Spring 2016 • Therapy Today

Spring 2016 • www.rmtao.com Ca
Massage Therapists: Bridging the Knowledge Gap 10
How Massage Therapists Can Share Stories 16
CaseRe3: A Digital Open-Access Repository for Case Reports 21
New Home for the Massage Therapy
Research Fund 25
2 Massage Therapy Today Summer 2015
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3Summer 2012 Massage Therapy Today
Message from the Editor Massage Therapy Today Putting Knowledge into Practice
Spring 2016 • Volume 10, No. 2
Published by BCS Group for the Registered Massage Therapists’ Association of Ontario Andrew Lewarne, Executive Director and CEO Laura Fixman, Communication and Member Services Coordinator
Submissions All editorial contributions are to be submitted to the RMTAO for review. All original articles become the property of and copyrighted to the RMTAO. Submission guidelines are available on the RMTAO website. For all inquiries, please contact the RMTAO.
The RMTAO does not guarantee, warrant or endorse any product advertised in this publication. The views expressed in this publication do not necessarily represent the views of the RMTAO, its Board of Directors or Advertisers. Please address all comments to the RMTAO Office.
Registered Massage Therapists’ Association of Ontario 2943B Bloor Street West Etobicoke, ON, M8X 1B3 Tel: 416.979.2010 Toll Free: 1.800.668.2022 Fax: 416.979.1144 www.rmtao.com Email: [email protected] ©2016 Registered Massage Therapists’ Association of Ontario
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MIX Paper from
Using Research in Your Practice
One of the mandates of the RMTAO is to encourage massage therapists to
analyze and apply the available research, and to undertake and participate
in research whenever possible. This culture of inquiry allows RMTs to build and
maintain an evidence-based practice, and offer their patients high-quality care
based on the latest research.
While it is easy to agree that research is valuable and important, it can be
harder to understand what constitutes valid research and how to incorporate the
findings into clinical practice. With this in mind, Jennifer Bloch takes us through
the important of research literacy and she provides suggestions for talking to your
patients about research, and the role that both research and anecdotes can play in
your practice. The first step is often the hardest; many RMTs are unsure of where
to look for research that interests them and is of value. Richard Lebert goes over
both where to find valid research, and how to thoroughly evaluate useful-looking
papers.
Once you are comfortable with accessing and evaluating research, you might
want to get more involved in conducting research yourself. One great way that
RMTs can participate in research is through case studies or case reports, which
provide a forum for communicating what practitioners see in their daily practice
to other health care professionals and researchers. In her article, Amanda Baskwill
discusses the general outline of a case study and the steps that should be followed
to create one. While randomized controlled trials offer evidence of efficacy on a
population level, Baskwill points out that case studies do the same on an individual
level. Dr. Martha Menard’s introduces us to CaseRe3, which provides a platform for
case studies making them easily searchable and accessible by massage therapists,
and thus enables productive use of this grey literature.
For larger studies, there is funding and support available from the Massage
Therapy Research Fund—the only funding source in Canada that is specifically
dedicated to the field of massage therapy. Read on and discover just how research
can make a difference to your practice.
Laura Fixman, Communication and Member Services Coordinator, RMTAO
4 Massage Therapy Today Spring 2016
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5Spring 2016 Massage Therapy Today
Jennifer Bloch, RMT, is dedicated to strengthening
the credibility of the massage therapy
profession. She hit the ground running when
shortly after graduating from CCMH she was
recognized by the Canadian Council of Massage Therapy
Schools for her case study on Trigger Point Release for post-surgical breast
cancer patients. She was also invited to speak at the Massage Therapy Canada
Business Forum on the value of research literacy
within the profession.
It is no secret that research is becoming more prevalent in the field of massage therapy.
But whose responsibility is that really? Many massage therapists push research literacy to the bottom of their list of selected continuing education units because of its perceived complexity or a preference for pursuing courses that enhance practical techniques or skills to drive in more business, such as marketing. In some cases, research literacy is at the bottom of the priority list because of the belief that it is something that should be provided by someone else rather than sought out by massage therapists individually.
Before you dismiss the value of research literacy, have a look at the following information, which explains how this skill can benefit you, your practice, your clients and, collectively, our profession. At the very least, research literacy is an important part of upholding our commitment to ethics and professionalism.
Level of research literacy Great strides have been made in the last few years with respect to evidence-based practice in massage therapy and, more recently, research literacy has become a mandatory part of curricula for massage therapists across the country. The question is, how can we expect massage therapists to review and assess research studies with the same competency as doctorate-level academics? Here is the answer: We don’t.
No one expects massage therapists to wear laboratory coats and evaluate the statistical significance of the results of their practice. The expectation for the research literacy of massage therapists is simply to know where to find high-quality research, how to read it, who to engage and what questions to ask to determine a study’s credibility. Another important expectation of massage therapists is to responsibly educate their clients about the results of research.
In Susan Salvo’s book Massage Therapy: Principles and Practice, Dr. JoEllen Sefton and Salvo define research literacy as the “ability to locate, read, understand, and evaluate research literature.” They continue: “For massage therapists, this means being able to incorporate the information found from reliable studies into your massage practice and to communicate research findings to others. It gives you the skills necessary to become good consumers, trustworthy sources of massage information, and independent lifelong learners.”
Let us look now at how these skills benefit your daily practice.
Enhanced professional development When you have a clear understanding of how a technique works, you naturally become better at it. By learning how to find, interpret and critique research articles, you are enhancing your knowledge on that particular topic, which in turn indirectly impacts your skills in a positive way.
