Massage Therapy Body of Knowledge

Comment

Comment by Mike Hinkle on October 2, 2009 at 3:14pm

Well, I see it a little different. Licensing "is" the law of the land. If I practice without it. I can be fined, arrested and even deemed never allowed to practice again. While I would like for there to be freedom for us to practice, however we would like, it doesn't exist. MBLEx and NCB have been designated by US State Boards to implement entry level tests. If you are going to work with these folks to have an organized effort to test (to protect the public) these therapist and everyone needs to be on the same page to have a real impact.

State Boards are charged with protecting the public. Whether needed or not is another discussion. This is their charge and they take it seriously. They want more uniformnity across the country, to organize the profession as well.

It is going to happen. Those concerned are getting their input to these folks. It has taken 5,000 years to get here. It is time to organize. If we all work at it, we can find our way. The good thing is, it is a "living document" and can be changed to reflect the profession's needs.

Comment by Carl W. Brown on October 2, 2009 at 2:54pm

Mike I don’t think it is a good idea of trying to worry now about the MBLEx/NCB. I believe that to do so perpetuates the problem with these tests. The primary reason for licensing is with the word “massage” and that it is being used for services that are not massage. It is not that the prostitutes give bad massage but that they do other things.

Licensing is a way to preserve the term “massage” as a legitimate profession and currently there seem to be two competing practices that are associated with the term massage. Swedish and acupressure. I think that each deserves a separate BOK, standards and tests.

The rest of bodywork is too diverse to fit into a single for of licensing. That is the purpose of the health freedom acts. They allow people who work in the specialized niches to operate legally and should not be a part of massage. It is like asking all religious leaders, priests, ministers, rabbis etc. to train in Catholic seminaries in order to practice. It may be the law in many states but I think that the BOK exercise is proving how wrong it is. Speaking of Catholics, if you publish the BOK with energy work will all MTs be excommunicated?

If there is a problem with too many “Rolfing parlors” then we may need to take some additional action but I hear that there are chiropractic parlors and they are licensed. I don’t think that will happen because studies have shown that licensing actually helps prostitution hide from the police.

I think we need to make the BOK real based on what we do and let the politics sort it out later. In the long run I believe we will all be better for it.

Comment by Carl W. Brown on October 2, 2009 at 2:23pm

Keith, taking your example of Delayed Onset Muscle Soreness (DOMS), the issue is do you really need to understand what causes it? I think that you do not need to know the cause to be able to make an assessment that the person likely has DOMS and how to help them. I say assessment because the work we should be doing does not depend on diagnosis because if we are wrong that we should be doing should not cause harm.

I feel that an MT should not have to know things like cell biology because to do so extends our scope of practice will beyond what it should be. For example it might be a nice service since we see a lot of skin to recognize the signs on melanoma. But if we add that to are training can we be held responsible if we fail to find it?

Consider each point and ask what responsibilities does requiring the MT to know this add to their Burdon of responsibility? On the other hand if they do not know this information are they either posing a risk to their client or are performing a substandard job?

As you have previously suggested I agree that we should start by looking are actual instances of harm done to clients. I believe that you will find that in the majority of cases it is doing things that they are not properly trained to do.

For example, what knowledge of prescription drugs do you expect an MT to have. I have found that most harm is MTs playing sorcerer’s apprentice and thinking they know more than they do. If you look at what a person really has to know it is very little. There are probably just a handful of drugs that an MT need to know about. Expecting them to know more is just asking for trouble. Replace the whole 591 section with a list of drugs that may indicate issues such as clotting that the MT should be aware of.

More and more I see people trying to make massage just like physical therapy. Instead I think we need to distinguish ourselves from PT. The way I visualize the PT model is that a doctor makes the diagnosis, describes what should be done, the PT does it and reports back to the doctor. This requires that the PT read and write in medical terms and understand a lot about medicine to do so.

Where the model has problems it that there is not instant feedback and things that cannot be expressed in words get dropped. As a consequence many people are not helped because their issues and treatment does not fit into the prescribed model.

Massage school seemed to follow the idea that we should be aspiring PTs until I discovered that when I was getting nowhere with clients all I had to do was stop trying. Empty my head and listen deeply in a non-verbal way. I ended up throwing out soap notes and the like and having to unlearn my massage training. I also found that rather that using more force it was better to use precision and patience and where possible wait for the body to do its own healing.

