{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T05:18:33Z","timestamp":1787980713752,"version":"build-2784847793"},"reference-count":61,"publisher":"MDPI AG","issue":"17","license":[{"start":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T00:00:00Z","timestamp":1787788800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["J. Clin. Med.","JCM"],"abstract":"<jats:p>Background\/Objectives: Aquatic therapy is widely used for children with cerebral palsy (CP), but existing approaches such as the Halliwick method focus primarily on postural control and mobility with limited active resistance exercise. The Bad Ragaz Ring Method (BRRM) integrates proprioceptive neuromuscular facilitation (PNF) diagonal patterns with closed kinetic chain (CKC) exercise in the aquatic environment, yet its direct application to children with spastic CP has rarely been examined. This pilot study compared the effects of BRRM and the Halliwick method on muscle thickness, strength, and balance in verbally cooperative children with spastic CP. Methods: Twelve children with spastic CP (Gross Motor Function Classification System [GMFCS] Levels I\u2013II, aged 5\u201318 years) were randomly allocated to the BRRM group (n = 6) or the Halliwick group (n = 6), stratified by GMFCS level. Both groups received 40-min sessions twice weekly for 8 weeks (16 sessions). Transversus abdominis (TrA) and tibialis anterior (TA) muscle thickness, ankle dorsiflexion (ADF) strength, one-leg stance (OLS) duration, and Timed Up and Go (TUG) performance were assessed at baseline and after 2, 4, 6, and 8 weeks. A linear mixed model was used to analyze group \u00d7 time interactions. Results: Significant group \u00d7 time interactions were observed for TrA thickness (p = 0.02, partial \u03b72 = 0.65), ADF strength (p &lt; 0.01, partial \u03b72 = 0.95), and OLS duration (p = 0.02, partial \u03b72 = 0.66), with larger changes in the BRRM group. No significant between-group differences were found for TA thickness or TUG performance. Conclusions: In verbally cooperative children with spastic CP at GMFCS Levels I\u2013II, BRRM was associated with larger changes than the Halliwick method in deep trunk muscle thickness, ankle dorsiflexion strength, and static balance. These preliminary findings support further investigation of BRRM in larger randomized controlled trials.<\/jats:p>","DOI":"10.3390\/jcm15176632","type":"journal-article","created":{"date-parts":[[2026,8,27]],"date-time":"2026-08-27T16:47:13Z","timestamp":1787849233000},"page":"6632","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Bad Ragaz Ring Method Versus Halliwick Method in Verbally Cooperative Children with Spastic Cerebral Palsy (GMFCS Levels I\u2013II): A Pilot Comparison Study"],"prefix":"10.3390","volume":"15","author":[{"given":"Na-Yeon","family":"Ye","sequence":"first","affiliation":[{"name":"Department of Physical Therapy, Graduate School of Life and Health, Kyungsung University, Busan 48434, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Eun-Ju","family":"Lee","sequence":"additional","affiliation":[{"name":"Department of Physical Therapy, Kyungsung University, Busan 48434, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,8,27]]},"reference":[{"key":"ref_1","first-page":"8","article-title":"A report: The definition and classification of cerebral palsy April 2006","volume":"109","author":"Rosenbaum","year":"2007","journal-title":"Dev. Med. Child Neurol. Suppl."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"1505","DOI":"10.2147\/NDT.S235165","article-title":"Cerebral palsy: Current opinions on definition, epidemiology, risk factors, classification and treatment options","volume":"16","author":"Sadowska","year":"2020","journal-title":"Neuropsychiatr. Dis. Treat."},{"key":"ref_3","first-page":"91","article-title":"Cerebral palsy: An overview","volume":"73","author":"Krigger","year":"2006","journal-title":"Am. Fam. Physician"},{"key":"ref_4","first-page":"317047","article-title":"Spasticity and its contribution to hypertonia in cerebral palsy","volume":"2015","author":"Molenaers","year":"2015","journal-title":"BioMed Res. Int."