Explaining the Impact of the COVID-19 Pandemic on Massage Therapists in Australia and Canada: A Mixed Methods Study

Abstract

Background:

The COVID-19 pandemic was a time of rapid change and uncertainty, with individual jurisdictions within countries implementing a variety of preventative measures. At the onset of the pandemic, as little was known about how COVID-19 was transmitted, restrictions, such as lockdowns, were implemented to prevent further spread of this virus. In many jurisdictions, massage therapists were deemed as nonessential for a period. This disruption to their livelihood, as a professional group and without autonomy to decide, was unprecedented. This prompted the question as to whether this experience had impacted massage therapists' professional identity.

Methods:

A sequential explanatory mixed methods design was used and massage therapists in Australia and Canada were recruited to participate. Results from a quantitative questionnaire completed by 649 respondents and from 31 semistructured interviews from a subset of the questionnaire participants were used in the mixed analysis.

Results:

Massage therapists, impacted by the pandemic, experienced a discord between what it means to be a massage therapist, providing patient-centered care and the public health initiatives implemented during the pandemic. This discord occurred in multiple situations and the type of discord was influenced by a number of factors, including how therapists identified themselves within the workforce (i.e., as a health care provider or a service provider).

Conclusion:

This study sought to understand how the COVID-19 pandemic impacted massage therapists' professional identity. Massage therapists reported that the pandemic impacted their professional identity through a lack of congruence and discord between their identity-constituting beliefs and what it means to be a massage therapist. The sequela to this discord was therapists experiencing different types of moral distress and or moral injury. Future research is needed to determine the longer-term impacts of COVID-19 on massage therapists.

Introduction

The COVID-19 pandemic was a time of rapid change and uncertainty for people around the globe. Each country responded with different measures, and individual jurisdictions within countries implemented a variety of preventative measures. At the onset of the pandemic, as little was known about how COVID-19 was transmitted, restrictions such as lockdowns, limited travel, personal protective equipment, physical distancing, and cleaning protocols were used by the government to prevent further spread of this virus.^1

–4

To assist the implementation of the above restrictions, some regions distinguished between essential and nonessential workers. Those deemed essential were able to continue to practice with modifications such as enhanced use of personal protective equipment and stringent cleaning protocols. Those deemed nonessential were restricted in their practice or not allowed to practice at all.

In many jurisdictions, massage therapists were deemed as nonessential for a period.^5
–7 This disruption to their livelihood, as a professional group and without autonomy to decide, was unprecedented. This prompted the question as to whether being removed from their workplaces and being unable to provide care to their clients had impacted massage therapists' professional identity.

Professional identity is “the values and beliefs held by [a professional] that guide her/his thinking, actions, and interactions with the patient.”⁸ Professional identities provide a lens through which to understand oneself and the professional community,⁹ and are influenced by identity-constituting beliefs, which are “[beliefs] that is fundamental to one's sense of self, one's place in the world, and one's purpose.”¹⁰

For practicing professionals, professional identity formation is influenced by: the workplace and workplace values, relationships with peers, professional culture and mentorship, an individual's personal experience, and their cumulative professional experience.^11

–14 A sense of belonging, such as that which comes with a strong professional identity, influences practitioners to maintain their professional ethics.^15,16 Caza and Creary¹⁷ theorize that a strong sense of role and feeling of contribution decreases the risk of anxiety and depression. A weak professional identity has been associated with an increased risk of burnout.^15,18,19

Research question

There is limited research to explain the impact of the pandemic on the professional identity of massage therapists. Research that has been conducted has focused on essential health care professionals involved in frontline care during the pandemic.^20

–23 This mixed methods study was designed to answer the question, “How did the COVID-19 global pandemic impact the professional identity of massage therapists in Australia and Canada?”

Methods

A sequential explanatory mixed methods design was used.²⁴ Research ethics approval was granted by the Humber College Research Ethics Board (REB-0230).

Sample and recruitment

The population from which participants were recruited was massage therapists in Australia and Canada. Recruitment for the initial, quantitative (QUANT) strand occurred from February to April 2021, when an online questionnaire-based study was conducted.²⁵ Participants were recruited using convenience sampling through email and social media. Participants from the first strand were invited to participate in the second qualitative (QUAL) strand by email on July 2, 2021. Participants were purposefully selected based on age, gender, type of practice, and experience with the four key phenomena of interest (experience of being labeled nonessential, with opening and closing of their practice, with burnout, and with connectedness with massage colleagues) using maximum variation sampling.²⁶ No separate recruitment was undertaken for the mixed analysis.

