Creating An Evidence-Informed Practice
Usually in this column, we focus on a particular condition and discuss related massage therapy research. With our backgrounds, we sometimes take our research literacy skills for granted and assume that everyone realizes how crucial these are for improving the quality of care practitioners provide to clients on a daily basis. Recently, we received a copy of an article written by our colleague Dr. Paul Finch, former director of education at the Sutherland-Chan School of Massage in Toronto, Canada. Originally published in 2007 in the Journal of Bodywork and Movement Therapies, the article highlights the role played by the critical evaluation of original health care research in creating an evidenceinformed practice. As we begin a new year, we would like to remind mtj readers of the need for incorporating research evidence into our clinical decision making.
The evidence-based movement in medicine & health care
Research has always formed the basis of scientific thought. In health care and medicine, research began with a combination of clinical observation and empirical testing—thoughtful trial and error. A practitioner would note a certain set of symptoms, try various remedies to see which were effective, and reject those that didn’t seem to work.
When another patient presented with the same or similar symptoms, the previously effective remedy would be tried first. For many years, most health care research consisted of observational and descriptive studies of naturally occurring events, and some before-and-after treatment studies. The widespread use of randomized controlled trials, where some kind of control or comparison group is used, is a relatively recent innovation. The randomized controlled trial (RCT), because of its design features, shows the strongest link between cause and effect using a single study. Credit for the modern RCT is usually given to Sir Austin Bradford Hill.
England’s Centre for Evidence-Based Medicine has defined evidence-based medicine (EBM) as “the conscientious, explicit and judicious use of current best evidence in making decisions about the care of individual patients.” While many aspects of health care depend on individual preferences related to personal values and quality of life, the primary goal of EBM is to clarify the components of medical practice that can be evaluated using the scientific method and to apply that method to best predict the outcome of a given course of treatment, even as dialogue about which therapies or outcomes are most desirable continues.
The growing trend towards evidence-based health care is here to stay. Both new and established treatments are now expected to demonstrate their effectiveness based on research, and insurance coverage of a treatment is increasingly likely to be linked to research supporting its use. An evidence-based focus requires the application of scientiic method to the clinical practices of the health care professions. This focus poses a challenge for complementary and conventional practitioners alike. Many established treatments have not been tested using randomized controlled trials, and in evaluating some treatments or therapies, RCTs may not be appropriate or feasible.
Fortunately, other types of descriptive and observational research designs, such as case reports and qualitative studies, are complementary to the RCT and provide valuable evidence to support the use of therapies such as massage and bodywork. Becoming an educated consumer of the research literature will enhance your credibility with clients, as well as with conventional health care practitioners.
How Some Massage Therapists Use Research
An informal sampling of my colleagues at the Cortiva Institute in Boston, Massachusetts, provided the following examples of how massage therapists can, and have, used research to inform their practices:
Several people mentioned the value of research findings that support the benefits of massage for wellness in general and for treating specific health conditions in particular. With recent economic pressures causing some people to cut back on massage, some therapists find it helpful to quote research.
All respondents mentioned seeking out research findings when faced with treating clients from special populations, for example clients who have health conditions they aren’t familiar with. Katy Magura, continuing education director at Cortiva, mentioned that research taught her about the pressure points in clients with fibromyalgia, as well as the high variability in the level of pressure that these clients can tolerate.
More than a few people noted how research taught them how safe and helpful massage can be for people suffering from cancer—contrary to what was earlier thought. For instance, by using the decision tree developed by Tracy Walton, massage therapists are able to assess if treatment is appropriate and what modifications in that treatment are appropriate.
Research can also be helpful in establishing institutional support for massage therapy. Lisa Santoro, a Boston Cortiva faculty member and massage therapist at Harvard University Health Services, used research to convince administrators at the university to add massage therapy to their health practice. “I presented Occupational Safety and Health Administration statistics on repetitive strain conditions and how many employees went out on short-term disability,” she explains. “I also presented information based on the study by David Eisenberg that noted how many Americans were using complementary medicine and not telling their doctors.”
The medical staff at Harvard became more interested in supporting the addition of massage therapy when they realized they’d know the practitioner was well-trained, ethical and professional, making referrals easy. This practice was established in 1995 and has expanded substantially since its inception.
What is an “evidence-informed” practice?
Evidence-based medicine does have its critics, however. One concern raised is that EBM applies best to populations— the more that data are pooled and aggregated, the more difficult it is to compare demographic characteristics of patients in the studies with the individual patient or client seen in one’s practice.
Another concern is that looking only at research studies ignores the expertise of the practitioner and the preferences of the client. The most common response to this concern is that evidence-based health care means integrating the patient’s goals, values, and preferences alongside the experience and knowledge of the clinician and the best available external evidence based on systematic research.
