Balance tests in healthy older people Reliability, validity and ability to identify fall status of the BESTest, Mini-BESTest and Brief-BESTest in older people living in the community

Prévia do material em texto

Accepted Manuscript
Balance tests in healthy older people Reliability, validity and ability to identify fall
status of the BESTest, Mini-BESTest and Brief-BESTest in older people living in the
community
Alda Marques, PhD, Sara Almeida, MSc, Joana Carvalho, MSc, Joana Cruz, PhD,
Ana Oliveira, MSc, Cristina Jácome, PhD
PII: S0003-9993(16)30380-X
DOI: 10.1016/j.apmr.2016.07.011
Reference: YAPMR 56621
To appear in: ARCHIVES OF PHYSICAL MEDICINE AND REHABILITATION
Received Date: 28 April 2016
Revised Date: 20 June 2016
Accepted Date: 1 July 2016
Please cite this article as: Marques A, Almeida S, Carvalho J, Cruz J, Oliveira A, Jácome C, Balance
tests in healthy older people Reliability, validity and ability to identify fall status of the BESTest, Mini-
BESTest and Brief-BESTest in older people living in the community, ARCHIVES OF PHYSICAL
MEDICINE AND REHABILITATION (2016), doi: 10.1016/j.apmr.2016.07.011.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to
our customers we are providing this early version of the manuscript. The manuscript will undergo
copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please
note that during the production process errors may be discovered which could affect the content, and all
legal disclaimers that apply to the journal pertain.
http://dx.doi.org/10.1016/j.apmr.2016.07.011
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Balance tests in healthy older people 
 
Reliability, validity and ability to identify fall status of the BESTest, Mini-
BESTest and Brief-BESTest in older people living in the community 
Alda Marques PhD 1,2, Sara Almeida MSc 1, Joana Carvalho MSc 1, Joana Cruz 
PhD 1,2, Ana Oliveira MSc 1,2, Cristina Jácome PhD 1 
 
1 Lab 3R – Respiratory Research and Rehabilitation Laboratory, School of 
Health Sciences, University of Aveiro (ESSUA), Aveiro, Portugal 
2 Institute for Research in Biomedicine (iBiMED), University of Aveiro, Aveiro, 
Portugal 
 
Acknowledgements: The authors would like to acknowledge the individuals who 
participated in this study. 
 
Funding support: This work was also partially supported by FEDER through 
COMPETE and FCT under project UID/BIM/04501/2013 and by National Funds 
through FCT, in the context of the projects UID/CEC/00127/2013 and 
Incentivo/EEI/UI0127/2014. 
Conflicts of interest: none. 
 
Corresponding author: Alda Marques, PT, MSc, PhD, Senior Lecturer, Lab 3R – 
Respiratory Research and Rehabilitation Laboratory, School of Health 
Sciences, University of Aveiro (ESSUA), Agras do Crasto - Campus 
Universitário de Santiago, Edifício 30, 3810-193 Aveiro, Portugal. Telephone 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
number: 00351 234 372 462. Fax number: 00351 234 401 597. Email: 
amarques@ua.pt 
 
 
 
 
 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
1 
 
Reliability, validity and ability to identify fall status of the BESTest, Mini-1 
BESTest and Brief-BESTest in older people living in the community 2 
 3 
Abstract 4 
Objective: The reliability, validity and ability to identify fall status of the Balance 5 
Evaluation Systems Test (BESTest), Mini-BESTest and Brief-BESTest with the Berg 6 
Balance Scale (BBS) in older people living in the community was assessed. 7 
Design: Cross-sectional. 8 
Setting: Community centers. 9 
Participants: 122 older adults (76±9 years) participated. 10 
Interventions: Not applicable. 11 
Main Outcome Measures: Participants reported on falls history in the preceding 12 
year and completed the Activities-specific Balance Confidence (ABC) Scale. BBS, 13 
BESTest and the Five times sit-to-stand test were administered. Interrater (two 14 
physiotherapists) and test-retest relative (48-72h) and absolute reliability were 15 
explored with the Intraclass correlation coefficient (ICC) equation (2,1) and the Bland 16 
and Altman method. Minimal detectable changes at the 95% confidence level 17 
(MDC95) were established. Validity was assessed by correlating the balance tests 18 
with each other and with the ABC Scale (Spearman correlation coefficients - rho). 19 
Receiver operating characteristics assessed the ability of each balance test to 20 
differentiate between people with and without a history of falls. 21 
Results: All balance tests presented good to excellent interrater (ICC 0.71-0.93) and 22 
test-retest (ICC 0.50-0.82) relative reliability, with no evidence of bias. MDC95 values 23 
were 4.6, 9, 3.8 and 4.1 points for the BBS, BESTest, Mini-BESTest and Brief-24 
BESTest, respectively. All tests were significantly correlated with each other 25 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
2 
 
(rho=0.83-0.96) and with the ABC Scale (rho=0.46-0.61). Acceptable ability to 26 
identify fall status (areas under the curve 0.71-0.78) was found for all tests. Cut-off 27 
points were 48.5, 82, 19.5 and 12.5 points for BBS, BESTest, Mini-BESTest and 28 
Brief-BESTest, respectively. 29 
Conclusions: All balance tests are reliable, valid and able to identify fall status in 30 
older people living in the community therefore, the choice of which test to use will 31 
depend on the level of balance impairment, purpose and time availability. 32 
 33 
Key-words: Postural Balance; geriatric assessment; risk assessment; ROC curve. 34 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
3 
 
List of abbreviations 35 
ABC Activities-specific Balance Confidence Scale 
AUC Area under the curve 
BBS Berg Balance Scale 
BESTest Balance Evaluation Systems Test 
COSMIN COnsensus‐based Standards for the selection of health 
Measurement INstruments 
GRRAS Guidelines for reliability and agreement studies 
ICC Intraclass correlation coefficient 
MDC Minimal detectable changes 
rho Spearman correlation coefficients 
SEM Standard error of measurement 
STROBE STrengthening the Reporting of OBservational studies in 
Epidemiology 
 36 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
4 
 
