The Bad Ragaz Ring Method® (BRRM) is a hands-on aquatic therapy concept, based on e.g. Proprioceptive Neuromuscular Facilitation (PNF). It developed at Bad Ragaz in Switzerland in the 1960s and aims at increasing muscular function at different levels of muscular intensity. Mainly inter-muscular coordination, intra-muscular coordination and muscular endurance are known to be addressed. Muscles are activated via patterns of movement, performed against operator resistance and utilizing a variety of techniques such as combination of isotonics and dynamic reversals.

BRRM and especially PNF are used widely in physical therapy / rehabilitation. BRRM includes some 20 well-described patterns, based on PNF but adapted to make a patient additionally stable when floating in water. Patterns exist for the upper extremities (1), the trunk (10) and the lower extremities (13). All patterns have shown to influence trunk muscles, either directly or indirectly.

Understanding the muscle activation patterns during the BRRM patterns in impaired persons may help target therapy more effectively. BRRM can be used in all clients with neuro-musculoskeletal problems who have problems to activate muscles.

BRRM has a long history of adaptations to the state of art in aquatic proprioceptive neuromuscular facilitation. Originally based on PNF, fluidmechanical elements were added to adapt it for aquatic therapy. The key element is the activation of muscles in (myofascial) chains as a preparation for functional activities in water and on land. Recently, principles of muscular fine tuning, PNF techniques, training physiology have been included. Also concepts like functional kinetics and core stabilization are a part of contemporary BRRM, and applied to working with neurologic, orthopedic and rheumatic populations. See www.badragazringmethod.org

Examples of contemporary topics that are included in the course are:

• reversals of antagonists: Reversals increase strength much more than contractions in one direction
• combination of isotonics: the eccentric component is very important to balance inflammation reactions in e.g. the muscle envelope
• proprioceptive discrimination training in an environment in which pain is “under the radar”, in order to influence neuro-inflammation; e.g. in low back pain
• three-dimensional movements are essential to a proper mechanotransduction, using fascia properties
• tensegrity of intramuscular fascia can be trained by smooth variable contractions and add to fascia resilience
• clinical reasoning with case related scripts

BRRM provides infinite possibilities for variation of exercise for the neurologic, orthopedic, & rheumatologic client. Examples are:

1. Tone reduction
2. Relaxation
3. Increasing range of motion
4. Muscle re-education
5. Strengthening
6. Spinal traction/elongation
7. Improving alignment & stability of the trunk
8. Preparation of the lower extremities for weight bearing.
9. Restoration of normal patterns of upper & lower extremity movements.
10. Improving general endurance
11. Training functional capacity of the body as a whole.

• Neuroprotective aquatic therapy for executive functions
• Environmental Enrichment with learning through games
• Stochastic motor learning
• Agility, muscle power and (an)aerobic condition
• Fascial resilience
• Muscular fine tuning
• Eccentric techniques

Strength of the courses:

• Patient centered approach based on clinical reasoning
• All treatments based on justification by evidence
• Skillful hands-on treatments
• Learning-by-reasoning-and-doing
• Faculty with great clinical and scientific expertise
• Embedded in a European aquatic network
• Recent topics from e.g. ICEBAT conferences are directly implemented
• Tacit knowledge of participants is encouraged to be used.

BAD RAGAZ RING METHOD® WITH LOW BACK PAIN:
Water offers the possibility to lower the confounding information of nociceptive input: it is a safe environment with potential to lower mechanical load because of buoyancy. This is an excellent starting point for spinal motor control as advocated by Hodges et al (2013).

Indeed, active aquatic exercise treatment in water is a potentially to moderately beneficial form of exercise for people with low back pain (Waller et al, 2009; Barker et al, 2014). A key element is trunk muscle control. This control can range from finely tuned proprioceptive contractions when pain is prevalent to (high level intensity) strength training in cases of muscle weakness without pain (Hodges et al, 2013).

The BRRM can include the entire range of contractions and the exercises as suggested in Hodges et al (2013) will be adapted to the BRRM. Support of the choice for active exercise therapy can be found in recent guidelines (Staal 2013), also stating that success of the intervention method depends on the knowledge and skills of the therapist.

BRRM not only includes finely tuned contractions, but also eccentric contractions, and dynamic reversals with plyometric possibilities. These contraction modes are important to address the plastic properties of connective tissue and help to restore tensegrity.

REFERENCES:

Hodges PW, Cholewicki J, Dieën van JH (2013). Spinal control, the rehabilitation of back pain. Churchill Livingstone, Edinburgh

Staal JB, Hendriks EJM, Heijmans M, Kiers H, Lutgers-Boomsma AM, Rutten G, Tulder van MW, Boer den J, Ostelo R, Custers JWH.(2013) KNGF-richtlijn lage rugpijn

Waller B, Lambeck J., Daly D. Therapeutic aquatic exercise in the treatment of low back pain: a systematic review. Clinical Rehabilitation,2009;23:3-14.

Barker AL, Talevski J, Morello RT, Brand CA, Rahmann AE, Urquhart DM. Effectiveness of aquatic exercise for musculoskeletal conditions: A meta-analysis. Archives Physical Medicine Rehabilitation,2014:DOI:10.1016/j.apmr.2014.04.005