Attitudes and practices of massage therapists as related to conventional medicine.

INTRODUCTION: Research into opinions about complementary and alternative medicine (CAM) has focused on conventional medical practitioners with little exploration of CAM practitioners' views.
PURPOSE: To survey attitudes and practices of massage therapists toward conventional medicine. RESEARCH
DESIGN: An anonymous online survey consisting of Likert-type scales, fill-in answers, and multiple-choice questions was used. PARTICIPANTS: Members of the Associated Bodywork & Massage Professionals (ABMP), the largest massage therapy association in the US with over 77,000 members. MAIN OUTCOME MEASURES: Participants were asked about their years of practice and training, choice of health care practitioners, sources for information about CAM and Western/allopathic medicine, client referral patterns, optimal treatment approaches for various medical conditions, and overall impressions of CAM and Western/ allopathic medicine.
RESULTS: Analysis of n = 3,148 responses indicated that while 66.9% of respondents had a neutral or worse impression of Western/allopathic medicine, 64.3% use a conventional medicine practitioner as their primary health care provider, 61.9% have referred clients to a conventional medicine practitioner in the past six months, and 90.5% seek out information on Western/allopathic medicine. The mode response of the best treatment approach to various medical problems was a mix of Western/allopathic medicine and CAM.
CONCLUSIONS: This study suggests that despite the ambivalence of many massage therapists towards conventional medicine, many use it, encourage clients to do so, and see involvement of both as crucial to health.

INTRODUCTION

Complementary and alternative medicine (CAM) consists of practices and systems that are “not presently considered to be part of conventional medicine(.” These systems were developed separately from conventional Western/allopathic medicine, have different underlying philosophies about the causes and treatment of disease, and incorporate multiple modalities(.

CAM usage is increasing. In 1990, 34% of people used it, and according to the National Center for Complementary and Alternative Medicine, CAM usage increased to 38.3% in 2007(. Higher use of CAM is associated with higher levels of education, higher incomes, women, and the 36–59 age group(. Across the US, the five most commonly used modalities are relaxation techniques and meditation (16.3%), herbal medicine (12.1%), massage (11.1%), chiropractic (11.0%), and spiritual healing by others (7.0%)(.

Numerous studies have been conducted to assess the conventional medical community’s attitudes and practices towards CAM. Studies have generally found that while most physicians have a neutral-to-positive attitude towards CAM(, physician assistants (PAs)( and advanced practice nurses (APNs) ( may be more knowledgeable about CAM, more likely personally to use it, and more likely to recommend it to their patients. There is little in the current literature that explores CAM practitioners’ attitudes about conventional medicine and how these attitudes impact their practice.

METHODS

Participants

The Associated Bodywork & Massage Professionals (ABMP) and the American Massage Therapy Association (AMTA) were approached for participation in the study. The ABMP agreed to participate, while the AMTA declined.

Founded in 1987, the ABMP is a national membership association that provides practice support and liability insurance for massage/bodywork practitioners. It is the largest massage therapy association in the US, with over 77,000 members. Of these members, 83% are female, the average age is 44, the average tenure in the field is 6.2 years, and 31.5% have a bachelor’s degree(.

Procedures

In 2007, ABMP sent e-mail to its members containing information about the purpose of the survey, investigator contact information, and a link and login information for the survey site. Respondents were given a two-month window in which to respond. The e-mail was sent by the ABMP to preserve member confidentiality.

