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The Integrated Systems Model For the Complex Patient

ISM A clinical reasoning approach to determine where to begin

treatment for those with multiple impairments and persistent pain

Instructor: Diane Lee

Course Host: OMT Sweden

2019

An Introduction to the Integrated Systems Model for the Complex PatientThe Integrated Systems Model

www.learnwithdianelee.com

The Integrated Systems Model

An Evidence Informed, Clinical Reasoning Framework to Optimize Strategies for

Function & Performance

Individualized Assessment & Treatment of the Whole Person

Diane Lee

Canada

Lecture Outline

Models that consider interdependence of body regions

Then present a synopsis of the current evidence on motor control, posture, movement and the neuroscience of pain that informs the ISM approach

What is ISM and where did it come from

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Lecture Outline

Principles of ISM approach. Is it evidence-based? Discuss the role of clinical reasoning in ISM

• Outline the specific tests and clinical reasoning of the findings that are used to facilitate better predictions of the relationships between impaired regions to determine where to focus treatment . In ISM this is called finding the driver

• Outline the further tests of the driver that help determine the underlying system impairment(s), articular, neural, myofascial and/or visceral, and thus develop individualized treatment programs based on the patient’s meaningful tasks and goals

Demonstrate an ISM assessment

Models that consider interdependence of body regions

Regional Interdependence (RI)Sueki, Cleland, Wainner 2013

2007 - The underlying premise of the original RI model was that seemingly unrelated impairments in remote anatomical regions of the body may contribute to and be associated with a patient’s primary report of symptoms. Primarily a musculoskeletal model

2013 updated definition - The concept that a patient’s primary musculoskeletal symptom(s) may be directly or indirectly related or influenced by impairments from various body regions and systems regardless of proximity to the primary symptom(s)

Regions do not have to be adjacent and response can be widespread

May result in responses that involve multiple systems of the body (musculoskeletal, neurophysiological, somatovisceral, biopychosocial)

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Not a New nor Novel Concept

”Regional Interdependence” evident in older osteopathic literature

(Fryette, Stoddard, Mitchell Moran Pruzzo etc.)

A concept embraced by the Canadian Orthopaedic Division since 1981 (Quadrant courses – Pettman &

Fowler, Back-Knee Syndrome)

Now becoming ‘formalized’ and studied (a good

thing!)

Most studies appear to be retrospective (i.e. study and

report on effect of treatment on distant regional pain and

mobility) i.e. no predictability testing or hypothesis generation

Motor control strategies are specific to both the task and individual

Motor control is influenced by thoughts, beliefs, experiences, pain, threat of pain

Spinal Control: The Rehabilitation of Back Pain – State of the Art and Science Hodges, Cholewicki, van Dieen 2013

Motor Control & Pain

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Pain and Motor Control - Consensus from the Evidence &Clinical Implications

Motor control (muscle activation) is challenging to investigate for several reasons

1. First the specific pattern of muscle changes are generally unique to the individual patient, and within the individual they may be unique to the movement, posture or task that is assessed

2. There will not be one strategy of muscle activation that is universally ideal for control of the spine and pelvis and not one strategy universally adopted by all patients in pain

3. Back pain patients present with a redistribution of activity within and between muscles (rather than inhibition or excitation of muscles in a stereotypical manner)

4. All of the multisegmental muscles of the trunk contribute to movement and control

5. If the goal of rehabilitation (e.g. using motor learning strategies) is to modify the adaptation (remove, modify or enhance) then this needs to be considered on an individual basis with respect to the unique solution adopted by the patient

2013 Hodges, Van Dillen, McGill, Brumagne, Hides, Moseley Ch 21 in: Spinal Control: The Rehabilitation of Back Pain – State of the Art and Science Hodges, Cholewicki, van Dieen

Regional Interdependence ModelPain and Motor Control

No study to date has demonstrated a direct relationship between pathology and pain for any pain related condition (Clauw 2015)

Neither the presence or absence of pain nor the intensity of pain can be accurately predicted by the presence or absence of pathology (Catley, Moseley & Jones 2019)

How do you know WHEN to treat what in any individual with multiple impairments and persistent pain?