Data collection

In the QUANT strand, a questionnaire was developed and pilot tested before being administered. Six hundred and forty-nine respondents [329 (50.7%) from Canada and 316 (48.7%) from Australia] completed the questionnaire. Results were presented as descriptive statistics for demographic information, and inferential statistics (chi-square tests of independence) were used to test frequency of distribution of dependent variables (the agreement with statements) with the independent variable of country.²⁵

In the QUAL strand, individuals participated in a 30–40-min semistructured interview either by phone or virtual meeting platform, depending on the preference of the participant. With consent, the interview was recorded and securely sent to an online transcription service (Scribie: https://scribie.com/audio-transcription-service#confidentiality). The transcripts were then checked by a researcher (A.B., S.F.) or a volunteer (S.B.).

All participant data from both strands were included in the mixed analysis.

Data analysis

The mixed analysis combined QUANT and QUAL approaches to integrate the data from the QUANT and QUAL strands to answer the research question (sequential QUANT–QUAL analysis²⁴). Data from the questionnaire were used to quantify the areas of impact, whereas data from the interviews were used to explain participants' experiences of the impact of the pandemic on their professional identity. In addition, open-ended questions from the QUANT strand were used in both ways; at times the responses were categorized and numerically reported, at other times the words were used to further explain participants' perspectives.

When open-ended data were transformed, two researchers (S.F., A.B.) reviewed the items and completed the classification independently. They then compared analyses and resolved any conflicting items.

Recategorization of the open-ended question, “How did being classified as a nonessential worker make you feel?” (Q27) in the QUANT strand, which was answered by 479 (74.9%) of the 649 respondents, was undertaken. Answers were categorized into the following feelings: not accepting (the response indicated the therapist did not find it acceptable and/or found it difficult to be classified as nonessential); mixed (the response indicated the therapist agreed and/or could see both sides of being classified as nonessential); accepting (the response indicated the therapist agreed with and/or found it acceptable to be classified as nonessential); and neutral (the response indicated the therapist had no feelings either way about being classified as nonessential). Question 6 of the QUANT survey asked participants to describe their beliefs about their role within the workforce by responding to the question: “Would you describe yourself as a healthcare worker, a service provider, both a healthcare worker and service provider, or neither?”

Question 64 of the QUANT survey asked about agreement with the statement: “Many of my clients need me for essential healthcare.” A Fisher's Exact test was used to test frequency of distribution of dependent variables (the agreement with statements to question 6 and question 64) with the independent variable of feelings about being classified as nonessential. The threshold for significance was p < 0.05. Significance was adjusted post hoc, using Bonferroni's correction, to reduce the chance of a type 1 error occurring.²⁷ Data analysis was undertaken using SPSS.²⁸

Results

The independent results of the QUANT strand and the QUAL strand are presented elsewhere.²⁵ However, as the mixed analysis uses data from participants from both strands, a summary of demographic information is provided.

Summary of demographic information

Most participants in the QUANT strand identified as female (n = 523; 80.6%), diploma qualified (n = 481; 74.1%), self-employed (n = 374; 57.6%) massage therapists with a mean age of 46.1 years (SD 11.5) and an average of 12.3 years (SD 8.7) in active practice. The most common workplace setting was a multipractitioner setting (n = 342; 52.7%) or as a sole practitioner (n = 294; 45.3%).

In the QUAL strand, 31 (16 Australian and 15 Canadian) participants were interviewed. The majority of participants identified as female (n = 25; 80.6%), diploma qualified (n = 25; 80.6%) with a mean age of 48.3 (SD = 11.9), and an average of 12.2 years (SD = 8.1) in active practice. Most reported their primary practice was in an urban setting. The mean interview time was 42.6 min (SD = 12.0).

Open-ended data transformation from the QUANT strand

Transformation of QUAL data [“How did being classified as a nonessential worker make you feel?” (Q27)] into QUANT data resulted in 259 (54.1%) respondents in the not accepting group, 32 (6.7%) in the mixed group, 183 (38.2%) in the accepting group, and 5 (1%) in the neutral group. There was a significant correlation between how respondents felt about being classified as nonessential and their belief about their role within the workforce (p < 0.001; Table 1). There was no significant correlation between how respondents felt about being labeled as nonessential and respondents' answers to “Many of my clients need me for essential healthcare” (p = 0.330; Table 1).

