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Evidence based massage therapy

What are your thoughts, beefs, opinions on massage therapy becoming evidence based practice?
I have posted 2 articles here and here

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Permalink Reply by Carl W. Brown on July 12, 2009 at 8:08pm
Jan, I consider my self a “muscle whisperer”. I “feel” pain and problems and if my training tells me that it is safe, I work the problem until I feel the problem is gone. I constantly challenge by intuitive perceptions. I make sure that the person is feeling the same pain that I am. More often than not the person will tell me that they did not feel pain until I had pointed it out. My feel back also includes objective feel back such as increased ROM. For example, I had a person who had had knee replacement surgery and the scar tissue prevented he from being able to move the joint properly. She had surgery to remove the scar tissue and guess what? More scar tissue. They even tried to put her out and forcibly try to move the joint to brake up the scar tissue. I felt that the scar tissue needed to me converted to good connective tissue by breaking the cross linking fibers so I did a modified form of myofascial work and in 10 15 min. sessions gave her 24 degrees more movement.
Another example I worked on a woman who had 4 hip replacements (the first two failed). After the fourth, she was in more pain than before. I immediately sensed that the obturator nerve was trapped by the obturator externus muscle. In seconds I freed it and she immediately felt better. How can my fingers sense a trapped nerve that deep?
Another time I was working on a person’s shoulder and I could not get it to loosen up. Finally I felt that a nerve in the neck was adhered so I freed it. Looking later in the anatomy texts I found that it was the auxiliary nerve and it enervated exactly the area in question.
At times I have wondered if the healing is nothing more than a shared illusion. Then I had a sick cat. My wife and I took him to the vet and the vet returned almost in tears and told us to take him home because there was nothing they could do from him. The vet then showed us an x-ray showing on lung filled with fluid. When we go home my wife asked be “You work on people don’t you”? So I worked on the cat and drained the lung. The next day the cat was fine. We called the vet and she asked us to bring the cat in, she would pay for the x-ray. The x-ray was clear. “This is medically impossible” to which I answered “yes”.
Permalink Reply by Robert Chute on July 12, 2009 at 11:25pm
Many of the problems with EBM implementation as they apply to Massage Therapy are economic.

1. Who pays? How much?

2. Is there enough research money available for an n large enough to be (a) significant and (b) taken seriously?

3. After all the research--and there is a lot to be done ahead of us because there isn't much that falls into the taken seriously category at the moment, primarily due to low numbers of subjects--will we be any better off? Will the economic benefits be shared as widely as the costs? Is this about insecurity, ego, better patient outcomes, fear? If you as a therapist do some technique you are sure works and EBM disproves or disapproves of it, will you change your practice?

4. Is EBM for making a small minority of therapists and clients feel better about the work we already do? Once EBM is in, will the skeptics who hold back on receiving massage now change their minds or is it really that what we all do for a living seems really weird to those non-clients and no amount of proof will get them on a massage table?

5. Will we be able to charge more to cover the bureaucratic costs of EBM? (It's a lot to ask on massage therapists salaries. See it as an investment in our future if you will and you'll be quick to answer that of course it's worth the cost so MT stays relevant. Many of us are comfortable with our current state of relevance and are concerned that chasing validation with EBM is buying into an already struggling system where we're forever relegated to the bottom of the medical hierarchy.

6. Is EBM worth the up front costs (and can it surmount the technical difficulties mentioned in other posts--low n, satisfactory gold standard protocols etc,)? I've worked with chiropractors. They've spent a lot of money and time developing studies to prove their claims. Chiropractors typically have a lot more money to spend as a group so they had an advantage we don't. However, my chiropractic friends grew all the more frustrated and disappointed because their critics have largely stayed critical/cynical.skeptical. The comon objection they found was, "Research done at a chiropractic school proved in a study that chirorpactic works. Well, surprise, surprise! Nice try, not good enough, push the goal posts back!" Granted it's an ad hominem argument, but the point is they didn't recruit anyone to their cause. (All the chiros I know got older, kept getting empiric results and decided to content themselves with the value of their work and the results they found and they'll happily wait for mainstream science to catch up. They tired of the argument and their clients are happy though some physios and neurologists still hate them.)

