As a manual therapist and educator, I have long been an advocate of guidelines and standards for massage therapy. I feel that creating core curriculum and continuing education requirements for massage has helped advance the field of massage therapy, but I have also come to realize that the parameters—defining who we are and what we can do—also exclude and divide what might otherwise be thought of as the larger world of manual and movement therapy.

The Larger Field

The realization that parameters can define as well as divide first came to me approximately 10 years ago while teaching my first Clinical Orthopedic Manual Therapy (COMT) workshops in Singapore. In the United States, I was accustomed to teaching to groups of massage and other manual therapists, with the occasional movement professional (fitness trainer, Pilates, or yoga instructor) attending. In Singapore, however, I was teaching primarily fitness trainers and Pilates and yoga instructors, with only a few massage therapists attending. In all fairness, one reason for this demographic shift was that the workshop organizer was in the world of fitness training, but I was still struck by teaching to a group composed primarily of movement professionals.

When the occasional movement professional attended my workshops in the US, I viewed the sharing of manual therapy skills as being valuable for them for three reasons: (1) there is a shared underlying foundation of musculoskeletal anatomy, physiology, and biomechanics that I would discuss; (2) stretching techniques are shared in both their movement world and our manual therapy world; and (3) the hands-on manual therapy skills, such as palpation and massage, would help inform their touch when working to cue and guide the movements of their clients. But now, in Singapore, I had movement professionals who were in my workshops to actually learn hands-on palpation and massage techniques.

Many of the workshop participants were employed as fitness trainers in the gym where I taught the workshop, and I saw that the gym had all the usual weight-training equipment in the center of the room. At the periphery of the room, though, there were massage tables that the trainers would use to palpate, massage, and stretch their clients during the workout session as they deemed appropriate.

This combination of therapies could occur because the scope of practice for the various fields of manual and movement therapy in Singapore (and many other countries where I taught) have not yet been sharply defined. This lack of definition allows for various methods of bodywork to be integrated together.

In Singapore, less regulation seemed to allow for fewer turf battles over who could and—more to the point—who could not perform certain techniques.

This lack of regulation allowed for a greater expression of assessment and treatment techniques being performed by these professionals.

Creating a More Cohesive Approach

What at first seemed discordant to me was actually much more cohesive and inclusive. Instead of dividing the world into many separate fields of manual and movement therapies—with each field denying the others the right to perform what they feel is their proprietary technique—why not combine them together in one inclusive world?

Yin and Yang

One reason for combining the worlds of manual and movement therapies is that each individual therapy addresses a fundamental component of musculoskeletal health, but by itself also misses another fundamental component. The strength of one field fills in the weakness of the other field. So, like yin and yang, manual therapy and movement therapy are two pieces that complement each other and create a greater whole that serves to benefit the client.

If we compare and contrast massage therapy and fitness training, we see that massage therapy primarily works to loosen taut/tight myofascial tissues but does little to increase the strength of these tissues. In effect, massage therapy’s principal aim is to increase flexibility but does little for strength and stability. On the other hand, fitness training primarily works to strengthen myofascial tissues but does little to loosen tautness in these tissues. In fact, the more we focus on resistance in strength training, the tighter our baseline tone of musculature tends to become. Let’s look at an example of when this might matter.

Example: Upper-Crossed Syndrome

We have a client with upper-crossed syndrome, meaning they have a postural distortion pattern that involves hyperkyphosis of the thoracic spine with protracted shoulder girdles and forward-head posture (Image 1).

The massage therapist knows that a major focus of their session would be to massage and stretch the locked-short pectoral shoulder girdle protraction muscles.

Loosening the pecs would allow the client to open their shoulder girdles back into retraction. But if this is all that is done, and if the retractor muscles of the shoulder girdles (rhomboids and trapezius, especially middle trapezius) are weak, the client would not be able to maintain this position of shoulder girdle retraction and would fall back into protraction.

On the other hand, a major focus of the fitness trainer would be to strengthen the retractor musculature to bring the shoulder girdles back into retraction. But if this is all that is done, their efforts will be thwarted by tight pectoral shoulder girdle protraction musculature that would not allow for the retractor muscles to bring the shoulder girdles back into retraction.

