About the Integrated Systems Model or ISM
Discovery consists of seeing what everybody has seen and thinking what nobody has thought.
-ALBERT VON SZENT-GYORGYI NAGYRAPOLT
The Integrated Systems Model or ISM (LJ Lee, Diane Lee) is simply a holistic model to be used in the assessment and treatment of patients. Put another way, the ISM is an alternative and specialized framework to assess and treat patients by. The unique piece to this model is that the ISM considers how various systems relate to and effect each other. It simply considers each individual as a whole person. Besides considering the whole person, the ISM fosters detailed clinical reasoning and is evidence-informed.
The ISM was invented by both Linda Joy (LJ) Lee and Diane Lee, and these inventors also teach and mentor the ISM to physical therapists all around the world. Both Diane Lee and LJ Lee are not only world-renowned physical therapists themselves, but also are clinic owners, researchers, authors, teachers, and mentors who dedicate ample time to the profession and progression of physical therapy.
The goal of the ISM is to find the “driver”. The driver is the source, root, or cause of the patient’s problem. The driver is found by assessing the patient’s “meaningful task”. The meaningful task is simply a goal the patient has and could be a task or activity you want to do better, with more ease, or without pain for example. Treatment is then focused at the driver. Focusing treatment at the driver is designed to aid symptoms at the driver’s victims throughout the body and allow for more optimal strategies for function and performance of the meaningful task in question.
In a quick summary,
The priority of the ISM is to use meaningful assessment to find and treat the driver to then create optimal strategies for function and performance.
- Meaningful assessment: assessment uses tasks that have meaning and are important to the patient to address. These tasks are used to assess the patient’s whole-body alignment, biomechanics, and control (ABC’s) of the task in question.
- Driver: the body region that is driving/causing the bulk of the non-optimal findings (the faulty ABC’s) for the patient’s meaningful task. The body region that is the root of the patient’s subjective concern. The driver is almost always somewhere other than the victim area itself. The driver is the body region that breeds dysfunction elsewhere in the body creating the victim areas including the victim area reported in the patient’s subjective concern.
- Treatment: focusses at the driver to aid the various victim areas noted in the patient’s meaningful task. Treatment uses analysis to find and then treat the impairments that are having the greatest impact on the driver. Impairments can include the dural (craniosacral tissue, nerve tissue and slings), visceral (organ / internal fascia scarring or adhesions, non-optimal organ mobility), neuromuscular (muscle recruitment strategies, bracing/ gripping strategies, overactive or underactive muscles), myofascial (scarring, adhesions, muscle-fascia tears, diastasis rectus abdominis), and/or articular (stiff joints, degenerative joints, instabilities) systems. The impairments are then treated with manual therapy as indicated. Treatment principles include Release, Align, Connect, and Move or RACM with focus on releasing the old dysfunctional strategy used in the meaningful task, releasing beliefs and barriers impeding recovery, aiding ABC’s for the meaningful task, and learning deep core connect cues to encourage optimal movement in the meaningful task.
- Optimal strategies for function and performance are created using the principles of neuroplasticity and includes education with respect to the patient’s meaningful task. With practice and mindfulness, the new optimal strategy is meant to replace the old dysfunctional habitual strategy.
In the words of ISM inventor Diane Lee: “Our model (The ISM) is derived from our evidence-based approach (science and clinical expertise) of over 50 years of clinical practice… LJ and I try to expose ourselves to everything and anything available to us that we feel will enhance the quality of care we can offer our patients that is within the scope of our practice and feel that all of this can be umbrellaed within the ISM approach.” “[The ISM] is an integrated, evidence-based model that considers disability and pain as defined and directed by the patient’s values and goals. The model relates impairments found in systems… [such as the] articular, myofascial, neural, visceral… systems, and the impact of these impairments on their current whole body strategies for function and performance…Thus the model analyzes the patient’s current whole body strategies, determines the underlying reasons for those strategies, and relates these to [what is ] required in all systems to provide optimal strategies for function and performance, and ultimately, for health.”
About the ISM
The ISM principles are to consider your entire body in both assessment and treatment. Assessment will catalogue all of the “shifts” or areas of mal-alignment you have throughout your body. Everything from your head (cranium) to your feet and everything in between (neck, shoulders, torso, pelvis, hips, knees) will be assessed from an alignment viewpoint. From there, the goal is to find the “driver” (source, root, cause) for your “meaningful task” (the task you want to do better, with more ease, without pain) and focus on the driver in treatment.