The Importance of Research Literacy
By Jennifer Bloch, RMT
Because research in massage therapy is still in its infancy, massage therapists have the opportunity to become trailblazers in the field.
Business growth By becoming research literate, you will be able to speak the language of other health care practitioners. Being able to explain research findings related to massage therapy to physicians, for example, in a way that they understand can increase your credibility and the likelihood that they will send you referrals.
Our profession is always justifying the role of massage therapy in health care to insurance companies, which are often hesitant to cover this treatment. What would happen to your practice if your clients were not be reimbursed for their sessions? Research-literate massage therapists can help change the way our profession is viewed by insurance companies, thereby creating less resistance to coverage for your clients.
Turning clients into better consumers Being able to understand and explain how a particular modality works can open the door to many new markets. Clients coming for a massage simply for relaxation might decide to increase the frequency of their visits to help treat symptoms they previously believed were off-limits to massage.
Clients are increasingly developing into better consumers as they become more familiar with the “evidence-based practice” movement. People may be more willing to tell their friends and family about their massage therapist if they think that person is familiar with the latest information about massage therapy.
By educating clients on the difference between what seems to work based on experience versus what has been shown to
work based on scientific evidence, massage therapists are empowering clients to become better consumers of health care. Massage therapy clients will appreciate this, and may even respect their practitioners’ opinions that much more because of it.
Professional priorities I have spent several months reviewing articles and obtain- ing the opinions of colleagues (including students), clients (including potential clients) and other health care professionals (including physicians) on research in the massage therapy profession. It is becoming increasingly clear that we need to do more to improve our credibility within the health care industry.
The results of my informal investigations reveal a divide among massage therapists. On
one side are therapists who believe the proof of effective practice lies in the results they have witnessed in their own experiences. On the other side are those who exclusively support evidence-based practice and believe there is no more room for anecdotal data. These two extremes make it difficult to unite as a profession in our goal to adhere to our commitment to responsible health care practices.
Author Susan Salvo has said, “Some [massage therapists] do not understand the role of research. It should inform our practice— enrich what we already do. Good research improves our understanding and helps us be more effective. On the flip side, we should use our knowledge and skills to best serve client goals without inserting our own agendas. For example, when clients request deep pressure massage to address pain in the neck and shoulders, it would be ‘professional suicide’ to use only lighter pressure because you read a study that indicated lighter pressure is more effective to reduce pain. When you put your own agendas ahead of your client’s goals, they may leave feeling like you were not listening to them and may not reschedule.”
“Clients are increasingly
with the “evidence-
based practice” movement.”
Anecdotal information is, by its very nature, unreliable. However, that is not to say it is not extremely important. After all, it can form the basis for a research question (hypothesis) that can change the face of how we practice. Without anecdotal information, we would not have research.
There is room for both schools of thought— the therapists who are dedicated to their personal experiences, and those who are dedicated to research. The trick is in conveying this information to our clients and using it to our advantage.
Enhancing our credibility and value My discussions with clients and other health care practitioners revealed a problem with the perception of massage therapists’ capabilities. Most clients are unaware of the extent of our knowledge and skills. Sure, we can expect our professional association to advertise our skills for us or wait until someone provides us with more funding. At the end of the day, however, it is the individual, day-to-day interactions of massage therapists with others that will make or break our credibility.
How can we convince people of our value if we are not able to support it with reliable information? Coming up with our own theories of how a treatment works may be satisfactory to some people, but is that really a responsible way to provide information? Try that same rationale with physicians who refer patients; you will not be taken seriously, and that alone will affect our entire profession.
Professional ethics in research The problem with relying solely on anecdotal information is that many factors can disprove a direct cause–effect relationship of a particular modality or technique. For example, you might have experience treating a hundred clients with trigger points using ischemic compressions, and, in every case, the pain decreased. It is easy to believe the ischemic compressions caused the decreased pain, given that all of the clients responded in the same way. There is, however, no way to be certain that clients’ breathing habits, the warm-up of effleurage
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“It is our moral duty to
ensure that the things we profess have validity.”
or the flushing of petrissage were not the real reasons behind the decreased of pain. There are other possibilities too: the lotion used, the positioning of the client, the mood and lighting in the room, the music used. Any one of these factors leaves room for the possibility that ischemic compression alone was not the main contributor to pain reduction. Even so, many of us feel confident enough to tell our clients: “Ischemic compressions will reduce your pain.”
Communicating research Bodhi Haraldsson, Research Director at the Massage Therapists’ Association of British Columbia (MTABC), has said, “As a profession, we have the duty to conduct the research that tests the many hypotheses we have developed over more than a century of our existence. We cannot just say, ‘we’ve been doing this, let’s keep doing it.’ We can’t just say, ‘I see it work in my office every day.’ The lack of control makes it impossible to determine if the
positive outcome we all see with our patients is actually due to what we do, rather than the other non-specific effects of placebo, context and faith in us. This is a moral duty of our profession to ensure that those things we profess (to profess expertise is where the word ‘profession’ comes from) have validity.”
Our peers, clients and other health care professionals expect massage therapists to have a basic understanding of what to look for in determining the credibility of evidence- based therapy. Although many clinical trials are performed, their mere existence does not mean they have been conducted properly—and yet more and more massage therapists are using these studies to support claims that a particular technique will yield a specific result. Factual statements should not be made on the basis of studies that are invalid or unreliable. Massage therapists, at the very least, need to have a basic understanding of how to seek out research, stay current with the latest information, identify red flags and know what questions to ask to critically evaluate an article or any information suggesting a cause–effect relationship.
