Beyond Diagnosis: Formulation-Informed Physiotherapy

Hello beautiful community,

On the daily, I feel incredibly privileged to do the work that I do.

I love welcoming people into my space, listening while you and your bodies share current and past challenges. I love observing movement patterns, noticing where there is fluidity or rigidity, and then palpating and testing to feel and understand the connections beneath what we see.

One of the best parts of my job (which probably speaks to my slightly insufferable determination) is that I love complex bodies. In particular, bodies that have sought help from multiple places and still haven’t found lasting relief. This is where I get energised in the nerdy sense.

I want to reassure you that I don’t relish in my clients’ suffering, I just genuinely love solving problems.

From diagnosis to formulation

I completed a Psychotherapy Master’s in 2023, and although I quickly realised I prefer hands-on therapy over talk therapy, one concept stayed with me. I had already dabbled in it prior to 2023, but it has now deeply shaped my physiotherapy practice: formulation.

In psychotherapy, formulations are used instead of relying solely on diagnoses to direct treatment. It asks:

“Why is this person experiencing this problem, in this particular way, at this particular time?”

It seeks to understand the meaning, origins, and maintaining factors behind symptoms by integrating history, environment, relationships, biology, strengths, and current stressors into one coherent picture.

In physiotherapy, this translates beautifully.

A physiotherapy formulation integrates symptoms, movement history, biomechanics, load capacity, nervous system behaviour, and environmental demands into a working understanding of why this body is presenting this way in this moment.

So instead of asking, “What is the diagnosis?”, we ask:

• How is the whole body behaving?

• What adaptations has the pain created?

• Where has the body lost its fluidity?

• Where is it protecting?

• What is overworking?

• What systems are no longer communicating efficiently?

• What forces are not being transferred well?

Take a client with ongoing knee pain and a confirmed lateral meniscus tear on MRI.

Yes, there is a structural lesion, but a formulation asks for a much wider lens.

The obvious stuff:

Local biomechanics:

• Tibiofemoral positioning

• Patellofemoral tracking

• Tissue tone and irritability

• Rigidity vs laxity

• Is this knee guarding?

• Is it under-supported and overworking?

Global biomechanics:

Where does the knee sit within the rest of the body?

• Hip control and femoral orientation

• Foot and ankle load absorption

• Lumbopelvic and cervicothoracic contributions to load transfer

Neural tissues (the often-overlooked layer)

What role is the nervous system and neural tissue playing in overall tone and movement strategy?

• Is this simply a mechanical restriction in neural tissue length or flexibility?

• Or a centrally driven protective strategy?

So do we need to mobilise the neural tissue (one of my favourite tasks), or help threat perception settle so the system allows it to let go?

The formulation framework makes us consider not just “what is tight?” but “why?”

Tensegrity and the interconnected body

This is where tensegrity becomes incredibly useful. Tensegrity is one of my favourite concepts (which I believe I have introduced before in a previous blog), but it provides another real paradigm shift for when working with the body.

The body can be understood as a tensegrity system, where bones act as compression elements, and fascia, muscles, and connective tissue distribute tension throughout the entire structure.

Think of the Sydney Harbour Bridge, a suspension bridge. The towers provide structure, but their integrity relies heavily on the constant tension of steel cables pulling in multiple, opposing directions. Remove or overload one cable, and the load redistributes everywhere.

The body behaves in a similar way.

Therefore, no problem or dysfunction is ever truly local.

What this really highlights is that symptoms often don’t emerge from a single failing structure. More often, they appear when the body has run out of adaptable options.

To use another slightly questionable analogy: it’s like a footy team where the winger gets injured, so the halfback steps in to cover the gap. Then the halfback goes down too, and suddenly there’s no one left with the right capacity to carry that role. The system doesn’t fail because one player is “bad”, it fails because the compensations have been stretched too far.

Once we understand that a diagnosis often sits at the tail end of a long chain of adaptations, the clinical approach has to change too. We start working backwards, exploring the precipitating factors and ongoing drivers that led to patterns like excessive lateral compression, reduced rotational control, and ultimately the tissue overload we can diagnose as a meniscal injury.

As always, the nervous system needs to be part of the story

When we consider how the nervous system organises itself under load, stress, and perceived threat, we are really asking how the body reflects safety or danger in real time.

Posture, movement, and breathing are not simply mechanical outputs, but adaptive strategies shaped by continuous neural influence. Under increased load, whether physical or emotional, the system tends to reduce variability and increase global tone as a way of creating stability, predictability, and control.

For example, my own snake phobia is expertly contained by only hiking in winter, wearing long pants and boots that cover my ankles. I’m always very elegant.

Bodies do something similar. A person may narrow their rib cage (grip through intercostals for example) and reduce diaphragmatic excursion to maintain an embodied sense of containment.

A formulation means that you consider these patterns as not solely a response to current mechanical load. They are shaped by the nervous system’s ongoing integration of past and present experience. The body learns from repeated exposure to stress, demand, and relational context, and these experiences become embedded in how it anticipates and prepares for future challenge.

As a result, what we observe clinically as “tone” or “posture” should also be understood as a form of embodied memory and an adaptive strategy that once made sense, and may still feel necessary.

What this means for treatment?

All of this feeds directly into how I treat.

Rather than chasing isolated symptoms, I am always asking:

• What is the body trying to achieve?

• What is it trying to avoid?

• What is it protecting against?

• Where did this strategy begin?

• Which systems are driving the compensation?

• Which patterns are primary, and which are secondary adaptations?

Because symptoms are often the end point of a much larger story.

A formulation-based approach means treatment becomes highly individualised. Sometimes it needs strengthening, sometimes multiplanar control, sometimes it needs reduced protective bracing, sometimes it needs nervous system regulation, sometimes it needs improved adaptability, and most of the time, it needs a combination of all the above.

I don’t chase pain reduction. But when communication between systems is improved and efficient load transfer is restored, the body has options and is in a calmer, less protective state. When that happens, the conditions that led to the pain are often no longer present, and the pain will usually dissipate too.

Thank you, as always, for trusting me with your bodies and stories, and for satisfying my brain’s insatiable appetite for problem solving.

Gina Kezelman

Blog May 2026