Massage Therapy Body of Knowledge

Comment

Comment by Greg Jones on November 12, 2009 at 12:17am

I agree with Bert, and Mike as massage therapists we should not have to memorize the PDR with all the side effects of every drug. Ruth Werner's fourth edition of A Massage Therapist's Guide to Pathology is another excellent reference when dealing with pathologies and the medications used for them. Until we have double blind studies of the effects of massage with every medication we can always check with the prescribing doctor and/or a pharmacists and get there opinions. I have not read the whole MTBOK, but I hope it includes training that enable the therapist to find the resources needed to make appropriate decisions on treatment modalities or when to refer out.

I know a lot has been said about massage education and educators as far as accreditation and certification of instructors which are all valid, but I have found inaccuracies or invalid information in every text I have used. Maybe some of the focus should be on getting better text books to teach from and/or more research in which to base the material from. I know I reference a lot of material from Travell & Simons, Leon Chaitow, and Judith DeLany for accuracy of the material presented, it is about as factual as I have found thus far.

Comment by Bert Davich on November 11, 2009 at 11:47pm

Thanks Keith,
I understand the dose dependence changing the contraindication/caution profile and I totally agree with what you are saying. (That was a good study example)

That illustrates the problem with introducing an Rx list through the BOK as well as the problem with therapists using a PDR or other medical reference books to determine when (and what) contraindication/caution is in order.

To use myself as an example, I'm not as knowledgeable about Rx drugs as you seem to be, but I know a lot of really good therapists and only a few of them have the working Rx knowledge I do, and I don't feel I have the training needed to make some of those Rx contraindication/caution decisions. Where does that leave the rest of the field, especially recent graduates? That's why I will refer back to the client's medical practitioner when unsure. I have one regular client 88 years old that takes a dozen pills a day. On my initial visit when she was temporarily in a nursing home the Nurse practitioner couldn't tell me what some of the drugs were, only what they were for. Her Doctor had already cleared her for massage but some precautions were called for by condition.

I just don't want to end up in the position of being expected to have the answer on every drug(s) a client takes or look it up using a medical reference book. Also if a physician's group like the AMA decides we are encroaching on their scope of practice, it could cause a turf war with MD's who will trounce us with their political clout.

Comment by Keith Eric Grant on November 11, 2009 at 10:08pm

Bert, one reason I bring up dose dependence is that there have been studies of low-dose warfarin treatment following a period of standard dose treatment, such as this study in NEJM. A low-dose regime might have a different contraindication/caution profile.

Comment by Mike Hinkle on November 11, 2009 at 9:15pm

I agree with you Bert on both accounts. They want to make the BOK so big and detailed, it becomes DOA. We should stay within a set scope of practice. If we don't know, we should refer, to those that do.

Comment by Bert Davich on November 11, 2009 at 9:07pm

Now I'm confused by the last volley of exchanges. I advocated the PDR should not be in the BOK, nor should therapists have to make medical determinations regarding drug & massage interactions. Regarding the NIA and a Rx list, that was suggested as a better alternative than having the BOK group create one. Not advocation it should be in the BOK. There are Rx precautions published in books currently used in schools in some states such as M'Ladys (and that is not an up or down for M'ladys). That should be enough.

Regarding pressure, it does not take much pressure to bruise someone on coumadin, which would indicate a precaution. Not to mention it is usually prescribed for those with arterial blockages of some nature.

Comment by Mike Hinkle on November 11, 2009 at 7:54pm

Once again, Keith because the data is not presently available, does not mean it isn't happening? With the best data one has right? The data doesn't exist except what you have written and have got in your data banks, right?

"This may be beyond the scope of the BOK" is exactly my point. I thought we were here to discuss the MTBOK. If "opportunity for harm" is really an issue now, where is that protocol for therapists?

I bring in the state aspect because I see the BOK being "loaded up!" Then it will be yelled it is too "restraining for therapists." You know the bigger it is and more demands it has on the therapists, the more they will reject it. You know thousands of therapists in CA want to be left alone and will fight this, especially if we keep adding on things "that must be learned".

This, to me is exactly what the GOP is doing to try and kill Healthcare Reform.

Aren't periodic reviews, additional education (ie ceus)? I thought there wasn't to be any additional education requirements placed on CA therapists?

So, the state (CA) that has no ceu requirements and no state test at any level has a few folks from that same state (CA) that are going to make it longer and harder to get an education, of which their state (CA) is exempt?

Everytime I ask for a time frame, all I get is, "I guess" or "possibly." This won't cut it for schools or therapists. You can call it competency level or whatever, time is the end result, and the issue isn't going away and won't be forgotten.

Yea, I am confused now. This is an entry level MTBOK. Can we stick to that right now? Carl started this discussion for asking for "minimal standards". He even made another discussion of "Minimal Requirements Strawman". The expansion you have added to the BOK, as you see needed, in the last three days have gotten so far away from the initial duties as outlined by the Task Force. No?

Comment by Keith Eric Grant on November 11, 2009 at 6:56pm

Mike, the discussion on massage and drug interactions and a methodology to create recommendations based on best assessment of practice and medical knowledge has nothing to do with any specific program or state. If there are clearly and specifically defined hazards, if specific mitigation protocols and treatments have been developed, and particularly if these are deemed to be of low frequency of need but of critical importance, then a clear case can be made for mandatory, periodic refreshing. That statement has nothing to do with any particular state's current laws or regulations or with current industry hiring practices or facility use requirements. It is simply a statement about a process of hazards management. I doubt that, except in specialized practice contexts, a collection of specific mitigations couldn't be taught in web presentations that take about 4 hours total. .That is simply my guess, based on cumulative experience with required trainings and the level of complexity of the content.

