JURNAL NASIONAL TENTANG PENCEGAHAN CEDERA DAN

MASSAGE
Massage for Sport Therapy and Injury, 1 (1), 2019, 7-17

Pengembangan model pencegahan dan penanganan pertama

cedera ankle pada pemain futsal berbasis adobeflash
Mufti Faozan, B. M. Wara Kushartanti
Program Studi Ilmu Keolahragaan, Program Pascasarjana Universitas Negeri Yogyakarta
Jalan Colombo No. 1, Karangmalang Yogyakarta, 55281, Indonesia
Email: mufti.faozan@yahoo.co.id, wkushartanti@gmail.com

Abstrak
Penelitian ini bertujuan untuk menghasilkan dan menguji efektivitas sebuah produk model pencegahan dan
penanganan pertama cedera ankle secara mandiri untuk pemain futsal yang dikemas dalam CD dan buku
panduan. Penelitian ini merupakan penelitian pengembangan, dengan tahapan: (1) analisis pendahuluan, (2)
mengembangkan produk awal: membuat storyboard dan prototype, (3) evaluasi produk: validasi ahli dan revisi,
(4) uji kelayakan produk dan revisi, dan uji efektivitas, (5) produk akhir. Subjek adalah ahli materi, ahli media,
dan pemain futsal. Data berupa hasil hasil penilaian mengenai kualitas produk, saran untuk perbaikan produk
serta data kualitatif lainnya. Hasil uji efektivitas menunjukkan kelompok eksperimen yang diberikan produk
pengembangan berupa model pencegahan dan penanganan berbasis adobe flash mengalami peningkatan yang
signifikan. Dari penelitian dihasilkan model pencegahan dan penanganan pertama cedera ankle pada pemain
futsal berbasis adobeflash yang dikemas dalam bentuk CD dan buku panduan.
Kata Kunci: model pencegahan, penanganan pertama, cedera ankle, futsal

Development of a model of prevention and treatment on the ankle

injury first futsal players based adobeflash
Abstract
The study aims to review Singer produce AN Model Product Prevention and treatment First Independently ankle
injury to review futsal player Yang hearts packaged CD and Manual. Research Singer is a research
development, WITH Stages: (1) analysis Introduction, (2) develop products Early: MAKE storyboards and
prototypes, (3) evaluation of the product: Validation Expert and revision, (4) test Feasibility Products and
revisions, and test the effectiveness of, (5) Final Product. Was the subject matter experts, media experts, and
futsal players. Data Form findings findings QUALITY ASSESSMENT Regarding Product, Product Improvement
Suggestions for review well as other qualitative data. The test results demonstrate the effectiveness of the
experimental group which, given the Product Development Model-Based Form of Prevention and handling
adobe flash Significantly increased. Research Model of Prevention and handling First produced an ankle injury
ON Players futsal Based AdobeFlash The packaged hearts Shape CD and Manual.
Keywords: model of prevention, first treatment, ankle injury, futsal

