Evidence-Based Practice in Sports Medicine

Evidence-Based Practice: Importance and Implications for Research in Sports Medicine

Definitions

• Evidence-based practice in medicine: Integration of clinical expertise, patient values, and the best available evidence in decision-making related to patient healthcare (Sackett et al., 2000).
• Evidence-based practice in sport: Integration of coaching expertise, athlete values, and the best relevant research evidence into the decision-making process for day-to-day service delivery to athletes (Coutts, 2017).

Development Process

• Key stakeholders identify relevant research questions.
• Available evidence is critically evaluated for validity, impact, and applicability.
• Strategies are developed to implement the best available evidence into contemporary practice.
• The effectiveness of the new practice is assessed.
• Continual re-evaluation of evidence and assessment.

Hierarchy of Studies

• Meta-Analysis: Statistical analysis that combines results of multiple studies.
• Reviews:
  • Systematic: Answers specific research questions using systematic & explicit methodology.
  • Narrative: Describes & discusses the state of science on a specific topic.
• Randomized controlled trials.
• Non-randomized intervention studies.
• Observational/Non-experimental studies.
• Expert opinion.

Stages of Development

• Methodological evaluation: Using defined criteria to evaluate methodological quality.
• Synthesis of evidence: Compiling an evidence table of studies of acceptable standard & identified as relevant to the practical question.
• Considered judgment: Judgment about the relevance & applicability of the evidence to the specific group of athletes.
• Grading system: Assigning a grading to the recommendation according to the strength of the evidence.

Rating & Recommendations

Quality Rating for Individual Studies

• ++: Applies if all or most criteria from the checklist are fulfilled; where criteria are not fulfilled, the conclusions of the study or review are thought very unlikely to alter.
• +: Applies if some of the criteria from the checklist are fulfilled; where criteria are not fulfilled or are not adequately described, the conclusions of the study or review are thought unlikely to alter.
• -: Applies if few or no criteria from the checklist are fulfilled; where criteria are not fulfilled or are not adequately described, the conclusions of the study or review are thought likely or very likely to alter.

Levels of Evidence

• 1++: High-quality meta-analyses, systematic reviews of RCTs, or RCTs with a very low risk of bias.
• 1+: Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with a low risk of bias.
• 1-: Meta-analyses, systematic reviews or RCTs, or RCTs with a high risk of bias.
• 2++: High-quality systematic reviews of case-control or cohort studies or high-quality case-control or cohort studies with a very low risk of confounding, bias, or chance and a high probability that the relationship is causal.
• 2+: Well-conducted case-control or cohort studies with a low risk of confounding, bias, or chance and a moderate probability that the relationship is causal.
• 2-: Case-control or cohort studies with a high risk of confounding, bias, or chance and a significant risk that the relationship is not causal.
• 3: Non-analytic studies, e.g., case reports, case series.
• 4: Expert opinion.

Grades of Recommendations

• A: At least one meta-analysis, systematic review, or RCT rated as 1++ and directly applicable to the target population or a systematic review of RCTs or a body of evidence consisting principally of studies rated as 1+ directly applicable to the target population and demonstrating overall consistency of results.
• B: A body of evidence including studies rated as 2++ directly applicable to the target population and demonstrating overall consistency of results or extrapolated evidence from studies rated as 1++ or 1+.
• C: A body of evidence including studies rated as 2+ directly applicable to the target population and demonstrating overall consistency of results or extrapolated evidence from studies rated as 2++.
• D: Evidence level 3 or 4 or extrapolated evidence from studies rated as 2+.

Example: Whole-Body Cryotherapy (WBC) for Recovery

• Evidence:
  • 3x systematic reviews and meta-analyses: Overall, insufficient and inconclusive evidence that WBC improves markers of recovery (subjective, inflammatory, performance-related). CWI (cold water immersion) is more effective than WBC. Insufficient evidence for use in elite athletes or football players.
  • Expert 1: Does not use WBC—insufficient evidence, high cost, lack of practicality (e.g., limited number of athletes can enter at any one time).
  • Expert 2: Does use WBC and suggests preliminary results suggest it may increase functional recovery.
• Considered Judgement:
  • High monetary cost.
  • Need to construct a new building to house the chamber.
  • Maintenance costs and time associated.
  • Not yet proven to be more effective than cold-water immersion (which is less expensive and already installed).
  • Anecdotally more tolerable than cold-water immersion (higher compliance?).
  • Are there any implications for 'future proofing' if evidence emerges regarding increased recovery?
• Graded Recommendation: D (insufficient evidence).

