From the conventional to the alternative: exploring patients' pathways of cancer treatment and care.

BACKGROUND: Complementary and alternative medicine (CAM) use is widespread and on the increase among cancer patients. Most research to date has involved a cross-sectional snapshot of CAM use rather than an exploration into the longitudinal, nonlinear treatment trajectories that cancer patients develop. Our aim is to explore and describe different treatment and decision-making pathways that individuals develop after receipt of a diagnosis of either breast, colorectal, or prostate cancer. METHODS: The study was part of a larger mixed-methods pilot project to explore the feasibility of conducting a five-year international study to assess cancer patients' treatment pathways, including health care use and the perceived impact of different patterns of use on health outcomes over the course of one year. The results presented in this paper are based on the analysis of personal interviews that were conducted over the course of 12 months with 30 participants. RESULTS: Five pathways emerged from the data: passive conventional, self-directed conventional, cautious integrative, aggressive integrative, and aggressive alternative. Factors that shaped each pathway included health beliefs, decision-making role, illness characteristics, and the patient-practitioner relationship. CONCLUSIONS: The results of this examination of the longitudinal treatment and decision-making trajectory provide important information to support health care professionals in their quest for individualized, targeted support at each stage of the patient pathway.

The professional role of massage therapists in patient care in Canadian urban hospitals--a mixed methods study.

BACKGROUND: Massage therapy (MT) is becoming established as a recognized health care profession in Canada. It has been integrated as a core service in settings such as health spas, private integrative health centers, and there is indication that MT is starting to be integrated into hospitals. Research in the area of hospital-based MT has primarily focused on the efficacy, effectiveness, and increasingly, the safety of MT. However, little is known about the professional role of massage therapists in the hospital setting. The purpose of this study was to conduct an in-depth exploration and description of massage therapists' professional role in patient care in the context of Canadian urban hospitals. METHODS: A sequential mixed methods study design was used. For the quantitative phase, a survey was sent to urban hospitals where MT services were organized by hospitals and provided by licensed massage therapists to patients to a) provide a contextual description of the hospitals and b) identify a sampling frame for the qualitative phase. The subsequent qualitative phase entailed semi structured interviews with a purposively diverse sample of participants massage therapists from the surveyed sites to explore their role perceptions. The quantitative and qualitative approaches were integrated during data collection and analysis. RESULTS: Of the hospitals that responded, sixteen urban hospitals across Canada (5%) provided MT to patients by licensed therapists. The majority of hospitals were located in Ontario and ranged from specialized small community hospitals to large multi-site hospitals. Based on interviews with 25 participants, six components of the massage therapists' professional role emerged: health care provider, team member, program support, educator, promoter of the profession, and researcher. CONCLUSIONS: While hospital-based MT in Canada is not a new phenomenon, MT is not yet an established health care profession in such settings. However, there is significant potential for the inclusion of the massage therapists' role in Canadian hospitals that should be evidence based for effective implementation.

Negotiating consent: exploring ethical issues when therapeutic massage bodywork practitioners are trained in multiple therapies.

INTRODUCTION: Obtaining informed consent from competent patients is essential to the ethical delivery of health care, including therapeutic massage and bodywork (TMB). The informed consent process used by TMB practitioners has not been previously studied. Little information is available about the practice of informed consent in a treatment-focused environment that may involve multiple decision points, use of multiple TMB therapies, or both. METHODS: As part of a larger study on the process of providing TMB therapy, 19 practitioners were asked about obtaining informed consent during practice. Qualitative description was used to analyze discussions of the consent process generally, and about its application when practitioners use multiple TMB therapies. RESULTS: Two main consent approaches emerged, one based on a general consent early in the treatment process, and a second ongoing consent process undertaken throughout the course of treatment. Both processes are constrained by how engaged a patient wants to be, and the amount of information and time needed to develop a truly informed consent. CONCLUSIONS: An understanding-based consent process that accommodates an acknowledged information differential between the patient and practitioner, and that is guided by clearly delineated goals within a trust-based relationship, may be the most effective consent process under the conditions of real practice conditions.

