Issue link: https://www.massageandbodyworkdigital.com/i/1208028
48 m a s s a g e & b o d y w o r k m a r c h / a p r i l 2 0 2 0 been noted repeatedly that its purpose is to assist and support clinical decision making—not replace it. The general consensus within evidence-based decision making suggests a model whereby clinical reasoning, patient preferences, and available research evidence suitably appraised should all be included in responsible practice, with critical appraisal and responsible judgment being applied to weigh them on a case-by-case basis. 3 Secondly, it has been established that when exploring the manual therapies, the application of methodology designed for biomedical investigations is problematic in itself and needs to be considered with care. 4 It is crucial to avoid extremes. The preceding bullet- point statements are not entirely true, but neither are their opposites, and blind insistence on either side will certainly lead to error. It has been argued that "Randomized trials have developed such high scientific stature and acceptance that they are accorded an almost religious sanctification . . . If relied on exclusively they may be dangerous." 5 This should not be interpreted to mean they should be ignored: the word exclusively is key here. It should go without saying that "rigorous research is key to the professionalization of any health field;" 6 but it should be further understood as emphasizing the need to understand and judge the quality of research (a skill known as research literacy), so that this can be responsibly combined with informed clinical judgment. Before challenging the assumptions of others, we must begin with our own, and it is all too easy to fall into a binary logical fallacy driven more by ideology than rational thought. A more subtle, pragmatic approach is vital. Research trials are both useful and necessary, and this discussion should in no way be interpreted as lessening their value. However, they incorporate a lot of moving parts, and the potential for errors of judgment or interpretation is always present. When focusing specifically on the research within the field of massage and bodywork therapies, there are additional specialized issues to consider. FOUR KEY DOMAINS OF RESEARCH FOR MTs In light of this, we need to ask ourselves the following: How do we recognize and appraise the difference between a robust study that should lead us to reconsider how we practice and one that should be taken with great caution? How do we balance clinical experience and training with the evidence? Which thought leaders should we trust? How do we appraise the evidence available to us? How do we convincingly participate in a professional discussion of controversial topics where evidence is inconclusive misguided. Take, for example, the aforementioned assumptions, where I either stated or implied that: • Readers know and agree that all therapies must be evidence-based. • RCTs provide the highest grade of evidence. • The classic RCT performed in a lab is appropriate for the investigation of all types of therapy. • We must trust researchers to ask the right questions, design studies appropriately, and provide us with the evidence for or against therapies currently in use. • All published RCTs can be trusted. • If there is no evidence that something works, then it is the same as saying it doesn't work. If these points truly applied, then we would probably have a very different health-care landscape worldwide. As it stands, some of these assumptions are naïve, and some are borderline dangerous. PROCEED WITH CAUTION Overreliance on the RCT has come in for criticism from a variety of quarters across medical disciplines and health-care stakeholders, and its limitations are being more openly debated. Despite this, public health policy, research funding, and public opinion continue to be more strongly influenced by what are perceived as the results of "hard science." This does not invalidate the RCT as an important tool in research, but it does mean we need to proceed with caution, as it has This does not invalidate the RCT as an important tool in research, but it does mean we need to proceed with caution, as it has been noted repeatedly that its purpose is to assist and support clinical decision making—not replace it.