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The Thorax – an integrated approach

This detailed foreword, by Gregory S Johnson, to Diane Lee‘s impressive and authoritative work on the thorax and its interconnections with the rest of the body, is both informative and enthusiastic. We hope it gives a suitable introduction to this keenly awaited book for physical therapists, osteopaths, chiropractors, massage therapists, yoga therapists and Pilates teachers. Full details of The Thorax: An integated approach available here.

Foreword by Gregory S Johnson

In 2003, when Diane Lee’s earlier book on the thorax was released, the content of that work was instrumental in enhancing my knowledge of the thoracic cage. In preparing for writing this foreword, I returned to my original book to find it well-worn with many loose pages, secondary to extensive study by our Fellows-in-training. I am delighted to report that this new book demonstrates extensive evolution in thought and organization.

Every major profession, to progress and define itself, must have visionaries who propel the present state of knowledge to a new level. Diane Lee is one of those visionaries. This book presents a unique paradigm of evaluation and treatment (The Integrated Systems Model) that has the potential to transform our profession. The existing science and extensive clinical knowledge are melded into a guide for others to better understand the human body, and how to manage their patient’s physical complaints. This book is not only about the thoracic cage, but one that explores the interconnections between the thoracic cage and the rest of the body. To quote from the text, as Diane expresses the concepts so well:

‘Today we understand that the thorax is part of many integrated and interdependent systems, including the musculoskeletal, neurological, respiratory, cardiovascular, digestive, and urogynecological systems. As such, it should not be considered in isolation from the rest of the body, but rather in relation to it…Sueki et al. (2013) refer to this as regional interdependence, a concept that suggests ‘the function and health of one region of the body could potentially affect the function of another.’

The Integrated Systems Model is described as: …an evidence-informed, clinical-reasoning, biopsychosocial approach. It is a framework, not a classification, that considers all three dimensions of the patient’s experience (sensorial, cognitive, emotional) and the barriers that each may present to the recovery process for both acute and persistent conditions. The body or person can no longer be considered as individual parts or problems in either assessment or treatment. Most tasks involve the whole body; therefore, assessment must include an analysis of the relationship between the body regions and the impact and interplay of each.

This well-organized book begins with an in-depth analysis of the anatomy of the thoracic cage including a guide to surface anatomy palpation.

Chapter 2 Biomechanics of the thorax

The second chapter, on biomechanics, begins with the following statement: The thorax plays a critical role in multiple conditions since it is part of many integrated, and interdependent, systems including the musculoskeletal, respiratory, cardiovascular,  digestive, and urogynecological systems. This chapter highlights the current state of research evidence, as well as clinical observations pertaining to the biomechanics (osteokinematics and arthrokinematics) of the various regions of the thorax.

Chapter 3 Assessment of the thorax and its relationship to the whole body

Assessment and treatment of the whole person (body, mind and spirit) require an understanding of the relationship between, and the contribution of, various body regions, systems, thoughts, beliefs, and social behaviors or contexts that are ultimately manifesting as cognitive, emotional or sensorial dissonance or altered performance. One of the brilliant breakthroughs that the book presents is the organized assessment to identify the primary drivers (body regions) to more effectively manage physical problems.

Chapter 4 Individualized treatment program

The goal of treatment is to motivate a change in the patient’s physical, cognitive and emotional behavior to improve the strategies they use for function and well-being. Treatment is presented as an integrated system of  manual therapy, motor facilitation, releases for the neural and dural systems, and a home program in a  biopsychosocial model.

Chapter 5 Case reports on the relationship of the thorax to the whole body

Well-organized and presented case studies illuminate the concepts of the integrated approach.

Chapter 6 Release techniques for system impairments

This great chapter which presents a step by step approach to treatment techniques begins with the following overview: The Integrated Systems Model (ISM) helps the clinician to organize all the information from the assessment to develop prescriptive, individual treatment programs. The ISM acronym for treatment is RACM: Release, Align, Connect and Control, Move. ISM treatment is initially directed toward the driver or drivers and each session contains components of techniques, exercises, and education to release and align the driver (region of the body that when corrected has the biggest impact on the function of other regions).

Chapter 7 Motor learning and movement training

The final chapter wraps up the treatment approach with progressive training of the motor system (motor control) and includes movement training exercises drawn from yoga and Pilates. Diane opens with the following paragraph: The final and critical part of each treatment session is to train better strategies for function and performance, which requires motor learning and movement training. The aim is to build and use new and better ‘brain maps’ and movement strategies that share loads and control excessive canister pressures (cranial, thoracic, abdominal, pelvic) in a way that sustains tissue structure, blood flow and drainage, function, and overall health. This is a ground-breaking text that can significantly contribute to the physical therapy profession.

The following quote says a lot about the author:

Diane Lee

‘Every patient has a story to tell and it is a privilege to be given the opportunity to listen to that story and to try to illuminate a path to change that will result in improved quality of life.’


Gregory S. Johnson PT, FFMT, FAAOMPT Co-Director & Co-Founder, Institute of Physical Art, Inc. Vice President, Functional Manual Therapy Foundation Director, FMT Fellowship Program, Colorado, USA 201