Integrated Systems Model
Last week I had the opportunity to listen to Diane Lee, PT, CGIMS. FCAMPT give a 3 hour lecture on her and her associate L.J Lee’s (no relation) theories as it relates to the pelvis and her Integrated Systems Model (ISM). This has not been the first time I have heard them speak about this either…at IFOMPT in Quebec they put on a very similar lecture. Now, before I get into a brief summery of what was said, I want to point out that Diane Lee is a true visionary in our profession. She has written 4 books on the pelvis and in all honesty, she is the true founder of the regional interdependence model of care that Gray Cook and Mike Boyle are so popular for creating. In summery, she has put in her time and knows a thing or two about this thing we call manual physical therapy.
Diane started off by explaining the idea that we should not start using interventions until there is sufficient evidence for them is essentially wrong. She stated that if we as PT’s waited until there was sufficient evidence for the things we do we would not be able to do a heck of a lot. While I agree with this, I think there are some loop holes. She demonstrated this point by talking to the room about the Stork or Gillet test and how the research around it is less that stellar for its reliability. Diane said that just because the literature tells us we can’t feel the pelvis move, we still can see how it moves with our hands and must be able to determine imbalances based on this test. This is key for her ISM of care…
“Being able to detect asymmetric motion of the pelvis between sides in this task is a key feature of the Integrated Systems Model (it’s a sign of failed load transfer if asymmetric) and requires that we can reliably feel the difference”
Thoracic rings
The ISM theory also talks quite extensively about how thoracic ring shifts (rib connected to spine, connected to sternum connected to adjacent rib and back to the spine=1 ring) can alter the kinetic chain up and down the body. They would call a ring shift a potential driver of an issue (the root cause). For example, they have attributed knee pain to a 4th thoracic ring shift and by correcting the ring shift by “stacking” the ribs into proper alignment, the joints below can function properly thus eliminating the knee pain.
There is much more to their theory than what I said out here. They have come up with a very cool concept that helps you organize your closet of tools to come to systematic approaches to dealing with problems. For someone like me who reads a lot of research and knows a bit about most things in our field, I can respect why this model would appeal to a lot of physiotherapists. It appealed to me! They really make it seem like their model is the missing link that brings all the “stuff” we know together to treat the patient holistically.
However (and it’s a big one), their model has one huge flaw (in my opinion). It relies on nitty gritty palpatory skills to “feel” where the driver is coming from. Essentially during the talk we got into partners and had to feel for subtle ring shifts, feeling posterior and anterior rib rolls with body rotation (based on THEORETICAL biomechanics). The issue is this…the ISM tells us we have to palpate to find imbalances (which research tells us we suck at AND that there is weak correlation to pain/dysfunction anyways) and that what we are supposed to palpate isn’t actually even proven to happen in the body in the first place. Then from those findings, we are supposed to hang our hat on what the cause (driver) of the patient’s complaint is. I for one just find that VERY hard to do faced with so much evidence to the contrary. It seems almost futile to argue over this model because of how well received its been with physiotherapists across the world. It makes me wonder if anyone really lets the research guide their practice. This model is hard to swallow because it relies on the ability to feel something that I’m not sure many therapists can actually feel. I’m sorry, but that’s just what I’ve determined by keeping up to date with current pain science literature.
At IFOMPT in front of 100’s of very smart physiotherapists and medical doctors they were applauded for their presentation on the ISM. However, many shared my concerns over this model that compartmentalizes bioemechanics into a package and sells it as a new way of looking at the body. I know I’m not the only one with these concerns. The over arching comment from both IFOMPT and the conference last week was that until a better model is proposed, we can’t argue with what is seemingly working for them in their practice. I mean, if it works, who cares? Right….?
Current pain science tells us that misalignments in the body rarely are the cause of chronic pain and may not even be relevant to pain at all (this I’m still not sure about). This is why I’m not sure I can endorse the IMS yet. I will surely learn more about it and keep you all posted on what comes up. I challenge you to read THIS article (it’s long) on why posture and alignment may not matter as much as we once thought. I warn you though..it will make most of you uncomfortable. It did to me the first time I read it.
To see a video of the Lee’s discussing their model you can view it here
Other interesting articles by the Lee’s click here
jessephysio 
Jesse, palpation forms the very essence of manual medicine and being able to pick up differences in connective tissues, articular barriers, trophic changes, etc. My palpation skills have increased dramatically since my first year of practice and finding articular dysfunctions is an important skill. So I agree with Diane in with developing manual palpation skills. I’m sure Dr. Spina would agree.
