In good hands?

Is massage still key to practice in the 21st century?Jennifer Trueland assesses the situation.

In the 5th century BC, Hippocrates wrote ‘the physician must be experienced in many things, but assuredly in rubbing’. And the ancient Greeks weren’t alone. Rubbing, or massage, has a long history which stretches back even further than the father of western medicine and, until recently, it was one of the main pillars of physiotherapy.

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But with students spending just a few short hours learning it as undergraduates and ever-tightening NHS resources turning it into a luxury, is massage still core for the profession? Indeed, should physiotherapy be concerned with it at all, or should it be ceded to growing numbers of alternative providers, such as sports massage practitioners? Physiotherapy has its very roots in massage. Indeed, the CSP evolved from the Society of Trained Masseuses, which was set up in 1894 by four young women with nursing/midwifery backgrounds. They wanted to protect the practice from association with other, less seemly, activities. They succeeded and massage was to be a mainstay of physiotherapy for the next nine decades. SEA CHANGE IN 1980s A sea change happened in the 1980s, says Liz Holey, deputy dean in the school of health and social care at the University of Teesside. When she trained in the late 1970s, she was taught massage half a day each week for a year. Now she says students get ‘just a few days’ of actual hands on massage practice. ‘Part of it was that people were trying to enhance the status of the profession – previously we were called things like “slap and tickle girls”. Also, at that time healthcare became very technological; there was a focus on getting value for money.’ As the emphasis moved on to electrotherapy and manipulation, massage began to take a back seat. It also came to be seen as ‘a bit of a luxury’, she believes, because it involves spending time one-to-one with patients. PROMOTING PASSIVITY? But the other side of the coin was that it was seen as promoting passivity: the idea that healthcare is something that’s done to patients, whereas the aim now is very much to get people up and doing. However the two aren’t mutually exclusive, Ms Holey says, because massage can be an important part of encouraging people to self-care. Partly this is because it promotes intimacy and trust between the physiotherapist and patient, which is part of holistic care. ‘People are forgetting that what we’re about is rehabilitation, and in a total rehabilitation package, massage has an important part to play in some circumstances,’ she says. Ann Thomson, programme consultant for two masters degree courses in physiotherapy at King’s College, London, agrees. ‘The great tragedy for physiotherapy is massage isn’t given credibility as an adjunct treatment. ‘Our job is to strengthen and rehabilitate and help people regain independence; sometimes massage or soft tissue therapy can be an important step in that direction.’ A distinct lack of solid research for the benefits of massage is also a disadvantage, as practice becomes ever more evidence-based. Such research as there is, says Ms Holey, can be counterproductive because it tends to show the value of touch, which can be done by anyone, rather than massage, which is done by more expensive professionals. Stuart Porter, a physiotherapy lecturer at Salford University, is an advocate of massage. As programme leader for first year physiotherapy, he says it’s a valued part of the course. STUDENTS ENJOY IT ‘I think it gives the human touch to a scientific profession,’ he says. ‘The students enjoy it. It’s not like having your head buried in a book; when they start to do massage the students really light up – that’s what they’re there for.’ He believes practising massage on each other in a classroom situation is a valuable learning experience for the students because they get a sense of how patients will feel to be asked to take their top off, for example. But he says he can think of at least a couple of former students who left the course because they hadn’t realised physiotherapy would involve touching people. His students get between 10 and 12 hours of actual massage teaching and practice, he says, but adds massage skills come into play in many other aspects of the degree course. Ms Thomson says the loss of massage in the undergraduate curriculum has knock-on effects. ‘We’ve lost the hidden agenda of teaching massage, which was that it promoted sensitivity and taught the students how to handle patients.’ MASSAGE VALUED AGAIN She believes, however, that there are signs physiotherapy might be going full circle and beginning to recognise the value of massage once more. ‘Massage therapy has proliferated in the United States and we tend to look to America,’ she says. ‘And there are many things which involve massage, but we tend to call it other things, like soft tissue therapy.’ Joan Watt, chair of the Chartered Physiotherapists in Massage and Soft Tissue Therapies, is spoken of as bringing massage into the 21st century. Certainly she has many years of experience, particularly in sports massage – as lead physiotherapist for the GB Olympic athletics team in the 1980s she’s had her hands on them all, from Sebastian Coe to Kris Akabusi. Last year, she was at the Beijing Olympics (as lead physiotherapist for the GB shooting team). Massage is an essential part of her armoury, although she accepts evidence for its benefits is hard to come by. ‘Trying to look for scientific proof is hard without being invasive. ‘If the world’s best sprinter says he couldn’t do it without massage – that it’s essential for him – and I want to find out what it’s doing, then I can only do so by taking fluid or a biopsy. ‘What will he say to me if I want to do a biopsy just before he runs in the final?’ LOSE IT IF YOU DON’T USE IT She believes physiotherapists are at risk of losing their massage role to others and thinks it would be a pity all round.  ‘Sports massage practitioners are trained to assess and massage, not to diagnose – that’s where physiotherapists come in, because they have that depth of education.’ She points out that while the use of massage by physiotherapists has declined, particularly in the NHS, the growth of alternative practitioners offering everything from shiatsu to Thai massage has been enormous. Clearly there’s an appetite for it. ‘I get so upset when physios can no longer massage. Call me an old fogey if you like, but I believe physiotherapy should be a practical course and that they are not getting enough practice.’ It’s partly to address this deficit that the CPMaSTT launched its own postgraduate course in massage and soft tissue therapies last year. ‘When I graduated in 1962 we had massage until it was coming out of our ears. Now, anecdotally, we hear students only do it for a couple of hours. I think physiotherapists should be concerned about this – let’s get our roots back.’  FL Frontline would like to hear from you What do you think? Is massage a core part of physiotherapy practice and should it be? Are physios in danger of losing their position as experts in massage? Should massage have a greater emphasis at university? Email your responses, stating if you are happy for them to be published, to Features editor Catherine Hill at The graduate perspective When she started looking for a job, physiotherapy graduate Vicki Spencer felt there was something missing in her practice: an expertise in massage. Having graduated in 2006, then taken a year out, it felt a long time since she had done any, and, indeed, what she had done wasn’t very much. ‘I’d estimate we received less than four hours of physiology and practical work on massage as students,’ she says. ‘What’s more, it was near the beginning of the course, so I really felt I needed a refresher.’ Ms Spencer decided to sign up for a seven-month graduate sports massage and remedial therapy course last January, which she started before taking up her current post, working for East Kent Hospitals in Ashford. She found she wasn’t alone in feeling she needed to learn more about massage before (literally) getting her hands on patients. But she doesn’t blame her university. ‘There was just so much else to fit in – and talking to other people, they all found the same. And I did do it as part of my degree: it was just that it was a long time ago.’ Having done the graduate course, she feels she uses the massage skills and knowledge. But while she believes it is an important thing to be able to do, she is unsure about whether it is still ‘core’ physiotherapy. ‘I think it has its place and it has its uses. But there’s not a lot of time in a 20-minute NHS outpatient consultation: when you’ve done everything else, you just about have enough time to tickle an arm.’ Massage on the run According to Darren Brown, the response when he offers to give a massage is invariably ‘oh yes, please’. ‘Everybody knows it feels good,’ he says simply. Mr Brown is one of the physios involved with the Physiotherapy Massage Network, a scheme enabling newly qualified and junior physiotherapists to provide therapeutic massage for charity runners at sporting events such as the Great North Run. The scheme has been particularly useful for newly qualified physiotherapists looking for jobs. ‘This is a way for them to get some experience; it also shows future employers they’re thinking out of the box,’ he says. Mr Brown says runners are offered quick, deep tissue, Swedish-style massages which take five to 10 minutes, once they have finished their run. ‘The runners love it because it makes them feel better. The charities I work with have told me the feedback is great: a lot of their runners say the massage was the best bit of the day.’ Qualified physiotherapists can contact the network on

Jennifer Trueland

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