Maria DiDanieli’s editorial in the Spring 2013 Massage Therapy Canada offers laudable counsel.
By Don Quinn Dillon
Maria DiDanieli’s editorial in the Spring 2013 Massage Therapy Canada offers laudable counsel. Regarding the categorization of massage therapy under Complementary and Alternative Medicine (CAM), however, I found her tone pejorative. She suggests massage therapy’s association with CAM is negative, stating “I would argue that when medical professionals – especially massage therapists themselves – persist in referring to it as CAM, they encode in the minds of the public, and the profession, biased notions of limited utility.”
In this article I offer an alternative view, one rooted in the economics of the marketplace and the bureaucracy that forms our health care system. I argue that the massage therapy profession is actually becoming less recognized as health care; the profession has more in common politically and historically with CAM than Western medicine; and collaboration with CAM provides a positive association that offers viable work opportunities for massage therapists now and in the future.
In the Fraser Institute report, Complementary and Alternative Medicine in Canada: Trends in Use and Public Attitudes, 1997-2006, the authors define the term “complementary and alternative medicine as usually used to describe medical therapies, practices, and products that are not typically seen as a part of conventional medicine, or that are not taught widely in medical schools or commonly available in North American hospitals.” Massage therapy is categorized squarely in this report as CAM.
This report also cites the definition posed by the National Center for Complementary and Alternative Medicine (a component of the National Institute of Health) in the United States as ““a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine. While some scientific evidence exists regarding some CAM therapies, for most there are key questions that are yet to be answered through well-designed scientific studies – questions such as whether these therapies are safe and whether they work for the diseases or medical conditions for which they are used.”
Defined in this way, CAM is a series of practices or interventions that have not been proven under well-funded studies, with the implication they would be inaugurated into health-care policy should they comply and show sufficient evidence. It would suggest that simply overcoming these hurdles would ensure massage therapy a position in government-endorsed health care. Is this true? Could we simply follow the path of our physiotherapy counterparts and secure a position in health care with more research and a degree-level program contributing to more practitioners applying evidence-based practice? Given my experiences in the field, I suspect that, even if these criteria were met, the government, insurance industry and existing and emerging gatekeepers would still not save a seat on the bus for massage therapists in the health-care hegemony.
GOVERNMENT, GATEKEEPERS AND INSURANCE CLAIM ISSUES
In government health-care funding and taxation policy, massage therapists are clearly not considered health-care providers. Massage therapy is omitted from provincial health-care funding in every province and subject to service taxes not imposed on its closest competitors – physiotherapists or chiropractors. It’s also clear government continues to bend to the influence of the auto-insurance industry and workers’ compensation arguments for restricting claims and claim amounts, despite public and media outcry over recent oppressive auto-insurance changes in Ontario.
Western medicine had a leg up on other professions when it enjoyed generous philanthropic donations on its way to becoming a regulated health profession, as outlined in Patricia O’Reilly’s Health Care Practitioners. In O’Reilly’s book, interference by Western medicine into the scope of practice and regulation of midwifery, nursing and pharmacy has imposed negative consequences on these respective professions. Apparently massage therapy squeaked through only because it wasn’t viewed as a threat to any other profession: massage is time- and labour-intensive – who else would want to do it? Midwifery and naturopathic medicine were not so lucky, and had to fight for years to eventually be included in the Regulated Health Professions Act.
Even Western biomedicine has not achieved evidence-based standards in all aspects of care, and in some cases there is a real insufficiency of evidence-based practice to support certain interventions.1 However, when other professions seek to gain more ground, the objection of “you don’t have sufficient evidence-based practice” is the repeated defence. At best, if massage therapists managed to penetrate the iron veil of the health-care system, they would be relegated as assistants to the well-positioned physiotherapists.
DOES EVIDENCE MAKE A DIFFERENCE?
Recent evidence into the efficacy of acupuncture for pain, and massage therapy for low back pain, has improved the status of these interventions at least in medical research journals. However, it has not helped change government policy or insurance claim approval. Massage therapy is not funded under provincial health plans anywhere in Canada or the United States, and anecdotal evidence suggests it has become harder, not easier, for massage therapists to get treatment plans approved under auto-insurance or workers’ compensation claims.
