Thoracic Rings and Integrated Systems: Paleolithic or Pathfinding?

I’ve been a mildly vocal critic of the thoracic ring and integrated systems model of treating pain and dysfunction for a number of years.  I’m not really a critic of Diane Lee though. I quite like her and respect her but have a number of reservations when it comes to the biomechanical foundations of the approach.  That always makes critical debate difficult when you heartily disagree with ideas that seem so interwoven into someone’s fabric of their person.  But, here goes…

Background: I started a discussion on the topic a number of years ago that you can see here at SomaSimple

Recently Antony Lo (the Physio Detective here) did aPelvic Health Podcast with Diane Lee (podcast here) and I thought it was good impetus to provide an alternative framework to what was offered.

As always there was a lot of good in what Diane said and there was the Other Stuff.  Other Stuff being either quite contentious and perhaps wrong.  I will choose a couple of nuggets of gold and dross to discuss.

What’s my angle? What’s the point of this bickering?

I think professionals need to challenge one another and themselves.  If you disagree you should say something.  I disagree with a lot of it and its my opinion that holding these overly complicated, often outdated (i.e. nothing is new here) views of human function can harm both young therapists and patients.  My extremely selfish motivation is that I champion a very simplistic biomechanical approach within the BioPsychoSocial (BPS) model.  That biomechanical simplicity lets you have a comprehensive approach to the multidimensional nature of pain.  I will try to demonstrate this over the next few sections.

Diane Lee’s Integrated Systems Model

This was an odd part of the podcast where Diane said it was difficult to come up with a name for their (also LJ Lee) approach. Their approach recognizes that pain and dysfunction is multifactorial and treatment needs to address all those areas.  It is a “whole person, whole body approach that goes from head to toe”.  They refer to finding drivers of dysfunction and seeing if changing those drivers influences themeaningful tasks of the patient in front of them.  This is Bloody Lovely. I’ve no problem with this.  I just call it the BioPsychoSocial approach like the rest of the world but I suppose its hard to brand that.  No real need for a new term.

I think where they felt it was different comes to the Bio realm.  Their Bio realms seem heavily influenced by Regional Interdependence.  Meaning a plantar fasciopathy could be influenced by the “faulty” biomechanics of a thoracic rib (also termed a Ring).

Examples of evaluating joints were given.  For example, they would look for  “failed” load transfer through the pelvic “ring” and suggest that that may be the cause or consequence of “faulty” alignment through out the kinetic chain or perhaps from faulty functioning in the thorax and this “failed load transfer” in some joint was the driver of the biological dysfunction.  Shit load of assumptions in there, eh?  We will get to them.

Separating Gold from Dross

Below are a few of the ideas put out in the podcast that appear reflective of the Integrated Systems Model.

1. Pelvic dysfunction is due to failed load transfer through the SI joint.

During a standing hip flexion task the therapist palpates the stance leg pelvis and sacrum and looks for “dysfunctions”.  Some dysfunctions being:

  • an innominate would anteriorly rotate relative to the sacrum (“the pelvis is doing something wrong”),
  • if the hip on the other side is “stiff” that is also a site of failed load transfer
  •  a knee that goes into valgus is considered non-optimal alignment.

All this leads to a judgement of HOW someone SHOULD or SHOULD NOT move.   Other dysfunction junction examples given were the “foot is collapsing”, the knee is caving in, the pelvis is shifting forward, the back is hinging, the thoracic is going scoliotic and the head is shooting forward.

In my opinion all predicated on simple ideas of optimal alignment and palpation skills that may be hallucinatory.

The single leg flexion tests is based on the work of  Hungerford (paper here on activation timing differences when someone has lower spine pain and a paper herewhether therapists can agree that some funny pelvic motion is going on).

