One of a therapist’s biggest mistakes when helping our patients are basing their recommendations on personal experience or anecdotal evidence. It’s not that these kinds of recommendations aren’t valuable.
On the contrary, they’re great in many situations, but it’s essential to understand what you don’t know and to use a bit more of the available evidence to help you determine the best course of action.
In one of our recent blog posts, some of the research cited: “high quality evidence” and “low quality evidence.” This is important for us to understand so we can evaluate the quality of evidence you’re using in your practice; plus, this gives us the most effective ways to communicate evidence to your patients.
The most important part of evaluating the quality of evidence in massage therapy is knowing where to look for it—and what constitutes the best available evidence.
Difficulties In An Being Evidence-Based Massage Therapist
One of the problems we face as Massage Therapists (especially if you’re trying to be evidence-based) is that there isn’t a lot of research done strictly on Massage Therapy, so we are often left to rely on the research being done under the umbrella of “physical therapy” or other manual-therapy professions.
Where this creates a lot of difficulty for us is actually getting access to quality papers.¹
Part of the reason for this is that we don’t come from a university program (typically) where those students have access to a larger base of papers due to university subscriptions.
Despite this, all hope is not lost as there are many options like google scholar, PubMed, Medline, and other options to gain access to papers online; it just takes a little work to find what you’re looking for.
Another issue is that most of us were not taught in school how to look at papers and decipher what good quality vs. bad quality papers is, but this can be learned (and is honestly the point of this blog post).
While these things create a bit of difficulty, we should not look at them as reasons not to embrace being an evidence-based practitioner or ignoring the research. Instead, we should embrace it as a challenge and do what we can to use more research in practice.
Different Types of Research
Some of the best research we can use are RCTs (randomized control trials), where the patients are randomly assigned to groups where they don’t know if they are getting the designated treatment or not, and Systematic Reviews. ¹
Systematic Reviews are important as they look at the available literature and use methods to minimize different biases and summarize the information for best practices. While they don’t make recommendations, they look at what is most “correct.”
This is great as we are essentially always trying to be less wrong in the care we deliver.
There is a system in place called GRADE that looks at what makes research good or bad ². There are five things they look at which lower the quality of evidence in a study which include:
- Study Limitations
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- those limitations bias their estimation of treatment effects
2. Inconsistent Results
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- Large differences in estimates of treatment effects
3. Indirectness of Evidence
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- ie: comparing a drug against placebo instead of against another drug
4. Imprecision
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- Study is only done on a few patients and few events yet state they have a wide application.
5. Publication Bias
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- Investigators/researchers ignore other studies in favour of published trials that are funded by industry.
That last one is crucial for us to consider. There are many modalities used in our profession where research papers were published in favour of said modality by the people who actually developed and taught the modality while citing the positive benefits of their own research.
So now we can look at what can increase the value of evidence. The same paper ² cites three different factors that can help us out:
- When strong observational studies have large, consistent estimates of treatment effect we can be more confident in the results
- The larger the magnitude of effect, the stronger the study
- A situation where all bias’ would decrease the effect
Looking at what we know constitutes good or bad research, it should be easier to apply in practice. However, it’s also important to consider that even some of the lower quality evidence can be of use. Primarily, if we focus on a population where there isn’t a lot of research on the one specific thing we are looking for. In these cases, we may have to look at some of the lower quality research to help guide our decision-making while putting out clinical experience to use as well.
Now What Do We Do?
It is more important than ever for our practice to comply with professional standards. Therefore, ensuring that the treatments we provide meet the standards and ethical guidelines of the profession should always be a priority for us and other manual therapy professionals.
The evidence-based approach isn’t just for the scientific community (although this seems to be regularly debated online).
To make more informed decisions, we can use the information available to evaluate the quality of evidence supporting the techniques and practices we use. The information from the papers we cited can help practitioners and educators identify which therapies and techniques are supported by a high level of evidence. While there are limitations and difficulties associated with this, we need to rise to the challenge of incorporating research and evidence into our practice. This is not only good for the people we see, but it’s beneficial for the profession as a whole. While there is concern about the extra time it takes to do this, we could start with choosing just one research paper a week to read in our spare time; you could start with the ones cited below?
Why not use this as an opportunity to see how you can use evidence-based practices to improve your practice.
References:
- Maher CG, Sherrington C, Elkins M, Herbert RD, Moseley AM. Challenges for evidence-based physical therapy: accessing and interpreting high-quality evidence on therapy. Physical Therapy. 2004 Jul 1;84(7):644-54.
- Guyatt GH, Oxman AD, Kunz R, Vist GE, Falck-Ytter Y, Schünemann HJ. What is “quality of evidence” and why is it important to clinicians?. Bmj. 2008 May 1;336(7651):995-8.
