MLN Vol. 15, No.3

Massage Law Newsletter

Vol. 15, No. 3                      ISSN 1073-5461                        October 2000

 ARE PAYMENTS TO REGISTERED MASSAGE THERAPISTS IN BRITISH COLUMBIA, UNDER THE MEDICAL SERVICES PLAN, COST-EFFECTIVE? IF NOT, SHOULD THESE PAYMENTS BE DISCONTINUED?

To: The President. College of   Massage

Therapists of British Columbia (CMTBC)

From:  Albert Schatz, Editor

It is obviously advantageous for Registered Massage Therapists (RMTs), in British Columbia, to have the Medical Services Plan pay them for their services. But is there well-documented evidence that these payments are cost effective?

If CMTBC is aware of such well-documented evidence, please tell me what that evidence is, and give me permission to publish your reply (with that evidence) in the Massage Law Newsletter.

If there is no such well-documented evidence, why should the Medical Services Plan continue paying RMTs in British Columbia?

In this report, the term "treatment" refers to treatment by RMTs. The terms "patient" and "patients" denote people whom doctors refer to RMTs for treatment.

The term "patient population" refers to patients for whose treatment the Medical Services Plan in British Columbia and insurance companies in the province of Ontario pay RMTs. Ontario has no governmental agency equivalent to the Medical Services Plan in British Columbia..

To determine whether those payments are cost-effective, it is necessary to compare the costs and benefits  of treatment by RMTs in British Columbia and Ontario.

For this comparison, it is necessary to have the following information for a period of at least two and preferably three years.

How many RMTs  are in each province and how many people are in the patient population in each province?

What does treatment by RMTs

 cost in each province?

1. What does the Medical Services Plan pay and what is the average amount of money that insurance companies in Ontario pay for each treatment?

2. What is the average number of treatments  a patient receives every time he is referred for treatment, in each province?

3. What is the total amount of money that the Medical Services Plan pays and that insurance companies in Ontario pay for the average number of treatments a patient receives every time he is referred for treatment?

4. Are the costs of treatment (in the above-mentioned questions 1 and 3) in British Columbia more than, less than, or about the same as the corresponding costs in Ontario?

Are the payments to RMTs in British

Columbia cost-effective?

1. How many days after treatment do patients (who have been out of work because of pain and incapacitation) go back to work, in each province?

2. Massage  is not always an effective treatment for all patients with the problems to which Peter Behr refers on the following pages. Therefore, in what percent of patients have RMTs' treatments been ineffective in each province?

 

3. What percent of patients are harmed by  the treatments RMTs provide, in each province?

4. How much money does the Medical Services Plan pay and do insurance companies in Ontario pay RMTs for treatments of patients who have been harmed by RMTs?

HOW MUCH IATROGENIC HARM IS CAUSED BY REGISTERED MASSAGE THERAPY IN         BRITISH COLUMBIA?

 Here's freedom to him who would read.

Here's freedom to him who would write.

There's none ever feared

 that the truth should be heard,

But they whom the truth would indite.

Robert Burns

Scottish poet, 1751-1796)

PART 1: UNREGULATED MASSAGE DOES NOT HAVE "A SIGNIFICANT RISK OF HARM"

The February, 1999, "Preliminary Report" of the Health Professions Council on the "Massage Therapists Scope of Practice," states, "There is no evidence that microtearing, bruising and inflammation are a widespread problem or a serious consequence of unregulated massage. The College" of Massage Therapists of British Columbia (CMTBC)] "has provided no literature or scientific studies to show objective evidence of a significant risk of harm."

Unregulated massage therapists in British Columbia do not get referrals from doctors, and are not compensated by the Medical Service Plan. Registered Massage Therapists (RMTs) get referrals from doctors and are compensated by the Medical Service Plan.

PART 2: MICROTEARING IS

 IATROGENIC HARM

A microtear of tissue may occur in the course of our day-to-day activities when we put more stress on our musculoskeletal system than it can normally accommodate. When that happens, we may injure the tissue of a joint by microtearing. This is usually not serious, and uneventful recovery usually occurs if we do not aggravate the injury.

But massaging people with serious musculo-skseletal problems, such as those to which Peter Behr refers (below), may entail a serious risk of harm because of the nature of the patients's problem and the amount of biomechanical force the RMT applies.

 Tearing tissues can cause serious

iatrogenic harm

When RMTs tear an individual's tissue, they are causing harm, and the consequences of that harm may be serious. Information (about those   serious consequences) is in CMTBC's "Supplemental Response to the Health Profession Council's February 1999 Preliminary Report on the Massage Therapists Scope of Practice." CMTBC filed this Submission on November 17,1999. The following information about those serious consequences is quoted from '"A Physician's Guide to Therapeutic Massage" (2nd edition), in which Dr. Yates wrote:

"Where the treatment involves sufficient biomechanical force to alter tissue structure, significant damage may be done to vulnerable tissues. The occurrence following treatment of pain, bruising, and inflammation in particular are indicators that the treatment has exceeded tissue tolerance and tissue damage has occurred.  There is real risk that such damage may not be trivial, that the presenting condition has been exacerbated, and that significant and lasting harm has been done and an otherwise treatable condition may have become chronic or disabling."

These serious consequences of excessive biomechanical force are iatrogenic harm.

Common sense tells us that Dr. Yates would not have cautioned practitioners about these serious kinds of harm unless they have actually occurred in a significant number of patients.  

PART 2: PETER BEHR'S COMMENTS ON THE NEED TO TEAR TISSUE 

Peter Behr is a RMT in Powell River, British Columbia. In CMTBC's July 28,1998, Submission, Behr reported that "Over 90% of my patients are referred by physicians." And "Typically, I give 40-50 treatment a week."

On June 8, 1999, Behr (who was then President of CMTBC) testified at a "Scope of Practice Hearing for the Profession of Massage Therapy" (for the Health Professions Council). At this hearing, Behr said, "When I started, I was getting more kind of just backaches and neck aches and then, over the 20 years that I've been in practice, the doctors have trusted me more with more complicated conditions."

Behr also acknowledged that some of the treatments he provided included "quite a bit of force" which was required to "actually tear tissue" (which he said he  needed to do), and that these treatments had "a fairly high risk of harm ... especially on the elderly."

"There are things," he said, "I do that I know have a fairly high risk of harm."  "One of ... the techniques I do ... is ... pelvic stabilization, and I often use it, especially on the elderly... The sacroiliac joint often gets pulled out of line by a fall, so I get people and they've had a fall and a broken hip or a pelvic fracture, and they're still getting pain. Now it takes quite a bit of force...  I actually have to get up on the table and push the pelvis back into line." 

Note how aggressively Behr treats some patients, including the elderly with a "broken hip" or "pelvic fracture" and when "they're still getting pain."

"Now there's certainly some risk of harm with people with osteoporosis or lymph --- arthritis or other, you know, elderly people, and I have to be careful. I've massaged about 4,000 people. I've done more than 35,000 treatments, and I think I know what's safe and what's not.  And there are things I do that I know have "a fairly high risk of harm."

"We do tear tissues sometimes ... we do that in the hip and in the shoulder and in other joints where we actually have to tear tissue" "The ligaments that surround the hip can be strained and often they will have adhesions, so that there will be pain, and you actually need to stretch these ligaments. Now that is microtearing." 

It is logical to assume that other Registered Massage Therapists in British Columbia also tear tissue with "a fairly high risk of harm" because Behr's use of the plural "we" indicates that  he is talking about what he and other RMTs do. Also, Behr, was then President of CMTBC and should therefore know what other RMTs did.

PART 2: REGISTERED MASSAGE THERAPISTS MAY CAUSE IATROGENIC HARM

The June 8, 1999, hearing included Behr's following testimony:

Mr. BEHR:  I guess my point is that there is a risk of harm. I disagree with Mr. Lau, who spoke first. In Powell River we had a man die of a heart attack from being in hydrotherapy. We had a man recently who had a stroke on the table..."

THE CHAIRMAN: You mean in a nonreg-ulated --

Mr. BEHR: No. They're regulated, but that means they're --. I realize that  -- I understand the difference, but they -- there is a risk of harm associated with these techniques. These techniques are not --

THE CHAIRMAN: But these things happen whether the profession was regulated or not regulated.

Mr. BEHR: That's right. That's right. But these are risky techniques, and I'm questioning whether they would have -- if more people hadn't  -- didn't have the amount of training they had.

THE CHAIRMAN: You mean the conditions that you're talking about were the results of the treatment they were being given?

Behr danced around this question which refers to the above-mentioned - "heart attack  from being in hydrotherapy" and "stroke on the table". Presumably, this table is  a massage table. But Behr did not answer the Chairman's question as to whether these two cases of harm, had actually  resulted from the treatment.

The fatal heart attack and the stroke both occurred in Powell River, where Behr's Massage Therapy Clinic is located, and there were only seven RMTs in Powell River. One year later, in his June 5, 2000, letter to Lincoln Lau, Behr wrote, "I do not recall making statements" [at the June 8, 1999, hearing]  "about deaths that have occurred in Powell River as a result of massage services." It is surprising that Behr does not know whether massage therapists were involved in the fatal heart attack  and  the"stroke ton the table".

PART 3: QUESTIONS FOR

PETER BEHR

I would appreciate it if you would please provide the information requested in the following questions, and give me permission to publish your reply in the Massage Law Newsletter. These questions concern some of your comments at the June 8, 1999, hearing.

1. If you have no well-documented evidence that the above-mentioned two cases of harm (a heart attack, and a stroke) were caused by the RMTs who were treating those patients, why did you refer to them at the June 8, 1999, hearing?

2.  If you have no well-documented evidence that the individual (in Alberta)  became a paraplegic as a result of a massage, why did you refer to  that at the June 8, 1999, hearing?

3. You testified  that you talked to "quite a few people" in  Powell River "who have been injured by" [unregulated] "practitioners," but they were not willing to testify, and you said, "I'm not making it up." Why did you present this information which is completely unacceptable as reliable evidence?

4. About 3.600 of your patients  (90% of the 4,000 patients your treated) were referrals from physicians. Approximately how many of these 3,600 patients had the kinds of problems for which your treatment involved what you call "a fairly high risk of harm" because you "actually" [had] "to tear tissue"?

5. For approximately how many of these 3.600 patients, did you get up  on the table in order to push their pelvises back into line? 

6. For approximately how many of these 3,600 patients, did you need to tear tissue?  How many of these patients had adverse effects that resulted from your having torn their tissues? What was the nature and seriousness of that iatrogenic harm?

7. Appendix H of CMTBC's 1998 Submission has your report "How RMT's Are Commonly Employed."  In this report, you refer to "Discussion of treatment and treatment plan and patient questions."

Do you discuss with each of the your patients, for whom it is relevant,that the treatment, you intend to provide, involves  "a fairly high risk of harm" because you would "actually have to tear tissue" and that tearing would be painful and could result in the iatrogenic harm described by Dr. Yates?

8, If you do not provide your patients with the information in the preceding paragraph, how can there be"patient questions" about that treatment and about the iatrogenic harm that might result? And how can your patients give their informed consent for a painful and severe treatment about which you do not provide what is legally called "full disclosure"?

9. In the June 9, 1999, hearing, you said, " I think I know what's safe and what's not."   If you only "think [you] know what's safe and what's not," does it not follow that you do not always  know "what's  safe and what's not"?  

10. How do you know what amount of tearing is safe and what amount of tearing is not safe" in treatments during which you "actually have to tear tissue"? 

11.  In how many of the approximately 3,600 patients, who were referred to you by physicians, did you cause any of the iatrogenic harm which  Dr. Yates  described?

PART 3: HOW MANY TREATMENTS

BY REGISTERED MASSAGE THERAPISTS HAVE CAUSED IATROGENIC HARM?

"In 1996, over 200,000 patient referrals were made." This information is in CMTBC's July 28, 1998 Submission.  You treated about 3,600 people (90% of 4,000 who were referred to you), and provided them with an estimated 31,500 treatments (90% of the total  35,000 treatments you provided). This amounts to an average of about 8.75 treatments per patient.

Using this 8.75 ratio, the  200,000 patient referrals in 1996, received about 1,750,000 treatments by RMTs in 1996. It is logical to assume that:

Some other RMTs have practices comparable to yours, and may sometimes "actually have to tear tissue," as you do. 

These treatments by other RMTs also entail the "fairly high risk of harm" (especially for the elderly who come with "broken hips, "pelvic fractures," and other serious injuries, and are in pain.  

Since RMTs gave about 1,750,000 treatments in 1996, it is difficult to believe that there were no adverse effects including the harm associated with tissue tearing, to which Dr. Yates directed attention.

It is therefore legitimate to ask, How many RMTs in British Columbia caused iatrogenic harm to how many patients in 1996, when they "actually " [had] "to tear tissue"?  What was the nature of  that iatrogenic harm? And how serious was it?

WHAT INFORMATION DOES THE COLLEGE OF MASSAGE THERAPISTS

OF BRITISH COLUMBIA HAVE ABOUT PETER BEHR'S TREATMENT AND ABOUT HARM CAUSED BY REGISTERED MASSAGE THERAPISTS?

AND WHY DO BRITISH COLUMBIA'S RMTs NEED A 3,000-HOUR-TRAINING?

To:       The President. College of Massage

             Therapists of British Columbia (CMTBC)

From: Albert Schatz, Editor

When Peter Behr testified at the June 8, 1999, hearing, he was President of CMTBC. One would therefore assume that he, of all people, would have presented well-documented evidence of harm by unregulated practitioners. But he presented no such information. Instead, his testimony included unsubstantiated and irrelevant allegations.

I would therefore appreciate if you would provide the information I am requesting in the following questions, and give me permission to publish your reply in the Massage Law Newsletter.

Questions

1. What well-documented evidence does CMTBC have that the three cases of harm, which Mr. Behr reported at the June 8, 1999 hearing actually occurred; and, if so, that massage therapists were responsible for that harm? These cases involved one man who died of a heart attack, another man who had a stroke, and an individual in Alberta who became a paraplegic.

2.  What well-documented evidence does CMTBC have that validates Peter Behr's allegation of harm (in Powell River) caused by allegedly unregulated practitioners who refused to testify about that harm?

3. Does CMTBC consider getting up on the table to use "quite a bit of force" an acceptable procedure in treating patients, especially the elderly, who have a "broken hip" or  a "pelvic fracture" and "when they're still getting pain"?

4. Do massage schools in British Columbia teach students to get up on the table in order to use "quite a bit of force" to treat patients?

5. Do massage schools in British Columbia teach students that tearing tissues is a necessary procedure in massage therapy?

6  Approximately how many RMTs presently tear tissues in approximately how many patients annually?

7. In how many patients, treated by RMTs during the last three years (a) has the "damage" (i.e., the iatrogenic harm) "not been trivial," (b) has "the presenting condition  been exacerbated," (c) has "significant and lasting harm been done", and (d) has "an otherwise treatable condition become chronic or disabling" as a result of tissue tearing"? I am using Dr. Yates Phraseology here.

Why do RMTs in British Columbia

need 3,000 hours of training?

What well-documented evidence does CMTBC have that justified increasing the number of hours of training, for RMTs, from 2,200 to 3,000 hours? Did RMTs with the 2,200-hour-training harm people?

The College of Physical Therapists of British Columbia (CPTBC) raised the question as to whether "an increase in hours at an educational institution translates into increased competencies for practitioners." This concern is spelled out in CPTBC's letters of April 3, 1996, and April 30, 1999, (to members of the Health Professions Council) about CMTBC's September 1995 and July 1998 Submissions.

The information requested in the four questions in the section entitled "Are the payments to RMTs in British Columbia cost-effective" (on page one of this report) may provide evidence that RMTs in British Columbia do not need 3,000 hours of training. The former 2,200-hour-training may be all they need.

Thank you for providing the information I request

cc:  Anne-Marie Persinger, (Manager. Medical Services Plan. Victoria),

David MacAulay, Mary McCrea, and Irvine Epstein (Health Professions Council)

Lincoln Lau (British Columbia Coalition of Allied Bodywork Practitioners)

Peter Behr. (Past President, CMTBC)

College of Physical Therapists BC 

Massage Therapists Association BC

British Columbia Medical Association

College of Physicians and Surgeons BC

Canadian Massage Therapy Alliance

Ontario Massage Therapist Association

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