Exercise is Medicine –
As seen in InMotion Magazine – March 2019
– Craig Phillips, Director of DMA Physiotherapy and Founder of Clinical Pilates.
What is the future going to look like as Health Reforms start coming into play.
We have all heard the “exercise as medicine” line and we know its well established that exercise is a major “key” in management of osteoarthritis, cancer, back pain, depression, cardiovascular disease, osteoporosis to name but a few medical conditions. Of all the professions Physiotherapists are the best placed to know when & what to treat with exercise and the time has come to lay claim to taking on the challenge with greater expertise skill & training than the fitness industry.
However in the upcoming Health Reforms (published Oct 2017) we are seeing exercise therapy under attack & further funding withdrawn despite the overwhelming evidence in its favour. Yes I agree that natural therapies such Aromatherapy, Rolfing, Bowen therapy, Homeopathy & Iridilogy, lack quality evidence as suggested by the Chief Medical Officer but to throw exercise based approaches like Yoga, Tai Chi, Butyeko, Feldenkrais & particularly Pilates into the same “natural therapies” bucket, makes me wonder what systematic reviews have actually been read. (p16) The reform document states that removing these “will ensure taxpayers funds are not directed to therapies lacking evidence”. Have any of these exercise methods actually been irrefutably disproven Specific Pilates approaches have undergone the rigours of RCT, interrater reliability & validity studies with positive findings. Many surgical & medical procedures which have been proven as “low value care” continue to attract funding without question and MAY be looked at (P4) meaning we will continue to see procedures that are actually disproven such as arthroscopies, spinal surgeries / fusion, most joint replacements, sub acromial decompressions, acromioplasties etc etc etc continue to be funded, unabated, with out question….. all being therapies “lacking evidence” but still strangely supported.
If exercise is so crucial in disease management why is it so absent from this important document. Numerous guidelines all point in favour of exercise as a first line approach, yet there is a glaring issue ……. There is no realistic funding. Unless patients pay out of their own pockets there is only a few hundred dollars here & there through EPC, health fund ancillary cover & some low paying “lifestyle” / “behaviour change” programs. Certainly nothing approaching what is needed to stave off an unnecessary surgery, or more worryingly, a revision surgery or procedure. Surgeries however, will continue to attract limitless funding in the foreseeable future.
For example the 2017-18 figures on knee arthroscopies saw some 32,429 performed (@ cost of $8000) = $259m. Bohensky (2012) reviewed data showing 190,881 knee scopes in Victoria alone 2000 – 2009 = $1.5B. Multiply that across all states and the figures are eye watering. Total knee arthroplasties in 2017 (APRA) 128,248 (@ $30,000 )= $3.8b and when considering the rapid increase yet evidence showing that only 44% are truly indicated (Riddle 2014) hence $2.15B overspent, we have to wonder why these, and the many other, big ticket items such as the “no better than conservative care“ ACL reconstructions escape the same level of scrutiny as physios doing exercise treatment.
This funding skew is even more apparent in John Orchards excellent article published recently in the SMA’s Sport Health magazine (vol 36 issue 2, 2018) about the lack of recognition of Exercise Medicine. The Australian Medical Councils “Clinical Care Standard” (2017) currently instructs GP’s to send OA knees to surgeons & rheumatologists for surgery & drugs rather than exercise based practitioners.
The time has come for physiotherapy to take control of the exercise treatment space. To define our clear point of difference. Enter pilates in its clinically specific form ……
Clinical Pilates & the next upgrade – MBCT.
Its now 30 years since Pilates started to become a mainstay of the physio profession & a major driver for physios into the “exercise as medicine” space. When Pilates was first presented to physiotherapists in Australia by physiotherapist Craig Phillips there were no other practitioners. It didnt take long for Pilates studios to pop up so “Clinical Pilates” was coined to create that point of difference for physios working specifically in the patient treatment space. This sharp focus on patient treatment has persisted to this day & helped distll the growing pilates repertoire down to one of treatment efficiency & efficacy.
Craig’s background as a professional dancer with the Australian Ballet for 10 years provided a deep knowledge of Pilates working with many of the Pilates masters during the 1970’s. After graduating as a physiotherapist this interest was reignited by an invitation from orthopaedic surgeon, James Garrick to work with St Francis Hospital sports medicine department in San Francisco in the late 1980’s. Garrick was ahead of his time stating that the San Francisco 49er’s would be better players if they did pilates & could gain the coordination & efficiency of the dancers. He was already aware that the focus on strength training just seemed to be making them more injured. The Australia Council saw the value in this project and awarded Craig a Special Projects grant to cover further study costs and help set up the first pilates clinic in Australia in 1988 at Prahran Sports Medicine Centre, Victoria House Hospital in Melbourne. History is repeating itself with Craig recently invited to present the keynote at the prestigious BASEM (British Association of Sports & Exercise Medicine) conference in Wales after the most recent World Rugby Cup. ACL injuries would virtually disappear if footballers trained like ballet dancers, the evidence is now all there!
