Stuart McGill and Paul Ingraham on back pain.

I’m not satisfied with my previous post on back pain.  Framing it as a review of three separate books was probably a mistake.  When you review two books at once, you can frame things as a “compare and contrast”, but grouping things in threes is awkward.

I’m going to try to correct my error by comparing and contrasting the back pain theories and treatment recommended by Stuart McGill of and Paul Ingraham of  The two both claim to be proponents of “evidence-based medicine” for low back pain, and they share quite a few beliefs in common; namely, they believe that many common treatments and diagnoses for low back pain are scams, including:

  • Most spinal surgeries – the success rate is low and bad outcomes are common.
  • Steroid injections – the success rate is low and outcomes are occasionally bad.
  • MRIs – expensive and rarely helpful for diagnosing causes, although it can help determine whether you have something rare and serious like cancer.
  • Opioid pain killers – in the long run, tolerance overcomes their effects, and they carry a risk of addiction; there’s an even greater risk that you’ll re-sell them to your junkie cousin.
  • Chiropractics – no better than placebo and has some risks.
  • Acupuncture – no better than placebo.
  • Pilates – no better than generic exercise.
  • Yoga – no better than generic exercise.

So in general, they agree on what not to do, and I don’t want to underplay how important that is.  Skipping the list above could save someone a tremendous amount of time, money, and risk.

But the two disagree in broad ways about what does work, and indeed about the fundamental causes of most low back pain.  And both claim to represent mainstream, evidence-based medicine!  The cruel fact seems to be that there currently not much mainstream consensus on the science of low back pain – certainly not within the practicing medical profession, and possibly not within the medical research community either.  My impression is that physiatry – rehabilitative medicine – is an understudied, underappreciated field, and that scientific progress in the field has probably suffered for that (possibly relevant: someone asks on Quora how hard it is to become a physiatrist; all responses mistakenly thought they asked how hard it is to become a psychiatrist.)

To the extent that there is a mainstream view, Stuart McGill seems to be the exemplar.  He believes that low back pain is most often due to inappropriate “postures, movements, and loads”, and that the best treatments are “spinal hygiene” – that is, re-training oneself to move and carry one’s body in ways to do not trigger pain – and corrective exercises that emphasize stability and endurance rather than strength or flexibility.  His approach calls for a step-by-step process of personal experimentation with movement and posture to diagnose one’s individual “pain triggers”, followed by corrections and exercises tailored to those particular triggers.  That sounds like a lot of work – probably worth it for someone with low back pain, but still discouraging – however, he does recommend three groups of exercises that he says are safe and effective for nearly everyone who suffers from low back pain.

McGill writes and speaks from what I might call a “solutions-centric” approach – he’s quite confident that he understands the problem and knows the answers, so he writes primarily about his recommended treatments, and debunking scammers is a side project.  This is very much in contrast with Paul Ingraham; he takes what he calls a “MythBusters approach” to medical evidence – he writes primarily as a debunker, plowing through one literature review after another, evaluating whether each treatment meets his criteria for statistical and clinical significance.

Ingraham also writes from a particular theoretical perspective that he admits is a bit dodgy – he believes that most low back pain, regardless of its original trigger, is “complicated” by muscular issues.  When he says “complicated”, he means that low back pain is sort of like a wildfire – you don’t care so much whether it was caused by cigarettes or lightning, because regardless of how it was caused it sustains itself in a certain way and how you fight it doesn’t depend much on how it started.  A vertebral disc may slip, but discs heal quickly and the muscular tension and pain caused by that slippage may last much longer, build on itself, and require separate treatment.

Specifically, Ingraham believes that anxiety and mistaken beliefs about low back pain can lead to increased muscle tension, which in turn increase low back pain, leading to a vicious cycle.  He says that his review of the literature found that the most promising treatment that met both his standards – statistical and clinical significance – was something called cognitive functional therapy.  The description reminds me, more than anything, of cognitive behavioral therapy for insomnia, another condition complicated by anxiety – there’s quite a bit of factual education that includes bordering-on-condescending pep talks, and it seems like it shouldn’t work but it kicks the ass of placebos in controlled trials (actually, I think my next blog post may be on insomnia.)

That’s not the only thing that Ingraham has ever found promising.  Scouring his long, long list of debunked treatments, I find positive appraisals of the following:

  • Intradiscal methylene blue injections.  Apparently squirting blue dye into your spine may reduce pain quite a bit in the short term, with almost no risks or side effects.  This sounds too good to be true, and it seems like the research is very preliminary on this one.
  • Massage therapy kind of works, maybe.  Ingraham is a former massage therapist, so there’s an (admitted) bias here, but he thinks the evidence for massage is tentatively positive.  His recommendations for self-massage are especially detailed, and this is something nice about both Ingraham and McGill – they aim to provide zero-cost solutions you can apply to yourself while saving you from expensive pseudoscience.  In general, he’s very certain that muscular “trigger points” are a real physical problem, but less sure of whether current medical science knows how to treat them.
  • Regular, moderate exercise is almost certainly helpful, although unlike McGill, he’s skeptical that any particular kind of exercise is better than any other.  He does think one kind is worse, though – he warns repeatedly against “weekend warrior-ism” – occasional, intensive exercise by a person who does not exercise regularly; he regards this as especially likely to cause injuries.
  • Insomnia and anxiety worsen low back pain, so treatments for those conditions should help with low back pain.
  • Voltaren gel is a topical, over-the-counter NSAID (non-steroidal anti-inflammatory drug) that seems to outperform all other pain medications for temporary relief of low back pain, with fewer side effects.
  • There is ridiculously tentative evidence that comfrey root ointment may help relieve low back pain.  Take this one with a grain of herbal salt substitute.
  • The section on TENS – transcutaneous electronic nerve stimulation – makes it sound like he’s disappointed with current results but still hopeful that something related might work – specifically, because he believes most low back pain in muscular, he believes that electrical stimulation targeting muscles rather than nerves may be more effective.

