Balance Evaluation Systems Test

The Balance Evaluation Systems Test (BESTest) serves as a 36-item clinical balance assessment tool, developed to assess balance impairments across six contexts of postural control: mechanical constraints, limits of stability, APAs, postural response to induced loss of balance, sensory orientation, and gait.

Link to Instrument

Area of Assessment

Assessment Type

Cost

Diagnosis/Conditions

• Multiple Sclerosis
• Parkinson's Disease & Movement Disorders
• Stroke Recovery

Populations

Key Descriptions

• The BESTest is a 36-item assessment of balance impairments across 6 postural control contexts.
• The 6 contexts are:
  1) Biomechanical constraints
  2) Stability limits/verticality
  3) Anticipatory postural adjustments
  4) Postural responses
  5) Sensory orientation
  6) Stability in gait
• Total score of 108 points total, calculated in to a percentage score (0-100%). Also total sub-scores exist for each above listed system.
• Item-level scores range from 0 (severe impairment) to 3 (no impairment).
• Subjects are to be tested with flat heeled shoes, or with shoes and socks off.
  
• Subjects who must use an assistive device should be scored one category lower for that item.
• Shortened into mini-BESTest and brief BESTest.
• Training DVD available for purchase - http://bestest.us/
• Administration instructions - http://bestest.us/training/
• For additional information, please see BESTest.us

Number of Items

Equipment Required

• Stopwatch
• Measuring tape mounted on wall
• Approximately 60 cm x 60 cm block of 4 inch, medium density, Tempur® foam
• 10 degree incline ramp (at least 2 x 2 ft)
• Stair step, 15 cm (6 inches) in height
• 2 stacked shoe boxes (for 9 inch obstacle height)
• 2.5 kg (5-lb) free weight
• Firm chair with arms with 3 meters in front marked with tape
• Masking tape to mark 3 m and 6 m lengths on the floor

Time to Administer

Required Training

Age Ranges

Instrument Reviewers

Initially reviewed by Kirsten Potter, PT, DPT, MS, NCS and the MS EDGE task force of the Neurology Section of the APTA in 3/2011; Updated with the TBI population by Katie Hays, PT, DPT, and the TBI EDGE task force of the Neurology Section of the APTA in 5/2012; Updated for PD population by Cathy Harro MS, PT, NCS and the PD EDGE Task Force of Neurology Section, APTA 3/2013; Updated for the Vestibular EDGE task force of the Neurology section by Diane Wrisley PT, PhD, NCS and Elizabeth Dannenbaum MScPT 11/2013; Updated by Evan Papa DPT, PhD for the University of North Texas Health Sciences Center, DPT class of 2015. Updated by StrokEdge II Task Force: Dorian Rose, PhD, PT and Carmen Capo-Lugo, PhD, PT; May 2016. Updated by Allison Peipert in August, 2018.

ICF Domain

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

Abbreviations:

HR

R

LS / UR

Reasonable to use, but limited study in target group / Unable to Recommend

NR

Recommendations for use based on acuity level of the patient:

Acute

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

Vestibular > 6 weeks

SCI EDGE

StrokEDGE

VEDGE

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

I

II

III

IV

V

PD EDGE

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

StrokEDGE

TBI EDGE

Recommendations based on SCI AIS Classification:

AIS A/B

AIS C/D

SCI EDGE

Recommendations for use based on ambulatory status after brain injury:

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

Recommendations based on EDSS Classification:

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

Recommendations based on vestibular diagnosis:

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

Recommendations for entry-level physical therapy education and use in research:

