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My Response To The EIP vs EBP Debate

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Sometimes we write posts around here that ruffle some feathers. 

This happened a few weeks ago when we talked about being evidence-based or evidence-informed. 

The post was basically making some arguments for being evidence-informed and looked at some of the limitations or downfalls around being evidence-based. 

A number of articles were thrown my way to look at the contrary, so let’s dig into those and see what they have to say and perhaps I’ll have to change my stance. 

Successful vs. Unsuccessful

It’s probably important to state right from the start there are limitations to both evidence-based (EBP) and evidence-informed practice (EIP). 

As I read through some of the research cited on EBP a few things stand out to me. 

First off, the literature (¹) fairly consistently talks about EBP in a multidisciplinary setting, typically in a hospital setting. 

This is not the same as working in a multidisciplinary musculoskeletal care clinic as most of us work in. In our case, you can’t interview your patient, then leave and chat with a few other colleagues for an extended period, then go back in and conduct your treatment. 

This is a situation that is probably very valuable for our Physiotherapist friends who are working in a hospital setting; however, there aren’t a lot of Massage Therapists who work in this environment (I know there are a few, but it’s not the norm). 

Part of how to successfully apply EBP is by giving staff opportunities for discussion. So, when we look at a hospital setting, you typically have union, hourly paid positions which enable this to happen. They are encouraged and given paid time as part of their employment to engage in this kind of activity. 

However, in our case, if we aren’t working, we aren’t making money, so implementing this is a lot more difficult. I know some clinics try to have monthly meetings and discussions (which is a noble effort), but I think most of us want to go home at the end of the day. 

Another caveat is that people are placed into (again paid hourly positions) leadership roles to accomplish the efforts mentioned above in these hospital settings; their sole job is implementation. 

When they compared hospitals who were trying to implement EBP, they were referred to as “high performing sites”, and “low performing sites”. 

The high performing sites had a consistent and strong emphasis on EBP throughout the organization along with: 

  • guideline development and implementation
  • evidence-based teams
  • leadership that provided an environment of support
  • they strove to build relationships with patients by placing them at the centre of the organization
  • structural mechanisms in place to support patient-centred care with contributions from all staff

When they looked at the low performing sites, they saw things like: 

  • it was up to individual providers to stay up to date
  • staff felt it was everyone’s responsibility to keep up with new developments
  • low numbers of implementation and support
  • more variation in leadership support 
  • more transactional interactions with patients
  • staff delivering patient-centred care instead of it being done as an organization
  • a passive or punitive culture

This is important to take into account because while we may be working in a multidisciplinary clinic, the values of each practitioner working there can be drastically different. 

We are most likely involved in what this paper would have called the low-performing site.

Even if we as Massage Therapists strive to be evidence-based, it doesn’t mean everyone else in the clinic is. We could be working with other practitioners pushing old narratives, so we don’t get the team environment that would make the clinic more successful as EBP and us. 

The Sicily Statement

There is a quote in this paper(2) that I love: 

“Knowing is not enough, we must apply. Willing is not enough, we must do.”

A few other things stand out in this paper. First off, it points out there are increasingly growing specialist databases for the professions working on EBP. However, there is very little research specifically on massage therapy. So we regularly have to depend on research being done in the Physio or manual therapy realm and using that to apply in our practice. 

So, there is no “specialist database” for us to rely on (hopefully, this changes at some point). 

Another part of implementing EBP is reading research, applying it in practice, all so you can build your knowledge and wisdom (which is something I hope we’re all doing), but this can take years of work to be proficient at. 

They propose we go from EBM to EBP to benefit entire health care teams and organizations adopting this approach. But, unfortunately, even in a multidisciplinary clinic, we don’t work in teams. So until our associations start setting firm boundaries and creating policies to put EBP in place, this won’t happen (and I doubt it will in my career). 

This is also hoping that EB practitioners are speaking the same language. So even in a multidisciplinary clinic, this won’t happen as many still believe they’re further up the healthcare hierarchy than us. Look at the fact it was only something like 53% of chiro’s here in Canada recently voted in favour of not using x-ray with every patient. This means that basically, 50% of the profession was choosing to remain doing something in practice that is not evidence-based. Think of how this would affect a team environment working in a clinic where this non-evidence-based approach is part of the culture. 

