlifting Encyclopedia:

      “Here is something new I can try. It has a wisp of plausibility and will make me appear to be on the leading edge of training technology. Best of all, no one has yet had the time or money to disprove the theory. In the meantime, no one will notice my general ineptitude as a coach with all the commotion that I can create with the application of this new theory.”

      I think the same idea applies to physical therapists the same as strength coaches.

  25. And what’s your take on kettlebells? I have a wide array of kettlebells ranging from 32 lb to 70 lb aproximately. What’s your opinion on using swings or kettlebell snatches for somebody with an injured back? Thanks.

  26. Well. That is true. Some years ago the lattest fitness fad were the kettlebells. Now the battling ropes, the trx, p90 something, crossfit, foam rolling, etc etc, and the list goes on. I mean, In some way it might be possitive that there are fads that make people do something for their physical states. But for example crossfit is very prevalent on injuries. Specially spinal injuries. I mean, doing timed snatches with poor form cannot be good for your poor disks! On the other hand it seems that these fads are ways in order for people not to carry the heavy water. In my case I think that most people could benefit by doing 3 sets of squats 2 to 3 times a week. If it is bad on the training department it is much worst on the nutrition department…The paleo diet, the atkins diet, the samurai caveman diet and etc etc etc.

    • Oh yeah, that reminds me, you asked what I thought about kettlebells and snatches with them. I agree I think kettlebells are another one of those faddy things and I use dumbbells instead. I can’t think of anything kettlebells will let me do (that I would want to do) that I can’t already do with dumbbells. That said if I were you and I already had them I figure you might as well use them like dumbbells.

      I think CrossFit is different though and I told a friend of mine that I thought it was the first fitness fad that wasn’t bullshit. I have a few reservations about it but mostly (mostly a large margin) I like it. They teach people what I think are mostly good exercises and they teach people to work out hard, both of which I think are missing when you go visit the average personal trainer. And I think CrossFit has the social aspect down, which makes it appeal to women, who would be otherwise taking another yoga class or doing circuit training with weights so light as to be completely ineffective. As a former Olympic lifter myself, I like the Olympic lifts and variants, and CrossFit made them popular. However like you say, if they are done with poor form, that’s not good. So far I haven’t seen any objective data regarding CrossFit and injuries, and I know a lot of them use bad technique, but I don’t think that’s necessarily different than people weight training with bad form anywhere else. Except maybe bad form with heavy weights might be worse than bad form with light weighs, but I think even that’s debatable. CrossFit might not be the best workout if you already have a number of orthopedic injuries, but as a general workout, I think it’s tough to beat.

      As for the kettlebell swings and snatches, I think if you kept your back neutral it would be reasonably safe. What I don’t like about kettlebell swings and snatches is that I would question what they are good for. I wouldn’t expect them to build as much strength as squats, RDLs or lunges, or as much strength, speed, power as real Olympic lifts or pulls. So I don’t think they are bad just maybe not good enough, which I why I don’t do them or put them into any programs. And yeah, what’s up with those ropes, is that the dumbest thing ever or what?

  27. Hi –
    I’ve had lower back pain for about 20 years, and 15 years ago, I started going to a chiropractor , and have been there every month or more since. About 6 weeks ago, I was having sciatica pain on the left. I saw the chiro each week for 4 weeks, and he keeps doing left SI adjustments, and I got a massage, but nothing was helping. I went to the doctor, who put me on 800mg ibuprofen 3 x per day, and sent me to the phys therapist. The therapist is 30 years McKenzie trained. my pain was in flexing, so he’s got me doing back bends, and cobra , at least every hour, and not sitting for more than 20-30 min at a time (I have a sedentary job). I’m generally feeling good if I’m up and walking, but sometimes getting some butt pain and upper hamstring tightness when I stand up to move around a bit, particularly when I’m due for my next does of ibuprofen.
    My therapist is doing weekly followups, to make sure things are going right, and really seems to know what he’s doing.
    This last week – he’s having me do back bends immediately if I experience the tightness, and that makes it go away. I want to not believe in McKenzie, but it really does seem to help.

    I’m scheduled for another deep tissue massage next week. Is that helping to fix things, or does it just make things feel good? I had one last week, and it seemed to improve things. He really worked the piriformis and everything around that, and I was definitely experiencing strong discomfort during some of the muscle working.

    I have canceled my chiropractor appointment, and am considering that maybe I shouldn’t go back there. Is that a good idea? Is chiro a long term waste of $?

    Thank you for your time.

  28. Hi Jamie,

    Whenever I hear people saying they have been doing something for their back pain for years and years, I can’t help but think that whatever that is, isn’t working. Unless there is significant spinal deformity, degeneration, or stenosis (and even sometimes if there is) the goal should be a complete elimination of pain and being able to keep it gone. The, or a, problem is that most clinicians (doctors, physical therapists, and chiropractors) don’t have a very good understanding of what causes the pain or what to do about it, and there is so much contradictory ideas regarding what to do about it that everyone breaks off into camps, doing and defending “their thing” whether it is vertebral manipulation, McKenzie method, spine stabilization, massage therapy, what have you. And it seems that once a person has invested a great deal of education time and dollars into learning “their thing” they are very resistant to new research findings that point to their thing not being as effective as they thought. And almost all of these camps were developed before the papers came out with regards to what generally causes spinal injuries and resulting back pain. So that said here’s what I think.

    I don’t think it very likely that the SI manipulations, or vertebral manipulations are doing you any real good aside from perhaps some placebo effect and social support. A number meta-analysis have shown that manipulation doesn’t work any better than sham/placebo treatments for either chronic or acute low back pain, so if it were me I wouldn’t continue with that.

    Your pain being worsened by flexion sounds really typical, which is probably 80-90% of people with back pain. It could be you have some mild disc bulging or a herniation likely on side with your sciatic pain. So if it’s just bulging some mild McKenzie extension stretches might help reduce it. However there are a few potential problems. One is that spine flexion in sitting is likely your contributor, so McKenzie extension stretches to try and put it back aren’t really correcting the problem, just trying to compensate for it after the fact. Thus I would suggest you really look at your sitting posture at work, home, and driving, to make sure that your spine is kept neutral during all those activities, such that you aren’t just pushing the nuclear material in your disc forward and backward. As there was a recent paper that found alternate spine flexion and extension made the discs herniate faster than just flexion by itself. Which might be part of the reason why that even though McKenzie can sometimes reduce a disc in a lab, on average patients treated with McKenzie method have such lackluster results, as described in the meta-analysis for which this blog is about. The other thing I would worry about with end range back extension, is that you might irritate the facet joints of the spine which might give you facet joint arthritis and bone spurs down the road. So if you are sitting in flexion at work, taking breaks to do some extension likely feel good in the short term, but I would really suggest you not sit in flexion in the first place if that makes sense. Still getting up and taking some breaks is likely a good idea, and maybe some mild extension, with a standing overhead arm stretch would be enough to counteract things without going so far as to cause the opposite type of spine damage. With good lumbar support I’d expect you would be able to sit a lot longer without discomfort.

    The furthest I would suggest going into extension in prone would be propped up on elbows and rather than going there repeatedly I would recommend just laying there for 10 minutes or so, and only if it feels good to do so. I never have my patients do a cobra stretch. The idea makes me cringe.

    As for the massage, I expect that might make you feel better, it should help decrease muscle spasms, but I don’t think it’s doing anything in the long term to affect you injury. So if spine flexion is causing you degenerative disc disease (DDD), and resulting muscle spasms, the massage might make the spasms feel better but will have no effect on the DDD. So if you want to massage, I’m all for it , just don’t expect it to be a cure all. As for your piriformis, it may feel tight and tender, but I think that pain is secondary to issues within the spine, I don’t think the piriformis itself is ever really THE problem such that I’m very skeptical of the diagnosis of piriformis syndrome.

    The cure all, or at least the best case option, is usually avoiding sustained/aggravating postures (in your case that sounds like prolonged spine flexion in sitting), improving your awareness/motor control as to when your spine is being flexed or twisted during dynamic activities as well, such as working out in the gym, moving from sitting to standing, brushing your teeth, etc, and then minimizing that spine flexion/twisting. Also increasing core and hip strength and endurance such that you can better maintain spine position goes a long way, which is generally not addressed in traditional McKenzie method or chiropractic treatment. Also it has been my observation that when most chiropractors and physical therapists do what they think are strength, endurance, and “stabilization” exercise the exercise selection is so lame and the intensity so low that it’s a big waste of time. If it’s done on a swiss ball, or with a stretch band, that’s a clue that something probably isn’t optimal. I have a lot of my favorite exercises on my youtube channel, but I really need to do a video of a typical back pain workout and link it here and on my general back pain page, so people can get a better idea of what kind of program I like.

    In addition to good posture, motor control, exercises that strengthen but don’t hurt anything, I think a 4 channel EMS unit goes a long way towards immediately reducing pain and increasing core strength while you wait for the exercises/postural adjustments to take effect. I hope that all makes sense, feel free to hit me up if you have anymore questions.

  29. Hey Chad. I wanted to give some insight to the people that is undergoing the problem that I currently have. In my case the pain is almost gone except for a very few instances. I use the McKenzie press up as an indicator of sorts of how the level of irritation of my hernated disk currently is. I never do it more than once a day. Just to check if you will.
    I have become proficient in the training of my core. I am currently able to do 20 consecutive reps of standing ab wheel rollouts. I can train my core almost every day as I never get DOMS in my core. I have also incorporated Kettlebell windmills.
    I am very keen on training my lower body. Right now I am able to lift up to 300 lbs on the back squat. I am more careful with the deadlifts but I do sets of 10 with 200 lbs. That might seem excessive for someone with a herniated disk. But I start by doing a high amount of good mornings with low weight. I have not had any discomfort or pain regarding that. Yesterday I started to experiment with a pair of parallettes and doing some planches. However. I got some tingling now so I might discontinue it. I can sit for long periods of time without pain but I rather not. I have still some stiffness when I bend to the oposite side of the injury but it is diminishing. I trully believe that strength training done the right way is the best way to manage this type of injury. I want to get back to judo/jiu jitsu but I don’t feel confident enough yet to do it. I might wait 6 months more of recovery/rehab and i MIGHT try it. Best regards to all the population of snapped back city!

    • Hi Francis,

      Sounds like everything is going great. I think as long as you are cautious, keep your spine neutral, and cut things back if you have any pain, that herniation should continue to improve. The judo/jiu jitsu might hurt it, but in 6 months it might not, the main caution being it’s a lot harder to gauge resistance levels in sports where you are often trying your hardest, and sometimes it’s not all about you, but what others are doing too you. So I can’t say I recommend it, but I wouldn’t tell you not to either. If you hurt your back again, just go easy for a while and progress from there. Oh and I just got the “snapped back city” reference. I’m very interested in intermittent fasting and just discovered the Hodge Twins. They’re great.

  30. Chad,

    First, let’s start by agreeing there isn’t good evidence for most any treatment for back pain. In the context of this, there is better evidence for Mckenzie Method than say, anything else (manipulation, oral steroids, acupuncture, massage, traction, lumbar supports, or regular exercise programs). The Journal of Family Practice and the American Family Physicians only mention the point you cited above (return to normal activities), Mckenzie, and NSAIDS as effective treatment methods for back pain without red flags. That’s a short to-do list.

    I would point out a study:

    The Tissue Origin of Low Back Pain and Sciatica:
    A Report of Pain Response to Tissue Stimulation During Operations on the
    Lumbar Spine Using Local Anesthesia

    Orthopedic Clinics of North America, Vol. 22, No. 2, April 1991, pp.181-7
    Stephen Kuslich, Cynthia Ulstrom, and Cami Michael

    It established disc as directly as 2/3rds and additionally (roughly 10% more) indirectly (as in PLL and vertebral end plate both directly attached to the disc) of the pain generators in spine surgery patients. It essentially excluded muscle as a pain generator. Remarkable study that goes unnoticed. I’d say, if this study were more well recognized, we might actually be treating the right thing. Whether Mckenzie is the right way, MAY be up for SOME debate, but right now, it’s the best we’ve got.

    • Hi Walter, (notice how I start with a friendly greeting before I start slamming;)

      Regarding McKenzie Method, that’s what this blog and subject meta-analysis I cited is all about. The evidence in favor of McKenzie Method indicates that if anything, it’s slightly INFERIOR to simple advice to stay active and overall shows an “absence of clinically worthwhile effects.” I certainly don’t think it’s the best “we’ve got” because I think “I’ve got” a number of techniques that are superior. So if that’s the best “you’ve got,” then I think it would benefit you to start looking at some newer research and applying it to your patients.

      I kind of feel bad, because I think Robin McKenzie himself was a pretty great guy. He had a great idea, certainly better than recommending 1930s based Williams flexion stretches, which were the dogma of the day back in the 1950s-80s when McKenzie Method was codified. A lot of his premises were largely correct, and as I’ve illustrated above in my comments, I just think he mostly went too far with it, and he didn’t do anything to restore lost strength and endurance. Of course it probably doesn’t help that after reducing pain through correcting posture and maybe some extension, he goes on recommending Williams type flexion exercises after the fact. If anyone knows flexion stretches contribute to disc bulges and herniations it should be Robin McKenzie.

      As for the paper you recommend, I read it last night with interest and it was a great paper, for which I don’t disagree with their findings, but I would take issue with a couple of their conclusions. However just because the disc and irritated nerves are the primary sites of pain, does not at all mean that extension stretches is the way to heal it. McKenzie in his books talks a good deal about bending your finger backwards and holding it there to elicit pain, using that as an analogy to what happens with our disc. I think his analogy is fairly apt, however where I think his analogy falls apart, and where McKenzie method as a treatment falls apart would be the promotion end range, with over pressure, finger (or spine) bending in the opposite direction. The answer to eliminating that pain is not to stretch in the finger (and I would say the spine as well) to end range in the opposite direction, but rather to simply remove the pathological stretch and let it return to neutral. Perhaps I would allow for some mild extension.

      In the case of treating low back pain my method (right now) is to teach the use of good lumbar supports when sitting, good motor control during active daily activities, and to increase not just core but total body strength and endurance. The right exercises not only strengthen but also further emphasize a neutral spine posture during those exercises, so they can practice such under progressively heavier loads. I even have what I think is a pretty good example of my basic low back pain exercise program that I, generally, try to work my patients towards. Those are the long term fixes, but I can’t overstate how effective I find the addition of high intensity EMS for low back pain to both increase strength and endurance while decreasing pain, which is a pretty neat combination.

      So I hope you don’t take this in the wrong light. I’m hoping to help you treat your patients better, and unlike the McKenzie Institute, I’m telling you for free. So do feel free to ask for clarification, and if you think I’m missing anything, by all means feel free to say where.

  31. I’m experiencing sciatic pain, mostly in my calf and also in the piriformis area. I also have tingling, numbness in the ball of my foot. I’ve been diagnosed with S-1 herniated disk (but have not had an MRI) and I’m seeing a Physical Therapist. She uses the McKenzie treatment method, but I am becoming more and more doubtful about it’s effectiveness. She wants me to do prone press-ups even though I experience increased calf pain when I do them. Her goal is for the pain to move away from my leg and for me to start to experience back pain instead. She says that will mean that the treatment is working. Currently I have no back pain at all. This seems a little crazy to me. My son, who is a Certified Athletic Trainer, does not believe the McKenzie method is the correct treatment. He, like you, believes very much in evidence-based treatment. My son has shown me some exercises to do (using TMR Total Motion Release) that already seem more helpful than what the PT has done. (And he has ideas for other treatments to try later and see if they help.) Do you think I should discontinue treatment with the PT? I would appreciate your perspective on this. (I am 63 years old and normally I am very active — walking, hiking, biking, cardio, etc.)

    • Hi Alice,

      I haven’t looked at you so I wouldn’t want to tell you what you should do. I can say what I would do for myself and what I would do for my patients that may or may not be similar to you. But I’ll try to think about one’s that are as similar to you as possible. Without an MRI your herniated disc diagnosis can’t be made for sure, but it sounds reasonable, so I don’t see any reason to get an MRI. For the most part I just assume all my low back pain patients have bulged or herniated discs and it doesn’t change how I treat them very much.

      What it sounds like your physical therapist is describing as a goal is centralization of pain and that is a McKenzie principle. That being you do the extension exercises, distal pain is abolished leaving only central/back pain, and the back pain should then go away as well. However I don’t think it should mean that symptoms in your legs would decrease, while back pain increases, since you say you don’t have back pain now. You saying that calf pain increases with your prone press ups is what Robin McKenzie would call “peripheralization,” and with peripheralization (worsening of distal/leg pain) you should stop doing the exercise that causes it. I would think the McKenzie ‘method’ where peripheralization happens with repeated back extension would be to begin black flexion exercises. So it seems to me that your physical therapist might not be doing McKenzie method properly per the paragraph 3, page 171 of Robin McKenzie’s book The Lumbar Spine Mechanical Diagnosis & Therapy Volume 1) where he writes:

      “Loading strategies may produce temporary or lasting distal pain. In response to repeated movements or a sustained posture, if pain is produced and remains in the limb, spreads distally, or increases distally, that loading strategy should be avoided.”

      Of course the above paragraph and following McKenzie quote assume one is a believer in the overall McKenzie method program of diagnosis and treatment, which of course, I don’t. Largely because the research tends to show, as per the above meta-analysis, that McKenzie Method isn’t that effective and isn’t better than advice to “stay active.” I like parts of McKenzie method but definitely not all of it, and prone press ups are part of what I don’t like. I tend to do a lot more coaching of hip and spine motor control such that you can maintain a neutral spine during exercises and daily activities, while working on total body fitness and strength. I think extremes of extension are likely to be aggravating to spine conditions much like flexion. I was unfamiliar with “Total Motion Release” exercises and from reading their website I can’t say I’m overly impressed with their methods either.

      I wouldn’t want to tell you to stop going to your physical therapist without more information but maybe talk with them about your leg getting worse and see if they, or perhaps another therapist in the office would be open to other treatment ideas. Maybe show her my blog and see if she can give you a satisfactory response.

      I have been trying to put together more about what I do on my low back pain page, including a video of a fairly stereotyped (but good) therapy session/workout for low back pain, so maybe check that out. I usually start with a couple exercises on day 1, generally do up to 3 sets of 15 reps per exercise, only increasing the weight if you can do 15 reps with good technique and NO INCREASE IN BACK OR LEG PAIN. I always have my patients stop the exercise or less resistance levels if there is an increase in symptoms. If my patients do well with a couple exercises I’ll usually add 1-2 exercises per day, with the squats and RDLs being added to the program last and always started without weight.

      Just an opinion but your activity level sounds very aerobics oriented, which is good for cardiovascular reasons, but if you were my patient I would almost assuredly recommend you add some strength training, maybe 45 minutes a day 2-3 times per week to your exercise program.

  32. Chad. I have been steadily recovering with some minor setbacks. I no longer have any sciatica related pain. I don’t have any pain whatsoever. What I do have some times is a slight feeling in my foot. Like very minor tingling specially when I am lying down. I have no pain or soreness even when bending forwards. Sometimes I have some tightness in the back. But it’s just sometimes. I can even sit for periods of time and nothing happens. However there is this tightness that I mention. What I want to ask you is that whenever I discontinue “heavy” lower back training my back starts getting tight. I worked out yesterday and did squats and deadlifts with 300 lbs. A lot of lower back work, meaning reverse hypers, hyperextensions, good mornings and kettlebell snatches with a 24 kg kb. After I workout and the days following my back feels as good as new. Not only this type of training do not aggravate my problem but it actually alleviates everything I mentioned earlier. I tell you it feels as good as new. Is there any scientific explanation for this? I have not been able to find anything in relation to this. It just seems counterintuitive as a disk herniation should be aggravated by this type of motion. I imagine at least! It feels great. I have been doing a lot of core and flexibility work also. Specially working my hip mobility. I can do a lot of standing ab wheel rollouts with excellent technique. Could you shed some light or at least give me something to research? Thanks in advance. Your work is excellent and the paper reviews are great.

    • Hi Francis, glad to hear things are going well.

      I have a number of comments. First the tingling in your leg is indicating that things aren’t 100%. So maybe that’s some residual nerve damage from the earlier herniation that still needs to heal. Also, it could mean that there is still some disc material in there impinging on that nerve, just less than before. I did a more recent blog on the rate of change in disc herniation recovery, and while improvements are generally rapid, they are often not complete. That might explain why bending forwards feels ok, it would open up space in the vertebral canal and foramen. However, in doing so, while it might feel good to open up this space, this motion is what causes/worsens disc herniations, so if it were my back, I wouldn’t do it.

      The feeling of tightness might be hypertonicity which could be your back responding with some degree of muscle tightness to protect itself from damage incurred during your workouts, or prolonged sitting with some degree of spine flexion, or perhaps extension beyond neutral.

      As for the heavy training, I think you want to be training your hips and spine supporting muscles and usually in doing so, my people with back pain report some degree of pain relief immediately afterwards. This relief is too soon to be due to the effects of strengthening, but is likely in part because it’s movement instead of sitting (which is usually the worst thing). It is most likely in part due to the beneficial effects of Gate Control Theory. The idea of Gate Control Theory is that anything that increases non-nociceptive (non-painful) sensory input to the brain, be it stretch, transcutaneous electrical nerve stimulation (TENS), electric muscle stimulation (EMS), massage, progressive resistance exercise (PRE), whatever, can decrease pain by interrupting the transmission of pain at the level of the spinal cord. There’s a bit more to it than that, but that’s the gist. One can exploit Gate Control Theory with things that makes the back better (PRE with a neutral spine, or EMS) you can do things that elicit Gate Control Theory that have little to no effect on the underlying problem; (TENS or massage), or you can do things that elicit gait control theory but are still damaging to the spine (like a bunch of end range spine stretches, or PRE with bad exercises or technique). Some things are a mix, like some PRE with a lot of spine motion might increase core muscle strength, which is good, all while jacking up the discs, which is bad.

      As for your exercise program, I have a feeling that your back is worked sufficiently with squats and deadlifts. So I would question the need to do much in addition. Good Mornings are a good exercise if done right, but I think RDLs are better. I think the hyperextensions, even if done right are too low in intensity and as such offer little additionally to your workout. You already know I think kettlebells are gimmicky. So if it were me, I’d cut out some of the exercises that might feel fine in the short term, but aren’t adding much with regards to conditioning, and might be overworking your discs/ligaments and might be contributing to the tightness you feel later. If you are doing all those exercises with you back neutral, they all might be just fine as far as your discs are concerned but I would be concerned you might be flying too close to the sun. All of which I said is just a guess, as I haven’t seen how you perform any of the exercises. In case I explained myself poorly, or misunderstood you, let me know.

  33. Thanks! Do you think there is something I can do to alleviate that slight tingling? Maybe discontinue my current lower back training or core training? It is not painful but it bothers me specially when I lie down. Moreover. What is your take on Foundation Training?

    • Yeah, if I were you, and I wanted to alleviate the tingling, I would do everything I talked about AND NOTHING ELSE! At least nothing else that relates to the low back, hips, legs and abdominals. I wouldn’t do ANY stretching through the spine (McKenzie, Williams or otherwise) except for perhaps to rest in prone propped on fists or elbows at most (which is more static positioning rather than a stretch) and only if that relieves symptoms. So I suppose you could call that McKenzie light. You know how you said you were continuing prone press up as a test of spine recovery? If I had a herniated disc, I would stop that immediately. Until I felt fully recovered I would keep my weight training reps high, maybe 3-5 sets of 15 reps per exercise. I would still lean towards handling as heavy a weight as possible for those 15 or so reps, so long as technique was perfect and there is no increase in symptoms. I would probably do the workout very similar to the one the gal in doing in the video I added in the addendum to this blog, but maybe add some dumbbell curl/overhead presses to make it a full body workout. Given what you tell me, weights would obviously be a lot higher.

      No bullshit, I would look to buy a Globus Genesy 300 electric muscle stimulator (EMS) to train abdominals. With EMS your spine should stay perfectly neutral throughout, and the intensity of abdominal contraction will blow away any other exercise you have ever tried, I assure you. As you can see in the workout video I still teach my patients the McGill “big three” exercises for core because they are easy to do at home without equipment, but with a good EMS machine it makes all the other abdominal exercises all but superfluous. I have a number of blogs on the power of EMS to increase strength, and for back pain in particular. However for some harder core propaganda, I would read Charlie Francis’ T-Nation article about it. For what it’s worth I don’t do any abdominal exercises except for EMS now and neither do any of my employees. EMS is just that much better, and if set up right (which is part of the trick) the benefits are immediately obvious. For what it’s worth I first learned the true potential of EMS from reading about it in Charlie Francis’ book, and from later writing on his message board before he died the Globus was his preferred machine. I just took his preferred settings for track athletes and applied it to low back pain patients and it worked a LOT better than expected.

      As for Foundation Training, I had never heard of it till a couple weeks ago when another guy (who was a lifter with disc herniations) asked about it. So last night I watched a youtube interview with the Eric Goodman. Per the interview he doesn’t teach all his exercises unless you buy his stuff, but most of what he did teach I thought was better than average. His sitting and standing posture advice was on point, and all good advice. The way he teaches people to bend through the hips and not the spine, while keeping the spine neutral was correct, and his “founder” exercise is essentially an unweighted RDL, which is one of my favorite exercises for low back pain. However, I think he spoils the RDL movement when he teaches people to flex the spine and put their hands on the floor. Unlike Dr. Mercola, I don’t expect you would find his exercises to be very challenging. Goodman’s exercises on average looked better than traditional yoga in that he flexed the spine relatively infrequent, which I would say is a lot better than flexing the spine a lot, but not as good as would be knocking that spine flexion off entirely. I figure I keep my spine flexion wholly adequate just putting on my shoes and socks. So I wanted to like him, I liked a lot of what he had to say, but none of that was new. Then he goes on and teaches his variations of the superman exercise for back extension, an exercise for which there is a fair degree of spine compression, which Start McGill (a legit spine researcher) would say is likely excessive (relative to any fitness improvements it gives), which is why he teaches the bird dog instead. Goodman, in the interview calls described his superman as a lumbar decompression exercise saying that cocontraction of the hip abductors would decompress the spine. Anatomically I can assure you he is incorrect. Active prone extension of the increases spine compressive forces regardless of adductor contractions. He said a number of other things in the interview for which I would either opine differently or are just plane factually incorrect and it would take more time than I have to go into. Still it was enough for me to think he’s not someone I’d purchase material from.

      Also I noticed Goodman says he doesn’t lift any weights anymore, so it’s hard to say how recovered his spine is, and it makes me doubt his claim that he’s stronger now than he used to be. Maybe he’s meant he’s stronger now than he was at his worst. Doing his exercises and weights is likely for the best because if he flexed his spine under heavy load in a deadlift or squat the way he does in the “foundation” exercise it might be snap city. What I don’t get is all the talk about how he figured this all out. It’s not as though maintaining good posture, improving motor control with a hip rather than spinal hinge, and strengthening the posterior chain is particularly original. That’s all good advice but Stuart McGill has been talking about all that since at least 2002 and he hasn’t been keeping it secret. It looks to me like Goodman’s really trying to hype up his program, with certifications reminding me of Gray Cook’s FMS certifications (which it so happens I like even less).

      So eh, Foundation Training might be the next fitness fad. Chiropractors like Goodman really need something, since scientifically, the word is getting out that vertebral manipulation is placebo at best. I do think it interesting that he tacitly admits as much by saying he was he had back pain in when he was in chiropractic school, for which apparently no one could “snap” him out of. However, then in the Mercola interview he hr continues to get regular adjustments, go figure. So to sum it up, when he talks about posture and hip hinges, sure do that, but would I do any of his exercises, buy his materials, or seek his certification? Nope.

  34. Thanks! I will implement the things you told me. I am going to incorporate RDL into my lower body training. The foundation training seems OK for a warmup but I’m gonna still doing what you told me 2 times a week. I saw a doctor this tuesday. It was the same specialist who saw me one year ago when I was at my worst. He told me I was ok. That I was going to take care of myself but that I could lift and do bjj (not judo and kickboxing though) And that if I wanted to do an MRI I could, but that the results were going to be “Excellent” according to his findings in some of the examinations he did. I took the mri yesterday (it was awful, the noise!) and I could see the screen. The herniation was, in my opinion very small (according to other images I have seen online, my uneducated opinion) the technitian told me it was a very, very small tear on the annulus fibrosus and that “That COULD be diagnosed as a herniation…Seems pretty normal to me” The other disks were black as the night though…That gave me the chills. Is that serious? I mean, I have read that DDD is pretty “normal” and If I keep myself strong I will have no issues. However is that genetic? Or I have done something to dehydrate my disks? I am getting that machine you told me ASAP. It seems great. Cheers!

