Massage Therapy Body of Knowledge

Comment

Comment by Carl W. Brown on October 18, 2009 at 11:31am

Keith, I think the misunderstanding is that they never specify the degree of KSA mastery needed so for them it must vary based on modality. That would make a very crazy testing system.

Looking at the MTBOK starting with 387 is just says “Atomic”. I presume that since the next category is “Chemical/elements” and that we are dealing with bodies that the chemistry is organic and as we all know includes inorganic which is a prerequisite.

So if I had to guess based on the other KSA’s in the list I think one would have to know atomic orbitals (energy shape & orientation), Coulomb’s law, electron shells (s, p & d), ionic bonding etc.

On the other hand I suspect that while most MTs know that atoms exist I doubt that they use that knowledge in their everyday work, at least the MTs I know.

In fact I am willing to bet that 99% of doctors have forgotten most of their chemistry and when they look at a drug insert and see the molecular structure of the compound their eyes glaze over. They learn about drugs from the pharmaceutical companies and know their classifications, actions contraindications dosing etc. but not their chemistry.

So what happens if an MT does not remember their atomic structure? Does it make a difference to their performance?

If someone who does CST does not know all the bones in the skull or cannot feel Craniosacral rhythms I agree that they are worthless at what they do but there are hundreds of other modalities that this knowledge is not needed.

If I were to study as an EMT there are things that I need to know or people will die, but there is a lot of medicine that they don’t kneed to know. I think that if you had one test for all medical professions and set the levels of each KSA to the minimum level that any one of the professions needed for safe practice the poor person would get have dementia set in before they learned it all.

KSAs without standards are like a shopping list with no quantities. Unlike the shopping list you don’t have the opportunity to buy 1 gram of flour for the cake. But if that is all you buy you might as well buy none and just cross it off your list. However, buying a 50 pound sack of flour makes no sense either, it is over kill. You might as well add quantum physics to your study of the atom.

While we are on the subject of quantum physics you might add “What the bleep do we know” to add fiction to fact. I am sure that unless you add physics to the list it will probably be distorted by their massage teachers.

Comment by Keith Eric Grant on October 17, 2009 at 12:37pm

Carl,

Separation (and/or separability/granularity) of essentially independent KSA (knowledge, skill, & ability) clusters is definitely the way the world of business and health care is moving. One of my Twitter contacts (@CompetencyMgmt) recently posted a link to a summary page of their competency management tools/skills. In addition, I see this same focus on learning gap identification, individualized educational trajectories, and competency profile management bought to health care via the working groups of the MedBiquitous consortium of medical societies and schools. All of this is enabled by changes in technology, including such tools as the Protégé Ontology Project, ontology being the structuring of knowledge. There is now, in fact, a relatively new profession/discipline of medical informatics at schools such as Stanford, University of Washington, and Oregon HSU. So, in this era, is does concern me that the massage BOK effort does not seem to be drawing on appropriate outside expertise in these areas. Bill Hersh, chair of the med informatics department at OHSU, writes a blog on health care informatics. With the rate that knowledge management has and is developing, the BOK committee may well be operating beyond their area of competence relative to current standards and expectations. A BOK, by its very nature as a claim to knowledge, does invite outside critique and analysis of its structure and underlying research and clinical basis.

I might also had, that a substantial part of the scientific, medical, and science writer domains are more than usually "sensitized" to unsupportable claims (i.e. things not having a sound basis) following the ongoing drama of a libel suit against science writer Simon Singh by the British Chiropractic Association for a relatively innocuous statement that they were "happily promulgating bogus treatments", relating to claims of curing childhood asthma, allergies, ... British libel law differs from U.S. law in placing the burden of proof on the defendant. In any case, such a suit is a stark violation of the social ethos of scientific and medical endeavor. Much of the details and relevant links are available on a blog by Allen Green as Jack of Kent which also links to an editorial in the British Medical Journal. Edzard Ernst has also been writing and reviewing the solidity (or lack of solidity) of CAM claims.

So, in this world context, it greatly behooves one to be conscious of both the structure and granularity of knowledge and the basis for claiming it is "knowledge" and not merely systems of belief or practice. What is done will get looked at critically. As Edzard Ernst put it: "An uncritical scientist is a contradiction in terms".

Comment by Carl W. Brown on October 17, 2009 at 9:43am

In the computer field each specialty has its own BOK. Those specialties that have written certifications focus on the specially alone. It would be meaningless to rites a single test to cover say web design, scientific programming, microprogramming, device driver design, local area networking, security, internationalization etc.

If I want a facility manager than I don’t want a financial application programmer.

If you wanted a geologist to work for your mining company would you hire someone who majored in geology or someone who graduated from a school who required 120 semester hours of classes and a bachelor exam that spanned all majors with questions ranging from French literature, physics, black studies, macro economics to psychology?

