Balance on Elderly

Fisioterapi Geriatri
 Balance?

• Balance : stability and steadiness when person is standing or sitting.

Good balance means someone can control and maintain their body’s
position comfortably while performing normal activities.
• Ability to control the COG over the BOS in a given sensory
environments
• Balance is defined as a “complex process involving the reception and
integration of sensory inputs, planning and execution of movements,
to achieve a goal requiring upright posture.”
 Keseimbangan

Statis Dinamis

• Kemampuan mempertahankan
keseimbangan Ketika bergerak.
• Pemeliharaan pada tubuh saat
• Kemampuan untuk menjaga
melakukan Gerakan, atau saat berdidri
keseimbangan pada posisi tetap pada landasan ang bergerak (dynamic
standing) yang akan menempatkan ke
dalam posisi yang tidak stabil
The System Approach of Balance

PERSON
ENVIRONMENT
Balance is the result of interactions
between the individual, task and
environtment TASK
The System Approach of Balance

Within the Individual/person :

 Sensory inputs and processing system (between E & P)
 Motor planning & execution system (between P & T)
 Influence of other systems
Person
• Sensory • execution
• Sensory
input processing and
motor planning

Environtment Task
Sensory input & Processing system

• Peripheral sensory reception.

 Somatosnsory
 Visual
 Vestibular
• Central sensory perception
 Multi sensory
Motor planning and Execution system

• Central motor planning and control

 Depends on: attention, intention and motivation
• Peripheral motor execution
 Through bilaretal joints and muscles, factors
influencing are:
 ROM
 Mucle strength
 Endurance
 Influence of other systems

• Cognitive and behavioral factors :

 Cognition
 Judgment
 Memory
 Depression
 Emotional liability
 Agitation
 Denial of impairment
 Environmental context

- Balancing is always accomplished in an environmental

context
- Some environmental factor influencing balance are:
- Gravity
- Surface conditions
- Visual environment
- Intention
- Task choice
Balance Pathway
Sensory component of balance

Biofeedback : Audio and Visual

Biofeedback provide
additional sensory
information
Vision
Sensory
Vestibular Internal Map
Integration
Somatosensory
Brain
Muscles
Sensory component of Balance

Somatosensory system Vestibular Systme Visual System

• Cutaneous receptors in • Located in the inner ear • Visual input

soles of the feet • Static information about
• Muscle spindle and golgi orientation
tendon organ information • Linear acceleration,
• Ankle joint receptors rotations in the space
• Proprioceptors located at
other body segments
 Motor component of Balance
Reflexes Automatic Postural Anticipatory postural Volitional Postural
Response adjustments Movement
• Vestibulo-ocular • Ankle strategy • Aim: to counteract • Self initiated
Reflex (VOR)  • Hip strategy the destabilizing disturbance of
coordination of eye • Suspensory consequence of a the COG to
and head movement strategy voluntary accomplish a
• Vestibulospinal • Stepping and movements goal
Reflex (VSR)  reaching strategy • Failure to produce
control movement this adjustments
and stabilize the  increases the
body risk of falling
Basic Principles of Postural Control - Balance
Summary
Motor cortex

Visual

for voluntary
Comparator

movement

Command
Processing &
Vestibular
Integration
Info on Desirable
body body
orientation orientation Arm/Leg position
Somatosensory
Corrective
command
Anticipatory
adjustment
Body Orientation
Destabilizing effext of voluntary
movement
BALANCE IN ELDERLY
Balance impairments resulting from:

• Neurological conditions

• Musculoskeletal conditions

• Psychological conditions.
 The Effect of Aging on Postural
Control and Balance

• The Sensory System

• With aging:
 Vision may decrease in acuity, contrast sensitivity, and depth
percention
 The vestibular system may ndergo age related changes, resulting in
dizziness and unsteadiness
 There may be a dcrease In proprioception and vibration
 The Effect of Aging on Postural
Control and Balance

• The Central Processing System

• Aging result in:
 Slowing of sensory information
 Slowing of nerve conduction velocity
 Increased postural sway
 Increase incidence of co-contraction
• Cognitive area
 High leve sensory adaptation : decreased ability to shift from the use of one
sensory input to other for postural control
 Attention: poorer performance in dual tasks (cognitive and posturan tasks)
 Risk of Fall in Older adults

2 Classification:
 Classification 1:
1. Intrinsic (Internal) risk factors
2. Extrinsic (External) risk factors
3. Acquired Risk factors
 Classification 2:
1. Modifiable Risk Factors
2. Non-Modifiable Risk Factors
 Assessment of Balance in Elderly

• Underlying components of balance control to be assessed include:

 Musculoskeletal
 Sensory
 Motor
 Cognitive
• Balance Task to be assessed include:
 Self report measurement
 Quiet Standing (Static)
 Active standing (Dynamic)
 Sensory Manipulation
 Vestiblar
 Functional Scales
 Dual Task and multiple task
Cont…
 Self Report Measures
The Activities-specific Balance Confidence (ABC) Scale

• Merupakan instrument pengukuran spesifik keseimbangan

yang memiliki 16 item-scale, dimana setiap item di nilai dari
0% (no confidence) to 100% (complete confidence)
• Form: Questionaire/Survey
• Reliabililty validity = Good
 Total the ratings (Possible range = 0 - 1600) divide by
16 to get each subject’s ABC Scores
Interpretation :
ⱶ Low level functioning = < 50
ⱶ Medium level of functioning = > 50 – 80
ⱶ High level of functioning = >80
 Assessment of Balance in Elderly
Quiet Standing
• Mengacu pada test dimana px berdiri (standing) dan tujuan nya
adalah meminta px untuk bertahan di posisi tersebut (hold still) 
static Balance
• Perturbation may or may not be applied
• Contohnya:
 Double limb standing
 Single limb standing (CLS)/Unileteral standing
 Tandem Stance
 Romberg, etc.
 Quiet Standing
One Legged Stance Test/ Single Leg Stand
Procedure
• Kedua Kaki harus bergantian di tes (kanan dan kiri)
• Perbedaan antara kedua nya harus di laporkan/di catat
∞ Px beridir dengan dua kaki, kedua tangan menyilang di
depan dada, Perintahakan untuk mengangkat sebelah kak
dan tahan dengan posisi netral dan knee flexed 90 derajat
∞ Kaki yang di angkat tidak boleh menumpu/bersandar pada
kaki sebelahnya
∞ 5 x 30 detik dilakukan untuk setiap bagian kanan dan kiri
• Interpretation
∞ Normal = dapat melakukan selama 30 detik
∞ Gehlsen and whaley mengemukakan bahwa dengan one
legged stance test membedakan lansia dengan resiko jatuh
dan yang tidak memiliki resiko jatuh
 Assessment of Balance in Elderly
Active Standing
• Mengacu pada test dimana px berdiri (standing) dan tujuan nya adalah
meminta px untuk bertahan di posisi tersebut dengan terdapat gaya
(voluntary weighing shifting)  Dynamic Balance
• Perturbation may or may not be applied
• Contohnya:
 Functional reach test
 Multidirectional reach
 Sit to stand, sit down
 Reaching movement
 Different waling tasks (turning, head rotation, stoop and start, ).
 Active Standing
Functional Reach Test
Procedure
Merupakan test cepat untuk pemeriksaan masalah keseimbangan pada lansia
- Px haru mampu bersiri independently atleast 30 dsec tanpa bantuan dan mampu
untuk flexi shoulder hingg 90 derajat
- Posisikan pasien dekat dengan tembok.
- Intruksikan px untuk memfleksikan shouder 90 derajat dekat dengan dinding
- Intruksikan untuk meraih (reach forward) tanpa menggerakkan kaki. Boleh
melakukan reaching strategy tetapi tanpa pergerakan pada kedua kaki (step)
- Di ukur hasil jangkauan awal dan akhir jangkauan
 Active Standing
Functional Reach Test

Interpretation:
Age related norms for functional reach test :
Age Men Women

20 – 40 yrs 16.7 14.6

41 – 69 yrs 14.9 13.8

70 – 87 yrs 13.2 10.5

 Assessment of Balance in Elderly
Vestibular System

• These tests use various body & head positions, eye movement, or stepping to
stimulate or restrict visual, vestibular or somatosensory input
• Contohnya:
 Hallpike-Dix Maneuver
 Visual acuity (Snellen chart)
 nystagmus,
 Fukuda stepping test
 Vertigous positions
 Visual-vestibular interaction, etc.
 Vestibular System
Hallpike-Dix Maneuver
• It is a vertiginous position test to stimulate
the post semicircular canal
• Procedure
• Moving the patients from a sitting
position with the head turned so that the
affected ear is 30 – 45 degree below the
horizontal stimulate post. Canal and may
produce nystagmus and vertigo
• A positive result leads to diagnosis of
Benign positional vertigo (BPV)
 Assessment of Balance in Elderly
Functional Scale

• Functional balance, mobility, and gait scales involve the performance of

whole body movement task
• Contohnya:
 Berg Balance Scale
 Tinetti Performance oriented assessment of gait
 Timed up and go test
 Gair assessment rating scale (GARS)
 Dynamic Gait Index
 Functional Gait Assessment
 Functional Test
Berg Balance Scale