Despite evidence suggesting the intervention of massage therapy has positive effects on mood, trait anxiety, biomechanical lower back pain and inflammation, evidently insurance companies are not weighing this evidence in their claim approval process. Brenda Locke, MTABC, ED, and Lori Green, MTAS, ED – both major contributors to the Canadian Massage Therapist Alliance – explain that insurers are wary of fraud and efficacy in the massage therapy profession and have warned they will deny claims without sufficient proof of greater organization and credibility in the profession.2 The evidence of efficacy has not swayed government either in forming favourable health care or goods and services taxation policy.
THE REAL YELLOW BRICK ROAD
Research and academic pundits in the massage therapy field may argue that the CAM moniker subscribes to an identity fused with fringe, questionable practices, and that massage therapists would be wise to avoid the association. This is a valid concern with some practices often lumped under the broad category of CAM, but it is not true of primary CAM professions. In Ontario, CAM professions chiropractic and massage therapy are regulated health professions, while naturopathic, traditional Chinese medicine (TCM) and acupuncture, and homeopathy, have formed transitional regulatory bodies. All these CAM professions want evidence-based practice, high-level training, continued research, and improved relations with government policy makers and insurance claim adjudicators.
Some suggest the massage therapy profession should act unilaterally, follow the example of established physiotherapists and avoid CAM association.
Reflecting on my experiences both as a practitioner and a representative of the profession in Ontario to government, insurance companies and gatekeeper health disciplines, I suggest this idea is ill-formed. Consider that academic ideologies of professionalism are typically formed in a bubble, negligent of the marketplace influences that strongly act in shaping the profession. Further, physiotherapy’s timing and positioning were unique and ideal during economic boom years and health care policy formation.
Obviously, no single profession or association has the resources to position well against – or in alignment with – the medical and pharmaceutical establishment. Combining resources and know-how gives CAM professions the best option in establishing themselves favourably in public health policy.
RECOMMENDATION FOR COLLABORATION
I’m not denying the profession should continue to pursue higher, better education and evidence-based practice; in fact, this is essential to our credibility. We may find, though, that the open marketplace offers more opportunities for the massage therapist profession associating with CAM than awaiting an opening in the health-care hegemony. In fact, collaboration with CAM may make our services more appealing because of higher marketplace value, effectiveness and exposure, eventually attracting the interest of Western medicine practitioners, government, insurance industry and public media.
Massage therapists are already benefiting from collaborative initiatives and conferences with organizations such as the Canadian Interdisciplinary Network for Complementary and Alternative Medicine Research, or IN-CAM, and the aforementioned National Center for Complementary and Alternative Medicine in the United States. ONE Concept, broker of both the Canadian and American Massage Conferences, has wisely merged chiropractic into its program and will merge acupuncture and other primary CAM methodologies into future programs. CAM practitioners will have more opportunity to share, to collaborate, to work together, and eventually to work towards common objectives.
I suggest we stop fighting the CAM identity and stop snubbing CAM professions with common interests. Instead, let’s align resources to better position ourselves in the open marketplace – a forum much larger than any health/wellness profession, the insurance industry, the health-care system or even government combined. Only when we, as CAM professionals, collectively improve our training and education, support research, effectively lobby government and the insurance industry, and strengthen our credibility in the eyes of the public and media, will we create opportunity to be welcomed into mainstream health care. Evidence and experience shows the existing politico-health-care culture is not waiting to embrace us.
Don Dillon, RMT, is the author of Massage Therapist Practice: Start. Sustain. Succeed. and the self-study workbook Charting Skills for Massage Therapists. Don has lectured in nine Canadian provinces and over 60 of his articles have appeared in massage industry publications in Canada, the United States and Australia. Don is the recipient of several awards from the Ontario Massage Therapist Association, and is one of the founding members of Massage Therapy Radio www.massagetherapyradio.com. His website, www.MassageTherapistPractice.com, provides a variety of resources for massage therapists.