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

PD EDGE

SCI EDGE

StrokEDGE

TBI EDGE

VEDGE

Considerations

The BESTest is suitable for assessing balance in individuals with subacute stroke across many levels of functional ability, demonstrated by the distribution of BESTest scores. The BESTest allows the clinician to tailor their intervention to specific postural control systems, due to the instrument’s ability to provide information regarding particular balance systems underlying balance impairments. The BESTest may be preferred to the BBS and Mini-BESTest for functional classification due to its slightly larger LR+. The BESTest may be more preferable than other balance scales due to its lack of floor and ceiling effects. Unknown whether or not the BESTest may be generalizable to patients with chronic stroke, cognitive impairment (Mini-Mental State Exam < 24), lesions involving the brainstem or cerebellum, aphasia, or presence of major conditions sufficient to disturb balance. Strong psychometric studies in PD population with ability to detect retrospective fallers and predict falls over 6 month period with 68% cut off score Limited evidence of its utility in directing treatment Time to complete BESTest may not be feasible in all clinical settings, but is a strong tool for more in depth diagnostic assessment of balance impairment in PD.

Balance Evaluation Systems Test translations:

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Multiple Sclerosis

Minimal Detectable Change (MDC)

Multiple Sclerosis: (Potter et al. 2018; n=21; Mean Age = 55.90 (9.60))

• Total BESTest MDC₉₅ was 9.47 points
  • Subsection MDC₉₅ values ranged from 2.25 to 4.58

  Test/Retest Reliability

  Multiple Sclerosis: (Potter et al. 2018; n=21; Mean Age = 55.90 (9.60))

  • Excellent: test-retest reliability for total BESTest score (ICC = 0.94; 95% CI =0.86 to 0.98)
    • Adequate: test-retest reliability for sensory orientation subsections (ICC=0.66; 95% CI=0.32 to 0.85)
    • Excellent: test-retest reliability for stability in gait subsections (ICC =0.93; 95% CI=0.84 to 0.97)

    Internal Consistency

    Multiple Sclerosis: (Potter et al. 2018)

    • Excellent: internal consistency for total BESTest (Chronach's Alpha =0.97)
      • Adequate internal consistency for sensory orientation subsection score (Chronach's Alpha =0.79)
      • Excellent internal consistency for stability in gait subsection score (Chronach's Alpha =0.96)

      Criterion Validity (Predictive/Concurrent)

      Concurrent Validity:

      Multiple Sclerosis (Jacobs and Kasser, 2012)

      • Excellent concurrent validity of the EDSS scores (r 2 = 0.85, P < 0.0005)
      • Adequate concurrent validity for center of pressure displacements during leaning (r 2 =0.55, P <0.005)
      • Adequate concurrent validity of step velocity during step initiation (r 2 = 0.48, P <0.01)
      • Excellent concurrent validity for center of pressure displacements during postural response tasks (r 2 = 0.76, P <0.0001)
      • Peak anticipatory postural adjustment (APA) amplitudes do not significantly correlate with BESTest total scores (r 2 = 0.17, P= 0.16)
      • Peak anticipatory postural adjustment (APA) amplitudes do not significantly correlate with BESTest sectional scores (r 2 = 0.26, P= 0.074)

      Predictive Validity:

      Multiple Sclerosis (Jacobs and Kasser, 2012)

      • High sensitivity (86%) to identify fallers
      • High specificity (95%) to identify non-fallers

      Construct Validity

      Multiple Sclerosis: (Potter et al. 2018; n=21; Mean Age = 55.90 (9.60))

      • Excellent convergent validity between total BESTest scores and subsections anticipatory/transitions (r=0.85), reactive (r=0.74), and stability in gait (r=0.90)
      • Poor to Excellent correlations between individual BESTest subsections (ranging from r=0.12 to r=0.68)
      • Poor to Adequate correlations between BESTest scores (subsections and total) with fall frequency

      Floor/Ceiling Effects

      Multiple Sclerosis: (Potter et al. 2018; n=21; Mean Age = 55.90 (9.60))

      • A ceiling effect was found for five subsections:
        • Biomechanical (38%)
        • Stability limits and Verticality (29%)
        • Reactive (24%)
        • Sensory Orientation (62%)
        • Stability in Gait (24%)

        Non-Specific Patient Population

        Minimal Detectable Change (MDC)

        When MDC values were unavailable or not reported, they were calculated using the reported reliability and standard deviation statistics.

