Journal of Bodywork and Movement Therapies (2005) 9, 142147

Bodywork and
Journal of
Movement Therapies
SELF-HELP: CLINICIAN SECTION
Sensory-motor trainingan update
$
Craig Liebenson, DC

10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA
Introduction
Balance is an often ignored, yet key musculoskele-
tal function. It has been known for many years that
poor balance is related to ankle sprain risk (Tropp
et al., 1984). New evidence validates its associa-
tion with falls, low back pain (LBP), osteoarthritis
of the knee, neck problems, and other disabling
conditions (Mok et al., 2004; Rose, 2003a, b; McGill
et al., 2003; Michaelson and Michaelson, 2003;
Mientjes and Frank, 1999; Wegener et al., 1997).
That this is not a coincidental nding is conrmed
by studies showing that balance training is an
effective treatment addressing fall prevention,
ankle instability, anterior cruciate ligament (ACL)
post-surgical rehabilitation, (Fitzgerald et al.,
2000; Wolf et al., 1996; Rozzi et al., 1999). A
previous article in this series summarized the
assessment and treatment of balance (Liebenson,
2001). This paper provides an update based on new
evidence.
Two recent papers highlighted the association of
balance problems and LBP. Mok et al. (2004)
recently reported that when compared with age
and gender matched pain-free controls, study
participants with LBP had poorer balance. This
was worse with removal of vision as well as
decreasing the size of the unstable supporting
platform. McGill et al. (2003) studied individuals
with a past history of disabling low back pain vs.
individuals with no prior history of LBP. Those with
a past history of LBP were less able to keep a
wobble board steady than those without a past
history.
Another recent paper by Fitzgerald et al. (2000)
demonstrated that balance training incorporating
the use of perturbations to stance led to less giving
way in the knee in ACL patients who avoided
surgery by undergoing a rehabilitation program.
Carrafa et al. (1996) demonstrated that balance
training given to balance compromised soccer
players reduced the incidence of future knee
injuries.
Few areas of medicine are more important than
reducing the burden of health care problems in the
elderly. In Canada, nearly one third of all seniors
will fall this year (The Falls Prevention Initiative,
2004). Falls are responsible for nearly 40% of the
Canadas senior health care costs! The California
Department of Aging in the Department of Health
Services has created a No More Falls! Program. The
self-care advice is responsible for a 20% reduction
in falls 1 year after completion of program (Rose,
2003a, b). Public health organizations such as the
Rand Corporation, Cochrane Collaboration have
mobilized recently to address this preventable
health care dilemma (Scott et al., 2001; Gillespie
et al., 2001; Shekelle et al., 2004; American
Geriatrics Society, 2001; Rubenstein et al., 2001).
Decreased single leg standing balance time (less
than 30 s) has been shown to correlate with a
history of falling, while a longer balance time
ARTICLE IN PRESS
www.intl.elsevierhealth.com/journals/jbmt
1360-8592/$ - see front matter & 2005 Published by Elsevier Ltd.
doi:10.1016/j.jbmt.2005.01.001
$
This paper may be photocopied for educational use.

Tel.: +1 310 470 2909; fax: +1 310 470 3286.

