Medical gymnastics : a series of articles

PART 1. MAtERIA GYMNASTlCA

Definition. — Medical Gymnastics means systematic exercise of the muscles and other tissues for therapeutic purposes While no distinct line can be drawn between Hygienic and Medical gymnastics, it will however be found that a majority of the medico-gymnastic procedures differ from ordinary gymnastics even though these are used as auxiliaries in special cases. In these chapters but few movements of the last-named kind will be described, as a masseur of to-day is expected to be well versed in the theory of educational gymnastics before he attempts the medical branch of the science.

Medical Gymnastics has been commonly known as “ Swedish Movement Cure,” “ Movement treatment,” etc., and whereas some authors cannot lay enough stress on the distinction between medical gymnastics and massage, others have included under the last name all forms of manual therapeutics. Massage, however, is usually understood as denoting one of the procedures of friction, kneading, pressure and percussion, each one of which may be regarded as passive exercise of the muscles. It will then be the most convenient to include massage in the name “ medical gymnastics,” all the more since a skilled masseur never relies exclusively on massage proper, nor a medical gymnast on “ Swedish movements.” Since times immemorial exercise of one kind or another has been used for curative purposes ; yet we owe it to the Swede Pehr Henrik Ling and to his pupils and followers that science was brought to bear on the subject ; and while scientific therapo-gymnastics may have been said to originate in Sweden, medical gymnastics to-day has ceased to be merely a “ Swedish Movement Cure.” While Dr. Metzger of Amsterdam has revived the interest in massage in continental Europe, neither he nor Ling invented this form of treatment. Dr. Metzger* applies what Ling** described before Metzger was born ; and Ling gathered his information from still remoter sources, not least from Chinese manuscripts handed down to the present generation since 3000 years B. C.

The claim madef for Dr. Weir Mitchell to be “ the father of modern massage ” is invalid, for the rubbing used in his rest-cure has very little in common with massage, if we are to judge by the operators claiming to have been taught by him.

The procedures of massage as described in these chapters are not according to the Metzger or “ wet school,”

but are nearly identical with those described by Dr.

Douglas Graham, and practised by the foremost masseurs of Europe, such as the late Prof. Cederschiold, Ulrich, etc.

•Before entering into the consideration of details, it may be well to state a few facts pertaining to movements in general.

Position and Movement. — A movement is a change from one position to another, and might be said to consist of a sequence of positions. In order to accomplish a definite, preconceived purpose, commencing position, final position, sphere of action, velocity, force, duration, etc., must be exact.

Effects of Movements. — “ The effect of a movement is the result of its action, and the reaction of our organism” (Roth). The effct may be physical, physiological and psychological, and movements also have both a general and a local effect. While the local effect usually decides the choice of a movement, its general effects should never be left entirely out of consideration. Also medical gymnastics may be applied as local or as constitutional treatment in accordance with these effects.

The general effects of active movements are those of ordinary gymnastics, i. e., a general increase of the functional activity; resistive movements emphasize these effects, while assistive movements produce them in a less degree. Active movements involve the use of attention, and consequently cultivate voluntary control, while passive movements diminish motor irritability and voluntary co-ordination, and favor inattention or inactivity of attention. Active movements diminish sensory, and heighten motor irritability, harden the fibrous tissues, and lessenthe adipose ones; passive movements may increase sensory and lessen motor irritability, make lamellous texture predominant and cause a greater amount of fat to accumulate between the muscles and under the skin.

The local effects of movements will be described with each procedure.

Positions. — Although massage proper is usually applied while the operator is reclining or lying down, for other procedures commencing positions of the most diverse kinds are used for exactness of effect — for its localization or generalization. Commencing positions are elementary and derived. Elementary are lying, sitting, kneeling, standing and hanging ; all others are derived from these.

