A Tale of Two Back Doctors

The two big doctors in the world of bad backs are Dr Stuart McGill and Dr Paul Sherwood.

Dr Sherwood passed away a few years ago, but is still very much a colossus in the back world.

In many ways they both say the same thing:
“High-end bad backs can be fixed without surgery”
and they both did the same thing:
“Fixing high-end bad backs”

Where they differ is in what they see as the cause of bad backs and the techniques they use to treat them.

For Dr Stuart McGill – AKA “The Back Mechanic” – the way people use their backs is a major cause of a bad back.
He sees repeated full range flexion (bending forward) and extension (bending backwards essentially)
of the spine and flexion under weight (sit-up exercises and picking up weights with a bent spine) as the cause of herniated discs.
His solution to a bad back is to find out what movements and use of your spine cause the problem – your pain triggers and then to fix it…
you stop it “… “stop picking the scab” and re-learn how to use your spine in pain free manner. Strengthening the stabilising muscles of the spine with the “Big 3” exercises is a common technique he uses. His book “The Back Mechanic” is the best place to start with this.

Dr Sherwood saw something different – He saw things like bad posture as a result of a bad back rather than its cause. The cause of a bad back he saw as being an injury – a trauma – and often an old one “…on average 11 years…” via this mechanism:

After a trauma injury, the facet joints are jammed together, and they send a nerve signal to the powerful para-spinal muscles to provide a protective corset in the form of a long term but painless spasm.
For light injuries, this mechanism works fine – in a short time, the back heals and spasm releases.
But for serious injuries, the spasm is too tight and too long lasting and as a result the tissues become all stagnant
and oedemas build up. Any healing ceases as fresh white blood cells cannot get past the oedemas to the damaged area and, as the
pressure of the para-spinal muscles in long term spasm is squashing the facet joints, the facet joints react in the only way they know how when they are stressed – they produce nerve signals that request the para-spinal muscles to go further into spasm to “protect” them.
After living like this for years, one day … “…while reaching for the toothpaste” or something like that… bang ! the painless spasm turns into a painful cramp and/or the nerve gets trapped, a disc moves and squashes a nerve….
Dr Sherwood’s solution to this is to wind things down and straighten things up:
a) Ultrasound is used to reduce the spasm in the muscles thus taking the stress off the facet joints
b) EMS – Electro-Muscular Stimulation is used to get the muscles to pump out the stale oedemas in the tissues
c) The ASMI (PAMM) machine is used to mobilise the vertebrae and get them moving to get them back into their correct place.

The position of the patient during Dr Sherwood’s Treatment can make a huge difference in the results: 

For most patients lying face down during Ultrasound is best, but a minority of patients benefit more from being is a sitting position.

With the EMS, lying face up with a cushion underneath that part where the electro-pads are to slightly arch the back backwards and to ensure good electrical contact is the best position. Again a minority of patients benefit more from being is a sitting or even a standing position, if lying down is difficult.

For the ASMI the standard plinth (massage table) – is slightly curved but other more curve postures using a kneeling chair, or the patient rolled up in a ball allows the ASMI to work on different parts of the spine that reveal their issues in different positions. So a single ASMI session might cycle through different positions

Can they both be right ?
Well as a back therapist myself, I have only ever had one patient come in with a bad back after doing sit-up exercises… but even then
I’m sure he had a previous trauma injury from what I saw.
Had this patient, or his gym instructor, read Dr Stuart McGill; then he would not have done the sit-up competition.
– Sit-ups being just about the dumbest exercise on the planet: During a sit-up, the spine is flexed – so squashing the discs towards the back of the spine – and the stress of the lifting your torso against the force of gravity is a powerful compressive force – all explained very well by Dr Stuart McGill in his books.
If Dr Sherwood is right – and an existing trauma injury needs to be present for a back to go like this – Dr Stuart McGill would still have been “right enough” to have prevented this painful back problem.
In a world of unknowns – which is the real world we live in – being “right enough” is as good as you need in most cases, which is why this blog is not entitled “Dr Sherwood Vs Dr McGill” or  some other such “either/or” type phrase.

At the time Dr Sherwood was building up his experience, many people still worked in factories in the UK and there was no such thing as
a “gym” outside of the world of professional wrestles and the like.
Now more people work in gyms than they do in factories in the UK never mind the numbers who use gyms.
So there may well be a new kid on the block – the dumb gym exercise that is causing a new wave of bad backs… but I have not actually seen it yet myself. So is it: “Roll up! Roll up! – do strange and unusual things to your body under weights to loud music to help reduce body awareness and repeat and repeat till you injure yourself” – I asked a Personal Trainer in a gym a couple of weeks ago: Why, when even the US navy has stopped doing sit-ups, do you continue to a) do this disc stressing exercise  and b) “enhance” them…and now add a sharp twist ! .. and repeat !” ? He replied: “Oh they are easy to do in the floor class and they take up very little space”

Does GoodBack use “The Sherwood Technique” ?
www.GoodBack.co.uk, based in London Colney UK, uses the Sherwood Technique quite a lot… but not entirely – The Dr Sherwood Technique can take some time to work – maybe 15 to 20 sessions and the patient has to have a treatment once every two days till the problem is fixed. In most therapy situations it is struggle enough for the patient to turn up for therapy weekly so at GoodBack a Sherwood-esque approach is used:
A typical protocol would be to use all 3 of the Ultra-Sound, EMS and ASMI on the first few sessions and when the tissues no longer look and feel stagnant, then to move to using the entire therapy session just with the ASMI machine.

