Response rate and Demographics
Seven hundred ninety-one completed questionnaires were returned, a 15.1% return rate, with 57% respondents from the NHPC, 14% from the MTAA, 6% from the ARMTS, and 24% who did not indicate their affiliation. Comments on returned questionnaires indicate that the response rate was impacted by the summer distribution and concerns that the questionnaire would be used for the purpose of regulating massage therapy in Alberta. Table compares this survey's results to previously published demographic surveys of the Natural Health Practitioners of Canada (NHPC) (pan-Canada survey of the massage therapy members) [6
], the College of Massage Therapists of Ontario (CMTO) (province of Ontario, Canada, Registered Massage Therapists survey) [5
], and the American Massage Therapy Association (AMTA) (pan-U.S.A. survey of massage therapy members) [15
]. Despite the lower response rate of the present survey, there were no significant differences between the demographics in the surveys' samples.
Demographic characteristics, and comparison to past surveys
TMB therapies identified
Respondents were trained in 62 out of the 65 therapies listed in the questionnaire (no practitioners of Aston Patterning, Looyen Work, or Mitzvah Technique). An additional 15 unique TMB therapies, and 36 non-TMB therapies (e.g., energy work, shamanism, counselling, herbology, movement and stretching therapies, acupuncture) were identified in the 'other' category. Of the total 77 TMB therapies, 22 (Table ) have been taught to more than 10% of the respondents (complete list of TMB therapies practiced available on request).
TMBs identified during the project practiced by 10% or more of respondents
Most practitioners (94.4%) are trained in more than one therapy, with a range of 1 to 40 therapies, and a median of 8 therapies (Figure ). Of the 77 therapies identified, practitioners indicated that for 51 of those therapies, the training programs usually incorporated one or more (median of 3, range 1 to 17) additional therapies. The correlation (r = 0.115, p = 0.001) between number of years in practice and number of therapies trained in is low.
Total number of therapies in which a practitioner has trained.
Participants listed a total of 2,477 training programs with one or more TMB components. Length of the training programs varied widely, with no standard length for non-trademarked therapies. Their minimum training length ranged from 1 to 50 hours, with maximum hours ranging from 100 to 4,000. The shorter lengths for some therapies may have been introductory courses providing rudimentary training in some of the therapies' techniques; the questionnaire did not address the extent and depth of a training program. Most trademarked therapies had narrow ranges of training program length, like Hellerwork Structural Integration™ with a range of 1200-1250 hours.
On the questionnaire, respondents provided detailed therapy components for 856 training programs that included two or more TMB therapies. Massage therapy training programs were the most common (504 out of 856), with a median of four additional therapies in the training programs. For 641 of the 856 training programs, training program length was provided, which allowed checking for possible similar training programs between practitioners. Of those 641 training programs, 622 were unique programs.
Fifty-nine different TMB therapies were identified within the 856 multiple therapy training programs. Of the 12 therapies that appear in 10% or more of the training programs (Table ), 10 are specialized techniques associated with the practice of massage therapy, either specific approaches (e.g., myofascial release, hydrotherapy) or for specific populations (e.g., sports massage, maternal massage).
Additional TMB components included in more than 10% of TMB training programs
The 19 interviewees indicated that they practiced between two and ten therapies on their volunteer form. During the interviews most practitioners described being trained in a greater number of therapies. Many participants also described taking introductory courses for additional therapies in which techniques from those therapies are sampled, as well as taking training in non-TMB therapies. Descriptors of the participants are included in Table . Number of years in practice was not a selection criterion for being interviewed, but it is included in Table to show the range of experience covered by the participants.
Interview participant characteristics, including reported therapies trained in
Interview participants expressed complex and widely different responses to the interview questions. Four key themes emerged from the interviews: 1) the complexity of career and training paths; 2) all treatment is individualized; 3) the practice of therapies evolves over time; and 4) clinical practice and research treatment protocols are different. The first three have components that are relevant to describing the training and practice of TMB practitioners. The fourth theme describes why practitioners reference their clinical experience to distinguish between clinical practice and research-protocol treatments. Interview results from the purposefully oversampled male and non-massage therapist populations compared to the interview results of females and massage therapists, respectively, did not reveal any differences.
Theme 1: Career and training paths are complex
A number of career and training factors emerged in the interviews related to: the practitioner's vision of their work before they began their training; the type of practice environment they desired; the availability, time, and cost of training programs; and the pressures that affected subsequent training choices. Participants followed training pathways that were quite variable right from the start of their careers.