The Chicken and the Egg

It is clear that a balanced approach to treating this client would be to massage and stretch the pectoralis muscles to loosen them, and then strengthen the retractor musculature with resistance training to increase the strength of its baseline tone. We might call this a yin-and-yang approach, or perhaps look at it as the chicken and the egg.

Is upper-crossed syndrome caused by tight protractors, or is it caused by weak retractors? The answer is, of course, both. And if one is present, the other will develop, which will then reinforce the first, and so on, causing a vicious cycle. For true healing, we need to address the chicken and the egg.

Curriculum Conundrum 

Let’s take a look at a typical massage therapy curriculum.

If someone attends a 700-hour massage therapy curriculum, it will contain approximately 150–200 hours of kinesiology (musculoskeletal anatomy and physiology), which is the basis for understanding muscle function. In many states, the graduate of this program is not legally/ethically allowed to recommend simple strength-training exercises to their clients under their massage therapy license. But, if this same person attends a weeklong or perhaps even a two-day weekend workshop for fitness training, they can attain a Certification in Fitness Training that would then legally allow them to work with clients for strength training. This is ironic because the educated massage therapist, with their many hours of kinesiology, would have the critical thinking skills to work with and advise their clients as to how to increase the strength of their weakened muscles. After all, strengthening a muscle is simply asking for it to undergo its concentric joint action(s) against some resistance.

A muscle’s actions are something that all massage therapists learn in core curriculum. Figuring out how to add resistance is a simple matter. Granted, there are longer fitness strength-training certification programs out there, but the central understanding of strength training, and how to create it lies within the conceptual seeds of the massage therapist’s core curriculum.

Similarly, the essence of massage therapy—using our hands to manipulate myofascial tissues—is a fairly simple technique that, if not taught to movement professionals in their core curriculum, can be safely taught in continuing education workshops. Aside from specific contraindications and precaution sites, working into myofascial tissues is a fairly straightforward technique—especially for someone who has already learned the underlying musculoskeletal anatomy and physiology, which well-trained movement professionals do.

I realize that some of these statements might be viewed as controversial. I am one of the biggest proponents of education and training, but I do believe that the application of any manual or movement technique is relatively simple and straightforward, as long as the therapist/trainer/instructor has learned the underlying foundational kinesiology and pathology, and can critically think through the mechanics to creatively apply the appropriate techniques.

In our current world, manual therapists have massage, movement professionals have strength training, and both worlds share the technique of stretching. I believe it would be better to combine these worlds into one of both manual and movement therapy. Perhaps each could have its advanced credentialing, but I believe the benefit to the client of having one cohesive approach of manual and movement therapy is clear.

Intersection of Stretching

Truth be told, there is already an intersection between the worlds of manual and movement therapy. That intersection is stretching. Stretching can be simply a movement technique that clients perform by themselves, such as during a fitness, Pilates, or yoga session, but stretching can also be performed by a manual therapist with hands on the client to facilitate and augment the stretch. But beyond this intersection of stretching, most manual therapy techniques are denied to movement professionals, and strength-training techniques are out of scope for most manual therapists. Scope of practice set by licensure varies from state to state in the US, but the foregoing is generally true.

Massage Can Strengthen; Strength Training Can Loosen

Massage therapy is primarily aimed at loosening myofascial tissue to increase flexibility; it does not directly increase muscle strength. After all, beyond breaking up fascial adhesions, the principal goal of massage is to lessen baseline muscle tone; in other words, to inhibit the nervous system’s control of musculature. But it could also be argued that massage can indirectly strengthen musculature. If musculature is painful or dysfunctional (perhaps due to a myofascial trigger point), then by healing the trigger point, the pain and dysfunction will be lessened, allowing for improved muscle function, and therefore greater strength.

Similarly, strength training’s principal goal is to strengthen musculature by increasing facilitation of muscle tone, so it is usually not thought of as loosening musculature. By strengthening musculature, though, we allow it to better deal with the demands placed on it. Strengthening decreases the likelihood that musculature will become dysfunctional and painful, which might otherwise result in protective muscle spasming with the resultant increased baseline tone tightness. So, strength training can indirectly loosen muscle tone.

Benefits of Combining Massage and Movement Therapies

In this article, I spoke of client benefits when combining the two worlds of manual and movement therapy into one cohesive world. But what about the massage therapist? Would there be a benefit for the therapist? I believe there would be many.

