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.