        Community dwelling adults with and without balance dysfunction:

        (Horak et al, 2009)

        • MDC calculated from data in Horak et al, 2009= 8.9

        Cut-Off Scores

        Balance Deficits:

        (Padgett PTJ 2012 ; 1 st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history. 2 nd cohort: n = 13 with MS, mean age 50, EDSS < 6 (range 0-4.5), 7 fallers)

        • 69% cut off score differentiated fallers from nonfallers, and healthy from those with neurologic diagnoses.
        • Adequate ability to detect fallers (sensitivity = 0.86, specificity = 0.95, LR+ = 17.2, LR- = 0.46, accuracy = 92%)

        Interrater/Intrarater Reliability

        Community dwelling adults with and without balance deficits: (Horak et al, 2009)

        • Excellent interrater reliability for total score (ICC = 0.91)
        • Excellent interrater reliability for test subsections (range of ICC 0.79-0.92)
          • Biomechanical constraints (ICC = 0.80)
          • Stability limits / vertically (ICC = 0.79)
          • Anticipatory postural adjustments (ICC = 0.92)
          • Postural responses (ICC = 0.92)
          • Sensory orientation (ICC = 0.88)
          • Stability in gait (ICC = 0.91)

          (Padgett 2012: 1 st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history.)

          • Excellent inter-rater reliability ICC = 0.985 (CI 0.959-0.994)

          Internal Consistency

          Balance Deficits:

          (Padgett 2012; 1 st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history)

          • Excellent Average Cronbach’s Alpha for 5 out of 6 BESTest subsections; poor for stability limits/verticality:
          1. Biomechanical constraints = 0.830
          2. Stability limits/verticality = 0.621
          3. Anticipatory Postural adjustments = 0.874
          4. Postural responses = 0.863
          5. Sensory orientation = 0.813
          6. Stability in gait = 0.920

          Criterion Validity (Predictive/Concurrent)

          Concurrent Validity:

          Community Dwelling with and without Balance Deficits:

          (Horak et al, 2009)

          • Excellent correlation between total BESTest and Activities-specific Balance Confidence Scale (ABC) (r = 0.636, p < 0.01)
          • Adequate to excellent correlation between BESTest sub-section scores and ABC (r = 0.41-0.78)

          Construct Validity

          Community Dwelling Adults with and without Balance deficits:

          (Horak et al, 2009)

          • Subjects with balance deficits score significantly lower than healthy controls (p = 0.36)
          • Discriminated between people with different balance deficits: Poorer performance on Section V: Sensory orientation in subjects with vestibular disorders; Section IV: Postural Responses in those with PD; and Section III: Anticipatory Postural Adjustments in subjects with neuropathy

          Balance deficits:

          (Padgett 2012)

          • 1 st cohort: (n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history). BESTest scores significantly differentiated between healthy and those with balance deficits;
          • 2nd cohort: (n = 13 with MS, mean age 50, EDSS < 6 (range 0-4.5)_, 7 fallers) BESTest scores differentiated those with self-reported fall history (mean score = 77 and those without fall history (mean score = 96)

          Parkinson's Disease

          Standard Error of Measurement (SEM)

          When SEM values were unavailable or not reported, they were calculated using the reported reliability and standard deviation statistics.

