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Evidence based massage therapy
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Replies to This Discussion
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Permalink Reply by Laura Allen on
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Employ them in what way? Leave it all up to the scientists? Pay a Ph.D. to come into their office? The best way to reach the most therapists would be if schools would include that in their training. As Jan Schwartz has pointed out, not everyone has any interest in research or EBM. For those that do, including an elective research track in massage programs would be a big step forward; those with the appropriate skills and education could be employed to teach that. AMTA also includes a research track at every national convention. I've attended several and found them to be very helpful.
Jennifer L. Hensley said:I suppose you know the process to go through review boards and to make your case ethically sound.
No? Neither does the average or even advanced MT. You said it yourself: we're not trained. So why would we not employ those trained to help us do research?
Laura Allen said: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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Permalink Reply by Noel Norwick on
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Teachers and practitioners interested in "evidence based" massage therapy would do well to track the progress and make suggestions regarding the current effort to establish a foundational "body of knowledge" for all massage modalities being practiced in the USA. This can be done by going to http://www.mtbok.org/
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Permalink Reply by Jan Schwartz on
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Good point Noel and that's what we're trying to do in the EBP Group which Bodhi started--if we can ever get the conversation to go there. Seems we are still arguing about the merits of EBP there too. I don't think anyone is saying that all massage therapists need to go there, but those who desire to see that model should be able to work toward it collaboratively. Of course that requires more participation than 4 or 5 people. I'm not sure that the MTBOK is the place for this to happen, but maybe.
Noel Norwick said:Teachers and practitioners interested in "evidence based" massage therapy would do well to track the progress and make suggestions regarding the current effort to establish a foundational "body of knowledge" for all massage modalities being practiced in the USA. This can be done by going to http://www.mtbok.org/
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Jan: My perspective is that currently "EBP" reflects the intellectual/financial research interests of those in our industry with the most money to spend. While I understand it, I remain uncomfortable about the likely impact on the field we all feel passionate about of the current "single-factor" bias in scientific research, especially when combined with the vast number of trademarked massage modalities/practice protocols.
Additionally, as an MBA who entered the corporate world in 1974, I suspect that the end result of this MTBOK project (given its sponsoring organizations) will likely become the "Gold Standard" for our industry and wonder what others think about this prospect.
Jan Schwartz said:Good point Noel and that's what we're trying to do in the EBP Group which Bodhi started--if we can ever get the conversation to go there. Seems we are still arguing about the merits of EBP there too. I don't think anyone is saying that all massage therapists need to go there, but those who desire to see that model should be able to work toward it collaboratively. Of course that requires more participation than 4 or 5 people. I'm not sure that the MTBOK is the place for this to happen, but maybe.
Noel Norwick said:Teachers and practitioners interested in "evidence based" massage therapy would do well to track the progress and make suggestions regarding the current effort to establish a foundational "body of knowledge" for all massage modalities being practiced in the USA. This can be done by going to http://www.mtbok.org/
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Bodhi: If I have offended you, I apologize. Regardless your efforts and those of other well intentioned people, I stand by and would still appreciate your take on my points as stated:
"My perspective is that currently "EBP" reflects the intellectual/financial research interests of those in our industry with the most money to spend. While I understand it, I remain uncomfortable about the likely impact on the field we all feel passionate about of the current "single-factor" bias in scientific research, especially when combined with the vast number of trademarked massage modalities/practice protocols.
Additionally, as an MBA who entered the corporate world in 1974, I suspect that the end result of this MTBOK project (given its sponsoring organizations) will likely become the "Gold Standard" for our industry and wonder what others think about this prospect."
