G Model
JPHYS-138; No. of Pages 1 Journal of Physiotherapy xxx (2015) xxx–xxx
Journal of
PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys
Appraisal
Clinimetrics
The Mini-Balance Evaluation Systems Test (Mini-BESTest) Summary The Balance Evaluation Systems Test1 (BESTest) was developed to identify the postural control system(s) that underly poor functional balance, enabling physiotherapists to target treatment to a person’s specific balance deficit. The BESTest consists of 36 items grouped into six subsections: biomechanical constraints, stability limits/verticality, transitions/anticipatory postural control, reactive postural control, sensory orientation and stability in gait. A limitation of the BESTest is the time to administer it (30 to 45 minutes). Therefore, a shorter version of the BESTest was developed via a Rasch analysis – the Mini-Balance Evaluation Systems Test2 (Mini-BESTest). The Mini-BESTest includes four subscales: transitions/anticipatory postural control, reactive postural control, sensory orientation and stability in gait. Each item is rated on a three-point ordinal scale (0 = severe to 2 = normal). Variations in the literature exist between the number of items (14 versus 16) and maximum points attainable (24 versus 32). King and Horak3 clarified this, stating that the MiniBESTest consists of 14 items, with a maximum score of 28 points. The Mini-BESTest takes 10 to 15 minutes to administer. Reliability and validity: With one exception,4 the reliability of the Mini-BESTest is excellent to good, with ICC values >0.90 for people with mixed diagnoses,5,6 stroke7 and Parkinson’s disease.8 The Mini-BEST test is reported to have high content validity.2 Multiple studies have demonstrated its criterion-related validity.5,7–11 Strong and statistically significant correlations exist between the Mini-BESTest and the BESTest in Parkinson’s disease,8 and to other balance and gait measures for people with various conditions, including the Timed Up-and-Go test and the Berg Balance Scale.3,5,9 Weaker correlations exist between the Mini-
BESTest and self-report measures of balance confidence in people with Parkinson’s disease and stroke.7,9,11 With the exception of one study,11 evidence exists to support the discriminative validity of the Mini-BESTest. It can discriminate between fallers versus nonfallers in people with various neurological conditions;6–8,10,12,13 people with Parkinson’s disease with balance deficits versus without balance deficits;10 neurologic versus control subjects;6,7 and high versus low-functioning stroke survivors.14 Studies indicate that the Mini-BESTest can predict falls in people with stroke7 (cut-off score = 17.5/28) and Parkinson’s disease.8,12,13,15 Cut-off scores for people with Parkinson’s disease have varied, including 19/28,13 20/328,12,15 and 23/32.8 Overall, the MiniBESTest appears to have acceptable sensitivity and specificity for predicting fall risk in stroke and Parkinson’s disease. Responsiveness: Two studies have examined the responsiveness of the Mini-BESTest. Tsang et al7 concluded that the minimal detectable change score is 3.0 for individuals with stroke. In a mixed population of people with imbalance, Godi et al5 concluded that the minimally important change score is four points. Floor and ceiling effects: With the exception of one study of lowfunctioning stroke survivors,14 the Mini-BESTest lacks a significant floor effect.2,5,7 Studies have indicated the lack of a ceiling effect in people with various conditions and levels of severity.2,5,7,10,14 Normative values: Mini-BESTest scores decrease with age and there is a significant difference across age groups.16 For various age groups, the mean scores (SD) are: ages 50 to 59: 26.3/28 (1.1); ages 60 to 69: 24.7/28 (2.2); ages 70 to 79: 21.0/28 (3.1); and ages 80 to 89: 19.6/28 (4.2).
Commentary The Mini-BESTest is a measure of balance and gait that is appropriate for people with imbalance and various neurological conditions. It was developed based on sound psychometric principles and it has high clinical utility. Therapists have found it easy to learn and feel that it provides relevant and valuable information that is consistent with functional level.11 It is available at no cost at http://www.bestest.us. Equipment is readily available at most clinical settings, and it takes little time to administer and score. The Mini-BEStest is reliable and able to predict falls. Lack of ceiling and floor effects indicate it is appropriate for a wide variety of people. Responsiveness and normative data exist to assist in goal setting and determining treatment effectiveness. Limitations of the Mini-BESTest include: variations in the literature about scoring, a floor effect for lower-functioning people and limited data from some populations. Administration may require two therapists, especially for people with significant physical or cognitive impairments.11 Researchers have suggested that, used alone, it may not be sufficient to develop a comprehensive balance intervention.11,14 In summary, the Mini-BESTest is a reliable, valid and responsive measure that has high clinical utility. It assesses four aspects of dynamic balance and is likely to have wide applicability to many people with imbalance and neurological conditions.
