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The Future Of Massage
Indeed, it is not possible to predict an absolute course

By Whitney Lowe

Originally published in Massage Bodywork magazine, January/February 2008. Copyright 2008. Associated Bodywork and Massage Professionals. All rights reserved.

Someone once said, "Predictions are frequently inaccurate--especially those about the future." It is likely that fifty years ago few in the profession could have guessed massage would grow in the ways and to the extent it has. Indeed, it is not possible to predict an absolute course for the future of massage therapy. Nevertheless, it is valuable to review the general trends in the profession to gauge its growth patterns and future possibilities.

In the last issue, which celebrated the twentieth anniversary of Associated Bodywork Massage Professionals (ABMP), industry leaders gave their perspectives on notable changes over the profession's last twenty years. Through the commitment of industry leadership and professional therapists, massage has grown into a modality that is garnering far more respect than at any time previously. Clearly, massage therapy's future, though not firmly defined, is exciting and full of possibilities. In this issue, we take a peek into how massage is developing, what trends are becoming established, and what opportunities are lying ahead.


Healthcare or Personal Service?
In the last few decades, a division developed in the profession between massage as a healthcare modality and massage as a personal care service. The boundaries between these styles are sometimes blurry and practitioners often practice both. However, an increasing number of therapists are choosing to identify with one aspect of the practice over the other. Each style has different professional and educational interests that can either merge or be quite disparate.


Healthcare Massage
Massage therapy has a long history in healthcare throughout parts of the world. However, in the United States, its use as a healthcare practice greatly diminished with the rise of technological medicine and the pharmaceutical industry in the early twentieth century. For example, although once an integral part of physical therapy, massage gradually became a much smaller part of this profession in the latter half of the twentieth century.

It wasn't long ago that healthcare professionals in the United States scoffed at the idea of massage as a serious modality for a wide array of healthcare complaints ranging from musculoskeletal injury to pain management for cancer patients. Today, views are changing significantly. Groundbreaking studies on alternative medicine use by researchers such as David Eisenberg and Daniel Cherkin have shown a consistent pattern of both increased use and acceptance of massage as not only a viable healthcare modality, but a valuable one.1,2

Massage and other complementary and alternative medicine (CAM) practices are gaining interest with students in traditional medical schools, which is an indicator of even greater acceptance of these approaches by tomorrow's physicians. An example of this came in June 2005 at the National Education Dialogue (NED) held at Georgetown University. This was a meeting of more than seventy healthcare professionals and educators from conventional medicine and nine CAM disciplines. These educators discussed how to integrate CAM training into future medical school curricula. As a fortunate participant, I was pleased at the warm reception we received from educators from some of the most prestigious medical schools in the country. Many seemed not only fascinated, but excited about the growth and potential of our emerging profession

A picture of the profoundly expanding use of massage as a healthcare practice can be gleaned from several studies on the use of massage in the United States. Recent investigations show close to two hundred thirty million massage sessions were provided to American adults in 2006.3 Ineffective results in traditional medical treatment for musculoskeletal disorders has driven millions of Americans to seek better care through CAM approaches, such as massage therapy.

Another study on the practice patterns of massage therapists shows 60 percent of office visits to massage therapists each year are to address musculoskeletal symptoms,4 or roughly 138 million massage sessions. That is a huge number of massage sessions used specifically for healthcare, and the numbers are almost certain to continue rising.

For massage therapists wanting to make inroads into the traditional healthcare system in the United States, the outlook for this branch of the profession is bright. Practitioners offering treatment for pain and injury conditions, palliative care, and stress and anxiety will find their services in ever greater demand. In fact, consumer expectations in this regard are increasingly placing pressure on massage therapists in terms of skills.

Therapists offering healthcare massage are found in private clinics, sports settings, and other healthcare facilities. Increasingly, practitioners work in chiropractic and physical therapy clinics, doctors' offices, hospitals, universities, or other healthcare establishments. Massage is also an integrated healthcare program in professional sports, dance, and other physically demanding professions. We can look for greater inclusion of massage in mainstream settings, such as hospitals and primary care health clinics. We can also expect massage to continue to garner greater respect, and thus referral, by traditional medical practitioners.

