Systematic review of the balance error scoring system

Assessing postural stability in the concussed athlete: what to do, what to expect, and when

Context:

Postural stability assessment is included as part of the diagnostic and monitoring process for sports-related concussions. Particularly, the relatively simple Balance Error Scoring System (BESS) and more sophisticated force plate measures like the Sensory Organization Test (SOT) are suggested.

Evidence Acquisition:

Relevant studies were identified via the following electronic databases: PubMed, MEDLINE, EMBASE, Web of Science, ScienceDirect, and CINAHL (1980 to July 2013). Inclusion was based on the evaluation of postural sway or balance in concussed athletes of any age or sex and investigating the reliability or validity of the included tests.

Study Design:

Clinical review.

Level of Evidence:

Level 4

Results:

Both the SOT and the BESS show moderate reliability, but a learning effect due to repetitive testing needs to be considered. Both tests indicate that postural stability returns to baseline by day 3 to 5 in most concussed athletes. While the BESS is a simple and valid method, it is sensitive to subjectivity in scoring and the learning effect. The SOT is very sensitive to even subtle changes in postural sway, and thus, more accurate than the BESS; however, it is a rather expensive method of balance testing.

Conclusion:

Both tests serve the purpose of monitoring balance performance in the concussed athlete; however, neither may serve as a stand-alone diagnostic or monitoring tool.

Strength of Recommendation Taxonomy:

B

The utility of the balance error scoring system for mild brain injury assessments in children and adolescents

The Balance Error Scoring System (BESS) is widely recognized as an acceptable assessment of postural control for adult patients following a mild traumatic brain injury (mTBI) or concussion. However, the measurement properties of the BESS as a post-mTBI assessment test for younger patients are not well understood. The purpose of this study was to evaluate the utility of the BESS as a post-mTBI assessment test for children and adolescents aged 8 to 18 years through 2 investigations: (1) a retrospective medical records review of the relationship among age, BESS scores, and other common post-mTBI assessment tests; and (2) a prospective study comparing BESS scores for a cohort of children with a recent mTBI and BESS scores for a cohort of matched healthy peers. Age was found to be significantly correlated with several of the BESS measures and the total BESS score (P < 0.05). Significant differences were observed between the injured and healthy cohorts for 3 of the BESS measures and the total BESS score. However, the observed differences were not likely to be clinically meaningful. Cumulatively, evidence from the literature and the results of these studies indicate that the BESS may be limited for producing accurate assessments of younger athletes' post-mTBI postural control abilities. Future research recommendations include testing of modified versions of the BESS or other alternatives for post-mTBI postural control assessments with younger individuals.

Effect of teaching with or without mirror on balance in young female ballet students

Background

In literature there is a general consensus that the use of the mirror improves proprioception. During rehabilitation the mirror is an important instrument to improve stability. In some sports, such as dancing, mirrors are widely used during training. The purpose of this study is to evaluate the effectiveness of the use of a mirror on balance in young dancers. Sixty-four young dancers (ranging from 9–10 years) were included in this study. Thirty-two attending lessons with a mirror (mirror- group) were compared to 32 young dancers that attended the same lessons without a mirror (non-mirror group). Balance was evaluated by BESS (Balance Error Scoring System), which consists of three stances (double limb, single limb, and tandem) on two surfaces (firm and foam). The errors were assessed at each stance and summed to create the two subtotal scores (firm and foam surface) and the final total score (BESS). The BESS was performed at recruitment (T0) and after 6 months of dance lessons (T1).

Results

The repeated measures ANOVA analysis showed that for the BESS total score there is a difference due to the time (F = 3.86; p < 0.05). No other differences due to the group or to the time of measurement were found (p > 0.05). The analysis of the multiple regression model showed the influence of the values at T0 for every BESS items and the dominance of limb for stability on an unstable surface standing on one or two legs.

Conclusions

These preliminary results suggest that the use of a mirror in a ballet classroom does not improve balance acquisition of the dancer. On the other hand, improvement found after 6 months confirms that at the age of the dancers studied motor skills and balance can easily be trained and improved.

Reliability and validity evidence of multiple balance assessments in athletes with a concussion

CONTEXT

An estimated 300 000 sport-related concussion injuries occur in the United States annually. Approximately 30% of individuals with concussions experience balance disturbances. Common methods of balance assessment include the Clinical Test of Sensory Organization and Balance (CTSIB), the Sensory Organization Test (SOT), the Balance Error Scoring System (BESS), and the Romberg test; however, the National Collegiate Athletic Association recommended the Wii Fit as an alternative measure of balance in athletes with a concussion. A central concern regarding the implementation of the Wii Fit is whether it is reliable and valid for measuring balance disturbance in athletes with concussion.

