Journal of Manual & Manipulative Therapy

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A regional interdependence model of

musculoskeletal dysfunction: research,
mechanisms, and clinical implications

Derrick G Sueki, Joshua A Cleland & Robert S Wainner

To cite this article: Derrick G Sueki, Joshua A Cleland & Robert S Wainner (2013) A
regional interdependence model of musculoskeletal dysfunction: research, mechanisms,
and clinical implications, Journal of Manual & Manipulative Therapy, 21:2, 90-102, DOI:
10.1179/2042618612Y.0000000027

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 Narrative Review
A regional interdependence model of
musculoskeletal dysfunction: research,
mechanisms, and clinical implications
Derrick G. Sueki1, Joshua A. Cleland2, Robert S. Wainner3
1
Department of Physical Therapy, Mount St Mary’s College, Los Angeles, CA, USA, 2Department of Physical
Therapy, Franklin Pierce University, Concord, NH, USA, 3Department of Physical Therapy, Texas State University,
San Marcos, TX, USA

The term ‘regional interdependence’ or RI has recently been introduced into the vernacular of physical
therapy and rehabilitation literature as a clinical model of musculoskeletal assessment and intervention. The
underlying premise of this model is that seemingly unrelated impairments in remote anatomical regions of
the body 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. The formalized concept of RI is relatively new and was originally
derived in an inductive manner from a variety of earlier publications and clinical observations. However,
recent literature has provided additional support to the concept. The primary purpose of this article will be
to further refine the operational definition for the concept of RI, examine supporting literature, discuss
possible clinically relevant mechanisms, and conclude with a discussion of the implications of these
findings on clinical practice and research.
Keywords: Physical therapy, Regional interdependence, Rehabilitation

Introduction delivery of abnormal stresses to other segments of the

‘Regional interdependence’ or ‘RI’ is the term that system with the development of a subsequent dysfunc-
has been utilized to describe the clinical observations tion here as well’.13 Although Erhard’s observation
related to the relationship purported to exist between preceded Wainner’s, RI was not proposed as a formal
regions of the body, specifically with respect to the concept and did not gain wider recognition as a model
management of musculoskeletal disorders.1 There is a of assessment and treatment in the peer-reviewed
growing body of literature demonstrating that inter- literature until Wainner et al. described it in an
ventions applied to one anatomical region can editorial in 2007.1 At that time, it was proposed
influence the outcome and function of other regions primarily as a clinical model to be considered and
of the body that may be seemingly unrelated.2–7 incorporated in the context of a ‘test-treat-retest’
Despite the growing interest, controversy exists approach14 to treating patients with musculoskeletal
regarding the relevance of the RI model in physical disorders. Commentary in response to the original RI
therapy research and practice.8 Therefore, RI war- editorial countered the suggestion that RI was the
rants further examination and scientific scrutiny. result of musculoskeletal factors and suggested that RI
RI was initially defined and proposed as a part of a may also involve a neurophysiological response.8 The
basic manipulation skills educational CD-ROM devel- points made by Bialosky et al. in the response brought
oped by Wainner et al. in 2001.9 The concept of RI to light the fact that while the primary interest of RI
stemmed from the review of literature during which has been physical manifestations (typically pain and
they observed that regions of the body appeared to be range-of-motion) involving the musculoskeletal sys-
musculoskeletally linked.10–12 Erhard and Bowling tem, the mechanisms underlying these primary man-
alluded to this concept in 1977 when they stated: ifestations can be much more complex involving other
‘Dysfunction in any unit of the system will cause physiological systems.15 Any condition or disorder
initiates a series of responses that involves multiple
systems of the body. Not only musculoskeletal but also
Correspondence to: D Sueki Department of Physical Therapy, Adjunct neurophysiological, somatovisceral, and biopsychoso-
Faculty, Mount St Mary’s College, 10 Chester Place, Los Angeles, CA
90007, USA. Email: [email protected] cial responses occur when a disorder or condition

ß W. S. Maney & Son Ltd 2013

90 DOI 10.1179/2042618612Y.0000000027 Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2
 Sueki et al. A RI model of musculoskeletal dysfunction

Figure 1 Regional interdependence involves the coordi-

nated and integrated action of multiple systems including
musculoskeletal, biopsychosocial, neurophysiological, and
somatovisceral.
Figure 2 The allostatic process is responsible for the
16,17 regulation and integration of biopsychosocial, neurophysio-
disrupts homeostasis (Fig. 1). These allostatic
logical, somatovisceral, and musculoskeletal responses.
responses are all pieces of an integrated physiological
process that functions to restore equilibrium and primary complaint.1 The definition was limited in
promote recovery18,19 (Fig. 2). The RI model as that it considered the musculoskeletal system as the
defined represents the musculoskeletal manifestation primary source as well as manifestation of impair-
of a larger interdependent process by which other ments and did not consider other systems as sources
systems may be involved in eliciting these musculos- or factors that could contribute to the impairments.
keletal changes. Therefore, the current definition may be incomplete
The biomedical model of disease has served as or misleading and requires further refinement. A
the foundation for assessment and treatment in more comprehensive definition of RI would be ‘the
the clinical management of patients and it is taught concept that a patient’s primary musculoskeletal
in first-professional physical therapists programs as a symptom(s) may be directly or indirectly related or
primary model for managing patients with muscu- influenced by impairments from various body regions
loskeletal disorders. In this model, clinical manage- and systems regardless of proximity to the primary
ment decisions are predicated on the identification of symptom(s)’. In this definition, impairments are not
a pathoanatomical source tissue. However, interven- limited to the musculoskeletal system and include
tions and treatment plans focused upon a single those that may originate from other systems, which
pathological structure can often result in poor out- may contribute to or influence the patient’s primary
comes, in particular with spinal disorders for which a musculoskeletal complaint(s). Validating this defini-
pathoanatomic source tissue cannot be identified in tion, therefore, requires researchers to demonstrate
the majority of cases.20,21 In addition, clinical deci- that impairments in one region of the body or one
sion making based on a single pathological finding system of the body can have a direct or indirect
has been credited as contributing to these poor results.22 influence upon the musculoskeletal symptoms and
Therefore, in orthopedic clinical settings, the biome- function of another region of the body.7,8,23–29
dical model should be expanded to include identifica-
tion of other factors or regions that may contribute to Origins of RI
the patient’s complaints. The RI model of assessment RI is a musculoskeletal model born out of earlier
and treatment provides a framework to incorporate clinical reports and clinical observation. In other
this expanded focus. words, clinicians treating one region of the body,
The purpose of this article is to propose a revised such as the hip, noticed that signs and symptoms in
operational definition for the concept of Regional areas remote to the area of treatment, such as the
Interdependence based on current best evidence and knee, were altered. From this insight followed the
supporting literature. In addition, this article will observation that impairments located in one region of
explore the literature underlying the concept of RI, as the body could also be affected or were associated
well as the implications of the RI model for clinical with the musculoskeletal function and symptoms of a
practice and research. completely separate region.
The concept that the function and health of one
RI Defined and Redefined region of the body could potentially affect the
RI was originally defined as a concept that seemingly function of another region is not novel. In 1944,
unrelated impairments in remote anatomical regions Inman and Saunders30 stated that both clinical and
could contribute to and be associated with a patient’s experimental evidence indicated that pain could be

Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2 91

Sueki et al. A RI model of musculoskeletal dysfunction

experienced over a considerable distance from the site motion, and mobility of the lower quarter have all
of the local lesion and in 1959, Slocum31 stated that it demonstrated a positive association with the presence
was not uncommon for a baseball pitcher with an of low back pain and impairments.37–40 A relationship
injured toe or foot to lose the effectiveness of the between the foot and ankle and the lumbosacral region
shoulder joint. has been proposed in publications by Cibulka11 and
From these published beginnings, backed by Rothbart and Estabrook.41 Kosashvili et al.42 demon-
clinical observation and established clinical practice strated that a positive correlation exists between a pes
patterns, additional works under experimental con- planus position in the foot and low back pain.
ditions began to appear that supported the clinical Similarly, Brantingham et al.43 established a potential
interdependent relationship between regions of the positive relationship between ankle impairment and
body. Cleland et al.,3 Fernandez-de-las-Penas et al.,32 lumbar pain.
and Gonzalez-Iglesias et al.33 have all demonstrated While the preponderance of literature has focused
that interventions focused on the thoracic spine could on the lumbopelvic region, there have also been a
affect impairments in the cervical region. Similarly, recent number of publications related to the knee.
Currier et al.4 and Souza and Powers6 have both Powers44 has suggested that proximal factors such as
provided evidence that treatment of the hip could hip impairment may play a contributory role in knee
alleviate impairments located at the knee. Since it was injuries. Bogla et al.,45 Finnoff et al.,46 Souza et al.,6
editorialized in 2007, multiple studies have been and Rowe et al.47 have all demonstrated that de-
published that directly reference the concept of RI ficits in hip strength and abnormal hip mechanics
(Table 1). are positively correlated with knee pain (Table 2).
Although it is common clinical practice to assess and
Evidence for RI
treat the foot and ankle in patients with other lower
An electronic search was conducted using PubMed,
quarter impairments, very few studies aside from
Medline, Google Scholar, and the Cochrane Library.
those mentioned previously have looked specifically
The pool of articles was initially screened for studies
at the influence that the ankle or foot can have on
that included the words ‘regional interdependence’
outcomes related to the hip, pelvis, or lumbar spine.
and were also relevant to musculoskeletal and
Molgaard et al.48 studied high school students with
orthopedic physical therapy. Because the term
‘regional interdependence’ is relatively new, the patellofemoral pain (PFPS) found greater navicular
literature with direct reference to its usage is some- drop, navicular drift, and dorsiflexion in the
what limited. Using the described search method, 16 subjects with PFPS compared with healthy students
articles were found that specifically utilize or describe (Table 2).
the term ‘regional interdependence’ and are listed in Upper quarter
Table 1. An even larger number of studies exist in the Like the lower quarter, there is also evidence of RI
literature that supports the concept of RI but do not relationships in the upper quarter. (Table 2). Studies
directly reference the model (Table 2). A similar by Cleland et al.3 and Gonzales-Iglesias et al.33
search method was utilized to identify these articles. linking cervical pain to thoracic interventions have
Keywords utilized for the search consisted of the been mentioned previously. Additionally, Strunce
regions of interest (i.e. lumbar spine and knee). The et al.,7 Boyles et al.,2 and Mintken5 have demon-
results were then screened for articles relevant to strated that interventions focused on the thoracic
the topic. The reference list of the relevant articles spine have the potential to alter shoulder symptoms.
was then examined to determine whether additional
Yoo et al.49 demonstrated that sympathetic blocks at
articles existed that were not identified in the previous
the thoracic spine could improve upper extremity
search. The most relevant publications from the
neuropathic pain and Berglund et al.50 showed that
search will be described in the following sections.
pain and dysfunction of the thoracic spine is
Clinical Studies positively correlated with the presence of lateral
Lower quarter elbow pain. For a more in depth discussion, the
The majority of lower extremity literature supporting reader is directed to a systematic review by Walser
the concept and model of RI is related to the et al.51 that discusses the effect of thoracic manipula-
lumbopelvic region (Tables 1 and 2). Low back pain tion on various musculoskeletal conditions.
has been positively associated with hip osteoarthritis, While not as prevalent, numerous studies have also
fractures, and following total hip replacement linked impairments in the cervical spine and upper
surgery.34–36 Stupar et al. has also demonstrated a quarter. Berglund et al.50 surveyed subjects with
positive relationship between low back pain and lateral elbow pain and found 70% of subjects also
the presence of knee osteoarthritis.34 Additionally, reported pain in the cervical and thoracic regions
decreased strength, neuromuscular control, range of compared to 16% in the asymptomatic control group.

92 Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2

 Table 1 Studies with direct mention of regional interdependence

Number of Level of
Authors Title and journal Regions Design subjects evidence*

Systematic reviews and meta analyses

Walser RF, Meserve BB, Boucher TR51 The effectiveness of thoracic spine Thoracic spine and various Systematic review N/A Level 2a
manipulation for the management musculoskeletal conditions of cohort RCTs
of musculoskeletal conditions: a
systematic review and meta-analysis
of randomized clinical trials.
J Man Manip Ther 2009
Randomized control trials and experimental studies
Bunn EA, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD103 Effects of paraspinal fatigue on lower Lumbar spine and lower extremity Cohort 20 Level 2b
extremity motoneuron excitability in
individuals with a history of low back
pain. J Electrophysiol Kinesiol 2011
de Oliveira Grassi D, Zanelli de Souza M, Belissa Immediate and lasting improvements Sacroiliac joint and lower extremity Prospective cohort 20 Level 2b
Ferrareto S, Imaculada de Lima Montebelo M, Caldeira in weight distribution seen in
de Oliveira Guirro E104 baropodometry following a high-velocity,
low-amplitude thrust manipulation of
the sacroiliac joint. Man Ther 2011
Iverson CA, Sutlive TG, Crowell MS, Morrell RL, Perkins Lumbopelvic manipulation for the Lumbar spine and knee Cohort CPR 50 Level 2b
MW, Garber MB, Moore JH, Wainner RS105 treatment of patients with patellofemoral
pain syndrome: development of a
clinical prediction rule. J Orthop Sports
Phys Ther 2008
Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Some factors predict successful short-term Cervicothoracic spine and shoulder Cohort CPR 80 Level 2b
Keirns M, Whitman JM5 outcomes in individuals with shoulder
pain receiving cervicothoracic manipulation:
a single-arm trial. Phys Ther 2010
Strunce JB, Walker MJ, Boyles RE, Young BA7 The immediate effects of thoracic spine Thoracic spine and shoulder Cohort 21 Level 2b
and rib manipulation on subjects with primary
complaints of shoulder pain. J Man Manip
Ther 2009
Case studies
Burns SA, Mintken PE, Austin GP106 Clinical decision making in a patient with Hip and lumbar spine Case study 1 Level 4
Sueki et al.

secondary hip-spine syndrome. Physiother

Theory Pract 2011

Journal of Manual and Manipulative Therapy

Lowry CD, Cleland JA, Dyke K107 Management of patients with patellofemoral Knee and multiple regions Case series 5 Level 4
pain syndrome using a multimodal approach:
A case series. J Orthop Sports Phys Ther 2008

2013
Vaughn DW108 Isolated knee pain: a case report highlighting Knee and pelvis Case study 1 Level 4
regional interdependence. J Orthop Sports
Phys Ther 2008

VOL .
Welsh C, Hanney WJ, Podschun L, Kolber MJ109 Rehabilitation of a female dancer with Knee and multiple regions Case study 1 Level 4

21
patellofemoral pain syndrome: applying
concepts of regional interdependence in

NO .
practice. N Am J Sports Phys Ther 2010

2
93
A RI model of musculoskeletal dysfunction
94
Sueki et al.

Table 1 Continued

Number of Level of
Authors Title and journal Regions Design subjects evidence*

Clinical commentaries
Lucado A, Kolber M, Echternach J, Cheng MS53 Subacromial impingement syndrome and Shoulder and elbow
lateral epicondylalgia in tennis players.

