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Massage therapists were randomly sampled from state licensure listings in Washington and Connecticut In both states, licensing requirements for massage therapists including having hours of education and a passing score on the national examination. We excluded providers without identifiable telephone numbers and those not currently practicing. All participating massage therapists were interviewed about their demographic, training, and practice characteristics. Those with at least 10 visits in a typical week were then invited to participate in visit-based data collection.

A sample of those seeing 5 to 9 visits per week were also invited to collect data on patient visits. Visit data were collected between May and September in in Washington and between June and March in Connecticut. Massage therapists were given visit forms marked with unique identification codes and were asked to record data on 20 consecutive visits even if the same patient was seen more than once.

Practitioners were randomly assigned weekdays to begin data collection. New questions asked if the patient was receiving care from a conventional medical provider for the primary problem and if the massage therapist had communicated about this problem with a conventional provider who also provided care for the patient's main problem.

We also designed special questions to capture information about massage treatments, including information on use of specific assessment techniques, massage techniques, and lifestyle recommendations. We asked practitioners to record up to five "complaints, symptoms, or other reasons for this visit" using the patients own words, listing the most important complaint or reason first. Individual reasons for visit were then clustered into larger categories that correspond to International Classification of Diseases, Ninth Edition ICD9 chapters.

No information was collected on adverse experiences as part of this study. In the massage therapist analyses, Chi-square and Fisher Exact tests were used to compare proportions, and Kruskal Wallis tests were used to compare medians. Even though standard errors are not presented, they are always within 5 percentage points of the estimate. In the visit analyses, each visit in the sample was weighted by the inverse of its sampling probability, which reflected both the chance that the particular provider participated and the estimated proportion of that provider's annual visits included in the study.

Because of the large sample sizes and visits the weighted percentages presented in the tables have small standard errors, generally between 0. As a result, moderate to large differences between the states are also statistically significant. Therefore, the standard errors are not included in the tables. Data were collected on visits in Connecticut and visits in Washington. Virtually all of them received their basic training in the US, with most having trained in the state where they were currently practicing. A small fraction had no formal training.

In both states, massage therapists reported training a median of about hours. Continuing education was extremely heterogeneous, with practitioners noting 56 different types of training in Connecticut and 37 types in Washington. All but one of those acupuncture were in biomedical areas, most commonly nursing.

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Visits to massage therapists were for a limited number of conditions. Visits for "wellness" i. Virtually all other visits were for general body symptoms mostly generalized pain or "nervous system" symptoms most commonly headache. Most common reasons for visits to massage therapists licensed in Connecticut and Washington by broad and specific categorization.

Most of these visits are for relaxation. The most frequent consultations were with chiropractors. Two percent of visits in both states ended with a referral to a medical or osteopathic physician. The most common methods were tissue assessment via palpation, range of motion, and postural assessment. Diagnostic assessments performed by massage therapists licensed in Connecticut and Washington Massage therapists in Connecticut were more likely to emphasize Oriental bodywork i. Definitions of some of the most commonly emphasized techniques are provided in Additional File 2. Massage techniques emphasized during visits to massage therapists licensed in Connecticut and Washington Increasing water intake, movement especially active movement , body awareness, and breathwork were the most common recommendations.

Visits lasted a median of 60 minutes. Self-care recommendations given by massage therapists licensed in Connecticut and Washington To our knowledge, this is the first study that describes the demographic and training characteristics of US massage therapists and uses systematically collected visit data to describe their treatment patterns.

Strengths of the study are the collection of data from licensed massage therapists practicing in geographically separated parts of the country where CAM use is relatively common, random sampling of providers from state licensing lists, relatively high response rates, and large sample sizes. The main limitation is that we collected data from only two states, which may not be representative of massage practice in other states.

However, licensure requirements in Connecticut and Washington are similar to those in most other states with licensure requirements. As of December, , 33 states and the District of Columbia had passed legislation regulating massage practice. Of those, 21 require exactly hours of training for licensure and 12 require between and hours [ 8 ].