    • Sounds good. I think the RDL is the perfect exercise for strengthening the low back, glutes and hamstrings as well as teaching one to hinge at the hips with keeping the spine neutral. The cool thing about the “Founder” is it mimics the RDL, so might be a fair warmup. However, I would leave out the part where you reach forward and touch the toes. If it were me, I’d just do some RDLs with an empty bar before you start adding weight to groove your technique before you start adding weight – same with squats. I have no use for any of the prone isometric extension type exercises. I think they are just added stress that, unlike the RDL, are insufficient to build any muscle if you are already fit. Couch potatoes might find them challenging but I still much prefer teaching them to lift real weights.

      As for the MRI, I’m not an imaging expert, but I wouldn’t expect the color of the discs to be something to worry about. Rather, more the thickness of the discs, thicker generally being better, and one would expect some loss of height with a herniation. DDD is “normal” like arthritis is normal. It’s something that lots of people get as they get older, but it’s not anything you want, particularly at a young age.

      Keeping yourself strong is good, but strength won’t protect the discs from further herniations and DDD if you have poor motor control of the spine when working out, performing sports and daily activities, and still slouch when you sit. If I recall correctly there is some genetic component to DDD, but I don’t think it was that big and how much is genetic is hard to determine as environmental factors are often in common as well. For example, twins usually sit and watch TV from the the same chairs as their parents. If you get that EMS machine, I would also look for some ~4” or 10cm rubber carbon electrodes to go with it, and here’s why. The rubber carbon electrodes seem to last forever if you take care of them, but they need straps to hold them in place. I forget if you are in the USA or not, but if so, maybe email the office and I can hook you up with all the same stuff I use in the office. I have a shipment of Genesey 300s in route too, which I preset my programs in. If you’re outside the USA, let me know and I can tell you my program parameters. That’s the reason I like the Genesy 300, in that it’s the least expensive Globus model that’s full strength that I can customize my own programs for. Someday I’m hoping to add a web store of all the EMS stuff I like, but I haven’t got to it yet.

  35. hey Chad. Went to see my exam results with my doctor today. He didn’t see the images but he read the report that said that I had a small disk herniation in l5 s1 and that I had DDD in almost every disk in my back. He was adamant in the fact that loading my spine in the “axial” (his term) manner would further aggravate my DDD and that over time the disks would be gone and it would only be bone on bone. Is there any merit to such a claim? I have read that degenerative disk disease is not a “disease” per se and it only accounts for the natural process of aging in the tissue of the body. Will squatting and deadlifting aggravate my DDD until there is no more disk left and spinal fusion is the only way to go? The doctor gave me the chills with this one. I feel like on day one. My back is not 100% percent today also. Thanks in advance.

    • Hi Francis, those are some hard questions, that I think deserve good answers, that unfortunately will be largely wasted on the world at the very bottom of this blog. So what I think I want to do is give you what I think is my best direct answer without any links now, but later start filling in the blanks with regards to study findings with some additional blogs on back pain research.

      First axial loading can cause disc problems, but it’s complicated, because it’s a question of how much loading, for how long, in what postures, etc., that can all have an effect and a lot of the research findings are done with loading patterns that aren’t something that can be very well compared to your weightlifting routine. There is research that says retired elite weightlifters have slightly more DDD than controls, but lesser complaints of back pain, while wrestlers are worst off. FWIW, I have most of my back pain patients working towards some kinds of squats and deadlifts, done to improve strength, lessen pain, and teach good spine mechanics/technique, which in turn helps to lessen pain. But how heavy, how many sets, reps, days per week, will give you the best long term outcome in relation to disc health, back pain, general health, looking good, etc., is something nobody knows. I would think that if you are lifting with your spine neutral and with low to moderate exercise volumes and moderate exercise intensities, and your symptoms are gradually improving rather than worsening, then you are on the right track.

      Also somewhere I saw a paper on patients with back pain getting MRIs and how they generally felt worse afterwards because the findings increased anxiety about their condition, so sometimes it’s better not to know. For my patients I pretty much assume they all have bulged/herniated discs or some DDD from the start. I start them light with a couple exercises, and EMS them hard, and go from there. If I work with them long enough, to where they start getting really strong, then I give them my “there is some limit where even with good technique your spine might not like the weights, and I don’t know where that limit is” talk. I don’t tell them to stop moving up, but I’ll say “if in doubt don’t move up” and they might be getting to the point where there are “diminishing returns.” So you sound like you are maybe nearing that point with 300 lb squats and deadlifts. The good news is that means your recovery thus far has been great. If it were me, I’d keep lifting, I’d just be real careful, and I’d know that I was gambling a bit in an area where nobody has perfect answers.

  36. Dear Chad.
    You are very right in the sense that the imaging and the prognosis only made things worse in the sense that they gave me great anxiety. But reading your response and other studies on the matter have cleared things up. In my case I never was a PR guy. Maybe in deadlifts but that is completely out of the question and is actually counter productive fitness wise. I feel excellent when I train my core and do squats and deadlifts. The days after my training sessions feel like I have a new lower back. I am gonna be cautious and keep working with moderate weights and sets. I have a lot of strength in my core and that makes things better. For example. If you asked me today what my level of pain/symptoms or tingling in my foot I would tell you zero. I trained upper body today and punched/kicked my heavy bag plus some rounds of rope jumping. I have never had any pain in any other parts of my back and my lower back never flares up. The last real flare up was like a year ago. The other is just anxiety I think. On a different note I would like to personally thank you. Even though I live hundreds of miles from you the fact that you take some of your personal time to answer the questions to a complete stranger is invaluable to me.Your posts have been informative and also given me true insight on what is going on. Thank you very much.

    • No problem and you’re welcome! It still sounds like things are going great. I don’t know what limits to set for you. I would keep progressing slowly if you are doing well. Just play it safe, and your body should start to tell you when you are hitting any limits. If you progress slowly then when you are getting close to any limits you might hopefully just feel some mild pain that goes away quickly when you back off. Going for big increases might have you jump well past a limit without knowing it, and then it’s snap city.

  37. I recently began a McKenzie method of treatment for lower back injury and pain.
    I’m a male, 48, engineer by profession and the history of my back injuries goes back to high school–football and a wrestling movements so injurious that it squashed my hopes for athletic stardom in other sports.
    Anyway, I was playing basketball with my kids the Sunday after Thanksgiving and I didn’t stretch. I heard a pop and felt instant pain and stiffness. It got worse by the next morning, so bad in fact, it reminded me of my original injury, and my wife had to help me dress.
    A week later I visited the doctor. During this week, I had a good night sleep 4 nights in and whatever was bulging seemed to slip right back in—no more “lightning and thunder pain” as I call it. I was still tender and cautious and stiff, but on the mend. Doctor examined me and prescribed PT.
    First McKenzie treatment, back bends in a supine position and standing–no problems. It helped lots. After three days no pain in daily activities. I could do more and more, no need for meds.
    Sixth day after first treatment the therapist strapped my hips down while I was supine; I did the back bends, no problem. Then he really tightened the strap severely. I’m not sure he meant to do it as much as he did, but rest assured my hips were completely immobilized by then. I did one back bend push-up and “POP”. It was pain I’d rate a 2 out of 10, but it persisted as a 1 or 2 for days. I was mad.
    One night the pain was nagging me, and I couldn’t sleep so I thought about it and decided the therapist had done something wrong. I drew what physicists and engineers call a “free body diagram” to describe what happened as it occurred to me.
    By strapping my hips so severely to the table he isolated my torso and upper spine. Compressive stress increased dramatically. Essentially the deflection of my spine stretched and tightened by the push-up became, for purposes of this crude diagram stiff. Moreover, some of my spine wasn’t supine but nearly upright, such as my head and neck. Made stiff by such extension, I modeled my spine as a beam a deformable single body.
    At this point the stress increase could only be relieved by a dislocation of the disc at L-5, S-1, the site of my hips, which were essentially a fixed object restrained from moving at all. If I pushed up with say 50 pounds of force over 2 feet, that’s 100 foot pounds of torque being applied to the only point at my back which at that point can rotate—the disc between L5, S1. S1 cannot rotate or translate (move) because it is fixed by the strap. There are two things that could have happened.
    One, the torque caused a rotation of L5 about S1, the pressure of which must have been equal to 100 foot-pounds of torque applied across a much smaller space, only a couple inches. The pressure on that disc must have been 400 PSI (which is a low rough estimate based on the size of my vertebrae there being 3 inches between top and bottom.

    Two, to relieve the stress, L-5 would have translated up toward the movement and shifted against S-1. That one scared me the most. It was then that I realized that my therapist (maybe unknowingly) was applying a mechanical shear force to my exercise routine. A shear force is a cutting force, and if, as an engineer, I do not engineer against shear failure, my structure can suffer catastrophic failure. You don’t want to fail in shear.
    I’m not sure what happened, but I’m still in pain, but I’m taking your advice and just staying active. Ironically, what has helped the most was me learning about the McKenzie method and then doing the opposite—hunching and flexing my back forward. I’m virtually pain free but still suffering occasionally.
    I will absolutely not allow that incredible stress to be applied to my spine again. The only thing I could think of on my night of pain that would apply such extreme internal forces to my back causing extreme strain in my spine would be a chiropractic adjustment, a sports injury or an automobile accident. I will avoid all these things.

    • Hi sean,

      That sounds like a bit of a horror story, and I have a few comments. You say you did the back bends in supine, but from the context I assume you mean prone, as in a prone press-up. Supine would mean you are lying on your back. Also I agree the extremes of extension are cringeworthy. I can’t confirm your math with regards to focused pressure to the lumbar region but it sounds right.

      I feel like McKenzie’s method is often getting a maligned by his followers who don’t implement it correctly. So per Robin McKenzie’s on book it sounds like you shouldn’t have done the belted overpressure stretches at all as he wrote that they should only be done “if previous procedures prove inadequate.” So to me it sounds to me like your symptoms were already improved such that there was no need for you to do such aggressive spine extension per McKenzie’s own words, page 462 of his book for therapists The Lumbar Spine Mechanical Diagnosis & Therapy Volume Two. That said, the end range extension with the gait belt is in his book. Knowing what we know about the spine these days, I can’t think of any reason, ever, that I would give it to any of my patients. I think it’s just too aggressive.

      Also per your story I wouldn’t be immediately concerned about your vertebral discs themselves with the extension stretches. However, with that aggressive of stretching I would be worried more about stress and/or fractures around facet joints/pars interarticularis posterior to the discs in what is which is fractured is called spondylolysis. It’s a fairly frequent injury among football players, wrestlers, gymnasts and other athletes that undergo extremes of extension in their sports so, per your history, there might have been a previous injury to this region of your spine already.

      So for sure I think you should stay active but I would try to avoid activities that cause pain. In my programs I don’t do any of what I would call real stretching of the spine itself, with static extension in prone on elbows (no belt) being the most I’ll ever recommend. If you have read more of my low back material, I avoid end ranges of the spine in all directions, as well as a fair degree of strength training, while keeping the spine neutral. So while the meta-analysis this blog is about found “advice to stay active” to as good or better than McKenzie method, my own programs consist of a lot more than advice to stay active. Good luck and feel free to hit me back if you have any other questions or comments.

  38. Until I read your article I was of the impression that my PT is was magician (and frankly, still do). At age 61 I developed sciatica in my right leg. My PCP gave me the standard lineup of pills which only temporarily masked the symptoms. My sister-in-law who is a PT advised me to find a PT in my area who is McKenzie certified. By the time I saw him I had developed drop foot in my right leg. He said I had a bulging disk between L4 and L5 and told me that if I did what he said, I could recover my lower leg strength and learn to control the condition. He instructed me to focus on living differently and utilize his recommended exercise regimen. His mantra is “surgery only as a last resort”. Living differently meant minimizing flexion in the daily routine, using back cushions, not hunching over a computer for hours on end, etc. The exercises started out with the McKenzie extension routine and as I progressed, incorporated more core strengthening. I have always maintained a high degree of fitness so that wasn’t much of a problem. The result is that I can now ride my bike, snow ski, and hike mountain trails. The drop foot cleared up after about 8 weeks and my right foot is now stronger than the left. I still have recurrences of lower back pain at which times I circle back to square one and start the routine over. It still works, but I do wonder if continual use of extensional exercises could be causing some yet- to- be- experienced collateral damage. I gotta say, I was surprised to see your negative comments regarding McKenzie. In reality, many of your responses to others (above) sounded a lot like my PT talking. For me, McKenzie helped me through what had become a very worrisome situation.

    • Thanks for the message Bill! I appreciate your input. Your experience gives me a chance to talk a lot about what’s right with McKenzie method, and a little bit about what it is and isn’t, which I think might still help you out with your back. Like a lot of things, McKenzie method is mixed bag of techniques, some parts are better than others and a lot of what I teach, McKenzie taught well before I did. Also I have read studies where some part of McKenzie method was refuted, some MDT (Mechanical Diagnosis and Therapy aka McKenzie certified therapist) would get all upset saying the findings or the conclusions were false, and then Robin McKenzie would write in himself saying he thought the findings were interesting and saying he came up with his method before MRIs existed, so he was doing the best he could at the time. Which if you ask me, sure was better than Paul Williams’ exclusive flexion stretches for low back pain. So I think if Robin Mckenzie was alive today, his method would be a bit different. The problem today is that if you are a MDT certified therapist doing McKenzie method for back pain, the McKenzie Institute is still teaching his method, which as far as I know his basic treatment hasn’t been updated since the 1980s.

      So looking at your case, the fact that you had a drop foot probably does indicate that you had a herniated disc. Like you said, pills would only mask the pain, and I agree with your therapist that surgery is a last resort. I also think your therapist taught you the right thing, to avoid spine flexion in your life. That was the big thing that McKenzie was right about. Repeated and sustained spine flexion is what causes posterior herniated discs, so minimizing such flexion during daily activities is, I think, a very good idea. However I have my doubts that the McKenzie extension stretches you did also resulted in your improvement for a couple of reasons. First, as you have probably seen me link above a number of times, research does show spine extension can in the reversal of disc protrusions (rearward movement of the nucleus that has not breached the outer wall of the annulus, at least in laboratory settings. However, in your case if the annulus was breached (aka, the disc herniated), it’s likely too late to try and push it back forward with extension. Also you said your foot drop got better in 8 weeks, which is right on schedule for how long it takes for your body to reabsorb the bulk of herniated disc material without treatment. Also if the core stabilizing exercises you were given, if good one’s, I think are a good idea. but I would point out that core stabilizing exercises are not part of McKenzie’s method. That’s one of the big things his method is lacking. I would also add that I agree with the concept of core stabilization but would point out that a lot of “core stabilizing” exercises don’t always do what they purport.

      As for your back pain recurrences and “collateral damage” with extension exercises, yeah I would be a little worried. I would say if you are doing mild extension, like just propping up on your elbows for 10-15 minutes per day, I don’t think that would be too much and I’ll sometimes have my patients do that if it’s a good feeling position to them. However I think full prone press-ups onto outstretched arms are higher risk, so I never have my patients do them. You can read the response right above yours to hear witness of bad things happening with prone press-ups with the hips belted down. Also classic McKenzie method, per his books would have you start doing spine flexion stretches (to restore range of motion) when symptom free, which I think is generally a bad idea, as it’s just more of what caused the original injury. And finally, while I think lumbar support cushions are beneficial to prevent low back pain, I think they should be just enough to keep the spine neutral and prevent flexion. The “lumbar rolls” shown in McKenzie’s books often push the spine beyond neutral into extension and my observation has been that prolonged extension becomes irritating too.

      So in short, I agree with McKenzie that spine flexion is bad, I just think his method often goes too far into extension, with both stretches and lumbar supports. His program doesn’t specifically address muscle weaknesses, which for a lot of people is important. Finally when McKenzie does sometimes recommend spine flexion exercises, I’m still against it. I still think his idea had a lot of merit, he just developed it before we knew what we know today about the spine, and with his passing he wasn’t able to further modify it. I hope that makes sense, so let me know if it doesn’t.

  39. Long thread going on here. I have to admit I haven’t read all of the discussion above, but a good bit of it. Chad, I have a couple of questions. First of all, I understand that you’ve read at least some of the McKenzie texts and the TYOB book. But have you attended any McKenzie courses? You know, for the amount of time you spend on this blog, I think the monetary and time costs of taking Part A for the back and Part B for the neck, will be a good value for your money and certainly your time. You sure seem to be able to say a lot about a topic you haven’t pursued all that far. Sure, you’ve read some studies and texts, but you should seriously just try out a course or two.

    I remember when I took Part A several years ago, I had already been sold on the importance of Transversus Abdominis and multifidus as critical core muscles for keeping the back stable and safe. I was shocked to hear nothing about their value in the Part A course and a direct questioning of the research out of Australia at the time that correlated their strength and control to a healthy back. I thought that the McKenzie instructor was a quack for questioning this. However, when I started trying out some of what I had learned in Part A and comparing it to the clinical results of what I got by working on TrA and Multifidus core strengthening, I started to become convinced that the McKenzie folks were on to something. The core strength folks sure couldn’t help me reduce radicular leg pain in my patients. In fact the overall results of core work were pretty pathetic.

    If you haven’t attended a course, talked to an instructor, and tried the motions out as instructed with directional preference and progression of forces as your guides, you’re simply not qualified to critique the method with any real authority. You just have to take a couple of courses and try it out. I get intermittent radicular pain in my left arm presumably from a bad disc in my lower cervical spine. It typically occurs if I fall asleep with my neck in right sidebending by mistake. When this occurs, I simply do a set of retractions and then retraction-extensions to abolish the pain and go back to sleep. The next day I do more of these than usual (4-6 times/day instead of the usual 2-3 times/day) to nail it home the rest of the way. Once my neck is showing no signs of returning, I cut back my exercises back to 2-3 times a day again and go on with life. Before taking Part B, I did neck strengthening, traditional stretches, manual therapy (from St. Augustine, FL courses) modalities, and traction for temporary relief at best (minutes to hours) and typically had several episodes of intermittent arm pain a month. Because it wasn’t that severely painful, I didn’t pursue more invasive treatment up to that point. After what I learned in Part B (and later Part D), I had a good management strategy such that since then I get radicular symptoms at most 2-3 times/year and these I quickly abolish and return to usual management again.

    I just think you’re way out of your realm of experience on this. Reading up on a topic does not make you a bit of an expert. That’s an arrogant joke. It gives you information, not experience. You need to do what I tell all of my therapists: “Learn and practice the MDT method for a while and THEN go with what works. If you have some things that work better, show me because I want to know them too.” Interestingly every therapist I’ve hired goes on to use MDT almost exclusively for reducing and managing symptoms and then adds compatible stabilization and strengthening exercises, posture and safe body mechanics. Yes, these last items have an important place for long-term management as well. But without the initial assessment and reduction of symptoms that MDT helps with so well, the latter items are usually insufficient on their own. The therapists I hire don’t go with MDT because I hold a hammer over them. They go with it because it helps them understand the problems patients present with and gives them a great framework for treating and for sending patients on to other professionals when it’s clear that it won’t be responsive. I’ve been a PT since 1991 and have attended a LOT of back and neck courses over those years and this method gives therapists a framework against which other techniques just don’t compare.

    • Hi Bill S!

      Yes, I’ve read ALL the McKenzie books on low back pain and most of the research papers. I haven’t taken any MDT courses and I have no intention to. IMO that’s all dated material and I don’t think there is anything in the course that I can’t learn as well or better, and a whole lot cheaper, from reading the techniques directly from the horse’s mouth. Plus as the above meta-analysis makes clear McKenzie method does NOT result in better outcomes for low back pain than simple advice to “stay active.” Likewise I don’t believe in manual therapy for back pain either, but I don’t think I need to go to chiropractic school to comment. I know how to read research just fine, all by myself. Besides another study, which I have also blogged on, shows no level of training in MDT courses leads to adequate classification of injury diagnosis anyway. Nor do I find the McKenzie diagnosis categories of derangement/dysfunction/postural to be particularly useful anyway.

      I agree with you about exercises to try and isolate the transverse abdominus and multifidus as I have linked already. That’s not real spine stabilization if you ask me, as I linked above already. Also I have linked, several times, what types of treatment I think are effective and even posted video. So if you have any questions about what I do like, please feel free to ask. However, I think if you read the responses above carefully, you will see I have listed out what I think are good ideas more than once.

      Also, if you think that there is anything in particular from McKenzie method that I have misinterpreted, or any research I missed, I would be very happy for you to point it out. Cheers.

    • Bill S., another thing…

      I was thinking about your neck pain which you say is recurrent. Like back pain I agree neck pain is often disc related, which is another thing that I tend to agree with McKenzie on. Also I think the chin tuck exercises are a good one to teach better neck positioning and postures. However, also like with low back pain, I think McKenzie overdoes the extension stretching, such that if I were you I would lessen or eliminate that from your program. Like lumbar DDD, if you have cervical DDD, your facet joints will be in close approximation such that end range extension might worsen arthritic changes, and bone spurs, that may in the long run be bad for your radiculopathy.

      I’m not surprised that typical neck flexion or rotation stretches caused irritation so I would keep them out of your program, and I’m no more a fan of manipulation and mobilization of the neck than I am for the back. I would think increasing strength and endurance of the neck is still good if it can be done pain free, avoiding end range positions. There are several studies now that show strength and endurance training helps to reduce neck pain, but unless you read the full paper you might get the idea that it was just neck strengthening they were doing, but they pretty much all include a general upper body strength and conditioning program.

      The big thing I would recommend for you, similar to low back pain would be more in the lines of prevention rather than after injury treatments. Avoid habitual neck flexion when looking at cell phones or computers (raise monitors or laptops up), get in the habit of look down with your eyes rather than your neck during daily activities, tilt car seats forward so you don’t have to flex your neck to see where you are going, when sleeping on your back get rid of the pillow, etc.

      Also I get really good results in strengthening and pain reduction for neck pain, much like I do for core strength and acute back pain reduction with EMS/TENS but I use large rubber carbon electrodes making the use of greater currents (to better exploit gate control theory) more comfortable. Hope that helps.

  40. First, I don’t think Mckenzie is the only answer to most non-traumatic LBP but I do think it’s the best we’ve got and theoretically it correctly targets the predominate discogenic problem (and not the “problem” of muscle strains in LBs that is a misnomer since cadaver studies show discs fail before muscle, without trauma there is no radiographic evidence of LB muscle injuries, and again, the surgical evidence does not support muscle injury). You disagree, citing “use of good lumbar supports when sitting, good motor control during active daily activities, and to increase not just core but total body strength and endurance”. While some of that is adopted by Mckenzie already and clearly you are making a concise summary or your specific approach which might leave out important details for this discussion, there is still some clarification needed here.

    First, when you say ” does not at all mean that extension stretches is the way to heal it (discogenic pain)” let’s be clear, there is considerable evidence to counter this statement and little to support it. I do agree that removing the negative stresses (often excessive flexion) is important (so does Mckenzie), but motion, particularly extension in most cases (not all) is important.

    First, let’s establish that motion is important to disc health. We can go all the way back the 1986 Presidential Address to the International Society for the Study of the Lumbar Spine where Dr. Vert Mooney first argued “The human intervertebral disc lives because of movement!” He also stated “The most rational approach…is mechanical therapy that restores the motion to the joints of the spine, especially to the disc.” This was demonstrated through predominately cadaver studies but has since been further substantiated.

    1) 2014 journal of spinal cord technology stated that “Disc Disease equates to/with a loss of segmental mobility and gross lumbar mobility
    “Segmental motion at levels with degenerated disks was decreased.”
    2) European Spine Journal 2015 study
    “Degenerated lumbar discs do NOT show hyper mobility…Loss of segmental ROM from advanced disc degeneration
    did not cause an increase in the ROM of the superior adjacent segment in vivo…resulted in whole lumbar motion (being) significantly decreased.” It also showed motion is good for disc health stating just that (“Motion is good for the lumbar disc”) and
    “Increased joint laxity was closely associated with lower prevalence of lumbar disc degeneration in young adults”

    If motion is good for discs, then what motion is best? In a 2000 spine article, “lumbar extension tended to reduce stresses in the posterior annulus…”“The posterior annulus can be stress shielded…in extended postures” and in a 1989 Spine article, monitoring compressive force and nerve root tension in cadaver spine specimens, “The amount of compressive force on and tension in the nerve root increased with flexion of the spine and decreased with extension of the spine.”

    Your case for general strengthening as compared to Mckenzie isn’t new. In a 2007 JMPT review of unloaded exercises facilitating lumbar spine movement compared to a no-treatment control (favoring mckenzie strongly) or other treatment, the evidence “slightly favored McKenzie when compared to strengthening and stabilization exercises”. Yes, “slightly favored” isn’t a ringing endorsement, but in the murky world of back treatment is the best we’ve got!

    A 2010 article “Comparison efficacy of combinations of Back Muscles Endurance Exercise (BMEE) and McKenzie Exercise (ME) and McKenzie Back Care Education (MBE) in the management of long term mechanical Low Back Pain (LBP)” found,
    Group A – BMEE, ME, and MBE
    Group B -BMEE, ME
    Group C – ME, MBE
    Group D – BMEE, MBE

    Findings would be as follows:
    1) “Group A was significantly more effective than Group B which was significantly more effective than Group C which was significantly more effective than group D”
    2) More is better
    3) Combined exercise effective over either exercise and education

    However, lost in the combined exercise is better are the DETAILS! The BMEE program consisted of 8 exercises taking 38 mins per day to complete every day!!! This is an unrealistic amount of exercise requiring gym equipment and time. It’s an unreasonable comparison AND it STILL was not as effective as ME alone which takes very little time, equipment to be MORE effective.

    So, summary, disc “lives for motion”, the motion preference is generally extension , Mckenzie generally prescribes that direction (although we all have to flex sometimes so Mckenzie with gradually reintroduce flexion safely into people’s lives), and it’s better (more realistic) than general exercise at treating back pain. There are more articles about all this. I just tried to keep it short.

    Sorry, it took so long to respond. Look, you may have case study success and be unwilling to accept the evidence I’ve cited. I’ll even acknowledge that the amount of evidence for any LBP treatment is limited. However, the evidence for Mckenzie/MDT is better than any other treatment or modality for LBP. That is not the case for cervical spine where there isn’t much evidence for anything (see the most recent Cochrane reviews on this – or I can summarize if you would like). But with LBP it IS the case. Both major physician journals and all the evidence I sighted and more agree with the fact that Mckenzie is the best, most proven single intervention. You can debate the accuracy of the Update and American Family Physician’s recommendations that ONLY include Mckenzie as part of it’s PT recommendations and you can specifically debate the evidence I cited, but you would have to realize that likely a lot of smartER people than you or I are making these scientific claims and overviews, so don’t expect that without some hard evidence that your position should be taken that seriously.

    To dismiss the solid if not spectacular evidence for Mckenzie over ANY other therapy out-right by selecting a single study and highlighting personal experience/outcomes just isn’t very responsible practice. We are all guilty of that. We all have a comfort level with certain things that lead to acceptable outcomes for us and our patients, whether or not they are evidenced-based, but that’s on us. That’s our bias. Our biases shouldn’t be made to paint a broad brush. Better to say “I believe this works for me and my patients despite the lack of evidence or the evidence to the contrary”.

    Walter Hill, PT

    • Hi Walter,

      I appreciate the time you took in preparing this reply (4 months, wow!) and I have a lot to say about it and some of the quotes and studies you cited. I was preparing a point by point response and then I thought, I’ve said most of this before, either directly in the discussion above or when blogging about other studies on low back pain. Also, based on what you have said thus far I am wondering how familiar you are with the great deal of research on back pain, spine mechanics, and exercise that has been done post/extra-McKenzie. So to prevent me from talking past you, could you do me a favor of reading this book (3rd Edition copyright 2016 is hot off the press)? It’s a very good review, it’s not anti-McKenzie by any means and I think it will bring you up to speed on exercises, disc motions, pressure, consequences, etc. I think further discussion will be considerably more fruitful and less repetitive if you do so, and I’ll be happy to address any remaining points you have. Cheers!

