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.

One topic that is also talked about in the debate about distance education is the quality of the assessment strategies. Web technologies have made it very easy to create simple multiple choice and true/false assessments. Many people who deploy online learning (e-learning) simply transfer material from a lecture type class (or in a worst case scenario, simply put a bunch of written text online) and then offer a multiple choice test at the end. This is not always bad if you are just trying to get people to memorize information, but hopefully the goals for most educators go beyond simple rote memorization.

In his book, Educative Assessment, Grant Wiggins states that assessment should be more than just a means to attempt documentation of learning. The assessment should be a learning process in and of itself. When designing tests or evaluations, I have always tried to keep that in mind.

I have been spending the last several days working on a comprehensive evaluation for our orthopedic massage certification program. I have become intrigued with the possibilities of the adaptive mode for test questions that is built into Moodle, our learning management system. When a student takes the exam and answers a question correctly they can immediately see that they got the question correct. Immediate feedback like this helps reinforce the learning process. When a question is answered incorrectly there is an opportunity to do the question again for a lower amount of credit and, if desired, see feedback on why the question was wrong. This ability to get immediate feedback about errors has great potential for using the assessment process for enhancing learning and not just measuring it. That kind of immediate feedback and grading option is not possible in a paper-based classroom evaluation test.

We had a number of people in this group, and as in any group, a wide variety of perspectives represented. I was curious to note that there was some strong opposition to allowing distance education to be used in a massage therapy education setting. The argument made was that massage is different than any other subject and is something that can’t be taught by distance education. Yet, nobody in the group was advocating that the hands-on techniques of massage would be taught in this environment. The distance education component would only cover those subjects such as business, anatomy, theory, etc., which involved non-hands-on instruction.

The policy eventually passed but one of the primary arguments against allowing distance education had been that it would require much greater oversight than the traditional face-to-face education programs. It was argued that the NCBTMB would have to use much greater scrutiny of these courses to make sure they were up to a certain quality. This is where the double standard comes in.

There is no current evaluation of the quality of face-to-face educational programs approved by the NCBTMB for continuing education. Yet, some believe a much higher degree of scrutiny of distance education programs is required. It is certainly true that the emergence of distance education has brought a whole host of new continuing education programs into existence, and many of them are poor quality. But, let’s be serious… there’s lots of workshops out there with the NCBTMB seal of approval on them that are really poor. If we are going to evaluate programs for their educational quality, then let’s do it. But let’s make sure that all programs are being evaluated on the same criteria.

I was having a discussion with a colleague yesterday about another aspect of change that both of us see in our work each day. This change has to do with distance education and the discomfort and resistance that many people have with it.

Distance education is clearly here to stay and how people are reacting to it in various ways is certainly interesting. The field of massage therapy is an interesting example. By nature of what we learn in this field it is clear that a big portion of our work involves psychomotor skills and is best taught in a face-to-face environment. However, much of what we learn or study is primarily cognitive and requires deeper types of thinking and not just rote movement. Distance education is clearly effective for addressing these issues.

What we were both remarking at is that there is acceptance of distance education for continuing education, but a strong resistance to it in entry level education. While training in continuing education may not be as intense as that in entry-level programs, it seems odd that a method of delivery for course work would be acceptable at the continuing education level and not in entry level programs. I’ll explore the reasons for this discrepancy in future posts.