Regional Interdependence – Are we treating the cause?

Physical therapists are not static movement therapists, but rather functional movement therapists that observe and integrate movement from multiple body parts. A good physical therapist will observe posture in dynamic conditions, such as walking, running and stepping. Only after observing the locomotor chain whilst doing activities such as these, can we truly treat the problem rather than just the symptoms.

For example, to help alleviate the pain associated with patellofemoral pain syndrome we could massage a tight rectus femoris muscle. This may help decrease some knee discomfort initially, but if we do not address the causative factors (weak hip flexor and abductor for example) we may be back at square one in 2-3 weeks with the same problem.

The concept of regional interdependence can best be defined where “seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.”[i][ii] This idea is not new to physical therapy – others may use the phrase “looking up or down the chain.” I contend, that the approach of regional interdependence, as outlined by Wainer et al (2007) in treating musculoskeletal conditions is current best practice in the field of physical therapy[iii].

Some recent examples of regional interdependence include, but are not limited to:

·      Manipulating the thoracic spine to treat mechanical neck pain [iv]

·      Manipulating the cervical spine to treat lateral epicondylalgia [v]

·      Hip joint mobilization and hip strengthening to help with the pain associated with knee osteoarthritis[vi] [vii]

·      Lumbar facet mobilization to decrease quads inhibition[viii],[ix] and patellofemoral pain [x]

·      Sacroiliac joint mobilization to treat hip pain [xi]

·      Manipulating the thoracic spine and upper ribs to help relieve shoulder pain and improve ROM [xii]

I am sure that for many physical therapists, treating one body part to have a treatment effect on another body part is not a novel concept. We all have some idiosyncratic treatment techniques, that although may not always be evidence-based, we perform anyway to address specific musculoskeletal problems. Most physical therapists with an ounce of clinical reasoning and artistic flair have thrown novel ideas around their head, trying to approach common conditions from a different angle. Where physical therapists are starting to do better though, is to trial and test these novel ideas in controlled environments.

Don’t get me wrong, treating the injured area is a very important part of physical therapy, necessary to reduce the pain and inflammation that can often cause muscle inhibition and further dysfunction.

Vaughn (2008) in his case report provides a methodological approach to investigating a female runner with knee pain.[xiii] Examination of the patient’s knee and hip did not find any abnormalities, besides medial joint line tenderness. A more proximal examination found asymmetrical sacroiliac joint dysfunction. After a series of pubic symphysis and sacroiliac joint manipulations, the patient’s pain was eliminated and she could run again. We know that sacroiliac joint tests alone have low reliability, and treating the SIJ remains one of the most controversial topics in physical therapy. We also know that case studies have a very low level of evidence to base treatment decisions from. This study provides an interesting approach though to using the regional interdependence model.

I argue that it may have been even better to assess the patient’s running style, record it on video and break down the functional movement patterns or inefficiencies. This allows us to really see the patient as a whole, and make observations at each joint from the thoracic spine to the toes – after all, we are movement specialists. Once the bigger picture has been examined, we can observe more specific tissue changes that may be occurring such as hamstring tightness or reduced hip flexion.  Only by using this combined approach of regionally specific and regionally distant assessment, followed by purposeful treatment, can we be truly practicing the concept of regional interdependence.

[i] Wainner R, Whitman J, Cleland J, Flynn T. Regional Interdependence: A musculoskeletal examination model whose time has come. Journal of Orthopaedic & Sports Physical Therapy. 2007;37(11):658-660.

[ii] Wainner RS, Flynn TW, Whitman JM. Spinal and Extremity Manipulation: The Basic Skill Set for Physical Therapists. San Antonio, TX: Manipula-tions, Inc; 2001.

[iii]   Wainner R, Whitman J, Cleland J, Flynn T. Regional Interdependence: A musculoskeletal examination model whose time has come. Journal of Orthopaedic & Sports Physical Therapy. 2007;37(11):658-660.

[iv] Cleland JA, Childs JD, Fritz JM, et al. Development of a clinical prediction rule for guiding treatment of a subgroup of patients with neck pain: use of thoracic spine manipulation, exercise, and patient education. Phys Ther. 2007;87(1):9–23.

[v] Cleland JA, Whitman JM, Fritz JM. Effectiveness of manual physical therapy to the cervical spine in the management of lateral epicondylalgia: a retrospective analysis. J Orthop Sports Phys Ther. 2004;34(11):713–722.

[vi] Currier LL, Froehlich PJ, Carow SD, et al. Development of a clinical prediction rule to identify patients with knee pain and clinical evidence of knee osteoarthritis who demonstrate a favorable short-term response to hip mobilization. Phys Ther. 2007;87(9):1106–1119.

[vii] Cliborne AV, Wainner RS, Rhon DI, et al. Clinical hip tests and a functional squat test in patients with knee osteoarthritis: reliability, prevalence of positive test findings, and short- term response to hip mobilization. J Orthop Sports Phys Ther. 2004;34(11):676–685.

[viii] Suter E, McMorland G, Herzog W, Bray R. Decrease in quadriceps inhibition after sacroiliac joint manipulation in patients with anterior knee pain. J Manipulative Physiol Ther. 1999;22(3):149–153

[ix] Suter E,McMorland G,Herzog W,Bray R.Conservativelowerbacktreatmentreduces inhibition in knee-extensor muscles: a randomized controlled trial. J Manipulative Physiol Ther. 2000;23(2):76–80.

[x] Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treat- ment of patients with patellofemoral pain syndrome: development of a clinical predic- tion rule. J Orthop Sports Phys Ther. 2008;38(6):297–312.

[xi] Cibulka MT, Delitto A. A comparison of two different methods to treat hip pain in runners. J Orthop Sports Phys Ther. 1993;17(4):172–176.

[xii] Strunce J, Walker M, Boyles R, Young B. The immediate effects of thoracic spine and rib manipulation on subjects with primary complaints of shoulder pain. Journal of Manual & Manipulative Therapy.2009;17(4):230-236

[xiii] Vaughn D. Isolated knee pain: a case report highlighting regional interdependence. Journal of Orthopaedic & Sports Physical Therapy. 2008;38(10):616-623.