Therapeutic Movement Seminars

The Next Generation in Continuing Education

[email protected]
206-930-9204
Cart
| Online Courses
My Profile

A Regional Interdependence Model of Musculoskeletal Dysfunction

by

Premise

This article is a statement of clinical reasoning related to regional interdependence, rather than a true ‘study’.  It is perhaps the flagship article for a rehab idea or principle. Bodies are integrated, connected and dependent upon each other—manifesting not just locally, but regionally and globally as well. The authors do a nice job of defining regional interdependence (RI) and relating it to clinical musculoskeletal practice:

 

    • ‘The underlying premise is that seemingly unrelated impairments in remote anatomical regions may contribute to and be associated with a patient’s primary report of symptoms’.
    • ‘The clinical implication of this premise is that interventions directed at one region of the body will often have effects at remote and seeming unrelated areas’.

 

Paraphrasing then—‘this is connected to that and limitations or dysfunction distally can contribute to negative effects locally’. And—‘assessing and treating areas other than just at the site of pain are an important part of the rehab process’. Though RI primarily relates to inter-actions and effects of one somatic region to another, the authors were thorough by including references to ‘neurophysiological, somatovisceral, and biopsychosocial’ inter-relationships with and effects on the health of the musculoskeletal system.

 

Mechanisms

How does it happen that mobilization of the thoracic spine reduces neck pain? How does strengthening the gluteus medius reduce anterior knee pain? How does improving hip internal rotation help reduce low back pain in a golfer? How does an ankle sprain turn off the gluteal muscles? These examples are taken directly from regional interdependence-related research.

 

Kinetic Mechanical Engineering Model is the first proposed mechanism by which RI works. This Kinetic Chain model ‘describes the body as a series of interconnected joints where the movement of one joint directly effects the movement of other joints above and below’. We already know this intuitively—if we lack ankle dorsi-flexion we get more foot pronation. If we lack hip flexion we get more lumbar flexion. If we lack thoracic extension we get more cervical extension.

 

If you can’t move in one place you end up moving more somewhere else, which is a recipe for joint hypermobilities. This phenomenon of movement imbalance or inefficiency has been aptly described by Shirley Sahrmann with language of ‘path of least resistance’ and ‘relative flexibility’. We can extrapolate, or can enlarge upon this concept, to include muscle imbalances. If you don’t work appropriately in one muscle, some other muscle will have to pick up the slack. This leads to muscle hypertonicities.

 

Neurophysiological Mechanisms is the second proposed mechanism for RI. The authors decline to define exactly what this means, other than to say it’s ‘related to temporal summation and pain perception related to manual therapy interventions’.  While the kinetic engineering model is more nuts and bolts and Newtonian physics, the neurophysiological model is more micro chips, fiber optic cable and Jungian psychology. How does the brain react to stimuli? Which chemicals are created? What affect does being touched have? When are neurotransmitters nullified? Where are hormones are housed? How are signals relayed through the nervous system and what inexplicable detours do they take into the endocrine and limbic systems? Why is pain reduced in the neck or shoulder immediately upon receiving thoracic mobilization or manipulation?

 

Mystery Solved?

Nobody really knows yet and, with continuously new discoveries about how wonderfully complex the mind is, perhaps we never will know. It’s not magic, but only because we have an impressive scientific name for it. We know the generalities (nervous system phenomenon creating somatic effects) but not the specifics (exact pathways, reliable and reproducible intervention strategies).

 

Dry needling of trigger points and cranio-sacral therapy are examples of rehab interventions that rely more on neurophysiological mechanisms. Joint mob/manipulation has a nuts and bolts aspect (more joint mobility or centering of the joint) and a neurophysiological aspect and there is a fair amount of research from manual therapy enthusiasts on the benefits of joint mob/manipulation.

