Imagine an auto accident victim as she puts her life back together. She schedules separate appointments with an orthopedist for her mending bones, a chiropractor for her post-whiplash spine, a massage therapist for her pain and scar tissue, and a counselor to help manage the psychological aftermath. What if she was instead able to meet with a team of experts who could not only address her issues from their singular place of expertise, but also collectively share the same understanding of who this patient is and what outcome she wants? This is the implementation of integrative medicine, a growing health-care movement that sees massage as a valuable partner.
Vision of a New Model
It was a certainty that the medical community could do much better that prompted Andrew Weil, MD, to create not only the first-of-its-kind Fellowship in Integrative Medicine in 2000 for physicians, nurses, and other clinicians, but also open the Arizona Center for Integrative Medicine (AzCIM), which hails as a leading provider of integrative medicine education worldwide. Weil knows that a transformation of the country’s fledgling health-care system is possible. “Our current medical system is ineffective at promoting the health of its citizens, far too expensive, and unsustainable,” he says. “I believe that integrative medicine is the only practical way to transform our health-care system and bring lower-cost, health-enhancing treatments into the mainstream.” And, it’s what consumers are increasingly seeking.
The premise of integrative medicine is just what its name implies. “Integrative medicine is really a healing-oriented medicine that takes into account all aspects of an individual—their body, mind, spirit, lifestyle—and it uses the most appropriate therapies, whether they are conventional or alternative,” says Tieraona Low Dog, MD, director of the Fellowship at AzCIM, and clinical associate professor at the University of Arizona College of Medicine. “Integrative medicine is patient-centered medicine,” she says. “It’s about healing, not curing. It doesn’t distinguish whether an appropriate therapy comes from a pharmaceutical company, a massage therapist’s hands, or a surgeon’s scalpel. We focus on wellness, not just the disease.”
By focusing on health promotion and disease prevention, Weil and others say integrative medicine promises to reduce health-care costs by utilizing less expensive treatments and producing better outcomes. “Still, integrative medicine neither rejects conventional medicine nor accepts alternative therapies uncritically,” he says. While open to new paradigms, Weil says integrative medicine is inquiry-driven and based in good science.
The team approach to integrative medicine is at the crux of its success. “By fostering integration, patients can enjoy more benefits and fewer side effects from their varied approaches to health than they would if they were seeking care from individual providers who aren’t communicating,” says Lisa Corbin, MD, medical director at The Center for Integrative Medicine at the University of Colorado Hospital (UCH). “Imagine being on a basketball team where no one was talking to each other or passing the ball, versus the integrative team where each member is performing together with the rest.”
Building a team made up of health-care practitioners (from massage therapists to acupuncturists to spiritual counselors), primary care providers, and the patient creates a collaborative force and strong therapeutic relationships. Including patients within that circle not only empowers them, but invests them in the process and gives them space to be heard.
Low Dog paints a picture of how an integrative medicine team might tackle a particular health issue. “Take arthritis, for example. It limits your ability to move. We ask how does your lack of mobility affect you and how does that affect your quality of life and mood? We look at how this has affected you on many, many levels. Instead of just considering pharmaceuticals, we ask if there are any supplements that would work for you. If walking or exercise is bothering you, maybe we can get you into swimming or tai chi.”
There is no hierarchy of treatment either, she says. “The only hierarchy we have is using the less risky approaches first. So, before jumping to an arthritis medication with lots of side effects, we would try acupuncture or nutrition first. Before considering surgery, we would maybe try a manipulative therapy. But, by the same token, if a medicine works really well and will improve the patient’s quality of life, then it should be a course of treatment.”
At the heart of integrative medicine, Low Dog says, is approaching health care from a broad and varied perspective, and ultimately considering what the patient wants. “If I tell a patient, who’s going through treatment for breast cancer, about acupuncture for the hot flashes she’s going through, but she has an aversion to needles, then we don’t go that route. We must ask what does the patient find healing and how do we try to incorporate that.” Low Dog says integrative medicine ensures you will have a “broad array of options to try with that cancer patient; that’s why it’s called the art of medicine.”
A Place for Massage
Within the integrative medicine framework, massage has become commonplace and is typically partnered with chiropractic care and acupuncture, among other bodywork therapies. Weil (whose primary medical partner, Brian Becker, MD, completed massage school training in 1988) thinks a big part of its inclusion in the integrative model comes from the research that has proven its benefits.
“I am a strong advocate of massage therapy and feel that it fits extremely well into the paradigm of integrative medicine,” Weil says. “Much of my firm support for massage therapy stems from the existence of a compelling research base. It’s also one of the CAM therapies most readily accepted by conventional medical doctors and hospital administrators. I consider massage therapy to be a core component of the CAM therapies offered within integrative medicine.”
