Spinal manipulation undertaken by massage therapist

Names have been removed to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Massage Therapist, Mr C

A Report by the Deputy Health and Disability Commissioner

Parties involved

Mrs A         Physiotherapist/complainant

Mrs B         Consumer

Mr C           Provider/massage therapist

Complaint

On 27 February 2007 the Health and Disability Commissioner (HDC) received a complaint from Mrs A about the services provided by Mr C. The following issue was identified for investigation:

The appropriateness of the care provided to Mrs B by Mr C on 21 December 2006, including the adequacy of the information Mr C provided to Mrs B.

An investigation was commenced on 27 April 2007.

Information reviewed

Information was obtained from:

• Mrs B
• Mr C
• Mr D (Mr C's teacher/mentor)
• Mrs A
• Mrs B's general practitioner
• The public hospital

Independent expert advice was obtained from massage therapist Mr Barry Vautier (see Appendix A) and physiotherapist Mr Duncan Reid (see Appendix B).

Information gathered during investigation

Background

On 21 December 2006, Mrs B, a 32-year-old woman, was experiencing severe back pain. Mrs B tried to book an appointment with a physiotherapist. However, because there were no appointments available for 24 hours she decided to book an appointment for a massage.

Mrs B went through the list of massage therapists in her local yellow pages, calling several listed. However, after she explained that she was currently suffering from severe back pain and had a history of irritable bowel syndrome she was advised that they could not help. She then called massage therapist Mr C, who said that he thought he could assist and scheduled an appointment for later that day.

Mr C

Mr C describes the service he provides as "sport and therapeutic massage". Mr C does not have any recognised qualifications in massage therapy. He is not a member of Massage New Zealand[1] (previously known as the Therapeutic Massage Association) or any other professional association.

Assessment and consent

On 21 December 2006, Mrs B attended Mr C's "purpose built" rooms situated at the front of his house. Mrs B's daughter, aged 12, was also present during this appointment. Mrs B explained to Mr C that she had been experiencing pain in the front of her chest. Over the last few days the pain had radiated to her back and become worse. She also advised that she had irritable bowel syndrome.

Mr C explained that it is his normal practice with all new clients to "discuss their needs" and have them complete a "client personal information" form outlining any existing conditions and the client's personal contact details. He stated:

"[Mrs B] was advised prior to commencing massage, the type of massage I perform and that my treatment method is different than any current techniques. I had a full consultation with her where I went over how the injury[2] occurred, when it occurred and what if any treatment she had already had."

On the "client personal information" form under the heading "Problem Area Eg Back, Neck, Arm, Leg etc" Mrs B documented "back". Under the heading "Any Relative Health Problems eg Diabetes, Asthma, Epilepsy" Mrs B documented "Bowel, [irritable bowel syndrome]". The form also had a question asking "Have you been referred by someone". Mrs B circled "No". The form also states "[Disclaimer]: This is not physiotherapy". Mrs B signed and dated the form.

Mrs B advised that after she had completed the client personal information form she showed Mr C where her pain was. She was then asked to take her top off, cover herself with a towel, and lie face down on the massage table - which she did. Mr C said that it was his standard practice to leave the treatment room while the patient disrobed and positioned him- or herself on the massage table. When Mr C returned he commenced treatment without any explanation. He did not ask Mrs B any further questions about her back pain or medical history.

Treatment

Mrs B explained that Mr C began treatment by pushing on the bottom area of her spine. He then moved up towards her neck, making the joints in her back "crack". Mrs B said that Mr C was quite a large, well-built man, and he applied quite a lot of force. If he was unable to make a specific joint crack, he pushed harder. When he reached her neck area, Mr C twisted her neck from side to side to make it "click". (Mr C commented that "it is possible" that the cracking Mrs B heard was either his wrist, elbow or ring finger.) Mrs B found this "quite uncomfortable", but believed Mr C knew what he was doing and thought it must be helping.

Mrs B advised that throughout the treatment Mr C "made small talk" with her daughter about what she wanted for Christmas. He did not provide Mrs B with any explanation about his treatment.

On the other hand, Mr C advised that throughout his treatment of Mrs B he "constantly asked for feedback" and at no stage did Mrs B express any concern about the treatment he was providing. Mr C explained that he made "small talk" with Mrs B's daughter "to try and keep her entertained when she started to become restless". He advised that he is happy for a patient to bring a support person. He stated: "I encourage any client to bring a support person to the appointment as this can make them feel at ease or help them during the treatment."

Mr C explained that because Mrs B is a "slightly built lady" he "attempted to gently alleviate some of her pain". He suggested that his relative size to Mrs B was "irrelevant". The technique he used is called the "[…] technique" which differs from classic manipulation as "nothing forceful is attempted". He stated:

"I choose to perform [this technique] as it has proven to be an extremely gentle, pain free realignment of the skeletal structure. This method relies on human circuitry to locate problem areas."

When asked to provide more detail about the technique, Mr C advised that Mr D had "forbidden" him to "share his teachings" without his consent.

The technique

This technique was developed by Mr D, who trained Mr C in the technique. Mr D has a Diploma of Massage Therapy. However, it is unclear where he obtained the qualification. Mr C began his training with Mr D in June 2001.

Mr D advised that only he and Mr C perform the technique, as Mr D has chosen not to share his "intellectual property" with anyone else. Mr D explained that the technique "originates from over twenty years of massage therapy and discovering how the human machine works in practice rather than theory". It is based on the following principles:

"- The human body is a well constructed, highly developed bio-organic machine, with the brain being the control centre.

  - Pain is the body's signal to the brain that something is wrong - if something causes pain it is incorrect treatment - don't do it.

  - The body is a precision machine which does not respond well to percussive adjustment. Don't force anything."

Treatment starts with educating the client how "human circuitry" works. Mr D explained that the spine is then "realigned" from the lumbar, up to the cervical spine. Mr D defines realignment as "to align or make straight" or "to put back into place". The realignment occurs by applying between 50 to 200 grams of gentle pressure to the vertebrae. The hands are placed over the relevant vertebrae and the direction of pressure is "as needed".

