Defining Pilates to make it clinical
We have all heard the ‘exercise is medicine’ line and out of all the professions, physiotherapists are best placed to know when and what to treat with exercise.
In the upcoming health reforms, due to come into effect 1 April (published October 2017), we are seeing exercise therapy under attack and further funding withdrawn despite the overwhelming evidence that puts exercise at the forefront of management of any medical condition. Yes, I agree that most natural therapies lack quality evidence as suggested by the Chief Medical Officer but to throw an exercise-based approach, such as clinical Pilates, into the same bucket shows the process has not been thorough.
Having read the review, no physiotherapists using Pilates exercise as a treatment tool were consulted and recent studies demonstrating efficacy were not included. If exercise is so crucial in disease management, with a mountain of guidelines and research, why is it missing from the reforms document as a target of extra funding, beyond the current meagre ancillary caps of the private insurers, low paying ‘behaviour change’ programs or a handful of enhanced primary care program’s under Medicare? The current funding model is heavily skewed in favour of high-cost, low-value surgeries, procedures and hospitalisation—not prevention.
Despite the fact that specific Pilates exercise treatment approaches have now undergone the rigours of randomised controlled trials, inter-rater reliability and validity studies with positive findings, surgical and medical procedures that have been proven to be ‘low-value care’ continue to attract funding without question and, according to page four of the reforms, ‘may be looked at’. This means that we will continue to see billions of dollars spent on procedures that are actually disproven. Arthroscopies, spinal surgeries and fusions, most joint replacements, subacromial decompressions, acromioplasties to name a few continue to be funded, unabated, without question—all being therapies lacking evidence, yet strangely still funded. How can we advance the exercise is medicine cause?
It has been 30 years since Pilates began its rise to become a mainstay of the physiotherapy profession and a major driver into the exercise as medicine space. When I first introduced Pilates to physiotherapists in Australia there were no other practitioners. It did not take long for Pilates’ instructor studios to appear, and the clinical Pilates name was coined to create that point of difference for physiotherapists working specifically in the patient treatment space. This sharp focus on patient treatment has persisted to this day and helped to distil the growing standard Pilates repertoire down to one focused on treatment efficiency and efficacy.
As said before, exercise is a critical adjunct in patient management and some exercise is better than no exercise. Despite the marketing and testimonials, Pilates is just a general exercise approach and no better than any other standard, generic exercise. So for a physiotherapist to demonstrate that they can treat a patient and maintain that point of difference, tailoring the exercises for treatment becomes crucial. We often hear about tailoring exercises, but we never hear clarity about the model, the pathway or what defines a tailored program.
Treating an isolated structure or tissue has a limited scope and the literature is becoming less supportive of treating structures or pathoanatomy. We keep hearing the need to move beyond impingement, tendon damage, degeneration, and ‘opathy and itis’ models and that structure-based classification and tests (SBCT) have minimal support with even less relevance in the chronic, complex patient. Radiology does not show pain and the correlation between radiology and patient is often tenuous and questionable. A key skill of physiotherapists is the ability to determine if the radiology matches the patient or if the tissue is truly the problem. We know pathoanatomy tests for shoulders, knees, and hip labrums are not actually tissue specific and it is now being suggested that this pathoanatomical layer should be removed altogether, dumping the old ‘this is your diagnosis’ or SBCT model. A diagnosis does not define the treatment pathway.
Conversely, a movement based classification and treatment (MBCT) approach allows a physiotherapist to classify a patient against a directional preference loading model and tailor their exercises into flexion versus extension, left versus right, and rotation. Exercise function tests are now showing far greater insight into the effect of treatment as they can guide treatment—something which structure tests fail to achieve.
Like all complex issues the best solutions are simple. It is known as heuristics. The best decision tools are often based on just three key points: Ottawa ankle rules, Goldman’s decision tree for cardiac arrest, and HINTS for cerebellar stroke.
Similarly clinical Pilates’ MBCT, as a treatment decision tool, uses four key points known as the BEAT process.
Body chart—frequently we see a body chart showing a strong unilateral history and patients tell us that all their problems are on the same side. Sports screening constantly highlights this fact. Movement asymmetry is key, finding they feel ‘lopsided’ or ‘uneven’. Despite this, we often insist on managing them symmetrically. It is as simple as exercises addressing one side as the primary focus, or problem.
Easing factors—again, simple: there is frequently a key direction that patients prefer, which is an inclusion in the treatment algorithm. If they prefer extension, this becomes a key inclusion criteria for their exercises; do not give them a combination of directions. This single direction becomes the preference.
Aggravating factors (what to avoid) are an exclusion for treatment—we often hear that flexion is an aggravating factor, then wonder why they are not responding well to exercise programs that include a significant number of flexion-orientated exercises.
Trauma—so often missed, this key point can play a major role as to the cause of their ongoing issue, usually matching their aggravating factor. Rotation is also frequently missed, in sport (name a sport where rotation doesn’t figure), car accidents or the classic bending and twisting injury. Both of these are exclusions from the classification algorithm.
Once a directional classification based on the first two key points has been determined, a physiotherapist can then treat the patient within a streamlined classification framework that meets the criteria or ‘bias’—a right/extension bias would see all exercises meeting that criteria as the treatment. Pre- and post-intervention function tests show any measurable within- session changes. Only a small number of exercises that meet the directional criteria are needed to make this difference. Otago University determined that four exercises were adequate to provide a 26.9 per cent improvement in proprioception within a single session consistently.
The health reforms have given physiotherapists an excellent opportunity to show the power of exercise medicine using clinical Pilates with MBCT as a specific treatment tool. The 21st century healthcare landscape is currently struggling under the weight of outmoded approaches, persisting low-value care models, unnecessary surgeries and resistance to change. Those prepared to accept this challenge and innovate will help the growing numbers in our profession survive by reducing surgeries and hospitalisation, generating multi-billion dollar cost benefits that can be measured and ultimately be rewarded with more competitive funding models.
We currently have the window to make change.
Craig Phillips is an APA Sports and Exercise Physiotherapist and Director at DMA Clinical Pilates and Physiotherapy.
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