7. I have encountered situations where it appeared to me (and others) that the proponents of more research for everyone were the only or primary beneficiaries of the change in policy. With the EBM push, they taught more courses and were first in line for the research money. (Their motives may well be pure, but it looked bad, especially when someone suggested fantastic and expensive schemes where thousands--yes thousands!--of therapists report their results electronically to a common database for research purposes. The flaws in the plan were breezed over and it's probably in some strategic committee somewhere where they're trying to formulate a viable apple/orange mutation.)

8. As a profession, I notice there's one level of discourse--that of proponents of more research and more demands on therapists generally--and then there's the average therapist who looks upon these demands as a curious hypothetical which they're not really interested in or don't understand (or both.) Small rudders can steer big ships, so EBM could come together, but is it what the majority wants? Do they want it enough to go back for more CEUs on research literacy (and soon research capacity)? If some clinical psychologists want to study massage therapy--and the field is very much wide open--let them. We don't have to initiate it, do we? In fact, it'll have more verisimilitude if we let them get into the pool first.

9. More simply, do we need it to survive? Do we need it to flourish? In a health care crisis where the worries are about MRI machines and getting expensive drugs paid for, are we better off serving as alternative health care providers instead of trying to squeeze into an already burdened system? There is a hierarchy of need here and finite dollars.

10. More etherically, Would EBM end up beng reductive (as I think some have expressed here)? Until much more research is completed, is EBM a homogenization of common clinical thought? How different is that really from what we have now (until said research is done?) Strategic plans make for busy bureaucrats, but when all is said and done, is much more said than done?

Regarding the "selling" of EBM...hmmm. It does feel like we're being sold at the moment and yes, I'm still worried about the bill for what may be buying the invisible. What I've noticed is that some proponents of EBM (not directed at anyone here BTW) bang the science and evidence gong pretty hard and when objections are raised the gong gets pounded harder. When we're reluctant to join the band, telling us we're stupid is not the way to get us to pick up a guiotar and sing along. Maybe I am stupid, in which case you'll have to explain nicely and type slooowly. Or maybe our belief systems don't match and I've got trust issues when change comes along that doesn't benefit me but increases my membership fees. (To be fair, there's really no way it could benefit me personally. I'm full up, not accepting new patients and the ones I have are very happy with the status quo.)

Many (most?) massage therapists have a miracle story. I don't believe in miracles anymore myself, but if I did, I'd be leery of ham-fisted protocols that don't allow for the unknown and reduce us to left-brained technicians who ignore the ephemeral. (e.g. "Energy work is not approved. CST is not approved. MFR is not approved. But we're sure of Swedish so do that and ignore what you're hands are telling you because we have studies and people who know better...at least until they change their minds some day." Older therapists--remember when you were called to the profession just so you wouldn't have to hearken to that voice and the Thumb of the Man all day? Yeah, I forget, too.) The concern is that good work will end up denigrated, and decreed an outlier, a fluke factoid inadmissable for study because it's outside the parameters of study.

Put another way, will EBM take away the magic and make us all work in one condoned-from-Central-Command way? Will it reduce us to protocols, technicians following recipes where once we were therapists, whole and fully engaged? Maybe. Maybe not.

I don't have answers. I've just got questions, a humble smile and bills to pay that seem of much more immediate concern. I'm also certain that despite whatever objections we may raise, they don't matter. EBM will come. It's too sexy and left-brained not to happen. Right-brainers may whine a bit, but they're not near as organized and they haven't thought ahead to infiltrate and subvert the bureacracy that seeks to control them further. I know movers and shakers and they're very motivated to take the profession to the next level (i.e. farther away from the comforts of our communal home and bodywork roots. There will be no more Tragers in the future, instance. Innovative and new only works under the future system if you're well-funded and pre-approved.)

Objectors will fail to stop it for the same reasons the Marijuana Party can't get it legalized and atheists don't hold Sunday morning meetings.) It'll hit regulated provinces in Canada first and will eventually make it to a bureacracy near you whether you understand it or want it or not. They'll tell us it's good for us. Who knows? Might be. The phrases "enhance credibility, improve patient outcomes, protect the viability of the profession" will be chanted often. Say the words "improved patient outcomes" enough and you can require and enforce anything (even if it's not necessarily true or crazy costly.)

Until then, like the poster above, continue to strive for excellence and, once in awhile at least, go ahead and do "the medically impossible" while you still can.

If you're a EBM promoter, please don't be annoyed with me. I question but I mean no harm. My time condenser/extrapolator says you've already won. The outcome is already on its way and shall be delivered with little fuss except for some minor grumbling among the ranks.