Measures

The two-paged survey had two sections. The first section consisted of fill-in and multiple-choice questions about participants’ backgrounds and practices. Questions addressed primary area of practice (acupuncture/Traditional Chinese Medicine (TCM), athletic training, chiropractic, energy therapy, herbalism, homeopathy, massage/bodywork, naturopathy, physical therapy, Western medicine); number of years of practice, CAM training, and overall education; geographic location and type of community (rural, suburban or urban); types of health care providers consulted (acupuncture/TCM, nurse practitioner (NP)/ APN, PA, naturopath, chiropractor, medical doctor (MD)/doctor of osteopathy (DO), homeopath, energy therapist, athletic trainer, dietician/nutritionist, herbalist, massage therapist/bodyworker, physical therapist, other); sources for information about CAM and Western/ allopathic medicine (books, friends/colleagues, journals/magazines, television, classes/conferences, the Internet, newspapers, other, do not seek information); and numbers of times clients had been referred to other practitioners and the types of practitioners.

The second section used Likert-type scales to obtain overall impressions of CAM and Western/allopathic medicine, and participants’ opinions of the best treatment approach for thirteen different conditions: allergies, arthritis, asthma, back pain, cancer, cold/ cough/flu, diabetes, headaches, high blood pressure, infertility, insomnia, menopause, and stress. The scale for ranking overall impressions was: 1 = Strongly Dislike, 2 = Dislike, 3 = Neutral, 4 = Like, 5 = Strongly Like. The scale for ranking best treatment approach was: 1 = Entirely Western, 2 = Mostly Western, 3 = Equal Mix, 4 = Mostly CAM, 5 = Entirely CAM.

No identifying information was asked. Participants were given the option of submitting additional comments anonymously or with their name and contact information.

Data Analysis

Data were collected using Seton Hall University’s ASSE T: Academic Survey System & Evaluation Tool, then exported to and analyzed using the statistical package SPSS Version 15.0. A significance level of α = .05 was considered statistically significant.

Descriptive statistics were performed to determine what sources of information were used, overall impressions of CAM and conventional medicine, whom the respondents used as their primary care provider (PCP), what additional types of practitioners they used for their own health, and types of practitioners to whom referrals were made. Kruskal-Wallis tests were performed to compare type of PCP and overall impression of Western/allopathic medicine, type of PCP and overall impression of CAM, types of additional practitioners seen and overall impression of Western/allopathic medicine, types of additional practitioners seen and overall impression of CAM, and overall impression of Western/allopathic medicine and the additional practitioners to whom clients had been referred.

RESULTS

Response

There were 3,148 responses, a response rate of 36.9% of those who opened the e-mail according to the ABMP, and 9.4% of total ABMP members who had provided an e-mail address at that time.

Information Sources

Almost all respondents indicated that they seek out information about CAM, with books, journals/ magazines, and classes/conferences being the most often used sources. Most also seek out information on Western/allopathic medicine, with the most common sources being the Internet, books, journals/magazines, and friends/colleagues (Table 1).

Table 1

Sources of Information about CAM and Western/Allopathic Medicine

Source	CAM (% used)	Western/Allopathic (% used)
Books	82.7%	47.3%
Classes/Conferences	79.4%	18.9%
Friends/Colleagues	68.2%	46.4%
Internet	68.0%	63.5%
Journals/Magazines	81.0%	46.5%
Newspapers	11.1%	23.6%
Television	8.8%	24.9%
Do not seek information	0.6%	9.5%
Other	6.1%	10.4%

Overall Impressions

Nearly all of the respondents indicated that they “Like” or “Strongly Like” CAM, with less than one-third expressing similar attitudes towards Western/ allopathic medicine (Figure 1).

Figure 1

Overall impression of medical approach.

Type of Providers Seen

Nearly two-thirds of respondents used a conventional medicine practitioner (MD, DO, PA, NP, or APN) as their PCP (Figure 2). Over 95% of respondents also sought care from other practitioners in addition to their PCP (Figure 3).

Figure 2

Type of primary health care provider.

Figure 3

Type of additional health care provider.

Respondents who used conventional medicine practitioners as their PCP held more favorable overall impressions of Western/allopathic medicine (chisquare = 409.8, p < .0005) and less favorable overall impressions of CAM (chi-square = 113.8, p < .0005) than those who used CAM practitioners as their PCP (Table 2).

