Evidence-based vs Evidence Informed Massage Therapy

Can massage therapy be evidence based or is it evidence informed? The two are often used interchangeably when they are two separate things. Many massage therapists will call themselves evidence based rather than evidence informed.

Evidence-based medicine was defined by Sackett et al. as the following: “Evidence based medicine is the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients. Taking the best available research that we have combined with our educated guesses from our practical hands on experience, and having a consensus of expert opinions, makes for evidence-informed practice.

The evidence-based process consists of:

  • Asking a well developed answerable question
  • Searching for evidence
  • Evaluating and appraising the evidence for the validity, size of effect and the applicability in clinical practice
  • Integrating the critical evaluation with clinical expertise and the patients unique circumstances and values
  • Evaluating the effectiveness for next time.

The EBP process described above relies on quantitative research studies that provide the highest levels of evidence for decisions about interventions and other practice topics such as assessment (diagnosis) and prevalence.

Miles and Loughlin promoted using the term ’evidence-informed’
practice to indicate that the process be person-centred rather than focused on the science of reducing the quantitative evidence, which, they claim, has taken humanity out of clinical practice. It implies that many different levels of evidence and types of evidence (described above) are needed and used to support decisions in clinical practice. Many people believe that “Evidence-informed practice extends beyond the early definitions of evidenced-based practice.

Currently, not enough high-quality research is available for therapeutic massage practice to be considered completely evidence based; however, the research is improving.

Fritz, Sandy; Fritz, Luke. Mosby’s Fundamentals of Therapeutic Massage – E-Book (Kindle Locations 2895-2898). Elsevier Health Sciences. Kindle Edition.

The original concept was evidence-based practice, meaning that quality evidence was available to support actions. However, in many disciplines, such as massage, research cannot always be related to practice. When we provide therapeutic massage for a client, we want to be as evidence based as possible and evidence informed when definitive evidence does not exist. Fritz, Sandy; Fritz, Luke. Mosby’s Fundamentals of Therapeutic Massage – E-Book (Kindle Locations 2944-2946). Elsevier Health Sciences. Kindle Edition.

Evidence informed from the Massage Therapy Foundation

To confuse the issue further, the Massage Therapy Foundation says that evidence informed practice is a 3 legged stool where the first leg is the Clients Values, the second Leg the Practitioners Judgement and the third leg–What does the research say? Since therapists rarely rely on the research or even know how to find research or know that there is research, the first 2 steps are often what we get. ~Massage Therapy Foundation

In today’s health care arena, therapists need evidence in order to provide the best care possible to their clients (Achilles and Dryden 2004; Menard and Piltch 2009; Menard 2008),to identify which practices are useful and safe for their clients, and to educate themselves and their clients about what massage can and cannot do. A solid foundation of evidence also facilitates acceptance of the value of massage and accountability for its increased second-party reimbursement.

Questions that need answering.

Does EBP or EIP actually provide a better way of working with clients? Can it really improve clinical outcomes? Is there research that shows EBP/EIP works?

Does EBP/EIP take into consideration the therapeutic relationship enough?

Does EBP/EIP make the profession focus more on fixing and less on caring?

Since we have little to no evidence on how or why massage therapy works and at best the research shows it looks promising, what are massage therapists who say they are evidence-based or evidence informed practicing?

Is research on massage valid? Studies will provide specific protocols for performing the massage like 15 minutes of effleurage on each the back and the neck…but who in real life practices like that?

The Medical Profession can’t even get this right. Only about 50% of the procedures and treatments done are evidence based…so how is the massage profession going to become 100% evidence based when most massage therapists don’t understand research and don’t need research to build a successful massage practice? The Massage Researchers and Skeptics have missed a big piece of their messaging—what is in it for me- the average joe massage therapist?  What is in it for me (the intuitive, caring, empathetic, massage therapist?) What is in it for my clients?  How will it make their lives better or make me a better massage therapist?  ~taken from Whitney Lowes speech at the MTF conference in 2010.

Studies have found that more than a decade can pass before the evidence alters clinical practice Patashnik, Eric M.; Gerber, Alan S.; Dowling, Conor M.. Unhealthy Politics: The Battle over Evidence-Based Medicine (p. 2). Princeton University Press. Kindle Edition.

The evidence allowed in EBM consists of selected large-scale trials and meta-analyses that attempt to make a conclusion more significant by aggregating results from wildly different groups. This constitutes a tiny percentage of the total evidence. Meta-analysis rejects the vast majority of data available, because it does not meet the strict criteria for EBM. This conflicts with yet another scientific principle, that of not selecting your data. Rather humorously in this context, science students who select the best data, to draw a graph of their results, for example, will be penalized and told not to do it again.

Could Evidence Informed/Based Massage be outdated?

An article in Massage and Bodywork (March/April 2021) sparked my interest. Listen, My Body Electric Narrative Medicine and the Holistic Revolution in Biomedicine, Part 1 By Sasha Chaitow, PhD

Evidence Based/Informed massage seems to be moving toward the Biopsychosocial model of Pain as the way to explaining how/why massage works. There is a whole other side to the BPS model and that is in they way they take the power away from the clients experience of pain.

Here are some highlights from the article that need more information and investigating.

In terms of application and outcomes, though, there has been little to actually show for “the revolution” beyond theoretical self-improvement and a checkbox approach that may pay lip service to BPS principles but does not necessarily have the desired impact on the patient.

The keyword here is humanity. The BPS model, as I explore in the next article in this series, has gone a long way toward shifting attitudes regarding the therapeutic relationship, but not far enough. The ultimate aim is still to “reeducate” the patient from a position of authority by imposing one’s opinion on the patient (regardless of whether they are ready to hear it) through a subject-object dynamic in which the patient remains largely a subject, and not an equal partner in the clinical encounter. The true revolution in the rapidly growing subdiscipline of narrative-based medicine (NBM), however, is to reeducate physicians to see their patients not in terms of their pathology, bad habits, lay or “pop” understandings of disease, or assumed ignorance. Instead, they are perceived as whole individuals whose lived experience and whose own narratives of illness will point the way to both assessment and treatment.