** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. Today is a little introduction to some of the lovely sounding words which the training and rehabilitation industry has enjoyed using, and over-using, for the last ten or fifteen years. This is not with a view to being critical of the concepts. Neither is it to disparage their use. It is only to hopefully add a little clarity and simplicity to some terms and ideas which have, in some cases, been used to complicate and pizzazzify* things unnecessarily. *the irony of making up such a word in the opening paragraph I love all the topics I’ve listed but let’s keep things simple. Physiology and Biomechanics Shorter version: I mention these together as they come as a great pair. In this context, physiology and biomechanics are, simply put, the study of human structure and movement. They are not secret witchcraft and neither are they necessarily ‘advanced’. I remember once being confidently informed by a lovely lad that his approach was “biomechanics-based”. That’s a little like describing a kick as “leg-based”. Every single motion of the human body can be described using physiology and biomechanics. They are not branches of advanced movement; they are every movement. Longer version: Physiology; the study of the functions of every structure of the body. Whilst we (we speak for ourselves here) are most concerned about the function of bone, ligament, tendon and muscle, the study of physiology pertains to the function of every single cell in the body and includes every function of those cells. Biomechanics; the study of the mechanical element of all body systems although we (speaking for ourselves again) are primarily interested in how the mechanical function of bones, muscles, tendons and ligaments interact to produce force and movement and how we can manipulate that function in order to improve health, wellbeing and performance. In simple terms, if we understand anatomy, physiology and biomechanics we become better equipped to manipulate the development, transference and control of the forces which the body can produce and as such move more efficiently whether getting up from a chair or running a marathon. Fascia We’ve been told to train it, release it, mobilise it and had it impressed upon us that it holds the key to our dreams and our demise but what on earth is this mystical web of ‘funkshunul’ goodness and is it true that one of the Kardashians has got two? Shorter version: essentially, fascia is a web, or a net, of tissue which surrounds all the muscles and bones of the body. There are deep layers of this net around muscle fibres and bundles of muscle fibres, a mid-layer around individual muscles and a more superficial layer around groups of muscles. If you were to imagine a very dense spider web, this is how your fascia would look if you could remove all your bones, and muscles and organs. A web of sheets and strings of tissue. Longer version: Fascia is made by, and surrounds, all our cells and runs from our heads to our toes in one continuous system. Far removed from the notion that one muscle with distinct attachments directly affects one or two joints, a knowledge of fascia has helped us view the body and our capacity for movement in a more holistic manner (‘Holistic’ should have a paragraph of it’s own). Even the layers described above are not truly distinct layers, they are all part of one connected system of tissue which transmits information about where we are in space, how much tension there is in any given part of our body and transmits and responds to forces and motion to facilitate movement by modulating the amount of tension around the body and holding everything together. Fascia transmits information around the body and is a means of communication between different body segments with over 5 times as many nerve endings in fascia than in your muscles. Similar to muscles however, it can add elasticity to movement and can remodel itself according to the demands placed upon it. Kinetic chain Short version: This is another term which has developed an association with “advanced” movement and exercises and in spite of being born around the 1950s is often viewed as new (and sparkly). In it’s most fundamental form, the kinetic chain describes the fact that the body is a stack of segments each with it’s own attributes and potential contributions to movement. As such a strong consideration for whether each segment is behaving as per it’s capacity and contributing to movement proportionally is key to efficient motion. A good starting point for this consideration is whether the stable segments are stable and the mobile segments are mobile; both statically and, crucially, dynamically. For the slightly longer version you can read a little more about that here There are of course many more examples of over-egging the pudding but these have definitely grown to be the ones I hear the most. In an industry where there is more than ample opportunity to come across confusing, ill-interpreted, “beefed up” information, it’s more important than ever that professionals avoid bulking out explanations with unhelpful sparkle and pizzaz. Just to reiterate, I love all the things listed above but I firmly believe knowledge is best shared narrow and deep not wide and shallow. We need to brush off the glitter and impart better understanding. Causing a state of bewildered admiration might massage the ego but it does nothing for clients, patients and students. Let’s keep it simple. I hope that helps.
** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. The hexbar deadlift The hexbar deadlift is an often overlooked, underappreciated exercise which is suitable for many more people than it gets credit for. Myself and my friends and colleagues have used this exercise extensively with a full spectrum of clients for many, many years. Now, just to be clear, I don’t have any issues whatsoever with the more traditional straight bar deadlift; it’s a fantastic exercise for many reasons…. but… the hexbar (often referred to as a trap bar) presents us with an option which for many people, is safer, more appropriate and requires less time to perfect. Let’s begin with hip motion. The internet provides us the endless debate as to whether the deadlift is a back exercise or a leg exercise. In fact, it is said that the hieroglyphic characters discovered inside Tutankhamun’s tomb meaning ‘leg’ and ‘back’ are both represented by the depiction of a deadlift. Suffice it to say, this is not a new debate. My response to this question is that the deadlift is a hinge exercise. The hinge occurs at the hip. When the load (barbell/hexbar/kettlebell etc) is held in the hands the hinge motion comes from the hips and legs and the load is supported and maintained by the back and as such it is BOTH a leg and back exercise. How people choose to include deadlifts in their program is another debate entirely and ultimately depends on many individual factors; that’s definitely one for another day. The important point for today is that the movement occurs at the hip. With that in mind, the further forward the load is, the greater the sheer force experienced by the spine, in particular the lumbar spine. Whilst the lumbar spine is capable of withstanding sheer force (force transmitted across the spine), those large, wide vertebrae are most suited to withstanding axial load i.e load transmitted vertically down the spine as opposed to across the spine. In short, the hexbar exposes the lumbar spine – and the hip - to less stress because the weight is closer to the side and not as far forward out in front of the body. For most people, that’s a plus. Technical advantages Most of us in the gym/rehabilitation setting aren’t competitive powerlifters. With that in mind, the hexbar deadlift offers us a lift which utilises upper body mechanics which are closer to that which we find familiar in our daily use. Consider carrying several bags of heavy shopping on either side having picked them up from close to the sides of your body. That’s fairly close to the hexbar. The hexbar deadlift also requires a more upright torso than a conventional deadlift which could help to negate some of the risk of ‘rounding’ of the spine often associated with a poorly executed deadlift. These factors potentially make the hexbar deadlift easier to learn and safer to perform for most people. In addition to this, if the worst was to happen and something did go wrong, the hexbar offers a safer option to abandon mid lift due to the shape of the bar offering a safer space for the lifter to remain unaffected by the falling bar when compared to the straight bar which is more likely to contact with the lifter’s legs during a direct vertical drop to the floor. One other notable advantage to the hex bar is that many recreational lifters make rather a mess of ‘finishing’ the deadlift by hyperextending the low back without managing to achieve full hip extension. This is an area the hexbar offers greater ease due to the fact that at the terminal point of the lift the bar is still being lifted ‘upwards’ and not being pulled ‘upwards and inwards’. Considerations It is, of course, certainly not perfect and many people performing deadlifts are doing so with a view to working the hip and posterior chain of muscles and the hexbar does transfer more of the effort to the quadricep muscles than a traditional straight bar deadlift. This could be overcome using supplementary barbell hip thrusts or even the Glute Ham Developer. In summary, the hexbar offers several advantages for most people who have the desire to lift relatively heavy weights from the floor in a safe and relatively easy-to-learn way. Why not add it into your programs or at least give it a go and see what you think. I hope that helps. Remember: pain doesn't always mean STOP but it's a good idea to PAUSE until you find out what it does mean, just in case.
** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. What on earth has the smell of anchovies got to do with chronic pain you may ask? Enter, stage left…… your prefrontal cortex. The prefrontal cortex is an area of the brain which is heavily involved in planning, problem solving, social control and other important functions pertaining to the processing of information. Crucially, the prefrontal cortex fills in the gaps where information is required to formulate a response to our environment but where all the required information is not immediately available. The information used to fill these information gaps is based on historical experiences of similar circumstances and is utilised to guide and direct our feelings, emotions and actions. This explains our strong aversion to the smell of anchovies since the great pizza-gate scandal of 1997 and our strong association of pain in previously injured parts of our bodies which have long since healed. Pain is an output of your brain, not an input of your environment. This should be a fact which is far more obvious than it actually is. Deep down, we all know that pain doesn’t enter our bodies from outside and yet somehow this fact still feels intuitively wrong. In the same way that I should not feel utterly ill at the smell of anchovies on pizza, many of us should not respond to movement with the strong sensation of pain. But, we do…. because pain is your brain’s interpretation of what is happening to you based on the available evidence even if that evidence is no longer valid or has been misinterpreted. Take ten or fifteen seconds to observe your environment right now, taking in as many details as possible. Have a good look around your room. You need to actually do this or the next bit won’t work. Are you back? Great…. Now repeat your look around the room but this time silently repeating your favourite colour to yourself. Now choose another colour and do the same again. It’s highly likely, you keep seeing things which you didn’t see before which are the colour you’re thinking of. Here’s the best bit….. you did see them before. You saw them every time; your brain simply didn’t make you aware of them. This is similar to being in a busy room and hearing your name being called. Your ear registers every word of every person; your brain simply filters most of it out. If you still don’t believe me, I bet you weren’t aware of the feeling of your sock on your foot until you just read it. Or the pressure of the chair on your bottom or your sleeve on your arm. This awareness won’t last long, because your ‘settings’ decide it’s not useful and it fades into the background. If only we could make chronic pain fade into the background. Very often we can. Take home message: Not everything your brain experiences is useful and your prefrontal cortex can occasionally respond to your environment using outdated settings. Now I’m not suggesting it’s easy to update your software, I just want to let you know that it’s usually possible. Take some time to consider your own responses to your environment which you feel may no longer be appropriate. Anchovies anyone? I hope that helps. Remember: pain doesn't always mean STOP but it's a good idea to PAUSE until you find out what it does mean, just in case.
** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. Quite a long post today. Do we neglect our feet? I think most of us do, at least to some degree and even fewer of us appreciate them for what they really are and what they really do. If you train your biceps twice per week and you haven’t trained your feet twice ever, I hope this gives you some useful information which could, at worst, improve your bicep workouts, and at best, help manage some of those aches and pains you never managed to get to the bottom of. Whilst most of us would consider our hands to be our primary ‘tools’, our hands may spend many minutes per day in a semi-redundant state. The same can rarely be said of the feet. There is barely a second of each day when the feet aren’t in contact with our environment and in fact, very often, they are the only tactile contact we have with our environment. But what a great piece of kit they are! The adult human foot is comprised of 26 bones with 33 articulations and over 100 ligaments, tendons and muscles combining to form a highly complex structure designed to provide a dynamic, functional base of support. This occurs via a complex interplay of rigidity and motion. A complexity unparalleled by other human musculoskeletal relationships. During waking hours the foot is required to almost continually respond to stimuli whilst managing significant loads, absorbing repeated impact and facilitating the transference of multi-directional forces and responding to continual changes in surface. As many as 200 thousand nerve endings in each foot, a density of nerve endings second only to the face and hands, provide the sensory and motor capacity to facilitate the foot in the role it plays in the fundamental functions of posture, balance and locomotion. Typical issues: Arch problems, over pronation and plantar fasciitis. There is strong correlation between the structure and function of the arches of the feet, with structure affecting function and vice versa. Structural deviations within the arch of the foot have been shown to associate with functional arch conditions such as pes planus, often referred to as ‘flat foot’, and pes cavus, often referred to as ‘high arches’. Both pes planus and pes cavus are conditions which result from insufficient or inappropriate structural stability of the arches and are associated with over-pronation and over-supination respectively. Deviation from normal arch structure and function has been shown to affect stable vertical posture and efficient walking gait and when left untreated patients even commonly report negative effects on their fundamental quality of life as we rely on our feet so much, though we may not fully realise it until they begin to hurt. Firstly, we all start out with flat feet, something referred to as paediatric flexible flat foot. If you observe a young child’s feet, they will have flat feet when they bear load, i.e their arches often appear ‘normal’ whilst sitting but will flatten when they stand up and subject their feet to load. Due to further growth and development and the associated increases in function and strength this would commonly begin to disappear at around the age of ten or eleven. The most common problematic category of flat feet is acquired flat foot and this condition is almost exclusively considered to have a corresponding pathology, such as having experienced some kind of injury or patterns of chronic overuse or the result of some kind of foot and lower limb dysfunction. It can also be the result of a paediatric flexible flat foot which failed to improve beyond the time of musculoskeletal maturity. The most prevalent cause of acquired