Exclusive use of alternative medicine as a positive choice: a qualitative study of treatment assumptions among people with multiple sclerosis in denmark.

BACKGROUND: A survey of members of the Danish MS Society revealed that a minority of MS patients choose to forgo all types of conventional treatment and use complementary and alternative medicine (CAM) exclusively. A qualitative follow-up study was performed to elucidate the choice of exclusive CAM use by exploring treatment assumptions among a group of exclusive CAM users. METHODS: The study was based on a phenomenological approach. Semistructured in-depth qualitative interviews were conducted with 17 participants, using program theory as an analytical tool, and emerging themes were extracted from the data through meaning condensation. RESULTS: Four themes characterized the participants' treatment assumptions: 1) conventional medicine contains chemical substances that affect the body in negative ways; 2) CAM treatments can strengthen the organism and make it more capable of resisting the impact of MS; 3) the patient's active participation is an important component of the healing process; 4) bodily sensations can be used to guide treatment selection. CONCLUSIONS: Exclusive use of CAM by MS patients may reflect embracing CAM rather than a rejection of conventional medicine. Health-care practitioners, patient organizations, and health authorities within the MS field should be aware of possible changes in patients' attitudes toward both CAM and conventional treatment interventions.

Decision-making about complementary and alternative medicine by cancer patients: integrative literature review.

BACKGROUND: Patients with cancer consistently report conflict and anxiety when making decisions about complementary and alternative medicine (CAM) treatment. To design evidence-informed decision-support strategies, a better understanding is needed of how the decision-making process unfolds for these patients during their experience with cancer. We undertook this study to review the research literature regarding CAM-related decision-making by patients with cancer within the context of treatment, survivorship, and palliation. We also aimed to summarize emergent concepts within a preliminary conceptual framework. METHODS: We conducted an integrative literature review, searching 12 electronic databases for articles published in English that described studies of the process, context, or outcomes of CAM-related decision-making. We summarized descriptive data using frequencies and used a descriptive constant comparative method to analyze statements about original qualitative results, with the goal of identifying distinct concepts pertaining to CAM-related decision-making by patients with cancer and the relationships among these concepts. RESULTS: Of 425 articles initially identified, 35 met our inclusion criteria. Seven unique concepts related to CAM and cancer decision-making emerged: decision-making phases, information-seeking and evaluation, decision-making roles, beliefs, contextual factors, decision-making outcomes, and the relationship between CAM and conventional medical decision-making. CAM decision-making begins with the diagnosis of cancer and encompasses 3 distinct phases (early, mid, and late), each marked by unique aims for CAM treatment and distinct patterns of information-seeking and evaluation. Phase transitions correspond to changes in health status or other milestones within the cancer trajectory. An emergent conceptual framework illustrating relationships among the 7 central concepts is presented. INTERPRETATION: CAM-related decision-making by patients with cancer occurs as a nonlinear, complex, dynamic process. The conceptual framework presented here identifies influential factors within that process, as well as patients' unique needs during different phases. The framework can guide the development and evaluation of theory-based decision-support programs that are responsive to patients' beliefs and preferences.

The Living Well Lab: a community-based HIV/AIDS research initiative.

