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1

Chapter 4The Bad Ragaz Ring Method

Urs N. Gamper and Johan Lambeck

CHAPTER OBJECTIVES

• Understand the relationship between the Bad Ragaz Ring Method (BRRM) and Proprio-ceptive Neuromuscular Facilitation

• Learn the connection between the properties of water and the manner in which BRRM makes use of them

• UnderstandthespecificclinicalusesofBRRMinpatientmanagementwithintherehabili-tative continuum

• UnderstandthelimitationsofBRRMwithintheInternationalClassificationofDisability(ICD)system

TheBadRagazRingMethod isanactiveone tooneaquaticphysical therapyconcept.Thetherapistprovidestheresistingfixpointstothepatients.Thetechniquerequireshighskillandaccuracyofthetherapists.Therefore,thetherapistmusthavetheexactknowledgeofthecon-ceptandmustshowarefinedgrippingtechnique.Botharecompulsoryforthesuccessofthemethod.

BACKGROUND

TheBadRagazRingMethod (BRRM) is a strengthening andmobilizing resistive exercisemodel based on the principles of proprioceptive neuromuscular facilitation techniques (PNF) (Kabat1952,1953andKnott&Voss1968).ThisspecifictreatmentconceptwasdevelopedbyphysiotherapistsinBadRagaz,SwitzerlandandpublishedbyDavies(1967).Thispublicationiswellknownworldwidebutincludedsomeinefficientpatternsforstrengtheningandmobiliiza-tion.EggerexpandedthemethodwithnewpatternsandpublishedthenewBadRagazMethodwithRingsin1990.Inthispublication,thepatternsareverywelldescribed,butatthattime,thetherapistsdidnotusethemethodwithimplementationofexercisephysiologyandwithimple-mentationofcontemporaryPNF-techniquestooptimizetheeffectofthemethod.

TheBRRMisn’t justastrengtheningandmobilizing technique,butacompletephysio-therapeutictreatmentconcept,whichcanbefocusedonmodulationofpainandmuscularrelax-ation.Toachievethis,specifictechniquesareused.

COMPREHENSIVE AQUATIC THERAPY2

PHYSIOTHERAPEUTICANDMECHANICALPRINCIPLES

Biomechanical,hydrodynamicandneurophysiologicknowledgeprovide themost importantfundamentals for the resistive therapyof theBadRagazRingMethod.When thepropertiesofamovementinonejointsuchasitsdirection,intensity,andvelocityinfluenceneighboringjoints,acontinuousmovementdevelops(Klein-Vogelbach1981).Everycontinuousmovementchangestheequilibrium,forcingthebodytoreacttofindapositionofstableequilibrium.Thesereactions occur in two steps:

1. Theclientstopsthecontinuousmovementwithacounter-activity,whichiscalledactivecounter force (or thrust).

2. Theclientusessomebodypart(s)asacounterweighttorestrictthecontinuousmovementeffects. This is called an activated passive counter force.

IntheBRRM,bothactiveandactivatedpassivecounterforcesareused.Fromanexercisephysiologicalpointofview,justtheactivecounterforcesareimportant.Knowledgeandproperactivation of these counter forces are of utmost importance in order to use the BRRM patterns inacorrectmanner.Forexample,whenusingaunilateralreciprocalpattern,thecenterofgrav-itymovesawayfromthemidline,causingthebodytoroll.Topreventthis,counteractivitieshavetobefollowedexactly.Movementswhichoccurasanactivatedpassivecounterforcehavealargetherapeuticvaluebecausetheseareautomatic,reactivemovementsofwhichthepatientmaybeunaware.Theseautomaticmovementsoccurwithasmallamountofforce,occurslowlyandcanbeeasilycontrolledbythetherapist.

Figure 4-1. Active counterforce: The primary movement of the left hand is reaching forward to ring the ring to the noodle. This movement automatically induces an extension of the spine to limit the movement of reaching forwards. In this example, it is not enough, to maintain the balance, it needs more counter weight. Activated passive counterforce: The movement of the right leg in ex-tension and right arm in flexion and abduction, out of the water.

The Bad Ragaz Ring Method 3

Therapeuticallyactivatedpassivecounterforcereactionsarealsoimportant.Inthiscase,theautomaticreactionsaredesiredandautomaticforthepatient.Thesetypesofmovementsareeconomicallyandhelpfulwhenpatientshaspainorwillnotallowmovementoftheaffectedextremity.

Whenafreefloatingbodyinwaterexperiencestractionononeside(distraction)andap-proximationattheothersideofitsextremitiesortrunk,atorqueexiststhatmovesthebodytoward the traction side. This movement is supported through the various mechanical forces of watergivingthebodyageneralmobilizationinaspecificdirection.Beforethebodystartstomove,theinertiaofthewatermustbeovercome.Onceinmotion,thebodyincreasesitsspeedgraduallywhichcreatesincreasedturbulentflowbehindthebody,increasinglyprovidingmoredrag.Inaddition,frontalpressureduetothewater’sviscosityalsoincreases.Dragforcesinwa-teraredependentontherelationshipbetweenthedifferencesindensityandviscositybetweenairandwater.Atrest,thedifferencebetweenwaterandairis1:14.Therefore,dragorresistancetomovementisattheleast14timesgreaterinwaterthaninairasfastermovementincreasesresistanceduetoturbulentflow.TheBadRagazRingMethodusesthesefluidmechanicalforcesasaresistance.Thatiswhyitisimportantthatthepatientalwaysfloatsatthewatersurfaceduring BRRM treatments.

Table 4-1. Exampleofthepatternflexion-abductioninternalrotationwithkneeflexionandtheautomaticcounterforcereaction.Ifwehaveassymetricalrotationinbothlegsthebodyisinstableandrollsinthewatertothesideoftheexternalrotation.

FlexionAbductioninFlexionInternalRotationinFlexion

Pelvic SinksBodyRollstotheRightBodyRollstotheRight

ExtensionExternalRotationAbduction

Primary Movement in the Right Hip Joint Effect

Counteraction in the Left Hip Joint

Figure 4-2. Turbulent flow provides drag at the left side of the patient (negative pressure) and gives resistance to the patient.


