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Balance Scale

Results: Twenty-one studies examining the psychometric properties of the BBS with a stroke population were retrieved. Internal consistency was excellent (Cronbach alpha=.92-.98) as was interrater reliability (intraclass correlation coefficients [ICCs]=.95-.98), intrarater reliability (ICC=.97), and test-retest reliability (ICC=.98). Sixteen studies focused on validity and generally found excellent correlations with the Barthel Index, the Postural Assessment Scale for Stroke Patients, Functional Reach Test, the balance subscale of Fugl-Meyer Assessment, the Functional Independence Measure, the Rivermead Mobility Index (except for weight shift and step-up items), and gait speed. Berg Balance Scale scores predicted length of stay, discharge destination, motor ability at 180 days poststroke, and disability level at 90 days, but these scores were not predictive of falls. Eight studies focused on responsiveness; all reported moderate to excellent sensitivity. Three studies found floor or ceiling effects.

balance scale


Discussion and conclusion: The BBS is a psychometrically sound measure of balance impairment for use in poststroke assessment. Given the floor and ceiling effects, clinicians may want to use the BBS in conjunction with other balance measures.

The Berg Balance Scale (BBS) is used to objectively determine a patient's ability (or inability) to safely balance during a series of predetermined tasks. It is a 14 item list with each item consisting of a five-point ordinal scale ranging from 0 to 4, with 0 indicating the lowest level of function and 4 the highest level of function and takes approximately 20 minutes to complete. It does not include the assessment of gait.

The subject should understand that they must maintain their balance while attempting the tasks. The choices of which leg to stand on or how far to reach are left to the subject. Poor judgment will adversely influence the performance and the scoring.

Figure 7. Study 3: (A) Replicated regression analyses confirming convergence and divergence validity of the Consistency subscale. (B) Replicated regression analysis confirming convergence and divergence validity of the Flexibility. MEMS, Multidimensional Existential Meaning Scale; SWLS, Satisfaction with Life Scale; SH, Subjective Happiness; PWB, Psychological Well-Being; PS, Perceived Stress.

To determine test-retest reliability, 20 children (aged five to 15 years) with known balance impairments were tested by one examiner on the PBS. Ten pediatric physical therapists independently scored 10 randomly selected videotaped test sessions.

The authors describe development of a Pediatric Balance Scale for use with school-aged children with motor impairments. Test-retest and interrater reliability of this scale is reported to be good when used with children with mild to moderate motor impairments.

Such documented limitations of the Berg have led many clinicians to do more than one validated balance assessment in order to identify deficits that may respond to treatment. Recently, a new and more comprehensive clinical balance test, the Balance Evaluation Systems Test (BESTest), has been developed that is essentially a battery of balance and mobility tests, borrowed from other validated tests such as the Berg and Dynamic Gait Index. The BESTest was uniquely designed as a comprehensive clinical tool for evaluating six different balance control systems: biomechanical, stability limits/verticality, anticipatory, reactive, sensory orientation, and stability in gait. Such system-specific assessment is helpful in directing treatment and to ensure that a meaningful deficit is not overlooked. The BESTest has good interrater reliability [10] and good validity in discerning fallers from nonfallers in patients with PD [11].

The purpose of this study was to explore the usefulness of the Mini-BESTest compared to the Berg in evaluating balance in people with PD of varying severity. Specifically, we evaluated (1) the distribution of patients scores to look for ceiling effects, (2) concurrent validity with severity of disease, and (3) the sensitivity/specificity of separating people who do or do not have postural response deficits.

Postural response deficits were identified as patients scoring 3 to 4 in the H&Y scale. [16]. A score of 3 and above indicates postural instability as defined by an abnormal stepping response to a backwards pull on the shoulders. The H&Y scale is the most commonly used method for evaluating the severity of PD [17], and the scale ranges from 0 (no symptoms of PD) to 5 (wheelchair bound).

The results from this study suggest that the Mini-BESTest may be more useful than the Berg in evaluating balance disorders in patients with PD, especially in those with mild PD or more subtle balance deficits. Specifically, results showed that (1) although the Mini-BESTest had a high correlation with the Berg, it did not have the same ceiling effects; (2) both the Berg and Mini-BESTest correlated with PD severity but the Mini-BESTest added value to the Berg score; (3) the Mini-BESTest test had better sensitivity/specificity then the Berg to identify people with abnormal postural responses.

