If your knee pain is caused by a problem in your back, you need to rehabilitate the "mugger" as well as treat the "victim"
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ISM 3: Driver Theory and Regional Interdependence

This is the third post in my series about Diane Lee’s Integrated Systems Model (ISM). I’ve previously explained how I discovered Diane and her work, and how it works in line with published literature. This week, it’s time to talk about regional interdependence, which is essentially the theory of how everything in your body is connected.

The regional interdependence theory is one that has gone in and out of fashion since 1944, when researchers Inman and Saunders noted that pain could be experienced a long way from the site of an injury. But it wasn’t until 2007 that Robert Wainner came up with the phrase “regional interdependence,” which simply means that a problem in one region or system of the body can influence the symptoms and function of another region of the body – in other words, that everything is connected. So, for example, if you have a very stiff foot, your foot may not hurt; but the loss of movement in your foot could affect the movement up the whole of your body, until your neck starts to hurt… or vice versa!

Most physiotherapists in the UK have been taught using the biomedical model, which essentially means that when a patient comes in saying that their knee hurts, the therapist will examine the knee to work out which structure (cartilage, ligament, tendon etc) is generating the pain; and they will focus their treatment on this area. This is effective in around 65% of cases, especially when the injury is recent – and this is why traditional physiotherapy is not a bad thing to do! (In my pre-Diane days, I like to think I was still an effective physiotherapist!)

However, the biomedical model still leaves around 35% of patients without a solution, because if your knee is hurting because it is being triggered by your stiff foot, hip or ribcage, then unless you rehabilitate the stiff foot, hip or ribcage, then you can strengthen the knee all you like – unless you continue doing your knee exercises for ever, then it will get triggered and sore again.

In the Integrated Systems Model, which Diane developed using the regional interdependence theory, we call the trigger area (in the example above, the stiff foot, hip or ribcage) the driver, because it is driving the knee pain. The knee in this instance is the victim.

An analogy I rather like is that of a mugger and a victim. If the mugger bashes the victim, then yes, you take the victim to hospital and treat her (in the ISM we don’t ignore the painful knee!) – but if you leave the mugger free to mug again, then he will. Either he will mug the victim again as soon as she gets out of hospital (ouch, poor knee!) or he will mug something else (so your foot or hip will start hurting).

However, if you also rehabilitate the mugger and stop him from mugging again (ie treat the stiff foot, hip or ribcage), then you will create a longer-term solution than if you simply treat the victim.

So, back in early 2013 when Simon told me that he was helping his player’s knee by treating his shoulder, he was rehabilitating the driver (the shoulder) in order to stop triggering the victim (the knee). Regional interdependence!

Of course the driver and the victim can be the same area (that’s the 65-ish% of patients for whom traditional physiotherapy works) and the ISM can tell us that, too.

But how do we work out where the driver is? Keep reading for the next instalment… or, if you think you’re one of the 35% with a problem that isn’t responding to traditional, biomedical physiotherapy, don’t wait – call us on 0207 175 0150 and book your assessment appointment, so that we can work out what’s driving your problem.

Or if you’re a physio and you’d like to learn how to do this stuff yourself, you have a rare opportunity because Diane is coming to the UK in 2019 to teach the ISM! The course is in Chichester and starts on 16 Feb, so don’t miss out! I loved it so much that I’m going back to do it all again, so I hope to see you there!

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