To the Editor:
Lately, I have been thinking a great deal about where the massage therapy profession is heading. I travel quite a bit and often schedule a massage when I am on the road. Over the last few years, I have had some good experiences, but more often than not, a mediocre or poor one. Recently, I attended the second North American Research Conference on Complementary and Integrative Medicine, held May 12 – 15 in Minneapolis, Minnesota. I had a wonderful massage at a nearby spa prior to the meeting. With my mixed experiences in mind that week, I found much of the information presented at the conference provocative, as a researcher and a practitioner.
Several presenters estimated the number of massage therapists in the United States at 250,000—a surprising quarter of a million practitioners. In the past few years, the number of massage schools, which are overwhelmingly structured as proprietary businesses, has dramatically increased. In 2001, there were 647 schools with a minimum of 500 hours, according to an American Massage Therapy Association annual industry survey; by 2008, that number had jumped to 1167 (American Massage Therapy Association. Industry research data. Personal communication; May 27, 2009). Program curricula and competency requirements vary widely, and instructional hours range from 500 to more than 1000. Some schools use an hours-based instructional standard; others use a competency-based standard. The therapeutic skills of graduates are likely to vary considerably as well, which may account for the uneven quality of my “on the road” massage experiences.
Considering the sizable numbers of practitioners and schools, I was struck by the relatively small number of presentations related to research on massage therapy, compared with other complementary and integrative health care disciplines represented at the conference. Very few of those presenters were massage practitioners as well as trained researchers. Most were nurses, physicians, or PhDs in other fields—not surprising, considering that the educational requirement for entry into most professional massage training programs is a high school diploma (and the absence of a felony conviction). Few massage or bodywork practitioners have advanced degrees. The same industry survey in 2008 reported that 8% of massage therapists have a master’s degree and only 2% hold a PhD.(1) This number is even less than the 4% of complementary and alternative medicine (CAM) practitioners overall who have dual credentials as a licensed practitioner and a PhD, according to the National Center for Complementary and Alternative Medicine (NCCAM) (NCCAM. Staff presentation at Advisory Council Meeting; Washington, DC; June 8, 2006). In fact, there is currently no baccalaureate or advanced degree program specifically in massage therapy or bodywork in the United States. Unlike colleges of chiropractic, naturopathy, or acupuncture, our massage schools do not grant tertiary degrees and are thus not eligible for most National Institutes of Health/NCCAM grant opportunities for research, career development, or research infrastructure funding. A relatively small number of schools require research literacy as a competency for practitioners, and an even smaller number operate anything resembling a research infrastructure—such as access to medical libraries and health care journal databases, or computer facilities and personnel for data management and analysis. Developing research capacity is a goal that seems likely to remain out of reach of the vast majority of existing massage programs.
At the closing session of the conference, Dr. Josephine Briggs, the new director of NCCAM, spoke to the development this year of the new NCCAM strategic plan. Its funding priorities will be driven by patterns of use of CAM therapies by the public. Based on 2007 data from the National Health Information Survey, massage therapy is gaining in popularity and is used primarily for musculoskeletal pain.(2) In fact, massage therapy is used almost as often as chiropractic. Massage is categorized as a manual therapy, which also includes osteopathic manual medicine, and it is one of NCCAM’s two main areas of interest for the next five years. Major research questions such as dose– response relationship and potential mechanisms of massage therapy’s effects remain largely unanswered, and research questions of interest to practitioners remain largely unarticulated. As NCCAM allocates funding for massage research in their new strategic plan, from where will those needed researchers come?
Mulling over all these numbers, it seems to me that as a profession, we are rapidly becoming diluted, both from within our own ranks and from without. In terms of education quality, we are inconsistent, and we now have a large number of practitioners whose skills are equally so. To put it bluntly, we have too many schools turning out too many poorly trained practitioners. I have personally experienced—and heard all too often from friends and clients about—massage therapy from practitioners who perform a rote routine for everyone regardless of health history or preferences, with little ability to palpate tissue and adjust their pressure accordingly, and with limited knowledge of pathophysiology and the critical thinking skills necessary for good clinical decision-making.
In terms of our ability to implement a cohesive research agenda, we are largely dependent on people outside our field to choose, design, and conduct research on what we do. Although a small number of us have worked as consultants and certainly influenced the design and conduct of specific projects, our collective voice is small and seldom heard in the larger research community. Although interdisciplinary collaborations are the norm in most research teams, principal investigators tend to view massage therapy from the perspective of their particular discipline. We don’t want to create more silos, but I think we do want to retain a distinct identity as a professional discipline. If we are to avoid once again becoming diminished by our own popularity (as we did a century ago), then this situation needs to change, sooner rather than later.
As a profession, massage therapy is at a crossroads, and has been for quite some time. We need to ask as a community, where do we want to be in five years, or ten years from now? I believe that we need to find a way to accommodate those who wish to be considered health care practitioners, without penalizing current practitioners who are content with less education. All practitioners need a basic understanding of anatomy, physiology, and pathology, if only to know when to refer out or how to avoid exacerbating an existing medical condition. Relaxation is also an important therapeutic goal of many integrative health practices. What medical condition isn’t improved by stimulating the parasympathetic nervous system? If we want to be taken seriously as peers with other medical and allied health care providers, we need to step up to the plate and put in the time it takes to become knowledgeable as well as skilled practitioners, and be willing to conduct research. This does not have to mean losing the “heart” that draws many of us to this work. It is possible to balance art with science. As a practitioner, I want to bring both sides of my brain and all of my heart to my work. As a researcher I want to investigate massage as a complex, biopsychosocial intervention, using a range of study designs, and asking questions that are clinically relevant.
I believe this means that professional schools need to ally with academic educational institutions, and that future massage practitioners have the option to graduate from their training with a baccalaureate degree. Imagine a massage and bodywork practitioner who has had four years to develop a knowledge of body systems in health and disease, and clinical reasoning abilities, along with soft tissue palpation, manipulative, and therapeutic skills, including the creation of an optimal healing environment and client–practitioner relationship. Imagine the professional credibility and respect that that practitioner could feel and inspire in others.
Toward that vision, I find the current trend of community colleges offering programs in massage therapy heartening, and I believe that this is the direction we need to take. Moving from an associate degree to a baccalaureate degree is a reasonable next step, and a necessary one to develop advanced degree programs focused specifically in massage therapy and bodywork. In addition, working with conventional academic institutions seems the best way to gain access to research infrastructure and funding resources, and to create a cadre of researchers who are sensitive to clinically relevant issues. Such an alliance could truly advance massage therapy and bodywork as a distinct discipline with a unique perspective and voice, and one that is informed by many kinds of evidence. I hope we can make that vision a reality.
Martha Brown Menard, PhD, CMT
University of Virginia Charlottesville, VA, U.S.A.
The author declares that there are no conflicts of interest.
Published under the CreativeCommons AttributionNonCommercial-NoDerivs 3.0 License.
INTERNATIONAL JOURNAL OF THERAPEUTIC MASSAGE AND BODYWORK—VOLUME 2, NUMBER 2, JUNE 2009