Home

Critical-thinking skills

The Ethical Implications of Research and Education in the Massage Therapy Profession (Chunco 2010)

Submitted by RST on Fri, 06/29/2012 - 18:10
Posted in

I want to thank the International Journal of Therapeutic Massage and Bodywork for their open access policy permitting free use with proper attribution in noncommercial settings, which--along with the fair use principle--permits us to engage with the text of this article in depth.

Entries in the IJTMB are governed stylistically and ethically by the publication guidelines of the International Committee of Medical Journal Editors' (ICMJE), Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Published articles are licensed under the Creative Commons Attribution-Noncommercial-No Derivative Works 3.0 license. Accordingly, copyright retention by authors, first publication rights for the journal, free use with proper attribution in noncommercial settings, and prohibition of derivative works are all ensured.

--Glenn M. Hymel, From the Executive Editor's Perspective ... IJTMB, Vol 1, No 1 (2008)

 

Full disclosure: Rosemary Chunco has been a supporter of the ideas behind POEM since the day I first mentioned the idea to her, and she has donated countless volunteer hours of technical and massage content expertise to bring it to fruition, as well as providing emotional support when I needed it along the way.

You should always read critically, and think about whether what you read makes sense, and that is especially true in this article, because I have a personal connection to the author.

It is my job to connect the dots and build my case to evaluate whether or not what she writes is correct, totally separate from the high esteem I personally hold her in.

Then, it is your job to read what I have written, and decide whether I was really successful in separating my evaluation of her work from what I think of her personally, or whether I am permitting my very high positive regard for her to bias what I write here about her work.

I hope you let me know in the comments whether or not I have succeeded at that task.

 

"The Ethical Implications of Research and Education in the Massage Therapy Profession", by Rosemary Chunco, LMT, BA, MSc, Owner (Private Practice), Shamrock Therapeutics LLC, Plano, TX, USA, International Journal of Therapeutic Massage and Bodywork, 2008:3(3).

Chunco sets the stage for the ethical and knowledge claims she will make in this article by grounding it in her practical experience of running her own massage practice for a number of years:

As a therapist operating my own practice, I am constantly reminded of the ethical aspects of my work in dealing with situations involving clients and the everyday running of my business. Professional boundaries and ethical practices are recognized within our profession as an important aspect of our work, as evidenced by mandatory classes on ethics in most U.S. states and also by the clearly stated ethical codes and practices set out by our professional organizations. The reasoning behind these measures is clear. Ethical declarations and a thorough understanding of them and their application are needed. They set standards of integrity. They help to define massage therapy as a profession and have significant repercussions on how massage therapists are perceived by the public.

 

From this foundation, she sets out to explore the connections between research, education, and ethics, and the meaning of those connections in everyday MT practice.

By drawing on specific points in the ethical code of each of MT's 2 major professional organizations in the US, as well as that of the NCBTMB certification board, she avoids partisanship, and focuses on what all of us--at least, those who subscribe to the ethical code of either professional organization--have in common with each other.

Whether it's ABMP's

I shall actively participate in educating the public regarding the actual benefits of massage, bodywork, somatic therapies and skin care.

and

I shall not make false claims regarding the potential benefits of the techniques rendered.

 

or AMTA's

[practitioners shall] be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results.

 

Chunco correctly emphasizes what they have in common with each other and with other professions' codes of ethics: actual benefits, not making false claims, being truthful and refraining from misrepresentations.

As she observes, this ethical value of veracity--truthfulness, accurately representing the facts--is core to the mission of a healthcare profession such as MT aspires to be.

But how do we gain that veracity about massage? She proposes:

Considering the increasing quantity—and importance—of research in our profession, and applying our understanding of professional ethics, it is apparent that keeping up to date with research findings could be viewed as an ethical responsibility. New research findings may uncover therapeutic benefits that we never learned in school. Conversely, some things we were taught in massage school have been overturned by the latest research. For example, many of us may have been taught that massage helps to release lactic acid from muscle tissue after exercise; research refutes that claim.

 

In this way, she grounds knowledge in empirical research findings, as well as describing the problem of outdated and ungrounded information that is taught in massage schools as fact.

She is touching on a huge problem here. You don't need to assume any bad intentions at all on the part of massage schools and educators in this situation--it makes perfect sense that the situation has developed because reality changed out from under us faster than we were prepared to keep up.

There was a time in the past when those explanations were the best we had for trying to figure out what was going on in the world around us.

But knowledge has moved on since then, and we were not prepared for that. So now, schools and their owners face tremendous sunk costs--costs already spent, that will never be recovered--as well as tremendous need for investment to bring the new knowledge on board, at exactly the time when the economy does not support such investment.

It is a huge problem, and you can really feel for the plight that educators find themselves in.

And yet, as difficult as the situation is, Chunco is correct: practicing MTs must, every day, confront the fact that what they were taught in school was insufficient, or even wrong, and to pass along that misinformation is to directly contradict the ethical codes of both of our major professional organizations, and of the board that certifies and attests to the integrity of our education.

Integrity means doing the right thing, not when it's easy and anyone can do it, but precisely when--although it would be easier to take the path of lesser integrity instead--you do the right thing anyway, even at greater cost. Chunco is correct in identifying that right thing as "a restructuring of existing knowledge, and that knowledge will continually evolve".

This integration of research findings into our profession’s training programs should be considered an ethical necessity.

 

"Ethical necessity" is a very strong term--and yet, entirely accurate and appropriate here. We must address the situation; to deny or ignore it is an ethical failure.

She ties that ethical necessity into what is required to actually carry it out. Our responsibilities to understand and integrate research findings run far deeper than just finding a source that says what we like, and slapping a citation onto our claims. Chunco refers to the established biomedical research literature, where others before us have encountered this challenge, to identify weaknesses in our relationship to massage research:

causism, a “tendency to imply a causal relationship where none has been established” (that is, the data are insufficient to support the claim), and data dropping...These, along with misrepresentation of findings, instances of poor research design, and an assortment of weaknesses in methodology can result in low-quality research. It follows that an uncritical acceptance of research by the massage community, and most of all by massage therapists, is a mistake, and that awareness of the ethical and methodologic issues common to any subfield of research is imperative.

 

But it's not all one-sided responsibility and burden, as she points out--there are professional benefits from being part of the biomedical healthcare team that shares a common body of translational client/patient-centered healthcare knowledge.

By sharing and communicating better with other members of the team, and by communicating a unified message to the client/patient (as she mentions with educating the public about massage), research literacy benefits us as well as putting higher expectations on us.

She deals compassionately and with integrity to common objections raised to changing practice in response to research findings:

When adherents of a specific modality are confronted with research findings showing that that modality has no therapeutic effect, I have often heard or read these three objections:

  • “More research is needed.”

  • “If the public wants it, and they believe it works, then we should supply it.”

  • “If I see results in my practice, then that’s all I need. All I want to do is help my clients.”

 

Although we frequently deal with these concerns here at POEM, she has said it in her article better and more concisely than I could do myself--I recommend you follow the link to her article and read her responses to these objections for yourself.