PROPRIOCEPTIVENEUROMUSCULARFACILITATIONANDBRRM

Intheprevioussection,weexplainedthatBRRMincorporatesvarioustherapeuticconcepts.However,sinceBRRMisregardedas“PNFinwater”,acomparisonofbothconceptsisimpor-tant.ProprioceptiveNeuromuscularFacilitation(PNF)isdefinedasamethodofpromotingorhastening the response of the neuromuscular mechanism through stimulation of the propriocep-tors(KnottandVoss1968).PNFisaspecificcollectionofland-basedtechniquespromotingtheresponseoftheneuromuscularsystemthroughstimulationoftheproprioceptors.Thepatientalwaysusesthephysiotherapist’sresistancewitharelativelyfixedbaseofsupport,soequilib-rium/balanceisguaranteedmoreorlesscontinuously.Gravityallowsthemaximaldistanceoforiginandinsertionofmusclesbyusingslowstretchreflexeswherebymovementscanbeinitiated.Thetherapist’sresistancestayspresentthroughoutthemovementexcursion.

Likewise,whenthehumanbodyisfloatinginwater,itisinstableequilibrium.However,asinglesmallmovementcanchangetherelationshipbetweenthecenterofgravityandthecenterofbuoyancyandthebodywillloseitsstableposition.EquilibriumcanberestoredintheBRRMintwoways:

1. Asmallsupportforstabilization,usingflotationaids2. Thetherapist,whosehandsformtheonlyrealpointsoffixation.

Inafreefloating,nonmovingbodyinwater,itisimpossibletomaximallystretch/tearapartoriginandinsertion,becausetheintramusculartensioncannotbeoverriddeninthisposi-tionoffreefloat.Therefore,unlikePNF,thestretchreflexcannotbeusedtoinitiateamovementinwater.TheresistanceeffectsintheBRRMexistbecauseofthetherapisthandsandofthedragdue to the movement through water. This subtle balance makes it impossible to move to the endoftherangeofmotioninallpatterns.Often,onlypartsofpatternsareusedintheBRRM.

INDICATIONS

TheBRRMisastrengtheningandmobilizingresistiveexercisemodelinaonetoonesituationwithavarietyofexcellentcharacteristics(seesectionontreatmentgoals).Itisaspecificthera-peuticregimenwithwell-definedindications.TheBRRMcannotbeusedforstrengtheninginaquaticfitnessgrouptreatments.Whentrainingwithavolunteer-partner,hemustknowthepat-tern,theresistance,thetechniquesandhaveadequateknowledgeofexercisephysiology.TheBRRMisanidealpartofthecomplextreatmentconceptofaquatictherapy.Aquaticstrengthen-ingwithoutusingtheBRRMorresistanceequipmentscanmaximallyincreasestrengthuptoforce3,withtheBRRMuptoforce5(PetersonKendall2005),whenusingtheasymmetricalreciprocalpatterns.However,alsoBRRMisparticularlyindicatedforrelativelyweakpatients.ByusingBRRMforstrongerpatients,thestrengthandstabilityofthetherapististhelimitingfactor of the strengthening process.

Thefunctionaltherapeuticabilitiesandlimitationsareanalyzedpreciselybythetherapistandthemostsuitablepatternschosenbytheknowledgeableaquaticpractitioner.Patientswhoneedtoimprovestrength,mobility,stabilityorfunctioncanbenefitfromBRRM.Thetechniqueis useful with:

• peripheraljointproblemslikeosteoarthritis,• inflammatorydiseaseslikerheumatoidarthritisorankylosingspondylitis,


Isotonic and isometric resistance are applied during the whole movement and adapted to the capabilities of the patient. Thetherapistfeelsthepatient‘squalityofmovementduringdynamicworkandisabletoinfluencethequalitybyadaptingtheresistance given.Correctholdingandtactilecueingbythetherapisthelpstostimulatetheskin,muscleandjointproprioceptorstofacilitatethemovement.Short,precisecommandsbythetherapiststimulatetheactivemovement.Tractionandapproximationatjointsstimulatesensorynerveendingsandinitiatereflexiveco-contraction(troughapproximation)or support an isotonic contraction (trough traction)Stretchcanbeusedasatechniqueonlythroughthepatternandnotat its beginning.A facilitation of strong muscles provides irradiation to the weaker onesandincreasestheiractivity.Three-dimensional diagonal movements has the most effective strengthening effectAchangefromaproximaltoadistalholdincreasesdifficultytoexecutecorrectpatterns.Themovementsalwaysstartdistally.Immersion destabilizes the therapist. He should not immerse deeper thanTH9,otherwisethecorrectexecuteoftheMethodisnotguaranteed.

Adapted resistance

Stimuli:tactile,verbal

Traction/approximation

Stretch

Irradiation

Patterns

Timing

Bodymechanics

• chronicspineproblems,• generalweaknessormotorcontroldeficitfromneurologicaldiseaseslikestroke,peripheral

nervelesions,polyneuropathies,or• impairmentspostsurgery,liketrauma,andjointreplacement.

Ingeneral,patternsthatdirectlyfocusontheareaofthefunctionalproblemareusedinalaterstage.Atfirsttheeffectsarecreatedwithadetour:indirectstrengtheningasareactiveeffect.Forexample,spinalstabilizationisfacilitatedbybilateralreciprocallegpatterns.Thetherapeuticgoaloftenisobtained‘reactively‘.Theactivitiesareeconomical,efficientandmustbemaximal to thepatient’s possibilities.Therefore ageneral strengtheningprogramcanbeperformed with correct dosage.

TheBRRMhoweverisn’tjustastrengtheningtechnique,butacompletephysiotherapeuti-caltreatmentconcept,whichcanbefocusedonmodulationofpainandmuscularrelaxation.Toachievethis,specifictechniquesareused(seeTable11.)

TREATMENT GOALS

TheWorldHealthOrganization(WHO,2001)hasclassifieddescriptionsofhealthproblemsinto4components,whicharebeingusedwidelyinrehabilitation.These4componentsarein-

Table 4-2. The basic principles of the PNF concept that are utilized in the BRRM.


terrelated,althoughanincreaseatoneleveldoesnotnecessarilyleadtoanincreaseatanotherlevel.Forexample,improvementsatthefunctionleveldonotautomaticallyleadtochangesattheactivityandparticipationlevels.Theadvantageofthisclassificationisthatthepatient’streatmentgoalscanbedefinedaccordingly.

The levels are:• Bodystructureandbodyfunction• Activity• Participation• Contextualfactors

AllgoalsoftheBRRM,aslistedinTable2,canbefoundatthelevelofbodyfunction.Thegoalsareusedforpatientswithneurological,orthopedic,andrheumatologicalproblemsandserveasapreparationfortherapyatthelevelsofactivityorparticipation.Ingeneral,theBRRMismostlyusedinanearlystageofrehabilitation.

