A Combined-Methods Study of the Training and Practice of Alberta's Therapeutic Massage Bodywork Providers

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2012-09-05 A combined-methods study of the training and practice of Alberta's therapeutic massage bodywork providers

Porcino, Antony

Porcino, A. (2012). A combined-methods study of the training and practice of Alberta's therapeutic massage bodywork providers (Unpublished doctoral thesis). University of Calgary, Calgary, AB. doi:10.11575/PRISM/24663 http://hdl.handle.net/11023/175 doctoral thesis

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A Combined-methods Study of the Training and Practice

of Alberta’s Therapeutic Massage Bodywork Providers

Antony Joseph Porcino

A THESIS SUBMITTED TO THE FACULTY OF GRADUATE STUDIES

IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE

OF DOCTOR OF PHILOSOPHY

DEPARTMENT OF COMMUNITY HEALTH SCIENCES,

FACULTY OF MEDICINE, GRADUATE PROGRAM IN

HEALTH SERVICES RESEARCH

CALGARY, ALBERTA

July, 2012

Abstract

Background

Therapeutic massage bodywork (TMB) therapies are commonly used by the public, nevertheless, research validating TMB is nascent. Practitioner variability may be affecting research outcomes. This study therefore describes and explores the relationship between therapist variables (e.g., training, practice focus) and clinical TMB experience, and the consequent implications for TMB research.

Methods

A combined methods design, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, was used to explore the training and practice of TMB practitioners in Alberta, Canada.

Results

Of the 5242 distributed surveys, 791 were returned (15.1%). The sample demographics did not significantly differ from other massage therapist study populations.

Practitioners were trained in 77 distinct TMB therapies. Most practitioners (94.4%) were trained in two or more therapies, with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen practitioners trained in multiple TMB therapies were interviewed.

Participants reported greatly varying training backgrounds, resulting in practitioners learning and practicing unique combinations of therapy techniques. Moreover, all practitioners described addressing patients’ needs by providing individualized patient treatment based on a responsive feedback process throughout practice. Additionally, practitioners distrust TMB research results because of perceived and actual treatment

provision differences between TMB clinical practice and TMB treatments used in research.

Conclusions

The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. Clinical experience and continuing education may further alter or enhance treatment techniques. Therefore, treatment provision and individualization are likely practitioner-specific. Practitioners surmise that clinical trials do not accommodate practitioner variability or treatment individualization, resulting in limited clinical application of TMB research. The high variability in training and experience between practitioners necessitates improved research reporting of practitioner qualifications and expertise, and the consequent impact on the results.

TMB research designs need to accommodate the inherent individualization of clinical practice and capture relevant contextual outcomes. Knowledge translation of research results must address TMB practitioners’ perceived differences between TMB research treatments and TMB clinical practice.

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Preface

In 1996 I graduated as a Hellerwork Structural Integration practitioner, specializing in myofascial chronic pain and injury rehabilitation treatments. While the treatments were effective in reducing or eliminating pain and increasing function, they occasionally had little effect. Thus, like many of my therapeutic massage bodywork

(TMB) colleagues, I pursued advanced myofascial training and progressively cross- trained in other complementary and alternative medicine (CAM) therapies, including cranial sacral therapy, acupressure, trigger point therapy, and energy healing.

I became involved with TMB Canadian national politics and competency standards in 1999 as a member of the board of what is now the Natural Health

Practitioners of Canada (NHPC). In 2001 I took the staff position of Deputy Registrar,

Research and Credentials. In that role, I regularly scanned the literature for research involving the professions of NHPC members. I undertook two surveys of the members, and frequently talked with members about their training and professional development.

They told me they generally did not value TMB research because it was so unlike practice, and some were frightened that negative research results would be used to limit their ability to practice. In the TMB research I was reading, I perceived a serious gap between research and practice: most earlier research projects were small, limited in scope, and often conducted by those with limited training and research experience in

TMB. The practitioners providing the research treatments did not represent the vast majority of the practitioners I was working with, nor the members of the associations I was liaising with, where the practitioners typically were experienced and trained in multiple forms of TMB therapies. I could find no published literature about the potential

of practitioner training or experience to influence research outcomes or interpretation.

Thus, I wanted to explore such issues and contribute to the development of relevant and effective TMB research.

When I started my TMB practice in the late 1990s, there was little research in the profession of massage therapy, and often none in the other TMB professions. Today, there is substantial TMB research activity and a profession-specific peer-reviewed TMB research journal, the International Journal of Therapeutic Massage and Bodywork.

Innovative clinical trial designs—e.g., two- or three-option treatment protocols, sham

TMB treatment, combined methods, and comparative effectiveness studies—are occasionally found in TMB research projects. Such designs present opportunities for addressing practitioner variability and for reflecting clinical practice. However, many

TMB research projects continue to be published using the former research designs, with the same research design problems, and no consideration about how the TMB practitioners may be affecting TMB research results.

In 2005 I received a grant from the Canadian Interdisciplinary Network for CAM

Research (IN-CAM) to do a survey of Canadian CAM practitioners about their professional training and practice descriptors, on the condition that I work with a university-based researcher. I began my graduate education at the University of Calgary under Dr. Verhoef’s direction in 2006. The IN-CAM funded project became a pilot survey for this study (two studies therefore comprise this thesis). The original descriptors survey was developed and refined into a combined methods study of the training and practice process of TMB practitioners in Alberta. The Massage Therapy Foundation

(MTF) provided the funding for this study.

I hope this study provides impetus for the greater uptake of TMB-appropriate research designs leading to better TMB research and knowledge transference, ultimately in the service of better practice and better healthcare. I hope it also contributes much needed knowledge for addressing the inclusion of training and clinical experience in research design.

List of Publications

1) Porcino, AJ, Verhoef, MJ. The Use of Mixed Methods for Therapeutic Massage

Research. IJTMB. 3(1): 15–25. (1)

2) Porcino, AJ, Boon, HS, Page, SA, Verhoef, MJ. Meaning and Challenges in the

Practice of Multiple Therapeutic Massage Modalities: A Combined Methods Study.

BMC Complementary and Alternative Medicine. 2011; 11:75. (2)

3) Porcino, AJ, Boon, HS, Page, SA, Verhoef, MJ. Exploring the Complexity of the

practice of Therapeutic Massage Bodywork. IJTMB. Manuscript accepted for

publication. (3)

4) Porcino, AJ, Boon, HS, Page, SA, Verhoef, MJ. Exploring the origins and potential

solutions to the research-practice gap for therapeutic massage bodywork. Manuscript

in process. (4)

5) Porcino, AJ, Page, SA, Boon, HS, Verhoef, MJ. Negotiating consent: commentary on

the ethical issues when therapeutic massage bodywork practitioners are trained in

multiple therapies. Manuscript in process. (5)

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Contributions of Authors

Article 1: Antony Porcino developed, researched and wrote the manuscript. Dr. Verhoef provided guidance and feedback on the content and structure of the manuscript, and made editing suggestions where needed.

Articles 2 to 5: Antony Porcino wrote the funding application, developed and implemented the research and data analysis, and wrote the articles. Dr. Verhoef provided guidance and editing for the funding application, guidance on the research design, reviewed the data analysis and editing suggestions on all drafts of the articles. Drs. Boon and Page provided guidance on the research design and editing suggestions on later drafts of the articles. Dr. Page has agreed to provide guidance and editing for the forthcoming

Article 5, concerning consent issues in therapeutic massage bodywork treatments involving multiple therapies.

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Acknowledgements

I am indebted to the 19 practitioners who were willing to explore their training choices and their process of practice, working to articulate the intrinsic, day-to-day application of therapeutic massage bodywork during our interviews. Verbalizing their kinesthetic knowledge of practice—the combined conscious and automatic whole-body experience of providing TMB treatment—is never easy, but they effectively and generously found the words to share their clinical experiences. At the same time, they all found the discussions stimulating, thought provoking, and illuminating about their own process of practice.

I would also like to thank the associations and spa managers who were willing to help me by distributing surveys to their members or employees on my behalf. I could not have done the work without their support.

With gratitude, I thank my PhD Supervisory Committee members Drs. Stacey

Page and Heather Boon for their advice and direction in the development of my research and the resulting manuscripts.

Finally, my sincerest thanks to Dr. Marja Verhoef, my PhD Supervisor, for her guidance and support in turning an enthusiastic and kinesthetic learner into an enthusiastic healthcare researcher, and especially for her dedication to holding her students to the highest standards of scholarship.

Dedication

This work is dedicated to my husband; my tireless supporter, who knows how to keep me going when writing, work, and life collide with too few hours in the day.

Thank you, Tom.

Table of Contents

Abstract ...... ii Preface ...... iv List of Publications ...... vii Contributions of Authors ...... viii Acknowledgements ...... ix Dedication ...... x Table of Contents ...... xi List of Tables ...... xv List of Figures ...... xvi List of Abbreviations ...... xvii Chapter One: Introduction ...... 1

1.1 THERAPIST VARIABILITY ...... 2

1.2 DESIGN VARIABILITY ...... 5

1.3 IN CONCLUSION, THE BROADER THESIS ENVIRONMENT ...... 6

1.4 THESIS OBJECTIVES ...... 6

1.5 THESIS OVERVIEW: CHAPTERS 2 TO 8 ...... 8 Chapter Two: Background ...... 10

2.1 DEFINING THERAPEUTIC MASSAGE BODYWORK AND RELATED TERMS ...... 10

2.2 THERAPEUTIC MASSAGE BODYWORK THERAPIES ...... 12

2.3 TRAINING IN TMB THERAPIES ...... 15 2.3.1 External influences on TMB therapy training: Regulation ...... 18 2.3.2 External influences on TMB therapy training: Professional organizations ....19

2.4 TMB RESEARCH METHODOLOGICAL ISSUES ...... 20 2.4.1 TMB research methodology issues arising from training and experience ...... 20 Chapter Three: Methods ...... 22

3.1 THE PILOT PROJECT...... 22

3.1.1 Jurisdiction ...... 22 3.1.2 The questionnaire ...... 23 3.1.3 Recruitment ...... 24

3.2 STUDY RESEARCH DESIGN: COMBINED METHODS ...... 25

3.3 JURISDICTION: ALBERTA, CANADA ...... 27

3.4 STUDY WEBSITE ...... 28

3.5 THE SURVEY ...... 29 3.5.1 Recruitment ...... 29 3.5.2 Data collection ...... 33 3.5.3 Analysis ...... 34

3.6 TMB PRACTITIONER INTERVIEWS ...... 34 3.6.1 Recruitment ...... 34 3.6.2 Data collection ...... 36 3.6.3 Analysis ...... 37

3.7 QUESTIONNAIRE–INTERVIEW INTEGRATION ...... 38 Chapter Four: The Pilot Project ...... 40

4.1 QUESTIONNAIRE DISTRIBUTION ...... 40

4.2 PLACE OF WORK ...... 41

4.3 LEARNING ABOUT AND PARTICIPATING IN SURVEYS ...... 41

4.4 RESEARCH INTEREST AND WRITTEN COMMENTS ...... 42

4.5 SURVEY SIZE AND RESPONSE CHANNEL ...... 42

4.6 SIGNIFICANCE AND IMPLICATIONS FOR THE THESIS STUDY ...... 43 Chapter Five: Combined-Methods Exploration of the Training and Practice of TMB ....44

5.1 QUESTIONNAIRE RESULTS ...... 44 5.1.1 Response Rate and Demographics ...... 44 5.1.2 TMB therapies identified ...... 47 5.1.3 Total TMB therapies learned ...... 50 5.1.4 Training programs ...... 51

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5.2 INTERVIEWS ...... 53 5.2.1 Theme 1: Career and training paths are complex ...... 55 5.2.2 Theme 2: All treatment is individualized ...... 57 5.2.3 Theme 3: Therapy provision will evolve over time ...... 60 5.2.4 Theme 4: Clinical practice and research treatment protocols are different .....61

5.3 INTEGRATION OF THE QUESTIONNAIRE AND INTERVIEW RESULTS ...... 62 Chapter Six: Qualitative Exploration of the Nature of TMB Practice ...... 64

6.1 PARTICIPANTS ...... 65

6.2 THE PROCESS OF PRACTICE: ALL TREATMENT IS INDIVIDUALIZED ...... 66 6.2.1 Individualization during assessment ...... 66 6.2.2 Individualizing during treatment application ...... 69 6.2.3 Using “toolkit” techniques ...... 71 6.2.4 In Summary: Individualization ...... 72

6.3 THE NATURE OF PRACTICE: THE PRACTICE OF THERAPIES EVOLVES THROUGH EXPERIENCE ...... 73 6.3.1 Exploring treatment options ...... 73 6.3.2 Exploring therapy integration ...... 74 6.3.3 In summary: the evolution of practice ...... 75

6.4 THE RESEARCH-PRACTICE GAP ...... 76 6.4.1 Treatment during research is not like the clinical treatment of practice ...... 76 6.4.2 Few practitioners directly apply research results to clinical practice ...... 79 6.4.3 In summary: the research-practice gap ...... 79 Chapter Seven: Exploration of Consent in the Practice of TMB Therapies ...... 80

7.1 EXPLORING CONSENT WITH THE PRACTITIONERS TRAINED IN MULTIPLE THERAPIES ...... 80

7.2 DESCRIPTIONS OF CONSENT ...... 81 7.2.1 Descriptions of general consent ...... 81 7.2.2 On-going consent negotiation ...... 83

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7.3 MOTIVATION FOR ENGAGING IN CONSENT ...... 85

7.4 ADDRESSING THE INTENT OF THE CONSENT PROCESS ...... 86 Chapter Eight: Discussion and Conclusions ...... 89

8.1 SUMMARY OF RESULTS ...... 89

8.2 DISCUSSION OF FINDINGS ...... 91 8.2.1 Variability of practitioner training ...... 92 8.2.2 Evolution of practitioners skills ...... 93 8.2.3 The individualization of treatments ...... 95 8.2.4 The integrated results ...... 97

8.3 METHODOLOGICAL CONSIDERATIONS ...... 97 8.3.1 Quantitative: Survey response rate and generalizability ...... 98 8.3.2 Qualitative: rigour of data analysis and interpretation ...... 101 8.3.3 Interview invitation response rate ...... 104 8.3.4 Combined methods: inference quality ...... 105

8.4 IMPLICATIONS OF THE RESULTS FOR RESEARCH ...... 109

8.5 RECOMMENDATIONS FOR TMB RESEARCH ...... 111 8.5.1 Recommendation 1: Publishing practitioner descriptors ...... 111 8.5.2 Recommendation 2: Appropriate research design ...... 112 8.5.3 Recommendation 3: Translating research results ...... 116

8.6 IMPLICATION OF THE RESULTS FOR TMB EDUCATION ...... 118

8.7 FUTURE RESEARCH INITIATIVES ...... 119

8.8 CONCLUSIONS ...... 121 BIBLIOGRAPHY ...... 125 Appendix 1: Commentary on Four TMB Research Protocols ...... 133 Appendix 2: Pilot Project Questionnaire ...... 141 Appendix 3: Cover Materials and Questionnaire ...... 143 Appendix 4: Questionnaire Communications ...... 151 Appendix 5: Consent and Final Interview Guide ...... 154

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List of Tables

Table 2-1. Distinct TMB therapies identified in Alberta for the survey ...... 13

Table 3-1: Organizations contacted for the pilot project ...... 25

Table 3-2: Organizations with members in Alberta ...... 30

Table 5-1. Demographic characteristics, and comparison to past surveys ...... 45

Table 5-2. TMB therapies practiced [in Alberta] ...... 47

Table 5-3. TMB therapies [trained in] by 10% or more of respondents ...... 49

Table 5-4. Additional TMB components included in more than 10% of TMB training programs ...... 53

Table 5-5. Participant descriptors ...... 54

List of Figures

Figure 5-1. Range of the number of TMB therapies in which practitioners have trained ...... 51

Figure 6-1. The process of treatment individualization ...... 72

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List of Abbreviations

AMTA American Massage Therapy Association

ARMTS Alberta Registered Massage Therapists’ Society

CAM complementary and alternative medicine

CMTO College of Massage Therapists of Ontario

IN-CAM Canadian Interdisciplinary Network for CAM Research

EBNMP Examining Board of Natural Medicine Practitioners

MTAA Massage Therapist Association of Alberta

MTF Massage Therapy Foundation

NCBTMB National Certification Board of Therapeutic Massage and

Bodywork

NHPC Natural Health Practitioners of Canada

RMTA Remedial Massage Therapists Association

TMB therapeutic massage bodywork

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Chapter One: Introduction

There are two discernable trends in Cochrane reviews that include TMB therapy evaluations: clinical trials aimed at specific clinical outcomes (e.g., deep transverse friction massage for the treatment of tendinitis, massage for low-back pain, abdominal massage for mechanical neck pain (6-8)) produce inconclusive or negative results in 73% of the reviews (n=28); research projects with general outcomes such as well-being (e.g.,

(9)), or depression (e.g., (10)) and stress reduction (e.g., (11)) produce positive research outcomes in 60% of the reviews (n=6). The vast number of positive patient testimonials for specific TMB clinical outcomes (e.g., a Google search on May 21, 2012 using the terms massage, testimonials, and frozen shoulder produced “About 3,020,000 results”) therefore suggests disconnect between outcomes from clinical practice and research.

Menard, Hymel, and Cawley (12-15) have called upon TMB practitioners and researchers to develop and implement higher quality research projects. Each has articulated barriers to the production of excellent research in the TMB field, though many of those barriers are issues identified as common to complementary and alternative medicine (CAM) research: clinical treatments are usually individualized for each patient, inadequate endpoints or appropriate validated measuring instruments, and inadequate controls (16-18). Issues specific to TMB research include: insufficient explanation of the impacts of the choice of TMB provider(s) providing the TMB service; insufficient standardization and validation of the time frames and techniques for maximizing outcomes; and lack of consistent reporting of treatment process and outcomes (12-15).

1.1 Therapist variability

Menard’s concerns regarding the education of the TMB practitioners providing the research treatments with respect to the standardization of the research treatment protocols and personnel, as well as her reflection on how they may be affecting the research outcomes (12) confirmed my own perceptions and concerns of those issues.

Menard’s comments are limited to the U.S.A., which has a national voluntary standard of

500 hours for massage therapy. Massage therapy training programs in all locales I reviewed are variable in length, content, and inclusion of other therapies. Canada has no national massage therapy standard or exam; training programs range from 250 to 3000 hours. International massage therapy programs range in length from 100 hours in the

United Kingdom to 1200 hours in Australia and China. Training programs for most other

TMB therapies are equally complex. Only trademarked therapies have structures in place to standardize their training.

Because variability in TMB training is already known (19, 20), readers of TMB research should be asking many questions relevant to the above issues, such as:

(a) Does the reader need to know the training standard of the TMB practitioners

providing the treatments in the specific region of the research to understand the

research and determine if it is applicable in the reader’s locale?

(b) Are the practitioners who provide the research treatments applying the TMB

techniques similarly to the manner they are applied by practitioners in the reader’s

locale? (i.e., is treatment application locale- or context-specific?)

education, or research treatment protocol training) and quality of training of the

practitioners providing the research treatments affecting the outcomes?

(d) How is the effect of the clinical experience—or lack thereof—of the practitioners

providing the research treatments accounted for in the research design or the

analysis of results?

TMB training and practice often incorporate multiple therapies. This suggests additional questions, such as:

(a) Are treatments and the outcome measures affected if the practitioner(s) has taken

training in multiple therapies?

(b) Has awareness of potential multiple therapy training been addressed in the

research?

multiple therapies?

(d) Does the research indicate awareness that techniques can blend and/or blur or has

the research design be altered to accommodate the possibility of blending or

blurring if the practitioner is trained in multiple therapies?

(e) Can that blending and/or blurring be undone if needed to standardize a research

treatment protocol?

In 2008, I carefully considered those questions during an extensive review of the

TMB literature. I examined the Massage Therapy Foundation database of published TMB research (drawn from research and non-indexed sources around the world, to 2006), and searched for “massage” in PubMed (2006 to 2008, updated in 2011). Articles of clinical trials or those relating to the process of TMB practice, approximately 700, were selected for further examination. The following are issues arising from that review warranting

consideration:

• There were no descriptions of the process of TMB clinical practice

• There were no descriptions or explorations of how experience changes clinical

practice (two research projects did find improved outcomes associated with

experience but did not explore why (21, 22))

• There were no descriptions or explorations of the effects of training in multiple

therapies on clinical practice or research outcomes.

• Many TMB research projects before 2006 (fewer after) used students, single

practitioners, or healthcare providers not normally practicing TMB therapies (e.g.,

nurses) but who were trained in a specific treatment protocol developed for the

research project to provide the research treatment.

• Comparison of the training of the practitioners in the studies’ articles with local

practitioners to assess whether the studies’ practitioners are representative of the

population was often not possible because the articles rarely report the full

training and experience profile of research trial practitioners—articles were not

explicit if such information was even considered or collected. The primary

exception occurs when TMB students were employed for the TMB treatments,

because the training stage and educational institution of the students is often

described.

• Usually descriptions of treatment interventions are limited or non-existent (four

examples of typical research treatment protocols are provided in Appendix 1

(page 133) with brief commentary based on the results of this study).

• Few research projects report procedures used to ensure treatment fidelity. 4

In 2002, Rich noted these issues as well (23). “Very few studies have examined therapist effects [on research outcomes] in detail. Therapists vary in amount and type of training, in years and type of experience, in their training in other disciplines relevant to massage, and in many other ways… To date [the effect of such] therapist variables have been neglected in massage research” (page 6 (23)). I believe therapist variables continue to be a critical, under-recognized, and under-researched gap in the literature regarding

TMB research methodology.

1.2 Design variability

Another issue not sufficiently addressed in the TMB literature is appropriateness of research design for TMB. Several contextual and conceptual issues of CAM treatments affect the application of conventional pharmaceutical research design, such as the randomized controlled trial, to CAM research, including preference and expectations of outcomes for certain therapies, ineffectual placebo or sham treatments, therapeutic learning and expectations of patient participation, and the synergistic effects of the multiple treatment components (environment, client-patient relationship, treatment techniques, etc.) of the CAM therapy involved (24-26). TMB shares those CAM research characteristics. However, there is currently little uptake of research designs that address those issues in TMB research. This may in part be due to the lack of TMB literature specifically addressing research trial design issues and potential solutions.

1.3 In conclusion, the broader thesis environment

Consideration of the therapist variables—training variability, multiple therapy training, clinical practice experience—leads to the question, “how are these factors affecting practice?” That question is critical, as published TMB research seems to rely on the unexplored assumption that practitioners have the ability to provide consistent research treatments. If incorrect, that assumption could be jeopardizing TMB research treatment fidelity and quality, thus affecting research project quality as well as replicability and generalizability. The choice of trial design and appropriate outcome measures would also need to change. This study will therefore explore the relationship between the therapist variables and clinical TMB practice, and consider the implications of the results for research methodology. With the publication of these results I hope the answers to the above question will consequently increase the quality of TMB research and improve the clinical uptake of TMB research.

1.4 Thesis objectives

The objective of this thesis is to assess and describe the scope and complexity of

TMB practitioner training, to relate that training to TMB practice, and to then consider the potential implications of training and practice for improvements to TMB research design and knowledge translation.

As explained in Chapter 4, Methods, a combined-methods design is used to address the broad objectives of this study, with different aspects of the objectives best addressed by different research methods. The decision was made therefore to distinguish the study’s objectives as the above overarching statements for the study, and the specific

questions that would direct the investigation needed to achieve the objectives.

Question 1 considers practice descriptors of Alberta’s TMB providers.

(Addressed in manuscript 2)

(a) What TMB therapies do the practitioners provide;

(b) What TMB training do they receive; and

These practice descriptors are quantitative, collected via questionnaire.

Question 2 considers the nature of practice when multiple therapies are involved.

(Addressed in manuscripts 2 and 3)

(a) How do practitioners trained in multiple TMB therapies use those

therapies in practice (e.g., in isolation, sequentially, blended)?

(b) How are clinical decisions made, generally, and specifically regarding the

use of multiple therapies?

Several secondary questions were explored to better understand the nuances of practice considered in Questions 2a and 2b. In particular:

(i) How does a therapist arrive at his/her combination of TMB therapies?

(ii) Does training in one therapy influence the practice of another, and can those

influences be isolated or removed? Are there other influences (personal,

practice, etc.) involved?

(iii) How does each therapist learn to use multiple therapies together?

(iv) How do practitioners perceive TMB research relative to their practice of

TMB?

Addressing these contextual questions will be by qualitative analysis of interview

data.

1.5 Thesis Overview: Chapters 2 to 8

The remainder of this thesis presents the pilot project and the study undertaken to address the thesis objectives. This thesis is a manuscript-based thesis; manuscripts based on this thesis are listed on page vii. The format used has two distinct features. First, it combines the pilot project, which will not be published as a manuscript, a theory-based published manuscript about combined methods and its value to the field of TMB research, and four results manuscripts: one published, one accepted, and two under development. Second, no manuscripts are included in their entirety. The Background

(Chapter 2) provides the information needed to understand the thesis as a whole, with few direct manuscript quotations. Methods from each component of the thesis research have been combined into the Methods chapter; substantial sections from the manuscripts are quoted. Each of the three results chapters (5 to 7) consist primarily of results sections from published or developing manuscripts, and are quoted when appropriate. The

Discussion (Chapter 8) draws considerably on quotations from published or developing manuscripts.

Chapter 2 provides specific information about the language and terminology used in this thesis, an overview of the variety of TMB therapies available and some concerns arising regarding the training programs of TMB therapies, and finishes with an overview of some of the key research concerns that likely arise from gaps in knowledge regarding the training and practice of TMB. Chapter 3 reviews the methods used in the pilot project for this study, and the combined methods employed for the study. The basis for the

combined methods described in Chapter 3 is the first thesis manuscript (1), which explores the foundational theory regarding the use of mixed methods in TMB research.

