Dr. Shirley Sahrmann — A Legendary PT Does a Deep Dive on Tim’s Low-Back Issues, Teaches How to Unlearn Painful Patterns, Talks About Movement as Medicine (or Poison), and More (#685)

Dear Tim, A fascinating story by Reuben Laukkonen that might be of some interest: https://open.substack.com/pub/rubenlaukkonen/p/how-ketamine-fixed-my-lower-back?r=34xpr&utm_campaign=post&utm_medium=web Wishing you healing and wellness brother

Tim, So sorry your back's been a thing for you. I wanted to reach out to you with this info a month or so back but completely spaced it! I am a physical therapist in the US, and have a ton of respect for Shirley Sarhmann. However, if you are still having issues please check out Peter O'Sullivan a PT and researcher out of Australia and consider having him on your podcast. He combines modern Pain Neuroscience Education with some seemingly counter-intuitive suggestions for movement. For example: many people who have spine pain are unconsciously actually co-contracting the muscles of their trunk too much, adding to compression on the spine. I have many years practicing with a similar approach, and feel this information needs to be heard far and wide. Here is a link to a video and a YouTube podcast. Good luck and godspeed! And I'd be happy to answer any other questions for you. Thanks for all you do! Derek Green DPT, OCS, Cert.MDT, etc etc. Bend, Oregon. [Moderator: links removed per embed policy.]

Hey Tim, great interview thanks. Just wondering if you have experimented with walking using a metronome ? If you’re striding out with a long stride that would definitely overactivate the hip flexors and stressing the lumbar spine. Switching to a high cadence / short step (approx 120-130 steps per minute) could be worth an experiment? Also you may interested in talking with Prof Peter O’Sullivan who specializes in chronic low back pain, he designed an approach called Cognitive Functional Therapy which sees recovery from a much broader lens, specifically targeting beliefs. Cheers Dan

Fantastic podcast …and woman!

Hi Tim You might wanna look into the work of Dr. John Sarno, Howard Schubiner, David Hanscom etc. Success rates are comparatively high and – if I may say so – your personality profile makes you a likely candidate. Another route, would be Prof. Stuart McGill. His evaluation method is exceptionally effective and results in a tailored set of exercises. Understanding its core principles might be more demanding of the practitioner than other modalities though. Your work has helped me immensely and I hate that you have to go through this. All the best Walter Stähli

Dear Tim, Listening to the latest episode makes me think you might carry PEC pattern with underlying L AIC pattern of PRI(Postural Restoration Institute). Dr, Sahrmann was and is a legendary pioneer in MSK PT field for sure and actually DNS, you mentioned, was, I believed, influenced by her works as well. Now, gotta add the most important Nervous and Respiratory systems on top of it. She mentioned about loading on lateral aspect of right foot and medial aspect of left foot and that is the part of typical L AIC pattern. I hope you have an interview with Ron Hrusak, the founder of PRI, to get more depth of being human.

Brilliant interview. Wills love some video clips of the exercises that were discussed!

Thank you for the thoughtful interview and for choosing wisely the PT to interview. She influenced my practice in the 90s and I am so grateful for her contribution to PT and to my professional life. Nice choice Tim!

YES! The Godmother!! I’m such a proud WashU PT grad right now. She is THE driving force pushing what PT can be. Thank you, thank you, THANK YOU, Tim, for having her on the podcast with you. She is such a magnetic personality, and every time I hear her speak, it’s a gift. She gives me hope in these dark ages of healthcare.

Tim, First of all, I want to thank you for the work you've been doing. Your podcasts and books have been very influential in my life and have helped me get through very tough times during my recovery from a brain injury. You stated in this episode you've gotten the most relief from releasing your iliacus. If the relief is only temporary or partial, my guess is they are not completely releasing the iliacus, psoas, and other involved muscles both in the shortened AND lengthened positions. I highly recommend checking out Moench Method Bodywork in Austin (official massage therapy provider for Austin FC). After experiencing the pain relief from their method and seeing many other clients (while shadowing) get "miraculously" healed from their chronic pain they've lived with for years, I left my engineering career and became a massage therapist to learn it. The founder travels all over the country and works on elite athletes including Aaron Judge. He's not available to book directly, but I can get you connected if you're interested. One more thing, your sleep position matters. To avoid shortening your hip flexors, sleep on your back (with a pillow underneath your knees if needed). Sleeping on your back will be much more comfortable if you release the hip flexors first. I hope you resolve your chronic pain so you can continue to do the amazing work you've been doing, but without the distraction of pain! -Yusef