This is followed by "tracing any open circuits or other electrical faults detected". Mr D explained:

"Open circuits are messages from the body to the brain that have not yet been processed by the brain. They are traced by following the neural pathway this is detected by using light fingertip pressure.

Electrical faults are signals that do not clear when spinal alignment is complete. These signals are usually identified as 'non-specific pain' and detected by the pain."

The patient is then shown "how much the brain actually controls the body and how much they are in control of the brain as the operator of their machine". Mr D explained that at different stages during the treatment the patient is asked to "realign or put back in place specific vertebrae"; they are also asked to "realign vertebrae in their own neck using only voice command". Mr D advised that Mr C has been trained in all aspects of the technique.

Completion of treatment

Mr C said that at the end of the treatment Mrs B said that she felt "great, a lot looser" and asked whether she could book another appointment to see him. When Mrs B's husband called to cancel the appointment that evening Mr C asked how she was feeling. Her husband advised Mr C that she was "feeling a lot better following [his] treatment". At no time was any concern expressed.

In contrast, Mrs B recalls telling Mr C at the completion of the treatment that she was feeling quite sore. Mr C said that this was normal and that she should start feeling better in the next few days. He then advised her to make an appointment in two days' time, which she did. However, because the pain did not get any better her husband called and cancelled the appointment. Mr C appeared annoyed by this and asked if Mrs B was all right. Mrs B's husband said that she was "fine", as he did not think it was necessary to provide any further details.

Physiotherapy services

On 22 December 2006, Mrs B had an initial consultation with physiotherapist Mrs A. Mrs B saw Mrs A because of her ongoing back pain. Mrs B advised Mrs A that she had been to see Mr C the previous day for soft tissue massage. Mrs A's record of this consultation states:

"[Seen by] sports massage yesterday - manipulated [thoracic spine] - tried to manipulate [cervical spine]. Was very uncomfortable for [patient] - didn't relieve."

Mrs A carried out an assessment of Mrs B's back and joint range of motion. The records of this assessment document that Mrs B had acute muscle spasm at the level of T4 to T9 (thoracic spine area), and that her left side was worse than her right. Mrs A also documented that Mrs B was tender when the joints between T4, T5 and T6 were glided centrally and rotated right. Mrs A concluded that Mrs B had an acute muscle strain of her thoracic spine with referred pain. Mrs A commented that she would not have considered manipulating Mrs B in this condition. Mrs A was also concerned that Mr C appeared to be practising outside his scope of practice.[3]

Treatment consisted of ultrasound, acupuncture, heat pack, soft tissue massage, and gentle mobilisation. Mrs A also applied tape to Mrs B's thoracic spine. She recommended that Mrs B continue with heat packs and soft tissue massage.

Mrs B advised that the treatment provided by Mrs A did relieve some of her pain. However, her pain continued to become steadily worse over the next few days.

Presentation at the Emergency Department

On 28 December 2006, Mrs B presented to the Emergency Department (ED) at the public hospital with severe pain. The ED records document a history of back pain for the last month which had become much worse in the last two or three days. It is noted that Mrs B had been receiving physiotherapy, which had helped, and she had been taking anti-inflammatory medication (diclofenac), but this had not been as effective recently. Mrs B was discharged that day with the provisional diagnosis of thoracic back strain and a plan for follow-up with her general practitioner (GP).

Ongoing care

Mrs B continued to receive regular physiotherapy,[4] which initially helped her pain. However, when her pain persisted Mrs A referred Mrs B to her GP on 23 January 2007. In her referral letter Mrs A raised concern that Mrs B's pain was not solely musculoskeletal and requested a gastrointestinal review.

Mrs B advised that due to ongoing pain she was referred to a general surgeon, and subsequently to a gynaecologist for review.

Comment from Mrs B

When Mrs B attended Mr C for a massage she did not consider that what he was doing could be dangerous or cause her harm. Mrs B advised that she has since attended another massage therapist. She explained that this experience was quite different. She advised:

"I was informed what [the massage therapist] was doing and I asked questions. [Mr C] failed to do this and the outcome could have been more serious."

Response to provisional opinion

Mr C

Mr C reiterated that the technique does not involve spinal manipulation and it "works on releasing tight muscles thus by realigning the spine". Mr C considers that my expert advisors had an "extremely limited knowledge" of the technique as they were provided with only a "brief description". He suggested that he was not given the opportunity to provide this Office with more detailed information about the technique.

Mr C stated that he finds it "preposterous" that my experts found that "he failed to pick up on the severity of Mrs B's irritable bowel syndrome". He commented that he would have been operating outside his scope of practice by offering any "diagnosis" to Mrs B.

Mr D

Mr D denies that manipulation or mobilisation "in the classical definition" is used as part of the technique, stating that they use "micropractics" to achieve mobilisation. He commented that manipulation is "at best ineffective" and "at its worst deadly". Mr D advised that "the [technique] is a complete philosophy on how and why our bodies work the way they do".

Mr D explained that the technique is "far more complicated than it has been credited for". It will be several years before he can complete a written description of the technique and begin teaching. He estimated that it would require "5000 hours of study and practice" to become competent in the technique.[5] He described Mr C as his "only peer" and is confident in his ability.

Mr D submitted that because the HDC expert advisors are not familiar with the difference between the technique and the "current medical paradigm" they are not qualified to comment on the technique. He stated:

"If [the HDC] advisors required more information it would have been to their benefit to have requested it, to make assumptions on incomplete information only leads to inaccuracies."

Mr D suggested that the lack of empirical testing of the technique should not be taken as proof that it is not effective or safe, offering the following quote from Carl Jung as "food for thought":

"Whoever denies the existence of the unconscious is in fact assuming that our present knowledge of the psyche is total. And this belief is clearly just as false as the assumption that we know all there is to be known about the natural universe, our psyche or nature. We can merely state what we believe them to be and describe as best we can how they function".

Mr D also provided a number of testimonials from former and current clients stating that they have found Mr D's treatment helpful and effective.

Code of Health and Disability Services Consumers' Rights

The following Rights in the Code of Health and Disability Services Consumers' Rights are applicable to this complaint:

RIGHT 4

Right to Services of an Appropriate Standard

(1)               Every consumer has the right to have services provided with reasonable care and skill.