How in this setting could we expect to work as a team of EB practitioners, taking what an RMT says into account? It probably happens a little bit, but we have light years to go before this is standard. 

The resounding message I got from this paper is that it is necessary to work as a team for anyone to be successful as an EBP. While I think we should be working towards this, this isn’t something that happens in private practice in the manner recommended. 

The second big takeaway is that changes in education are necessary. 

Until students are taught about research, critical thinking, and how to have a critical attitude to your practice, we won’t be able to implement this as a profession properly. 

Part of the problem with this lack of education at the college level is that when students graduate and start looking for their first continuing education course they get blindsided by some of the (for lack of a better term) “guru’s” out there teaching non-evidence-based courses.

As the article points out: “Attitudes are caught not taught,” and unfortunately, a lot of this happens with these continuing education courses. 

Are We Even EIM?

So, the terms EIP and EBP often get used interchangeably, and I have no issue with this but it’s been brought to my attention this could be confusing to some, I just think when we really look at it, we’re closer to EIP than EBP. 

Fair enough. 

So, the difference I see is that EIP takes into account more types of research. As Massage Therapists, we need to consider this since there isn’t much specific massage research out there, and we have to be able to look at the research and apply it to the person in front of us. 

I like this image that was cited(4) in another article which shows the short-term and long-term goals of both EIP & EBP: 

I know it’s a bit tough to see in this image, but what stood out to me was the difference in the long-term goal comparison between EBP & EIP. While there are some similarities there are a couple of interesting differences:

EBP long term goals:

  • Improved patient assessment and treatment
  • Increased staff retention

EIP long term goals:

  • Improved patient outcomes (patient safety, reduced morbidity and mortality, and less healthcare costs to patients and patient relatives
  • An evidence-based practitioner who is a critical thinker and doer
  • Job satisfaction among practitioners

I don’t know about you, but I like the long-term goals of EIP a lot more, however it has it’s own set of challenges as well.

One of the more difficult challenges in EIP also has to do with education. One of the main factors to be evidence-informed is the ability to critically think, and be critical of research (3). 

This again comes down to what is being taught at the college level; critical thinking skills are not part of the curriculum. 

When we look at the five steps recommended in EBP this is how it looks (2): 

  1. The professions and their colleges should incorporate the necessary knowledge, skills and attitudes of EBP into their training and registration requirements
  2. Curricula to deliver these competencies should be grounded in the 5 step model 
  3. Further research into the most effective and efficient methods for teaching each step should be fostered and linked with ongoing systematic reviews on each step
  4. core assessment tools for each of the steps should be developed, validated, and made freely available internationally
  5. courses that claim to teach EBP should have effective methods for teaching and evaluating all components. 

Looking at those five steps it is clear to me (and also in the research papers) that changes in education are necessary!

EBP cannot happen successfully until our education changes. One of the major themes throughout the papers is leadership. 

For us, this means our associations, regulatory bodies, and schools need to step up and make a change. These organizations must create and implement policies that push the profession toward EBP. 

This isn’t limited to just our entry to practice education, it should include continuing education courses. When we look at the courses that our associations are willing to promote (and get CEC approval from the regulatory bodies), 1% of them are EB (yes, I’m making up 1%, but I’d be willing to bet it’s not much better than that).

When it comes down to it, I don’t care what we call it anymore, EIP or EBP. All that matters is we are reading the best available research and trying our best to implement evidence into practice while also putting the people in front of us first. My buddy Rey Allen left a comment on a thread that said something to the effect of “Let’s just call it science based practice”. I’m good with that too (in fact, maybe that’s better overall). But, until the leadership in our profession changes and starts to implement policies to make things like this mandatory, I’m not sure we can apply any of these titles appropriately. However,  this doesn’t mean we shouldn’t be putting every effort forth to make this happen, it’s quite the opposite. We HAVE to make these changes so the profession as a whole is applying evidence in practice. So, let’s start pushing leadership to make a change to make us better and do better for the people seeking out our help and truly deliver care that is being influenced by the best available evidence. 

