61: Massage Therapy Research (with Niki Munk)
Episode Transcript
Summary: Whitney talks with Niki Munk about massage therapy research.
They delve into these important topics: such as:
-What are levels of evidence and why does this matter?
-Why should massage therapists care about research?
-How to get involved with research
-Challenges of massage education existing outside traditional academic models
…and much more.
- Whitney Lowe’s online Clinical & Orthopedic Massage Courses
- Til Luchau’s courses at Advanced-Trainings.com
Resources mentioned
Whitney Lowe:
Hello, this is Whitney Lowe and Books of Discovery has been a part of massage therapy education over 20 years. Thousands of schools around the world teach with their textbooks, eTextbooks and digital resources. In these trying times, this beloved publisher is dedicated to helping educators with online friendly digital resources that make instruction easier and more effective in the classroom or virtually. Books of Discovery likes to say learning adventures start here. They see that same spirit here on the Thinking Practitioner Podcast, and they’re proud to support our work, knowing we share the mission to bring the massage and bodywork community enlivening content that advances our profession. So, check out their collection of eTextbooks and digital learning resources for pathology, kinesiology, anatomy, and physiology at BooksofDiscovery.com, where Thinking Practitioner listeners can save 15% by entering THINKING at checkout.
Whitney Lowe:
Hello, and this is Whitney Lowe, and I am joined here today by a good friend of mine, Niki Munk, who is an associate professor of health sciences, and going to talk to us about research. So Niki, welcome to the Thinking Practitioner Podcast. Great to have you here.
Niki Munk:
Hey, Whitney. It’s so good to be here. I am with Indiana University, the School of Health and Human Sciences, and I’m on the IUPUI campus. So, when people think of Indiana University, they often think of the Bloomington campus, which is the beautiful, beautiful flagship campus for the system. But we’re on the IUPUI, which is in Indianapolis and it’s where all of the health affiliated and graduate programs at the School of Dentistry and School of Medicine … and then we’re the School of Health and Human Sciences.
Whitney Lowe:
All right, that sounds great. I think I asked you this one time a long time … Is it IUPUI, is that how you say that abbreviation?
Niki Munk:
Well, it’s IUPUI. Back in the day, that was a common nickname that was used back when, gosh, we had the Pan Am Games back in the 80s or 90s when we got our beautiful, beautiful sports facilities out here. And of course, right in our backyard across the street actually from my office is the NCAA headquarters.
Whitney Lowe:
Wow, okay.
Niki Munk:
So, it’s really, really great for sports enthusiasts around the world.
Whitney Lowe:
Yeah. All right, so is IUPUI not a correct acronym or moniker for-
Niki Munk:
Correct. IUPUI.
Whitney Lowe:
I will dismiss that from my mind from here forward. Good. Niki, tell our listeners, if you would, a little bit about … You have a fascinating background here. This is so unusual for us to have individuals who are both massage therapists and PhD researchers. And this of course puts you in a very unique position in regards to what you’re doing with research. Tell us a little bit about your background, how you got into these two separate tracks here.
Niki Munk:
Oh, sure. It’s all so meandering because my undergraduate training was actually in theater. You probably remember that because me and Ambler Kennedy both hail from that background and my-
Whitney Lowe:
And, Ruth Warner does too, if I remember-
Niki Munk:
Yes, and Ruth. Yes, the three of us, we enjoy when we’re all around together going back into thespian roots. But yeah, so I did that and my acting career did not last very long when a job up in New York fell through, and I found myself doing outdoor drama and trying to figure out what to do with my life. And, my parents actually led bicycle tours for about 25 years after they retired for the military, and I went to visit them when I was bartending and working three jobs trying to just make ends meet. And, I had a wonderful experience with them watching these people who were riding across country and just having the time of their lives, and I went to bed thinking, “Oh my gosh, how can I get to that, retirement age and things, without having to live most of my life?”
Niki Munk:
And I literally woke up the next morning and went they need a massage therapist. And, I went to massage school because I was going to travel the country with my parents and do sports massage and the like. That ended up not being what happened. I ended up specializing actually in older adults, and I did not feel that my training had prepared me to do the work and really understand what was happening with the massage and the aging process. And so I thought I would go back to school and get my masters in aging or something like that, and when I arrived at University of Kentucky to get information about a gerontology program that they had, I came to found out that they did not have a master’s, but they had a PhD program. Not knowing what PhDs were or what research was other than what I considered research to be, going to the library and looking in the indexes, looking into things-
Whitney Lowe:
And perhaps good that you didn’t know what you were getting into at that time.
Niki Munk:
Truly, truly. And I was like, “Okay, well, I could do that. I can get a PhD.” And, I started the program. I think they were a little unsure about me, but I went in and in the process of course learning about aging and that whole aging process with the full intention of going back to community and teaching, doing continuing education on aging and biology of aging for massage therapists, I learned a lot more about the actual research process, and I started reading the research that I had gone through massage school revering as the end all be all and realizing that it wasn’t terribly strong.
Whitney Lowe:
Yes.