Table 4-3. Indication of BRRM and relationship to ICF

StrengthCoordination

JointstabilityRange of motion

Local muscle endurance

Preparing lower extremitiesforweight-bearing

Muscle power functionsInvoluntarymovement

reaction functionsStabilityofjointfunctionsMobilityofjointfunctions

Muscle endurance functions

Gait pattern functions

IncreasingMuscular tone

PainMuscle tone functions

Sensation of pain

ICF Body Function ICF Body FunctionDecreasing

APPLICATION OF TECHNIQUES

BRRMisnotsimplyamatterofworkingagainst theresistanceofwaterandaddingafixedpointtoapatientfloatinginsupinewithbuoyancyringsandthenaskingforactivemovements(in straight planes). The patient must be evaluated with an emphasis on determining the inter-ventionneeds.Asaresult,thetherapistchoosestheadequatepatternsandparameters.Physi-ological parametersdiffer dependingupon the therapeuticgoal such as increasingmobility,enduranceorstrength.Theamountofresistanceiscarefullygradedintimingandintensity.Thepatientmustbeeducatedabout theprocedureandwhennecessary,mentaladjustment (Hal-liwick Concept) has to precede BRRM. This mental preparation is an important component of theBRRMtreatmentprogram.Whenthepatientisuncomfortableinasupinepositionandhasdifficultywithbreathcontrol,equilibriumreactionsand/orstiffnesswill interferewith treat-ment.

TheexerciseprogramoftheBRRMrequiresflotationaidsthatprovidepatientsafetyandstabilizationinthewater.Theseflotationaidsalsoslowdownrotationofthebodyinthepool.Theneckandhipsaresupportedbyringspreferablyfilledwithair,anddependingontheexer-cise,athirdringmaysupportoneorbothankles.


The positioning and inflation of the flotation aids are quite specific.The flotation aidsshouldbeplacedinsuchawaythatmovementisnotrestricted.Ringsaroundtheanklesandhipshouldhavealimitedamountofair.Whentheringsareover-inflated,thebodybecomesun-stableandrisestoohighoutofthewater.Consquentlylessforcedevelopmentcanbeexpected(Harrison 1982).

TheringatthehipsshouldsupportthecenterofgravityatS2ratherthanthewaist.Acollararoundtheneckfacilitatescervicalspineneutralalignment,andallowsthepatienttohearthetherapist’sinstructions.Inaddition,insomelegpatterns,theneckcollarservestocreatethecounterthrust.ThetherapististhepointoffixationforthepatientduringallBRRMexercise.Thismeans that the therapistmust be in stable equilibrium, avoiding excessivemovement.Consequently,waterdepthforthetherapistshouldmaximallybeatapproximatelythe9th tho-racicvertebrae;deeperwatersignificantlydecreasesthetherapist’sstability.

MuscularactivityelicitedwithBRRMincludesbothvariableandisometriccontractions.Thevariablecontractiontypeiscommonlyreferredtoasisotonicorisokinetic.Thiscontractiontypeisutilizedwhenthetherapist’sexternalresistancevariestomatchthetorqueproducedbythepatient.Thisallowsnearmaximumforceproductionatanyjointangle.Themuscleadjustsitstensiondependinguponitslengthandchangesinmovementvelocityandexternalleverage.ThisishowthedynamicpatternsoftheBRRMfunction.ByusingspecifictreatmenttechniquesduringaBRRMsession,isotonicmuscularcontractionscanbedividedintoisotonicconcentriccontractions and isotonic eccentric contractions. These techniques are derived from PNF. Be-causeofthefluidmechanicinfluences,onlyaportionofthetreatmenttechniquesthatareusedinPNFcanbeintegratedintheBRRM.AnoverviewisgiveninTable4.

Thetherapiststartswiththepatternpassively,andthenheasksthepatienttohelpmoreandmore.Attheend,thepatientmovesintheexactpatternhimself.Change from one pattern to the opposite without break andwithoutrelaxinginbetweenpatterns.Repeatedstretchthroughtherange,resistthepatternandstretch the active muscles and ask for increased contraction.In the desired movement combine isotonic concentric work with isometrics and isotonic eccentric work. There isnorelaxationbetweenthedifferenttypesofmuscleactivity.Change the normal timing of the movement to applied timing in other joints. Stabilize the strong joints and move the weak one.Bringthebodyinthedesiredpositionandincreaseslowlytheresistancewithoutanymovement.Askforholdtheposition.Bringthebodyinthedesiredpositionandasktopullthebodyinadesireddirection.Resistthemovement.

Rhythmicinitiation

Reversal of antagonists

Repeated contractions or stretch

Combination of isotonics

Timing for emphasis

Holdrelax

Contractrelax

Table 4-4. Treatment Techniques from PNF Utilized in BRRMTreatment Techniques


Thesecondtypeofmusclecontractionisisometric.Inthissituation,thepatientmaintainsacertainpositionwhilebeingmovedby the therapist through thewater.Thehydrodynamicforces are used as the resistance. The patient can also be asked to hold a certain position in one partofthebodywhileanotherpartmoves.Specificallyatthebilateralasymmetricalreciprocallegpatterns,onelegwillstabilizethebodyinanisometriccontractionandtheotheronewillmoveisotonically.

Itmaybenecessary,beforestartingtheactualBRRMtreatmenttointegrateashortpassivemovementsessiontoworkonrelaxation,regulationoftoneandtractionofthespine.ThisisanidealpreparationforthespecificresistancetrainingofBRRM.Relaxationduringthepatternscanbeachievedbyincorporatingtheneurophysiologicphenomenaofreciprocalinhibitionandpost-facilitation inhibition.

TREATMENT

Treatment time in the BRRM depends on the treatment goals. The minimum time should not be shorterthan15minutes,especiallywiththosepatientshavingsignificantweakness.Strengthen-ingexercisesinthesepatientsshouldnotexceedafewminutesineachinterval,becausefatigueathighload(morethan80%ofonerepetitionmaximum)contractionsisrapid.Inthesecases,startwith6contractionsfortheweakmusclesand12-16contractionsshouldbepossibleforthestronger groups (Mc Ardle 2000).

Considertherestperiodin-betweeneachsetofexercises.Thisperiodshouldbe1.5-3min-uteswhenusinghighloadcontractions.Onlythencanasecondsetcanbeappliedtothesamegroupofmuscles,butinadecreasingfashion.Sixcontractionsinthefirstset,fivecontractionsinthesecondset,and,whenapplicable,fourcontractionsinthethirdsetistypicallyagoodstartingdosage.Inexercisephysiology,thisprocedureiscalledaninvertedpyramid(Ehlenz1983).

