High-performance sports medicine and performance staff (i.e. physical therapists, strength and conditioning coaches and athletic trainers) are employed to provide cutting-edge support to athletes. This support usually includes (but not necessarily limited to) the application of innovative, evidence-based strength and conditioning, recovery and rehabilitation strategies. However, anyone who works regularly with high performance athletes understands that published research, which is commonly performed on lower-level athletes or university students, doesn’t always apply to elite athletes!
Just as not all research is applicable to high-performance organizations, not all work done in these environments is publishable in peer-reviewed journals. It is not uncommon to hear academic researchers decry the work done by applied practitioners because it is not “evidence-based”. Presumably, in the eyes of the researcher, unless the work is of a publishable standard or applied in the exact manner the original study was conducted, then the work lacks scientific rigour or fails to meet the standard of “evidence-based practice”.
What Happens When There is No Evidence?
Every time a study is published, a question is answered. But if the research has done its job, then it should also stimulate more questions. With this in mind, all research evidence is incomplete. Furthermore, given the lengthy process involved in peer-reviewed publication, if sports medicine and performance staff relied solely on research publications to inform their innovative strategies, the research would likely be out of date by the time that strategy is applied! So, if (1) all research is incomplete and/or outdated, (2) the vast majority of performance research is conducted on sub-elite athletes or university students, and (3) sports medicine and performance staff are to rely on this evidence to inform their practice, how can evidence-based practice truly represent “best practice” for the elite level athlete?
Using Research Alone is NOT Evidence-Based Practice!
Although practitioners should try and use the best available research evidence when supporting athletes, the use of research alone is not evidence-based practice. Let’s use chronic low back pain as our example. Research has demonstrated that passive therapies are less effective than active therapies for improving functional outcomes in patients with chronic low back pain.1 This evidence might be interpreted by practitioners that they should never use passive therapies with their patients and athletes. But if that was the case, why are passive therapies so commonly used by sports medicine practitioners? It’s because experienced practitioners know that passive therapies have their place in treating patients and athletes. They understand that active therapies result in better long-term outcomes than passive therapies, but they also know that convincing their patients/athletes to perform those active therapies requires a degree of trust – and gaining that trust might involve them touching the patient/athlete. This might involve some manual therapy, or it could simply involve a reassuring squeeze on the arm to let them know they are “safe” and that things are going to be OK.
The final piece of the evidence-based practice model is the patient/athlete. Let’s imagine our patient/athlete limps into the clinic with back pain. Armed with the latest research evidence the physical therapist or athletic trainer could say to that patient “the research says that active therapies are better than passive therapies for long-term outcomes – so you’ve got to load it!” I could almost guarantee that the patient will glare at the therapist, turn around and limp straight back out the door! This is because in the majority of cases, their expectation is that the physical therapist or athletic trainer is going to lay their healing hands on them and make them “feel” a little better! They don’t mind doing some exercise – just make them feel a little better first!
Evidence-Based Practice and Practice-Based Evidence Go Hand in Hand!
Although I’ve used chronic back pain to illustrate the evidence-based practice model, there are a multitude of examples where the research evidence (conducted under very controlled conditions) doesn’t apply in the chaotic environment of sport. An evidence-based practice model values the athlete’s beliefs and also acknowledges that in the absence of empirical evidence (i.e. research), sports medicine and performance staff will use their clinical reasoning skills and experience to provide the best support to their patients and athletes (Figure 1).2 So, when limited research evidence exists on a specific topic, a few options are available to sports medicine and performance staff. They could do nothing – this approach is unlikely to endear them to the head coach, the general manager, or the athlete! Or they can accept that all research on any topic, will always be incomplete and that evidence-based practice involves the integration of research evidence, clinical experience, and athlete values and expectations into the clinical decision-making process.3
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1. Timm, KE. A randomized-control study of active and passive treatments for chronic low back pain following L5 laminectomy. Journal of Orthopaedic and Sports Physical Therapy, 1994;20:276-286.
2. Sackett D, Strauss S, Richardson W, et al. Evidence-based medicine: How to practice and teach EBM. 2nd ed. Churchill Livingstone; Edinburgh: 2000.
3. Gabbett TJ. The training—performance puzzle: how can the past inform future training directions? Journal of Athletic Training, 2020;55:874-884.