Evidence Based Practice and Pilates?

Evidence-based practice and pilates are some of the buzzwords that have been bandied about as the hallmark of University Qualifications.  Sadly, I have seen many inexperienced recent graduates use the term to try and lord it over experienced and knowledgeable practitioners, to the detriment of client outcomes. I have also seen many education providers use the terms to imply they are providing quality education.  The issue has befuddled me for a number of years, and I have procrastinated in writing this blog,  but a chance discussion with a lovely ecologist, Dr Anna Renwick, prompted me to think through the issue a little bit more and finish writing.  She also helped me to clarify my concern that whilst there are many courses saying they are evidence-based,  they have no focus on creating evidence-based practitioners.

In this article we explore the terms “evidence based” and “research based”,  and what it means for you as a practitioner when determining a client intervention, choosing a course or even using certain terms in your own marketing or standing up to uppity vocal practitioners who fail to consider the experience and client goals. Furthermore, we look at ideas on how to promote evidence-based practice in your own approach to Pilates.

In this article, we address:

//vWhat is the evidence-based model?

//The concept of reflective practice

// The level of research needed to show a scientific underpinning of a decision

//What is a PICO question? Why you would use a PICO question to identify the type of research needed when looking for supporting evidence?

Does Evidence Based mean that you only read scientific peer review papers?

Evidence based practice is a concept that allows practitioners to take the best available research and apply that to their practice context, given their own clinical experience and the nature of their client’s goals. All of these elements are important in a clinic, Pilates studio or any type of practice seeking to ensure the best possible outcomes for their clients. In other words, evidence based practice is about:

//  the decision making process aimed at achieving the best possible outcome for a client; 

//  making informed and appropriate decisions collaboratively wherever possible.

An evidence based practice is NOT the nature of a university qualification, and is not simply using the abstract or conclusion of a scientific paper to determine practice  (Gilgun JF., 2006). The diagram below is one of my favourites showing the four components of evidence based practice. I like to note that nowhere in that model does it state that a university degree qualification is required inorder to implement evidence based practice, however there is a need to be able to correctly interpret the scientific research and not simply rely on the abstract or conclusion of a paper for evidence. It is important to note that many models of evidence based practice fail to include the context of practice.  I like this image as it highlights that all the elements sit within the practice context.

When you hear that a person is applying an evidenced based model it does not mean that they are simply using the result from the scientific literature. What it means is they have critically examined multiple factors in order to develop an intervention/ program for a particular client. The evidence based model was intended to improve the recognition of the science and clinical experience and show its importance in decision making. Some of these important factors we need to consider or understand are listed below.

// The Scientific Research that is used by a practitioner with a scientific approach.       

Remember a scientific approach is to explore the research, develop a null hypothesis, testing the information in the context of the client’s specific situation and reflecting on their experiences when applying these observations to other situations. In exploring a scientific approach we need to be aware of research bias that is within the research and how we ourselves their use the information. As practitioners we must be scrupulous to ensure we read more than simply an abstract of an article but look at the full details of the paper including the method and intricacies of the results. When reviewing an article we need to ask if the authors have appropriately tested their null hypothesis and identify gaps in the literature that need further study. It is like you were debating with your teenage child, you need to find the gaps and drill in on those if you are to be able to work towards an appropriate solution.

The research we explore must be relevant to our clients and their goals. The quality of the research as identified in the hierarchy, this is discussed later.

// In our own clinical experience from working with clients, we have found that sometimes that experience will not tally with our own practice. A new graduate should know a lot about what happens in a theoretical setting but this does not always relate to what happens in the real world. For instance, a new graduate may always teach a series of exercises in a specific sequence because that is the way it is taught. Whilst an experienced practitioner would know that the sequence is often varied because there are subtleties in a movement that can contribute to better outcomes for specific types of clients. An experienced practitioner has come to their understanding from years of practice, observation and reflection, there is no text book or degree explaining this wisdom. A good practitioner takes advantage of this wisdom by observing and working with supervisors and mentors. 

