What the….?

In this week’s RMTAO Friday File Board Chair Ian Kamm announced his wishes to survey the membership re: massaging spouses. It’s hard to comprehend why the Board Chair is dedicating any time to an immutable regulatory policy, and especially when:

  • the profession has recently twice suffered negative media coverage, yet there appears no initiative taken towards a national media response team
  • the RMT/ACT (for HST de-registration) website has been offline since last year
  • the Resources page for members on the RMTAO website has been “under construction” for over 2 years
  • the last member earnings survey is almost 10 years old, and the last comprehensive survey of the profession (commissioned by the CMTO) is almost 20 years old
  • The Canadian Massage Therapist Alliance – a coalition of the sister provincial associations – appears inactive. Their last Facebook post is from October 2019
  • the Community Based Networks (CBNs) – the hubs of support for many RMTs – are under-resourced and under-utilized
  • the main point of engagement for RMTAO members – the social media page – has been unavailable for interactive dialogue and debate for over a year

In fact the usual opportunities members would expect from their professional association to dialogue and debate, to grow and evolve the profession – symposia, round table discussions with subject matter experts, town halls – are not currently offered by the professional association.

And the same old, persistent struggles for the profession – defining professional identity, supporting research and higher education for RMTs, mentoring RMTs at the entry-to-practice level, positioning MT in the health care system, HST de-registration, raising business acumen across the profession, improving relationships with insurers and gatekeeper health practitioners, ensuring across-the-board quality education and accreditation of training schools, supporting RMTs who face barriers to practice due to ethnicity, culture or gender, and strategizing how to bring massage therapy care to more people facing barriers of inequity, bias and trauma – go largely unaddressed.

Send a message to Ian Kamm, Board_Chair@RMTAO.com, and tell him where you would prefer he spend his time and attention.

On the Same Page

Since publishing Massage Therapist Practice in 2010, I’ve been considering how to effectively raise the practice/business acumen of all massage therapists up to the same level. It seems to me, knowledge and experience transfer on these subjects has suffered within our profession. Typically, roles and expectations in a business relationship are incompletely defined. And, we can do better with providing practitioners practical ways to attract and retain clients (patients) to grow and sustain their practices.

So I’ve amalgamated some helpful information from my 30 years in the field as contracted practitioner, practice broker for other practitioners, and now in private practice. In my cross-country lectures, through social media or in direct conversations, I’ve tapped the experience of hundreds of massage therapists I’ve been fortunate to visit with, learning about their pressing practice problems.

The product of these conversations and experiences is the treatise On Practice: Entry-Level to Established Massage Therapist. I’m making available, with my compliments, the first part of the curriculum in electronic format. Part I targets entry-level (0-5 years) practitioners or students, but seasoned practitioners may find something of value too. Massage Therapists who broker practice opportunities for others, will certainly want to share it with their budding associates.

Please share broadly with practitioners you believe could use a firmer foundation in their practices. Use this information however it might benefit you. I would be grateful for any feedback you might provide as I work on the latter section over the next 1/2 year. You can reach me at don@DonDillon-RMT.com.

With sincere gratitude.


CBC Article Illuminates Alarming Vulnerabilities

In the previous post, I mentioned I was contacted by a CBC reporter. I contacted the Executive Directors (ED) in both Ontario and Saskatchewan to respond to the reporter’s inquiries, as I attempted to suss what information the reporter was looking for. The reporter went on to publish an article that showcases an illegitimate association that permits sex trade workers to bill employee health benefits for their services.

This CBC expose has, of course, embarrassed legitimate practitioners. But it has also illuminated alarming vulnerabilities in our profession. My questions to those salaried to properly represent us:

1) What is the MT profession doing to thwart illegitimate associations – via representation from the Canadian Massage Therapist Alliance, and the Federation of Massage Therapy Regulatory Authorities of Canada (FOMTRAC) – and work with government to protect the public and the profession from such exploitive operations? 

2) How closely is the MT profession working with the insurance industry via Canadian Life and Health Insurance Association (CHLIA) to make fraud unlikely?  It’s been inferred by the ED of RMTAO this is an important and functional relationship.  If so, why isn’t there more collaboration with insurers?

So I wrote the RMTAO ED and asked for action. I have concerns with how the ED has responded previously, particularly to Global News. While the RMTAO ED asserts he’s had public and media relations training, his training isn’t apparent in these two instances. Please write the RMTAO and ask them to push for a national public and media relations response team, properly trained, and proactive in improving our image in the public eye.

When an Investigative Reporter from the CBC calls…

When a Senior Investigative Reporter for CBC News contacted me last Thursday with a simple email, “I see that you have done some writing on the area of insurance fraud in the massage industry. I’m working on a story related to this and I’m wondering if you’d have a moment to chat”, I paused to consider my next step.  I’ve received some public and media relations training, and I know one should never get on the phone with an investigative reporter from national media without being prepared, or knowing the questions.

Anticipating there was more to his inquiry, I responded, “Hello G.L, and thanks for the opportunity.  I’m forwarding your inquiry to the Executive Director of our RMT association in Ontario.  Based on your questions, he may be the best to speak to, as he meets with a coalition of health disciplines who regularly find themselves at the table with insurers to discuss mutual concerns.

(I pressed) What are your questions? I could then discern if I’m the best person to offer an informed opinion.  If your questions are within my expertise, I’d be happy to speak with you Monday.”

