clinical commentary najspt using rolling to …...mental pattern of rolling with techniques derived...

ABSTRACT

Rolling is a movement pattern seldom used by physicaltherapists for assessment and intervention with adultclientele with normal neurologic function. Rolling, as anadult motor skill, combines the use of the upper extremi-ties, core, and lower extremities in a coordinated mannerto move from one posture to another. Rolling is accom-plished from prone to supine and supine to prone,although the method by which it is performed variesamong adults. Assessment of rolling for both the ability tocomplete the task and bilateral symmetry may be benefi-cial for use with athletes who perform rotationally-biasedsports such as golf, throwing, tennis, and twisting sportssuch as dance, gymnastics, and figure skating.Additionally, when used as intervention techniques, therolling patterns have the ability to affect dysfunction ofthe upper quarter, core, and lower quarter. By applyingproprioceptive neuromuscular facilitation (PNF) princi-ples, the therapist may assist patients and clients who areunable to complete a rolling pattern. Examples given inthe article include distraction/elongation, compression,and manual contacts to facilitate proper rolling. The com-bined experience of the four authors is used to describe

techniques for testing, assessment, and treatment ofdysfunction, using case examples that incorporate rolling.The authors assert that therapeutic use of the develop-mental pattern of rolling with techniques derived fromPNF is a hallmark in rehabilitation of patients with neuro-logic dysfunction, but can be creatively and effectivelyutilized in musculoskeletal rehabilitation.

CORRESPONDENCEBarbara HoogenboomGrand Valley State UniversitySchool of Physical TherapyCook-DeVos Center for Health Sciences301 Michigan NE, Room 266 Grand Rapids, MI 49503Email: [email protected]

CLINICAL COMMENTARY

Using Rolling to Develop Neuromuscular

Control and Coordination of the Core and

Extremities of Athletes

Barbara J. Hoogenboom, PT, EdD, SCS, ATCa

Michael L. Voight, PT, DHSc, OCS, SCS, ATCb

Gray Cook, MSPT, OCSc

Lance Gill, MS, ATCd

a Grand Valley State UniversityGrand Rapids, MI

b Belmont UniversityNashville, TN

c Averett UniversityDanville, VA

d Titleist Performance InstituteOceanside, CA

North American Journal of Sports Physical Therapy | Volume 4, Number 2 | May 2009 | Page 70

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INTRODUCTIONAs humans develop from small, relatively immobileinfants at birth into fully developed, amazingly mobileadults, they pass through many predictable patterns ofbody control and movement. In motor development,these patterns can be described as both reflexive andintentional movements, both of which serve as develop-mental milestones.1 These concepts are familiar to thetherapists who treat pediatric clientele with neurodevel-opmental diagnoses. Many therapists who treat adultpatients and clients may fail to remember the principlesof developmental postures and their sequence. In settingswhere patients with orthopedic and sports injuries pre-dominate, the therapist can easily become focused on dis-crete local problems (or impairments) and miss the glob-al effects (functional limitations) these problems create. Inmature movement strategies/motor programs, the pres-ence of developmental skills are not readily identifiable,but may in fact be a part of movement. An example of thisprinciple is the movement of rolling. Although mostadults do not consider the act of rolling to be an importantpart of complex movement skills, rolling may be a novelmethod to assess for, and intervene with, inefficient move-ments that involve rotation of the trunk and body, weightshifting in the lower body, and coordinated movements ofthe head, neck, and upper body.

The developmental milestones through which humansprogress are related to developmental postures.2 Humaninfants are initially able to exist in sidelying, prone, orsupine and are unable to move between these positionswithout assistance. These postures offer the infant thegreatest amount of support/contact from the surface, andare the beginning of the developmental sequence and thedevelopment of motor control. As the infant matures,head control is achieved by four months of age leading tothe ability to transition from one posture to the other, alsoknown as rolling.2 Rolling is defined as “moving fromsupine to prone or from prone to supine position” 1 andinvolves some aspect of axial rotation. Rotational move-ments are described as a form of a righting reactionbecause, as the head rotates, the remainder of the bodytwists or rotates to become realigned with the head.1,2

Rolling can be initiated either by the upper extremity orthe lower extremity, each pattern producing the samefunctional outcome: movement from prone to supine orsupine to prone.


The authors propose four variations of rolling which canbe used to accomplish movement from prone to supineand supine to prone. Movement from the start position(either supine or prone) can be accomplished by usingone upper extremity or one lower extremity to initiatemovement. These four variations will be described indetail in the assessment section of this article. Each of thefour variations is performed first with one upper extremi-ty or lower extremity and then with the contralateralupper extremity or lower extremity in order to assess forsymmetry, control, quality, and the ability to complete theroll.