Table 1.

Correlation of Feelings About Being Labeled Nonssential

	Not accepting of being labeled nonessential, n (%)	Mixed feelings about being labeled nonessential, n (%)	Accepting of being labeled nonessential, n (%)	Neutral about being labeled nonessential, n (%)
Question 6
I am a health care provider	175^a (71.1%)	8^b (13.3%)	61^b (24.8%)	2^ab (0.8%)
I am a service provider	6^a (23.1%)	11^b (42.3%)	9^a (134.6%)	0^ab (0%)
I am both a health care provider and a service provider	74^a (37.2%)	12^ab (6.0%)	112^b (56.3%)	1^ab (0.5%)
I am neither a health care provider nor a service provider	4^a (50%)	1^a (12.5%)	1^a (12.5%)	2^b (25.0%)
Fisher's exact test	p < 0.001^*
Question 64—Many of my clients need me for essential health care
Agree	189 (52.9%)	25 (7.0%)	140 (39.2%)	3 (0.8%)
Neither agree nor disagree	30 (48.4%)	4 (6.5%)	26 (41.9%)	2 (3.2%)
Disagree	29 (67.4%)	1 (2.3%)	13 (30.2%)	0 (0%)
Not applicable	1 (50.0%)	0 (0%)	1 (50.0%)	0 (0%)
Fisher's exact test	p = 0.330

Within a row, each subscript letter denotes categories whose proportions do not differ significantly from each other at the 0.05 level for the same response.

Significant at p < 0.05.

Integration of transformed data and data from the QUANT and QUAL strands

The main theme that emerged from the data was that massage therapists impacted by the pandemic experienced a discord between what it means to be a massage therapist providing patient-centered care and the public health initiatives implemented during the pandemic. This discord affected the professional identity of massage therapists and was evidenced in multiple contexts. The results are presented based on the different contexts where discord occurred: (1) how therapists identify themselves within the workforce (i.e., as a health care provider or a service provider), (2) bringing to light value conflicts, (3) the measures used to manage COVID-19, and (4) exposure to morally injurious events and moral-constraint distress.

How therapists identify themselves within the workforce

Massage Therapists who identified as Health care Providers: Massage therapists who viewed themselves as health care providers were less accepting of being labeled as nonessential (Table 1); believing that massage therapy had a place in the provision of care during the COVID-19 lockdowns. Respondents experienced a discord between the way they perceived massage therapy in the context of health care compared with the perception of massage therapists held by government agents and agencies and other health care professionals. In addition, they experienced a lack of congruence between their patients' needs and being labeled as nonessential.

“Everything that I do for my clients to assist with their pain, body restrictions, and conditions was not recognized by the government… I was not taken seriously as a health professional.” (QUANT398—Australia)

“When similar healthcare providers were allowed back (chiro, physio, etc.) and massage therapists were excluded it felt very disrespectful.” (QUANT594—Canada)

Respondents often felt constricted from doing what they thought was the ethically appropriate action.

“… Some of my clients need massage [therapy] to continue functioning day to day. I was looking after those clients, so I felt I was essential to them to continue moving, to be able to get up and go to the toilet, to do the very basic stuff.” (QUAL10—Australia)

“It was devastating because I worked in palliative care and with seniors who depended on me for pain management.” (QUANT16—Canada)

Massage Therapists who identify as Health care and Service Providers: Massage therapists who viewed themselves as health care and service providers were more accepting of being labeled as nonessential (Table 1). They felt that massage was not lifesaving and therefore could be paused while the measures introduced to prevent the spread of the COVID-19 virus were in place. Respondents expressed a strong belief about the role massage therapy had in the provision of care during the lockdowns as a risk and benefit analysis.

“I don't think I was essential. I think while massage therapy is extremely helpful, it's not life-saving, and so it's not worth risking, significantly risking, health and safety for.” (QUAL08—Canada)

“It was around making choices about the public good compared to individual good. Then there was weighing up harms and benefits.” (QUAL07—Australia)

Massage Therapists who identify as Service Providers: Massage therapists that identified solely as a service provider were able to see the advantages and disadvantages of being essential or nonessential and felt more mixed about the labels, however, this provided the elements and environment for tension about the most appropriate ethical action to take.

