Purpose & Definition
The purpose of this article is to explain the examination model of regional interdependence. Simply put, regional interdependence is the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint. Current research has shown that regional interdependence can be affected not only by other regions in the musculoskeletal system but impairements from varying body systems and regions.
Why Use the Regional Interdependence Model?
The regional interdependence model of examination allows the PT to go beyond traditional, often vague, and even sometimes misleading musculoskeletal diagnoses, and provide optimal care to their patients. Often times, the contributors for these disorders may not be as straight-forward as they appear. For example, patients who complain of LBP may actually be suffering from disorders of the hip or knee joint. Examination of proximal and distal joints in the same region of the reported pain and dysfunction is vital to the concept of regional interdependence. It is important to remember, that regional interdependence is different than referred pain.
Examples in Literature
There are numerous examples in the literature of the concept of regional interdependence being a viable option for PT examination and intervention planning. Here are a few examples of regional interdependence at work:
1. Interventions aimed at the hip have been used to treat:
2. Interventions aimed at the lumbar spine have been used to treat:
3. Inteventions aimed at the thoracic spine and ribs have been used to treat:
4. Interventions aimed at the cervical spine have been used to treat:
Regional interdependence is part of the rationale behind the use of thrust manipulations for regional conditions, Recent research has shown that there may be a neurophysiological change that produces an improvement in pain and outcomes in musculoskeletal disorders. While local treatment is usually the first approach to rehab, the regional interdependence model can be utilized for persistent and chronic pain.
- Wainner RS, Flynn TW, Whitman JM. Spinal and Extremity Manipulation: The Basic Skill Set for Physical Therapists. San Antonio, TX: Manipulations, Inc; 2001.
- Sueki DG, Cleland JA, Wainner RS. A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. J Man Manip Ther. 2013 May;21(2):90–102.
- 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):658-660.
- Childs JD, Fritz JM, Flynn TW, et al. A clinicalfckLRprediction rule to identify patients with low back pain most likely to benefit from spinal ma- nipulation: a validation study. Ann Intern Med. 2004;141:920-928.
- Cibulka MT, Sinacore DR, Cromer GS, Delitto A. Unilateral hip rotation range of motion asymme- try in patients with sacroiliac joint regional pain. Spine. 1998;23:1009-1015.
- Porter JL, Wilkinson A. Lumbar-hip flexion motion. A comparative study between asymp- tomatic and chronic low back pain in 18- to 36-year-old men. Spine. 1997;22:1508-1513; discussion 1513-1504.
- Whitman JM, Flynn TW, Childs JD, et al. A comparison between two physical therapy treat- ment programs for patients with lumbar spinal stenosis: a randomized clinical trial. Spine. 2006;31:2541-2549.
- Reiman MP, Weisbach PC, Glynn PE. The hips influence on low back pain: a distal link to a proximal problem. J Sport Rehabil. 2009;18(1):24-32.
- 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;34:676-685.
- Deyle GD, Allison SC, Matekel RL, et al. Physical therapy treatment effectiveness for osteoarthri- tis of the knee: a randomized comparison of supervised clinical exercise and manual therapy procedures versus a home exercise program. Phys Ther. 2005;85:1301-1317.
- Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber MB, Allison SC. Effectiveness of manual physical therapy and exercise in osteoarthritis of the knee. A randomized, controlled trial. Ann Intern Med. 2000;132:173-181.
- Cibulka MT, Delitto A. A comparison of two dif- ferent methods to treat hip pain in runners. J Orthop Sports Phys Ther. 1993;17:172-176.
- Suter E, McMorland G, Herzog W, Bray R. Con- servative lower back treatment reduces inhibi- tion in knee-extensor muscles: a randomized controlled trial. J Manipulative Physiol Ther. 2000;23:76-80.
- Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. Immediate effects of thoracic manipu- lation in patients with neck pain: a randomized clinical trial. Man Ther. 2005;10:127-135.
- 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):230-236.
- Bang MD, Deyle GD. Comparison of supervised exercise with and without manual physical therapy for patients with shoulder impinge- ment syndrome. J Orthop Sports Phys Ther. 2000;30:126-137.
- Bergman GJ, Winters JC, Groenier KH, et al. Manipulative therapy in addition to usual medical care for patients with shoulder dysfunction and pain: a randomized, controlled trial. Ann Intern Med. 2004;141:432-439.
- McDevitt A, Young J, Mintken P, Cleland J. Regional interdependence and manual therapy directed at the thoracic spine. J Man Manip Ther. 2015 Jul;23(3):139–46.
- Fernández-Carnero J, Fernández-de-las-Peñas C, Cleland JA. Immediate hypoalgesic and motor effects after a single cervical spine manipulation in subjects with lateral epicondylalgia. J Manipulative Physiol Ther. 2008;31(9):675-681.
- Herd CR, Meserve BB. A systematic review of the effectiveness of manipulative therapy in treating lateral epicondylalgia. J Man Manip Ther. 2008;16(4):225-237.
- 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; discussion 722-724.