PENDAHULUAN
Olahraga Futsal merupakan olahraga yang sedang digemari di kalangan pelajar dan mahasiswa.
Olahraga futsal pertama kali dipopulerkan oleh Juan Carlos Ceriani pada tahun 1930 di Montevideo,
Uruguay. Olahraga futsal merupakan permainan bola yang dimainkan oleh dua tim yang
beranggotakan masing-masing 5 orang pemain di dalam lapangan. Tujuan dari olahraga futsal adalah
mencetak gol atau memasukan bola sebanyak-banyaknya ke gawang lawan dan menjaga gawang
sendiri agar tidak kemasukan. Lapangan untuk olahraga futsal memiliki ukuran sekitar panjang 25
meter-42 meter x lebar 15 meter-25 meter. Olahraga Futsal mempunyai karakteristik permainan yang
sangat cepat dan dinamis yang menuntut pemain untuk bergerak cepat dan dinamis di lapangan.
Dengan ukuran lapangan yang relatif kecil dan permainan yang sangat cepat dan dinamis, pemain
dalam permainan futsal akan mengalami lebih banyak benturan dengan pemain lainnya yang dapat
memperbesar resiko terjadinya cedera.
 Wibowo (1995, p.11) menyatakan cedera olahraga adalah segala macam cedera yang timbul
pada saat latihan ataupun pada waktu pertandingan ataupun sesudah pertandingan. Cedera merupakan
rusaknya jaringan yang disebabkan adanya kesalahan teknis, benturan, atau aktivitas fisik yang
melebihi batas beban latihan, yang dapat menimbulkan rasa sakit akibat dari kelebihan latihan melalui
pembebanan latihan yang terlalu berat sehingga otot dan tulang tidak lagi dalam keadaan anatomis
(Cava, 1995, p.145).
Berdasarkan hasil observasi dengan cara menggunakan angket yang disebar ke 103 Pemain
Futsal, 58,25% pemain pernah mengalami cedera ankle dalam olahraga futsal. Selain itu dari data
yang diperoleh pada tahun 2014 dari Rumah terapi Cedera olahraga, 12,9% orang yang mengunjungi
tempat tersebut mengalami cedera ankle. Hasil dari penelitian yang dilakukan oleh Shariff (2014) yang
berjudul “Incidence and Characteristics of Injuries during the 2010 FELDA/FAM National Futsal
League in Malaysia” sebanyak 39% pemain futsal mengalami cedera ankle. Selain itu dari hasil
penelitian yang dilakukan Nugroho (2016) menunjukkan bahwa sebanyak 16 atlet (53,3%) memiliki
pengetahuan kurang tentang cedera ankle, sebanyak 14 atlet (46,7%) memiliki pengetahuan sedang
tentang cedera ankle. Lin, Christine, Hiller, & A. de Bie. (2010, p.22) mengatakan studi yang mengkaji
tentang cedera ankle ada 24 dari 70 kajian dengan 22% cedera olahraga adalah cedera ankle dengan
rasio perbandingan sprain dan fraktur adalah 8:1.
Berdasarkan data tersebut, pemain futsal yang mengalami cedera ankle cukup signifikan akan
tetapi pemain yang memeriksakan cederanya ke tempat penanganan cedera tidak signifikan. Ini
mengindikasikan bahwa masih banyak pemain futsal yang mengalami cedera ankle masih
mengabaikan cedera yang dialaminya. Apabila ini dibiarkan maka akan terjadi resiko cedera yang
lebih besar. Selain itu masih banyak pemain yang belum mengetahui pengetahuan tentang cedera
ankle. Untuk itu, perlu dibuat suatu Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara
Mandiri pada pemain futsal yang dilakukan secara terpadu agar tidak menimbulkan resiko cedera yang
lebih besar dan menambah pengetahuan mengenai cedera ankle.
Saat ini model pencegahan dan penanganan pertama cedera ankle secara mandiri masih dalam
bentuk buku yang berukuran cukup tebal, buku saku atau lewat internet yang membutuhkan kuota
paket data untuk membukanya. Berdasarkan hasil observasi dengan cara menggunakan angket yang
disebar ke 103 orang, 64% pemain futsal belum mengetahui cara pencegahan dan penanganan cedera
ankle, 67% pemain mengatakan model pencegahan dan penanganan cedera belum efektif, dan 76%
pemain futsal membutuhkan model pencegahan dan penanganan cedera ankle yang lebih efektif. Dari
data tersebut maka perlu dikembangkan model pencegahan dan penanganan pertama cedera ankle
secara mandiri pada pemain futsal yang lebih efektif untuk mempermudah pemain futsal dalam
mengetahui informasi mengenai pencegahan dan penanganan secara mandiri cedera ankle.
Model pencegahan dan penanganan pertama cedera ankle secara mandiri pada pemain futsal
dapat menggunakan software adobe flash. Adobe Flash merupakan aplikasi yang digunakan untuk
melakukan desain dan membangun perangkat presentasi, publikasi, atau aplikasi lainnya yang
membutuhkan ketersediaan sarana interaksi dengan penggunanya. Melalui Media Adobe Flash pemain
futsal dapat mengetahui dan memahami informasi pencegahan dan penanganan secara mandiri cedera
ankle sehingga diharapkan dapat mengurangi resiko terjadinya cedera yang lebih besar.
Berdasarkan permasalahan di atas, maka akan dibuat sebuah Model Pencegahan dan
Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal.
METODE
Jenis penelitian ini adalah penelitian dan pengembangan (Research and Development) yaitu
jenis penelitian yang digunakan untuk menghasilkan produk tertentu, dan menguji keefektifan produk
tersebut (Sugiyono, 2014, p.297). Penelitian ini menggunakan pendekatan penelitian dan
pengembangan, Borg & Gall (2007) mendefinisikan penelitian pengembangan, sebagai berikut:
“Research and development (R & D) is a process used to develop and validate educational
products. By product we meat only such things as textbooks, intructional films, and computer
software, but also methods, such as a methods of teaching, and program such as a drug education
program or a staff development program”.
Prosedur penelitian dan pengembangan ini menggunakan langkah-langkah Borg & Gall (2007,
pp.775-776) yang disederhanakan. Desain penelitian pengembangan model pengembangan Borg dan
Gall kemudian diubah dengan lebih sederhana melibatkan lima langkah utama: (1) analisis kebutuhan,
(2) mengembangkan produk awal: membuat storyboard dan prototype, (3) evaluasi produk: validasi
ahli dan revisi, (4) uji kelayakan produk dan revisi, dan uji efektivitas, (5) produk akhir.
Desain uji coba dimaksudkan untuk mendapat umpan balik secara langsung dari pengguna
tentang kualitas produk yang sedang dikembangkan. Sebelum uji coba, produk dikonsultasikan kepada
ahli materi dan ahli media. setelah mendapat saran maka perlu melakukan revisi terhadap produk.
langkah berikutnya uji coba yang diharapkan mampu menemukan kelemahan, kekurangan,
kesalahan dan saran-saran perbaikan sehingga produk yang dihasilkan dapat direvisi sehingga
menghasilkan produk yang valid dan layak untuk dipergunakan.
Desain uji coba meliputi dua tahap yaitu uji coba kelayakan dan uji efektivitas. Dalam
pelaksanaan uji kelayakan yaitu 10 pemain futsal yang dipilih secara insidental. Data yang digunakan
untuk merevisi produk dan setelah direvisi dan dinyatakan layak selanjutnya uji efektifitas. Uji
efektivitas merupakan uji coba tahap akhir, yang dilakukan pada 20 pemain futsal.
Untuk menghasilkan model pengembangan yang berkualitas diperlukan instrumen yang mampu
menggali data yang diperlukan untuk mengumpulkan data pada penelitian ini berupa kuesioner dan tes
model pencegahan dan penanganan cedera ankle pada pemain futsal. Instrumen yang digunakan
berupa kuisioner dan lembar evaluasi.
Instrumen dalam penelitian ini diberikan untuk: (1) ahli media, untuk menilai aspek tampilan
dan pemrograman, (2) ahli materi, untuk menilai aspek kualitas materi dan isi, dan (3) untuk pemain
futsal untuk menilai aspej tampilan dan isi/materi.
Data yang dikumpulkan berupa data kuantitatif sebagai data pokok dan data kualitatif berupa
saran dan masukan dari respon sebagai data tambahan. Data tersebut memberi gambaran mengenai
kualitas produk yang dikembangkan. (1) Data dari ahli materi: berupa kualitas produk ditinjau dari
aspek isi materi dan desain, (2) Dari data ahli media: berupa kualitas teknik tampilan, pemrograman,
keterbacaan menyampaikan konten tertentu, (3) Data dari pemain futsal: digunakan untuk
menganalisis daya tarik dan ketepatan materi yang diberikan kepada pemain futsal.
Data yang digunakan dalam penelitian ini adalah data kualitatif dan kuantitatif. Data kuantitatif
yang diperoleh melalui angket penilaian dan dianalisis dengan menggunakan statistik deskriptif
kemudian dikonversikan ke data kualitatif yang diadaptasi dari (Kusumawardana & Sukadiyanto,
2013)
Data kualilatif dalam penelitian ini adalah data yang diperoleh melalui validasi dari ahli materi,
ahli media, dan pemain futsal. Data kuantitatif dalam penelitian ini diperoleh melalui kuesioner
penilaian dianalisis dengan statistik deskriptif yang berupa pernyataan sangat kurang, kurang, cukup,
baik, sangat baik.
Pada uji efektivitas, dilakukan dengan metode eksperimen dengan desain ‘Control Group
Pretest Posttest Desaign”. Menurut Arikunto (2010, p.272) penelitian eksperimen merupakan
penelitian yang dimaksudkan untuk mengetahui adanya akibat atau tidak terhadap subjek yang dikenai
perlakuan. pemain akan diberikan produk yang dikembangkan dalam penelitian ini. Selanjutnya hasil
pretest akan dibandingkan dengan hasil posttest menggunakan analisis uji t pada taraf signifikansi 5%.
HASIL DAN PEMBAHASAN
Langkah pertama yang dilakukan pengembang adalah melakukan analisis kebutuhan, sebelum
melakukan pengembangan produk. Analisis kebutuhan dilakukan untuk mengumpulkan data yang
didapat melalui studi lapangan dan studi literatur. Analisis melalui studi lapangan dilakukan dengan
menyebar angket angket yang disebar ke 103 Pemain Futsal, 58,25% pemain pernah mengalami
cedera ankle dalam olahraga futsal. selain itu dari data yang diperoleh pada tahun 2014 dari rumah
terapi cedera olahraga, 12,9% orang yang mengunjungi tempat tersebut mengalami cedera ankle. Hasil
dari penelitian yang dilakukan oleh Nugroho (2016) yang berjudul “Incidence and Characteristics of
Injuries during the 2010 FELDA/FAM National Futsal League in Malaysia” sebanyak 39% pemain
futsal mengalami cedera ankle. Selain itu dari hasil penelitian menunjukkan bahwa sebanyak 16 atlet
(53,3%) memiliki pengetahuan kurang tentang cedera ankle, sebanyak 14 atlet (46,7%) memiliki
pengetahuan sedang tentang cedera ankle.
Produk pencegahan dan penanganan pertama secara mandiri cedera lutut pada pemain futsal
yang dikembangkan dengan software Adobe Flash CS6. Produk ini dikemas dalam format .exe ke
dalam CD, selain itu produk ini dapat langsung dijalankan (run) tanpa harus diinstal terlebih dahulu
pada komputer pengguna. Pengemasan produk dalam format .exe adalah agar pengguna tidak perlu
lagi menginstal Flash Player ketika ingin mengakses produk ini. Sehingga lebih memudahkan
pengguna dalam mengakses atau menggunakannya.
Produk ini dibangun dengan konsep penggabungan media video, gambar dan suara serta
teknologi flash yang membuat produk lebih interaktif, teknologi flash membuat produk lebih user
friendly yang bearti pengguna dapat dengan mudah mengontrol dan mengakses menu-menu yang ada
pada produk.
Konten produk pencegahan dan penanganan pertama secara mandiri cedera lutut pada pemain
futsal dibalut ke dalam media berupa video, direkam dengan kamera kemudian ditambahkan suara
narasi sesuai gerakan sehingga memudahkan pengguna dalam memahami maksud dan tujuan serta
petunjuk pada konten video.
Produk ini dikembangkan dengan menggunakan software Adobe Flash CS6. Adobe Flash CS6
merupakan perangkat lunak versi terbaru setelah Adobe Flash CS5, menggunakan bahasa
pemrograman ActionScript dan mendukung pembuatan media dengan video, gambar, suara, dan
animasi sehingga sangat cocok dalam pengembangan produk pada penelitian ini. Selain Adobe Flash
CS4, terdapat beberapa software pendukung lainnya yang digunakan dalam pengembangan produk ini
antara lain, VideoPad Video Editor; software ini digunakan untuk mengedit konten video, seperti
memotong durasi, size, merotasi video, menggabungkan narasi suara pada video serta menambahkan
efek dan transisi pada video. Recorder; merupakan perangkat yang berfungsi untuk merekam suara
narasi konten, perangkat ini adalah produk bawaan dari Smartphone Asus Zenphone 5. Adobe
Photoshop CS6; berfungsi dalam pengolahan konten gambar.
Dalam proses pengembangan produk, maka produk yang dikembangkan perlu melalui proses
validasi dan uji coba, proses validasi dalam penelitian ini terdiri dari validasi materi dengan ahli materi
dan validasi media dengan ahli media, yang selanjutnya dilakukan proses uji coba dengan pemain
futsal sebagai pengguna. Proses ini dilakukan agar produk yang dikembangkan layak untuk digunakan
dalam mendapatkan informasi tentang pencegahan dan penanganan pertama cedera ankle secara
mandiri.
Evaluasi dilakukan untuk menilai dan merevisi produk awal dari Model Pencegahan dan
Penanganan Pertama Cedera Ankle Secara Mandiri pada pemain futsal. Data yang diperoleh dalam
penelitian ini adalah dengan cara memberikan produk yang telah dikembangkan berupa model
pencegahan dan penanganan pertama cedera ankle secara mandiri pada pemain futsal yang berbentuk
produk software dan materi hardware disertai validasi untuk ahli materi yang berupa angket.
Dalam hal ini, ahli materi memberikan penilaian terhadap produk yang dikembangkan serta
memberikan saran perbaikan untuk selanjutnya dilakukan revisi produk. Data hasil penilaian setiap
komponen produk berupa skor dikonversikan menjadi nilai skala lima. Data hasil evaluasi model
pencegahan dan penanganan pertama cedera ankle secara mandiri berbasis adobeflash oleh ahli materi
dipaparkan pada Tabel 1.
Tabel 1. Data Hasil Penilaian Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara
Mandiri Berbasis Adobeflash oleh Ahli Materi
No. Aspek yang dinilai Skor Kategori
1. Kualitas Materi 18 Sangat Baik
2. Aspek Isi 32 Sangat Baik
Data hasil evaluasi produk oleh ahli materi yang ada pada tabel memperlihatkan bahwa Model
Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal, hasil
pengembangan ini dari aspek kualitas materi mendapatkan skor “18” dan aspek isi mendapatkan Skor
“32”, skor tersebut kemudian dikonversikan menjadi nilai berdasarkan tabel skala penilaian. Dengan
demikian dapat dinyatakan bahwa menurut ahli materi, model pencegahan dan penanganan pertama
cedera ankle secara mandiri pada pemain futsal yang telah dikembangkan dari aspek kualitas materi
mendapatkan nilai 18 dengan kategori “Sangat Baik”dan aspek isi mendapat nilai 32 dengan kategori “
Sangat Baik”.
Data yang diperoleh dalam penelitian ini adalah dengan cara memberikan produk yang telah
dikembangkan berupa “Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri
pada Pemain Futsal” yang berbentuk produk software disertai validasi untuk ahli materi yang berupa
angket.
 Dalam hal ini, ahli media memberikan penilaian terhadap produk yang dikembangkan serta
memberikan saran perbaikan untuk selanjutnya dilakukan revisi produk. Data hasil penilaian
komponen produk yang berupa skor dikonversikan menjadi nilai skala lima.
Data hasil evaluasi model pencegahan dan penanganan pertama cedera ankle secara mandiri
berbasis adobeflash oleh ahli media dapat dilihat di Tabel 2.
Tabel 2. Data Hasil Penilaian Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara
Mandiri Berbasis Adobeflash oleh Ahli Media
No Aspek yang dinilai Skor Kategori
1 Aspek Tampilan 87 Baik
2 Aspek Pemrograman 20 Baik
Data hasil evaluasi produk oleh ahli media yang ada pada tabel memperlihatkan bahwa Model
Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal, hasil
pengembangan ini dari aspek tampilan mendapatkan skor 87 dan aspek pemrograman 20. Skor
tersebut kemudian dikonversikan menjadi nilai berdasarkan tabel skala penilaian. Dengan demikian
dapat dinyatakan bahwa menurut ahli media, Model Pencegahan dan Penanganan Pertama Cedera
Ankle Secara Mandiri pada Pemain Futsal yang telah dikembangkan dari aspek tampilan mendapatkan
nilai 87 dengan kategori ”Baik” dan aspek pemrograman mendapat nilai 20 dengan kategori “Baik”.
Uji kelayakan produk diberikan kepada 10 pemain futsal yang dipilih secara acak. Uji coba
dilaksanakan di arena futsal. Proses pelaksanaan uji kelayakan produk ini adalah dengan memberikan
produk yang berupa model pencegahan dan penanganan pertama cedera ankle secara mandiri yang
dijalankan di laptop/komputer dan selanjutnya mahasiswa diberi waktu untuk mengoperasikan dan
melakukan gerakan yang ada video. Kemudian untuk mengetahui kualitas produk yang
dikembangkan, peneliti mengobservasi dan mewawancarai serta memberikan lembar penilaian kepada
pemain futsal. Selama proses observasi dan wawancara serta pengisian lembar penilaian, pemain
masih dapat melihat kembali model pencegahan dan penanganan pertama cedera ankle secara mandiri
yang ada pada pemain futsal.
Respon terhadap model pencegahan dan penanganan pertama cedera ankle secara mandiri
berbasis adobe flash pada pemain futsal memiliki 2 aspek yaitu aspek tampilan dan aspek isi/materi.
Data respon pemain tersebut dapat dilihat pada Tabel 3.
Tabel 3. Hasil Respon Pemain Futsal terhadap Model Pencegahan dan Penanganan Pertama Cedera
Ankle Secara Mandiri Berbasis Adobeflash pada Uji Kelayakan Produk
No. Aspek yang dinilai Skor Kategori
1. Aspek Tampilan 87 Baik
2. Aspek Pemrograman 20 Baik
Respon pemain futsal terhadap model pencegahan dan penanganan pertama cedera ankle secara
mandiri berbasis adobe flash ditunjukkan pada 2 aspek, yaitu aspek tampilan dan aspek isi/materi.
Data pada tabel memperlihatkan bahwa respon pemain futsal terhadap model pencegahan dan
penanganan pertama cedera ankle secara mandiri berbasis adobeflash hasil pengembangan ini dari
aspek tampilan mendapatkan skor 40,4 dan aspek isi mendapatkan skor 17,2 skor tersebut kemudian
dikonversikan menjadi nilai berdasarkan tabel skala penilaian. Dengan demikian dapat dinyatakan
bahwa berdasarkan respon pemain futsal, produk yang telah dikembangkan dari aspek tampilan
mendapat nilai B dengan kategori Baik dan aspek isi mendapatkan nilai A dengan kategori Sangat
Baik.
Pada uji kelayakan produk, pemain futsal memberikan saran terhadap model pencegahan dan
penanganan pertama cedera ankle berbasis adobeflash yaitu lebih mudahkan penggunaan video untuk
kalangan yang kurang memahami cedera, penjelasan dibuat lebih mudah, warna tombol kurang
kontras. Hasil observasi dan wawancara uji kelayakan produk disajikan pada Tabel 4. Sedangkan
masukan dan saran ahli materi ditampilkan dalam Tabel 5.
Revisi produk dilakukan sebanyak dua kali, yaitu: (1) revisi I dilakukan pada tahap validasi dan
(2) revisi II dilakukan setelah uji kelayakan produk. Revisi-revisi ini didasarkan pada data saran dan
masukan dari para pakar ahli materi dan ahli media. Adapun hasil revisi tersebut adalah sebagai
berikut. Revisi produk dilakukan setelah mendapatkan saran dan komentar dari ahli materi. Saran
perbaikan ini didapatkan setelah dilakukannya validasi produk kepada ahli materi. Hasil validasi oleh
ahli materi mendapatkan saran perbaikan dan kritikan yang menjadi pedoman dalam melakukan revisi
produk. setelah divalidasi oleh ahli materi terdapat kekurangan pada model pencegahan dan
penanganan pertama cedera ankle secara mandiri pada pemain futsal yaitu Materi dibuat lebih mudah
dimengerti karena untuk masyakarat (bukan hanya atlet), gambar atau video gunakan yang original,
tambahkan materi HARM.
Tabel 4. Hasil Observasi dan Wawancara Uji Kelayakan Produk
Aspek Masukan
Aspek Dari hasil observasi dan wawancara pemain futsal tidak ada yang kesulitan untuk
Kemudahan mempraktekkan gerakan yang ada pada video.
Aspek Durasi Dari hasil wawancara pemain futsal mengatakan, dengan durasi video 7 menit 23 detik tidak
terlalu lama dan dari hasil observasi dengan pemain futsal melakukan gerakan yang ada pada
video memerlukan durasi waktu minimal.... rata- rata... dan maksimal
Aspek Dari hasil observasi dan wawancara pemain futsal tidak ada rasa nyeri, cedera atau rasa tidak
keamanan nyaman setelah melakukan gerakan
Aspek Dari hasil observasi dan wawancara didapatkan bahwa semua pemain futsal merasa senang
Kesenangan dengan adanya produk yang dibuat karena lebih interaktif.
Aspek Dari hasil observasi dan wawancara bahwa huruf sudah jelas dan menarik namun bahasa
Keterbacaan terlalu panjang.
Aspek Dari hasil observasi dan wawancara pemain futsal mengatakan bahwa produk yang dibuat
Kemenarikan sangat menarik.
Tabel 5. Komentar dan Saran Umum dari Ahli Materi
No. Masukan dan Saran
1. Materi dibuat lebih “Pop” karena untuk masyarakat (tidak hanya atlet)
2. Gambar gunakan yang original
3. Tambahkan materi HARM
Revisi produk dilakukan setelah mendapatkan saran dan komentar dari ahli media. Saran
perbaikan ini didapatkan setelah dilakukannya validasi produk kepada ahli media. Hasil validasi oleh
ahli materi mendapatkan saran perbaikan dan kritikan yang menjadi pedoman dalam melakukan revisi
produk. setelah divalidasi oleh ahli media terdapat beberapa saran pada model pencegahan dan
penanganan pertama cedera ankle secara mandiri pada pemain futsal yaitu pada title page perlu
ditambahkan info prodi, pada tombol exit perlu diberi tombol konfirmasi, profil sebaiknya lebih
lengkap, label untuk next dan back direvisi, video perlu diberi tombol-tombol navigasi, dan narasi
diperjelas, pada video play background music mati. Hasil masukan dan saran dari ahli media
ditampilkan dalam Tabel 6.
Tabel 6. Komentar dan Saran Umum dari Ahli Media
No. Masukan dan Saran
1. Pada title page perlu ditambah info Prodi
2. Pada tombol exit perlu diberi konfirmasi
3. Prodil sebaiknya lebih lengkap (foto, email)
4. Label untuk next dan back direvisi
5. Video perlu diberi tombol-tombol navigasi dan penjelasan
6. Pada saat video play (background music mati)
Panduan pencegahan dan perawatan cedera lutut dan cedera pergelangan kaki yang berisi materi
pencegahan dan perawatan cedera lutut dan pergelangan kaki sebagai panduan yang digunakan untuk
masyarakat telah selesai dikembangkan pada tahap evaluasi dan uji coba yang dilalui yaitu validasi
ahli materi, ahli media, uji kelayakan produk, dan uji efektivitas produk. Pembahasan kajian produk
akhir pengembangan model pencegahan dan penanganan pertama cedera ankle secara mandiri pada
pemain futsal ini merupakan hasil konfirmasi antar kajian teori dengan hasil penelitian yang diperoleh.
Penilaian terhadap produk yang telah selesai dikembangkan yang berupa “Model Pencegahan
dan Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal” menunjukan hasil yang
positif. Beberapa tampilan produk yang sudah mengalami revisi dari ahli materi, ahli media dan tahap
uji coba. Kajian produk akhir berdasarkan hasil penilaian ahli dan respon masyarakat dipaparkan
sebagai berikut: (a) Ahli Materi: Hasil penilaian akhir oleh ahli materi, “Model Pencegahan dan
Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal” hasil pengembangan dari dua
aspek penilaian yang berupa kualitas materi panduan dan aspek isi masuk dalam kategori sangat baik.
Hasil penilaian tersebut mengindisikan bahwa model pencegahan dan penanganan pertama cedera
ankle secara mandiri pada pemain futsal ini memiliki kelayakan materi panduan dan aspek isi yang
sangat baik. (b) Ahli Media: Hasil penilaian oleh ahli media dari dua aspek yang berupa aspek
tampilan dan aspek pemrograman dalam kategori sangat baik. Hasil ini mengindisikan bahwa “Model
Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal” memiliki
aspek tampilan dan aspek pemrograman yang sangat baik. (c) Respon Pemain Futsal: Hasil uji coba
kelompok kecil dengan 3 aspek penilaian yang berupa aspek tampilan dalam kategori sangat baik,
aspek isi/materi dalam kategori baik dan dari aspek panduan masuk dalam kategori sangat baik
kemudian pada uji coba kelompok besar pada aspek tampilan mendapat kategori sangat baik, aspek
isi/materi baik dan aspek panduan dapat kategori baik. Hasil ini mengindikasikan bahwa model
pencegahan dan penanganan pertama cedera ankle secara mandiri pada pemain futsal ini memiliki
tampilan, materi dan aspek panduan yang baik. dengan demikian, berdasarkan kajian akhir tersebut
dapat dikatakan bahwa “Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri
pada Pemain Futsal” hasil pengembangan ini merupakan produk yang telah layak digunakan untuk
mahasiswa sebagai panduan informasi mengenai pencegahan dan perawatan cedera lutut dan
pergelangan kaki.
Hasil penilaian akhir oleh ahli materi, “Model Pencegahan dan Penanganan Pertama Cedera
Ankle Secara Mandiri pada Pemain Futsal” hasil pengembangan dari dua aspek penilaian yang berupa
kualitas materi panduan dan aspek isi masuk dalam kategori sangat baik. Hasil penilaian tersebut
mengindisikan bahwa model pencegahan dan penanganan pertama cedera ankle secara mandiri pada
pemain futsal ini memiliki kelayakan materi panduan dan aspek isi yang sangat baik.
Hasil penilaian oleh ahli media dari dua aspek yang berupa aspek tampilan dan aspek
pemrograman dalam kategori sangat baik. Hasil ini mengindisikan bahwa “Model Pencegahan dan
Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal” memiliki aspek tampilan dan
aspek pemrograman yang sangat baik.
Hasil uji coba kelompok kecil dengan 3 aspek penilaian yang berupa aspek tampilan dalam
kategori sangat baik, aspek isi/materi dalam kategori baik dan dari aspek panduan masuk dalam
kategori sangat baik kemudian pada uji coba kelompok besar pada aspek tampilan mendapat kategori
sangat baik, aspek isi/materi baik dan aspek panduan dapat kategori baik. Hasil ini mengindikasikan
bahwa model pencegahan dan penanganan pertama cedera ankle secara mandiri pada pemain futsal ini
memiliki tampilan, materi dan aspek panduan yang baik. dengan demikian, berdasarkan kajian akhir
tersebut dapat dikatakan bahwa “Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara
Mandiri pada Pemain Futsal” hasil pengembangan ini merupakan produk yang telah layak digunakan
untuk mahasiswa sebagai panduan informasi mengenai pencegahan dan perawatan cedera lutut dan
pergelangan kaki.
Uji efektivitas digunakan untuk mengetahui apakah produk yang dikembangkan efektif atau
tidak. Produk dinilai efektif apabila model yang telah dikembangkan setelah diterapkan dapat
meningkatkan fleksibilitas ankle, togok, dan kekuatan otot tungkai bawah. Uji efektivitas dilakukan
dengan membandingkan dua kelompok, yaitu kelompok eksperimen yang diberikan produk yang
dikembangkan, dan kelompok kontrol tanpa diberikan produk yang dikembangkan. Hasil fleksibilitas
ankle kelompok eksperimen pada Gambar 1.
 Kelompok Eksperimen

50 46,15
45 40,75
40
35
27,8
30 24,25 Pretest
25
20 14,4Posttest
8, 11,5 10,95
15 9
10
5
0
PlantarDorsoInverseEversi

Gambar 1. Diagram Batang Pretest dan Posttest Hasil Uji Fleksibilitas Ankle Kelompok Eksperimen
Hasil fleksibilitas ankle kelompok kontrol pada Gambar 2.

Gambar 2. Diagram Batang Pretest dan Posttest Hasil Uji Fleksibilitas Ankle Kelompok Kontrol
Deskriptif statistik fleksibilitas togok, kelompok eksperimen dan kelompok kontrol disajikan
pada Tabel 7.
Tabel 7. Hasil Uji Fleksibilitas Togok Kelompok Eskperimen dan Kelompok Kontrol
Kelompok Eksperimen Kelompok Kontrol
Statistik Pre Post Pre Post
N 10 10 10 10
Mean 30,70 36,7 31 31,7
Sd 4,372 5,25 3,59 4,57
Min 25 29 25 25
Max 39 46 37 40
Apabila ditampilkan dalam bentuk diagram, hasil fleksibilitas togok kelompok eksperimen dan
kelompok kontrol pada gambar 3.
Gambar 3. Diagram Batang Pretest dan Posttest Hasil Uji Fleksibilitas Togok Kelompok Eksperimen
dan Kelompok Kontrol
Deskriptif statistik data hasil kekuatan otot tungkai bawah, kelompok eksperimen dan kontrol
disajikan pada Tabel 8.
Tabel 8. Hasil Uji Kekuatan Otot Tungkai Bawah Kelompok Eskperimen dan Kelompok Kontrol
Kelompok Eksperimen Kelompok Kontrol
Statistik Pre Post Pre Post
N 10 10 10 10
Mean 195,5 236 216 224
Sd 39,18 35,26 33,06 28,751
Min 140 180 160 180
Max 270 300 260 260
Apabila ditampilkan dalam bentuk diagram, hasil kekuatan otot tungkai bawah kelompok
eksperimen dan kelompok kontrol pada Gambar 4.

Gambar 4. Diagram Batang Pretest dan Posttest Hasil Uji Kekuatan Otot Tungkai Bawah Kelompok
Eksperimen dan Kelompok Kontrol
Uji efektivitas menggunakan analisis uji-t dengan bantuan SPSS versi 20. Apabila hasil analisis
menunjukkan perbedaan yang signifikan maka model yang telah dikembangkan setelah diterapkan
dapat meningkatkan fleksibilitas ankle, togok, dan kekuatan otot tungkai bawah pada pemain futsal.
Kesimpulan penelitian dinyatakan signifikan jika nilai t hitung > t tabel dan nilai sig lebih kecil dari 0,05
(Sig < 0,05).
Perbandingan pretest dan posttest hasil uji fleksibilitas ankle, fleksibilitas togok, dan kekuatan
otot tungkai bawah pada kelompok eksperimen disajikan pada Tabel 9, 10 dan 11.
Tabel 9. Uji t Pretest dan Posttest Fleksibilitas Ankle Kelompok Eksperimen

No. Jenis t ht Sig Selisih %

1. Plantar 6,000 ,000 5,400 13,25%
2. Dorso 6,000 ,000 2,600 29,21%
3. Inverse 8,115 ,000 3,550 14,69%
4. Eversi 9,769 ,000 3,450 31,51%
Tabel 10. Uji t Pretest dan Posttest Fleksibilitas Togok Kelompok Eksperimen

Kelompok t ht Sig Selisih %

Pretest
Posttest 12,136 .000 6,000 19,54%

Tabel 11. Uji t Pretest dan Posttest Kekuatan Otot Tungkai Bawah Kelompok Eksperimen
 Kelompok t ht Sig Selisih %
Pretest
Posttest 11,221 .000 40,50 20,72%

