An Interview with Sarah Key Part 1

QUESTION 1 Can you please give us a brief rundown on Masterclasses consist of? 

Levels 1 & 2 the Sarah Key Masterclasses are run together. They consist of 9 webinars that that you
complete online in the comfort of your own home at your own rate (this may take several weeks)
followed by 2 highly intensive Practical Adjunct days from daylight to dark, where I take you through
refining palpation skills with the hands and learning to use the feet to treat the spine. You will hear
more about the feet later.  

Level 1 SKMCs consists of 4 webinars, starting with the critically important ‘Anatomy and
Biomechanics of the Lumbar Spine', followed by intensive information about the two most common
spinal problems - ‘Stiff Spinal Segment' and ‘Facet Joint Arthropathy’ - including the causes, how they
manifest, MRI findings, the manual treatment of and what patients can do themselves (including using
the BackBlock). Then there is the lecture on the ‘The Importance of Spinal Decompression’. Level 2
SKMCs comprises the next three syndromes in my 5 stages of breakdown - ‘Acute Locked Back',
'Prolapsed Intervertebral Disc' and 'Segmental Instability' followed by a lecture on ‘Bending' and an equally important one on ‘Sitting' both of which are factors that feature very much in the life of
somebody with a bad back.
The webinars of Levels 1 and 2 are substantial lectures, between 45 minutes and an hour long, with a
printable Manual downloadable from my own Moodle platform (where the webinars are hosted). 
There is a multiple-choice exam after each webinar with an 80% pass rate which you must complete
successfully in order to progress to the next lecture. The Practicals involve intensive up-skilling of
manual techniques of palpation and spinal treatment. They involve me palpating and ‘treating' each
student’s spine, interactive student-to-student practice sessions and observing me treating multiple
patients with back pain. We are targeting late February 2020 for me to come to India to hold the first
Practical Adjunct sessions.  

QUESTION 2 What started you doing your Masterclasses? 

I don’t really remember the 1990’s. They passed in a sort of blur travelling back and forth between the
two hemispheres, between my home and clinic in Sydney clinic and treating the Royal Family in the
UK. It was some time in the late 1990s that HRH the Prince of Wales suggested I start teaching
physiotherapists in the UK.  I remember I was a bit shocked; like being asked to get over a six-foot
high jump without a run-up. I also was wracked by self-doubt because, remember, I am not an
academic physio. Even my undergraduate training was somewhat lacking. The course in Australia in
those days was a diploma not a degree course and it was deficient in all sorts of areas - scant
biosciences, no research, no anatomical dissection, nor statistics - so I always felt I wasn’t the right
person to be running courses. But I also realised that if felt I felt under-educated
(and underperforming) in the realms of back treatment, then others would too. It was really was when
I started using the BackBlock (more about that later) and seeing the beneficial effects of patients
doing this themselves that I became intrigued what the scientific evidence base for what might be
going on.  
Back pain is difficult to treat and I was finding it hard. Yet I knew I had the runs on the board with the
patients, so I mustbe doing something right. I became intrigued to actually see if I could explain
through science why it was working. But it was a big ask designing a course from scratch. Because by
the time I went back to the college (Cumberland College in New South Wales) and back to the books,
so to speak, there was no library and no books; the ‘library' was a sea of computers. Finding the
authors and following threads to the various papers was a steep learning curve in many ways. The
work of two brilliant anatomical researchers, Nikolai Bogduk (Australia) and Mike Adams (UK) gave
me the first fertile ground to explore and to take leads from. 
Believe it or not, the pearls of scientific data - treasure troves of it - was sitting there, waiting to be
found. It seemed to me that it’d been quietly gathering dust, just waiting for the treating professions (a
hands-on physio like me) to find it and parlay it into the therapeutic world.  I was dumbfounded by how
the science threw itself at me and I went into a sort of working-frenzy writing the Masterclass lectures
in only few months. I found I enjoyed deciphering the science and applying it to therapy, so
that physios could get a sense of what their hands-on treatment and various specific exercises might
be doing.

QUESTION 3 Why are you emphasizing the bio-mechanical treatment of back pain? 

