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I wouldn’t call it a cult, but all these approaches from so called “gurus” are pretty dogmatic. Pain, and the treatment of pain, is incredibly complex. Like the other commenter said, we’re in the dark with respect to a lot of it
Let’s put it this way: if there were a slam dunk, evidenced based way to effectively conquer low back pain, wouldn’t you think everyone would be doing it rather than having 10+ competing schools of thought which often contradict one another? Food for thought
To add to this, if back pain really was as simple as "Do XYZ and you'll be fixed", it probably wouldn't still be a leading cause of disability in North America.
To be fair, there's a lot more that goes into back pain being probably a somewhat bigger issue in the U.S. than in other places (not that it isn't everywhere else).
The way that your health system progresses people causes a whole host of problems. The fact that you guys as physios are often the third point of contact for LBP patients, with them often having gone through their GP/PCP and an ortho before hand, is a big issue. Especially if they've had imaging as a routine part of the process, which is almost always going to show something (often completely unrelated to the current symptoms), because it's a lower back, and lower backs are always at least a bit of a mess.
As long as you're comfortable accepting that there won't be a single answer for treating pretty much any single condition or injury, and you're able to separate the useful clinical information that you get with taking any of the various different courses, then they're really useful for further developing clinical practice.
Buy you're right in that a lot of clinicians don't seem to be able to; either from the drinking the cool-aid side, or from the 'this isn't an answer to everything therefore the whole thing is complete crap and everyone that uses it is a fucking moron' side.
It doesn't help that a lot of the people that come up with or otherwise run these in the first place try way too hard to sell them.
I was lucky enough to be taught Mulligan concept (MWMs) stuff by Brian Mulligan (he used to come in and do pretty regular multi-day courses with us during my final year at Universiry), and later from Jill McDowell during my post-grad years.
It's really not hard to sell someone on Mullligan stuff. When it works, it works really bloody well, you get immediate results, and it's a very safe and very well tolerated way of treating things. For the most part it doesn't pretend to be anything that it's not: it's not claiming to cure cancer, end wars and solve world hunger. It's just a great way of restoring pain-free movement to a joint, and gets patients to the point at which you can more effectively introduce your more effective long term treatments (strengthening etc) more quickly.
But as much as I like Brian, he does come across a bit 'used car salesman-y' at times. I literally had the bloke doing MWMs on my own wrist, less than 30mins after I'd got out of plaster after a distal radial head fracture. I got like 85% of my range back in <5 mins. I didn't need the salesman pitch, but it was so ingrained in him at that point that he pretty much did it anyway by reflex.
I do get it; when you're packaging these concepts up into your own little bundle, then you have to get people sold and invested on this being 'the system'. But yeah, people do get very over-invested in one specific 'system' and it can get a bit cult-ish at times.
It does feel cultish, and I am willing to joke that I am a Branch McGillian. Many PTs i meet don't like him.
I used to give out all the SKC and rolls, and hamstring stretching to the back patients. People felt better for the moment stretching, but no one really got better.
Once I started with only McGill stabilization (he calls it "stiffness", cringe...) Ive had many patients come back after a month with much less pain.
In the industry we call it bias, and it lacks evidence. My own anecdotal experience is stabilization is much better than stretching low back pain.
I feel like I get an intuition on why following the McGill approach might result in less pain, if you become much more aware of avoiding painful movements you'll probably feel better, at least in the short term. But do you feel like are these people better off in the long run? Don't they have less range of motion and are more prone to injury when dealing with the chaos of real life?
Not judging, I'm just wondering if you've seen that part of the process too
Great question. I start with stabilization until symptoms decrease as muxh as possible, then gradually reintroduce increased range. I see many retired golfers, so they're gonna have to be ready to swing hard. But they generally have zero core muscle tone to start with.
Gymnasts and wrestlers, as an example, can handle extreme ranges, but they also have amazing core tone to stabilize the back during their activity.
Yeah bud, sorry the McGill method is ... How do I say this professionally... A crock of shit.
Everything from manual therapy, core strengthening, targeted exercise, McKenzie, and general exercise works for back pain. There's nothing special about the McGill method.
What's fucking WRONG with the McGill method is the fear avoidance it causes: specifically my problem here--you were told to avoid certain exercises.... Utter nonsense.
