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Sensorimotor training: A “global” approach for balance training

Article  in  Journal of Bodywork and Movement Therapies · January 2006

DOI: 10.1016/j.jbmt.2005.04.006

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 ARTICLE IN PRESS
Journal of Bodywork and Movement Therapies (2006) 10, 77–84

Journal of
Bodywork and
Movement Therapies
www.intl.elsevierhealth.com/journals/jbmt

REVIEW

Sensorimotor training: A ‘‘global’’ approach for

balance training
Phil Page, MS,PT,ATC,CSCS

P.O. Box 77030, Baton Rouge, LA 70879, USA

Received 4 February 2005; received in revised form 3 April 2005; accepted 7 April 2005

KEYWORDS Summary Sensorimotor training was developed by Dr. Vladimir Janda as part of a
Sensorimotor treatment approach to chronic musculoskeletal pain syndromes. He noted that many
training; of these syndromes exhibited characteristic patterns of muscle imbalance, which
Chronic pain; were manifested with changes to the central nervous system motor programming.
Muscle imbalance; Janda emphasized the importance of proprioception in the rehabilitation process. In
Proprioception; order to restore normal muscle firing patterns and reflexive stabilization, he
Stabilization; developed a specific proprioceptive exercise progression for patients with chronic
Rehabilitation musculoskeletal pain. Sensorimotor training emphasizes postural control and
progressive challenges to the sensorimotor system to restore normal motor programs
in patients with chronic musculoskeletal pain. Patients progress through static,
dynamic, and functional phases using simple rehabilitation tools such as balance
boards, foam pads, and elastic bands. This paper will describe the scientific
rationale for the program and describe the clinical progression of sensorimotor
training.
& 2005 Elsevier Ltd. All rights reserved.

Introduction pathological process for instability was unknown at

the time. Further research led Freeman and his
In the early 1900s, Dr. Charles Sherrington first colleagues to discover the actual proprioceptive
defined proprioception as a sense of position, receptors in encapsulated nerve endings in the
posture, and movement (Sherrington, 1906). He joints of cats. They found that cats were unable to
noted that special receptors were present to walk properly after their peripheral afferent joint
transmit the afferent information into the central receptors had been severed from the CNS (Freeman
nervous system (CNS). During the 1960s, British and Wyke, 1966). They termed this ‘‘deafferenta-
physician Michael Freeman (1965b) reported tion’’ and suggested that this was a mechanism for
chronic instability in the ankles of soldiers who chronic ankle instability, noting that repetitive
had suffered an ankle injury. He noted that the ankle sprains were most likely a result of impaired
proprioceptive information from damaged ankle
E-mail address: [email protected]. ligamentous receptors, rather than a mechanical

1360-8592/$ - see front matter & 2005 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2005.04.006
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Table 1 Postural and phasic groups (adapted from Janda (1987)).

Postural muscles prone to tightness or shortness Phasic muscles prone to weakness or inhibition

Gastroc-soleus Peroneus longus, brevis

Tibialis posterior Tibialis anterior
Hip adductors Vastus medialis, lateralis
Hamstrings Gluteus maximus, medius, minimus
Rectus femoris Rectus abdominus
Iliopsoas Serratus anterior
Tensor fascia lata Rhomboids
Piriformis Lower trapezius
Thoraco-lumbar extensors Deep neck flexors
Quadratus lumborum Upper limb extensors
Pectoralis major
Upper trapezius
Levator scapulae
Scalenes
Sternocleidomastoid
Upper limb flexors

