MLN Vol.5.No.2

Massage Law Newsletter

Vol. 5, No. 2                                       I SSN 1073-5461                                  November 1998

 MASSAGE SHOULD BE DEREGULATED

BECAUSE IT DOES NOT CAUSE HARM

Albert Schatz, Ph.D

ABSTRACT

      None can love freedom , but good men.

The rest love not freedom, but license. -

 John Milton

Regulation violates constitutional law

and U.S. Supreme Court decisions

that prohibit arbitrary governmental interference in an individual's right to engage in a lawful business, restraint of trade, monopolies, and unfair trade practices; and that protect freedom of speech and freedom of the press.

Massage does not cause harm

The idea that massage causes harm is a myth because there are no statistics on how much and what kinds of harm occur. The mantra that regulation of massage is needed to protect the public from harm rests on the myth that massage causes harm. This myth is  used to  justify monopoly control of massage. Since harm is a myth, we should deregulate massage.

Where's the harm?

An estimated  200,000 massages therapists  and other bodyworkers provide over 200,000,000 treatments annually.

Governmental agencies

found no harm

Where governmental agencies have done their own research, they have found no harm and have not regulated massage.

Georgia legislators did their own research to find out how much harm occurred, and concluded:

"There is no documented danger of actual harm to the public...  The potential for harm to the public appears to be remote and would not be alleviated by licensing."

The Office of Professions, in the Canadian Province of Quebec, conducted a two-year research project, and concluded that unregulated massage practitioners did not cause harm.

Other research reveals  no harm

In 1992, Alexander conducted a Medline data base survey which uncovered 30 cases of harm during a period of 25 years. No harm was caused by massage therapists, regulated or unregulated. The harm was caused by doctors, bone setters in India, New Zealand Polynesians, and one husband.

Alexander recently told Massage Magazine: "Massage and bodywork are safe. There have never been any cases of physical injury to people." Alexander is editor of The Journal of Soft Tissue Manipulation which is published in Ontario.  He is also a Contributing Writer for the Massage Therapy Journal published by the American Massage Therapy Association.®

The California Coalition on Somatic Practices reported. "We injure very few clients. As a result ... we will have difficulty meeting the" legislature's] "Sunrise criteria" which requires well-documented evidence of sufficient harm "without manipulation of the data."

Why? Why? Why?

WHY have so many states regulated massage without having done their own research to find out whether harm has actually occurred, as Georgia and Quebec did?

WHY should states regulate massage to protect the public from harm when they have no well-documented evidence that harm has actually occurred?

WHY did the Pennsylvania Licensure Coalition promote licensure "first and foremost to protect the public from harm" - with no evidence that harm has occurred?

WHY did Elizabeth Leach, Executive Director of the Ontario Massage Therapist Association, claim that: "Massage therapy performed by unregulated individuals is not" safe - without providing any evidence that harm has actually occurred?

WHY don't people who claim that massage causes harm tell us how many people have actually been harmed, and the nature and seriousness of the injuries?

Contents

Abstract

Part   1: Massage should be deregulated because it does not cause harm.

Part   2: Sunrise and Sunset laws prevent and eliminate unnecessary regulation.

Part   3: Massage is safe in the United States.      

Part   4: Massage is safe in the  Province of Quebec.

Part   5: Massage is safe in other Canadian provinces.

Part   6: Additional evidence that massage is safe in Ontario.

Part   7: Conclusions about alleged harm in Ontario.

Part   8: There's no evidence that massage causes significant harm.

Part   9: Questions about the Schwartz Commission.

Part 10: The verdict, "Not guilty, Your Honor".

Part 11:  The Pew Report recommends title protection  becausethere's little risk of harm

Part 12: Alternatives to compulsory state regulation.

Part 13: Freedom of choice.

Part 14: Massage therapists harm themselves, not their clients.

Part 15: Conclusions - A reality check.

References

Loyalty to a petrified opinion never yet broke a chain or freed a human soul. - Mark Twain

 

PART 1: MASSAGE SHOULD BE

DEREGULATED BECAUSE IT

DOES NOT CAUSE HARM

 

Regulation violates constitutional law

and U.S. Supreme Court decisions

that prohibit arbitrary governmental interference in an individual's right to engage in a lawful business, restraint of trade, monopolies, and unfair trade practices; and that protect freedom of speech and freedom of the press.41

The mythology of massage

The idea that massage causes harm is a myth because there are no statistics on how much and what kinds of harm occur. The mantra that regulation of massage is needed to protect the public from harm rests on the myth that massage causes harm. This myth is  used to  justify monopoly control of massage.

 Since harm is a myth, we should deregulate massage.

"Deregulation of some professions"

is "a positive move."

Regulation of some professions has reached the height of absurdity1,2,3 Some states are therefore considering deregulating professions for which there have been few or no complaints.4,5  One report considered "Deregulation of some professions ... a positive move."5

Regulation of some professions is

unnecessary state bureaucracy

"During the ... 1980s, the number of state bureaucracies increased significantly... Pennsylvania created 83 new authorities, boards, commissions, committees and departments. These bodies frequently became bastions for special interests and appointments to them often" repaid "political favors."6

PART 2:  SUNRISE AND SUNSET LAWS PREVENT AND ELIMINATE UN-NECESSARY REGULATION

Sunrise prevented massage

regulation in California

The California legislature's Sunrise Process requires all proposed regulatory legislation for health care professions meet the following criteria:

1. The unlicensed profession is a serious danger to  the public health and safety.

2. State licensing will adequately protect the public health and safety.

3. No other means can protect the public health and safety.

The California Coalition on Somatic Practices reported that "We injure very few clients. As a result ... we will have difficulty meeting the Sunrise criteria without manipulation of the data." 7,8

The Coalition refused to falsify data to meet the state legislative requirement for evidence that unlicensed massage practitioners endanger the public.

If there's not enough harm to justify regulating massage in California, why would there be enough harm to justify regulating massage in any other state?

How Sunset works

A state agency automatically terminates after, for example, three years unless the legislature acts to reauthorize its continued existence for another three years. Therefore, sunrise and sunset are legislative partners. "If you're guarding the back door but not guarding the front door, it doesn't make sense."6

First things first

The California Sunrise law puts the burden of providing evidence to justify the need for state regulation of massage on the group that is promoting it, which is where it belongs.

When the issue of regulating massage comes before a state legislature, in a state which doesn't have a Sunrise law, the first thing that legislature should do is conduct its own research to determine whether massage has actually harmed people. If the legislature finds no well-documented evidence that people have actually been harmed, there's no need for regulation to protect the public from harm.

To find out whether harm has occurred, and if so, how much harm has occurred, requires research because public hearings may not provide that information.  Such research, done by the Georgia legislature and the Canadian Province of Quebec, Office of Professions, found no harm. They therefore did not regulate massage.

If there's no harm in Georgia and  Quebec, why would there be harm in other states and provinces?

More evidence that massage is safe

Because massage is safe, the cost of professional liability insurance for massage therapists has decreased significantly, while the cost of medical malpractice insurance has significantly increased.

In 1984, the wholesale cost of $1,000,000 coverage for massage therapists was $65.00 a year. Now the wholesale cost for $2,00,000 coverage is only $32.50 a year.9

The most likely explanation for this 75% drop in the cost of professional liability insurance is that insurance companies recognize that massage is not harmful.

 If massage were harmful, there would be more and more harm because more and more people are being massaged by more and more massage therapists, regulated and unregulated.. The cost of insurance would therefore increase. But the cost has decreased

Insurance offers more protection

than state regulation

Insurance protects both the public and massage therapists. If a massage therapist harms a client, insurance protects the massage therapist in a personal injury claim, and provides compensation for the injured client.

State regulation of massage does not prevent injuries, does not protect the massage therapist in a personal injury claim, and does not pay the injured client any compensation. Insurance therefore provides more protection for all concerned than state regulation does.

Dog bites and insurance

About 4.5 million people in the U.S. are bitten by dogs each year. About 334,000 victims, half of whom are under age 15, receive emergency room treatment which costs over $100,000,000. Dog bites are the main cause for which children receive emergency room treatment. "The costs are even higher when additional medical care, such as cosmetic surgery and follow-up doctor visits are factored in... The problem is so acute that the Insurance Information Institute put a $1 billion figure on what dog bites cost the insurance industry in homeowner claims."11

How much money have insurance companies paid to settle personal injury claims against massage therapists?

PART 3: MASSAGE IS SAFE IN 

THE UNITED STATES

 Massage is safe in Georgia

When the Georgia AMTA Chapter promoted licensure, it pointed out the potential harm, but did not present any well-documented evidence of harm that had actually occurred, The senators disregarded all oral descriptions of harm which allegedly had occurred, and then did its own research to find out how much harm had actually occurred.10

In October, 1997, the Georgia Occupational Regulation Review Council issued its Review of Senate Bill 300 Which Proposes to Regulate Massage Therapists. This Review reported the research, which the senators had done and their conclusions:

"There is no documented danger of actual harm to the public."

"The potential for harm to the public appears to be remote and would not be alleviated by licensing."

The Georgia legislators are to be commended for doing their own research. The above-mentioned Review of Senate Bill 300, which  consists of a 12 page report and 32 pages of appendices, is a model for legislators, in other states, who have to consider the issue of whether massage should be regulated.

The Georgia legislative committee sought evidence of harm in neighboring states, and reported:

"Most of the other southeastern states' regulation is quite new, but their staffs indicate that to date they have received few complaints and have taken few disciplinary actions."

The nature of complaints most often cited was "practicing without a license; and sexual misconduct." Only one state reported receiving a complaint that a therapist had injured a client. I estimated that one report of harm occurred in 19,240.000 massages in Georgia and the surrounding states.10

The senators were told there were  "probably 1,000 massage practitioners in Georgia and that each practitioner performs an average of 20 massages per week." The senators realized this  "translates into over one million massages currently being performed during a one year period." They then decided to do their own research to find out how much harm actually occurred as a result of the more than 1,000,000 massages per year.

There are an estimated 200,000 massage therapists and other bodyworkers in the U.S.44 It they each give an average of 20 treatments a week, that amounts to over 200 MILLION TREATMENTS A YEAR.

WITH OVER 200 MILLION TREATMENTS A YEAR, WHERE'S THE HARM?

 Massage is safe in California

Information about why massage is safe in California is in Part 2.

If there's not enough harm to justify regulating massage in California, why would there be enough harm to justify regulating massage in any other state?

Massage is safe in Pennsylvania

"Harm" popped up in Pennsylvania when the Pennsylvania Licensure Coalition promoted state licensure.11,12 The Coalition alleged:

"Licensure is first and foremost to protect the public from harm."

"State licensing will ... create educational requirements for that public protection."

"We are working to create a bill which protects the public from harm."

The Coalition did not reply to several requests for information about what harm had actually occurred. I therefore conclude that little, if any, harm has occurred.

Does any state need to regulate massage to protect the public from harm which has not occurred? 

The December, 1997, issue of The Balanced Body (the quarterly newsletter of the Pennsylvania Chapter of the (PA-AMTA) included Barbara Mikos' questionnaire.12

This questionnaire solicited information from PA-AMTA members about harm caused by untrained massage therapists and the extent to which untrained massage therapists pose a threat to the safety of the public.

Mikos did not reply to our requests, in February and April, 1998, for information about what harm her questionnaire revealed.12,13 She died on July 8, 1998.  The results of that questionnaire have not been  published in The Balanced Body.

She had been Treasurer of the Pennsylvania Licensure Coalition, Second Vice President of the Pennsylvania Chapter of the American Massage Therapy Association® (PA-AMTA), and in charge of Government Relations for that chapter.

Massage is safe in Hawaii

Hawaii's 1992 Sunset Evaluation Update: Massage  tells us, "Incompetent massage therapists could cause injury to consumers... The regulation of massage helps to reduce the potential harm to consumers." The report14 presents the following information:

"There are about 1800 massage therapists licensed in Hawaii, nearly a doubling during the past six years."

"There is a slight potential for personal injury from practice of massage. During the past six years, four" individuals "claimed physical injury to the neck or back due to negligence ... RICO" [the Regulated Industries Complaints Office of the Department of Commerce of Hawaii] "sent an advisory letter in the first case, found no violation or insufficient evidence in the second and third cases, and the fourth is still pending."

"In the four cases ... where personal injury was charged, two of the massage therapists under investigation had been licensed through the apprenticeship route and two through the school route. All four therapists had been licensed for over two years prior to the allegations."

There were no reports of harm caused by unlicensed people doing massage. If we disregard the two cases, for which there was "no violation or insufficient evidence" of harm, the remaining two reports of harm over a  period of six years average 2 ÷ 6 = 0.33 or 1/3 of a  complaint annually. This is one complaint every three years, and 33 complaints of harm in a century.

This little amount of harm is not significant, especially because the injuries themselves were not serious.

Why does Hawaii regulate massage? There's no harm in states which don't regulate massage?

More evidence that massage is  safe

Many people with little training are doing massage without causing harm. Dr. Tiffany Fields and her colleagues at the University of Miami, Medical School's Touch Research Institute teach people how to do massage in less than 500 hours. These people then massage individuals with a variety of health problems, some of which are quite serious. None of the patients were harmed despite the fact that those who massaged  them had less than 500 hours of training.

Husbands are taught, in 15 hours, to massage their pregnant wives.15  People are certified in foot massage (reflexology) after taking a one-day (7-hour) workshop.16

"A workshop on self-hatred and suicide and cooperation at the 1977 Feminist Forum in San Francisco was so full of pain that women began massaging one another.

"At that crucial moment, the experience of being touched, soothed, caressed, and cared for did more to heal permanently the self-hatred than any discussion would have. It was an essential first step in breaking down the patriarchal fiction that we are worthless and unlovable."17 The women had no massage training.

Only a few hours of training, or less, are needed to teach young children "how they can bring appropriate touch [massage] into their lives."18

In a research project, "some of [a] school's toughest kids ... most [of whom] have been abused and have trouble trusting adults ... were" with little training "sitting Indian-style on the floor, doing hand massage and moving freely."19

The Sept./Oct./Nov./Dec. 1998, brochure of the Mt.  Airy Learning Tree listed a 4-hour massage course for partners. The Learning Tree is a community organization in the Mt Airy section of Philadelphia. It arranges workshops, lectures, and other activities for the public.

Reflexology, commonly known as "foot massage" does not harm people. It's taught to children and church parishioners. Parents learn reflexology from books.20

Barbara York, who had a 1,000 hour accredited training and passed the National Certification., wrote; "The most impressive training I have ever had was in 1966. I was fresh out of high school and had as part of my training as nurse's aide a half hour instruction in back massage. I was assigned the 'Terminal ward' and gave the late term cancer and congestive heart failure patients a massage at their bedside. Knowing that some of them would 'wait up' to get their 20 minutes of touch left a profound mark on me.

"My minimal training in massage was in-significant to those patients. I massaged them to the best of my ability and with all the compassion my 18 years of age could muster. If the hospital could risk allowing nurses aides to work unsupervised with fragile patients, I am certainly willing to receive a massage from someone I believe has the compassion to give one."9

Some states regulate massage without any

 evidence that regulation is needed

In 1993, I wrote to the "Director" of the State Board of Massage (or the equivalent agency) in 17 states which regulated massage. I asked if they were aware of any  research or other documented information which provides convincing evidence that credentialing of massage therapists (a) results in more competent massage therapists, (b) protects the public, or (c) is advantageous in any other way; and, if so, how?

Of the 17 individuals to whom I wrote, seven did not reply. Five sent copies of their state laws or other documents which did not provide the information I requested. I am grateful to five individuals who provided the following information:

Connecticut. "The Department has not compiled any data with regard to your questions." Joseph J. Gillen, Ph.D. Section Chief. Applications, Examinations & Licensure. Division of Medical Quality Assurance. Department of Health Services. May 5, 1993.

New Hampshire. "I am unaware of any research report or documented studies which indicate that credentialing results in more competent massage therapists, protects the public or is advantageous in any way." Theresa A. Jarvis, R.N., Health Facilities Coordinator. Bureau  of Health Facilities Admin-istration. Department of Health and Human Services. June 2, l993. 

Washington. "We do not have the information you requested; however, we are forwarding your request to the [two] professional associations in this state who may be able to help you." Sharon E. Streechan. Program Representative. Professional Licensing services. State Board of Massage. Department of Health. May 10, 1993. (I never heard from the two professional associations.)

Rhode Island. "I am not aware of any studies regarding the improvements in treatment delivery which you mention." Russell J. Spaight. Administrator. Professional Regulating. Department of Health. May 13, 1993.

Texas. "This is in response to your questionnaire concerning massage therapists. I am not aware of any research in a scholarly journal concerning the regulation of massage therapists." Becky Berryhill. Program Administrator. Massage Therapy Registration Program. Professional Licensing and Certification Division. Department of Health. May 6, l993.

 PART 4: MASSAGE IS SAFE IN THE

PROVINCE OF QUEBEC 

Thomas J. Mulcair, President of the government Office des professions of the Province of Quebec, wrote me, on June 13, 1993,  to explain why that Province  did not regulate massage. His letter reads as follows:

___________ 

"We are in receipt of your letter dated May 10th, l993, concerning massage therapy.

"I would like to inform you that  in the Province of Quebec, the title and the activities of massage therapists are not regulated.

 "The Office des professions conducted, in l990 and l99l, an extensive research project on the need to regulate alternative professions in Quebec. A part of the study covered manual therapies and massage.

"A research report and the position of the Office des professions to the Minister Responsible for the Application of Professional Laws, which are enclosed, were released in April 1992.

"One of the main recommendations is that it is not necessary to regulate alternative therapies, including massage therapy, because they do not represent any serious risk of harm to the public.

"This recommendation is based on the fact that none of  the 38 groups that we consulted specifically on manual therapies was able to demonstrate or document any prejudice or damage caused by incompetent massage therapists."

___________ 

I am most grateful to Mr. Mulcair for the two reports (in French) which he so kindly sent me. The research report (on the protocol and results) consists of 83 pages. The recommendations, based on the research, are in a separate volume of 25 pages.21,22

Evaluation of the research in Quebec

The research, conducted by the Office des professions, is outstanding. It is a well-designed, objective, broad and comprehensive, in-depth, study that considered the problem from different points of view. This  research is a model for other provinces.

I have not seen references to the Quebec reports (which are in French) in publications on harm and regulation in the English-speaking provinces of Canada and in the United States.

To the best of my knowledge, my colleagues and I are the only ones who have written about, quoted from, and included references to the Quebec reports in what we have published.

PART 5: MASSAGE IS SAFE IN OTHER CANADIAN PROVINCES

Elizabeth Leach, Executive-Director of the Ontario Massage Therapist Association, wrote, "Massage by unregulated individuals is not" safe.27  But she presented no evidence that unregulated individuals have actually harmed people in Ontario or anywhere else.

Massage is safe in Ontario

Alexander, in Ontario, recently told Massage Magazine, "Massage and bodywork are safe. There have never been any cases of physical injury to people."23 

Alexander is editor of The Journal of Soft Tissue Manipulation which is published in Ontario.  He is also a Contributing Writer for the Massage Therapy Journal published by the American Massage Therapy Association.®  

Others, in Ontario, informed Lincoln Lau that they were not aware of people being harmed by massage in that province.

Lincoln Lau found

no evidence of harm

The following information is taken from letters addressed to Lincoln Lau, President of the British Columbia Coalition of Allied Bodywork Practitioners. Lau had written, on July 20, 1998, to request information about the issue of harm, regulation, and other matters. The replies he received include the following comments.

From Ontario which

 regulates massage

"The Ministry of Health has not received any letters from the public complaining against massage therapists or other massage practitioners."

"In Ontario, the profession of massage therapy is regulated by the Regulated Health Professions Act 1991 (RHPA) and the Massage Therapy Act 1991 (the Act)... The RPHA is based on the concept of controlling potentially dangerous acts.

"In fact the RHPA structure is, by policy design, intended to eliminate 'licensed monopolies' in Ontario's health professions. Therefore... 'legislated massage therapists' have not been given a monopoly over massage and manual therapies.

"The Act does, however, provide for title protection by restricting the use of the title 'massage therapist', a variation or abbreviation or an equivalent in another language, to members  of the College of Massage Therapists of Ontario (CMTO). The College is the independent regulatory body for massage therapy in Ontario.

"The protected title would not prevent someone from advertising or using the term 'massage', as long as it is not used together with the word 'therapy'. There is also a provision in the Act which prohibits someone from holding themselves out as a person who is qualified to practice in Ontario as a massage therapist or in a specialty of massage therapy if they are not a member of the CMTO." Alan. R. Burrows, Director. Ministry of Health. Professional Relations Branch. North York, Ontario. August 26,1998.

Ontario. "Our office has received no such complaints by the public."  Margaret Anne McHugh. Executive Coordinator. Health Professions Regulatory Advisory Council. Toronto. August 24, 1998.

From provinces which do

not regulate massage

 Alberta. "We are not aware of any complaints made by the public or other individuals against massage practitioners. The Health Workforce Planning Branch of Alberta Health also reports that it is not aware of any complaints or inquiries concerning these health care providers.

"Alberta does not currently regulate massage therapists. The Health Disciplines Board (HDB) investigated two formal requests (in 1983 and 1993) from massage therapists for designation under the Health Disciplines Act (HDA), an umbrella right-to-title statute.

"Following ... investigations, the HDB concluded designation was not appropriate on the basis that 'the practice of massage for the promotion of relaxation and relief of stress, while valuable and health promoting, does not involve the degree of risk of harm that warrants regulation of practitioners under the HDA.'" Sheryl Prescott Paterson, Acting Director of Health Disciplines. Alberta Labour. Technical and Safety Services. Professions and Occupations. Edmonton. July 28, 1998.

Alberta. "Massage therapists are not regulated in the Province of Alberta... Neither Alberta Health or the Department of Labour are aware of any complaints made by the public or other individuals against massage practitioners." Bill DuPerron. Principal Consultant. Workforce Education and Planning. Alberta Labour. Edmonton.  August 11, 1998.

Saskatchewan. "Saskatchewan Health has not received complaints about massage practitioners."

"Saskatchewan does not regulate massage therapy. In fact, about two years ago Saskatchewan Health declined a submission from the Massage Therapist Association of Saskatchewan to regulate the profession under provincial legislation.

"Generally, massage therapy was not seen to pose a physical risk to the public to warrant regulation. We are not considering regulating these health practitioners in the near future." Drew Johnson. Senior Health Professions Analyst. Saskatchewan Health. Policy and Planning. Regina. July 28, 1998.

Manitoba. "We are not  aware of any com-plaints relative to the use or misuse of massage therapy that have been made to Manitoba Health." Barbara Millar. Manitoba Health. Legislative Unit. Winnipeg. August 7, 1998.

New Brunswick. "The Department has not received any complaints against massage therapists and is not aware of any injuries caused by these practitioners." Paul M. LeBreton. Deputy Minister. New Brunswick Health and Community Services. Fredericton. August 17, 1998.

Nova Scotia. "None that I am aware of." Wayne D. Cochrane. Legal Counsel. Department of Health. Nova Scotia Department of Justice. Halifax. August 6, 1998.

Prince Edward Island. "We -- the Health Department Services -- are not aware of any complaints about massage practitioners." Rob Thomson. Legislation. Prince Edward Island. Heath and Services. Charlottetown. August 5, 1998.

Newfoundland. "I am not aware of any complaints made to the Department by the public against massage therapists." Kathy Babstock. Program & Policy Development Specialist. Newfoundland Department of Health and Community Services. Policy Division St. John's. August 6, 1998.

 Yukon. "As massage therapy is not legislated or regulated by the territory, there is no mechanism to document complaints." Bruce McLennen, Deputy Minister. Health and Social Services. Yukon Health and Social Services. Whitehorse. August 12, 1998.