          Community dwelling adults with and without balance dysfunction: (Unilateral and bilateral dysfunction, Parkinson's disease, peripheral neuropathy, total hip arthroplasty):

          (Horak et al, 2009; n = 19; age range 50-88; Session 1 n = 12, mean age = 63 (10); 5 female and 7 male; 3 Parkinsons, 2 unilateral vestibular loss, 3 bilateral vestibular loss, 1 peripheral neuropathy and total hip arthroplasty, 3 controls; Session 2 n = 11, mean age = 75 (7.6); 5 female, 6 male; 2 Parkinsons, 1 unilateral vestibular loss, 1 bilateral vestibular loss, 1 peripheral neuropathy and total hip arthroplasty, 6 controls)

          • SEM calculated from data in Horak et al, 2009= 3.21

          Parkinson's Disease:

          (Leddy et al, 2011; n = 80; mean age = 68.2 (9.3) time since diagnosis = 8.5 (0.54) years; mean MDS-UPDRS score = 72.6 (25.1); mean Hoehn and Yahr scale stage = 2.45 (0.64), separated into fallers vs. nonfallers; subset of n = 15 used for interrater reliability testing, subset of n = 24 used for test retest reliability testing)

          • SEM calculated from data in Leddy et al, 2011= 2.35

          (Leddy et al, 2011a; subset of subjects n = 24, MDS-UPDRS = 71 (21.9), disease duration mean 6.9 (3.38), 21% fallers)

          • SEM calculated from data in Leddy et al, 2011a = 5.78

          Minimal Detectable Change (MDC)

          Parkinson's Disease:

          (Leddy et al, 2011)

          • MDC calculated from data in Leddy et al, 2011= 6.5

          (Leddy et al, 2011a)

          • MDC calculated from data in Leddy et al, 2011a= 16.02

          Cut-Off Scores

          Parkinson’s disease:

          (Leddy et al, 2011)

          • 69% cut off score (sensitivity = 0.84, specificity = 0.76, LR+ = 3.49, LR- = 0.21, AUC = 0.85) to identify individual as a faller vs. nonfaller
          • Sensitivity higher for BESTest as compared to Functional Gait Assessment and Berg Balance Scale

          (Duncan RP 2013 PTJ; Comparative utility of BESTest, Mini BESTest, and Brief BESTest; n = 80 with idiopathic PD, mean age = 68.2 (9.7), mean MDS-UPDRS 41.3 (14.7), H & Y stage [1=4, 2=27, 2.5=30, 3=13, 4=6]; retrospective fallers n = 25 (31%), 6 month prospective fallers n = 14 (27.5%), 12 month prospective fallers n = 13 (32.5%))

          • 69% cut off score to detect fallers
          • Adequate for detecting retrospective fallers (sensitivity = 0.84, specificity = 0.76, LR+ = 3.49, LR- = 0.21, AUC = 0.84)
          • Adequate for predicting 6 month prospective fallers (sensitivity = 0.93, specificity = 0.84, LR+ = 5.81, LR- = 0.08, AUC = 0.89)
          • Poor for predicting 12 month prospective falls (sensitivity = 0.46, specificity = 0.74, LR+ = 1.77, LR- = 0.73, AUC = 0.68
          • 69% cut off score
          • Adequate prediction of fallers at 6 months (sensitivity = 0.93, specificity = 0.84, LR+ = 5.81, LR- = 0.08, AUC = 0.89 (CI 0.74-0.95))
          • Poor prediction of fallers at 12 months (sensitivity = 0.46, specificity = 0.74, LR+ = 1.77, LR- = 0.73, AUC = 0.68 (CI = 0.45- .83))

          Test/Retest Reliability

          Parkinson’s disease:

          (Leddy et al, 2011a)

          • Excellent test-retest reliability for total BEST score (ICC = 0.88) across the group
          • Adequate to Excellent test-retest reliability for sections of the test (ICC = 0.63-0.87 - see table below)

          Test Section

          ICC

          Rating

          Total BEST Score

          Excellent

          Section 1: Biomechanical Constraints

          Adequate

          Section 2: Stability

          Adequate

          Section 3: Anticipatory Postural Adjustments

          Excellent

          Section 4: Postural Adjustments

          Excellent

          Section 5: Sensory Orientation

          Adequate

          Section 6; Stability in Gait

          Adequate

          (Leddy et al, 2011)