Chapter 4 comprises a summary of the pilot project results regarding research participation interest and facilitators in the Alberta TMB population. Chapter 5 presents the mixed-methods results (second manuscript (2)): the survey results, the key themes arising from the interviews, and the key interpretations of the survey results in context of the interview results. The qualitative analysis findings in Chapter 5 are the key findings that contextualize the survey data. Further analysis of the interview material, presented in

Chapter 6, provides insight into the nature of practice, with extensive description of the individualization of treatment and treatment decision-making, the evolution of practitioners’ therapy provision, and the consequent concerns regarding the application of

TMB research to clinical practice. That material is part of two manuscripts, one accepted for publication (3) and one in development (4). During the interviews, the issue arose regarding having the informed consent of a patient when treatment may involve multiple therapies. This topic is described and discussed in Chapter 7 and in the body of the fifth manuscript in development (5). Chapter 8 begins with a summary and discussion of the results presented in Chapters 5 to 7. Methodological concerns of the study and the consequent limitations of the study results are then presented, followed by the discussion of the study’s significance and implications. Future research arising from consideration of the study results and conclusions complete Chapter 8.

Throughout this thesis “research project(s)” refers to the process of undertaking research as well as to research work undertaken by other researchers. “This study” or “the study” refers specifically to this thesis research project.

Chapter Two: Background

While the thesis introduction provides the context for this study’s research objectives and questions, the background provides the contextual knowledge needed to properly design this study and interpret its results. The following topics are covered:

(a) Definition and type of TMB therapies (Sections 2.1 and 2.2);

(b) TMB training programs (Section 2.3); and

Educational texts within individual TMB professions explain how to apply treatment techniques and routines, how to perform assessments (sometimes in the same document as the treatment methods), as well as other aspects of treatment provision (e.g., consent, business practices, etc.). However, no books, peer-reviewed manuscripts, or other texts were found that carefully describe how practice occurs when experienced practitioners follow one treatment or routine with another, if and how on-going assessment occurs, or how multiple therapies may be combined during practice.

Therefore, these issues were explored using qualitative methods to fill critical gaps in the literature. The findings will inform the thesis objective about improving TMB research through consideration of how clinical practice occurs.

2.1 Defining Therapeutic Massage Bodywork and related terms

Therapeutic massage bodywork (TMB) describes any therapy that uses one or more massage techniques (kneading, stroking, pressing, vibrating, holding, etc.) of the soft tissues, viscera, and joints as the primary means to achieve therapeutic effects (2).

This broad definition encompasses the many different forms of massage included under

the rubric complementary and alternative medicine (CAM). The definition excludes forms of health care, such as chiropractic, nursing, and acupuncture, that are physically applied to the patient and that may include TMB techniques during treatment but that do not use massage techniques as the primary form of treatment application. The reason for the exclusion is that while many forms of healthcare include TMB techniques in their training, the expected scope, knowledge base, and integration of TMB in those therapies may produce very different practice, and therefore potentially also different research issues, than therapies with a primary focus on treatment via massage. The intention of this study is to focus on areas relevant to the continued professionalization and increased research success in TMB.

Four terms used in this field have potential multiple meanings that can create confusion: therapy, treatment, technique, and massage therapy. In this thesis, therapy will refer to a TMB type, such as craniosacral therapy or shiatsu. Treatment will refer to the provision of therapy. Some therapy names incorporate “technique” to imply a type of therapy, such as Alexander Technique™, or neuromuscular technique. In this thesis, the term technique will only be used when referring to the specific, individual ways of executing a particular treatment stroke, skill, or procedure.

Massage therapy is a distinct TMB therapy, discussed in detail in Section 2.3, and will only be used in this thesis to refer to that particular type of TMB therapy. The term

“massage therapy” can also refer generically to any form of massage used for therapeutic purposes, which is the origin of the term “therapeutic massage” used throughout this thesis. Specific cultural groups may use “massage therapy” to refer to their own indigenous form of TMB, for example, a Chinese immigrant going for “massage therapy”

but in fact seeking out a tui’na practitioner. In provinces where massage therapy is not regulated, including Alberta, any TMB practitioner may practice as a massage therapist.

Finally, while TMB practitioners carefully delineate differences between the many TMB therapies, consumers often do not discern those differences (D. Beckett, A/Director,

Professional Regulation, Health Services British Columbia, personal communication,

January 5, 2005).

2.2 Therapeutic Massage Bodywork Therapies

In the first U.S.A. national survey on CAM use in 1993, Eisenberg et al. (27) found there is lack of consensus on what “massage” is, with respondents identifying over

100 variants (pg. 248). In preparation for this study I compiled a list of 170 TMB therapies (comprising unique therapies as well as therapy clusters such as three distinctly- named forms of Shiatsu) in North America, most of which are also available in Canada, from governmental, CAM practitioner organization, and individual therapist websites. Of those 170 therapies, 25 are proprietary and trademarked, such as Trager™ and Onsen™, with tightly controlled training standards. The remaining TMB therapies, including reflexology, acupressure, and massage therapy, are not uniformly standardized with respect to their definitions, training components or competencies (which can vary in training length and content by jurisdiction or school decisions), or regulation (28). While shorter programs are usually focused only on a single therapy, longer, non-introductory training programs may include a diverse mixture of introductory level and full competency TMB and non-TMB therapies. Table 2.1 lists the distinct therapies (i.e., not including variants) identified in Alberta at the time of undertaking this study, along with

the specializations that involve additional training (requiring unique protocols or specific competencies) such as maternal or sports massage.

Table 2-1. Distinct TMB therapies identified in Alberta for the survey acupressure Hellerwork™

Alexander Technique™ hot/cold stones massage amma/anma massage Hurley/Osborn Technique™

Applied Kinesiology™ hydrotherapy aromatherapy Jin Shin Do™

A.R.T./Active Release Kinesis Myofascial Integration

Aston Patterning™ Lomi Lomi

Ayurvedic massage Looyenwork™

Bonnie Prudden Myotherapy™ lymphatic drainage massage or manual

lymph drainage

Bowen work (any type) massage therapy

Breema maternal/pregnancy massage chair massage Mitzvah Technique

Chi Nei Tsang myofascial release

Core Bodywork™ myomassology

Craniosacral™ or cranial sacral therapy neuromuscular technique

Esalen™ massage Orthobionomy

Feldenkrais™ Orthotherapy geriatric massage pædiatric massage

Table 2-1 continued

Postural Integration structural integration

PNF (proprioceptive neuromuscular Swedish/spa massage facilitation)

Raindrop Therapy/Technique™ Tantsu™

Rebalancing Thai Massage/Thai Yoga/Nuad Bo-rarn reflexology Tibetan massage

Reflexology Deep Muscle Massage TMJ therapy

Rolfing™ Touch for Health™

Rosen Method™ Trager™

Rubenfeld Synergy™ Method trigger point therapy

Russian massage tsubo therapy shiatsu tui’na

Soma Neuromuscular Integration Visceral Manipulation™ sports massage Watsu™

St. John Neuromuscular Therapy Zero Balancing™

Historical connections can be traced between many TMB therapies (29). For example, stone massage uses strokes that are based on Swedish massage (30), which in turn is based on both medieval European techniques of healing and Chinese massage

(properly called tui’na) (31). Similar treatment techniques also arose in unrelated therapies, independent of the therapies’ origins or the conceptual constructs and beliefs

on which the therapies are based. For example, Mitzvah (modern Jewish massage) and

Jin Shin Do™ (Asian energy meridian-based massage) use similar forms of connective tissue manipulation (32). While the historical context of some therapies is documented

(e.g., Watsu™ (33, 34)), other therapies require extensive knowledge or research of both the theory and treatment application to recognize the roots of the work (e.g., Craniosacral

Therapy™ (root: osteopathy) or Bowen therapy (root: shiatsu and tui’na)). Thus, few of these therapies exist in isolation and many have influenced each other (29).

2.3 Training in TMB Therapies

TMB therapy training may occur through any of the following types of education:

• apprenticeship;

• introductory courses (a sampling of some techniques from a therapy);

• training courses (certificate programs of a few hours to hundreds of hours)

focused on a single therapy;

• extensive training and education programs (certificate or diploma programs

that run from about 50 hours to 3000 hours) that may include one or more

types of therapies and which may also include introductions to additional

therapies; or

• self-study.

Many TMB therapies can be learned through more than one of those routes.

Throughout this thesis, the term training will be used to refer to any of the educational routes through which a practitioner learns TMB skills, unless another term such as education is more contextually appropriate. Within each therapy training program, a

practitioner learns the therapy’s foundational theories and the therapy’s treatment techniques, the specific methods of therapy application.

Massage therapist surveys conducted by a few massage therapy associations

(NHPC (19), American Massage Therapy Association (AMTA) (35, 36), and the

National Certification Board of Therapeutic Massage and Bodywork (NCBTMB) (37)) show that practitioners are usually trained in multiple therapies. However, while the published survey results signal that a majority of practitioners are trained in multiple therapies by reporting per listed therapy the percentage of practitioners providing the therapy, none have described the training profile of an individual practitioner.

Few TMB therapies are taught in fully standardized training programs. Most training programs have different combinations of educational components and competencies, making an understanding of the therapies very complex. In general, shorter training programs tend to be focused on a primary therapy or basic service specialization of a therapy (e.g., geriatric or maternal massage), while longer programs may include advanced application techniques or combine multiple related TMB therapies. Of the

TMB therapies, massage therapy (describing basic Swedish to advanced “therapeutic” or

“remedial” massage therapy) is the most commonly available and researched form in

North America. A review I conducted in 2007 (unpublished) of the training programs of

64 Canadian massage therapy schools, the regulatory standards of British Columbia (38) and Ontario (39), and the competency standards of the NCBTMB in the U.S.A. (40) indicated that all massage therapy training programs, from basic Swedish massage to advanced “therapeutic” or “remedial” massage therapy, are based on five core TMB components consisting of Swedish massage techniques as well as introductions to or full

competency training in the use of essential oils (aromatherapy) during massage, hydrotherapy, stretching techniques, and trigger point therapy.

Massage therapy training programs may incorporate additional therapies.

Common additional therapies include acupressure, shiatsu, fascial manipulation, reflexology, hot-stone massage, Thai massage, cranial sacral therapy, and non-TMB therapies such as reiki, energy work, and movement instruction. For example, of a 500- hour myomassology program, 276 hours were clinical training that included

“myomassology massage [based on Swedish massage], aromatherapy blending, reflexology, craniosacral therapy, chair massage, acupressure, Chinese cupping, body mechanics, paraffin therapy, tui’na Chinese massage, pregnancy massage, and information on Bach Flowers, hydrotherapy, cleansing and detoxification” [retrieved

August 13, 2011 from www.aromatica.ca/course-myomassology].

Non-massage therapy training programs (i.e., TMB programs that do not include the five core “massage therapy” TMB components listed above) may also incorporate a broad variety of TMB competencies. “Natural Health Practitioner” programs may include an eclectic variety of TMB and non-TMB therapies because there are no competency standards or independent certification organizations for such a designation. Trademarked

TMB therapies, however, have highly controlled training competencies and lengths, and usually focus on only one or a combination of select therapies.

2.3.1 External influences on TMB therapy training: Regulation

Regulation of a health profession includes creating uniform competency and quality assurance standards for the regulated jurisdiction. Regulation therefore has a direct impact on the educational standards in that jurisdiction. Regulation creates an additional impact on practice through mandatory continuing education requirements.

Regulation does not prevent the inclusion of additional therapies or techniques beyond those included in the competency standards for the jurisdiction.

Massage therapy is partially regulated in North America. Three Canadian provinces self-regulate massage therapy at either 2200 hours of training (Ontario,

Newfoundland & Labrador) or 3000 hours of training (British Columbia). Massage therapy in these provinces is defined to include a core set of TMB therapies commonly used in a massage therapy practice environment. Thirty-nine states in the U.S.A. have regulatory standards for massage therapy, with requirements ranging from 300 to 1000 hours. The remainder of the North American provinces and states have no regulated standards. Multi-level certification systems (e.g., Massage Therapists at 500 hours training and Remedial Massage Therapists at 1000 hours training) are being developed for the U.S.A. An application for regulation using a three-level system was under consideration by the Alberta government during the data collection phase of this study

(the Alberta government chose to regulate massage therapy, but standards had not yet been set as of March 7, 2012). Quality assurance standards usually include mandatory continuing education requirements. These requirements can often be met by undertaking training in specialized areas of treatment or in additional TMB therapies.

Other TMB therapies are not regulated in North America. In British Columbia,

members of the Shiatsu Therapy Association of British Columbia and the British

Columbia Association of Aromatherapists can use the protected titles of “Registered

Shiatsu Therapist” and “Registered Aromatherapist” respectively. These have been provided under the Occupational Title Protection section of the British Columbia Society

Act, on condition that the organizations have and maintain competency standards control and transparent disciplinary procedures (41).

2.3.2 External influences on TMB therapy training: Professional organizations

Practitioners often form self-interest organizations—associations or societies—to advocate and promote on behalf of the members in their jurisdictions. When regulation does not exist in a jurisdiction, there is no mandatory control over a practitioner’s education or competency standards nor continuing competency requirements. Most organizations therefore also provide a number of the same functions as regulatory bodies by having minimum training competency requirements, continuing education requirements as part of quality control (often encouraging additional training in TMB therapies and treatment specializations), and disciplinary procedures linked to codes of ethics/conduct. Some organizations even have entrance exams. Organizations exist for most TMB therapies; some represent multiple CAM therapies including several TMB therapies, such as the Natural Health Practitioners of Canada (NHPC) and the Examining

Board of Natural Medicine Practitioners (EBNMP). Trademarked therapies have organizations that tightly control the therapy’s competency standards. Practicing a trademarked therapy often requires membership in the therapy’s organization.

2.4 TMB Research Methodological Issues

As mentioned at the beginning of the Introduction (page 1), Menard, Hymel, and

Cawley, have called for higher quality research in TMB, and all have specified that research projects should, at a minimum, describe the training and experience of the TMB practitioners providing the research treatments and the details of the protocols including how training and adherence monitoring are managed (12-15). Sections 2.2 and 2.3 indicate that multiple therapy training is the norm within TMB professions. Yet, few articles report practitioner credentials; examples are still rare and appear predominantly in TMB graduate theses (42-44). Reporting or discussion of the other points they raise remain limited, though calls continue for better design and disclosure of practitioner details, such as in the Cochrane review, “Massage for mechanical neck disorders” (8).

Other research design problems that are often identified for improving TMB research are issues typical to CAM research projects generally (16-18). These issues include clinical treatment usually provided as individualized to the patient, lack of clear or appropriate outcome measures, blinding of patients and practitioners, implementation of sham or comparative treatments, treatment protocol development, and understanding of placebo effects relevant to the field.

2.4.1 TMB research methodology issues arising from training and experience

Given the wide variability in practitioner training (19, 35, 37, 45) and missing information on the effects of multiple therapy training or experience on practice—and therefore also on research outcomes—the following may be factors negatively influencing research outcomes:

(a) A lack of comprehension of the myriad forms of TMB, including how several

TMB therapies may have been part of a single training program;

(b) Assumptions regarding the definition or provision of a given TMB therapy (e.g.,

an expectation of uniformity of “massage therapy” treatment by local

practitioners, no consideration that training in multiple therapies may change the

provision of a specific TMB therapy);

choice in clinical TMB practice relative to research TMB treatment protocols;

(d) The potential impact of practitioner training and experience on the results; and

(e) The possible impact of patient expectation on the outcomes.

Understanding the influence of these factors on research results is needed to develop more effective TMB research. This study will provide a foundation for TMB research to explicitly address those knowledge gaps, and provide perspective on what information may still be needed to address practitioner effects in TMB research.

Chapter Three: Methods

This chapter begins with the methods used in the pilot project for this study; the remainder of the Chapter is devoted to the principal study. The first published manuscript associated with this research explores and discusses the value of combined methods research specific to the TMB professions (1). While it provides the foundation for the study, only Section 3.2 of this chapter, a description the theoretical underpinnings of combined methods, draws directly from it, as the remainder of this chapter focuses on the specific methods used in the pilot project and in this study. All results of the study

(Chapters 5 to 7) derive from the same research process described below. When results are based on specific data subsets, the data and analyses used will be described in detail in the applicable chapter.

3.1 The pilot project

The study began with a pilot survey to ascertain the level of interest within the

TMB professions for participating in research, and to identify factors that could limit such participation.

3.1.1 Jurisdiction

The pilot project was run in the Greater Calgary Health Region, which includes the city of Calgary, the outlying semi-urban commuter communities, and the region to the west including the rural communities of Canmore, Banff, and Lake Louise and their surrounding areas. This area was chosen for its convenience, clear demarcation, and inclusion of both urban and rural environments that would therefore include types of

practitioners expected to be found throughout the province, the geographical scope of the main project.

3.1.2 The questionnaire

The pilot project questionnaire questions were based on the experience of Dr.

Verhoef (questionnaire development, and research in the Greater Calgary Health Region), and Mr. Porcino (TMB practitioner contact and research issues). The questions were to assess:

1) The geographic area TMB practitioners work in, to establish whether there were

rural/urban differences in responses;

2) The best process to recruit TMB practitioners for surveys (e.g., notices at work,

advertisements in industry and organization magazines, direct emails or postal

mail outs, word of mouth);

3) The best mode of distributing questionnaires to this population, (e.g., mail-outs

through organizations, distribution at spas to workers, online surveys);

4) Preference for on-line or mail-in questionnaires; and

5) The level of active support for research in the TMB professions (e.g., participate

in profession-relevant surveys, talk to colleagues).

Appendix 2 comprises the pilot project questionnaire, slightly reformatted to fit the thesis margins (page 141).

3.1.3 Recruitment

The website portal (detail, Section 3.4) was created at the time of the pilot project, to provide information about the project, and to provide a link to the online questionnaire during the survey period. The on-line questionnaire, created through the on-line survey service Survey Monkey, was identical in content, and as much as possible in layout, to the mail-in questionnaire.

An advertisement was purchased in a popular Canadian CAM magazine with free- of-charge Alberta distribution, directing TMB practitioners to the website. TMB association magazine/newsletter advertising (Natural Health Practitioners of Canada

(NHPC) and Massage Therapists Association of Alberta (MTAA)) informed readers to watch their mail for the questionnaire, and included the website link and project contact phone number. Rural spas (more likely to not have association-affiliated members) were sought on-line, through the yellow pages of the rural communities, and in tourism advertising for the rural communities. Seven rural spas were identified and received a letter of introduction to the project with a follow-up phone call. The letter outlined the project and two options for participation:

1) Distribute questionnaires to their workers;

2) Post an information poster with tear-off tags of the phone number and website

address.

Seven organizations with TMB practitioners in the Greater Calgary Health Region

(Table 3.1) were contacted with personalized letters outlining the project, and a request for support in mailing out questionnaires to their members in the study region. Funds for postage, labels and time spent labeling envelopes were provided.

Table 3-1: Organizations contacted for the pilot project Organization

• Natural Health Practitioners of Canada (NHPC)

• Massage Therapy Association of Alberta (MTAA)

• American Polarity Therapy Association

• Bowtech (Bowen)

• Reflexology Association of Canada (RAC)

• International BodyTalk Association

• Canadian Association of Specialized Kinesiology

The survey was run from March 15 to April 30, 2007. Due to one participating

organization’s logistics mishap, the online survey access was extended by two weeks to

allow more response time. Mail-in questionnaires were received until the end of June.

Percentages and Chi-squared analyses were used for the results.

3.2 Study research design: Combined methods

A combined methods approach, also described as mixed methods, was used for

this study. Typical definitions of combined methods research concern the combination of

quantitative and qualitative methods within one research project (46, 47). Combined

methods research requires understanding both quantitative and qualitative research

methods, the underlying theory, and the perspectives or paradigms (ways of viewing the

world) of each, as well as an appreciation of how new knowledge may become available

when the two are brought together within a single research project (46-49). “Combined

methods is particularly appropriate for TMB research because the research approach allows more than one facet of an issue to be studied within a single project. This is important because TMB therapies are complex systems of treatment that: (a) lack proven modes of action; (b) create individualized treatment using multiple approaches of engagement with patients; (c) involve considerable patient-practitioner interaction time, and (d) are sometimes based on differing foundational belief systems. Treatment outcomes may depend on interactions between these four factors.” (1)

In this study, the combined-methods focus consists of the relationship between quantitatively assessed type(s) and amount of TMB training and the qualitatively assessed nature and process of TMB treatment provision, including clinical decision- making. Thus the design incorporated a combined methods lens from the early stages of development. The description of TMB providers (Objectives: Question 1, page 7) is addressed using a survey, described in detail below. However, questionnaires cannot explain how multiple therapies are used and therapeutic decisions are made during a therapeutic session (Objectives: Question 2 page 7). That issue is best addressed using a qualitative approach, which can provide a comprehensive description of a phenomenon

(50). The qualitative interview data provide and augment contextual understanding of the questionnaire results. The interviews were also used to clarify results from the questionnaire. The questionnaire and interview methods will be described separately below.

3.3 Jurisdiction: Alberta, Canada

There were several reasons for choosing Alberta as the jurisdiction for this study.

(a) Convenience: As the research base was the University of Calgary in Alberta,

convenience and reduced costs by working locally were a consideration. It was

also assumed that TMB practitioners would more willingly participate in research

about them from a university within their province than they would in research

coming from out of province.

(b) Numbers of Practitioners: At greater than 5000 TMB practitioners, Alberta has

one of the highest number of known TMB practitioners. This establishes Alberta

as an ideal locale for this project. Alberta’s TMB practitioner organizations are

also easy to locate. Regulation of massage therapy in British Columbia, Ontario,

and Newfoundland & Labrador has created discrete, at times covert, networks of

non-registered TMB practitioners who are more difficult to identify and contact;

many regional groups and organizations are low-key and not easily accessible.

Québec has a large practitioner base, but the practitioners are represented by a

multitude (>40) of small provincial, regional, and school alumni organizations,

not to mention the national and international organizations, making contact very

complex. In Québec, the questionnaire and interviews would also have to be

offered in French, increasing the complexity and cost of the project. Finally, other

provinces have smaller practitioner bases, lessening the potential validity and use

of the research results.

and free-market influences of training available in North America, thus increasing

the validity of extrapolating results beyond the province’s borders. Research done

in British Columbia or Ontario, for example, would not be as useful because the

regulated high entrance standards of the dominant TMB profession, i.e., massage

therapy at 3000 hours in BC and 2200 hours in ON, has affected the initial

training demographics (28). While there has been some effort to establish a

uniform Canadian regulatory competency standard based on the BC and ON

standards, more variety in training options and TMB therapies remain openly

available in the non-regulated provinces (28). Non-regulated provinces also attract

more immigrants, including massage therapists from the U.S.A., because the

standards in the regulated provinces are in the range of two-and-one-half to

twenty-two times the massage therapy training hours in all other parts of the

world. (28)

3.4 Study website

All recruitment methods described below in Sections 3.5.1 and 3.6.1 were supported by an information website, www.manualtherapysurvey.ca. The website describes the scope and purpose of the project, the stage of the project (e.g., pilot project, main survey), recruiting status (yes, no), results as applicable, and contact information.

During the recruitment periods, the website encouraged potential participants to request a questionnaire if they had not yet received one and to talk to their colleagues about the

project. During the pilot project, a link to the online version of the questionnaire was available.

3.5 The survey

3.5.1 Recruitment

Any health practitioner who practiced one or more TMB therapies as a primary service was eligible to participate in the survey. Recruitment focused on practitioners who primarily identify as TMB providers through CAM and TMB organizations or at their place of employment in a spa. Other healthcare providers who may employ TMB therapies during the provision of their services (e.g., Traditional Chinese Medicine doctors, physicians, nurses, naturopaths, osteopaths, and chiropractors) were excluded because these providers’ training experience and use of TMB during clinical practice will likely be different from the TMB-focused CAM practitioners that are the subject of this study.

Questionnaires were distributed through multiple channels. Several large provincial, federal, and international CAM and TMB practitioner organizations were identified as having TMB members in Alberta. Table 3-2 outlines the number of practitioners who could be contacted (known email or postal address) as of June 1, 2008, either via the large organizations (Natural Health Practitioners of Canada (NHPC),

Massage Therapy Association of Alberta, Alberta Registered Massage Therapists’

Society, and Examining Board of Natural Medicine Practitioners) or through on-line organization practitioner directories. The largest organization, the NHPC, specifically requested that the survey be distributed in the summer to minimize conflict with their

organization’s work cycles. This was agreed to in order to facilitate distribution, even though it was recognized by the researchers it would likely have a detrimental effect on the questionnaire return rate.

Table 3-2: Organizations with members in Alberta

Organization Number of contactable

members in Alberta

• Natural Health Practitioners of Canada (NHPC) 4171

• Massage Therapy Association of Alberta (MTAA) 650

• Alberta Registered Massage Therapists’ Society (ARMTS) 279

(includes the Remedial Massage Therapy Association)

• Examining Board of Natural Medicine Practitioners (EBNMP) 60

• Bowtech (Bowen) 38

• Reflexology Association of Canada (RAC) 37

• Orthobionomy Association of Canada 11

• The Rolfing Guild 9

• Jin Shin Do Foundation for Bodymind Acupressure™ 7

• Onsen International 6

• Dorn 6

• Hurley Osborn Practitioner’s Association 5

• The Feldenkrais Guild 5

• Canadian Trager Association 5

• International Institute of Applied Health Services 3

Table 3-2 continued

Organization Number of contactable

members in Alberta

• Society of the Teachers of the Alexander Technique 3

• BC Association of Practicing Aromatherapists 1

• The Guild for Structural Integration 1

• Canadian Federation of Aromatherapists 1

• Zero Balancing 1

Total 5299

The larger organizations (i.e., > 40 contactable members) mailed the questionnaires to their members on the researcher’s behalf. The researcher directly mailed the questionnaires to the members of the smaller organizations. Addresses for those practitioners were gained directly from the online member directories or by correlating the member name and business name with published addresses in other directories such as phone books and business websites; none were returned as undeliverable. The mailed questionnaire package included: (a) the cover letter comprising the letter of invitation, a request to encourage colleagues to participate, a notice of the participation draw for one of three $50 book certificates, and a request/volunteer form to participate in the research interviews; (b) the questionnaire; and

(c) a postage-paid addressed return envelope for the questionnaire. The complete written components can be found in Appendix 3 (formatting slightly adjusted to accommodate the thesis formatting requirements, page 143).