I then attempted to also reach the Executive Director of the Saskatchewan massage therapist association, as the reporter indicated he was stationed in Saskatchewan.  She was unavailable for Friday, as was the RMTAO Executive Director, Michael Feraday.  Thankfully my email to RMTAO Director of Operations Jill Haig was forwarded onto Feraday, and he did manage to respond by email Friday. 

Feraday stated he was out of the office for a few days but would be happy to talk next week on return.  He provided supplemental information on some initiatives the coalition had undertaken to address insurance fraud.

By this time, I was cc’d on the response by the reporter.  “I am working on a story with a Montreal colleague about insurance fraud in the massage industry. This investigation was initiated after I learned that some massage businesses that offer sexual services are also offering insurance receipts. Please take a look at the story to see what I found specifically.


Since doing this story we have been looking into other massage parlours and other associations of massage practitioners. We have found that it is not uncommon that those claiming to be legitimate massage therapists would be offering sexual services and providing insurance receipts.  I do note that our investigation is focussing on provinces that are not regulated. I would be very interested in learning about what sorts of fraud you are encountering and what you are doing about it.”

I was painfully reminded our profession, incredibly, does not have a national public and media relations response team.  The press may call anytime, and the profession requires a team of skilled, trained, well-spoken representatives.  This is particularly essential, given the media seem to be attracted to shock-and-awe sensationalist stories that would prove embarrassing and damaging to the profession if not well handled.  You may wish to read PR nightmare – Massage Therapy Canada and Report on health benefits use misses the point – Massage Therapy Canada as examples of how the press has represented our profession to the public.

It was wise of me not to accept the interview.  I had in fact written on improving relations between insurers and massage therapists…insurance fraud was merely a side point.  I could not offer any helpful information on the reporter’s subject.  Caveat: if you who receive media inquiries…ask for the subject up front and how they qualified you to speak before you consider it.  If you are uninformed on the subject, and untrained in public and media relations, I suggest you pass it to the professional association or other seasoned authority. 

I did, however, see the opportunity to reframe the situation and provide the reporter with something to think about…hopefully influencing his future behaviour.  Here’s what I wrote back.

“G.L. I’m pleased to have put you in touch with the RMTAO’s Executive Director.  As he explained, the coalition he associates with works diligently with insurers to address insurance fraud.  I’m sorry I could not speak with you Friday or Saturday.  My schedule was full in providing patients with care, and that of course takes priority.

Further, I am not a subject matter expert on the subject you’re investigating: individuals working in the sex trade in unregulated provinces, posing as legitimate practitioners to exploit employee benefit plans.  I can speak to the subject of registered massage therapists in regulated provinces, the populations they provide care for and some of the common conditions individuals seek massage therapy for.

I notice when I use the CBC search engine for “massage” or “massage therapy” the CBC’s coverage tends largely towards sensationalist stories of mis-association with the sex trade or insurance fraud.  In fact, there’s a paucity of stories – by our publicly funded national broadcaster, the CBC – representing everyday individuals who benefit from massage therapy, like this person https://secure.rmtao.com/blog/meet-paddi

In 2018, 24 registered massage therapists attended Queen’s Park, which houses Ontario’s legislative assembly, to meet with Members of Provincial Parliament, Senior Policy Analysts, and other government representatives to discuss how massage therapy can best be incorporated into health and community care – specifically pilot projects that address chronic pain, and improve patient outcomes in palliative care and homecare. 

Here were some of the talking points we presented:

the Registered Massage Therapists Association of Ontario (RMTAO) represents 14,000 members, who provide care to over 1 million Ontario residents each year.

According to a 2016 Simon Fraser Institute report, 44% of Canadians have utilized massage therapy care at some point.

Citizens seek our care for neck pain, low back pain, headaches, recovery from work injuries and physical trauma.  Citizens also seek MT for psychosocial outcomes including lowered anxiety, relatability, better quality of sleep, and reduced self-reported pain perception.

Nearly one in five Canadians suffers from chronic pain. (reference available) Estimates place direct health care costs for Canada at more than $6 billion per year, and productivity costs related to job loss and sick days at $37 billion per year.(reference available)  Massage therapy can reduce pain and improve function in people with chronic pain, keeping them at their jobs and enjoying their normal activities for longer.

Jill Haig, RMTAO’s Director of Operations can provide you with the references and research data that accompanied our presentation that day, if you’d like to request it.

I hope, G.L., once you’re finished your present project, you will consider looking into these subjects:

  1. If you have a heart, lung, gastro-intestinal, kidney or brain condition, there’s publicly funded health care services available.  If you have a problem with the structural and functional movement system of your body – muscles, joints, connective tissue – you pay out of pocket, or utilize capped employee benefits if you’re lucky to have them.  With consideration of society’s costs related to physical pain and impairment, why is therapy not supported by our provincial health plans?  Further, how can the treatment of physical pain and impairment be fully integrated into our health care system if funding remains with private insurers, or citizen’s are limited to what they can afford out of pocket?
  2. Insurers are the gatekeepers in approving claims for physical pain and impairment.  What more can be done by insurers, health care providers, patients and regulators to improve information flow, reduce fraud and resources wasted, demand evidence-informed practice and positive patient outcomes, address decision-making and accountability measures for insurers, and improve the integration and effectiveness of health care?

You may find your research into these subjects yields important information for the public you serve, and ultimately nudge more equitable, comprehensive and functional health care delivery.