Chunco is clear on what needs to be done, yet she is compassionate and empathetic to the practitioners, teachers, and students who find themselves confronted with this new reality:

Having invested time, energy, and money to be trained in a modality and then being confronted with new information showing that that modality may have no therapeutic effect is undoubtedly an unpleasant and uncomfortable situation. The attachment to the modality could even go so far as to be an emotional one. Of course, the power of choice will always lie with the therapist. It is my hope that the ethical core of the therapist will make the right choice and that our profession will accept what good science is showing us; for in doing so, we are using science to raise our own levels of integrity and the universal integrity of the profession. Each of us has a role to play, and we should not view ourselves as detached. The decision that each therapist makes will affect the profession as a whole.

To conclude, it is reasonable to deduce that the link between research, education, and professional ethics is strong. Examination of our ethical codes indicates that it is our responsibility to keep up to date with research findings and to apply them in our work. The decisions that we make as a profession—from every angle and by every participant, whether it be researchers, policymakers, educators, or therapists in practice—will have a significant influence on the true ethical barometer of our field.

 

Chunco has written a very good and convincing review of the issues and a call for ethical action in integrating the volume of massage research going on into our educational system and our daily practices. As she points out, we're all in this together, and history will record the outcomes for the practice of massage from how individual therapists choose to face our common challenge.

 

 

 

Metaphysical boundary collapse

Submitted by RST on Wed, 06/27/2012 - 14:01
Posted in

One of massage's biggest culture wars at present arises out of the dispute between monistic and dualistic philosophies. It has implications for how we practice with clients, and how we teach our students in our schools.

Although we're experiencing this culture war every day in our own field, this argument is centuries-old and is not limited to massage. Throughout human history, great minds have tried--and failed--to resolve it. I don't expect us to resolve it anytime soon, but we do need to resolve whether those of us on opposite sides of the philosophical divide can work together, or whether it divides us irreconcilably.

The argument goes back much further in history, but in the early 1800s, advances in the relatively new science of chemistry caused a seismic shift in the evolving field of medicine. As Siddhartha Mukherjee describes the experiment that shattered previous thought on dualism in health and medicine:

Early interactions between synthetic chemistry and medicine had largely been disappointing. Gideon Harvey, a seventeenth-century physician, had once called chemists the "most impudent, ignorant, flatulent, fleshy, and vainly boasting sort of mankind." The mutual scorn and animosity between the two disciplines had persisted. In 1849, August Hofmann, William Perkin's teacher at the Royal College, gloomily acknowledged the chasm between medicine and chemistry: "None of these compounds have, as yet, found their way into any of the appliances of life. We have not been able to use them...for curing disease."

But even Hofmann knew that the boundary between the synthetic world and the natural world was inevitably collapsing. In 1828, a Berlin scientist named Friedrich Wöhler had sparked a metaphysical storm in science by building ammonium cyanate, a plain, inorganic salt, and creating urea, a chemical typically produced by the kidneys.

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

This drawing shows a molecule of ammonium cyanate, a compound that doesn't come from living things. It's made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray (since this is a 2-D drawing of a 3-D molecule, one of the hydrogens is hidden behind a nitrogen, but it really is there, even though we can't see it in this arrangement);
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

Urea, a kind of waste product produced by the kidneys in many different species of living things, forms molecules that are made up of:

  • 2 nitrogen atoms, shown in blue;
  • 4 hydrogen atoms, shown in gray;
  • 1 carbon atom, shown in black; and
  • 1 oxygen atom, shown in red.

Source: modified from http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

These two very different substances, one found in living organisms and one not found in them at all, have exactly the same atoms in exactly the same amounts. The only difference is the arrangement of those atoms in 3D space.

 

 

Source: http://upload.wikimedia.org/wikipedia/commons/8/8c/Wohler_synthesis.gif accessed 27 June 2012

 

 

The Wöhler experiment--seemingly trivial--had enormous implications. Urea was a "natural" chemical, while its precursor was an inorganic salt. That a chemical produced by natural organisms could be derived so easily in a flask threatened to overturn the entire conception of living organisms: for centuries, the chemistry of living organisms was thought to be imbued with some mystical property, a vital essence that could not be duplicated in a laboratory--a theory called vitalism. Wöhler's experiment demolished vitalism. Organic and inorganic chemicals, he proved, were interchangeable. Biology was chemistry: perhaps even a human body was no different from a bag of busily reacting chemicals--a beaker with arms, legs, eyes, brain, and soul.

With vitalism dead, the extension of this logic to medicine was inevitable. If the chemicals of life could be synthesized in a laboratory, could they work on living systems? If biology and chemistry were so interchangeable, could a molecule concocted in a flask affect the inner workings of a biological organism?

--Siddhartha Mukherjee, The Emperor of All Maladies: A Biography of Cancer, Scribner 2010, p. 83.

 

In one way, Mukherjee is right--this experiment showed that the vitalistic claim that a distinction based on vital essence existed between living organisms and non-living things had no basis in material physical reality. By "dead", he means that its foundation was shown to be false, and that there was therefore no basis to continue to use it as a basis for explanations in medicine or science. His usage refers to the "referent" part of the Semantic Triangle--no referent means no vitalism.

But in another sense, he's prematurely pronouncing it dead. There are still many people who believe in vitalism and dualism, not only in their own personal belief systems, but also by bringing dualistic concepts such as "spirit" and "energy healing" into the therapeutic encounter. The fact that there is no material physical referent in support of the idea does not prevent them from operating in the "concept" and "terms" part of the Semantic Triangle.

Whoever wrote the Wikipedia article on vitalism correctly observed that vitalism didn't disappear just because of that one experiment:

The concept of vitalism in chemistry can be traced back to Jöns Jakob Berzelius who suggested that in the division of organic and inorganic that a mysterious vital force exists in organic compounds.

Vitalism played a pivotal role in the history of chemistry since it gave rise to the basic distinction between organic and inorganic substances, following Aristotle's distinction between the mineral kingdom and the animal and vegetative kingdoms. The basic premise was that organic materials differed from inorganic materials fundamentally; accordingly, vitalist chemists predicted that organic materials could not be synthesized from inorganic components. However, as chemical techniques advanced, Friedrich Wöhler synthesised urea from inorganic components in 1828.

Further discoveries continued to marginalise need for a "vital force" explanation as more and more life processes came to be described in chemical or physical terms. However, contemporary accounts do not support the common belief that vitalism died when Wöhler made urea. This Wöhler Myth, as historian of science Peter J. Ramberg called it, originated from a popular history of chemistry published in 1931, which, "ignoring all pretense of historical accuracy, turned Wöhler into a crusader who made attempt after attempt to synthesize a natural product that would refute vitalism and lift the veil of ignorance, until 'one afternoon the miracle happened'". However, in 1845, Adolph Kolbe succeeded in making acetic acid from inorganic compounds, and in the 1850s, Marcellin Berthelot repeated this feat for numerous organic compounds. In retrospect, Wöhler's work was the beginning of the end of Berzelius's vitalist hypothesis, but only in retrospect, as Ramberg had shown.

In fact, some of the greatest scientific minds of the time continued to investigate the possibility of vital properties. Louis Pasteur, shortly after his famous rebuttal of spontaneous generation, performed several experiments that he felt supported the vital concepts of life. According to Bechtel, Pasteur "fitted fermentation into a more general programme describing special reactions that only occur in living organisms. These are irreducibly vital phenomena." In 1858, Pasteur showed that fermentation only occurs when living cells are present and, that fermentation only occurs in the absence of oxygen; he was thus led to describe fermentation as 'life without air'. Rejecting the claims of Berzelius, Liebig, Traube and others that fermentation resulted from chemical agents or catalysts within cells, he concluded that fermentation was a "vital action".