          • Excellent test re-test reliability (ICC = 0.91 for PT students, 0.88 for PTs)

          Interrater/Intrarater Reliability

          Parkinson’s Disease (PD): (Leddy et al, 2011a, n = 15 people with PD; mean disease duration = 6.8 (3.26) years; MDS-UPDRS mean score = 74.2 (18.6); Hoehn and Yahr scale stage 1 = 2, stage 2 = 7, stage 2.5 = 3, stage 3 = 2, and stage 4 = 1)

          • Excellent interrater reliability total score (ICC = 0.96, 95% CI = 0.89-0.99)
          • Excellent Inter-rater reliability of subsections range from ICC= 0.79-0.96:

          Test Section

          ICC

          Rating

          Total BESTest Score

          Excellent

          Section 1 Biomechanical Constraints

          Excellent

          Section 2 Stability

          Excellent

          Section 3 Anticipatory Postural Adjustments

          Excellent

          Section 4 Postural Adjustments

          Excellent

          Section 5 Sensory Orientation

          Excellent

          Section 6 Stability in Gait

          Excellent

          Parkinson's Disease:

          (Leddy et al, 2011, subset of 15 participants)

          • Excellent inter-rater reliability ICC = 0.96

          Criterion Validity (Predictive/Concurrent)

          Parkinson’s Disease (PD):

          (Leddy et al, 2011)

          • Excellent correlation between total BESTest and ABC (r = 0.757)
          • Excellent correlation between total BESTest and Berg Balance Scale (r = 0.873)
          • Excellent correlation between total BESTest and Functional Gait Assessment (r = 0.882)

          Parkinson's Disease:

          (Leddy et al, 2011a)

          • Excellent correlation with miniBESTest (r = 0.955)

          Construct Validity

          Parkinson’s Disease:

          (Leddy et al, 2011, FGA and BEST):

          • Excellent correlation with:
            • Modified Hoehn and Yahr Scale (r = -0.736)
            • MDS-UPDRS-3 (r = -0.758)
            • MDS-UPDRS (r = -0.780)

            (Leddy et al, 2011, Utility of the mini-BEST):

            • Excellent correlation with mini-BEST (r = 0.955)
            • Statistically significant difference between BESTest scores in fallers (n = 25, mean score= 57.1% (15.4) and nonfallers (n = 55, mean score= 76.4% (13.6)

            Parkinson’s Disease:

            (Duncan 2013; Excellent correlation between BESTest and Brief BESTest r = 0.95)

            Floor/Ceiling Effects

            Parkinson's Diease:

            (Leddy et al, 2011; FGA & BESTest)

            • Excellent, lack of ceiling effect (no perfect score, only 6.4% of subjects scored in top 10%; Specificity = 0.76; Sample BesTest scores were normally distributed representing range of H&Y disease severity)
            • Excellent, no floor effects were observed with the BESTest

            Stroke

            Standard Error of Measurement (SEM)

            Subacute Stroke (Chinsongkram et al., 2014)

            SEM was not provided by this study, but was calculated.

            • Standard Deviation = 28.19
            • ICC = 0.99
            • SEM calculated from data in Chinsongkram et al., 2014 = 2.819

            Minimal Detectable Change (MDC)

            Subacute Stroke (Chinsongkram et al., 2014)

            MDC was not provided by this study, but was calculated.

            • MDC calculated from data in Chinsongkram et al., 2014= 7.81

            Cut-Off Scores

            Subacute Stroke (Chinsongkram et al., 2014)

            The following cut off scores help distinguish high functional ability from low functional ability:

            • >49% indicates those with high functional ability
            • Mini-Best > 9 indicates high functional ability
            • BBS > 19 indicates high functional ability

            Normative Data

            Subacute Stroke (Chinsongkram et al., 2014)

            Mean (SD) BESTest score for all participants = 41.7 (28.19)

            • Low Functional Ability Mean (SD) = 23.89 (18.87)
            • High Functional Ability Mean (SD) = 59.52 (24.82)

            Interrater/Intrarater Reliability

            Subacute Stroke (Chinsongkram et al., 2014)

            • Excellent interrater reliability: ICC= .99
              • Subsection ICCs = .95 - .99
              • Subsection ICCs = .87 - .98

              Criterion Validity (Predictive/Concurrent)

              Predictive Validity:

              Subacute Stroke: (Chinsongkram et al., 2014)

              • Adequate sensitivity (71.4%) in classifying high or low functional ability
              • High specificity (91.4%) in classifying high or low functional ability
              • Moderate positive likelihood ratio (LR+) (8.33) in classifying high or low functional ability
              • Moderate negative likelihood ratio (LR-) (0.31) in classifying high or low functional ability

              Construct Validity

              Subacute Stroke: (Chinsongkram et al., 2014)

              ● Excellent correlation with the BBS (r = 0.96)

              ● Excellent correlation with the PASS (r = 0.96)

              ● Excellent correlation with the CB&B (r = 0.91)

              ● Excellent correlation with the Mini-BEST (r = 0.96)

              Floor/Ceiling Effects

              Subacute Stroke: (Chinsongkram et al., 2014)

              ● Excellent, no floor effects were observed with the BESTest

              ● Excellent, no ceiling effects were observed with the BESTest

              Mixed Populations

              Standard Error of Measurement (SEM)

              When SEM values were unavailable or not reported, they were calculated using the reported reliability and standard deviation statistics.

              Community dwelling adults with and without balance dysfunction: (Unilateral and bilateral dysfunction, Parkinson's disease, peripheral neuropathy, total hip arthroplasty):

              (Horak et al, 2009; n = 19; age range 50-88; Session 1 n = 12, mean age = 63 (10); 5 female and 7 male; 3 Parkinsons, 2 unilateral vestibular loss, 3 bilateral vestibular loss, 1 peripheral neuropathy and total hip arthroplasty, 3 controls; Session 2 n = 11, mean age = 75 (7.6); 5 female, 6 male; 2 Parkinsons, 1 unilateral vestibular loss, 1 bilateral vestibular loss, 1 peripheral neuropathy and total hip arthroplasty, 6 controls)

              • SEM calculated from data in Horak et al, 2009= 3.21

              Minimal Detectable Change (MDC)

              Community dwelling adults with and without balance dysfunction: (Horak et al, 2009)

              • MDC calculated from data in Horak et al, 2009= 8.9

              Cut-Off Scores

              Balance Deficits:

              (Padgett PTJ 2012 ; 1 st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history. 2 nd cohort: n = 13 with MS, mean age 50, EDSS < 6 (range 0-4.5), 7 fallers)

              • 69% cut off score differentiated fallers from nonfallers, and healthy from those with neurologic diagnoses.
              • Adequate ability to detect fallers (sensitivity = 0.86, specificity = 0.95, LR+ = 17.2, LR- = 0.46, accuracy = 92%)

              Interrater/Intrarater Reliability

              Community dwelling adults with and without balance deficits: (Horak et al, 2009)

              • Excellent interrater reliability for total score (ICC = 0.91)
              • Excellent interrater reliability for test subsections (range of ICC 0.79-0.92)
                • Biomechanical constraints (ICC = 0.80)
                • Stability limits / vertically (ICC = 0.79)
                • Anticipatory postural adjustments (ICC = 0.92)
                • Postural responses (ICC = 0.92)
                • Sensory orientation (ICC = 0.88)
                • Stability in gait (ICC = 0.91)

                (Padgett 2012: 1 st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history.)