An unsettled issue for massage as a healthcare modality is whether greater use of insurance reimbursement would have a positive or negative impact on the profession. This issue has been discussed with more detail in other articles. However, the main points of contention pose several legitimate questions that those in the profession should think seriously about prior to pursuing this course. Will, for example, insurance reimbursement truly lead to greater access for the consumer? Will the cost per massage then increase, as it did with physical therapy, thus reducing access by those without insurance? What will be the avenues and processes for approval by health insurance companies? How will this impact the profession? Will practitioners make more money? What are the true costs/benefits for practitioners doing insurance reimbursement? History has shown that professions that have become enmeshed with the insurance reimbursement system have lost autonomy in determining treatment for their patients.

There are other concerns not mentioned here. Suffice it to say that insurance reimbursement is one of the issues facing massage that could seriously alter the profession's course. Clearly, the current climate of increasing insurance reimbursement has both pros and cons. The trend toward increased insurance reimbursement in massage makes me nervous because corporate greed has a way of superseding what is best for the consumer/patient in many cases, especially in the current U.S. healthcare system.


Personal Care Massage
Ask the average person what he thinks of when you mention massage therapy and he is likely to describe an image straight out of popular media--someone with a blissful expression getting pampered in a luxurious resort. This aspect of the profession is considered a personal care service--that which someone uses for overall wellness enhancement, general relaxation, and to feel good, not for specific pain, injury, palliative care, or other ailment.

A majority of practitioners offer personal care massage and work in diverse settings such as home-based practices, private clinics, spas, and high-end resorts. With the development of chair massage, a plethora of settings has emerged--from corporate offices to airports to malls.

The fastest growing environment for this sector in the last decade is the spa industry. Spas in the United States employ more than two hundred fifty thousand people and massage therapy is the most requested service.5 The spa industry is experiencing a high growth rate, an estimated 15-16 percent per year.6 Spas provide a distinct employment advantage for some massage therapists, especially those fresh out of school. A new therapist needs to gain confidence and experience by working on a large number of people. In addition, the economic pressures of setting up a private practice may be overwhelming when combined with remaining school expenses. We can expect steady growth in the spa sector for at least several more years.

One area where health and personal care styles of massage are beginning to converge is in medical spas. Medical spas offer similar services to traditional spas but also frequently employ licensed physicians or other healthcare providers. Treatments at medical spas often address not only wellness or beauty enhancement, but also various health problems as well. This innovative development could provide a greater degree of communication and participation between the healthcare and personal care sectors of massage. However, medical spas will need to employ practitioners with the skill base to adequately accomplish spas' advertised healthcare massage services.

Another trend likely to continue in the coming decades is the growth of massage franchise businesses. Advocates for these businesses claim to offer longer hours and charge less in an effort to make massage more accessible to a greater number of people. Some practitioners are uncomfortable with the franchise business model because they believe the lower cost may undercut services provided by private individuals or independent clinics. However, franchise businesses could serve an important niche in making massage more visible and accessible to those who might not ordinarily pursue it. On the other hand, there are concerns about how it will affect the overall perception of massage therapy by the general consumer. It remains to be seen how or if franchise businesses--where treatments are designed to be similar and greater emphasis is placed on business success for the franchise owner--will change the nature of personal care massage. In general, there are concerns about quality with the franchise setting. This issue is discussed below in education and training.

Given the demand for personal care massage therapy, the outlook is quite positive for these practitioners. There are increasing opportunities and lots of room for the entrepreneurial creativity of massage therapists.


Education and Training
For years, the profession's growth rate has been considerable. Concurrently, exponential growth occurred in the number of massage schools. Statistics from the recent ABMP school enrollment survey indicate that close to 1,530 massage training programs are currently in operation in the United States.7 That number is up 7.8 percent over the figures from 2004. It is also notable that while the school numbers were going up, total enrollment went down. The number of students enrolled in or graduating from massage programs declined from 2004 to 2006. Thus today we have a greater number of training programs competing for a declining number of students.