Niki Munk:
And so this was back in the early 2000s. I finished massage school in February of 2002. So, realizing that I could probably touch more people if I helped improve the evidence base, because I would be able to help make massage more accessible, hopefully. The whole reason why I’ve gotten into research to increase the accessibility so that more people can then access massage. So, while I may not be the person laying hands on, more people would be able to do that by elevating the field, elevating the research and the like. So that’s what brought me here and my alignment with the department and my faculty position was really fortuitous in that, like massage therapy that does not reside in the academy, gerontology doesn’t necessarily have its own discipline by itself either.
Niki Munk:
It is a discipline that cross cuts a lot of other disciplines, so you have of folks who study aging who are in the biology side of things, some in the psychology side, some of the social aspects. So, it’s very interdisciplinary fields. And so, I have these two interdisciplinary fields, massage or integrative medicine and health is what I really focus on and then also gerontology. I was able to find a really nice fit and faculty home within the School of Health Sciences. And I teach gerontology classes and aging classes to undergraduates, but then my doctoral students and my master students are getting their degrees in health and rehabilitation sciences, and I teach the foundation of theory building and research concepts and how to construct research questions and do research studies and things like that.
Niki Munk:
And then for my masters and doctoral students, teaching theory building, theory application, research methodology, so how to do the clinical research, and then also the foundations of rehabilitation, because I tell you what, that’s another really lovely umbrella discipline that therapeutic massage and body work really can fall under as well. I’m scheduled to give a talk in Canada. It’s been postponed several years, but it’s going to be focusing on rehabilitation as an umbrella discipline for massage clinicians to consider themselves within.
Whitney Lowe:
Tell me a little bit more about that in terms of what that entails. Is that specifically talking about massage as a rehabilitative practice or massage across the spectrum in rehabilitation in lots of different areas? What’s that about?
Niki Munk:
Yeah, so it’s really fascinating, much like research, when I became engaged and involved in rehabilitation, I didn’t really know the full details of what all rehabilitation entails. And, there’s a really great journal article with first author named Stucki, S-T-U-C-K-I, I believe and it came out in maybe 2007. I will get a PDF of that and send that to you if you want to have-
Whitney Lowe:
Excellent. Yeah, we can put it in the show notes. That would be great.
Niki Munk:
Yeah, yeah. It outlines rehabilitation as having four key components that it can be, health situations that rehabilitation could be applied within. And one is from a curative standpoint, so to actually fix something. Another one is what we would consider rehabilitation, so there’s been an injury and we are rehabilitating it. Then there is a palliative aspect of it, which palliative care of course is all wellbeing, very quality of life focused, and then … So, there is the acute curative, rehabilitative. Oh, and I think wellbeing and supportive. And so, there’s these four different components that massage therapy can really fall within … Oh, preventative. That’s the fourth one … and prevention. You wouldn’t think of rehabilitation having a preventative component, and that’s actually a key component of rehabilitation, not only for those who might be considered a rehabilitation population and keeping them from either further decline or increasing their susceptibility to other conditions.
Niki Munk:
And then, or even somebody who is fully functional, being able to keep folks at their top performance level so that they are able to withstand any assault to their system better and bounce back quicker. So, with that, it just seems like massage can fit within those different tracks so easily. I think that’s one of the things that makes me crazy, and you and I have talked about this before, is that so much of the systems within which people are thinking are often with this notion of massage is going to fix, or X is going to fix, but there’s a lot of things, a lot of conditions or experiences that people have that are either progressive, so they are going to get worse, or the piece that is making the issue happen isn’t going to be removed and taken away. Either because if somebody’s hobby that they enjoy doing or their job that’s going to be done.
Niki Munk:
And so to say, “Okay, everything is curative. You have this condition and now we’re going to fix it,” that isn’t the way massage therapy is practiced very often and it certainly isn’t the way that rehabilitation is done. It’s not an issue unique to massage therapists for sure, because physical therapy, occupational, everybody deals with that.
Whitney Lowe:
I want to get back to something you said earlier talking about this idea that massage therapy didn’t really reside in the academy. I think you and I may have talked about this, and I know I’ve had this conversation with lots of other people before. We really have far more of a lineage model of education than we do a true academic environment, and I want to hear your perspective from a researcher. Do you think that has been, or may continue to be more of a challenge or impairment for us that a lot of students don’t really understand the whole world of research and what this means because we don’t have that much of an academic orientation to our training?
Niki Munk:
Yeah, I think it will continue to be quite hindering for the progression of the field, and certainly for the progression of the research components. One of the pieces that we have talked about … and in fact, I’m remembering a little booth that we sat in over lunch one day. So you’re right, Whitney, I believe that is going to continue to be a little problematic, and we have discussed this before. Because there is progression in all of these other fields and we think of clinicians as mainly people in our field, massage therapists or somebody who has a medical background, but almost all disciplines have a clinician aspect to it because we are part of an applied discipline and there’s these different levels that happen.
Niki Munk:
You’ve got the clinician piece that works within the context of the known knowledge of a particular field. And, our field is not necessarily the ones who are devising and developing the contextual knowledge of the work that we do, and that will always cause a disconnect between the clinicians and well, the research, right? That’s a problematic piece as well that we’re not the ones doing the research either. Not to say that the research that’s being done isn’t good and sound and important, but it isn’t necessarily being done within the context of our field and how it’s being delivered.
Whitney Lowe:
So, how do we change that? I mean, how do we shift the perspective on that or shift the process? That sounds like one of those big things of how do you turn a giant aircraft carrier around in one mile?
Niki Munk:
It is, and I don’t think it’s something that can happen overnight, and it’s one of these pieces that … You’ve probably seen my Venn diagram that any talk that I do, I share this Venn diagram that it has one bubble is research, one bubble is practice and one bubble is education and then they have this really nice overlap. But then there’s this great big bubble that encapsulates everything, and that is policy and context. In an ideal situation, all of those things, the three bubbles are all together and then that contextual piece is all surrounding it and encompassing it because the regulations and the credentialing and the oversight, all of it works with all of those pieces.
Niki Munk:
And in some fields, that actually occurs. That isn’t necessarily the way … Well, it’s not the way that it occurs in our realm for sure, and in a lot of integrative health practices. So the question of how can that change or can that shift, there has to be work done on all those different fronts and levels and ideally, those things will be done concurrently and with communication with one another. And, not very many fields do that well.
Whitney Lowe:
I would also suspect that there’s language barriers, that researchers don’t understand some of the language that massage therapists use when they talk about their work, and massage therapists don’t understand a lot of the language that researchers talk about when they’re doing those things and that makes it difficult for them to communicate and work with each other on what are we really trying to learn about what’s happening here?
Niki Munk:
Yes. Well, that language disconnect can happen even within the realms of researchers. When you have conferences of different disciplines coming together and they’re all researchers, there’s a whole day set aside at the beginning to just set the contextual and shared language.
Whitney Lowe:
Wow.
Niki Munk:
To know that when I say this, this is what I mean, not what you think I mean, or what means in your language. I’ll put that in air quotes. It’s tricky. It’s tricky. And then, you’ve always got the ego pieces that occur with individuals or institutions or what have you, the history pieces as well, and then unfortunately there’s all also turf and other motivators. So whether it’s financial backing or support or what have you, those things come into play. We see that in legislation a lot and other disciplines will come in and they will pigeonhole, “No, this is ours and nobody else can …” That’s not good for ultimately patients, clients, the humanity that we’re supposed to be helping.
Whitney Lowe:
That’s right. Right. So, I hear from massage therapists all the time who say, “Well yeah, we hear everybody talking about how research is really important and this is something we should know a lot about, but I just do my work and I get good results. Why do I need to know about this?” So, tell me how does research help the average massage therapist in their daily work?
Niki Munk:
What a great question. Well, there’s several different ways in which it can help. One, it can impact people in their daily practices just by an awareness from others and the respect and understanding that other community members may have, not just the clinicians. So that’s one piece, the more research that’s out there, the more recognition that it’s getting and understanding, people getting an understanding of what it is and how it is brings more validity and could help establish trust, also. And, that’s not to say that people having great results in their practice and they’re able to leverage that and continue getting clients or what have you, but that key piece around making it accessible, and the way that it’s going to be accessible to the most people, and particularly the people who need it the most and in a way that will be a sustaining career for clinicians, is to get it within the healthcare system.
Niki Munk:
Now, I know that our healthcare system is not ideal. It is not perfect, but it’s the system that we have and figuring out how to get that link is going to be important. And, the research that’s being done is helping to build that argument and helping to build that justification. So while certainly individuals can practice, practice well, have a thriving practice and not be head on into research and research literacy and what have you, the confidence that their community that they’re practicing within is definitely impacted by it. And then bottom line too, when you understand the mechanisms that you’re working within, you’re going to better be able to take your clinical reasoning with different situations that come at you and that present themselves on the table to be able to do the most effective work that you can.
Whitney Lowe:
Yeah. That piece of clinical reasoning is really critical, because I know we hear a lot these days about the importance of critical thinking and clinical reasoning. So, I personally believe just from my own experience of reading, studying, analyzing, picking apart research studies for years has been really helpful in developing clinical reasoning. Do you feel like this is something that could be a beneficial tool for massage therapists to help sharpen some of those things that then translate also into what they’re doing in their clinical work?
Niki Munk:
Absolutely, yeah. And not just research and clinical findings in our particular field. There’s so many other research pieces too, that might not be a massage therapist doing the work or might not even be within a rehabilitation setting or what have you, but that information can apply to us. I always get really excited … I listen to NPR a lot and I’ll get all kinds of excited sometimes when I hear about new mechanisms of processes, even from a psychological piece or endocrinology piece, and I’m constantly going click, click, click, click, click, how does this apply to the body work that I do? And how might this … additional research questions that can come up.
Niki Munk:
But anytime we’re given the opportunity to exercise our thinking makes us better clinicians and better practitioners, because one of the things that you said, too, over the years, it has benefited me, and that’s one of the things that critical thinking and that clinical intuition, because that is a thing, right? It takes time for that to develop. Experiences, and the more experiences we are exposing ourselves to, the better honed and developed that clinical reasoning is going to be.
Whitney Lowe:
Yeah. One of the things that’s been particularly challenging for me is acknowledging that many of the things that I have taught and written about and put down in writing or put on a film on a DVD or video or whatever, things that I’ve done for years are just plain wrong based on more current research. So, what are some of the ways that educators and practitioners can navigate these challenges when they feel like … I hear a lot of people say they feel like the rug has been pulled out from under them and what they previously learned, and just throwing up their hands like, “Well, what’s the point? Everything I learned is wrong.” I understand that frustration, so as a researcher, do you have any hints and suggestions for people of how to navigate those challenges?
Niki Munk:
Well, the first thing is keeping our humility and our humbleness is always important. And also giving ourselves a break. We can only do the best that we can in any moment. And we have to understand and accept … and this is all manner of fields … information is always developing, new understandings are coming our way. I think of this a lot in parenting too. I’m raising my kids a certain way, and then I learn this other … You’re like, “Crap, I’ve ruined them.”
Whitney Lowe:
They’re going to be in therapy for years because of this.
Niki Munk:
Right. We do the best that we can. Our good intention is always very important, but we also have to be open and letting our egos down a little bit by saying, “Okay, you’ve got to be able to change and make those adjustments.” But if you’re not keeping up with the literature, then you may miss things. You hear a lot about in implementation work, implementation studies where there’s a process that has been developed and has been tested for efficacy, and now they’re trying to implement it within a system, so the healthcare system or what have you. And there was lots of focus on this idea of implementation, but there’s a key piece that we also have to consider that we don’t hear very much about and that’s the opposite, and that’s de-implementation. So taking things out of service, if you will, and doing so for the benefit of the field overall, keeping everybody singing out of the same hymnal as much as possible, right?
Niki Munk:
And not having to wait for a whole generation of clinicians, whatever the discipline is, to flow out. So, that shifting things takes flexibility, staying up with the literature and then also being and flexible and being able to say, “You know what? We thought we were doing this, we thought we understood it to be this way. What the literature is telling us now, we’ve evolved our understanding to be this.” We’re still in the middle of that thinking, seeing how fast can change in these two years of the pandemic so far.
Whitney Lowe:
Yeah, that’s true.
Niki Munk:
And seeing how quick these pieces go and what applies today may not be the same thing that applied in a whole different context a month ago. We’re lucky that it doesn’t move that fast.
Whitney Lowe:
Yeah, yeah. So, one of the critical aspects of evaluating and interpreting research, at least from what I have learned, is understanding levels of evidence. Can you speak briefly about that means and why that’s important?
Niki Munk:
Yeah. Levels of evidence can be very, very nuanced, and this is where you’re getting into when you understand the methodology of research and the if/then’s because nothing is dichotomous. Nothing is it’s either this way or that way. Things shift as different components of particular methodology changes. You can have at the very base of the hierarchy of evidence is professional opinions, opinion pieces, and-
Whitney Lowe:
Nobody ever shares those.
Niki Munk:
They don’t, right? They should talk more. But, there are some opinions that have higher clout than others. So even within that realm of experience, what that information is being based on or what have you, changes the dynamic of how strong that evidence may be. And, the same is true as we’re going up that pyramid.
Whitney Lowe:
Okay, so let me pause right there. So tell me what makes one opinion more … I don’t know. I don’t want to say valid, but structurally sound than another?
Niki Munk:
Or, stronger than another, right? Well, if we’re from a clinician standpoint, so it’s massage therapy … We’ll talk massage therapy clinician. An opinion of a one month strong student versus Whitney Lowe, there’s an experience be that might be there. There’s also other credibility pieces that might be underlaying those pieces.
Niki Munk:
An opinion piece that comes from the CEO of Company X about a thing that really impacts Company X is going to be considered very differently from an absolute independent somebody giving an opinion. They might have the exact same experience level, but some of those other contextual pieces diminishes the company spokesperson who’s giving the opinion about that piece versus … You know what I mean?
Whitney Lowe:
Yeah, so what I hear you saying is that everybody should listen to me and do what I say, right?
Niki Munk:
Oh boy, if that were the case, I should have used myself. But, those things go into it, and so the same is true because … You see at the very top of the pyramid or near the top of the pyramid, these randomized control trials, and while those have the potential to have the strongest gold standard … supposedly … evidence, there’s components within that randomized controlled trial, that if they’re not addressed, it could make the evidence or whatever’s coming out of it junk.
Whitney Lowe:
Yeah, absolutely.
Niki Munk:
If the statistics are wrong, and there’s too much bias, right?
Whitney Lowe:
Right, and then isn’t it also a significant factor, which is that randomized controlled trials don’t tend to work so well for a lot of the things that we’re trying to study about our field, because it’s very difficult to do controlled applications of massage with sham massage and placebo touch and things like that … make some of those trials a lot trickier to construct accurately. Is that true?
