Massage Therapy Body of Knowledge

Comment

Comment by Keith Eric Grant on October 25, 2009 at 4:02am

Don said

The Health Professions Act Allowed for not only Title protection but ‘scope of practice’ restriction. Put another way, not just the name but action was restricted. It was therefore possible to enforce practice monopolies based on theses scope of practice statements using both the Act and the Regulation.

This statement seems antithetical to what I read in BC's statement on their new Shared Scope of Practice model that came with reformation of their system in the 1990's (following Ontario's similar reformation)

Under the new regulatory framework set out in the Terms of Reference, scope of practice statements for health professions will no longer be exclusive. Henceforth, a scope of practice statement will define an individual profession's activities in broad, non-exclusive terms. Defined in these terms, aspects of the scope of practice of each health profession may overlap, or be shared, with those of other health professions.

Within this framework of shared scopes of practice, the Terms of Reference recognize that certain tasks or services performed by a health profession may carry such a significant risk of harm to the health, safety or well-being of the public that they should be reserved to a particular profession, or shared amongst qualified professions. The only restrictive element of a profession's scope of practice will be any reserved acts within that scope.

Thus, unlike the present system in which each profession is granted exclusivity within its entire defined scope of practice (subject to specified exceptions), only those acts which present a significant risk of harm will be reserved. In short, the government has assigned the Council the task of creating a regulatory model based on broad, non-exclusive scope of practice statements and narrowly defined reserved acts.

Don is talking about being able to enforce practice monopolies while the foundation documents of the the model is talking about exactly the reverse. The six member Health Professions Council Scope of Practice Update to the Preliminary Review notes that "The Council has seen no evidence that massage therapy carries with it such a sufficient risk of harm to warrant making any portion of its practice a reserved act". In fact, the statement goes further:

In the Council's view, the College's request for these proposed new reserved acts is an attempt to reserve the entire scope of massage practice. If the College's rationale were adopted and if the proposed reserved acts were added to the Reserved Acts List and granted to massage therapists, the practice of unregulated massage practitioners would be inhibited. Every act of massage could be subject to investigation and evaluation of the intent of the massage practitioner. To accede to the College's request would result in an unwarranted infringement of the public's right to chose a massage practitioner.
The Council has seen no evidence that massage therapy carries with it such a sufficient risk of harm to warrant making any portion of its practice a reserved act.

It later on grants exclusive use of the title "Massage Therapist" and abbreviations thereof while noting that

The title "Practitioner" has not been recommended for any other health profession and its reservation for the exclusive use of registrants of the College might impede others who are practising massage.
Therefore, the Council recommends a single title for registrants of the College.

So, while the act allows for restriction of scope of practice based on reserved acts, this does not to be what the HPC chose for the practice of massage therapy, instead recommending a single title protection and being protective of unregulated massage. And, as Don has noted, a very extensive model aimed toward the health care system. It is also notable that the document is very clear about the scope of massage:

The practice of massage therapy is the assessment of the soft tissues and joints of the body and the treatment and prevention of dysfunction, injury, pain and physical disorders of the soft tissues and joints by manual and physical methods to develop, maintain, rehabilitate or augment physical function, to relieve pain and promote health.

The use of the statement "by manual and physical methods" is indicative of what this scope of practice does not contain.

Comment by Stephen Jeffrey on October 25, 2009 at 3:21am

Thankyou Don, have a great trip to Amsterdam.
It sounds like your scientificaly based massage therapy profession is completely trusted and respected to function/diagnose appropiate massage in any given health or medical areana negaiting the need for constant supervision by senior medical staff. Therefore it becomes easy to understand the increasing number of hours required by your profession.

Comment by Mike Hinkle on October 25, 2009 at 12:29am

Wow, Don! Thanks!

That was some interesting reading. Mostly it made me feel sad about those saying we need to do away with licensure and at the same time contemplating our entry into any healthcare field.

I find our system lacking a lot. Canadiens are self-emposing more education and we are crying for less. We have a lot to learn before we can begin to even consider that merger.

Comment by Mike Hinkle on October 25, 2009 at 12:24am

You have a great point Greg!

Comment by Greg Jones on October 25, 2009 at 12:20am

In my opinion 250 hours is inadequate training. I have received many massages from graduates of local schools with over 700 hours and they would often have problems with basic swedish technique and most could not answer simple A&P questions. I have found this primarily with schools offering a smorgasbord of training. They have the hours, but there has been no consistency in their training, and are fragmented in their process.

Another major issue with MTBOK is to get the states to go along with it and to do something about it, like truly regulate the massage schools curriculum. Arizona's state board of massage has had such sever cuts they will no longer be putting our pictures on our license. The first year the state took over massage licensing they didn't put pictures on the licenses which caused a great deal of fraud. If we can't get pictures on our licenses how can we expect them to police the schools they certify? Without addressing massage school accreditation I don't think I will see the consistency I would like to see in the industry.

Comment by Don Solomon on October 24, 2009 at 11:59pm

Dear Keith, Mike, Stephen, Bert and Group
Like the USA, Canada has had a rather checkered history with regards to the regulation of Massage Therapists. Currently Massage Therapy is regulated by provincial statute in only 3 provinces British Columbia, Ontario and Newfoundland/Labrador. Put another way about ¾ of the Provinces have no regulation. Alberta is currently in the process of regulating their Massage Therapists. British Columbia is the only Province to currently include Massage Therapists with in the socialized health care system.
The current regulatory framework for health care professions has undergone a major change over the past 10 years. The Health Professions Council (HPC) (a 3 person Panel of Non-medical Members) conducted an exhaustive overall of the regulatory system governing health care professions in British Columbia between 1993-2001
Prior to this overhaul Massage Therapists and Physiotherapists had been covered under the same regulatory structure and regulator body called the APMP. However, in 1992 The Heath Professions act was adopted. This allowed Physiotherapist and Massage Therapists to separate and form their own regulatory Bodies, The Collage Of Massage Therapists’ of BC and The College of Physiotherapy of BC respectively. The Health Professions Act Allowed for not only Title protection but ‘scope of practice’ restriction. Put another way, not just the name but action was restricted. It was therefore possible to enforce practice monopolies based on theses scope of practice statements using both the Act and the Regulation.
I lifted the following out of a submission the CMTBC made to the HPC back in 1999
From its inception, massage therapy in BC has been employed as a rehabilitative and therapeutic technique, rather than simply a method to help people relax.
For almost 50 years, starting in 1946, massage practitioners had a co-regulation relationship with physiotherapists.
Since the inception of Canada’s national medicare system in the 1960s, massage therapy has been an integral part of the medical model of health care in BC.
The BC government led the way in Canada and across North America by recognizing that massage treatments were medically necessary and should be publicly funded. The resultant access by massage therapists to Medical Service Plan payments has, in turn, increased the need for more precise medical knowledge on the part of massage therapists.
Accreditation ensures that each of the massage therapy schools operating in BC provides students with the same level of knowledge and skills essential for the safe and effective practice of massage therapy.
Registration requirements are the public’s assurance that only persons deemed safe to practice according to BC standards – i.e. meeting the expectations of referring physicians and the standards of practice of the profession – are granted registration. (1)

