Becoming Pain-Free: Andy Marlow Of The Back Coach On How to Alleviate Chronic Pain
An interview with Maria Angelova
Daily exercise to promote muscular endurance of your ‘core’ muscles. In order to practice spine hygiene consistently, you’ll need to develop the endurance of your torso muscles that support your spine. This will allow you to maintain pain-free postures as you go about your daily activities. Stuart McGill’s ‘Big 3’ exercises: the side plank, the modified curl-up and the bird dog were selected by him after testing in his lab revealed them to be optimal in terms of the high stimulation they apply to the ‘core’ muscles whilst applying minimal stress to the spine. There are regressions and progressions of each exercise. The appropriate version and its dosage should be adapted to each individual.
So many people suffer from chronic pain. Often people believe that they have tried everything, and that there is no real hope for them to live pain-free. What are some things these individuals can do, to help reduce or even eliminate their pain? In this interview series, called “Becoming Pain-Free: How to Alleviate Chronic Pain” we are talking to medical professionals, pain management specialists and authors who can share their insights and strategies about how to alleviate chronic pain. As a part of this series we had the pleasure of interviewing Andy Marlow.
Andy Marlow, originally from the UK, has been working as a personal trainer in France since 2010. While seeking out the best evidence-based information to help his clients with low back pain, he discovered the work of Professor Stuart McGill. Since becoming certified in the McGill Method in 2019, he has made helping people overcome their low back pain the main focus of his online business, www.theback.coach working with clients all over the world.
Thank you so much for joining us in this interview series! Before we dive in, our readers would love to “get to know you” better. Can you share your “backstory” with us?
When I began my personal training career 12 years ago I would often have clients who suffered from low back pain and had been told by their doctor they needed to exercise more. I soon discovered that a generic exercise intervention may work for some people but for others it could actually make their back pain worse.
Not only did exercise make some clients’ pain worse, but sometimes so did the treatment they received from their manual therapists. I had one client whose pain only started to improve when her physical therapist went on holiday. He had been making her do stretches and mobility exercises that provoked her specific pain triggers.
I realized there had to be a better way to help my clients who were being let down by medical professionals who obviously weren’t back pain experts. This led to me to discover Professor Stuart McGill’s evidence-based approach, and eventually, in 2019, I became a certified practitioner in the McGill Method.
Can you share the most interesting story that happened to you since you started your career? What were the main lessons or takeaways from that story?
At the beginning of the pandemic, I was invited to a barbecue and ended up exchanging business cards with a guy I met there. When I got home that evening, I received a message from his wife, Rosine, saying she’d aggravated a chronic back injury during the car journey home. She had severe pain in her back and leg and, knowing that I helped people with low back pain, wanted to know if there was anything I could do to help.
I called her straight away and explained how she could maneuver herself into a position of respite, lying face down on the floor. However, this didn’t initially relieve her pain (which she placed at nine on a pain scale of one to ten).
So, I asked her more about the origin and history of her back pain before tentatively concluding she probably had an unstable lumbar spine. This was causing her spine to overextend while lying prone which triggered her pain. I told her to place a cushion under her belly to position and support her spine in a more neutral position, and this brought her pain down from nine to zero in less than a minute.
This was enough to get Rosine through the night, then we did a full assessment the following day, online via Zoom. We confirmed that she had an instability issue in her lumbar spine and did a weekly online session over the following 6 weeks focusing on teaching her how to avoid her pain triggers and improving the endurance of her ‘core’ muscles. By the end she was able to move confidently and pick up her young daughter without provoking her pain. When I checked in with her again about a year later she was still pain-free (although she did admit that whenever she slacked off the daily exercise program I had given her, her pain started to come back!).
Firstly, this experience confirmed to me that the details matter. A small difference in the position of Rosine’s spine was the difference between extreme pain and no pain. What works for one person doesn’t necessarily work for the next person which is why generic approaches rarely work.
