Regional Interdependence

Regional Interdependence is the concept that a patient’s primary musculoskeletal symptoms may be directly or indirectly influenced by impairments in other body regions or systems. The clinical implication is that interventions targeted to one region of the body can alter symptoms, function, or performance in other body segments.

The term “regional interdependence” was first formalized by Wainner et al. (1) as a musculoskeletal examination model, and later expanded by Sueki, Cleland, and Wainner (2) into a broader neuromusculoskeletal and biopsychosocial framework.

Citations

1. Wainner, R. S., Whitman, J. M., Cleland, J. A., & Flynn, T. W. (2007). Regional interdependence: a musculoskeletal examination model whose time has come. Journal of orthopaedic & sports physical therapy, 37(11), 658-660.
2. Sueki, D. G., Cleland, J. A., & Wainner, R. S. (2013). A regional interdependence model of musculoskeletal dysfunction: research, mechanisms, and clinical implications. Journal of manual & manipulative therapy, 21(2), 90-102.

Semantic Clarification

Local versus Interdependent Models

• Local: In older conventional models, intervention selection is based on patient symptoms, and treatment is generally focused on the joint or structure exhibiting symptoms. For example, shoulder pain is treated with shoulder-specific interventions.
• Interdependent: Models that account for regional interdependence consider impairments in local, neighboring, and sometimes distal regions that may contribute to the patient’s primary complaint. For example, shoulder pain results in evaluation of at least the scapula, thoracic spine, and cervical spine, and may include the trunk and pelvis.

Regional Interdependence vs. Referred or Radicular Pain

• Referred pain and radicular pain are symptom patterns with predictable patterns. For example, an active trigger point will produce a pattern of pain that is referred outward from an active site when pressed on. Further, radicular pain is pain along a nerve, generally resulting from irritation to the nerve or nerve root.
• Regional interdependence describes how impairments or symptoms in one region (for example, loss of thoracic extension, weak hip abductors, limited ankle dorsiflexion) may alter load distribution, motor control, or pain processing in other regions. For example, a lack of ankle dorsiflexion can alter lower extremity, pelvic, and trunk motion, resulting in lower back pain.

Regional Interdependence vs. Kinetic Chain

• Kinetic Chain: A concept that has expanded over the past several decades to describe the integration of 4 body systems (muscle, joints, fascia, and nerves), as well as the coordinated function of various body segments (e.g., hip, knee, and ankle) to produce motion. Kinetic refers to motion, and chain is an analogy for the interdependent link between systems.
• Regional Interdependence and the kinetic chain are likely referring to similar concepts; however, Regional Interdependence considers the effects of interdependent segments on pain and dysfunction.

Related Terms:

• Kinetic Chain
• Posture

Article:

• Correcting an Asymmetrical Weight Shift (Lateral Pelvic Shift or Tilt)

Courses

• Overhead Squat Assessment: Signs of Dysfunction
• Overhead Squat Assessment: Sign Clusters and Compensation Patterns
• Total Body Exercises and Functional Exercise Progressions
• Lower Extremity Dysfunction (LED)
• Lumbopelvic Hip Complex Dysfunction (LPHCD)
• Upper Body Dysfunction (UBD)

Applied Examples

1. Thoracic spine and shoulder pain: A patient with subacromial pain during overhead motion presents with limited thoracic extension and rotation, scapular dyskinesis, and normal local shoulder strength testing. Interventions include thoracic mobilization or manipulation, thoracic extension exercises, and scapular control drills. Improvement in overhead ROM and pain without direct shoulder joint mobilization illustrates regional interdependence between the thoracic spine, scapula, and shoulder.
2. Hip abductors and knee valgus / patellofemoral pain: A runner reports anterior knee pain and exhibits knee valgus during single-leg squat, with weak hip abductors and poor trunk control. A program focused on hip abductor and external rotator strengthening, trunk stability, and gait retraining results in reduced knee valgus and knee symptoms. Here, proximal hip and trunk impairments influence distal knee mechanics and symptoms.
3. Ankle dorsiflexion and squat depth / medial knee collapse: During an overhead squat, a client demonstrates limited depth, heel rise, and medial knee collapse on one side. Assessment reveals restricted ankle dorsiflexion and tight gastroc–soleus complex. After ankle joint mobilizations, soft-tissue techniques, and dorsiflexion-biased strengthening, squat depth and frontal-plane knee alignment improve. This represents interdependence between ankle mobility and knee–hip mechanics.

