Regional Interdependence: The “Off Label” Treatment

, ,

The FDA dictates specific uses and indications of a drug based on pharmaceutical trials. These specific uses and indications are “on the label”. Physicians frequently utilize pharmaceuticals “off label” from their branded purpose based on clinical reasoning. This is a legal and widely accepted practice and necessary to treat conditions which at this time may not have the research evidence available to support the practice but has demonstrated good clinical outcomes. The advent of Clinical Prediction Rules (CPR) and subclassifying of conditions towards specific treatment protocols has been growing in the physical therapy realm5,8,12,13. This is particularly true with manual therapy and CPR for joint mobilizations/manipulations for the cervical, thoracic, and lumbar spine. In general, these guidelines tend to be region specific, IE: a lumbar manipulation for a lumbar condition5,8and cervical spine mobilization/manipulation for neck pain12. Although not as well known, predictive factors for the influence of cervicothoracic manipulation on shoulder pain10 and lumbopelvic manipulation in patellofemoral pain syndrome9 have also been proposed. You could say that the advent of CPRs/classifications is the rehabilitation world’s attempt at providing an “on label” guideline for treatment. However, little other attempt has been made to provide subclassifications for conditions and treatments regarding manual therapy interventions on extremity conditions. Clinically, worldwide, many movement professionals treat extremity conditions one to two joints proximally or distally, in particular through addressing mobility at the spine. This practice is based in the idea of regional interdependence, or “the concept that seemingly unrelated impairments in a remote anatomical region may contribute to, or be associated with, the patient’s primary complaint.”18 In an essence, this practice is “off label”, but unlike the pharmaceutical practice, it is not widely accepted and frequently questioned. This is particularly true from a medical billing and, depending on the location, referral/medical prescription level. Even from within our profession itself, it is not terribly uncommon for the concept of regional interdependence to questioned and perceived as a “wild goose chase around the body” 18.  As I have mentioned in previous posts, Thomas Myer’s Anatomy Trains based system KMI, Gray Cook’s SFMA and Gary Gray’s Chain Reaction Biomechanics™/GIFT Fellowship are perhaps the first to develop standardized evaluation and treatment methods of looking at the body globally rather than locally. Although the terminology varies between each, all of these programs have essentially provided a road map towards understanding regional interdependence. I have minimal exposure to all of these programs, so I cannot give justice to any of them trying to give additional details from their models. However, I wanted to share my thoughts on regional interdependence based on the experience I have gained through my mentors, research, and my limited full-time clinical experience thus far.

A JOSPT guest editorial by Wainner, Whitmann, Cleland, and Flynn titled Regional Interdependence: A Musculoskeletal Examination Model Whose Time Has Come (Freely available directly from JOSPT) written in 2007 probably first popularized the term “Regional Interdependence”, because very little literature prior to this date utilized this term. This editorial presented a great case, both from a clinical and a research perspective, that the practice of examining musculoskeletal conditions beyond the single joint/primarily complaint area is woeful inadequate to address the needs of both common and complicated conditions 18. Research has increasingly been supportive of regional interdependence. Improved pain scores and functional outcomes have been demonstrated painful shoulder conditions as a result of the use of cervicothoracic and rib manipulation 2,4,10,15. Similarly, lumbar and pelvic manipulation has demonstrated improvement in patellofemoral pain syndrome9,16,19. Beyond manual therapy, evidence for the use of foot orthotics for various lower extremity injury as a preventative measure7 and as a method of treating PFPS 17.  However, the role of distal contributions, or more specifically excessive pronation, was recently questioned in a systematic review by Chuter and Janse de Jonge6. In their review, they proposed that a greater influence on lower extremity injury arises proximally from the “core”6. Regardless, what is evident in available research is that proximal and distance regions to the site of injury have some role either as a result of the injury, or as a precursor to the injury1,6,11,14.

