To our knowledge, this is the first study that describes the demographic and training characteristics of US massage therapists and uses systematically collected visit data to describe their treatment patterns. Strengths of the study are the collection of data from licensed massage therapists practicing in geographically separated parts of the country where CAM use is relatively common, random sampling of providers from state licensing lists, relatively high response rates, and large sample sizes. The main limitation is that we collected data from only two states, which may not be representative of massage practice in other states.
However, licensure requirements in Connecticut and Washington are similar to those in most other states with licensure requirements. As of December, 2004, 33 states and the District of Columbia had passed legislation regulating massage practice. Of those, 21 require exactly 500 hours of training for licensure and 12 require between 570 and 1000 hours . Licensure in both Connecticut and Washington requires 500 hours of training plus a passing score on the national certification exam administered by the National Certification Board for Therapeutic Massage and Bodywork (NCBTMB). The latter is required for licensure in 24 states and is an option for licensure in another 5 states. In some states, including Massachusetts and California, massage regulations vary within the state (i.e., between townships, cities or counties). By contrast, the two provinces in Canada with regulatory requirements mandate that massage therapists receive 2500 hours (Ontario) or 3300 hours (British Columbia) of training.
Characteristics of the massage therapists
Our study describes an eclectic group of health professionals. Most massage therapists have taken continuing education training that includes both Western-oriented treatment techniques (e.g., neuromuscular therapy, myofascial release), and non-Western oriented treatment techniques (e.g., Reiki, meridian-based massage). Our finding that most massage therapists are white females with a median age around 40 is consistent with the findings of the only other published study of the characteristics of massage therapists, which surveyed 82 massage practices in the Boston area . However, that study reported that the median length of practice was 7 years (compared to our 4 to 5 years), that providers received a median of 1000 hours of clinical training (compared to our 600 hours), and that practitioners saw a median of 20 patients per week (compared to our 10 to 15 visits per week). The other study used the telephone book in a single urban area to recruit massage therapists whereas we used state – wide licensing lists. Their restriction to an urban area, their recruitment methods and their lower response rate may have biased their sample toward busier practitioners.
Why patients visit massage therapists and evidence for efficacy
The majority of visits to massage therapists focused on musculoskeletal conditions, possibly reflecting the extensive use of massage by physical therapists for rehabilitation during the first half of the 20th century . These are conditions for which Western medical care is often of limited value, which may explain why back and neck pain are the most common reasons why patients seek CAM care in general . While massage as a relaxation technique has received abundant attention in the popular culture, we found that less than one-third of all visits to licensed massage therapists focused on non-illness care.
CAM is also commonly used for self-defined anxiety and depression [2, 11]. Among such a group of respondents to a national survey, 5% and 2% of respondents said that they used massage therapy to treat these conditions, respectively . Since massage therapists do not make diagnoses, no information is available on whether patients' visiting for anxiety and depression in our study actually had these disorders diagnosed by physicians.
We could find no other published studies presenting data on patients' reasons for visits to massage therapists from a large population-based sample of visits, so we do not know how comparable these results are. A survey of a representative sample of US adults reported that massage therapy was one of the most common CAM therapies used for back problems, neck problems and fatigue . While fatigue was not a commonly listed reason for visiting massage therapists in our study, some patients who received wellness care or care for anxiety or depression could conceivably have had fatigue as a symptom.
The use of massage for treating medical conditions has grown substantially since 1990 . Although massage is one of the most popular forms of CAM care and has been found to have intriguing physiological effects (reviewed by Field ), few studies with moderate to large sample sizes have been conducted to evaluate its clinical effectiveness, even for most musculoskeletal conditions, conditions for which massage is frequently sought and for which conventional medicine has few good treatments. Three recent studies, including two that were well designed and had reasonable sample sizes, evaluated therapeutic massage as a treatment for subacute or chronic back pain and all three found positive results . In addition, several studies of acupressure for back pain have also found positive results [14, 15]. A recent Cochrane review of massage for back pain  concluded that "massage might be beneficial for patients with subacute and chronic non-specific back pain, especially when combined with exercises and education. More studies are needed to confirm these conclusions". While even fewer studies of massage have been conducted for other musculoskeletal pain conditions, there are small studies suggesting that massage may have benefits for patients with fibromyalgia , shoulder pain  and diffuse chronic pain , while Irnich  did not find massage effective for neck pain. Most of those studies lacked follow-up after the treatments had stopped, but Hasson found that the benefits of massage did not persist three months after the last treatment.
