Information provided by massage therapist

Names have been removed (except the expert who advised on this case) to protect privacy. Identifying letters are assigned in alphabetical order and bear no relationship to the person's actual name.

Massage Therapist, Ms A

A Report by the Deputy Health and Disability Commissioner

Table of Contents

Executive summary

1. On 8 October 2013, Mrs B had a 90-minute Tui Na massage with Ms A, a massage therapist. Mrs B had purchased an online promotional voucher for the treatment. Tui Na massage is a form of Chinese medical massage using acupressure (focussed on acupuncture points). The treatment often uses very deep pressure. The voucher did not describe Tui Na in any detail. Mrs B was under the impression that the massage would be a relaxation treatment. 
2. A sign outside Ms A's treatment room displayed "Acupuncture Clinic" and "free ACC" on it. Mrs B told HDC that she "felt safe that they were accredited by ACC". However, Ms A was renting a room at the acupuncture clinic (the Clinic). The Clinic's ACC accreditation did not extend to Ms A. 
3. Ms A trained in Chinese osteopathy and Tui Na massage therapy overseas in 1986. She then worked in a clinic overseas for 16 years. She began offering massage therapy treatments in New Zealand in 2008. 
4. Ms A began the treatment without taking a client history or explaining to or discussing with Mrs B what to expect from the treatment. Mrs B found the treatment to be very forceful and painful. The treatment involved Ms A at one point climbing onto the massage table on all fours and slowly lowering her knees onto the larger muscles of Mrs B's back. Ms A submitted that her hands and feet were always supporting her own weight. Ms A provided a copy of brief handwritten notes relating to the treatment. 
5. After the treatment, Mrs B had a very bad night's sleep. She had a sore back, neck, and shoulders in the days afterwards. Mrs B said that she had none of these symptoms prior to the appointment. She also had a headache, which continued for a few days. Mrs B telephoned ACC and discovered that Ms A was not ACC accredited. 

Findings summary

6. Given the nature of the treatment, Ms A should have clearly explained and communicated to Mrs B, a new client, that Tui Na massage was a deep tissue massage and could potentially be uncomfortable and painful for her. That is information that a reasonable consumer would need to receive to give informed consent. The absence of information given to Mrs B about what the treatment would entail meant that she did not have the information she required in order to give informed consent. Therefore, Ms A breached Right 6(2) of the Code.  
7. Except in limited circumstances, Right 7 of the Code provides that services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent. Due to the lack of information provided to Mrs B, she was unable to make an informed choice or give informed consent. It follows, therefore, that Ms A also breached Right 7(1) of the Code. 
8. Adverse comment was made about Ms A's use of her knees as a technique to apply pressure, as it is not usual practice for a Tui Na massage therapist. Adverse comment was also made that Ms A should have kept a more detailed record of the care she provided to Mrs B. 

Complaint and investigation

9. The Commissioner received a complaint from Mrs B about the services provided to her by Ms A. The following issue was identified for investigation: 

Whether massage therapist Ms A provided Mrs B with an appropriate standard of care in October 2013. 

10. An investigation was commenced on 28 May 2014. This report is the opinion of Ms Theo Baker, Deputy Commissioner, and is made in accordance with the power delegated to her by the Commissioner.
11. The key parties referred to in the report are:

Ms A Massage therapist

Mrs B Consumer

12. Information was also reviewed from:

Ms C Acupuncturist

Massage New Zealand

13. Independent expert advice was obtained from Mr Martin Greenleaf, an acupuncturist and massage therapist (Appendix A).

Information gathered during investigation

Background

14. In October 2013, Mrs B saw an online promotion for a 90-minute full body Tui Na massage with Ms A, massage therapist. The offer was one of three 90-minute packages.  
15. Tui Na massage  is a form of Chinese medical massage using acupressure (focussed on acupuncture points) and kneading and rubbing. The treatment often uses very deep pressure. 
16. Ms A stated:

"Tui Na massage can be an aggressive form of massage … Tui Na could be compared to Thai massage, deep tissue massage, or physiotherapy where the treatment involves applying localised pressure to muscles in order to aggravate the heal[ing] process; a form of therapeutic treatment as opposed to relaxation. Pain and bruising is an unfortunate side effect of these types of aggressive treatment; however pain tolerance differs based on individuals. The sore sensation in the muscles can last up to one week post treatment.