There’s been a fashion of late in the Orthopaedic world to downplay the importance of the biosciences
in the conservative treatment of back pain, which I have found difficult to reconcile. With the truly
awesome function of the highly sophisticated mechanical structure we call the human spine, a tall
multi-segmented column that can bend over double and straighten up again, often carrying weights, it
seemed ludicrous to me not to be trying to understand that function - and how it goes awry. It also felt
like passing the buck - not to mention downright insulting - to fob patients off with thinly disguised
questions about their psycho-social circumstances and their mental attitude towards their pain. 
Agreed, there are some circumstances and some patients who are indeed ‘unfixable' and they are
unfixable by virtue of their emotional attitude and their mind-set. But I think this is only a small group
in a sea of suffering and for this reason, I think we are abrogating our duties as physical therapists not
to be looking for the physical cause of their pain - and not to be treating it physically too.  
One of the scientific advisors in my Masterclasses, Professor Mike Adams of Bristol University, wrote
a fabulous textbook ‘The Biomechanics of Back Pain’ which lays it all out. He is one of the most cited
spinal researchers in the would today, yet Physiotherapy has continued to ignore the basic anatomy,
physics, biomechanics and physiology in applying spinal treatment. I feel we continue this at out peril
and that other professionals - chiropractors and the osteopaths, even masseuses - will step in and
take over from the slot that Physiotherapy should be holding.

QUESTION 4 What about the much-vaunted psycho-social aspects of back pain? Isn’t that

As I said above, there’s a certain category of chronic back sufferer that is unrewarding to treat
manually. And there are some very worrying figures, I think they came out of the the north of England,
where the same small group of people kept representing back at Outpatients Departments seeking
treatment - at significant cost to the public purse. They were 'passive recipients' of hands-on
treatment, not doing much to help themselves, with a sense that they needed to be 'looked after'. The
same patients were frequently diagnosed with clinical depression. 
Dealing with the depression and teaching these patients cognitive behaviour techniques is one way to
go. However, I believe the results are far better if they are provided with very limited hands-on
treatment, combined with information sessions about the way the spine works - and then shown what
they can do to help. Explaining that a segment has become stiff and therefore the IV disc at that level
can’t feed itself (remember 90% of the cases you will see) and how it slowly degenerates if left
unchecked, is a concept that patients can easily grasp. At the same time, it feels a relief to have the
painful segment found (touching the pain is important) and mobilised free.  
Showing patients how they can keep the newfound freedom with their own decompression regime of
exercises will make almost all patients brighten up, feel hope and feel a sense of purposeful
involvement. Usually, the depression fades as the pain lifts. In short, these patients feel brighter for
many reasons: They have been listened to, their pain has been found, the pain focus has been
worked on and they can also do something about it themselves. 

QUESTION 5 What would you say were the 3 key features of the Sarah Key Method as taught
in your Masterclasses?

1. The 5 stages of breakdown of a lumbar motion segment (as discussed in my book ‘The Back
Sufferers’ Bible’) charts the decline of a normal healthy spinal segment, to a stiff spinal
segment, through to an unstable segment. Central to this concept is the function and
physiology of the intervertebral disc, and how it works both in a tensile way as a spinal
connector and in a compressive way as a shock absorber. If the function of water-filled disc
becomes deficient through its sensitive outer skin being traumatised and the segment
becoming stiffer, it may then go on to become dehydrated - and eventually thinner. This
throws extra loading on to both the disc wall (annulus) and the facet joints at the same spinal level. Both the disc and facet joint scenarios cause pain; that oh-so-familiar back pain, either central or one-sided.  

2. Patients using a BackBlock to do their own 'pressure change therapy' regime at home is a
key part of the Practical Adjunct sessions. The disc is a large avascular structure,
metabolically torpid, while at the same time having a high maintenance load from its wear ’n'
tear dual roles. Therapeutic intervention must focus on aiding fluid flow in and out of the discs
to enhance their nutritional supply and speed maintenance and repair of the outer wall. This is
where their daily BackBlock regime comes in with its three step extremes of end-of-range
spinal moment shunting fluid in and out.

