General Information
Diane Lee teaches post graduate courses in Orthopaedic Manual Therapy throughout North America, the United Kingdom, Europe, Asia and Australia. She is frequently asked to give lectures pertaining to the "Integrated Model of Function" to multidisciplinary groups and the response to these lectures frequently reinforces her desire to facilitate communication between professions.
This section of the website contains some relevant articles/chapters and abstracts that Diane has published and/or presented that will allow health care practitioners, as well as the public, access to information pertaining to this evidence-based integrated model of function. The intent is to empower through knowledge the effective management of musculoskeletal syndromes (including pelvic girdle pain) through protocols which are evidence-based (scientific) and yet clinically practical and valid.
An abstract of each paper/presentation is available to read directly in this section whereas the pdf file below each abstract contains the full article for downloading.
Abstracts
- Principles of the Integrated Model of Function
- Stress Urinary Incontinence
- Myths & Facts of the Pelvis
- Load Transfer Tests for the Pelvis
- Recent Advances in the Assessment & Treatment of the SIJ
- Forward for 'The Pelvic Girdle, 3rd Edition' by Dr. Paul Hodges
Principles of the Integrated Model of Function and its Application to the Lumbopelvic-hip region.
Chapter 5 In: Lee D G 2004 The Pelvic Girdle 3rd edn. Elsevier
The 5th chapter of Diane's 3rd edition of The Pelvic Girdle introduces the principles of an integrated model for managing impaired function. This model comes from anatomical and biomechanical studies of the pelvis, as well as from the clinical experience of treating patients with lumbopelvic pain (Lee 2001, Lee & Vleeming 2003). This approach addresses why the pelvis is painful and no longer able to sustain and transfer loads as opposed to one which seeks to identify pain generating structures. Several studies have sought to understand pelvic function. The anatomical research on the SIJ and the connections between it and the lumbopelvic muscles (Snijders et al 1993a, Vleeming et al 1990a,b, Vleeming et al 1995b, Vleeming et al 1996) led to conclusions regarding the role the passive and active elements play in stabilization of the pelvis (form and force closure of joints). The timing of specific muscle activation (Hodges & Richardson 1997a, Hodges 1997b, 2003, Hodges et al 1999, 2001, 2003b, Hungerford 2002) and the pattern of muscular co-contraction (or lack thereof) in patients with low back pain (Danneels et al 2000, Hides et al 1994, Hides et al 1996, Hodges 2003, Hodges & Moseley 2003, Hodges & Richardson 1996, Hungerford 2002, O'Sullivan 2000, O'Sullivan et al 2002) further enhanced the force closure theory and suggested a crucial role for motor control. Based on this knowledge, functional tests for the pelvis were developed (Buyruk et al 1995a,b 1999, Lee 1999, Mens et al 1999, 2001) and treatment protocols were established (Richardson et al 1999, Lee 1999, O'Sullivan 2000). Clinically, it was soon apparent that the patient's emotional state could significantly influence the outcome. Over time, the 'Integrated Model of Function' was developed (Lee & Vleeming 1998, 2003).
It has been long recognized that physical factors impact joint function. The model presented in this chapter suggests that joint mechanics can be influenced by multiple factors, some intrinsic to the joint itself while others are produced by muscle action which in turn is influenced by the emotional state. The effective management of pain in the lumbopelvic-hip region which is associated with dysfunction requires attention to all four components - form closure, force closure, motor control and emotions with the goal being to guide patients towards a healthier way to live and move.
Stress Urinary Incontinence - A Consequence of Failed Load Transfer through the Pelvic Girdle?
