Health Professions Council
Massage Therapists Scope of Practice Preliminary Report

FOREWORD

This report is the result of the Health Professions Council's review of the scope of practice of massage therapy pursuant to the Terms of Reference from the Minister of Health and Minister Responsible for Seniors. Under the Health Professions Act, the Health Professions Council is a six person advisory body appointed by the Government of British Columbia to make recommendations to the Minister of Health and Minister Responsible for Seniors about the regulation of health professions.

In this report the Health Professions Council examines how the existing scope of practice of Massage Therapy should be legislatively defined in order to reflect fairly and accurately the current state of practice and the public interest in the practice of massage therapy.

EXECUTIVE SUMMARY

The Health Professions Council has conducted a review of the scope of practice of massage therapy.

The purpose of the review is to provide recommendations to the Minister of Health and Minister Responsible for Seniors regarding four matters: scope of practice statements, reserved acts, supervised acts, and reserved titles.

The Health Professions Council has conducted a detailed consultation process and its conclusions and recommendations regarding the four elements of the scope review are as follows:

1. The Council recommends the following scope of practice statement for members of the College of Massage Therapists:

   The practice of massage therapy is the assessment of the soft tissues and joints of the body and the treatment and prevention of dysfunction, injury, pain, and physical disorders of the soft tissues and joints primarily by manipulation to develop, maintain, rehabilitate or augment physical function, to relieve pain and promote health.

2. The Council recommends that massage therapists not be granted any reserved acts.

3. The Council recommends the title "Registered Massage Therapist" be reserved for members of the College of Massage Therapists.

I.    INTRODUCTION

A.     THE NATURE OF THE REVIEW

This is the preliminary report of the review of the scope of practice of massage therapy by the Health Professions Council (the Council).

The review was conducted pursuant to Terms of Reference issued by the Minister of Health and Minister Responsible for Seniors in accordance with section 25 [24] of the Health Professions Act (the HPA). The Terms of Reference direct the Council to review the scopes of practice of the recognized health professions, of which massage therapy is one.

The Terms of Reference, which are included as Appendix A to this report, indicate that there are four main elements to the scope of practice review:

1. scope of practice statements which describe what the profession does, the methods it uses and the purpose for which it does it;

2. reserved acts which are those acts that present such a significant risk of harm that they should be performed only by professionals who are qualified to perform them;

3. supervised acts which are reserved acts, or aspects of reserved acts, which may be performed by persons supervised by health professionals; and

4. reserved titles which are titles that describe a profession's services and which are reserved exclusively for the health profession.

B.     THE PROCESS FOR THE REVIEW

The general process for the review provides for an initial meeting with the profession(s), submission of briefs by the regulatory body and professional association for each profession, a consultation process involving all health professions and interested parties regarding each professions' submission, drafting of a preliminary report, public hearings and a final report.

This report will be circulated to all health professions and other interested parties who participated in the Council's consultation process.

The HPC met with representatives of the British Columbia College of Massage Therapists (the "College") in December 1994. The B.C. Association of Massage Therapists (BCAMT) was not in attendance. In September 1995 a second meeting was held with representatives of the College who, at that time, presented the HPC with a copy of their scope of practice submission. Only the College submitted a scope of practice brief on behalf of the profession of massage therapy. In January 1996, the brief was summarized and distributed to interested groups and individuals including other regulated and unregulated health professions, teaching facilities and other provinces. After discussion with the Council, the College subsequently amended its original brief by letters in July and September 1996.

Respondents to this consultation process focussed on a number of issues which the Council felt warranted further investigation. In July 1996, members of the Council made a site visit to the West Coast College of Massage Therapy to clarify concerns regarding the education and training of massage therapists which had arisen as a result of the consultation process. Following this visit, the Council requested that the College clarify issues which were unresolved by the Council's own investigation. In August 1996, members of the Council again met with representatives of the College for discussions about issues raised during the consultation process. In July 1998, the College submitted a second scope of practice brief in response to the Council's Shared Scope of Practice Model Working Paper (the Working Paper) which was issued in January 1998. This July 1998 submission replaces the September 1995 submission which was withdrawn in response to the Working Paper.

This report is written to reflect both the 1998 submission and relevant parts of the original 1995 submission. Those parts of the 1995 submission which the Council considers relevant are those which were reiterated in the 1998 submission. The 1995 submission was the subject of the initial consultation process in 1996 and comments made about relevant parts of that submission by respondents will be included in this preliminary report. The Council will conduct public hearings in 1999 and interested parties who wish to comment about the BCCMT 1998 submission and this preliminary report should submit their comments in writing to the Council prior to that hearing. Both documents are available on the HPC website. Only those who have responded in writing to the 1998 submission and/or this preliminary report will be invited to make an oral presentation at the hearing.

C.     THE REGULATION OF MASSAGE THERAPY IN BRITISH COLUMBIA

Massage therapists were initially governed under one act with physiotherapists. The first provincial enactment was the Physiotherapists and Massage Practitioners Act, S.B.C. 1946, c. 59. It created the Association of Physiotherapists and Massage Practitioners of British Columbia, the regulatory body, as well as the Board of Physiotherapists and Massage Practitioners. The first enactment defined massage and physiotherapy and restricted the use of the following reserved titles: chartered physiotherapists, physiotherapists, massage practitioner, and masseur.

In 1954, the Physiotherapists and Massage Practitioners Amendment Act, 1954, c.32, provided for several amendments. The Board of Physiotherapists and Massage Practitioners was renamed the Council of Physiotherapists and Massage Practitioners, and was given the power to make regulations respecting applications, cancellations, suspensions, and reinstatement of members. Educational qualifications were revised while the requirements of a school to be able to teach massage were defined. Registered physiotherapists and masseurs were given the exclusive right to practise their respective fields and the Council was given authority to approve all schools teaching physiotherapy and massage. The Physiotherapists and Massage Practitioners Amendment Act, 1957, c.48 made it illegal for a hospital employee, other than a registered physiotherapist or massage practitioner, to provide massage of any kind for patients. An amendment was made to exempt from the prohibition certain hospitals, particularly those which were too small to employ a physiotherapist or massage practitioner.