As said before, exercise is a critical adjunct in the management of virtually any condition and we also know that some exercise is better than no exercise. Despite all the marketing & testimonials Pilates is really just a general exercise approach and not really any better than any other standard, generic, exercise (Lim E 2011). So for a physio to demonstrate that they can treat a patient and maintain that “point of difference” there is another level where tailoring the exercises becomes critical. Yet we often hear about “tailoring the exercises” but never about the model, the pathway or what tailoring actually means.
Treating an isolated structure or tissue has a limited scope and the literature is becoming less supportive of treating structures or pathanatomy. We keep hearing that we need to move beyond “impingement” ”tendon damage” “degeneration” “opathy / itis” models and that structure based classification & tests have minimal support with even less relevance in the chronic / complex patient. Radiology doesn’t show pain and the correlation between radiology & the patient is even more tenuous & questionable. It’s becoming the job of the physio to determine if the radiology actually matches the patient or if the tissue is truly the problem. In the same way pathoanatomy tests for shoulders, knees, hip labrum, etc are not actually tissue specific, it is being suggested that the pathoanatomical layer should be removed (Docking 2016) and that clinical tests drive the intervention. Exercise function tests are showing far greater insight in to the effect of treatment as they can also guide treatment something which structure tests fail to achieve. We can hypothesise later as to what the anatomy or pathoanatomy may be as there is no real evidence anymore to support the old isolated tissue diagnosis.
So where do we go with all these suggestions and recommendations?
The way forward with Exercise as Medicine is redefining Clinical Pilates as a “Movement Based Classification & Treatment“ (MBCT) tool. In the hands of a physiotherapist it takes the treatment model beyond “structure based management” & manual therapy. MBCT allows a physio to classify the patient against a directional preference model and “tailor” the exercises into flexion vs extension , left vs right & rotation. While structure & muscle specific management has struggled to achieve Level 1 evidence, it certainly exists for directional models. McKenzie is probably the best known example & has survived based on a directional modelling tool while muscle specific & structure specific approaches have come & gone.
Like all complex issues the best solutions are simple. The best clinical decision tools can be based on just a few key points. Goldmans decision tree for cardiac arrest patients, the Ottowa ankle rules, the HINTS test for cerebellar stroke, to name just a few, require only four key pieces of information to make a clear decision for management.
Similarly the clinical pathway for Clinical Pilates MBCT is based on 4 key points to classify a patient.
KEY POINT 1 – PROBLEM
All too often we hear a patients tell us that “all their problems are on the same side” their Body Chart shows a strong unilateral history & predictor for where their next injury will be. Wainner discusses this pattern as regional interdependence and its as simple as Right or Left side as the focus. Movement asymmetry is a key, patients tell us they feel “lop sided” “ out of whack” ”uneven” yet we insist on managing them symmetrically.
KEY POINT 2 – PREFERENCE
The simple Easing Factors, what direction must be isolated for inclusion in the treatment algorithm. They prefer extension, just do extension.
KEY POINT 3 – EXCLUSION
Aggravating Factors (what to avoid) are exclusion for treatment. We often hear that flexion is an agg factor, then wonder why they are not responding well to exercise programs that include a significant number of flexion orientated exercises.
KEY POINT 4 – EXCLUSION
Trauma. So often this key is missed but plays a major role as to the cause of their ongoing issue, usually matching their Agg factor. E.g Flexion Trauma = Flexion Agg factor. Rotation is frequently missed, in sport (name a sport where rotation doesn’t figure!) car accidents or the old bending and twisting injury. Both of these are exclusions from the classification algorithm.
While simple, this clinical algorithm its based on the laws of heuristics or “bias variance dilemma” – making complex problems simple or KISS
Once a directional classification based on the PROBLEM & the PREFERENCE has been determined a physiotherapist can then “treat” the patient within a streamlined classification framework using pre & post intervention tests to show the 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 4 exercises were adequate. (Tulloch 2012)
For Pilates, and for that matter physiotherapy, to survive in the 21st Century healthcare landscape it has to satisfy outcome predictors, be tight, efficient, replicable & duplicable. Functional outcome measures are an ideal tool to prove the efficacy of patient specific programs and only a select few are needed to support the benefit see from the program.