Great strides have been made in the last few years with respect to evidence-based practice in massage therapy and, more recently, research literacy has become a mandatory part of curricula for massage therapists across the country. The question is, since doctorate level academics are those who are considered competent to assess and review scientific research articles, how can we expect massage therapists to do so at the same level? Here is the answer: we don’t.
No one is expecting massage therapists to wear lab coats and evaluate the statistical significance of the results of their practice. The expectation for the research literacy of massage therapists is simply to know where to find it, how to read it, who to engage, and how to ask the right questions to determine the study’s credibility. Another important expectation of massage therapists is to responsibly educate clients about the results the research identifies.
Susan Salvo’s book, Massage Therapy Principles and Practice, cited Dr. JoEllen Sefton, author of Research Literacy and Massage Therapy, defining research literacy as the “ability to locate, read, understand, and evaluate research literature. For massage therapists, this means being able to incorporate the information found from reliable studies into your massage practice and to communicate research findings to others. It gives you the skills necessary to become good consumers, trustworthy sources of massage information, and independent lifelong learners.”
Enhancing professional development
When you have a clear understanding of how a technique works, you become better at it naturally. By learning how to find, interpret and criticize research articles, you are enhancing your knowledge on that particular topic, indirectly impacting your skills in a positive way.
Because research in massage therapy is still in its infancy, massage therapists have an opportunity to become a trailblazer in the field, an expert in a particular modality that not only clients but your peers will rely on for expertise.
Grow your business
By becoming research literate, you will be able to speak the language of other health-care practitioners. Being able to explain research findings related to massage therapy to physicians, for example, in a way that they understand can increase your credibility and the likelihood that they will send you referrals.
Our profession is always justifying our role in health care to insurance companies who are often hesitant to cover massage therapy. What would your clients not being able to be reimbursed for massage do to your practice? Research literate massage therapists can help change the way our profession is viewed by the insurance companies, thereby creating less resistance to coverage for your clients.
Having an ability to understand and to explain how a particular modality works can open the door to many new markets. Clients coming for massage simply for relaxation may decide to increase the frequency of their visits to help treat symptoms they previously believed were off limits to massage.
Through word of mouth, people will recognize you as a well-informed practitioner. Clients are increasingly becoming better consumers these days as they are becoming more familiar with the “evidence-based practice” movement. People may be more willing to tell their friends and family about their massage therapists if they think their therapists are familiar with the latest information about massage therapy.
Turning your clients into better consumers
By educating the client on the difference between what seems to work based on experience versus what has been shown to work based on scientific evidence, massage therapists are empowering their clients to become better consumers of their health care. Massage therapy clients will appreciate this and may even respect their practitioners’ opinions that much more because of it.
Making a difference in the profession
I spent the last few months reviewing articles, and obtaining the opinions of colleagues (including students), clients (including potential clients) and other health-care professionals (including physicians) on research in this profession. It is becoming increasingly clear that we need to do more to improve our credibility within the health-care industry.
The results of my informal investigation revealed a divide amongst the profession. On the one side are massage therapists who believe the proof of effective practice lies in the results they have witnessed in their own experiences. On the other side are those who exclusively support evidence-based practice and believe there is no more room for such anecdotal data.
These two extremes make it difficult to unite as a profession in our goal to adhere to our commitment to responsible health-care practices.
Author Susan Salvo says, “Some MTs do not understand the role of research. It should inform our practice – enrich what we already do. Good research improves our understanding and helps us be more effective. On the flip side, we should use our knowledge and skills to best serve client goals without inserting our own agendas. For example, when clients request deep pressure massage to address pain in the neck and shoulders, it would be ‘professional suicide’ to use only lighter pressure because you read a study that indicated lighter pressure is more effective to reduce pain. When you put your own agendas ahead of your client’s goals, they may leave feeling like you were not listening to them and may not reschedule.”
Anecdotal information is, by its very nature, unreliable. However, that is not to say it is not extremely important. After all, it can form the basis for a research question (hypothesis) that can change the face of how we practice. Without anecdotal information, we wouldn’t have research.
There is room for both schools of thought: the therapists who are dedicated to their personal experiences, and those who are dedicated to research. The trick is how we are conveying the information to our clients.
My discussions with clients, and other health-care practitioners revealed a gap in the perception of what massage therapists are capable of. Most clients are not aware of the extent of our knowledge and skills. Sure, we can expect the Registered Massage Therapists Association of Ontario (RMTAO) to do this advertising for us or wait until someone provides us with more funding. At the end of the day, it is the individual interactions that massage therapists have day-after-day that will make or break our credibility.
How can we convince people of our value if we are not able to support it with reliable information? Coming up with our own theories of how the treatment works may be satisfactory to some people, but is that really a responsible way to provide information? Try that same rationale with physicians who refer clients; you won’t be taken seriously, and that alone will affect our entire profession.
