(646) 355-8777

Herman & Wallace Blog

Walk this Way: 5 Visual Imagery Cues to Improve Your Patient’s Posture and Gait

Deb Gulbrandson, PT, DPT is teaming up with Frank J Ciuba DPT, MS to create a new course called Osteoporosis Management: A Comprehensive Approach for Healthcare Professionals! This new course is launching remotely this July 25-26, 2020, and it emphasizes visual imagery cues which leads to enhanced performance for patients. Both course authors are trained by Sara Meeks, and have adapted her method to create this updated, evidence-based course on osteoporosis management.


How many times have you told your patients to stand up straight and stop looking down while walking? How’d that work out? Probably not so good. At best you may have noticed a temporary correction only for the patient to return to the formerly mentioned poor posture. We know that balance is affected by alignment of our trunk and spine. 1 Everyone needs to avoid falls but it’s particularly important with osteoporosis patients due to bone fragility.

PostureWe want our patients not only to move, but to move with optimal alignment. According to Fritz, et al 2 in the vhitepaper: “Walking Speed: The Sixth Vital Sign”, walking is a complex functional activity. Our ability to influence motor control, muscle performance, sensory and perceptual function, endurance and habitual activity level can result in a more efficient and safer gait.

Visual imagery cuing had been popular in the sports world for decades. By changing one or two words, physical performance has been shown to improve. 3 In a study involving standing long jump, Wu et al instructed undergraduate students to either “Jump as far as you can and think about extending your legs” (internal focus) or “Jump as far as you can and think about jumping as close to the green target as possible” (external focus). The external focus group jumped 10% farther. Lohse et al 4 and Zachry et al 5 surmised that an external focus reduces the "noise" in the motor system which affects muscular tension and optimal function.

It Starts with Posture

Before you can expect your patients to walk well, they have to stand well- stability before mobility. Assess their posture from all angles and determine where to start. One visual image may change a host of problems. A common postural fault, “slumping” is seen as forward head, increased thoracic kyphosis accompanied with either lumbar hyper or hypo lordosis. Your goal is to get the optimal alignment image that you have in your mind……. into their body.

Most people think in pictures rather than words. 6 Yet the medical industry uses words to communicate. Often we say, “Don’t slouch. Don’t look down.” Telling your patient what not to do is not helpful. Our brain hears the words, “Slouch or look down.” We don’t discern the negative. If I say to you, “Don’t think of a pink elephant,” what does your mind see? How can you not see a pink elephant?

Below are five common visual cues to improve a patient’s posture in standing and walking. These tend to follow the Pareto Principle. 20% of your cues work 80% of the time.

    1. “In standing, imagine a bungee cord running from the top of your head to the ceiling. Visualize a mother cat lifting her kitten up by the scruff of the neck.”
    2. “When breathing, imagine an umbrella inside your ribcage, opening up upon inhale, and closing on exhale. Breathe in all directions including into the back of your lungs as if you were filling up the sails of a sailboat.”
    3. “When walking, widen your collarbones as if they were arrows, shooting off the tips of your shoulders. Imagine your head is a floating balloon, gliding along above your shoulders.”
    4. “Pretend you are the King (or Queen) of England as you walk among your subjects. “
    5. “Slide your shoulder blades down toward your opposite hip pockets.”

Choose a cue and instruct your patient. Observe changes in posture, alignment, efficiency of movement, or length of step during gait. Ask your patient for feedback. “What did you notice?” Certain cues resonate more than others. Give them variety and options. The best cues are the ones they create themselves. When a patient says, “You mean like………..?” you know it’s a great cue for them. They have an intuitive understanding and relate to it which translates into their body. A patient’s response to the bungee cord cue was, “You mean like a Christmas ornament hanging from the tree?” My response? Absolutely!

While some visual cues may seem too flowery or not “medical” enough, the research is solid the impact powerful. Plus your patients love it! Visual cues are sticky. They help remind us when we’re out in the real world. Isn’t that the ultimate goal – helping patients become independent in their pursuit of health and safety?


1. Shiro Imagam, et all. Influence of spinal sagittal alignment, body balance, muscle strength, and physical ability on falling of middle-aged and elderly males. Eur Spine J. 2013 Jun;
2. Fritz S. et al White Paper: “Walking Speed: The Sixth Vital Sign” J Geriatr Phys Ther. 2009
3. Wu, et al Effect of Attentional Focus Strategies on Peak Force and Performance in the Standing Long Jump. Joun of Strength and Conditioning Research 2012
4. Lohse and Sherwood Defining the Focus of Attention: Effects of Attention on Perceived Exertion and Fatigue
5. Zachry, T et al. Increased Movement Accuracy and Reduced EMG Activity as a Result of Adopting an External Focus of Attention. Brain Research Bulletin Oct 2005
6. Dynamic Alignment Through Imagery. Franklin, Eric. Second Edition, 2012

Treating Non-Motor Symptoms of Parkinson Disease
What is Restorative Yoga?

