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1.  Negotiating Consent: Exploring Ethical Issues when Therapeutic Massage Bodywork Practitioners Are Trained in Multiple Therapies 
Introduction
Obtaining informed consent from competent patients is essential to the ethical delivery of health care, including therapeutic massage and bodywork (TMB). The informed consent process used by TMB practitioners has not been previously studied. Little information is available about the practice of informed consent in a treatment-focused environment that may involve multiple decision points, use of multiple TMB therapies, or both.
Methods
As part of a larger study on the process of providing TMB therapy, 19 practitioners were asked about obtaining informed consent during practice. Qualitative description was used to analyze discussions of the consent process generally, and about its application when practitioners use multiple TMB therapies.
Results
Two main consent approaches emerged, one based on a general consent early in the treatment process, and a second ongoing consent process undertaken throughout the course of treatment. Both processes are constrained by how engaged a patient wants to be, and the amount of information and time needed to develop a truly informed consent.
Conclusions
An understanding-based consent process that accommodates an acknowledged information differential between the patient and practitioner, and that is guided by clearly delineated goals within a trust-based relationship, may be the most effective consent process under the conditions of real practice conditions.
PMCID: PMC4240696  PMID: 25452820
complementary therapies/methods; massage; musculoskeletal manipulations; consent; decision-making; qualitative research; clinical practice
2.  Exploring the Nature of Therapeutic Massage Bodywork Practice 
Background
Research on therapeutic massage bodywork (TMB) continues to expand, but few studies consider how research or knowledge translation may be affected by the lack of uniformly standardized competencies for most TMB therapies, by practitioner variability from training in different forms of TMB, or from the effects of experience on practice.
Purpose
This study explores and describes how TMB practitioners practice, for the purpose of improving TMB training, practice, and research.
Participants & Setting
19 TMB practitioners trained in multiple TMB therapies, in Alberta, Canada.
Research Design
Qualitative descriptive sub-analysis of interviews from a comprehensive project on the training and practice of TMB, focused on the delivery of TMB therapies in practice.
Results
Two broad themes emerged from the data: (1) every treatment is individualized, and (2) each practitioner’s practice of TMB therapies evolves. Individualization involves adapting treatment to the needs of the patient in the moment, based on deliberate and unconscious responses to verbal and nonverbal cues. Individualization starts with initial assessment and continues throughout the treatment encounter. Expertise is depicted as more nuanced and skilful individualization and treatment, evolved through experience, ongoing training, and spontaneous technique exploration. Practitioners consider such individualization and development of experience desirable. Furthermore, ongoing training and experience result in therapy application unique to each practitioner. Most practitioners believed they could not apply a TMB therapy without influence from other TMB therapies they had learned.
Conclusions
There are ramifications for research design, knowledge translation, and education. Few practitioners are likely able to administer treatments in the same way, and most would not like to practice without being able to individualize treatment. TMB clinical studies need to employ research methods that accommodate the complexity of clinical practice. TMB education should facilitate the maturation of practice skills and self-reflection, including the mindful integration of multiple TMB therapies.
PMCID: PMC3577637  PMID: 23481609
complementary therapies/methods; massage; musculoskeletal manipulations; clinical competence; decision-making; qualitative research; clinical practice
3.  A descriptive study of chiropractors' opinions and practices regarding office-based health product sales 
Background
Although the sale of non-prescription health products is ubiquitous, the views of health professionals, such as chiropractors, regarding the sale of such products are not well known. Practitioner opinion is important to understand and inform professional practice. The purpose of this study was to describe chiropractors' perspectives and practices on the sale of health care products from practitioners' offices.
Methods
Chiropractors were invited to provide written comments about health product sales at the end of a fixed choice, mailed survey. Respondents' comments were analyzed using qualitative description. Ethics approval was received from the Conjoint Health Research Ethics Board at the University of Calgary.
Results
One hundred seven of the 265 respondents (response rate of 51%) provided written comments. Approximately 30 pages of double-spaced, typed text were gathered. Respondents did not consistently endorse or condemn health product sales, and engaged in the practice to greater and lesser extents. While some were opposed to health products sales, some accepted the practice with a degree of ambivalence whereas others clearly embraced it. Some respondents acknowledged a professional conflict of interest in such sales and marketing, and described strategies used to mitigate it. Others provided a range of justifications for the practice. Personal integrity and professional standards were discussed and a need for monitoring identified.
Conclusions
A wide range of opinions and practices were described and this is consistent with resulting variation in practice. In light of this, standards that facilitate consistency in practice may benefit professionals and the public alike.
doi:10.1186/2045-709X-20-10
PMCID: PMC3348054  PMID: 22480278
Chiropractic; Professional ethics; Codes of ethics; Marketing
4.  Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study 
Background
Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice.
Methods
Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada.
Results
Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision.
Conclusions
The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.
doi:10.1186/1472-6882-11-75
PMCID: PMC3187727  PMID: 21929823
5.  Components of an Anticancer Diet: Dietary Recommendations, Restrictions and Supplements of the Bill Henderson Protocol 
Nutrients  2010;3(1):1-26.