References: 

  1. Engle RL, Mohr DC, Holmes SK, Seibert MN, Afable M, Leyson J, Meterko M. Evidence-based practice and patient-centered care: Doing both well. Health care management review. 2021 Jul;46(3):174.
  2. Dawes M, Summerskill W, Glasziou P, Cartabellotta A, Martin J, Hopayian K, Porzsolt F, Burls A, Osborne J. Sicily statement on evidence-based practice. BMC medical education. 2005 Dec;5(1):1-7.
  3. Finch PM. The evidence funnel: highlighting the importance of research literacy in the delivery of evidence informed complementary health care. Journal of Bodywork and Movement Therapies. 2007 Jan 1;11(1):78-81.
  4. Kumah EA, McSherry R, Bettany-Saltikov J, Hamilton S, Hogg J, Whittaker V, Van Schaik P. Evidence‐informed practice versus evidence‐based practice educational interventions for improving knowledge, attitudes, understanding, and behavior toward the application of evidence into practice: A comprehensive systematic review of undergraduate students. Campbell Systematic Reviews. 2019 Jul 23.

 

Articles Of The Week July 4, 2021

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We frequently talk about the importance of changing basic education in our profession. However, we’re not alone. This article demonstrates that even doctors may need an overhaul of their profession as well. At least it’s good to know we’re not alone. 

How well do doctors understand probability? – Sebastian Rushworth

Super interesting article to look at how focusing or paying attention to one thing could make us miss another thing. Makes me think of using things like the “pain scale” with patients, if we’re too focused on their pain and not focusing on some other helpful things in their life, are we missing something?

Sometimes, paying attention means we see the world less clearly – Henry Taylor

Trauma can be a result of many things and of course trauma can also cause many things including a persons pain experience. So, how can we work and help people as a “trauma informed” therapist? Read on and see. 

Trauma Informed Massage Therapy – Jenn Sharman

I really like to get my bias confirmed because it makes me feel like I’m right…but am I? Sometimes yes, most times probably no, but at least there’s a name for it. Motivated Reasoning. 

Why you think you’re right — even if you’re wrong – Julia Galef

Trigger point therapy is a hotly debated topic in manual therapy. Here’s an updated discussion on what this actually is and how it can be applied in our clinical setting.

What Is Trigger Point Therapy? – Nick Ng & Tania Velásquez

Talking Templates for Common Misconceptions

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I saw a post on Facebook a couple of weeks ago where a therapist was looking for advice on communicating with their patients.

This is partially because of frustration when a patient has an outdated belief around pain and their body, but you’re now trying to give them a different story.

This can be tough, especially as we learn new research and terminology and try to update ourselves.

Sometimes we want to vomit all the info we know, and people aren’t always receptive to this new information.

So, I figured I’d take a shot at how we can better communicate some of the things in question.

Here we go.

Do I Feel Tight?

This one is a classic.

I’m sure we’ve all had that person get on the table, turn and look at us, then ask, “Am I the tightest you’ve ever felt!?”

The funny thing about “tight” is that somehow as a society, we’ve bastardized this into being something associated with pain. Tight is just a sensation, and it’s a very personalized sensation.

I like feeling tight. When I go to the gym in the morning and do a good workout, I usually feel “tight” for the rest of the day. It makes me feel like I’ve accomplished something, and I’m taking care of myself. However, I don’t associate this feeling with pain (but again, this is a personal, subjective experience).

I think back to an experience I had working with some athletes a few years ago, and this is usually how the conversation goes with someone who asks about this:

Athlete: Do I feel tight?

Me: I don’t know. I’ve never treated you before, so how would I know if you feel tight or not?

Athlete: Oh, well, it’s just that my therapist at home always tells me how tight I am.

Me: Well, the more important thing is how you feel. Do you feel especially tight today?

Athlete: No, I don’t really feel tight at all?