Many experienced practitioners will often find it difficult to quickly explain why they know something is happening in a particular movement pattern or in a posture. It is like asking a driver how they avoid hitting that car that veered into their path on a busy road. The reality is that much of this occurs because of years of experience and reflection leading to an instinctual understanding of what is happening or what could be happening in the moment of a movement. This experience and intuitive understanding is an important element of evidence based practice.

Sadly, this level of clinical experience is often dismissed as irrelevant or unscientific. When in fact clinical experience is an important element in an evidence based model that needs to be considered and weighed up in determining what is the best approach for an individual client.  A good practitioner will surround themselves with many different practitioners, mentors and colleagues who are open to discussion and exploration of ideas in a safe and supportive environment. The person will prompt themselves to ask questions, explore and then apply a considered apprrach. More importantly they will reflect on what happened and adapt and adjust to what they saw in their client and respond appropriately.

// The practice context

When we are talking about movement as therapy we need to consider the context of the clients class setting and environment. For instance if a person is undertaking a HIIT reformer class with 6 other people, that setting is unlikely to be the best setting for an evidenced based intervention for a person with a hip pathology. The hip pathology is probably not going to be addressed even if the instructor is a Physiotherapist. However, if a person with a hip pathology is attending a small individualised movement class with an experienced Pilates teacher with training in hip pathologies this could be considered the more appropriate setting using evidenced based approach for that client.

Remember, an evidence based approach requires the intervention to be very specific to a clients needs, goals and using the best available research in an appropriate setting. If you do not have the knowledge, experience or interest to learn or even the set up to work with a client’s specific goals; then you should not be taking on those clients or students and you should be honest in referring those people to a more appropriate practitioner. The clients/students will appreciate your honesty and will return to you when they want or need the type of service you offer.

// The clients goals and insights are as much a part of an evidence based model as the clinical experience of a practitioner. When a client is seeking help with a particular problem their answers of why they are coming can be many and varied. 

For example, I recall a client (let’s call him Juan) coming for help after he had a stroke. When asked about what his goals were, he stated that it was to be able to dress himself. Juan particularly wanted to wear his polo shirts, not the button up shirts everyone was telling him to wear. When I first met him he was wearing a shirt he put on with the assistance of his wife Maria. Juan had been seeing many practitioners none of whom were interested in his goal of putting on a shirt, and he was growing increasingly frustrated. As an experienced practitioner I knew the movement patterns needed to put on a polo shirt, I understood how those movement patterns could be facilitated by the use of equipment in our studio, and how modifications could be used to strengthen him safely. As an evidenced based practitioner I had read the Australian Stroke Guidelines about issues with potential subluxation of shoulders post stroke. Juan had been working with many Allied Health Practitioners who were focussing on mobility, but Juan’s goal was to put his shirt on. It took us a while but we worked with Juan and Maria to build his strength and stability using the resources within our practice and taking into account the appropriate guidelines and research available. This was an example of evidenced based practice, where our intervention was based on finding the best way to achieve the best possible outcome for the client, and listening to his goals. 

Evidence Based practice and research

Evidence based is not about finding the latest research paper and cherry picking the bits you believe are the most supportive of your own view point.

 When we are looking at research to inform our decisions, there are a few steps that we need to undertake. These include:

// Asking the appropriate question and knowing where and what to search. 

// What is an appropriate clinical question and knowing when to ask a PICO ( population, intervention, comparison, outcome) question to underpin your research.

// The hierarchy of research and its quality.

// After we have acquired the information we apply it to our clients and then assess whether or not there was an appropriate outcome.

These critical steps have been described as the five “As” strategy can be used (Dijkers, 2012).  Whilst not exactly the A’s this diagram highlights the 5 steps or stages you should be considering when looking at a research question.

What question do I ask?

If your question is what would be considered a background question, that is asking:

// A question root (who, what, when, where, how, why) and

// About a disorder, test, treatment or general aspects of health care

For example if you are asking a question about the appropriate protocols when working with a client with a posterior cut hip replacement, a procedure that has been used for many decades by surgeons. Then looking at a text book or a clinical database such as PEDro ( https:// pedro.org.au/) could be considered a sufficient level of enquiry. Remembering that you still have to apply appropriate judgment when reading that paper.

