E-Learning in Massage Therapy

By Whitney Lowe

One of the most significant changes in higher education in the last decade is the explosive growth in online courses. A 2007 report, Online Nation: Five Years of Growth in Online Learning, by the Sloan Consortium, found that in 2006 “nearly 20 percent of all U.S. higher education students were taking at least one course online”—around 3.5 million students.1 These researchers point out that, “For the past several years, online enrollments have been growing substantially faster than overall higher education enrollment.”2 Clearly this trend is changing the face of higher education in the United States.

While e-learning has made inroads into mainstream higher education, its adoption in the massage field is much slower. Traditionally, massage therapists have not been heavy computer users. However, this is changing. Massage therapists now routinely use the computer as part of their practice for communication, record keeping, research, marketing, scheduling, and other purposes.

Because massage therapy is a kinesthetic practice, educators may feel that e-learning methods are not appropriate for massage education. This is a concern of educators in related healthcare fields, such as occupational therapy.3 E-learning is clearly not a desirable teaching method for the hands-on techniques of massage. However, there is much more to massage education than just hands-on techniques, and for these other subjects e-learning holds great promise.

The National Certification Board for Therapeutic Massage & Bodywork (NCBTMB) adjusted the eligibility criteria for their National Certification Exam recently, allowing up to 300 hours of initial training as distance education. Under the new guidelines, massage technique courses must still be taken in a face-to-face classroom setting, but other non-technique courses can be delivered through distance or e-learning methods. While numerous subjects can be taught online, few programs use e-learning for entry level training at this time.

E-learning is more common in continuing education (CE), where it is a valuable learning option for the busy professional or those without access to face-to-face course offerings. CE requirements are a part of licensure renewal in most states and most professionals recognize the benefits of updating skills and expanding expertise.

For some subjects, e-learning is proving to be an equally and sometimes better teaching format. In higher education, e-learning has been shown to increase student learning, increase integration of material, and improve outcomes. These advantages have potential in the massage therapy profession as well. Like other formats, quality makes or breaks student success and learning. Although current online courses are often designed as simple “read and test” courses, innovative educational models in e-learning offer far more effective-learning formats with multiple advantages.

What is E-Learning?

Distance education has been around for centuries in the form of correspondence courses. However, the rapid expansion of the Internet and widespread use of the World Wide Web is feeding the exponential growth of these courses. Online-learning, now commonly called e-learning, involves delivering course content via computer instead of the traditional classroom. Most e-learning courses use a web-based interface and more robust courses use some type of learning management system (such as Blackboard or Desire2Learn) that can track student activity and records.4

E-learning courses are delivered as either synchronous or asynchronous. In a synchronous course, students perform learning activities together at the same time (usually in the same time zone). Examples include web-based seminars (webinars), live chat activities, or video conferencing. Synchronous activities can require a high-speed internet connection. Due to technological and geographic limitations, most higher education applications of e-learning do not use synchronous activities.

With asynchronous learning, students do not perform course activities at a set time. The flexibility to work on an individual schedule and in different time zones is a primary advantage of e-learning. Because of this flexibility for both instructors and students, most higher education e-learning classes use an asynchronous format.


No learning method is superior for every student, instructor, or every topic. However, there are distinct advantages to e-learning for students, teachers, and educational institutions. The ability to offer courses at any time and in any location greatly enhances student access, allows flexibility for instructors, and provides schools more teaching opportunities.

Physical distance and expense are primary barriers to education that are overcome by e-learning. Many people live in areas where there are few educational opportunities in their selected area of study. Taking time off work, and then paying for travel, lodging, and the course are hard for many students in today’s economy.

Massage school students are a diverse population with some students just out of high school and others close to retirement age. E-learning formats can be designed as a more individualized educational experience tailored to the unique needs and learning styles of this diverse group. Once developed, e-learning courses can actually save enormous costs, time, and workloads at the instructor and institutional level. Offering such courses can also open educational opportunities to new students who might ordinarily not be able to consider the traditional school schedule, due to restraints of time or physical location.

For students, when the courses are designed effectively, the potential advantages of e-learning can be great. These benefits include convenience and cost, quality of educational experience, and successful outcomes and integration of material. As with any type of educational format, a good quality program will produce better results for students than those of poor design.

The quality of the e-learning educational experience for students can be greater or equal to traditional courses. This is due to several factors. First, the immediate access in e-learning allows students to work on those days and times they are most interested, attentive, and receptive—increasing their learning. These benefits are greater if the course is asynchronous.

