TERAPI LATIHAN 2

BALANCE EXERCISE

Amriansyah Syetiawinanda, S.Ft, M.Or

Disampaikan Pada Perkuliahan Online
Fakultas Fisioterapi
Universitas Esa Unggul
2020

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 Definitions Balance Exercises

“Balance or postural stability, is a generic term used to describe the

dynamic process by which the body’s position is maintained in
equilibrium. Equilibrium means that the body is either at rest (static
equilibrium) or in steady-state motion (dynamic equilibrium).”

“Keseimbangan atau stabilitas postural, adalah istilah umum yang

digunakan untuk menggambarkan proses dinamis dengan posisi
tubuh yang dipertahankan dalam keseimbangan.”

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 Key Concepts In Balance Control
 Keseimbangan: Sebuah tugas kontrol motor yang kompleks
yang melibatkan: :
 Detection and integration adalah informasi sensorik untuk
menilai posisi dan gerakan tubuh
 Execution adalah untuk mengontrol posisi tubuh dalam
konteks lingkungan dan tugas

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 Components of balance control :
 Sensory input : Persepsi dan gerak tubuh terdiri dari tiga sistem terintegrasi
:
• Visual system-position & orientation (arah dan kecepatan)
• Somatosensory system-position & motion gerak bagian tubuh relatif
terhadap satu sama lain :
– Muscle proprioceptor that sense muscle length & tension
– Joint receptors that sense joint position, movement, & stress
– Skin mechanoreceptors that sense vibration, light touch, deep pessure, &
skin stretch

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• Vestibular system-position & gerak kepala sehubungan dengan
gravitasi & gaya inersia :
– Semicircular canals that detect angular acceleration of head
– Utricle & saccule in the otoliths, mendeteksi percepatan gerak kepala
 Sensorimotor integration : Processing of incoming sensory
information in basal ganglia, cerebellum, or supplementary motor
area.
 Biomechanical & motor output : Effect of musculoskeletal &
neuromuscular system on motor output

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• Musculoskeletal system : Relationship of center of mass to the base of
support affected by posture, ROM, & muscle strength
• Neuromuscular system : Effect of motor coordination & pain on
stability
Balance deficits with aging
 All sensory systems (somatosensory, visual, & vestibular) decline
 All stages of information processing (sensory processing, sensori
motor intergration, & motor output) decline
 More difficulty maintaining balance if sensory input from more than
one system greatly reduced

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Motor Strategies for Balance Control

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 Ankle strategy (Anteroposterior Plane)
 Ankle plantarflex or dorsalflex in respone to small A/P
perturbations typically while on firm, stable surfaces
 Muscle activation : Distal-proximal
• Primally Gastrocnimeus & anterior tibia
• Some Hamstring-paraspinal & some quads-abdominals

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 Weight-Shift Strategy (Lateral Plane)
 Shifting body weight from one leg to other in response to
displacement right or left
 Muscle activation : Proximal-distal
– Primarily hip abductors & adductors
– Some ankle invetors & evetors

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 Hip Strategy
 Hip flex or ext in response to rapid, large A/P plane
perturbations, typically while on narrow, moving, or uneven
surfaces
 Muscle activation : Proximal-distal
• Primarily hip/trunk extensors & hip/trunk flexors
• Some Gastrocnimeus & anterior tibia

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 Suspension strategy
 Rapid knee flex, causing hip flex & ankle dflex to lower body
to maintain balance
 Often combined with ankle or hip strategy
 Stepping strategy
 A step for balance to change base of support in response to a
large, rapid pertubration, which moves body beyond limits of
stability

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Categories of Balance Control & Examples of
interventions
Category Interventions if Deficits Present
Static balance : Ability to maintain different postures • Vary postures
or positions in variety of surface, visual, displacment • Vary support surface
condition • Vary visual cues
• Incorporate external loads
Dynamic balance : Ability to make necessary postural • Move support surface
adjusments to maintain balance when moving from one • Move hand, trunk, arms, legs
position to another or from one place to another • Perform transitional & locomotor activities
Anticipatory (feedforward) balance : Ability to • Reach
make necessary, automatic postural adjustment in • Catch or throw
preparation for change of posture of activity • Kick
• Lift
• Negotiate obstacle course
Reactive (feedback) balance : Ability to respond to • Distrub balance manually
external disturbances of balance (small/large, • Move support surface
slow/rapid, anticipated/unanticipated) • Use unstable support suface
• Superimpose external push or pull

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 Precautions for Balance Training

 Safety
 Gunakan sabuk atau alat pengaman selama kegiatan yang
menantang atau mengguncang keseimbangan
 Bila mungkin, kegiatan keseimbangan praktek dekat pagar atau
di paralel bar
 Berlatih bergoyang postural dalam batas stabilitas; bila perlu,
memodifikasi atau menggunakan alat bantu

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 Health considerations
 Low vision : Schedule regular eye examination & lens adjustments as
necessary; avoid bifocal glasses when walking; wear hat & sun glasses in bright
sunlight; walk in well lit areas at night
 Sensory loss : Use extra care when walking on soft carpet or uneven ground;
wear firm rubber shoes with low heels
 Medication: Be aware of pt’s medications that may cause dizziness & ↑ risk of
falling (sedatives, antideppressants, BP medications)
 Medical examinations : Schedule regular medical examinations/blood tests to
control blood glucose, cholesterol, lipids (seek medical attention with any
symptoms of dizziness

