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A letter to the editor is presented in response to the article "Structural Validity of the Mini-Balance Evaluation Systems Test (Mini-BESTest) in People with Mild to Moderate Parkinson Disease," by Sorjonen et al, published in the 2016;97 issue.

Background. The Mini-Balance Evaluation Systems Test (Mini-BESTest) is a clinical balance test comprising 14 items assumed to reflect the unidimensional construct "dynamic balance." Objective. The study objective was to examine the dimensionality of the test and the properties of each item and their interrelationships in elderly people with mild to moderate Parkinson disease (PD). Design. This was a cross-sectional study in a laboratory setting. Methods. A total of 112 participants (mean age=73 years) with idiopathic PD (Hoehn and Yahr stages 1-3) were assessed by physical therapists. Local independence among items was examined with Rasch modeling. Unidimensionality was tested by running a principal component analysis on the residuals. An exploratory factor analysis was used to examine the structure of the test, and a confirmatory factor analysis was used to evaluate the fit of the derived model. Results. The first residual component of the principal component analysis, with an eigenvalue of greater than 2, superseded the assumption of unidimensionality. After the omission of item 7 because of convergence problems, the exploratory factor analysis suggested that a 3-factor solution best fit the data. A confirmatory factor analysis demonstrated acceptable fit of the final model, although item 14 loaded poorly on its factor. Limitations. The sample size was on the lower end of what is generally recommended. Conclusions. This study could not confirm that the Mini-BESTest is unidimensional. Gait items were dispersed over all factors, indicating that they may reflect different constructs. Nonetheless, as there arguably is no clinical balance test superior to the Mini-BESTest today, we recommend using the total score for assessing gross balance in this population and individual items to identify specific weaknesses. Moreover, dual tasks should be assessed separately because they are an important aspect of balance control in people with PD, reflected in only one item of the test. [ABSTRACT FROM AUTHOR]

Background. Body-worn, inertial sensors can provide many objective measures of balance and gait. However, the objective measures that best reflect patient perception of mobility disability and clinician assessment of Parkinson disease (PD) are unknown. Objective. The purposes of this study were: (1) to determine which objective measures of balance and gait are most related to patient perception of mobility' disability and disease severity' in people with PD and (2) to examine the effect of levodopa therapy on these correlates. Design. This was an experimental correlation study. Methods. One hundred four people with idiopathic PD performed 3 trials of the Instrumented Stand and Walk Test (ISAW) in the "on" and "off" medication states. The ISAW consists of quiet standing (30 seconds), gait initiation, straight walking (7 m), and turning (180°), yielding 34 objective measures of mobility from body-worn inertial sensors. Patient perception of mobility disability was assessed with the Activities-specific Balance Confidence (ABC) scale and the mobility subscale of the Parkinson's Disease Questionnaire (PDQ-39). Disease severity was assessed with the Unified Parkinson's Disease Rating Scale, part III (motor UPDRS). Spearman correlations were used to relate objective measures of mobility to patient perception and disease severity. Results. Turning speed, gait speed, and stride length were most highly correlated to severity of disease and patient perception of mobility disability. The objective measures of mobility in the off-medication state were more indicative of patient perception of mobility disability and balance confidence compared with on-medication state measures. Limitations. Causation is an inherent problem of correlation studies. Conclusion. Physical therapists should evaluate mobility in people with PD in the off-medication state because the off-medication state is more related to disease severity and patient perception of mobility disability than the on-medication state mobility. Assessment and treatment of mobility in people with PD should target specific measures (ie, turning, gait speed, and stride length) because these measures best reflect patients' quality of life and balance confidence. [ABSTRACT FROM AUTHOR]