Let us reflect on the Code of Ethics put forth by the College of Massage Therapists of Ontario (CMTO), and how being research literate is a basic requirement for adhering to our ethical principles.
• The respect for persons principle includes “ensuring that clients are as fully involved as possible in the planning and imple- mentation of their own health care” (all quotes are from the CMTO). If we tell our clients that a modality or technique will decrease their pain when we are basing this statement on anecdotal data, and not factoring in other potential contributors, our clients will plan their health care based on misleading information.
• The responsible caring principle includes “promoting the client’s best interest and well-being, through the highest possible standard of professional practice.” Do we define “the highest possible standard” as providing clients with information that leaves room for error?
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“ Massage therapists need to have a basic understanding of how to seek out research, stay current with the latest information, identify red flags and know what questions to ask.”
• The definition of integrity in relationships is “to practice with integrity, honesty and diligence in our professional relationships, with ourselves, our clients, our professional colleagues and society.” We are not acting with integrity when, for example, we know that there might be other factors contributing to someone’s pain reduction, yet we say it is definitely due to the ischemic compression.
• Finally, responsibility to society not only dictates our “commitment to continuous improvement,” but also expects us to participate in “the promotion of the profession of massage therapy through advocacy, research and maintenance of the highest possible standards of practice.” Unless we are using scientific evidence to support our claims of cause–effect relationships then we are not fulfilling our responsibility to society using the highest possible standards of practice.
Responsible communication When communicating with our clients, there are ways to educate them about the difference between anecdotal information and evidence-based practice. Once you are familiar with what is out there in terms of trustworthy research, you can say, for example, “In my experience, whenever I perform ischemic compressions, my clients seem to experience a reduction in pain, but there is no evidence
that I am aware of to support that ischemic compressions are directly responsible for the reduced pain. If you are willing to try it, we can get started.” Or, “Some small studies have shown that ischemic compressions can reduce pain, but more research still needs to be conducted. We can try this technique and see if it works for you.”
These types of statements allow therapists to continue practicing a modality or technique that they believe works, while providing responsible, informed information to the client, who now fully understands that ischemic compressions might not actually reduce their pain before they provide consent to treatment. Research in massage therapy is still in its infancy. We cannot stop our careers while advances in science are still being hypothe- sized. We can, however, change our thinking about the effects of our work by becoming curious and skeptical—continuing to ask ourselves why the result is the way it is, and encouraging those practitioners who are interested in pursuing a career in research to answer these questions for us.
In the meantime, we can continue to practice modalities and techniques that are safe and seemingly effective, provided we educate our clients responsibly about the differences between anecdotal information and evidence- based practice so that they can make informed decisions about their own health care treatment plans.
Online resources Here are some online resources to help you learn more about research literacy and access
articles related to massage therapy.
Basics of Research Literacy
Coursera: University of California, San Francisco
(www.coursera.org/course/researchforhealth)
Time Commitment: Six weeks (two to four hours per week)
Richard Lebert, RMT, works at The Fowler
Kennedy Sports Medicine Clinic, a sports injuries clinic in London, Ontario. Richard is passionate about helping
therapists reach their full potential, which led to
the creation of The RMT Education Project, an online evidence-based resource for
massage therapists. Twitter @AdaptiveTherapy;
www.RMTedu.com.
The Oxford Handbook of Public Health Practice states that it takes 17 years for new
research to be implemented in clinical practice. This gap between scientific research and clinical practice can only be bridged by raising practitioners’ awareness and understanding of research. Social media sites provide massage therapists with a digital meeting ground where they can bridge the knowledge gap between scientific research and clinical practice by exchanging ideas with their peers at the local, regional and global levels.
Evidence-informed massage In the past 10 years, Registered Massage Therapy has exploded into mainstream health care; it is now a recognized treatment option for a wide range of injuries. This means the profession is moving into more formal clinical settings, and these changes to the profession have led to the need to adapt to an evidence-informed model of care—“evidence-informed massage.” In this model of health care, massage therapists are aware of emerging evidence, and integrate this new information into their clinical practice in a timely manner.
It is important to understand the concept of evidence-informed massage therapy in order to apply it to clinical practice. Evidence-
informed massage is the synthesis of: • therapist expertise • patient values • best available evidence With the emergence of evidence-informed
massage, it is important that therapists have the tools and resources to bridge the knowledge gap between scientific research and clinical practice. A 2015 survey of Ontario RMTs published in the Journal of Complementary and Integrative Medicine concluded that there is room for improvement when it comes to research awareness in the profession1. Fortunately, there are many ways in which massage therapists can work together to improve their research literacy skills.
Working together Social media—more specifically, Facebook—is one of the more effective tools available to improve research literacy skills, because it provides a platform from which massage therapists from all over the world can work together to critically evaluate the latest academic research papers, teasing out the clinically relevant points. This critical evaluation is vitally important, because Facebook is flooded with blog posts and other articles, with little research backing.
Massage Therapists: Bridging the Knowledge Gap
By Richard Lebert, RMT
So, what types of material are available, and how do they stack up?
Research material Sources of research With the “CAARP” test (see sidebar) in mind, if you are looking for an authoritative opinion on a given topic, systematic reviews are considered the gold standard. The Cochrane Handbook for Systematic Reviews of Interventions suggests that, “A systematic review attempts to identify, appraise and synthesize all the empirical evidence that meets pre-specified eligibility criteria to answer a given research question. Researchers conducting systematic reviews use explicit methods aimed at minimizing bias, in order to produce more reliable findings that can be used to inform decision making.” The Cochrane Library (www.cochranelibrary.com) is the best known source of systematic reviews. To date, however, there have been only a few large- scale randomized control trials of massage therapy, which means that systematic reviews of massage therapy can be hard to come by.
Another way to inform your clinical practice is through peer-reviewed publications geared towards massage therapy. The two leading publications for massage therapists are the International Journal of Therapeutic Massage & Bodywork and the Journal of Bodywork and Movement Therapies.
Research databases If you would like to read articles on a broader
range of topics then you can use a research database. PubMed (www.ncbi.nlm.nih.gov/ pubmed) is the largest medical database, and has many functions that will help you narrow down your search. One limitation with PubMed is that unless you are affiliated with an educational institution, many of the articles it lists will be behind a paywall, which can limit access to the entire article. However, you will still be able to read the abstract, which will give a brief summary of the key points of the article.
Open-access research The last 10 years have seen rapid growth in the open-access publishing model, in which the full text of research articles is freely provided. The RMT Education Project (www.rmtedu.com) is an online resource where massage therapists can access a curated list of open-access articles. This website can serve as a starting point in the development of a body of knowledge that massage therapists can use to guide their evidence-informed practice.
Grey literature Another way to access timely information is through the grey literature, which includes information or research produced by organizations that are outside of commercial or academic publishing and distribution channels. It can include magazines, articles, videos, e-mails, newsletters, blogs and even tweets. There is an abundance of grey literature available on the internet. However, this information requires a critical eye to evaluate the content—think CAARP.
“ A 2015 survey of Ontario RMTs concluded that there is room for improvement when it comes to research awareness in the profession.”
SIDEBAR
CAARP considerations The CAARP test is one tool that can be used to evaluate materials.
n Currency: Is the information current for your topic?
n Authority: Who are the authors and what are their qualifications?
n Accuracy: Where does the information come from and is it supported by evidence?
n Relevance: Does the information relate to your topic or answer your question?
n Purpose: What is the purpose of the information? Are the authors’ intentions clear?
Why research matters Evidence-informed massage continues to be more common in environments such as hospitals, sports medicine clinics and long- term care facilities. These settings require massage therapists to work directly with physicians and allied health professions, which requires a sound understanding of the latest research findings. Evidence-informed massage is important because the last five years have seen major changes in the scientific knowledge about pain science, myofascial trigger points and myofascial release. This new knowledge might not revolutionize the way you practice, but it will change the way you communicate with other health care professionals. Massage therapists who are able to understand and incorporate research into their clinical practice will be well positioned to transition into these multidisciplinary clinical settings.
Regardless of the setting in which you work, it is important that RMTs, as regulated health professionals, develop and maintain
evidence-informed practices, and keep up to date with the latest research and information. With this in mind, the following sections look at the latest research evidence in three areas, and how it is changing clinical practice.
Pain science Scientific research has changed the way in which we view injuries, and we now know that pain has the potential to transform the way the nervous system functions. The brain is a neuroplastic structure that is capable of changing over time. Long after the tissue has healed, patients can feel pain due to changes in the nervous system. This has important implications for assessment and treatments, essentially as the experience of pain does not always correlate to the severity of the injury.
Myofascial release Before reviewing the literature on myofascial release, I used a heavy-handed approach in my practice to invoke a mechanical “tissue release.” Then I came across a research paper by Robert Schleip entitled “Fascial plasticity—a new neurobiological explanation.” In short, this paper suggests that massage therapy stim- ulates fascial mechanoreceptors, which can, in turn, trigger tonus changes in connected skel- etal muscle fibres. These muscle tonus changes might then be felt by the therapist. This paper was an easy to understand review of Schleip’s research, complete with helpful illustrations. It helped me to move from a mechanical mindset to one that is inclusive of the nervous system.
For me, Robert Schleip was a starting point. His paper cited other useful articles that were relevant to myofascial release, and this “citation chaining” lead me to work by other authors, including Carla Stecco, Antonio Stecco and Leon Chaitow.
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Health Discipline Unit Cameron C.R. Godden
Lisa E. Hamilton
Professional advice on defence of complaints and malpractice claims including representation before the Ontario College of Massage Therapists
and the Health Professions Appeal & Review Board.
393 University Avenue, Suite 1300393 University Avenue, Suite 1300 Toronto, Ontario M5G 1E6
Telephone: (416) 581-8200 Fax: (416) 596-0952 Toll Free: 1-888-263-8600 email: [email protected] website: www.belltemple.com
Myofascial trigger points There has been a monumental shift in knowledge about the pathological entity that we call myofascial trigger points. Late in 2014, a critical analysis of trigger points was published in the journal Rheumatology that served to decon- struct the known etiology of myofascial trigger points.2 The authors suggested that researchers move their search for myofascial trigger points from muscles to nerves, or other structures.
This was followed in the summer of 2015 by another paper on the topic of myofascial trigger points: “Myofascial trigger points then and now: a historical and scientific perspective.”3 This narrative review provided perspective on the topic of myofascial trigger points. It might surprise you to know that, with more than 30 years of research, there is still no consensus as to what these sore spots are. Theories include nerve inflammation, fascial densification and central sensitization.
