In the last decade, the popularity, availability, and complexity of Internet-based learning have increased dramatically. Significant developments are being seen with innovative educational designs and technological strategies created by developers working in advanced online education.1

While the massage profession may be slow to adopt advanced forms of online learning, the influence of online technology and its capability to improve learning though design is changing the overall educational landscape. We can be sure this trend will influence massage education significantly in the near future. Today it’s inspiring review of our current (and often antiquated) theories and best practices for teaching and learning.  
Some educators might argue that using technology for massage education decreases the quality of learning or suppresses the artistic, intuitive side of massage. Those who describe themselves as kinesthetic learners—and therefore claim that online learning does not work for them—may have yet to experience the more advanced designs that offer an entirely new, highly effective, and engaging learning opportunity.
 Like any physical skill, the palpatory and motor skills of massage are still best learned through hands-on practice. And entry-level massage technique is still most effectively learned with a teacher present who can guide the student in specific movement skills. However, massage is far more than a series of movements. As massage therapy gains acceptance as a legitimate health-care profession, there are expectations for practitioners to have solid foundations that inform their treatments. There is a significant cognitive component to skilled massage treatment and decision making in the clinic. For instance, a practitioner treating clients with musculoskeletal conditions must have not only good technique, but also a substantial level of knowledge, reasoning/analytical skill, and complex decision-making ability.
These latter components could arguably be better taught with certain advanced forms of online courses. New research in learning shows that the quality of instructional design is far more important than the method of delivery (online versus classroom) when determining outcomes. Consequently, an online course with very high-quality instructional design can produce superior results to a poorly designed classroom course, and vice versa.
Quality in courses runs the gamut in all fields of study, regardless of method. To fully appraise how effective online learning might be, it is important to know more about the course itself: who authored the course content, who designed the learning elements in the course, and what platform and technological design supports the course. Additionally, what theories/methods ground the educational design, and how does the course reflect that?  
What Online Learning Looks Like
First, it is very important to distinguish between e-learning and online learning. E-learning is a broad category that includes the use of almost any type of technology in a course—computer, video, audio, etc. Video- and book-based distance education courses with online tests can be considered e-learning.
Online courses are a narrower category. They are taught through an Internet-based platform, and online course technology includes both the platform the course operates in and the development (authoring) tools the course content and activities are built with. Platforms range from simple online tests to full-on complex learning management systems. The more robust a platform and authoring tools, the greater the opportunity for innovation and interactivity. A high-quality course built with advanced authoring tools can integrate more educational, engaging, and interactive instructional design.
The more advanced platforms offer the greatest advances in competency-based learning design. This is why the most reputable universities are integrating online learning and have entire departments for online course design and technology.
At this time, it is rare to find an online course in the massage profession that employs advanced educational theory and complex technological design. Wider adoption of key concepts of online learning could significantly improve the competence and quality of massage education at the entry level and in continuing education.

The Basics
At the simplest level, online learning includes what are considered passive-learning technologies: podcasts, videos, webinars, and written works. For topics not requiring complex cognitive application or reasoning skills, these are fine. These elements are found in both simple and advanced courses, but the active learning course is built to allow the student to interact with the course and participate in more sophisticated learning activities.  
Increasingly, educators are integrating online elements into their classroom curricula—these are called hybrid courses. This style of learning, in which complex, cognitive instruction is done online and students engage in various activities and practice skills in class, has enormous potential in our profession.
Online courses are either synchronous (all students take the course at the same time) or asynchronous (students work alone, self-paced). Scheduling difficulties are an obstacle to synchronous courses, while asynchronous course activities can be performed any time. Flexibility is the primary advantage of asynchronous learning.
A course in which the student works directly with an instructor is called a facilitated course. Like in a classroom, the instructor is available to answer questions, give feedback on assignments, and provide direct one-to-one instruction. Online entry-level courses are more effective when an instructor is available. Most facilitated online courses in our field are offered at entry level. It is rare to find them in continuing education.

Undiscovered Potential
The most prevalent online courses currently available in the massage profession are online tests, with supplied materials such as text, video, and webinars that are either downloaded or emailed. These are basically home-study courses with online tests and are considered passive-learning designs because the student does not engage the content in an interactive interface. There is a distinct difference in quality between passive-learning courses and the innovative courses that include branching scenarios, virtual learning elements, and advanced interactivity built into a complex platform.
A rather large quality issue with online courses (and home-study courses) involves who authored the course. If the course is not authored by content experts, not designed by someone trained in instructional theory and design, and not constructed by a designer skilled in multimedia course design, then the quality can suffer significantly. Thus, the educational benefit is seriously degraded.
Unfortunately, poorly designed courses create a negative perception about online learning overall. The courses that rely on passive-learning elements, and are not constructed or designed with enough skill and sophistication to challenge and engage the student, are far from inspiring. More importantly, they do not capitalize on strategies and technologies that can completely change the learning experience for the better and greatly improve what students retain and achieve from the course.
Not only can students gain far more knowledge with better courses, but their enjoyment and engagement with that knowledge and content—their interest in learning—can be enhanced, leading to a more successful career.
 