  41. I had longstanding right knee pain at the crease just below the knee on the outside. I had a total knee replacement and while my knee is more stable, I still have the same knee pain. I also have right outside leg pain from the right buttock down into the foot with areas of numbness (i.e., I broke both bones in my right ankle and had little pain). I have had left leg weakness for 2 1/2 years which causes me to sometimes drag my foot – especially at the end of the day when I am tired; this began after several sessions with a personal trainer doing one legged squats with TRX bands.

    MRI in April 2014:
    Focal lateral subluxation with rightward displacement of L2 on L3. There is also anterolisthesis of L4 on L5 for a distance of 8 mm. There is no compression deformity. There is no focal marrow edema. The conus ends behind L1 and demonstrates normal signal. L5/S1 shows normal disc height without bulge or herniation. There is mild facet arthropathy left greater than right where there is a 1 cm synovial cyst projecting posterior to the facet into the left paraspinal muscles.

    MYELOGRAM in August 2015:
    Findings: “There is severe stenosis at L2-L3 [where the MRI found subluxation] with degenerative facet arthropathy on the left. Ventral extradural defects are identified at L1-L2, L2-L3, L3-L4 and L4-L5. There is mild anterolisthesis at L4-L5.

    Surgery is not recommended and I was sent for physical therapy. I have been doing McKenzie flexion exercises for weeks. The only thing these exercises have accomplished is I now have intermittent lower back pain, which I did not have before. Should I continue with McKenzie? Should I be doing the extension exercises instead?

    • Hi Patricia,

      I suppose it’s conceivable that McKenzie flexion stretches are only causing short term pain, but will make you better in the future. It’s also conceivable that switching to extension exercises (I’m assuming you mean stretches?) will help too, however I wouldn’t bet my own back on either outcome.

      I would guess that if your physical therapist is partial to McKenzie method, he/she would have already tested your back in extension and found that irritating, which is why they went with flexion stretches for treatment. McKenzie therapist generally default towards extension, so the fact that they are treating you with flexion indicates they already know extension aggravate your symptoms. I think your case is illustrating one of the flaws in McKenzie method. That being because extension may have hurt and extension seemed to relieve symptoms at the time of your evaluation, that does not mean that flexion stretches are going to be good for your back in the long term.

      So based on what you are telling me, regarding your response and your MRI, report this is what I would speculate ‘MIGHT’ be going on. The leg weakness, either from the knee replacement or neurological loss is likely making you have to use your back more during daily activities, everything from bending over to sitting and standing, thus accelerating wear and tear on your spine. It sounds like you know this and sought to strengthen it, but your personal trainer overdid something. So I wouldn’t give up on the weight training, I’d just try a more gradual approach. I would expect 9/10 personal trainers to be absolutely clueless as to what to do for you, and unfortunately I have no idea how you can find the 1/10 that might help. And as you might be finding out, it’s much the same with physical therapists.

      The stenosis at L2-3 is what gets irritated with extension, and per McKenzie’s method, they are trying to open it up with flexion stretches. The problem is that while flexion might in fact transiently open up L2-3, the same flexion is likely accelerating disc bulging, herniations and degeneration at every other segment in your lumbar spine. So if I were you I’d be working on increasing total body strength and fitness in a pain free manner, while keeping your spine neutral during all exercises, and during all your daily activities. If tight I might stretch my hamstrings and shoulders. If it were me, I wouldn’t stretch my spine at all in any direction, flexion, extension or rotation. In my experience, letting the discs and facet joints rest and heal, while I improve posture/motor control/ and fitness leads to better increases in long term range of motion anyway.

      I would also be doing a lot of EMS to decrease pain and increase core strength isometrically. EMS would likely be a good adjunct (in addition to progressive resistance exercise with weights) to increasing your weaker leg also. I have a number of exercises in the video on my main low back page, however if one leg is stronger than the other it might be good to do some machine based exercises, one leg at a time to try and restore balance between them.

  42. I haven’t had the chance to read all the comments but I just want to mention that the McKenzie approach never states to do extension exercises with any patient that presents with low back pain. It puts utmost importance in the assessment process, which may take several sessions to determine. If your problem is then evaluated as a non derangement nor dysfunction problem, then McKenzie is not applicable as a treatment. That being said, many people fortunately fall within these categories, but not all. And where it gets difficult is if you have a patient presenting with two directional preferences (eg. Stenosis and post disc derangement). McKenzie is more complex than just simply prescribing cobras. It is a wonderful tool but must not be used blindly. A good understanding is necessary.

    • Hi Jaclyn

      Check out more of the responses above as I think I have addressed your every concern. Sure McKenzie is in part an evaluation system, however one of the problems is that as an evaluation it’s not very good either. I have already blogged about a research study that showed regardless of training, McKenzie certified practitioners, regardless of education level, aren’t very good diagnosing back pain into the respective categories of derangement, dysfunction or whatever. Nor do I think said classifications are very helpful, nor do they lead to ideal treatments based on current knowledge of spine anatomy and physiology. If you read through the discussion above you’ll see I go into nauseating detail about all of that to include your example about stenosis combined disc bulges/herniation.

      If you are a therapist I think you owe your patients more than circa 1980s methods. FWIW, I think half of McKenzie’s tools are great, particularly all his advice about posture and avoiding prolonged spine flexion, the problem is the other half is overkill in extension, and the promotion of Williams flexion type exercises when extension is irritating. Not to mention a lack of fitness training, or use of modalities that could help (regarding modalities I’m thinking EMS, but otherwise I agree with McKenzie that passive modalities are for the birds). The combination, I think, explains why some of his ideas are great, as was his basic concept, but in practice as the above meta-analysis indicates, patients don’t get much better than they would have without treatment. If you think I’ve missed something specific or my analysis is wrong I’d be happy to hear about it, but definitely read my responses above to see if I’ve covered it.

      I’m not trying to be strident, I just think back pain is a big problem for which McKenzie Method had its chance, it was a definite improvement over Williams flexion exercises at the time it came out but as a whole system it just doesn’t work very well. From what I have read from Robin McKenzie, both in his books and his reaction to papers regarding his work, he seems like a very cool and open minded guy. I’m pretty sure I remember him saying he came up with his theories before MRI machines were invented and he was very open to learning new things about back pain up until the end of his life. If he were still with us I have a feeling he’d keep his method up to date and he’d probably modify a few things to make it better.

  43. Hello guys.
    It’s me again! I have been pretty Ok. I mean there is some discomfort in my back. However the radicular pain/tingling is rare, almost completely gone. I have been diligent on my training and flexibility regime. I have a very, very strong core and I have been able to squat up to 300 lbs for reps. I have incredible hip mobility and flexibility in my legs. I can even do full splits. There are some things that bother my back, like sitting in a couch for too long and stuff like that. I had a little scare some weeks ago doing squats. I felt a slight “pop” in my back. The next day I was Ok though. I went to BJJ and I didn’t have any issues. I could grapple pretty hard. However I haven’t gone to train extensively because I want to be careful. I am being optimistic because even though I have seen slow progress it has been steady. Even though decompression is somewhat a myth I have been doing it and I feel it kinda relaxes my lower back. Stiff legged deadlifts are very, very useful. The other day I had to lift some logs in my backyard. Lifted them with no issue. Carefully though! Other thing I wanted to ask you Chad. I have been punching/kicking my heavy bag pretty intensely. With absolutely no problem whatsoever. But could the heavy rotation and movement of this type of activity negatively affect my lower back? It’s kinda stiff and sore but that is just a constant feeling that has always been there since I injured it. Thanks in advance and keep the good work!!!! And to all the people suffering from this. You can improve your situation if you commit yourself to a routine. Keep your chin up.

    • Haha Francis, great to hear from you! I just scrolled through my feedback and it’s been almost exactly one year since you first posted.

      The big thing that stands out to me from your post is this:

      “There are some things that bother my back, like sitting in a couch for too long and stuff like that.”

      You want to fix that! Sitting for a long time should be painless if you’re sitting with your spine perfectly neutral. However if you are sitting for a long time in flexion, no amount of exercise will make up for it and your back will always hurt a little, at least. Couches are notorious for being so long that under the legs that you can’t properly support your back in sitting. However if you pile up the right amount of pillows behind your lumbar region (my couch needs 2-3) you should be able to sit for as long as you want without spine flexion which we all know promotes posterior disc migration, bulges and herniations, which in theory makes you unable to tolerate the lifting and BJJ as well. So fix that and it should go a long way towards making your other exercises feel better. I expect BJJ, like wresting might be higher risk with regards to the spine so keep being careful there. But not irritating your back for hours while you rest, should go a long way towards making it able to handle the sports you want to do. Everybody gets into bad positions sometimes, and some sports are more problematic than others, but it’s a lot better if your spine gets twisted and flexed in BJJ for just a couple hours per day, if it’s the only couple hours, rather than ON TOP OF eight hours of continuous spine flexion when working or resting in bad posture.

      As for your question about the rotational forces during punching and kicking. I would think if your core is strong your back should be able to tolerate that pretty well. Like with lifting I would use pain as a guide and back off if your back starts to hurt. Rotational motions and stretching through the spine discs does cause them to delaminate if repeated to often and is thought to lead to facet joint arthritis, however that’s if the rotation is happening IN THE SPINE. If however the rotational force is coming FROM YOUR LEGS AND HIPS while you keep your spine BRACED ISOMETRICALLY you should be pretty safe. Here’s Stuart McGill talking about exactly that. If however, you did do a lot of twisting through the spine itself you might run into problems.

  44. Thanks for the reply! I try to avoid couches like the plage. I am also very careful in how I sit. I just get some cracking and some tension, strange feelings that I could not define as “pain” but as a strange feeling sometimes. Specially when bending sideways. What about the cracking? Is that part of the injury? I feel my whole back cracks sometimes. Well I had a small regression yesterday. See I had a stomach flu and I was unable to train for a couple of weeks, The last days I have been training somewhat hard and yesterday my back started to ache during some squats. No radicular pain but this dull back pain I used to have. Today it’s much better. I think I might re-start my weights very slowly when training the lower body. Focusing on higher reps and technique. I do have the feeling that I have been improving. Specially when doing some motions. The stiffness was going away completely before yesterdays blunder. I have the feeling that all that ab work “protects” my back from episodes like yesterday’s. When they come they are milder and I get over them in a couple of days. I don’t want to make them a habit though. What to do about that stiffness/cracking chief? Is that common? I was getting over them but I have not found anything about that on the web. It feels unerving sometimes! I think that my BJJ days might be over but I don’t want to leave weight training. It keeps me sane. Maybe I can take up kickboxing instead but slowly. Thanks in advance!

  45. Ah and one last thing. What is your opinion on back bridges? I don’t do them but I can do them without pain or discomfort. Are like the McKenzie movements in the sense that they can induce unwanted stress on the facet joint? Do they have a place or benefit? I have been reading posts about them and peple seem to love them but I am not sure. It seems like a lot of stress for a injured back.

    • Yeah, I don’t think it’s bad to sit in a couch, it’s just bad to do so without piling enough pillows behind you to keep the spine neutral.

      For the cracking the conventional wisdom is that if it doesn’t hurt it’s OK, and if it hurts during, or hurts after, it’s bad. However that’s kind of broscience, I just don’t know of anything better. I would think increased feelings of stiffness would be a sign you overdid something.

      For the pain during squats, I would definitely stop the set as soon as you feel any increased pain. People do get away with pushing through a little pain sometimes but I don’t think it’s worth the risk. Plus if you have a back that has already been compromised keeping the reps at 15 for all but the last set and then only increasing the weight when you can get 15 good reps without pain works well for me. Doing 5 sets of 5, or even maxing out might be something you can work towards but it’s outside of my “low back pain rehab experience”. Lifters I have treated and had pain come often reported they strained something doing heavy weight low reps sets so I would be aware of that. I definitely wouldn’t leave the weight training, it’s mostly how I rehab back pain, but I’d just be more careful than usual.

      For the ab work, I think abs do help protect the back but only so long as the ab exercises aren’t hurting the spine themselves, so nothing with spine flexion or rotation. Planks are good, electric muscle stimulation (EMS) with a well programmed Globus Genesy is BY FAR the best.

      If it were me, I’d avoid the back bridges, for pretty much the reasons you say, too much stress on the facets, which is already going to be increased in your because if I remember right you already lost some disc height. Plus I can’t think of much in the way of benefit, they don’t build much in the way of muscle, motor control or pain reduction that I can think of. Good questions!

  46. Dear Chad:
    I have been resting my back these days. I will review my technique on the squat and deadlift. Starting with the bar only and slowly moving up with small increments in weight. I am trying to maintain a neutral back in everything I do and I have been immediately feeling it. I also stretch a lot still and do my core workouts. Neutral sitting/standing up really makes a difference. The pain has subsided but there is always this feeling that something is not right. I know the exercise that irritated my back. I am kinda bummed because I was making strides in my recovery and this is a small bump on the road. Well things like this happen. I have two questions for you this time if I may:
    -What is your thought on starting lower body workouts with movements that help engaging the posterior chain, such as lunges, glute bridges and so on and then starting squats and deadlifts?
    -What is your thought on McGill’s “Lifter’s wedge” in which they use a different type of movement when doing the deadlift. I do my deadlifts with mixed grip but McGill advises to use an overhand grip and trying to “bend” the bar, which, according to him helps to engage the lats more. I also do the movements from pins, not from the ground.

    Thanks!!

    • In general I think stretching is overrated. I figure if I’m doing my weightlifting exercises through a full range of motion, I don’t need to do any additional stretches and though I’m not trying to set any flexibility records I’m more flexible than average. I definitely don’t ever stretch my spine in flexion, extension or rotation. Spine range of motion is more genetic than anything else and I think daily activities give us all the stretch we need without trying. I figure most people hit full range of motion spine flexion whenever they tie their shoes. I would imagine a problem with your BJJ is you just can’t control your spine range of motion, someone else is going to take you where you don’t want to go. So as cool as it is, you are being taken to places where your already damaged spine doesn’t like it. I would guess you were making great strides, thought all was well, then you tried to do too much. Consider it a cheap lesson.

      I think lunges are awesome, I put them in most of my low back programs now. They let you work the legs very hard while the trunk stays vertical (at least it should) therefore spine stress is minimal. I never do glute bridges, I just think I have better stuff. I do squats on most of my low back pain patients within just a few visits, but I start light and keep the reps high (15s).

      For deadlifts I have my patients do Romanian Deadlifts (RDLs) from the rack, so I’m never going to the floor and I’m never doing conventional or sumo style deadlifts with my back pain patients. I think deadlifts from the floor are great exercises, but they overlap in muscles being worked with the squats more so than RDLs (still a lot of quads). RDLs really emphasises hamstrings and stretches the hamstrings (in a way that squats or deadlifts from the floor don’t do the same) with every repetition. Plus RDLs are teaching a pure hip hinge with a neutral spine. The way most people perform deadlifts from the floor is to allow a bit of spine flexion, which might be ideal for lifting a lot of weight but I don’t think it’s ideal if you already have bulged, or herniated vertebral discs. So with the RDL I don’t have my back pain patients lifting either from the floor or pins, rather I have them keeping their spines as neutral as possible and going down until they feel a sharp stretch in the hamstrings. If the patient genuinely has tight hamstrings I’ll have them do additional stretches, but if they can do a straight leg raise of 80 or 90 degrees I won’t waste the time, I’ll just do RDLs. If I wanted my patients to start lifting from the floor, I would use more a “clean deadlift” technique keeping the spine neutral all the way down with more knee/hip flexion and shoulder retraction than is typically done with a conventional or sumo deadlift. The downside of the clean deadlift is that you can’t do as much weight, but the back is in a safer position.

      As for the “lifter’s wedge” I had to google that one. I can keep my spine neutral with either a mixed or overhand grip when I do RDLs but with my Olympic weightlifting background I prefer overhand, and I use straps when the weights are heavy. Almost all the rotation for the different grips happens at the forearm so I can’t imagine the different hand positions have much effect on the lats or low back. I like McGill’s stuff a lot but he uses teaching and coaching points that are different from mine. He’ll say things like bend the bar, grip the floor with your feet, press your feet out when squatting, all kinds of stuff I don’t use. I say things like “keep the weight on your heels” or “chest out shoulders back” and “explode” or “up! up! up!” I think it likely all serves much the same purpose, you just want to keep the spine as neutral as possible, especially under a heavy load.

  47. Hello,
    I have stumbled upon this blog while researching mckenzie method. I have never heard of this method until the last 6 months (I know I am not with the times….) But I am only a patient, with no training or knowledge of PT. I have had CHRONIC neck, upper back and lower back pain. I can have some good spells, followed by acute spells. Over time those acute spells are happening more and more, and other symptoms have developed.

    For instance, my cervical spine (per MRI) has facet arthritis, 3 bulging discs (C4-C5, C5-C6, C6-C7) and osteophyte complexes at each of those levels. The MRI says some weird things (to me) about, “effaces anterior subarachnoid space, slightly displaces the cord posteriorly and remodels the anterior left aspect of the cord” It says basically that same thing for C5-6 and C6-7. BUT it doesn’t see any impingement of nerves or stenosis. Despite those findings, I have a terrible time with chronic headaches that start in the occipital region. They can last a week or more STRAIGHT. No matter what I do, I can’t get relief when I have one of these “episodes” I have also had in the last few months some weird dizzy spells. It isn’t the room spinning on me, nor is it like I am going to pass out… it is me feeling like I had one too many beers and I am uncoordinated, or off center (even though I don’t drink). I feel strongly that my headaches and these new dizzy spells are related to my neck, because in the spring in summer when I am much more active I have them a lot. In the winter I have very very few of these spells, and I am more sedentary during those times. Plus the dizziness is frequently at the same time of the headaches, and they always coordinate with an actual physical activity, like digging in the garden.

    Then for my lumbar spine, again a chronic problem. Mostly a nagging ache for a long time, then in the last 2-3 years my entire pelvis, hips and sometimes groin all really bother me. Sometimes my legs feel like the muscles are just being completely STRETCHED, or over stretched I should say. it is the most uncomfortable feeling and no position seems to help when that happens. Then a few weeks ago I had an acute episode. i couldn’t stand up straight, it just hurt too bad, for days I walked around hunched over which then flared up the center/lower back and hips and buttocks really really bad. I finally convinced my doctor to get an MRI of my lumber spine.
    And here is the list of those findings
    dextroconvex scoliosis in the upper lumbar region
    There is loss of hydration of the L5-S1 disc. There is asymmetric disc space narrowing on the right at the L4-5 level.
    L4-5 Hypertrophic Facet joints.
    L5 – S1 bulging of the disc, annular tear to the right midline. The disc slightly indents the thecal sac. There are hypertrophic changes in the facet joints greater on the right than the left

    Basically DDD, and they say spondylosis.

    Ok with that long history there, I have done PT multiple times. I feel I may get some relief but it is minimal and short lived. i had a therapist that seemed to get my problems, he was hands on, he would do dry needling for trigger points…. he did the electrical stimulation that would make my muscles JUMP, not just that buzzing feeling… but I felt improvement pretty quick with what he was doing I did a bunch of exercises too, bridges, stretches, all the rubber bands on the ankles to walk around with them etc. THEN he was transferred to another office, and since then I have been with this McKenzie fanatic. My impression is it seems like pure laziness. I am not really sure why I would bother wasting my gas and mileage and time to go to an office to do press ups on a table and stretch my hamstrings and quads. I can do this stuff at home on my own.

    But more importantly, I have told her that I used to LOVE to sleep on my stomach and just can’t it is way too painful for me now. Sometimes in the middle of the night I roll over onto my stomach out of habit and I can’t barely get OFF my stomach it hurts so bad. Yet she wants me to do these press ups every 2 hours at home, and a ton at the PT office. Plus, having hypertrophic facet joints…. clearly bending back like that bothers my facet joints. And yes I told her these things bother me and I even said so even with the latest MRI results you still want me to do these press ups and she looked at me like I was crazy to even ask. I mean she has made it clear that the entire mckenzie method is based upon press ups apparently. I haven’t read the books on this, but it would seem that is the only part of the course she took in. LOL

    Anyways, you seem very knowledgeable and I am hoping you can tell me what can I do with my situation.
    I am only in my late 30’s and feel like my entire space is jacked and that I am doomed as I get older.
    Can I really somehow improve and STOP the progression ??
    Or am I only postponing the inevitable (surgery) with all the PT and babying of my spine? Because I do NOT want surgery but I want surgery even less when I am older and more frail.
    Can an annular tear where the disc lost hydration and is bulging actually go back into place AND Heal with press ups? because literally I asked my PT that and she said that press ups with push the bulging material back in and then if we keep it there the annual tear area will scar over to heal. I find this all very hard to believe.

    Can the annular tear be the cause of my buttocks and hip pain?? I am having a TERRIBLE time sleeping, I can’t lay on my stomach but if I lay on EITHER side for more than an hour the hip area on the side will hurt so bad that I wake up to rotate. My back pain is mostly over the spine in the lower back, and slightly more on the right side. But then there is all this hip and butt pain on both sides and it REALLY hurts to sit. and obviously laying I am having a hard time too.

    I realize you are not a doctor, and haven’t physically evaluated me, but just with your experience and this history do you have any advice please?

    Thanks so much!

    • Hi Janet, great questions and it sounds like you have some real problems. I hate to say it but if it were me I would stop going to your physical therapist. Her treatment sounds worse than nothing. In part because I don’t think any McKenzie stretches would help you, and in part because it sounds like she isn’t even doing McKenzie method correctly, which per other reports on this very blog sounds like a frequent problem. Everything you say about extension being bad for the stenosis, DDD, and it’s causing you more pain therefore being bad for your back sounds correct, with overpressure extension being clearly contraindicated in my opinion. If your current PT knew her McKenzie well enough she would know that Robin McKenzie himself teaches flexion stretches in such cases (which I also think is a bad idea). Perhaps when she evaluated you in flexion and that hurt too or hurt worse, so she went with extension as the default move. Unfortunately McKenzie didn’t teach a good move for when both spine flexion and extension hurt, which with a spine like yours is what I expect is the case.

      You’re prior physical therapist sounds better and like he wasn’t jacking up your spine with irritating stretches. However, while I think stretch bands are fair for exercise I don’t think they are ideal and able to efficiently build the strength or fitness you need. Still it’s better than nothing and the TENS is better than nothing. His use of dry needling concerns me. Scientifically/anatomically speaking (excluding psychological placebo effects) given your spine’s condition, how could dry needling help? I know dry needling is a fad in physical therapy right now, but to me it just seems like the promotion of dry needling is an intelligence test these guys failed. It’s funny because to be a physical therapist you have to get really good grades, so maybe it’s more a lack of critical thinking and herd mentality, and maybe it’s just poor curriculum once you get in school. Which brings up a real problem of what do you do if all the physical therapists around you are not up to date with science based medicine? Chiropractic manipulation isn’t the answer, Naturopathy is no better, and pain pills/surgery isn’t a panacea either.

      As for your dizziness, I’m really not sure but it doesn’t sound like BPPV, for that I would maybe have an MD or DO look at that. I would definitely NOT be stretching your neck, it sounds already unstable and I would expect a lot of stretching to only make it worse, same with your low back. I would really start looking at your postures and motor control (how your spine is positioned when you move). Working in the garden might be irritating your neck, not because you are active, but because you are looking down so much when gardening. Looking down results in cervical flexion and cervical flexion will bulge, then herniate, a cervical disc resulting in DDD in much the same way it will a lumbar disc. So there are definite reasons why your spine MRIs show so much degeneration particularly at your young age. Intense high impact sports when you were younger could be a reason, as could being sedentary with bad postures, and poor motor control. So posture needs to be fixed, which can be as simple as stuffing pillows behind you (I have two behind my low back right now as I type this on my sofa) repositioning and adding lumbar support to your car seat, buying a better office chair or adding support to the one you have, and raising your computer monitor up, perhaps a solid foot, until the center of the screen is at eye level.

      The static posture fixes are relatively effortless but the motor control requires some work to learn to sit, stand, bend over, get things off the floor, and garden while keeping the spine neutral or at least close to neutral. And all that requires some muscle strength, which sounds like you might not have, and home exercises might not be enough, so it’s probably worth joining a gym or buying some exercise equipment (perhaps just a bench and adjustable dumbbells to start). I’d like to say you could ask a personal trainer for advice and I know there are good ones, but most are going to be as bad as your physical therapists with a lot less education. The exercise program in the video above is my basic back program, which isn’t hard to do, but it’s hard to get started on when you’re already in pain, and it’s hard to know if you are doing things correctly without someone watching you. So that might be where coming up with a skype or similar solution would be best. Also I still haven’t read it yet (but I’ve read all his other stuff) so I expect McGill’s Back Mechanic is good and it’s directed at self treatment of back pain. At first glance it doesn’t look that simple though.

      And you mention you had some success with TENS, and I have blogged on how I prefer EMS over TENS for low back pain. EMS gives you the benefit of TENS and more, but also does a bang up job of increasing muscle strength at the same time and where and when regular exercises might otherwise hurt. So I use EMS for all of my back and neck pain patients. The good news there is that good (EV-906) and even great (Globus Genesy 300) machines are getting inexpensive enough to have at home.

      Now on to your specific questions:

      To some degree I think you can improve your spine. If you avoid bad postures (too much flexion or too much extension, and too much rotation) I would expect your anular tears to start to heal up, perhaps some bulges might lessen in size or go away, and herniations, the extruded material your body should partially or fully reabsorb. I would expect disc height loss (DDD) and arthritic changes/bone spurs to be permanent, but if you improve your fitness, posture, and motor control I’m confident you could both increase function and lessen pain, maybe even eliminate pain. I’d consider youth to be on your side.

      As for surgery sometimes it helps and it’s all you can do. However you still have to take care of the problems that caused the degeneration in the first place or else surgery will have little long term benefit, other segments will break down, and you’d need additional surgeries and usually after two they consider to have “failed back syndrome.” I’m of the opinion that people usually only need surgery because their physical therapy is so poor, it doesn’t’ work, and they go back to their doctor with the conclusion “conservative treatment failed” then off to surgery and/or pain management. The dizziness is maybe a red flag, if you start having problems with bowel or bladder movements, or you have loss of motor function in your legs, surgery might be necessary. I’m worried that too aggressive of Mckenzie stretches might be hastening the need for surgery. Aggressive extension stretching with already established DDD and arthritic changes just sounds like a bad idea to me.

      If your discs still have greater than 50% of disc height there is a chance that extension can reverse posterior movement of disc material, however if the annulus is torn and the disc material has already escaped I share your skepticism that it could help. As mentioned in the linked McGill study, even McGill is against the use of repeated press ups however, with him preferring a sustained mild extension stretch, and only if it lessens symptoms. He said if it increased pain he would stop immediately. In my example program video, when I am applying EMS at the end, the patient is in mild extension (prone on elbows) which is as far as McGill recommended and as far as I ever go. I only did it for her because she said she had relief in that position. If it increased her pain at all I probably would have had her do EMS laying flat on her back.

      The low back problems could easily cause buttock and hip pain but I would also test to see if you have greater trochanteric pain syndrome, which has a very common comorbidity with low back pain, particularly in women. I would treat that with hip and leg strengthening (which I would already be doing for low back pain) with an emphasis on hip abduction/adduction strength.

      For sleep I love a memory foam mattress. My evidence is anecdotal but it’s what I like. I’d test out a Tempurpedic mattress to see if you like it, then buy a generic memory foam mattress off Amazon.com or Ebay and save $2-3000. Regardless of what the Tempurpedic salesman might say, memory foam sure feels like memory foam to me. Hope all that helps, if you have any other questions let me know.

  48. Thanks so much for replying!

    So just strengthening and trying the EMS on my own should help and work on proper posture?

    I guess I have done everything I could to destroy my spine. I have had whiplash twice in my life, car accidents. I used to play in high school/college junior olympic volleyball, and varsity softball and basketball too. Then, I joined the Navy and did active duty for 6 years, and my first actual experience of sharp back pain was carrying around my 100lb seabag. Now, unfortunately I have become overweight because of pain which has led a bit to depression and just not wanting to move too much, which is only perpetuating the pain.

