A commonly cited question to researchers or massage therapists involved in research from other massage therapists is, “How can I be involved in research?” As an author of the therapeutic massage and bodywork adapted case report (CARE) guidelines, my usual initial response to that question is to write and publish a case report.1

While I stand by this answer (case reports are a great “gateway” to research), I realize that writing a case report is not enough for many individual massage therapists to scratch their research itch. More importantly, case reports are not enough for the massage therapy field to hang their hat on as the main avenue for massage-practice–generated research. The Somatic Research column tends to focus on a specific, recently published research article, but in this issue, I’d like to take a different approach and explore the concept of practice-based research networks (PBRNs) and practice-based research generally, and point readers to a variety of sources, resources, and articles to allow potential engagement in research activities beyond writing case reports.

Practice-based research networks derive from and mainly reside within the primary care and family medicine realm. At its foundation, a PBRN is a group of practices and/or practitioners with common health-care foci who work together to answer practice- and community-related questions. In addition, PBRNs work together to translate findings from research into practice, participate in quality improvement activities, and promote through practice an evidence-based culture in the interest of patient/client/individual/community care and health. From the founding and traditional perspective, PBRNs are made up of practices and clinicians within the health-care system’s primary care delivery cadre, focused on patient health and outcomes through individual, preventive, and community care system approaches. Generalized more broadly, a PBRN can be formed and made up of non-primary care-related clinicians with a commitment to evidence-based care, who practice within a shared context, and who focus on health outcomes for individuals within their care. This more generalized consideration of PBRNs is where I will focus reflection of how the massage therapy field can utilize the construct to produce and promote practice-based research in our field. But first, an aside is needed to situate the PBRN discussion within the context and importance of practice-based research.

Distinction and Importance of Evidence-Based Practice (EBP) and Practice-Based Research

Most Somatic Research readers are familiar with the concept of evidence-based practice (EBP), which derives from evidence-based medicine (EBM). Essentially, EBM/EBP is founded on the principle that individual care decisions made by clinicians are based on input from and a balance between the practitioner’s clinical expertise, the best available systematic clinical research, and patient values, circumstances, characteristics, and wishes.3 In the massage field and elsewhere, these three constructs make up the EBP three-legged stool. In an effort to promote and strengthen the extent to which EBP occurs in massage practice, massage therapy organizations, educators, and advocates have put a lot of effort into increasing research literacy among massage therapists. While practicing EBP does not require practitioners or clinicians to conduct research, it does expect and require them to access, assess, and apply research-derived evidence to their treatment plan efforts. As efforts to improve research literacy in the massage field have progressed, it has become more commonly known to practitioners in our field that relative to other applied health disciplines (e.g., medicine, nursing, dentistry, physical therapy), massage therapy has a very small (but growing) research evidence base. Another massage-related research evidence base aspect that became more apparent as practitioner research literacy rose was the realization that almost all the large, funded, and high-quality massage-related research conducted is led or completely conducted by non-massage therapy clinicians or researchers. The takeaway from this point is that clinicians and other field leaders began to ask the question: How reflective of actual massage therapy practice is the research that is supposed to be providing the evidence base for our field? The concern that research be reflective of massage practice in relation to EBP is based in part on the principle that strictly controlled research protocols examining massage therapy (or any practitioner-applied intervention) only answers the question, “can a treatment in the most controlled and ‘perfect’ circumstances work?”, not “does a treatment work?” Ultimately, clinicians and patients/clients are more interested in the extent to which a treatment does work in practice (treatment effectiveness), not the extent to which a treatment can work (treatment efficacy) in some unrealistic setting with a low probability of replication in their situation. 

The massage field is not alone in its concern of practice reflective research, particularly when interventions or treatments are clinician applied. Many clinician-applied disciplines (e.g., physical therapy, primary care, nursing) contributed to the movement toward practice-based research and pragmatic/effectiveness designs due to concern that the “gold standard” randomized control trial research approach is ill-suited for practitioner-delivered interventions. If controlled environments are the “labs” in which the highest quality, randomized controlled trials take place, and it is recognized that clinics and practice situations are the antithesis of controlled, then controlled lab settings are not terribly practice reflective. It only makes sense then that the ideal “lab” for practice-reflective research is in the clinic or practice environment; thus, practice-based research derives from and is conducted in clinic or practice environments that inherently preserve practice reflectiveness (i.e., “messy” but real).

