In dealing with the toes the same routine should be followed; but here we find that, as a rule, it is the interphalangeal joints which the patient fails to exercise for himself and which tend to get fixed, while the metatarso-phalangeal joints often remain quite supple.

Clinical observation has shown that, for some reason which is not quite clear, forced mobilisation of the fingers and toes, when this is painful, can best be performed if we first exert tension in the long axis of the digit and then proceed with the movements of flexion, extension, rotation and lateralisation. Much pain can be obviated by observing this simple rule in technique. A possible explanation is that, by exerting tension, we unconsciously tend to produce the gliding movement that is essential to success. Particularly is this so if, while exerting tension on the digit with one hand, we employ the other in such a manner as to exert pressure in the opposite direction on the head of the proximal bone.

The aim of relaxed movement is to maintain suppleness, i.e., to prevent contractures and the formation of definite adhesions or a general matting of the soft tissues. "Little and often" should be our guide while performing such movement as can be carried out with perfect ease and freedom, each movement being almost imperceptibly greater than the preceding. As the limit of movement that has been reached on a previous occasion approaches, the frequency gradually decreases till finally any additional movement beyond the previous limit is performed only once. To secure the additional movement - no matter how slight it may be - is the chief aim in view, as a single relaxed movement through the extreme limits possible is of more value than a hundred movements through three-quarters of the possible range. At the same time we must remember that any trace of pain, of unevenness in our movement, of doubt in the patient's mind - conscious or subconscious - of insecurity, will defeat our end by calling up a protective muscular contraction.

It must not be imagined that it is possible to take hold of a limb in which a joint is apparently firmly fixed, and administer a single relaxed movement throughout the full range. The faintest trace of pressure should be exercised in two opposing directions just as if the joint were really moving; even though no trace of movement is seen at first, a minute flicker may soon be noticed. The process is continued, and presently the pressure, which a minute before failed to produce movement, will definitely do so. Gradually the range increases without any corresponding increase in pressure, and so the process is continued till the fullest possible range of relaxed movement has been performed. As the amplitude increases, light surface stroking should be performed continuously, and the movement should cease directly the full range that is possible in the circumstances has been attained. Return to the rest position must be no less gradual than the original movement away from it.

No useful purpose can be served by repeating a relaxed movement unless there is a reasonable chance that, by doing so, an increased range of movement will be secured. The proof that the limit of relaxed movement has been reached is the appearance of a trace of contraction in a muscle either to assist or resist the movement, the first trace being a minute fibrillary tremor that can often be detected by the finger when the eye still fails to note it.

Insistence on the true nature of relaxed movement and on the technique that is indispensable to its accurate administration is of paramount importance, for two gross misconceptions on both these points are frequently encountered. There is one school of thought which prohibits the use of passive movement on the ground that its administration is fraught with too much danger, preferring that active movements alone should be encouraged. The reason given is that the patient is more likely to stop short of the point at which danger is to be encountered than even an expert manipulator. The result of "passive movement," as so frequently administered in the absence of the concomitant active relaxation on the part of the patient, has been responsible for so much injury that this view rests on a rational foundation. But experience has shown that, when passive movement is performed only in the presence of complete relaxation, and only when the technique is faithfully followed and the danger signals are duly appreciated, then the prescription of relaxed movement is much more safe than that of active movement, even though the movement is performed through a far wider range. Skilled relaxed movement should be less liable to cause trouble than the regular change of a dressing.

The second misconception is that the administration of relaxed movement is performed as a substitute for the prescription of active movement. This idea has arisen from sheer ignorance, though it is an ignorance that has spread, at least in one country abroad, to high official quarters. Just as massage is used as a means by which we can secure relaxed movement, so this in turn is only a means by which we prepare the way for active movement. To call upon a patient who has had an arthroplasty of wrist a few days ago to bend or extend the joint may be to demand the impossible; whereas, after a few relaxed movements, active movement may not only be possible but may be actually a source of pleasure and comfort. But active movement through the same range is sure to be impossible, yet the increased movement secured passively will prove of the utmost service on the morrow when the way has been prepared for active movement through a wider range. Thus relaxed movement is futile unless used as a means to an end, and the end is to prepare the way to-day for active movement on the morrow - be it the immediate morrow or one more remote.

The objectives in view in administering relaxed movement might be summarised thus: -