TIME IS RUNNING OUT

 

This blog consists of  highlights from the last four blog posts.  The time for comment on the ELAP project is almost over. I repost my observations as a source of information (biased by how I feel ) to help you better understand  the critical juncture we are at in the massage therapy community.

 elapmassage.org

One of my main concerns has been the choice of terminology used in the ELAP document.  I think the MTBOK did a much better job in presenting this content.  The entire massage platform in the ELAP is based on a foundation of Swedish massage.  Here are the comments from the original blog:

“Swedish Massage as an approach is too limiting and has current and historical confusion about what it means.  I searched state licenses and seldom is the term Swedish Massage used. Massage Therapy and Therapeutic massage are much more common.  In the state licensing descriptions of massage application terms such as gliding, kneading, pressing, shaking and so forth are use almost exclusively instead of effleurage, petrissage and so forth. If effleurage means “gliding” then use gliding and if petrissage means “ to knead” then  use the term knead.   I strongly believe that is time to use terminology that explains what is done and qualified by how it is done if for no other reason than to help researchers be able to standardize protocols.  The project is attempting to describe entry level practice so the simpler the better

Alteration of the ELAP is simply a term replacing process while leaving the intent of the document in place. Easy to do and clinging to the historical terminology is not worth the potential problems that can arise and how this language could undermine the whole project.  Please –the language should be as generic as possible.

These next sections get really odd for me.

 

Myofascial Approaches

 

Deep Tissue Approaches

 

Proprioceptive Approaches

 

Neuromuscular Approaches

 

 

I do not understand why they are seen as specific methods rather than adaptation of general massage application. The fascia appears to respond to tension forces, however why is not understood. Tension force is created with gliding methods that drag the tissues.  Lubricant is reduced or eliminated during application to create drag. In addition, the myofascial and deep tissue content areas were overlapping and the separation between the two is artificial. Fascia and other forms of connective tissue are structures of the body (anatomy) with interconnected function with other body systems (physiology). Deep tissues are under surface tissues or am I missing something here.  Don't you adapt depth of pressure to address the various layers of the body from surface to deep.  I recall Gil Hedley's dissection videos where he sequentially reveals various tissue layers.  http://www.gilhedley.com/index.php.

As problematic is the inclusion of deep tissue massage.   There is little agreement about what deep tissue massage is and that is a huge issue for entry level education.  I strongly feel that this section should be eliminated and the general massage platform include the ability to adapt pressure to address the various tissue layers of the body.

The method of compression was totally left out and yet it is the approach that is used in many situations especially over clothing and when lubricant is limited or not used.  This is a flaw in supporting methods like seated massage or in situation where static pressure is used.  This is anatomy-not method.  Pin and stretch was considered deep tissue (I think because once you complete an area you can't get back in). However, pin and stretch is considered a direct method (into the resistance) and by nature of the application isn't this myofascial????--or is it???.  You can see the problem I hope.

Proprioceptive approaches was confusing.  It appears to me that what is meant is the use of muscle energy techniques and pressure on muscular attachments.  Muscle energy techniques consist of a variety of controlled muscle contractions that are used primarily to support stretching. Since stretching and joint movement is part of the general massage (Swedish in the document) why is this a separate method?  In addition compression as a method described for both this category and neuromuscular as well as seated massage was not included in the methods of Swedish massage. 

Neuromuscular approaches are reflected as trigger point focus. The concept of trigger points as a condition (not a method) is under scrutiny.  It is likely that some sort of tender spot phenomenon exists but this would be a pathological condition or an adaptive response which would be addressed if appropriate with an adaptation of general massage. Besides the trigger point concepts in only a small aspect of neuromuscular methods as a system.  I have been fortunate enough to have Dr. Chaitow as a teacher and mentor for years and his analysis of trigger points and how to address when appropriate has evolved. His uncle Bois formalized neuromuscular applications. I just cannot support the way proprioceptive and neuromuscular methods were presented.

Hydrotherapy for Massage- Hydrotherapy is not massage. The complete system of treatment can compliment massage and therefor falls under my understanding of adjunct (something added to another thing but not essential to it.) I did not have issues with the content specifically but how does this fit under the category of- Massage Forms and Styles.  While there are some simple hydo/thermotherapy methods that an entry level massage therapist could add to the massage session I would really see this as a specific specialty beyond entry level.

Seated Massage- Why is seated massage a whole different concept than general massage adapted to the seated position and why was there a specific business and marketing strategy involve?

I propose that entry level should be based more on safe practice of general nonspecific massage with outcomes of wellness, relaxation, stress management, and able to address minor manifestations of pain and mobility in the generally health client.

 

There is NO DEFINITION OF MASSAGE  in the ELAP!!!!