Thank you G.L. for your time and consideration.  Don’t hesitate to contact me should I be of service in the future.


Petition RMTAO for Consultation on the Salient Issues

Open Letter to the RMTAO Board of Directors,
and Executive Director re: strategic planning 2021

Thank you for your dedicated service to our professional representative, the RMTAO.  As an RMT practicing in Ontario, I acknowledge this has been a turbulent year, and commend your courage in taking the leadership seat as we collectively reflect on the past, assign meaning to the present and look towards the future.  

According to the RMTAO website[i], the role of the RMTAO Board, “to envision the future of the organization and the profession while ensuring the organizational structure is present for the vision to be achieved. The Board of Directors provide overall strategic direction for the Association and monitor the organization’s performance towards achieving these strategic goals. The Board is also responsible for setting governing policies for the organization and establishing position statements on matters of importance impacting the profession.”

As such, I ask for both consultation and representation on the following points as you deliberate strategic planning this year.  I request and expect opportunities to assemble with other RMTs, to consult the Board transparently and vigorously, to engage and exchange experience and perspective on these salient issues in an inclusive, supportive and coherent forum.  To deny such a vigorous exchange would forfeit trust, respect and loyalty I have for my professional representative.

These points will be shared through the available social media channels and other mechanisms, to allow RMTs across Ontario to endorse this action.  Over this year, I ask the RMTAO to conduct town hall meetings, utilize Community Based Networks (CBNs) for two-way exchanges with the Board and Executive Director, and to make available other forums to facilitate interaction among all Ontario RMTs, so we can believe we have been consulted and duly represented.

Following are the 12 areas I believe require the most urgent redress:

Nurture Insurer Relations.  Relationships with insurers are essential to RMTs.  Many patients rely on health benefits for Musculo-skeletal injuries not reimbursed under the provincial health plan.  Respectful, beneficial ongoing discussions with insurers are critical to massage therapists.  Insurers are signalling changes in coverage for massage therapy (MT) services, and the profession seems ill-prepared to respond.  Specifically:

Insurers acknowledge MT provides short-term pain relief. They want comparative studies to demonstrate efficacy as compared to exercise, a yoga class, mindfulness practice or “a nap”.

Insurers are skeptical of a broad scope of practice not linked directly to evidence or measured outcomes. They want treatment guidelines that estimate costs of treatment plans and deliver tangible benefits to claimants.

Insurers demand services claimed to be evidence-based and demonstrate efficacy.

Insurers imply claims reimbursement can contribute to exploitive business models geared to maximizing financial gain rather than better health outcomes. They want measures taken against fraud and exploitation.

My question for Operations: What, specifically, are the action steps the RMTAO will take to improve relationships with insurers?

Bolster RMT Earnings.  Many RMTs complain their incomes are insufficient, and they fear risk of overuse injury.  Delivery of care models are time and labour intensive, RMTs regularly lack business acumen, the coherent relationship of employer/employee versus contractor/practice broker has, from the beginning been muddled…all factors affecting the lucrativeness of practice.

The Profession of Massage Therapy in Canada, An Environmental Scan (CMTA 2016) laid out RMT annual earnings: 20% <$25 K, 23% $25-39 K, 18% $40 – 55 K, 12% $55-69 K, 11% $70 K+.

From the most recent RMTAO earnings survey (2013):

Average income hands-on/direct care $39,163.

Most respondents do not have secondary sources of income.

Average service fee $76.00/hour.

21 hours/week ‘hands-on’, Average volume of patients – 19.3/week.

9.5 hours/week dedicated to business activities.

50%+ respondents would choose to work 10 additional hours, but suffer or worry for physical strain, lack clients, or “fear burnout.”

54% are satisfied with pay – but would work more if not for the aforementioned

From the same survey, “56% not earning what they expected…because of market saturation, inconsistent pay, lack of public understanding (re: MT scope/profession).…told earlier / during training they would be making much more than they do.…MVA insurance and HST taxes have negatively impacted finances.”

Massage Therapists who broker practice opportunities for other RMTs, who take on large leases, risk capital, business interruption and loss, who work diligently in their communities to build credibility and awareness of the profession, provide an essential service to all of us.  They particularly require support and encouragement.

My question for Operations: How will the RMTAO work with members to improve the viability and lucrativeness of practice?

Support RMT Scholars and Research Literacy.  Highly educated RMTs have trouble advancing in their field for lack of research and leadership positions, resulting in a tremendous loss of perspective and intellectual capital within our profession.

From a Massage Therapy Canada article entitled Preventing Brain Drain: Opportunities and Challenges for Higher Education, “Trish Dryden confirms the self-employed status of RMTs may limit their proclivity toward an administrative or academic position. When RMTs do obtain these positions, they are full-time, with few resources allotted to do research.  This speaks to a much larger social question around access to the production and distribution of knowledge,’ states Dryden.[ii]

It is difficult to discern the level of research literacy of RMTs in Ontario, although a study was undertaken in Saskatchewan in 2008.[iii] It is expected that research literacy and generation will improve the credibility, status and possible funding of massage therapy services in the health care sector.  The RMTAO could improve research literacy of its members via improving access to research abstracts, consulting research thought-leaders in the field to define and lay out the research agenda, liaison with universities interested in conducting research in massage therapy, and supporting the generation of research.

My question for the Board and Operations:  What is the comprehensive plan for funding and supporting massage therapy research, and improving research literacy and capacity for RMTs?  What will the RMTAO do to support RMTs seeking higher education and research positions in the field?