Me: Then you’re probably good!

We then carried on the treatment, and at least for the rest of the camp, the athlete never really worried about feeling tight.

In the case where this is someone who maybe we’ve seen for a while, and they come in and ask if they feel tight, we could change the term to “protected”.

Perhaps we say something like: “well if this area is feeling tight to you, maybe for some reason the body is trying to protect the area, let’s just try to calm the area down and send some safety signals to decrease that protection”.

Whatever language we develop around something like this, let’s make sure we’re not using language that could cause someone to catastrophize what’s happening.

Don’t be the therapist telling people they’re “tight” like it’s a bad thing; let’s reassure them this is okay, normal, and they’re not damaged or broken.

My Posture Is So Bad

Unfortunately, there is so much in the media these days proclaiming that bad posture is the root of all evil.

People have heard things like “sitting is the new smoking” or that they have “text neck”.

Well, we know neither of these things is true, but it’s likely our patients don’t.

But this is where we could take a little time to educate them and even ask questions like, “well why do you think your posture is so bad”?

Depending on their answer, we could try to re-direct their thoughts by making some comparisons.

On things like text neck, we could point out that in the past, we’ve never seen anything like “encyclopedia neck,” “knitting neck,” or in reverse “ceiling painters neck”.

When it comes to sitting, we could point out how any posture held for an extended period will likely get irritating. I can’t imagine how those guards outside Buckingham Palace who have to stand in that “perfect” position all day aren’t going home and just wanting to sit for extended periods after work.

The reality is our best posture is our next posture (I don’t remember where I first heard that to reference it, but I think it was Greg Lehman).

Just showing them that any posture is safe and frequently moving to change your posture is a good idea might be enough to get rid of those old beliefs.

If not, we could cite several research articles that show posture doesn’t correlate to pain, but I’m not sure how many non-therapists want to dig deeply into that info.

Did You Feel That Release?

Well, we know that we can’t actually “release” anything with our hands.

However, many people have been told by other very well-meaning practitioners that they’ve released their fascia, a muscle, or a trigger point.

So what would be a simple way to communicate how we aren’t “releasing” anything but rather are having an influence on the nervous system?

As we mentioned earlier, it could be a matter of changing the language to a chat about protection mode and sending a safety signal to reduce that protection.

Another way is to say:

“Well all the new research has shown us that we’re actually having more of an influence on the nervous system. So, this area is probably a little sensitized right now, we’re not actually releasing something, we’re just calming down that sensitized area. So what you felt is more likely just the nervous system calming down.”

We will all have our way of communicating these things, and I’m sure you can come up with something better than what I’ve jotted down (and honestly, I’d love to hear your take on it).

Let’s make sure that we’re changing the narratives on many of these things along with the techniques we use, and we’re not giving our patients any reason to catastrophize an individualized sensation. We can do better than that.

Articles Of The Week June 27, 2021

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I had a great conversation with a fellow skeptical Massage Therapist about a continuing education course they had taken and were debating taking “the next level”. This is an issue in our profession and I love how this post pokes a bit of fun at it but also teaches a valuable lesson.

The ABT Dilemma: Testing The Limits Of Evidence -Based Practice, Or Undermining It? – Tristen Attenborough

Any of you suffer from imposter syndrome the same way I do (honestly I hope you don’t). This is a great breakdown of how to overcome some self-doubt, but also a great rundown of how to look at information and gaining new knowledge.

The 5-step method that turns “I don’t know what I’m doing!” into a coaching superpower. – Alisa Bowman

The therapeutic relationship we have with our patients is a crucial part of any therapeutic intervention. But what happens if our empathy for people actually worked against us and how would we recognize that?

Three Ways Empathy Can Work Against You and How to Avoid Them – John Woolf

There are many, many things that can influence a person’s pain experience. One that is being brought to my attention with this article is the stigma of being a woman, and yes, some research is being done to show this.

The Stigma Of Being A Woman In Pain – Bronnie Lennox Thompson

With any hope we are helping the people who come to see us with establishing some achievable goals that will reduce disability and increase what they are able to do on a day-to-day basis. But something important to take into account is how we are communicating with our patients about this, so they are engaged in the importance and increasing their buy in.

