Several challenges exist when defining the scope of practice for any profession—who is being regulated, who is exempt, practice guidelines, and the consequences of not following these guidelines. Let’s consider what scope of practice is for massage and bodywork professionals, how it relates to law, and what controversies revolve around this issue.
What is Scope of Practice?
Scope of practice is a phrase used by licensing boards or certifying bodies for various professions that defines the procedures, actions, and processes that are permitted for a licensed individual. A board’s purpose is to ensure qualified individuals practice in a safe and effective manner, according to local, state, or national laws. Public protection is the board’s primary concern.1
In medical or health professions, a qualified professional has been trained in the physiological effects, indications, contraindications, and proper application of a technique or skill. Typically, this is confirmed through educational guidelines, licensing examination(s), and/or a competency evaluation. The board ensures that these qualifications have been met.
In the field of massage therapy, the scope of practice varies from state to state. For example, in New York, “The practice of the profession of massage therapy is defined as engaging in applying a scientific system of activity to the muscular structure of the human body by means of stroking, kneading, tapping, and vibrating with the hands or vibrators for the purpose of improving muscle tone and circulation.”2
Ohio identifies massage therapy as “the treatment of disorders of the human body by the manipulation of soft tissue through the systematic external application of massage techniques, including touch, stroking, friction, vibration, percussion, kneading, stretching, compression, and joint movements within the normal physiologic range of motion; and adjunctive thereto, the external application of water, heat, cold, topical preparations, and mechanical devices.”3
Texas describes massage therapy as “the manipulation of soft tissue by hand or through a mechanical or electrical apparatus for the purpose of body massage and includes effleurage (stroking), petrissage (kneading), tapotement (percussion), compression, vibration, friction, nerve strokes, and Swedish gymnastics.”4
Among state laws, common themes emerge with regard to the scope of practice for massage therapy: (1) massage therapy involves the manipulation of soft tissue; (2) this soft-tissue manipulation should have a specific therapeutic intent or purpose. Beyond these two major points, legislative and professional discrepancy begins.
Terminology
Terminology, excluded forms of soft-tissue therapy, exemptions, and other issues about scope of practice warrant great debate among legislators, lobbyists, massage practitioners, and other healthcare providers. Legislators are motivated to protect the public, streamline processes, and minimize complaints. Massage practitioners want to protect their profession and ensure the greatest possible freedom to practice their craft. Other healthcare providers want to protect their own profession from infringement by other disciplines.
One of the greatest areas of confusion for massage practitioners is terminology. Massage practitioners need to develop a vocabulary that the medical field can adopt. Terms that draw frequent fire are range of motion, joint mobilization, therapeutic exercise, neuromuscular reeducation, and manual therapy. Other professions may try to limit the scope of practice of massage therapists by writing a definition that restricts treatment of illness or injury or by including language that specifically excludes particular techniques such as those listed above.
Range of Motion
Range of motion as a technique involves moving a joint through its normal, physiological motions. The direction and degree of movement possible varies between joints and is usually described as flexion, extension, abduction, adduction, internal or medial rotation, external or lateral rotation, or other joint-specific, gross movements.
There are three universally accepted forms of range of motion: active, passive, and resisted. Active range of motion occurs when clients perform the movement themselves. Passive range of motion is executed when the practitioner performs the movement as the client remains relaxed. Resisted range of motion occurs when the client attempts to move against the practitioner’s resistance. Within the massage community, range of motion may be referred to as Swedish gymnastics.
Controversy typically arises when describing the use of range of motion as an assessment or diagnostic tool rather than a treatment technique. It is not often disputed that massage therapists are within their qualifications to move the body or have their clients move their own bodies during a massage session. The most heated debate is over the ability to measure the amount of movement using a tool such as a goniometer or inclinometer, thus entering the realm of physical therapists, athletic trainers, and physicians. It is often these groups who claim that the use of range of motion is outside of the scope of practice of massage therapists.
