The Effect of Ankle Strategy Exercises on Static Balance in The Elderly

Received: April, 8, 2020 Revised: October, 26, 2020 Available online: February, 2021 Decreased muscle strength is a musculoskeletal disorder in the elderly, resulting in slow movements and impaired physical mobility. Physical changes that occur in the elderly cause the risk of falling. This study analyzes the ankle strategy exercise's effect on static balance in the elderly at Regional Technical Implementation Unit (UPTD) Griya Werdha Surabaya. This study was Pre-Experimental with One Group Pre-Post Test Design. From the population, there were thirty-five respondents by simple random sampling. This study's independent variable was ankle strategy exercises with frequency three times a week within a month. The dependent variable was a static balance with the instrument Time Up Go (TUG) test. The authors analyzed the data with the Wilcoxon test. The study results showed a significant effect of the ankle strategy exercise on static balance in the elderly (p=0,000). The result showed a decrease in the number of elderly who have the high-risk of falling before the ankle strategy exercise (60% of elderly have a high risk of falling) and after the intervention (34% of elderly have a decreased risk of falling). The elderly should do the ankle strategy exercise independently or with assistant three times a week to improve their static balance and decrease their high-risk of falls.


INTRODUCTION
The Elderly will experience a physical decline condition characterized by less clear hearing, worsening vision, decreased muscle strength, musculoskeletal disorders resulting in a slow movement, and excessive body movement (Kurnianingsi et al., 2012). Musculoskeletal impairment plays a significant role in the risk of falling in the elderly (Sunaryo & Christian, 2016).
The physical changes condition in elderly would limit the independence in meeting daily needs and cause the risk of falling (Kurnianingsi et al., 2012). The balance disorders affect incidents of falls (Supriyono, 2015). Low balance is the cause of falls' risk (Nejc, Loefler, Cvecka, Sedliak Milan, & Kern, 2013).
Static balance is the ability to maintain postural stability or individuals' ability to sustain the center of gravity and the support base (Inggrid, 2016). Static balance describes as a standing position without any activity. An inactive or silent state is the prefix before the move occurs. This position needs a healthy balance base for the coordination of better movement and more target. Static position improvement may lower the risk of falling on the elderly while sitting or standing (Pristianto, Adiputra, & Irfan, 2016).
A previous study showed that in Indonesia, the injury prevalence due to falls at the age of 65-74 years old was about 67.1%, and 75 years old was approximately 78.2% (Balitbangkes, 2013). The falls among seniors living in the community increased from 25% at 70 to 35% after 75 years old (Kurnianingsi et al.,  ). An initial survey conducted on September 1, 2018, in 10 elders at the Regional Technical Implementation Unit of Griya Werdha (UPTD Griya Werdha) Surabaya found three of seven seniors were at risk of fall incidents. Those elderly used aids and had an acute disease, such as hypertension, arthritis, and diabetes mellitus. The activities that often caused the elderly to fall were waking up immediately, standing up, and into the bathroom-injuries sustained by the elderly, often with bruises on certain parts of the body. The elderly made some efforts like handled on wall handrail while going down (Stainless Steel). The activities performed in the orphanage are usually gymnastics every morning.
Older people who have a risk of falling have daily activities with a range of dependency levels or lack physical activity (Tamher & Noorkasiani, 2009). Conditions with decreased visual ability, vestibular, and somatosensory will undoubtedly worsen the balance in the elderly, and their focus also gets impaired (Base of Support) (Pristianto et al., 2016). Besides, the musculoskeletal decrease condition also affects muscles and postural, which lead to the change of gravity center toward the focus in the elderly. The strengths of both lower and upper extremities will decrease over time. It causes the elderly to experience balance disorders often while standing and prone to falls (Pristianto et al., 2016).
There are two factors cause falls in the elderly. Intrinsic factors include walking disorders, weakness of lower extremities, joint stiffness, syncope. Extrinsic factors include poorly lit room light, slippery floors, tripping objects, dangerous holding places, lying down beds, or low squat toilets (Ashar, 2016).
The efforts that can reduce the risk of falling on the elderly are exercises using ankle strategy exercise (Widiarti & Fatarudin, 2018). Ankle Strategy Exercise is the first adjustment strategy to optimize balance through joint contractions (Hyun Choi & Jun Kim, 2015;Widiarti & Fatarudin, 2018). The ankle strategy exercise movements are the head and body forward, accompanying the forward shift in the middle of the mass. The head backward, and the body accompanies the change (Widiarti & Triyono, 2018). This study analyzes the Ankle Strategy Exercise on static balance in the elderly in UPTD Griya Werdha Surabaya.

METHOD
The study design was pre-experimental with One Group Pre-Post Test Design. The authors did this study Strategy Exercise three times a week for one month. The statistic test applied Wilcoxon Signed-Rank with a significance value α <0.05.
There was human ethics in selecting respondents, such as providing information about the research implementation, signing informed consent without mentioning names, and keeping all respondents' data confidential.
The bivariate data analysis includes the effect of static balance before and after the ankle strategy exercise. signed-rank statistical test (p-value=0.000) shows a significant effect of Ankle Strategy Exercise on the static balance in the elderly.

