COMBINATION OF VESTIBULAR STIMULATION AND PERCEPTUAL MOTOR PROGRAM COULD IMPROVE BALANCE IN CHILDREN WITH FLAT FOOT

Background: Flat foot is a common lower extremity deformity in children. Underdeveloped arches can lead to complaints such as fatigue during prolonged walking, impaired balance, frequent injuries, and pain. Several interventions can be employed to address these issues, including arch muscle strength exercises, toe curls exercises, calf stretches, and plantar fascia stretches. Purpose: This study aims to prove the effectiveness of a combination of heel raises exercise and vestibular stimulation versus a combination of heel raises exercise and perceptual motor program in increasing lower extremity muscle strength and standing balance in children with flat foot. Method: This research is a quasi-experimental study that utilized a pre-test and post-test two-group design with a purposive sampling method. A total of 30 subjects were put into 2 groups. Group 1 received a combination of heel raise exercises and vestibular stimulation. Group 2 received a combination of heel raise exercise and perceptual motor program. Lower extremity muscle strength was assessed using the Manual Muscle Test (MMT), and standing balance was evaluated using the Pediatric Balance Scale (PBS). Result: Both groups showed differences in the measurement aspects of MMT and PBS (p-value < 0.05). However, no significant difference was found between the groups in the MMT score. In contrast, a significant difference was observed in PBS scores, with Group 2 demonstrating greater improvement (p-value < 0.05). Conclusion: The combination of heel raises exercise and a perceptual motor program is more effective in improving balance in children with flat foot compared to the combination with vestibular stimulation.

Introduction

The rapid development of technology in Indonesia has contributed to a decline in physical activities and changes in lifestyle, leading to health problems. This trend is not limited to adults, but is also evident in children. Many children at present prefer sedentary activities such as playing with gadgets at home, which results in limited physical movement. Over time, it could affect their physical structure and function(Amrynia & Prameswari, 2022).

The lower extremities are one part of the limbs that is very important for performing various physical activities and sports. The lower extremity is a special region that performs two different functions, namely providing balance and generating power(Sahri et al., 2017). To support these two functions, one part of the lower extremity, namely the plantar, contains an arch formed by a combination of bone structure, aponeurosis, ligaments, and tendons(Sharma & Upadhyaya, 2016).

The arch plays an important role in the biomechanics of the lower extremities by enhancing stability during standing, stepping, evenly distributing weight on the feet, increasing speed and agility while walking, and supporting balance and flexibility(Kodithuwakku Arachchige et al., 2019);(Witari et al., 2018). There are types of arches, namely the medial longitudinal arch, lateral longitudinal arch, and anterior transverse arch(Sharma & Upadhyaya, 2016). Biomechanically, even minor changes in the plantar structure, particularly in the arch, can lead to reduced support, deformity, and impaired balance function(Hazzaa et al., 2015).

Deformities of the lower extremities are common in children, with the flat foot being one of the most frequently encountered conditions. In fact, up to 90% of clinical visits for related complaints are due to flat foot. It is considered normal for children under the age of three to have flat feet, as the foot arch typically begins to develop after this age(Sahri et al., 2017). A study conducted in India in 2014 reported that 11.25% of individuals aged 18 - 25 years had bilateral flat feet. In Taiwan, it was also reported that the prevalence of pes planus in children aged 6 - 12 years was 13.88%. Meanwhile, a study on flat foot in Indonesia reported that 24.14% of boys aged 8 - 12 years and 17.24% of girls had flat feet(Witari et al., 2018).

A study conducted by(Jaya et al., 2022)on elementary school children aged 7 - 12 years old at the Cipta Dharma Denpasar School in 2020 found that 496 students had flat feet (53.3%). The majority of the participants involved in the study were 502 male students (53.9%). Most of the participants were in the 7 and 11-year-old age groups, comprising 163 students (17.5%) and 173 students (18.6%), respectively. In addition, research conducted by(Kejadian Flat Foot pada Anak Overweight dan Obesitas di Kota Denpasar, 2023). In Denpasar City, it was reported that the prevalence of flat foot was 49 people out of 62 students who were classified (79%) as overweight or obese.

Foot deformity in the form of a flat foot can lead to long-term pain in the soles of the foot ankles, and knees. It may also cause recurrent acute trauma that worsens foot deformity. Foot deformities occur due to disruptions in the development of the foot arch, specifically when the medial longitudinal arch is reduced or absent. Flexible flat foot is a condition that is mostly caused by physiological factors and does not require surgical intervention. Normally, the foot arch develops within the first five years of life, typically between the ages of 2 - 6 years(Damayanti et al., 2018). The arch of the foot plays an important role in absorbing ground reaction forces and supporting body weight during physical activities. Changes in the structure of the foot arch of the foot cause biomechanical changes in the lower extremities(Sung, 2016). The height of the arch is also a risk factor for lower extremity injuries and musculoskeletal pain. Foot and ankle muscle strength plays an important role in supporting the arch structure of the foot and increasing movement initiation(Sativani & Pahlawi, 2020).

Changes in posture caused by flat foot can lead to decreased functional ability and performance of the foot and ankle, reduced elasticity in ligaments and muscles, and alterations in the body’s Center of Gravity (COG). Ligaments, muscles, range of motion, and COG are essential for effective body movements. Body movements are a critical means by which children interact with their environment. Postural balance serves as the foundation for coordinated movement and is defined as the integration of sensorimotor systems that help maintain body posture within normal limits. Postural control and stability are influenced by the visual, vestibular, and proprioceptive systems. During childhood, increased patterns of postural control over daily activities experience a peak of maturation for the proprioceptive system between the ages of 3 - 4 years. The visual and vestibular systems achieve peak maturation at age 15 or 16 years(Sativani & Pahlawi, 2020).

During the weight-bearing activities, flat feet position the foot in plantar flexion and adduction of the talus along with valgus of the calcaneus. These structural changes in the lower limbs alter the transmission of sensory information, which will affect muscle activation to maintain body posture. The reduction in foot function leads to increased performance demands on both intrinsic and extrinsic foot muscles as a compensatory to maintain postural stability