Niki Munk:
Absolutely. Yes, sir. There’s a really lovely movement that is occurring and has been occurring for the past about decade, I guess, really starting to look at pragmatic trials. And, the argument being made that these trials … essentially pragmatic is what’s happening in the real world, like how it would happen in the clinical space. And, they can still be randomized. There can be some other aspects. It’s certainly a trial, but there’s these components that keep it very real world and effectiveness versus efficacy. And, a lot of applied disciplines are pointing to that as this is the evidence that we need. It’s much more practice reflective of what we’re doing and it gets to that picture or it gets to that question of does it work in practice. Because ultimately, these randomized control trials, these gold standard trials are based on the pharmacological model.
Niki Munk:
When you have an intervention that is a pill that you can very specifically control the absolute active ingredients that are in that dose, that dosage piece, and in the work that we do and that so many applied disciplines are, there’s the human factor. There’s the human factor who is doing the intervention and all that that entails. And then you’ve got the human factor, who’s receiving it, too. Because ultimately, if we’ve got a perfect technique, it doesn’t mean that that technique is going to be applied the same if I do it, if you do it, Sam does it, whoever does it. Various levels or what have you, those things can’t necessarily be controlled.
Whitney Lowe:
Yeah. I’ve always thought that a lot of the work that we’re doing and a lot of the research that we’re trying to engage in regarding clinical efficacy in our field has a lot more in common, for example, with studies in psychology than they might have with studies in pharmacology. I learned that when I was in graduate school studying psychology that everybody was saying your technique of counseling doesn’t matter anywhere near as much as your development of the client-therapist relationship, and that’s just a factor that you can’t isolate specifically like you can in a traditional randomized control trial for pharmacological interventions. It seems like there’s a lot more similarity there for us.
Niki Munk:
Oh, definitely. And, I’ll tell you another little bit. There is some interesting work that’s being done in rehabilitation world, and they’re looking at the black box and the descriptor … How can we describe the intervention? Because there’s so many pieces that are going in, and they’re talking about an intervention taxonomy, and very different from the ICF … and we’re all familiar with the ICF model of health and function, right?
Whitney Lowe:
Can you briefly go over that for anyone’s not familiar with that?
Niki Munk:
Yep. So the ICF model is what we tend to think about. It’s this picture where you have the condition and the person at the center, and then you have the body structures component. You’ve got the activity component, you’ve got the participation component, and then you have the environmental contextual aspects and the personal contextual aspects that all of these things can be written about as articulating with a condition and different access points of where you can provide intervention to help with the condition.
Whitney Lowe:
Yeah, okay.
Niki Munk:
So you can look at it from a structures and function, so this particular muscle isn’t firing correctly, or this is going on. The activities that are being done, range of motion, participation is more being able to being able to transition, to walk, to do activities with meaning, play with your kids, go shopping. And then the personal factors, age, attitude, self-efficacy and environmental … the environment within which someone’s functioning. And all of those pieces can have impact on somebody’s experience of disability. So, that’s what we think of when we think of the ICF, but what the ICF is … is the WHO, World Health Organization, ICF model but what it actually-
Whitney Lowe:
What does the ICF stand for?
Niki Munk:
Oh, the International Classification of Function.
Whitney Lowe:
Okay, great.
Niki Munk:
Yep. Boy, I’m so glad that I knew that off the top of my head, Whitney. You almost caught me there. I’m so bad with acronyms. That’s one I know.
Whitney Lowe:
Right.
Niki Munk:
But, that’s how oftentimes clinicians think about the ICF, but what it actually is is a taxonomy that within that you can have a number with decimal, like there’s seven decimals or what have you, because it breaks down each movement that when you do an ICF taxonomy assessment, you get all the way down to the nitty gritty of what’s happening with whatever function is going on with the patient.
Whitney Lowe:
Yeah, okay.
Niki Munk:
It can be really, really challenging. It takes time to do it. It’s hit or miss, but the concept of the model is really, really great and important. And, the reason that I’m talking about this is because there are others who now are taking this concept and are looking at trying to create a taxonomy for interventions. And while that can also be incredibly arduous … I mean, imagine you do an hour long session and now you’re going to come back and you’re going to do a documentation that says every single thing that you did in the intervention in the session. That’s crazy cakes. You can’t. It’s crazy cakes to think of doing that. But, what they’re also talking about is this creation of a model that when you’re thinking about what it is that you’re doing, that you articulate what the active ingredients are of your intervention and that you’re able to articulate the nonspecific ingredients.
Niki Munk:
They’re essential, but they’re not the main ingredients, but they’re beneficial ingredients. The therapeutic relationship, I would argue, is actually one of the primary ingredients to almost anything. But, there may be some other ingredients that have an impact but aren’t the main pieces, like the temperature of the room, the color of the room, the music that’s being listened to, the amount of time. All of these pieces, but if you’re able to articulate and point to … you don’t know for sure, but theoretically, what is it that you’re trying to do?
Niki Munk:
That helps put that intention in, and there’s this nice movement within rehabilitation for all clinicians to be thinking that way, and then also documenting those pieces. And most importantly is in the literature when you’re designing interventions to research, or what have you, that you’re articulating these necessary ingredients for the intervention so that we’re able to start looking while we may not be able to measure in this moment, this is what we’re expecting to happen at the cellular level. We’re at least able to articulate those pieces, again, making us better clinicians.
