Although many ideas were presented, almost all stakeholders felt that increased research on the benefits of MT would help elevate the profession. Stakeholders’ views on advancing the profession are summarized below. As they identified research as a particularly important facet in moving MT forward, we discuss it in more detail.
Advancing the profession: regulators and educators
Members of the MTRB felt that acceptance from other health professionals, respect from government as well as strong validation of what RMTs do through research would advance the profession.
"“[RMTs would benefit from] strong validation of what we do through research [in addition to] greater acceptance by other health professions, greater referrals [and] no GST.”"
"“If we had national professional recognition we’d be able to move forward.”"
"“[We need to] integrate evidence into practice.”"
"“[We would benefit from respect from] other health professionals, respect from government.”"
The response of MT colleges to “what steps do RMTs need to take in order to elevate the status of the profession” included the following: increasing research in the area of MT and health and educating the public on the qualifications and roles of RMTs.
"“People don’t know how well educated RMTs are. RMTs have excellent training – let’s talk to the public!”"
"“[We need to] establish evidence-based research.”"
One MT college administrator felt that providing leadership to spearhead the needs of RMTs as well as establishing best business practice courses in colleges could help RMTs succeed in their careers.
"“Resistance to business practices in colleges. Chiros realised this and train to be both a good business person and practitioner. The MTA (Massage Therapists’ Association) could look at AMTA (American Massage Therapy Association) and invite them to speak at conferences – they know how to help members.”"
"“Leadership! We need better leadership to raise [the] status of our profession. Let’s bring in the expertise to help us move forward. It would be good to have leaders setting direction for the program [but] we need all the stakeholders working together!”"
Massage colleges and the MTRB recognized the significant role of research in getting greater acceptance for MT from other healthcare professionals and respect from the government. All stakeholders highlighted the importance of research in moving the profession forward. However, although the importance of research was frequently cited, peer-reviewed literature and research education practices are minimal. This topic is discussed in more detail next.
Role of research in moving MT forward
The importance of research in advancing the profession
The MTRB was interested in research on safety and efficacy of MT as well as cost-effectiveness. Research on safety of MT was cited by 6 of the MTRB respondents as an important component of MT that requires further research. The primary role of regulatory bodies is to protect the public. It is therefore understandable that safety is a top concern for regulators. However, there is currently no documented evidence of side effects of MT[14]. It is, therefore, considered to be safe.
“[Research is important] to help produce evidence or risk of harm in order to communicate more effectively with the government. It would be helpful in our negotiations with the Ministry of Health.”
Research on efficacy was cited as important by 3 MTRB respondents and the remaining one thought cost-effectiveness would be the most valuable aspect of MT to research. Interestingly, if responses were analyzed by summing the total of the top two responses to the question, “what aspect of MT should be researched further,” 9 MTRB respondents cited efficacy. This highlights the importance of researching efficacy of MT; an issue echoed in later statements by members of public and private insurers. Understandably, people want to prove that MT improves health status; therefore, research on efficacy is essential to the advancement of this profession.
"“If we want the profession to grow and advance, [research] has to be very important.”"
"“We can’t expect physios and others to view us (RMTs) as their peers when we don’t do research.”"
All participants representing MT colleges indicated that they believe research is very important to the profession of MT. One MT college administrator noted:
"“If we want the profession to grow and advance, research has to be very important. If we’re saying our training and our practice in the health field is equal to others we have to be doing it too. For RMTs to take it to the next step they’d need a researcher to work with.”"
Both MT colleges and the MTRB identified research as an important component in advancing the profession. For many, research proving the efficacy and safety of MT would be beneficial in enhancing the profession’s image in the eyes of the provincial government. More research was also cited as important in gaining recognition from their peers, such as physiotherapists, chiropractors and importantly, medical doctors, as valuable members of the healthcare team.
Research education in MT colleges
Responses of MTRB participants with the current regulation of research education in MT colleges varied from somewhat satisfied to extremely unsatisfied. Most MTRB participants (8) were somewhat satisfied with the current regulation of MT research curricula in MT colleges whereas 1 was extremely unsatisfied and 1 was undecided.
"“[It’s a] work in progress. Faculty needs to buy into research with their world view.”"
"“Extremely unsatisfied [with the current regulation of MT curricula]; further integration is needed.”"