When we are asking a specific question about interventions that include a broad range of biological, physiological and sociological issues you would be looking at sorting your questions into what is known as a PICO format and you would be looking at primary research material, see later in this blog about what is the best research.

This approach was summarised by The Evidence-Based Medicine Working Group (updated by Straus, 2018) in the following guidelines and include:

1. Converting the need for information into an answerable question.
2. Tracking down the best evidence with which to answer that question.
3. Critically appraising that evidence for its validity (closeness to the truth), impact (size of the effect), and applicability (usefulness in our clinical practice).
4. Integrating the critical appraisal with our clinical expertise and with our patient’s unique biology, values, and circumstances.
5. Evaluating our effectiveness and efficiency in executing steps 1 to 4 and seeking ways to improve.

What is the best research?

When looking at scientific papers there is a hierarchy model of what is considered to have met the level of scientific rigour.  I like to think of it a bit like a game of cards where a systematic review is the ace that everyone wants to use, but you can still get a win from a controlled trial or any of the other types of studies if you are thinking about what you are wanting and why you are wanting it. For example qualitative research can be far more useful if you are considering a client’s perspective and experience as important for an outcome or intervention.

However, the golden hierarchy of research methods is below, in order of considered quality.

1. Systemic Review

2. Randomized Control Study 

3. Control studies without randomization

4. Cohort studies/ case-controlled studies

5. Evidence from systematic reviews of descriptive and qualitative studies

6. Evidence from single descriptive or qualitative studies

Evidence from the opinions of authorities or reports from expert committees

Even within these research methods, there are a variety of methods used to rate the quality and integrity of the studies. These more advanced methods of assessment require some study and research in themselves.  This is beyond the scope of this article, but it is something to remember when you are looking at “the science behind research quoted to you in a discussion about the quality of research”.

Summary

When you are wanting to understand the how, what and why when working with a client. It is OK to ask an experienced practitioner about their clinical experience and judgment as a starting point. A good practitioner will reflect and suggest where you may find more information or provide you with insights. When you do look at that more detailed information you need to read more than the abstract, and always question what are the biases of the research and yourself when you draw conclusions from that research.

Remember that evidence-based practice requires you to reflect and review the outcome for your client. When you work in private practice often the client will tell you the outcome by voting with their feet if they are not happy. However, as a practitioner, you should be reviewing your work and your outcomes to create a reflective practice. In my experience those experienced practitioners who are constantly undertaking reflective practice truly become a great practitioners and one worthy of being a mentor. As to the issue of mentoring and evidence-based practice that is a whole new question and article in itself.

Finally, these models are all about the client. When you put on your evidence based practice hat you are working with integrity to help your client find the best outcome and helping you learn and develop as a practitioner. If you are not doing this you are simply buying a gym membership and not showing up.

Carla Mullins is a Director of Body Organics Education and has delivered Pilates Method Certification trainings on behalf of the APMA for many years, she also delivers a PAA approved Certification in conjunction with a number of partners throughout Australia. Her Continuing Education Both online and in person is recognised by Pilates Associations, Exercises Science Associations and Physical Activity Austrlalia  She is also a proud member of the PAA and PMA supporting quality education in the Pilates Method and the cetification of considered pilates teachers able to critically reason and apply the Pilates method to all clients in all settings. ( to learn more you can email us at info@bodyorganicseducation.com) 

References

Dijkers MO, Murphy SL. Krellman. J Evidenced Based Practice for Rehabilitation Professionals: Concepts and Controversies, June 2012 ACRMhttps://doi.org/10.1016/j.apmr.2011.12.014

Gilgun JF. The four cornerstones of qualitative research. Qual Health Res. 2006 Mar;16(3):436-43. doi: 10.1177/1049732305285338. PMID: 16449692.

Evidence-based medicine : how to practice and teach EBM. – 3rd ed. / Sharon E. Strauss … [et al.]. – Edinburgh ; New York : Elsevier/Churchill Livingstone, 2005.

Strauss S. Evidenced Based Medice 5th Edition (2018), Elsevier