Classification of Moveme?its.— Medico-gymnastic movements are active when executed by the patient himself ; if the operator makes resistance against the movement it becomes resistive ; if he helps the patient in performing it, it becomes assistive ; if he is doing the movement without any voluntary effort whatsoever from the patient, the movement is called passive , while the movement executed by the patient without aid or resistance from the operator is called single. Besides these general names, each procedure has one denoting its mechanics, so that a synopsis of the subject would present the following appearance : —

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While this classification will be of assistance in describing the movements, yet for therapeutic purposes a classification according to effects will be more rational and after the masseur has acquired the mechanics of the various procedures, he will be best helped by memorizing the following synopsis:

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The rationale of this will be plain after the various movements have been described.

Lying pos. (fig. i) — The patient is lying on his back, his arms along his sides ; knees straight ; heels together ; and the body supported along its entire length. Characteristics of this position are the total relaxation of all voluntary muscles and the consequent diminution of cerebration. As compared to the standing pos., respiration is now more labored ; for the inspiratory muscles especially the diaphragm, are directly opposing gravity in their effect upon the abdominal organs : the sagittal expansion of the abdomen diminishes while the lateral one increases. Viscera gravitate toward the posterior side of the body, and the total circulation increases in this direction, even to causing spinal congestion.

Sit-lying (Fig.2) — Lying with the legs hanging unsupported. Fascia Lata has now become somewhat tense, and the inferior attachments of the abdominal muscles are slightly drawn down. The inspiratory condensation wave in the abdomen becomes shallower ; and the pelvic contents are pressed toward the sacrum.

Leg-lying (Fig.3) — The body is supported only from feet to waist. The muscles of the abdomen and thigh are now tense ; viscera are forced backward ; and the blood is driven into chest and head, especially toward the medulla. At first there is an increase of attention which is soon followed by dizziness.

Side-lying. — The body is resting on the side. Side-leg-lying. (Fig.4) — A combination of the last two. Here gravity assisted by the carrying muscles causes the spine to curve to the under side, which becomes expanded.

Prone-lying, (Fig.5) — The body is lying face down. It is usually taken so that the plantar side of the toes braces the body behind ; and the elbows, vertically under the shoulders, with hands grasping opposite arms, support the body in front. In this situation, viscera gravitate forward ; the chest is expanded ; and internal elevation results. Gravity draws the blood into the anterior portion of the body, away from the spine ajjd cerebellum. The position is one of “ meditation. r’

Forward lyingl^ Fig.6) — The body, turned face down, is supported from the waist down. The glutei and extensors of the back are in contraction ; the dorsal spine straight ens and the chest becomes vaulted. The position heightens respiration and cerebration. The farther the support is from the head, the lower in the back will be found the strongest muscular contraction ; so that, if the upper dorsal region is to be affected, the support is placed under the thorax.

Crook-lying — (Fig.7) — The knees are drawn Up and feet supported (vertically under the knees). The muscles of the abdomen are now relaxed and viscera fall backward-upward. The tension in the lumbar fascia through the glutei causes the lumbar curvature to straighten. The position favors thoracic aspiration.

Reclining (fig. 8) — The body is resting on a couch so that the trunk is inclined backward. Respiration is easier than in ly. pos. This position is specially suited for massage or other movements where a saving of energy is desired. The more the body inclines, the less is the relaxation of the abdomen. The posture is one of ease and comfort, although less passive than the ly. pos.

Ci-ook reclining (fig. 9) — Reclining with knees drawn up as in cr. ly. The abdomen is completely relaxed ; viscera spread laterally and fall toward the sacrum. The blood also gravitates toward this region. The position is especially suitable for massage of the abdomen and for active movements of other parts where the abdomen is to be excluded from the effect.

Sitting position (tig io) — Ordinary sitting posture with erect trunk and head, hips and knees flexed at right angles, heels together and toes turned out, hands resting on the knees. Viscera become slightly compressed.

The posture is one of physical rest with mental activity, and produces isolation of the trunk from the legs. The short line of gravity makes this position less tiresome than standing.

