folklore vs. evidence informed practice

In the fall of 2005, I attended an event that shaped the rest of my professional life.

It was a post-convention meeting, and it was the first iteration of what is now called the International Massage Therapy Research Conference.

At that meeting, for the first time in my life, I was surrounded by people who were interested in evidence-informed practice, who had the gall to question the folklore and revered traditional wisdom of our field. I was challenged to analyze every claim I’d ever made about massage therapy, to see if it would hold up to close scrutiny. Through that experience, I came to know the Massage Therapy Foundation, where I proudly served as a trustee for 10 years, four of them as president.

It is only in hindsight that I see how important that meeting was — not just to me, but to the profession as a whole. That meeting shined the first public spotlight on massage therapy research and evidence-informed practice.

A Growing Body of Research

At that time, according to, an average of about 30 research articles with the search term “massage therapy” were generated each year. After 2005 that yearly number began to climb, and now 100 or more research articles are published each year on this topic.

A hundred articles a year isn’t a lot. This result is a function of many things, but perhaps most of all it is a reflection that massage therapy does not have an educational infrastructure with dedicated advanced degrees like other health care fields do — so we don’t have a contingent of practitioners who must do a research project to obtain their credentials.

But here’s the thing: I just referenced, and I bet you know what that is. (It is the world’s largest database of academic peer-reviewed research articles about the life sciences.) You may even have done some searches there. Maybe you’ve accessed an article that helped you with a client, or that opened a conversation with a primary care provider, or that gave you some information for a presentation to a special interest group.

This tool reveals a remarkable evolution in our profession: From a tradition built on folklore, we now have the beginnings of an expectation that clinical decisions should be based on our clients’ priorities, our own expertise, and what the research says — in short, evidence-informed practice.

Making Research Literacy a Priority

Back in the days of that first massage therapy research conference, the topic of research literacy — the ability to find, read, evaluate and apply research findings — was not high on anyone’s radar. At the Massage Therapy Foundation we had an uphill climb, just making the case that research literacy was a useful skill, and that what was happening in the research realm was relevant to all practicing massage therapists.

Today, every one of the major industry trade journals has a dedicated column about research. Both the Commission on Massage Therapy Accreditation and the Entry Level Analysis Project list research literacy skills as key competencies for massage therapists. The National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) requires continuing education in research in order to maintain board certification.

It’s safe to suggest that our profession has begun to accept that research literacy is a baseline skill; however, one aspect of research literacy — the ability to evaluate what we read — is a special challenge.

How Do We Evaluate Research?

Evaluating research means looking for flaws: evidence of bias, poor design that might alter outcomes, or inaccurately interpreted results. To a certain extent we must depend on the (often brutal) peer review process that scientists undergo when they submit to publish an article in an academic journal to evaluate findings for us.

We may assume these publications work to weed out weak research, and to demand that scientists defend virtually every sentence they write. But articles about shoddy, poorly executed projects still make it into publication — and sometimes into practice decisions.

Massage therapy is by no means the only field that struggles with this. Inferior, badly interpreted, or, frankly, falsified research has contributed to many health care crises. It led to the fear that vaccines might cause autism, to the idea that cigarette smoking isn’t really linked to lung cancer risk, and most recently, to the claim that synthetic opioids like OxyContin are not highly addictive. All of these “findings” are demonstrably wrong, but undoing the damage done by this bad research takes decades.

What do we do, then? We learn to read research with a critical eye. We look for freedom from bias, for reproducible descriptions of the work, for appropriate comparisons, and for consistent internal logic. If we can’t find those qualities, then the project we are reading may not be truly reliable.

No Project is Perfect

In issue 270 of MASSAGE Magazine, my esteemed colleagues Whitney Lowe, Judith Delany and Doug Nelson combined their expertise to critically evaluate a research project: a study on low-back pain (“An Examination of Challenges in Massage Therapy Research”).

I am familiar with this article, and I frequently cite it because the project was innovative, executed well, and has a clear and defensible conclusion. It also happens to be a finding that makes a lot of massage therapists uncomfortable — which is part of what makes this article so important. All that said, it is not a perfect study.

Lowe, Nelson and Delaney each chose some aspects of the low-back pain study to point out shortcomings, weaknesses or things they would have done differently. This is a good practice, and it demonstrates an important point: There is no such thing as a perfect research project. Every project, including this one, is a product of its time, the technology available, the current trends in research design, and the limitations inherent in putting boundaries on any inquiry.

This high-quality study has flaws. Does that make all research useless? Far from it!

When we critically evaluate what we read, we create new pathways for knowledge. We are enriched and our clients benefit. Reading this critique of the low-back pain study will help you look at other research studies with eyes that are open to more possibilities.

Clinical Decision-Making and Evidence-Informed Practice

We look for good research to help us make good choices for our clients, but the idea of evidence-informed practice is surprisingly new. It wasn’t until the 1990s that the medical field began to institutionalize the incorporation of evidence in clinical decision-making. (See Sacket DL, Rosenberg WM, Gray JAM, et al. Evidence based medicine: what it is and what it isn’t. British Medical Journal. 1996;312:71-72.)

Before that point, physicians, like massage therapists, relied on the traditions they had been taught, along with their own observations, to make clinical decisions. Now research is also part of patient care, and it is vital to evaluate that research carefully.

Massage therapy can make that commitment, too. Evidence-informed practice doesn’t mean that our decisions must be limited by what the research says; it simply means that research findings (about massage and low-back pain, for instance) may influence some of our choices. And that influence should be balanced in relation to our clients’ goals, and our own experience and expertise.

I hope it’s safe to say that most massage therapists want to engage in evidence-informed practice, just like our cohorts in other forms of health care. And to do that we must achieve research literacy — including being able to identify strengths and weaknesses in the research we read.

Ruth Werner

About the Author

Ruth Werner, BCTMB, is a former massage therapist, writer and an NCBTMB-approved continuing education provider. She wrote A Massage Therapist’s Guide to Pathology, (available at, now in its sixth edition, which is used in massage schools worldwide.