Reference values for the balance error scoring system in adolescents

Footwear Type and Testing Environment Do Not Affect Baseline Modified Balance Error Scoring System Performance Among Middle School Athletes

CONTEXT

Limited evidence exists to demonstrate the effect of extrinsic factors, such as footwear worn or the testing environment, on performance of the modified balance error scoring system (mBESS) in the middle school age (10-14 y) population. Therefore, the purpose of our study was to investigate the effect of footwear types and testing environments on performance of the mBESS by middle school athletes.

DESIGN

Cross-sectional.

METHODS

In total, 2667 middle school athletes (55.9% boys and 44.1% girls; age = 12.3 [0.94] y) were administered the mBESS while wearing their self-selected footwear (barefoot, cleats, or shoes) either indoors (basketball court) or outdoors (football field or track). The number of errors committed (range = 0-10) during the double-leg, single-leg, and tandem stances of the mBESS were summed to calculate a total score (range = 0-30). Kruskal-Wallis tests were used to assess for differences among the footwear groups for each mBESS stance and the total score. Mann-Whitney U tests with calculated nonparametric effect sizes (r) were used to assess for differences between the footwear groups and testing environments when appropriate.

RESULTS

There were significant differences for the number of committed errors among the footwear groups in the single-leg (P < .001) and tandem (P < .001) stances of the mBESS and mBESS total scores (P < .001). Significantly fewer errors (better) were committed while wearing shoes compared with other footwear in the single-leg and tandem stances of the mBESS (Ps ≤ .032, r = .07-.13). Participants assessed indoors committed significantly fewer errors than those assessed outdoors in each stance of the mBESS (Ps ≤ .022, r = .04-.14). Lower (better) mBESS total scores were observed for participants while wearing shoes (Ps ≤ .002, r = .10-.15) or assessed indoors (P = .001, r = .14).

CONCLUSIONS

Although our data suggest that the type of footwear worn and the testing environment have a significant effect on mBESS scores of middle school athletes, the magnitudes of these differences are negligible.

Static and Dynamic Balance Assessment in Healthy and Concussed Adolescent Athletes

OBJECTIVE

The purpose of this study was to explore the utilization of the Y Balance Test (YBT) alongside the Balance Error Scoring System (BESS) during examination of healthy adolescent athletes (14-18 year old) as well as those with acute and chronic concussion.

DESIGN

A repeated-measures study of balance in a cross-sectional convenience sample of adolescents participating in high-school athletics.

SETTING

Data were collected on healthy athletes in their school setting for comparison purposes and on concussed athletes in the physical therapy rehabilitation center at the hospital.

PARTICIPANTS

Participants were a convenience sample of male and female athletes between the ages of 14 to 18 year old [180 healthy (111 male, 69 female) and 44 (28 male, 16 female) with concussion].

ASSESSMENT OF RISK FACTORS

All participants were cleared for participation by preparticipation examination or by the treating sport medicine physician.

MAIN OUTCOME MEASURES

Healthy athletes performed the YBT, a dynamic assessment of balance. Athletes with concussion also performed the BESS, a static assessment of balance.

RESULTS

Means for each YBT reach direction were statistically different for both healthy males and females ( P < 0.05). Within both the acute and chronic subsets of the concussed sample, some participants performed over the median value for the BESS but not the YBT.

CONCLUSIONS

These data may suggest that dynamic balance testing in conjunction with static balance testing could be valuable in both the acute and chronic phases of concussion to ensure a comprehensive assessment of the necessary balance skills for athletic play.

Analysis of Head Impact Biomechanics in Youth Female Soccer Players Following the Get aHEAD Safely in Soccer™ Heading Intervention

The effects of repetitive head impacts associated with soccer heading, especially in the youth population, are unknown. The purpose of this study was to examine balance, neurocognitive function, and head impact biomechanics after an acute bout of heading before and after the Get aHEAD Safely in Soccer™ program intervention. Twelve youth female soccer players wore a Triax SIM-G head impact sensor during two bouts of heading, using a lightweight soccer ball, one before and one after completion of the Get aHEAD Safely in Soccer™ program intervention. Participants completed balance (BESS and SWAY) and neurocognitive function (ImPACT) tests at baseline and after each bout of heading. There were no significant changes in head impact biomechanics, BESS, or ImPACT scores pre- to post-season. Deficits in three of the five SWAY positions were observed from baseline to post-season. Although we expected to see beneficial changes in head impact biomechanics following the intervention, the coaches and researchers observed an improvement in heading technique/form. Lightweight soccer balls would be a beneficial addition to header drills during training as they are safe and help build confidence in youth soccer players.