When using rolling as an intervention, the upper extrem-ity patterns make use of the fact that movements of theneck facilitate trunk motions3-5 or stated more simply,“where the eyes, head, and neck go, the trunk will follow.”By applying the proprioceptive neuromuscular facilitation(PNF) principle of irradiation (defined later in this article),the following can be utilized therapeutically: neck flexionfacilitates trunk flexion, neck extension facilitates trunkextension, and full neck rotation facilitates lateral flexionof the trunk.3,4 Neck patterns can even be used to achieveirradiation into distal parts of the body, for example, neckextension can facilitate extension and abduction of thehip.3,4

Typically an infant can perform basic log rolling, with thebody moving as a unit at four to five months of age, typi-cally moving from prone to supine at four months of age,followed by moving from supine to prone (although theorder varies in infants). Finally, segmental or “automatic”rolling occurs at six to eight months of age, which involvesdeliberate, organized progressive rotation of segments ofthe body.1 Some children actually combine multiple rolls,performed consecutively, as a method of locomotionacross a floor. Adults use a form of rolling that is segmen-tal, but has also been described as “deliberate.” Adultrolling described by Richter and colleagues6 found thatnormal adults use a variety of movement patterns to roll,most likely related to the flexibility and strength (or lackthereof) in the individual performing the movement.Several of the movement patterns described by Richter etal,6 were similar to the original patterns of rolling move-ment described by Voss et al4 in their original text on PNF.The variability of movement patterns used by adults toroll gives therapists multiple options to use when trainingor retraining adults in the task of rolling.6


Although the skill of rolling is an early developmental taskthat continues to be used throughout a lifetime, rollingmay become altered or uncoordinated due to muscularweakness, stiffness or tightness of structures, or lack ofstability in the core muscles. Several potential dysfunc-tions and assessments for these problems that affectrolling in adults will be addressed in detail in a subsequentsection. Adults often use inefficient strategies to completethe task of rolling, some of which are compensatory anddisorganized, serving to perpetuate the dysfunction(s)associated with the movement. The authors assert thatwhen rolling is asymmetrical, the client demonstrates abreak in normal patterning (symmetry), which can helpthe clinician visualize the interplay between the local(impairment level) problem and the global effect (func-tional limitation).

Developmentally important positions, such as kneelingand quadruped, are useful to the breakdown of complexmotor patterns.7 While these two postures are used com-monly by the sports physical therapist in interventions fororthopedic pathology by addressing muscular strength,core control, balance, and coordination, rolling is not.Although this article deals with the movement of rolling,these other postures are still important to the examinationand training of athletes whose sports involve the use ofrotation (tennis, golf, swimming, baseball).

Once a human is upright for motor tasks, rolling becomesless important for movement or access to the environ-ment and, thus, is used less. Adults generally only userolling to transition from prone to supine, as if turningover in bed. Most adults do not consciously make use ofrolling in everyday mobility tasks, exercise routines, or asa part of more difficult rotational movements/skills.Rolling is a good choice for assessment and trainingbecause rolling is not commonly practiced. Therefore,compensation and incorrect performance can be easilyobserved. Rolling can be used as both a functional activityand an exercise for the entire body.3 It is the assertion ofthe authors of this article that many sports physical thera-pists forget or ignore rolling as an assessment and rehabil-itative technique.

The Relationship of Rolling to RotationFrequently, even highly functional patients demonstratedysfunctional sequencing or poor coordination duringactive rotational movements that are part of their func-tional demands/tasks. Rolling patterns can easily illumi-

nate rotational movement pattern dysfunction, especiallywhen comparing between sides. It should be noted thatthe movement dysfunction is usually a problem withsequence and stabilization rather than a deficiency instrength of a prime mover. Theoretically, a person shouldbe able to roll (rotate) equally easily to either the right orthe left. Frequently athletes have a typical pattern orhabitual “good side” for rotational activities. Consider thegymnast, thrower, or golfer; each of whom rotates to thesame direction repeatedly, according to the demands oftheir sport. Examples include the twisting and spinningmotions used during tumbling, the unidirectional rotationused during the throwing motion, and the same-side rota-tional motions that comprise the golf swing. In each ofthese examples, the athlete has a preferential side, and apattern of rotation (e.g. always to the left in a right hand-ed thrower or golfer) which is typical for the performanceof their sport, and may have asymmetry in rolling to theopposite side.

The Relationship of Rolling to Other Movement TasksAlthough described in relationship to rotational tasks andmovements, rolling is not only related to rotational tasks.The rolling patterns can function as a basic assessment ofthe ability to shift weight, cross midline, and coordinatemovements of the extremities and the core. Abnormalitiesof the rolling patterns frequently expose proximal to distaland distal to proximal sequencing errors or proprioceptiveinefficiency that may present during general motor tasks.Finally, many adults have lost the ability to capture thepower or utilize the innate relationship of the head, neck,and shoulders to positively affect coordinated movements.

Rolling as AssessmentAs indicated previously, many high level tasks performedare often in a prescribed and unilateral motion. Eventhough a task or sport specific skill may be demonstratedby patients and clients at high levels, the fundamentals ofthe task of rolling should not be altered when comparedbilaterally. Whether rolling is initiated by the upper orlower extremities, the state of optimal muscle recruit-ment, coordination, and function is reached whensymmetry is present. For example, a right handed throw-er should be able to complete all four variations of rolling,with equal ease regardless of direction. If during assess-ment the different rolling tasks are not symmetrical andequal, the clinician should consider that foundational


mobility or neuromuscular coordination may be compro-mised.