Somewhatlongerperiodsoftreatmentareneededtotrainaerobiccapacityorlocalmuscu-larendurance.Inthiscase,atreatmentshouldlastatmost30minutes.Muscularcontractionsshouldbemorethantwentysubmaximalcontractionsperseries,withabreakofoneminuteorlessbetweentwosets.Duringthisbreakothermusclegroupsareexercisedwhilerelaxingthemusclespreviouslyexercised.

EXERCISE PROGRESSION

Exercisesareprogressedcapitalizingon thewater’shydrodynamicforces.Fastermovementthroughthewatercreatesgreaterdragbecauseofturbulentflow.Thisdragincreasesinasquaredfunctiontothevelocityofthepatient.Thisprincipleresultsinaself-regulationofresistance,dependingontheabilitiesofthepatient.Theresistanceexercisesthusadapttothecapabilitiesof the patient. Resistance equipment such as hand paddles can be used to increase resistance. It isbetternottofocusdirectlyontheaffectedarea,particularlyinpatientswhoareweakorwhohavechronicpain.Ifperformedproperly,beginningtheexercisesindistalbodypartsproducesirradiation to the affected areas.

Aprogressionofexercisescanbeaccomplishedasfollows:1. Move through increasing range of motion.2. Changehandholdsfromproximaltodistal.


3. Increase the speed of motion.4. Changethebodyshapetolengthenthelever.5. Include techniques like combination of isotonics or repeated contractions. 6. Increaseresistancebyusinghandpaddlesorotherresistiveequipment.7. Uselessflotationintherings(patientliesdeeperinthewater.)8. Change the frontal surface area.

MOVEMENT PATTERNS

TheBRRMcanbedividedintopatternsthatworkonthebodythroughthelegs,throughthetrunkorthroughthearms.Patternscanalsobeclassifiedasunilateralorbilateral.Thebilateralpatterns have symmetrical and asymmetrical options.Allmovement patterns are applied insupine position.

Lower Extremities

TounderstandtheprinciplesofhowtheBRRMfunction,itisnecessarytoanalyzehowchainsofmovementsinthebodyfunctionaswellashowtheyinfluenceequilibrium.Thisisespeciallyimportantforthebilateralasymmetricreciprocallegpatterns.

Anexampleofthisconceptisthebilateralasymmetricreciprocallegpattern,withkneeflexionoftheisotonicleg.Inthispattern,theextendedrightlegismovedwhilethepatientisinthesupineposition.Thehipjointstartsinextension,adduction,andexternalrotation,andmovesintohipflexion,abduction,andinternalrotationwithkneeflexion.Theabductionintheflexedend position of the right hip produces a chain of movements across the pelvis causing the left hipjointtoexternallyrotate.Theinternalrotationoftheflexedrighthipproducesabductioninthelefthip.Thissequenceresultsinthefinalpositionof:

Right hip: flexion – abduction –internal rotationLeft hip: extension – abduction – external rotation

The result of the position of the hips is as follows:

Therighthipflexionandthelefthipextensionstabilizethebody.• Theabductionofbothlegsstabilizesthebody.• Therighthipinternalrotationandthelefthipexternalrotationdestabilizethebodycausing

thebodytorolltotheleft.

Table5summarizestheprimarymovement,itseffectsandthecounteractionthatoccursintheoppositeextremity.

Inordertohaveastabilizingpatternworkingonthebody,theleftsidedexternalrotationmustbereplacedbyaninternalrotation.Thestabilizingpatternintheleftlegisextension, ab-duction, and internal rotation.

Theabductionoftheflexedhiptransfersalargemasstowardstherightside,partlytobecompensatedbyalateraltrunkflexiontotheleftside.Thisresultsinanincreaseofabductioninthelefthip,whichcontributestostabilizinginthebodyposition.Butnowthemovementmightnotoccurinthediagonalplane,whichisimportantintheBRRM.Toensureappropriate


stabilizationfortheisotonicallymovingrighthip,thelefthipneedstobeheldisometricallyintheextension,abduction,andinternalrotationpattern(Egger1990).Theresultingpatternis:

Righthipisotonically:flexion – abduction –internal rotation with knee flexionLefthipisometrically:extension – abduction – internal rotation with knee extension

Bilateralsymmetricalpatternscanbeperformedwithandwithoutkneeflexion.Thepatternstopswhenthelegscloseinthesymmetricaladduction.Thesepatternsarecharacterizedbythefact that a transversal rotation is more prevalent than a longitudinal rotation. The trunk takes partintheflexionandextensionofthehipjointsbecauseinthesepatternstheproximallever(trunk) also moves.

Table6showstheprimarymovement,it’seffectsandthecounteractionthatoccursintheoppositeextremity.

Theproperstartingpositionatthebilateralreciprocalpatternsisdifficult.Patientsareveryunstablebecauseofthenarrowsupinepositionandtheyeasilyrotatearoundthelongitudinalaxis.Tofindtheproperstartingposition,movethepatientthroughthewatergently.Thedynam-ic forces of the water help to achieve the good adduction or abduction in the hip joint. A slight tractionatonesideandaslightapproximationattheoppositesideofthebodywillfacilitatethestartingposition.Inordertogetthecorrectstartingposition,itmaybehelpfultoachievethispositionwithaneccentriccontraction,startingintheendposition.Bystartingintheendposi-tion,allcounterforcesarebalanced,sothebodydoesn’texperienceatorque.

Table 4-5. Bilateral Reciprocal Leg PatternPrimaryMovement: Right Leg (Hip) withKneeFlexionFlexionInternal Rotation*inflexionAbductioninflexion

Reaction Left Leg (Hip)

ExtensionAbduction

External Rotation*

Effect

Lowering the PelvisRolling to the RightSide Loss of VolumeRolling to the Right Side

Table 4-6. The CounteractionPrimaryMovement: Right Leg (Hip) withKneeFlexion

Flexion

External Rotation*inflexion

Adductioninflexion

Effect

Stable

Stable

Couteractive Movement: Left Leg (Hip)

Extension

Adduction

External Rotation*

↓ ↓

↓ ↓↓ ↓


Table 4-7. ReciprocalPatternoftheLowerExtremityLeg PatternBilateral Reciprocal

isotonic

isometric

Flexion – adduction - external rotationkneeflexion,dorsalextension-inversionExtension – adduction – external rotationkneeextended,plantarflexion–inversion

End Positions (hip components)Extension–abduction–internalrotationkneeextended,plantarflexion-eversionExtension–adduction–externalrotationkneeextended,plantarflexion,inversion

Starting Postions

isotonic

isometric

Flexion – abduction – internal rotationkneeflexion,dorsalextension-eversionExtension – abduction – internal rotationkneeextended,plantarflexion–eversion

