Gamper (2013) Bad Ragaz (ECEBAT)

History
1930: active aquatic therapy (Ott 1955)

The Bad Ragaz Ring 1952: PNF (Kabat and Knott)
Method: 1955: Wildbad (Germany): start with Rings

(Knupfer and tum Suden)
fine tuning and eccentric 1957: The Wildbad Method started in BR (Ipsen)
1965: Included PNF (Davies 1967, 71; Muggli, Lagutt)
muscular training 1973: Developed the New Bad Ragaz Ring Method (Egger
and McMillan 1975, Boyle 1981)
1990: Book publication (Zinn, Egger, Gamper and Klaus)
Urs Gamper, Johan Lambeck and Ben Waller
2003: CD-Publication (Lambeck, Gamper)
Pre-conference workshop
2008: www.badragazringmethod.org (Lambeck, Gamper)
ECEBAT, March 20th, 2013
2009: Chapter in a book (Thein Brody & Geigle Ed.)
2011: Chapter in a book (Becker BE & Cole AJ Ed.)
History History
Boyle A-M: Physiotherapy 1981;67 (9)
Publications 1967, 71, 81, 90. Only patterns, no techniques,
no exercise physiology
Reduction of patterns, specifically arm patterns in publication
of 1990 (in German)
Between 1990 and 2003 adding techniques and principles of
exercise physiology
Fine tuning exercise (FTE) versus maximal strength exercise
Bilateral symmetrical leg pattern
(MSE) 2010
Flexion-Adduction-External Trademark for guaranteed quality: IATF
Rotation
BRRM pre-conference workshop, ECEBAT, March 20, 2013. Johan Lambeck & Ben Waller 1
Trademark registration
Statement
BRRM is an active treatment technique with

adapted resistance to the patients needs.
The technique requires high skill and accuracy

of the therapist.
Therefore, the exact knowledge of the

concept and a refined gripping technique are
compulsory for the success of BRRM.
Therapeutic concepts Principles in PNF
PNF (Kabat)
Basic concept
General biomechanics
Laws of fluidmechanics
The body has to balance constantly PNF philosophy
Use the resistance of water
Exercise physiology
Techniques
Basic concept PNF Patterns
Stimuli: tactile, verbal, visual

1. Trunk
Adapt resistance acting trough theupper extremities
Body mechanics acting trough the lower extremities
Traction / Approximation 2. Arm
Irradiation
3. Leg
Patterns bilateral symmetrical
Timing bilateral reciprocal
Stretch
Summation of stimuli
Components of the leg patterns

Pelvis Timing
ELEV
FLEX / ADD / ER Foot FLEX / ABD / IR

From distal to proximal
DE
Toes
In such a way, that the patient can follow
EXT
Verbal, tactile, and visual in time
Pelvis ANT Pelvis POST
Foot PRON
ABD
Pelvis
DEP
Foot SUP
Foot
ADD PF
Toes
FLEX
EXT / ADD / ER EXT / ABD / IR
Spatial summation Spatial summation
Subliminal stimuli are coming in the same moment

from different body parts, herewith you could easier
pass the depolarization threshold and easier
achieve a muscle contraction.
Temporal summation Temporal summation
excitatory
postsynaptical
Subliminal stimuli are coming successive in a very potential
short interval, fast enough to pass the threshold and

acievning a contraction.
excitatory
postsynaptical
contraction
Techniques Goals of the techniques
Rhythmic initiation To promote functional movement, using concentric,

eccentric and static muscle contractions with properly
Combination of isotonics graded resistance and suitable facilitatory procedures.
Hold relax To increase ROM and strengthen muscles in the newly
Contract relax gained ROM.
Repeated stretch/contractions To reduce muscle fatigue when strengthening.
Timing for emphasis To reduce pain.
Reversal of antagonists Aid in /teach the initiation in movement, help the patient
Replication to adapt the muscle tone, Improve the sense of the
movement.
Rhythmic initiation Combination of isotonics

T. resists the active movement through the desired
T. starts to move the pattern (passive). ROM (concentric contraction).
P. aids to move more and more (assistive). T. tells patient to stay in that position (stabilizing
contraction).
T. gives more and more resistance (active).
T. asks patient to allow the part to be moved back
Use the speed of the verbal command to set the slowly (eccentrically).
rhythm. No relaxation between the different types of muscle
At the end the patient should make the movement activity.
independently and correct. Use it in the bilateral symmetric and reciprocal leg
Rhythmic initiation is followed by other techniques patterns
when necessary. Use it in the trunk patterns
Use it in the arm patterns
Combination of isotonics Reversal of antagonists
Active movement changing from one direction to

Goals
the opposite without pause or relaxation.
- Active control of movement, increase active ROM,
coordination, strengthening, functional training in T. resists the patient moving in 1 direction and
eccentric control of movement. then changes grip to change direction.
Indications
- Decreased eccentric control, decreased active ROM, Indications
lack of active motion within the ROM. - Decreased active ROM, weakness of agonists,
Modification decreased ability to change movement direction,
- May be combined with reversals. normalization of muscle tone.
- The technique can start with the eccentric contraction.