The afore speaks to the need to maintain and indeed push the education boundaries forward. Plus to require the schools provide that knowledge be accredited by the CMTBC.
It is this careful attention to education detail I should like to touch on now.
Many of you will be familiar with the concept of layered education.
‘The taxonomy of learning’ as it where.
Introduce, Assimilate, Integrate
First, you introduce knowledge
Next, the person assimilates that information.
Lastly, they integrate that knowledge into their practice
It is this approach that sets the British Columbia Massage Therapist education apart from other Regulated Provinces. And this is accomplished through careful accreditation standards overseen by the CMTBC ‘Core Curriculum’
What follows is another excerpt from the submission the CMTBC made to the HPC back in 1999. This was originally authored by Dr John Yates, PhD in his book A Physician's Guide to Therapeutic Massage (2nd ed), in which he made the following observations concerning the
training received by BC's massage therapy students:
Principle-based therapy vs. recipe-based massage practice Massage therapy training programs of less than about 2000 hours (i.e. approximately five to six semesters of full-time post-secondary instruction) commonly focus on teaching massage techniques, or even massage "routines" learned through imitation, together with formulas or "recipes" for treatment of specific conditions. These treatment recipes are coupled with codified lists of contraindications to treatment.
This approach assumes that the abnormality responsible for the presenting complaint is either already known to the client (perhaps as a result of having visited a physician), or that the practitioner will be able to recognize it as one of the common lesions covered in their training based upon a classic presentation of history, signs and symptoms. Often this is not the case, and it is not uncommon for massage practitioners so trained to resort to oversimplification or apply non-scientific paradigms in their attempts to obtain a diagnosis to guide them in their selection of treatment methods. Undue emphasis is often placed on intuition in the absence of both a basic foundation of knowledge and adequate supervised practicum experience for the development of intuitive skills.
Safety issues are similarly dealt with by determining whether the client is aware of, or the practitioner can identify by observation and history taking, the existence of conditions for which the selected treatment is contraindicated.
Having somehow identified the nature of the presenting condition and ruled out any contraindications, a treatment or series of treatments is provided according to a formula.
Because the choice of techniques for treatment is defined by a formula,
treatment tends to be technique-centred rather than client-centred. This is not to say that the practitioner does not modify and adapt the formula based on his or her observation and experience, but such modification is limited by their knowledge and training. With sincere dedication and much experience, some practitioners can transcend the limitations of their training and become very skilled and effective. There are also numerous post-graduate workshops available to massage practitioners that provide further training in more sophisticated assessment and treatment techniques. Unfortunately, it is quite rare for those with lesser levels of formal training to seek further education in the basic health sciences of anatomy, kinesiology, physiology, and pathology that are required for the transition to a principle-based approach to treatment.
Principle-based therapy requires the formulation of an overall treatment plan directed towards the achievement of specific treatment goals. These goals are determined by the causal factors involved in the presenting condition, the type and degree of tissue involvement, and the therapeutic potential of available treatment methods. Appropriate treatment techniques and modalities are selected, integrated, and adapted as necessary in order to achieve specific effects, and are modified according to the changing physiological and psychological state of the patient as treatment proceeds. Treatment is therefore patient-centred rather than technique-centred.
Principle-based therapy requires that the therapist be able to:
- identify as closely as possible the underlying cause of the patient's complaint;
- understand the pathophysiological processes responsible for the patient's signs and symptoms;
- understand the physiological effects of the techniques and modalities available for treatment, and their potential interaction with the pathophysiological processes they attempt to alter;
- formulate specific treatment goals, devise a treatment plan by which to achieve those goals, and select, integrate, and adapt treatment methods accordingly;
- apply treatment competently and safely;
- continuously evaluate the impact of treatment on an ongoing basis;
- modify treatment as necessary due to the presence of other conditions and according to the patient's response to treatment.