flat foot is dysfunction of the posterior tibial tendon, muscle tightness in the posterior compartment of the lower leg (including, but not limited to, the calf muscles) and joint hypermobility. Although these aren’t mutually exclusive; very often joint hypermobility is an underlying factor contributing to your tight muscles. The topic of tight muscles was covered a little more here . There is also strong correlation between flat feet and excessive pronation. In particular, pronation which is excessive in duration i.e spending too much time on the inside of a flat foot whilst mid stride. Let’s not forget though, pronation is a fundamental function of our feet in order that we can walk efficiently on varying terrain. Poor old pronation has been given a bad name recently by many health and fitness professionals who have either misunderstood it’s mechanism or who have erroneously deduced that their over pronation is causing their running problems when it may well be that their running problems are causing their over pronation. Pronation only becomes a problem when we pronate too far or for too long – usually a little of both. High arches. Whilst they don’t get the same internet attention, high arches can equally cause problems such as less compliant arches, pain in the plantar surface of the foot due to reduced surface area contact with the ground and reduced flexibility in the lower leg muscles and Achilles tendon. Both high arches and flat feet have been strongly linked to lower limb issues right up to, and including, the hip and low back. This is the result of the malalignment at the foot causing malalignment further up the body. All the above issues can of course aggravate the tissues of the body contributing to muscle strains, bursitis and not least, plantar fasciitis. All of which can further affect our movement and so the cycle continues. What do we do about it? Aside the standard response; see an appropriate therapist, balance the body, improve movement competency and increase capacity (these are large topics in their own right) we can start by introducing small daily habits aimed at making our feet a little happier and healthier. Whilst this may not make miracles happen, it’s a great place to start and at the very least offers a decent foundation upon which to build a more complete program later on if necessary. Spend a little time barefoot. This does not have to be hours of running round the woods like Tarzan. A short period each day around the house is a good start for lots of people. Just uncovering the feet and allowing them to feel the floor can help to increase proprioception and develop more awareness of how we use our feet as we move. To increase this benefit, try adding some extra stimulation from a soft, spikey massage ball or similar. Just a few minutes per day rolling the ball around the sole of your feet will help relax the soles of your feet and wake them up a little. In addition to this most people could benefit from spreading their toes out after being restricted by the narrow toe box offered by most modern footwear. Again, this does not have to be a huge endeavour; just a few minutes with your feet flat on the floor, lifting and spreading the toes a far as possible for a few seconds before placing them back onto the floor whilst maintaining the spread of the toes. Repeating this for just a few repetitions daily could help to begin to make your feet feel more relaxed and maybe even begin to develop a little more strength in some of the small intrinsic muscles of your feet which rarely have chance to work in most modern footwear. As with most things, little and often is key. Make a new habit for even a week or two and you should begin to feel some benefit. I hope that helps.
** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. Just a short one today and here’s the good news first; if you have good and bad days with your pain you almost certainly have the capacity to influence those days to increase the good days and reduce, if not totally eradicate, the bad days. Whilst this may feel like it doesn’t apply to you if you’re in pain right now, something is making those days better and worse and the likelihood that those things are both identifiable and modifiable is fairly high. It will of course require accurate diagnosis and most certainly take considerable effort and consistent dedication to the good cause to make a change but – and this deserves repeating - if you have good and bad days you’re likely to have the capacity to take control of the factors which cause the bad ones. This is a pertinent place to draw attention to the opening caveat with a reminder that if you have non-mechanical pain this may not apply to you in quite the same way. Although don’t forget that trapped nerves, bulging discs and similar may have a neural element to them but they can still be considered mechanical by virtue of whatever is trapping or aggravating them. It is also worth mentioning that just because pain is long-term does not mean it isn’t intermittent or modifiable. If you have good days and bad days…… The first step in identifying triggers of intermittent pain is self-awareness, in order that we can identify specific combinations of motions, postures and loads which cause pain. The tricky thing is to narrow these pain triggers down to precisely which combinations are troublesome. A painful posture at work may not be painful at home when load or other subtle motions may be absent. For instance, bending forward to tie your shoe may not be painful; bending forward whilst stretching to reach something with one hand may be painful. In addition to this, the pain may not occur at the time of the trigger. But, pain always has a cause. Always. Here are some suggestions for a starting point to identify pain triggers: · Identify specifically what hurts e.g precisely which muscle/tendon etc (not just ‘shoulder’) · Identify, if possible, specific motions/activities which aggravate your pain (consider during and after) · Identify postural deviations (not just static posture but your ability to maintain form during motion) · Identify imbalance e.g left-right difference in joint range of motion · Identify strength imbalances (side-to-side, top-to-bottom, front to back) · Identify excessive movement behaviours e.g sport or work-based repetition · Identify how varying loads affect the above This list is of course far from comprehensive but provides a decent starting point to developing awareness of factors which may contribute to your ongoing painful problem. It is worth mentioning of course, that you could identify significant factors from the list above and have no pain, but these factors help form a picture from which to make a diagnosis and at the very least give you a head start in tackling your problem. Remember: pain doesn't always mean STOP but it's a good idea to PAUSE until you find out what it does mean, just in case.
** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. For many years we were told that bad posture would send us into a downward spiral of pain, increased risk of injury and ruined performance. Fast forward to today and we have a plethora of resources insisting bad posture does non of those things. What changed? As with many things in the health and fitness industry trends and ideas are often quick to come and go. We are after all, a relatively new and evolving industry and what starts out as a nice idea for one person on one day quickly becomes all things to all men and it takes the confusing passage of time – read; experience – for us to realise that general rules do not always apply to specific circumstances and vice versa. And so with a full swing of the pendulum we throw the baby out with the bath water and many trainers and therapists who would once have assessed you to within an inch of your life now pay total disregard to posture and movement symmetry. It is of course true that many people live for many decades with bad posture, movement dysfunction and imbalance without any ill effects whatsoever. It is equally true however that for others, two days of unusual slouching can cause tremendous discomfort. Most of us of course, are somewhere between these extremes and this is just one reason why posture, movement dysfunction and asymmetry should always play an important role in assessment but should never get the blame for every ache and pain simply because they are present and we don’t have any other answers. So, are posture, asymmetry and imbalance really important? Or more specifically, when are they important and why? Firstly, let’s consider when they are not as important. To be clear, I still believe these factors should be assessed and considered even if they will likely be deemed to present no significant, immediate detriment. High level athletes. As a general rule, high level athletes experience asymmetry and imbalance as a direct result of getting great at their chosen activity. An obvious example being significantly increased strength, endurance and range of motion in the dominant arm of squash players when compared with their non-playing arm. If this extra performance is developed appropriately and alongside a relevant care plan this increased capacity is likely to be not only perfectly healthy and risk-free but indeed absolutely necessary. Now let’s consider a more recreational squash player who is largely sedentary off-court and presents with less-than-optimal range of motion across several joints but has greater than normal range of motion in only their playing arm. Whilst this does not necessarily predict injury it most certainly needs to be considered when developing a training program as they will often have developed their increased motion via sub-optimal biomechanics and have a lower level of general fitness and therefore are potentially less resilient to the stresses they are exposing themselves to on court. Add to that, the fatigue from a full-time job which also adds stressful load to the dominant shoulder and the risk of injury increases considerably. This is not due to any single risk factor but to the accumulation of several factors. The removal of bad posture or workload or low resilience or general tightness could reduce this individual’s overall risk of injury to below their tolerance threshold. Equally, 8 hours overtime at work next week could be enough to tip the scales the opposite way. The fact that we typically only learn our threshold retrospectively is why all things should be considered prospectively. Short version: · Bad posture does NOT necessarily mean pain or predict injury · Asymmetry and imbalance does NOT necessarily mean pain or predict injury · All lifestyle factors combine to establish overall risk level · Bad posture, asymmetry and imbalance can disproportionately load and fatigue tissues which may also be relied upon for full-speed recreational/work activities · We often only realise our threshold for injury when we cross over it! · Don’t ignore bad posture, asymmetry and imbalance just because they may not be the cause of your pain and may not increase your risk of injury because they also could do! Remember: pain doesn't always mean STOP but it's a good idea to PAUSE until you find out what it does mean, just in case. I hope that helps.