The ISM’s goal in assessment is to find what shift or area of mal-alignment is responsible for your pain or dysfunction in a “meaningful task”. The ISM states that just because you have a sore shoulder, for example, doesn’t at all mean the shoulder is the root of the problem nor that the shoulder necessarily requires treatment. Your shoulder may be sore from any mal-alignment or shift at your head (cranium) to your feet or any shift in between (neck, shoulders, thoracic rings, pelvis, hips, knees). The whole point is to determine which shift is responsible for your symptoms or difficulty in your meaningful task. Most often the sore area is just the victim of the driver, and the driver is flying under your radar because it may be a symptom-free area. The driver, though, is a highly dysfunctional area breeding dysfunction throughout the rest of the body that then creates symptoms at the victim area(s).
Whatever activity you desire to do without pain, with ease of function, with optimal balance, stability, flexibility, and/or adaptability is termed your “meaningful task”. This meaningful task is broken down into components and it is these components that are then used for assessment to find the “driver” (source, root, cause) of your problem specifically in your meaningful task. The ISM states that the more specific assessment and treatment are to your goals, the more likelihood for efficient and effective treatment to take place and the more likely a successful outcome can be reached. Meaningful tasks may involve pain, difficulty with an activity, just not feeling right with a certain activity, or activities that you desire to do but are fearful to do. Examples of meaningful tasks could be to walk further with less hip pain, lift grandchildren without low back pain, sit through a movie without nerve pain down an extremity, do stairs with better balance or any other activity you want to do better, with more ease, without pain, with optimal flexibility, adaptability, or coordination.
The ISM teaches that every single patient is a unique individual who will present in an entirely different way than another patient of the exact same physical stature and with the exact same injury. We are all individuals with our own unique beliefs, past experiences, goals, pain experience, and personality that interweave each of us into our own unique tapestry. This unique tapestry requires respect and attention to allow for the best possible outcome. Further, every painful shoulder or sore low back, for example, will have a different driver. A patient’s first meaningful task may have a different driver than a second meaningful task. Further yet, drivers can change relatively quickly. As the initial driver is detected and treated, a new driver may likely present itself.
An analogy to think of is that one snowball started the whole snowball effect of shifts and twists throughout your body. Our goal is to work through the driving shifts and get to that one instigating snowball that started the snowball effect. Another way to look at is that our body adapts (shifts) to each trauma we incur from childhood on, and eventually our body hits a “max out” point where it cannot adapt anymore. When we hit this “max out” point is typically when we have a concerning symptom that isn’t recovering in the expected timeline.
Treatment is geared to unwinding these traumas one by one, from the most recent backwards. We are healing the body in the reverse order it was injured. For these reasons, an individual assessment and an adaptable individual treatment plan is necessary to address your specific goals.
For some patients, pain isn’t their issue at all. They may say “When I run, my right leg feels heavy”, or “When I swim I always veer over to the left”, or “When I sneeze I lose control of my bladder”, or “I can’t swing a golf club like I used to anymore” or “I lose my balance easily and can’t walk well”, or ” I just don’t have the strength to throw a baseball normally” or “My shoulder just doesn’t feel right”. Most any meaningful task can be assessed and the driver figured out. Pain is not a requirement to finding the driver and reaching your goals. Pain doesn’t dictate your assessment with the ISM – your meaningful task does.
The ISM does not encourage the use of modalities for treatment. Instead, the driver for a meaningful task is focused on and treated through the principles of Release, Align, Connect, and Move or RACM. The driving shift is assessed to find what vectors (impairments, abnormalities) are creating the shift in the first place. These vectors may present as abnormalities in the neural (nervous system), articular (joint system), myofascial (muscles, tendon, and fascial system), or visceral (organ and dural systems) components of the body. The goal is to release or address these vectors to allow for proper alignment which satisfies the R and A out of RACM. Then specific movement training and brain training for maintenance are required to satisfy the C and M. “Exercises” given are neuroplastic in nature meaning they train the brain to use an optimal strategy instead of your old, habitual, dysfunctional strategy. This is often the key to progressing a meaningful task and is very often necessary for long-term maintenance and aiding prevention of re-injury or new injury.
Further, treatment modalities are often targeted to the painful area, and recall that the ISM states that the painful area is usually just the victim of the driver, and not the driver (source, root, cause) at all.
"There are two ways to be fooled. One is to believe what isn't true; the other is to refuse to believe what is true."