I would say that the main difference between Ingraham and McGill is that Ingraham does not believe that most low back pain is caused by what he calls “mechanical” factors – his review of the literature has convinced him that no particular habits of posture or movement are consistently associated with low back pain or lack thereof.  One interesting thing to note is that Paul Ingraham’s review of the literature never once mentions Stuart McGill; the closest he comes is some negative evaluations of “core stabilization.”

I’m coming to the point in this post where I feel like I should recommend one approach or the other, McGill’s or Ingraham’s.  But I can’t honestly do that – I have neither McGill’s practical experience nor Ingraham’s knowledge of the literature.  I’ve devoted more paragraphs to Ingraham than to McGill, but that’s because Ingraham’s approach is more atomic; less holistic.  Both say things that “ring true” to me:

  • Ingraham’s emphasis on muscle pain fits my personal experience.  Several years ago I had a back spasm that was followed by extreme pain; after an implausibly short visit with my primary care physician, I was diagnosed with a slipped disc.  Even at the time this seemed dodgy to me; the pain felt muscular, was worst in the morning, and reacted to massage and hot baths the way I would expect muscular pain to react.
  • On the other hand, McGill’s emphasis on “pain triggers” also matches my experience.  You won’t hear about it much on this blog, but my main physical hobby is fire spinning.  I’m almost forty years old, involved in a hobby dominated by twenty-somethings; I bend and twist my body in many different ways, and I have noticed unmistakable connections between particular movements – as in, “postures, movements, and loads” – that consistently cause more back pain than others (if you’re curious, the main thing I’ve noticed is that bending and twisting my waist at the same time seems to be a bad idea.)  Also, for a bit over one year I took lessons in the Alexander Technique, and while this does render me somewhat vulnerable to effort justification bias, I kept with it because it did seem to me that certain postures and movements feel healthier and less painful than others.

Summary time?  Avoid the things I listed, in bullet-point form, that McGill and Ingraham agree against.  They are usually expensive and they rarely work.  Try both McGill and Ingraham’s recommendations; neither is expensive and either or both might work.  If you try both “cognitive functional therapy” and “the Big Three” exercises, you will be following the recommendations of both at once.  Don’t get spinal fusion surgery; don’t pay for an MRI; I said those things once, but they’re probably worth saying twice.

7 comments on “Stuart McGill and Paul Ingraham on back pain.

  1. Michael Cohn says:

    Ingraham makes a number of comments about the need to prevent trigger points from recurring by assessing ergonomics and sources of “postural strain”. I think he just portrays himself as anti-mechanics because he’s so strongly opposed to the one-size-fits-all pseudoscience you hear from most practitioners who think they understand the subject. He believes in experimentation and self-treatment, and on that he seems to agree perfectly with McGill.

    • nintimdoblog says:

      would you and author recommend purchasing the ebooks? generally I don’t like to buy anything, I’d prefer if the information was free and I could donate (since I’m so skeptical)

      • It depends on how interested you are in the topic, I think. His writing is a one-of-a-kind resource, so if you’re deeply interested in the topic, I would recommend buying. Although, I think he has quite a few free articles on his site, so you might look at those first to get a sense of whether you’re interested in the paywalled ones.

    • nintimdoblog says:

      By that I mean Paul Ingraham’s ebooks

  2. H says:

    Excellent post thankyou. Three herniated discs and a few other things and five months in. Am a huge proponent of learning stuff myself and I really liked reading this blog and found it very helpful. Thank you for taking the time to write.

  3. Moonstone Valley says:

    Can’t believe this post has only a few comments… you’ve saved me hours of reading through Ingraham’s endless rants against various treatments, you’ve put it all down clearly and helpfully. I really appreciate it.

  4. Michele G Rogers says:

    Yes, thank you for doing this. Really. I’ve been battling chronic low back pain since I was 18 after getting rear ended in a stopped go kart. Turned into a spondy. Now I’m 40 and it’s also arthritis and severe degeneration after 2 kids. Maybe there isn’t always a correlation with pathology and pain, but damn if this doesn’t seem a lot worse now than it was 10 years ago. I’m a fitness professional with a niche in corrective exercise because of battling this back issue. I feel like I should know how to fix this by now. Frustrating isn’t even the word. BUT I clearly haven’t tried everything. Maybe this cognitive functional therapy is the way to go now. I can sense and acknowledge that I actively “guard” my back at times without realizing it, creating more and more tension. The pain is most certainly real but my fear of it is probably compounding it.

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