Active Movement notes

Description This section is from the book "Massage Its Principles And Practice", by James B. Mennell. Also available from Amazon: Massage It's Principles and Practice.

Chapter VIII. Mobilisation As A Sequel To Massage. 2. Active Movement

There is one manoeuvre which can often find a place in our treatment, but which cannot be classed under the heading of "movement." It consists of teaching the patient to contract certain muscles, or groups of muscles, voluntarily without moving any joint as a result of the contraction. For example, the quadriceps can be exercised freely even though the knee be firmly fixed by a splint; the deltoid can be made to contract without any effect on the shoulder-joint. There are two requisites, a little tact and patience on the part of the instructor and perseverance on the part of the patient, if the full benefit is to be reaped. Few things are more injurious to muscular strength than absolute rest; it is surprising how little exercise will maintain it. Even in the absence of joint movement, the performance of the natural function of a muscle alternate contraction and relaxation - will often suffice, if not to prevent wasting, at least to minimise it and to maintain its vitality. It will also help to maintain intact the muscle-sense on which co-ordinated movement will subsequently rely. Active movement may be divided into the following groups: 1. Free movement, 2. Assistive movement, 3. Resistive movement.

FREE MOVEMENT Free Movement. - We must remember that gravity serves as an effective resistance against which to work, and, if a movement is performed against gravity, we are really performing a concentric movement against resistance; if with gravity, our movement is assisted. Thus it comes about that, in certain positions, assistance may be required if a movement is to be truly "free." In movement of the shoulder, for instance, if the patient is standing, exercise with the weight and pulley may mean that movements of abduction and adduction are almost "free" because the weights counteract the weight of the limb during the movements. The so-called "free" abduction is a movement against the resistance of gravity if the patient is upright, while adduction is a movement assisted by gravity. True "free" movement is, therefore, excessively rare; and the division of movement into "free" and "assistive" is arbitrary. It is useful, nevertheless, as it serves to remind us that active movement may be "active," even though only

performed with assistance. Free flexion and extension of the fingers is best performed with the hand supported on its ulnar border, the forearm being held mid-way between pronation and supination. For the exercise of free adduction and abduction the hand should be placed flat upon a table, and the fingers are then separated and approximated. It is sometimes of service to keep them rigid by means of light posterior splints.

Fig. 41. - To show the position for free rotation of the forearm, the patient being recumbent.

Fig. 42. - To show the same position as in Fig. 41, free movement having been performed from almost full supination to full pronation.

Fig. 43. - To show the starting position for free flexion of the elbow. This is also the end position of free extension. The forearm being supported in this position with the hand hanging free is the correct attitude in which to perform free flexion and extension of the wrist.

Fig. 44. - To show the starting position for free extension of the elbow. This is also the end position of free flexion. Free rotation is performed starting from the same position, the hand being supported or not, according to the nature of the case. Better still, the patient lies flat on his back, the posterior aspect of the arm rests on the couch, and the forearm is kept vertical by flexion of the elbow to a right angle (see Figs. 41 and 42). Free flexion and extension of the forearm is best performed with the patient recumbent, the inner side of the arm and the elbow being fully supported and the hand moved up and down over the chest (see Figs. 43 and 44). The movement is almost free through an angle of 15 degrees in either direction if the forearm is kept vertical. As an alternative method, if shoulder movement will permit, the patient sits beside a table in such a position that its surface is on a level with the axilla.

Fig. 45. - To show flexion and extension of the elbow while the limb rests on an adjustable board. When the board is horizontal the movement is free except for the resistance due to friction. As its outer edge is depressed flexion is resisted by gravity and extension is assisted. The whole arm then rests upon the top of the table while flexion and extension are performed (see Fig. 45). Free movement of the shoulder entails the supporting, by one means or another, of the weight of the forearm and hand.

Mobilisation with Active Movement. Part 2

Fig. 46. - To show a simple method of reducing the action of gravity on the upper extremity while performing abduction. The hand should be supported by a sling round the neck, omitted in the photograph for the sake of rep-o-duction. This may be done by placing the patient fully recumbent, the whole weight of the limb being supported by the couch. By means of gradually elevating the position of the couch on which the trunk and shoulders rest, the resistance to abduction and the assistance to adduction can be regulated to a nicety. Other ways of achieving a similar end are by giving manual assistance by the aid of the weight and pulley, or by some other device. The resistance to shoulder movements offered by gravity can be largely counteracted if the elbow is maintained in the acutely flexed position (see Fig. 46).