Like most work on spine stability no one actually measures load transfer.  They measure pain, tiny differences in muscle activity onsets (we are talking milliseconds) and the reliability of therapists agreeing if something moves differently.  No one actually measured motion of the pelvic next to the sacrum since we know that that motion is super tiny – by tiny I mean .5 degrees of rotation and minimal translation (See Kibsgard).

So we have a highly questionable test and a proposed dysfunction that also has little support.  We can say that the person hurts and that they might move differently with pain.  The rest is just conjecture.

These tests still have value and we can re-conceptualize them. They show us a painful movement and habit movement.  Maybe this is an area we can intervene to break up that habit and start decoupling pain from movements.  Like Gwyneth Paltrow CONSCIOUSLY UNCOUPLING from Chris Martin.

What the integrated systems model now does is try to influence that painful or meaningful task. Which is fantastic because this is just oldSymptom Modification testing.


Step 1: Find pain – change pain….and thats it.  Now go treat the entire person.

  • Its the clinical audit process.
  • Its a mobilization with movement guided my symptoms.
  • Its the shoulder symptom modification procedure.
  • Its Maitland’s comparable sign.
  • Its McKenzie’s repeated movement testing.

Its SIMPLE.  Its the narrative in this model that is complex and perhaps unnecessary. 

Which leads into interventions.  Here I really liked what Diane said.   To paraphrase she initially and essentially said that it wasn’t the exact technique that was important it was how the patient experienced what you were doing.  Meaning you find the thing they have trouble with.  And then you do an intervention that some how changes the feeling of the movement that they have trouble with.  Interestingly, at this part of the discussionDiane backed off the idea that she was correcting ideal mechanics or changing load transfer abilities.  It was purely symptom and perceptual modification.  All driven by the patient’s feedback not some arbitrary arthrokinematics or faulty ideals of function.  Some comments by Diane and Antony.

1. The mechanism by how the model works may be via “brain training”  (words by Antony) or it doesn’t really matter what you do.

Diane agreed that the context of the manual therapy (light hands, creating a sense of confidence, non-threatening) is more important than fixing the actual physical dysfunction (e.g the improperly rotated rib).  She noted that there are a number of different ways to do something and it doesn’t have to be perfect…it has to be that an individual’s nervous system feels safe with it and “lets something go”.  “you gotta change the sensory input to get a change in the motor output and there are so many ways to do that”.

2.  We can’t trust the motion palpation literature

The thrust here was that patients will move differently from test to test and from therapist to therapist therefore we won’t have inter-individual agreement.  My simple interpretation from this is that if what you feel changes so quickly (e.g. the tests that they base their treatments on) and so easily it probably isn’t a relevant dysfunction.  If its so ethereal then its not something to worry about.  Like those flickers you see when you close your eyes.

A few biomechanical areas that might be a bunch of bunk

So Diane gave a lovely explanation for how things might work and explained that it might not matter how you try to change how someone moves BUT she then went on to say somethings that were pretty debatable…or wrong.

i. Dysfunction drivers  in the thorax can come from compressed or improperly rotated “rings” and this can be driven by different muscles or dysfunctions thus it is very important to find the true cause.

ii. “i can take a ring and distract it…I can anteriorly rotate one rib or posteriorly rotate another”

iii. anything that attaches to the ribs has the potential to disrupt the proper movement of those ribs and hence “force closure” of those ribs and load transfer ability.

iv. dysfunctions of muscles attaching to rings can be fascicle specific.  Meaning just part of the muscle is naughty.

v. if the external oblique is over active  and can not eccentrically lengthen it will inhibit posterior rotation of a ring during inspiration and limit right rotation of the thorax because right rotation requires the right fascicle of the external oblique…This example lead to the notion that you should now go and look in anatomy and see all the muscles that attach to ribs and then you can realize that they can all become criminals.

Thoughts on i-v.

1. You need to be able to reliable detect these altered movements.  This has never been established with any motion palpation techniques in any other joint and it is unlikely that the thorax is different.  You might be feeling gross movement differences like bracing, breath holding, tilting or rigidity but these are Macro changes and shouldn’t be blamed on micro function like arthrokinematics and a completely unsupported notion of loss force closure in the thorax.