Moving the profession forward Evidence-informed massage therapy provides
the profession with an opportunity for unprecedented growth, and one of the most effective ways to facilitate this growth is by connecting with like-minded peers on social media. These sites offer a forum where massage therapists can work together to critically evaluate the contents of research papers and tease out the clinically relevant points, and provide some of the best tools available to bridge the knowledge gap between scientific research and clinical practice. Whether you are new to the profession or have decades of experience, there is someone out there who will benefit from your knowledge—so join the conversation and help move the profession forward.
References available upon request.
Curties-Overzet Publications is pleased to announce our new distribution relationship with Handspring Publishing, a U.K. company that specializes in books about fascia, movement and manual therapies.
Images Types of scientific evidence. Reproduced with permission from Compound Interest (www.compoundchem.com).
14 Massage Therapy Today Summer 2015
15Summer 2015 Massage Therapy Today
When I am asked how massage therapists can become involved in research, the
first thing that comes to mind is to share the outcomes of clinical case studies, whether positive or negative. A clinical case study is a form of research in which one patient or subject is described in detail.4 Massage therapists are well positioned to complete this type of research because they already follow a clinical decision-making structure and interact with interesting clients and patients (“cases”).
A case study, sometimes called an n=1 or case report, is one way in which massage therapists can communicate what they see in their daily practice to other health care professionals and researchers. When a massage therapist tells the story of a patient and the care being provided, others might think the account is “just another anecdote.” But by adding the structure required for a case study, massage therapists elevate their anecdotes to contributions to research.
Parts of a case study As mentioned previously, a case study uses information from one individual, organization or system.7 Clinical case studies are usually written about a single patient with whom a massage therapist or health care team is working. If a number of case studies are written on the same topic, they can sometimes be combined to create a case series.7
Other professions use case studies to high- light negative outcomes or harmful incidences
(also known as adverse events8).Case studies in massage therapy should describe interesting findings or treatment outcomes, whether they are successful or not.
A case study usually comprises an introduction, details of the case, results of the treatment plan, discussion of the findings and a conclusion.9 This article explores each of these areas in a little more detail.
Introduction The introduction allows the massage therapist to present the topic that will be discussed to the reader in a general way. In this section, authors provide an overview of what is already known about the subject of their case study. They also connect the presenting condition to the outcome of interest.
You can read an example of this in a case study published on the topic of bilateral cleft lip reconstruction scars.6 In the introduction, the author describes the condition of bilateral cleft lip, and moves on to the reconstructive surgery that was done and the resulting scar. She then links the scar to the related impairments that are part of this presentation. This sets up the reader to understand the case that follows.
Details of the case The details of case usually consist of a description of: the client/patient, commonly referred to as the participant, assessment or outcome measures, the practitioner(s) who delivered the
Not Just Another Anecdote: How Massage Therapists Can Share Stories
Amanda Baskwill, MSc, RMT, is an educator,
researcher, practitioner and advocate for
massage therapy. Her research interests include:
investigation into the efficacy of massage therapy for various
conditions including post-traumatic stress
disorder, diabetes, and sleep disorders; the use of technology in education;
innovative educational strategies; and, evidence-
informed practice.
Focus on Research
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A Diploma in Osteopathic Manipulative Practice will be presented to qualied graduates.
• Graduates will become members of the Ontario Federation of Osteopathic Professionals allowing insurance billing and reimbursement for clients.
Major educational modules for manual osteopathic training in rst year (2016 and beginning of 2017) •
•
•
•
Individual modules recognized by the College of Massage Therapists of Ontario, Quality Assurance Programme as recordable Continuing Education Units (CEU’s). For a full list of the courses or additional information please visit:
www.clinicalosteopathy.com. For registration or any inquiries please
contact 905-916-SOCO (7626) or [email protected] and follow us on
Southern Ontario College of Osteopathy
•
•

At SOCO by emphasizing the appropriate clinical application of techniques we aim at developing exceptional clinicians above theorists. Students participate in 320 hours of clinical training including clinical sessions with public clients in preparation for a successful osteopathic practice.
“Case studies are a type of research that
massage therapists can perform
what they are seeing in their
practice to other stakeholders.”
treatment, and the treatment provided, often referred to as the intervention.9
Description of the participant The description of the participant is arguably one of the most important elements of a case study. In this section, information is provided about the participant’s current and previous health, relevant to the condition. It is also important to present information about the condition that is the focus of the case study, including the results of any assessments conducted when the participant first presented with the condition.
Keep in mind when you are writing that you should provide enough specific information about your patient so that other practitioners can understand the patient’s situation and details specific to the presenting condition, without revealing the participant’s identity. Patient confidentiality is one of the ethical considerations we will discuss later in this article.
Assessment measures In this section, the author should describe the key measures used to monitor the patient’s progress related to the outcome of interest. For example, if you were measuring pain, you might indicate that you used a visual analog scale for perceived pain.3 You would also indicate when you used the measure—for example, before and after each treatment, or at the beginning and end of the treatment plan. This is also where you describe your evaluation and re-evaluation plan.
If you are interested in measuring an outcome but you are not sure what tool to use, consult the IN-CAM Health Outcomes Database (www.incamresearch.ca). To use the database, search for a topic or choose a health domain. Once you find the outcome you are interested in, review the information. In particular, look at the extended details to see how to access your chosen tool (some require
payment), the mode of administration (some required advanced training) and whether you need permission from the creator to use it. Usually, this last step is as simple as sending an email or completing an online form. Once you have described your assessment measures, you are ready to move on to the therapeutic intervention section.
Therapeutic intervention This section starts with the practitioner’s details. An example of this can be found in a case study on narcolepsy.4 Some authors prefer to put such details in a distinct section. Practitioner details should include information about your practice, such as your scope of practice (as this will differ from province to
province, and country to country), education and credentials. Include anything that is relevant to the treatment provided or that might impact your clinical decision-making or your ability to evaluate the participant. You should also include a description of your clinical experience.
Next, describe the treatment provided. For massage therapists who already create treatment plans as a part of their clinical decision-making model1, this is the easy part. Important information from the treatment plan should be included is the proposed length of the treatment plan, the frequency and dura- tion of the treatment, planned outcomes of the treatment, techniques and modalities used to achieve the planned outcomes, and any hydrotherapy or remedial exercises prescribed.
Results This section is self-explanatory; it is where you put your results. What did you find when you compared your assessment measures? It is recommended that you set out your results in the same order as in the section on assessment measures.9 Do not discuss your findings—save this for the next section. Just present the results with no comment.
Discussion and conclusions In the final sections of your case study, discuss what you have learned from this case. What are the implications for future research, education and practice? Some of your comments might connect to other research articles you have read as you prepared for this case. This is your chance to make meaning out of the results you presented earlier. While all sections of case studies are interesting, many readers find that the discussion section has the most value.
Getting started on your case study Now that we have discussed structure of a case report, it is time to consider which clients/ patients might make a good case. Keep in mind the point of a case study—to describe an interesting case. Case studies do not answer questions about causality. In other words, the results of a case study will not tell us with certainty that massage therapy caused the reported changes. However, it does begin
interesting conversations about what might be happening and will often stimulate further investigation.
If you have an interesting case but you are not sure you are ready to take on the writing of a case study, as described above, consider finding a partner to help out. Your case study partner might be a colleague, another health care provider or massage therapist, or an academic—someone at a college or university who would be willing to help you write up what you have found. This person can provide a lot of support, and might make the difference between having an idea for a case study and achieving a published case report.
Ethical considerations Once you have chosen a client/patient who you think would make a good case, you need to consider the ethical considerations. I recom- mend using a written consent form that out- lines what you will do and what you need from the participant. For example, it is important to
“ While all sections of case studies are interesting, many readers find that the discussion section has the most value.”
“Case studies should describe
whether they are successful or not.”
let the individual know if the treatment is the same as that which they would usually receive, or if you are trying out something new within your scope of practice. Be sure to also obtain the participant’s permission to publish the case study. Finally, let the participant know that they can stop the case study and withdraw their consent at any time and for any reason.
Try it out! Case studies are a type of research that massage therapists can perform as a means of communicating what they are seeing in their practice to other stakeholders. Some case studies might become the inspiration for larger studies conducted by researchers in the field. To get started: 1. Think about the information you will need
to write up your case study. 2. Consider which client/patient case might be
interesting to share. 3. Ensure you have permission from the partic-
ipant to publish their case, while keeping their personal identity confidential.
4. Consider working with a partner as you hone your abilities. All that is left is for you to try it out!
Note from the author All of the examples of case studies used in this article are from the International Journal of Therapeutic Massage & Bodywork. This journal is open access and can be viewed by all massage therapists. High-quality case studies have also been published in other journals, but
reading them often requires payment or insti- tutional access. Reading case studies can help further your understanding of this research form and will hopefully inspire you to take action with a case study of your own.
References available upon request.
Martha Brown Menard, PhD, LMT, has been a
massage therapist for more than 30 years, working in
hospice, oncology, pain management and trauma
recovery. As Director of the Crocker Institute, she
develops and manages CaseRe3, an open-access
research repository of case reports in integrative
health care; offers program evaluation, research design
and data analysis; and teaches courses.
Case reports have become popular again. Long regarded as only a mere step
above the clinical anecdote in terms of the traditional evidence hierarchy, case reports are now becoming more highly valued as a type of clinically applicable research. While randomized controlled trials offer evidence of efficacy at the population level, case reports are different in that they offer evidence of effectiveness on an individual level. Case reports are relatively weak at demonstrating a link between cause and effect, but are instead a rich source of descriptive and observational data. Typically, they provide an important foundation of evidence that informs the development of more rigorous experimental studies, particularly in newly established fields where there is relatively little research.
A useful case report emphasizes the clinical applicability of the information presented, and places a single instance into a larger context. A case report documents the kind of critical thinking and clinical judgment in which health care practitioners engage every day. It authen- ticates the continuous and usually continual process of researching and evaluating a client’s condition, determining or revising a treatment plan, and then evaluating the effectiveness of the applied interventions. For these reasons, case reports provide a valuable tool for both teaching critical thinking skills and assessing
clinical decision making. Case reports are also a form of research that
is within the grasp of any interested practitioner. The most basic form of practice-based research, a case report is a detailed account of the history, presenting symptoms, assessment, observations, treatment and follow-up of an individual client or patient. Many people use the term “case study” synonymously with case report. Technically speaking, “case report” is used more often in health care research, while “case study” is used more often in the social sciences. The case report or study lends itself to a combined or mixed-methods approach to research design through the incorporation of both quantitative and qualitative data. A growing trend in medical case reports, perhaps due to the increasing emphasis on patient-centred outcomes in research, is the incorporation of patient commentaries.