All practitioners were contacted for participation using a modified Dillman (51) process: (a) an email announcement of the survey was sent out the morning of mailing the questionnaires; (b) questionnaires were mailed out; (c) a follow up email was sent two weeks after mailing the questionnaires; and (d) a final email was sent four weeks after mailing the questionnaires. The larger organizations distributed the emails to their members while direct researcher–practitioner contact was used for the remaining organizations. The announcement and follow-up emails can be found in Appendix 4

(page 151). Advertisements in the NHPC and MTAA newsletters were purchased for reminder purposes, especially since only about 80% of their members had email for receiving the email communications. To prevent mailing multiple questionnaires to one practitioner, only members of the small organizations who did not have membership in the large organizations were sent survey packages, reducing the contact number to 5233.

Thirty-four spas advertising TMB services in Alberta were contacted by phone regarding possible TMB practitioner employees who might not be members of organizations. After discussion regarding the project, eligibility criteria, and the purpose for contacting the spas directly, managers at all but three spas confirmed their employees were members of organizations. The three spas where the managers were unable to confirm employees’ membership status agreed to distribute questionnaire packages to their employees, and to post a one-page reminder of the survey in a work area.

Confirmation of receipt, distribution of the questionnaires, and posting the participation reminder were confirmed one week after couriering the materials to those spas. Sixteen practitioners received the survey package through this distribution channel.

3.5.2 Data collection

While surveys of TMB practitioners have not been conducted before, massage therapy practitioner surveys have been undertaken by the NHPC, the CMTO, and the

AMTA (19, 20, 36, 45). The questionnaires used in those surveys were reviewed before developing the questionnaire for this survey. This study’s survey questions were focused on the training and practice items of this study’s objectives (Question 1, page 7). The questionnaire underwent two rounds of pilot testing with 10 TMB practitioners each round, to maximize comprehension, usability, and outcome validity, and minimize problems that could reduce participation. Additionally, during the second round of pilot testing two practitioners did a “think out loud” process (52), which involves speaking their thoughts about the questions, their responses to the questions, or observations about the questionnaire in general to the researcher as they complete the questionnaire. The feedback from all the testers was carefully evaluated and appropriate changes made to the questionnaire. The final questionnaire package, including the letter of invitation, draw participation form, interview volunteering form, and the questionnaire comprise

Appendix 3 (page 143).

The prize draw and interview volunteer forms were immediately separated from the returned questionnaires and regularly shuffled to prevent possible association with the corresponding survey. The questionnaires were numbered in the order they were received, and the data entered into an encrypted SPSS database (53) for descriptive statistical analysis. Comments written on the questionnaires were documented verbatim in a Word document. They were first clustered by question, then by concept, and reviewed after the statistical analysis to see if they provided further understanding or

insight into the questionnaire results.

3.5.3 Analysis

In addition to a few practitioner demographics, the questionnaire covers three main topics: (1) practice descriptors including clientele gender, work place and type; (2) TMB training details; and (3) some questions regarding focus of treatments provided by them and reasons for treatment access (the questionnaire is part of the Appendix 3 material, page 143). Descriptive statistics were used to examine these topics. Comparison analyses within and between these categories were conducted using Chi-squared tests. Three relationships were chosen as the most likely comparisons that could indicate either practitioner preference, market-related influences, or both on therapy training choices and service provision: (1) practice type (home clinic, medical clinic, spa, etc.) and therapies trained in; (2) practice type and municipality population; and (3) therapies trained in and municipality population.

3.6 TMB practitioner interviews

3.6.1 Recruitment

Requests for interview participation were highlighted in the questionnaire cover letter and on the manualtherapysurvey.ca website. The interview application form included with the questionnaire requested the person’s name, phone and email contact, municipality(s) of practice, type of practice (solo or multi-person clinic, spa, club, etc.), and the TMB therapies practiced. To increase the volunteer recruitment rate, all interview volunteers were entered in a prize draw for two $50 gift certificates.

Volunteer forms were collected simultaneously to the questionnaires, but selection of interview participants did not begin until an initial analysis of the questionnaire data had be done, to determine if questionnaire-specific questions would need to be included in the interviews. From the volunteer TMB practitioners providing multiple therapies, participants were purposively selected to provide maximum variation for the following variables: gender; urban or rural practice setting; practice type such as spa employee, sole clinic proprietor, or multi-disciplinary clinic; and differing TMB therapies, including therapists not practicing massage therapy. Early selections ensured variation in practice setting and types of therapies, while later selections filled in gaps in gender, practice type, and therapy type. Males and non-massage therapists were interviewed at a higher proportion than occurs in the population to ensure that their perspectives were represented within the data. Each interviewed volunteer received a $40 honorarium to compensate them for their time. Not all volunteers were interviewed, a point clarified in the response to each volunteer.

Contact for participation and interviewing began once an initial analysis of the questionnaire data had been done, so that potential knowledge gaps or questions arising from unexpected or surprising results could be addressed during the interviews.

Recruitment for interviews continued until data saturation was considered attained (see

Data Analysis, below).

3.6.2 Data collection

The researcher contacted potential participants to discuss participation and arrange for the interview. Participants would receive the consent form at least three days before the interview, and each interview began with a discussion of the consent. Once consent was received, the digital recorder was turned on, and the semi-structured interviews would begin.

The consent and final interview guide can be found in Appendix 5 (page 154).

The interview questions were chosen to address the study’s Objectives, as per study

Question 2 (page 7). The interviews were semi-structured (54, 55), thus the open-ended interview questions provided an initial guide for logically progressing—where one topic emerges from the last—through the training and decision-making components of clinical practice, concluding with the exploration of the value of TMB research in TMB clinical practice. Other questions and ideas could emerge from the dialogue between the researcher and the participants.

The participants were interviewed at their place of preference if possible, or by phone. A transcriptionist transcribed the interviews verbatim, and the researcher verified them in their entirety for accuracy by reading the transcripts while listening to the tapes.

The transcriptions, using coded identifiers for the participants, were used for data analysis.

3.6.3 Analysis

The computer program ATLAS.ti (56), was used to organize and assist content analysis of the qualitative data. A qualitative descriptive analysis was done (50, 57).

Qualitative description involves creating a low inference understanding and explanation of a phenomenon, in which interpretation of the data by the researcher occurs (the nature of qualitative research) but the goal of the analysis is to straightforwardly describe the salient features of the data rather than exploring for conceptual meaning or motive, or integrating the results into previous theory (50, 57). Qualitative descriptive analysis thus proceeds by creating codes (concept labels) that directly reflect and use the participants’ perceptions and language. The codes are clustered into groups that represent conceptual themes that explain aspects of the phenomenon (57, 58). In this project the phenomenon was the process of practice for TMB practitioners trained in more than one TMB therapy and the themes represent different aspects of the process of practice or becoming trained in TMB. During the analysis, the predominant analytic techniques consisted of making comparisons and exploratory questioning. Asking questions helped to further understanding of the data, but also ensured that reflexivity was maintained by questioning the expectations, assumptions, and experiences of the researcher relative to the data (59).

Analysis began after the first interview and was ongoing throughout data collection. As analysis progressed, the coding scheme was progressively modified and refined. The interview guide was modified based on the first two interviews and further refined after the tenth, to better explore the developing material. Interviewing continued until data saturation was reached, the point at which new data did not contribute new ideas, concepts, or distinct variations to the findings (59).

The descriptive material regarding the process of practice was particularly rich, and beyond the scope of the first manuscript, which only examined the relationship between the survey results and relevant descriptions of training and practice. A secondary analysis was therefore conducted to better understand the complex nature of TMB practice and potential influences on practice. This material was developed into a separate article (3), with the results presented in Chapter 6. This in-depth exploration of the process of TMB practice began with the previously developed codes relating to the process of practice. “Conceptual similarities and differences for similar practice phenomena were sought between interviews. Codes were combined or split as better understanding of participants’ concepts developed, and patterns and gaps were sought within the data. Reanalysis of several codes and code clusters was applied as analysis progressed to deepen understanding and prevent bias from researcher expectation by the necessity of keeping close to the data underlying the codes. The themes arising from the code clusters were refined to provide the best fit to the data. Codes and themes were finalized after no new variations [about,] or insights into, the [nature or provision of

TMB] were found in the data.” (3) The resultant coding and themes were similar to the original analysis, but more accurately reflect the focus of this particular exploration into the delivery of TMB service.

3.7 Questionnaire–interview integration

The final analysis step was bringing the results from the quantitative and qualitative components (questionnaire and interviews) together to investigate how they each could explain or complement the other’s material. Investigation of the influences of

multiple therapy training and practice were the focus at this stage, along with exploration of the potential meaning on the research of TMB involving practitioners trained in more than one therapy. This process entailed questioning whether any given quantitative or qualitative result added to or influenced the understanding or interpretation of results from the other study component. For example, interpretation or understanding of the qualitative result that all treatment is individualized could change or be enhanced when considering the survey result that therapists were trained in a median of eight therapies.

Each possible influence was also considered for its relevance to addressing the study objectives. In this way, the final interpretation of both the quantitative and qualitative results express a cohesive understanding of the results from both methods.

Chapter Four: The Pilot Project

As mentioned earlier, the pilot project was to assess factors that could help and hinder participation in the main thesis study. This section will describe the outcomes, significance of the outcomes, and decisions made about the main thesis study based on the results. While no manuscript was produced, the results were presented at three organization conferences: the Canadian Interdisciplinary Network for CAM Research, the

Canadian Society for Epidemiology and Biostatistics, and the NHCP (60-62).

4.1 Questionnaire Distribution

A total of 259 questionnaires were returned from the1516 questionnaires sent out.

Four of the eight organizations contacted engaged in dialogue regarding distribution of the questionnaire; only two followed through to distribution, one national (1468 distributed) and one local to Calgary (15 distributed). The organization with 1468 questionnaires to distribute was in the middle of spring membership renewals (over 3000 members involved) during the survey period. The low priority for the survey resulted in their questionnaires being mailed out two business days before the deadline for survey submission or participation on line. The organization sent out emails announcing a two- week extension, and the website listed the extension as well. Thirteen respondents commented on the timing, however it is difficult to gauge the degree of impact the lateness had on the response rate (16.9%). Thirty-three questionnaires were handed to workers in two spas that agreed to participate; seven respondents resulted. One spa agreed to post a poster, but no responses appear to have come from the poster. Supporting research is not a priority for these groups; effort must be made to ensure engagement in

the process and follow-through.

4.2 Place of work

Twenty-eight questionnaires came from rural practices; six of the seven spa practitioners who received the questionnaire through distribution at work indicated that no other contact occurred. Therefore spa delivery does contact practitioners who might otherwise be missed. Aside from having received the questionnaire at work, and a preference for receiving questionnaires at work, there were no significant differences between these spa workers and other rural respondents. There were also no significant differences between urban and rural participants.

4.3 Learning about and participating in surveys

The vast majority of respondents (83.3%) want to learn of questionnaires by receiving them or receiving links to web surveys in the mail. 36.1% also want e-mail notification, and 30.2% want organization newsletter advertising. However, only 8.0% indicated noticing the newsletter advertising. Both the organization newsletters (to 5600 members) and public magazine (>2500 in Calgary) were distributed in early April.

Advertising in organization newsletters and public magazines is not effective: there were no website visits until the surveys were distributed.

4.4 Research interest and written comments

Despite the late distribution, to which some attributed their negative responses about talking about or recommending participating in the questionnaire, 59% of respondents indicated talking to or interest in talking to their colleagues about this survey.

78.6% did or would recommend participating in this survey. 88.1% felt that the briefly described demographics and practice descriptors survey that would follow (the thesis study) would be useful, 5.5% did not, and the other 6.1% did not recall the demographics and practice descriptors project mentioned in the cover letter. Some of the non-support responders also did not recall it, as evidenced by negative comments about this survey

(e.g., “useless questions,” “why doesn’t my organization already know this”—not comprehending that their organization was not doing the survey—, “waste of paper”). At least eight respondents commented on regulation and organization matters. Twelve questionnaires included specific messages of encouragement and appreciation. Because participants may predominantly represent research-positive practitioners, they may not represent the total respondent body.

4.5 Survey size and response channel

46.6% of respondents want questionnaires to be no longer than 4 pages; an additional 23.7% would prefer 2 pages or fewer. Thus, to maximize response rates, the total questionnaire size should be 4 pages or fewer (which would also accommodate those 29.6% of practitioners willing to answer 5 or more pages of questionnaire). For the mode of receiving/completing questionnaires, 53.4% prefer mail-in, 40.1% prefer on-line, and the remainder have no preference.

4.6 Significance and implications for the thesis study

As a whole, this survey was successful. It provides clear guidance to researchers who must work through organizations and dispersed practitioner communities to reach

CAM practitioners as well as specific recommendations for the implementation of the thesis study. Time factors with the organizations are important, as is having diverse distribution channels. Minimizing the burden on the organizations and spa employees doing the distribution is extremely important, as is close consultation on their work cycles and in doing follow-up, as the research project will not be a priority for either organizations or spas. The value of advertising to increase participation or awareness of research projects recruiting within the TMB professions is questionable, and was used minimally for the thesis study. Though both hard-copy and web response are desired as response vehicles (59.1% and 46.8% respectively, non-exclusive) other literature indicates that providing only a single response vehicle is the most effective (63).

Therefore only a mail-in questionnaire (highest desired format) was used for the main study. Of the 276 pilot project respondents, 19.0% indicated they would not complete surveys longer than two pages and only 30.8% would answer a survey longer than four pages. The thesis study questionnaire was therefore kept within four pages.

Implementation of these results for the main survey was used to maximize the questionnaire return rates.

Chapter Five: Combined-Methods Exploration of the Training and Practice of TMB

This chapter contains the combined-methods findings in which results addressing and integrating answers to both the first and second questions of the Objectives (page 7) are presented. Sections 5.1 and 5.2 are as published in manuscript 2 (2). Additions and clarifications for the purpose of this dissertation to the published material in Sections 5.1 and 5.2 are identified using editorial brackets, to ensure veracity of the quoted material.

Section 5.3 summarizes the key results that arise from the integrative analysis of the results in Sections 5.1 and 5.2. In the interviews, practitioners discussed many topics related to the process of practice, education, and research, but not all topics required integration with the questionnaire results. Those additional results are in the subsequent two chapters.

5.1 Questionnaire results

5.1.1 Response Rate and Demographics

Seven hundred ninety-one completed questionnaires were returned, a 15.1% return rate, with 57% respondents from the NHPC, 14% from the MTAA, 6% from the

ARMTS, and 24% who did not indicate their affiliation. Table 5-1 compares this survey’s results to previously published demographic surveys of the Natural Health Practitioners of Canada (NHPC) (pan-Canada survey of the massage therapy members) (19), the

College of Massage Therapists of Ontario (CMTO) (province of Ontario, Canada,

Registered Massage Therapists survey) (45), and the American Massage Therapy

Association (AMTA) (pan-U.S.A. survey of massage therapy members) (35). Despite the

lower response rate of the present survey, there were no significant differences between the demographics in the surveys’ samples.

Table 5-1. Demographic characteristics, and comparison to past surveys Question Category This Survey NHPC CMTO AMTA χ2 (df),

(19) (45) (20) significance

Participants (n) 791 707 1221 705

Practitioner Male 8.3 14.1 17 15 3.562 (3), gender (%) Female 91.7 85.9 83 85 p=0.313

Years in 8.3 (s.d. 6.2) NP* 5.5 7 0.566 (2), practice (range: 0 to p=0.753

(mean years) 37 yrs)

Mean Hours 20.5 18.2 18.9 20 0.168 (3)

Worked with (sd: 11.6, p=0.983 client (mean range 2 to hours) 80)

Top three work Private clinic 44.0 / 32.2 41.8 / NP* 46 / NP* NC* 3.59(4), settings: Home clinic 34.3 / 29.7 42.2 / NP* 25 / NP* NC* p=0.464

Total / Outcalls 29.7 / 8.6 32.1 / NP* 29 / NP* NC*

Primary** (%)

(Table continued next page) * NP = information not published; NC = information was published, but the categories were not compatible. ** “Total” is based on all places of work per practitioner, “primary” is a reduction to their single place of the most work.

Table 5-1 continued Question Category This Survey NHPC CMTO AMTA χ2 (df),

(19) (45) (20) significance

Municipality Rural/small 38.8 NC* NP* NP* size (%) town settings

(under

50,000)

Small cities 15.3 NC* NP* NP*

(50,000 to

100,000)

Cities over 45.8 49.6 NP* NP* z test of

100,000 proportions:

population z=1.383; p=0.168

Return rate (%) 15.1 39.4*** 18.2 NP* 14.437 (2);

p<0.001

* NP = information not published; NC = information was published, but the categories were not compatible. ***included follow-up phone calls to increase participation.

A number of comments on returned questionnaires indicated issues that may have lowered the participation rate. Nine participating practitioners raised concerns that participation would be lowered because of the summer distribution. Five participants also questioned whether the survey results would be used in some way in the regulation process for massage therapy in front of the Alberta Health Professions Council at the time

of the of the survey.

5.1.2 TMB therapies identified

Respondents were trained in 62 out of the 65 therapies listed in the questionnaire

(no practitioners of Aston Patterning, Looyen Work, or Mitzvah Technique). An additional 15 unique TMB therapies, and 36 non-TMB therapies (e.g., energy work, shamanism, counselling, herbology, movement and stretching therapies, acupuncture) were identified in the ‘other’ category. Of the total 77 TMB therapies (Table 5-2), 22

(Table 5-3) have been taught to more than 10% of the respondents.

Table 5-2. TMB therapies practiced [in Alberta] TMB Therapy Proportion of TMB Therapy Proportion of

practitioners (%) practitioners (%) acupressure * 21.9 Ayurvedic massage * 3.4

Alexander Technique™ * 0.9 Balinese massage 0.1 amma/anma massage * 0.3 Bonnie Prudden Myotherapy™ * 0.1

Applied Kinesiology™ * 7.5 Bowen work (any type) * 3.0 aromatherapy * 22.1 Brazilian toe massage 0.3

A.R.T./Active Release Technique* 9.7 Breast massage 0.9

Aston Patterning™ * 0.0 Breema * 0.3

* therapy included on the original questionnaire

Table 5-2 continued

TMB Therapy Proportion of TMB Therapy Proportion of

practitioners (%) practitioners (%) chair massage * 45.4 Looyenwork™ * 0.0

Chi Nei Tsang * 1.8 lymphatic drainage massage 43.2

Core Bodywork™ * 0.6 or manual lymph drainage *

Craniosacral™ 27.3 massage therapy (Western) * 89.4

or cranial sacral therapy * maternal/pregnancy massage * 52.7

Dorn™ 0.5 Mitzvah Technique * 0.0

Esalen™ massage * 1.3 myofascial release * 44.5 esthetics massage & wraps 1.4 myomassology 0.5

Feldenkrais™ * 1.0 Neuromuscular Technique * 12.0 geriatric massage * 15.5 Onsen™ * 4.0 gyrokinetics 0.1 Rebalancing * 1.3 head massage 0.9 reflexology * 38.2

Hellerwork™ * 0.4 Reflexology deep muscle massage * 4.7 hot/cold stones massage * 30.1 Rolfing™ * 0.9

Hurley/Osborn Technique™ * 0.5 Rosen Method™ * 0.1 hydrotherapy * 43.1 Rubenfeld Synergy™ Method * 0.3

Jin Shin Do™ * 2.8 Russian massage * 2.8

Kinesis Myofascial Integration * 1.4 sexological counselling bodywork * 0.6

Lomi Lomi * 2.9 shiatsu * 45.9

* therapy included on the original questionnaire

Table 5-2 continued

TMB Therapy Proportion of TMB Therapy Proportion of

practitioners (%) practitioners (%)

Sho-Tai™ 6.1 Tibetan massage * 0.6

Soma Neuromuscular Integration 4.2 TMJ therapy * 35.7

*somato-emotional release (SER) 3.2 (temporomandibular joint therapy) sports massage * 0.1 Touch for Health™ * 7.6

St. John Neuromuscular Therapy * 63.2 tsubo therapy * 0.3 strain-counterstrain 0.5 Trager™ * 2.9 structural integration * 0.3 trigger point therapy * 58.4

Suikodo™ 12.3 tui’na * 3.0

Swedish/spa massage * 0.3 Vamu massage™ 0.1

Switzer deep tissue massage™ 0.9 Visceral Manipulation™ * 11.5

Tantsu™ * 0.3 Watsu™ * 0.9

Thai foot massage 1.3 Zero Balancing™ * 0.6

Thai Massage / Thai yoga / 10.6

nuad bo-rarn *

* therapy included on the original questionnaire

Table 5-3. TMB therapies [trained in] by 10% or more of respondents TMB Therapy Proportion of TMB Therapy Proportion of

practitioners (%) practitioners (%) massage therapy (Western) 89.4 TMJ therapy (temporo- 35.7

Swedish/spa massage 63.2 mandibular joint therapy) trigger point therapy 58.4 hot/cold stones massage 30.1 maternal/pregnancy massage 52.7 Craniosacral™ 27.3 sports massage 45.9 or cranial sacral therapy chair massage 45.4 aromatherapy 22.1 myofascial release 44.5 acupressure 21.9 lymphatic drainage massage 43.2 geriatric massage 15.5

or manual lymph drainage pædiatric massage 15.0 hydrotherapy 43.1 shiatsu 12.3 reflexology 38.2 Neuromuscular Technique 12.0

PNF (proprio-neuromuscular 36.4 Visceral Manipulation™ 11.5

facilitation) Thai Massage/Thai yoga/ 10.6

nuad bo-rarn

5.1.3 Total TMB therapies learned

Most practitioners (94.4%) are trained in more than one therapy, with a range of 1 to 40 therapies, and a median of 8 therapies (Figure 5-1). Of the 77 therapies identified, practitioners indicated that for 51 of those therapies, the training programs usually incorporated one or more (median of 3, range 1 to 17) additional therapies. [A Pearson

product-moment correlation coefficient was computed to assess the relationship] between number of years in practice and number of therapies trained in; the correlation is low

(r =0.115, p = 0.001).

Figure 5-1. Range of the number of TMB therapies in which practitioners have trained

5.1.4 Training programs

Participants listed a total of 2,477 training programs with one or more TMB components. There was little consistency in training program lengths for most therapies[.] [T]he minimum length [of training] ranged from 1 to 50 hours, and the maximum ranged from 100 to 4,000 hours. It is probable that for some therapies, including some trademarked therapies (where a narrow range of training length is expected because of the control over educational standards), the shorter training lengths

represent introductory courses that provide limited training in a therapy. The questionnaire did not address the intent or scope of practice associated with each training program.

On the questionnaire, respondents provided a detailed therapy components breakdown for 856 training programs that included two or more TMB therapies. Massage therapy training programs were most common (504 out of 856), with a median of four additional therapies in the training programs. For 641 of the 856 training programs, training program length was provided, which allowed checking for possible similar training programs between practitioners. Of those 641 training programs, 622 were unique programs.

Fifty-nine different TMB therapies were identified within the 856 multiple therapy training programs. Of the 12 therapies that appear in 10% or more of the training programs (Table 5-4), 10 are specialized techniques associated with the practice of massage therapy, either specific approaches (e.g., myofascial release, hydrotherapy) or for specific populations (e.g., sports massage, maternal massage).

Table 5-4. Additional TMB components included in more than 10% of TMB training programs TMB Training Component % of TMB Trainings Including the Component

Trigger point therapy* 38.6

Swedish/spa massage* 35.5 maternal/pregnancy massage 31.4 hydrotherapy* 28.5 chair massage 28.3 sports massage 26.3 manual lymph drainage 23.8 myofascial release 23.7

PNF 22.1

TMJ therapy 20.7 aromatherapy* 11.9 acupressure 11.3

* expected as part of a massage therapy training program, based on a review of massage therapy schools and common competency documents

5.2 Interviews

The 19 interviewees indicated that they practiced between two and ten therapies on their volunteer form. During the interviews most practitioners described being trained in a greater number of therapies. Many participants also described taking introductory courses for additional therapies in which techniques from those therapies are sampled, as

well as taking training in non-TMB therapies. Descriptors of the participants are included in Table 5-5. Number of years in practice was not a selection criterion for being interviewed, but it is included in Table 5-5 to show the range of experience covered by the participants.

Table 5-5. Participant descriptors Gender F = 15; M = 4

Work setting Shared clinic (4), private clinic (6), home clinic (4),

(n, not exclusive) salon (1), fitness club (1), spa (4), chiropractic clinic

(2), medical clinic (1), outcalls/on-site (1)

Years in practice Range 3 – more than 30 years

Number of TMB therapies Median 10, range 5 – 17 trained in

[Self-identified as] non- No massage therapy training: 2 massage therapists Not practicing massage therapy: 1

Number of introductory Mean 2, range 0 – 5

TMB courses taken*

Number who also practice 12. Therapies include: devices, bio-energy non-MTB therapies (n) treatments (e.g., Reiki), nutrition, ingested/topical

products, systems approaches (shamanism,

counselling).

