Note: In the following blog entry there are (#'s) and they correspond to online resources. Please contact me if you'd like the resource document that it is referring to.
The American Massage Therapy Association (AMTA) is a non-profit serving massage therapists nation-wide. Their mission is to advance the art, science, and practice of massage therapy. The annual conventions are a way to bring practitioners together from all over the country to advance their knowledge and gain perspective. And, of course, to connect with one another. The first convention was in Chicago in 1943 – they met to pledge service to the ethical practice of massage therapy. In 1946 there were a whopping 68 members. Now – 71,000.
Next year’s convention will be here in California, just over in Pasadena. No excuses to miss it. One note about AMTA is they fund the Massage Therapy Foundation (MTF) to do research and there are many ways to get involved; more to follow.
AMTA created a constitution that said they’d “foster the spirit of cooperation, exchange of ideas and techniques, and advance the science of massage to merit respect and confidence of all people and benefit mankind.”
This is a huge statement and one that is just as relevant as ever before. In the 1950’s and beyond there were issues with the basic legitimization of massage through state law. We still struggle with separating massage from ‘illicit activities’ and keeping our practices in the realm of health, wellness, and medicine.
A beginning place is to know our industry; truly understand who we are so we can act together instead of separately. In January 2006, AMTA released its first summary overview of the industry and since then you can access it as an awesome resource. (1) Understanding who we are will help to know where we’re going and the best way to plug our own practices into the greater picture.
Licensing is mandatory. Certification is voluntary. There are laws governing massage therapy as an industry and then bylaws which are established by local agencies. California Massage Therapy Council (CMTC) is an agency that represents and establishes our bylaws.
We are going to activate the corset muscles as Dr. Bruce Costello focused on at the convention. This includes the transverse abdominals which are directly under the internal obliques. They are responsible for compressing our abdominal contents – ‘minor details’. They also provide thoracic and pelvic stability. Also, included in the corset are the multifidus along the spine(iliocostalis, longissimus and spinalis), the diaphragm(lumbar, rib costals 7-12, xiphoid process), and the pelvic floor muscles.
To begin, let’s stand up, hands on hips, deep breath in and with full exhalation, let the chest expand which pulling the abdominals in toward the spine. Keep shoulders from rounding, look straight ahead. Repeat twice.
Okay, let’s sit. We’re going to take a deep breath and reach for stars. Expanding the ribcage, but keep it fixed. Activate the corset, lower the shoulders, extend the neck, look forward, feet flat on the ground. Let the arms drop down, but keep everything else in position. It might feel unnatural or difficult because it requires an engagement of the muscles. One note: If we don’t resist gravity, with muscle contraction, we’re literally hanging on our joints and that creates muscle tonicity.
Next, remaining seated, flex the hip, keeping a straight leg. Notice any restrictions, what happens to your spine. S.I. joint discomfort? Which is usually the result of a tight piriformis and weak glute maximus. Let’s clasp our hands behind of our heads and, keep a neutral spine, breathing, bring opposite elbows to opposite knee. Don’t compromise the neutral spine by reaching for the knees. If you can’t reach, stop where is comfortable. Remember a neutral spine is essentially when the PSIS and ASIS are in line. If you know you already have either a posterior or anterior pelvic tilt, take that into consideration when performing exercises.
Now we’re going to do a bridge with a straight leg raise. This will activate the transverse abdominals as well as the glutes. DO NOT perform if you know you have S.I. joint issues as this will increase the shearing effect placed on the joint.
- Keep your hips level for the entire exercise.
- Keep abdominals tight. o Slowly raise buttocks from the surface.
- While keeping your hips raised, straighten out one leg.
- Slowly return leg to start position, and repeat with the other leg.
- Slowly lower hips to the surface.
- Do not arch your back.
- Do not raise your hips too far off the surface.
Okay, we’re now going to re-measure ourselves and see if we’ve gained any length in our spines. These are basic exercises that we can use ourselves as well as teach our clients to integrate in their morning routines or even on lunch breaks during work.
