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Rehab Measures: Brief Balance Evaluation Systems Test

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Title of Assessment

Brief Balance Evaluation Systems Test 

Acronym

Brief BESTest

Instrument Reviewer(s)

Cathy Harro MS, PT, NCS and the PD EDGE Task Force of Neurology Section of the APTA

Summary Date

6/3/2013 

Purpose

Clinical balance assessment tool: Abbreviated version of Balance Evaluation Systems Test (BESTest), designed to assess 6 different aspects contributing to postural control in standing and walking.

Description

This is a 6-item revised version of the BESTest, designed to improve the clinical utility and to preserve the construct validity of BESTest. One item from each of the BESTest system subsections (biomechanical constraints, stability limits/verticality, anticipatory postural adjustments, postural responses, sensory orientation, stability in gait) was selected for the Brief BESTest based on highest item correlation coefficients with their respective system section.

Each item is scored: 0 - 3 points (0 representing severe impairment and 3 representing no balance impairment).

Total score = 24 points (2 items include both a R/L component)

Scoring form and test available in original article, Padgett 2012

Six categories included in the Brief BESTest (8 scored):

1) Biomechanical constraints: Hip strength

2) Stability limits/verticality: Reach forward

3) Anticipatory postural responses: Stand on one limb: left and right each scored

4) Postural responses: Compensatory Stepping right and left each scored

5) Sensory orientation: Stance on foam with eyes closed

6) Stability in gait: Get up and Go test

Area of Assessment

Balance Non-Vestibular; Functional Mobility 

Body Part

Not Applicable 

ICF Domain

Body Function; Activity 

Domain

Motor; Sensory 

Assessment Type

Performance Measure 

Length of Test

06 to 30 Minutes 

Time to Administer

10 minutes to administer

Number of Items

6 items 

Equipment Required

  • Medium density 4-inch foam pad
  • Stop watch
  • Meter stick
  • Space to complete the TUG
  • Stable chair

Training Required

Training tape for BESTest can be used to train the 6 items for Brief BESTest.  Tape available for purchase at http://bestest.us/

Type of training required

reading an article/manual 

Cost

Free 

Actual Cost

Test is free; Training DVD for BESTest full test is $200.00

Age Range

Adult: 18-64 years; Elderly adult: 65+ 

Administration Mode

Paper/Pencil 

Diagnosis

Acquired Brain Injury; Geriatrics; Parkinson’s Disease; Peripheral Neuropathy; Traumatic Brain Injury; Vestibular Disorders 

Populations Tested

  • Multiple Sclerosis
  • Parkinson's Disease
  • Stroke
  • Peripheral Neuropathy

Standard Error of Measurement (SEM)

Not Established

Minimal Detectable Change (MDC)

Not Established

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Parkinson’s Disease:

(Duncan, et al, 2013; n = 80 with idiopathic PD, mean age = 68.2 (9.7), mean MDS-UPDRS 41.3 (14.7), H & Y stage [1 = 4, 2 = 27, 2.5 = 30, 3 = 13, 4 = 6]; retrospective fallers n = 25 (31%), 6 month prospective fallers n = 14 (27.5%), 12 month prospective fallers n = 13 (32.5%))

  • Fall risk Cut score < 11/24 points; Adequate detection of retrospective fallers in PD cohort, (AUC = 0.82, sensitivity = 0.76, specificity = 0.84, LR+ = 4.64, LR- = 0.29)

Normative Data

Parkinson’s Disease:

(Duncan , et al., 2013; n = 80 with PD varied stages (see above cohort description))

  • mean Brief BESTest = 13.2 (55%) sd = 5.5

Test-retest Reliability

Not Established

Interrater/Intrarater Reliability

Balance Deficits:

(Padgett, Jacobs, & Kasser, 2012; 1st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history. 2nd cohort: n = 13 with MS, mean age 50, EDSS < 6 (range 0 - 4.5), 7 fallers)

  • Excellent inter-rater reliability ICC = 0.994 (0.986 - 0.997) with three trained raters concurrently rating Brief BESTest

Internal Consistency

Balance Deficits:

(Padgett, Jacobs, & Kasser, 2012)

  • Excellent internal consistency 1st cohort Cronbach Alpha = 0.917 with average item correlation = 0.737; 2nd cohort Cronbach Alpha = 0.856, with average item correlation = 0.617

Criterion Validity (Predictive/Concurrent)

Parkinson’s Disease:

(Duncan , et al., 2013)

  • Cut score < 11/24; Prospective prediction of fall risk in PD cohort
    • (n = 51) 6-month adequate predictive validity (AUC = 0.88, sensitivity = 0.71, specificity = 0.87, LR+ = 5.29, LR- = 0.50);
    • n = 40 12-month adequate predictive validity (AUC = 0.76, sensitivity = 0.53, specificity = 0.93, LR+7.27, LR- = 0.50)

Construct Validity (Convergent/Discriminant)

Balance Deficits:

(Padgett, Jacobs, & Kasser, 2012)

  • Brief BESTest significantly differentiated those with neurologic conditions from healthy subjects for all three raters (1st cohort)
  • Rater 1: neurologic conditions (mean score = 59 (CI 39-79)) and healthy subjects (mean score = 91 (CI 83-100))
  • Rater 2: neurologic conditions (mean score = 57 (38-76)) and healthy subjects (mean score = 84 (80-87))
  • Rater 3: neurologic conditions (mean score = 61 (43-80)) and healthy subjects (mean score = 90 (82-97))
  • Excellent discriminative validity in MS cohort (2nd cohort), able to distinguish fallers (Mean score = 59% (45 - 73)) from nonfallers (mean score = 95% (92 - 98)); Sensitivity to detect fallers = 100%, specificity = 100%, accuracy = 100%.

Content Validity

Parkinson’s Disease:

(Duncan , et al., 2013)

Brief BESTest demonstrated excellent correlation with

BESTest (r = 0.94) and Mini BESTest (r = 0.95)

*Each item on Brief BESTest correlated with its respective section on BESTest as follows:

  • adequate correlation (anticipatory postural adjustments r = 0.89, postural responses r = 0.91, sensory orientation r = 0.78, stability in gait r = 0.78);
  • poor correlation (biomechanical constraints r = 0.61, stability limits/verticality r = 0.69)

Face Validity

Supported by the theoretical construct of BESTest six subsections, Brief BESTest includes the strongest psychometric item from each section.

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks post)

VEDGE

LS

 

LS

 

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

 

I

II

III

IV

V

PD EDGE

LS/UR

R

R

R

NR

 

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

LS

LS

LS

LS

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

PD EDGE

No

No

No

Not reported

VEDGE

Yes

Yes

Yes

Yes

Considerations

  • REVISED version of BESTest with goal of improving clinical utility
  • Limited psychometric studies (2 published)
  • Time to complete testing (10 minutes) is more feasible in clinical setting that complete BESTest. Consider MiniBESTest as another option of valid and reliable revised version of BESTest that has good clinical utility.

Bibliography

Duncan, R. P., Leddy, A. L., et al. (2013). "Comparative utility of the BESTest, mini-BESTest, and brief-BESTest for predicting falls in individuals with Parkinson disease: a cohort study." Phys Ther 93(4): 542-550. Find it on PubMed

Padgett, P. K., Jacobs, J. V., et al. (2012). "Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct." Phys Ther 92(9): 1197-1207. Find it on PubMed

Year published

2012 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Created at 1/8/2014 10:40 AM  by Jason Raad 
Last modified at 8/29/2014 1:50 PM  by Jason Raad