Address Inequities in Access to Care.  According to the 2019 CMTO Annual Report, almost 4/5 (78%) of the RMT population in Ontario are women.  While not tracked, we can speculate current massage therapy patient populations are likely not representative of the diversity in gender, socio-economic status and ethnicity of the general Ontario citizen population. 

My question for the Board and Operations:  How will the RMTAO promote massage therapy to a broader and diverse patient population, and support the concerns and interests of its largely female member population?

Produce Promotional Practice Materials.  I need help educating the public on massage therapy.  I would like to access a wide variety of media – stock photos, illustrations, short animations, and videos.  The infographics provided by the RMTAO are a good start, and I believe many RMTs would be happy to pay for effective patient education media.  The RMTAO could off-set costs by designing images and materials centrally, making them available to all members at a reasonable cost.  The Canadian Massage Therapist Alliance (CMTA) could procure such media to be used across the nation, improving coherence of the profession’s promotional messaging and further reducing costs to acquire such media.  Look to British Columbia and Manitoba’s MT association for good examples of public awareness campaigns.  Perhaps RMTAO members could be approached to crowdfund public advertising campaigns.

My question for Operations:  Will the RMTAO produce a variety of effective media to help members educate the public at the front-line of practice?

Capture and Share Statistics on the Profession.  Our profession suffers from a paucity of information on itself.  As noted, the last RMTAO earnings survey was eight years ago, the last comprehensive survey by the Ontario regulator was 18 years ago.  Information on the profession is required by prospective individuals considering massage therapy vocationally, and by existing practitioners measuring their results against peers:

Range of net incomes RMTs realize (annual survey)
Sectors/populations served, and common conditions/complaints addressed
Perception by MTs of greatest barriers to practice, and best opportunities
Forecasting 5-to-10 years-out critical practice issues

The first wave of the COVID pandemic in Spring 2020 presented a tremendous opportunity to engage RMTs while they were literally sitting on their hands, awaiting for return-to-work restrictions to abate.  As White House Chief of Staff Rahm Emanuel said, “You never want a serious crisis to go to waste.”  We could have used this time to hold virtual townhall meetings and symposia to address salient issues in the profession – facilitating member engagement and soliciting their perspectives and ideas – to finally tackle the critical issues that divide us.  The RMTAO fell short here.

Currently, the RMTAO social media page for member engagement has been archived, local hubs (CBNs) have been left largely unsupported, and the Board has not engaged the membership on the mission-critical Ends policy for some time. 

It appears, frankly, the RMTAO goes out of its way not to engage its membership.

My question for Operations and The Board:  Will the RMTAO engage its members regularly so RMTAO members (and prospective RMTs) can participate in the direction of the profession, accumulate accurate and helpful metrics on the profession, and be more informed in their individual practice operations and decisions?

Follow up question: The regulator last performed a comprehensive survey of the profession in 2003.  RMTAO members and prospective practitioners require current profession statistics to make good practice decisions.  Will the RMTAO lobby the regulator to commit resources for a new comprehensive survey?

Recruit and Train Media Representatives.  RMTs have suffered increasingly poor media coverage.  Searching several national media sites, news articles featuring the words “massage” or “massage therapist” are regrettably underweight in citing benefits of care, research developments or community health/populations served.  Most searches produce stories linked to insurance fraud, the sex trade and professional misconduct / sexual abuse.  Through imbalanced journalism and resultant influence on public perception, we might collectively be concerned RMTs are disproportionately vulnerable to complaints.

I argue the RMTAO is underutilizing the skills and resourcefulness of thought leaders, and front-line practitioners in its Community Based Networks. Trained media representatives at the local level could proactively submit informative, positive press releases to help guide public perception of massage therapists.

My question for Operations:  Will the RMTAO recruit and train a team of members – as well as the Executive Director! – to consistently and competently respond locally or provincially to imbalanced and negative media coverage? 

Strengthen Advocacy, Demonstrate Leadership.  Massage therapy, although a regulated health profession in Ontario, is excluded from provincial health insurance imbursement and subject to the consumption tax (HST).  Compared to smaller, perhaps considered more “alternative” professions (chiropractic, naturopathy, Chinese Medicine/acupuncture) the MT profession appears fragmented, under-resourced and unfocused in its activism. 

Astonishingly, despite the formation of the Federation of Massage Therapy Regulatory Authorities of Canada (FOMTRAC) in 2003, and diligent work by several MT associations across Canada, progress on regulation has been exceedingly slow.  The Ontario regulator now commands a budget greater than 12 times that of our Ontario representative…a concerning and unsustainable imbalance of resources and power.

Momentum has been lost from the RMTAO’s 2018 government relations exercise, and the privilege of self-regulation is being critically examined in British Columbia, with implications for Ontario.  The RMTAO needs to do better in portraying leadership qualities, and advocating for the interests of its members.

My question for Operations: Will the RMTAO demonstrate better leadership, focus its advocacy efforts, and regularly report to the membership the purpose and outcomes of those efforts?

Position Massage Therapists in Health Care.  Massage therapists are not being employed in community and public health – arguably more strategic targets for inclusion than hospital or emergency medicine.  Beyond the absence of a clear lobbying strategy, the profession lacks infrastructure for generating research and affecting public policy.  There are other disciplines with the same objectives as ours, and the massage therapy profession would benefit from alliances with like-minded professions to pool resources and focus lobbying efforts for inclusion in public health.

