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.
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?
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.
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?
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