However, I don't think the decline in students is something to be immediately concerned with. ABMP President Les Sweeney refers to the decline in schools as "a healthy market correction." Growth cannot continue like a runaway train forever. This market correction could remove lower quality or less competitive programs and schools. However, there is no guarantee that the reduction in schools will leave only the very best schools. An unfortunate consequence already appearing is the loss of some very good training programs. These long-established schools are getting caught up in the economic pressures and are unable to compete. A key question for the future of the profession is whether educational quality will rise or erode with the various changes in the field
.
In the last couple of decades, new players entered the arena of massage school education. According to the ABMP school enrollment survey, 65 percent of recent graduates received training in proprietary (private) schools, 29 percent from career schools, and 6 percent from colleges.8 Increasingly, technical schools and community colleges provide massage education. These larger institutions are able to leverage their resources to offer massage programs at a significant cost reduction. The easier availability of federal financial aid in these institutions is also attractive.

Another influential trend that is likely to continue is corporate ownership of schools, which often entails the purchase of established schools. As a rule, corporations are primarily concerned with efficiency, growth, and financial viability. These are positive aspirations as long as the quality of the product--in this case education--continues to be high. Advocates argue that standardized curriculum and resource sharing can lead to better, more consistent quality. However, others express concern that corporate ownership will remove the individual elements that set the school apart. There are also concerns about how corporate ownership will impact massage education overall.

Distance education is another educational trend in entry-level training. The development of Internet technology has made significant inroads in colleges and universities. There are now hybrid distance education programs for entry-level massage training. These programs offer some course work through distance learning while hands-on techniques are taught in the classroom. Distance education makes training more accessible to people with difficult schedules or time constraints.

How these hybrid programs compare with training from a traditional educational environment is a question time will answer. Current education research does, however, indicate that most subjects can be taught effectively in either format. There are advantages and disadvantages to each approach. Given that a significant proportion of massage education is not hands-on--such as anatomy and physiology, ethics and business, pathology, kinesiology, etc.--distance education is likely to continue gaining ground and be a beneficial option.


Quality Control
The fundamental issue of most concern is educational quality and the image of the profession by other healthcare professionals and consumers. If massage therapy is going to continue on the strong path it is today, then these elements must be addressed by educators, administrators, and practitioners. In either health or personal care massage, high-quality education for practitioners is important--both for their clients and for the practitioner's business success. For those practicing therapeutic treatment, sufficient and quality education is essential.

The issue of educational quality is challenging and something that as a developing profession we have yet to resolve. The question of industry standards is something other healthcare professions were forced to address at some point. Admittedly a hot button topic, standards will be something that, at least for healthcare massage, the profession will need to deal with as we progress. Healthcare massage may eventually run into the same issue that other healthcare professions have, where different educational levels needed to be established.

There are already large discrepancies in the number of hours, curriculum, and content in educational programs. Yet, no identifying degrees that distinguish those with advanced training from entry-level exist. Some community colleges offer associate degrees for students graduating from two-year programs. Private schools sometimes offer tiered training. Purely in terms of marketing, practitioners would benefit from additional ways to set themselves apart given their education and training. Historically, certification in advanced continuing education has attempted to fulfill this need.

There are seven accrediting agencies for the massage profession, but no agreed upon standards. Not everyone even agrees on the necessity of accreditation. Part of the issue with standards is the way in which they would be established. Most believe that competencies versus a random number of hours should be the basis for an entry-level standard. Organizations such as the Commission on Massage Training Accreditation (COMTA) have worked to develop competency-based training standards. However, only a small percentage of schools currently are accredited by COMTA. Competency evaluation should be developed for the various levels in which massage is performed. As massage develops as a legitimate healthcare profession, industry standards and competency will become even more of an issue.


Quality Staffing
Massage therapists will continue to rely on continuing education (CE) for most of their advanced training. With the greater number of courses available, there are multiple opportunities for advanced education. Certification and licensure requirements continue to fuel the need for continuing education courses. What is distressing is the trend toward poor quality training programs used simply to fulfill CE requirements. There will continue to be a wide discrepancy in quality of continuing education.