This patient had had Chemotherapy, This weakened her bone density so we did not use the ASMI on her – just the Sherwood Technique – with quite spectacular effect:

This patient waited for two hours outside the MRI centre on her hands and knees, such was the pain from her herniated discs.  3 weeks later using just the Sherwood Technique without the need for the ASMI…

This patient was treated with US, EMS and the ASMI …but it was mostly the ASMI on the highest power that was needed to fix him in this case:

This patient was treated by Dr Stuart McGill himself. Stuart gave up on him; “You need surgery, your back is beyond even me”. By using Dr Paul Sherwood’s Technique his pain reduced dramatically in a few days, he was able to sleep and walk. Just one month later after being bed-ridden in agony he is now back at work, pain free.


While doing the Dr Sherwood based therapies – which take about 90 minutes per session – we talk about different movements to make and not to make so as not to agitate the spine when back home – Dr Stuart McGill material. I send links to Stuart’s website and Youtube videos for them to watch. “My job is to fix your back (Dr Paul Sherwood’s work). Your job is not to make it worse again (Dr Stuart McGill’s work) “- is the general approach I take.  I find that works very well, as you can see for yourself.

There are 3 modes on the ASMI machine: the Anti-Spasm, the Reflex stimulation and the Mobilisation mode. Dr Sherwood only used the
Anti-Spasm and the Mobilisation mode, restricting his therapy this way I think he missed a trick: At GoodBack, all three modes are used.
The Reflex mode mode, not used by Dr Sherwood, stimulates the nerve reflexes in the spine and gets the vertebrae to “jump” back
into the correct place bit by bit after the ligaments had been stretched by the mobilisation mode. So the Reflex mode is an integral part of the therapy and a huge reason why patients can get better in a far quicker time frame than without it.

This approach fixes most bad backs in a few treatments.

Does GoodBack use “The McGill Technique” ? – as homework – it is usually a good idea to point the patient in the direction of the McGill books and videos and pick out the best bits for them:
His method of getting up from chair when you have lots of back pain is brilliant, as is his whole “Spinal Hygiene” section – brushing teeth etc – all explained in “The Back Mechanic”. McGill’s lifting advice is also brilliant.

His “Big 3” exercises are floor exercises and most of the pain patients I have would struggle to get on the floor and back up again, so I don’t tend to recommend them. As trauma damage is usually visible and palpable (you can feel the vertebrae dip up & down, twist here & there as you run your fingers along the spine) – and is fixable via the “GoodBack Big 3”:  Ultra sound, EMS & ASMI, I like to get the vertebrae back into their correct position before doing exercises – and by then you don’t really need anything specific. Add to this the risk of the patient not doing the exercise correctly unattended… this is why exercise is not a treatment modality I much recommend. But if the patient asks… then Dr Stuart McGill is the place to go to. If you are able to get up and down from the floor, then the exercises are very good for getting the muscle pump to work, which is where I think on of the main benefits of them comes from. Stuart McGill non-sit up sit up or “modified curl up”- the first of his “Big 3”, it can be quite effective – i.e. a quick fix for bulging disc pain if done properly. It cannot work by “Strengthening the core” in such a short amount of time. An aspect of why it works will be the activation of the muscle pump but I also think it might work by pushing the bulging disc back in. This exercise feels more like a bomb disposal exercise than a gym exercise though as the nerves are all hair trigger, so be careful, if your back is at the level of “feeling a bit twingy” then McGill’s Big 3 are worth a try, but if you have serious back pain, then I advise against any exercise as such, supervised or not.

If you are going to do it, the first thing to do is to “clamp things down”. While in the position on the floor that is shown in the Big 3 videos, release the breath from your belly a lot – but not all – about 60%. then build up a brace over two to three seconds, – no sudden movements like in a bomb disposal. When you have this firm brace lift up your torso from the floor by the slightest amount, once you are slightly off the floor you will feel the weight of your whole upper body being transferred into a powerful compressive force in the lower back. It is very powerful but because you pre-braced it is even and may help push the disc bulge back into place. Lower the spine back down, but still maintain the brace, once your body is down on then floor then release the brace as slowly as you built it up and breathe again. Have a moment rest to prepare yourself mentally to do all the steps – don’t miss any – and repeat the whole thing once or twice more. The repeat a few times during the day. Watch the videos before or during each time you do the exercise so as not to miss a bit.

If this causes pain then stop, back off, and maybe come back later in a week or so and do less of it. It might be that your issue is not a disc bulge and this does not help the issue quickly, but if it is – it can be very effective. repeat for the next few days.