If people want to make massage therapy just another flavor of PT then just make sure that you don’t legislate “muscle whisperers” like me out of business.

What I have found, however, is a better approach to insuring that one provides professional results is to shift the focus from theory and how things work to measuring results objectively. One does not have to understand the principles and scientific theory to know how to use tools and how to assess and what works and what it just a myth.

For example, if I feel a coracobrachialis and it feels “ropey” it often means that it has shifted and can be pressing on the medial or ulnar nerve. Stranger still I can place my hand on a person’s chest and tell if they are having breathing problems if the problem is bronchial, or in the lungs and if so where. I cannot explain it but I know that if I try to develop an explanation for soothing that I do not understand I will follow the model of the idea and stop looking for what actually produces independently verifiable results.

Too often in this business we encounter perceptions of things that we cannot explain. But we need to understand that even in medicine we are operating with incomplete information and sometimes with perception that are not scientifically proven. Then we go off into the world of the “woo woo” rather than acknowledge that we work with both the rational and extra-rational. But regardless we need to always look to see how we can develop ways to objectively test what we do and gear out choices of therapy to provable results.

Comment by Mike Hinkle on October 2, 2009 at 1:51pm

Won't it take more correlation between MBLEx/NCB and those setting what entry level licensees need? And how will this affect the newly designed tests?

Comment by Keith Eric Grant on October 2, 2009 at 1:33pm

Mike,

Line 230 puts massage therapy into healthcare. I remember (some) of the field wanting in but not everyone. Do you see this as acceptance or wishing?

Both. I'd written a bit on this in a discussion started by Bodhi Harraldson. When we can guarantee specific KSA's as outcomes of training, then we are in a far better position for referrals. It isn't clear that inclusion of massage in the health care payment system, provides more that added cost, except when the treatment is for specific conditions as part of other medical care. If one is simply using massage as a self-reward for some task accomplished, the question becomes about the same as "do you think chocolate will become part of the health care system?".It has it's benefits, but that isn't the best conceptual system for the provision of the service/item.

Comment by Keith Eric Grant on October 2, 2009 at 1:20pm

Mike,

Hours don't tell you much. If you are interested in competence assurance, then competence, not hours, is what one should manage. Competence involves specification of the KSA's necessary to do a task and the level of proficiency required for a particular job description.

I'd posted some resources on a group that Whitney Lows had started -- also via Ning. Competencies in Medical Education. In this one might consider, in particular, Patrica Benner's (et al.) "Expertise in Nursing Practice".

I've also drawn on Gary Klein's field research on the exercise of expertise in Sources of Power and Beth Crandall's (Klein is a coauthor) "Working Minds: Cognitive Task Analysis".

Meanwhile, the MedBiquitous Consortium is forging ahead with creating tools and data standards for tracking practitioner competence (i.e. profile management) and identifying "learning gaps" with far more refined granularity than has formerly been possible. This work also draws on concepts such as the late Claude Ostyn's proposal for Simple Reusable Competence Maps (Ostyn headed the IEEE working group on competency data standards).

Comment by Mike Hinkle on October 2, 2009 at 12:10pm

Keith, specifics are being outlined and it is more clinical. I have heard you advocate the KSAs as opposed to hours and wonder how many versions of school hours each state will come up with. If they all arrive at the end result of students passing I guess that's one way.

Line 230 puts massage therapy into healthcare. I remember (some) of the field wanting in but not everyone. Do you see this as acceptance or wishing?

I was really interested in your breakdown of Section 100 and Section 200. Does the latter leave open for Section 220 Advanced Level 1 Massage Therapist KSAs, Section 230 Advanced Level 2 Massage Therapists KSAs? Are we creating perpetual schools forever?

Comment by Keith Eric Grant on October 2, 2009 at 11:02am

This draft raises a lot of questions for me.

I first agree with Carl that there needs to be a distinction between rules and standards of practice and delineation of knowledge. I am reminded of a statement by Robert Mager (Criterion Referenced Instruction), "If they could do it if you held a gun to their head, you don't have a training issue but a motivation one". That "standard" of differentiation (i.e. a specific measurable/ assessable criterion) extends to knowledge versus rules of practice.