Berdasarkan hasil uji-t, dapat dilihat bahwa nilai signifikansi p < 0,000. Oleh karena nilai
signifikansi < 0,05, maka hasil ini menunjukkan terdapat perbedaan yang signifikan, artinya bahwa
kelompok eksperimen yang diberikan produk pengembangan berupa model pencegahan dan
penanganan berbasis adobe flash mengalami peningkatan yang signifikan.
Berdasarkan hasil uji-t pada, dapat dilihat bahwa nilai signifikansi p > 0,000. Oleh karena nilai
signifikansi > 0,05, maka hasil ini menunjukkan tidak terdapat perbedaan yang signifikan, artinya
bahwa kelompok kontrol yang tanpa diberikan produk pengembangan berupa model pencegahan dan
penanganan berbasis adobe flash tidak mengalami peningkatan yang signifikan.
Berdasarkan hasil uji-t pada tabel di atas, dapat dilihat bahwa nilai signifikansi p < 0,000. Oleh
karena nilai signifikansi < 0,05, maka hasil ini menunjukkan terdapat perbedaan yang signifikan,
artinya bahwa ada perbedaan yang signifikan antara kelompok eksperimen dan kelompok kontrol.
Dilihat dari selisih rata-rata antara kelompok eksperimen dan kelompok kontrol menunjukkan bahwa
kelompok eksperimen lebih baik dari pada kelompok kontrol.
Pembahasan
Pengembangan model pencegahan dan penanganan pertama cedera ankle secara mandiri pada
pemain futsal berbasis adobeflash berdasarkan analisis kebutuhan adalah untuk membantu
memudahkan pemain futsal untuk mencegah dan menangani cedera ankle secara mandiri. Hal ini
sesuai dengan hasil obesrvasi dilapangan yang menyebar angket angket yang disebar ke 103 Pemain
Futsal, 58,25% pemain pernah mengalami cedera ankle dalam olahraga futsal. selain itu dari data yang
diperoleh pada tahun 2014 dari Rumah terapi Cedera olahraga, 12,9% orang yang mengunjungi tempat
tersebut mengalami cedera ankle. Hasil dari penelitian yang dilakukan oleh Shariff (2010) yang
berjudul “Incidence and Characteristics of Injuries during the 2010 FELDA/FAM National Futsal
League in Malaysia” sebanyak 39% pemain futsal mengalami cedera ankle. Selain itu dari hasil
penelitian yang dilakukan Nugroho tahun 2016 menunjukan menunjukkan bahwa sebanyak 16 atlet
(53,3%) memiliki pengetahuan kurang tentang cedera ankle, sebanyak 14 atlet (46,7%) memiliki
pengetahuan sedang tentang cedera ankle.
Sementara Walker (2005, p.185) mengutarakan untuk mencapai tingkat kesembuhan 100% kita
diperlukan untuk melakukan terapi latihan (rehabilitasi). Tanpa rehabilitasi keadaan ankle yang cedera
hanya mencapai tingkat 80% itupun jikalau proses penyembuhan dilakukan dengan baik. Jadi,
rehabilitasi yang hanya 20% ini sangat krusial untuk melengkapi proses penyembuhan. Kaminski
(2013) menyatakan manajemen ankle sprain terbaik adalah memasukkan latihan dan teknik mobilisasi
untuk mengembalikan jangkauan gerak sendi (Range of Motion), kekuatan otot dan latihan
keseimbangan untuk mengembalikan fungsi dan mengurangi resiko cedera kembali.
Dari data tersebut kemudian dikembangkan sebuah Model Pencegahan dan Penanganan Pertama
Cedera Ankle Secara Mandiri pada Pemain Futsal. Panduan Model Pencegahan dan Penanganan
Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal memungkinkan pemain futsal untuk
mendapatkan informasi mengenai model pencegahan dan penanganan cedera ankle secara mandiri.
Dalam “Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain
Futsal” ada beberapa menu pokok yaitu: (1) Menu Pencegahan yang berisi tentang Pencegahan
melalui physical conditioning, alat pelindung dan teknik landing. (2) Menu Penanganan yang berisi
tentang penanganan pertama Rest, Ice, Compression, Elevation serta HARM (Heat, Alcohol, Running,
Massage). (3) Menu Petunjuk yang berisi tentang petunjuk penggunaan produk. (4) Menu Profil berisi
tentang Profil Ahli Materi, Ahli Media, Dosen Pembimbing dan Pengembang.
Berdasarkan penilaian para ahli, revisi, uji kelayakan dan uji keefektifan, pengembangan
“Model Pencegahan dan Penanganan Pertama Cedera Ankle Secara Mandiri pada Pemain Futsal”
diperoleh hasil yang ditarik kesimpulan bahwa model pencegahan dan penanganan pertama cedera
ankle secara mandiri pada pemain futsal ini dinilai valid dan efektif dalam mendapatkan informasi
mengenai model pencegahan dan penanganan cedera ankle secara mandiri untuk pemain futsal.
SIMPULAN
 Dari hasil pengembangan yang dilakukan disimpulkan bahwa: (1) Telah dikembangkan “Model
Pencegahan dan Penanganan Cedera Ankle Secara Mandiri pada Pemain Futsal Berbasis Adobeflash” yang
berisi menu pokok yaitu: (a) Menu Pencegahan; (b) Menu Penanganan; (c) Menu Petunjuk; dan
(d) Menu Profil, yang dikemas dalam bentuk CD dan buku panduan. Pengembengan ini melalui lima langkah
utama: (a) analisis kebutuhan; (b) mengembangkan produk awal: membuat storyboard dan prototype; (c)
evaluasi produk: validasi ahli dan revisi, (d) uji kelayakan produk dan revisi, dan uji efektivitas, (e) produk
akhir. (2) Model pencegahan dan penanganan pertama cedera ankle secara mandiri pada pemain futsal berbasis
adobe flash layak digunakan. Berdasarkan data evaluasi oleh ahli materi menunjukkan bahwa aspek kualitas
materi mendapatkan nilai 18 dengan kategori “Sangat Baik” dan aspek isi mendapat nilai 32 dengan kategori “
Sangat Baik”, sedangkan ahli media menunjukkan bahwa aspek kualitas materi mendapatkan nilai 18 dengan
kategori “Sangat Baik”dan aspek isi mendapat nilai 32 dengan kategori “ Sangat Baik”. (3) Pada uji efektivitas
menunjukkan bahwa kelompok eksperimen yang diberikan produk pengembangan berupa model pencegahan
dan penanganan berbasis adobe flash mengalami peningkatan yang signifikan.
DAFTAR PUSTAKA
Borg, W.R. & Gall, M.D. (2007). Educational research. (an introduction), 7th edition. New York & London:
Longman.
Cava. (1995). Pengobatan dan olahraga bunga rampai. Semarang: Dahara Prize.
Kusumawardana, D & Sukadiyanto. (2013). Pengembangan media pembelajaran vcd tenis lapangan bagi siswa
sekolah dasar. Jurnal Keolahragaan Volume 3 – Nomor 1, (79 - 90). Diakses
darijournal.uny.ac.id/index.php/jolahraga/article/view/4973/4615.
Lin, Christine, C.W, Hiller, C.E & Rob A. de Bie. (2010). Evidence-based treatment for ankle injuries.
Journal of Manual and Manipulative Therapy: 18(1): 22-28.
Nugroho, B.S. (2016). Tingkat pengetahuan atlet tentang cedera ankle dan terapi latihan di persatuan sepak bola
Telaga Utama. Skripsi. (Tidak diterbitkan). Yogyakarta: FIK UNY.
Shariff, M. (2014). Incidence and characteristics of injuries during the 2010 FELDA/FAM nasional futsal
league in malaysia. PlosOne. Vol 9.
Wibowo, H. (1994/1995). Pencegahan dan penatalaksanaan cedera olahraga. Jakarta: Buku Kedokteran.
 JURNAL INTERNATIONAL
PRACTICE
A Series of Case Reports Regarding the Use of Massage Therapy to Improve Sleep Quality in
Individuals with
Post-Traumatic Stress Disorder (PTSD)
Bryn Sumpton, BScN,1 Amanda Baskwill, PhD, MSc, BEd, RMT2
1
Sutherland-Chan Clinic Inc., Toronto, Ontario, 2Faculty of Health Sciences and Wellness, Humber College, Toronto, Ontario
Background: Post-traumatic stress dis-
order (PTSD) is a common mental health
diagnosis in Canada with prevalence
estimated at about 2.4% in the general
population. Previous studies have sug-
gested massage therapy may be able to reduce
the symptoms of PTSD. One of the
symptoms commonly experienced is
difficulty falling or staying asleep. No
previously published massage therapy
research has specifically assessed sleep
symptoms of PTSD.
INTRODUCTION
Objectives: The research question was,
“For individuals who have PTSD as a result
of experiencing traumatic events, does MT
have an effect on sleep quality?”
Methods: A prospective series of case
reports describing 10-week MT treatment
plans provided by Registered Massage
Therapists at Sutherland-Chan Clinic’s
Belleville location. Three individuals with
PTSD were recruited using promotional
posters in the community. Treatment
focused on improving sleep quality and
followed a pragmatic treatment protocol using
light to moderate pressure. Out- comes were
measured using a sleep diary, Pittsburgh Sleep
Quality Index, and the Leeds Sleep Evaluation
Questionnaire.
Results: Data collected at baseline and
throughout the series showed incon-
sistent improvement and worsening of
symptoms amongst participants. Treat-
ment was well tolerated and attended. No
harmful incidents were noted.
Conclusion: For these participants, MT did
not predictably impact sleep quality. It is
possible, as the underlying cause of poor sleep
quality was unlikely resolved, the participants
did not have a significant change in their sleep
quality. This differs
from findings of previous studies in which
MT improved sleep for patients with poor
sleep quality due to exposure to traumatic
events. There is need for further under-
standing of how MT affects sleep.
KEYWORDS: massage therapy; post-
traumatic stress disorder; PTSD; sleep; sleep
quality; symptom management; case study
Post-traumatic stress disorder (PTSD) is a
common mental health diagnosis in Can- ada,
with prevalence estimated at about 2.4% in the
general population.(1) PTSD is defined as when
an individual recurrently re-experiences a
traumatic event lead- ing to persistent
symptoms of increased arousal that cause
clinically significant distress or impairment
for a month or lon- ger.(2) One commonly
experienced symp- tom is difficulty falling or
staying asleep.(3) Patients diagnosed with
PTSD often have comorbid conditions, such as
sleep apnea or pre-existing sleep conditions,
that fur- ther contribute to their poor sleep
quality. While the exact economic cost of
PTSD in Canada is unknown, U.S.-based
studies suggest anxiety disorders, including
PTSD, account for $65 billion in both direct
and indirect costs.(4) Further, more than half
those costs are believed to be associated with
ineffectual or repeated use of health care
services.(5)
PTSD is associated with exposure to a
traumatic event, including those related to
violence, danger, or injury experienced by
military personnel or first respond- ers.(2,6) In
the last 15 years, the Canadian Military has
deployed troops in a number of war zones.
Since the commencement
3
 of combat operations in Afghanistan in 2002,
the rate of post-traumatic stress disorder
(PTSD) in the Canadian Forces Mental
Health Survey has doubled from 2.8% in 2002
to 5.3% in 2013.(7) Additionally, there has been
an increasing awareness of the high prevalence
of PTSD among first responders. (8) In Canada,
the rates of PTSD for first responders has been
estimated at 12%–23%.(8)
Treatment for PTSD often includes psy-
chotherapy, medications, or both.(9) These are
designed to manage symptoms and re- duce, or
stop, recurrent re-experiencing of the traumatic
event. Medications for PTSD regulate the
function of the hypothalamic- pituitary-adrenal
axis, controlling the re- lease of cortisol;
alternatively, medications are selective
serotonin reuptake inhibitors, increasing the
availability of serotonin.
Patients with PTSD commonly also seek
complementary and alternative medicine
(CAM) treatment options. Recently, 95% of
US veterans with PTSD reported incor-
porating at least one form of CAM in their
treatment programs.(10) In a recent survey of
US veterans returning from deployment in Iraq
and Afghanistan, over 40% reported using
CAM in the last 12 months, with mas- sage
therapy as the most common CAM treatment
modality at 21%.(11)
Studies suggest massage therapy (MT) may
be able to reduce some symptoms of PTSD
such as irritability, anxiety, depres- sion, and
tension.(12,13) Massage therapy for sleep
symptoms related to PTSD have not been
studied in this population. (14) While the
mechanism for these effects is not clear, MT
has been linked to changes in neurotransmitter
levels, such as cortisol, serotonin, and
dopamine, which control psychological
arousal.(15) Additionally, MT improves sleep in
certain patient subpopu- lations.(16-18) Therefore,
it is possible that MT may be an effective
treatment for sleep- related symptoms of
PTSD. The research question was, “For
individuals who have PTSD as a result of
experiencing traumatic events, does MT have
an effect on sleep quality?”
METHODS
To investigate the research question, a
prospective case series was undertaken.
Participants received 10-weeks of mas- sage
therapy treatment, and measures were used
to assess sleep quality. Research
ethics approval was granted by Humber
College’s Research Ethics Board. Consent for
the study was obtained prior to the first
treatment and ongoing consent for treat- ment
was given throughout.
Patient Information
Over a three-month period, new pa- tients
presenting with a diagnosis of PTSD were
screened for eligibility. The inclusion criteria
required that participants were a member of
the Canadian military, a Ca- nadian military
veteran, a first responder, or retired first
responder; were currently experiencing
decreased sleep quality; were receiving
treatment from a primary health care provider
for PTSD; and were willing to complete a 10-
week MT treatment plan. Ex- clusion criteria
included having conditions contraindicated for
MT treatment, a diag- nosis of PTSD within
the last six months, or an inability to provide
consent.
One woman and two men were enrolled.
Their ages ranged from 38 to 59 (mean of 50)
years. One participant was a first responder and
two were veterans of the Canadian military.
They had been diagnosed with PTSD, and the
time since diagnosis ranged from four to 19
years (mean of 10). All three had symptoms of
disturbed sleep including difficulty falling
asleep, frequent waking, nightmares or
disturbing dreams, and also had difficulty
returning to sleep after wak- ing. Additionally,
all there were receiving concurrent treatment for
PTSD from other health care providers and
where taking medications for the symptoms of
PTSD.
Participant 1, female, 59 years old, had a
previous hand injury with chronic pain, a
history of colitis, and presented with back and
neck pain. Participant 2, male, 53 years old,
had previous abdominal surgery due to cancer,
high blood pressure, and pre- sented with back
and leg pain. He had been diagnosed with
sleep apnea and used a continuous positive
airway pressure (CPAP) machine while
sleeping. Participant 3, male, 38 years old,
had previous abdominal surgery for an
umbilical hernia, had nerve damage and
compartment syndrome in both legs, patella
femoral disorder in both knees, a history of
migraines and concus- sion, and presented with
back and arm pain.
Practitioner DESCRIPTIONS
Three therapists provided treatment at the
Belleville, Ontario, clinic. All were
4
 female, had completed a 2-year MT pro-
gram in Ontario within the last six years, and
were RMTs in good standing with the
College of Massage Therapists of On- tario
(CMTO). The therapists had between one
and five years of clinical experience. None
had previous experiences treat- ing patients
with PTSD. Clinical support for treatment
was provided by the clinic owner; an RMT
with 18 years of clinical ex- perience and
previous experience work- ing with patients
with PTSD. All therapists were provided a
study orientation sheet which included
information on PTSD and its symptoms, an
outline of the study’s methods, aims, and
measurement tools, as well as information on
additional treat- ment resources in the
community.
An information session was provided by
one author and an RMT experienced in the
treatment of the sleep symptoms of PTSD
prior to commencement of treatment. No
PTSD-specific training was provided beyond
the resources indicated and the information
session. Each participant was treated by the
same therapist for all treat- ments except for
Participant 2, who was treated by two
therapists.
Therapeutic Intervention
Sixty-minute MT sessions were provided
once a week for 10-weeks. A pragmatic MT
treatment protocol was followed, within the
scope of practice for Ontario,(19) which
allowed therapists to choose from a selec-
tion of massage therapy techniques that best
suited the participant and individual
presentation. Therapists were instructed to
focus on improving sleep, include the whole
body, use light to moderate pres- sure, and to
not use muscle stripping, trig- ger point
release, fascial release, or other deep
pressure techniques. (20) Treatment occurred in
a professional multidisciplinary clinic in
Belleville, Ontario.
ASSESSMENT MEASURES
Participants completed the Pittsburgh Sleep
Quality Indicator (PSQI), the Leeds Sleep
Evaluation Questionnaire (LSEQ), and kept a
daily sleep diary. The PSQI is a 10-item,
self-report questionnaire designed to
capture sleep quality and disturbances over
the previous month.
(21)
The PSQI was completed by patients
prior to their first and last treatment. Per-
mission was granted by Anne Germain,
PhD, Associate Professor of Psychiatry and
Psychology at the University of Pittsburgh,
School of Medicine.
The LSEQ is a self-report questionnaire
consisting of ten 100 mm visual analog scales.
(22)
Each line represents a stage of sleep (i.e.,
getting to sleep, trouble upon waking, etc.). The
patient marks a line they feel best represents
their experience.(23) The LESQ was completed
each week prior to treatment. The daily sleep
diary noted the time participants fell asleep, the
time they woke, and the number of times they
awoke. It was completed after the first
treatment until the final treatment, record- ing
each day’s sleep cycle.
Data AnalySIS