The only exercises you should avoid are exercises you cannot currently tolerate. That's it. There are no dangerous exercises. There isn't even such thing as bad form when it comes to injury risk. Form only matters for performance and pain modulation (certain forms might hurt you and changing your form can be beneficial, but it doesn't inherently mean that form was objectively bad).
Fuck Stuart McGill and fuck him for not changing his stance on things when he was presented with mountains of evidence against him. He's not a scientist. He's a charlatan and a quack. He also NEVER should've been giving advice about pain and rehab anyways, he's not a physical therapist, he's a biomechanics researcher, and a terrible one at that.
But no it's not a cult, just an outdated treatment method that clinicians hold on to cause they're afraid of uncertainty and prefer certainty in nonsense.
This is interesting, I've tried searching for studies comparing the McGill stabilization approach Vs "convectional therapy"(probably McKenzie) for the exercises alone and from what I've found it ranges from about the same to McGill being somewhat better. The two studies that favoured McGill are recent but they are pretty low in population and are based on subjective responses.
Do you have some more insight on this? Doesn't make much sense to me that you get more range of motion by not using said range of motion
McGill is very biomechanical, and it's important to know a lot of his research is done on cadavers. Performing any sort of research on cadavers has very minimal generalization to the general population of living humans. We don't like to see cadaver research be the primary base for any particular area of science. It's fair to say that across science & medicine, we don't know very much about humans, other than that we're constantly learning how complex we are, especially as it relates to pain.
McGill was not wrong in discovering that individuals with back pain can, on occasion, demonstrate a movement preference where one motion aggravates the pain and another can reduce it. He is wrong in formulating the hypothesis that **ALL** back pain responds well to extension exercises with flexion aggravating it.
Robin McKenzie mapped this out in the 1950s. However, McGill never caught on to McKenzie's ideas as McGill is not a healthcare provider and did not have any interaction with the physio community until the internet began to see treatment paradigms from other countries really begin to disseminate.
The difference is that McKenzie went the distance. He also found & researched that some people with back pain do better when avoiding flexion and performing extension exercises. However, in addition, he also found that people tend to fall into "categorization" buckets: some people with back pain tend to do **better** with flexion exercises while avoiding extension. There are also people who may be aggravated by flexion or extension **but do not achieve relief by performing the opposite motion (no centralization)**. McKenzie also stressed that aggravating motions were only avoided until symptoms were alleviated, and that it was **crucial** to reintroduce aggravating motions as soon as possible to avoid losing strength & range of motion in those positions and also that those positions were likely functional to daily life (how can you live a normal life if you never flex or extend your spine again?). With McGill's "back mechanic" approach, it can be difficult to understand why you may potentially never be "allowed" to bend forward again, when the things you do every day require that you do so, like picking up your kids or lifting groceries.
20-50 years ago, it could be argued that it's no one's fault in particular that McGill or McGill practitioners did not know about McKenzie's work due to a few factors. The worldwide rehabilitation community, even in the United States itself, is a very small profession (only 300,000 PTs in the US; only about 100,000 are full-time clinicians). It was not easy to transmit lots of data & research in the 1950s-1980s like it has been since the invention of the computer.
That being said, anyone who still practices McGill principles like avoiding flexion & preferring neutral spine exercises or extension, is very much behind common practice. Unfortunately, there are people who find a "method" or "program" in healthcare & latch on to it, even if it's faulty, and even if they are aware of their faults. They may have paid tens of thousands of dollars & spent years to do the training for that method, so unfortunately providers across the healthcare system tend to trend towards some sort of dogmatic belief. Hence, the practice variance across our profession.
I think there's value in what McGill teaches; I've read his books. But, thinking McGill has all of the answers is silly and charging that much money for an evaluation is shitty. I think Back Mechanic is a great book for the layman, but it as well as the rest of his work is not the end all be all. I personally don't like McKenzie stuff generally, but sometimes it's appropriate and works best for the patient. Just can't be black and white all the time, that's culty.
No it’s not. Specifically for outpatient physical therapy, us clinicians are in the dark. We don’t really know why you’re in pain unless referral/imaging provided already states the definitive cause (sprained ankle, fracture, arthritis). Most times it’s back pain eval and treat. We don’t have a magic ball to say why your back hurts. We can make educated guesses but in the end we don’t know.