 

Many more articles are cited looking at somatic relationships—hip to knee, hamstring to plantar fascia, hip rotation and low back pain. These types of studies are more supportive of the kinetic chain aspect of RI. Where do the authors fall? Right in the middle—there is probably a combination of biomechanical and neurophysiological factors (as well as biopsychosocial factors) and, as always, further study is warranted. Take home?

 

    • Musculoskeletal interdependence exists between regions of the body. Interconnected kinetic chains and synergistic muscle groups are the reality—isolate and localized is illusory.
    • Changes in the musculoskeletal system must also be accompanied by changes in neurophysiology because these and other systems work in concert to perform tasks.

 

Choices

There are actually 125 citations at the end of this article. Many are manual therapy focused, with some perhaps indicating more of a ‘neurophysiological model’ benefit—mobilizing the thorax helps the neck, mobilizing the neck helps the elbow, etc. But, many also fit into the ‘kinetic mechanical engineering model’—strengthening the hip helps the knee, loosening the hip helps the low back, etc.

 

You will likely be drawn to the kinetic model if you tend to think in terms of exercise and the mechanics of joint movement, muscle activation or muscle inhibition. Or, you might be more drawn to the neurophysiological model if you like the manual therapy paradigms—or if you consider yourself a healer. However, it’s not really an either/or choice. Both mechanisms are in play, with varying degrees of impact, with either type of intervention we propose:

 

    • Joint mobilization gets a person touched, lubricates joints, stimulates blood flow, creates a slew of proprioceptive and neurological information, provides pressure against joint surfaces and ligamentous articular structures, improves joint play and range of motion, or helps center the joint.
    • Dynamic movement training, in the form of motor control exercise—does all that too, except for the touch part. But movement has the following advantages:

 

      • Nervous system involvement in muscle control. Activating and inhibiting their own muscles. Coordinating synergists. Coordinating and cooperating antagonists. Training the Motor—wiring and firing muscle activation patterns.
      • Nervous system involvement in ‘control tower’ activities. ‘What can I sense’ and ‘what do I want to do’? Training the Sensor and the Decider—attention to feedback and intension to target.
      • They can practice at home.

 

So, can we piggyback regional interdependence research based on manual therapy paradigms, or on localize and isolate exercise techniques, to dynamic integrated movement training? Can we expect the same kinetic and neurophysiological benefits with motor control exercise that we have seen in these studies? In our view, yes—and probably even better.

 

We don’t normally provide a bibliography, but wanted to in this instance. This is just a short list of regional interdependence material out there, and just taken from the bibliography of this one article—glance through the titles to get a flavor:

 

    • Thorax to neck and shoulder.
    • Hip to lumbar.
    • Hip to knee.
    • Ribs to shoulder.
    • Low back to foot.
    • Lower extremity strength to shoulder.
    • Think that this is an all-inclusive list of body inter-connections?

 

A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Sueki DG1, Cleland JA2, Wainner RS3 J Man Manip Ther. 2013 May;21(2):90-102.

 

