September 15, Dear Ms. Johnson,

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1 September 15, 2008 Ms. Margaret Johnson, Chair Health Professions Advisory Board Alberta Health and Wellness 10 th Floor, Telus Plaza North Tower Jasper Ave. Edmonton, AB T5H 1S6 Dear Ms. Johnson, On behalf of the Alberta Registered Massage Therapists Society (ARMTS), Massage Therapist Association of Alberta (MTAA) and the Remedial Massage Therapist Association (RMTA), we are pleased to provide our written submission to the Health Professions Advisory Board (HPAB) in support of our application (see attachment) for the regulation of massage therapy in Alberta. The purpose of the written submission is to outline for the Board the general flow and direction of the presentation we will be making at the upcoming hearing regarding our application, scheduled for October 15 and 16, Having reviewed in detail the Health Professions Act, in particular Section 25(4) Criteria for the Health Professions Advisory Board to Consider When Deciding if it is in the Public Interest for a Profession to be Regulated under HPA, the direction of our presentation will be to address each of these considerations. This document provides a brief outline of our key points which will be elaborated on during our presentation, consistent with Alberta Health and Wellness' May 31, 2006 Health Professions Advisory Board Guidelines - "Becoming a Regulated Health Profession." Introduction Our organizations represent a combined 95 years of service and member standards in the profession of massage therapy in Alberta. Yet, the lack of regulation leaves the public at a risk that cannot be satisfactorily contained by professional associations such as ours, where membership is voluntary. Regulation of massage therapy under the Health Professions Act will address protection of the public s best interest through standardized education, entry to practice requirements, continuing competency and formal investigation and disciplinary processes. Specifics

2 2 25(4) (a) evaluate the risk to the physical and psychological health and safety of the public from incompetent, unethical or impaired practice of the profession; In the current unregulated environment patients are vulnerable to unscrupulous practitioners who may expose them to inappropriate interventions, intended or unintended injury, sexual misconduct, and/or misleading suggestions about how to improve their health. Similarly, inadequately trained practitioners who do not understand their professional limitations or the many contra-indications to massage therapy also place the public at risk. If a practitioner does not recognize contra-indications and therefore does not modify treatment or applies inappropriate treatment, the results can have medically serious effects. The very nature of contact in massage therapy treatment involves risk to the public. Typically, the therapist works on a nearly too completely disrobed patient who is under a sheet on a massage table, for an extended period of time in a closed office setting. As such the therapist is in a position of considerable authority, power and influence. In the current unregulated environment, there is no accountability system to ensure safe and effective practice or to protect the best interests of the patient. The best a professional association can do is to establish a complaints and disciplinary process to govern its own membership, however this does not always provide for an adequate venue of recourse for the public. In fact, unless the complained act falls under a serious violation of the law, where it can be addressed by the police, the best an association can do is suspend or revoke the practitioner s membership. As membership is not a requirement to practice, these individuals are free to continue to practice on the public. 25(4) (b) ascertain what constitutes the practice of the profession, whether persons practicing the profession should be authorized to provide restricted activities and the conditions, if any, that should apply to the practice of the profession or the provision of restricted activities; Members of the three associations do not currently nor contemplate practicing restricted activities. They use their hands on the patient's musculo- skeletal system, intended to result in: 1. Reduction of muscular spasm and pain (i) Friction has a thermodynamic effect, by warming and softening the tight hard tissues (ii) When myofascial trigger points are manually treated, blood flow to the area is stimulated and the local nerves are soothed, allowing a decrease in related soft tissue pain and dysfunction; this is intended to elicit the release of endorphins, reducing pain impulses. (iii) The brain increases the release of enkephalins and endorphins, producing an analgesic effect (iv) The conduction of pain impulses throughout the peripheral nervous system is reduced 2. Improvement in the circulation of blood and lymph

