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The Importance Of Curriculum Change For Massage Therapy

The Importance Of Curriculum Change For Massage Therapy

When I graduated from massage therapy school in 2005 I had already completed my bachelor of science and felt very comfortable in my knowledge and abilities to become a great therapist.  

It became very evident to me over the ensuing years that there was a lot more I needed to know and understand in order to more effectively treat complex problems, particularly those who lived with persistent pain.

It was through the experience of seeing my wife struggle with disabling pain and realizing the treatments she was receiving from medical doctors and allied health care providers were inadequate.

Something was missing in how myself, and other health professionals were educated.  

The conceptual framework and understanding of the human pain experience and how we conduct our treatments appeared incomplete.

This quest for answers led me on a fantastic journey that completely changed how I view the body, the brain, and how I treat my patients.  Last February at the San Diego Pain Summit I was convinced that the path I was going on was the correct one.

Treating people in pain is what we do, and there is a much better way to do it than what we learn in school.  I felt inspired and realized one of the main problems with our profession is that there are not enough of us with advanced degrees to lead the profession towards the changes it needs.

I decided that in order to help advance our profession I couldn’t sit on the sidelines, I would need to be involved and pursued more education.  In September I started my Masters in rehabilitation sciences at the University of BC.

Already, in a short period of time I feel I have gained invaluable tools for critiquing research, finding and utilizing evidence for practice and critical thinking skills.  These skills need to be fundamental to all health-care professionals.

Changes are necessary for us to evolve.

National Standards For Massage Therapists

The profession of massage therapy in Canada (particularly in British Columbia), has a long history of being leaders in its curriculum, standards of education and licensure that can exceed our colleagues in other parts of the world.

There is a strong desire among our membership in BC to increase our education to that of a baccalaureate program.  Our professional association, the RMTBC has completed great work in attempting to make this happen.  Ideally, it would be great if all education for massage therapists was standardized regardless of what province or state you were educated in, much like it is for physical therapists, nurses, pharmacists, opticians, and medical doctors.

Currently in Canada the regulated provinces are working on a national standard of competencies.  

I applaud their attempts in pioneering this endeavour as it could provide a framework that other massage therapy regulatory bodies throughout the world could follow.  However, the lack of quality research used to support the development of the competencies is embarrassingly evident.

As a regulated health-care profession, the educational curriculum and practice standards of massage therapy need to be based on strong scientific principles and good quality relevant research.  In order to make informed practice decisions and incorporate an evidence-based approach to treatment planning the educational standards of RMT’s must be recreated.

As it currently stands, the Interjurisdictional Competency Document and its companion, the Guidelines for Foundational Knowledge in Massage Therapy Educational Programs, which together form the framework of what is taught in the massage therapy colleges and creates the material for what is required to pass board exams, are both regrettably unacceptable as documents around which an entire profession’s competencies are created.

Creating A Greater Understanding Of Massage Therapy

What is wrong with this document and what is a fundamental problem in our profession?

The primary faults I see is the research on the actual mechanisms of manual therapy are ignored and an inadequate understanding of pain and its bio-psycho-social components are missing.

Unfortunately, manual therapy professions base their treatment models and understanding of pain and dysfunction through out-dated biomedical beliefs, structuralism and connective tissues modalities.  There is a better direction to go, we simply need to follow the science.

Manual techniques exhibit the majority of their effects based on mechanoreceptor input from the skin, not the muscles or fascia.  

The words we use, how we interact with our patients and the explanations we give are more important than any miraculous technique that we learn.  This short article provides a great discussion of the need to move beyond our techniques.

All positive or negative changes our patients have in their pain perception or movements are from alterations in their nervous system.  Nervous tissue is the only tissue in the body that can adapt and change quickly within the confines of a treatment session.

Once a therapist realizes that every effect we have is through the nervous system, primarily the brain, massage therapy becomes much more simplified, more powerful as a therapeutic tool and prevents unnecessary and unrealistic treatment plans that do not serve the best interests of the patient.

Research has shown that connective tissue cannot be altered for any length of time through manual techniques, and we shouldn’t want to alter it anyway.  Here are a couple great articles worth the read that refutes fascia’s importance, here and here.  I could post numerous links to all the research, but these two sum it up succinctly.

Trigger points, another sacred doctrine of massage therapy are likely not a problem in muscle tissue, more plausibly it is referred pain from peripheral nerves.  Posture and biomechanics are not always as important as we think they are either, here is a free full text pdf available worth the read.  

These links are not meant to completely invalidate other ways of thinking.  

