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Editor's note: The following is a position statement from the American Medical Massage Association (AMMA), titled "The Training and Care of a Medical Massage Therapist: Developing Medical Massage Curriculum." The AMMA functions alongside sister organizations the American Manual Medicine Association (also AMMA), the North American Naprapathic Association and the American Institute of Naturopathic Medicine.

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The development and presentation of medical massage curriculum may not be as difficult a task as many believe. In some aspects, medical massage is actually simpler than the non-medical or non- physiological systems of massage therapy taught in many massage schools. Medical massage techniques, protocols, methods, terminology, theories, and science are based on universal and standardized approaches to biomechanical research, health care practice, and manual therapy.

General massage education and training currently involves the review and study of dozens of different (and often differing) systems and forms of massage therapy, many of which are based on outdated or erroneous theories that are now known not to conform to current knowledge about the body's physiological and neurological processes. The massage profession and its leadership have developed and continue to espouse massage training that has become "massage dogma."

Medical massage therapy is massage that uses techniques supported by current knowledge regarding the body's natural physiological, biochemical, and neurological processes. Medical massage is first and foremost, massage, and is therefore a natural and non invasive approach to health care and seeks to support the body's own natural healing capacities. The power that created the body is the power that heals the body. This "power" is identifiable and understandable in scientific terms, to the limits of our ability to observe it, but the frontier of our understanding and knowledge keeps advancing and evolving.

Medical massage training and education, as with all health professions, begins with a detailed and thorough study of the structure and function of the human body. A major advance in health education is a concept called "problem-based education." This concept holds that the best training for a medical massage therapist is training centered on the purpose of the training. In the case of medical massage, this simply means that training is based first and foremost on the treatment of patients, known as "patient-centered education."

Medical massage therapy students, in addition to gaining a detailed and thorough knowledge of the human body, need extensive training in the actual treatment of the human body and its pathology. Medical massage curriculum will focus much of its training on assisting students to become knowledgeable about the kind of patient pathology that they will encounter in practice by providing students with actual patients to treat under supervision. At least one half of medical massage training needs to be conducted in a supervised clinic or practicum environment where students treat patients with real presenting symptoms. In addition, students should complete a supervised internship program in a medical or chiropractic clinic, so that they gain experience and confidence outside of the school.

Since medical massage therapists treat various musculoskeletal conditions, an effective means of systematically educating medical massage students is by training body part by body part, joint by joint, or condition by condition. That is, the medical massage curriculum should begin with a body region, such as the hand and wrist. Hand and wrist bony topography and anatomy is covered first, followed by the hand and wrist connective tissue structures and other soft tissue physiology. After the anatomy and physiology of the region have been covered, the next step in the training process is the presentation of the basic pathology's of the hand and wrist that the medical massage therapist would commonly see in practice. This would include arthritis, carpal tunnel, and sprain and strain.

The next step in the educational process should include the application of massage techniques and treatment protocols directed at the pathological problem or condition. The medical massage approach uses technique to achieve four important clinical objectives:

1. reduction of the inflammatory process;
2. restoration of a normal soft tissue environment;
3. establishment of normal range of motion and
4. improvement in objective findings and the patient's subjective complaints.

It is important that the techniques and treatment protocols being taught conform to current and correct applications of medical massage therapy.

Training of the medical massage therapist proceeds to the next body region or joint, perhaps the elbow and the treatment of elbow conditions. By this method, the medical massage therapist is systematically taught how to treat the acute and chronic conditions that represent most patients' common complaints. At this point, it should be pointed out that medical massage is not "full-body massage," and that medical massage therapists do not provide relaxation massage or use oil-based spa or salon techniques. The medical massage therapist is trained in the use of "medicated" oil-based products and liniments, but these medications are used as an adjunct to focused medical massage treatments applied without oil. The use of these treatment modalities is normally applied after the massage technique or protocol has been completed.