Joint Mobilization
Joint mobilization can be confused with range of motion. According to the American Medical Association (AMA), joint mobilization is a “manual technique used to increase joint range of motion by enhancing accessory motion, joint play, or manipulating the alignment of the articulating surfaces.”5
The American Physical Therapy Association (APTA) describes it as “the attempt at restoration of full, painless joint function by rhythmic, repetitive, passive movements within the patient’s tolerance and within the voluntary and accessory range, and graded according to examination findings.”6
Massage and bodywork education programs typically do not cover accessory motion, which is the foundational principle behind joint mobilization. Accessory motion is the change in spatial relationship between the articular surfaces of one bone relative to another, characterized as roll, spin, and glide. These movements describe how the articular surfaces shift as the joint moves through physiological or gross movements and is considered essential to normal range of motion. Additionally, joint mobilization techniques are considered both an assessment technique and a treatment method.
Traditionally, joint mobilization falls under the scope of practice of physical therapists, osteopaths, and chiropractors. There is tremendous controversy about this particular technique among those professions. There are five grades of joint mobilization ranging from grade I (small oscillations at midrange of accessory motion) to grade V (rapid, thrusting forces at end range of accessory motion to realign articulating surfaces). Grade V is the most commonly challenged. This technique is also called manipulation and most often falls to chiropractors and osteopaths, but sometimes falls under the scope of practice of physical therapists or naturopathic physicians.
Range of motion works with physiological motion and is not joint mobilization. Craniosacral therapy targets the dura and flow of cerebrospinal fluid and is also not joint mobilization. Swedish gymnastics are not joint mobilization. Muscle energy techniques, proprioceptive techniques, and strain-counterstrain methods affect joints, but are not considered joint mobilization. Joint mobilization is a specific technique that utilizes various grades of oscillating movement in specific ranges of accessory motion to increase joint play.
Therapeutic Exercise
Therapeutic exercise involves the prescription of bodily movement to correct an impairment, improve musculoskeletal function, or maintain a state of well-being. Of all of the techniques discussed in this article, therapeutic exercise is the easiest to argue excluding from a massage therapist’s scope of practice. Physical therapists, athletic trainers, exercise physiologists, personal trainers, and other exercise professionals argue this point vehemently.
There are a host of methods for prescribing bodily movement or exercise. For each, exercise professionals must master the physiological effects, indications, contraindications, and methods of safe, effective application. Most study exercise physiology, biomechanics, fitness assessment, and programming to establish this baseline competency. These topics are not core curriculum for massage education and therefore massage practitioners would not be qualified to assign therapeutic exercises.
While many massage professionals pursue additional education in fitness and exercise, they are working outside of their scope of practice if they integrate therapeutic exercise, or any exercise for that matter, into their massage practice. I have multiple certifications and am able to utilize exercise as part of my overall practice. I make separate appointments for different modalities (massage versus exercise), and I do not bill insurance companies for services outside of my scope of practice for massage.
There is some question about assigning homework for massage clients. It is tempting to encourage your client to do shoulder rolls to relieve their neck tension between appointments or to stretch their wrist flexors after heavy computer use. Be clear that this is not within your scope of practice as a massage professional and may actually be excluded by your state law. Be particularly mindful not to assign any numbers to suggested movements (i.e., do this stretch three times a day and hold for 30 seconds each time); that is clearly exercise prescription and the territory of physicians, exercise physiologists, physical therapists, and fitness professionals. When in doubt, refer out.
Neuromuscular Reeducation
Neuromuscular reeducation is a lot less clear than therapeutic exercise. The AMA defines it as “a therapeutic technique that is used to improve balance, coordination, posture, kinesthetic sense, and proprioception.”7 Typically, neuromuscular reeducation utilizes visual, audio, and kinesthetic cues to alter dysfunctional movement patterns or reestablish normal motor programs following disease or injury.
There is no question that massage affects the nervous system and can affect proprioception. If you are mechanically manipulating muscles and tendons, proprioception is affected. The question is whether this is reeducation of the nervous system. Most in the medical community would say no.
Neuromuscular reeducation involves clear understanding of human movement, the ability to detect abnormal human movement and the causes of that abnormality, and the ability to alter or reeducate the client in movement. Physical therapists, chiropractors, and other movement specialists have extensive training in neuroanatomy, kinesiology, biomechanics, and physics. They are protective of this area of their profession because they are highly trained in these specific skills, especially compared to the amount of training a massage therapist receives in a typical 500-hour program.