Language Matters: Why No One Cares About Your Functional Goals – Heidi Jannenga

Putting Patient Preferences and Values Back In EBP

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Evidence-based practice (EBP) has been the accepted norm in medicine and rehabilitation for nearly 30 years, though exploration began of its concepts in the early 1970s (Zimerman, 2013).

EBP consists of three elements: the best available evidence, the clinician’s knowledge, and skills, and the patient’s wants and needs (APTA, 2020).

This latter component is also stated as patient perspectives and values (ASHA). All descriptions of the EBP model point to an equal weighting among the three tenets, though most provide little detailed instructions on how to assure the weighting is carried out in that fashion. Many professional bodies established clinical guidelines and pathways to determine how to rank evidence, with case studies and clinician experience at the bottom of the ranking and systematic reviews and RCTs at the top. Clinicians are expected to use their clinical reasoning, expertise, and judgment to apply the evidence appropriately. However, how to go about assuring patient preferences and values are met is a bit unclear.

I have a specific podcast that I am particularly fond of, as the presenter speaks on topics dear to my values (and clicks my bias button continually). On a recent podcast, there was a conversation about applying principles of EBP while assuring the uniqueness of the individual patient was met, something not always addressed in EBP. As the best available evidence requires rigorous trials involving randomized groups, single incidents are often seen as less-than-relevant, though there is a trend toward allowing such individual cases greater weight (Anjum, 2020). While discussing how to apply EBP within such emerging models and how to allow weight to patient perspectives and values, a comment was made to the effect, “well, it is not like we can have our patients choose the intervention.” Really? Why not?

Patients lack the depth of knowledge and experience to build their treatment plan, and if they did, why would they need us? However, can’t they contribute?

In my 35-plus years as a physical therapist, I’ve overheard many different ways that clinicians try to assure that patient expectations and values are met. However, most fall short of the 33% contribution mandate of EBP standards. In a manual therapy setting, asking, “how’s the pressure?” seems to suffice for many, while in the exercise-based setting, so much power is given over to the clinician that few questions are asked. Patients often assume that we know the cause of a problem and also know the best way to intervene. Power is given. However, are there better ways to go further in allowing patient input to be equivalent to clinician input?

I once studied with a brilliant clinician who had a deep level of knowledge about how past psychological aspects often led to certain functional problems and applied his manual therapy skillset to remediate those problems.

However, I saw as problematic that though psychosocial factors leading to those problems were acknowledged, little if any attention was given to those factors during the intervention. The clinician simply applied what they knew to be necessary for the problem that they palpated. Did the clinician have an impact? Indeed, and their work was published and well-regarded. However, could they have improved their allowance of patient perspectives and values in the therapeutic interaction? Yes, indeed.

How can we elevate that 3rd leg of the EBP model to assure an equal weight is allowed to patient perspectives and values?

Many ways, but to start, we can include them more in the decision-making process. In my work, which is to improve function and reduce pain using a manual therapy-based and movement-based blended model, I make it a requirement that my patient fully participates in treatment decisions. This mandate is not always straightforward for the patient to accept, as they often feel ill-informed in treatment decisions. It takes some time to establish both the need for their input and the skillset for them to put this plan into action.

Below is an excerpt from one of my seminar manuals, in which I describe the basics of such a patient-centred model.