E-mail address: cldc@ash.net.
S
e
n
s
o
r
y
-
m
o
t
o
r
t
r
a
i
n
i
n
g

a
n
u
p
d
a
t
e
suggests a much lower risk (Hurvitz et al., 2000)
(see balance test in accompanying Self-Help:
Patients Advice article).
Balance assessment can be performed in a
reliable, valid way without any special equipment
(Bohannon et al., 1984). Balance training is an ideal
ofce and self-treatment due to its simplicity and
effectiveness (Liebenson and Oslance, 1996; Janda
and Va vrova, 1996). It is a highly efcient
approach which has been shown to yield superior
strength gains when compared to a more time-
consuming traditional strength training approach
(Bologun et al., 1992). This paper will highlight the
basic steps for managing a rehabilitation program
from assessment to training, to self-care prescription.
Assessment
Quantiable single leg stance balance test
A quantiable test of balance is the single leg
stance (SLS) test. It is reliable, has normative data
and requires no equipment other than a timer
(Bohannon et al., 1984).
Procedure:
The patient is instructed to raise one foot up
without touching it to the support leg.
J They can raise to their preferred height.
Balance for upto 30 s with eyes open (EO).
Switch back and forth between the legs until a
successful trial is achieved. The maximum of
trials for each leg is 5.
If successful, then try again by at rst keeping
the eyes open, then immediately spotting
something on a wall in front, and then closing the
eyes and visualizing that spot.
Attempt to balance for 30 s.
Scoring: The time is recorded when any of the
following occurs:
The raised foot touches the ground or more than
grazes the other leg.
The stance foot changes position (shifts posi-
tion).
The stance leg hops.
The hands touch anything other than themselves.
The best EO and eyes closed (EC) results are
recorded out of a total of 5 trials (combined). Also,
it is good idea to record the number of trials it
takes to successfully balance for 30 seconds (EO
and EC) (Table 1).
Jandas single leg standing balance test
A second version of this test was developed by
Janda (Janda and Va vrova, 1996; Liebenson and
Oslance, 1996). This qualitative test provides more
subtle information about gluteus medius function,
weight shift stability, and stability of the foot/
ankle. It can provide useful information to guide
the clinician in troubleshooting ways to customize
the balance training prescription. Jonsson et al.
(2004) recently performed quantiable force plate
measurements to the SLS test and conrmed that
difculty balancing on one leg is due to a)
inadequate compensation for the weight shift,
and b) musculoskeletal weakness.
Procedure:
With eyes open the patient is instructed to raise
one foot up without touching it to the support
leg.
J The foot is raised to knee height and not
allowed to touch stance leg.
J The hip should be exed approximately 601.
J Stand in this position for 20 s.
Score:
Fail if:
J If 41 in pelvic side shift towards the weight
bearing side.
Note:
J Subtalar pronation.
J Lifting up of the toes.
J Tibial torsion.
Training
Basic balance or sensory-motor training is not a new
approach (Freeman et al., 1965; Bullock-Saxton
et al., 1993; Janda and Va vrova, 1990, 1996). A
brief summary will be presented here. Balance
ARTICLE IN PRESS
Table 1 Normative data for 1 leg standing
balance testeyes closed (Bohannon et al., 1984)
Age (years) Eyes closed (s)
2049 24.228.8
5059 21.0
6069 10.2
7079 4.3
Sensory-motor trainingan update 143
S
e
n
s
o
r
y
-
m
o
t
o
r
t
r
a
i
n
i
n
g

a
n
u
p
d
a
t
e
training includes the following (Fig. 1):
Postural correction beginning with the short
foot.
Double and single leg stance (D&SLS) on rm
surfaces with EO and EC.
Weight shifts (falling forward, lunges, push/
pulls).
D&SLS on unstable surfaces (rocker board,
wobble board, balance sandals, balance pads).
D&SLS with perturbations.
Functional balance exercises.
Balance training begins with proper alignment of
all key joints. In particular, the foot, lumbo-pelvic
(LP), T4-8, and cervico-cranial (CO-C1) regions.
The patient should be able to functionally
centrate each joint in its neutral posture. The
training begins with the foot.
If a neutral foot position in double leg stance is
not easily managed then training can begin in a
seated position. Jandas approach begins with
careful attention to formation of an actively
shortened longitudinal arch of the foot without
exion of the toes This is called the short foot
and is based on the work of Freeman (Freeman et
al., 1965) (see Fig. 2).
The short foot position can be difcult for the
patient to form so clinician assistance is often
required. Passive modeling by the clinician to
approximate the medial calcaneus and the rst
metatarsal can be performed. The toes should stay
fairly at and the medial arch should also be
brought together (see Fig. 2). The patient can
progress to forming the short foot with the
clinicians active assistance (semi-active), and then
nally they can perform it actively.
Formation of the short foot
Once the patient is able to create the short foot
sitting and standing they are ready for full body
(foot, LP, T4-8, C0-C1) postural correction in an
upright posture includes the following key points:
short foot (described below),
unlocked knees,
slight lumbar lordosis,
avoidance of excessive thoracic kyphosis,
avoidance of forward head posture.
A novel approach to facilitate postural correction
automatically is to press the heels into the oor in
ARTICLE IN PRESS
Figure 1 Single-leg stance balance test. Reproduced
from Liebenson CS. Advice for the clinician and patient:
Sensory-motor training. Journal of Bodywork and Move-
ment Therapies, 5;1:2128, 2001.
Figure 2 The short foot; (a) passive modeling, (b) active. Reproduced from Liebenson CS. Advice for the clinician
and patient: sensory-motor training. Journal of Bodywork and Movement Therapies 5(1): 2128, 2001.
C. Liebenson 144
S
e
n
s
o
r
y
-
m
o
t
o
r
t
r
a
i
n
i
n
g