The latter is required for licensure in 24 states and is an option for licensure in another 5 states. In some states, including Massachusetts and California, massage regulations vary within the state i. By contrast, the two provinces in Canada with regulatory requirements mandate that massage therapists receive hours Ontario or hours British Columbia of training.

The Bodywork and Massage Sourcebook

Our study describes an eclectic group of health professionals. Most massage therapists have taken continuing education training that includes both Western-oriented treatment techniques e. Our finding that most massage therapists are white females with a median age around 40 is consistent with the findings of the only other published study of the characteristics of massage therapists, which surveyed 82 massage practices in the Boston area [ 9 ].

However, that study reported that the median length of practice was 7 years compared to our 4 to 5 years , that providers received a median of hours of clinical training compared to our hours , and that practitioners saw a median of 20 patients per week compared to our 10 to 15 visits per week.

The other study used the telephone book in a single urban area to recruit massage therapists whereas we used state — wide licensing lists. Their restriction to an urban area, their recruitment methods and their lower response rate may have biased their sample toward busier practitioners. The majority of visits to massage therapists focused on musculoskeletal conditions, possibly reflecting the extensive use of massage by physical therapists for rehabilitation during the first half of the 20 th century [ 10 ]. These are conditions for which Western medical care is often of limited value, which may explain why back and neck pain are the most common reasons why patients seek CAM care in general [ 2 ].

While massage as a relaxation technique has received abundant attention in the popular culture, we found that less than one-third of all visits to licensed massage therapists focused on non-illness care. CAM is also commonly used for self-defined anxiety and depression [ 2 , 11 ]. Since massage therapists do not make diagnoses, no information is available on whether patients' visiting for anxiety and depression in our study actually had these disorders diagnosed by physicians.

We could find no other published studies presenting data on patients' reasons for visits to massage therapists from a large population-based sample of visits, so we do not know how comparable these results are. A survey of a representative sample of US adults reported that massage therapy was one of the most common CAM therapies used for back problems, neck problems and fatigue [ 2 ]. While fatigue was not a commonly listed reason for visiting massage therapists in our study, some patients who received wellness care or care for anxiety or depression could conceivably have had fatigue as a symptom.

The use of massage for treating medical conditions has grown substantially since [ 2 ]. Although massage is one of the most popular forms of CAM care and has been found to have intriguing physiological effects reviewed by Field [ 12 ] , few studies with moderate to large sample sizes have been conducted to evaluate its clinical effectiveness, even for most musculoskeletal conditions, conditions for which massage is frequently sought and for which conventional medicine has few good treatments.

Three recent studies, including two that were well designed and had reasonable sample sizes, evaluated therapeutic massage as a treatment for subacute or chronic back pain and all three found positive results [ 13 ]. In addition, several studies of acupressure for back pain have also found positive results [ 14 , 15 ]. A recent Cochrane review of massage for back pain [ 16 ] concluded that "massage might be beneficial for patients with subacute and chronic non-specific back pain, especially when combined with exercises and education.

More studies are needed to confirm these conclusions". While even fewer studies of massage have been conducted for other musculoskeletal pain conditions, there are small studies suggesting that massage may have benefits for patients with fibromyalgia [ 17 ], shoulder pain [ 18 ] and diffuse chronic pain [ 19 ], while Irnich [ 20 ] did not find massage effective for neck pain. Most of those studies lacked follow-up after the treatments had stopped, but Hasson found that the benefits of massage did not persist three months after the last treatment.

A recent meta-analysis of randomized trials of massage for various conditions found that massage had its greatest short-term benefits in reducing trait anxiety and depression, but no studies have evaluated these effects after the end of the treatment period [ 21 ]. A systematic review of massage for symptom relief in cancer patients found preliminary evidence that massage had short term benefits on psychological well-being and possibly anxiety [ 22 ], but called for additional studies to confirm and extend these findings.