Secondly, I learnt that I could help people with low back pain, working exclusively online with them. Rosine was becoming desperate with her chronic back pain which had persisted for years despite having seen local physical therapists in person and doing pilates and yoga regularly. What she had never been shown was how to avoid her specific pain triggers and how to build a resilient back using exercises that had been adapted to her as an individual. We were able to do this all via Zoom.
Finally, I learnt to always take my business cards with me whenever I’m invited to a barbecue!
It has been said that our mistakes can be our greatest teachers. Can you share a story about a mistake you made when you were first starting? Can you tell us what lesson you learned from that?
Before I became a certified McGill Method practitioner, I had a client who had a badly herniated disc but wanted to continue exercising and achieve some modest fitness goals. We agreed that he should take things slowly, and he made good progress, while avoiding any back pain for about a month.
But, when we went through his monthly movement assessment, I asked him what was stopping him from squatting any lower, expecting a verbal reply. However, my client, who was a ‘type A’, dynamic guy took this as a challenge to see how low he could squat.
As soon as his thighs got to about parallel with the floor, which caused his back to round, he shrieked in pain, dropping to his side on the floor while holding his back. I instantly realized that I should have chosen my words more carefully. My client was surprisingly gracious under the circumstances and asked me to get him his phone so he could call his wife, before politely insisting that I leave.
We spoke on the phone a few days later, and he accepted my apology, saying that he didn’t blame me and wanted to resume training with me once he had recovered. However, that didn’t transpire in the end because his wife wouldn’t let him. I understood her point of view because looking back now, I didn’t have the necessary knowledge or experience at that point in my career to be training people with the type of injury he had.
The other crucial lesson I learnt from that experience is the importance of unambiguous communication, especially when dealing with ‘type A’ individuals who have back pain!
When it comes to health and wellness, how is the work you are doing helping to make a bigger impact in the world?
People often come to me when they have seemingly already tried everything else: chiropractor, physical therapist, yoga, etc. Yet, in nearly all cases, they’ve never undergone an extensive movement assessment that has identified their specific pain triggers. This means they’ve never been shown how to avoid their pain while getting through their daily routine, so they continually provoke it which prevents their back from healing.
For example, one of my current clients had been suffering from chronic back pain for seven years, despite having had regular physical therapy and acupuncture. I taught him how to hinge through his hips instead of moving through his spine (which he did habitually, despite this being a pain trigger for him), and after one month of consistently incorporating this into his daily routine, his back pain disappeared. That was over a year ago now and he is still pain-free (he still does a weekly session with me online). He used to spend the first few minutes of every session expressing his thanks and disbelief at how what we were doing was actually working.
There are a lot of people like my client who are suffering unnecessarily. So, in terms of making an impact, I want to help as many people like him as possible get over their back pain so they can live a healthy, active life. The influence I have is restricted to helping one individual at a time due to the necessity of an in-depth, individual assessment which lasts, on average, around two and a half hours for each client. However, the effect this intervention has on each of these individuals can be life-changing.
Let’s jump to the main focus of this series. For the benefit of our readers, can you please tell us why you are an authority on the subject of chronic pain?
Unfortunately, the people we often turn to to help us with chronic back pain neither have the necessary experience nor the time in their schedules to carry out the in-depth, individual assessment required to identify the cause of your pain. Low back pain is not a homogeneous condition; it can have many different causes. This is why you should never accept a diagnosis of ‘non-specific low back pain’ and a prescription of pain pills after a 10 minute consultation with your doctor. It’s also why the generic exercises and stretches that many physical therapists prescribe may actually make your back pain worse instead of better.
My expertise is in carrying out a thorough assessment. This begins with an interview that helps me understand the context of my client’s s life and how additional factors may be contributing towards their pain: their injury history, their personality, lifestyle factors such as work, sleep and nutrition, and psychosocial factors such as stressful life events which may be affecting them and how they perceive pain.
There are occasions when I will refer someone to see their doctor before they work with me. For example, if your pain is constant and unresponsive to changes in spine postures, motions and loads, this should be treated as a red flag. Your doctor will be able to rule out any more sinister cause of your pain such as a tumor, although I should emphasize that this is rare.