My [online] special offered a very specific type of massage (Tui Na) which can be quite deep and it's not uncommon for clients to feel more pain immediately after than before … however, the Qi  energy is released, the blood flows freely and the client feels greater mobility and less pain in a day or two."

17. Ms A said that "typically a Tui Na session is a standard practice, with slight variations to conform to a client's particular needs …". 
18. Mrs B no longer possesses a printed version of the voucher associated with the online promotion, but provided a copy of the confirmation email she received The voucher does not describe Tui Na techniques in any detail.
19. Mrs B told HDC that initially she thought that Tui Na was part of Ms A's name. Mrs B said she was under the impression that the massage would be more of a relaxation treatment. 

Clinic location

20. Mrs B told HDC that she recognised the advertised address where Ms A's treatment room was located, having driven by it. Mrs B recalled that a sign on a post outside said "[The Acupuncture Clinic]" and "free ACC" on it. Mrs B told HDC that she "felt safe that they were accredited by ACC".
21. Mrs B said that she paid  online and then telephoned Ms A, making an appointment for 3pm on 8 October 2013. 
22. At the time of the appointment with Mrs B, Ms A used a treatment room as a tenant of the Clinic, a large healthcare provider owned by chief acupuncturist Ms C through her company. Ms A's beauty and massage treatment room was located at the Clinic. 
23. Ms C told HDC that Ms A is not an employee or agent of her company, and that the ACC accreditation it has does not extend to Ms A. Ms A is able, however, to use the Clinic's landline telephone number for bookings. 

Training

24. Ms A told HDC that initially she trained in Chinese osteopathy and Tui Na massage therapy in 1986. She then worked in a clinic overseas for 16 years before moving to NZ, and worked with Ms C's company from August 2008 to February 2011. 
25. Ms C's company stopped operating in February 2011. Ms A subsequently worked independently at the Clinic rooms. In January 2014, Ms A renewed a tenant's agreement with Ms C's company.
26. Ms A is not affiliated or registered with any New Zealand massage therapy organisation. 

Massage appointment - 8 October 2013

Information

27. Mrs B said that when she arrived at the treatment rooms, no other staff were present. Mrs B found Ms A, who asked her to take a seat while she prepared the treatment room. Mrs B then lay face down on the treatment table and was draped with a towel. 
28. Ms A said that her usual practice is to ask a client if there are any areas of pain or discomfort. Mrs B said that Ms A did not do this, and did not take her health history or discuss the treatment beforehand. Mrs B said that, as a result, she volunteered some information, telling Ms A that she had tightness in the shoulders and had some stress owing to exams.
29. Mrs B said that Ms A began the treatment without explaining or discussing what to expect. Mrs B said that, as she believed Ms A to be ACC approved, she told herself that everything was OK. 
30. Ms A stated to HDC:

"One would assume that when a voucher for a treatment or service is purchased, that it's already known and understood apriori [original emphasis] what the service entails … [Mrs B] never asked any questions until after she had the massage."

Treatment

31. Mrs B could not recall all the details of the treatment she received, but stated:

"The massage was of a very violent nature and painful, contortion style. I reacted to my right shoulder clicking back and forward with her strong massage technique and she reassured me in broken English 'you will relax' or something like that. She continued with pushing, pulling limbs, very forceful pressure on the back of my neck and the front of my throat hurt, she climbed on my back on two occasions; digging her knees into my back. She thumped my back 4 times with a closed fist, I felt winded. I again reacted and she said 'you OK' but I couldn't speak."

32. Ms A described to HDC the usual sequence of Tui Na treatment as beginning with head massage, followed by relaxing the back muscles using long strokes; massaging the arms, neck and shoulders; stimulation of acupressure points with her thumbs and fingers; climbing on to the massage table, straddling the client, and rapidly tapping the client's back using the side of her fists; slowly lowering her knees into the sides of the lower back (to release muscle knots); climbing off the table and massaging each leg; turning the client over to a face-up position and massaging the back of the neck and shoulders, frontal head, arms, hands, fingers, lower legs, feet and toes; and finishing with a warm towel compress to the legs. 
33. Ms A told HDC that she always asks clients while she is massaging if her pressure is too hard or if the client is uncomfortable. Ms A said her English is limited but that she knows and understands enough to ask if clients are OK and to recognise if a client responds with "Stop", or "Ow", or "Too hard" or any sounds that could be interpreted as severe pain. 
34. Ms A said that Mrs B did not speak at all during the treatment, and that in relation to her use of her knees to treat Mrs B:

"At no time did I ever put my whole body weight on to [Mrs B's] back by kneeling on her … I climbed onto the massage table 'on all-fours' and I slowly lowered my knees onto the large muscles of her back. My feet and hands are always supporting my weight. I lowered my knees so slowly and gently that at any time, [Mrs B] could've said 'STOP!'."

