How To Evaluate The Quality Of Evidence In Massage Therapy

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: 

  1. Study Limitations
    • those limitations bias their estimation of treatment effects

       2. Inconsistent Results

    • Large differences in estimates of treatment effects

        3. Indirectness of Evidence

    • ie: comparing a drug against placebo instead of against another drug

        4. Imprecision

    • Study is only done on a few patients and few events yet state they have a wide application. 

         5. Publication Bias

    • 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: 

  1. When strong observational studies have large, consistent estimates of treatment effect we can be more confident in the results
  2. The larger the magnitude of effect, the stronger the study
  3. 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.


  1. 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.
  2. 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.

Articles Of The Week January 9, 2022


Quite often we have people who experience persistent pain where we can’t necessarily help their pain but can make a difference in their disability. Sometimes it isn’t about taking pain away but rather helping their quality of life.

STUDY: Treatment for pain versus disability – Paul Ingraham

While this article is aimed at convincing science deniers on bigger topics like climate change, we could use the same information when it comes to other therapists in our industry who deny what current research has to say about what we do.

How to convince a science denier to reconsider their beliefs – Lee McIntyre

There seems to be a theme here this week! Reflexology is one of those techniques that are commonly used in our profession, yet there isn’t any good research behind its use, other than some anecdotal evidence. The reality is that using something like this can do more harm than good with the people we are trying to help.

Reflexology Research Doesn’t Put Its Best Foot Forward – Jonathan Jarry

I’d love to say that I’m some sort of out of the box thinker, but alas..I am not. However, there are ways that we can learn to become a more lateral thinker, so maybe there’s hope for me yet!?

The most undervalued skill? Lateral thinking – Matt Davis

Richard does a great job of putting together lists of research papers for Massage Therapists and he’s at it again. Here is a list of papers from the past year that could be beneficial for your practice.

10 Impactful Open Access Papers for Massage Therapists – Richard Lebert

Podcast Episode #19 The Epic Fails Episode

On this episode, we chat about some of the failures we’ve had in our careers.

It’s important to talk about failures because you can’t succeed without failing. Also because we all make mistakes in practice but we’re not alone, the more we discuss them, the greater growth we can have.

And as always, check out our websites.


and our emails:


Articles Of The Week December 19, 2021

Most of the time when someone is dealing with pain, they want to know why. However, when it comes to healthcare, it’s a business and sending people out for more imaging etc. is part of that business. So, it’s great to see a doctor putting out the kind of information that is presented in this article.

Sometimes our joints just hurt, and it’s ok not to know why – Howard J. Luks MD

With all the information being thrown at us on a daily basis (especially in the last couple of years) we can get pretty overwhelmed. So, how do we know what works well for us personally in all this information for sustainable well-being? Here are some tips:

Nailing The Basics Is Simple Not Easy—The Growth Equation Manifesto – Brad Stulberg & Steve Magness

There is many a “myth” around our profession (in fact we’ve written about several of them). However, quite often when we learn that some of the things we’ve been telling patients isn’t true it can be quite disheartening. But as this ebook tells us…don’t lose heart, we are still doing some great things.

5 Myths and Truths about Massage Therapy Letting Go Without Losing Heart – Tracy Walton

Is the medical system lacking humanity? Well, with this article coming from someone who has dealt with persistent pain for most of their life and being put through the medical system, I listen when they talk about healthcare. So, yes, I’d say we need to put more humanity back in healthcare.

We Need to Put Humanity Back Into Healthcare – Keith Meldrum

Getting a good health history is a really important part of what we do. However, there are times where even with a good history we may not be able to rule everything out and in turn could have something confusing happen with a person on our table. This is just one of those situations:

Medical Mystery: A spa day with lasting consequences for US professor – Sandra G Boodman

Education In Rehab – WTF Does It Mean…?

Education, education, education. How often do you hear this term in relation to modern MSK practice?

Sorry, I got that wrong. Education & exercise, Education & exercise, Education & exercise : )

All the bloody time is the simple answer!

But education, just like exercise, suffers from the issue that we talk about it in very general terms but have little in the way of actual frameworks for application. Every guideline going seems to point towards these as core treatments but often without any real direction. I can see why therapists fall back on more traditional perspectives faced with uncertainty.