Because rolling precedes other locomotion activities in thedevelopmental postures of infants and children, rollingcan be used as a discriminatory test that uses regression toa more basic developmental task to locate and identifydysfunction in the form of poor coordination and stabilityof rotation. Without a doubt, mobility, core stability, con-trolled mobility, and properly sequenced loading of thesegments of the body are required to perform these rollingtests correctly. Assessment of necessary precursor abili-ties should always precede common measurements offunction which include strength, endurance, balance, gait,etc. Simply stated, movement quality appraisal shouldprecede movement quantity appraisal.

Patients or clientswho are being askedto perform the rollingtests must have suffi-cient trunk, upperextremity, and lowerextremity mobility.An example of thisprinciple is the use ofthe seated trunk rota-tion test that isdesigned to identifyhow much rotationalmobility is present inthe thoracolumbarspine. To pass thisscreen the patientmust demonstratesufficient mobility toensure greater than30 degrees of rotationbilaterally (Figure 1).

If a patient or clientcannot roll, it maysimply be due to amobility impairmentin the thoracic spine.A mobility problemshould not beaddressed by a stabil-ity exercise. It is

imperative that potentially contributory mobility prob-lems are addressed prior to assessing the functional rollingmotions. Figures 2a and 2b depict an example interven-tion for a patient or client who fails the rotation screen sec-ondary to diminished thoracic rotation. Note how theanteriorly tilted position of the pelvis in the quadrupedposition locks the lumbar spine in extension which allowsfor a targeted stretch of the thoracic spine. Once the rota-tion motion is equal bilaterally (patient can pass the rota-tion screen test) or has significantly progressed towardappropriate mobility, interventions for assisted rollingmay begin. In this case, rolling may be viewed as anadjunct exercise to encourage mobility.

Rolling tasks occur about diagonal axes.3 Figures 3a and 3bdepict the two diagonals that comprise the axes of move-ment used by humans during the task of rolling. Thesegraphics also demonstrate the starting positions for supineto prone rolling and prone to supine rolling movements,respectively. Typically, the axis for rolling does notinvolve the extremity that leads the movement.

Several neurophysiologic principles of PNF can be appliedto the assessment and enhancement of the task of rolling.During treatment, the therapist may use visual, verbal,and tactile techniques to cue and resist the neck, trunk, orextremities to promote a maximal response from musclegroups used during rolling.3-5 These cues serve to enhancethe quality of the skilled motion and to move the patienttoward functional gains. Verbal cues will be describedwith each variant of rolling, as well as suggestions for visu-al and tactile cues to enhance overflow or irradiation.

Overflow or irradiation can be defined as the increase infacilitation that alters the excitatory threshold level at theanterior horn cell.8 By facilitating the stronger portions ofa pattern, the motor unit activation of the involved orweaker portions is enhanced, thereby strengthening theresponse of the involved segments.9 Normally, overflowoccurs into those muscles that offer synergistic support forthe prime movers used during a motor task. Overflow canoccur from proximal to distal or vice versa. The increasedperipheral feedback that occurs when more than theinvolved segment participates in the activity mayenhance the ability to respond and to learn the motortask.9

For example, when using tubing for axis elongationfacilitation, the patient’s upper extremity or lower extrem-ity is placed and held in a traction or elongated position,

Figure 1. Seated rotation test usedto identify thoracolumbar rotation-al mobility. Begin in a seated posi-tion with knees and feet together,body upright and erect, armscrossed across the chest, whilemaintaining a gaze to the front.Ask patient to rotate the trunk tothe right and to the left as far aspossible. Examine for asymmetryby measuring with a goniometer.Normal is 30º bilaterally.


Figure 2A. Example mobility technique for lower thoracic rotation, note pelvic position to ensure locking of lumbar segments. Therapist can use an interlocked arm to assist patient into rotation.

Figure 2B. Example mobility technique for upperthoracic rotation. Again,note pelvic position to ensurelocking of lumbar segments.

Figure 3A. (Left)Diagonal axes of rotationshown in supine, andbeginning position forsupine to prone rolling.

Figure 3B. (Right)Diagonal axes of rotationshown in prone, andbeginning position forprone to supine rolling.


thereby pre-activating the phasic Type II receptors and pro-moting stretching of the synergistic trunk musculature.These elongated muscles provide a stable base upon whichrolling occurs and utilize multiple segments to enhancemotor learning. Conversely, joint approximation by com-pression of joint surfaces stimulates the static Type I recep-tors that facilitate the postural extensors and stabilizers.9

This technique, applied to the upper extremity or lowerextremity which are a part of the rolling axis, can be usedto improve the performance of a person having difficultywith the rolling task.

Four different rolling tasks are described. Each descriptionwill include the axis of rotation, specific instructions forperformance of the test, verbal cues, and potential tactile orresistance cues.