In 1972, the Physiotherapists and Massage Practitioners Act, 1972, c. 42, eliminated the reference to the Trade-School Regulation Act and the teaching of physiotherapy as well as the requirement that standards of education of the Canadian Physiotherapy Association apply under the Act. In 1979, the statute was renamed the Physiotherapists Act, R.S.B.C. 1979, c.327. The Health Statutes Amendment Act, 1984, c. 19, removed the specific reference to the minimum academic requirements for registration as a massage therapist and allowed the Minister and the Council to determine the requirements.

In 1987, the Health Statutes Amendment Act, 1987, c. 55, revised educational and training qualifications for registration as a physiotherapist to include training as a remedial gymnast. The educational qualifications for registration as a masseur were likewise revised. While the act repealed the power of the Lieutenant Governor in Council to make regulations prescribing educational qualifications and requirements for temporary registration, it permitted the Minister to request an amendment to a rule. Subsequently, the Health Professions Statutes Amendment Act, 1993, c. 50, set out the duties and objects for the regulatory body and Association of Physiotherapists and Massage Practitioners. It mandated for the requirement of public representation in the association while enhancing the association's investigatory and suspension powers.

Finally, the Health Professions Statutes Amendment Act, 1994, c. 42, repealed the Physiotherapists Act, R.S.B.C. 1979, c. 327, as the professions of Physiotherapists and Massage Practitioners were designated under the HPA in December, 1994. The designation was pursuant to the Lieutenant Governor in Council's power to designate a health profession under section 12 [12] of the HPA without directing the Council to conduct an investigation. Under the HPA two separate colleges were established: the College of Physical Therapists of British Columbia and the College of Massage Therapists of British Columbia.

D. THE REGULATION OF MASSAGE THERAPY IN OTHER PROVINCES

In Ontario, massage therapy is regulated under the Massage Therapy Act. The title "massage therapist" is reserved to members of the College of Massage Therapy, however massage therapists have been granted no controlled acts under the Regulated Health Professions Act.

In Quebec, the Office des professions du Quebec conducted an extensive consultation process to determine whether massage therapy should be regulated under the Code des professions. Their report was issued in 1992 and determined that massage therapy did not meet the criteria required for this type of professional regulation. In particular "the gravity of the prejudice or damage which might be sustained by those who have recourse to the services of such persons because their competence or integrity was not supervised by the order" did not meet the level required. The report found at page 10 that "In general, the techniques utilized in massage do not present acute risk" to the public and would therefore not be regulated under the Code des professions.

No other provinces have granted massage therapy self-regulating status or title protection.

II.       THE POLICY BACKGROUND

The main impetus for a scope of practice review was the Report of the British Columbia Royal Commission on Health Care and Costs (the Seaton Commission). The Seaton Commission stated that the existing legislation governing the health professions creates persistent jurisdictional disputes and a distinct lack of cooperation among the health professions, despite the fact that all health professional colleges have the same mandate - to protect the public from preventable harm.

The Seaton Commission stated that the primary reason for the jurisdictional disputes was the present regulatory system's reliance on exclusive scopes of practice. Under the exclusive scope of practice model, the various health professions have been granted an exclusive right to practice within a legislatively defined scope of practice. No one, other than a member in good standing of that profession, can perform acts within the profession's scope of practice unless they are granted an exemption.

The Commission concluded:

...exclusive scopes of practice should be narrowed to focus on preventing harm, as has been initiated recently in Ontario. We believe that more appropriate, cost-effective and timely health care could be provided to more patients if B.C. were to follow the Ontario initiative.

(Closer to Home, The Report of the Royal Commission on Health Care and Costs in British Columbia, Volume 2, 1991, p. D-33)

This recommendation is also consistent with legislative initiatives underway in Alberta. The Seaton Commission was not the first review body to suggest that the present legislative model of exclusive scopes of practice was inappropriate. Restricting professional monopolies (exclusive scopes of practice) was also recommended in an earlier study commissioned by the British Columbia Minister of Health. In discussing the conflicts which may arise between the professional college and the public interest, the issue of exclusive scopes of practice was raised:

It must be emphasized that any professional legislation which unduly restricts the scope of practice of skilled personnel may be contrary to the public interest in greater supply and accessibility of service through the development of team practice. Therefore, it is urged that: Professional legislation should not contain narrow restrictions or rigid definitions of scope of practice which are excessively exclusive; that measures should be taken (as indicated below) to reduce the area of interprofessional strain and conflict; and that no prosecutions for violations of scope of practice legislation should be undertaken without the prior consent of the appropriate public authority. Insofar as may be possible with due regard for public safety, professional law should not place rigid restrictions on the scope of practice of allied health personnel, and greater flexibility should be encouraged in the allocation of roles etween the health disciplines.

(Professor J.T. McLeod, Public Regulation of the Professions in Health Security for British Columbians, Special Report: Consumer Participation, Regulation of the Professions, and Decentralization (1974), the report of Richard G. Foulkes, B.A., M.D., F.A.P.H.A. to the Minister of Health, Province of British Columbia, Tome Three, p. 145)

Thus, the trend in regulatory policy for the health professions has been towards reducing exclusivity in order to enhance interdisciplinary practice, improve accessibility to health care services and increase consumer choice, while at the same time maintaining the fundamental objective of protecting the public.

These policy trends are clearly reflected in the Terms of Reference for the scope of practice review which provide the basis for a new regulatory framework for health professions in British Columbia. The core elements of the new framework are scope of practice statements and reserved acts.

Under the present system, scope of practice statements are exclusive. In the new system, scope statements will not be exclusive but professions may be granted reserved acts.

