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herniated disc treatment options

gotgame

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I get a lot of PMs about people with back pain ( upper, mid and lower). So i figured id make a short post that might give people some direction.

First, you have to know what is wrong. Im not about to try to use some magical abilities and figure out what is wrong and how bad. Some people can have severe spinal stenosis and barely have symptoms and others can have a small focal protrusion rubbing up on a nerve and they are in severe pain. Physical exam is not a really good indicator....well unless you have loss of bowel and bladder function then thats just bad...

GET AN MRI.

It should be a noncontrast MRI on a high field 1.5 of 3t magnet. DO NOT opt for an open magnet unless ur like 330lbs and cant fit in a 3t bore. The MRI will guide managment. Stop guessing...its pointless to say you have backpain so it must be a disc. An xray is not that helpful..get the MRI

COMMON ISSUES FOR BODYBUILDERS

The most common things i see in bodybuilders are disc issues, facet arthrosis, spinal stenosis and compression fractures.

Disc issues: Years of axial loading take its toll. Sometimes the disc will protrude straight back into the canal, off to one side a bit or into the neural foramen. We need to know where it is and what its doing before trying to treat. The mri report will describe it. Sometimes is a small buldge that can get smaller overtime ( natural progression) or sometimes its just completely extruded and your effed and its unlikely to decrease too much in size but sometimes it can a bit.

Facets: those things in the back that allow you to bend. Susceptible to repetitive motion and to a lesser degree axial loading. This often will cause more focal back pain with motion and less likely to cause radicular symptoms BUT THEY CAN! The facet is the back part of your neural foramen and make up part of our lateral recess so it can bang into nerve when it gets enlarged and inflammed. Sometimes perifacet cysts form and project into the canal compression nerves.

Spinal stenosis: Could be caused by many things such as a disc, facet, ligamentum flavum or epidural fat. Sometimes its even congenital. With respect to epidural fat...i bet ya didnt know that being overweight can cause spinal stenosis! Look up epidural lipamotosis.... look how narrow that canal gets from being overweight and insulin resistance.

Compression fractures: The human body can only physically support so much weight. Suddenly overcoming those limits either via trauma or sudden increase in axial loading can cause a fracture..even in young healthy guys. That can be not too significant or very bad. That why its important to know what is causing your back pain. A guy on another board had bad pain and thought it was a disc. he showed me his MRI before he saw his doctor and he had a bad T12 compresssion fracture!


Ok...GG you are boring us again...can we get to some treatments.

Rest: WTF how is that a treatment option??! Well after you have a disc herniation sometimes you get an annular tear and fluid leaks out. THis can cause a lot of pain but often over time as the disc loses hydration it will get smaller and have less mass effect on the nerves its hitting. Ok...in laymans terms... a lot of the time if you do nothing it will get better!! Guys take all types of supplements...do traction...bracing..voodoo... whatever and they think they got better because of that when many times its just the natural disc dessication and the disc got smaller on its own.

Anti-inflam meds

NSAIDS: I like aleve as a general good option. 440mg PO 2x daily with food is a good option. THis is better then advil

Selective cox2 inhib like celebrex and etoricoxib are great. Etoricoxib is my personal Nsaid of choice but its not available in the usa because of the vioxx isssues around 2004. Selective cox2 inhibs dont cause gastric issues like advil does. 60mg etoricoxib daily> 2000mg advil with respect to pain relief.

Toradol : Yea buddy! now we are getting into the fun stuff. 40mg PO x 5 days works nice for acute pain. but dont use for more then 5 days.


Oral Corticosteroids:

Things like prednisone, dexamethasone etc. These are gonna work on the very first part of the inflammatory cascade so its gonna knock out a lot of inflammation but they have sides. Dont stay on for too long...if anything just use for a few days then stop. Longer term issues can occur not just with ACTH suppression but can lead to things like avascular necrosis of the hips etc.


Injections:

Ok so you know what is wrong with your back and its not responding to oral treatments and you want to step up your game a bit... lets talk epidural

Epidurals allow for greater concentration of corticosteroids to be applied more directly to the inflammed nerve roots rather then everything going systemic, but keep in mind the meds do go systemic a bit.