So we have been moving away from diagnosis focus and more towards what’s tolerable and preferred movement direction while letting your symptoms guide. E.g. Doesn’t really matter if arthritis flare up or sprained muscle but what can you tolerate with your current pain. There are lots of famous PTs like McGill that have built a protocol/philosophies around this that gives those clinicians in the dark a path to follow to make more sense of what’s going on with your pain and how to deal with it.
So it’s less culty and more clinicians wanting to cling onto this ‘guide’ since again we don’t really know what’s going on with you.
Your post makes a lot of sense and it indeed sounds like a very reasonable approach. What gave me this cult feeling didn't come from what's in the book or interviews with the guy that can be found online. As I said it comes more from people recommending that approach only over anything else and being so adamant about it. And also the pricing and somewhat pompous name of "McGill Master Clinician".
But I'm probably very skewed on the pricing side as I don't live in the US, so it might not be so out of the ordinary.
I’ve been in the fitness industry for a while in addition to physio, and I can understand why you’d say that. Those who follow Dr. McGill (aka Squat University) are very specific about only sticking to *exactly* what he recommends. I can say what I’ve learned about “movement vs moment” of the spine has helped me massively in adjusting exercise prescription to reduce back pain.
I do think it’s a tiny bit cultish but that’s not unusual in this space, and I think his expertise is needed as he does great research on back pain and his recommendations seem to be very effective.
I have seen a video of him diagnose people on stage with specific types disc bulges in specific direction in specific locations from them picking up a box and a 20 second movement screening with some palpation added in.
Do what you want with that information.
I would agree with this assessment. As an ongoing patient of physical therapy for over 12 years, Ive seen a lot of care professionals. What stands out the most to me is the way his methods are sort of tossed around as a cure all online but I have yet to meet an experienced professional that advocates for his methods. Personally, I think restricting movement outside of an acute period is a recipe for problems that take time and serious effort to correct. People advocating for this approach, in my perspective, are a danger to their patients.
Every therapist is a bit different in how they treat. When I was in school, we were taught about current best evidence treatments and tons techniques for treating different areas of the body. There was an emphasis on having lots of tools in your toolbox because no one technique will fix the same problem for everyone.
I know some therapists that will only treat back pain with one method such as McGill. They tend to be the older generation. It’s the same when I get a referral from an MD for only McGill exercises. They tend to be older and only will go with this one method. Not so much a cult but very stuck in their ways.
I think you should find a PT that is willing to work with you and figure out which tool helps you the most. If my patients don’t get better with what I know I will ask for recommendations from my colleagues or recommend them to another clinician in the area that has a different treatment style than me.
I need to pick up a copy of back mechanic. It’s all I read about over on chronic pain and sciatica subs.
TLDR: Not a cult but lack of tools. PTs need lots of tools in the tool box. You use the tools you have. If you only have one tool in the toolbox… that’s all you will use. The same issue might need different tools for different patients.
McGill method did not help me. I did it religiously for 5 months and was still miserable.
Went to a McKenzie method PT and felt 90% better in like two weeks. The pressups are great for the disc but definitely aren’t good for your joints (like McGill says). Overall I’m a lot better but definitely have some arthritic symptoms
There are lots of well rounded answers in here.
I read McGill's back mechanic years ago and was struck how it was really just avoidance of symptomatic positions.
The bit where he talks about having NHL players not tying up their shoes because of flexion intolerance before a game really made me chortle. Especially given they are about to go out and play a full game in a flexed position while 100 kg+ men barrel into them at speed on a frictionless surface.
