Over the past few weeks, I’ve been writing about Diane Lee’s Integrated Systems Model (ISM), which is a big part of how I work at my physiotherapy practice. I’ve explained how I found Diane, how the ISM works with the published evidence, and the theory of regional interdependence from which the ISM derived. This week it’s time to discuss what happens when we assess your posture and movement, and how we work out whether your movement patterning is optimal.
First, I think I need to explain what Diane means by “optimal”, as most of the assessment process is based on working out whether postures and movements are “optimal” or not.
It’s important to be clear that what is optimal for one person, will not necessarily be the optimal way for another. We are all different shapes and sizes, with different anatomy and different movement patterns. So in this context, what does optimal look like?
An optimal movement strategy or posture is one in which you have optimal alignment, biomechanics and control (or ABCs). This means that your weight is loading through the middle of your joints (so the appropriate bit of joint cartilage is getting loaded, and nothing is awkwardly twisted or shifted out of place), and that when you move, your bones move in the appropriate direction by the appropriate amount, with the appropriate muscles switching on and off. This is where clinical experience comes in – your therapist needs to understand what your body should be doing to produce the movement or position they are assessing (eg should your pelvis be flexing or rotating or staying still?), and then work out what your body is actually doing, relative to that.
Optimal pressure distribution
Your body has arms and legs, but it also has regions we describe as canisters: open-ended bags separated by valves. The main canisters we talk about are your cranium (the skull, whose contents are contained in a bag called the dura, ending at the brain stem), your thorax (ie your lungs, contained by the pleura at the top and the diaphragm at the bottom) and your abdomen (ie your abdominal organs – including liver, kidneys and intestine – contained by your diaphragm at the top, surrounded by your abdominal muscles and thoracolumbar fascia, and then with your pelvic floor muscles at the bottom). An optimal strategy or posture should distribute and balance pressure evenly in the canisters – cranium, thorax and abdomen. To work out whether this is happening, we observe your breathing as you perform a task or maintain a posture. We’re looking to see whether you start to breathe from the top of your chest, or whether you’re still using your diaphragm. We’re checking as to whether you go red in the face, or complain of pressure behind your eyes or in your pelvic floor? If the way you perform a task or maintain a posture causes any of these issues, it tells us that something’s not optimal, because you’re having to grip with your muscles, rather than being able to move easily and smoothly.
The technical term for this is “neutral zone glide” but I prefer to think of it as “wiggle”. My patients are familiar with me trying to wiggle their joints as they move, and this is why: it’s all about how relaxed you are during a task or posture. If the way you move or position yourself is optimal, then you should be able to accommodate perturbations such as a gentle push or wiggle – you should be able to “roll with the punches” (not that I’ll be punching you, don’t worry!). Think of the way a tennis player or a rugby player stands, preparing to move – good players are relaxed enough to be able to react and move in any direction, and they look as though they have lots of time; whereas beginners often stand more stiffly and react more slowly. So effectively, I want to see if you’re a pro or a beginner at your task; because if you can’t be wiggled, the chances are that you’re off balance somewhere, and that’s not optimal.
Finally, an optimal position or task should simply look and feel good – with movement being easy and effortless. Think about how a healthy cheetah looks when it’s running flat out across the savannah – poised, balanced and effortless. Now compare that to how someone moves with an injured leg – halting and limping, concentrating on getting from A to B, and clearly hard work. The cheetah doesn’t move in a rigid, patterned way, with every step the same – it is able to accommodate uneven ground, and swerve around obstacles. It’s adaptable, and still optimal, because while a suboptimal, injured central nervous system creates rigid patterns, a healthy, optimal central nervous system has choices as to how it moves.
When a movement is not optimal – when your ABCs are imperfect (eg your body twists when you touch your toes), your canister pressures are uneven (eg you hold your breath when you stand on one leg), you hold yourself rigid when your therapist tries to wiggle you (eg you subconsciously grip the floor with your toes when you squat) or your movement is otherwise difficult or excessively effortful (eg one arm feels heavier than the other when you lift it), we consider this an area of failed load transfer or FLT. It doesn’t mean we know why things have gone wrong for you (yet) or where the issues are coming from (yet); but it’s a sign that something isn’t quite right, and it gives us clues as to where to investigate further, to find the underlying cause of your symptoms.
As we’ve discussed previously, your symptoms really could be coming from the problem area (in around 65% of cases, the “mugger” is also the “victim”) but in around 35% of cases, the bit that hurts could be compensating for the mugger or driver. And while – especially if you’ve had the problem a while – you’ll have created a chain of compensatory poor movement patterns or FLTs, the driver is likely to be one of the areas of FLT.
So – when your therapist is looking at the way you stand or move, they should be analysing more than just the painful or stiff area. And… what movements will your therapist be analysing? Is it the same for everyone, or do we test different movements for different people? Find out next week… or, if you’d rather learn about your own ABCs, pressure balance, wiggle and grace, and have your own FLTs identified, then why not call my team on 0207 175 0150 and book a 90-minute assessment?