Table 2

Impression of CAM and Western/Allopathic Medicine by Type of PCP

PCP	CAM Mean (SD)	Western/Allopathic Mean (SD)
Acupuncture/TCM	4.8 (0.5)	2.5 (1.0)
Chiropractor	4.8 (0.4)	2.7 (1.0)
Homeopath	4.8 (0.4)	2.2 (0.7)
MD/DO	4.6 (0.6)	3.3 (0.9)
Naturopath	4.8 (0.5)	2.5 (0.8)
NP/APN	4.7 (0.5)	3.2 (0.9)
PA	4.5 (0.7)	3.1 (0.9)
Other	4.7 (0.6)	2.8 (0.9)
None	4.7 (0.6)	2.5 (0.9)

1 = Strongly Dislike, 2 = Dislike, 3 = Neutral, 4 = Like, 5 = Strongly Like.

Respondents were more likely to indicate that they “Dislike” or “Strongly Dislike” Western/allopathic medicine if they consulted certain additional providers: acupuncture/TCM (chi-square = 13.9, p < .01), energy therapy (chi-square = 24.9, p < .0005), herbalism (chi-square = 48.8, p < .0005), homeopathy (chi-square = 42.7, p < .0005), and naturopathy (chi-square = 43.0, p < .0005). They were more likely to indicate that they “Like” or “Strongly Like” Western/allopathic medicine if they consulted an MD/DO (chi-square = 10.6, p < .05), PA (chi-square = 9.8, p < .05), or physical therapist (chi-square = 18.1, p < .005) in addition to their PCP.

Respondents were more likely to indicate that they “Dislike” or “Strongly Dislike” CAM if they used chiropractic in addition to their PCP (chi-square = 40.7, p < .0005) or saw no additional practitioners (chi-square = 111.3, p < .0005). They were more likely to indicate that they “Like” or “Strongly Like” CAM if they if they consulted certain additional providers: acupuncture/TCM (chi-square = 50.8, p < .0005), energy therapy (chi-square = 79.5, p < .0005), herbalism (chi-square = 28.9, p < .0005), homeopathy (chi-square = 36.1, p < .0005), or naturopathy (chisquare = 26.0, p < .0005).

Treatment Approach

The mode responses for the best approach to treatment for all conditions were 3 and 4, indicating an “Equal Mix” or “Mostly CAM” (Figure 4).

Figure 4

Best treatment for medical conditions.

Note: 1=entirely western, 2=Mostly western, 3=equal Mix, 4=Mostly CAM, 5=entirely CAM.

Referrals

Respondents most commonly referred clients to chiropractors, acupuncture/TCM, and MD/DO s (Figure 5). Respondents were more likely to indicate that they “Dislike” or “Strongly Dislike” Western/ allopathic medicine if they had referred clients to acupuncture/TCM (chi-square = 36.8, p < .0005), energy therapy (chi-square= 13.9, p < .01), herbalism (chi-square = 39.9, p < .0005), homeopathy (chisquare = 51.9, p < .0005), or naturopathy (chi-square = 73.3, p < .0005). Respondents were more likely to indicate that they “Like” or “Strongly Like” Western/ allopathic medicine if they had referred clients to an MD/DO (chi-square = 160.6, p < .0005), NP/APN (chi-square = 15.5, p < .005), or PT (chi-square = 39.1, p < .0005) (Table 3).

Figure 5

Additional practitioners to whom clients were referred.

Table 3

Impression of Western/Allopathic Medicine by Type of Referral

Type of Referral	Mean (SD)
Acupuncture/TCM	3.0 (0.9)
Athletic Trainer	3.1 (1.0)
Chiropractor	3.0 (1.0)
Dietician/Nutritionist	3.0 (1.0)
Energy Therapy	2.9 (1.0)
Herbalist	2.8 (1.0)
Homeopath	2.8 (1.0)
Massage	3.0 (1.0)
MD/DO	3.2 (0.9)
Naturopath	2.8 (0.9)
NP/APN	3.2 (1.0)
Physical Therapist	3.2 (0.9)
Physician Assistant	3.4 (1.0)
None	3.3 (0.9)
Other	2.9 (1.0)

1 = Strongly Dislike, 2= Dislike, 3 = Neutral, 4 = Like, 5 = Strongly Like.