Presented together with Linda-Joy Lee at the 5th Interdisciplinary World Congress on Low Back and Pelvic Pain in Melbourne, Australia, November 2004 Published in the Congress Proceedings
The anatomical and biomechanical research in the last decade has led to a clearer understanding of how load is transferred through the low back and pelvic girdle (Hodges & Richardson 1996, 1997, Hodges 1997, 2003, Hodges et al 1999, 2001a,b,c, 2003b, Hungerford 2001, Mens et al 1999, Richardson et al 1999, Snijders et al 1993a,b Vleeming et al 1990a,b, Vleeming et al 1995, Vleeming et al 1996). From this research, an integrated model of function evolved (Lee & Vleeming 1998, 2004) and clinical extrapolations based on this model were developed (Richardson et al 1999, Hodges (Course Notes, 2004), Lee 2004, Lee & Lee 2004). Further research based on the model continued (Hungerford et al 2004, O'Sullivan et al 2002, Pool-Goodzwaard 2003, Stuge et al 2004) and it soon became evident that two conditions of failed load transfer through the pelvis, low back/pelvic girdle pain and stress urinary incontinence, had components in common. Recently, Pool-Goudzwaard (2003) conducted a multi-centered study in Holland to investigate, in part, the prevalence of low back/pelvic girdle pain and pelvic floor disorders. In this study of 66 patients, 52% reported a combination of low back and/or pelvic girdle pain along with pelvic floor dysfunction which included voiding dysfunction, urinary incontinence, sexual dysfunction and/or constipation. Of these 52%, 82% stated that their symptoms began with either low back or pelvic girdle pain.
Our journey into considering the relationship between load transfer through the musculoskeletal components of the pelvis and the organs it contains began at the 4th World Congress on Low Back and Pelvic Girdle Pain after hearing a paper (O'Sullivan et al. 2002) which demonstrated via real-time ultrasound imaging the impact of the active straight leg raise (ASLR) (Mens et al 1999) on the position of the bladder in pelvic girdle pain patients. They noted that the bladder tended to descend during the ASLR and that this descent decreased when compression was applied to the pelvis. Our question at the time was, "How much should the bladder move when you lift your leg?" This led to a search of the literature pertaining to stress urinary incontinence and several revelations followed regarding the parallel features of both low back/pelvic girdle pain and stress urinary incontinence. We now recognize that the factors which must be optimal for effective force closure and stability of the pelvic girdle and those which must be present for optimal force closure of the urethra are the same. The intent of this paper is to briefly review the literature regarding effective force closure of the pelvic girdle, present the anatomical and neurophysiological requirements for effective force closure of the urethra and conclude with a case presentation which will clinically integrate the material.
The Evolution of Myths and Facts Regarding Function and Dysfunction of the Pelvic Girdle
In: Vleeming A et al eds. Movement, Stability & Low Back Pain - The Essential Role of the Pelvis 2nd edn (in press 2006)
The pelvic girdle is a source of mystery to many health practitioners and yet amongst some there is a long held belief that it plays a significant role in low back pain. In the past, models for assessment and treatment of the pelvic girdle were taught by experienced clinicians whose protocols and techniques were accepted without scientific evidence of reliability or efficacy. Recently, some of these long held beliefs have been challenged for their apparent lack of reliability, sensitivity and specificity. This chapter outlines the evolution of some of these myths and what the recent research has revealed regarding them. In addition, some of the conclusions from this research are challenged in the hope of preventing the perpetuation of more myths. The gap between what we know about the function of the pelvic girdle and what we need to know as clinicians treating pelvic girdle pain is outlined and suggestions for future research offered.
The One-Leg Standing Test and the Active Straight Leg Raise Test: A Clinical Interpretation of Two Tests of Load Transfer through the Pelvic Girdle
Published in the Canadian Orthopaedic Division Review - 2005
I read with interest and some concern the discussion in the last issue of the Orthopaedic Division Review on evidence based practise and how it is impacting our clinical practise. Of concern was the statement made by Peter Huibregts in his article "Lumbar spine coupled motion: A literature review with clinical implications" that "At this time, no evidence-based diagnostic tools in either history or physical examination seem to be available to the primary care manual medicine practitioner to determine the nature of these inter-individual differences" (how the lumbar spine couples in motion and how to use this information for treatment technique selection). Fair enough, however - now what do I do if I want to treat my patient? On what do I guide my technique selection for the restoration of function i.e. mobility and stability? In the same issue, Diane Jacob eloquently reminds us of Melzack's post Cartesion neuro-matrix theory that "proposes that most of what is called chronic pain is neurological malfunction more than it is physical, tissue based dysfunction" therefore using pain provocation tests (which they do have reliability and sensitivity for the pelvic girdle - Laslett & Williams 1994) is not the way to go either. Both Richard Rosedale and Scott Whitmore quote Sackett who feels that "Evidence-based medicine is the integration of best research evidence with clinical expertise and patient values'. I like this sentence a lot - to be an evidence-based clinician, Sackett suggests that we must use a combination of evidence from the research, clinical expertise and patient input; not just research. To the working clinician this must ring true since we need many more clinical tests/techniques than are currently 'scientifically reliable, valid, sensitive and specific' to assess and treat our patients.
