Celebrating the Insecure Practitioner. A Critique of Evidence-Based Practice in Adapted Physical Activity

Abstract

Over the past decade there has been a trend within adapted physical activity (APA) to question the hegemony of the medical understanding of disability. This debate has consequences for professional practice, which some argue should be regarded as a learning situation with a pedagogical orientation. The concept of evidence-based practice and research has spread from its origin in medicine to other allied health fields and education. In this article I discuss the limitations of applying evidence-based practice to a pedagogical approach to APA. More specifically, I use the Aristotelian notion phronesis to show that professional practice of APA is essentially characterized by an indeterminacy that cannot be eradicated through the technological thinking inherent in evidence-based practice.

Resumen

Durante la última década ha habido una tendencia dentro de la actividad física adaptada (AFA) [adaped physical activity (APA)] a cuestionar la hegemonía de la concepción médica de la discapacidad. Este debate repercute en la práctica profesional, que algunos arguyen, debería ser considerada como una situación de aprendizaje con una orientación pedagógica. El concepto de práctica basada en la evidencia se ha extendido desde su orígen en medicina a otros campos de la salud aliados y la educación. La posibilidad de práctica basada en la evidencia ha sido debatida en el campo de la AFA hasta cierto punto. Dado que el campo de la AFA misma se encuentra en un proceso de redefinición como una profesión que depende de más perspectivas que las meramente médicas, este artículo indaga algunos problemas potenciales al aplicar una conceptualización de práctica professional que ha surgido desde el campo de la medicina.

Zusammenfassung

Über die letzten zehn Jahre zeichnete sich innerhalb der APA (adapted physical activity = Bewegung, Spiel und Sport in Prävention, Rehabilitation und Behinderung) ein Trend ab, der die Vormachtstellung des medizinischen Verständnisses von Behinderung infrage stellt. Diese Debatte hat Konsequenzen für die professionelle Praxis, von der einige behaupten, sie sei als pädagogische Lernsituation zu betrachten. Das Konzept der evidenzbasierten Praxis und Forschung hat sich von seinen Ursprüngen in der Medizin in andere gesundheitsbezogene Felder weiter verbreitet. Die Möglichkeiten der evidenzbasierten Praxis wurden bisher nur in begrenztem Maße in der APA diskutiert. Dieser Artikel untersucht potenzielle Probleme der Anwendung von Konzepten professioneller Praxis, wie sie sich seitens der Medizin verbreitet haben Dies geschieht unter der Annahme, dass dieses gesundheitsbezogene Feld von APA in seinem fachlichen Erneuerungsprozess von mehr als nur medizinischen Perspektiven abhängig ist.

Keywords:

• adapted physical activity
• evidence-based practice
• phronesis
• professional practice

Acknowledgements

The author would like to thank professor Kjetil Steinsholt and the editors for helpful comments on the manuscript. This article is part of a larger project funded by the a grant from Helse og Rehabilitering.

Notes

1. Here it must be pointed out that in the APA literature education is almost exclusively connected to the instruction of school-aged children (cf. Porretta et al. 1993; Sherrill 2004). However, as Morisbak (1988, 73) pointed out, an educational approach is to be understood more broadly encompassing organised physical activity not only in ‘schools, [but also in] sports competitions, recreational activities and remedial/corrective therapies’.

2. This hierarchy is identical to the one developed by the Oxford Centre for Evidence-based Medicine (Odom et al. 2005). Note also here that on level four one leaves the secure foundation of evidence and enters the dubious terrain of opinions.

3. It should be noted that due to the lack of scientific evidence, the recommendations actually given by SHDIR draw to a large extent on experiences from experts in the field (i.e. level four). In addition to lack of scientific evidence, the report also states that the large variation in how different disabilities affect the individual ‘makes a clear approach difficult’ (SHDIR 2004, 9). This important point will be discussed below.

4. In order to understand the concept phronesis, I will mainly draw on Joseph Dunne's seminal book Back to the Rough Ground, which is a philosophical exposition of Aristotle's distinction between techne and phronesis motivated from problems in the educational domain, not too distant from the challenges regarding EBP.

5. Dunne notes that seeing something as an end in itself is somewhat problematic because it operates within the rational logic of means to ends. The full significance of phronesis is according to Dunne not to be grasped ‘unless we see that it involves nothing less than what Gadamer calls a “fundamental modification” of the means-end framework’ (Dunne 1993, 262).

6. This does not mean that pedagogical encounters are totally subjected to chance. However, ‘the play of chance is simply ineliminable’, so that what is required is a ‘flexible kind of dynamism. … [T]his is the meaning of kairos; one's active intervention has skilfully awaited until one's polyvalent materials – be they the wind and the waves in play upon one's boat or the changing humors in the sick body – are at their most propitious, i.e. are most able to help, or at least able to hinder, the accomplishment of one's end’ (Dunne 1993, 256).

7. Even if this premise is not universally accepted, and APA is still conceived of as a medical practice (as it indeed sometimes will be), there will still be at least a marginal room for the critical approach offered here. For instance Svenaeus (2000; 2003) has discussed the non-technical nature of medical practice, and the need for the general physician to exhibit phronesis.

8. Implicit in this argument is the idea that research in special education, and in APA, uses medical diagnostics as the groups or labels whereby research participants are divided into to intervention and control group. With regard to APA, one can ask how research done in a medical model of disability can inform a practice that is supposed to move away from the medical model.

9. This matter is more complicated: One could say that there is good and bad self-determination, much like there is good and bad paternalism. Respecting the autonomy of the participant is of course crucial, but as Loewy argues, a stark autonomy where the participant is left to make all the choices is to ‘abandon [the participants] to their own autonomy’ (Loewy 2005, 446). This means that, at worst, too much emphasis on autonomy and self-determination is a form of professional abdication, jeopardising the good of the participants. Balancing between stepping back and letting the participant make decisions (self-determination), and stepping in and assuming responsibility when needed (good paternalism) is an ethical issue that has received little attention within APA, but one that merits some closer examination.

10. Of course, it might be argued that this form of collaborative research, tending towards action research, fails to address an underlying problem with EBR, namely whether the questions one is concerned with at all are ‘best approached via any sort of empirically or experimentally conceived research’ (Carr 2001, 465).