Once you have collected their history and complaints and spoken on their functional needs, ask them where they feel their issue. The issue/location could be where they feel the pain, the part of their body where they feel their movement difficulty, where their voice has challenges, where swallowing is impaired, where the tongue gets tight, or whatever brought them to you. Ask them where they feel the problem lies. Some may have no idea, while most will be able to localize the problem area.
• Let them know that the point of this evaluation process is for you to be able to touch, press, stretch, or do something with your hand(s) that connects them to their complaint. You may increase the feeling to a point where you bring it to the edge of the patient’s awareness or even calm the issue to a point where it is barely apparent, but either way, you need to do something with them that they feel relevant. You are looking to replicate a familiar feeling.
• If they are confused by this, or ask, “why do you want to make me feel it?” I suggest that you tell them that it is not your goal to make them worse or to make the problem worse. However, this work’s nature is such that to know that we can help requires us to connect them with their issues. If we cannot replicate the symptom or link them to their problem, both from the periphery (the tissues) and their perception (sensation), then we stand a lessened chance of helping.
• If at rest, they feel nothing, none of their issues, let them know that you may be seeking to allow them to begin to feel it through the therapy process. The concept of bringing their concern to their awareness may be difficult for them, as, for instance, they only notice the problem after doing something. Someone with a vocal strain that only occurs after a performance may wonder how you will be able to replicate the feeling when they have not sung. Someone suffering from back pain that comes on only after standing for a certain length of time may wonder how you will be able to get them to feel something familiar when they have been sitting and have no pain. Let them know that this is your mandate; to connect them with their issue, whether it is present at that moment or not.
• Ask permission to touch them and then place a hand or hands on the identified area. Initially, do nothing; allow your hand to rest on their skin lightly. I will typically then ask them if they feel any of their issues. That gives me an idea if I need to mildly replicate the feeling of the problem or try to reduce it with my stretch.
• Begin to apply a light stretch in the 1-2/10 range on your scale.
• Work in slow-motion; do not move quickly or apply heavy or aggressive pressure. Your pressure might be a lateral
stretch in any direction to the skin or deeper layers, used with a combination of pressure or gentle inward probing. The type and orientation of stretch necessary to connect with the patient’s condition are unique, varying from person to person. Think of this process as one of talking to a person who speaks another language. Each of you has little ability to speak each other’s language, and communication will be slow. It takes each of you a while to find the correct word to communicate an idea correctly, so you work your way through the process until each of you made your point. This process of evaluation is similar. You are trying to find a direction and pressure of stretch in and around the soft and hard tissues, one that your patient begins to feel that you have touched their problem.
• Once you have found a connection, you will need to work out if what you are doing should be continued as treatment. Ask the patient:
• Does this feel familiar?
• Are you feeling a replication or lessening of the issue?
• Does this stretch feel like it might be helpful?
• Is there anything about what you feel that feels like it could be harmful?
• Would you like me to add more pressure? If yes, slowly add pressure until the patient says that now better feel
connected to their issue.
• Finally, once you have adjusted the pressures and direction, ask them if they want you to continue with the stretch.
• When you start to use this work, hold a stretch for 2-4 minutes. During the stretch, you are asking the
patient if they still feel like the stretch is helpful. After 2-4 minutes, slowly release your pressures and retest. Do they
feel different? Have you been able to help them modify the sensation of the issue?
• Depending on your comfort with the techniques, you may now wish to treat more in the same spot or try a slightly
different area. If the patient has felt a change, you might move into the other intervention strategies you use.
• Treating for 2-4 minutes is a suggestion. I spend much longer with this work, often allowing a series of stretches
interventions to a single area take up nearly the entire session.
• No matter if you are using just this manual therapy work or combining it with other interventions, always teach the patient self-treatment. Many forms of manual therapy are too passive; they do not build self-efficacy. I always encourage my patients to follow through with self-stretching, if it feels helpful to them, and increase their movement through exercise, strengthening, or simply moving more. Passivity happens when we do not include the patient in treatment decisions, whether it is through manual therapy or exercise-based models of care.

The original intentions of EBP have been lost, though many feel they honor it. I think we can do better.

  • Anjum, R.L., Copeland, S. and Rocca, E. (Eds) (2020) Rethinking Causality, Complexity and Evidence for the Unique Patient. A CauseHealth Resource for Health Professionals and the Clinical Encounter, Springer (open access book).
  • Components of Evidence-Based Practice, 2020. APTA.org.
  • Evidence-Based Practice (EBP), ASHA.org.
  • Zimerman, AL. 2013. Evidence-Based Medicine: A Short History of a Modern Medical Movement, AMA J of Ethics, 15(1):71-76.

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