Reliability and validity of the Balance Evaluation Systems Test (BESTest) in people with subacute stroke

Abstract

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.

© 2014 American Physical Therapy Association.

Figures

Figure 1

Relationships between the total scores of the Balance Evaluation System Test (BESTest) and scores from other clinical balance scales: Mini-Balance Evaluation System Test (Mini-BESTest), Berg Balance Scale (BBS), Postural Assessment Scale for Stroke Patients (PASS), and Community Balance and Mobility Scale (CB&M). High concurrent validity of the BESTest with other clinical scales of balance was found, as well as ceiling effects for the BBS and PASS and a floor effect for the CB&M.

Figure 2

Distribution of all participants' scores from the Balance Evaluation System Test (BESTest), Mini-Balance Evaluation System Test (Mini-BESTest), Berg Balance Scale (BBS), Postural Assessment Scale for Stroke Patients (PASS), and Community Balance and Mobility Scale (CB&M) across levels of functional ability as determined with the Fugl-Meyer Stroke Assessment–motor subscale (FM-motor). The figure shows that the FM-motor cannot predict balance function, except at lowest and highest levels. Ceiling and floor effects were found for last 2 tests.

Figure 3

Receiver operating characteristic curve plots of the Balance Evaluation System Test (BESTest), Mini-Balance Evaluation System Test (Mini-BESTest), and Berg Balance Scale (BBS) for classifying patients with subacute stroke in the low and high functional ability groups. Arrow indicates the cutoff point for group classification.