Post-treatment

35. Mrs B said that after the treatment Ms A gave her Chinese tea. Mrs B said she told Ms A that her shoulder was sore, and asked if she would still be sore the next day. Mrs B said that Ms A told her she would not be sore. 
36. Mrs B then had a bad night's sleep. She had a sore back, neck, shoulders and throat. She told HDC that she had none of these symptoms prior to the appointment. She also had a headache, which continued for a few days. 
37. Mrs B said she telephoned ACC and discovered that Ms A was not accredited with it. Mrs B felt that Ms A's use of the Clinic's signage had been misleading. 
38. Mrs B said that she was concerned about Ms A's level of communication with her about the nature of the treatment, and that Ms A had not taken a health history from her.

Subsequent events

39. In her response to HDC, Ms A stated:

"I am, of course, quite distressed to learn that [Mrs B] found the massage to be harmful to her rather than helpful, and I would like to extend my apology to her …"

40. In her later response to HDC, Ms A provided a copy of some brief handwritten notes. The page provided has no heading or contact details for Mrs B. An entry dated 8 October 2013 at 3.00pm states:

"[Mrs B] sore neck sore back … [had] sore shoulder and had headaches. After her feel ok … talking and asked [about] my [history and] my store."

41. Ms A acknowledged that there was some miscommunication with Mrs B. Ms A has now changed her practice. Ms A's clients must now fill out forms on arrival, which include patient details and history. Ms A is now able to access systems in place through Ms C's company, such as client questionnaires, and she is confident that the miscommunication that arose with Mrs B will not recur. 
42. Ms A has offered to:

• apologise to Mrs B in person;
• provide a refund of the amount paid; and 
• in conjunction with Ms C, provide a free consultation to review Mrs B's condition. 

Responses to provisional opinion

43. Mrs B had no further comments to make in relation to the "information gathered" section of my provisional opinion.
44. Ms A's response was in the form of an apology letter to Mrs B, and included the following:

"It was an unfortunate situation, resulting partly from my limited English language skills, and partly perhaps your misunderstanding about the 'ACC treatments' sign outside the building, which you assumed meant that I was the ACC accredited acupuncturist.

When I was informed of your agitation and subsequent discomfort, I was deeply concerned. Perhaps in trying to relieve the hard knots I could feel in your neck and shoulders, I was over-bearing in my pressure. I regret that my TuiNa massage brought you undue suffering. I shall endeavour, in the future, to make sure clients understand that I am NOT an ACC accredited acupuncturist, and to also engage in greater pre-massage dialogue with clients, so that we can avoid any misunderstandings and stressful experiences. Please accept my apology …"

Opinion: Ms A

Introduction

45. When Mrs B visited Ms A for treatment, she was entitled, under the Code, to receive services provided with reasonable care and skill, and to be fully informed. 
46. Based on the information provided, it is evident that Mrs B was initially unaware of the nature of the Tui Na treatment she was about to receive. She did not anticipate experiencing pain after the 8 October appointment.

Provision of health services

47. Section 3(k) of the Health and Disability Commissioner Act 1994 (the Act) states that the term "health care provider" means "any person who provides, or holds himself or herself or itself out as providing, health services to the public or to any section of the public, whether or not any charge is made for those services".
48. Ms A's advertising material and response to HDC indicate that she provides a form of deep tissue massage therapy treatment that purports to offer therapeutic health benefits. Ms A is providing services in an unregistered capacity. There is no requirement in New Zealand for a massage therapist to hold membership of, or affiliation with, a professional organisation. 
49. I find that Ms A is a provider of health services as defined by the Act. 