As most in the massage field understand or can at least imagine, conducting research in practice is hard and often takes a combined skill set that massage education does not provide (and arguably should not at an entry level, given the field’s current approach to foundation education).

In addition, few massage therapists have the needed skills beyond their clinical training from other secondary education to design, conduct, analyze, or disseminate rigorous research. The same can be said for most, if not all, of the other aforementioned clinicians from applied health disciplines. In clinical practice settings, whether for primary care, physical therapy, chiropractic, or massage therapy, there is enough going on to keep everyone who works there (administrative to clinician) busy just keeping up with the day-to-day clinic, patient/client, and business needs. There is little room in practice for the additional resources and needs a valid and rigorous research study requires. The desire and commitment alone to conduct or even participate in practice-based research is not enough to make it happen. Usually, collaborative partnerships and/or efforts above and beyond those needed for general clinical practice are necessary for the successful implementation and completion of a research study in clinical practice; and infrastructure resources for such endeavors take a lot of time and effort to build. One such infrastructure with a building historical significance is the PBRN model. Medicine, particularly primary care, has developed and honed this model and shares its short history in an open access article by Larry Green, MD, and John Hickner, MD, in the Journal of the American Board of Family Medicine.4 The model is one that several in complementary and integrative medicine generally, and massage therapy specifically, have sought to leverage in efforts to increase and improve practice-based research in their respective fields. 

Examples of Massage Therapy-Relevant PBRNs

Access is an essential research component that provides particularly challenging barriers to research conduct and completion. Specifically, the alignment of research acuity, study population, and, in some cases, intervention delivery is necessary for research to happen. Inaccessibility to any of these necessary components is a study completion deal breaker, but the natural alignment of these properties in a single setting is unusual. The PBRN model and approach provides a bridge between these components in a unique way and three PBRN examples of note exist related to complementary and integrative health generally and massage therapy specifically.

The Practitioner Research and Collaboration Initiative (PRACI) is a relatively new PBRN established in 2014 and based in Australia.5 PRACI consists of over 760 members from various complementary and integrative medicine fields, including massage therapy, naturopathy, reflexology, acupuncture, aromatherapy, yoga, and ayurveda. Massage therapists make up a majority of PRACI’s membership (~58 percent), perhaps indicating a particularly strong interest by these therapists to take an engaged approach to research in their field. Resources, including published papers and descriptions of the research taking place through the PRACI PBRN, are available at their website (www.praci.com.au). While PRACI-based research may not include US-based massage therapists or patients/clients, the contextual similarities between Australia and the United States are certainly stronger than their differences, making PRACI and their efforts potentially important models. The massage-related findings and research coming out of PRACI efforts could provide valuable frameworks for which considerations or study approach could be replicated or based in the US massage therapist or patient populations.

There are a handful of US-based massage related PBRN affiliated research studies and massage-specific PBRNs. The Kentucky Pain and Research Outcomes Study (KYPROS), highlighted in Somatic Research in the November/December 2017 and January/February 2018 issues of Massage & Bodywork magazine, included a PBRN approach and study design couched in the primary care setting.6 Primary care providers who were part of the Kentucky Ambulatory Network PBRN referred their patients with chronic low-back pain to the KYPROS study team, who enrolled them into the study and paired them with community-based massage therapists for the intervention.7 While not identified as such at the time, the cadre of community massage therapists affiliated with KYPROS made up an informal PBRN and served as the practice sites for the intervention. The two PBRN usage approaches in KYPROS addressed potential accessibility barriers by providing researchers access to both the patient population and community practicing therapists. This was particularly important considering the aim of the study was to understand real-world massage therapy effects for real-world, complex chronic low-back pain patients. In both cases, the networking aspect of the PBRNs provided the entry point to critical study design components (patients and intervention delivery), without which the study could not have been conducted. In addition, the community of practicing massage therapists had the opportunity to train in human subjects’ protection and data collection, all the while serving as instrumental study personnel and well-representing the massage field in the academic research realm.