Provenance: Invited. Not peer-reviewed. Kirsten Potter1 and Kathi Brandfass2 Department of Physical Therapy Education, Rockhurst University, Kansas City, MO, USA 2 Department of Physical Therapy, University of Pittsburgh, Medical Center/Center for Rehab Services, Pittsburgh, PA, USA 1
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
Horak FB, et al. Phys Ther. 2009;89:484–498. Franchignoni F, et al. J Rehabil Med. 2010;42:323–331. King L, et al. Phys Ther. 2013;93:571–575. Lo¨fgren N, et al. BMC Neurol. 2014;14:90–105. Godi M, et al. Phys Ther. 2013;93:158–167. Padgett PK, et al. Phys Ther. 2012;92:1197–1207. Tsang CSL, et al. Phys Ther. 2013;93:1102–1115. Leddy AL, et al. J Neurol Phys Ther. 2011;35:90–97. Bergstro¨m M, et al. Physiother Theory Pract. 2012;28:509–514. King LA, et al. Park Dis. 2012;1–7. Roaldsen KS, et al. Int J Phys Ther Rehabil 2:104. Duncan RP, et al. Park Dis. 2012;2012:e923493. Mak MKY, et al. J Rehabil Med. 2013;45:565–571. Chinsongkram B, et al. Phys Ther. 2014;94:1632–1643. Duncan RP, et al. Phys Ther. 2013;93:542–550. O’Hoski S, et al. Phys Ther. 2014;94:334–342.
http://dx.doi.org/10.1016/j.jphys.2015.04.002 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Potter K, Brandfass K. The Mini-Balance Evaluation Systems Test (Mini-BESTest). J Physiother. (2015), http://dx.doi.org/10.1016/j.jphys.2015.04.002
JPHYS-138; No. of Pages 1 Journal of Physiotherapy xxx (2015) xxx–xxx
Journal of
PHYSIOTHERAPY journal homepage: www.elsevier.com/locate/jphys
Appraisal
Clinimetrics
The Mini-Balance Evaluation Systems Test (Mini-BESTest) Summary The Balance Evaluation Systems Test1 (BESTest) was developed to identify the postural control system(s) that underly poor functional balance, enabling physiotherapists to target treatment to a person’s specific balance deficit. The BESTest consists of 36 items grouped into six subsections: biomechanical constraints, stability limits/verticality, transitions/anticipatory postural control, reactive postural control, sensory orientation and stability in gait. A limitation of the BESTest is the time to administer it (30 to 45 minutes). Therefore, a shorter version of the BESTest was developed via a Rasch analysis – the Mini-Balance Evaluation Systems Test2 (Mini-BESTest). The Mini-BESTest includes four subscales: transitions/anticipatory postural control, reactive postural control, sensory orientation and stability in gait. Each item is rated on a three-point ordinal scale (0 = severe to 2 = normal). Variations in the literature exist between the number of items (14 versus 16) and maximum points attainable (24 versus 32). King and Horak3 clarified this, stating that the MiniBESTest consists of 14 items, with a maximum score of 28 points. The Mini-BESTest takes 10 to 15 minutes to administer. Reliability and validity: With one exception,4 the reliability of the Mini-BESTest is excellent to good, with ICC values >0.90 for people with mixed diagnoses,5,6 stroke7 and Parkinson’s disease.8 The Mini-BEST test is reported to have high content validity.2 Multiple studies have demonstrated its criterion-related validity.5,7–11 Strong and statistically significant correlations exist between the Mini-BESTest and the BESTest in Parkinson’s disease,8 and to other balance and gait measures for people with various conditions, including the Timed Up-and-Go test and the Berg Balance Scale.3,5,9 Weaker correlations exist between the Mini-
BESTest and self-report measures of balance confidence in people with Parkinson’s disease and stroke.7,9,11 With the exception of one study,11 evidence exists to support the discriminative validity of the Mini-BESTest. It can discriminate between fallers versus nonfallers in people with various neurological conditions;6–8,10,12,13 people with Parkinson’s disease with balance deficits versus without balance deficits;10 neurologic versus control subjects;6,7 and high versus low-functioning stroke survivors.14 Studies indicate that the Mini-BESTest can predict falls in people with stroke7 (cut-off score = 17.5/28) and