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Regional Interdependence ModelPain and Motor Control

Jones & Rivett 2019

Because research-supported management efficacy is still lacking for most clinical problems, skilled reasoning is the clinician’s best tool to minimize the risk of mismanagement and over-servicing

Clinical experience and the evidence suggests that clinical reasoning and individualized assessment and treatment are required for best outcomes


An Evidence Informed, Clinical Reasoning Framework to Optimize Strategies for

Function & Performance Individualized Assessment & Treatment of the

Whole Person

Lee D 2013 – current Lee D, Lee LJ 2007 – 2013

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The Integrated Systems Model A Closet Organizer for Theoretical

and Propositional Knowledge

• Evidence informed

• Emphasizes clinical reasoning

• Individual assessment

• Targeted to patient’s goals (task specific)• Based on function

• Considers neuroscience of pain (nociceptive, neuropathic, nociplastic) as well as

• Psychological and social influences and their potential barriers to recovery

• Individual programs and no recipes/protocols

Assessment - Hearing the Patient’s Story & Meaningful ComplaintWhat is their experience and how does this influence their posture & movement behaviour?

Sensorial dimension • Location & behaviour of primary complaint – is pain nociceptive, neuropathic

or nociplastic?

Cognitive dimension• Beliefs and attitudes about their experience

Emotional dimension• Feelings associated with experience (anger, fear, anxiety, sadness)

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Hearing the the Patient’s Story & Meaningful ComplaintWhat is their experience and how does this influence their posture

& movement behaviour?

Goal - to understand the patient’s experience and which dimension is likely

creating the biggest barrier for change

Then – figure out how to ‘illuminate a path’ for

change

How to motivate change?

Conversations, education, relationship, trust, movement, touch

Change the sensory input (thoughts, feelings, body) to change the motor output

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From the story comes the Meaningful Task

What does the patient want to change/work on?

Meaningful Tasks are those that are:• Painful or aggravating of the meaningful

complaint • Difficult and relate to meaningful

performance goals • Tasks where the patient experiences

‘not feeling right’ • Reported to create respiratory or

urogynecological symptoms• Being avoided yet are desired

Consensus from the EvidenceMotor control of the spine

and changes in pain

It makes biological sense that management should require careful consideration of all aspects of control

• including posture, movement and muscle activation strategies

• identification of the aspects that require correction and then

• implementation of a rehabilitation program to achieve/restore/rectify this control

Hodges, McGill, Hides Chapter 20 page 233

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How does ISM facilitate the identification of the aspects that require correction in individual patients?

Pick screening tasks that relate to the patient’s meaningful task

Walking (one leg standing, step forward, thorax rotation)Sitting (standing, squat, sitting posture)Parsvakonasana (lunge, thorax rotation)Analyse tasks that are requisite for the meaningful task

Identify areas of the body that demonstrate suboptimal alignment, biomechanics and/or control for that task

FIND THE DRIVERS – key component of the ISM approach

DRIVER = Word to represent the body region that when corrected (alignment, biomechanics and/or control) improves

1. the performance of other sites of impairment when the task is repeated AND2. the patient’s experience of the task

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Correct one site and note the impact on another

Often there is more than one body region that regions treatment

Don’t go for perfection, go for improvement

The patient’s body experience often guides the decision

Functional Units Expediting Finding Drivers

To expedite finding drivers and where to focus treatment in an ISM approach, the body can be divided into three functional units:

1. First Unit: 3rd thoracic ring to the hip joints2. Second Unit: 2nd thoracic ring to the

cranium, shoulder girdle, shoulder

3. Third Unit: Lower extremity (knee to foot) and upper extremity (elbow to wrist)

4. The driver is found in each functional unit and then the relationship between the unit drivers is tested until the priority driver is determined – this is the body region where treatment should begin

5. Then what?

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Further assessment of the driver determines the system impairment(s) collectively contributing to the persistent suboptimal motor control strategy for that individual for that task

• Active Mobility• Active Control• Passive Mobility• Passive Control

‘Listening’ during all tests helps to determine the underlying system impairments

Tests done on the driver

Definitions of ’Listening’

Term listening coined by Dr. Rollin Becker (osteopath) and JP Barral introduced the concept into visceral manual therapy. Gail Wetzler further developed the concept into active vs passive listeningActive Listening: feeling what happens to the skeletal system during active movement Passive Listening #1: feeling what happens when you move the skeleton/joints passivelyPassive Listening #2: feeling for the direction, length, strength of vector upon release of correction of the skeleton/joints

