Monday, February 6, 2017

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

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

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

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

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

McGill 2.

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

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

Movement Screens.

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

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

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

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

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

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

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

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

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

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

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

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


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

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

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

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

Non specific back pain and imaging.

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

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

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

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

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

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

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

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

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

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

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

The assessment.

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

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

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

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

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

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

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

The practical.

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

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

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

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

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

Three hour assessment.

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

Courses like this re-energise you.

McGill 1 or 2?

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

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

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

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

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

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

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


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

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

Why do some people sit into their pain?

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

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

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

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

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

Closing thoughts.

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

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

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

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

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

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

Take home message - be better, know more.

Now should I do McGill 3?

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