Pediatric Balance Scale: A ModifiedVersion of the Berg Balance Scalefor the School-Age Child with Mildto Moderate Motor ImpairmentMary Rose Franjoine, MS, PT, PCS, Joan S. Gunther, PhD, PT, and Mary Jean Taylor, MA, PT, PCS
Physical Therapy Program, Daemen College, Amherst, New York
Purpose: The Pediatric Balance Scale (PBS), a modification of Berg’s Balance Scale, was developed as a balancemeasure for school-age children with mild to moderate motor impairments. The purpose of this study was todetermine the test-retest and interrater reliability of the PBS. Methods: To determine test-retest reliability, 20children (aged five to 15 years) with known balance impairments were tested by one examiner on the PBS. Tenpediatric physical therapists independently scored 10 randomly selected videotaped test sessions. Results:There was no significant difference in total test scores [intraclass correlation coefficient (ICC) model 3,1 �0.998] or individual items (Kappa Coefficients, k � 0.87 to 1.0; Spearman Rank Correlation Coefficients, r �0.89 to 1.0) measured by one therapist on two occasions. No significant difference among ratings by differentphysical therapists was found on the PBS for total test score (ICC 3,1 � 0.997). Conclusion: The PBS has beendemonstrated to have good test-retest and interrater reliability when used with school-age children with mildto moderate motor impairments. (Pediatr Phys Ther 2003;15:114–128) Key words: child, posture, equilibrium,cerebral palsy, spinal dysraphism, mental retardation, activities of daily living, reproducibility of results,physical therapy techniques/methods
INTRODUCTION AND PURPOSE
Examination of balance is an important element of aphysical therapy evaluation for a school-age child. The cli-nician must predict the ability of the child to safely andindependently function in a variety of environments (ie,home, school, and community). Valid and reliable func-tional balance measures are of critical importance if thepediatric physical therapist is to justify that intervention iswarranted and demonstrate that improved balance func-tion has occurred as a result of intervention.
Traditionally, pediatric physical therapists have ex-amined balance through the observation of the underlyingelements of the balance response, timed measures of static
postures, and standardized developmental measures ofgross motor function.1–4 The ability to describe the extentto which a child demonstrates righting reactions, protec-tive responses, and equilibrium reactions in response to atherapist generated perturbation formed the foundation ofthe “classic” balance assessment.1,2 Traditional balance as-sessment also included timed measures of static sitting andstanding balance including single limb stance.4 Standard-ized examination tools currently utilized by pediatric phys-ical therapists for school-age children with mild to moder-ate motor impairment include the Bruininks-OseretskyTest of Motor Proficiency,5 the Peabody DevelopmentalMotor Scale,6 and the Gross Motor Function Measure.7 Inaddition, clinicians have developed their own non-stan-dardized measures in an attempt to obtain information rel-ative to the quality of performance during basic and instru-mental activities of daily living, and higher-level grossmotor tasks.4 The standardized and non-standardized mea-sures that currently exist provide clinicians with valuableinformation, but may not fully meet their needs to assess achild’s functional balance abilities.
Functional balance, for the purpose of this study,has been defined as the element(s) of postural control
Address correspondence to: Mary Rose Franjoine, MS, PT, PCS, PhysicalTherapy Program, Daemen College, 4380 Main St., Amherst, NY 14226.Email: [email protected]
DOI: 10.1097/01.PEP.0000068117.48023.18
114 Franjoine et al Pediatric Physical Therapy
that allow a child to safely perform everyday tasks. Achild of school age is expected to function indepen-dently within his/her home and school environmentwhen performing self-help (basic activities of daily liv-ing), locomotor (mobility), and gross motor activities,including recreational activities/play (instrumental ac-tivities of daily living). As the child approaches adoles-cence and young adulthood increased proficiency in ba-sic and instrumental activities of daily living isanticipated. Balance, the ability to maintain a state ofequilibrium, is one of the critical underlying elements ofmovement that facilitates the performance of functionalskills. Other critical elements for successful functioninclude cognition, vision, vestibular function, musclestrength, and range of motion. The physical therapistmust determine if the child possesses adequate func-tional balance to safely meet the demands of everydaylife at home, in school, and within the community.