Supine to Prone Leading with the Upper Body This pattern isolates shoulder flexion/horizontal adduc-tion, which leads to trunk flexion/rotation, culminating inpelvic rotation/hip flexion that allows for completion of theroll. The patient lies supine with legs extended and slight-ly abducted; arms flexed overhead, also slightly abducted.Head is in neutral rotation (Refer to Figure 3a for the startposition). When rolling to the left, the axis of rotation isformed by the upper extremity of theside that the individual is rollingtowards and the lower extremity of theside the individual is rolling from.

Ask patient to actively roll his or herbody to the prone position startingwith his or her left arm by reachingobliquely across body.

• The patient’s head and neck shouldflex and turn toward the right axilla.Remember, the head and neck areconnected to the core, thereforewhere the head and neck lead thebody will follow. (Figure 4) Facilitationof rolling from supine to prone fromthe cranial end of the body involvesactivation of the flexor chain: theneck, trunk, and hip flexors sequen-tially.

• The lower body should notcontribute to the roll. Cue the patientto resist the temptation to push withthe left lower extremity.

• The therapist can also give visual reference by placing hisor her body on the side toward which the rotation is occur-ring, in this case, on the right side.

• Evaluate for quality, ease of movement, synergy, andability to complete the roll.

• Repeat to the opposite side, leading with the right arm.Evaluate carefully for symmetry between the rolling to theright and rolling to the left.

Verbal cueing:

• Look with the eyes and head

• Reach arm across body and turn head into shoulder

• Elongate the axis:- Make the axis (left) leg long – “reach”- Make the axis (right) arm long – “reach”- Stay long through the axis- Verbal sequence: “Reach-lift arm-look into shoulder-roll”

NOTE: The following techniques are not used during theinitial assessment, rather, may be used when dysfunction-al patterns of movement are identified. These facilitorytechniques are intended to be used for short term assis-tance and then eliminated as soon as technique isimproved and perfected.

Tactile/resistance cueing to assist rolling:

• Use proximal manual contacts tofacilitate protraction of the scapula bythe therapist positioning him or herselfon the side toward which the patient isrolling, while cueing the patient to“pull your shoulder down toward youropposite hip.”

• Use distal manual contacts to approx-imate the upper extremity of the axisarm to facilitate elongation of the axis.For example, in an upper body drivenroll led with the left upper extremity,offer manual approximation throughthe right upper extremity at thewrist/hand to encourage the responseof elongation.

• Use tubing to cue the patient/clientto elongate the axis either through thelower or upper body. For example, inan upper body driven roll led with theleft upper extremity, place tubing on

Figure 4. Intermediate position forrolling supine to prone, leading with leftupper extremity.

North American Journal of Sports Physical Therapy | Volume 4, Number 2 | May 2009 | 6

either the right distal upper extremity anchored lower onthe body or on the left distal lower extremity to encouragethe response of elongation.

Prone to Supine Leading with Upper BodyThis pattern begins with isolated shoulder flexion, leadingto trunk extension/rotation, culminating in pelvic rotationthat allows for the completion of the roll. Patient lies pronewith legs extended and slightly abducted; arms flexed over-head, also slightly abducted as depict-ed in Figure 3b. When rolling towardthe left side of the body, the axis ofrotation is formed by the upperextremity of the side that the individ-ual is rolling towards and the lowerextremity of the side the individual isrolling from, or in this case the leftupper extremity and right lowerextremity, respectively.

Ask patient to actively roll his or herbody to the supine position startingwith his or her left arm only. Thehead should extend and rotate towardthe opposite side. Remember, the headand neck are connected to the core,therefore where the head and necklead the body will follow.

• During this form of the test, thelower body should not contribute tothe roll.

• The body will always follow thehead. Facilitation of rolling from proneto supine from the cranial end of thebody, involves activation of the exten-sor chain: the neck, trunk, and hipextensors, sequentially.

• The therapist can also givevisual/auditory reference by placinghis or her body on the side towardwhich the rotation is occurring, in thiscase the left side. (Figure 5 demon-strates the therapist giving a cue whileplaced on the right side.)

• Evaluate for quality, ease of move-ment, synergy, and ability to completethe roll.

• Repeat to the opposite side leading with the right arm.Evaluate carefully for symmetry between rolling to theright and rolling to the left.

Verbal cueing:• Lift arm and look up and over the opposite shoulder. • Elongate the axis (see tactile cues below):

- Make the axis (right) leg long – “reach”- Make the axis (left) arm long – “reach”

- Stay long through the axis- Verbal sequence: “Reach-lift arm-lookover shoulder-roll”

NOTE: The following techniques arenot used during the initial assessment,rather, these may be used when dys-functional patterns of movement areidentified. These facilitory techniquesare intended to be used for short termassistance and then eliminated as soonas the technique is improved and per-fected.