BACKGROUND: Complementary and Alternative Medicine (CAM) is becoming a pillar in the rehabilitative efforts for many living with HIV/AIDS. A community-based research program called the Living Well Lab (LWL) was established in 2007, operating out of Friends For Life (FFL), a non-profit wellness center in Vancouver, Canada offering free CAM therapies to people living with HIV/AIDS. Therapies range from naturopathy to yoga. The LWL partnered with academic and community organizations to evaluate CAM use and changes in health and quality of life outcomes of FFL's HIV+ members. METHODS: A longitudinal, combined methods approach assessed the health- and quality-of-life-related outcomes and experiences of CAM users. Participants completed outcome packages (5 time points) over 18 months, which focused on changes in physical and emotional states, satisfaction with services and social support. Interviews were conducted at baseline, 9- and 18-month time points. Quantitative analyses were descriptive while content analysis and thematic coding were used in the qualitative analysis. RESULTS: Two hundred and seven members enrolled in the LWL. Quantitative data demonstrated improvement in mental and physical wellbeing, social support and patient satisfaction specifically: SF-12, Arizona Integrative Outcomes Scale and three visual analog scales (stress, pain and energy). Participants felt several factors contributed to these changes such as managing anxiety, accepting their illness, learning to relax, an increased capacity for self-care and social support. CONCLUSIONS: CAM use may be associated with changes to physical, social and mental wellbeing. Issues throughout the study provided important lessons for future research.

Retrospective case analyses of two people with cancer who followed the Bill Henderson Protocol.

OBJECTIVE: To provide a retrospective case analyses of Bill Henderson Protocol adherence, a dietary cancer treatment regimen. DESIGN: Case study analysis based on the National Cancer Institute's Best Case Series approach. SUBJECTS: Using Mr Henderson's listserv (N = 31,000), members meeting certain criteria were invited to submit case documentation (diagnostic, treatment, outcome information). Ninety-two people responded. RESULTS: Two people met the Best Case criteria. Both used conventional treatment initially (surgery, radiation, chemotherapy), but later turned exclusively to the Bill Henderson Protocol. Each case perceived benefit. One person eventually passed away. The second has returned to full health. CONCLUSIONS: The 2 cases provide a preliminary, detailed description of Bill Henderson Protocol adherence. They do not provide clear evidence of the protocol's effectiveness but do suggest further research be undertaken to assess the extent to which the Bill Henderson Protocol is followed in real-world settings, including consideration of adherence, side effects, and outcomes.

Use of bodily sensations as a risk assessment tool: exploring people with Multiple Sclerosis' views on risks of negative interactions between herbal medicine and conventional drug therapies.

BACKGROUND: Most users of complementary and alternative medicine (CAM) combine it with conventional medicine. Recent risk assessment studies have shown risks of negative interactions between CAM and conventional medicine, particularly when combining herbal medicine and conventional drug therapies (CDT). Little is known about the way users consider such risks. The present paper aims to gain knowledge about this issue by exploring views on risks of negative interactions when combining herbal medicine and CDT among people with multiple sclerosis (MS). METHODS: This paper draws on a qualitative follow-up study on a survey among members of the Danish MS Society. Semi-structured, in-depth qualitative interviews were conducted with a strategic selection from the survey respondents. The study was inspired by a phenomenological approach and emerging themes were extracted from the data through meaning condensation. RESULTS: Four themes characterized the informants' views on risks of negative interactions when combining herbal medicine and CDT: 1) 'naturalness' in herbal medicine; 2) 'bodily sensations' as guidelines; 3) trust in the CAM practitioner; 4) lack of dialogue with medical doctor. CONCLUSIONS: Generally, the combination of herbal medicine and CDT was considered by the informants to be safe. In particular, they emphasized the 'non-chemical' nature of herbal medicine and of their own bodily sensations as warrants of safety. A trustful relation to the CAM practitioner furthermore made some of them feel safe in their use of herbal medicine and CDT in combination. The informants' use of bodily sensations as a non-discursive risk assessment may be a relevant element in understanding these issues.

Developing an operational model for an integrative oncology program: a qualitative descriptive feasibility study.

PURPOSE: We describe a descriptive qualitative study with the purpose of assessing the feasibility of developing an integrative oncology program in our region. METHODS: We conducted 39 interviews and two focus groups (n = 20) with cancer patients, their caregivers and complementary and conventional (n = 15) healthcare professionals. RESULTS: One primary theme emerged, acceptance or tolerance of an integrative oncology program, which represents concepts within four emergent categories: (1) operational model; (2) values to guide an integrative oncology program; (3) physical location and design; and (4) facilitators and barriers to establishing an integrative oncology program. CONCLUSIONS: The study was instrumental in establishing support for an integrative oncology program in our region, including a feasible model. Based in part on the results of this study, the Ottawa Integrative Cancer Centre ( www.oicc.ca ) opened in November 2011. We recommend a similar process of stakeholder engagement for others who wish to develop an integrative program in their location.

