Rolling…yeah I roll

Rolling…rolling…really? This is something that I have done enough times that I have seen great responses with. It has a purpose and if done and followed through with can be very beneficial. Even though I have done this several times I still continue to get questions and stares in clinic from both physical therapists, students and patients.

When do you decide to roll?

In the SFMA course that I took, the instructor (Greg Rose DC) referred to it as turning the switch on. For whatever reason, your “switch” has been turned off and we need to turn it back on. This “switch” is the motor control switch. Usually, in more chronic or longer lasting issues (pain or faulty movement patterns) there is this global motor control issue.

So, when you test functional movements and then break it down into individual segments there are many deficits. Each time you test a passive vs active ROM there is this overwhelming amount of full PROM and limited AROM. Also, the AROM looks “dirty” as in they compensate greatly to achieve a desired outcome. I will test rolling when someone has asymmetrical global weakness (such as in the hips or shoulder), when they show me poor movement patterns in deep squat/backward bend/full body rotation/lumbar flexion and/or they can’t activate their glutes (with prone hip extension they say they feel it in their hamstrings and/or they have a lot of compensations to get the leg smoothly up).

Why do you roll?

It is actually quite simple. If someone can’t roll correctly then how can they possibly perform exercises in any other position such as half/tall kneeling and standing? The way we develop, we start by rolling and then crawling then standing. We can’t skip steps!

The reason why we can’t roll?

I really think, from seeing the patients who fail at it, that we develop faulty movement patterns over the course of time. This could be a result of a previous injury years ago, our very sedentary lifestyles/jobs or the result of our chosen sport. The longer we go with a poor movement pattern then the more engrained into our nervous system that pattern becomes. Rolling is just the first step.

How do you test rolling?

There are four quadrants in both supine and in prone. I usually start in supine. You want to move one body part only and attempt to roll using that one body part. If you are going to use the upper body then the lower body is paralyzed and not allowed to help at all. If there is any activation then that attempt doesn’t count and they should redo it. The patient has to be honest with you and usually after seeing a couple good movements then most times you can see the compensation. Once the upper body is tested in supine then you test the lower body when the upper body is paralyzed.

Supine right shoulder flexion -> supine right leg flexion -> supine left shoulder flexion -> supine left leg flexion

Prone right shoulder extension -> prone right hip extension -> prone left shoulder extension -> prone left hip extension.

How do you treat rolling?

Most often times you will see one area that is especially dysfunctional though there may be multiple areas that need to be worked on. Say the right hip extension is dysfunctional. In order to treat that (this way is easier so that they can replicate it at home versus using a sport cord) dysfunction you place a pillow under there right hip/torso (decreases difficulty by 25%). If they still can’t do this properly you add another pillow to make it 50% easier and so on until they can easily roll.

Once they accomplish the rolling task with, let’s say two pillows, then you want to take one pillow out and make them work for the 25%. Once they pass a step I would make them do a bunch of reps first before increasing the difficulty. Do this at each stage until they are able to roll successfully from the floor.

What can it help clear up?

Remember, whenever you want to make a quick fix always have that movement or test that they failed and retest after they perform the intervention to see if it helped clear anything up. So, if they failed prone hip extension because of both poor active ROM and excessive hamstring activation then you want to go back to that test and see if it is better. It may not be an excellent grade after but you should see a considerable change. This change should be enough to allow you the “in” to start working on those individual motor control deficits.

Sometimes over the course of the session they still aren’t able to roll without assistance. That is okay! That would be there HEP and to progress to the floor. You can give a few small, simple motor control exercises after rolling but I would make their HEP following their initial evaluation focused on the rolling. The changes should maintain and stay as long as they are consistent with working on the movement at home. Most likely these patients will have a lot of deficits to slowly work on because their entire system has been shut off for so long. Those inhibitory muscles, overtime, can become actually weak as well.

What patients will this help?

Most athletes and people who have sedentary jobs where that extension mechanism is just lost. Chronic pain patients where the general programs just haven’t work to decrease their pain or improve their function.

Runners: usually their injuries are a lack/loss of active hip extension when running. This hip extension needs to be from the glutes and not the hamstrings or lower back. Ankle injuries/shin splints fall in line with this as well. Activate the glutes and entire posterior chain extension mechanism.

Swimmers: who have been using their shoulders/neck/lower back and hamstrings for long periods in the water will sometimes just need that relearning of proper muscle activation to go with all that motion.

Baseball players: Like swimmers, upper/lower body sports require better movement patterns

Golfers: they lose that motor control with rotations which can translate up/down the chain

Flexion based activities: just because they can’t reach down and touch their toes doesn’t mean tight hamstrings or lack of mobility. Often times they have impaired whole body movement patterns.

Questions…?

TJ Slowik PT DPT

Active Vs Passive ROM (Cervical Spine)

Active VS Passive ROM (Cervical)

This is my first post relating to active vs passive ROM testing and treatments. I want to start in the cervical region.

One thing that I noticed going through school and then as a floater and now as a clinical instructor is how little therapists respect the great knowledge that you can gain by knowing the difference between active and passive ROM. Many, if not all, therapists check active/passive ROM of the shoulder. We mobes/PROM shoulders that have restrictions in both. If just active is limited but passive is full then we work on correcting the deficits in shoulder strength/control. Why don’t we take this into account throughout the rest of the body?

