Standardized tools for assessing balance and mobility in stroke clinical practice guidelines worldwide: A scoping review

Comparing the Postural Assessment Scale for Stroke and Berg Balance Scale for predicting community walking ability at discharge in subacute stroke: a prospective cohort study

Background

Balance assessment is crucial for predicting community ambulation outcomes in subacute stroke patients undergoing rehabilitation. This study aims to compare the accuracy of the Postural Assessment Scale for Stroke Patients (PASS) and the Berg Balance Scale (BBS) in predicting community walking ability at discharge from rehabilitation.

Methods

This prospective cohort study included 47 stroke patients admitted to a 4-week inpatient rehabilitation program. Patients were assessed with PASS and BBS at admission. Discharge assessments included the Functional Ambulation Categories and 6-Min Walk Distance tests. Statistical analysis involved calculating the area under the receiver operating characteristic curve (AUC), sensitivity, specificity, likelihood ratios, and cut-off scores.

Results

PASS and BBS demonstrated excellent predictive accuracy, with AUC values of 0.955 (95% CI [0.850-0.994]) for PASS and 0.991 (95% CI [0.906-1.000]) for BBS. Cut-off scores were >28 for PASS and >46 for BBS. Sensitivity was high for both (94.44%, 95% CI [72.7-99.9]), while BBS had superior specificity (96.43%, 95% CI [81.7-99.9]) compared to PASS (85.71%, 95% CI [67.3-96.0]). BBS also had a higher positive likelihood ratio (26.44 vs. 6.61). The difference in AUC values was non-significant (p = 0.093).

Conclusions

PASS and BBS assessed at admission are highly accurate tools for predicting community ambulation at discharge in subacute stroke patients, with BBS demonstrating a slight advantage, particularly in its positive predictive value. These findings support the use of both scales to guide rehabilitative clinical decision-making.

Non-Verbal Working Memory in Post-Stroke Motor Aphasia: A Pilot Study Using the Tactual Span

Background: Working memory (WM) impairment is a potential consequence of motor aphasia resulting from left-hemisphere ischemic stroke. While verbal WM has been studied extensively in this disorder, research regarding non-verbal modalities remains limited, particularly visuospatial WM, tactile WM, and the relationship between them. Additionally, language impairments limit the ability to assess WM in aphasia patients, highlighting the necessity of non-verbal diagnostic tools in clinical practice. The current study's objectives were to compare tactile and visuospatial WM in patients with post-stroke motor aphasia and to validate the one-hand version of the Tactual Span task as a clinical measure of WM. Methods: A total of 29 participants-14 with post-stroke motor aphasia and 15 healthy controls-completed a battery of cognitive tests, including the Raven's Colored Progressive Matrices Test, the Visuospatial Span, the Tactual Span, and a visual 1-Back task. Results: There was significantly lower performance across all WM tasks in the aphasia group compared to the controls. Additionally, the Tactual Span successfully discriminated between patients and controls, showing sensitivity estimates of 92.9% and a specificity of 66.7%, with a cut-off score of 4.5 (AUC = 0.91), for the forward stage. The backward stage revealed a sensitivity of 71.4% and a specificity of 73.3%, with a cut-off score of 3.5 (AUC = 0.83). Conclusions: The findings may suggest that non-verbal WM impairment in post-stroke aphasia affects both visuospatial and tactile modalities similarly. Furthermore, the Tactual Span appears to be sensitive to left-hemisphere stroke damage, suggesting its potential utility as a clinical tool for WM assessment in patients with motor aphasia.

Utilizing Balance Assessment Tools by Physical Therapists for Patients with Balance Disorders

Background/Objectives: Physical therapists' use of various balance assessment tools is essential for accurately identifying deficits and guiding rehabilitation plans. This study aimed to investigate clinical balance assessment practices in Saudi Arabia, examine physical therapists' preferences for different balance assessment tools, and analyze how participant characteristics-such as age, experience, and practice setting-affect these preferences. Methods: A descriptive cross-sectional study was conducted between April and July 2024 in Saudi Arabia. A total of 194 physical therapists (62.9% male; 45.9% with 1-5 years of experience) who actively manage individuals with balance disorders were recruited using a convenience sampling technique. Data were collected through a self-structured questionnaire. Participants reported their use of balance assessment tools on a six-point Likert scale, incorporating both numeric and descriptive anchors. Results: The Single-Leg Stance was the most regularly used tool (54.6%), followed by the Berg Balance Scale and Functional Gait Assessment (FGA) (both 43.8%). Conversely, tools such as the Performance-Oriented Mobility Assessment (68.1%), Mini Balance Evaluation System (65.4%), and Fall Efficacy Scale International (56.2%) were the most underutilized. Significant associations were observed between tool preferences and participant characteristics, including area of practice, academic qualification, experience level, and work environment (p < 0.05). However, several validated assessment tools remain underutilized, highlighting gaps in awareness and training. Conclusions: The findings of this study highlight the need for greater standardization in balance assessment practices. Improving training programs, establishing clear clinical guidelines, and standardizing assessment protocols across healthcare settings can help make balance evaluations more consistent and effective.