instability or loss of strength. In 1965, Dr. Freeman ‘‘phasic’’ (Table 1) are pre-disposed to tightness or
then suggested a simple treatment approach to weakness, respectively, based on their function and
‘‘compensate for a peripheral sensory deficit’’ in control by the CNS (Janda, 1987). His classification
patients with functional instability of the ankle was based on the assertion that these two groups
(Freeman, 1965a). His treatment consisted of served different functions in human development
balancing on a simple wooden rocker or wobble and movement patterns, and that their balanced
board. He noted significant decreases in recurrent function was essential to normal movement. Often,
ankle sprains among the 85 patients completing the the ‘‘postural’’ muscles would respond to dysfunc-
training. tion with increased tightness, while the ‘‘phasic’’
The results of Freeman and colleagues helped muscles would respond with weakness, creating
pioneer proprioceptive rehabilitation not only by characteristic muscle imbalance syndromes he
identifying the importance of mechanoreceptors in classified as ‘‘upper crossed’’, ‘‘lower crossed’’,
joints, but also by noting the importance of the CNS and ‘‘layer’’ syndrome (Fig. 1).
in rehabilitation of peripheral joints. Researchers Janda believed that these muscle imbalances led
and clinicians began to investigate the role of the to movement impairments and ultimately changed
CNS in chronic musculoskeletal dysfunction. the motor programming within the CNS. He noted
During the 1950s and 1960s, Dr. Vladimir Janda that chronic musculoskeletal pain is mediated
(1928–2002), a physiatrist and neurologist from the centrally within the CNS. The only way to correct
Czech Republic, noted that it was impossible to these impairments was to first normalize the
separate the sensory system and the motor system peripheral proprioceptive structures (through joint
in the control of human movement, thus he used mobilization or soft tissue mobilization), then
the term, ‘‘sensorimotor system.’’ He emphasized correct muscle balance, and finally facilitate a
that the sensorimotor system functions as one unit correct motor program. He placed emphasis on
and that changes within one section of the system restoring function of the nervous system through
are reflected by adaptations elsewhere in the motor re-learning, rather than emphasizing treat-
system (Janda, 1987). Dr. Janda had done extensive ment of isolated structural components.
work on the patterns of muscle imbalance and the Janda noted two basic stages of motor learning
importance of proper firing patterns in maintaining in rehabilitation of muscle imbalance syndromes
joint stability, recognizing the importance of the (Janda, 1987). The first stage is characterized
CNS in regulating movement. Rather than empha- as ‘‘voluntary’’ control of movement, requiring
sizing isolated strength of a joint, Janda noted that cortical regulation of movement and much con-
the most important aspect of coordinated move- centration on the part of the patient. This stage
ments was proprioception. requires constant feedback from both positive
Janda’s approach to chronic musculoskeletal pain and negative experiences, and is thus somewhat
was that certain muscle groups, the ‘‘postural’’ and inefficient.
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Sensorimotor training: A ‘‘global’’ approach for balance training 79

Upper Crossed
Upper Crossed
Weak Tight

Syndrome

Syndrome
Deep cervical flexors Upper Trap / Levator Scapula

Tight Weak
SCM / Pectoralis Lower Trap / Serratus Ant.

Lower Crossed
Lower Crossed
Weak Tight
Syndrome

Syndrome
Abdominals Thoraco-lumbar erectors

Tight Weak
Rectus Femoris / Iliopsoas Gluteus Medius & Maximus

Figure. 1 Janda’s muscle imbalance (‘crossed’) syndromes. Used with permission of the Hygenic Corporation.

As the patient learns, the new coordinated areas in order to stimulate subcortial pathways and
movement pattern is programmed in the subcor- facilitate automatic coordinated movement pat-
tical region, becoming more ‘‘automatic’’ and terns. Therefore, it is vital to ensure proper
requiring less conscious thought processing, thus positioning of the joints at these three key points
becoming much quicker. At this point, ‘‘feed- during any exercise movement.
forward’’ mechanisms become important. Feed- The first postural key point is the foot (Freeman
forward mechanisms occur unconsciously and are and Wyke, 1967). Proprioceptive exercises are best
important in preparing the body for movement by performed without shoes (barefoot is best) to
contracting stabilizing muscles prior to initiating ensure the maximum amount of appropriate affer-
the movement. The importance of this mechanism ent information entering the sensorimotor system.
is most noted in the transverse abdominus muscle, First, stimulate the sole of the foot with tactile
which normally contracts prior to extremity move- input such as a sensory/reflex ball or brush, and the
ment (Hodges and Richardson, 1997a, b), and joints of the foot and ankle are mobilized. Most
becomes delayed in chronic musculoskeletal dys- importantly, instruct patients in the concept of the
function (Hodges and Richardson, 1998). ‘‘short foot’’, used to describe the shortening and
Janda felt that this automatic level of processing narrowing of the foot while the toes remain
was essential to protect joints for dynamic func- relaxed. This is accomplished by contracting the
tional stability throughout the body, and he devel- intrinsic muscles of the foot, thereby increasing the
oped his sensorimotor training (SMT) program in medial longitudinal arch and effectively ‘‘short-
1970 for rehabilitation of the lower extremities as ening’’ the length of the foot.
well as the spine (Janda and VaVrova, 1996). Janda stated that proprioception and postural
Influenced by the work of Freeman and collea- stability improve when exercises are performed
gues, noting the importance of foot proprioception, with a short foot (Janda and VaVrova, 1996). Begin
Janda focused on providing input into the sensor- training the patient in the short foot in sitting,
imotor system ‘‘from the ground-up’’. He empha- using ‘‘passive modeling’’ or hand positioning
sized the importance of optimal foot position and to help facilitate the patient to perform an
sensory stimulation to the sole of the foot to ensure active short foot (Figs. 2a and b). For patients
maximal afferent information during stance (Janda having difficulty maintaining a short foot, a strip of
and VaVrova, 1996). He suggested that the sensory Thera-Band is sometimes taped to the sole of the
information coming into the CNS must be optimal at foot as an ‘‘active-assist’’ to help patients maintain
three locations in the body due to their large the short foot position. (Fig. 3).
amounts of proproiceptors: the foot, the sacroiliac The next key point in postural stability is the SI
(SI) joint, and the cervical spine. The goal of SMT is joint (Hinoki and Ushio, 1975). The lumbopelvic
to increase proprioceptive input of these three region must be maintained in a ‘‘neutral’’ position,
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Figure. 2 (a) Passive modeling of the short foot. (b) Active modeling of the short foot. Used with permission of the
Hygenic Corporation.