Interview participants expressed complex and widely different responses to the interview questions. Four key themes emerged from the interviews: 1) career and training paths are complex; 2) all treatment is individualized; 3) the practice of therapies evolves over time; and 4) clinical practice and research treatment protocols are different. The first three have components that are relevant to describing the training and practice of TMB practitioners. The fourth theme describes why practitioners reference their clinical experience to distinguish between clinical practice and research-protocol treatments.

Interview results from the purposefully oversampled male and non-massage therapist populations compared to the interview results of females and massage therapists, respectively, did not reveal any differences.

5.2.1 Theme 1: Career and training paths are complex

A number of career and training factors emerged in the interviews related to: the practitioner’s vision of their work before they began their training; the type of practice environment they desired; the availability, time, and cost of training programs; and the pressures that affected subsequent training choices. Participants followed training pathways that were quite variable right from the start of their careers.

Entry into a TMB profession sometimes came from a long-time desire, or the realization that they were finally coming “home” to the profession, often after receiving some TMB or taking an introductory course. For others, it was a progression from previous employment, or an opportunity that enabled a switch into a new profession.

“My nurse friend said… ‘You really are in the wrong profession. … you should do it [massage]’ and got me an interview with the school. And when I did my first body I knew I had come home.” (Practitioner 9)

Some practitioners had pre-conceived ideas of what the style of their first or primary training should be, e.g., focused on injury treatment and prevention relative to general health and well-being treatments, focused on one or a few specific, related TMB therapies, or wanting a program that was “holistic,” incorporating multiple therapies and perspectives. Others instead chose their training programs for pragmatic reasons such as availability or because they could accommodate the training program schedule.

“I found this program in Medicine Hat that you could get the reflexology along with the massage and a whole whack of other stuff, and decided I would give it a try.” (Practitioner 3)

Many training programs incorporate two or more therapies. Several practitioners talked about the inclusion of some “extra” introductory versions of therapies added to their primary therapy training program(s), giving them a couple of extra techniques, or a

“taster” of the other therapies that they could then pursue at a later date. They often incorporate these introductory courses’ techniques into their daily practices, but do not practice under the name of those therapies.

All the interviewed practitioners had taken more training after completing their initial training program. For all of them, the trend was to train in an increasingly diverse and often complex set of therapies over time. They spoke of these training choices as pursuing ideas and therapies of personal interest. This could be to refine or expand skills within their current treatment framework (e.g., remedial service), or to branch out to incorporate completely new therapy forms.

“I often took classes because I felt I needed more, ’cause I didn’t have everything. When I first took massage therapy, I was ready to heal the world… And it doesn’t. I mean, it’s a really nice thing to do, but massage works on muscle, and muscle isn’t the only cause of people’s pain and dysfunction in this world.” (Practitioner 10)

These additional therapies are often referred to as added “tools in the toolbox.” The importance of the toolbox concept became clear as practitioners talked about how and why each treatment they provide is individualized (see also

Theme 2 below).

“… and then I just go through my tool kit and say okay this is what would work best for that. That’s how I fit things together.” (Practitioner 4)

5.2.2 Theme 2: All treatment is individualized

The drawing on tools—the many therapies and techniques practitioners have learned—is an important process of individualizing a patient’s treatment. Practitioners described three increasing levels of specificity in the individualization of treatment delivery: 1) the initial treatment plan; 2) treatment plan variation; and 3) within-therapy variation.

At the first level, an initial treatment plan is developed based on the treatment goals, which come from initial assessments (visual, testing, palpation) as well as dialogue with the clients about their goals, needs, and experiences. A treatment plan outlines the therapeutic intent(s) and treatment(s) for the current session and will map out the planned treatment progression for subsequent sessions, though a reassessment will occur at the start of each subsequent session.

“I start picking up the cues about how they [the patients] are functioning right from the beginning… whatever levels they’re describing at: ‘My shoulder is painful.’ ‘It happens when I’m doing these particular things.’ … I watch how their body is in space and I palpate to see what that feels like as they move those parts of the body that we’re paying attention to at any particular time and I have certain set of movement check-ins that I do with people… then the next level that I work with, I check in with touch to find out exactly what is going on [in the person’s structure]…” (Practitioner 14)

The second level of individualization is treatment plan variation, which occurs throughout every treatment session. Complex feedback loops based on palpation [cues]

(tissue texture, temperature, pliability or tone), visual cues (pain, motion or tension changes, breath patterns), verbal feedback from patients, intuition, and the pressure of time frame are used to gauge the progress of the treatment at any moment. These cues inform awareness of the treatment progress and choices at that moment, suggesting either to continue, to change therapy techniques, or move to a different therapy as they continue to work. They may also pause treatment to do a more deliberate reassessment before continuing treatment. All interviewees, regardless of whether they kept to only one therapy during a treatment (two interviewees) or integrated several therapies into the treatment plan (17 interviewees), described modifying their treatment plans based on in- the-moment assessment.

“If I’ve been working there for a while and I’m not getting any releases there, then I go from the microscopic, you know, looking at that hip for example, and I broaden my scope and go to macroscopic, and I start looking at what’s going on in the low back, what’s going on in the pelvis area—on the front of the pelvis— that could be affecting what’s going on in the hip. Or I might need to go down into the leg. So just broadening my scope, and usually the body will draw me to the next place that needs to be addressed.” (Practitioner 12)

“Sometimes I’ve kicked in three different things back-to-back. Depends on how the body is releasing.” (Practitioner 10)

The final layer of individualizing is within-therapy variation. Occurring at any

moment during a session, this may be a spontaneous or planned shift in a particular therapy’s technique, or the integration of another therapy’s technique within the therapy the practitioner is currently applying so as to better address the perceived treatment need.

This level includes the described variations on “listening to the hands,” where practitioners let their hands spontaneously react to tissue cues.

“The more I learn the more I know I don’t know. (laughs) My hands really have to … [interrupting herself] I listen to my hands. My hands tell me where to go next, and they don’t care what definition the technique is listed under.” (Practitioner 10)

Practitioners consider the strength and healing possibilities in their work to be at the second and third levels of individualizing treatment.

“Palpation is probably the most paramount ingredient to use during the course of the treatment. You’re evaluating throughout the course of treatment. You’re evaluating the tissue, the texture of the tone, everything like that in the muscle, determining how it’s responding.” (Practitioner 5)

Some had critical words for practitioners who would tend to practice using routine patterns with little adaptation or individualizing.

“I mean, you know this is the most important thing actually. I mean if you just follow a stupid protocol, you know we just call these people the skin pushers.” (Practitioner 11)

The importance of this complex, adaptive treatment process based on continual feedback from multiple information sources was echoed in ideas expressed about TMB research based on restrictive protocols compared to clinical practice (Theme 4).

5.2.3 Theme 3: Therapy provision will evolve over time

Discussions of within-therapy variation of technique led to a critical question of exploration: does a given therapy, as practiced, change over time from the accumulating experience of a practitioner, including influences from the multiple-therapy integration that happens as part of the process of individualizing patient care? The practitioners expressed two primary, contrary opinions about this. Most asserted that it would be easy to provide a therapy uninfluenced by techniques from other therapies they had learned, or at least with disciplined focus they could do so.

“I think definitely who I am today, all of that has influenced me. But I also know that if somebody said to me, ‘I want a straight fascial work’ or ‘I want a straight sport massage work’ or ‘I want a straight Swedish massage work’, I could do that. I could pull them apart and still do them.” (Practitioner 1)

However, they all acknowledged that practice becomes refined due to practice experience, exposure to different therapy techniques over time, or both, making every practitioner’s application unique. As Practitioner 11 put it, referring to the idea of a generic practitioner practicing a pure, as-trained therapy, “they could, but you know they haven’t learned then.” Several highly self-reflective practitioners speculated that no one fundamentally practices an unaltered therapy. They postulated that any TMB application is likely permanently altered due to practice experience and alteration of perception or techniques from multiple TMB training programs, even if that alteration is not conscious.

“…my hands just can’t operate at the gross [basic] level they used to for massage. When I’m doing a massage... sometimes I’m feeling the lymph and sometimes I’m feeling the energy… some type of an energy cyst, from the Craniosacral perspective. Or I’m feeling that the fluids are not moving from the lymphatic drainage [perspective].” (Practitioner 10)

5.2.4 Theme 4: Clinical practice and research treatment protocols are different

The individualization process underlies the fourth theme, clinical practice treatments are different from the treatment protocols used in research. Based on deduction from published research, practitioners insist there is a distinction between the two, which they dichotomize as either individualized clinical practice or pre-defined, restrictive research treatment protocols.

“Well, I think research is research and practice is practice. Research, you’re setting out to find a specific thing. You’re not trying to …well, you are trying to help someone, but you’re more about how this particular thing affects that person or that pathology or that injury. So you have to be consistent... you can’t change it, or how do you know that it wasn’t one of the other things, right? Practice is a whole different thing. You’re not there to prove to the client that this technique works. It either does or it doesn’t, and if it doesn’t you need to move onto something else, ’cause it’s different for every person. So you’re treating the person, whereas with research you’re researching.” (Practitioner 15)

Underlying these comments is a shared practitioner wariness of the clinical usefulness of research results. As described above, clinical practice treatment normally would be individualized to maximize therapeutic outcome. Commonly, applying a research protocol or using a single approach to a symptom is highly constrained; practitioners may not consider such a treatment process as appropriately responsive to what was occurring in the body. Therefore the relevance of treatments in research seems removed from everyday clinical practice.

“I think that when I’ve seen the early research that’s been done with short stroke and all that kind of stuff for tension and pain management, I think that they are flawed because they do not take in [to account] tissue response. …You would have to do proper assessment of the appropriateness of your approach for the person. As long as you provide massage or any other technique only as a set routine, you always miss the broader lived experience, the organism’s response to what you’re doing. There necessarily needs to be the capacity for ongoing assessment and adjustment of the treatment approach to the person’s response to the treatment as part of getting a proper reading of whether it’s doing what it

should be doing.” (Practitioner 14)

5.3 Integration of the questionnaire and interview results

Combined-methods integration of the questionnaire and interview results largely involves the interpretation of the results or understanding of the consequent implications of the results from each method on the other. The key qualitative-quantitative data integration result, which provides the context for addressing the study’s overarching objective, is that almost 100% of practitioners are trained in more than one form of TMB therapy, and that in clinical practice the norm is to use and combine those therapies, or techniques, from those therapies.

Several additional integration results arise from the integration process described earlier in the Methods section on integration (page 38):

1) Practitioners increase their number of TMB therapies over time through

continuing education, which along with practice experience, will change and

refine a practitioner’s approach and skills in providing clinical treatment;

2) The variability in practitioner training along with clinical experience will

produce practice skills and treatment application unique to each practitioner;

and

3) Many training and educational programs include instruction in multiple TMB

skills and therapies as well as coaching in treatment individualization when

learning each of those different therapies, yet often do not prepare the student

for the effective and deliberate integration of the program’s multiple therapies

during treatment individualization.

Together, these mixed-methods integration results provide key understanding of the relationship between the training, experience, and practice of TMB by practitioners, and provide the needed context for understanding how to optimize research designs for TMB.

Chapter Six: Qualitative Exploration of the Nature of TMB Practice

The qualitative analysis results in the previous chapter addressed the main study objectives. The themes and results presented in this chapter are superficially similar to three themes in Chapter 5, all treatment is individualized (page 57), therapy provision will evolve over time (page 60), and clinical practice and research treatment protocols are different (page 61). Those themes were developed with only enough depth to provide the context for the combined methods analysis of the study results in Chapter 5. They are considerably expanded and deepened in this Chapter’s results: all treatment is individualized, experience evolves the practice of therapies, and treatment during research is not like the clinical treatment of practice. This chapter provide the rich descriptions needed to understand the nature of TMB practice and thus make possible the critical examination of whether TMB practice needs to be considered during the design or interpretation of TMB research. This more focused analysis of the interview transcripts, as described in Methods, Section 3.6.3, page 37, addresses Question 2 of the study

Objectives as well as the secondary questions within Question 2 (page 7).

After re-reading and analysing the data and developing the resultant themes into an initial manuscript draft, it was recognized that the research-practice gap required different background, development, and interpretation relative to the first two themes

(e.g., more focus on the development of expertise within professions, differences between practice and research as perceived by practitioners, TMB practitioners’ research literacy).

Sections 6.1 to 6.3 are as per manuscript 3 (3) on the process of practice, presently accepted for publication. Additions and clarifications for the purpose of this dissertation

to the submitted manuscript material are identified using editorial brackets, to ensure veracity of the quoted material. Section 6.4, based on manuscript 4 that is still under development (4), is about the research-practice gap.

6.1 Participants

While the 19 participants indicated on the volunteer forms that they practiced between two to ten (median 5) TMB therapies, during the interviews, most practitioners described being trained in a greater number of therapies (5 to 17, median 10). Many participants also discussed taking introductory courses in additional therapies, as well as taking training in non-TMB therapies. Sociodemographic and practice descriptors of the participants are in Table 5-5 (previous chapter, page 54).

The interviews with practitioners produced a large, diverse body of data regarding the process of applying TMB therapies. Key aspects of the process of practice are described by the two main themes:

1) All treatment is individualized and

2) Experience evolves the practice of therapies.

The first theme details the physical processes involved in practice, including the subthemes of individualization during assessment, individualization during treatment, and using “toolkit” techniques. The second describes how practitioners’ clinical treatments change because of on-going learning and experience, including the subthemes of exploring treatment options, and exploring therapy integration. [Together, this material fully addresses the primary and secondary questions of Question 2 of the thesis objectives

(page 7).]

6.2 The process of practice: All treatment is individualized

The practitioners were clear that they adapt their assessments and treatments to the needs of each patient from the first moment of arrival at the clinic and throughout treatment, for each treatment session. “Every [patient] has to be individualized, 'cause everybody is different.” (Practitioner 16) [Individualization is an intrinsic part of training in TMB. Even for TMB therapies where routines or patterns of treatment are standard, the practitioners are taught to assess before and during the clinical treatment, and to select or alter the treatment accordingly. These] two inter-related stages of individualization, during assessment, and during treatment, [are explored in detail below].

Assessment, examination with concomitant feedback by means of directed touch, is fundamental to clinical practice. This assessment informs the practitioner’s on-going decision-making and response to the patient’s tissue state or reaction to treatment at any moment. The application of treatment also involves touch. Thus, as the therapy techniques are applied, assessment feedback from the tissue is occurring simultaneously.

Several practitioners described that it occasionally is difficult to differentiate the functions occurring during engagement with the patients’ tissues. This simultaneous assessment-treatment-feedback cycle is an inherent part of the individualization process.

6.2.1 Individualization during assessment

6.2.1.1 Initial assessments

When patients first visit a TMB practitioner for a treatment session, regardless of any previous medical diagnosis, the practitioner conducts an initial assessment that involves learning about the patient’s medical history, the current goals for the patient

visit, the patient’s experience of the problem or reason for the treatment session, and the patient’s treatment preferences. The practitioner will perform a physical exam of the patient that may include visual and movement assessments, range of motion or other function tests, and palpation of the tissues. Practitioners described many palpation cues in the tissues including levels of tension, texture and density, temperature, tone (elasticity in the muscle), adhesions or separation of the muscle fibres or bundles, and initial “ease of movement” through or into the tissues.

Based on the assessment, practitioners develop a session treatment plan and discuss it with the patient. The plan includes their understanding of the patient’s issue(s) and treatment preferences, their planned approach of treatment, and consent for treatment. Depending on the assessment, a plan may include multiple sessions with progressive treatment goals and planned changes to, or inclusion of, different therapies.

Re-assessment occurs at the beginning of each session to determine progress and suitability of the planned treatment. Several practitioners mentioned that they “get to know” a patient’s tissues over time and thus learn how to improve each patient’s treatment plan and care.

Other areas of expertise are brought to bear on the initial assessment, including potential contraindications and experience, as illustrated by the following comment:

“I’m so used to looking at people that they just walk in and I’ll say, ‘Oh-oh-ohhh, it’s your lower backside. Ouchy! Now, that would be that glute’ [gluteus muscle]. And I’m right! I think it just comes with time, experience.” (Practitioner 9)

6.2.1.2 During-treatment assessment

Practitioners described how assessment during treatment uses many of the same assessment cues and process as described above, but focuses more on perceiving changes, especially the palpatory cues within the patients’ tissues of texture, tone, temperature, ease of movement through the tissues, adhesions, and involuntary movements.

Practitioner 10 described knowing when work in an area was complete by experiencing the tissues “repelling” and “pushing away” the practitioner’s hands. The extent of the palpatory information gathered may be quite distant from the area being worked, a phenomenon described by several practitioners (see 6.2.1.3: Discrete Palpatory

Sensitivity). Verbal feedback is used as well.

6.2.1.3 Discrete Palpatory Sensitivity

Practitioner 14 depicted the development of “discrete palpatory sensitivity” and the effect of that development on the treatment assessment and treatment decisions that are made:

“Developing discrete palpatory sensitivity is something that lots of different people work at. …Putting a hair underneath a page of the phone book and slowly adding more and more pages and being able to still locate the hair over a period of time... Putting a coin on a big sheet on a [massage] table and then getting people to pull on [the sheet progressively farther from the coin] and be able to see if they can locate where the coin is. These are very like receiving response back from the tissue about what’s happening farther away... The more we can become aware of those effects, that the rebound or lack of response that I’m feeling in the shoulder actually flows all the way from the lower back, goes down, and it’s something that’s stuck at the ankle, is not “off the page” once you start following the rationale of that flow.”

6.2.1.4 Intuition as an important assessment tool

Over half of the practitioners describe the use of intuition as an assessment tool, especially during treatment. Different levels and types of intuition cues were described, from just letting the hands do what they want—“following the hands”—(Practitioners 2,

4, 10, 11, 12); or their hands “acting like radars” honing in to the important areas

(Practitioners 9, 17); to more intuitive “knowing” what should be done next (Practitioners

4, 13, 17, 18); seeing the energy of the patient’s body or seeing other interpretive imagery like symbols and using that as part of the feedback process (Practitioners 17, 18); being

“drawn” or “pulled” to another part of the body (Practitioners 7, 9, 10, 17, 18); or feeling the patient’s response or need in their own body (Practitioner 14, 17). These descriptions of the use of intuition in therapy invoke a subjective explanation for assessment that may be based on an unconscious processing of one or more cues (e.g., “like opening up the peripheral vision…heightening all of your senses” (Practitioner 13).

6.2.2 Individualizing during treatment application

Participants were asked about factors that affected how, when, and why they chose what to do during practice. Practitioners described constantly assessing and then deciding whether to continue with the current treatment choice, stroke choice, or direction or depth of the current technique, or whether some kind of change in therapy, area, or stroke characteristic was needed. The treatment process as described had both deliberate and spontaneous elements.

6.2.2.1 Deliberate individualization

Practitioners apply a deliberate, conscious decision-making process during treatment, such as monitoring whether a specific therapy, technique, or stroke is achieving the desired response, and if not, deciding to switch to a different one.

Practitioners are constantly evaluating their treatment effectiveness and learning from it both through in-the-moment reflection of their treatment, and through observation of the same client over multiple visits.

“I noticed two things in my practice. One was that things that worked with one person would not necessarily work with the next person, and so I needed to understand why that was, how could I get more effective. And second of all was that… the techniques didn’t necessarily make the same change every time.” (Practitioner 14)

6.2.2.2 Spontaneous individualization

The spontaneous element includes practitioner response and action based on the intuitive feedback as described above in Section 6.2.1.4, “Intuition as an important assessment tool”. It also includes the moment-to-moment adjustment of their therapy application based on the on-going assessment, which with experience becomes increasingly automatic. For the interviewees, spontaneous response was a common part of the treatment process.

“I could almost not have any awareness and my hands would still be responding. It’s just like green light, red light, and yellow light when you’re driving. You don’t have to think about it anymore, but you’re responding to some kind of a cue that’s coming into your hand.” (Practitioner 12)

Finding the best therapy or technique for a situation may sometimes also involve guessing or trying one or more options.

“Sometimes it’s desperation. Like I’ll say, ‘if this doesn’t, [pause] you know,

maybe it’s this: Maybe I should try this.’… A lot of it’s experience. The longer I do this the more instinct I have…” (Practitioner 15)

6.2.3 Using “toolkit” techniques

The practitioners described how they usually use one, two, or three preferred

TMB therapies as their treatment foundation. These foundational therapies comprise specific techniques and routines bound together by unifying concepts and theory that enable the practitioner to choose and apply techniques as they see fit. At any moment, practitioners may choose to incorporate techniques, skills, or ideas from supplementary therapies, or may switch over to the supplementary therapy, in order to benefit from its particular strength(s) or perspective on a treatment issue. Many practitioners described these supplementary therapies as their “toolkit” for enhancing treatment. The extent to which a toolkit therapy may be used depends on several factors including: 1) the foundational therapy normally being applied to the patient in an individualized manner;

2) the similarity or complementary nature of techniques between the foundational and the added toolkit techniques; 3) the ease of drawing on or switching over to the toolkit therapies; and 4) beliefs about the value or importance of practicing a foundational therapy free from influence of other therapies or addition of toolkit techniques. Using toolkit techniques to individualize treatment is a characteristic part of the evolution of practice, initiating the integration of multiple therapies.

6.2.4 In Summary: Individualization

The value of assessment is in the information it provides for making treatment decisions in all stages of the individualization process (see Figure 6-1). Individualization continues during the adjustments and decisions made during the application of treatments through both deliberate and spontaneous individualization of the treatment course at any moment. Most of the therapists use their preferred therapies as the foundation for their treatments, but individualize treatment by incorporating techniques of their toolkit therapies to best serve the needs of the patient at any given moment.

Figure 6-1. The process of treatment individualization

Initial Treatment assessment plan

TREATMENT PROCESS Application of Therapy techniques Therapy variation Therapy (deliberative, intuitive) integration

During-treatment Treatment plan assessment variation

6.3 The nature of practice: The practice of therapies evolves through experience

Many of the practitioners described the deliberate development of particular skills or knowledge. They also explained how, over time, experience increased the complexity of the treatments they delivered. This arises from their developing clinical expertise and confidence in their ability to effectively individualize treatments.

“I think [being able to combine or transition between therapies] is a very important skill, but I think it’s also the difference between knowledge and wisdom. And that kind of thing only comes over time—and learning to trust what you know. So, falling back on your knowledge of course, [pause] but the wisdom from doing thousands and thousands of treatments has taught me how to be a better therapist.” (Practitioner 7)

6.3.1 Exploring treatment options

A practitioner’s decision-making process can be deliberate or spontaneous when refining their approach to consistently arising therapeutic situations. Several practitioners described how they would methodically test different treatment options, such as different therapies or techniques, suggested by colleagues and the literature. Several practitioners also described a more spontaneous exploration process—“I just started one day thinking,

‘Okay, you know I think this would work better’” (Practitioner 9). They will continue to explore treatment options until they find a solution. These exploration processes will slowly develop and confirm a personalized repertoire of approaches that they apply to similar situations.

Few of the interviewed practitioners were taught how to consciously approach the ongoing development and evaluation of their practice skills and techniques. Two practitioners pointedly outlined the need for such training.

6.3.2 Exploring therapy integration

Participants described several integration processes for the use of multiple therapies, which we have labelled as 1) sequential, with planned completion of one therapy process before another begins; 2) flowing, which involves seamlessly moving from one therapy to another as the need arises; and 3) blending, during which techniques of one therapy are used along with other techniques or in which techniques of one therapy are altered by the technique, experience, or theory of one or more other therapies.

While sequential integration is usually deliberate, flowing and blending integration can be deliberate or spontaneous. Some therapies do not integrate well for practical reasons

(such as equipment requirements or preparation), and some practitioners strive to practice certain therapies free of influence from other therapies or may do so upon patient request.

However, the majority described integration as a fundamental part of their practice because it enables more ways to respond during the assessment–treatment process, allowing for a more refined therapeutic application of skills, and thus more effective delivery of individualized care. [In programs with multiple therapies, practitioners experienced differing levels of training regarding integration, with most programs teaching and examining each therapy, one at a time. Some programs required students to combine the program therapies during practicums in later stages of the trainings, while other programs left exploration of the integration process to the student after graduation.]

Generally, since few training programs explicitly teach integration, particularly the single-therapy programs, it is a practitioner-specific process learned through experience and shared between colleagues.

Practitioners’ opinions were split as to whether the effects and influences of

integration could be unblended or unwoven once begun. Some asserted that they practiced therapies as if uninfluenced by other therapies, or could do so with effort if asked to isolate and provide a given therapy. Other practitioners were doubtful that this could be done or would not want to try, and a few postulated it would not be possible for them or any practitioner because each additional therapy learned provides an additional layer of perception or experience, irrevocably changing practice.

“I know that even if someone has done an introductory course, it is possible that they learned [at least] one technique that they find is real useful. They will use it a lot. And it just becomes blended into the other things that they [practice].” (Practitioner 1)

“It is really hard to separate each different therapy because they all get blended and combined in different ways as each specific therapist sees fit.” (Practitioner 3)

Most practitioners described how the learning and then integration of multiple therapies has evolved their TMB practice, creating more nuance and sensitivity during the application of therapies, as well as to a better perception of therapeutic need.

“Craniosacral affected my touch in all of my therapies. I’m very, very sensitive to anything now.” (Practitioner 8)

6.3.3 In summary: the evolution of practice

All practitioners described the development of nuance and sensitivity in their work, and an ability to individualize treatments. Developing expertise requires experience

[derived from time evaluating] the outcomes of their exploration of treatment options and therapy integration over the course of many treatments.