As more integrative medicine clinics and hospital-based programs open to the public, there has become a demand for massage therapists qualified to fit these new integrative roles. Dale Healey, DC, dean of the School of Massage Therapy at Northwestern Health Sciences University in Bloomington, Minnesota, says the hospital administrators he collaborates with are eager for more MTs trained to work in these settings. “The next big demand is going to be for therapists who are trained in this environment specifically,” Healey says. “We see the demand coming. The US Bureau of Labor Statistics is predicting a hefty demand for MTs, and an increased demand in medical settings will be the biggest factor in that growth.”
At Northwestern, graduates from the three schools of massage therapy, chiropractic, and acupuncture and oriental medicine are trained to practice and manage cases together. “They are exposed to approaches, philosophies, and outcomes of other professionals,” Healey says. “The goal is when these students graduate, they’re graduating with their biggest strength being their own techniques, but they have a broader mind-set.”
Educational partnerships and allopathic collaborations are other ways Northwestern is fueling the integrative paradigm and supplying the MT demand. Students have several opportunities to test their skills in integrative environments, including a free, student-run integrative clinic for clients of a local social services organization and on-campus clinical training opportunities through the student health center. Northwestern also has a close relationship with the Penny George Institute for Health and Healing at Abbott Northwestern Hospital in Minneapolis, where MTs go for externships after finishing the hospital-based massage therapy program. The tables are turned a bit when medical students from the University of Minnesota Medical School come to Northwestern for a crash course in CAM therapies. Giving these medical students a firsthand look at massage, acupuncture, and chiropractic care opens the door to possibilities.
Having gone to massage school herself in 1976, Low Dog says without a doubt that massage is a valuable component of integrative medicine. The challenge massage faces comes in trying to quantify and replicate it.
Massage is about the “element of one,” Low Dog explains. “There’s one patient sitting in front of you, not the 400 from a study sample.” Massage, presented as part of a double-blind, randomized study, doesn’t necessarily fit. “Massage is not all one thing, nor are therapists all of one type or trained in one way. Some doctors are really great in understanding that; some are not. I think many clinicians would benefit from having more exposure to massage therapy, even just a small amount in their medical training, because there’s something about using the hands to palpate, to connect on that very deep level, that, as a physician, you just don’t get.”
She says when a doctor doesn’t understand that a psoas can cause back pain, or can’t see the connections between structure and pain, there is a definite disadvantage for the patient. Having an MT on the team can change all that. “When you get a really skilled therapist in there, the results speak for themselves,” Low Dog says.
An Integrative,
Hospital-Based Perspective
Of her 27 years as a massage therapist, Ann Mathews has spent the last six with The Center for Integrative Medicine at UCH near Denver. She describes the work as rewarding on many levels. From the collaboration she has with other members of the integrative medicine team, to the variety of patient cases she’s brought in on, Mathews finds the process fulfilling and challenging at the same time.
At UCH, Mathews works with a chiropractor, acupuncturists, nutritionists, psychotherapists, and a medical director. Her day might entail conferring with members of the team about a common patient, informing each other of recent referrals, and making suggestions on what course of action patients need. Twice a month, the group has case conferencing meetings to offer even more in-depth integration for certain patients. “I value our collaboration very much,” Mathews says of the process.
Does this type of collaborative work mean that massage therapists have been officially invited to the integrative table? “We’re already here,” says massage therapist Mollie O’Brien, an integrative health practitioner at The Penny George Institute for Health and Healing. “Not every physician is onboard, but they’re reading our notes, and we’re equal partners at the table with other health-care practitioners,” she says. “We’re fully integrated and have the respect of other staff.” Layering integration on top of integration, O’Brien says the institute has 23 in-patient practitioners who are cross-trained in a variety of disciplines—guided imagery, aromatherapy, Oriental medicine, reflexology, healing touch, as well as massage. The core of their work is patient education, O’Brien says, and empowering patients as they heal the physical, mental, emotional, and spiritual aspects of a hospitalization.
The success of their work is not going unnoted. O’Brien says her group has enjoyed continued funding from the hospital as they’ve repeatedly shown their interventions decrease pain and reduce overall hospital charges. In fact, a recent observational study from the institute, published in the Journal of Patient Safety, found that patients reported a 50 percent reduction in pain after receiving integrative medicine care.
As in any job setting, this work has a mix of challenges and rewards. For Mathews, setting her own work schedule and hours and being part of a collaborative team combats the isolation she once felt in her private practice, while still affording her the freedom she enjoyed in that solo setting.
MTs working in an integrative hospital/clinic setting say educating physicians, nurses, administrators, and patients about the role of integrative medicine is a fundamental, daily practice. Being able to see outside the box, while working within the box, is one way O’Brien handles the challenges of practicing holistically within an acute care setting, especially since—until now—there have been no models for how this should look. “We are creating a new model of care,” she says. While it may be challenging to work within this model, O’Brien says it’s also exhilarating. “You need to see the really, really big picture. You need to think beyond your traditional role as a massage therapist.”