Falls are a major public health problem.1 About a third of community-living older 37 
people fall each year.2 For older people living in the community, the human cost of 38 
falling includes distress, pain, injury, loss of confidence, and ultimately loss of 39 
independence and mortality.3 Therefore, falling has an enormous impact on quality of 40 
life and health of community-living older people. Fall prevention programs are 41 
currently a worldwide priority1 and to develop such programs it is essential to tackle 42 
modifiable fall risk factors. Balance impairment is one of the major modifiable risk 43 
factor for falls.4 44 
 45 
Several clinical balance tests are directed at screening for balance impairments and 46 
predicting falls. One of the most commonly used tool in clinical situations is the Berg 47 
Balance Scale (BBS), which has shown to be reliable, valid,5,6 sensitive and specific 48 
in predicting falls in community-based older populations.7 Despite being well-studied, 49 
this scale has considerable ceiling effect in various populations,5,8-10 namely in older 50 
people living in the community who often represent a population with a higher level of 51 
functioning, transmitting the idea that no balance impairment is present, when in fact 52 
specific balance training is often warrant. 53 
 54 
Development of balance tests able to identify the underlying systems responsible for 55 
balance deficits are critical for health professionals to diagnose specific impairments 56 
and develop individualized treatment plans in community-living older people.11 The 57 
Balance Evaluation Systems Test (BESTest) was developed to assess functioning of 58 
six balance control systems.12 This test has been widely used13-17 however, its 59 
administration takes a considerable amount of time (20-30 minutes), which may not 60 
be feasible and practicalfor routine clinical use. Thus, two abbreviated versions of 61 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
5 
 
the BESTest, i.e., Mini-BESTest and Brief-BESTest, which take approximately half of 62 
the time to be administrated (10-15 minutes), have been developed.18,19 The 63 
measurement properties of BESTest,12,13 Mini-BESTest20,21 and Brief-BESTest19 64 
have been explored in people with balance disorders and with specific conditions 65 
(e.g., Parkinson disease, chronic stoke), however little is known in healthy older 66 
people. Recently, construct validity and discriminative ability for older people living in 67 
the community have been explored for the BESTest, Mini-BESTest and Brief-68 
BESTest22 however, a comparison with BBS was not performed and reliability and 69 
cut-offs to differentiate between fallers and non-fallers were not established. 70 
 71 
Therefore, this study aimed to compare the reliability, validity and the ability to 72 
identify fall status of the BESTest, the Mini-BESTest and the Brief-BESTest with the 73 
BBS in older people living in the community. We hypothesized that all four balance 74 
tests will be i) moderately reliable, ii) highly correlated with each other and with self-75 
reported balance confidence and iii) able to differentiate between fallers and non-76 
fallers. Our secondary aims were to determine the minimal detectable change and 77 
propose cut-offs to differentiate between fallers and non-fallers for the same balance 78 
tests. 79 
 80 
Methods 81 
 82 
 83 
Study design and ethics 84 
A cross-sectional study was conducted from November 2014 to February 2015 in the 85 
central region of Portugal. Ethical approval was obtained from the Ethics Committee 86 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
6 
 
(238/10-2014). This study is reported following the COnsensus‐based Standards for 87 
the selection of health Measurement INstruments (COSMIN),23 the STROBE 88 
(STrengthening the Reporting of OBservational studies in Epidemiology) statement24 89 
and the guidelines for reliability and agreement studies (GRRAS).25 90 
 91 
Participants 92 
Fifteen community centers, which main purpose is to promote physical activity and 93 
active cognitive functioning of older adults were contacted. Nine agreed to 94 
participate, i.e., 2 community activity “clubs”, offering exercises classes, and 7 day 95 
care centers, offering a range of recreational, cultural, educational, health and social 96 
support services. Staff from the community-centers identified eligible participants 97 
according to the following criteria: (i) aged 60 years or older; (ii) living independently 98 
in the community and iii) able to ambulate with or without a walking aid (but without 99 
the assistance of another person). Individuals were excluded if they i) had 100 
comorbidities that interfered with independent ambulation (e.g., hip fracture, lower 101 
limb amputation and hemiplegia); ii) were taking medication that could cause 102 
dizziness or affect their balance (e.g., psychotropic medications); iii) had self-103 
reported cardiorespiratory diseases (e.g., chronic obstructive pulmonary disease, 104 
heart failure) or neurological (e.g., Parkinson disease, multiple sclerosis, dementia), 105 
musculoskeletal (e.g., severe osteoarthritis) or psychiatric impairments (e.g., 106 
psychosis, schizophrenia), that could interfere with the measurements. Individuals 107 
were contacted by the researchers, who explained the purpose of the study and 108 
asked about their willingness to participate. When individuals agreed to participate, 109 
an appointment with the researchers was scheduled at their institution. Written 110 
informed consent was obtained prior to data collection. 111 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
7 
 
 112 
Data collection procedures 113 
Socio-demographic (age and gender), anthropometric (height, weight, body mass 114 
index) and clinical (self-reported medication and common age-related comorbidities - 115 
e.g., hypertension and hyperlipidemia) data were collected. Individuals were provided 116 
with a clear definition of falls (an event when you find yourself unintentionally on the 117 
ground, floor or lower level)26 and required to report their history of falls using two 118 
standardized questions (1. “Have you had any falls in the last 12 months?” and, if 119 
yes, 2.“How many times did you fall down in the last 12 months?”).27 The self-120 
reported Activities-Specific Balance Confidence (ABC) scale was used to assess 121 
balance confidence.28 The ABC Scale quantifies an individual’s perceived ability to 122 
maintain his/her balance under different circumstances, using a scale of 0% (no 123 
confidence) to 100% (total confidence).29 Then, the BBS, the BESTest and the Five 124 
times sit-to-stand test (FTSTS) were performed and participants were encouraged to 125 
rest, as needed. Two trained physiotherapists, collected the data. 126 
 127 
For interrater reliability, each of the two physiotherapists performed a simultaneous 128 
independent balance assessment at baseline.30,31 For each item of the BBS and of 129 
BESTest, one physiotherapist read the instructions to the participant while the other 130 
physiotherapist performed the task. Then, the participant performed the task with 131 
close supervision. Each task was scored immediately after completion by the two 132 
physiotherapists and scoring was not discussed. For test-retest reliability, participants 133 
were reassessed by 1 of the 2 physiotherapists after a 48−72h interval. The order of 134 
testing was the same. 135 
 136 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
8 
 
