4 P H Y S I O T H E R A P Y JUNE, 1975 Rhythmic Stabilisation — a new approach L . M . D A V ID S , B.Sc. (P hysio.) Witwatersrand, B .A . H ons, U .V ., D ip . E .D . P hysiother. Pret. T h e te c h n iq u e of rh y th m ic s ta b iliz a tio n as described by K n o tt “ e m p lo y s iso m e tric c o n tra c tio n o f a n ta g o n istic a n d a g o n is tic p a tte rn s , w h ic h re su lts in c o -c o n tra c tio n of a n ta g o n is ts if th e iso m e tric c o n tra c tio n is n o t b ro k e n by th e p h y sic a l th e r a p is t” . ( 1) In o rd e r to o b ta in the d esired c o -c o n tra c tio n th e th e ra p is t m u s t b e e x tre m e ly skilled a n d the p a tie n t m u s t e x e rt c o n sid e ra b le v o lu n ta ry effort. I t is g e n e ra lly fo u n d t h a t th e re is a c o n sid era b le tim e lag b e tw e e n th e d e m a n d fo r e ffo rt a n d the achiev e m en t o f a c o -c o n tra c tio n . A c c o rd in g to S to c k m e y e r, c o -c o n tra c tio n s a re “r e ­ c ip ro c a l c o n tra c tio n s a lte rn a tin g so ra p id ly th a t th e sh ift o f fa c ilita tin g influences is n o t v isible a n d th e re fo re flex o rs a n d e x te n so rs in te rm s of o b se rv a b le fu nction a re c o n tra c tin g to g e th e r” . (2) I f th is de fin itio n is a ccepted, it is d o u b tf u l w h e th e r a tru e c o -c o n tra c tio n can ever be o b ta in e d w ith rh y th m ic s ta b iliz a tio n . T h e key w ords in th e a b o v e d e fin itio n a re ‘a lte rn a tin g so ra p id ly ’ a n d K n o t t d o e s n o t a lte rn a te h e r iso m e tric c o n tra c tio n s v ery ra p id ly . A lso , th e d e g re e o f c o n tra c tio n re q u ire d by th e p a tie n t p re c lu d e s a n a tu r a l s ta b iliz a tio n . V o lu n ta ry c o n ­ tro l is u n n a tu r a l in th e m a in te n a n c e o r ach iev e m en t o f p o s tu r a l to n e . J o i n t sta b ility , e sp e c ia lly p ro x im a l sta b ility , is e sse n ­ tia l fo r sk ille d m o v e m e n t a n d the th e ra p is t needs to fa c ilita te th is b e fo re p ro g re s sin g to d ista l skills. A m e th o d w hich is fa r less d e m a n d in g o f b oth th e ra p is t a n d p a tie n t, h a s been devised to o b ta in a c o -co n trac tio n in th e e x te n d e d p o s itio n (in w h ich c o -c o n tra c tio n is fu n c tio n a l). I t c a n a lso be u se d to f a c ilita te any m uscle g ro u p d e p e n d in g o n th e p o s itio n o f th e jo in t a n d the p o in t o f a p p lic a tio n o f th e fa c ilita tio n . T h e j o in t is p la c e d in th e d e sire d p o sitio n and quick, a lte rn a te , s m a ll-ra n g e r o ta tio n s a re a p p lie d to any p a rt of th e lim b d ista l to th e m uscles w h ic h a re to c o n tra ct. T h e p a tie n t is re q u e ste d to h o ld th e p a r t still i.e. to p re v e n t a n y ro ta tio n fro m ta k in g p la c e . It m a y be fo u n d n e c e ssa ry to p e rfo rm th e m a n o e u v e r slow ly a n d in a la rg e r ra n g e th a n u se d to fa c ilita te , in o rd e r to e x ­ p la in to th e p a tie n t w h a t is re q u ire d o f him . O nce the p a tie n t u n d e rsta n d s , it w ill be fo u n d t h a t a c o-contrac- tio n c a n b e e lic ited w ith o u t th e tim e la g a n d the in tense v o lu n ta ry e ffo rt so c o m m o n ly e x p e rie n c e d w ith rh y th m ic sta b iliz a tio n s . I t h a s b e en o u n d th a t th e finer a n d the m o re r a p id ro ta tio n s , th e g re a te r th e fa c ilita tio n . I t is th o u g h t th a t c o -c o n tra c tio n is in itia te d by m ea n s o f stim u la tio n o f s e c o n d a ry a ffe re n ts of single jo in t ex­ te n s o r m u sc le s. (3, 4) T h e o p tim u m p o sitio n fo r th is is th e e x te n d e d p o s itio n o f th e jo in t i.e. the n o rm a l w eight- b e a rin g p o sitio n . In F ig . 