Entry into a TMB profession sometimes came from a long-time desire, or the realization that they were finally coming "home" to the profession, often after receiving some TMB or taking an introductory course. For others, it was a progression from previous employment, or an opportunity that enabled a switch into a new profession.
"My nurse friend said..., 'You really are in the wrong profession. ... you should do it [massage]' and got me an interview with the school. And when I did my first body I knew I had come home." (Practitioner 9)
Some practitioners had pre-conceived ideas of what the style of their first or primary training should be, e.g., focused on injury treatment and prevention relative to general health and well-being treatments, focused on one or a few specific, related TMB therapies, or wanting a program that was "holistic," incorporating multiple therapies and perspectives. Others instead chose their training programs for pragmatic reasons such as availability or because they could accommodate the training program schedule.
"I found this program in Medicine Hat that you could get the reflexology along with the massage and a whole whack of other stuff, and decided I would give it a try." (Practitioner 3)
Many training programs incorporate two or more therapies. Several practitioners talked about the inclusion of some "extra" introductory versions of therapies added to their primary therapy training program(s), giving them a couple of extra techniques, or a "taster" of the other therapies that they could then pursue at a later date. They often incorporate these introductory courses' techniques into their daily practices, but do not practice under the name of those therapies.
All the interviewed practitioners had taken more training after completing their initial training program. For all of them, the trend was to train in an increasingly diverse and often complex set of therapies over time. They spoke of these training choices as pursuing ideas and therapies of personal interest. This could be to refine or expand skills within their current treatment framework (e.g., remedial service), or to branch out to incorporate completely new therapy forms.
"I often took classes because I felt I needed more, 'cause I didn't have everything. When I first took massage therapy, I was ready to heal the world... And it doesn't. I mean, it's a really nice thing to do, but massage works on muscle, and muscle isn't the only cause of people's pain and dysfunction in this world." (Practitioner 10)
These additional therapies are often referred to as added "tools in the toolbox." The importance of the toolbox concept became clear as practitioners talked about how and why each treatment they provide is individualized (see also Theme 2 below).
"... and then I just go through my tool kit and say okay this is what would work best for that. That's how I fit things together." (Practitioner 4)
Theme 2: All treatment is individualized
The drawing on tools--the many therapies and techniques practitioners have learned--is an important process of individualizing a patient's treatment. Practitioners described three increasing levels of specificity in the individualization of treatment delivery: 1) the initial treatment plan; 2) treatment plan variation; and 3) within-therapy variation.
At the first level, an initial treatment plan is developed based on the treatment goals, which come from initial assessments (visual, testing, palpation) as well as dialogue with the clients about their goals, needs, and experiences. A treatment plan outlines the therapeutic intent(s) and treatment(s) for the current session and will map out the planned treatment progression for subsequent sessions, though a reassessment will occur at the start of each subsequent session.
"I start picking up the cues about how they [the patients] are functioning right from the beginning... whatever levels they're describing at: 'My shoulder is painful.' 'It happens when I'm doing these particular things.' ... I watch how their body is in space and I palpate to see what that feels like as they move those parts of the body that we're paying attention to at any particular time and I have certain set of movement check-ins that I do with people... then the next level that I work with, I check in with touch to find out exactly what is going on [in the person's structure]..." (Practitioner 14)
The second level of individualization is treatment plan variation, which occurs throughout every treatment session. Complex feedback loops based on palpation (tissue texture, temperature, pliability or tone), visual cues (pain, motion or tension changes, breath patterns), verbal feedback from patients, intuition, and the pressure of time frame are used to gauge the progress of the treatment at any moment. These cues inform awareness of the treatment progress and choices at that moment, suggesting either to continue, to change therapy techniques, or move to a different therapy as they continue to work. They may also pause treatment to do a more deliberate reassessment before continuing treatment. All interviewees, regardless of whether they kept to only one therapy during a treatment (two interviewees) or integrated several therapies into the treatment plan (17 interviewees), described modifying their treatment plans based on in-the-moment assessment.
"If I've been working there for a while and I'm not getting any releases there, then I go from the microscopic, you know, looking at that hip for example, and I broaden my scope and go to macroscopic, and I start looking at what's going on in the low back, what's going on in the pelvis area--on the front of the pelvis--that could be affecting what's going on in the hip. Or I might need to go down into the leg. So just broadening my scope, and usually the body will draw me to the next place that needs to be addressed." (Practitioner 12)
"Sometimes I've kicked in three different things back-to-back. Depends on how the body is releasing." (Practitioner 10)
The final layer of individualizing is within-therapy variation. Occurring at any moment during a session, this may be a spontaneous or planned shift in a particular therapy's technique, or the integration of another therapy's technique within the therapy the practitioner is currently applying so as to better address the perceived treatment need. This level includes the described variations on "listening to the hands," where practitioners let their hands spontaneously react to tissue cues.
