Massage Therapy Licensing: An In-Depth Look

By Enrique Fabian Fernandez
May 29, 2009

Massage Therapy Licensing: An In-Depth Look

By Enrique Fabian Fernandez
May 29, 2009

The Romans indulged in it; Hippocrates of Cos (460-377 BC), the father of modern medicine, prescribed it; and in today's fast-paced modern world it is not only a means for rehabilitation but also for relaxation. What is it? Massage therapy.

The question in today's world is not the validity of the benefits of massage therapy or whether to prescribe or not to prescribe, but rather to license or not to license. To explore the dilemma of whether licensing will be a benefit or a detriment to the career, one must explore the career as a whole from the beginning of time until now.

Picture being in China in 2,000 BC and getting struck by torticollis (Wryneck). What do you do? Most likely the village doctor would employ his or her massage techniques accompanied by a special ointment, which was the only option at the time, to relieve the muscle tightness. By 598-617 AD, the time of the Sui Dynasty, massage was well-established within the Chinese medicine practices (Fritz 2000).

In the Middle Ages the career underwent a revolution that would change its course and set back its progress; however, in the sixteenth century massage therapy regained respect in Europe (Fritz 2000). Rules and regulations for the practice of massage therapy present in 33 states have allowed quantum-leap advances with regards to the validity of licensing.

Where does the massage therapy career go from here? Is there evidence to support the benefits or harm, that a massage therapy career has had on the public? Why are some states struggling with licensing? Has licensing affected the quality of treatment or how insurance companies view the career? All good questions that beg to be answered and that will ultimately lead to the conclusion that massage therapy licensing is a great benefit, not only to our health care system but also to the personal health and protection of the public and the therapists.

Massage therapy has been in existence for one purpose and one purpose only: to aid human beings in their pursuit of pain management and take away their stress. From the paintings in ancient caves depicting one person rubbing another's foot to ancient Egyptian artwork often found in temples and pyramids showing foot, hand, and head massages, all have one thing in common, the universal language of therapeutic touch.

Though ancient Mayans in Central America and the Incas in South America commonly used the practice of massage, its origins are believed to have come from China where it was known as Anmo Amma, which means press-rub and Tui-na, which means push-pull (Fritz 2000). However, the Chinese were not the only ones to have had encounters with pain relief. Eskimos and African tribes also used a technique involving rubbing stones against the muscles and skin for pain relief, and massage has been a common practice in India for the past 3,000 years. From South America to the North Pole and from China to the ancient Egyptians, the practice of massage was a frequent every day occurrence.

Hippocrates of Cos lived from 460-377 B.C. and was the first physician to describe the medicinal benefits of anointing and massage (Fritz 2000). His methods and techniques were so beneficial that many are still in use today. Julius Caesar 100-44 B.C., who suffered from neuralgia and common epileptic attacks, would get "pinched all over" to relieve his episodes (Tappan 1998). Furthermore, during the Renaissance, a series of eight books were widely used called De Medicina, seven of which deal greatly with the use of techniques such as exercise, rubbing, bathing and anointing. This series was written by Aulus Cornelius Celsus, who lived from 25 BC to 50 AD, and was believed to have been lost forever until it was rediscovered by Pope Nicholas V (1397- 1455).

However, massage therapy has had to undergo a metamorphosis, which has not always been beneficial. In the Middle Ages the Catholic Church persecuted practitioners accusing them that their healing powers came from the Devil. Fortunately, advances have been made to the extent that a 1999 national research study by The International Foundation called "Health Benefits for Alternative Medicine: Is There a Fit?" revealed that out of 534 respondents 54 percent used massage therapy as alternative care (Health Benefits 2004).