Stoop sitt. (tig. n) — Sitting, with the trunk inclined forward. The abdomen is now completely relaxed, and viscera compressed forw., while the back muscles are in contraction vaulting the chest. In this position attention is more active than in the previous one.

Fall sitt. (Jig. 12) — Sitting with the trunk inclined backward. The feet should be inserted in some firm support, or an assistant gives support on the knees. The muscles of the abdomen are in contraction compressing viscera from above downward, driving the blood into the pelvis, and into the chest. The lumbar spine straightens.

Turn sitt. — Sitting with the body rotated to one side. This produces a unilateral expansion of the chest, and an oblique compression of the abdomen. The elongation of the thorax occurs towards the everted shoulder, and there is an elevation of viscera in this direction. The position is used chiefly in the treatment of scoliosis.

Long sitting (fig. 13) — Sitting with the legs put up. The relaxation of the fascia lata causes the lower insertions of the abdominal muscles to rise, with a consequent relaxation of the abdomen. The tension in the glutei is communicated into the hamstrings, so that the whole posterior leg is in passive extension. This determines a greater flow of blood through the legs, with a greater diminution of the supply to the spine. Mental activity is less than in sitt. pos.

Ride sitting — Sitting astride a chair, usually with the feet fixed. This produces absolute isolation of the hip joint so that trunk movements will be confined to the spine.

Half sitting (Jig. 14)— Standing with one thigh resting over a support, the leg of that side hanging. — Is to be considered as a unilateral standing pos.

knees ; body erect ; knees one foot length apart ; heels together ; toes turned out and resting with the plantar surface on the ground. The pelvis is compressed through the tension in fascia lata. The hip is fixed laterally through the tensor vaginae femoris, and movements of the trunk are communicated into the pelvis instead of into the thigh, as in st. pos. The position is suitable in movements for pelvic disorders, but is fatiguing if long continued.

Half knee-standing (Jig. 16) — 1-2 kn. st. — Kneeling on one knee, the other foot on the floor in front, with the knee of that side bent so that the leg is vertical ; the body erect from the backward knee. The tension in the muscles of the kneeling side causes fixation of linea alba, so that sagittal movements will be executed chiefly with the muscles of the opposite side, while the effect of internal elevation will be the strongest on the first named side. The position is suitable for unilateral effects upon the pelvis and groin.

Standing (fig. 17) — St. — Feet at right angles ; heels together ; knees straight ; hips drawn backward ; chest well elevated and brought forward ; head high with chin drawn in ; arms hanging along the sides. This position, characteristic of man, is expressive of concentrated energy, and is fundamental to all human locomotion. Yet, on account of the lack of isolation in this position, and because of its being tiresome, it is used but little in medical gymnastics, except for “ single ” movements. In this position respiration occurs more easily than in any other.

Close st.—' The feet are turned straight forward. Equilibrium is less stable, and the abdomen is more relaxed than in st. pos.

Toe st. — The heels are raised from the ground. The dorsal spine is straighter, the chest more expanded and the abdomen more flattened than in st. pos.

Walk st. — One foot in advance of the other ; the distance between the heels, two foot lengths ; both knees straight ; weight equally on both feet.

Wlk. a st. — fig. 1 8 ; wlk b st. — fig. 19 ; wlk. c st. — fig. 20 ; wlk. d st. — fig. 2 1 .

Stride st. — (fig. 22) — Feet twice their own length apart; a line through the heels parallel with one through the shoulders. Both knees straight and weight equally on both feet. In this position equilibrium is better laterally, poorer sagittally,’than in st. pos., through the corresponding fixation and relaxation of the hip joint.

The wlk. st. positions are used for muscular isolation, so that for instance trunk rotations are made more difficult and localized higher in the thorax by progressing from stride st. to wlk. a, wlk. b, wlk. c, and wlk d, st. pos., in the order enumerated, the rotations of the thigh becoming excluded from the movement. In wlk. b pos. backward movements produce a stronger tension in the posterior leg, and forward movements in the anterior one. The hip of the advanced leg is raised and the pelvis rotates to the opposite side. Whenever unilateral effects are desired, as in scoliosis, these positions are very useful.