The PSQI was analyzed using the instruc-
tions provided (available from http://www.
psychiatry.pitt.edu/node/8240). The result- ing
score was categorized as ‘good sleep quality’ or
‘poor sleep quality’. The LESQ was evaluated by
measuring the length from the starting end to
the line made by the participant. This was
measured by both research assistants and
averaged to produce 10 scores for each week. A
global score was calculated by adding all 10
scores together. The percent change was calcu-
lated for each category and global score us- ing
(Week 10 - Week 1)/Week 1. The average
number of hours slept and times awake were
calculated from sleep diary data.
RESULTS
All three participants completed the
treatment period. There were no harmful
incidents reported by participants. Treat- ment
was well tolerated, and all partici- pants
adhered to the treatment with the exception of
one missed appointment provided the
following day. The results of the measures are
described by participant below and presented
in Table 1.
Participant 1
The PSQI indicated the participant be- gan
and ended with poor sleep quality (pre = 17;
post = 15). The results of the LSEQ are
presented by cluster and then global score. For
Participant 1, there was a 52.6% worsening in
the Getting to Sleep (GTS) cluster. Quality of
Sleep (QOS) improved by 79.3%. The clusters
of Awake Following
5
Tab le 1. Results of Leeds Sleep Evaluation Question- naire (LSEQ)
Score – Score –
Participant
Week 1 Week 10
Cluster 1 – Getting to Sleep
1 173 82
2 82 147
3 171.5 254
Cluster 2 – Quality of Sleep
1 29 52
2 41 86
3 14 169
Cluster 3 – Awake following Sleep
1 27 50
2 40 114
3 136 127
Cluster 4 – Behaviour following Wakening
1 42 76
2 114 123
3 66 22
Global Scale
1 271 260
2 277 470
3 388 772
Sleep (AFS) and Behaviour Following Wak- ening
(BFW) both improved by 85.1% and 80.1%,
respectively. The global score for the LESQ
worsened by 4.1%. Despite this wors- ening,
Participant 1 continued to receive treatment
following the study. The results of the sleep diary
indicate Participant 1 at- tempted to sleep an
average of 6.6 hours a night. Participant 1 awoke,
on average, three times a night. In addition,
Participant 1 noted that, in an effort to accurately
com- plete the sleep diary, she would repeatedly
check her clock to note the time.
Participant 2
For Participant 2, the PSQI showed poor
sleep quality at the beginning and end of the
study (pre = 13; post = 15). The LSEQ showed
a 79.3% improvement for the GTS cluster, a
109.8% improvement for the QOS cluster, a
185.0% improvement for the AFS cluster, and
a 7.9% increase in the BFW cluster.
Participant 2 reported having dif- ficulty
falling asleep after waking due to
6
memories of combat or nightmares, al-
though he noted this improved following a
visit with a psychiatrist. The global score
Percent for the LSEQ improved by 69.7%. The sleep
Change diary showed Participant 2 attempted to
sleep, on average, 7.5 hours a night and
-52.6% woke three times. However, he reported that
79.3% sometimes the amount of time he was
48.1% awake was sometimes more than the time he
was asleep. Participant 2 reported he noticed
his mood had improved.
79.3%
109.8% Participant 3
1107.1%
The PSQI indicated the participant be- gan and
ended with poor sleep quality (pre = 9; post = 8).
85.2% For Participant 3, there was a 48.1%
185.0% improvement in Getting to Sleep. Quality of
Sleep improved by 1107.1%. The participant
-6.6% noted a worsening in Awake Following Sleep
(AFS) by 6.6%. Improvement noted in
80.9% Behaviour Follow- ing Wakening of 236.4%.
The global score improved by 99.2%. The results
7.9%
of the sleep diary indicate Participant 3
236.4% attempted to sleep an average of 7.2 hours and
awoke 2 times a night. Participant 3 started us-
-4.1% ing baclofen and amitriptyline in Weeks 5 and
6, respectively, and discontinued their use in
69.7%
Week 7 (baclofen) and Week 9 (amitriptyline).
99.2%
DISCUSSION
This case series provides preliminary
evidence that massage therapy is a well-
tolerated treatment for individuals with PTSD.
There was concern participants may be
challenged to attend regularly sched- uled
treatment, as this population some- times has
issues with absenteeism. (24,25) However, each
participant attended all ap- pointments and no
safety incidents were reported. This suggests
massage therapy was well tolerated by
participants and may have a role in the
treatment of PTSD- related sleep symptoms.
This case series also illuminated the need
to reconsider the choice of outcome measures.
All participants mentioned to their RMT they
felt they were sleeping better, which
corresponds to the results of the QOS cluster
of the LSEQ. While some improvement was
seen within the LSEQ for each participant, the
area and amount of improvement varied. If the
sleep diary data were reviewed alone,
participants would seem to have, on
average, an
 adequate number of hours of sleep with few
awakenings. However, all participants began,
and ended, with poor sleep qual- ity. The
results captured in the outcome measures did
not match patients’ commu- nicated
experience. Furthermore, Partici- pant 2
reported that he noticed his mood had
improved, which was an outcome not
measured. Participant 1 continue to receive
treatment following the study despite
experiencing a worsening of LSEQ global
score, suggesting she found some benefit that
was not captured.
USEfULNESS Of the Sleep Diary
Using the sleep diary, the number of hours
slept is calculated by the difference between
when the participant awoke and when they went
to bed.(26) However, what is actually used is the
time the participant ‘got up’ the next morning
and the time they went to bed. For example, if
the participant went to bed at 9:00 p.m. but could
not fall asleep until 11:00 p.m., this is not noted,
which may be why the results suggest par-
ticipants got an adequate number of hours of
sleep per night.
Further, the number of awakenings relies
on the participant recording the number of
awakenings they remember or tracking their
awakenings while they try to get back to sleep.
Participant 1 noted she found herself watching
the clock at times so she could accurately
complete the sleep diary. Participant 2 reported
his sleep diary did not accurately record his
sleep quality, as the amount of time he was
awake was sometimes more than the time he
was asleep.
In future, wearable technology to evalu-
ate sleep, in addition to patient self-report
measures, should be explored. A study con-
ducted on university students concluded that
Fitbit© (Fitbit Inc., San Francisco, CA) was a
“valid, reliable, and alternative device to use
for sleep evaluation”.(27) As technol- ogy
continues to improve and become more
accessible, wearable devices should be
considered as a way to non-invasively monitor
sleep.(28)
MASSAGE Therapy and Sleep Quality
Poor sleep quality persisted for partici-
pants, as measured by the PSQI. Review of the
ongoing notes and participant health
histories led to the hypothesis that MT had
little impact as it did not remove the cause.
7
Participant 2 reported having difficulty
falling asleep after waking due to memo- ries
of combat or nightmares. He reported
improved sleep following a visit with a psy-
chiatrist, which may have better addressed the
cause of his sleep disturbance.
Medication may have also impacted the
results. Participant 3 started using baclofen and
amitriptyline in Weeks 5 and 6, re- spectively.
In Week 7, the patient stopped taking baclofen
and, in Week 9, stopped taking amitriptyline.
Both amitriptyline and baclofen have
potential side effects of troubled sleep,
nightmares, and depres- sion or anxiety.(29,30)
The use or disuse of these over a short period
may have had an impact on sleep quality.
ImplicATIONS for Practice, Education and RESEARCH
In clinical practice, the results illustrate a
need to consider sleep evaluation. A sleep
diary may not be useful for either patient or
practitioner. Exploring technology to more
accurately discuss patterns of sleep quality
may be useful. The LSEQ would be
worthwhile for practitioners provided they
focus on any changes seen and reported by the
patient, rather than the actual number, to gauge
patients’ progress.
In entry-to-practice education pro-
grams, students should be exposed to sleep
and its role in health. Further, stu- dents should
monitor sleep and use the results of common
sleep assessment tools. Both entry-to-practice
and continuing education should explore
mental health conditions, such as PTSD, so
students and RMTs understand their role
within the larger health care team. Programs,
such as Mental Health First Aid,(31) should be
of- fered to both students and RMTs, so they
thoughtfully support patients with mental
health issues.
Researchers should consider how to
measure the most appropriate dosage of MT
needed to achieve outcomes related to sleep.
The appropriate dosage of MT for sleep
outcomes is unknown, and the dos- age used in
this study may not be realistic in practice.
Changes in chronicity, such as a shorter period
between diagnosis and in- tervention, could be
explored as it relates to dosage and outcome.
Further, future stud- ies should explore other
tools to measure sleep quality. The PSQI has
an extension for PTSD that might improve how
participants’ experiences are recorded,(32) and
wearable
 technology may improve the assessment of Funding and support from Humber Col- lege,
sleep.
Sutherland-Chan Clinics, and the Registered
Massage Therapists’ Association of Ontario
STRENGTHS and LIMITATIONS
made this study possible.
This study adds to the growing body of
research for MT. The ecological validity is
high due to the use of case study design. The CONFLICT OF INTEREST NOTIFICATION
participants, while not representative of the
entire population of individuals with PTSD, The authors declare there are no conflicts of
illustrate patients’ complex health interest.
presentations. The MT intervention was
pragmatic, and practitioners pro- vided
techniques based on the patient’s
presentation, with few limitations. The lack COPYRIGHT
of experience treating individuals with
PTSD of the practitioners may be a Published under the CreativeCommons
limitation, although the training that was Attribution-NonCommercial-NoDerivs 3.0
provided attempted to reduce this. Caution License.
should be taken when broadly applying these
results.
REFERENCES
CONCLUSION
The participants did not experience a
demonstrable change in sleep quality fol-
lowing MT treatment. Practitioners should
consider how they are measuring sleep quality
and consider using tools, such as the Leeds
Sleep Evaluation Questionnaire, as a way to
discuss their patients’ experi- ences. As there
are multiple factors that impact sleep quality,
RMTs should ensure their patients are
receiving treatment as part of a larger health
care team and con- nect with the other
practitioners treating the individual.
The benefit of case study design and,
subsequently, case series design, is that it is the
closest to the actual setting in which MT is
practiced. However, this also limits the
generalizability. Future research should explore
dosage of MT treatment, the use of wearable
technology in the measurement of sleep, both
in practice and in research settings, and
multidimensional tools to measure sleep
quality.
ACKNOWLEDGMENTS
We would like to thank the registered
massage therapists who participated by
providing treatment, and Trish Dryden
for her mentorship regarding massage
therapy care for individuals with PTSD. We
would also like to thank our research as-
sistants Sarah Wadhwa and Natalie Rinaldi.
8
a. AVmeringen M, Mancini C, Patterson B, et al.
n1 Post-traumatic stress disorder in Canada. CNS Neurosci Ther.
2008;14(3):171–181.
2. American Psychiatric Association. Diagnostic
and Statistical Manual of Mental Disorders, 5th
ed. Washington, DC: APA; 2013.
3. Koffel E, Khawaja IS, Germain A. Sleep
disturbances in posttraumatic stress disorder:
updated review and implications for treatment.
Psychiatric Ann. 2016;46(3):173–176.
4. DuPont RL, DuPont CM, Rice DR. The economic
costs of anxiety disorders. In: Stein DJ,
Hollander E, Rothbaum BO, editors. Textbook
for Anxiety Disorders, 2nd edition. Washington,
DC: American Psychiatric Assoc. Pub.; 2002. p.
475–483.
5. Greenberg PE, Sisitsky T, Kessler RC, et al. The
eco- nomic burden of anxiety disorders in the
1990s. J Clin Psychiatry. 1999;60(7):427–435.
6. Young A. Reasons and causes for post-traumatic
stress disorder. Transcultural Psychiatric Res
Rev. 1995;32(3):287–298.
7. Pearson C, Zamorski M, Janz T. Mental health of
the Canadian Armed Forces. Ottawa, ON:
Statistics Canada; 2014.
8. Wilson JP. PTSD and complex PTSD: Symptoms,
syndromes, and diagnoses. In: Wilson JP, Keane
TM, editors. Assessing Psychological Trauma
and PTSD, 2nd ed. New York NY: Guilford Prss;
2004. p. 7-44.
. 9 National Institute of Mental Health. Post-trau- matic stress
disorder. Bethesda, MD: NIMH; 2016. Available from:
https://www.nimh.nih.gov/health/ topics/post-traumatic-
stress-disorder-ptsd/in- dex.shtml
b10b. yLiDJ, Pilver CE, Desai R. Complemen -
tary and alternative medicine in VA specialized PTSD
treatment programs. Psychiatric Services.
2012;63(11):1134–1136.
11. Park CL, Finkelstein-Fox L, Barnes DM, et al.
24. Hoge CW, Terhakopian A, Castro CA, et al. As-
CAM use in recently-returned OEF/OIF/OND US
sociation of posttraumatic stress disorder with
veter- ans: demographic and psychosocial
somatic symptoms, health care visits, and
predictors. Complement Ther Med. 2016;28:50–
absen- teeism among Iraq war veterans. Am J
56.
Psychiatry. 2007;164(1):150–153.
12. Collinge W, Kahn J, Soltysik R. Promoting
25. Belleville G, Marchand A, St-Hilaire MH, et al.
reinte- gration of National Guard veterans and
PTSD and depression following armed robbery:
their part- ners using a self-directed program of
pat- terns of appearance and impact on
integrative therapies: a pilot study. Military Med.
absenteeism and use of health care services. J
2012;177(12): 1477–1485.
Trauma Stress. 2012;25(4):465–458.
13. Field T, Seligman S, Scafidi F, et al. Alleviating
26. Carney CE, Buysse DJ, Ancoli-Israel S, et al.
post- traumatic stress in children following
The consensus sleep diary: standardizing
Hurricane Andrew. J Appl Dev Psychol.
prospective sleep self-monitoring. Sleep.
1996;17(1):37–50.
2012;35(2):287–302.
14. Mckenna Longacre MM, Silver-Highfield E, Lama
27. Lee PH, Suen LK. The convergent validity of Ac-
P, et al. Complementary and alternative medi-
tiwatch 2 and ActiGraph Link accelerometers in
cine in the treatment of refugees and survivors
measuring total sleeping period, wake after
of torture: a review and proposal for action.
sleep onset, and sleep efficiency in free-living
Torture. 2012;22(1):38–57.
condition. Sleep Breath. 2017;21(1):209–215.
15. Field T, Hernandez-Reif M, Diego M, et al. Corti-
28. Shih PC, Han K, Poole ES, et al. Use and
sol decreases and serotonin and dopamine in-
adoption challenges of aearable activity
crease following massage therapy. Int J
trackers. iConfer- ence 2015 Proceedings.
Neurosci. 2005;115(10):1397–1413.
Urbana-Champaign, IL: IDEALS University of
16. Kashani F, Kashani P. The effect of massage
Illinois; 2015.
therapy on quality of sleep in breast cancer
29. Rexall. Elavil. What side effects are possible
patients. Iran J Nurs Midwifery Res.
with this medication? Toronto, ON: Rexall;
2014;19(2):113–118.
2017. Avail- able from:
17. Hill R, Baskwill A. Positive effects of massage
http://www.rexall.ca/articles/view/591/
therapy on a patient with narcolepsy. Int J Ther Elavil#adverseeffects_title
Massage Bodywork. 2013;6(2):24–28.
30. Rexall. Apo-Baclofen. What side effects are pos-
18. Oliveira DS, Hachul H, Goto V, et al. Effect of
sible with this medication? Toronto, ON: Rexall;
therapeutic massage on insomnia and
2017. Available from:
climacteric symptoms in postmenopausal
http://www.rexall.ca/articles/ view/856/Apo-
women. Climac- teric. 2012;15(1):21–29.
Baclofen#adverseeffects_title
19. Government of Ontario. Massage Therapy Act,
31. Mental Health Commission of Canada. Mental
1991. Ottawa, ON: Queen’s Press; 1991.
health first aid. Ottawa, ON: The Commission;
20. Andrade CK. Outcome-Based Massage: Putting
2017. Available from: http://www.mentalhealth-
Evidence Into Practice, 3rd ed. Philadelphia, PA: firstaid.ca/en
Lippincott Williams & Wilkins; 2014.
32. Germain A, Hall M, Krakow B, et al. A brief sleep
21. Buysse DJ, Reynolds CF, Monk TH, et al. The
scale for posttraumatic stress disorder:
Pittsburgh Sleep Quality Index (PSQI): A new
Pittsburgh Sleep Quality Index Addendum for
in- strument for psychiatric practice and
PTSD. J Anxiety Disord. 2005;19(2):233–244.
research. Psychiatry Res. 1989;28(2):193–213.
22. Parrott, AC. The Leeds Sleep Evaluation Ques-
tionnaire [online document]. 1980. Available
from: https://www.theseus.fi/bitstream/han-
dle/10024/36268/leeds-sleep-evaluation-question-
naire.pdf?sequence=4&isAllowed=y Corresponding author: Bryn Sumpton,
23. Parrott AC, Hindmarch I. Factor analysis of a BScN, Sutherland-Chan Clinic Inc.—Head
sleep evaluation questionnaire. Psychological Office, 738 Spadina Ave., Suite 200, Toronto,
Med. 1978;8(2):325–329. ON, M5S 2J8
E-mail: bryn@sc-clinic.com
9
International Journal of Massage Therapy and Bodywork

