Creating an ELAP-Friendly Textbook

By Ruth Werner
[Pathology Perspectives]

I am fond of telling the story of a phone call with a person who had found my brand-new business card—my first potential client who was not already a friend or acquaintance. I had my beautiful 1985 calendar out, and I was ready to write in her name, and then she said it: “By the way, I have Guillain-Barré syndrome. That won’t be a problem, will it?” I didn’t know. I didn’t know how to find out. I had to turn her away. It broke my heart.
Much later, I was blessed with the opportunity to write the book that I wished I’d had while I was a student: A Massage Therapist’s Guide to Pathology (MTGP). The first edition came out in 1998, and it was far more successful than anyone predicted. My publisher has supported the book’s success by encouraging me to update it on an aggressive schedule. The sixth edition, now subtitled Critical Thinking and Practical Application, is now available.
The solid success of MTGP has allowed me to both witness and participate in the evolution of our profession, going from an occasional treat for people with a little extra money to being part of an integrated strategy to achieve and maintain health and wellness.

New Era, New Tools—But Are They the Right Tools?
I speak with some authority when I say that the landscape of decision-making tools for massage therapists is fundamentally different today from what it was 30 years ago. Far from operating in a bubble with a few nonmassage textbooks that might apply (but no one really knew for sure), we can now instantly reach out to hundreds, even thousands, of our colleagues for advice and input for those “Guillain-Barré” moments. We can crowdsource pathology decisions! Sounds great, right?
Truthfully, I see questions in massage therapy Facebook groups that make my blood run cold: “My client has one kidney. I should just go light, right?” “My client has cancer. I don’t know what kind. I should just go light, right?” “My client has MRSA …”
This suggests two things: that pathology education in many schools may not be adequate and/or many massage therapists do not have the skills or motivation to independently seek credible information, analyze it, and make decisions based on what they find. And without that ability, we are even more limited than we were back in the pre-Internet dark age.  

The Entry Level Analysis Project (ELAP): Identifying Baseline Learning Outcomes
Readers may be familiar with the monumental work of the Entry Level Analysis Project (ELAP) that was released to the public in 2013. The whole project and its supporting documents are available at
www.elapmassage.org. The ELAP workgroup worked with the results of the Massage Therapy Body of Knowledge project (www.mtbok.org), along with multiple surveys and job task analyses that incorporated input from thousands of massage therapists across the country. Their goal: to establish baseline learning outcomes needed for a person to enter the massage therapy profession. As the president of the Massage Therapy Foundation
(www.massagetherapyfoundation.org) at the time, I was honored to be a part of the coalition of national massage therapy organizations that sponsored the ELAP.
In the process, this group developed a dedicated and extremely practical learning taxonomy for manual therapists (see graph on page 36) and created an extensive blueprint of suggested curricula structured on the learning levels and domains defined by the taxonomy.
I support the ELAP’s purpose, and I write a widely used core-curriculum textbook that was due for an update, so … it seemed a natural fit to take advantage of the opportunity to incorporate some of the ELAP principles into the sixth edition of MTGP.

Critical Thinking, Clinical Reasoning
From my perspective, the thing that is missing from many pathology courses is specific guidance in critical thinking and how that applies to clinical reasoning.  
Critical thinking is one of those terms that gets thrown around a lot without being specifically defined. For the purpose of developing my textbook and this article, I refer to the Foundation for Critical Thinking (www.criticalthinking.org). Here is a paraphrase of one of their suggested definitions:

Critical thinking is the intellectually disciplined process of actively and skillfully analyzing, and/or evaluating information gathered by observation, experience, or communication, as a guide to belief and action.1

In this context, critical thinking means “gathering and evaluating information, and putting it to use for the benefit of our clients.” This ultimately leads to good clinical reasoning—and that is exactly the goal of my book. I want to help educators develop new massage therapists who are capable of effective critical thinking and clinical reasoning for their clients who live with health challenges.
Happily, the ELAP supports this priority. One of the standards listed for pathology education is that learners should be able to “discuss the use of a clinical reasoning model (or critical thinking model) to problem-solve when working with pathologies.”2

What Does This Look Like in a Textbook?
I updated information on every single condition in MTGP from the previous editions, I brought it into alignment with the newest edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), and I also added new sections on current research findings for relevant topics. This makes the book useful to massage therapists in practice who might want a more current pathology book than they already have. I am also excited to see this edition available as the first fully integrated ebook for massage therapy, with live links, embedded videos, and many other fun features. But the biggest structural changes in this edition apply more to educators than to readers.
The conversion to the ELAP learning structure is most obvious in the end of chapter questions, in the student resources, and in the instructor resources.
Everything in education begins with language. I tell my students (too many times, some might say), “If you can’t say the word, you don’t own the word.” Readers may or may not remember what it was like to learn the language of massage, anatomy, or pathology, but I guarantee you didn’t retain or internalize anything important until you had a way to express it.
Vocabulary is the starting place for new ideas. In MTGP, much of Chapter 1 (“Fundamental Concepts in Pathology”) is given to Greek and Latin word roots and to baseline vocabulary words that show up again and again in the text. Each chapter highlights words learners may not have encountered before, and definitions are found in the margins on the same page for instant incorporation. Further, for those who use the ebook, a clickable audio glossary provides an instant recording of the word in question.