Background. The reliability and convergent validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke have been established, but its responsiveness to rehabilitation has not been examined. Objective. The study objective was to compare the responsiveness of the BESTest with those of other clinical balance tools in people with subacute stroke. Design. This was a prospective cohort study. Methods. Forty-nine people with subacute stroke (mean age = 57.8 years, SD = 11.8) participated in this study. Five balance measures--the BESTest, the Mini-BESTest, the Berg Balance Scale, the Postural Assessment Scale for Stroke Patients, and the Community Balance and Mobility Scale (CB&M)--were used to measure balance performance before and after rehabilitation or before discharge from the hospital, whichever came first. The internal responsiveness of each balance measure was classified with the standardized response mean (SRM); changes in Berg Balance Scale scores of greater than 7 were used as the external standard for determining the external responsiveness. Analysis of the receiver operating characteristic curve was used to determine the accuracy and cutoff scores for identifying participants with balance improvement. Results. Participants received 13.7 days (SD=93, range = 5-44) of physical therapy rehabilitation. The internal responsiveness of all balance measures, except for the CB&M, was high (SRM=0.9-1.2). The BESTest had a higher SRM than the Mini-BESTest and the CB&M, indicating that the BESTest was more sensitive for detecting balance changes than the Mini-BESTest and the CB&M. In addition, compared with other balance measures, the BESTest had no floor, ceiling, or responsive ceiling effects. The results also indicated that the percentage of participants with no change in scores after rehabilitation was smaller with the BESTest than with the Mini-BESTest and the CB&M. With regard to the external responsiveness, the BESTest had higher accuracy, sensitivity, specificity, and posttest accuracy than the Postural Assessment Scale for Stroke Patients and the CB&M for identifying participants with balance improvement. Changes in BESTest scores of 10% or more indicated changes in balance performance. Limitations. A limitation of this study was the difference in the time periods between the first and the second assessments across participants. Conclusions. The BESTest was the most sensitive scale for assessing balance recovery in participants with subacute stroke because of its high internal and external responsiveness and lack of floor and ceiling effects. [ABSTRACT FROM AUTHOR]

Background. The Berg Balance Scale (BBS) is a balance measure commonly used for people with multiple sclerosis (MS). The Mini-BESTest is an alternative based on balance systems. Objective. The study objective was to compare the BBS and the Mini-BESTest for sensitivity to change, likelihood ratios for walking aid use and falls, and associations with clinical variables in people who have MS and are ambulatory. Design. This was a cohort study with measurements before and after exposure to 8 weeks of routine physical therapy intervention. Methods. For 52 participants who had a primary diagnosis of MS and who were indepen- dently mobile, with or without an aid, demographic details and a history of falls and near falls were collected. Participants completed the Mini-BESTest, Multiple Sclerosis Impact Scale-29, Multiple Sclerosis Walking Scale-12, BBS, Modified Fatigue Impact Scale, and Six-Minute Walk Test. Results. No participant started with a baseline Mini-BESTest maximum score of 28, whereas 38.5% (n20) started with a baseline BBS maximum score of 56. Statistically significant changes in the Mini-BESTest score (X=5.31, SD3.5) and the BBS score (X=1.4, SD1.9) were demonstrated. Effect sizes for the Mini-BESTest and the BBS were 0.70 and 0.37, respectively; standard response means for the Mini-BESTest and the BBS were 1.52 and 0.74, respectively. Areas under the receiver operating characteristic curves for the Mini-BESTest and the BBS were 0.88 and 0.77, respectively, for detecting mobility device use and 0.88 and 0.75, respectively, for detecting self-reported near falls. The Mini-BESTest had a higher correlation for each secondary measure than did the BBS. Limitations. This study involved a sample of convenience; 61% of the participants did not use a walking aid. The order of testing was not randomized, and fall status was obtained through retrospective recall. Conclusions. The Mini-BESTest had a lower ceiling effect and higher values on responsiveness tests. These findings suggest that the Mini-BESTest may be better at detecting changes in balance in people who have MS, are ambulatory, and have relatively little walking disability. [ABSTRACT FROM AUTHOR]

Background. The correct identification of patients with Parkinson disease (PD) at risk for falling is important to initiate appropriate treatment early. Objective. This study compared the Fullerton Advanced Balance (FAB) scale with the Mini-Balance Evaluation Systems Test (Mini-BESTest) and Berg Balance Scale (BBS) to identify individuals with PD at risk for falls and to analyze which of the items of the scales best predict future falls. Design. This was a prospective study to assess predictive criterion-related validity. Setting. The study was conducted at a university hospital in an urban community. Patients. Eighty-five patients with idiopathic PD (Hoehn and Yahr stages: 1- 4) participated in the study. Measurements. Measures were number of falls (assessed prospectively over 6 months), FAB scale, Mini-BESTest, BBS, and Unified Parkinson's Disease Rating Scale. Results. The FAB scale, Mini-BESTest, and BBS showed similar accuracy to predict future falls, with values for area under the curve (AUC) of the receiver operating characteristic (ROC) curve of 0.68, 0.65, and 0.69, respectively. A model combining the items "tandem stance," "rise to toes," "one-leg stance," "compensatory stepping backward," "turning," and "placing alternate foot on stool" had an AUC of 0.84 of the ROC curve. Limitations. There was a dropout rate of 19/85 participants. Conclusions. The FAB scale, Mini-BESTest, and BBS provide moderate capacity to predict "fallers" (people with one or more falls) from "nonfallers." Only some items of the 3 scales contribute to the detection of future falls. Clinicians should particularly focus on the item "tandem stance" along with the items "one-leg stance," "rise to toes," "compensatory stepping backward," "turning 360°," and "placing foot on stool" when analyzing postural control deficits related to fall risk. Future research should analyze whether balance training including the aforementioned items is effective in reducing fall risk. [ABSTRACT FROM AUTHOR]