My question for Operations: Considering disciplines aligned with MT objectives in pursuing government and insurer relations, public and media relations, and research funding/generation, what steps will the RMTAO take towards building these strategic relationships?

Support Prospective and Entry-Level Practitioners.  Training college accreditation helps ensure a standard quality of education, and contributes to the profession’s credibility in the public eye.  The Canadian Massage Therapy Council for Accreditation reports the process stalled in all but 4 provinces – BC resigned but re-enlisted.

American schools are seeing a precipitous drop in enrollment and anecdotally in Canada the supply of massage therapists is not meeting demand by employers.  Stakeholders in the profession – representative associations, regulatory bodies, training schools – appear uninterested to attract prospective candidates to the field upstream.

My question for the Board: What steps will the RMTAO take to promote the profession, and attract the next generation of massage therapists to the profession?  What specifically will the RMTAO do to support entry-level practitioners to become better informed and prepared as they enter the profession?

Follow up question:  Does the RMTAO have a functional relationship with the Canadian Council of Massage Therapy Schools[iv] (CCMTS) and the Heads of Massage Therapy Programs in Community Colleges?  If so, what is the scope and extent of the relationship?  What joint projects are these decision-makers working on?

National Coordination and Representation.  The Canadian Massage Therapist Alliance (CMTA) states its objectives are to advance the MT profession, collaborate with industry partners, and encourage regulation[v].  This coalition of the sister provincial associations is funded by membership dollars.  The CMTA does not provide an annual report on its site, and appears ineffective in coordinating a national strategy for government and insurer relations, gatekeeper HCP relations and public/media relations.  It falls short of contributing to research literacy in the profession or facilitating national media to inform all representative associations.  The website appears to be infrequently updated. 

The CMTA could be much better coordinated and focused on common national issues, while the sister associations support each other addressing province-level challenges.

My question for the Board: What is necessary to improve the function and coordination of the CMTA, to the benefit of all sister associations?  How will the RMTAO nudge the CMTA to meet these objectives?

Engagement Leading to Evolution. There are many extrinsic forces affecting the practices of massage therapists, now and into the future.  RMTs must consider how technology, health care delivery, digital knowledge transfer, government policy, socio-economic shifts, the specific needs of marginalized populations, and other factors affect day-to-day practice.  Our profession requires think-tanks and opportunity to consult subject matter experts to forecast and prepare for these issues.

Additionally, there are a myriad of substantive issues within the profession that suffer an inchoate conceptual framework, and thus remain unresolved.  Two examples: 1) the confusion around what defines the employee/employee or contractor/practice broker relationship from a legal, taxation, functional and economically-viable-for-both-parties viewpoint 2) the dialectic assertion that “relaxation” as a therapeutic outcome is diametrically opposed with the credibility the profession seeks. 

Such issues require long but necessary hours of thoughtful and respectful engagement, ultimately fruitful to the profession in its coherent messaging to government, insurers, gatekeeper HCPs and the public / media.  Symposia, think-tanks, round table discussions, and facilitated social media platforms are all vehicles for development and maturation of the professional context and theoretical framework.

My question for the Board:  Will the RMTAO create multiple opportunities for RMTs to contribute, to dialogue and debate, and ultimately influence the narrative of their chosen vocation?

I the undersigned respectfully demand both consultation and representation on the 12 points included therein, as the RMTAO Board deliberates strategic planning this year.

I request and expect opportunities to assemble with other RMTs, to consult the Board transparently and vigorously, to engage and exchange experience and perspective on these salient issues in an inclusive, supportive, and coherent forum. 

Name (print)                                                               Signature

Date Signed

[i] https://www.rmtao.com/about-rmtao/our-board

[ii] https://www.massagetherapycanada.com/preventing-brain-drain-4009/

[iii] Research utilization and evidence-based practice among Saskatchewan massage therapists (degruyter.com)

[iv] http://www.ccmts.ca/member_schools.html

[v] http://www.crmta.ca/?page=9

Evidence Informed or Averse?

Recently the regulator in Ontario conducted a survey to determine the perspective and application by RMTs to evidence-informed practice. The questions were comprehensive enough, but I suspect the survey will fail to deliver. It didn’t allow participants to address whether they value evidence-informed practice, and what are the barriers to doing so. So I wrote Bryn Sumpton, Manager, Research, College of Massage Therapists of Ontario (CMTO), with my perspective.

Research literacy and capacity were not part of my education 1989-1991.  I value what research can provide the profession, so I since acquired M.B. Menard’s “Making Sense of Research” and Dryden/Moyer’s “Massage Therapy: Integrating Research into Practice”.  I am a quarterly supporter of the Massage Research Fund in the USA https://massagetherapyfoundation.org/

I attended several of the IN-CAM conferences, and wrote of my attempts to understand how research could be better incorporated in my critical decision making https://www.massagetherapycanada.com/research-made-relevant-2137/

What’s more, I’ve made one of my STRiVE competencies to obtain a higher level of research literacy.

When the RMTAO offered access to research search engines a few years back, I spent time looking for studies that might inform my everyday practice. 

I’m frustrated that the studies reported on conditions and populations I rarely see, for example paralysis, COPD.  As for other studies, I don’t qualify to “massage the heart” in cardiac surgery. 

