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Bridging the Evidence Divide

Does evidence-informed practice involve favouring hard science over the art of massage, clinical experience and all else that makes for an excellent massage therapist? I would emphatically say “no!”

In addition to expanding the clinician’s knowledge base and skill set, evidence-informed practice tends to get the nod within health-care systems.

The indiscriminate use of hard science when making clinical decisions doesn’t necessarily guarantee the most effective and client-appreciated treatment. However, there is ‘‘value’’ – for all stakeholders – in skilled hands supported by evidence-informed clinical strategies.

In addition to expanding the clinician’s knowledge base and skill set, evidence-informed practice tends to get the nod within health-care systems and among coverage providers. In turn, this will generate a greater awareness of modalities (e.g., massage therapy) that can provide safe, cost-effective treatment and greater access to treatment for those in need. Furthermore, evidence-informed practices foster the development of valid and reliable diagnostic/assessment tools with which to establish a baseline, monitor change and identify dose-related variables – all of which support achieving more predictive therapeutic responses/outcomes.

Enhancing professional credibility
Massage therapy education and training in Canada is considered to be some of the best available in the world. However, professional credibility (due to limited evidential information) is an issue even we – massage therapists (MTs) trained in one of the Canadian regulated provinces – come up against routinely. We are registered and regulated; however, we still have room for growth with regard to establishing a solid body of knowledge supported by evidence-informed practices. Evidence-informed practices support a commitment to best practices. As F. Rafferty, MD, said, “Best-practice procedures must be continuously updated based on the best science available and must be delivered through humane and compassionate relationships with our patients.”

Meaningful evidence
In order to continually update our procedures based on the best science available, we need meaningful research to be conducted with massage therapy in mind.

One challenge to useful research for MTs was cited by Langevin: “large scale clinical trials of MT are being conducted without the knowledge of how effects are produced.”1 For instance, on a relatively regular basis, MTs can be heard conveying that effleurage increases circulation.

However, we don’t (yet) have conclusive evidential information to support this claim nor can we clearly explain the mechanism of action (i.e., how the effect is produced). That said, far be it from me to discount results. We observe massage therapy working regularly in our practices and it is fantastic that our clients often feel better at the conclusion of a treatment. However, if we more clearly understand the mechanisms of action, we are better positioned to produce more predictive/productive therapeutic outcomes and avoid any risks involved, and we may discover other potential uses for our techniques and methods beyond those currently known to us. This can go a long way in helping our clients and our cause.

The need for collaboration
In order to understand mechanism of action – we need scientists/researchers helping us answer our questions. Geoffrey Bove, a chiropractor and researcher who is well known within the fascia community, notes, “For clinical science to advance most efficiently clinicians will need to better inform scientists of their pressing questions and the scientists will need to develop clinically relevant approaches to answer these questions.”2

Clinician/scientist collaboration is a critical element in constructing better research. Bidirectional collaboration is needed in order to avoid poorly constructed research designs or methodologies that lead to flawed or limited conclusions. As noted by Bove and Cherkin3, “Translation must be a goal in mind prior to the onset of a study or research and collaboration during the design phase of a clinical trial is essential to ensuring the construct of meaningful research.”

Better-constructed research measures lead to conclusions that are more clinically valid and viable. The ultimate outcome is clinically useful and applicable information that can be put into practice to improve the quality of care we provide for our clients.

Dissemination
Once meaningful research is produced, we then move on to dissemination – the distribution of the meaningful information. Trade publications (e.g., journals, magazines), conferences, educators, educational institutions, research promoting foundations and professional associations are all important sources from which we can access meaningful information that helps us in our quest to be knowledge current. Your support helps to keep these sources available and accessible.

The role of the clinician
Once the information is made available, it becomes the responsibility of the clinician to put the information to good use by moving the information off the page and on to the treatment table. Evidential information has its “moment” when it can be successfully utilized to influence decision making and result in changes in clinical behaviours that improve the delivery of quality of care.
But before this, training in research literacy and involvement in knowledge transfer is crucial! Otherwise, what is the point of all that fantastic information!

Trish Dryden has been instrumental to the professionalization of massage therapy and the development of research and health care in Canada and internationally.