3. Honing diagnostic skill using the hands, literally playing the fingers up and down the spine like
a keyboard, to find out which - and in what direction - a spinal segment is stiff is another key
part of the SKM Practicals. Equally, learning how to use the feet (the heel in particular) to
mobilise free a stiff spinal segment is globally unique to the SKM. Students quickly learn how
much easier it is to loosen a spinal link, so that it can ‘pump’ fluid with spinal movement. The
feet are quite controversial - but no place better than India to start with its long history of
Chavutti massage!  

QUESTION 6 Would you say that using your feet to treat spines has been controversial? 

In a word, yes, I think it has.  There’s no doubt about it that in some quarters using feet is looked upon
as being ‘primitive’ and in the universal drive towards all things modern - even though they might be
quite meretricious or valueless - seen as a regressive, non-medical, old-fashioned craft. In
some societies there exist cultural taboos that prevent a man to treat anybody with his feet. So there
are certainly barriers to it. There’s also another aspect to do with it being seen as a sort of folkloric
thing and not crisp and white and ‘sciency-modern enough’.  I couldn’t agree less with this.  I think
that it’s infinitely important to incorporate all ancient wisdoms and crafts into this profession of ours -
this physical-touch profession - and to use it to our advantage as therapists.  People in pain are
desperate; they need it. 
I hope I don’t run up against this in India because there’s no doubt about it the ancient art of Chavutti
massage using feet is extraordinarily valuable and, of course, it’s Indian and been copied the world
over. I think Indian physiotherapists must have an innate advantage over all sorts of other nationalities
and I think that’s really one of the reasons I’ve chosen to branch out from the UK and Australia and
come to India first. 
Interestingly enough, the raised eyebrows about using feet mainly comes from within the profession -
other physios being judgmental before the event - whereas from the patient’s point of view there’s
never any doubt that it feels supremely effective; getting right to the nub of things. The main challenge
is to see it taught properly in a clinical Orthopaedic setting - with appropriate contraindications - and
that it’s taught carefully and safely and hygienically and ‘ticking all the boxes’. Once they take it on,
physios quickly become born again converts about using feet. Apart from the gratification of seeing
their patients’ obvious enthusiasm they quickly see that it’s much more effective and certainly adds to
the ease and longevity of a working life as a physical therapist. 
QUESTION 7 Which parts of your Sarah Key Method are you most proudof ?
As you would know, 'back pain of unknown aetiology' - otherwise known as 'non-specific back pain',
or 'simple back pain' - is the most vexed conundrum facing modern Medicine today. In every society,
it is the diagnosis accorded some 80-90% of cases of back pain and yet there’s still no common
consensus as to what causes the pain.  
Now you might think I'm crazy to be positing an explanation where nobody else seems to have done
so. But I think if you look carefully at the anatomy of the intervertebral disc - where you find that the
outer ‘tensile skin' of the annulus (disc wall) is highly sensitive and works like a ligament, whereas all
of the rest of the disc (the inner and middle annulus and the nucleus) is insensate - you will see that
it’s relatively easy to catch the coordination mechanism unawares and traumatise, or tweak, a spinal
level with a chance unguarded action. I believe ligamentous injury of the outer disc wall is the
root cause of non-specific back pain. In other words, it doesn’t have to a slipped disc, a torn disc, a