They are to identify the science and other opinions in the manual therapy field.  As a profession we need to be more open-minded and become science-based clinicians, and not continue to base our curriculum and practices on historical beliefs.  This is still possible while not forgetting the art of what it is we do.

https://flic.kr/p/bN15Tk

Photo by: BU Interactive News

Three Pillars Of Massage Therapy

The three pillars that guide our profession as outlined by our regulatory Colleges is safe, effective and ethical health care.

By purposely neglecting the wealth of evidence on manual therapy mechanisms we are failing on all three pillars.  This purposeful neglect is unforgivable with the wealth of modern science on pain, fascia, biomechanics and the mechanisms of manual therapy.

By focusing on out-dated beliefs and a biomedical structuralist approach to care, and furthering the pseudoscientific beliefs about fascia, trigger points, cranio-sacral therapy, visceral manipulation, postural asymmetries and adhesions to name a few, we are supporting unsafe, unethical and ineffective practices.  

Our profession needs to move towards an evidence-based model that includes plausible scientific principles of manual therapy.

We do not need to make up stories to explain what we are doing.  Touch is therapeutic, massage and movement is analgesic.  These effects occur because of our interaction with another person’s nervous system.

By adopting a curriculum that includes biopsychosocial approaches to pain management, peripheral and central mechanisms of pain, understanding nonspecific treatment effects, motor control, graded exposure to movement, principles of patient centred care and the pillars of an evidence based practice, we would be much better suited to provide safe, effective and ethical care.  

Those approaches are much more supported by science and encourage a feeling of security, robustness and self-efficacy that can elicit more consistent results and better patient outcomes.

The problem with overcoming this dilemma is the belief systems are so ingrained in the profession.  Too much of what we do is based on faith and not on fact.  Changing the profession will require great force of will and continuous efforts, because it is an entire culture that will need to adapt and change.  

From the top down, national massage therapy organizations, provincial regulatory Colleges’, massage therapy educator’s, current RMT’s, and students will need to adjust.

Changing Massage Therapist Focus

We are so focused on our modalities and learning new techniques to add to our toolbox, that we lose focus on what really matters.

Our profession has made the care we provide more complex than it needs to be.  

If we could focus on having a solid foundation in the core sciences, learn how to interpret research, critically think, and learn advanced skills to more effectively interact and educate patients we would be significantly farther in our progression as a useful component of the health care system.

Patient centred care and evidence-based practices should be the foundation of what we learn in our education.  Assessment and manual skills are important and these skills will always be central to our profession.  RMT’s can still historically do what we have always done, but the time is here for us to adapt and reinvent ourselves.  The regulatory Colleges, professional associations, all the private colleges and most importantly the massage therapists have roles to play in this process and a desire from each organization or individual to implement change is needed for our profession to become leaders in manual therapy education. Change is constant, it is not to be feared, and it needs to be embraced, as change is necessary for the long-term survival and relevancy of our profession.

Visit Somasimple.com, Body in Mind at http://www.bodyinmind.org, the NOI Group at http://noijam.com, www.greglehman.ca, or go on Facebook and interact with clinicians from Skeptical Massage Therapists, Biopsychosocial therapists, Explaining Pain Science or Dermoneuromodualtion among many others and you will find great debate, discussion and heaps of research to sift through that will quickly get you questioning your current practice and beliefs.

Eric Purves

Eric has been a Registered Massage Therapist since 2006 and is the co-owner of Achieve Health Chiropractic and Massage Therapy in Victoria, BC. His area of therapeutic and research interest is in the treatment and management of persistent pain. He currently sits on the executive of the Registered Massage Therapists Association of British Columbia’s (RMTBC’s) professional practice group in pain management. The groups’ mandate is to provide education and evidence-based practice guidelines for massage therapists in the treatment and management for those who live in persistent pain. He authored and instructs a continuing education course, Introduction to Pain Science: Pain Management Strategies for Effective Massage Therapy Practice. Because of a desire to advance the profession of massage therapy, in September 2015, Eric began his Masters in Rehabilitation Sciences at UBC. Living an active and healthy lifestyle is the key to well being. When not at work, studying, or spending time with his young family, he is a passionate soccer player, runner and cyclist and spent many years training in a variety of martial arts.