Clinically, there are presentations and treatments related to regional interdependence which are a long way (if ever) from being able to be demonstrated or clearly explained in a research design. We are still in the early stages of understanding manual therapy, let alone regional interdependence. Bialosky, et al. (Open access link) provides a great review and proposed a model which encompasses both joint and soft tissue mobilization/manipulation 3.  Although the emphasis of this model and much of the research on manual therapy is based on a neurophysiological, peripheral, spinal, or supraspinal mediated mechanism 3, it is difficult to extrapolate whether these the neurological models also play a key role in regional interdependence. Perhaps now, with the treated “dysfunction” one or more joints away from the injury location, the importance of “movement”, as biomechanically dictated, plays a more important role? Or perhaps still, somewhere in “homunculus land”, a map of regional interdependence is now changed to alter both pain and movement patterns. It is too early to tell, but hopefully this question will soon answered! Whatever the mechanism may be, clinically, there still appears to be a degree of specificity and clinical reasoning necessary in order to provide an optimal outcome. To illustrate this, I want to present a brief clinical case.

This case involves a 23 year old male competitive soccer player who originally presented with posterior left rib pain around T5 region which somehow evolved into some form of left posterior shoulder pain and restricted ROM. Somatic dysfunctions for the thoracic spine, ribs, scapula, glenohumeral capsule, and surrounding tissue(including an incredibly tight latissimus dorsi) were identified. These factors were assumed to be key to recovering the 10-15 degree loss of shoulder flexion with a painful posterior “pinch” at the endrange. A gambit of joint mobilizations and attempts to lengthen the latissimus dorsi, as well as, various techniques for “releasing” other soft tissue restriction was started.  Despite 4 sessions of valiant attempts to regain this loss of shoulder flexion through manual therapy and stretching even up to two joints away, little progress was made. Out of shear randomness, I observed an obscurity in the way the inferior aspect of his rib cage moved when I passively flexed his left shoulder. Perhaps it was an illusion generated by my mind from years of staring at Thomas Meyer’s Anatomy Trains, but something made me believe it was worth looking at his rectus abdominis. Needless to say, simply palpating the rectus abdominis was enough to generate a startle response similar to a typical trigger point presentation. Tension and “restriction” was felt through the lateral band of the rectus abdominis. Much to the patient’s dismay, I spent two minutes “releasing” this restriction and without any other treatment. Immediately afterward, I was able to move him into those last 10-15 degrees of shoulder flexion pain free. One additional treatment was scheduled and the patient was set for a one week recheck, at which point they were still symptom free and discharged.

Looking back now, I could pretend I know what happened and propose a theory to explain it from a biomechanical model utilizing Anatomy trains. I could state that since the rectus abdominis inserts on ribs 5-7, it must then pull on the fascial origins of the pectoralis minor directly or through pulling the rib cage down. Consequently, the pec minor then pulls on the coracoid process of the scapula, which could  result in anterior tilting of the scapula, and therefore give a possible mechanical cause for the “pinching sensation” and  restricting shoulder flexion. The honest truth is, I don’t know why it worked, because it was such a random find. Yet oddly enough, it seemed as though I had to be specific enough in my treatment approach in order to get a positive outcome for this patient. Simply addressing classic restrictions around the shoulder was not enough in this case, I had to go even farther, and I had to use soft tissue! Did I truly decrease the tension in the rectus abdominis and therefore produce the mechanical cascade which lead to this resolution? Could it have been placebo, was the shear randomness of the treatment approach a psychological effect that somehow modulated the pain or ROM changes? I am completely open to any suggestions!

Clearly not every case needs to be this involved or complicated, and sometimes the area of injury is the best place to focus your treatment and leave it at that. At the same time, both clinical and research evidence seems to be paving way the importance of remembering that the leg bone is connected to the knee bone, and the knee bone connected to the thigh bone…

1. Berglund KM, Persson BH, Denison E. Prevalence of pain and dysfunction in the cervical and thoracic spine in persons with and without lateral elbow pain. Man Ther. 2008;13(4):295-299. doi: 10.1016/j.math.2007.01.015.