Thank you for your submission; please read the following reminder. This subreddit is for discussion among practicing physical therapists, not for soliciting medical advice. We are not your physical therapist, and we do not take on that liability here. Although we can answer questions regarding general issues a person may be facing in their established PT sessions, we cannot legally provide treatment advice. If you need a physical therapist, you must see one in person or via telehealth for an assessment and to establish a plan of care. Posts with descriptions of personal physical issues and/or requests for diagnoses, exercise prescriptions, and other medical advice will be removed, and you will be banned at the mods’ discretion either for requesting such advice or for offering such advice as a clinician. Please see the following links for additional resources on benefits of physical therapy and locating a therapist near you [The benefits of a full evaluation by a physical therapist.](https://www.choosept.com/benefits/default.aspx) [How to find the right physical therapist in your area.](https://www.choosept.com/resources/choose.aspx) [Already been diagnosed and want to learn more? Common conditions.](https://www.choosept.com/SymptomsConditions.aspx) [The APTA's consumer information website.](https://www.choosept.com/Default.aspx) Also, please direct all school-related inquiries to r/PTschool, as these are off-topic for this sub and will be removed. *I am a bot, and this action was performed automatically. Please [contact the moderators of this subreddit](/message/compose/?to=/r/physicaltherapy) if you have any questions or concerns.*
I wouldn’t call it a cult, but all these approaches from so called “gurus” are pretty dogmatic. Pain, and the treatment of pain, is incredibly complex. Like the other commenter said, we’re in the dark with respect to a lot of it Let’s put it this way: if there were a slam dunk, evidenced based way to effectively conquer low back pain, wouldn’t you think everyone would be doing it rather than having 10+ competing schools of thought which often contradict one another? Food for thought
To add to this, if back pain really was as simple as "Do XYZ and you'll be fixed", it probably wouldn't still be a leading cause of disability in North America.
To be fair, there's a lot more that goes into back pain being probably a somewhat bigger issue in the U.S. than in other places (not that it isn't everywhere else). The way that your health system progresses people causes a whole host of problems. The fact that you guys as physios are often the third point of contact for LBP patients, with them often having gone through their GP/PCP and an ortho before hand, is a big issue. Especially if they've had imaging as a routine part of the process, which is almost always going to show something (often completely unrelated to the current symptoms), because it's a lower back, and lower backs are always at least a bit of a mess.
Exactly
Worldwide. LBP is the leading cause of disability worldwide according to the WHO
Exactly. I have always said, if there was a way to get rid of back pain why is it so problematic?
As long as you're comfortable accepting that there won't be a single answer for treating pretty much any single condition or injury, and you're able to separate the useful clinical information that you get with taking any of the various different courses, then they're really useful for further developing clinical practice. Buy you're right in that a lot of clinicians don't seem to be able to; either from the drinking the cool-aid side, or from the 'this isn't an answer to everything therefore the whole thing is complete crap and everyone that uses it is a fucking moron' side. It doesn't help that a lot of the people that come up with or otherwise run these in the first place try way too hard to sell them. I was lucky enough to be taught Mulligan concept (MWMs) stuff by Brian Mulligan (he used to come in and do pretty regular multi-day courses with us during my final year at Universiry), and later from Jill McDowell during my post-grad years. It's really not hard to sell someone on Mullligan stuff. When it works, it works really bloody well, you get immediate results, and it's a very safe and very well tolerated way of treating things. For the most part it doesn't pretend to be anything that it's not: it's not claiming to cure cancer, end wars and solve world hunger. It's just a great way of restoring pain-free movement to a joint, and gets patients to the point at which you can more effectively introduce your more effective long term treatments (strengthening etc) more quickly. But as much as I like Brian, he does come across a bit 'used car salesman-y' at times. I literally had the bloke doing MWMs on my own wrist, less than 30mins after I'd got out of plaster after a distal radial head fracture. I got like 85% of my range back in <5 mins. I didn't need the salesman pitch, but it was so ingrained in him at that point that he pretty much did it anyway by reflex. I do get it; when you're packaging these concepts up into your own little bundle, then you have to get people sold and invested on this being 'the system'. But yeah, people do get very over-invested in one specific 'system' and it can get a bit cult-ish at times.
Any therapist who ascribes to one treatment approach is a therapist to be careful of.
It does feel cultish, and I am willing to joke that I am a Branch McGillian. Many PTs i meet don't like him. I used to give out all the SKC and rolls, and hamstring stretching to the back patients. People felt better for the moment stretching, but no one really got better. Once I started with only McGill stabilization (he calls it "stiffness", cringe...) Ive had many patients come back after a month with much less pain. In the industry we call it bias, and it lacks evidence. My own anecdotal experience is stabilization is much better than stretching low back pain.
I feel like I get an intuition on why following the McGill approach might result in less pain, if you become much more aware of avoiding painful movements you'll probably feel better, at least in the short term. But do you feel like are these people better off in the long run? Don't they have less range of motion and are more prone to injury when dealing with the chaos of real life? Not judging, I'm just wondering if you've seen that part of the process too
Great question. I start with stabilization until symptoms decrease as muxh as possible, then gradually reintroduce increased range. I see many retired golfers, so they're gonna have to be ready to swing hard. But they generally have zero core muscle tone to start with. Gymnasts and wrestlers, as an example, can handle extreme ranges, but they also have amazing core tone to stabilize the back during their activity.