I wonder when research design will better reflect the cases I see in everyday practice?  Here are two examples:

1) A 65 year old woman, multiple medications for cardiac/circulatory conditions reports regular neck and back pain from her work in the lab at a local winery.  She stands on mats over concrete floors, taxes her back and upper extremities with sophisticated lab procedures and has significant lordotic-kyphotic curvature in her spine, likely occupationally induced.  She was looking forward to retirement this year but her husband died suddenly, apparently from medical error resulting in sepsis followed by death.  She describes being “out of it” for several months and has returned to work in hopes of a sense of normalcy and purpose as she mourns the loss of her husband and the retirement plans they had.

2) A 64 year old woman, HR professional has experienced progressive hip and lower back pain.  The severity of the pain required her to turn over and back out of her bed in the mornings, reduce her walks and eliminate bicycle rides.  She relied on sleeping pills for years to help her sleep.  The apparent origin of the pain: 20 years ago she fell out of a tree onto a mature, exposed tree root, while 8 years ago she slipped in the tub and impacted her rib cage and flank.  She admits the progressive pain and immobility has affected her sleep, mobility and quality of life for several years.  She has tried a number of practitioners and methods with minimal improvement to her function.

Why aren’t more research studies designed to inform practitioners how to address the physical-psychological-social complexity of cases like these? 

I believe some of the barriers to RMTs embracing evidence-informed practice are 1) RMTs can’t find studies with outcomes relevant to their specific practice 2) Are research illiterate/not trained in methodology 3) Resources spent for reviewing research or writing case studies are not incentivized properly and 4) higher educated, research literate RMTs are regularly forced to look outside the profession for positions commensurate with their knowledge and experience https://www.massagetherapycanada.com/preventing-brain-drain-4009/ 

So, I think the survey design would illicit more useful information if it was anteceded by open-ended, qualitative questions like “What does evidence-informed practice mean to you?  What barriers do you have incorporating evidence into your practice?  What research questions do you want to see answered?  If not interested in informing your practice with evidence, why not?” 

I think the answers to these questions would be robust and insightful in advancing the CMTO’s stated objective of increasing research literacy in the MT profession.

The CMTO has been a generous contributor to the Massage Therapy Research Fund http://www.cmto.com/about-mtrf/.  I wonder if the CMTO would also consider hosting a round-table (virtual broadcast) jointly with the RMTAO of thought leaders from the profession to address the consistent roadblocks WRT research literacy, capacity and building infrastructure to support research.

As an aside, you might find this article by Sasha Chaitow “Science, Pseudoscience and the Communication Battle” in Massage & Bodywork, July/August 2020 clearly nails the urgency of advancing research in our field, and points to some solutions in addressing the problems we are facing. http://www.massageandbodyworkdigital.com/i/1256819-july-august-2020

Thank you for your most considerate attention to my concerns, and I wish you all the best in your position with the CMTO.

Don Dillon

Think Canada’s MT Infrastructure is Superior to the USA’s?

This is a response to the first part of episode #1 Massage Therapy Without Borders where cohost Canadian RMT Cathy Ryan provides a helpful but not complete picture of the massage therapy infrastructure in Canada. So, I just had to say something. 🙂

Hello Cal and Cathy,

I’ve just come across your podcast and have been enjoying the quality of content.

image, https://www.cgai.ca/canada_us_relations_on_the_eve_of_prime_minister_trudeaus_visit_to_washington

I appreciate the unique opportunity your podcast provides for discussing massage therapy from a more integrated North American perspective. 

In speaking with my American colleagues, I believe there has been an artificial divide between USA and Canada massage therapy (MT) issues.  We share many of the same opportunities and frustrations across the border.  We can and should be working more closely together.

In your podcast you invited feedback, so in response to that invitation, I’m writing to fill out more of the picture regarding your episode #1.  While co-host Cathy Ryan provided a fair assessment of some of the aspects of the Canadian MT infrastructure, your listeners may be interested in greater context, and perhaps particularly the egregious bits.  I hope you’ll take opportunity to delve further into the Canadian context in a future podcast.

I’ve been surprised when my American colleagues have expressed a belief that Canada’s MT framework has its act together.  They perceive the standards are high, education in Canada is superior and integration into health care is de facto.  That spurious perspective requires an upgrade.

Here are some things you should know about the Canadian MT infrastructure:

School accreditation is occurring in only 4 of 10 provinces (and BC was a late entry) and none of the territories.  https://www.cmtca.ca/post/2019/10/01/cmtca-will-resume-providing-accreditation-services-for-massage-therapy-education-programs  Therefore, efforts to increase the quality and standardization of education for MTs in Canada is fractured at best.

Regulation is slow.  It’s taken 25 years to regulate only 1/2 the provinces: Ontario 1994, BC 1995, Newfoundland/Labrador 2003, New Brunswick 2014 and Prince Edward Island 2019.  Even longer if you consider Ontario had basic regulation in place since 1918. https://www.fomtrac.ca/

The Canadian Massage Therapist Alliance (CMTA) is a coalition of the various MT provincial associations.  While it’s mandate is ambitious http://www.crmta.ca/?page=8 the CMTA does not produce an annual report on its actions, despite being financed by membership dollars directly.  In the last five years it produced a cross-Canada scan https://secure.rmtao.com/blog/national-environmental-scan-of-massage-therapy  and is involved in a national campaign to deregister from the consumption tax (HST).  However without annual reports, it’s hard to discern how active or effective the CMTA is.