                • Excellent inter-rater reliability ICC = 0.985 (CI 0.959-0.994)

                Internal Consistency

                Balance Deficits:

                (Padgett 2012; 1 st cohort: n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history)

                • Excellent Average Cronbach’s Alpha for 5 out of 6 BESTest subsections; poor for stability limits/verticality:
                1. Biomechanical constraints = 0.830
                2. Stability limits/verticality = 0.621
                3. Anticipatory Postural adjustments = 0.874
                4. Postural responses = 0.863
                5. Sensory orientation = 0.813
                6. Stability in gait = 0.920

                Criterion Validity (Predictive/Concurrent)

                Concurrent Validity:

                Community Dwelling with and without Balance Deficits:

                (Horak et al, 2009)

                Excellent correlation between total BESTest and Activities-specific Balance Confidence Scale (ABC) (r = 0.636, p < 0.01)

                Adequate to excellent correlation between BESTest sub-section scores and ABC (r = 0.41-0.78)

                Construct Validity

                Community Dwelling Adults with and without Balance deficits:

                (Horak et al, 2009)

                • Subjects with balance deficits score significantly lower than healthy controls (p = 0.36)
                • Discriminated between people with different balance deficits: Poorer performance on Section V: Sensory orientation in subjects with vestibular disorders; Section IV: Postural Responses in those with PD; and Section III: Anticipatory Postural Adjustments in subjects with neuropathy

                Balance deficits:

                (Padgett 2012)

                • 1 st cohort: (n = 20 varied Dx (4 PD, 1 CVA, 4 MS, 1 PN, 1 tremor) and 9 healthy; 5 with positive fall history). BESTest scores significantly differentiated between healthy and those with balance deficits;
                • 2nd cohort: (n = 13 with MS, mean age 50, EDSS < 6 (range 0-4.5)_, 7 fallers) BESTest scores differentiated those with self-reported fall history (mean score = 77 and those without fall history (mean score = 96)

                Bibliography

                Chinsongkram, B., Chaikeeree, N., et. al. (2014). Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke. Physical Therapy 94(11), 1632-1643.

                Duncan, R. P., Leddy, A. L., et al. (2012). "Accuracy of fall prediction in Parkinson disease: six-month and 12-month prospective analyses." Parkinsons Dis 2012: 237673. Find it on PubMed

                Duncan, R. P., Leddy, A. L., et al. (2013). "Comparative utility of the BESTest, Mini-BESTest, and Brief-BESTest for predicting falls in individuals with Parkinson disease: a cohort study." Physical therapy 93(4): 542-550.

                Franchignoni, F., Horak, F., et al. (2010). "Using psychometric techniques to improve the Balance Evaluation System’s Test: the mini-BESTest." Journal of rehabilitation medicine: official journal of the UEMS European Board of Physical and Rehabilitation Medicine 42(4): 323.

                Franchignoni, F., Horak, F., et al. (2010). "Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest." J Rehabil Med 42(4): 323-331. Find it on PubMed

                Horak, F. B., Wrisley, D. M., et al. (2009). "The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits." Physical Therapy 89(5): 484-498. Find it on PubMed

                Horak, F. B., Wrisley, D. M., et al. (2009). "The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits." Phys Ther 89(5): 484-498. Find it on PubMed

                Jacobs, JV. & Kasser, SL, (2012). Balance impairment in people with multiple sclerosis: Preliminary evidence for the Balance Evaluation Systems Test.Gait & Posture 36: 414-418.

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                Padgett, P. K., Jacobs, J. V., et al. (2012). "Is the BESTest at its best? A suggested brief version based on interrater reliability, validity, internal consistency, and theoretical construct." Physical therapy 92(9): 1197-1207.

                Potter, K., Aderberg, L., Anderson, D., Bauer, B., Beste, M., Navrat, S., Kohia, M. (2018). "Reliability, validity, and responsiveness of the Balance Evaluation Systems Test (BESTest) in individuals with multiple sclerosis. Physiotherapy 104: 142-148. Find it on PubMed

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