Massage therapists are partnering with other healthcare professionals more than ever before to deliver therapeutic massage and bodywork as part of a medical regimen. And it’s not just about leasing a room in a chiropractor’s office or maintaining a friendly referral with the orthopedic specialist in the community. It’s also about working as part of a team of healthcare specialists—an integrative approach, where a massage therapist might confer with a medical doctor, an acupuncturist, and a psychotherapist regarding the condition of a client/patient, then act on it together.
Even before, massage might still be listed on Quackwatch.com, the surging tide of newcomers to massage and the steady, growing stream of massage veterans is evidence that massage works. Despite the growing breadth of scientific research supporting massage, may medical professionals may not yet acknowledge the work and doctors may not necessarily recommend massage to their patients, even though they and their wives appreciate a good spa visit or have a bodyworker on speed dial. But some doctors do refer out, or better yet, have a massage therapist on staff for their patients’ varying bodywork needs. These medical professionals are opening new doors for massage therapists, as well as opening new doors for a public eager to feel better and live better. And ultimately, they’re helping to broaden the definition of healthcare.
Consumer Demand Creates Opportunity
When the latest survey from the American Hospital Association (AHA) shows that the number of hospitals offering massage increased by more than one-third from 2004 to 2006,1 or that it’s rare to find a conventional medical school that doesn’t offer courses in complementary, alternative, or integrative medicine,2 it’s evident there is a changing tide for massage and bodywork within the medical community. Yet, despite the growing inclusion of massage into traditional Western medicine, it’s not necessarily the medical community that’s rallying for massage services. Instead, it’s largely the consumer, hungry for options and answers to their own healthcare needs, who’s increasing demand for massage and other alternative therapies in medical settings.
Janet Kahn, research scientist, massage therapist, and executive director of the Integrated Healthcare Policy Consortium (IHPC), says while complementary and alternative medicine (CAM) is slowly saturating the U.S. culture and increasing numbers of medical schools are starting to teach meaningful courses on complementary therapies, one of the most important influences—especially in an era of return on investment (ROI)—is consumer demand. “Many hospitals and clinics include massage, or somehow make it available to their patients, because it attracts people to their practice and because they can still have the patients pick up much, if not all, of the tab,” she says.
While newly minted doctors no doubt have a broader view of complementary medicine than ever before, many say it’s ultimately the consumer laying down a path for the massage therapist in what can often be a very guarded, allopathic world. “I am seeing a slow recognition of massage in the medical community—not often enthusiastically, but realistically,” says Larry “Doc” Warnock, LMT, owner of The Center for Health and Athletic Performance in Reading, Massachusetts. “I think the impetus for this comes from consumers.” Warnock, who works primarily with young athletes, says that many of his clients ask why their doctors don’t know about or recommend these “alternative” therapies. “This statement is often followed by angst against the traditional medical world. I do think consumers are beginning to question, rather than just accept, their doctor’s edicts.”
As a result of this consumer demand, hospitals are opening in-house and off-site spas, chiropractors and physical therapists are contracting or outright hiring MTs in greater numbers, and staff physicians are writing prescriptions for massage. Still, even though massage is requested and recommended, it’s typically not reimbursed by health insurance, and that is one of several critical barriers for the medical community when it comes to massage acceptance.
Barriers in the Brave New World
Maggi Griffin, vice president of patient care services at Condell Medical Center in Libertyville, Illinois, has been putting patient service programs together for years. The types of CAM treatments she’s seen easily implemented into the hospital framework include those with few costs attached, such as music therapy, animal therapy, and herbal remedies (the use of which has become a part of the Western pharmaceutical approach for several hospitals). In the United States, massage is still lagging behind in terms of acceptance within the medical community, Griffin says. The irony of it all, however, is that massage is often provided to hospital staff who work with high-stress, acute care patients, but not the patients themselves. Still, the biggest obstacle for massage is that it’s not covered by health insurance. “The hurdle is who pays for it,” she says. “That is the battle.”