Extension–adduction–externalrotationkneeextended,plantarflexion-inversionExtension–abduction–internalrotationkneeextended,plantarflexion–eversion

isotonic

isometric

Extension – adduction – external rotationKneeflexion,plantarflexion-inversionFlexion – adduction – external rotationkneeextended,dorsalextension–inversion

Flexion–abduction–internalrotationkneeextended,dorsalextension-eversionFlexion–adduction–externalrotationkneeextended,dorsalextension–inversion

(continued)


Table 4-7. ReciprocalPatternoftheLowerExtremity- continued

isotonic

isometric

Extension – abduction – internal rotationkneeflexion,plantarflexion-eversionFlexion –abduction – internal rotationkneeextended,dorsalextension–eversion

End Positions (hip components)Flexion–adduction–externalrotationkneeextended,dorsalextension-inversionFlexion–abduction–internalrotationkneeextended,dorsalextension–eversion

Starting Postions

isotonic

isotonic

Flexion – abduction – internal rotationkneeextended,dorsalextension-eversionExtension – abduction – internal rotationkneeextended,plantarflexion–eversion

Extension–adduction–externalrotationkneeextended,plantarflexion-inversionFlexion–adduction–externalrotationkneeextended,dorsalflexion–inversion

isotonic

isotonic

Extension – adduction – external rotationkneeextended,plantarflexion-inversionFlexion – adduction – external rotationkneeextended,dorsalextension–inversion

Flexion–abduction–internalrotationkneeextended,dorsalextension-eversionExtension–abduction–internalrotationkneeextended,plantarflexion–eversion

(continued)

Leg PatternBilateral Reciprocal


Table 4-8. SymmetricalPatternoftheLowerExtremityLeg PatternBilateralSymmetrical

isotonic Flexion – adduction – external rotationkneeflexionandtrunkflexion,dorsalextension–inversion

End Positions (hip components)Extension–abduction–internalrotationkneeandtrunkextended,plantarflexion–eversion

Starting Postions

isotonic Extension – abduction – internal rotationkneeandtrunkextended,plantarflexion–eversion

Flexion-adduction–externalrotationkneeflexionandtrunkflexion,dorsalexten-sion–inversion

isotonic Flexion – adduction – external rotationkneeextendedandtrunkflexion,dorsalextension–inversion

Extension–abduction–internalrotationkneeandtrunkextended,plantarflexion–eversion

(continued)


Table 4-8. SymmetricalPatternoftheLowerExtremity-continuedLeg PatternBilateralSymmetrical

isotonic Extension – abduction – internal rotationkneeandtrunkextended,plantarflexion–eversion

End Positions (hip components)Flexion-adduction–externalrotationkneeextendedandtrunkflexion,dorsalextension–inversion

Starting Postions

isotonic Flexion – abduction – internal rotationkneeandtrunkflexion,dorsalextension–eversion

Extension–adduction–externalrotationkneeandtrunkextended,plantarflexion–inversion

isotonic Extension – adduction – external rotationkneeandtrunkextended,plantarflexion–inversion

Flexion–abduction–internalrotationkneeandtrunkflexion,dorsalextension–eversion

(continued)


Table 4-8. SymmetricalPatternoftheLowerExtremity-continuedLeg PatternBilateralSymmetrical

isotonic Flexion – abduction – internal rotationkneeandtrunkextended,dorsalextension–eversion

End Positions (hip components)Extension–adduction–externalrotationkneeandtrunkextended,plantarflexion–inversion

Starting Postions

Trunk

Tractionandapproximationareusedsimultaneouslythroughtheextremitiesorthetrunkwhenworking.Thebodyexperiencesanaccelerationbecauseofhydrodynamicforceswhich thenleadstoalateralflexion.Thislateralflexionisfullypassive.Thepatientisaskedtoactivelypullhis/herfeetalongthesurfacetotheoppositeside.Whenthetractionandapproximationforcesworkthroughtheshouldergirdle,apre-activationmusclecontractionattheshoulderjointisnecessaryinordertostabilizesafely.Thispre-activationcanbeelicitedthroughabilateralap-proximationinbothshoulderjoints.Progressthepre-activationmusclecontractionbyusingalongerleverarmforapproximationandtraction(i.e.throughthepatient’sextendedarms).

Whenapplyingthetractionandapproximationforcesthroughthelowerextremities,thetherapist stands in between the abducted legs of the patient. The forces can be applied at the pel-vis,theupperlegsorthelowerlegs.Thesimultaneoustractionononesidewithapproximationonthecontra-lateralsideresultsinapassivelateralflexionofthetrunk.Thepatientisaskedtobringarmsorelbowsactivelytotheoppositelateralside.Forexample,simultaneoustractionattherightsidewithapproximationattheleftsideresultsinalateralflexiontotheleftside.Progresstheexercisebyincreasingtheleverarm.Themostdifficultactivityisapplyingforcesatthelowerlegswithmaximalelevationofthepatient’sarms.

Anotherpossibilityistoworkonthetrunkthroughtwoipsilateralextremities.Whenthepatientmovesthestretchedlegtoextension,abduction,andinternalrotation,thetrunkisacti-vatedinextensionandlateralflexion.Anipsilateralextension,abduction,andinternalrotationofthearmalsofacilitatesextensionandlateralflexionofthetrunk.


Table 4-9. Pattern of the TrunkTrunk PatternActingthroughlowerandupperextremity

isotonic Lateral flexionFeetindorsalextension

End Positions (trunk components)Straight-lineFeetinplantarflexion

Starting Postions

(continued)


Table 4-9. Pattern of the Trunk - continuedTrunk PatternActingthroughlowerandupperextremity

isotonic Flexion - lateral flexion – rotationFeetindorsalextension

End Positions (trunk components)Straight-line–pelvicortrunkrotation30°FeetinplantarflexionStraight-line–pelvicortrunkrotation30°Feetplantarflexion

Starting Postions

(continued)


Table 4-9. Pattern of the Trunk - continuedTrunk PatternActingthroughlowerandupperextremity

isotonic Extension – lateral flexion – rotationFeetinplantarflexion

End Positions (trunk components)Straight-line–pelvicortrunkrotation30°Feetindorsalextension

Starting Postions

(continued)


Extension – rotation (trunk components)Arm:Extension–abduction–internalrotationfingersandwristextension,elbowextendedLeg:Extension–abduction–internalrotationwithplantarflexion–evasion,kneeextended