The Mini-BESTest and Brief-BESTest scores were computed based on the 137 
performance of the BESTest tasks. A custom designed worksheet was used by the 138 
physiotherapists to simultaneously record the BESTest and the Mini-BESTest item 139 
scores. Brief-BESTest scores were extracted from the relevant subset of BESTest 140 
items. 141 
 142 
Tests 143 
Berg Balance scale. The BBS is composed of 14 items to assess performance of 144 
specific functional tasks. Each item is scored from 0 (unable to perform) to 4 (normal 145 
performance) and the maximum score is 56 points. BBS has been shown to have 146 
high interrater and test-retest reliability in personal care home residents32 and in 147 
patients with Parkinson disease and stroke.13,33,34 148 
 149 
BESTest. The BESTest contains 36 items organized into 6 subsections: 150 
biomechanical constraints, stability limits and verticality, anticipatory postural 151 
adjustments, postural responses to external perturbations, sensory orientation during 152 
stance and stability in gait.12 Each item is scored from 0 (severe balance impairment) 153 
to 3 (no balance impairment) and the maximum possible total score is 108 points. 154 
BESTest has high interrater reliability (ICC=0.91-0.99) and test-retest reliability 155 
(ICC=0.80-0.99) in subjects with and without balance disorders, in patients with 156 
Parkinson disease and in older cancer survivors.12,13,16 Moreover, the BESTest has 157 
been found to be accurate in identifying future recurrent fallers in patients with 158 
Parkinson disease.35 159 
 160 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
9 
 
Mini-BESTest. The Mini-BESTest includes 14 items from sections of the BESTest 161 
related to anticipatory postural adjustments, reactive postural responses, sensory 162 
orientation and stability in gait.18 Two of the 14 items are scored bilaterally. Each item 163 
is scored from 0 (severe balance impairment) to 2 (no balance impairment) and the 164 
maximum possible score is 28 points. Higher scores indicate better balance 165 
performance. In patients with Parkinson disease, the Mini-BESTest test showed high 166 
sensitivity (89%)and specificity (81%) in identifying people with abnormal postural 167 
responses.36 High interrater (ICC=0.86-0.98) and test-retest reliability (ICC=0.88-168 
0.97) have also been found in patients with balance disorders, Parkinson disease, 169 
chronic stroke and also in older cancer survivors.16,20,21,31 170 
 171 
Brief-BESTest. The Brief-BESTest is a 6-item balance test, which contains 1 item 172 
from each of the 6 subsections of the BESTest.19 Two of the 6 items, are scored 173 
bilaterally, resulting in an 8-item balance test. Each item is scored from 0 (severe 174 
balance impairment) to 3 (no balance impairment) and the maximum possible score 175 
is 24 points. Higher scores indicate better balance performance.19 The Brief-BESTest 176 
was accurate in identifying future recurrent fallers in patients with Parkinson 177 
disease.35 It has also showed high interrater (ICC=0.86-0.96) and test-retest 178 
(ICC=0.90-0.98) reliability in individuals with and without neurological diagnoses19 179 
and older cancer survivors.16 180 
 181 
A summary of the core components of each balance test, based on the information 182 
provided in the Rehabilitation Measures Database,37 is presented in Supplementary 183 
Table 1. 184 
(Supplementary table 1) 185 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
10 
 
 186 
FTSTS 187 
The FTSTS was used as a measure of functional mobility.38 Participants started the 188 
test in a seated position with their arms folded across their chests and their back 189 
against the chair backrest. The following verbal instructions were given: “Please 190 
stand up and sit down 5 times as quickly as possible”. Timing (seconds) with a digital 191 
stopwatch was initiated manually at the “Go” instruction, and stopped when the 192 
subject’s back touched the backrest after the fifth stand. Two trials were performed 193 
and the mean of the trials was used in the analysis. This test has shown good 194 
intrarater, interrater and test-retest reliability in healthy older adults.39 195 
 196 
Statistical analysis 197 
Descriptive statistics were used to describe the sample. A z-test was applied for 198 
normality test using skewness and kurtosis.40 Individuals with a history of falls were 199 
defined as those who reported at least one fall during the past year; individuals 200 
without a history of falls were defined as those who reported no falls during the past 201 
year. Participants’ characteristics were compared between those with and without a 202 
history of falls, using independent t-tests for normally distributed data, Mann-Whitney 203 
U-tests for non-normally distributed and ordinal data and Chi-square tests for 204 
categorical data. When significant differences on the performance of balance tests 205 
were found between those with and without a history of falls, effect sizes were 206 
computed. The Cohen’s d was used as this is the effect size estimate recommended 207 
for Independent t-tests.41 Cohen’s d was calculated using the G*Power 3.1 software 208 
(University Düsseldorf, Düsseldorf, Germany) and was interpreted as a small (≥0.2), 209 
medium (≥0.5), or large (≥0.8) effect.42 The skewness of the distribution of scores 210 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
11 
 
was also assessed for each balance test to verify the occurrence of ceiling and floor 211 
effects. A positive skewness value greater than 1 denoted a substantial floor effect 212 
and a negative value lower than -1.0 indicated a substantial ceiling effect.43 213 
 214 
Reliability 215 
Interrater and test-retest reliability were analyzed in a subsample of the first 216 
consecutive 28 participants. This sample size was determined according to the study 217 
from Bonnet,44 where it has been established that a sample size of 21 individuals is 218 
sufficient to estimate an ICC of 0.9 with a 95% confidence interval width of 0.2 219 
(α=0.05 and k=2).44 A 30% attrition rate was estimated, yielding a sample of 28 220 
individuals. 221 
 222 
Interrater reliability was computed using the scores obtained from the 2 223 
physiotherapists in session 1 and test-retest reliability using the scores from 1 224 
physiotherapist in sessions 1 and 2. For relative reliability, the ICC equation (2,1) was 225 
used as it was intended to generalize the present results to a variety of raters.45 ICC 226 
was interpreted as excellent (>0.75), moderate to good (0.4-0.75) or poor (<0.4).46 227 
Absolute reliability was explored with the Bland and Altman method and standard 228 
error of measurement (SEM). The Bland and Altman method was used for visual 229 
judgement of how well the measurements between raters or sessions agreed.47 230 
 231 
The SEM indicates the extent to which a score varies on repeated measurements. It 232 
provides a value for measurement error in the same units as the measurement itself 233 
and thus, is easier to use in clinical practice.48 It was calculated using equation 1: 234 
��� = ��	�(1 − �

) (1) 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
12 
 
where SD is the standard deviation of the scores obtained from all individuals and 
235 
ICC is the test-retest reliability coefficient. 
236 
 
237 
Minimal Detectable Change 238 
The MDC at the 95% level of confidence (MDC95), is also reported in the same units 239 
as the measurement itself and represents the smallest change that can be 240 
interpreted as a real difference. It was calculated as follows (equation 2): 241 
��
�� = ��� × 1.96 × √2 (2) 
The MDC was also expressed as a percentage (MDC%), defined as (equation 3): 242 
��
% = (��
�� ����) × 100⁄ (3) 
where mean is the mean of the scores obtained in the 2 testing sessions. The MDC% 243 
is independent of the units of measurement and facilitates the comparison of the 244 
random measurement error among different measures.49 A MDC% below 30% is 245 
considered acceptable and below 10% excellent.50 246 
 247 
Validity 248 
Spearman’s correlation coefficient (rho) was used to examine the relationship among 249 
balance tests (concurrent validity) and between each balance test and the ABC Scale 250 
(convergent validity). 251 
 252 
Ability to identify fall status 253 
Receiver operating characteristic analysis and area under the curves (AUC) and the 254 
95% confidence interval were used to determine the cut-off points of each balance 255 
test differentiating individuals with and without a history of falls.41 Receiver operating 256 
characteristic analysis is a plot of a true-positive rate (sensitivity) and false-positive 257 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
13 
 
rate (1-specificity) across the full range of cut-off scores. The AUC is an index of the 258 
diagnostic accuracy of the test. Interpretation of the AUC values was as follow: 259 
AUC=0.5 no discrimination; 0.7≤AUC<0.8 acceptable discrimination; 0.8≤AUC<0.9 260 
excellent discrimination and AUC≥0.9 outstanding discrimination.51 The optimal cut-261 
off value for each balance test to differentiate between individuals with and without a 262 
history of falls was chosen as the intersection point which maximized both, sensitivity 263 
and specificity values. 264 
 265 
All statistical analyses were performed using IBM SPSS Statistics version 20.0 (IBM 266 
Corporation, Armonk, NY, USA) and plots created using GraphPad Prism version 267 
5.01 (GraphPad Software, Inc., La Jolla, CA, USA). The level of significance was set 268 
at 0.05. 269 
 270 
Results 
271 
 
272 
 
273 
Participants 
274 
A total of 130 individuals were invited to participate. However, 8 refused to complete 
275 
the assessment. Therefore, 122 participants were included. Participants were mainly 
276 
female (n=86; 70.5%), with a mean age of 76±9 years old. Thirteen participants used 
277 
walking aids, eleven used a cane and two used a walker. Participants’ characteristics278 
and balance scores are presented in Table 1. 
279 
(table 1) 
280 
 
281 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
14 
 
Skewness of BESTest (-0.62), Mini-BESTest (-0.67) and Brief-BESTest (-0.40) were 
282 
lower than the BBS (-1.46). 
283 
 
284 
Reliability and Minimal Detectable Change 
285 
Table 2 presents the relative and absolute interrater and test-retest reliability results. 
286 
Moderate to good interrater relative reliability was observed for the Mini-BESTest 
287 
(ICC 0.71), while the other balance tests presented excellent interrater relative 
288 
reliability (ICC from 0.86 to 0.93). The Bland and Altman method also showed good 
289 
agreement between the two physiotherapists, with small mean differences (from -
290 
0.1±1.1 to 0.4±3.5) for all balance tests (Table 2). BBS (ICC=0.50) and Mini-BESTest 
291 
had moderate to good (ICC=0.73) whereas BESTest and Brief-BESTest had 
292 
excellent (ICC of 0.77 and 0.82) relative test-retest reliability (Table 2). 
293 
(table 2) 
294 
 
295 
The MDC95 was 4.6 (SEM=1.7 MDC%=8.6%), 9 (SEM=3.3; MDC%=10.2%), 3.8 296 
(SEM=1.4; MDC%=16.3%) and 4.1 (SEM=1.5; MDC%=21.5%) points for BBS, 297 
BESTest, Mini-BESTest and Brief-BESTest, respectively. 298 
 299 
Validity 
300 
All balance tests were strongly correlated with each other (rho ranged from 0.83-301 
0.96; p<0.001). Scores of the ABC Scale were also significantly correlated with the 302 
scores of BBS (rho=0.58; p<0.001), BESTest (rho=0.46; p<0.001), Mini-BESTest 303 
(rho=0.57; p<0.001) and Brief-BESTest (rho=0.61; p<0.001). 304 
 305 
Ability to identify fall status 
306 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
15 
 
Thirty four participants (27.9%) had a history of falls and were significantly older than 
307 
those without a history of falls (Table 1). The FTSTS and balance tests were able to 
308 
significantly differentiate between participants with and without a history of falls 
309 
(p<0.007) (Table 1). Large effect sizes were found for BBS (Cohen’s d =1.00), 
310 
BESTest (Cohen’s d =0.81), Mini-BESTest (Cohen’s d =1.02) and Brief-BESTest 
311 
(Cohen’s d =1.00). 
312 
 
313 
Table 3 presents the results from the receiver operating characteristic analysis. 
314 
Balance tests had acceptable ability to differentiate participants with and without a 
315 
history of falls (AUC from 0.71 to 0.78). Sensitivity to differentiate fall status was 
316 
similar across balance tests (71-74%). Specificity, however, was higher for the Brief-
317 
BESTest (76%), Mini-BESTest (71%) and BBS (72%) than for BESTest (67%). The 
318 
identified cut-offs are 48.5 points for BBS, 82 points for BESTest, 19.5 points for 
319 
Mini-BESTest and 12.5 points for Brief-BESTest (Table 3). Figure 1 illustrates the 
320 
AUC as well as the identified cut-off points. 
321 
 