Reserved acts are those elements of a profession's scope of practice which present such a significant risk of harm that they should be reserved to a particular profession, or shared amongst particular professions. Thus, unlike the present system in which each profession is granted exclusivity within its entire defined scope of practice (subject to specified exceptions), only those acts which present a significant risk of harm will be reserved.

In short, the government has assigned the Council the task of creating a regulatory model based on broad, non-exclusive scope of practice statements and narrowly defined reserved acts.

The government has the responsibility to ensure that those services which are accessible are safe and that the regulatory framework for the practice of health professions protects the public from incompetent, impaired, or unethical practitioners. At the same time, the regulatory framework should not entrench a paternalistic function for professions or reserve exclusive areas of practice simply to enhance professional status and control.

The new system of overlapping scopes of practice and narrow reserved acts removes barriers to interdisciplinary practice and offers greater choice and accessibility to the public. In the Council's view, the public interest is served by professional legislation which promotes quality in the delivery of health care services within safe parameters. Indeed, the Council's primary policy objective in conducting its review is achieving the optimum balance between safe practice and consumer choice.

With this in mind, the Council proposes to consider the practice of Massage Therapy having regard to the four elements of the scope review.

III.     DISCUSSION OF ISSUES

The main issues raised by this review are the following four elements: scope of practice, reserved acts, supervised acts and reserved titles.

A. SCOPE OF PRACTICE STATEMENT

In the Council's view the scope statement should describe what the profession does, the methods it uses, and the purpose for which it does it. Unlike the present legislative scheme, the statement itself does not grant an exclusive scope of practice. Nonetheless, the statement is important because: it defines the area of practice for which the governing body must establish registration requirements and standards of practice; it defines the parameters of the profession for members of the profession, employers, courts and educators; and it informs the public about the services practitioners are qualified to perform. It is expected that the Council's recommendations will increase overlapping scopes of practice.

The Council believes that it is not necessary or useful to itemize every facet of a profession's scope of practice. Rather, a scope of practice definition should be sufficiently descriptive so that other health professions and members of the public alike can understand what the particular health professional does.

1. Current Scope of Practice

The College of Massage Therapy was formed in 1994 when the Minister of Health separated the governance of physical therapy from that of massage therapy and created a separate college for each under the existing system for regulation of health professions. The Massage Therapists Regulation (the "Regulation") under the HPA continued verbatim the definition of massage therapy as it was worded in the Physiotherapists Act, R.S.B.C. 1979, c. 327. In 1995, the Council was directed by its Terms of Reference to review the scope of practice of thirteen health professions, including massage therapy.

The current scope of practice of massage therapy is set out in the Regulation under the HPA:

"massage therapy" means the kneading, rubbing or massaging of the human body, whether with or without steam baths, vapour baths, fume baths, electric light baths or other appliances, and hydrotherapy or any similar method taught in schools of massage approved under the former Physiotherapists Act, but does not include any form of medical electricity.

Section 5(1) of the Regulation reads:

Subject to section 14 of the Act, no person other than a registrant may practise massage therapy.

Section 14 of the HPA states:

Despite section 13, nothing in this Act, the regulations or the bylaws prohibits a person from

• practising a profession, discipline or other occupation in accordance with this or another Act, or

• providing or giving first aid or temporary assistance to another person in case of emergency if that aid or assistance is given without gain or reward.

The combined effect of s.5(1) of the Regulation and s.14 of the HPA essentially reserves the entire scope of massage therapy practice exclusively to massage therapists or other regulated health professionals whose scope of practice encompasses such activities without regard to whether these activities present a significant risk of harm and should be reserved acts or not. The Regulation under the HPA, as currently worded, makes the entire existing scope of practice exclusive for members of the College. In contrast, the Terms of Reference clearly state that the rationale underlying the granting of reserved acts is to protect the public by restricting only those acts which present a significant risk of harm. Such acts are to be restricted to members of specific professions who are qualified to perform them. The entire thrust of the scope review process, as set out in the Working Paper, is to restrict only those activities which carry a significant risk of harm.

The Council has received numerous responses including letters, petitions and telephone calls during the consultation process indicating that the current reservation of "massage therapy" exclusively to members of the College has caused confusion, concern and alarm among members of the public and alternative practitioners. The Regulation has given rise to numerous investigations of alternative practitioners by the College and has been the subject of litigation to clarify its meaning. Such exclusivity which is contrary to the Terms of Reference represents an unwarranted barrier which may prevent the practice of massage by individuals who are not members of the College.

The College recognizes in its brief that the Regulation which currently reserves the entire scope of practice is too broadly stated and cites the British Columbia Royal Commission on Health Care and Costs which identified this sort of legislative shortcoming as one of its major reasons in recommending a wholesale change in the legislative system used to regulated British Columbia's health care professionals. The Commission felt that the reserved acts granted to professions should be narrowly focussed on preventing harm. The Council's Terms of Reference for the scope of practice review have reflected this view.

The Council wishes to emphasize that under the new regulatory model envisaged by the Council's Terms of Reference, the scope statement is not exclusive, only descriptive. Further, it is expected that the scope of practice review process will result in more overlapping scopes of practice. To the extent that a broad scope of practice statement might encompass acts which carry a significant risk of harm, the reserved acts system will address such acts.

The College submits that the current scope statement is poorly worded and insufficient for several reasons. The submission states the current scope statement inadequately describes massage therapy by using a list of techniques which is limited and incomplete. The submission also states that the current scope statement contains no reference to therapeutic intent which is fundamental to current training and practice of massage therapy.

2. Proposed Scope of Practice by the College of Massage Therapists of B.C.

The College proposed the following options for a revised scope of practice statement in its 1995 submission:

Option 1: The practice of massage therapy is the assessment of the soft tissues and joints of the body and the treatment and prevention of physical disorders, dysfunction, injury and pain of the soft tissues and joints to develop, maintain, rehabilitate or augment physical function to relieve pain, and to promote health.