Journal of Manual and Manipulative Therapy

A RI model of musculoskeletal dysfunction

Phys Ther Rev 2010

Isabel de-la-Llave-Rincon, A., Puentedura EJ., Clinical presentation and manual therapy Upper quadrant
Fernandez-de-las-Penas C110 for upper quadrant musculoskeletal

2013
conditions. J Man Manip Ther 2011
Reiman MP, Weisbach PC, Glynn PE111 The hips influence on low back pain: a Hip and lumbar spine
distal link to a proximal problem. J Sport

VOL .
Rehabil 2009

21
Sueki DG, Chaconas EJ26 The effects of thoracic manipulation of Thoracic spine and shoulder
shoulder function: a regional interdependence
model. Phys Ther Rev 2011

NO .
2
Editorials
Wainner RS, Whitman JM, Cleland JA, Flynn TW1 Regional interdependence: a musculoskeletal Not applicable
examination model whose time has come.
J Orthop Sports Phys Ther 2007
Bialosky JE, Bishop MD, George SZ8 Regional interdependence: a musculoskeletal Not applicable
examination model whose time has come.
J Orthop Sports Phys Ther 2008

Note: RCT: randomized control trial; CPR: clinical prediction rule.

*Oxford Centre for Evidence-Based Medicine Levels of Evidence Criteria: 2a, systematic review of cohort studies; 2b, individual cohort study; 3a, systematic review of case control studies; 3b, individual case
control study; 4, case series.
 Table 2 Evidence of regional interdependence

Quarter Regions Study Type of study Number of subjects Level of evidence*

37
Lower quarter Hip and lumbar Arab AM, Nourbakhsh MR (2010) Cross-sectional cohort 300 Level 2b
Arab AM, Nourbakhsh MR (2010);37 Arab et al. (2011)40 Cohort 20 Level 2b
Ben-Galim P et al. (2007)35 Prospective cohort 25 Level 2b
Di Lorenzo L et al. (2007)36 Prospective cohort 37 Level 2b
Ellison JB et al. (1990)112 Case–control 150 Level 3b
Kendall KD et al. (2010)113 Quasi-experiment cohort 20 Level 2b
Mellin G (1988)39 Case–control 476 Level 3b
Nadler SF et al. (2000)114 Cohort 210 Level 2b
Nelson-Wong et al. (2009)115 Prospective cohort 43 Level 2b
Paquet N et al. (1994)116 Case–control 20 Level 3b
Stupar M et al. (2010)34 Population-based cohort 983 Level 2b
van Dillen LR et al. (2008)117 Case–control 48 Level 3b
Yoshimoto H et al. (2005)118 Retrospective case–control 150 Level 3b
Deyle GD et al. (2005)119 Prospecitve cohort 134 Level 2b
Knee and lumbar Deyle GD et al. (2000)120 RCT of cohort 83 Level 2b
Stupar M et al. (2010)34 Population-based cohort 983 Level 2b
Suri P et al. (2010)121 Case–ontrol 1389 Level 3b
Foot/ankle and lumbar Bjonness T (1975)122 Case–control 93 Level 3b
Brantingham JW et al. (2006)43 Case–control 100 Level 3b
Kosashvili Y et al. (2008)42 Retrospective case–control 97 279 Level 3b
Hip and knee Astephen JL et al. (2008)90 Cross-sectional case–control 181 Level 3b
Bennell KL et al. (2007)123 RCT of cohort 88 Level 2b
Bolgla LA et al. (2011);45 Bolgla LA et al. (2008)124 Cross-sectional case–control 18 Level 3b
Currier LL et al. (2007)4 Cohort CPR 60 Level 2b
Finnoff JY et al. (2011)46 Prospective cohort 98 Level 2b
Rowe J et al. (2007)47 Case–control 19 Level 3b
Souza RB et al. (2009)6 Cross-sectional case–control 41 Level 3b
Ankle and knee Astephen JL et al. (2008)90 Cross-sectional case–control 181 Level 3b
Molgaard C et al. (2011)48 Case–control 299 Level 3b
Upper quarter Thoracic and cervical spine Cleland JA et al. (2005)3 Cohort RCT 36 Level 2b
Cleland JA et al. (2010)102 Cohort CPR 140
Fernandez-de-las-Penas C et al. (2009)32 Cohort 45 Level 2b
Gonzalez-Iglesias J et al. (2009)33 Cohort RCT 45 Level 2b
Sueki et al.

Thoracic spine and shoulder Boyles RE et al. (2010)2 Cohort 56 Level 2b

Mintkin PE et al. (2010)5 Cohort CPR 80 Level 2b

Journal of Manual and Manipulative Therapy

Thoracic spine and upper extremity Strunce JB et al. (2009)7 Cohort 21 Level 2b
Berglund et al. (2008)50 Cohort 62 Level 2b
Cervical spine and upper extremity Berglund et al. (2008)50 Cohort 62 Level 2b
Suter E et al. (2002)52 Cohort 16 Level 2b

2013
Vicenzino B et al. (1996)125 Cohort RCT 15 Level 2b
Shoulder and elbow No known experimental studies
Elbow and hand No known experimental studies

VOL .
Upper and lower quarter Lower extremity and shoulder Klein MG et al. (2000)55 Cohort 194 Level 2b

21
Note: RCT: randomized control trial; CPR: clinical prediction rule.
*Oxford Centre for Evidence-Based Medicine Levels of Evidence Criteria: 2a, systematic review of cohort studies; 2b, individual cohort study; 3a, systematic review of case control studies; 3b, individual case

NO .
2
control study; 4, case series.

95
A RI model of musculoskeletal dysfunction
Sueki et al. A RI model of musculoskeletal dysfunction

Vicenzino et al.25 has linked cervical manipulation have speculated about physiological and biomecha-
with decreases in pressure pain threshold and increases nical mechanisms underlying these long-standing
in grip strength in subjects with lateral elbow pain. clinical observations. In 1955, Steindler56 proposed
Suter et al.52 demonstrated an increase in bicep muscle a model based on a kinetic mechanical engineering
strength and a decrease in muscle inhibition following model. He termed this relationship the ‘Kinetic
cervical manipulation. Clinically, and in published Chain’ and in his model, he described the body as a
reviews,53,54 it has been hypothesized that the function series of interconnected joints where the movement of
of the shoulder can directly influence impairments at one joint directly effects the movement of other joints
the elbow and hand, but to date, no studies have above and below. His model is based primarily upon
validated this hypothesis. Like the lower quarter the biomechanical relationship between regions of the
studies, much of the research was not designed body. For example, decreased dorsiflexion in the
specifically to study the RI model, yet the results of talocrural joint can produce biomechanical compen-
the studies suggest that RI may be a viable concept and satory changes in knee, hip, and lumbar spine. The
model. recent literature demonstrating interdependent rela-
tionships between the thoracic spine/cervical spine
Upper and lower quarter
and the hip/knee are examples of this potential
While the vast majority of available research
biomechanical link or kinetic chain.3,4,44
has focused on establishing a relationship between
Bialosky et al. have suggested that RI may be
adjacent regions of the upper or lower quarter, the RI
the result of neurophysiological mechanisms or the
model suggests that a patient’s primary musculoske-
combined interaction between biomechanical and
letal symptoms may be influenced by impairments
neurophysiological mechanisms.15 This observation
regardless of proximity to the patient’s primary
has its basis in recent work related to temporal
symptoms. There is a small amount of evidence that
summation and pain perception related to manual
is beginning to suggest that these relationships extend
therapy interventions.24,57,58 The result of this work
beyond adjacent regions of the body to more remote
combined with prior research has led to the sugges-
sites (Table 2). As mentioned previously, Kosashvili
tion that neurophysiological mechanisms play a
et al.42 and Brantingham et al.43 both established a
major role in the physiological effects experienced
potential positive relationship between ankle and foot
by patients.58 Like the biomechanical proposition
impairment and lumbar pain. In the upper quarter,
mentioned previously, more research is needed before
Berglund et al.50 established a potential relationship
any definitive conclusions or statements can be made.
between the thoracic spine and elbow impairments.
While the mechanisms previously discussed pro-
These studies emphasize relationships between
vide feasible explanations for the RI model, neither
upper or lower quarter regions. However, theoreti-
have been definitively established or well investigated.
cally impairments in the the lower quarter could
It is unlikely that a single mechanism or body system
influence the function of the upper quarter and
explanation is sufficient, thus a more comprehensive
similarly, dysfunction in the upper quarter could have
model is needed. The revised definition of RI
an impact upon the function of the lower quarter.
acknowledges that biomechanical and neurophysio-
Klein et al.55 screened polio survivors and the results
logical factors may account for musculoskeletal
of the study suggest that lower extremity weakness
responses seen in conjunction with treating impair-
may predisposed subjects to shoulder overuse symp-
ments, but it expands upon the previous definition
toms and has the potential to negatively influence the
and includes the provision that various body regions
function of the shoulder. While it is only one study in
and systems may contribute to these observed
a specific sample pool and does not establish a direct
musculoskeletal responses and their associated clin-
linkage between the upper and lower quarter, the
ical outcomes and likely also include other factors
results do seem to support the concept that regions of
(Fig. 1). From a clinical management perspective,
the body are interrelated and may influence symp-
the redefined RI model is more comprehensive then
toms irrespective of their proximity. Considerably,
the original definition and allows for the considera-
more research is needed in order to determine if
tion and subsequent management of numerous fac-
clinically meaningful relationships exist beyond adja-
tors including other body regions and systems that
cent regions and extend to the upper and lower
may be contributing to a patient’s musculoskeletal
quarters.
symptoms.
Proposed Mechanisms The redefined concept of RI proposes that:
The RI model has its roots in clinical practice and has N Response(s) to a disorder or condition and the
associated clinical outcome(s) are not limited to local
been utilized primarily to support clinical decision- and adjacent regions of the body but can involve a
making. Even before recent clinical research appear- neuromusculoskeletal response that may be more
ing to support the model, clinicians and researchers widespread.