2. Bergman GJ, Winters JC, van der Heijden GJ, Postema K, Meyboom-de Jong B. Groningen manipulation study. the effect of manipulation of the structures of the shoulder girdle as additional treatment for symptom relief and for prevention of chronicity or recurrence of shoulder symptoms. design of a randomized controlled trial within a comprehensive prognostic cohort study. J Manipulative Physiol Ther. 2002;25(9):543-549. doi: 10.1067/mmt.2002.128373.

3. Bialosky JE, Bishop MD, Price DD, Robinson ME, George SZ. The mechanisms of manual therapy in the treatment of musculoskeletal pain: A comprehensive model. Man Ther. 2009;14(5):531-538. doi: 10.1016/j.math.2008.09.001.

4. Boyles RE, Ritland BM, Miracle BM, et al. The short-term effects of thoracic spine thrust manipulation on patients with shoulder impingement syndrome. Man Ther. 2009;14(4):375-380. doi: 10.1016/j.math.2008.05.005.

5. Childs JD, Fritz JM, Flynn TW, et al. A clinical prediction rule to identify patients with low back pain most likely to benefit from spinal manipulation: A validation study. Ann Intern Med. 2004;141(12):920-928.

6. Chuter VH, Janse de Jonge XA. Proximal and distal contributions to lower extremity injury: A review of the literature. Gait Posture. 2012. doi: 10.1016/j.gaitpost.2012.02.001.

7. Collins N, Bisset L, McPoil T, Vicenzino B. Foot orthoses in lower limb overuse conditions: A systematic review and meta-analysis. Foot Ankle Int. 2007;28(3):396-412. doi: 10.3113/FAI.2007.0396.

8. Flynn T, Fritz J, Whitman J, et al. A clinical prediction rule for classifying patients with low back pain who demonstrate short-term improvement with spinal manipulation. Spine (Phila Pa 1976). 2002;27(24):2835-2843. doi: 10.1097/01.BRS.0000035681.33747.8D.

9. Iverson CA, Sutlive TG, Crowell MS, et al. Lumbopelvic manipulation for the treatment of patients with patellofemoral pain syndrome: Development of a clinical prediction rule. J Orthop Sports Phys Ther. 2008;38(6):297-309; discussion 309-12. doi: 10.2519/jospt.2008.2669.

10. Mintken PE, Cleland JA, Carpenter KJ, Bieniek ML, Keirns M, Whitman JM. Some factors predict successful short-term outcomes in individuals with shoulder pain receiving cervicothoracic manipulation: A single-arm trial. Phys Ther. 2010;90(1):26-42. doi: 10.2522/ptj.20090095.

11. 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.

12. Schellingerhout JM, Verhagen AP, Heymans MW, et al. Which subgroups of patients with non-specific neck pain are more likely to benefit from spinal manipulation therapy, physiotherapy, or usual care? Pain. 2008;139(3):670-680. doi: 10.1016/j.pain.2008.07.015.

13. Slater SL, Ford JJ, Richards MC, Taylor NF, Surkitt LD, Hahne AJ. The effectiveness of sub-group specific manual therapy for low back pain: A systematic review. Man Ther. 2012;17(3):201-212. doi: 10.1016/j.math.2012.01.006.

14. Souza RB, Powers CM. Differences in hip kinematics, muscle strength, and muscle activation between subjects with and without patellofemoral pain. J Orthop Sports Phys Ther. 2009;39(1):12-19. doi: 10.2519/jospt.2009.2885.

15. 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.

16. Vaughn DW. Isolated knee pain: A case report highlighting regional interdependence. J Orthop Sports Phys Ther. 2008;38(10):616-623. doi: 10.2519/jospt.2008.2759.

