Regional Interdependence in the Physical Therapy Practice

 

By Jamie Mey, PT, DPT, CMTPT & Tim Swenson, PT, DPT

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We’ve all heard the classic debate of what came first, “the chicken or the egg?” Of course, there are logical explanations to whichever side of the argument you find yourself on. There is no one correct answer; a chicken comes from an egg, and the egg comes from a chicken. This maddening debate will last an eternity, but there is one takeaway from this debate that always resonates with me – you cannot have one without the other. This parallel corresponds to conditions & diagnoses we come across as physical therapists. According to Mintken et al., the theory of examining and treating impairments away from the primary source of pain is gaining popularity in the orthopedic manual therapy setting (Mintken at al, 2015). Let’s discuss an example of this concept. There is an evident link between thoracic spine mobility and shoulder function, however is the shoulder pain causing thoracic hypomobility (the chicken) or is the thoracic hypomobility leading to shoulder impingement (the egg)?

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The human body is a complex phenomenon composed of hundreds of joints. Think of these joints as links in a mechanical chain that function together to complete a particular movement. Much like any mechanical system, if there is a weak link anywhere along the chain, the movement can break down. As a result of the weak link(s), an individual may or may not experience pain in a particular area. There is a growing body of evidence that is beginning to identify the importance of treating adjacent joints within a particular “chain”. Here is where the term “regional interdependence” comes into play. This term describes the clinical model that seemingly unrelated impairments in individual body parts may contribute to a patient’s primary complaint of pain (Sueki et al, 2013). If you’re having pain in any one joint, it may be a summation of movement deficiencies in the surrounding joints. A referral for physical therapy could be just what you need to start moving better and optimize your overall function.  

How about some examples from evidence-based research? Boyles et al depicts the short term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. This journal article proves how manual interventions, such as cervicothoracic spine thrust manipulation and rib opening techniques, can influence functional shoulder impairments associated with dysfunction of the glenohumeral joint and subacromial space (Boyles et al, 2015). Reiman et al portrays the biomechanical relationship between the hip and the low back, particularly the multiple shared muscles (psoas, quadratus lumborum, erector spinae, and gluteus maximus).  Furthermore, this article introduces the concept of ‘hip-spine’ syndrome, which depicts the influence of a pathological hip joint on the alignment of the spine and subsequent muscle length and joint forces. For example, severe hip osteoarthritis (OA) has the potential to cause abnormal spinal sagittal alignment and hip-flexion contractures can ultimately result in compensatory lumbar hyperlordosis.

Question #1: If a patient comes in for an initial evaluation for knee pain, are we just assessing knee impairments or are we taking additional objective measures of the hip and ankle as well? As a highly qualified physical therapist, it is essential we are attentive to other dysfunctions throughout the kinetic chain. In fact, it would be a disservice to neglect assessing the joints proximally and distally to the joint of pain. Let’s consider the game Jenga. Jenga is a classic game consisting of a tower constructed of 54 wooden blocks. With the removal of each block, the tower becomes increasingly more unstable. Ultimately, the removal of one wooden block can lead to the collapse of the entire tower and bring the game to an end. This relates to the concept of regional interdependence as it portrays how one minor physical impairment can influence connecting joints, potentially leading to distant pain.

Question #2: So, does it matter which came first – the chicken or the egg? In our practice, it is crucial to understand the link between the two and be sure to treat all connected impairments. The concept of regional interdependence is becoming much more recognized, regardless of the fact that the ‘cause & effect’ has not yet been established. It is obvious that dysfunction of one body part has the potential to impart dysfunction upon another body part. It is our job to look beyond physical deficiencies and abnormalities as compensatory or contributory. Instead, focus on the fact that there is a relationship and both need to be independently addressed to completely resolve dysfunction as a whole. It is crucial we add regional interdependence to our ‘toolbox’ and allow it to help guide decision making and improve results. 

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