Health Professions Council
POST-HEARING UPDATE OF PRELIMINARY REPORT:
MASSAGE THERAPISTS

The Council issued its Massage Therapists Scope of Practice (Preliminary Report) in August 1998. The public hearing was held on 31 May 1999. The following are changes to the Preliminary Report which arose from the submissions made either at the public hearing or in subsequent written submissions.

I.     SCOPE OF PRACTICE

The Council’s Preliminary Report recommended the following scope of practice for 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.

A.    Methods of Practice

In its May 1999 response to the Preliminary Report, at the public hearing and in a subsequent submission in November 2000, the College of Massage Therapists of BC (College) objected to the use of the phrase "primarily by manipulation." The College suggests rather the phrase "by manual and physical methods." The College provided its reasons for supporting this phrase:

It avoids having to quantify…the proportion of time that massage therapists provide a particular form of massage therapy…the term "manual methods" encompasses actual massage of the body and includes techniques such as deep friction massage, stretch, manual lymph drainage, connective tissue mobilisation, position release therapy, and other osteopathic techniques. This term also incorporates joint mobilisation techniques, traction, and strain reduction and muscle balancing techniques…the term "physical methods" covers methods and techniques that are not manual…do not involve direct touching…(i.e., therapeutic exercise, hydrotherapy, and the use of physical agents such as heat, infrared and ultraviolet, and cryotherapy.)

B.     Patient Education

The College had also requested the phrase "and patient education" be added. However, the Council believes that patient education is a component of every health profession’s practice and need not be included in scope statements.

The Council agrees with these proposed changes and recommends the following scope of practice statement:

In its Preliminary Report, the Council did not recommend that massage therapists be granted any reserved acts.

At the public hearing on 31 May 1999 and subsequently in November 1999 and in July 2000, the College submitted revised proposals for reserved acts. Those revised requests were:

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

2. Using massage techniques for the treatment of an acute or chronic injury, structural abnormality or disease of the musculoskeletal system, or for the treatment of a circulatory or lymphatic condition that compromises either system;

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

4. Moving body joints beyond the individual's current physiological range of motion;

5. Putting a finger beyond the labia majora or the anal verge: accessing the muscles of the pelvic floor.

In its rationale for the first three reserved acts, the College made a distinction between forms of therapeutic massage. The first form is where the primary intent of the treatment is the production of specific therapeutic effects. The second form is massage treatment in which the primary intent is the production of therapeutic benefits of a more general nature. The College asserted that the type of massage associated with specific therapeutic intent often involves working on soft tissues to a greater depth and with the application of more force as compared to massage performed with general therapeutic intent. The College asserted that the first type of massage has "significant implications for the potential risk of harm associated with massage treatment. The College outlines the risks as:

• Failure to recognize the presence of a condition for which the effects of massage may be harmful;

• Failure to avoid or modify treatment appropriately to prevent injury where an abnormal or pathological condition is known to exist;

• Inappropriate application of therapeutic massage techniques that are potentially harmful in and of themselves.

The College presented written submissions about massage therapists' training in differential diagnosis, asserting that the medical diagnoses which are provided from referring physicians are often incomplete. The College asserted that without a reserved act of diagnosis, its members would be subject to prosecutions under the Health Professions Act for breaches of the diagnosis reserved acts that will be granted to other health professions.

The College has not requested this reserved act nor implied that its members are trained in laboratory diagnostic testing or medical imaging to aid its members in diagnosis of any kind. In fact, the College submits that massage therapists treat most of their patients (approximately 70 per cent) on referral from medical practitioners. The College also submits that:

reports in the medical literature of injury resulting from massage have been rare in the past. (However,) several reports of injury resulting from massage have recently appeared in the medical literature and we may expect this to occur with increasing frequency.

The College asserts that there are three reasons for the potential increase:

• The standards of training for massage therapy remain very low. The majority of regulatory jurisdictions within the United States require 500 hours or less of training, and these are based almost solely on hours of instruction and practice with no real definition of content;
• The increased public interest in traditional and alternative therapies increases the likelihood of minimally trained massage practitioners treating clients who are seeking therapy for pre-existing medical conditions; and
• An increased tendency on the part of minimally trained massage practitioners to view their role as providers of specific rather than general therapeutic benefits results in an increased willingness to treat clients for medical conditions, and to use potentially harmful methods and techniques without adequate training to support this practice.