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"65","DOI":"10.1016\/j.humov.2014.11.003","article-title":"Effects of whole-body vibration on spasticity and lower extremity function in children with cerebral palsy","volume":"39","author":"Cheng","year":"2015","journal-title":"Hum. Mov. Sci."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"715","DOI":"10.1097\/01241398-198411000-00012","article-title":"Pre- and postoperative gait analysis in patients with spastic diplegia","volume":"4","author":"Gage","year":"1984","journal-title":"J. Pediatr. Orthop."},{"key":"ref_7","unstructured":"Hong, J.S. (2009). Normal Development for Cerebral Palsy Treatment, Gunja Publishing."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"534","DOI":"10.1111\/j.1469-8749.2001.tb00757.x","article-title":"Influence of two different sitting positions on postural adjustments in children with spastic diplegia","volume":"43","author":"Brogren","year":"2001","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"11","DOI":"10.12674\/ptk.2014.21.3.011","article-title":"The effects of different sitting positions on transversus abdominis thickness and sitting balance in patients with cerebral palsy","volume":"21","author":"Yoon","year":"2014","journal-title":"Phys. Ther. Korea"},{"key":"ref_10","unstructured":"Gage, J.R., Schwartz, M.H., Koop, S.E., and Novacheck, T.F. (2009). The Identification and Treatment of Gait Problems in Cerebral Palsy, John Wiley & Sons."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"1369","DOI":"10.1152\/jn.1986.55.6.1369","article-title":"Central programming of postural movements: Adaptation to altered support surface configurations","volume":"55","author":"Horak","year":"1986","journal-title":"J. Neurophysiol."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"838","DOI":"10.1111\/j.1469-8749.2005.tb01091.x","article-title":"Aquatic exercise for children with cerebral palsy","volume":"47","author":"Kelly","year":"2005","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"268","DOI":"10.1177\/1545968304270002","article-title":"The use of hydrotherapy for the management of spasticity","volume":"18","author":"Kesiktas","year":"2004","journal-title":"Neurorehabil. Neural Repair"},{"key":"ref_14","unstructured":"Cole, A.J., and Becker, B.E. (2004). Biophysiologic aspects of hydrotherapy. Comprehensive Aquatic Therapy, Butterworth-Heinemann. [2nd ed.]."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"514","DOI":"10.1016\/S0031-9406(05)60134-4","article-title":"Evidence for effective hydrotherapy","volume":"88","author":"Geytenbeek","year":"2002","journal-title":"Physiotherapy"},{"key":"ref_16","unstructured":"McMillan, J. (1977). The Halliwick Method, Association of Swimming Therapy."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"43","DOI":"10.5627\/KACE.2010.8.1.043","article-title":"The effect of balance control and vestibular function by an aquatic rotation control and the obstacle avoidance underwater with hemiplegia patients","volume":"8","author":"Kwon","year":"2010","journal-title":"J. Korean Acad. Clin. Electrophysiol."},{"key":"ref_18","unstructured":"Becker, B.E., and Cole, A.J. (2011). The Bad Ragaz Ring Method. Comprehensive Aquatic Therapy, Washington State University Press. [3rd ed.]."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"236","DOI":"10.18857\/jkpt.2019.31.4.236","article-title":"Effects of aquatic proprioceptive neuromuscular facilitation pattern exercise on balance, gait ability and depression in patients with chronic stroke","volume":"31","author":"Lee","year":"2019","journal-title":"J. Korean Soc. Phys. Ther."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"213","DOI":"10.1589\/jpts.27.213","article-title":"Effects of aquatic PNF lower extremity patterns on balance and activities of daily living in stroke patients","volume":"27","author":"Kim","year":"2015","journal-title":"J. Phys. Ther. Sci."