6.4 The research-practice gap

The practitioners articulated two core distinctions regarding clinical and research treatments. One was the assumption that research treatment protocols do not allow for the normal clinical practice individualization process that allows them to respond, moment- by-moment, to patient needs (Section 6.4.1). The second distinction was that because they understand the research process and research treatment protocols to be highly defined, they question whether research results may be useful for their own patients or clinical treatment process (Section 6.4.2).

6.4.1 Treatment during research is not like the clinical treatment of practice

Through diverse and sometimes indirect language, the interviewed practitioners described how and why they consider their clinical TMB treatments to be different from research treatments. Their homologous experiences of the practice of TMB, highly individualized and usually drawing on their toolkits of therapies, provoked a consistent questioning of the value of the TMB research to date. None described having been involved in designing, or providing treatments for, a TMB research project.

6.4.1.1 Research treatment protocols do not reflect clinical practice treatments

Most of the interviewed practitioners described how, when applying standard routines in practice, they still modify such routines. They then described concerns, based on their responses to research they had read or what they assumed about particular types of research methods, that during research treatments a standardized, non-flexible protocol is assigned based on a symptom or syndrome rather than a full physiological assessment

such as they would do in their practice. Rote, inflexible protocols would not allow for the flexible adaptation to the patient needs that they normally implement during clinical treatment. Practitioners did not seem aware of research projects using more practice-like research treatment protocols or methods.

“Research, you’re setting out to find a specific thing. … You’re more about how this particular thing affects that person or that pathology or that injury. You can’t change it [the protocol] or how do you know that it wasn’t one of the other things? Practice is a whole different thing. You’re not there to prove to the client that this technique works. It either does or it doesn’t, and if it doesn’t you need to move onto something else, ‘cause it’s different for every person. So you’re treating the person, whereas with research you’re researching. You’re trying to find out and prove what works best.” (Practitioner 15).

Additionally, practitioners were clear that because of the normal process of individualization they would likely have difficulty complying with strict protocols.

“I don’t know how… I could actually follow a [research protocol] structure and comply with what’s required of me in a session to fulfil the research part and not listen to the body. I don’t know—maybe some people can get to that and figure that out, but for myself at this moment, I don’t think I could.” (Practitioner 13) “You would have to do proper assessment of the appropriateness of your approach for the person…” (Practitioner 16)

The practitioners therefore clearly demarcated clinical treatment from research treatment, and did not perceive a useful linking between the two because the differences were so fundamental to how treatment is applied.

6.4.1.2 Traditional clinical trial research design may not fit the needs of TMB research

A few practitioners, without prompting, went further. They thought about their clinical practice and clinical experience, the processes involved in their TMB education, and being trained in multiple therapies, and then reflected on the implications for treatments in research.

“Even though I have exactly the same training as every other student I took the massage therapy course with, we each practice differently and we each choose to do something different with that training. So it’s a really hard subject to research. I would say it is really hard to separate each different therapy because they all get blended and combined in different ways as each specific therapist sees fit.” (Practitioner 3)

“I think that when I’ve seen the early research that’s been done with short stroke and all that kind of stuff for tension and pain management, I think that they are flawed because they do not take in tissue response. … As long as you treat a massage or any other technique as a physical therapy, you always miss the … organism’s response to what you’re doing. There needs to be the capacity for ongoing assessment and adjustment of the treatment approach to the person’s response to the treatment as part of getting proper reading of whether it’s doing what it should be doing.” (Practitioner 14)

Practitioner 14 had a high level of research literacy, and articulately questioned whether the research methods derived from medical science fit the research needs of the practice of TMB.

“We’re trying to apply [research] approaches which… are not appropriate to what’s being studied… [They are] being drawn from different areas that may have developed well in medicine and science, but certainly aren’t applicable to these particular kinds of approaches. … I think we’re still trying to figure out how to develop research designs to treatment that actually match with what people are doing in practice. For example, understanding the difference between a technique- orientated approach to massage or a “listening hands-oriented” approach [basing treatment on the constant palpation assessment-treatment response cycle that occurs during normal practice] to massage. Different things like that are levels of sophistication that are a ways away, and desperately need work on.” (Practitioner 14)

The majority of practitioners expressed discontent or concern regarding the relationship between the production of research and clinical practice. No practitioner felt that the way they practiced was reflected in the research they were reading.

6.4.2 Few practitioners directly apply research results to clinical practice

Most practitioners seemed ambivalent about published results of TMB research.

Positive results were, for example, more likely to be described as useful for advocacy than for changing daily practice. Many practitioners concluded that “research is research, and practice is practice” (Practitioner 15), that they comprise “two different types of sessions” (Practitioner 18). While some of them believe that proof of efficacy or harm from a protocol should change clinical practice, few of them take time to read research, fewer felt confident interpreting research, and some declared they would simply keep practicing regardless of research outcomes because their experience was perceived as more valuable than research evidence, a view that seemed shared amongst many of the participants.

“Now, if another project come out and said this doesn’t work, yet I’ve been treating people with it and it’s been working, then no, I’m not going to change, because it’s working! You know, whether it worked [or not] for your 2000 people that you tested, it’s working for my five.” (Practitioner 15)

6.4.3 In summary: the research-practice gap

Practitioners feel that TMB research does not reflect clinical TMB practice in that clinical practice focuses on individualized treatment, and extended clinical experience results in increased palpatory and multiple-therapy integration expertise. Practitioners therefore feel that unless TMB research design better addresses the nature of clinical

TMB practice, that the application of TMB research to clinical practice will remain limited.

Chapter Seven: Exploration of Consent in the Practice of TMB Therapies

(as per manuscript 5 (in process, (5))

During the first interview, discussing whether patients knew different therapy techniques were being applied during the practitioner’s treatments, the practitioner spontaneously linked the topic to the clinic’s consent process. The issue of negotiating consent for multiple therapies was unexpected, and thought provoking. After it arose in a second interview, a specific question regarding consent was added to the interview guide.

This chapter is therefore based on a subset of the data not related to the objectives or purpose of this study. Both results and discussion regarding this topic are presented here so that the study Discussion (Chapter 8) can focus on the results relevant to the thesis objectives. This chapter is the early stage of an ethics commentary-format manuscript being developed for publication.

7.1 Exploring consent with the practitioners trained in multiple therapies

The practitioner interviews began by asking practitioners about their various TMB training programs. Discussions then progressed to whether they combined their therapies, and if so when and how that was done. At that point, the 12th question in the interview guide fit well: “If you are combining therapies like this, how do you negotiate consent?”

This question assumes that the practitioners understand the ethical reasons that require them to engage in a consent process and therefore proceeds directly to how the practitioners engage into a consent process, not if or why. Practitioners’ explanations of how they address consent inadvertently reveal that the ethical principles underlying the

reasons why consent is sought are sometimes not the primary motivators for engaging in a consent process. The gamut of their consent approaches is discussed in this chapter.

While this article focuses on the provision of TMB therapies, many of the practitioners provide non-TMB therapies as well, including various forms of energy work, shamanism or counselling, and devices (e.g., laser acupressure, TENS machines) that may be incorporated into their TMB sessions. In most cases there was no distinction of these services from the provision of the TMB therapies because they could be smoothly integrated into the TMB services. Therefore the issues here represent a broader perspective than just TMB services, however, as this study focused on the practice of

TMB, this chapter will discuss only TMB practice.

7.2 Descriptions of consent

All practitioners, regardless of their reason for obtaining a patient’s consent, engaged in processes of informed consent. The two primary variations they offered were similar: general consent and on-going negotiation. Neither process engages specific consent for every therapy that is applied in the session, but rather relies on contextual consent of the therapeutic encounter.

7.2.1 Descriptions of general consent

“They’re consenting to come in and allow me to manipulate their body. So, you know, whether I do it with Reiki, with massage, or with acupressure, I think it’s not an issue.” (Practitioner 2)

General consent, as introduced by the quote, is when practitioners do not specifically address consent for each therapy provided. Rather, the initial consent for

treatment is intended to fulfil the primary consent need. Practitioners described several related assumptions: (1) that the patient understands that the practitioner offers

“bodywork” of some sort and that the patient does not need or want to know explicitly the individual TMB therapies or when different TMB therapies are being applied; (2) that the patient knows that the practitioner provides a set of TMB therapies and expects the practitioner will choose whatever is most appropriate, or (3) that the patient may not be distinguishing, or cannot distinguish, between the different types of TMB therapies being applied.

“To my understanding and my belief these are all massage techniques. It all is kind of an umbrella of massage… So when they’ve come to me to be treated, they want me to do what needs to be done to make it better. They’re trusting me to make that decision. So as far as informed consent, I don’t ask them, ‘Is it okay if I do myofascial on you?’ because that means nothing to a client. You might as well say something in Greek. So I don’t generally do that.” (Practitioner 16)

In these scenarios, there seem to be two intrinsic assumptions: (1) that the patient’s goal or goals are more important than the therapy, and (2) that the added TMB therapies have equal or lesser degrees of risk of harm than the therapy that the patient believes or expects they are receiving and therefore don’t warrant special consent consideration. The first assumption, that the patient’s overall goal is more important than knowing the therapies applied, may take additional research to understand the source and implications; some patients seem willing to be complicit in such an assumption.

“I think in general, some clients don’t want to know anything and they just want to feel the end result, while other clients will ask and want to know. So I don’t generally tell them unless the client seems to be inquisitive… In my informed consent I do with my clients I don’t specify that out. I give them a general treatment goal…” (Practitioner 1)

Given the lack of documented harm from the provision of TMB therapies (TMB

regulations in North America are based on potential risk of harm), the second assumption has yet to be challenged in any substantial way (64-66).

7.2.2 On-going consent negotiation

“What I do is I usually have people come in for general therapeutic massage. At some point when they’re lying there, you work on their scalp and then I just do a little bit of Indian Head massage. I do gentle stretching, which is Thai massage, so people aren’t aware that they’re getting the full-meal deal kind of thing. But I do say to them, ‘You know this is a Thai stretch,’ or ‘This is Indian Head massage,’ or such, so they’re aware of what I’m doing.” (Practitioner 8)

Some practitioners, like Practitioner 8, will mention a therapy as they apply it.

While not a true informed-consent process, they are alerting the patient to a change in therapy, engaging acknowledgement and therefore creating a form of consent under duress. However, most patients are not likely to consider it under duress either because they are continuing to experience a continuity of bodywork or they are focused on receiving therapy for a goal regardless of how it is achieved, as discussed above. Such an on-going consent process does provide an opening for the patient to comment on or participate in the choice for the on-going application of the therapy. Knowing that a practitioner provides a variety of therapies also gives the patient the option up front to request or refuse therapies at the beginning or at any point during a session.

A more nuanced form of on-going negotiation involves explaining changes or choices to the patient as they arise if a shift in treatment needs to take place. Practitioner

15 describes two such scenarios:

“I will maybe explain to them, ‘I really think we need to do some fascial work on your shoulders. Now, it’s gonna take a little bit longer because the way I do it, it’s not a forced thing. It’s slow, so I maybe have to do a three quarter hour instead of a half hour. Would that be okay?’ That kind of thing. If I’m adjusting a time or

[therapy], like with cranial sacral, if I really think they’d benefit from that I’ll say, ‘You know, I really think you should try this. I think it could help you. Would you be willing to try that?’”

Other practitioners don’t think of consent specifically in terms of therapies that they provide but rather consider consent for each component of on-going treatment.

Comments about this form of consent were some of the most detailed responses about consent with regards to the consideration of the meaning inherent in receiving informed consent for treatment.

“I find that the formal consent as it’s taught is not practiced at all… I think there’s a really important part of that language which is informed consent and I tend to focus on the informed part as leading into consent. … The more that I can educate people to understand what it is that I’m doing, to give them some sense of why, like how that’s connected, then what I find is that people can move with me. If I listen to their tissue response and check, ‘Okay, how does that work? Does that feel like you can go with it?’ if I ever have any question about what I’m reading [sensing in their tissues], then we find our sense of consent, of mutual agreement, arising naturally out of that approach. (Practitioner 14)

“I’ll explain that I do physical and energetic work and I’m trying to work as much with their body as I possibly can. So the more we work together we’re gonna be communicating. I’m gonna be asking ‘how do you feel about this?’” (Practitioner 15)

The result of these processes of on-going negotiating consent is that the patient is explicitly brought into awareness of the therapeutic process being applied to their body.

That is not to imply that practitioners doing a general consent process do not also elicit client feedback and input during the treatment process, but they may not be specifically soliciting consent during the variation and mixing that occurs during treatment application. The potential similarity between some TMB techniques and the possibility that some techniques may be merged with other TMB techniques or may be affected by training in other TMB therapies (2) may not be recognized by many patients. Therefore,

perhaps the critical informed consent issue is not the identification of the individual therapies (unless they differ substantially in some way) but ensuring that the patient understands why they are receiving any given therapeutic technique at any point in time and that they can participate in choosing how that therapy is or is not applied.

7.3 Motivation for engaging in consent

The process of negotiating consent does not seem to have been taught in a uniform manner in the TMB professions, where professionalism and standards of practice continue to evolve. The above general consent processes present a less nuanced understanding or application of the ethical principles underlying informed consent, specifically the right of a patient to be given enough information regarding possible treatment choices so that the patient can make a decision that will affect or involve their body (67). The associated ethical duty of the health care provider is to involve the patient in health care decision-making (67). The on-going consent negotiation processes described in Section 7.2.2 are more closely aligned with the principles of informed consent. A few practitioners specifically explained their rationale for engaging in a consent process. Responses ranged from engaging in a consent process to comply with association membership requirements, to wanting their patients to understand what they were doing, to very specific concerns about maintaining patient autonomy and the power dynamics of the patient-practitioner relationship (i.e., concerns regarding the health care provider’s authority position relative to the patient who is physically vulnerable and for whom there is an information differential arising from a lesser knowledge position relative to the health care provider). Examples of the two ends of the spectrum are:

Professional association code of conduct compliance:

“The only reason I started to do the things that I do now is because I made a promise as a… person who belongs to the association. I have signed that I will adhere to a certain code of ethics and those require me to disclose and get permission, and tell the client what to expect. That’s part of my commitment that I have to do that.” (Practitioner 17)

Maintaining patient autonomy concern:

“The tricky part about [on-going mutual consent] is that it can be a rational for people doing all kinds of, you know, whatever they please. And there’s also this question about how much can a person truly give informed consent when they are lying naked on a table. I think those are issues I’m always trying to pay attention to, particularly with the intensive experiences I’ve had around working with people who have been abused at different levels and lose their ability to even advocate for their experience…” (Practitioner 14)

7.4 Addressing the intent of the consent process

The process of practice is a complex treatment phenomenon involving ongoing assessment and treatment choices, where practitioners may not even be consciously aware that they are mixing therapies or techniques or are using multiple simultaneous assessment inputs (3). At what points during the treatment process is it appropriate or necessary to engage in a consent process? How can they be defined or identified? Paiva, a bioethicist and TMB educator has addressed this issue to some extent (68). According to her, a morally valid healthcare choice by a patient,

“…is not a form signed by the patient… A morally valid choice is a living, continuous dialogue: it involves an ongoing educational and relational process. The therapist continues to educate and dialogue with the patient throughout the therapeutic relationship to ensure that the patient has sufficient information and the opportunity to ask questions and find out what they need to know in order to ensure that the decision that he or she makes is his or her own personal choice. If the patient chooses to consent, confirmation of the continuing consent may be necessary or even required in recognition of the ongoing nature of the process and experience.” (page 190 (68)).

Such encompassing statements would capture the practice of multiple TMB therapies, a topic not otherwise explicitly addressed in the general TMB literature

(individual school texts were not reviewed for this article). However, the practitioners’ statements indicate that understanding and applying consent knowledge to the extent described by Paiva has not been achieved within the TMB professions. While all the interviewed practitioners described at least some of the consent features in their process with patients, including on-going validation of the patients’ experiences and needs, there was a distinct lack of agreement on what the process of consent may look like in the light of the practice of multiple therapies. Given that most patients are trained in multiple therapies and may mix therapies and treatments during sessions (2), clarification regarding the management of ongoing consent should be an important component of any

TMB body of knowledge.

This data suggests that the education of TMB therapies, from short courses to the

2000+ hour programs, should be more explicit about how informed consent is managed during the provision of the TMB therapy being taught. Additionally TMB education should include training on managing informed consent if and when the TMB therapy is incorporated into treatments with other therapies or has other therapies or skills incorporated into it. For practitioners already practicing, professional organizations should make available ethics programs and literature that address consent issues to this depth, and that specifically address the process of consent for multiple TMB-trained practitioners.

This ethical discourse regarding the provision of multiple therapies or the use of techniques from multiple therapies during a single treatment is nascent within the TMB

professions. This study has revealed the problem, but as it was an unexpected component of the interviews, no work was undertaken with the practitioners during the interviews to find solutions. Engaging with practitioners regarding that work will be left to the educators and ethicists working within the TMB professions.

Chapter Eight: Discussion and Conclusions

This study began with a fundamental concern that the training and clinical experience of TMB practitioners could be affecting the outcomes of TMB research. That proposition could not be directly tested using a clinical trial, because not enough was known about the training or practice of TMB practitioners to define such a trial. Using combined methods, this study gathered data on TMB practitioner training and explored with practitioners how training and clinical experience affect clinical practice. In the discussion, this information will be used to examine and assess current TMB research practices.

Section 8.1 provides a summary of the results presented in Chapters 5 to 7. Section

8.2 examines the three key study results and discusses: (a) what was learned from this study, and (b) how the significant concepts fit within the broader context of the original research questions and the relevant literature. Section 8.3 explores methodological issues of this study. Section 8.4 presents implications of the results for conducting more effective and clinically relevant TMB research. Section 8.5 comprises exploration of the results implications for possible improvements to TMB education. Section 8.6 presents some possible areas of future research based on these results. This chapter culminates with Section 8.7, Conclusions.

8.1 Summary of Results

The results, Chapters 5 and 6, present the key findings. Survey respondents provide treatments in a wide variety of practice types and municipality sizes throughout

Alberta. Their demographic characteristics were similar to published demographics from

other massage therapist surveys (19, 20, 36, 45, 69). The questionnaire results revealed a high degree of variability in the number and types of therapies that respondents practice

(median 8 therapies, range 1 to 40). This variability arises from: a lack of uniformity within a therapy’s training programs; common but highly inconsistent inclusion of additional therapies or therapy skills into another therapy’s training program; and additional training during the practitioner’s career. Practitioner interviews revealed that many practitioners pursue training in a broad set of TMB and other therapy skills, driven by personal interest and professional continuing education requirements.

All practitioners assess and individualize treatment for patients. During the initial assessment, goals of the session are identified. During treatment provision, assessment continues through tactile, verbal, visual and intuitive feedback. Practitioners vary treatment, from subtle stroke adjustments, to broad changes in plan, area of treatment, or therapies applied. Most practitioners use toolkit therapies along with their principal service delivery therapies. Most preferentially integrate therapies as part of the individualization process, though some others try to avoid mixing skills or techniques from different therapies. Clinical experience appears to refine and develop a practitioner’s skills. Learning other TMB skills, even if not integrated with other therapies, may also refine and develop clinical practice. Practitioners expressed concern that TMB research does not translate well to clinical practice because of differences between normal clinical practice and treatments applied for research purposes. Their resultant dismissal of or ignoring TMB research likely contributes significantly to the research-practice gap.

Integrating the survey and interview results leads to a focus on three particular

facets of TMB practice. Most important is that almost all practitioners train in more than one form of TMB therapy, and that most practitioners will use and combine those therapies during normal clinical care. The other integrated results expand on this knowledge: most practitioners increase their number of TMB therapies over time, which along with practice experience, will refine and change each practitioner’s skills in the application of individualized care; the variability in practitioner training along with clinical experience will produce practice skills and treatment application unique to each practitioner; and that training programs, even with multiple therapies, rarely teach individualization of treatment that incorporates conscientious use of multiple therapies as an integrated whole.

Finally, Chapter 7 details the lack of consistent understanding and implementation of the ethical principles underlying informed consent for treatment when multiple therapies in sequence, therapy integration, or both are involved.

8.2 Discussion of Findings

This section begins with the three main results from which the integrated outcomes were primarily derived: (a) the variability of practitioner training; (b) the evolution of practitioners’ skills; and (c) the nexus of individualization in practice. The final sub-section (8.2.4) includes brief commentary on the integrated results. This section is closely tied with Sections 8.4 to 8.6, which will address the significance and implications of this study for TMB research and education, respectively.

8.2.1 Variability of practitioner training

While results from several massage therapy surveys have indicated that practitioners train in multiple TMB therapies (19, 20, 36, 45, 69), none addresses the implications of those results from the perspective of an individual practitioner. This study showed that some practitioners start their careers after training in several TMB educational programs. Additionally, many educational programs incorporate multiple therapies, but with no standardization. This leads to many practitioners starting their professional careers able to practice more than one TMB therapy. However, even then, graduates from different schools are rarely uniformly trained in any given therapy. Many practitioners pursue additional TMB therapy training by choice. “Most TMB practitioner associations require on-going education and upgrading of skills, which encourages learning a wide variety of therapies and techniques… Over time, it seems likely that practitioners… will acquire additional therapies and techniques and refine their skills through experience, therefore changing their techniques and their experience of applying therapies.” (2). Thus, through clinical experience and further training, divergent skill sets and idiosyncratic practice evolve; even the few survey respondents only trained in one therapy may develop idiosyncratic practice. Common strategies found in TMB research designs over the last 20 years, utilized to avoid the effects of idiosyncratic practice on the outcomes, are: (a) the use of TMB students as practitioners providing the research treatments; (b) the use of non-TMB practitioners such as nurses trained in a brief TMB treatment protocol; or (c) the use of a single TMB practitioner to provide the research treatments. The research problems that arise from these attempts will be discussed in

Section 8.4.

Most of the practitioners interviewed in this study experienced two fundamental shortcomings in their training programs: (a) a lack of description on how, once graduated, practitioners could best continue to purposefully develop and refine their assessment and treatment skills; (b) no acknowledgement that practitioners were likely to continue to learn TMB therapies after the course was over, thereby failing to prepare practitioners on how to best incorporate other therapies into that course’s core therapy(s) or merge the therapy(s) into other therapies. Without this information, practitioners are left on their own to find solutions to these issues, leaving the patients to be the testing ground. That vulnerability is exacerbated by the corresponding lack of education about how to consistently and appropriately apply a consent process when multiple therapies are involved. Two practitioners identified a total of three continuing education courses where integration of the therapy into other therapies was specifically addressed (A.R.T.,

St. John’s Neuromuscular Technique, and one craniosacral course). While some therapies such as maternal massage or manual lymph drainage are often used to supplement other therapies as well as be used as stand-alone therapies, practitioners did not specifically identify courses about them.

8.2.2 Evolution of practitioners skills

“The confident application of treatment depicted by the more experienced TMB practitioners includes fluid shifting between therapies or techniques, and in-the-moment treatment response. These features correspond to educational theories concerning the development and application of expertise developed independently by Dreyfus and

Schön. The end-stage of Dreyfus’ model of development of skill acquisition is expertise,

in which a performer has ‘an immediate intuitive response to each situation’ (p5) (70).

Dreyfus explains that such intuition is possible because repetition and learning from similar clinical situations becomes synthesized into a response ‘which experience has shown to be appropriate’ for a given situation (p.146) (71)” (3). Schön described a similar development from rule-bound novice to intuitive-reacting expert. (72). “The practitioners’ confidence in their skills and in integrating multiple TMB techniques, and the prevalence of the intuitive processes among the TMB practitioners suggests that an evolution toward Schön’s ‘reflection-in-action’ or Dreyfus’ ‘intuitive-reacting’ expert is the norm (71, 72)” (3). In such a situation, it seems unlikely that any experienced practitioner could apply tightly delineated research treatment protocols uniformly, unless they were somehow capable of disengaging their intuitive responses and on-going assessment skills.

Given 57.9% of the interviewed practitioners use some form of intuitive assessment during practice, the spontaneous, unconscious assessment-treatment response—particularly as practiced by the experienced practitioners—is likely the source of the disagreement between practitioners regarding whether pure, as-trained therapies can be provided. “While some practitioners believed they could provide an as-trained therapy, they also discussed how they had learned from clinical experience. Most described having ‘refined’ or ‘enhanced’ their therapeutic skills via new awareness from other therapies’ techniques or skills. This accords with the strong comments from other practitioners that the practice of therapies is likely irrevocably changed because of clinical experience and learning new therapies” (2). In such a situation, the application of a particular TMB therapy may not have high therapy application fidelity. The replication

of results under such circumstances therefore requires awareness and careful management of these issues throughout the research process, as would the translation of the results to general practice.

The descriptions of intuition given by the interviewed practitioners include a broad range of experiences with non-standardized terminology. With the continuing increase in TMB communication and research, there is a need within the TMB literature for more precise terminology and careful articulation of practice details. Sherman et al.

(73) explain that a common language of practice is needed for communication between

TMB practitioners and accurate description of treatment protocols. This is the same reason North American physiotherapists, for example, undertook standardizing physiotherapy manipulation terminology (74). Some TMB research treatment protocols are described with clarity. For example, those employed by Patterson (75) and Albert

(76) include precise descriptions of the entire treatment protocol. Patterson additionally mentions possible variations allowed and training/assessment of the practitioners.

However, because most other published research protocols are not so detailed and rarely explain how practitioners are trained to apply or adhere to protocols, it is not clear if a lack of uniform TMB terminology is also affecting research results.