The modest evidence base for massage therapy's clinically important effects provides physicians with little information for advising patients about its effectiveness for conditions other than subacute or chronic back pain. However, given the safety profile and preliminary evidence of effectiveness for back pain, physicians should feel comfortable recommending massage for selected patients with musculoskeletal conditions and, possibly, for mild stress-related anxiety. Massage therapists in Washington were more likely than those in Connecticut to use postural assessment and range of motion as assessments tools.

Such differences likely reflect differences in training. In general, these differences in assessment were not associated with differences in the massage techniques emphasized by practitioners. Swedish, deep tissue, and trigger pressure point were by far the most popular techniques in both states.

A substantial minority of visits included techniques with a non-Western origin, such as some forms of energy work e. In addition, this study as well as a previous study [ 23 ], found that massage therapists often emphasize self-care e. Recommendations often include increasing the patients' awareness of how they are using their bodies coupled with exercises designed to enhance movement and posture, based on the assumption that many musculoskeletal conditions result from poor use of the body.

While these recommendations have not been scientifically validated, they are likely to be safe and may enhance the patient's sense of well-being. In a review of the safety of massage therapy, Ernst [ 24 ] found 16 case reports and 4 case series in the biomedical literature over a 6 year period describing adverse effects associated with various forms of massage. However, only 3 reports including 7 cases described adverse effects that were probably attributable to treatments by massage therapists practicing Western forms of massage.

These included the displacement of a ureteral stent, a hepatic hematoma after deep tissue massage [ 25 ] and the deterioration in hearing among patients who received neck massage. Ernst found three additional reports of adverse events associated with shiatsu, the most serious of which was retinal artery embolism with partial loss of vision after application of shiatsu to the upper neck.

Although the rate of adverse effects over this period of time is unknown, in the US alone an estimated million visits were made to massage therapists in [ 2 ], suggesting that serious adverse experiences due to massage are extremely rare. Despite these scattered reports of adverse experiences, common forms of massage e. While it is still generally assumed that patients with deep vein thrombosis should not receive massage to the lower extremities, many previous contraindications, such as proscribing massage to patients with metastatic cancer, are no longer considered warranted.

Massage therapists are trained not to massage anatomic sites containing localized conditions such as skin injuries or burns. Massage therapy is an increasingly popular form of care used by patients who are often also being treated by a physician for the same condition. Nevertheless, we found that massage therapists and physicians rarely communicated with each other.

Possible barriers to communication include our observation that most patients who see both a physician and a massage therapist for a particular condition were not referred to massage by the physician. Furthermore many massage therapists are not trained in charting language familiar to physicians, nor are they permitted to make "diagnoses". In addition, referring patients to massage therapists has not been part of the training of physicians. Finally, we suspect that most massage therapists, who are typically part-time solo practitioners, lack office staff and record systems to assist with administrative tasks, including routine and written communication with other care providers.

We believe that patients may benefit from increased communication between their physicians and massage therapists. Physicians can foster improved communication by asking patients about the care they are receiving from a massage therapist and learning about the treatment plan. Some patients will want to try massage therapy only after consultation with their physician.

In these circumstances, physicians can use the framework recommended by Eisenberg [ 26 ] to guide patients through the process of selecting a well-trained, therapeutically-oriented massage therapist, jointly negotiating the treatment plan, and monitoring the effects of the treatment over time. While substantial barriers to the full integration of massage therapy into the healthcare system remain e.

KJS participated in the design of the overall project and the data analyses and drafted this manuscript. DCC was the PI on one of the grants funding the study, designed and directed the data collection and analysis of the overall project.

JK helped design the data collection instruments. JE participated in the design of the overall project, directed the data collection, quality control, and participated in the analyses for this paper. AH directed the data collection for Connecticut. RD participated in the design of the overall project and data collection procedures and helped to obtain funding. DME was the PI on one of the grants funding the study and participated in the design of the overall project and data collection procedures.