Bodhi Haraldsson said:
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The entities to which I referred are many, so I shall only name those whose output I currently consider most worthy of being regularly followed:
1. NIH PUB Med - http://www.ncbi.nlm.nih.gov/pubmed/
2. NIH Office of Alternative Medicine - http://nccam.nih.gov/
3. Massage Therapy Foundation - http://www.ijtmb.org/index.php/ijtmb/login?source=/index.php/ijtmb/...
4. Massage Therapy Body of Knowledge - http://www.mtbok.org/ (as a new group, this one has yet to offer anything)
With regard to your question of what impact I think the above referenced organizations may have: My concern is that they, regulatory agencies and the courts/judges will ultimately determine the legally accepted meaning of "evidence based massage" rather than a definition that you and I might agree upon. Additionally, in the mainstream medical community "evidence based medicine" currently is a highly contentious and legally risky approach when compared to following "generally recognized best practice protocols." While I don't have a current reference handy, I recall it being reported that M.D.s take the risks involved of prescribing "off label" treatment about 20% of the time. How risk assumptive do you think massage practitioners are collectively?
Bodhi Haraldsson said:Noel
You have not offended me at all, discussion and debate is crucial.
I cant address any of your points as you have stated them, as they are to vague and broad in nature to take them on.
Please elaborate on who or what entity you are referring to, what is the impact you are concerned about, please be specific.
Noel Norwick said:Bodhi: If I have offended you, I apologize. Regardless your efforts and those of other well intentioned people, I stand by and would still appreciate your take on my points as stated:
"My perspective is that currently "EBP" reflects the intellectual/financial research interests of those in our industry with the most money to spend. While I understand it, I remain uncomfortable about the likely impact on the field we all feel passionate about of the current "single-factor" bias in scientific research, especially when combined with the vast number of trademarked massage modalities/practice protocols.
Additionally, as an MBA who entered the corporate world in 1974, I suspect that the end result of this MTBOK project (given its sponsoring organizations) will likely become the "Gold Standard" for our industry and wonder what others think about this prospect."
Bodhi Haraldsson said:
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My rough, but serviceable, definitions are:
Generally recognized best practice protocols - These are typically court/lawsuit tested techniques, procedures & theories taught in professional schools, based on materials published by firms that specialize in providing training books, videos, etc., for that field. This is usually about ten years behind what some leaders in the field are actually doing.
Evidence Based Practice - These are typically procedures and techniques that recent pilot study research and empirical studies suggest may be more effective than current generally recognized best practice protocols and theories. This is usually cutting edge stuff that may or may not withstand subsequent testing in large scale studies and/ or trial reviews/lawsuits.
Bodhi Haraldsson said:Noel could you define for me the difference between EBP and "generally recognized best practise protocols."
To me they are one and the same. Noel Norwick said:The entities to which I referred are many, so I shall only name those whose output I currently consider most worthy of being regularly followed:
1. NIH PUB Med - http://www.ncbi.nlm.nih.gov/pubmed/
2. NIH Office of Alternative Medicine - http://nccam.nih.gov/ 3. Massage Therapy Foundation - http://www.ijtmb.org/index.php/ijtmb/login?source=/index.php/ijtmb/... 4. Massage Therapy Body of Knowledge - http://www.mtbok.org/ (as a new group, this one has yet to offer anything)
With regard to your question of what impact I think the above referenced organizations may have: My concern is that they, regulatory agencies and the courts/judges will ultimately determine the legally accepted meaning of "evidence based massage" rather than a definition that you and I might agree upon. Additionally, in the mainstream medical community "evidence based medicine" currently is a highly contentious and legally risky approach when compared to following "generally recognized best practice protocols." While I don't have a current reference handy, I recall it being reported that M.D.s take the risks involved of prescribing "off label" treatment about 20% of the time. How risk assumptive do you think massage practitioners are collectively?
Bodhi Haraldsson said:Noel
You have not offended me at all, discussion and debate is crucial.
I cant address any of your points as you have stated them, as they are to vague and broad in nature to take them on.
Please elaborate on who or what entity you are referring to, what is the impact you are concerned about, please be specific. Noel Norwick said:Bodhi: If I have offended you, I apologize. Regardless your efforts and those of other well intentioned people, I stand by and would still appreciate your take on my points as stated:
"My perspective is that currently "EBP" reflects the intellectual/financial research interests of those in our industry with the most money to spend. While I understand it, I remain uncomfortable about the likely impact on the field we all feel passionate about of the current "single-factor" bias in scientific research, especially when combined with the vast number of trademarked massage modalities/practice protocols.