8.2.3 The individualization of treatments

The practitioners’ comments link the skills that develop with clinical experience, including intuitive practice, with the skills that affect individualization. The TMB treatment process involves “an intricate feedback loop of assessment and treatment decision making occurring continuously throughout practice” (3). Conscious and

unconscious treatment decisions in response to this on-going feedback are part of individualizing treatment, even when standard TMB treatment routines are used. While all practitioners are taught how to individualize treatment, the ability to further increase potentially beneficial outcomes by individualizing treatment will increase over time due to the increased clinical skills and insight developed from clinical experience. This may underlie the results of two research projects (21, 22) that found the therapeutic outcomes of advanced students or an educator were significantly better when were compared to lesser-trained student practitioners. “Both research projects conclude that the proficiency and clinical experience of the practitioners may be contributing to the results, but do not explore why” (3). This current study’s results suggest that the increased treatment individualization (both conscious and unconscious) attainable from experience-refined

TMB skills may be an important factor in maximizing beneficial treatment outcomes even when using routine protocols. This postulate should be tested, because if true, there should be more focus on development of expertise within the TMB professions.

Practitioners were explicit when describing how the process of individualization is central to the complete experience of practice. Individualization drives clinical assessment, treatment choices, and treatment variation. The value of new treatment ideas and even of research is filtered through a practitioner’s perspective of being able to apply knowledge to the needs of an individual. Individualization therefore is the primary conceptual focus of practice—the nexus of individualization—and should be consciously addressed in research and TMB education initiatives.

8.2.4 The integrated results

Undertaking a combined methods study is primarily for the purpose of enhancing insight and depth of understanding as well as corroboration of results (77). The results from the mixed methods analysis (results, page 62–63) may initially appear to be common sense once the underlying key results, as discussed above, are understood.

However, they are succinct summaries that indicate that neither TMB practitioner skills, nor the TMB treatments that practitioners provide, are likely to be alike: during treatment, an interconnected flow of decision-making and individualization arises naturally from an amalgam comprising each client’s needs plus palpatory feedback together with the practitioner’s total training and experience. Practitioners work towards developing a fluency and ease in that flow, and would like more instruction in their programs on integrating assessment, techniques, and therapies during treatment.

The supposition of similarity in treatment underlies the classic randomized controlled clinical trial research, particularly those that assume a similarity of dosing (78,

79), including many of the TMB articles reviewed for this study. The importance of these combined methods results is therefore the explicit knowledge that researchers cannot assume a similarity of treatment provision by TMB practitioners. The results authoritatively address that knowledge gap based on properly collected and analyzed data.

8.3 Methodological considerations

The primary concern in quantitative survey research consists of confidence levels/intervals and generalizability of the results. In qualitative work, the primary

concern is how integrity and rigour are maintained during the interviews and subsequent data analysis. The inference quality (80) arising from using combined methods has additional considerations based on how the quantitative and qualitative components were combined. Each of those will be explored below.

8.3.1 Quantitative: Survey response rate and generalizability

The survey had 791 responses, enough for overall analysis (α = 0.05, confidence intervals of ±3.2%). However, the survey’s low response rate (15.1%) is a primary limitation of this study that could restrict the survey’s generalizability to other TMB populations (selection bias). A low response rate was not unexpected, given (a) the respondents’ concerns as described in the results section (i.e., distribution of the survey during summer and potential use of the survey results to influence the massage therapy regulation process occurring in Alberta during that time), (b) feedback from three North

American massage therapy organization executives that ‘if you are getting a 15% response rate, you’re doing well in this profession’, and (c) the pilot result that 23.7% of participants were not interested in or did not have the time to complete surveys longer than two pages” (2). To review the degree to which study respondents were similar to other surveyed TMB practitioners, our findings were compared with previous survey results. In 2010, the AMTA survey recorded that its member practitioners train in an average of seven therapies (20). There was also high concurrence between the demographics from this survey and the other North American TMB surveys (Table 5-1).

This suggests similarity of the current study respondents with those of the other surveys.

The main limitation to generalizing the results would therefore be whether the

practitioners responding to this survey (or to the other massage therapy surveys) differ from TMB practitioners in general, e.g., if non-respondents train in more, fewer, or different therapies, or have very different work habits or environments (non-respondent bias). “The NHPC Membership, Credentialing, and Education Manager, Laura Finley

(personal communication, June 1, 2011), confirmed that our participant demographics correspond to the NHPC Alberta TMB membership [over 4000 members] as well as its pan-Canada TMB membership [over 6000 members] in two aspects relevant to this discussion: (a) TMB practitioners train in multiple therapies (to an even greater degree if considering their continuing education choices and the components of educational programs); and (b) TMB training programs exhibit high variability in their educational components, including number and types of incorporated therapies” (2). Together, these factors suggest that the survey captured the wide variety of possible practice variations that exists within the TMB professions, thus most non-responders should be represented within the results. A possible misrepresentation of the population could exist relative to the current survey results if a large proportion of the true TMB practitioner population were to have an under- or over-representation of a particular type of training, therapy or cluster of therapies, or amount of clinical experience within the survey results. While statistically the results would be different, the contextual meaning of the main results, particularly the recommendations and results arising from the effects of training and clinical experience on practice and the nexus of individualization, would remain an important consideration for relevant TMB research methodology.

These results are likely most generalizable to environments where the norm is the common availability of multiple TMB therapies. Many cultures have well-established

local TMB traditions, for example Thai massage, Japanese anma and shiatsu, Chinese and Taiwanese tui’na, Maori mirimiri and romiromi, and many other Aboriginal groups with localized forms of massage. Thai, Japanese, and Chinese/Taiwanese massage are all linked to well documented, established medical traditions (29, 34, 81-83). The historical lineages of these therapies could result in less training or practice variation within the culture of origin. Less variation is also likely when knowledge is kept private and practiced within Aboriginal communities, such as for the Maori or North American

Natives (in-person discussion, Iwi Puihi Tipene (representative for Te Paepae Matua mo

Rongoa, national Maori healer collective) and Laura Antoine (Coast Salish healing elder), November 1, 2010). Cultures with strong links to their own traditional medicines may also have a more limited variety of “foreign” TMB therapies available and therefore less integration of multiple TMB therapies. A more standardized practice of those therapies in their native environment may therefore exist, and the applicability of these results regarding cross-therapy influences would need substantiation. Issues relating to individualization and the effects of clinical experience are likely pertinent but should be verified for each TMB population if research on those therapies occurs.

The survey results suggest that the total number of TMB therapies in which practitioners are trained may be under-reported. “There was a possible bias to under- reporting the number of therapies taught in multiple-therapy training programs in this survey. Some therapists indicated on their surveys that their two- to three-year education contained only a single therapy: massage therapy. However, the Canadian standard and published school curricula of these long, non-standardized programs indicate they provide training in multiple therapies. [The survey asked which therapies they had

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training in, rather than what therapy courses they had taken, to work around this language limitation (this issue also relates to the politics of massage therapy (28), which is beyond the scope of this discussion).] This possible conception by practitioners of several TMB therapies as a single named therapy (e.g., massage therapy) could indicate that there is greater under-reporting than is recognized within the data. In addition, the number of therapies in which practitioners receive training will not represent all therapies used in practice. Some of the interviewed practitioners asked whether to discuss ‘introductions’ to therapies within training programs or as part of continuing education opportunities, and some talked about self-education. As this training could affect practice, the potential impact was explored. The practitioners explained that while they may regularly use these additionally learned techniques during their practice, they do not consider themselves as having formally learned the therapy, and therefore did not report them in the survey question regarding the therapies in which they are trained. Hence the reported number of therapies the practitioners are trained in may actually under-represent the true total number of therapies or therapy techniques being used in or influencing practice.” (2)

8.3.2 Qualitative: rigour of data analysis and interpretation

There are a number of qualities of analysis rigour that must be carefully considered for qualitative analyses. Krefting, based on Guba, outlined in 1991 (84) four items of trustworthiness of results from qualitative analysis: (a) truth value; (b) transferability; (c) consistency; and (d) neutrality. Each of those will be considered below.

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8.3.2.1 Truth value

A research project has truth value when steps are taken to ensure that the multiple realities of the participants are accurately reflected in the results. Qualitative description focuses on a direct description of ideas of the data, with little inference or abstracting (see

Section 3.6.3, page 37 for detail). Themes are developed as categories of the related codes, which are based on direct reading of the data within context, with little interpretation. The lack of research projects in the literature documenting the practice of

TMB therapies prevented influence from theories or expectations from previous work during data analysis (for personal experience influence, see Section 8.3.2.4). Finally, comments at a TMB research conference where the results were presented, along with manuscript reviewer feedback regarding the manuscript on the process of practice, confirm that TMB practitioners consider the results to truthfully reflect TMB practice.

8.3.2.2 Transferability

Establishing the potential applicability of any qualitative work to a new situation is the responsibility of the person or group looking to apply the results. For them to be able do so, the research project methods and results should be thorough enough to provide the context and understanding necessary to know what parts of the results are, and are not, transferable to new populations of interest. Qualitative descriptive work is straightforward in method and the ensuing results should be easily evaluated for applicability to similar populations. This study’s results are sufficiently thorough to enable accurate evaluation of the applicability to other potential populations.

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8.3.2.3 Consistency

Consistency is a construct that questions whether another researcher replicating the research project would find similar results. Qualitative description is an advantage here, because the extent of theoretical extrapolation beyond the data is minimal. While there was substantial variation in the details provided by the interviewees, saturation was reached in the sample and the developed themes capture the practitioners’ diversity of experience. Based on the encompassing nature of those themes, if another researcher were to ask similar questions of practitioners in similar environments, they would likely find many similarly expressed ideas. Given the use of qualitative description and the steps taken to maintain neutrality (see neutrality below), another researcher’s replication of this study could achieve a high level of consistency.

8.3.2.4 Neutrality

This fourth factor gives consideration to how carefully the researcher represents the participants’ voices and points of view without unnecessary intrusion of the researcher’s perspectives. My eight years experience as a deep-tissue therapist trained in multiple therapies (1996–2003) and five years as a registrar for the Natural Health

Practitioners of Canada (2001–6), responsible for understanding credentials and practice issues, could both enhance my ability to understand the complex issues that the interviewees described, and limit perception of the TMB practice of, or differing approaches to, multi-therapy integration in the interviewed practitioners’ practices. Given the potential limitations my experience could create during analysis, my neutrality was maintained throughout the analysis by: employing the practice of self-reflection and

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writing memos; questioning my understanding of developing concepts and how different practitioners’ data supported or contradicted ideas; and clarifying distinctions between what was developing in the data and my expectations or beliefs based on my experience.

These techniques of self-reflection are based on methods recommended by Strauss and

Corbin (59).

8.3.3 Interview invitation response rate

Of the 791 respondents, 283 volunteered for interviews. While research project manuscripts generally do not include the volunteer rate for interviews, typically the response rate is small. Some plausible hypotheses for this high response rate among the survey participants include: (a) volunteering more than doubled their chance of winning one of the draw prizes; (b) the interview honorarium was roughly equal to 45 to 60 minutes of professional practice income, reducing the burden of time lost from practice;

(c) there was a low barrier to volunteering: participation only required filling in the brief form and mailing it back with the survey; (d) practitioners were genuinely eager to discuss what practices with multiple therapies are like; and (e) practitioners were committed to supporting research within their professions, perhaps particularly research that was engaging them about their perceptions and experience of their professions.

Likely, individual reasons for volunteering involved a combination of factors. My status as a TMB practitioner colleague may also have facilitated participation.

Of concern is whether the high interview response rate represents a significant form of respondent bias influencing the results. Reviewing the above hypotheses, the most likely one to have influence on the results would be if the survey respondents, the

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interview volunteers, or both were more positive toward research, or at least to this particular study. The effect would be a higher participation proportion of practitioners with either a professional interest in research or more training in research (indicative of longer training programs). Such a participation trend was discernible in the data: the two small massage therapy associations with regulatory and high competency policies each had 17.1% participation rates, while the TMB association with lower competency standards had a 10.2% participation rate. However, the two small associations contributed only 20–25% (range because some responses had no association affiliation listed) of the total questionnaire responses. As well, 41.3% of all participating practitioners listed their primary training programs as 500 hours or fewer, including members of those two smaller associations. The net result is that the interview volunteer rate does not seem to indicate that either research-positive longer training programs or organization policies significantly influenced the questionnaire participation rate. However, even if skewing were affecting the data, the effect on the key results summarized in Section 8.2 would be minimal: TMB training will still be highly variable; practitioners will still be trained in many therapies; clinical experience will continue to change practice; and individualization will remain important to the process of clinical treatment. The arising conclusions and recommendations therefore would remain unchanged.

8.3.4 Combined methods: inference quality

This study’s use of combined methods to address the research question was critical to achieving the outcomes. The study started with a quantitative-dominant, qualitative-supportive combined methods model in which the interviews were expected to

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primarily provide context for the survey results. By the time analysis was complete, however, the study’s model had evolved to equal weighting of quantitative and qualitative data. Results arising from each research method synergistically led to much deeper understanding of how training, clinical experience, and practice goals come together in clinical treatment provision. Specifically, clinical practice is critically dependent on a practitioner’s entire training profile and ongoing clinical experience, and little can be understood about clinical practice by solely looking at training demographics or any other isolated practice aspect. These interdependent factors of practice seem self- evident, yet without them having been critically considered during the research process, much research on TMB has failed to appropriately accommodate or address the potential effects of these practice issues. The use of combined methods in this study has therefore led to understanding what changes need to occur and why they are needed in TMB research (Section 8.5) and education (Section 8.6).

8.3.4.1 Combined methods design quality (combined methods legitimation)

The quality of a combined methods research process should be assessed (85) using criteria specific to its methods. Teddlie and Tashakkori (80) outline two domains, design quality and interpretive rigour, that should be examined to ascertain the overall inference quality achieved by the combined methods research process. Design quality encompasses the criteria used to assess the degree of rigour applied throughout the combined methods process. Assessing it involves asking six specific questions (80). Two questions that relate to the quality of qualitative and quantitative data have been addressed in the limitations sections above. That leaves the following four issues (p 40)

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(80).

1) Whether the design is consistent with the research question and purpose.

2) Whether the data analysis techniques are sufficient and appropriate for

providing answers to the research questions.

3) Whether the derived inferences are consistent with the research questions and

purposes. Additionally, the inferences obtained from the qualitative and

quantitative research components should be consistent with the corresponding

research questions.

4) Whether the inferences are consistent with the results of the data analyses and

strongly reflect the data findings.

The purpose of this study was to ascertain the relationship of TMB practitioner training and practice demographics with how TMB practice occurs, and thence the implications for TMB research. The design and data analysis methods were chosen to best address the research purpose and questions. The results and conclusions, based on both the qualitative and quantitative results, appear internally consistent, and are consistent with the research questions and purpose of the study. Furthermore, because the results are based on descriptive statistics and a qualitative descriptive analysis, the derivation of the results minimizes need of interpretive extrapolation from the data. Thus, the design and processes used appear to present—notwithstanding the low survey response rate—a reasonable degree of combined methods design quality.

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8.3.4.2 Combined methods interpretive rigour

Interpretive rigour encompasses the standards used to assess the validity of the combined methods conclusions. These are more complex issues, including (p 40–41)

(80):

1) Whether the degree to which the answers to different aspects of the research

questions are consistent with each other, and the known state of knowledge

and theory.

2) Whether the final inferences are consistent with the ones obtained from the

qualitative and quantitative components of the research project.

3) Whether the inferences consider the current literature and are consistent with it.

4) Whether the inferences are distinctively superior to other possible

interpretations.

Based on these issues, I believe that a high degree of combined methods interpretive rigour has been achieved. The answers to the different components of the research questions are strongly consistent, and lead to tightly and synergistically- developed global inferences. The answers and final inferences concur with other TMB research, as well as with the theoretical literature found on practice, expertise, and ethics as described earlier in this thesis. Finally, focusing on the meaning of the qualitative and quantitative results, I explored other possible inferences of the combined methods approach, particularly others that could arise from the scenarios identified in the above limitations sections. No convincing alternate interpretations were derived.

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8.4 Implications of the results for research

Many TMB research projects have used simple, prescribed treatment protocols because they provide the greatest treatment control and ease of analysis, but they rarely reflect normal practice. This study’s results suggest that high practitioner variability and the attempt to minimize individualization may be important factors when those research projects produce non-conclusive results for all but the most general of outcome effects such as reduction of stress or depression (two common positive TMB research outcomes). Additionally, there is a barrier to the translation of the research results into practice because of how practitioners conceive of and experience clinical practice relative to the protocols. Some TMB research projects have attempted to circumvent the issue of differences between practitioners by using a single practitioner to provide all treatments.

This choice assumes that all practitioners would have equal success applying the protocol, significantly reducing generalizability because of the actual training and clinical experience differences between most TMB practitioners. As discussed above, treatments using students or inexperienced practitioners can have different outcomes than those of experienced practitioners. This suggests there will also be research translation problems

“because few experienced practitioners practice in the simple, mechanical manner of a student or recent graduate (71, 86).” (3) Thus, research projects with designs that do not reflect the complex reality of clinical TMB practice should include scrutiny of the research design, results, and interpretation for the potential effects of practitioner-specific training(s) and clinical experience on the treatment outcomes. Additionally, “practitioner input in protocol design is important [so that the protocols can better reflect clinical practice]. Practitioners and researchers not fully understanding or discussing the

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implications of the variability in training and in normal treatment provision may still produce research protocols that yield inconclusive results.” (3)

A key finding of this study was the nexus of individualization to normal clinical practice. Practitioners’ descriptions of immersing their awareness in the nuanced and contextual reality of their clients’ tissues and experiences suggest a similarity to Schön’s

“immersed practice epistemology” (72) where clinical treatment requires fluid, mutable engagement and a state of “unknowing”. This contrasts with the explicit and controlled research treatment protocols of a post-positivist “rational” research epistemology (72).

Based on previous experience reading published research literature, the interviewed practitioners surmised that TMB clinical trials employ restrictive post-positivist research designs or other constricting factors, such as non-typical practitioners (discussed below), that limit credibility from a practice epistemology perspective (for four protocol examples with commentary, see Appendix 1, page 133). Thus, as research treatments have rarely reflected how therapies are applied in practice, the interviewed practitioners have developed a cautionary scepticism toward the applicability of TMB research results.

This indicates that standard randomized controlled trial research methods and knowledge translation of TMB research results are failing the TMB community. The dissimilarity of the immersed-practice and post-positivist epistemologies is likely the source of the TMB research-practice gap.

Amongst other factors, bridging that gap between the two epistemologies requires an understanding by the researchers of the reality of clinical practice (87). This study has articulated some of the practitioner’s “private knowledge” and “intuitive practice” (p 229

(87)) that underlie experienced practitioners’ clinical treatment processes. This will help

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the development and implementation of practice-reflective research methods.

One related gap in the interview data is the lack of practitioners’ awareness of the body of TMB research and research designs with relevance to a practice-based epistemology. Exploring the reasons for that lack was beyond the scope of this project, though the recent advent of research literacy within the TMB professions, as well as the significant barriers to accessing much of TMB research literature, are likely involved (88,

89). The fourth research protocol described in Appendix 1, page 133 is an example of this gap, an early research project that in many ways did not fit the interviewed practitioners’ concerns about research projects.

Careful review of each of the above issues leads to very specific recommendations regarding TMB research. There is a clear need for: (a) reporting and comparing precisely the education and clinical experience of practitioners participating in research; and (b) closing the research-practice gap through (i) using research treatments that more closely resemble clinical practice and (ii) reporting research results in a manner that facilitates translation into clinical practice. The next sections present recommendations for addressing each of these issues.

8.5 Recommendations for TMB research

8.5.1 Recommendation 1: Publishing practitioner descriptors

This study’s results indicate that finding similarly trained or similarly practicing practitioners will be unlikely. Effective translation of research results will therefore require a thorough understanding of the particular skills and clinical experience of the practitioners providing the TMB research treatments.

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The lack of practitioner uniformity and sparse reporting of practitioner skills is not unique to TMB, as indicated by the inclusion of practitioner qualifications and expertise in the 2008 Consolidated Standards of Reporting Trials (CONSORT) Statement extension for Non-Pharmacological Treatment Interventions (internationally adopted publication guidelines for clinical trials) (90). The CONSORT Statement also includes intervention standardization and tailoring. Specifically identifying those variables in the

CONSORT Statement “indicates a growing awareness that practitioner variability may be affecting clinical trial results of many healthcare procedures, such as, ‘… physiotherapy,

… and complementary and alternative medicine’ (emphasis mine based on the relevance and similarity to TMB practices) (page W60 (90))” (2). While the CONSORT

Statement is specific to randomized, controlled, clinical trials, this study’s results indicate the CONSORT Statement is relevant to any form of TMB trial, study, or case report, all of which may be affected by idiosyncratic practice.

8.5.2 Recommendation 2: Appropriate research design

Several research designs and approaches (longitudinal observation, case reports/series and single subject research, pragmatic and comparative effectiveness trials, combined/mixed methods, and whole systems research) are able to capture the intuitive and deliberate practitioner responses to clinical situations. These designs should therefore preferentially be used in TMB research. These designs can also accommodate the innate and deliberate individualizing process, accepting that idiosyncratic practice likely cannot be eliminated from practitioners’ treatments and may be contributing to better treatment outcomes. These designs should be examined in research literacy courses, accompanied

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by exemplars of research projects using them, so that practitioners are exposed to forms of profession-relevant research designs.

The complexity of practice and the multiple factors contributing to successful treatment outcomes makes TMB clinical trials strong candidates for combined- or mixed- methods research. Combined-methods research integrates qualitative and quantitative research approaches, and can be used to identify and capture the expected and unknown practice inputs, contextual issues, and relevant outcomes that would otherwise be lost in single-method trial designs. Details relevant to this particular research design and its appropriateness for TMB research are discussed in the first manuscript of this thesis (1).

Pragmatic trials and comparative effectiveness trials are two research designs that can be used to address the methodological problems caused by the individualized nature of clinical practice. They do not require uniformly applied treatments, but rather focus on achieving specific treatment outcomes, treating the therapy as a “package” (including practitioner-patient relationship, patient expectations of the therapy, natural treatment setting, individualization (91-93)). These trial designs could also be employed to identify whether application fidelity of a therapy treatment or protocol is critical for achieving a specific treatment goal, for example, assessing how variability or choices in treatment protocol application affects the treatment outcomes. This knowledge could increase the long-term value of TMB research by helping focus TMB researchers on the training or practice issues that are critical to achieving successful, relevant research outcomes. (1,

91, 94-96) Other classic forms of research, such as longitudinal observational and cohort research projects, case reports or case series, and single subject research are often overlooked. This neglect may arise from a focus on the tip of the evidence pyramid and

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on evidence-based medicine, which emphasise the randomized controlled trial design and literature reviews/meta-analyses as the “gold standards” (26, 97). However, the other classic forms of research provide reputable researched knowledge, and may be better able to reflect clinically relevant TMB research results (26). Ultimately, the field of whole systems research, a research movement focused on addressing the shortcomings of randomized controlled trials in CAM research by viewing CAM treatments as complex systems, provides a rich theoretical and conceptual framework (98) in which all of the above research designs fit (97, 99, 100). A primary tenet of whole systems research is the indivisibility of a complex system (network of patient, therapist, and treatment effects within the system context) into component parts, addressing the problem that a reductionist approach will likely miss significant factors that have important input and effect on the measured outcomes (99, 100).

With clinical practice based on individualization, development of treatment protocols for TMB research should accommodate the variations inherent in TMB practice. One approach would be to use clinical practice-based standardized protocols with potential, planned variations. These should be established during the development of

TMB research projects in collaboration with TMB practitioners so that treatments can be more individualized to the patient during treatment. Such protocols also would ensure the practitioners providing the research treatments understand what variations are allowable within the context of the research treatment. This type of treatment protocol design often includes training of practitioners to help equalize the treatment process between practitioners, ensuring treatment fidelity during the research process. Such an approach has been documented in acupuncture and physiotherapy trials (see for example a recent

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multi-modal physiotherapy trial (101) and in the acupuncture extension to the CONSORT guidelines (102)). In such a system, the TMB practitioners can also precisely record their initial and on-going assessments and resultant treatment choices for a specific treatment issue or when using a delineated but somewhat flexible routine. Such treatment notes can be analyzed qualitatively and, thus, increase understanding of the situational factors (e.g., experience-base practitioner assessments and details of the treatment decision making) that produce the most successful or least effective outcomes (103, 104). While using such protocols with potential variations may require larger sample sizes, the results should yield greater clinical relevance. Consideration of practitioner variability and subsequent

TMB dosing variation on the research outcomes should also be routinely discussed in dissemination of the research results.

“No TMB literature directly addresses the research-practice gap. A modest body of work about the research-practice gap to which this study’s results could be compared was found in the literature of the paramedical fields of nursing and physiotherapy from the early 2000s, usually linked to the development of professional practice and expertise

(86, 87, 105-107)” (4), and in the field of education (e.g., Schön) from the mid-1980s.

This suggests those professions’ literature should be regularly reviewed for new literature and research project collaboration opportunities focussed on addressing the research- practice gap.

Issues of practitioner variability and protocol flexibility are also part of the inherent nature of psychotherapy, and are being actively explored in that field e.g., the work of Davidson and Scott (108), and Walwyn (109). In 1991, Persons summarized then-current perspectives on psychotherapy research issues of practitioner variability, 115

protocol adherence, practitioner-patient effects, and consideration of the “scientist- practitioner gap” (110). Many of the issues parallel the issues and solutions suggested in this study. Future exploration of this profession therefore should be considered for additional ideas on addressing these key research issues in TMB research.

