Reproducibility of the Balance Evaluation Systems Test (BESTest) and the Mini-BESTest in school-aged children

Correlations between Trunk Control and Balance in Children with Bilateral Spastic Cerebral Palsy

Impairments of postural responses are a salient feature of children with cerebral palsy (CP). While the systems approach describes balance in seven components, the relationship between trunk control and balance in children with CP has not been previously examined with all seven of these components. In this study, we aimed to identify correlations between trunk control and all seven systems approach balance components in children with bilateral spastic CP. Our participants were 30 children (M age = 11.83, SD = 2.32 years) with CP having a Gross Motor Function Classification System level ranging from I to III. We assessed trunk control with the Trunk Control Measurement Scale, including static and dynamic balance (selective voluntary control and reaching). Balance in standing was assessed using Kids-Mini-BESTest involving four domains: anticipatory, reactive, sensory orientation and stability in gait. We used Spearman's rank correlations to correlate trunk control and balance, and we obtained a moderate correlation between the trunk control measurement scale and the Kids-Mini-BESTest in children with both bilateral spastic CP (rs = .618, p < .001) and spastic diplegic CP (rs = .52, p = .02). Analysis of the correlations between separate domains of the Kids-Mini-BESTest and the trunk control measurement scale subscales revealed moderate correlations between the static sitting balance subscale and all four domains of the Kids-Mini-BESTest. The dynamic selective motor control subscale of the trunk control measurement scale moderately correlated with the anticipatory domain of the Kids-Mini-BESTest. The dynamic reaching subscale also correlated moderately with anticipatory and stability in gait domains. This correlation was statistically significant in the 13 to 17-year-old age group and was strong among females, whereas the correlation was moderate in males. Trunk control was moderately associated with balance considering all the systems theory components of balance in children with bilateral spastic cerebral palsy.

Effects of a highly intensive balance therapy camp in children with developmental coordination disorder - An intervention protocol

BACKGROUND

Children with Developmental Coordination Disorder (DCD) often (<87 %) experience postural control problems, impacting all levels of the International Classification of Functioning, Disability and Health (ICF) including their daily participation, self-esteem and mental health. Due to the multisystemic nature of postural control, comprehensive therapy should target all systems which is currently not the case. Highly intensive therapy is effective and commonly used in pediatric populations, but has not been explored yet to train postural control in children with DCD.

AIMS

To investigate the effects of a highly intensive functional balance therapy camp at all ICF levels in children with DCD.

METHODS AND PROCEDURES

The effects on postural control, muscle activity, brain alterations, self-perceived competence, self-identified goals, gross motor activities and participation are evaluated. Participants are assessed pre- and post-intervention, including a 3 months follow-up. Forty-eight children with DCD, aged 6-12 years old, receive 40 h of comprehensive balance training. This intervention is fun, individually tailored, targets all postural control systems, implements different motor learning strategies and includes both individual and group activities.

CONCLUSION

Novel insights into the effects of a highly intensive comprehensive balance therapy camp designed for children with DCD will be gained at all levels of the ICF.

The test-retest reliability and limits of agreement of the balance evaluation systems test (BESTest) in young people with intellectual disability

Clinical tests for the assessment of postural balance in people with intellectual disability have been the most commonly used single or multi-item tests, but some tests have been developed, such as the BESTest. The purpose of the study was to evaluate the test-retest reliability and limits of agreement of the Balance Evaluation Systems Test (BESTest) in young people with intellectual disabilities. A descriptive cross-sectional study was conducted with 65 young people (ages 16-25 years) with intellectual disability. The participants completed the BESTest (27 items) twice. Intraclass correlation coefficients (ICC), 95% confidence intervals (CIs), and standard error of measurement (SEM) were calculated to determine the test-retest reliability of the BESTest. The BESTest overall scores' test-retest reliability was rated as excellent (≥ 0.75). Stability limits/verticality and reactive are fair to good (≥ 0.40- < 0.75). Biomechanical constraints, transitions and anticipatory movements, sensory orientation, and gait stability were excellent (≥ 0.75). Current evidence shows that young people with intellectual disabilities have impaired postural balance. However, there appears to be a lack of assessment tools that reliably evaluate the postural balance of this population. The results from this investigation show that BESTest provides "excellent reliability" (≥ 0.75) to assess postural balance in young people with intellectual disability.

