That exquisitely human contact we know as massage is in essence a universal birthright of our kind. - Raphael Tuburan

PART 1: CONTRAINDICATIONS

In this report, we focus on contraindications,  which are potentially harmful. We do this because how much content the National Certification Examination (NCE) allocates to contraindi-cations indicates how important NCE considers contraindications in the practice of massage, even though they are only potentially harmful.

If contraindications have been associated with a significant amount of serious harm which has actually occurred, one  would expect that a relatively large percent of the content of NCE would refer directly to contraindications; and  many questions and answers would include the word contraindication.

Conversely, if contraindications have not been associated with a significant amount of serious harm which has actually occurred, one would expect that a relatively small percent of the content of NCE would refer directly to contra-indications; and  few questions and answers would include the word contraindication. 

 Without serious harm which has actually occurred (due to contraindications or for other reasons), one can legitimately assume that  massage is safe. If massage is safe, it does not cause harm. If it does not cause harm, there's no need for state regulation of massage therapists to protect the public from harm because harm has not actually occurred. 

So many massage therapists with so many kinds of training in so many states (which do not regulate massage) have been massaging so many people with so many contraindications, so many times for so many years, with so many well-documented reports of so many benefits, but with so few if any well-documented reports of harm.

If the millions of  massages, which have al-ready been done, have not caused significant harm, one may legitimately assume that massage will be as safe in the future as it has been in the past. 

Reports on our website <www.tiac.net/users/maryella> present well-documented evidence that massage therapists do not cause enough  harm to justify the alleged need for state regulation to protect thepublic from that harm

According to Doug Alexander, who researched the issue of harm, "Massage and bodywork are safe. There have never been any cases of physical injury to people."

1. If massage causes little if any well-documented harm in people with contra- indications, massage is less likely to harm people who have no contraindications.

2. If massage causes little if any serious harm, then massage is safe.

3. If massage is safe, it's not harmful.

4. If massage is not harmful, there's no need for state regulation which allegedly protects the public from harm.

If there's no need for state regulation to protect the public from harm, why do so many states regulate massage therapists?

One might say that many questions in NCE are relevant, in one way or another, to contra- indications. This is true in the sense that all NCE questions should apply, directly of indirectly, to massage.

But two important questions about NCE are: How much of NCE's content refers directly to contraindications? And, what does the answer to the previous question tell us?

What we find is that NCE allocates only about 1.2% of its total content to contraindications. Although this 1.2% is an approximation, it is significant because it's so low. Even if the content, allocated to contraindications, were 100% or 200% greater than 1.2%, it would still be low. 

This 1.2% indicates that NCE does not consider contraindications very  important, at least not as a risk of harm. This 1.2% also cor- relates with the fact that there are so few if any well-documented cases of people with contra-indications who have been seriously harmed by massage therapists.

Therefore, why is state regulation allegedly needed to protect the public from harm? We believe the  answer to the question is obvious. Regulation is not needed to protect the public from harm because there's no harm from which the public needed to be protected.

PART 3: CALCULATIONS

We calculated the 1.2% from information in the August, 1998, edition of the National Cert-ification Examination Candidate Handbook. Page 15 provides information about the Exam- ination Content Outline with Percentage Weights of Major Content Areas.

We assume the relative importance of individual subject areas and topics within each Major Content Areas can be approximated in terms of percentage weights.

The four Major Content Areas and their re- spective percentage weights are:

Content Area 1: Human Anatomy, Phys-iology, and Kinesiology (27%)

Content Area II: Clinical Pathology and Recognition of Various Conditions (20%). This Content Area includes contraindications.

Content Area III: Massage Therapy and Bodywork Theory, Assessment, and Application. (41%).

Content Area IV: Professional Standards, Ethics, and Business Practices (12%).

What percentage weight does NCE

The percentage weights reported below (other than the 20% for Major Content Area II) have been calculated for minor content areas of NCE.

Content Area II, which has 20% of the entire exam, includes parts A and B, both of which have a total of six subject areas.

Part A, which is entitled "History and client intake process," has four subject areas which amount to 13% (= 4/6 of 20%) of NCE.

Part B, which is entitled "Disease and injury related conditions," has two subject areas, each of which has 3.5% (= [2/6 of 20%] ÷ 2) of NCE.

The first of the two subject areas in Part B is entitled "Signs and symptoms of disease of the major systems of the body; indications and con-traindications."

"Contraindications" are one of three topics in the first subject area. Therefore, NCE allocates only 1.2% (= 3.5 ÷ 3)  of its total content area to contraindications.

This 1.2% indicates that NCE does not consider contraindications to bevery important.

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Part 1 of this report examined the content of the August, 1998, edition of the National Cer-tification Examination (NCE) Candidate Hand-book, and concluded that NCE did not consider contraindications very important because;

1. NCE allocated only 1.2% of its content to contraindications.

2. NCE allocated 42% more content to Basic business and accounting practices than it did to contraindications.

The book's Preface tells us, "All areas of therapeutic massage and bodywork are covered in 600 questions that closely correlate in percentage to the content areas outlined in the NCTMB Candidate Handbook.

"The content is divided into Anatomy, Physiology and Kinesiology (30%), Massage/Bodywork Theory, Assessment, and Practice (40%), Clinical Pathology and Recognition of Various Conditions (15%), Adjunct Techniques (5%), and Business (10%)."

