Licensed massage therapy is so much more than just a little portion of Physical Therapy

By Esteban Ruvalcaba

This past legislative session was a relatively quiet one, the first such session in many years. The most notable event occurred in the Fall of 2018, prior to the legislative year. In September, the Department of Social Services issued a series of proposed rules that would, for the first time, require Missouri HealthNet to pay for massage therapy when used to treat chronic pain in participants in the Missouri’s Medicaid program. This was an attempt to begin dealing with the opioid crisis. I submitted a comment on the rules on October 5th. While supporting the proposed rules, in general, my comment suggested a few changes to better support the at risk population and to support the profession. My principal concern was that the proposed rules would have physical therapists perform the covered massages. The AMTA national office reviewed and approved of these comments, before they were submitted. The Department of Social Services rejected my comments, saying that there is insufficient data to support my argument. The comments included 12 endnotes. I plan to submit a slightly expanded comment in the near future but will add substantially more endnotes. The text of my comments follows below:


The purpose of this comment is to support the Division of Social Services/MO HealthNet’s proposed rule change (13 CSR 70-3.300), published in the Missouri Register on September 17, 2018 (Complementary Medicine and Alternative Therapies for Chronic Pain Management). The Missouri Chapter of the American Massage Therapy Association commends the use of Complementary Medicine and alternative therapy as tools to manage chronic pain for MO HealthNet participants. Over the last few years, a growing body of peer-reviewed clinical literature has documented the effectiveness of massage therapy as a tool for managing chronic and acute pain for populations ranging from cancer sufferers through post-operative patients. According to the Joint Commission and the American College of Physicians, nonpharmacological techniques like massage can replace opioids to treat many types of pain.1

In light of this growing evidence, some of the leading hospitals in the country now employ massage therapists as part of their pain management teams. These hospitals include: Dana-Farber Cancer Institute; Memorial Sloan-Kettering Cancer Center; Mayo Clinic; and M. D. Anderson Cancer Center. In addition several health systems also use massage therapists for pain management. Those systems include: Duke Health Systems (massage therapists are integrated into the patient care teams) ; Beaumont Health (Michigan’s largest health care system); and Nationwide Children’s (based in Ohio, this is one of the country’s largest pediatric health care and research centers).

Many studies demonstrate the effectiveness of massage therapy in the treatment of pain. Massage therapy has been shown to be an effective in treatment for: back pain,2 headaches,3 cancer pain,4 osteoarthritis,5 fibromyalgia,6 postoperative pain,7 anxiety and stress,8 depression,9 and neck and shoulder pain.10

We strongly approve of the proposed rule change, and would like to suggest a small change to the definitions section. In section C, lines 2 and 3, the rule includes the following definitions, “2. ’Complementary medicine and alternative therapy for chronic pain’ combines the use of physical therapy, cognitive behavioral therapy, chiropractic therapy, and/or acupuncture to promote chronic pain relief for adult participants; 3.’Physical therapy treatment for chronic pain’ includes, but is not limited to, participant education and counseling, manual techniques, therapeutic exercises, electrotherapy, and massage.”

We think that participants in MO HealthNet will be better served if massage therapy were included in line 2 as part of the definition of “Complementary medicine and alternative therapy” and simultaneously removed from the definition of the aspects of physical therapy. Massage therapy is recognized as an effective modality, apart from and as contrasted to physical therapy. For example, in 2014, a study of women who suffered from chronic low back pain found that participants who received massage therapy experienced a greater decrease in their pain and disability when compared to participants who received standard care (physical therapy).11 Another study found that massage therapy performed in coordination with physical therapy helped reduce pain and anxiety in joint replacement patients.12

It is important to remember that the inclusion of “manual techniques” under the rubric of physical therapy includes all manual techniques that physical therapist are licensed to perform, including some elements of joint manipulations and massage.

Line 8 of section C, reads, “’ Complementary medicine and alternative therapy provider’ means a complementary medicine and alternative therapy care provider licensed by the state of Missouri and authorized to prescribe medication or other therapy within the scope of such person’s practice. . . .” Massage therapists licensed under the rules of the Missouri State Board of Therapeutic Massage meet this requirement since they are defined, by statute, as health care providers [324.240 (6)]. Moreover their training in massage therapy exceeds that of others licensed to provide therapeutic massage in Missouri. While some physical therapists and Occupational therapists may take as much as a three credit course in massage therapy (the equivalent of 35 contact hours of training). Some specialized massage techniques are included in training for working with specialized populations of patients, perhaps another 35 hours over the course of the degree program. By contrast, the minimum amount of training in massage therapy, provided by schools in Missouri is 300 hours, or in excess of four times the training that other health care practitioners receive. We believe this makes licensed massage therapists (LMT’s) the most qualified professionals to deliver these important therapeutic and health care services.


We support the proposed rule change, and would like to see the changes we propose adopted as part of that rule. Thank you for your time and consideration to our letter.


1 The Joint Commission, The Joint Commisssion Elevates Acupuncture, Chiropractic, Massage, and Relaxation in Pain Care in Response to Integrative Team Advocacy, Integrative Medicine: A Clinician’s Journal, April 2015, PMC4566474.


2 Kumar S, Beaton K, Hughes T (2013) The effectiveness of massage therapy for the treatment of nonspecific low back pain: a systematic review of systematic reviews. Int J Gen Med 6: 733-741.


3 Lawler SP, Cameron LD (2006) A randomized, controlled trial of massage therapy as a treatment for migraine. Behav Med 32: 50-59.


4 Lee SH, Kim JY, Yeo S, Kim SH, Lim S, Meta-Analysis of Massage Therapy on Cancer Pain, Integr CancerTher. 2015 Jul;14(4):297-304…


5 Perlman Al, Sabina A, Williams AL, et al. Massage therapy for osteoarthritis of the knee: a randomized controlled trial. Arch Intern Med. 2006;166(22):2533-2538.


6 Yuan SL, Matsutani LA, Marques AP. Effectiveness of different styles of massage therapy in fibromyalgia: a systematic review and meta-analysis. Man Ther. 2015 Apr;20(2):257-64.


7 Buyukyilmaz F. Asti T (2013) The effect of relaxation techniques and back massage on pain and anxiety in Turkish total hip or knee arthroplasty patients. Pain Manag Nurs 14: 143-154.


8 Rapaport MH, Schettler P, Larson ER, Edwards SA, Dunlop BW, Rakofsky JJ, Kinkead a. Acute Swedish Massage Monotherapy Successfully Remediates Symptoms of Generalized Anxiety Disorder: A Proof-of-Concept, Randomized Controlled Study. J Clin Psychiatry. 2016 Jul;77(7):e883-91.


9 Poland RE, Gertsik L, Favreau JT, Smith Sl, Mirocha JM, Rao U, Daar ES (2013) Open-label, randomized, parallel-group controlled clinical trial of massage for treatment of depression in HIV-infected subjects. J Altern Complement Med 19: 334-340


10 Nahin RL, Boineau R, Khalsa PS, Stussman BJ, WeberwJ. Evidence-Based Evaluation of complementary Health Approaches for Pain Management in the United States. Mayo Clin Proc. 2016 Sep;91 (9):1292-306.


11 Kamali F, Panahi F, Ebrahimi S, Abbasi L., Comparison between massage and routine physical therapy in women with sub acute and chronic nonspecific low back pain, J Back Musculoskelet Rehabil. 2014;27(4):475-80. doi: 10.3233/BMR-140468.


12 Morien A(2014) Understanding a patient’s surgical journey: what joint replacement surgery entails and the role massage therapy plays in pre-and postsurgery. Mass Ther J 66-78.