Two formal and massage-specific PBRNs exist in the United States and are listed within the US Department of Health and Human Services Agency for Healthcare Research and Quality (AHRQ) PBRN Registry. MassageNet (www.massagenet.org) was founded in 2009 and was established with the intention to facilitate communication and linkage between massage practice, education (students and teachers), and research. MassageNet’s AHRQ registration page (https://pbrn.ahrq.gov/pbrn-registry/massagenet) indicates MassageNet has over 600 member clinics and practices from 47 US states and territories with potential access to approximately 14,500 patients. To date, no clinical trials have been conducted in conjunction with MassageNet, but a recent publication in Preventive Medicine Reports described findings from a survey conducted through MassageNet examining health promotion within massage practice.8 In addition to MassageNet and its broad US representation, a smaller, regional-specific US PBRN provides a model for a more locally driven and supported PBRN approach. The Massage Northern Ohio (MNO) PBRN was founded in 2014 and was listed on the AHRQ PBRN registry in 2015 with 68 practices or clinics (https://pbrn.ahrq.gov/pbrn-registry/massage-northern-ohio-practice-based-research-network). Though relatively small compared to traditional or other complementary therapy related PBRNs, the MNO-PBRN website (www.mnopbrn.weebly.com) highlights several completed affiliated studies, including a pilot randomized controlled trial examining massage effectiveness on cramping in dialysis patients.9 Both MassageNet and MNO-PBRN have great potential to provide a means through which interested massage therapists can engage more with research while providing frameworks for others interested in developing similar networks in their therapist communities.

The massage therapy field is ripe with interesting and important questions that educational and clinical practice settings provide the ideal laboratory for. PBRNs provide mediums through which research-interested massage clinicians, practices, and educators can link to researchers and vice versa in efforts to increase massage-related, practice-based research. Such activity would inevitably increase the massage field’s contribution to the growing evidence within its work; an occurrence that would bring us more in line with other health-focused applied disciplines. While the PBRN resource is not large in the massage field at this time, it is poised for growth potential and, at the very least, is something all research interested massage therapists, educators, and stakeholders should be knowledgeable of, and engaged with, when and if the opportunity presents itself.

Notes

1. Niki Munk and Karen Boulanger, “Adaptation of the CARE Guidelines for Therapeutic Massage and Bodywork Publications: Efforts to Improve the Impact of Case Reports,” International Journal of Therapeutic Massage & Bodywork 7, no. 3 (2014): 32.

2. US Department of Health and Human Services, Agency for Healthcare Research and Quality (home page), accessed November 2018, www.ahrq.gov.; US Department of Health and Human Services, Agency for Healthcare Research and Quality, “Practice-Based Research Networks,” accessed November 2018, https://pbrn.ahrq.gov.

3. David L. Sackett et al., “Evidence Based Medicine: What It Is and What It Isn’t,” BMJ 312 (1996): 71–2.

4. Larry A. Green and John Hickner, “A Short History of Primary Care Practice-Based Research Networks: From Concept to Essential Research Laboratories,” The Journal of the American Board of Family Medicine 19, no. 1 (2006): 1–10; accessed November 2019, available at www.jabfm.org/content/19/1/1.full.pdf.

5. Amie Steel et al., “An Overview of the Practitioner Research and Collaboration Initiative (PRACI): A Practice-Based Research Network for Complementary Medicine,” BMC Complementary and Alternative Medicine 17, no. 1 (2017): 87.

6. William G. Elder et al., “Real-World Massage Therapy Produces Meaningful Effectiveness Signal for Primary Care Patients with Chronic Low Back Pain: Results of a Repeated Measures Cohort Study,” Pain Medicine 18, no. 7 (2017): 1394–1405; Jerrilyn Cambron, “Real-World Massage Research and Therapist Research Involvement,” Massage & Bodywork 32, no. 6 (November/December, 2017): 44–7; Niki Munk, “4 Points Arising From Low-Back Pain Study,” Massage & Bodywork 33, no. 1 (January/February, 2018): 46–9.

7. Niki Munk et al., “The Intersection of Massage Practice and Research: Community Massage Therapists as Research Personnel on an NIH-Funded Effectiveness Study,” International Journal of Therapeutic Massage & Bodywork 7, no. 2 (2014): 10.

8. Ann Blair Kennedy et al., “Advancing Health Promotion through Massage Therapy Practice: A Cross-Sectional Survey Study,” Preventive Medicine Reports 11 (2018): 49–55.