3 3 (i) The increase in blood flow through the capillaries supplies the tissues with oxygen and other nutrients, thus decreasing ischemic pain and improving health of tissues (ii) The increase in lymph flow through the capillaries aids in removal of metabolic waste materials from muscles, joints and soft tissues (iii) The increase in venous and lymph return, provides an improvement in health for those with edemic conditions 3. Reduction and prevention of adhesions Tension applied to fibrous tissue breaks down adhesions and prevents new ones from forming. Passive movements also break down adhesions and stretch joint capsules, thereby increasing mobility 4. Increasing the range of motion and flexibility Deep cross fibre friction applied to muscle/tendon junctions and ligaments assists in the restoration of pain-free motion of the joints; ischemic compression results in the release of muscular contractures 25(4) (c) evaluate and make recommendations on the services normally provided by a person practicing the profession, including the complexity of the services and how they are carried out; Massage therapists practice in a broad scope of settings; they work independently in private practice, in inter-disciplinary treatment settings, rehabilitation clinics, health clubs, health care facilities, spas and many other settings. Massage therapists are involved with professional and amateur sports teams and athletic clubs. They work in continuing care facilities, and assist with pre - and post - natal care. Massage therapists complement and support health services provided by regulated practitioners, including; physicians, regulated nurses, dentists, chiropractors, physical therapists, occupational therapists, acupuncturists, midwives, psychologists, social workers and others. As a result, all massage therapists should demonstrate competencies to assess the needs of their patients, and, where appropriate, treat the concern or refer the patient to another health care provider. In an unregulated environment, there is no common standard of education or minimum level of competency required for entry to practice, resulting in a wide variance in levels of competencies amongst practitioners. Some practitioners receive education surrounding clinical reasoning, clinical assessment, treatment planning and remedial exercise for rehabilitation in addition to basic and advanced soft tissue theory and techniques. Others receive only the most basic training in massage techniques with no additional training or requirement to continue building clinical competence. Massage therapy's current unregulated circumstances place regulated practitioners in a professional and ethical dilemma when considering referrals. For example, the College of Physicians and Surgeons of Alberta's December 2003 policy entitled "Practice in Association" notes: (10) "A referral to a non-regulated health care provider is acceptable when the physician is satisfied that those services can reasonably be expected to benefit the patient, and not to cause harm."

4 4 25(4) (d) consider whether the services normally provided by persons practicing the profession are regulated by an enactment; Massage therapy is currently regulated in British Columbia, Ontario, and Newfoundland and Labrador. Their legislated scope of practice and protected title is outlined in our application. Other provinces including, Saskatchewan, New Brunswick and Manitoba are presently pursuing self-regulation. 25(4) (e) consider whether the profession is a distinct and identifiable profession; Although massage therapy may be practiced to a limited extent by physical therapists, occupational therapists, chiropractors and some other regulated health professionals (and regulation of massage therapists is not intended to change these practices), massage therapists who practice in accordance with the standards and requirements proposed in our application will provide distinct and identifiable therapeutic health services to their patients. The massage therapy profession includes a range of modalities and the role of massage therapists is, within their range of competencies, to assess the patient and apply appropriate treatments. Often in conjunction with regulated health professionals and guided by their recommendations, these treatments include the assessment and manual manipulation of the soft tissues and joints with the incorporation of hydrotherapy and suggestions for appropriate self-care. Massage therapists make use of their hands as primary therapeutic instruments on the patient's musculoskeletal system. Massage treatments are directed with "hands-on" massage of soft tissues and joints, with therapeutic intent and continuous feedback from the involved body parts. Depending on the patient's present circumstances, treatments last between 30 and 90 minutes of uninterrupted time. Massage therapists remain with their patients for the entire duration of treatment which involves rubbing, kneading and stretching of body tissues and feedback by tactile sensation in the therapist s hands. Massage therapists involve their patients in the process to rebalance the muscles, soft tissue and joint structures and thus restore optimal physical functioning. 25(4) (f) consider whether the proposed protected title is appropriately descriptive and whether it is likely to cause public confusion; We believe that the proposed protected title of Registered Massage Therapist (RMT), which is consistent with protected titles in other regulated jurisdictions in Canada, accurately describes the profession and will address current confusion by assisting the public and other health care providers to distinguish between regulated and unregulated practitioners. Given that massage therapists practice in a broad scope of settings, the public needs to have direct and transparent knowledge of which practitioners are regulated and which are not, in order to make informed choices about their health care. In the absence of regulation, and therefore title protection, the inappropriate use of the term Registered