Tim and his Team, I thought it might be useful to synthesize some of the great suggestions for Tim and his podcast given in this comment section, because there is some overlap. 1) Dr. Sarno was a pioneer decades ago in identifying the potential mind-body reasons for someone's chronic pain, especially in the spine. However, I think it is safe to say that his theories and suggestions, though helpful for many people, might be a bit simplistic to be applied to everyone. Which leads us to… 2) Modern Pain Neuroscience Education teaches patients about the "Biopsychosocial" model of pain and that most persistent pain is not due to simple tissue damage, instead that the nervous system has become "sensitized" and that pain becomes an over-active protection system that has outlived its usefulness. Stress, hyper-vigilance, catastrophic thinking, past traumas, etc can all lead to increased sensitization. By learning that pain is not always due to tissue damage or "something wrong" this alone can decrease the vigilance, sensitivity and maladaptive patterns around pain. Some people that would be excellent to have on your podcast would be Dr. Rachel Zoffness or Alan Gordon LCSW, both have written books and are wonderful ambassadors to this world. As is Professor Lorimer Moseley out of Australia. I have long thought this information is not as widely understood by the public as it should be, and that big podcasts like yours, Peter Attia, Huberman, etc would be doing a huge public service to get this information out there more. 3) One commenter suggested Ketamine therapy. Indeed psychedelic-assisted therapy for chronic pain has great potential, with many studies currently underway (I can give you more info on this if needed). My own opinion is that it would be especially helpful if given within the context of PNE. Of course psychedelic-assisted therapy can help on its own if the root cause of someone's sensitization or hyper-vigilance can be addressed, such as working through past traumas,depression/anxiety, etc. 4) Professor Peter O'Sullivan out of Australia takes the lessons of PNE and applies it to the specifics of lumbar spine pain with amazing results. He focuses on the beliefs around the pain, what people think they should or shouldn't be doing (often from well-meaning professional), which are often making things worse. And addressing those maladaptive patterns. My original suggestion of Tim checking Peter O'Sullivan out is due to how his approach checks a lot of boxes, and in my own experience are often crucial for this population. 5) As a physical therapist myself I would be remiss if I did not include more of the "bio" part of the "biopsychosocial" approach. There are clearly mechanical reasons for pain, even in the sensitized individual. Sarhmann is one approach. Stuart McGill was also recommended in these comments. He has had a lot of success with being really good at the basics of mechanical triggers and strengthening. Another approach is Mechanical Diagnosis and Treatment (MDT), also known as the McKenzie method. When MDT works it is remarkable how quick acting it is and it gives the patient tools that can last a lifetime. There is a great practioner/teacher of this method in the Austin area, if you are still living there. Scott Herbowy PT, practicing at Tillman PT in Cedar Park, Tx. 6) As a PT myself who works with chronic low back pain, I would say some combination of PNE, movement re-training, self management, and targeted manual work all contribute to the most lasting changes. Good luck and hope this helps! Derek Green DPT, etc, etc. Bend, Oregon.

Dr. Sahrmann is amazing! The extreme wealth of knowledge she has at her fingertips shows that she as a true professional/artist in her field. But I just need to make a comment here because of something else. Dr. Sahrmann's sense of humor just completely overwhelmed me. It's subtle, fantastically timed, and (to my taste) laugh-out-loud funny without ever trying to be a comedy night. Cheers, Saša

Absolutely captivating! The episode featuring Dr. Shirley Sahrmann on "The Tim Ferriss Show" is a masterpiece. Dr. Sahrmann's expertise in physical therapy shines in this illuminating conversation. Her insights into the link between movement patterns and pain are enlightening. Her emphasis on recognizing problematic movement and unlearning pain is motivating. Her explanation of the body's tendency to follow the path of least resistance and its impact offers perspective.

Hi Tim, Thanks for the episode with Dr. Sahrmann, it was really interesting and motivating! Would you share with us some graphics, photos, or some visual aid with the exercises recomended by the Dr, please. Thank you again Best Regards Alejo

Hi Tim, I know this is unrelated, but while browsing the NASA website with my son, I came across this amazing video of the Apollo 13 mission. I was so moved by it – the sheer human ingenuity and problem solving that led to the successful return of human life was immensely inspirational. The comments of the astronauts and the clips of the united patriotism surrounding it was a refreshing journey. I hope you can watch it and share with your audience. Here is the link: [Moderator: YouTube link to video "Apollo 13: Home Safe," which may be found on NASA's official YouTube page, redacted per embed policy.] Best, Vince

I'm a long-time listener as well as a physical therapist. Although I'm sorry to hear that you've been dealing with chronic low back pain, I've found your recent series of episodes with various specialists really interesting. My specific area of practice is pelvic health, which is closely related to the low back and hip regions. I'm wondering if Tim has heard of pelvic health physical therapy and/or worked with any experts in this specialty? I think he'd find this area of practice fascinating, independent of whether or not he specifically would benefit. In addition, thank you for your show. I have learned so much from Tim's podcast, and I credit him in part to opening my own business and inspiring me to try my hand at being an entrepreneur. I can honestly say the podcast enriches my life and am grateful to Tim and the team! Many thanks and kind regards, Jen

Prof. Sahrmann is awesome! If you’re interested in “alternative” ways of treating persistent low back pain, you could interview Prof. Lorimer Moseley. He’s dedicated 30 years studying pain science and finding out ways to retrain the brain. He’s also quite entertaining during his conferences.