1 th e e lb o w w as h e ld in a n e x te n d ed p o sitio n . R o ta tio n o f th e s h o u ld e r w as a p p lie d u sin g th e h a n d as th e p o in t o f a p p lic a tio n . T h e u p p e r re ad in g is the e.m .g. r e c o rd in g o f th e tric ep s m u sc le , th e lo w e r is th a t o f th e b iceps. T h e p a p e r sp e e d w as 25 m m /se c . T h e c a lib ra tio n was 1 c m /m v o lt. In this s im u lta n e o u s re c o rd in g it can be seen t h a t th e a m p litu d e a n d fre q u e n c y o f th e a c tio n p o te n tia l sp ik e s a re a lm o s t e q u a l — a tru e c o ­ c o n tra c tio n . A s im ila r te c h n iq u e w as a p p lie d w ith th e e lbow held a t 30° (F ig . 2) a n d 90° (Fig. 3) flexion respectively. T h e jo in t a n g le w as m e a s u re d a n d k e p t c o n s ta n t b y use o f a L e ig h to n F le x o m e te r. T h e u p p e r re a d in g is the triceps a n d th e lo w e r one, th e biceps. ( S F ig. 2 I1I S M F ig. 3 R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. ) j UNIE 1975 F I S I O T E R A P I E 5 It can be seen t h a t w ith a n in c re a s e in flexion th e re js far g re a te r a c tiv ity in th e biceps, w hile activ ity in the tric ep s is m in im a l. T h u s th is te c h n iq u e c an b e used to fa c ilita te a n y m u sc le g ro u p d e p e n d in g on th e p o sitio n 0f the jo in ts a n d th e p o in t of a p p lic a tio n o f th e ro ta tio n s. T he uses to w hich this te c h n iq u e can b e p u t a re legion, so long as th e jo in ts a re c a re fu lly p o sitio n e d t0 o b ta in th e o p tim a l re sp o n se . Since th e c o n tra c tio n o b t a i n e d is iso m e tric , th e re is n o d a n g e r o f m o ving joints w hich m u s t b e k e p t im m o b lie . T h e o n e c o n tr a ­ indication to this te c h n iq u e is th e p a tie n t w ith a h e a r t c o m p l a i n t . Iso m e tric c o n tra c tio n s , p a r tic u la r o f the u p p e r lim b s, a re k n o w n to c a u s e an in c re a s e in h e a rt rate a n d b lo o d p re ssu re . (2) A few e x a m p le s o f th e uses o f q u ic k r o ta tio n s no w follow:— (a) F o r fa c ilita tio n o f h e ad c o n tro l in fo re a rm re st p ro n e lying, r o ta t io n o f th e s h o u ld e rs can b e given T h is c au ses a c o -c o n tra c tio n of th e n e ck m uscles — as a d d e d fa c ilita tio n to t h a t o f the sta rtin g p o sitio n . (b) Jn o rd e r to f a c ilita te a c tio n o f th e r o t a t o r cuff a n d the s c a p u la r r o ta to rs , q u ick ro ta tio n s c an be a p p lie d in th e fo re a rm r e s t p o sitio n , to th e s h o u ld e rs (w eak fa c ilita tio n ) o r to th e f o re a rm s (used as levers to cause r o ta tio n a t th e sh o u ld e rs) o r to th e h a n d s w hich a re g rip p in g cones, f o r ev en g re a te r facili- tion. I f w e ig h t-b e a rin g is n o t a llo w e d , th e a rm s can be p la c e d in th e b e n d p o sitio n a n d q u ick r o ta tio n s a p p lie d . O nce th e r o t a to r cuff m u sc le s a re a ctive, it is p o ssib le in th e la tte r p o sitio n , to su p e rim p o s e an is o ta n ic d e lto id c o n tra c tio n w ith a re s u lta n t e lim in a tio n o f a re v erse d sc a p u lo -h u m e ra l rh y th m . (c) In lying, q u ick r o ta tio n s a p p lie d to th e h ip jo in t using th e d o rsiflexed fo o t as th e p o i n t o f a p p lic a ­ tio n , f a c ilita te h a m s trin g a n d q u a d ric e p s a ctivity (p a rtic u la rly v a stu s m ed ia lis a ctivity). (d) Q u ic k r o ta tio n s a p p lie d to th e big to e h e ld in th e n e u tra l p o s itio n fa c ilita te c o n tr a c tio n o f th e a b d u c - Passive Movements (continued from page 2) R E F E R E N C E S : 1. G a rd in e r, M .D . (1973), T h e P rinciples and Practice o f E xercise Therapy, 70. 2. M a itla n d , G . D . (1970), Peripheral M an ip u lation , 22. -'■-s Ibid, 23. '!.& Ib id , 4. 5. D avies, D . V. (1967), G ray’s A n atom y, 492. 6. L effe la a r, E . G . (1971), Com pendium O efentherapie, 1, 96. 7. Ibid, 96. 8. G u ttm a n , L . (1973), Spinal Cord Injuries C om pre­ hensive M anagem en t and R esearch , 235. 9. Ibid, 235. 10. B a sm asjia n , J. V . (1974), M u scles A liv e, 157. 11. T w o m ey , L. A. (1974), A M o re N a tu r a l A p p ro a c h to M o v e m e n t in T r e a tm e n t, Austr. J. Physiother, X X , 4, 172. 