**2. The Acral Coactivation Therapy (ACT) characteristics**

The Acral Coactivation Therapy is a physiotherapeutic method based on neurophysiology. The founder of the ACT is PhDr. Ingrid Palaščáková Špringrová Ph.D. and the basic ideas are inspired by Roswitha Brunkow's method.

Physical Therapy Based on Closed Kinematic Chain Patterns for Patients after Total Hip… http://dx.doi.org/10.5772/intechopen.76756 163

**Figure 1.** Dorsal and ventral muscle chain.

Degenerative changes of weight-bearing joints rank, without hesitation, among diseases of civilization of the musculoskeletal system. In the final stage of this disease the patients are significantly limited, in particular their movement abilities in ADL, and they suffer from strong pain which is frequently alleviated by pharmaceutical drugs. In the final stage total replacement of the afflicted joint, a hip joint in this case, is indicated in the patients. There is no doubt that postoperative care of the patients is a multi-branch matter and that rehabilitation man-

In total hip replacement the joint capsule is damaged, which results in the reduction of statesthetic and kinetic proprioception and aggravation of postural stability mainly in vertical positions and deterioration of locomotion skills. Postoperative recovery is accompanied by other problematic factors, e.g. pain caused by the surgical intervention itself or limited mobility of the operated limb due to anti-luxation regime. All the named factors reflect on the patient's

The aim of the managed postoperative rehabilitation should be not only motor recovery of the operated lower limb but also setting stereotyped physiological movement concerning ADL. The selected movement patterns, which the patient performs within the therapy, should reflect on their daily performance. The therapy should not lack a principle of similarity, i.e. the patients are provided with such movement patterns that can be integrated in activities of daily living. Many authors consider learning and mastering closed kinetic chain (CKC) activities as a factor indispensable for carrying out physiological movements in an open kinetic chain (OKC). It means that the therapy itself should always start in a position which is relatively easy for muscle chains activation, i.e. applying pressure. Closed kinetic chain movements optimize activity of the engaged muscle groups which besides other things helps reduce subjective

For the purposes of our study we chose the Acral Coactivation Therapy (ACT) that meets all the above mentioned criteria for the management of high quality rehabilitation of the patients

This study also aims at pointing out that minimum objectivization means are used in the branch of rehabilitation, which results in interpretation of movement therapy as an empirical branch lacking objective values. The patients´ subjective feedback concerning evaluation of therapy results is certainly important, however, efficacy of therapy cannot be objectively assessed without recorded data. For this reason we chose a measurement system of a force plate by Tekscan or specific questionnaires tailor-made for patients with a given diagnosis in

The Acral Coactivation Therapy is a physiotherapeutic method based on neurophysiology. The founder of the ACT is PhDr. Ingrid Palaščáková Špringrová Ph.D. and the basic ideas are

**2. The Acral Coactivation Therapy (ACT) characteristics**

aged by a qualified physiotherapist is its integral part [1, 2].

final movement expression.

162 Total Hip Replacement - An Overview

pain perception [3–7].

after total hip joint replacement.

order to make the results objective.

inspired by Roswitha Brunkow's method.

One of the basic ACT principles is applying pressure on the acral parts of extremities (both upper and lower). Applying pressure on the acral parts leads to straightening the spine and activating posture against external forces. Setting and maintaining correct posture is fundamental for creating a physiological movement programme, thus part and parcel of a movement itself. Muscle contraction proceeds in the disto-proximal direction, i.e. from the acral parts toward the trunk. Applying pressure aims at co-activation of muscle chains (see **Figure 1**). In order to improve movement pattern quality, thus better co-activation of muscle chains, manual techniques are used. Muscle tone balance of co-activated muscle chains is achieved by exteroceptive and proprioceptive inputs [7].

The ACT works on the principle of repetition of a movement pattern based on applying pressure on the acral parts. These conscious repetitive presses form the basic element of mastering the practised movement skills (motor learning). Mastering new skills by means of conscious repetition of movement patterns is one of the basic principles of the ACT. Motor learning can be simply characterized as a set of processes connected with training or experience leading to relatively constant changes of the ability to react [7, 8].

The acres are significantly represented in human brain matter so they initiate motor activity in the ACT. Unlike proximally placed muscle groups, which are significantly represented in the pre-motor brain area, the acres are located mainly in the primary motor cortical areas [7, 8–10].