Canadian MTs appear to suffer from inactivism, despite every reason to act in their best interests.  In Ontario, a province with over 14,000 RMTs http://www.cmto.com/key-publications/annual-report/ only 43% are members of their professional association.  It’s hard to fathom why the association – which represents MT interests to government, insurers, gatekeeper HCPs and the public/media – would not engender overwhelming support from all MTs, despite effective representation under a paucity of support and resources.

The cost of regulation is huge.  In Ontario, the regulator takes in 12X the professional association’s budget.  The cost of regulation is terribly disproportionate to the cost of representation, and RMTs should be very concerned about sustainability.  To its credit, the regulator has graciously allocated a small amount of its budget towards the Massage Therapy Research Fund.  This is something the professional association cannot afford to do, despite its mandate to support research.

RMT earnings are concerning.  Here are some numbers from the Registered Massage Therapists’ Association of Ontario (RMTAO) from their most recent earnings survey of 2013:

Average income hands-on/direct care $39,163 (before taxes)
Majority of respondents do not work outside MT practice (therefore, only source of income).
21 hours/week ‘hands-on’, Avg volume of patients – 19.3/week
9.5 hours/week – business activities
50%+ respondents would work 10 additional hours/week, but fear physical strain, lack clients, or fear “burn out”
Only 54% are satisfied with earnings – many would work more if not for the previously mentioned concerns.

From the report, “56% not earning what they expected…because of market saturation, inconsistent pay, lack of public understanding (re: MT profession).…told earlier / during training they would be making much more than they do.…MVA (automobile) insurance and HST (consumption) taxes have negatively impacted finances.”

There are other issues facing Canadian MTs.  They lack coordinated public and media relations in response to increasingly negative news stories re: insurance fraud, inappropriate touch or associations with the sex trade.  MTs are over-reliant in remuneration from employee health benefit plans. 

Despite regulation, the public does not perceive massage therapists working in health care because they are overwhelmingly not integrated into provincially-funded and endorsed health care settings, and their services are subject to a consumption tax (HST) that most health care services are not. 

In Ania Kania-Richmond’s 2013 look at hospital-based massage in Canada, few hospitals offer massage therapy, and for those that do, they are not providing care directly to hospital patients. “It is important to recognize that a significant activity of massage therapy in hospitals is focused on hospital staff and employees…over half of the hospitals that responded in this study provided massage therapy to employees only.” https://www.cmto.com/assets/MTRF-Project-Summary-Kania-Richmond.pdf 

There are a few exceptions where MTs are working directly with patients https://www.massagetherapycanada.com/coming-soon-podcast-episode-6-working-with-vulnerable-stigmatized-patient-populations/ but these are indeed exceptions. 

Our profession also lacks a strategy to provide care to underserved populations in public health – those in palliative and hospice care, the elderly, children with illnesses, the homeless, refugees and indigenous populations.

There are many things I admire about our American cohort.  You’ve managed to indeed incorporate massage therapy into direct patient care https://www.healwell.org/what-we-do/research and http://blogs.jefferson.edu/atjeff/2011/07/08/treating-chronic-lower-back-pain-with-massage/   The US Department of Health and Human Services under the NIH provides funding for research into Complimentary and Integrative Health https://www.nccih.nih.gov/, something not endorsed by our Canadian government.  And the Massage Therapy Foundation https://massagetherapyfoundation.org/ appears to be very progressive in generating research dollars and promoting research literacy. 

 I know the massage therapy profession in the USA has faced its own challenges in defining identity, insurer relations, school accreditation, generating research and promoting professionalism.  But I would not put its growth or evolution below our advances in Canada.  Hopefully we can find more ways to collaborate between our countries on shared interests, and move the profession to the next level of development.

Thanks for the show, and I look forward to future episodes!

Insurers signal changes to Massage Therapy Claims

Insurers have been signalling for some time they have concerns with claims for massage therapy. Recent podcasts and blogposts from Greenshield Canada and Benefits Canada may imply significant changes are coming.

1) Insurers acknowledge MT provides short-term pain relief. They want comparative studies to demonstrate more or less efficacy compared to exercise, a yoga class, mindfulness practice or “a nap”.
2) Insurers are skeptical of a broad scope of practice not linked directly to evidence or measured outcomes. They want treatment guidelines that estimate costs of treatment plans and deliver tangible benefits to claimants.
3) Insurers demand services claimed to be evidence-based and demonstrate efficacy.
4) Insurers imply claims reimbursement can contribute to exploitive business models geared to maximizing financial gain rather than better health outcomes. They want measures taken against fraud and exploitation

Without provincial health plan coverage of musculo-skeletal injuries, citizens rely heavily on employee benefits provided by their employer. Good insurer relations are key for massage therapists to ensure continued access by their patients. The MT profession needs to come up to speed and galvanize its representatives to ensure good insurer relations.

Regarding “up to speed”, following are a number of resources – from most recent to archived – to help you understand and articulate the issues, make informed statements when speaking to colleagues, and to ask your advocates in your professional association to act.