The better skill, of course, is to determine whether or not the dysfunctional articulation is a compensation for a weak link in the kinetic chain and fix the underlying motor control issue. Without addressing and rehabbing inefficient motor/movement issues, then a solo-manual approach is limited. The flip side is, without the manual, in addressing soft tissue and articular dysfunctions, then motor learning is inhibited. Two sides to the same coin, IMO. I find it intriguing how PT is moving towards a more holistic approach, especially manual PTs. Now we just have to get rid of politics (articular dysfunction/subluxation) and move continue with the rehab renaissance going on 🙂
Thanks for your post Marc and I agree with much of it. I would say that my only concern is how much evidence there is negating our ability to palpate the SI joint since it moves 2-3 degrees. Can we really palpate stiffness at this joint based on the literature? The undeniable answer seem to be no (and that bothers me) because it’s what I was and am still am being taught to feel. Can we really feel the ribs roll anterior or posterior and then be able to classify it as dysfunctional or misaligned? And do this misalignments have any correlation to pain/injury? After reading the literature I really can’t be sure any more …out of school I was more sure of things than I am now 3 years in practice, because now I don’t shy away of reading things that may challenge the very foundation of how I practice. For me stumbling upon saveyourself.ca was a pivotal moment..it’s a tough site to read because well.. i think you know why,
Thanks Marc!
Great article Jesse. You are describing a situation I find myself in often when attending a conference. This is great stuff, brilliant, I want to believe, but …..
Jesse,
I’m sure believed I could palpate a difference, I trained myself as a OMPT and fellowship trained PT that I could. Hell, I still think I can… but do my findings agree with someone who practices with me? Possibly closer than someone who doesn’t, but that’s about it and you already know that in your early career. I also believe someone as experienced as Paris, Diane Lee, Maitland… etc… can or could feed the difference, but you and I both know you DON:T have to.
Thousands of MDT trained therapists out there just use a reliable and simple movement based assessment to categorize a patient. The entire basis of my current approach says forget palpation, just use your eyes and repeated motion. We can always apply manual therapy to areas to get them to move and feel better, but that’s really only so the HEP is performed at the mode it needs to be for the window of improvement to stay open. These paradigms make sense because we all learned this in school and in many cases after school as well. It’s hard to give up things like palpation and special tests… but it’s liberating once you do!
Thanks for reading Erson,
How does someone like Lee, Paris, Maitland etc get so much better then all the rest at palpating for subtle biomechanical articular differences? Do they have more tactile ability then say me or you? Do they or have they acquired some innate ability to feel dysfunction that others just can’t? My point is, if these great therapists can feel these things then why can’t the rest if us? (with any measure of agreement that is). I haven’t given up on my palpation skills entirely. I still grossly feel for end feels, tissue mobility, “quality” etc.. But to say I feel a restriction in the 4th rib posterior roll….I’ll just say i’s not there yet. This is something I would have NEVER admitted even a year ago. But hey, I don’t think most can anyways…I’m just not afraid to say it! I rather treat movement as opposed to specific joint issues anyways (most if the time that is)
Hi Jesse,
Good post. I am taking the ISM course right now and must say its a really good model and Diane and LJ do a great job. I understand the lack of reliability of palpation, but how great is the reliability of our vision? Not saying this isn’t an issue, just don’t know if the alternative is ‘better’.
The model also uses a lot of patient feedback, noting if a correction feels better, so it’s not all palpation. While also putting the patient in charge of their recovery, which is always greats
Glad to hear your thoughts on the ISM!
Hi vsphysio,
Thanks for the response. I’m happy you’re taking the ISM course now. I would love to speak to you about it more if you’re up for it. I understand your views on hands vs eyes assessment…there are flaws to both. However, doing a movement screen like the SFMA is quite telling because t gives us an easy way to see side to side imbalances without much guess work, The art of what we do comes when determining the root cause for an imbalance. Is it a ring shift? I really don’t know…I will say that it’s not something I’m willing to tell to my patient yet… “you’re knee pain is because one of your thoracic rings is shifted”. It just seems foreign and kind of guruish to me to believe I can tell a patient that confidently at this point with virtually no evidence to back me up. Hope that makes sense!
Thanks again
Definitely up for chatting sometime. I have taken the SFMA as well and totally agree, you can narrow things down and then use the ISM as well to verify, etc, especially if the thorax is involved. Shoot me an email sometime and we can chat amanda at vsphysio.ca
Chat soon.
Hi Jesse. Great post and well done for admitting your potential limitations as a therapist. We all have areas in our skill base and seeing gifted practitioners like the Lee’s at work can be threatening. I quite like their work on the thoracic spine and I have no doubt that some practitioners who apply themselves (usually through post graduate courses) can develop sufficient manual skills to make this work clinically. There are usually flaws (from a clinical perspective) in many of the reliability trials on manual therapy but despite this there is some evidence that Maitland type palpatory skills are in fact reliable, particularly when looking at pain provocation.
Landel, R., K. Kulig, et al. (2008). “Intertester reliability and validity of motion assessments during lumbar spine accessory motion testing.” Phys Ther 88(1): 43-49.
Schneider, M., R. Erhard, et al. (2008). “Spinal palpation for lumbar segmental mobility and pain provocation: an interexaminer reliability study.” J Manipulative Physiol Ther 31(6): 465-473.
I guess my main issue with the Lee’s is their “out with the old, in with the new” approach; at least based on what I saw at IFOMPT (see http://bit.ly/SSOzsM). They seem to be advocating a whole new method of assessment based on functional testing, intervening and then reassessing. That’s fine but lets not forget the value of thorough subjective and physical examination using a range of functional and non-functional tests combines with clinical reasoning skills to determine the most effective treatment.