Table 4-9. Pattern of the Trunk - continuedTrunk PatternActingthroughipsilateralextremities

isotonicEnd Positions

Straight-lineArm:Flexion–adduction–externalrotationfingersandwristflexion,elbowextendedLeg:Flexion–adduction–externalrotationdorsalextension–inversion,kneeextended

Starting Postions

Return to straight line (trunk components)Arm:Flexion–adduction–externalrotationfingersandwristflexion,elbowextendedLeg:Flexion–adduction–externalrotationDorsalextension–inversion,kneeextended

isotonic Extension–rotation(trunkcomponents)Arm:Extension–abduction–internalrota-tionfingersandwristextension,elbowextendedLeg:Extension–abduction–internalrotationplantarflexion–evasion,kneeextended

Upper Extremities

Thecomplexityoftheshoulderjoint,thehydrodynamics,andthespecificdimensionsoftheleversinvolvedlimitthepossibilitiestotreatshouldersaccordingtheBRRM.Onlyoneunilat-eralpatternhasbeenfoundtobeeffective.Recently,avariationinthepronepositionusingamaskandsnorkelhasincreasedthepossibilitytoincorporatethearmpatterns(Becker1997).

Movementsinflexionandextensionarenotconsidered,becausethesearenoteasilyper-formedunderwaterwhen in supine.Themovements inabductionandadduction, includingtheirrotationscanbeperformed.Therapeuticallyonehastofocusonincreasingrangeofmo-tion.Thearmmovesawayfromthe trunkinabductionandexternalrotation tofullflexion/elevation.Theglenohumeraljointisthepivotforbotharmandtrunkwiththetrunklaterallyflexingtowardtheoppositeside.Attheendofthepattern,stabilizeinthenewpositionandiniti-atethesecondphaseofthemovement,whichisbringingthearmandtrunktowardeachotherwith shoulder adduction and internal rotation.


Abduction – external rotation – flexionFingers,wristandelbowextended

Table 4-10. PatternoftheUpperExtremityArm Pattern

isotonicEnd Positions (gleno-humeral components)

Adduction–internalrotation–extensionFingerandwristflexion,elbowextended

Starting Postions

Adduction – internal rotation –extensionfingersandwristflexion,elbowextended

isotonic Abduction–externalrotation–flexionfingers,wristandelbowextended

APPLICATION OF TECHNIQUES

AccurateknowledgeoftechniquesinBRRMisveryimportantforaspecifictreatment.Dif-ferenttechniqueshelptotreatpain,force,mobilityorlocalmuscularendurance.Only7tech-niques are used in BRRM. Not all techniques can be applied in each pattern.

Forlearningortoinitiateamovement,rhythmicinitiationandcombinationsofisotonicmovementscanbeused.Ifthetreatmentgoalispaininhibition,hold/relaxisthefirsttechniquetoutilize.If increasingstrengthis theaim,repeatedcontraction,accompaniedbytimingforemphasiswithcombinationsofisotonicsshouldbeused.Contract/relaxandhold/relaxaretechniquestotreatmobility.

SUMMARY

TheBadRagazRingMethodconceptismostusefulforaquaticrehabilitationintheearlyre-habilitativestagesofpatientcare.TheMethodfocusesuponusingthepatient’smuscularforce,which should be less than the therapist’s force. The treatment goals in Bad Ragaz Ring Method arealwaysat the levelofbodyfunctions.SoBadRagazRingMethodhas tocombinewithother aquatic rehabilitation concepts whose focus to increase activities and participation like the waterspecifictherapyoftheHalliwickconcept.


Table 4-11. Application of Techniques

TrunkPurelateralflexionFlexion-lateralflexion-rotationExtension–lateralflexion-rotation

Patterns RhymthmicInitiation

Reversal of Antagonists

Combination of Isotonics

Repeated Contraction

Hold Relax Contract- Relax

Timing for Emphasis

ArmFlexion–abduction–externalrotationExtension–adduction–internal rotation

Leg Bilateral SymmetricalFlexion–adduction–externalrotationExtension–abduction–internal rotationFlexion–abduction–internal rotationExtension–adduction–externalrotation

Leg bilateral Reciprocal Knee FlexionFlexion–adduction–externalrotation(isotonic)Extension–adduction–externalrotation(isometric)Flexion–abduction–internal rotation (isotonic)Extension–abduction–internal rotation (isometric)Extension–adduction–externalrotation(isotonic)Flexion–adduction–externalrotation(isometric)Extension–abduction–internal rotation (isotonic)Flexion–abduction–internal rotation (isometric)

Leg Bilateral Reciprocal Knee ExtensionFlexion–abduction–internal rotation (isotonic)Extension–abduction–internal rotation (isotonic)Extension–adduction–externalrotation(isotonic)Flexion–adduction–externalrotation(isotonic)

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CASESTUDY

A33-year-old teacherwas referred toaquatic therapyafter a4-weekhistoryof lumbarandlegpain,startingacutelyafteronedayofgardenworkinvolvingmuchbending.Thepainwasmostsevereacrossthelowbackandirradiatingintotherightleg,laterallytotheknee.Withpainkillersthebackpaindecreasedabout50%,butinthelegwasunchanged.Forwardbendingof the torso caused pain in the back with radiation up to the knee. At the lateral edge of foot the patientindicatedaslightnumbfeelingforthepast2weeks.MRIdone2daysprevioustothevisitshowedalateraldiskherniationatL4/L5constrictingtheL5root.Hewasstillcontinuingtowork,butparticipatinginthevolleyballteamofteachersisimpossible.

Whensittinglongerthan15minutes,hehadtroublerising,needinghishandsandonlywithdifficultycanslowlycometofullextensionofthelumbarspine.Inthemorninghisbackwascompletelyrigidandsore,improvingonlyafterawarmshower.Themorningstiffnesslastsanhour.Hewastaking50mgdiclofenac3timesaday,whichhelpedtorelievepain.Thebackexercisesgivenbythefamilydoctorasabrochuredidnothelpandactuallyworsenedsymp-toms of his legs.

Investigation / Initial examination

Thepatientmovesaboutguardedly.Inparticularwhenundressingandbendingforward,return-inguprightisdifficult.Inuprightstanceheshowsalumbarshiftwithlumbardeviation/sco-liosistotheleftandanyattempttocorrectthisincreasesthepainintheRlegandback.Whenbendingforward,hecantouchtheupperrimofhispatellawithbothhands,butpainincreasesinhisbackandrightleg.Thelowbackisheldrigidly,andthespinousprocessesseemfixed.Abackwardsleanofhistorsoisexquisitelyuncomfortable.Thepatientjustreachesthestraightneutralposition.TheRSLRtestispositiveat45°.TheL5dermatomeisslightlynumb,andthemyotomeislikewiseinvolved,withtheM.gluteusmediusandM.extensorhallucislongusbothweak.ThePatellarTendonReflexandAchillesTendonReflexarenormal.