},{"key":"ref_21","doi-asserted-by":"crossref","unstructured":"Uhre, C.F., Caspersen, I.D., Lose, C., Rackauskaite, G., Robotham, R., and Hoei-Hansen, C.E. (2024). Cognitive functioning in children and adolescents with cerebral palsy: Protocol for the Danish CPCog-Youth study. BMC Pediatr., 24.","DOI":"10.1186\/s12887-024-05305-w"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"39","DOI":"10.1016\/j.hkpj.2017.02.001","article-title":"Effects of the Bad Ragaz Ring Method on lower extremity muscle activation and balance ability in chronic stroke: A randomized controlled trial","volume":"37","author":"Cha","year":"2017","journal-title":"Hong. Kong Physiother. J."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"755","DOI":"10.3233\/BMR-171059","article-title":"A 4-week community aquatic physiotherapy program with Ai Chi or Bad Ragaz Ring Method improves disability and trunk muscle endurance in adults with chronic low back pain: A pilot study","volume":"32","author":"So","year":"2019","journal-title":"J. Back. Musculoskelet. Rehabil."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"e34457","DOI":"10.1097\/MD.0000000000034457","article-title":"Impact of Bad Ragaz ring in hot spring water on knee osteoarthritis: A prospective observational study","volume":"102","author":"Wang","year":"2023","journal-title":"Medicine"},{"key":"ref_25","unstructured":"Jung, B.K. (2007). Effects of Aquatic Rehabilitation Exercise Intervention Methods on Functional Movements in Children with Spastic Cerebral Palsy. [Ph.D. Thesis, Hanyang University]."},{"key":"ref_26","first-page":"99","article-title":"The effects on the gross motor skills of the children with hemiplegia by aquatic rehabilitation exercise","volume":"17","author":"Kim","year":"2009","journal-title":"Korean J. Growth Dev."},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"i5239","DOI":"10.1136\/bmj.i5239","article-title":"CONSORT 2010 statement: Extension to randomised pilot and feasibility trials","volume":"355","author":"Eldridge","year":"2016","journal-title":"BMJ"},{"key":"ref_28","unstructured":"National Institute of Special Education (2026, July 21). Screening Test for Children Eligible for Special Education [E-Book], Available online: http:\/\/www.nise.go.kr\/ebook\/src\/viewer\/main.php?host=main&site=20170206_114805&page=425."},{"key":"ref_29","doi-asserted-by":"crossref","unstructured":"Mentiplay, B.F., Perraton, L.G., Bower, K.J., Adair, B., Pua, Y.H., Williams, G.P., McGaw, R., and Clark, R.A. (2015). Assessment of lower limb muscle strength and power using hand-held and fixed dynamometry: A reliability and validity study. PLoS ONE, 10.","DOI":"10.1371\/journal.pone.0140822"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"136","DOI":"10.1097\/PEP.0000000000000228","article-title":"Lower extremity handheld dynamometry strength measurement in children with cerebral palsy","volume":"28","author":"Rameckers","year":"2016","journal-title":"Pediatr. Phys. Ther."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"1641","DOI":"10.1016\/j.apmr.2005.01.011","article-title":"The timed up & go test: Its reliability and association with lower-limb impairments and locomotor capacities in people with chronic stroke","volume":"86","author":"Ng","year":"2005","journal-title":"Arch. Phys. Med. Rehabil."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"135","DOI":"10.1016\/j.edurev.2010.12.001","article-title":"Eta squared and partial eta squared as measures of effect size in educational research","volume":"6","author":"Richardson","year":"2011","journal-title":"Educ. Res. Rev."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"569","DOI":"10.1186\/s40001-024-02171-1","article-title":"Aquatic therapy for spastic cerebral palsy: A scoping review","volume":"29","author":"Xiang","year":"2024","journal-title":"Eur. J. Med. Res."