 

but he/she ends the chemistry section rather abruptly with Pasteur, rather than following through continuously to the present. This, too, is premature--vitalistic thought persists to this day. The developments in chemistry and other sciences that--among people who are familiar with the subject--convinced them that vitalism is no longer a compelling alternative explanation.

I think this overlooks a great number of people who aspire to be healthcare professionals, but who have not had access to an in-depth scientific and biomedical ethics education.

The issue of vitalism/dualism in MT is a huge issue for us. To continue to insist on vitalistic mechanisms as explanations is an obstacle to integration with other members of the healthcare team in fields that have long ago accepted the scientific consensus that--as a source of explanation in the lab and in the clinic--vitalism is dead.

And it directly contradicts established consensus of what belongs in an MT body of knowledge. As we've seen, vitalism contradicts chemistry and pharmacology.

Yet MTs are expected to know basic principles of pharmacology in order to practice.

The Massage Therapy Body of Knowledge (MTBoK) calls for the following required knowledge:

Pharmacology

  • General classification and types of drugs, herbs, supplements, their effects and their side effects.
  • Massage therapy considerations and potential responses to general classes of drugs, herbs and supplements.
  • Use of authoritative, medically accepted drug reference to look up drugs, their effects and their side effects.

--MTBoK, p. 18

 

while the Massage and Bodywork Licensing Examination (MBLEX) states the following expectations:

PATHOLOGY, CONTRAINDICATIONS, AREAS OF CAUTION, SPECIAL POPULATIONS (13%)
...

E. Classes of medications

--Massage and Bodywork Licensing Examination Candidate Handbook, Content Outline, p. 15

 

and the National Certification Exam in Therapeutic Massage and Bodywork/National Certification Exam in Therapeutic Massage lists the following topics:

III. Pathology (13%)

...

L. Drug interactions with massage/bodywork
1. medications (e.g., prescription; over-thecounter)
2. recreational drugs (e.g., tobacco; alcohol)
3. herbs
4. natural supplements

--NCETMB/NCETM Candidate Handbook, pp. 21, 23

 

and yet, at the same time, they require vitalistic concepts on the very same test--concepts that directly contradict the science on which these learning expectations are based.

This puts our students in an impossible position for learning, when one set of expectations directly contradicts another, as well as putting the teachers and schools in the position of being required to teach mutually contradictory information, and to assess students on how well they perform the impossible task of integrating that knowledge.

We need to figure out what this means to us as a community and as a developing profession. As Mukherjee observes, the metaphysical boundary collapsed a century and a half ago, but not all of us have quite gotten word of the collapse yet.

We need to address, at the very least (there may be even more issues that I have overlooked here):

  • how do we balance ethical standards and best practices in the client's interests in the therapeutic encounter with the practitioner's freedom of conscience?
  • how do we--schools, teachers, mentors--provide an education to our MT students that prepares them to build bridges to integration with other members of the biomedical healthcare team?
  • what do we do about the sunk costs in the previous unsustainable path, and the tremendous investment that it will require for us to practice as an integrated healthcare profession?

 

Source: The 7 November 1940 collapse of the Tacoma Narrows suspension bridge, http://upload.wikimedia.org/wikipedia/en/5/5c/TacomaNarrowsBridgeCollapse_in_color.jpg accessed 27 June 2012

Foundational concepts: Abstraction/abstract and concrete

Submitted by RST on Fri, 05/18/2012 - 00:38
Posted in

"Abstract" has two important meanings in research literacy.

One meaning is a short summary of a research article; we'll explore the abstracts of research articles in more depth in Chapter 13: Reading massage research--The Abstract.

The meaning that is important to us here and now is "abstract" as a property, or quality, or aspect of things after they have gone through a process of abstraction. "Concrete" is the opposite of "abstract" in this sense.

The process of abstraction means concentrating on what things have in common with each other, and classifying them on that basis.

Wikipedia has a good example, proceeding from more abstract to less abstract (and, in that way, proceeding from less concrete to more concrete):

Thus something as simple as a newspaper might be specified to six levels, as in Douglas Hofstadter's illustration of that ambiguity, with a progression from abstract to concrete in Gödel, Escher, Bach (1979):

  (1) a publication

    (2) a newspaper

      (3) The San Francisco Chronicle

        (4) the May 18 edition of the The San Francisco Chronicle

          (5) my copy of the May 18 edition of the The San Francisco Chronicle

            (6) my copy of the May 18 edition of the The San Francisco Chronicle as it was when I first picked it up (as contrasted with my copy as it was a few days later: in my fireplace, burning)

 

In a healthcare context, you could abstract from "Miguel's kidney"--a concrete, tangible object that you can actually hold in your hand--to the class (like a set) of human kidneys, of which Miguel's kidney is one of many.

Source: http://keyhealthcareblog.com/wp-content/uploads/2011/09/kidney-transplant-small.jpg accessed 18 May 2012

 

All of those human kidneys have a lot of structural and functional things in common with Miguel's kidney, which makes them all members of the abstract class "human kidney".

Although they have lots of differences too, it's the similarities we focus on in the process of abstraction--they are "kidney-bean" shaped; they are composed of a medulla and a cortex, they are located retroperitoneally in the abdominal cavity, and they are part of the human urinary system, among many other qualities they share.

So while you can hold Miguel's concrete kidney in your hand, and it may have unique qualities of its own--larger or smaller than usual, perhaps suffering from some kind of condition or disease--it also shares common or universal qualities with other member of the class of "human kidney".

We can continue to perform abstraction: if we take away the description requirement that it has to be in a human, we can abstract from Miguel's kidney to the abstract class "Mammalian kidney", whose members have many of the same qualities as each other.

Source: A walrus kidney, one member of the abstract class "Mammalian kidney", http://cvmbsresearch.files.wordpress.com/2010/06/2091.jpg accessed 18 May 2012

 

If we take away the requirement that it has to be located retroperitoneally in the abdominal cavity, and that it has to be kidney-bean-shaped, then we can bring in the fishes whose kidneys migrate during develoment to a position near their heads. Then we can abstract even further, all the way from Miguel's kidney to the abstract class "Vertebrate kidney".

Source: Fish kidneys, members of the abstract class "Vertebrate kidneys", http://australianmuseum.net.au/Uploads/Images/13770/dissection8_big.jpg accessed 18 May 2012

 

The members of this class also have many of the same qualities, although they have fewer of those, and are more different from each other, than the members of the class "Mammalian kidney". In turn, members of the class "Mammalian kidney" are more diverse than are the members of the class "Human kidney".

The more abstract a class is, the less all the members have in common with each other, and the more they vary from one another. Still, they all have a certain foundational similarity that is the basis for their membership in the class.

What is the purpose of this kind of classification and abstraction? Based on their similarity, we can talk about things that are universal ("kidneys in animals filter urine"), rather than being constrained to only the concrete ("Miguel's kidney filters urine") and nothing more.

So, since research studies are carried out on individuals, rather than being able to say only "massage reduces anxiety in 25 selected elderly residents of a long-term care facility", we can--if the research is carried out in a methodologically sound fashion--use those similarities that connect members of a class ("elderly residents of a long-term care facility") to use that abstraction to reason about the validity of applying those results to other members of that class.

That abstraction is at the heart of how we can carry out a study on a sampling of a population, and--if the study's methods are sound--use the outcomes from that sample population to reason that, because the sample has things in common with the larger abstract class, that we would expect to see those results in the larger class, or population.

It makes possible the change from "this treatment worked on this one small group of people and that's all we can say" to "because this treatment worked on this one small group of people, we expect it will work in a similar fashion on the larger population that this small group has characteristics in common with".

Puffin Abstraction

Source: Puffin Abstraction, photographed by Tim Ford. A tufted puffin at the Point Defiance Zoo and Aquarium in Tacoma, Washington, USA. accessed 17 May 2012

 

 

It's not just us it's happening to

Submitted by RST on Thu, 05/17/2012 - 13:24
Posted in

I had the privilege of studying with the anatomist Cornelius Rosse, one of the co-authors of the article that I'm about to introduce, while I was in grad school. A brilliant researcher, he also won the medical school's "Distinguished Teacher" award so many years that they had to retire him from eligibility to give others a chance at it.

Anyway, with all the upheaval and the resulting moral distress going on in the massage world about the state of our education, and how we've not always been taught correct facts, I remembered an excellent article that Rosse had co-authored some time back.

The team decided to go back and investigate a "fact" about cranial nerves that anatomists had taught--and had been taught by those before them--literally for centuries. This "fact" has been recorded in generations of anatomy books as well.

I can only include the reference and abstract here, since it's behind a paywall:

Lachman N, Acland RD, Rosse C. Anatomical evidence for the absence of a morphologically distinct cranial root of the accessory nerve in man. Clin Anat. 2002 Jan;15(1):4-10. PMID: 11835537 (if you or your institution do have access behind the paywall, here's the link.)

The accessory nerve is conventionally described as having a cranial and spinal root. According to standard descriptions the cranial root (or part) is formed by rootlets that emerge from the medulla between the olive and the inferior cerebellar peduncle. These rootlets are considered to join the spinal root, travel with it briefly, then separate within the jugular foramen to become part of the vagus nerve. In 15 fresh specimens we exposed the posterior cranial fossa with a coronal cut through the foramen magnum and explored the course of each posterior medullary rootlet (PMR) arising from within the retro-olivary groove. We chose the caudal end of the olive as the landmark for the caudal end of the medulla. In all specimens every PMR that did not contribute to the glossopharyngeal nerve joined the vagus nerve at the jugular foramen. The distance between the caudal limit of the olive and the origin of the most caudal PMR that contributed to the vagus nerve ranged from 1-21 mm (mean = 8.8 mm). All rootlets that joined the accessory nerve arose caudal to the olive. The distance from the caudal limit of the olive and the most rostral accessory rootlet ranged from 1-15 mm (mean = 5.4 mm). We were unable to demonstrate any connection between the accessory and vagus nerves within the jugular foramen. Our findings indicate that the accessory nerve has no cranial root; it consists only of the structure hitherto referred to as its spinal root.

 

but what is freely available is an editorial comment on the article from the very same issue of the journal.

 

It's hard to read in the graphic, so here's the text (emphasis added):

Carmichael SW. The accessory nerve clarified. Clin Anat. 2002 Jan;15(1):1. PMID: 11835535

The Accessory Nerve Clarified

On page 4 of this issue, Lachman, Acland, and Rosse shed startling light upon an anatomic relationship which for years has seemed established fact. We were all taught that cranial nerve XI has a spinal root and a cranial root, the latter having some relationship with the vagus nerve. Furthermore, we faithfully passed this information along in our teaching, even if occasional observations in the dissecting laboratory did not exactly correspond to the facts. Lachman et al. [and the other members of the team] have performed meticulous dissections, carefully observed, and convincingly demonstrated that the former cranial root of XI should be considered part of the vagus nerve and not part of the accessory nerve.

Misrepresentation of the anatomy of the accessory nerve has had an interesting history. Early anatomists correctly described its anatomy; however, in 1838, Arnold identified it as having a spinal and cranial root. This inaccuracy was perpetuated by Gray in his Anatomy (1858) and by many anatomists since. Dalley, in his Glimpse of Our Past article (page 2-3), describes how Willis also misinterpreted the anatomy of the accessory nerve.

Lachman et al. offer explanation as to how this misperception may have occurred. They suggest, for example, that because the brainstem and upper spinal cord are usually approached from above during dissection, the anatomy of the accessory nerve may not have been as clearly exposed as when they approached from a posterior direction. To compound matters, the arachnoid mater can cling to the nerve roots and obscure the anatomy. Lachman et al. also argue that a cranial nerve needs to have a contribution from the brainstem, and thereby question the designation of the accessory nerve as such in light of their findings. However, the accessory nerve does exit through a foramen in the cranium and, therefore, I believe we should continue to regard it as a cranial nerve, notwithstanding its exclusive origin from cervical spinal cord segments.

Lachman et al. have taught us a simple but extremely valuable lesson as to how to resolve discrepancies in gross anatomy: consult the final authority, the human body itself. This seminal article brings our understanding full circle.

Stephen W. Carmichael, Editor-in-Chief, Mayo Clinic, Rochester, Minnesota

 

It's never easy or fun to admit we've made a mistake (or many), and the sheer amount of work needed to do to correct the mistakes in massage education can feel overwhelming.

But Rosse and his co-authors model the way to do it:

  1. consult the final authority--the human body itself--to get the correct information via empirical evidence;
  2. no blame, no shame--identify the problem and how it occurred to understand how to avoid similar problems in future, but don't spend precious time on recriminations;
  3. publish and otherwise disseminate the correct information to reach as wide an audience as possible.

It's going to be a lot of work, but we're in this together. And not just us MTs; other healthcare fields are re-examining their assumptions as evidence indicates the need to do so.

Let's resolve to fix things, keep going by putting one foot in front of the other, and build bridges to those others who are also on the same journey as we are.

 


Source: Cranial nerves accessed 17 May 2012

 

 

Hands-on experiential learning: Qualitative evaluation project--Interviewing people about what massage means to them

Submitted by RST on Sun, 05/06/2012 - 11:10
Posted in

Introduction

This exercise asks you to collect and record data about the personal and unique meanings that people take from massage.

The purpose is to give you the experience of conducting qualitative research on a very small scale, so that from it, you get a sense of how researchers design and carry out studies to investigate a particular research question.

We're going to use an ethnographic interview, which is a qualitative research method. It's a way of interviewing people, usually one-on-one, to find out basic facts about their lives, how they understand the world around them, and possibly such things as what meaning they derive from it.

 

Designing your project

The research design for this project is fairly straightforward:

Decide on 2 or 3 people whom you would like to interview to learn what they think about massage, and what their experience with massage is.

Decide on the setting where you would like to interview them--invite them to your place, drop by theirs, invite them out for coffee, or whatever other setting works well for you to ask questions and note down their answers.

Invite people to participate in your study. Two or three is enough for this, as it is really a demo more than it is an actual project.

Make sure that before you interview anyone, they have signed and given you a copy of the consent form later in this post.

Meet them for the interview, and record their answers to your questions.

Write up their answers to your questions, and--making sure you observe accepted practices of confidentiality--tell us in the comments below what you wanted to explore, what questions you asked in order to explore that, what their answers are, what you think their answers tell you about the meaning they take from massage, and anything else about the process that strikes you as worth mentioning.

 

Primum non nocere--First, do no harm.

 

Remember that, as a healthcare professional and as a researcher--even in an exercise as small-scale as this one--you have a responsibility and a duty above all to protect the identities of the people you interview.

Before you share information with the rest of us in the POEM community, make sure that you have removed or shielded any information that would help people to figure out the identity of the people you interview.

Perhaps the most obvious thing to do first is to make sure you don't use someone's real name. But by itself, that may not be enough to protect the identity of your participants.

Consider, for example, the following description:

"Mary", an MT originally from Alabama who now lives in the Seattle area, and who speaks Cambodian and works with refugee clients...

 

That description is specific enough for people who know me to figure out that "Mary" is really me; changing the name was not enough to hide that fact.

Consider changing the sex and age of your participants, as well as any other relevant demographic characteristics, that will protect their identity. In a context where it doesn't affect the meaning of the results, a 27-year-old man can become a 50-year-old woman, if necessary for the sake of protecting confidentiality in a research project.

Change details in the interviews that don't affect the meaning of the answers your participants provide. For example, with 1684 residents, Oshoto, WY is small enough that people from there might know each other well enough to recognize each other's stories. So if I interviewed someone who said something like "When I was growing up in Oshoto, ...", then I would either change the name of the town, or I would remove it altogether and just report the person said "When I was growing up, ...".

Although your sample size in this exercise is so small that this may not be practical here, for future projects you might combine two or more people into a composite character, whose identity can't be guessed because that single individual doesn't exist.

 

Does this changing of facts feel somehow deceptive--enough so that you're wondering about the ethics of it all? If you're new to qualitative research, and it does feel that way, then that's a good thing, because it means that you're integrating previous ethical principles with what you're learning now about research, and you're pushing at the boundaries of what you know.

You're right that integrity is at the core of research, and--although this can feel somewhat deceptive--this way of protecting your participants is squarely at the heart of research integrity.

First of all, you are doing it to protect your participants--they do not need to fear embarrassment, financial consequences, or worse, because they shared information with you. Your focus is on the information itself; nothing will happen to the participants as a result of giving you their answers to your questions.

Second, you will be faithful in the information you provide. You will not make up characters that do not exist at all, and you will not make up answers or information that someone did not share with you.

You are not changing the heart of the content of the answers. Changing someone's birthplace from Oshoto, WY to Pinson, AL, for example, or leaving it out entirely, is a detail that does not substantively change what massage means to that person, which is what this exercise is about.

On the other hand, to totally invent a person who you didn't really interview, and then to report an answer that you made up as being from that person--that would be a major ethical breach of integrity. But you're not doing anything like that here--in changing the details of real people who really exist, and who really gave you those answers you are reporting, you're nowhere near that ethical lapse.

 

Think about how you are going to invite your participants to talk to you. You want this to be about them, not about their trying to please you by telling you what they think you want to hear, so give some thought to your questions before you sit down with them for an interview.

Closed-ended questions, where the person being interviewed has a limited set of responses to choose from--"yes" or "no" questions, for example--tend not to be as good for this purpose as open-ended questions.

"Do you think massage benefits you?" does not encourage someone to open up to you as "Tell me about what you think massage does for people."

Decide on the questions you want to ask, and think about what you will do if the discussion goes in very different ways from what you expect. Think about what you will be reporting in future, and keep that in mind as you are deciding on the questions you will ask.

 

Carrying out your project

Informed consent

A core foundational principle of research is that the person you're interviewing should be participating willingly, and should understand why they are participating. If that willingness changes, they are free to stop participating at any time they want to.

This consent form is based on the one available at this link.

You can paste this consent form into a document, and print out two copies--one for your interview participant to keep for themselves, and one to sign and give to you to keep.

 

Participant's Agreement

I am aware that my participation in this interview is voluntary.

If, for any reason, at any time, I wish to stop the interview, I may do so without having to give an explanation.

I understand the intent and purpose of this research, and I understand that I will be asked about my understanding and experiences of massage.

I understand that I am free to expand on the topic or talk about related ideas.

I also understand that if there are any questions I would rather not answer or that I do not feel comfortable answering, then I have the choice of stopping the interview or moving on to the next question, whichever I prefer.

I understand that the information I provide will be used in a general way for a group online discussion of how people understand and experience massage, and that my identity will be kept confidential. Only the interviewer will know my identity; none of the other participants in the discussion of the answers to the interview questions will be aware of who I am.

I have been offered a copy of this consent form that I may keep for my own reference.

I have read the above form and, with the understanding that I can withdraw at any time and for whatever reason, I consent to participate in today's interview.



_________________________________                       ___________________
Participant's signature                                         Date
 

_________________________________
Interviewer's signature
 

 

 

 

Reporting on your project

In the comments to this story, please share your findings, and outline your evaluation of the interview.

Tell us how you approached the task, and what your key findings were.

In addition, think about the kinds of quantitative data you'd like to collect to boost your qualitative findings--what are your qualitative findings, what other processes do they point to, and how would you use quantative methods to investigate those processes?

 

Information sources on ethnographic interviewing

Design4Instruction: The Ethnographic Interview accessed 6 May 2012

Ethnomed: "Collecting Ethnographic Data: The Ethnographic Interview" accessed 6 May 2012

Johns Hopkins Bloomberg School of Public Health Center for Refugee and Disaster Response (CRDR) publication: Training in Qualitative Research Methods for Private Voluntary Organizations and Non-Governmental Organizations accessed 6 May 2012

Sakai Project article: "Ethnographic Interviews - Interviewing and Observing Users" accessed 6 May 2012

Wikipedia article "Ethnography" accessed 6 May 2012

 

 

 

What is evidence?

Submitted by RST on Fri, 05/04/2012 - 16:00
Posted in

Extraordinary claims require extraordinary evidence.--Carl Sagan

 

The term “evidence” has slightly different shades of meaning, depending on who uses it and for what purpose.

For example, courts of law have very strict rules about what types of facts and findings constitute sufficient legal evidence to justify taking away a person's freedom in a criminal trial.

Social science disciplines such as anthropology, sociology, and history, which can't, for the most part, use controlled experiments, also use the term in ways particularly suited to their own fields.

Natural science disciplines such as biology, chemistry, and physics, have the ability, in many cases, to run controlled studies to test ideas, and the results of those studies add to their body of evidence.

For that reason, so that we can communicate with each other, and with clients, and with healthcare providers and other stakeholders of massage about what we do and don't know, it is very important to establish what evidence means in our contexts most deeply involved with massage. Let's do that by building on the work we have already done up to this point.

As we've discussed, a claim is a statement that proposes the existence of a relationship between a treatment and an outcome.

 

 

Until a claim is tested (validated) to determine how correct or incorrect it is, that claim is usually considered to be unvalidated, or neutral, unless there are other very good reasons to treat it differently.

Evidence, for our operational definition here at POEM, consists of the cumulative body of facts, data, or information that result when claims are tested empirically for their correctness or incorrectness in the material physical universe.

Sagan’s quote at the beginning of this section highlights the fact that we evaluate claims in that way within the whole integrated framework of our cumulative shared existing knowledge.

For example, if someone made a claim that

massage lowers high blood pressure in heart patients with dangerously high blood pressure

 

that claim would not be considered particularly extraordinary, because there is already a body of evidence supporting the idea that massage lowers blood pressure in people with a variety of conditions.