School-age children with mild to moderate motor im-pairment pose unique challenges for the pediatric physicaltherapist. Generally, they have acquired basic motor abili-ties. At first glance, these children appear to possess themotor skills necessary for successful function within theirhomes, schools, and communities. They are able to ambu-late independently with or without assistive devices. It isour observation, however, that a closer examination oftheir abilities reveals that they have a limited movementrepertoire that allows for minimal variation of movementstrategies within a given environment. Examples of suchlimitations include the ability to turn only in one directionin preparation to sit in a chair, or the ability to initiatesingle limb stance with only one limb in preparation forstepping onto a curb. Strong preferences or limited optionsmay create movement strategies that are unique to givenenvironments and appear slow, precarious, or impulsive.Children with mild to moderate motor impairment mayappear to lack endurance for long duration/distance activ-ities, such as standing still while waiting in a line. Standard-ized tests, such as the Bruininks-Oseretsky Test of MotorProficiency,5 often reveal a significant delay in motor func-tion for children with mild to moderate impairments com-pared to children of the same chronological age withoutimpairments.
Current standardized pediatric clinical measures maynot provide the clinician with adequate information tofully assess a child with mild to moderate motor impair-ment’s functional balance. A review of balance in the liter-ature suggested that the Berg Balance Scale (BBS) might beuseful with the school-age population.8–12 The 14 itemscontained within BBS (see Table 1) assess many of thefunctional activities a child must perform to safely andindependently function within his/her home, school, orcommunity: sitting balance, standing balance, sit to stand/stand to sit, transfers, stepping, reaching forward, reachingto the floor, turning, and stepping on and off of an elevatedsurface. The test item “forward reaching” is conceptuallysimilar to “functional reach,” which has been studied in thepediatric population.13 The purpose of this study was
threefold: 1) to pilot test BBS for use with children; 2) torefine the instrument as needed for use with children; and3) to determine test-retest and interrater reliability of theBalance Scale for school-age children with mild to moder-ate motor impairments.
The BBS
The BBS has undergone extensive reliability andvalidity testing within the geriatric patient popula-tion.8,10 The intraclass correlation coefficients (ICC) forinterrater and test-retest reliability for the test as a wholewere 0.98 and 0.99, respectively. The ICC for individualtest items ranged from 0.71 to 0.99. Berg has suggestedthat for older persons the Balance Scale is an appropriatescreening tool with respect to functional balance, is pre-dictive of future dysfunction, is sensitive to changes infunctional balance skills, and may be used to monitor apatient’s status over time.9,10 The BBS is easy to admin-ister, does not require specialized equipment, and can becompleted in �20 minutes. A 0 to 4 grading scale pro-vides a quantitative and qualitative measure of perfor-mance. An overall numeric score is obtained at the con-clusion of testing.10
METHODS
Pilot Testing of the BBS with Children
The BBS (see Table 1) was administered to 13 childrenwho were typically developing who ranged in age from fourto 12 years, on two separate occasions scheduled one weekapart. A physical therapist (M.R.F.), a clinical specialist inpediatric physical therapy with 13 years of experience inschool-based therapy, administered the BBS per test proto-col to all 13 participants during both test sessions. Thesame test site was used for both test sessions. Preliminaryresults revealed unsatisfactory test-retest reliability. For-mal statistical analysis of this data could not be completedas nine of the 13 participants (69%) had difficulty complet-ing two or more of the test items that required prolongedmaintenance of static postures. Marked variation withinindividual participant’s performance was noted from theinitial test session to the follow-up test session with totaltest scores (TTS) decreasing by greater than six points ineight of the 13 (62%) participants. Issues associated withtypical child behavior, attention span and following direc-tions were consistently encountered throughout test ad-ministration during both sessions.
On the basis of the results of pilot testing of the BBSwith children who were typically developing, the 14 itemscontained within Berg’s scale were modified to create apediatric version of this tool. The modifications were mi-nor and included: 1) reordering of test items; 2) reducingtime standards for maintenance of static postures; and 3)clarifying directions. Test items within the BBS are orga-nized by increasing difficulty of task (see Table 1). In thepediatric version, items were reordered into functional se-quences with novel tasks placed at the end of the scale (see
Table 1). Time standards for BBS item 2, “standing unsup-ported,” item 3, “sitting unsupported,” and item 7, “stand-ing unsupported feet together” were decreased to 30 sec-onds. In the BBS, a maximal score of “4” is earned in items2 and 3 by maintaining a static posture for two minutes andin item 7 by maintaining a static posture for one minute.The scoring criteria to earn a “0” to “3” for each of theseitems were also modified. Directions and suggested equip-ment were modified throughout the balance scale. Exam-ples include the use of footprints or a taped line to facilitatetask completion in BBS items 2, 6–10, 13, and 14. Equip-ment modification also included the use a child-size benchfor BBS items 3–5, the use of a chalkboard eraser for BBSitem 8, the use of a flash card for BBS item 10, and the useof a 6-inch step for BBS item 12. Care was taken to ensurethat the intent of the items was not altered by the modifi-cations. The Pediatric Balance Scale (PBS) and instructionsfor administration are presented in the Appendix.
Pilot Testing of the PBS with Children
The PBS, the revised version of the BBS, was adminis-tered per the protocol detailed in the Appendix, to 40 chil-dren aged five to seven years who were developing typi-cally. They were recruited from two local elementaryschools and participated in two separate test sessionsscheduled two weeks apart for the purpose of determiningtest-retest reliability. Two entry-level physical therapy stu-dents (K.K. and J.L.) under the advisement of an experi-enced pediatric physical therapist (S.H.) administered andscored the test. Before test administration, the clinical spe-cialist in pediatric physical therapy (M.R.F.) who partici-pated in the initial pilot testing of the BBS with childrenwho were typically developing and in the revision processto create the PBS, trained the two examiners. They partic-ipated in two three-hour training sessions, which con-cluded one week before their initial data collection session.Before the examiners completed their training, they dem-onstrated the ability to accurately administer and score thePBS for three children of varying ages. Their results re-vealed no significant difference for total test and retestscores of the 40 children who were developing typically on
the PBS (p � 0.2489, Wilcoxon Matched Pairs SignedRanks Test; r � 0.931, Spearman Signed Rank Correla-tion).14 The test-retest reliability was extremely high (ICC3,1 � 0.850).
Reliability of the PBS with Children with Mild toModerate Motor Impairment
Sample. Twenty children (12 boys and eight girls)ranging in age from five to 15 years (mean age nine years)with mild to moderate motor impairments were recruitedfor participation in this study from local elementaryschools (see Table 2). The children were referred for par-ticipation in this study by their community-based physicaltherapist or their parent(s) or legal guardian(s). Informedconsent was obtained before participation from the child’sparent(s) or legal guardian(s). A formal medical diagnosiswas not considered essential for inclusion in this study. Allchildren had a known functional limitation and/or disabil-ity that presented, clinically, as an impaired state of balance(disequilibrium). Etiologies of balance deficits variedamong the participants and included neurological, muscu-loskeletal, and/or unknown causes (see Table 2). For in-clusion in this sample, children had to be able to standindependently without upper extremity support for fourseconds. All children who participated in this study werereceiving physical therapy at the time of this study, al-though the amount of intervention varied from educationalconsult (one to three times per school year) to intensiveoutpatient physical therapy four times per week. (See Table2) The children’s level of motor impairment also varied.Descriptions of the children provided by their physicaltherapists identified mobility skills, which ranged from in-dependent community ambulation, without external assis-tive devices, to wheelchair dependent, able to ambulate forshort distances. Children with a mental age of less than twoyears, attention deficit disorder, pervasive developmentaldelay, or a severe receptive language disorder were ex-cluded from this study. The decision to exclude childrenfrom this study with significant cognitive, attention, be-havioral, and/or language disorders was necessary becausethese disorders may severely compromise a child’s ability
TABLE 1.The Berg Balance Scale and the Pediatric Balance Scale
1 Sitting to standing 1 Sitting to standing2 Standing unsupported 2 Standing to sitting3 Sitting unsupported 3 Transfers4 Standing to sitting 4 Standing unsupported5 Transfers 5 Sitting unsupported6 Standing with eyes closed 6 Standing with eyes closed7 Standing with feet together 7 Standing with feet together8 Reaching forward with outstretched arm 8 Standing with one foot in front9 Retrieving object from floor 9 Standing on one foot
10 Turning to look behind 10 Turning 360 degrees11 Turning 360 degrees 11 Turning to look behind12 Placing alternate foot on stool 12 Retrieving object from floor13 Standing with one foot in front 13 Placing alternate foot on stool14 Standing on one foot 14 Reaching forward with outstretched arm
116 Franjoine et al Pediatric Physical Therapy
to comprehend and comply with test instructions in thestandardized manner necessary for determining the reli-ability of a tool.