Fig. 47. - To show the position for free movement of the ankle. Movement of the toes in this position is also "free."

Fig. 48. - To show the position for free movement of the knee. If the patient's left thigh were drawn back, the knee well flexed, and if the right thigh were drawn forward, extension of the right knee would be assisted by gravity. Free movement of the toes can be performed with the leg flat on its side on the couch. Free movement of the ankle can only be performed with the patient lying on his side on a couch, the weight of the leg being supported on the couch or on a pillow (see Fig. 47). Free movement of the knee necessitates that the patient should assume a position similar to that employed when giving free movement to the ankle. The only difference is that, in this case, it is better that

the patient should lie on the injured side (see Fig. 48), though a little ingenuity will enable the movement to be performed when lying on the sound side. Free movement of the hip is very difficult to secure in any position without assistance from some weightbearing mechanism. Rotation is almost free when recumbent with the limb fully extended on a couch. By means of a weight and pulley flexion and extension can be rendered almost free when the patient is recumbent, while free adduction and abduction are rendered possible by simple suspension from a cord. As a matter of fact, swinging the whole extremity in the erect posture approximates very closely to a free movement, provided that movement does not exceed a few degrees from the perpendicular. Lying on the back with the knee drawn up so that the sole of the foot rests flat upon the couch, a few degrees of almost free adduction and abduction can be performed. When making the first tentative experiments with free movement, the patient will often find that his endeavours are crowned with success more readily if the limb is placed in water, preferably hot. The probable explanation of the success of these adjuvants is that the water, by giving perfect and even support to all the parts immersed, removes every trace of external resistance to movement. The tendency of cold to render all movement more difficult by giving rise to a sense of stiffness is a natural phenomena: heat tends to relieve this sense, and movement becomes more easy. The effect of the swirling of the water, if an eau courante bath is used, is possibly comparable to the effect of the superficial stroking massage already described. An ordinary bath of hot water is generally as useful as any other form of bath. It is well, whenever possible, to arrange that any free movement should be performed in combination with other movements as indicated when considering relaxed movements. The value of the knowledge of the positions in which doses of true free movement can be administered is realised even less than the value of true relaxed movement. Yet a full appreciation is required as an essential foundation for re-education in cases of extreme weakness and of paralysis . Until these fundamental positions are studied and their value realised all early training must be faulty and progress thereby retarded. The first essential in muscle re-education is to devise something that the muscle, despite its enfeebled condition, can effect as the result of its contraction. The most simple actions any muscle can perform are those that are assisted by gravity. By postural change the assistance thus afforded can be reduced from a maximum to zero - the posture for true free movement - while further change in position adds gradually to the resistance afforded by gravity to the movement. Thus, and thus only, can early muscle re-education be scientifically gradated, and the keystone of the training is the knowledge of the neutral positions, or the positions in which alone true free movement is possible (see Chapter XIX (The Re-Education Of Muscle).). 2. ASSISTIVE MOVEMENT Assistive Movement opens a wide sphere for inventive capacity in the individual masseur. The assistance given varies from the mildest possible touch to a finger, while the forearm floats in an arm

bath, to a vigorous and long-sustained pulling process, while the patient himself is exerting the full power of normal muscle, with all the assistance that can be obtained from gravity and the body-weight.