This new claim fits with what has already been tested and demonstrated on a number of occasions. So while this particular novel claim would still be treated as unvalidated until someone actually tests it to determine how well it reflects reality, it is not an especially extraordinary claim, in light of the existing evidence already available.

On the other hand, if someone were to make a claim such as

massage can cure rabies in children

 

that claim, in light of what is known both about massage and about infectious disease, would be quite extraordinary.

Rabies is a disease caused by a virus that attacks the brain, and without pharmacological treatment for infected victims before symptoms appear, it's virtually 100% fatal, with a great deal of pain and distress before death.

Source: http://upload.wikimedia.org/wikipedia/commons/9/9f/Middle_Ages_rabid_dog.jpg accessed 4 May 2012

 

To claim that a noninvasive treatment such as massage can cure a fatal viral brain disease would require overturning a great deal of existing knowledge about massage, microbiology, and how the material physical universe operates--meaning that much or all of the previous evidence gathered would have to be shown to have been in error all along.

To claim that would also be a clear statement that, to the claimer, massage has no intention of integrating with the shared body of knowledge of healthcare professions--to reject that body of knowledge as strongly and unambiguously as this claim does would present an obstacle to integration into a client-centered healthcare team, unified through that body of knowledge.

Of course, that only applies if it were really a serious claim, not just a made-up example, as this one is--but there are a large number of extraordinary claims routinely made about massage that present just such obstacles to integration, and we'll talk about them as they come up in the discussion.

The evidentiary burden (burden of proof) of this extraordinary claim is much higher than the previous one about blood pressure--not only does it have to demonstrate its own validity, but it also has to account for why so many observers have been wrong about so many other interconnected questions over so many centuries.

This rarely happens in science, and when it does happen, it is almost always in domains that are new and still poorly understood--"frontier science", as it's often called. And it's even rare in frontier science; what happens there much more often is that ideas that initially looked promising don't survive the scrutiny of thorough testing.

For something that we already understand as well as we understand infectious disease, we don't need to take this particular claim seriously. We are justified in rejecting the claim "massage cures rabies in children" without doing the work of subjecting it to rigorous clinical trials before we make up our minds.

Multiple lines of evidence across many centuries in many places around the world have produced a body of evidence that is very strong, and the claim has such a huge evidentiary burden to overcome to replace all that evidence, that it is extremely unlikely--effectively impossible--that the claim will meet its burden of proof.

For more thoroughly studied areas of inquiry--what's often called "textbook science" or "consensus science"--the more typical outcome resembles the results of Einstein’s theories of relativity.

Although his ideas drastically changed how we view the universe, they did not actually replace previous knowledge so much as build a whole new area of knowledge on top of it—much like how adding a jet engine to a skateboard would radically change what the skateboard would be able to do but would not change what we already know about ordinary skateboards.

 

Source: http://www.youtube.com/watch?v=LPnHr_SxkRU accessed 4 May 2012

 

Of course, scientists never say "never"--there can be very, very high levels of confidence in a claim, but there is never absolute certainty.

One day, extraordinary evidence might conceivably be gathered that would support some particular extraordinary claim--but to do so will always be a very tall order, in light of what the body of existing evidence and knowledge indicates.

Science is almost never a totally all-or-nothing proposition; rather, it all comes down to the overall strength of the facts taken in combination and how well this combination supports--or does not support--a given claim.

In this way, judging what counts as evidence is not only a function of how valid each single piece of evidence might be, but it is also a function of how well each piece of evidence fits with every other piece.

Scientific knowledge is considered provisional and contingent—it is always subject to being replaced later, if new and better evidence warrants the replacement. But until such a replacement occurs, any particular piece of scientific knowledge is considered to be good enough, for now--as long as the cumulative body of validated and shared evidence, built by a community of people working with a shared commitment to the integrity of the process, supports it.

(By "good enough", we mean only "good enough to meet the standard of evidence that we are comparing it to in the lack of absolute perfectly certain knowledge that we find ourselves having to operate in". We don't mean "good enough for the client" at all--one of the worst and most helpless feelings there is is to have to tell a suffering fellow human being "we truly don't know how to help you". In that sense, as long as people and animals are suffering in ways that we don't understand, our knowledge will never, ever be "good enough".)

 

 

The challenge of reconciling our mental models with the material physical universe: Top-down and bottom-up approaches

Submitted by RST on Wed, 05/02/2012 - 10:06
Posted in

A recurring theme that you'll find at POEM is how the practice of science is defined, in large measure, by its central value of seeking to avoid bias and by a collection of methods designed to assist scientists in avoiding bias when interpreting research results.

Even more than other methods for avoiding cognitive and logical traps, statistical measures are some of the most rigorous tools scientists have for providing clear frameworks for interpreting what the data from empirical observations and experiments actually mean.

To lay the foundation for discussing statistics in evaluating massage research, let's first talk about different approaches to the challenge of reconciling our mental models with the material physical world.

Data, information, facts, and truth

Data is a collection of factual information used as the basis for reasoning, discussion, or calculation. When a scientist talks about a fact that is rooted in research, they are referring to a piece of information that is being presented as objective reality.

Because that information is a fact, a scientist will often say "It is true that..." and then go on to state whatever that particular fact means.

It is easy for a casual listener to believe the scientist must be referring to absolute “Truth”, because of the way these words are commonly used in everyday conversation.

For example, the media may cover scientific topics in a way that implies that science points directly to “Truth” in the same way the term is used in philosophy or meaning-making and self-expression.

But this is not a faithful representation, because science—which deals only with aspects of the natural material physical universe—takes for granted that the measurement of things observed in the natural world contains a certain amount of error. By "error", we mean the Merriam-Webster dictionary meaning of "a variation in measurement, calculation, or observation due to mistakes or uncontrollable factors".

As we will discuss in Chapter 4 of the research literacy e-Book, it is impossible to observe or measure reality from a completely 100% neutral position, and there are no perfect measurement tools.

For this reason, scientists emphasize working in a way to obtain the best results possible, knowing that no observations of reality can be completely error-free.

There can be no achievement of absolute truth, just--if the process is carried out with integrity--getting closer and closer to what the facts are.

In order to work toward this goal, scientists have developed methods for managing observational errors, because those errors can be understood and controlled by making skillful choices about experimental design and statistical techniques.

The Semantic Triangle, introduced in Chapter 2 of the research literacy e-Book here at POEM and available later this month, shows how the elements of meaning can be divided among concepts (the meanings people attach to ideas), terms (the language used to describe ideas), and referents (the things in the natural world to which terms and concepts refer).

Source: http://sig.biostr.washington.edu/~raven/semantic-triangle.jpg accessed 2 May 2012

 

The big question is how to know—given that perceptions and experience vary so much from one person to another—that those concepts and terms in our minds really connect to the referents they claim to represent.

Sorting out how best to connect those internal aspects of meaning to the external physical world is an ongoing problem that challenges all of us.

Top-down vs. bottom-up approaches to data

One approach that has been taken throughout history is to decide in advance what the “truth” is, and then to look for empirically observed facts that will reinforce that “truth.”

This is known as the top-down approach, in which a researcher starts with a desired answer in mind and then fits the questions and the data into that answer.

Obviously, this approach implies a great deal of bias from the start.

Ptolemy, a Greek astronomer who lived in Egypt during the first and second centuries CE/AD, developed a model showing the sun and the planets in a circular orbit around the Earth. This model depicted the Earth at the center of everything, or geocentrism: a view that seemed at first to fit with what people observed when they looked up at the sky.