RESEARCH
The Influence of Practice Standards on Massage
Therapists’ Work Experience: A
Phenomenological Pilot Study
Luann D. Fortune, LMT, MA; Elena Gillespie, MA
School of Human Organization and Development, Fielding Graduate University, Santa Barbara, CA, USA

This original research is framed in phenom- psychodynamic perspective on work dynamics and
enological methodology, based on interviews identity.
con- ducted and interpreted using qualitative
research methods. The findings suggest that,
because of both direct and indirect factors (such The Changing Environment of
as the nebu- lous nature of the work, general Massage Therapy
isolation in work conditions, and physical
concerns), massage thera- pists perform their Massage is an ancient tradition that, until recently,
work with multiple sources of ambiguity that was more aligned with folk medicine and tradition
are potentially anxiety-causing. Li- censing
offers potential relief for this anxiety, but also
generates a new set of frustrations and work
concerns. The new concerns include the
potential that practice will change to adapt to
non-relevant standards and the difficulty of
defining a body of work that frequently defies a
“one size fits all” cat- egorization. This pilot
study suggests several areas for further
exploration and also demonstrates the
generativity of phenomenological methodology
for research related to massage therapy.

KEYWORDS: Bodyworker, professions,

licens- ing, jurisdiction, anxiety, hermeneutic,
qualitative, health care

INTRODUCTION

Symptoms of professionalization are

emerging in the field of massage therapy (1,2).
The present article documents original
findings, situated in the context of the social
psychology literature, about the impact of the
movement toward professionalization on the
work experience of massage therapists. Using
quali- tative methodology and
phenomenological research methods, our study
examined the lived experience of three
massage therapists for emerging typifications
related to the influence of licensing(3). The
discussion invokes constructs from socio-
historical views on professionalization and a
than with science(4,5). Today, massage has
gained increased acceptance in North
America as an inter- vention to promote
wellness and rehabilitation (6). In 2007,
consumers spent an estimated $11.9
billion on visits to alternative care
providers including massage therapists(7).
Most professional massage is procured
through self-payment(8), although its
practice is in- creasingly being seen as
an adjunct medical service.
Simultaneously, massage therapists are
coming to be viewed as service
professionals with corresponding
expectations and responsibilities(5).
Sociology has a long history of
examining the process whereby
occupations are restructured into
professions. According to the literature,
fiscal growth of a service can reshape its
delivery channels, result- ing in a
synergistic relationship between its
growth and a reorientation of its
workers(9). In response to the changing
environment, massage therapy
assuming structures, functions, and
governance traits consistent with
professional evolution(1,5). According to
socio- logic theory, professionalization is
characterized by increased standards,
formation of member-governed
associations(10), licensure, and formalized
codes of ethics(11). General traits that qualify
“occupa- tions” to rise to the status of
“professions” involve complexities of
definable knowledge, organization, education,
and standardized codes of ethics (11,12). In
addition, professions increasingly promote
science as a source of occupational legitimacy
and cultural principles(13). Consistent with
professionalization, massage therapy is
moving toward increasingly formalized
standards and requirements(14), evidence- based
practice(15,16), and regionally occurring disputes
over jurisdiction(17).
Increased licensing is one manifestation of the
professionalization dynamic apparent in
massage therapy. In 1980, nine states
regulated massage(18). At the time of writing,
42 states and the District of Columbia
regulate the practice(18,19). Increased regulation
accompanies tighter standards and other
measures of professional conduct, and also
less tan- gible features such as elevated social
is status for the practitioner. The effects of
licensing have not been fully explored,
especially at the level of individual
practitioners and their massage craft. Although
the therapeutic effects of massage are
currently being

5
InternatIonal Journal of therapeutIc Massage and Bodywork—VoluMe 3, nuMBer 3, septeMBer 2010
measured, little research has considered the
qualita- tive impact of the professionalization
movement.
Walkley suggests that the
professionalization and medicalization of
massage will reframe the experi- ence of the
therapist(5). How practitioners view and
experience their work is likely to evolve as
related institutions and organizations exercise
greater control over what was previously the
artisan’s realm. Beyond influencing the
logistics and techniques of service delivery,
this control will likely affect how therapists
conceptualize their work and “what they feel
in their hands”(5). Hence, the move to
professionalization car- ries inherent and
possibly unforeseen implications for the
practitioner and ultimately for the consumer.
EG, is a Reiki practitioner who has conducted
empirical research in alternative and complementary
therapies; she is also a phenomenological research
investigator. EG assisted in framing the written
study to CON- SORT and the accepted standards of
the Uniform Re- quirements for Manuscripts
Submitted to Biomedical Journals. In future
investigations involving multiple analysts, steps
should be taken to identify and resolve variances
between the analysts. In this pilot study, perceptual
variances were not a factor because of the division of
tasks.