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"859","DOI":"10.1016\/j.pmrj.2009.05.017","article-title":"Aquatic therapy: Scientific foundations and clinical rehabilitation applications","volume":"1","author":"Becker","year":"2009","journal-title":"PM&R"},{"key":"ref_35","first-page":"247","article-title":"The scientific and clinical rationale for the integrated approach to open and closed kinetic chain rehabilitation","volume":"9","author":"Davies","year":"2000","journal-title":"Orthop. Phys. Ther. Clin. N. Am."},{"key":"ref_36","doi-asserted-by":"crossref","unstructured":"Adler, S.S., Beckers, D., and Buck, M. (2014). PNF in Practice: An Illustrated Guide, Springer. [4th ed.].","DOI":"10.1007\/978-3-642-34988-1"},{"key":"ref_37","doi-asserted-by":"crossref","first-page":"2640","DOI":"10.1097\/00007632-199611150-00014","article-title":"Inefficient muscular stabilization of the lumbar spine associated with low back pain: A motor control evaluation of transversus abdominis","volume":"21","author":"Hodges","year":"1996","journal-title":"Spine"},{"key":"ref_38","unstructured":"Richardson, C., Hodges, P.W., and Hides, J. (2004). Therapeutic Exercise for Lumbopelvic Stabilization: A Motor Control Approach for the Treatment and Prevention of Low Back Pain, Churchill Livingstone. [2nd ed.]."},{"key":"ref_39","first-page":"53","article-title":"Trunk stabilization by the Bad Ragaz method in sedentary women","volume":"82","author":"Scremim","year":"2019","journal-title":"J. Balneol. Climatol. Phys. Med."},{"key":"ref_40","first-page":"11","article-title":"The effects of PNF leg flexion patterns according to the hip joint angle on EMG activity of the trunk","volume":"9","author":"Ki","year":"2011","journal-title":"J. Korean Propriocept. Neuromuscul. Facil. Assoc."},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"67","DOI":"10.15268\/ksim.2013.1.2.067","article-title":"The effect of closed kinetic and open kinetic exercise on thickness of low back stabilization exercise using an ultrasonography imaging","volume":"1","author":"Bae","year":"2013","journal-title":"J. Korea Integr. Med."},{"key":"ref_42","unstructured":"Kabat, H., Knott, M., and Voss, D.E. (1959). Proprioceptive Neuromuscular Facilitation: Patterns and Techniques, Harper & Row."},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"8","DOI":"10.1016\/j.neulet.2017.02.022","article-title":"Diagonal movement of the upper limb produces greater adaptive plasticity than sagittal plane flexion in the shoulder","volume":"643","author":"Moreira","year":"2017","journal-title":"Neurosci. Lett."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"402","DOI":"10.2165\/00007256-199111060-00005","article-title":"Kinetic chain exercise in knee rehabilitation","volume":"11","author":"Palmitier","year":"1991","journal-title":"Sports Med."},{"key":"ref_45","first-page":"215","article-title":"The effects of PNF arm patterns on activation of leg muscles according to open and closed kinematic chains","volume":"6","author":"Park","year":"2011","journal-title":"J. Korean Soc. Phys. Med."},{"key":"ref_46","first-page":"95","article-title":"The effect of PNF arm flexion pattern on the muscle activation of lower extremity by kinematic chain positions","volume":"13","author":"Kim","year":"2015","journal-title":"J. Korean Propriocept. Neuromuscul. Facil. Assoc."},{"key":"ref_47","first-page":"49","article-title":"The effects of proprioceptive neuromuscular facilitation lower extremity pattern on muscular strength and flexibility in an aquatic environment","volume":"25","author":"Lee","year":"2013","journal-title":"J. Korean Soc. Phys. Ther."},{"key":"ref_48","first-page":"115","article-title":"Neural factors versus hypertrophy in the time course of muscle strength gain","volume":"58","author":"Moritani","year":"1979","journal-title":"Am. J. Phys. Med."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"S135","DOI":"10.1249\/00005768-198810001-00009","article-title":"Neural adaptation to resistance training","volume":"20","author":"Sale","year":"1988","journal-title":"Med. Sci. Sports Exerc."},{"key":"ref_50","doi-asserted-by":"crossref","first-page":"829","DOI":"10.2165\/00007256-200131120-00001","article-title":"Neural adaptations to resistance training: Implications for movement control","volume":"31","author":"Carroll","year":"2001","journal-title":"Sports Med."