Dragon boat racing and health-related quality of life of breast cancer survivors: a mixed methods evaluation.

BACKGROUND: Breast cancer survivors who participate in physical activity (PA) are reported to experience improved health-related quality of life (HRQOL). However, the quantitative research exploring the relationship between the team-based activity of dragon boat racing and the HRQOL of breast cancer survivors is limited. Given the rising number of breast cancer survivors, and their growing attraction to dragon boating, further exploration of the influence of this activity on HRQOL is warranted. METHODS: This study is designed to: 1) quantitatively assess whether and how breast cancer survivors' participation in a season of dragon boat racing is related to HRQOL and 2) qualitatively explore the survivors' lived experience of dragon boating and how and why this experience is perceived to influence HRQOL. A mixed methods sequential explanatory design was used with the purpose of complementing quantitative findings with qualitative data. Quantitative data measuring HRQOL were collected at baseline and post-season (N=100); semi-structured qualitative interviews were used to elicit a personal account of the dragon boat experience (N=15). RESULTS: Statistically significant improvements were shown for HRQOL, physical, functional, emotional and spiritual well-being, breast cancer-specific concerns and cancer-related fatigue. A trend towards significance was shown for social/family well-being. Qualitative data elaborated on the quantitative findings, greatly enhancing the understanding of how and why dragon boat racing influences HRQOL. CONCLUSIONS: The use of a mixed methods design effectively captured the complex yet positive influence of dragon boating on survivor HRQOL. These findings contribute to a growing body of literature supporting the value of dragon boat racing as a viable PA intervention for enhancing survivor HRQOL.

Differences between users and non-users of complementary and alternative medicine among people with multiple sclerosis in Denmark: a comparison of descriptive characteristics.

AIMS: The aim of this study was to investigate differences in socio-economic characteristics between CAM users and CAM non-users among people with MS in Denmark as well as differences in characteristics related to the use of CAM among CAM users and the use of conventional treatments among CAM non-users. METHODS: An internet-based questionnaire was used to collect data from 3361 patient members of the Danish MS society. A letter with a personal code was sent to all respondents, asking them to fill out the questionnaire online. Reminders to non-respondents were sent twice and the final response rate was 55.5%. Statistical associations were presented as odds ratios and with respective 95% confidence intervals. RESULTS: People with MS in Denmark use a wide range of CAM treatments for a variety of reasons. CAM users were more likely to be of female gender, 18-40 years of age, educated at bachelor level or above, and have a high income compared to CAM non-users (p < 0.05). CAM users more often addressed non-specific/preventive treatment purposes through their use of CAM treatments, they communicated less often with a medical doctor about the CAM treatments used, and they experienced less side effects as well as less positive effects from the CAM treatments used when compared with the use of conventional treatments among CAM non-users (p < 0.05). CONCLUSIONS: People with MS in Denmark reported use of a large range of CAM treatments. CAM users differed from CAN non-users in relation to socio-economic factors as well as treatment characteristics.

Exploring the nature of therapeutic massage bodywork practice.