(2)               Every consumer has the right to have services provided that comply with legal, professional, ethical, and other relevant standards.

RIGHT 6

Right to be Fully Informed

(1)               Every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, would expect to receive.

RIGHT 7

Right to Make an Informed Choice and Give Informed Consent

(2)               Services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent, except where any enactment, or the common law, or any other provision of this Code provides otherwise.

Other relevant standards

• New Zealand College of Massage Training Manual (2006)Ethics and Legalities of Massage:

 "Scope of Practice and Your Legal Position:   

Scope of practice refers to the areas of expertise that a person practising relaxation massage may safely and competently practice. It is important to check that the client is in general good health and there should be no attempt to 'fix' any particular condition, apart from releasing tight tissues. …

Any clients with medical conditions or past injuries must be cleared for massage prior to any work being done. …"  

• Health Practitioners Competence Assurance (Restricted Activities) Order (2005):

"Restricted Activities:

…

Applying high velocity, low amplitude manipulative techniques to cervical spinal joints. …"[6]

• Standards New Zealand Health Records NZS 8153:2002:

"1.1 Content Accuracy

Outcome:

1.1.1        The health record is an accurate reflection of the interaction between the healthcare provider and the consumer/patient …"

Opinion

This report is the opinion of Tania Thomas, Deputy Commissioner, and is made in accordance with the power delegated to her by the Commissioner.

Opinion: Breach - Mr C

Under Right 4(1) of the Code of Health and Disability Services Consumers' Rights (the Code), Mr C was expected to provide services with reasonable care and skill to Mrs B. Under Right 4(2) of the Code he was expected to provide services that complied with professional standards.

Under Right 6(1) of the Code, Mr C also had a duty to provide sufficient information about the proposed massage. Mr C also had an obligation to ensure that Mrs B gave informed consent before providing the massage services, as required by Right 7(1) of the Code.

Mr C does not have a formal qualification and is not affiliated with any regulatory body. However, at the time of this incident, he held himself out to provide "sport and therapeutic massage". It is therefore a reasonable expectation that Mr C would have professional competence in this area. Accordingly, expert advice was obtained from a massage therapist. Expert advice was also obtained from a physiotherapist because manipulation techniques are undertaken by physiotherapists. As the technique has not been disseminated other than to Mr C, neither of my advisors have specific knowledge of the technique itself, and were therefore reliant on the information provided by Mr C and Mr D. I note that, despite their assertions to the contrary, both Mr C and Mr D have been provided with ample opportunity to fully explain the technique. However, both advisors are well placed to provide comment about the appropriate standards of massage therapy and manipulation.

My expert advisor, Mr Barry Vautier, made reference to the professional standards set out by Massage New Zealand and the New Zealand College of Massage,[7] as well as the NZQA standards for a certificate in massage. These are relevant standards for any massage therapist practising in New Zealand irrespective of actual membership of the bodies. Under Right 4(2) of the Code consumers have a right to a service that complies with these standards.

Informed consent

On 21 December 2006, Mrs B was experiencing severe acute back pain radiating from her chest. Because she was unable to make an appointment with a physiotherapist until the following day, she made an appointment for a massage with Mr C. She understood that she would be having a one-hour soft tissue massage. The clinical records from Mrs B's initial consultation with Mrs A document that this was a "sports massage".

Mrs B does not recall any explanation about the treatment or being given the opportunity to ask questions. Mr C explained that he advised Mrs B that his technique is "different from any other current technique". However, there is no information, or documentation, to suggest that he informed Mrs B that he would attempt to "realign" her spine using this technique. Overall, I prefer Mrs B's account that she did not receive any explanation from Mr C about the technique, particularly given his reluctance to disclose any information about the technique when requested to by this Office.

Mr C had a duty to explain to Mrs B the nature of the technique he proposed to use, and any risks or side effects associated with the technique, before starting treatment. This was particularly important when the proposed treatment was significantly different from what Mrs B reasonably expected - a soft tissue, or "sports" massage.

Given the lack of information Mr C has provided me regarding the technique, and the limited information he provided to Mrs B, I consider it unlikely that Mrs B was given adequate information to allow her to make an informed choice. Both Mr C and Mr D have been unable to adequately explain the technique when requested. Overall, I consider that Mr C did not adequately explain the technique or obtain Mrs B's consent for the proposed treatment. Accordingly, Mr C breached Right 6(1) of the Code. As a consequence, Mr C also breached Right 7(1), as he provided a service without Mrs B's informed consent.

Standard of care

Mrs B had an extensive history of bowel problems and associated back pain which she made clear to Mr C, first over the telephone when she was booking her appointment, then again when she arrived for her appointment. In addition to this, on the "client personal information" form, Mrs B documented that her main problem was back pain. She also recorded that she had irritable bowel syndrome.

After Mrs B had shown Mr C where her pain was - originating in the front of her chest and radiating around into her thoracic spine area - Mr C told her to undress and cover herself with a towel. Mr C then started his treatment. He carried out no further assessment.

Both Mr Vautier, and my physiotherapy advisor, Duncan Reid, consider that Mr C's assessment was inadequate. Mr Vautier stated:

"[Mr C] failed to adequately assess [Mrs B] in the first instance as his client screening did not pick up on the severity of her Irritable Bowel Syndrome problems."

Mr Reid explained that there are a number of complications associated with spinal manual therapy due to the risk of damage to the joint and surrounding structures. Therefore, before applying any manual therapy techniques to the spine, it is necessary to carry out a thorough assessment in order to screen for contraindications to treatment.

Mr Reid stated:

"As it turns out that [Mrs B's] back pain was not of spinal origin, this screening is of greater relevance. There is a need to determine that the pain is mechanical and coming from the spine before applying manipulation. In this case [Mrs B] has no history of trauma or other mechanical stress that would have indicated damage to the spine."

Mr C stated it was "preposterous" that my expert advisors criticised him for failing to pick up on the severity of Mrs B's irritable bowel syndrome.

Of course it would have been inappropriate for Mr C to diagnose Mrs B's bowel condition. However, there is no information to suggest that Mr C took any steps to clear Mrs B of any relevant pre-existing medical conditions.

