The Sloan Consortium performs a survey of online education in the U.S. each year  (http://bit.ly/Dws1L). According to their 2008 survey:
• Over 3.9 million students were taking at least one online course during the fall 2007 term; a 12 percent increase over the number reported the previous year.
• The 12.9 percent growth rate for online enrollments far exceeds the 1.2 percent growth of the overall higher education student population.
• Over twenty percent of all U.S. higher education students were taking at least one online course in the fall of 2007.

Business, universities, and K-12 schools throughout the country have recognized what a powerful and effective educational model online learning can be. Yet, in the massage profession we still don’t recognize or acknowledge this. Many states do not allow distance education as part of the entry-level curriculum in massage schools. In those states that do, very few massage programs use online learning at all.

I often hear the argument that online learning is not appropriate for massage because this is a hands-on profession. I would heartily agree that the techniques of massage should be taught in a supervised classroom environment. However, there are many subjects (anatomy, physiology, business, kinesiology, pathology, etc.) that could be taught very effectively using innovating online learning strategies. There are some exceptional new technologies that are highly effective at teaching these types of subjects and we are lagging far behind by not employing them for our students’ benefit. It’s time for us to start forging new ground as educators and explore the opportunities of innovative 21st century learning

Regardless of the type of advanced certification that the NCBTMB chooses to pursue, they will have to grapple with a sticky issue when it comes to eligibility criteria. The nature of an advanced exam suggests that education above and beyond the entry level will be required to sit for the exam. However, in this profession we don’t have any existing model to evaluate what that advanced education looks like.

The most common method of evaluating additional education would be to simply add up hours of continuing education (CE) courses that an individual has taken. However, there could easily be loads of accumulated CE hours in topics that don’t significantly contribute to an individual’s advanced knowledge for addressing compromised health care conditions. There could also be years of clinical practice in a medical setting where there were no formal educational hours earned, but the environment was a valuable educational experience. How will the NCBTMB grapple with these diverse educational environments when attempting to evaluate advanced education? It remains to be seen how this will be done, but it will certainly be one of the most difficult aspects of developing this new credential.

Unfortunately I missed the deadline on the essay contest, but still felt it was worth thinking and writing about the issue. The question itself is interesting and reminds me of a similar question that we hear debated in much of the popular literature about whether science and technology can save us from global climate change. The answer to both questions, unfortunately, is no.

The reason that science is unlikely to end the process of animal research lies in the very title of the essay contest ad. It suggests that there is a need for animal research. I realize many people will argue with me about this and say animal research is necessary for advances in biomedical engineering, health care, etc. But this isn’t a question about science. It is a question of ethics.

Where do you place yourself in relation to the other creatures that inhabit the planet with us? The idea that science needs animal research is one that is based on the assumption that we as humans have the right to decide how we use other animals without considering if they want to be involved in our research. If we subjected humans to many of the processes that are used in animal research there is no doubt that we would call this torture. Yet, somehow we are able to look the other way and say it is OK because it saves lives. Well, it doesn’t save the lives of the animals that are “sacrificed” in the process.

Eliminating animal research would clearly slow the advancement of many medical procedures and processes. Many people feel that increased human survival offsets any moral obligation we have to the way we treat other sentient beings. I can’t agree with that. It is time to recognize that if we are holding ourselves up to be the most intelligent creatures on the planet, we must also confront the ethical dilemmas of our actions. I would agree with the underlying assumptions of the New Scientist essay contest that science can make significant advances without the need for animal research. But we must go much further than that and recognize that it is really time to end the use of ALL animal research.

There has been a tug of war between these two approaches for some time when discussing educational standards and credentialing.  Those who want to make sure there are not unreasonable hurdles for entry into practice (especially for personal care service approaches to massage) don’t want to see rapidly escalating educational requirements. Those who emphasize massage as a health care practice recognize there is no way it will be taken seriously by the health care community unless the educational requirements are increased.

Can we have our cake and eat it too? Yes, I think we can. I do agree that massage is an important skill and there should not be unreasonable barriers to entry for those that want to practice it as a personal care service. I still think it is important for people who practice in this manner to have a solid foundation in the sciences because they are still performing a practice that can have adverse effects on someone’s health and they should understand this thoroughly. For that reason the existing entry level requirements (about 500 hours of eduction in most locales) is a good starting place. Of course it would be better to focus on specific competencies as opposed to hours, but that’s an issue for a different day.

For those that want to practice massage in a health care environment we need to have a credential that designates a higher educational standard—perhaps something like a “massage therapy specialist.” At this level there would be far more attention focused on the necessary knowledge, skills, and abilities that are missing in our current training to prepare people to work as a health care provider. The length of this training program should be constructed by investigating competencies needed by similar health care professionals. It will be hard to predict how that will be converted to hours, but it seems reasonable to suggest this could be at least 750- 1000 hours of additional training above the initial 500 hours that most people currently have.