Additionally, as an MBA who entered the corporate world in 1974, I suspect that the end result of this MTBOK project (given its sponsoring organizations) will likely become the "Gold Standard" for our industry and wonder what others think about this prospect."
Bodhi Haraldsson said:
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From your response, may I presume that you believe that Medicare/Medicaid, insurance companies and medical malpractice lawyers share your opinion?
Bodhi Haraldsson said:I can see were your confusion is coming from now.
EBP simply put is research put in to a real life scenario. This is were your experience, the patient and her preferences and research meet. It's the application of best available evidence, not pilot studies etc. Best available evidence can differ based on the type of question you need answered. An RCT or two of high quality are preferred for therapies for example.
A best practise guidelines use EBP protocols and expert opinion ( in that specific field) to come out with general recommendation for a specific area of practise.
Thus they are essentially one and the same.
I would highly encourage you to read my blog post and slide presentation on my profile to get a clear picture of EBP.
Noel Norwick said:My rough, but serviceable, definitions are:
Generally recognized best practice protocols - These are typically court/lawsuit tested techniques, procedures & theories taught in professional schools, based on materials published by firms that specialize in providing training books, videos, etc., for that field. This is usually about ten years behind what some leaders in the field are actually doing.
Evidence Based Practice - These are typically procedures and techniques that recent pilot study research and empirical studies suggest may be more effective than current generally recognized best practice protocols and theories. This is usually cutting edge stuff that may or may not withstand subsequent testing in large scale studies and/ or trial reviews/lawsuits.
Bodhi Haraldsson said:Noel could you define for me the difference between EBP and "generally recognized best practise protocols."
To me they are one and the same. Noel Norwick said:The entities to which I referred are many, so I shall only name those whose output I currently consider most worthy of being regularly followed:
1. NIH PUB Med - http://www.ncbi.nlm.nih.gov/pubmed/
2. NIH Office of Alternative Medicine - http://nccam.nih.gov/ 3. Massage Therapy Foundation - http://www.ijtmb.org/index.php/ijtmb/login?source=/index.php/ijtmb/... 4. Massage Therapy Body of Knowledge - http://www.mtbok.org/ (as a new group, this one has yet to offer anything)
With regard to your question of what impact I think the above referenced organizations may have: My concern is that they, regulatory agencies and the courts/judges will ultimately determine the legally accepted meaning of "evidence based massage" rather than a definition that you and I might agree upon. Additionally, in the mainstream medical community "evidence based medicine" currently is a highly contentious and legally risky approach when compared to following "generally recognized best practice protocols." While I don't have a current reference handy, I recall it being reported that M.D.s take the risks involved of prescribing "off label" treatment about 20% of the time. How risk assumptive do you think massage practitioners are collectively?
Bodhi Haraldsson said:Noel
You have not offended me at all, discussion and debate is crucial.
I cant address any of your points as you have stated them, as they are to vague and broad in nature to take them on.
Please elaborate on who or what entity you are referring to, what is the impact you are concerned about, please be specific. Noel Norwick said:Bodhi: If I have offended you, I apologize. Regardless your efforts and those of other well intentioned people, I stand by and would still appreciate your take on my points as stated:
"My perspective is that currently "EBP" reflects the intellectual/financial research interests of those in our industry with the most money to spend. While I understand it, I remain uncomfortable about the likely impact on the field we all feel passionate about of the current "single-factor" bias in scientific research, especially when combined with the vast number of trademarked massage modalities/practice protocols.
Additionally, as an MBA who entered the corporate world in 1974, I suspect that the end result of this MTBOK project (given its sponsoring organizations) will likely become the "Gold Standard" for our industry and wonder what others think about this prospect."