Cognitive Domain Level 1: Receive and Respond
The first level of learning, according to the ELAP taxonomy,3 involves the transfer of basic facts. This is where the objective of knowing the definition of specific pathologies might fall. I chose also to treat the discussion of etiology and signs and symptoms at this level, but a higher-learning setting might bump those topics up a notch on the learning scale, since being able to link an understanding of pathophysiology to a condition’s signs and symptoms reveals the ability to apply concepts in an abstract way.
Receive-and-respond type learning is the foundation on which all more abstract thinking must be built. It is also the type of learning that lends itself to the simplest forms of assessment. A typical Level 1 test question might look like this:

What is a synonym for adhesive capsulitis?
a. Jumper’s knee
b. Student’s elbow
c. Frozen shoulder
d. Lockjaw
The answer is C (congratulations—I knew you could do it).

Cognitive Domain Level 2: Apply
This asks learners to use what they find in the pages of MTGP to help make decisions for their clients (critical thinking and clinical reasoning, at least at a basic level). In the text, this is covered in “Risk/Benefit” boxes that conclude each discussion.
This has to be a nuanced conversation, because the answers may be determined by many variables. It is impossible to rubber stamp recommendations, so instead I encourage students to consider these simple questions:
• What are the best things that could happen because of your massage?
• What are the worst things that could happen because of your massage?
• How can you design a session that maximizes the benefits and eliminates the risks?
Your client reports that she had a minor transient ischemic attack six months ago. What area of her body must be treated with the most caution?
a. Anterior triangle of the neck
b. Suboccipital triangle
c. Calves
d. Between the scapulae

The correct answer is A, but the second-most correct answer would be, “Excuse me, let me just check my pathology book.”

Cognitive Domain Level 3: Problem Solving
For the purposes of entry-level pathology education, the cognitive domains of Level 2 and 3 are often interchangeable, with room for more extensive exploration in Level 3 thinking. The point is to support problem solving with credible information that has been analyzed and evaluated by the learner or practitioner.
Affective and Interpersonal Domains
When teaching and learning about pathology stretches beyond the processing of facts into strategies, then we begin to cross over into education about ethics and communication. I have supported this by providing some “What Would You Do?” questions intended to spark conversations rather than to lead to specific conclusions. Here is an example:
You have volunteered to work at an outpatient dialysis facility where patients with end-stage renal failure are treated. Your client today is Rick, a 56-year-old man on disability because he has lost one leg below the knee and half of his other foot due to diabetes. Rick is about 80 pounds overweight and it is obvious from the smell he is a heavy smoker. His hands are grimy, and although he says he feels fine, he has a heavy, phlegmy cough.
You have agreed to give Rick a 30-minute gentle massage while he is receiving his dialysis treatment. You will be working with his arms and hands and possibly his neck, shoulders, and head.
Make a list of the questions you want to ask. Also, pay attention to whatever reactions and personal responses you have about working with Rick. Do you have any concerns? How can they be answered? When you discuss this prospective client with your classmates, are their reactions similar to yours?

Call to Action
Readers of this article are not likely to be shopping for an entry-level pathology book, but you are called on to be critical thinkers. The next time you see a client with a condition that you’re not familiar with, I encourage you to put on your critical thinking/clinical reasoning cap. Before you ask your Facebook group, go to credible sources of information, either in print or online. A Massage Therapist’s Guide to Pathology is a good place to start, but it’s not the only good place to start. Other pathology texts have different strengths, and I also hope to see the ability to do a good PubMed (www.pubmed.gov) search become part of our job description. Here is an example of the rest of that decision-making process:
• Find out how this condition affects function: What does it do to sensation, circulation, the integrity of the skin? What other systems might be involved? What medications might alter your choices, and in what ways?
• Identify the possible risks and benefits of your style of massage therapy for your client’s situation.
• Make a session plan that minimizes or eliminates the risks and maximizes potential benefits.
• Record your results.
This process is the essence of evidence-informed practice, the essence of clinical reasoning, and the essence of best practices. It is vital this becomes our standard of care and a reasonable expectation for every massage therapist—newbies and veterans alike. Our clients deserve no less.
I am proud to provide a resource that supports our soon-to-be colleagues in raising the bar for the practice of massage therapy. I hope it helps to move our profession toward this goal.

1. Foundation for Critical Thinking, “Defining Critical Thinking,” accessed November 2015, www.criticalthinking.org/pages/defining-critical-thinking/766.
2. Coalition of National Massage Therapy Organizations, “Entry-Level Massage Education Blueprint,” accessed November 2015, under “Anatomy, Physiology, and Pathology,” www.elapmassage.org/_files/ELAP_Blueprint.pdf.
3. Ibid.

Ruth Werner, BCTMB is a former massage therapist, a writer, and a continuing education provider approved by the NCBTMB. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2015), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.