The New Zealand College of Massage's statement of Ethics and Legalities of Massage outlines the scope of practice for a person practising massage at certificate level. It states that, prior to commencing treatment, "it is important to check that the client is in general good health and there should be no attempt to 'fix' any particular condition, apart from releasing tight tissues". Further to this, it states that "any clients with medical conditions or past injuries must be cleared for massage prior to any work being done".

Mr C then went on to carry out manual therapy techniques on Mrs B's spine. Mrs B explained that treatment consisted of Mr C pushing on her spine, and rotating her neck, making her joints "crack" and "click". Mrs B found the treatment quite uncomfortable.

Mr C stated that the technique "has proven to be an extremely gentle, pain free realignment of the skeletal structure" and "nothing forceful is attempted". Mr D explained that the technique involves realignment of the patient's vertebrae through the application of gentle pressure (50-200 grams). Mr D bases the technique on "over twenty years of massage therapy and discovering how the human machine works in practice rather than theory".

I do not find Mr C's view that the "crack" Mrs B heard during the treatment may have been his own wrist, elbow or finger to be a particularly credible explanation.

Neither Mr D nor Mr C has provided a particularly clear explanation of the technique they are using (my expert advisors have no knowledge of micropratics). Mr C and Mr D have explained that the technique does not involve manipulation. Mr D is clearly of the view that the technique is complex and difficult to describe. Aspects of the technique are clearly beyond the realm of conventional medicine. However, the issue is relatively straightforward and the information I have obtained indicates that Mr C manipulated Mrs B's spinal joints. Whether this was gentle or forceful, there was the potential for it to cause harm. Mr Reid noted that Mrs B's comments indicate that it may not have been particularly gentle.

Quite clearly, realignment of the spine, as described by Mr C and Mr D, falls outside the scope of practice of a massage therapist. Mr Vautier explained that spinal manipulation should only be carried out by a suitably qualified health professional as it is associated with a level of risk. He stated:

"If a person is untrained in their understanding of the various possibilities of directional dysfunction of given vertebrae, then they may unwittingly cause further dysfunction and pain to a client. This is more likely to happen with a forceful manipulation of the bony structures of the spine, but can also occur if the manipulation is gentle."

This view is also shared by Mr Reid. In particular, Mr Reid advised that manipulation and mobilisation of the cervical spine may compromise the vertebral artery. Arterial insufficiency may lead to serious complications including stroke. He stated:

"While [Mr C] is not a physiotherapist and clearly states this, if he wishes to manipulate the neck he needs to be aware of the dangers and contraindications of using such a technique. This is the very reason that [cervical manipulation] is a restricted scope under the HPCA Act (2003)."

Mr Reid also raised concern about the lack of clinical justification for carrying out manual therapy techniques on an undiagnosed condition. Mr Reid stated:

"I also do not feel it is appropriate to manipulate multiple areas of the spine without sufficient clinical findings to justify this. While [Mr C] has stated that [the technique] relies on human circuitry to locate the problem this is still not a relevant justification to manipulate other pain free areas of the spine."

It is important when health professionals are providing a service that they are able to recognise their limits, particularly in a situation when the service they are providing has the potential to cause harm.

I accept that Mr C was acting under the understanding that Mr D had trained him appropriately. However, it is my view that this does not excuse Mr C. I consider Mr C's lack of assessment demonstrates his limited insight and understanding of the risks and contraindications for massage and manual therapy techniques. I am not convinced by Mr C's submission that the technique is an "alignment" rather than a manipulation. It is the view of my experts that the technique is unsafe and would be viewed as a serious departure from professional standards.

Overall, I consider that Mr C should not have undertaken any form of manipulation of the spine. I am particularly concerned about the potential for this technique causing harm, including the risk of arterial disturbance. Accordingly, Mr C breached Right 4(1) by failing to provide services with reasonable care and skill.

Documentation

Documentation of services provided is important to ensure quality and continuity of services. I consider that all health service providers, including massage therapists, have a professional obligation to document the services provided to consumers. The key principles are set out in the Standards New Zealand Health Records NZS 8153:2002 under clause 1.1, which states: "The health record is an accurate reflection of the interaction between the healthcare provider and the consumer/patient …" Mr C stated that he did not document the care he provided to Mrs B. By not keeping any record of the services he provided to Mrs B, Mr C failed to provide services that complied with relevant standards, and breached Right 4(2) of the Code.

Action taken

Mr C advised that he has implemented a number of changes to his service. The client information sheet now asks for more detail from the patient. He has also introduced a consent form, and he now has a sign in his treatment room advising patients how to address any concerns they have with the treatment. In addition, Mr C no longer advertises his service as "massage", instead calling it "Sport & Therapeutic Bodywork".

Other Comment

The technique used was developed by Mr D, who trained Mr C in the technique. The technique is not a recognised technique in New Zealand. Mr D explained that the technique "originates from over twenty years of massage therapy and discovering how the human machine works in practice rather than theory".  Mr D has provided me with only a limited explanation of what is involved in the technique. He advised that he has chosen not to share his "intellectual property" with anyone other than Mr C. He asserts that he uses "micropractics" rather than manipulation, but has provided no further explanation about what this is. Neither of my experts has heard of "micropractics". Mr D has suggested that the technique has a subconscious component and the technique should not be discounted just because it is not recognised. He provided a number of testimonials from present and past patients who vouch for the effectiveness of the technique.

However, as discussed above, it appears that the technique involves manipulation of the spinal joints. I note Mr Reid's comments that "[the technique] is not part of a relevant qualification and the manipulative treatment provided is outside the scope of massage therapy". As discussed above, there are a number of complications associated with spinal manual therapy, in particular manipulation of the cervical spine. It is for this reason cervical manipulation has a restricted scope under section 9 (performing a restricted activity) of the Health Practitioners Competence Assurance Act (2003). In the circumstances, I propose to refer the matter to the Ministry of Health.

Recommendations

I recommend that Mr C stop using the manipulative aspects of the technique and consult with Massage New Zealand regarding the safety and appropriateness of the technique.