Quebec. "In Quebec,  massage is not regulated by the Code of Professions (L.R.Q., c. C-26) which regulates 43 professions, or by the Consumer Protection Law (L.R.Q., c. P-40.1)." [translated from French]. André Contant. Direction de la recherche. Office des professions du Québec. Québec. August 27, 1998. (from the reply to Lau)

PART 6: ADDITIONAL EVIDENCE THAT MASSAGE IS SAFE IN ONTARIO

Alexander recently told Massage Magazine, "Massage and bodywork are safe. There have never been any cases of physical injury to people."23  Alexander is editor of The Journal of Soft Tissue Manipulation which is published in Ontario.  He is also a Contributing Writer for the Massage Therapy Journal published by the American Massage Therapy Association.® 

Alexander had concluded, from his 1992 Medline survey: "The small number of references [to harm] suggests the relative safety of massage." He reported that research in 1992 in the Ontario Massage Therapist Newsletter. 24

Why did Alexander

do research?

In his own words, "Massage therapy is generally considered a very safe intervention. Even among those who doubt its effectiveness, there is seldom any fear that it may actually harm someone. However, there has been no attempt to explore how safe massage therapy actually is, and thereby make it more safe. We owe it to the health care consumer, and  to ourselves, to explore this issue."

Note that Alexander is concerned with harm that actually occurred, not potential harm. Also note the second sentence in the preceding paragraph. The reason why "there is seldom any fear that" massage "may actually harm someone" is because people have not heard  about harm that has occurred. And the reason they have not heard about harm that has occurred is because harm hasn't occurred. If it did, people would have know about it.

This is precisely the point I have been making. So, Alexander and I both agree. There is little, if any, well-documented evidence that massage has actually harmed people.

Alexander's research objective was "to discover what kind of scientific evidence was available on contraindications to massage." He did this research because he was looking for evidence that contraindications were associated with actual harm caused by massage.

The massage literature does not provide that information. It simply tells us that massage is potentially harmful for individuals with contraindications. Alexander therefore surveyed the medical literature in the hope that it would provide convincing evidence of an association between contraindications and harm actually caused by massage.

What harm

 did Alexander find?

Alexander  was looking for physical harm that had actually occurred, not potential harm. He found no evidence that any contraindication was associated with harm caused by a massage therapist, regulated or unregulated, in Ontario or anywhere else.

Nor did he find a single case of any other kind of harm caused by a massage therapist, regulated or unregulated. This is significant because many or most massage therapists -  in the United States, Ontario, and other Canadian provinces during the 30-year period (1967-1992) Alexander surveyed - were unregulated.

"The one case" he "found that relates" only "relatively directly to a group such as massage therapists is a report from a phsysiotherapist of a hypersensitive reaction to ice massage." 

Alexander uncovered only 30 cases of harm reported over a period of 25 years. This averages out to 1.2 people harmed in one year, and 120 people harmed in a century.  None of the people who caused the harm were massage therapists, regulated or unregulated.

Alexander therefore asked, "When is massage dangerous?" His answer: "According to what has been published in the medical literature, massage has been dangerous in either of two types of situations: when it is applied as a medical specialty by a medical doctor, or when it is used as folklore remedy by a lay person." Note that he did not include unregulated massage therapists among those who caused harm.

He categorized those who injured people as follows:

"A husband massaging the thrombophlebitic calf of his wife and giving her a pulmonary embolism."

"Bone setters" and lay masseurs in India. Most of the people whom they injured had "myositis ossificans about the elbow."

"New Zealand "traditional Pacific islander massage techniques [which] were thought to be the cause of prenatal intracranial haemorrhage and death, although this type of case may be more the result of attempts at abortion rather than traditional massage techniques, which tend to be very light over the pregnant abdomen."

 Doctors. Alexander specifically pointed out, "The bulk of the articles found in my search described adverse effects of massage performed by  medical doctors."

The case of Alexander's

missing reference

How did massage, which was relatively safe in 1992,24 become physically dangerous in 199425  - even though there was no more harm in 1994 than there had been in 1992?

In 1994,25 Aexander took issue with a 1993 publication, in which my colleagues and I claimed massage was safe.26 His 1994 article reported, among other things, the harm that had actually occurred, which he had previously reported in 1992 in the Ontario Massage Therapist Association Newsletter.

Unfortunately, he did not give the reference to that 1992 newsletter article in his 1994 report. Therefore, many and perhaps all who read his 1994 report, in Massage and Bodywork Quarterly, did not know that his 1992 report existed. 

Consequently, they would not know that in 1992 Alexander acknowledged there was little evidence of harm caused by massage, and that he had concluded, "The small number of references [to harm] suggests the relative safety of massage." They would only know his 1994 conclusion, "Massage can, in fact, be physically dangerous."

Finally, Alexander did not inform his readers that, in 1992, he concluded massage was relatively safe because so little harm had actually occurred. But, in 1994, he concluded massage was  physically dangerous, because massage was potentially harmful.

Information from

Toronto

On July 13, 1993, I wrote Deborah Worrad, Registrar of The Board of Directors of Masseurs in Toronto, Ontario:

"We are particularly interested in obtaining research reports or other information which indicates that laws which require credentialing of massage therapists result in more competent massage therapists, [and/or] protect the public, etc."

Her reply of July 26, 1993, stated: "The Board has not conducted specific research and therefore does not have hard data on the topics to which you referred."

PART 7: CONCLUSIONS ABOUT

HARM IN ONTARIO 

Alexander reported: "In Ontario, roughly once every twelve months one massage therapist out of the 1,700 massage therapists currently licensed in the province is publicly disciplined or has their license revoked for sexual impropriety."25

Does this mean that people are more likely to be sexually harassed than physically harmed by licensed massage therapists in Ontario?

How many unregulated massage practitioners in Ontario have sexually harassed clients?

There's no research which provides convincing evidence that unregulated massage practitioners have caused significant physical harm in Ontario. Consequently, there's no need for Ontario to regulate massage to protect the pubic from being physically harmed by unregulated massage practitioners.

Ontario also does not need to protect the public from Indian bone setters and New Zealand islanders.

The one husband who massaged his wife's thrombophlebitic calf does not justify requiring  all husbands to take Ontario's 2,200-hour training before massaging their wives legs.

Alexander found that some doctors, who massage their patients, harmed them, but unlicensed massage therapists did not harm people.

Ontario doesn't protect the public from harm by prohibiting doctors from doing massage, even though doctors have harmed some people they massaged.

Ontario purportedly protects the public from harm by regulating massage therapists who don't harm people.

PART 8: THERE'S  NO EVIDENCE

THAT MASSAGE CAUSES

SIGNIFICANT HARM

Alexander recently told Massage Magazine, "Massage and bodywork are safe. There have never been any cases of physical injury to people."23 Alexander is editor of The Journal of Soft Tissue Manipulation which is published in Ontario. He is also a Contributing Writer for the Massage Therapy Journal published by the American Massage Therapy Association.® 

In a recent Letter to the Editor,27 Elizabeth Leach (Executive Director of the Ontario Massage Therapist Association) took issue with some comments in my Guest Editorial Massage Therapists Do Not Harm People  in Massage Magazine.28

This present report on harm and regulation is my response to some of her comments. I welcome dialogue because much of the history of progress is the history of controversy. Constructive disagreement can contribute to progress. Where all think alike, no one thinks very much - Walter Lippmann

 Leach's Letter to the Editor concludes, "Massage therapy performed by unregulated individuals is not" safe. If it's not safe, it's harmful. If it's harmful, how much  harm has actually occurred? In epidemiological terms, what is the morbidity of harm caused by unregulated massage practitioners?

Leach's Letter presented no well-documented evidence  of harm, which has actually occurred, to support her allegation that "Massage therapy performed by unregulated individuals is not" safe.

Her Letter contains no information about how many people in Ontario have been harmed by unregulated massage practitioners before and since massage was regulated, and how serious their injuries were.

PART 9: QUESTIONS ABOUT THE SCHWARTZ COMMISSION

What does "unqualified" mean?

And who's unqualified?

Leach's Letter tell us that the Schwartz Commission was concerned about "unqualified persons" doing massage. What does "unqualified" mean, and who's "unqualified"?

Massage therapists, with Ontario's 2,200-hour training, are unqualified to do massage therapy in British Columbia which requires a 3,000-hour training

Massage therapists, with Nebraska's 1,000-hour training, are unqualified to do massage therapy in Ontario which requires a 2,200-hour training.

Massage therapists, with Florida's 500-hour training, are unqualified to do massage therapy in Nebraska which requires a 1,000-hour training.