BACKGROUND: Research on therapeutic massage bodywork (TMB) continues to expand, but few studies consider how research or knowledge translation may be affected by the lack of uniformly standardized competencies for most TMB therapies, by practitioner variability from training in different forms of TMB, or from the effects of experience on practice. PURPOSE: This study explores and describes how TMB practitioners practice, for the purpose of improving TMB training, practice, and research. PARTICIPANTS SETTING: 19 TMB practitioners trained in multiple TMB therapies, in Alberta, Canada. RESEARCH DESIGN: Qualitative descriptive sub-analysis of interviews from a comprehensive project on the training and practice of TMB, focused on the delivery of TMB therapies in practice. RESULTS: TWO BROAD THEMES EMERGED FROM THE DATA: (1) every treatment is individualized, and (2) each practitioner's practice of TMB therapies evolves. Individualization involves adapting treatment to the needs of the patient in the moment, based on deliberate and unconscious responses to verbal and nonverbal cues. Individualization starts with initial assessment and continues throughout the treatment encounter. Expertise is depicted as more nuanced and skilful individualization and treatment, evolved through experience, ongoing training, and spontaneous technique exploration. Practitioners consider such individualization and development of experience desirable. Furthermore, ongoing training and experience result in therapy application unique to each practitioner. Most practitioners believed they could not apply a TMB therapy without influence from other TMB therapies they had learned. CONCLUSIONS: There are ramifications for research design, knowledge translation, and education. Few practitioners are likely able to administer treatments in the same way, and most would not like to practice without being able to individualize treatment. TMB clinical studies need to employ research methods that accommodate the complexity of clinical practice. TMB education should facilitate the maturation of practice skills and self-reflection, including the mindful integration of multiple TMB therapies.

*Abstracts - 7th IN-CAM Research Symposium, Evaluating CAM Practices: Effectiveness, Integration, Economics & Safety - November 2012.

Abstract The following are abstracts of oral and poster presentations given at the 7th IN-CAM Research Symposium - Evaluating CAM Practices: Effectiveness, Integration, Economics & Safety, and the 4th HomeoNet Research Forum, a pre-Symposium event. The IN-CAM Research Symposium was held November 2 to 4, 2012 at the Leslie Dan Faculty of Pharmacy, University of Toronto, in Toronto, Ontario, Canada. For more information, please visit: www.incamresearch.ca.

A qualitative study on the term CAM: is there a need to reinvent the wheel?

BACKGROUND: As complementary and alternative medicine (CAM) has developed extensively, uncertainty about the appropriateness of the terms CAM and other CAM-related terms has grown both in the research and practice communities. Various terms and definitions have been proposed over the last three decades, highlighting how little agreement exits in the field. Contextual use of current terms and their respective definitions needs to be discussed and addressed. METHODS: Relying upon the results of a large international Delphi survey on the adequacy of the term CAM, a focus group of 13 international experts in the field of CAM was held. A forum was also set up for 28 international experts to discuss and refine proposed definitions of both CAM and integrative healthcare (IHC) terms. Audio recordings of the meeting and forum discussion threads were analyzed using interpretive description. RESULTS: Multiple terms to describe the therapies, products, and disciplines often referred to as CAM, were considered. Even though participants generally agreed there is a lack of optimal definitions for popular CAM-related umbrella terms and that all terms that have so far been introduced are to some extent problematic, CAM and IHC remained the most popular and accepted terms by far. The names of the specific disciplines were also deemed adequate in certain contexts. Focus group participants clarified the context in which those three terms are appropriate. Existing and emergent definitions of both CAM and integrative healthcare terms were discussed. CONCLUSIONS: CAM and other related terms could be used more effectively, provided they are used in the proper context. It appears difficult for the time being to reach a consensus on the definition of the term CAM due to the uncertainty of the positioning of CAM in the contemporary healthcare systems. While umbrella terms such as CAM and IHC are useful in the context of research, policy making and education, relevant stakeholders should limit the use of those terms.

The healing experience-how can we capture it?