Follow-up actions

• Mr C and Mr D will be referred to the Ministry of Health in accordance with section 59(4) of the Health and Disability Commissioner Act, which states that the Commissioner may refer any matter to an appropriate authority for reasons of public safety.
• A copy of this report, with details identifying the parties removed, except the names of Mr C and Mr D, will be sent to Massage New Zealand and the New Zealand College of Massage.
• A copy of this report, with details identifying the parties removed will be placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

 

Appendix A

Massage Therapy advice

The following expert advice was obtained from Barry J Vautier:

"I have been asked to provide an opinion on case number 07/03068, and have read and agree to follow the Commissioner's Guidelines for Independent Advisors.

Qualifications

• Naturopath Diploma (N.D.).
• 1990 Specialising in Remedial Body Therapies. South Pacific College of Natural Therapeutics.
• Diploma Therapeutic Massage (Dip. Ther. Mass.).
• 1994 New Zealand Association Therapeutic Massage Practitioners (NZATMP).
• Postgrad Diploma of Herbal Medicine (DHM) 1996 Southern Cross Herbal School of Herbal Medicine (Australia).

Current Memberships

• Massage New Zealand (MNZ) - Current President of MNZ.

(Member of NZATMP since 1989, which became Therapeutic Massage Association (TMA) in 2000 and merged in 2006 with Massage Institute of New Zealand Inc. (MINZI) to become MNZ).

• Society of Naturopaths (SN).
• Natural Health Council (NZ) Inc. (previously - NZ Natural Health Practitioners Accreditation Board).
• On-site Massage Association.

Experience in Massage 

• I have been massaging since 1979 and in part time professional practice since 1990, and full time since 1995 in a variety of clinical settings - home-based clinic, medical centre, natural health centres and on-site massage in a variety of locations.
• Part time tutor for Wellpark College (1994 & 1995) and the New Zealand College of Massage from 1996 to the present. Tutor and examiner for the NZQA national certificate and diploma levels of therapeutic massage.
• National examiner for NZATMP 1996 to 2000.
• I have actively participated and fostered ongoing professional development in massage throughout my career including gaining further advanced techniques in massage, mentoring and teacher training in adult education, designing and moderating massage courses.

…

Summary

1. In my opinion [Mr C] did not provide [Mrs B] with an appropriate standard of care. The evidence presented indicates he may be practising outside the scope of practice of a massage therapist by performing spinal manipulation.
2. The following standards of practice have been applied:

a.   Industry standards as taught by massage schools in New Zealand.

b.   Educational standards as per the NZQA unit standards for the certificate of relaxation massage.

c.   Standards as defined by the Code of Ethics of Massage New Zealand.

d.   Various Acts of Parliament.

1. The standards of massage practice of [Mr C] were not well complied with overall. Massage involves the manipulation of the soft tissues of the body and does NOT include manipulation of the bony (hard) tissues, such as the vertebrae of the spine. From the evidence of [Mrs B] it would seem [Mr C] manipulated her spine.
2. Given the insufficient evidence of the [technique] its safety and appropriateness as a technique is very questionable. The principles behind this technique as described by [Mr D] in his letter [dated 12 June 2007] are vague and need further investigation for public safety.
3. The advice and information given to [Mrs B] by [Mr C] regarding this technique was inadequate.
4. The consent process was inadequate.
5. The initial assessment was inadequate.
6. Whether [Mr C] should be offering the [technique] is open to conjecture as there is insufficient information about what the [technique] involves. Of note is that neither [Mr C] nor [Mr D]has given any evidence about their training and qualifications in massage or other body therapies.

Thus until further evidence is presented and a thorough assessment of this technique undertaken by a qualified health professional, then for public safety, [Mr C], should NOT be using this technique, because as claimed by [Mrs B] it involves spinal manipulation. Spinal manipulation is outside the scope of practice of a Massage Practitioner.

In my professional opinion [Mr C] did not provide [Mrs B] with an appropriate massage, based on the evidence presented. Other massage providers would view [Mr C's] conduct with severe disapproval.

Body of the Report

1. In my opinion [Mr C] did not provide [Mrs B] with an appropriate standard of care. In particular in terms of industry expectations of a massage service, the following areas were inadequate:

 - Information gathering and goal setting (Verbal and written screening) [See Appendix C]

 - Physical assessment and session planning

 - Massage principles

 - Application of strokes and techniques - probably outside of scope of practice

 - Post massage advice

 - Communication and language skills.

2. Standards of practice - overview

There are two main levels of professional massage practice in New Zealand as defined by the professional association Massage New Zealand (MNZ) and by the New Zealand Qualifications Authority (NZQA) unit standards of massage.

The two levels are:

National Certificate of massage (level 4 - approx 47 credits - about 500 hours of training)

National Diploma of massage (level 5 - approx 120 credits - about 1200 hours of training)

Most massage schools in New Zealand teach to these standards or equivalent.

In considering the case of [Mr C] I have compared the evidence presented against the NZQA national certificate of massage.

The following are some general standards which apply in New Zealand to the certificate level of massage.

a)      Industry standards for the theory and practice of massage as taught by massage schools in New Zealand, especially those teaching to the NZQA unit standards as applied to the certificate level of massage.

b)      Educational standards as per the [New Zealand Qualifications Authority] unit standards for the certificate of massage.

The scope of practice applies to giving a relaxation massage to healthy individuals. A practitioner at this level of training would be expected to screen the client for health concerns, and depending on the severity of the condition, get consent from another qualified health professional for any medical conditions presented. In some cases the client would be referred to another health practitioner for assessment and /or treatment.

c)      Standards as defined by the Code of Ethics of Massage New Zealand.

d)      Ethics and legalities of massage. Scope of practice massage - New Zealand College of Massage training manual pp 9-13.

Various Acts of parliament including:

 - Health Practitioners' Competence Assurance Act (2003) Health and Disability Commissioners Act (1994) and its Code of Rights Consumer Guarantees Act

 - Privacy Act

 - Occupational Safety and Health Act

 - Human Rights Act

 - Fair Trading Act

 - Local body bylaws

3. The standards of massage practice of [Mr C] were not complied with in terms of some of the above standards. There is also a lack of evidence around what the [technique] involves (see below) however in particular the evidence from [Mrs B] would suggest he operated outside the scope of practice of a massage therapist with the use of spinal manipulation. There was also a lack of health screening as evidenced by his client information sheet and the lack of client records.