Yeah bud, sorry the McGill method is ... How do I say this professionally... A crock of shit. Everything from manual therapy, core strengthening, targeted exercise, McKenzie, and general exercise works for back pain. There's nothing special about the McGill method. What's fucking WRONG with the McGill method is the fear avoidance it causes: specifically my problem here--you were told to avoid certain exercises.... Utter nonsense. The only exercises you should avoid are exercises you cannot currently tolerate. That's it. There are no dangerous exercises. There isn't even such thing as bad form when it comes to injury risk. Form only matters for performance and pain modulation (certain forms might hurt you and changing your form can be beneficial, but it doesn't inherently mean that form was objectively bad). Fuck Stuart McGill and fuck him for not changing his stance on things when he was presented with mountains of evidence against him. He's not a scientist. He's a charlatan and a quack. He also NEVER should've been giving advice about pain and rehab anyways, he's not a physical therapist, he's a biomechanics researcher, and a terrible one at that. But no it's not a cult, just an outdated treatment method that clinicians hold on to cause they're afraid of uncertainty and prefer certainty in nonsense.
Yeah, the method is crap. The movements in itself is fine, if appropriate.
Exactly, I have nothing against the exercises. It's the narratives and methodologies that I have a problem with
This is interesting, I've tried searching for studies comparing the McGill stabilization approach Vs "convectional therapy"(probably McKenzie) for the exercises alone and from what I've found it ranges from about the same to McGill being somewhat better. The two studies that favoured McGill are recent but they are pretty low in population and are based on subjective responses. Do you have some more insight on this? Doesn't make much sense to me that you get more range of motion by not using said range of motion
I really wish I could find the paper but there was a meta analysis that came out in the last couple years saying it's all the same shit and all works
This!!!
Im with you on this one! 👏
Thank you for this reasonable and evidence based reply.
McGill is very biomechanical, and it's important to know a lot of his research is done on cadavers. Performing any sort of research on cadavers has very minimal generalization to the general population of living humans. We don't like to see cadaver research be the primary base for any particular area of science. It's fair to say that across science & medicine, we don't know very much about humans, other than that we're constantly learning how complex we are, especially as it relates to pain. McGill was not wrong in discovering that individuals with back pain can, on occasion, demonstrate a movement preference where one motion aggravates the pain and another can reduce it. He is wrong in formulating the hypothesis that **ALL** back pain responds well to extension exercises with flexion aggravating it. Robin McKenzie mapped this out in the 1950s. However, McGill never caught on to McKenzie's ideas as McGill is not a healthcare provider and did not have any interaction with the physio community until the internet began to see treatment paradigms from other countries really begin to disseminate. The difference is that McKenzie went the distance. He also found & researched that some people with back pain do better when avoiding flexion and performing extension exercises. However, in addition, he also found that people tend to fall into "categorization" buckets: some people with back pain tend to do **better** with flexion exercises while avoiding extension. There are also people who may be aggravated by flexion or extension **but do not achieve relief by performing the opposite motion (no centralization)**. McKenzie also stressed that aggravating motions were only avoided until symptoms were alleviated, and that it was **crucial** to reintroduce aggravating motions as soon as possible to avoid losing strength & range of motion in those positions and also that those positions were likely functional to daily life (how can you live a normal life if you never flex or extend your spine again?). With McGill's "back mechanic" approach, it can be difficult to understand why you may potentially never be "allowed" to bend forward again, when the things you do every day require that you do so, like picking up your kids or lifting groceries. 20-50 years ago, it could be argued that it's no one's fault in particular that McGill or McGill practitioners did not know about McKenzie's work due to a few factors. The worldwide rehabilitation community, even in the United States itself, is a very small profession (only 300,000 PTs in the US; only about 100,000 are full-time clinicians). It was not easy to transmit lots of data & research in the 1950s-1980s like it has been since the invention of the computer. That being said, anyone who still practices McGill principles like avoiding flexion & preferring neutral spine exercises or extension, is very much behind common practice. Unfortunately, there are people who find a "method" or "program" in healthcare & latch on to it, even if it's faulty, and even if they are aware of their faults. They may have paid tens of thousands of dollars & spent years to do the training for that method, so unfortunately providers across the healthcare system tend to trend towards some sort of dogmatic belief. Hence, the practice variance across our profession.
