Facilitation Technique Category: Aquatic Therapy

Title: Bad Ragaz

Source: Chapter 4 in Comprehensive Aquatic Therapy 3rd edition
Equipment:
Warm water pool that measures at least 7-by-8-foot diameter, is 3 to 4 feet in depth, and
is 92-98 degrees Fahrenheit, Floatation aid devices, such as flotation belt for waist, a cervical
floatation collar, a buoyancy cuff for the ankle and wrists
Activity Description:
The Bad Ragaz Ring Method (BRRM) is a form of aquatic therapy developed in Bad
Ragaz, Switzerland where it derives part of its name. This type of aquatic therapy uses the
physical properties of water, such as buoyancy and turbulence, to interact with the patient in
a 1:1 therapist to client ratio. These properties create progressive passive to active exercises. As
well as, isometric, isokinetic, and isotonic exercise. Where passive exercises are characterized by
the client being slowly moved through the water with movement such as, rocking or swaying, for
passive trunk elongation, tone inhibition, and relaxation. Then active exercises require more
movement, activities, and stretches.
Isometric exercises involved in aquatic therapy provide stability, where the client is held
in a fixed position while being moved through the water. This movement creates muscle
contraction. Isotonic exercises are characterized by a graded resistance that is controlled by the
therapist, who moves through the water but acts as a stabilizing factor. Isokinetic exercises are
exercises that are graded resistance and controlled by the client. The therapist stabilizes the body
part while the client moves through the water in either a motion that is away, toward, or around
the therapist. This technique utilizes specific patterns of resistance, endurance, elongation,
relaxation, range of motion and tonal reduction.
The purpose of engaging in this activity is to participate in strengthening and mobilizing
resistive exercises. There are many benefits to participating in Bad Ragaz, the buoyancy of the
water can decrease joint compression, can assist in preparation for weight bearing, remove stress
from connective tissues, increase range of motion and flexibility, and for the therapist, it allows
for a more ease of handling. The goals of Bad Ragaz are generally an increase in strength and
coordination, improved joint stability, and greater endurance.
The first step of beginning to implement this method is to evaluate the client to determine
the intervention needs. This way the therapist can calculate the amount of resistance to apply and
how long it will be applied for. The next step is to educate the client about the procedure. It may
be necessary to provide mental adjustment, which involves a few considerations revolving
around fear. These include, the client not avoiding water to his/her face, movement should not
create a startle reaction, the client should feel comfort with the variety of movement, the client
should be able to move in all directions and positions freely without showing fear, movements in
the water should not create fearful behavior, such as crying, vocalization, clinging onto the
handrails or therapist. The client should not show fear when changing postures and positioning.
Then, the client is provided floatation aids that are placed on the hips, neck, and
sometimes the ankles and guided in an exploratory process to follow a sequence of moves. The

sequence of moves is based very closely to those that an infant experience in early childhood
development. Beginning with passive movements including breath control, relaxation, and
regulation of tone. The client will be participating for at least 15 minutes and the strengthening
sequences should be no longer than a few minutes. After each sequence, a rest period is provided
for 1.5 to 3 minutes. After the passive treatment is provided, active treatment begins. This
involves one leg straight and one leg bent at 90 degrees underneath the water, the client will
place pressure on the therapists hand with the bent leg with the straight leg staying as is. After
the exercises are completed, it is important to facilitate a cool down.
Leadership considerations:
One leadership consideration is to ensure the accessibility of the pool that will be utilized.
Another consideration is that there be one person who is CPR certified. The ratio of participants
to instructor should be 1:1. Another consideration to be made is the mental adjustment of clients.
This involves the recognition of buoyancy and rotational control of the body in the water.
Activities should be facilitated from the most basic and work up to more challenging postures
and stretches. It is important for the CTRS to understand body language and listen to the client,
as well as be sure to keep an open dialogue with the client. If a client feels uncomfortable, it is
important to adapt the activity to allow for the client to feel safe and comfortable. The CTRS
should assist in providing a safe environment and discuss with clients pool safety, with pictures
and verbal instruction. The CTRS should utilize most sensory systems, especially vestibular and
proprioceptive. The CTRS should be aware of medications or even the change of medications
that clients are taking to ensure he/she is knowledgeable on possible side effects that could be
present.
Adaptations:
Participants who have had a Stroke:
Participants who have had a stroke will all present with different symptoms. Depending
on which part of the brain was affected by the stroke will depend the amount of injury.
Participants who have experienced a right-brain stroke will have difficulty on the left side of
his/her body. If a stroke participant has paralysis or weakness, it will be important to have a pool
lift to assist in entrance and exit of the pool. For participants who have had a stroke, the
facilitator should give the person time to respond and understand reflexive behaviors. Some
participants may portray reflexive emotions; it will be beneficial to discuss how the client would
like to be treated if an episode does occur. Participants who have had a stroke could fatigue,
provide frequent breaks and rest periods. Encourage participants to hydrate appropriately.
Participants with Rheumatoid Arthritis:
Participants who have rheumatoid arthritis will benefit from higher water temperature,
generally it is recommended that water be nearly 90 degrees. Symptoms of rheumatoid arthritis
could include a constant or recurring pain or tenderness in the joints and stiffness and difficulty
in using or moving his/her joints. Because of this, it is important that the therapist adapt
communication towards the client, making sure to create an environment that allows for open
dialogue and frequent break periods. As the therapist, it is important to ask questions that guide
clients to an awareness of what they are feeling.

The therapist can stretch the joints and adapt stretches to target clients specific needs. It
may be beneficial to adapt the setting to suit the client. For example, utilizing an indoor pool
with set indoor conditions could be beneficial, as weather conditions could affect the extent of
stiffness or pain. However, the individual could be affected by weather conditions before
stepping indoors, therefore it is important to understand how the client is feeling that particular
session. As one day could be better than the next time you see the client. Another adaptation to
be considered is with the floatation aids, as well as the depth of the pool. It is important to be
sure the floatation aids have just the right amount of air to provide comfort and that the pool is
just the right depth.
Adaptations References:
-

Dattilo, John. Inclusive Leisure Services. 3rd ed. State College, PA: Venture Pub., 1999.
Print.

@jhrheumatology. "Rehabilitation Management for the Rheumatoid Arthritis Patients

from Johns Hopkins Arthritis." Arthritis Information. N.p., n.d. Web. 19 Sept. 2016.

By Contrast, Rheumatoid Arthritis or Another Inflammatory Arthritis May Cause Pain,

Stiffness, and Fatigue That Worsen in as Little as Several Weeks or a Few Months.
"Living with Rheumatoid Arthritis." Patient Education Center. N.p., n.d. Web. 19 Sept.
2016.