** usual opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at ‘most people, most of the time’. It is estimated that around 85% of us will experience pain in our low back at some point during our lives with around 40% of the population visiting a healthcare provider for treatment. This comes at an annual cost of over £1 Billion. This combination is something unequaled by other conditions. In addition to this, the overwhelming majority of these cases are described as chronic and 'non-specific', with this type of pain typically being attributed to life's general aches and pains. However, low back pain is often far more debilitating than pain experienced elsewhere in the body. Low back pain is often a highly complex, multi-factorial condition which rarely receives an early diagnosis (we typically don't stop until we have to) and as such, this increases the complexity of reliable diagnoses. What we DON’T know about low back pain: · most things. What we DO KNOW about low back pain: · surgery, injections and medication is rarely a solution. · pain with movement isn't always bad. · MRI scans rarely show the cause of back pain. · 'flare ups' do not necessarily mean more tissue damage. · ‘getting old’ is NOT a cause of low back pain. · complete rest is neither necessary nor a solution. · lifestyle and movement retraining is crucial. · most people fail to properly engage with movement-based interventions. · most back pain comes back. The overwhelming consensus is very clear; medication, cortisone injections and surgery are not solutions to ongoing back pain. That is not to suggest that these things are never helpful or that they do not represent a potential element of treatment for some people, some of the time! It is important to be aware however that even in cases where surgery, for instance, is necessary - that all other conservative interventions should be adhered to, and exhausted, prior to surgery becoming an option. Here, adherence is key. It's true, exercises for back pain can be boring and may take some time to take effect even with dedicated consistency but given the amount of literature available which clearly outlines the need for therapeutic exercise interventions even after surgery in order for surgery to be fully effective it is impossible to ignore the benefits of improving stability, movement quality and habitual movement strategies. At the very least, it will increase your resilience to surgery and put you ahead of the game recovery-wise if more invasive interventions are eventually necessary and in many cases the preparation negates the need for these other interventions altogether. In short, dedicating yourself to a properly supervised program of suitable movement retraining is a no-lose situation. Exercise-based interventions One of the most often overlooked factors in habilitative exercise programming is that strength and stability are not the same thing. We need to be stable before we are strong. Not only can excessive 'bracing, squeezing and clenching' often exacerbate symptoms but such effort can simply not be maintained for long periods. There are 168 hours in each week and your body needs to be properly supported and pain-free for all of them. That's a lot of bracing, squeezing and clenching! Appropriate stability then is more often the answer although strength and endurance must clearly also play a role. Whilst the exercise interventions for low back care are as vastly varied as low backs themselves, there are a number of exercises which have been consistently shown to help most people, most of the time, including three exercises which are almost always helpful in offering quality stability in a relatively spine-sparing manner. So much so that Professor Stuart McGill, world renowned low back specialist, refers to them as 'The Big 3'. These are the bird dog/superman, side plank and modified curl-up; of course they come in many guises, progressions and regressions. Lifestyle modifications Lastly, modifications to the ways in which we move daily can play a huge role in the way we manage long term back pain. Stuart McGill has published an amazing resource called Back Mechanic aimed at the lay person, to be used in conjunction with a suitable professional and in it he offers many methods of self-evaluation and modification of daily tasks in order to avoid and manage painful movements. I have recommended this book many times and have yet to receive bad feedback from anyone who has purchased it. In summary; surgery is sometimes, but very rarely the answer and is not intended to be a stand-alone solution for low back pain. Back pain can mostly be managed via adjustments made to habitual lifestyle choices, movement strategies and an appropriate exercise program. This strategy should always be included in low back care, whether as a stand-alone intervention or as a precursor to surgery or as a conclusion to surgery. It should focus on improved motor patterns, function and stability with strength and endurance being developed once these have been achieved. It takes dedication and consistency. That is easy to say although often difficult to maintain but it is never wasted effort! I hope this helps. Remember: pain doesn't always mean STOP but it's a good idea to PAUSE until you find out what it does mean, just in case.
** opening caveat: it is well beyond the scope of this short piece to address myriad pretexts and contexts and as such this represents one opinion aimed at most people, most of the time .