Non-regulated providers and the Code

50. During my consideration of this matter, I have been mindful of the standards and accepted practices adopted by providers of similar treatment therapies.  Mr Martin Greenleaf, an acupuncturist and massage therapist, has provided me with expert advice. 
51. Ms A is not a member of, or affiliated with, any relevant professional association and, therefore, is not subject to any explicit professional standards. She is, nonetheless, bound by the Code. 
52. As pointed out by the Human Rights Review Tribunal:

"The obligations of the Code apply to those who provide health services, whether or not they belong to any professional association or similar body, and whether or not they are aware of the standards set out in the Code." 

53. It is my expectation that unregistered providers, such as Ms A, make every effort to be familiar with the accepted practices and standards that apply to their area of practice.

Information provided - Breach

54. Mrs B was a new client, unfamiliar with Tui Na treatment methods. In addition, Ms A's promotion voucher did not describe the exact nature of Tui Na treatment. Ms A did not provide any verbal or written information to Mrs B about the treatment before it commenced. As a result, Mrs B was under the mistaken impression that she would receive a relaxation treatment as opposed to a deep pressure massage. 
55. I do not accept Ms A's view that she assumes that a new client responding to a promotion will already understand what that treatment entails. 
56. As stated in a previous HDC opinion concerning a natural therapies practitioner, "[p]roviders who do not adequately explain the services being provided run the risk of making the consumer feel confused and uncomfortable".  
57. Under Right 6(2) of the Code, every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, needs to receive to give informed consent. Given the nature of the treatment, Ms A should have clearly explained to Mrs B, a new client, that Tui Na massage is a deep tissue massage, involving very deep pressure, and could potentially be uncomfortable for her. That is information that a reasonable consumer would need to receive to give informed consent to the treatment. 
58. The absence of information given to Mrs B about what the treatment would entail meant that she did not have the information she required in order to give informed consent. Therefore, I find that Ms A breached Right 6(2) of the Code. Except in limited circumstances, Right 7 of the Code provides that services may be provided to a consumer only if that consumer makes an informed choice and gives informed consent. Due to the lack of information provided to Mrs B, I am of the view that Mrs B was unable to make an informed choice or give informed consent. It follows, therefore, that Ms A also breached Right 7(1) of the Code.

Treatment - Adverse comment

59. Mrs B told HDC that she found the massage very painful, involving forceful pressure. She said that Ms A "climbed on my back on two occasions; digging her knees into my back", and that Ms A thumped her back four times with a closed fist. 
60. Ms A acknowledges that she made a fist and rapidly tapped Mrs B's back with the side of her fists and used her knees to apply pressure to the musculature of Mrs B's back, but submits that she did so gently and with control, by supporting her own weight on the treatment table.
61. Mr Greenleaf advised me that "it is not unusual to use your elbows when giving a Tui Na massage", and that "pounding with a closed or semi-open fist is just a normal part of Tui Na". 
62. Mr Greenleaf also advised: "I feel the Tui Na treatment was inappropriate if [Ms A] climbed on [Mrs B's] back using her knees to massage. I have heard of Thai massage practitioners using these types of treatment, but not Chinese Tui Na practitioners."
63. On the issue of the use of knees, Mr Greenleaf elaborated:

"I have never seen or heard of a Tui Na massage therapist having to climb onto the massage table, and straddle the client to do acupressure massage with their knees. First of all I feel unless the therapist is extremely strong so that she can support her own body weight with her arms, she could not help but use most of her body weight on her client.

Secondly, acupressure points are very sensitive to pressure, and usually enough pressure can be applied using hands, fingers and especially the thumbs. If more pressure is required for usually a large muscular build, then the elbows are used (checking closely with the client that they are comfortable with that amount of pressure).

The use of elbows on the lower back is sufficient to relieve even the tightest back, by a small built female practitioner on large muscular males. So therefore I would consider the therapist using their knees while supporting their own body weight with their arms, to be excessive use of force on the part of the practitioner."

64. I accept, taking into account Ms A's response and Mr Greenleaf's advice, that Tui Na massage can be uncomfortable and often involves deep tissue acupressure, including the potential use of percussive closed fist techniques. I am also mindful that the degree of pressure perceived to be in use is quite subjective, hence the importance of obtaining ongoing feedback from the client as to how comfortable he or she is feeling. 
65. I accept Mr Greenleaf's advice that use of the knees is not a usual part of Tui Na practice, but am reluctant to find that it amounts to a lack of care and skill. Because massage therapy may involve a range of techniques, I am not in a position to find that one school of practice may not borrow from another. Rather, I consider that this practice should have been discussed and explained to Mrs B prior to treatment.