Bodhi Haraldsson said:
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Published literature does not always reflect reality and though I suspect that I might agree with you in principle, we would all do well to keep in mind that it's ethically/morally defensible to hold that "He who pays the piper calls the tune".
The large scale introduction and growth of so called "insurance" in healthcare since the 1960s has created the troublesome conflict of interest issues between the healthcare that consumers, government, providers/practitioners want everyone to receive and what those who must pay for it can afford and are willing to freely provide.
Possibly you would clarify for us why in our litigious society one should practice (or government/insurers pay for) medical/massage theories, principles, techniques and practices that have not yet proven to be legally defensible (or even effective for all) rather than what has? Additionally, how do you and the literature you refer to distinguish between these two objectively distinct categories?
Bodhi Haraldsson said:Hi Noel
This is not my opinion, its what the published literature is saying. Insurance companies have their own agenda and are very adapt at twisting information to suit them. EBP has often been presented as evidence only practise. It's not, and if we don't engage in the discussion and stick out collective heads in the sand then some one else will define EBP in massage therapy.
Noel Norwick said:From your response, may I presume that you believe that Medicare/Medicaid, insurance companies and medical malpractice lawyers share your opinion?
Bodhi Haraldsson said:I can see were your confusion is coming from now.
EBP simply put is research put in to a real life scenario. This is were your experience, the patient and her preferences and research meet. It's the application of best available evidence, not pilot studies etc. Best available evidence can differ based on the type of question you need answered. An RCT or two of high quality are preferred for therapies for example.
A best practise guidelines use EBP protocols and expert opinion ( in that specific field) to come out with general recommendation for a specific area of practise. Thus they are essentially one and the same.
I would highly encourage you to read my blog post and slide presentation on my profile to get a clear picture of EBP.
Noel Norwick said:My rough, but serviceable, definitions are:
Generally recognized best practice protocols - These are typically court/lawsuit tested techniques, procedures & theories taught in professional schools, based on materials published by firms that specialize in providing training books, videos, etc., for that field. This is usually about ten years behind what some leaders in the field are actually doing.
Evidence Based Practice - These are typically procedures and techniques that recent pilot study research and empirical studies suggest may be more effective than current generally recognized best practice protocols and theories. This is usually cutting edge stuff that may or may not withstand subsequent testing in large scale studies and/ or trial reviews/lawsuits. Bodhi Haraldsson said:Noel could you define for me the difference between EBP and "generally recognized best practise protocols."
To me they are one and the same. Noel Norwick said:The entities to which I referred are many, so I shall only name those whose output I currently consider most worthy of being regularly followed:
1. NIH PUB Med - http://www.ncbi.nlm.nih.gov/pubmed/
2. NIH Office of Alternative Medicine - http://nccam.nih.gov/ 3. Massage Therapy Foundation - http://www.ijtmb.org/index.php/ijtmb/login?source=/index.php/ijtmb/... 4. Massage Therapy Body of Knowledge - http://www.mtbok.org/ (as a new group, this one has yet to offer anything)
With regard to your question of what impact I think the above referenced organizations may have: My concern is that they, regulatory agencies and the courts/judges will ultimately determine the legally accepted meaning of "evidence based massage" rather than a definition that you and I might agree upon. Additionally, in the mainstream medical community "evidence based medicine" currently is a highly contentious and legally risky approach when compared to following "generally recognized best practice protocols." While I don't have a current reference handy, I recall it being reported that M.D.s take the risks involved of prescribing "off label" treatment about 20% of the time. How risk assumptive do you think massage practitioners are collectively?
Bodhi Haraldsson said:Noel
You have not offended me at all, discussion and debate is crucial.
I cant address any of your points as you have stated them, as they are to vague and broad in nature to take them on.
Please elaborate on who or what entity you are referring to, what is the impact you are concerned about, please be specific. Noel Norwick said:Bodhi: If I have offended you, I apologize. Regardless your efforts and those of other well intentioned people, I stand by and would still appreciate your take on my points as stated:
"My perspective is that currently "EBP" reflects the intellectual/financial research interests of those in our industry with the most money to spend. While I understand it, I remain uncomfortable about the likely impact on the field we all feel passionate about of the current "single-factor" bias in scientific research, especially when combined with the vast number of trademarked massage modalities/practice protocols.