Parkinson’s disease.8,12,13,15 Cut-off scores for people with Parkinson’s disease have varied, including 19/28,13 20/328,12,15 and 23/32.8 Overall, the MiniBESTest appears to have acceptable sensitivity and specificity for predicting fall risk in stroke and Parkinson’s disease. Responsiveness: Two studies have examined the responsiveness of the Mini-BESTest. Tsang et al7 concluded that the minimal detectable change score is 3.0 for individuals with stroke. In a mixed population of people with imbalance, Godi et al5 concluded that the minimally important change score is four points. Floor and ceiling effects: With the exception of one study of lowfunctioning stroke survivors,14 the Mini-BESTest lacks a significant floor effect.2,5,7 Studies have indicated the lack of a ceiling effect in people with various conditions and levels of severity.2,5,7,10,14 Normative values: Mini-BESTest scores decrease with age and there is a significant difference across age groups.16 For various age groups, the mean scores (SD) are: ages 50 to 59: 26.3/28 (1.1); ages 60 to 69: 24.7/28 (2.2); ages 70 to 79: 21.0/28 (3.1); and ages 80 to 89: 19.6/28 (4.2).
Commentary The Mini-BESTest is a measure of balance and gait that is appropriate for people with imbalance and various neurological conditions. It was developed based on sound psychometric principles and it has high clinical utility. Therapists have found it easy to learn and feel that it provides relevant and valuable information that is consistent with functional level.11 It is available at no cost at http://www.bestest.us. Equipment is readily available at most clinical settings, and it takes little time to administer and score. The Mini-BEStest is reliable and able to predict falls. Lack of ceiling and floor effects indicate it is appropriate for a wide variety of people. Responsiveness and normative data exist to assist in goal setting and determining treatment effectiveness. Limitations of the Mini-BESTest include: variations in the literature about scoring, a floor effect for lower-functioning people and limited data from some populations. Administration may require two therapists, especially for people with significant physical or cognitive impairments.11 Researchers have suggested that, used alone, it may not be sufficient to develop a comprehensive balance intervention.11,14 In summary, the Mini-BESTest is a reliable, valid and responsive measure that has high clinical utility. It assesses four aspects of dynamic balance and is likely to have wide applicability to many people with imbalance and neurological conditions.
Provenance: Invited. Not peer-reviewed. Kirsten Potter1 and Kathi Brandfass2 Department of Physical Therapy Education, Rockhurst University, Kansas City, MO, USA 2 Department of Physical Therapy, University of Pittsburgh, Medical Center/Center for Rehab Services, Pittsburgh, PA, USA 1
References 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.
Horak FB, et al. Phys Ther. 2009;89:484–498. Franchignoni F, et al. J Rehabil Med. 2010;42:323–331. King L, et al. Phys Ther. 2013;93:571–575. Lo¨fgren N, et al. BMC Neurol. 2014;14:90–105. Godi M, et al. Phys Ther. 2013;93:158–167. Padgett PK, et al. Phys Ther. 2012;92:1197–1207. Tsang CSL, et al. Phys Ther. 2013;93:1102–1115. Leddy AL, et al. J Neurol Phys Ther. 2011;35:90–97. Bergstro¨m M, et al. Physiother Theory Pract. 2012;28:509–514. King LA, et al. Park Dis. 2012;1–7. Roaldsen KS, et al. Int J Phys Ther Rehabil 2:104. Duncan RP, et al. Park Dis. 2012;2012:e923493. Mak MKY, et al. J Rehabil Med. 2013;45:565–571. Chinsongkram B, et al. Phys Ther. 2014;94:1632–1643. Duncan RP, et al. Phys Ther. 2013;93:542–550. O’Hoski S, et al. Phys Ther. 2014;94:334–342.
http://dx.doi.org/10.1016/j.jphys.2015.04.002 1836-9553/ß 2015 Australian Physiotherapy Association. Published by Elsevier B.V. All rights reserved.
Please cite this article in press as: Potter K, Brandfass K. The Mini-Balance Evaluation Systems Test (Mini-BESTest). J Physiother. (2015), http://dx.doi.org/10.1016/j.jphys.2015.04.002