In school and in practice I see many people using the cervical ROM diagram. It allows us to easily list ROM, pain, stretching, radicular symptoms, etc. in one easy to find/use space. It works well and acts as a quick reference for busy times. The problem is: why is there only one of these on most initial evals? There should be one for active AND one for passive ROM. When one of these diagrams looks like the following:

pain diagram

Then we assume (as manual therapists) that there is a closing restriction on the right side. We then put them supine and check each individual segment for mobility and pain. I don’t want this to turn into a discussion of our palpation skills. That can be saved for another time. In short, they are not good. Have you seen a cadaver?

If AROM is limited in all planes or just one plane but passive ROM is full then we really need to start thinking motor control! If AROM and Passive ROM are both restricted then we do need to asses to see where that restriction is coming from. This passive restriction can have many components and that is where we use our heavily developed manual skills to address then retest and check for improvements. Most times, if there is a passive restriction to motion and you clear that up with manual therapy then there is usually a motor control deficit to follow when you re-test the AROM and PROM. Also, don’t just check that first day but rather continue to check the Active vs Passive ROM.

Passive ROM restrictions is a result of something. It doesn’t just happen (like hamstring tightness which is a very long future post). Often times, if you fix that passive restriction they may have full AROM right after as well. This doesn’t mean that there isn’t a motor control issue to address. This change in AROM can be a result of the neurological feedback that you get with manual therapy. It can help reset the system including the active restraints to motion. Re-test the PROM/AROM the next visit to make sure that the PROM remained. If it didn’t then suspect a motor control issue that is preventing motion on continual basis. Follow your manual therapy up with some motor control exercises and see what happens the next visit. If they are consistent with their HEP then there should be those lasting changes.

When I first started thinking of adding more motor control exercises (opposed to the usual row/shoulder/scapular therex) into my treatment plan I was skeptical that it would carry over from one treatment to the next. Once I saw the results I was excited. I always question how we can be better at treating patients and the thought processes behind certain treatments. If PROM is full and AROM of the cervical region is limited then how can I regain full/painless AROM?

I hear a lot of experts talk about the reasons why we aren’t great at treating patients and areas that we need to improve upon. In the SFMA course I took over the summer (the philosophy behind there treatments pretty much changed the way I treat) they had mentioned that diagnosis is the area that we struggle in the most and that we are passible with the interventions. I don’t disagree with that assessment. We struggle with the “real” diagnosis with many patients, that is, in regards to what are focus should be on. But, I also think we really struggle with our treatments. This includes doing too much, not enough, poor progression, targeting the wrong areas, etc.

The big area that we struggle in regards to treatments is wanting to strength train everyone. Motor control is a huge component of a lot of areas and compensations. This is a talk for maybe my next post and many, many posts after that. For now, let’s talk about just improving that cervical AROM. In some ways I don’t even care what is limiting AROM. AROM involves contractile movements as well as non-contractile structures. If PROM is free and clear then what is more of a concern to me is how I can access that motor control system or nervous system.

It isn’t about strengthening the muscles or stretching non-stop to restore motion but rather about the amount of inactivation that is occurring. The motor control system just isn’t working. Overtime, the patient, somehow, developed a poor movement pattern. This poor movement pattern is possibly a result of a poor nervous system activation. It is not strength! You can do all the muscular strengthening and upper trap stretching you want but if you can’t get the system to respond normally then there will not be lasting changes. The body is a system of nerves, nervous system firing and brain mapping that churns out a desired response.

Try going weight bearing first and then if they can’t complete the below exercises go to supine and work on first.

Pull a thera-band apart into shoulder horizontal abduction with both hands and then have the patient actively rotate their head to the left then right. Once finished with that have the patient relax the band back to a relaxed state. Repeat ten times. Then do the same with any other motion that is restricted.

Horizontalabductionpull

You should see an instant improvement in AROM. It will look cleaner, be less painful and the patient should also instantly see/feel the results. I am not saying that it will be pain-free but there should be a noticeable difference in pain levels as well as AROM. If they are still painful then try some sustained overpressure with movement (at some level of the cervical spine from posterior) while they complete the above exercise. This can provide a little neurological feedback to the system and help with the perception of pain.

There is no one definition of motor control or what happens/why we see altered movement patterns when there is pain present. Why/how the nervous system goes about its processes is poorly understood and needs a lot more research focused on this. Hodges and Tucker have a good article on this process in 2011 (see below). A possible mechanism could be through the nervous system. If we can activate a “core” muscular group such as the scapular stabilizers in the upper quarter then maybe this will feedforward. The goal of this exercise is to get the CNS firing first then performing the abnormal movement hoping that it restores the correct timing/coordination of muscles thereby reducing the perception of pain.

Remember this is just one way of improving that active ROM and should be combined with other techniques and ways to reduce the hyperactivity of the nervous systems in through the cervical region. I will only quickly mention the couple other ways that I use as well but save for another post.

Mackenzie extension (clean up PROM/AROM)

Instrument assisted soft tissue massage to the cervical region (neurological feedback not scar tissue!)

Nerve tensioning/slides/glides/release via David Butler

I intend on going through the rest of my cervical treatment interventions to decrease pain and increase ROM as well as increasing function in following posts. I believe that it is very important to know why you perform the interventions as opposed to just assigning interventions because “you have always done it like that”. My interventions and treatment strategies have changed a lot over time and it is because I am trying to constantly look for ways to improve my outcomes and question the norm.

TJ Slowik PT DPT

Hodges, P.W., Tucker (2011). Moving differently in pain: A new theory to explain the adaptation to pain.

Hodges, P.W (2011). Pain and Motor Control: From laboratory to rehabilitation.