Mobilisation with Active Movement. Part 3

The object in administering a dose of assistive movement is to enable the patient to accomplish more than he could do unassisted. Thus it may serve its purpose in either of two ways: first, by enabling the patient to perform a movement without undue fatigue or strain; second, by enabling him to do so through a greater amplitude than he could otherwise manage. But a nicety of judgment and an exquisite tact are required to enable the masseur to decide how much assistance is to be given, be it manual or mechanical, or by the use of gravity alone. It also requires common sense. For instance, let us take the case of a patient with a wasted deltoid who is told to raise his arm into a position of full abduction at the shoulder by means of a weight and pulley. It is not unusual to find that the masseur allows the patient to perform almost the entire movement with the scapula; or, perhaps, fondly imagines that by increasing the weights the exercise to the deltoid will be increased, whereas the real effect is to render elevation of the arm more easy, while only increasing the exercise of the adductors. If, on the other hand, the deltoid is called upon to abduct the arm in the standing position before it has adequate strength to accomplish the movement, it will frequently be found that the muscle makes no attempt to perform its hopeless task. It remains quite inert, and any movement that is accomplished is the result of scapular movement. Place the same patient fully recumbent, supporting the weight of the limb on the couch, and the deltoid will at once respond to the call for abduction by a contraction, provided that there is any continuity of nerve supply and that the patient, from desuetude, has not forgotten how to pass his voluntary impulse along the nerve to the muscle. Another point, frequently overlooked, but worthy of the closest attention, is this: There is a universal law that if one muscle contracts, and movement of a joint takes place in consequence, some other muscle or group of muscles must relax. This does not mean to imply that, during contraction of a muscle, its antagonist passes into a condition of complete flaccidity. This is not so. The elongation of the antagonist is due to an active and voluntary relaxation, and the amount of the relaxation performed at any given moment is dependent on the voluntary control of the movement at the joint. Thus, if a muscle is made to contract and the joint it controls is free to move, and if movement is voluntarily prohibited, the antagonist contracts with exactly the same strength as the muscle concerned. If movement takes place as the result of muscle contraction, the antagonist voluntarily "pays out the slack," as it were, to allow the amount of movement that is required. And this it can do albeit that it is in a state of constant contraction even while visibly relaxing. The relaxation, in other words, can, in accordance with voluntary control, be negative, partial or complete. If movement is prohibited, as by a splint, and a muscle is called upon to contract, the antagonist may pass into a condition of complete relaxation, equivalent to that which would be allowed were full freedom of action given to the muscle contracting. If any severe effort is made, probably the whole of the muscles throughout the limb will pass into a state of contraction, including the antagonist. Let

us be sure also that, when we want to assist the movement performed by one muscle, we are not merely giving a resistive movement to its antagonist. A third consideration is of vital importance to the success of the administration of assistive movement, namely, that the dose of assistance is progressively lessened if the range of movement is unaltered. On the other hand, with increase of range of movement there should be no increase of assistance, unless the resistance to be overcome is out of proportion to the increased range. Let us now consider in detail the various methods in which assistive movement can be administered. The most simple has already been mentioned, namely, assistance rendered to the movement of a limb which is floating freely in a water bath. If the patient is sufficiently bad to require this treatment, it will probably be necessary to make our first movements purely passive, and then to instruct the patient to make an effort to copy, while we merely guide the movement. The next stage is to teach the patient to perform slight movements with the assistance of gravity, then pure free movements and, finally, movements against the resistance of gravity. When voluntary movement has been restored to this extent, assistance should not be given to such portion of the movement as can be performed voluntarily; but, as the power to complete the movement gradually fails, we commence, and equally gradually increase, the assistance given. But as our assistance is only a means to an end, it is essential that we should note the amount of assistance given on any one day, and aim to secure a similar result with a decreased amount of assistance at some definite date in the near future. The amount of improvement may indeed be infinitesimal, but still it should be there and should be noted, otherwise we are wasting time. There is one exception to the rule always to allow a patient to perform a movement without aid as far as possible, and then gradually to add and increase assistance. No movement should ever be allowed, the performance of which calls forth coarse, functional tremor in the contracting muscles. The contraction must be stopped immediately and the patient shown how to perform the movement without tremor - by first performing it for him with all the muscles in a state of active relaxation and then allowing the muscles gradually to assist. In other words, the patient assists the masseur rather than vice versa. If any difficulty is encountered by the patient in the performance of the contraction of any muscle, he must be shown how the corresponding muscle on the sound side contracts and then learn to copy it on the injured side.

Mobilisation with Active Movement. Part 4

If the impediment to movement is due to causes other than pure muscular disability the administration of movement becomes a more difficult process, owing to the fact that, almost inevitably, the muscles that oppose the movement will pass into protective spasm. Here the skill acquired in securing relaxed movements finds its greatest test in efficiency. The problem presented is how to administer what is really