4. The [technique] would be considered unsafe given the lack of documentary evidence about its history, use and lack of peer review. Until there is evidence to the contrary including documentation of case histories, assessment by other body therapy modalities including massage, and a more detailed description from [Mr D], then for public safety, caution needs to be exercised. [Mr D] does not belong to any professional body and as such does not come under a code of practice or ethics.

Comment on the questions posed by HDC

Question 1

a)   The statement of origin of the [technique] lacks descriptive detail. [Mr D] has made no statement of his qualifications in massage, where he obtained them and when. There is no information about any professional development he has undertaken as a source of the [technique]'

b)   His principles as stated in clauses (i) and (ii) of his letter [12 June 2007] are generic to most body therapies and thus doesn't differentiate the [technique]. The principle in clause (iii) states 'The body is a Precision Machine which does not respond well to percussive adjustment. Don't force anything.'What does he mean by percussive adjustments? In massage, percussive generally refers to tapotement (or striking) type strokes such as 'hacking', 'cupping', 'pounding' and 'flicking'. I suspect he means 'thrust adjustments' as a chiropractor, osteopath or manipulative physiotherapist might apply. His principle of not forcing anything would fit within the scope of massage.

c)   The techniques described by [Mr D] are 'different from any other'. But he does not explain how they are different. There is no explanation of what is meant by the 'human circuitry'. He states, 'Realign spine…' (the whole spine from L5 to C1) but does not say HOW this is done. He does not explain what 'open circuits' or 'electrical faults' are and how they are detected. (Or presumably corrected) Detail is also lacking about showing the client '…how much the brain actually controls the body…'

Question 2

By choosing to not share his 'Intellectual Property' of the [technique], [Mr D] runs counter to ethical standards of most health modalities, as peer review and scrutiny of a technique provides public safety and the ongoing professional development of an industry. This secretiveness suggests he has something to hide. If the concern is financial it is mostly unjustified. In the body therapies industry a 'new' technique or specialisation usually gives the founder credibility and the ability to earn above average income through his practice and lectures. [His technique] is unheard of in the massage industry.

Question 3

[Mr D] claims to have trained [Mr C] from June 2001. The content, duration and scope of this training are not presented and detail is lacking about what he means by 'Skeletal Positioning, Human Circuitry, Fault Tracing and Brain Training'.

1. According to the documentary evidence of [Mrs B], she seems to have received inadequate consultation, advice and information. She states 'He didn't inform me what he was doing…' and that he was 'making small talk' to her daughter. [Mrs B] gives no evidence as to whether she understood the [technique] and was under the impression she was having a massage. A subsequent massage from another massage therapist highlighted to [Mrs B] the difference in advice and professionalism as the other therapist. She stated: 'I was informed what she was doing and I asked Questions'. [Mr C] failed to do this...' This suggests a lack of rapport between [Mr C] with [Mrs B], and I would question his communication skills and training.
2. The consent process was inadequate. [Mr C] didn't get adequate client informed consent, or explain that he was going to 'crack' her spine. She states '[Mr C] didn't inform me when he did this.' - referring to him 'cracking' her spine.
3. Given the lack of detail in [Mr C's] written questionnaire and the reported lack of verbal screening by [Mrs B], I would suggest his initial assessment was inadequate. There is no written evidence that he discussed her bowel or IBS (Irritable Bowel Syndrome) as indicated on her client information sheet. Some discussion here might have alerted a therapist to refer her to a GP, as did eventually her physiotherapist. Her pain showed up as a requirement for subsequent surgery. However identifying functional versus structural source of pain can be difficult even for the most practiced health professional. In [Mrs B's] case her pain turned out to be functional (referred pain from her digestive system). According to [Mrs B's] evidence the techniques applied to her by [Mr C], made her pain worse. But in [Mr C's] evidence [letter dated 1 April 2007] he states that when he asked her husband 2 days after the massage, he was 'advised than she felt a lot better'.
4. Whether [Mr C] should be offering the [technique] is open to conjecture as there is insufficient information about what is involved with the [technique]. Of note is that neither [Mr C] nor [Mr D] has given any evidence as to their training and qualifications in massage or other body therapies.

Thus, until there is further evidence presented and a thorough assessment of this technique undertaken by qualified health professionals, then for public safety, [Mr C], should NOT be using this technique as evidenced by [Mrs B], it involves spinal manipulation. Spinal manipulation is outside the scope of practice of a massage therapist.

Additional comments about the care provided by [Mr C]

He failed to adequately assess [Mrs B] in the first instance as his client screening did not pick up on the severity of her irritable bowel syndrome and Bowel problems. No indication of possible medication is indicated on his client information sheet. His screening form lacks detail as per expectations of the massage industry [see Appendix C].

There are no other client notes present to indicate what he found and what techniques he used. Record keeping was insufficient as a massage practitioner. Are his client records kept in a secure location?

[Mr C] does not belong to a professional massage association. He states his training is American based but has not supplied any evidence of this.

Does [Mr C] display a Code of Ethics at his clinic?

Does [Mr C] have a complaints procedure displayed in a visible place and pointed out to clients?

Does [Mr C] have a referral network to send clients to presenting with conditions outside his scope of practice? According to the complaint by [Mrs A] ([Mrs B's] physiotherapist), [Mr C's] business card does not list his qualifications. It is unclear what professional training [Mr C] has received, and to what standard.

I also question the safety and appropriateness of the [technique] as described by [Mr D].

He has presented little evidence of its efficacy. For public safety a thorough assessment of this technique should be undertaken by an appropriate body therapy professional. If the [technique] does involve spinal manipulation, then this is a serious public health concern for a practitioner who is untrained and unqualified in this area. …"

Further Massage Therapy Expert Advice

[Following the receipt of additional information from [Mr C], Mr Vautier was asked to provide further advice. In particular, he was asked to comment on the difference between realignment (as defined by [Mr C] and [Mr D]) and manipulation, and what risk is associated with this type of technique.]

"In reply to HDC's letter of 2 October, please find below comment on the four points raised, and based on the further information supplied in letters by [Mr C] (16 September 2007) and [Mr D] (18 September 2007).