Source: http://upload.wikimedia.org/wikipedia/commons/7/7b/Bartolomeu_Velho_1568.jpg accessed 1 May 2012

 

But some careful observers noted that a planet such as Mars would sometimes be seen moving in its normal direction, but then it would come to a stop and begin to move in the opposite direction—backward across the sky—before returning to its expected path. It seemed to move in a retrograde way.

Source: http://upload.wikimedia.org/wikipedia/commons/6/6a/Retrograde_Motion.bjb.svg accessed 1 May 2012.

 

The left side of the drawing shows the Earth's actual motion around the sun in the blue points 1-5. Mars' actual motion around the sun is shown by the red points on the left of the diagram, and the right side of the diagram shows what Mars' motion looks like to an observer on the Earth. So there is no such thing as Mars (or Mercury, for that matter) in retrograde; it's actually an illusion produced by our motion relative to the other planet around the sun.

To reconcile this observation with the idea of the planets and sun making simple circles around the Earth, advocates for Ptolemaic astronomy used the concept of epicycles, or loops, that represented the additional movements of the planets. Epicycles were explained as looping paths that averaged out to simple circles. In the expanded Ptolemaic system, the planets and sun were continually looping around given points, which were themselves moving in simple perfect circles around the earth.

Source: http://upload.wikimedia.org/wikipedia/commons/2/29/Ptolemaic_elements.svg accessed 1 May 2012.

 

As in the previous image, Mars is shown in red, and Earth in blue. This is the model of epicycles introduced to account for what looked to observers on Earth to be retrograde motion.

Because of the observed referent (occasional apparent or seeming reversals in movement of the planets), it was necessary to add this new term and concept (epicycles) in order to hold onto and protect the Ptolemaic idea that something was moving in perfect circles around the earth. The advocates of Ptolemaic astronomy kept adding epicycles as necessary to force the model to fit the observations.

And for a very long time, despite the hacks and cobbled-together epicycle justifications, the Ptolemaic model continued to have a great influence on astronomy’s view of the Earth’s place in the universe, because there was not much change in the data available to observers.

But over time, new observational instruments such as telescopes were invented, and these made it possible to add new information to the accumulated body of knowledge about the sky.

Eventually, a tipping point was reached, and the weight of evidence made it clear that Ptolemy’s model of the universe no longer matched the observed facts.

A newer explanation, called the heliocentric model, was developed by Polish astronomer Nicolaus Copernicus (1473-1543) in which all the planets, including Earth, orbited around the sun.

Source: http://upload.wikimedia.org/wikipedia/commons/5/57/Heliocentric.jpg accessed 1 May 2012

 

Source: http://upload.wikimedia.org/wikipedia/commons/3/33/Geoz_wb_en.svg accessed 1 May 2012

 

A century later, Johannes Kepler introduced his laws of planetary motion, which demonstrated that the planets actually move in elliptical paths around the sun, not in perfect circles--a model which was an even better fit to the empirical data.

Those who insisted on retaining Ptolemy’s view of the universe, despite the growing evidence against it, were holding on to the top-down approach to data. They practiced apologetics, and used cherry-picking, special pleading, and other fallacious techniques, to protect their model from the challenge the material physical world confronted it with.

In contrast, the bottom-up approach of Copernicus and Kepler, who worked from the data to develop their conclusions, won out.

These new thinkers prevailed over the Ptolemaists because they were willing to let go of their previous beliefs (Kepler, in particular, was disappointed by the idea that planets moved in ellipses rather than in the perfect circular shapes he found so beautiful, but he followed his conscience in following the process where it led) and to let the data itself tell the story.

[Of course, by "prevailed", we never mean "100% accepted": there are, after all, modern-day adherents to the Flat Earth model in the incarnation of the Flat Earth society, just to name one example (Motto: "Replace the science religion...with SANITY.").

What we mean is that the majority of professionals, who have actually done the work to understand the domain, vouch for the work as having been carried out with integrity, and to be validated as showing the results it claims to demonstrate.]

Statistics is one methodology that we apply in a bottom-up approach to understand the meaning of the story that the data is telling us.

Exercise

Can you think of some real-life examples of where people try, or have tried, to protect an old model that has been discredited, despite the mounting evidence against it?

Areas where you might find examples nowadays include healthcare and politics, among others.

How far are some people prepared to go to protect old models?

What techniques do they use to do so?

What are the stakes--politically, psychologically, economically, and in other domains?

 

 

Mashup: The ethics of being honest about what we do and do not know

Submitted by RST on Wed, 05/02/2012 - 08:48
Posted in

When it comes to our ethical duties to be honest with clients and other stakeholders about what we really do and do not know, the AMTA, ABMP, NCBTMB, and MTBoK speak with one voice:

As a member of Associated Bodywork & Massage Professionals, I hereby pledge to abide by the ABMP Code of Ethics as outlined below.

Client Relationships

...

I shall maintain clear and honest communications with my clients...

I shall acknowledge the limitations of my skills...

...

Scope of Practice / Appropriate Techniques

...

I shall...represent my education, training, qualifications and abilities honestly.

I shall be thoroughly educated and understand the physiological effects of the specific massage, bodywork, somatic or skin care techniques utilized...

Image / Advertising Claims

...

I shall practice honesty in advertising...I shall not make false claims regarding the potential benefits of the techniques rendered.--ABMP Code of Ethics accessed 2 May 2012

 

This Code of Ethics is a summary statement of the standards of conduct that define ethical behavior for the massage therapist. Adherence to the Code is a prerequisite for admission to and continued membership in the American Massage Therapy Association (AMTA).

...

Rules of Ethics. The Rules of Ethics are mandatory and direct specific standards of minimally-acceptable professional conduct for all members of the association. The Rules of Ethics are enforceable for all association members, and any members who violate this Code shall be subject to disciplinary action.

Massage therapists/practitioners shall:

...

Be truthful in advertising and marketing, and refrain from misrepresenting his or her services, charges for services, credentials, training, experience, ability or results...

Refrain from using AMTA membership, including the AMTA name, logo or other intellectual property, or the member’s position, in any way that is unauthorized, improper or misleading...--AMTA Code of Ethics accessed 2 May 2012

 

NCBTMB certificants and applicants for certification shall act in a manner that justifies public trust and confidence, enhances the reputation of the profession, and safeguards the interest of individual clients. Certificants and applicants for certification will:

...

Represent their qualifications honestly, including education...

Accurately inform clients, other health care practitioners, and the public of the scope and limitations of their discipline.

Acknowledge the limitations of and contraindications for massage and bodywork...

...

Consistently maintain and improve professional knowledge and competence, striving for professional excellence through regular assessment of personal and professional strengths and weaknesses and through continued education training.

Conduct their business and professional activities with honesty and integrity...--NCBTMB Code of Ethics accessed 2 May 2012

 

...

- Be thoroughly familiar and operate with a rigorous code of ethics.

...
Operate under a professionally recognized code of ethics.
• Practice with competence and within the individual knowledge, skills and abilities and the legal limits of the massage therapy profession.

...
• Represent credentials and training honestly.--Massage Therapy Body of Knowledge accessed 2 May 2012

 

Source: http://www.ieet.org/images/uploads/025035ea6dbd328768e7b25c37f14057_thumb.jpg accessed 2 May 2012

The germ theory is too Western

Submitted by RST on Sat, 04/28/2012 - 13:04
Posted in

Laura Allen embodies the very ideas of transparency and accountability when she says that anyone is free to quote anything she says anytime and anywhere, and I believe I'll take her up on that.