The high correlation of the Mini-BESTest with the Berg supports concurrent validity since the Berg remains one of the most commonly used clinical scales for balance assessment in people with PD. But importantly, we found very different test score distributions across patients with varied levels of severity. Though neither test had a normal distribution, the Mini-BESTest was significantly less skewed, indicating that there are less ceiling effects as has been shown previously with the Berg [22]. These results are not surprising since the Berg was originally intended for frail elderly and remains an excellent measure of balance deficits for those with more severe PD.

The high sensitivity of the Mini-BEST is important for clinicians who see patients with mild balance deficits who are seeking to identify and treat potentially preventable mobility problems early in the disease progression.

The Berg has been shown to have excellent test-retest reliability [3] and to correlate significantly with disease severity in PD [23], and our results support the relationship with the UPDRS. Both exercise and physical therapy have been shown to improve UPDRS scores. Therapists need measures that reflect improvements with intervention so comparing the Mini-BESTest with the UPDRS establishes concurrent validity of the new test with an established one. The novel information obtained from our study is that while both the Berg and Mini-BESTest correlate with disease severity, the Mini-BESTest adds value not included in the Berg, but the Berg does not add value to the Mini-BESTest. These findings suggest that the Mini-BESTest distinguishes among PD subjects who all get similar, high scores in the Berg, and this information can add to the prediction of disease severity. A previous study demonstrated the Berg to be useful in identifying balance impairments in people with very severe PD (i.e., H&Y 4), but it could not discriminate subgroups of H&Y scores successfully [24]. Here, we found similar results in that the Mini-BESTest was more successful than the Berg at discriminating subgroups of PD severity as measured by the H&Y scale. Franchignoni et al. examined the clinimetric properties of the Berg with 57 participants with PD [9]. They found excellent internal consistency, good correlations to other scales of disease severity, and quality of life, all agreeing with previously published work [4]. However, they did find, using a Rasch analysis, that some rating categories were not used and others were underutilized. The authors suggested that improving the rating scale structure would improve the test. The same type of Rasch analysis was performed on the full BESTest to obtain the shortened Mini-BESTest that excludes redundant or underused items [12].

It has been suggested that postural instability in PD is multifactorial, therefore, a multitude of tests should be administered by physical therapists [25, 26]. For example, the Berg does not include tests of postural reactions or dynamic gait, and, therefore, some deficits may be missed. Since the Mini-BESTest is essentially a combination of tests, this may be a reason it successfully identified people with mild balance deficits. As outlined in Table 2, each test item primarily tests one of 4 categories of balance: anticipatory, dynamic gait, reactive control, and sensory orientation. The Berg was not designed with such systems in mind but if a system categorization is assigned to each item, the Berg items primarily evaluate anticipatory and sensory contributions to balance. There are two additional systems that the Mini-BESTest evaluates, dynamic gait, and reactive postural control, this may explain the added variable plot being significant for the Mini-BESTest adding value to the Berg in relating to disease severity. In other words, the Mini-BESTest usefully distinguishes among those persons that are overly range compressed in the Berg. If a clinician is using the Berg for their PD patients, it may be beneficial to augment testing with the Dynamic Gait Index and the Pull test from the UPDRS. Dynamic gait (cognitive task with gait) and reactive postural control (response to perturbation) items were the most difficult items for people with PD, balance systems that are not assessed using the Berg.

Clinicians commonly use single-limb stance for balance assessment. An example of a difference between testing items in the Berg and Mini-BESTest is the assessment of the single-limb stance (item #14 Berg, item #3 Mini-BESTest). In the Berg, the participant chooses either leg, and it is only this side that is assessed. Comparatively, the Mini-BESTest assesses both the left and right leg and records the worst side. In this study, when the Berg was used, assessing only one leg, 39% of the participants had some observable difficulty. When the Mini-BESTest was used, assessing both left and right leg, 81% of the participants had some difficulty. Therefore, clinicians should test standing balance on both sides. 041b061a72


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