He goes on to talk about: Standards of training
Massage therapists with the skills and abilities described above are the product of a high quality educational process where adequate time and resources are devoted to health sciences education and the development of diagnostic assessment skills, as well as application skills. A curriculum meeting these requirements has evolved over a period of 15 years of careful development in British Columbia, where the profession has consistently demonstrated its belief that therapeutic massage requires adequate training for safety and effectiveness. It has been our experience that a minimum, or threshold, for massage therapy instruction using a principle-based rather than a recipe-based approach to treatment is approximately 2000 hours. Between 700 and 1000 of these hours must be in the basic health sciences of anatomy, physiology, kinesiology, and pathology. Adequate training in assessment techniques, soft tissue diagnosis, and history taking requires a minimum of 150 hours, and must be complemented by supervised clinical practice experience in the form of internships.
A 2500 hour program of instruction using the principle-based approach to therapy was introduced 1983. In recognition of the considerable time that is required to learn and truly master the many skills required to become a competent massage therapist, members of the profession recently chose to increase the minimum standard of training from 2200 to 3000 hours, effective in 1998, even though for more than 13 years British Columbia had the highest standard of training in North America.
Four major categories of instruction are defined in the Curriculum Standard for BC, collectively constituting a total of 3000 hours of training, in Health Sciences, Professional Development, Clinical Sciences, and Clinical Practicum. This is comparable to RN, PT and other university science baccalaureate programs. Both content and performance standards are defined for all categories of instruction.
Of the 3000 hours, 2440 hours are classroom instruction and 560 hours
consist of clinical practicum. One third of the 3000 curriculum hours are devoted to the Health Sciences, including anatomy, physiology, kinesiology, and pathology, and with a special emphasis on musculoskeletal anatomy and kinesiology; neurology (including CNS physiology of motor control, sensory physiology, the physiology of pain and pain modulation, and interactions between pain and motor physiology); pathophysiology of inflammation, healing, and repair; and orthopedic pathology. This curriculum standard recognizes that the health sciences provide the foundation for clinical and practical training in massage therapy, and are required for the performance and, most especially, the interpretation of clinical/physical assessment techniques.
Assessment affects choice of treatment modality and the ability to adapt treatment to tissue conditions and patient needs in order to achieve safe and effective treatment.
1270 hours of Clinical Sciences education includes extensive training in diagnostic assessment and treatment planning as well as in clinical case management and treatment applications and technique.
Soft tissue diagnosis is an essential first step in formulating treatment and applying massage therapy or some other form of active or passive intervention to the soft tissues. (1, 2)
A list of Review material is available on the CMTBC web site at http://www.cmtbc.bc.ca/article_35.shtml

You can see from the above that the CMTBC sought not just to create a minimum standard that students could squeak by but instead, to create a robust training program that would serve to bring massage therapists into practice with fully a integrated knowledge bases. Indeed, the CMTBC went one step further and required a heavy emphasis on research. As a result the 3000 hour graduates from theses programs are starting to play a leadership roll in Research Manual therapies.

My Back ground is: I was trained back in 1984 in Auckland New Zealand. I had to retrain when I chose to live in British Columbia. I studied first year sciences then studied Massage Therapy at the West Coast College of Massage Therapy in the 2500 hour program 1990-1993. I sat on the board of directors of the Massage Therapists’ Association of BC (MTABC): 1992-1993 as a non-voting student board member; 1993-1995 as full board member and was committee member on many committees. In 1995 resigned MTABC Board to take up a position on the College of Massage Therapists’ of British Columbia (CMTBC), Or professions regulatory Agency. I served on the board of directors from 1995-1999 and served on several committees as chair and member at large those committees are:
Scope of Practice Committee
The mandate of this committee is to monitor the current scope of practice of the profession, as defined under the Act and Regulation, and propose amendments to the scope of practice. The committee also represents the College before the Health Professions Council and other agencies on scope of practice and related issues.
Unauthorized Practice Committee
The mandate of this committee is to receive and investigate complaints concerning nonregistrants who are using one of the protected titles or otherwise practicing massage therapy contrary to the Act and Regulation.
Inquiry Committee
The function of this committee is to investigate and attempt to resolve complaints concerning Registered Massage Therapists.

Communications Committee
The function of this committee is to improve communication, both within the profession and with the general public and other health professions.
I am now engaged in Private Practice in West Vancouver, BC, Canada and am enjoying the simple life (when I’m now jet setting off to Amsterdam for Fascial Conferences that is  ).
I will be away from Oct 25th to November 1st so will not be up on Massage Professionals till I get back.. Bye for now.. I look forward to reading the discussion when I return.

Yours truly,
Don Solomon, RMT (Vancouver, BC, Canada)

1. 3) CMTBC's November 17, 1999 supplementary response.
2. From A Physician's Guide to Therapeutic Massage (2nd ed), Dr. Yates contact MTABC to purchase a copy http://www.massagetherapy.bc.ca/

Comment by Mike Hinkle on October 24, 2009 at 11:32pm

And you are correct about being lucky, not having to have the state cut funds. It is a shame, legislators are doing that, when the FSMTB is doing such great work. Those boards need funded more, not less.

Wow, that is a smorgasbord. I really feel for CA. I could take years to get the education someone could in other states in a shorter time. The scheduling aspects alone were complex as you have to wait for classes. I do understand you are just getting going.