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Articular System Impairments

Capsular FibrosisAnkylosisLoss of Ligament & Capsular Integrity(+/- Fixation)Bone/Cartilage loss of Integrity

Clinical:Can’t correct alignment/biomechanicsHard end feelShort local listening on correction and release

Neural System Impairments

Altered Timing, Recruitment

(early, delayed, asymmetrical, absent, excessive)

Over-activity, Under-activity

Loss of Conduction

Sensitization (Central & Peripheral)

Altered Body Schema/ Virtual Body

Altered Neurodynamics – ability of neural and/or dural tissue to permit elongation or movement of the skeleton

Clinical: can correct ABCs, variable length, location and strength of vector on release of correction

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Myofascial System Impairments

Scarring, adhesions

Altered muscle & fascia structural length

Loss of musculotendinous or aponeurotic integrity

Clinical: correction is variable, strong vectors of variable length

Living Fascia (Guimberteau)Chaotic Fibrillar Arrangement – Fluid TubulesMacrovacuoles

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Fascia is the tensional, continuous fibrillar network within the body, extending from the surface of the skin to the nucleus of the cell. This global network is mobile, adaptable, fractal, and irregular

This is far more than simple connective tissue

It constitutes the basic structural architecture of the human body

Visceral System Impairments

Scarring, adhesions of internal fascia/ligaments (loose or regular dense connective tissue)

Altered mobility

Organ disease

Clinical: can correct ABCs, vector of pull is internal on release of correction

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Interpretive reasoning of multiple test findings determines the most likely hypothesis to explain both the symptom and disability experience

What are the Goals of Treatment?

• Address the patient’s meaningful complaints (disability and/or pain) -influenced by person’s goals

• Restore optimal strategies for function and performance that relate to their meaningful tasks

• Change the person’s experience of their body and mind

• Empower responsibility towards self-management and less practitioner dependence

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An Introduction to the Integrated Systems Model for the Complex PatientPrinciples for Treatment and Training


Treatment is Multi-model

and Individual

Release the sub-optimal strategy -Remove barriers

Train a better strategy

Based on the meaningful task

A Clinical Reasoning Framework

Every person’s Bio-Psycho-Social components are unique therefore every treatment program will be uniqueEach session will have components of:• R – release (Bio – Psycho –

Social)• A – align (Align thoughts,

beliefs, posture and movement for load sharing and de-sensitization of nervous system – remove threat)

• C – connect (To build new neural pathways, may need cognitive training)

• M – move (in ways that have meaning to goals and provide positive experiences in the body-mind)

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Principles for treatment How to Organize Your Closet?

Release Cognitive & EmotionalBarriers

Books - Explain Pain, The Brain that Changes Itself, Mindsight

Explain problem – provide a logical hypothesis that explains both their pain experience and their disability

Create a safe environment to explore barriers such as fear, belief systems (“I’ll never get better”), Create a different (better) experience in their body

Meditation, breathing practice (parasympathetic facilitation), ventral vagal stimulation (Porges Polyvagal Theory)

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Neurotoxins & Systemic Considerations

High blood glucose levels (sugar)

Alcohol

Hydrogenated oils (takes 4 months to leave cells)

Aspartame (Nutrasweet) – breaks down to methanol then formaldehyde

Hormone imbalance

Gut health (leaky gut & inflammation)

Release System Barriers

Oscillatory mobilizations, manipulationMuscle energy, PNF, Contract relax, Neuromyofascial release Dry needling, dermoneuromodulationvia K-tape Visceral mobilization

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‘Listening’ during correction and release to determine the underlying system impairment



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Vector analysis and

system impairments

ArticularCorrection of alignment is not possible. Mobilize first and then see if this body region is the driver

NeuralCorrection of alignment is possible and minimal sensory/manual intervention is required to achieve a correction. Feel for the location, direction, length and strength of the vector, then use anatomical knowledge and palpation to confirm

Vector analysis and

system impairments

VisceralCorrection of alignment is possible and minimal sensory/manual intervention is required to achieve a correction. On release of the correction the vector of pull goes into the thorax, abdomen, cranium or pelvis