PARTICIPANTS AND METHODS

This pilot study used a phenomenological(3)

and hermeneutic research design(20). In qualitative
research, hermeneutics is the theory and practice
of interpreting the meaning of text as it is
embedded in its culture, times, and social
milieu(21). Phenomenology strives to capture
lived experience through research strategies that
look for the essence of the object or
interaction(22). The researcher’s primary role is to
collect and inte- grate data from multiple sources
into an analytical format that reveals the inter-
subjective meaning for the participants(22).
Phenomenological research is most appropriate
in circumstances new to empirical inquiry or
when prevailing conditions are changing(21).
In keeping with phenomenological theory,
research results are not necessarily
representative of or able to be generalized to
the entire population of massage therapists.
Our pilot study is intended to inform subse-
quent phenomenological studies and
quantitative and survey research.
Phenomenological significance is ex- pressed
in relevance through typifications (as distinct
from the reliability factors of quantitative
results). Typifications are correlations in
experience identi- fied across all participants
in a particular study; they generally require
verification through further study of the
phenomenon. Typifications are also shaped by
the researcher’s knowledge and awareness,
which are considered to be an integral part of
the analysis(3). In the present study, the primary
researcher is also a practicing massage
therapist.
The primary researcher, LDF, conducted the
study
and the analysis. The secondary investigator,
 Participant Recruitment practice in a large ur- ban metropolitan area.
Two were men (49 and 50 years of age), and
Participants were recruited by e-mail one was a woman (40 years of age). One
message and telephone in a large US man began practicing in 1986; the other, in
urban area in which massage therapists 1992. The woman began practice in 1999.
are required to be licensed. To meet the The woman carried licenses from multiple
selection criteria, practitioners had to be bordering jurisdictions and also had
practicing massage therapy currently or advanced training creden- tials. One man
had to have practiced within the was licensed, but had no advanced training
preceding 6 months. Practitioners that credentials or certifications. The other man
did not possess a license qualified to be did not qualify for licensure and was
Participant 1. Practitioners that lacked practicing without a license.
advanced credentials or specialty
licenses were offered the position of Par-
ticipant 2. Practitioners that had
advanced credentials in addition to a
license were offered the position of
Participant 3. These licensure criteria
were intended to allow for an
exploration of variances related to the
relatively new authority of licensure.

Yes
Practitioners were excluded if they
had not been actively practicing during
the preceding 6 months, did not meet the
study criteria (Figure 1), or could not
commit time within the necessary
schedule. Each participant in the study is
identified by an alias of their choosing.
The Institutional Review Board at No Lic Sp
Lic en ec
Fielding Graduate University approved se ial
ens
this research project, and all participants e? ? ty
gave written informed consent for the Li
study. Participants received no monetary Pt.
#1
Pt.
#2
Pt
ce
.
compen- sation for their participation in M, M, ns
#3
49 50 F,
the study. y.o. y.o e?
49

The participants enrolled in the study o.

y.

were 3 massage therapists in active fIgure 1. Participant (Pt) selection flowchart. M = male;
y.o. = years old; F = female.

6
InternatIonal Journal of therapeutIc Massage and Bodywork—VoluMe 3, nuMBer 3, septeMBer 2010

g
ticin
Prac ge
s a
mas y for No-
p d
thera ast 6 exclu
l ed
the
n ths?
mo
 Interviews through recognized strategies es- tablished for
qualitative research design(24): member- checking
Consistent with phenomenological (taking the final report of specific themes back to the
research methods(22), data were collected participants to obtain their thoughts about the
during interviews. Each participant was accuracy of the representations of their comments)
interviewed twice. The first interview was and use of an external auditor (a published expert in
structured into two parts: the first col- lected the area of applied psychodynamic theory (25)). This
the background and work experience of the strategy provided further external consistency by tri-
therapists; the second explored their thoughts angulating the themes emerging from the data
about how licensing had affected their against applied and theoretical constructs(23).
practice. The initial interview was conducted
in person, took 60 – 90 min- utes, and was
audiotaped and transcribed. Hardcopy and e-
mail messages were used to collect corrections
and revisions from the participants, and
changes were made as instructed. A
subsequent conversation asked the participants
to comment on the initial interview and to
offer any interpretive thoughts. These second
interviews were conducted by telephone or
exchange of e-mail messages, and each one
took 10 – 20 min- utes (Figure 1).

Analysis

Interview text was analyzed and categorized

using phenomenological methodology (20). In
listening to and reading the text several times,
LDF highlighted phrases that seemed essential
or revealing about the phenomenon and then
created a visual board to dis- play words or
phrases that captured the essence of the text.
These words and phrases were moved around
the board and grouped by similar
characteristics. Identified patterns were
categorized into emerging themes
(typifications). LDF then copied representa-
tive quotes from each interview into another
docu- ment and grouped those quotes by
typification. At each step, LDF used color-
coding to identify the source by level of
credentialing (a technique to track whether the
variation in credentials was associated with
different emerging typifications—Figure 2).
The analysis invoked a hermeneutic approach
to interpret the data within the theoretical
constructs related to professionalization and
psychodynamics(21).
In this study (consistent with established
phenom-
enological, hermeneutic research methods),
reliability is achieved through consistency (23).
In qualitative field research, the analyst
represents a variable be- cause of the inherent
subjectivity of the data. As the single
researcher, LDF executed the data collection
and analysis in a completely transparent
framework, contributing to internal
consistency. Validity in the study was achieved
 developmental internalization of authority
Written text
Unlicensed participant
attitudes, anxiety issues continue to trigger
unconscious psy- chological reactions in the
adult(26,27). Hence, iden- tifying particular
anxiety threads provides a better
understanding of the forces interacting with
profes- sionalization on a personal level.
Several anxiety-related themes emerged
Written text
Licensed participant

2 part interview
Informed consent
Participant selection
from the work of the participating massage
therapists. The am- biguity and nebulousness
of massage therapy, while affording creativity
and deep rewards, contribute to a climate of
uncertainty. Because the experience is
structured to be intensely private, the value or
ef- fectiveness of the therapist’s work goes
Written text
Specialty Licenses

unmonitored and unevaluated. Except for the

feedback of the very people they are touching,
the therapists have few touchstones available
to gauge task-related excel- lence. In addition,
all participants described a word- lessness
about the work: not only are sessions usually
quiet, they lack a coherent language to
describe what happens. To further contribute to
anxiety potential, the work is often performed
in isolation, with the secluded, lone settings
Identify
Identify Themes
Identify Themes
Themes

fIgure 2. Study flow chart.

es by
Group them
color and
RESULTS therapist
Triangulate
resulting in isolation for the
for relatedtherapist. Tensions
themes
According to psychodynamic theory, over unclear boundaries, and past and
anxiety is a predictable byproduct of continuing associations with prostitution add
tensions in the workplace. Entrenched in real
early childhood experiences and the

7
InternatIonal Journal of therapeutIc Massage and Bodywork—VoluMe 3, nuMBer 3, septeMBer 2010
 and perceived threats. Participants who had I’m
satisfied minimum credentials found licensing feeling, I just want to pay attention here.
to be a source of comfort and support. — Billy Bass; July 26, 2009; line 611

I think we don’t talk enough about our work. We

Task-Related Anxiety Threads work in a vacuum.
— Billy Bass; July 26, 2009; lines 784–786
Nebulous Nature of Massage Therapy Silence does not necessarily translate into isolation.
Several threads of uncertainty emerged from the However, the quietness of the sessions, the depen-
data: dence on nonverbal communication, and the solitude
● Unclear definitions about what
massage consists of
● Vagueness related to the parameters of
excellence
● Lack of language to name the work

The components of massage are highly

variable and often prescribed by a particular
school(5,7). De- spite recent efforts toward
evidence-based practice, most massage
routines, protocols, and techniques are not
reinforced by science, but are grounded in folk
wisdom and intuition(15). Most therapists work
independently(28). Even if monitoring is
occurring, the parameters of excellence for any
particular therapist are highly qualitative,
subjective, and even wordless(5). Those in the
field often talk about “quality of touch,” a
commonly held opinion being that it is an
innate talent that defies cultivation through
training(5). The ambiguous nature of the work
and the setting surfaced in several areas of the
text, including this statement:

I know it’s good, and I know that it makes

sense, and I know it’s got depth, and it’s hard
to put words to it. When I was teaching, that
was one of my big-
gest struggles with students, was articulating
what it was I was feeling.
— Billy Bass; July 26, 2009; lines 708–720

Isolation in the Work and Work Setting

The data reflected that, even in a group
practice, the actual work is isolated and lacks a
well-developed language. All three of the
participants expressed a preference for
performing massage without talking with the
client. For example:

I don’t like to talk; it’s my preference during

the session. I’ll intentionally breath certain
ways, and you know, the recipient’s body just
picks right up on that, I don’t have to say
anything
— Joseph; June 29, 2009; line 298
We’re not going to talk today. I just the stuff
 of the work’s execution combine to
contribute to a sense of isolation. Unlike
other somatic practices or performance-
based vocations such as sports or dance,
the work of a massage therapist lacks a
viewing au- dience. The touch-linked
intimacy and expectations related to
wellness with quasi-medical
responsibilities contribute to underlying
performance insecurities:
Maybe I’m just projecting my old
insecurity ... but I think that a lot of the
reason we work in a vacuum is that
we’re afraid that somebody’s going to
think that we don’t know what we’re
doing.
— Billy Bass; July 26, 2009; lines 788–792
The data also indicated that licensing,
accompanied by other characteristics of
professionalization, can help to alleviate
the anxieties related to the ambiguous
na- ture of the work, as demonstrated in
this statement:
I think that it really lets people know
that we’re for real. And we’ve done
this training, and we have standards.
— P3; July 2, 2009; lines 800–803
Threatening Aspects of Massage Therapy
Massage therapists face real and
perceived threats. The link between
massage and prostitution has been in
existence for centuries(5). For women,
InternatIonal Journal of therapeutIc Massage and Bodywork—VoluMe 3, nuMBer 3, septeMBer 2010
who account for more than 80% of massage
therapists, the real and perceived threat of
insult and possible attack is a predictable
source of anxiety(2,28,29). Male therapists are
also reportedly vulnerable (P3; July 2, 2009;
lines 749–751). Referring to work in spas, our
female par- ticipant described particular
situations in which she felt threatened (P3;
July 2, 2009; lines 696–697):
He had already been asking, hinting ... at not
want- ing the sheet, and working his inner
thigh. I don’t
think he was that happy that I was only
working his outer thigh when he was face up.
And I ended up ending the session early
because I realized that
I was getting so uncomfortable. And so I said
to him, “I’m so sorry. We’re going to have
end early. You’ll be charged less. They
booked this without enough time.”
— P3; July 2, 2009; lines 708–727
Licensing creates a barrier against the
danger from threats of sexual harassment and
confusion with prostitution. In one situation,
our female participant described relying on
licensing-related standards:
What I blurted out was “No, it’s the law. You
have to have a sheet on, you have to be
covered. I will undrape you as I work, parts
that I’m working on.” I just blurted that out,
and I thought it was the law, but I wasn’t for
certain. I mean I figured you had to be
covered by something.
— P3; July 2, 2009; lines 560–567
8
Anxiety Reduction Through
Professionalization
Licensure can serve to reduce anxiety
related to the work of massage therapy by
increasing credibility:
When I first did the licensing, and the
NCTMB ap- plication, going through that
process was just good in terms of realizing
this is a serious job.
— P3; July 2, 2009; lines 804–806
Licensing also provides substantive support,
as demonstrated in these statements:
outside authority can be another source of anxiety,
because the independent massage therapist (p. 30–
31)(5) is forced to conform to regulatory
requirements(30). The underlying profes- sionalization
movement, linking tensions between individuality
and group conformity, is both revered and
resented(5,30):
This has all been put in place for a reason you
know, getting a notary and all this other stuff is such
a pain. But, it gives us credibility.
— P3; July 2, 2009; lines 804–810

