In discussion with a fellow PT last week we came to the realization that many healthcare professionals (including ourselves) at one point or another prescribed exercises or utilized interventions that they did not fully understand. Perhaps it was a blog, a research report, a social media clip, or a mentor who explained or demonstrated a certain technique or intervention which resulted in the immediate implementation of such strategy on every patient without truly understanding its benefits and uses. After all it worked right? What we called "Blind Marriage" of a patient to a treatment. This is often a topic I bring up at the courses I teach, "What makes you do the things you do?" Are you on auto pilot? Do you do them "just because" or are we truly using objective measures to guide our entry points into therapeutic exercise. Among others, the main focus of our discussion was on rolling patterns as discussed in such courses as the SFMA, FMS and seemingly more and more blogs, etc.
Rolling, as an adult motor skill, combines the use of the upper extremities, core, and lower extremities in a coordinated manner to move from one posture to another - specifically supine to prone and vice versa. It is of many clinicians opinions that assessments of rolling may be beneficial for use with athletes who perform rotationally-biased sports such as golf, throwing, tennis, or twisting sports such as dance, gymnastics, and figure skating, particularly since athletes have "preferred" sides or movements that become overused. But can this be applied to more patients? After all isn't life, including walking, more oriented in the transverse plane? Yet it seems that most exercises and treatment plans focus on and continue to work in the sagittal plane - usually the plane in which most patients suffer from overuse injury in the first place.
Rolling is the first aspect of locomotion we learn as infants (with the exception of eye and head movement). It is how we begin to transition from postures and develop a righting response, aka "as the head goes so does the body". If this is the most basic aspect of locomotion we could argue that the older we are the better we should be at it, after all we would have many years of "practice" over a 4-6 month old. However, when asking the adult population to roll it becomes evident that there are many weaknesses, compensations and motor strategies that develop which can lead to asymmetry in higher level activities such as standing and activities of daily living. After all if we cannot control motion on the floor (a position which requires no stability through the trunk) how can we possible control movement against gravity and ground reaction forces in standing?
Before we as clinicians begin to assess rolling patterns we need to understand what the patient should demonstrate first. Think quantity BEFORE quality:
- No joint mobility restrictions (Particularly of the Cervical/Thoracic Spine)
- Screening Cervical rotation in standing or supine can rule in or out mobility deficits
- Screening Thoracic rotation in sitting or quadruped can rule in or out mobility deficits
- Ability to assume a child's pose/touch toes in long sitting
- Rules out asymmetry of hips, posterior chain/lumbar flexion restriction
- Ability to perform prone press up
- Rules out extension limitation of spine, hips/anterior chain restriction
- Ability to assume a rolling position (As pictured below)
Rolling patterns are best thought about occurring around an "X" axis. An important cue to consider is maintaining "length" through these axes. So when rolling to the Right we would cue our patient to reach through the right arm and the left leg. Consistency with the initiation of activity is also important: Reach, lift arm, look into shoulder, roll (If performing an upper extremity pattern). Or reach, lift leg across body, roll (If performing a lower extremity pattern). Whether rolling from prone to supine or supine to prone, or using the upper or lower extremity be sure to look for asymmetry NOT perfection. Can they first achieve the transition of posture? If they can, it is at that point we can dive further into qualitative assessments such as push off, breathe holding, and inability to disassociate segments.
However this is where I begin to have differing opinions then some on rolling patterns. If rolling is a developmental pattern it WILL change with age and previous experience. If you never rolled as an infant then your pattern will be very different from someone who did, as such it will be different from someone who never crawled and went straight to walking. In that sense I really think it is hard to make assumptions of what is "working or not working" - especially if the goal of the movement (change of posture) is achieved. As Gray Cook specifically says in his book Movement, "Don't look for a weak muscle to train or something to activate. If they cannot roll the pattern is broken." He goes on to say, "From this point it is a brain-body thing. We either have it or we don't."
I never taught my child, nor has anyone taught their child how to roll and move. Watching my daughter move/crawl or squat there is always an intention involved, some sort of interaction occurring with her environment and she often NEVER does the same thing, especially when it came to rolling. Sometimes she would lead with a different limb, look up/down, use momentum but the goal of the movement was achieved: Get to that toy, switch postures, or put "x" in my mouth. If I cannot coach my daughter and babies are the gold standard then why do we try to coach adults? We do not want to perfect rolling as much as we simply want it to tell us how we are programming movement initiation, if it can be performed on both sides, and if our core is reflexively activating. The core muscles are so deep that they are more likely proprioceptive messengers than something we are actually capable of strengthening or placing under volitional control (as an example I do not think about drawing in my belly to activate my transverse abdominis everytime I move) even though at times I have tried to teach patients that very thing. Since most of us lack spinal and hip mobility it is no wonder why these muscles are underactive in the first place - hence the reason for screening even prior to rolling. If an area is not moving - the muscles are not active, hence they are not used, which is often why we talk about weakness and atrophy in the first place. We have to create joints before we learn how to control them - a novel concept from Dr. Andreo Spina and his Functional Range Conditioning courses which we highly recommend.
If you are trying to correct a rolling pattern the most practical thing seems to be to give manual assist, or allow a patient to be propped which can be easily re-created and more importantly progressed. None of my athletes have ever gotten stronger on the floor, once they can roll we move on - I have never tried to make the exercise harder. We need to know why we are prescribing or trying to work with them (the same is true for all exercise!). I think of them as entry points to movement as I mentioned on Instagram (@perfectstridept), which is a phrase I stole from Mark Cheng. If a patient is struggling with a developmental position such as rolling then yes I might start treatment in "supine or prone" or more likely empower them to complete the activity and "re-wire" the movement as previously stated. Forcing any exercise onto a patient without explaining why your doing it will likely result in altered trust, poor outcomes, or more likely low compliance and that is something we can all agree on.
What is your opinion on rolling? Have you had experience as a clinician practicing or implementing something you did not fully grasp or understand?
Until next time Happy Rehabbing!
Cook, Gray. Movement: Functional Movement Systems: Screening, Assessment, and Corrective Strategies. Aptos, CA: On Target Publications, 2010. Print.
Randy R Richter, Ann F VanSant, and Roberta A Newton. Hypothesis of Developmental Sequences Description of Adult Rolling Movements and Developmental Sequences. Physical Therapy, 1989, 69: 63-71
Barbara J. Hoogenboom, PT, EdD, SCS, ATC,a Michael L. Voight, PT, DHSc, OCS, SCS, ATC,b Gray Cook, MSPT, OCS,c and Lance Gill, MS, ATCd. Using Rolling to Develop Neuromuscular Control and Coordination of the Core and Extremities of Athletes. N Am J Sports Phys Ther. 2009 May; 4(2): 70–82.