Improving Quality of Care

By Toby Coy

The massage therapy industry is a beautiful mess.

Students finish their studies and are launched into a world of conflicting information, contradictory models of care, and potentially unhelpful professional stereotypes. As if navigating these choppy waters wasn’t hard enough, we also exist in a health care system that is becoming increasingly integrated across health professions. We need to be able to communicate our scope and methodology to health providers who may know nothing about massage.

Unfortunately, however great the current diploma of remedial massage is – and I do believe that it can produce great therapists who help their clients – one thing it fails to provide is a robust account of what we are actually doing. As our postural and tissue-based models continue to age, the task of updating our clinical reasoning and effectively collaborating with up-to-date professionals becomes increasingly difficult. To use an analogy with tennis: it is difficult to keep up with modern players if you’re still using a wooden racquet.

Rethinking Our Practice

For better or worse, we aren’t the only profession that struggles with the baggage of outdated ideas. In a recent conversation about applying pain science to clinical reasoning, a student physiotherapist in the second year of their masters program told me:

“Off in the distance there’s this beautiful simplicity where everything fits together … But in between here and there is a thick forest and I have no idea how to get through. Sometimes I feel like I’m getting it, but mostly I have no idea whether I’m heading in the right direction. I feel like I’m being taught all these assessment models and then need to immediately discard them.”

I can relate. As a student I was particularly interested in Myofascial Release (MFR). It became a useful mental scaffold to hang my clinical reasoning from. Patterns of pain, postural deviation and treatment strategies all unfolded from an assessment of myofascial dysfunction.

Later on I discovered that the science behind MFR relied on an awful lot of wishful thinking. I had to rethink my entire practice.

The result was a kind of professional free-fall; both stressful and exciting. I could see the emergence of a new understanding of treatment that stripped away unsupported models of dysfunction and looked at the whole person, which was exhilarating. But I also frequently felt lost, frustrated and disillusioned. It was wonderful, and awful. It also could have been completely avoided if my diploma had featured a mental model of what we do that was bigger than the treatment of structure, connective tissue or pet techniques.

What is the tonal centre of massage?

In music theory there is the concept of a tonal centre: the ‘home base’ note around which other notes in a scale sit. It ‘sounds right’ whenever we return to the tonal centre, and the notes seem to fit together around it.

When I was a student, one of my teachers emphasised that knowledge of anatomy would be our bread and butter. That made sense to me at the time but now I disagree.

We cannot change anatomy with our hands.

Structural variations do not predict pain, injury or functional capacity, yet our clients feel better. The results of massage – profound as they can be – are first and foremost changes in perception. They are changes in how the body feels. With that in mind, the basis of our work must instead be in the science of pain, sensation, perception and, more broadly, the biopsychosocial model of health. This is the science of the lived experience or the forest rather than the trees.

How Other Professionals Understand Massage Therapy

An exercise physiologist (EP) recently reached out to me for advice on effective collaboration with a massage therapist on a persistent pain case. The massage therapist was hunting for unnecessary and unsupported treatment targets in a well-meaning attempt to provide quality care. Viewed from a certain angle, it makes sense: if massage relaxes tight muscles and the client felt much better after their massage, it would indicate that a large part of the problem was that their muscles are too tight (or their fascia, or their ligaments, or their craniosacral rhythm, or …).

The EP wanted advice on how to explain that manual therapy does not have to try to fix things in order to be useful. They wanted to politely explain that it is enough to provide an hour of relaxation, interoception, non-threatening movement, and novel stimulation in order to be of benefit. It is tragic that a professional with absolutely no background in manual therapy might understand our worth more than we do.

That same day, I was liaising with a physiotherapist about a shared client with shoulder pain. The physiotherapist was confused because I had found a way of gently stretching the skin over the painful shoulder that provided relief.

‘That’s odd. What do you think that is? Placebo?’

It was odd to them because I had obviously not done anything that could have changed the person’s muscles or other tissues. As if tactile stimulation and a comforting context was not enough to modify pain.

It’s little wonder that other health professionals may have a confused picture of what massage therapists do if we haven’t got a coherent narrative to approach our interactions.

Pondering the Way Forward

How long will we continue to teach obsolete models of how and why people feel better from manual therapy?

Is it time we connected the dots at the earliest levels of our professional education, to save therapists from the burden of earnestly applying a model of care known to be disruptive and outdated?

If we don’t, will the field of manual therapy continue to languish in the pursuit of irrelevant treatment targets and be baffled by its own successes?

About the Author

Toby Coy is a Remedial Massage Therapist based in Sydney. He enjoys tennis, reading, cooking and computer programming. His professional interests are in the implementation of biopsychosocial care and exploring what we are actually doing during manual and exercise therapy. He has dreams about developing software to make BPS care easier to implement.

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  1. Toby,
    Thank you, thank you, thank you! and AMT thank you so much for promoting this message.
    I firmly and passionately feel that we as a profession need to re-think very broadly what we think we are doing when we touch our clients.

    Pseudoscientific nonsense, fantasy physiology, manual therapy gurus, outdated explanations of the body and disproven syndromes and assessment tests, have no place in modern healthcare.
    We cannot continue to operate in a science based healthcare system with this outdated way of thinking. We are 100% shooting ourselves in the foot and will never be taken seriously by other health care professionals if we continue down this road.
    We are not changing tissue with our hands. If I was I would not be working in a little clinic in Ryde. I’d be charging a motsa to the world’s best athletes!

    Learn basic neuroscience. Understand the logical fallacies and confirmation bias. Learn how to read research. Take the Explain Pain courses. Read Explain Pain Supercharged!Step outside the manual therapy social media bubbles and really question what other mechanisms may explain why you are making someone feel better. And please stop hurting people with your hands because you think you must push really hard to change their tissue.

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