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Evidence-based vs evidence-informed
I had an interesting conversation with my buddy, Matt Phillips, last week when he asked my opinion on the difference between “Evidence-Based” practice and “Evidence-Informed” practice.
When I gave it a bit of thought, this is what I came up with (which was just an uneducated opinion at the time).
Evidence-based to me means you’re building a foundation or a BASE to work from in your practice. You’re making that base around research and evidence and work from that standpoint in your clinical setting.
Evidence-Informed to me means you’ve been informed of the evidence and know what the evidence says, but you’re not necessarily working from that information; you know it’s there.
It was then pointed out to me that the research says we’re better to be evidence-informed.
So as always, I had to start looking at the research.
We have long preached about evidence-based practice, and as I start to look into the research, some other topics worth discussing came up.
The first article to reference comes from evidence-based medicine or EBM. In general, I had no idea that medicine has faced many of the same issues we face in our profession.
Much of the EBM arguments were based on creating government policies to identify different therapies or interventions that lacked science or evidence of treatment efficacy. (1) The intent was to weed out an intervention that didn’t follow science or showed no evidence of treatment efficacy.
This should generally be a good thing. Right?
It seems there were some limitations to this.
When these new findings came out, some therapies would get pushed out while more expensive, technological ones became the preference, which was clearly not popular with insurance companies who had to pay for it. So, there are suggestions the root of EBM was to satisfy those insurance companies instead of focusing on patient care(2), and even the possibility of some propaganda from pharmaceutical companies having an influence. (3)
Some argued that the human side of treatment was being sacrificed for the more biomedical model (and we all know how our opinion on a strictly biomedical model), which led to a term I’ve never heard of; ‘scientism.’(1)
Those who leaned more toward the humanistic approach were labelled with scientism and accused of being anti-science, where the word ‘dogma’ was also thrown around (where have I heard these kinds of things before!?).
I would have thought this to be more prevalent in our profession by comparison. Many of the narratives and things we are taught come from what was once just opinion and then taken as gospel. Part of the issue here is that many of those narratives are overinflated claims, relying on anecdotal experience instead of what is actually happening. (3)
Fortunately (at least within our profession), this is slowly starting to change.
The argument is also made(2) that when it comes to evidence-based practice (EBP), we evaluate the best evidence for the patients’ problem. It seems the ‘patient’ is not part of the equation.
This isn’t to say science should not be used as a base for what we do. As this article points out, our challenge is to apply this within a humanistic framework that respects the patient and their values and recognizes the psycho-social aspects. (1)
When I do a quick google search for definitions, there are two for the term, base that comes up which are applicable:
a conceptual structure or entity on which something draws or depends.
and
“have as the foundation for (something); use as a point from which (something) can develop” (clearly where I got my original idea from).
When we look at informed, we get:
give an essential or formative principle or quality to.
and
having or showing knowledge of a particular subject or situation.
We have often heard statements like “well, science just hasn’t caught up yet,” or: “my experience tells me what I’m doing is right.” Usually, statements like this are used as an argument against using research in our practice.
When we look at that second definition for informed, we have to be careful with its interpretation. Having or showing knowledge of a particular subject or situation does not make us an expert, especially in our clinical practice and the techniques we use.
This could be misconstrued with some research I’ve cited where it mentions the limitations to evidence-based practice was taking the patient out of the decision-making.
This brings me to a portion of one paper that I have to quote:
While excluding entirely baseless interventions or interventions rooted in prejudice and superstition, evidence informed practice (EIP) should be understood as leaving ample room for the constructive and imaginative judgement and knowledge of practitioners and clients who must be in constant interaction and dialogue with one another for most interventions to succeed.(2)
This is where evidence-informed practice becomes a possibly more accurate description of what we should do.
The evidence-informed practice encourages that we still use research (while discarding those old, false narratives) and suggests we use a more comprehensive range of research to apply in our practice. While evidence-based practice suggests we only apply best practices and minimize social interventions(2), evidence-informed promotes including qualitative research and including the patient’s values in the decision-making process.
This is an essential inclusion for us as Massage Therapists because qualitative research isn’t simply relying on data; it includes looking at things like contextual factors of treatment (which our treatments have A LOT of).
So, it becomes crucial for us to use our clinical decision-making appropriately. Part of the ability to do this is to apply the current evidence and effectively communicate with our patients, care for them, include them in the decision-making process and goal setting. Then be able to adjust each appointment appropriately.