A recent meta-analysis of randomized trials of massage for various conditions found that massage had its greatest short-term benefits in reducing trait anxiety and depression, but no studies have evaluated these effects after the end of the treatment period . A systematic review of massage for symptom relief in cancer patients found preliminary evidence that massage had short term benefits on psychological well-being and possibly anxiety , but called for additional studies to confirm and extend these findings.
The modest evidence base for massage therapy's clinically important effects provides physicians with little information for advising patients about its effectiveness for conditions other than subacute or chronic back pain. However, given the safety profile and preliminary evidence of effectiveness for back pain, physicians should feel comfortable recommending massage for selected patients with musculoskeletal conditions and, possibly, for mild stress-related anxiety.
Care during visits to massage therapists
Massage therapists in Washington were more likely than those in Connecticut to use postural assessment and range of motion as assessments tools. Such differences likely reflect differences in training. In general, these differences in assessment were not associated with differences in the massage techniques emphasized by practitioners. Swedish, deep tissue, and trigger (pressure) point were by far the most popular techniques in both states. In their survey of massage therapists in Boston, Lee and Kemper  found similar results: 90% of practitioners reported using Swedish techniques and more than half reported using trigger point massage, sports massage, myofascial release, and aromatherapy.
A substantial minority of visits included techniques with a non-Western origin, such as some forms of energy work (e.g., Reiki) and meridian-based massage. In addition, this study as well as a previous study , found that massage therapists often emphasize self-care (e.g., drinking more water, movement, body awareness). Recommendations often include increasing the patients' awareness of how they are using their bodies coupled with exercises designed to enhance movement and posture, based on the assumption that many musculoskeletal conditions result from poor use of the body. While these recommendations have not been scientifically validated, they are likely to be safe and may enhance the patient's sense of well-being.
Safety of massage
In a review of the safety of massage therapy, Ernst  found 16 case reports and 4 case series in the biomedical literature over a 6 year period describing adverse effects associated with various forms of massage. However, only 3 reports (including 7 cases) described adverse effects that were probably attributable to treatments by massage therapists practicing Western forms of massage. These included the displacement of a ureteral stent, a hepatic hematoma after deep tissue massage  and the deterioration in hearing among patients who received neck massage. Ernst found three additional reports of adverse events associated with shiatsu, the most serious of which was retinal artery embolism with partial loss of vision after application of shiatsu to the upper neck. Although the rate of adverse effects over this period of time is unknown, in the US alone an estimated 113 million visits were made to massage therapists in 1997 , suggesting that serious adverse experiences due to massage are extremely rare.
Despite these scattered reports of adverse experiences, common forms of massage (e.g., Swedish, deep tissue, and neuromuscular) are considered very low risk, especially when massage is tailored appropriately to the individual (e.g., possible pressure or anatomic site restrictions), as massage therapists are commonly trained to do . While it is still generally assumed that patients with deep vein thrombosis should not receive massage to the lower extremities, many previous contraindications, such as proscribing massage to patients with metastatic cancer, are no longer considered warranted. Massage therapists are trained not to massage anatomic sites containing localized conditions such as skin injuries or burns.
Communication between massage therapists and physicians
Massage therapy is an increasingly popular form of care used by patients who are often also being treated by a physician for the same condition. Nevertheless, we found that massage therapists and physicians rarely communicated with each other. Possible barriers to communication include our observation that most patients who see both a physician and a massage therapist for a particular condition were not referred to massage by the physician. Furthermore many massage therapists are not trained in charting language familiar to physicians, nor are they permitted to make "diagnoses". In addition, referring patients to massage therapists has not been part of the training of physicians. Finally, we suspect that most massage therapists, who are typically part-time solo practitioners, lack office staff and record systems to assist with administrative tasks, including routine (and written) communication with other care providers.
We believe that patients may benefit from increased communication between their physicians and massage therapists. Physicians can foster improved communication by asking patients about the care they are receiving from a massage therapist and learning about the treatment plan. Some patients will want to try massage therapy only after consultation with their physician. In these circumstances, physicians can use the framework recommended by Eisenberg  to guide patients through the process of selecting a well-trained, therapeutically-oriented massage therapist, jointly negotiating the treatment plan, and monitoring the effects of the treatment over time.