Additionally, as an MBA who entered the corporate world in 1974, I suspect that the end result of this MTBOK project (given its sponsoring organizations) will likely become the "Gold Standard" for our industry and wonder what others think about this prospect."
Bodhi Haraldsson said:
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Permalink Reply by Christopher A. Moyer on
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Greetings everyone.
As someone who does massage therapy research, I've read this thread with interest. I'd like to comment on a few of the themes I have noticed here. I hope it will be O.K. to address several points in one message, as opposed to replying to many single posts individually.
Money and Research: Yes, it takes money to do research. But it is not true that research is entirely guided by money, or that research will only be funded when it is in some person's or company's best interest to get a particular finding. I am glad to see that many of you are skeptical of scientific research such as drug research, and can recognize that drug-company funded research may be biased and suspect. But, I would encourage you to try and think of counterexamples to your concerns, too - are there not plenty of cases of research that was conducted merely to find something out, or to benefit humanity, without any profit motive? (Yes, there has been - there are thousands of examples.) When research is skewed by a profit motive, doesn't the self-corrective nature of science usually discover that and reveal it? (This usually happens - that's why you know about it! Also, scientists love nothing more than proving someone else wrong, so skewed results are vulnerable to being overturned.) I myself have done, and am doing, massage therapy research which I do not profit from, except indirectly as it bolsters my standing within a university.
MT isn't standardized: Some folks are often quick to conclude that MT cannot be studied scientifically because no two therapists will practice in the same way, no two patients are the same, no two massages are the same, etc. Yes, this makes our job as researchers more difficult. But it does not at all mean that we cannot do meaningful research. Many things that scientists study in nature have this quality. No two animals are exactly the same, but biology has been chugging along and making plenty of progress for hundreds of years! No human circulatory systems are exactly alike, but research into heart surgery advances every day. In fact, explaining some of the variability in MT is exactly what we need to do. WHY is this massage therapist especially good at X, and this one is better at Y? Why did John Doe give great massages yesterday, but can't seem to do so today? These questions can be difficult to answer, but they are not impossible, at least not in principle. Obtaining answers to them will be good for the profession and for the recipients.
"Holism" and "left-brain" thinking: Yes, I put scare quotes around those terms; please forgive me. I did so because I think these terms can be misleading and simplistic. Yes, it is true that certain important things can be more than the sum of their parts - "taking apart" a session of MT to understand it may not always work or may miss something critical. But again, this is not unique to massage - this is a problem that can be encountered in all the sciences. The solution is to do various forms of research that focus at different levels of the phenomenon. In MT research, sometimes it makes sense to focus on a single part of the anatomy, but at other times our unit of analysis may be the recipient-therapist dyad. In the first case we are focused on only a part of a single person, in the second we are focused on more than two entire organisms. Regarding "left-brain" phenomena, it seems to me that people use this to refer to that which is intuitive. Intuitive phenomena can be difficult to understand and to study, but that does not mean we just throw our hands in the air and declare them to be magic. Intuitive phenomena and other difficult to explain phenomena are what attract some of us scientists to massage therapy as a subject.
Alright, I'm not sure how articulate I've been, especially in that last part, but I think that's the best I can right now. I enjoy reading this discussion that combines many different viewpoints and hope I can make a meaningful contribution.
-CM
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Something else I'd like to add - someone mentioned that the profession cannot simply leave the research up to PhDs in their labs. To some degree, I agree with this. (Full disclosure moment - I'm a PhD with a lab.) While many types of research do require special training or facilities to conduct them, dedicated practitioners CAN make a contribution to research by means of case studies. Be informed that the Massage Therapy Foundation has TWO different case study competitions (one for students, and one for practitioners). Also, the recently established online journal, International Journal of Therapeutic Massage and Bodywork (see www.ijtmb.org), is a possible publication outlet for well-conducted case studies.