There are many forms (modalities) of massage in use today; however, most techniques used in the United States can be traced to Swedish massage. Per Henrick Ling (1776-1839) perfected this technique (he did not create it) and he was not even a massage therapist -- he was a fencing master. By observing the movement within his sport, he was able to incorporate them into his massages. Charles and George Taylor, who were students of Ling's techniques, introduced the Swedish movement into the United States in 1856 (Fritz 2000); however, due to a lack of standards in the study and practice of massage, accompanied by unethical health claims, the practice of massage once again hit rock bottom. The scandals were so bad that in cities such a New York and Boston the massage parlors were nothing more than houses for prostitution. Nevertheless, by the 1900s the practice of massage therapy went from an unrecognized career to a field within the medical health care community.

According to the American Massage Therapy Association, Ohio was the first state to adopt massage practice regulations in 1916, and it was soon followed by Florida in 1943 and Hawaii in 1947 (States with Massage Practice Laws 2004). According to the National Board of Therapeutic Massage and Bodywork, 33 states, plus the District of Columbia, currently regulate massage therapists and/or body workers (States Utilizing/Recognizing the National Certification Examination for Therapeutic Massage and Bodywork 2004).

In many states such as Florida, massage therapy is regulated by a board designated strictly to the practice and regulating of massage therapy careers, which in turn it is regulated by the Department of Health. These massage therapy boards hold every licensed practitioner to standards of practice that are created with the sole purpose of protecting the public.

Having basic ethical and professional standards has helped shape the massage therapy into the reputable profession it is today. Nevertheless, the practice of massage can still be a dangerous endeavor if the therapist does not have knowledge of anatomy, physiology, and the basic understandings of the effects and contra-effects that massage has on the body. Chapter 480 section .032 of the Florida Rules and Regulations describes the purpose of legislature to regulate massage as follows:

"The legislature recognizes that the practice of massage is potentially dangerous to the public in that massage therapists must have a knowledge of anatomy and physiology, and an understanding of the relationship between the structure and the function of tissues being treated and the total function of the body. Massage is therapeutic and regulations are necessary to protect the public from unqualified practitioners.

"It is therefore deemed necessary in the interest of public health, safety, and welfare to regulate the practice of massage in this state; however, restrictions shall be imposed to the extent necessary to protect the public from significant and discernable danger to health and yet not in such a manner, which will unreasonable by affect the competitive market. Further, consumer protection for both health and economic matters shall be afforded the public through legal remedies provided for in this act" (Chapter 480 Massage Practice 2004).

In an article published by the Cincinnati Enquirer referring to new laws being implemented by Butler County for the practice of massage, city council members encouraged other cities and communities by saying "More communities should take similar action, to get across the message that massage is not synonymous with prostitution" (License 2004).

Many of the 17 unlicensed states, including critics, use the excuse that there is no research available to prove the benefits of massage therapy or the dangers involved in having practitioners practice without standards of practice; such is the case in an article published by the Center for the Health Professions wherein it says: "Critics suggest that the primary reason for the professional regulations is to protect the public from harm but since there is little evidence that massage is harmful and little scientific evidence of its benefits, regulation can hurt the profession more than help" (Center for the Health Professions 2004).

If appropriate research would have been performed by these states or critics, they would have found abundant research performed by the American Massage Therapy Association (AMTA), the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB), and countless reputable individuals and universities including The Touch Research Institute (TRI), established by the University of Miami, which specializes in the effects of therapeutic touch on the body, general public, and special populations.

Research performed by the TRI include topics such as: massage alters biochemistry, massage decreases stress, massage decreases depression, massage enhances our immune system and helps us fight disease, and the benefits of massage are bi-directional. This research, along with many others, may be found at the TRI Web site at

Dr. Carlyle Clyde P. Wippernagel, Jr. also conducted a research, which appeared in the issue of International Journal of Massage Medical Modelology (4[2]:231-239. July/August 2000), titled "The medical model will benefit the public by protecting people from harm by incompetent massage therapists." The research had two groups of 50 massage therapists: 50 from unlicensed states (self taught or with 10-100 hours of training), 50 from licensing states, all with several years of experience providing massage.

