Introduction
Increasingly, physicians are facing requests from their patients for referral to massage therapy. Discussions with physicians across BC indicate that many doctors are perplexed by these requests. They are unclear as to whether there are any proven benefits from massage therapy and have little knowledge as to the specific indications for this treatment. Many acquiesce to demands on the (mistaken) basis that there can be no harm and because they are reluctant to offend their patients by refusal; others find it too tiresome to discuss the merits of the treatment and take the line of least resistance; yet others seek refuge in the dubious logic that they cannot say that the treatment isn’t beneficial.

In the light of the amendment to the Policy Manual of the College of Physicians and Surgeons of BC (7 July 1999)[1] relating to alternative and complementary therapies, doctors may have cause to take another look at these attitudes. Indeed, feature articles in recent issues of the BC Massage Practitioner by Dressler[2,3] refer to the policy amendment and anticipate a challenge to the validity of their procedures.

This review does not pretend to be comprehensive. Rather the intent is to highlight certain points that merit further discussion and to provide a list of references from which the interested physician can seek further information.

Background
Physicians wishing to know more about the training of massage therapists in BC can contact the Massage Therapists’ Association of British Columbia (MTABC) (34 East 12th Avenue, Vancouver, BC, V5T 2G5), from whom they will receive a comprehensive package of information. This review will explore this information in particular as well as other information from the Massage Therapists’ Association of BC and the College of Massage Therapists of BC (CMTBC) (103–1089 West Broadway, Vancouver, BC, V6H 1E5), and will also consider other sources of information about the practice known as massage therapy.

The MTABC information package contains a description of a course outline that includes training in basic medical sciences (especially anatomy and pathology), the clinical skills involved in taking a history and performing an examination, and the various manipulative techniques that are typically employed by massage therapists. The caveat is expressed, however, that the course outline, and it appears impressive, is a guideline only and “does not necessarily reflect the actual hours offered at any specific massage school."

Standards of training and practice are established and supervised by the College of Massage Therapists of British Columbia. From 1983 to 1998 the program of instruction comprised 2500 hours; in 1998 this was increased to 3000 hours. There were 76 new registrants last year, of whom five had immigrated from other jurisdictions. Criteria for registration include a successful challenge of the registration exam (the pass rate is said to be 50% to 75%; personal communication from Mr Doug McRae, registrar of the CMTBC), and demonstration of an educational background equivalent to that of British Columbia’s program.

There are currently three schools in the province: the West Coast College of Massage Therapy in Vancouver and Victoria and the Okanagan College of Massage Therapy in Vernon. The Massage Therapists’ Association of BC claims that the standards of training in BC are the highest in North America and that they have become a model other jurisdictions are seeking to emulate.[4,5] In the United States, for example, training programs are mostly of only 500 hours’ duration. There are no uniform national standards for massage therapy in Canada, nor in other jurisdictions.

The scope of practice of massage therapists in BC is determined by the provincial 1995 Health Professions’ Act. The legislation defines and regulates various practices that may be involved in treating patients. Certain activities or procedures (e.g., who may use a TENS machine on a patient) are the subject of continuing study by the Health Professions’ Council, a body constituted by and reporting to the Minister of Health, which may determine that certain procedures are /reserved acts/, i.e., that they may be performed only by persons licensed by a particular professional body.

Readers are encouraged to explore the web site of the College of Massage Therapists (www.cmtbc.bc.ca [8]) to review the current scope of practice of massage therapists and the revisions to that scope that they are currently seeking.[6-8] This web site describes the role of the College, information about registration procedures, complaint procedures for members of the public, regulations and bylaws, and various other items of potentially useful information.

In their submissions to the Health Professions’ Council, the massage therapists are seeking authority to make diagnosis of soft tissue disorders, put a finger beyond the labia majora or the anal verge, move body joints beyond the individual’s current physiological range, and use massage therapy techniques when a contraindication exists. Similarly, readers will find it instructive to visit the web site of the Health Professions’ Council (www.hpc.bc.ca [9]) where definitions of that body’s “Three Primary Tasks,” terms of reference, and membership composition may be found.

Evidence
Objective evidence in the form of controlled studies on the effects and outcomes of massage therapy is virtually non-existent. John Yates, PhD, a physiologist and author of the Physician’s Guide to Therapeutic Massage,[9] admits that past attempts to explain the results of a massage technique were “frequently based on pure—and inaccurate—conjecture.” The very nature of the treatment precludes the possibility of any form of blinded study. At the same time he points to the inevitability of a significant placebo response when he states with refreshing candor: “…any attempt to separate muscle relaxation from the psychological effects of massage…is probably meaningless…” and “…pleasant sensations elicited by massage together with the psychological response to being touched in a caring way must be expected to directly impact on the emotional status of the patient."

Notwithstanding these limitations, Yates provides more than 170 references from a variety of nursing, medical, physical therapy, and other scientific journals and books that seem to support a physiologic basis for the benefit of massage therapy. Readers may conclude that a number of the physiologic studies in particular offer an acceptable level of credibility for some of the benefits claimed by massage therapy advocates. The caveat then remains (as it does for all science) as to what extent laboratory findings can be extrapolated into practice. Again in submission to the Health Professions’ Council,[6] the College of Massage Therapy states candidly that “…it is unfortunate there has been relatively little research done on this continent into the effectiveness of massage therapy.”

