MANUAL THERAPY

We were motivated to collect information on what massage therapists actually did during their sessions, by a desire to describe their treatment in as simple and unambiguous terminology as possible, and at the level of detail necessary to reproduce the treatments. Therefore, we did not always ask the therapists to record their treatment details using one of the 36 techniques shown in Table 2. Our protocol allowed therapists using craniosacral therapy and manual lymph drainage (two styles which are not focused on the treatment of muscle or general connective tissue) in a session to record these as styles because these two styles typically use their full set of techniques in a massage session. In addition, we included three distinct sets of “related techniques" such as: 1) rock- ing, jostling, shaking, vibration; 2) active or resisted range of motion, which consists of three types of resistive stretching: i) lengthening, contracting the agonist, ii) lengthening the agonist, contracting the antagonist, and iii) lengthening the agonist, contracting ago- nist and antagonist; 3) passive range of motion, which consists of passive stretch- ing and positional release) due to the similarity in application and anticipated results of the “related techniques”.

The 13 specific techniques were: applica- tion of cold; application of heat; com- pression; cross-fibre friction; friction or direct pressure; gliding (effluerage) - Swedish; gliding - deep (deep effluerage, longitudinal friction, stripping) - clinical massage; holding; kneading (petrissage); percussion (tapotement); skin rolling; stretching - manual; traction. Finally, the last element of the protocol, trigger point therapy, was a subcategory of friction or direct pressure technique with a specific intention (ie. applied to trigger points). We chose to distinguish the application of direct pressure to trigger points from the application of direct pressure to other soft tissue components because relief of trigger points was anticipated to be an important part of the massage treatment for neck pain. Thus, our protocol involved substantial detail on the techniques most likely to be applied to muscles and general connective tissue. While our protocol also permitted self-care recommendations, a discussion of those is beyond the scope of this article.

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DISCUSSION This taxonomy is a first step in enabling researchers and massage therapists to more clearly articulate massage interventions, using common language to describe specif- ic techniques that may have originally been learned as part of training in differ- ent styles of massage. Even though only two massage therapists were involved in the development of this taxonomy, seven others were involved in the study that employed many of

the described tech-

niques and all were comfortable using these descriptions to characterise the com- ponent techniques of their sessions. We believe, however, that future development of this taxonomy should include feedback from a broader range of massage therapists in the US and other Western countries as well as from manual medicine practitioners, such as physiotherapists, osteopaths, and physical therapists, who have different basic training.

We expect that our taxonomy will offer practical applications for the education of new massage therapists. Students receiv- ing basic training in massage school would benefit from having the entire fac- ulty use the same language to describe a particular technique. Describing strokes and soft tissue manipulations with neutral language could help students more clearly understand

what they are doing.

Consistent terminology would make it eas- ier for US students who are taking the national certification exam in massage administered by the National Certification Board for Therapeutic Massage and Bodywork, which is required for licensure in at least US 24 states (22). We also believe that participants in continuing education programs, which are required for continued licensure in many US states, would benefit from consistent terminology.

Future clinical research studies, regardless of whether they are evaluating massage as a whole system of care or investigating specific styles of massage, may benefit from creating a video or DVD that illus- trates the application of specific tech- niques in a variety of circumstances to limit confusion about each hands-on technique. In addition, researchers could provide a training and discussion session for massage therapists to ensure that ter- minology was being used consistently. Because our taxonomy was developed for a neck pain study, it will likely be most

useful when describing the treatment of musculoskeletal conditions.

While these are among the most common reasons people seek out massage (22), we believe that additional refinement of this taxonomy would be needed to extend its use in studies of such topics as massage for cancer patients, geriatric patients or for somatic psychotherapy. Although var- ious descriptions of massage exist (5,8, 17,18), we are unaware of other tax- onomies that use a multi-level system of classification, include the concept of “intent”, and that describe what massage therapists are actually doing in a way that is reproducible. Our example of the use of this taxonomy for the development of treatment protocols in our neck pain study illustrates how researchers need to carefully consider the condition being treated and the likely nature of the treat- ment in order to specify the protocol in sufficient detail.

However, developing treatment protocols for massage studies involves more than simply specifying the styles and/or tech- niques to be included in the study. Researchers will need to consider the qualifications of the massage therapists providing treatment

and specify any

restrictions regarding: 1) the anatomic sites to be massaged, 2) the pressure applied using various techniques, and 3) the intention to be used with specific techniques.

Finally, we wish to emphasise that massage therapists recognise the importance of creating a warm and caring relationship in the healing process and that they regard touch itself as a central healing feature of all techniques they employ. One consequence of their training is that massage therapists do not believe that a “placebo” massage exists and thus researchers who wish to study massage within its own worldview would need to design studies with more appropriate controls than, for example, light touching. Even though many challenging issues regarding design and conduct of studies of massage therapy remain, our proposed taxonomy provides an initial step toward standardised descriptions of massage interventions. We suspect that such standardisation will be useful for studying massage from a wide variety of perspectives.

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