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Treating using the Integrated Systems Model and Thoracic Ring Approach – Part 1

by David Pope

The Integrated Systems Model (ISM) (LJ Lee & Diane Lee) and the Thoracic Ring Approach (LJ Lee) are the clinical approaches I have been using predominantly over the past four years since completing the Discover the Sports Pelvis course in 2010, Discover the Sports Thorax, and 15 day Discover Physio Series in 2011 with Linda-Joy (LJ) Lee. These clinical approaches give you the option of using your favorite Physio techniques, mobilisation, dry needling, loading programs, load management, movement retraining and exercises, and using new techniques you learn on the courses, and putting it all together in strong clinical reasoning frameworks to know when and how to apply your techniques and exercises.

The key concept of Meaningful Task Analysis as developed by LJ also teaches you how to assess control of the body throughout whatever movement is important to the patient, whether that is running, warrior pose in yoga, snowboarding or performing leg kicks in martial arts. I love using these approaches, enjoy the results I get, and the tough clinical nuts you are able to crack by “finding the driver(s)”. As with all good approaches, the ISM and Thoracic Ring Approach have continued to evolve and develop over the time since I was first was exposed to it in 2010. One of the aspects that has evolved over the past few years and made this system work really well clinically is the approach to drivers. If you have been using these approaches and loving it, that’s fantastic; here are some ideas to further your results with the ISM and Thoracic Ring Approach.

As a bit of background, “Finding the Driver” in the ISM involves finding the part of the body that is creating overload in that or another area. For example, poor control of the pelvis or “Failed Load Transfer” (FLT) might cause poor hip and foot control, and lead to anterior knee pain or patellofemoral issues. So in this case, we would call this “Pelvic driven knee pain” or “Pelvic driven fat pad irritation” or whatever the clinical diagnosis is. We would need a number of clinical findings (at least three) to support our clinical hypothesis of “Pelvic driven knee pain”, which might include (but not limited to):

• Timing of FLT in the persons meaningful task (eg during right one leg stance (OLS) of the gait cycle – in this example of a pelvis driver, the pelvis unlocks prior to the femoral head moving anteriorly and femur internally rotating; and before the navicular and cuboid internally rotate). Early timing of FLT of the pelvis supports a hypothesis of a pelvis driver

• Correction of the area improves performance of the meaningful task and changes symptoms eg during the patients right one leg stance or one leg squat, their right SIJ unlocks, and the pelvis rotates to the left. If in this case we correct their Intra-Pelvic Torsion (IPT), their femoral head then stays centred and neutral, the knee alignment is improved, and they have no pain on a one leg stance. We get a “WOW” from our patient, they stare at us, and say “How does that work?”. We thus have some more findings that support our hypothesis of “Pelvic driven knee pain”

• Correcting the area improves other areas eg as we just mentioned, correcting the IPT L improves their hip, knee and foot alignment

• Correcting other areas is not helpful for the meaningful task or symptoms. You need to try correcting other areas to challenge and strengthen your hypothesis, and assess the effect on the pelvis, hip and knee for example. Eg You correct the navicular and cuboid, which causes the pelvis, hip and knee alignment during OLS to get worse, and the patient has no change in the meaningful task of one leg stance

So following this example through, the King in this scenario is the pelvis, which makes everything including their Meaningful Task (MT) and control of other body parts better, we (meaning you or me in combination with our happy patient doing a home program) can treat their pelvis by releasing any overactive muscles with release work/mobilisation/needling, and temporarily support it with tape or a belt (if necessary) while you teach your patient better motor control strategies around the pelvis. They can look forward to running on the beach without their knee pain, without having irritated the skin around their knee with tape, or had them stare at their vastus medialis like it is a crystal ball.

This is all a recap that will be a familiar story to anyone that learnt these skills while completing a Discover Physio course eg the Sports Thorax and Sports Pelvis with LJ Lee, or the 15 day Discover Physio Series. If you haven’t completed one of these courses, it is quite possible you are scratching your head about this point, and wondering why I haven’t just taped their patella and given them Glute Max and Med exercises. Good question, but it may go someways towards answering why some of your “Patello-femoral pain” patients may not have improved as quickly as some of the other patients you gave the exact same exercises to.

In the next post, I will explore the types of drivers. What success have you had treating the pelvis or thorax for pain or dysfunction beyond these areas? Let us know below…


Links of Interest

Sports Pelvis course with LJ in Brisbane

Sports Thorax course with LJ

Discover Physio Series Part 4 with LJ in Sydney

Other courses with LJ Lee in Australia

Videos on the Thoracic Ring Approach with LJ

Article written by LJ for MPA on Thoracic Ring Control

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