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Rehab Measures: Community Balance and Mobility Scale

Link to instrument

Find it on Toronto Rehab's website 

Title of Assessment

Community Balance and Mobility Scale 

Acronym

CB&M

Instrument Reviewer(s)

Initially reviewed by the Rehabilitation Measures Team; Updated with references from the TBI population by Tammie Keller Johnson, PT, DPT, MS and the TBI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Minu M. Nair, PT in 10/2012

Summary Date

2/19/2013 

Purpose

Used to detect ‘high level’ balance and mobility deficits based on tasks that are commonly encountered in community environments

Description

  • A performance measure composed of 13 challenging tasks with six tasks performed on both sides
  • Scaling is specific to the task being measured
  • Scoring is done using the first trial for each item
  • Maximum possible score of 96
    • Item scores range from 0 to 5 and reflect progressive task difficulty
    • A score of "0" = complete inability to perform the task
    • A score of "5" = the most successful completion of the item possible
  • All tasks performed without ambulation aides.
  • Patients are permitted to wear an orthotic

Area of Assessment

Balance Vestibular 

Body Part

Not Applicable 

ICF Domain

Body Structure; Body Function 

Domain

Motor 

Assessment Type

Performance Measure 

Length of Test

31 to 60 Minutes 

Time to Administer

COMBI reports 20-30 minutes

Number of Items

13 

Equipment Required

  • An 8-m track is used in the evaluation of the various tasks performed
  • Stop watch
  • Laundry basket
  • 2lb and 7lb weights
  • Visual target (a paper circle 20cm in diameter with a 5cm diameter black circle in the middle)
  • Bean bag

Training Required

None

Type of training required

Reading an Article/Manual 

Cost

Free 

Actual Cost

Free Permission to distribute

Age Range

Adolescent: 13-17 years; Adult: 18-64 years 

Administration Mode

Paper/Pencil 

Diagnosis

Acquired Brain Injury; Cerebral Palsy; Geriatrics; Stroke; Traumatic Brain Injury 

Populations Tested

  • TBI
  • Cerebral Palsy
  • Stroke
  • Geriatric
  • Acquired Brain Injury
  • Healthy Adults

Standard Error of Measurement (SEM)

Traumatic Brain Injury (TBI): (Howe et al, 2006; phase 1: n=36; mean age(SD)= 31(9) years; mean time post-injury (SD)= 11(23) months; phase 2: n=32; mean age(SD)=34(12) years; mean time post-injury (SD)= 4(6) months) • SEM = 4.1 (calculated using Cronbach’s α value 0.96) • SEM = 3.2 (calculated using test-retest ICC 0.975)

Minimal Detectable Change (MDC)

Traumatic Brain Injury (TBI): (Howe et al, 2006)

  • MDC90 = 9.6 (calculated using SEM and Cronbach’s α value)
  • MDC90 = 7.5 (calculated using SEM and test-retest ICC values)

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

  • MDC90 = 13.5% points (established)
  • MDC95=14.6% points (established)

Minimally Clinically Important Difference (MCID)

Not Established

Cut-Off Scores

Not Established

Normative Data

Traumatic Brain Injury: (Howe, 2006; n = 32; participants were able to ambulate with or without aid, participants drawn from 3 locations including acute care, inpatient, day hospital and outpatient; 5 days between assessments)
 
Care Setting Norms*:
Population
Mean
Standard Deviation
Acute care
30.39
11.7
Outpatients
41.69
18.0
Inpatient rehabilitation
53.59

21.2

Day hospital setting

62.49

17.1

*Statistically different across all settings (p < 0.03)
 
Older Women With Low Bone Mass: (Liu-Ambrose et al, 2006; n = 98; mean age = 79.3 (2.7) years)
 
CB&M Norms: 
Measure

Scale

Mean (SD)
Range
CB & M

max. 85 pts

42 (19)
0–81
MMSE

max. 30 pts

29 (2)
24–30
ABC

max. 100 pts

77 (20)
5–100
PASE
85.8 (40.6)
17.9–224.1
Fast-paced gait (m/s)
1.38 (0.30)
0.51–2.24
MMSE = Mini-Mental State Examination
ABC = Activities-Specific Balance Confidence
PASE = Physical Activity Scale for the Elderly

Healthy individuals aged 20-79 years (Clegg et al, 2009; n=54)

Age group

N

Mean*

SD

95% CI

20-29

24

88.71

3.53

87.2-90.2

30-39

27

86.33

5.78

84.1-88.6

40-49

23

84.35

4.03

82.6-86.1

50-59**

26

77.43

6.55

75.0-79.9

60-69**

17

64.94

8.22

60.7-69.2

70-79**

4

49.75

6.95

38.7-60.8

*CB&M scored out of 96
**Significant difference from the group in the previous decade

Test-retest Reliability

Traumatic Brain Injury: (Howe, 2006)
 
Test-retest Reliability:
Item
Test-retest (5 days apart)
Test-retest (Immediate)
Unilateral stance left
0.81
0.76
Unilateral stance right
0.44

0.8

Tandem walking
0.59
0.85
1808 tandem pivot
0.53
0.9
Lateral foot scooting left
0.54
0.74
Lateral foot scooting right
0.58
0.92
Hopping forward left
0.68
0.85
Hopping forward right
0.6
0.87
Crouch and walk
0.45
0.92
Lateral dodging
0.61
0.61
Walking & looking left
0.3

0.86

Walking & looking right

0.35

0.87

Running with controlled stop

0.58

0.85

Forward to backward walking

0.64

0.77

Walk, look & carry left

0.69

N/A

Walk, look & carry right

0.77

N/A

Descending stairs

0.77

0.96

Step-ups X 1 step left

0.6

0.98

Step-ups X 1 step right

0.51

0.94

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

  • Excellent test re-test reliability (3–10-day re-test interval) (ICC=0.90)

Interrater/Intrarater Reliability

Traumatic Brain Injury: (Howe, 2006; n = 13 Physical Therapist raters, mean practice experience = 5.89 (4.4) years)
  • Intra-rater = 0.977 (CI = 0.957-0.986)
  • Inter-rater = 0.977 (CI = 0.972-0.988)

Inter and Intra-rater Reliability:

Item
Intra-rater
Inter-rater
Unilateral stance left
0.89
0.87
Unilateral stance right
0.92
0.98
Tandem walking
0.71
0.85
1808 tandem pivot
0.64
0.59
Lateral foot scooting left
0.84
0.78
Lateral foot scooting right
0.62
0.88
Hopping forward left
0.81
0.81
Hopping forward right
0.76
0.86
Crouch and walk
0.64
0.7
Lateral dodging
0.53
0.78
Walking & looking left
0.34
0.53
Walking & looking right

0.72

0.64

Running with controlled stop

0.78

0.67

Forward to backward walking

0.76

0.71

Walk, look & carry left

0.58

0.75

Walk, look & carry right

0.71

0.8

Descending stairs

0.85

0.78

Step-ups X 1 step left

0.71

0.84

Step-ups X 1 step right

0.82

0.85

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

  • Excellent interrater reliability (ICC=0.93)

Internal Consistency

Traumatic Brain Injury: (Howe, 2006; n = 32; participants were able to ambulate with or without aid, participants drawn from 3 locations including acute care, inpatient, day hospital, and outpatient; 5 days between assessments)
  • Excellent internal consistency (Cronbach's alpha > 0.95)

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

  • Excellent internal consistency (Cronbach’s alpha=0.89) for the primary assessors’ baseline CB&M scores.

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Knorr et al, 2010)
 
Chedoke McMaster Stroke Assessment (CMSA) and Lower-Limb Strength Results across measures~:
Variables
CB&M
(n = 44)
BBS
(n = 44)
TUG
(n = 42)
CMSA leg
0.63*
0.54*
-0.70*
CMSA foot
0.61*
0.50†
-0.69*
Paretic limb
0.67*
0.50*
-0.71*
Nonparetic limb
0.46†
0.28

-0.44†

~Spearman correlation coefficients
Adjusted level of significance = p < .01
* p < .001
p < .01

Construct Validity (Convergent/Discriminant)

Traumatic Brain Injury: (Howe, 2006)
  • Adequate: self-paced gait velocity (r = 0.53; p = 0.001)
  • Excellent: maximal gait velocity (r = 0. 64; p = 0.001)

Traumatic Brain Injury : (Inness, 2011 n= 35 patients with TBI; 13 in-patients, 22 outpatients)

  • Adequate : a moderate to good magnitude (r =0.54, p < 0.001) was demonstrated between the CB&M and the CIQ. This was obtained by combining current study data with a prior study for n=47
  • Excellent : a significant relationship between CB&M and ABC scores emerged (r = 0.60, p = 0.011)

Community-dwelling persons after stroke: (Knorr et al, 2010)

  • Excellent (ρ=.70 to .83, P=.001) correlation were observed among the CB&M, BBS, and TUG

Content Validity

TBI patients and clinicians experienced in neurorehabilitation were involved in item generation.  A group of PT's then rated items for relevance (Howe, 2006).

Face Validity

Traumatic Brain Injury: (Howe, 2006; n = 32; participants were able to ambulate with or without aid, participants drawn from 3 locations including acute care, inpatient, day hospital and outpatient; 5 days between assessments)

  • Items for the CB&M scale were derived from a series of interviews and discussions with individuals with traumatic brain injury living in the community, students in physical therapy with experience in neurological rehabilitation and therapists. Items were added or eliminated based on expert opinion on relevance to key constructs of balance and mobility.

Floor/Ceiling Effects

Acute Stroke: (Knorr et al, 2010; n = 44; time post stroke (baseline assessment) 98.6 (52.6) days; Mean FIM scores, Motor = 82.0 (range = 20 to 91) Cog = 33.0 (range = 23 to 35) points)

  • Scores on the CB&M covered the scale’s range; the maximum score was not achieved by any of the participants.

Floor and Ceiling Effects:
 
Baseline (n = 44)
Follow-Up (n = 44)
Scale
Floor Effect
Ceiling Effect
Floor Effect
Ceiling Effect
CB&M
4 (9.1)
0 (0.0)
3 (6.8)
0 (0.0)
BBS
0 (0.0)
15 (34.1)*
0 (0.0)
21 (47.7)*
TUG
2 (4.5)
10 (22.7)*
0 (0.0)
16 (36.4)*
*Significant effect (> 20%)

Responsiveness

Cerebral Palsy: (Bien et al, 2011; n = 4; mean age = 16 (2.25) years; The study span 5 days and used a 90 minute virtual reality balance intervention)
  • True change from the mean CB&M score were achieved in 3 of 4 participants
  • In a follow-up, these improvements were maintained and true change was observed in all participants

Acute Stroke: (Knorr et al, 2010)

  • The Standardized Response Mean (SRM) suggests a large effect size for the CB&M and small effect sizes for the BBS and TUG.

Standardized Response Mean Across Measures:
Variable
Metric
Baseline*
Follow-Up*
p
SRM
CB&M
96 points
42.7 (22.6)
51.3 (24.6)
<.001
0.83
BBS
56 points
48.9 (12.4)
50.4 (11.0)
<.010
0.42
TUG
Seconds

16.7 (17.1)

13.7 (16.0)

<.010
0.34
*Mean (SD)
p = between the baseline and follow-up

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 based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

R

R

R

R

R

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

R

R

NR

NR

 

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)

TBI EDGE

Yes

Yes

Yes

Not reported

Considerations

  • In patients with mild to moderate neurologic deficits secondary to stroke, the CB&M was superior to either the TUG or BBS five months after stroke onset
  • Designed for ambulatory individuals living in the community.
  • The CB&M is a valid outcome measure for detecting dynamic instability and for evaluating the ability of patients of TBI to successfully return to community living (Inness, 2011)
  • “Clinical feedback and preliminary evidence indicates that the scale is also appropriate for clients with diagnoses other than traumatic brain injury. The items of the CB&M encompass challenging balance and mobility tasks and, therefore, the CB&M may be more appropriate for patients in the rehabilitation and community setting rather than acute care.” (Toronto rehab CB&M pdf document)
  • The population that I was supposed to find literature on was community-dwelling elderly.
  • Since the tool has not been specifically studied in community dwelling elderly population, the psychometric properties of the other studies can be considered which have included the age group of more than 60 years of age.
  • The studies which have taken the community dwelling elderly group into consideration are as follows:
    • Knorr et al, 2010: For community dwelling elderly group with stroke, the available psychometric properties include convergent validity, sensitivity to change, and floor and ceiling effects as detailed above.
    • Clegg et al, 2009 (healthy individuals aged 20-79 years: normative data): The age related reference values for community dwelling elderly show that the CB&MS score decline after the age of 50 indicating that balance is affected significantly in healthy elderly population.
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Brien, M. and Sveistrup, H. (2011). "An intensive virtual reality program improves functional balance and mobility of adolescents with cerebral palsy." Pediatr Phys Ther 23(3): 258-266. Find it on PubMed

Clegg, H., Fernande, S., et al. (2009). "Community balance and mobility scale: age-related reference values."

Howe, J. A., Inness, E. L., et al. (2006). "The Community Balance and Mobility Scale--a balance measure for individuals with traumatic brain injury." Clin Rehabil 20(10): 885-895. Find it on PubMed 

Inness, E. L., Howe, J. A., et al. (2011). "Measuring Balance and Mobility after Traumatic Brain Injury: Validation of the Community Balance and Mobility Scale (CB&M)." Physiotherapy Canada 63(2): 199-208.

Knorr, S., Brouwer, B., et al. (2010). "Validity of the Community Balance and Mobility Scale in community-dwelling persons after stroke." Arch Phys Med Rehabil 91(6): 890-896. Find it on PubMed 

Liu-Ambrose, T., Khan, K. M., et al. (2006). "Falls-related self-efficacy is independently associated with balance and mobility in older women with low bone mass." J Gerontol A Biol Sci Med Sci 61(8): 832-838. Find it on PubMed

Wright, F. V., Ryan, J., et al. (2010). "Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury." Brain Inj 24(13-14): 1585-1594. Find it on PubMed

Year published

2006 

Instrument in PDF Format

Yes 
Approval Status Approved 
 
Attachments
Community Balance and Mobility Scale Revised Guidelines June 2011.pdf    
Created at 7/19/2011 1:52 PM  by Jason Raad 
Last modified at 11/7/2014 3:14 PM  by Jason Raad