Option 2: The practice of massage therapy is the assessment, treatment and prevention of soft tissue and joint disorders, dysfunction or injury using treatment methods which include but are not limited to manual techniques, hydrotherapy, light therapy, electrical modalities, therapeutic exercise and patient education to rehabilitate, relieve pain and promote health.

In 1996, after reviewing the responses to the consultation process the Council requested a meeting with the College. At an August 1996 meeting with the Council the College discussed the proposed Options for the scope of practice statement.

On September 3, 1996 the College sent a letter to the Council in which the College requested the following changes to Option 2 Scope of Practice Statement (emphasis added by the Council to indicate changes from Option 2). For ease of reference, the Council will refer to this as Option 3:

Option 3: The practice of massage therapy is the assessment, treatment and prevention of soft tissue and joint disorders, dysfunction or injury using treatment methods which include but are not limited to manual techniques, hydrotherapy, light therapy, electrical modalities, therapeutic exercise and patient education to rehabilitate, relieve pain, facilitate relaxation, reduce stress and promote health.

The College requested the changes "to reflect the broadest possible description of the massage profession's activities".

In July 1998, the College proposed a fourth scope of practice definition, after having withdrawn its previous submissions (emphasis added by the Council to indicate changes from Option 2). For ease of reference, the Council will refer to this as Option 4:

Option 4: The practice of massage therapy is the assessment and diagnosis of soft tissue and joint disorders and the treatment and prevention of physical disorders, dysfunction, injury and pain of the soft tissues and joints using treatment methods which include but are not limited to manual techniques, hydrotherapy, light therapy, electrical modalities, therapeutic exercise and patient education to rehabilitate, augment physical function, relieve pain, facilitate relaxation, reduce stress and promote health.

In Option 4, the College has added "diagnosis" to their previous submissions, based on their rationale that diagnosis is an essential first step in providing any form of therapy. The issue of diagnosis will be dealt with in the Reserved Acts section of this report.

The College provided the following rationale for changes to its scope of practice statement:

• specific examples of the more common massage treatment techniques in order to provide greater specificity than the Ontario definition

• the therapeutic objectives of "to facilitate relaxation" and "to reduce stress" as these are important features of massage therapy generally, and indicate that massage therapists are capable of providing both therapeutic and simple relaxation massage

• electrical modalities. Currently, massage therapists are prohibited from using any form of electrical medical therapies. The College is proposing that this prohibition be eliminated - in light of the Council's approach to defining reserved acts British Columbia set out in its Working Paper, it is legislatively redundant. (See Part 6, Prohibited Acts, for further discussion on this point).

3. Responses from Consultation Process to Proposed Scope of Practice Statements (Options 1 and 2)

Because the proposed scope of practice statements available at the time of the consultation process were Options 1 and 2, the following comments reflect the views expressed on those two Options. These are still relevant however because they represent opinions regarding elements which are components of revised option 4.

A number of respondents commented that the scope of practice statement overlapped with their scope of practice. These included the Registered Nurses Association of B.C. (RNABC), the B.C. Naturopathic Association (BCNA), and the College of Licensed Practical Nurses of B.C. (CLPNBC). Under the Terms of Reference scope of practice statements are descriptive, not exclusive, and regulated health professions may share areas of scopes of practice.

The British Columbia Medical Association (BCMA) commented that the proposed scope "is quite an extension from the current scope...We have grave concerns that the assessment of soft tissue and joint injuries is well beyond the scope of massage therapy and should be reserved for those with medical training. We recommend that the scope of practice remain as currently defined."

The College of Physicians and Surgeons of B.C. (CPSBC) shares the concerns of the BCMA: "the proposed new definition...conveys the impression of diagnostic abilities going well beyond what can be confidently expected, and fails to define the quite narrow field of therapeutic modalities that should be permitted with respect to the qualifications and training of massage therapists and which the public should be able to easily identify."

The British Columbia College of Chiropractors (BCCC) commented that the College has serious concerns about the second half of the scope definition "the treatment and prevention of physical disorders, dysfunction, injury and pain of the soft tissues and joints to develop, maintain, rehabilitate or injury and pain of the soft tissues and joints to develop, maintain, rehabilitate or augment physical function". The College states that it is unaware of any physical disorders that are treated by massage therapists and comments that their proposal represents a significant expansion of the scope of practice that does not appear, from their submission, to be based on any mandatory core educational training.

New Brunswick Health commented that the scope of practice which has been proposed "is broader than the current practice...particularly so in the case of the massage therapy proposal which describes what is the current scope of practice for physiotherapy." The submission goes on to say:

At present, in New Brunswick, massage therapy is considered a specific modality, not a process of assessment, treatment and prevention of a broad description of physical dysfunction. We presume that the training the members of the professions would receive, would support the enhanced scopes of practice which are being proposed.

The Canadian Athletic Therapists Association (CATA) commented that its main concern was with the proposed increased scope of practice and pointed out that the College had not provided any curriculum or standards on which to base the increased scope of practice.

The Tripartite Committee of the College of Massage Therapists of Ontario, the Ontario Massage Therapists Association, and the five Ontario massage therapy schools support the increased scope of practice and they commented on the specifics of the proposed reserved acts which will be discussed later in this report.

The College of Physical Therapists of B.C. (CPTBC) commented that the proposed scope is a significant expansion of the existing scope. "The actual risk of physical harm for massage therapy, as currently defined, is minimal. We are concerned that expanding the scope of practice as proposed may place the public at greater risk."

The CPTBC also made a lengthy submission discussing the relationship between education of practitioners, educational institutions and processes, and the professional regulatory body's role in accreditation of educational organizations. This latter submission will be forwarded to the Minister of Health as it is germane to the regulation of health professions but is not within the Council's Terms of Reference for the scope of practice review.

In summary, massage therapists' education and training for the scope of practice proposed has been questioned by the BCMA, the BCCC, the CATA, New Brunswick Health, and the CPTBC. All of these groups question whether the massage therapy curriculum is currently adequate for training in assessment. The BCCC also questions whether massage therapists are trained in "treatment of physical disorders".