So education about what? When? How? To who? The usual questions come out when we unpick it a bit. Education has been hijacked by PAIN education over the last few years but in reality, its formed a backbone of MSK practice…..well forever. Education is something I talk about in class A LOT,  but I do feel people are like hurry up and get to the REAL treatment Ben, i’m getting bored over here.

Is education seen as PROPER treatment? I am not convinced yet.

People Always Have Wanted Information


This is nothing new!

How often have you had someone come in and say “My back pain has been going on a little bit longer than usual and I thought I had better have it checked out”.  We know back pain, as an example, can last for 2-6 weeks and it’s perfectly normal for this to happen. But if someone has only ever had the problem before for a few days it’s probably a bit worrying and they want to know what is going on to decrease the worry that can flourish in stressful situations.

People definitely come to see us to get rid of their pain, but they also want to understand their problem, the implications and know how to manage it as well.

Louis Gifford highlighted a few things that is fairly universal amongst people. What is it? How long will it last? What can we do about it? Another question I get asked regularly is “Can I still do….”. People still want to do things but not to make the problem worse but often get scared into reducing activities rather than receive knowledge to sensibly manage them.

Education Or Knowledge Transfer?


We use the term education, but for me, that can conjures up images of stern teachers in front of naughty school kids and does not really reflect what we often do with people.  Maybe it is really about helping someone make coherent sense of the issue, decreasing the uncertainty and danger around the problem and providing paths forward. This is more of a partnership perspective that incorporates knowledge transfer than traditional didactic models of teaching. So maybe knowledge transfer or sense-making is a better term?

What Can We ‘Educate’ About?




What Is It?

Probably the most important thing that people want is a diagnosis. If we know what it is we can effectively treat it, right? Er…maybe as we know in so many MSK issues that are simply not possible from a structural perspective. In the absence of this, we need a positive & coherent narrative around the problem. That could include pain ed but information about pain does not need to dominate.

“Cases of nonspecific musculoskeletal pain where, although the source of the pain is unclear, diagnostic imaging is not indicated, and the pain may not always be completely alleviated with treatment. In such cases, concrete, clear, and consistent information can help the recovery process, even in the absence of a specific diagnosis” Carroll et al 2016

How Long Will It Take?

Prognosis and the factors that influence it can be really helpful with often unclear diagnoses like back, knee or shoulder pain. Setting realistic expectations is important as well. Too high and it can lead to disappointment when they are not reached, too low and the motivation to engage in the process can limit the outcomes.

What Can I Do About It?

Health and lifestyle, exercise, activity and self-management are all areas that we can help people with. Helping people to effectively create management plans is sorely missing IMO. Again perhaps this is not seen as treatment?

What Does The Person Want To Know?


For a really effective transfer of knowledge maybe taking the time to find out what the person WANTS  to know is important. Just throwing out information might lead to important questions remaining unanswered. There are so many questions that people have that we may not have considered or we feel are not important. If they are important to the person they should be important to us!

“What concerns you the most about your problem?”

“Do you have any major concerns you would like to talk to me about?”

“What’s your biggest fear about this?”

“What’s the most important question I can answer for you today?”



It needs to make “biological and biographical sense” as my friend Joletta Belton would say. This was the great failing of pain education IMO, it does not automatically integrate with the person’s story, it’s like talking to a stranger in a pub when they are telling you about their life story and you are being talked AT without the conversation ever relating to YOU. A friend that just talks about themselves is another example, you just want to get the hell out of there, or . So make sure your knowledge transfer actually fits the person and their story in a way that relates.



Maybe this is why some of the things we expect to be helpful don’t succeed? Without a knowledge of what to do, why they are doing it and how it is going to help, exercise, as an example, does not relate to the person and their problem?

Lots of my failures (professional ones : ) may have come from not aligning in terms of treatment philosophy with the person I am working with. My vision of what to do does not match theirs and in part that might stem from my inability or failure to ‘educate’ about the what, why’s and how’s.



  • Education IS treatment
  • What does it really mean?
  • People have always wanted information from therapists
  • Think person centred rather than teacher style
  • What is it? How long will it take? What can I do about it?
  • Find out what the person wants to know
  • Apply information in context

A Good Response To: “Manual Therapy Sucks”

Not too long ago, we did a post about how manual therapy actually works (as opposed to many of the narratives offered in continuing education).

