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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.
COMPREHENSIVE AQUATIC THERAPY4
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,
The Bad Ragaz Ring Method 5
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.
COMPREHENSIVE AQUATIC THERAPY6
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 Bad Ragaz Ring Method 7
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
COMPREHENSIVE AQUATIC THERAPY8
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.
The Bad Ragaz Ring Method 9
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
COMPREHENSIVE AQUATIC THERAPY10
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*
↓ ↓
↓ ↓↓ ↓
The Bad Ragaz Ring Method 11
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)
COMPREHENSIVE AQUATIC THERAPY12
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
The Bad Ragaz Ring Method 13
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)
COMPREHENSIVE AQUATIC THERAPY14
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)
The Bad Ragaz Ring Method 15
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.
COMPREHENSIVE AQUATIC THERAPY16
Table 4-9. Pattern of the TrunkTrunk PatternActingthroughlowerandupperextremity
isotonic Lateral flexionFeetindorsalextension
End Positions (trunk components)Straight-lineFeetinplantarflexion
Starting Postions
(continued)
The Bad Ragaz Ring Method 17
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)
COMPREHENSIVE AQUATIC THERAPY18
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)
The Bad Ragaz Ring Method 19
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.
COMPREHENSIVE AQUATIC THERAPY20
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.
The Bad Ragaz Ring Method 21
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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COMPREHENSIVE AQUATIC THERAPY22
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°)
The Bad Ragaz Ring Method 23
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.
COMPREHENSIVE AQUATIC THERAPY24
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-
The Bad Ragaz Ring Method 25
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.
COMPREHENSIVE AQUATIC THERAPY26
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.
The Bad Ragaz Ring Method 27
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
COMPREHENSIVE AQUATIC THERAPY28
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
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