      1. Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2007;37(11):658–60 [PubMed] [Google Scholar]
      2. Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Moore JH, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther.2009;14(4):375–80 [PubMed] [Google Scholar]
      3. Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipulation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10(2):127–35 [PubMed] [Google Scholar]
      4. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: a single-arm trial. Phys Ther. 2010;90(1):26–42 [PubMed] [Google Scholar]
      5. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12–9 [PubMed] [Google Scholar]
      6. Strunce JB, Walker MJ, Boyles RE, Young BA. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. J Man Manip Ther. 2009;17(4):230–6 [PMC free article] [PubMed] [Google Scholar]
      7. Bialosky JE, Bishop MD, George SZ. Regional interdependence: a musculoskeletal examination model whose time has come. J Orthop Sports Phys Ther. 2008;38(3):159–60; author reply 160 [PubMed] [Google Scholar]
      8. Cibulka MT. Low back pain and its relation to the hip and foot. J Orthop Sports Phys Ther.1999;29(10):595–601 [PubMed] [Google Scholar]
      9. Porter JL, Wilkinson A. Lumbar-hip flexion motion. A comparative study between asymptomatic and chronic low back pain in 18- to 36-year-old men. Spine. 1997;22(13):1508–13; discussion 1513–4 [PubMed] [Google Scholar]
      1. Sueki DG, Chaconcas EJ. The effect of thoracic manipulation on shoulder pain: a regional interdependence model. Phys Ther Rev. 2011;16(5):399–408 [Google Scholar]
      2. Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, Gutierrez-Vega Mdel R. Thoracic spine manipulation for the management of patients with neck pain: a randomized clinical trial. J Orthop Sports Phys Ther. 2009;39(1):20–7 [PubMed] [Google Scholar]
      3. Stupar M, Cote P, French MR, Hawker GA. The association between low back pain and osteoarthritis of the hip and knee: a population-based cohort study. J Manipulative Physiol Ther. 2010;33(5):349–54 [PubMed] [Google Scholar]
      4. Arab AM, Nourbakhsh MR. The relationship between hip abductor muscle strength and iliotibial band tightness in individuals with low back pain. Chiropr
      5. Johnson EN, Thomas JS. Effect of hamstring flexibility on hip and lumbar spine joint excursions during forward-reaching tasks in participants with and without low back pain. Arch Phys Med Rehabil.2010;91(7):1140–2 [PMC free article] [PubMed] [Google Scholar]
      6. Mellin G. Correlations of hip mobility with degree of back pain and lumbar spinal mobility in chronic low-back pain patients. Spine. 1988;13(6):668–70 [PubMed] [Google Scholar]
      7. Rothbart BA, Estabrook L. Excessive pronation: a major biomechanical determinant in the development of chondromalacia and pelvic lists. J Manipulative Physiol Ther. 1988;11(5):373–9 [PubMed] [Google Scholar]
      8. Brantingham JW, Lee Gilbert J, Shaik J, Globe G. Sagittal plane blockage of the foot, ankle and hallux and foot alignment-prevalence and association with low back pain. J Chiropr Med. 2006;5(4):123–7 [PMC free article] [PubMed] [Google Scholar]
      9. Powers CM. The influence of abnormal hip mechanics on knee injury: a biomechanical perspective. J Orthop Sports Phys Ther. 2010;40(2):42–51 [PubMed] [Google Scholar]
      10. Bolgla LA, Malone TR, Umberger BR, Uhl TL. Comparison of hip and knee strength and neuromuscular activity in subjects with and without patellofemoral pain syndrome. Int J Sports Phys Ther.2011;6(4):285–96 [PMC free article] [PubMed] [Google Scholar]
      11. Finnoff JT, Hall MM, Kyle K, Krause DA, Lai J, Smith J. Hip strength and knee pain in high school runners: a prospective study. J Inj Funct Rehabil. 2011;3(9):792–801 [PubMed] [Google Scholar]
      12. Rowe J, Shafer L, Kelley K, West N, Dunning T, Smith R, et al. Hip strength and knee pain in females.N Am J Sports Phys Ther. 2007;2(3):164–9 [PMC free article] [PubMed] [Google Scholar]
      13. Molgaard C, Rathleff MS, Simonsen O. Patellofemoral pain syndrome and its association with hip, ankle, and foot function in 16- to 18-year-old high school students: a single-blind case–control study. J Am Podiatr Med Assoc. 2011;101(3):215–22 [PubMed] [Google Scholar]
      1. Lucado AM, Kolber MJ, Cheng MS, Ecternach JL. Subacromial impingement syndrome and lateral epicondylalgia in tennis players. Phys Ther Rev. 2010;15(2):55–61 [Google Scholar]
      2. Ben Kibler W, Sciascia A. Kinetic chain contributions to elbow function and dysfunction in sports. Clin Sports Med. 2004;23(4):545–52, viii [PubMed] [Google Scholar]