All authors read and approved the manuscript. In-kind support was provided by the Centers for Disease Control and Prevention. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Complementary and Alternative Medicine, National Institutes of Health. We thank the 33 members of the original massage therapy study team for data collection and Kristin Delaney for help with data analysis.

National Center for Biotechnology Information , U. Published online Jun Author information Article notes Copyright and License information Disclaimer. Corresponding author. Strengths of the study are the collection of data from licensed massage therapists practicing in geographically separated parts of the country where CAM use is relatively common, random sampling of providers from state licensing lists, relatively high response rates, and large sample sizes.

The main limitation is that we collected data from only two states, which may not be representative of massage practice in other states. However, licensure requirements in Connecticut and Washington are similar to those in most other states with licensure requirements. As of December, , 33 states and the District of Columbia had passed legislation regulating massage practice. Of those, 21 require exactly hours of training for licensure and 12 require between and hours [ 8 ]. The latter is required for licensure in 24 states and is an option for licensure in another 5 states. In some states, including Massachusetts and California, massage regulations vary within the state i.

By contrast, the two provinces in Canada with regulatory requirements mandate that massage therapists receive hours Ontario or hours British Columbia of training. Our study describes an eclectic group of health professionals. Most massage therapists have taken continuing education training that includes both Western-oriented treatment techniques e.

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Our finding that most massage therapists are white females with a median age around 40 is consistent with the findings of the only other published study of the characteristics of massage therapists, which surveyed 82 massage practices in the Boston area [ 9 ]. However, that study reported that the median length of practice was 7 years compared to our 4 to 5 years , that providers received a median of hours of clinical training compared to our hours , and that practitioners saw a median of 20 patients per week compared to our 10 to 15 visits per week.

The other study used the telephone book in a single urban area to recruit massage therapists whereas we used state — wide licensing lists. Their restriction to an urban area, their recruitment methods and their lower response rate may have biased their sample toward busier practitioners. The majority of visits to massage therapists focused on musculoskeletal conditions, possibly reflecting the extensive use of massage by physical therapists for rehabilitation during the first half of the 20 th century [ 10 ]. These are conditions for which Western medical care is often of limited value, which may explain why back and neck pain are the most common reasons why patients seek CAM care in general [ 2 ].

While massage as a relaxation technique has received abundant attention in the popular culture, we found that less than one-third of all visits to licensed massage therapists focused on non-illness care. CAM is also commonly used for self-defined anxiety and depression [ 2 , 11 ]. Since massage therapists do not make diagnoses, no information is available on whether patients' visiting for anxiety and depression in our study actually had these disorders diagnosed by physicians.

We could find no other published studies presenting data on patients' reasons for visits to massage therapists from a large population-based sample of visits, so we do not know how comparable these results are. A survey of a representative sample of US adults reported that massage therapy was one of the most common CAM therapies used for back problems, neck problems and fatigue [ 2 ].

While fatigue was not a commonly listed reason for visiting massage therapists in our study, some patients who received wellness care or care for anxiety or depression could conceivably have had fatigue as a symptom. The use of massage for treating medical conditions has grown substantially since [ 2 ]. Although massage is one of the most popular forms of CAM care and has been found to have intriguing physiological effects reviewed by Field [ 12 ] , few studies with moderate to large sample sizes have been conducted to evaluate its clinical effectiveness, even for most musculoskeletal conditions, conditions for which massage is frequently sought and for which conventional medicine has few good treatments.

Three recent studies, including two that were well designed and had reasonable sample sizes, evaluated therapeutic massage as a treatment for subacute or chronic back pain and all three found positive results [ 13 ]. In addition, several studies of acupressure for back pain have also found positive results [ 14 , 15 ]. A recent Cochrane review of massage for back pain [ 16 ] concluded that "massage might be beneficial for patients with subacute and chronic non-specific back pain, especially when combined with exercises and education. More studies are needed to confirm these conclusions".