Eric Purves

Eric has been a Registered Massage Therapist since 2006 and is the co-owner of Achieve Health Chiropractic and Massage Therapy in Victoria, BC.His area of therapeutic and research interest is in the treatment and management of persistent pain.He currently sits on the executive of the Registered Massage Therapists Association of British Columbia’s (RMTBC’s) professional practice group in pain management.The groups’ mandate is to provide education and evidence-based practice guidelines for massage therapists in the treatment and management for those who live in persistent pain. He authored and instructs a continuing education course, Introduction to Pain Science:Pain Management Strategies for Effective Massage Therapy Practice.Because of a desire to advance the profession of massage therapy, in September 2015, Eric began his Masters in Rehabilitation Sciences at UBC. Living an active and healthy lifestyle is the key to well being.When not at work, studying, or spending time with his young family, he is a passionate soccer player, runner and cyclist and spent many years training in a variety of martial arts.

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17 Comments

  1. A Danee Cowley January 19, 2016

    Great information Eric. As a new grad I look forward to reading these articles and putting the ideas and concepts into practice. It is frustrating coming out of school with conflicting information which makes putting the puzzle pieces of a new client together much more difficult. A clearly science based education benefits client and practitioner.

    reply
  2. Christina January 19, 2016

    I can identify with this. It frustrates me, in my first year of practice, that I spent over two years and a lot of money in school only to become aware now that the research is showing the majority of techniques that I learned are outdated and and have no lasting effect. Yet, I do feel and see change in my clients. I don’t have a full understanding of what is causing the changes, and because of this I struggle with effective assessment and treatment plans. I agree that how massage therapy is taught needs to change.

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  3. Valerie Anderson January 19, 2016

    I am very grateful that there are other massage therapists that are like minded And are concentrating on making massage more relevant and acceptable for public safety And positive outcomes. I have been practicing for 35 years And over this time Have definitely changed my approach based on the evidence that supports working with the nervous system and not just plowing away into tissues with elbows and thumbs. In the last 2 years I have spent a considerable amount of time contacting the regulatory bodies in Ontario With information and questions about the curriculum. There has been significant resistance To accepting The fact that the present curriculum is not evidence based And needs an overhaul. I continue Inquiring and supporting change so that all massage therapists see themselves as professionals And understand the benefits of massage and how to achieve them.

    reply
    • Eric Purves January 19, 2016

      Thanks to those who have posted so far.
      I feel your frustrations Valerie, also those of Christina and Danee.
      My experience dealing with the regulatory college in BC was equally useless. I was an examiner for 2 years and I eventually quit, as they were unwilling to listen to evidence or research that refuted what they were promoting in the curriculums or basing their licensing requirements for new registrants.
      Don’t give up! Once there is a critical mass of RMT’s that demand better the regulatory colleges and privare educational institutes will have to listen.

      reply
  4. Jason Erickson January 20, 2016

    Good article, Eric!

    I have been fighting for similar changes in the education of American Massage therapists for years, yet I am one of only about four MTs teaching classes on modern pain science and its applications in North America. We need more teachers to learn this material, or the situation will not change.

    I hope to see you at the San Diego Pain Summit next month. I think we could have a great conversation.

    reply
    • Eric Purves January 20, 2016

      Thanks Jason. Yes, let’s chat in San Diego. I look forward to it! There are too few of us, I agree.
      The comment we finished with at least years conference, “Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it’s the only thing that ever has,” has been in my mind ever since.

      reply
  5. Marvin Mohring January 20, 2016

    Thank you for collecting your thoughts and experiences. Many factors are involved in such change. Would you see the continuing education cycle play a role in the unlearning of current therapists? If so, how so?

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    • Eric Purves January 20, 2016

      Hi Marvin,
      In the immediate term, yes, continuing education classes are in my opinion the best way to go to educate current therapists. We need more therapists that are willing to read and critique the research and follow a science based approach in treating patients. If more therapists can be educated and willing to teach current material then the unlearning of current therapists can begin. Once this occurs, our curriculum’s and competencies will need to be redeveloped and new therapists will hopefully graduate school educated with the appropriate tools to have an evidence based practice and critical thinking skills that allows them to stay current in their knowledge.
      It’s not going to be an easy process. The course I teach is all about ‘unlearning’ and to be open to change and presenting current research that identifies the problems with our old models of massage therapy mechanisms.
      Send me an email and we can chat about this more if you’d like.

      reply
      • Marvin Mohring January 21, 2016

        Thank you for your response. It’s nice to read encouraging responses. If the CEU process, controlled by the regulator, were to have a selection method, rating system, or incentive system (the list could go on with other suggestions) that encouraged (rather than rigidly influenced) CEUs that were in line with the path the profession is encouraged to take, then protecting the public through the appropriate professional development (CEU cycle) may shift the market choice away from less idealistic courses (definition left intentionally ambiguous).