12. M a itla n d , G . D . (1973), T h e T re a tm e n t o f J o in ts by P assive M o v e m e n t, Austr. J. Physiother., X V IV , 2, p. 65. 13. Ib id , p. 67. 14. M e lza ck , R ., W all, P . D . (1965), P a in M e c h a n ism s: A N e w T h e o ry , Science, 150, 3699, 791. 15. tbid. 16- L e c tu re N o te s (1972), “ S p in a l M a n ip u la tio n C o u rse ” , S o u th A u s tra lia n B ra n c h of th e A u s tra lia n P h y s io th e ra p y A s so c ia tio n . 17. P e rso n a l N o te s. to r h a llu c is . If th e to e is h e ld in th e do rsiflex e d p o s itio n , th e q u a d ric e p s is fa c ilita te d . T h is is p a r ­ tic u la rly u se fu l fo r p a tie n ts im m o b iliz e d in P .O .P . (e) T r u n k s ta b iliz a tio n is o b ta in e d b y q u ick r o ta tio n of th e p e lv is a n d la te r th e s h o u ld e rs in e ith e r sittin g o r sta n d in g . P e lv is ro ta tio n c a n a lso be a p p lie d in th e b rid g in g p o s itio n w h ich c au ses a v e ry s tro n g tr u n k c o -c o n tra c tio n . I t c a n th u s be seen t h a t this te c h n iq u e o ffers endless p o ss ib ilitie s . O ne m u s t b e a r in m in d th a t th e p o s itio n o f th e jo in t a lte rs th e d e g re e o f f a c ilita tio n in th e d e sired m uscle. T h e p o in t o f a p p lic a tio n o f the r o ta tio n s also a lte rs th e fa c ilita tio n , th e m o re d is ta l th e a p p lic a tio n th e g r e a te r th e f a c ilita tio n . T h e te c h n iq u e is sim p le , b u t s h a k in g of th e p a r t m u s t be a v o id e d . Q u ic k a lt e r ­ n a te rotation o f th e p a r t is re q u ire d , n o t flexion a n d e x te n sio n o r ab- a n d a d d u c tio n . T h e m o v e m e n t a p p lie d sh o u ld b e so fine as to b e a lm o s t im p e rc e p tib le to th e p a tie n t. W ith th is te c h n iq u e it is p o ssib le to e licit a c o -c o n tra c tio n o f a n y p a r t as w ell as to f a c ilita te a n y w e ak o r in h ib ite d m u sc le g ro u p . I t has a lso b e e n su c c e ss fu lly a p p lie d in th e e a rly re h a b ilita tio n o f p e r i ­ p h e ra l n e rv e lesio n s a n d w ith c a re , can b e used in sp a stic c o n d itio n s w h e re sta b ility is d e sired . R E F E R E N C E S 1. K n o tt, M . & V oss, D . E .: P rop rioceptive neuro­ m uscular facilita tio n . 2 nd e d . L o n d o n , B aillie re, T in d a ll & C a sse ll, 1968. 2. N a u g h to n , J. P . & H e lle rste in , H . K . ed s.: Exercise testing and exercise training in coronary heart disease. N e w Y o rk , A c a d e m ic P re ss, 1973. 3. O ’C o n n e ll, A . L . & G a r d n e r , E . B.: U nderstanding the scientific bases o f hum an m ovem ent. B a ltim o re , W illia m s & W ilk in s, 1972. 4. S to c k m e y e r, S. A .: A n in te r p r e ta tio n o f th e a p ­ p ro a c h o f R o o d to th e tr e a tm e n t o f n e u ro m u s c u la r d y sfu n c tio n . A m . J. P hys. M e d . 46: 900-961, 1967. (A rticle re c e iv e d D e c e m b e r, 1974) C O U R S E O N N E U R O D E V E L O P M E N T A L T H E R A P Y A Course on N eu rod evelop m en tal T herapy, b a se d on th e w o rk o f D r. K a r e l a n d M rs. B e rta B o b a th , w ill be r u n a t th e W est R a n d S c h o o l f o r C e re b ra l P a lsied C h ild re n , K ru g e rs d o rp , fro m 17th M a y , 1976, to th e 9 th J u ly , 1976. C o st; R250-00, ex clu d in g p rin te d m a tte r. C lo sin g d a te fo r a p p lic a tio n s : 3 0th S e p tem b e r, 1975. A p p lic a tio n s m u s t in clu d e : 1. B asic q u a lific a tio n s a n d y e a r o b ta in e d . 2. E x p erien c e . 3. P re s e n t w ork. 4. In te n d e d f u t u r e w ork. 5. Age. 6. In s u ra n c e cover. 7. M e m b e rs h ip o f P ro fe s s io n a l O rg a n iz a tio n . A ll c o rre sp o n d e n c e to : M rs. H . E v an s, P h y s io th e ra p y D e p a rtm e n t, P .O . B ox 792, K R U G E R S D O R P . R ep ro du ce d by S ab in et G at ew ay u nd er li ce nc e gr an te d by th e P ub lis he r (d at ed 2 01 3. )