Each practitioner was to give a full body massage to 50 randomly selected individuals who had previously received professional massages in the past two years. After each individual received a massage they completed a survey which asked in-depth questions about their sessions and therapists. The research concluded that the volunteers were unable to differentiate between competent and incompetent massage therapists. Dr. Wippernagel concluded that the research revealed that subjects are exposed to a great deal of harm precisely because they are unable to distinguish between competent and incompetent massage therapists. (Healing 2004)

It is clear that certain states such as Florida, Ohio and Hawaii have understood that a massage practice without rules, regulations, or standards of education is a dangerous practice. Certain contraindications exist in the practice of massage such as diabetes, history of heart attacks, varicose veins, phlebitis, edema (swelling), fractures, and acute injuries among others.

Suppose you own a Spa in a state such a Georgia, which does not regulate the practice of massage therapy, and a client comes for a basic Swedish massage. The massage therapist, having learned his or her techniques from a school requiring only 300 hours of basic training, lacks the training to perform a basic health intake and proceeds without knowing that the client has had a history of chronic heart failure and is currently experiencing an anxiety attack, which he attributes to stress in the workplace. Thirty minutes after the massage has begun, the client starts experiencing dizziness and numbness to his left arm; however, the therapist attributes the effects to the release of toxins into the bloodstream and proceeds with the massage.

Upon getting up from the massage table, following the massage, the client becomes paralyzed on the left side of the body and falls to the ground with a massive heart attack. The therapist, having failed to learn basic CPR skills not required by the state, could spring into action and help save his life until the paramedics arrive, however failing to understand the severity of the situation instead opts to pick him up and sit him on a chair thinking he fell from a dizzy spell, and by doing so aiding the heart attack to its full potential. According to Ruth Werner, the author of A Massage Therapist's Guide to Pathology, a massage would mechanically push fluid thru the system which would hinder rather than help these damaged structures (Werner 2002).

Furthermore, imagine having a client with a history of cancer that has just finished undergoing an intense chemotherapy treatment at an out-of-state hospital. Failing to ask crucial questions, required by any basic standards of practice, the masseur (as they are commonly known in unlicensed states such as California) performs a full body massage. The friction caused by manipulating the soft tissues (muscles, tendons and fascia) stimulates the circulatory system by vasodilating (widening) the veins and arteries, which in turn stimulates the blood flow thru the area being massaged. Since it is a proven fact that an increase in blood flow stimulates cell reproduction, among many other functions, the client runs a high risk of the cancer retuning to its mitotic (reproductive) state, and in turn places the patient's life in danger.

In the year 2000, a serious case occurred that shook a small school in Florida. Due to the nature of the case and for the protection of all parties involved the actual names will be concealed. It was early in the morning and the school day at this trade school began classes as usual.

At 10:00 am, a young lady familiar to the massage therapy program, stepped into the massage clinic to look for her friend, as she regularly did, to go on her snack break. The instructor looked at her and casually mentioned that she looked pale and in pain. The student agreed with a whispering voice and proceeded to mention that she was having a migraine attack. The professor asked her to sit on a stool and proceeded to perform an apparent harmless massage to her shoulders and neck region.

The invasive techniques he was using were not accurately being performed, and by doing so he was massaging the carotid artery which, properly executed, is a delicate technique used by cardiologists in a last minute attempt to save their patients lives. The massage lasted only 10 minutes; however, it was enough to achieve the undesired reaction of lowering her blood pressure to dangerous levels. The 95-pound student began sweating and shaking uncontrollably to the point that she had to be covered with blankets and placed on a massage table in an effort to warm up her body.

During the five to seven minute wait for the ambulance the student came in and out of consciousness, which was accompanied by vomiting. While in the hospital the student reached dangerously low levels of blood pressure causing minor brain damage due to reduced levels of blood flow to the brain. Needless to say, that said episode was followed by legal action resulting in a settlement and legal action being taken toward the therapist. Having licensing in the state of Florida did not prevent said case, yet it did allow for legal action to be taken against the therapist, which for obvious reasons the outcome cannot be disclosed, for not abiding by the state standards of practice, among other violations and not following a basic patient intake procedure such as performing a basic health history.

