Trends are like ocean waves. The can gently lap up on the shore and recede or they can come inland with a mighty force and dramatically change the landscape. Anyone who has been watching the regulatory landscape in the massage therapy profession in the U.S. in the last several years will clearly recognize that we have been watching a trend that is gathering momentum and increasing in its size. I am of course speaking of the emergence of the Massage & Bodywork Licensing Exam (MBLEx) as an alternative to the National Certification Exam for Therapeutic Massage & Bodywork (NCETMB).

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.

One of the great things about keeping up with current research is that it often causes us to change course and reconsider ways that we may have been treating various pathologies. While it is certainly frustrating to have to reverse something you have been teaching for years, it is actually refreshing to develop a better understanding of how the body functions. A colleague recently sent me a link to this article on the anatomy of the iliotibial band and it is one of those things that is a radical shift from our previous understanding.

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.

There is no doubt that some things are better taught in a traditional classroom environment and some are better taught in distance education environments. And, of course, many topics that can be taught well in either environment. In most cases it is far more important to consider the instructional design method used for the course than the medium of course delivery. If the instructional design fits properly you can make a good educational experience in many different subject areas.

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.

I was talking yesterday about some of the difficulties in acceptance of distance education in the massage therapy community. One of those difficulties relates to a double standard of evaluation. This double standard became evident to me when I was working on the National Certification Board (NCBTMB) Distance Education Task Force that was considering allowing a certain percentage of hours in entry-level programs to be earned in a distance education format.

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.

Here in the U.S. we can all finally take a breath now and know that we won’t be barraged every day with the constant drone of what is happening on the election trail. If there is any clear message that came out of the U.S. elections I think it was clear that people are ready for a change. It is refreshing to see change being welcomed because many people have difficulty with change. In this instance change seems to be desirable because what we are currently living with seems to have so many problems.

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.