Upcoming Continuing Education Courses

Male Pelvic Floor - San Diego, CA (Postponed)

Dec 4, 2020 - Dec 6, 2020
Location: FunctionSmart Physical Therapy

Chronic Pelvic Pain - Medford, OR (Postponed)

Dec 4, 2020 - Dec 6, 2020
Location: Asante Rogue Valley Medical Center

Pediatric Functional Gastrointestinal Disorders - Ann Arbor, MI (Postponed)

Dec 4, 2020 - Dec 6, 2020
Location: Michigan Medicine

Sacral Nerve Manual Assessment and Treatment - Madison, WI (NOW REMOTE)

Dec 4, 2020 - Dec 6, 2020
Location: SSM Health

Yoga for Pelvic Pain - Phoenix, AZ (Postponed)

Dec 5, 2020 - Dec 6, 2020
Location: St. Joseph's Hospital - Phoenix

Yoga for Pelvic Pain - Remote Course (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Replacement Remote Course

Male Pelvic Floor - Satellite Lab Course

Dec 5, 2020 - Dec 6, 2020
Location: Replacement Remote Course

Male Pelvic Floor - San Diego, CA Satellite Location (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: FunctionSmart Physical Therapy

Male Pelvic Floor - Washington, DC Satellite Location

Dec 5, 2020 - Dec 6, 2020
Location: Georgetown University Hospital

Pelvic Floor Level 1 - Satellite Lab Course

Dec 5, 2020 - Dec 6, 2020
Location: Replacement Remote Course

Pelvic Floor Level 1 - Little Rock, AR Satellite Location (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Core Pelvic Physical Therapy

Pelvic Floor Level 1 - Burlington, WA Satellite Location (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Northwest Physical Therapy

Pelvic Floor Level 1 - Self-Hosted (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Self-Hosted Course

Pelvic Floor Level 1 - Canton, OH Satellite Location (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Mercy Hospital

Male Pelvic Floor - Minneapolis, MN Satellite Location (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Fairview Institute of Athletic Medicine

Pelvic Floor Level 1 - Medford, OR Satellite Location (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Asante Rogue Valley Medical Center

Male Pelvic Floor - Self Hosted

Dec 5, 2020 - Dec 6, 2020
Location: Self-Hosted Course

Pelvic Floor Level 2A - New Orleans, LA Satellite Location

Dec 5, 2020 - Dec 6, 2020
Location: Ochsner Therapy and Wellness/Ochsner Health System

Pelvic Floor Level 2A - Self-Hosted

Dec 5, 2020 - Dec 6, 2020
Location: Self-Hosted Course

Pelvic Floor Level 2A - New Orleans, LA (SOLD OUT)

Dec 5, 2020 - Dec 6, 2020
Location: Ochsner Health System

Pediatric Functional Gastrointestinal Disorders - Remote Course

Dec 5, 2020 - Dec 6, 2020
Location: Replacement Remote Course

Pelvic Floor Series Capstone - Washington, DC (POSTPONED)

Dec 12, 2020 - Dec 13, 2020
Location: The George Washington University

Pelvic Floor Level 1 - Tallahassee, FL (Postponed)

Dec 12, 2020 - Dec 13, 2020
Location: Tallahassee Memorial HealthCare

Breathing and the Diaphragm - Remote Course

Dec 12, 2020 - Dec 13, 2020
Location: Replacement Remote Course

Manual Therapy for the Abdominal Wall - Remote Course (SOLD OUT)

Dec 12, 2020
Location: Short Form Remote Course

Pelvic Floor Capstone - Washington, DC Satellite Location

Dec 12, 2020 - Dec 13, 2020
Location: Georgetown University Hospital

Pelvic Floor Capstone - East Norriton, PA Satellite Location

Dec 12, 2020 - Dec 13, 2020
Location: Core 3 Physical Therapy

Pelvic Floor Capstone - Salt Lake City, UT Satellite Location

Dec 12, 2020 - Dec 13, 2020
Location: Pagnani Physical Therapy

Pelvic Floor Capstone - Self-Hosted

Dec 12, 2020 - Dec 13, 2020
Location: Self-Hosted Course

Pelvic Floor Capstone - Greenville, SC Satellite Location (Postponed)

Dec 12, 2020 - Dec 13, 2020
Location: Restore Pelvic Health and Wellness