Prior to the 20th century, all massage was medical massage. Only the very rich had the money for recreational massage therapy. Since the time of Hippocrates, in the Western tradition, massage therapy has been primarily used as a form of medical care. Massage therapy is a powerful form of natural healing and is critically needed to assist patients with various musculoskeletal, neurological and organic conditions. Medical massage is not a physical therapy "wanna-be." Massage predates the physical therapy profession by thousands of years. Over these thousands of years, massage therapists have innovated the use of therapeutic exercise, range of motion, mobilization, hydrotherapy, and nutrition and herbal medicine within the practice of massage therapy. This is well-documented in historic texts and articles published on massage worldwide.

The next stage in the training and care of a medical massage therapist is training in clinical protocols and patient management. This is the most difficult part of the training process, because the beginning student does not have the treatment and patient experience needed to determine how many treatments are needed, how often treatment is needed, and how long the treatment for a specific condition will take. This knowledge is gained over time with clinical experience in treating various conditions. A good starting point for training new students is the six-visit, three- week approach. The therapist simply informs the patient that he or she will need to see the patient for six visits, two visits per week for three weeks, after which time the therapist and the patient "will mutually re-evaluate the patient's condition to determine if further care, and how much, is required." This patient-management scenario allows the inexperienced medical massage therapist to set incremental, short-term treatment goals.

Since the medical massage therapist is treating patient conditions, rather than providing a full-body massage, less time is needed during a patient visit. Most medical massage therapists are trained to work on a half-hour schedule, and can therefore charge less per patient visit and are trained to see at least two patients per hour. By seeing two patients per hour, the medical massage therapist can earn as much or more than the relaxation massage therapist, who often is tied to a single patient for 60 minutes. When medical massage therapists compete with other therapeutic massage therapists, they can extend the patient visit time, and still keep their fees low, by using therapeutic modalities such as hot and cold packs, infrared lamps, or cold low-level laser therapy.

This leads us to the next level of training for the medical massage therapist: therapeutic modalities. Therapeutic modalities or the use of adjunctive clinical therapy in treating various patient conditions should be standard components of medical massage therapy training. These therapeutic modalities should be incorporated before, during or after the application of medical massage techniques. Therapeutic modalities for the medical massage therapist include the following:

• hot and cold packs;
• infrared lamp (element, not bulb);
• thermophore;
• percussion or vibrational devices;
• cold low-level soft tissue lasers;
• electrotherapies;
• medical acupuncture (needle, laser or electro); and
• topical herbal medications or liniments.

Therapeutic modalities are commonly applied in increments of 15 minutes. The use of these modalities is a historic part of massage practice for medical or clinical purposes, and confers the following benefits:

1. provides beneficial physiological responses in the patient's condition;
2. prolongs the patient visit without tying the therapist to the treatment room;
3. allows the therapist to see more than one patient per hour;
4. reduces patient fees, allowing more patients to seek affordable care;
5. vroadens the therapist's scope of practice;
6. makes the treatment program more effective; and
7. combats therapist burnout by diversifying the workday.

Since the training of the medical massage therapist is based on standard medical terminology, health sciences, and clinical approaches to patient treatment and management, the medical massage therapist is comfortable in medical interface and communication. The medical massage treatment model is, however, neither a "medical model," nor is it "allopathic." Since it is massage therapy, the medical model is based on a natural and holistic philosophy of care.

The medical massage therapist needs to be trained to work in a variety of health care settings, including private or group practice, holistic clinics or treatment centers, hospitals, and medical or chiropractic clinics. Because of the diverse practice opportunities available, the medical massage therapist needs to be trained in medical office practices, administration and billing procedures. An individual who is trained in medical massage can work in any environment, especially clinical facilities and practices. The massage therapist who is only trained in relaxation therapy, on the other hand, is not trained or qualified to work in these clinical environments.

Medical massage therapy training should include practice administrative procedures that include the use of medical case or SOAP notes, medical diagnostic and procedure codes, and medical report writing. Billing codes, medical terminology and record keeping are just part of the ordinary process of doing business in health care. Whether you decide to bill insurance or not, if you treat any patient condition, a headache or a sore bicep muscle, you are required by law to maintain patient case records. Medical massage students are required to maintain patient case files and use medical terminology and medical coding for all patients treated during practicum and internship. In addition, if any massage therapist is involved in a malpractice suit, the only proof against any allegations may be case notes and patient records. In the absence of this evidence, courts tend to accept the testimony of the complaining patient.