MyofascialCorrection of alignment is variable depending on the amount stiffness in the fascial tissue. More force is required than neural or visceral system impairments to achieve a correction. Feel for the location, direction, length and strength of the vector, then use anatomical knowledge and palpation to confirm

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Drivers & Motor Control – Connect?• There is a group of individuals with pain, UI, POP, and

DRA who do NOT need specific isolated muscle training of individual muscles (e.g. TrA, pelvic floor, dmf)

• In this group the recruitment strategy improves when the driver is corrected

• Further assessment of the driver including vector analysis during ‘correction and release’ of the driver combined with an understanding of anatomy and biomechanics then determines the muscles that require release and the home exercise practice given

• Release and align, then move• This group typically do well with many movement based

programs that aim to lengthen and align the body (e.g. Yoga, Pilates) and programs that don’t specifically address underlying deep muscle deficits in recruitment and capacity

Drivers & Motor Control – Connect?

• There is a group of individuals with pain, UI, POP, and DRA who DO need specific isolated muscle training of individual muscles

• In this group the recruitment strategy may not change or only become slightly better (still asymmetric, delayed, absent) when the driver is corrected

• In addition to treatment of the primary driver, specific muscle training is indicated for the secondary region

• Release, align and then

• Connect - Use imagery, cues, sensory input to activate/wake up deep muscles responsible for segmental or local control, then movement training using neuroplastic principles for building new bring maps and changing habitual strategies – task specific

• This group does not usually do well with only movement programs that are general and do require specific muscle training BEFORE strength and capacity training

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Motor Learning & Movement Training Stages

3 Phases of Motor Learning

• Cognitive – wake up the muscle to be trained• Associative – build capacity for the new integrated strategy –

i.e. add load and movement• Automatic – integrate into meaningful tasks

Principles for Multi-modal Individualized Treatment

Stage 1 Posture and

motor learning training

Posture/alignment training with ability to produce contraction of deep segmental muscles responsible for control without over-activation of superficial muscles (static alignment control)

Motor Learning & Movement

Training Stages


Training Stages

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Release and align – release the old strategies/habits Release cognitive, emotional, social, and physical barriers, using a variety of techniques

Connect/control – cues for activation and co-

ordination of the deep and superficial muscle systems

Connect - Use Principles of Neuroplasticity

What is neuroplasticity?

The ability of the nervous system to respond to intrinsic and extrinsic stimuli by re-organising its structure, function and connections Snodgrass et al 2014

There is overwhelming evidence that the brain is continuously re-modelled in response to new or novel experiences

Therefore, an appreciation of the influence of the CNS on all forms of movement as well as pain should underpin all forms of rehabilitation Kleim & Jones 2008

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Stage 2 Build Capacity by Adding Load

Maintain static alignment of the body region being trained and build capacity both for the new strategy and for the muscles by adding load, initially short lever, then progress to longer levers and higher loads


Training Stages


Training Stages

Connect/control – cues for activation and co-

ordination of the deep and superficial muscle systems

Stage 2 – Build Capacity

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Stage 2 – Build Capacity

Stage 2Build

Capacity

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Stage 3 Add Movement and More

Complex Tasks

Level 1 - Add controlled movement of region being trained in multiple planes

Level 2 - Move the targeted region with either static control or controlled movement of another region

Level 3 - Progress training to higher equilibrium challenges or unpredictable situations


Training Stages


Training Stages

Stage 3 Level 1 - Move

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Stage 3 Level 2 – Move Two Regions

Stage 3 Level 3 – Add Equilibrium Challenge, Speed and More Complexity

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More information here!www.learnwithdianelee.com


An Evidence Informed, Clinical Reasoning Framework to Optimize Strategies for Function & Performance Individualized Assessment & Treatment of the Whole Person

More online learning and the schedule for practical classes in ISM at www.learnwithdianelee.com

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An Introduction to the Integrated Systems Model for the Complex PatientThoracic Ring Biomechanics and Clinical Application for Function of Rotation


The Integrated Systems Model & the Thorax

Thoracic Ring Biomechanics and Clinical Application for Function of Rotation

The Thorax in Optimal Function

Thoracic spine - largest region of the vertebral column ~ 20% of overall body length (vs. lumbar spine 12%, cervical spine 8%)