If you get an injection DO NOT EVER let someone inject you blinding. I dont care how good they claim they are or what there google reviews are. You must have it done with either fluoro or ct guidance. Most pain docs use fluoro as they dont have access CT and thats fine.

Cspine: Options are interlaminar or transforaminal injection.

Interlaminar : You get injected in the back and with interlaminar the meds get everywhere about 2-3 segements above and below. The meds as you can imagine get a bit diluted because they are coating everything within a few inches. The good thing about interlaminar in the neck is you can use depo-medrol ( a particulate) and less risk of injecting into a vessel that could cause a minor side effect like paralysis and death...

Yea...im sure you can find some studies showing comparable efficacy of particulate vs non but from many people experience the particulates give great longer term effects due to delayed release

Transforaminal/peri-isthmic approach: This is basically coming in from the side-ish and putting the meds directly next to which ever nerve has the issues. you get high local concentration and often gets better results then interlaminar. But the risk here is the vessels so you cant use a particulate and instead have to use dexa or betamethasone


Lumbar:

You have interlaminar, transforaminal and caudal injections here. less risk with the transforaminal in the lumbar then cervical spine and the interlaminar approach is a layup because there is more epidural fat her. If its my back id probably opt for like 80mg depo medrol interlaminar approach first and if that didnt give adequate relief then id go transforaminal.


If the pain you have is mostly inflammatory from a disc hitting it but you dont have severe stenosis then a steroid injection could help you until the disc dessicates and therefore you could have almost perminant relief ( because disc became smaller and is no longer hitting nerve). If the disc continue to hit the nerve but there is still space then the epidural could easily give a year plus of relief and some guys get a few years if there is still space. BUT if there isnt much space and theres constant contact then you are looking at maybe 3-6 months of relief.

Traction:
It may help in some situations where its a small bulge. If is extruded or there is a large facet/lig flav component its not gonna help. That is why its important to know what is wrong first. I personally use the Saunders neck traction unit for some relief of my disc issues in my neck. Im not against it but know that my MRI has never improved from using it...only temporary relief.

Percussive massage:
Good for muscle spasms associated with nerve root irritation and not gonna fix your disc


AAS/peptides etc:
Big old NOPE. Sorry pal..whatever peptide you wanna name isnt gonna fix that big old herniated disc. And no deca isnt gonna hydrate your discs and have you grow taller.

Surgery:
Last resort but be smart...if you need it you need it. Given the conditions bodybuilder usually have the best options usually are discectomy and interbody fusion. If the posterior elements are playing a significant role then you will need a laminectomy and posterior fusion to go with it. I will personally be getting an ACDF on my cspine but right now im managing with epidural and etoricoxib but when the times comes ill get it done.
 

thethinker48

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What are your thoughts on Chiropractic services that many bodybuilders heavily invest in (preventatively)? Going in for adjustments, Hip alignment, managing leg discrepancy, that sort of thing
 

gotgame

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What are your thoughts on Chiropractic services that many bodybuilders heavily invest in (preventatively)? Going in for adjustments, Hip alignment, managing leg discrepancy, that sort of thing


NO!

Ok now that i got that out of my system i know a TON of chiros. I mean a ton. Unfortunately most of very bad at understanding the limitations of what they can do but i do know a few good ones.

As for chiros...you are not adjusting crap..your not realigning someones back. People arent coming in with perched facets of something. You arent changing a "hip alignment". If one leg is longer then another they certainly arent doing an osteotomy.

I have be sat as an expert witness 20 plus times in cases against chiros who have injured patients by attempting to manipulate them without knowing what was wrong first such as the patient having severe central canal stenosis or a huge disc extrusion and they caused cord damage because they either didnt get imaging or they didnt understand what the imaging said and the limits of what they were doing.

Now there are some good ones... i know a few. There are certain muscular things they can do which could help with pain, injury recover etc and i know some that are good for patients. However in my experience, i would say just please dont go to most chiros...could do more harm then good. Get and MRI and go from there.