2.  It needs to be established that these proposed dysfunctions are truly dysfunctions and not normal variability.

3. It needs to be established that any of these things NEED to be corrected for pain resolution. This is different than showing that the action of attempting to address these things can lead to less pain or better function in our patients.  Diane has already suggested that it is not the specific treatment.  Thus there is probably something else going on then laying the blame at these proposed dysfunction.

4. Side note: she keeps mentioning Peter O’Sullivan and Darren Beales’ research to justify that these notions are relevant.  I can fairly certainly say that those two couldn’t give a rat’s ass about this.

5. This is all so pessimistic, redunctionist and really simple even though its couched in such complexity.  It implies that tiny little rib movements, and tiny increases in muscle activity (who has said that more activity in the external oblique stops the ribs from moving?) are something that a robust, incredibly adaptable system can’t tolerate.  Its the epitome of FRAGILISTIC thinking.

6.  All of these notions suggest the patient is in need of FIXING.  That they body is inherently weak and can only work well when optimally aligned, with precise muscle activity and perfect motor control and that some magical therapist needs to come in and correct.  The body is more self cleaning oven than mechanically tuned carburetor.

7. The big one: You can’t feel rotations of ribs.  You can’t distract a rib.  You can’t laterally translate a rib.

You can’t do any of these because of one physiological principle.  The skin-fascia frictionless interface.  Any forces delivered to the body attempting to influence bone movement only have an effective force vector perpendicular to the bone surface.  Every other force requires friction to slide, rotate or translate a rib or any bone.

Its funny that such a simple concept can challenge so much Jenga Complexity.  See the video below.


I know I am just discussing the Bio part of the approach and do not doubt that Diane’s approach also wishes to address the multifactorial nature of pain and she is undoubtable well versed in pain science literature.  But the BIO component is not a tiny dispute.  The bio part of this model is regional interdependence taken to an extreme and is very similar to old school chiropractic theories about properly aligning all joints for the body to function at its most optimal.  The approach is pessimistic in its view of the body and could create a sense therapist dependence.  It can also actively amplify the other contributors to pain in the BioPsychoSocial Model.  Our beliefs and cognitions about our body are so important for pain and function.  Will Tiger Woods next year tell us that not just is his Sacrum out but that its out because he has thoracic ring shift from all those years of swinging a golf club.

I also worry what it tells young therapists. Motion palpation is such a huge component of this approach.  It is the palpation that finds the faulty joint movements.  We know that this is just not valid and the days of telling therapists that you just need to “wait 5 years” before you can feel it should be past us. You don’t need to practice this way and since the approach isn’t necessary its one I’m willing to forgo.

How can this be reconceptualized?

  • focus on all life and person variables that might contribute to sensitivity
  • use the testing as insights into habits of motion rather than faults
  • use the tests as global movements indicators rather than tiny indicators of arthrokinematic nonsense
  • recognize that the intervention’s biomechanical pecificity is not that important – its your interaction with the patient that is
  • meaningful tasks can just be started – there is no precursor function that needs fixing before you can start doing the things that are important
  • simplify

Is there value in learning from Diane Lee?

Absolutely.  Diane is fully cognizant that pain is multidimensional and is fully aware that there are other reasons for why her approach is helpful.  My impression is that the biomechanical explanations and approach work for her, its how she tells her story to the patient, but she doesn’t seem to say that you HAVE to do it her way.  As with many things we often disagree on a small portion of what is said so its easy to gloss over what is good and common amongst therapies.  I’d love to write a post or here a podcast on her insights into addressing the psychosocial aspects of pain.

So paleolithic or pathfinding.  Trick question: we are all dinosaurs.  There is really nothing new in therapy. If you think you’ve come up with something you just haven’t read enough.

2016Ryan Smith