The Council considered the comments made during the consultation process, in particular those regarding the educational preparation of massage therapists as it relates to the increased scope of practice proposed particularly with regard to education and training in assessment and diagnosis. In a letter of July 3, 1996, the Council requested more specific information from the College regarding education and training of massage therapists. The College responded by providing the Curriculum Standard of the College of Massage Therapists of B.C.. The Council has reviewed this document along with the College's revised brief and other information provided in letter form by the College to assess the scope of practice of massage therapists.

In the Working Paper, the Council describes "assessment" as a process of observation and evaluation of the physical status or progress of a patient, which may involve observation of symptoms, but does not include naming or identifying a disease, disorder, or condition as the cause of these symptoms. The Council has determined that the materials submitted support massage therapists' training in the use of assessment. The issue of diagnosis will be dealt with in the Reserved Act section of this report.

4. Conclusion

The Council has reworded the proposed scope of practice statement (Option 4) to more closely conform to its Terms of Reference. The Council has described general categories of techniques, not specific techniques. By making a broad statement regarding techniques, the public and the other health professions will have sufficient information to define massage therapy and the scope will not be limited to narrowly stated techniques which would constrain growth and development of the profession. In the Council's view, the reworded scope statement represents a concise definition which fairly and accurately reflects the current state of massage therapy practice. It describes what the profession does, the methods the profession uses, and the purpose for which the profession performs its functions.

The College's proposed additional references to "...pain of soft tissues and joints ... facilitate relaxation, reduce stress ..." are encompassed in "treatment and prevention of soft tissue and joint disorders" and in "relieve pain and promote health". The Council has added "by manipulation" which gives a general description of massage therapy techniques and is part of the Ontario scope of practice definition.

B.     RESERVED ACTS

The rationale underlying the granting of reserved acts is to protect the public by limiting provision of those particularly dangerous acts to members of specific professions who are qualified to perform them. Only those acts which present a significant risk of harm will be reserved. The Council has developed a list of reserved acts (Appendix B) which is set out in it's the Working Paper". The Working Paper was, in large part, a result of the Council's review of information provided by the various professions during the scope of practice consultation process.

The Council wishes to emphasize that its recommendations will likely provide for the sharing of many of the reserved acts. Thus, in conducting its review of any of the reserved acts of a profession, the Council is not necessarily deciding which acts would be reserved exclusively to that profession. It is possible and indeed likely that acts reserved to a profession will also be reserved to other professions. However, each profession may perform the reserved acts granted to it only within the context of its defined scope of practice. Each profession is being given the opportunity to describe which of the reserved acts its members are qualified to perform and therefore should be reserved to members of that profession.

The current definition of the scope of practice of massage therapy is contained in the Regulation. Section 5(1) of the Regulation reserves the entire scope of massage practice exclusively to members of the College, with the s.14(1) exceptions at page10, supra.

In response to the Working Paper, the College withdrew its earlier submissions to the Council and in a revised submission of July 30, 1998, proposed the following reserved acts for members of the College:

1. Making a soft tissue diagnosis by identifying a disease, disorder or condition of the soft tissue as the cause of signs or symptoms of an individual.

2. Manipulation of soft tissues with sufficient biomechanical pressure to cause tissue damage, including microtearing, bruising or inflammation.

3. Moving body joints beyond the individual's current physiological range.

4. Putting a finger beyond the labia majora or the anal verge.

5. Using massage therapy techniques on a patient when a contraindication for that patient exists that would necessitate avoidance or modification of the technique, and the technique to be given

   1. would significantly increase the blood or lymph circulation of that patient,

   2. requires deep pressure or stretch to be applied to the soft tissues of the patient's body, or

   3. would passively mobilize the patient's joint (excluding high velocity manipulation).

6. Using massage therapy techniques on a patient when a contraindication exists that would necessitate avoidance or modification of the technique, including but not limited to

   1. an acute or chronic injury, structural abnormality or disease of a joint, muscle, ligament, tendon, connective tissue, bone or organ of the body,

   2. a circulatory or lymphatic condition that compromises either system, and

   3. a neurological injury or disease.

   The Council will discuss each of these in turn using the reserved acts outlined in the Working Paper as its focus. The Council wishes to point out that proposed reserved acts #1, 2, and 3 have not been the subject of a broad consultation process, since they were part of the College's July 1998 submission. The Council invites written comments to these proposed reserved acts and to this preliminary report prior to the public hearings. Reserved acts #4, 5, and 6 were part of the College's original 1995 submission and, as such, were subject to review and comment during the consultation process.

1. Diagnosis

The College's first proposed reserved act is: "making a soft tissue diagnosis by identifying a disease, disorder, or condition of the soft tissue as the cause of signs or symptoms of an individual". The College submitted the following rationale for the risk of harm associated with this act:

In this context, "soft tissue" means muscle, fascia, tendon, ligament, bursae, joint capsules, and other associated connective tissue components.

Soft tissue diagnosis is an essential component of the services normally provided by massage therapists. If this service is not provided, or is provided by someone who is not sufficiently trained and skilled, there is a risk that musculoskeletal injuries and disorders may be exacerbated through treatment that is not of an appropriate type or intensity. There is a risk that injury may occur due to a failure to recognize contraindications to treatment or that systemic disease or other medical conditions that contribute to the presenting signs and symptoms may go unrecognized and untreated.

Differential diagnosis is also required to rule out systemic disease or other causes that may mimic musculoskeletal disorders but are not treatable through massage therapy. A review of the patient's past and present symptoms and medical history may indicate that an unidentified medical condition is causing the patient's symptoms and a visit to a physician is required instead of massage therapy. For example, a patient with chest pain should be asked specifically about both musculoskeletal and systemic origins of present pain and symptoms. Similarly, a patient with a history of kidney infection may experience back pain that is not treatable by massage therapy.

