Random Thoughts: Instrument Assisted Soft Tissue Mobilization (IASTM)

I recently encountered a Twitter post featuring a link to a systematic review that concluded “evidence does not support the use of IASTM”.  A thread ensued between snarky people who derided the use of IASTM and defenders who cited favorable clinical outcomes with IASTM.  I don’t personally utilize IASTM. I can’t exactly articulate why though I suspect it has less to do with what randomized controlled trials and systematic reviews say and more to do with the fact that time and resources are finite and I prefer to prioritize other things, some of which may not be “evidenced based” either.  I am not personally offended by IASTM, however, as some of the people on that thread appeared to be. Regardless of what the “evidence” may say, I trust that most providers aren’t using things like IASTM in isolation. Since I’m not privy to other clinicians’ complete treatment plans, I try to not judge them based on one thing they may do even if I don’t find that particular thing very influential.

I certainly have moments where I see something on the internet (not necessarily IASTM) and think to myself, “Wow, this is incredibly stupid.”  I also recognize that a snapshot of some of things I do, or perhaps even the entire portfolio, might yield a similar response from other professionals.  Moreover, while I totally support cooperation among health care providers and appreciate that the distinctions between various professions are often highly arbitrary, sports medicine practitioners, regardless of their speciality, are competing for market share.  If employing more evidenced based treatments yields such superior results, those critical of IASTM based on the results of a systematic review should, to some degree, welcome competition from less enlightened providers.

This is not a conversation about IASTM alone though.  One can substitute any treatment for which there is “poor evidence” for IASTM.  Critics of these modalities intimate that they are a waste of time and should be replaced by more evidenced based treatments.  I am always intrigued when people effectively tell others how to spend their time and money. I am also intrigued when medical providers attempt to dictate how their colleagues should practice.  Telling other professionals what they should and shouldn’t be doing is somewhat self-righteous which isn’t necessarily a bad thing when one considers the degree to which poor treatment has the potential to harm patients and undermine medicine as a field.  Self-righteousness often accompanies confidence and conviction but needs to be balanced by the humility of recognizing that there is no single arbiter of “evidence”.  

To be sure, healthcare is a complicated case because market forces don’t operate as freely as they do in other spaces so we might have reason to care about how other people choose to spend their time and money when they are sick or injured.  Here are some things to consider when assessing a tool like IASTM in the absence of empirical data supporting its effectiveness:

1. Is it safe?  What is the potential for harm and the “tail risk” or worst case scenario?  
2. Assuming a treatment is “safe” but not necessarily effective and people are willing to pay for it, why should anybody care whether said treatment is implemented or not?  This is where healthcare is tricky…
3. What is the justification provided for said treatment/tool assuming that it’s safe?  Many medical treatments that are not per se harmful are justified with explanations that have been largely disproven empirically.  The justification for “soft tissue” treatments like IASTM is often that they “break up scar tissue” or acutely alter tissue properties.  There is strong empirical data demonstrating that things like IASTM, massage, joint “manipulations”, etc do not elicit acute histological adaptations.  Therefore, we’re being deceptive if, when doing IASTM, we tell people that we’re eliminating scar tissue. As an ethical matter, clinicians should generally refrain from speculating about theoretical mechanisms unless they can explain how their treatment works with reasonable certainty.  Medical providers, myself included, usually resort to analogies to avoid being overly technical. Analogies are necessarily oversimplifications and therefore less “truthful”. To the extent possible, these analogies shouldn’t be egregiously at odds with what is “known”. Medicine’s dirty secret is that much of it is trial and error/risk mitigation with other people’s bodies.  Medical providers like to appear confident and decisive but they should not do so at the expense of nocebic or misleading verbiage. Time and resources in medicine are finite, however, so a non-evidenced based treatment that isn’t per se harmful may still unnecessarily perpetuate a patient’s suffering relative to a superior alternative. Short of a top-down, highly governed system of medicine that minimizes provider discretion (something I’m not personally fond of) I’m not sure what the work around is here though.
4. The confounder in health care regarding how consumers spend their money is health insurance.  If somebody wants to pay to get his/her horoscope read by a psychic, that decision has little to no bearing on my financial well being.  If my health insurance plan paid for horoscope readings, however, my premiums would be affected by fellow policyholders’ consumption of horoscopes even if I did not receive a single horoscope.  Assuming the same health insurance policy, underconsumers of healthcare subsidize the cost of overconsumers of healthcare. Underconsumers overpay for healthcare while overconsumers underpay for healthcare when healthcare and health insurance are so intertwined.  The economic argument in favor “evidenced based” treatment under the current system is perhaps one of the strongest because individual patient treatment doesn’t occur in a vacuum. If people were paying totally out of pocket for something like IASTM, its efficacy relative to other treatments wouldn’t matter very much.  When it’s deemed a medical treatment reimbursable by health insurance, however, its utilization becomes everyone’s concern.
5. There are two potential courses of action here, one that relatively empowers health insurance companies and one that relatively empowers patients or consumers of healthcare.  The former would let health insurance companies dictate what treatments are “evidenced based” and medically necessary and only reimburse for said services. It’s obviously not in a health insurance company’s interest to pay for things that don’t “work”.  The downside here is it’s not always clear what works and this option reduces patient choice and provider discretion/decentralized command. The latter or alternative option would provide patients with a “budget” (after some type of vetting process) for their particular ailment/condition and allow them to choose whatever provider, and presumably treatment, they desire.  This system would force medical providers to actually compete on price and efficiency/efficacy of treatment. It would also force patients to be better informed consumers. There would be incentives, perhaps some type of rebate, for patients to spend less money than what their “budget” allows. Additionally, this option would eliminate the distinction between in and out of network providers.  Health insurance companies and patients should want to work with medical providers who do the most with the least (time and money). Something else to consider in this alternative system is whether a “non-medical” service like a gym membership, as an example, would be covered in the budget. Health care providers may not always be the best people to solve medical problems- heresy I know. To be clear, some mechanism should exist to provide adequate/additional care to patients for whom the preallocated budget is insufficient.  Another option, even more radical relative to the status quo, is to reserve health insurance for truly catastrophic, unforeseeable expenses and not comparatively routine procedures like IASTM.  This option would likely foster even more competition on price because patients are “paying out of pocket” for routine services like annual physicals even though much of the care covered by health insurance under the current system isn’t as gratuitous as consumers perceive it to be.

In conclusion, it is fair to question the benefit of something like IASTM in a complex healthcare environment. Randomized controlled trials and systematic reviews should help inform the discussion, not end it. Additionally, rehabilitation providers who wish that IASTM would cease to exist might consider that their treatment(s) of choice could soon disappear too depending on who ultimately presides over the “evidence”.