    So I have a fitbit to motivate me and I have been walking 10,000 steps a day. I don’t feel I am doing much good WALKING but I figure it is better than nothing because I don’t want to have this vicious cycle where I just decline. Do you think an elliptical machine would be ok? I want to get weight off so I need cardio to help with that.

    I am really having a hard time sitting right now due to pain at the very base of my butt cheeks, and if I try to sit off to one side my hips hurt. I just feel like I am falling apart. I know my PT said my hips are weak when she did some initial testing of strength so i will look into the abduction/adduction exercises to strengthen my hips.

    I am going to look into the EMS machine. I did get a new mattress last year which did help at the time, I could lay on my sides again without too much pain. But it seems my hips or whatever is wrong has become worse because they hurt again.
    After reading your response I feel a little frustrated, if PT, chiro, naturopath are all pretty much out I feel my options narrowing. 🙁

    But I greatly appreciate your honesty and insight. Thank you so much.

    • Janet,

      Yes, I think so, kind of, but I got an idea! I think strength, good posture (if that includes motor control) and EMS is absolutely state combination for the treatment of chronic neck and back pain and I regularly see it fully restore strength and resolve pain in my office in people with spines like yours. The bad news is that it takes some time and effort, and keeping the pain away is a lifestyle change, but the good news is that the lifestyle is healthier all the way around, and I would expect it to help with weight loss and depression as well.

      Also all that about prior sports and military wear and tear and the condition of your spine now makes sense. However I think that’s also reason to be optimistic. It means you probably had a lot of muscle before, for which it is a lot easier to gain it back then to gain it in the first place. Also it means, though injured you are also athletic and coordinated, thus you should be able to pick up on the motor control aspects of my program faster than average. Lastly it means you are used to discipline and training hard, such that you should find the right exercises relatively easy. So I think you just need to know what to do to get better, and how to progress without making yourself worse.

      More good news is that my therapy programs are very “hands off.” I’ve just never been that touchy feely. I educate people about their condition and how to stop making it worse. I teach them exercises to start making it better. This is the hard part because teaching proper technique is hard to do without my physically demonstrating what’s correct and without seeing how well you are mimicking it and knowing in real time how it makes your back or neck feel. However, with the internet and Skype there is no reason I can think of for why we would have to be in the same building.

      So if you are interested this is what I’m proposing. Email or call my office next week and we can try and set up a Skype appointment, where to do a brief eval, find out some information about your pain levels and see if we can gradually teach get you on a good exercise program the same as I would in the office. Hopefully in the process we would eliminate your back and neck pain, free of charge. You might want to buy an EMS machine (if it were me I would), but the coaching would be for nothing. What I get out of it is to test and see if this works, and I expect it will. Though we might have to work through some technological kinks. I think though a bit of trial and error, I’ll be able to figure out how to come up with a program to help anyone with internet access in a way that’s economically viable for me. So you could be my first test case. I’ve treated a number of tendinitis cases with over the phone and text but for back pain I feel like Skype will definitely be necessary to make sure everything being performed correctly and to know if the weights look right.

  49. Hello Chad. I also stumbled across your website while trying to learn more about the Mckenzie method, and was very interested in your opinions and views on the method and back pain in general. I have been doing a fair bit of research on the subject recently, and would be very interested in your views on my situation, as I have been unable to find any good information that describes what I have been experiencing, as my symptoms are not so much pain related (although there is some), but numbness and tingling.

    I am 48 yrs old, and have had the typical signs and symptoms of low back pain and sciatica since I was in my mid twenties. Over the years I would have periods of pain and spasms that would generally last from a few days to a few weeks, but would mostly return to normal, and there would be long periods of relative good health, but with an awareness that there was obviously an issue in my lower back. About five years ago, I noticed two areas on my right leg, the bottom heel – outer side of my foot, and the middle back of my thigh that were numb to the touch. This was followed a while later by a very severe (the worst I had experienced) bout of pain and sciatica, which eventually lead to a CT scan and a diagnosis of bulging discs at L4-L5, and L5-S1, with the bulge being to the right side. In time the pain and symptoms went away and things went back to normal with the exception of the two numb areas, which have never gone back to normal, but diminished to the point that I could mostly forget about them in daily life.

    Late last year I started noticing some changes in my back, and while there was no big event, was starting to get some pain and discomfort. In January, I started to get a lot of numbness and tingling in the two areas of my right leg, but also general tingling in both legs, mostly down in the foot, lower leg areas, and sometimes over the entire leg up to the buttocks, the left leg never being as bad as the right. Trips to the Dr. eventually led to another CT scan last week, which shows the same two discs bulging, but according to the Dr. does not look overly serious. He did refer me to a neurosurgeon, however. It has now been around six months since these symptoms started, and although I have had pain for periods of time, in general it has been mild and tolerable, and seems to change, but the numbness/tingling/burning sensations, have been there the entire time, and while the intensity ebbs and flows, it does not appear to have changed much in that time.

    During this time I have tried to stay active and keep to my normal routine, which I mostly have, but there is no way that I could comfortably do any intense work or exercise. I have not yet gone to see a PT, as I wanted to get a proper diagnosis first, before beginning any program. So the diagnosis at this point appears to be, as before, bulging discs putting pressure on the nerves.

    This brings me to my questions for you. Do you have any insight, as to why a person would be experiencing numbness/tingling as opposed to pain? Is there anything that could be going on that would make this more likely to happen, or does it simply come down to the individual? Does the fact that I am experiencing these symptoms and not so much pain change how I should approach my recovery and healing process, or will it be the same? What type of program would you recommend for my situation? Lastly, is EMS used solely to reduce pain, or does it have a beneficial effect in healing an injury? Would you expect there to be a benefit in my situation?

    As I said earlier, I have not yet been to see a PT, but that is my next course of action Unfortunately I live in a small town and my options are limited, if the local 1 or 2 are not right for me, it means a 2 hr drive. Not the best situation. So any advice you have would be appreciated, I realize you can only do so much over the internet, but anything you have to offer will help. Thanks.

    • Hi Brian,

      First off, your diagnosis sounds correct, given your description bulged discs putting pressure on the nerves is what I’d come up with. As for numbness instead of pain, it sounds like you have had a fair amount of pain over the years that resolved as it normally does, but the nerves must have gotten pinched pretty good, perhaps to the point where some of the individual nerve cells, or axons of the nerve cells got killed off. Sometimes they grow back, which takes a long time, and sometimes they don’t grow back. So the return of feeling will often take a lot longer than the reduction of pain, which often happens pretty quick. I would think it’s the same thing causing both, which is likely the bulging discs. So the treatment program for both pain and numbness would be identical. That is to get you to stop bulging those discs, and hopefully give them and the nerves a chance to heal.

      It sounds like your discs are bulging posteriorly, which is the direction they pretty much always go. That means (like a typical earthling) you are flexing your spine too much, either actively (as you squat, bend over, go from sitting to standing, lift things) or passively if you sit in a slouched position (in your car, at your computer, as you relax to watch TV. Usually it’s both, so the trick is to improve your sitting postures with properly placed pillows or lumbar supports, and improve the way you move during activity (motor control) generally to use more hip action rather than spine action. The posture part is easy and mostly just takes awareness, the motor control is harder, takes awareness, lots of practice, and sometimes some fitness. The good news, is you can work on the fitness and the motor control at the same time, so you get a two for one.

      The EMS is the most effective thing I know of for pain (in the short/medium term) but it (EMS as opposed to TENS) is really designed for muscle strengthening, which for low back pain I usually direct at the core. This is for a couple reasons. First, it decreases low back pain better than TENS because it works like TENS TURNED UP, it’s just a higher dose of pain relief. The other part was that in my years of EMS as exercise experiment that I did on myself (AFAIK I’m the only one who’s done that) I found EMS worked my abdominal muscles way better than anything else I had ever tried. I wouldn’t say EMS works the legs better than squats, but it sure works all the abdominal muscles to include transverse abdominus and obliques better than any conventional exercise. I don’t think there are any researched comparisons, but it’s obvious when you do it if you turn the machine up enough. So, in your situation I would think it would help with spine stabilization via increasing muscle strength, while it decreases pain via gate control theory, but I wouldn’t expect EMS to have a direct effect on your discs.

      If you’re interested I’m still looking for a few sample cases to try exercise/back rehab over Skype to see if it’s viable, so if you want to try that I’d offer it free of charge. Just call or send Erin an email to set up.

  50. Low neck and back pain is a horrible feeling. In the beginning, special creams aided me to handle it, then I began taking medicines, but after a while, they stopped to help and even the most basic activity began to trigger dreadful discomfort. Now I wonder about natural medicine and also its new instructions, such as DNS- treatment https://nydnrehab.com/treatment-methods/dns/ or Pain Management http://englintonmedical.com/services/pain-management/. I understand that we must first eliminate the reason for the discomfort, right? That recognizes with such techniques? Trigger whether to attempt?

  51. Thank you for all this great information. Do you know if the Meckenzie meathod works for SI joint pain? I was told by my PT that’s what I had.

    So I went to PT for about 5 weeks and slowly was getting better, but still with pain. A friend suggested the Mckenzie meathod. He said I could read the book and do it on my own. So, my pain has been worse after starting the meathod. It started 5 days ago I went for a bike ride .. because I was feeling better and wanted to increase my activity. Maybe I went too long…but I wasn’t in pain at that time. That same day I was at a picnic and sitting on the ground a lot. That night I stated to try the Mckenzie meathod exercises I read about. The next day I was in a good amount of pain, more than ever before. I thought that I should keep doing these meckenzie exercises for the pain…so I did for two or three days. My pain is now worse. Also, a side note… I have a family history of spondylolisthesis….which i know I should probably get checked for. But, do you think this meckenzie meathod could be harmful for either of these conditions? Thank!

    • Hi Karen,

      I’m out of town right now and so my internet access is limited. The short answer is that I would not expect Mckenzie Method to have any positive effect on SI pain. However, I’m a little skeptical of the SI pain as a diagnosis. Usually it’s just back pain, and maybe some GTPS that isn’t responding to conventional treatment, so the therapist thinks it’s the SI joint. I’ll be back in town Tuesday, and can give you a more detailed response if you can hold out. In the meantime, don’t stretch too hard. 🙂

  52. Hey chad, i didn’t already read all the comment above your article, but the whole article you wrote.
    And i think it’s pretty interessant to confront ourself to the other side of the mirror,
    so that’s why i’m already delighted about our futur discussion and i wish it’ll be beneficial fur us.

    First of all i’m planning to read everything (every comment) on this page and then to discuss with you.

    But after the reading of the main script something something came to my mind
    and i’m asking myself if you’re not building a Strawman Fallacy about the McKenzie Method instead of speaking clearly about what the MDT is.
    It even bring me to the feeling that you’re using only the material which are assessing your point of view.

    I don’t mean to be disrespectfull at all and i do as i can with my modest english skils (i’m French).
    I’ll be clear from the start, i’m a MDT practitioner, so i may not be bias exempt, i’m just speaking for myself here,
    and i’m trying to build my daily practice as much as i can on the EBM.
    With my current understanding from the MDT approach and practice,
    it sound like as exactly the same process is what goes around from the whole MDT Worlwilde Institute : EBM

    I’ll explain myself : let me ask you somethink did you read the research and ressources section on the website from the MDT Institute?

    i’m just asking it myself because i confronted the systematical review dated from 2006 that you’re using to the other ones speaking about the MDT and since then a lot was done and i think we are progressing further,
    tough i haven’t enough time yet to go trough all of them.

    So that’s why i may have the feeling that you’re using only those which are assessing your point of view,
    and that is not how the scientific is builded. To attein this point we have to take as much systematical reviews
    as possible and not just one.

    Everything is listed here, and it is the same for all the systematical review, meta-analysis (http://www.mckenzieinstitute.org/clinicians/research-and-resources/reference-list/lumbar%3A-systematic-reviews/), or the guidelines (http://www.mckenzieinstitute.org/clinicians/research-and-resources/reference-list/guidelines/) and even the reviews (http://www.mckenzieinstitute.org/clinicians/research-and-resources/reference-list/cervical%3A-reviews/)speaking about MDT inclusive those positively, neutraly, or negatively inclined.

    So from what i’ve already read, i’m understanding it this way.
    The McKenzie whole (!) method, is a good classification system an bring a good cleanical reasonning,
    and that is none to laugh about and is really helpfull with our patient.
    Plus there seems to be some evidences (moderate) in term of therapy (DP, centralisation…).

    My point is that it’s the MDT is far more than what you described, sure it is far far away from a panacea,
    but the MDT PT are building constantly new trials, researchs and biographical works, and publishing it.
    I find it really stimulating and it may even bring something good to our profession.
    I’ll be happy to discuss it further with you, and to learn new knowledge too.

    Best Regards

    • Hi Driss! I’ve been to France twice and so far it’s my favorite travel destination. I thought the people were really great!

      Definitely let me know what you think after you have read through pro and con messages and my replies. I really do think I have a good handle on everything that encompasses McKenzie method, and while there are parts that I like, I think as a general approach McKenzie took his good points too far, he has some other points I just don’t agree with, and he doesn’t do anything to restore core and hip strength and endurance. I did another blog on McKenzie diagnosis and how it’s sketchy regardless of one’s level of training in McKenzie method.

      I still think his method is better than Williams flexion exercises, so there’s that. After reading through it all, let me know if you think I missed anything.

  53. Can McKenzie exercises cause a herniated disk or other low back injuries? I have tried it on my own and with a Physical therapist certified in the McKenzie method….It made my pain much worse. Now I’m scheduled for an MRI after very little improvement from a short course of steroids ice and rest. Also wondering what you think of traction therapy? Thanks!

    • Hi Karen. I would not expect Mckenzie exercises to herniate a disc but it kind of depends on what you are talking about with regards “McKenzie exercises.” Generally McKenzie is associated with extension stretches, which is moving your back in the opposite direction of what causes herniations (flexion). However, per McKenzie’s books if the person’s back pain is reduced with flexion, he’ll give flexion stretches as part of treatment , which I would think is just as bad for a disc as when Williams prescribed the exercise. Plus after giving extension exercises for treatment and the patient is feeling better, he’ll later prescribe flexion stretches to restore normal spine range of motion. I understand his reasoning but don’t agree with doing that either, but I have the benefit of having been able to read a lot of additional research papers that didn’t come out until well after “McKenzie method” was codified.

      Playing the odds, since it doesn’t sound like you did McKenzie method that long it’s unlikely you did the flexion exercises to restore range of motion, and since ~80% of patients who see a MDT certified therapist are prescribed extension stretches, I would thus be ~80% sure the stretches you were given didn’t cause or worsen a bulged or herniated disc. However, that’s assuming you’re McKenzie therapist did things the same as McKenzie himself would advocate, and having read a number of responses above of McKenzie therapist not doing what I would expect McKenzie himself to do, I don’t know if that’s a safe assumption.

      I could speculate that if you had a herniated disc, with extruded disc material in your taking up space in your spinal or vertebral foramen irritating nerves, then extension could cause further irritation of said nerves, thus worsening your pain, but likely not affecting the size of your disc herniation. I suspect end range spine extension could irritate the facet joints, with increased risk of said irritation if you already had degenerative disc disease. That’s all just guesses though because I don’t know the nature condition of your spine or exactly what stretches/exercises you did.

      I did a blog on traction, with the gist of it being that evidence in favor of traction is pretty scarce. I have an inversion table, which is a low cost way of doing traction, though I hardly ever use it because anecdotally I haven’t seen it help much either. On the bright side I don’t think an inversion table is likely to cause much harm, and they are relatively inexpensive.

      I definitely think improved posture, fitness, and motor control will take pressure off the nerves and decrease pain. The problem with traction is that it might decrease pain by reducing compression stress and spine flexion while you are doing it, but everything returns to normal once you get off of it. So I’ll sometimes tell people that good posture/motor control is like traction that lasts all day. Improved strength and endurance with the right kind of exercises improves motor control and the ability to maintain good postures longer. And I love my Globus Genesy 300 Pro EMS unit combined with large rubber carbon electrodes, to both increase core strength and endurance while decreasing pain (usually). Lumbar supports, motor control and strength/endurance exercise, and EMS pretty much sums up my treatment approach.

  54. Hey brothers and sisters. I wanna tell you that patience is key in relation to back issues. Sometimes you want to feel well immediatelly. So sometimes your overdo things. Have patience. Take care of yourselves. I was bedridden and now (3 years later) I can squat, deadlift, do grappling, hit the heavy bag. Sit badly and all that good stuff. ( I don’t act so silly don’t worry) Things are never “the same” but you can improve tremendously. Just have faith. Take care of yourselves and be patient! Don’t rush any decision, specially surgery. Take care and Thanks to Chad for his great advice! Keep doing the good work. Giving hope.

  55. Hi Chad, I have been crossfitting for the past 8 years (I am 38) and just recently stopped this summer due to an injury to my lower back. The pain ended up just holding inside the right glute I believe due to the pinched L5 nerve root. It was excruciating for a month. I went to PT for 2 months and everything is going well so far with very little soreness now on my back. I have started deadlifting and squatting with minimal weight because of the fear or reinjury and I just can’t get myself to overcome this fear. My form has always been great however my PT thinks that this happened due to wear and tear and repetitive motion over the past 8 years. I have started doing the McKenzie method of stretches and it appears to be working. My question is based on the following MRI report of my spine, should I continue with this method and continue with deadlifts and squats or completely stop these movements? Any advice would be very much appreciated

    At T12-L1 there is a small right parasagittal disc protrusion associated with a tiny annular fissure. This results in mild effacement of the anterior thecal sac on the right side. No foraminal impingement

    At L3-L4 ther is a mild degree of central disc bulging.

    At L4-l5 there is broad based centralzied disc bulging. There is a more localized right parasagital disc protrusion taht appears to abut the right L5 root just after existing the thecal sac without nerve displacement. Mild to moderate spinal stenosis at L4-5

    At L5-S1 there is minimal disc bulge

    • Hi Ergun,
      Regarding squats and deadlifts, I use them regularly (I use Romanian Deadlifts) in my rehab process for low back pain. However, I work up to them and only do them if they are 100% pain free. I’m real strict about maintaining a neutral spine and I keep my reps high (15s). I use them to both strengthen, legs hips and spine extensors, but also to teach the hip hinge. The danger in squats us usually the hips tilting under, thus flexing the spine, if you go lower than your hip joints themselves want to go. Deadlifts from the floor can still be good, but “good” form is relative. Good form in powerlifting allows for a fair amount of spine flexion, which lets you start with your hips higher and is conducive to lifting more weight, but might not be ideal if you already have some spine damage.

      Honestly, I might be more concerned about wear and tear to your back from abdominal training, or maybe impact from depth jumps. Overall I’m a fan of CrossFit, but I think there are a few exercises that might be problematic, particularly if your spine starts flexing or extending as you fatigue and are trying to gut out a few more reps. Also, exercises might not even be your biggest problem. It might be how you sit in front of a computer, in your car, or how you sit watching TV in the evening that does most of the damage, and working out might be the last thing that gets you.

      With your bulged but not herniated discs per your MRI report, I could see some mild extension stretches helping, maybe combined with a side bend to the right, sort of McKenzie light. I would keep it mild and sustained for maybe 10 minutes rather than repeated extension stretches to end range (based on a study and conversation I had with Stuart McGill). That’s the thing with McKenzie method, parts of it I think are really good, and parts I think just go to far, and he’s no longer around to amend anything. Also I’d definitely EMS your core!

      Your questions remind me a lot of what I talked about with Francis’ above. We went back and forth starting June 4th 2015 thru September 22, 2016. Maybe scroll above and see what he asked and I responded over that time. I think I cover a lot of my philosophy with regards to low back pain and heavier lifting in that exchange and it worked out well for him. If you have any additional questions after that, be sure to let me know.

  56. I had a bad experience with a mackenzie trained physical therapist.

    Before I saw him I had injured my back – I was doing a push up and I lost control of my lower back and it went into extension. I basically sprained my lumbar spine. It was very painful and hurt for many months. I tried to walk it off so to speak but it still hurt and it felt like if you ever sprained a finger by hyperextending it.. that’s how my lower back felt. Anyway, I also knew that I have a grade one l5/s1 isthmic spondlylisthesis – probably from childhood- which usually would leave me alone as long as I avoid extension so I decided a month or so after the push up injury to see a physiatrist to do another xray to make sure the spondy was not affected by the hyperextension injury- that it was still stable.

    The physiatrist told me that it is extremely difficult to move a stable spondy and would like take getting hit by a truck. He explained that if he could reach inside and grab with both hands on L5 he could not move it. He explained that there is a very strong ligament holding it in addition to other things and most people have no issue with spondylolisthesis. Anyway, the xray showed a very mild grade one spondy just like he expected.

    He thought I just strained some muscles and recommended PT. So as luck would have it they PT I got was a mackenzie guy. I had read about mackenzie a long time ago I think in the 80’s and tried it out – I found all the extension stuff painful and in a bad way. At that time I did not know i had spondlylolisthesis. Anyway, he spent a lot of time trying to get me to go into a full on back extension push up. I resisted this all the way and he would try to convince me that it will not hurt the spondy – which disagreed with everything i had read and also my own body which generally does not like a lot of extension and if anything prefers flexion. I finally ditched him for another therapist – this time I said no mackenzie therapist. The next therapist was a little horrified with what i told him.

    I found PT in general not very helpful. It seemed what helped the most was just the passage of time and doing normal activities. I recently injured my knee and again, PT seemed to make it worse. I ditched PT again and the knee is slowly but steadily getting better.

    • Hi Tenseys,

      I’m sorry to hear that. I wouldn’t think McKenzie method, particularly his extension stretches, to be a very good choice for you, especially considering your back was injured in extension. Spondylolisthesis is thought to be a progression of vertebral pedicle fractures called spondylolysis which probably has a genetic component but is also thought to be injured by repeated extension (like McKenzie stretches). So whether your spine is “stable” or not, I’m not sure what they were hoping to accomplish with additional stretching anyway.

      Unfortunately, other types of physical therapy aren’t that evidence based either. Even “spine stabilization” exercises, which I tend to agree with and practice are done with exercises that are impractical so they don’t help with everyday activities very well, or are of such low intensity that they don’t build much in the way of strength and endurance. Anyway, therapy is often a sad state of affairs, and options like manipulation, and drugs are not much better. I still get a lot of results with my adaptations of McGill’s research, so if you are going to rehab on your own, his book Back Mechanic is written for laymen and should be very helpful. Read that and I expect you’ll know more about back pain than most back pain specialists.

  57. “To help it all, unless a patient has an abdominal hernia, or a pacemaker, I almost ALWAYS perform electric muscle stimulation (EMS) to the abdominal and low back region to both decrease pain and improve core strength. This works especially well when patients can’t perform regular exercises intense enough to increase strength, and the lucky side effect is the harder you do EMS, generally the less pain you have after. ”

    Chad- I read about 1/3 of this thread, but really all I needed to do was stop at the quote above from your initial comments along with your citation of using the “Charlie Francis training method” as a major influence on your practice. While I applaud your willingness to incorporate current evidence into your treatment of patients, the responses to comments you have made above demonstrate a confirmation bias approach at best and an irresponsible representation of this profession at worst. And as a matter of factual observation many of the questions and answers above are rather focused on patho-anatomical assumptions / citations / theories / ideas that tend to hold exceedingly low value to the patient experience and don’t hold up to correlative studies with regard to imaging for symptoms / pain in asymptomatic vs symptomatic people.

    The phrase “I almost ALWAYS” is wrought with problems from the very start when you consider the vast ugly world of variable individual symptom patterns. Cold laser treatment warehouses “almost always” do cold laser for anything / everything and places called the “Disc Institute” or some similar sounding moniker “almost always” do spinal decompression for wads of cash with fingers crossed. Your background appears to be in the strength training / body building world which is great. But without strong evidence from multiple RCT’s and meta-analyses, EMS for low back pain is an educated guess and anecdotal adventure on your part. Recent studies (huge meta-analysis by Smith in 2015) show value in general strengthening for low back pain regardless of whether it was specific “core re-training (i.e. transversus abdominus / multifidus) or just regular old leg and trunk strengthening. Thus we can agree that strengthening has value for LBP patients. Whether that is equal or better with EMS vs traditional exercise approaches is a fun topic for further debate.

    However, a patient with persistent long-term back pain with findings of direction preference for lumbar position / movement and neural tension signs probably isn’t going to get very far with either strengthening approach until those issues are dealt with fully. How do we do that? Assessment of symptom response, trial treatment, and re-assessment of impairments and function. Period. That’s it. I didn’t tell you WHICH kind of trial treatment, because the answer is (like in most aspects of life)…it DEPENDS. Hammering folks 3x/week with EMS or planks may get us some improvement, but how do you REALLY know unless you assess and re-assess….At. Every. Visit.

    I find it interesting that you are conducting a sort of individual case-by-case study on its effects yet are unwilling to consider the value of manual therapy or specific-exercise approaches. Here’s a weird thought: What if you knew which one was the right treatment for the right patient at the right time based on a very strong / detailed assessment of their symptom response to testing and treatments? That, in a nutshell, would be the ideal world. If it isn’t harming your patients and some of them get better, god bless ya and keep on truckin’. However, stating that you don’t do manual therapy at all for the spine or that McKenzie treatment goes out with the bathwater indicates a shortsightedness that should concern any PT reading this thread. Newsflash: None of us has the whole and complete answer or the “best” approach. But all of us should stay engaged in current literature and continue to seek improvement in our clinical outcomes. Leaving entire segments out treatment because of a preference doesn’t serve the entirety of the patient population well. It would be nice if we could be “the exercise PT” or the “manual guy” but in today’s payment world it serves us to be all of those to the best of our ability.

    An unfortunate throng of us in PT fail to provide intervention to achieve either an improvement in impairment or function during a session and then (wonder be to the world) actually re-assess its effects during the very same session (as well as between sessions). That, my friends, is not a “McKenzie” approach or Maitland or Mulligan or Barnes or insert guru here…it is the foundation of what we do to help patients reduce pain and improve function. Whether there’s a name on it does little to make me sleep better at night. Sorry if it offends you or anyone else, but in my nearly 20 years as a PT it has become blatantly clear that a frightening percentage of PT’s don’t do the basics of examination / re-examination well and therefore miss important findings that would guide evidence-based treatment. Such treatment might fall under the category of “specific exercise” (aka McKenzie) or perhaps under the umbrella of stability training. It may require traction (albeit rarely according to research) or manipulation / mobilization depending on the criteria presented. These are not my ideas. They are all being heavily researched in the literature (most notably for low back pain) with regard to classification-based treatment guidelines. It is a work in progress for sure. Or it could fall under none of the above and require a pain science/ cognitive-behavioral therapy approach for chronic pain syndromes in which centralized pain persists.

    It would be a refreshing state of affairs for all of us to lighten up on the Guru gas pedals a bit, as ALL of them will posit anecdotal successes coupled with a bit of conflicting research. Charlie Francis has the about the same strength of evidence for treatment of LBP as ingesting essential oils so let’s maybe not get too far down the McKenzie analysis road (particularly since you’ve admitted to never actually learning it or employing it).

    Outpatient orthopedic physical therapy in 2016 is messy. Deal with it. We aren’t afforded the comfortable warm blanket of “truth” about damn near anything and are stuck between the medical world beholden to pathoanatomical diagnoses and the therapy world of treating what is before us based on the individual patient’s presentation regardless of always knowing “why”…The terms “always” and “never” don’t pass the sniff test for almost anything in life, and hearing them in reference to approaching patient treatment concerns me greatly.

    • Hi Rob,

      I’m not sure exactly what you want me to say so I’ll keep it short. I like EMS a lot. I “almost always” use it because I find it very effective at both increasing core strength and endurance, and acutely decreasing pain, which are very good things. Adding EMS with my Core-1 and Core-2 pad placements and 10-50-10 program out of my Globus Genesy 300 machines improved/sped my low back pain outcomes a full 100%. I expect you don’t know how powerful EMS (the way I do it) is as a tool because you don’t do it the way I do it. Charlie Francis was a sprint coach, he didn’t treat people with back pain. I just think he knew more about how to effectively use EMS than anyone else, and I applied that to my back pain patients with a lot of success. However I was able to find research to support my observations. And yes, some of what I share is anecdotal. I present it as such, as well as how it relates to various papers as it does not seem right to keep it a secret.