You cannot teach what you do not know! Medical massage schools and instructors need to be trained in these various aspects of medical massage curriculum. Medical massage school staff should include instructors who are both massage therapists and allied health care professionals such as physical therapists, occupational therapists, and nurses. These multiskilled health care professionals are fluent in "medicalese" and can easily bring this dimension, which has not been a traditional component of contemporary massage education, into a massage training program. The medical massage therapist is, therefore, thoroughly trained in the human sciences of anatomy, physiology, and pathology, as well as, the clinical sciences of massage therapy and manual therapy. The medical massage therapist also receives training in traditional therapeutic modalities and the clinical aspects of patient management, office administration, and patient record-keeping. The medical massage therapist is capable of maintaining a professional and competent office environment, while at the same time providing all of the clinical and holistic benefits of massage therapy. Who says that professional competency and healing are incompatible?

General massage training and education are commonly based on hours in training, and many massage school do not subdivide this training into specific tasks. Emphasis is on the total number of hours spent in a training program. In many massage schools, a significant portion of the training hours are spent in the practice of a single full-body massage form, often practiced by students on students, with little or no internship experience provided to the students. As previously mentioned, medical massage training needs to be both "problem-centered" and "patient-based," and should focus on the accomplishment of specific tasks and educational objectives. Tasks and objectives need to have measurable outcomes. Medical massage therapy tasks and objectives include the following:

Task and Objective	Measurement
Training in human anatomy	Quiz/examination
Training in human physiology	Quiz/examination
Training in human pathology	Quiz/examination
Regional assessment skills	Practical demonstration
SOAP notes	SOAP note review
Clinical treatment plan	Treatment plan review
Therapeutic modalities	Checklist/supervision
Internship	Completion of hours/supervision
Clinical competency	Practical examination

Additional tasks and objectives for the medical massage therapist in training include the completion of homework assignments. Log sheets are developed for all of the training tasks and objectives of the medical massage program; as these items are completed, they are noted in the log sheets. Class practicum (concentrated, hands-on practice with real patients) and internship training are very important components of a medical massage training program, and should be provided within a medical massage clinical environment that involves practice supervision. Massage schools can establish medical massage practicum within a school clinic environment with a discounted student fee structure. Medical massage internship programs should be established in hospitals, medical clinics, adult care facilities, and chiropractic offices. Medical massage internships should not be conducted at relaxation spas or salons.

Currently, massage education is fixated on "hours in training," and various programs vie for ascendancy based on having more training hours than another school or competitive massage training program. This is like comparing apples and oranges. Medical massage training programs like nursing programs can vary in length, in depth of study, and in level of certification. Medical technical schools produce nurse and medical assistants in a few months of part time training, so can well organized massage schools with competent instructors. With an increasing number of medical technical schools and community colleges entering the massage field, the massage profession can expect to see more focused and streamlined massage training programs entering the massage training market. Time in training is not the central factor in developing good medical massage therapists, it is simply one factor. A major issue is the experience and competency of the training staff: very few massage therapy instructors currently teaching in massage schools can lay claim to any actual experience within the medical massage field. The other key issue in medical massage education is providing valid medical massage training that is based on accepted clinical technique and protocols.

Establishing a medical massage training curriculum, and training medical massage therapists, is not as difficult as it might appear. Program development and organization simply requires a basic curriculum outline, a competent and experienced teaching staff, and an active clinical environment in which students can train and gain experience. Opportunities for massage therapists who are trained to work in clinical environments are rapidly increasing within the health care profession, and for those who prefer private practice, the ability to treat patient musculoskeletal and neurological disorders will help develop and maintain a thriving practice.

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For more information on the AMMA, contact:

Terrance R. A. Jacob
Managing Director
American Medical Massage Association
705 North Mountain Road, Suite B-116
Newington, Connecticut 06111
Tel: (888) 269-2551
Fax: (860) 953-2406
www.americanmedicalmassage.com