Tactile/resistance cueing to assist rolling:• Use proximal manual contacts tofacilitate retraction of the scapula bythe therapist positioning him or her-self on the side toward which thepatient is rolling, using the verbal cue“lift and pull your shoulder bladedown and in.” (Figure 6)

• Use manual contacts to approximatethe upper extremity of the axis arm tofacilitate elongation of the axis. Forexample, in an upper body driven rollled with the right upper extremity,offer manual approximation throughthe left upper extremity to encouragethe response of elongation.

• Use tubing to cue the patient/clientto elongate the axis either through thelower or upper body. For example, inan upper body driven roll led with theright upper extremity, place tubing oneither the left distal upper extremityanchored lower on the body or on theright distal lower extremity to encour-age the response of elongation.

Figure 5. Intermediate position forrolling prone to supine, leading with leftupper extremity, with therapist placed invisual field for cueing, also using audito-ry cueing by snapping fingers.

Figure 6. Intermediate position forrolling prone to supine, leading with rightupper extremity, using manual contacton scapula for facilitation.


Supine to Prone Leading with the Lower Body This pattern isolates hip flexion, which leads to pelvicrotation/lumbar flexion, and culminates in trunkflexion/rotation to allow for completion of the roll. Thepatient lies supine on the ground with his or her legsextended and his or her arms flexed over his or her headon the ground. The head is in neutral rotation. (Refer toFigure 3a for start position.) Like the upper extremity initi-ated supine to prone roll, this task utilizes a flexed postureand is often easier than the prone to supine task. Whenrolling to the left, the axis of rotation is formed by the lowerextremity of the side that the individual is rolling towardsand the upper extremity of the side the individual is rollingfrom, or in this case the left lower extremity and rightupper extremity, respectively.

Ask patient to actively roll his or her body to the proneposition starting with the right leg only.

• Lead with right hip flexion followed by the adduction ofthe extended leg.

• The upper body should and not contribute to the roll.During lower body initiated rolls, the head and neck playless of a role, and are therefore not cued.


• Repeat to the opposite side, leading with the left lowerextremity. Evaluate carefully for symmetry betweenrolling to the right and rolling to the left.

Verbal cueing:• Elongate the axis:

- Make the axis (right) leg long – “reach”- Make the axis (left) arm long – “reach”- Stay long through the axis- Verbal sequence: “Reach – lift leg across body – roll”

NOTE: The following techniques are not used during theinitial assessment, rather, may be used when dysfunction-al patterns of movement are identified. These facilitorytechniques are intended to be used for short term assis-tance and then eliminated as soon as technique isimproved and perfected.

Tactile/resistance cueing to assist rolling:• Use proximal manual contacts to facilitate protraction ofthe pelvis by the therapist positioning him or herself on theside toward which the patient is rolling, using the verbalcue “pull your pelvis up and forward.”

• Use distal manual contacts to approximate the lowerextremity of the axis leg to facilitate elongation of the axis.For example, in a lower body driven roll led with the rightlower extremity, offer manual approximation through thesole of the foot to encourage the response of elongation.

• Use tubing to cue the patient to elongate the axis eitherthrough the lower body or through the upper body. Forexample, in a lower body driven roll led with the rightlower extremity, place tubing on either the left distallower extremity anchored higher on the body or on theright distal upper extremity to encourage the response ofelongation.

Prone to Supine Leading with the Lower BodyThis pattern begins with hip extension which initiates theroll and leads to pelvic rotation/lumbar extension and cul-minates in trunk extension/rotation, completing the roll.This pattern helps to identify weak gluteal muscles by iso-lating hip extension/lateral rotation. Patient lies pronewith legs extended and slightly abducted; arms flexedoverhead, also slightly abducted. Head is in neutral rota-tion. (Refer again to Figure 3b.) When rolling toward theleft side of the body the axis of rotation is formed by thelower extremity of the side that the individual is rollingtoward and the upper extremity of the side the individualis rolling from, or in this case the left lower extremity andright upper extremity, respectively.

Ask patient to actively roll his or her body to the supineposition starting with the right leg only.

• Attempt to perform with a fully extended lower extrem-ity, but if unable to complete the roll, the patient may flexthe knee if needed in order to initiate the roll. Cue toextend at the hip and then at the knee.

• During this form of the test, the upper body should notcontribute to the roll. During lower body initiated rolls thehead and neck play less of a role, and are therefore notcued.


• Repeat to the opposite side, leading with the left lowerextremity. Evaluate carefully for symmetry betweenrolling to the right and rolling to the left.

Verbal cueing:• Elongate the axis:

- Make the axis (right) leg long – “reach”

- Make the axis (left) arm long – “reach”- Stay long through the axis- Verbal sequence: “Reach – lift leg across body – roll”

NOTE: The following techniques are not used during theinitial assessment; rather, these may be used when dys-functional patterns of movement are identified. Thesefacilitory techniques are intended to be used for short termassistance and then eliminated as soon as the technique isimproved and perfected.

Tactile/resistance cueing to assist rolling:

• Use proximal manual contacts to facilitate retraction ofthe pelvis by the therapist positioning him or herself on theside toward which the patient is rolling using the verbal cue“lift and pull your pelvis back” (Figure 7)

• Use distal manual contacts to approximate the lowerextremity of the axis leg to facilitate elongation of the axis.For example, in a lower body driven roll led with the rightlower extremity, offer manual approx-imation through the sole of the foot toencourage the response of elongation.

