- Email: [email protected]
Sensory-motor training—an update
ARTICLE IN PRESS Journal of Bodywork and Movement Therapies (2005) 9, 142–147
Journal of Bodywork and Movement Therapies www.intl.elsevierhealth.com/journals/jbmt
SELF-HELP: CLINICIAN SECTION
Sensory-motor training—an update$ Craig Liebenson, DC 10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA
Sensory-motor training—an update
Introduction Balance is an often ignored, yet key musculoskeletal 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 association 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 finding is confirmed 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 $
This paper may be photocopied for educational use.
Tel.: +1 310 470 2909; fax: +1 310 470 3286.
E-mail address: [email protected]. 1360-8592/$ - see front matter & 2005 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2005.01.001
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 Canada’s 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 Sensory-motor training—an update
Assessment Quantifiable single leg stance balance test A quantifiable 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 first 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.
Table 1 Normative data for 1 leg standing balance test—eyes closed (Bohannon et al., 1984)
24.2–28.8 21.0 10.2 4.3
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 flexed approximately 601. J Stand in this position for 20 s. Score:
20–49 50–59 60–69 70–79
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 quantifiable force plate measurements to the SLS test and confirmed that difficulty balancing on one leg is due to a) inadequate compensation for the weight shift, and b) musculoskeletal weakness. Procedure:
Eyes closed (s)
Janda’s single leg standing balance test
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 position). The stance leg hops. The hands touch anything other than themselves.
Age (years)
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 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).
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
Sensory-motor training—an update
suggests a much lower risk (Hurvitz et al., 2000) (see balance test in accompanying Self-Help: Patient’s 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 office and self-treatment due to its simplicity and effectiveness (Liebenson and Oslance, 1996; Janda and Va’ vrova’, 1996). It is a highly efficient approach which has been shown to yield superior strength gains when compared to a more timeconsuming 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.
143
ARTICLE IN PRESS 144 training includes the following (Fig. 1):
Postural correction beginning with the ‘‘short foot’’. Double and single leg stance (D&SLS) on firm 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.
C. Liebenson 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. Janda’s approach begins with careful attention to formation of an actively shortened longitudinal arch of the foot without flexion 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 difficult for the patient to form so clinician assistance is often required. Passive modeling by the clinician to approximate the medial calcaneus and the first metatarsal can be performed. The toes should stay fairly flat and the medial arch should also be brought together (see Fig. 2). The patient can progress to forming the ‘‘short foot’’ with the clinician’s active assistance (semi-active), and then finally they can perform it actively.
Formation of the ‘‘short foot
Sensory-motor training—an update
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:
Figure 1 Single-leg stance balance test. Reproduced from Liebenson CS. Advice for the clinician and patient: Sensory-motor training. Journal of Bodywork and Movement Therapies, 5;1:21–28, 2001.
‘‘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 floor in
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): 21–28, 2001.
ARTICLE IN PRESS Sensory-motor training—an update
Figure 3 Neutral postural correction.
Figure 4 (a–c) Forward stepping lunge.
Sensory-motor training—an update
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 exercise—forward stepping lunge—are 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 flex during the stepping motion,
145
ARTICLE IN PRESS 146 but at not be allowed to pass beyond the toes at impact. The back leg should be relaxed with slight knee flexion, and the heel should rise from the floor. 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 musculoskeletal 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.
Sensory-motor training—an update
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, 664–772. 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, 23–30. 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), 1067–1070. Bullock-Saxton, J.E., Janda, V., Bullock, M.I., 1993. Reflex activation of gluteal muscles in walking. Spine 18 (6), 704–708. 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), 19–21. Fitzgerald, G.K., Axe, M.J., Snyder-Mackler, L., 2000. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Physical Therapy 80, 128–140. 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, 678–685. Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E., Cumming, R.G., Rowe, B.H., 2001. Interventions for preventing 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, 587–591. Janda, V., Va’ vrova’, M., 1990. Sensory Motor Stimulation: A Video. Presented by JE Bullock-Saxton, Brisbance, Australlia, Body Control Systems.
C. Liebenson 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.), Rehabilitation 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, 688–694. Liebenson, C.S., 2001. Advice for the clinician and patient: sensory-motor training. Journal of Bodywork and Movement Therapies 5 (1), 21–28. 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, 647–660. 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), 731–746. Michaelson, P., Michaelson, M., 2003. Vertical posture and head stability in patients with chronic neck pain. J Rehabil Med Sept 35 (5), 229–235. 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, 710–716. 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, E107–E112. 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, 478–486. 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, 686–693. 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 Officials 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. RANDHCFA 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
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, 64–66. Wegener, L., Kisner, C., Nichols, D., 1997. Static and dyamic balance responses in persons with bilateral knee osteoar-
147 thritis. Journal of Orthopaedic & Sports Physical Therapy 25, 13–18. 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, 489–497.