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  6. Bruce Martell January 20, 2016

    Great post Eric. Fills me with hope. I have had an epiphany of sorts since you turned me on to modern pain science. A massive paradigm shift. The shift was easy for me because this pain stuff really resonates with me, it just made sense. So many things we learned in college seemed so wishy-washy to me, like they didn’t have much science to back them. Until I learned more about pain and the nervous system I always felt a little hesitant to explain to my patients how what I was doing worked. I feel much more confident doing that now knowing I’m not perpetuating any lies or half truths. lets make sure everyone gets this information. I’m all in. Looking forward to San Diego!

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  7. Melissa April 29, 2016

    Great article Eric! Very informative and will help the majority of massage therapists who find your page online. Thankyou for sharing! 🙂

    reply
    • Eric Purves April 29, 2016

      Thanks for taking the time to read my article and for the positive comment Melissa. Glad to know you found the article informative!

      reply
  8. Amitava Sarkar January 19, 2017

    The Bio-psycho-social (and Neuromatrix) model actually shows that pain is far more complex – rather than simpler. So now a MT has to first determine if the problem/solution lies within SOP. This mean far more education/experience.

    “Once a therapist realizes that every effect we have is through the nervous system, primarily the brain, massage therapy becomes much more simplified” Actually it is the opposite IMO. Since perception/interpretation in/of pain is a complex phenomenon, determining the most efficient approach becomes more difficult and individualized.

    Pain specialists also forget that relaxation massages – which are FAR FAR less complicated – are an important part of the tradition and serve a niche. Sometimes a fantastic relaxation massage can help resolve many problems. Not everyone in industry is interested in providing more than a relaxation/anxiety reduction goal. This is an issue that should be addressed as well.

    Other that that I am generally in agreement with the thoughts.

    reply
    • Eric Purves January 19, 2017

      Thanks for your comments and thoughts Amitava.
      I agree with your point about pain being more complex. By making massage therapy simpler my meaning was to emphasize that pathoanatomical models and biomedical approaches to care aren’t very helpful in most cases and often can complicate the therapist/patient relationship. If therapists understand the multifactorial nature of the pain experience and provide non-threatening touch in the appropriate context than I think that makes care simpler to provide.
      You make some good points and I appreciate you taking the time to read and comment.

      reply
  9. Tania Velasquez January 25, 2017

    Excellent article! Thanks for writing it and putting what many of us feel on the internet 🙂 As an instructor and practitioner, I do my best to incorporate these concepts into class time (there is never enough!), however, it would be so much more productive to have everyone on board with this model. I believe the shift to it is inevitable- how long it takes is another story. In the meantime, I will continue to share the most current, best approaches in manual therapy.

    reply
    • Eric Purves January 25, 2017

      Tania,
      I am so glad you liked the article. It is always so great to hear there are other passionate and motivated therapists out there who want to see change in our profession. Thanks for taking the time to respond.
      Eric

      reply
  10. Deane Juhan October 23, 2017

    Eric,
    Yes, focus on the memories, feeling states and responses of the nervous system is definitely the necessary focus that is left out of the training of so many modalities. My long-time teacher, Dr. Milton Trager, was fond of saying,”There is no such thing as a tight muscle–only a tight mind.”
    I have been practicing and teaching his approach for 40 years, and primarily it uses the quality of touch and movement evoked in the client to induce a more sensorily aware, pleasurably relaxed and free state of mental being in order to address postural, movement patterning and restrictions of all kinds. If the mental sensory/cognitive/emotional state undergoes a shift, the tissues follow suit. Tissue can only respond to what the mind projects.
    Per Roger Sperry, Nobel laureate in neurology, 90% of the nervous system is involved one way or another with motor control. And 90% of that takes place on a subconscious level. My own “three pillars” of effective therapy are: 1) enhanced sensory awareness (if you can’t feel it, you can’t change it; 2) access to self-regulatory processes (the unconscious is not inaccessible–new reflex response patterns can be changed); 3) successful adaptation, which flows from heightened sensory awareness and self-regulatory processes.
    I have taught continuing education classes in this approach for many years, and consistently find students who are hungry for this perspective and feel the lack of it in the mechanical and biomedical protocols they have been taught in their training programs. There is a large population awaiting this shift in perspective.
    The arrogance of mechanically and psuedo-medically minded practitioners boggle me. It seems they must make thing complicated in order to feel important and authoritative (and to make money drawing in a population who is conditioned to expect this kind of kinda-allopathic mindset.
    Keep it simple. It used to be called “alternative therapy.” The simple precepts of quality of touch and the presence of the practitioner are the most effective way of reaching the mind of the client, and awareness is the most powerful medicine of all.

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