sending information on posture to the CNS from the

lumbopelvic region. In addition, facilitation of the
transverse abdominus is cued by slightly drawing
the umbilicus inward.
Finally, the cervical spine plays an important role
in posture (Abrahams, 1977). These mechanore-
ceptors are important in maintaining equilibrium
and postural reflexes from birth. Placing the
cervical spine in a neutral position with the chin
slightly tucked helps activate the deep neck
flexors. Once the individual learns the proper
positioning of these three proprioceptive points,
SMT can begin.

Figure. 3 Thera-Band assist taping for short foot. Used

with permission of the Hygenic Corporation. Sensorimotor training progression
Patients progress through three stages of SMT:
neither too lordotic nor too kyphotic. It is im- static, dynamic, and functional (Table 2). Within
portant that any dysfunction of the SI joint be each stage, patients progress through exercises in
corrected prior to initiating SMT because of its role different postures, bases of support, and chal-
in proprioception. This helps ensure proper length- lenges to their center of gravity. Each exercise
tension relationships of the joint mechanoreceptors should elicit automatic and reflexive muscular
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Sensorimotor training: A ‘‘global’’ approach for balance training 81

Table 2 SMT progression.

Stage Description Posture Base of support Center of gravity

Static Maintain postural stability on Standing Firm Weight shifts

progressively unstable surfaces
1-leg balance Stability trainer Perturbations
Progress by shifting weight, 1/2 step Rocker board
closing eyes, or adding head
movements
Minisquat Wobble board
Minitrampoline
Dynamic Add arm and leg movements (progress above) (progress above) Upper extremity -
while maintaining postural Resisted band
stability on progressively
unstable surfaces. Use other
devices for additional challenge
(bands, balls, etc)
Lower extremity -
Resisted band
Weighted ball toss
Functional Perform functional movements Walk Balance sandals
(such as lunge or squat) on
progressively unstable surfaces
Squat
Lunge
Step
Jump
Run

stabilization, challenging the patient to maintain over the short foot while the patient maintains a
postural control under a variety of situations. neutral cervical and lumbar spine. Vary the
Static phase: In the static phase, emphasis is patient’s base of support by progressing from a
placed on developing a stable pelvis (‘‘core’’) from firm surface to a foam surface, and then progress to
which to build movement in subsequent phases. the rocker and wobble boards (Fig. 5). Using labile
The pelvis is stabilized by a ‘‘pelvic chain’’ of surfaces during exercises increases speed of con-
muscles (Lewit, 1999): the multifidus, transverse traction and motor output (Beard et al., 1994;
abdominus, pelvic floor, and diaphragm. Janda Blackburn et al., 2002; Bullock-Saxton et al., 1993;
(1987) noted that many movement impairments Ihara and Nakayama, 1986). During the static
are caused by, or reflected in the pelvis and hip phase, patients are challenged to maintain their
musculature. Without a stable base at the pelvis, center of gravity using passive weight shifts or
extremity movement will be compensated else- challenges to the center of gravity. These weight
where in the kinematic chain. This is the principle shifts and perturbations are used to elicit reflexive
of ‘‘proximal stability for distal mobility’’. Distal and automatic postural reactions (Nashner, 1989)
dysfunction (in the extremities) may be caused by that teach the patient pelvic stabilization in a more
or the result of proximal (lumbopelvic) dysfunction. functional position.
For example, knee dysfunction has been associated Dynamic phase: Once the patient exhibits the
with hip muscle weakness (Jaramillo et al., 1994, ability to maintain pelvic stability in the half-step
p. 2001). position under a variety of conditions, progress the
Remembering the importance of Janda’s three challenges of their center of gravity in the dynamic
key proprioceptive joints, patients maintain proper phase. The patient begins ‘‘building’’ on the stable
foot, SI, and cervical positioning during each pelvis by performing movements of the upper and
exercise. They progress from bilateral to unilateral lower extremity, gradually adding resistance to the
stance, and then to a ‘‘half-step’’ position (Fig. 4). movements. One of the most effective exercises to
In this half-step position, the trunk leans forward elicit automatic muscular contractions of the leg is
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It is important to re-train these feed-forward