Differences between Novice and Expert Raters Assessing Trunk Control Using the Trunk Control Measurement Scale Spanish Version (TCMS-S) in Children with Cerebral Palsy

The Trunk Control Measurement Scale (TCMS) is a valid and reliable tool to assess static and dynamic trunk control in cerebral palsy. However, there is no evidence informing about differences between novice and expert raters. A cross-sectional study was conducted with participants between the ages of 6 and 18 years with a CP diagnosis. The TCMS Spanish version (TCMS-S) was administered in-person by an expert rater, and video recordings were taken for later scoring by the expert and three other raters with varying levels of clinical experience. The intraclass correlation coefficient (ICC) was used to evaluate reliability between raters for the total and subscales of the TCMS-S scores. Standard Error of Measurement (SEM) and Minimal Detectable Change (MDC) were also calculated. There was a high level of agreement between expert raters (ICC ≥ 0.93), while novice raters demonstrated good agreement (ICC > 0.72). Additionally, it was observed that novice raters had a slightly higher SEM and MDC than expert raters. The Selective Movement Control subscale exhibited slightly higher SEM and MDC values compared to the TCMS-S total and other subscales, irrespective of the rater's level of expertise. Overall, the study showed that the TCMS-S is a reliable tool for evaluating trunk control in the Spanish pediatric population with cerebral palsy, regardless of the rater's experience level.

Psychometric properties of functional postural control tests in children: A systematic review

BACKGROUND

Postural control deficits are one of the most common impairments treated in pediatric physiotherapeutic practice. Adequate evaluation of these deficits is imperative to identify postural control deficits, plan treatment and assess efficacy. Currently, there is no gold standard evaluation for postural control deficits. However, the number of studies investigating the psychometric properties of functional pediatric postural control tests has increased significantly.

OBJECTIVE

To facilitate the selection of an appropriate pediatric functional postural control test in research and clinical practice.

METHODS

Systematic review following the PRISMA guidelines. PubMed, Web of Science and Scopus were systematically searched (last update: June 2022; PROSPERO: CRD42021246995). Studies were selected using the PICOs-method (pediatric populations (P), functional assessment tools for postural control (I) and psychometric properties (O). The risk of bias was rated with the COSMIN checklist and the level of evidence was determined with GRADE. For each test, the postural control systems were mapped, and the psychometric properties were extracted.

RESULTS

Seventy studies investigating 26 different postural control tests were included. Most children were healthy or had cerebral palsy. Overall, the evidence for all measurement properties was low to very low. Most tests (95%) showed good reliability (ICC>0.70), but inconsistent validity results. Structural validity, internal consistency and responsiveness were only available for 3 tests. Only the Kids-BESTest and FAB covered all postural control systems.

CONCLUSION

Currently, 2 functional tests encompass the entire construct of postural control. Although reliability is overall good, validity results depend on task, age and pathology. Future research should focus on test batteries and should particularly explore structural validity and responsiveness in different populations with methodologically strong study designs.

Reproducibility of Hypermobility Assessment Scales for Children When Performed Using Telehealth versus In-Person Modes

AIMS

Evaluate reproducibility of hypermobility assessments using in-person versus telehealth modes.

METHODS

Hypermobility of 20 children (7-12 years) was evaluated using the Beighton Score, Upper Limb Hypermobility Assessment Tool (ULHAT), and Lower Limb Assessment Score (LLAS) via in-person and telehealth modes. Agreement between the two modes was examined using percentage of exact agreement (%EA and %EA ± 2), Limits of Agreement (LoA) and Smallest detectable change (SDC). Reliability was calculated using intra-class correlation coefficients (ICCs).