Over on her Facebook account, which you may or may not be able to see unless you're already friends with her, she writes:

It's a concern to me that three times in the past couple of days, I have seen stories on here about employers who don't want the massage therapists to change the sheets for every client. That is so unethical, not to mention a health hazard. If you are working in such a place I suggest getting out immediately and reporting the owners to the massage board AND the health board. As one person said to the owner who was mad about her changing the sheets, would you want to check into a hotel and sleep on the sheets the last person used? I don't think so. And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.

 

Clear, concise, and correct. And if the guilty owner was reading the post, they didn't choose that hill to (metaphorically) die on; Laura's commenters were 100% supportive of the bright shining biomedical and ethical line in the sand that she drew.

It occurred to me that there could be correlation between the type of massage practiced and its underlying conceptual model, with the degree of sanitation and hygienic practices adhered to.

For example, if you truly believe that disease is caused by a bad wind entering the body, or by negative thinking, or by karma, then that's not really much of a motivation for paying attention to getting rid of germs on surfaces.

And an interesting followup question is, if you do believe in one of those conceptual models, and you are scrupulously diligent about observing good hygiene, then why do you go to that trouble?

I mentioned that that would be a fascinating study that I would probably never get around to carrying out, but if someone else did, I would love to read about it.

Well, ask and you shall receive, I guess.

One of Laura's commenters told a story from her own experience, that is a perfect case study of the correlation I was thinking about:

I had an MT friend who worked in a chiro's office and he reused disposable acupuncture needles. He was quite careless with them and they'd often fall on the carpet where you wouldn't notice them until you got off the table, barefoot, and get one in your foot. When the MTs in his office complained, he waved them off for being too "Western." In China, they reuse needles from person to person. At least, he bragged, he only reused them on the same person. Eventually he agreed not to do acupuncture in the massage rooms so massage clients didn't get stuck by stray needles. Sheesh.

 

/facepalm

There are so many issues here, that it's difficult to know where to start.

Disease transmission by infected reused needles, or Hygiene 101, is only the first one.

To get back to our topic from needles, I'm sure the POEM commenters can name several conditions that can be passed from one person to another by dirty bed linen.

Sources: Left: http://www.stanford.edu/class/humbio103/ParaSites2004/Scabies/scabies.jpg accessed 29 April 2012, Right: http://www.stanford.edu/class/humbio103/ParaSites2004/Scabies/scabies1.jpg accessed 29 April 2012

 

And although this may come as news to the chiropractor in the story, in resource-poor areas of the world, they don't share needles because they *want* to; they do it because they have no other options.

Every time something like that reinforces the perception of MTs as elitist, classist, ethnocentric, and generally oblivious, it just makes more work for the rest of us to dismantle that perception.

So here we go, gradually chipping away at it:

First of all, the session is about what the client wants and needs, not about forcing the client--with or without full disclosure and informed consent--to settle for what people in resource-poor environments are compelled to make do with. The chiropractor in the study is not practicing in a client-centered way; his practice is centered on something else, where infection control is not a priority.

Second, in chiding others for being "too 'Western'", he probably sees himself as all diversity-oriented, and transcending elitism and ethnocentrism.

Nothing could be further from the truth.

He is claiming, in effect, that Chinese people don't value their own lives and bodily integrity enough to care about basic biomedical best practices. Where he got the idea that he gets to speak for them is unclear, but his claim positively advocates poorer medical care based on nationality and ethnicity.

This violates Ethics 101 in a big way.

If Chinese people do reuse needles, what could be the explanation?

Unlike the chiropractor in the story above, who implies they are choosing to do so when they have better options, I think that looking at the availability of resources is a useful source for possible explanations.

According to the Wikipedia article "List of countries by GDP (nominal) per capita", the US per capita annual income ranges (depending on the reporting source) from $47,153-48,387.

The per capita annual income in China ranges (depending on the reporting source) from $4,428-5,414.

The per capita annual income in Ethiopia ranges (depending on the reporting source) from $300-360.

I'll leave as an exercise for the readers to evaluate whether Chinese people and Ethiopian people reuse acupuncture and injection needles because:

  • they don't care about their own lives and health, or about each other, and consider infection control "too 'Western'", or whether
  • unused needles are much harder to come by in environments where the average person earns 11% (China) or 0.007% (Ethiopia) of what the average American earns.

 

 

 

And if you consider it a do-or-die cost issue--if your business, in the US context, is so iffy that you need to operate it in the American context with Chinese or Ethiopian standards of practice and margins on clean linens, unused acupuncture needles, or any other compromise on infection-control best practice, then your business is not dying.

It is already dead, and you just haven't acknowledged the fact. If you cannot afford to practice infection control, it's over. Deader than the parrot in the Monty Python sketch.

 

I'll heartily second Laura's recommendation:

And if the guilty owner happens to be reading this, do us all a favor and get the hell out of this business.

 

and I'll add some of my own.

Recommendations for educators:

  • The history of massage is an important thing for students to know about, but infection-control trumps it every time.
  • If you don't have time in the curriculum to teach both about how people used to believe humors or bad winds caused disease, AND what we know now about how to prevent infection in a massage therapy practice, so that the students not only rotely deliver the correct answer on tests, but really show that they understand and can apply it in context, then the curriculum resources have to be devoted to infection control at the expense of pre-modern concepts of illness and disease.

 

Recommendations for students and practicing MTs:

  • Check to see if your school is teaching (or did teach, if you've graduated) proper infection-control practices.
  • Make sure that you know how to protect clients by reporting unethical and unsafe practices to the correct regulatory authorities in your area.
  • If not, make sure that you get all that information somewhere else, and use it in your practice--it's just that important.

 

Recommendations for clients:

  • The time in a session is time that you have paid for, and you should not feel hesitant to ask questions about the care or service you are receiving.
  • A client-centered healthcare professional will be happy to answer any questions you may have. Hospitals in the US, UK, and elsewhere are now actively promoting campaigns (as shown in the buttons below) to ask your provider whether they've washed their hands before examining you. MTs who want to be part of an integrated healthcare team will not balk at following the same infection-control best practices as other members of that healthcare team.
  • Don't hesitate to ask what infection-control procedures your MT uses.
  • When you are getting on the massage table, take a moment to look at the linens you will be lying on--do they look clean and unused, or do they appear to be re-used?
  • How many layers of linens are on the table? If it's more than one, the establishment may be cutting corners by stacking sheets to save time between clients. The problem with stacking sheets is that mere layering will not prevent transmissible conditions from crossing those layers. Don't accept sheet-stacking from your MT; insist on a single layer of clean and unused linens every single time. This is your time and your care; it is reasonable that you expect it to be conducted in a way that looks out for your best interests.

 

Sources: Left: http://www.jcrinc.com/Common/Images/custom/products/HHB-05.jpg accessed 29 April 2012; Center and Right: http://www.healthcareinspirations.com/hci_fe03_single_quantity.html?&prodid=513 accessed 29 April 2012

 

These are steps we can take, and encourage our clients to take, to show that we are serious about developing into a healthcare profession that will accept the responsibility of self-regulation and client protection that comes along with that status.

Syndicate content