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 Environmental considerations
 Assess environment for hazards to balance
 Modify environment: Install grab bars or stair-railing in home;
remove throw rugs
 Use assistive devices & external support to compensate for
inadequate balance

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 General Consideration for Balance Training

 Sensory organization considerations

 Change or reduce visual input: close eyes, wear prism glasses,
move eyes, read aloud during balance activity
 Change or reduce somatosensory cues: Narrow base of
support, stand on foam, stand on incline board.
 Task-specific considerations
 Integrate function into dynamic balance activities
 Increase number & complexity of tasks as balance improves

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 Musculoskeletal consideration
 Stretching exer : Develop adequate flexibility to assume
aligment over base of support
 Strength & postural awareness training : Develop adequate
strength & postural awareness to stabilize trunk & maintain
balance over base of support

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Parameters for Progressing Balance Interventions
Parameter Progression
Upright posture • Sitting→kneeling→standing

Base of support • Sitting: Feet on floor→off floor

• Standing : wide→narrow base (double leg stance→tandem
stance→single leg stance
Support surface • Nonmoving, firm, or flat surface (floor)→ moving, soft,
uneven surface (ball, foam, sand, gravel, wooble board, slide
board)
Visual cues • Eyes open→ eyes closed

Superimposed movements • Head, trunk movements

• Small → large range UE or LE movements
• Unresisted→resisted
Perturbations • Anticipated→ unaticipated
• Low→ high magnitude
• Low→ high speed
Environment • Surroundings closed (nonmoving)→open (moving)

Functional task • Simple→complex task & single→multiple tasks intergrated

into balance training

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 Balance Activities (Sitting & Kneeling)
Purpose : The exercises & activities in this section are designed to develop balance
responses in sitting or kneeling positions on stable & unstable surface

Techniques : Sitting balance on

stable surface while reaching
•Reach for an object to the side or
overhead

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Techniques : Sitting balance on unstable surface while reaching

• Reach to side • Reach with both hands to side &

back; rotate trunk

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Technique : Sitting balance while lifting Technique : Sitting balance with
one leg or arm resisted UE movements
• Alternately lift legs with arms at side (not
pictured)
•Lift opposite arm & leg simultaneously

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 Technique : Balance in half-kneeling positions
•Reach in a variety of directions

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Technique: Balance in high-kneeling
position on stable surfaces
•Throw & catch a ball
•Reach in various direction for an
object or target
•Knee on unstable surface (foam
roller or balance board
•Transition from high kneeling to
half kneeling: alternate sides

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 Balance Activities (Standing)
Purpose : The exercises & activities in this section are designed to develop balance
response in bilateral→unilateral standing posture on stable→unstable surfaces
Technique : Disturbed balance activities-bilateral stance
Apply forward, backward, lateral, & diagonal parturbations

• Small perturbation to evoke ankle • Large perturbation to evoke

strategy stepping strategy
• Moderate perturbation to
evoke hip strategy

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Technique : Standing balance (bilateral Technique : Lateral lunges to catch ball
stance) on stable surface while moving •Partner throws ball to side of pt almost
head & arms out of reach
•Perform UE movements against elastic
resistance
•Throw & catch ball

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Technique : Stoop & side bend to pick up objects from floor
•Place small objects in various posittion on floor
Technique: Balance (bilateral stance) on stable, but narrow, surface
•Throw & catch ball
•Perform resisted UE movements
Technique : Balance in tandem stence on stable, but narrow, surface (line on
floor balance(beam)

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 Techniques : Unilateral stance on stable surface
• Balance disturbed on elatic band
• Stand on toes to↑ challenge
• Balance while touching foot to floor in clock pattern
• Balance while reaching & rotating trunk to pick up object
• Balance while performing trunk rotation & UE movement in
diagonal patterns against elastic resistance

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• Balance while combining a kicking • Balance while bending forward at hips
motion with the NWB LE & & moving into “skater” position
resisted UE movement • Reach for objects on floor↑ challenge

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Additional techniques : unilateral stance on stable surface
•Kick a ball
•Maintain balance on one LE while performing hip flex, ext, abd & add with
order LE against elastic resistance
•Ascend & descend stairs slowly with/o using handrailling for balance

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Techniques: Balance activities on unstable surfaces (bilateral stance)
Unstable surfaces include thick foam pad, balance or rocker boards, foam roller, mini-
trampoline, gravel, sand

• Stand in upright position balance • Squat & return to standing on

board balance board

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• Balance on two wobble disk • Perform alternating, resisted UE
movements while maintaining
balance on two wooble disk
• Catch & throw weighted ball to ↑
challenge

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• Balance in “surfer” position on
foam roller : move between
upright & squat position

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 Technique : Balance activities on unstable surfaces (unilateral stance)

Unilateral standing balance Unilateral standing balance on Unilateral standing balance

on balance board disk; flex & exs knee on stace in “skater” position on a
side; catch & throw weighted disk
ball to↑ challenge

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Techniques : Marching & walking activities-eyes open→closed
•March in place, forward, backward
•Walk in straight line, turning head side to side
•Walk, chaging speed
•Walk & perform cognitive task
•Walk on toes
•Tandem walk on straight line on floor
•Walk & pivot on balance beam on floor

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• Grapevine walking (carioca) : • High-step over & around cones on
Walk to one side, than to other in floor : Move forward, side to side &
weaving or braiding pattern backward; ↑ speed to progress

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Technique : Jump down from & onto a Technique: Hop down from & onto a
platform & “freeze” palatform & “freeze”

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TERIMA KASIH