During the workout patients carry out planned (intentional) movements. It is presumed that applying pressure activates the limbic system. Motivation is indispensable for movement as well. Activation of the limbic system is followed by a sensory analysis of the movement, the function of which is to draw up an ideal plan of the press. While pressing up the central nervous system (CNS) uses peripheral information and assesses quality of the press, in particular straightening the spine apparatus. If the spinal alignment is not correct (the spine is not straightened), the posture is adjusted, i.e., the angle of the acres is changed. After adjusting posture, pressure is applied again and a new movement pattern with the identical objective of straightening the spine apparatus is ingrained [7, 9, 11, 12].

The ACT therapy exploits positions from ontogenetic development of human motor activity. The early motor activity of newborns manifests itself in open kinetic chains. However, during development the postural activity caused by confrontation of the CNS and external


spine. The ACD exploits measuring instruments, e.g. PodoCam or Tekscan, thanks to which position of the acral parts of limbs can be objectively evaluated. If a pathological position of arches (of a hand or a foot) occurs, a press is not possible in the quality ensuring physiological muscle coactivation that results in straightening the spine and centration of root joints. The ACT uses also entry and exit questionnaires including, beside other things, basic case history, visual analog scale (VAS) and questions targeted at early motor development [7] (**Figure 2**).

Physical Therapy Based on Closed Kinematic Chain Patterns for Patients after Total Hip…

http://dx.doi.org/10.5772/intechopen.76756

165

Thirty patients of the Department of Orthopedics and Traumatology of Přerov Hospital (SMN Přerov), branch of the business Středomoravská nemocniční a.s., took part in the study. In order to be included in the study the patients had to meet the following criteria: they had not undergone any endoprosthesis or lower extremities surgery in the past and they were not diagnosed with any mental illness or neurological disorder of central or peripheral nervous system.

"Only" 30 patients out of total 352 applicants who had undergone total hip joint replacement

The CKC group consisting of 15 patients (7 men and 8 women) of the Department of Orthopedics and Traumatology of SMN Přerov went through postoperative rehabilitation according to the Acral Coactivation Therapy principles. The average age of the patients was

Also the OKC group included 15 patients (8 men and 7 women) of the Department of Orthopedics and Traumatology of SMN Přerov who underwent postoperative therapy, which is based mostly on open kinetic chain exercises, according to the standard procedures of SMN

The probands were divided into individual groups by means of adaptive randomization. At the beginning of the study both groups of the patients did not differ considerably in terms of the observed parameters (**Table 1**). At-entry differences of the observed groups did

The CKC group therapy followed the basic principles of the Acral Coactivation Therapy. The rehabilitation plan consisted of (on average) six 30-min workout units under the guidance of a qualified physiotherapist who supervised quality of the carried out motor patterns. The therapy itself began the second postoperative day and continued until the patients were dis-

in Přerov Hospital met these criteria. Collecting data for this study took 12 months.

**3. Methodology of the study**

**3.1. The CKC group (CKC=closed kinetic chain)**

**3.2. The OKC group (OKC=open kinetic chain)**

not show any statistical significance.

**3.3. The CKC group therapy**

Přerov. The average age of the patients was 58 ± 9.7 years.

charged and took part in subsequent rehabilitation treatment.

59 ± 13.9 years.

**Figure 2.** Evaluation of arches of the hand and the foot by means of the ACD.

stimuli increases. Movement patterns in closed kinetic chains are involved. Due to increasing demand on movement patterns the CNS is forced to choose an adequate movement pattern in terms of its economy and function [7, 13–15].

The closed kinetic chain activities provide the basis for postural presumptions of all motor activities of a child. The open kinetic chain motor activity is focused mainly on movements with a particular purpose, i.e. teleological movements [3, 4, 7, 13].

Many authors consider learning and mastering closed kinetic chain (CKC) activities as a factor indispensable for carrying out physiological movements in an open kinetic chain (OKC). It means that the therapy itself should start in a position which is relatively easy for muscle chain activation, i.e. applying pressure. Closed kinetic chain movements optimize activity of the engaged muscle groups. Correct involvement of muscle groups as well as centration of key joints in closed kinetic chains requires correct physiological position of the trunk and the limbs. The ACT method uses mainly closed kinetic chain movements since many authors consider them more functional, thus more effective in the therapy [3–5, 7].

The Acral Coactivation Diagnostics (ACD) is irreplaceable in the Acral Coactivation Therapy. It includes evaluation of position of upper and lower extremities and straightening of the spine. The ACD exploits measuring instruments, e.g. PodoCam or Tekscan, thanks to which position of the acral parts of limbs can be objectively evaluated. If a pathological position of arches (of a hand or a foot) occurs, a press is not possible in the quality ensuring physiological muscle coactivation that results in straightening the spine and centration of root joints. The ACT uses also entry and exit questionnaires including, beside other things, basic case history, visual analog scale (VAS) and questions targeted at early motor development [7] (**Figure 2**).