Documentation - Adverse comment 

66. Ms A has provided HDC with the brief record she made regarding Mrs B, dated 8 October 2013.
67. Ms A took no client details prior to treatment. Her records constitute a few lines indicating that Mrs B had a sore back and shoulders, and a headache, and that after the treatment she felt "ok". This is a very limited record given that this was the initial assessment and treatment of a new client. 
68. Mr Greenleaf advised:

"I would consider it normal in a professional practice to keep notes or a file on a patient ie full name and address, date of birth and list main complaints, or which area the patient wanted worked on with massage."

69. This Office has frequently emphasised the importance of record-keeping, which applies to all healthcare providers.
70. I consider that Ms A should have kept a more detailed record of Mrs B's treatment. Such records enable care to be provided in an appropriate fashion, given past treatment, particularly if a new provider becomes involved. I note that Ms A has now altered her documentation practices as part of her renewed association with Ms C's company. 

Recommendations

71. In my provisional report, I recommended that Ms A provide a written apology to Mrs B for her breach of the Code, and proceed with her offer to provide Mrs B with a refund. In her response to my provisional report, Ms A provided an apology letter and a refund to Mrs B, which HDC forwarded on.
72. I recommend that Ms A discuss and review, with a peer or colleague, her approach to initial assessment of clients and, based on that review and this report, provide HDC with a feedback document on the changes and improvements she will make to her practice, including a copy of the client questionnaire now in use. This should be sent to HDC within two months of this report being issued.
73. As part of the above process, I recommend that Ms A ensure (as she has indicated she will do) that clients are aware that she is not ACC accredited, arrange an independent review of her record-keeping for the last six months, and produce a brief pamphlet of written information about Tui Na to give to potential new clients, and for use in any advertising or promotional material. 

Follow-up actions

74. A copy of this report, with details identifying the parties removed, except the expert used in this case, will be sent to the DHB, and it will be advised of Ms A's name in the cover letter. This is in recognition of the DHB's responsibilities for improving, promoting and protecting the health of people within its area.
75. A copy of this report, with details identifying the parties removed, will be sent to ACC, and the New Zealand College of Chinese Medicine, and placed on the Health and Disability Commissioner website, www.hdc.org.nz, for educational purposes.

Appendix A - Independent advice to the Deputy Commissioner

The following expert advice was obtained from Mr Martin Greenleaf, an acupuncturist and massage therapist. 

"I, Martin Greenleaf do not know of any personal or professional conflict in this case.

Tui Na translated means push/pull. It is a Chinese Medical massage using acupressure (pressure on acupuncture points), kneading and rubbing (push) with some circulation rotation type circular movements to help remove blockages and mobilize the joints. (Usually the larger joints) like shoulders, elbows, wrists, hips, and knees for a therapeutic outcome.

In my experience I haven't heard or seen Chinese Tui Na massage therapists climb on people's (patients') backs. So I would consider this a severe departure from normal Tui Na massage. 

I would consider it normal in a professional practice to keep notes or a file on a patient ie full name and address, date of birth and list main complaints, or which area the patient wanted worked on with massage. If it was a cheap deal and the patient, [Mrs B] just wanted a relaxation massage and bearing in mind, [Ms A's] poor grasp of English, the practitioner may just go ahead using a looking and touching diagnosis to help her proceed with the massage. If this was the case then I would expect a far more gentle approach for a first time patient. If the practitioner felt that stronger pressure was needed then it is usually to watch for visible signs of discomfort and also ask the patient if they are feeling okay, especially lying face down.

It is not unusual to use your elbows when giving a Tui Na back massage but I've never heard of knees being used. This seems very excessive, but pounding with a closed or semi-open fist is just a normal part of Tui Na. The practitioner [Ms A] asking 'you okay' seems to me that she is enquiring if her patient [Mrs B] is handling the procedure and if not she should have said so, even a simple 'NO' which most people understand.

It is not uncommon after a good strong Tui Na massage to feel that 'you have been run over by a bus', your muscles and joints can really hurt for four or five days after a treatment session, so the practitioner should advise the patient of this, suggest they have a hot bath with Epsom salts and drink at least 5 or 6 glasses of water a day to flush out toxins and help with the healing process.