Be well.
Permalink Reply by Andrea McCully on July 13, 2009 at 1:30am
I am curious about what kind of study you are interested in doing. I recently graduated from Cortiva myself. I may be interested if you can give me any info.

Robin Byler Thomas said:
My thoughts exactly Jan. I'm trying to do just that. I've been a LMT for 15 years and a part-time grad student at the U of A for the past 3. I'm preparing for my internship before graduating and would like to set up a colloboration with Cortiva, PCC, or the Providence Institutes, and the U for either student research case studies or a micro-longitudinal pilot study. You and I met more than 15 years ago at DIHA when I was just starting out; I don't expect you to remember as we talked only once and I actually graduated from SWIHA. I have a UA professor who is interested in helping with my project and I'm gathering information now to get this ball rolling. Do you have any contacts you could recommend left at Cortiva that I could talk to who might be interested?

Jan Schwartz said:
In my opinion Evidence Based Practice is critical for the advancement of our profession, especially for those who want to be a part of the American health care system. I understand that some therapists do not want to go there, and that's fine--I'm speaking about those who do. EBP makes the most sense for massage because, as you point out Bodhi, it is a three pronged approach, taking into account the patient/client preferences and clinical experiences as well as using best available evidence.

The first step is to get research literacy into the schools so that new graduates can evaluate research and use it appropriately. Then we need massage therapists to actually conduct research. At least in this country, most research having to do with massage is being conducted by other health care professionals--as the principal investigator. That too needs to change and requires massage therapists to have a higher level of education. The result of research is the evidence, and who better to conduct it than those who were trained in it?
Permalink Reply by Dennis Gibbons on July 13, 2009 at 5:34am
Evidence or Experienced based?
Permalink Reply by Laura Allen on July 13, 2009 at 6:26am
You're so right, Dennis, about the pharmaceutical companies funding studies--and there's no way in hell they'll fund massage therapy studies, because they might lose money if the efficacy of massage was scientifically proven--lord knows that most of the populace is used to taking a pill every time the doctor says to take one. Heaven forbid something as simple and non-invasive as getting a massage could reduce or eliminate pain.

I have a brother who works for a pharmaceutical company. They pay for him to belong to 5 different country clubs so he can play golf with and wine and dine physicians in the interest of getting them to prescribe their drugs. He has lunch catered to their offices for their whole staff. He sends them exorbitant fruit and wine baskets every year at Christmas, more than 500 every year, all paid for by the drug co. Big Pharm spends millions and bends over backwards to insure that doctors are going to keep on writing those prescriptions. It is impossible for us to compete with those kinds of marketing tactics--and would any of us want to?.

I'm in no way dismissing EBM, but as I stated in my first post here, when it comes down to a massage making someone feel better, that's all the evidence that particular person is interested in. With the exception of grants handed out by AMTA and possibly a few other enlightened entities, most of the burden seems to be left on us to fund our own research.




Dennis Gibbons said:
approximately three weeks ago I had a medical doctor on my table for back pain, he was asking many questions on how this technique worked. after I had explained many of the theories to him he said to me, "What scientific proof do you have of these statements?" My reply to him was, "What scientific proof do you have that refutes what I am telling you?" I further asked him, "Do you feel better?" His reply was, "Yes." I then replied, "What more proof do you need then how you feel." I do believe that it would be good to get this evidence based massage but in my 23 years of practice and having worked on thousands of individuals it would be difficult for me to set up a study of 100 people that have exactly the same issue. I do know that after talking to many of the researches at the Cleveland Clinic that it takes them a long time to come up with a satisfactory group to study. Their asset though is that the pharmaceutical companies are funding the research. I do believe it would be difficult to have comparable studies without that type of funding. If large enough grants were available I would be happy to compare the theory I developed, Muscle Release Therapy, MRTh(R) to many other modalites.
Permalink Reply by Lina Petridis on July 14, 2009 at 1:39pm
I do understand that Big Pharma has researched its way right into an addicted society. Here is data..researchers can moon walk with..
.Australian authorities were enforcing a procedure for SIDS in the 50's ..in spite of the tremendous losses of aboriginal chidren.When new and successful methods by Archie Kalokerinos was introduced He was asked where is your research? His simple answer was.."With one method they die. the other they live! "The question to ask is if they were so scientific why did they choose to oppose him rather find the truth? Is it pride and prejudice...Angels or Demons? Or is the truth a jumping off place for your beliefs?