• Use tubing to cue the patient to elon-gate the axis either through the lowerbody or through the upper body. Forexample, in a lower body driven rollled with the right lower extremity,place tubing on either the left distallower extremity anchored higher onthe body or on the right distal upperextremity to encourage the responseof elongation.

Dysfunctional Patterns of Rollingand Contributory FactorsKnowledge of typical functionalmovement patterns of the bodyenables the therapist to identify dys-functional patterns of motion. As each of the four describedrolling tasks are performed, the therapist should carefullyobserve and document the qualitative differences betweenupper and lower body initiated rolls and side to side differ-ences. Outcomes that display less than optimal perform-ance include: inability to complete the roll, use of inertia orswinging of the extremities to complete the roll, use ofextremities not being tested during the roll, and pushing orbracing with the opposite lower or upper extremity in orderto artificially supply stability during the attempt. Many

contributory factors may play a role in a patient’s ability orinability to roll in a smooth, coordinated, and controlledmanner. These factors include: strength of the pelvis andscapula (proximal links) and the extremities, length/stiff-ness of important muscle groups, and insufficient coordina-tion of all the moving parts of the system.4,9 The ideal is forthe individual to be able to roll easily and symmetricallywhile adjusting to various demands.

Patients with many diagnoses may demonstrate difficultywith attempts to roll. Some examples of these diagnosesinclude: poor neuromuscular control and stability of thecore muscles, low back pain of multiple origins, sacro-iliacpain/dysfunction, and various upper and lower extremitymobility or stability problems. The following examplesillustrate the power of rolling as an assessment strategy.

Case Example-Upper Extremity Consider the pitcher has undergone a right rotator cuff

repair and has progressed through therehabilitation process, as prescribed bythe therapist, regaining full activerange of motion in all planes, manualmuscle test scores for the muscles ofthe shoulder complex of 4+/5 or bet-ter, and functional abilities to performall activities of daily living with 10pounds at shoulder height withoutdysfunctional movement. He still com-plains of “fatigue and lack ofendurance” with the initiation of areturn to throwing program. Whenassessed using the rolling tasks, thepatient was able to roll from supine toprone leading with each of the extrem-ities, but was unable to roll from proneto supine when leading with the rightupper extremity.

Case Example-Lower ExtremityConsider the recreational soccer player who hasundergone a partial medial menisectomy on the left knee.The patient has progressed well throughout the rehabilita-tion process and has full active and passive range ofmotion, normal manual muscle test scores of the lowerquarter, and knee flexion/extension isokinetic scores thatdemonstrate less than 10% difference in peak torque whencompared bilaterally to the uninjured lower extremity.


Figure 7. Intermediate position forrolling prone to supine, leading with rightlower extremity, using manual contact tothe pelvis for facilitation.

The patient can perform a full, painfree functional squatand can jump and land without difficulty (single limb hopfor a given distance is within 90% of uninvolved lowerextremity). Functionally, this soccer player still has difficul-ty with performance of cutting and lateral movements.When assessed using the rolling tasks, the patient was ableto perform all upper extremity initiated rolls without diffi-culty. Lower extremity initiatedrolls by the right lower extremitywere also achieved without diffi-culty. He was unable to roll fromsupine to prone to the right (initi-ating movement with the leftlower extremity) and also wasunable to roll prone to supine tothe right (also initiating with theleft lower extremity). The patienthad difficulty crossing the mid-line of the body with the leftlower extremity initiated rollingtask.

Although impairments had beenaddressed and quantitative per-formance tests were essentiallysymmetrical to the uninvolvedextremity, qualitative perform-ance assessment of rollingrevealed a deficiency in each ofthe two case examples. Thisassessment indicated the inabilityto effectively coordinate, time,and sequence the movements ofthe extremities and the trunk dur-ing a lower level developmentaltask. Normal impairment meas-ures and quantitative functionalmeasures do not necessarilyimply normal function.

ROLLING AS INTERVENTIONRolling has thus far beendescribed as an assessment. Afterthe assessment is complete, thetherapist must draw conclusionsabout bilateral symmetry androlling ability, as well as possiblecauses for less-than-optimal

rolling. Multiple interventions exist that can assist thepatient or client to enhance the ability to roll, and therebyenhance core stability, rotational function, and overallfunction of the upper and lower extremities. Many alter-nate exercise postures and modifications to the task ofrolling exist, each attempting to begin to elicit core controlof the scapula and pelvis or diminish the demands of the

task.

The quadruped posture can be usedto recruit and facilitate underuti-lized proximal musculature such asthe scapular stabilizers and glutealmuscles (Figures 8 and 9). Anotherexample that could be used for apatient who is unable to completethe roll is the use of assistance inthe form of a rolled airex mat orfoam roller behind the trunk orpelvis to place him or her in an eas-ier starting position when rollingfrom supine to prone (Figure 10),referred to as assisted or facilitatedrolling.

