Sunday, March 9, 2014
The Integrated Systems Model, and evidence based practice
I recently listened to Diane Lee's lecture on the Integrated Systems Model, which she uses to classify her treatment strategy (more information can be found on her website here: http://dianelee.ca/the-classroom.php). I am quite fond of her presentation style- she has a good sense of humor, doesn't seem to take herself too seriously, and is passionate about her subject matter. If she allowed personal trainers to take her courses, I would figure out a way to get up to Canada and attend one of her 4 day workshops. She made a number of points in this particular lecture that resonated with me, and one thing she discussed rather extensively was evidence based practice.
Evidence based practice (EBP) has become a bit of a buzz word in the last 5 years. Practitioners want credibility, so they search out evidence (i.e., research) that demonstrates they are on the right path, while consumers want proof that what they are doing will help them become healthier/fitter/stronger/better. This is fair; the profession of exercise or movement science is quite young, and for every person that claims exercise helped, another says that exercise caused pain. It is muddy, and unclear, and everyone has an opinion. The term "evidence based medicine" was coined by Dr. David Sackett in 1996. He wrote, "...evidence-based medicine is the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients," (http://en.wikipedia.org/wiki/Evidence-based_medicine). According to Ms. Lee, there are 3 components associated with this. The first (and the one most people attach to) is the research. For the research to be high quality, it should be a random control trial. Here is the thing with research when it comes to exercise- you can find a study supporting almost any view you want to take. In graduate school, I noticed over and over again during class discussions that people could take completely opposing views on something and there would be research to support both sides. By the time I was in my second year, I began to realize that sample sizes of things I was interested in were typically extremely small, the studies weren't always designed in a way that mimicked actual performance (who runs solely on a treadmill?), and not very much research on functional exercise or performance actually existed. I read through several studies last weekend examining deep core stabilization and how the intrinsic muscles of the core affect function. What I found was dismal. Saunders, Roth, and Hodges state, "despite the importance of the deep intrinsic spinal muscles for core control, few studies have investigated their activity during human locomotion or how this may change with speed and more of locomotion." This was in 2004, and not much has been done in the last decade to improve upon this.
The next component to the evidence based model is expertise. Experience comes from learning the material, practicing the material, and figuring out how to apply it. In the ISM, having a variety of tools is encouraged; the key is knowing when to apply those tools. It took me a while, but I eventually realized I am happiest in my career when I am learning. I find that what works best for me is learning a system fairly well, integrating it fully into my own workout/movement practice, and then using it with my clients. At this point, my tool box is diverse, and I feel comfortable using what I know. When I first learn something, I tend to use it on everyone; as the material becomes less foreign to me, I am able to more readily identify which tools fit best with each client. This is the final component to an evidence based model. The sample size that ultimately matters is when n=1. Not every modality works for every person. Some people respond really well to certain things, while others need a completely different approach. Working solely in an exercise setting, I can genuinely say I have experienced situations where 90 percent of clients do really well with one particular movement, while for the other 10 percent, that movement doesn't work at all. Experience comes largely into play, and over the years, I find I am able to figure out the best course of action with people a little more quickly.
Another note about EBP is a lot of the techniques that are out there are seriously lacking in research. Anecdotally, people will tell you "system x/y/z changed my life." Again, the sample size of n=1 is what matters. The beauty of this is that there is something out there that will work for everyone. It might take a while to find it, but patience and an open mind are key. From a consumer's perspective, I recommend trying something 4-6 times. This is enough time to let you know whether you a) hate it, b) don't really mind it, but aren't sure it's doing something for you, c) notice a little bit of difference, but maybe that's attributed to the 5 other things you changed at the same time or d) you know in your heart this is it. It's changing your life. As a practitioner, it is extremely important to learn things that resonate with you on some level. Maybe it's the material, maybe it's the teacher, but whatever it is, it needs to move you to learn it well and apply it in a manner that your passion for the material can be conveyed. This means that maybe not every workshop you go to will work for you, and maybe some things will work for you for a while, but then you might stumble upon something else that works a little better. Or maybe one specific system is your thing and you want to study that intensively for years. Find what works for you. Personally, I find that each system/teacher has strengths (and obviously, I haven't studied every system that is out there); the flip side, is they all have weaknesses. This is why I immerse my body into whatever it is I am learning about. I try it on, see how it fits, see how it makes me feel. Studying anatomy and physiology and reading a bit about the brain also allows me to better understand why things work (and I am very much a "why" person). Keeping an open mind when it comes to movement techniques and searching out quality, passionate instructors will help individuals find movement that they both enjoy and enhances their lives.
Yours in health and wellness,