In Summary

I feel the Tui Na treatment was inappropriate if [Ms A] climbed on [Mrs B's] back using her knees to massage. I have heard of Thai massage practitioners using these types of treatments, but not Chinese Tui Na practitioners.

A closed fist is used as a percussion method to relax deeper muscles and remove stagnation in blood (xue) and energy (qi), and this can be uncomfortable for some people, so it is best to ask if they 'are okay' with this, and try to tailor the strength of the massage to suit the individual patient especially a new patient. 

Yours sincerely,

Martin Greenleaf"

Mr Greenleaf provided additional comments:

"It is normal for the Massage Therapist (Tui Na) in this case, [Ms A], to ask the client/patient which are the main areas of pain or discomfort, before starting treatment.

It is also very important once the massage session has started, that the therapist checks with the client that they are comfortable with the pressure applied, especially with acupressure points. 

I have never seen or heard of a Tui Na massage therapist having to climb onto the massage table, and straddle the client to do acupressure massage with their knees.

First of all I feel unless the therapist is extremely strong so that she can support her own body weight with her arms, she could not help but use most of her body weight on her client.

Secondly, acupressure points are very sensitive to pressure, and usually enough pressure can be applied using hands, fingers and especially the thumbs. If more pressure is required for usually a large muscular build, then the elbows are used (checking closely with the client that they are comfortable with that amount of pressure).

The use of elbows on the lower back is sufficient to relieve even the tightest back, by a small built female practitioner on large muscular males. 

So therefore I would consider the therapist using their knees while supporting their own body weight with their arms to be excessive use of force on the part of the practitioner. If the therapist was supporting their own body weight by ropes hanging from the ceiling, they could better control the pressure applied with their knees on the acupressure points, but I've only seen this method used by therapists massaging elephants at [a] Zoo.

Also the therapist using their hands, fingers, thumbs and to a certain extent elbows, the therapist has a better feel (tactile sense) for the underlying tissue they are working on, and therefore is much less likely to cause damage or pain. This, I feel is particularly important when massaging a person for the first time, and also, all clients have a different pain tolerance while some clients may not know what is normal pressure or what is excessive, and therefore may just 'grin and bear it'. 

Also with the client lying face down (prone) on the massage table the therapist can't see if they are 'grinning and bearing it'. For a first time massage it is better to start with the client lying on the massage table face-up (supine) so the therapist can closely monitor the client's facial expression for excessive pressure causing pain, then turn the client over to the prone or prostrate position once you have worked out exactly how much pressure the client does feel comfortable with.

To sum up I do feel that the therapist, [Ms A] in all probability has used excessive pressure on her client [Mrs B] by climbing on to the table while the client is face down (prone or prostrate position), for a first time massage treatment. Massage generally is very relaxing so the client doesn't want to talk, conversely, if the massage is too strong, it can 'take your breath away' so you can't talk and just want it to stop. Too strong a massage can make you 'speechless' and also in a state of relaxed shock, so it is not until sometime afterwards that the full effects are felt. This can be from one to three days.

Yours sincerely,

Martin Greenleaf"

[1] Right 6(2) states: "Before making a choice or giving consent, every consumer has the right to the information that a reasonable consumer, in that consumer's circumstances, needs to make an informed choice or give informed consent."

[2] Right 7(1) states: "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."

[3] The others were for a facial and massage package, or a foot reflexology and massage package.

[4] Sometimes written as "Tuina".

[5] Qi is a term used in Chinese medicine - generally it is translated as "vital energy".

[6] Ms C is the owner and chief acupuncturist of the Clinic. Ms C has assisted Ms A to respond to HDC.

[7] There is no requirement in New Zealand for a massage therapist to hold membership of a professional organisation or affiliation.

[8] For example, the New Zealand College of Chinese Medicine, which opened in 2003, is approved and accredited by the New Zealand Qualifications Authority (NZQA). A Diploma in Tui Na programme is being developed, and an application for approval is in progress with NZQA (as at February 2015).

[9] See Director of Proceedings v Mogridge [2007] NZHRRT 27 (21 December 2007) at 103.

[10] Opinion 06HDC09882, page 11 (25 January 2007).