Jennifer L. Hensley said:
See, this is a perfect example of what a lot of bodyworkers don't understand about research: you absolutely _do_ need scientifically proven evidence to prove data...otherwise it is not data. If you don't have a scientific rationing for the way you collect data, it's useless.

You also don't seem to understand that research scientists absolutely take the placebo effect into account, that's why scientifically-approved studies have a control group with no intervention and a control group with "sham" or placebo intervention.

And I don't know of any intervention that is universal: it's not about that. It's about it being effective for the _majority_ of people with the condition.

Lina Petridis said:
Totally agree Elena...We don't need scientifically proven evidence to prove data.. We cannot deny the advances made in science like stem -cell research...ex: growing a new finger.. but to prove a method as universal...is also a dilemma . The placebo effect,.where Japanese scientists asked for volunteers to expose themselves to poison Ivy..and resulted in an itching red burning rash were eventually told it was not poison Ivy.
You could replace that experiment with any practise..its the belief in what the client is exposing themself to that has the result they expect. How do you measure what the mind believes? Isn't this a question with a simple answer? Elena Barrioz said:
Hmmmm, why is it, that unless it can be proven "scientifically", it must not be viable. Massage (to me) is such an individual experience. I would question the intent behind EBM, is it just monetary (to be more readily accepted by the insurance companies) or is it to find techniques/modalities that consistently provide clients with positive results. I would think that answer would then be used to skew the data to favor which ever outcome was wanted.
Permalink Reply by Lina Petridis on July 14, 2009 at 1:42pm
Lina Petridis said:
I do understand that Big Pharma has researched its way right into an addicted society. Here is data..researchers can moon walk with..
.Australian authorities were enforcing a procedure for SIDS in the 50's ..in spite of the tremendous losses of aboriginal chidren.When new and successful methods by Archie Kalokerinos was introduced He was asked where is your research? His simple answer was.."With one method they die. the other they live! "The question to ask is if they were so scientific why did they choose to oppose him rather find the truth? Is it pride and prejudice...Angels or Demons? Or is the truth a jumping off place for your beliefs?

Jennifer L. Hensley said:
See, this is a perfect example of what a lot of bodyworkers don't understand about research: you absolutely _do_ need scientifically proven evidence to prove data...otherwise it is not data. If you don't have a scientific rationing for the way you collect data, it's useless.

You also don't seem to understand that research scientists absolutely take the placebo effect into account, that's why scientifically-approved studies have a control group with no intervention and a control group with "sham" or placebo intervention.

And I don't know of any intervention that is universal: it's not about that. It's about it being effective for the _majority_ of people with the condition.

Lina Petridis said:
Totally agree Elena...We don't need scientifically proven evidence to prove data.. We cannot deny the advances made in science like stem -cell research...ex: growing a new finger.. but to prove a method as universal...is also a dilemma . The placebo effect,.where Japanese scientists asked for volunteers to expose themselves to poison Ivy..and resulted in an itching red burning rash were eventually told it was not poison Ivy.
You could replace that experiment with any practise..its the belief in what the client is exposing themself to that has the result they expect. How do you measure what the mind believes? Isn't this a question with a simple answer? Elena Barrioz said:
Hmmmm, why is it, that unless it can be proven "scientifically", it must not be viable. Massage (to me) is such an individual experience. I would question the intent behind EBM, is it just monetary (to be more readily accepted by the insurance companies) or is it to find techniques/modalities that consistently provide clients with positive results. I would think that answer would then be used to skew the data to favor which ever outcome was wanted.
Permalink Reply by The Rev on July 14, 2009 at 5:17pm
With all the hooplah over the BOK amongst other things, I am moving to a faith based enterprise. I have more than enough evidence the/my work works. Contributing to such a thing as evidence based massage therapy is not really in the interest of most of those doing the work as a personal service.

Thanks for the invite though.
Permalink Reply by Robin Byler Thomas on July 14, 2009 at 7:54pm
Hmmm, maybe we should find out. Maybe instead of a research study I should start with a needs assessment among ABMP members surveying the need, or interest for EBP? Unless this was your intent Bodhi?
Permalink Reply by Robin Byler Thomas on July 14, 2009 at 7:58pm
Hi Andrea,

Thanks for your interest. At the moment I've trying to establish a collaboration between the MT schools and the U of A. I'll let you know how it goes and keep you in mind for possible research. I have several ideas but have to find out what they want to do first.