Can be used in bilateral symmetric leg and trunk
patterns and one reciprocal leg pattern.
Principles in BRRM PNF compared to BRRM

Optimal isotonic and isometric resistance.
Correct grips help to stimulate receptors and
facilitate the patterns.
Push and pull stimulate nerve endings for stability
and movement.
Short, precise commands stimulate active
movements.
Facilitation provides irradiation to the weak
muscles.
Distal holds increase difficulty to execute correct
patterns.
The therapist feels the quality of movement and
can adapt the resistance.
General biomechanics
Fluidmechanics
Greater muscle response in 3-dimensional PNF

patterns No fixed points due to buoyancy
More power when work in the groove The inertia influences motion
Mc Mullen 200, Arai 2001, Marek 2005, Kofotolis 2005 Turbulent drag provides resistance
Skin friction provides proprioceptive stimulation
Neurophysiology
Load (% of maximum)
Exercise physiology
100
Recruiting motor units
90
80 Intra/intermuscular coordination
Push/approximation facilitates stabilization
Pull/traction facilitates movement
50
Proprioceptive stimulation facilitates movement
Overflow from strong to weak muscles Endurance
Fine tuning
exercise
30
Repetitions
1/3-10- 30 50 70 90 110 130 150 170
Movement velocity and load curve Load repetition courve 1RM
Hilfiker R: physio acitve; (5) 2012 Hilfiker R: Physio active; (5) 2012
General treatment recommendations
Start at a distance from the problem

Focus on the problem
Treat with the suitable technique
Fine tuning exercise in
Count the number of repetitions
Give the suitable brakes between the sets and
BRRM
series
Definition
Fine-tuning exercise low level
To get an optimal performance or effectiveness with
small adjustments in changes of tension for a Quality of activation with discrimination
economic use of the locomotor system, with Good timing: activation from distal to proximal
feedforward principles.
optimal (damage muscles) Inter-muscular coordination
economic High number of repetitions
resources (al muscles works)
In BRRM, fine tuning is used as low intensity Muscles underlying pain inhibition
exercise. or are damaged, need low grade
activities to initiate activation!
Fine tuning exercises in BRRM

LBP strength training HIT / LIT
Helmhout PH et al: Eur Spine (2004)
High intensity protocol for Lumbar extensors 12 wk

Not maximal resistance
optimal resistance
Exercise physiology
10 sessions in total
Start at 35% of max back extensor strength
low activity exercises
Wk 1 + 2: 15 to 20 reps = 50% of 1 RM
Wk 3 12: 10 to 15 reps = 70% of 1 RM
high number of repetitions Max test: 6 sec of which 2 max force
Technogym machine
Use fluidmechanical principles
for a reduction of activities!
LBP HIT / LIT Exercise dose response in muscle
Duscha BD et al: Int J Sports Med 2012
Low intensity training, non-progressive Investigation: Capillaries per fibre, capillaries per area and
citrate synthesis.
During all weeks: 20% of 1 RM 3 groups:
Alway 15 reps with 2.5 kg at the machine low amount moderate intensity
low amount high intensity
high amount high intensity
HIT and LIT: always through full ROM and slow
Results:
In 2 sec from max flex to max ext
Capillary supply increased in all exercise groups (p<0.05)
Return in 4 seconds Citrate synthesis improved in high intensity groups (p<0.05)
NO differences in restoring low back function in Citrate synthesis approached in low amount moderate
ACLBP (except mean isometric strength > HIT and intensity group P<0.059)
kinesiofobia > LIT was better) Conclusion:
Muscle adaptation occurs following low and high exercise
dose.
Shoulder muscle activity in water

Kelly BT et al: Orthop Sports Phys Ther (2000) Shoulder muscle activity in water
Kelly BT et al: J Orthop Sports Phys Ther (2000)
Rotator cuff in water and on land Muscle Test 30/S 60/S 90/S
6 muscles: supraspin, infraspin, subscap, deltiod 3 Supraspinatus Land 16.68 17.46 22.79
parts Water 3.93 5.71 27.32
p=.015 p=.015 p=.73
Scapular abduction from 0 to 90 degrees Infraspinatus Land 11.10 10.76 15.03
Water 2.28 2.89 21.06
30, 45, 90 degrees/sec velocity p=.0325 p=.0524 p=.5566
At 30 and 45 /sec: sign less activity in water of all Subscapularis Land 5.96 6.83 7.45
muscles, e.g. supraspinatus at 30/s: 17% maximal Water 1.49 2.26 10.73
p=.0072 p=.0346 p=.2421
voluntary contraction (MVC) land and 4% MVC
Anterior Land 15.88 18.82 22.09
water deltoideus Water 3.61 4.49 32.83
p=.0047 p=.0273 p=.3273
Percentage of maximal voluntary contraction
Trunk muscle activity in pool Trunk muscle activity in pool
Bressel E et al: Phys Ther Sport 2012 Bressel E et al: Phys Ther Sport 2012
Effect on cytokines
Eccentric contractions provoke the production of