Question: Esalen; is that class at Esalen Institute?
Also you can teach enough A&P, Business, ethics/hygiene and Swedish in 100 hours? I understand they have to take an accompaning class for 150 additional hours.

Different, but well thought out. I think some states with comparable hours were charging more. I just really don't like tier systems.

Comment by Keith Eric Grant on October 24, 2009 at 10:50pm

If you click on any individual program on this page you should see a cost breakdown for that certificate program in the upper left.

Carl, except for some exceptions is largely wrong if he believes that 100 hours is generally viable. 100 hour local licenses have become considerably more of a rarity even in the last five years as a number of cities changed ordinances that hadn't been updated in a while or that previously didn't have ordinances. A fair number of the new ordinances fell in the 250-300 hour range, largely consistent with CAMTC's entry tier.

California's new certification law is a mixture. At the state level it is voluntary. Local agencies have the option of passing ordinances that allow no avenue for practice except certification by CAMTC. If that action was widespread enough, the certification would no longer be effectively voluntary and that could raise anti-trust issues since CAMTC is not a state agency, even though a beast of the state.

The board does have considerable disciplinary discretion, to my knowledge. If it pulls a certificate, the individual is back under the control of local licensing laws. It only started issuing certificates in the last several weeks, so there is little information on their effect. There are still some definite issues with cities that don't want to give up local control. That could result in legal challenges or an end-run to legislatively gut the law. On the positive side, CAMTC's budget is independent of the state budget and the mess that's in. CAMTC is also not affected by state hiring freezes, furlough orders, or suspensions of travel by state employees. CAMTC fees can also not be raided by the state to balance other budget sections. All of these things can and have happened to state licensing boards. From what our representative gleaned from the FSMTB meeting, other boards in some states are getting their funds raided. CAMTC can be very glad to only be under state review and not be part of the state itself over the next few years.

Comment by Mike Hinkle on October 24, 2009 at 10:19pm

I understand, yet I have reviewed your answers and I see no cost. Could you direct me to that entry? If you wish to discuss things off-line, just send it that way. I am being open for all to see. When I agree with something I say so and when I think something will have the profession backslide I say so as well. I mean you no ill feelings or am trying to challenge your servitude. You have done the best you can with what you have had to deal with. I simply hope the nation doesn't follow down that road. It was prepared based on CA's situation. It will present more problems and not advance the profession in my opinion. That doesn't mean that those that do decide will vote the way I see it.

I keep saying 100 hours because Carl said this was still in practice. I think it is wrong. That won't change your program. Neither will 100,000 therapists outside of CA, if they felt that same way. Your legislature, as with every state, will make the final decisions on laws in their state.

I appreciate your time and opinions on this project. We will agree on some and some will probably rub each of us in different ways. I think we are both capable of handling these discussions. Shall we continue? Just point me to the costs numbers and let's ....

Comment by Keith Eric Grant on October 24, 2009 at 9:58pm

Mike,

How will those already be licensed be handled in any change that leads to greater uniformity between states? Generally by grandfathering. If the states identified particularly serious learning gaps, they could always have people pick those up as directed CE classes, which is a specific purpose for applying CE. One example would be if it were determined that all licensees should be aware of cervical arterial dissections and stroke symptoms and it was not definite that this was uniformly the case.

What I was referring to in terms of nonprofessional demeanor was this. As far as I know, everyone active in the discussions here has been or is making significant contributions to the massage profession. They are also using their good time to provide their insights to this professional discussion. I believe that appreciation is more appropriate and professional than deriding other professionals in a public place. Some things are best said privately or not at all.

you keep referring to 100 hours despite my repeating multiple time that the minimum certification level under CAMTC is 250 hours. At one time, a 100 hour certificate would get you locally licensed. Except in the northern reaches of California, this is not common now (several cities have updated their laws in the last 5 years) nor do I expect it to become more common. In the current paradigm, even in a modular program, one would have to combine an initial 100 hour certificate with a subsequent 150 hour certificate to be able to practice. Nor have I been mentioning particular certificates except in response to your question on content and cost. I have now iterated this point several times. Please go back and look at my post of an hour ago on this same matter.

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