Frequently Asked Questions (FAQs)

What is regional interdependence in physical therapy?

• Regional interdependence is a clinical model that proposes that impairments may influence a patient’s primary symptoms in other regions or systems of the body, and that targeting those remote impairments can meaningfully change symptoms or function at the primary site.

Does evidence support treating remote regions to improve local pain?

• Evidence is growing, but likely not as robust as some other topics in physical rehabilitation. Some examples of regional interdependence demonstrated in research include the benefits of thoracic spine mobilization/manipulation for shoulder and cervical pain, a correlation between cervical pain and reduced serratus anterior activity, a correlation between hip ROM asymmetry and low back pain, and a correlation between Achilles tendinopathy and altered gluteal activity.

Is regional interdependence just a justification for “treat anywhere”?

No. The model does not support random or purely preference-based remote treatment. Instead, it supports:

• Systematic assessment of regions most likely to influence the primary complaint (for example, thoracic and cervical spine for shoulder pain, hips and ankles for knee pain).
• Prioritization of impairments that are plausibly related to task demands, biomechanics, and known neurophysiological or psychosocial mechanisms.

Regional interdependence should narrow clinical reasoning to high-yield regions, not expand it to “anything goes.”

Is regional interdependence only about manual therapy and manipulation?

• No. Although the concept was popularized in the context of spinal and extremity manipulation, research and clinical models incorporate exercise, motor-control training, education, and other interventions that address remote impairments.JOSPT+2PMC+2 For example, kinetic chain–based rehabilitation for shoulder pain emphasizes lower extremity and trunk impairments, not just local manual therapy.

How is regional interdependence different from the biopsychosocial model?

• The biopsychosocial model describes how biological, psychological, and social factors interact to influence pain and disability. Regional interdependence can be seen as a more specific application within this broader framework: it emphasizes how physical impairments and system-level responses (neuromuscular, neurophysiologic, cognitive, affective) in one region may influence musculoskeletal symptoms elsewhere.

How should clinicians apply regional interdependence in practice?

1. Start with a detailed history and local examination of the primary symptomatic region.
2. Add targeted assessment of regions that are biomechanically or neurologically linked to the primary complaint (for example, thoracic spine and rib cage for shoulder, hips for knee, lumbar–pelvic–hip complex for lower extremity).
3. Identify impairments that are both common and plausibly linked to the complaint (for example, limited ankle dorsiflexion, poor hip abductor control, thoracic stiffness, high pain-related fear).
4. Integrate local and regional interventions, and reassess the primary symptom after each intervention or short block of interventions.

Brookbush Institute Position

Regional interdependence is a useful model for structuring assessment and intervention planning, especially for complex or persistent musculoskeletal conditions. We support the following positions:

• Local examination is necessary but not sufficient. Most patients benefit from assessment of adjacent and functionally linked regions, rather than a single-joint focus.
• Use regional interdependence to prioritize likely contributors, not to justify random remote treatments. Interventions should target impairments that are common, measurable, and plausibly related to the patient’s task limitations and symptoms.
• Integrate multiple mechanisms. Biomechanical load transfer, neuromuscular control, neurophysiological modulation, and psychosocial factors can all contribute to regional interdependence.
• Maintain an evidence-based, outcome-driven approach. The regional interdependence model should be paired with reassessment after each intervention or small sequence of interventions, expected-value thinking, and progressive refinement of the treatment plan based on observed responses.