Whitney Lowe:
And, I would assume there’s probably a tendency just because of, at least the way science in the last couple centuries is more and more reductionistic in trying to isolate the individual variables that made the difference. What was it that really did that? There’s probably a tendency- one like, “Okay, is it the soft lighting? Is it the music? Is it the type of lotion that was used? What is the factor that really was the key thing?”
Whitney Lowe:
And, it seems a lot more difficult to try to find how to measure the whole, all those pieces together. And like you said, your work is very different from my work, which is very different from Susan’s work and Bob’s work and Steve’s work, and everybody else. So, how do you measure those kinds of things when you’re trying to determine efficacy, let’s say, for example, to a third-party payer about why they should support the use of massage for rehabilitation because we find it works? But, what piece of it really does that?
Niki Munk:
Right, exactly. And that’s the story of the elephant, right? You don’t see the elephant unless you look at all of its parts altogether, not just the tail or the tusk or whatever, and the same is true for massage in all manner of applied disciplines. And, this shift to pragmatic research is one of the pieces that’s trying to get at the whole of that. Now, there’s not one that’s better than the other, in my opinion. I think that all aspects of it are necessary. The reductionalist model, so that there are pieces that we can point to and say, “We know at this piece, this is what’s going on.” And then we’re able to come and see the greater picture. We’ve got to be able to take that information and apply it in other settings and situations.
Niki Munk:
And not all researchers do all of those different pieces. And in fact, because research can be so challenging, it’s important to be able to get those folks who are really, really good at this, for example, bench science, doing that bench science and then taking that information and going to the next level of research or being able to apply the information that is known there into the clinical realms of while we may not be testing that particular enzyme or that particular gene expression, or what have you, we can talk about in our proposals and in our discussion sections, which are basically the so what of the clinical findings that we have, that we’re able to translate it back to some of these mechanistic aspects. And that’s going to help all the way around from patients or clients feeling confident in the work that they’re doing with their therapists to also community trusting and respecting the work that we do, and elevating that in society’s eyes.
Whitney Lowe:
Yeah, right. So, I want to take this on a slightly different track here for a second and talk about some issues around consuming research for the average clinician who’s trying to learn how to do a better job of this. You listen to, or sit in on some of the discussions on social media or in groups of people, you’ll hear people claim that a particular perspective or idea should be supported and they’ll cite a paper on this particular claim. Why might they be getting led astray a little bit if they just rely on one paper only to tell them whether or not something is accurate or true?
Niki Munk:
Well, I’ll tell you what, I can break down that comment in several different ways. One piece, I’ll start with the easiest fruit here, truth and proof … Proof is the really hard one. Anytime I hear somebody say, “It’s proven.” No.
Niki Munk:
That’s a challenging piece. And, there’s strength of evidence. The evidence suggested in one paper, one study can’t have all the findings. And not only that, I would also caution folks away from that because citation isn’t necessarily done skillfully, and when you see a citation, that is supposed to mean that that is the study that demonstrated whatever it was that is being said. And I see a lot of citation of things like I might have said something, but it wasn’t the original source and I might be being cited for that. And that can be a little tricky as well, so being able to read and assess for yourself, as much as possible … We can’t read everything, right?
Whitney Lowe:
Yeah. Well, let me pick that up and follow along with something that is taking that from where we are here is that one of the other things that troubles me a little bit, and I hear this comment a fair amount from people, is the increasing number of studies that people say are just bad quality or poor quality. Let’s say, because methodology is not good or the inferences that come from that are really not accurate. And so, you got to be really careful when you cite something, because maybe it’s not actually really a good study, and there’s all this now pressure to publish in the academic world, whether or not something one’s really good or not. There’s a lot of stuff that goes through peer review process that really shouldn’t. How do you determine whether something is really good and valid to keep pursuing or citing or making reference to?
Niki Munk:
Sure. Well, and that right there is why it is so important to have some research literacy, so that if you’re able to go … and if you’re only reading the abstracts, or if you’re only reading the conclusion pieces, you can very easily be led astray. And it’s not necessarily that the outcomes aren’t necessarily valid. It’s just that they can sometimes … the strength of the evidence might be being padded a little bit. So if you’ve got a single group study, for instance, it could be a really great one group study, but it can’t be the end all to be all positive when there’s nothing to compare it to.
Niki Munk:
Right? And so to say then, “This proves that this is good for everybody.” You can’t make such huge claims like that. I think that we’ve actually gotten a lot better in our reputable journals, the ones that have really rigorous peer review processes, the potential for that junk research getting through … Junk research, that’s a really strong term, but I feel like it’s getting less. Now, certainly, there may be a lot more papers out there that okay, maybe it didn’t warrant its own publication all by itself. There had been a little more in there, because researchers get more points, if you will, for promotion and tenure the more they publish. Back in the day, if you published one paper a year, because it took forever to get things published, that was great.
Niki Munk:
But, we’ve got a lot of journals out there right now and there is a lot of pressure to publish. But, I don’t think that the troubling research that’s out there is because people are always being dishonest intentionally. I would warrant that there’s a lot of folks who get very advocacy-based in their work that they’re doing, and particularly if perhaps publications are coming from clinician researchers, but that aren’t necessarily research-researchers, and they may be just over-exuberant in their claims and discussion points around that.