Additional Comments

Several respondents wrote additional comments stating that they perceive CAM as the better approach because it treats the cause of an illness, while conventional medicine has value for life-threatening emergencies but often merely alleviates symptoms without correcting underlying problems. Respondents stated that they found conventional medicine “impersonal, scary, authoritarian, and harsh,” that it has “disempowering attitudes” towards patients, and that it focuses too much on illness and not enough on health and prevention. Many people also wrote to express their mistrust of the pharmaceutical industry and its products. Respondents made references to “the monster known as the FDA,” “pill pushers,” and “Pharma Boys,” and opined that “drugs should be used as the option of last resort.” No respondents who indicated that they disliked CAM wrote comments to explain their rating.

DISCUSION

Attitudes and Practices

Respondents’ overall opinions of conventional medicine were mixed, while their opinions of CAM were strongly favorable. Despite their ambivalence towards conventional medicine, a majority of respondents use it for their primary care, have referred clients to it, and see it as part of the optimal treatment approach.

Massage therapists are not PCPs, as opposed to CAM practitioners in systems such as TCM and naturopathy. Surveying CAM practitioners who are not PCPs might have led to higher rates of referral to and use of conventional medicine than might be seen with a survey of CAM PCPs.

Another reason for the high utilization of conventional medicine may be cost: while health insurance in the US may pay some or all of the costs for visits to a conventional medicine practitioner, it rarely pays for visits to CAM practitioners. Having to pay increasingly expensive out-of-pocket costs for health care may encourage individuals to use those practitioners covered by their health insurance: MDs, DOs, PAs, and APN/NPs.

The vast majority of respondents indicate that they seek out information on both CAM and Western/ allopathic medicine, but at different rates. The only information sources used more for Western/allopathic medicine than for CAM are newspapers and television. The survey did not ask the names of the most frequently used sources of information and, as a result, their quality is not known. There are both factually accurate and highly suspect materials published in all media, so it cannot be assumed that information from books, classes, and journals and magazines is reputable, nor that information from the Internet and from television is inherently unreliable.

The findings of this study are consistent with previous research which used focus groups to examine the beliefs of 32 CAM practitioners(. Researchers found that despite holding mixed views of conventional medicine, CAM practitioners supported a health care system that integrated CAM and conventional medicine and they made referrals to conventional medicine practitioners.

Study Limitations

A major limitation of the study is that only members of the ABMP were surveyed, which excluded those massage therapists who belong to a different association or who do not belong to any associations. The authors approached the ABMP and AMTA because they are the two largest massage therapy associations in the US. The AMTA has 56,000 members and membership is similar to that of the ABMP in that it is mostly female (85%), but the average age of AMTA members is five years older, the average tenure in the field is 12 years, and a greater percentage (38%) of AMTA members have completed bachelor’s degrees(.

A further study limitation was the format of the study. Members of the ABMP who did not have e-mail or who had not provided the ABMP with an e-mail address at the time of the study were excluded. There were no data available on whether these members differed significantly in other ways from the overall membership. As this study was limited to massage therapists, future research could explore attitudes of different types of CAM practitioners, such as acupuncturists/TCM practitioners, herbalists, and naturopaths.

CONCLUSION

These findings suggest that despite their concerns regarding conventional medicine, most respondents use it, encourage clients to do so, and see involvement of both it and CAM as necessary for health. Our hope is that with better understanding between the CAM and conventional medicine communities, medicine as a whole will be better able to serve our patients.