Almost every task requires the transference of loads through the thorax and therefore it needs control

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A Functional Thorax is Essential for Almost Every Task

A Functional Thorax Must be Capable of Opposite Rotations

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The thorax is the platform for the shoulder girdle and thus the glenohumeral joint

It is in relationship to the major vessels supplying and draining the cranium and upper extremity

It is intimately related to the pericardium of the heart and the diaphragm and all things that go through it

Contribution of the Thorax to Movements of the Trunk

Hsu et al 2008

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Thoracic mobility and control is essential for the trunk to act as a ‘spring’ during compressive loading

Thorax adjusts for changes in center of mass over base of support – especially to lateral perturbations

Zazulak et al 2007

Why Consider the Thorax as Separate Rings? Entire thoracic ring needs to be intact for optimal biomechanics (mobility & control) (Lee 1994)

A thoracic ring contains two ribs (same number) and the vertebrae to which they attach and the anterior costal attachments to sternum/manubrium

4th thoracic ring = left and right 4th ribs, T3, T4, 4th

costocartilages and sternum

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Biomechanics are Important

A Foundation to Understand Movement which Requires both Mobility & Control

Biomechanics of the ThoraxThere are 10 complete thoracic rings (1-10) and 2 incomplete rings (11 & 12)

There are 136 joints in the thorax

All thoracic joints move and therefore an understanding of how they move is necessary for training any task that requires the thorax to move!

1993 JMMT

2015 JMMT

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Thoracic Ring Biomechanics

Rotation

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How to Determine Relevant Region of the Thorax to Assess for

Rotation

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How to Determine the Relevant Thoracic Ring to Assess for the Task

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• Place your index, middle and ring fingers along the lower ribs 7 –10 on the left and right sides of the thorax

• Ask your partner to rotate to the left• The right ribs should anteriorly rotate and the left ribs should

posteriorly rotate – these biomechanics are the same in all 3 three regions of the thorax (upper middle lower) but feel different because the anatomy is different

• The thoracic segment sideflexes left – note the C-curve• There is also a very small mediolateral translation of the thoracic

ring to the contralateral side of the rotation (left rotation/right translation)

• See if you can feel the thoracic rings translate to the opposite side of the rotation (right)

• Find a thoracic ring that is translating left/rotating right during left rotation. This is non-optimal biomechanics for this task

• Note the response of the spinal segment associated with this thoracic ring

Group Lab – Left Rotation

Thoracic Ring Correction

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Group Lab – Single Thoracic Ring Correction

• Lift the entire thoracic ring slightly above the one below – use both hands – this is a very small movement

• Wait…..• Slightly posteriorly rotate the rib on the side the

thoracic ring is translated towards (left in this case)• WAIT for the thoracic ring to auto-correct (if it can)

You will feel the thoracic ring translate back to center and the breath will automatically expand the thoracic ring under your hands

• Once you feel the thoracic ring has corrected, recheck the rotation of thorax

• Release and LISTEN... Which rib moves first? Is the vector on the front or back of the thorax? Is the pull long or short, strong or light, does it go into the thorax or abdomen?



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What if the Thoracic Ring Can’t Correct?

Stiff joints within the thoracic ring will prevent correction zygapophyseal and/or costotransverse joint (articular system impairment) à assess passive joint mobility, mobilize and reassess

Myofascial restriction (scar tissue inside the thorax, between the thoracic rings, between multiple thoracic rings) will prevent complete correction àrelease (visceral, myofascial systems) and reassess

Upper Thoracic Rings & Head & Neck Rotation

Check left and right rotation of the head and neckPick the stiffest directionNote how far into the range the head can turn before the movement becomes more effortfulLook for an upper thoracic ring that is rotated in the opposite direction for the biomechanics of this taskCorrect it and assess the impact on the taskIf you found the driver, hypothesize on the system impairment from the passive listening and determine which tests should follow to confirm/negate your hypothesis

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Thoracic Rings & the Pelvis

The Integrated Systems Model & the Thorax

Thoracic Ring Biomechanics and Clinical Application for Function of Rotation

www.handspringpublishing.com

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http://www.handspringpublishing.com/

An Introduction to the Integrated Systems Model for the Complex PatientA deeper look at the foot and its relationship to impairments of function in the pelvis and thorax