MT colleges devote very little time in their curriculum, approximately 30–40 hours of the 3,000 hours, to teaching research methodologies. Some conduct a lecture-based research and statistics course which focuses on research literacy, validity and research design. Typically the research training consists of a single course taken in the advanced years of the program. However, many MT schools report that research training courses are not well received by the students. One college participant reported that 80% of students ask “why do we have to take this course?” Others reported that those with degrees tend to be more interested in research while other students could see the value of being able to search the literature.
MT colleges provided contradictory reflections regarding the status of their students’ research capabilities. Participants reported that their students had varying levels of research literacy, with some students studying the literature regularly while others rarely doing so and lacking critical thinking skills. In contrast, half the college participants stated that the majority of their graduates could design and conduct independent research. However, this sentiment was not echoed in statements given made by MT college participants. For example, one college representative stated that students do not have the experience or the time (while in college) to participate in research. Their college had only one student in a class of 33 that actually participated in their study last summer.
It is unlikely that a substantial portion of MT college graduates could indeed design and conduct independent research for a number of reasons. Firstly, courses regarding research design and statistical analyses form only a small percentage of the total courses taken during MT college training: approximately 30–40 of the total 3000 hours. This is largely due to MT colleges’ focus on accrediting their graduates to practice under the MTRB regulations. Secondly, as noted above, RMT students do not seem keen on conducting research; instead, their focus is on clinical practice. The reason they choose to enter MT is to work with patients and MT research is often less lucrative than clinical practice[2]. Also, some administrators noted that most of their faculty do not have a research background and, therefore, are not willing or able to implement new research courses into the curricula. If faculty are not able to teach MT students about research design and/or literacy skills it is unlikely that many graduates could conduct MT research projects themselves. For half of the MT college participants to state, therefore, that their graduates could design and conduct independent research is questionable.
Barriers to incorporating research education in MT colleges
Participants noted that the greatest barriers to MT research in colleges were time, money and lack of research expertise. One MT college board member summarized these barriers:
"“One, our curriculum [is] designed to be a clinical model. My job is to prepare students to pass board exams. They have 30–40 hours out of 3000 hours to spend on research. I have a 5 year plan which includes research. Two, the majority of our faculty are not well versed on how to [conduct] research. Three, time. Four, our goal is to get accredited [by the provincial MTRB]; therefore, our main goal is accreditation.”"
To overcome these barriers, college representatives said that it would be helpful if someone was designated at the colleges or other MT professional associations to review the literature, organize new research by category and then convey summaries of the information to the staff and members. Another representative said that RMTs and researchers should work together: therapists could form partnerships with people who are knowledgeable in research to grow research competency and increase the faculty’s interest. However, all felt that the college curricula were already so full that it would be difficult to incorporate another module on advancing research capacity.
The MTRB participants believed that encouraging members to enroll in research-based courses for continuing education credits (CEC) is an important step in improving research literacy within the RMT community. Other ideas included increasing the amount of information provided on MT-related websites and making research literacy a mandate for MT colleges.
All the colleges were interested in collaborating with organizations such as the MTRB or other MT professional associations to develop, test and evaluate a best practice guideline to mentor students to carry out research. However, one wasn’t sure how it would work or fit into the current curriculum. Another stated that the medical model does not appeal to them and that they would prefer a broader model that would encompass all facets of MT including the wellness and holistic aspects. One college representative said that they would prefer to work with the MT professional organizations to benefit all RMTs, not just students. From their experience, they were better off using just a few well-trained RMTs for studies.
When interviewing the MTRB, the majority of respondents (9) were also interested in pursuing cooperative research projects with other MT-related organizations. They emphasized that their organization would likely play a funding-provider role as conducting research was not a mandate of the organization.
All the colleges needed funding to support their ability to integrate the research competencies throughout the curriculum. This would have to be mandated by the MTRB and supported by them, said one college. Ultimately it was felt that the board examination process drove everything. This is echoed in a statement from one MT college representative below:
"“In the end, the issues are time, money and motivation. Ultimately the board examination process drives everything. If the board examiners don’t incorporate research into the process, the motivation isn’t there.”"
Other college representatives felt that there were too many who would be resistant to such a move. As all MT colleges felt that the current curriculum is tight, creating space for the development of research literacy means removing other courses which they are unwilling or unable to do.
"“We need a curriculum review. Do we need 4000 hours or do we pull out stuff to make space for research? We can’t lose manual skills [and] the university recognizes what we are doing [but] what will it take [for us] to become a degree-granting institution?” "
In general, the most significant barriers to incorporating research training in MT colleges were time and the focus of the MTRB board examination. Both MT colleges and the MTRB stated they were keen on collaborating with each other and with other MT-related organizations to increase the quantity and quality of research currently being conducted in the field.