      If you have read this blog, you know I’m not a big fan of McKenzie method. As for manual therapy, I’m very skeptical of it whether it is being done by acute low back pain, chronic low back pain, back pain in general, and I’m especially skeptical of it when I hear other physical therapists try and explain how they think it works. I’m not a big fan of the psychosocial model of low back pain either. I don’t think that being a well read, and a expert in a bunch of ineffective treatments does anyone with back pain a lot of good.

      What I am a fan of is removing the source of damaging stress to the spine and usually this is done by keeping the spine neutral during ADLs with good lumbar supports when sitting and good motor control when moving. Good exercises both improve fitness and teach motor control. Fitness is good for people in general, outside of just how it relates to low back pain, so I “almost always” have my patients exercise. A lot of what you are commenting on goes beyond general statements and I think should be discussed with exercises or EMS parameters/pad placements in particular. So if you have any questions or specific comments please share.

      As for continued and repeated evaluations, yeah of course. I have patients try an exercise, I evaluate how they do with it, and how they respond to each exercise as well as the program overall, always. It’s implicit to my protocol.

  58. Hi Chad – thanks.

    Yeah the mackenzie PT inititally had me do a lot of forward bends – toe touches, and I was able to do them without much issue. So he reasoned their was no herniations and the issue was likely with the ligaments in part of the spine that extension would address. I was surprised by this and didn’t stay with him long. I’m glad i didn’t allow him to put me in full end range type extension. He almost convinced me. The next therapist couldn’t believe it.

    I don’t have much pain from spondy most of the time – really I’m not even sure if its from that when I do to be honest. I’ve also read that most people that have it don’t have pain or ill effects. I think I get a little stiffness sometimes. Probably sitting too much is behind some of this.

    I’m familiar with Mcgill.. I’ve tried his 3 exercises before but honestly didn’t find them very helpful. Bird dog especially felt irritating. I almost went to see him but decided on another direction.

    Have you read this? Its a kind of a response to the idea that flexion is bad. It mentions Mcgill’s studies a lot.

    https://www.t-nation.com/training/to-crunch-or-not-to-crunch

    I do find flexion sometimes helpful. Walking is good.

    The PT guy who wrote the Multifidus solution also does not like Mackenzie.

    • Yeah, McKenzie is typically extension but if extension is irritating your symptoms during the evaluation then McKenzie per his book/method would have you do flexion exercises to relieve symptoms caused by extension. So if that’s what your first physical therapist had you do then, that’s correct per the method and perhaps due to your symptom response. Still I think flexion is a bad idea and I almost never give spine flexion exercises to my patients whether they feel good or not. If extension is irritating then I think avoiding end range extension is the answer, while working into end range flexion is besides the point and risking disk health. Spine irritation might cause spine extensor muscle spasms, and spine flexion might ease those spasms, but I think it’s still a bad move as I think you are risking disk health in efforts to stretch the spasmed muscles. I did a blog about that very thing with spine flexion increasing spasms. I would rather lessen muscle spasms with the spine kept neutral using EMS. Massage probably works by lessening spasms too, but I find EMS more cost effective in the long run and EMS has that beneficial side effect of increasing core strength/endurance.

      Sitting too much, likely has something to do with it. Most people when they sit, sit with their spine in some degree of flexion. Prolonged flexion, even low load, damages both ligaments and discs. So a good chair, with good lumbar support, or putting the right amount of pillows behind you in a bad chair might go a long way.

      As for McGill, the “big three” exercises (curl ups, side bridges and bird dogs) are a very small portion of what he has to say regarding lessening low back pain. The exercises get a lot more extensive, but the big thing about his research and books is to eliminate the source of the pain. Even he would tell you that the big three would do almost nothing to lessen pain if you don’t correct aggravating postures and movement patterns. Pretty much everything I said about EMS being incomplete would apply to the big three, except the exercises don’t give you as much short term relief as the EMS. For what it’s worth I don’t think the big three work abdominal muscles near as well as EMS, but they are something you can do at home without equipment. The big three also don’t teach the hip hinge like you get with squats, and RDLs, or strengthen legs/hips anything like lunges. McGill’s book talks about more comprehensive exercises similar to what I teach so if I had your spine and I didn’t like pain, I’d read it.

      I read the Contreras link. I don’t find the bulk of his reasoning very compelling. If you’re back is painful because you sit in some flexion, doing crunches on top of that is giving your back more of what it’s already had too much of. And it’s not like crunches are that great of an ab exercise anyway. EMS (with the right machine, pads and parameters) feels considerably more intense, if you turn it up enough. Thus I prefer this testosterone article.

      I don’t think there is any reason to try and isolate the multifidus. Sure multifidus function is often impaired in people with chronic low back pain, but so are all the other muscles around the core and hips, such that I don’t think isolation of the multifidus are the answer. Ditto for the transverse abdominus. I think it helps to think of back pain as a multi-factorial problem, so for treatment to be effective it needs to target all the important causal factors.

  59. Thanks Chad.

    What do you think about the FMS and similar movement screens?
    Do you think this can be helpful?

    Are you familiar with the painscience.com site? Seems very skeptical about PT and things like the FMS and posture correction and what he calls “structuralism” etc Any thought on his criticisms if you are familiar?

    Thanks again!

    • I’m not a fan of FMS. I used to work weekends at a fitness center that was all into FMS when it first came out and I thought it was a big waste of time. I always figured (and still think) I can tell by looking at someone where to start an exercise program and since I start relatively easy there is minimal risk of injury. If they have back pain to start, then I’m going to do a number of different assessments to see what irritates them and none of those tests are in the FMS. Either way I adjust the program as I go. For example, for general fitness if I have someone adducting their hip (knee coming in during squats) I just tell them not to do that, rather than look for a “corrective exercise” for hip abduction. Most of the time the person can correct their “error” if you tell them too. Other things I consider more important, like spine flexion during squats or dead lifts, which are harder to correct weren’t even addressed in the FMS (at least that’s my recollection). Plus, there have been several papers that have come out since that indicating that the FMS does not do a very good job of predicting or lessening injury in either athletes and workers.

      I actually like a lot of the painscience.com stuff and the sciencebasedmedicine.org material. I share a lot of his/their skepticism with what is often done in medicine, to include physical therapy. I think the painscience.com guy charges you to see what what he thinks does work, but I’m skeptical of that too. I do think postural correction is important, but it’s just part of the equation (my full equation is postural correction, motor control during dynamic movement, fitness, and EMS). So I think he might be quick to throw out the baby with the bathwater when looking at papers in isolation. Plus when you start reading the papers in detail you can see where where they went wrong and why expected benefits were not found. For example it’s frequent that spine stabilization exercises used in studies are do a real poor job of stabilizing the spine, or that spine strengthening exercises include a lot of spine flexion/extension that likely worsens disc/pain while strengthening muscles. Very often the researchers just don’t know what they are doing, which I think is why they often don’t show much benefit.

      It’s really well established what causes back pain now, the trick is to avoid the mechanism of injury both when exercising and during the day and let the back heal. Posture helps with that, as does motor control, as does fitness, as does EMS. I hate to keep bringing up McGill but if you are really into this stuff you might like the 3rd Edition of Low Back Disorders. I’d read the 2nd edition and I’m mid way through the 3rd right now and I think it’s great. It’s got a lot of new information since his last edition and I think he does a great job of tying a lot of low back pain research together to paint a clear picture. His “method” really isn’t some static “his way” thing. He reads a lot of research, comes up with theories, tests those theories in his lab and collaborating with others, then modifies his diagnosis and treatment ideas based on that. It’s the best single source of information on low back pain that I’m aware of because it’s not a single source. It’s a synthesis of sources. Unfortunately Low Back Disorders isn’t for laymen like Back Mechanic is but it’s more comprehensive and if you google some words I think it’s still followable.

  60. Thanks – I’ll take a look at that. One of the things I’ve always been curious about is how the body works – or how it should work – if there is such a thing – the simplified version. What I mean is, especially in the legs and hips and back, how should the muscles behave – their “firing patterns or sequences” with various motions. A lot of personal trainers and such talk about this. Like for example, if your psoas or quads are too tight, this will tend to happen – or an over compensation will happen here. What is the correct balance of muscles – what should fire first in a given movement etc, that kind of thing. I guess better body mechanics. I was asking about FMS cause I thought that is what it was about but I don’t really know. I know painscience cites those studies and is very skeptical since it is acting as more than a screen but also a therapy etc.

    Of the biased directions, I’ve always found flexion “better” than extension. Probably some to do with spondy. When I had the lumbar extension injury – while extension was terrible, flexion didn’t really seem to help either. It just didn’t bring pain like ext did. But it did not seem to help the injury much. What helped after a few PTs was just half hour walks almost every day – and time. Just walking around.

    • I’m often skeptical about muscle balance and firing pattern talk as well. Personal trainers are often trying to make everything sound harder than it is to justify their existence to their clients. Fitness writers need to keep coming up with new stuff to write about so they can sell their articles. And there is a lot of money to be made in CEUs teaching people how to exercise with ropes, kettle bells, swiss balls, slings, manual therapy techniques, dry needling, or whatever fad is coming along. I think all of that dilutes knowledge of both patient and practitioner alike with regards to good anatomy and sound/effective exercise principles. The painscience guy wrote a great blog once on “Modality Empires” and I think everything he said their was on point and applies equally well to exercise or psychological techniques. It makes finding out what’s really important difficult. That’s why I like McGill’s material so much. He actually researched what it takes to herniate a disc (repeated flexion), then wondered if extension would help (in moderation it sometimes did), then wondered what extension interspersed between each flexion moment did (the discs herniated faster), and looked at repeated twisting of the spine did (it caused delamination of the annulus so that when combined with flexion, discs herniated faster). At the same time he was researching exercises to see what worked the muscle best while putting the least stress on the damaged structures of the spine, and that’s where the big three came from. I don’t always agree with him or use the same types or order of exercises, but I agree with him more than any other single source and my exercise choices are generally in the spirit of his findings. So he’s who I would read first, then you can start judging others recommendations with that in mind. McKenzie’s stuff was actually a good idea at the time, but that time was the 1980s, and while some of his ideas were genius, as a system it doesn’t really work that well because other parts were based on ideas that didn’t play out.

      With your history, flexion is likely better than extension, but flexion is still worse than nothing. That’s probably why you like walking so much. Walking keeps the spine very neutral, avoiding both extremes of flexion and extension. Unfortunately, walking doesn’t teach one how to move correctly in more challenging positions, or help when you have to sit down.

  61. I had a book by Mcgill – it might have been low back disorders. Can’t find it at the moment.
    I recall that he wasn’t a big fan of fixed posture like especially on the chair. I think he would say the best posture on the chair is the next posture and i think it had a picture reflecting different positions. That’s sort of what I do. Sometimes I sit up relatively straight, sometimes collapse, sometimes leg up, I vary it. I also don’t use lumbar support as I find them extremely uncomfortable. I use either a chair without a back or a relatively flat back. Also no arms on the chair. I’ve wondered if no arms is a good idea espeically with typing a lot.

    • Regarding McGill and sitting his comments on that you want to move around a lot when sitting from edition two as well as taking frequent breaks to stand and stretch in mild extension every hour or so. I haven’t got to that part yet in edition 3 to see if he has changed anything. I did like, and blogged about his use of lumbar supports on airline flights and I apply that type of information to desks and sitting on my sofa at home.

      My feelings are that lumbar supports should not really be felt. They should prevent spine flexion beyond neutral, but not force you into any extension. So a support needs to be customized for a given chair and your anatomy. I’m sitting in a Herman Miller Aeron chair right now, which I think is awesome. However, I thought the thicker lumbar support adjustment was too much and the lesser support setting was not enough. So I have the lesser support in place, plus three layers of cardboard between it and the mesh and it’s perfect. I can sit a long time with no discomfort whatsoever. On an airline flight I think the thick catalog in front of you, folded long ways and placed in the small of your back is perfect and always present. In my jeep, I like 4-5 layers of cardboard, some cars none, and on my sofa usually two throw pillows. Also in a car a lumbar support does little good if the seat is reclined such that you have to flex the trunk to reach the steering wheel, and most people do this. So what I think you want to know is the principle and the knowledge/habits to apply it as needed. So if you are sitting down and the support irritates you, it might be too thick or too thin, and how your back is positioned when it feels best (walking) is a pretty good guide as to where you should be when sitting. I think the McKenzie lumbar rolls are almost always too thick with too little surface area. I think he had the right idea, he just went too far with it.

      I don’t think arms make much of a difference, though in theory and pressure on your arms would be taking compression force off your back.

  62. Yeah I notice after typing a lot (touch typing) sometimes it can start to bother my back and then I get up more often. It feels like my body has too much happening forward of it..like I’m forward heavy and it stresses back. I remember when I had arms on chair I didn’t exp. that much but then sometimes would lean or collapse into an arm so that’s not good either i suppose. I do try and get up a lot for 2 minutes. Yeah with lumbar supports I usually always feel them and it doesn’t take much to bother my back. If I wouldn’t feel it and it was supportive then that would be fine. I think my lumbar spine is a little on the flat side (maybe as an anti-spondy adaptation). I don’t have a lot of lordosis but not totally flat. Thanks so much for all the information.

    • You’re welcome. Sometimes the back appears flatter than it is because a person doesn’t have that much gluteal development, and if that’s the case a lesser still back support is likely warranted. Also if you don’t have thick spinal extensor muscles, a softer support is more comfortable as it presses less into the vertebral transverse processes. Let me know if you have any other questions or comments. As you can probably tell, I find all this back pain talk very interesting.

  63. Yeah I have okay gluteal development I think – definititely not flat like some are with spondy or some are in general. I notice though that I seem to like to tuck my pelvis a little at times, sometimes even just lying down on back I’ll do it sort of almost unconsciously like to get the glutes out of the way and to flatten the lumber spine a little – maybe also to help encourage muscle release there. I think I’ve always done it most of the time. Like the pelvic tilts that are often recommended for spondy. I wonder if that habit contributes a little. That’s another area that sometimes bothers me – for example, I can’t lie on the floor on back with legs extended straight – uncomfortable in lumbar area – like a war. On the bed lying on back I can manage it with pillow under knees. When my back is feeling particularly good, I can lower the height of pillows under knees and it’s okay. I guess due to tight hips and muscles- maybe hip flexors?

    I remember when I was a teenager I did a little weight training (never did squats though – they didn’t feel comfortable) and for “situps’ I used to do the full sit ups on an inclined board with a heavy weight behind my neck. Now of course its known situps are not good in general for back and that was probably the worst way to do it. I think I may have over strengthened my hip flexors too much and maybe this became incorporated in postural habit, I don’t know.

  64. Perhaps you are right though – maybe there is a degree of under development in gluteals esp muscle wise. I remember though asking the PT I saw after the mackenzie guy if he thought I had much arch/inward curve/lordosis in the lumber area (as some people with spondy do) and he thought I didn’t. My spondy is pretty mild in any case in terms of displacement on last xray about 8 years ago so maybe I wouldn’t have the same curve affect as someone with a grade 2 spondy or more.

    The sits up I described i did a long long time ago so I imagine any over development in hip flexors from that probably has lessened but I do think maybe some of my back/hip issue has to do with tight hips. Maybe when the hip flexors are tight/stiff and are tugged/stretched on (through activities that require some degree of hip flexibility – like lunge and maybe bird dog as examples) they pull on the lumbar area and L5 and cause irritation – I don’t know. I wish i knew more about how the muscles interact like that – that was what I was talking about before. But you’re right, you run into a lot of confusing stuff in this area with “muscle firing activation patterns” and it all seems so complicated, like you need to totally relearn to move and walk and you can’t trust your reflexes and what you normally do.

    I noticed you mentioned back mechanic by mcgill. I wasn’t familiar with this title – it looks very new. Looks like it has very good amazon reviews and is geared toward the non professional. I might take a look at this too. I think what you say about neutral spine is right. It was in this position like while walking that the back got better. I think also time helped and not doing specific exercises some of which may have involved leaving neutral spine.

    Anyway, sorry to hog up your comment section. Again thanks!

  65. One last thing – just some general questions if you don’t mind.

    I tried “stretching” a long time ago (had the bob stretching book in the 80’s) and have never found it helpful and I never gained much range of motion from it. Tried different types/methods of stretching too. Pretty much same result. I think you are right about flexion/toe touches – not helpful and probably makes back feel tighter etc. I’ve also wondered if it makes sense to try and “stretch” lets say the hamstrings if the reason they are tight in the first place is because the body is using this to help stabilize something – like a vertabrae or whatever etc.

    Later I read other books that suggested the secret to increasing range of motion is not stretching so much, but strengthening the muscle in a given range of motion. The idea being that the nervous system will not allow a range of motion if there is not strength in it since one could get hurt. That sort of makes sense to me.

    So lets say you want to do a lunge, but because of lack of range of motion in a muscle, lets say due to weakness in the muscle, it exerts a force on the spine that is irritating/painful. The way out of it possibly is to strengthen that muscle. If this is all true would the way forward be to try and gently strengthen it – going mildly into a lunge maybe with support, with the goal of not irritating the lumbar spine, and over time, as the muscles strengthen, you go more into it normally, and then you won’t have the pull effect on spine since it will have strengthened and perhaps lengthened due to strength increase. I don’t know if that makes sense. Not sure if I’m remembering all this correctly in terms of hip flexors etc.

    Also – do you think flip flops are bad to wear a lot? Using them as slippers at home for example where you may wear them hours a day?

    Thanks again.

    • I’m thinking the lunges might be a good exercise for you. They would strengthen the glutes a lot, but without the trunk inclination you would get from squats and RDLs. Not that squats and RDLs would necessarily be bad for you, but you would probably want to proceed with more caution on the latter. Spondylolisthesis has not been studied very well with the effects of exercise, but my patients with spondylolisthesis, depending on the degree, seem to do well with my basic program. Even the thought of standing with more of a posterior pelvic tilt is unproven with regards to lessening pain or anterior slippage. And the problem with the anterior pelvic tilt is even if it did lessen L5-S1 shear stress, it’s still flexing and increasing the risk of herniation at all the lumbar levels above L5-S1. I’d expect standing rows and presses to be well tolerated. EMS to the core and maybe EMS to the muscles that you have trouble hitting with exercise due to pain.

      Yeah Back Mechanic is new. I have a copy of it, thumbed through it and it looks good but I haven’t read it yet, so my recommendations on it are a little faith based thus far. The new edition of Low Back Disorders came out at the same time, plus I have several other books going… You get the idea, but I expect it’s good.

      As for the stretching, almost never have my patients stretch their spine. Stretching the hamstrings might be a good idea if they are really tight, but I do specific hamstring stretches only if they are tight. A 80-90 degree straight leg raise is considered “normal” but there was a study that found that people who had only a 60 degree straight leg raise were no more at risk for low back pain. The pro-hamstring-stretch theory is that if you have tight hamstrings/hips and you try and bend forward you will run out of range and thus flex/damage your low back. However, what seems to be the case is that the spine flexion happens more as a bad habit rather than subsequent to decreased hip/hamstring range of motion. Such that people with normal and even exceptional hamstring/hip ROM still flex their spines when they bend over. So that back pain is frequently more of a “motor control” issue than a “range of motion” issue, so that you want to retrain motor patterns so that you squat/bend over/deadlift through the hips keeping the spine neutral and thus better preserving your spine. If hamstrings are severely tight, they could be a factor however. That’s why I like RDLs so much, they teach the hip hinge, they strengthen the low back muscles isometrically, they recruit glutes and hamstrings and they fully stretch the hamstrings with every repetition.

      I’d expect flip flops to be just fine to wear, so long as your balance is good.

  66. Hi, Chad. Im wondering what experience you have had with patients recovering from lumbar disc replacement? I have a bulge at l5-s1 and have been out of work for a year now due to not being able to walk, sit, or stand for long periods of time. After exhausting conventional treatment methods, I been told by my nuerosurgen that Disk replacement and fusion are my only treatment options. I am reluctant to undergo surgery due to the risks associated. The Mckinsey method coupled with a priformis stretch, helps to alleviate my pain considerably but the effects only last for about 10-20 minutes. I understand the legality of you not being able to provide too much personal care online. You are incredibly intelligent and thorough, any information or insight you can provide will be cherished greatly.

    – Ray G.

    • Hi Ray,

      Thanks for the kind words. If all you have is a bulged disc, I’d be pretty hesitant to get surgery as well. I have rehabilitated a lot of fusions over the years but I think only one disc replacement years ago that as I recall went well enough, but with no long term follow up. A friend of mine got a disc replacement and he’s been really happy with the outcome but he’s otherwise exceptionally fit (he works as a fitness instructor). Plus, I gave him a lot of advice about motor control and exercise technique, all of which probably made his outcome better than average. Replacement is still a relatively new procedure and I know McGill expresses his skepticism of it saying he hadn’t seen a successful one yet. He states,

      “The artificial disc creates a axis of rotation that does not mimic the natural axis of the natural disc. This places more stress on the other two facet joints, so that, over time, they become arthritic and intolerant to motion.”

      Also, I would think that if all you have had for therapy is McKenzie method (I’ve found what constitutes McKenzie method in practice is highly variable) and piriformis stretches (which I don’t think help anything whatsoever) then I would say your treatment is ‘not ideal.’ Has anyone addressed the cause of your injury? No amount of therapy is going to help that disc if you are still flexing your spine during daily activities, which can generally be addressed with lumbar supports sitting (at desk, in car, watching TV…) and with good motor control with during dynamic activities like moving from sitting to standing, twisting and bending over and exercise to increase leg, hip and core endurance and strength. You have probably read above how effective EMS is for decreasing pain/increasing core strength/endurance. I have a sample exercise program on my main low back pain page. If you need more help than that I’m starting to do some work with Skype, so maybe call my office and we could work something out. Feel free to ask more questions here though.

  67. I am student of physical therapy and I just encountered this blog while studying for my advanced spine course midterm tomorrow. Reading your critical interpretation and application of the research (I especially appreciate your assessment of McKenzie and psuedo-McKenzie treatments) and responses to real life cases has been way more helpful than reviewing textbooks, notes and lectures. Im amazed that you provide this quality of advice and level of effort without expecting any sort of direct remuneration.
    On behalf of the patients and clinicians who get to read this, thank you!

    ps if you dont already, you should consider clinical mentorship or running some sort of CEC

    • Hi Nathan,

      Thanks for the encouragement. At some point teaching continuing education classes is what I would like to do, with some kind of question and answer format. Back/neck pain, tendinopathy, and applied EMS are the topics I would like to do thus far.

  68. Hey Chad,

    I just came across your post and want to thank you for taking the time to write it. I read the McKenzie book and was a little concerned – there is no miracle cure for anything in life. I believe every situation is different and deserves careful assessment. It seems you are doing that. Of course it is great that a book comes out that helps a large percentage of people but we should still be careful.

    Anyway, I am an avid runner (up to ultrarunning distances) and just recovering of a flare-up of my L4-L5-S1 bulges/herniations. Three years ago I picked up a gallon of milk after 30 years of sedentary computer lifestyle without exercise. What followed was maybe the most traumatic time in my life, it took so long to get better and PT didn’t really help. After a long time I went to a second PT and finally someone showed me core strength. 🙂 Four weeks later I went downhill skiing. Even later I climbed a 14000ft mountain on crampons and became a runner. The activity and exercise was my core because it got me core strength and mobility. Since then never any problems until a month or two ago when I hurt my back through a sneeze. It had been tight because I couldn’t run for a while due to a foot injury. The PT that I have this time is pretty incredible and showed me how to align myself, and that only after having seen it go the same direction over many sessions. I tried McKenzie on my own and I think it is too much extension. I think that I have a bit of a delicate balance – flexion is quite bad, but too much extension isn’t great either. Either way, I am back to easy running. I just can’t sit yet. I have very tense QLs but my hamstrings/glutes/other are quite taken care of by now. The QLs aren’t resolved yet even though I rub the marble-like trigger points all the time. Maybe I’ll try acupuncture. Cupping helped temporarily. I think something still pulls on the QLs such that they return to the tense state even after successful release. Maybe you have any advice, and if not, let me congratulate you on this page – how dedicated you are to everybody’s story here, and how great of you to question the techniques out there. A huge wave from Stanford, California (doing biomedical engineering research here.)! I’ll be back to full running soon – qualified for the Boston marathon!

    Happy New Year!!
    Simone

    • Hi Simone,

      Thanks for appreciating my blog! Some comments I have are:

      Core strength is important as you found out. However, I think as important is hip/leg strength. One of the counterintuitive findings in recent low back pain research is that people with strong core muscles are not less likely to have back pain. Apparently, what happens is that people with relatively strong cores and weaker hips/legs end up using their cores more, bending through their spines, which exercises those muscles, at the expense of their discs. So you want your core strength (and more so endurance) developed enough to maintain a neutral spine during activities, but you want your legs and hips strong enough that you can do the bulk of your lifting and get almost all of your motion through them, thus sparing your back from damaging motions. So rather than “core” strengthening, I think you want more “total body” strengthening, for which the core muscles are just a component. As a runner the leg strength should really help reduce the risk of leg and foot injuries and likely help absorb the impact of foot strike, thus reducing stress that travels up to the spine as well. I’ve done a series of blogs on running related injuries here, that you might appreciate.

      “Core mobility” is what you are actively trying to avoid. Not that all core motion is bad, and that you don’t want any, however if you have herniated discs, then the amount of core motion you have been getting is too much already, and the amount of core mobility you can tolerate going forward is going to be less than you could have pre-injury, because the discs are already damaged. Also in my experience, by avoiding core motion and stretches during exercise and activities of daily living, it lets the discs better heal. As they heal from the rest, pain decreases, and mobility starts to increase as you are no longer as limited by damaged/inflamed spine structures or spasmed muscles that are only spasming reflexively to get you to rest your spine and avoid further damaging stresses.

      I completely agree with you that Mckenzie stretches are too extension and that flexion is quite bad. Twisting is no picnic either. Sitting should be better tolerated if you have a good chair that fits you and keeps your spine neutral. Sitting generally hurts because poor lumbar support lets you pelvis rotate backwards causing prolonged spine flexion. If you sit at a computer for a living, then for chairs I love my Herman Miller Aeron. The Aeron is pricey, but a lot cheaper than back surgery.

      I would save my money on the acupuncture, and trying to rub out the trigger points. I think trigger points are a symptom of spine damage, not the cause. If you rest your discs, ligaments, and facet joint and strengthen the supporting muscles, the trigger points should go away with your back pain. Cupping I would expect to be no better or worse than acupuncture. It’s all theatrical placebo if you ask me, and scientifically should and could have zero effect on your spine structures. Placebo effects do seem to really affect endorphins, so they are not a complete waste, but decreasing pain without protecting the spine I would theoretically would accelerate spine degeneration, because it would make damaging stresses more tolerable. That’s why I REALLY like EMS for back pain. In my experience it decreases soft tissue pain better than any other modality and the way I do it, increases core strength at the same time. In fact I think EMS increases abdominal strength better than any real exercise. I find both the pain relief and muscle strengthening of EMS act synergistically to help my patients tolerate their regular exercises allowing them to both feel better and improve fitness faster. So trigger points are something I don’t pay any attention to other than to notice they are present and that it hopefully they go away with treatment.

      I hope that helps! Everyone’s story is interesting to me and answering these questions helps me clarify my thoughts on a number of subjects, so if you have any other questions or comments don’t hesitate to say!

  69. Hi Chad, I was an active 69 year old female with lots of energy until about 4 months ago. I have been to 2 Chiropractors 1st one said I have a disc problem, the 2nd one said I have SI joint locked. Then I went to a doctor and the MRI said: (Focal right subarticular disc protrusion at L5-S1 compresses the descending right S1 nerve root. Additional mild degenerative changes in the lumbar spine without significant foraminal narrowing or spinal canal stenosis.)
    My pain is to the extent that I can’t lay on my stomach or on my back or either side. I can’t stand or walk for more than 10 minutes. I live out in the sticks so there are no gyms for me to go to that would know how to help me. I write this with tears in my eyes because I feel my life is over. If there is any exercises that I could try at home that you think might help my suffering I will try to do them no matter how much they hurt. Just tell me how many times a day, how many reps and how many time a week. At this point I will try anything. I have a treadmill and 2 hand held weights, a stair stepper and that is it. The doctor didn’t even tell me what the MRI really means so if you know please help me understand that as well. You are the first blog I have ever written to, I write to you because I am at the end of the road, this is not living it is just suffering.

    • Hi Peggy,

      Think positive! 🙂 The MRI is saying that your first chiropractor was right, it was a disc problem, you have a herniated disc and disc material from the inside shot out back and right (like a squished jelly donut) and that material is compressing a nerve that goes down into your right leg. The good news is it sounds like you don’t have much arthritis so it’s not bone or a bone spur pinching your nerve. The other good news is that if you treat your back correctly your body should reabsorb that disc material so that it no longer pinches that nerve and your pain should lessen and hopefully go away.

      The bad news is that from afar I can only make guesses as to what exercises you can or should tolerate at this point in your recovery process. Sometimes when disc protrusion is fresh, everything hurts so much that even the good exercises increase pain. So I think what you want to think about right now, is what caused you to herniate L5-S1 in the first place. If you are 4 months post injury it should be starting to feel better, so since it’s still hurting real bad, you’re likely doing something that’s keeping it aggravated. With a posterior herniation, the cause is almost always some kind of spine flexion. Depending how active you are spine flexion could be caused by bending over and gardening, riding a bike with handle bars to far forward or too low, bending over a sink to wash dishes. Those would all be active forms of spine flexion, but passive and sustained spine flexion is bad too, which is what happens if you sit with poor lumbar support. What often happens is people have too much of both active and passive spine flexion. Then after the injury they know to stop the activities that cause active spine flexion, then increase their time resting but that’s more passive flexion so they still don’t get better. So if I were treating you in my office I’d be teaching you log rolls to get up and down from bed without tweaking your back, likely some very easy exercises to improve spine stabilization strength and some isolated leg and hip exercises that would increase strength without stressing your spine. All of that combined with EMS to your core to both decrease pain and increase core strength so that you can later transition into more multi-joint exercises (like sit to stands, RDLs and maybe lunges) which might cause more harm then good if you did them now. I still recommend McGill’s book Back Mechanic if you are trying to treat yourself at home, and on top of that I would add my favorite EMS machine, and here’s why. McGills’ material isn’t what I do, but I think it’s the best out there and my stuff is based overwhelmingly on his research findings. If you needed more help than that and nothing good is local, you could call or email my office and we could try and do some real time consulting with you over Skype. That’s very labor intensive on my part so McGill’s book is less expensive.

  70. Hey Chad,

    (and sorry Peggy to hijack your post, I feel with you. I felt like this too and IT WILL GET BETTER!!!)

    thank you so very much for your reply. I hope I don’t mess up the comments by writing again.

    I think you’re so right about acupuncture. It’s a topical relief much like a beer when you’re down. It did relieve my QL trigger point almost entirely, and nothing else had, but it came back after sleeping. That said my back felt amazing and the stiffest part of my body was now the legs!!

    I am not sure how much of my problem comes from discs since the MRI didn’t show new damage. I suppose one can reintroduce inflammation in these areas. It’s been 6 weeks, so I think it should be largely reduced. You’re so wise to attribute the muscle tension to trying to encapsulate the spine such that it can heal. I have a little EMS device, I use it about once a day, maybe I could even learn how to do it the right way, like you! 🙂

    I’ve noticed though that rest is not working so well for me, walking is really the best. I run once or twice a week too, do you think that’s a bad thing? It helps the muscles so much and above all the mind. In the original injury years ago the final thing that pulled me out of the injury was beginning to run and afterwards I only ever felt my back when I didn’t run for a week or so.

    Either way, I think I need to find a way to get back to work (sitting and standing) – I know you are so far away but I was wondering what you’d suggest – more PT? Or a chiropractor, or a person who knows about running? Or maybe an epidural after all? Probably just time but I don’t know how long this will take still. I looked at your chair, seems great! I’ll try to find it somewhere so I can test it.

    Thanks so much for answering to these things! It’s ok if these are too many questions.
    Have a lovely day!!
    Simone

    • Hi Simone, I think we can keep things straight. That’s funny what you said about acupuncture and beer. I think I’ll steal that quote.

      From what I understand, sometimes disc damage doesn’t show up on an MRI. So if you have some torn posterior annulus fibers allowing the disc to bulge, it may bulge only when your spine is flexed under load. But when you have an MRI you are usually lying flat with your spine neutral so the MRI would miss seeing the damage. It could also be strained or torn ligaments, or a fresh Schmorl’s node but the treatment is generally the same regardless. That being to find the stresses that are causing the damage to your back and lessen/eliminate them both when moving and when still, then gradually increase total body fitness so you have the strength and endurance to maintain good spine positions when under stress. It does sound like you are doing better so that’s great!

      About your EMS device maybe check out my blog on making EMS for strength, EMS for back pain, and my notes from the year I did EMS instead of strength training. I learned a lot by reading what the pros were doing and matching up the parameters and seeing how they worked on me. When I added it to McGill’s program I found I was really onto something for back pain.

      Regarding the rest, really think about how you are sitting. Sitting should not hurt the spine, so likely your spine isn’t staying neutral when you sit. Walking generally is good for the back, and often is better than rest because if you are standing up straight the spine is usually perfectly neutral. I’m typing this from my laptop, on a typical sofa with horrific lumbar support. But I just stuff a couple throw pillows behind my low back and I can relax as long as I would want to with 0.0 discomfort. It’s still better to get up and move though. It’s not so much that rest is good for you, but rather that if rest you are doing is causing pain then it’s not very good rest, so you would want to think about your back position when doing so.

      Regarding the running, I think as long as it’s not making your back worse while you do it, or soon after then it should be fine. I think running is great exercise overall, and I think you are right about it’s effects on the brain. I’m becoming of the opinion that aerobic exercise’s most important effects are on the brain, and strength training keeps your bones, joints, and muscles strong enough that you can keep doing cardio. For the most part, in running the spine is kept neutral, so it’s not inherently problematic. Core,hip and leg strength/endurance both help absorb shock and keep the spine from twisting and laterally bending when you run.

      If I were you I’d maybe try calling a local PT and ask what their philosophies are and if they are familiar and follow McGill’s type of back program. I really think it’s the only game in town worth doing, but it does take practice to get good motor control and you have to change a lot of habits, which isn’t easy. It does help to have someone watch you to tell you if you are doing something wrong, unfortunately, the odds are against you that you will find someone who knows what they are doing. So if it were me, I’d look into joining a gym and progressing into a total body strength training program 2-3 times per week. Research is becoming overwhelming that vertebral manipulation and manual therapy are “indistinguishable from placebo” (that’s a nice way of saying they don’t work) for both acute and chronic low back pain. I’d say the same is true for most physical therapists’ passive modalities, and half the time most therapists exercises are too easy to do much good either, or they have you stretch the spine which makes it worse. I hope that helps. And if you have any ideas of how to better help people from afar, I’d love to hear them. I’m working on a low back pain FAQ, which I hope will help.

  71. Chad, It is Peggy from the fly over country again. Thank you for your suggestions. A friend has the book “Low Back Disorders by Stuart McGill”. Will it have the same exercises I need as the “Back Mechanic” book? Tell me a little about the EMS machine you suggested like what to expect after using it, the Chiropractor put a (Isotron 1000 Plus Stimulator with wired pads) on my back but it didn’t seem to do much (I have a picture of it but don’t know if pictures will post). Is it like the machine you are talking about? Do you think walking on the Treadmill would help, I can walk for about 10 minutes on one which is so slow (like a snail). Yesterday I thought I saw a some improvement but when it got bed time oh my the pain came like you wouldn’t believe. No laying in any position would help, is this normal? Would you try some squats, if so how may times a day or week? Two months ago I tried the McKenzie stuff but resting on the elbows hurts. If you can think of a link to a video that I might try please send the link. What are the key points to tell if I am keeping my body in the neutral position while sitting, standing and laying.

    • Hi Peggy!

      I read the 2nd edition of Low Back Disorders and it was pretty great. The 3rd edition recently came out and I’m about halfway through. It does have a lot more material added into it. The exercise recommendations aren’t that different between the two, but if I were you and we’re going to take the time to read one I’d read the third edition. If you can can understand it, you’ll know more about back pain and rehab than most professionals. I just started reading Back Mechanic and it appears the exercise recommendations are pretty much the same. However, so far, I really do like the wording of Back Mechanic. I think it’s easier to understand as a laymen. Low Back Disorders might be overwhelming.

      I don’t have any first hand experience with the stimulator you mention but if it didn’t feel like much then either 1) the machine isn’t that great 2) it’s not programmed properly (or not like I would program it), 3) the electrodes are too small to allow you to tolerate the current necessary to have much impact, 4) their aren’t enough electrodes, 5) they are not placed in the right spot, and 6) it wasn’t turned up high enough. My guess is it’s some combination of all six factors.

      Walking on a treadmill is likely good for you but isn’t building back or hip stabilization strength, nor teaching you good spine/hip motor control. Squats are maybe too much too soon. I have my patients try squats after they have mastered some easier exercises like standing cable rows and presses. If doing a home exercise program, you might have to start with bird dogs, curl ups and side bridges. Usually I have my patients do their exercises once a day, 3 times a week if they are strengthening. Motor control type exercises can be done daily, but I generally make my programs both strength and motor control combined. It’s just hard to tell you how to do that without seeing you do them. I would not do prone extension on the elbows if it hurts. Key points I would say are to keep the chest out/shoulders back to help keep the spine neutral, but you also want to look at how much your hips are rotated in relation to the spine and you don’t want to go too far in any direction. Neutral is kind of “in the middle” neither in flexion or extension. It’s explained pretty well, with illustrations in Back Mechanic.

      It’s not normal that it hurts to lay in any position, you might not like your mattress (I like memory foam) and you may be twisting, flexing, or extending your spine as you assume or change position in bed. If your back is hurting before bed, then likely how you are sitting before bed is causing the problem. Almost all home furniture has poor lumbar support, but a couple throw pillows in the small of your back often does the trick. I’m trying to organize some of this into a back pain FAQ, and in doing so maybe I can add some videos to go along with it. Till then I have a number of exercise instruction videos on my youtube channel. I hope that helps.

  72. Chad you are right about the 2nd edition of Low Back Disorders. I just finished reading it and this old gal has no idea what it says. Now down to the good news I am getting around better, actually went to the grocery store, call me crazy but it was good to get out.
    What I have been doing since I talked to you is listed here:
    1.) 20 squats a day, holding a broom stick behind my shoulders to keep shoulders back.
    2.) I have 2 pieces of plywood, one in a chair at the eating table and one in the chair that I set in during the day. On each plywood I have a small piece of foam stapled to support my lower back arch. I sit up perfectly straight at all times. It doesn’t hurt to sit now thank goodness for that.
    3.) I have a small stair stepper, so I do 100 steps a day that is 50 for each leg. I couldn’t step up at all at first but now I can. I am getting the use of the right leg back.
    4.) I can ride in the car pretty good, no driving yet.
    I haven’t ask you about sleeping positions, should I be putting something around my waist to keep the spine in neutral position or not. What is this I read about the knees should always be together all night while sleeping. Sometimes I find myself with one knee bent and the other leg straight.
    I don’t bend forward at all if something falls in the floor I leave it there. I am scared to because of fear of going back to that awful pain. Is there a way you know of getting something off the floor and not cause damage?
    You mentioned motor control type exercise, give me a few examples of them. I am not up on all of this as you can tell. Well thanks again for all of your effort helping me.

    • Hey, great to hear you are doing better! Yeah, I think you might like Back Mechanic better Low Back Disorders.

      For sleeping I generally tell people not to worry about it much. In theory the roll around the waist might help you keep things more neutral at night but only if your waist is real narrow, however I have never felt it necessary nor advised anybody to do that. I do tell people I love my memory foam mattress though. I don’t think sleep positions matter much because your body is going to do what it wants to as soon as you fall asleep anyway. Google the “golfer’s pickup” as a way to lift light objects off the floor. I think there are pics of it in Back Mechanic, as well as other motor control examples.

      Motor control exercises are those in which you practice lifting, bending, or rotating in such a way as to keep your spine neutral throughout. McGill has several examples, but I don’t teach very many of them. That’s an area where we differ in approach. He’ll work motor control exercises by themselves, then go to endurance exercise, then strength if needed. I just start strength training right away, but with higher reps so I get endurance too and and I teach motor control through my strength exercises. So I’ll commonly (almost always) use standing cable rows, presses, squats, RDLs etc., starting very little or no weight and move up as tolerated. I hardly ever use the big three (curl ups, side bridges, and bird dogs) anymore, mostly because my EMS machines work so well thus letting me skip them. If you’re not doing EMS then you would probably want to work on the big three. I have examples video’s of all of that on my youtube page. Honestly, I never train abdominals anymore, EMS is just that much better. The other thing I do for motor control is have my patients pick up and load a lot of their weights, and I watch how they move habitually when doing so and I tell them when they are doing it right or if they are breaking form and putting damaging stresses through the spine.

      I’d really get that book if I were you. It has hundreds of pages of text to explain everything thoroughly and he already did that. 🙂

  73. Chad, I have attended all the mckenzie seminars, and recently I might add. I asked the same questions about what if the disc is too compromised or the annular wall is breached as their is evidence that a full herniated or sequestered disc will approximate. The old terminology for this is “Irreducible derangement” the new terminology is “mechanically unresponsive radiculopathy or MUR” They have 4 categories of classification: derangement, dysfunction, postural, and “other” MUR and Mechanically inconclusive , MI are in the other category.
    They recognize that some individuals are not going to respond to extension or flexion centralization, but they attempt the techniques to see if any relief can be achieved. If there is no relief with either direction, or with additional force progression techniques, they teach exactly what you mentioned. If the structure is that compromised, and no directional preference is indicated, and that centralization is not going to occur, then they teach the patient to protect with neutral spine.. attempting not to go either direction and modify their activity.

    But actually, evidence suggests that there are more individuals that respond than not. And in all transparency, Patient compliance is the absolute key. Out of 100%, their evidence suggests that only 30% of patients will actually be compliant with the treatment regimen. If compliancy is in place, results do happen and it is pretty neat to observe. I have seen it for myself as I have had chronic hip issues ( pretty severe if I might add) and it is working well for me. My hip is actually compromised so I have to maintain the regimen to manage my symptoms which would probably be surgery if I did not. Also, It has completely abolished my back issues. All I can say is for me, it has, and is working well. For my patients, I have seen improvements in only one treatment that decreased discomfort and increased ROM with people that have had issues for months to years. It is effective, but requires patient strict compliancy. And no, it is not fully effective for every person. Sometimes the damage is to severe. But McKenzie MDT method realizes this. It really is a good method I have found.

    • Hi Don,

      I’m not really sure what to do with this. According to their website taking all the McKenzie seminars leads comes to $3530. That’s a lot of money to pay for education on what amounts to circa 1980s techniques. I wish you would have just read his books for $140 and called it a day. Honestly, I really don’t get it. If you were going to get your knee replaced would you want your surgeon trained in techniques from the 1980s? While I’m sure there were great surgeons from that time that there is much to learn from, there has MUCH has been learned about back pain in DECADES since. If Robin McKenzie were alive and still practicing today, I really think he would have changed things considerably over the years. His basic theory wasn’t wrong, I just think his treatment protocol needs some fine tuning, (less extreme extension stretches, less extreme back rolls) some omissions (take out all flexion stretches) and some additions (real exercise to increase core, hip, and leg strength and endurance). I’d add EMS as well.

      Also, I really don’t like the terminology used about derangement, dysfunction, MUR, whatever. It’s not particularly descriptive of what one might deduce is really going on in the back. Mechanically unresponsive radiculopathy might just be a herniated disc, that the body will likely reabsorb in time being seemingly “unresponsive” only to seem “responsive” after macrophages lessen disc material in the vertebral canal. Yet, it would have nothing to do with how many prone extension stretches a person did. Also a person with a herniated disc might initially feel worse with extension, and ‘seemingly’ be better with some degree of flexion, leading a McKenzie proponent to prescribe flexion exercises. However, what we KNOW regarding spine flexion as the cause of disc bulges and herniations said stretches would in all probability make the disc herniation worse leading to problems down the road.

      McKenzie method has a lot of good ideas in it, but some ideas don’t seem to have held up over time. Regarding what you might suggest is helpful for a given patient, I’m not sure how to respond because I don’t know if you are talking about a technique in particular or the system as a whole. I don’t agree with spine flexion hardly ever or force progressions in any direction. Also, I don’t like that he basically ignores what I would describe as real exercises to increase core, hip and LE strength and endurance.

      I’m not against the idea that people with back pain will get better with McKenzie method. It’s just that after you factor out psychological issues (placebo effects) I don’t think they (and the above meta-analysis attests to this) get any much, if any better than they would have otherwise without McKenzie method, but probably some of that depends on which parts of his program are taught.

      Also I don’t think compliance is necessarily responsible for success or failure with McKenzie method as you state for at least two reasons. First, if you read any of the several patient reports above of people getting worse with their physical therapist prescribed McKenzie stretches there is good reason to think their stretches were in fact making them worse, yet the prescribing therapist could just blame their lack of progress as being secondary to non-compliance. Second, even in the case where a person might have a posterior disc bulge, where some amount of extension stretches have the potential to be helpful, McKenzie’s books describe him having his patients resume flexion stretches after pain is eliminated (to restore lost ROM) which I think would still promote posterior movement of the disc nucleus per McKenzie’s main (and correct) theory.

      I would be happy to hear from you if I am mistaken in any statements or assumptions above or if MDT therapy courses are now teaching differently than what McKenzie wrote in his books. If so, I think it would be best to talk about exactly what techniques are now regarded by McKenzie practitioners and taught by MDT. Also, I would encourage you to read above and find discussions I have had with other McKenzie practitioners already as I think it would save my having to retread as much old ground. A lot of what I just wrote sounds really familiar.

      BTW, what kind of hip issues do you have?

  74. Hello Chad, I am impressed with your diligence in keeping this stream live for so long. I have L5 sciatica with a L4/5 disc herniation and a tight canal. This cause spinal stenosis symptoms with claudication at 50m. and pain on standing. My family which is medical want me to go the surgery or epidural steroid route. I’m reluctant, I’ve lived with a crook back for 50 years (too much rugby, fractures L2&3). I recently had an MRI after 3 month’s delay hoping the symptoms would ease. This confirmed the 4/5 herniation with breach of the annulus and extrusion to the right. The disc height is better than 60%. My question is “will steroid therapy delay any immune reaction to extruded disc material?”. Seems to me the epidural is best reserved for pain control, which for me is a 4/10 problem.
    Thanks In anticipation,
    Bob.

    • Hi Bob,

      That’s a good question on whether a steroid injection would delay the body’s clean up of the disc material. I’ve never really thought about that with regards to a herniated disc in particular for in inflammation is cleaning up foreign matter, and the pain associated with it is keeping you from doing things that might cause further damage, anti-inflammatory medication might be anti-healatory. However, I’ve tried to look up that connection and I wasn’t able to find anything definitive either way.

      However, if I were you, I’d shy away from the epidural direction for a couple reasons at least. The first being that the FDA has started discouraging their use with the reason being they generally offer only minimal pain improvement in the short term, with little in the way of long term benefits. And safety reports showed that while negative side effects were very rare, they were very very terrible. Like they sometimes left you paralyzed and in a wheelchair terrible. Apparently the particulates of the steroid suspended in the solution if accidentally injected into an artery can cause an infarct of the spinal cord leaving you paralyzed from that point and below. Here’s a paper all about it, from a perspective that the FDA had gone too far, but I thought even from the pro-injection perspective it still sounded not worth it. Also, in the cases where I have seen epidurals work has been when pain is so severe (maybe 8-10/10) such that if you’re pain is only 4/10 the pain might not be inflammatory in nature enough for the epidural to have much effect. That’s a fairly limited observation however.

      Surgery would be a last resort. To paraphrase McGill put it, “surgery constitutes rolling the dice. There is no undo button.”

      I would think that if the stenosis resulting in your leg pain walking is from that disc fragment that it might be best to just ride it out, with evidence being that it might take 6 months for the bulk of the disc to be reabsorbed. I would also think you would want to avoid whatever it was (which is probably more than one thing) that caused it to herniate back to the right in the first place. Which is mostly likely some combination of repeated (bending over, going from sitting to standing and back) or sustain spine flexion (poor sitting posture), possibly with side bending or rotation to the left. So it’s still the same standard answer. Build strength, endurance, and skills in your ability to keep your spine neutral all day long. If you don’t do those things then it might be your body is reabsorbing the disc material, but you’re continuing to herniate more disc material out there due to poor back habits. And of course the standard caveats remain, being I’m not your therapist, so I can’t really tell you what you should do, rather I’m saying what I would probably do if I were you, in the situation described. I hope that helps.

  75. Thanks for your prompt reply. You’ve reinforced my prejudice. I’ll tough it out for a while.
    Since you seem to be so well versed in things disc. Do you know anything about perispinal etanercept? It seems to becoming popular. I gather it is a monoclonal antibody with interesting effects in the context of sciatica, said to block cytokines and cytokine receptors. Very expensive and not approved in most countries though FDA OK.
    Thanks again,
    Bob.

    • Bob, unfortunately I know almost nothing about perispinal etanercept. Doing a quick pubmed search leaves me skeptical. I wouldn’t say it doesn’t work but it sounds a little too good to be true for something that’s new, and when I did a pubmed search of the terms “perispinal etanercept” I got 23 references for which one guy “Tobinick E” was an author on almost all of them. And at the bottom of one of them it says he has a number of patents related to its use. Sciencebasedmedicine.org critiqued it, and him, as well. Plus there is always publication bias to keep in mind.

  76. Is there any research showing before/after MRIS of herniated discs reductions using Mckenzie’s method? Their claim that the disc will be pushed back little by little is very bold. I wonder if there is any proof out there.

  77. Wow! When do you get time to work?
    Thanks for the great reference. As they say “When it walks like a duck and quacks like a duck…”.

    • Hi Ralph,

      I don’t know so much if you should think of exercises healing lumbar discs. Good exercises increase strength and endurance so that you can move more about your hips and spare your spine such that your body can then, hopefully on its own heal it’s discs and reabsorb material. So in a way you are exercising so you can better rest the injured area. However, I would not be surprised if a certain amount of compressive and tensile stresses do help in disc healing, I just haven’t seen it demonstrated in the research yet. What we know of disc flexion/extension/rotation stretches is that seem to do more harm than good, or at least in the amounts we see in subjects with back pain already. So for example all lumbar flexion might not be harmful, and a certain amount is maybe useful, however if you have a posterior herniated disc the amount of flexion stress you are getting thus far has been too much.

      So about chin ups and pull ups. I don’t have a reference on hand, but I recall a paper which found that even though the body is hanging in traction, reflexive muscle contractions about the core are raised such that lumbar compressive stress is increased rather than decreased. That said I don’t recall those compressive stresses being harmful and I think pull ups and chin ups are both good exercises if you are strong enough to do them. I use machine lat pulls all the time in my back pain workouts as I think the lat strength does help stabilize the spine, and the exercise is usually well tolerated. I would caution that I generally have my patients stop any exercise if they have increasing back pain. Also I have my patients lock their spines in neutral to slight extension, and a bunch of kipping if the motion came at the level of the spine might be irritating.

  78. Hi Chad,

    I have 2 bulging discs, at my L4-5 and L5-S1, both from weightlifting from 2 years ago. I went to physical therapy just about 6 months ago, and all they had me do was strengthen my core with a bunch of exercises and do the yoga cobra pose every hour (the McKenzie stretch)? I’d say physical therapy got me 75% better, but up until then, I’ve been having sciatica on my left butt everyday for a week now. I’m fairly certain its from my L5-S1 disc bulge since the MRI showed “central bulging up to 5-6mm” and “the disc bulge abuts the central aspect of the S1 nerve roots. Thecal sac is fairly small by this level and relatively unaffected. Mild bilateral facet hypertrophy noted.”

    Have you any advice on what to do to cure my sciatica? Will I be able to squat with weights again? Please advise!

    • Hi James,

      Yeah, the yoga cobra sounds like the primary McKenzie stretch. I would think you probably can squat again. Almost all my patients eventually work back to squatting even if they never did them before. Maybe look up through the questions and comments above between Francis and I. We went back and forth for more than a year regarding low back pain and weight lifting, to include squats. I think that might fairly applicable to your situation. Then let me know if you have any additional questions.

  79. Thank you very much Chad, I’m learning a lot here. I have central stenosis in two levels (L4-L5, L5-S1) and no pain in my legs, only shocking like sensations from time to time but I have some mild problems in my urination (sometimes I have some retention), reduced anal tone and also weaker erections (70% from what it was). From what I’ve read online, when you have troubles with pelvic floor caused by stenosis from herniated discs, surgery is recommended and depending on the case it should be done as soon as possible. I already went to 6 doctors and 4 of them want to take the conservative route before surgery and 2 of them offered me a spinal fusion one through the back and the other one offered an anterior approach (ALIF). But none of them seemed to think my problem is urgent. My PT had some clients with similar problems like mine and they got better with time. Do you know any cases like that? Mild pelvic floor disturbances that didn’t required surgery and got better with PT?
    My MRI:
    https://image.ibb.co/mmhJkk/IM0015.jpg
    https://image.ibb.co/gE60y5/IM00081.jpg

    • Hi Ralph,

      That’s a well timed question. I had just been reading about cauda equina syndrome (which is what everyone is worried about if you are having pelvic floor issues with back pain) wondering if there was a link between milder cases and various pelvic floor issues. It’s a long story but I recently took my first pelvic floor case because of my interest in electric stimulation for which there is a fair amount of research on so I thought I could help from that angle. But it turned out that my new patient had both central obesity and chronic low back pain, both of which I thought might be related and worth treating along with what turned out to be overactive bladder syndrome.

      Regarding lumbar stenosis and cauda equina syndrome, there was not any research linking low back pain with milder pelvic floor issues that I could find. Logically I would expect that if severe stenosis can cause full on cauda equina syndrome, then milder stenosis could cause milder symptoms. There is research that the body can reabsorb extruded disc material so that you symptoms might abate in time, so that’s reason to be hopeful. I’d think your rehab would really want to be on point, and you would want to be very cautious about maintaining a neutral spine, both during exercises and ADLs as spine flexion might worsen the disc extrusions and spine extension might further pinch off nerve space. So it’s largely the same advice as with everyone else, you’re just a little more on the edge.

      Looking at your MRI your disc extrusions don’t appear near as bad as what I saw in the papers with full on cauda equina syndrome so if most of your surgeons feel that it’s safe to wait, that’s probably what I would do if it were me. However, I’m far from an expert at interpreting MRIs.
      As with back pain in general my approach would be to figure out what caused you to blow out those two discs in the first place. It’s almost assuredly some kind of repeated or prolonged spine flexion, and remove that stress from your life. Then in a pain free manner start working on core, hip and leg strength and endurance, learning to bend from your hips and not your spine, use appropriate sized lumbar supports when sitting, stretch the hamstrings if tight, EMS the core, yadda yadda yadda is all what I would do.

      I’m doing a lot of reading now on central obesity causing/accelerating degenerative disc disease and systemic inflammation/high cholesterol and blood glucose all seems really relevant to pelvic floor muscle/nerve issues as well, so if any of that’s an issue it would probably be worth looking at diet as well as exercise. I hope that helps, and I’m curious how things turn out so if you have more questions or comments let me know.

  80. Hi Chad,

    I’ve finished reading your conversation with Francis and it was quite informative. Thank you for that. However, whenever I have sciatica on my left butt, I do “clams” while lying on my side and raise my left leg hip flexors. When I do these, I can feel a pinch from where the sciatica is coming from, but after I finish doing them and walk around, the symptoms are 90% more relieved. Should I be doing these for relief? Does it damage the disk somehow? Also, sometimes I will have sciatica and other times I will have radiating pain on my left calf and the area below it. Any idea why I’m showing different symptoms at different times?