Many integrative health care training programs, including those for massage therapy, require their senior students to complete a case report as a final or capstone project. In recent years, case report contests have become a popular way to incentiv- ize schools to produce student-authored case reports. Some organizations, such as the Massage Therapy Foundation, have expanded their case report contests to include practitioners as well. While a few of these
CaseRe3: A Digital Open-Access Repository for Case Reports
Focus on Research
help create the broad foundation
of descriptive and observational
development of well-designed experimental
studies in massage therapy.”
contest-winning case reports have been published in peer-reviewed academic journals or professional association publications, the vast majority languish in file cabinets and on shelves once the student graduates, and orphaned case reports become part of the unread and unavailable grey literature. Instead of gathering dust, case reports could be used to help create the broad foundation of descriptive and observational studies needed to inform the development of well-designed experimental studies in massage therapy.
About CaseRe3 To meet this need, and to make productive use of this grey literature, the Registered Massage Therapists’ Association of British Columbia (RMTBC) has partnered with the Crocker Institute to create CaseRe3, a repository for
case reports in integrative health care. CaseRe3 is a digital, open-access repository
that provides a permanent archive and publication venue for student and practitioner case reports across multiple disciplines. The project’s goal is to create a readily available foundation
of descriptive and observational research in integrative health care—a resource for educators, practitioners and researchers. CaseRe3 has the exciting potential to provide a shared research infrastructure, support practitioners and their clients/patients, inform more rigorous types of studies and
serve as an educational resource for years to come.
Bodhi Haraldsson, RMT, Director of Research at the RMTBC, and I serve as the project directors. The project’s advisory board includes several internationally known researchers,
NISA Neu
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us cu
lar In
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including: Jon Adams, MA, PhD, who is a professor of public health and Director of the Australian Research Centre in Complementary and Integrative Medicine (ARCCIM); Anita Salamonsen, PhD, from the National Research Center in Complementary and Alternative Medicine (NAFKAM) in Tromsø, Norway; Cheryl Hawk, DC, PhD, CHES, who is the Executive Director of the Northwest Center for Lifestyle and Functional Medicine at the University of Western States in Portland, Oregon; and Benjamin Kligler, MD, MPH, who is the Vice Chair and Research Director of the Mount Sinai Beth Israel Department of Integrative Medicine in New York City.
How it works The repository uses flexible and powerful software called DSpace, which functions like a library. DSpace was developed by the Massachusetts Institute of Technology and Hewlett-Packard, and is employed by leading universities and museums worldwide to house their digital collections. An individual case report stored in CaseRe3 as a pdf file is an “item,” and can have other types of files, such as data, video or audio files, associated with it. The repository is searchable by the author, title and subject, and also by discipline and technique, all with full-text indexing. In contrast to databases such as PubMed, full-text indexing eliminates the requirement for searching only by subject headings and keywords, making the case reports more easily searchable.
CaseRe3 can store and retrieve items including documents, associated data files, and video and audio files. Another useful feature is faceted browsing. When a particular case report is retrieved and viewed, faceted browsing automatically retrieves and groups similar items, just as when you shop on Amazon. So, users searching for case reports on a particular topic will also pull up a list of related case reports, eliminating the need for complex Boolean searches, although it is possible to perform these if a user wishes to do so. This will help practitioners looking to explore a
specific topic in depth to find all case reports related to that area.
Items in the repository are also grouped into “collections” and “communities.” Currently CaseRe3 has communities for peer-reviewed case reports that have been
previously published, and a learning resources community for educators, with information on how to develop case reports and model data collection, and client informed consent forms. Journals that have agreed to allow the reproduction of previously published articles include Explore:
The Journal of Science and Healing, the Journal of Bodywork and Movement Therapies, the Journal of Clinical Chiropractic Pediatrics and Topics in Integrative Health Care.
The multimedia capabilities of CaseRe3 offer exciting possibilities for educators, practitioners and researchers. With the ubiquity of smart phones and their recording capabilities, videos of treatment demonstrations or audio files of client or patient commentaries, stated in their own words, can be easily captured. Therefore, students and even experienced practitioners can be encouraged to create multimedia case reports that include raw data, video demonstrations and audio recordings. The possibilities for combining comparable data from case reports using the same outcome measures for the same conditions are also intriguing. Users can potentially create virtual case series by combining de-identified raw data files. Thus, the repository has the potential to be an ongoing and ever-increasing source of rich quantitative and qualitative data that can serve multiple purposes. These include: • Educators promoting evidence-informed
practice, integrating research that is imme- diately relevant to students and accessing learning resources for designing, conducting and writing case reports
• Practitioners having quick access to the clinical experience of others in their own discipline and comparing approaches across disciplines
• Researchers using real-world data to design study protocols and estimate sample sizes
“ CaseRe3 is a digital, open-access repository that provides a permanent archive and publication venue for student and practitioner case reports across multiple disciplines.”
“For less than the price of a daily cup of
coffee, schools can archive
their students’ work, contribute
to creating a research
practice.”
Open science, open access and project funding CaseRe3 is part of the growing open-science and open-access movement. Open science fosters the openness, integrity and reproduc- ibility of scientific research. CaseRe3 supports open science by encouraging submissions of associated data files with case reports that have been de-identified to protect patient confidentiality. Case reports that are submitted should also have documented informed consent from the patient or client.
In the traditional publication model, authors sign over their copyright to the publisher, who pays all production costs and then charges subscribers to access the journal or even to access a single article. With open access, anyone can access the full text of the complete article at no cost. The open-access model of publication works by charging individual authors a fee to cover the costs of publication; these fees can run to thousands of dollars, depending on the journal.