Combining divergent BOKs into a single test just invalidates the test. Combining different disciplines into a single BOK invalidates the BOK because there are portions to the BOK that are irrelevant to performance. The whole point of a BOK is that it contains a set of KSAs that are all essential to performance.

Comment by Carl W. Brown on October 11, 2009 at 5:27pm

Keith, I just had a client who had gone to a Feldenkrais practitioner and I explained who he worked on the dynamic parts of the problem an I work on the static ones. They complement but take totally different perspectives to do. While some modalities build on others, many forms of bodywork have very little to do with each other. However when individualizing the work one may take from very divergent modalities but that doesn’t mean that by choosing a specific path you are not also ruling out others.

Comment by Carl W. Brown on October 11, 2009 at 5:14pm

When I did internationalization work, adapting computer programs to different languages and cultures, I discovered that a cultures strengths were also its weaknesses. For example I feel that American inventiveness’ comes from the fact that we are such poor planers and we need to be inventive to get us out of the jambs we get ourselves into. In Japan for example they will do nothing rather than make a mistake while if we try 10 things and one succeeds we are happy. If we figure out how to solve a problem we often loose interest before we have even started working on a solution but the Japanese while that don’t take risks love to hone ideas and perfect tem. We will live with faulty products as long as they are new and interesting the Japanese will not.
As Keith pointed out Swedish and other forms of massage are like dance. It is dynamic involving both parties and good body mechanics not only affects the giver but the receiver as well. However my “muscle whispering” is static in nature movement breaks to communication with the body because you are moving form place to place without any true focus. Heightening your tissue listening skills also is distracting when you are gliding over the body. Your focus is totally within the client and it is not you and them but you feel pain, problems and emotions within them. You cannot be a part of this. With Swedish you focus of fixing problems you find by instead I find that you have to discover how the body will best fix itself. With deep tissue it is how to affect change and when it does not happen how to use more force without hurting yourself or the client. With my work it is learning how to back off. Treatment is very different in that rather than assessing the problem treating it and checking the results, you have to back off from the left brain thinking because it is filtering you deeper right brain perceptions. If I am not getting anywhere it is probably because I think I know how to fix the problem.
I believe that 500+ hours of Swedish training would make it almost impossible for a person to become a “muscle whisperer”. It would be like being raised in this country speaking English and then trying to learn another language without any English thought contamination.

Comment by Mike Hinkle on October 10, 2009 at 10:05pm

Sorry, it's taken me so long to get back to you. I had to go to Nashville to the FSMTB Annual Meeting. Therapists would be so proud of their State Boards if they only knew how hard these folks are working to organize this profession. It was a real eye opener. Folks, with the FSMTB in place, we are in good hands. It was so great to see the level of professionalism.

Comment by Carl W. Brown on October 9, 2009 at 12:30pm

Keith, I agree with you about Swedish. It is a form of dance. If you don’t feel it with your whole body and match with your client, you will only produce an awkward and disconnect session.

The way I practice is also communication but very different from dance. I dialogue with the tissues I feel pain, discomfort and embedded emotion in the tissues. It is an entirely different focus from Swedish. I found that as I got better at Swedish I started to lose my talents and after completing my massage school I had to unlearn it. It took years to recover my skills and I only had 140 hours of Swedish. Now if I try it do Swedish it is a total disaster.

Comment by Keith Eric Grant on October 9, 2009 at 11:12am

Carl,

On your comments on training, just below. Yes, I have a number of issues of divergence with the training "framework" that has been pushed over the past 15+ years. Massage practice has some marked similarities to learning to dance or playing a musical instrument and the issues of developing proficiency have been markedly ignored. Proficiency only begins to happen when people start on a progressive program of learning in practice -- i.e. start simply, and add complexity as you develop expertise. One of my earlier formal writings, although dated 1999, was started in about 1996 in response to this lack. Doug Barhorst recently commented to the same side of the aisle in suggesting that one of the best ways for a new graduate to improve their practice would be to take classes in ballroom dancing -- i.e. to learn to perceive and work with others at a level of nonverbal communication and perception.

I am often reminded of a quote by Charles Kettering:

In 1941 on a similar occasion, he observed, "If we taught music the way we try to teach engineering, in an unbroken four-year course, we could end up with all theory and no music. When we study music, we start to practice from the beginning, and we practice for the entire time, because there is no other way to become a musician. Neither can we become engineers just by studying a text book, because practical experience is needed to correlate the so-called theory with practice." Thus Kettering reiterated his belief in the value of a practical education, a blending of theoretical knowledge with experience and common sense, to do the right thing at the right time.