96 Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2

 Sueki et al. A RI model of musculoskeletal dysfunction

N Multiple systems respond to impairment and may that exists between regions of the body, as well as,
influence the function of the neuromusculoskeletal other systems. In the initial model of RI, it was
system and associated symptoms.
inferred that the adapting structures were musculos-
Response to any disorder or condition is not keletal in nature. In the revised model of RI, it
limited to local and adjacent regions of the body is proposed that not only neurophysiological8
but can involve a neuromusculoskeletal and musculoskeletal1 structures but biopsychosocial64
response that may be more widespread and somatovisceral65 systems can all potentially affect
The musculoskeletal interdependence between re- the function of the musculoskeletal system (Fig. 3).
gions of the body does not exist in isolation.
Changes in the musculoskeletal system must also be Biopsychosocial Considerations
accompanied by changes in neurophysiology because The biopsychosocial model proposes that the experi-
these and other systems work in concert to perform ence of pain and resultant responses stem from
tasks. Interventional-based studies have demon- the interaction of biological, psychological, and
strated that treatments targeting one area of the social factors.66,67 The recognition of an association
body can affect neuromuscular performance in between physiology and psychology is not new and
remote regions of the body. It has been demonstrated dates as far back as 350 BC. Both Aristotle19 and
that manual therapy and spinal manipulation can Abu Zayd Al-Balkhi68 suggested that health was tied
alter local and distal motoneuron excitability. Of to the interweaving of the psyche and its biological
particular interest to the RI model are the effects of manifestations and a large body of current literature
spinal manipulation on distal neuromuscular func- supports such a relationship.27,67,69–73
tion. Suter et al.59,60 has demonstrated that thrust Bialosky et al.,74 George et al.,27,75 and Fritz et al.76
manipulation of the sacroiliac joint decreased motor have all demonstrated that factors such as fear
inhibition of the knee extensor muscles, while avoidance, pain catastrophizing, and anticipation
Dishman et al.61 showed that lumbar spinal manip- can impact musculoskeletal function and pain.
ulation increased electromyographic (EMG) activity Moseley77,78 and Butler and Page79 have demonstrated
remotely in the gastrocnemius muscle. Additionally, that altering a patient’s perception of pain allows
Murphy et al.62 and Dishman et al.61,63 showed that for improved neuromuscular function. Similarly,
manipulation of the lumbosacral region has the Moseley28 and van Oosterwijck et al.80 have demon-
potential to produce a decrease in distal neuromus- strated that educating patients about pain mechanisms
cular function as measure by the magnitude of the may subsequently alter neuromuscular function and
tibial nerve H-reflex. These studies may be reflective pain. Bialosky et al.57 has demonstrated that a
of an interventional effect on nerve and muscular subject’s expectations can affect the pain perceptions
function beyond the immediate and adjacent regions following an intervention. In addition, a clinician’s
of the body. While the evidence supporting a attitude towards a patient’s treatment and recovery
neurophysiological relationship between lumbosacral has the potential to impact the prognosis of a patient
manipulation and remote lower extremity neurophy- both negatively and positively.74,81
siological responses exists, a recent follow-up study Depression,82 post-traumatic stress,83,84 fear avoid-
by Suter et al.59 has suggested that manipulation may ance,75,76,85 anxiety,86 pain catastrophizing,87 and
not have a significant effect on distal motoneuron negative emotions88 have all been demonstrated to
excitability (H-reflex testing). It is unclear whether exert influence upon musculoskeletal pain. An in-
these studies refute the previous studies, are indica- depth discussion regarding specific psychological
tive of the variability normally seen when utilizing H- impairments observed in patients with musculoskele-
reflex as an outcome measure, or whether magnitude tal disorders and their underlying physiological
and direction of response are preferentially influ- mechanisms are beyond the scope of this paper.
enced. In either case, a potential relationship exists However, given the strong influence of biopsychoso-
between interventions targeting one region of the cial factors and potential to be positively influenced,
body and the neuromuscular performance in regions it is important for clinicians to understand and
remote to the area of intervention that warrants consider the interdependent relationship between
further exploration. biopsychosocial, neurophysiological, and musculos-
keletal factors when assessing and treating patients.
Multiple systems respond to impairment and
may influence the function of the Referred, Somatovisceral, and Radicular Pain:
musculoskeletal system Special Considerations
A previously noted, the body appears to utilize Referred and radicular pain and their relationship
physiological mechanisms in an integrated fashion in with RI have some unique considerations. By
order to adapt or reduce the loads or stress placed definition, referred pain is pain that is perceived in
upon involved structures. There is an interdependence a location other than the actual site of painful

Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2 97

Sueki et al. A RI model of musculoskeletal dysfunction

Acute radicular pain can be defined as pain that

originates from the spinal nerve roots and is
experienced remotely from the site of the nerve root
lesion.96 As was the case with referred pain, radicular
pain also represents a special case of RI (musculos-
keletal symptoms experienced remotely to the affected
region), which is a modification of the original des-
cription by Wainner et al.1 With radicular pain, the
nerve root is the source of symptoms, but it may also
result in other local and remote impairments that
contribute to the source of symptoms. These related
impairments may contribute to that patient’s source of
symptoms within the RI model, but would be distinct
from true acute nerve root pain. Examples of such
impairments would be abnormal motor responses97
Figure 3 Multiple systems can contribute to a musculoske-
letal response by the body. Both local and remote responses
and limited nerve root mobility.97,98
occur, but the Regional Interdependence Model represents
remote responses by the body.
Clinical Implications
The RI model does not suggest that the biomedical
model should be abandoned, but instead modified
stimulus or source of symptoms (tissue symptom
to include additional considerations and concepts.
generator).89 For example, primary hip disorders
Assessment and management strategies should seek
can refer pain into the lower extremity,4,44 but it can
to identify pathoanatomical tissues that may be the
also exhibit impairments that affect symptoms and
source of the patient’s symptoms. Unfortunately, a
musculoskeletal responses without the referral of pain,
single underlying pathoanatomical cause that is
as in the case with patients with knee osteoarthritis.90
responsible for a patient’s primary and secondary
Both of these examples would fall within the definition
complaints often cannot be identified in patients with
of RI. In this instance, referred pain is a special case
musculoskeletal disorders, particularly those with
with the hip disorder being the source of symptoms.
spine problems.99 Therefore, while clinicians should
However, hip impairments may not necessarily refer
initially seek to identify a specific pathoanatomic
pain, but may be associated and influence remote
source of the patient’s symptoms, in particular red-
symptoms in other regions of the body.
flag conditions, they should also consider impair-
It is well supported in literature that somatovisc-
ments of other systems or regions that may be
eral tissue can be a source of referred pain as well as
directly or indirectly associated with the patient’s
mimic musculoskeletal pain.65,91 For example, left
complaints. There is some research to suggest that
shoulder pain can be due to heart disorders, right
such an expanded approach can produce positive
shoulder pain can be the result of liver disorders, and
results. Trials utilizing a multi-modal treatment
low back pain can be the product of urogenital
approach supported by RI concepts have demon-
disorders.92 It is not known whether somatovisceral
strated efficacy.3,100–102 The RI model should be
structures may be a source of disability and limita-
viewed as an integrative model that eliminates the
tions in musculoskeletal function, but literature
dichotomy of having to choose between a biomedical,
suggests that such a relationship may exist.93 In a
neurophysiological, or biopsychosocial model. It uses
longitudinal study of women’s health, Smith et al.29,94
pathoanatomy as a starting point and expands the
found that in women, menstrual cramping, incon-
search to look for the other factors that may
tinence, gastrointestinal symptoms, and respiratory
contribute to the patient’s symptoms.
problems were all associated with the development of
low back pain. This is not to suggest a causal Future Research
relationship, but simply that somatovisceral struc- The concept of RI is still preliminary and speculative.
tures have the potential to contribute to musculoske- Therefore, basic science as well as clinical research is
letal symptoms and should be screened as potential required to more fully develop the model described
contributors to these symptoms. Clinically, the in this paper. Specifically, evidence derived from
consideration of somatovisceral structures as a source prospective studies with the specific purpose of
of symptoms, in particular with regard to Red Flag testing hypotheses related to RI concepts is required
findings, is a routine and recommended component to establish a viable theory and validate a working
of a physical therapist’s practice95 and if suspected, model of RI.
referral to appropriate health care practitioner is The majority of supporting evidence that does exist
warranted. has been taken from various musculoskeletal-related

98 Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2

 Sueki et al. A RI model of musculoskeletal dysfunction

studies with other purposes and used inductively to short-term response to hip mobilization. Phys Ther.
2007;87(9):1106–19.
construct the concept of RI. The revised RI model 5 Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns
proposes that impairments in one region of the body M, Whitman JM. Some factors predict successful short-term
outcomes in individuals with shoulder pain receiving cervi-
can influence the musculoskeletal and neuromuscular cothoracic manipulation: a single-arm trial. Phys Ther.
function and symptoms in other remote regions of the 2010;90(1):26–42.
6 Souza RB, Powers CM. Differences in hip kinematics, muscle
body. Researchers should continue to focus on strength, and muscle activation between subjects with and
exploratory studies to establish potential new rela- without patellofemoral pain. J Orthop Sports Phys Ther.
tionships, but should also focus on validating the 2009;39(1):12–9.
7 Strunce JB, Walker MJ, Boyles RE, Young BA. The
studies that already exist with specific RI hypotheses immediate effects of thoracic spine and rib manipulation on
in mind. Researchers have begun to validate the subjects with primary complaints of shoulder pain. J Man
Manip Ther. 2009;17(4):230–6.
relationship between the thoracic spine and cervical 8 Bialosky JE, Bishop MD, George SZ. Regional interdepen-
impairments and also the hip and knee, but further dence: a musculoskeletal examination model whose time has
come. J Orthop Sports Phys Ther. 2008;38(3):159–60; author
validation is required. In addition, the revised reply 160.
RI model states that the interdependence between 9 Wainner RS, Flynn TW, Whitman JM. Spinal and extremity
regions of the body may involve the musculoskeletal manipulation: the basic skill set for physical therapists. San
Antonio (TX): Manipulations, Inc. 2001.
system, but that neurophysiological, biopsychosocial, 10 Bang MD, Deyle GD. Comparison of supervised exercise with
and somatovisceral systems can also influence mus- and without manual physical therapy for patients with
shoulder impingement syndrome. J Orthop Sports Phys
culoskeletal function both locally and at remote sites. Ther. 2000;30(3):126–37.
Research is needed to further establish whether and 11 Cibulka MT. Low back pain and its relation to the hip and
foot. J Orthop Sports Phys Ther. 1999;29(10):595–601.
how such relationships exist and how they may
12 Porter JL, Wilkinson A. Lumbar-hip flexion motion.
influence clinical practice. A comparative study between asymptomatic and chronic low
back pain in 18- to 36-year-old men. Spine. 1997;22(13):1508–
Conclusions 13; discussion 1513–4.
13 Erhard R, Bowling R. The recognition and management of the
The revised definition of RI refers to the concept and pelvic component of low back and sciatic pain. Bull Orthop
clinical model that a patient’s primary musculoske- Sect Am Phys Ther Assoc. 1977;2(3):4–15.
14 Maitland GD, Banks K, English K, Hengeveld E, editors.
letal symptom(s) may be directly or indirectly related Maitland’s vertebral manipulation. 6th ed. Boston (MA):
to or influenced by impairments from various body Butterworth-Heinemann; 2001.
15 Bialosky JE, Bishop MD, Price DD, Robinson ME, George
systems regardless of proximity to the primary SZ. The mechanisms of manual therapy in the treatment of
symptom(s). Although initial local treatment of a musculoskeletal pain: a comprehensive model. Man Ther.
patient’s primary complaint is typically a first step in 2009;14(5):531–8.
16 Chapman CR, Tuckett RP, Song CW. Pain and stress in a
clinical management, RI is a model that may be systems perspective: reciprocal neural, endocrine, and immune
helpful in identifying treatment strategies for recalci- interactions. J Pain. 2008 Feb;9(2):122–45.
17 McEwen BS, Wingfield JC. What is in a name? Integrating
trant and persistent symptoms that may be due to homeostasis, allostasis and stress. Horm Behav. 2010;
associated functional limitations and impairments in 57(2):105–11.
18 McEwen BS. Stress, adaptation, and disease. Allostasis and
more distant body regions as well as other body allostatic load. Ann NY Acad Sci. 1998;840:33–44.
systems. The model of RI is in its infancy and will no 19 Craig AD. A new view of pain as a homeostatic emotion.
doubt change and evolve as our understanding is Trends Neurosci. 2003;26(6):303–7.
20 van Tulder MW, Koes BW, Bouter LM. Conservative
informed from the results of future, formal investiga- treatment of acute and chronic nonspecific low back pain.
tions. The model presented in this paper is meant to A systematic review of randomized controlled trials of the
most common interventions. Spine. 1997;22(18):2128–56.
serve as a framework for clinicians and researchers 21 Bogduk N. What’s in a name? The labelling of back pain. Med
alike as they seek to identify the factors that may J Aust. 2000;173(8):400–1.
contribute to a patient’s impairments as well as for 22 Waddell G. 1987 Volvo award in clinical sciences. A new
clinical model for the treatment of low-back pain. Spine.
stimulating future research. 1987;12(7):632–44.
23 Dishman JD, Cunningham BM, Burke J. Comparison of tibial
nerve H-reflex excitability after cervical and lumbar spine
References manipulation. J Manipulative Physiol Ther. 2002;25(5):318–
1 Wainner RS, Whitman JM, Cleland JA, Flynn TW. Regional 25.
interdependence: a musculoskeletal examination model whose 24 George SZ, Bishop MD, Bialosky JE, Zeppieri G, Jr,
time has come. J Orthop Sports Phys Ther. 2007;37(11):658– Robinson ME. Immediate effects of spinal manipulation on
60. thermal pain sensitivity: an experimental study. BMC
2 Boyles RE, Ritland BM, Miracle BM, Barclay DM, Faul MS, Musculoskelet Disord. 2006;7:68.
Moore JH, et al. The short-term effects of thoracic spine thrust 25 Vicenzino B, Cleland JA, Bisset L. Joint manipulation in the
manipulation on patients with shoulder impingement syn- management of lateral epicondylalgia: a clinical commentary.
drome. Man Ther. 2009;14(4):375–80. J Man Manip Ther. 2007;15(1):50–6.
3 Cleland JA, Childs JD, McRae M, Palmer JA, Stowell T. 26 Sueki DG, Chaconcas EJ. The effect of thoracic manipulation
Immediate effects of thoracic manipulation in patients with on shoulder pain: a regional interdependence model. Phys
neck pain: a randomized clinical trial. Man Ther. Ther Rev. 2011;16(5):399–408.
2005;10(2):127–35. 27 George SZ, Wallace MR, Wright TW, Moser MW, Greenfield
4 Currier LL, Froehlich PJ, Carow SD, McAndrew RK, WH, 3rd, Sack BK, et al. Evidence for a biopsychosocial
Cliborne AV, Boyles RE, et al. Development of a clinical influence on shoulder pain: pain catastrophizing and catechol-
prediction rule to identify patients with knee pain and clinical O-methyltransferase (COMT) diplotype predict clinical pain
evidence of knee osteoarthritis who demonstrate a favorable ratings. Pain. 2008;136(1–2):53–61.

Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2 99

Sueki et al. A RI model of musculoskeletal dysfunction

28 Moseley GL. Evidence for a direct relationship between with and without lateral elbow pain. Man Ther.
cognitive and physical change during an education interven- 2008;13(4):295–9.
tion in people with chronic low back pain. Eur J Pain. 51 Walser RF, Meserve BB, Boucher TR. The effectiveness of
2004;8(1):39–45. thoracic spine manipulation for the management of muscu-
29 Smith MD, Russell A, Hodges PW. Do incontinence, breath- loskeletal conditions: a systematic review and meta-analysis of
ing difficulties, and gastrointestinal symptoms increase the risk randomized clinical trials. J Man Manip Ther. 2009;17(4):237–
of future back pain? J Pain. 2009;10(8):876–86. 46.
30 Inman VT, Saunders JB. Referred pain from skeletal 52 Suter E, McMorland G. Decrease in elbow flexor inhibition
structures. J Nerv Ment Dis. 1944;99:660–7. after cervical spine manipulation in patients with chronic neck
31 Slocum DB. The mechanics of some common injuries to the pain. Clin Biomech. 2002;17(7):541–4.
shoulder in sports. Am J Surg. 1959;98:394–400. 53 Lucado AM, Kolber MJ, Cheng MS, Ecternach JL.
32 Fernandez-de-las-Penas C, Cleland JA, Huijbregts P, Subacromial impingement syndrome and lateral epicondylal-
Palomeque-del-Cerro L, Gonzalez-Iglesias J. Repeated appli- gia in tennis players. Phys Ther Rev. 2010;15(2):55–61.
cations of thoracic spine thrust manipulation do not lead to 54 Ben Kibler W, Sciascia A. Kinetic chain contributions to
tolerance in patients presenting with acute mechanical elbow function and dysfunction in sports. Clin Sports Med.
neck pain: a secondary analysis. J Man Manip Ther. 2009; 2004;23(4):545–52, viii.
17(3):154–62. 55 Klein MG, Whyte J, Keenan MA, Esquenazi A, Polansky M.
33 Gonzalez-Iglesias J, Fernandez-de-las-Penas C, Cleland JA, The relation between lower extremity strength and shoulder
Gutierrez-Vega Mdel R. Thoracic spine manipulation for the overuse symptoms: a model based on polio survivors. Arch
management of patients with neck pain: a randomized clinical Phys Med Rehabil. 2000;81(6):789–95.
trial. J Orthop Sports Phys Ther. 2009;39(1):20–7. 56 Steindler A. Kinesiology of the human body: under normal
34 Stupar M, Cote P, French MR, Hawker GA. The association and pathological conditions. Springfield (IL): Charles C
between low back pain and osteoarthritis of the hip and knee: Thomas; 1955.
a population-based cohort study. J Manipulative Physiol 57 Bialosky JE, Bishop MD, Robinson ME, Barabas JA, George
Ther. 2010;33(5):349–54. SZ. The influence of expectation on spinal manipulation
35 Ben-Galim P, Ben-Galim T, Rand N, Haim A, Hipp J, Dekel induced hypoalgesia: an experimental study in normal
S, et al. Hip-spine syndrome: the effect of total hip subjects. BMC Musculoskelet Disord. 2008;9:19.
replacement surgery on low back pain in severe osteoarthritis 58 Bialosky JE, Bishop MD, Robinson ME, Zeppieri G, Jr,
of the hip. Spine. 2007;32(19):2099–102. George SZ. Spinal manipulative therapy has an immediate
36 Di Lorenzo L, Forte A, Formisano R, Gimigliano R, Gatto S. effect on thermal pain sensitivity in people with low back pain:
Low back pain after unstable extracapsular hip fractures: a randomized controlled trial. Phys Ther. 2009;89(12):1292–
randomized control trial on a specific training. Eur 303.
Medicophys. 2007;43(3):349–57. 59 Suter E, McMorland G, Herzog W. Short-term effects of
37 Arab AM, Nourbakhsh MR. The relationship between hip spinal manipulation on H-reflex amplitude in healthy
abductor muscle strength and iliotibial band tightness in and symptomatic subjects. J Manipulative Physiol Ther.
individuals with low back pain. Chiropr Osteopat. 2010;18:1. 2005;28(9):667–72.
38 Johnson EN, Thomas JS. Effect of hamstring flexibility on hip 60 Suter E, McMorland G, Herzog W, Bray R. Decrease in
and lumbar spine joint excursions during forward-reaching quadriceps inhibition after sacroiliac joint manipulation in
tasks in participants with and without low back pain. Arch patients with anterior knee pain. J Manipulative Physiol Ther.
Phys Med Rehabil. 2010;91(7):1140–2. 1999;22(3):149–53.
39 Mellin G. Correlations of hip mobility with degree of back 61 Dishman JD, Bulbulian R. Spinal reflex attenuation asso-
pain and lumbar spinal mobility in chronic low-back pain ciated with spinal manipulation. Spine. 2000;25(19):2519–24;
patients. Spine. 1988;13(6):668–70. discussion 2525.
40 Arab AM, Ghamkhar L, Emami M, Nourbakhsh MR. 62 Murphy BA, Dawson NJ, Slack JR. Sacroiliac joint manip-
Altered muscular activation during prone hip extension in ulation decreases the H-reflex. Electromyogr Clin
women with and without low back pain. Chiropr Man Ther. Neurophysiol. 1995;35(2):87–94.
2011;19:18. 63 Dishman JD, Burke J. Spinal reflex excitability changes after
41 Rothbart BA, Estabrook L. Excessive pronation: a major cervical and lumbar spinal manipulation: a comparative study.
biomechanical determinant in the development of chondro- Spine J. 2003;3(3):204–12.
malacia and pelvic lists. J Manipulative Physiol Ther. 64 Hill JC, Fritz JM. Psychosocial influences on low back
1988;11(5):373–9. pain, disability, and response to treatment. Phys Ther. 2011;
42 Kosashvili Y, Fridman T, Backstein D, Safir O, Bar Ziv Y. 91(5):712–21.
The correlation between pes planus and anterior knee or 65 Cervero F, Laird JM. Visceral pain. Lancet. 1999;
intermittent low back pain. Foot Ankle Int. 2008;29(9):910–3. 353(9170):2145–8.
43 Brantingham JW, Lee Gilbert J, Shaik J, Globe G. Sagittal 66 Engel GL. The biopsychosocial model and the education of
plane blockage of the foot, ankle and hallux and foot health professionals. Ann NY Acad Sci. 1978;310:169–87.
alignment-prevalence and association with low back pain. J 67 Main CJ, Richards HL, Fortune DG. Why put new wine in
Chiropr Med. 2006;5(4):123–7. old bottles: the need for a biopsychosocial approach to the
44 Powers CM. The influence of abnormal hip mechanics on knee assessment, treatment, and understanding of unexplained and
injury: a biomechanical perspective. J Orthop Sports Phys explained symptoms in medicine. J Psychosom Res. 2000;
Ther. 2010;40(2):42–51. 48(6):511–4.
45 Bolgla LA, Malone TR, Umberger BR, Uhl TL. Comparison 68 Deuraseh N, Abu Talib M. Mental health in islamic medical
of hip and knee strength and neuromuscular activity in tradition. Int Med J. 2005;4(2):76–9.
subjects with and without patellofemoral pain syndrome. Int J 69 Sterling M, Jull G, Vicenzino B, Kenardy J, Darnell R.
Sports Phys Ther. 2011;6(4):285–96. Physical and psychological factors predict outcome following
46 Finnoff JT, Hall MM, Kyle K, Krause DA, Lai J, Smith J. whiplash injury. Pain. 2005;114(1–2):141–8.
Hip strength and knee pain in high school runners: a 70 McFarlane AC. Stress-related musculoskeletal pain. Best
prospective study. J Inj Funct Rehabil. 2011;3(9):792–801. Pract Res Clin Rheumatol. 2007;21(3):549–65.
47 Rowe J, Shafer L, Kelley K, West N, Dunning T, Smith R, 71 Engel GL. The clinical application of the biopsychosocial
et al. Hip strength and knee pain in females. N Am J Sports model. Am J Psychiatry. 1980;137(5):535–44.
Phys Ther. 2007;2(3):164–9. 72 McCarthy C. The biopsychosocial classification of non
48 Molgaard C, Rathleff MS, Simonsen O. Patellofemoral pain specific low back pain: a systematic review. Phyis Ther Rev.
syndrome and its association with hip, ankle, and foot 2004;9(1):17–30.
function in 16- to 18-year-old high school students: a single- 73 Overmeer T, Boersma K, Denison E, Linton SJ. Does teaching
blind case–control study. J Am Podiatr Med Assoc. 2011; physical therapists to deliver a biopsychosocial treatment
101(3):215–22. program result in better patient outcomes? A randomized
49 Yoo HS, Nahm FS, Lee PB, Lee CJ. Early thoracic controlled trial. Phys Ther. 2011;91(5):804–19.
sympathetic block improves the treatment effect for upper 74 Bialosky JE, Bishop MD, Cleland JA. Individual expectation:
extremity neuropathic pain. Anesth Analg. 2011;113(3):605–9. an overlooked, but pertinent, factor in the treatment of
50 Berglund KM, Persson BH, Denison E. Prevalence of pain individuals experiencing musculoskeletal pain. Phys Ther.
and dysfunction in the cervical and thoracic spine in persons 2010;90(9):1345–55.