From previous blogs

“I propose the MTBOK definition with a couple of suggested edits. Mtbok.org

Section 120 Massage Therapy Definition

Massage therapy is a healthcare and wellness profession involving manipulation of soft tissue. The practice of massage therapy includes assessment, treatment planning and treatment through the manipulation of soft tissue ( I suggest deleting :, circulatory fluids and energy fields ), affecting and benefiting all of the body systems, for therapeutic purposes including, but not limited to, enhancing health and wellbeing, providing emotional and physical relaxation, reducing stress, improving posture (add and movement ), facilitating circulation of blood, lymph and interstitial fluids (, balancing  energy –suggest alternate wording : -enlivening  physiological balance  ), remediating, relieving pain, repairing and preventing injury and rehabilitating. Massage therapy treatment includes a hands-on component, as well as providing information, ( delete-education and non-strenuous activity)s for the purposes of self care and health maintenance. The hands-on component of massage therapy is accomplished by use of digits, hands, forearms, elbows, knees and feet with or without the use of emollients, liniments, heat and cold, hand-held tools or other external apparatus. It is performed in a variety of employment and practice settings.

There are no overarching competencies in the ELAP document.

From pervious blogs

“I also propose the use of the COMTA competencies. http://www.comta.org/

I modified these just a bit for use in my curriculum at my school.

•PLAN AND ORGANIZE AN EFFECTIVE OUTCOME BASED THERAPETUIC MASSAGE SESSION •PERFORM MASSAGE FOR THE THERAPEUTIC BENEFIT OF THE CLIENT •DEVELOP AND IMPLEMENT SOUND BODY MECHANICS DURING MASSAGE APPLICATION •PERFORM MASSAGE IN AN ERGONOMICALLY SUPPORTIVE ENVIROMENT •INPLEMENT SELF-CARE STRATEGIES TO SUPPORT CAREER LONGEVITY •DEVELOP SUCCESSFUL AND ETHICAL THERAPEUTIC RELATIONSHIPS WITH CLIENTS, PEERS AND OTHERS IN THE HEALTH AND WELLNESS PROFESSIONS •DEVELOP STRATEGIES FOR A SUCCESSFUL PRACTICE IN BOTH A SELF-EMPLOYED OR EMPLOYEE CAREER PATHWAY •IDENTIFY STRATEGIES FOR LIFE LONG LEARNING AND ONGOING PROFESSIONAL DEVELOPMENT

 

 

 

Finally ,for this blog the ELAP-Entry Level Analysis Project needs to be revised based on the comments being collected right now and the feedback from the many experts in the field who have expressed concern over both the process and the content in the project.  The work group needs to be more transparent and when the final report is published please provide the original survey, raw data and the procedure used to analyze the data for the first draft.  I would also like to see the revisions made from the comment process and the raw data from the comments.

And---Why ELAP anyway?   ELAP was meant to inform development of model legislation

Model legislation will define who we are and what we do (scope of practice) . 

Model legislation will direct educational content and delivery

Please all of you who are reading this blog, I hope you use it as a launch pad to becoming informed. We do not have to always agree but we need to stay informed and work together. I hope you will share this information and encourage others a to be informed. I also hope that we all remember that the people involved in doing all this work are good, caring committed people. Support the people please as you share your comments and concerns.  I hope we will be productive and offer suggestions, be willing to compromise and not complain and bitch just for the sake of it. I hope we get this done.

We need to organize our definition of massage, our competencies, our body of knowledge and our core educational content into a unified statement.

MODEL PRACTICE ACT FOR MASSAGE-

I THINK WE NEED A HAND.
 

A model act is a draft of suggested occupational licensing  that is written with the intention of providing an example for legislation. A special interest group, a lawyers' conference, or a government agency may draft a model act. The goal is that the model act will be passed into law by local, state, or federal governments.

For Massage the Federation of State Massage Boards is creating the model practice act. https://www.fsmtb.org/userfiles/PDFs/MPA_Inaugural_Meeting_Press_Release_032811.pdf

There are a couple of organizations that help  create model practice act legislation.

The National Conference of Commissioners on Uniform State Laws (NCCUSL) works to propose model act legislation in the United States. The NCCUSL is a group of attorneys appointed by states who write model legislation for states, focusing on areas of statutory law. The model legislation provided by this organization strives to be non-partisan.

The American Legislative Exchange Council (ALEC) is another organization known for writing model legislation. ALEC is conservative and has both private members and state legislators as members. At its three annual meetings, ALEC’s members vote on proposed model legislation. From there, the model legislation goes to the organization's board of directors. If the board approves it, the draft becomes an official model bill.

I do not know if the Federation of state massage boards  is using such a group but it would seem to be a good idea.

http://www.wisegeek.com/what-is-a-model-act.

