Know Your Sources!

I’ve noticed a disturbing and recurring problem among some massage therapists, chiropractors, and other manual therapists: that of citing studies to support a claim which, in fact, do not support it, leaving the impression that either they did not read their citation or, if they did, clearly did not understand it. 

I first noticed these glaring discrepancies a few years ago when Paul Ingraham published his extensively researched article on fascia. A number of massage therapists disputed his claims and, when politely asked to support their arguments, they would put up links to various studies. However, each and every time I diligently followed their links to the studies cited and read the full text, I found that, in fact, the studies did not support the claims being made, not a single one. In most cases, the study had nothing to do with the topic being discussed and was irrelevant. In other cases, the study actually contradicted the claim being made. When asked if they had read the paper and, if so, could they point out exactly where they thought the paper supported their position, the commenters did not answer. Not one. They either left the conversation or changed the subject. I was left wondering: did they actually read the paper they cited? If so, did they understand it? Or did they see a word in a title and jump to the conclusion that the paper somehow supported their position? Did they take someone else’s word for it without reading it themselves? Did they intentionally put up a citation they knew did not support their point, thinking no one would check it out? We’ll never know because  none of them ever answered the question.

This was not an isolated incident. In fact, it is disturbingly common. Science-minded therapists are usually quite willing to discuss questions about their citations. Conversely, those who put up questionable "evidence" usually evade answering direct questions about it. During one discussion regarding the lack of evidence for the claim that fascia can be stretched with manual therapy, a paper testing the tensile strength of collagen fibers (Threlkeld 1992) was cited. One fascia enthusiast, in trying to argue a point, noted a graph in the paper and thought the "toe" section of the graph demonstrated something about the flexibility of the toes of the foot. The referred to “toe region” is a specific section of the graph showing the lengthening of collagen fibers as they are put under strain and the slack is taken out of them. If the commenter had read the paper, they would have known that the toes of the feet were never mentioned and that the “toe region” was a specific section of the graph and was clearly explained in the paper. When this was pointed out and the commenter asked if he had read the paper, he ignored the question and did not answer. Did he realize his error but was embarrassed to admit it? One would hope so, but in later comments he continued to misrepresent, or misinterpret, other research. Getting caught citing research he did not understand did not deter him from doing it again repeatedly. Was this intentional and meant to impress naive readers who could not distinguish between a valid representation of the research and a misrepresentation of it? Or was it a case of gross ignorance? We may never know but it's an important question to ask. Are some intentionally misleading the less informed, or do they not know that they have no idea of what they are saying?

Readers who are not research literate may not recognize these gaffes, but those who take the time to read references quickly realize that either the author cites research he has not read or does not understand the research he cites. When a massage therapist who has not been schooled in research literacy does this, it may not be of great consquence, but when a highly respected manual therapist or a person claiming the title of "Doctor" does this, it is deeply troubling. Do they not know better? Or do they know better but do it any way? Either way, rather than supporting a position, it weakens it further by making it appear the author does not have real evidence to support their position, for if they did, they would be citing that instead of misrepresenting real science or citing irrelevant or contradictory papers.

More recently, my attention was drawn to a paper cited in several articles authored by a particular chiropractor and one authored by a well known massage therapy instructor. The paper supposedly supported some (questionable) ideas about fascia. Curious, I tried to find the paper. At first, I could only find the abstract. It was highly technical and I found even just the abstract unreadable (I am not a chemist) but what very little I understood did not appear even remotely relevant to manual therapy. I searched for other papers by the same author to see if this would give me a clue. They were also very technical chemistry papers and none had anything to do with manual therapy. I was finally able to obtain the full text from a cell biologist friend who does biomedical research. My very limited grasp of the paper led me to think that this paper had nothing to do with manual therapy. The cell biologist read the paper, was able to understand it, and agreed. He explained the experiments were done entirely in test tubes under laboratory conditions (something I was able to understand on my own) with concentrations of an acid millions of times greater than exists in the human body. The cell biologist commented that he could see no way anyone could draw any conclusions from this study that would have anything to do with manual therapy. So why were these authors citing this paper? Exactly what did they think it had to do with manual therapy?

I sent messages to both the chiropractor and the instructor inquiring about their articles and asked if they had read the paper, and if they did, could they explain exactly how they thought the study was relevant to manual therapy? I told them what the biomedical researcher said and asked about their response to that. The massage instructor answered promptly and was very nice. He said he’d read the paper and did not understand it, but indicated that someone else had told him the paper was relevant . He had no comment about the researcher’s comments. The chiropractor never answered.

Most massage therapists have not been schooled in reading and evaluating research unless they have learned it in another field. They are at a disadvantage when someone cites a study and they have no way to determine whether it actually supports a person’s claims or not. I once asked a biomedical researcher, “How can the average person distinguish junk science from valid science?” His reply was, “Good question.” One might also ask how does one recognize when someone is citing valid science but misrepresenting it? There is no easy answer. It is like asking, “How do you know when someone is telling the truth?” Perhaps Neil DeGrasse Tyson answers this question when he says that science literacy is not about how many facts you have memorized but is knowing what questions to ask, and that science literacy will innoculate you against those who would exploit your ignorance. Fortunately, massage therapy education is beginning to include research literacy and we will all benefit as massage therapists grow more research literate. All of us can, if we desire, begin to educate ourselves and take advantage of a wide array of resources available to us. The Massage Therapy Foundation’s Research Literacy Course, and books such as Massage Therapy: Integrating Research and Practice by Trish Dryden and Christopher Moyer, are great places to start. There are online forums available where science-minded and research-literate practitioners gather and discuss science relevant to manual therapists. These discussions provide a place where a therapist can discuss studies with other knowledgeable practitioners and learn from them and with them. If you are not yet very research literate, don't be intimidated by those who are. Read, listen, ask questions, and don't be afraid to be questioned yourself. Having to provide answers to valid questions helps to sharpen your thinking and find the flaws in it, which you are then able to correct. If you are seriously interested in learning, most research literate practitionerse are happy to share their knowledge and are pleased when another massage therapist is eager to expand their research literacy. A number of online bloggers write excellent plain language articles about science relevant to manual therapists. We can cultivate our own research literacy starting now.

We are all capable of making mistakes. It’s easy to misunderstand a paper, or to read in haste, or to confuse two different but similar papers. However, the practice of putting up a paper for evidence that one has neither read nor understood cannot be excused and must stop. Perhaps it has been done out of ignorance but that can be avoided by actually understanding the evidence before presenting it to support a point of view. If misrepresentation of evidence is intentional, that is downright shameful and reflects very poorly on anyone who would resort to that. We should be spending our time in honest and informed discussion, trying to understand how the body works and how we can help our clients, not creating confusion by spreading predatory misinformation. Rather than clinging to baseless claims, we should look at the available evidence truthfully and discuss it in good faith. If the evidence demonstrates that our ideas are unsupported, we should be ready to change our thinking to agree with the available evidence. If we think someone else’s ideas are wrong, we should be willing to describe exactly how they are wrong and support our position with real, not fake, evidence. If we make a commitment to do that, we will all learn more quickly and easily. When everyone in a discussion is abiding by these rules, it can be a joy to examine a paper or a hypothesis, even with those with whom we disagree, because the conversation is about the information, not the person, and the goal is to understand how the body actually works, not to cling to a particular explanation that may be mistaken or sell a false idea. True and honest discussion is an exciting process of discovery and learning. 

Before we cite a study as evidence, we should read it and understand it. If we do not understand it, we can seek out those who do, discuss it with them, and make sure that we understand it correctly. Reasonable people may still disagree, but at least we are making an honest effort. Sometimes the full text of a study is not available. A study may be behind a paywall – that is, one must be a subscriber to the publication, work at an institution that pays for access, or pay for a copy of the individual study itself, which can be quite expensive. There may be ways to gain access to the full text if one is persistent. Sometimes it can be gotten directly from the author themselves. If one lives near a medical school, it can sometimes be accessed at the med school library even if one is not affiliated with the school. Ask the librarian at the desk for help in finding it. Sometimes a paper can be gotten from a researcher friend who has access. Some papers are freely accessible for a limited period of time when first released. If you find a recently published open access paper that seems like it may be useful, download it right away because it may not remain accessible.

Citing sources when we don’t know what we’re talking about erodes our credibility in front of those who know better. When we do that, we not only appear ill-informed, we haven’t really learned anything and are reinforcing, in ourselves and others, mistaken and unsupported ideas which hold us back. It’s much better to learn, drop outdated and unsupported ideas, move forward, and have the trust of our colleagues and clients who can see when we are a reliable source of information.

It may a bit intimidating at first to try to learn and understand research, but little by little, through repeated reading and discussion with others who are research literate, it is possible to learn more than you imagined possible. It's rather exciting when you look back and realize you can now read material that once was incomprensible and that this information is actually useful to you in your practice. It can help you make better decisions when working with clients and help in your communication with other health care professionals. It’s a lot of fun to learn something new! When someone asks where did you get your information or on what basis do you make a claim, it is very nice to be able to point, with confidence, to relevant studies. Invite such questions! It will sharpen your critical thinking skills to have to defend your ideas. Be prepared that others may have different information that may be newer, have better controls, may contradict your evidence, etc. Be prepared to discuss the issues honestly, openly, and with facts rather than personal attacks and unfounded opinions. Be committed to knowing how the body actually works rather than remaining attached to an idea of how it works that may not be accurate. Be prepared to change your thinking when it is called for. When we do that, we all win. When therapists are better informed, our clients benefit.

Some excellent resources to help massage therapists cultivate research literacy and critical thinking skills can be found here.

Remember, know your references before you cite them. Make sure they are credible and actually say what you think they are saying. Be willing to change your thinking when the evidence suggests it. We may never be completely right, but we can hope to be “less wrong” in the end.