100 Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2

 Sueki et al. A RI model of musculoskeletal dysfunction

75 George SZ, Fritz JM, Bialosky JE, Donald DA. The effect of a initial medical diagnosis of work-related back injuries. Spine.
fear-avoidance-based physical therapy intervention for 1995;20(7):791–5.
patients with acute low back pain: results of a randomized 100 Fritz JM, Brennan GP. Preliminary examination of a
clinical trial. Spine. 2003;28(23):2551–60. proposed treatment-based classification system for patients
76 Fritz JM, George SZ, Delitto A. The role of fear-avoidance receiving physical therapy interventions for neck pain. Phys
beliefs in acute low back pain: relationships with current and Ther. 2007;87(5):513–24.
future disability and work status. Pain. 2001;94(1):7–15. 101 Walker MJ, Boyles RE, Young BA, Strunce JB, Garber MB,
77 Moseley GL. Graded motor imagery is effective for long- Whitman JM, et al. The effectiveness of manual physical
standing complex regional pain syndrome: a randomised therapy and exercise for mechanical neck pain: a randomized
controlled trial. Pain. 2004;108(1–2):192–8. clinical trial. Spine. 2008;33(22):2371–8.
78 Moseley GL. Graded motor imagery for pathologic pain: a 102 Cleland JA, Mintken PE, Carpenter K, Fritz JM, Glynn P,
randomized controlled trial. Neurology. 2006;67(12):2129–34. Whitman J, et al. Examination of a clinical prediction rule to
79 Butler AJ, Page SJ. Mental practice with motor imagery: identify patients with neck pain likely to benefit from thoracic
evidence for motor recovery and cortical reorganization after spine thrust manipulation and a general cervical range of
stroke. Arch Phys Med Rehabil. 2006;87(12 Suppl 2):S2–11. motion exercise: multi-center randomized clinical trial. Phys
80 van Oosterwijck J, Nijs J, Meeus M, Truijen S, Craps J, van Ther. 2010;90(9):1239–50.
den Keybus N, et al. Pain neurophysiology education 103 Bunn EA, Grindstaff TL, Hart JM, Hertel J, Ingersoll CD.
improves cognitions, pain thresholds, and movement perfor- Effects of paraspinal fatigue on lower extremity motoneuron
mance in people with chronic whiplash: a pilot study. excitability in individuals with a history of low back pain. J
J Rehabil Res Dev. 2011;48(1):43–58. Electromyogr Kinesiol. 2011;21(3):466–70.
81 Pollo A, Amanzio M, Arslanian A, Casadio C, Maggi G, 104 de Oliveira Grassi D, de Souza MZ, Ferrareto SB, de Lima
Benedetti F. Response expectancies in placebo analgesia and Montebelo MI, de Oliveira Guirro EC. Immediate and lasting
their clinical relevance. Pain. 2001;93(1):77–84. improvements in weight distribution seen in baropodometry
82 Carroll LJ, Cassidy JD, Cote P. Depression as a risk factor for following a high-velocity, low-amplitude thrust manipulation
onset of an episode of troublesome neck and low back pain. of the sacroiliac joint. Man Ther. 2011;16(5):495–500.
Pain. 2004;107(1–2):134–9. 105 Iverson CA, Sutlive TG, Crowell MS, Morrell RL, Perkins
83 Otis JD, Keane TM, Kerns RD. An examination of the MW, Garber MB, et al. Lumbopelvic manipulation for the
relationship between chronic pain and post-traumatic stress treatment of patients with patellofemoral pain syndrome:
disorder. J Rehabil Res Dev. 2003;40(5):397–405. development of a clinical prediction rule. J Orthop Sports
84 Arguelles LM, Afari N, Buchwald DS, Clauw DJ, Furner S, Phys Ther. 2008;38(6):297–309; discussion 312.
Goldberg J. A twin study of posttraumatic stress disorder 106 Burns SA, Mintken PE, Austin GP. Clinical decision making
symptoms and chronic widespread pain. Pain. 2006;124(1– in a patient with secondary hip-spine syndrome. Physiother
2):150–7. Theory Pract. 2011;27(5):384–97.
85 Linton SJ, Buer N, Vlaeyen J, Hellsing AL. Are fear- 107 Lowry CD, Cleland JA, Dyke K. Management of patients with
avoidance beliefs related to the inception of an episode patellofemoral pain syndrome using a multimodal approach: a
of back pain? A prospective study. Psychol Health. case series. J Orthop Sports Phys Ther. 2008;38(11):691–702.
2000;14(6):1051–9. 108 Vaughn DW. Isolated knee pain: a case report highlighting
regional interdependence. J Orthop Sports Phys Ther.
86 Al-Obaidi SM, Nelson RM, Al-Awadhi S, Al-Shuwaie N. The
2008;38(10):616–23.
role of anticipation and fear of pain in the persistence of
109 Welsh C, Hanney WJ, Podschun L, Kolber MJ. Rehabilitation
avoidance behavior in patients with chronic low back pain.
of a female dancer with patellofemoral pain syndrome:
Spine. 2000;25(9):1126–31.
applying concepts of regional interdependence in practice. N
87 Carty J, O’Donnell M, Evans L, Kazantzis N, Creamer M.
Am J Sports Phys Ther. 2010;5(2):85–97.
Predicting posttraumatic stress disorder symptoms and pain
110 Isabel de-la-Llave-Rincon A, Puentedura E, Fernandez-de-las-
intensity following severe injury: the role of catastrophizing.
Penas C. Clinical presentation and manual therapy for upper
Eur J Psychotraumatol. 2011;2:10.3402/ejpt.v2i0.5652.
quadrant musculoskeletal conditions. J Man Manip Ther.