This is a challenging topic as ppl associate pain relief with success..but as i mentioned in my post a lot of back pain can go away on its own if its disc related and not too bad. If its just muscular then strains heal on there own but certain things offered by chiros could help with pain relief in the short term.

if i could say one final word...never ever let a chiro manipulate your neck..EVER.
 

finephysique

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Do you rate stretching, yoga or core strengthening as ways to manage pain?
 

thethinker48

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NO!

Ok now that i got that out of my system i know a TON of chiros. I mean a ton. Unfortunately most of very bad at understanding the limitations of what they can do but i do know a few good ones.

As for chiros...you are not adjusting crap..your not realigning someones back. People arent coming in with perched facets of something. You arent changing a "hip alignment". If one leg is longer then another they certainly arent doing an osteotomy.

I have be sat as an expert witness 20 plus times in cases against chiros who have injured patients by attempting to manipulate them without knowing what was wrong first such as the patient having severe central canal stenosis or a huge disc extrusion and they caused cord damage because they either didnt get imaging or they didnt understand what the imaging said and the limits of what they were doing.

Now there are some good ones... i know a few. There are certain muscular things they can do which could help with pain, injury recover etc and i know some that are good for patients. However in my experience, i would say just please dont go to most chiros...could do more harm then good. Get and MRI and go from there.

This is a challenging topic as ppl associate pain relief with success..but as i mentioned in my post a lot of back pain can go away on its own if its disc related and not too bad. If its just muscular then strains heal on there own but certain things offered by chiros could help with pain relief in the short term.

if i could say one final word...never ever let a chiro manipulate your neck..EVER.

Thank you for sharing your thoughts on this

I used to work at a rehab clinic where we had Chiros working as well; let's just say I've seen some interesting "claims" from folks. One of them was really cool though, worked a lot on mobility exercises, stretching, and was upfront to people about fixing serious issues with manipulations.

Reason I brought this up is I've seen vids like this quite a few times:


And not to pick on this guy, he does a lot of mobility work, and active+passive forms of stretching on athletes which is good, But then you get to the cervical/lb adjustment part, and it makes one reconsider what kind of utility that provides

Just things to reconsider

A lot of guys including myself have some mobility issues (traps firing weird, and muscle imbalances in areas from loading exercises in a specific ROM), and I think that stuff could be worked on to prevent injuries, and train more efficiently with mobility exercises, maybe deep tissue work, and proper stretching
 

Matsuo Munefusa

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Thank you for sharing your thoughts on this

I used to work at a rehab clinic where we had Chiros working as well; let's just say I've seen some interesting "claims" from folks. One of them was really cool though, worked a lot on mobility exercises, stretching, and was upfront to people about fixing serious issues with manipulations.

Reason I brought this up is I've seen vids like this quite a few times:


And not to pick on this guy, he does a lot of mobility work, and active+passive forms of stretching on athletes which is good, But then you get to the cervical/lb adjustment part, and it makes one reconsider what kind of utility that provides

Just things to reconsider

A lot of guys including myself have some mobility issues (traps firing weird, and muscle imbalances in areas from loading exercises in a specific ROM), and I think that stuff could be worked on to prevent injuries, and train more efficiently with mobility exercises, maybe deep tissue work, and proper stretching
your last point is a great one and one I've been thinking about a lot lately. I'd love to hear GG talk about "functional training" especially in regards to upper trap dominance/lower trap and shoulder girdle in general. I think a lot of problems stem from that but outside of the scope of the original topic I guess.

GG you are good people, sir! thanks for posting this.
 

Gravyv

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What is your opinion on potential new therapies for back problems in the future (10yr, 20yr+)? Do you see any progress being made that will improve outcomes that can allow patients back to doing high impact activities?