While even fewer studies of massage have been conducted for other musculoskeletal pain conditions, there are small studies suggesting that massage may have benefits for patients with fibromyalgia [ 17 ], shoulder pain [ 18 ] and diffuse chronic pain [ 19 ], while Irnich [ 20 ] did not find massage effective for neck pain. Most of those studies lacked follow-up after the treatments had stopped, but Hasson found that the benefits of massage did not persist three months after the last treatment.

A recent meta-analysis of randomized trials of massage for various conditions found that massage had its greatest short-term benefits in reducing trait anxiety and depression, but no studies have evaluated these effects after the end of the treatment period [ 21 ]. A systematic review of massage for symptom relief in cancer patients found preliminary evidence that massage had short term benefits on psychological well-being and possibly anxiety [ 22 ], but called for additional studies to confirm and extend these findings.

The modest evidence base for massage therapy's clinically important effects provides physicians with little information for advising patients about its effectiveness for conditions other than subacute or chronic back pain. However, given the safety profile and preliminary evidence of effectiveness for back pain, physicians should feel comfortable recommending massage for selected patients with musculoskeletal conditions and, possibly, for mild stress-related anxiety.

Massage therapists in Washington were more likely than those in Connecticut to use postural assessment and range of motion as assessments tools. Such differences likely reflect differences in training. In general, these differences in assessment were not associated with differences in the massage techniques emphasized by practitioners.

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Swedish, deep tissue, and trigger pressure point were by far the most popular techniques in both states. A substantial minority of visits included techniques with a non-Western origin, such as some forms of energy work e. In addition, this study as well as a previous study [ 23 ], found that massage therapists often emphasize self-care e.

Recommendations often include increasing the patients' awareness of how they are using their bodies coupled with exercises designed to enhance movement and posture, based on the assumption that many musculoskeletal conditions result from poor use of the body. While these recommendations have not been scientifically validated, they are likely to be safe and may enhance the patient's sense of well-being. In a review of the safety of massage therapy, Ernst [ 24 ] found 16 case reports and 4 case series in the biomedical literature over a 6 year period describing adverse effects associated with various forms of massage.

However, only 3 reports including 7 cases described adverse effects that were probably attributable to treatments by massage therapists practicing Western forms of massage. These included the displacement of a ureteral stent, a hepatic hematoma after deep tissue massage [ 25 ] and the deterioration in hearing among patients who received neck massage. Ernst found three additional reports of adverse events associated with shiatsu, the most serious of which was retinal artery embolism with partial loss of vision after application of shiatsu to the upper neck. Although the rate of adverse effects over this period of time is unknown, in the US alone an estimated million visits were made to massage therapists in [ 2 ], suggesting that serious adverse experiences due to massage are extremely rare.

Despite these scattered reports of adverse experiences, common forms of massage e. While it is still generally assumed that patients with deep vein thrombosis should not receive massage to the lower extremities, many previous contraindications, such as proscribing massage to patients with metastatic cancer, are no longer considered warranted. Massage therapists are trained not to massage anatomic sites containing localized conditions such as skin injuries or burns. Massage therapy is an increasingly popular form of care used by patients who are often also being treated by a physician for the same condition.

Nevertheless, we found that massage therapists and physicians rarely communicated with each other. Possible barriers to communication include our observation that most patients who see both a physician and a massage therapist for a particular condition were not referred to massage by the physician. Furthermore many massage therapists are not trained in charting language familiar to physicians, nor are they permitted to make "diagnoses". In addition, referring patients to massage therapists has not been part of the training of physicians. Finally, we suspect that most massage therapists, who are typically part-time solo practitioners, lack office staff and record systems to assist with administrative tasks, including routine and written communication with other care providers.