Model licensure for massage therapy is is a good concept. The massage community needs to be active in the development.  The most current aspect of the development of a model practice act is the Entry Level Analysis Project.  The Federation of State Massage Boards actually has a task force about ELAP which interests me. https://www.fsmtb.org/content/?id=36. I thought the ELAP idea came from the Leadership group of the massage professional organizations.  I tried to find out more information about the Federation task force but it was not available at least to my searches.  A main goal of the ELAP is to inform the Federation for the development of the Model Practice Act for massage which seems to be the end result of the endeavor. A model practice act will define massage, set educational standards, set forth scope of practice and be the platform of standards of practice.  My educated guess is that many in the massage there community do not understand the process or ramifications of this project.

I searched around and found the procedures and information for the development Emergency Medical Services (EMS). The pathway is very similar to massage therapy so instead of reinventing the wheel I suggest the massage community learn from them.  HERE IS SOME GENERAL INFORMATION.  I ENCOURAGE YOU TO CLICK THE LINKS AND READ THE DOCUMENTS. NOTE: CAPS INDICATE MY THOUGHTS.

The National EMS Scope of Practice Model defines and describes four levels of EMS licensure: Emergency Medical Responder (EMR), Emergency Medical Technician (EMT), Advanced EMT (AEMT), and Paramedic. Each level represents a unique role, set of skills, and knowledge base. National EMS Education Standards will be developed for each level. When used in conjunction with the National EMS Core Content, National EMS Certification, and National EMS Education Program Accreditation, the National EMS Scope of Practice Model and the National EMS Education Standards create a strong and interdependent system that will provide the foundation to assure the competency of out-of-hospital emergency medical personnel throughout the United States.

I AM NOT SUGGESTING A TIERED SYSTEM FOR MASSAGE BUT I AM NOT DISCOURAGING IT EITHER. IT COULD WORK.  Following is a link to the information and I suggest you read it keeping massage therapy in mind.

National EMS Scope of Practice Model http://www.nhtsa.gov/people/injury/ems/EMSScope.pdf

Here are some clips from the document. See if this does not sound like massage therapy. Remember the document is for EMS ok.

“identify 39 different licensure levels between the EMT

and Paramedic levels. This patchwork of EMS personnel certifications has created

considerable problems, including but not limited to:

• public confusion;

• reciprocity challenges;

• limited professional mobility; and

• decreased efficiency due to duplication of effort. “

 

“The National EMS Scope of Practice Model supports a system of licensure common in

other allied health professions. Such a system offers the following benefits:

• establishes national standards for the minimum psychomotor skills and

knowledge for EMS personnel;

• improves consistency among States’ scopes of practice;

• facilitates reciprocity;

• improves professional mobility;

• promotes consistency of EMS personnel titles; and

• improves the name recognition and public understanding of EMS personnel.

The licensure of EMS personnel, like that of other health care licensure systems, is part of an integrated and comprehensive system to improve patient care and safety and to protect the public. The challenge facing the EMS community is to develop a system that establishes national standards for personnel licensure and their minimum competencies while remaining flexible enough to meet the unique needs of State and local jurisdictions. This document recognizes the need for “freedom within limits.” ( I LIKE THIS)

 

“In 1993, the National Registry of EMTs (NREMT) released the National Emergency

Medical Services Education and Practice Blueprint. The Blueprint defined an EMS

educational and training system that would provide both the flexibility and structure

needed to guide the development of national standard training curricula and guide the

issuance of licensure and certification by the individual States.”

MASSAGE THERAPY STILL DOES NOT HAVE THIS.

 

THIS IS INTERESTING.

As a relatively young discipline, EMS has a limited research base which makes it

difficult to make evidence-based decisions; however, this project was guided by research

whenever possible. The development process used the National EMS Core Content,

State EMS office and medical director surveys, the National EMS Practice Analysis, the

National EMS Information System (NEMSIS) pilot project data, the Longitudinal EMT

Attributes and Demographics Study (LEADS), and peer-reviewed literature where

appropriate.

 

The Scope of Practice Model was also influenced by extensive literature review of other

professions, systematic analysis of policy documents regarding health care licensing and

patient safety, presentations by other allied health credentialing bodies, and crossprofessional

and international comparative analysis.

 

Statistical analysis and research on patient safety, scope of practice, and EMS personnel

competency must become a priority among the leadership of national associations,

Federal agencies, and research institutions. When EMS data collection, subsequent

analysis, and scientific conclusions are published and replicated, later versions of the

National EMS Scope of Practice Model should be driven by those findings.

 

I THINK THE ELAP PROJECT IS KIND OF TRY TO DO THIS BUT I WONDER WHY CURRENT MASSAGE LEGISLATION WAS NOT INCLUDED AS PART OF THE DATA.  ALSO I HOPE THAT  WE ALSO DO - extensive literature review of other professions, systematic analysis of policy documents regarding health care licensing and patient safety, presentations by other allied health credentialing bodies, and cross professional and international comparative analysis.