The percent of each content area in this book differs somewhat from the corresponding percentage weights of the major content areas in the August, 1998, edition of the National Certification Examination Candidate Hand-book, which we examined in Part 1, because the book was published in 1997, a year earlier than the 1998 Handbook.

The first part of the book contains  600 questions and answers. The second part is a Comprehensive Simulated Exam with 150 questions  selected from the 600. All questions are multiple-choice with four answers to choose from. Therefore, the 600 Practice Test questions have 2,400 possible answers and the 150 Simulated Exam Questions  have 600 possible answers.

Let us now see how frequently the words contraindication, business, CPR, and First Aid appear in the content, questions and answers.

How much content does NCE allocate

The NCE, to which Garofano's book refers, lists contraindications as one of 12 subjects in Content Area III: Clinical Physiology and Recognition of Various Conditions, which makes of 15% of the total content of NCE.

Contraindications are therefore allocated about 1.3% = {[(15 ÷ 12)] x 100} of the total content of NCE. This 1.3% is comparable to the 1.2% for the August, 1998, edition of NCE, which we reported in Part 1.

Content Area V has five subject, two of which are Basic Business Practices and Standards, and CPR and First Aid. Therefore, NCE allocates 2.0% = [(10 ÷ 5) x 100] of its content to Business Practices and Professionalism and about 2.0% to CPR and First Aid.

NCE therefore allocates 54% = {[(2 -1.3) ÷ 1.3] x 100} more content (a) to business matters and (b) 54% more to CPR and First Aid than it does to contraindications.

Calculations based on the 600 questions

and 2,400 possible answers

The word contraindication appears in only:

1. four (0.67%) of the 600 questions  and five (0.21%) of the 2,400 answers.

2. nine (four + five )(which is 0.3%) of the 3,000 (600 + 2,400) questions and answers combined.

The words business, money, ledger, in-surance, etc. appear in at least 20 (0.67%) of the 3,000 questions and answers.

The acronym CPR and the words First Aid appear in at least 17  (0.57%) of the 3,000 questions and answers. 

Therefore, the business  terms appear 123% = {[(0.67 - 0.3) ÷ 0.3]  x 100} more frequently than the word contraindication.

The acronym CPR and the words First Aid appear 90% = {[(0.57 - 0.3) ÷ 0.3] x 100} more frequently than the word contraindication.

This indicates that NCE attaches little importance to  contraindications in general, and considers contraindications significantly less important, in the practice of massage, than (a) business matters, and (b) CPR and First Aid.

Why does NCE devote so little attention

The most likely reason why NCE devotes so little attention to contraindications  is that NCE considers contraindications of so little importance in the practice of massage.

The most likely reason why NCE considers contraindications of so little importance in the practice of massage is because so little if any harm has actually occurred with clients who have contraindications. 

Why does NCE devote attention

CPR and First Aid are not required to get a driving license even though auto accidents frequently injure people, who then have to wait until the police or an ambulance to arrive.

The massage literature is replete with comments about contraindications and their potential harm. But how many reports in the massage literature reveal why it is important for massage therapists to know how to administer CPR and First Aid.

Therefore, since NCE  allocates so little content to contraindications, why does it allocate so much more content to CPR and First Aid?

Why does NCE devote 90% more attention to CPR and First Aid than to contraindications? What well-documented research tells us:

1. How many massage therapists have had to administer CPR and First Aid  to how many clients (and on others), for what reasons, and with what results?

2. How many clients have fallen off massage tables, and how seriously were they injured?

3. How many clients have tripped on stairs or had other accidents on the premises of their massage therapists? If so, what was the nature of these other accidents, and how serious were they?

4. For how many clients, have how many massage therapists had to call for emergency treatment? How many clients have had to be rushed  from the massage table to get emergency room treatment?

In other words, how necessary has it been  for massage therapists to know CPR and First Aid in order to protect their clients?

If there's no well-documented evidence that training in CPR and First Aid has actually been necessary for a significant number of  massage therapists, why are CPR and First Aid included in NCE?

How many clients have to be injured in ways, which require massage therapists to know CPR and First Aid, in order to justify including CPR and First Aid in NCE?

Conclusions

In the practice of massage, the risk of harm from contraindications, is directly proportional to the  amount of serious harm which has actually occurred.

Therefore, if contraindications pose a high risk of harm, one would expect NCE to allocate a proportionally large amount of its content to con-traindications and include the word contra-indication, perhaps in bold type, in a pro-portionally  high percent of its questions and answers.

However, when we consider the numbers of questions and answers, in NCE, which contain the word contraindication and the content of NCE allocated to contraindications, the results indicate that NCE attaches relatively little importance to contraindications. NCE also considers contra-indications to be less important, in the practice of massage, than (a) business matters,  CPR, and First Aid.

This little attention which NCE allocates to contraindications correlates with the well-documented evidence that:

So many massage therapists with so many kinds of training in so many states (which do not regulate massage) have been massaging so many people with so many contraindications, so many times for so many years, with so many well-documented reports of so many benefits, but with so few if any well-documented reports of harm.

 Consequently, massage therapists cause so little if any harm that there is no justification for the alleged need for state regulation to protect the public from that harm.

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Our other reports on National Certification and on regulation, the issue of harm, etc are on the interned <www.healinglaw.com>.

We welcome and will publish comments from those who have different views of what we present.