Imagine if your primary doctor didn’t accept insurance, but you seriously required treatment. The only thing standing between you and the treatment was the cost. Now replace doctor with MT. If we value our work as a healing modality and want others to, one good way is to make our work accessible by taking the financial burden off the table and getting more people on our table.
As massage therapists, we are on the cusp of multiple waves. ACA healthcare reform, preventative and wellness care trends, “self-actualization consumerism”, the experience economy, and chronic disease/sick-care paradigm shifts. Let’s not forget about the opiate epidemic and CAM therapies joining the mainstream. Worth looking into the following:
- ACO’s and Physician-Owned entities (4)
- Medicare Part B – PT/OT/referral (5)
- Worker’s Comp, Personal Injury Protection (PIP) (6)
Also of importance to massage therapists is that insurance companies must offer a set of essential health benefits in the following 10 categories:
- ambulatory care
- emergency care
- maternity and newborn care
- mental health and substance abuse
- prescription drugs
- rehabilitative and habilitative care
- laboratory services
- preventative and wellness services
- pediatric services
Imagine that we are like subcontractors to the insurance companies. Our job is to know these 7 guidelines:
- Which types of cases can or cannot be accepted
- Obtain authorization & verification of coverage
- Be prepared with forms
- Conduct an intake interview & get proper signatures
- Evaluate before and during sessions – SOAP notes
- Document & understand rules
- Prepare and submit accompanying documents
We need to get a physician’s prescription – this is a good opportunity to make connections and receive referrals.
Claims are reimbursed for a percentage of what they are billed for. There is a recommendation that there are not “different” prices for cash vs insurance clients, rather a “fee scale” that is based on particular services. The reimbursement is based on: patient eligibility, provider credentials, and medical necessity. It might be good to get a professional CMRS (certified medical reimbursement specialist) or RHIA (registered health information administrator) who is trained in medical billing to help enter the CPT and ICD codes and process the paperwork correctly. (7) ICD-10 - 14,000 codes within the International Statistical Classification of Diseases and Related Health Problem. (8) CPT - Current Procedural Terminology. These are some of the CPT codes commonly used by massage therapists:
- CPT Code 97124 Massage Therapy
- CPT Code 97140 Manual Therapy
- CPT Code 97112 Neuromuscular Re-education
- CPT Codes 97010 Hot/Cold Packs
- CPT Codes 97110 Therapeutic Exercise (9)
One key piece to becoming more integrated into the medical community and finding legitimacy in billing, reimbursement, research, and referrals is to act within our scope and know where we stand within the legal aspects of the industry. This is where industry ethics, guidelines, and Practice Acts come in. Practice Acts are based on mandatory licensing, not voluntary certification, however, Practice Acts for massage therapy are in the CAMTC guidelines. Begin to understand the SB731 and how it was revised to become AB1147 (here are the basic tenets: deals with local regulation, voluntary certification, ability to shut down human trafficking and illicit massage establishments). (10) & (11) AB2194 was recently agreed upon and as of 1/1/17 will help reduce redundant background checks, make it so only “reasonable and necessary fees can be imposed”, extends voluntary certification through the year 2020, prevents local ordinances from requiring showers in massage businesses (which can be costly), and gives local government ‘revocable establishment’ tools to help battle the illicit and trafficking issues*.
Superman and/or Plank
We accept that science requires research. Business requires research. Most things in life demand a depth of understanding in order to dig deep and find breadth. Massage is no different, on this level. This is what the MTF has to say:
Humans instinctively value the healing power of touch, and modern massage therapy comes from a long and venerable tradition reaching through time and across cultural boundaries. Rigorous research about massage can challenge tradition, but it strengthens our profession, and provides guidance for massage therapists to be as effective as possible. Since its inception, the Massage Therapy Foundation has funded 39 research projects, with a total of $720,366. Topics have ranged from massage for peripheral neuropathy related to chemotherapy, to postural control of elders, to migraines, cancer, and spinal cord injury. In addition, the Massage Therapy Foundation has consulted on numerous large-scale studies, funded two systematic reviews (one on stress, and one on sports massage), founded and published the International Journal of Therapeutic Massage & Bodywork (IJTMB), and hosted three international science conferences on massage therapy research.