Kettering's thoughts are consistent with more recent field research on the development of expertise by Patricia Benner (et al.), Gary Klein (et al.), and Hubert and Stuart Dreyfus in sources I've already referenced or that are references in the "guidelines" paper I linked to earlier.

Ultimately, any body of knowledge will be non-singular and get compared with other efforts. There has already been one massage ontology (structure of knowledge) published, and I believe more efforts are underway by our neighbors to the north. Any document produced will be subject to ongoing critique. As with making wine, care and time are required or the "tasters" will be merciless. (largely off topic, but I recommend seeing the movie Bottle Shock which considers such issues). You really do have to capture the nuances of massage as a kinesthetic skill, a perceptual skill, an interpersonal skill, a business skill, and a cognitive skill -- there is a lot of tacit knowledge as well as explicit knowledge that can be included in consideration and conveyed much as with music and dance training. The motivation and love of the art have to come from within, although they can be sparked by good example.

Comment by Carl W. Brown on October 9, 2009 at 11:11am

Keith, to the “Reliability/reproducibility” item I would add that it requires that the other set of experts independently develop the standards and come up with the same results. If they we all taught the lactic acid myth then that would not make it right. If they were all taught in schools teaching to the NCE it would seem that it would influence their view of a BOK.

Comment by Keith Eric Grant on October 9, 2009 at 10:21am

Carl, your note on CIs and precautions points out one of the problems with building a body of knowledge quickly and without thorough review of information; you can't rely on massage texts as primary sources of information or on their necessarily providing accurate information. One often has to go back to research papers or texts, for example, on exercise physiology. Inherent in a BOK is that one is formalizing both the structure of a domain of knowledge and, at the level of detailed covered, the content and connections with needs of practice.

There was a relatively recent meta-analysis of contraindications for massage done my Mitchell Batavia and published in the Journal of Bodywork & Movement Therapies.The results were not encouraging as to consistency of recommendations or as to referencing back to primary sources of information (i.e. establishment of an objective basis). One cannot effectively establish a body of knowledge without either establishing an objective basis for the knowledge or providing a discussion of the basis in clinical experience and sources of that experience. lack of establishing such a "paper trail" of documentation also precludes any meaningful periodic review from comparison of prior information and inclusion of new research.

Necessary in the included in consideration of CI's are the context of practice and the possible need for modifications due to co-morbidities. One of the notable features of the British Columbia competency profile is, I believe, inclusion of a specific list of co-morbidities affecting practice.

In the Massage Therapy Foundation's Best Practices Committee's first report to the community, we quoted from an Institute of Medicine's report on principles for creation of guidelines. My belief is that these are also, with slight modifications, applicable to creation of a body of knowledge.

One of the early results of the AHCPR effort was the report Clinical Practice Guidelines: Directions for a New Program, published by the National Academies Press in 1990(17). A major conclusion of that report was that clinical guidelines should be founded on eight key principles:

• Validity: Practice guidelines are valid if, when followed, they lead to the health and cost outcomes projected for them, other things being equal. A prospective assessment of validity will consider the projected health outcomes and costs of alternative courses of action, the relationship between the evidence and recommendations, the substance and quality of the scientific and clinical evidence cited, and the means used to evaluate the evidence.
• Reliability/reproducibility: Practice guidelines are reliable and reproducible
  • (1) if—given the same evidence and methods for guidelines development—another set of experts would produce essentially the same statements and
  • (2) if—given the same circumstances—the guidelines are interpreted and applied consistently by practitioners or other appropriate parties. A prospective assessment of reliability may consider the results of independent external reviews and pretests of the guidelines.
• Clinical applicability: Practice guidelines should be as inclusive of appropriately defined patient populations as scientific and clinical evidence and expert judgment permit, and they should explicitly state the populations to which statements apply.
• Clinical flexibility: Practice guidelines should identify the specifically known or generally expected exceptions to their recommendations.
• Clarity: Practice guidelines should use unambiguous language, define terms precisely, and use logical, easy-to-follow modes of presentation.
• Multidisciplinary process: Practice guidelines should be developed by a process that includes participation by representatives of key affected groups. Participation may include serving on panels that develop guidelines, providing evidence and viewpoints to the panels and reviewing draft guidelines.
• Scheduled review: Practice guidelines should include statements about when they should be reviewed to determine whether revisions are warranted, given new clinical evidence or changing professional consensus.
• Documentation: The procedures followed in developing guidelines, the participants involved, the evidence used, the assumptions and rationales accepted, and the analytic methods employed should be meticulously documented and described.

It's pretty apparent from the above, that part of doing a good job in such an endeavor is to document both the sources and the evaluation of the sources so that subsequent reviews have a clear place to start and so that independent reviewers have a specific basis for comment. In other words, creation of a body of knowledge needs to be viewed as an ongoing project with a clear paper/cognitive trail and review documents.

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