mechanisms at this point in the rehabilitation.
Other techniques which may contribute to the
feed-forward mechanism include oscillation train-
ing of the extremity or perturbations to the center
of gravity. Imparting these additional challenges to
postural control may help facilitate these antici-
patory muscular stabilizing functions.
Functional phase: The final stage of SMT is
functional progression of postures with extremity
movement with a stable pelvis. These include
walking, squats, lunges, steps, jumps, and running.
At this point, patients are ready to begin using
Janda’s ‘‘Balance Sandals’’. These are simply
sandals with a hard rubber ball (cut in half)
attached to the mid-sole, providing a very unstable
and challenging position for the foot (Fig. 6).
Patients are encouraged to maintain a short foot
while maintaining correct posture at the pelvis and
head. Begin with small steps and progress to
forward, retro, and lateral walking in the shoes,
while avoiding lateral or vertical shifting of the
pelvis. Dr. Joanne Bullock-Saxton et al. (1993)
found that patients using Janda’s balance sandals
five times a day for 3 minutes improved their speed
of contraction of the gluteus maximus and medius
by as much as 200%, after just 7 days of training.
Blackburn et al. (2002) recently reported that the
balance shoes produced the same, if not more, EMG
activity of the lower leg during other closed-chain
exercises.
Advanced SMT activities combine many different
challenges to postural stability. For example,
patients may perform a lunge onto a wobble board,
with a concurrent anterior weight shift using an
elastic band (Fig. 7). This would promote eccentric
control of posture during the initial stance phase.
Posture is the most important consideration
when performing SMT. Patients are progressed
through various stages of SMT with progressive
challenges to their postural stability through the
base of support, center of gravity, or external
Figure. 4 Half-step position. Used with permission of the challenges. It is helpful to remind patients to
Hygenic Corporation. maintain proper posture at the three key areas of
proprioception (neck, low back, and foot). There-
fore, quality is more important than quantity when
the ‘‘T-Band Kick’’. Several studies have demon- performing SMT.
strated reflexive activation of muscles in the stance SMT exercises are typically performed to fatigue
leg while kicking an elastic band (Cordova et al., or for a certain amount of time. Rather than
1999; Hopkins et al., 1999; Schulthies et al., 1998) prescribe a specified number of repetitions, have
with the other leg. For example, when kicking the patient perform the exercise under direct
forward with the left leg, the hamstrings on the supervision to the point of fatigue. Remember that
stance leg are activated. In addition, movement of the goal of SMT is to increase muscle reaction and
the upper or lower extremity reflexively activates tissue endurance rather than joint strength. At the
the transverse abdominus (Hodges and Richardson, first sign of fatigue (the initial burning sensation or
1997a, b), thus improving pelvic stabilization. any compensated movement) the exercise is
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Sensorimotor training: A ‘‘global’’ approach for balance training 83

Figure. 5 Balance board progressions. Used with permission of the Hygenic Corporation.

stopped to avoid further compensatory movements

that may promote dysfunction.
SMT improves proprioception, strength, and
postural stability in lower extremity rehabilitation
(Beard et al., 1994; Ihara and Nakayama, 1986;
Pavlu and Novosadova, 2001). Clinically the author
has found SMT to be effective in treating chronic
low back pain, fibromyalgia and chronic neck pain.
While not appropriate for all chronic pain syn-
dromes, more research is needed in the use of SMT
for chronic musculoskeletal pain.
Figure. 6 Janda’s balance sandals (avialable in USA from
Janda prescribed SMT for chronic pain patients
OPTP: (800) 367-7393 or from The Gym Ball Store: (800)
393-7255). who exhibited his muscle imbalance syndromes in
order to re-program the CNS. To treat chronic
musculoskeletal pain, it if often necessary to treat
the entire sensorimotor system, not just involved
structures. The largest advantage to SMT is that
this progression can be easily performed as part of
a home program with inexpensive equipment, but it
is important that the therapist monitor the
patient’s ability to perform the exercises properly.

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