Applied Learning & Formative Feedback
Online courses with more robust development elements can integrate newer ideas in educational/instructional theory and methods. One of these newer innovations is the realistic learning scenario. Technological advances allow for learning activities that mimic contexts students are likely to encounter in practice. These learning activities are, without a doubt, far more educational, engaging, and interesting than reading content from a textbook.
Learning and knowledge transfer are more effective if content is presented in a context similar to how it might be applied in practice (i.e., applied learning). The more a learning activity is contextualized, the greater the potential for long-term integration of the concepts. The failure to connect what happens in the classroom with real life is a common educational pitfall. For example, students may score high on a kinesiology test, but then not know whether a range-of-motion test involves concentric or eccentric action. Certain online learning designs can create scenarios where the learning activity requires the individual to apply specific concepts as they might in their decision-making process in practice. The clinical reasoning and decision-making process is individualized enough to make this type of activity difficult to do in the classroom.  
Additionally, certain types of online technology and programming can allow activities to be immediately followed up with formative feedback, which is detailed student feedback intended to modify and expand the learner’s understanding. Often a student is only told if an answer is correct or incorrect, but not why. Without understanding their mistakes, students miss the opportunity to improve and fully understand the concepts.
Formative feedback is directly connected to the student activity at that moment and thus is highly personalized. In the classroom, individualized formative feedback is often difficult to provide to each student. However, instructors using high-quality online instructional designs can build this kind of responsiveness into the course.

Virtual Clients/Patients
Many medical schools have been integrating a new learning strategy called virtual patients, in which students interact with a simulated patient. These are currently expensive and complex to produce, but highly effective. I use a modified virtual patient/client format in online courses and find it exceptionally effective for teaching key clinical concepts and developing clinical reasoning skills that were otherwise escaping students in the traditional classroom.
Students report that virtual patient cases are a far more interesting way to learn. Students have time to consider various facets and details of a case over a longer period of time than might be possible in the classroom. Time for integration and concept application helps deepen understanding and solidify student knowledge and skills.

Adaptive Learning
Perhaps the most exciting development in the world of online education is the emergence of adaptive learning strategies. Providing an educational experience that fits everyone has always been a challenge. In adaptive learning, course content adapts to the learner’s mastery of previous content. An online course can be constructed to recognize when a student has mastered initial stages, so highly skilled students can move to more challenging parts of the course more quickly. Students who need or want more help with early course concepts can be presented with additional information so they can master understanding before moving ahead. Adaptive learning strategies dramatically reduce student frustration with standardized courses. The online course can be programmed with personalized adaptive learning elements, which is an advantage for teacher and student alike.

Challenges Ahead
Incredible potential exists for effective online learning in massage therapy education. However, as with any new innovation, there are challenges. Instructor training is by far the greatest. A common misconception for online course development is that it is easy, with some instructors simply posting their course content to the web and calling it an online course. We know from multimedia learning theory that the instructional design strategies for an effective online course are very different from those of a classroom course. Creating and developing an online course involves a very different skill set than course development for a classroom.
Additionally, in most physical classrooms, one individual is responsible for being the subject matter specialist and constructing educational activities. The successful online course requires three specialists: a subject matter expert (SME), an instructional designer who understands and can produce effective multimedia instructional design, and a developer who can implement the course in an online platform and ensure it works correctly. It is rare to find these three specialized skill sets in one individual.
Finally, online courses require complex and advanced software programs and training whose costs may be challenging for schools or educators. Usually a school or educator works with a company that specializes in online course development, rather than trying to produce courses in-house. There are a variety of financial arrangements that can be made with online course development and hosting companies. An ideal company would have both an instructional designer and a technology expert, with the school instructor or consultant acting as SME.

Online Learning in Massage
Online strategies hold tremendous potential for stimulating and advancing education within the massage profession. The ability to incorporate unique and advanced instructional design strategies—along with multimedia such as audio, video, and highly interactive and engaging learning activities—holds great promise. We are now moving past the infancy of online learning, and it is time to progress beyond simple online offerings like webinars or “text and test” courses and welcome the challenge of new learning methods that can excite students and improve their competence.

Author note: an earlier version of this article previously appeared in the Journal of the Australian Association of Massage Therapists 12, no.3, www.aamt.com.au.

Note
1. Barbara Means et al., “Evaluation of Evidence-Based Practices in Online Learning: A Meta-Analysis and Review of Online Learning Studies,” US Department of Education (revised September 2010), accessed January 2015, http://search.ebscohost.com/login.aspx?direct=true&db=eric&AN=ED505824&site=ehost-live.

Whitney Lowe’s texts and courses have benefitted professionals and schools for more than 25 years. Learn about Lowe’s engaging, innovative, and interactive instructional designs, and gain free CEs at www.academyofclinicalmassage.com.