Role of research in the advancement of other professions
Increasing the number and quality of studies examining the efficacy and safety of physiotherapy, nursing and chiropractic practice have helped these professions gain recognition from both other healthcare professionals and governing bodies of healthcare. RMTs and stakeholders of MT feel these issues are of great importance in advancing the profession of MT within British Columbia[2]. Chiropractic, physiotherapy and nursing have advanced partly through research. Each of these professions emphasizes research literacy and other research skills in their curricula. A significant number of their practitioners are actively engaged in evidence-based studies producing a number of robust research articles annually. This has been discussed in detail previously[15].
Why is evidence-based MT lagging behind?
Both RMTs[2] and other stakeholders of MT recognize the importance of high quality research in advancing MT’s professional recognition with other healthcare professionals, governmental healthcare organizations as well as the general public. Lack of research capacity is a substantial obstacle to moving MT forward. There is a lack of research training in MT colleges and consequently, a lack of research personnel. Ideally, academic researchers and RMTs ought to be working in teams in order to conduct studies on the effects of MT. Part of this problem stems from the fact that research skills and literacy are not emphasized in MT colleges. The focus of these colleges is to have their graduates become accredited RMTs by the MTRB which means passing the MTRB board examinations. As this is the final goal for most MT colleges and as the examination process is focused on clinical knowledge and skills and less on research, there is little motivation to pursue research literacy and development.
Another reason has to do with the limited funding opportunities available to RMTs who wish to involve themselves in MT research. Only two organizations across Canada have directly provided funding for MT research: the Holistic Health Research Foundation of Canada and the Massage Therapy Foundation. The limited funding opportunities, coupled with the fact that clinical MT practice is more lucrative and MT college gradudates are often saddled with large debts means the incentive to pursue MT research is low.
Degree status for MT education could help advance the profession
Some MTRB participants liked the idea of RMTs earning a degree from a public university and others did not. Half of respondents were supportive of the idea, 3 respondents opposed the idea and 2 were undecided. Of those that were supportive, maintaining standards on par with other health professionals, increasing opportunities to transfer course credits and recognition for the amount of course work completed in the MT program were frequently cited reasons.
"“University degree status is unavoidable. We could create a working agreement between colleges and universities to make [the] TRU (Thompson Rivers University) agreement mandatory. Education may be better delivered at a public university than a private college [as we] don’t need to raise the bar to get into university.”"
"“Yes – to remain viable as profession.”"
"“Yes … in order to remain competitive with other health professions.”"
"“Last time we had a stakeholders’ meeting people were not keen to mandate a degree, to allow laddering is good. I’d be quite upset if this happened. In Ontario there is public education and it has created chaos.”"
In meeting with colleges of MT they too noted that they would like to see RMTs gaining a university degree but they would like to be granted the authority to grant degrees themselves. One of the college’s faculty members suggested that 3,000 hours of education was more than an undergraduate degree so it was only fair that RMTs should earn a degree and not a diploma.
"“What will it take [for us] to become a degree-granting institution? [Our graduates require] 3000 hours of training, [that is] more than university degree.”"
"“[We would like a] degree program [but] universities may not because private colleges [would be] offering it.”"
"“A local university/college was willing to partner with us [to obtain degree granting status for RMTs] but it didn’t work after 3.5 years of trying. We spent approximately $100,000 trying to obtain such a status.”"
Baccalaureate status has helped advance the professions of physiotherapy and chiropractic, professions with similar “hands-on” approaches to healthcare[16]. To become a chiropractor in Canada, for example, one must complete undergraduate credits and then enrol in a postgraduate chiropractic college for 3–4 years[17]. Physiotherapists undergo a similar process with most students completing an undergraduate degree and then enrolling in a Masters of Physical Therapy program now available in many public universities across the country[18]. Increased educational requirements for both chiropractors and physiotherapists have meant, 1) graduates of these programs are more knowledgeable regarding clinical and research practice in their professions and, 2) exclusivity related to requiring a post-baccalaureate degree allows colleges to be highly selective in selecting their students for these programs, accepting only the most qualified and/or accomplished[16]. It is likely expected that a push for obtaining degree status for RMTs could facilitate their advancement in a similar way.
