Reflections: Evidence-Based Practice and Pilates (Part 3 of 3)
Welcome to part three…you came back! Bless you..
This really is the last part. In part one we looked at JP’s vision and how evidence has crept into Pilates education and practice. Part two asked a lot of questions about research and what are we to do with it when it comes to how we work with our clients. This final section looks more deeply into what is meant by the term ‘Evidence-based practice’.
What does evidence-based practice (EBP) actually mean?
I’m driven by growth and learning, so love to get stuck into a subject and the web is made for people like me who used to spend hours in a library scouring the card catalogues for books and publications relevant to whatever I was looking into at the time. Now, there is Google!!! This comes with a downside in that there is no one in charge of ensuring what shows up when we type our questions onto the ‘search bar’ the answers that show up will be accurate or relevant to what we are searching for. Using Google is a bit like research in that the quality of the question asked has a direct impact on the validity of the answers. I decided to type in the question at the start of this paragraph and up popped about 282,000,000 results. Looks like I’m not the only one with this question, so much for being original.
This is the top response:
“It means integrating individual clinical expertise with the best available external clinical evidence from systematic research.” (Sackett D, 1996) EBP is the integration of clinical expertise, patient values, and the best research evidence into the decision-making process for patient care.”
The nitty gritty of what is meant by ‘Evidence-based Practice’.
The term Evidence-based Practice has been attributed to Sackett and their colleagues who wrote a book back in 2000. They came up with a five-step program to be done in a clinical setting (Evidence-based practice – imperfect but necessary paper). Here are the original five steps:
Step one: Ask a question (seems evident to me and I would add that the quality of this question should be considered).
Step two: Find the best evidence to answer the question (hmmm, more tricky and requires a bit of work to determine best from worse and if you aren’t a student, can be hard to find the most current research).
Step three: Evaluate evidence (there are particular skills involved in this one).
Step four: Apply information along with clinical experience and patient values (this part was revolutionary – consider what the patient wants/needs – wow).
Step five: Evaluate the effectiveness of this with the outcomes (did what we did make a difference, and if it did/didn’t – reflect on why).
Three components of EBP involves the triad of Scientific Research/Evidence, Clinical Expertise/Judgment along with Patients Values/Circumstances/Preferences.
When all three of these come together = Evidence-Based Practice.
Let’s take a quick look at each of these components and how they might relate to Pilates Therapy.
This is where ongoing learning comes in. Our experience and judgement are only going to be as good as our education prepares us. The longer we practice, the more clients we see, the more knowledge we gain. We learn as much by our failures as we do our successes as long as we are willing to take time to reflect on what has worked and what has not. This ability to apply our learning to the person in front of us is key to being a competent practitioner. We all have experienced a session that was like a colour by number where no thought appeared to be put into what was done. I have had many clients given a ‘tick box’ of what to do to manage their issue by their physiotherapist/osteopath/chiropractor. I always ask to be shown what they have been asked to do and then diplomatically take the time to explain why it might be better if they did things in a slightly different way. It is my expertise in observing how people move that can make all the difference between a program to rehab a shoulder/knee/hip being effective as well as ensuring the program is making the difference it should. I leave the diagnosis to those qualified to do so, and I’m afraid I have come across medical professionals who don’t extend the same professional respect to Pilates teachers. The reasons for this could fill another blog, but the main point is to acknowledge what our areas of expertise are and allow us to make judgements based on this.
We are movement professionals, and our ability to observe, cue and guide our clients to move in more optimal ways can make a massive difference to their experience in their bodies.
Relevant Scientific Evidence.
This should include the ‘best evidence’ from reputable sources – which often means published in peer-reviewed journals. This is the first challenge for us Pilates Teachers who aren’t from a medical background. Access to these journals is not always readily available to us. I often come across research papers I am interested in only to find I cannot have access to them as I don’t meet the criteria – not a student, medically qualified or a researcher myself which can often prove to be annoying, to say the least. Another challenge with this is identifying an optimally designed study from the gazillions out there. We at Pilates Therapy do the best we can to stay on top of current thinking as it relates to the work we do with our clients and what we teach those who attend our courses. If we find new evidence that is compelling enough to modify or change what we teach, then we do and will continue to do so.
Patients Values & Preferences.
Finding that taking into account the values, circumstances and preferences of the patient/client is a significant part of an EBP warms my heart. I have always believed that what I do is support/facilitate a better moving experience for my clients. The bonus of this is that for many of them, their experience of pain or less than optimal movement/biomechanics often improves. Pilates sessions should be about the client, not the teacher. If the goal is to power through the classic mat or to cover all the choreography on a piece of equipment, where is space is for those for whom this isn’t ideal? For me, Pilates is about choosing what exercise is best for the person/people in front of me at that moment. Shoot me, but I don’t expect all my clients to execute the 100’s in every session, in fact, some of my clients never do this exercise, but if their goal is to perfect the Teaser then that is what we will do. Seeking what is best for each client and putting their needs first makes sure that they walk out the door feeling better than they did when they arrived.
One of the biggest challenges I believe for us professionals is acknowledging we don’t know it all. Identifying gaps in our skill set is a challenge because we often don’t know what we don’t know. When I started out as a newbie Pilates Teacher in the UK, I was lucky in that I had practised the mat as part of my dance training and recognised there were gaps in what Body Control Pilates was teaching at the time. I had the advantage of realising there were pieces of the Pilates puzzle missing in my training. Maybe this is why I’ve never been afraid to carry on with my learning as I have never felt I ‘know it all’. I was pleased to discover that EBP includes embracing this uncertainty.
This ability to sit comfortably with not knowing it all allows space for adapting to new evidence or ideas when they come along. Many of us are not comfortable with this uncertainty and are afraid to be seen as lacking in skills. Maybe it’s my age, but I am happy admitting I don’t have all the answers, but that doesn’t stop me from continuously seeking to know more or refer my clients on to someone who may be better equipped to deal with issues my clients present with.
Critical Thinking doesn’t mean judging or criticising.
One of the challenges of EBP is acknowledging what does and what doesn’t work. This leads to another question, when does something work? When we start out we have our exercises banked in our repertoire and some general guidelines as to which postural type/condition to include them but we quickly come to realise that humans don’t fit in tidy categories of ‘kyphotic’ or ‘flat back’ and not all knees/hips/shoulders are the same. How do we know when it is appropriate to ‘correct’ something? Does lining up everyone’s hips, knees, toes on the reformer benefit all of them or for some clients, does it make some things worse? Should we teach neutral pelvis and spine to every client or do we teach them all to imprint? These questions are ones we should ask and not assume the answers are the same for everyone who finds themselves in our studios/classes. Our experience with our clients may not be compatible with the scientific evidence. The needs of a person who regularly lifts heavy objects will differ from someone who swings a racket or club when it comes to spinal control and strength. When we come across pieces of evidence that seem to contradict each other, knowing who were the test subjects and how the study was conducted can make all the difference in how we interpret the results. We want to be able to understand where our clients are at, what they need and take on board research-based evidence that enables us to make the best decisions possible regarding our clients’ needs and goals. We should seek to identify where our client shares characteristics of the participants in a trial whenever possible. I prefer to remain sceptical of research where I feel it may contradict what has worked with my clients. Sometimes the research has to catch up, and when it’s new and hasn’t been challenged, I prefer to wait and see and, dare I say, ignore it if my gut tells me to.
The takeaway from this is to consider evidence that comes our way and let it inform what we do but perhaps not to let it dictate what we do….let us know what you think!
Lederman, Professor Eyal, (2007) The Myth of Core Stability CPDO Online Journal p1-17