CaseRe3 keeps its costs low through the use of open-source software running on virtual servers. The project seeks only to cover its
operating costs, so that it remains financially sustainable as it grows. CaseRe3 allows any educational institution to cover the publication/ archival costs for all of its students, faculty and alumni for a low annual fee of $299. Authors who submit case reports retain copyright to
their work under a Creative Commons licence, and still have the option to publish in other venues, including subscription-based, peer-reviewed journals. For less than the price of a daily cup of coffee, schools can archive their students’ work, contribute to creating a research
infrastructure and promote evidence-informed practice. This might also encourage students to continue to produce case reports and other research even after they graduate and start clinical practice. One of the project’s goals for 2016 is to recruit at least 15 participating institutions.
For more information Visit the repository at www.casere3.org to perform a search and see the repository in action. For more information, or to have your institution participate in the CaseRe3 project, please contact Dr. Martha Menard at
[email protected].
X
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Increase your treatment effectiveness in:
Sports Injury Pain Management Neurological Disorders Quality of Life Musculoskeletal Conditions
College of Acupuncture & Therapeutics
Laura Fixman, BAA, is the Communications
and Member Services Coordinator with the Registered Massage
Therapists’ Association of Ontario (RMTAO). A graduate of the
University of Guelph- Humber, Laura answers
RMTAO member concerns and takes charge of
RMTAO marketing initiatives.
The Massage Therapy Research Fund (MTRF) has a new home—the Centre for
Integrative Medicine (CIM) at the University of Toronto! CIM Director Dr. Lynda Balneaves is now responsible for managing the MTRF and the related annual funding competition.
CIM was established in 2014, and is a collaboration between the Leslie Dan Faculty of Pharmacy at the University of Toronto and Scarborough Hospital. The centre has three primary goals: to conduct research to help individuals make evidence-informed decisions about the use of complementary and alternative medicine (CAM); to identify evidence-informed practices that improve the planning, delivery, outcomes and cost- effectiveness of health care; and to educate patients and health professionals about CAM.
Continuing to lead the way The MTRF is recognized in Canada as a national leader in massage therapy research, which is a good fit with CIM’s goal of educating integrative health professionals, by advancing research and supporting research that is already underway. The announcement that CIM would be taking over responsibility for the MTRF was made to registrants and stakeholders of the CMTO at the end of 2015.
Dr. Balneaves feels honoured that CIM has
been selected. “We’re really excited to be part of the advancement and knowledge building of massage therapy, which is a really valuable health profession and has an important place in the integrative medicine landscape,” she said. “The MTRF is a great fit for the overall goals of CIM because of the high quality of research in the area of integrative medicine that it already represents. The fund is already recognized in Canada as advancing important research, and that’s something we want to be a part of.”
CIM has committed to oversee a minimum of two funding competitions, in 2016 and 2017. Dr. Balneaves believes that the role of CIM, and her role in particular when it comes to the MTRF, will be to provide administrative and scientific oversight and to evaluate the impact of new programs and research. CIM also facilitates research in a clinical setting, particularly with its partners at Scarborough Hospital, and reaches out to the complementary science research community and other experts to ensure approval of the highest-quality submissions. “Our goal is to be recognized in Canada as one of the centres bringing complementary research together,” says Dr. Balneaves. Furthermore, she hopes that CIM will be able to continue working with the MTRF beyond its initial existing two-year
New Home for the Massage Therapy Research Fund
Focus on Research
By Laura Fixman
conversation around
integrative medicine,
research and training in this area in Canada.”
About the MTRF The Massage Therapy Research Fund (MTRF),
established in 2004, was last administered by
the IN-CAM Research Fund, in which CIM is
also heavily involved. The MTRF focuses on
funding high-quality research, and prioritizes
research into massage therapy effectiveness,
efficacy and safety; access to and delivery of
massage therapy services; the professional-
ization of massage therapy; massage therapy
competencies and competency assessment;
practices.
that is run on an annual basis, and the
amount of funding is determined each year
by the CMTO. The CMTO has been the
primary contributor, ensuring the sustainability
of the fund since 2006.
MTRF grants are open to established
Canadian researchers; research trainees in an
MSc, PhD or postdoctoral program in Canada;
students (undergraduate or graduate)
massage therapists who are collaborating
with an established researcher or a research
trainee at a recognized Canadian research
institution for the purposes of conducting
research.
will ensure that the knowledge gained at a
bench in a laboratory is put into action at the
bedside, and is designed so that the lessons
learned from how patients currently use CAM
will inform future research.
website at www.cmto.com and look under
the “Follow the evidence” tab.
commitment, providing that the necessary resources remain available.
The growth of CIM CIM also partners with well-respected institutions that offer a range of complementary therapies, including major academic consortia and universities in Hong Kong and China. Dr. Balneaves feels that there is no real ability to specialize in complementary medicine in Canada, in terms of the educational opportu- nities available. CIM would like to increase the capacity for clinical practice and the development of research in this area. “We want to really build the conversation around integrative medicine, and build the capacity for research and training in this area in Canada,” says Dr. Balneaves.
From the lead-up to the launch of CIM in 2014, and looking towards the future, its initial goals have been about laying a lot of the groundwork, including developing a five-year strategic plan and a long-term budget. CIM
is also looking to expand by first approach- ing members that are already engaged in the centre, and bringing together faculty, students and clinicians with an interest and expertise in integrative medicine. In expand- ing the education and research surrounding complementary and integrative medicine, CIM is hoping to develop this area of expertise among health practitioners, as well as improve access for patients. “We want to determine if the research being conducted and treatments performed are effective for patients, as well as whether they’re cost effective,” Dr. Balneaves adds. “If you’re creating evidence, you need to translate it both for patients and for health professionals.”
“ Callout.”
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Spring 2016 • Therapy Today