Measurement Properties of the BESTest Scale in People With Neurological Conditions: A Systematic Review With Meta-Analysis

OBJECTIVE

People with neurological conditions (PwNC) frequently fall, mainly due to balance impairments. Among the scales assessing balance, the Balance Evaluation System Test (BESTest) is one of the most comprehensive in evaluating all components of postural control. This study aimed to systematically review and summarize the measurement properties of the BESTest in PwNC.

METHODS

Embase, MEDLINE, ScienceDirect, Scopus, and PEDro were searched up to December 2023. Studies assessing at least 1 BESTest measurement property in PwNC were included. Methodological quality of studies was assessed with the COSMIN Risk of Bias checklist. Overall rating and level of evidence for each property were given according to COSMIN criteria. Where possible, meta-analysis was performed.

RESULTS

Thirty-six studies (1749 PwNC) were included. The BESTest demonstrated a high quality of evidence supporting good reliability (intraclass correlation coefficients = 0.96-0.98 for total score, and 0.70-0.98 for subsections), internal consistency, and measurement error. High quality levels of responsiveness, and content and construct validity were also found. However, evidence for structural validity was insufficient to be sure the BESTest actually tests several, or 1, balance constructs. Criterion validity cannot be evaluated. While translated into different languages, cross-cultural validity has never been assessed in PwNC. Evidence to support use of the BESTest for specific neurological conditions is limited to Parkinson disease and stroke, due to the small sample sizes and number of studies in other populations.

CONCLUSION

This systematic review provided high quality evidence supporting the reliability, content and construct validity, and responsiveness of the BESTest to intervention, being able to detect balance changes and to differentiate heterogeneous PwNC based on fall history, falling risk, and physical performance. However, low-quality evidence was found when considering each neurological condition alone. To comprehensively understand the BESTest measurement properties, future studies are needed with larger samples for each neurological condition, especially assessing cross-cultural and structural validity.

IMPACT

Assessing balance is crucial for fall risk prevention. The BESTest has been demonstrated to be a reliable, responsive, and valid scale usable in clinical setting for assessing balance in PwNC.

LAY SUMMARY

Assessing balance is crucial for fall risk prevention. The BESTest has been demonstrated to be a reliable, responsive, and valid scale usable in clinical setting for assessing balance in PwNC.

Computerized Adaptive Testing for the Berg Balance Scale Improves Measurement Efficiency Without Compromising Precision in People With Stroke

OBJECTIVE

The objectives of this study were to confirm the Berg Balance Scale's (BBS) measurement properties and unidimensionality with an item response theory analysis in persons with subacute and chronic stroke and to examine the precision and efficiency of computerized adaptive testing (CAT).

METHODS

Data were obtained from 519 ambulatory persons with subacute and chronic stroke in 2 retrospective databases. A principal component analysis (PCA) of residuals was used to evaluate unidimensionality. BBS fit to a rating scale model versus a partial credit model was examined, and item parameters were generated for CAT calibration. Person measures from all 14 items were defined as actual balance ability. BBS CAT simulations were used to examine changes in measurement precision with increasing number of items administered and a precision-based stopping rule (0.5 logit standard error [SE] threshold).

RESULTS

A PCA of residuals supports the BBS unidimensionality and Rasch analysis supports using the rating scale model for measurement. Maximum precision for BBS CAT was SE = 0.40 logits when administering all items. BBS CAT estimated balance ability was highly correlated with actual ability when 4 or more items were administered (r > 0.9). Precision was within 0.5 logits when 5 or more items were administered (SE < 0.48 logits). BBS CAT estimated balance ability was highly correlated with actual ability (r = 0.952) using a precision-based stopping rule. The average number of items administered with the precision-based stopping rule was 5.43.

CONCLUSION

The BBS is sufficiently unidimensional, and the rating scale model can be used for measurement. BBS CAT is efficient and replicates the full instrument's reliability when measuring balance ability in ambulatory persons with subacute and chronic stroke. Future work should aim to enhance the interpretability of measures to facilitate clinical decision-making.

