The Integrated Systems Model in the Treatment of the Whole Person

An Introduction to The Integrated Systems Model in the Treatment of the Whole Person


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 that many movement habits, past injuries, thoughts/beliefs, and emotional states have collectively led to changes in strategies for posture, movement, continence and organ support.

painShould 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 behaviour always predict treatment outcomes?

Research suggests that pain probably involves all mechanisms.  Butler notes that, “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 behaviour 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 patient’s experience to facilitate decision-making and treatment planning.

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 is a graphic that conceptualizes this model and is used as a reflection tool for the development of clinical reasoning and ultimately clinical expertise. The patient’s goals and meaningful complaints are noted in the centre of the Clinical Puzzle and from their story a meaningful task is identified.

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, 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.

Complex and confusing but when practiced by a trained and experienced Chartered Physiotherapist, leads to helping solve those problems that failed elsewhere.

This approach can be used from the simplest of niggles to the most complex of cases.

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IMG_0129Patrick Mc Carrick MISCP



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