I've had back surgery before and looking at another (fusion or disc replacement), but only if my pain gets worse. For now, I've settled for pain management because I still have my mobility and the pain isn't too bad. I wasn't recommended any surgery that will allow me to get back to heavy lifting or running. The only reason i'll get it is for pain since there are risks that surgeries can fail.
 

buck

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I tried going back to a chiro before my spine surgery. and the more they adjusted the more the lumbar region hurt.
Anti inflammatory work for as long as you take them.
The only study I could find on inversion showed people with hernias had increased pain when using the inversion table on the average.
Injections can work. But are less effective the longer you use them.
A bit of my personal experience.
 

cage99

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I have a lot of back issues (20yrs now) and have run the gambit on every remedy aside from a spinal fusion. That’s what’ll fix it, but I’m not there yet. I’m hoping to put it off anutha 10-15yrs if at all possible. One thing I didn’t see mentioned is RFA treatment. You’ll be under the knife for this but it minimally invasive. They basically burn off your nerve endings to put it quite simply. Epidurals worked for me at first, but quickly faded. Pain meds were given out by the boatload to me. However they will just lead to your downfall. So stay away if your young still. Fortunately I’m strong willed and decided to get off em cold turkey. That was a shitty week, but necessary! Stretching every morning once you awake helps too for lower back issues. If your in my shoes you just have to come to terms with certain exercises are off limits.... Sucks but I’ve learned to live with it.

Cage
 

sickboy

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What’s your opinion on Radiofrequency Ablation for cervical kyphosis or military neck? My doctor says it could keep me pain free for at least a year.....Thanks

NO!

Ok now that i got that out of my system i know a TON of chiros. I mean a ton. Unfortunately most of very bad at understanding the limitations of what they can do but i do know a few good ones.

As for chiros...you are not adjusting crap..your not realigning someones back. People arent coming in with perched facets of something. You arent changing a "hip alignment". If one leg is longer then another they certainly arent doing an osteotomy.

I have be sat as an expert witness 20 plus times in cases against chiros who have injured patients by attempting to manipulate them without knowing what was wrong first such as the patient having severe central canal stenosis or a huge disc extrusion and they caused cord damage because they either didnt get imaging or they didnt understand what the imaging said and the limits of what they were doing.

Now there are some good ones... i know a few. There are certain muscular things they can do which could help with pain, injury recover etc and i know some that are good for patients. However in my experience, i would say just please dont go to most chiros...could do more harm then good. Get and MRI and go from there.

This is a challenging topic as ppl associate pain relief with success..but as i mentioned in my post a lot of back pain can go away on its own if its disc related and not too bad. If its just muscular then strains heal on there own but certain things offered by chiros could help with pain relief in the short term.

if i could say one final word...never ever let a chiro manipulate your neck..EVER.
 

gotgame

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Do you rate stretching, yoga or core strengthening as ways to manage pain?

Sure... if it help you then do it. its not going to correct the underlying pathology but if the nerve is being irritated resulting in referred muscular pain and yoga helps then sure.
 

gotgame

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Thank you for sharing your thoughts on this

I used to work at a rehab clinic where we had Chiros working as well; let's just say I've seen some interesting "claims" from folks. One of them was really cool though, worked a lot on mobility exercises, stretching, and was upfront to people about fixing serious issues with manipulations.

Reason I brought this up is I've seen vids like this quite a few times:


And not to pick on this guy, he does a lot of mobility work, and active+passive forms of stretching on athletes which is good, But then you get to the cervical/lb adjustment part, and it makes one reconsider what kind of utility that provides

Just things to reconsider

A lot of guys including myself have some mobility issues (traps firing weird, and muscle imbalances in areas from loading exercises in a specific ROM), and I think that stuff could be worked on to prevent injuries, and train more efficiently with mobility exercises, maybe deep tissue work, and proper stretching

Those can certainly help and if have no problem with someone doing some deep tissue work, stretching, some ROM type stuff to help with pain associated with that. My issue is more when someone has a huge disc extrusion, severe facet arthrosis etc and the chiro is charging them for those mobility type things when thats gonna make any longer term difference.

If someone is having backpain and MRI doesnt show anything significant then id certainly advocate for someone trying the above things you mentioned. I like to rule out badness first though.
 

gotgame

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your last point is a great one and one I've been thinking about a lot lately. I'd love to hear GG talk about "functional training" especially in regards to upper trap dominance/lower trap and shoulder girdle in general. I think a lot of problems stem from that but outside of the scope of the original topic I guess.