IMPACT

BBS CAT provides an efficient way of measuring balance ability for individuals in stroke rehabilitation giving clinicians more time with patients.

Development of a clinical diagnostic model for Bell's palsy in patients with facial muscle weakness

Early diagnosis of Bell's palsy is crucial for effective patient management in primary care settings. This study aimed to develop a simplified diagnostic tool to enhance the accuracy of identifying Bell's palsy among patients with facial muscle weakness. Data from 240 patients were analyzed using seven potential clinical evaluation indicators. Two diagnostic benchmarks were established: one based on clinical assessment and the other incorporating magnetic resonance imaging (MRI) findings. A multivariate logistic regression model was developed based on these benchmarks, resulting in the construction of a predictive tool evaluated through latent class models. Both models retained four key clinical indicators: absence of forehead wrinkles, accumulation of food and saliva inside the mouth on the affected side, presence of vesicular rash in the ear or pharynx, and lack of pain or symptoms associated with tick exposure, rash, or joint pain. The first model demonstrated excellent discriminative ability (area under the curve [AUC] = 0.96, 95% confidence interval [CI] 0.94 - 0.99) and calibration (P < 0.001), while the second model also showed good performance (AUC = 0.88, 95% CI 0.83 - 0.92) and calibration (P = 0.005). Bootstrap validation indicated no significant overfitting. The latent class defined by the first model significantly aligned with the clinical diagnosis group, while the second model showed lower consistency.

European Portuguese version of the Mini-BESTest: a cross-cultural adaptation and psychometric measurements in individuals with sensorimotor impairments

PURPOSE

This study aimed to translate and cross-culturally adapt the Mini-BESTest into European Portuguese and to evaluate its psychometric properties in individuals with sensorimotor impairments.

MATERIAL AND METHODS

A cross-sectional cross-cultural adaptation and validation study was conducted according to the COSMIN guidelines and the STROBE statement. The study included 100 participants with sensorimotor impairments who were able to walk 6 m. Cronbach's alpha and item-total correlations were used to assess internal consistency. Interpretability was assessed by examining floor and ceiling effects and skewness. To investigate construct validity, Spearman correlation coefficients and Bland-Altman analysis were performed to compare the Berg Balance Scale and the Mini-BESTest Inter- and intra-rater reliability were assessed by calculating the ICC, SEM and MDC based on video recordings of the participants during the Mini-BESTest assessments.

RESULTS

The European Portuguese Mini-BESTest showed good internal consistency (Cronbach's α = 0.892) and no significant floor or ceiling effects. Excellent inter- and intra-rater reliability (ICC = 0.97) were also demonstrated, with MDC of 2.58 and 2.57, respectively. Furthermore, this instrument showed a significant correlation with the BBS (r = 0.902). Bland-Altman analysis showed small absolute differences.

CONCLUSION

The European Portuguese Mini-BESTest is comparable to the original English version in terms of validity and reliability and is therefore highly recommended for use by Portuguese-speaking professionals to assess postural control.

Do measures of physical capacity and walking self-efficacy relate to frailty in older adults with difficulty walking outdoors? A secondary data analysis

PURPOSE

Measures of physical capacity and self-efficacy may help rehabilitation professionals better understand and detect frailty in older adults. We aimed to characterize frailty, walking self-efficacy, physical capacity, and their inter-relationships in older adults with difficulty walking outdoors.

MATERIALS AND METHODS

A secondary analysis of baseline data from 187 older adults (age ≥ 65 years) with mobility limitations was performed. Frailty was evaluated using the cardiovascular health study frailty index. Physical capacity was measured using the 10-meter walk test (10mWT), 6-min walk test (6MWT), 30-second sit-to-stand test (30STST), mini balance evaluation systems test (mini-BESTest), and hand dynamometry. Self-efficacy was assessed using the ambulatory self-confidence questionnaire (ASCQ). We evaluated associations between scores on physical capacity and walking self-efficacy measures and frailty level using an ANOVA or the Kruskal Wallis H-test.

RESULTS

The percentage of participants not frail, pre-frail, and frail was 33.7%, 57.2%, and 9.1%, respectively. Median score on the 10mWT-comfortable pace, 10mWT-fast pace, 6MWT, 30STST, mini-BESTest, grip strength, and ASCQ was 1.06 m/s, 1.42 m/s, 354.0 m, 9.0 repetitions, 22 points, 23.0 kg, and 8.1 points, respectively. Scores on physical capacity and walking self-efficacy measures were associated with frailty level (p < 0.01).