322 
(table 3 and Figure 1) 
323 
 
324 
Discussion 
325 
 
326 
 
327 
This study showed that the four balance tests presented good to excellent inter-rater 328 
and test-retest reliability, were highly correlated with each other (concurrent validity) 329 
and with the self-reported balance confidence (convergent validity), and were able to 330 
differentiate between older people living in the community with and without a history 331 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
16 
 
of falls with similar sensitivity/specificity. Therefore, findings support the use of all 332 
tests to assess balance impairment. However, similar to previous studies the BBS 333 
presented a substantial ceiling effect.8,36 Thus it may be more appropriate for health 334 
professionals to use the BESTest and its short versions to assess balance in older 335 
people living in the community. 336 
 337 
Although the reliability of the BBS has been widely studied,5,8 much less is known 338 
about the BESTest and its short versions. This study showed that the BBS, BESTest, 339 
Mini-BESTest and Brief-BESTest have good to excellent interrater (ICC 0.71-0.93) 340 
and test-retest (ICC 0.50-0.82) relative reliability in older people living in the 341 
community. Similar findings have been reported for relative reliability of BESTest and 342 
its short versions in other studied populations.13,16,19-21 343 
 344 
Absolute reliability has been much less studied than relative reliability despite the 345 
GRRAS guidelines25 recommendations to study both. In this study, balance tests 346 
showed good agreement with no systematic bias between raters and sessions, with 347 
relatively small SEM. Although, the Bland and Altman method has not been 348 
commonly used for visual inspection of BESTest and its short versions, some studies 349 
have reported the SEM for BESTest,16 Mini-BESTest16,20 and Brief-BESTest.16 The 350 
SEM is largely independent of the population from which it is determined however, its 351 
calculation depends of the standard deviation of the scores from all individuals 352 
studied.48 In this study, the standard deviations of BESTest and its short versions 353 
were higher than those already reported when studying patients with balance 354 
disorders or older cancer survivors, thus higher values of SEM have been found 355 
(BESTest - 3.3 vs 1.75;16 Mini-BESTest – 1.4 vs 1.2216 or 1.26;20 Brief-BESTest – 1.5 356 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
17 
 
vs 1.1316). Nevertheless, these SEM differences might not be of clinical relevance 357 
considering the score range of the balance tests assessed and the achieved changes 358 
(considerably higher than the SEM values here reported) in studies conducting 359 
balance training.20,52 Nevertheless, results should be interpreted with caution as 360 
absolute reliability has been little studied in BESTest and its short versions. Future 361 
studies exploring both types of reliability are needed. 362 
 363 
In this study, acceptable values of MDC% and MDC95 values were found. Higher 364 
MDC95 (6.5
53 and 6.220) have been reported for BBS however, in this study, a sample 365 
of healthy older people were studied and a substantial ceiling effect for the BBS was 366 
found, which may explain the lower MDC95 found. For BESTest and its short versions 367 
no ceiling or floor effects were observed and all MDC95 values were higher than 368 
those previously published.15,16,20,21 However, these studies were conducted with 369 
patients with specific health conditions, such as chronic stroke, total knee 370 
arthroplasty, balance disorders and history of cancer.15,16,20,21 Therefore, it is not 371 
surprising that higher MDC95 values were found in a healthy older population. 372 
Therefore, the MDC95 established in this study will be useful for health professionals 373 
working with older people living in the community in determining whether an 374 
intervention (e.g., fall prevention program) has caused any real change in balance 375 
ability. 376 
 377 
Similarly to other studies,16,20-22 all balance tests were significantly correlated with 378 
each other and with the ABC scale, indicating good concurrent and convergent 379 
validity. All balance tests were also able to significantly differentiate between 380 
participants with and without a history of falls with large effect sizes, acceptable 381 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
18 
 
ability and similar sensitivity and specificity. The cut-off points identified were similar 382 
to those previously published for BBS,36 BESTest,35 Mini-BESTest35,36 and Brief-383 
BESTest35. These cut-off scores indicate the level of balance impairment that is 384 
associated with falling. This is especially important for health professionals to detect 385 
fall risk in older adults before a fall occurs and implement preventive effective 386 
interventions. 387 
 388 
Study Limitations 389 
The sample included older people living in the community, which limits the390 
generalizability of the results to the overall older population. It is unclear whether the 391 
participation in community centers activities have contributed to minimize the risk of 392 
falling. Future studies could compare the balance impairment and risk of falling 393 
between older people integrating and not integrating community centers in order to 394 
clarify these issues. Older people living in the community were classified as having or 395 
not having a history of falls based on their self-report hence, some degree of bias in 396 
their responses might have been present. Moreover, tasks that were similar among 397 
BESTest, Mini-BESTest and Brief-BESTest were only performed once and therefore, 398 
this influenced the correlation results. Future studies should assess the reliability, 399 
validity and ability to identify fall status of the Mini-BESTest and of the Brief-BESTest 400 
when performed separately from the BESTest. Finally, as this was a cross-sectional 401 
study, the ability of the balance tests to identify fall status in older people living in the 402 
community was analyzed retrospectively. Longitudinal studies should be conducted 403 
in order to assess the ability of these tests in identifying recurrent fallers 404 
prospectively. 405 
 406 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
19 
 
Conclusions 407 
 408 
 409 
BBS, BESTest, Mini-BESTest and Brief-BESTest are highly reliable, valid and able to 410 
differentiate between older people living in the community with and without a history 411 
of falls. However, as BBS presented a substantial ceiling effect, BESTest and its 412 
short versions seem more appropriate to assess specific balance impairments in 413 
older people living in the community. MDC95 values and cut-off points for BBS, 414 
BESTest, Mini-BESTest and Brief-BESTest, were established. It is believed that 415 
these findings will help health professionals to assess balance impairments in older 416 
people living in the community and will also provide information on whom to prioritize 417 
intervention. 418 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
20 
 
References 
419 
 
420 
 
421 
1. World Health Organization. Falls. 2012:Fact sheet N°344. 422 
2. Tinetti M, Speechley M, Ginter S. Risk factors for falls among elderly persons 423 
living in the community. N Engl J Med. 1988;319:1701–1707. 424 
3. National Institute for Health and Care Excellence. Falls in older people: 425 
assessing risk and prevention (CG161). 2013: 426 
https://www.nice.org.uk/guidance/cg161. 427 
4. Delbaere K, Close JC, Heim J, Sachdev PS, et al. A multifactorial approach to 428 
understanding fall risk in older people. J Am Geriatr Soc. 2010;58(9):1679-429 
1685. 430 
5. Steffen T, Seney M. Test-Retest Reliability and Minimal Detectable Change on 431 
Balance and Ambulation Tests, the 36-Item Short-Form Health Survey, and 432 
the Unified Parkinson Disease Rating Scale in People With Parkinsonism. 433 
Phys Ther. 2008;88(6):733-746. 434 
6. Oliveira CC, Lee A, Granger CL, Miller KJ, et al. Postural control and fear of 435 
falling assessment in people with chronic obstructive pulmonary disease: a 436 
systematic review of instruments, international classification of functioning, 437 
disability and health linkage, and measurement properties. Arch Phys Med 438 
Rehabil. 2013;94(9):1784-1799.e1787. 439 
7. Wang CY, Hsieh CL, Olson SL, Wang CH, et al. Psychometric properties of 440 
the Berg Balance Scale in a community-dwelling elderly resident population in 441 
Taiwan. J Formos Med Assoc. 2006;105(12):992-1000. 442 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
21 
 
8. Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale in stroke 443 
rehabilitation: a systematic review. Phys Ther. 2008;88(5):559-566. 444 
9. Tanji H, Gruber-Baldini AL, Anderson KE, Pretzer-Aboff I, et al. A comparative 445 
study of physical performance measures in Parkinson's disease. Mov Disord. 446 
2008;23(13):1897-1905. 447 
10. Beauchamp MK, O’Hoski S, Goldstein RS, Brooks D. Effect of Pulmonary 448 
Rehabilitation on Balance in Persons With Chronic Obstructive Pulmonary 449 
Disease. American Congress of Rehabilitation Medicine. 2010;91:1460-1465. 450 
11. Horak FB. Postural orientation and equilibrium: what do we need to know 451 
about neural control of balance to prevent falls? Age Ageing. 2006;35 Suppl 452 
2:ii7-ii11. 453 
12. Horak FB, Wrisley DM, Frank J. The Balance Evaluation Systems Test 454 
(BESTest) to Differentiate Balance Deficits. Phys Ther. 2009;89(5):484-498. 455 
13. Leddy AL, Crowner BE, Earhart GM. Functional gait assessment and balance 456 
evaluation system test: reliability, validity, sensitivity, and specificity for 457 
identifying individuals with Parkinson disease who fall. Phys Ther. 458 
2011;91(1):102-113. 459 
14. Beauchamp MK, Sibley KM, Lakhani B, Romano J, et al. Impairments in 460 
systems underlying control of balance in COPD. Chest. 2012;141(6):1496-461 
1503. 462 
15. Chan AC, Pang MY. Assessing Balance Function in Patients With Total Knee 463 
Arthroplasty. Phys Ther. 2015;[Epub ahead of print]. 464 
16. Huang MH, Miller K, Smith K, Fredrickson K, et al. Reliability, Validity, and 465 
Minimal Detectable Change of Balance Evaluation Systems Test and Its Short 466 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
22 
 
Versions in Older Cancer Survivors: A Pilot Study. J Geriatr Phys Ther. 467 
2015;[Epub ahead of print]. 468 
17. O'Hoski S, Winship B, Herridge L, Agha T, et al. Increasing the clinical utility of 469 
the BESTest, mini-BESTest, and brief-BESTest: normative values in Canadian 470 
adults who are healthy and aged 50 years or older. Phys Ther. 471 
2014;94(3):334-342. 472 
18. Franchignoni F, Horak F, Godi M, Nardone A, et al. Using psychometric 473 
techniques to improve the Balance Evaluation Systems Test: the mini-474 
BESTest. J Rehabil Med. 2010;42(4):323-331. 475 
19. Padgett PK, Jacobs JV, Kasser SL. Is the BESTest at its best? A suggested 476 
brief version based on interrater reliability, validity, internal consistency, and 477 
theoretical construct. Phys Ther. 2012;92(9):1197-1207. 478 
20. Godi M, Franchignoni F, Caligari M, Giordano A, et al. Comparison of 479 
reliability, validity, and responsiveness of the mini-BESTest and Berg Balance 480 
Scale in patients with balance disorders. Phys Ther. 2013;93(2):158-167. 481 
21. Tsang CS, Liao LR, Chung RC, Pang MY. Psychometric properties of the 482 
Mini-Balance Evaluation Systems Test (Mini-BESTest) in community-dwelling 483 
individuals with chronic stroke. Phys Ther. 2013;93(8):1102-1115. 484 
22. O'Hoski S, Sibley KM, Brooks D, Beauchamp MK. Construct validity of the 485 
BESTest, mini-BESTest and briefBESTest in adults aged 50 years and older. 486 
Gait Posture. 2015;42(3):301-305. 487 
23. Terwee CB, Mokkink LB, Knol DL, Ostelo RWJG, et al. Rating the 488 
methodological quality in systematic reviews of studies on measurement 489 
properties: a scoring system for the COSMIN checklist. Qual Life Res. 490 
2012;21(4):651-657. 491 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
23 
 
24. von Elm E, Altman DG, Egger M, Pocock SJ, et al. Strengthening the 492 
Reporting of Observational Studies in Epidemiology (STROBE) statement: 493 
guidelines for reporting observational studies. BMJ. 2007;335(7624):806-808. 494 
25. Kottner J, Audigé L, Brorson S, Donner A, et al. Guidelines for Reporting 495 
Reliability and Agreement Studies (GRRAS) were proposed. J Clin Epidemiol. 496 
2011;64(1):96-106. 497 
26. Biderman A, Cwikel J, Fried A, Galinsky D. Depression and falls among 498 
community dwelling elderly people: a search for common risk factors. J 499 
Epidemiol Community Health. 2002;56(8):631-636. 500 
27. Whitney SL, Poole JL, Cass SP. A review of balance instruments for older 501 
adults.Am J Occup Ther. 1998;52(8):666-671. 502 
28. Myers AM, Fletcher PC, Myers AH, Sherk W. Discriminative and evaluative 503 
properties of the activities-specific balance confidence (ABC) scale. J Gerontol 504 
A Biol Sci Med Sci. 1998;53(4):M287-294. 505 
29. Branco PS. Validation of the Portuguese Version of the “Activities-specific 506 
Balance Confidence Scale”. RSPMFR. 2010;19(2):20-25. 507 
30. Schlenstedt C, Brombacher S, Hartwigsen G, Weisser B, et al. Comparing the 508 
Fullerton Advanced Balance Scale with the Mini-BESTest and Berg Balance 509 
Scale to assess postural control in patients with Parkinson disease. Arch Phys 510 
Med Rehabil. 2015;96(2):218-225. 511 
31. Leddy AL, Crowner BE, Earhart GM. Utility of the Mini-BESTest, BESTest, 512 
and BESTest sections for balance assessments in individuals with Parkinson 513 
disease. J Neurol Phys Ther. 2011;35(2):90-97. 514 
32. Holbein-Jenny MA, Billek-Sawhney B, Beckman E, Smith T. Balance in 515 
personal care home residents: a comparison of the Berg Balance Scale, the 516 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
24 
 
Multi-Directional Reach Test, and the Activities-Specific Balance Confidence 517 
Scale. J Geriatr Phys Ther. 2005;28(2):48-53. 518 
33. Mao HF, Hsueh IP, Tang PF, Sheu CF, et al. Analysis and comparison of the 519 
psychometric properties of three balance measures for stroke patients. Stroke. 520 
2002;33(4):1022-1027. 521 
34. Flansbjer UB, Blom J, Brogardh C. The reproducibility of Berg Balance Scale 522 
and the Single-leg Stance in chronic stroke and the relationship between the 523 
two tests. PM R. 2012;4(3):165-170. 524 
35. Duncan RP, Leddy AL, Cavanaugh JT, Dibble LE, et al. Comparative utility of 525 
the BESTest, mini-BESTest, and brief-BESTest for predicting falls in 526 
individuals with Parkinson disease: a cohort study. Phys Ther. 527 
2013;93(4):542-550. 528 
36. King LA, Priest KC, Salarian A, Pierce D, et al. Comparing the Mini-BESTest 529 
with the Berg Balance Scale to Evaluate Balance Disorders in Parkinson's 530 
Disease. Parkinsons Dis. 2012;2012:375419. 531 
37. Rehabilitation Measures Database. 532 
http://www.rehabmeasures.org/default.aspx. Accessed April 20th, 2016. 533 
38. Goldberg A, Chavis M, Watkins J, Wilson T. The five-times-sit-to-stand test: 534 
validity, reliability and detectable change in older females. Aging Clin Exp Res. 535 
2012;24(4):339-344. 536 
39. Teo TW, Mong Y, Ng SS. The repetitive Five-Times-Sit-To-Stand test: its 537 
reliability in older adults. International Journal of Therapy and Rehabilitation. 538 
2013;20(3):122-130. 539 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
25 
 
40. Troiano RP, Berrigan D, Dodd KW, Masse LC, et al. Physical activity in the 540 
United States measured by accelerometer. Med Sci Sports Exerc. 541 
2008;40(1):181-188. 542 
41. Faul F, Erdfelder E, Lang A-G, Buchner A. G*Power 3: A flexible statistical 543 
power analysis program for the social, behavioral, and biomedical sciences. 544 
Behav Res Methods. 2007;39(2):175-191. 545 
42. Cohen J. Statistical power analysis for the behavioral sciences. 2 ed. Hillsdale, 546 
NJ: Lawrence Earlbaum Associates; 1988. 547 
43. Bulmer MG. Principles of statistics. New York: Dover Publications; 1979. 548 
44. Bonett DG. Sample size requirements for estimating intraclass correlations 549 
with desired precision. Stat Med. 2002;21(9):1331-1335. 550 
45. Rankin G, Stokes M. Reliability of assessment tools in rehabilitation: an 551 
illustration of appropriate statistical analyses. Clin Rehabil. 1998;12(3):187-552 
199. 553 
46. Fleiss J. Reliability of measurements. In: Fleiss J, ed. The design and analysis 554 
of clinical experiments. 1 ed. New York: John Wiley & Sons; 1986. 555 
47. Rankin G, Stokes M. Reliability of assessment tools in rehabilitation: an 556 
illustration of appropriate statistical analyses. Clin Rehabil. 1998;12:187-199. 557 
48. Weir JP. Quantifying test-retest reliability using the intraclass correlation 558 
coefficient and the SEM. J Strength Cond Res. 2005;19(1):231-240. 559 
49. Huang S-LH, Ching-Lin; Wu, Ruey-Meei; Tai, Chun-Hwei; Lin, Chin-Hsien; Lu, 560 
Wen-Shian. Minimal Detectable Change of the Timed ''Up & Go'' Test and the 561 
Dynamic Gait Index in People With Parkinson Disease. Phys Ther. 562 
2011;91(1):114-121. 563 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
26 
 
50. Smidt N, van der Windt DA, Assendelft WJ, Mourits AJ, et al. Interobserver 564 
reproducibility of the assessment of severity of complaints, grip strength, and 565 
pressure pain threshold in patients with lateral epicondylitis. Arch Phys Med 566 
Rehabil. 2002;83(8):1145-1150. 567 
51. Cohen HS, Kimball KT. Usefulness of some current balance tests for 568 
identifying individuals with disequilibrium due to vestibular impairments. J 569 
Vestib Res. 2008;18(5-6):295-303. 570 
52. Beauchamp MK, Janaudis-Ferreira T, Parreira V, Romano JM, et al. A 571 
randomized controlled trial of balance training during pulmonary rehabilitation 572 
for individuals with COPD. Chest. 2013;144(6):1803-1810. 573 
53. Romero S, Bishop MD, Velozo CA, Light K. Minimum detectable change of the 574 
Berg Balance Scale and Dynamic Gait Index in older persons at risk for falling. 575 
J Geriatr Phys Ther. 2011;34(3):131-137. 576 
 577 
 578 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
27 
 
