215-

Rolling to the nonplegic side: influence of teaching

and limb strength in hemiplegic stroke patients
Richard W Bohannon Associate Professor, School of Allied Health Professions, University of Connecticut

This study was undertaken to determine in patients with hemiplegia; (1) the
influence of patient teaching on independence in rolling to the nonplegic side; and
(2) the relationship between limb muscle strength and independence in rolling.
Twenty patients who had experienced cerebrovascular accidents were studied.
Their capacity to roll to the nonplegic side before, immediately after, and five
minutes after instruction was measured. Also measured, but with a hand-held
dynamometer, was the static strength of seven muscle groups of each extremity.
The mean strength of each extremity’s muscle groups was calculated and
normalized against (divided by) body weight. Correlations were calculated between
normalized strength scores and rolling capacity. The Cohran Q test demonstrated
that the proportion of subjects rolling independently was significantly different
before and after teaching. Rolling capacity during every trial was significantly
correlated with the static strength of the limbs of the nonparetic side. The results
suggest that teaching may be beneficial for increasing patient independence in
rolling, but that such capacity is not independent of the patient’s strength.

Introduction over is often given excessive emphasis in rehabili-

The importance of functional independence in
stroke patients is self evident. Toward this end,
numerous texts offer recommendations as to how
functional activities, such as bed mobility, can be
accomplished. Bobath suggested that one of the
first activities on which a physical therapist should
work with patients is turning to either side. In
contrast, Carr and Shepard indicated that ’rolling
Address for correspondence: Associate Professor, School of
Allied Health Professions, University of Connecticut, U-101,
Storrs, CT 06268, USA.
tation.’2 Whether emphasized or not, rolling par-
ticularly from supine to the nonplegic side, can
be a difficult task for some hemiplegic patients.33
Several strategies for rolling have been pre-
sented.3-5 Although the strategies differ in some
specifics, most entail flexing the hips and knees,
either unilaterally or bilaterally, grasping the
plegic upper limb with the nonplegic hand, reach-
ing with the upper limbs (elbows extended and
shoulders flexed) toward the nonplegic side, and
lifting and turning the head to the nonplegic side.
Studies of hemiplegic stroke patients have
shown that functional status tends to improve

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216
during rehabilitation. Although the rehabilita-
tion of patients is ’fundamentally a process of
relearning how to move to carry out their needs
successfully’,9 the extent to which the teaching of
patients contributes to their capacity to function,
has not been documented. Such documentation
is essential if physical therapists are to justify their
services. In undertaking this study I accepted the
principles of motor control espoused by Carr et
al. More specifically I accepted that the correct-
ness of a movement pattern is based on its utility
in helping a patient to achieve a goal, not in its
conforming to some ideal and that what is learned
can be communicated to the patient by verbal
instruction and demonstration.99
Like function, the static muscle strength of
hemiplegic patients shows improvement following
the stroke.l° As static muscle strength is related
to the performance of some functional activities,
for example gait,&dquo; improvements in function in
stroke patients might be at least partially the
consequence of increased strength.
The purposes of this investigation were to deter-
mine : (1) the influence of patient teaching (instruc-
tion and demonstration) on the independence of
stroke patients in rolling to the nonplegic side;
and (2) the relationship between the mean nor-
malized strength of the patients’ four limbs and
independence in rolling to the nonplegic side. My
expectations were that more patients would be
able to roll independently after instruction and
demonstration and that rolling independence
would be correlated with extremity strengths.
’
Method .
Subjects
Twenty consecutive patients with hemiplegia,
secondary to cerebrovascular accidents (CVAs),
who could follow instructions and who provided
informed consent, participated as subjects in this
study. Fourteen were men and six were women.
Fifteen were plegic on the left and five were plegic
on the right. The subjects’ age was 68.7 ± 9.3
(range, 48-83 years). The time since onset of
CVA, at the time of assessment, was 47.2 ± 86.7
(range, 12-410) days.
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Procedure
Two aspects of patient performance were mea-
sured during each patient’s initial assessment: roll-
ing to the nonplegic side and muscle group
strength. Rolling was classified dichotomously as
independent or dependent. To be classified as
independent at rolling, a patient had to go from
supine to full side-lying (with the frontal plane of
the body perpendicular to the mat surface) in less
than 15 seconds without concomitant verbal or
physical assistance of another person. Subjects
were not allowed to roll by grasping the edge of
the mat with the nonplegic hand. In a separate
study (unpublished research, 1987), two raters
concurrently observed rolling to the nonplegic
side in 10 patients and separately rated the patients
as independent or dependent. The raters de-
monstrated 100% agreement in their ratings.
Muscle group strength was tested with a hand-
held dynamometer, as described by Bohannon. 12
Briefly, each muscle group’s strength was mea-
sured during a single maximum voluntary effort
of four to five seconds. All measurements were
obtained with gravity eliminated while most of
the muscle groups were in the middle half of their
range. Test-retest and interater reliability have
been demonstrated previously for such measure-
ments. 12,13 Seven muscle groups were tested in
each upper extremity (wrist extensors, elbow
flexors and extensors, shoulder abductors, exten-
sors, internal and external rotators), and lower
extremity (ankle dorsiflexors and plantar flexors,
knee flexors and extensors, hip flexors, extensors,
and abductors). The mean strength of seven
muscle groups of each extremity calculated was
normalized by dividing by body weight.
To test the influence of teaching on rolling to
the nonplegic side, subjects were asked to roll all
the way on to their nonplegic sides on three
separate occasions. The first request preceded any
teaching. The second request was immediately
following instruction and demonstration on how
to roll to the nonplegic side. The third request
followed the second attempt to roll by five mi-
nutes. Patients rested during the five-minute
period. The instructions were as follows: (1) grasp
your weak wrist with your strong hand; (2) lift
-
your arms together toward the ceiling; (3) bring
your strong leg up, bending your hip and knee;
(4) let the bent leg fall to the strong side; (5) turn
your head toward your strong side and reach to