RESULTS

Agreement between modes for total Scores was best for the Beighton (%EA = fair, %EA ± 2 = good), then the ULHAT (%EA = poor, %EA ± 2 = excellent), and LLAS (%EA = poor, %EA ± 2 = fair). Total scores for all scales showed wide LoA, large SDC (25-31%), and fair to good reliability (ICC = 0.54-0.61). Exact agreement for Generalized Joint Hypermobility classification was excellent for the Beighton (≥7/9 threshold) and fair for the ULHAT and LLAS (≥7/12 threshold). Percentage of individual test items with good/excellent agreement was highest for the Beighton (78%, 7/9 items), then the ULHAT (58%, 14/24) and LLAS (42%, 10/24).

CONCLUSION

Total Scores of hypermobility scales showed low exact agreement between in-person and telehealth, but fair-excellent agreement within two points. Classification using the Beighton ≥7/9 threshold was excellent. Research is recommended to increase accuracy of online assessments.

The effect and durability of functional exercises on Balance Evaluation Systems Test (BESTest) scores in people with intellectual disabilities: a preliminary report

BACKGROUND

Problems and limitations of movement in individuals with ID are highly common, which particularly may cause the loss of basic performance and limit the person's independence in doing their daily activities. The purpose of this study was to examine the effect and durability of functional exercises on balance evaluation systems test (BESTest) scores of individuals with ID.

METHODS

In the present study, 34 participants with ID were selected randomly and divided into three groups: training groups [unstable group (UG); n = 12; age = 21.46 ± 5.37 years and stable group (SG); n = 12; age = 18.50 ± 2.11 years] or the control group (CG; n = 10; age = 19.50 ± 1.27 years). The postural stability measure was collected with the BESTest. The training groups did the functional exercises for 8 weeks, 3 days/week and 1 h/day. The control group did not experience any training. Statistical analysis was performed in SPSS 22 software on a significance level (P < 0.05).

RESULTS

Both UG and SG training improved the outcome measures [biomechanical constraints (F = 14.04; P = 0.001), limits of stability/verticality (F = 54.39; P = 0.001), postural responses (F = 26.28; P = 0.001), anticipatory postural adjustment (F = 22.72; P = 0.001), stability in gait (F = 51.95; P = 0.001), sensory orientation (F = 83.87; P = 0.001) and total score (F = 114.1; P = 0.001)]. These improvements were maintained at a 1-month follow-up, although the effect was slightly reduced. The results showed that the training group at an unstable level has more balanced improvement compared to the training group at a stable level.

CONCLUSION

This study presents evidence that functional exercises can be recognised as a comprehensive and effective mediator in the improvement of balance in individuals with ID and also affect performance and movement activities.

Randomised trial of virtual reality gaming and physiotherapy on balance, gross motor performance and daily functions among children with bilateral spastic cerebral palsy

BACKGROUND

Balance issues and poor gross motor function affect the daily needs of children with cerebral palsy.

PURPOSE

The study objective was to examine the effects of virtual reality gaming and physiotherapy on balance, gross motor performance and daily functioning among children with bilateral spastic cerebral palsy.

METHOD

Thirty-eight children with bilateral spastic cerebral palsy aged 6-12 years with GMFCS- level II-III, Manual Ability Classification System level I-III participated in this randomized controlled trial. The experimental group performed virtual reality games and physiotherapy, while the control group underwent physiotherapy alone. The exercise intensity was 60 minutes session a day, 4-days a week for 6-weeks. Paediatric Balance Scale (PBS), Kids-Mini-Balance Evaluation System Test (Kids-Mini-BESTest), Gross Motor Function Measure-88 (GMFM-88), and Wee-Functional Independence Measure (WeeFIM) were the outcome measures collected at baseline, 6-week post-training and 2-months follow-up.

RESULTS

The time by group interaction of repeated measures ANOVA revealed no statistical significance for all the outcome measures except Kids-Mini-BESTest (p < 0.05). The PBS and, Kids-Mini-BESTest improved by a mean (standard deviation) score of 5.1(1.7) and 8.7(2.8) points, respectively in the experimental group as compared to control group [3.4(1.6) and 5.8(2.5) points]. These gains remained at follow-up (p < 0.001).