Sensory-motor training—an update
Sensory-motor training—an update
Journal of Bodywork and Movement Therapies www.intl.elsevierhealth.com/journals/jbmt
SELF-HELP: CLINICIAN SECTION
Sensory-motor training—an update$ Craig Liebenson, DC 10474 Santa Monica Blvd., No. 202, Los Angeles, CA 90025, USA
Sensory-motor training—an update
Introduction Balance is an often ignored, yet key musculoskeletal 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 association 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 finding is confirmed 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 $
This paper may be photocopied for educational use.
Tel.: +1 310 470 2909; fax: +1 310 470 3286.
E-mail address: [email protected]. 1360-8592/$ - see front matter & 2005 Published by Elsevier Ltd. doi:10.1016/j.jbmt.2005.01.001
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 Canada’s 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 Sensory-motor training—an update
Assessment Quantifiable single leg stance balance test A quantifiable 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 first 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.
Table 1 Normative data for 1 leg standing balance test—eyes closed (Bohannon et al., 1984)
24.2–28.8 21.0 10.2 4.3
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 flexed approximately 601. J Stand in this position for 20 s. Score:
20–49 50–59 60–69 70–79
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 quantifiable force plate measurements to the SLS test and confirmed that difficulty balancing on one leg is due to a) inadequate compensation for the weight shift, and b) musculoskeletal weakness. Procedure:
Eyes closed (s)
Janda’s single leg standing balance test
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 position). The stance leg hops. The hands touch anything other than themselves.
Age (years)
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 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).
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
Sensory-motor training—an update
suggests a much lower risk (Hurvitz et al., 2000) (see balance test in accompanying Self-Help: Patient’s 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 office and self-treatment due to its simplicity and effectiveness (Liebenson and Oslance, 1996; Janda and Va’ vrova’, 1996). It is a highly efficient approach which has been shown to yield superior strength gains when compared to a more timeconsuming 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.
143
ARTICLE IN PRESS 144 training includes the following (Fig. 1):
Postural correction beginning with the ‘‘short foot’’. Double and single leg stance (D&SLS) on firm 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.
C. Liebenson 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. Janda’s approach begins with careful attention to formation of an actively shortened longitudinal arch of the foot without flexion 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 difficult for the patient to form so clinician assistance is often required. Passive modeling by the clinician to approximate the medial calcaneus and the first metatarsal can be performed. The toes should stay fairly flat and the medial arch should also be brought together (see Fig. 2). The patient can progress to forming the ‘‘short foot’’ with the clinician’s active assistance (semi-active), and then finally they can perform it actively.
Formation of the ‘‘short foot
Sensory-motor training—an update
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:
Figure 1 Single-leg stance balance test. Reproduced from Liebenson CS. Advice for the clinician and patient: Sensory-motor training. Journal of Bodywork and Movement Therapies, 5;1:21–28, 2001.
‘‘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 floor in
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): 21–28, 2001.
ARTICLE IN PRESS Sensory-motor training—an update
Figure 3 Neutral postural correction.
Figure 4 (a–c) Forward stepping lunge.
Sensory-motor training—an update
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 exercise—forward stepping lunge—are 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 flex during the stepping motion,
145
ARTICLE IN PRESS 146 but at not be allowed to pass beyond the toes at impact. The back leg should be relaxed with slight knee flexion, and the heel should rise from the floor. 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 musculoskeletal 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.
Sensory-motor training—an update
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, 664–772. 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, 23–30. 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), 1067–1070. Bullock-Saxton, J.E., Janda, V., Bullock, M.I., 1993. Reflex activation of gluteal muscles in walking. Spine 18 (6), 704–708. 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), 19–21. Fitzgerald, G.K., Axe, M.J., Snyder-Mackler, L., 2000. The efficacy of perturbation training in nonoperative anterior cruciate ligament rehabilitation programs for physical active individuals. Physical Therapy 80, 128–140. 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, 678–685. Gillespie, L.D., Gillespie, W.J., Robertson, M.C., Lamb, S.E., Cumming, R.G., Rowe, B.H., 2001. Interventions for preventing 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, 587–591. Janda, V., Va’ vrova’, M., 1990. Sensory Motor Stimulation: A Video. Presented by JE Bullock-Saxton, Brisbance, Australlia, Body Control Systems.
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Sensory-motor training—an update
Sensory-motor training—an update