Insurance company participants express requirements for evidence-based practice
The top health issues that our insurance company participants address are mental health issues, as well as soft tissue injuries – neck, back, shoulders and knees. All company representatives noted that RMTs effectively address these health issues and that MT provides positive health benefits. They also believed that MT successfully prevents disease and treats injury although some wanted more research-backed evidence regarding the effect on disease prevention. In terms of helping people get back to work, one insurer felt that RMT outcomes were good but not great, as the return to work (RTW) outcomes during 2000–2006 was, on average, 44.6%. The goal was to improve the RTW within 5 weeks of first visit to 50%.
Insurers also told us that their company would cover RMTs more widely for visits and larger maximum annual pay outs if there was proof of effectiveness, research and more endorsement from MDs. One said that they always gave approval to MT if doctors had recommended it. A review of massage therapy by a BC physician recommended that the physician who has referred a patient should ask the therapist to provide a progress note describing measured outcomes of the therapy[19].
One insurer felt that the perception of MT as a ‘touchy/feely therapy’ had to change and that MT needs to be seen as an active therapy that shouldn’t create dependency. The concept of active therapy came up in all interviews with insurance companies as they continuously compared exercises taught by physiotherapists to time on the table with RMTs. They encouraged the MTRB to make MT as ‘active’ as possible.
Empirical evidence linking MT to benefit and outcomes would make RMT more appealing to all insurance company respondents we interviewed. All the insurance companies stated that they utilized research literature in determining the approval of claims and one even had an evidence-based practice group which did reviews of findings. All wanted to receive research literature on MT including information on return to work outcomes, new studies, emerging techniques and other focused information.
Concurring with the views expressed by the insurance companies, one member of an MT college stated:
"“The results speak for themselves. RMTs that do not keep up with best practice techniques may not get the results in their practice. Insurance companies see the poor results (and poor reporting of outcomes) by some therapists and generalize to all massage therapists. Published studies in peer-reviewed journals are what the insurance providers want to see. Even case reports and case series can be of benefit to the profession.”"
The MT-related organizations are keen to improve relations between RMTs and insurance providers. They hold information sessions for RMTs to learn about interacting with insurance companies effectively.
Abuse of claims
Another important issue insurance company participant’s noted is the perceived abuse of claims, although they noted that these were not necessarily done deliberately. One private insurance company was concerned that some RMTs are billing for medically unnecessary MT. We repeatedly heard one example during an interview: a $300 receipt from a spa from an RMT. When the insurance company asked for an itemized receipt they saw that $300 included wine, chocolate covered strawberries and other items that were not legitimate. This company urged RMTs to be better informed about billing only for medically necessary MT. Currently, most RMTs use generic, non-specific receipts. They suggested that if RMTs had more official receipts they would be better able to judge the legitimacy of the claims. The other concern this private insurer had was that MT claims had substantially increased over the past 2 years. Participants were disturbed by this trend as they suspected part of the increase was due to illegitimate expenses.
Insurer respondents felt that there needed to be a clear distinction between medical massage and wellness massage. Within the MT profession there is a parallel discussion where some RMTs would like the profession to devote itself to rehabilitation and purely therapeutic practices whereas others believe MT better serves population health by being more comprehensive as a form of health promotion, disease prevention, rehabilitation and palliation. The latter group incorporate wellness massage into their practice. A third group, the spa practitioners, only practice relaxation massage. Insurers made it clear that they were interested in funding medical massage.
However, it was interesting to ask each participant about their own personal experience with MT. Those who had received regular MT stated that they were willing to pay out of pocket for relaxation massage and be covered for injuries only. The one participant who had never received the services of an RMT held the most negative views on MT. This suggests that personal experience with MT can have a significant influence on individuals’ professional views of it. Literature on holistic practices in general echo this idea. For example, physicians who have received MT treatment for their own healthcare services or have more knowledge regarding MT feel more comfortable discussing MT treatments with their patients[20].
Stakeholder dynamics
Each of these stakeholders has an agenda. The regulatory agency’s agenda is related to their mandate of protecting the public. The agenda of the insurance companies is to protect their profits while assisting patients to improve their health. The agenda of the educational institutions is educating RMTs while maintaining profitability. Profit margins are important to at least two out of our three stakeholder groups and this is where conflict within the profession may exist. Furthermore, within each of these groups also lie many conflicts, partly based on personalities, egos and politics. The profession of MT in BC is fraught with internal struggles that impede its progress. It will not move forward until the agenda of all stakeholder groups are aligned and unity amongst groups and individuals is achieved.
