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After my article, "Outside the Box: investigating a new model of assessing musculoskeletal disorder," appeared in ADVANCE (Aug. 11, 2008), I received several responses referencing the topic. I was glad to see that the article provoked thought on the subject as this is always my intent and purpose. However, after reading through some of the responses, I am not sure that my point was completely clear.
I prefaced my article by discussing "regional interdependence" as discussed by Wainner et al.1 I used this as a jumping off point to discuss "system interdependence".2 It seemed as though at least some who read the article had difficulty separating regional interdependence and system interdependence as two separate and unique concepts. While I think system interdependence may be at play and help to explain the occurrence of regional interdependence, they are not one in the same.
 The regional interdependence model suggests the patient's primary complaint may be related to impairments in anatomical regions distal or proximal to the region of the primary complaint. In regard to regional interdependence, Wainner states that there is a need to "further define the relevant relationships and interdependence between anatomical regions ..." and I believe that this is exactly where the system interdependence model comes in.
The Neuromuscular System
When we begin to view the neuromuscular system as the inter-connectedness of the osseoligamentous system, muscle system and neural control system as suggested by Panjabi's model, the relevant relationships and interdependence between anatomical regions begins to take shape.3 System interdependence focuses on the inability to stimulate any one of the osseoligamentous, muscular or neural systems without having an effect on the others. However, for some, that inter-connectedness of the neuromuscular systems, "system interdependence" can only be thought of in a limited anatomical range.
In my previous article I attempted to give examples that spread across larger regions of the body or at least regions and systems that had not typically been connected or related in the past. In one example I was trying to connect anatomical regions of the body such as mid- to upper thoracic spine with sacroiliac joint and hip. However, by doing this I now realize I only made new boundaries when I was actually trying to eliminate all boundaries.
The more new research I read about the nervous system, the more it seems that there are connections to and from all parts of the body. It seems we are continually gaining more and more information about reflex loops as well as neural pathways that connect segments above and below what we previously thought were the boundaries of the anatomical system. If you then include the autonomic nervous system with its sympathetic and parasympathetic connections throughout the body, the connectedness continues to expand.
Eliminating Boundaries
I recently read an incredible book entitled The Body Has a Mind of Its Own by Sandra and Matthew Blakeslee.4 Though this book is not specific to physical therapy, in my opinion it has thrown fuel to the fire of system interdependence and in most cases helps to eliminate any boundaries between regions of the body. It opens the door to new areas of potential orthopedic treatment. The book looks at many areas of the mind and body interaction that have been discovered through repeated and reproducible research.
It is beyond the scope of this article to relay all details of this book. In brief summation, this book details the amazing connectedness of the brain (neural control) to the body (osseoligamentous and muscular systems). It outlines the changes in body maps in the brain when injury occurs to the physical body. More importantly, it discusses how flexible and responsive the body maps of the brain and the physical body can be when given the proper stimulus. There are even some specific examples of mirror therapy and vibration techniques that may be directly applicable to orthopedic physical therapy.
Research
While attending physical therapy school back in the mid 1980s, we discussed research that showed mental imagery or mental practice improved a task (shooting baskets) as much as actually performing the task itself. Since those days, this type of research has been repeated many times over. Since 1894 we have known about "cross education" which shows strength training in one limb creates strength gain in the opposite, untrained, limb. We are just beginning to understand the neurophysiologic adaptations that occur in this phenomenon.
I have also read volumes on neural system memory. Researchers believe that following an injury to the osseoligamentous or muscular system the neural system can be sensitized or "primed" causing pain situations to easily recur or become chronic. There are even the clinical examples of peripheral nerve injury in one extremity causing corresponding EMG deficits in the opposite uninjured extremity. Again it seems researchers are only scratching the surface of how this is perpetuated.
What does all this mean in orthopedic practice? What would happen if we routinely taught our orthopedic patients who are immobilized for weeks in a sling to visualize the involved arm performing a jumping jack motion as they actually moved the uninvolved arm through the motion? Would they recover ROM faster when we get them out of the sling? What if we performed vibration of the muscle group, anterior deltoid and biceps, as the patient visualizes shoulder flexion? Would these patients get strength return faster when out of the sling?
What about using mirror therapy on a patient who has had two ulnar nerve surgeries at the elbow and has not had normal function of the extremity for the past three years? Would that patient's brain maps really be much different than a stroke patient since they have not used the arm in a normal functional manner or without pain over this extended period.
What about an elderly, severely osteoporotic patient with a recent humeral fracture with ORIF? This same patient also has a history of fracturing the same location 20 years ago and complications suggestive of RSD for which she had received "nerve blocks in my neck". Would it be worth the effort to try cross education and mirror therapy while she is immobilized? Has the neuroplasticity of the brain changed significantly from its normal state in these patients? Has the neural system been sensitized? Can we help the neural input by using the muscle and osseoligamentous system?
Evidence-Based Practice
There are a lot of questions with only logic and reason to try and answer. Research into these areas as it pertains specifically to physical therapy, have yet to be addressed. This brings up even more questions about evidence-based practice. I am a firm believer that research must guide our practice. However, I am also a believer that not all of the evidence lies squarely in the physical therapy literature. I am often interested in the position of some who feel evidence-based practice is simply typing in a query about iontophoresis and how it pertains to lateral epicondylitis. I believe it is more complicated than that.
Evidence exists in many areas of research from neurology, physiology, biology, psychology and exercise science, etc. which may shed light on our practice. The evidence needs to be continually updated in the clinician's brain so that as they approach each individual case, logical reasoning can be used based on years of clinical practice and years of research data. If the clinician is waiting for each treatment technique to be clarified by research for each patient population within physical therapy, there will be a long wait.
As orthopedic clinicians, we need to continue to push the envelope of available research. When we come across new systems, such as Total Motion Release or Primal Reflex Therapy, which seem to create significant clinical response, we should try to critically think about the system interdependence that may explain the phenomenon. (Note that I am not affiliated with or currently trained in either of these approaches.) Rather than dismiss these or other unusual and "out-of-the-box" therapies, we should use all the research available to see how system interdependence may be at work.
Dr. Swartzlander is the clinic coordinator for St. Mary's Good Samaritan Inc., Centralia IL, and instructor for theraPTeach in-house seminars.
References
1. Wainner R, Whitman J, Cleland J, Flynn T. Regional Interdependence: A Musculoskeletal Examination Model Whose Time has Come. J Orthop Sports Phys Ther. 2007;37:658-660.
2. Swartzlander B, Outside the Box: investigating a new model of assessing musculoskeletal disorder. ADVANCE. 2008;19:62-63
3. Panjabi M. The stabilizing System of the spine. Part I. Function, dysfunction, adaptation, and enhancement. J Spinal Disord. 1992;5:383-389.
4. Blakeslee S, Blakeslee M. The Body Has a Mind of Its Own. New York, NY: Random House; 2007.
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