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Purpose: The Pediatric Balance Scale (PBS), a modification of Berg’s Balance Scale, was developed as a balance
measure for school-age children with mild to moderate motor impairments. The purpose of this study was to
determine the test-retest and interrater reliability of the PBS. Methods: To determine test-retest reliability, 20
children (aged five to 15 years) with known balance impairments were tested by one examiner on the PBS. Ten
pediatric 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 different
physical therapists was found on the PBS for total test score (ICC 3,1 ⫽ 0.997). Conclusion: The PBS has been
demonstrated to have good test-retest and interrater reliability when used with school-age children with mild
to 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
TABLE 1.
The Berg Balance Scale and the Pediatric Balance Scale
to comprehend and comply with test instructions in the minutes, and was designed to put the child at ease, allow-
standardized manner necessary for determining the reli- ing the examiner to develop effective communication strat-
ability of a tool. egies with the child. The child’s parent(s) and the referring
therapist(s) were invited to attend the test sessions.
Procedure
Test-retest reliability. The PBS was administered to
all 20 participants following the criteria set forth in Appen- Interrater Reliability
dix 1. The same physical therapist (M.R.F.) tested all chil- Interrater reliability of the PBS for total test score was
dren at both test sessions. She was responsible for direct determined by using the videotapes created during the test
interaction with the child, administration of the test, scor- and retest data collection. Item 14, “forward reach,” was
ing of the test, and ensuring the child’s safety during test- omitted from videotape analysis because a two-dimen-
ing. An assistant was responsible for videotaping. Each sional videotape does not adequately record test perfor-
item was scored on the criterion-based 0 to 4 scale. Only mance.13 To ensure a range of performance scores, video-
one practice trial per item was allowed. Verbal, visual, and taped test sessions were subdivided into three categories:
physical cues were provided to ensure the child under-
TTS ⬍20, TTS ⱖ20 and ⬍40, and TTS ⱖ40. Three to four
stood the requested task. If a child successfully completed
videotapes were randomly selected from the tapes in each
the task (ie, scored a four on the first trial), additional trials
category. Ten pediatric physical therapists with a mini-
were not administered. It took approximately 15 minutes
mum of two years of clinical experience participated in the
to administer and score the PBS.
interrater reliability phase of this study. All therapists were
A variety of test sites within the community were uti-
lized in this study, including the child’s home, school, and volunteers and were recruited from the local therapeutic
private physical therapy clinic. For each child, the location community. Their level of pediatric clinical experience var-
of the test site for test one and two were the same. Selection ied, ranging from two to 25 years (mean experience 9.4
of the test site was determined according to child, caretaker years). All participating therapists were involved in pedi-
or clinician convenience. atric clinical practice, although their practice setting var-
All children who participated in the study were sched- ied: school-based, five therapists; outpatient hospital
uled for two test sessions that occurred within 14 days. based, three therapists; outpatient private practice, two
Whenever possible, the day of the week and time of day therapists. Each therapist participated in a single, 45-
were kept consistent. Scheduling of the test session was at minute training session on scoring of the PBS before scor-
the convenience of the child, their parent(s) or legal guard- ing of the videotapes. The 10 therapists independently
ian(s), and/or the facility. Before each test session, a brief viewed and scored the 10 videotaped test sessions within
introductory period occurred. This period did not exceed 5 one week of their training session.
DISCUSSION
Analysis of Interrater Reliability
Preliminary testing of the PBS reveals very high test-
A single-factor repeated-measure analysis of variance retest and interrater reliability for children five to 15 years of
(alpha ⫽ 0.05) and an ICC(3,1) were used to evaluate age with mild to moderate motor impairments. The PBS may
interrater reliability of total test score (exclusive of item therefore provide clinicians with an additional, reliable means
14) on the PBS. of assessing a child’s balance. The PBS also affords clinicians a
standardized protocol for test administration and scoring.
RESULTS Our preliminary work does not specifically address the valid-
Test-Retest Reliability ity of the PBS as a pediatric balance measure, nor does it
provide normative information. Clinical observations sup-
The age, gender, diagnosis, and frequency of physical
port the content (face) validity of the PBS, because items con-
therapy services as well as time between initial test and
tained within are routinely performed by children throughout
follow-up test are presented in Table 2 for all 20 children
the day and are frequently examined by pediatric physical
who participated in this study. The distribution of the TTS
therapist as a component of assessment. Examples of such
for test and retest data is also shown in Table 2. Individual
tasks include the following: item 1, sit to stand; item 2, stand
TTS scores ranged from 5 to 52. The maximal possible TTS
to sit; item 10, turning around; item 11, turning to look be-
for the PBS is 56. There was no significant difference be-
hind; and item 12, picking an object up from the floor (see the
tween total test and retest scores on the PBS (p ⫽ 0.2733,
Appendix and Table 1).
Wilcoxon Matched Pairs Signed Ranks Test). The test-re-
The PBS incorporates a 0 to 4 grading scale to assess
test reliability for individual items is presented in Table 3.
performance. The scoring criterion within an item incor-
k ranged from 0.87 to 1.0. The Spearman Signed Ranked
porates qualitative and quantitative measures that allow for
Correlation, r, ranged from 0.89 to 1.0 for individual items.