a forced movement. There are two ways: the first is to do it for the patient, the second to let the patient do it for himself. To do it for the patient it is essential that, as far as possible, the movement should be performed during active relaxation of all muscles. But sooner or later the antagonists of the movement will pass into protective spasm. The closest possible watch must be kept for this reflex contraction, as it is possible to counter it, by calling on the patient voluntarily to contract the muscles which control the movement we are attempting to perform. Voluntary contraction of any muscle involves reflex relaxation of its antagonists, and this, so to speak, voluntary reflex, can overcome the involuntary protective reflex, provided that the stimulus exciting the latter is not too severe. If it is, the patient will suffer all the pain of severe cramp in both groups of muscles, and this is equivalent to the pain of the muscular spasm that follows recent fracture. Hence the need for care, gentleness, and tact in the performance of forced movement in the massage-room. Another method of performing a forced movement for the patient is to accept the contraction of the antagonistic muscles as inevitable, and attempt to overcome their resistance by a very protracted, steady pull, while applying firm kneading to the whole of the area throughout which contraction can be detected. This is a slow, laborious and not over-successful scheme, and forms a very indifferent substitute for prolonged splintage with pressure or tension. If utilised, the relief of the tension must be very gradual, or great pain will be given. One useful little scheme is worthy of record. If a patient is flexing his elbow and then straightens it, at the moment when he changes his action from flexion to extension all muscles must be uniformly relaxed. If assistance is being administered to flexion at this moment, i.e., if flexion is assisted and extension resisted, the whole of our assistance is given for a short space of time during which perfect relaxation is present. By this simple expedient it is often possible to administer a considerable dose of forced movement unknown to the patient. If it is omitted, mechanical assistance to a movement, e.g., by weight and pulley, possesses an incontestable advantage over manual assistance. If, however, it is kept in mind, intelligent manual assistance must always take precedence over the unintelligent mechanical assistance, save only in expenditure of skilled labour and time. A patient can perform a forced movement for himself by utilising the force of gravity in various ways, though the most simple is, as a rule, through the medium of the body-weight. Thus the ordinary squatting, heel-raising-knee-bending exercise can secure a forced movement of flexion of the knee, provided that the patient will learn to relax his quadriceps resistance to the uttermost. As this muscle is strong enough to raise the body-weight from any position assumed during the exercise, it is plain that, in the absence of its relaxation, no forced movement of the knee is possible. Exercises on a horizontal bar can be made to perform the same function for a stiff elbow, but only under similar conditions, viz., active relaxation of the brachialis anticus. The vital importance of securing relaxation when utilising gravity for the performance of a forced movement I have long realised. I was convinced of the fallacious nature of the teaching that the way to extend every stiff elbow, for example, was to carry weights, or to sit with the arm hanging freely over the

back of a chair for some half-hour or more at a time, while grasping a heavy weight in the hand. The use of static hanging for the same purpose seemed equally to be based on an unsound principle. Rational treatment seemed to be to secure extension of the elbow by exercising the extensor (the triceps), not by stretching the flexor (brachialis anticus); and to secure flexion of the knee by strengthening the hamstrings rather than by stretching the quadriceps. I have now had occasion to examine several patients who, by their after-history, have demonstrated conclusively that this theoretical speculation is justified by fact. One example must suffice. A military patient, who was unable completely to extend his elbow, was employed as a gardener before the war. All attempts to straighten his elbow by means of massage, weight-holding and hanging had failed. All alike were painful. It was thought that return to his employment, which, I learned, entailed considerable use of a wheelbarrow, would soon put the matter right. A few weeks later, far from being better, he could barely extend his elbow beyond a right angle. This meant a loss of movement of some 70 degrees. The whole of his brachialis anticus was hard and tender. The raison d'etre of his loss of function was not hard to elucidate. At a certain point in extension of the elbow pain supervened. Reflex contraction of the brachialis anticus took place to inhibit further extension the moment this point was reached. In other words, extension was checked by muscular contraction just short of the point at which further extension was painful. Thus the whole strain of the weight-bearing was taken by the brachialis anticus, which accordingly suffered from a severe dose of static contraction. This resulted in general strain of the muscle, and the next day reflex contraction took place at a slightly earlier point in extension than the day before. Daily repetition of the strain thus slowly and steadily led to increasing inability to extend the joint. The brachialis anticus was rested and massage was applied for a few days. The triceps was then given a steadily increasing dose of exercise, involving, of course, relaxation of the brachialis anticus, with the result that the former power of extension was quickly restored. He was then recommended to return to his work, to dig, and otherwise exercise his triceps, while avoiding strain of his flexors.