It is when we start to see care being informed by evidence rather than based on it, and the patient is the centre of care is where we will have success. (1)
So, we should be using evidence to inform, influence, or to build our practice. However, we still need to use our experience, patient values, preferences, and other contextual factors to affect outcomes positively. We can’t rely on narratives rooted in opinion or superstition and altogether avoid new research in favour of our own experience. BUT, our experience still plays a role as we progress to hopefully becoming a more evidence-informed profession. So, as it has been done so many times before, I stand proven wrong on my assumptions and will now start to promote evidence-informed over evidence-based (although I’m sure I’ll screw that up somewhere along the way…old habits die hard). In all honesty, I don’t care what we call it, (perhaps EBIP would be better as it would have based and informed in the title) as long as we’re using evidence as a significant part of our practice. A big thanks to Matt Phillips for his gentle nudge in this direction. You’ve got to love colleagues that help you change. And let’s make sure there’s ALWAYS a human element to our treatments and interactions.
Social media is an interesting thing. Sometimes people share things without thinking about it other times there’s plenty of thought put into it. When it comes to our professional associations, they have a responsibility to make sure anything they are sharing is not only accurate but also good for the profession as a whole. We need to hold them to a higher standard.
If professional associations don’t read the studies they share, then who does? – Tristen Attenborough
This could be a game-changer for the chiropractic profession (at least here in British Columbia). Their regulator is taking away their ability to do routine x-rays unless there is a history of red flags in a patient’s intake. We know that more imaging is not conducive to good outcomes, so it will be interesting to see what happens here.
Battle over chiropractors’ ability to do routine X-rays headed for B.C. court. – Bethany Lindsay
Great info around the limitations of MRI in detecting what someone is actually feeling or thinking, and whether MRI can find a ‘signature’ for pain. Along with emotional learning and pain. Make sure to give this one a listen.
Podcast With Dr. Melissa Farmer on Pain and Emotional Learning – Todd Hargrove & Melissa Farmer
Sometimes it can be tough spotting what is ‘good science’ vs ‘bad science’. This is especially true in many online debates within our profession. These are five great ways to know if someone is trying to mislead you in those arguments…I mean discussions.
5 ways to spot if someone is trying to mislead you when it comes to science. – Hassan Vally
I remember one of my teachers in college saying: “you may have people come in for treatment just to be touched”. We all know how important human touch is, but what happens during times like this where touch is limited, and how can we handle it? Read on to find out.
Humans are made to be touched — so what happens when we aren’t? – Mary Halton
[The following is an adapted excerpt from my new book Playing With Movement.]
Play often involves risk. When kids play, they learn how fast they can run without falling, how hard they can fight without getting hurt, and how much they can bother Mom before she gets mad. They learn where the lines are by crossing them repeatedly. There’s risk in stepping too far, but also risk in not stepping far enough, and failing to discover the limits of potential. As we age, we start with games that are very safe, and then progress to games with more risk. Many people graduate to doing things that are truly stupid. If they survive, they learn some very valuable lessons (hopefully).
But in the beginning, playful exploration presents little risk. When babies are learning to roll over and crawl, there is no way to get hurt if something goes wrong. Without fear of injury, it’s easy to engage in many trials and many errors, and to learn a ton about how to get coordinated. But they are learning nothing about how to protect themselves. As soon as babies stand up and start walking, their education in the potential risks of movement begins.
Toddlers taking their first steps will fall many times a day. This is unlikely to cause injury because they are close to the ground and have a nice layer of protective fat over their butts. But falling creates nociception, which is the sensory signaling that can result in pain. This puts the nervous system to work in reading evidence about physical threat and deciding whether pain is necessary for protection. Has the butt been injured? Is this a dangerous situation?
There are other important questions raised by falling. Is backward better than forward? Is it a good idea to cry to get Mom’s attention? Should we give up on walking for now and return to crawling? Confronting these questions is a form of training in weighing the risks and rewards of various kinds of movement.
As kids get older, they start playing with movements that can cause minor injuries. Jumping off couches or benches, running on sidewalks, or going down slides will frequently bruise knees and scrape hands. Each fall is a learning opportunity — did I get injured, how long will it hurt, will I need a band-aid? If I cry enough, will I get ice cream?
Kids who fall after running often don’t know exactly what to think or feel. They were running along without a care in the world, and now they are face down in the dirt. They usually look around for the face of a parent. If Mom is looking panicked and sprinting over, the kid will probably start crying. And if Mom plays it cool, gives a bit of a shrug and smile, the kid usually gets back up and continues to play. Pain always has a social dimension, and kids start learning about it through play.
After getting some significant experience with scraped knees and bruised elbows, kids will start to refine their movement strategies related to self-protection. Some will become cautious, avoiding climbing, contact sports and roughhousing. Better safe than sorry. Other kids take the opposite path: no guts, no glory. They make several trips to the ER before their 6th birthday, but are rewarded by superior skills in skateboarding.

