How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions

Rasch analysis of the modified version of the postural assessment scale for stroke patients: postural stroke study in Gothenburg (POSTGOT)

Background

The modified version of the Postural Assessment Scale for Stroke Patients (SwePASS) is a new ordinal outcome measurement designed to assess postural control in patients with stroke. Before implementation of SwePASS into the clinical setting, it is necessary to know its measurement properties. Thus, the aim of the study was to evaluate the measurement properties of the SwePASS.

Methods

Rasch analysis, based on data of 150 SwePASS assessments was made the first week after stroke onset. The measurement properties referred to were unidimensionality, local independence, invariance, category function, targeting of persons and items and the reliability.

Results

The initial analysis showed disordered thresholds in four items. After adjustment of the scoring categories, this was resolved. However, analyses of local dependency revealed correlations between two of the items. These two items were collapsed into one. After adjustments, the person separation index that acts as an indicator of the whole model fit was 0.96. The adjusted SwePASS is a global scale that works the same way regardless of gender, age and location of stroke lesion. Overall, the population had better postural control than was targeted with the items in the scale.

Conclusions

Rasch analysis of the adjusted SwePASS showed that the scale was unidimensional. In SwePASS, equal capacity in postural control provides the same response to an individual item in patients with stroke, regardless of gender, age and location of stroke lesion. Regarding clinical implications, before introducing SwePASS in clinical routine and to confirm the results, further research including a larger sample with poorer postural control is suggested.

Systematic review of the psychometric properties of balance measures for cerebellar ataxia

OBJECTIVE

To review systematically the psychometric properties of balance measures for use in people with cerebellar ataxia.

DATA SOURCES

Medline, AMED, CINAHL, Web of Science and EMBASE were searched between 1946 and April 2014.

REVIEW METHODS

Two reviewers independently searched data sources. Cerebellar-specific and generic measures of balance were considered. Included studies tested psychometric properties of balance measures in people with cerebellar ataxia of any cause. Quality of reported studies was rated using the Consensus Based Standards for the selection of health status Measurement INstruments (COSMIN) checklist.

RESULTS

Twenty-one articles across which 16 measures had been tested were included for review. Using the COSMIN, quality of methodology in studies investigating psychometric properties of generic balance measures (n=10) was rated predominantly as 'poor'. Furthermore, responsiveness has not been tested for any generic measures in this population. The quality of studies investigating psychometric properties of balance sub-components of the cerebellar-specific measures (n=6) ranged from 'poor' to 'excellent'; however, Minimally Clinically Important Difference has not been determined for these cerebellar-specific measures.

CONCLUSION

The Posture and Gait (PG) sub-component of the International Cooperative Ataxia Rating Scale (ICARS) demonstrates the most robust psychometric properties with acceptable clinical utility.

Validity of the performance-oriented mobility assessment in predicting fall of stroke survivors: a retrospective cohort study

Falling is one of the most common complications in stroke survivors. It is therefore important to evaluate the risk of falls. In this study, we investigated the usability of the performance-oriented mobility assessment (POMA) for predicting falls in stroke patients. The POMA examines the level of balance and mobility. Data were collected on the number of falls and physical functions from 72 stroke survivors. Physical functions were measured using the POMA balance subscale, One Leg Stand test (OLS), Sit To Stand test (STS), 10-m Walk Test (10WT), Fugl-Meyer assessment (FM), and Trunk Impairment Scale (TIS). Since the accuracy of the POMA balance subscale was moderate, the cutoff value used for predicting falls was 12.5 points (sensitivity: 72%; specificity: 74%), and the area under the curve was 0.78 (95% confidence interval: 0.66-0.91, p < 0.001). When comparing the physical functions (i.e., OLS, STS, 10WT, FM, and TIS) to the cutoff value for the POMA balance subscale, the physical functions of the group over 12.5 points for the subscale were significantly higher than those in the group below 12.5 points (p < 0.05). The muscle strength shown in the STS was the most important factor affecting the performance in the POMA balance subscale (β = -0.447). For the group below 12.5 points on the POMA balance subscale, the risk of falling increased by 0.304 times more than the group over 12.5 points. The POMA balance subscale is a valid tool for assessing the physical function and fall risk of stroke survivors.

Balance and walking after three different models of stroke rehabilitation: early supported discharge in a day unit or at home, and traditional treatment (control)

OBJECTIVE

To compare the effects on balance and walking of three models of stroke rehabilitation: early supported discharge with rehabilitation in a day unit or at home, and traditional uncoordinated treatment (control).

DESIGN

Group comparison study within a randomised controlled trial.

SETTING

Hospital stroke unit and primary healthcare.

INCLUSION CRITERIA

a score of 2-26 on National Institutes of Health Stroke Scale, assessed with Postural Assessment Scale for Stroke (PASS), and discharge directly home from the hospital stroke unit.

INTERVENTIONS

Two intervention groups were given early supported discharge with treatment in either a day unit or the patient's own home. The controls were offered traditional, uncoordinated treatment.

OUTCOME MEASURES

Primary: PASS. Secondary: Trunk Impairment Scale-modified Norwegian version; timed Up-and-Go; 5 m timed walk; self-reports on problems with walking, balance, ADL, physical activity, pain and tiredness. The patients were tested before randomisation and 3 months after inclusion.

RESULTS

From a total of 306 randomised patients, 167 were tested with PASS at baseline and discharged directly home. 105 were retested at 3 months: mean age 69 years, 63 men, 27 patients in day unit rehabilitation, 43 in home rehabilitation and 35 in a control group. There were no group differences, either at baseline for demographic and test data or for length of stroke unit stay. At 3 months, there was no group difference in change on PASS (p>0.05). Some secondary measures tended to show better outcome for the intervention groups, that is, trunk control, median (95% CI): day unit, 2 (0.28 to 2.31); home rehabilitation, 4 (1.80 to 3.78); control, 1 (0.56 to 2.53), p=0.044; and for self-report on walking, p=0.021 and ADL, p=0.016.

CONCLUSIONS

There was no difference in change between the groups for postural balance, but the secondary outcomes indicated that improvement of trunk control and walking was better in the intervention groups than in the control group.

TRIAL REGISTRATION

This study is part of the Early Supported Discharge after Stroke in Bergen, ClinicalTrials.gov (NCT00771771).

Clinical feasibility of the Nintendo Wii™ for balance training post-stroke: a phase II randomized controlled trial in an inpatient setting

OBJECTIVE

To investigate the feasibility and potential efficacy of the Nintendo Wii™ for balance rehabilitation after stroke.

DESIGN

Phase II, single-blind, randomized controlled trial.

SETTING

Inpatient rehabilitation facility.

SUBJECTS

Thirty adults (mean age 63.6 (14.7) years) undergoing inpatient rehabilitation who were less than three months post-stroke and able to stand unsupported.

INTERVENTIONS

Participants were allocated to a Balance Group, using the 'Wii Fit Plus' in standing, or Upper Limb Group, using the 'Wii Sports/Sports Resort' in sitting. Both groups undertook three 45 minute sessions per week over two to four weeks in addition to standard care.

MAIN MEASURES

The primary focus was feasibility, addressed by recruitment, retention, adherence, acceptability and safety. Efficacy was evaluated by balance, mobility and upper limb outcomes.

RESULTS

Twenty-one percent of individuals screened were recruited and 86% (n = 30) of eligible people agreed to participate. Study retention and session adherence was 90% and > 99%, respectively, at two weeks; dropping to 70% and 87% at four weeks due to early discharge. All participants reported enjoying the sessions and most felt they were beneficial. No major adverse events occurred. Wii use by the Balance Group was associated with trends for improved balance, with significantly greater improvement in outcomes including the Step Test and Wii Balance Board-derived centre of pressure scores. The Upper Limb Group had larger, non-significant changes in arm function.

CONCLUSIONS

A Wii-based approach appears feasible and promising for post-stroke balance rehabilitation. A larger randomized controlled trial is recommended to further investigate efficacy.

Interpreting lateral dynamic weight shifts using a simple inverted pendulum model

Seventy-five young, healthy adults completed a lateral weight-shifting activity in which each shifted his/her center of pressure (CoP) to visually displayed target locations with the aid of visual CoP feedback. Each subject's CoP data were modeled using a single-link inverted pendulum system with a spring-damper at the joint. This extends the simple inverted pendulum model of static balance in the sagittal plane to lateral weight-shifting balance. The model controlled pendulum angle using PD control and a ramp setpoint trajectory, and weight-shifting was characterized by both shift speed and a non-minimum phase (NMP) behavior metric. This NMP behavior metric examines the force magnitude at shift initiation and provides weight-shifting balance performance information that parallels the examination of peak ground reaction forces in gait analysis. Control parameters were optimized on a subject-by-subject basis to match balance metrics for modeled results to metric values calculated from experimental data. Overall, the model matches experimental data well (average percent error of 0.35% for shifting speed and 0.05% for NMP behavior). These results suggest that the single-link inverted pendulum model can be used effectively to capture lateral weight-shifting balance, as it has been shown to model static balance.

Interrater reliability of the Berg Balance Scale when used by clinicians of various experience levels to assess people with lower limb amputations

BACKGROUND

People with lower limb amputations frequently have impaired balance ability. The Berg Balance Scale (BBS) has excellent psychometric properties for people with neurologic disorders and elderly people dwelling in the community. A Rasch analysis demonstrated the validity of the BBS for people with lower limb amputations of all ability strata, but rater reliability has not been tested.

OBJECTIVE

The study objective was to determine the interrater reliability and intrarater reliability of BBS scores and the differences in scores assigned by testers with various levels of experience when assessing people with lower limb amputations.

DESIGN

This reliability study of video-recorded single-session BBS assessments had a cross-sectional design.

METHODS

From a larger study of people with lower limb amputations, 5 consecutively recruited participants using prostheses were video recorded during an in-person BBS assessment. Sixteen testers independently rated the video-recorded assessments. Testers were 3 physical therapists, 1 occupational therapist, 3 third-year and 4 second-year doctor of physical therapy (DPT) students, and 5 first-year DPT students without clinical training. Rater reliability was calculated using intraclass correlation coefficients (ICC [2,k]). Differences in scores assigned by testers with various levels of experience were determined by use of an analysis of variance with Tukey post hoc tests.

RESULTS

The average age of the participants was 53.0 years (SD=15.7). Amputations had occurred at the ankle disarticulation, transtibial, and transfemoral levels because of vascular, trauma, and medical etiologies an average of 8.2 years earlier (SD=7.9). Berg Balance Scale scores spanned all ability strata. Interrater reliability (ICC [2,k]=.99) and intrarater reliability of scores determined in person and through video-recorded assessments by the same testers (ICC [2,k]=.99) were excellent. For participants with the lowest levels of ability, licensed professionals assigned lower scores than did DPT students without clinical training.

LIMITATIONS

Intrarater reliability calculations were based on 2 testers.

CONCLUSIONS

Berg Balance Scale scores assigned to people using prostheses by testers with various levels of clinical experience had excellent interrater reliability and intrarater reliability.

Huntington's Disease: Characteristics of Fallers

INTRODUCTION

Individuals with Huntington's disease have a high prevalence of falls, but the specific factors that may increase the risk of falling have not been clearly identified in this clinical population. This study aimed to identify the characteristics of individuals with early to mid-stage Huntington's disease who had a history of falls, compared with a cohort with no history of falls.

METHODS

Twenty-four participants (10 non-fallers and 14 recurrent fallers) with a diagnosis of early to mid-stage Huntington's disease were included in this study. Falls data were collected using retrospective survey analysis. Participants were assessed using measures of balance (Berg Balance Scale), mobility (Rivermead mobility index [RMI]), fear of falling (Activity-specific Balance Confidence Scale) and gait (6-min walk test; 10-m walk test self-paced and dual tasking).

RESULTS

There was no difference in severity of disease state between fallers (Unified Huntington Disease Rating Scale [UHDRS] motor 25.33) and non-fallers (UHDRS motor 25.13) (p = 0.97). The prevalence of falls was high with 66.7% of participants reporting at least one fall and 58.3% reporting two or more falls in the past 12 months. There was no difference in age or gender between recurrent fallers and non-fallers. Recurrent fallers had significantly lower scores on the Activity-specific Balance Confidence Scale (p < 0.01) and the RMI (p < 0.05). The probability of falling increases rapidly with a RMI score of less than 10.

DISCUSSION

Recurrent falls are common in people with Huntington's disease. Individuals with a history of falls were found to have a greater fear of falling and lower functional mobility performance than those who did not have a history of falls. These measures may be useful in the identification of individuals with Huntington's disease who might benefit from a falls prevention programme. Copyright © 2014 John Wiley & Sons, Ltd.

Evaluating the Adequacy of Social-Emotional Measures in Early Childhood

Technical adequacy and usability are important considerations in selecting early childhood social-emotional (SE) screening and assessment measures. As identification of difficulties can be tied to programming, intervention, accountability, and funding, it is imperative that practitioners and decision makers select appropriate and quality measures from the plethora of measures available. This study systematically reviewed and evaluated the technical adequacy and usability of 10 commonly used SE assessment and screening measures, using a framework for evaluating selected properties of measures (e.g., reliability, validity). Through this review, it was found that there are inadequacies in many commonly used SE measures, deserving the attention of both users and developers.

Understanding approaches to balance assessment in physical therapy practice for elderly inpatients of a rehabilitation hospital

PURPOSE

Balance is a critical modifiable risk factor for falls in older adults. The purpose of this study was to identify the physiotherapy assessment tools used to evaluate balance in clinical practice and to determine the components of balance assessed through the use of standardized and/or other measures.

METHODS

A retrospective chart review was performed on 250 patients aged 65 and older undergoing in-patient rehabilitation with a clinical diagnosis associated with a balance impairment (stroke, musculoskeletal conditions, lower limb amputation, deconditioning, or cardiac surgery) at a rehabilitation hospital in Ontario.

RESULTS

All patients received at least one assessment that incorporated a balance component. Standardized balance measures were performed for 73% of patients; the timed up-and-go test (48%) and Berg Balance Scale (36%) were most commonly used for this assessment. Reactive movement strategies and cognitive processing were the least commonly assessed components of balance. Balance was assessed least often among people with cardiac surgery.

CONCLUSIONS

Considerable variation exists in the assessment of balance, and the data suggest that not all relevant components are equally considered. Future research should be conducted in other clinical settings and should include other health care practitioners' assessments to develop a more complete understanding of current balance assessment procedures.

How to measure pain in neurological conditions? A systematic review of psychometric properties and clinical utility of measurement tools

OBJECTIVE

To systematically review the psychometric properties and clinical utility of measures of pain in neurological conditions.

DATA SOURCES

Electronic databases (AMED, CINAHL, MEDLINE, PEDro and Web of Knowledge) were searched from their inception to February 2013.

REVIEW METHODS

Studies investigating any measurement tool to assess pain in central nervous system conditions were systematically identified. Data about their psychometric properties and clinical utility were extracted and analysed independently. The strength of the psychometric properties and clinical utility were assessed.

RESULTS

A total of 13 articles met the selection criteria, which assessed 11 measurement tools; eight pain rating scales; one Neuropathic Pain Scale; and two measures of pain interference with every-day life. Most of the pain rating scales were specifically for hemiplegic shoulder pain. None had been sufficiently developed to recommend for use in clinical practice or research. Evaluation of reliability and the ability to detect change were particularly sparse. Reliability depended on the type of tools used. Patients with right hemisphere damage favoured verbal/written responses, while people with left hemisphere damage preferred and reported more effectively using visual/numeric responses. Validity between measures of pain intensity was moderate, while validity with mood or quality of life was weak to moderate.

CONCLUSION

None of the selected measures of pain have been fully developed or evaluated to demonstrate that they provide accurate, relevant reproducible information.

Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review

We aimed to review tools used to assess balance in clinical practice in children and adults with cerebral palsy (CP), to describe their content and measurement properties and to evaluate the quality of the studies that have examined these properties. CINAHL, Embase, and PubMed/MEDLINE were searched. The COnsensus-based Standards for selection of health Measurement INstruments (COSMIN) was used to assess the 'quality of studies' and the Terwee criteria were used to assess the 'result of studies'. Twenty-two clinical balance tools were identified from 35 papers. The content and focus of the tools varied significantly. There was moderate or limited levels of evidence for most of the measurement properties of the tools; the strongest level of evidence was found for the Trunk Control Measurement Scale and the Level of Sitting Scale, in the category 'maintain balance', the Timed Up and Go and the Segmental Assessment of Trunk Control in the categories 'achieve balance' and 'restore balance' respectively. Information on responsiveness was scarce. Further studies providing better evidence for reliability and responsiveness for clinical balance tools are needed. In the meantime, results of studies evaluating effects of treatment of balance in individuals with CP should be interpreted with caution.

Preliminary assessment of balance with the Berg Balance Scale in adults who have a leg amputation and dwell in the community: Rasch rating scale analysis

BACKGROUND

Self-report measures of balance and multidimensional mobility assessments are common for people with a leg amputation, yet clinical assessment of balance ability remains less explored. The Berg Balance Scale (BBS), typically used for other populations with impaired balance, has been used for young people with a high level of functioning after traumatic amputation but rarely for older people after vascular amputation.

OBJECTIVE

The study objective was to examine the psychometric properties of the BBS with Rasch rating scale analysis to determine the validity and utility of the BBS in assessing balance ability in adults who have a leg amputation and dwell in the community.

DESIGN

Rating scale analysis was applied to BBS scores obtained from a single assessment.

METHODS

Adult volunteers (men and women) who had a leg amputation (any level and etiology) and dwelled in the community were recruited from a hospital-based community support group and a prosthetic clinic. Rating scale analysis of the BBS was used to assess unidimensionality, internal validity, goodness of fit, structural integrity, and person and item analyses.

RESULTS

The study participants were 40 people (26 men and 14 women; 57.8 [SD=9.7] years old) with leg amputations (24 transtibial, 13 transfemoral, and 3 bilateral) of mixed etiology (32 vascular and 8 nonvascular). The psychometric properties of the BBS confirmed that it measures the unidimensional construct of balance ability with adequate validity and with goodness of fit and structural integrity that meet the acceptability criteria. Person measures revealed that some participants scored near the top of the BBS, suggesting a ceiling effect; item measures revealed that participants with leg amputations had the most difficulty performing the following tasks: standing with 1 leg in front, turning 360 degrees, and placing alternate foot on a stool.

LIMITATIONS

Limitations included a convenience sample and a lack of rater reliability testing.

CONCLUSIONS

The BBS cohered with the unidimensional construct of balance ability and had strong internal validity for use in a variety of people with leg amputations.

Clinical assessment of reactive postural control among physiotherapists in Ontario, Canada

Reactive postural control, the ability to recover from an external perturbation to stability, ultimately determines whether an individual will fall following a loss of balance and should be routinely incorporated in balance assessment. The purpose of this study was to identify (1) methods used to assess reactive postural control in clinical practice and (2) factors associated with regular assessment of reactive postural control. A cross-sectional survey was conducted. Three hundred and fifty-seven physiotherapists in Ontario, Canada who treated adults with balance impairments answered questions about the components of balance they assess and how they assess reactive control in their practice. Of the 273 respondents who assessed reactive postural control at least some of the time, 15.4% used a standardized measure, 79.1% used a non-standardized approach, and 5.5% used both. Forty-five methods of assessing reactive control were reported. The most common methods used were non-standardized perturbations (43.5%; 104/239 respondents) and movement observation (18.8%; 45/239). The remaining 43 methods were each used by less than 8% of respondents. Practice area had the strongest association with regular assessment of reactive postural control (>60% of the time), and respondents working with neurological disorders were more likely to regularly evaluate reactive control than those working with people with orthopedic conditions. Despite the availability of valid standardized measures to evaluate reactive postural control, respondents relied primarily on non-standardized approaches and observational assessment. Future work should examine the factors influencing choice of reactive control assessment tools and awareness of standardized measures for reactive postural control.

Virtual walking training program using a real-world video recording for patients with chronic stroke: a pilot study

OBJECTIVE

The purpose of this study was to investigate the effectiveness of the virtual walking training program using a real-world video recording on walking balance and spatiotemporal gait parameters in patients with chronic stroke.

DESIGN

Fourteen patients with chronic stroke were randomly assigned to either the experimental group (n = 7) or the control group (n = 7). The subjects in both groups underwent a standard rehabilitation program; in addition, the experimental group participated in the virtual walking training program using a real-world video recording for 30 mins a day, three times a week, for 6 wks, and the control group participated in treadmill gait training for 30 mins a day, three times a week, for 6 wks. Walking balance was measured using the Berg Balance Scale (BBS) and the Timed Up and Go test. Gait performance was measured using an electrical walkway system.

RESULTS

In walking balance, greater improvement on the Berg Balance Scale (experimental group: 4.14 vs. control group: 1.85) and the Timed Up and Go test (-2.25 vs. -0.94) was observed in the experimental group compared with the control group (P <; 0.05). In the spatiotemporal gait parameters, greater improvement on velocity (25.40 vs. 9.74) and cadence (26.71 vs. 11.11) was observed in the experimental group compared with the control group (P <; 0.05).

CONCLUSIONS

This study demonstrated the positive effects of the virtual walking training program using a real-world video recording on gait performance. These findings suggest that the virtual walking training program using a real-world video recording may be a valid approach to enhance gait performance in patients with chronic stroke.

Comparison of reliability, validity, and responsiveness of the mini-BESTest and Berg Balance Scale in patients with balance disorders

BACKGROUND

Recently, a new tool for assessing dynamic balance impairments has been presented: the 14-item Mini-BESTest.

OBJECTIVE

The aim of this study was to compare the psychometric performance of the Mini-BESTest and the Berg Balance Scale (BBS).

DESIGN

A prospective, single-group, observational design was used in the study.

METHODS

Ninety-three participants (mean age=66.2 years, SD=13.2; 53 women, 40 men) with balance deficits were recruited. Interrater (3 raters) and test-retest (1-3 days) reliability were calculated using intraclass correlation coefficients (ICCs). Responsiveness and minimal important change were assessed (after 10 sessions of physical therapy) using both distribution-based and anchor-based methods (external criterion: the 15-point Global Rating of Change [GRC] scale).

RESULTS

At baseline, neither floor effects nor ceiling effects were found in either the Mini-BESTest or the BBS. After treatment, the maximum score was found in 12 participants (12.9%) with BBS and in 2 participants (2.1%) with Mini-BESTest. Test-retest reliability for total scores was significantly higher for the Mini-BESTest (ICC=.96) than for the BBS (ICC=.92), whereas interrater reliability was similar (ICC=.98 versus .97, respectively). The standard error of measurement (SEM) was 1.26 and the minimum detectable change at the 95% confidence level (MDC(95)) was 3.5 points for Mini-BESTest, whereas the SEM was 2.18 and the MDC(95) was 6.2 points for the BBS. In receiver operating characteristic curves, the area under the curve was 0.92 for the Mini-BESTest and 0.91 for the BBS. The best minimal important change (MIC) was 4 points for the Mini-BESTest and 7 points for the BBS. After treatment, 38 participants evaluated with the Mini-BESTest and only 23 participants evaluated with the BBS (out of the 40 participants who had a GRC score of ≥ 3.5) showed a score change equal to or greater than the MIC values.

LIMITATIONS

The consecutive sampling method drawn from a single rehabilitation facility and the intrinsic weakness of the GRC for calculating MIC values were limitations of the study.

CONCLUSIONS

The 2 scales behave similarly, but the Mini-BESTest appears to have a lower ceiling effect, slightly higher reliability levels, and greater accuracy in classifying individual patients who show significant improvement in balance function.

The effects of a rhythm and music-based therapy program and therapeutic riding in late recovery phase following stroke: a study protocol for a three-armed randomized controlled trial

BACKGROUND

Stroke represents one of the most costly and long-term disabling conditions in adulthood worldwide and there is a need to determine the effectiveness of rehabilitation programs in the late phase after stroke. Limited scientific support exists for training incorporating rhythm and music as well as therapeutic riding and well-designed trials to determine the effectiveness of these treatment modalities are warranted.

METHODS/DESIGN

A single blinded three-armed randomized controlled trial is described with the aim to evaluate whether it is possible to improve the overall health status and functioning of individuals in the late phase of stroke (1-5 years after stroke) through a rhythm and music-based therapy program or therapeutic riding. About 120 individuals will be consecutively and randomly allocated to one of three groups: (T1) rhythm and music-based therapy program; (T2) therapeutic riding; or (T3) control group receiving the T1 training program a year later. Evaluation is conducted prior to and after the 12-week long intervention as well as three and six months later. The evaluation comprises a comprehensive functional and cognitive assessment (both qualitative and quantitative), and questionnaires. Based on the International classification of functioning, disability, and health (ICF), the outcome measures are classified into six comprehensive domains, with participation as the primary outcome measure assessed by the Stroke Impact Scale (SIS, version 2.0.). The secondary outcome measures are grouped within the following domains: body function, activity, environmental factors and personal factors. Life satisfaction and health related quality of life constitute an additional domain.

CURRENT STATUS

A total of 84 participants were randomised and have completed the intervention. Recruitment proceeds and follow-up is on-going, trial results are expected in early 2014.

DISCUSSION

This study will ascertain whether any of the two intervention programs can improve overall health status and functioning in the late phase of stroke. A positive outcome would increase the scientific basis for the use of such interventions in the late phase after stroke.

TRIAL REGISTRATION

Clinical Trials.gov Identifier: NCT01372059.

Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct

BACKGROUND

The Balance Evaluation Systems Test (BESTest) and Mini-BESTest are clinical examinations of balance impairment, but the tests are lengthy and the Mini-BESTest is theoretically inconsistent with the BESTest.

OBJECTIVE

The purpose of this study was to generate an alternative version of the BESTest that is valid, reliable, time efficient, and founded upon the same theoretical underpinnings as the original test.

DESIGN

This was a cross-sectional study.

METHODS

Three raters evaluated 20 people with and without a neurological diagnosis. Test items with the highest item-section correlations defined the new Brief-BESTest. The validity of the BESTest, the Mini-BESTest, and the new Brief-BESTest to identify people with or without a neurological diagnosis was compared. Interrater reliability of the test versions was evaluated by intraclass correlation coefficients. Validity was further investigated by determining the ability of each version of the examination to identify the fall status of a second cohort of 26 people with and without multiple sclerosis.

RESULTS

Items of hip abductor strength, functional reach, one-leg stance, lateral push-and-release, standing on foam with eyes closed, and the Timed "Up & Go" Test defined the Brief-BESTest. Intraclass correlation coefficients for all examination versions were greater than .98. The accuracy of identifying people from the first cohort with or without a neurological diagnosis was 78% for the BESTest versus 72% for the Mini-BESTest or Brief-BESTest. The sensitivity to fallers from the second cohort was 100% for the Brief-BESTest, 71% for the Mini-BESTest, and 86% for the BESTest, and all versions exhibited specificity of 95% to 100% to identify nonfallers. Limitations Further testing is needed to improve the generalizability of findings.

CONCLUSIONS

Although preliminary, the Brief-BESTest demonstrated reliability comparable to that of the Mini-BESTest and potentially superior sensitivity while requiring half the items of the Mini-BESTest and representing all theoretically based sections of the original BESTest.

Validity of the Sitting Balance Scale in older adults who are non-ambulatory or have limited functional mobility

OBJECTIVE

To determine whether the Sitting Balance Scale is an acceptable alternative to the Trunk Impairment Scale for measuring the construct of sitting balance, to examine relationships with other clinical outcomes and to establish discriminative validity.

DESIGN

Prospective descriptive methodological study.

SETTING

Acute care, inpatient rehabilitation, skilled nursing facility and home health.

PARTICIPANTS

Patients receiving physical therapy (N = 98; n = 20 acute care, n = 18 inpatient rehabilitation, n = 30 skilled nursing facility, n = 30 home setting) mean (SD) age, 80.5 (7.9) years. Nineteen were non-ambulatory and 79 had limited functional mobility with Timed Up and Go scores ≥20 seconds.

MAIN MEASURES

Sitting Balance Scale, Trunk Impairment Scale, Timed Up and Go, length of stay and setting specific clinical measures of sitting balance (OASIS-C M1850; MDS G-3b).

RESULTS

Moderate association between ambulatory status and sitting balance measures (Sitting Balance Scale r = 0.67, Trunk Impairment Scale r = 0.61; P = 0.0001). Moderate to strong relationships between Sitting Balance Scale, Trunk Impairment Scale and clinical outcomes varying by setting. MANOVA results revealed differences between ambulators and non-ambulators and among diagnostic categories for both instruments (P < 0.001).

CONCLUSIONS

The Sitting Balance Scale is comparable to the Trunk Impairment Scale for measuring sitting balance in older adults who are non-ambulatory or have limited mobility.

[Assessment of balance in community dwelling older adults: reliability and validity of the German version of the Fullerton Advanced Balance Scale]

The purpose of this study was to validate the German translation of the originally English Fullerton Advanced Balance Scale (FAB-D). The 10-item test battery is a performance-based measure that addresses the multiple dimensions of balance. The German FAB-D using a forward-backward procedure was examined by a sample of n = 96 community dwelling older adults (71,6 ± 7,5 years of age) who had reported no history of a fall in the previous 6 months (non-fallers) and 66 older adults (age 75,3 ± 7,3 years of age) who reported falling one or more times (recurrent fallers). The following internationally accepted instruments were used for validation: The Berg-Balance-Scale (BBS), the Activities-Specific Balance Confidence (ABC-D) scale, the Short Form Health Survey (SF-36), the Physical Activity Scale for the Elderly (PASE), the Trail-Making-Test (TMT), and motor tests (balance, strength, mobility). Explorative and confirmative factor analysis showed the best fit for a one dimensional solution. Cronbach's alpha of the German version of the FAB-D was 0.988. Test-retest reliability for the total score was 0.965 and ranged from 0.86-0.88 for individual items. The scales correlate with convergent measures assessing postural control and falls-related confidence (BBS, r = 0.685; Timed-Up-and-Go-Test, r = -0.632; ABC-D, r = 0.561). Criterion validity of the FAB-D was established by statistically significant correlations between the total scale, and the subdimensions of the SF-36 (physical 0.52, mental 0.38), the PASE (0.29), the TMT A (-0.30) and B (-0.41), the Chair Rising Test (0.59) and the 10 m walk (normal velocity -0.49; fast velocity -0.56). Significant differences in the FAB-D scores were found in older adults with (30,3 ± 8,6) and without falls (36,1 ± 4,2). Older adults with a recent fall history scored lower on the FAB-D than older adults without a recent fall history. To conclude, the German version of the FAB-D has properties analogous to the original English version and is apparently useful in assessing the multiple dimensions of balance in community dwelling older adults.

Clinical reality of measuring upper-limb ability in neurologic conditions: a systematic review

OBJECTIVE

To review the psychometric properties and clinical utility of upper-limb measurement tools in people with neurologic conditions to provide recommendations for practice.

DATA SOURCES

MEDLINE, CINAHL, EMBASE, PEDro, and AMED.

STUDY SELECTION

Independent reviewers searched, selected, and extracted data from articles that assessed reliability, validity, ability to detect change, and clinical utility of measures of the upper limb in adult neurologic conditions.

DATA EXTRACTION

Measures with good psychometrics and 8 or higher (out of 10) clinical utility scores were recommended.

DATA SYNTHESIS

The searches identified 31 measures of the upper limb. However, only 2 measures fulfilled all of the psychometric and clinical utility criteria; the Box and Block Test and the Action Research Arm Test.

CONCLUSIONS

The Box and Block and the Action Research Arm Tests produce robust data and are feasible for use in clinical practice. Future development of new or existing measures should ensure the construct and content validity of the measure is clearly identified, standardized guidelines are easily available, and ensure that it is individualized and contemporary. Attention to measures of upper-limb activity for people who are unable to grip objects is also needed.

The reproducibility of Berg Balance Scale and the Single-leg Stance in chronic stroke and the relationship between the two tests

OBJECTIVE

To assess the reproducibility of the Berg Balance Scale (BBS) and the Single-leg Stance (SLS), and the validity of the SLS as an independent test of upright postural control in patients with chronic stroke.

DESIGN

An intra-rater test-retest reproducibility study. The BBS and the SLS were assessed twice, 7 days apart.

SETTING

A university hospital.

PARTICIPANTS

Fifty individuals; 6-46 months after a stroke.

MAIN OUTCOME MEASUREMENTS

The reproducibility of the BBS and the SLS was evaluated with intraclass correlation coefficient (ICC(2,1)), the mean difference between the 2 test sessions (d) with 95% confidence interval (95% CI), the standard error of measurement (standard error of measurement [SEM]%), the smallest real difference (SRD%), and the Bland-Altman graphs. To assess validity of SLS, the relationship between the SLS and the BBS was analyzed by the Pearson correlation coefficient.

RESULTS

The ICC(2,1) was 0.88 for the BBS, and the ICC(2,1) values were 0.88 for the nonparetic limb and 0.92 for the paretic lower limb for the SLS. The smallest change that indicates a real improvement for a group of individuals, SEM%, was 3% for BBS, 15% for the nonparetic limb and 27% for the paretic limb for SLS. The smallest real difference for a single individual was 8% for BBS but was higher for SLS, at 42% for the nonparetic limb, and 74% for the paretic limb. There was a significant relationship between the SLS and the BBS (r = 0.65-0.79; P < .001).

CONCLUSIONS

The BBS and the SLS are reproducible measurements in patients with chronic stroke, but only the BBS is sensitive enough to follow changes over time or after an intervention. The SLS is strongly related to the BBS and can be used as an independent test to measure upright postural control after a stroke.

The Trunk Impairment Scale - modified to ordinal scales in the Norwegian version

PURPOSE

To translate the Trunk Impairment Scale (TIS), a measure of trunk control in patients after stroke, into Norwegian (TIS-NV), and to explore its construct validity, internal consistency, intertester and test-retest reliability.

METHOD

TIS was translated according to international guidelines. The validity study was performed on data from 201 patients with acute stroke. Fifty patients with stroke and acquired brain injury were recruited to examine intertester and test-retest reliability. Construct validity was analyzed with exploratory and confirmatory factor analysis and item response theory, internal consistency with Cronbach's alpha test, and intertester and test-retest reliability with kappa and intraclass correlation coefficient tests.

RESULTS

The back-translated version of TIS-NV was validated by the original developer. The subscale Static sitting balance was removed. By combining items from the subscales Dynamic sitting balance and Coordination, six ordinal superitems (testlets) were constructed. The TIS-NV was renamed the modified TIS-NV (TIS-modNV). After modifications the TIS-modNV fitted well to a locally dependent unidimensional item response theory model. It demonstrated good construct validity, excellent internal consistency, and high intertester and test-retest reliability for the total score.

CONCLUSIONS

This study supports that the TIS-modNV is a valid and reliable scale for use in clinical practice and research.

The effects of a 12-week leisure centre-based, group exercise intervention for people moderately affected with multiple sclerosis: a randomized controlled pilot study

OBJECTIVE

To establish the effects of a 12-week, community-based group exercise intervention for people moderately affected with multiple sclerosis.

DESIGN

Randomized controlled pilot trial.

SETTING

Two community leisure centres.

PARTICIPANTS

Thirty-two participants with multiple sclerosis randomized into intervention or control groups.

INTERVENTION

The intervention group received 12 weeks of twice weekly, 60-minute group exercise sessions, including mobility, balance and resistance exercises. The control group received usual care.

MAIN OUTCOME MEASURES

An assessor blinded to group allocation assessed participants at baseline, after eight weeks and after 12 weeks. The primary outcome measure was 25-foot (7.6 m) walk time, secondary outcomes assessed walking endurance, balance, physical function, leg strength, body mass index, activity levels, fatigue, anxiety and depression, quality of life and goal attainment.

RESULTS

The intervention made no statistically significant difference to the results of participants' 25-foot walk time. However the intervention led to many improvements. In the intervention group levels of physical activity improved statistically between baseline and week 8 (P < 0.001) and baseline and week 12 (P = 0.005). Balance confidence results showed a significant difference between baseline and week 12 (P = 0.013). Good effect sizes were found for dynamic balance (d = 0.80), leg strength (d = 1.33), activity levels (d = 1.05) and perceived balance (d = 0.94).

CONCLUSION

The results of the study suggest that community-based group exercise classes are a feasible option for people moderately affected with multiple sclerosis, and offer benefits such as improved physical activity levels, balance and leg strength.

Measures of sensation in neurological conditions: a systematic review

Objective: To systematically review the psychometric properties and clinical utility of measures of sensation in neurological conditions to inform future research studies and clinical practice.

Data sources: Electronic databases (MEDLINE, CINAHL, EMBASE and AMED) were searched from their inception to December 2010.

Review methods: Search terms were used to identify articles that investigated any sensory measures in neurological conditions. Data about their psychometric properties and clinical utility were extracted and analyzed independently. The strength of the psychometric properties and clinical utility were assessed following recommendations. 1

Results: Sixteen sensory measures were identified. Inter-rater reliability and redundancy of testing protocols are particular issues for this area of assessment. Eleven were rejected because they were not available for a researcher or clinician to use. Of the remaining five measures, the Erasmus MC modifications of the Nottingham Sensory Assessment and the Sensory section of the Fugl–Meyer Assessment showed the best balance of clinical utility and psychometric properties.

Conclusion: Many measures of sensory impairment have been used in research but few have been fully developed to produce robust data and be easy to use. At present, the sensory section of the Fugl–Meyer Assessment and the Erasmus MC modifications of the Nottingham Sensory Assessment show the most effective balance of usability and robustness, when delivered according to the operating instructions.

A computerized dynamic posturography (CDP) program to reduce fall risk in a community dwelling older adult with chronic stroke: a case report

A systematic review by Barclay-Goddard et al (2004) reported that force platform feedback improved stance symmetry but not sway, clinical balance outcomes, or measures of independence in adults with stroke. However, the role of computerized dynamic posturography (CDP) systems was not explored. The purpose of this case report was to describe a CDP training program to improve balance and reduce fall risk in a patient with a diagnosis of chronic stroke. A 61-year-old patient 8 years poststroke participated in 1 hour of CDP training, three times a week over a period of 6 weeks. Examination was conducted before and after intervention using the Sensory Organization Test (SOT), Limits of Stability (LOS) test, and Weight Bearing/Squat Symmetry test on a CDP system, and clinical testing with the Berg Balance Scale (BBS), Timed Up and Go (TUG), Activities-specific Balance Confidence (ABC) scale, 30-second Chair Stand (CS), and range of motion of the ankle joints. The patient improved in sensory integration abilities on the SOT for conditions 4, 5, and 6, and maximum excursion abilities improved by a range of 23-103% on the LOS test. Scores on the BBS increased from 37/56 to 47/56, which indicated reduced fall risk and her ABC score improved from 50% to 70%. Ankle ROM improved bilaterally by 6 to 8 degrees. This CDP training program showed promise as a systematic, objective method to reduce fall risk with improved overground performance of balance tasks in an individual with chronic stroke.

Calculations of mechanisms for balance control during narrow and single-leg standing in fit older adults: A reliability study

For older people balance control in standing is critical for performance of activities of daily living without falling. The aims were to investigate reliability of quantification of the usage of the two balance mechanisms M(1) 'moving the centre of pressure' and M(2) 'segment acceleration' and also to compare calculation methods based on a combination of kinetic (K) and kinematic (Km) data, (K-Km), or Km data only concerning M(2). For this purpose nine physically fit persons aged 70-78 years were tested in narrow and single-leg standing. Data were collected by a 7-camera motion capture system and two force plates. Repeated measure ANOVA and Tukey's post hoc tests were used to detect differences between the standing tasks. Reliability was estimated by ICCs, standard error of measurement including its 95% CI, and minimal detectable change, whereas Pearson's correlation coefficient was used to investigate agreement between the two calculation methods. The results indicated that for the tasks investigated, M(1) and M(2) can be measured with acceptable inter- and intrasession reliability, and that both Km and K-Km based calculations may be useful for M(2), although Km data may give slightly lower values. The proportional M(1):M(2) usage was approximately 9:1, in both anterio-posterior (AP) and medio-lateral (ML) directions for narrow standing, and about 2:1 in the AP and of 1:2 in the ML direction in single-leg standing, respectively. In conclusion, the tested measurements and calculations appear to constitute a reliable way of quantifying one important aspect of balance capacity in fit older people.

Technology Innovation Enabling Falls Risk Assessment in a Community Setting

Approximately one in three people over the age of 65 will fall each year, resulting in significant financial, physical, and emotional cost on the individual, their family, and society. Currently, falls are managed using on-body sensors and alarm pendants to notify others when a falls event occurs. However these technologies do not prevent a fall from occurring. There is now a growing focus on falls risk assessment and preventative interventions. Falls risk is currently assessed in a clinical setting by expert physiotherapists, geriatricians, or occupational therapists following the occurrence of an injurious fall. As the population ages, this reactive model of care will become increasingly unsatisfactory, and a proactive community-based prevention strategy will be required. Recent advances in technology can support this new model of care by enabling community-based practitioners to perform tests that previously required expensive technology or expert interpretation. Gait and balance impairment is one of the most common risk factors for falls. This paper reviews the current technical and non-technical gait and balance assessments, discusses how low-cost technology can be applied to objectively administer and interpret these tests in the community, and reports on recent research where body-worn sensors have been utilized. It also discusses the barriers to adoption in the community and proposes ethnographic research as a method to investigate solutions to these barriers.

Clinical measurement of walking balance in people post stroke: a systematic review

OBJECTIVE

To identify walking balance measures which have been established for use with ambulatory people post stroke and reflect the balance requirements of community walking.

DATA SOURCES

MEDLINE, Embase, AMED.

REVIEW METHODS

Measures reflecting walking balance, with tasks that include a stepping action in standing, used with people post stroke were reviewed. Measures with clinical utility were evaluated for psychometric properties, including reliability, validity and clinical interpretation.

RESULTS

Nine measures (24 papers) were identified that met the requirement of measuring walking balance in people post stroke with demonstrated clinical utility. Outcome measures with multiple tasks (Brunel Balance Assessment, Modified Emory Functional Ambulation Profile, Dynamic Gait Index, Community Balance and Mobility Scale, and mini-Balance Evaluation Systems Test) as opposed to single task measures (Step Test, Side Step Test and Four Square Step Test, Timed Up and Go), reflect a broader range of walking balance required to accommodate the variable challenges which may be expected at the community level of walking. Most tools report excellent reliability when used by physiotherapists. Validity remains far more challenging to establish. Evaluation of clinical interpretation is limited for all measures.

CONCLUSION

The multiple-task outcome measures reviewed reflected walking balance activities often undertaken during community mobility. Single-task measures may be useful as screening measures, identifying walking balance deficits associated with basic/lower levels of walking balance. Construct validity and clinical interpretability of each measure in ambulatory people post stroke requires further research to identify the level of community mobility represented by each measure of walking balance.

Comparison of physio ball and plinth trunk exercises regimens on trunk control and functional balance in patients with acute stroke: a pilot randomized controlled trial

Objective: To examine the effects of trunk exercises performed using the physio ball as against the plinth, on trunk control and functional balance in patients with acute stroke.

Design: An observer-blinded pilot randomized controlled trial.

Subjects: Thirty patients with acute stroke (mean post-stroke duration 12 (95% confidence interval (CI) 2–34) days) who had the first onset of unilateral haemorrhagic or ischaemic lesion and an independent ability to sit for 30 seconds.

Setting: Inpatient stroke rehabilitation centre.

Interventions: The experimental group performed task-specific trunk exercises on an unstable surface (physio ball) while the control group performed them on a stable surface (plinth). In addition to regular acute physiotherapy, both the groups underwent 1 hour of trunk exercises a day, four days a week for three weeks.

Main measures: Trunk Impairment Scale and Brunel Balance Assessment.

Results: The difference between the baseline characteristics of the patients belonging to both groups was not statistically significant. Post-intervention, both the groups improved on trunk control and functional balance but the experimental group improved more significantly than the control group (change scores of between-group comparison for the total Trunk Impairment Scale 3.06 (1.43), dynamic sitting balance 1.47 (1.36) and coordination 1.3 (0.67) subscales of Trunk Impairment Scale; the total Brunel Balance Assessment 1.8 (1.4) and stepping 1.87 (1.6) component of Brunel Balance Assessment). The level of significance was set at P < 0.05.

Conclusions: The trunk exercises performed on the physio ball are more effective than those performed on the plinth in improving both trunk control and functional balance in acute stroke patients, suggesting a task-specific effect and also a carry-over effect.

Postural control under visual and proprioceptive perturbations during double and single limb stances: insights for balance training

Single Limb Stance under visual and proprioceptive disturbances is largely used in clinical settings in order to improve balance in a wide range of functional disabilities. However, the proper role of vision and proprioception in SLS is not completely understood. The objectives of this study were to test the hypotheses that when ankle proprioception is perturbed, the role of vision in postural control increases according to the difficulty of the standing task. And to test the effect of vision during postural adaptation after withdrawal of the somesthetic perturbation during double and single limb stance Eleven males were submitted to double (DLS) and single limb (SLS) stances under conditions of normal or reduced vision, both with normal and perturbed proprioception. Center of pressure parameters were analyzed across conditions. Vision had a main effect in SLS, whereas proprioception perturbation showed effects only during DLS. Baseline stability was promptly achieved independently of visual input after proprioception reintegration. In conclusion, the role of vision increases in SLS. After proprioception reintegration, vision does not affect postural recovery. Balance training programs must take that into account.

Functional gait assessment and balance evaluation system test: reliability, validity, sensitivity, and specificity for identifying individuals with Parkinson disease who fall

BACKGROUND

Gait impairments, balance impairments, and falls are prevalent in individuals with Parkinson disease (PD). Although the Berg Balance Scale (BBS) can be considered the reference standard for the determination of fall risk, it has a noted ceiling effect. Development of ceiling-free measures that can assess balance and are good at discriminating "fallers" from "nonfallers" is needed.

OBJECTIVE

The purpose of this study was to compare the Functional Gait Assessment (FGA) and the Balance Evaluation Systems Test (BESTest) with the BBS among individuals with PD and evaluate the tests' reliability, validity, and discriminatory sensitivity and specificity for fallers versus nonfallers.

DESIGN

This was an observational study of community-dwelling individuals with idiopathic PD.

METHODS

The BBS, FGA, and BESTest were administered to 80 individuals with PD. Interrater reliability (n=15) was assessed by 3 raters. Test-retest reliability was based on 2 tests of participants (n=24), 2 weeks apart. Intraclass correlation coefficients (2,1) were used to calculate reliability, and Spearman correlation coefficients were used to assess validity. Cutoff points, sensitivity, and specificity were based on receiver operating characteristic plots.

RESULTS

Test-retest reliability was .80 for the BBS, .91 for the FGA, and .88 for the BESTest. Interrater reliability was greater than .93 for all 3 tests. The FGA and BESTest were correlated with the BBS (r=.78 and r=.87, respectively). Cutoff scores to identify fallers were 47/56 for the BBS, 15/30 for the FGA, and 69% for the BESTest. The overall accuracy (area under the curve) for the BBS, FGA, and BESTest was .79, .80, and .85, respectively.

LIMITATIONS

Fall reports were retrospective.

CONCLUSION

Both the FGA and the BESTest have reliability and validity for assessing balance in individuals with PD. The BESTest is most sensitive for identifying fallers.

Deficits in postural control in individuals with COPD - emerging evidence for an important secondary impairment

Emerging evidence suggests that individuals with COPD demonstrate reductions in balance control that may be associated with an increased fall risk. The purpose of this review is to: 1) provide a brief overview of balance control and its assessment; 2) review relevant literature describing balance impairment in individuals with COPD; and 3) highlight important areas for future research. The observation of balance deficits and an increased fall risk in patients with COPD suggests the need for including balance assessment and training for patients enrolled in pulmonary rehabilitation who may be vulnerable. Further studies are needed to determine which aspects of balance are affected and to examine the impact of interventions.

Kinaesthesia and Methods for its Assessment: Literature Review

In this review measurement techniques used for kinaesthetic sense assessment are presented. Kinaesthesia is an important part of human movement control and provides us with better understanding of specific movement system adaptations to fatigue, training and injury. Additionally, decreased kinaesthesia can be an injury predisposing factor, which stresses the necessity for its assessment in sports injury prevention programs. First, terminology and functional concept of kinaesthesia is presented in relation to other related concepts like proprioception and sensory-motor function. For better understanding, basic underlying neurological backgrounds are discussed in chapter two, encompassing peripheral sensory fields as well as the basics of the central processing. Additionally, factors affecting kinaesthesia and its adaptations to training are presented. Functional aspects are discussed, supporting the role of assessment of kinaesthesia in sports and rehabilitation. In the third chapter, a proposal for measuring methods classification is given. In the final chapter, different measuring protocols and their modifications are presented. Due to their usefulness in sports and injury prevention, methods for measuring sense of joint position, movement onset and active tracking are discussed in more detail. Possibilities and examples of their application to sports and sports injury rehabilitation settings are presented. Some basic guidelines are given of how to use these methods in training or for screening kinaesthesia.

Investigating the internal validity of the Trunk Impairment Scale (TIS) using Rasch analysis: the TIS 2.0

PURPOSE

To examine the internal validity of the static sitting balance, dynamic sitting balance, and coordination subscales of the Trunk Impairment Scale (TIS), a reliable and valid scale measuring trunk performance and sitting balance in people after stroke.

METHOD

A total of 162 people after stroke were included in the study. Participants were recruited from an acute unit and in- and out- patient rehabilitation setting. To examine internal validity of the subscales of the TIS, we conducted a Rasch analysis by means of the Partial Credit Model. For each subscale, we examined whether the distribution of scores fitted the theoretical Rasch model.

RESULTS

The first item of the static sitting balance subscale had to be removed since it had a large ceiling effect. The remaining static sitting balance subscale did not fit the Rasch model (Chi-square = 7.03, p < 0.0001 with Bonferroni adjusted p-level = 0.01). Both the dynamic sitting balance (Chi-square = 42.65, p = 0.0052 with Bonferroni adjusted p-level = 0.005) and coordination subscales (Chi-square = 7.87, p = 0.4461 with Bonferroni adjusted p-level = 0.01) fitted the Rasch model.

CONCLUSIONS

Internal validity of the dynamic sitting balance and coordination subscales was confirmed. Based on our results, we present the TIS, version 2.0 (TIS 2.0).