A second issues is vagueness. Simply saying "understands" is meaningless without a measure of understanding (i.e. expected level of proficiency and observable assessment). There are, for example, different levels of understanding that can be brought to something like Delayed Onset Muscle Soreness (DOMS), from knowing that it is the primary cause of post-exercise pain, to understanding details of the mechanisms of micro-tissue damage, Ca++ leakage, and ensuing inflammatory/healing processes. This also gets to the point that it is difficult to discuss the relevance of particular knowledge without a clear path to the tasks and proficiency levels motivating the items inclusion. Understands DOMS doesn't cut it as a specification.

A statement of knowledge needs to be specific enough that it delineates the knowledge being considered. Something like "understands the effects of massage on circulation" is abominable. Are we promoting the lactic acid myth? Are we noting research that massage doesn't have an effect on arterial blood flow but, via changing local tissue pressure can affect distribution of that flow? Such statement are not sufficient to differentiate between something that is based on current research or is a propagation of misinformation.

The structure of knowledge is also not uniform. Carl has noted this in the need for separating out different areas. The analogy that I have used is that the structure of knowledge is often like a state or national level roadmap. What one sees are dense clusters of interconnections (cities) that are much more sparsely connected to each other (via interstates). There's a considerable and growing body of knowledge/research on knowledge structure that I do not believe is ignorable is a BOK is to be taken seriously. As an example, a PNAS special issue on Mapping Knowledge Domains. Basically, the clusters of knowledge should be dealt with individually as with street maps while noting the connections between clusters at a higher level. The pudding has plums -- it is not just uniform gruel.

Inclusion of "knowledge" that is currently unknown or unknowable is going to be problematic to say the least. Since Edzard Ernst is one of the more active reviewers of alternative medicine, I pinged him via Twitter to take a look at the BOK draft. "Energy" systems are one of these areas. Although practiced by a numerous massage practitioners, it is not clear that these are massage and not a separate but perhaps synergistic domain. From a scientific standpoint, "subtle energies" is a meaningless statement (I am a physicist as well as a massage instructor). It is difficult to consider a BOK when you can't define what you are talking about in terms of current understanding. And again, there is the problem of specificity. James Oschman has published papers on electromagnetic measurements, but I don't that there is agreement to limit "energy" to this. What remains wanders into spiritual belief systems, which is particularly problematic when one talks about required curricula and regulation. This is exemplified by recent discourse on the Catholic Church vs Reiki. The basic point, however, is that if it is not based on science, not based on concepts of human emotional support tied into psychoneuroimmunology, then it becomes part of spiritual belief. This is fine as a personal choice, but needs delineation from other areas.

I could note, that based on current understanding of synesthesia (mapping of one sensory channel into another), I could hypothesize that energy workers are simply working with synesthetic perception of minute EM fields and modulating (smooth) slight fluctuations in such fields. But we currently only have belief systems, not knowledge.

Similarly, with current cybernetic understanding, I could hypothesize that the eastern meridian systems, which show no physical manifestation, are, if based on accurate observations, derived for sensory correlations in how the brain integrates a body-sense from the millions of individual bits of sensory information. In short, an emergent property of the computational aspect of having a human body rather than a physical property. This would be consistent with Ron Melzack's research on phantom limb pain and his hypothesis of a analog neuro-matrix body in the brain. But again, the point is that we have a well-developed belief system but little in solid evidence-base. We can talk about regulating for safety, but knowledge is more elusive. One needs to look at research based reviews such as that by White and Ernst (also see this) and not simply add current practice to the shopping cart.

I'll also note, just in passing, that "biological energy" is the electromagnetic-energy of chemical bonding -- i.e. chemical energy obtained either through chemistry of photochemistry by biological processes. i.e. it is not a special type of energy unto itself.Biological systems synthesize or breakdown molecules to either store or retrieve the energy differences in the chemical bonding.

That's 30 for this post.

Comment by Carl W. Brown on October 1, 2009 at 3:57pm

Chip, I think that while it might be laudable to be familiar with other modalities, should it be a required part of the BOK? In any case I think they you agree that the BOK is inadequate to actually practice Asian forms of massage and therefore is not a massage BOK but rather a Swedish massage BOK.

BTW I think this discussion group and your news blog serve two different purposes.

Comment by Mike Hinkle on October 1, 2009 at 3:15pm

I think efforts are ongoing that will combine these two aspects as well as give them their own areas of control. You are right on the button there. I think soon you will have a Model Practice Act and BOK. Both should be used to progress the profession.

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