Insurers Signal Change in Massage Therapy Coverage (podcast) (June 2019)

Insurers Question the Value of Massage Therapy…A Signal of Changes to Come? (May 2019)

Consider the Insurer’s Perspective (February 2019)

Can Massage Therapists Improve Relations with the Insurance Industry? (podcast, February 2019)

Manage Massage Therapy’s Reputation in the Marketplace (June 2015)

Report on Health Benefits Misses the Point (May 2015)

Claims Crisis in Health Insurance (September 2013)

Insurance Coverage for Massage Therapy: Going…going…gone? (July 2012)

10 Years on

How government policy, technology, corporate capitalization, user demand for convenience and integration will shape Massage Therapy Care

Please note, this is a draft article for Massage Therapy Canada magazine for which I’m soliciting input. What have I called correctly, in your perspective? What have I missed? Please share your perspective in the feedback space below…and thank you!

What does the future hold for the profession?  While no one can know for sure, forecasting based on best available information – and a little intuition – can yield a look-see for what is trending.  Forecasting can guide practitioners to fortify against risk, design their practices to remain relevant and identify new opportunities.  Forecasting is essential for regulators, professional associations, training colleges and other stakeholders for resource allocation and planning for contingencies in addressing the needs of their members/students.

Here’s my speculation for the next 10+ years to come in the massage therapy profession in Canada.

Advent of Health Technology:

The fields of bio-technology, robotics and artificial intelligence impact all aspects of our lives.  While current massage devices appear crude, advances are being made in sensate machines that detect pressure.  Robotics are incorporated in a variety of sophisticated applications like surgery and, linked with artificial intelligence, will foray into the bodywork space. Mechanized touch providing pressure and stretch to a stiff body can be applied daily and cost-effectively and will increasingly be employed in rehabilitation and assisted movement.  This won’t replace the personalized human touch provided by skilled practitioners but augment it.  Watch for DIY (Do-It-Yourself) applications to bodywork continue to expand.

Technology will be incorporated in patient safety, security and quality of outcomes. Virtual Reality (VR) will expand the cognitive and sensory experience of health care applications.  VR can enhance massage experience, but also modulate pain in the brain.  People will adopt more sophisticated bio-sensors in all their activities, measuring heart rate, blood pressure, and stress response.  I believe we’ll see increasingly sophisticated data generated on physiologic effects of massage in real-time.

Personalized and Convenient Care:

Massago provides convenient, on-demand massage services in Toronto, Ottawa, Kitchener, Calgary and a growing list of Canadian cities.  Patrons use a phone app to arrange same-day appointments at home or alternative location, choose from a variety of massage service types, pay for service and the rate their massage experience. Technology verifies patron identity for the security of the practitioner.  Massago aggregates user feedback to build best practices and improve user experience over time.

While Massago addresses the on-demand market, CEO Allan Skok shared users build a preference for an excellent practitioner and are willing to postpone an appointment several days to get their practitioner of choice.    I expect technological improvements to lighten and strengthen portable massage tables, make hydro/electro-therapies novel and portable to augment services.

Antithetical to the always-on, technology-saturated social and work environments we occupy, expect the values of embodiment and mindfulness to drive massage experience.  In addition to virtual reality integration, I expect massage practitioners to work in tandem with practitioners of psychotherapy (who perhaps incorporate legalized psychedelic drugs) to address deep-seated trauma, promote higher consciousness and a sense of embodiment.

More Populations Served:

Massage therapy already serves a number of market sectors: rehabilitation, spa/wellness, holistic/integrated care, palliative care, athletics and work performance on-site.  Adopting a bio-psycho-social model of care, greater research literacy and capacity, and if the profession can galvanize on government/insurer/media advocacy, we may see massage therapists incorporated in mental health, public health, home care and intensive rehabilitation programs.  Massage therapy may prove especially helpful in socially marginalized populations – the poor, indigenous, victims of domestic violence, refugees, the elderly and disabled. 

Government funding and efficiencies may drive individual disciplines to work collaboratively together – for example in home care, a physiotherapist or nurse, massage therapist, personal support worker and social worker.  Massage therapy will continue to be valued as an antithesis to the felt effects of aggression, violence, workplace stress, sensory overload and trauma.

Increased Accountability Demanded by Third-Party Payers:

Insurers want accountability in claims.  They want customers to use benefits judiciously and expect health practitioners to work efficiently within financial constraints and demonstrate efficacy in outcomes.  Increasingly insurers may only fund services that are evidence-backed.  Insurers have the ear of employers regarding cost-savings and efficiency in purchasing employee benefit plans.  We may see massage therapy services positioned in higher cost, add-on premium insurance products, which will reduce the number of employers signing on.

A shift to an employee spending account with a suite of options puts the user in charge of spending, hence greater scrutiny and accountability by the user for how benefit dollars are invested.  Insurers may look to WSIB and auto-insurance service fee schedules and apply downward pressure on practitioner compensation for all their insurance products.

Watch for insurers to incorporate user reviews to determine preferred providers to work with, insurer control over spending and citizens actively engaged in sourcing their best health and wellness options.

Corporations and Capitalization:

The wellness industry is valued at $4.2 trillion globally[1][2].  Massage therapy will continue to be popular, and corporations will continue to capitalize on market demand.  Watch for growth in corporate employers of practitioners, high profile locations in commercial real estate hubs, strong branding and messaging, and vigorous recruiting of practitioners.  Also watch for branded methods/customized protocols designed and promoted towards marketplace pain-points – similar to the many types of yoga and fitness products now available. 

How do you see the future playing out? What else is trending that will affect the massage therapy field?

Please comment below or on the Facebook page.

[1] https://interestingengineering.com/3d-printed-skin-could-finally-give-robots-a-sense-of-touch

[2] https://www.globalwellnesssummit.com/2018-global-wellness-trends/ 00000000