Interesting episode. Working on your iliacus helps the psoas to relax. SIJ pain from tight Piriformis and other deep rotators like the gemelli and obturator internus which fight the TFL (internal rotatior). QL tight (short) because it's protecting the spine from forward sheer from the tight psoas. Tight psoas causes pain in the low lumbar especially when you first stand up after sitting a while. Then you can walk it out by warming up the psoas. You just need motor point acupuncture to get your muscles back to their normal and elastic state so your pelvis is aligned and you can move without pain. I'd demonstrate if to you in 30 minutes if you are interested.

https://sonjemayo.com/ Sonje Mayo is a South African born PT now living in Nashville. She is world renown for her Pilates training and has worked with men with Scherman’s Disease. She is also skilled with the treatment of scoliosis and other movement pathologies. Like Dr. Sahrmann, she has been in the business for decades..born in 1945 and trained directly with Joseph Pilates. It would be fascinating to see her take you through a basic Pilates workout designed with your “issues” in mind. Perhaps less emphasis on the rectus abdominus and instead focus on their elongation plus gentle thoracic extension. She has a number of workshops online at Pilatesology if you want to check her out.

Missing one key piece…. As a PT, I first attended a Shirley Sahrmann course a couple of decades ago. She is a giant in the field and has contributed so much (and I agree, most PTs don't look at movement patterns and larger pictures as much as they need to). But after switching into neurological PT, treating patients after stroke and brain injury, I was introduced to the mind-bendingly incredible world of the Bobath concept. It is everything Dr. Sahrmann says (and more) but without the patient having to cognize their movements. After 15 years working alongside and studying with advanced Bobath teachers and colleagues, I know that creating a change in movement patterns through cognition is limited. In other words, telling someone to "think about keeping your back still while you lift your leg" isn't going to have as dramatic (or sometimes any lasting) effect as skillfully facilitating the desired movement so that the patient's brain experiences the new and more efficient movement pattern. Exercises to lengthen certain muscles can help make this retraining more possible, but may not do it on its own. Walking (or any other movement) is not a thought process, and shouldn't require one. In other words, you have to be able to walk and chew gum (or have a conversation or watch for cars crossing the street). In order to change how we move and which muscles are kicked in and which relax, you have to re-wire the movement parts of your brain so that you don't have to cognitively strategize getting out of bed. Of course, especially for someone with your degree of knowledge, awareness will help. I hope it solves your pain. But if you can find a advanced-level Bobath PT to work with (who doesn't exclude you because they have a long waitlist of catastrophically neuro-impaired patients!), your brain will change how it tells your body to move, and the muscles will follow. This is a clinic teaching video, but a quick demo of the topic on a neuro-intact subject: [Moderator: Link to YouTube video titled "Stimulating the extensor muscles of the forearm for early grasp recovery BBTA July 2020" removed due to embed policy.]

Hi Tim, This interview is great. I've only listened to it, but feel like I have some similarities with my own back pain issues, so plan to watch in the near future. Something popped into my head when I was stretching out, which is related to Shirley saying that you shouldn't point your feet forwards when dead lifting if that isn't naturally your posture. Now where I'm going with this relates to previous podcasts and one of your sponsours, so I apologise if it becomes controversial. You have talked about a product, (that will not be named…), that has lots of sensors that guide you in the use of it. What if your back pain stems from use of this product, by following the guidelines that don't work for your natural posture and body movement? A quick search of this website shows that it was first mentioned about 9 months ago so the timing matches up with how long you said that you've had back pain for. Obviously I have no proof, and it would be pretty hard to show as a difinitive cause, but think that it is something that is worth considering. Hope that you find this useful.

Excellent Information in this Podcast- I am a Yoga Instructor and there is a question that came up during the interview at one Point Shirley mentioned completely leaving the back alone as much as possible for some times of pain What are your thoughts of taking that advice vs strengthening exercises (which were also mentioned in the podcast) its seems to me that in most cases increasing the Mobility in said region and strategic rest would be preferred

Hi Tim, Thanks for everything you do. I have been learning from your content for years. The most useful books I have found on back pain are Healing Yoga by Dr. Loren Fishman and Treat your own back by Rob McKenzie. I have written of my own experiences in backpain on my website in case you find it helpful.