CONCLUSIONS

Findings provide insight into the utility of rehabilitation measures to indicate frailty among older adults with mobility limitations.

Multidisciplinary Delphi Panel on Rehabilitation Approaches and Unmet Needs for Chronic Stroke Walking Impairment and the Role of Rhythmic Auditory Stimulation

INTRODUCTION

Walking or gait impairment is a common consequence of stroke that persists into the chronic phase of recovery for many stroke survivors. The goals of this work were to obtain consensus from a multidisciplinary panel on current practice patterns and treatment options for walking impairment after stroke, to better understand the unmet needs for rehabilitation in the chronic phase of recovery and to explore opportunities to address them, and to discuss the potential role of rhythmic auditory stimulation (RAS) in gait rehabilitation.

METHODS

A panel of eight experts specializing in neurology, physical therapy, and physiatry participated in this three-part, modified Delphi study. Survey 1 focused on gathering information to develop statements that were discussed and polled during Survey 2 (interactive session), after which revised and new statements were polled in Survey 3. Consensus was defined as ≥75% (6/8 of panelists) agreement or disagreement with a statement.

RESULTS

Consensus agreement was ultimately reached on all 24 statements created and polled during this process. The panelists agreed that individuals with gait or walking impairment in the chronic phase of stroke recovery can achieve meaningful improvement in walking by utilizing various evidence-based interventions. Barriers to treatment included cost, access, participation in long-term treatment, and safety. Consensus was achieved for interventions that have the following features challenging, personalized, accessible, and engaging. Improvement of gait speed and quality, durability of effect, safety, affordability, and ability for home or community use also emerged as important treatment features. In addition to conventional treatments (e.g., physical therapy, including mobility-task training and walking/exercise therapy), RAS was recognized as a potentially valuable treatment modality.  Discussion: This panel highlighted limitations of current treatments and opportunities to improve access, participation, and outcomes through a consideration of newer treatment strategies and patient/healthcare provider education and engagement.

Dual Tasking Affects the Outcomes of Instrumented Timed up and Go, Sit-to-Stand, Balance, and 10-Meter Walk Tests in Stroke Survivors

Stroke can impair mobility, with deficits more pronounced while simultaneously performing multiple activities. In this study, common clinical tests were instrumented with wearable motion sensors to study motor-cognitive interference effects in stroke survivors (SS). A total of 21 SS and 20 healthy controls performed the Timed Up and Go (TUG), Sit-to-Stand (STS), balance, and 10-Meter Walk (10MWT) tests under single and dual-task (counting backward) conditions. Calculated measures included total time and gait measures for TUG, STS, and 10MWT. Balance tests for both open and closed eyes conditions were assessed using sway, measured using the linear acceleration of the thorax, pelvis, and thighs. SS exhibited poorer performance with slower TUG (16.15 s vs. 13.34 s, single-task p < 0.001), greater sway in the eyes open balance test (0.1 m/s2 vs. 0.08 m/s2, p = 0.035), and slower 10MWT (12.94 s vs. 10.98 s p = 0.01) compared to the controls. Dual tasking increased the TUG time (~14%, p < 0.001), balance thorax sway (~64%, p < 0.001), and 10MWT time (~17%, p < 0.001) in the SS group. Interaction effects were minimal, suggesting similar dual-task costs. The findings demonstrate exaggerated mobility deficits in SS during dual-task clinical testing. Dual-task assessments may be more effective in revealing impairments. Integrating cognitive challenges into evaluation can optimize the identification of fall risks and personalize interventions targeting identified cognitive-motor limitations post stroke.

Inter-tester reliability and agreement of the Cumulated Ambulation Score in acute stroke: The InTRO-CAS-stroke study

TITLE

Inter-Tester Reliability and Agreement of the Cumulated Ambulation Score in Stroke patients: The InTRO-CAS-stroke study OBJECTIVE: To examine the inter-tester reliability of the total Cumulated Ambulation Score (CAS) and the three activities of the CAS, and to define limits for the smallest change in basic mobility that indicates a real change in patients with stroke.

METHODS

An intertester reliability study.