One benefit would be an increase in business from having more skills to treat our clients with—and from the improved results we attain with more comprehensive care. Another benefit would be direct and more personal for the therapist: By entering and becoming involved in the world of movement therapy, the manual therapist’s mindset and philosophy will temper in the direction of incorporating movement therapy into their own lives, with the same improved health that their clients will enjoy. And being in better shape will more likely ensure career longevity, which is challenging in a field as physically stressful as massage therapy.

These same advantages could be stated for movement professionals. The advantage to the movement professional’s personal health is especially true for fitness trainers who often deviate excessively toward strength and away from flexibility. Entering the world of manual therapy would raise their awareness of the value of manual therapy and would likely result in them having manual therapy treatment more often for their own bodies.

Manual or Movement Therapy: Which Comes First?

If you do possess both manual and movement therapy skills, the question might be how to choose which skill to employ first. There is not an exact recipe for what is best for every client, but when a client presents with a musculoskeletal pathology, I believe manual therapy should generally be done first to remove the painful pathology and restore the tissue integrity. This is because all manual and movement therapy by definition places a stress into the tissues. If a tissue does not have proper integrity, then it is best to minimize this physical stress force in the initial stages of treatment. Generally, movement therapy—and strength training in particular—tends to place a greater stress into the tissues. For this reason, I generally recommend that manual therapy should be done first to lessen pain and restore tissue integrity, then the movement therapy strength training can be commenced for long-term stability and health.

Merging Manual and Movement Therapies

Ideally, there would be a meeting of the minds of the professions that would allow for a kind of reciprocity, or a bridge program that would allow a merging of the fields. Until then, this integrated world can exist only by having a massage therapist that is also certified as a fitness trainer (or Pilates or yoga instructor) or by having a fitness trainer (or Pilates or yoga instructor) who has also attended massage therapy school. The logistics of this are challenging, and a bit expensive, but I do believe that the benefits make this a worthy pursuit.

Three Keys to Musculoskeletal Health

I prefaced that the keys to improved musculoskeletal health (perhaps better stated as myofascioskeletal health) are strength and flexibility of myofascial tissue. Let’s expand the term to “neuro-myo-fascio-skeletal” instead, which adds in the incredibly important concept of nervous system control. Proper neural control addresses the nervous system’s ability to order and co-order (coordinate) various synergistic groups of muscles for healthy posture and movement patterns. Thus, the strength and flexibility of myofascial tissues plus proper neural control by the nervous system might be the three major factors needed for healthy somatic functioning (Image 2).

Movement Professions to Include

So, which field might a massage therapist add to their education and skill set? When looking at the world of movement therapies, the three biggest choices are fitness strength training, yoga, and Pilates.

The starkest counterpoint to massage therapy’s focus on loosening taut myofascial tissue is likely fitness training, so if the massage therapist is looking to complement their base with the other end of the spectrum, fitness training would be the obvious choice. Choosing yoga or Pilates, however, might be the more natural step away from manual therapy. These methods of body conditioning have a dual focus on strengthening and stretching. Another choice would be Feldenkrais, which concerns itself with neural control.

Expand Your Skill Set . . . or Partner Up

Of course, my intent with this article is not to try to convince each and every manual therapist to train to be a movement therapist. One can believe in the efficacy of movement therapy without having to enter the field. The alternative is to build a network of movement professionals to whom you can refer clients. But if adding in movement therapy to your practice does interest you, then it would round out your practice and allow for a greater, more comprehensive care of your clients. 

Dr. Joe Muscolino has been a manual and movement therapy educator for more than 30 years. He is the author of multiple textbooks, including The Muscular System Manual: The Skeletal Muscles of the Human Body (Elsevier, 2017); The Muscle and Bone Palpation Manual with Trigger Points, Referral Patterns, and Stretching (Elsevier, 2016); and Kinesiology: The Skeletal System and Muscle Function (Elsevier, 2017). He teaches continuing education workshops around the world, including a certification in Clinical Orthopedic Manual Therapy (COMT), and has created LearnMuscles Continuing Education (LMCE), a video streaming subscription service for manual and movement professionals, with seven new video lessons added each and every week. And he has created Muscle Anatomy Master Class (MAMC), the most comprehensive and detailed muscle anatomy online class in the world, with each muscle taught in five distinct video lessons. Visit www.learnmuscles.com for more information or reach him directly at joseph.e.muscolino@gmail.com.