The College further described the process utilized by massage therapists before initiating treatment:

Identifying causative factors or etiology by the massage therapist is limited primarily to neuromusculoskeletal abnormalities that result in pain and pathokinesiologic problems (disorders affecting movement) and massage therapists may often be able to make a more accurate diagnosis of such conditions than most general practice physicians. Physicians, unless they have specialized in such fields such as orthopedics or sports medicine, do not receive the lengthy and detailed training in soft tissue/musculoskeletal assessment procedures that massage therapists receive, nor are they called on to perform related procedures on a daily basis. (This may explain why general practice physicians in particular seem to consider spending the time required to perform detailed diagnostic procedures not necessary once their preliminary evaluation has indicated that referral to a massage therapist or physiotherapist is indicated.)

In all cases it is a skilled physical assessment, palpative examination and accurate and complete history taking and diagnostic assessment performed by the massage therapist that identifies the location, etiology, and other relevant characteristics of the condition to be treated. The therapist differentiates between neuromusculoskeletal problems and systemic disease or other medical condition as the source of signs and symptoms, and identifies the presence of contraindications to certain types of treatment.

In regard to training in "diagnostic assessment", the College submitted their curriculum standards and provided the following description:

A minimum of 150 hours of training is provided to massage therapy students attending British Columbia's two accredited educational programs in history taking, interviewing and physical assessment. However, the education director of the West Coast College of Massage Therapy estimates that, when all academic and clinical subjects and courses dealing specifically with diagnostic assessment are combined with approximately 38 hours spent practicing these methods in the student clinic, massage therapists receive more than 400 hours of training in history taking, physical assessment and diagnostic skills. This is comparable to the number of hours of training that students in similar health professions, such as physical therapy and chiropractic, receive. (Appendix "I" provides examples of the basic case history and assessment forms that are used by the West Coast College of Massage Therapy.)

In its Working Paper, the Council distinguished between diagnosis and assessment, describing diagnosis as "the identification of the cause of signs and symptoms" and assessment as "a process of observation and evaluation of the physical status or progress of a patient, which may involve observation of symptoms, but does not include naming or identifying a disease, disorder or condition as the cause of these symptoms."

The Council reflected on this distinction in its review of the scope of physical therapy:

Assessment must be an integral and fundamental part of every health professional's practice. Assessment refers to the first step in how physical therapists practice their profession. Evaluation includes history taking and assessment (not diagnosis) for the purpose of initiation and modification of treatment. Use of the term "diagnosis" can become problematic if used interchangeably with "assessment".

The diagnostic process requires education and training to interpret the data collected in determining the full range of pathological conditions which may be present. This may require the use of a range of diagnostic tools, including laboratory data, x-rays and other imaging procedures where necessary.

The College indicated in its submission that massage therapists generally practice on referral from a medical doctor when treating injuries or chronic conditions and that a medical doctor was actively involved with the majority of patients who seek treatment for an injury or previously diagnosed condition.

In Ontario, the only other province to grant self-regulatory status to massage therapy, diagnosis which is a controlled [reserved] act, is not part of the scope of massage therapy. Relevant to the issue of diagnosis, the Council has been provided with the College of Dental Hygienists of Ontario (CDHO) April 1995 submission to the Health Professions Regulatory Advisory Council. In distinguishing between assessment and diagnosis the CDHO states:

We wish to confront the issue as to whether absence of the RHPA's controlled act of "communicating a diagnosis" inhibits dental hygienists' abilities to take and interpret a medical history to the extent required by the . . . proposed regulations and standards of practice. We firmly believe that the ability to "assess" teeth and adjacent tissues is sufficient. In letter to the Royal College of Dental Surgeons (RCDS) in 1987, Alan Schwartz, who headed the Health Professions Legislation Review, wrote:

What the Review does not intend to restrict through the licensure of "diagnosis" is the ability of others to assess their patients or clients, as they do now. We recognize that undertaking treatment of any sort in the absence of an assessment would be improper practice, and would fall below the standards of care of any profession.

In recognition of this fact the proposed general scope statements of many professions include the word "assessment". The Review believes that the proposed system will not in any way impede practitioners not licensed to diagnose from assessing their patients or clients to determine the applicability of a particular range of treatments and from undertaking a course of treatment in appropriate situations. As is the case today, if the treatment has no beneficial effect, or if the patient continues to deteriorate, further investigation is undertaken or, where appropriate, a referral to another profession is made.

In our view, a diagnosis is rarely necessary or in fact done. We believe . . that an assessment, rather than a diagnosis is precisely what a physician or dentist does in most cases.

The Council considered the information provided by the College, the comments by the respondents in the consultation process, and the curriculum and training. The Council finds that the processes are more accurately described as assessment and that the education and training are more appropriate for soft tissue and joint assessment than for differential diagnosis. Assessment is an integral component of the proposed scope of practice of massage therapists but is not a reserved act. Assessment is discussed further at page 26 of this report.

2. Physically Invasive or Physically Manipulative Acts

The College's second proposed reserved act is: "manipulation of soft tissues with sufficient biomechanical pressure to cause tissue damage, including, microtearing, bruising or inflammation". The College's rationale for risk of harm is as follows:

Therapeutic massage often involves working on soft tissues to a greater depth and with the application of more force than recreational massage or massage performed for the purpose of relaxation. Treatment may also focus on isolated structures such as tendons, musculotendinous or tenoperiosteal junctions, ligaments, or joint capsules. This creates the possibility of tissue damage in the form of microtears, and can result in bruising and inflammation, particularly where injury, disease, or other medical conditions are present.

Implicit within the therapeutic intent of massage is the expectation that the tissues being treated are not normal, healthy tissues, and that they are more easily injured. The manipulation of injured tissue through the application of pressure and stretching, becomes potentially more harmful in proportion to the amount of force used and the severity of the injury or other pathology that is present.

