ISM DianeLee

12/07/15 03:00The Integrated Systems Model - Diane Lee and Associates in Physiotherapy

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An Introduction to The Integrated SystemsModel in the Treatment of the WholePerson

Introduction

In clinical practice, it is common to see complex patients with acombination of impairments in multiple systems including themusculoskeletal, urogynecological, respiratory andsensory/equilibrium. A thorough evaluation often reveals manymovement habits, past injuries, thoughts/beliefs, and emotionalstates that have collectively led to changes in strategies for posture,movement, continence and organ support. Should the location ofpain, or the primary region of impairment, direct the location andfocus of treatment? In other words, does pelvic girdle pain, with orwithout incontinence and/or prolapse mean that the pelvisrequires treatment? Can approaches that classify pain states andbehavior always predict treatment outcomes? Butler notes that,



“The word “division” can be instant trouble because thesemechanisms all occur in a continuum. All pain states probablyinvolve all mechanisms, however in some, a dominance of onemechanism may become obvious. Pain mechanisms are notdiseases or specific injuries. They simply represent a process orbiological state.” (Butler 2000).

There is little scientific evidence to guide clinicians for thesecomplex, yet common, patients. Jull (2012) notes that clinicalreasoning remains the recommended approach for determiningbest treatment for the individual patient. Given the same painfulimpairment, no two individuals will have exactly the sameexperience and behavior because how they manifest their pain orillness is shaped in part by who they are (Jones & Rivett 2004)what they think and how they feel. There are sensorial, cognitiveand emotional dimensions that are individual to every experience.The Integrated Systems Model for Disability & Pain (ISM) is anevidence-based clinical reasoning approach that considers all threedimensions of the patient’s experience to facilitate decision-makingand treatment planning.

The Integrated Systems Model for Disability & Pain

The Integrated Systems Model for Disability and Pain (ISM) (LeeL-J and Lee D 2011) is not a protocol nor a classification but rathera framework to help clinicians organize knowledge and developclinical reasoning to facilitate wise decisions for treatment. TheClinical Puzzle (figure right) is a graphic that conceptualizes this

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model and is used as a reflection tool for thedevelopment of clinical reasoning andultimately clinical expertise. The patient’sgoals and meaningful complaints are notedin the center of the Clinical Puzzle and fromtheir story a meaningful task is identified.

Two to three screening tasks that pertain to their meaningful taskare listed in the outer circle (strategies for function andperformance) of the Clinical Puzzle and key results from strategyanalysis of each task are listed. For example, if the patient’sprimary complaint is pelvic girdle pain (PGP) aggravated by sitting,then three meaningful screening tasks that relate to sitting wouldbe:

standing posturesquatsitting posture.

Each of these tasks would then be assessed to determine if thestrategy chosen was optimal for both function and performance ofthe task. An optimal strategy produces appropriate alignment,biomechanics and control for the whole body/person. Optimalstrategies allow the body to distribute and share loads effectivelyand safely.

A key feature of The Integrated Systems Model approach is Findingthe Primary Driver (the best place to focus treatment). In short,this involves understanding the relationships between, and within,

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multiple regions of the body and how impairments in one regioncan impact the other. Specific tests are used to determine sites ofnon-optimal alignment, biomechanics and control (defined asfailed load transfer).

Subsequently, the timing of failed load transfer (which site failsfirst, second, third etc.), as well as the impact of manuallycorrecting one site on another, is noted. Clinical reasoning of thevarious results determines the site of the primary driver, or theprimary region of the body, that if corrected will have a significantimpact on the function of the whole body/person.

In the squat task below, three sites of failed load transfer werenoted; the right sacroiliac joint gave way (i.e. the right innominateanteriorly rotated relative to the sacrum), the right hip translatedanterior relative to the innominate (failed to remain centered inthe hip joint) and the 4th thoracic ring translated to theleft/rotated to the right. Where should treatment begin, the pelvis,hip or thorax? In other words, which region of the body is theprimary driver?

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Timing of failed load transfer: The 4th thoracic ring translated tothe left before the right sacroiliac joint gave way (figure above left)and before the right femoral head translated anteriorly (figureabove right), this suggests that the 4th thoracic ring is the primarydriver for this task.

Impact of corrections: This hypothesis was confirmed whenmanually correcting the 4th thoracic ring (correcting its alignment,biomechanics and control for this task) produced optimal functionof the right SIJ and hip.

Further tests directed to the 4th thoracic ring then determined theunderlying system impairment (e.g. articular, neural, myofascial,visceral) causing the non-optimal alignment, biomechanics and/orcontrol for this squat task. Once the impaired system isdetermined, specific techniques and training for release,alignment, control and integration into movement (includingstrength and conditioning) can be implemented to improve the

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function of the primary driver (4th thoracic ring in this case) andthus impact the function of the whole body/person.

This keynote presentation will go deeper into the various aspects ofThe Integrated Systems Model for Disability & Pain (Lee & Lee)through short clinical case reports. The principles for treatmentwill also be outlined. For more information The 4th Edition of ThePelvic Girdle (Lee D 2011) is now translated into Japanese and is avaluable resource for more information.

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References

Jull G 2012 Management of cervical spine disorders: where tonow? IFOMPT Quebec City, CanadaButler D S 2000 The sensitive nervous system. NOI GroupPublications, Adelaide, AustraliaJones M A, Rivett D 2004 Introduction to clinical reasoning. In:Jones M A, Rivett D A (eds) Clinical reasoning for manualtherapists. Elsevier, Edinburgh p 3Lee D 2011 The Pelvic Girdle, An Integration of Clinical Expertiseand Research, Churchill Livingstone, Elsevier, EdinburghLee L-J, Lee D 2011 Clinical Practice – The Reality for Clinicians.Chapter 7 in: 2011, The Pelvic Girdle, 4th edn. Elsevier, Edinburgh

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