Cases such as these should not and can not be allowed to happen. Many states mentioned that regulating this career would involve establishing an official board within the Department of Health and would additionally require regulating massage schools via the Department of Education to ensure the standardization of education.

If these states believe that regulating this profession and the educational aspect is expensive, they obviously have not contemplated the cost that ignorance has caused the public or the massage therapy profession. Recognizing the importance of preventive medicine and the benefits of therapeutic massage many insurance companies are opting to begin including massage benefits into their insurance policies. In certain states such as Virginia, Florida, and New York insurance companies are required to pay for massage treatments performed on their clients. Furthermore Maryland has a two-tier system in which a Certified Massage Therapist can refer and receive referrals to treat patients, proving once more that insurance companies have realized the importance on the benefits that massage therapy licensing has. Therapists can not only work on patients but they can also bill insurance companies for their own treatments. Such steps are a positive move towards protecting the public and the health infrastructure in licensed states.

As massage moves further into the mainstream of health care, rules and regulations will not only have to exist, but they will also have to be tougher and stricter to protect the public from harm. It is not acceptable to sit back and say there is no evidence to support that the practice of massage therapy is harmful to the public. The evidence that supports that there are definite dangers the public exposes themselves to, when they submit themselves to the practice of massage therapy, are real and obvious. In ancient times rules and regulations did not exist because there was no infrastructure present to regulate the career, or any other for that matter, however in today's advanced world the rules have changed.

It is understandable that states such as California, Georgia, and Colorado be worried with the cost involved in regulating therapists or the schools where they learn however, they must outweigh the cost of even one life protected. It is their responsibility; nay, their duty to protect the public from harm. The practice of massage therapy has truly outlived thousands of generations before us proving to be a career worthy of recognition. However, it will also outlive our generation and hundreds to come, therefore it is our time to act and protect the future generations from incompetent therapeutic practices. This career is no longer bound by myths such as "work of the Devil" or "prostitution", this career is a legitimate career with legitimate therapists who are proud of their work and that fully support the regulation of their career.

In the 21st-century we have the ability to combat ignorance, incompetence, and public danger by implementing rules and regulations. It is about time that rules and regulations exist to protect the public from any unprofessional and dangerous activity in the entire United States; this would greatly minimize the danger the public exposes themselves to every time they place themselves under the hands of a massage practitioner. From the first state in 1916 to the last ones in 2003 to regulate massage, they all had one thing in common, protecting the public from harm. In the hands of a competent professional, massage is one of the best natural avenues to return a body back to health however, in the hands of the unskilled practitioner it is a lethal weapon with the ability to take a life.


  • Chapter 480 Massage Practice: The Florida Senate Homepage. Tallahassee, FL. Retrieved May 28, 2004. Fritz S: Mosby's fundamentals of therapeutic massage, second edition, St. Louis, Missouri (2000), Elsevier Health Sciences.
  • Healing and Law: Healing and Law Homepage. Philadelphia, PA. Retrieved June 20, 2004.
  • Health benefits for alternative medicine: Is there a fit? International Foundation Homepage. Brookfield, WI. Retrieved June 7, 2004.
  • License rule aims to stop fronts for prostitution. The Cincinnati Enquirer Homepage. Cincinnati, OH. Retrieved June 7, 2004.
  • States utilizing/recognizing the National Certification Examination for Therapeutic Massage and Bodywork: NCBTMB homepage. Mclean, VA. Retrieved May 20, 2004.
  • States with massage practice laws: AMTA homepage. Evanston, IL. Retrieved May 20, 2004.
  • Tappan FM, Benjamin PJ. Tappan's handbook of healing massage techniques: holistic, classic, and emerging methods. 3rd ed. Norwalk, Conn. (1998). Appleton and Lange.
  • Werner R. A massage therapist's guide to pathology. 2nd ed. Philadelphia, Penn. (2002), Lippincott, Williams & Wilkins.