In fact, in the treatment of musculoskeletal injuries, where fibrosis, adhesions, and loss of normal tissue extensibility contribute to pain and reduced range of motion, some carefully controlled intentional tissue disruption does occur. However, bruising and inflammation are undesired side effects of such treatment, and often indicate that the force, duration, or frequency of treatment is in excess of tissue tolerances. The presence of inflammation in particular indicates that tissue damage has occurred to an extent that manipulation may make the presenting condition worse rather than better. Where such damage occurs, there exists a real risk that significant and lasting harm may be done: An otherwise treatable condition may become chronic or disabling.

The College does not believe that it is in the public interest to allow inadequately trained individuals to perform soft tissue manipulations with sufficient force to produce tissue damage, particularly in therapeutic situations. Where the treatment involves sufficient biomechanical force to alter tissue structure, inadequately trained individuals may do significant damage.

The College has classified this proposed reserved act as a "non-invasive but physically manipulative procedure . . . on tissue below the dermis".

In support of its contention that this proposed reserved act should be reserved to massage therapists, the College cites an anecdotal incident in which two patients were injured by the same unregulated practitioner.

Where a person is seriously harmed during treatment by an unregulated practitioner, the general harm clause, one of the elements of the reserved acts system described in the Council's Working Paper, addresses this issue:

. . . there should be a general risk of harm clause, which provides:

No one, other than a qualified health professional acting within the scope of practice of his/her profession, shall deliver health services in circumstances in which it is reasonably foreseeable that serious harm may result from the delivery or omission of such services.

This clause protects patients from (a) regulated professionals who do something harmful that is outside their scope of practice, and (b) unregulated practitioners who cause patients serious harm in the course of providing health care services.

The College has stated that microtearing, bruising and inflammation often occur during normal physical exercise. There is little or no evidence that microtearing, bruising and inflammation are a widespread problem or a serious consequence of unregulated massage. The College has provided no literature or scientific studies to show objective evidence of significant risk of harm.

3. Movement of the Joints of the Spine

The third reserved act proposed by the College is "moving joints beyond the individual's current physiological range". In a letter of October 5, 1998, the College requested that this wording be changed to: "moving body joints beyond the limits the body can voluntarily achieve but within the anatomical range of motion". The College's rationale for risk of harm is:

The College offers this change because massage therapists and physical therapists commonly use joint mobilization techniques which are applied to joints other than the spine, and which are performed at low velocity. The potential for harm to joints is not limited to those of the spine.

Low velocity joint manipulations involving progressively greater amplitude are technically known as grade I through IV joint mobilizations. High velocity, low amplitude thrust is a grade V mobilization. Mobilizations using lower velocity can be potentially as harmful as high velocity mobilizations, in particular if the range of motion of an individual's joint is currently limited due to soft tissue or joint disorders, dysfunction or injury.

A wide variety of musculoskeletal disorders, including trauma and certain chronic conditions, result in a reduction of the physiological range of motion to less than normal due to shortening and/or the formation of adhesions within the connective tissue structures associated with joints. Specific manipulations are used to assess restricted movement and to restore normal joint movement.

The College has proposed modifying the Council's Reserved Act 2(c) by removing the qualifying phrase "using a high velocity, low amplitude thrust" and changing "joints of the spine" to "body joints".

The College provides two separate anecdotal situations in which patients were injured by an "unlicensed" practitioner. The situation of an unlicensed practitioner causing harm while performing what would be considered a health care service would be covered by the general risk of harm clause previously discussed.

The College has not provided any studies or literature review to support this broadening of the Council's narrowly focussed reserved act 2(c) "movement of the joints of the spine beyond the limits the body can voluntarily achieve but within the anatomical range of motion using a high velocity, low amplitude thrust". This act carries a significant risk of harm, even when performed by a trained and regulated health professional. The most serious risk is cardio-vascular accident (CVA) or stroke, as it is commonly known.

To modify this reserved act by the wording suggested by the College would be contrary to the Council's mandate, unless it is clearly demonstrated that these other joint mobilization techniques carry a significant risk of harm. Amending the Council's reserved act 2(c) would result in the serious risks represented by reserved act 2(c) becoming only one aspect of a vaguely worded, overly broad reserved act. Massage therapists are not qualified for the reserved act as currently worded as acknowledged in their submission of September 1995. The Council has seen no evidence which supports expanding the scope of this reserved act.

4. Putting a Finger(s) Beyond Various Parts of the Body

After consultation with the College in August 1996, the Council learned that the College's proposed reserved act "putting a finger beyond the labia majora or the anal verge" is not currently practiced nor taught in the curricula of colleges of massage therapy.

There are no massage therapists practicing in British Columbia utilizing these techniques, and no certification process exists, according to information provided by the College at the August 1996 meeting.

This was supported by the submission of the Tripartite Committee of the College of Massage Therapists of Ontario, the Ontario Massage Therapists Association and the five Ontario Massage Therapy schools whose comments expressed concern that inclusion of invasive techniques as reserved acts in a general scope of practice "creates the need for training of all massage therapy students to a level of proficiency...[greater] than is currently considered entry to practice level." The Tripartite Committee explained that "any significant change in B.C.'s massage therapy scope of practice will impact the profession nationally especially in light of the internal trade agreement. As well, Ontario graduates frequently sit the B.C. registration examinations, and we have an interest in the curriculum they are required to take."

The Council is not prepared to recommend a proposed reserved act which is not part of current massage therapy practice and for which there is no education or training process in place.

5. Other Proposed Reserved Acts Not Included in the Council's Working Paper

The College's rationale for proposing that massage therapists be granted proposed reserved acts 5 and 6 is as follows:

The risk of harm associated with massage therapy treatment of certain medical conditions and musculoskeletal injuries has long been recognized by massage therapists, and is the reason contraindications are taught in massage therapy schools. The goal is to treat the patient in whom a contraindication exists such that a beneficial response may be obtained without producing unnecessary pain, causing further injury, or adversely affecting other medical conditions. Many contraindications are relative, meaning that certain techniques may be safe, while others are not. The contraindication may also mean that a particular technique may have to be modified in order to be safe.