 

EMS ALSO CREATED EDUCATIONAL STANDARDS.

The National EMS Education Standards are not a stand-alone document. EMS education

programs will incorporate each element of the education system proposed in the Education

Agenda. These elements include:

• National EMS Core Content

• National EMS Scope of Practice

• National EMS Education Standards

• National EMS Certification

• National EMS Program Accreditation

This integrated system is essential to achieving the goals of program efficiency, consistency of

instructional quality, and student competence as outlined in the Education Agenda.

For the purpose of this model, one licensure level is substantially different from other

licensure levels in:

• Skills

• Practice environment

• Knowledge

• Qualifications

• Services provided

• Risk

• Level of supervisory responsibility

• Amount of autonomy

• Judgment/critical thinking/decision

making.

The National EMS Education Standards comprise four components :

1. Competency - This statement represents the minimum competency required for entry-level personnel at each licensure level.

2. Knowledge Required to Achieve Competency - This represents an elaboration of the knowledge within each competency (when appropriate) that entry-level personnel would need to master in order to achieve competency.

3. Clinical Behaviors/Judgments  - This section describes the clinical behaviors and judgments essential for entry-level EMS personnel at each licensure level.

4. Educational Infrastructure  - This section describes the support standards necessary for conducting EMS training programs at each licensure level.

 

Course Length

Course length is based on competency, not hours

Course material can be delivered in multiple formats including but not limited to:

• Independent student preparation

• Synchronous/Asynchronous distributive education

• Face-to-face instruction

• Pre- or co-requisites

 

YOU CHECK IT OUT.  I THINK IT IS A GOOD MODEL: http://www.ems.gov/pdf/811077a.pdf

 

IT MAY INTEREST YOU TO KNOW THAT EMS EDUCATION IS CLOCK HOURS BASED:

At the EMT-Basic level, training includes instruction in assessing patients' conditions, dealing with trauma and cardiac emergencies, clearing obstructed airways, using field equipment, and handling emergencies. Formal courses include about 100 hours of specialized training. Some training may be required in a hospital or ambulance setting. The EMT-Intermediate 1985 or EMT-Intermediate 1999 level, also known as the Advanced EMT level, typically requires 1,000 hours of training based on the scope of practice. At this level, people must complete the training required at the EMT level, as well as more advanced training, such as training in the use of complex airway devices, intravenous fluids, and some medications. Paramedics have the most advanced level of training. They must complete EMT-level and Advanced EMT training, as well as training in advanced medical skills. Community colleges and technical schools may offer this training, in which graduates may receive an associate's degree. Paramedic programs require about 1,300 hours of training and may take up to 2 years. Their broader scope of practice may include stitching wounds or administering IV medications.

http://www.bls.gov/ooh/Healthcare/EMTs-and-paramedics.htm#tab-4

 

So what does this mean for us right now?  Here is my take on it.

 

Model legislation will define who we are and what we do (scope of practice) . 

Model legislation will direct educational content and delivery

ELAP was meant to inform development of model legislation

We need to organize our definition of massage, our competencies, our body of knowledge and our core educational content into a unified statement.

The EMS model gives us an idea about how other occupations did these things.

 

Vocational education is appropriate for entry level massage practice based on clock hours.

 

Based on EMS scope of practice example the 500-600 model for entry level massage education may be more accurate than we think.

 

We should be using “outside of the massage community” experts to help us do this.  

WE NEED TO BE INFORMED !!!!!!!!!!!!!!!!!!!!!!!!!!!

 

 

 

 

 

RAVE-RANT-HOPE

 

Rave- .give high praise: to give praise in a very enthusiastic way

Rant- speak in loud exaggerated manner: to speak or say something in a very loud, aggressive, or bombastic way, usually at length and repetitively

Hope- want or expect something: to have a wish to get or do something or for something to happen or be true, especially something that seems possible or likely

 

This blog series has the intention to identify great things going on that affect the massage profession,  speak candidly my opinions about issues that impede and complicate these great things from happening and  express my hopes (and suggestions) for the future of this needed and important profession.

I am going to use the word profession in a hopeful way. A profession is : Occupation, practice, or vocation requiring mastery of a complex set of knowledge and skills through formal education and/or practical experience.

We are close. We could do this so I begin this blog series with HOPE.   

I do not believe that entry level massage practice needs to be a degree level program and support vocational training (certificate/diploma)  for initial training .  I also think that the Board Certification process now offered by the National Certification Board for Therapeutic Massage and Bodywork http://www.ncbtmb.org/ is an important step in differentiating entry level (licensing-novice) practitioner from those who have committed to the next level ,not because they have to  (licensing) but because they want to  strive for excellence.  I think that the educational requirement post-graduation is too low but we have to begin someplace and it is only one part of the qualifications for BOARD CERTIFICATION.  So NCBTMB gets a qualified RAVE from me and the board certification process and future specialty certification that can be a pathway to higher degrees such as bachelor’s degrees for those who want to achieve a high degree of excellent in that manner.