“[I felt] in some ways ‘devalued’, but also thankful that there was a hard stop (i.e., could easily say no to clients who kept asking for an appointment).” (QUANT86—Australia)

“It was kind of a mixed bag because there was the personal relief of, ‘thank God I don't wanna deal with this right now’, because I had my own concerns, but I had so many clients who were like, ‘Oh my God, I get more relief from seeing you than I do from the physiotherapist or from the chiropractor, why can't you guys open?” (QUAL03-Canada)

Bringing to light value conflicts

Respondents identified that COVID-19 brought to light differing values and beliefs among therapists resulting in respondents feeling conflicted about sharing their views and beliefs with others. Respondents felt distress when their beliefs about practice were incongruent with other massage therapists' and it created an estrangement and divide between therapists.

“There has been a great divide with massage colleagues. I have felt incredibly connected and also at total odds depending on the individual value system of the person. I have gained new connections and cut some old ties due to the conflicting nature of interactions.” (QUANT165—Australia)

“I think at that point, there was a certain sense of camaraderie with the people who had come to the same position on COVID. I can't say that's necessarily stayed in terms of keeping a sense of camaraderie, but I think that has been a bit of a divide.” (QUAL06—Australia)

The differing values held by massage therapists about what was the “right,” ethical, and moral decision regarding staying open or closing, lead to some respondents experiencing hostility and threats from their peers.

“At one point I did receive a text message from someone who I thought was a friend who said, ‘did you know you're breaking the law and that I will report you?’” (QUAL10—Australia)

The measures used to manage COVID-19

Respondents described situations where they experienced a dissonance in their belief about what it means to be a massage therapist and the measures used to manage COVID-19. These were often in direct conflict with the frameworks and values that respondents felt defined massage therapists, individually and as a profession.

“Bodywork is clearly one of the vocations that is least conducive to social distancing. By nature, we are people-focused, where working in close proximity with others is natural and essential. Humans…need, and even crave, touch, so it is understandable that those of us that are hard-wired to provide therapeutic touch might feel misaligned when we are unable to fulfil our calling.” (QUANT425—Australia)

“There is that small idea or notion that we were not providing the best care possible. Well, we were but the environment had changed so much that our version of best care possible wasn't the version that we really liked.” (QUAL07—Australia)

When respondents were able to provide face-to-face care, there were often restrictions placed on caregiving creating an ethical tension on who they could provide care for and who they had to refuse to treat.

“It has been extremely difficult to determine if a person receiving treatment is more important than the risk. I have had some new patients come in with very mild discomfort due to tension patterns and have found it very difficult to navigate how to tell them it is not an appropriate time to come in for those ailments. Because the experience of pain and the impact of pain is subjective it makes it difficult to inform people that they shouldn't come back unless they need to.” (QUANT513—Canada)

The constraints put in place by governments, associations, and regulatory bodies contributed to respondents' uncertainty about whether they were doing the right thing in terms of continuing to see clients or temporarily shutting down. This was exacerbated when financial needs and professional values about practice collided. Some therapists had to approach decisions they made about opening, closing, or reducing hours based on their financial need rather than from the perspective of the needs of their clients.

“Working between two locations because of financial need feels super selfish and irresponsible and that has been draining. I am constantly afraid I may unintentionally expose vulnerable hospital patients [to COVID], but I don't know what else to do because I need the money from both locations. [T]he government will not provide me with any assistance beyond the CERB limits’’ (QUANT282—Canada)

Some respondents could not afford to stop working and “were made to feel bad about what is essentially a socioeconomic issue” (QUANT202—Australia). Even when respondents choose clients' needs over finances, they continued to question their decisions.

“I won't take new clients right now. I won't treat unless I can justify the need for treatment. [I am] taking a big financial hit and I question myself if I am wrong” (QUANT685—Canada).

Exposure to morally injurious events and moral-constraint distress

Massage therapists reported a specific type of exposure to morally injurious event leading to moral distress, which was when a therapist was constrained from following through with what they thought was the right course of action (known as moral-constraint distress²⁹). Respondents felt ineffective and faced the challenge of simultaneously knowing what care patients needed but being unable to provide it due to constraints beyond their control. Predominantly it was acts of omission that resulted in moral distress and injury, such as bearing witness to the deterioration of clients' health and quality of life and failing to be able to provide services.