The College's request for the addition to the Reserved Acts List of soft tissue diagnosis and the proposed reserved acts associated with soft tissue massage have not been substantiated by evidence of risk of harm. It appears that a substantial majority of patients who are treated for injury are referred by a medical practitioner who makes a differential diagnosis prior to referral. The medical practitioner referral is a requirement for MSP payment. The College acknowledges that there are few reported cases of harm from massage therapy but asks for this reserved act in anticipation of harm which may increase in the future.

In the Council's view, the College's request for these proposed new reserved acts is an attempt to reserve the entire scope of massage practice. If the College's rationale were adopted and if the proposed reserved acts were added to the Reserved Acts List and granted to massage therapists, the practice of unregulated massage practitioners would be inhibited. Every act of massage could be subject to investigation and evaluation of the intent of the massage practitioner. To accede to the College's request would result in an unwarranted infringement of the public's right to chose a massage practitioner.

The Council has seen no evidence that massage therapy carries with it such a sufficient risk of harm to warrant making any portion of its practice a reserved act.

The College submitted an excerpt from a revised Physician's Guide by John Yates, Ph.D, in further support of its position that this form of therapy be made a reserved act.

Dr. Yates has been a faculty member of the West Coast College of Massage Therapy in Vancouver and has written texts which are used in the West Coast College of Massage Therapy, as well as guides for medical practitioners to assist in referrals to massage therapists.

The Council notes the College submission that there are very few cases of documented harm resulting from massage therapy. There has not been sufficient evidence presented which supports this proposed reserved act and the Council again declines to recommend it be reserved.

Representatives of the College made submissions at the public hearing indicating that there were a small number of massage therapists who were trained by a physiotherapist to perform this type of massage therapy for pelvic floor dysfunction. The College made post-hearing submissions which indicated that it has proposed an amendment to its bylaws to "license pelvic floor work." The College also provided a letter from Dr. Wolfgang Schamberger, FRCPC, Musculoskeletal and Sports Medicine, Division of Rehabilitation Medicine, University of British Columbia, that supports therapists continuing to treat problems related to pelvic floor dysfunction by accessing the muscles of the pelvic floor via the labia majora or the anal verge. Dr. Schamberger made suggestions about the kind of training program that would be necessary for advanced practitioners in this specialized therapy. The College indicated that they are developing criteria for inclusion in an advanced competency examination for members of the College.

Subsequently, the Council received letters from the College of Physicians and Surgeons of British Columbia The first letter indicated that it was "unable to support" the College's request for inclusion of this reserved act in the massage therapy scope of practice. The second letter indicated that the College of Physicians and Surgeons of British Columbia had requested the B.C. Medical Association, Section of Physical Medicine and Rehabilitation, review the subject and respond with regard to evidence of current knowledge and practice in this area. To date the Council has not had any further information about the B.C. Medical Association or College of Physicians and Surgeons of British Columbia position with regard to use of this reserved act for this purpose by massage therapists or others.

The College has acknowledged that this type of therapy is a newly emerging treatment for pelvic floor dysfunction and that there are very few massage therapists trained in its use. This is consistent with information provided by the College of Physical Therapists of British Columbia in its scope of practice review, during which physical therapists also requested this reserved act.

Without commenting on the efficacy of this type of treatment, the Council notes the lack of a recognized training program or advanced competency assessment or credentialling program in both the College of Massage Therapists of British Columbia and the College of Physical Therapists of British Columbia Without a College approved program for post-graduate training and in the absence of clinical undergraduate training, this service can continue to be provided only as a delegated reserved act following the Council's delegation protocols outlined in the Council’s Final Report on the Scope of Practice Review. This would allow for the services to continue uninterrupted, but only when a physician refers the patient to a massage therapist who the physician is confident can provide this service in a safe manner.

III.     RESERVED TITLES

The Council’s Preliminary Report recommended the following reserved title for massage therapists:

• "Registered Massage Therapist"

In its November 1999 response to the Council's Preliminary Report and at the public hearing, the College expressed its concerns with the single title "Registered Massage Therapist." The College reasons can be summarized as: inconsistency with title protection recommended for other health professions and loss of the title "Massage Practitioner." A third concern was that requiring the term "Registered Massage Therapist" might permit non-registrants to call themselves "Massage Therapist" which would be confusing to the public.

The Council has carefully considered the submissions of the College and the numerous responses by its registrants. The Council agrees that in the interest of consistency and in support of the public’s freedom of choice among massage practitioners, recommendation of the title "registered" is potentially confusing and unnecessary. The title "Practitioner" has not been recommended for any other health profession and its reservation for the exclusive use of registrants of the College might impede others who are practising massage.

Therefore, the Council recommends a single title for registrants of the College.