Do the clients of unregulated massage practitioners in Ontario consider them to be unqualified?

In 1992, Alexander (in Ontario) wrote "I am inadequately trained "to steer myself away from trouble" (i.e., harming clients) "all the time."24 Was Alexander unqualified (in 1992) to do massage? If so, how many other unqualified massage therapists are registered in Ontario?

Leach wrote, "Massage performed by unregulated individuals is not" safe. Massage practitioners are unregulated in eight Canadian provinces that do not regulate massage. Are those unregulated individuals unqualified to do massage? Is massage is unsafe in those eight provinces? I have already reported that those eight provinces have no evidence of harm.

Recapitulation of

that evidence 

Ontario. Alexander recently told Massage Magazine, "Massage and bodywork are safe. There have never been any cases of physical injury to people."23  Alexander is editor of The Journal of Soft Tissue Manipulation which is published in Ontario.  He is also a Contributing Writer for the Massage Therapy Journal published by the American Massage Therapy Association.® 

Quebec. "Massage is not regulated by the Code of Professions (L.R.Q., c. C-26) which regulates 43 professions, or by the Consumer Protection Law (L.R.Q., c. P-40.1)."

"The title and the activities of massage therapists are not regulated."

"It is not necessary to regulate alternative therapies, including massage therapy, because they do not represent any serious risk of harm to the public.

"This recommendation is based on the fact that none of  the 38 groups that we consulted specifically on manual therapies was able to demonstrate or document any prejudice or damage caused by incompetent massage therapists."

Alberta. "The practice of massage for the promotion of relaxation and relief of stress, while valuable and health promoting, does not involve the degree of risk of harm that warrants regulation of practitioners under the HDA.'"

"Neither Alberta Health or the Department of Labour are aware of any complaints made by the public or other individuals against massage practitioners."

Saskatchewan. "Saskatchewan Health has not received complaints about massage practitioners." ..."Generally, massage therapy was not seen to pose a physical risk to the public to warrant regulation.

Manitoba. "We are not  aware of any complaints relative to the use or misuse of massage therapy that have been made to Manitoba Health."

New Brunswick. "The Department has not received any complaints against massage therapists and is not aware of any injuries caused by these practitioners."

Nova Scotia. "None" [no harm] "that I am aware of."

Prince Edward Island. "We -- the Health Department Services -- are not aware of any complaints about massage practitioners.

Newfoundland. "I am not aware of any complaints made to the Department by the public against massage therapists."

The Georgia state legislature researched the issue of harm, and concluded: "There is no documented danger of actual harm to the public... [and]  The potential for harm to the public appears to be remote and would not be alleviated by licensing."

In California, there was not enough harm to meet the requirements of the legislature's Sunrise Process, which requires evidence of harm.

The Schwartz Commission

was inconsistent

Cowell, in Ontario, reported that: "Rolfers and Trager therapists ... went forward to the Schwartz  Commission and they could not prove significant risk of potential harm to the public to be regulated. The Shiatsu people had tried very desperately to become regulated, but they still could not fulfill the criteria of proving risk of harm to the public."29

Aren't contraindications, which are potentially harmful for massage, also potentially harmful for Rolfing, Tragerwork, and Shiatsu? If not, why not? If so, isn't there at least as much risk of potential harm caused by Rolfers, Tragerworkers, and Shiatsu practitioners as there is by massage therapists?

Since Rolfing and Shiatsu are more vigorous than massage therapy, aren't they potentially more harmful than massage? If not, why not?  If so, why didn't the Schwartz Commission regulate these modalities?

The Schwartz Commission

did not do research

If the  provisions of the Regulated Health Professions Act of 1991 require evidence of potential harm instead of harm which had actually occurred, there's something seriously wrong with that Act. Be that as it may, the Commission held hearings at which people, who wanted regulation, presented information about how serious a risk of potential harm was associated with their modalities.

They did not inform the Commission that no harm had actually occurred. The Commission did not know that risk is determined by harm which has actually occurred, not by potential harm, and did no research to ascertain whether harm had actually occurred.

It therefore regulated massage to protect the public from potential harm, which was as unnecessary then as it is now. The fact that unregulated massage practitioners in Ontario have not caused harm proves that regulation to prevent harm was and is unnecessary.

In  1991 (the same year of Ontario's above-mentioned Regulated Health Professions Act), the Office of Professions in the Province of Quebec was conducting the second of a 2-year research project to ascertain whether massage caused harm. Quebec found that no harm had actually occurred, and therefore did not to regulate massage.21,22

Most if not all of the 30 reports of actual harm, which Alexander reported in 1992, would have been discovered by the Schwartz Commission, if it had done the Medline survey which Alexander did.

Alexander "picked the keyword massage and the category adverse effects, and asked for a Medline computerized search of all the indexed English language medical literature for the past 25 years."24  He searched the medical literature because the massage literature had nothing on harm because massage does not cause harm.

It's unlikely that the Schwartz Commission would have considered that the risk of harm was serious if it had looked for harm which actually occurred. That's what the Georgia legislators looked for.  That's what the Quebec research looked for. That's what Alexander looked for.  And none of them found any harm caused by massage therapists.

The Province of Quebec, which borders on Ontario, does not regulate massage because its 2-year research project revealed that unregulated massage therapists had not harmed anybody?

People in Quebec have the same contrindications as people in Ontario have, but they're not harmed by unregulated massage therapists.

Why did Elizabeth Leach, Executive Director of the Ontario Massage Therapist  Association, write, "Massage therapy performed by unregulated individuals is not" safe."?

PART 10: THE VERDICT,

"NOT GUILTY, YOUR HONOR"

Nobody should have to prove massage is safe. Massage should be presumed to be innocent (safe) until proved guilty (of harm). Those who allege it's harmful have an obligation to provide convincing evidence that it is harmful..

Leach wrote, "Using the Ontario criteria for risk of harm, Mr. Schatz provides a compelling argument for the regulation of massage therapy." 27

I did not "provide a compelling argument for the regulation of massage therapy" by "using the Ontario criterion for risk of harm," or in any other way. 

On the contrary, I believe massage should not be regulated to protect the public from harm in Ontario or anywhere else.

 I also believe all nine Ontario criteria are irrelevant for regulating massage to protect the public from harm because there is no well-documented evidence that unregulated practitioners have caused significant harm in Ontario or anywhere else

Potential harm

versus actual harm

Leach and others (e.g., the Schwartz Commission) evaluate risk of harm by massage in terms of potential harm. I evaluate risk of harm by massage in terms of well-documented actual harm.

My focus on well-documented, actual harm is supported by:

Epidemiology, which reports mortality and morbidity data as well-documented actual harm, not potential harm.

Professional liability insurance, for which premiums are based on risk that is determined by well-documented actual harm, not potential harm.

Personal injury claims, which have to be based on well-documented actual harm, not potential harm, if they are to be taken seriously.

I am well aware of potential harm. As I have pointed out elsewhere: The air we breathe is potentially harmful. The water we drink is potentially harmful.

The food we eat is potentially harmful.  Many other things to which we are repeatedly exposed are also potentially harmful.28,30

However, risk is determined by the amount and seriousness of harm that has actually occurred, not by potential harm.

Lightning causes

serious harm 

Lightning clearly illustrates the difference between potential harm and actual harm. A lightning storm over a large metropolitan area is potentially harmful  for  millions of people. Anyone could be harmed. But very few are actually harmed.

According to Actual Facts,  published by the National Safety Council in 1994: 75  people were killed by lightning in the United States in 1989;  89 were killed in 1990; and 75 were killed in 1991.11 Massage has not killed anybody.

Shopping carts cause

serious harm

33,000 people were injured by shopping carts in 1990. Half were children under four who had been left unattended and fell out of the carts. The rest were injured in other ways. Many required emergency room treatment.31

In 1991, the following injuries required

emergency room treatment

400,000 football injuries and 400,000 baseball injuries, excluding injuries in professional sports.

580,000 injuries  associated with bicycles.

82,000 skateboard injuries.

98,000 injuries associated with roller skates.31

Emergency rooms keep records of how many people they treat for different kinds of injuries. How many people required emergency room treatment because of injuries caused by massage?