Normative Data for the Sway Balance System

OBJECTIVE

Static balance, postural stability, and reaction time are commonly impaired after a sport-related concussion. The Sway Balance System assesses postural sway (ie, stability) and simple reaction time using the triaxial accelerometer built into iOS mobile devices. The purpose of this study was to provide normative data for children and adolescents and to examine for age and sex differences on the Sway Balance System.

DESIGN

Cross-sectional study.

SETTING

Middle and high schools across the United States.

PARTICIPANTS

Participants were 3763 youth aged 9 to 21 years who completed the Sway Balance System Sports protocol in accordance with the company's recommended methods (ie, 1 acclimation trial and 2-3 baseline tests).

INDEPENDENT VARIABLES

Age and sex.

MAIN OUTCOME MEASURES

Sway Balance score (0-100) and Sway Reaction Time score (0-100).

STATISTICAL ANALYSIS

A multivariate analysis of variance examined the effects of age and sex on balance and reaction time scores.

RESULTS

Sway Balance and Reaction Time scores significantly differed by age [F(10, 7494) = 39.68, P < 0.001, V = 0.10, = 0.05] and sex [F(4, 7494) = 55.29, P < 0.001, V = 0.06, = 0.03]. Post hoc analyses revealed that older groups generally had better scores than younger groups on all balance comparisons (ps < 0.001) and many reaction time comparisons. Girls performed better than boys on balance [F(2, 3747) = 53.79, P < 0.001, = 0.03] and boys had faster reaction times [F(2, 3747) = 37.11, P < 0.001, = 0.02].

CONCLUSIONS

Age and sex are important factors to consider when assessing Balance and Reaction Time scores using the Sway Balance System's Sports protocol in youth. We provide age- and sex-based normative values for the Sway Balance System, which will likely be helpful when using this technology to assess and manage concussions.

Normative Data for the Balance Error Scoring System in Iranian Adults

CONTEXT

The Balance Error Scoring System (BESS), originally designed to diagnose and assess athletes with concussion syndrome, is now widely used to evaluate postural stability. To interpret balance status, a normative database can be a reliable source. However, different anthropometric characteristics and sociocultural backgrounds across populations hinder the application of previously developed databases in different populations.

OBJECTIVE

The present study was designed to develop a normative data set for the general population of healthy Iranian adults according to their age groups and to study the correlation between BESS scores and the participants' sex, height, weight, and body mass index.

DESIGN

A cross-sectional study.

PARTICIPANTS

A total of 1051 community-dwelling adults aged 20-69 years not suffering from balance disorders, dizziness, or other neurological or musculoskeletal diseases were recruited and stratified into 5 different age groups by decade.

MAIN OUTCOME MEASURES

The BESS tests were composed of single-leg, double-leg, and tandem stances, each on a rigid surface and a foam pad. The individuals maintained each position for 20 seconds with eyes closed. The assessor recorded the total number of errors as the individuals' BESS score (range: 0-60).

RESULTS

Significant but weak correlations were found between BESS score and height (r = -.13, P < .001) and between BESS score and body mass index (r = .11, P < .001), and the difference between sexes in BESS score was statistically significant in the 50- to 59-year-old (P = .021) and 60- to 69-year-old (P < .001) groups. The BESS scores were significantly different between all age groups (P < .05), except between the 20- to 29-year-old and 30- to 39-year-old groups (P = 1.000) and between the 40- to 49-year-old and 50- to 59-year-old groups (P = .086).

CONCLUSIONS

This study provided a normative database for different age groups of asymptomatic Iranian adults. The BESS score had weak correlations with height and body mass index and no correlation with weight, and significant differences were found between sexes in 50- to 69-year-old individuals. This study emphasizes the importance of obtaining specific normative data for different populations.

A virtual reality head stability test for patients with vestibular dysfunction

BACKGROUND

The contribution of visual information to standing balance in patients with vestibular dysfunction varies between patients. Sensitive tools to detect kinematic response to visual perturbation are needed to individualize treatment.

OBJECTIVE

Using the Oculus Rift headset and sensors, we developed a novel virtual reality (VR) test of head stability (HST) in response to visual perturbation. During the test, head movements were tracked in six degrees-of-freedom. The purpose of this pilot study was to test the sensitivity of the VR_HST to differences between patients with vestibular dysfunction and controls.

METHODS

Seventeen patients and 16 controls performed static balance tasks with eyes closed (feet together or tandem on floor and foam) and observing 'moving stars' (amplitude 32 mm, frequency 0.2 Hz) via the Oculus (tandem). Directional Path and Root Mean Square Velocity were calculated for postural and head oscillations.