According to Helene Langevin, MD, researcher with the Department of Neurology at the University of Vermont College of Medicine, the financial question is the most difficult. “What do you do about insurance reimbursement, and how do you also serve the people who can’t pay out of pocket? As research progresses and insurance companies realize that it is cost-effective to cover these modalities, that people are indeed being helped to stay healthy, it becomes advantageous to cover them. But we’re a long way from proving that.”
Langevin, who has been studying the mechanism behind acupuncture, and is now focusing on connective tissue, says a lack of understanding is another roadblock in the professional partnership dynamic. “The massage therapist and the physical therapist can be doing exactly the same thing, in terms of applying pressure to the skin. They have all kinds of professional barriers, however, to becoming integrated together. This whole issue of credentialing and who can do what, and who gets reimbursed … these are all issues that need to be ironed out within the various professions. They need to talk and decide what’s in the best interest of the patient and how do we maximize the benefit to the patient.”
Experts say one of the biggest barriers to working with the medical community is not talking the talk. “Massage therapists will not be fully accepted by the allopathic community until they are willing and able to speak both languages and until such time as MTs are more fully educated,” Warnock says. He believes a tier system will facilitate the spectrum of knowledge held within the bodywork community and make it simpler for both ends of the spectrum to exist together. “I view the word therapist as depicting broad knowledge, skills, and abilities. But everyone wants to call him or herself a therapist. Someone graduating from one of the massage-mill educational programs with a couple hundred hours of training is not a therapist.”
In the same vein, Kahn says massage therapists need to be well informed in order to reach out to the allopathic world. “If you want to work with a hospital or clinic in your area, research the possibilities and decide whose mission and focus is a good match for your skills, experience, and interest. Be up to date on the research in our field in general and very specifically in the massage applications that you are hoping to offer to the hospital. Explore what types of connections are possible. Employment at a hospital is one possibility, but may be rare compared with the potential of setting up a good referral network, or working at the hospital, but as an independent contractor.”
Another barrier in gaining acceptance is that the medical community still views massage with uncertainty. “It’s not a proven science,” Griffin says. “So litigation, or fear of, is also a problem.” As research validating the benefits of massage continues, so, too, will acceptance by a community trained in random, double-blind studies. Showing improved outcomes is one way to combat this issue and is what Griffin believes will nurture the relationship between massage and medicine. “The massage community has got to collect objective data that shows patient outcome is better … that [massage] helped the patient to die [more peacefully], helped them to get better quicker, reduced the need for pain medication, etc. The medical community operates on objective data. Massage therapists have got to prove better outcome.”
Working out of mutual respect is a key issue when working with other healthcare providers, says Terrie Yardley-Nohr, author of Ethics for Massage Therapists. “Working with other providers requires a respect for others and the treatments they provide,” she says.3 Communication is key in this process, as understanding everyone’s expectations is critical for success. Whether it be discussing the treatment protocol, the number of sessions being referred, or any other aspect of the client’s care, Yardley-Nohr says talk it through. “Always remember that your referred client should not be caught in the middle between providers. For example, if a chiropractor has referred a client to you for neuromuscular therapy for a shoulder injury and you feel that another type of therapy would be more beneficial for the client, you should talk to the referring doctor before discussing it with the client.”4 Not doing so, she says, is unethical.
Understanding expectations will also keep these relationships healthy, she says. “For example, a doctor may expect the therapist to work on a patient for six sessions and only six. The therapist may expect to work on the patient until the patient feels better. This could easily lead to a conflict between the two parties, and referrals may stop. Simple ground rules can be established between the two referring parties to prevent conflict and maintain a good working relationship to benefit patients or clients.”5
Coming Full Circle
Even though many hospitals are entrenched in a high-tech, low-touch philosophy, it wasn’t that long ago that massage was part of traditional medical care. Hospital nurses would settle their patients in for the evening with a relaxing hand, foot, or neck massage, all the while prepping their bed and room for the night. “It’s what nurses used to do,” Griffin says. “What happened was technology took over … We got technological alternatives that were considered more scientific.” As a result, the comforting, person-to-person contact fell off. Griffin says in addition to technology, nurses’ workloads were increased by regulatory documentation, distancing them even more from those original hands-on protocols. Eventually, the idea of massaging patients slipped away.
