A Holistic Approach… The Beauty of the Integrated Systems Model
INTRODUCTION
The Integrated Systems Model (ISM) was developed in 2011 by Diane Lee (PT, FCAMPT, CGIMS), a physiotherapist who graduated in 1976 and now owns an established clinic based in South Surrey, Canada. The ISM model was created in association with Linda-Joy Lee. Diane has since written two books (“The Thorax: An Integrated Approach” and “The Pelvic Girdle”- now on its 4th edition) and holds a specialist interest in women’s health physiotherapy, with published research utilising the ISM for the treatment of pelvic girdle pain, urinary incontinence and diastasis rectus abdominis (Lee, 2014).
The ISM approach is an evidence based framework which uses clinical reasoning to piece together “the story”, by discovering past injury, beliefs, mentality and movement habits through accurate assessment, in order to understand the driver and other factors that contribute to current biomechanics and state of health. It has been adopted by a handful of clinicians across the globe, whilst certified clinicians must complete a course of training to be officially recongised as “ISM practitioners”. The course consists of four stages: Completion of the ISM series; Completion of a written case report; Skills demonstration via video; And case review which is completed by Diane Lee (Learn with Diane Lee, N.D.).
| Image Reference: Learn with Diane Lee (N.D.) |
WHAT DOES THE RESEARCH SHOW US?
Lee (2014) introduces her model of assessment by quoting Butler (2000): “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.” Butler (2000) postulates that whilst pain or dysfunction may manifest in one area of the body, this may not be the source of pain. This is a good description of ISM, which holds the ethos that the whole body should be assessed using a holistic approach to identify the best course of symptom management.
Lee (2014) moves on to state that no two individuals will have the same experience, and that pain and illness manifests according to their identity as a human being. ISM was developed as a constantly evolving framework to help clinicians develop clinical reasoning to facilitate treatment decisions; this can be achieved using the clinical puzzle, which divides story and goals relating to function and performance amongst articular, myofascial, neural and visceral elements (Lee, 2014). Clinicians will recognise a handful of screening tasks to test and retest function; for example, clinicians may choose to assess a squat, sit to stand and sitting posture for patients with pelvic girdle pain aggravated by sitting (Lee, 2014).
These screening tasks will be used, according to Lee (2014), to find the “primary driver”, which is considered the best point to focus on physiotherapy treatment within the chain. Hides et al. (2019) further articulate this in relation to lower back pain (LBP), which the ISM states can manifest as a result of multiple past high loads or accumulative traumas to different areas of the body, beliefs or cognitions and poor lifestyle habits. Once the meaningful task has been identified- which Hides et al. (2019) state may largely vary for individuals with LBP depending on their aggravating factors- the driver is identified. For the lower back, this may be the hip, foot, pelvis, thorax, neck, or a combination of the prior (Hides et al., 2019). This will allow the clinician to treat the first area that likely has the greatest impact on dysfunction for optimal treatment efficacy.
To conclude, Lee (2013) describes the four treatment principles of ISM- Release, Align, Connect, Move (RACM). Through release of tissue contributing to non-optimal strategies, alignment should improve, which allows the ability to teach a new functional task using motor control principles. Based on the meaningful task, these exercises will re-wire a new neural network which allows better movement strategies to support the body functionally (Lee, 2013).
MY REFLECTIONS IN CLINICAL PRACTICE SO FAR…
The beauty of writing this blog is that I can develop my own understanding of ISM, which is still a relatively new concept to me. Indeed, my practice as an NHS MSK Physiotherapist very much consisted of ‘hands off’ therapy, so altering my perceptions has been challenging in the sense that I have had to rethink my identity as a clinician- but the key is to remain open minded when approaching new techniques of assessment and treatment. My current beliefs are that the human being must be encouraged to autonomously manage their rehabilitation, but that this must be facilitated with manual techniques to allow the change to happen.
Another reflection of mine over the past 6 months is that it has been a huge benefit as a newly qualified Veterinary Physiotherapist to make the transition into ISM. The beauty of ISM is developing the ability as a clinician to be able to “feel” the positioning and symmetry of the body and practice a good eye when assessing biomechanics and movement patterns. It has posed the question- could Veterinary Physiotherapist’s consider the use of ISM as an assessment tool for animals? Recently, I have noticed the pattern in which myofascially release in one area may have resolved another on reassessment– for instance, when given a history by the owner or handler, treatment to the ‘current’ symptoms may not resolve them whilst treatment to a related ‘historical’ symptomatic area may resolve the ‘current’ symptoms.
These are certainly theories I will continue to develop and consider in my future practice and clinical development. My next port of call is to familiarise myself thoroughly with Diane Lee’s novel work (“The Thorax: An Integrated Approach” and “The Pelvic Girdle”); I find it fascinating in particular how Diane separates the body into “functional units”, which clearly marks each component of the functional body without creating complete distinction between each element. I look forward to attending her courses in the future, with the hope that one day I may better incorporate ISM into my clinical practice.
References
Butler, D. (2000) The sensitive nervous system. NOI Group Publications, Adelaide, Australia.
Hides, J., Donelson, R., Lee, D., Prather, H., Sahrmann, S. and Hodges, P. (2019) Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain. Journal of Orthopaedic and Sports Physical Therapy, 49, (6), 437-452.
Learn with Diane Lee (N.D.) Certification. Available at: https://learnwithdianelee.com/ism-certification/ [Accessed 19th March 2024].
Lee, D. (2011) The Pelvic Girdle: 4th Edition. Churchill Livingstone, London, England.
Lee, D. (2013) New perspectives from the Integrated Systems Model for treating women with pelvic girdle pain, urinary incontinence, pelvic organ prolapse and/or diastasis rectus abdominis. ACPWH Conference 2013. Available at: https://thepogp.co.uk/_userfiles/pages/files/lee.pdf [Accessed 19th March 2024].
Lee, D. (2014) An lntroduction to the Integrated Systems Model in the Treatment of the Whole Person.Japanese Physical Therapy Association. Available at: https://www.jstage.jst.go.jp/article/cjpt/2014.41.1/0/2014.41.1_190/_pdf [Accessed 12th March 2024].
Lee, D. (2018) The Thorax: An Integrated Approach. Handspring Publishing, East Lothian, Scotland.
TO SUMMARISE…
ISM (Integrated Systems Model) was developed by associates Diane Lee and LJ Lee as an assessment tool and model in 2011.
ISM is useful to build a “story” of previous injuries, beliefs and movement habits to develop goals and a treatment programme linked to function and motor control.
Once the meaningful task and the primary driver have been identified, RACM can be incorporated (Release, Align, Connect, Move).
This approach could be utilised by musculoskeletal, neurology, women’s/men’s health and orthopaedic physiotherapists. Its application to other disciplines has not yet necessarily been explored.
Could ISM be utilised by Veterinary Physiotherapist’s? This is a good question to pose for an ever evolving framework.