RESULTS

Postural sway differed significantly between groups when standing on foam with feet together and on floor while observing the 'moving stars' task. Head oscillations were larger among patients, primarily in pitch, yaw, and roll rotation.

CONCLUSIONS

The VR_HST was found to be sensitive to differences between small and diverse groups. Its clinical utility should be studied in larger samples of patients with vestibular dysfunction.

Reference values for the Balance Error Scoring System as measured by the Tekscan MobileMat™ in a physically active population

OBJECTIVES

The Balance Error Scoring System (BESS) is commonly used to measure postural stability; however, it has demonstrated inconsistent reliability values when administered by humans. The Tekscan MobileMat™ was developed to automate the assessment of BESS errors and eliminate rater subjectivity. The objective of this study was to report reference values for the BESS, as measured by the MobileMat™, and examine the effect of sex, concussion history, and competitive sport level on BESS performance.

METHODS

Four hundred and forty participants performed the BESS on the MobileMat™. Participants were asked to maintain each stance with their eyes closed for 20 s. The MobileMat™ was used to quantify the number of errors.

RESULTS

Concussion history (p = 0.279-0.979) and competitive sport level (p = 0.422-0.979) did not affect BESS performance. Males performed significantly better than females for the single-limb foam stance (p = 0.032). No sex differences were detected for the other BESS stances or BESS total score (p = 0.067-0.744).

CONCLUSIONS

Previously reported reference values in collegiate athletes and adolescents were slightly higher thus highlighting the value in establishing population norms and in developing new technologies to objectively quantify BESS performance. Furthermore, sex, concussion history, and competitive sport level do not appear to influence BESS performance as measured by the MobileMat™.

Sport-Related Concussion in Children and Adolescents

Sport-related concussion is an important topic in nearly all sports and at all levels of sport for children and adolescents. Concussion knowledge and approaches to management have progressed since the American Academy of Pediatrics published its first clinical report on the subject in 2010. Concussion's definition, signs, and symptoms must be understood to diagnose it and rule out more severe intracranial injury. Pediatric health care providers should have a good understanding of diagnostic evaluation and initial management strategies. Effective management can aid recovery and potentially reduce the risk of long-term symptoms and complications. Because concussion symptoms often interfere with school, social life, family relationships, and athletics, a concussion may affect the emotional well-being of the injured athlete. Because every concussion has its own unique spectrum and severity of symptoms, individualized management is appropriate. The reduction, not necessarily elimination, of physical and cognitive activity is the mainstay of treatment. A full return to activity and/or sport is accomplished by using a stepwise program while evaluating for a return of symptoms. An understanding of prolonged symptoms and complications will help the pediatric health care provider know when to refer to a specialist. Additional research is needed in nearly all aspects of concussion in the young athlete. This report provides education on the current state of sport-related concussion knowledge, diagnosis, and management in children and adolescents.

Normative Performance on the Balance Error Scoring System by Youth, High School, and Collegiate Athletes

CONTEXT

  Annually, more than 1 million youth athletes in the United States receive or are suspected of receiving a concussion. The Balance Error Scoring System (BESS) is the most commonly used clinical balance evaluation designed to provide a better understanding of the motor-control processes of individuals with concussion. Despite the widespread use of the BESS, a fundamental gap exists in applying this tool to young athletes, as normative values are lacking for this population.

OBJECTIVE

  To determine age- and sex-specific normative values for the BESS in youth, high school, and collegiate athletes.

DESIGN

  Cross-sectional study.

SETTING

  Local youth sport organizations, high schools, and colleges.

PATIENTS OR OTHER PARTICIPANTS

  Student-athletes (N = 6762) completed preseason baseline concussion testing as part of a comprehensive concussion-management program. Groups were youth males aged 5 to 13 years (n = 360), high school males aged 14 to 18 years (n = 3743), collegiate males aged 19 to 23 years (n = 497), youth females aged 5 to 13 years (n = 246), high school females aged 14 to 18 years (n = 1673), and collegiate females aged 19 to 23 years (n = 243).

MAIN OUTCOME MEASURE(S)

  Errors according to the BESS specifications.

RESULTS

  Performance on the BESS was worse ( P < .01) in youth athletes than in high school and collegiate athletes. In the youth and high school cohorts, females exhibited better scores than males ( P < .05). Sex was not a factor for collegiate athletes. Data from the youth cohort were further subdivided into 4-year bins to evaluate potential motor-development differences. The error count was highest for 5- to 9-year-old males and decreased with age.

CONCLUSIONS

  Performance on the BESS depended on sex and age, particularly in youth athletes. These sex- and age-specific normative values provide a reference to facilitate and unify clinical decision making across multiple providers caring for youth athletes with concussions.