Crassshhhhh, boooom, THUD….

As your car changes gear there is an almighty sound, as if the whole bottom end of the vehicle has dropped out onto the road. This can’t be good!

The tow truck wheels into the mechanic and leaves your car to be assessed.

Complete gear box failure!

A mechanical problem that requires a pragmatic solution – replace the gear box!

Sometimes this approach is completely warranted. Say you have an elite athlete who tears their hamstring while sprinting. Clinical presentation + imaging reveals a G3c injury. It requires a progressive rehab program, where you will be focused on treating the tissue, and of course you must do this to get this player back!

But at the same time you must zoom out and consider the problem from a higher vantage point.

• What else does this PERSON need, to perform at their best when they return?
• What is their past injury history?
• What is their role in the team?
• What systems must they train and optimise (respecting injury healing status)?
• What is their current mental status?
• Are they in the twilight of their career?
• What about contract pressures?

All of these factors must come into consideration when designing a rehab program with the PERSON central to the process.

Treating the low back pain, knee injury or an achilles tendon that walks through your clinic doors (Yes, there is a PERSON attached to these injured body parts!) is something that we must get comfortable with as a new clinician.

• What to assess?
• When to assess?
• How this type of injury ‘should’ respond
• How do we best manage the injury
• How long will it take?

These re all questions that we have in the early years of clinical practice, and our patients will certainly ask! In fact, these questions are still bubbling to the surface as a more experienced clinician, with advances in clinical research that we must stay abreast of.

But here we see a reductionist approach, thinking like the mechanic…. We must fix what is broken?

‘Dynamic systems theory (DST) is an area of mathematics that offers useful principles, concepts and tools for understanding and modelling complex, dynamic and non- linear scenarios of the kind that occur in sport.’

(Pol et al, 2019)

DST highlights a non-linear relationship between personal, task & environmental factors that initiate a cascade of potential injury leading from micro to macro injury.

If we consider a patient with low back pain, sudden onset while bending forward to pick up a pen from the floor. An action they have done over and over across years, without having any issue. Why on this occasion did the back go?

Such a common presentation that we see with low back injuries, and always very difficult to explain to our patients.

But if we apply a dynamic systems theory to our thinking, it can start to become tangible, in our minds at least!

Consider the personal factors:

• This persons sleep has been poor over the previous 2 weeks due to work stress.
• Their work has been demanding 12+ hour days with big blocks of sitting
• Physical activity levels have been compromised, they haven’t been able to make their regular gym class for 4 weeks, where they would routinely complete a lower body strength program involving squats, deadlifts.

What about the environment?

• More time spent sitting in the office, less time spent in the gym
• End of financial year was fast approaching, which contributed toward increased working hours & hence, stress levels.

& the task?

• Nothing out of the ordinary, a simple task!

So we see how personal & environmental factors can influence each other to potentially contribute towards injury.

At the professional level, there are various monitoring systems in place to give clinicians as much information as possible, in the hope that we can proactively mitigate injury risk for players. But if we apply Dynamic systems theory, it can become a minefield.

Consider the following factors:

• Wellbeing monitoring – mood, fatigue, stress levels
• Sleep volume & quality
• Immune system status
• Training loads/ stage of season
• Recovery measures – ie CMJ, Heart rate variability
• Gym loads/ changes to gym program
• Coaching directives – “This player isn’t hitting enough high speed running during training drills”
• Past history & sensitivity to various load parameters.
• Extra curricular activities outside the club ” I played a game of pick up Bball with mates on the day off”
• Presence of other areas of soreness – “Low back tightness”

This list could go on & on!

Then if you break each of these categories down into the micro parts, each part can have a differently weighted effect on the next part…….and at any one time, one aspect might be more relevant & influential than another.

The complexities of dynamic systems theory!

This is all well & good in theory.

But how might you apply this to your clinical practice?

Take home tips for your initial assessment

1. Understand and start where the patient is at – Physically & mentally.

2. Understand where they want to go.

3. Learn what makes them light up – The best exercise for LBP is the exercise the person will do!

4. Don’t try and do too much – The patient in front of you probably remembers 10% of what you say and the exercises you prescribe.

Treating the injury is something that we focus on really hard as new clinicians. If you start to treat the person from an early stage in your career, it will set you up to be that prodigy, ‘go-to’ clinician who gets the full book of patients and opens up possibilities to work in elite settings.

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