Second, e-learning is self-paced. The ability to work at the student’s own pace is a significant advantage of e-learning, as it meets the needs of a wide-range of students with various learning styles. The self-paced nature of many e-learning activities requires the student to take a larger role in the learning process; active participation is proven to provide deeper understanding.5

Third, mental overload can be avoided in an e-learning environment because it allows students to work for shorter periods. Anyone who has sat for three days in a workshop and felt overwhelmed will relate to the mental-overload factor that can come with face-to-face settings. Quality e-learning courses allow students to gradually integrate material. Difficult topics can be more easily learned with this approach.

Finally, effective e-learning designs integrate cutting-edge educational methods that improve student learning. The research into e-learning and educational outcomes is producing a host of innovative educational options for instructors working in this setting. These new designs improve student outcomes and their integration of material greatly. In the world of hands-on application, like massage therapy, integration of new material with physical skills is a key to successful application in real practice.

A popular e-learning approach is called a hybrid course, which combines classroom activity with online course work. In higher education, research shows hybrid courses to be effective at enhancing student outcomes. In one study, students in a hybrid exercise physiology class had higher final grades than their counterparts who attended the same course in a traditional classroom setting.6 These students showed “significant improvement in student grade performance,” moving up one whole grade (Ex: B to A).7

In Online Learning, authors Allen and Seaman state, “Most academic leaders believe online-learning quality is already equal to or superior to face-to-face instruction.”8 It is difficult to make an accurate comparison of educational outcomes between e-learning and traditional classroom courses because there are so many variables. Yet, there is growing consensus that e-learning has great potential to improve educational outcomes when it is used effectively.

Instructional Design

The quality of any educational course is not determined solely by its method of delivery. The most important factor is the way course activities are constructed to achieve specific educational outcomes—known as the course’s instructional design. In e-learning, technological complexity does not equate with quality instructional design. Technological enhancements, such as streaming video or complex animations, are interesting and can play a role. Yet, too often in e-learning courses, developers put more effort into fancy technology than the course’s design. Quality instructional design is essential for an effective e-learning experience and is more important than technological enhancements.

Classroom courses often emphasize rote memorization to prepare students to pass exams. Most massage CE e-learning courses rely on a similar format—the student reads material on the computer and interacts with an evaluation tool, such as a multiple-choice test. Use of a simple instructional design like this should be limited to basic course material where the educational goal is little more than memorization and recall. Memorization only does not develop the type of skills and knowledge required by massage therapists in clinical practice. Instructional strategies that get students to think deeper and at higher cognitive levels prove more successful at improving student knowledge and application.

Educational strategies, such as problem-based learning, which are now being employed in many of the country’s medical schools, create deeper understanding of coursework.9 In problem-based learning, the course content is delivered through real-life case problems that a practitioner would normally encounter in practice. Problem-based learning methods translate very well into the e-learning environment and produce excellent outcomes when taught properly.

Part of the reason the simple “read and test” method does not work in advanced education, massage or otherwise, is due to student maturity. The majority of people in massage are adult learners who are past the age of traditional college students. Principles of adult education are different from those at the K–12 level. Adult learners have a greater need to know the reasoning behind the things they are learning and how they apply to their immediate and future experience. Advanced learning strategies, such as problem-based learning, allow students to focus more on the practical applications of their learning experience and not so much on absorbing or memorizing content.

A significant component in a well-built e-learning course is student-instructor and student-student interaction. University e-learning courses are generally constructed so that the instructor participates in the class (usually asynchronously) with the students using e-mail and interactive discussion forums. Students also have a forum for engaging in thoughtful dialogue with their fellow students. In this environment, students are able to develop a greater sense of community, which is shown to improve the educational experience. In fact, students report frequently feeling a greater sense of rapport with their online classmates than they do with face-to-face classmates. To date, very few massage e-learning courses use this instructional design.

A more interactive course structure poses both greater opportunities and challenges for the instructor. A primary change for instructors of e-learning courses occurs in their role as teachers. Educational theorists describe this shift as moving from the “sage on the stage” to the “guide on the side.” The instructor becomes much more of a facilitator for students’ learning experience, as opposed to the primary person directing it. This role is consistent with learning theory that encourages practice and engagement (rather than simply watching or reading). 


While e-learning methods hold great promise, this new educational model is not without its disadvantages and detractors. Some of the challenges with acceptance of e-learning are the result of perceptual bias and resistance to change. Others are genuine problems for which solutions need to be sought.