A deeper look at the foot and its relationship to impairments of function in the pelvis and thorax

Lecture Outline

Meaningful task Walking

Consider the biomechanics required for the foot, pelvis and thorax for efficient gait

Then describe common clinical

presentations whereby:

Foot driver for pelvic girdle and low back

pain and impairment

Pelvis driver for impaired foot function

and pain

Foot driver for mid-back (thorax) pain

Thorax driver for plantar fasciitis

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The FootThree Functional Divisions

Sub talar joints

Talocrural joint

Talonavicular joint

Calcaneocuboid joint

Cuboideonavicular joint

Navicular cuneiform joints

Cuboid cuneiform jointsTarsometatarsal joints

Metatarsophalangeal/sesamoid joints

Hind foot

Mid Foot

Forefoot

Biomechanical Requirements of the Foot for Walking

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Heel Strike to Push OffTalocrural Joint

Talocrural jointHind foot

Heel strikeTalocrural joint – dorsiflexion/posterior glide of the talus relative to the mortice (tibia-fibula)

Foot flatTalocrural joint – plantarflexes but not fully/anterior glide of the talus relative to the mortice (tibia-fibula)

Push offTalocrural joint – dorsiflexion/posterior glide relative to the mortice (tibia-fibula)

Heel Strike to Foot FlatSubtalar Joints - Pronation


Sub talar joints

Lateral rotation of calcaneus relative to the talus as it plantarflexes in space (direction the front of the calcaneus moves)

Plantarflexion/adduction of the talus as the calcaneus rotates laterally beneath it

This is the front view of the right foot

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Heel Strike to Foot FlatMidfoot Pronation

Internal/External rotation of the medial and lateral columns of the foot

Fanning during pronation = external rotation of the navicular and medial cuneiform & internal rotation of the cuboid and lateral cuneiform

Axis is the 2nd ray

Talonavicular joint



Mid Foot

Heel Strike to Foot FlatForefoot Pronation


Fanning during pronation = external rotation of the navicular and medial cuneiform & internal rotation of the cuboid and lateral cuneiform

Axis is the 2nd ray



Forefoot

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Foot Flat to Push OffSubtalar Joints - Supination


Sub talar joints

Medial rotation of calcaneus relative to the talus as it dorsiflexes in space (direction the front of the calcaneus moves)

Dorsiflexion/abduction of the talus as the calcaneus rotates medially beneath it

This is the front view of the right foot

Foot Flat to Push OffMidfoot Supination


Folding during supination = internal rotation of the navicular and medial cuneiform & external rotation of the cuboid and lateral cuneiform

Axis is the 2nd ray

Talonavicular joint



Mid Foot

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Foot Flat to Push OffForefoot Supination


Folding during supination = internal rotation of the navicular and medial cuneiform & external rotation of the cuboid and lateral cuneiform

Axis is the 2nd ray



Forefoot

Foot Flat to Push OffForefoot Supination

First metatarsal plantarflexes on the sesamoids2nd – 5th metatarsals plantarflex on the ground

No rotation or abduction/adduction of the phalanges should occur

Metatarsophalangeal joints/sesamoidsForefoot

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Heel Strike to Push Off

Pron

atio

nSu

pina

tion

Anterior Facet is tilted

Pronate earlier faster deeper

Body Weight Passes over an unlocked foot

Heel Strike in Less Supination

Foot flat pronation – mobile adaptor through midstance

As weight transfers forward, foot needs to reach "locked" position at time of toe off

Supination

When not achieved increased work and strain on soft tissue

What causes the foot to heel strike in less supination?

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Heel Strike in Insufficient SupinationLocal Factors1. Restricted mobility of the subtalar joints due to stiffness. Subtalar joint can’t supinate due to decreased medial rotation of the calcaneus relative to the talus – e.g. ankle sprains2. Imbalance of tibialus posterior and peroneus longus3. Any impairment proximally that shifts the center of mass for the foot medially

Other foot impairments that impede biomechanics for walking:

1. inability of the midfoot and forefoot to fan and fold for pronation and supination (articular or neuromuscular restrictions)

2. inability of the MTPs to dorsiflex with optimal axis for push off

3. control impairments at any of the joints

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Biomechanical Requirements of the Pelvis for Walking