1. Realignment of the spine is typically carried out by trained health practitioners in order to improve a client's health and spinal functionality. There are many techniques for achieving this result, including those done by 'forceful' or by 'gentle' manipulation of either the soft tissues or bony tissues of the structures associated with the spine. Realignment requires manipulation of some sort. There are some practitioners who work with 'energy' techniques who claim to 'realign' the spine without manual touch. The scope of practice for a massage therapist is to massage ('manipulate') the soft tissues of the body. [Mr C] and [Mr D] claim to realign ('put back in place', 'make straight') the spine by gentle manipulation (50 to 200 grams [of pressure]).
2. The risk associated with realignment is that damage may occur to nerve and connective tissue due to compressive forces. If a person is untrained in their understanding of the various possibilities of directional dysfunction of given vertebrae, then they may unwittingly cause further dysfunction and pain to a client. This is more likely to happen with a forceful manipulation of the bony structures of the spine, but can also occur if the manipulation is gentle. This may have happened with the treatment of [Mrs B] by [Mr C]. Deep tissue massage to the soft tissues (muscles, tendons, ligaments and fascia) is also known to realign the spine. These are advanced massage techniques involving manipulation of the soft tissues and would fall into the scope of the diploma level of training and beyond.

What is not clear in this case is the training [Mr D] has received in his techniques, and thus what knowledge he has passed onto [Mr C]. [Mr D] claims to be self taught, but what has he based his learning on. He has not provided information of his massage training (CMT - presumably 'Certified Massage Therapist'), and where he obtained it. [Mr C] does not seem to have any massage qualification.

1. [Mr C] by his own definition does Sports and Therapeutic Massage. Spinal manipulation, whether forceful or gentle, is outside the scope of practice of a massage therapist. [Mr C] in his letter of 16 September 2007 states that 'nothing forceful is attempted' yet his client [Mrs B] experienced her spine 'cracking' due to his compressions on it. This plus indirect evidence from the Physiotherapist would suggest he is working outside the scope of a massage therapist.
2. Comments in response to [Mr D's] letter of 18^th September 2007

Point 1

The goals of the [technique] as described by [Mr D] are not that different from many body therapies which have the same goals of 'enabling clients to regain control of their own body'. Encouraging clients to be "responsible for their own wellbeing" is also universal.

Point 2

[Mr D's] 'Human Circuitry' sounds like a description of the functions of the nervous system.

Point 3

The definition of realignment is not in dispute.[8]

Point 4

[Mr D] states: 'Hands are directly on the spine and direction of pressure is as needed'. This seems to be a description of manipulation of the bony structures of the spine, even if the pressure is light (50 to 200 grams).

Point 5

It is common for practitioners to assess as they treat. What subjective and objective assessments were made with [Mrs B] by [Mr C], and where are the records of these.

Points 6, 7 & 8

[Mr D's] descriptions are unconventional and don't make sense in terms of medical terminology. He needs to elaborate and describe his techniques in the universal language of conventional medical terminology. I would question whether [Mr D] has training in Anatomy and physiology to accurately describe what he does.

[Mr C] has suggested that someone assess their technique first hand, and this may be required in order to get further understanding on how he and [Mr D] operate. I back up statements made previously and would reiterate that secrecy of a technique for fear of it being copied is not in the interests of public safety nor the development of a professional industry.

Further advice may need to be sought from practitioners who manipulate the bony structures of the spine such as a Chiropractor, Osteopath or Manipulative physiotherapist."

Appendix B

Physiotherapy advice

The following advice was received from independent physiotherapy advisor Duncan Reid:

"I, Duncan Reid, Physiotherapist, Auckland, have been asked to provide an opinion on case number 07/03068. I have read and agree to follow the Commissioner's Guidelines for Independent Advisors.

I also declare that there is no conflict of interest in this case. I do not know [Mrs B], the complainant or [Mr C] the Massage Therapist at the centre of the complaint.

Expert Qualifications

Duncan Reid, Master of Health Science (Hons), Postgraduate Diploma Health Science (Manipulative Physiotherapy), Diploma Manipulative Therapy, Diploma Physiotherapy, Bachelor of Science (Physiology).

I have been a practicing Musculoskeletal Physiotherapist for 27 years. I am currently Head of the School of Rehabilitation and Occupation Studies at AUT. I am a senior lecturer in the School of Physiotherapy. I teach both undergraduate and post-graduate Musculoskeletal Physiotherapy papers. I am very familiar with the teaching of spinal manipulation I have been teaching these skills nationally and internationally for 22 years. I have also published in peer reviewed journals on the topics of cervical manipulation and problems arising from damage to the blood vessels in the neck. Hence, I have the required skills and expertise to comment on the treatment and management [Mrs B's] back pain.

…

Answers to questions

Before answering these specific questions I need to clarify some of the issues and terms.

[Mr C] is not a registered health professional or a member of the NZ Massage Therapist Association. He states to have performed extremely gentle pain free alignment to the spine of [Mrs B], based on the [technique] which he states he is trained in. There are many philosophical and technical approaches to manual therapy applied to the spine. The current registered health professionals working under the Health Practitioners Competence Assurance Act (2003) who provide spinal manual therapy in New Zealand are chiropractors, osteopaths, physiotherapists and medical doctors. The [technique] is not a recognised philosophy or technique in common practice in NZ.

[Mrs B] states in her submission of 2.5.07 that [Mr C] made her back and neck 'crack' as part of his massage treatment. This crack is often termed a cavitation and can be a sign of a successful manipulative procedure to the spine. One of the fundamental issues here is to determine the difference between a mobilisation and a manipulation. While the term manipulation is often used to describe any technique using the hands, in the medical world it has a specific meaning.

A mobilisation is defined as low velocity small or large amplitude passive movement of a spinal segment undertaken within the normal physiological range of joint. A manipulation is a high velocity, low amplitude (HVLA) movement of the joint, taking the joint beyond its normal physiological range. This is often associated with an audible crack (cavitation) and is thought to be a release of carbon dioxide from the joint.