Clinical Reasoning

Thepatientshowstheclassicalsymptomsofadiscopathywithnerverootcompressionwithinvolvementofboththemyotomeandthedermatome.Thedermatomesymptomatologyonlystarted in the course of the disease. Pain in the back has diminished. Leg pain is persisting howeverwithaconsecutiveclearshiftofthetorsoawayfromtheherniatedside.Thelocal(in-flammation)reactiontothediscopathy(event)seemstofollowthespontaneous(physiological)healing process.

Theeffectsofthediskopathyandshiftseemtobeunfavorablyaffectedbylongersitting.activities.Forthisreasonfirstashiftcorrectionmustbeachieved,beforeextensionandflexioncan be improved. The patient has continued to work as a teacher during this event. At present theredonotappeartobeanypsychologicalredflags.

Assessment

• Finger to ground distance during forward bend was to the upper patella edge) • Numericratingscaleforpainintheback(6/10),aswellasmorningstiffness(8/10)• Numericratingscaleforlegpain(8/10)• Extensionofthelumbarspineinstanding(0°)


AQUATIC INTERVENTION PLAN

Weplanatreatmentprotocolfor2timesperweek.

1st Treatment

Webeginwiththispatientinthepoolwithpositioningoftheringsatthepositionofminimizedpain.AsthefirstpatternweselecttheRarminExtension-Adduction-internalrotation.Weapplythispatternwithrelativelysmallenergyexpenditure;weuse20repetitionsdonein3sets.The1-minutebreakinbetweenthesetsisusedfortheleftarmFlexion-Abduction–externalrotationpattern.Inordertomanagetheshiftcorrection,weselectnowthetrunkpatterninpurelateralflexion,appliedthroughthelowerextremities.Weselectthelateralflexionontherightfirsttoseetheextentofthelowpainorpain-freemovement.Thepatternsareperformedinthisrangeofmotion.Wethentrytoholdatthepainthresholdfor6-10secondsasanisometrichold.Thisinterventionwouldrepeat10timesin3series,followedofaseriesbreakof2minutes.DuringthisbreakwewouldagainexercisethearmmovementsExtension-Adduction-internalrotation.

Instructions to the patient: Thecorrectexecutionoftheshiftcorrectiononlandisinstructedandthepatientisaskedtodolumbar shift (or lumbar deviation / scoliosis) correction in standing all waking hours during theday10times.Thepatientiscoachedtoavoidlongsittingperiods:teachingshouldbedonewhen standing and he shouldn’t sit watching TV.

Information for the patientWeexpectthatthelegpainwilldecrease,butthelowbackpainmightincreasetemporarily.Thelatterwouldbeanormalandfairlycommonreaction.

2nd Treatment

Patient short report: ThepainintheRleggoesonlytocenterthigh.Thebackpainisthesame(6/10),butthemorn-ingstiffnessisreduced(6/10).

Examination: Finger - ground distance reach is to the upper patellar margin.

Afterthefirst3seriesofthetrunkassessmentpurelateralflexionwasaccomplishedontherightfor6-10secondsisometricallyholdingatthepainthreshold,repeatingthesamepatternswiththeCombinationofIsotonicstechnique.Againoneworksonlyinpain-freeorverylightpainrange.Isometricworkisalwaysusedbetweentheconcentricandeccentricmusclework.Themovement limit goes in each case to the pain threshold in the correction of direction of the shift. Alsowewouldusethistechniqueduring10repetitionsin3series.Theseriesbreakscanbekeptshort. The treatment is ended with the bilateral reciprocal leg patterns:

1. flexion–adduction-externalrotationisotonicallywithkneeflexion2. extension-adduction-externalrotationisometricallywithkneeextension.

Welet thispatternremainisometric in thecentralpositionfor10secondsineachcase.


Atbothlegswewouldmovethrough10repetitions in3series.With thispatternweaimatstrengtheningtheweaklegmusculature,aswellasisometricactivationofthemultifidusandabdominal musculature.

Instructions to the patient: Homeexercisesandsittingprecautionsshouldcontinue.

3rd Treatment

Patient complaints: Nomoredistallegpain,painradiatingonlyuptotheRtrochanter,backpain(5/10),morningstiffness(4/10).

Examination: Thepatientshowsnolumbarshift(orlumbardeviation/scoliosis)totheleft,fingergrounddistanceistothecenterofcalf,SLRRH70°.

Webeginthetherapywiththebilateralreciprocallegpatternsinisotonicflexion-adduction–externalrotationwithkneeflexionandextension-adduction–externalrotationwithkneeextensionisometrically.Thispatternisaccomplishedovertheentiremovementextentwithanintensityof70-80%ofthemaximumforce.Twelverepetitionsperlegareperformedin4series,thespeedofthemovementtimedsothatthe12repetitionstakeplaceinoneminute.Wethenworkimmediatelywiththeotherleg.Thisresultsinabreakforthepreviousactivatedmuscu-lature,becausetheoppositesideworks.

Themovementpatternofpure lateralflexionto theright is likewiseaccomplishednowwith12repetitionsin4series.Themovementextentisasfaraspossible,andisaimedattheendposition.Asatthefirstweselecttheapplicationthroughthelowerextremities,followedfromtheapplicationthroughtheupperextremities.BothpatternsaresupplementedwiththeCombinationofIsotonicstechnique.Ontheleftsidenowthearmpatternsofflexion-abduc-tion–externalrotationandextension-adduction-internalrotationareaccomplishedwiththetechniqueofreversalsofantagonistslikewisewith12repetitionsin4series.IntheseriesbreakweworkwiththeRarminthepatternextension-adduction-internalrotation.Thetechniqueofrepeatedcontractionsisused.Thetreatmentendsfinallywiththebilateralstretchedlegpat-ternextension–abduction-internalrotation.Weselectthesepatternsinordertoincreasetheextensioninthelumbarspine.

Instruction to the patient: Thepatientisinstructedtomoveintoextensionofthelumbarspinewhilestandingeachhourwhile up.

4th Treatment

Patient complaints: Hehasonlylowbackpain(2/10),andmildmorningstiffnessof15minutes(2/10).

Examination: Fingergrounddistancetoankle,Extension20°,SLRR80°.Repeatthetreatmentsoftheprevioussessionwiththetrunkpatternofextension-lateralflex-


ion-rotationappliedfromtheupperextremitynowincorporated.Firstthemovementextentiscarefullyassessed,andthenthemovementisachievedwith10repetitionsin3series.Thesideischangedregularly.