17. Vicenzino B, Collins N, Cleland J, McPoil T. A clinical prediction rule for identifying patients with patellofemoral pain who are likely to benefit from foot orthoses: A preliminary determination. Br J Sports Med. 2010;44(12):862-866. doi: 10.1136/bjsm.2008.052613.

18. 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. doi: 10.2519/jospt.2007.0110.

19. Welsh C, Hanney WJ, Podschun L, Kolber MJ. Rehabilitation of a female dancer with patellofemoral pain syndrome: Applying concepts of regional interdependence in practice. N Am J Sports Phys Ther. 2010;5(2):85-97.

/1 Comment/by

Rope Climbing Progressions

, ,

Eric Cressey put out a great post a few months ago regarding the possible risk of doing excessive amounts of heavy pull-ups/chin-ups. Eric also made a good point that perhaps for some individuals, we should be doing a cost-benefit analysis regarding whether they should even be doing the exercise. Since then, I have seen a number of individuals post their concerns regarding excessive chinning/pull-ups. Along with many of these posts came the suggestion of complimenting, supplementing, or possibly replacing pull-ups/chins with rowing and other pulling techniques. Although this isn’t exactly a new idea, many coaches are attempting to balance between the two motions, it just hasn’t had as wide of recognition as it should have because so many people hold the pull-up/chin as a sacred cow which cannot be degraded or changed in any shape or form. Needless to say, I still love pull-ups/chins, but I have found myself drifting more towards doing variations of heavy rope climbing as my primary grip, arm, and back strengthening exercises. For this post, I put together video of my favorite rope climbing progressions as a supplement to, or replacement for pull-ups/chin-ups.

This is a basic rope climbing progression toward climbing single and double ropes without leg assistance. Rope climbing is an excellent grip, arm, and back challenge that demands strong functional muscle synergies in order to complete each pull. This progression is designed for rope lengths between 7-10 feet, such as those attached to a power rack/squat rack or a low ceiling. At this distance, climbing up and back down equals 1 rep. As each unweighted progression becomes easy (3 sets of 10 reps easy), you progress to the next technique, or skip around as you see fit. Treat the “no leg” climbs like a heavy lift, aiming for sets of 5. If you can get to the point of doing 5 sets of 5 reps with the no leg technique, you are solid and should either strap on some weight or find a place to use a decent height rope (20+ feet).

**Caution: Although I really enjoy the suspension strap assisted climbs, there is a risk of getting yourself tangled up and coming down without your legs to protect you. If you can’t safely bail out with just your arms at this height, don’t use this technique.

[youtube http://www.youtube.com/watch?v=0nrtQoek31E&w=420&h=315]

/0 Comments/by

The EDGE Review and My Introduction to IASTM

***FULL DISCLOSURE: I am planning on becoming an affiliate for the EDGE. I hope this review stands for itself that monetary reasons have no influence on my perspective or this review, but I wanted to be upfront about my future intentions.

I have been following Dr. E’s Blog off and on for the last year, primarily for the excellent education resource it provides for those with strong interests in manual therapy. I had looked at the EDGE tool a number of times, but never really thought seriously about trying it out because I’ve always had a bias towards the exclusive use of my hands in manual therapy. The whole Graston/ASTYM and the  Instrument Assisted Soft Tissue Mobilization (IASTM) seemed like a fad to me, so I thought I’d wait it out.  However, in January, I mentioned Dr. E in a Twitter reference and was surprised to hear back from the man himself.  We spoke off and on since then, and he mentioned he wanted to get my thoughts on the EDGE as a self-treatment tool for the martial artist. It took me a while, because I was still skeptical, but I finally ordered my own EDGE at the end of February to try it out.  I quickly found out, I really couldn’t do it justice by only speaking from the perspective of a martial artist, but also someone who is completely new to the concept of IASTM and how different it is from traditional soft tissue mobilization (STM).