Once any red flags have been ruled out, I take you through a series of deliberate pain provocation tests to identify the specific postures, movements and loads that provoke your pain. This helps me form a hypothesis regarding the source of your pain. I also observe you carrying out actions from your typical daily routine, to understand how you may be provoking your pain without realizing it. For example, it’s common for flexion-intolerant individuals to repeatedly flex their spines when sitting down or tying their shoe laces. These are movement patterns that need to be modified if these individuals want to become pain-free.
In addition, I look for movement restrictions in other parts of your body, particularly the hip, the shoulder, the thoracic spine and the ankle which often contribute to your pain by redirecting forces through your spine. These should also be addressed, but at the right time. For example, someone may have a very tight psoas muscle because it provides stability to their unstable lumbar spine (where it attaches to every vertebrae). However, before stretching the psoas (and removing the stability it provides), stability should be gained by improving the endurance of the underactive ‘core’ muscles that should be doing that job.
Can you please share with us a few of the most common causes of chronic pain?
There are many mechanisms that can be labeled the cause of chronic low back pain, such as sciatica (where a root of the sciatic nerve is inflamed or compressed, often by a disc bulge), stenosis (where the canals in which the spinal nerves travel have narrowed, often as a result of arthritic bone or hypertrophied ligaments) or spondylolisthesis (where a vertebra becomes unstable and slips forward across the vertebra below it).
However, most of the time, all of these pain mechanisms are the result of behaviors which can be seen as the real cause of the pain: poor posture, excessive movement through the spine and weak muscles (through deconditioning) that don’t provide the spine with sufficient support.
Your posture determines the amount of stress that is applied to your joints. And this stress influences how much pain you experience. For example, if you have a forward head and rounded shoulders posture, the muscles in your back and neck have to maintain a constant low level contraction to support the weight of your head and shoulders drifting forward. This applies compressive forces to the spine and fatigues the muscles which stops them from being able to respond appropriately when you actually need them to protect your spine, for example when bending down to pick something up.
Excessive movement through the spine causes accumulative wear and tear to the intervertebral discs which can result in their delamination and, eventually, herniation where the nucleus seeps out, irritating a nerve. This is a common cause of sciatica and can be prevented by learning how to move through the hips instead of through the spine. This is particularly important when placing the spine under load.
Many people who suffer from low back pain don’t engage in regular exercise and have let their torso muscles become deconditioned to the point where they don’t offer the spine sufficient protection. An inability to maintain the spine in a neutral position whilst repeatedly generating force through the limbs places additional stress on the soft tissues of the spine such as the ligaments and discs which can suffer damage and generate pain. The bottom line is that when poor movement patterns are ingrained in a weak body, the result is often chronic pain.
There are many different types of pain that people struggle with. Which specific form of pain would you like to focus on in this interview? Why that one?
Non-specific low back pain. This is a non-diagnosis which is unhelpful, disempowering and always the result of an inadequate assessment. There is always a cause to your pain. Believing there is no specific cause of your pain prevents you from making the necessary behavioral changes to reduce it and allow your back to heal. You wouldn’t accept a diagnosis of non-specific knee pain, so why accept one for your back? The first thing you need to do if you receive such a diagnosis is find a qualified movement expert who can guide you through a thorough assessment. They can help you to identify the specific movements, postures and loads that trigger your pain, and teach you how to avoid them.
Here is the main question of our interview. Can you share your top five “lifestyle tweaks” that you believe will help support people’s journey toward becoming pain-free?
1 . Consistent spine hygiene. This means avoiding painful postures and movements to give your back the opportunity it needs to heal. This can be the hardest lifestyle change to make at the very beginning because you need to unlearn old movement habits and ingrain new ones that place less stress on your spine. A common example of this for flexion-intolerant individuals is learning how to sit down and get up from a chair without overloading your spine. This involves positioning your feet wider than usual and hinging back through your hips to sit down whilst maintaining your spine in a more neutral position by bracing your abs.