Specific massage techniques such as craniosacral therapy and neuromuscular therapy target the nervous system, but do not reeducate the system through movement in the way that Feldenkrais or physical therapy do. Proprioceptive techniques also manipulate the nervous system in an effort to alter the soft tissue of muscle, but again, this is not considered neuromuscular reeducation as described by the AMA.
Manual Therapy
In 1998, the AMA created a new current procedural terminology (CPT) code specifically for physical therapists. Billing practices prior to this had identified individual procedures such as joint mobilization, myofascial release, and muscle energy techniques under separate codes. The new system lumped all of these techniques under a single code (CPT code 97140 for manual therapy) and limited the number of times this code could be billed during a single treatment.
The American Academy of Orthopedic Manual Physical Therapy and APTA define manual therapy as “a clinical approach utilizing skilled, specific hands-on techniques, including but not limited to manipulation/mobilization, used by the physical therapist to diagnose and treat soft tissues and joint structures for the purpose of modulating pain; increasing range of motion; reducing or eliminating soft-tissue inflammation; inducing relaxation; improving contractile and non-contractile tissue repair, extensibility, and/or stability; facilitating movement; and improving function.”8 These organizations consider the following techniques to be manual therapy: mobilization/manipulation, muscle energy techniques, strain-counterstrain, soft-tissue mobilization, and myofascial release.
You may have noticed the use of soft-tissue mobilization within their definition. That’s massage, right? Well, not exactly. Typically, insurance companies assign it a separate CPT code (97124 for massage therapists). It differentiates services provided by a physical therapist (97140 for manual therapy) from “the manipulation of soft tissue for therapeutic purposes” delivered by a massage therapist.
Many massage therapists saw an opportunity to increase their reimbursement by using the 97140 code for manual therapy, as it was assigned a higher dollar amount. After all, massage therapy is manual therapy. Herein lies the seed of the controversy: massage therapists use billing codes intended for physical therapists. This has fueled the turf wars between physical therapists and massage therapists. This controversy grows as other health professionals, such as chiropractors, employ massage therapists and bill multiple codes not clearly identified as appropriate.
Exclusions and Exemptions
Once issues of terminology are clear, legislators must tackle the issue of exclusions and exemptions. This identifies disciplines similar to massage, but that not be regulated by massage law. Typical exclusions and exemptions include reflexology, structural integration, movement reeducation, Asian bodywork, and energetic modalities such as reiki. Many practitioners, organizations, and associations lobby for exclusion or exemption in an effort to keep themselves or their members unregulated.
There is some consistency from state to state with regard to exempt modalities, but legislators must consider the prevalence of particular disciplines, public safety concerns, enforcement practices and resources, and budgetary issues of their particular state when deciding exclusions and exemptions. Many ancillary professions lobby or sit on state boards in an effort to protect their profession’s scope of practice or exempt status. The major consideration for exclusion or exemption should be public safety.
Grandfathering Provisions
Another issue that is addressed with new massage legislation and revisions of existing ones are grandfathering provisions or clauses. A grandfathering provision should not be confused with an exclusion or exemption. Grandfathering allows existing practitioners to continue working without going back to school or taking an exam to qualify. It credits both their experience and formal training and gives a finite time frame to qualify for a license under a different set of qualifications than what will be enforced in the future. This term is often used as a verb: to grandfather means to create an exemption based on previous education and experience, allowing the practitioner to continue working. Often, such a provision is used as a compromise, to affect new rules without upsetting a well-established logistical or political situation. This extends the idea of a rule not being retroactively applied.
Grandfather clauses include very specific guidelines and are spelled out within the new law. Most of these clauses are effective for a given amount of time after the new law is enacted. One year is fairly common, but grandfather clauses may be for shorter or longer periods. Current massage therapists practicing in states adopting new legislation should be aware of the specific parameters of grandfathering provisions, including education requirements, experience, and time frames. If you don’t meet the grandfathering provisions on time, you will be subjected to the new guidelines. Occasionally, grandfathering is extended if there are complications with the process.
