Moving Out of the Fringes

Changing the Perception of How Massage Fits into Community Health Care

By Cal Cates
[Massage Therapy as Health Care ]

Massage therapists are often considered members of the health-care workforce,1 but in reality, we exist on the fringes. When it comes to state regulation, only about half of the states in the US recognize massage therapy as health care. (Remember the “essential” versus “nonessential” debate?)

There has been a good bit of research about employer-sponsored health programs in recent years, and the narrative that emerges is that “health-care delivery [is] based on augmented physician-patient relationship and focused on personalized preventive health care.”2 That sounds a lot like massage therapy to me.

Most services provided in health programs happen outside the direct supervision of a primary care physician and are led by allied health professionals like dietitians, exercise physiologists, or nurse counselors. Physician encounters are limited to patients with existing and serious health conditions. The bulk of patients are essentially working to never “qualify” for a physician visit in these programs.

Massage Therapy as Preventive Care

Lifestyle and behavior are primary indicators of long-term health. When policy think tanks and progressive research efforts look at how to build and maintain health, they look at prevention in terms of screening exams and lifestyle and behavior modification counseling interventions.3 They are not thinking about massage therapists, but we are at least partly to blame for this. We have given them no reason to think about us as providers of a discreet clinical preventive service.

The research funded to show the benefits of massage therapy is rarely about health-care savings, value, or promoting health in people who may be on a trajectory to develop chronic illness but who could remain healthy with the right support. We don’t endeavor to capture the number of manual laborers whose injuries are privately and effectively managed by massage therapists. We don’t look at how massage therapists are already improving outcomes for regular people who won’t show up on a list of those affected by illness. We are also never measuring the value of massage therapists—only of the intervention.

Chronic Pain

The financial and personal impacts of chronic pain alone on individuals and our national economy are staggering.4 A full 53 percent of American workers use their bodies in repetitive, weight-bearing, and potentially injury-inducing ways.5 Admittedly, many of these people can’t afford massage therapy (see my column about access in the January/February 2001 issue, “Equity in Massage Therapy,” page 32), but those who do are likely “costing” the health-care system much less by staying out of doctors’ offices and urgent care clinics and avoiding a path that would find them missing work or pursuing costly surgeries. So, if you don’t wind up at the hospital or in physical therapy, you don’t get counted, and neither does the person who had a hand in keeping you healthy and moving.


Then there’s stress. The data about stress and massage are mixed and often target stress in health-care workers or in people living with dementia or cancer. We don’t have much data about the effect of massage therapy on stress in ambulatory, ostensibly “healthy” people. By extension, we don’t have data about how decreasing stress may keep these people from becoming part of the health-care statistics landscape. Stress creates a huge and understudied ripple in terms of health and disease. Stress itself has direct and specific effects, but many of the behaviors and symptoms that can be prevented develop in response to stress. To put it simply, unchecked stress results in behaviors that lead to illness.

 Behaviors like smoking, drinking alcohol, being sedentary, and habitual eating are inspired and magnified by stress. These behaviors can lead to high blood pressure and increased cholesterol levels. This dynamic paves a bumpy but clear path to conditions like heart disease and diabetes.6 Annually, as many as 3.8 million people die from diabetes and dangerously high blood glucose levels.7 In addition, one in every four US deaths is the result of cardiovascular disease.8 Chronic, unmanaged stress is a major but unquantified factor in these deaths.

Closing the Gap

Massage therapy is screening. Massage therapy is behavior modification. We hardly have to open our mouths as practitioners for this to be true. We touch our clients regularly. We see how they walk into our treatment spaces. We notice changes in their skin and muscles. We notice decreases in energy. They tell us about their sleep habits and what they eat and other important indicators of health—and disease. We take it all in, but we have nowhere to go with it once they leave our table.

We can ask open-ended, nondiagnostic questions of clients, inviting them to consider choices that they express as challenging to their health. We can touch them in a way that invites them to notice areas of pain or dysfunction, but there’s no continuity between our care and the observations and guidance they receive from other clinicians. When our clients see their primary care physician (PCP) or psychotherapist, we don’t exist and neither do our observations. And when they don’t have to see their PCP or another health professional because some regular stress maintenance and soft-tissue tune-up keeps them functioning, we are truly invisible. This is a huge gap, and this gap will persist unless we close it.

Health-care providers of all stripes—including massage therapists—need to foster care that is patient-centered, comprehensive, and interdisciplinary; and financing, referrals, records management, and other systems need to support this flexibility. This will be yet another overlapping and heavy lift, but we need to make ourselves hard to miss in this conversation.

As massage therapists who are invested in an inclusive and integrative future, we need to start following the work of organizations like the Coalition to Transform Advanced Care (C-TAC), Integrative Health Policy Consortium (IHPC), Centers for Medicare & Medicaid Services (CMS), and America’s Health Insurance Plans (AHIP). The US Department of Veteran’s Affairs is also leading the way in looking at how massage therapy fits into a picture of whole community health. You and I need to do this. These are our relationships to build and solutions to create. We can’t expect others to take up this mantle on our behalf. This is our work (yours and mine) to do.


1. U.S. Bureau of Labor Statistics, “Massage Therapists,” updated September 1, 2020, accessed January 2021,; Center for Health Workforce Studies, “Who’s In the Health Workforce?” accessed January 2021,; Jaclyn Chadbourne, “What is an Allied Healthcare Professional?” March 20, 2018,

2. Shirley Musich et al., “The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures,” Population Health Management 19, no. 6 (December 2016): 389–97,

3. Shirley Musich et al., “The Impact of Personalized Preventive Care on Health Care Quality, Utilization, and Expenditures.”

4. Committee on Advancing Pain Research Care and Education, Board on Health Sciences Policy, and Institute of Medicine, “A Call For Cultural Transformation of Attitudes Toward Pain and Its Prevention and Management,” Journal of Pain and Palliative Care Pharmacotherapy 25, no. 4 (November 2011): 365–69,

5. Institute of Medicine Committee on Advancing Pain Research, Care, and Education, Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research (Book summary, Washington: National Academies Press, 2011), accessed January 2021,; Drew DeSilver, “10 Facts About American Workers,” Pew Research, August 29, 2019,

6. Will Evans, “Ruthless Quotas at Amazon Are Maiming Employees,” The Atlantic, updated December 5, 2019,

7. American Heart Association, “Stress and Heart Health,” reviewed June 17, 2014,

8. World Health Organization, “Diabetes,” June 8, 2020,; Centers for Disease Control and Prevention, “Heart Disease Facts,” reviewed September 8, 2020,

Cal Cates is an educator, writer, and speaker on topics ranging from massage therapy in the hospital setting to end-of-life care and massage therapy policy and regulation. A founding director of the Society for Oncology Massage from 2007 to 2014 and current executive director and founder of Healwell, Cates works within and beyond the massage therapy community to elevate the level of practice and integration of massage overall and in health care specifically. Cates also is the co-creator of the podcasts Massage Therapy Without Borders and Interdisciplinary.