    I also do McKenzie press ups (as prescribed by my pt) for 10 reps every hour and sometimes it will feel fine for my back. At other times, I can feel a pinch in my back/butt area (I’m guessing its the disc at the L5-S1 area), and I will show symptoms of the sciatica or calf pain. Should I still be doing these McKenzie press ups, even though it sometimes causes me pain? My own answer is no, but I’ve heard the press ups are supposed to get the discs back into its original place, so maybe these symptoms are normal (its supposed to hurt before it gets better)?

    • James,

      You know, maybe read my more recent blog about sacroiliac (SI) joint/region pain maybe being tendinopathy and see if that sounds at all like you. Tendinopathy “warms up” and feels better with exercise. So clams might be warming up what might be some kind of proximal gluteal tendinopathy right where it attaches at the SI joint. A bunch of back extensor muscle tendons attach there too.

      I’m won’t you not to listen to your physical therapist, however if I had your back, I personally would not be doing end range extension stretches. In fact if I any kind of back pain or even a normal back, the floppy pushup is not something I would put into my program. Nor is it something I put in the programs of any of my patients. Reasons it might be causing you pain is that you already have a disc bulge pinching on your L5-S1. There is some reason to think *mild prolonged” extension might be helpful and sometimes I use it, with a little more information here. However, end range repeated extension I avoid. You said you already have facet joint issues, google up what the facet joints are and then think about what hourly end range extension stretches might be doing to them. Ten impacts on the hour? I’m of the opinion (in agreement with McGill) that training through increasing low back pain only makes things worse, or at best slows the natural recovery. When you say your back has improved some with McKenzie stretches, I would say it’s likely that it would have improved at least as much without them, which is what the meta analysis this blog refers to suggest is the case, in addition to this study.

      • Hi Natasha, I’m sorry you’re disturbed.

        Perhaps read further into the comments as you are not the first McKenzie advocate to take offense. I think I have addressed all your issues already. McKenzie himself would probably not treat based on MRI results because the MRI machine wasn’t widely available until after McKenzie came up with his diagnosis and treatment. However, MRIs can and do show disc pathologies that McKenzie hoped in theory to be treating with his various techniques. For the record, I rarely treat per MRI results either, but I always take a look at them if available. Also if given I feel I can comment reasonably on what stresses I expect to be more helpful or more harmful given a particular MRI result.

        McKenzie used the words “slide glide” which is effectively the same as a side bend as illustrated on page 407 of his book “The Lumbar Spine Mechanical Diagnosis and Treatment” so tomato tomato’. All semantics are trivial when you consider the above meta-analysis for which this blog is dedicated, finding that McKenzie method to be no more effective than giving people a pamphlet and advice to stay active. As I said above, I’m not going to take any courses on outdated techniques, I read all of McKenzie’s books on low back pain cover to cover. I know his method, to include evaluation just fine. It just so happens I disagree with much of it, to include his evaluation and back pain classifications. I even blogged on research findings indicating his evaluation techniques aren’t so great either, regardless of how much training McKenzie advocates had.

        Perhaps read through other physical therapists’ comments above and if you think I have missed something let me know. Maybe read the latest edition of McGill’s Low Back Disorders, which has discussions about McKenzie method. Or if you don’t want to spend any money, at least read through the papers to which the rest of my low back pain blogs are referencing, however I highly recommend McGill’s books, which are a hell of a lot cheaper than taking courses.

        Also above you can read examples of McKenzie therapists causing pain to the spines of a number of patients. I don’t think those patients are lying. You’ll see a lot of those same people coming back and saying my blog was a service to them.

        As for your comments on electric stimulation, I appreciate your skepticism. However, even here I think you are out of date. I used to think TENS was placebo at best, with early studies not showing consistent benefit over sham treatments. However, a lot has been learned since then to make electric stimulation better. In fact try a pubmed search to see there are literally thousands of studies showing all kinds of beneficial effects of electrical stimulation. What seems to have been the case was that older research with poor controls let people underdose their TENS with insufficient pad placement, and insufficient electrical stimulation intensity, such that there wasn’t much of a treatment effect. A later analysis found that in studies where the TENS was applied directly over the site of pain, and turned the intensity up from “whatever the patient wants” to the “strongest comfortable current” there were consistent pain reducing effects above that of placebo. Not to mention that I don’t even advocate TENS for back pain. Anyways I much prefer EMS because research tells me that EMS decreases pain better than TENS, probably because the dose of electric current is not just the “strongest comfortable” but rather the “highest tolerable” current and as a ‘side effect’ you are not only decreasing pain but strengthening and increasing endurance of core musculature, for which MY real world experience agrees with. Unfortunately, although I learned about electric stimulation in physical therapy school, I didn’t learn how to make it effective. I’m happy to share as much of that as I can with you, per my blog category on electric stimulation.

        I wish you were local to Phoenix because I’m sure that if I gave you a core workout with a properly programmed Globus Genesy 300, and large carbonized rubber electrodes (instead of small sticky ones) I’m sure you would agree with me instantly. It does not require any faith, just direct experience. In fact, if you are willing to cover shipping and leave a deposit, I’ll ship you one of my machines pre-programmed and decked out with the best pads and straps to try for yourself for a week. And I’ll do a free Skype session with you, showing how I use it. Just be willing to leave your honest comments on how you thought it worked.

        Also, regarding selling those machines, I was only able to get the results I do when I combined the machines capable of being programmed as I thought best, combined with the large carbonized rubber electrodes, which the above cited research, and my own experience, found to be markedly superior. So I would have to tell my patients to go to one website to buy a machine, another website to buy electrodes, and nobody made elastic straps that I liked. Thus I had to send my patients to a third website, ebay, to get what I thought were still junky straps. Do you know how many patients were willing to go through all that hassle to get good results with home EMS? Almost none. To get good straps at all (that firmly and fully hold the larger pads against the skin on a wide variety of muscle groups) I had to have them custom made. To get any kind of price break I had to order my straps 1000 at at time. Also by buying in bulk I was able to get a deal on electrodes, and machines too, lessening the price for my patients. I thought it would help the most people (and allow enough profit to cover what has been considerable effort) if I made a package of what I think are the best machines, with the best programs, electrodes, and straps available online. So that’s why I sell electric stimulation machines.

        Cheers.

  81. Wow, I don’t know how I stumbled on your page, but I am disturbed.

    Your comment to an above patient based upon MRI results: ” So while McKenzie method is usually associated with extension exercises, in your case a trained McKenzie therapist would likely have you do a number of spine stretches in flexion (forward bending) and side bending right, in order to open up your left foramen. That’s according to the theory at least. ” —- do you even know what you are talking about? That is not at all how a Mckenzie therapist does an assessment. If you truly understood the method, than you would know that a Mckenzie trained therapist would never perform a treatment based on MRI results. I suggest you take a course to truly grasp the entire method rather than telling patients on your blog that you “get it because you read a few books.” And Mckenzie therapists do not do “side bends” either if you truly understood the method.

    As a licensed physical therapist and one who has taken numerous Mckenzie courses in addition to other physical therapy courses (so as to let you know I am not only following one school of thought, or part of the Mckenzie cult; I am open to a variety of treatment strategies), your blog exists as a huge disservice to many patients.

    And since you tout yourself as an “evidence based” therapist– why are you selling e-stim machines on your website which lacks evidence for effective use as treatment?

  82. Thanks for your blog, good stuff. I too am disillusioned with the McKenzie Method. I have a bulging disc with symptoms of sciatica that seems to have been going on for a few years. It seems that perhaps the McKenzie Method would be useful for those who have extremely sturdy joints (particularly sturdy facet joints). I personally have experienced increased sciatica symptoms when doing extreme back extension exercises as proposed by McKenzie. Back flexion is also irritating. I don’t think extreme back extension exercises work for me, although I’m not going to say it wouldn’t work for anyone. I have hypermobile joints that are injured/irritated easily. I have been doing pilates for the past year with fairly good results, increased function/strength/flexibility and decreased pain. However, I am open to other programs that encourage increased strength in safe neutral positions that avoid extreme extension/flexion. Do you recommend any books, methods or exercise gurus who promote overall strength and stability? While I have seen improvements in overall function with my pilates program, I still have had to give up so many of the activities I used to love since my back injury 2 years ago. I even get numbness when turning a grocery cart to the right or the left and I’m 34! Any suggestions you have would be greatly appreciated.

    • Hi David, Sorry for getting back to you late, but I’ve been doing a lot of study working to come up with a home exercise based back pain treatment that incorporates all of what I like from my weights based program. I don’t think extremes of range of motion in any direction are ideal for back pain regardless of cause. I’d be real cautious with Pilates as well. Unfortunately, with Pilates it’s hard to know what you are doing/getting as there are the exercises he taught in his books, and then there is what everyone has come up with since, and taught as “Pilates” exercises, that may be better or worse, but often have nothing to do with him. Regarding what Pilates himself taught, for the most part I would avoid that too. He does some back and abdominal strengthening, but his stuff has as almost as much extension as McKenzie, combined with a lot more compression as it’s active extension, plus his exercises have a tone of spine flexion that I wouldn’t think would do your bulging disc any good at all. All the exercise he taught with the posterior pelvic tilt, as you try and press your low back flat to the floor? That’s lumbar flexion.

      The books I would recommend are Stuart McGill’s, that I’m sure I have linked up above. Back Mechanic, Low Back Disorders, and Ultimate Back Fitness & Performance are all great. I incorporate all his principles into my weights routines. Also look above to see what I wrote about my use of EMS with back pain. I can’t say enough about how much that helps, but it’s all based on the combination of machines, electrodes, straps and programs I have incorporated. If you are just 34 and your MRI indicates you just have a bulging disc, there is no reason why you shouldn’t have a full recovery if you do everything right.

  83. Hello Chad,

    I’m thrilled to have found your blog and this discussion. I arrived here by looking for some intersection between the work of Stuart McGill and information about the McKenzie method as I began researching physical therapy clinics in my area. I was hoping I could find a local PT who either knows McGill’s work or uses methods in alignment with with his findings. The one that seemed most promising based on its website (thorough, individualized assessment process; emphasis on active therapies, etc.) mentioned McKenzie certifications a lot, which I hadn’t heard of.

    I have had annoying lower back pain for a few years now — since becoming a mom — and it has been getting worse in the last several weeks despite what I’ve been learning about how the spine works. (I devoured McGill’s books Back Mechanic and Ultimate Back Fitness and Performance (6th ed) in January.) A medically-trained friend suggested seeing a doctor just to rule out weird stuff like cancer. I haven’t gotten an appointment yet, but I’m preparing for the expected prescription for physical therapy by figuring out if there’s anyone around here I would trust with my back.

    I feel like my saga has a few things that make it different from others I’ve read about. It seems like shear forces have a particularly bad effect on me and I can’t find much to read that addresses that, so I wonder if you have any insight on anything I need to avoid (besides the obvious “anything that hurts”) or focus on as I move forward on my own with following McGill’s exercise recommendations (and yours, now that I’ve seen your LBP routine video).

    I’m trying to take this thing from gargantuan down to just huge so maybe a list format.

    Timeline:

    (1) I’m in my late 30s. I play semi-competitive soccer on a weekly basis. I’ve played my whole life, with a hiatus for a few years of pregnancy/newborns.
    (2) Had baby #1 five years ago. Sat on the couch a lot nursing. Lowered baby into crib a lot. Picked up a lot of toys. Picked up the baby a lot. Wore the baby in a front carrier a lot. I recall having some mild lower back ache that came and went, and it seemed like something that happens to everybody so I didn’t do much about it. Had baby #2 two years ago.
    (3) Started playing soccer again when #2 was a few months old. It was rough getting back in shape, but it didn’t bother my back. Since then I’ve been getting in better and better condition and frequently play whole games with no subs.
    (4) Joined a CrossFit gym January last year and stayed for about 6 months. I enjoyed it, and I became interested in barbell weightlifting. I can remember, though, that some things made my lower back feel especially “tired” or “sore.” In particular, heavy kettlebell swings. Let me emphasize that this gym’s coaches were patient instructors who were adamant about proper form for weightlifting and would insist on perfect form before increasing weight. I learned the importance of neutral spine position in this context. Toward the end of my time there, I was participating in a barbell lifting series that resembled what my husband was doing at his gym (StrongLifts 5×5).
    (5) Had to switch from CrossFit to the Y solely because of childcare. I continued doing barbell lifting using SL 5×5 alongside my husband. We checked each other’s form constantly, making small tweaks, watching videos, being as smart as we could.
    (6) My lower back would frequently feel “tired” or “achey” despite the level of care with which I did my back squats, deadlifts and barbell rows. Each of these three seemed to cause the same feeling. I reduced my weights on these in the late fall to see if I could get to a point where the ache went away completely. I remember bending over and touching my toes to stretch sometimes between sets because that seemed to provide relief and I didn’t know any better at the time.
    (7) One day in December, I had a sudden, distinct, but not very severe pain when lowering my third (100lb) deadlift rep, just before it reached the floor. If I broke out of neutral at all, I couldn’t tell. I was certainly trying to maintain neutral and it wasn’t a terribly heavy lift. As I got up and walked around, and later at home, the pain got a lot worse.
    (8) I recovered pretty quickly from the acute incident and cautiously returned to lifting with some changes. I read Starting Strength which had been on my list, and switched to low bar squats, working my way back up from the unloaded bar. I eliminated deadlifts and switched to dumbbell rows.
    (9) I found out about Stuart McGill in January, read his books, and have been doing my best to practice good spine hygiene from then on. I must admit that I haven’t been consistent with the Big 3 and related exercises, in part because soccer games and treadmill interval run/walks, along with some continued lifting kept me pretty busy all spring.
    (10) The mild lower back ache kept happening, and I suspected squats were still contributing, so I drifted away from them a few months ago.
    (11) Soccer never seemed to contribute to my back pain; I never felt any during a game or afterward that was notable. Until the last few games I played. Two games ago, I took ibuprofen beforehand so I’d feel okay during, but I seemed to pay for it in the days after. The last game I played, I did not take anything, and felt okay during, though I could tell it was taxing when I made sudden sprints and stops. Immediately afterward, I was in pretty bad pain. Everything except lying down in bed hurt. This lasted a day or two. This was when it was suggested I see a doctor.
    (12) That game was a couple of weeks ago and I seem to be back to my “normal” annoying daily level of back ache/fatigue, but I’m getting used to the idea that I may have to quit soccer while I address this.

    The pain:

    (1) It goes away when I’m in the right positions (walking, standing upright, lying down); it’s felt in response to specific movements or activities.
    (2) There is never pain shooting into any other parts like butt, legs, hips.
    (3) It’s centered/spread evenly across the lumbar area, not on one side or the other.
    (4) It’s triggered most by leaning forward, even though I don’t allow flexion. Sometimes if I lean forward only slightly from a standing upright posture, bearing no weight. The more I lean the more the weight of my own torso feels like too much for the lumbar spine to support. I can bend over to pick up a toy pain-free if I get into a wide squat stance and really focus on keeping neutral curvature and staying tight. I just tried mimicking your RDL exercise movement with no weight and I was able to do it pain free, but I think I have to maintain an absolutely pristine movement pattern.
    (5) Sitting for a couple of hours (e.g. to write this ridiculous comment) in an Aeron chair with the lumbar attachment will still cause it to ache. Walking around relieves it.
    (6) When I did the self-assessment in Back Mechanic, I didn’t fit easily into one of the common pain types. Flexion actually didn’t bother me much, but I have been avoiding it anyway on principle. “Exercise-specific” seemed closest.

    Is it possible that although the squats seemed to make my back tired or achey, I also received some protective stability that balanced out whatever was actually manifesting as an ache? If I were to try doing squats again, how do I know how heavy to go? What kind of rep scheme would you recommend?

    Thanks so much for what you’re doing with this blog. I’ve never conversed with another human being who knows who McGill is and it’s really exciting, sorry.

    • Hi Allison,

      Wow, that’s quite a story and you have done your homework! A physical therapist trumpeting their McKenzie certification is a red flag for me. It’s like saying “hey we use circa 1980s techniques” and it almost a given you are going to do a floppy pushup. From afar (so this is very imperfect) I’m wondering if you aren’t overdoing it. With my program, with weights at least, I have people do 3 sets of 15 reps, maybe adding another warm up set for squats and RDLs if they are working up to heavier weights (more than ~135 lb). I keep intensity relatively low by only doing one hard set of each exercise and not advancing unless they can get 15 perfect reps, with no increase in back pain either before or after the workout. You’re back being achy at other times during the day just doesn’t sound acceptable, so there must be sometime that you are injuring it, or every time you feel better you start lifting too hard too fast.

      For the most part I like Crossfit, though I’m not crazy about any kettlebell lifts and I don’t like plyometrics at all. I think Crossfit is good if all your parts are healthy, but if you have a bulged or herniated disc in your low back it just might be too much. Same with 5×5 training. I’ve had a number of low back pain patients get seemingly 100% recovered in my office, then when they returned to heavier training with less reps, the pain came back. So I told them maybe they aren’t meant to train that heavy anymore. Deadlifts from the floor might be a bit much, particularly with light weights where the bar lower to the floor. Such that even if you are staying neutral you will have to crank real hard with your spine extensors and that might be enough to increase pain in a compression sensitive back. If you lost neutral in the process, well there you go.

      My thinking is that a little bit of fitness done pain free and forever, is better than hard till you have to stop when you are injured, and then almost always being injured.

      That said you’re spine could also be a little compression intolerant. Perhaps having some end plate damage. It’s not something I would get an MRI for, but I know people who even with perfect technique can’t go that heavy on squats or deadlifts, so I either just keep them lighter or use other exercises.

      Definitely, I would encourage you to read about my use of EMS to the core with people with low back pain. It’s no joke. The lady in my video is doing it at the end and you can see her straining. I think it makes my program at least 100% better. It trains your abdominals harder than any exercise and with the spine kept neutral, and it hits the paraspinals pretty hard, not as hard as deadlifts but without as much compression. The Genesy 300 I sell in my shop is the bomb for chronic low back pain, if and only if, combined with all the exercise principles and spine hygiene talked about above.

      The Herman Miller Aeron chair is my favorite, but you have to adjust and use it correctly. It’s no good if you don’t have you hips all the way to the back so that the lumbar support, supports your spine in neutral. The tension should allow you to lean back with minimal effort (which should decrease spine compression) but the chair should come forward with you, so it still supports you if want to sit up and type. I thought my Aeron chair gave me too much lordosis with the thicker setting, but not enough with the support flipped around, so I keep mine on the lesser support side and added two layer of cardboard and it feels perfect. I think a good lumbar support should not be felt.

      If the squats are hurting, and making you feel worse then either you are losing neutral, perhaps trying to squat too deep, or you are training too heavy. I don’t introduce squats into my low back program until people can do standing rows, and presses without pain, and usually the hip out/hip in machine, and I will almost always have done EMS on them to start really increasing core strength and decreasing pain sensitivity first.

      Otherwise it sounds like you are doing everything correctly. It’s very cool to see someone who is making the effort to familiarize themselves with McGill’s work too. Feel free to ask follow up questions.

  84. Yeah. Agreed; in retrospect it’s getting easier and easier to see that I overdid it, and I’m not built for heavier lifting. How I wish I had found those books earlier, and respected the messages my back was trying to send me. I am thinking hard about this EMS thing. I’m trying to find out if there are local PTs who offer it as I continue to research those.

    Forgive me for another long post, but in the last several days, the pain has changed and gotten worse, which puzzles me to say the least. I haven’t played any more soccer. I did do the McGill Big 3 routine last week, along with walking with incline on a treadmill and doing a couple of cautious sets of goblet squats with just a 20lb kettlebell, none of which caused discomfort. That stuff was last Wednesday; I felt pretty good that day which is why I tried to be a little more active. Saturday, I rode in the car for a few hours, which perhaps didn’t quite have enough lumbar support, but I didn’t feel any particular discomfort with that either. But Sunday and today have suddenly been more painful, seemingly out of nowhere.

    Now, sitting upright hurts most of the time. Standing in a normal posture hurts most of the time. Leaning back a little bit hurts more. Walking around provided some relief yesterday, but not today. Today there is asymmetry going on. Leaning to the right hurts. Not to the left. So I’m walking around with my hip sticking out to the right a little. It hurt quite a bit when I lifted the milk out of the fridge with my left hand.

    Any idea what might have happened? The little 20lb front squat? It’s so weird. Maybe I’m still in denial about this. Given what you wrote above though, I promise not to do squats of any kind until I tolerate the other kinds of exercises you mentioned.

    On compression intolerance: I forgot to include that the pain flares when I sneeze/cough; is that compression? On that note, now, when I pull up on the bottom of a chair re: McGill’s self-test, I do indeed feel it. That wasn’t the case when I first went through that book, so I probably need to retake that whole thing.

    I can lie down to completely rest it without pain, so I’m trying to do that. But it seems like the pain these last couple days is just as bad first thing in the morning after I’ve rested it all night.

    I still intend to see a primary care doctor to filter out the most sinister possible causes. I’m not exactly hopeful that I will find a PT clinic I can completely trust not to make things worse. Maybe one where they would be willing to discuss and accommodate my “preferences.” But I feel like I’d still be better off following McGill’s and/or your approach on my own, assuming I can get to a place where I’m not feeling pain like today. Have you ever heard of insurance helping with the cost of the EMS device?

    Thanks again.

    • It sounds to me like you’re still overdoing it. By trying to “make” make your back get better, you are not “letting” it get better. I definitely would NOT do anymore self tests. Tests just aggravate you, the solution is probably already known. You probably need to stay neutral, rest more and GRADUALLY build back fitness. If you feel at all worse after something then you overdid it. Going forward your exercises will tell you where you are. Retesting is just reaggravating in my opinion.

      The goblet squats might have been too heavy. I always start my patients off with zero pounds on squats and not until they have done other exercises, standing rows and presses, hip outs and hip ins. The big three I don’t usually go to until after a visit or two. Actually, I’ve been moving away from doing the big three routinely because the EMS just works better. However, the big three are great for home exercise if you don’t have EMS.

      The drive, unless your back was perfectly supported could easily be what hurt you. When driving, and sitting in general, your back should be perfectly neutral. Almost everyone, if a driver, has their seat too far back, and too reclined so that they have to flex forward to reach the steering wheel. The goblet squats could have been too heavy, or you could have gone too low and flexed your spine. The sneeze could be either compression or flexion.

      Unfortunately insurance doesn’t cover the EMS machines. Probably your local physical therapist wouldn’t have one with the right power, settings, or electrodes. Ideal use of EMS took me almost as much work as getting good at treating low back pain. It sure helps though. Here’s my notes where I did EMS instead of weights for a year. I think I mention in there where I first started using it for patients with back pain.

  85. Hi Chad,

    Thank you for going over the mechanism of mckenzie exercises so well. Based on my last MRI lumbar spine I have L4-L5 posterior central disc herniation with caudal migration compressing the thecal sac at the L5 nerve root and mild narrowing of the canal and the foramina. At the L3- L4 level disc protusion impinging on the ganglion at the nerve root laterally.

    Symptoms wise, I have left lower back pain and left lateral calf pain which makes me limp a lot. My pain is sometimes so unbearable that I cannot walk. I like to keep my left leg elevated to help with the pain when I sleep. I even got steroid injections, but it was of not much help. I have been doing PT and mckenzie exercises for the past 1 month now, but it has been of little help. I do both mckenzie extension and flexion. While flexion makes my pain moderately better, extension makes it worse. My PT believes that I should continue the extension and some day my pain would “centralize” and my leg pain would get better. My question is given my MRI findings should I be doing mckenzie extension at all or only do flexion exercises?

    • Hi Ankur,

      If it were me, I wouldn’t do flexion or extension stretching/exercises. Rather I would be working on keeping my spine neutral (all day long) while improving overall fitness. Extension, combined with your disc protrusion, is perhaps pinching/irritating your L5 nerve root, which is why you don’t like it. Flexion might remove that pressure in the near term and feel better, but flexion is what causes and worsens disc protrusions in the first place, so I would avoid that too. That’s likely why on balance, McKenzie method wasn’t found to work any better than advice to “stay active” as per the above meta-analysis. The good news is that if you treat your back right pain should centralize without any stretching. I would encourage you to read above all the a questions and answers to people in very similar situations to you and feel free to ask if you have any other questions.

  86. Thanks Chad, really helpful info.

    I’m 32 years old, in relatively good shape. However, I’ve had years of bad posture(a lot of sitting). Last Friday evening, I felt something snap when I was changing my trouser and lifted my leg. Next few days were horrible, I could walk, but with a lot of pain. I had sciatica pain down by both legs(it would sometimes alternate), no numbness or footdrop. I took NSAID for 3 days and the major part of pain subsided. I do still have constant pain, it’s very mild, sitting long obviously makes it worse. No sciatica now.

    I went for a lumbar MRI and the scan showed broad central disk bulges at L4-L5 and L5-S1 causing mild impression on the thecal sac. Also a muscle spasm which was straightning my lumbar region.

    Do you think I should follow McKenzie or Williams’s protocol or just staying active would help alleviate symptoms ? I used to follow a bodyweight fitness program before this incident, that included pushups, pullups, dips, rows and core exercises, no flexion or extension involved. I got a really conflicting opinion from a doctor, who told me to complete bed rest for 10 days.

    • Hi Hassan, I like your idea of staying active. Doing a fitness program (bodyweight or not) with “no flexion or extension involved” sounds almost perfect. I would avoid all spine flexion for sure (people stretch plenty into flexion daily anyway. Mild extension, prone propped on elbows at most, for maybe 15 minutes might be worth trying, but only if it feels good. You still need to think about what caused your disc bulges in the first place though. Perhaps a lot of flexion through the spine with activity at work, or abdominal training, or slouching at a computer, being flexed for long periods driving, or in sofa with poor lumbar support (which I think is all of them).

      Bedrest is really old school. I recall McGill citing research that if you stay in bed overnight your disc rehydrate to normal, if you stay in bed longer they overhydrate, making them more at risk for injury. In Waddell’s book “Back Pain Revolution” he pretty much describes bedrest as the bane of back pain recovery and I think he was right. It used to be the standard, but was never based on any research that I have ever seen. So if your doctor has any, ask him to please share. Most doctors are swamped by paperwork and red tape, it really impedes their ability to stay up on newer findings.

      The only other thing I would think to say right now is that I just read a few papers that found abdominal “central obesity” in particular makes discs break down at an accelerated rate, either due to inflammatory cytokines damaging the discs or cholesterol clogging up the blood vessels that feed those discs the same way the clog up the vessels that feed your heart. If you’re doing bodyweight exercises then that’s probably not an issue. It’s enough of an issue that I’m starting to talk about intermittent fasting for back pain in my office. I’ve been wanting to blog about that paper but I’ve been neglecting my blog because I’ve been working hard on another project, which you just made me think about since you mention bodyweight exercise. Actually, I’m thinking about it every day anyway, haha. I’m working on what I think is the best equipmentless, home based exercise program for back and neck pain because I know my weights based routine doesn’t translate best for people without gym access. The routine is pretty much finished and so far it’s working great in my office. Now I’m trying to figure out how to best explain and distribute it. I’ll add notifications here for sure.

      I hope that helps, and let me know if you have any other questions.

  87. Hi Chad,

    I am a therapist that works in a protocol driven evidence based outpatient physical therapy clinic in Michigan that specializes in back and neck rehabilitation. We use McKenzie to assess and treat our patients along with Lumbar and Cervical MedX machines to strengthen and neuromuscular therapy to treat tissue damage. We do research (for almost 30 years now) and track outcomes through out the year. We have an 85% positive outcome rating where most of our patients have already had traditional therapy elsewhere as well as other interventions up to and including surgery that has failed. So our 85% outcome rating is with some of the most difficult spinal pathologies. I see McKenzie work before my eyes every day in a way that not only helps reduce and/or abolish symptoms and increase function and quality of life but also show a patient how to treat themselves so they can stay out of the medical revolving door. There are over 100 research studies that support McKenzie. Why don’t you consider taking the McKenzie courses? Change your patients life 🙂

    • Hi Allen, I think it’s interesting that we both think we are doing “evidence based” therapy yet have such different views on McKenzie. Maybe they aren’t that different. I do think a lot of what McKenzie taught was very insightful and turned out correct. It’s just that as a whole system, it’s turned out less than exceptional, as found in the above meta-analysis. I would encourage you to maybe press “command f” or “control f” on the words “physical therapist” to find the physical therapists that have responded to my blog much the same as you, and we sometimes had long dialog. If there is anything you think I missed, bring it up and I would be happy to talk about it. It might also interest you to read the stories of all the patients who wrote in saying they were made worse doing McKenzie method.