a
n
u
p
d
a
t
e
order to feel the sternum pushing anterior and
superior (see Fig. 3). It is important that the
thoraco-lumbar junction does not hyperextend, but
that a smooth neutral lumbar lordosis is
achieved. A slight muscular effort deep to the
gluteal muscles may also be felt when performing
this activity. This should also centrate the C0-C1
junction. If not, then verbally cue the patient to
nod as if saying yes to lift the occiput and
achieve a horizontal visual gaze.
Once a natural, relaxed upright posture is
achieved balance can be progressively challenged.
Weight shifts such as during a falling forward
exerciseforward stepping lungeare a good
introduction to balance or sensory-motor training
(see Fig. 4) (Janda, 2005). In this exercise, the
patient stands upright in good posture and slowly
leans forward from the heels. When the weight has
perceptually shifted forward, and the heels begin
to lift, one leg steps forward as in a lunge. At heel
strike the patient should attempt to quickly
stabilize the body so no further forward movement
occurs.
This is an excellent way to train eccentric
quadriceps control of the patello-femoral joint.
The knee should ex during the stepping motion,
ARTICLE IN PRESS
Figure 4 (ac) Forward stepping lunge.
Figure 3 Neutral postural correction.
Sensory-motor trainingan update 145
S
e
n
s
o
r
y
-
m
o
t
o
r
t
r
a
i
n
i
n
g