I'm the Research Section editor for the journal, and would be happy to answer questions or provide guidance to practitioners who are thinking of conducting a case study. The journal website should have all my contact information.
-CM
P.S. At the risk of building up cynicism for academics, you do all know what PhD stands for, right? Your BS degree is Bull***, your MS is More ****, but the PhD is Piled Higher, and Deeper. :)
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Christopher: Delighted that you have joined the discussion as I wonder what your perspective is regarding what I perceive to be:
1. A "single factor" bias in current scientific research (that doesn't exist in what for the most part is a multifactorial reality)
2. A quantitative research vs. a qualitative research bias (as discussed in Working Minds, A Practitioner's Guide to Cognitive Task Analysis by Beth Crandall, Gary Klien & Robert Hoffman, The MIT Press, 2006).
Additionally, I would welcome your suggestions regarding what I (and possibly others) might do to overcome both of my above noted concerns.
Christopher A. Moyer said:Greetings everyone.
As someone who does massage therapy research, I've read this thread with interest. I'd like to comment on a few of the themes I have noticed here. I hope it will be O.K. to address several points in one message, as opposed to replying to many single posts individually.
Money and Research: Yes, it takes money to do research. But it is not true that research is entirely guided by money, or that research will only be funded when it is in some person's or company's best interest to get a particular finding. I am glad to see that many of you are skeptical of scientific research such as drug research, and can recognize that drug-company funded research may be biased and suspect. But, I would encourage you to try and think of counterexamples to your concerns, too - are there not plenty of cases of research that was conducted merely to find something out, or to benefit humanity, without any profit motive? (Yes, there has been - there are thousands of examples.) When research is skewed by a profit motive, doesn't the self-corrective nature of science usually discover that and reveal it? (This usually happens - that's why you know about it! Also, scientists love nothing more than proving someone else wrong, so skewed results are vulnerable to being overturned.) I myself have done, and am doing, massage therapy research which I do not profit from, except indirectly as it bolsters my standing within a university.
MT isn't standardized: Some folks are often quick to conclude that MT cannot be studied scientifically because no two therapists will practice in the same way, no two patients are the same, no two massages are the same, etc. Yes, this makes our job as researchers more difficult. But it does not at all mean that we cannot do meaningful research. Many things that scientists study in nature have this quality. No two animals are exactly the same, but biology has been chugging along and making plenty of progress for hundreds of years! No human circulatory systems are exactly alike, but research into heart surgery advances every day. In fact, explaining some of the variability in MT is exactly what we need to do. WHY is this massage therapist especially good at X, and this one is better at Y? Why did John Doe give great massages yesterday, but can't seem to do so today? These questions can be difficult to answer, but they are not impossible, at least not in principle. Obtaining answers to them will be good for the profession and for the recipients.
"Holism" and "left-brain" thinking: Yes, I put scare quotes around those terms; please forgive me. I did so because I think these terms can be misleading and simplistic. Yes, it is true that certain important things can be more than the sum of their parts - "taking apart" a session of MT to understand it may not always work or may miss something critical. But again, this is not unique to massage - this is a problem that can be encountered in all the sciences. The solution is to do various forms of research that focus at different levels of the phenomenon. In MT research, sometimes it makes sense to focus on a single part of the anatomy, but at other times our unit of analysis may be the recipient-therapist dyad. In the first case we are focused on only a part of a single person, in the second we are focused on more than two entire organisms. Regarding "left-brain" phenomena, it seems to me that people use this to refer to that which is intuitive. Intuitive phenomena can be difficult to understand and to study, but that does not mean we just throw our hands in the air and declare them to be magic. Intuitive phenomena and other difficult to explain phenomena are what attract some of us scientists to massage therapy as a subject.
Alright, I'm not sure how articulate I've been, especially in that last part, but I think that's the best I can right now. I enjoy reading this discussion that combines many different viewpoints and hope I can make a meaningful contribution.
-CM
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