• Merupakan pengukuran untuk menentukan kemampuan

atau ketidak mampuan mempertahankan keseimbangan
seseorang ktika melakukan serangkaian tugas yang telah
ditentukan.
• 14 items, 0 – 4 point, 0 = lowest level, 4 highest level of
function
 A score 56 indicates functional balance
A score < 45 indicates individuals may be at a grater
risk of fall
 Interpretation :
 0 – 20  wheelchair bound
 21 – 40  walking with assistance
 41 – 56  independent
 Timed Up and Go Test
Timed Up and Go Test  clinical test bertujuan untuk mengukur mobility, balance/
keseimbangan static dan dynamic

 Sebelum test dilakukan Fts memberikan penjelasan,

tujuan dan contoh terkait test yang akan dilakukan
 Pasien menggunakan pakaian yang nyaman untuk
bergerak
 Pasien diminta untuk duduk di kursi
 Fts memberikan aba-aba kepada pasien :
Berdiri  lalu berjalan 3 meter  putar balik 
berjalan kembali menuju kursi  kembali duduk
 Stopwatch di mulai sejak Fts memberikan aba-aba
‘Mulai’ dan stop saat pasien kembali duduk.
 Timed Up and Go Test
Timed Up and Go Test  clinical test bertujuan untuk mengukur mobility, balance/
keseimbangan static dan dynamic

 Cut of Scores :
 Community dwelling adults : 13.5 s
 Frail elderly : 32.6 s
 Hip OA : 10 s
 Functional Test
Finger to Nose test

• Gangguan pada serebelum atau saraf-saraf propioseptif dapat juga menyebabkan ataxia
tipe dysmetria. Dismetria berarti hilang nya kemampuan untuk memulai atau
menghentikan susatu Gerakan motoric halus. Untuk menguji adanya suatu dysmetria bisa
dilakukan beberapa pemeriksaan, salah satunya adalah finger to nose test.
• Pemeriksaan ini bisa dilakukan dengan pasien dalam kondisi berbaring, duduk atau berdiri.
Diawali dengan mengabduksikan lengan serta posisi ekstensi total, lalu pasien diminta
untuk menyentuh ujung hidung nya seniri dengan ujung jari telunjurnya. Mula-mula
dengan Gerakan perlahan kemudian dengan Gerakan cepat, baik dengan mata terbuka dan
tertutup.
 Functional Test
Nose to finger nose test

• Serupa dengan finger to nose test tetapi setelah paien menyentuh hidung nya, pasien
diminta untuk menyentuh ujung jari pemeriksa dan kemudian Kembali menyentuh
hidungnya. Jari pemeriksa dapat diubah baik daam jarak maupun dalam bidang gerakan

Finger to Finger
• Pasien diminta mengabduksikan lengan pada bidang horizontal dan diminta untuk
menggerakkan kedua ujung jari telunjuknya saling bertemu tepat di tengah-tengah bidang
horizontal tersebut. Pertama dengan Gerakan perlahan kemudian dengan Gerakan cepat
dengan mata ditutup atau dibuka
 Latihan Keseimbangan

• Berdiri satu kaki

Beginer • Berpegangan

• Berdiri satu kaki

Intermediete • Tanpa berpegangan

• Berdiri satu kaki

Advance • Tanpa berpegangan
• Pejamkan kedua mata
 Sideways Walking
- Stand with the feet together, knee slightly bend
- Step sideways in a slow and controlled manner,moving one foot to the side first
- Move the other to join it
- Avoid dropping the hips as the step.
- Perform 10 steps each way or str from one side of the room to the other
 Simple Grapevine

This involves walking sideways by crossing one

foot over the other
- Start by crossing your right foot over your left
- Bring your left foot to join it

Attempt five across steps on each side

If necessary, put your fingers against a wall for
stability.
The smaller the step, the more you work on your
balance
 Heel to toe walk

- Standing upright, place your right heel on the

floor directly in front of your left toe
- Then do the same with our left heel. Make
sure you keep looking forwards at all times

If necessary, put your fingers against a wall for

stability
Try to perform at least five steps. As you
progress, move away
 One Leg Stand

- Start by standing facil the wall, with arms

outstretched and your fingertios touching the
wall
- Lift your left leg, keep your hips level and
keep a slight bend in the opposite leg.
Gentrly place your foot back in the floor

- Hold the lift for 5-10 seconds and perform

three on each side.
 Step Up
Use a step/stools, preferably with a railing or near a wall to use as support
a. Step up with your right leg
b. Bring your left leg up to join it
c. Step down again and return to the start position
The key for building balance is to step up and down slowly and in a controlled
manner. Perform up to five step with each leg.