IGF-1 = insuline-like growth factor 1. (Grow factors
Eccentric muscular regulate tissue recovery)
Eccentric strengthening:
exercise in BRRM Anti-inflammation cytokines increase (important in
metabolic syndromes). Effects of eccentric exercise in
water same as on land (shortening-stretch cycle /
plyometrics), but no pain / DOMS
Effect of resistive exercise on muscle damage in Eccentric vs. Concentric Training
water and on land
Pantoja PD et al: J Strength Conditioning Res; 2009, 23(3)
n=9 men, ellbow flex 3 sets 10 rep max, 2 min brake 6 weeks eccentric and concentric training on leg
extension machine. One leg concentric, other
eccentric.
Isokinetic force increases in both trainings
Concentric 18% p <0.01
Eccentric 31% p <0.001
Spurway NC et al: Eur J Appl Physiol: 2000; 82 (5-6) 374-80
Effects of early progressive eccentric exercise on muscle size and function after Combined strength training
cruciate ligament reconstruction: A 1-year follow-up study of RCT
Shortening negatively influences strength, because

changes of the strength-length curve.
Training of strength should include lengthening.
Eccentric training influences the curve and
influences length.
Programme:
3/wk, 3 sets of 10 reps, 5% load increase / week
Concentric at 30/60/90/s and eccentric at 30/s
Gerber J.P. et al: Physical Therapy; (89) 2009
Aquatic resistance training Elderly
Repeated flexion/extension has concentric and Higher functional reserve of eccentric strength can be
eccentric components (= stretch shortening cycle used to initiate resistance training in individuals with
type of exercise). low levels of strength. Eccentric training is more
effective than concentric training and is related to the
This type results in greater gains in power and
CT stretch component
strength than pure concentric movements in
water.
This is used in the BRRM reversals
Pyhnen T et al: Med Sci Sports Exerc; 2002 Roig 2010, Experimental Gerontology
Elderly
Patella and Achilles tendon research
Curvin 1984, Sesh 1997, Alfredson 1998, Jonsson 200
Eccentric force importance

Slow eccentric drop squats (with some discomfort)
Feet in 115 plantair flexion to activate Quadriceps
Anti-gravity
Stair walking No dorsal flexion in Achilles pathology
Siting down 3 sets of 15, 2/day, 12 weeks
Important in postural control / balance Sesh: also looked at ankle sprains

Short reaction times (till 80 ms) do not increase through
Shock absorption during falls proprioceptive training, but inversion mm become slower
Healing of chronic connective tissue
problems
Eccentric training normalises tendon structure and thickness in
chronic achillodynia
n = 25, 19 , 6 , 12 w eccentric calf muscle training
Diameter Achilles tendon in mm
T0 T1 3.8y p
Exp. 8.3 +/- 3.0 7.6 +/- 2.3 p<0.005
Contr. 5.3 +/- 1.3 5.9 +/- 0.8 n.s.
Ohberg L et al: Br J Sports Med 2004

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History

1930: active aquatic therapy (Ott 1955)

Method: 1955: Wildbad (Germany): start with Rings

BRRM is an active treatment technique with

The technique requires high skill and accuracy

Therefore, the exact knowledge of the

Therapeutic concepts Principles in PNF

Stimuli: tactile, verbal, visual

Components of the leg patterns

FLEX / ADD / ER Foot FLEX / ABD / IR

Pelvis ANT Pelvis POST

EXT / ADD / ER EXT / ABD / IR

Subliminal stimuli are coming in the same moment

Temporal summation Temporal summation

short interval, fast enough to pass the threshold and

Rhythmic initiation To promote functional movement, using concentric,

Rhythmic initiation Combination of isotonics

Active movement changing from one direction to

Principles in BRRM PNF compared to BRRM

Greater muscle response in 3-dimensional PNF

General treatment recommendations

Start at a distance from the problem

Fine tuning exercises in BRRM

High intensity protocol for Lumbar extensors 12 wk

Shoulder muscle activity in water

Eccentric contractions provoke the production of

Isokinetic force increases in both trainings

Concentric 18% p <0.01

Eccentric 31% p <0.001

Spurway NC et al: Eur J Appl Physiol: 2000; 82 (5-6) 374-80

Shortening negatively influences strength, because

Gerber J.P. et al: Physical Therapy; (89) 2009

Eccentric force importance

Important in postural control / balance Sesh: also looked at ankle sprains

Ohberg L et al: Br J Sports Med 2004

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