Figure captions 579 
Figure 1 - Receiver operator characteristics of the Berg Balance Scale (BBS), 580 
Balance Evaluation Systems Test (BESTest), Mini-BESTest and the Brief-BESTest 581 
to differentiate participants with and without a history of falls (n=122). 582 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Table 1 - Participants’ characteristics and balance scores (n=122). 
Characteristics Total 
(n=122) 
Without a history 
of falls (n=88) 
With a history of 
falls (n=34) 
p-value 
Age (years) 75.9 ± 8.9 74.7 ± 8.8 78.9 ± 8.6 0.020 
Gender 
 Female 86 (70.5%) 58 (65.9%) 28 (82.4%) 0.081 
 Male 36 (29.5%) 30 (34.1%) 6 (17.6%) 
BMI (Kg/m2) 26.8 ± 4 26.9 ± 4 26.6 ± 4.2 0.715 
Walking aid 13 (10.7%) 7 (8%) 6 (17.6%) 0.187 
Comorbidities, M[IQR] 2 [1, 3] 1.5 [1, 3] 2 [1, 3] 0.573 
ABC scale 80.9 ± 22.1 86.6 ± 17.7 66.1 ± 25.4 <0.001 
FTSTS (seconds) 12.9 ± 5 12.2 ± 4.4 15 ± 6.1 0.007 
BBS 47.2 ± 10 49.9 ± 8.3 40.2 ± 10.9 <0.001 
BESTest 84.7 ± 24.5 84 ± 13.9 71.7 ± 16.5 <0.001 
Mini-BESTest 19.8 ± 6.8 21.6 ± 5.8 15 ± 7.1 <0.001 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
 
 
Note: values show mean ± SD or n(%) unless otherwise indicated. Abbreviations: ABC, Activities-Specific Balance Confidence; 
BBS, Berg Balance Scale, BESTest, Balance Evaluation Systems Test; BMI, body mass index; FTSTS, Five times sit-to-stand test; 
M, median; IQR, interquartile range. 
Brief-BESTest 14.3 ± 6.8 16 ± 6 9.7 ± 6.6 <0.001 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Table 2 – Interrater and test-retest reliability of the Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), Mini-
BESTest and Brief-BESTest (n=28). 
 Interrater reliability Test-retest reliability 
Balance test ICC (95% CI) MD±SD 95% LA ICC (95% CI) MD±SD 95% LA 
BBS 0.88 (0.77→0.94) -0.1 ± 1.1 -2.2→2 0.50 (0.15→0.73) -0.7 ± 2 -4.6→3.2 
BESTest 0.86 (0.73→0.92) 0.4 ± 3.5 -6.5→7.2 0.77 (0.55→0.88) -1.6 ± 4.3 -10.1→6.9 
Mini-BESTest 0.71 (0.50→0.84) -0.2 ± 2 -4.2→3.7 0.73 (0.49→0.86) -0.4 ± 1.9 -4.2→3.3 
Brief-BESTest 0.93 (0.87→0.97) -0.2 ± 1.2 -2.5→2.1 0.82 (0.65→0.91) -0.4 ± 2 -4.4→3.5 
Abbreviations: 95% CI, 95% confidence intervals; ICC, Intraclass Correlation Coefficient; 95% LA, 95% limits of agreement; MD, 
mean difference; SD, standard deviation. 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Table 3 – Ability of the Berg Balance Scale (BBS), Balance Evaluation Systems Test (BESTest), Mini-BESTest and Brief-BESTestto identify fall status (n=122). 
Abbreviations: AUC, area under the curve; 95%CI, 95% confidence intervals; SEM, standard error. 
Balance test AUC (SEM) 95% CI Cut-off point % Sensitivity / 
% Specificity 
Positive / 
Negative 
Likelihood Ratios 
BBS 0.78 (0.05) 0.68→0.87 48.5 74 / 72 2.59 / 0.37 
BESTest 0.71 (0.06) 0.60→0.82 82 74 / 67 2.23 / 0.40 
Mini-BESTest 0.76 (0.05) 0.66→0.86 19.5 74 / 71 2.49 / 0.38 
Brief-BESTest 0.76 (0.05) 0.66→0.86 12.5 71 / 76 2.92 / 0.39 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Highlights 
 
• BBS, BESTest, Mini-BESTest and Brief-BESTest are reliable in older 
people living in the community. 
• MDC values were established for the BBS, BESTest, Mini-BESTest and 
Brief-BESTest. 
• The four balance tests are able to differentiate between community-living 
older people with and without a history of falls 
• Test selection depends on balance impairment level, purpose and time 
availability. 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Supplementary Table 1 – Summary of the core components of each balance test. 
Balance 
test 
Number 
of items 
Scoring Maximum 
score 
Time to 
Administer 
Populations tested 
BBS 14 0-4 56 15-20 min Brain injury 
Cerebral palsy 
Chronic Obstructive Pulmonary Disease 
Community-living older adults 
Lower-limb amputation 
Multiple sclerosis 
Older people living in residential care facilities 
Orthopedic Surgery 
Osteoarthritis 
Parkinson Disease 
Spinal Cord Injury 
Stroke 
Total knee arthroplasty 
Traumatic and acquired brain injury 
Vestibular Dysfunction 
BESTest 36 0-3 108 20-30 min Balance deficits 
Cancer survivors 
Cerebellar Infarct 
Chronic Obstructive Pulmonary Disease 
Community-living older adults 
Multiple Sclerosis 
Parkinson Disease 
Peripheral neuropathy 
Stroke 
Total knee arthroplasty 
Vestibular dysfunction 
M
AN
US
CR
IP
T
 
AC
CE
PT
ED
ACCEPTED MANUSCRIPT
Mini-
BESTest 
14 0-2 28 10-15 min Age-Related Balance Disorders 
Ataxia 
Cancer survivors 
Cervical Myelopathy 
Chronic Obstructive Pulmonary Disease 
CNS Neoplasm 
Community-living older adults 
Multiple Sclerosis 
Neuromuscular Disease 
Nontraumatic Brain Injury 
Parkinson Disease 
Peripheral neuropathy 
Peripheral Vestibular Disorders 
Spinal cord injury 
Stroke 
Total knee arthroplasty 
Traumatic Brain Injury 
Wolfram syndrome 
Brief-
BESTest 
6 0-3 24 10 min Cancer survivors 
Chronic Obstructive Pulmonary Disease 
Community-living older adults 
Multiple Sclerosis 
Parkinson Disease 
Peripheral Neuropathy 
Stroke 
Total knee arthroplasty