These proposed reserved acts numbers 5 and 6 were part of the College's original brief submitted in 1995.

A number of respondents to the consultation process questioned the training of massage therapists in the area of assessment, including the area of assessment of contraindications.

Under section 19 [18] of the HPA, the issue of competency to practice is the responsibility of the College. The minimum standards of good practice of any profession would require the individual practitioner to practice safely and within their scope of practice as educated and trained. This would include, for any health professional, an assessment of the patient to determine whether professional intervention would be beneficial, should be modified in a particular situation to avoid harm to the patient, or indeed whether referral to another health profession is indicated in lieu of undertaking any treatment. Since assessment is included in their scope of practice, all registrants of the College must be adequately trained in assessment, including recognition of contraindications to massage therapy.

6. Conclusion

Results of research commissioned by the College and discussed in its July 98 brief were also submitted to the Council by one of the respondents to the consultation process, the British Columbia Coalition of Allied Bodywork Practitioners. That research indicates that, while therapeutic massage forms part of health care systems in various parts of the world across a range of cultures, no jurisdiction grants exclusive rights to practice to massage therapists. The Council was not convinced by the arguments or anecdotal evidence presented, that any reserved acts should be granted to massage therapists.

C.     SUPERVISED ACTS

The issue of supervised or delegated acts arises only when a profession has been granted a reserved act(s). The Council is not currently recommending any reserved acts be granted to members of the College, consequently there is no need to discuss the submission of the College on this issue.

D.     RESERVED TITLES

Reserved titles are titles reserved exclusively to a health profession. Reserved titles afford a means for consumers to identify the different types of health care providers, to distinguish the qualified from the unqualified, and to differentiate those practitioners who are regulated from those who are not. Titles must adequately serve the public in describing the practitioner and the services being provided and must distinguish the practitioner from others performing services outside the jurisdiction of the college.

Currently, section 3 of the Regulation sets out four occupational titles that have been granted to members of the College:

No person other than a registrant may use the title "massage therapist", "registered massage therapist", "massage practitioner" or "registered massage practitioner".

The College proposes that the current four titles continue to be the exclusive occupational titles granted to the profession.

In addition, the College proposes a new title for members of the profession: "registered myofascial therapist" which would also be abbreviated as "RMT".

The College's rationale for use of and definition of the word "myofascial" to describe the therapists who are licensed to practice this form of therapy in British Columbia is as follows:

"myo-" word element (Gr.), "muscle" (Dorland's Pocket Medical Dictionary - 22nd Edition); "myo-" (from the Greek mys, muscle) "Combining form [pertaining] to muscle." (Taber's Cyclopedic Medical Dictionary - 16th Edition).

"Fascia" (L.) a sheet or band of fibrous tissue such as lies deep to the skin or invests muscles." (Dorland's Pocket Medical Dictionary - 22nd Edition); "Fascia" (L. a band). A fibrous membrane covering, supporting, and separating muscles. It also unites the skin with underlying tissue. Fascia may be superficial, a nearly subcutaneous covering permitting free movement of the skin, or it may be deep, enveloping and binding muscles. . "(Taber's Cyclopedic Medical Dictionary - 16th Edition).

The College believes that "myofascial" is a reasonable and useful alternative word to describe the therapists who are licensed to practice this form of therapy in B.C. . . .

When members of the public and the medical community see the title, Registered Massage Therapist, they often respond according to their past experience with "massage". Their experience may or may not have been acquired from a personal experience of therapy provided by a Registered Massage Therapist. The services of a Registered Massage Therapist are medical or health care services, in the same way that the services provided by a Physical Therapist are medical services. On the other hand, there is evidence of public confusion regarding the services provided by Registered Massage Therapists and the non-therapeutic massage services provided by persons who include the word "massage" in their titles or advertising. The new title Registered Myofascial Therapist would further help to differentiate members of the College from those who include the word "massage" to describe themselves or their services, but who are not providing a medical or therapeutic service, and are not covered by public and private health care insurance plans.

The College distinguishes therapeutic from relaxation massage. Whether therapeutic or relaxation, all massage is in the public domain as not being included as part of a reserved act.

When members of the public receive massage services from a registrant of the College of Massage Therapy, they can rely on the fact that a regulatory body has established standards of practice, ethical and disciplinary processes. If they choose an unregulated practitioner, they do not have this assurance.

The Council believes the term "myofascial therapist" does not inform, and has the potential to confuse, the public. The word "myofascial" is technical, not commonly understood and is more narrow than the word "massage". When used in conjunction with "therapist" this title may describe a type of therapist whose scope is narrower than the general scope of practice of massage therapy. Therefore, the Council does not recommend the use of the term "myofascial".

The Council recommends that the title for massage therapists should include the word "therapist" to educate the public as is the case with "physical therapist" and "physiotherapist". The use of the term "practitioner" does not differentiate a member of the College from others performing similar services.

It has been the Council's practice to avoid use of the term "registered" where possible, as the system which is envisaged by the Terms of Reference is not a "registration" system, per se. However, in this instance, the Council believes that the term "registered" would be helpful to distinguish members of the College from unregulated practitioners.

IV.     RECOMMENDATIONS

1. The Council recommends the following scope of practice statement for members of the College of Massage Therapists:

   The practice of massage therapy is the assessment of the soft tissues and joints of the body and the treatment and prevention of dysfunction, injury, pain, and physical disorders of the soft tissues and joints primarily by manipulation to develop, maintain, rehabilitate or augment physical function, to relieve pain and promote health.

2. The Council recommends that massage therapists not be granted any reserved acts.

3. The Council recommends the title "Registered Massage Therapist" be reserved for members of the College of Massage Therapists.

APPENDIX C

Throughout this report, the Council makes reference to the College submission and to the responses received during the consultation process. The Council has abbreviated its references to many of the responses received and for ease of reference, the Council has included the following glossary of terms and abbreviations used: