Balance assessment scales

This presentation includes 11 balance assessment scales

1. Submitted to: Dr. Richa Rai Submitted by: Aditi Pre PhD Student 03/pre PhD DPSRU/2021 Balance Scales

2. Contents Activity Specific Balance Confidence Scale Balance Evaluation Scale Berg Balance Scale Performance Oriented Mobility Assessment Tinetti Fall Efficacy Scale Modified Fall Efficacy Scale Fullerton Advanced Balance Scale Balance Evaluation System Test Mini BEStest Brief BEStest Community Balance And Mobility Scale Dynamic Gait Index

3. What and Why ?

4. ACTIVITY SPECIFIC BALANCE CONFIDENCE SCALE SELF REPORT TOOL used to gather information about the patient’s confidence with performing various activities. 16 items are included Percentages are added and divided by 16 to give an overall confidence % 0% = no confidence 100% = completely confidence Instrument format: Questionnaire/ Survey Reliability/validity: Good

5. Article: Measuring balance confidence after spinal cord injury: the reliability and validity of the Activities-specific Balance Confidence Scale Authors: Garima Shah, Alison R. Oates, Tarun Arora, et al. Journal: the journal of spinal cord medicine Year: 2017 Type of study: Prospective cross sectional study Sample size: 26 individuals with iSCI and 26 able bodied individuals Results: The ABC scale demonstrated high test-retest reliability (intra class correlation coefficient = 0.93) among participants with iSCI. The minimal detectable change was 14.87%. ABC scale scores correlated with performance on all clinical measures (ρ=0.60-0.80, P<0.01), with the exception of proprioception and cutaneous pressure sensitivity (P=0.20–0.70), demonstrating convergent validity. ABC scale scores also correlated with overall COP velocity (ρ=-0.69, P<0.001) and COP velocity in the anterior-posterior direction (ρ=-0.71, P<0.001). Participants with iSCI scored significantly lower on the ABC scale than the AB participants (P<0.001), and the area under the receiver operating characteristic curve was 0.95, demonstrating discriminative validity. Conclusion: The ABC scale is a reliable and valid measure of balance confidence in community dwelling, ambulatory individuals with chronic iSCI.

6. BALANCE EVALUATION SCALE BES is a self-report measure that examines how confident an individual feels while performing 10 items of ADL and functional mobility. The ADL items on the test include both basic ADL (getting dressed and undressed, taking a bath or shower) and instrumental ADL (cleaning house, preparing simple meals, simple shopping). The functional mobility items include getting in and out of a car, going up and down stairs, walking around the neighbourhood, reaching, and hurrying to answer the phone. Individuals are asked to consider how confident they feel in doing each of the activities listed without falling.

7. The individual is asked to rate his or her confidence level on a 0 (not at all) to 10 (completely confident) scale. The highest score is 100 (completely confident on all 10 items) and represents high self efficacy whereas the bottom score of 0 represents low self-efficacy

8. BERG BALANCE SCALE It is a multi task test 14 balance task (6 static & 8 dynamic) Focused on: Maintenance of position Postural adjustment to voluntary movement Simple and easy to administer Patient should be able to stand Provide baseline and outcome data; score o f 45 or below are predictive falls in the elderly

9. Reliability: inter = 0.98 Intra = 0.99 Scoring: 5 point ordinal scale with specific task criteria Limitations: It has very high ceiling effect Lack of items requiring postural response to external stimuli or uneven support surfaces The use of the BBS as an outcome measure is compromised when participants score high on initial trials

10. Article: Characteristics that affect score reliability in the Berg Balance Scale: a meta-analytic reliability generalization study Authors: Ana-Belén MESEGUER-HENAREJOS , María RUBIO-A et. Al Journal : European Journal of Physical and Rehabilitation Medicine Year : 2019 Type of study : systematic review & meta-analytic study Sample size: 65 studies Result: Coefficient alpha ranged from 0.62 to .98, with a mean of 0.92. For intra-rater agreement, the mean intra class correlation was ICC=0.957 , and for inter-rater agreement ICC+=0.97. The SD of the Berg Balance Scale scores presented statistically significant relationships with the coefficient alpha and with ICC (intra-rater). Conclusion: The alpha coefficient and intra- and inter-rater agreement for Berg Balance Scale scores was very satisfactory. Several characteristics of the studies were statistically associated to the alpha coefficient and with intra-rater reliability

11. PERFORMANCE ORIENTED MOBILITY ASSESSMENT It is a multi level task : have 2 parts It is a test to measure balance and mobility skills in older adults and to determine the likelihood for falls and mobility scale, which rates performance on a three-point scale. The maximum score is 28 points. Focused on: Maintenance of position Postural response to perturbation Gait mobility Equipment needed: Chair, walk way, patient can use usual walking aid

12. It takes 10-15 minutes to complete the assessment with good reliability Scoring: Some items graded can/cannot perform; some 3 point scale with specific criteria Simple and easy to administer Provide baseline data; predictive of fall in elderly >24 low risk 19-24 moderate risk <18 high risk Reliability: Inter = .85 Requirements: should be able to stand and walk independently

13. Article: Predictive accuracy of performance oriented mobility assessment for fall in older adults: A systematic review Authors : saifullah jahantabi-nejad , akram azad Journal: medical journal of Islamic republic of Iran Year: 2019 Type of study: systematic review Sample size: 12 Results : sensitivity and specificity of POMA ranged from 24-91 to 37-97, respectively. Conclusion: due to heterogeneity of the studies, it was not possible to determine a specific cutoff point for POMA .

14. TINETTI FALL EFFICACY SCALE It measures level of confidence in doing each of the activities without falling (0 = not at all, 10 = completely confident). Total score is sum of 10 individual scores (range: 0 [low self-efficacy] to 100 [high self- efficacy]). Time to administer : 10-15 minutes Equipment Required: Pen Paper A total score greater than 70 indicates the fear of fall Reliability : Adequate Test- retest reliabilty is 0.71 Internal consistency : excellent (Cronbach’s alpha 0.91)

15. Excellent correlation(0.84) but adequate predictive validity (0.55) with ABC scale Construct validity : Excellent correlation with balance (r=0.66) Poor correlation with age(r=0.23) Excellent correlation with gait(r=0.67) Excellent correlation with mobility (r=0.71) Adequate correlation with history of falling (r= 0.47) Adequate correlation with self- rated health status (r=0.36) Poor correlation with medical history (r= 0.18)

16. MODIFIED FALL EFFICACY SCALE MFES is a 14 activity questionnaire that is an expanded version of original 10 activity fall efficacy scale(FES) The MEFS includes outdoor activities, which the FES does not cover Scoring: each item is scored on a 10 point visual analogue scale. 0= not confident/not sure at all 5= fairly confident/fairly sure 10= completely confident/ completely sure Scores can fall between 0,5 and10

17. Reliability and validity Cronbach’s alpha was used to demonstrate internal consistency of the items on the questionnaire and the result was 0.95. The lowest ICC was 0.54 for the individual items and the overall ICC was .93 In order to validate MFES, subjects from two separate groups were scored. The sample consisted of healthy elderly and other group included patients from fall and balance clinic (FBC ). Significant differences were found between the two groups using multivariate analysis of variance(MANOVA) with post hoc univariate ANOVA.

18. FULLERTON ADVANCED BALANCE SCALE The FAB Scale is developed for higher-functioning older adults which tests both static and dynamic balance under varying sensory conditions. The FAB includes 10 items which are scored between 0 to 4, with a score range of 0 (poor balance) to 40 (good balance). It takes 10-12 minutes to administer this scale Excellent test- retest reliability for fall (r=0.96) Adequate reliability for individual test items (r= 0.55 to 0.82) Excellent internal consistency (r= 0.9555 to 0.999) Criterion validity is excellent in correlation with BBS (r= 0.75) in 7/10 cases who scores 25 or less than 25 is at a high risk for falls Construct validity is excellent in correlation with BBS (r=0.75) Ceiling effect: item 1 may have the ceiling effect for independent functioning older adults

19. BALANCE EVALUATION SYSTEMS TEST (BESTest) was developed by Horak and colleagues (2009) to examine multiple aspects of postural control. The BESTest consists of 36 items, grouped into six systems: - Biomechanical Constraints, - Stability Limits - Verticality, - Anticipatory Postural Adjustments - Postural Responses, - Sensory Orientation, and - Stability in gait

20. Mini-BESTest The Mini-BESTest is a shortened version of the original BESTest. It has 14 items scored from 0 to 2 with a maximum score of 28.The items chosen had the highest correlation with the overall /complete score of the BESTest using a Rasch analysis. The Mini version can be administered in 15 to 20 minutes and is as reliable and capable of detecting fall status as the original version. The construct differs from the BESTest as it only considers dynamic balance by omitting items related to mechanical constraints and limits of stability. The Mini-BESTest has similar clinometric properties as the BESTest.

21. Brief BESTest The brief version of the BESTest was developed to improve the clinical utility of the BESTest and to preserve the construct validity of the BESTest. The Brief BESTest included the most representative item from each of the six domain sections of the original BESTest for a total of 8 items scored 0 to 3 with a maximum score of 24. The Brief-BESTest has similar clinometric properties as the BESTest and Mini BESTest.

22. Equipment required: Stopwatch, 36” ruler, 4” foam pad (12” x12”), 10-degree-incline ramp, 6” stair step, two stacked shoe boxes, 5-lb free weight, and chair with arms. The authors emphasize that only the worst performance in items “stand on one leg” and “lateral stepping” are to be scored. Item 14 (Mini-BESTest) is clarified by the authors as “if a person’s gait slows >10% between the TUG with and without a dual task, the score should be decreased by a point.”

23. Article: Reliability and Fall risk Detection for the BESTest and miniBESTest in Older Adults Authors: Eric Anson, Elizabeth Thompson, Lei Ma, et al. Journal: Journal of Geriatric Physical Therapy Year: 2019 Type of study: Observational Sample size : 58 Results: —Balance scores did not significantly change over a 4 week period. Test-retest reliability for the BESTest (.86) and mini-BEST (.84) was good to excellent. MDC95 scores were identified for the BESTest (8.9) and mini-BEST. Conclusion : —The BESTest and mini-BEST scores were stable and reliable over a period of 4 weeks for a population of older adults with self-reported balance problems or a history of falling. MDC95 scores allow interpretation of change in BESTest and mBEST scores following rehabilitation.

24. COMMUNITY BALANCE AND MOBILITY SCALE The Community Balance and Mobility Scale (CBM) assesses higher level balance and mobility skills through performance of tasks that are common to community environments. The purpose of the CBM is to reflect balance and mobility skills necessary for full participation in the community. 13 tasks make up the test scored from 0 (inability) to 5 for a maximum score of 96. Item arrangement reflects progressive task difficulty. The test takes 20 to 30 minutes to administer. It is reliable, valid, and responsive to change in community-dwelling older adults, those with arthritis, those in cardiac rehabilitation, and those with stroke. The CBM does not have the ceiling effects of other measures of balance (e.g., BBS) and correlates with the FAB; therefore, it may be more useful for healthy, higher-functioning, younger community-dwelling older adults.

25. List of Items: Unilateral Stance Tandem Walking 180 Tandem Pivot Lateral Foot Scooting Hopping Forward Crouch and Walk Lateral Dodging Walking & Looking Running with Controlled Stop Forward to Backward Walking Walk, Look and Carry Descending Stairs Step-Ups x 1 Step

26. Directions: The CB&M is completed using a set 8-meter measured track and a full flight of stairs is required. This test requires approximately 20-30 minutes to administer. It is recommended that the assessor instructs the patient verbally as well as demonstrates all of the items to ensure proper understanding. In brief, tasks 1 through 11 are performed on an 8-m track outlined on the floor and tasks 12 and 13 are performed on a flight of ≥8 steps ( Figure 1 ). All tasks are scored on a scale of 0 to 5 (0 = unable to perform, 5 = able to perform independently). Thus, 13 tasks are performed, 6 bilaterally, for a maximum of 95 points. Of note, any participant who receives a score of ≥4 for task 12 (descending stairs) can reattempt the task carrying a weighted laundry basket. If the participant is able to complete the modified task in a coordinated manner without continually watching his or her feet, he or she is awarded a bonus point. Thus, the maximum score achievable for the CBMS is 96. [1] Equipment needed includes a laundry basket, 2- and 7-lb weights, a bean bag, a visual target, and stairs. Tasks are conducted on an 8-m track that is 2 m wide (Fig. 7.8). The test is to be done without a mobility aid and is tested on both sides.

27. Article: Concurrent validity and reliability of the Community Balance and Mobility scale in young-older adults Authors: Michaela Weber1 , Jeanine Van Ancum2 , Ronny Bergquist4 et al. Journal: BMC Geriatrics Year: 2018 Type of study: Cross Sectional Sample size: 51 Results: The CBM significantly correlated with the FAB ( ρ = 0.75; p < .001), 3MTW errors ( ρ = − 0.61; p < .001), 3MTW time ( ρ = − 0.35; p = .05), the 8-level balance scale ( ρ = 0.35; p < .05), the TUG ( ρ = − 0.42; p < .01), and 7-m habitual gait speed ( ρ = 0.46, p < .001). Inter- (ICC2,k = 0.97), intra rater reliability (ICC3,k = 1.00) were excellent, and internal consistency ( α = 0.88; ρ = 0.28–0.81) was good to satisfactory. The CBM did not show ceiling effects in contrast to other scales. Conclusion: Concurrent validity of the CBM was good when compared to the FAB and moderate to good when compared to other measures of balance and mobility. Based on this study, the CBM can be recommended to measure balance and mobility performance in the specific population of young-older adults.

28. Article: Validity and Reliability of the Community Balance and Mobility Scale in Individuals With Knee Osteoarthritis Authors: Judit Takacs, S. Jayne Garland, Mark G. Carpenter, et al. Journal: Physical Therapy Journal APTA Year: 2014 Type of study: Cross-Sectional Study Sample size: 50 Results: Scores on the CB&M were significantly correlated with all measures of balance and mobility for those with knee OA. There were significant differences in CB&M scores between groups. Scores on the CB&M were highly reliable in people with knee OA (ICC.95, 95% confidence interval [95% CI]0.70 to 0.99; SEM3, 95% CI2.68 to 4.67). Conclusion: The CB&M displayed moderate convergent validity, excellent known-groups validity, and high test-retest reliability. The CB&M can be used as a valid and reliable tool to assess dynamic balance and mobility deficits in people with knee OA

29. DYNAMIC GAIT INDEX DGI examines a patient’s ability to perform variations in walking on command. Items include changing speed (walk at normal speed and at fast speed), walk with head turns (look right or left, look up or down), walk and pivot turn, step over or around an obstacle, and climb stairs (up and down). A four-point scale (0 to 3) includes specific descriptors of normal control (3), mild impairment (2), moderate impairment (1), and severe impairment (0), with a maximum possible score of 24. The DGI app pears to be sensitive in predicting likelihood for falls with older adults (a score below 19 is indicative of increased fall risk). It has also been used with individuals with vestibular dysfunction, chronic stroke, and multiple sclerosis. Whitney et al., found a moderate correlation between the Dynamic Gait Index and the Berg Balance Scale when testing individuals with vestibular and balance dysfunction.

30. Directions: The scoring system for the original 8 item DGI was modified and expanded in 2013.The new scoring system, called the modified DGI, includes time, level of assistance, and gait pattern for each task to attempt to avoid the ceiling effect noted with the original DGI. The test allows the use of an assistive device but results in a loss of points. Floor and ceiling effects is The number of respondents who achieved the lowest or highest possible score Interpretation: A score of 19 or less on the original DGI indicates an increased risk of falling in older adults and in patients with vestibular disorders. It is reliable and valid as well as responsive. Fall risk is indicated on the 4-item DGI with a score of <10. It has demonstrated a ceiling effect.

31. Article: Reliability, validity, and responsiveness of three scales for measuring balance in patients with chronic stroke Authors: Ahmad H. Alghadir1 , Einas S. Al-Eisa1 , Shahnawaz Anwer et al. Journal: BMC Neurology Year: 2018 Type of Study: ? Results: The reliability of the TUG (intra class correlation coefficient [ICC2,1] = 0.98), DGI (ICC2,1 = 0.98) and BBS (ICC2,1 = 0.99) were excellent. The standard error of measurement (SEM) of the TUG, DGI, and BBS were 1.16, 0.71, and 0.98, respectively. The minimal detectable change (MDC) of the TUG, DGI, and BBS were 3.2, 1.9, and 2.7, respectively. There was a significant correlation found between the DGI and BBS (first reading [r] = 0. 75; second reading [r] = 0.77), TUG and BBS (first reading [r] = −.52; second reading [r] = −.53), and the TUG and DGI (first reading [r] = 0.45; second reading [r] = 0.48), respectively. Conclusion: The test-retest reliability of the TUG, BBS, and DGI was excellent. The DGI demonstrated better responsiveness than TUG and BBS. The results of the present study support the use of these scales for measuring balance and mobility in patients with chronic stroke

32. Article: The Frail'BESTest. An Adaptation of the "Balance Evaluation System Test" for Frail Older Adults. Description, Internal Consistency and Inter-Rater Reliability Authors: A Kubicki1,2 M Brika2 L Coquisart3 et al. Journal: Dove Press journal: Clinical Interventions in Aging Year: 2020 Type of study: ? Sample size: 64 Results: : The internal consistency was moderate to good for five systems and limited for “biomechanical constraints”. The distribution of the Frail’BESTest was more centered than that of the Tinetti and Mini-Motor tests. The Kendall’s tau showed strong concordance in center 1 for all systems and only for 4 on 6 systems in center 2 Discussion: Completing a systemic evaluation, the therapist may prioritize the patient’s needs identifying the most challenging systems. This paper presents the Frail’BESTest and confirms the psychometric properties at a first step level

33. References A Kubicki1,2 M Brika2 L Coquisart3 et al., The Frail'BESTest. An Adaptation of the "Balance Evaluation System Test" for Frail Older Adults. Description, Internal Consistency and Inter-Rater Reliability, Clin Interv Aging:2019 Jul. Anson E, Thompson E, Ma L, Jeka J. Reliability and Fall Risk Detection for the BESTest and Mini-BESTest in Older Adults.  J Geriatr Phys Ther . 2019;42(2):81-85. doi:10.1519/JPT.0000000000000123 Takacs J, Garland SJ, Carpenter MG, Hunt MA. Validity and reliability of the community balance and mobility scale in individuals with knee osteoarthritis. Phys Ther. 2014 Jun;94(6):866-74. doi: 10.2522/ptj.20130385. Epub 2014 Feb 20. PMID: 24557649; PMCID: PMC4040425. Shah G, Oates AR, Arora T, Lanovaz JL, Musselman KE. Measuring balance confidence after spinal cord injury: the reliability and validity of the Activities-specific Balance Confidence Scale. J Spinal Cord Med. 2017 Nov;40(6):768-776. doi: 10.1080/10790268.2017.1369212. Epub 2017 Sep 6. PMID: 28875768; PMCID: PMC5778940. Meseguer-Henarejos AB, Rubio-Aparicio M, López-Pina JA, Carles-Hernández R, Gómez-Conesa A. Characteristics that affect score reliability in the Berg Balance Scale: a meta-analytic reliability generalization study. Euro J Phys Rehabil Med. 2019 Oct;55(5):570-584. doi: 10.23736/S1973-9087.19.05363-2. Epub 2019 Apr 4. PMID: 30955319.

34. Weber M, Van Ancum J, Bergquist R, Taraldsen K, Gordt K, Mikolaizak AS, Nerz C, Pijnappels M, Jonkman NH, Maier AB, Helbostad JL, Vereijken B, Becker C, Schwenk M. Concurrent validity and reliability of the Community Balance and Mobility scale in young-older adults. BMC Geriatr. 2018 Jul 3;18(1):156. doi: 10.1186/s12877-018-0845-9. PMID: 29970010; PMCID: PMC6031142. Jahantabi-Nejad S, Azad A. Predictive accuracy of performance oriented mobility assessment for falls in older adults: A systematic review. Med J Islam Repub Iran. 2019 May 1;33:38. doi: 10.34171/mjiri.33.38. PMID: 31456962; PMCID: PMC6708086 Alghadir AH, Al-Eisa ES, Anwer S, Sarkar B. Reliability, validity, and responsiveness of three scales for measuring balance in patients with chronic stroke. BMC Neurol. 2018 Sep 13;18(1):141. doi: 10.1186/s12883-018-1146-9. PMID: 30213258; PMCID: PMC6136166.. Huang TT, Wang WS. Comparison of three established measures of fear of falling in community-dwelling older adults: psychometric testing. Int J Nurs Stud. 2009 Oct;46(10):1313-9. doi: 10.1016/j.ijnurstu.2009.03.010. Epub 2009 Apr 24. PMID: 19394017. Dale Avers, Chapter 7 - Functional Performance Measures and Assessment for Older Adults, Editor(s): Dale Avers, Rita A. Wong, Guccione's Geriatric Physical Therapy (Fourth Edition),Mosby,2020,Pages 137-165,SBN 9780323609128, O'Sullivan, Susan B., Schmitz, Thomas J. and Fulk, George D. Chapter 11: Locomotor Training , Physical Rehabilitation (FIFTH EDITION), 2014, PAGES 373-400 , ISBN: 978-0-80-36257 9-2

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