Variable Quality of Research Evidence

Introduction         

Few of us would argue with the importance of evidence-based practice (EBP) in sports medicine, but to develop such a culture we must have ‘quality’ research literature (1). Research is simply a way of solving problems. Questions are raised, and methods are devised in an attempt to answer them (2). Research enables us to convert theory into practice to solve clinical problems. Research in medicine and sciences has developed within a framework of thinking that is known as the ‘scientific method’. This framework has become the predominant model for rigorous research investigation.

Unfortunately, owing to the vast quantities of research material now available, searching and locating relevant literature can be difficult and often very time consuming. Furthermore, the ‘quality’ of research evidence cannot always be relied upon for EBP. This article will attempt to identify some of the typical pit-falls, discuss the necessary research skills required for EBP.
 

The Quality Issue

Evidence-based practice (EBP) is a process of turning clinical problems into questions, then systematically locating, critically appraising, and using robust contemporary research evidence as the basis for clinical decisions (3). It is widely accepted the reading of peer reviewed research articles is essential for EBP and vital to continuing professional development (CPD) (4, 5, 6). Journal reading enables the therapist to keep up-to-date with current thinking (7). However, research evidence should never be accepted blindly and certainly not taken at face value (8). Therefore, research needs to be critically evaluated for both quality (validity) and relevance (9) to help the clinician make better use of the evidence (10) to inform clinical decisions and practice. Almost 12 years ago, Rothstein (11) realised the survival of his profession (physical therapy) depended not on the quantity of dubious research but on the quality of focused and meaningful research. Rosenberg and Donald (3) said “we are confronted by a growing body of information, much of it invalid or irrelevant to clinical practice”.

Many authors share this view, for example; Marshall (8) reminds us of the need to read literature with a critical mind even that published in peer reviewed journals. More drastically, Greenhalgh (12) suggests most published articles belong in the bin, and should certainly not be used to inform practice. According to Del Mar (13) most research papers are written as communications from scientists to scientists and relatively few have immediate clinical relevance - most of the remainder are not rigorous enough to warrant applying clinically. Consequently, the proportion of useful information is very small. Greenhalgh (12) reported many papers published in medical journals have potentially serious methodological flaws. Therefore, if you are deciding whether a paper is worth reading, you should do so on the design of the methods section. In support of Greenhalgh, Sheldon et al. (14) suggests that when designing studies investigators should consider how and by whom their results will be used. The design should be sufficiently robust, the setting sufficiently similar to that in which the results are likely to be implemented, the outcomes should be relevant, and the study size large enough for the results to convince decision makers of their importance. Although textbooks play an important role in providing basic information to learners the drawback with all textbooks is staying current (15). Some concepts described in textbooks can lag behind the empirical evidence by as much as 10 years. This lag is in part attributable to the more prolonged publication cycle for textbooks than for journal articles. In summary, treatment interventions should be chosen from the most relevant, scientifically sound and rigorous evidence currently available. Fortunately, the use of hierarchies of evidence can assist clinicians in this process.

Conclusion

The need for effective high-quality research evidence has arisen from evidence-based practice, fundamentally driven by patients’ expectations and their ever increasing demands, and rightly so. Indirectly, the need has arisen from increasingly stringent legislation, and the looming threat of civil action resulting from negligence and malpractice. Regardless of the driving forces involved, it remains abundantly clear to all concerned that high-quality evidence is a necessity, now, and will remain so in the future. Notwithstanding the reasons above, the development of research skills remains a key issue and constitutes suitable components for future professional development. Understanding the concept of and the components within the hierarchy of evidence would represent a good starting point.
              