Whitney Lowe:
Yeah, and I wonder … maybe you can tell me, too, your perspective of how much this happens. There’s a common parable story about a guy who is at night walking around in this town and he comes upon this drunk guy underneath a streetlight looking for his wallet. And he goes, “What are you doing?” And the guy said, “Oh, I’m looking for my wallet.” And the guy said, “Well, I’ll help you. Did you lose it here?” And he said, “No, it wasn’t here. It was actually over there where I lost it.”
Whitney Lowe:
He said, “Well, why are you looking here?” He said, “Because there’s a light here and I can see.” It makes me wonder, because I’ve heard from researchers sometimes what they study is what they happen to, for example, have equipment in the laboratory for or have a particular design or particular capability to answer this question but then is it really a worthy question? Is this really worthy of something I’m studying? Does that happen a lot or much, or do you see that occurring?
Niki Munk:
Oh, I would say so, and I would say so definitely because another piece is the discipline and the lens through which they’re conducting the research. So, if massage based research is being done primarily by, for instance, athletic trainers, there’s a lot of performance work out there about massage being used from a recovery standpoint or for running the fastest sprint, or what have you. But, those questions aren’t the types of things that a majority of those who are going to benefit the most from massage therapy are really going to be able to use. But, that’s the frame that they’re doing the work in.
Niki Munk:
So, short answer to your question, I love that. I’ve never heard that parable before. I’m going to start using it in my research classes because-
Whitney Lowe:
Yeah, it’s relevant.
Niki Munk:
That’s true. And then, it’s also what people can get funding for.
Whitney Lowe:
Right.
Niki Munk:
Research costs money and if you’re doing something that is not sexy at the time, like opioids are really sexy right now, COVID, really sexy right now. It might not be the best or most worthy questions in the moment or that mean the most to the field.
Whitney Lowe:
So wrapping up here, another thing I want to ask you, because I get asked this question all the time and I’m not the person who really should be answering this because it’s not something I’m involved with very much, but if someone wants to learn how to get more involved with research, either on the participating process or helping to design things, what’s the best way for somebody to get started doing that? I mean, do they need to have an advanced degree or how do massage practitioners, clinicians get more involved with the research end of things?
Niki Munk:
Yeah. Oh boy, there’s so many answers to that, and part of it is because there’s so many different ways that people can be engaged and involved in research. It can be as simple as being a good research consumer, being able to access Google Scholar and being able to access literature and read it and read it well to wanting to ask meaningful research questions and maybe collecting data in their practice. Because technically, we’re doing that all the time. We’re making clinical decision making and we’re not conducting human research as part of practice. But, we do experiment, right? Okay, I think this might be something that’s going on so I’m going to try this application. And so, this process of trial and error and seeing what works, building our clinical critical thinking and that expertise.
Niki Munk:
So, it may be as simple as just reading and consuming it, but it may be doing some of these trial … or being able to report back to the field through a case study and writing those pieces out and learning and then getting it published so that it’s actually read and seen. I know that was something that when I had my first client that I was going to go and do an in-home interview, and it was somebody who was in hospice and they had come home. They had three months to live and they wanted him to be as comfortable as possible. I went immediately to Google and tried to find information on what do I do? What’s step one? I happened to find a book and I was able to get it shipped to me really, really quick, so I could have at least some template to follow for myself.
Niki Munk:
But now going into a Google Scholar, you can type in some key pieces, and if there’s a case study out there, now you’ve got a template too of what you might try in your practice. So being able to potentially write a case report, getting it published so other people can access that.
Niki Munk:
Another way that somebody may be involved in research is actually providing an intervention for a research team. So there have been several instances where people have been in the right place at the right time. That’s not necessarily something you can just raise your hand and say, “I want to give an intervention for research,” because if there’s not a researcher in your area that’s doing that, then you can’t necessarily do that.
Niki Munk:
Another way to be engaged in research is through participation in research, of being an actual participant. So, if there’s research being done on the massage field, you could potentially volunteer to be a participant in that, and either be observed or provide survey information, or what have you. The Massage Therapy Foundation is getting ready to relaunch their PBRN, which is a Practice-Based Research Network, MassageNet, and that is to essentially put together a cadre of people who are interested in either being research participants themselves for the field, or perhaps this is another way that you can get involved in research is by implementing research in your practice through other researchers. For instance, there’s a great PBRN down in Australia, PRACI, that I was involved with the research study that was looking at lower back pain. And so, we were interested in people who were coming to receive massage therapy for the first time, and then we were going to follow them over three treatments or what have you.
Niki Munk:
But as researchers, we don’t necessarily have access to populations. I’m a researcher in an academic institution, but I don’t have patients that I see. I’m not part of the School of Medicine, and then I don’t have time anymore … I’m no longer a clinician, so I don’t have access to massage clients. And so, providing that link, if there’s a research study here and then clinicians can say, “You know what? I can do this research. I can help do this research,” and they may collect data for the researchers and send that back. There’s training and stuff that is involved in that, but that’s another way potentially, through Practice-Based Research Networks, that hopefully we’ll have up and running very soon again, that they could be involved in that way when research studies arise.