Instructions to the patient:SittingrestrictionsslowlyreleasedAgainsittingistobeginatschoolincreasedastoleratedandstarttowatchTVasbefore.Extensionexerciseswhenuphourly.

5th Treatment

Patient complaints: No lumbar pain and no morning stiffness.

Examination: Finger–floor0cm,fullExtensionofthelumbarspine.SLR90°andequalatbothsides.

We begin pure lateral flexion applied through the outstretched armswith the technique in-volvingreversalsforantagonistsfromrighttoleftviceversa.Wewouldproceedthrough20repetitionsoneachside in3series.Between theseries thebilateralsymmetrical legpatternextension-abduction-internalrotationwithlumbarextensionaccomplishedwithineachcasethrough20repetitionsin3series.Thetrunkpatternofextension–lateralflexion-rotationisaccomplishedwith20repetitionsin3seriesovertheoutstretchedarms.Thepatternsaresub-jectivelyperceivedbythepatientassomewhathard.Inthebreaksthebilateralsymmetricallegpatternsofflexion–adduction-externalrotationandextension-abduction-internalrotationwiththetechniqueofreversalsforantagonists,20repetitionsforeachseries.Subsequently,thetrunkpatternsflexion–lateralflexion-rotationandextension-lateralflexion-rotationwiththe techniques of reversals for antagonists and combination of isotonics are accomplished. The repetitionnumberamountsto20in4series.Thesessionconcludeswithbilateralreciprocallegpatternofisotonicflexion-abduction-internalrotationandextension-abduction-internalrotationisometricallywith25repetitionsin4series.

6th Treatment

Patient complaints: Allgoeswell,nomorecomplaints.

Assessments:Backpain(0/10),legpain(0/10),morningstiffness(0/10)absent.SLR90°,finger–floor0cm.Extensionlumbarspine30°.

Resembles treatmentas treatment5, additionally instructionofbreaststrokeand front crawlwithfins.Duringthecrawl,theprimarystabilizingmusclesystemsarethemultifidiandtrans-versusabdominis.Trainingofthesesystemsistohelptoavoidrecurrenceofsymptoms.Instructionstothepatient:Whenswimming,usethecrawlifpossible.Withfuturegardenworkcombinebendingactivitieswithextensionsforthelumbarspine.Furtherspecialmeasuresarenotnecessaryanylonger.

The treatment is completed.


REFERENCES

1. KabatH.Studiesofneuromusculardysfunction:XV.Theroleofcentralfacilitationinres-torationofmotorfunctioninparalysis.ArchPhysMed1952;33,521-533.

2. KabatH.Proprioceptivefacilitationtechniquesfortreatmentofparalysis.PhysTherErv1953;33:2.

3. KnottM,VossDE. Proprioceptive neuromuscular facilitation, patterns and techniques.NewYork:SecHöber,1968

4. DaviesBC.A techniqueof re-education in the treatmentpool.Physiotherapy1967;53:57-59.

5. EggerB,ZinnWM.AktivePhysiotherapieimWasser,NeueRagazerMethodemitRingen.Stuttgart:GustavFischerVerlag,1990.

6. Klein-VogelbachS.FunktionelleBewegungslehre.Stuttgart:ThiemeVerlag,1981.7. LehmannJF.Therapeuticheatandcold.Williams&Wilkins,1970.8. WHO.InternationalClassificationofDisability,Functioning,DisabilityandHealth(IDF)

WHO,2001.9. KendallFP,KendallMcCrearyE,GeiseProvanceP.Muscles:Testingandfunctionwith

postureandpain.5.Edition.LippincottWilliams&Wilkins,200510. McArdleWD,KatchFI.,KatchVL.Essentialsinexercisephysiology.Philadelphia:Lip-

pincottWilliams&Williams,2000.11. EhlenzH,GosserM,ZimmermannE.Krafttraining.Blv,1983.12. HarrisonRA,AllardLL.AnAttempttoQuantifytheResistancesProducedUsingtheBad

RagazRingMethod.Physiotherapy1982;68:330-331.13. BeckerA.ABadRagazRingMethodVariationForUseWiththeCervicalSpine.TheJour-

nalofAquaticPhysicalTherapy1997;5:4-7.


REVIEWQUESTIONS

1.InBRRM,themostsignificantpointofstabilizationisa.Thelargefloatationringthatisappliedtothetrunkb. The counterforce of the water as movement occursc. The therapist’s holding positionsd.Muscularcontractionoftheipsilateralextremity

2. A major method of movement initiation in BRRM isa.Utilizationofthetonicstretchreflexb. Voice commands to the patientc.Theweakestmuscleswhicharefirstrecruitedd. Joint restrictions causing passive movement

3.InBRRM,thetherapistspositionshouldalwaysbea. At the head of the patientb.Withfeetplacedatapproximatelyhipwidthc. Immersed to levels below T9d.Withshouldersandelbowsinneutralrotation

4.WithintheICDsystem,thegoalsofBRRMfalla.Atthelevelofbodystructureandfunctionb.Atthelevelofpatientactivityc. At the level of clinical participationd. At the level of social integration

5. BRRM is best practiceda. In large group formatsb.Insmallgroupformats,neverexceeding2-3patientspertherapistc.Withcarefulon-deckguidanceofpatientmovementsd.Withone-on-onepatientcontact

6.Whenusingatrunkring,placementshouldbeata. The level of the umbilicusb. The level of the bottom of the buttocksc. The level of the upper pelvisd.Thelevelofxiphoid

7.InBRRMa. There is more emphasis upon concentric contractionsb. There is more emphasis upon eccentric contractionsc. There is more emphasis upon passive stretchd.Eccentricandconcentriccontractionsarebothusedextensively


8.BRRMtreatmentforinitiatingstrengtheninginaveryweakpatientshouldbea. 15 minutes or longer to startb.Alwayslessthan15minutesc.Focusingonmultiplerepetitionsofsinglemusclemovements,12-16atleastd.Sufficienttogotosignificantfatigueandthenadd5-8morerepetitions

9.Ofthephysicalprinciplesofwater,themostimportantinBRRMisa.Buoyancyb.Thermalconductivityc.Densityd.Viscosityandturbulence

10. The BRRM is most useful fora.Aquatictherapyinpatientsearlyintorehabilitationb.Specificmusclestrengtheninginhighlevelathletesc. Joint range of motion in acute arthritis patientsd.Balanceandcoordinationtrainingforcerebralpalsy

bad ragaz ring method gamper lambeck chapter 4 comp aq th (2010)

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