SETTING

Participants: 60 participants from a specialized stroke unit with a mean age of 69.10 ± 13.23 years. The CAS describes a patient's independency in three activities - (1) getting in and out of bed, (2) sit to stand from a chair, and (3) walking ability and was assessed by two independent physiotherapists at median day 3 poststroke. Each activity was assessed on a three-point ordinal scale from 0 (not able to) to 2 (independent). The cumulated score for each activity provides a total CAS from 0 to 6, with 6 indicating independent basic mobility. Relative and absolute reliability was evaluated using weighted kappa, the standard error of measurement (SEM) and minimal detectable change (MDC).

RESULTS

The weighted kappa for the total CAS score was 0.816 and ranged from 0.733 to 0.904 for the 3 CAS activities. The SEM and the MDC of the total CAS was 0.37 and 1.03 respectively.

CONCLUSIONS

The intertester reliability of the CAS is almost perfect, and a change of 1 CAS point for the total CAS indicates a real change in basic mobility, at group level and for an individual patient with stroke CLINICALTRIALS.

GOV IDENTIFIER

NCT05601089.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.

Comparison of usefulness between the Mini-Balance Evaluation Systems Test and the Berg Balance Scale for measuring balance in patients with subacute stroke: a prospective cohort study

Introduction

The aim of this study was to compare the clinical applicability of the Mini-Balance Evaluation Systems Test and the Berg Balance Scale for measuring balance in inpatients with subacute stroke.

Methods

This was a prospective observational study which included 58 consecutive patients admitted to a convalescent rehabilitation hospital with a first-ever stroke and who met the inclusion/exclusion criteria. The Mini-Balance Evaluation Systems Test and the Berg Balance Scale were used to assess patient balance at admission and discharge. The ceiling and floor effects and responsiveness of each balance score were examined. In addition, receiver operating characteristic analysis based on each balance score at admission was used to examine its discriminative power to predict ambulatory independence and falls during hospitalization.

Results

The mean (standard deviation) change between admission and discharge for each balance scale was 4.4 (4.7) for the Mini-Balance Evaluation Systems Test and 8.3 (10.0) for the Berg Balance Scale, with standard response means, a measure of responsiveness of 0.9 (large) and 0.8 (medium), respectively. Each balance score at admission almost equally predicted gait independence and fallers during hospitalization. On the contrary, only the distribution of scores on the Berg Balance Scale at discharge showed a ceiling effect, with 25 patients (43%) obtaining a perfect score.

Discussion

The Mini-Balance Evaluation Systems Test may be useful as a balance measure for inpatients with subacute stroke because it is less susceptible to ceiling effects and more responsive than the Berg Balance Scale.

Standardized measurement of balance and mobility post-stroke: Consensus-based core recommendations from the third Stroke Recovery and Rehabilitation Roundtable

BACKGROUND

Mobility is a key priority for stroke survivors. Worldwide consensus of standardized outcome instruments for measuring mobility recovery after stroke is an essential milestone to optimize the quality of stroke rehabilitation and recovery studies and to enable data synthesis across trials.

METHODS

Using a standardized methodology, which involved convening of 13 worldwide experts in the field of mobility rehabilitation, consensus was established through an a priori defined survey-based approach followed by group discussions. The group agreed on balance- and mobility-related definitions and recommended a core set of outcome measure instruments for lower extremity motor function, balance and mobility, biomechanical metrics, and technologies for measuring quality of movement.

RESULTS

Selected measures included the Fugl-Meyer Motor Assessment lower extremity subscale for motor function, the Trunk Impairment Scale for sitting balance, and the Mini Balance Evaluation System Test (Mini-BESTest) and Berg Balance Scale (BBS) for standing balance. The group recommended the Functional Ambulation Category (FAC, 0-5) for walking independence, the 10-meter Walk Test (10 mWT) for walking speed, the 6-Minute Walk Test (6 MWT) for walking endurance, and the Dynamic Gait Index (DGI) for complex walking. An FAC score of less than three should be used to determine the need for an additional standing test (FAC < 3, add BBS to Mini-BESTest) or the feasibility to assess walking (FAC < 3, 10 mWT, 6 MWT, and DGI are "not testable"). In addition, recommendations are given for prioritized kinetic and kinematic metrics to be investigated that measure recovery of movement quality of standing balance and walking, as well as for assessment protocols and preferred equipment to be used.

CONCLUSIONS

The present recommendations of measures, metrics, technology, and protocols build on previous consensus meetings of the International Stroke Recovery and Rehabilitation Alliance to guide the research community to improve the validity and comparability between stroke recovery and rehabilitation studies as a prerequisite for building high-quality, standardized "big data" sets. Ultimately, these recommendations could lead to high-quality, participant-specific data sets to aid the progress toward precision medicine in stroke rehabilitation.