We believe that patients may benefit from increased communication between their physicians and massage therapists. Physicians can foster improved communication by asking patients about the care they are receiving from a massage therapist and learning about the treatment plan. Some patients will want to try massage therapy only after consultation with their physician. In these circumstances, physicians can use the framework recommended by Eisenberg [ 26 ] to guide patients through the process of selecting a well-trained, therapeutically-oriented massage therapist, jointly negotiating the treatment plan, and monitoring the effects of the treatment over time.

While substantial barriers to the full integration of massage therapy into the healthcare system remain e. KJS participated in the design of the overall project and the data analyses and drafted this manuscript. DCC was the PI on one of the grants funding the study, designed and directed the data collection and analysis of the overall project. JK helped design the data collection instruments.

JE participated in the design of the overall project, directed the data collection, quality control, and participated in the analyses for this paper. AH directed the data collection for Connecticut. RD participated in the design of the overall project and data collection procedures and helped to obtain funding. DME was the PI on one of the grants funding the study and participated in the design of the overall project and data collection procedures.

All authors read and approved the manuscript. In-kind support was provided by the Centers for Disease Control and Prevention. The contents of this manuscript are solely the responsibility of the authors and do not necessarily represent the official views of the National Center for Complementary and Alternative Medicine, National Institutes of Health.

We thank the 33 members of the original massage therapy study team for data collection and Kristin Delaney for help with data analysis. National Center for Biotechnology Information , U. Published online Jun Author information Article notes Copyright and License information Disclaimer. Corresponding author. Karen J Sherman: gro.

Received Mar 16; Accepted Jun This article has been cited by other articles in PMC. The visit form used for each of the massage therapy visits. Definitions of selected massage techniques. Abstract Background Despite the growing popularity of therapeutic massage in the US, little is known about the training or practice characteristics of massage therapists. Conclusion This study provides new information about licensed massage therapists that should be useful to physicians and other healthcare providers interested in learning about massage therapy in order to advise their patients about this popular CAM therapy.

Background Although massage is one of the oldest healthcare practices in the world, with references to it found in ancient Chinese medical texts as well as in the writings of Hippocrates, medical doctors in the US have not practiced therapeutic massage for nearly years [ 1 ]. Methods Original study The data presented in this paper were collected as part of a larger study of four licensed CAM professions, including massage therapy. Analysis In the massage therapist analyses, Chi-square and Fisher Exact tests were used to compare proportions, and Kruskal Wallis tests were used to compare medians.

Table 1 Demographic and training characteristics of massage therapists. Open in a separate window. Reasons for visits to massage therapists Visits to massage therapists were for a limited number of conditions. Table 2 Most common reasons for visits to massage therapists licensed in Connecticut and Washington by broad and specific categorization. Musculoskeletal Symptoms Psychological and Mental Health Symtoms 8.

Psychological and Mental Health Symtoms 5. General Symptoms 4.

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Nervous System Symptoms 4. Nervous System Symptoms 3. General Symptoms 3. Back Symptoms Massage Wellness Neck Symptoms Shoulder Symptoms 8. Shoulder Symptoms 7. Anxiety or Depression 8. Anxiety or Depression 5. Leg Symptoms 5. Headache 3. Unspecified Muscle Symptoms 4.

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Leg Symptoms 2. Generalized Pain 3. Generalized Pain 2. Headache 1. Hip Symptoms 1. Unspecified Joint Symptoms 1. Arm Symptoms 1. Table 3 Diagnostic assessments performed by massage therapists licensed in Connecticut and Washington Table 4 Massage techniques emphasized during visits to massage therapists licensed in Connecticut and Washington Table 5 Self-care recommendations given by massage therapists licensed in Connecticut and Washington Discussion To our knowledge, this is the first study that describes the demographic and training characteristics of US massage therapists and uses systematically collected visit data to describe their treatment patterns.