Niki Munk:
Or, you can go and get a PhD.
Whitney Lowe:
Yeah, there you go. You’ve mentioned a couple of times Google Scholar, and I’ve been surprised a number of times mentioning things in the classroom of people who didn’t know what that was. Can you briefly tell our listeners, people who are not familiar with that, what Google Scholar is?
Niki Munk:
I would love to, Whitney Lowe. Google Scholar is a branch of Google, but it’s specific to research literature. And it’s really nice, too, because it accesses what’s called gray literature a little bit more than a PubMed … and gray literature is other pieces like abstracts, sometimes even periodical articles, like magazine articles that aren’t necessarily peer reviewed. Because a journal is a peer reviewed publication whereas a periodical, even if it’s something that calls themselves a journal, they aren’t necessarily peer reviewed journals. They’re periodicals.
Niki Munk:
But, you can type in an individual’s name or you can type in a couple of keywords, like massage and pain, and you hit the go button and unlike Google that brings up all manner of things and products and what have you, it filters out all of that extra noise and it just focuses on the scholarly literature, patents and things like that, that might be engaged and involved in that.
Niki Munk:
And, you’re able to do some narrowing down. You can actually look up researchers, too, because there’s Google Scholar pages, such as LinkedIn, that you can have Google Scholar information biographies. I’ve got a Google Scholar. You can look me up.
Whitney Lowe:
Hey, well, we’ll do that. I’m going to do that soon as we’re done here, see what I got from you. Excellent.
Whitney Lowe:
Well, Niki, thank you so much for your time here. This has been a delightful conversation and a delightful insight into a lot of things around research. And, I just think we’ve got a lot of fascinating things ahead of us on this road looking into the whole world of massage and figuring out what really happens with us and what are we doing that’s helping people in all these different ways? So, I want to applaud you and thank you for all of your work in this arena of marrying the world of academics with massage therapy, because we sure need a whole lot more people doing that kind of thing. I certainly applaud and thank you for all your efforts doing those things over the years.
Niki Munk:
Thanks, Whitney. I appreciate that. I’ve had so much fun doing it, and whereas when I first started this journey, this academic journey, I had no idea that this is where I was going to end up. And, when I decided to go into the faculty realm and research all the way, I had delusions of grandeur perhaps of being a huge research scientist, and I’m realizing I think the place where I’m going to land and try to make my best splash is yes, I’ve got research out there and it’s making an impact but I think it’s going to be in helping to develop the next generation and the people that are going to be the big researchers in our field.
Niki Munk:
We’re still very young in our research development, and that training piece is so important, and training massage clinicians who have the interest to go to that next level and get that higher degree, helping to cultivate them and mentor them into those larger spheres of huge NIH funding and science funding and things like that.
Whitney Lowe:
Yeah. Well, that’s wonderful. I can’t think of anybody better to do that, so thank you for all your efforts-
Niki Munk:
Oh, you’re so nice.
Whitney Lowe:
Yes. So Niki, if people want to find out more from you, connect with you, how can they reach you, find out more about what you’re up to?
Niki Munk:
Sure. So, I’ve got the Google Scholar page and I’m also on a ResearchGate. LinkedIn, I am not a social media person, so I don’t have any of those pieces, but old school email, I’m at [email protected]. I tend to have a pretty slow response time, unfortunately, because I am so focused on the academic work as chair of the department. It’s a lot of work. But, I do try to get back in touch with folks. And of course, at conferences, I go to many of the conventions and conferences and things, so I’m always happy to meet people there too.
Whitney Lowe:
Wonderful. Well, we sure thank you for carving out some time for us today to have some discussions to explore this a little bit further. So, thanks again so much and it was really delightful.
Niki Munk:
Thanks, Whitney. See you next time, or see you soon hopefully.
Whitney Lowe:
Yes, I hope so too.
Whitney Lowe:
And, please remember the Thinking Practitioner Podcast is supported by ABMP, the Association Body Work and Massage Professionals. ABMP membership gives professional practitioners like you a package, including individual liability insurance, free continuing education and quick reference apps, legislative advocacy, and much more. ABMP’s CE courses, podcasts and the Massage and BodyWork magazine always feature expert voices and new perspectives in the profession, including both Til and me. Thinking Practitioner listeners can save on joining ABMP at abp.com/thinking.
Whitney Lowe:
So, we would like to say a thank you to all our sponsors and of course, to all of our listeners. Thanks for hanging out with us today on this discussion. You can stop by our sites for show notes, transcripts and extras. You can find that over on my site at AcademyofClinicalMassage.com, and also over on Til’s site at Advanced-Trainings.com.
Whitney Lowe:
Please do send questions or things you’d like to hear us talk about. You can email us at [email protected], or look for us on social media under our names, Til Luchau and mine, Whitney Lowe.
Whitney Lowe:
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Whitney Lowe:
And of course, if you’re unable to find us in any of those locations, you can spin your finger around a Tibetan singing bowl, counterclockwise if you’re in the Southern hemisphere, and you can hear us right there. Thanks again, and we’ll see you next time.