To start,  I wanted to talk about how oblivious I was to the difference between IASTM and STM. I was fortunate enough to have some great physical therapy mentors introduce me to STM in 2003, prior to even starting school for athletic training or physical therapy. Over time, I began to favor a treatment approach that was biased towards combinations of ischemic pressure based releases and blunt (finger) deep cross friction. This treatment style did not transition well into IASTM , which I believe fits better within  the realm of differentiating and treating based on “dysfunctions” in myofascial tissue layers. I have been historically biased against popular myofascial release techniques because I do not see as rapid of a change as I do when I deal directly with hypertonicity in contractile tissue (trigger points, etc.). In my attempts to transition the EDGE over to this style of treatment, I was frustrated in overlapping these techniques because of the abrasions and skin pinching that resulted from attempting to use the tool in this manner. Over the first few weeks, I was able to get a few individuals willing to subject themselves as gracious guinea pigs for me test the EDGE on, including myself. Our first impressions were that we were uncomfortable with the “abrasive feeling” in comparison to the way I had been treating before, in particular the residual burning skin (not bruising) discomfort for the day following. I also became concerned with some of my deeper treatments possibly breaking the skin because I made that mistake on myself in my first treatment session. I nearly gave up on IASTM two weeks into it because I simply was ignorant to the purpose of it. I decided to step away from the drawing board and started reviewing the EDGE basics videos and a number of ASTYM videos. With paused reflection, I realized I had to come to IASTM with an open mind towards learning a new style of treatment rather than forcing my own idea of how to use it.

The next time I picked up the EDGE, I started working on an old achilles issue of mine and really spent time working superficially before progressing to deeper layers, and this time I actually made a change in the symptoms and the tissue, very quickly. The strokes were now intent on stripping and scraping in a layer approach rather ignoring the superficial layers and going straight for the deep tissue. An e-mail communication with Dr. E. at that point confirmed to me that my early attempts were really rather futile and that the emphasis of IASTM is stripping and scraping technique in order to facilitate the inflammatory process in healing.  Now, six weeks later, not only am I am able to use the stripping and scraping techniques in a manner which is resulting in symptom reduction but I have also slowly been able to adapt my ischemic pressure releases into the EDGE and reduce the dependency of my hands for all my STM treatments.

From my limited experience so far, I can say that the EDGE certainly is not for every condition and does not work well for everyone (I have one volunteer I definitely cannot use it on), but it has found an important place in my developing manual therapy skill set. Nevertheless, the EDGE has dramatically changed the way I think about treating soft tissue dysfunction and I am thankful that I have had the opportunity to start developing IASTM skillset prior to my full time practice as a physical therapist in manual therapy.

One thing that I wanted to comment on was the type of lubricant/medium used as an interface for IASTM.  After a week of trying out Albolene, Dr. E’s favorite medium for IASTM, I switched to Cramer Skin Lube. I was introduced to Skin Lube during one of my clinical rotations in athletic training where we did an extensive amount of STM using a medium (new to me, since again, I didn’t use “massage like” techniques at this point) on track and field athletes. Skin Lube has a much higher melting point, was cheaper than Cocoa Butter which is commonly used in “massage like” techniques. It is odorless similar to Albolene and seems to last longer than Cocoa Butter and Albolene. For me personally, it felt as though I need a significant amount of Albolene before I felt like it was providing a protective layer against excessive early skin abrasion and I felt at times I needed to re-apply it. With Skin Lube, it took only a single application for roughly 1/4th of the amount of medium. Price wise, both products are nearly equal costs on Amazon.com, Skin Lube just barely came in cheaper, 454 grams for $13.41 vs  $13.37 for 340 grams of Albolene. I’m still way new to this whole IASTM thing, but I have to say that my initial experience is that I like the protective feeling of the skin it gives me, but the downside is that it takes quite a bit more work to remove the remaining product in comparison to Albolene. Although perhaps that could be a benefit!