Who is Qualified?
New regulation and revision of current regulations for massage and bodywork continue nationwide. Issues such as scope of practice for massage, exclusions and exemptions, and grandfathering provisions will continue to be debated by legislators, lobbyists, massage practitioners, professional associations, and other health providers such as chiropractors, physical therapists, and athletic trainers. At the heart of the debate: what makes a qualified practitioner and who is qualified to deliver services that cross multiple professions?
Added to this debate are insurance billing practices and increases in employment or contracting of massage therapists by medical clinics, chiropractic offices, and rehabilitation centers. Massage therapists need to stay informed about evolving legislation in their own profession as well as those of complementary disciplines. Working within your own scope of practice and intelligently referring clients to appropriate disciplines is key to developing a safe and effective massage and bodywork career.
Christy Cael is a nationally certified massage therapist, certified athletic trainer, and certified strength and conditioning specialist. Her private practice focuses on injury treatment, biomechanical analysis, craniosacral therapy, and massage for clients with neurological issues. She is the author of Functional Anatomy: Kinesiology and Palpation for Manual Therapists (Lippincott Williams & Wilkins, 2009), scheduled for release in October. Contact her at functionalbook@hotmail.com.
Notes
1. Council on Licensure, Enforcement and Regulation (CLEAR), Glossary of General Terminology Used in Professional and Occupational Regulation. Available at www.clearhq.org/links.htm (accessed July 2009).
2. New York State Education Department, Office of the Professions. Available at www.statutes.legis.state.tx.us/ViewChapter.aspx?key=55039.47435 (accessed July 2009).
3. State Medical Board of Ohio. Available at www.med.ohio.gov/rules/4731-1.htm (accessed July 2009).
4. Texas Department of State Health Services. Available at www.statutes.legis.state.tx.us/ViewChapter.aspx?key=55039.47435 (accessed July 2009).
5. American Medical Association, Principles of CPT Coding, fourth ed. (Chicago, Illinois: AMA Press, 2006).
6. American Physical Therapy Association, Frequently Asked CPT Coding Questions. Available at www.apta.org/AM/Template.cfm?Section=FAQs1&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=31264 (accessed July 2009).
7. Kenneth A. Olson, “American Academy of Orthopedic Manual Physical Therapy (AAOMPT): History, Advocacy, and Education,” The Journal of Manual & Manipulative Therapy 16, no. 1 (2008): E20–E22.
8. American Physical Therapy Association, Guidelines: Physical Therapist Scope of Practice BOD G03-01-09-29. Available at www.apta.org/AM/Template.cfm?Section=Home&TEMPLATE=/CM/ContentDisplay.cfm&CONTENTID=53675 (accessed July 2009).
ABMP Definitions
Massage
Massage, or massage therapy, is a system of structured palpation or movement of the
soft tissue of the body. (For simplicity’s sake, massage and massage therapy are often
used interchangeably to describe more than 250 massage, bodywork, and somatic therapies or modalities.)
The massage system may include, but is not limited to, such techniques as stroking, kneading, gliding, percussion, friction, vibration, compression, passive or active stretching within the normal anatomical range of movement; effleurage (either firm or light soothing, stroking movement, without dragging the skin, using either padded parts of fingertips or palms); petrissage (lifting or picking up muscles and rolling the folds of skin); or tapotement (striking with the side of the hand, usually with partly flexed fingers, rhythmic movements with fingers or short rapid movements of sides of the hand). These techniques may be applied with or without the aid of lubricants, salt or herbal preparations, hydromassage, thermal massage, or a massage device that mimics or enhances the actions possible by human hands. The purpose of the practice of massage is to enhance the general health and well-being of the recipient. Massage does not include the diagnosis of a specific pathology, the prescription of drugs or controlled substances, spinal manipulation, or those acts of physical therapy that are outside the scope of massage therapy.
Bodywork
An outgrowth of massage and other systems, bodywork is defined as various forms of touch therapies that may use manipulation, movement, and/or repatterning to affect structural changes to the body.
Somatic Therapies
Somatic means “of the body” and is often used to denote a mind-body or
whole-body approach, as distinguished from a physiology-only perspective.