One estimates the likelihood and seriousness of potential harm with the best data one has. There are, as noted, few medical reports. Studdert et al. analyzed massage insurance claims in a 1998 paper. Massage liability insurance rates are also low.

I know of no information correlating potential for harm from levels of pressure, movement, and friction with specific drugs and common dosage protocols. If anyone is aware of such, I would be delighted to know of them. I am not aware of any standard documents on specific mitigation training in the U.S. If anyone has such a list of potential injuries and the specific training being used to mitigate them, I would again be delighted to know. In the absence of actual data, we are left with looking at model mechanisms of potential injury from massage/drug interactions by specifying what is being done and relying on those with medical expertise related to such drugs to evaluate potential consequences. I am not aware of documents on such are process. This is what we were discussing in terms of need and bit of brainstorming on implementation by involving NCCAM.

This may be beyond the scope of the BOK, but it is a related concept of knowledge management and competence management. Opportunity for harm is not the same as observed harm or probable harm. One definition of life is "opportunity for harm". It falls within a more general definition of life as "opportunity for experience". If we believe that there are specific mechanisms that could produce significant harm, on best available research and clinical experience, then we should be teaching such and making sure that it is highlighted in practitioner awareness. We should be making the analysis and protocols freely and clearly available on regulatory agency and organizational websites. I turn again to standard hazard management steps:

Specify the scope of work
Identify hazards within that scope
Develop training and protocols to mitigate specific hazards
Work within scope and training
Periodically review effectiveness of mitigations and changes in context

Ever look at the National Transportation Safety Board's synopsis of accident reports.Those reports become the basis for changes in protocols, training, and currency requirements that get included in NOTAMS (notices to airmen). In other words, a clear process of hazard identification and management. You start with what you can identify and refine it as information accumulates. By defining a standard (i.e. measurable outcome) for information collection, you ensure that the process reflects reality on an ongoing basis.

Comment by Mike Hinkle on November 11, 2009 at 6:52pm

What scary stories? Keith says they don't exist. I agree. I have heard of just two instances causing harm. Nobody is saying anything about harm being a reason for licensure. What insurance claims? Where are they?

Carl, I will not forget hours. Nor will therapists, there is an army that agrees with me. You are going to have to put hours to KSAs or they aren't going to accept the concept. But that puts you right back to having to decide how much time to give each area needed for knowledge doesn't it? By doing this there are no time frames for completion. Your statement of 15 minutes to teach contraindications, proves it.

It takes more than 15 minutes just to read Keith's Cautionary Statement.

Comment by Carl W. Brown on November 11, 2009 at 6:25pm

Mike I don’t think that anyone is opposed to the BOK. My objection is that a BOK is a model and that if the model is not right or even close it will not help and at best distort our profession.

There is a lot of talk about contraindications and precautions. We are not experts and should not be the ones to develop this. I hear lots of scary stories and ideas of what may cause harm. But based on insurance claims I suspect that most of what is claimed to be dangerous other than universal precautions is probably an over exaggeration.

“Carl says he sees a two year course needed now to be a massage therapist.” It could take 15 min. to teach contraindications, I don’t know. Forget about hours we need to judge education by performance of the students not hours.

Comment by Mike Hinkle on November 11, 2009 at 5:16pm

Hi Keith,

Sorry to be a distraction. I feel that is what is going on by those opposed to the MTBOK. I have just sat out, a few days, watching the discussion and seeing a lot of potential for harm that therapists can do to the public from those posing opinions here and watching the BOK just keep getting more detailed and more detailed and let's add this and maybe a little of that.

This effort reminds me of the GOP's effort to derail the Healthcare Reform underway, the more detailed the BOK gets the more it will "slow it down" or stop it. I am glad they are doing the work.

Different directions keep branching out and more opportunity for harm keeps rising. Each instance can be explained away, Keith. But surely the points you are discussing, from the NIH accepting resposibilities to PDRs not being therapist friendly, show you "potential for harm."

Just because there is "limited data" does not mean it does not exist. All problems exist prior to data, no? You keep some records and update them sometimes. Who else does and how often? Would it benefit the profession to know this or keep records at all or keep saying there is limited data?

I think the fact there is limited data is very distracting. Why is that the case? There are a lot of aspects that are wise, but what data is so overwhelming to cause such concern? I don't see associations data banks out there gathering this information. If it is that important, why not? Do they agree with your cautionary statements?

Per your article on massage safety, hour wise, how long to learn just the data outlined in that article concerning identifying specific hazards, their methods and contexts of occurrence, and creating training and protocols specifically identified to mitigate such hazards? You go on to add more: could be done in a series of web videos of about 2-4 hours and required biannually to maintain currency. The review could also include refreshers on universal precautions and blood borne pathogens.That is exactly the kind of training currency requirements I experienced while working at a national research lab. I would currently consider awareness of cervical arterial dissections, stroke symptoms (goes with CADs), deep vein thrombosis, and whatever develops in specific drug interaction protocols to be on the list. You are going to have mandatory CE's in CA, I thought there was a rule against that?

Carl says he sees a two year course needed now to be a massage therapist. How long do you think, because all this is in addition to what he went through? We have to tell people how long it takes to become a massage therapist and I know you don't want to put hours on anything but could you tell me months or years?

I know of your work with the Foundation and it is commendable. I just feel it is way, way, way down the road before this will be implemented in any form. But you are laying groundwork. Thanks.

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