Mobilisation with Active Movement. Part 5

The conclusion, then, is obvious, and is drawn, not from this case alone, but from many similar experiences. When a movement is impeded by adaptive shortening and attempted increase in movement is painless, passive stretching by the use of gravity may be used as a definite curative agent. It is not, however, the best at our disposal. If, on the other hand, the movement is painful, as is usually the case when adhesions are present or when there has been septic infection, passive stretching will inevitably tend to increase the deformity unless the tension is constant (as, for instance, when elbow flexion is secured by the use of a "cuff and collar," as shown in Fig. 76, p. 150). It is the intermittent nature of the strain that is fatal to success. But if, in order to secure extension when pain is present, our correct plan of action is to train the extensor muscles, surely it is rational to suppose that this treatment will prove no less efficacious if pain is absent. And, indeed, I regard it now as a sine qua non that every movement which is deficient should be restored by training the muscles that control the movement, while, at the same time, we teach the antagonists to relax instead of trying to stretch them. Even if an adhesion is present, which when stretched is the cause of pain on extension, active contraction of the extensors and relaxation of the

flexors is calculated to effect the stretching of the offending band far more readily than any amount of tension that is not constant. In the first edition of this book I was content - though with qualms - to leave unqualified the statement made above that "a patient can perform a forced movement by utilising the force of gravity in various ways," and quoted "squatting" as an example of forced flexion of the knee, and the use of a horizontal bar for that of extension of the elbow. I now believe that this was an error, and that rarely is very much gained by either expedient in the direction desired. The former trains the quadriceps, the latter the brachialis anticus, whereas the correct way to deal with the problem is to train the hamstrings or the triceps. I have devoted much space to the elucidation of this principle, partly, perhaps, because I formerly failed to recognise its full truth, and partly because of its bearing on all remedial gymnastics. Few medical gymnasts, so far as I know, are aware of its existence; fewer still appreciate its importance. Examples might be multiplied throughout the whole range of remedial and educational exercises and gymnastics. 3. RESISTIVE EXERCISES Resistive Exercises. - The resistance may be administered by the masseur in two ways, or, as in the case of assistive exercises, the force used may be derived from mechanical apparatus, or from gravity alone. The last has already been fully dealt with; and little need be said in this connection of the use of apparatus, as the converse of the various points raised when dealing with assistive exercises by apparatus will be found to hold good. If the masseur is supplying the resistance, a movement may be performed by the masseur while the patient resists (excen-tric), or by the patient while the masseur resists (concentric). It is plain that in performing the latter the amount of resistance given depends on the masseur, whereas in excentric the patient arranges the matter for himself. In concentric movement the muscle exercised shortens in length in the natural manner; whereas in excentric movement, although contracted, the muscle may actually lengthen. When treating a muscle during the early stages of recovery from paralysis , excentric movement should never be employed throughout the whole range of movement. But during recovery it is sometimes found that a patient is able to offer slight resistance before any actual voluntary movement can be performed, except with the assistance of gravity or in a position in which true free movement is possible. At the same time we must bear in mind that whatever tends to stretch the muscular fibres is to be deprecated. Hence the law governing treatment of this condition is that the administration of excentric resistive exercise may be performed only in the inner half of the path of contraction. This means that the movement of the part is limited in range to the final half of the movement that can be attained by the contraction of the muscle when in health. Concentric movement is easy in application and of the utmost service during all the earlier stages of treatment. It is of particular importance to utilise it as early as possible, when it may take its place in the middle of a prolonged assistive movement. For instance, if the brachialis anticus is very weak, it is

possible that movement from the vertical to 300 may call for assistance; from 300 to 6o there may be enough strength to raise the forearm against the resistance of gravity. By this time the muscle is shortening and gaining in power, so it may be possible to supplement the resistance of gravity up to the right angle. Soon after, perhaps, the muscle is only strong enough to continue the movement against gravity, and lastly assistance may be required to finish the last few degrees of movement. The management of the resistance obviously requires skill and care, since it starts from negative (during the assistive stage), passes zero, rises to a maximum, passes to zero again, and finally becomes negative. In a movement of wide amplitude, such as that of full flexion and extension of the elbow, the problem is fairly simple; but in dealing with a movement of small amplitude, such as rotation of a forearm, which perhaps is further limited by pathological change, the utmost delicacy of touch can alone suffice. But incontestably the best way of regulating resistance is to regulate by postural change the resistance afforded by gravity. Further details as to the technique will be found in the chapter dealing with the re-education of muscle (see Chapter XIX (The Re-Education Of Muscle).).