GG you are good people, sir! thanks for posting this.


I have no expertise in "functional training" with regards to the things you mentioned. If someone doesnt have any clear and present injuries on imaging causing there pain that id certainly consider other avenues of treatment such as functional training, mobility, myofascial type stuff etc. The latter is not really an area that im on expert on and there are plenty of other guys on this board who have more experience there.
 

gotgame

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What is your opinion on potential new therapies for back problems in the future (10yr, 20yr+)? Do you see any progress being made that will improve outcomes that can allow patients back to doing high impact activities?

I've had back surgery before and looking at another (fusion or disc replacement), but only if my pain gets worse. For now, I've settled for pain management because I still have my mobility and the pain isn't too bad. I wasn't recommended any surgery that will allow me to get back to heavy lifting or running. The only reason i'll get it is for pain since there are risks that surgeries can fail.

I think overall there is a push towards maintaining disc space with an anterior spinal fusion/disc prosthesis which allows for the neural foramen to not collapse so much over time as well hardware posterior at the spinous processes that effectively TRY to do the same. I say try as ive seen the marketing on that posterior hardware and then ive seen the real life post procedural imaging which often times doesnt show much improvement in the foraminal narrowing.
 

gotgame

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I tried going back to a chiro before my spine surgery. and the more they adjusted the more the lumbar region hurt.
Anti inflammatory work for as long as you take them.
The only study I could find on inversion showed people with hernias had increased pain when using the inversion table on the average.
Injections can work. But are less effective the longer you use them.
A bit of my personal experience.

That sorta depends on what the initial condition is. Epidurals work better for herniated discs then spinal canal stenosis. Its usually not that they are intrinsically less effective..its usually that the disc or whatever the underlying issue was has gotten worse therefore its not responding as well as it once did.

If the condition is spinal canal stenosis you are attempting to treat with an epidural...then long term usage of epidurals can sometimes result in epidural lipamatosis and make your canal stenosis worse. At that point id just opt for a lami and call it a day.
 

gotgame

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I have a lot of back issues (20yrs now) and have run the gambit on every remedy aside from a spinal fusion. That’s what’ll fix it, but I’m not there yet. I’m hoping to put it off anutha 10-15yrs if at all possible. One thing I didn’t see mentioned is RFA treatment. You’ll be under the knife for this but it minimally invasive. They basically burn off your nerve endings to put it quite simply. Epidurals worked for me at first, but quickly faded. Pain meds were given out by the boatload to me. However they will just lead to your downfall. So stay away if your young still. Fortunately I’m strong willed and decided to get off em cold turkey. That was a shitty week, but necessary! Stretching every morning once you awake helps too for lower back issues. If your in my shoes you just have to come to terms with certain exercises are off limits.... Sucks but I’ve learned to live with it.

Cage

RFA treatments can be useful for very specific pathologies. For those of you are arent sure what the is...its basically heating up the tissues and burning the nerve endings causing pain.

So heres the deal and i want anyone considering RFA to read this. RFA is good for local back pain not really causing any radicular symptoms. So lets say you have a really bad facet causing you issues...first you need to know if your pain is actually coming from there. Sometimes an MRI with contrast can be useful but in my opinion if the MRI is showing pathology there and its corresponding to your pain then id have them inject local lidocaine and steroids right next to your facet.

If your pain is actually coming from that facet then you will get immediate relief from the local and if the steroids do not offer you long term relief ( after upping the dose) then RFA could be useful. RFA can also useful for SI joint pain. I would NOT recommend it for discogenic pain and i dont want anyone burning anything nerve motor neurons.

RFA in some patients can also cause issues as your are burning the pain fibers but occasinally you can get neuromas the form and those are quite challenging to treat with pain but another RFA could just burn those too.