Recently, two tests of load transfer through the pelvic girdle have been scrutinized scientifically; the one leg standing test (also known in Canada as the ipsilateral and contralateral kinetic test or Gillet test (Hungerford et al 2004)) and the active straight leg raise test (Mens et al 2001, 2002). I'd like to explain how these tests can help the clinician when prescribing a specific exercise program for stabilization of the pelvic girdle. Parts of what follows is 'proven' in the scientific iterature and part still remains based on clinical experience; evidence-based practise ala Sackett. The article describes these tests and is taken in part from the 3rd edition of the Pelvic Girdle (Lee 2004).
Recent Advances in the Assessment and Treatment of the Sacroiliac Joint - Stability & The Role of Motor Control
Presented in whole or part at the:
American Back Society Meeting - San Francisco 2005
BC Trial Lawyers Meeting - Vancouver 2005
Japanese Society of Posture & Movement Meeting - Tokyo 2006
A primary function of the pelvis is to transfer the loads generated by body weight and gravity during standing, walking, sitting and other functional tasks. How well this load is managed dictates how efficient function will be. The word 'stability' is often used to describe effective load transfer and requires optimal function of three systems: the passive (form closure), active (force closure) and control (motor control) (Panjabi 1992). Collectively these systems produce approximation of the joint surfaces (Snijders & Vleeming 1993a,b). The amount of approximation required is variable and difficult to quantify since it depends on an individual's structure (form closure) and the forces they need to control (force closure). The following definition of joint stability comes from the European guidelines on the diagnosis and treatment of pelvic girdle pain (Vleeming et al 2004). Definition of Joint Stability
Definition of Joint Stability
"The effective accommodation of the joints to each specific load demand through an adequately tailored joint compression, as a function of gravity, coordinated muscle and ligament forces, to produce effective joint reaction forces under changing conditions. Optimal stability is achieved when the balance between performance (the level of stability) and effort is optimized to economize the use of energy. Non-optimal joint stability implicates altered laxity/stiffness values leading to increased joint translations resulting in a new joint position and/or exaggerated/reduced joint compression, with a disturbed performance/effort ratio. (Vleeming A, Albert H B, van der Helm F C T, Lee D, Ostgaard H C, Stuge B, Sturesson B).
Based on this definition, the analysis of pelvic girdle function will require tests for excessive/reduced joint compression (mobility) as well as tests for motion control of the joints (sacroiliac (SIJ) and pubic symphysis) during functional tasks (one leg standing, active straight leg raise). Motion control of the joints requires the timely activation of various muscle groups such that the co-activation pattern occurs at minimal cost (minimal compression or tension loading and the least amount of effort) to the musculoskeletal system. Analysis of neuromuscular function will require tests for both motor control (timing of muscle activation) and muscular capacity (strength and endurance) since both are required for intersegmental or intrapelvic control, regional control (between thorax and pelvis, pelvis and legs) as well as the maintenance of whole body equilibrium during functional tasks. Treatment protocols should include techniques to reduce joint compression where necessary, exercises to increase joint compression where and when necessary and education to foster understanding of both the mechanical and emotional components of the patient's experience.
Forward for 'The Pelvic Girdle, 3rd Edition' by Dr. Paul Hodges
"Bridging the gap between science and clinical practice presents enormous challenges. Often we are faced with clinical techniques that develop with little consideration of biomechanical and neurophysiological findings or, conversely, basic science that contributes little to the progression of clinical practice. What Diane Lee and her colleagues have attempted and largely achieved here is a successful collaboration between science and practice. The result is an integrated clinical approach that incorporates a blend of concepts that are underpinned by research and clinical ideas that are based on observation of countless patients. Diane's clinical reasoning, based on observation of patterns of function and dysfunction, is attractive and thought-provoking..."