References:              

1. Bleakley C, & MacAuley D. (2002). The quality of research in sports journals. British Journal of Sports Medicine,  36:124-125.
2. Thomas JR, & Nelson JK. (2001). Research methods in physical activity, 4th edition. Human Kinetics.
3. Rosenberg W, & Donald A. (1995). Evidence based medicine: an approach to clinical problem-solving. British Medical Journal, 310:1122-1126.
4. Bury T, & Mead J. (1998). Evidence-based healthcare: a practical guide for therapists. Butterworth Heinemann.
5. Turner PA, & Whitfield AW. (1999). Physiotherapists’ reasons for selection of treatment techniques: A cross-national survey. Physiotherapy Theory and Practice, 15(4): 235-246.
6. Turner PA. (2001). Evidence-based practice and physiotherapy in the 1990s. Physiotherapy Theory and Practice, 17:107-121.
7. Alsop A. (1997). Evidence-based practice and continuing professional development. British Journal of Occupational Therapy, 60(11): 503-550.
8. Marshall G. (2005). Critiquing a research article. Radiography, 11:55-59.
9. Straus SE, & Sackett DL. (1998). Using research findings in clinical practice. British Medical Journal, 317: 339-342.
10. Cape J. (2000). Clinical effectiveness in the UK: Definitions, history and policy trends. Journal of Mental Health, 9(3):237-246.
11. Rothstein JM. (1996). Outcomes and survival. Physical Therapy, 76(2):126-127.
12. Greenhalgh T.(1997).  How to read a paper: getting your bearings (deciding what the paper is about). British Medical Journal, 315:243-246.
13. Del Mar C. (2005).  Clever searching for evidence. British Medical Journal,  330:1162-1163.
14. Sheldon TA, Guyatt GH, Haines A. (1998).  When to act on the evidence. British Medical Journal, 317:139-142.
15. Steves R, & Hootman JM. (2004).  Evidence-based medicine: what is it and how does it apply to athletic training? Journal of Athletic Training,  39(1):83-87.

Massage - an introduction to the evidence 

Research Evidence in Massage

Massage involves the manipulation of soft tissues of the body (1), especially muscles, tendons, ligaments and fascia (2). Massage can be adapted to treat athletes and non-athletes alike for many reasons. Massage can be used to treat various musculoskeletal injuries or conditions, ranging from acute to chronic. Massage is thought to improve circulation, cell metabolism, venous and lymphatic flow, removal of chemical irritants, stretch superficial scar tissue, and alleviate adhesion. As a result, relaxation, pain relief, oedema reduction, increased range of movement, enhanced recovery, and injury prevention can be achieved (3). The growing use by elite athletes suggests there is belief that massage works (4, 5), and has an important role to play in prevention, preparation, rehabilitation, and recovery of athletes (6).

This belief reflects, and supports, my own positive experiences of massage; i) as a retired race cyclist, ii) as an ex-masseur to the GB cycling team, iii) working as a sports therapist. Surprisingly the research literature has yet to demonstrate any clear benefits.

Characteristics of a good massage therapist

Like all interventions, massage needs to be based on sound scientific ‘essential principles’. A good therapist, in addition to being competent in manual therapy should have an understanding of human anatomy, physiology, pathology; and the ability to apply this knowledge when practising massage (15). Frequently cited by many authors, therapists must acquire adequate knowledge of the pathophysiology of soft tissue injury and the healing process (15, 16, 17, 18). Because, an understanding of tissue healing is fundamental to effective massage as the phases of healing guide clinical decision-making with respect to what, when, and how to apply appropriate massage (3, 15). Otherwise, massage may result in poor performance and cause further tissue damage (19). Experience is an essential component in any profession and massage is no exception. For example, a pre-requisite for masseurs applying for major sporting events e.g. Olympics and Commonwealth games require a minimum of 500 hours practical sports massage. In a recent study by Moraska (20), the level of therapist training was shown to impact effectiveness of massage as a post-race recovery tool following a 10-Km run. A greater reduction in muscle soreness was achieved by therapists with 950 hours of training as opposed to those with 450 hours. Interestingly, Bramah (5) believes the reason why chartered physiotherapists fail to understand ‘massage’ is because they only receive approx 6 hours of massage training throughout their entire university degree.

What the research literature says

Massage is not without its critics and the lack of robust research on the benefits or otherwise leaves the discipline open to criticism. Research evidence is scarce (6) and when it does exist produces equivocal findings (7). In many studies, authors cite the lack of positive findings is down to flawed methodology and poor design (6, 7, 8), in some studies, lack of therapist experience (9). Furthermore, within the literature, treatment styles and descriptions use conflicting or inconsistent terminology (10), which creates more confusion, further adding to the research dilemma.
 

In support of the continued use of massage

Although often frowned upon by some professions for its poor evidence-base, the lack of robust evidence is not just confined to massage. Watson (11) reports if one looks critically at the full range of physiotherapy treatments, there is simply insufficient evidence to support or reject many of them in all known circumstances. Furthermore, the absence of evidence does not always mean that there is evidence of absence (11). Although we should strive for evidence-based practice, the lack of sound evidence doesn’t mean a treatment doesn’t work in practice (12), or, shouldn’t be used. However, when sound evidence is lacking, treatment should be guided by experience and clinical reasoning (13). Crucially, treatment outcomes can be enhanced by taking opportunity to compliment massage using other suitable interventions, thereby adopting a multi-factorial and/or multi-disciplinary approach (4, 12, 14). Modern therapy encourages a wider approach.
 

Conclusion

Although relatively few robust randomised controlled studies exist and much of the research is flawed, a strong belief remains that massage has significant therapeutic benefits. If massage failed to produce benefits, it is unlikely that experienced therapists would have continued its use throughout the decades.

References:

1. Westland G. (1993). Massage as a therapeutic tool. British Journal of Occupational Therapy, 56(4), 129-134.
2. Brukner P, Khan K. (2001). Clinical sports medicine. 2nd edition. Sydney: The McGraw-Hill Companies.
3. Anderson MK, Hall SJ, Martin M. (2004). Foundations of athletic training. Prevention, assessment, and management. 3rd edition. USA: Lippincott Williams & Wilkins.
4. Cash M. (2003). Sports massage - hands on help. sportEX Health 18, 28-29.
5. Bramah B. (2006). Massage training and the physiotherapy BSc degree. sportEX dynamics, 9, 9-10.
6. Galloway S, Hunter A. (2005). Mind or Body? Research into sports massage. sportEX dynamics 4, 12-14.
7. Robertson A, Watt JM, Galloway SD. (2004). Effects of massage on recovery from high intensity cycling exercise. British Journal of Sports Medicine, 38,173-176.
8. Heymanson N, Hiskins B. (2006). Delayed onset muscle soreness and soft tissue therapy - what makes good research? sportEX dynamics, 10, 8-11.
9. Hilbert J, Sforzo G, Swensen T. (2003). The effects of massage on delayed onset muscle soreness. British Journal of Sports Medicine. 37, 72-75.
10. Dixon MW, Sherman KJ, Thompson D, Cherkin DC. (2007). Massage terminology - it’s all in the name. sportEX dynamics 11, 14-21.
11. Watson T. (2000). The role of electrotherapy in contemporary physiotherapy practice. Manual Therapy, 5, 132-141.
12. Patel K, Patel S. (2007). Low back pain - a multidisciplinary symposium and debate. sportEX dynamics 13, 19-22.
13. Naylor CD. (1995). Grey zones of clinical practice: some limits to evidence-based medicine. Lancet, 345, 840-842.
14. Bury T, Mead J. (1998). Evidence-based healthcare: a practical guide for therapists. Oxford: Butterworth Heinemann.
15. Holey E, Cook E. (2003). Evidence-Based Therapeutic Massage. Edinburgh: Churchill Livingstone.
16. Glasgow P. (2007). Sports rehabilitation: principles and practice. sportEX medicine. 32, 10-16.
17. Kannus P, Parkkari TL, Jarvinen T., et al. (2003). Basic science and clinical studies coincide: active treatment approach is needed after a sports injury. Scandinavian Journal of Medicine and Science in Sports. 13, 150-154.
18. Clark N. (2004). Principles of injury rehabilitation. sportEX medicine. 19, 6-10.
19. Hunter G. (1998). Specific soft tissue mobilisation in the management of soft tissue dysfunction. Manual Therapy. 3(1), 2-11.
20. Moraska A. (2007). Therapist education impacts the massage effect on postrace muscle recovery. Medicine & Science in Sports & Exercise, 39 (1), 34-37.