Effects
The physiologic effects that massage therapy purports to influence and modify are:

• Circulation of blood and lymph
• Skeletal muscle tone
• Formation of abnormal collagenous connective tissue
• Modulation of afferent neuronal pathways (pain)
• Pulmonary function through changes to thoracic cage compliance

Another benefit described is psychological, wherein claims are made for positive outcomes in conditions as disparate as attention deficit disorder and bulimia.

The clinical relevance and application of these effects is not necessarily apparent. The massage technique of effleurage is claimed to reduce tissue edema. Under what circumstances this would be appropriate and even preferable to, say, a diuretic is not described. Moreover, dependent edema secondary to congestive heart failure is listed as one of the contraindications to massage therapy, as is the edema of a lower limb from deep vein thrombosis. In an era when governments demand that only the most cost-effective form of therapy shall be provided, the benefits of massage over “conventional” therapies must be demonstrated with exactness.

The visit
The first consultation with a massage therapist may last about 1 hour, during which time the therapist is expected to take a complete medical history, to perform a methodical assessment of the area to be treated, to ascertain whether there are any contraindications to the treatment (there may well be), and to formulate a treatment plan. This last item is essentially a decision as to which of a number of massage techniques is deemed to be appropriate.

It follows that a referring physician should have at least some rudimentary insight into the nature of the treatment and should also be made aware of the treatment plan at the beginning and any subsequent modification to the treatment plan. In making a referral to a massage therapist, a physician is endorsing treatment and may become vicariously responsible for any complications.

Methods
A variety of manipulative techniques may be employed, ranging from light and superficial stroking to deep and vigorous kneading of tissues. After an assessment of the patient’s general medical history and that of the condition or body part to be treated, and depending on the conclusions as to the nature of the underlying disorder, the therapist may elect to administer one or more of these techniques. However, some massage therapists are employing alternative or additional techniques, including acupuncture, laser therapy, exercise therapy, and hydrotherapy.

A further description of techniques is to be found in the Physician’s Guide to Therapeutic Massage[9] as well as in a recent review article in the British Medical Journal.[10] Massage therapists, through the CMTBC, are also petitioning the Health Professions’ Council to be allowed to use medical electricity such as TENS machines. Thus it seems there is a blurring of the lines between massage therapy, physiotherapy, and even chiropractic, since the CMTBC is petitioning the Health Professions’ Council for the authority to use low velocity manipulations of increasing amplitude—a therapy so far reserved to the chiropractors.

It is interesting to note, in passing, that physiotherapists evaluated massage as a therapy 25 years ago and found it to be relatively ineffective.

Risks and complications
The College of Massage Therapists of British Columbia, in its submission to the Health Professions’ Council,[8] proposed a definition of massage as “Manipulation of soft tissues with sufficient biomechanical pressure to cause tissue damage, including microtearing, bruising or inflammation.” Elsewhere it stated, “The presence of inflammation …indicates that…manipulation may make the presenting condition worse rather than better.” More recently there was a report of a significant hepatic hematoma caused by deep abdominal massage.[11] Other recently described complications of massage therapy include posterior interosseous syndrome,[12] popliteal artery pseudoaneurysm,[13] and renal artery embolization.[14]

It is not difficult to conceive how a physician may find himself or herself unexpectedly on the receiving end of a writ from an injured patient who had been referred to a massage (or other) therapist. In the event that such a referral was made without an appropriate prior clinical assessment, duly documented, and that the chosen treatment was an appropriate part of a defined treatment plan, the outcome would not likely be pleasant for the physician.

Conclusion
While massage therapy has been around for a long time, it is only relatively recently that exacting standards of training and certification have evolved in BC. Similar standards are evolving in Ontario, but throughout the rest of the country the practice is unregulated. Physicians in BC may feel that referral to a massage therapist constitutes an appropriate part of a treatment plan for a specified condition once the physician has properly assessed and documented the disorder.

The physician’s plan, as with any other treatment, should be subject to periodic re-assessment and revision as dictated by circumstances. The writer suggests that referrals for massage therapy (and perhaps other therapies) should be made only in writing and should include a diagnosis, the body part to be treated, the goals of therapy, and the anticipated duration of therapy or number of treatments. Finally, the physician should ask that the therapist provide a progress note describing measured outcomes of the therapy.

Author’s note
Between submission of this review and going to press, I have seen two new papers on massage therapy. The one published in the Canadian Medical Association Journal by Michele Preyde (Can Med Assoc J 2000;162(13):1815-1820) also refers to the absence of randomized controlled trials of massage therapy. Unfortunately, Preyde’s own study is also severely flawed on a number of counts. The other paper is not yet in print, and I have been asked not to identify it so as to avoid prejudicing publication. While it too suffers from some methodological flaws, it comes much closer to the desired standards for a randomized controlled trial (large study population and fairly rigorous selection and control criteria) and does appear to show some limited improved benefits (for back pain) for short-term massage (about 6 treatments) over other modalities at 6- and 12-month follow-up.

Dr Sedergreen is a family practitioner, a clinical instructor at the UBC Department of Family Practice, and a regional medical officer for Veterans’ Affairs Canada.