There will clearly be many obstacles to this process, but other health care professionals are beginning to look at massage as a health care practice. I attended a recent meeting with the Academic Consortium for Complementary and Alternative Health Care. At this meeting it was clear that other licensed health care professions that fall under the CAM umbrella have substantially greater training requirements than massage therapists, yet we face many of the same clinical decisions. We simply can’t continue to be taken seriously as a health care field with only 500 hours of training required. It will take a long time to make this transition so the time is now to get started on this process.

The research literature has studied stretching extensively but there is no conclusive evidence for a best stretching method yet. It appears that certain stretching methods work better in one situation while others work better in another. As I was doing some research on stretching recently it occurred to me that there are some additional factors in stretching that we may want to investigate.

In any stretching procedure there are two primary components that need to be addressed to effectively encourage muscle elongation. The first is a neurological component that governs the muscle’s resistance to stretch. It is here that the proprioceptors play a major role in stretching techniques. Techniques such as PNF or other facilitated stretching methods have been developed to focus on the neurological components of stretching.

Another factor in stretching is the mechanical elasticity of connective tissue (fascia) that surrounds muscles and bundles of muscle fibers. This connective tissue has a resistance to tensile (stretching) forces when those forces are rapidly applied. As you hold tensile force on this connective tissue, its resistance to stretching decreases. The decreasing resistance to stretch tension in connective tissue is a property called creep. Maximizing the effectiveness of connective tissue creep is an argument for a longer held stretch.

Recent research into the physiological properties of fascia have shown that it contains contractile cells. It has also been determined that a prolonged tensile force on connective tissue, such as that used in myofascial release or other fascial techniques, can cause a reduction in contractile activity in these fascial cells.

We now know that connective tissue elongation is enhanced by manual therapy methods of stretching fascia. We also know that connective tissue stretch (resistance to creep) is a limiting factor in stretching methods.  What if we were to combine the two and encourage use of these myofascial techniques on muscles as they were in their fully stretched position? I’m sure some practitioners must be doing this already, so it would be interesting to see some comparative studies performed on this method.

Multimedia presentation is one area where e-learning can offer a significant advantage over the traditional classroom delivery structure. There is no question that you can produce a great live multimedia presentation with lecture and accompanying visual aids- especially if you are a good live presenter. However, one of the great challenges is that once the lecture is over, the students don’t have it to go back to for further study. That’s why so many of them are so frantic to write down everything that is said during the presentation. Many students tape record lectures and this is a great advantage for audio playback, but that misses the important visual aids that are an important part of explaining important concepts.

A well-constructed (and this is crucial) e-learning presentation that includes audio and visuals can be an excellent learning tool because the student can go back to the same original presentation over and over until the concepts have really been absorbed. Research has shown a greater degree of retention and knowledge transfer with high quality multimedia presentations, so I think this learning strategy holds great promise. Our big challenge now is to get people to learn what a high quality multimedia presentation entails and how to produce one.

I experienced this increased interest first hand several years ago as scores of administrators and educators from the nation’s medical schools gathered at Georgetown Medical School with a group of educators from the complementary and alternative health fields during the National Education Dialogue (NED). One goal of that gathering was to discuss the future of medical education and how it could include greater representation from these CAM perspectives.

Judging from these advances it would be easy to suggest that the massage therapy field is growing, maturing, and the skills and abilities of its practitioners are advancing. There is no question that the number of people in the field has increased dramatically during that time. However, although certain individuals have gone very far, I don’t believe there has been a corresponding growth in the knowledge, skills and abilities (KSAs) of the average practitioner. In fact, I think we have actually been witness to a decline in the quality of KSAs that the average professional displays.

While there is no hard data to back up these perceptions, I have been paying close attention to this for quite some time and talking to many different educators and leaders in the field about this trend. I noticed some years ago that as a continuing education provider, people were coming in to my workshops with less solid knowledge and poorer manual therapy skills. At first I wrote it off as just a widening gap between the advanced work I was studying and what the average practitioner would be likely to know. But then, I started making specific notes about what people seemed to know and be able to demonstrate with quality skills. It was clear that I could no longer rely on people having certain basic knowledge and understanding or being able to perform fundamental technical skills.

It pains me greatly to witness this decline in the quality of our field’s practitioners. But more important is looking at the reason for this decline and what can be done about it. I believe the reason for the decline is very clear. In the last decade and a half we have had a proliferation of schools and training programs to where it is somewhere near 1500 now.

A large number of training programs is not necessarily bad. However, there are nowhere near enough qualified massage therapy instructors to staff these training programs and consequently many programs are being taught by recent graduates or those that do not have seasoned skills, knowledge, or any significant instructor training. This is a massive problem and I don’t know what the immediate solution is, but it seems there is an urgency to look at some form of teacher credentialing or instructor training. What form should that teacher training or credentialing take? This is a discussion we must immediately engage because our future is at stake.

For years the National Certification Board (NCBTMB) has been able to hold their domain as an organization that encouraged the licensing of massage therapists in an increasing number of states. The existence of their exam was a big piece of that puzzle because it meant the states did not have to go to the expense of creating a psychometrically valid exam (an expensive undertaking). But at the same time the NCBTMB was also trying to promote the exam as a certification exam that demonstrated a higher level of knowledge, skill, and ability by practitioners who took this exam. But you can’t have it both ways… The exam can’t be the entry level credential for everyone and also be a more advanced certification exam that is supposed to set you apart from others.