RANT: WE NEED AN AGREED UPON DEFINITION OF MASSAGE.

RAVE: I propose the MTBOK definition with a couple of suggested edits. Mtbok.org

Section 120 Massage Therapy Definition

Massage therapy is a healthcare and wellness profession involving manipulation of soft tissue. The practice of massage therapy includes assessment, treatment planning and treatment through the manipulation of soft tissue ( I suggest deleting :, circulatory fluids and energy fields ), affecting and benefiting all of the body systems, for therapeutic purposes including, but not limited to, enhancing health and wellbeing, providing emotional and physical relaxation, reducing stress, improving posture (add and movement ), facilitating circulation of blood, lymph and interstitial fluids (, balancing  energy –suggest alternate wording : -enlivening  physiological balance  ), remediating, relieving pain, repairing and preventing injury and rehabilitating. Massage therapy treatment includes a hands-on component, as well as providing information, ( delete-education and non-strenuous activity)s for the purposes of self care and health maintenance. The hands-on component of massage therapy is accomplished by use of digits, hands, forearms, elbows, knees and feet with or without the use of emollients, liniments, heat and cold, hand-held tools or other external apparatus. It is performed in a variety of employment and practice settings.

I also propose the use of the COMTA competencies. http://www.comta.org/

I modified these just a bit for use in my curriculum at my school.

•PLAN AND ORGANIZE AN EFFECTIVE OUTCOME BASED THERAPETUIC MASSAGE SESSION

•PERFORM MASSAGE FOR THE THERAPEUTIC BENEFIT OF THE CLIENT

•DEVELOP AND IMPLEMENT SOUND BODY MECHANICS DURING MASSAGE APPLICATION

•PERFORM MASSAGE IN AN ERGONOMICALLY SUPPORTIVE ENVIROMENT

•INPLEMENT SELF-CARE STRATEGIES TO SUPPORT CAREER LONGEVITY

•DEVELOP SUCCESSFUL AND ETHICAL THERAPEUTIC RELATIONSHIPS WITH CLIENTS, PEERS AND OTHERS IN THE HEALTH AND WELLNESS PROFESSIONS

•DEVELOP STRATEGIES FOR A SUCCESSFUL PRACTICE IN BOTH A SELF-EMPLOYED OR EMPLOYEE CAREER PATHWAY

•IDENTIFY STRATEGIES FOR LIFE LONG LEARNING AND ONGOING PROFESSIONAL DEVELOPMENT

COMTA gets a RAVE from me even though at this time my school is not accredited due to current economical struggles.  I hope COMTA can find a way for small school like mine not wanting to participate in financial aid can achieve affordable programmatic accreditation. .  I know they are trying to do this but have to be accountable to their own compliance issues. Until then I run my school in a COMTA ready process and encourage others to do this as well.

I have a qualified RAVE for the MTBOK and believe that if the scope of practice statement were eliminated and a few changes were made to the entry level knowledge, skill and abilities (KSA) section following the review done by the Alliance for Massage Therapy Education (http://www.afmte.org/education/mtbok/ ) that is  an important document in a statement of professionalism and unification of the massage profession.  I have a big RANT as well.   There is no reason for that document to be sitting on the webpage shelf and ignored.  It is not perfect but it is a great source of information.   It should not be minimalized and ignored but actively improved and integrated into the unifying statement of the massage profession.

Finally ,for this blog the ELAP-Entry Level Analysis Project needs to be revised based on the comments being collected right now and the feedback from the many experts in the field who have expressed concern over both the process and the content in the project.  The work group needs to be more transparent and when the final report is published please provide the original survey, raw data and the procedure used to analyze the data for the first draft.  I would also like to see the revisions made from the comment process and the raw data from the comments.

 I give the work group a RAVE for being open to discussion and support them in the work they are doing but also encourage then to continue to reach out the research experts and subject matter experts in massage that want to help this initiative be successful.   They need support and input and I believe they will listen and respond.   So comment- elapmassage.org

A finial RANT for this blog: All organization serving the massage profession-STOP WORKING BEHIND CLOSED DOORS. PROVIDE REGULAR UPDATES ON WHAT YOU ARE DOING AND REALIZE THAT YOUR INDIVIDUAL PROJECTS ARE ONLY PART OF THE WHOLE.

A finial RAVE for these same organizations working together and please keep in up with even more inter-cooperation.