Procedure
Test-retest reliability. The PBS was administered toall 20 participants following the criteria set forth in Appen-dix 1. The same physical therapist (M.R.F.) tested all chil-dren at both test sessions. She was responsible for directinteraction with the child, administration of the test, scor-ing of the test, and ensuring the child’s safety during test-ing. An assistant was responsible for videotaping. Eachitem was scored on the criterion-based 0 to 4 scale. Onlyone practice trial per item was allowed. Verbal, visual, andphysical cues were provided to ensure the child under-stood the requested task. If a child successfully completedthe task (ie, scored a four on the first trial), additional trialswere not administered. It took approximately 15 minutesto administer and score the PBS.
A variety of test sites within the community were uti-lized in this study, including the child’s home, school, andprivate physical therapy clinic. For each child, the locationof the test site for test one and two were the same. Selectionof the test site was determined according to child, caretakeror clinician convenience.
All children who participated in the study were sched-uled for two test sessions that occurred within 14 days.Whenever possible, the day of the week and time of daywere kept consistent. Scheduling of the test session was atthe convenience of the child, their parent(s) or legal guard-ian(s), and/or the facility. Before each test session, a briefintroductory period occurred. This period did not exceed 5
minutes, and was designed to put the child at ease, allow-ing the examiner to develop effective communication strat-egies with the child. The child’s parent(s) and the referringtherapist(s) were invited to attend the test sessions.
Interrater Reliability
Interrater reliability of the PBS for total test score wasdetermined by using the videotapes created during the testand retest data collection. Item 14, “forward reach,” wasomitted from videotape analysis because a two-dimen-sional videotape does not adequately record test perfor-mance.13 To ensure a range of performance scores, video-taped test sessions were subdivided into three categories:TTS �20, TTS �20 and �40, and TTS �40. Three to fourvideotapes were randomly selected from the tapes in eachcategory. Ten pediatric physical therapists with a mini-mum of two years of clinical experience participated in theinterrater reliability phase of this study. All therapists werevolunteers and were recruited from the local therapeuticcommunity. Their level of pediatric clinical experience var-ied, ranging from two to 25 years (mean experience 9.4years). All participating therapists were involved in pedi-atric clinical practice, although their practice setting var-ied: school-based, five therapists; outpatient hospitalbased, three therapists; outpatient private practice, twotherapists. Each therapist participated in a single, 45-minute training session on scoring of the PBS before scor-ing of the videotapes. The 10 therapists independentlyviewed and scored the 10 videotaped test sessions withinone week of their training session.
TABLE 2.Characteristics of children participating in this study and their total test scores for test and retest
SubjectAge inYears Gender Diagnosis
Physical TherapySessions per Week
Number of DaysBetween Test-Retest Functional Level
To determine test-retest reliability of the PBS, scoreson the initial administration of the PBS were comparedwith those obtained by the same investigator on the secondadministration of the PBS. Scores on the PBS are ordinallevel data; therefore, the nonparametric WilcoxonMatched Pairs Signed Ranks Test (alpha � 0.05) was usedto test for significant difference between total test and totalretest scores. The Kappa statistic, k, was used to evaluatethe agreement of test and retest scores on individual testitems. Each ordinal score from 0 to 4 was considered to bea category. The kappa corrects for the proportion of agree-ments between test and retest scores that occur as a resultof chance.15 Correlation coefficients evaluate the corre-spondence between measurements. The correlation be-tween test and retest scores was determined using theSpearman Rank Correlation coefficient. This test reflectsthe consistency of ranks of data, but not the degree ofsimilarity between repeated test scores.15 An ICC model 3,1[ICC(3,1)], which is a reliability coefficient based on ananalysis of variance, was also determined.