During a five year period in Chicago, 12 people were killed  and many more injured because of  faulty elevators in buidings.2

One could cite additional data on how many people have been injured in other ways.

Where are comparable data on how many people have been injured by massage?

Unacceptable evidence of harm

 associated with massage

Here are reports of so-called harm, which are all I have been able to obtain during the past several years. The individuals who told me about the third and fourth cases got their information second-hand, and could not provide me with or tell me where I might obtain additional information.11

My informants considered the so-called harm acceptable evidence that licensure is needed to protect the public from harm by incompetent massage therapists.

1. One individual told me that he recently had major surgery on his back, and might be seriously injured if he were worked on by an incompetent massage therapist. This is not a report of harm which has occurred, but of fear that harm might occur.

The pain and discomfort he described would have made it difficult for him to disrobe, get on and off a massage table, and then dress without assistance. I do not understand why anyone who recently had major surgery on his back and was in his condition would get a massage. I also do not understand why any massage therapists would work on anybody in his condition.

2. Someone informed me that he had a long list of anecdotal reports about people who were injured by massage therapists. He refused to give me detailed information.

3. One man complained of a bad backache after a massage.

4. One individual got a bad case of poison ivy after a massage.

I obtained the following information about poison ivy from the College of Physicians of Philadelphia which culled it from Clinical Reference Systems. p. 1639. December, 1994.

"Contagiousness: The fluid from the sores themselves is not contagious. However, the oil or sap from the poisonous plant may remain on a pet's fur or on items such as clothes or shoes. The oil or sap is contagious for about a week. Be sure to wash it off clothes or pets with soap and water."

In view of this information, I do not understand why anyone would assume that the "bad case of poison ivy" was directly caused by the massage per se.

Let's assume that someone actually got poison ivy from exposure to the oil (of a poison ivy plant) on the clothes or shoes of the massage therapist, or on the fur of her dog or cat.

Does this one case of poison ivy and the other cases of so-called harm justify regulating massage to protect the public from harm?

A well-documented

report of harm

This case history32 was published in 1993, one year after Alexander published the results of his data base survey11 in 1992.

The report, entitled "Zoster after shiatsu massage," was published in The Lancet, a British medical journal. One of the four authors was at the Tripler Army Medical Center, Preventive Medicine Service. Honolulu. The three other authors were at the University of Hawaii, School of Medicine, Department of Tropical Medicine and Medical Microbiology. Honolulu.

This case history is a good  example of the  well-documented evidence which should be compiled for  harm caused by massage.

"A 64-year-old woman ... had ... an overly vigorous shiatsu massage that caused pain in the left peri-cervical and suprascapcular areas." She subsequently developed other symptoms, and sought medical treatment seven days after the massage.

The report concluded, "Though possibly coincidental, a causal link between shiatsu massage and zoster is supported by the patient's claim of massage-induced neck trauma, and the temporal relation between trauma and onset of symptoms that progressed to zoster. Described by Charcot and Brown-Séquard in 1859, 'traumatic zoster' has long been controversial.

"Enactment of workmen's compensation laws around the turn of the century prompted publication of many case reports, but sceptics attributed them to chance. The condition is rarely diagnosed today; much of the evidence for its existence is anecdotal.

"Nevertheless the apparent clustering onset of rash at around 3-4 days post-trauma and the preponderance of right versus left involvement, especially in cervical dermatomes, are otherwise difficult to explain.

"We speculate that in our patient zoster resulted from either direct trauma to the nerve or nerve root damage during the massage, or to subsequent tissue inflammation causing swelling or immunological injury to the nerve."

The reason why the authors only speculate on the etiology of the zoster is probably because of what their literature survey revealed and because they had only one case of its kind. At least several similar cases are usually required to determine a cause-effect with certainty.

 PART 11: THE PEW REPORT RECOMMENDED TITLE PROTECTION 

BECAUSE THERE'S LITTLE

RISK OF HARM

This following information is taken from the report, Reforming Health Care Workforce Regulation, Policy Considerations for the 21st Century,  was issued in December, 1995, by the Taskforce on Health Care Workforce Regulation.

The Pew Health Professions Commission "charged the Taskforce ... to identify and explore how regulation protects the public's health and to propose new approaches to health care workforce regulation to better serve the public's interest."33

The report recommends that "title protection... is appropriate for professions" which provide services which are not especially risky to consumers." The report refers to massage therapy as such a service.

One of the "policy options" which the report recommends "for state consideration" is to "grant title protection without accompanying scope of practice acts to some professions." "Practice acts" refer to licensure which is "permission granted by government to engage in a business or occupation or in an activity otherwise unlawful"

"Title protection," also known as "right-to-title" acts, is "often referred to as 'state' certification... State 'certification' regulates the use of a specific occupational title... but does not provide a service monopoly; anyone may deliver the service, but only those actually certified may use a protected title."

Title protection permits people to do massage without having to comply with state-defined educational requirements. It does that because the risk of harm is negligible. This means there is  very little risk of harm. 

Since there is so little risk of harm, why  have so many states enacted practice laws which require all people, who want to do massage, to meet state-defined educational requirements allegedly to protect the public from harm?

PART 12: ALTERNATIVES TO COMPULSORY STATE REGULATION

Live and let live

Practice Acts are not needed to protect massage therapists from battle wars and turf battles, where other professions attempt to prevent their doing massage. Nor are practice acts needed to obtain third party payments.

There are two alternatives to practice acts. One is voluntary title regulation.11 This provides a state credential for massage therapists who want it and comply with state requirements. Others, who don't want a state credential, would be permitted to do massage without complying with the requirements.

The second alternative is self-regulation which, like  voluntary title protection, should be voluntary. It should not be mandatory for all massage practitioners.

However, those who want self-regulation should regulate themselves. They should respect the right of others (who don't want to be regulated) to massage people who are willing to pay for their unregulated service.

Self-regulation should not establish monopoly control, which practice acts do. Ontario has self-regulation with title protection, without monopoly control.

For both alternatives, those who are credentialed could call themselves Certified Massage Therapists. Others could call themselves Massage Providers, Massage Practitioners, or use some other title which does not indicate they're Certified Massage Therapists.

This is comparable to what the Regulated Health Professions Act 1991 of Ontario has established.

PART 13: FREEDOM OF CHOICE

We are an

endangered species

Global ecological damage, which has already caused the extinction of some species of plants and animals, is now detrimental to our well-being.

Practice acts, which cause the extinction of unregulated species of bodyworkers are also detrimental to our well-being.

All plants and animals are needed to maintain a balance in nature. That's why we have the Endangered Species Act. In like manner, unregulated massage therapists are needed to maintain a balance in available health care.

Freedom of choice. Who's freedom?

Two freedoms. Freedom of choice in health care is important because it gives us the right to get the treatment we want from the health care providers we want. But we don't have that freedom of choice unless the health care providers we want have freedom to practice.

We therefore need: Freedom of choice for the consumer, and  freedom of choice for the practitioner.

PART 14: MASSAGE THERAPISTS

HARM THEMSELVES, NOT

THEIR CLIENTS

While harm to clients is not a problem, massage therapists have to be careful not to injure themselves while doing massage.34 

It is therefore not the public, but massage therapists who need to be protected from harm. Those, who are concerned about unregulated massage therapists' harming the public, should direct their concern to massage therapists who harm themselves by doing massage.34

These are the people who really need to be protected from harm. But state regulation of massage will not prevent them from harming themselves.. They have to be taught how to avoid doing that.

All massage schools should warn their students that Giving a massage is a contraindication which may result in massage therapists' harming themselves.

They should teach their students how massage therapists harm themselves, how they can avoid harming themselves, and how they can help themselves recover from this self-inflicted harm. This information is now readily available.34Massage schools should also teach their student about burnout; how they can avoid this kind of harm;35 and how to minimize sexual harassment by male clients.

 

Educational programs in self-care for massage therapists should replace the controversial promotion of state regulation to prevent the public from harm allegedly caused by unregulated massage therapists; and attempts to gain monopoly control of massage and other kinds of bodywork.

Controversy recently flared up in British Columbia.23  Susan Stewart, President of the College of Massage Therapy (which is accused of wanting monopoly control of all bodywork), admitted the College's first proposal to expand regulatory control "was silly."23 This proposal is why the controversy erupted.