},{"key":"ref_51","doi-asserted-by":"crossref","unstructured":"Hanssen, B., Peeters, N., Beukelaer, N., Hollevoet, K., Feys, H., Bar-On, L., Molenaers, G., Van Campenhout, A., Van den Broeck, C., and Desloovere, K. (2022). Progressive resistance training for children with cerebral palsy: A randomized controlled trial evaluating the effects on muscle strength and morphology. Front. Physiol., 13.","DOI":"10.3389\/fphys.2022.911162"},{"key":"ref_52","doi-asserted-by":"crossref","first-page":"429","DOI":"10.1111\/j.1469-8749.2008.03230.x","article-title":"Increases in muscle volume after plantarflexor strength training in children with spastic cerebral palsy","volume":"51","author":"McNee","year":"2009","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_53","doi-asserted-by":"crossref","first-page":"794","DOI":"10.1111\/j.1469-8749.2010.03686.x","article-title":"Gross muscle morphology and structure in spastic cerebral palsy: A systematic review","volume":"52","author":"Barrett","year":"2010","journal-title":"Dev. Med. Child Neurol."},{"key":"ref_54","doi-asserted-by":"crossref","first-page":"933","DOI":"10.1002\/mus.24972","article-title":"Heterogeneity of muscle sizes in the lower limbs of children with cerebral palsy","volume":"53","author":"Handsfield","year":"2016","journal-title":"Muscle Nerve"},{"key":"ref_55","first-page":"13","article-title":"The influence of changes in trunk and pelvic posture during single leg standing on hip and thigh muscle activation in a pain free population","volume":"1","author":"Prior","year":"2014","journal-title":"J. Exp. Orthop."},{"key":"ref_56","doi-asserted-by":"crossref","unstructured":"Murofushi, K., Morito, T., Akuzawa, H., Oshikawa, T., and Kaneoka, K. (2024). External focus instruction using a paper balloon: Impact on trunk and lower extremity muscle activity in isometric single-leg stance for healthy males. Front. Sports Act. Living, 6.","DOI":"10.3389\/fspor.2024.1343888"},{"key":"ref_57","doi-asserted-by":"crossref","first-page":"189","DOI":"10.2165\/00007256-200636030-00001","article-title":"The role of core stability in athletic function","volume":"36","author":"Kibler","year":"2006","journal-title":"Sports Med."},{"key":"ref_58","first-page":"35","article-title":"PNF training for improving lower limb coordination in cerebral palsy: A case study in a child with spastic diplegia","volume":"6","author":"Sharma","year":"2021","journal-title":"Int. J. Sci. Healthc. Res."},{"key":"ref_59","doi-asserted-by":"crossref","first-page":"142","DOI":"10.1111\/j.1532-5415.1991.tb01616.x","article-title":"The timed \u201cUp & Go\u201d: A test of basic functional mobility for frail elderly persons","volume":"39","author":"Podsiadlo","year":"1991","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_60","doi-asserted-by":"crossref","first-page":"401","DOI":"10.1097\/PEP.0000000000000301","article-title":"Reliability and responsiveness of the Timed Up and Go test in children with cerebral palsy","volume":"28","author":"Carey","year":"2016","journal-title":"Pediatr. Phys. Ther."},{"key":"ref_61","doi-asserted-by":"crossref","first-page":"482","DOI":"10.1111\/dmcn.12325","article-title":"One-Minute Walk and modified Timed Up and Go tests in children with cerebral palsy: Performance and minimum clinically important differences","volume":"56","author":"Hassani","year":"2014","journal-title":"Dev. Med. Child Neurol."}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6632\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,29]],"date-time":"2026-08-29T04:39:54Z","timestamp":1787978394000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/17\/6632"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,8,27]]},"references-count":61,"journal-issue":{"issue":"17","published-online":{"date-parts":[[2026,9]]}},"alternative-id":["jcm15176632"],"URL":"https:\/\/doi.org\/10.3390\/jcm15176632","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,8,27]]}}}