And a closing HOPE. Please all of you who are reading this blog, I hope you use it as a launch pad to becoming informed. We do not have to always agree but we need to stay informed and work together. I hope you will share this information and encourage others a to be informed. I also hope that we all remember that the people involved in doing all this work are good, caring committed people. Support the people please as you share your comments and concerns.  I hope we will be productive and offer suggestions, be willing to compromise and not complain and bitch just for the sake of it. I hope we get this done.

Additional Link list for gathering information.

http://www.afmte.org

http://massagenerd.com

 http://massagenerd.tv/

http://www.youtube.com/massagenerd

http://lauraallenmt.com/blog

I AM BIASED

A DEFINITION OF BIAS- A predisposition or preconceived opinion that prevents a person from impartially evaluating facts.

We are all biased.  Knowing this we can work really hard to remain open to information and do our very best to identify bias, acknowledge it and sometimes move beyond it.  The scientific method is a process that attempts to limit bias.

A conflict of interest is a situation where an organization or individual is involved in multiple interests that might influence the ability to be objective.  I have conflicts of interest that have impact on what I choose to do or not do within the massage profession.  Because I write textbooks used to teach both entry level and advanced practice massage I refrain from organizational board service and instead contribute behind the scenes on committees or as a subject matter expert.  Before I agree to be involved I question my biases and disclose my conflicts of interest.   With my textbook writing the publisher requires all my work to undergo extensive peer review that is blinded so individuals can be frank with their observation and opinions.  For last revision of Fundamentals of Therapeutic Massage I had 17 reviewers and let me tell you they had no problem telling me about errors, bias, when I was on a “soap box” and so forth.  I depend on this so that the textbooks are as current and objectively reflective of the massage profession at the time of publication as possible.  However—in spite of all the checks and balances there are still biases and opinions found in the textbooks— not just mine but in textbooks in general.

There are two projects that have or are attempting to describe entry level massage therapy.  The Massage Therapy Body of Knowledge (MTBOK) released in 2010 and currently the Entry Level Analysis Project (ELAP).  As the massage therapy community, we must analysis for bias and conflict of interest.  To do this we need clear disclosure from all individuals directly involved with supervision, data collection and interpretation and project management. 

I strongly encourage you to revisit the MTBOK document at MTBOK.org and specifically read through the vision and information provided in the FAQ tab.  Personally---( and I am biased) I thought the outcome of the MTBOK was  good in relationship to how entry level knowledge was described and how a common language used to describe massage was developed. The content was developed by mining through textbooks used in massage therapy schools all over the country as well as data from professional organization and state regulators. There were no surveys or original data collected to my knowledge. There was opportunity for comment by the massage community.  Most of the conflict and push back from the profession related to the scope of practice statement so I just ignored that ( bias) and concentrated on the knowledge, skills and abilities identified for entry level massage education.  The Alliance for Massage Therapy Education  (aftme.org)  did a comprehensive review of the MTBOK entry level educational recommendations and I served on that committee  and we all had our biases which hopefully evened out the end result, which was reviewed by the Alliance board and then went out for public comment and remains on the website for review. .  I am biased but it is a very good guide for curriculum development.

 Now the ELAP project.  I don’t have as much information about how the vision of the project was determined. I have been kind of confused in general.  I am not opposed to the project however in the beginning I did point out the potential for bias and conflict of interest not that I think any of the work group would intentionally do this but even the appearance of bias and conflict of interest would be detrimental to the validity of the project.

 I repeatedly recommended that an objective group of educational experts outside of the massage profession guide the project.   I thought that if the project was conducted in a specific way that controlled for bias using individuals outside the massage community, but experts in education, there would be a more accurate outcome and less suspicion from the massage community.  I suggested that the MTBOK also be part of the data as well as other information from the various JTA’s (job task analyses.)

 My biased little self- became a pest I think as I pointed out the problems of bias and conflict of interest.  When the original survey came out (as an add on to the Federation of State Massage Boards JTA relating to the MBLEX ) I felt uneasy with the way many of the questions were designed. As I have pointed out before- Swedish massage was the ONLY term presented for the concept of general relaxation massage.   Also it was hard enough to get through the JTA survey let alone the ELAP add on. I communicated with the work group and the leadership  group about this  in my typical pesky biased manner.  

Research bias, also called experimenter bias, is a process where the individuals performing the research influence the results, in order to portray a certain outcome. (explorable.com/research-bias) . Bias is so pervasive because we want to confirm our beliefs  and the scientific methods are organized around proving itself wrong not right in an attempt to limit bias.

 In my opinion the ELAP survey process was and continues to be flawed and displayed the following forms of research bias:

·         Confirmation Bias is the tendency for us to favor information that confirms our belief about something.

·         Design bias is introduced NOT when the study fails to control for threats to internal and external validity  but rather when the study fails to identify the validity problems OR when publicity about the research fails to incorporate the researchers cautions.