Andrea Rose said:
I am curious about what kind of study you are interested in doing. I recently graduated from Cortiva myself. I may be interested if you can give me any info.

Robin Byler Thomas said:
My thoughts exactly Jan. I'm trying to do just that. I've been a LMT for 15 years and a part-time grad student at the U of A for the past 3. I'm preparing for my internship before graduating and would like to set up a colloboration with Cortiva, PCC, or the Providence Institutes, and the U for either student research case studies or a micro-longitudinal pilot study. You and I met more than 15 years ago at DIHA when I was just starting out; I don't expect you to remember as we talked only once and I actually graduated from SWIHA. I have a UA professor who is interested in helping with my project and I'm gathering information now to get this ball rolling. Do you have any contacts you could recommend left at Cortiva that I could talk to who might be interested?

Jan Schwartz said:
In my opinion Evidence Based Practice is critical for the advancement of our profession, especially for those who want to be a part of the American health care system. I understand that some therapists do not want to go there, and that's fine--I'm speaking about those who do. EBP makes the most sense for massage because, as you point out Bodhi, it is a three pronged approach, taking into account the patient/client preferences and clinical experiences as well as using best available evidence.

The first step is to get research literacy into the schools so that new graduates can evaluate research and use it appropriately. Then we need massage therapists to actually conduct research. At least in this country, most research having to do with massage is being conducted by other health care professionals--as the principal investigator. That too needs to change and requires massage therapists to have a higher level of education. The result of research is the evidence, and who better to conduct it than those who were trained in it?
Permalink Reply by Patricia J. Pape on July 15, 2009 at 11:28am
I agree, Jennifer. I think we have to look to scientifically sound, well designed studies as models for research in MT and guess who is doing those well designed studies? I have a few cousins who are post-doc.'s doing pure science research (gene splicing and the like) and they make their livings from grant $$$ and teaching. If we want to attract this caliber mind, there needs to be a living in it for the researchers.

Jennifer L. Hensley said:
I think part of the problem is that we are not hiring enough people with adequate scientific background in research to help the profession figure out what it can do to have massage and bodywork appropriately studied: we seem to have lots of people involved with a B.S. in various science disciplines, but what about PhDs with a decade or more of experience in post-grad biological or organic chemistry research? I think a lot of times the thought is "Oh, they don't have a massage or bodywork background, so what could they do to help?" And the answer is plenty.
Permalink Reply by Laura Allen on July 15, 2009 at 6:40pm
Bodhi is good at making research sound less intimidating to the masses. I have a huge collection of massage school catalogs from the US, and not one of them includes in their program anything about research methodology. A few require a "research project," but they don't give students any real scientific background to work with in order to do that, so it's too informal to be acceptable as validated information, and not publication-worthy. Most therapists just don't know how to conduct a study. But as Bodhi says, if you intend to cause a certain change in the patient's life, that is measurable.

EBM has to start with us. We can't, and shouldn't, leave it to some Ph.D. in a laboratory. Tiffany Fields can't do everything by herself! The working massage therapists are the ones with the most opportunity to document results. We just have to be educated on how to properly do it. There are several informative articles on the AMTA website on how to conduct good research. http://www.massagetherapyfoundation.org/or_methodsintro.html

Bodhi Haraldsson said:
You can always study the results of your therapy, its not necessary to first understand the mechanism at work. If your intention is to cause a certain change in your patients life then that change is measurable.

Lina Petridis said:
Totally agree Elena...We don't need scientifically proven evidence to prove data.. We cannot deny the advances made in science like stem -cell research...ex: growing a new finger.. but to prove a method as universal...is also a dilemma . The placebo effect,.where Japanese scientists asked for volunteers to expose themselves to poison Ivy..and resulted in an itching red burning rash were eventually told it was not poison Ivy.
You could replace that experiment with any practise..its the belief in what the client is exposing themself to that has the result they expect.
How do you measure what the mind believes? Isn't this a question with a simple answer?


Elena Barrioz said:
Hmmmm, why is it, that unless it can be proven "scientifically", it must not be viable. Massage (to me) is such an individual experience. I would question the intent behind EBM, is it just monetary (to be more readily accepted by the insurance companies) or is it to find techniques/modalities that consistently provide clients with positive results. I would think that answer would then be used to skew the data to favor which ever outcome was wanted.

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