88 Tan G, Jensen M, Thornby J, Sloan P. Negative emotions, 2011;19(4):201–11.
pain, and functioning. Psychol Serv. 2008;5(1):26–35.
111 Reiman MP, Weisbach PC, Glynn PE. The hips influence on
89 Arendt-Nielsen L, Svensson P. Referred muscle pain: basic low back pain: a disal link to a proximal problem. J Sports
and clinical findings. Clin J Pain. 2001;17(1):11–9. Rehabil. 2009;18(1):24–32.
90 Astephen JL, Deluzio KJ, Caldwell GE, Dunbar MJ. 112 Ellison JB, Rose SJ, Sahrmann SA. Patterns of hip rotation
Biomechanical changes at the hip, knee, and ankle joints range of motion: a comparison between healthy subjects and
during gait are associated with knee osteoarthritis severity. patients with low back pain. Phys Ther. 1990;70(9):537–41.
J Orthop Res. 2008;26(3):332–41. 113 Kendall KD, Schmidt C, Ferber R. The relationship between
91 Sengupta JN. Visceral pain: the neurophysiological mechan- hip-abductor strength and the magnitude of pelvic drop in
ism. Handb Exp Pharmacol. 2009(194):31–74. patients with low back pain. J Sport Rehabil. 2010;19(4):422–
92 Gerwin R. Myofascial and visceral pain syndromes: visceral- 35.
somatic pain representations. J Musculoskelet Pain. 114 Nadler SF, Malanga GA, Feinberg JH, Prybicien M, Stitik
2002;10(2):165–75. TP, DePrince M. Relationship between hip muscle imbalance
93 Hyman PE, Bursch B, Sood M, Schwankovsky L, Cocjin J, and occurrence of low back pain in collegiate athletes: a
Zeltzer LK. Visceral pain-associated disability syndrome: prospective study. Am J Phys Med Rehabil. 2001;80(8):572–7.
a descriptive analysis. J Pediatr Gastroenterol Nutr. 115 Nelson-Wong E, Flynn T, Callaghan JP. Development of
2002;35(5):663–8. active hip abduction as a screening test for identifying
94 Smith MD, Russell A, Hodges PW. How common is back occupational low back pain. J Orthop Sports Phys Ther.
pain in women with gastrointestinal problems? Clin J Pain. 2009;39(9):649–57.
2008;24(3):199–203. 116 Paquet N, Malouin F, Richards CL. Hip-spine movement
95 Guide to Physical Therapist Practice. Second Edition. interaction and muscle activation patterns during sagittal trunk
American Physical Therapy Association. Phys Ther. movements in low back pain patients. Spine. 1994;19(5):596–
2001;81(1):9–746. 603.
96 Wainner RS, Gill H. Diagnosis and nonoperative management 117 van Dillen LR, Bloom NJ, Gombatto SP, Susco TM. Hip
of cervical radiculopathy. J Orthop Sports Phys Ther. rotation range of motion in people with and without low back
2000;30(12):728–44. pain who participate in rotation-related sports. Phys Ther
97 Boyd BS, Wanek L, Gray AT, Topp KS. Mechanosensitivity Sport. 2008;9(2):72–81.
of the lower extremity nervous system during straight-leg raise 118 Yoshimoto H, Sato S, Masuda T, Kanno T, Shundo M,
neurodynamic testing in healthy individuals. J Orthop Sports Hyakumachi T, et al. Spinopelvic alignment in patients with
Phys Ther. 2009;39(11):780–90. osteoarthrosis of the hip: a radiographic comparison to
98 Coppieters MW, Alshami AM. Longitudinal excursion and patients with low back pain. Spine. 2005;30(14):1650–7.
strain in the median nerve during novel nerve gliding exercises 119 Deyle GD, Allison SC, Matekel RL, Ryder MG, Stang JM,
for carpal tunnel syndrome. J Orthop Res. 2007;25(7):972–80. Gohdes DD, et al. Physical therapy treatment effectiveness for
99 Abenhaim L, Rossignol M, Gobeille D, Bonvalot Y, Fines P, osteoarthritis of the knee: a randomized comparison of
Scott S. The prognostic consequences in the making of the supervised clinical exercise and manual therapy procedures

Journal of Manual and Manipulative Therapy 2013 VOL . 21 NO . 2 101

Sueki et al. A RI model of musculoskeletal dysfunction

versus a home exercise program. Phys Ther. 2005;85(12):1301– 123 Bennell KL, Hunt MA, Wrigley TV, Hunter DJ, Hinman RS.
17. The effects of hip muscle strengthening on knee load, pain,
120 Deyle GD, Henderson NE, Matekel RL, Ryder MG, Garber and function in people with knee osteoarthritis: a protocol
MB, Allison SC. Effectiveness of manual physical therapy and for a randomised, single-blind controlled trial. BMC
exercise in osteoarthritis of the knee. A randomized, controlled Musculoskelet Disord. 2007;8:121.
trial. Ann Intern Med. 2000;132(3):173–81. 124 Bolgla LA, Malone TR, Umberger BR, Uhl TL. Hip strength
121 Suri P, Morgenroth DC, Kwoh CK, Bean JF, Kalichman L, and hip and knee kinematics during stair descent in females
Hunter DJ. Low back pain and other musculoskeletal pain with and without patellofemoral pain syndrome. J Orthop
comorbidities in individuals with symptomatic osteoarthritis Sports Phys Ther. 2008;38(1):12–8.
of the knee: data from the osteoarthritis initiative. Arthritis 125 Vicenzino B, Collins D, Wright A. The initial effects of a
Care Res. 2010;62(12):1715–23. cervical spine manipulative physiotherapy treatment on the
122 Bjonness T. Low back pain in persons with congenital club pain and dysfunction of lateral epicondylalgia. Pain.
foot. Scand J Rehabil Med. 1975;7(4):163–5. 1996;68(1):69–74.

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