Pelvic Platform and 3 Levers

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A Functional Pelvis Requires Optimal Function of the

Passive, Active and Control Systems

Lee & Vleeming 1998A Collaboration from Research & Clinical Expertise

The Integrated Model

Of Function

Form Closure

Force Closure

Motor Control

Emotions

Heel Strike to Push OffPelvis - Alternating Intra-pelvic Torsion

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Intra-pelvic impairments that impede biomechanics for walking:

1. inability of the sacroiliac joints to move and allow a small amount of rotation between the innominates and sacrum

2. poor control of the sacroiliac joints and/or pubic symphysis during loading (articular or neuromuscular (motor control) impairments)

Biomechanical Requirements of the Thorax for Walking

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Heel Strike to Push OffThorax - Alternating Congruent Thorax Rotation

Thoracic ring impairments that impede biomechanics for walking:

1. inability of the thoracic rings to rotate congruently(articular, neuromuscular, myofascial, visceral impairments or combinations thereof)

2. poor control of the thoracic ring during loading and/or rotation (articular or neuromuscular (motor control) impairments)

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Lecture Outline






pain and impairment


and pain



Foot driver for pelvic girdle and low back pain and impairment

Any foot impairment that causes excessive and prolonged pronation through midstance

(articular stiffness or loss of neuromuscular control)

Causes an increased internal rotation force up

the lower extremity

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Foot driver for pelvic girdle and low back pain and impairment

If the pelvis becomes unable to resist the internal rotation forces on the innominate (multifidus and glut fatigue, weakness or loss of appropriate timing), the sacroiliac joint will ‘unlock’ or give way through midstance The innominate on the weight bearing side will anteriorly rotate relative to the sacrumTestCorrect the hindfoot alignment (possible or not? If not then mobilize the subtalar joint and retest). Test the impact of this foot correction on pelvic control in single leg stance

Foot driven loss of pelvic control

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Lecture Outline






pain and impairment


and pain



Pelvic driver for impaired foot function

Loss of mobility of posterior rotation of the innominate at heel strike results in shortened stride length and potentially and midfoot strike à loading of foot in

pronation

Causes sudden and excessive loading of the foot in a more

loose pack position

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Potential for plantar fasciitis or excessive dorsal translation of the navicular or medial cuneiform with exostosis formation

If pelvis prevents external rotation of the lower extremity then supination will not occur and push off will be off the medial hallux

Treatment: Mobilize the SIJRetest: foot biomechanics of heel strikeAlignment of first ray for push off


Loss of control of the SIJ at heel strike or midstance

Causes excessive loading of the foot in pronation

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Potential for plantar fasciitis or excessive dorsal translation of the navicular or medial cuneiform with

exostosis formation

Correct the alignment (TPR) and provide manual compression of the pelvis

(increase force closure) and reassess the biomechanics of the foot through heel

strike and midstance

Lecture Outline






pain and impairment


and pain



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Foot driver for impaired thoracic function

Failure of the foot to either pronate through midstance or

supinate for push off will impact the ability of the thorax to rotate

Potential to cause a region of the thorax (usually lower), or just one

thoracic ring, to excessively rotate/translate

Foot driver for impaired thoracic function

Potential for tissue overuse, strain and nociceptive pain in the thorax with

walking

Body Twist to see if feet can pronate/supinate and how far the

thorax can rotateCorrect/restore ability of the foot to

pronate supinate and retest biomechanics of the thoracic rings and

patient’s experience

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Lecture Outline






pain and impairment


and pain




Failure of the thorax to rotate (often due to 1-2 thoracic rings rotating

incongruent to the task)e.g. 4th thoracic ring translated

left/rotated right and unable to left rotate

Potential to cause prolonged pronation of the left foot

through midstance and delayed or no supination for push off

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Potential for tissue overuse, strain and

nociceptive pain in the foot (plantar fascia is common)

with walking

Body Twist to see if feet can pronate/supinate and how far the thorax can rotate

Correct/restore ability of the thoracic rings to rotate congruently, then retest body twist, and step forward task to see if the biomechanics of

the foot is restored

A deeper look at the foot and its relationship to impairments of function in the pelvis and thorax

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ism a clinical reasoning approach to determine where to ... · because research-supported...

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