      I’m a little concerned about your use of MedX exercise machines to strengthen the core. They do so by locking the pelvis in place and isolating resistive spine flexion and extension, correct? Are you aware that doing so almost perfectly reproduces the combined flexion and compression stresses that cause disc herniations? Wouldn’t it maybe be safer strengthen the core isometrically and teach people to get motion when lifting more about their hips?

      I have said several times above I read McKenzie’s books myself so I don’t feel like I need to take courses taught by his followers. I also blogged about research that says taking even advanced level McKenzie courses doesn’t seem to help very much with diagnosis of people with different types of back pain. If you want I’m happy to talk about why I think that is. I’m fairly busy on another project right now, so I would only ask that you discuss one issue with me at a time. Thanks for your interest!

      P.S. I wonder if this TED Talk explains much of the difference in what we see in the research. What do you think?

  88. Thanks for the response Chad! I never realized until I checked the notification email just now, which conveniently landed in another label in gmail 🙂

    I’m actually a bit underweight for my height(155 pounds at 6 feet plus), so no case of abdominal obesity, heh.

    I’ve got about 6800 hours on a PC game called Dota 2, I think that might be a big culprit as I used to slide down in the chair and put my feet on the table with my bum sliding to the edge of the seat all the time. And I’m a software engineer by profession, more sitting with poor posture. Never realized the importance of good posture until the recent injury.

    So I met with another doctor yesterday, he said the same thing, I would like you to bed rest for 2 weeks. To his credit, he was around the same age as the last doctor and are probably not caught up with modern standards..I’m from Pakistan by the way.

    Back in 2010, I had some mild lower back pain along with some pain radiating to my right leg on an off. It wasn’t really bad and I sort of ignored it(being young sometimes make you overlook things) and it went away on it’s own probably in an year or less.

    Do you think there might have been a case of bulging disc around that time ? And can these problems occur over time as in my case, years of bad posture and not a one time lifting etc. injury ?

    These days my pain is ‘stable’ you can say. When I get up in the morning I don’t think I feel pain pain, but maybe stiffness in lower back ?
    Around evening/night time I sometimes get mild discomfort and some tingling in my left leg and some lower back pain.

    I’ve been going to the gym and I do pullups and dips without feeling any discomfort, I tried to do bodyweight rows last week, but it didn’t feel good, so I stopped after 1 rep.

    I wanted to keep it short, but I got one more question for you. Do you think I should be doing any core strengthening work or should I wait until this injury is healed up ? And if I should, do you have any recommendation on any exercises ?

    • Haha, sounds like diet isn’t your problem. But I agree with you, the gaming combined with your sit down job probably is. I think a few tricks if you are spending all that time sitting is to get up and walk around frequently, and when sitting make sure you have good lumbar support, but I think I already talked about that. I think you can still game, just make sure you have a pillow or something behind your back that maintains a normal lordosis.

      The other thing to worry about is “motor control,” which is when you are getting up and down, or doing other things are you bending through your hips (which is good) or bending through your spine (which is bad, at least if you do it too much and if you have a bulged disc you are obviously doing it too much). The hip hinge is something you can practice getting up and down from sitting positions or bending over a sink and definitely when working out at your gym. I almost always start some light core strengthening right away in my office. Usually standing cable rows and presses, for 3 sets of 15 reps with easy medium, and over time hard weights but only if it’s painless. Then if that goes well I’ll add an exercise with easy weights each day (so long as none of them hurt) and then work the weights up over time. I always have my people try for sets of 15 reps and if they can’t get the third (eventually heavy) set with good form and no increase in pain for all 15 reps I don’t move them up. If it hurts I’ll lighten the weight or take out the exercise. I never have back patients train through increasing pain. Most of my favorite exercises if you have a gym are in a video here.

      That’s cool, you’re from Pakistan! It seems a lot of the people who respond to my blog are outside the country, and almost all outside my state. So I’m currently working on my own yoga routine (writing it today) that incorporates all my idea into a routine that doesn’t require a gym so people anywhere can do it. I’m really excited about it and it’s the reason I haven’t had any new blogs in a while. But in the meantime if I were you I’d lift weights but light at first and carefully, with no spine motion. I hope that helps and let me know how it goes!

  89. Hello Chad,

    As I have read through this blog i has given me some hope that I may not have to go under the knife at some point. One month ago I had a hiking accident and sustained a Grade IV / V AC joint separation which I had reconstructive surgery for.

    20+ years ago i herniated the disk between L4 and 5 and have had minor issues ever since, i.e constant paresthesia in my left foot and sometime in the right. Has not stopped me from doing anything but at 64 years old I try not to do stupid stuff.

    The hiking accident seems to have exacerbated the symptoms now as i have constant paresthesia in right foot the most and can feel slight sensation through my leg up to the right buttock.

    I am taking careful walks for 30 minutes or so and using ice and am looking for things I can do to centralize and remove nerve root pressure and was hoping for any feedback.

    Thanks wyatt

    • Hi Wyatt, it’s difficult for me to say what you should do from afar other than what I have said to others. Keep the spine neutral during the day by sitting with good lumbar support, use exercise to practice and improve good spine motor control so that you can keep the spine neutral during activity. I love my EMS machines for core strength and EMS would directed to your left leg, if weaker, might help in combination with exercise. I’ve linked my usual exercise routine above. The only problem with my routine is you have to have a gym like mine to replicate it. I’m working hard now on a yoga sequence that incorporates all my principles, but doesn’t require a gym. I’m almost ready to release it. Sorry it’s not ready now. In the meantime my best writing with regards to general principles for back pain is all above.

  90. Hi Chad,

    After reading lots of the above I could not resist asking you a few questions – I hope that is ok with you…

    After 5 years of on and off back pain I finally had an MRI and the findings were as follows:

    1) Flattening of normal lumbar lordosis
    2) Disc protrusion L4 L5 – posterior with a radial tear which causes narrowing of the lateral recess on the left. This touches the transiting L5 nerve root but no overt compression.

    I have family and friends each suggesting what I ought to do which ranges from surgery to chiropractor to Mckenzie. In addition I have been told that this will correct the normal lumbar curve.

    I am at my wits end as I cannot decide what is best to do going forward.

    Any help would be much appreciated.

    Many many thanks

    • Hi Darren,

      You have a familiar complaint. Much like I said to the last guy, I linked my basic low back pain workout, I go on and on about, strength, endurance, motor control, lumbar supports and EMS. It requires you have a gym and get one of my EMS machines to fully duplicate my routine. I’m still working on the yoga/body weight spine routine, but it’s still not ready yet. In the meantime Stuart McGill’s Back Mechanic is a great laymen’s read on back pain and his methods are most similar to mine.

      I’m not sure what to say about your flattened lordosis. It might be normal for you, or showing up on the MRI due to pain. The disc protrusion is overwhelmingly likely due to spine flexion, so you want to eliminate that stress from your life. If you do that your body will likely reabsorb that fragment to some degree at least. I hope that helps.

  91. Following up to say (to anyone this will help) that I have been approximating Chad’s low back routine at my gym, minus the EMS, for several weeks, and that feels fine. I actually feel no pain when doing that workout and walking/jogging. But I reached a point one day at the beginning of August where I kept having the usual annoying pain that would accumulate when sitting in a chair (even with good posture) along with some hip pain flaring up which has been with me off and on for years prior to the back pain. I got frustrated enough that I decided I would try Whole30, starting from that moment.

    Seven days into the Whole30, I sh*t you all not, the back pain was gone.

    It stayed gone until about two weeks in, when I broke the Whole30 (becuase reasons; restarting next month). After a few days of returning to normal eating habits, the pain was (is) back, but really at a level that is irritating more than impairing.

    • Thanks for sharing Alison! I’m writing up my program for neck and back pain that “equipmentless” and I’m doing a chapter on diet inflammation. Not exactly the same as what you did, but in the ballpark.

  92. Hi Chad – Im reading through the comments of this thread and as a student I love the nuance of your clinical reasoning, especially in regards to relating pathology to spinal posture/motion. I also recently finished McGill’s Low Back Disorders and one thing I took away was that schmorels nodes are common, are pain drivers, precipitate degeneration within most other spine structures, and are essentially only caused by compressive forces in neutral posture. Given all that I was wondering a couple things:
    – Is there any way to identify the presence of Schmorels nodes clinically (ie absent imaging)?
    – If they are identified by imaging does it affect your treatment approach? Given the MOI it would seem logical that you would want to moderate loading in neutral and possibly encourage loading more in flexion and/or extension?
    Thanks for your thoughts!

    • The heel drop test is supposed to test for compression intolerance that would be indicative of a Schmorl’s node. However, unlike combined flexion/compression testing, the heel drop is rarely positive for me. When it is, I’m still not sure if there’s a Schmorl’s node or not, but I’ll suspect it. Much like a posterior herniation, I’m rarely sure if it’s there without an MRI. For the most part I just assume the worst and progress my basic routine as tolerated, mading deviations only if I run into problems. If I have a person getting upper lumbar/lower thoracic pain (where Schmorl’s nodes are most common), especially when doing a higher compression exercise like an RDL with a perfectly neutral spine, then I’d be more likely to suspect a Schmorl’s node.

      If I suspect a Schmorl’s node, I’ll still have them exercise with a neutral spine, still teach them neutral spine motor control, use of lumbar supports, EMS… But I’ll have them train lighter or skip an exercise if it causes enough compression as to increase symptoms. So yes, I would moderate their loading in neutral.

      You’re welcome. I like your questions they make me think.

  93. As everyone knows Meta-analysis studies lack notable validity and to dismiss the Mckenzie Method based on this is typical of therapists who have not been through the course study. Reading the “How to Treat Your Own Back Pain” books is certainly not adequate information for the practitioner but is actually meant for the patient to read so they can formulate an understanding of the approach while being treated by a certified McKenzie therapist. Although core strengthening and general activation of the body via exercise does have benefit to well being and function it does not hold any water when treating spine disorders that present as a derangement. To pay a $45 co-pay to do rows in standing for back pain is highway robbery and is contributing to health care cost inflation. If your patients are getting better you are probably doing McKenzie based movements but just don’t know it. Fire away!

    • Meta-analysis lack validity? How do you figure? For the record I dismiss much (but not all) of McKenzie’s method for more reason than meta-analysis finding it simply does’t work very well. To say I can’t dismiss his method because I haven’t been through his courses is like saying I can’t dismiss Scientology because I haven’t achieved the status of “clear.” Also I not only read “Treat Your Own Back” (your titles are a bit off) but his more in depth books, these, cover to cover. So unless McKenzie was poor author, I think I know his system better than most. You know, like someone who’s actually read L Ron Hubbard as opposed to paying thousands of dollars getting certified as an auditor.

      I don’t think what you are saying about exercise and “derangement” is very evidence based, whether you are talking about McKenzie or core strengthening, and “core strengthening” isn’t exactly what do either. Perhaps just in part. As for rows, not that I’ve ever given anyone just rows, but how would you do them?

  94. Hello Chad,

    Well I think I’ve earned an Absolute PT Medal. It took about a week, but I read this entire blog and all comments. A family road trip is where most of it was consumed. I want to sincerely thank you for all of the time you dedicate to your craft and this site. Understand that you are helping/educating a lot more people than just the ones that comment, so thank you.

    Now, I would like to tell you about my situation, as I think it may be a little unique. I have always been a fit individual. Working out 3-5 times a week since I was 15. I was a lean 6’1” and I could never put on any significant size and didn’t know why. It wasn’t until I was 34 years old that I dedicated and educated myself on the proper training and diet. I went from 170 lbs to 191 lbs in around 6-8 months. It took a lot of tweaking but I found a workout routine that worked for me. Doing no more than 8 reps down to 2 reps with heavy weight, well heavy for me. And Lifting 5-6X a wk. I will admit, I completely abandoned my cardio and core sessions. All I cared about was SIZE. I guess that came back to bite me in the ass. January 16 of this year I finished a heavy back workout, my last deadlift was 315 lbs. January 17, I had a heavy leg day. My last set on squats was 225 for 3 reps. Both sessions went as normal as any other, however the next morning (Jan. 18th), when I tried to get out of bed and stand up , my back locked up. It took me about 5-7 mins to stand up straight. I felt very sore all day long in my lower back, but it didn’t hinder me from going to work. I did skip lifting. Next day the same thing in the morning. Takes 5 mins to stand up straight, but I get through my workday. By the 3rd day I have no issues getting out of bed. I’m just very sore from lower back. I head back to the gym. I get a lot of Bro Science from my buddies who are mainly crossfitters. They basically say to lay off Deadlifts and probably my hip flexors are too tight.

    So Month 1, I continue lifting but no deadlifts. I am still squatting and even seated Leg Press. With a little discomfort. I also see a massage therapist twice within the 1st month. I am also doing a bunch of stretches I found online for hip flexors, piriformis & hamstrings. That first month I was feeling good. Not great, but not bad at all. The initial pain was all in my lower back, above the tailbone. It did start to spread down to my upper left glute, then to the entire left glute and down to my left hamstring.

    So I knew something was still wrong. I opted to see a Chiro. This is month 2 now. He snapped, cracked & popped me every which way. He had me try different movements and his assessment was a “Hot Disc” in my L5-S1. Gave me some stretches (supine, legs up on a wall), told me to stop lifting and scheduled me for a 1 week follow-up. I go back a week later and he snaps and cracks again along with 15 min of massage and 10 min of EMS machine. EMS machine feels awesome. 2 pads on lower back, 1 on glute and 1 on hamstring. Gives me more stretches and tells me to run on treadmill. I follow instruction and run on treadmill and as soon as I’m done, I feel so much pressure and pain in my lower back. I go back on the 3rd week and tell him. He advises me to use the stationary bike instead. Gives me the same treatment as previous visit. I do the stationary bike and as soon as I’m done, I now have full blown Sciatica pain. It has run down my hamstring, calf and into my foot. For 3 days straight my pinky toe and 4th toe are numb. My entire foot is tingling and numb. I see him 1 more time and tell him. He gives me the same treatment and also 15 min of compression air boots that cover your entire feet and legs. I decide its time to move on. I always felt better for a day or two after the Chiro sessions. I did those stretches he gave me along with the others I picked up in month 1. So I was stretching for about 30 min in morning and 30 min in the evening. Month 2 left me feeling worse than month 1, and I had all of the Sciatica symptoms ( funny thing was no back pain).

    Month 3 (Mid March to Mid April). I opt for PT. My best friend from high school tells me to go see his dad who is an MD. He examines me and refers me to a friend/colleague PT that practices McKenzie Method. At this point I am looking for any and all help. On first visit he puts me on the REPEX machine after assessing me. I’m getting a bunch of tingling sensations from left foot up the leg and centralizes to my back. He says that’s what we want. I say “Great”. He prescribes the extension (aka floppy push-up) and to see him in a week. I stop doing all other stretches and still no lifting. I just do the extensions 4-5x a day. Every time the same results. Full blown tingling from foot up entire leg and back pain. Only the home sessions don’t centralize and stay there. It just see-saws back and forth. From foot to back and then back to foot. It is extremely painful standing up after extensions. But I have little symptoms between each extension session. I tell my PT and he switches me to Flexion in Rotation and Side Glides. I do these for the next 2 weeks. I get no symptoms when I preform them, but I still have all the sciatica symptoms and back pain now. In week 3 I start searching for possibly not being a candidate for McKenzie. I find you Blog. I try to stay optimistic in hope for recovery, but I am starting to doubt. That being the reason why I even searched for not being a McKenzie candidate.

    Week 4 PT says its back to the extensions. I do it for 2 days and I am in incredible pain. He is closed on Fridays and weekends. It was Thursday evening while going for my nightly 1 mile walk, my back felt like it was hanging by a string. I knew my body was telling me something loud and clear. That’s when I decide to stop the McKenzie stretches. I also come to the realization that I actually never gave my body any time to try and recover and heal itself. Since 3 days after I woke up with that initial back pain, I found the stretches online. Did that for the 1st month. Month 2, I continued my stretches, Chiro sessions and Chiro stretches. Month 3 was strictly McKenzie. So for 3 months straight I have been stretching, flexing and extending my back every single day. I completely stopped all back stretches and have gone 4 days without doing anything and I feel significantly better. I still have a little bit of tingling around the foot. A little discomfort on the back of my left knee. Back feels better and I’m finally allowing my body to try to repair itself. It does flare up in the evenings and I just have to lay on the couch for a while. Very tough when you have a 4yr old and 2 yr old asking to play with them.

    I forgot to mention the MD had prescribed 800 mg of Ibuprofren 3x day. I did that for 3 wks straight. It wasn’t until wk 4 that I decided to stop completely as I think it was just masking all pain/inflammation that the McKenzie stretches were causing. So now I’m not masking anything and I can feel my body telling me if I’m not in neutral spine position.

    That’s my story. Like I mentioned I did read your entire blog, so I know what you normally recommend and prescribe. I am 35 years old. The last 3 months I barely got any real workout sessions in. Core (if you can even call it that) has gotten bigger than ever. Thanks to not working out. What do you recommend for me? I want to get back to full recovery and hopefully get back to my normal workout routines. After 3 months straight of basically keeping my back under stress and compromising positions, when/how should I begin my next chapter on my road to recovery sessions?

    • Wow, all your helpers really put you thru the ringer! And I think you landed on most the solution yourself:

      “I completely stopped all back stretches and have gone 4 days without doing anything and I feel significantly better.”

      I don’t think I would tell you anything much different from what I wrote to Francis way above. EMS is fantastic for strengthening the core without hurting the discs, but it doesn’t teach you how to move properly, and it doesn’t teach you how to keep your spine neutral during daily activities regardless of whether it is moving furniture or sitting at a computer. One of the problems with spine pain is that it’s an overuse injury that we often overuse when we try and rest it, and I think it likely that both your chiropractors and physical therapists stretches were worse than the lifting you were doing, and that’s a problem I hear ALL THE TIME. However, with lifting, most people flex their spines to some degree when performing deadlifts, and many do so at the bottom of their squats if they squad deeper than their hip sockets allow, even though neither is an inherently bad exercise. However, I do think leg presses with both legs at the same time are generally awful for the spine.

      So definitely you could follow my normal advice above and I’m pretty sure that would work. HOWEVER, I’ve been working really hard on trying to solve the problems of helping people from far away, and my new website SpinalFlowYoga.com is the culmination of that work, that was largely inspired by this blog. It just sucks when you have back pain and all the professionals around you are so clueless as to literally make you worse with their treatment. And it doesn’t help me out either, because so many people come to the conclusion that “physical therapy” doesn’t work. And they are largely right to come to that conclusion as I’m sure you came to realize. And worse (though maybe in a way fortunately) is that all that treatment is too expensive for many people to afford with insurances not reimbursing like they used to (not that I would either, cause I read the same research on the effectiveness of physical therapy as the insurance companies do.

      So my idea is to teach the science of what you read above that works on total body fitness at the same time as it rehabilitates the spine. It starts in a way that really easy and does not require the exact same lifting equipment I use (or any lifting equipment for that matter). Someone said it was basically Crossfit on a yoga mat, which isn’t all that wrong, but it’s done with the spine as neutral as possible the entire time, and it’s just $20 for a years membership. I haven’t fully described the theory behind it on SpinalFlow.com yet but since you read my entire blog (good job BTW, haha) you should know all of that very well. However, the exercise program is up in entirety, and in a way that’s good enough to start helping you now, and I would be happy to answer questions along the way. Doing so would actually help me to dial in the delivery of my exercises in a way that’s easiest to understand.

      If you started on Level-one of Spinal Flow, progressed through Level-two you would probably be good to start lifting weights again, and/or you could then progress to Level-3 of Spinal Flow, which is probably harder than most people lift, which was one of my goals.

      EMS would certainly work synergistically with Spinal Flow, but isn’t absolutely necessary. Everything is a longer story than I have time to fully describe but I’m shutting down my office and moving to India to teach anatomy and Spinal Flow at a yoga school. I also shut down my absolutept web-store that sold my EMS machines, pads, and straps because I didn’t have time to deal with it and work on Spinal Flow. However, I’m getting more inquiries about machines and I maybe found someone who can take orders and ship orders while I’m away. So if you are interested in that my web guy should be putting the store back online shortly. I just got a message from him about it today, and it might be back up as early as today.

      So my best advice, join SpinalFlowYoga.com, help me make it awesome for you and everyone else. Oh, and about your core getting bigger because you can’t exercise, I love, love, love intermittent fasting and it’s better than free, it saves money!

  95. Thank you so much for the quick response. I wish you nothing but the Best on your new endeavors. I will definitely be checking out your new website and look forward to becoming a Member. Would you recommend still giving my Back a few more days of Recovery before engaging in any vigorous activity? My wife has been intermittent fasting for a month now. I guess it’s my turn to give it a shot. And yes I will be checking back for the online store. I may still be interested in 1 of the EMS.

  96. Hello, I have had a bad back for about 18 years, but until this year i was able to fix it by just maintaining a neutral position, I rested and maintained my normal home tasks etc. However just this year a number of things happened, I fell in a hole and also my bed was not on an even mattress base (has now been fixed) and I visited a physio who recommended cobra exercises of extension, three times a day X 10 lots. As soon as I did the ‘cobra’ extension exercises my back got much worse and shortly after I was in excruciating pain, got an MRI and found that I had a lumbar herniated disc at l4-l5 with slight nerve impingement. This was in January this year, 2018. After a few visits to a flexion distraction table chiro where I lie on my stomach and my feet are dangling legs at a slight angle are gently lowered and then raised, I was much improved. The herniated material must have shrunk back or been resorbed into my body. I took care during this time to wear a back brace for some of the time and also to not bend to pick things up, I had a reaching aid relatively inexpensive that I bought online. I can only say I will never ever go back to a physio who recommends McKenzies exercises again! They were the absolute end of me, causing me excruciating pain which I was glad improved. I was then a bit enthusiastic just two weeks ago hopped up on a bike again and stumbled, came down hard on my sore leg (Which felt almost fully better but there you go) and all the sciatica and bad pain radiating down my leg to my ankle returned. SO now I am on voltaren and panadol again, and doing same as I last did hoping I will repair again. Soon as I do I won’t hop up on a bike again for quite a while!

    • Hello Jane,

      The body does tend to reabsorb herniated disc material. In fact there is evidence that the worse the herniation, the better the body reabsorbs it because there is a greater inflammatory response. Probably what happened was that the herniated disc material was pinching on something, and then the extension from the cobras pinched on it further, worsening you as you found. Flexion would open the space and that would give you some relief and I suppose combined with traction would lessen the risk for further herniations, in a way that flexion combined with compression would. However, my concern is that after a herniation the disc is shorter and the surrounding vertebral ligaments are looser, creating instability. Such that the traction might worsen this, or at least certainly wouldn’t help. So it is hard to say if the flexion/traction did any good at all, or if it was just the rest you did at the same time, the stopping of extension, or the natural course of the healing process. The downside of all that rest is your muscles end up weaker than it was to begin with, and the disc weaker too. And knowing what I know about back pain, though an MRI showed a herniation at L4-5, it’s likely that L3-4 and L5-S1 are heading in that direction. Discs don’t degenerate all at once, but rather gradually, though the final burst as the last fibers of the annulus fail can be quite sudden and eventful.

      I would absolutely avoid the flexion as you change directions in the pool. It might “seem to help” right now but it hurts you in the long run I assure assure you. Flexion is how you herniate discs posteriorly, in fact research is reasonably clear that it’s the only way to do so.

      If it were me, I would do EMS to my core so as to both decrease pain and strengthen without aggravation. And slowly progress into a total body weights routine much as I show on my low back pain page. Or if you don’t have gym access, I am starting to tell people about SpinalFlowYoga.com, which I have been working on. It’s still a ‘minimal viable product’ and I have much work to do on it before I start to push it, but even as is, it is the best equipmentless, web-delivered, home exercise program specific for neck and back pain. And I allowed comments on all the workout pages so people can ask specific questions. And with this (RSiDQtV71S) coupon code is only $21 per year.

  97. Sorry I forgot to tick the square to notify me of follow up comments etc by email…will do so now, hoping it gets through allright.
    Thanks for your blog it is much needed in the online world where McKenzies although it may have some advantages, does need quite a bit of refining and should be carefully used not universally recommended to people. My flexion distraction treatment opens me up just a little on my spine, gently and I believe does benefit me. How else did I heal so quickly last time?

  98. One last thing! Sorry to send so many emails – I just wanted to add that swimming, at first just gentle walking in waist deep water, seems to help. At first I cannot do much at all, am too sore and inflamed and only ice packs panadol and voltaren will help, but I start back when I can after a few weeks, and have found that doing some freestyle (definitely not breast stroke or backstroke) gently trailing my legs behind, and it seemed to help a great deal. And the freedom feeling at being able to at last swim again, was excellent! Swimming freestyle has always calmed my back and in the days before herniation, when I walked all bent over, I would do a flexion forward once or twice in the water gently after each lap of freestyle, that helped too somehow.

  99. Hi Ive been reading your blog and hope you can help me. I am now a 30 years old male.

    I have been a keen weight lifter for over 2 years and must admit I rarely warmed up before each session. I was 13 stone, muscular and could deadlift over 200kg with good form. I first felt my back go when doing an ab roller exercise. I believe I extended my back too far. I believe this was Sciatica down my leg although I had no back pain. I ignored the pain for over a year before going to the doctor.

    They didnt believe because of my athletic appearance that anything was wrong and sent me away with Naproxen.

    I assumed it was all in my head but avoided deadlifts, squats and extension exercises. Fast forward a year and I was still actively in the gym, running 8 miles with no pain but getting pain when lifting, I imagine I was lifting with ego rather than form most of the time. No pain at any other time though.

    I went to the doctor and had an MRI which showed L4L5/L5S1 broad based posterior herniations and mild/moderate degenerative spondylotic changes in those discs. My herniation’s barely cause any nerve compression.

    Since the MRI results my back has been in constant pain, like seeing those shortened black discs has just knocked me over. I have been doing Mckenzie stretches and purchased an inversion table. However the Cobra exercise hurts me the most, I can feel and hear my spine crunching. I currently do no flexion exercise as didnt want to herniate more. I no longer have Sciatica though but the lower back pain will not fade.

    I am changing my job at the end of the month from an office job to a field engineer so will be more active, I hope that will help and I wont need any sick leave to combat this.

    What are your thoughts on how I should fight this as I dont want to do flexion to herniate further and cant do cobra extension as this crunches my back?

    Thanks in advance

    • Hello!

      There is research that says people who get MRIs have more pain than those who don’t and they think it’s precisely because it freaks them out. If it were me I would avoid the McKenzie exercises because if anything all that extension will give you nerve compression (from the bones instead of the discs). There is a chance that laying prone in mild extension (on elbows at the most) for 10-15 minutes (not repeated by sustained) would do some good without the damage, sort of ‘McKenzie lite.” However, for the most part I think you want to learn to keep your spine more neutral, all day long, both in the gym and during your day (particularly how you sit, in a car, at a desk in a sofa, gaming…). That’s what will stop further damage and give your body a chance to heal. The cobra probably hurts because it is pinching your discs/nerves. You might not have impingement on your MRI laying flat, but in extension you likely do. Stay thin as central fat increases inflammatory cytokines thought to soften discs according to a recent paper I read.

      EMS is awesome for strengthening the core in a way that does not hurt the spine, and decreases pain at the same time. If you are in the UK a programmable 4 channel stimulator would go a long way towards helping you. My favorite model now is the Globus Triathlon. The electrodes that come with it are poor, so you would want to get aftermarket 9-10 cm circular rubber carbon electrodes and straps to hold them in place, but that combo will be amazing. I do it with all my spine pain patients.

      It’s hard for me to tell people what to do over the internet as far as exercises go, so I came up with SpinalFlowYoga.com that still needs work but it’s good enough to help people. Spinal Flow is like the opposite of regular yoga where you learn how NOT to bend your spine. However, it sounds like you are into weights and your story is very similar to Francis’s above. I had a long back and forth with him over many months. I bet if you read that dialog you would find a lot that would help you. Control, or command F and search for Francis it should bring it right up.

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