The use of complementary and alternative medicines including dietary supplements, herbals and special diets to prevent or treat disease continues to be popular. The following paper provides a description of an alternative dietary approach to the self-management and treatment of cancer, the Bill Henderson Protocol (BHP). This diet encourages daily intake of raw foods, a combination of cottage cheese and flaxseed oil and a number of supplements. Some foods and food groups are restricted (e.g., gluten, meat, dairy). Early background theory that contributed to the protocol’s development is presented as is a summary of relevant evidence concerning the anti-cancer fighting properties of the individual components. Supplement intake is considered in relation to daily recommended intakes. Challenges and risks to protocol adherence are discussed. As with many complementary and alternative interventions, clear evidence of this dietary protocol’s safety and efficacy is lacking. Consumers of this protocol may require guidance on the ability of this protocol to meet their individual nutritional needs.
doi:10.3390/nu3010001
PMCID: PMC3257729  PMID: 22254073
anticancer diet; cancer; complementary and alternative medicine; supplements
7.  An audit of health products and services marketed on chiropractic websites in Alberta and consideration of these practices in the context of chiropractic codes of conduct and ethics 
Background
Chiropractic’s success as a health care profession is evidenced in part by the rising number of practitioners. Paradoxically, this success may start to cost the profession, as the number of consumers may not be increasing proportionally. Fewer patients mean less income for practitioners. Some chiropractors are responding to these pressures by marketing health products, and services
Objectives
To describe the extent to which Alberta chiropractors with websites sold health products and the extent to which fee discounts/service inducements were advertised. To consider these practices in the context of chiropractic codes of conduct and ethics.
Methods
Chiropractic websites in the province of Alberta were identified using the online Telus Business Finder and cross-referenced with the Yellow Pages print directories. The websites were searched and an inventory of the health products for sale was recorded. Fee discounts and service inducements were also recorded.
Results
56 websites were identified and reviewed. Just under two-thirds of the chiropractic websites surveyed contained information on health products for sale. Orthotics were sold most often (N = 29 practices; 51.8%), followed by pillows and supports (N = 15: 26.8%), vitamins/nutritional supplements (N = 15; 26.8%) and exercise/rehabilitation products (N = 10; 17.9%). Nine practices (16.1%) offered some type of inducement to potential customers. These included discounts on treatment packages (N = 2; 3.6%), free gait/ posture analyses (N = 2; 3.6%) and free general consultations with the chiropractors (N = 3; 5.4%)
Conclusions
The marketing of health care products and services by chiropractors in Alberta is common. Such practices raise ethical considerations for the profession. Professional guidelines vary on the acceptability of these practices. Consumer and practitioner perspectives and practices regarding retailing need to be further examined.
PMCID: PMC1924677  PMID: 17657302
chiropractor; marketing; ethics; chiropraticien; marketing; déontologie
8.  Medicinal marijuana use 
Canadian Family Physician  2006;52(1):65.
OBJECTIVE
To describe medical marijuana use from the perspectives of patients with multiple sclerosis.
DESIGN
A qualitative, descriptive design was used. Participants discussed their medicinal marijuana use in one-to-one, semistructured interviews.
SETTING
Interviews were conducted at a time and place convenient to participants.
PARTICIPANTS
Six men and eight women with multiple sclerosis participated.
METHOD
Potential participants identified themselves to the researcher after receiving an invitation in a mailed survey. Eligibility was confirmed, and purposive sampling was used to recruit subjects. A range of issues emerged from the interviews. Interviews and data analysis continued until saturation occurred.
MAIN FINDINGS
Descriptions fell into three broad areas: patterns of use, legal or social concerns, and perceived effects. Consumption patterns ranged from very infrequent to very regular and were influenced by symptoms, social factors, and supply. Legal concerns expressed by most respondents were negligible. Social concerns centred on to whom use was revealed. The perceived benefits of use were consistent with previous reports in the literature: reduction in pain, spasms, tremors, nausea, numbness, sleep problems, bladder and bowel problems, and fatigue and improved mood, ability to eat and drink, ability to write, and sexual functioning. Adverse effects included problems with cognition, balance, and fatigue and the feeling of being high. Although participants described risks associated with using marijuana, the benefits they derived made the risks acceptable.
CONCLUSION
Further research is needed to clarify the safety and efficacy of marijuana use by patients with multiple sclerosis. If evidence of benefit is seen, medicinal marijuana should be made available to patients who could benefit from it. Until then, discussing medicinal marijuana use with patients will be awkward for health professionals.
PMCID: PMC1479734  PMID: 16926966
9.  Physicians’ perspectives on chiropractic treatment 
The objective of this study was to examine general practitioners’ opinions and behaviours concerning chiropractic. The study was a secondary analysis of the data collected in a cross-sectional survey of 400 general practitioners from Alberta and Ontario that assessed opinions and behaviours concerning several types of complementary medicine. The response rate was 52% Twenty-eight percent indicated they had considerable knowledge about chiropractic, overall 58% found chiropractic useful or very useful and 43% believed that chiropractic is efficacious for neck and back problems. Forty-four percent of the total sample stated they referred patients to chiropractors, primarily for back pain, musculoskeletal indications in general and chronic pain. Efforts need to be made to further improve the relationship between general practitioners and chiropractors and, thus, establish chiropractic as a viable treatment option.
PMCID: PMC2485293
chiropractic; physician; complementary

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