Test-retest reliability was extremely high [ICC(3,1) ⫽
0.998]. TABLE 4.
Median, mode and range of TTS on PBS for 10 subjects evaluated by 10
Interrater Reliability pediatric physical therapists
Ten pediatric physical therapists with varied clinical Subjects Median Mode Range
background, including years of experience and practice 1 5 5 1
setting, independently viewed and scored the videotaped 2 12 12 0
performance of 10 children. The median, mode, and range 3 12 12 0
4 27 27 0
of TTS on the PBS for each of the videotaped subjects are 5 11 11 0
presented in Table 4. The total test scores of the subjects 6 31 31 1
examined by the 10 therapists ranged from five to 49 with 7 49 49 2
only a zero-to-two point difference in the total test scores 8 45 45 1
for each subject. There was no significant difference among 9 40 40 1
10 43 43 0
ratings by different physical therapists on PBS TTS (F ⫽
normal variability in performance. This aspect of the grad- change? Is it capable of documenting skill progression or
ing scale is extremely important, in that variability is a regression over time? Do the criteria used in the grading
hallmark of typical motor development. PBS item 8, scale reflect different levels of motor proficiency? Are the
“standing one foot in front” (see Appendix) illustrates the scale increments (zero to four) reflective of an overall
use of qualitative measures, quantitative measures and change in function? Ongoing investigation with the PBS
variability within the scoring criteria of a single item. This includes collection of normative data on children who are
item examines a child’s ability to assume and maintain a typically developing. Preliminary results suggest that chil-
tandem posture. To obtain the maximal score of four the dren who are typically developing by the age of seven years
child must be able to independently assume a tandem foot can successfully complete all items within the PBS, obtain-
placement position and maintain it for 30 seconds. A lesser ing the maximal score of 56. Additionally, three subjects
score is earned if the child requires assistance to step, can have been tested using the PBS for a period of two years in
maintain a stride stance, but not tandem stance, or main- conjunction with their ongoing clinical intervention pro-
tains the tandem posture for ⬍30 seconds. grams. Trends in their data suggest that the PBS may be
Extreme care was taken during the modification pro- sensitive to changes in a child’s functional balance abilities
cess of the BBS to ensure that the intent of the task was not over time. It is hoped that the PBS can be used clinically to
altered. The reduction in time parameters for static stance screen for functional balance deficits, identify a need for
in BBS items 2, 3, and 7 was necessary to ensure the mea- physical therapy intervention, and to monitor progress
sure of elements of postural control vs attention span. The within a therapeutic program.
reduction to 30 seconds may limit the ability of this tool to
assess the underlying element of muscle strength/postural CONCLUSION
stability as a component of functional balance. The time
Preliminary data supports the use of the PBS as a reli-
parameter of 30 seconds was chosen based in part upon
able measure of functional balance for use with the school-
clinical observation during pilot testing of the BBS and
age child with mild to moderate motor impairment. It is
current clinical research in the area of pediatric balance.1,4
quick to administer and is easily scored. Total test admin-
Care was taken to limit the effects of learning during
istration and scoring time is ⬍15 minutes. The PBS does
the test-retest phase of this study. Verbal, visual, and tactile
not require the use of specialized equipment. It provides
feedback, for each item, was provided during test session
clinicians with a standardized format for measurement of
one and two during the practice trial only. Qualitative per-
functional balance tasks which are routine components of
formance feedback, positive or negative, was not provided
physical therapy examination for the school-age child with
during test administration and/or scoring. Additional feed-
mild to moderate motor impairments.
back relative to individual item(s) or overall task perfor-
mance was also not provided. At the conclusion of each test
the child received a small toy of their choice as a thank you ACKNOWLEDGMENTS
for participating. The test and retest session were sched- The authors thank the children, their families, and the
uled at least seven days apart and no longer than 14 days to community clinicians who participated in this study. The
minimize the effects of leaning, retention, and develop- authors acknowledge and thank Sharon L. Held, MS, PT,
mental-based changes. PCS, Kim Kobes, PT, and Jeff Lach, PT, for their contribu-
The PBS has limitations. For example, the PBS does tions to this study. A special thank you is extended to
not examine a child’s ability to reach overhead. If one con- Katherine Carey Carney, Theresa Kolodziej, Deborah Sc-
siders the strategies that children use as they interact with heider, and Jane Montgomery for their assistance and
their environment, we have observed that items which are support.
out of reach are frequently overhead. Additionally, the PBS This study is dedicated in loving memory of Gregory
does not examine issues associated with balance during James Heiser (November 9, 1988 to August 23, 1996).
locomotion. Inclusion of such items in the PBS would re- Sleep well my little angel.
quire further investigation.
Several questions remain with respect to the validity REFERENCES
of the PBS. Does the TTS have meaning, and if so, what 1. Woollacott MH, ed. Development of Posture and Gait Across the Life
does it mean? Do age, height, weight, or gender influence Span, 2nd ed. Columbia, SC: University of South Carolina Press;
test performance? Is the PBS sensitive to functional 1989.