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Treating using the Integrated Systems Model and Thoracic Ring Approach – Part 2

by David Pope

In the previous post we explored the concept of Drivers, or the biomechanical cause of overload in that or another area, using the The Integrated Systems Model (ISM) (LJ Lee & Diane Lee) and the Thoracic Ring Approach (LJ Lee). This post will make a whole lot more sense if you read the previous post first. In this post, part 2, we explore some of the different types of drivers, including primary and secondary drivers.

The example I used in the previous post was that of a single driver, the Pelvis, and this is where it starts to get even more interesting. Are there always single drivers?

Here is an outline of the categories of drivers

• Primary driver

• Primary driver with a secondary driver

• Co-drivers (with or without vectors between them)

Primary Driver

As in the example of a Pelvis Driver above – one driver that makes their meaningful task better, and improves the alignment of every other area. eg we correct their pelvis rotation, and their thoracic rings “stack” up, their cervical spine “stacks” up, their hip is centred, their knee and foot alignment is ideal, and we get a “WOW” moment as the person performs the functional screening task. This is a “Pelvis driver” If you have completed courses in the ISM and Thoracic Ring Approach, and in particular the 15-day Series with LJ Lee, the following categories of drivers may be helpful. If you haven’t completed any courses in the ISM/ Thoracic Ring Approach, please feel free to keep reading, but don’t worry if it isn’t all clear. If you are interested in this, you can learn these skills on LJ’s Sports PelvisSports Thorax and Discover Physio Series courses at

In the following scenarios, for the sake of brevity, and so it does not take you all day to read this post, I have summarised the important aspects, and not included all clinical findings.

Primary driver with a secondary driver

Similar to the above example – correcting the primary driver improves their MT and improves the whole body alignment and task performance. In this case however, there is one area of their body that is improved, but not fully, by correcting the primary driver. Correcting the primary driver, then adding in correction of the secondary driver is the best correction. Correcting either area might improve their meaningful task, but correcting the primary driver and adding the secondary driver gets us our infamous “WOW”. Here are a couple of examples:

  1. Primary driver 3rd and 4th Thoracic rings, secondary driver R foot for a meaningful task of running. Patient presents with pain after running 2kms normally. Correcting their third and fourth thoracic rings improves their step forward, their neck, pelvic and hip alignment, their R foot is improved, but they still have internal rotation of the talus which goes medial in the mortice, and they have external rotation of their navicular and cuboid, and weight bear laterally through their step forward. Ideally we would like their talus staying centred in the mortice, and a nice fanning action through the navicular and cuboid when they bring their weight onto the foot and dorsiflex. Correcting the 3rd and 4th rings, then correcting the R foot gets us a Wow and ideal movement in their step through. So here we are looking at a Primary third and fourth thoracic ring driver, with a secondary R foot.
  2. Primary Pelvis, secondary 7th and 8th thoracic rings. Meaningful task – triangle pose to the left in yoga, in which they normally get L hip pain. In this case, unwinding the R Pelvic IPT and TPR with anterior compression makes the triangle pose much easier, their L hip which was forward in the pose is now centred, and the patient is able to move into triangle pose much easier. Everything gets better except their thoracic rings 7 & 8, but these are improved, just not fully. The patient still ring shifts R at ring 8, and L at ring 7. Correcting rings 7 and 8 has a small improvement in their meaningful task, but not significant, and ring correction does not correct the pelvis. Correcting the pelvis, then the rings aligns everything else, the patient gives a “Wow”, and they achive full ROM in their triangle pose pain free. Thus we have a primary pelvis, and secondary thoracic rings 7/8.
  3. Primary driver L elbow with a secondary R scapula for C6 dermatomal pain in the R arm. Meaningful task: cervical right rotation when driving. Manually opening up/gently gapping the medial aspect of the left elbow eliminates pain with C/sp RR, and improved the range from approx 10 degrees to 70 degrees. This improves the position of the R scap, thoracic rings and C6/7. The opposite scap i.e. R scap is still “dumped” (down rotated and inferior) and adding in protraction/upward rotation of the R scapula gains full C/Sp RR pain free. This also corrects the C6/7 position/rotation, and upper thoracic rings. Initial treatment focuses on the L elbow, then we added in the R scap the following session. Primary driver: L elbow, secondary driver: R scap.

In this case, we can happily treat their primary driver, and spend some (less) time treating their secondary driver, and cue their primary driver with their HEP.

Well, I hope that has clarified drivers in the ISM and Thoracic Ring Approach for you. There are a myriad of different examples I could have used for each one, but I hope these examples give you the general idea for each category. The ISM and Thoracic Ring Approach are amazing clinical systems to use, they really push your clinical reasoning, and give great treatment results. Incorporating primary drivers, secondary drivers and co-drivers will help get you the best results possible. Enjoy, and I hope this helps get you even more homegrown oranges, home cooked chocolate brownies, and smiles as thank-you presents from your patients!

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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