I recently did some soccer coaching for eight-year-old girls, most of them novices. I watched something interesting happen on at least three occasions. A girl got hit with the ball unexpectedly in the thigh, or trunk, or arm. She would look startled, confused, and then start crying about 10 seconds later. She would leave the game, settle down, and then return to the game feeling fine. I think what happened was that she experienced a completely novel and surprising feeling and didn’t know what it meant. Eventually she learned that it was not really a problem — the body is pretty tolerant to getting smacked with a soccer ball, and this isn’t something that should cause pain.
As kids (especially boys) approach the teenage years, they may start playing with some seriously risky stuff, like fighting, extreme skiing, and football. Some of these “games” may be more in the nature of contests intended to establish dominance hierarchies. Either way, there are important lessons for the players. First, there are many occasions to differentiate between minor and more serious injuries, and this can increase body awareness and refine a sense of threat perception. Scrapes and bruises are very different from sprains and breaks. The former should be pretty much ignored, and the latter requires a trip to the doc. With this sense of perspective in place, minor injuries become more tolerable, and may not even be noticed. Another lesson from risky activities relates to fear management. For example, proper skiing technique (much like asking someone for a date) requires that you lean forward with confidence. You may fall flat on your face, but you need to forget about that for the time being. In many situations, worrying about a bad outcome will make it more likely. Fear is the enemy, and playing with risk is a way to learn to master it. Further, handling a risky situation builds confidence, and a sense of self-efficacy. These qualities are protective against chronic pain and disability.
Peter Gray argues that young mammals have an instinct to “dose” themselves with risky situations as a way to inoculate themselves against the disease of anxiety:
In their motor play and rough-and-tumble play, juvenile mammals appear to put themselves deliberately into awkward, moderately frightening situations. . . . When they leap, for example, they twist and turn in ways that make it difficult to land. They seem to be dosing themselves with moderate degrees of fear, as if deliberately learning how to deal with both the physical and emotional challenges of the moderately dangerous conditions they generate.
Kids have less chance to do this in the modern world. Gone are the days when parents let kids play unsupervised for hours at a time near trees, fields, streets, or large groups of multi-age kids. These activities are now considered dangerous unless parents are constantly supervising, monitoring, encouraging, discouraging, coaching, hydrating, child-proofing and doing almost everything short of bubble-wrapping their kids. If the parents weren’t there, heaven forbid that a child might fall down, get hurt, be exposed to germs, or suffer a temporary drop in self-esteem. Many experts believe this approach actually makes kids less safe, and more fragile, sensitive and anxious. Helicopter parenting pushes kids toward safe spaces like couches, and away from uncontrolled spaces where they might actually engage in some playful activities like climbing a tree, riding a bike or even playing a game of tag. This prevents them for learning that they can control risk, and some argue this is a cause for rising rates of teen anxiety. It is certainly not a good idea to be reckless and irresponsible, but it can be just as destructive to fear and avoid movement that makes you healthy and robust.
All the above points have implications for adults. Perception of threat is at the root of many undesirable conditions in the body. Pain, fatigue, inflammation, anxiety, stiffness, and weakness are all caused, at least in part, by the unconscious perception that the body is weak, under attack, incapable, broken, fragile, damaged, vulnerable to threats. Playing with risky movement is one way to build a self-image that is far more robust, strong and capable. So is disregarding the well-intended but counterproductive advice of many helicoptering personal trainers and physical therapists, who would seek to prevent us from sitting, standing, running, or drawing even a single breath without the “correct” form.
To learn more about the value of play for movement skill and health, check out my book Playing With Movement.
Richard always does a great job compiling resources for us all to learn from. Here’s his list of the best podcasts for Massage Therapists and we’re honoured to be mentioned.
Best Podcasts For Massage Therapists – Richard Lebert
This is a condition I have only seen a few times in practice, so it’s great to listen in on those with a bit more experience. Listen in to learn more about Thoracic Outlet Syndrome.
Thoracic Outlet Syndrome: What You Didn’t Know – Whitney Lowe & Til Luchau
Setting goals and having them come to fruition can sometimes be difficult. That’s where having a playbook might be helpful. Check out how a playbook in life can be a thorough plan of action to achieve your intentions.
Building Your Playbook! – Scott Livingston
A great chat looking at pain from a different approach (at least for us manual therapists). Rachel Zoffness is a pain psychologist, so very interesting to listen to how a psychologist helps people with pain.
Healing Our Pandemic – Dr. Zubin Damania & Rachell Zoffness
Okay for once I’m putting myself in the articles of the week. Had a great chat with Matt Phillips about staying evidence informed. It doesn’t have to be expensive or time consuming, but it is necessary!
How To Stay Evidence Informed – Matt Phillips & ME!