Restoring Balance

Postural stability is key to strengthening balance and reducing the risk of falls.

By Marcella Durand, May 15, 2019

For Jeffrey Forman, Ph.D., improving postural stability doesn't start at the top. Rather, it begins from the ground up.

“It all starts with the feet,” says Forman, who leads workshops on balance and postural stability training for massage therapists, “and it moves up the kinetic chain.”

According to Forman, the loss of sensory stimulation in the feet, due to sedentary lifestyles and years of “cramming in shoes,” is an important contributor to posture and balance issues. These issues, in turn, can lead to a range of problems, including increased risk of falls, a significant health issue, particularly for older people.

Drawing from his experience in rehab, Forman teaches massage and exercise techniques to reconnect the brain to the feet, and from there, to improve stability overall. “We want to get people as stable as possible,” he says. To massage therapists like Tony Davenport, M.Sc., LMT, MMP, posture deficits are “leading causes of acute and chronic pain—the reason many people want and need massage.” For that reason, postural stability is a growing area of attention for massage therapists.

A Complex Connection

According to the Centers for Disease Control and Prevention, more than 1 out of 4 seniors experience a fall each year. And once someone falls, their chances double of falling again.1 “When you don’t trust your body anymore, you think about it all the time,” says JoEllen M. Sefton, Ph.D., ATC, LAT, director of the Warrior Research Center, School of Kinesiology, at Auburn University in Alabama.

Sefton was the lead author of a 2012 study,2 funded by the Massage Therapy Foundation, which investigated the effects of a 60-minute full-body massage therapy treatment on 35 healthy, older people. The results showed that the treatment improved stability and balance compared to the control group, and the researchers concluded that massage therapy “should be investigated as a potential intervention to decrease falls in older individuals.”

“We see some older people acquiring a slightly flexed posture,” says Sefton. “Their muscles are working a lot harder to maintain an upright balance.” In addition, she points out that falling can also set up a fear of falling, which, ironically, may lead to more falls. “If they are afraid of falling, they get more rigid, and that rigid stance makes them more susceptible to falling.”

Good Posture for All

Younger people can have postural problems brewing, too, as sitting at a desk and relying on electronics are key contributors to poor posture and balance. “Clients lock into postural patterns, then come to see us with the consequences, which can include pain, stiffness, tension and trapped nerves,” says Zhanna Root, LMT, the founder of Princeton Posture and Massage in Princeton, New Jersey.

During a session, Davenport may spot issues that a client might not be aware of—yet. “You can see partial distortions in people lying prone on the table,” he says. “If you’re looking close enough, you can see the alignment of hips to shoulders, and whether they have a slight scoliotic curve developing that they may not be aware of.”

Root decided that she needed more training to understand body mechanics, balance and postural compensation to get to the root causes of clients’ issues. Once she began applying what she was learning, she saw improvements. “When we apply postural principles to soft-tissue release, we are getting to the cause of the problem, while removing locked-in misalignment restrictions.” However, she also likes to refer clients to physical therapists when necessary. “What brings long-lasting results is building new postural patterns while releasing old restrictions, and this is when I refer out to physical therapy or personal training, depending on the severity of muscle imbalance and chronic conditions.”

Davenport, who is currently working on his Ph.D. in Health and Human Performance, also consults with chiropractors regularly and applies what he learns to his own practice. He talks about which muscles are “locked short” and which are “locked long.” “When you do targeted work, you’re looking at which tissues you need to lengthen, or are ‘locked short,’ and which are overstretched, or ‘locked long,’ that you need to stimulate and contract.”

This all helps bring back into balance what has been out of balance. “Poor posture leads to bad balance, which leads to diminished flexibility,” says Davenport. “Poor posture will lead to poor performance.”

Bringing Back Balance

In combination with massage, certain tools and activities may help improve postural stability. Forman conducted an unpublished research project at Wichita State University in 2014 on the effects of massage combined with resistance in adults aged 50–65 years. In the study, he found that balance scores increased by close to 5 percent, and that all measures of ankle flexibility improved, with a 12.5 percent increase in range of movement. This project followed an earlier study by Forman, published in the Journal of Bodywork and Movement Therapies ( January 2014),3 of the effects of massage combined with eccentric resistance exercise on hamstring length and strength. The study found that combining massage with resistance increased hamstring flexibility.

“We want to speed up nervous transmission from afferent receptors located in peripheral joints, muscles, the fascia, ligaments and other mechanoreceptors for touch pressure, pain and temperature to the central nervous system, then back to the muscles for corrective action,” says Forman. “The soles of the feet, the sacroiliac joint and the cervical spine are considered posture regulators due to their density of mechanoreceptors and influence on movement and postural stability.” To increase proprioceptive input from these areas, he uses big toe movement exercises, a progressive series of short foot modeling exercises and stimulating strokes to the feet. He follows with short foot kinesiology taping, then moves up with stimulating strokes to the sacrum and cervical spines.

“I can actually do things with my toes I couldn’t do before his class,” says Sharon Bryant, founder of Harvest Moon Massage Therapy & Reflexology in Decatur, Alabama, who was curious enough about postural stability training that she signed up to attend Forman’s presentation at the AMTA 2018 National Convention in Washington, D.C. “That action of just taking your foot in your hand begins to connect your brain to your feet.”

Self-Care for the Massage Therapist

Massage therapists also need to be aware of their own posture when they are working, says Jeffrey Forman, Ph.D. Poor posture from bending over clients can lead to a range of issues, including headaches, neck pain, shoulder pain, lower back pain and foot problems. Forman recommends using a full set of “tools” for self-care, including heat and ice, instrument-assisted soft-tissue mobilization (IASTM), stretching, Theraband exercises and topical analgesics.

Tony Davenport, M.Sc., LMT, MMP, says he visits a chiropractor regularly, gets massages and keeps fit through regular gym visits. He also brings a small stool to sessions to sit on when he needs to. “I listen to my body,” he says. “If my back is hurting or my shoulders are tired, I bring the work to my level so I can do my work without feeling pain.”

As a barefoot massage therapist, Sharon Bryant found Forman’s techniques particularly useful for keeping her own feet flexible and healthy. “[His class] fit right into my niche—taking care of myself and taking care of my clients.”

Related: Exercises for Maintaining Flexibility

Assessment Is Key

For massage therapists, assessing a client’s posture and balance issues may be immediate.

“I start assessing my clients’ movement and balancing patterns as soon as they walk into my office. I look for imbalances, alignment or misalignment,” says Zhanna Root, LMT, who says she collects “as much information as possible,” including hobbies, occupation, if someone sits at a desk—anything that might point to repetitive motions or patterns that could cause problems. “You need to know their story, then you know what the body is compensating for.”

JoEllen M. Sefton, Ph.D., ATC, LAT, also recommends considering medications in an assessment, particularly as some medications can contribute to balance issues. Tony Davenport, M.Sc., LMT, MMP, uses a postural assessment app that analyzes photos he takes of clients’ posture from the front and side. “It produces a report [that I can use] for a more thorough orthopedic assessment.”


1. Centers for Disease Control and Prevention.
2. Sefton JE, Ceren Yarar C, Berry JW. Massage therapy produces short-term improvements in balance, neurological, and cardiovascular measures in older persons. Int J Ther Massage Bodywork, 2012 Sep 26; 5(3):16–27.
3. Forman J, Geertsen L, Rogers ME. Effect of deep stripping massage alone or with eccentric resistance on hamstring length and strength. Journal of Bodywork and Movement Therapies. 2014 Jan; 18(1): 139–144.