Finally, this study addressed the effect on research of variability between TMB practitioners. This is not the only source of practice variability that could be affecting outcomes in TMB research. A review of the placebo, medical, and psychological literature reveals several factors that may need similar consideration; among them is the practitioner-patient relationship (111-114). This relationship is considered a corner-stone of health care delivery, and is acknowledged to have beneficial effects on treatment outcome (115). At its most basic, the relationship is conceived as one of trust, honesty, respect, and a desire by both the patient and practitioner to improve the patient’s outcomes (115). It is mediated by both the skills and experience of the practitioner and the personal attributes of the patient, as well as being affected by the environment/context of the interaction (115). It therefore represents another research variable that should be considered in a manner similar to practitioner variability during the design and interpretation of TMB research (111).

8.5.3 Recommendation 3: Translating research results

The creation of new knowledge through research does not automatically lead to uptake or application of the results (116); effective knowledge translation initiatives bridge those gaps (117, 118). TMB knowledge translation initiatives can be implemented through more effective, TMB-focused reporting of research results, and through specific

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education of the practitioners, which will be the priority of Section 8.6. Practitioner responses during this study’s interviews indicate that current research uptake and clinical application is minimal. Increasing the uptake and application of TMB research would require addressing the practitioners’ concerns causing the disconnect between research treatment protocols and the process of clinical practice. This could occur through several strategies. For example, a discussion of the congruence or dissimilarity between the research treatment protocols used in a TMB research project and clinical practice could be reported in research articles. Interpretation of the research project results in comparison with clinical practice could also be provided. Both strategies would help elucidate the limitations and opportunities for applying the results to clinical practice.

Using practice-friendly educational formats such as case studies in which the research results are applied in practice, especially using the language and perceptions of clinical practice, could also help increase the clinical relevance of the results. If clinical practice change is a goal of the research, the TMB practitioners in the research projects should be involved in writing the results to ensure the language and results presentation meet the clinical practice needs of their TMB colleagues. TMB practitioners should also be approached to help develop knowledge translation and dissemination solutions appropriate to their professions because peer-reviewed research journals focused on TMB are not yet the primary source of information accessed for practice-changing information.

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8.6 Implication of the results for TMB education

Several TMB schools and practitioner organizations are now offering research literacy courses or recommend the Massage Therapy Foundation courses

(www.massagetherapyfoundation.org/education/research-literacy-courses/). As mentioned above, the implementation of knowledge translation initiatives is increasingly being recognized as a critical part of the research process, leading to practice change when needed and appropriate (117, 118). From an educational perspective, this requires practitioners to have the research literacy and knowledge translation skills necessary to read and critique research in their field as well as to determine if the research results are applicable to their work or patients, and if so how to adapt the results to practice.

However, research literacy definitions and course competencies do not always include provision for the ability to extrapolate and apply skills, protocols, and ideas from the limited scenario of the research to real-life clinical situations. This study’s results indicate that only having the skills to read and interpret TMB research will not fully empower

TMB practitioners to translate and adapt research results into clinical practice.

Additionally, “creating profession-wide agreed-upon competency standards for each TMB therapy being taught would be prudent.” (3) This would facilitate consistent communication and ensure that core or root therapy techniques would be consistently transferred to the next generation.

“Applying the theories of Schön and Dreyfus, the development of clinical practice expertise comes from both integrating and embodying the practitioner’s many clinical experiences, which is facilitated by conscious self-reflection on the clinical outcomes from actions and choices made during practice (71, 72, 119). Most of the interviewed

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practitioners believed their TMB training programs did not prepare them for consciously and efficiently developing advanced practice skills and expertise in their TMB therapies, a process instead left to personal exploration. [They specifically criticised the limited provision in most programs for developing skills in integrating multiple therapies during treatment, even when the programs included multiple therapy training.] Based on the interview data, at least three related educational concepts can be proposed: (a) Educate students to consciously reflect on how they are learning their skills and techniques, and how to consciously contemplate the results of their actions in practice; (b) Include in educational programs discussion of whether and how the therapy can effectively integrate other therapies or be gainfully integrated into other therapies, or whether it is best in isolation, and why; and (c) Include discussion in educational programs regarding how, as practitioners, students might best learn to integrate other therapies (TMB or other) into their repertoire of techniques, or guard against their influence or integration if that might be needed in a given clinical situation or desired by a therapy’s profession.” (3)

8.7 Future research initiatives

No research projects have addressed the effects of multiple-therapy training or clinical experience on practice. Previous research projects of TMB practitioner education and practice demographics (19, 20, 36, 45, 69) have been limited in scope and usually focused only on massage therapists. Results were not based on the perspective of an individual practitioner, listing only population percentages of the different therapies practiced. As the first TMB research project to carefully consider the similarities and differences between TMB practitioners, the current investigation should therefore be

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replicated in other jurisdictions, and secondary analyses of the previous surveys done for comparative purposes. As well, the low response rate of non-massage therapist participants (n=53, 6.7%) prevented statistical comparisons between the massage therapy and non-massage therapy practitioners, though no difference was found during review of the practitioner interviews. Future TMB research will need to determine if substantial differences not identified in this study exist between the massage and non-massage therapists. If substantial differences were to be found, a review of this study’s results from the non-massage therapist perspective would be needed to confirm or disprove its applicability to that group.

The results lead to recommendations for the design of TMB research as discussed above in Section 8.5.2, but also suggest some specific research projects that could verify significant effects of practitioner variability on research treatment outcomes. One such project could ascertain the differences in clinical outcomes of a TMB practitioner- approved protocol applied by a cohort of similarly trained and experienced practitioners compared to a cohort of dissimilarly trained but experienced practitioners who practice the particular therapy being applied or studied. This would help discern the extent of the impact of practitioner variability on TMB research outcomes, and therefore what level of accommodation is warranted with regard to practitioner variability when designing TMB research. Documenting and understanding the process and use of intuition and other forms of TMB practitioner decision-making during practice may help elucidate the treatment provision factors affecting practice outcomes. Finally, the literature is not clear on whether the differences between therapies or techniques results in germane differences between treatment outcomes or if the skills and clinical experience of the practitioners are

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more relevant, an intriguing and important question given the high degree of practitioner training variability.

The above suggestions and the recommendations in Section 8.5.1 to 8.5.3 address closing the research-practice gap from the perspective of designing and reporting research from a researcher’s perspective. Additional knowledge translation and implementation research are necessary to ascertain how to best translate research into clinical practice, for example, what pedagogical forms and distribution routes of research reporting are most effective for TMB practitioners? What modifications are needed in the current research literacy courses for TMB practitioners to facilitate research transference, implementation, and practice change? How can language for TMB practice communication be developed and implemented to facilitate intra- and inter-professional communication? Answers to these questions would inform both research reporting and research literacy and transference training.

8.8 CONCLUSIONS

This is the first study to carefully examine the influences of training and clinical experience on practice, and subsequently consider the implications of the findings for

TMB research. Using a variety of strategies, traditional-design TMB efficacy trials have attempted to compensate for practitioner variability without understanding the nature of that variability or its impact on the research outcomes. The four study results below provide information critical to this topic:

1) Practitioners are variably trained: there is no typical training except perhaps

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some typical core competencies for some therapies, and the variety of therapy

competencies practitioners train in over time is unique to each practitioner.

2) The variety of therapies trained in and practitioners’ clinical experience create

idiosyncratic practice for each practitioner.

3) Clinical practice has a nexus of individualization.

4) Practitioners do not surmise clinical trials to be accommodating practitioner

variability or individualization. They therefore question the motivation of the

research and the applicability of its results to their personal practice.

The study results imply that efficacy trials that do not address practitioner training and clinical experience but are meant to find clinically relevant results are likely a waste of resources. This is because translation of such efficacy trials to clinical practice will neither represent a “typical” practitioner, nor reflect “typical” practice when they employ

TMB students, non-TMB, or singular-idiosyncratic practitioners and non-practice style

(highly proscribed) treatments. The practitioners’ descriptions of these issues identify these issues as the origin of the sizable research-practice gap that underlies the practitioners’ expressed distrust of such research. Developing research methods that accommodate the above four factors when evaluating clinical effectiveness of a therapy, or determining best clinical practice for specific clinical situations seems crucial for producing clinically relevant results.

Examining potential implications of the study results provides an informed perspective on specific research design and knowledge solutions that could resolve the above-identified issues and current barriers to creating TMB practice-relevant research.

Recommendations based on these implications include:

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Research:

1) Ascertain the potential impacts of practitioner training, qualifications, and

expertise on any planned TMB research;

2) Use combined methods to identify and capture the relevant outcomes of the

specific TMB being applied; and

3) Use research methodologies such as pragmatic and comparative effectiveness

trials that are better able to accommodate the inherent individualization of

clinical practice (which likely occurs in all clinical trial protocols).

Knowledge translation:

1) Research results should be reported using pedagogical and knowledge

translation strategies that make the results relevant to TMB practitioners and

transferable to their clinical practice;

2) Fully describe the qualifications of the TMB practitioners providing the

research treatments: the relevant training background, experience level, and

expertise, and their consequent potential impacts on the results as well as on

the generalizability and transferability of the results; and

3) Precisely detail the research treatment protocols and patient inclusion/exclusion

criteria so that the limitations and possibilities are clear for adapting the

research results by into clinical practice.

Education:

1) Ensure that TMB research literacy programmes include competencies on how

to adapt research results to the high patient variability and individualized care

that constitutes actual clinical practice; and

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2) Educate TMB practitioners to learn how to consciously and intentionally

evolve their practice.

It is hoped that the study results and these consequent recommendations will lead to two critical outcomes. One is the discussion, debate, refinement, and finally implementation of these recommendations in order to create clinically relevant and transferable or adaptable TMB research. The second is to ensure that TMB practitioners can maintain and evolve an evidence-informed practice, which would ultimately create better patient care.

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86. Benner P. From Novice to Expert: Excellence and Power in Clinical Nursing Practice. Upper Saddle River, USA: Prentice Hall; 2000. 87. Roskell C, Hewison A, Wildman S. The Theory-Practice Gap and Physiotherapy in the UK: Insights from the nursing experience. Physiotherapy Theory and Practice. 1998;14(4):223–33. 88. Dryden T, Findlay B, Boon H, Mior S, Verhoef M, Baskwill A. Research requirement: literacy amongst complementary and alternative health care practitioners - Phase 1 Report. Ottawa, Canada: Natural Health Products Directorate, Health Canada, 2004. 89. Willinsky J, Quint-Rapoport M. How Complementary and Alternative Medicine Practitioners Use PubMed. Journal of medical Internet research. 2007;9(2):e19. Epub 2007/07/07. 90. Boutron I, Moher D, Altman D, Schulz K, Ravaud P, The CONSORT Group. Methods and Processes of the CONSORT Group: Example of an Extension for Trials Assessing Nonpharmacologic Treatments. Annals of Internal Medicine. 2008;148(4):W60 - W6. 91. MacPherson H. Pragmatic clinical trials. Complementary Therapies in Medicine. 2004;12(2-3):136-40. 92. Linde K, Jonas W. Evaluating Complementary and Alternative Medicine: The Balance of Rigor and Relevance. In: Jonas W, Levin JS, editors. Essentials of Complementary and Alternative Medicine. Baltimore, U.S.A.: Lippincott Williams & Wilkins; 1999. p. 57–71. 93. Thomas K, Fitter M. Possible Research Strategies for Evaluating CAM Interventions. In: Lewith G, Jonas W, Walach H, editors. Clinical Research in Complementary Therapies: Principles, Problems and Solutions. London, UK: Churchill Livingstone; 2002. p. 59–91. 94. Verhoef M, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A. Complementary and alternative medicine whole systems research: Beyond identification of inadequacies of the RCT. Complemenary Therapies in Medicine. 2005;13(3):206–12. 95. Verhoef M, Vanderheyden L. Combining qualitative methods and RCTs in CAM intervention research. In: Adams J, editor. Researching Complementary and Alternative Medicine. Milton Park, Oxon: Routledge; 2007. p. 72–86. 96. Horn SD, Gassaway J. Practice-based evidence study design for comparative effectiveness research. Med Care. 2007;45(10):S50. 97. Walach H, Jonas W, Lewith G. The Role of Outcomes Research in Evaluating Complementary and Alternative Medicine. In: Lewith G, Jonas W, Walach H, editors. Clinical Research in Complementary Therapies: Principles, Problems and Solutions. 1 ed. London, UK.: Churchill Livingstone; 2002. p. 29–45. 98. Botha ME. Theory Development in Perspective: The role of conceptual frameworks and models in theory development. J Adv Nurs. 1989;14(1):49–55. 99. Verhoef M, Lewith G, Ritenbaugh C, Boon H, Fleishman S, Leis A. Complementary and alternative medicine whole systems research: Beyond identification of inadequacies of the RCT. Complementary Therapies in Medicine. 2005;13(3):206–12.

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100. Ritenbaugh C, Verhoef M, Fleishman S, Boon H, Leis A. Whole Systems Research: A discipline for studying complementary and alternative medicine. Alternative Therapies. 2003;9(4):32–6. 101. Bennell KL, Egerton T, Pua YH, Abbott JH, Sims K, Buchbinder R. Building the Rationale and Structure for a Complex Physical Therapy Intervention Within the Context of a Clinical Trial: A Multimodal Individualized Treatment for Patients With Hip Osteoarthritis. Phys Ther. 2011;91(10):1525-41. 102. MacPherson H, Altman D, Hammerschlag R, Youping L, Taixiang W, White A, et al. Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): Extending the CONSORT Statement. PLoS Med. 2010;7(6):e1000261. Epub June 8, 2010. 103. Caspi O, Bell I. One Size Does Not Fit All: Aptitude x Treatment Interaction (ATI) as a Conceptual Framework for Complementary and Alternative Medicine Outcome Research. Part I—What is ATI Research? . The Journal of Alternative and Complementary Medicine. 2004;10(3):580–6. 104. Caspi O, Bell I. One Size Does Not Fit All: Aptitude x Treatment Interaction (ATI) as a Conceptual Framework for Complementary and Alternative Medicine Outcome Research. Part II—Research designs and their applications The Journal of Alternative and Complementary Medicine. 2004;10(4):698–705. 105. Bero LA, Grilli R, Grimshaw JM, Harvey E, Oxman AD, Thomson MA. Closing the Gap between Research and Practice: An Overview of Systematic Reviews of Interventions to Promote the Implementation of Research Findings. BMJ. 1998;317(7156):465–8. 106. Dunphy BC, Williamson SL. In Pursuit of Expertise. Advances in Health Sciences Education. 2004;9(1):107–27. 107. Jensen GM, Gwyer J, Shepard KF, Hack LM. Expert practice in physical therapy. Phys Ther. 2000;80(1):28. 108. Davidson K, Scott J. Does therapists' competence matter in delivering psychological therapy? The Psychiatrist. 2009;33:121–3. 109. Walwyn R. Therapist variation within randomised trials of psychotherapy: implications for precision, internal and external validity. Stat Methods Med Res. 2010;19(3):291 – 315. 110. Persons JB. Psychotherapy Outcome Studies Do Not Accurately Represent Current Models of Psychotherapy. Am Psychol. 1991;46(2):99 – 106. 111. Squier RW. A model of empathic understanding and adherence to treatment regimens in practitioner-patient relationships. Soc Sci Med. 1990;30(3):325 – 39. 112. Kelley JM, Lembo AJ, Ablon JS, Villanueva JJ, Conboy LA, Levy R, et al. Patient and Practitioner Influences on the Placebo Effect in Irritable Bowel Syndrome. Psychosom Med. 2009;71(7):789 – 97. 113. Richardson J. Intersubjectivity and the Therapeutic Relationship. In: Peters D, editor. Understanding the Placebo Effect in Complementary Medicine. 1 ed. London, U.K.: Churchill Livingstone; 2001. p. 131 – 46. 114. Di Blasi Z, Harkness E, Ernst E, Georgiou A, Kleijnen J. Influence of context effects on health outcomes: a systematic review. The Lancet. 2001;357(9258):757 – 62.

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115. American Health Ways. Defing the Patient-Physician Relationship for the 21st Century. Nashville, U.S.A: American Healthways, 2003. 116. Agency for Healthcare Research and Quality. Translating Research into Practice. Rockville, U.S.A.: U.S. Department of Health and Human Services, Public Health Service, 2001. 117. Graham ID, Logan J, Harrison MB, Straus SE, Tetroe J, Caswell W, et al. Lost in knowledge translation: Time for a map? J Contin Educ Health Prof. 2006;26(1):13-24. 118. Canadian Institutes of Health Research. More About Knowledge Translation at CIHR. 2012 [March 5, 2012]; Available from: http://www.cihr-irsc.gc.ca/e/39033.html. 119. Schön D, A. Educating the Reflective Practitioner. 1 ed. San Francisco: Jossey- Bass Publishers; 1987. 355 p. 120. Hsieh LL, Kuo CH, Lee LH, Yen AM, Chien KL, Chen TH. Treatment of low back pain by acupressure and physical therapy: randomised controlled trial. BMJ. 2006;332(7543):696-700. Epub 2006/02/21. 121. Aourell M, Skoog M, Carleson J. Effects of Swedish massage on blood pressure. Complemenary Therapies in Clinical Practice. 2005;11:242–6. 122. Soden K, Vincent K, Craske S, Lucas C, Ashley S. A randomized controlled trial of aromatherapy massage in a hospice setting. Palliat Med. 2004;18(1):87–92. 123. Preyde M. Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Canadian Association of Medicine Journal. 2000;162(13):1815–20.

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Appendix 1: Commentary on Four TMB Research Protocols

Example 1.

Lisa Li-Chen Hsieh, Chung-Hung Kuo, Liang Huei Lee, Amy Ming-Fang Yen, Kuo-

Liong Chien and Tony Hsiu-Hsi Chen. Treatment of low back pain by acupressure and physical therapy: a randomized controlled trial. BMJ 2006; 332: 696-700. (120)

From the Methods:

“Each participant received six sessions within one month. One senior acupressure therapist gave each session of acupressure treatment to ensure a uniform technique and consistent experience.” (page 697 (120))

From the Discussion:

“Finally, the effectiveness of any manipulation therapy is highly dependent on the therapist’s technique and experience. The selection of treatment modality and technique to be applied to patients depended on the discretion of the therapist for both physical therapy and acupressure, even though standardised procedures were established… The use of a single therapist may enhance internal validity but also imposes a threat to external validity. We hope that this technique can be imparted to other therapists…”

(page 700 (120))

Commentary:

This pragmatic trial of acupressure uses standard practice of physiotherapy (many possible treatment options allowed at the physiotherapists’ discretion) as a comparative group, with no descriptors provided for the physiotherapists (training, regulation, experience, etc.). The reported treatment methods provide no insight into the clinical

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relevance of the acupressure treatments, because it cannot be determined if one standard protocol, multiple possible protocols, or therapist discretion was used to provide treatment. The description, “one senior acupressure therapist” (page 697 (120)) leaves significant gaps regarding the training and experience of the therapist: (a) What style or lineage of acupressure is practiced?; (b) Are there influences from other therapies the practitioner may be trained in?; and (c) what are the expectations of being a “senior” practitioner? Additionally, being experienced can imply that there is unconscious individualization occurring during the practitioner’s treatments. It is only in the discussion that any mention of standardized procedures are mentioned, but not enough to answer the earlier questions. No explanation of the choice to use only one therapist is provided. Yet, the authors acknowledge that the use of a single therapist could limit external validity, and assume (no references provided) that “effectiveness of any manipulation therapy is highly dependent on the therapist’s technique and experience.”

(page 700 (120))

Researchers cannot easily develop further research based on these results, nor could they assume that a local acupressure practitioner would achieve the same results without further details. Similarly, medical clinicians cannot easily make recommendations or referrals to local acupressure practitioners because the research project’s lack of information about the practitioner or the treatments provided prevents generalizing to the local acupressure practitioners. Acupressurists may feel that the research supports the idea that acupressure has therapeutic value for low back pain, but the research provides no guidance on how they might provide similar treatments or assess their patients to determine if a protocol similar to the one used (should they learn of the

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protocol) might be appropriate. Thus, while the research found positive results, the research design and lack of reporting of both protocol(s) and therapist qualifications severely limit the use of this research.

Example 2

Moa Aourell, Martina Skoog, and J Carleson. Effects of Swedish massage on blood pressure. Complementary therapies in clinical practice 2005; 11(4): 242–246. (121)

From the methods:

“The participants were randomised to receive massage either on BNC [the back, neck, and chest] or extremities (LAF) in the first period. During the washout period, the participants were asked not to participate in any similar treatment, but to continue normal daily life. In the second period, the massage was applied to the other body areas compared to the first period. All treatments were carried out between 1700 and 2000 h

[hours], with the minimum of 1 day and maximum of 2 days in between the treatments per week. All participants received two treatments per week during each treatment period consisting of 4 weeks. The participants were given massage for 30 min [minutes] in each treatment. They lay on a bench, face down, at the start of treatment, and changed position during treatment to lie on the back. Massage was given on back (17 min), chest (7 min), and neck (6 min) in one group. The other group received massage on leg and foot (left and right 2 x 8.5 min), arm and hand, right and left (4.5 min), and face (4 min). Massage lotion was used and all massage treatment was done with the participants listening to soft classical music.” (page 243 (121))

From the discussion:

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[No information about the practitioners or the protocol was discussed.]

From the acknowledgment:

“We are grateful to … the Physiotherapists Miss Moa Aourell, Miss Martina

Skoog, Miss Maria Glemme and Miss Elisabeth Hallberg for doing all the massage treatment during their last semester during their basic training as physiotherapists.” (page

245 (121))

Commentary

This research project is typical of many. The introduction of the article mentions

Swedish massage once, and then uses the generic term “massage” for the rest of the article. The actual treatment techniques and protocols appropriate to each area massaged are never mentioned in the methods section or in the discussion. Nor is there indication of the basis on which the treatment protocol was developed. No mention is made of the practitioners or their training until the acknowledgements, which reveals that physiotherapy students provided the treatments (two of whom are also the lead authors).

There are therefore many unverifiable assumptions: 1) whether this was based on training in Swedish massage and other techniques as part of their physiotherapy training or if they learned special techniques for this intervention; 2) the similarities and differences between Swedish massage provided by physiotherapy students and massage providers who regularly use Swedish massage (who may or may not be trained in other TMB therapies); and 3) how the possible lack of clinical experience may or may not be affecting the outcomes. The results showed a statistically significant but “minor decrease” in blood pressure. Based on this the authors suggest Swedish massage may be tried in patients with slightly elevated blood pressure due to stress, even though stress or

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anxiety were never measured, only blood pressure. All the recommendations in Section

8.4 of this thesis are appropriate to this research project, as it is difficult to develop further research, make clinical recommendations, or provide clinical treatments based on the information provided in the article.

Example 3.

Soden, K., Vincent, K., Craske, S., Lucas, C., & Ashley, S. (2004). A randomized controlled trial of aromatherapy massage in a hospice setting. Palliative medicine, 18(2),

87–92. (122)

From the Methods:

“The two massage groups received a standardized 30-minute back massage weekly for four weeks.” (page 88 (122))

From the Discussion:

“The controlled nature of the massage intervention meant the therapists were unable to tailor the treatment to individual patients. This factor, together with the giving of massage within a research setting, may have undermined its true effects… If the provision of aromatherapy and massage within palliative care is to be further expanded, however, there are considerable cost implications in terms of training, nursing time and equipment.” (page 91 (122))

Commentary:

Interpretation and application of the results are hindered by the lack of specificity regarding the type and location of pain, only described as cancer-induced, that the massage treatments are meant to affect. The pain measurement scales are equally vague

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regarding type and location. The methods section of the article is extremely sparse on detail, and information in the article does not adequately support the choice of massage for treatment of pain: there is no indication that 30 minutes of undefined massage on a patient’s back is appropriate or adequate treatment for pain (the primary outcome measure). The discussion reveals that a controlled protocol preventing individualization was used, with no further detail about the protocol or how it was developed. The authors do acknowledge that the inability to tailor treatment may have affected outcomes, but provide no basis for such statement. The final quoted passage seems to indicate that nurses were the actual treatment providers, but no further information about the practitioners or their training in massage or the specific protocol can be gleaned. Further research cannot be developed based on this research project. Clinicians could assume that massage therapy is inappropriate for pain management if they do not critically read the entire article. Such articles and research likely negatively affect how massage therapy practitioners perceive research of their profession.

Example 4.

Preyde, M. (2000). Effectiveness of massage therapy for subacute low-back pain: a randomized controlled trial. Canadian Medical Association Journal, 162(13), 1815 – 20.

(123)

From the Methods:

“For subjects in the comprehensive massage therapy group various soft-tissue manipulation techniques such as friction, trigger points and neuromuscular therapy were

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used to promote circulation and relaxation of spasm or tension. The exact soft tissue that the subject described as the source of pain was located and treated with the specific technique indicated for the specific condition of the soft tissue (e.g., friction for fibrous tissue and gentle trigger points for muscle spasm). The duration of the soft-tissue manipulation was between 30 and 35 minutes… Two treatment providers were hired to deliver treatments, but it became necessary for the principle investigator, who is also a registered massage therapist, to provide treatment when the other providers experienced personal distress (e.g., death of a family member). The two providers hired for this research project underwent training to enhance treatment delivery and similarity of delivery techniques; they also underwent process checks. Two of the treatment providers were massage therapists with more than 10 years' experience each; they provided treatment for the comprehensive massage therapy and soft-tissue manipulation groups.”