PART 15: CONCLUSIONS -

A REALITY CHECK

We have to know what harm

we're talking about

It is necessary to clearly recognize the important difference between the following two questions in order to avoid confusion in discussing whether regulation is needed to protect the public from harm:

1. Does harm actually occur?

2. Does enough harm actually occur to justify regulating massage to protect the public from that amount of harm?

If the answer to either of these questions is "No" there's no need for regulation to protect the public from harm

Definitions

Harm, with respect to regulation, means that a sufficient number of people have been injured by massage, and their injuries were sufficiently serious to justify regulating massage to protect the public from that harm.

Significant harm is harm which affects a large number of people and is serious.

 No harm means that a sufficient number of people have not been harmed to justify regulation to protect the public from that harm.

Actual harm is harm that has actually occurred.

Potential harm  refers to harm that may or may not occur.

Well-documented harm is harm for which there is well-documented evidence of a cause-effect relationship with massage.

Anecdotal harm is harm for which there's no convincing evidence of a cause-effect relationship. 

The risk of harm is determined by the number of people who have been harmed and how serious their injuries have been. Risk is not determined by potential harm, as I pointed out for lightning. 

If  no actual harm has occurred, there's no need for regulation to protect the pubic from harm.

Harm, allegedly caused by massage, is unique because:

If massage causes harm, why is that harm not included in statistics which agencies compile on the numbers of people injured and killed by different causes? As I have pointed out in Part 10, we know how many people in the U.S. are killed by lightning annually, even though the numbers are low.

If massage causes harm, why aren't massage therapists told how many of them have injured clients, how serious those injuries were, whether personal injury claims were filed, and whether their insurance covered the claims?  

Consumer Protection Agencies have not lobbied state legislators to regulate massage to protect consumers (the public) from harm.

Regulation, by practice acts, has been promoted by special interest groups that benefit from the monopoly control that practice acts provides.

Those who promote regulation to protect the public from harm have not provided enough well-documented harm to justify the need for regulation to protect the public from harm.

Those, who allege that contraindications justify regulating massage to protect the public from harm, have not provided information about how many people with each contraindication have been harmed.

Is massage iatrogenic?

The term iatrogenic refers to medical treatment which unexpectedly caused serious harm. If massage caused harm, the term iatrogenic massage would appropriately designate massage which unexpectedly caused serious harm.

The term iatrogenic massage does not appear in the massage literature because iatrogenic refers to harm which has actually occurred, not to potential harm. Contraindications are conditions which are potentially harmful because they predispose an individual to harm. But that harm may or may not occur. If contraindications were linked to serious harm, the term iatrogenic massage would probably be in the massage literature.

There are many, well-documented reports about numerous benefits of  massage. But, despite all the concern and warnings about contraindications, there are no reliable statistics about the incidence of massage-caused harm.

The incidence of harm is the amount of harm, expressed as the number of people who have actually been harmed. Because massage does not cause harm, the term incidence, like the term iatrogenic, does not appear in the massage literature.

Isolated reports of such harm do not prove it is widespread. Repeated allegations about harm are repeated allegations, not evidence about how much harm has occurred. Reports which are not well-documented are comparable to financial reports which cannot be audited because they are incomplete. Reports of massage therapists who did not harm people with contraindications are no substitute for definitive information about massage therapists who did harm people.

Since massage has adopted what it calls the medical model, it should provide information about the incidence of iatrogenic massage comparable to the well-documented information about the  incidence of iatrogenic medical treatment.

The incidence of iatrogenic

medical treatment

"Medical malpractice alone kills an estimated 45,000 people annually, making it the leading cause of accidental injury and death."36 "Conventional medicine is the "fourth major cause of death."  It follows heart disease, cancer, and stroke." Drugs which doctors prescribe kill more than 100,000 people a year, but the cause of death is listed as infection, cardiac arrest, or something else. "Every year, prescription drugs cause 1,000,000 injuries so severe that those affected  require hospitalization. Another 2,000,000 drug-related injuries occur during hospital care."37

One of  20 contraindicated drugs was given to 6.64 million (23.5%) Americans 65 years and older. Two or more such drugs were given to 5.75 million (20.4%) in the same age group.30 Harmful drug-induced effects have been responsible for "61,000 people with Parkinson's symptoms, 163,000 with memory loss or other cognitive deficits, 41,000 people hospitalized for ulcers, 32,000 hip fractures from falls caused by drugs that sedated patients or unbalanced patients, and 16,000 car crashes a year due to adverse drug reactions."38

How to do research to find out

if massage is iatrogenic

There are innumerable reports of well-documented benefits of massage, but so few if any well-documented reports of harm. For this and other reasons, set forth in this report, some people see no need to regulate massage to protect the public from harm.

Others believe it is important to document harm associated with contraindications.39,40   But accumulating convincing evidence that regulation is needed to protect the public from harm, associated with contraindications, requires well-designed research with adequate sample populations of (a) regulated and unregulated massage therapists and (b) their clients who do and do not have contraindications.

The controls are the regulated massage therapists and the clients without contraindications. The four categories of subjects should be followed over a period of at least two or three years.

The research should compile the following  well-documented information:

How many people, in each category, were injured? How many people with each contraindication were injured? What was the nature of each injury, and how serious was it? How many massage therapists injured people in each category, and with each contraindication? What training, and how many years of experience did those massage therapists have? What were their grades on the National Certification Examination?

The following estimated information should also be recorded:

How many people were doing massage? How many people were massaged? How many massages were given? There should be enough data to work with. There are an estimated 200,000 massage therapists and other bodyworkers in the U.S.44 It they each give an average of 20 treatments a week, that amounts to over 200 MILLION TREATMENTS A YEAR.

WITH OVER 200 MILLION TREATMENTS A YEAR, WHERE'S THE HARM?

What we have to know

 about regulation

Is there well-documented evidence that regulation really protects the public from harm? If it does:

1. How many people have to be injured to justify the need for regulation to protect the public from harm?

2. Should regulation be enacted to protect the public from very little harm such as, for example, one complaint of harm every three years, which amounts to 33 complaints in a century (as in Hawaii)?

3. How do those, who make decisions about the previous two questions, justify their decisions?

Some state legislatures have regulated massage without having done their own research to find out whether massage has actually harmed people, and whether regulation does indeed protect the public from harm.

The public does not need to be protected from unregulated massage practitioners because they don't cause harm.

The public does need to be protected from regulation which establishes state-sanctioned monopoly control.11,26,41-43  because monopoly control:

1. denies people the right to be treated by unregulated massage practitioners, if that's what they want.

2. denies people the right to make a living or earn supplemental income by providing an unregulated massage service which the public wants and which doesn't harm people.

3. violates laws that protect freedom of speech and freedom of the press; and laws that prohibit (a) arbitrary governmental interference in an individual's right to engage in a lawful business, and (b) restraint of trade, monopolies, and unfair trade practices.41

For these reasons, regulation is iatrogenic, even if it's promoted with the best of intentions.

If there's no harm from which the public needs to be protected, is the establishment of monopoly control the hidden agenda in the promotion of  regulation allegedly to protect the public from harm?11,26,41-43

The allegation of harm is the

beginning of monopoly control

It seems that proponents of licensing are hopeful that a state license would mean more money, status, and power. - Jerry A. Green, Attorney  for the California Coalition on Somatic Practices.11

 I think the move toward licensure is regrettable. I believe licensing creates state-sanctioned monopolies ... with the explicit goal of  'protecting the public,' but with the real effect of protecting those who hold the monopolies' respective entitlements, reducing information to the public, and restricting competition. - Don Schwartz.11

Massage regulation is illogical

Why does regulation, allegedly to protect the public from harm, require hundreds and thousands of hours of training to do massage which does not cause harm?

The American Red Cross offers 4 to 9 hour trainings in  Cardiopulmonary Rescusitation (CPR) and 4 to 7 hour trainings in First Aid . These trainings prepare  people to treat individuals with  life-threatening conditions. Massage therapists do not work on people with life-threatening conditions.