CONCLUSION

Combined virtual reality gaming and physiotherapy is not superior over physiotherapy alone in improving the gross motor performance and daily functioning among children with bilateral spastic cerebral palsy. Virtual gaming, along with physiotherapy, appears to be beneficial in their balance capacity, warranting further trials to investigate the same in children with GMFCS level-III.

Evaluating validity of the Kids-Balance Evaluation Systems Test (Kids-BESTest) Clinical Test of Sensory Integration of Balance (CTSIB) criteria to categorise stance postural control of ambulant children with CP

PURPOSE

Evaluate the validity of the Clinical Test of Sensory Integration of Balance (CTSIB) scored using Kids-Balance Evaluation Systems Test (Kids-BESTest) criteria compared to laboratory measures of postural control.

METHOD

Participants were 58 children, 7-18 years, 17 with ambulant cerebral palsy (CP) (GMFCS I-II), and 41 typically developing (TD). Postural control in standing was assessed using CTSIB items firm and foam surfaces, eyes open (EO) then closed (EC). Face validity was evaluated comparing clinical Kids-BESTest scores between groups. Correlating force plate centre-of-pressure (CoP) data and clinical scores allowed evaluation of concurrent and content validity.

RESULTS

Face validity: TD children scored higher for all CTSIB conditions when compared to children with CP. Concurrent validity: the agreement between clinical and CoP derived scores was poor to excellent (Firm-EO = 76%, Firm-EC = 76%, Foam-EO = 59%, Foam-EC = 94%). Clinical scores of "2-unstable" and "3-stable" were not distinguished reliably by force plate measures. Content validity: significant correlations were found between clinical scores and CoP data for the two intermediate conditions (Firm-EC: r_s -0.40 to -0.72; Foam-EO: r_s -0.12 to -0.50), but not the easier (Firm-EO: r_s -0.41 to -0.36) or harder conditions (Foam-EC: r_s -0.25 to -0.27).

CONCLUSION

Face validity of Kids-BESTest CTSIB criteria was supported. Content and concurrent validity were partially supported. Improved Kids-BESTest scoring terms were recommended to describe postural characteristics of "2-unstable."IMPLICATIONS FOR REHABILITATIONFace validity of the Kids-BESTest criteria for the CTSIB was confirmed.The Kids-BESTest criteria for the CTSIB can identify children with atypical postural control.Concurrent validity and content validity were partially supported, since children with CP resorted to a range of different balance strategies when "unstable."To improve CTSIB Kids-BESTest criteria, new terms were recommended to better describe postural characteristics of "2-unstable."

Postural Control Performance on the Functional Reach Test: Validity of the Kids-Balance Evaluation Systems Test (Kids-BESTest) Criteria

OBJECTIVE

Evaluate the validity of the Kids-Balance Evaluation Systems Test (Kids-BESTest) clinical criteria for the Functional Reach Test (FRT) forward and lateral with laboratory measures of postural control in children with cerebral palsy (CP).

DESIGN

Psychometric study of face, concurrent, and content validity.

SETTING

Clinical laboratory.

PARTICIPANTS

Children (N=58) aged 7-18 years (ambulant CP n=17, typically developing [TD] n=41).

INTERVENTION

Not applicable.

MAIN OUTCOME MEASURES

Stability limits in standing were assessed using the Kids-BESTest items for FRT forwards (FRT_FORWARD), FRT lateral preferred (FRT_LATERAL(P)), and FRT lateral nonpreferred (FRT_LATERAL(NP)). Force platforms and kinematic markers were used to collect information on center of pressure (CoP) and joint movement during reach. Analyses included face validity (Kids-BESTest scores compared between CP and TD groups), concurrent validity (agreement between Kids-BESTest scores and digitally derived scores), and content validity (relations between Kids-BESTest scores with kinematic and CoP data).