Professional ethics in research
The problem with relying solely on anecdotal information is that there are many other factors that can disprove a direct cause-effect relationship of a particular modality or technique. For example, you may have experience treating a hundred clients with trigger points using ischemic compressions, and in every case, the pain decreased. It is easy to believe the ischemic compressions caused the decreased pain given that all of the clients responded in the same way. There is, however, no way to be certain the clients’ breathing habits, the warm up of effleurage, or the flushing of petrissage aren’t what actually contributed to the decrease of pain. There are other possibilities too: the lotion used, the positioning of the client, the mood and lighting in the room, the music used. Any one of these factors leaves room for the possibility that the ischemic compression alone was not the main contributor to pain reduction among clients yet, many of us feel confident enough to make a statement to our clients saying, “Ischemic compressions will reduce your pain.”
Bodhi Haraldsson, research director with the Massage Therapists' Association of British Columbia (MTABC) said, “As a profession, we have the duty to conduct the research that tests the many hypotheses we have developed over more than a century of our existence. We cannot just say, we've been doing this, let's keep doing it. We can't just say, I see it work in my office every day. The lack of control makes it impossible to determine if the positive outcome we all see with our patients is actually due to what we do, rather than the other non-specific effects of placebo, context and faith in us. This is a moral duty of our profession to ensure that those things we profess (to profess expertise is where the word profession comes from) have validity." Haraldsson previously sat on the board of the College of Massage Therapists of British Columbia and served as vice-president at the MTABC.
Our peers, clients and other health-care professionals expect massage therapists to have a basic understanding of what to look for in determining the credibility of evidence-based therapy. So many clinical trials exist today, but that doesn’t mean they were conducted properly, yet more and more massage therapists are using these studies to support their claims that a particular technique will yield a particular result. Factual statements should not be made on the basis of studies that are invalid or unreliable. Massage therapists, at the very least, need to have a basic understanding of how to seek out research to stay current with the latest information and identify red flags and know what questions to ask to critically evaluate an article, or any information suggesting a cause-effect relationship.
Let us reflect on our Code of Ethics principles put forth by the College of Massage Therapists of Ontario (CMTO) and how being research literate is a basic requirement to adhere to our ethical principles:
- The Respect for Persons principle includes “ensuring that clients are as fully involved as possible in the planning and implementation of their own health care” (CMTO). If we inform our clients that a modality or technique will decrease their pain when we are basing it on anecdotal data, not factoring in the other potential contributors, our clients are planning their health care based on misleading information.
- Responsible Caring includes “promoting the client's best interest and well-being, through the highest possible standard of professional practice” (CMTO). Do we define the highest possible standards as providing the client with information that leaves room for error?
- The definition of Integrity in Relationships is “to practice with integrity, honesty and diligence in our professional relationships, with ourselves, our clients, our professional colleagues and society” (CMTO). We are not acting with integrity when, for example, we know that there may be other factors contributing to someone’s pain reduction, yet we say it is definitely due to the ischemic compression.
- And finally, Responsibility to Society not only dictates our “commitment to continuous improvement” (CMTO), it also expects us to participate in “the promotion of the profession of massage therapy through advocacy, research and maintenance of the highest possible standards of practice” (CMTO). Unless we are using scientific evidence to support our claims of cause-effect relationships, we are not fulfilling our responsibility to society using the highest possible standards of practice.
When communicating with our clients, there are ways to educate them about the difference between anecdotal information and evidence-based practice. Once you are familiar with what is out there in terms of trustworthy research, you can say for example, “In my experience, whenever I perform ischemic compressions, my clients seem to experience a reduction in pain, but there is no evidence that I am aware of to support that this is what causes the reduction of pain. If you are willing to try it, we can get started.” Or, “Some small studies have shown that ischemic compressions may result in the reduction of pain, however more research still needs to be conducted. We can always try this technique and see if it works for you.”
These types of responses allow the therapist to continue practicing a modality or technique that they believe works, while providing responsible, informed information to the client who now fully understands that ischemic compressions may not actually cause a reduction in pain before they provide consent to treatment.
Research in massage therapy is still in its infancy. We cannot stop our careers while advances in science are still being hypothesized. We can, however, change our thinking about the effects of our work by becoming curious and skeptical – continuing to ask ourselves “why the result is the way it is”, encouraging those practitioners who are interested in pursuing their careers in research to answer these questions for us.
In the meantime, we can continue to practice modalities and techniques that are safe and seemingly effective, provided we educate our clients responsibly about the differences between anecdotal information and evidence-based practice, so they can make an informed decision about their own health-care treatment plan.
Here are some inexpensive online resources to help you learn more about research literacy and access articles related to massage therapy.
The Basics of Research Literacy
Massage Therapy Foundation
Time Commitment: 8 hours
Understanding Research: An Overview for Health Professionals
Coursera: University of California
Time Commitment: 6 weeks (2-4 hrs per week)
Jennifer Bloch, RMT, is dedicated to research and supporting the integrity of the massage therapy profession. She was a recipient of the 2013 Award for Excellence in Research and Interpretive Studies by the Canadian Council of Massage Therapy Schools. Jennifer is the owner of BusyBodies Health, a mobile massage company that provides other health-care services in the interest of saving people time to focus on their healthy lifestyle. BusyBodies Health also offers professional development workshops to health-care practitioners leveraging the expertise of Jennifer’s previous career as a human resources manager. Jennifer plays an active role in educating the public and her peers on the difference between anecdotal information and evidence-based practice, enabling clients to make informed decisions about their health-care plans, and by providing her peers with resources to help interpret research studies related to massage.