Interview with Trish Dryden, RMT
Trish Dryden, M.Ed., RMT, is the Associate Vice-President of Research and Corporate Planning at Centennial College, in Toronto, Ontario. A trail blazer and catalyst for change, she is instrumental to the professionalization of massage therapy and the development of integrative and interprofessional research and health care in Canada and internationally. In the Fall 2002 issue of Massage Therapy Canada magazine, Trish provided a detailed “Report on Research.” In the following interview we check in with her to see what has changed since 2002 with regard to massage therapy research and where we are headed in the near future.

Massage Therapy Canada: How are we doing with regard to meaningful massage therapy research? Have we made any significant strides in the past 10 years?

Trish Dryden: There has been an explosion of research in massage therapy in the last 10 years! Not all of it is high quality, from a methodological perspective, and not all of the outcomes are clinically relevant. As well, there is still very little data about mechanism of action. But cumulatively, the level of research activity demonstrates an accelerated focus and interest by funders, policy makers, clinicians and the public in understanding why massage therapy is beneficial across a broad range of outcomes – for example, in non-specific low back pain, anxiety and depression, and sleep – and a real interest in answering questions about dosage, specific techniques, cost effectiveness, specific conditions and populations across the life span, from infants to end-of-life care.

Among well-known and respected scientists and academics, in the broader integrative medicine field, I frankly no longer hear comments about “if” massage therapy is effective or safe. I hear excitement and interest in understanding how and why MT works. That’s a sea-change in attitudes and perception from a decade ago!

A body of evidence in any field – whether massage therapy or any other intervention – is built slowly and painstakingly over many, many years. From our early studies in the ’80s until now, those of us working in research have been building incrementally upon each other’s work. With better methods, better outcome measures, imaging techniques, biomarkers, more clarity in clinical protocols, more interrelationship between the virtuous cycle of bench, bedside and boardroom (i.e., from basic discovery-based research, to clinically relevant outcomes research and knowledge of how research is funded and made public); with the increased engagement of practitioners and clients in study design; with higher levels of educational preparation for massage therapy practitioners so that they can better find, critically evaluate, and utilize best available evidence; and with greater availability of new knowledge to more people, I think we are making enormous strides!

I don’t think we can underestimate the impact of the Internet and personal data devices of all kinds – for example, e-readers, tablets and smartphones, and the explosion of professional and social networking sites – on how we consume information and new ideas.

MTC: Once meaningful research has been produced, in order for it to be clinically useful, it needs to be accessible to the “masses.” How are we doing here? And what can be done to improve the accessibility and distribution of evidential information?

TD: Many people have access to just about everything that gets produced now – the good, the bad and the ugly. Accessibility and distribution is rarely the issue any more, at least among middle-class Canadian clinicians, as we are among the most wired group in the world – and people are increasingly savvy about how to find information.

The question remains is the evidence any good? Can we read critically for ourselves? Do we know how to evaluate the strength of the outcomes; do we self-reflect; do we confirm, alter or modify what we do in practice based on best available evidence? Too much information and too little personal time may be a stronger influencer of how and what we consume, in the knowledge economy.

Frankly, I am reminded of Gutenberg’s invention of the printing press in 1439 and the revolutions in thinking that soon followed when people discovered that they didn’t need a priestly class to interpret the Bible, as long as they could get their hands on a copy and they knew how to read. Anyone who wants to find current research can do so – not always the entire original research article, perhaps only the abstract if access to the whole article requires a subscription to an academic journal – but increasingly, online open access and peer-reviewed journals exist which contain both original research and interpretations of research.

MTC: I view reading research abstracts as analogous to ripping into a juicy novel. But, I acknowledge that my excitement is not analogous to having a critical eye. Can you share some advice on how to read research critically?

TD: Martha Menard’s book, Making Sense of Research, and CK Andrade and Paul Clifford’s book, Outcome-Based Massage, are wonderfully helpful to both novice and more experienced MTs regarding how to find, and critically assess, research. And, if I may put in my own plug … Christopher A. Moyer and I have a brand new book coming out in 2012 from Human Kinetics titled Massage Therapy: Integrating Research and Practice, in which we have tried to create the best single source of the latest research with relevance to the practice of massage therapy. By compiling this information in a single book, we present readers with a synthesis of information from diverse fields, including kinesiology, medicine, nursing, physical therapy and psychology. We strived to do this in a way that is clear and concise, without resorting to oversimplification. Each of the population- and condition-based chapters in the book contains a review and critique of the research to date and concludes with evidence-based best practice guidelines and a case example written by many of the top MT researchers in the world.

Many professional associations such as the RMTAO and MTABC, and a number of educational institutions offer excellent, brief courses in “research literacy” which are fun and inexpensive and practitioners walk away with a terrific set of critical thinking skills and tips that they can then apply to whatever source of information they are reading.

It comes down to knowing enough about what is supposed to be in each section of a research article from the abstract at the beginning, to the literature review, to the methods section in the middle and the discussion and conclusions at the end. The reader must also know:

• whether or not the evidence being presented is sound – i.e., logical and thoroughly enough presented, so that you can figure out what the researchers actually did;
• how much it bears resemblance to how massage is actually practised by the practitioner who is reading, as opposed to massage protocols that only work in the “lab”; and
• whether or not their conclusions logically would fall from the research question(s) they asked and the methods and measures they used to answer the research questions.

I also look for whether the authors have been both humble and thoughtful enough to clearly reveal the limitations of their study and to have offered possible alternate explanations for their outcomes. Research studies ultimately are like snapshots in time – they are never the whole picture and must always be critically weighed for strengths, weaknesses and balanced with the practitioner’s own experience and clients’ preferences.

MTC: Shifting clinician inertia … from your perspective what are some of the challenges you have identified with regard to knowledge transfer and how can this be improved?

TD: In my opinion, the vast majority of massage therapists are wonderfully caring professionals who are truly committed to helping their clients get better. Part of that professional commitment must be about a dedication to lifelong learning and reflective practice.

Nothing stays the same – what we believed to be true about massage’s effects and how it worked, when I graduated from massage therapy school over 30 years ago, was, largely, not based on science but on a model of inherited wisdom passed, uncritically, from one generation to the next. There is nothing wrong with the sharing of wisdom through anecdote and experience, but clinical decision making that is ethical and in the best interests of our clients needs to take into account an array of evidence from a variety of sources – including best available scientific evidence based on well-done research from across disciplines – tempered with the practitioner’s own experience and the individual client’s needs, values, culture and preferences.

Therapists need to make the time necessary to read, discuss, share information and ideas from all the sources that are now available to them, and take responsibility for ensuring that they stay current and informed. Ethical, client-centred care is an inherently collaborative, interactive process. The MTs who worry me are the ones that work in isolation and never talk about their cases or their work with anyone else, never explore new ideas, and who are not interested in changing anything they do. They place little value on self-awareness and reflection. Most of us would never knowingly go to a dentist, a chiropractor, a doctor, or a massage therapist, for that matter, who does not stay current in their field and does not question what they are doing and therefore does not strive to do it better.

MTC: On occasion I have heard it expressed that too much science might detract from the “art” and intuitive and compassionate aspects of massage therapy. Is it necessary to sacrifice artistry in order to embrace current science – your thoughts on this?

TD: Sounds like some folks think science is like the common cold – get the bugs in you and you get sick. Yikes!

Seriously, I just can’t image the art-science, body-mind, intuition-reason dualities giving anybody an issue these days. Massage therapy is a science and an art. Period. Critically read everything you can  …  science and poetry, enjoy the arts, make music, keep good clinical notes, prepare and eat beautiful and healthy food, reflect on your practice, question what you are doing and talk about your thinking with others – ask yourself:  is my practice as effective, safe, and cost-effective as it can be, and how can I improve my clients’ outcomes? It really comes down to life-long learning and staying connected with others.

References
Bove, G. DC, PhD, Chapelle, S. RMT: Lessons from the Conference; Highlighting Massage Therapy in Complimentary and Integrative Medicine (2010): Journal of Bodywork & Movement Therapies – 14, 312-414. Elsevier.

Hamm, M. LMP, CCST: A Massage Therapists Perspective; Highlighting Massage Therapy in Complimentary and Integrative Medicine (2010): Journal of Bodywork & Movement Therapies – 14, 315-317. Elsevier. Ibid.

Cathy Ryan has maintained a diverse, treatment- oriented massage therapy practice and an extensive postgraduate training roster since 1990. Cathy is a long standing member of provincial massage therapy associations and has served as a subject matter expert and examiner trainer at the CMTO’s provincial licensing examinations. Currently residing and working in beautiful B.C., Cathy maintains a private practice, teaches and writes massage therapy related material and is the managing editor for TouchU.ca; an online source providing accredited continuing education for touch professionals and students. Cathy can be reached at: cryanrmt@gmail.com or via www.touchu.ca