BACKGROUND: The Integrative Medicine (I-MED) Index, designed to be a universal instrument to assess the 5 levels of healing (physical, energetic, emotional, subconscious, spiritual) among individuals who use complementary therapies, is based on the hypothesis of healing (HH), which considers healing as a dynamic process towards wholeness generally following the same steps. When we pilot-tested the instrument, it became clear that the way participants experience healing in their lives was not as the HH suggested. This led us to ask how patients experience healing and what outcomes they identify as key to their journey. METHODS: In-depth, semistructured interviews were conducted with 35 individuals with previous healing experiences at 2 wellness centers in Vancouver, BC. Qualitative content analysis and thematic coding were used to analyze the data. ANALYSIS AND RESULTS: Four themes emerged from participants' stories; they suggested that healing is (1) a personal and subjective experience, (2) a return to wholeness, (3) self-directed and requiring positive intention and (4) experienced in varying degrees. Symptom resolution, goal attainment, changes in social support, mental outlook, and the subtle but significant changes like engaging in life differently were important healing outcomes. Contrary to the assumptions of the HH, healing is an individualized process that does not follow a uniform pattern. CONCLUSIONS: A lack of consensus on the key concepts of healing has hindered efforts to evaluate the effects of complementary therapies and outcome. The results from this study provide the basis for an instrument to assess individuals' healing experiences in a more dynamic manner.

Whole complementary and alternative medical systems and complexity: creating collaborative relationships.

In recent years, investigators have discovered significant limitations in applying biomedical cause-effect assumptions and using conventional efficacy study designs to assess the clinical outcomes of whole systems of complementary and alternative medicine (WS-CAM). A group of WS-CAM researchers has been working collaboratively since 2001 to address the limitations of studies evaluating WS-CAM and discern ways to conduct research that would capture the complexity of such systems and the synergistic effects between the various elements of the system and would take into account treatment individualization and/or the patient-centered nature of treatment systems. In 2009, 14 complexity scientists from systems biology, psychology and the social sciences were invited to attend a workshop with these CAM scientists to (a) identify and discuss analytical techniques that can be used to study phenomena from a complex/nonlinear dynamical sciences perspective, (b) establish working relationships with these researchers, and (c) develop working research projects/ protocols to collaboratively study patient-centered responses to CAM treatments. This paper provides an overview of the workshop goals and outcomes, introducing this special issue of Forschende Komplementärmedizin.

The Complementary Medicine Education and Outcomes (CAMEO) program: a foundation for patient and health professional education and decision support programs.

OBJECTIVE: This paper describes the background, design and evaluation of a theory-informed education and decision support program for cancer patients considering complementary medicine (CM). METHODS: The program was informed by the Shared Decision Making theory, the Ottawa Decision Support Framework and the Supportive Care Framework. Previous empirical evidence and baseline research were used to identify patients' and health professionals' (HPs) information and decision support needs related to CM. RESULTS: To address the continuum of CM needs, a variety of education and decision support interventions were developed, including basic CM information and resources for patients and HPs, a group education program and one-on-one decision support coaching for patients, and an on-line education module for HPs. Evaluation of the program and individual interventions is underway. CONCLUSIONS: This education and decision support program addresses a significant gap in care and offers an evidence-informed framework in which to translate CM evidence to conventional care settings and promote communication about CM. PRACTICE IMPLICATIONS: Evidence-informed CM education and decision support interventions are needed to shift the culture around CM within conventional care settings and promote open communication that will lead to CM therapies being safely integrated into care.

The flexner report of 1910 and its impact on complementary and alternative medicine and psychiatry in north america in the 20th century.

America experienced a genuinely vast development of biomedical science in the early decades of the twentieth century, which in turn impacted the community of academic psychiatry and changed the way in which clinical and basic research approaches in psychiatry were conceptualized. This development was largely based on the restructuring of research universities in both of the USA and Canada following the influential report of Johns Hopkins-trained science administrator and politician Abraham Flexner (1866-1959). Flexner's report written in commission for the Carnegie Foundation for the Advancement of Teaching in Washington, DC, also had a major influence on complementary and alternative medicine (CAM) in psychiatry throughout the 20th century. This paper explores the lasting impact of Flexner's research published on modern medicine and particularly on what he interpreted as the various forms of health care and psychiatric treatment that appeared to compete with the paradigm of biomedicine. We will particularly draw attention to the serious effects of the closing of so many CAM-oriented hospitals, colleges, and medical teaching programs following to the publication of the Flexner Report in 1910.