(page 1816 (123))

From the Discussion:

“Limitations of the study included the use of a single setting, the use of a specific form of massage therapy provided by only 2 massage therapists, unmeasured provider effects on the validity of outcome measures, and the confines of the protocol (e.g., a set number of treatments regardless of the severity or complexity of the problem and short- term follow-up). The treatment was provided by therapists with clinical experience and continuing education that focused on physiology. It is likely that massage therapists with similar education and training based on physiology, as opposed to reflexology or craniosacral therapy, would provide similar treatment.” (page 1819 (123))

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Commentary:

This final example was chosen as an early example of a TMB project done reasonably well, and appropriate information included in the article. While more detail could have been provided, this article pre-dates many calls for better methods and reporting in TMB research. Variation was allowed within the protocols based on precise instructions provided to the practitioners, and training and process checks were performed to maintain consistency of treatment. The qualifications of the practitioners can be gleaned from the writing (registered massage therapists of Ontario), though that could have been more directly stated. Some discussion is provided about the choice of practitioners as well as consideration of the limitations arising from the choices made about the protocols and the practitioners. There is a clear basis for further clinical research here, clinicians in Ontario, Canada could verify if local registered massage therapists (RMTs) could provide similar treatment, and likely Ontario’s RMTs would feel comfortable using this research to support clinical practice, particularly if some indication were provided of how the research treatment protocols compare to standard practice. That said, the description “(e.g., friction for fibrous tissue and gentle trigger points for muscle spasm)” would indicate a treatment approach that many RMTs would consider attempting for similar clinical conditions (lower back pain).

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Appendix 2: Pilot Project Questionnaire

To all providers of complementary and alternative health care manual therapy services Why are we contacting you? Many Canadians use complementary and alternative health care manual therapy services, and consider them as part of their total health care plan. However, very little is known about these practitioners and their services. Important questions are: • What is the scope of your professional services and your training to provide those services? • What is the total number of practitioners? • What is the role and potential impact of manual therapies on the Canadian Health Care system? Better-studied therapies such as Traditional Chinese Medicine, acupuncture, and Chiropractic, are all supported by substantial research in these areas. What are we asking you now? In order to address this gap in knowledge we wish to conduct a large-scale survey of providers of complementary and alternative health care manual therapy services. However, we don’t know who or where these providers are. Therefore we are starting with this brief (one page) survey in the Calgary Health Region to help us learn how best to locate practitioners, as well as to determine the preferred methods of contact. This information is needed in order to conduct our large-scale survey, in which we will assess these practitioners demographic and practice characteristics. What does my participation require? The attached survey takes only a couple of minutes to fill out. It can be mailed in the provided self- addressed stamped envelope by the end of April. If you prefer to do surveys on line you can go to www.manualtherapysurvey.ca and do the survey there—it is exactly the same as the mail version. At the end of the survey we request that you let your colleagues know about this survey, so we can hear from as many practitioners as possible. This step is completely optional and voluntary. This research project is independent of any organization, and results will be available to all interested parties. Summary information will be posted on www.manualtherapysurvey.ca Ethical Clearance The Conjoint Health Research Ethics Board of the University of Calgary has approved this survey. Results will only be released as summaries of the data—in no way will it be possible to identify individual participants. If you are receiving this letter in the mail, it is because 1) your organization has agreed to assist me by sending the survey out on my behalf—so I never get your contact information—or 2) your mailing information was posted on a website listing. Investigator Contact Information Antony Porcino Call: 403 475 1676 Email: [email protected] Write: Manual Therapy Survey Department of Community Health Sciences, University of Calgary 3330 Hospital Drive NW. Calgary, Alberta. T2N 4N1 Thank you for your vital assistance in this work. If you would like to help test-drive the larger, in-depth demographics survey, or be put on an email list for notification of the demographics survey, please email the researcher, or mail a separate note—so as to keep your survey anonymous—to the investigator as listed above.

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Survey Questions If you prefer to complete this survey on-line, please go to www.manualtherapysurvey.ca

1. Please indicate where you work: Banff Calgary Canmore Kananaskis Lake Louise 2. How did you hear about this survey? Check all that apply. my association newsletter survey came in the mail poster at work survey given to me at work a colleague told me about it saw an advertisement for it in Common Ground a friend/client told me about it saw an advertisement somewhere Other______3. What is the best way for you to find out about surveys like this? Check all that apply. my association newsletter receiving a survey in the mail poster at work having a survey given to me at work advertisement for it in magazines receiving an email to go to an on-line survey colleague or client referrals Other:______4. Do you prefer: on-line surveys postage-paid mail-in surveys 5. Did you or would you talk to your colleagues about this survey? Yes No 6. Did you or would you recommend your colleagues participate in this survey? Yes No 7. Do you think the Canada-wide project could be useful for your profession? Yes No 8. If we limit the survey to 15–20 minutes, what is the maximum number of pages that you would like a demographic survey to cover (about 6–10 questions per page): 1–2 pages 3–4 pages 5–6 pages I’m okay with a couple more pages than 6

9. If you have any comments, please write them here.

This is the end of the contact survey. Thank you for participating! Please use the enclosed postage-paid envelope to return the survey. If you have misplaced the envelope, you can do the survey online at www.manualtherapysurvey.ca or mail the survey to: Manual Therapy Survey Department of Community Health Sciences, University of Calgary 3330 Hospital Drive NW. Calgary, Alberta. T2N 4N1

Because manual therapy providers are so diverse, it is difficult to contact all potential participants. If you know of any practitioners who may be interested in participating or learning more about this survey, lead them to the website: www.manualtherapysurvey.ca or have them contact the primary researcher to receive a mailed copy of the survey (info on the cover page). Your assistance in this is very much appreciated.

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Appendix 3: Cover Materials and Questionnaire

Practice Descriptors Survey of Alberta’s Complementary and Alternative Medicine Manual Therapy Providers

Note: This survey is for practitioners of manual therapies not currently recognized as part of standard health care and that are provided as the primary purpose of the client/patient visit. Page 4 has a list of examples of such therapies. Licensed medical practitioners such as chiropractors, nurses, or physiotherapists are not included in this project.

Contact Information Antony Porcino Phone: 403 220 7813 Email: [email protected] Write: Manual Therapy Survey Department of Community Health Sciences, University of Calgary 3330 Hospital Drive NW Calgary, Alberta. T2N 4N1

The University of Calgary Conjoint Health Research Ethics Board has approved this study

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This survey is for all providers of manual therapy services that are not yet part of the standard medical system, including massage therapy, shiatsu, reflexology, cranial sacral therapy, and other hands-on therapies, and receiving those therapies is the primary purpose of a client’s visit. A more descriptive list of therapies is on page 4 of this survey. If you have received this survey and you did not request it, it is because: 1. Your organization has agreed to assist me by sending the survey on my behalf, so I never get your contact information; OR 2. I found your name and contact information on a manual therapy organization website, listing practitioners of specific therapies; OR 3. Your Spa manger/owner agreed to distribute the survey to you. Why am I contacting you? Many Canadians use your complementary and alternative medicine manual therapy services. Little is known about these services, limiting research and widespread adoption. Important questions are: • What is the scope of your professional services and your training to provide those services? • What is the role and potential impact of your services on your clients’ health care? Who am I? I am a Doctoral student at the University of Calgary who is a past professional manual therapist. My interest is in advancing research and research literacy in manual therapies. I am not affiliated with any manual therapy organizations. What am I asking you? The survey asks questions about different areas of your practice, including the therapies you provide, the time it took to learn them, time spent providing them, and an optional section on practice income. The answers you provide are vital for understanding manual therapy services. What does your participation require? This 4-page survey should take less than 20 minutes to complete. An application for a draw to win one of three $50 certificates is on the next page. Mail the completed survey and draw application in the provided self-addressed stamped envelope. No personal information will be linked to your answers, and all information you provide will remain confidential. Anonymous survey results will be available to everyone in summary format, available on www.manualtherapysurvey.ca/results What is the included volunteer form on the back of the next page? I am looking for 25 practitioners who practice multiple therapies to participate in personal interviews. You will be compensated for your time for the interviews. There is an additional draw for one of two $50 book certificates for the interview volunteers. For more information, please see page 7 and the enclosed yellow sheet, or go to www.manualtherapysurvey.ca/volunteer.html

Thank you for your vital assistance in this work.

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If you have any questions, please contact the researcher:

Antony Porcino Phone: 403 220-7813 Email: [email protected] Write: Manual Therapy Survey Department of Community Health Sciences, University of Calgary 3330 Hospital Drive NW. Calgary, Alberta. T2N 4N1

Because manual therapy providers are so diverse, it is difficult to contact all potential participants. If you know of any practitioners who may be interested in participating or learning more about this survey, please direct them to the website: www.manualtherapysurvey.ca or have them contact the primary researcher to request a copy of the survey—the contact information is above.

Your voluntary assistance with this is very much appreciated.

If you are interested in participating in the in-depth interviews, please fill out the volunteering form on the back side of this page, and return this page with your survey.

To participate in a draw for 1 of 3 Chapters-Indigo gift certificates, please provide the following information and return this page with your survey. Print your name . and a contact phone number or email .

The draw will be on August 29, 2008.

The winners will be contacted directly.

This page will be separated from the survey upon receipt to preserve the anonymity of your survey answers. 145

Volunteer form for practitioners with training in multiple therapies —two or more boxes checked on page 2 of the survey— interested in participating in the in-depth interviews

The interviews are to gather information about what practices with multiple therapies are like: • How do you combine, or keep separate, different therapies? • How do you make decisions regarding therapy and technique choices? • How do you incorporate clinical assessment during a treatment?

We aim to interview practitioners from different practice settings, and with different combinations of therapies. All volunteers will be entered in a draw for 1 of 2 Chapters-Indigo $50 gift certificates.

The interviews will take about one hour. For those interviewed, a cash honorarium of $40 will be offered for your time.

To volunteer for the interviews, please provide the following information and mail this form with the survey. It will be immediately separated from the survey to preserve the anonymity of your answers. You can also volunteer by filling the form in at www.manualtherapysurvey.ca/volunteer

• Your name (please print) .

• A contact phone number ( ) – . the best times to contact you at this number: _ .

• An email address .

• Your municipality(s) where you practice .

• Your type(s) of practice (solo or multiple-person clinic, spa, club, on-site, etc.) . .

• The therapies that you practice. Indicate which you would consider your “main” or “primary” therapy a: . b: . c: . d: . e: . f: . g: . h: .

All volunteers will be entered in a draw for 1 of 2 Chapters-Indigo gift certificates.

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Section I Practice Descriptors These questions are to gather information about manual therapy practice businesses.

1) Per week, approximately how many hours do you spend working directly with clients? hrs. 2) Approximately what percentage (%) of your clients are female? % 3) Considering females and males separately, approximate the percentage of your practice clientele’s age range. Under 20 years old % Under 20 years old % Females 20–40 years old % Males 20–40 years old % 41–65 years old % 41–65 years old % Over 65 years old % Over 65 years old % Total 100% . Total 100%

Manual therapists may be self-employed, work for others as an employee, or work in both situations. 4) For each work setting that applies to you, please indicate the percentage of time spent in each setting.

Work Setting Self-employed Employee Health professionals you work % of work % of work with in this setting. Private practice clinic/office

Private practice at home

Spa

Chiropractor office

Outcalls/mobile practice

Beauty salon

Fitness centre/health club

Holistic health centre

Physical therapy office

Resort/hotel/cruise ship

Medical practice (MD office/hospital)

Corporation onsite

Sports medicine facility

Other______

Other ______

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Section II Education and Practice The following questions are to provide information on the therapies being used by the public for personal health care.

5) From the following list of common manual therapies, put an X in the box of each therapy you have been trained in. 1 acupressure 35 Orthobionomy 2 Alexander Technique™ 36 Orthotherapy 3 amma/anma massage 37 pædiatric massage 4 Applied Kinesiology™ 38 Postural Integration 5 aromatherapy 39 PNF 6 A.R.T./Active Release 40 Raindrop Therapy/Technique™ 7 Aston Patterning™ 41 Rebalancing 8 Ayurvedic massage 42 reflexology 9 Bonnie Prudden Myotherapy™ 43 Reflexology Deep Muscle Massage 10 Bowen work (any type) 44 Rolfing™ 11 Breema 45 Rosen Method™ 12 chair massage 46 Rubenfeld Synergy™ Method 13 Chi Nei Tsang 47 Russian massage 14 Core Bodywork™ 48 shiatsu 15 Craniosacral™ or cranial sacral therapy 49 Soma Neuromuscular Integration 16 Esalen™ massage 50 sports massage 17 Feldenkrais™ 51 St. John Neuromuscular Therapy 18 geriatric massage 52 structural integration 19 Hellerwork™ 53 Swedish/spa massage 20 hot/cold stones massage 54 Tantsu™ 21 Hurley/Osborn Technique™ 55 Thai Massage/Thai Yoga/Nuad Bo-rarn 22 hydrotherapy 56 Tibetan massage 23 Jin Shin Do™ 57 TMJ therapy 24 Kinesis Myofascial Integration 58 Touch for Health™ 25 Lomi Lomi 59 tsubo therapy 26 Looyenwork™ 60 Trager™ 27 lymphatic drainage massage or 61 trigger point therapy manual lymph drainage 28 massage therapy 62 tuina 29 maternal/pregnancy massage 63 Visceral Manipulation™ 30 Mitzvah Technique 64 Watsu™ 31 myofascial release 65 Zero Balancing™ 32 myomassology 66 Other . 33 Neuromuscular Technique 67 Other . 34 Onsen™ 68 Other .

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6) For the therapies you marked in Question 5, list the therapies you currently use in your practice, and the frequency you use them in your practice. For example: a: # 48 (shiatsu, Question 5) Frequently; b: #65 (Watsu™ Question 5) Occasionally. Always Frequently Occasionally Rarely a: # . b: # . c: # . d: # . e: # . f: # . g: # . h: all others, #s

7) Did training for any of the therapies you marked in Question 6 include training in other therapies in the Question 5 or Question 6 list? For example: your shiatsu course (#48 of Question 6) may have included aromatherapy (#5 of Question 5) and chair massage (#12 of Question 5). If yes: 48 . included the following therapies: #s 5, 12 .

If yes: # . included the following therapies: #s . If yes: # . included the following therapies: #s . If yes: # . included the following therapies: #s . If yes: # . included the following therapies: #s .

8) For the therapies you listed in Question 6, indicate the initial training hours, and any additional/advanced (post initial) training hours you took in that therapy. For example: your initial shiatsu training (#48, listed as “a” in Question 6) may have been 1000 hours, plus you have done a further 400 hours of advanced shiatsu. a: # 48 . training hours: 1000 advanced training hours: 400 . a: # . training hours: . advanced training hours: . b: # . training hours: . advanced training hours: . c: # . training hours: . advanced training hours: . d: # . training hours: . advanced training hours: . e: # . training hours: . advanced training hours: . f: # . training hours: . advanced training hours: . g: # . training hours: . advanced training hours: . h: all others, #s (no hours, continuing education hours needed)

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9A) Do you provide wellness-based services (health maintenance, stress reduction—compare to 9B)? No Yes what percentage of your time is spent on these services? % 9B) Do you provide treatment-based services (meant to alter processes of disease, physiological damage, or disorders, or to specifically enhance functioning or performance—compare to 9A)? No Yes what percentage of your time is spent on these services? % Total 9A and 9B 100%

10) Do you treat people who would not be able to continue employment without your treatments? No Yes what percentage of your time is spent on these treatments? % 11) Do you treat people who would not be able to perform daily living activities without your treatments? No Yes what percentage of your time is spent on these treatments? %

Section III About You

12) Please indicate your gender: Female Male 13) What year were you born? 19 . 14) How many years have you been in practice? . 15) What is the estimated population of the municipality in which you practise? . 16) Did you receive this survey in the mail. If so, which organization(s) sent it to you? . . at work by requesting a copy from the research project other . 17) Did you receive email messages about this survey? Yes No 18) If you have any comments, please write them here.

This is the end of the survey. Thank you for participating.

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Appendix 4: Questionnaire Communications

Email # 1

Dear member,

The ______(organization name) is participating in a research project that is being run at the University of Calgary. The researcher, Antony Porcino is trying to contact as many manual therapists as possible. Due to our privacy policy, we cannot give him your contact information, so we will be distributing his questionnaire on his behalf. The purpose is to help improve research on the effectiveness of all forms of manual therapy.

We encourage you to participate by filling out the questionnaire that will be mailed to you today.

If you have any questions about the project, check out the project website at http://www.manualtherapysurvey.ca, contact the researcher at 403-220-7813, or email him at [email protected]

Sincerely,

Email #2

Dear member,

Two weeks ago we mailed a research project questionnaire about manual therapy delivery on behalf of the researcher at the University of Calgary. This is the first of only two follow-up emails that we are sending about this questionnaire. If you have received the questionnaire and completed it, thank you. Please disregard this email.

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If you have not yet received it, let us know soon if you would like us to send you another copy. The survey can also be downloaded from the survey website and printed

(http://www.manualtherapysurvey.ca/survey2). The survey wraps up on August 22, so please take the time to complete the survey and send it back before then.

If you find the project interesting, do encourage your colleagues to return their surveys, and consider volunteering for a one-on-one interview. If you need to know more about volunteering, visit http://www.manualtherapysurvey.ca/volunteers.

If you have any questions about the project, check out the project website at http://www.manualtherapysurvey.ca, contact the researcher at 403-220-7813, or email him at [email protected]

Also, don’t forget to send in the draw application form with your questionnaire.

Sincerely,

Email #3

Dear member,

One month ago we mailed a research project questionnaire about manual therapy delivery on behalf of the researcher at the University of Calgary. This is the final follow-up email that we are sending about this questionnaire. If you have received the questionnaire and completed it, thank you. Please disregard this email.

If you have not yet received it, let us know quickly if you would like us to send you another copy. The survey can also be downloaded from the survey website and printed

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(http://www.manualtherapysurvey.ca/survey2). The survey wraps up on August 22, so

please take the time to complete the survey and send it back before then.

If you find the project interesting, do encourage your colleagues to return their surveys,

and consider volunteering for a one-on-one interview. If you need to know more about

volunteering, visit http://www.manualtherapysurvey.ca/volunteers

If you have any questions about the project, check out the project website at

http://www.manualtherapysurvey.ca, contact the researcher at 403-220-7813, or email

him at [email protected]

Also, don’t forget to send in the draw application form with your questionnaire.

Sincerely,

Organization Newsletter Advertisement:

Do you provide Massage Health Care Services ?

CMVSCCMVSC Do you or someone you know provide massage health care services in Alberta? 4HE This survey for practitioners of Massage Therapy, Shiatsu, Thai Massage, CMVSC4HE Reflexology, Craniosacral Therapy, Somatics, Aromatherapy, and so on, is to learn more about your professional training and practice. CMVSC4HE More information: www.manualtherapysurvey.ca or call 403-220-7813 4HE

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)S IT SO )S IT SO &0/&0/ )S IT SO DETOX&0/ )S IT SO DETOX &0/ DETOX DETOX

&0/ &0/ &0/ &0/ &0/ ARTHRITIS&0/ ARTHRITIS &0/'( &0/ 0,5''( ARTHRITIS 0,5' '( ARTHRITIS 0,5''( 0,5'

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Appendix 5: Consent and Final Interview Guide

Department of Community Health Sciences Heritage Medical Research Building 3330 Hospital Drive NW Calgary AB, Canada. T2N 4N1 T: 403 220 7813 E: [email protected] or [email protected]

Interviewee Information Sheet and Informed Consent Form

A Descriptive Combined-methods Study of Alberta’s Complementary and Alternative Medicine Manual Therapy Providers

INVESTIGATORS: Marja Verhoef, PhD. (Principal Investigator) Professor, Department of Community Health Sciences University of Calgary 1(403) 220-7813

Antony Porcino, BSc (Co-Investigator) PhD Candidate, Department of Community Health Sciences University of Calgary 1(403) 220-7813 or 1(604) 874-3975

SPONSORS: Massage Therapy Foundation; IN-CAM

This consent form is only part of the process of informed consent. It should give you the basic idea of what the research is about and what your participation will involve. If you would like more detail about something mentioned here, or information not included here, please ask. Take the time to read this carefully and to understand any accompanying information. You will receive a copy of this form.

THE BACKGROUND AND PURPOSE OF THIS STUDY CAM manual therapies, such as massage therapy, shiatsu, Thai massage, hot stone massage and so on, are increasingly part of people’s health care regimens. Use of manual therapies creates the need for information about this field of treatment, and research on manual therapies has been increasing over the last few years. Many manual therapy studies have inconclusive or negative results even though potential methodological solutions such as creating precise protocols and selecting appropriate comparison groups have been suggested. Personal discussions with CAM manual therapists, as well as a review of manual therapy research indicate that a majority of CAM manual therapists train in and practice multiple modalities, potentially blurring the meaning of treatment or research of such treatments under the name of a specific modality. Discussions with manual therapy researchers and practitioners, and a review of manual therapy research

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also indicate a lack of understanding of how 1) cross-practice in multiple therapies and 2) length of education in those therapies may impact research design, results, and interpretation, as well as health service planning. No systematic research has been specifically conducted within Canada or elsewhere to examine how cross-practice occurs during standard treatment in order to address this research barrier. This combined methods study will use questionnaires and interviews to examine: 1) practitioner education; 2) the extent to which blending of techniques from cross-training in multiple therapies occurs in practice; 3) treatment practice descriptors (work setting, treatment focus); and 4) related client demographics (gender, age) that may affect practice focus. Recommendations based on this study will enable future manual therapy research to be more effective. They will do so by providing a clear understanding of the complexity of manual therapy practice and how that may affect research design, results, or interpretation of manual therapy research.

ELEGIBILITY We have contacted you because of your response to our request for interview volunteers.

WHAT DOES MY PARTICIPATION REQUIRE ? As we discussed on the phone, you will be asked to participate in one, one-hour (or so), audio-taped in-person or telephone interview. In-person interviews will occur at a place that is convenient and appropriate for you, and would preferably be in a quiet atmosphere where we would not be disturbed during the interview. During this interview, we will ask you about the manual therapy trainings you have taken, how you choose to use therapies in your practice, how therapies may be blended during practice, and assessment or choices during practice that affect your use of techniques or therapies. Once the analysis of all the interviews has been done, you will be invited to review the research findings and provide feedback. This step is optional.

WILL I BENEFIT IF I TAKE PART ? No one knows whether or not you will benefit from this study, or whether or not there will be direct benefits to you from participating in the interviews. We hope that the information learned from this study will increase the quality of future research on manual therapies.

WILL I BE PAID FOR PARTICIPATING ? DO I HAVE TO PAY FOR ANYTHING ? All interviewed people will be given an honorarium of $40 at the end of the interview. It will be provided in cash at the in-person interviews, or a cheque will be mailed after the phone interviews. Depending on the setting, during the in-person interviews a regular coffee, tea, or water may be provided, along with up to $5 for transportation or parking costs if requested.

PRIVACY AND CONFIDENTIALITY Your confidentiality will always be respected. No information that discloses your identity will be released or published without your specific consent to the disclosure. Interview records may be inspected by members of the research team, or by representatives of the University of Calgary Conjoint Health Research Ethics Board for the purpose of monitoring the research. No records that identify you in any way will be allowed to leave the Investigators’ offices.

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Your interview will be audio-taped to ensure no information is lost during the meeting. Audiotapes will be stored in a locked cabinet, and destroyed once they have been transcribed. All documents will be identified only by code number, and kept in locked filing cabinet. Only the research staff directly involved in the data collection and analysis will have access to the information. Any direct reference to you or your work setting in the results will be coded. References to practice features (type of work setting and therapies provided) will be minimized if needed to maintain your anonymity. You may call the study investigator at the number below at any time to discuss any questions you may have about the study.

SIGNATURES Your signature on this form indicates that you have understood to your satisfaction the information regarding your participation in the research project and agree to participate as a participant. In no way does this waive your legal rights nor release the investigators, or involved institutions from their legal and professional responsibilities. You are free to withdraw from further participation in the study at any time. If you have further questions concerning matters related to this research, please contact:

Antony Porcino (604) 874-3975)

Dr. Marja Verhoef (403) 220-7813

If you have any questions concerning your rights as a possible participant in this research, please contact The Ethics Resources Officer, Internal Awards, Research Services, University of Calgary, at (403) 220-3782.

Participant’s Name Signature and Date

Investigator/Delegate’s Name Signature and Date

Witness’ Name Signature and Date

The University of Calgary Conjoint Health Research Ethics Board has approved this research study.

A signed copy of this consent will been given to you to keep for your records and reference.

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Interview Guide

1. Could you briefly describe the manual therapy trainings that you have taken?

We’ll get to the details of them later.

2. I’d like to get a little more depth on each of those now. Can we start with the

first training you did. (Prompt for reasons for that training, what it included,

how long, practicum/cases studies and clinic time. Importance in practice now.)

3. What about the next trainings you took? (Prompt for reasons on why chosen,

etc. Importance in practice now.)

4. Did practice setting influence your choice of trainings?

5. Did the initial training influence your style or current approach to your work?

6. How do you use these therapies in your practice? (Prompt for defining

separation or mixing of therapies, any specific training on combining, attitudes,

concerns, reasons, etc.)

7. How do you choose which therapies to use together? What are the influences on

your decision to use one technique or therapy over another?

8. What forms of feedback do you use? How do you know when you are done in a

specific area or using a specific technique/therapy?

9. What was your process for learning how to use therapies together like this?

10. Have some techniques or your experience changed the way you practice other

techniques? Is this common for you? In what ways?

11. Do you think that your later training and experience has changed you such that

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you could no longer offer your modalities as purely as when you first learned

them? Could you provide a pure therapy if you had to?

12. If you are combining therapies like this, how do you negotiate consent?

13. Given what we’ve been discussing, what do you think about the idea of using a

set routine for therapy X in a research project? Does it matter that

switching/blending therapies might make it hard to research or evaluate what

you do? (If time, explore a bit more about the use of evidence or perceived

barriers for use in their practice.)

14. Do you think that research and regulation are linked?

15. My final question is from a result in the questionnaire part of the project where I

asked if you treat people who cannot perform activities of daily living without

your treatments. I’d like to get a sense of your understanding of what “activities

of daily living” means.

16. Is there anything else about the decisions, use, or training in therapies that you’d

like me to know before we wrap up?

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