“…it was very distressing not to be able to work and support my clients in a time where they really needed body work support” (QUANT145—Australia)

“[I felt] awful, powerless, and insulted. To be a health care provider and literally not allowed to provide for my patients during a time of extreme stress was one of the most difficult things I have ever done. I seriously considered risking the $10,000 a day fine to open my practice for my patients who were desperate for care.” (QUANT247—Canada)

“[I felt] invalidated. Helpless. [I was] stressed because people were calling in pain begging for help and I couldn't treat them” (QUANT690—Canada).

A small sample of the study participants were restricted or unable to provide care at the end of life and for some, their client had died by the time massage care was able to be resumed.

“There are people that I had on my program before Covid …who died without me seeing them again, and I mean that does happen from time to time, ‘cause people will deteriorate faster than you thought or, whatever, but nevertheless it feels like at some level, I feel like they were abandoned.” (QUAL07-Australia)

“She [the client] actually did pass away, and I felt helpless then ‘cause I couldn't do anything for her.” (QUAL03-Australia)

Discussion

The COVID-19 pandemic and the public measures put in place to manage COVID-19 led to an epistemic disruption of massage therapist's professional role and identity, in particular, a disruption of their sense of what it means to be a massage therapist. While each massage therapist's experience of COVID-19 and the resulting impact on professional identity was individual, a common thread that ran through the data was the resultant challenges and discord that occurred.

Research in health care professionals found that COVID-19 impacted professional identity and created a discord between health professionals' belief about what it is to be a clinician, their clinical role, and their core values.^30
–32 Despite much of the research focusing on health care workers that were frontline^30,31 and where services were not withdrawn as part of the containment measures put in place, the similarities between health care workers and massage therapists' sense of discord and disruption to their professional identity are profound. Similar to frontline health care workers, massage therapists felt alienated from their clinical role when they were unable to practice, and this created fractures in their professional identity. Frontline health care professionals were able to make new meaning during the COVID-19 pandemic due to being able to still participate in direct patient care and make a difference by filling gaps left by COVID-19 restrictions such as substituting for a family member at the bedside of ill patients.³⁰

However, massage therapists had limited opportunities to make new meaning as the hands-on nature of massage makes it very difficult for massage therapists to adapt new methods of care provision within the confines of nonface-to-face treatment. This inability to create new meaning confounded massage therapists' loss of sense of purpose and meaning of their work resulting in therapists reevaluating their core values and place in the workforce.

Much of the literature about moral distress of health care providers during COVID-19 pandemic is about the impact of moral decision making in the treatment of patients;^33
–35 however, this study explains the experience of moral distress due to the constraints restricting care to individuals whom they believed needed treatment. Acting with moral integrity is a central part of professional identity,³⁶ and during COVID-19, massage therapists had to bear witness to client's pain, suffering, deteriorating health, and/or death when their services were withdrawn resulting in a sense of powerlessness and moral distress. Research on the impact of COVID-19 found that many health professionals experienced moral distress,^32

–35,37 including massage therapists who experienced moral distress two to three times a week during COVID-19.³⁸ There is limited research on the cessation of COVID-19 as a method of restoration of professional and moral identity of health care providers due to the fact that the COVID-19 pandemic is still ongoing.

Research on professionals that experience moral injury indicates that time alone does not heal moral injuries³⁹ and that support and help is required as massage therapists make sense of the COVID-19 crisis and resume their lives and livelihoods.⁴⁰ A number of strategies, including self-compassion and mindfulness have been identified to help support individuals experiencing moral distress and moral injury and move toward moral restoration³⁹ (the “restoration of moral selves and professional relationships that are constituted by shared values and standards”⁴¹). Seeking professional help may be required by massage therapists to help restore professional identity and manage moral restoration.

Professional implications

Most massage therapists engage in limited education in their undergraduate studies about professional identity and situations in which their values and beliefs are challenged and disrupted. Thus, many massage therapists may be unaware of what moral distress is and be unaware that they have been experiencing it. Consequently, they may not be aware of how to manage it and “restore and build their internal capacity to sustain their personal integrity.”⁴² The provision of structured and professional forums “in which care professionals can talk through and contextualize the ethical and personal challenges and uncertainties they faced”⁴⁰ may give massage therapists the opportunity to voice their lived experience and a place for their stress and burdens to be acknowledged.⁴⁰ Communities of practice have been shown to be “crucial in fostering the moral resilience of healthcare professionals to support them to manage unavoidable moral distress.”⁴³ Many massage therapists report being sole traders, self-employed, or independent contractors and do not have the benefits and support of larger organizations and systems.