In an evidence-informed practice, the therapist searches and sorts the available research on a given topic or question according to its relevance to an individual clinical case. The therapist then prioritizes the most relevant research according to the design of the research and its alignment with the clinical question posed. For example, if the question is related to treatment effectiveness, studies with quantitative experimental designs would take precedence as best evidence.
A clinical question related to patient or client experience would be better served by qualitative studies focused on the nature of that experience. Research literacy is a necessary skill for practitioners to employ so that they can determine which studies constitute the best evidence in relation to a given clinical question.
Another appealing feature of this paradigm from the clinical perspective is the integration of the practitioner’s expertise and the client’s values with relevant research evidence. In using this concept we have the best of both worlds, where appropriate research evidence informs individual clinical practice and is tempered by practitioner judgment and client preferences.
How do I find research I’m interested in?
Most of you are probably familiar with PubMed, the National Library of Medicine’s online database of medical literature. PubMed is easy to use, and the abstracts of articles on the site often contain links to the full text. Articles in PubMed Central, which have been funded with federal grants from the National Institutes of Health, are free. However, many journal publishers charge a hefty fee even for a single article. A less well-known source for tracking down articles of interest is BioMed Central. This British publishing house has almost 200 peer-reviewed biomedical and scientific journals available on its website at www.biomedcentral.com.
BioMed Central offers many different services, and the website is well-worth exploring. Journals on the site that publish articles on complementary therapies include BMC Complementary and Alternative Medicine, Chinese Medicine, Chiropractic & Osteopathy, and the Journal of Ethnobiology and Ethnomedicine.
All its biomedical journals are open access and provide the full text of each article at no charge, in both HTML and PDF format options. Another good source is a new online journal published by the Massage Therapy Foundation— the International Journal of Therapeutic Massage and Bodywork—available at www.journals.sfu.ca/ijtmb.
How do I tell whether it’s good or poor evidence?
Evaluating health care research may seem difficult at first glance, and it is a skill that requires some familiarity with the basics of scientific method and regular practice. Research literacy is a basic competency that is now required by many professional training programs. But the fundamental skill needed for the critical evaluation of a journal article is common sense.
As you are reading a study, keep in mind the specific question being investigated. Look closely at the methods and procedures used to carry out the research, and think about whether these make sense in relation to the study question. Ask yourself whether there is another plausible explanation for the study’s results, based on how the study was carried out. Almost every study has some limitation in terms of its design or methods; the crucial question is whether any limitation provides a compelling alternate explanation.
Remember that the discussion section of an article is the author’s interpretation of what the data or results mean. Any conclusion should be supported by the actual data provided in the results section. A sweeping generalization based on a sample of 10 participants is a red flag; a discussion of the study’s limitations is a plus.
A brief history of evidence-based medicine
Isolated attempts to assess treatment efficacy date back several centuries, but only in the 20th century has this impetus evolved to widely impact almost all fields of health care and policy. The efforts of Dr. Archie Cochrane, a Scottish epidemiologist, through his vigorous advocacy and his book, Effectiveness and Efficiency: Random Reflections on Health Services (1972), resulted in increasing acceptance of the concepts behind evidence-based practice. Cochrane’s work was honored through the naming of centers of evidence-based medical research—Cochrane Centers—and an international organization, the Cochrane Collaboration.
A Cochrane field group for complementary and alternative medicine research is based at the University of Maryland. The methodologies used to determine “best evidence” were largely established by the McMaster University research group led by David Sackett and Gordon Guyatt. The term “evidence-based medicine” first appeared in the medical literature in a 1992 paper by Guyatt and colleagues, titled “Evidence-based medicine. A new approach to teaching the practice of medicine,” and published by the Journal of the American Medical Association (JAMA. 1992 Nov;268(17):2420-5).
Using research to inform clinical practice is a trend that will continue to increase across both conventional and complementary health care. Combined with the professional experience and expertise of the massage therapist, and taking into account the client’s goals, values and preference, research gives us a valuable tool to improve the quality of care we provide—and enhance our confidence in what we do.
As you continue to find and read research studies, the important questions to consider are whether the design of the study is consistent with the hypothesis being tested and whether the study conclusions are justified by the weight and kind of results presented. Remember, no study is perfect. Scrutinized closely enough, any study will reveal flaws and limitations. The crucial issue is whether and to what extent these may provide a plausible alternative explanation for a study’s findings, casting reasonable doubt on the author’s conclusions. Do you have ideas for specific conditions you’d like to see discussed in the “Research Literacy” column? Email us at email@example.com with Research Literacy in the subject line.
Finch P. The evidence funnel: highlighting the importance of research literacy in the delivery of evidence informed health care. J Bodyw Mov Ther. 2007 Jan;11(1):78–81.
Hill AB. The clinical trial. N Engl J Med. 1952 Jul;247(4):113–19.
Sackett DL, Rosenberg WM, Gray JA, et al. (1996). Evidence based medicine: what it is and what it isn’t. BMJ. 1996 Jan 13;312(7023): 71–2.