By trying to play both sides of the fence the NCBTMB has lost its focus and in the mean time become a victim of its own success. Out of this turmoil the Federation of State Massage Therapy Boards (FSMTB) has emerged with an exam and a structure that makes very good sense. The initial licensing exam is administered by a group of state licensing boards and they determine its structure, content and handle the logistics of its administration. This exam also helps more with portability of credentials between different states. It just makes sense (as long as it is administered well).

Yesterday the American Massage Therapy Association (AMTA) sent out a press release supporting the use of the MBLEx as the single primary licensing exam for our profession. Because the AMTA gave birth to the the NCBTMB, this is a very significant development. It is another indication that the NCBTMB is losing its hold on the huge revenue stream that is tied to entry level licensure in our profession. With that slipping away, how will the organization re-invent itself? What will become of them? They have reached what Andrew Grove, former chairman of Intel, has called a Strategic Inflection Point– a place that is defined by a major paradigm shift in the way they have to look at their future. They can either re-invent themselves or they may be watching as that huge wave sweeps them back out to sea… My recommendation is that every member of the board and leadership read Grove’s book, Only the Paranoid Survive. Actually the book contains some pretty good messages for all of us in these very challenging economic times.

Most of us who have been immersed in the field of orthopedics, sports medicine, and biomechanics have been talking for years about iliotibial Band (ITB) friction syndrome as a repetitive overuse disorder caused by excess friction between the distal ITB and the lateral epicondyle of the femur. However, now it turns out that this concept may be mistaken.

One of the common misconceptions of the ITB is that it is a single discrete band of connective tissue running down the lateral side of the thigh. Actually it is a thickened part of a fascial sleeve that surrounds the entire thigh (the fascia lata). The authors of this study investigated a number of cadaver specimens and live individuals with MRI and found some interesting new discoveries. Apparently the ITB is firmly anchored to the distal femur and does not rub back and forth across the lateral epicondyle of the femur as most of us have been describing it. In addition, they state that there actually isn’t a bursa under the ITB, as it is often described.

When the knee moves into flexion, there is a simultaneous internal rotation of the tibia. This internal tibial rotation puts increased tensile loads on the ITB. The authors suggest that the increased tensile load on the ITB further compresses it against underlying tissue. There is a layer of fatty tissue under the distal ITB that is richly innervated with Pacinian corpuscles. They suggest it is this increased compression against the fatty tissue that is the cause of the pain and not a bursitis or friction of the ITB against the femoral epicondyle.

So, now that we know this, how should we change treatment strategies? One would think that if the primary problem in this condition were additional compression of the ITB against underlying tissues, then further direct compression in this area would not be a good idea. The authors suggest that the primary problem originates with improper function of the hip musculature (which tensions the band). As a result, the primary treatment should focus much more on correct hip muscle function and not on treating the knee region. The article and abstract are located under this citation:

Fairclough J, Hayashi K, Toumi H, et al. The functional anatomy of the iliotibial band during flexion and extension of the knee: implications for understanding iliotibial band syndrome. J Anat. Mar 2006;208(3):309-316.

The article was about the environmental impacts of this perpetual cycle of increasing consumption that we are mired in…. a subject that begins to bother me excessively every year around this time. For me the most disturbing thing that came to me out of that article was a relatively simple equation. I rarely have an emotional reaction to an equation, but this one has continued to haunt me so I recognize that it has major significance.

The equation was originally proposed by Paul Ehrlich and John Holdren in the early 1970s. It has since become known as the Ehrlich equation and is represented simply as: I=PAT where

I= The impact of human activity
P= Population
A= The level of affluence associated with the population
T= A technology factor, which is an impact on the planet of each dollar we spend

I once again watch the holiday madness in this country, including hearing that a Wal-Mart employee was trampled to death the day after Thanksgiving in people’s mad rush to get into the store. I realize that with our exponentially increasing population (P) and the great deal of affluence associated with it (A), we are also using a tremendous amount of resources to produce the things we just have to have (T). Most people don’t want to talk about the population problem and they defend the necessity of having children. It is strange the odd responses and looks I get from people when I say I deliberately chose not to have children because of the world’s population and resource consumption problems.

If our population continues to increase at its current exponential rate, and a much greater segment of the world aspires to live a life of technological advancement and affluence that we enjoy in this country, we are headed for a catastrophe of major proportions. We simply can’t sustain that kind of impact. Changing light bulbs and lowering our personal carbon footprint is important, but will pale in comparison to the impact of all these people continuing to buy, buy, buy… With our current economic crisis we are all being told how important it is to return to healthy economic growth, but nobody seems to be talking about the giant elephant in the room. There is actually no such thing as sustainable growth. There will come a time before long that continual growth will cause a catastrophic economic, environmental and sociological collapse… Troubling thoughts for the holiday season, but I can’t continue to just look away because of this unpleasantness…