But, as Western medicine tries to reconnect with its patients/clients once again, touch may not be that far behind. Once an intensive care unit (ICU) nurse, Griffin says compassion is returning to the medical environment. In several U.S. hospitals, intensive care is being administered in what looks like a bedroom, she says, where a once sterile, rigid protocol is being replaced with one that encourages family and children and touching the patient. “That kind of compassion is returning to our environment. We’ve gone through that magical technological era, and we’re seeing what else we can do and really going back to the basics.” Whether it’s in the more literal addition of complementary and alternative therapies to hospital services or simply the appreciation of something that falls outside the cut-and-dried medicinal treatments, changes are taking place. Griffin says she’s seeing more of this philosophy every day, and that, she says, is alternative in and of itself.
Doctor Approved
In spite of all the barriers between the integration of massage and Western medicine, doctors are increasingly giving their thumbs-up to bodywork. A notable ally is Mehmet C. Oz, MD, director of the Cardiovascular Institute at New York Presbyterian Hospital-Columbia Presbyterian Medical Center. Oz, an avid proponent of massage, tells Massage & Bodywork that approximately 95 percent of his surgical patients receive massage, and for himself, weekly massage at the nearby club is his own prescription. Oz says that massage definitely fits into a Western medical paradigm, because of the benefits it offers. “Relaxation, deep breathing, lymphatic stimulation with diuresis are all critical benefits (of massage),” he says. Add to that the ability to avoid medication for similar purposes and Oz says you’ve got a winning combination with massage.
For Milwaukee family practice doctor Pamela Ogor, DO, working with massage therapists on the front lines in the aftermath of Hurricane Katrina changed her whole professional perspective and turned her toward an alternative framework. “It’s not that I was skeptical,” she says. “In DO school, I knew what craniosacral was, but it was still considered ‘woo woo’ 20 years ago. That’s all changed.” Ogor says she went to Biloxi, Mississippi, three weeks after Hurricane Katrina to work with traumatized survivors. There, she met and worked side by side with New York massage therapist Jim Kearney (see more about Kearney in Massage & Bodywork, August/September 2006, “Loss of Innocence: Massage at Ground Zero”). “It was when working with him that I started really seeing the value of massage therapy. He turned me to an alternative mode.” She explains that the work she contributed in Biloxi was for acute medical care. “With massage, [Jim] brought the acuteness of the trauma down to a lower level. That’s the part I was really moved and impressed by, and what I’m now recommending more for my practice, for those with trauma or fibromyalgia. That’s where the uselessness of the medicine I have to offer happens and where the usefulness of alternative medicine lies. I was really amazed, and it changed how I looked at things.”
Ogor says massage therapists have an opportunity to make significant contributions to healthcare, but their success might lie in partnering with a medical professional. “The important thing is to find somebody that’s like-minded.”
The Good and the Bad
For more than three decades, Los Angeles-based massage therapist Cynthia Bartholmey, LCMT, has been creating relationships with other healthcare professionals. Borne out of a search for professional respect, Bartholmey, CEO of Lymphatic Bodyworks, chose to continue educating herself throughout her career. “When I started out 30 years ago, massage didn’t have the respect it does today. My family back East was snickering, saying, ‘I wonder what she’s really doing out in California.’ I struggled for that respect, so I kept going back to school, studying different modalities.” From a master course in Dr. Vodder’s manual of lymphatic drainage and reflexology to a study in postural alignment, Bartholmey frequently sought out 200- and 300-hour programs to broaden the depth of her bodywork knowledge. “I kept reinventing myself.” That, she says, has been key to working with, and adapting to, other professions.
Whether it was referrals from internists, plastic surgeons, acupuncturists, or dentists, Bartholmey found herself developing a very specialized private practice. As she was marketing herself to physicians, Bartholmey says she stumbled across an opportunity to be involved with massage research at Cedars-Sinai Medical Center in Los Angeles and is now involved with a National Institutes of Health (NIH) grant in psychiatric research there. “Western medicine and Western minds are opening up,” she says. “The people I work with know what I do; they’re not in the dark ages any more in the medical centers.” Bartholmey says there is more recognition and honoring of massage therapy as a profession than ever before. But she is quick to tell you she knows her professional scope of practice, and that’s an element necessary for a successful professional partnership. “I have always known where my place is as a massage therapist and not crossing the line into areas that are not my expertise. I’m completely comfortable referring out.”