There are several issues related to educational quality that the profession will continue to deal with, particularly faculty qualifications, content, and curriculum. Faculty experience remains a challenge for schools. Schools have generally faced difficulty finding and retaining qualified faculty, often resorting to recent graduates. There is concern that with the rise in the number of training programs there become more challenges staffing programs. Educators across the field express concern that the lack of qualified staff is leading to lesser quality training. Colleges requiring degrees from their massage faculty face a greater challenge as the best educators may not have college educations. Educational design also affects quality; schools seeking to graduate the best students work to develop effective and well-developed curriculum and content.

As a growing profession that is gaining respect among other healthcare providers, it behooves us to continue to work toward improving overall educational quality. Superior training is a financial advantage to practitioners and educational institutions.


The Business Of Massage
Tabulating realistic numbers of practicing massage professionals is difficult. It is apparent, though, that there is an exceptionally high rate of attrition in the profession. Most people leave the profession after only a few years. While physical burnout is a key factor, the most commonly cited reason is inability to make an adequate living.

As discussed above, there are increasing opportunities for practitioners to work in settings where they are employed versus private practice. The advantage of employment is being able to focus on the practice of massage instead of business building. While these options are appropriate for some, the majority of therapists will continue to work for themselves. Business and entrepreneurial skills are mandatory for practitioners promoting themselves.

There are estimates of close to two hundred fifty thousand massage therapists and bodyworkers in the United States.9 Such a large number introduces the question of saturation: how many people can be reasonably employed in this field in a given region? Those two hundred fifty thousand practitioners are not evenly spread across the country, and it is doubtful they are evenly spread out to match the population densities in various geographical regions. The number of practitioners in any geographical area is influenced by the population's attitudes toward massage, number of schools in the area, licensure requirements, and other factors. In certain regions there seems to be an overabundance of practitioners. Competition and greater economic pressure will continue to affect some of these high density areas.

Consumer education is a developing issue for practitioners. As the general population becomes more familiar with their options and the promise of massage, they will have greater expectations. For some clients, a bad experience will swear them off massage; other consumers will be more adaptive. Studies show that clients are disinclined to express discomfort or unhappiness. Yet, referral and repeat clients are the thrust of a successful practice. Good marketing, quality effective therapy, and good communication will continue to be keys for success. With increasing competition, therapists will increasingly need to find ways to set themselves apart from their competition.


Associations Politics and Licensure
As the saying goes, if you want a civil environment at the dinner table, don't discuss religion or politics. Similarly if you want to get a heated discussion going between a group of massage therapists just ask them, "What do you think about state licensure, which association do you prefer, what about the NCBTMB, or maybe medical massage certification?" These are all hot button topics and are likely to continue being so.

Like it or not, licensing of massage therapists in the United States is a trend that will continue for the next few years. At the time of this writing, thirty-seven states, the District of Columbia, and four Canadian provinces offer some type of massage therapy credential. Several other states are debating licensure legislation. It is reasonable to predict that we'll see massage licensure in all fifty states within a decade or so.

State licensure has its adherents and opponents. An interesting development to watch in the next few years is the emergence of the Federation of State Massage Therapy Boards (FSMTB). This organization gives states a way to work together in the regulatory process; it is an excellent and timely idea. We have yet to know how the testing and examination process will unfold (the Massage Bodywork Licensing Examination, MBLEx, was launched October 1). A primary question is what the presence of another exam option for state licensing will mean.

The National Certification Board for Therapeutic Massage and Bodywork (NCBTMB) was originally created to establish entry-level certification. Today, a large number of states rely on the NCBTMB's tests for granting massage licenses. Opponents argue a certification program should be voluntary; state's use of the tests makes it mandatory. Recent problems with the administration of the tests, including lawsuits, resignations of several members of the board of directors, as well as accusations of mismanagement and violations of bylaws, do not bode well for this organization. As a former chair of NCBTMB, these issues are troubling. The organization needs to regain its footing and improve its credibility with the profession. Instead of focusing on entry-level credentials and state licensure, NCBTMB would better serve the profession by offering advanced credentials that designate higher and specific levels of training.