RESULTS

Face validity of Kids-BESTest criteria was demonstrated with lower scores for CP compared to TD groups for FRT_FORWARD (P<.001) and FRT_LATERAL(NP) (P=.03) and equal scores for FRT_LATERAL(P) (P=.12). For concurrent validity, agreement between Kids-BESTest scores and digitally derived scores was good to excellent for FRT_{LATERAL(both P/NP)} (88%-100%) and good for FRT_FORWARD (86%-88%) for both groups. For content validity, the CP group Kids-BESTest scores were correlated with CoP-Range_FORWARD during FRT_FORWARD (ρ=0.68) and CoP-Range_LATERAL during FRT_LATERAL(NP) (ρ=0.57). For kinematic data, correlations were moderate-high between Kids-BESTest scores and range of hip flexion (ρ=0.51) and ankle plantar flexion (ρ=0.75) during FRT_FORWARD, and trunk lateral flexion (ρ=0.66) during FRT_LATERAL(NP).

CONCLUSION

The FRT_FORWARD demonstrated face, concurrent, and content validity. The FRT_{LATERAL(P/NP)} demonstrated concurrent validity, but partial face and content validity. To improve validity of Kids-BESTest FRT criteria, additional descriptors have been added under the scoring criteria to enable clinicians to quantify observed reach strategies.

Balance control in individuals with developmental coordination disorder: A systematic review and meta-analysis

BACKGROUND

Although it is recognized that the majority of children with developmental coordination disorder (DCD) have balance deficits, comprehensive insights into which balance domains are affected, are still lacking in literature.

RESEARCH QUESTION

To what extent is balance control deficient in individuals with DCD compared to controls?

METHODS

Pubmed, Scopus and Web of Science were systematically searched. Risk of bias was assessed with the Scottish Intercollegiate Guidelines Network checklist for case-control studies. Mean and standard deviations characterizing balance control were extracted to calculate standardized mean differences (SMD) and pooled, if possible, using Review Manager.

RESULTS

The results of 31 studies (1152 individuals with DCD, 1103 typically developing (TD) peers, mean age 10.4 years old) were extracted of which 17 were used for meta-analysis. The mean SMD for the balance subscale of the Movement Assessment Battery for Children was 1.63 (pooled 95 %CI =[1.30;1.97]), indicating children with DCD to perform significantly poorer than their TD peers. Force plate studies also revealed that children with DCD present with a larger sway path during bipedal stance with eyes closed (pooled mean SMD = 0.55; 95 %CI=[0.32;0.78]). Children with DCD tend to have direction-specific limited stability limits and task-independent delayed onset of anticipatory postural adjustments.

INTERPRETATION

Children with DCD perform poorer on different domains of balance compared to TD peers. Future research should focus on comprehensive balance assessment in these children, preferably using a longitudinal design.

Independent walking and balance in children with CHARGE syndrome

Children with CHARGE syndrome (CWCS) are born with multiple physical disabilities, several of which impair balance and the onset of motor milestones. Early motor development problems can include delayed independent walking, which has been found in CWCS. In addition, few studies have examined balance in CWCS and these studies have been limited in scope, necessitating a more comprehensive examination of balance in this population. Motor development occurs as a progression of stages as represented by Seefeldt’s conceptual model. As such, it is essential to examine the association of early development of foundational skills, such as balance, with the onset of motor milestones as they are building blocks to motor competence. The aims of this study are to (1) examine the differential effects of children with and without CHARGE syndrome on balance and (2) examine the association of age of walking to these balance measures. In this study, 27 CWCS and 22 children without CHARGE syndrome, aged 7 to 16 years, were assessed on four components of balance including anticipatory control, reactive postural control, sensory orientation, and dynamic gait using the shortened version of the Balance Evaluation Systems Test (mini-BESTest) and parental reported age of independent walking. Their balance and age of walking were compared to 22 typically developing peers of similar age and gender distribution. Results revealed that CWCS walked three times later than their peers without CHARGE syndrome and had significant deficits on all balance systems assessed with the largest difference occurring in anticipatory control. Anticipatory control is critically important in maintaining static and dynamic postural control. These results indicate a critical need for early functional balance training and compensatory strategies in CWCS.