Depending on the skill of the operator both of these techniques can be performed gently and with little stress to the tissue. Equally, they can both be performed badly with great stress to the joint and surrounding structures. However, in the case of a HVLA there is a greater risk of harm because the speed of the technique does not allow the patient to easily resist the technique as is the case in a mobilisation. There are a number of contraindications to the use of HVLA techniques. These are outlined in Appendix [D].

Under the current HPCA Act manipulation (HVLA) to the cervical spine in particular, is a restricted activity as outlined in the [HPCAA (2003) restricted activities guidelines].[9]Massage therapists are not within the list of professions who have this scope.

1. Given [Mrs B's] symptoms, was the treatment [Mr C] provided safe and appropriate? Please comment on whether you consider [Mr C's] assessment of [Mrs B] was adequate.

No, the treatment was neither safe nor appropriate. While [Mr C] states that on his initial assessment he discusses the needs of the patient and they complete a form outlining existing conditions and personal details, he has not provided evidence of this. However, as he has gone on to provide spinal manual therapy (SMT) there is a need to provide a reasonable amount of depth in the questions asked. I have provided in Appendix [D], a form that we use at the physiotherapy school to screen the students before they learn and apply manual therapy to themselves and this is carried over into their assessment of the patients they treat. There are a number of absolute and relative contraindications to SMT. It is not clear if [Mr C] has screened for these. As it turns out that [Mrs B's] back pain was not of spinal origin, this screening is of greater relevance. There is a need to determine that the pain is mechanical and coming from the spine before applying manipulation. In this case [Mrs B] has no history of trauma or other mechanical stress that would have indicated damage to spine. The pain was likely referred from the internal organs and therefore not likely to change with mechanical treatment. He has gone on to manipulate the neck. [Mrs B] has no history of neck pain and therefore there seems little justification for treating this area. The Australian Physiotherapy Association (APA) has developed a set of guidelines to be used prior to the treatment of patients with cervical pain.[10] …. The NZ Manipulative Physiotherapist Association (NZMPA) has adopted these guidelines that are considered the minimum requirement for screening patients for arterial disturbance before manipulating the neck. While [Mr C] is not a physiotherapist and clearly states this, if he wishes to manipulate the neck he needs to be aware of the dangers and contraindications of using such a technique. This is the very reason that HVLA is a restricted scope under the HPCA Act (2003).   

2. Please comment on [Mr C], as an unregistered health practitioner, providing the [technique]. Please include comment on the following:

(a)   Given [Mr C's] qualifications, should he have been providing this treatment?

The [technique] is not part of a relevant qualification and the manipulative treatment provided is outside the scope of massage therapy.

(b)   Should the [technique], as described, be provided by an unregistered massage therapist?

No, as with above, because [Mr C] is not on the massage therapist register and therefore he should not be applying these techniques as they are not part of the massage therapy scope.

Other matters

There is a clear difference of opinion in this case about the amount of force used in the delivery of the technique. [Mr C] states in his letter of the 1/4/07 that his technique attempted to "gently alleviate some of [Mrs B's] pain". He also states that following the techniques that he asked her how she felt and the reply was 'great, a lot looser'. He also states that there was no problem following the treatment. On the other hand when [Mrs B] was interviewed by [the HDC] investigator on the 14/11/07, she states that [Mr C] was 'pushing quite hard, making her back crack' and that she found the treatment 'uncomfortable and made her pain worse'. She also states that [Mr C] told her that this increase in pain was normal as he 'had got it all out'. This would imply to me that some force was used and that it was not gentle in its application. Given that [Mr C] was treating an undiagnosed pain syndrome this is not an appropriate or safe way of dealing with the problem. I also do not feel it is appropriate to manipulate multiple areas of the spine without sufficient clinical findings to justify this. While [Mr C] has stated that the [technique] relies on human circuitry to locate the problem this is still not a relevant justification to manipulate other pain free areas of the spine.

Finally, there appears to be no documented consent to the manipulation or evidence of screening for vertebro-basilar insufficiency or upper cervical ligament instability as per the APA guidelines. [11] As you will see in the guidelines on page 7[12] there is a section on consent. [Mr C] has not provided any evidence of such a consent form prior to performing any of the manipulative techniques on [Mrs B]. Again this is not appropriate.

Departure from appropriate standard of care

I feel that [Mr C's] treatment of [Mrs B] is a significant departure from the expected standard of care. …"

Further comment from Mr Reid

Mr Reid advised that, in his view, [Mr C] was manipulating [Mrs B's] spine. He viewed it as a manipulation because the joint was being passively forced beyond its end range causing a cavitation. Mr Reid advised that there are a number of risks associated with manipulation, particularly in the cervical spine. Mr Reid is concerned that [Mr C] did not carry out any screening tests and does not appear to be aware of the risks association with manipulation.

Appendix C [please refer to pdf for scanned image]

Appendix D [please refer to pdf for scanned image]

 

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[1] Massage New Zealand is a self-regulated association and incorporated body. Membership is voluntary.

[2] Mrs B advised that her pain began approximately three days prior to seeing Mr C. She was unable to recall any injury prior to this which she could attribute her pain to.

[3] Mrs A reported her concerns about Mr C to this Office.

[4] Mrs B attended physiotherapy appointments with Mrs A on 3, 5, 12, 19, 22 and 23 January 2007.

[5] It is not clear whether Mr C has completed 5000 hours of training. (In comparison, Physiotherapy is a four-year degree and includes around 1000 hours of clinical practice.)

[6] Section 9 of the Health Practitioners Competence Assurance Act (2003) allows for specified activities to be restricted to registered health practitioners, in order to protect members of the public from the risk of serious or permanent harm.

[7] The New Zealand College of Massage is an educational institute that provides NZQA approved courses in massage therapy.

[8] Mr D stated that to realign means to "align or make straight" or "to put back in place".

[9] Refer to www.moh.govt.nz/moh.nsf/indexmh/hpca-restricted-guidelines#restricted-activities

[10] Australian Physiotherapy Association Clinical Guidelines for Assessing Vertebrobasilar Insufficiency in the Management of Cervical Spine Disorders (2006) see:

http://apa.advsol.com.au/members/documents/download/AssessingVertebrobasilarInsuffic.pdf

[11] Symptoms associated with decreased blood flow to the brain.

[12] Refer to footnote 6.