Fallout st. — (fig. 23) — One foot three times its own length in advance of the other; feet turned out and fully on the ground ; forward knee bent ; backward knee straight, and this leg in a line with the body which inclines forward. The erectors of the spine are in stronger contraction than in st. pos., especially those of the side corresponding to the backward leg. There is a diminution of capacity in the side of the thorax which corresponds to the advanced leg, the hip of this side rising, and there is an increase of capacity on the opposite side accompanied by a flattening of the abdomen. The blood is drawn from abdomen and pelvis into chest and legs. The position is very tiresome.

If the backward foot is inserted into some firm apparatus, the position is called foot grasp falloutst., which possesses all the qualities of the preceding one in exaggeration.

Courtesy st. (fig. 24) — From toe st. the knees are bent to right angles. The knees are turned out in direction of the feet ; the heels are held together. The activity of the muscles of the legs determines a greater afflux in this direction. The chest is expanded more than in st. pos., and the abdomen compressed. The total result is a diminution of blood supply in the abdomen and pelvis. Internal organs of these cavities are forced backward. The position demands a great deal of co-ordination, and hence intensifies cerebellar activity and voluntary attention.

This position is also taken from stride st. pos. and from wlk. b st.

Courtesy sitting (fig. 25) — The knees are bent as far as possible. The effects are similar to those of the preceding position, although highly increased. The effect upon he brain is diminished, as this position requires less effort of equilibrium.

Half standing — 1-2 st. (fig. 26) — Standing on one foot, the other raised backward. The contraction of the extensors of the back are strongest on the side of the lifted leg, so that the spine curves to the opposite side. The chest is the most expanded on the side of the carrying jeg, and the trunk is slightly rotated to that side. Unilateral cerebration.

Crook a 1-2 st. (Cr. a 1-2 st.) (fig. 27) — Standing on one foot, the other leg lifted forward with hip and knee bent at right angles. Effects like preceding, added to which pelvic viscera on the side of the lifted leg become compressed from behind forward.

Cr. b 1-2 st. (fig. 28) — Standing on one foot, the other leg lifted forward with straight knee. Effects similar to the preceding, but the anterior wall of the abdomen is also brought into contraction, producing internal elevation of pelvic viscera of that side. The posterior leg is in passive extension and consequently the quantity of blood in that leg increases.

Step. st. (fig. 30). — Standing on one foot, the other placed forward on a chair or other support, knee and hips at right angles. — The hip of the advanced foot is raised without disturbance of the dorsal spine, and the abdomen is relaxed on that side.

Side step st. (fig. 29).=preceding, but the foot is placed sideways instead of forward. — The principal change of effect is in the abdomen, which here is tense toward the lifted leg.

Heel grasp 1-2 st. (fig. 31). — One foot is placed forward with the heel resting on some support ; knee straight. — The passive extension of the hamstrings of the lifted leg causes a greater quantity of blood to flow into that leg, lessening the supply to the lumbar spine.

Instep gr. 1-2 st. (fig. 32) — One foot is placed backward upon some support, the knee flexed. — The passive extension of the anterior thigh draws the blood from the abdomen.

Brace st. (fig. 33.) — One foot is braced forward against the wall. — Produces passive extension of the forward calf.

Besides the above positions the trunk may assume any of the following:

Arch pos. (fig. 34.) — Body arched backward from sacrum to head.— The intervertebral substances are compressed behind, distended in front. The chest is arched forward, the inferior ribs drawn apart, abdomen flattened and viscera drawn upward. Inhalation increases and mental activity decreases.

Fall pos. (fig 12.) — Body inclined backward without being arched.— There is no change in the chest worth mentioning, but the muscles of the abdomen are in strong contraction, driving viscera upward and diminishing the quantity of blood in the abdomen. The sagittal curve of the lumbar spine straightens.