Example: Hamstring Injury

• One in five players become injured.
• 20% re-occurrence.
• On average, 17 days lost from training & competition.
• Cost: €280,000 per injury (Ekstrand et al. 2001, 2013, 2016).
• Relevant research question.

Fascicle Length and Nordic Force

• Level of evidence = B
• Uninjured vs. Injured
  • It appears that a shorter fascicle length is correlated with increased likelihood of injury, particularly at lower Nordic force levels.

Top 5 Most Effective Exercises to Prevent Non-Contact Injury

• Nordic
• Glute activation
• Core
• Ham eccentric
• Balance/proprioception
• Eccentric exercises

Example: Previous Injury

• Level of evidence = B
• Previous history of ACL injury increases risk ratio: $1.17 [0.30, 4.58]$, $2.19 [0.94, 5.08]$, $2.25 [1.34, 3.76]$
• Previous history of chronic groin pain decreases risk ratio: $0.76 [0.11, 5.18]$, $0.40 [0.06, 2.74]$, $2.54 [1.32, 4.88]$

Example: Movement Screening

• Movement quality = maintenance of correct posture & joint alignment in addition to balance while performing movement (McCunn et al., 2016).
• Movement screen = highlight poor movement.
• Several tests exist, e.g., FMS, LESS, Single-leg squat screen.
• Eight studies observed increased risk when FMS composite score < 14.
• Eight studies found no relationship (McCunn et al., 2016).
• Level of evidence = D (Chorba et al., 2010; Bardenett et al., 2015).
• Necessary to understand risk factors & injury mechanisms (Bahr, 2016).
• Substantial overlap in test results.

Example: Cold Water Immersion

• Decreased muscle & body temperature.
• Reduced muscle damage, inflammation, heart rate & cardiac output.
• Peripheral vasoconstriction reducing edema formation.
• Temperature: 10 – 15 °C.
• Duration: 5 – 15 minutes depending on temperature.
• Depth: Greater depth = greater physiological effect.
• Timing: As soon as possible, 30 minutes post-exercise.
• Time to subsequent exercise: > 45 minutes.
• Speed: +2.6%, ES = 0.69 (Poppendieck et al. 2013).
• Strength: +1.8%, ES = 0.10 (Poppendieck et al. 2013).
• Level of evidence = B.
• Users of Ice bath, massage, sleep/nap, food/ fluid are the highest percentage of recoveries.

Examples

• Importance of sleep for recovery & performance is clearly established (Fullagar et al., 2015).
  • Fact: Professional (football) teams often train in the morning the day after an away match.
• Beta-alanine & beetroot juice have clear ergogenetic effects on some aspects of performance (Burke et al., 2017).
  • Fact: The majority of athletes does not use them because of the constraining ingestion protocol & awful taste.

Communication

• Practitioners want simple “yes/no” answers.
• Researchers are interested in “what, why, and how.”
• The ability to communicate relevant data is paramount.
• Hydrotherapy allows athletes to perform subsequent training sessions with a greater training load or quality, thus resulting in an enhanced stimulus for adaptation.
• Cold water immersion may decrease adaptations to training due to minimization of fatigue and inflammation occurring following training.
• Fast: Practitioner. Feeds data to research.
• Slow: Researcher.
• Immediate decision-making/assessment. Has direct application.
• Quality control, exploratory, validation. Has indirect application.
• Fast, automatic, intuitive, non-invasive.
• Provides evidence base to daily systems.
• Slow, deliberate, focused, effort.
• Service provision to players/coaches.
• Informing coach/medical decisions.
• Case studies.
• Dashboard analytics.
• Provides evidence for systems.
• Establishing signal and noise.
• Cost-benefit analyses.
• Statistics.
• Simple stats (spreadsheets).
• Excel graphs.
• Visualization tools.
• Daily monitoring (e.g., with reserve team).

Barriers and Perceptions

• Financial costs
• Coach buy-in
• Time
• Nonapplicable/relevant research
• Inability to transfer from research to applied setting
• Lack of staff
• Player compliance
• Difficulty sourcing research
• Front office/ organization support
• Limited collaborations with universities
• Limited knowledge of performance staff
• I don't understand peer-reviewed research
• Preferred methods of learning include reading scientific articles, networking, and attending conferences.
• Practitioners prefer conversations to disseminate research.
• Conflicting opinions exist between practitioners, researchers, and coaches on how much sport science knowledge coaches 'need'.
• Applied PhD's incorporated into organizational/ club settings
• Researchers could produce research that targets coach-specific needs and preferences

Take Home Messages

• What is EBP – not ONLY research evidence.
• The process.
• Ratings and recommendations - how do we develop rigour.
• Understanding perceptions, context, and environment.
• Importance of communication and dissemination.
• Critiquing evidence – revise literature.