In general RFA can be useful but you better be damn sure where your pain is coming from first. if its SI joint pain make sure you have CT GUIDED steroid injection first. Soooo many times patients come to me saying they had SI joint injections without results and then they see me and i drop steroids deep into the SI joint and months later they are still pain free.
 

gotgame

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What’s your opinion on Radiofrequency Ablation for cervical kyphosis or military neck? My doctor says it could keep me pain free for at least a year.....Thanks

You need to be sure your pain is coming from your facets. Just because you have reversal of the normal cervical curvature that doesnt mean that its causing your pain. If your mri showed facet issues and id have an image guided injection to that particular facet. See if you respond first. See if steroids work. If its just kyphosis then 40-80mg depo medrol dropped around a facet would help the vast majority of people long term. If that offers you relief and after a few injections you want a more definitive treatment then RFA may be useful.

But do not let anyone burn your pain fibers until you know what the issue is. Kyphosis in itself doesnt cause pain...anatomically is has to be doing something and you have to find out what that is.
 

buck

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That sorta depends on what the initial condition is. Epidurals work better for herniated discs then spinal canal stenosis. Its usually not that they are intrinsically less effective..its usually that the disc or whatever the underlying issue was has gotten worse therefore its not responding as well as it once did.

If the condition is spinal canal stenosis you are attempting to treat with an epidural...then long term usage of epidurals can sometimes result in epidural lipamatosis and make your canal stenosis worse. At that point id just opt for a lami and call it a day.
I got the Laminectomy while they were fusing L4-5 along with the hardware to realign the spine a few years ago. An MRI last year showed every disc around the lumbar region is bulged with half of them herniated and a few other conditions. I find that not loading several hundred pounds a few times a week takes care of the pain for the most part. But after decades of doing that I am not surprised and the car that hit me last year didn't help either.
 

gotgame

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I got the Laminectomy while they were fusing L4-5 along with the hardware to realign the spine a few years ago. An MRI last year showed every disc around the lumbar region is bulged with half of them herniated and a few other conditions. I find that not loading several hundred pounds a few times a week takes care of the pain for the most part. But after decades of doing that I am not surprised and the car that hit me last year didn't help either.

In general when its so many levels you certainly want to try conservative measures first. Ive seen so many train wreck spines where people are fused L1-S1 with lamis and anterior fusion as well and you still get post op issues such a scarring cause issues and osteophytes projecting into neural foramen... and its just a wreck.

For situations like you mentioned with multilevel disc issues id try epidurals and anti inflam meds and if surgery is needed try to pinpoint which level is causing you the most issues.


ohhhh and something i didnt mention! One of the reasons i use selective cox2 inhib is becuase of muscle growth. Many studies point to cox1 as being the primary muscle inflammatory mediator needed for post exercise muscle growth. Early studies were done looking at muscle trauma ( like cutting it) and it showed cox2 and we thought it was cox2...but turns out in physiologic muscle growth post exercise its mostly cox1.


So wtf does that mean....that means if you were to take large doses of say advil before working out...your muscle protein synthesis is probably gonna be blunted to the degree of over 80-90%. ( sorry no studies of guys on AAS). There seems to be less effect if advil or other cox1 inhibs are taken like the next day but if its in your system prior to exercise its mostly likely going to decrease your gains.


If you look at some studies on older people it showed that they made better muscle growth when taking advil...but you have to read the study to see that advil increased there functionality due to decreased pain so they were more active then there counterparts.

So thats one of the reasons i take a selective cox2 inhib when im in pain.
 

lookslikesausage

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Have to ask about it since i see it everywhere...McGill Method. Before i go any further, understand that McGill Method in my experience was good for practicing abdominal bracing and conditioning one's core (i've tried it, was coached in it by someone trained by McGill himself and yet i still have pain) but what i never understood is this: they claim McGill Method will heal your spine and cure your pain. Ummm...how? How will getting a stronger core cure things like a herniated disc? No one ever answers this when i've asked it before to the people who just claim McGill for any and all back pain. "Just do McGill and the pain will go away. You watch!" and if it didn't, "Well, you didn't do the exercises long enough".


Not trying to hate on McGill but i'd like to know if I'm off here. It's a good practice to train and re-educate your core muscles (if they were poorly trained to begin with), but it won't solve the issue of physiological changes in the spine that are the causes of pain. Is that last statement incorrect Gotgame (because that was the conclusion i came to)?

Gotgame, I'd love to hear what you have to say about the McGill Method.
 

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