Issue link: https://www.massageandbodyworkdigital.com/i/1451559
74 m a s s a g e & b o d y wo r k m a rc h /a p r i l 2 0 2 2 It is around these points that debates continue to rage regarding whether it is unethical and downright dishonest to continue to offer therapies that are known to be inefficacious (even if they appear effective and do no immediate harm), since there is a danger of misleading a patient or indeed, delaying referral for more urgent cases. In the case of missing evidence (where we do not yet know the degree of efficacy, but clinical experience suggests effectiveness and the safety profile is good), things are even more complicated. According to Sackett, this is where conscientiousness and good judgment need to come into play, tempered and balanced with clinical experience. This is where many practitioners will cite "evidence-informed practice" as a more honest and accurate description of what they do—but definitions sometimes vary quite wildly. EVIDENCE-INFORMED PRACTICE The evidence-informed approach 5 is described as being "fundamental to practice" aiming "to address the large gap between what is known and what is consistently done." More specifically, "Evidence-informed decision- making models advocate for research evidence to be considered in conjunction with clinical expertise, patient preferences and values, and available resources." (emphasis mine) This perspective addresses real-world scenarios and "interactions between evidence and action . . . and complex relationships between health-care interventions and outcomes." 6 These statements come not from some niche profession struggling to achieve validation, but from a well-cited article addressing the down-to-earth questions of how far uptake of evidence can be improved, and what this means in real-world health care in relation to both policy-making and patient outcomes. The aim is to promote specifically evidence-informed health care, and since its publication almost a decade ago, it has been repeatedly cited in studies focused on realistic approaches to improving health-care standards across specialties. When looking more closely at this literature, it quickly becomes clear that the evidence pyramid is not as solid as we often think. It has been considered outdated for nearly a decade yet remains received wisdom among many health-care professionals. Unfortunately, the reason for this shift is the sheer poor quality of supposedly "high- level" evidence in the form of systematic reviews. This is partly due to poor reporting and study design of the reviews themselves, and partly due to poor input material in the form of badly designed or performed primary research. 7 Unfortunately, the example illustrated in this source reflects poorly on manual therapy research design since it includes several poor-quality reviews of manual techniques to address idiopathic adolescent scoliosis. Do we conclude then, that those techniques do not work? That the researchers did a poor job? Or that the techniques are not worth investigating further? Presumably, more and better research is needed, as is the ability to critically appraise the literature. What is clearly not needed, however, is for such a report to generate ideological sparring when there is work to be done. 8 We cannot, on the basis of such a review, conclude anything about these techniques apart from the fact that improvements are needed in research design and literacy. A CDC report commissioned in 2007 spells out the significance of evidence-informed practice even more clearly. The failings of systematic reviews and meta-analyses—the foundations of policy-making—are well acknowledged by major stakeholders, and calls for significant improvements to their usefulness have been made at the highest levels for well over a decade. Yet, the same report concludes that misinformation regarding the relative value of such reviews continues to circulate in the media and among researchers in diverse fields as a result of their poor understanding of the speed of advances being made and a general lack of research literacy. Nevertheless, it concludes, "Advocating an unquestioning or inappropriate overreliance on systematic reviews might discourage innovation or promising practices." 9 After establishing that "evidence-informed" practice and policy is the desired ideal, it proposes to promote and improve this through "identifying, mentoring, and supporting the champions of evidence- informed policy." Interestingly, the points listed for improvement (higher-quality basic research and better communication between sectors) are the same ones concerning integrative and allied health professions. These findings come from the main health authority in the US, acknowledging that the quest for knowledge and evidence and the need to reap their benefits must also reflect the "real-world interaction between evidence and action." This is not controversial in biomedicine nor in public health; it is a pragmatic evaluation of the limitations of our scientific tools, and an equally realistic acknowledgment that clinical experience is of equal value. Yet, in the struggle to validate and professionalize manual therapy approaches and practices, it is often forgotten that many critical biomedical procedures rely a great deal more on experience and lower quality evidence than is often realized. A telling example comes from the world of surgery. Though surgical techniques can be, and often are, tested on animals and 3D models before