Recall the patient that underwent arotator cuff repair who demonstrat-ed the inability to roll from prone tosupine leading with the involvedupper extremity. For this patient,an exercise progression mightinclude the following:

• Quadruped position stabilizationfor the scapula (Figure 8)

• Resisted rolling with manual con-tact on the scapula (Figure 6)

• Axis elongation using manualcontact or tubing applied to theuninvolved upper extremity

Early exercises encourage the useof the scapula in a facilitated, stabi-lized position, and then subsequentexercises progress to the recruit-ment of the scapular primemovers, which serve to facilitatecoordinated upper extremity andtrunk movement as well as to pro-


Figure 8. Quadruped with tubing to facilitatescapular control/stability.

Figure 9. Quadruped with tubing to facilitatecore/scapular/pelvic stability.

Figure 10. Assisted rolling supine to prone, leftupper extremity led. Note the use of a half foamroll behind the trunk for assistance.

vide opportunities to cross the midline. Although thepatient in this case had all of their impairments addressed(range of motion, manual muscle test, etc.), the qualitativeassessment of the task of rolling revealed an alteration oftiming and coordination between the involved upperextremity and the trunk. This examination of a lower leveldevelopmental task revealed another area for potentialintervention. Rolling was an effective low-level functionalintervention because of its requi-site demands of timing and reflexstabilization between the extremi-ties and trunk which serve to“reset” the timing and coordinationnecessary for higher level func-tion, such as throwing.

Now return to the patient whounderwent the partial medialmenisectomy of the left knee andwas unable to roll from supine toprone or prone to supine whenleading with the involved lowerextremity. This patient might use asimilar exercise progression,including the following:

• Bridging exercises for stabiliza-tion of the pelvis/gluteals, using atubing loop for abduction resisi-tance

• Quadruped stabilization ofpelvis/gluteals, core, and scapula,using tubing (Figure 9)

• Hip abduction with core stabi-lization might follow to addressboth proximal lower extremitystrength and stability (throughgluteus medius and minimus muscles) and core stability(Figure 11) or the side plank with abduction for same (Figure12)

• Proximal stabilization/manual contacts during rolling viapelvic resistance (Figure 7), (Note that this principle couldalso be applied to the supine to prone task by utilizing ante-rior pelvic contact.)

• The rolling task itself, facilitated with tubing in the formof the Starfish 1 drill for supine to prone (Figures 13A & B)and the Starfish 2 drill (Figures 14A & B)

Early exercises encourage the use of the pelvic and coremuscles in a facilitated, stabilized position, and thenprogress to the recruitment of the movements of thehip/pelvis to facilitate coordinated lower extremity andtrunk movement, as well as to provide opportunities tocross the midline. Again, although the patient in this casehad all of their impairments addressed (range of motion,manual muscle test, isokinetic scores, etc.), the qualitative

assessment of the task of rollingrevealed an alteration of timingand coordination between theinvolved lower extremity and thetrunk. This examination of a lowerlevel developmental task revealedanother area for potential inter-vention. Rolling was an effectivelow-level functional interventionbecause of its requisite demandsof timing and reflex stabilizationbetween the extremities andtrunk. The task of rolling serves to“reset” the timing and coordina-tion necessary for higher levelfunction, such as lower extremitymovements that cross the midlineand require high proprioceptiveacuity.

In the two case examples, rollingwas being used for its impact onneuromuscular time and coordi-nation of movement, as well asrecruitment of important musclesof the proximal extremities andcore. It is important that thepatient be instructed to performthe tasks associated with rolling

with precision and perfection. When attempting to deter-mine dosage for the previously described exercises, it isimportant to dose below the threshold of the inappropriatemotor pattern domination. If the patient has difficulty withmore than one rolling pattern, begin with the componentparts of the roll that are most dysfunctional. Select an exer-cise that is achievable for the patient (may be a lower devel-opmental posture or assisted rolling exercise) and select thenumber of repetitions based upon the ability to perform therepititions with precision and accuracy. A simple pneu-monic for this is “PMRS”, Position, Movement, Resistance,


Figure 11. Sidelying hip abduction with coreresistance. Note that tube is anchored to bottomlower extremity and also anchored at top of doorheight. During the exercise the trunk is held sta-bilized in sidelying while upper extremities per-form the lift pattern.

Figure 12. Side plank with lower extremityabduction.


Speed. Begin the intervention bychoosing the position in which thepatient can successfully challengemuscles that are weak/dysfunction-al in movements that address thedysfunction. This movement maybe isolated (scapula, pelvis, or limb)or a functional movement such asrolling. It is entirely possible thatresistance, the next element, couldbe minimal to none, but subsequentsessions may build upon it. Finally,the addition of speed to a carefullyselected posture, movement, andresistance exercise can make theactivity more difficult, noting thatspeed masks substitution and

requires a base of strength to be effective as a train-ing parameter.