Analysis of Interrater Reliability
A single-factor repeated-measure analysis of variance(alpha � 0.05) and an ICC(3,1) were used to evaluateinterrater reliability of total test score (exclusive of item14) on the PBS.
RESULTS
Test-Retest Reliability
The age, gender, diagnosis, and frequency of physicaltherapy services as well as time between initial test andfollow-up test are presented in Table 2 for all 20 childrenwho participated in this study. The distribution of the TTSfor test and retest data is also shown in Table 2. IndividualTTS scores ranged from 5 to 52. The maximal possible TTSfor the PBS is 56. There was no significant difference be-tween total test and retest scores on the PBS (p � 0.2733,Wilcoxon Matched Pairs Signed Ranks Test). The test-re-test reliability for individual items is presented in Table 3.k ranged from 0.87 to 1.0. The Spearman Signed RankedCorrelation, r, ranged from 0.89 to 1.0 for individual items.Test-retest reliability was extremely high [ICC(3,1) �0.998].
Interrater Reliability
Ten pediatric physical therapists with varied clinicalbackground, including years of experience and practicesetting, independently viewed and scored the videotapedperformance of 10 children. The median, mode, and rangeof TTS on the PBS for each of the videotaped subjects arepresented in Table 4. The total test scores of the subjectsexamined by the 10 therapists ranged from five to 49 withonly a zero-to-two point difference in the total test scoresfor each subject. There was no significant difference amongratings by different physical therapists on PBS TTS (F �
1.574; p � 0.1087) (see Table 5) and high interrater reli-ability was demonstrated via an ICC(3,1) � 0.997.
DISCUSSION
Preliminary testing of the PBS reveals very high test-retest and interrater reliability for children five to 15 years ofage with mild to moderate motor impairments. The PBS maytherefore provide clinicians with an additional, reliable meansof assessing a child’s balance. The PBS also affords clinicians astandardized protocol for test administration and scoring.Our preliminary work does not specifically address the valid-ity of the PBS as a pediatric balance measure, nor does itprovide normative information. Clinical observations sup-port the content (face) validity of the PBS, because items con-tained within are routinely performed by children throughoutthe day and are frequently examined by pediatric physicaltherapist as a component of assessment. Examples of suchtasks include the following: item 1, sit to stand; item 2, standto sit; item 10, turning around; item 11, turning to look be-hind; and item 12, picking an object up from the floor (see theAppendix and Table 1).
The PBS incorporates a 0 to 4 grading scale to assessperformance. The scoring criterion within an item incor-porates qualitative and quantitative measures that allow for
TABLE 4.Median, mode and range of TTS on PBS for 10 subjects evaluated by 10
1. Sit-Stand 1.00 1.002. Stand-Sit 1.00 1.003. Transfers 1.00 1.004. Standing Balance 0.92 0.895. Sitting Balance 1.00 1.006. Stand Eyes Closed 1.00 1.007. Stand Feet Together 0.91 0.998. Stand One Foot in
Front-Tandem0.92 0.96
9. Stand on One Foot 0.87 0.9510. Turn 360 Degrees 0.91 0.9911. Turn and Look Behind 0.93 1.0012. Pick Up Object 1.00 0.9313. Stepping 0.93 1.0014. Functional Reach 1.00 1.00
PBS � pediatric balance scale.
