The Integrated Systems Model - Diane Lee and Associates in Physiotherapy

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An Introduction to The Integrated Systems

Model in the Treatment of the Whole
Person

Introduction
In clinical practice, it is common to see complex patients with a
combination of impairments in multiple systems including the
musculoskeletal, urogynecological, respiratory and
sensory/equilibrium. A thorough evaluation often reveals many
movement habits, past injuries, thoughts/beliefs, and emotional
states that have collectively led to changes in strategies for posture,
movement, continence and organ support. Should the location of
pain, or the primary region of impairment, direct the location and
focus of treatment? In other words, does pelvic girdle pain, with or
without incontinence and/or prolapse mean that the pelvis
requires treatment? Can approaches that classify pain states and
behavior always predict treatment outcomes? Butler notes that,

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The word division can be instant trouble because these

mechanisms all occur in a continuum. All pain states probably
involve all mechanisms, however in some, a dominance of one
mechanism may become obvious. Pain mechanisms are not
diseases or specific injuries. They simply represent a process or
biological state. (Butler 2000).
There is little scientific evidence to guide clinicians for these
complex, yet common, patients. Jull (2012) notes that clinical
reasoning remains the recommended approach for determining
best treatment for the individual patient. Given the same painful
impairment, no two individuals will have exactly the same
experience and behavior because how they manifest their pain or
illness is shaped in part by who they are (Jones & Rivett 2004)
what they think and how they feel. There are sensorial, cognitive
and emotional dimensions that are individual to every experience.
The Integrated Systems Model for Disability & Pain (ISM) is an
evidence-based clinical reasoning approach that considers all three
dimensions of the patients experience to facilitate decision-making
and treatment planning.
The Integrated Systems Model for Disability & Pain
The Integrated Systems Model for Disability and Pain (ISM) (Lee
L-J and Lee D 2011) is not a protocol nor a classification but rather
a framework to help clinicians organize knowledge and develop
clinical reasoning to facilitate wise decisions for treatment. The
Clinical Puzzle (figure right) is a graphic that conceptualizes this
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model and is used as a reflection tool for the

development of clinical reasoning and
ultimately clinical expertise. The patients
goals and meaningful complaints are noted
in the center of the Clinical Puzzle and from
their story a meaningful task is identified.
Two to three screening tasks that pertain to their meaningful task
are listed in the outer circle (strategies for function and
performance) of the Clinical Puzzle and key results from strategy
analysis of each task are listed. For example, if the patients
primary complaint is pelvic girdle pain (PGP) aggravated by sitting,
then three meaningful screening tasks that relate to sitting would
be:
standing posture
squat
sitting posture.
Each of these tasks would then be assessed to determine if the
strategy chosen was optimal for both function and performance of
the task. An optimal strategy produces appropriate alignment,
biomechanics and control for the whole body/person. Optimal
strategies allow the body to distribute and share loads effectively
and safely.
A key feature of The Integrated Systems Model approach is Finding
the 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 region

can impact the other. Specific tests are used to determine sites of
non-optimal alignment, biomechanics and control (defined as
failed load transfer).
Subsequently, the timing of failed load transfer (which site fails
first, second, third etc.), as well as the impact of manually
correcting one site on another, is noted. Clinical reasoning of the
various results determines the site of the primary driver, or the
primary region of the body, that if corrected will have a significant
impact on the function of the whole body/person.
In the squat task below, three sites of failed load transfer were
noted; the right sacroiliac joint gave way (i.e. the right innominate
anteriorly rotated relative to the sacrum), the right hip translated
anterior relative to the innominate (failed to remain centered in
the hip joint) and the 4th thoracic ring translated to the
left/rotated to the right. Where should treatment begin, the pelvis,
hip or thorax? In other words, which region of the body is the
primary driver?

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Timing of failed load transfer: The 4th thoracic ring translated to

the left before the right sacroiliac joint gave way (figure above left)
and before the right femoral head translated anteriorly (figure
above right), this suggests that the 4th thoracic ring is the primary
driver for this task.
Impact of corrections: This hypothesis was confirmed when
manually correcting the 4th thoracic ring (correcting its alignment,
biomechanics and control for this task) produced optimal function
of the right SIJ and hip.
Further tests directed to the 4th thoracic ring then determined the
underlying system impairment (e.g. articular, neural, myofascial,
visceral) causing the non-optimal alignment, biomechanics and/or
control for this squat task. Once the impaired system is
determined, specific techniques and training for release,
alignment, control and integration into movement (including
strength and conditioning) can be implemented to improve the
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function of the primary driver (4th thoracic ring in this case) and
thus impact the function of the whole body/person.
This keynote presentation will go deeper into the various aspects of
The Integrated Systems Model for Disability & Pain (Lee & Lee)
through short clinical case reports. The principles for treatment
will also be outlined. For more information The 4th Edition of The
Pelvic Girdle (Lee D 2011) is now translated into Japanese and is a
valuable resource for more information.

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References
Jull G 2012 Management of cervical spine disorders: where to
now? IFOMPT Quebec City, Canada
Butler D S 2000 The sensitive nervous system. NOI Group
Publications, Adelaide, Australia
Jones M A, Rivett D 2004 Introduction to clinical reasoning. In:
Jones M A, Rivett D A (eds) Clinical reasoning for manual
therapists. Elsevier, Edinburgh p 3
Lee D 2011 The Pelvic Girdle, An Integration of Clinical Expertise
and Research, Churchill Livingstone, Elsevier, Edinburgh
Lee 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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