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ISM 8: Alignment, Biomechanics or Control?

As one of the UK’s leading London physiotherapists, I regularly write about injuries, treatment and assessment techniques.

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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. 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. As everyone’s body and movement patterns are (and should be) different, I then wrote about the meaning of optimal movement as opposed to suboptimal movement with areas of failed load transfer (FLT). We went through how we assess for FLTs during screening tasks, corrected his impairments to find our driver, and then found the vectors. But what does that mean for our fictional patient David?

To recap, David came to see us complaining of pain in his right knee when he walked, especially when he had his weight over his right leg. When we watched him loading through his right leg, we found that his right hip was sliding forwards in its socket. When we corrected this, his knee stopped hurting, confirming that his right hip was driving his right knee pain. We then analysed his right hip further, through direct and indirect listening to work out his vector – the reason his hip was losing its alignment.

So, what is the problem here?

Well, we know that David has an alignment problem – his hip starts and finishes in a position of FLT. (If the issue were his biomechanics, it wouldn’t move when it should; if it were a control issue, it would move too much when it shouldn’t!)

We then have to work out which of David’s systems are most impaired, and causing that alignment problem.

The main systems that Diane focuses on, in the Integrated Systems Model, are the articular system (the joints), the neural/myofascial system (nerves, muscles and connective tissue) and the visceral system (the organs such as liver, kidneys and intestine).

In general, if the issue is in the articular system, David’s hip will feel blocked and the vector will be short. A neural/myofascial vector will feel like a pull which follows the line of the muscle or fascia (so you have to know your anatomy!) and a visceral vector also feels like a pull, but is deeper and often more diffuse than a neural/myofascial vector.

In David’s case, we can feel a pull along the line of the tensor fascia lata, which is one of the hip flexors. When it’s working normally, this muscle’s job is to pull the hip into flexion, internal rotation and abduction; but when it is out of balance with the muscles at the back of the hip, it can become overactive, pulling the hip forward when it should be relaxed. This is a neural/myofascial vector.

So, David’s knee pain on walking is driven by an alignment problem in his right hip, with a neural/myofascial vector into his overactive tensor fascia lata. You can see why the “standard knee exercises” haven’t worked for him!

And what do we do next? We use our clinical reasoning and our understanding of David’s underlying issues to prescribe him a bespoke treatment and rehabilitation plan, that’s what! Let’s talk about that next week.

Are you, like David, one of the 35(ish)% of people with problems that don’t stem from the bit that hurts, or are you not responding to the traditional “magic” strengthening exercises? Click the button below or call my team on 0207 175 0150 and book an assessment, so that we can help to work out what’s really causing your issues, and then put together an individual plan to help you in the long term.

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Many people assume that a stiff or sore neck is an inevitable part of aging. 

I’m here to show you that doesn’t have to be the case!