·         Measurement bias exists when researchers fails to control for the effects of data collection and measurement. Often the problem is not the sample, it's the failure to acknowledge the bias the sample brings.

·         Procedural bias exists most often when we administer the research interview or questionnaire under adverse conditions ( the multiple surveys as part of the ELAP as well as not being able to go back and review content or seeing the project as a whole and or in paper form plus the videos can be seen as procedural bias in my biased opinion.  

·         Bias via assumptions is the failure to adequately identify more problematic background assumptions. For example, in the ELAP document there is the assumption that the content is presented by an effective teacher.  There are other imbedded assumptions in the questions on the surveys.

·         Bias in Survey Sampling: Bias often occurs when the survey sample does not accurately represent the population. The bias that results from an unrepresentative sample is called selection bias. A good sample is representative. This means that each sample point represents the attributes of a known number of population elements. I contend that The ELAP survey respondents are not representative of the massage community.

·         Voluntary response bias. Voluntary response bias occurs when sample members are self-selected volunteers, as in voluntary samples.  The ELAP has problems with this type of bias. The resulting sample tends to over represent individuals who have strong opinions. LIKE ME

·         Bias Due to Measurement Error. In survey research, the measurement process includes the environment in which the survey is conducted, the way that questions are asked, and the state of the survey respondents and leading questions. The wording of the question may be loaded in some way to unduly favor one response over another.  I have no idea how the original survey and the current one on the curriculum map was developed or how they controlled for bias.

I would hate to see the work of the ELAP group discounted. To counter this I recommend that the ELAP process be evaluated by experts outside the massage profession that can identify the inherent biases that have and will occur.   This recommendation in no way reflects of the integrity and the commitment of the ELAP work group.   My bias is that the massage profession is biased, suspicious and frustrated with projects such as this.   For the ELAP project to be useful for the future of massage therapy it must be valid and if the unintentional biases and conflicts of interest taint the project it will sit on the shelf along with the MTBOK and that will be very unfortunate. – My biased opinion.

 Bias definitions adapted from http://stattrek.com/survey-research/survey-bias.aspx

MORE ELAP OBSERVATIONS

As I continue wading though the ELAP document I find myself longing for a definition of massage but I can't find one. Instead what I find is  a tab that says Massage Forms and Styles.  Under this tab is :
Foundation Principles and Skills
Swedish Massage
Myofascial Approaches
Deep Tissue Approaches
Proprioceptive Approaches
Neuromuscular Approaches
Hydrotherapy for Massage
Seated Massage

I guess that this is the definition for massage. I have issues for sure.

Foundation Principles and Skills- This section was well done and reflective of entry level.


Swedish Massage - In my previous post I explain the problem with using the term Swedish massage as the platform for massage language. I suggest a term such as general massage or massage therapy or massage.

These next sections get really odd for me.
Myofascial Approaches
Deep Tissue Approaches
Proprioceptive Approaches
Neuromuscular Approaches

I do not understand why they are seen as specific methods rather than adaptation of general massage application. The fascia appears to respond to  tension forces, however why is not understood. Tension force is created with gliding methods that drag the tissues.  Lubricant is reduced or eliminated during application to create drag. In addition, the myofascial and deep tissue content areas were overlapping and the separation between the two is artificial. Fascia and other forms of connective tissue are structures of the body (anatomy) with interconnected function with other body systems (physiology). Deep tissues are under surface tissues or am I missing something here.  Don't you adapt depth of pressure to address the various layers of the body from surface to deep.  I recall Gil Hedley's dissection videos where he sequentially reveals various tissue layers.  http://www.gilhedley.com/index.php.
This is anatomy-not method.  Pin and stretch was considered deep tissue (I think because once you complete an area you can't get back in). However, pin and stretch is considered a direct method (into the resistance) and by nature of the application isn't this myofascial????--or is it???.  You can see the problem I hope.

Proprioceptive approaches was confusing.  It appears to me that what is meant is the use of muscle energy techniques and pressure on muscular attachments.  Muscle energy techniques consist of a variety of controlled muscle contractions that are used primarily to support stretching. Since stretching and joint movement is part of the general massage (Swedish in the document) why is this a separate method?  In addition compression as a method described for both this category and neuromuscular as well as seated massage was not included in the methods of Swedish massage. 

Neuromuscular approaches are reflected as trigger point focus. The concept of trigger points as a condition (not a method) is under scrutiny.  It is likely that some sort of tender spot phenomenon exists but this would be a pathological condition or an adaptive response which would be addressed if appropriate with an adaptation of general massage. Besides the trigger point concepts in only a small aspect of neuromuscular methods as a system.  I have been fortunate enough to have Dr. Chaitow as a teacher and mentor for years and his analysis of trigger points and how to address when appropriate has evolved. His uncle Bois formalized neuromuscular applications. I just cannot support the way proprioceptive and neuromuscular methods were presented.