OBJECTIVE

To examine the reliability and validity evidence for the CTSIB, SOT, BESS, Romberg test, and Wii Fit for detecting balance disturbance in athletes with a concussion.

DATA SOURCES

Literature considered for review included publications with reliability and validity data for the assessments of balance (CTSIB, SOT, BESS, Romberg test, and Wii Fit) from PubMed, PsycINFO, and CINAHL.

DATA EXTRACTION

We identified 63 relevant articles for consideration in the review. Of the 63 articles, 28 were considered appropriate for inclusion and 35 were excluded.

DATA SYNTHESIS

No current reliability or validity information supports the use of the CTSIB, SOT, Romberg test, or Wii Fit for balance assessment in athletes with a concussion. The BESS demonstrated moderate to high reliability (interclass correlation coefficient = 0.87) and low to moderate validity (sensitivity = 34%, specificity = 87%). However, the Romberg test and Wii Fit have been shown to be reliable tools in the assessment of balance in Parkinson patients.

CONCLUSIONS

The BESS can evaluate balance problems after a concussion. However, it lacks the ability to detect balance problems after the third day of recovery. Further investigation is needed to establish the use of the CTSIB, SOT, Romberg test, and Wii Fit for assessing balance in athletes with concussions.

Comparison of a Mobile Technology Application With the Balance Error Scoring System

Context:

The most widely used method for postural balance assessment relies on the subjective observations of a test administrator. Accelerometry has been shown to provide a valid and reliable method for assessment of balance, and recent advances in microelectromechanical systems have made the technology available in mobile electronic devices.

Objective:

To compare a mobile technology application with a commonly used subjective balance assessment.

Setting:

Biomechanics laboratory.

Participants:

Twenty-one nonathlete college-aged individuals (7 men, 14 women; mean age 23 ± 3 years) volunteered to participate. Subjects were excluded if they reported any preexisting condition that might affect postural balance.

Results:

A strong inverse correlation was found between the scores for the two balance assessment methods (r= -.767,p< .01).

Conclusions:

Advances in technology have provided an attractive means to objectively quantify postural balance with off-the-shelf mobile consumer electronic devices.

An alternative to the balance error scoring system: using a low-cost balance board to improve the validity/reliability of sports-related concussion balance testing

OBJECTIVE

Recent guidelines advocate sports medicine professionals to use balance tests to assess sensorimotor status in the management of concussions. The present study sought to determine whether a low-cost balance board could provide a valid, reliable, and objective means of performing this balance testing.

DESIGN

Criterion validity testing relative to a gold standard and 7 day test-retest reliability.

SETTING

University biomechanics laboratory.

PARTICIPANTS

Thirty healthy young adults.

ASSESSMENT OF RISK FACTORS

Balance ability was assessed on 2 days separated by 1 week using (1) a gold standard measure (ie, scientific grade force plate), (2) a low-cost Nintendo Wii Balance Board (WBB), and (3) the Balance Error Scoring System (BESS).

MAIN OUTCOME MEASURES

Validity of the WBB center of pressure path length and BESS scores were determined relative to the force plate data. Test-retest reliability was established based on intraclass correlation coefficients.

RESULTS

Composite scores for the WBB had excellent validity (r = 0.99) and test-retest reliability (R = 0.88). Both the validity (r = 0.10-0.52) and test-retest reliability (r = 0.61-0.78) were lower for the BESS.

CONCLUSIONS

These findings demonstrate that a low-cost balance board can provide improved balance testing accuracy/reliability compared with the BESS.

CLINICAL RELEVANCE

This approach provides a potentially more valid/reliable, yet affordable, means of assessing sports-related concussion compared with current methods.

Validation of measures from the smartphone sway balance application: a pilot study

PURPOSE/BACKGROUND

A number of different balance assessment techniques are currently available and widely used. These include both subjective and objective assessments. The ability to provide quantitative measures of balance and posture is the benefit of objective tools, however these instruments are not generally utilized outside of research laboratory settings due to cost, complexity of operation, size, duration of assessment, and general practicality. The purpose of this pilot study was to assess the value and validity of using software developed to access the iPod and iPhone accelerometers output and translate that to the measurement of human balance.

METHODS

Thirty healthy college-aged individuals (13 male, 17 female; age = 26.1 ± 8.5 years) volunteered. Participants performed a static Athlete's Single Leg Test protocol for 10 sec, on a Biodex Balance System SD while concurrently utilizing a mobile device with balance software. Anterior/posterior stability was recorded using both devices, described as the displacement in degrees from level, and was termed the "balance score."

RESULTS

There were no significant differences between the two reported balance scores (p = 0.818. Mean balance score on the balance platform was 1.41 ± 0.90, as compared to 1.38 ± 0.72 using the mobile device.

CONCLUSIONS

There is a need for a valid, convenient, and cost-effective tool to objectively measure balance. Results of this study are promising, as balance score derived from the Smartphone accelerometers were consistent with balance scores obtained from a previously validated balance system. However, further investigation is necessary as this version of the mobile software only assessed balance in the anterior/posterior direction. Additionally, further testing is necessary on a healthy populations and as well as those with impairment of the motor control system.

LEVEL OF EVIDENCE

Level 2b (Observational study of validity)(1.)

Performance of high school adolescents on functional gait and balance measures

PURPOSE

To describe the performance of high school adolescents during common functional gait and balance measures used in vestibular physical therapy.

METHODS

A cross-sectional study of 91 participants determined their performance on the Activities-specific Balance Confidence (ABC) scale, Dynamic Gait Index, Functional Gait Assessment, Timed "Up and Go" (TUG), Five Times Sit to Stand (FTSTS) test, tests of gait speed (GS), and the Balance Error Scoring System. In a subset of this sample, GS, TUG, and the FTSTS were repeated twice to examine test-retest reliability.

RESULTS

The measures of GS, TUG, and FTSTS were normally distributed. The Activities-specific Balance Confidence, Dynamic Gait Index, and Functional Gait Assessment exhibited a ceiling effect. The timed measures exhibited moderate to good reliability.

CONCLUSIONS

These performance scores may provide end points for discharge from vestibular physical therapy. However, clinicians should be aware of the ceiling effect exhibited by some measures.

Tracking postural stability of young concussion patients using dual-task interference

OBJECTIVES

This study examined the diagnostic benefit of using dual-task interference balance testing in young concussion patients and the longitudinal changes in postural stability that occur relative to other standard clinical assessments of concussion injury.

DESIGN

Longitudinal, case-control.

METHODS

Eighteen patients (16.6 (1.6)y) diagnosed with a concussion provided 22 separate ratings to characterize the severity of their current concussion-related symptoms and were evaluated for postural stability at each of four clinical visits. Twenty-six injury-free adolescents (17 (2.8)y) performed balance testing on two occasions, separated by ∼1 week.

RESULTS

There was a progressive decrease in self-reported symptoms from visit 1 to visit 4 (P<0.0001-0.001). A similar improvement occurred in postural stability, indicated by 95% ellipse area and velocity. However, the differences in ellipse area and velocity were significant only between visit 1 and the rest of the visits as a whole (P<0.0001-0.05). There was a significant difference between concussion patients and healthy, injury-free participants in ellipse area and velocity during visit 1. A group difference was also observed in ellipse area on visit 2, but only during the two balance tests that involved a concomitant secondary cognitive task.

CONCLUSIONS

Improvements in postural stability coincide with reductions in reported symptoms, though apparent recovery of these selected measures of postural stability seemingly occurs sooner. Because of the distinguishing time course of recovery indicated by dual-task interference balance testing, this type of balance testing assessment may be particularly valuable in evaluating integrated functional impairment and recovery in young concussion patients.

Test-retest consistency of a postural sway assessment protocol for adolescent athletes measured with a force plate

PURPOSE/BACKGROUND

Postural control assessments can provide a powerful means of detecting concussion-related neurophysiological abnormalities and are considered an important part of the concussion management processes. Studies with college athletes indicate that postural sway analyzed using complexity metrics may provide a sensitive and novel way to detect post-concussion postural control impairments. The purpose of this study was to determine if a postural sway assessment protocol (PSAP) measured using a force plate system can serve as a reliable assessment tool for adolescent athletes.

METHODS

The short-term and long-term test-retest reliability of the PSAP was examined in a group of adolescent female athletes under eyes open and eyes closed conditions. Detrended fluctuation analysis was used to evaluate the complexity of the times series data (i.e., degree of self-similarity across time scales). Conventional measures of standard deviation and total path length (distance traveled by the center-of-pressure) were also assessed.