Hi Tim and Team , Long time listener, first time caller as they like to say. I've been listening since the very beginning and have learnt so much from you!! Please look into Dr Stuart McGill. He has been mentioned elsewhere in the comments and Eric Cressey mentioned him a few times in your interview with him. By following his method and doing the "Big Three" exercises daily I have cured my back pain and quite literally changed my life. Try and reach out to him, or simply buy his book "Back Mechanic" and make your own opinion on his viewpoint. I wish you a speedy and successful recovery from your back pain! All the best Will.

Hi Tim, Are your pants too tight? Have you tried going commando? Sounds silly at first, but I've noticed that the trunks style boxer shorts cause my back to hurt more. Also track pants with a tight waist band and tight, stretchy jeans cause the same discomfort. I suspect that it has to do with the muscles of the waist and hips being constrained and pushing back unnaturally. I'm not saying that they are the root cause, but I do think that they may exacerbate the issue. Although it would be slightly funny, in a ridiculous way, if Calvin Klein underwear was the root cause of a low back pain epidemic. Anyway. You should try loose pants commando day. See if it helps.

By far, one of your best programs I've ever seen. Shirley Sahrman is amazing! I loved seeing her put her principles into practice by having you stand & move certain ways.

I loved listening to this podcast and Dr. Sahrmann is an amazing ambassador for the Physical Therapy profession. Agreed most people move improperly due to: The path of least resistance. They were never taught the safest and most effective way for their body. Potentially more important, and what wasn't addressed, is that most people do not have a body that allows them to move properly. Dr. Sahrmann alluded to this when speaking about and idiopathic condition called Scheuermann’s disease. As an aside, both personally and professionally, I do not believe in idiopathic. I believe that we are a manifestation of our compensations. Most professionals will agree that this can and does occur anywhere within the kinetic chain. As healthcare professionals, effective permanent change requires that we remove the cause of the compensation first, then give the patient a body that is capable of uncompensated safe and efficient movement. Then teach them to move properly. I 100% agree that safe and efficient movement is far more important than home exercises. While the pelvis is the base of support of the lower back. The feet are the base of support of the pelvis. When patients have pain in standing and less or none when sitting then the cause of the compensation must be, at the very least, impacted by legs and feet. Dr. Sahrmann shared a personal story about when she changed her pelvis, the wearing of her shoes changed. Conversely, it is possible to change the pelvis by addressing the functioning feet. I would love to see an episode about that.

I came here exclusively to say this after the numerous podcasts on exclusively physical treatments to heal from chronic pain with! Tim, for the love of god, please check out the work of Alan Gordon (derived from Dr. Sarno) and the concept of Neuroplastic pain. Keep an open mind that the source of your pain is not physical and imaging is not prescriptive. Wishing you freedom from your chronic pain. I've been there (not any more 😉 ) and it is in a massive energy drainer.

Sorry, didn't know you couldn't post a link. The Video you can check out on Youtube is: "Back pain: separating fact from fiction. Professor Peter O'Sullivan." The podcast is: Empowered Beyond Pain. Episode 17. The Myth of Core Stability. To dive deeper into Pain Neuroscience Education, which is a therapeutic technique that reframes ones story of pain away from that of pure tissue damage and encompasses a Biopsychosocial approach, please see the work of Lorimer Moseley, TED talks, videos etc. Cheers!

100,000% yes to this!

Totally concur with above comment! Find a good Postural Restoration Certified PT. As a Marine, suffered for 4 decades with lower back, sciatic, SI joint, IT band, shoulder and foot pain. Went to an amazing PRI therapist and through a series of exercises, I am now in “neutral” and have zero pain. I am 63 but move like I’m in my 20’s. This PT method looks at the whole body, vice treating body parts. It has been nothing short of miraculous for me. I don’t have to keep going to repeat appointments; if I start feeling twinges, I just do MY exercises and I am back to neutral.

Where can one find these people?

Hi, Will – And thank you for the recommendation. Tim actually included Dr. McGill's book and exercises in his most recent 5-Bullet Friday newsletter! Best, Team Tim Ferriss

That's most likely an entrapment of the superior cluneal nerves. I think Tim's issue is a tight and short psoas and QL. Not his abs.

Just reading this comment has improved my chronic neck, thoracic back, and tension headaches. Thank you! I am absorbing at much podcasts and reading from the people you recommended.

Wow, perfect timing! Fingers crossed that his method will help Tim as much as it has helped me and countless others !! Will