McGill has a far better understanding of “stabilising the core” than you get in a Pilates class, with McGill , there is no “sucking in the navel” as this switches off half your muscles and destabilises the spine. McGill’s core bracing is bracing your stomach as if you were about to take a punch – so no sucking in, and no isolating just one set of muscles – in this area – they are designed to all work together. Don’t brace too strongly – just to the appropriate level for the activity and patient and don’t do it all the time – a “tuned brace” – and you tune so that you stop the pain where you have it, but don’t over do it so that you then cause more pain.  Many years ago in a Pilates class I remember we were instructed to use every opportunity to engage our core – a bit of a recipe for a back disaster as if you are moving your back and are also bracing then you are putting lots of unnecessary stress in lots of directions on the spine. If you have back pain, then there will be few people who will not find something very useful in Stuart McGill’s books and videos.

Prevention – Well the best prevention is not being in car accident, not falling off a horse… as trauma is the main cause.
But for those niggling pains and for safe gym work, McGill’s standing exercises he recommends in his “Ultimate Back Fitness and Performance” using the “Cables” and Kettle bells in the gym are very good.

If you look at the paintings of human “work” since the dawn of time, we are not lying down on an ancient gym mat, neither are we lifting heavy weights gym style – most of it is pushing carts and pulling ropes with donkeys or buckets on the end of them – these are great back friendly activities.
Dr Stuart McGill is rightly “against sitting down machines” in the gym. He recommends standing up and using the cable machines to push and pull – while holding a stiff full core, stiff arms, firm hand grip, stick neck, stiff legs, well placed feet, a neutral back – don’t bend over – even a bit. So I see cable work as a wonderful early bronze age… up to quite recent times… style – full body engagement – human sized back friendly exercise – with the advantage that you can start with a very light weight and don’t have to struggle to get down on a mat and back up again.

McGill has this idea of what he terms “Virtual Surgery”. What this is, is you pretend that you’ve had surgery, then “rest up” as if this has taken place to see if you feel better, as in his experience, he has seen many times where the benefits of surgery come from the enforced rest afterwards, rather than the surgery itself. If he says he’s seen it, I’ll take it that he has, but from my experience I prefer to “bench” my patients – you take it easy and don’t do lots, but you don’t go for post surgical level of stagnation as this, in my experience, can cause huge problems – you need to keep the muscle pump working – so McGill’s extreme “Virtual Surgery” is something that GoodBack does not advise. 

A lot of McGill’s work is based on cadavers – dead bodies donated to science. He did flexion and extension on these spines repeatably under compression and found that the discs herniate quite quickly and that this damage is cumulative. For a person who has had a prior back injury, and so stagnant lymph flow around the spine as a result of the protective spasm, their back will be similar to the back of a dead person – their repair mechanism will be low to none. So repeated flexion and extension under a compressive load will result in damage that won’t be repaired and will be cumulative. But for those who have not had a prior injury, their fully functioning repair mechanisms may be able to repair the damage and repair it stronger – adaptability – given reasonable amounts of rest. Given lots of people have a bad back they don’t know about, it’s sensible to avoid such high risk movements. So Stuart McGill may not be fully right about this, but he is certainly “right enough”.

So two excellent back doctors, both have added  huge amount to the world of bad backs. Not quite an “either-or” situation but in the therapy room I do tend to “Dr Sherwood it” a lot more than I “Dr Stuart McGill it”. Outside of the therapy room, Dr Stuart McGill’s how to move around the house and brush your teeth work – “Spinal Hygiene” and gym work is the go to. A distinctive feature of a Dr Stuart McGill therapy session is the long initial assessment that can be 3 or 4 hours long. Most high end back pain patients I treat are either fixed or nearly fixed after 4 hours in my therapy room and is seems more reasonable with 100 patients, that after a total of 400 hours in the therapy room that 99 would be now pain free and the odd 1 that is a particularly difficult case would get the extra time for a deep assessment dive than have the 100 people only to the starting line of the therapy.

Stuart’s main work was what he termed “the mechanism of injury”, in likewise language, Paul’s main work is “the mechanism of repair”.

Dr Paul Sherwood’s Materials:

“Your Back, Your Heath” & “Get Well Stay Well”

Obituary Independent Newspaper

Obituary by Brian May from Queen 

Thames TV News

TV Interview

Dr Stuart McGill’s Materials:

Stuart McGill’s Big 3 core exercises for your lower back

“The Back Mechanic”, “Ultimate Back Fitness and Performance” & “Low Back Disorders”

Stuart McGill’s Main Website 

A nice high speed summary McGill video

A longer, more detailed McGill video – “No such thing as non-specific back pain”

 A video in which he explains that it is the vertebrae, not the discs that are the shock absorbers

“Bob & Brad” meet Stuart McGill : https://www.youtube.com/watch?v=EbPavwB9H0M

Nerve Flossing – an exercise highly recommended by Stuart McGill

McGill Showing how to lift Heavy Weights in the Gym

Another Good McGill based video on weight lifting

#StuartMcGill  #SherwoodTechnique