RESULTS

The complexity and conventional measures generally demonstrated good reliability coefficients for short-term and long-term test-retest reliability with both eyes open and eyes closed conditions. Intra-class Correlation Coefficient (ICC) values ranged from .38-.90 The highest ICC values corresponded with the short-term reliability for the eyes open condition, while the lower ICC values corresponded with the long-term reliability for the eyes closed condition.

CONCLUSIONS

The results of this study indicate that the PSAP demonstrated good short-term and long-term test-retest reliability. In addition, no evidence of learning effects was elicited through this study. Future studies should further explore the validity and feasibility of the use of this protocol for different age groups, different types of athletes, and longitudinal evaluations of post-concussion impairments.

CLINICAL RELEVANCE

This study provides preliminary support for the utility of a postural sway assessment protocol measured using a force plate for use with adolescent athletes.

LEVEL OF EVIDENCE

Level III.

Are divided attention tasks useful in the assessment and management of sport-related concussion?

This article is a systematic review of the literature on divided attention assessment inclusive of a cognitive and motor task (balance or gait) for use in concussion management. The systematic review drew from published papers listed in PubMed, MEDLINE, EMBASE and CINAHL databases. The search identified 19 empirical research papers meeting the inclusion criteria. Study results were considered for the psychometric properties of the paradigms, the influence of divided attention on measures of cognition and postural control and the comparison of divided attention task outcomes between individuals with concussion and healthy controls (all samples were age 17 years or older). The review highlights that the reliability of the tasks under a divided attention paradigm presented ranges from low to high (ICC: 0.1-0.9); however, only 3/19 articles included psychometric information. Response times are greater, gait strategies are less efficient, and postural control deficits are greater in concussed participants compared with healthy controls both immediately and for some period following concussive injury, specifically under divided attention conditions. Dual task assessments in some cases were more reliable than single task assessments and may be better able to detect lingering effects following concussion. Few of the studies have been replicated and applied across various age groups. A key limitation of these studies is that many include laboratory and time-intensive measures. Future research is needed to refine a time and cost efficient divided attention assessment paradigm, and more work is needed in younger (pre-teens) populations where the application may be of greatest utility.

Balance error scoring system performance changes after a competitive athletic season

OBJECTIVE

To evaluate the change in Balance Error Scoring System (BESS) performance after an athletic season.

DESIGN

A prospective longitudinal group study.

SETTING

University biomechanics research laboratory.

PARTICIPANTS

A total of 58 college-aged females (23 soccer student-athletes, 16 volleyball student-athletes, and 19 recreationally active healthy college students) participated in the study.

INTERVENTIONS

The BESS test was administered on 2 occasions 90 days apart. For the student-athletes, the first test (PRE) was administered before the start of their athletic season and the second test (POST) was administered immediately after the season. For the recreationally active college students, the PRE test was at the beginning of the academic semester and the POST test exactly 90 days thereafter.

MAIN OUTCOME MEASURES

Total BESS score at PRE and POST was compared with a 3 × 2 repeated measures analysis of variance. The overall change score and absolute value change score were also calculated and compared with a 1-sample t test to an expected change of zero errors.

RESULTS

There was no group by time interaction; however, there was a main effect for time. There was a significant improvement (P = 0.003) between PRE (9.00 ± 2.97 errors) and POST (7.92 ± 2.78 errors) BESS performance. There were significant differences for both the overall change score (1.08 errors) and the absolute value change score (2.00 errors).

CONCLUSIONS

A clinically and statistically significant difference in BESS performance was identified after a 90-day intercollegiate athletic season.

Normative data for the balance error scoring system in adults

Background. The balance error scoring system (BESS) is a brief, easily administered test of static balance. The purpose of this study is to develop normative data for this test. Study Design. Cross-sectional, descriptive, and cohort design. Methods. The sample was drawn from a population of clients taking part in a comprehensive preventive health screen at a multidisciplinary healthcare center. Community-dwelling adults aged 20–69 (N = 1, 236) were administered the BESS within the context of a fitness evaluation. They did not have significant medical, neurological, or lower extremity problems that might have an adverse effect on balance. Results. There was a significant positive correlation between BESS scores and age (r = .34). BESS performance was similar for participants between the ages of 20 and 49 and significantly declined between ages 50 and 69. Men performed slightly better than women on the BESS. Women who were overweight performed significantly more poorly on the test compared to women who were not overweight (P < .0001; Cohen's d = .62). The BESS normative data are stratified by age and sex. Conclusions. These normative data provide a frame of reference for interpreting BESS performance in adults who sustain traumatic brain injuries and adults with diverse neurological or vestibular problems.