"The more I learn the more I know I don't know. (laughs) My hands really have to ... [interrupting herself] I listen to my hands. My hands tell me where to go next, and they don't care what definition the technique is listed under." (Practitioner 10)
Practitioners consider the strength and healing possibilities in their work to be at the second and third levels of individualizing treatment.
"Palpation is probably the most paramount ingredient to use during the course of the treatment. You're evaluating throughout the course of treatment. You're evaluating the tissue, the texture of the tone, everything like that in the muscle, determining how it's responding." (Practitioner 5)
Some had critical words for practitioners who would tend to practice using routine patterns with little adaptation or individualizing.
"I mean, you know this is the most important thing actually. I mean if you just follow a stupid protocol, you know we just call these people the skin pushers." (Practitioner 11)
The importance of this complex, adaptive treatment process based on continual feedback from multiple information sources was echoed in ideas expressed about TMB research based on restrictive protocols compared to clinical practice (Theme 4).
Theme 3: Therapy provision will evolve over time
Discussions of within-therapy variation of technique led to a critical question of exploration: does a given therapy, as practiced, change over time from the accumulating experience of a practitioner, including influences from the multiple-therapy integration that happens as part of the process of individualizing patient care? The practitioners expressed two primary, contrary opinions about this. Most asserted that it would be easy to provide a therapy uninfluenced by techniques from other therapies they had learned, or at least with disciplined focus they could do so.
"I think definitely who I am today, all of that has influenced me. But I also know that if somebody said to me, 'I want a straight fascial work' or 'I want a straight sport massage work' or 'I want a straight Swedish massage work', I could do that. I could pull them apart and still do them." (Practitioner 1)
However, they all acknowledged that practice becomes refined due to practice experience, exposure to different therapy techniques over time, or both, making every therapist's application unique. As Practitioner 11 put it, referring to the idea of a generic practitioner practicing a pure, as-trained therapy, "they could, but you know they haven't learned then." Several highly self-reflective practitioners speculated that no one fundamentally practices an unaltered therapy. They postulated that any TMB application is likely permanently altered due to practice experience and alteration of perception or techniques from multiple TMB training programs, even if that alteration is not conscious.
"...my hands just can't operate at the gross [basic] level they used to for massage. When I'm doing a massage... sometimes I'm feeling the lymph and sometimes I'm feeling the energy... some type of an energy cyst, from the Craniosacral perspective. Or I'm feeling that the fluids are not moving from the lymphatic drainage [perspective]." (Practitioner 10)
Theme 4: Clinical practice and research treatment protocols are different
The individualization process underlies the fourth theme, clinical practice treatments are different from the treatment protocols used in research. Based on deduction from published research, practitioners insist there is a distinction between the two, which they dichotomize as either individualized clinical practice or pre-defined, restrictive research treatment protocols.
"Well, I think research is research and practice is practice. Research, you're setting out to find a specific thing. You're not trying to ...well, you are trying to help someone, but you're more about how this particular thing affects that person or that pathology or that injury. So you have to be consistent... you can't change it, or how do you know that it wasn't one of the other things, right?
Practice is a whole different thing. You're not there to prove to the client that this technique works. It either does or it doesn't, and if it doesn't you need to move onto something else, 'cause it's different for every person. So you're treating the person, whereas with research you're researching." (Practitioner 15)
Underlying these comments is a shared practitioner wariness of the clinical usefulness of research results. As described above, clinical practice treatment normally would be individualized to maximize therapeutic outcome. Commonly, applying a research protocol or using a single approach to a symptom is highly constrained; practitioners may not consider such a treatment process as appropriately responsive to what was occurring in the body. Therefore the relevance of treatments in research seems removed from everyday clinical practice.
"I think that when I've seen the early research that's been done with short stroke and all that kind of stuff for tension and pain management, I think that they are flawed because they do not take in [to account] tissue response. ...You would have to do proper assessment of the appropriateness of your approach for the person. As long as you provide massage or any other technique only as a set routine, you always miss the broader lived experience, the organism's response to what you're doing. There necessarily needs to be the capacity for ongoing assessment and adjustment of the treatment approach to the person's response to the treatment as part of getting a proper reading of whether it's doing what it should be doing." (Practitioner 14)