Her advice for other massage therapists looking to build partnerships is candid. “Expect a lot of rejection. Someone may refer to you, but not necessarily because they appreciate the value of your work. Don’t be disappointed by that.” Keep moving the bar higher on your education and expertise, she says, and you’ll be successful. “I always recommend to young people getting into the profession to continue their education. A lot of MTs think they know everything because they’ve had a 500- or 1,000-hour class, but they know nothing. They really need to continue their education.”
For Warnock, working with other medical professionals has been both rewarding and challenging. He says he’s had some great experiences working with the University of New Hampshire’s athletes, where the focus becomes a collaborative effort between him and the athletic trainers and coaches in keeping athletes healthy and productive. “Together we form a very formidable team—all focused on providing the best service for the school’s athletes, who all deserve the best, not just someone’s ego-idea of what is best,” Warnock says. Yet, other experiences working within a university community have left Warnock isolated, with few referrals from athletic trainers and little if any acknowledgement of the work he does. He recalls even getting tested by clinicians who threw some anatomy and physiology at him before sending over any of their patients. When athletes seek Warnock’s services on their own, he says they are usually “blown away with the level and success of my work with them. This is the typical turf-protecting situation I run into with many athletic trainers, physical therapists, and others who view my work as inferior to theirs. It’s very sad.”
Warnock, who’s owned a private practice for 25 years and studied with both Janet Travell and Jack Meagher, says in some instances, despite his lengthy career helping athletes, he feels his work is ignored, with the unseen athlete/client ultimately paying the price. In successful professional partnerships, however, he says that his role in administering a viable and helpful modality becomes a means to the goal of providing athletes with the best and most inclusive services available.
Work in Progress
By most accounts, integrative healthcare is a good thing, and it’s only going to become more prevalent as a health-starved public seeks answers. Challenges aside, working with other professionals can be rewarding on many levels for massage therapists. Langevin says when looking at integrative approaches to healthcare, what we see is a work in progress. “We’re all learning about each other and our different points of view. We need to learn from each other and learn how to work together.”
Kahn concurs, but finds it important that massage therapists not lose their identity along the way. “I think it is a good thing for both massage therapists and consumers to have MTs working in a wide range of settings, including hospitals and clinics. I believe it can make massage therapy available to people who otherwise would not, or perhaps could not, access it. I believe this sort of interaction has the potential to educate other health professionals about the benefits of massage,” she says. “I think when we make some inroad into these institutions, perhaps through having massage available to cancer patients, for example, there is potential for other appropriate applications of massage to be seen. This, of course, is more likely if the MTs involved are able to function as advocates for our work and are not just focused narrowly on their own employment.
“Having said all that, let me stress that it is vital for the field that we also practice in our own offices, in yoga and dance studios, in workplaces, etc. Massage is such a potent vehicle for well-being and self-awareness. It would be tragic to have it reduced to being only an adjunctive medical treatment, especially when we still have a form of medicine in this country that is so focused on disease and not on wellness.”
Karrie Osborn is the contributing editor for Massage & Bodywork magazine.
Notes
1 “Use of Massage Therapy in Hospitals Up 30 Percent.” American Massage Therapy Foundation press release, May 24, 2006. www.amtamassage.org/news/052406release.html (accessed December 2007).
2 “CAM Medical Courses, Continuing Education, and Training.” The Richard and Hinda Rosenthal Center for Complementary and Alternative Medicine at Columbia University, www.rosenthal.hs.columbia.edu/Med_Courses.html (accessed November 2007).
3 Terrie Yardley-Nohr, Ethics for Massage Therapists (Baltimore, MD: Lippincott, Williams & Wilkins, 2007), 105.
4 Ibid.
5 Ibid.
6 James Waslaski, “Orthopedic Massage vs. Medical Massage: Are We Using the Correct Terminology,” Massage Today 4, no. 2 (February 2004).
7 Ibid.