Foot and Ankle Somatosensory Deficits Affect Balance and Motor Function in Children With Cerebral Palsy

Sensory dysfunction is prevalent in cerebral palsy (CP). Evidence suggests that sensory deficits can contribute to manual ability impairments in children with CP, yet it is still unclear how they contribute to balance and motor performance. Therefore, the objective of this study was to investigate the relationship between lower extremity (LE) somatosensation and functional performance in children with CP. Ten participants with spastic diplegia (Gross Motor Function Classification Scale: I-III) and who were able to stand independently completed the study. Threshold of light touch pressure, two-point discriminatory ability of the plantar side of the foot, duration of cutaneous vibration sensation, and error in the joint position sense of the ankle were assessed to quantify somatosensory function. The balance was tested by the Balance Evaluation System Test (BESTest) and postural sway measures during a standing task. Motor performance was evaluated by using a battery of clinical assessments: (1) Gross Motor Function Measure (GMFM-66-IS) to test gross motor ability; (2) spatiotemporal gait characteristics (velocity, step length) to evaluate walking ability; (3) Timed Up and Go (TUG) and 6 Min Walk (6MWT) tests to assess functional mobility; and (4) an isokinetic dynamometer was used to test the Maximum Volitional Isometric Contraction (MVIC) of the plantar flexor muscles. The results showed that the light touch pressure measure was strongly associated only with the 6MWT. Vibration and two-point discrimination were strongly related to balance performance. Further, the vibration sensation of the first metatarsal head demonstrated a significantly strong relationship with motor performance as measured by GMFM-66-IS, spatiotemporal gait parameters, TUG, and ankle plantar flexors strength test. The joint position sense of the ankle was only related to one subdomain of the BESTest (Postural Responses). This study provides preliminary evidence that LE sensory deficits can possibly contribute to the pronounced balance and motor impairments in CP. The findings emphasize the importance of developing a thorough LE sensory test battery that can guide traditional treatment protocols toward a more holistic therapeutic approach by combining both motor and sensory rehabilitative strategies to improve motor function in CP.

Comparison of measurement properties of three shortened versions of the balance evaluation system test (BESTest) in people with subacute stroke

OBJECTIVES

To examine the reliability, validity and responsiveness of 3 different short versions of the Balance Evaluation Systems Test (BESTest: S--BESTest, Brief-BESTest and Mini-BESTest) in patients with subacute stroke.

DESIGN

A prospective cohort study.

PARTICIPANTS

Patients with subacute stroke.

METHODS

Patients were assessed using the full BESTest. Scores of 3 short-form BESTests were later extracted. The intra-rater and inter-rater reliability (n = 12) were gathered from 5 raters. Concurrent validity was assessed with the Berg Balance Scale (BBS). Floor/ceiling effect, internal responsiveness and external responsiveness with the BBS (n = 70) were assessed at baseline, 2 weeks and 4 weeks post-rehabilitation.

RESULTS AND CONCLUSION

All short-form BESTests demonstrated excellent intra-rater and inter-rater reliability (intraclass correlation coefficient (ICC) = 0.95-0.99) and excellent concurrent validity (r = 0.93-0.96). Unlike the Brief-BESTest and Mini-BESTest, the S-BESTest and BESTest had no significant floor/ceiling effects (< 20%). The standardized response mean of all 4 BESTest versions were large, ranging between 1.19 and 1.57, indicating sufficient internal responsiveness. The area under the curve of the S-BESTest and BESTest were significantly higher than the Brief-BESTest and Mini-BESTest, reflecting better accuracy of the S-BESTest and BESTest in identifying patients with subacute stroke who had balance improvement using the minimal clinically important difference of 6 and 16 points, respectively. These findings suggest that the S-BESTest is a short-form BESTest that is appropriate for assessing balance impairments in patients with subacute stroke.