Hydrotherapy for Massage- Hydrotherapy is not massage. The complete system of treatment can compliment massage and therefor falls under my understanding of adjunct (something added to another thing but not essential to it.) I did not have issues with the content specifically but how does this fit under the category of- Massage Forms and Styles.  While there are some simple hydo/thermotherapy methods that an entry level massage therapist could add to the massage session I would really see this as a specific specialty beyond entry level.

Seated Massage- Why is seated massage a whole different concept than general massage adapted to the seated position and why was there a specific business and marketing strategy involve?


Also as a side note, I had my entry level students complete the section on the skeletal system and they thought is was good and that they should know the content. I agree with them.  I did take issue with being told how to teach the content however.  I actually choose to use the ELAP to teach today and that was not a possibility listed in the curriculum map.

I realize that this blog is coming a crossed sarcastic but I am choosing to leave it this way because I believe my frustration is valid.  I also know what it is like to be on the other side of a review like this. The individuals who worked hard on this, I believe were doing the best they identified at the time of creating this draft.  I also know how important it is to pay careful attention to reviewers.  Reviewers see things differently and can point out flaws, inaccuracies and biases when as an author or in this instance part of a work group cannot see because of being too close and attached to the project.. Please workgroup--pay attention.

ELAP-Some of my observations for you to consider.

 

 

First, before I write anything else it is important to state that I am supportive of the ELAP project.   I want it to succeed.

Now here are some of my observations and concerns:

The initial survey attached to the Federation of State Massage Boards job task analysis survey was flawed.  The only option for general massage was the term Swedish Massage and for a therapeutic intervention was deep tissue massage.  The problem is:

Swedish Massage as an approach is too limiting and has current and historical confusion about what it means.  I searched state licenses and seldom is the term Swedish Massage used. Massage Therapy and Therapeutic massage are much more common.  In the state licensing descriptions of massage application terms such as gliding, kneading, pressing, shaking and so forth are use almost exclusively instead of effleurage, petrissage and so forth. If effleurage means “gliding” then use gliding and if petrissage means “ to knead” then  use the term knead.   I strongly believe that is time to use terminology that explains what is done and qualified by how it is done if for no other reason than to help researchers be able to standardize protocols.  The project is attempting to describe entry level practice so the simpler the better

Alteration of the ELAP is simply a term replacing process while leaving the intent of the document in place. Easy to do and clinging to the historical terminology is not worth the potential  problems that can arise and how this language could undermine the whole project.  Please –the language should be as generic as possible.

As problematic is the inclusion of deep tissue massage.   There is little agreement about what deep tissue massage is and that is a huge issue for entry level education.  I strongly feel that this section should be eliminated and the general massage platform include the ability to adapt pressure to address the various tissue layers of the body.

The method of compression was totally left out and yet it is the approach that is used in many situations especially over clothing and when lubricant is limited or not used.  This is a flaw in supporting methods like seated massage or in situation where static pressure is used. 

I propose that entry level should be based more on safe practice of general nonspecific massage with outcomes of wellness, relaxation, stress management, and able to address minor manifestations of pain and mobility in the generally health client.

Content related to professional communication is important and I believed covered well in the document.   There are aspects of specific methods for communication skill based on organized systems integrated into the document and I think this should be more generic.  For example- I am skilled in the used the Myers Briggs system but would never suggest that this approach be incorporated into the ELAP document.

I also am concerned over content in the ELAP document that relates to psycho/emotional issues.   Topics such as breath work, emotional release, psycho/social l behavior and energy balance are too controversial and if and when valid are way outside the realm of entry level. These topics should be eliminated.  

I have some concern over the use of the taxonomy created by the work group.   I think it would have been better to use a method to create the document that is grounded in current education and implementation into standard academia may be an issue. This being said, I believe what the work group did develop is workable.  I do think that the curriculum map based on the taxonomy is too tight and could be perceived as dictatorial.  I personally understand the domains and how a bit of content is addressed in each domain, but as I reviewed the document it felt like the curriculum map was telling me HOW to teach instead to indicating WHAT to teach.  WHAT AND HOW ARE VERY DIFFERENT.  For example many times it is stated to use mock forms to analysis something or write a sample massage plan or role pay and critique peer. These are all fine educational methods but they are HOW to teach something instead of WHAT to teach.  I suggest that the curriculum map stick with WHAT to cover and if appropriate list methods that are used to teach this type of content separately. Personally I think the HOW should be more directly related to teacher training.

Also removing the HOW TO TEACH SOMETHING and concentrating on WHAT TO TEACH would significantly simplify the document which is overwhelming.   I think the work group attempted to do too much and suggest that the document be simplified.

This is enough for now. More to come.   What do you think? 

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