5 5 Massage Therapist is widespread. As a result there is widespread confusion among the public as to the status of Massage Therapy as a profession. There is also misconception by the public that massage therapists are "regulated" by municipalities. The reality is that over 90% of Alberta municipalities have no requirements in place for ensuring that individuals practicing massage therapy in their jurisdiction have adequate if any training. Regulation of health professionals is a provincial, rather than municipal, responsibility. Many members of the public and even other health care providers perceive Massage Therapy as a regulated profession and have the impression to look for a therapist whom is Registered. Individuals promoting themselves in this way however may in fact be untrained or minimally trained, incompetent, impaired, unethical, and/or even sex trade workers. Some of these individuals have even been granted billing rights by unsuspecting third-party payers and insurance agencies, including plans underwritten by taxpayers and employers. Given the positive results many regulated health care providers have experienced in collaborating with massage therapists, there is definitely a move toward referring massage therapy as a supportive modality to augment health care treatments. As noted previously with the example of the College of Physicians and Surgeons, in the absence of a protected title, this referral process presents risks not only to patients, but to regulated practitioners who initiate referrals broadly and freely - with the belief that their patients will receive a minimally competent level of treatment and/or not be harmed. 25(4) (g) consider the potential costs and benefits of regulating the profession, including the expected effect on practitioner availability and on education and training programs, the expected effect on enhancement of quality of service and the expected effect on prices, access and service efficiency; Practitioner availability would not be negatively affected by the regulation of the profession as outlined in our application. Availability would actually be enhanced by providing the public with a clear understanding of the services and treatment available to them from a regulated massage therapist. In this way the public can make an informed decision as to the type of care, given their current circumstance, they wish to have. As in all other regulated jurisdictions non-registered practitioners would still be available to provide services. With respect to education and training, consistent with the Health Professions Act, it is intended that the proposed College assume a collaborative role in partnership with educators to standardize educational programs. The application includes a competency profile, developed in conjunction with other regulated jurisdictions. In other jurisdictions, educational programs are in place to assist Massage Therapists to increase their competencies to meet the minimum provincial standard and pursue continuing competency programs. Similar to other regulated professions, entry to practice would be governed by an independently administered examination process (overseen by the College's Registration Committee) that determines the presence of the minimum level of competency required to provide high-quality, safe and effective health services. A

6 6 competency-based certification or licensing examination creates a level playing field and promotes confidence in the practitioner's knowledge, skills, attitude and judgment. 25(4) (h) ascertain the qualifications and minimum standards of competence that are required for a person applying to practice the profession and how the continuing competence of practitioners is to be maintained, ascertain what education programs are available and evaluate the available education programs; Regulated Massage Therapists should have the same entry-level scope of practice, educational requirements and ability to assess and treat patients. In provinces where the profession is regulated, this principle is always respected. This is not the case in an unregulated environment such as Alberta, where there are no legislated entry to practice standards. Given public perception, that membership with an association provides assurance of monitored competence, ethical conduct and safety in practice, the result is an increased risk to the public. As noted previously, most members of the public perceive that the profession is regulated, however, since this is not the case, the absence of standards to monitor competence, quality, safety and ethical behavior provides an increased risk to the public. The competencies outlined within our application reflect models successfully used for decades in Ontario, British Columbia and Newfoundland / Labrador. The basic premise of this model for regulation is that there is one standard set of minimum competencies that must be met by a person wishing to enter the profession. The process to accept existing practitioners into the proposed college would be to assess their existing levels of competency by reviewing their active professional membership, prior professional experience and core education and training in relation to the standard minimum level of competency. Following this evaluation a recommendation for action, if any, would be made required to meet the minimum level of competency. This is consistent with the approach that has been used by other emerging regulated professions and the HPA's "substantial equivalency provisions for registering members of regulated professions. Continuing competence of practitioners will be achieved through implementation of a quality management system designed to include qualified massage therapists, assess their existing level of competency and obligate registrants to participate in continuing competence programs. 25(4) (i) ascertain the ability of the proposed college of the profession to carry out its powers and the duties under this Act or consider whether they could be carried out by an existing college; As noted previously, our organizations have 95 years experience with bylaw and policy development, registration, continuing education, and investigation and discipline. Yet, our effectiveness is limited by the fact that membership in our associations is entirely voluntary.

7 7 The Steering Committee, composed of representatives from each of the three associations, has been closely involved in policy development to recommend regulation under the HPA since January A presentation was scheduled to the Health Professions Advisory Board in May 2004, but was deferred. Significant resources and planning have been devoted to comprehensively address the proposed College's regulatory responsibilities, as well as the required human, financial and other resources required for massage therapy to become a regulated profession. Other jurisdictions where massage therapy is regulated have offered any assistance required with bylaw, policy and procedure, forms, governance handbooks, information systems, office management development and other matters relating to implementation of regulation under our proposed model. Steering Committee members and their three respective associations have collaborated on a code of ethics and also endorsed standards of practice for many decades. Although belonging to one or more of the groups has always been voluntary, a large majority of qualified massage therapy professionals have chosen to seek and maintain membership in order to be held accountable and demonstrate pride in their professional competencies. This accountability has included rigorous entry to practice requirements, continuing competency, commitment to the standards of practice and codes of ethics of the profession, and being subject to "investigation" and "discipline as set forth by each organizations policies and procedures. The Steering Committee also have long histories of "investigating" and "disciplining" members, consistent with principles of natural justice, fairness and administrative law. However, the sanctions are limited by virtue of the voluntary nature of these organizations to, in the most serious circumstances, expulsion from the association/society. The groups have established mechanisms for dealing with complaints over the years intended to be fair, objective and transparent. They understand the requirements of the HPA for a Complaints Director, a Complaint Reviews Committee, a Hearing Tribunal and other requirements for investigation of complaints and possible discipline. In the course of our policy development, we have consulted with various health professional regulatory colleges in Alberta (e.g., physical therapy, occupational therapy and chiropractic), and health professional regulatory colleges and associations in other provinces. 25(4) (j) evaluate the effect, if any, that there would be on any agreements on trade and mobility to which Canada or Alberta is a signatory if the profession would become a regulated profession; The Agreement of Internal Trade (AIT) (see attachment) exists among provinces where massage therapy is regulated. Communication takes place on a regular basis ensuring current provincial requirements for massage therapists are shared. Massage Therapists from regulated provinces will in the future be able to move freely among provinces and territories.

8 8 The Trade Investment and Labour Mobility Agreement (TILMA) (see attachment) between Alberta and British Columbia is now in its second year of implementation. Over 100 occupations, including massage therapy, in Alberta and British Columbia have been identified under TILMA. However, given that Alberta massage therapists are not regulated, the profession has no status with respect to TILMA. 25(4) (k) on the request of the Minister, consider any other matters i.e.; recommended model for regulation; The model recommended in our application has been carefully weighed and considered over the past decade. The application under review is substantially similar to the application which was intended to be presented to the Health Professions Advisory Board in May That supported by numerous stakeholders, including the then Registrar of the College of Physicians and Surgeons of Alberta on April 14, 2004 (see attachment). This model supports the HPA's definition of competence as the combined knowledge, skills, attitudes, and judgment required to provide professional services. The underlying belief is that the practitioner as well as the public interest would be better protected through regulating practitioners and promoting their competence, adherence to a code of ethics and standards of practice, continuing competence, and investigation and discipline. The model focuses on competence, quality and safety. The public and practitioner are further protected by the jointly proposed model, as all massage therapy must be performed within the overarching context of uniform standards of practice in patient care. Conclusion All Albertans need adequate assurance that the health care professional they choose is responsible for and capable of assessing their current health status to determine the risks and benefits of receiving or not receiving treatment prior to commencing treatment. The public has a right to be protected from any risk of harm associated with health services, including massage therapy. Regulation under the Health Professions Act will provide increased protection to the public by minimizing the potential for incompetent, untrained, unscrupulous and unethical individuals to present themselves as regulated massage therapists. Sincerely, Marty Way Chandra Kastern Roxanne Smith ARMTS MTAA RMTA