Because e-learning uses technology as a delivery medium, any technology limitation is a barrier to effective delivery of the course. Some e-learning courses are built with technical requirements that limit who can access the course material. For example, if a course is loaded with streaming video or interactive live Web demonstrations, those who do not have a high-speed internet connection will not be able use the course.

Another common concern with e-learning is that some people are afraid they will not get quality interaction with other students. If a course is limited to reading material on the screen and then simply answering multiple-choice questions on the computer, the chance for interaction is clearly limited. As mentioned previously, online engagement with others can be very rewarding, as evidenced in the plethora of online forums. Again, it boils down to the way the course developer has designed the learning activities.

In the e-learning environment, the student takes a much more active role, which is a problem for some students and an advantage for others. Without a certain amount of motivation and self-discipline, it may be difficult for some students to stay on task and complete the course work. Greater self-discipline by the student is a critical component of successful e-learning and leads to better educational outcomes from the course.10, 11

Some have raised concerns about managing academic integrity in e-learning programs. A critical concern is how to verify the person enrolled in the course is really the one on the computer doing the work. Cheating in the academic environment is an increasing problem in schools, in both e-learning and traditional classroom courses. There are ways to encourage academic integrity, but no system is flawless. New designs and strategies are being integrated to address this problem.

One factor that seems to influence the likelihood of cheating in both classroom and e-learning environments is if the course is high stakes. A high stakes course is one that is essential for achieving a specific qualification or credential necessary for practice. For example, passing anatomy and physiology is necessary to complete massage therapy training. With all the pressures of school, there may be a greater temptation to cheat on an anatomy and physiology test or course assignment than on a voluntary continuing education course. Again, quality instructional design can help address this challenge by creating course activities that decrease the opportunity or incentive for cheating in the e-learning environment.12

School administrators and instructors who first approach e-learning want to know how much time and money it will take to construct, maintain, and deliver an e-learning course. Once built, course delivery costs may actually be less than face-to-face courses because course offerings can increase as costs go down. However, there are certain technological and educational hurdles that must be overcome in order to integrate an e-learning course. Building a quality e-learning course requires a complex group of skills, including an ability to implement quality instructional design, comprehensive knowledge of the subject matter, and familiarity with web-based software technology, along with the ability to solve technical problems.

It is difficult to find all these skills in one person, so course construction often requires a collaborative effort. The more people involved, the greater the development cost to the instructor or school. The time spent building an e-learning course is much greater than that required to create a classroom course. Instructors already have limited time for course content development and some may feel overwhelmed by the time and cost requirements, especially if they are not particularly interested in e-learning.

New software technologies have made the job of creating e-learning courses easier, but just because one can do something easily with software does not mean one should. It is easy to post a bunch of text on the Web and make a multiple choice test. Yet, poor quality courses simply do not provide the advantages discussed earlier. Creating a quality educational course with effective-learning strategies and a superior educational design is much harder. Over time, subject matter specialists in massage who are interested in e-learning may choose to study the requisite fields and help bring these costs down. As this aspect of massage education develops, there may also be more opportunities to work with those willing to contract out these services.

Tracking student progress, managing submitted assignments, and facilitating effective communication in an e-learning course is accomplished with a software platform called a learning management system (LMS). Colleges and universities use various LMSs, such as Blackboard, WebCT (now owned by Blackboard), eClassrooms, or Desire2Learn. A fully integrated LMS can cost thousands of dollars and is often prohibitive in cost for massage education programs. However, the recent emergence of open-source LMS platforms, such as Moodle or The Sakai Project, make the cost of LMS management within reach of any massage program. Learning effective course design, even in open source LMS platforms, can be challenging and time consuming.

One of the biggest hurdles facing e-learning in the massage field is acceptance of this learning method as a valid instructional strategy. Despite the widespread acceptance of e-learning at the K–12, university, and adult professional education levels, there is still a perceptual bias against it by those regulating massage education. Of the states that require licensure for massage, only a small percentage recognize e-learning as a valid means of meeting portions of the educational requirements. The opposition to e-learning for entry-level training is due to the fear that e-learning will reduce the quality of education. There is greater acceptance of e-learning for CE, but there are still limitations to full acceptance in many state CE requirements. If quality e-learning programs are brought online, however, the reputation of this style of education will improve and their benefits will prove their worth.