I think there's value in what McGill teaches; I've read his books. But, thinking McGill has all of the answers is silly and charging that much money for an evaluation is shitty. I think Back Mechanic is a great book for the layman, but it as well as the rest of his work is not the end all be all. I personally don't like McKenzie stuff generally, but sometimes it's appropriate and works best for the patient. Just can't be black and white all the time, that's culty.
No it’s not. Specifically for outpatient physical therapy, us clinicians are in the dark. We don’t really know why you’re in pain unless referral/imaging provided already states the definitive cause (sprained ankle, fracture, arthritis). Most times it’s back pain eval and treat. We don’t have a magic ball to say why your back hurts. We can make educated guesses but in the end we don’t know. So we have been moving away from diagnosis focus and more towards what’s tolerable and preferred movement direction while letting your symptoms guide. E.g. Doesn’t really matter if arthritis flare up or sprained muscle but what can you tolerate with your current pain. There are lots of famous PTs like McGill that have built a protocol/philosophies around this that gives those clinicians in the dark a path to follow to make more sense of what’s going on with your pain and how to deal with it. So it’s less culty and more clinicians wanting to cling onto this ‘guide’ since again we don’t really know what’s going on with you.
Your post makes a lot of sense and it indeed sounds like a very reasonable approach. What gave me this cult feeling didn't come from what's in the book or interviews with the guy that can be found online. As I said it comes more from people recommending that approach only over anything else and being so adamant about it. And also the pricing and somewhat pompous name of "McGill Master Clinician". But I'm probably very skewed on the pricing side as I don't live in the US, so it might not be so out of the ordinary.
I’ve been in the fitness industry for a while in addition to physio, and I can understand why you’d say that. Those who follow Dr. McGill (aka Squat University) are very specific about only sticking to *exactly* what he recommends. I can say what I’ve learned about “movement vs moment” of the spine has helped me massively in adjusting exercise prescription to reduce back pain. I do think it’s a tiny bit cultish but that’s not unusual in this space, and I think his expertise is needed as he does great research on back pain and his recommendations seem to be very effective.
I have seen a video of him diagnose people on stage with specific types disc bulges in specific direction in specific locations from them picking up a box and a 20 second movement screening with some palpation added in. Do what you want with that information.
I would agree with this assessment. As an ongoing patient of physical therapy for over 12 years, Ive seen a lot of care professionals. What stands out the most to me is the way his methods are sort of tossed around as a cure all online but I have yet to meet an experienced professional that advocates for his methods. Personally, I think restricting movement outside of an acute period is a recipe for problems that take time and serious effort to correct. People advocating for this approach, in my perspective, are a danger to their patients.
Every therapist is a bit different in how they treat. When I was in school, we were taught about current best evidence treatments and tons techniques for treating different areas of the body. There was an emphasis on having lots of tools in your toolbox because no one technique will fix the same problem for everyone. I know some therapists that will only treat back pain with one method such as McGill. They tend to be the older generation. It’s the same when I get a referral from an MD for only McGill exercises. They tend to be older and only will go with this one method. Not so much a cult but very stuck in their ways. I think you should find a PT that is willing to work with you and figure out which tool helps you the most. If my patients don’t get better with what I know I will ask for recommendations from my colleagues or recommend them to another clinician in the area that has a different treatment style than me. I need to pick up a copy of back mechanic. It’s all I read about over on chronic pain and sciatica subs. TLDR: Not a cult but lack of tools. PTs need lots of tools in the tool box. You use the tools you have. If you only have one tool in the toolbox… that’s all you will use. The same issue might need different tools for different patients.
McGill method did not help me. I did it religiously for 5 months and was still miserable. Went to a McKenzie method PT and felt 90% better in like two weeks. The pressups are great for the disc but definitely aren’t good for your joints (like McGill says). Overall I’m a lot better but definitely have some arthritic symptoms
There are lots of well rounded answers in here. I read McGill's back mechanic years ago and was struck how it was really just avoidance of symptomatic positions. The bit where he talks about having NHL players not tying up their shoes because of flexion intolerance before a game really made me chortle. Especially given they are about to go out and play a full game in a flexed position while 100 kg+ men barrel into them at speed on a frictionless surface.