Using Research Evidence
By Bodhi G Haraldsson RMT
The evidence for massage therapy is growing fast. How can you begin to integrate it into your practice? The best tools for integration of research into practice come to us from the Evidence Based Practice movement.
By Bodhi G Haraldsson RMT
The evidence for massage therapy is growing fast. How can you begin to integrate it into your practice? The best tools for integration of research into practice come to us from the Evidence Based Practice movement. This movement started in the early ’90s, when a group of clinicians and epidemiologists at McMaster University in Ontario, Canada, officially coined the term “evidence-based medicine.” Its philosophical base dates back to the skeptics of post-revolutionary Paris.
As a therapist caring for patients, you have an obligation to provide the best possible care. You also have a moral obligation to stay up to date. Evidence-Based Practices can help you do that.
What is Evidence-Based Medicine?
Evidence-based medicine (EBM) is a potential important change in the way massage therapists practice and teach.
EBM is defined as: “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.” (Sackett, 2000)
Three cornerstones of evidence-based practice are: 1. best available research evidence (as determined by critical appraisal), 2. clinical experience, clinical reasoning, 3. practical, patient-centred application.
Many of the arguments raised against EBM within the health care community are based on a caricature radically at odds with established, accepted and published principles of EBM practice. Contrary to what has sometimes been argued, EBM is not cookbook medicine that ignores individual needs. Neither does EBM mandate that only proven therapies should be used.
Before EBM, decisions on health care tended to be based on tradition, power and influence. Such modes usually act to the disadvantage of marginal groups (AJ Vickers).
Hicks (1997) states that evidence-based care ‘takes place when decisions that affect the care of patients are taken with due weight accorded to all valid, relevant information.’
How to Find the Right Information
Every clinician’s time is limited. Your efforts should focus on identifying, validating, and applying common POEMs to practice.
The term POEM stands for “Patient Oriented Evidence that Matters,” and refers to the kind of article that: addresses a clinical problem or clinical question that therapists will encounter in their practice uses patient-oriented outcomes has the potential to change our practice if the results are valid and applicable.
EBM is not only about evaluating original research. Finding good secondary sources that summarize the literature and give you a useful, actionable bottom line based on the evidence.
In the article Making EBM Doable in everyday practice, White (2004) reports on PP-ICONS.
They help you to decide quickly whether a study warrants attention, look at the abstract and answer 7 questions (PP-ICONS, for short):
- Problem – Is it a problem I see in my practice?
- Patient population – Does the study’s patient population look like my patient population?
- Intervention – What is the intervention, and is it realistic in my setting?
- Comparison – What is the intervention being compared to, and is it a reasonable comparison?
- Outcomes – Would the outcomes matter to my patients?
- Number – How many patients were in the study? Studies with small numbers, generally less than 80, may be interesting, but not worth applying.
- Statistics – How does the study present its findings? Most research papers use the relative risk reduction, which tends to emphasize small differences in the research findings.
A better statistic is the number needed to treat (NNT), which is simply the reciprocal of the absolute risk reduction. It tells you how many patients you need to treat for one patient to benefit.
Look at the evidence in the context of the patient and make sure you are doing things that will make a difference to the patient
Therapists may be discomfited by searching the literature for evidence of an intervention’s efficacy, only
to discover just how meager that evidence is in many cases.
Often different sources of evidence conflict, it’s important to bear in mind that building a collection of evidence for or against a given intervention is an ongoing process.
Evaluating the Literature
Evaluate the strength and validity of the literature that supports the discussion. Look for meta-analyses or systematic reviews, high-quality, randomized clinical trials with important patient oriented outcomes (such as changes in function, symptom improvement, or quality of life) or well-designed, non-randomized clinical trials, clinical cohort studies, or case-controlled studies with consistent findings.
• Level A (randomized controlled trial/meta-analysis): High-quality randomized controlled trial (RCT) that considers all important outcomes. High-quality meta-analysis quantitative (systematic review) using comprehensive search strategies.
• Level B (other evidence): A well-designed, non-randomized clinical trial. A non quantitative systematic review with appropriate search strategies and well-substan-tiated conclusions. Includes lower quality RCTs, clinical cohort studies, and case-controlled studies with non-biased selection of study participants and consistent findings.
Other evidence, such as high quality, historical, uncontrolled studies, or well-designed epidemiologic studies with compelling findings, is also included.
• Level C (consensus/expert opinion): Consensus viewpoint or expert opinion.
EBM is an important tool for your profession as we move into the
Gone are the days when the answer “I know it works” would suffice.
- RD Herbert, M Gabriel Effects of stretching before and after exercising on muscle soreness and risk of injury: systematic review BMJ VOLUME 325 31 AUGUST 2002
- Hicks N 1997 Evidence-based health care. Bandolier 4(39): 8
- DL. Sackett et al Evidence-Based Medicine: How to Practice and Teach EBM.” 2nd edition, Churchill-Livingstone, New York, 2000
- Andrew J Vickers* Message to complementary and alternative medicine: evidence is a better friend than power BMC Complementary and Alternative Medicine (2001) 1:1
- B White Making EVIDENCE-BASED MEDICINE Doable IN EVERYDAY PRACTICE FAMILYPRACTICE MANAGEMENT _ www.aafp.org/fpm _ February 2004
- EW Yeung, SS Yeung A systematic review of interventions to prevent lower limb soft tissue running injuries Br J Sports Med 2001;35:383–389