Research and The Frontiers of The Field
The growth of any healthcare discipline is related to its ability to demonstrate beneficial therapeutic outcomes. Due to funding challenges and the fact that so few massage therapists possess PhDs, there has not been anywhere near as much focus on research in the massage profession as there has been in other healthcare disciplines. The groundbreaking work of Tiffany Field and her colleagues at the Touch Research Institute in Miami has paved the way for those interested in massage research. These practitioners and researchers help us look for ways to validate and better understand the outcomes we see in the treatment room.

In the next few decades massage therapy will be increasingly integrated into research protocols as effective treatments are researched and evaluated. A healthcare profession must determine the most effective means for addressing key complaints presented to that profession. These approaches are called best practices. The massage profession, along with researchers from other healthcare disciplines, is looking to establish best practices for massage as well. Best practices guidelines are not rules or recipes, they simply provide guidance about what are the most effective treatments.


A Snapshot
The future of massage therapy in the United States is promising. Yet, numerous issues face the profession, and it is premature to know how they will affect it in years to come. The divergence in practice of massage as health or personal care is one of the largest issues facing the profession. This division affects education, licensure, and professional advancement. Developments in educational options, practice settings, and business options present both opportunities and challenges to the profession.

The increasing popularity of massage as a personal service and health option present a positive financial future for those in the field. There is continually greater acceptance of massage by other healthcare professionals as a viable and valuable healthcare modality. Concurrently, those with ailments wanting other healthcare options are increasingly looking to massage. The number of consumers seeking massage as a personal care service is expanding. The options and potentials for those wanting to practice massage are extremely high.

Given the advancement to date of massage as a therapy, it is to everyone's benefit to continue striving for the highest quality in education, industry reputation, and professional stature.

As an educator, I have had the wonderful opportunity to meet and work with some of our profession's most influential colleagues. These visionaries have worked hard to help shape and promote our profession in the last twenty years. While many of these people are well known, some of the most inspirational people I have met are those who are not well known, but are out there in the trenches doing great work every day.

Looking at a snapshot of our field is like watching a river that passes before us moving from the past to the future. The water is different from day to day, but it remains the same river. While tomorrow's massage therapy field will be filled with different individuals and experiences, it will remain the same magnificent field we are all so fortunate to be a part of today.

Whitney Lowe is a recognized authority on pain and injury treatment with massage therapy. His contributions to the massage field are wide ranging and include extensive research, professional publications, teaching, clinical work, consulting, and participation in national boards and committees. He is the author of the books Orthopedic Assessment in Massage Therapy (Daviau-Scott, 2006) and Orthopedic Massage: Theory and Technique (Mosby, 2003), which are used in training programs and schools nationally and internationally. In 1994 he founded the Orthopedic Massage Education Research Institute (OMERI) to provide massage therapists the advanced education they would need for treating orthopedic soft-tissue disorders. He can be contacted at omeri@omeri.com.

NOTES
1. D. C. Cherkin, R. A. Deyo, K. J. Sherman, et al., "Characteristics of Licensed Acupuncturists, Chiropractors, Massage Therapists, and Naturopathic Physicians," J Am Board Fam Pract. 15, no. 5 (2002): 378-90.
2. D. M. Eisenberg, R. B. Davis, S. L., et al., "Trends in Alternative Medicine Use in the United States, 1990-1997: Results of a Follow-Up National Survey," JAMA 280, no 18 (1990): 1569-75.
3. ABMP, 2007 National Consumer Survey, Evergreen, CO; 2007.
4. K. J. Sherman, D. C. Cherkin, J. Kahn, et al., "A Survey of Training and Practice Patterns of Massage Therapists in Two US States," BMC Complement Altern Med. 5 (2005): 13.
5. ABMP, 2007 National Consumer Survey.
6. ISPA, Spa Industry Update, Lexington, KY: International Spa Association; 2006.
7. ABMP, "A Changing Environment: Has the Popularity of Massage School Peaked?" The ABMP School Connection, vol. 5; 2007 (Spring).
8. ISPA, Spa Industry Update.
9. ABMP, 2007 National Consumer Survey.





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