Developing a patient-centered outcome measure for complementary and alternative medicine therapies I: defining content and format.

BACKGROUND: Patients receiving complementary and alternative medicine (CAM) therapies often report shifts in well-being that go beyond resolution of the original presenting symptoms. We undertook a research program to develop and evaluate a patient-centered outcome measure to assess the multidimensional impacts of CAM therapies, utilizing a novel mixed methods approach that relied upon techniques from the fields of anthropology and psychometrics. This tool would have broad applicability, both for CAM practitioners to measure shifts in patients' states following treatments, and conventional clinical trial researchers needing validated outcome measures. The US Food and Drug Administration has highlighted the importance of valid and reliable measurement of patient-reported outcomes in the evaluation of conventional medical products. Here we describe Phase I of our research program, the iterative process of content identification, item development and refinement, and response format selection. Cognitive interviews and psychometric evaluation are reported separately. METHODS: From a database of patient interviews (n = 177) from six diverse CAM studies, 150 interviews were identified for secondary analysis in which individuals spontaneously discussed unexpected changes associated with CAM. Using ATLAS.ti, we identified common themes and language to inform questionnaire item content and wording. Respondents' language was often richly textured, but item development required a stripping down of language to extract essential meaning and minimize potential comprehension barriers across populations. Through an evocative card sort interview process, we identified those items most widely applicable and covering standard psychometric domains. We developed, pilot-tested, and refined the format, yielding a questionnaire for cognitive interviews and psychometric evaluation. RESULTS: The resulting questionnaire contained 18 items, in visual analog scale format, in which each line was anchored by the positive and negative extremes relevant to the experiential domain. Because of frequent informant allusions to response set shifts from before to after CAM therapies, we chose a retrospective pretest format. Items cover physical, emotional, cognitive, social, spiritual, and whole person domains. CONCLUSIONS: This paper reports the success of a novel approach to the development of outcome instruments, in which items are extracted from patients' words instead of being distilled from pre-existing theory. The resulting instrument, focused on measuring shifts in patients' perceptions of health and well-being along pre-specified axes, is undergoing continued testing, and is available for use by cooperating investigators.

Meaning and challenges in the practice of multiple therapeutic massage modalities: a combined methods study.

BACKGROUND: Therapeutic massage and bodywork (TMB) practitioners are predominantly trained in programs that are not uniformly standardized, and in variable combinations of therapies. To date no studies have explored this variability in training and how this affects clinical practice. METHODS: Combined methods, consisting of a quantitative, population-based survey and qualitative interviews with practitioners trained in multiple therapies, were used to explore the training and practice of TMB practitioners in Alberta, Canada. RESULTS: Of the 5242 distributed surveys, 791 were returned (15.1%). Practitioners were predominantly female (91.7%), worked in a range of environments, primarily private (44.4%) and home clinics (35.4%), and were not significantly different from other surveyed massage therapist populations. Seventy-seven distinct TMB therapies were identified. Most practitioners were trained in two or more therapies (94.4%), with a median of 8 and range of 40 therapies. Training programs varied widely in number and type of TMB components, training length, or both. Nineteen interviews were conducted. Participants described highly variable training backgrounds, resulting in practitioners learning unique combinations of therapy techniques. All practitioners reported providing individualized patient treatment based on a responsive feedback process throughout practice that they described as being critical to appropriately address the needs of patients. They also felt that research treatment protocols were different from clinical practice because researchers do not usually sufficiently acknowledge the individualized nature of TMB care provision. CONCLUSIONS: The training received, the number of therapies trained in, and the practice descriptors of TMB practitioners are all highly variable. In addition, clinical experience and continuing education may further alter or enhance treatment techniques. Practitioners individualize each patient's treatment through a highly adaptive process. Therefore, treatment provision is likely unique to each practitioner. These results may be of interest to researchers considering similar practice issues in other professions. The use of a combined-methods design effectively captured this complexity of TMB practice. TMB research needs to consider research approaches that can capture or adapt to the individualized nature of practice.