Where To Go From Here

Judging by the trends in mainstream education, e-learning is here to stay. It is also safe to assume it will play a greater role in the educational options in the massage field in years to come. Massage therapy education has changed enormously in just the 20 years of my involvement in the profession. Five years before developing my first online course, I began studying and researching instructional design and web-based educational technologies. I was looking for better ways to teach concepts and material that were difficult to convey in the traditional classroom environment or weekend workshop. I am convinced that, when properly constructed, e-learning has some distinct advantages over traditional classroom instruction. Taking into consideration the unique aspects and needs of the massage and bodywork community, here are some recommendations for implementation and evaluation of e-learning that can move the field toward educational excellence.

Recognize the value of asynchronous learning strategies in today’s busy world. People have increasingly busy schedules, transportation costs are higher, and sitting in a classroom for hours on end with an inflexible schedule is not always the best way to accomplish educational goals. For many, especially adult learners, an asynchronous e-learning strategy can be highly effective.

Evaluate the quality of e-learning programs with an equal measure. Courses delivered online are often held to a higher standard of scrutiny than their face-to-face counterparts. Just because a person sits in a classroom does not mean he or she has had a quality learning experience. Measures of quality learning should focus on educational outcomes and program results. E-learning and classroom courses should be evaluated by the same criteria. Students in e-learning programs, especially hybrid programs that combine classroom and online experiences, have routinely performed as well as or better than those in classroom programs alone.

Avoid the temptation to be captivated by technology at the expense of instructional design. It can be easy to be carried away with all the fancy technology that can be included in an e-learning course. It also may be tempting to throw articles or lecture content on the Web with a simple quiz at the end. An exceptional e-learning experience minimizes technological challenges and focuses attention on the design of quality instructional activities that deepen the student’s learning.

Use e-learning for appropriate educational goals. Massage will always be predominantly a kinesthetic skill. It is not appropriate to attempt teaching the manual skills of massage and bodywork in an e-learning environment. Yet, manual techniques only comprise part of the knowledge, skills, and abilities needed to be an effective practitioner. Other academic subjects that require more complex learning and analysis can easily be delivered online. If constructed properly, more effective-learning methods can be employed and better outcomes can be achieved in an e-learning environment.

It is easy to be swept up in the excitement of e-learning and think it a great solution to many more problems than it really is. It is also easy to resist any implementation of e-learning with a perception that it must be of inferior quality and too costly. These perspectives represent two extremes and both can be erroneous perceptions. What is needed is a middle ground that recognizes the value of e-learning without overzealous adoption of it as a technological panacea to our educational challenges. This middle ground also requires an open mind to judge this new method on its merits and its ability to make unique and positive contributions to our educational landscape. Massage is once again entering a place of new opportunity. What the profession chooses to do with this new technology will dictate how it affects our education and our future. Hopefully, we will move toward higher quality e-learning programs to benefit our educational goals and the clients who are seeking our skills.



  Whitney Lowe is a key author, educator, and consultant in the massage therapy profession. He offers continuing education seminars, online courses, and program development  to schools. He can be contacted at omeri@omeri.com.


1.    E. Allen and J. Seaman, Online Nation: Five Years of Growth in Online Learning. (Needham, MA: Sloan Consortium, 2007).

2. Ibid.

3.   V. Hollis and H. Madill, “Online-learning: The Potential for Occupational Therapy Education,” Occupational Therapy International. 13, no. 2 (2006): 61–78.

4. Ibid.

5. Ibid.

6. B. K. McFarlin, “Hybrid Lecture-online Format Increases Student Grades in an Undergraduate Exercise Physiology Course at a Large Urban University,” Advances in Physiology Education. 32, no. 1 (2008): 86–91.

7. Ibid.

8. E. Allen and J. Seaman, Entering the Mainstream: The Quality and Extent of Online Education in the United States, 2003 and 2004. (Wellesley, MA: Sloan Consortium, 2004).

9. R. M. Harden, “A New Vision for Distance-learning and Continuing Medical Education,” Journal of Continuing Education in the Health Professions. 25, no. 1 (2005): 43.

10. E. Allen and J. Seaman. Online Nation: Five Years of Growth in Online Learning. (Needham, MA: Sloan Consortium, 2007).

11. R. M. Harden, “A New Vision for Distance-learning and Continuing Medical Education,” Journal of Continuing Education in the Health Professions 25, no. 1 (2005): 43.

12. S. Trenholm, “A Review of Cheating in Fully Asynchronous Online Courses: A Math or Fact-Based Course Perspective. Journal of Educational Technology Systems. 35, no. 3 (2007): 281.