2 . Daily exercise to promote muscular endurance of your ‘core’ muscles. In order to practice spine hygiene consistently, you’ll need to develop the endurance of your torso muscles that support your spine. This will allow you to maintain pain-free postures as you go about your daily activities. Stuart McGill’s ‘Big 3’ exercises: the side plank, the modified curl-up and the bird dog were selected by him after testing in his lab revealed them to be optimal in terms of the high stimulation they apply to the ‘core’ muscles whilst applying minimal stress to the spine. There are regressions and progressions of each exercise. The appropriate version and its dosage should be adapted to each individual.
3. Walking. Not only is walking good cardiovascular exercise, it’s also essential for back health. With every step you take, the weight of your pelvis and free leg must be supported by muscles that stabilize your spine (specifically, the quadratus lumborum). The more you walk, the more you improve the endurance of these muscles and their ability to stabilize your spine. How you walk is also important. Avoid a slumped posture by standing tall, ears over shoulders, with a proud chest. This will allow your back extensors to relax as you are propelled along by your glutes and lats as you take long strides at a brisk pace. For many people this will reduce their back pain. However, if you find that after walking a short distance your pain gets worse, you should break it down into manageable intervals, taking a break before your pain starts.Then gradually lengthen the intervals as your capacity increases.
4. Sleep. A lack of good quality sleep has a negative impact on every system in the body, as well as causing inevitable fatigue and depleted energy levels. This impairs your ability to maintain spine-sparing postures consistently, leading to additional stress being placed on the spine. For someone with back pain, it’s also crucial to sleep on the right kind of mattress for your body. Generally speaking, if you have a relatively flat back you will be more comfortable on a harder mattress, whereas if you have a pronounced lordotic curve you will need a softer mattress that your hips can sink into to keep your spine in a more neutral position.
5. Diet. Eating a diet composed mainly of whole foods (as opposed to ultra-processed foods) has a significant, positive impact on your joint health. Firstly, it helps you maintain a healthy weight which places less mechanical stress on your joints. Secondly, your joints are less susceptible to inflammation, and, as a result, osteoarthritis. Finally, it will help you to maintain consistent energy levels which further reduces joint stress by allowing you to maintain joint-sparing postures for longer periods. This is particularly important for people suffering from low back pain.
If you could start a movement that would bring the most amount of wellness to the most amount of people, what would that be?
Walking. Because it has multiple beneficial effects on the body and mind, and, importantly, it’s accessible to everybody. As explained above, it has cardiovascular benefits and is essential for the health of your spine. It also helps you burn calories and will help you maintain a healthy weight which has a positive impact on every system in the body. Finally, it can have psychological benefits whether as a group activity or alone, especially when practiced in nature.
What is the best way for our readers to further follow your work online?
You can find me at my website, www.theback.coach
Thank you for these really excellent insights, and we greatly appreciate the time you spent with this. We wish you continued success.
About The Interviewer: Maria Angelova, MBA is a disruptor, author, motivational speaker, body-mind expert, Pilates teacher and founder and CEO of Rebellious Intl. As a disruptor, Maria is on a mission to change the face of the wellness industry by shifting the self-care mindset for consumers and providers alike. As a mind-body coach, Maria’s superpower is alignment which helps clients create a strong body and a calm mind so they can live a life of freedom, happiness and fulfillment. Prior to founding Rebellious Intl, Maria was a Finance Director and a professional with 17+ years of progressive corporate experience in the Telecommunications, Finance, and Insurance industries. Born in Bulgaria, Maria moved to the United States in 1992. She graduated summa cum laude from both Georgia State University (MBA, Finance) and the University of Georgia (BBA, Finance). Maria’s favorite job is being a mom. Maria enjoys learning, coaching, creating authentic connections, working out, Latin dancing, traveling, and spending time with her tribe. To contact Maria, email her at angelova@rebellious-intl.com. To schedule a free consultation, click here.