degenerated disc (many of which are entirely painless). It’s more likely to be a simple sprain of the
innervated outer few layers of the annulus - and therefore passing un-noticed under the MRI radar. 
The micro-trauma of the annulus makes that segment sore as it sets up a local inflammatory focus
and this immediately sets off a protective response form the local muscles, thereby adding to the pain
and stiffness of the back. Importantly, if this hurt segment stays stiff, a whole degenerative cascade
may play out over time, as a result of the disc at this level being too locked away to feed itself.
Carefully treating the painfully stiff segment with manual mobilisation ekes it back into mobility with
the rest of the spinal and stops degeneration of the spinal segment setting in (the 5 stages of
QUESTION 8 What you say about lifting seems to be totally at odds with conventional wisdom.
How can that be?  
Once again, understanding the biomechanics of the spine makes it easy to see where I’m coming
from here.  As you know, the established wisdom’s always been that to lift safely you must keep your
back straight and use the legs. I believe that is fundamentally flawed - even dangerous! Not only is it
very awkward and difficult to lift this way, it actually makes a bad back worse.
There are three sound biomechanics reasons why you should not be lifting with an arched (or
straight) back. 
1. Remember discs are meant to provide mobility at low load and stability at high load. When
lifting you need to make the lumbar segments into a braced and stable stack. To achieve this
you must flex (round) the lower back and roll your weight forward to ‘prime’ or pressurises the
lumbar discs. Conversely, lifting with a straight/arched back unloads the disc and makes the
segments wobbly and vulnerable to shear. It's also very difficult - well nigh impossible - to pull
your belly in to brace the spine with an arched back.   
2. Lifting with an arched back also means you are taking load through your facet joints at the
back of the spine, which are not designed to bear load (they are movement-controllers). It is
highly vexatious to the facet joints - particularly if you have a painful facet joint (which is,
remember, the second most common cause of back pain). Lifting with the spine flexed is not
only safer, it spares the facet joints from the crushing forces of lifting. 
3. Lifting with an arched back also puts the muscles and ligaments of the ‘posterior ligamentous
lock’ in a shortened position, making the segments less stable. By putting them on the slack
they lose all their tensile strength which is hugely disadvantageous when the spine is
loaded. Conversely, when you lift with your belly pulled in and your low back rounded you put
the spinal ligaments on the stretch, invoking huge 'multiplyer forces' that help
the spinal muscles with the lifting. 
QUESTION 9 You don’t seem very keen on using Pilates either.  Why is that so? 
There’s no doubt about it, I do feel that Pilates is over-used in the world of Physiotherapy and that as
therapists, we should be doing the more skilled and specific hands-on to treat the pain. That’s our
forte. Don’t get me wrong, there's certainly a place for Pilates. Part of the human condition is that the
more sedentary we are, the less fit we become and the weaker and flabbier we get around the girth.
Our tummies will always to be our weak link - like a soft, pouchy under-belly - that lets the spine sink,
or should I say pile-drive down on to the sacrum. 
So, we do need abdominal strengthening. All lumbar spines are inherently in need of a retaining wall
working effectively at the front to support the spine as it bends forward. Good core stability and good
abdominal control is essential. But remember, we need to concentrate on strengthening ALL the
abdominal muscles - all three layers - not just the deepest one Transverse Abdominus, which was the
focus of the early Pilates regimes. But I don’t believe we should  be doing Pilates classes alone as a
way of dealing with back problems.  
Yes, there’s an element of therapeutic efficiency putting people in classes and a certain percentage of
not very bad backs will be helped by simply making the tummy muscles stronger. But in terms of

fixing a stubborn linkage problem at source I really do believe you have to roll your sleeves up and
find the function fault.  You have to do that diagnostically with the hands and then you have to work
that function fault free with hands (or feet). No other profession can do this as thoughtfully and
effectively as Physiotherapy. 

QUESTION 10 Is there any way you would like to evolve your Masterclasses? 
In planning stages at the moment are Residential SK Masterclass programs. They are to be run in
Australia initially, at my Fernleigh Spinal Retreat in the Upper Hunter Valley of New South Wales. This
is where I have been bringing patients to my ‘Back-in-a-Week’ programs since 2003 (see where they have hands-on treatment, spinal information lectures,
decompression classes, proscribed rest periods - as well as the general mentoring and bonding begot
of interaction with other people in the same boat. 
I will be bringing students to Fernleigh with the patients (up to 8) so they can experience ‘total
immersion learning’ putting into effect everything from the webinars and the Practical Adjuncts.
Students will be allocated their own patients where they put into practice proper diagnosis and
treatment. They will experience first hand patients shedding their pain; watching as they arrive, tell
their story and history of their problem, the nature of their pain and their past treatments - and then
watching as they undergo treatment and improve. 
Then the physios may then choose to go on to become an Accredited Practitioner of The Sarah Key
Method (APSKM) and then at later stages become a Teacher of the Sarah Key Method (TSKM). The
residential programs are starting later in 2020.

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