your strong side with your arms; (6) roll as hard
as you can to your strong side. Accompanying
the instructions was a demonstration of the activity
using the technique described.
Data analysis
The influence of teaching on rolling capacity
was analysed using contingency table and the
a
Cochran Q test.’4 The relationship between rolling
capacity and the four limbs’ strengths were calcu-
lated using point-biserial correlations. 15
Results
Table 1 illustrates the number of subjects who
were able to roll independently before and after
(immediately and five minutes) teaching. All pa-
tients rolling independently prior to instruction
could do so afterwards. The number of subjects
rolling independently, however, increased more
than two-fold after instruction. The Cochran Q
test demonstrated that the proportion of subjects
rolling independently was significantly different
during the rolling trial before and after teaching.
(Q 7.9, p 0.02). The normalized mean muscle
= =
group strengths (X ± S) of the four limbs were:
nonplegic upper limb = 0.199 ± 0.055, nonplegic
lower limb =
0.319 ± 0.099, plegic upper limb
=
0.022 ± 0.025, plegic lower limb 0.155 ±
=
0.109. The correlations between these strengths
and rolling independence are reported in Table
2. Rolling independence, before and after teach-
ing, was significantly correlated with nonplegic
limb-strength. The only plegic limb strength cor-
related significantly with rolling independence was
that of the lower limb before teaching.
’
Discussion
The results suggest, in keeping with my expecta-
tions, that the provision of teaching on how to
roll to the nonplegic side was accompanied by an
increase in the number of stroke patients who
were independent at the activity. As nothing other
than teaching followed the initial request for the
patients to roll and their subsequent attempts at
the activity, it is reasonable to assume that the
teaching had some influence. That instruction can
influence even a seemingly simple activity such
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217
Table 1 Number of hemiplegic subjects independent in
rolling to the nonplegic side under three instructional
conditions
Table 2 Point biserial correlations between normalized limb
strength and rolling independence*
~*Significant correlations (p<.05 two tailed test) are underlined.
as is important evidence of the potential
rolling
value ofphysical therapy. To the best of my
knowledge no such evidence has been published
before.
The teaching, in this study which consisted of
instruction and demonstration, was supposed to
clarify the way in which a goal, rolling, could be
accomplished.9 Apparently it did. With a
minimum time since onset of 12 days, all patients
had considerable opportunity, prior to my testing,
to attempt rolling to the nonplegic side. Neverthe-
less, 13 could not do so independently prior to
the teaching session. Although the activity (roll-
ing) was probably not novel, the technique might
have been. Much of what a therapist has to offer
a disabled patient may be an alternative method
for accomplishing a task.
Because of the large differences that can exist
in stroke patients and the limited number of sub-
jects tested I selected a repeated measures design
on the same subjects rather than the use of a
control group. The use of a control group may
or may not result in findings comparable to those
obtained and should be attempted as practical in
the future.
The findings reported here indicate that the
residual effects of teaching may be limited, as
more patients were independent immediately than
218