Static Balance before Ankle Strategy Exercise
The results showed that 21 older people (60%) were mostly at high risk of falls by measuring static balance with the TUG test. The Time Up and Go (TUG) test is a valid tool for screening falling on older people (Virtuoso, Gregório, de Medeiros, & Mazo, 2014). Static movement on the Time Up Go to Test measuring instrument is from sitting to stand or prefix before moving. This test is faster, simpler, and uses minimal tools. The Elderly will experience a physical decline characterized by less clear hearing, worsening vision, decreased muscle strength, and musculoskeletal disorders, leading to slow movement and excessive body movement (Kurnianingsi et al., 2012). Elderly who have a high dependency level and lack physical activity at risk of falling (Tamher & Noorkasiani, 2009).
Lack of physical activity will further decrease the physical ability of the elderly. Low postural muscle ability will disrupt the static balance in the elderly and lead to fall incident. Musculoskeletal impairment plays a significant role in the risk of falling in the elderly (Sunaryo & Christian, 2016).
The decrease in musculoskeletal function will also affect muscles and postural in the elderly. The change in posture affects the shift in the Center of Gravity in the elderly. The decrease of both lower and upper muscles causes the elderly to experience balance disorders often while standing and prone to falls (Pristianto et al., 2016).
The elder who is at high risk of falling is over the age of 74. Besides, physiological changes due to the increasing age will decrease alertness and limiting physical activity. Restrictions on physical activity will lead to atrophy or muscle weakness that disrupts balance (Achmanagara, 2012). Musculoskeletal disorders can weaken muscles, bones, and joints. It creates a low body balance, which is the cause of the risk of falling (Nejc et al., 2013). Lack of physical activity will further decrease the physical ability of the elderly. Low postural muscle ability in supporting the body will cause a static balance in the elderly to fall (Pristianto et al., 2016).
Factors that influence body balance are age, activity, musculoskeletal, and gender, affecting low static balance that causing a high-risk of falls. 60-70 years old seniors have decreased muscle strength in doing activities, so they experience muscle weakness. The female elderly have a lower level of balance and a higher risk of falls than males. It is associated with a decrease in the hormone estrogen in older women post-menopause. The higher the level of education also affects the balance of static, because the higher the level of education, the easier it is to perform the ankle strategy exercise well.
Age, activity, musculoskeletal, and gender can cause static to unbalance.

Static Balance after Ankle Strategy Exercise
This study result showed that 12 of 35 (34%) respondents had a decreased number of high-risk static balance. A previous study on 32 elderly showed that ankle strategy exercise reduced the number of seniors who had a high risk of falling, from 12 to 5 respondents (Widiarti & Triyono, 2018) All physical activity requires body balance (Achmanagara, 2012). Physical activity restrictions can lead to atrophy or muscle weakness that interferes with body balance (Achmanagara, 2012). Physical activity can slow bone density loss and increase muscle size and strength. Physical activity can prevent the occurrence of falls in the elderly. It can carry out at leisure and leads to a person's ability to maintain flexibility, strength, and flexibility in the so-called physical exercise (Achmanagara, 2012). Improvement of the static position may lower the risk of falling on the elderly while sitting or standing (Pristianto et al., 2016).
This study results suggest that physical activity can improve static balance. Intense physical exercise can improve muscle strength in the elderly. Doing physical activity at least three times a week can help the elderly in improving balance. Physical exercise with sufficient intensity can affect muscles' size, strength, and capacity on the musculoskeletal system changes due to aging. Ankle Strategy Exercise will reduce the risk of falls in the elderly.

The Effect of Ankle Strategy Exercise on Static Balance in the Elderly
Based on the results, most respondents (60%) were at high risk of falls before the Ankle Strategy Exercise. While after the intervention, most of them (66%) were in the category of no risk of falls. The Wilcoxon test results get Z = -5,114 and p=0.000 and α = < 0.05. When a p-value is lower than α, there is rejection in H 0 and acceptance in H 1 . There was an effect before and after the intervention.
Prior research on 63 respondents showed no more improving static balance in undergraduate students in Physiotherapy Stikes' Aisyiyah, Yogyakarta. The analysis utilized a paired t-test before and after intervention with p=0.000 (intervention group) and p=0.025 (control group). Based on the complementary tests in both groups, hypothetical testing used data after treatment. Static balance variables in both groups using the independent hypothesis test of the t-test sample obtained p=0.625 (p>0.05) (Yuliana et al., 2014). It indicates an influenced ankle strategy exercise factor, such as age, activity, musculoskeletal, and gender. The ankle strategy exercise duration to improve the static balance in older people is three times a week for one month. This study's influenced factors were age, activity, how to do the right Ankle Strategy Exercise, and respondents' participation in ankle strategy exercise. Seniors who are active and adequately doing the ankle strategy exercise can improve static balance and reduce the high-risk of falls.

CONCLUSIONS
There is a significant effect of ankle strategy exercise on the static balance in the elderly (p =0.000). The Frequency of ankle strategy exercise is three times a week to improve static balance and reduce the highrisk of falls in the elderly. Further research should consider adding a control group to evaluate the differences between intervention and control groups.