While we know manual therapy can be a very helpful component in helping people dealing with pain, we still see some opposition to this once in a while.

We see people making some bold statements like:

“manual therapy sucks” or

“exercise is the only thing that works.”

In reality, neither of these things are true but using both in treatment will likely give you better outcomes than just one as a singular intervention.

Putting The Human Back In Human Touch

For the past few years, the manual therapy field has paid a lot of attention to the biopsychosocial aspects of pain management.

However, it almost seems like manual therapy has taken a back seat to other interventions like exercise (which I’m a big fan of using in treatment).

But is this the best approach for us to take?

A great new paper¹ outlines several reasons why it is still REALLY important for us to use and incorporate manual therapy into treatments and fortunately, there are a number of things I never thought of.

Firstly, think about the aspects of your clinical encounter when a patient comes to see you, especially when it’s the first time.

Usually, we would start with some orthopedic tests and a good conversation. Part of what is happening during this time is demonstrating your clinical competence

Your hands-on movement of an injured area shows not just that you know what you’re doing, but it also demonstrates compassion and humanizes the treatment for the person receiving it.

This also helps us set up treatment boundaries where we find out what the person is comfortable with while creating a safe space. While it is very important for us to set up our clinical encounter with people to create that safe space (and to show your clinical competence) there are some other really important aspects to touch that are invaluable in helping a person with pain.

Analgesic Touch

Ever hit your shin on the side of a coffee table and then rub it incessantly like Peter Griffin in family guy (obviously after you’ve sworn at the table!)?

Well, there’s a reason we do this because touch feels really good!

There is a pain modulation that happens with touch that feels good. While there are other techniques we use that do things like distraction to take attention away from a painful area, good touch actually helps to downregulate pain signals through various fibres and pathways that are mediated at the brainstem.

Affective Touch

When touch is delivered in a therapeutic setting, it prepares the brain for touch which stimulates C-Tactile fibres which set things up for a positive therapeutic experience. This promotes positive feelings like safety and relaxation while also reducing things like avoidance behaviours and stress.

Now because this is an empathetic touch it helps remove some of the psychosocial barriers that contribute to a person’s pain experience.

Somatoperceptual Touch

We have seen over the past few years how when a person dealing with persistent pain can experience a misrepresentation of how their body actually feels and what it experiences.

Turns out a therapist’s touch can help in this regard as well.

Just by putting our hands on people, we can help to change a person’s body perception by helping to reorganize mental representations of their body. This helps a patient be able to discriminate between safe and threatening stimuli while also showing how their body isn’t damaged.

This also helps to reduce stress, anxiety, and avoidance behaviours around pain.

Does This Mean Our Touch Is Enough?

Well…it depends.

There are certainly times when someone just needs a good old delicious feeling massage and there is certainly NOTHING wrong with that.

If we have those people (say nurses or other first responders for example) who aren’t necessarily dealing with an injury and are using us as part of a wellness plan, then by all means give them that delicious massage.

However, when we have those individuals who are dealing with an injury say from a car accident, workplace, sports, or some other type of injury we need to incorporate more than just hands-on into the treatments.

We still need to follow the best guidelines for MSK care and provide education, reassurance, movement…and of course some massage. While a lot of what we do in treatment is communicating with our hands, our communication verbally is still a really important part of the therapeutic experience. This paper ¹ points out how this should also be a responsibility of educators and students alike to veer away from the biomechanical constructs of communication to include the person’s emotional experiences as well when we talk to them. While I will always be an advocate to include exercise and movement into our treatments, it doesn’t mean we need to abandon manual therapy (as some would like to promote) and strictly adhere to an exercise-only program. It’s quite the opposite. To be a better therapist and have better outcomes with our patients, let’s not throw the baby out with the bathwater as it were, let’s include education, movement, and massage. The more well-rounded we are as therapists and the more well-rounded our delivery, the better it is for the people who come to see us. As for those who say manual therapy sucks…well…this paper proves that wrong. There is still a really important place for that delicious feeling massage.



  1. Geri T, Viceconti A, Minacci M, Testa M, Rossettini G. Manual therapy: exploiting the role of human touch. Musculoskeletal Science and Practice. 2019 Dec 1;44:102044.