The Pie Chart of Injury and Recovery

So this is a bit of a big analogy mission and you may love it or hate it but it’s currently the best I could come up with.

Alright. Let’s dive into it.

There is a lot of debate happening in the health world regarding injury management, rehab and recovery. For one, we all want to follow the evidence based triangle (some more than others cough cough) but there are a few dynamic, variable, and subjective parts within that triangle that make “hard rules” nearly impossible. And maybe that’s the point. Rehab is individual in a sense that it is only as successful as it is relevant to the patient it addresses.

Before going further, here is the evidence based triangle I’m talking about.

This shows how evidence based practice relies on three main pillars:

• Research

• Clinical expertise

• Patient specific traits

Evidence-based practice isn’t just “following research.” It’s the integration of best available evidence, clinical expertise, and patient values and context. Importantly, patient values aren’t just preferences. They include beliefs, expectations, fears, past experiences, and goals, all of which meaningfully influence outcomes. So as you can see it’s complex. But complex doesn't have to mean complicated. So let’s break it down:

Research is great. The problem with research is that it can be interpreted in various ways. It can be biased and unreliable, it can be poorly set up or over/understate its findings. Researchers pour years of their lives into the project. Biases will emerge. Data is up for interpretation and only as good as its set up. What I mean by this is that if you have a sample group of 1 versus 100 that makes a difference. Or you may find a research paper that advocates for trigger guns just to find that upon reading the small print it’s been sponsored by the exact same company that produces them.

But it can also be less dramatic than this.

Say you’re looking at research on lumbar spine flexion and disc behaviour; something that’s been studied quite a bit. You might find studies showing that repeated flexion under load can lead to disc changes or herniation, often in animal cadavers.

Now, looking through a “micro” filter, we’d first ask: Is this study valid? Is it reliable?

Let’s say it is. What was measured is accurate and reproducible.

But then comes the bigger question: How well does this apply to a living human?

We are not cadavers just yet and we are also no pigs. So it can’t really be applied to us without context, can it? Let’s say the experiment was done on human cadavers then - we are still not accounting for the human biological factor of being alive and adaptable.

Cadaver studies remove key factors like:

• muscle activity

• blood flow

• healing capacity

• and adaptation over time

They show us what can happen under certain conditions, not what will happen in real life. Even when similar studies are done in living humans, they’re often short-term and controlled, which doesn’t reflect how the body actually adapts to progressive loading over weeks, months, or years. And we know that biological systems adapt. With gradual exposure, tissues can become stronger, more tolerant, and less sensitive to the same loads that may have once been provocative.

So when we ask whether something is clinically relevant, it’s not just about whether the study is valid, whether it measures what it set out to measure, but also whether it applies to the system in front of us. Because if we compare pig spine load tolerance to our living breathing human spine tolerance it’s comparing apples to oranges.

Besides that, most biological systems work in ranges. This means our body is constantly trying to maintain a kind of equilibrium. There’s a range of change that can happen without anything really feeling different.

Think of mixing colours. If you add blue to green, how many drops would it take before you actually notice a change? There’s likely a point where nothing seems different, until suddenly, it does. And that tipping point isn’t fixed. Adding blue to white might reach that tipping point sooner than adding blue to black. Same input, different outcome, depending on the starting point, or “base”. That’s important.

Because when we look at results in a paper, we’re not just asking “is there a change?” We’re asking "Is this change meaningful?"

Does it make a noticeable difference to someone’s body?

To their movement?

To their life?

So whenever considering a finding it has to pass through several “relevance filters” to become clinically significant. It needs to make a difference to you.

Clinical expertise is important, because as we just discussed, research can only take us so far. It can be a little muddled and in the end so many factors need to be considered and cannot always be controlled for. So it’s important to apply what we have seen and use our experience. This is the part where the nuance that a paper can’t produce such as the gender, age, training history, medical history, genetics and more can be accounted for. We weight this up against the person in front of us and it can give us some intuition of what may or may not work. It can tell us when to stick it out, when to switch strategy, when to stick to a timeline and when it’s advisable to push or pull back.

So clinical expertise is not about knowing more, it’s about navigating uncertainty better.

Because even the best plan cannot predict everything.

Funnily enough, the ability to adapt rehab programming mirrors the very skill we try to instil in our patients. The ability to adapt. To become resilient. Because aiming to never feel pain or never encounter injury is wishful thinking. I would much rather go out to sea knowing I can navigate the changing winds than hope for a good day.

Lastly there is the patient in front of us.

We are all same-same but different. What I mean by that is that we are often made up of the same ingredients and have similar factors that impact us, but in the end the distribution or the combinations might be different and so we will respond to treatments in different ways and may be more responsive to some than others.

Person 1 Person 2

This is a made up example but here you could see how person 1 might respond better to a change in their load, while person 2 might just need some rest before getting back into training. Similarly, person 1 might not care for any manual therapies while person 2 actually benefits greatly from it because it gives them reassurance and pain relief to feel more confident to move.

This will need to be a whole seperate post because there is a whole war about hands on/off therapies. But the short of it is that from what I know and understand, hands on therapies can serve as a pain reduction/ desensitisation/ temporary improvement of pain and range. It’s like a pain killer: useful in the right context, but rarely a complete solution on its own.

But back to the pie.

Let’s say it’s an apple pie. Thinking about your range your strength, your balance, your load tolerance, your tissue sensitivity etc. they all operate in ranges. At what point does straying outside a range affect the whole system?

In the pie example, if I add a pinch of salt it might not make a difference at all. Now maybe if I add two - suddenly the pie tastes different, but still good. Different doesn’t have to ruin the whole pie right? Now if I add more salt maybe at some point it becomes inedible, but this could potentially be delayed by adding more of other ingredients to counter-act that right? At what point is the pie so to say “ruined” and we have to start over again? I would wager that there is a lot that can be changed without noticeable difference, but there are probably main ingredients let’s say the “pillars” that could have a larger impact when changed. The system is more sensitive to these.

So Why are we talking about the evidence-based triangle (EBT) and pies?

Because the EBT shows us why there may be a lot of confusion or disagreement on what works and what doesn’t. Because no matter how good a study design, it cannot account for all of the past health history of every person in there. So we’re applying findings from one dynamic group to another dynamic group.

But if we zoom out we can see that some treatments work for some people and not others. If we see that cross many different studies for many different interventions, we can see that what they often have in common is this: interventions tend to work best when they address a person’s biggest ‘pie slice’.

By combining research with our clinical experience we can identify what slices make up a patient’s presentation and what slices we should prioritise addressing to get them the outcome they want.

So where does this leave us?

I guess the point of this rant is to not only share my thoughts but to get you curious.

Whether you are a clinician that likes to think in systems like me, or whether you want to understand more about your rehab and your body: I hope I made you think.

And maybe those thoughts are “I am more confused than ever”.

Good.

Confusion usually precedes understanding. And as they say, knowing what you don’t know is a much better place to be in than thinking you know it all…

So maybe the main take away is that sometimes things feel “off” not because something is structurally damaged beyond repair, but because the system as a whole has become more sensitive, less tolerant, or pushed closer to its threshold. And that threshold is not fixed. It shifts with your sleep, your stress, your beliefs, your training history, your confidence, and how safe your body feels. That’s why two people with the “same injury” can have completely different experiences.

If rehab isn’t about finding the one cause, but instead understanding the different factors and how they interact, then we’re not stuck. We’re left with options.

Instead of fixating on how much salt was added and why, let’s focus on what we want to do to re-calibrate and make it our pie again.