Massage therapy associations have a pivotal part to play in helping massage therapists (re)build communities of practice and provide information and forums to rectify professional identity and learn about dealing with moral distress/moral injury and build moral resilience. Equally, it is important massage therapists understand moral distress as it is likely that their clients may have also experienced moral distress due to restrictions placed on individuals during COVID-19 and the withdrawal of some health services.

COVID-19 has exposed a gap in massage therapy education around massage therapists' professional identity formation and situations where moral integrity is challenged and disrupted. Massage educators could consider the role of moral integrity as part of professional identity and incorporate case-based ethics education sessions into their teaching structure to help identify environments and elements that create discord and may lead to moral distress or moral injury. It is important that massage therapy educators are able to “create a safe space” for learners to talk openly about moral concerns related to clinical practice and the ways in which massage therapists can foster safe spaces for diverse opinions when they enter the workforce.¹⁰

Further research

Future research could investigate whether massage therapists are experiencing ongoing moral distress, moral injury, and or moral residue, which is “the distress that remains when the situation generating the moral distress ends.”⁴⁴ Many countries have now removed lockdown orders and massage therapists are able to return to practice, although with some remaining safety constraints. Future research should identify which supports are needed for massage therapists who find themselves experiencing moral injury, investigate how massage therapists facilitate moral restoration and restore professional identity, and explore whether the resumption of practice is enough to encourage restoration. Further research into the formation of massage therapists' professional identity both during the COVID-19 pandemic and outside of the pandemic is warranted.

Limitations

Combining methods in mixed methods research creates stronger inferences than either method on its own. However, mixed methods research is not without its limits. As this is a sequential explanatory design, the initial sample of participants becomes the population for the second strand. The QUANT sample oversampled the subgroup of massage therapists in regulated Canadian jurisdictions. Therefore, caution should be used by readers when applying the findings to unregulated practitioner experiences.

In addition, each province, state, and territory of Australia and Canada experienced different restrictions and requirements of its residents. It is not clear whether these differences may have influenced the results. This may be compounded by the above, as the experience across several jurisdictions may not have been captured.

Conclusion

The COVID-19 pandemic was an unprecedented time of rapid change and uncertainty, and this study sought to understand how this time impacted massage therapists' professional identity. Through this mixed methods study, massage therapists explained that the COVID-19 pandemic impacted their professional identity through a lack of congruence and discord between their identity-constituting beliefs and what it means to be a massage therapist. This discord occurred in multiple situations and the type of discord was influenced by how therapists identified themselves within the workforce (i.e., as a health care provider or a service provider), the measures used to manage COVID-19, the public bringing to light of value conflicts, and exposure to morally injurious events and moral-constraint distress. The sequela to this discord was therapists experiencing moral distress and or moral injury. Future research is needed to determine the longer-term impacts of COVID-19 on massage therapists.

Footnotes

Acknowledgments

The authors wish to acknowledge Steve Baskwill (S.B.) for his assistance with transcription verification. In addition, they are grateful to all the massage therapists and massage therapy organizations in Australia and Canada who showed their support for this project.

Ethics Approval

Consent was provided by participants in both strands of the study.

Availability of Data and Materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Authors' Contributions

All persons listed as authors have participated sufficiently in the work to take public responsibility for the content, including participation in the concept, design, analysis, writing, or revision of the article. All authors (A.B., P.H., F.C., L.F., R.B., and S.F.) contributed to the conception or design of the work; authors A.B. and S.F. collected the data; all authors (A.B., P.H., F.C., L.F., R.B., and S.F.) contributed to the data analysis and interpretation; A.B. and S.F. drafted the article; and all authors (A.B., P.H., F.C., L.F., R.B., and S.F.) critically revised the article.

Author Disclosure Statement

S.F. declares that she works as a massage therapist. F.C. declares that she is a massage therapist. R.B. works for a massage association. P.H., A.B., and L.F. declare they have no conflicts of interest.

Funding Information

No funding was received for this article.

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