Stoop pos. (fig. 35.) — The body inclines forward with arched spine ; chest well expanded.- — The abdomen is compressed from above downward forward ; the extensors of the spine are in strong contraction, (less so than in forw. ly. and falloutst. pos.) drawing the shoulder blades backward, downward. Respiration and mental activity are increased. The posterior leg-muscles are contracting excentrically, (compare “ active movements ” below) causing a greater afflux to this region.

Lax. pos. — The body is bent forward and completely relaxed. — Respiration diminishes, the chest being compressed. The abdomen is completely relaxed, with contents falling forward, downward. The blood gravitates from the thorax into the head and abdomen.

Turn pos. (fig. 36.) — The body is rotated to one side — The oblique muscles of the abdomen contracting, viscera become lifted toward the chest, the latter having expanded toward the side to which rotation occurred.

The spinal vessels become stretched, the afflux increasing, and the spine shows a tendency to convexity toward the side to which the vertebras have been turned. Respiration is greater in the lung of that side than in the other one.

If one foot is in advance of the other and the body is rotated toward the backward foot, the position is called reverse turn (rev. turn).

Stoop falling pos. (fig. 37.) — Hands and feet on the floor, the body from head to heels forming a straight line. The hands are turned obliquely inward, and the toes are braced against the floor. This position has the same effects as prone ly. pos., (fig. 5), but requires more muscular strength for execution. The chest widens between the shoulders, and the effect of internal elevation is emphasized. The higher the hands are placed above the door, the greater the effect upon the chest, the less on the abdomen.

Side falling pos. (fig. 38.) — One hand and one foot on the floor, the body in a straight line from head to heels. — The waist muscles of the under side are in strong contraction ; the level of the hips deviates to the opposite side. Internal organs gravitate to the under side.

Side grasp, etc. (fig. 39.) — The arms are extended upward, the body bent to the side and the hands grasping a firm support. — The hip-level deviates to the upper side ; the lumbar spine is arched to that side and the thorax is forcibly expanded with the upper side in passive extension.

Finally the arms can assume the following positions :

Wing pos. — (wg., fig. 40. 1.) — Hands grasp the waist in the middle, fingers in front, thumbs behind, palms resting on the hips. The elbows are drawn slightly backward.— The hips carry the shoulders through the oblique beams formed by the arms. The inspiratory muscles are given one more fixed insertion (on the arm), the chest is raised and respiration deeper. In movements of the trunk the body below the waist is more easily isolated, and in movements of the legs the trunk can be kept steadier.

Bend pos. (fig. 40. 2.) — The elbows are bent as far as possible ; wrists and fingers bent ; hands in front of the shoulders ; arms vertical ; elbows close to the waist. — The extensors of the elbow are in passive extension. There is a slight transverse tension in the clavicular region.

Rest pos. (fig. 40. 3.) — Hands locked behind the neck ; elbows drawn well back ; head high. — The whole chest is elevated, the pectoral portion fixed. The dorsal spine is straightened, and the shoulder-blades flattened on the back and rotated outward. The relation of the axillary artery favors the afflux to the arm with consequent diminution of supply to the head. The centre of gravity of the body is raised.

Shelter pos. (fig. 40. 4.) — The hands are locked on the top of the head. — The pectoral region is less tense than in rest pos. The position is used to one side in scoliosis to draw the head to that side.

Think pos. (fig. 40. 5.)— The hands resting on the forehead, elbows back. — Is used only in sitt. res. exc. T. forward flex., to prevent the chest from contracting.

A each pos. (fig. 41. 1.) — Arms lifted forward to horizontal, palms turned toward each other.

Stretch pos. (Str., fig. 40. 6.) — Arms extended upward to vertical ; hands shoulder width apart, and palms turned toward each other. — The chest widens laterally and rises vertically with a slight transverse compression of the clavicular region. The abdomen flattens through passive extension of its muscles. The back widens, the shoulder-blades become fixed and the dorsal spine straightens. The total capacity of the chest has increased, but the tidal volume of air diminishes. The position is one of strong internal elevation with increased afflux in thorax and arms.