Research and meta-analysis on the impact of massage therapy on pain (12)
In massage, there are ethics and guidelines as well. Here is the form for a research grant (13)
Case Studies are part of research (14)
For the Science Community
Adherence to the principles of good clinical practices (GCPs), including adequate human subject protection (HSP) is universally recognized as a critical requirement to the conduct of research involving human subjects. Many countries have adopted GCP principles as laws and/or regulations. The Food and Drug Administration’s (FDA’s) regulations for the conduct of clinical trials, which have been in effect since the 1970s, address both GCP and HSP.
For the Medical Community outside of Therapeutic Massage & Bodywork (TMB)
Title, keywords, abstract, introduction, client information, clinical findings, timeline, diagnostic assessment, therapeutic intervention, follow up and outcomes, discussion, client perspective, and informed consent.
TMB – that’s US!
Title, keywords, abstract, patient information, assessment measures, practitioner descriptors, therapeutic intervention (MASSAGE!), results, discussion Systematic Research Review Methods: Assemble a working group, develop a research question, search literature, screen literature, review methodology Data Extraction is where data is analyzed and crawled through to retrieve relevant information from data sources (like a database) in a specific pattern. Further data processing is done, which involves adding metadata and other data integration; another process is the data workflow. (15) Meta-analysis is a systematic review that answers a defined research question by collecting and summarizing all empirical evidence that fits pre-specified eligibility criteria. A meta-analysis is the use of statistical methods to summarize the results of these studies. PUBMED (16) – further research and data Sign 50 Checklist for validity in research and meta-analysis (17)
April 17, 2017 MTF will be sponsoring a team for the Boston Marathon – raise $10,000 and pay a $355 entry fee. “Running for Research”
PAIN – NOT AS FUN
Biopsychosocial cycle: 1977 George Engel called for a new medical model. Components: biology effects actions which effect interpretation of experience and symptoms. Social, environmental, religious, and economic status can all effect health. Well-being is based on medicine, psychology, and sociology which are all inextricable.
Pain is universal, how we experience it is unique. Pain is a riot. Acute pain = damage. Chronic pain ≠ damage = experience. Sensitivity = generalized experience, “oh, this again.”
Difficulty in measuring pain – scale might be taken out of E.R. admittance
1:5 report pain 1:10 report chronic pain – that’s 100+ million in chronic pain $560-$635 annual cost for pain management
military – 44% report being in pain 15% are on opiates
civilians – 26% report being in pain 4% are on opiates
>47,000 deaths/year from drug overdoses including opiate use – 2,000% increase since 2002.
Since 2014, CAM therapies for pain management include: yoga, tai chi, and music therapy -- hey, wait, why not massage??
Diana Thompson, works with the MTF – Author of the book: Massage, Movement, and Mindfulness Based Approaches
Douglas Nelson at the AMTA Convention reminds us that pain is a mystery not a puzzle and a process, not an event. This is to say that the experience of pain is not a single event, rather a compilation of many.
- Primary pain – secondary gain *Do I identify with my pain??*
- Nociceptors *Alarm System!*
- Heterotopic pain *Is that pain in your arm or are you happy to see me?*
- Spatial Summation *Brace for the instant; relax for the minute*
- Placebo/Nocebo *Heal or Harm*
- Amygdala Hijack (18) *I know what I was feeling, but what was I thinking?!*
- Descending inhibitory system *Foot in mouth* (19)
- Bi-directionality and avoidance *Relax?! I AM RELAXED!”
- Alpha – C Fibers *I may be slow, but I’m not dumb*