Background. The Balance Evaluation Systems Test (BESTest) is a relatively new balance assessment tool. Recently, the Mini-BESTest and the Brief-BESTest, which are shortened versions of the BESTest, were developed. Objective. The purpose of this study was to estimate interrater and intrarater-interoccasion reliability, internal consistency, concurrent and convergent validity, and floor and ceiling effects of the 3 BESTests and other related measures, namely, the Berg Balance Scale (BBS), Functional Gait Assessment (FGA), and Activities-specific Balance Confidence (ABC) Scale, among patients with total knee arthroplasty (TKA). Design. This was an observational measurement study. Methods. To establish interrater reliability, the 3 BESTests were administered by 3 independent raters to 25 participants with TKA. Intrarater-interoccasion reliability was evaluated in 46 participants with TKA (including the 25 individuals who participated in the interrater reliability experiments) by repeating the 3 BESTests, BBS, and FGA within 1 week by the same rater. Internal consistency of each test also was assessed with Cronbach alpha. Validity was assessed in another 46 patients with TKA by correlating the 3 BESTests with BBS, FGA, and ABC. The floor and ceiling effects also were examined. Results. The 3 BESTests demonstrated excellent interrater reliability (intraclass correlation coefficient [ICC] [2,1] = .96-.99), intrarater-interoccasion reliability (ICC [2,1] = .92-.96), and internal consistency (Cronbach alpha =.96-.98). These values were comparable to those for the BBS and FGA. The 3 BESTests also showed moderate-to-strong correlations with the BBS, FGA, and ABC (r=.35-81), thus demonstrating good concurrent and convergent validity. No significant floor and ceiling effects were observed, except for the BBS. Limitations. The results are generalizable only to patients with TKA due to end-stage knee osteoarthritis. Conclusions. The 3 BESTests have good reliability and validity for evaluating balance in people with TKA. The Brief-BESTest is the least time-consuming and may be more useful clinically. [ABSTRACT FROM AUTHOR]

BACKGROUND: The Balance Evaluation Systems Test (BESTest) is a new clinical balance assessment tool, but it has never been validated in patients with subacute stroke. OBJECTIVE: The purpose of this study was to examine the reliability and validity of the BESTest in patients with subacute stroke. DESIGN: This was an observational reliability and validity study. METHODS: Twelve patients participated in the interrater and intrarater reliability study. Convergent validity was investigated in 70 patients using the Berg Balance Scale (BBS), Postural Assessment Scale for Stroke (PASS), Community Balance and Mobility Scale (CB&M), and Mini-BESTest. The receiver operating characteristic curve was used to calculate the sensitivity, specificity, and accuracy of the BESTest, Mini-BESTest, and BBS in classifying participants into low functional ability (LFA) and high functional ability (HFA) groups based on Fugl-Meyer Assessment motor subscale scores. RESULTS: The BESTest showed excellent intrarater reliability and interrater reliability (intraclass correlation coefficient=.99) and was highly correlated with the BBS (Spearman r=.96), PASS (r=.96), CB&M (r=.91), and Mini-BESTest (r=.96), indicating excellent convergent validity. No floor or ceiling effects were observed with the BESTest. In contrast, the Mini-BESTest and CB&M had a floor effect in the LFA group, and the BBS and PASS demonstrated responsive ceiling effects in the HFA group. In addition, the BESTest showed high accuracy as the BBS and Mini-BESTest in separating participants into HFA and LFA groups. LIMITATION: Whether the results are generalizable to patients with chronic stroke is unknown. CONCLUSION: The BESTest is reliable, valid, sensitive, and specific in assessing balance in people with subacute stroke across all levels of functional disability. [ABSTRACT FROM AUTHOR]