When a client ... wants to know about my

credentials, [then I say,] “Let me tell you what
I have.”
— P3; July 2, 2009; lines 784–785

I think it’s really given me support and

guidance, probably many times. Again, I feel
real lucky that when I started, the licensing
had just begun. I think it would have been
harder to get started.
— P3; July 2, 2009; lines 823–828

Professional status also confers social status

and various conditions that make the work
more pleas- ant and more therapeutic (10). Our
female participant described a social situation
in which she relied on her status as a licensed
professional:

I think it helps, I would say, in work and in

social situations I remember one person
saying, “Oh
that’s so great you’re a massage therapist.”
She said, “You must get a lot of dates.” I
think my jaw
dropped, and I was sort of mad, because I
realized that she didn’t get it. She didn’t get
that A) you’re not allowed to date your
clients unless you cut it off for at least six
months ; B) that it would be real
awkward anyway; and C) that I would use the
work to get dates! So, it’s very helpful, I
can say, “Oh
no, I’m licensed.” And I think I said to her,
“No, no, we don’t date clients. That really
helps keep it a very therapeutic session and
makes it beneficial to the client and the
therapist.
— P3; July 2, 2009; lines 533–547

Anxiety Related to Licensing

Licensing establishes an external authority
as a voice in the work and addresses the
workers’ need for stability and status. But this
 According to psychodynamic theory,
workers display reactions associated
with inherent authority issues (27). The
power of licensure as an authority was
referenced by the unlicensed participant:
With all these battles with licensure ...
I just want to use my skill, I can’t even
get a job ... there’s no job security.... I
don’t have disability insurance....
So, that’s where the anxiety comes from.
could
actually lose this.
— Joseph; June 29, 2009; lines 837–849
Applied Quality in Licensing and
Training
As Joseph points out in his interview,
current re- quirements for national
examination and licensing do not
directly contain an applied component.
The basic training requisite to sit for the
exam is intended to cul- tivate applied
skills competence. But of the estimated
1500 massage therapy programs in the
United States, most are now approved by
generic certifying agen- cies with limited
massage therapy–specific pedagogy
requirements(31). As a result,
[there are] a lot of things not being
taught that should be taught.
— Joseph; June 29, 2009; lines 244–245
To increase professional standards of practice
InternatIonal Journal of therapeutIc Massage and Bodywork—VoluMe 3, nuMBer 3, septeMBer 2010
....................................................................I’d
like to see a hands-on [exam]. If you are going
to become a massage therapistyou got to spend
at least 15 or 20 minutes working on designated
people that want to see what the quality of your
touch is.
— Joseph; June 29, 2009; lines 499–505
DISCUSSION
I
Licensure can serve to reduce anxiety in several ways:
● It is attached to standards that
convey work integrity, and it adds
clarity to an inherently obscure work
process.
● It also provides a right to work and
protects occupational jurisdiction.
● It elevates social status and confers
legitimacy, and separates massage
therapy from prostitution and reduces
threat of sexual harassment.
The effects of licensing can be differentiated
into “entry level” and “ongoing oversight.”
This distinc- tion guided how the themes
emerged from the data. Specific inquiry into
the basis of this distinction was beyond the
scope of this pilot study, but could prove to be
a valuable project for the future. Licensing—
and conditions related to professionalization—
also create new anxieties, not only for the
unsanctioned. The spiral toward higher
professional standards demands greater
consistency and uniformity of practice. The
9
work itself could be changed, with the The therapists interviewed consistently conveyed
associated anxiety of who has a voice in that deep passion and reverence for their work. If the col-
change. Being judged by rapidly changing lective body of massage therapy can manage to
knowledge and new constructs makes the incor- porate the depth and wisdom arising from its
therapist susceptible to potential failure in a roots into the vision of its future, the energy driving
system in which the rules are changing— an the move to professionalization could be enhanced
additional source of anxiety. by increased personal investment from the
The data also indicated one emerging gap: community:
effec- tive monitoring of the therapist’s
qualitative skills beyond the number of hours I feel like I’m blessed, ’cause I’ve had a vocation.
trained. Other themes that arose included the It’s not just a job. In fact, I would go so far as calling
complications from being self-employed,
inconsistent training, confused social status,
cultural norms about touch, and workplace
isolation. Some of the individual anxieties
expressed by the study participants speaks to
an underlying inconsistency in definitions,
characteristics, and even expectations about
the nature of the work. As is typical of manual
therapies, virtuosity in tactile experience is
innate and also takes years to develop(5). Rather
than ignore this critical aspect of the essence
of massage, its elusiveness in language calls
for a holistic appreciation. The praxis of
massage could describe a new approach to
credentialing based on a theoretical–
practitioner model. According to Walk- ley, a
new category of manual practitioner, with a
different range of techniques and education,
will emerge in the United States(5).
Still, the empowerment resulting from
profession-
alization projects can influence context.
Although professionalization alone does not
directly mitigate the challenges of anxiety and
the lack of definitions, it could have a long-
term impact on how massage therapy is
delivered(12). Integration into the health care
delivery system is an increasing possibility
“because people look at massage therapists
these days ... as health care practitioners”
(Billy Bass; June 26, 2009; lines 231–232)(5).
At a time when the entire system is subject to
reordering, the evolution of massage therapy
can work synergistically to affect the delivery
of wellness services, as evidenced by the
literature.
Finally, the lack of clarity concerning what
con- stitutes massage therapy points to an
integrity issue. Although various components
of the craft currently defy categorization, the
practice balances on the cusp of change.
Better definition of the synergistic properties
of massage today is a logical first step in
designing and promoting a vision of what
massage therapy should become. This area is
clearly calling out for further investigation,
including variations based on regional
practices and training factors.
 it a spiritual calling. But it’s taken me
a while to get to the place where I can
say, “Yeah, this is a calling” ’cause I COPYRIGHT
think a lot of things have to come
together ... going beyond ... the Published under the CreativeCommons
mechanical aspect of giving a massage Attribution- NonCommercial-NoDerivs 3.0
— Joseph; June 29, 2009; lines 279–286 License.

The study’s results indicate that

licensing is a fac- tor in the work
experience of each of the participants.
The effects of licensing carry over to
multiple aspects of the work experience,
especially for the unlicensed participant.
This pilot study suggests several areas
for further exploration, including
consideration of regional, training, and
demographic factors. The study also
demonstrates the potential generativ-
ity of phenomenological methodology
for massage therapy–related research.
ACKNOWLEDGMENTS
Thanks go to Dr. Larry Hirschhorn, Dr.
Katrina Rog- ers, Dr. Valerie Bentz, Dr.
David Rehorick, and Dori- anne Cotter-
Lockard, and to the study participants.
CONFLICT OF INTEREST NOTIFICATION
The author declares that there are no
conflicts of interest.
REFERENCES
1. Kahn J. Massage Therapy Research Agenda.
Evanston, IL: Massage Therapy Foundation;
2002.
2. American Massage Therapy Association (AMTA).
AMTA Timeline – Full Version: Advancing the
Massage Therapy Profession for 60+ Years.
AMTA website. http://www.amta-
massage.org/About-AMTA/AMTA-History.html.
Published
n.d. Updated n.d. Accessed January 8, 2010.
3. Bentz VM, Rehorick DA. Transformative
phenomenology: a scholarly scaffold for
practitioners. In: Rehorick DA, Bentz VM, eds.
Transformative Phenomenology: Changing Our-
selves, Lifeworlds, and Professional Practice.
Lanham, MD: Lexington Books; 2008: 3–31.
4. Rich GJ, ed. Massage Therapy: The Evidence for
Practice.
Edinburgh, UK: Mosby; 2002.
5. Walkley S. When the body leads the mind:
perspectives on massage therapy in the United
States. In: Oths KS, Hinojosa SZ, eds. Healing
by Hand: Manual Medicine and Bonesetting in
Global Perspective. Walnut Creek, CA: AltaMira
Press: 2004: 23–42.

10
InternatIonal Journal of therapeutIc Massage and Bodywork—VoluMe 3, nuMBer 3, septeMBer 2010
 6. Eisenberg DM, Cohen MH, Hrbek A, Grayzel J,
21. Bentz VM, Shapiro JJ. Mindful Inquiry in Social
Van Rompay M, Cooper R. Credentialing Research.
complementary and alternative medical Thousand Oaks, CA: Sage; 1998.
providers. Ann Intern Med. 2002;137(12):965– 22. Hymel GM. Research Methods for Massage and
973. Holistic Therapies. St. Louis, MO: Elsevier
7. Nahin RL, Barnes PM, Stussman BJ, Bloom B. Mosby; 2006.
Costs of complementary and alternative 23. Neuman WL. Social Research Methods:
medicine (CAM) and frequency of visits to CAM Qualitative and Quan- titative Approaches. New
practitioners: United States, 2007. Natl Health York, NY: Allyn and Bacon; 2003.
Stat Report. 2009;(18):1–14. 24. Creswell JW. Research Design: Qualitative,
8. Field T. Touch. Cambridge, MA: MIT Press; Quantitative, and Mixed Method Approaches.
2001. 2nd ed. Thousand Oaks, CA: Sage Publications;
9. Macdonald KM. The Sociology of Professions. 2003.
London, UK: Sage; 1995. 25. Hirschhorn L, Barnett CK, eds. The
10. Jackson JA. Professions and Professionalization. Psychodynamics of Orga- nizations.
London, UK: Cambridge University Press; 1970. Philadelphia, PA: Temple University Press; 1993.
11. Abbott A. The Systems of Professions: An Essay 26. Hirschhorn L. The Workplace Within: The
on the Divi- sion of Expert Labor. Chicago, IL: Psychodynamics of Organizational Life.
University of Chicago Press; 1988. Cambridge, MA: MIT Press; 1988.
12. Hatch NO, ed. The Professions in American 27. Hirschhorn L, Gilmore TN. The psychodynamics
History. Notre Dame, IN: University of Notre of a cultural change: learnings from a factory.
Dame Press; 1988. In: Hirschhorn L, Barnett CK, eds. The
13. Kimball B. “True Professional Ideal” in America: Psychodynamics of Organizations. Philadelphia,
A History. PA: Temple University Press; 1993: 119–142.
Cambridge, MA: Blackwell; 1992.
28. Associated Bodywork and Massage Professionals
14. Bondurant C. Why massage therapy guidelines?
(ABMP). Massage Profession Metrics:
Massage Today. 2008;8(10):1–3,11.
Practitioner Characteristics and Professional
15. Kahn J. Introduction. In: Rich GJ, ed. Massage
Membership Patterns. ABMP website. http://
Therapy: The Evidence for Practice. Edinburgh:
www.massagetherapy.com/media/metricschara
Mosby; 2002: xi–xvii.
cteristics.php. Published n.d. Updated n.d.
16. Hymel GM. Advancing massage therapy
Accessed January 8, 2010.
research competen- cies: dimensions for
29. Stokes J. The unconscious at work in groups
thought and action. J Bodyw Mov Ther.
and teams: contri- butions from the work of
2003;7(3):194–199.
Wilfred Bion. In: Obholzer A, Roberts V, eds.
17. Greene E. Maryland massage therapy bill passes
The Unconscious at Work. London, UK:
after 10 years.
Routledge; 1994; 19–27.
J Altern Complement Med. 1997;3(1):87–90.
30. Aronson E. The Social Animal. 4th ed. New York,
18. American Massage Therapy Association (AMTA).
NY: WH Freeman and Company; 1972.
Michigan Governor Signs Massage Therapy
31. National Center for Complementary and
Licensing Act. AMTA website.
Alternative Medi- cine (NCCAM).
http://www.amtamassage.org/articles/2/PressRelea
Backgrounder—Massage Therapy: An
se/detail/2138. Published January 9, 2009.
Introduction. Training, Licensing, and
Accessed March 2, 2009.
Certification. NC- CAM website.
19. Crownfield PW, Beychok T, Bondurant C. Winds
http://nccam.nih.gov/health/massage/#certs.
of change in North Carolina and Pennsylvania.
Published September 2006. Updated June
Massage Today. 2008;8(12):1 -3.
2009. Accessed January 8, 2010.
20. Van Manen M. Researching Lived Experience:
Human Science for an Action Sensitive Corresponding author: Luann D. Fortune, 5305 Broad
Pedagogy. Albany, NY: State University of New Branch Road NW, Washington, DC 20015 USA.
York Press; 1990. E-mail: lfortune@email.fielding.edu