Hanging pos. (Hang.)=Str. pos., but the body is suspended from the hands grasping a firm support. All the muscles, with exception of those of the forearm, are in passive extension. The effect of internal elevation is emphasized : the chest is forcibly expanded in all directions, and the abdomen extremely tense. The weight of the legs acting through the sacrum stretches the spine, drawing its segments apart, and accelerating the return current from the cord. (The old-time theory that the weight of the legs dragging the abdomen down should cause downward displacement of pelvic viscera is fallacious ; for the abdomen does not carry the legs, and the tension in the abdomen is upward, toward the expanded chest.) The position is one of labored respiration, but tends to remove nervous fatigue.

When the palms face the body, the position is called under grasp hang., when the opposite way, over grasp hang.; and when the palms face each other, it is called double gr. hang.

In und. gr. the pectoral tendon is rolled up over the humerus, and the tension in the muscles is greater than in ov. gr. If one hand takes und. grasp the body rotates to the opposite side. In ov. gr. the expansion of the chest is chiefly transverse ; in und. gr. it is sagittal.

By combination with preceding positions we get cr* hang., bend hang., arch hang., etc.

Yard pos. — The arms are lifted sideways to horizontal. According to the position of the forearms we have

Yd. a pos. (fig. 41. 2.) — Elbows drawn well back and flexed as far as possible ; palms turned down ; forearms and hands in a straight line. — Effect : tension in clavicular and pectoral chest, with increased apicial respiration; straightening of dorsal spine through contraction of rhomboidei and trapezii ; shoulder-blades drawn toward the spine.

Yd. b pos. (fig. 41. 3.) — Elbows flexed at right angles ; palms turned edgewise, radial border upward.

Yd. c pos. (fig. 40. 7.) — Elbows extended ; arms and forearms in a line ; palms turned down. — Effect : lateral expansion of the chest ; straightening of axillary arteries, with consequent increase of afflux to the arms.

Yd. d pos. — Yd. c with palms turned up. — The outward rotation of the humerus increases the tension in the pectoralis major ; consequently, as compared to the preceding position, the chest has been vaulted forward. The fixation of the shoulder-blades has also increased.

Yd. e pos. (fig. 40. 8.) — The forearms are vertical, palms turned toward each other.— The shoulder-blades have been drawn farther down, and the pectoralis minor brought into extension (the coracoid process being drawn backward); the expansion of the pectoral chest (with elevation of the sternum) is very great.

When only one side is to take the position, the figure 1-2 precedes the name, for instance: 1-2 str. wg. wlk. b

st.; 1-2 Yd. c sitt.; 1-2 str., reach gr., stoop st., etc.

APovements. — Before entering into details, it might be well to state that when applying massage or Swedish movements the operator should place himself in such a position that he can accomplish the most with the least expenditure of energy; he should place the patient in the position which in passive movements will afford the utmost passivity and in active movements the proper muscular isolation.

At first but little force or duration is to be used, and a gradual increase is made only as the patient becomes accustomed to the movement.

When applying massage proper, no grease or lubricant is to be used (except in a few instances mentioned in Part II), unless the patient’s skin is dry and scaly. Always apply as large a surface of the hand as possible, as this wili increase the effect and save time. For more convenience divide the body into convenient spaces — from articulation to articulation — and finish one space before proceeding to the next. The general direction of the manipulations should be such as to favor the veunos currents — usually from the muscle’s insertion to its origin ; from the periphery of the body towards the heart.

When only one hand is employed, use the right hand for the patient’s right side, the left for the left.

Muscles that are being masseed should be in relaxation. Passive Movements : —

Friction. — Friction is applied on the bare skin ; it may be dry or wet, rectilinear or oval. The wet friction, or rubbing with lubricants, is not used by skilled masseurs except when the skin is dry and scaly or when it needs

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in part II. Synopsis :

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( (b) Irritated

Brain and cord mildly stimulated