118 Franjoine et al Pediatric Physical Therapy
normal variability in performance. This aspect of the grad-ing scale is extremely important, in that variability is ahallmark of typical motor development. PBS item 8,“standing one foot in front” (see Appendix) illustrates theuse of qualitative measures, quantitative measures andvariability within the scoring criteria of a single item. Thisitem examines a child’s ability to assume and maintain atandem posture. To obtain the maximal score of four thechild must be able to independently assume a tandem footplacement position and maintain it for 30 seconds. A lesserscore is earned if the child requires assistance to step, canmaintain a stride stance, but not tandem stance, or main-tains the tandem posture for �30 seconds.
Extreme care was taken during the modification pro-cess of the BBS to ensure that the intent of the task was notaltered. The reduction in time parameters for static stancein BBS items 2, 3, and 7 was necessary to ensure the mea-sure of elements of postural control vs attention span. Thereduction to 30 seconds may limit the ability of this tool toassess the underlying element of muscle strength/posturalstability as a component of functional balance. The timeparameter of 30 seconds was chosen based in part uponclinical observation during pilot testing of the BBS andcurrent clinical research in the area of pediatric balance.1,4
Care was taken to limit the effects of learning duringthe test-retest phase of this study. Verbal, visual, and tactilefeedback, for each item, was provided during test sessionone and two during the practice trial only. Qualitative per-formance feedback, positive or negative, was not providedduring test administration and/or scoring. Additional feed-back relative to individual item(s) or overall task perfor-mance was also not provided. At the conclusion of each testthe child received a small toy of their choice as a thank youfor participating. The test and retest session were sched-uled at least seven days apart and no longer than 14 days tominimize the effects of leaning, retention, and develop-mental-based changes.
The PBS has limitations. For example, the PBS doesnot examine a child’s ability to reach overhead. If one con-siders the strategies that children use as they interact withtheir environment, we have observed that items which areout of reach are frequently overhead. Additionally, the PBSdoes not examine issues associated with balance duringlocomotion. Inclusion of such items in the PBS would re-quire further investigation.
Several questions remain with respect to the validityof the PBS. Does the TTS have meaning, and if so, whatdoes it mean? Do age, height, weight, or gender influencetest performance? Is the PBS sensitive to functional
change? Is it capable of documenting skill progression orregression over time? Do the criteria used in the gradingscale reflect different levels of motor proficiency? Are thescale increments (zero to four) reflective of an overallchange in function? Ongoing investigation with the PBSincludes collection of normative data on children who aretypically developing. Preliminary results suggest that chil-dren who are typically developing by the age of seven yearscan successfully complete all items within the PBS, obtain-ing the maximal score of 56. Additionally, three subjectshave been tested using the PBS for a period of two years inconjunction with their ongoing clinical intervention pro-grams. Trends in their data suggest that the PBS may besensitive to changes in a child’s functional balance abilitiesover time. It is hoped that the PBS can be used clinically toscreen for functional balance deficits, identify a need forphysical therapy intervention, and to monitor progresswithin a therapeutic program.
CONCLUSION
Preliminary data supports the use of the PBS as a reli-able measure of functional balance for use with the school-age child with mild to moderate motor impairment. It isquick to administer and is easily scored. Total test admin-istration and scoring time is �15 minutes. The PBS doesnot require the use of specialized equipment. It providesclinicians with a standardized format for measurement offunctional balance tasks which are routine components ofphysical therapy examination for the school-age child withmild to moderate motor impairments.
ACKNOWLEDGMENTS
The authors thank the children, their families, and thecommunity clinicians who participated in this study. Theauthors acknowledge and thank Sharon L. Held, MS, PT,PCS, Kim Kobes, PT, and Jeff Lach, PT, for their contribu-tions to this study. A special thank you is extended toKatherine Carey Carney, Theresa Kolodziej, Deborah Sc-heider, and Jane Montgomery for their assistance andsupport.
This study is dedicated in loving memory of GregoryJames Heiser (November 9, 1988 to August 23, 1996).Sleep well my little angel.
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TABLE 5.Summary table for single-factor repeated-measures analysis of variance: PBS total scores of 10 videotaped subjects scored by 10 pediatric physical
therapists
df Sum of Squares Mean Square F Value p Value
Subjects (S) 9 24430.800 2714.533Therapists (T) 9 1.600 0.178 1.674 0.109Error (S � T) 81 8.600 0.106
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