For example, the patient with rotator cuff dysfunc-tion described previously might be able to performquadruped stabilization with scapular movementwithout any resistance 18 times before a formbreak. Start with that number of repetitions, andhave the patient attempt to perform two or moresets. Progress the quadruped exercise by addingthe resistance of tubing, again determining thenumber of repetitions that can be performed withprecision. Next, progress to the roll itself, using anassisted or facilitated technique, yet again deter-mining the number of repetitions that can be per-formed properly, without substitution or compen-sation, and dose accordingly. Eventually the assis-tance will not be needed and resistance (manualcontacts or tubing) can be added to the roll.Finally, the speed at which the exercise is beingperformed can be altered to mimic more function-al motion demands.

Figure 13A. Start position for“Starfish 1” pattern, used for trainingof supine to prone rolling, leadingwith the lower extremity. Note tubingloops have been placed around bothfeet; with the length of the bandaround both upper extremities. Tostart, the lead hip is flexed, abducted,and slightly internally rotated whilethe knee is flexed. The rolling move-ment is initiated by extending,adducting, and externally rotating thehip while extending the knee. Notethat the patient is concurrently elon-gating the opposite lower extremity(axis lower extremity) against the tub-ing.

Figure 13B. Intermediateposition “Starfish 1.” Patientwill finish in the prone positionwith all four extremities extend-ed and slightly abducted.

Figure 14A. Start position for “Starfish 2” pat-tern, used for training of prone to supine rolling,leading with the lower extremity. Tubing placedas described previously, the lead leg then isflexed, abducted, and externally rotated. Therolling movement is initiated by extending,adducting, and internally rotating the hip, whileextending the knee. Note that the patient is con-currently elongating the opposite lower extremity(axis lower extremity) against the tubing.

Figure 14B. Intermediate position“Starfish 2” pattern. Patient willfinish in the supine position withall four extremities slightly abducted.


Learning the building blocks of a motor sequence and thecontrol of the rolling movement is paramount to perfectingthe task. The rolling task maximally challenges the coremuscle stabilizers and extremities during a developmental,atypical movement. As motor learning occurs, the patientor client accomplishes the control and skilled use of mobil-ity to accomplish the task of rolling. The authors of thisarticle believe that rolling can facilitate enhanced use of thetrunk, core musculature, and the extremities during a widevariety of functional tasks.

CONCLUSIONThe human body is built on and relies upon symmetry.During static postures and dynamic functional tasks,length, strength, and stability/mobility must exhibitdelicate integration or balance.8 Side-to-side and anterior-posterior balance are both important to healthy, normalfunction. Without symmetry, a state of asymmetry occurswhich may eventually lead to injury, imbalance, and dys-function. Normal functional activities are rhythmic andreversing, which both establishes and depends upon bal-ance and interaction between stabilizers, agonists, andantagonists.5 Often, athletes become “stuck” in patterns ofmovement that do not promote symmetry and reversal,such as tasks that require rotation in one direction, includ-ing pitching, tennis, and golf. Determining alterations insymmetry or the inability to reverse a movement is the firststep to successfully addressing dysfunction. Treatmentmust facilitate movement in both directions in order toenhance normal functional movement and provide ade-quate postural responses to motion.5 Improvement ofmotor ability depends on motor learning which can beenhanced by auditory, tactile, and visual stimuli.3-5 Duringintervention, specific developmental postures may be usedto enhance the use of the head, neck, and trunk as impor-tant parts of the movement. The use of the skill of rollingas an assessment and intervention technique can serve asa possible method by which symmetry, reversal, and motorlearning can be achieved.

REFERENCES1. Cech DJ, Martin S. Functional Movement Development

Across the Lifespan, 2nd Edition. Philadelphia, PA: WB Saunders; 2002.

2. Piper MC, Darrah J. Motor Assessment of the Developing Infant. Philadelphia, PA: WB Saunders; 1994.

3. Adler SS, Beckers D, Buck M. PNF in Practice: An Illustrated Guide. New York, NY: Springer; 2007.

4. Voss DE, Ionta MK, Myers BJ. Proprioceptive Neuromuscular Facilitation. Patterns and Techniques. Philadelphia, PA: Harper & Row Publishers; 1985.

5. Hall CM, Thein-Brody LM. Proprioceptive neuromuscular facilitation, in: Therapeutic Exercise: Moving Toward Function, 2nd edition. Philadelphia, PA: Lippincott Williams & Wilkins;2004.

6. Richter R, VanSant AF, Newton RA. Description of adult rolling movements and hypothesis of developmental sequences. Phys Ther. 1989;69:63-71.

7. Voight ML, Hoogenboom BJ, Cook G. The chop and lift reconsidered: Integrating neuromuscular principles into orthopedic and sports rehabilitation. N Am J Sports Phys Ther. 2008;3:151-159.

8. Sherrington, C. The Integrative Action of the Nervous System.New Haven, CT: Yale University Press; 1961.

9. Sullivan PE, Markos PD. Clinical Decision Making in Therapeutic Exercise. Norwalk, CT: Appleton & Lange; 1995.

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