One might say that  CPR and First Aid are applied to people whose health problems are apparent, whereas contraindications for massage are not apparent. That is true. But are hundreds and thousands of hours of training required for massage therapists to learn to avoid harming clients with contraindications, for which there is little if any well-documented evidence of harm by unregulated massage therapists?

Many states have enacted practice acts without having any well-documented evidence that massage has actually caused significant harm. Their laws are based on the unjustified assumption that, because massage is potentially harmful, it should be regulated to protect the public from harm that may occur.

But no significant harm has actually occurred, despite the fact that so many unregulated massage therapists have treated so many people with so many contraindications for so many years.

If there's enough well-documented harm to justify regulation to protect the public from harm, the existence of that harm has been the best kept secret in the history of massage.

Nobody should have to prove massage is safe. Massage should be presumed to be innocent (safe) until proved guilty (of harm). Those who allege massage is harmful have an obligation to provide well-documented evidence that it's harmful.

Nobody should have to prove regulation is not needed to protect the public from harm. It should be assumed that regulation is not needed for that purpose, unless there is  well-documented evidence that it is.

Where government agencies (Georgia and Quebec) have done their own research, they have found no harm and have not regulated massage

This report is not to be construed as legal advice.

References

1. McKibben, B. Too hot to handle. The Nation. p.10. Nov. 10. 1997.

2. Ehrenhalt, A. Why we're hooked on credentialism. Governing.  pp. 7-8. November. 1997.

3. Shepard, P. Hair-braiding boom turns into a battle. San Francisco Chronicle. 0ctober 2. 1997.

4. Cosmetology: one business that wants to keep its license. San Luis Obispo Telegram-Tribune (CA). July 9, 1997.

5. Deregulation of some professions is positive move. Atlanta Daily News. Feb. 10. 1997.

6. Greenawalt, II, C.E. Issue Brief. Sunrise legislation - a new curb on bureaucracy. The Commonwealth Foundation. Harrisburg, PA. February 1993.

7. Special Report. California Coalition on Somatic Practices. September, 1996. (California Coalition on Somatic Practices. P.O. Box 5611. San Mateo. CA. 94402-0611)

8. Schatz, A., and Brewster, M. Massage does not cause enough harm in California  to justify regulation. Journal of Spiritual Bodywork. 2(4):6-7. 1996.

9. York, B. I must speak up. Part 1. The Rub (Newsletter published by Robert Flammia) P.O. Box 459. Berkeley, CA 94701)

10. Schatz, A. The Georgia AMTA's data  reveal that massage is safe, not harmful. Licensure is not needed to protect the public from harm which does not occur. Spiritual Massage Ministry Newsletter. 3(2):1-4. 1998.

11 Schatz. A. Follow the money trail to find out why scare tactics tell us secular massage is harmful. Journal of Spiritual Bodywork. Special Issue No. 4. 1997.

12. Schatz, A. Pennsylvania does not need to regulate massage and does not need Senate Bill 1171. Pennsylvania senators should find out whether massage causes harm, as Georgia senators did. Massage Law Newsletter. 3(1):1-3.1998.

13. Schatz, A. An open letter to Barbara Mikos. Massage Law Newsletter. 4(2):3. 1998.

14. Overview. Sunset Evaluation Update: Massage. A Report to the Governor and the Legislature of the State of Hawaii by The Auditor of the State of Hawaii. Report No. 92-17. November. l992.

15. Napolitano, R. Teaching prenatal massage to pregnant couples. A worthwhile mission for massage therapists and bodyworkers. Massage & Bodywork. pp. 94-97. Spring. 1998.

16. National Center for Wellness & Health Promotion. Silver Spring. MD.

17. Iglehart, H. The unnatural divorce of spirituality and politics. pp. 405-414. In The Politics of Women's Spirituality. Essays on the Rise of Spiritual Power within the Feminist Movement. Edited by Charlene Spretnak. Anchor Books. New York. 1982.

18. Eabry, S. Book review of The Art of Touch: A Massage Manual for Young People, by Chia Martin. Massage Magazine. p. 153. January/February. 1998.

19. Reading, Writing, and Relaxation. Mind-Body Connection. News from the Center for Mind-Body Medicine. Washington, D.C. Fall. 1995.

20 Schatz, A. Senate Bill 1171's 200-hour training for reflexology is absurd. Massage Law Newsletter. 3(4):1-2. 1998.

21. Étude sur les thérapies manuelles et le massage réalisée en vue de l'avise au ministre responsable de l'application des lois professionnelles sur l'opportunité de constituer une corporation professionnelle dans le domaine des médicines douces. Office des professions du Québec. Direction de la recherche. Montreal. Mai 1991. 

22 Avis au ministre responsable de l'application des lois professionnelle sur l'oppportunité de construir une corporation professionnelle dans le domaine des médicines douces. Office des professions du Québec. Montreal. Avril 1992.

23. Walsh, K. British Columbia's battle of the bodyworkers. Animosity grows toward BC Massage College as legislative changes to massage regulations are proposed. Massage Magazine. Issue 76. pp. 117-124.  Nov/Dec. 1998.

24. Alexander, D. How Safe is Massage?  Ontario Massage Therapist Newsletter, Feb/March 1992.  

25. Alexander, D. Professionalism and Licensure in Massage.  Massage & Bodywork Quarterly. pp. 77-80. Winter 1994.

26. Carlson, K, Barbera, R.M. and Schatz, A. The public doesn't need state regulation of massage. So who wants it and why? Massage & Bodywork Quarterly. pp. 83-86. Fall. 1993.  

27. Leach, E. Letter to the Editor. Massage Magazine. Issue # 75. Sept/Oct 1998.  

28. Schatz, A. Guest Editorial. Massage Therapists do not harm people. Massage Magazine. Issue #72. March/April 1998.  

29. Cowell, E. A Rose by Any Other Name: AMTA Sponsors Title Debate. Part II.  Massage Therapy Journal. page.45. Spring 1994.  

30. Schatz, A. Letter to the Editor. (My reply to Sonia Turanski's Letter to the Editor). Massage Magazine. Nov/Dec. 1998. 

31. Blumenthal, M. How safe are herbal products? Health Counselor, pp. 14-15. October. 1991.   32. Mumm, A.H., Morens, D.M., Elm, J.L., and Diwan, A.R. Zoster after shiatsu massage. The Lancet 341:447, 1993.  

33. Reforming Health Care Workforce. Regulation Policy Considerations for the 21st Century. Report of the Taskforce on Health Care Work-force Regulation. The Pew Health Professions Commission. Center for Health Professions. University of California. San Francisco. December 1995.

34. Greene. L. Save Your Hands! Injury Prevention for Massage Therapists. Edited by Robert A. Green, M.D.) Infinity Press. Seattle, WA. 1995.

35. Crawford, D.P. Burnout. Massage Therapy Journal 37(1):115. Spring. 1998.

36. Fugh-Berman, A. The case for 'natural' medicine. The Nation. p. 240. Sept.6/13. 1993.

37. Moore, T. J. Prescription for safety. Natural Health. pp. 52-55. September/October. 1998.

38. Dr. Julian Whitaker's Health & Healing® (newsletter). 6(1):1-3. :Jan. 1996. Phillips Publishing, Inc. Potomac. MD.

39 Benjamin, B.E., and Walton, T.H. Risks and benefits of massage and bodywork. Massage Therapy Journal. 37(1):23-28. Spring. 1998. 

40. Walton, T.H. Contraindications to massage therapy. Part 1: Roadblocks on the way to consensus. Massage Therapy Journal. 37(2):108-112. Summer. 1998.

41 Schatz, A. Do state massage laws and local ordinances violate U.S. Constitutional law, U.S. Supreme  Court decisions, and the United Nations International Bill of Human Rights? Massage Law Newsletter. 4(3):1-6. 1998.  

42. Schatz, A. The corporatization of massage. An economic perspective. Massage Law Newsletter. 2(2):1-7. 1997.

43. Carlson, K., Barbera, R.A., and Schatz, A. Is state regulation of massage illegal? Massage & Bodywork Quarterly. pp. 42-52. Fall. 1993.

44. A career in massage and bodywork. pp. 2-5. Touch Training Directory. Associated Bodywork & Massage Professionals. Evergreen, CO. 1997.

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