The challenges facing MTs on an integrative team are similar to those experienced by other health-care providers, O’Brien says. Resilience, she says, is what’s needed, as is the need for self-care to avoid burnout. “It’s an intense, demanding, often sad, often inspiring and profound environment to work in,” she says. “You’re a care provider and you’re giving a lot of energy to your patients.” Replenishing yourself is imperative.
Being part of an integrative medicine team is also filled with great rewards. Seeing the patient transform before your eyes is one of them, O’Brien says. When working in a private practice, she explains, clients have made some sort of conscious decision to heal. “In our setting, we are going to the patients’ rooms, in many cases when they’re not asking for it. We are seeing people who might not otherwise have an opportunity to be exposed to the services, and we’re reaching a wide, often underserved population. You know you’re helping them make a difference for their own future.”
The Integrative Partnership
As massage therapists continue to be included in the integrative model, whether in a hospital, clinic, or private practice, there are some things they should do to ensure their therapeutic roles. “As more people, including doctors, experience its benefits and appreciate the healing power of appropriate human touch, I am confident that massage therapy will soon be offered within most medical centers,” Weil says. “Of course, additional sound research will help drive the inclusion of massage in the conventional medicine armamentarium.” On that front, he says he would like to see more studies comparing the effects of massage therapy to pharmaceutical agents for the relief of pain and anxiety, cost-benefit analyses of the preventive effects of regular massage, and an investigation into the underlying mechanisms behind the benefits of massage.
To succeed in an integrative model, Healey says most massage therapists have the right academic knowledge (although a contraindications refresher would be helpful), but not necessarily the environmental experience and considerations. “It’s about doing massage in a bright room, with interruptions, on a hospital bed and the body mechanics considerations that go with that, dealing with staff—it’s those factors that are lacking, not a particular technique.”
Proper charting skills and speaking the language, O’Brien says, are also essential to a successful integrative experience. Being able to converse with your colleagues and being able to document your work can speak loudly in a hospital setting. Some suggest a refresher course in pathology is another sound move.
Mathews, who considers her integrative hospital work the most satisfying thing she’s done in her career, would add a few more to the list. “To be successful in the hospital setting, massage therapists need to be computer-savvy for record keeping, be willing to work with a wide scope of patients and as a member of a team of colleagues, have a high level of professionalism, and be willing to collaborate and learn.”
The Perfect Storm
The growth of integrative medicine is on the rise, Weil says, in large part because of the number of practitioners being exposed to its tenets. He says this comes from the commitment of major medical universities to integrative medicine, the establishment of the Consortium of Academic Health Centers for Integrative Medicine, and the presence, albeit sometimes small, of CAM courses in nearly all US medical schools. Weil says AzCIM has developed a model integrative medicine curriculum that exposes medical residents to new ways of thinking about health and healing. “The curriculum is in use at a number of medical institutions, with the expectation that one day it will be adopted by medical schools and residency programs around the country,” he says. “No future doctor should leave training without a working concept of health, an in-depth understanding of the importance of healthy dietary and lifestyle measures, and an honoring of the body’s innate healing capacity.”
Healey sees opportunity rising on the crest. “We’re reaching a ‘perfect storm’ of clinical and economic forces, which is creating a real sea change in acute health care settings,” he says. “If I were a betting man, I would say massage therapy will play a significant role. The health-care system is collapsing—insurance rates are increasing by double digits every year, patient outcomes are not reflecting patient investment, baby boomers are retiring and will soon need advanced care … and there is an increase in obesity, diabetes, and cancer care. People are scrambling for solutions.”
The role of the MT is going to be to “respond to the increased attention and awareness that has come to this idea that you can’t poke, prod, and drug in isolation and expect any kind of realistic outcome,” Healey says. The evidence is building for clinical outcomes MTs can achieve in areas of pain, anxiety, and stress reduction. “Pain control is the number one reason for prescriptions in the hospital, so it’s no small thing if we can have an impact on pain and anxiety,” he says. “Also, from the patient perspective, there is a growing demand and growing awareness. I think patients have easier access to information and are feeling more empowered to make decisions about their health care. Those decisions are not ‘I want more drugs and surgery,’ it’s ‘I want a kinder, more gentle approach to my health.’” Massage is aligned with that request.
After the Shift
As a member of a successful integrative medicine team, Mathews is not only fulfilled in the challenging work she does, but sees a bigger picture in her role as an MT. “This is a new field of practice and I feel it is my responsibility, as a pioneering therapist, to do my best so that the opportunities in hospital systems continue,” she says. “We are needed there.”
If consumers, patients/clients, doctors, health-care practitioners, clinicians, and administrators continue to embrace the paradigm, more and more practitioners like Mathews will be needed to meet the demand. For advocates, this would be a very good thing.
“It is important to note that integrative medicine is not a field unto itself, nor a medical specialty,” Weil reminds us. “It represents an attempt to bring health care back to its roots in relationship and healing. When that is achieved, the word integrative will no longer be necessary—it will simply be good medicine.”
Karrie Osborn is the contributing editor for Associated Bodywork & Massage Professionals. Contact her at karrie@abmp.com.