five minutes after instruction. As rolling capacity 3 Charness A. Stroke/head injury. A guide to
was not retested after the five-minute test, the functional outcomes in physical therapy
long term benefits of teaching cannot be deter- . Rockville, MD: Aspen Systems
management
mined from this study. The effectiveness of alter- Corp, 1986: 250.
native teaching strategies as well as the effective- 4 Todd JM, Davies PM. Hemiplegia II. In: Cash
ness of teaching for increasing independence at J ed, Neurology for physiotherapists
.
other functional activities were not addressed and Philadelphia, PA: JB Lippincott, 1977: 308-
merit further testing. 309.
My prestudy expectations were partially sup- 5 Jonstone M. Home care for the stroke patients
.
ported. Although independence in rolling was not New York, NY: Churchill Livingstone, 1980:
related to the normalized strength of the plegic 76-77.
side (except in the lower limb prior to teaching) 6 Harmin E. One year after stroke: a follow-up
independence was related consistently to the nor- of an experimental study. Scand J Rehabil Med
malized strength of the nonplegic side. The find- : 111-16.
1982; 14
ing, however, does not mean that strength is 7 Lehmann JF, Delateur BJ, Fowler RS et al .
responsible for independence. It does indicate, Stroke: does rehabilitation affect outcome?
like a previous study by Bohannon,&dquo; that limb Arch Phys Med Rehabil 1975; 56 : 375-82.
muscle strength should be taken into account 8 Smith DS, Goldenberg E, Ashburn A et al .
when making judgements about patient capacity. Remedial therapy after stroke: a randomized
controlled trial. 1981;
Br Med J 282 : 517-20.
9 Carr JH, Shepherd RB, Gordon J et al .
Conclusions Movement science foundations for physical
therapy in rehabilitation
. Rockville, MD:
The number of hemiplegic stroke patients showing Aspen Publishers Inc., 1987.
a capacity to roll to the nonplegic side increased 10 Bohannon RW, Smith MB. Assessment of
following teaching. This finding provides some strength deficits in eight upper extremity
support for a common physical therapy interven- muscle groups of stroke patients with
tion, the teaching of functional activities. Whether hemiplegia. Phys Ther 1987; 67 : 522-25.
rolling independence was measured before or after 11 Bohannon RW. Strength of lower limb related
teaching it was related to the strength of the to gait velocity and cadence in stroke patients.
nonplegic limbs. Consequently, independent from Physiotherapy Canada 1986; 38 : 204-206.
teaching, patient rolling capacity can be explained 12 Bohannon RW. Test-retest reliability of hand-
in part by the limb muscle strengths of the held dynamometry during a single session of
nonplegic side. strength assessment. Phys Ther 1986; 66 : 206-
209.
13 Bohannon RW, Andrews AW. Interrater
’ ’
reliability of hand-held dynamometry. Phys
References ...
Ther 1987; 67: 931-33.
14 Sharp VF. Statistics for the social sciences
.
1 Bobath B. Adult hemiplegia: evaluation and Boston, MA: Little, Brown and Co, 1979:199-
, second edition. London: William
treatment 205.
Heinemann Medical Books Ltd, 1978: 84-86. 15 Edwards AL. An introduction to linear
2 Carr JH, Shepherd RB. A motor relearning regression and correlation
, second edition.
program for stroke
. Rockville, MD: Aspen New York, NY: WH Freeman and Co, 1976:
Systems Corp, 1983: 75-76. 54-58.

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