a
n
u
p
d
a
t
e
but at not be allowed to pass beyond the toes at
impact. The back leg should be relaxed with slight
knee exion, and the heel should rise from the oor.
Functional exercises such as balance reaches
with arm or leg, single leg stance with contralateral
arm exercise (pulley, band, hand weight), single leg
stance with medial trunk rotation vs. resistance
(Mascal et al., 2003) are all excellent ways to train
gluteus medius function as an ankle, knee, hip and
spine stabilizer.
Self-care prescription
It is important to give patients home exercises to
improve their self-management of their musculos-
keletal conditions. Balance training is very simple
to use and requires very little, if any, equipment so
it is ideal for self-care. The accompanying Self-Care
Advice article discusses a practical way to begin
such care.
References
American Geriatrics Society, British Geriatrics Society, Academy
of Orthopaedic Surgeons Panel on Falls Prevention, 2001.
Guideline for the prevention of falls in older persons. Journal
of the American Geriatric Society 49, 664772.
Bologun, J.A., Adesinasi, C.O., Marzouk, D.K., 1992. The effects
of a wobble board exercise training program on static
balance performance and strength of lower extremity
muscles. Physiotherapy Canada 44, 2330.
Bohannon, R.W., Larkin, P.A., Cook, A.C., Gear, J., Singer, J.,
1984. Decrease in timed balance test scores with aging.
Physical Therapy 64 (7), 10671070.
Bullock-Saxton, J.E., Janda, V., Bullock, M.I., 1993. Reex
activation of gluteal muscles in walking. Spine 18 (6), 704708.
Carrafa, A., Cerulli, G., Projectti, M., Aisa, G., Rizzo, A., 1996.
Prevention of anterior cruciate ligament injuries in soccer. A
prospective controlled study of proprioceptive training. Knee
Surg. Sports Traumatol. Arth. 4 (1), 1921.
Fitzgerald, G.K., Axe, M.J., Snyder-Mackler, L., 2000. The
efcacy of perturbation training in nonoperative anterior
cruciate ligament rehabilitation programs for physical active
individuals. Physical Therapy 80, 128140.
Freeman, M.A.R., Dean, M.R.E., Hanham, I.W.F., 1965. The
etiology and prevention of functional instability of the foot.
Journal of Bone and Joint Surgery-British Volume 47B,
678685.
Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E.,
Cumming, R.G., Rowe, B.H., 2001. Interventions for pre-
venting falls in elderly people. Cochrane Database System
Reviews 3, CD000340.
Hurvitz, E.A., Richardson, J.K., Werner, R.A., Ruhl, A., Dixon,
M.R., 2000. Unipedal stance testing as an indicator of fall risk
among older outpatients. Archives of Physical Medicine and
Rehabilitation 81, 587591.
Janda, V., Va vrova, M., 1990. Sensory Motor Stimulation: A
Video. Presented by JE Bullock-Saxton, Brisbance, Australlia,
Body Control Systems.
Janda, V., Va vrova, M., 1996. Sensory motor stimulation. In:
Liebenson, C. (Ed.), Rehabilitation of the Spine: A Manual of
Active Care Procedures. Williams and Wilkins, Baltimore.
Janda, V., Veverokova, M., Herboneva, M., Liebenson, C., 2005.
Sensory-motor training. In: Liebenson, C. (Ed.), Rehabilita-
tion of the Spine: A Manual of Active Care Procedures.
Lippincott/Williams and Wilkins, Baltimore (sched pub
2005).
Jonsson, E., Seiger, A., Hirschfeld, H., 2004. One-leg stance in
healthy young and elderly adults: a measure of postural
steadiness? Clinical Biomechanics 19, 688694.
Liebenson, C.S., 2001. Advice for the clinician and patient:
sensory-motor training. Journal of Bodywork and Movement
Therapies 5 (1), 2128.
Liebenson, C., Oslance, J., 1996. Outcome assessment in the
short private practice. In: Liebenson, C. (Ed.), Spinal
Rehabilitation: A Manual of Active Care Procedures. Williams
and Wilkins, Baltimore.
Mascal, C.L., Landel, R., Powers, C., 2003. Management of
patellofemoral pain targeting hip, pelvis, and trunk muscle
function: 2 case reports. Journal of Orthopaedic & Sports
Physical Therapy 33, 647660.
McGill, S.M., Grenier, S., Bluhm, M., Preuss, R., Brown, S.,
Russell, C., 2003. Previous history of LBP with work is related
to lingering effects in biomechanical physiological, personal,
and psychosocial characteristics. Ergonomics 56 (7),
731746.
Michaelson, P., Michaelson, M., 2003. Vertical posture and head
stability in patients with chronic neck pain. J Rehabil Med
Sept 35 (5), 229235.
Mientjes, M.I.V., Frank, J.S., 1999. Balance in chronic low back
pain patients compared to healthy people under various
conditions in upright standing. Clinical Biomechanics 14,
710716.
Mok, N.W., Brauer, S., Hodges, P.W., 2004. Hip strategy for
balance control in quiet standing is reduced in people with
low back pain. Spine 29, E107E112.
Rose, D.J., 2003a. FallProof balance and mobility program
developed by Center for Successful Aging at California State
University, Fullerton.
Rose, D.J., 2003b. Fallproof. A Comprehensive Balance and
Mobility Training Program, Human Kinetics, Champaign,
Illinois.
Rozzi, S.L., Lephart, S.M., Sterner, R., Kuligowski, L., 1999.
Balance training for persons with functional unstable ankles.
J Orthop Sports Phys Ther 29, 478486.
Rubenstein, L., Powers, C.M., MacLean, C.H., 2001. Quality
indicators for management and prevention of falls and
mobility problems in vulnerable elders. Annals of Internal
Medicine 135, 686693.
Scott, V.J., Dukeshire, S., Gallagher, E., Scanlan, A., 2001. A
best practices guide for the prevention of falls among seniors
living in the community. Report prepared on behalf of the
Federal/Provincial/Territorial Committee of Ofcials Seniors)
for the Ministers Responsible for Seniors, Ottawa. Available
at: http://www.hc-sc.gc.ca/seniorsaines/pubs/best_
practices/intro_e.htm. www.hc-sc.gc.ca/seniorsaines/pubs/
best_practices/intro_e.htm. Accessed May 11, 2004.
Shekelle, P., Maglione, M., Chang, J., et al., 2004. Falls
Prevention Interventions in the Medicare Population. RAND-
HCFA Evidence Report Monograph. Baltimore: HCFA;2002.
Publication #HCFA-500-98-0281.
The Falls Prevention Initiative, 2004. Division of Aging and
Seniors Publich Health Agency of Canada. http://www.
phac-aspc.gc.ca/seniors-aines/pubs/injury_prevention/falls_
factsheets/fallsprevtn8_e.htm.
ARTICLE IN PRESS
C. Liebenson 146
S
e
n
s
o
r
y
-
m
o
t
o
r
t
r
a
i
n
i
n
g

a
n
u
p
d
a
t
e
Tropp, H., Ekstrand, J., Gillquist, J., 1984. Stabilometry in
functional instability of the ankle and its value in predicting
injury. Medicine and Science in Sports and Exercise 16, 6466.
Wegener, L., Kisner, C., Nichols, D., 1997. Static and dyamic
balance responses in persons with bilateral knee osteoar-
thritis. Journal of Orthopaedic & Sports Physical Therapy 25,
1318.
Wolf, S.L., Barnhart, H.X., Kutner, N.G., et al., 1996. Reducing
frailty and falls in older persons: An investigation of Tai Chi
and computerized balance training. JAGS 44, 489497.
ARTICLE IN PRESS
Sensory-motor trainingan update 147
S
e
n
s
o
r
y
-
m
o
t
o
r
t
r
a
i
n
i
n
g

a
n
u
p
d
a
t
e