The EDGE for Martial Artists as a self-treatment/preventative tool

Chronic injuries in martial artists are similar to many other sports, although I will highlight a couple of areas I have found the EDGE to be particularly useful.  Hundreds of thousands of hours and repetitions of striking, gripping, pulling, pushing, and chin na/joint locking lends to numerous opportunities to develop overuse injuries in the forearms and hands. The contours of the EDGE are perfectly designed to reach these areas and could possibly play a valuable preventative and treatment intervention for the martial artist’s hands and forearms. Similarly, as martial artists, we are highly susceptible to patellofemoral pain syndromes(PFPS), achilles tendinosis, chronic hamstring, and IT band issues. These areas are also easily accessible with the diverse contours of the EDGE for self-preventative maintenance. Specifically, I found it very effective in addressing problems around tendinous insertions.  I have been able to completely calm down some irritation in my achilles tendon insertion with a single 5 minute session IASTM session allowing me to train pain free for that day. I also had a recent flare-up of PFPS which I have been able to manage symptomatic with a quick session with the EDGE.

When I spoke to Dr. E originally, I mentioned I typically just recommend foam rollers and tennis balls for self-treatment, I was not sure how valuable this tool is going to be to the martial artist. Now 6 weeks into it, I believe I have found a definitive place for the EDGE in self-treatment of areas I didn’t think about treating because I couldn’t really address them with a tennis ball or foam roller.

I would make only one cautionary statement. Our natural instinct as martial artists (and most athletes) is that more is better (“More Chi Train Harder!”), which may make us use the tool more aggressively than it should be utilized, especially if we are used to deep tissue work such as releasing trigger points. I should have known this myself, but my first self-treatment session with the EDGE I actually kept working through the abrasive sensation to the point broke open some skin while I stopped looking at the treatment site. Clearly it’s the users fault, but it was the first time I had to think a intently about being less aggressive and layering my treatment as to avoid making the same mistake. I think with a little instruction and practice, this would be valuable addition to the martial artist’s preventative maintenance program.

“BONUS”: Here is a video clip of a movement based technique I have been using for symptom management of some PFPS that started flaring up for me a few weeks ago. As an update to what I said on the video, not sure if it is coincidence, chance, spontaneous healing, a recent increase in training intensity, or the daily EDGE treatment technique I show here, but my PFPS is pretty much 90% resolved in the last week after only using this technique. Which is surprising to me because I usually have to think more critically about how I was going to treat it “properly” in order for it to get better. Anyway, check it out:

[youtube http://www.youtube.com/watch?v=dd7evKe0U_E&w=560&h=315]

/0 Comments/by

Grip Strength Tools

I was  recently motivated by Rogue Fitness and their new grip strength toys to look into incorporating some new grip strengthening strategies into my own arsenal. Thanks to our “opposable thumb”, we have a variety ways in which we can hold on to things. So it makes sense that if we want to have a “strong grip”, we’re going to want to challenge the hand in more than one way, because a bar, rope, rubber band, and a weight plate can only go so far. John Napier classically categorized grip types simply into “power grips” and “precision grips”. Most textbooks these days have tried to sub-categorize these two groups into roughly 5 different types of grips. Our “power grips” consist of the cylindrical grip, spherical grip, hook grip, and lateral prehension (thumb adduction). While our “precision grips” are all the variations of tip-to-tip pinching and thumb positioning for grabbing small objects.

Unfortunately, my college student budget does not have room for the high quality workmanship of Rogue’s tools at this time. So I decided to channel my inner Ross Enamait and Zach Even-Esh to build my own. Clearly, I’d recommend that you buy the real deal from Rogue [or Elite FTS]***, but I’ve been made do with the following:

[youtube http://www.youtube.com/watch?v=l038yDOCkqw&w=560&h=315]

***Update: I was informed that Elite FTS also has a great grip kit as well.

/0 Comments/by