ConnectTherapy™ & the Thoracic Ring Approach™ models provide broad frameworks to understand all the influences and connections that contribute to a patient’s current undesired experience of their body and their current non-optimal strategies for posture & movement. These models aim to integrate and include knowledge from all sources, and techniques and tests from all paradigms, but to interpret the results from these tests in a broader framework.
Both approaches incorporate evaluation of specific impairments into functional movement analysis to determine the most relevant impairments to address at each phase of rehabilitation. The whole body and the whole person are evaluated and considered. The aim is to identify the relationships between multiple areas of regional dysfunction, impairment and pain, so that the current “Drivers” for the problem can be determined. “Drivers” are the true underlying cause of the problem, and may be the same as the are of pain, or can be remote to the painful site and related to past injuries and other features of the patient’s story.
In manual therapy, we have many tests for specific structural impairments – for joints, muscles, the nervous system… But are these test findings only representative of local structures?
Check out this short excerpt from a case presentation by participants on the 2014 Series in Vancouver.
Amongst other symptoms, the patient model was experiencing left medial knee pain and a sense of loss of stability due to a 2nd degree tear of the left MCL. This tear was also visualized on MRI imaging. Using the whole person frameworks of ConnectTherapy & the Thoracic Ring Approach, the group identified that dysfunction of the lower thoracic rings (thoracic rings 6/7) were the Primary Driver for not only the knee pain and loss of stability, but also for hip pain experienced during running.
As part of the assessment, the passive integrity of structures contributing to medial knee stability were tested. Without correction of the thoracic rings (6/7) (Primary Driver), the medial knee stability test was positive for both pain and laxity… but then with correction of the Thoracic Rings 6/7, the same test was painfree and no laxity was present.
Dr. LJ Lee has previously found similar clinical findings in patients identified as having “unstable sacroiliac joints (SIJ)” – where the passive ligament tests for the SIJ were positive, and then correction of the patient’s thoracic ring Driver resulted in a completely negative test (firm endfeel, no increased neutral zone, and no movement in closed pack position of the SIJ).
How does this work?
We can gain some insight into the answer to this question when we consider the work of anatomist Jaap Van der Wal. Van der Wal proposes that we need to re-conceptualize our beliefs about the anatomy of ligaments & the way they support joints. Instead of thinking that the joint capsule, ligaments, and muscles are arranged in parallel – that is, that you have layers of tissue supporting the joints (capsule, then ligaments, and then muscle insertions with their associated fascia) – these structures are in fact arranged in series. Instead of distinct layers of structures supporting joints, Van der Wal asserts that the capsule, ligaments, and muscle tissue blend together to form a complex connective tissue complex. Thus, these structures are not simply “passive”, but tension is modulated in the connective tissue complex by changes in muscle activity, which provides a dynamic and more efficient system to provide stability to joints in all different positions and ranges of motion. The MCL is not a true ligament, but rather a thickening in the connective tissue complex that is connected to muscle insertions. The only true ligaments are intra-articular structures like the ACL.
So – how can a thoracic ring correction at the 6th/7th rings change a test for medial knee stability from being positive to negative? Or correcting the 4th/3rd rings change passive integrity tests of the SI joint? It’s because muscle activity in multiple different regions changes as a result of thoracic ring corrections being performed. This likely happens via multiple neurophysiological mechanisms. LJ’s proposal is that optimizing the thoracic rings changes resting muscle tone/ activity in multiple muscles 3-dimensionally around the trunk (including the abdominal wall, the erector spinae, the lumbar multifidus, etc), resulting in changes in tension in the connective tissue complexes around the sacroiliac joints. Changes in lower limb muscle activity, and specifically changes in muscle activation around the knee, could be a downstream result of the trunk muscle changes, or due to changes in afferent input from the structures around the driving thoracic rings when a correction is performed. Any changes in resting muscle tone/ activity will increase or decrease tension in the structures providing resistance to our “passive” joint stability tests.
So how do we interpret our tests? Our specific tests of impairment do give us the ability to evaluate the current status of a joint (or system). However, the status of the joint is a reflection of all the systems and connections in the entire body, and indeed all influences on the whole person at that moment in time (which includes emotions & beliefs). We need to consider that a positive test finding – whether indicating reduced range of motion at the shoulder, laxity on a “passive” stability test, or decreased muscle strength – may be the result of dysfunction in distal regions or in other systems. All of our tests are influenced by the current state of the whole person. Everything is truly Connected!
To learn more about Van der Wal’s research, watch his keynote presentation from the 2nd International Fascia Research Congress in Amsterdam here: