Archives of Physical Medicine and Rehabilitation

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Archives of Physical Medicine and Rehabilitation 2017;98:2066-78

REVIEW ARTICLE

Components of Standing Postural Control Evaluated in

Pediatric Balance Measures: A Scoping Review
Kathryn M. Sibley, PhD,a,b,c Marla K. Beauchamp, PhD, PT,d Karen Van Ooteghem, PhD,e
Marie Paterson, BMR, PT,f Kristy D. Wittmeier, PhD, PTb,g,h
From the aDepartment of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; bGeorge & Fay Yee Centre for
Healthcare Innovation, Winnipeg, Manitoba, Canada; cToronto Rehabilitation Institute-University Health Network, Toronto, Ontario, Canada;
d
School of Rehabilitation Science, McMaster University, Hamilton, Ontario; eDepartment of Kinesiology, University of Waterloo, Waterloo,
Ontario, Canada; fDepartment of Child Health Physiotherapy, Winnipeg Health Sciences Centre, Winnipeg, Manitoba, Canada; gDepartment of
Physiotherapy, Winnipeg Health Sciences Centre; and hDepartment of Pediatrics and Child Health, University of Manitoba, Winnipeg,
Manitoba, Canada.

Abstract
Objective: To identify measures of standing balance validated in pediatric populations, and to determine the components of postural control
captured in each tool.
Data Sources: Electronic searches of MEDLINE, Embase, and CINAHL databases using key word combinations of postural balance/
equilibrium, psychometrics/reproducibility of results/predictive value of tests, and child/pediatrics; gray literature; and hand searches.
Study Selection: Inclusion criteria were measures with a stated objective to assess balance, with pediatric (18y) populations, with at least
1 psychometric evaluation, with at least 1 standing task, with a standardized protocol and evaluation criteria, and published in English. Two
reviewers independently identified studies for inclusion. There were 21 measures included.
Data Extraction: Two reviewers extracted descriptive characteristics, and 2 investigators independently coded components of balance in each
measure using a systems perspective for postural control, an established framework for balance in pediatric populations.
Data Synthesis: Components of balance evaluated in measures were underlying motor systems (100% of measures), anticipatory postural control
(72%), static stability (62%), sensory integration (52%), dynamic stability (48%), functional stability limits (24%), cognitive influences (24%),
verticality (9%), and reactive postural control (0%).
Conclusions: Assessing children’s balance with valid and comprehensive measures is important for ensuring development of safe mobility and
independence with functional tasks. Balance measures validated in pediatric populations to date do not comprehensively assess standing postural
control and omit some key components for safe mobility and independence. Existing balance measures, that have been validated in adult
populations and address some of the existing gaps in pediatric measures, warrant consideration for validation in children.
Archives of Physical Medicine and Rehabilitation 2017;98:2066-78
ª 2017 by the American Congress of Rehabilitation Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-NC-ND
license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Balance is defined as the ability to control the center of mass relative associated with delayed motor development and mobility function.3,4
to the base of support.1 Described as both a structure/function and Fortunately, impairments in standing balance can be effectively
activity within the International Classification of Functioning, treated through therapeutic exercise.5-7 Accordingly, assessment of
Disability and Health framework,2 the ability to achieve and main- postural control in standing is important for monitoring development,
tain balance in upright stance is a critical and complex lifelong skill. diagnosing impairments, planning treatment programs, and evalu-
Commonly observed impairments in postural control among pedi- ating change in pediatric populations.
atric populations, traditionally defined as those 18 years, are The assessment of standing balance in pediatric populations is
complicated both by its multicomponent structure and by the in-
fluence of development on postural control. The multicomponent
Disclosures: none. nature of balance is reflected in contemporary postural control
0003-9993/17/ª 2017 by the American Congress of Rehabilitation Medicine. Published by Elsevier Inc. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
http://dx.doi.org/10.1016/j.apmr.2017.02.032
Components of pediatric balance measures 2067

theory, which has adopted a systems perspective that conceptualizes measure. The review was guided by the following question: Which
balance as the product of interaction among multiple biologic sys- components of standing postural control are evaluated in balance
tems in a continuously changing environment.8-11 Although no measures whose validity or reliability are established in pediatric
unified description of a systems perspective to postural control has populations (18y)? The findings may be useful in developing
been ratified, the approach is supported by evidence from multiple recommendations for more standardized use of balance outcome
laboratories demonstrating how imposed constraints or deficits in measures in pediatric rehabilitation research and clinical practice.
1 underlying systems impair balance and affect development of
postural control.12 Commonly described balance components in
pediatric and adult populations include underlying motor system Methods
elements (eg, strength, coordination), static stability during quiet
standing, limits of stability affecting the ability to move the center of A scoping review was conducted.20 Scoping reviews are rigorous
mass as far as possible within the base of support, orienting relative knowledge syntheses that comprehensively summarize evidence to
to gravity, postural reactions to recover stability, anticipatory ad- inform policy, practice, and future research.21 We applied Arksey
justments prior to discrete voluntary movements, dynamic stability and O’Malley’s 5-stage framework for scoping reviews20 and
when the base of support changes, integrating sensory information, incorporated recent recommendations for enhancing this method-
and influence of cognitive processing on the maintenance of stability ology22,23 (eg, using an iterative approach to develop the research
(table 1).10,12,14-16 A systems perspective to postural control high- question with stakeholder involvement, defining relevant concepts,
lights the importance of considering each component individually including quality indicators in the eligibility criteria). Preferred
because each can independently lead to balance impairment. Reporting Items for Systematic Reviews and Meta-Analyses rec-
Furthermore, development of each of these components takes place ommendations for systematic review conduct and reporting24 also
over multiple years, with neurophysiologic and biomechanical ev- informed the methodology, and were adopted where appropriate.
idence suggesting that adult-like postural control requires approxi-
mately 7 years from birth to mature.1 As such, there is much Data sources and searches
diversity regarding how pediatric balance may be expected to pre-
sent within this time frame. A professional librarian developed the search strategy, which was
The intersection of systems and developmental considerations on reviewed by a second librarian. Published literature indexed in
postural control emphasizes the need for assessment of each MEDLINE (1946 to December 1, 2015), Embase (1974 to
component and tailored treatment on a case-by-case basis. Choosing December 1, 2015), and CINAHL (1981 to December 1, 2015) was
an appropriate measure of balance has important implications for searched. Combinations of the following terms were used: postural
diagnosis, prognosis, and treatment, and content validity should be a balance/equilibrium, psychometrics/reproducibility of results/
primary consideration given the recognized absence of a criterion predictive value of tests, and child/pediatrics. A sample search
standard for evaluating balance.17 However, evidence based on adult strategy for MEDLINE is presented in supplemental table S1
data suggests that commonly used measures of standing balance do (available online only at http://www.archives-pmr.org/). A
not comprehensively assess postural control. A 2015 scoping review comprehensive hand search was also conducted to identify measures
of 66 standing balance measures validated in adult populations not captured by database searches, including a search of published
showed that most did not examine all relevant balance components narrative review articles describing balance measures identified in
for functional mobility and fall avoidance.13 Although recent reviews the database search, the Health and Psychosocial Instruments data-
of postural control assessment and functional balance tests in pedi- base, and a search for pediatric validation of measures identified in a
atric populations have focused on specific impairments,18 psycho- previous scoping review of balance measures for adult pop-
metric properties, and some components of balance,19 none have ulations.13 In addition, a local team of practicing pediatric physical
explored the content of the measures using a comprehensive systems therapists were consulted to identify additional measures commonly
perspective. Furthermore, to our knowledge, no reviews to date have used to assess balance potentially not identified by the search.
examined the stage of postural development considered in the
development of pediatric balance measures. Study selection
Systematically examining the underlying constructs in pediatric
balance measures is critical to improving understanding of the Level one title and abstract screening criteria included descriptive
strengths and limitations of balance measures, and for facilitating studies which (1) focused on balance measurement, (2) included
selection of optimal measures for clinical use and future research. pediatric populations (18y), and (3) were published in the
The primary objectives of this study were (1) to identify measures English language. Screening criteria were piloted on a random
of standing balance for pediatric populations, and (2) to determine 10% sample of abstracts and clarified where necessary. The search
the components of standing postural control captured in each was specific for index publicationsda measure’s first publication
measure using a systems perspective. A secondary objective was to presenting its development and/or initial psychometric
examine how developmental considerations for balance were evaluationdand/or initial psychometric evaluation in pediatric
accounted for in the development or initial pediatric testing of each populations for consideration as a measure’s definitive reference.
However, in anticipation that not all measures would be published
in a way that it would be possible to identify the first publication
List of abbreviations: from the abstract, the names of all balance measures identified in
BESTest Balance Evaluation Systems Test the abstract screen were recorded for manual cross-checking and
BOT-2 Bruininks-Oseretsky Test of Motor hand search for the index publication. Teams of 2 research
Proficiency, Second Edition
assistants with health sciences backgrounds and graduate research
PDMS-2 Peabody Developmental Motor Scales, Second
training independently screened abstracts of studies identified in
Edition
the database search using the screening criteria. The principal

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2068 K.M. Sibley et al

investigator, who also reviewed the list of all measures identified hand search and Health & Psychosocial Instruments search yielded an
in the abstract screening, resolved disagreements and flagged additional 59 records. After removing duplicates, 1283 abstracts were
relevant abstracts for follow-up hand search. The principal identified for screening. Of these, 155 articles were selected for full-
investigator had an educational background in kinesiology with text review. After full-text screening, 21 measures met the inclusion
graduate training in rehabilitation and medical sciences focused criteria.25-45 During review and consultation with the local team of
on fundamental and clinical research in postural control. practicing pediatric physical therapists, an additional 3 measures were
Level 2 full-text screening criteria included (1) index identified that included a clinically relevant standing balance
publication in pediatric population, (2) have a stated objective or component within a broader developmental motor measure.46-48
commonly used to assess balance, (3) include at least 1 standing Although these measures did not meet the criteria of a balance mea-
task, (4) have both a standardized testing protocol and standardized sure for this review, because clinicians conceived these measures as
evaluation criteria, and (5) evaluate a minimum of 1 psychometric useful tools for assessing balance, they were also coded against the
property (validity or reliability). The last criterion (minimum of 1 Systems Framework for Postural Control as an addendum to the full
psychometric property evaluated) was included for quality review. Data abstraction and mapping results were tabulated, and
assessment purposes to prevent inclusion of measures with no descriptive statistics were calculated for all variables.
empirical support. Hand searches were triggered at this phase if (1)
no psychometric data were reported in the index publication (to
determine whether companion articles existed that would support Results
inclusion of the measure in the review); or (2) it was not clear from
the full text whether the identified article was the index publication. Measure characteristics
Full-text screening was performed by teams of 2 research assis-
tants, with disagreements resolved by the principal investigator. Table 2 presents selected characteristics of each measure. The
The preliminary list of included measures was reviewed and dis- 21 measures were published or first used in pediatric populations
cussed by a local team of practicing pediatric physical therapists to between 1990 and 2015. Most measures (17/21, 81%) were
confirm inclusion of all known relevant measures. developed in adult populations and subsequently validated for use
with pediatric populations. The remaining measures were devel-
oped specifically for children either through consultation with
Data extraction and quality assessment clinicians (nZ2; Pediatric Reach Test43 and Early Clinical
Descriptive data abstraction was performed by teams of 2 research Assessment of Balance45) or by unreported methods (nZ2; Ghent
assistants and reviewed by the principal investigator. A standardized Developmental Balance Test27 and Timed Up and Down Stairs
template was used to extract the measures’ stated purpose and Test41). The number of items in each measure ranged between
development methods, characteristics (evaluation parameters and 1 and 35, with a median of 4 items. One measure included graded
number of items), and results of preliminary psychometric testing progression in which participants must meet specific criteria to
(pediatric population and age range, and reliability and/or validity). complete additional items. Fourteen measures (67%) were evalu-
The components of balance evaluated in each measure were ated on a continuous scale, and the remaining 7 measures used a
explored by coding the individual test items and tasks using a categorical scale with 2 to 7 categories. One measure (Ghent
systems perspective to postural control. Operational definitions for Developmental Balance Test27) was criterion-referenced, whereas
9 components of balance were applied from a previous review of the other 20 measures were norm-referenced. Both reliability and
standing balance measures in adult populations13 after confirming validity statistics were presented in the original report for
that all components were identified as relevant to pediatric 10 measures (48%), whereas 9 (43%) presented reliability only,
populations in the literature.10,14-16 Several pediatric balance mea- and 2 (9%) presented validity only in the original report. Detailed
sures were identical to the adult version (with respect to test items, psychometric data published with the index pediatric publication
evaluation criteria, and referenced associated index publication for are presented in supplemental table S2.
adult populations), and the coding scheme from the previous
scoping review of adult balance measures13 was adopted for these Components of balance evaluated and postural
pediatric measures. For all other pediatric measures, 2 investigators development considerations in each measure
independently reviewed the tasks and scoring criteria of each
measure and identified on a binary scale (yes/no) which balance Of the 21 included pediatric balance measures, 12 were identical
components were included in each measure. Individual components to the adult-validated version and the codes were adopted from
were defined as included if they were integral to task performance, the previous adult review.24 Among the 9 newly coded measures,
even if not explicitly part of the measure’s evaluation criteria. coding agreement by the 2 independent reviewers was 94%.
Shumway-Cook and Woollacott’s reference1 of 7 years to reach Total agreement was achieved after consensus discussion with a
postural maturity was used to determine whether each measure’s third reviewer. Coding results identifying the components of
initial development and psychometric testing occurred in children balance included in each measure are presented in table 3.
who were in the development phase of postural control (study age, Underlying motor systems were evaluated in all 21 measures,
<7y), fully matured (study age, 7e18y), or crossed the postural anticipatory postural control in 15 measures (72%), static
development continuum. Disagreements were resolved through stability in 13 measures (62%), sensory integration in 11 mea-
consensus discussion with a third investigator. sures (52%), dynamic stability in 10 measures (48%), functional
stability limits in 5 measures (24%), cognitive influences in
Data synthesis and analysis 5 measures (24%), verticality in 2 measures (9%), and reactive
postural control in 0 measures. All measures included between
Figure 1 illustrates the study selection process. The MEDLINE, 3 and 6 components of balance; no measures included all
CINAHL, and Embase searches yielded a total of 1405 records. The 9 components.

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Components of pediatric balance measures 2069

Table 1 Components of balance operational definitions13

Component Definition/Example
1. Functional stability limits Ability to move the center of mass as far as possible in the anterior-posterior or mediolateral directions
within the base of support
2. Underlying motor systems For example, strength or coordination
3. Static stability Ability to maintain position of the center of mass in unsupported stance when the base of support does
not change (may include wide stance, narrow stance, 1-legged stance, tandemdany standing
condition)
4. Verticality Ability to orient appropriately with respect to gravity (eg, evaluation of lean)
5. Reactive postural control Ability to recover stability after an external perturbation to bring the center of mass within the base of
support through corrective movements (eg, ankle, hip, stepping strategies)
6. Anticipatory postural control Ability to shift the center of mass prior to a discrete voluntary movement (eg, steppingdlifting leg, arm
raise, head turn)
7. Dynamic stability Ability to exert ongoing control of center of mass when the base of support is changing (eg, during gait,
postural transitions)
8. Sensory integration Ability to reweigh sensory information (vision, vestibular, somatosensory) when input altered
9. Cognitive influences Ability to maintain stability while responding to commands during the task or attend to additional tasks
(eg, dual-tasking)

Two of the 21 measures (9%) were initially tested in chil- control (study age, 7e18y) only, and 12 (57%) were initially
dren developing postural control (study age, <7y), 7 (33%) tested with individuals across the postural develop-
were initially tested in individuals with mature postural ment continuum.

Fig 1 Study flow diagram. Abbreviation: HAPI, Health and Psychosocial Instruments.

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 2070
Table 2 Selected characteristics of balance measures validated in pediatric populations
Initial
No. of Pediatric
Components of Balance Target Pediatric No. of Items Scoring Graded Age Range
Measure Reference Stated Purpose of Measure Purportedly Assessed Population Development Methods in Test Evaluation Parameters Categories Progression Validated
Balance Error Scoring Valovich Not specified Not specified Youth sport Developed in adult 6 (3 stances, Continuous N/A No 9e14y
System McLeod et al33 participants population 2 surfaces) (no. of errors),
(Riemann)49 criterion referenced
Modified Balance Error Hunt et al39 Evaluate postural stability Not specified High school athletes Modified from adult 4 (2 stances, Continuous N/A No 13e19y
Scoring System after concussion version adult 2 surfaces) (no. of errors),
population criterion referenced
(Riemann)49
Community Balance Wright et al38 Assess high-level balance Not specified Children with Developed in adult 20 (13 items, Categorical, criterion 4 No 7e18y
and Mobility Scale that mimics acquired brain population (Howe)50 6 performed referenced
requirements injury bilaterally)
underlying community
mobility skills
Dynamic Gait Index Lubetzky- Quantify dynamic balance Mobility function and Children developing Developed in adult 8 Categorical, criterion 4 No 8e15y
Vilnai et al30 abilities and evaluate dynamic balance in typically, children population (Shumway- referenced
individual’s ability to walking and stair- with fetal alcohol Cook and Woollacott)51
modify gait in response climbing spectrum disorder
to changing task
demands
Five Times Sit to Kumban et al26 Measure lower limb Not specified Children with mild to Developed in adult 1 Continuous (time), N/A No 6e18y
Stand Test strength and balance moderate cerebral population (Whitney et criterion referenced
ability palsy al.)52
Four Square Step Test Bandong et al37 Assess balance in the Not specified Children with Developed in adult 1 Continuous (time), N/A No 5e12y
presence of task and developmental population (Dite and criterion referenced
environmental disabilities Temple)53
constraints
Functional Reach Test Donahoe et al42 Measure distance reached Dynamic balance, Children developing Developed in adult 1 Continuous (distance), N/A No 5e15y
beyond arm’s length strength, typically population (Duncan)54 criterion referenced
while maintaining a biomechanics,
fixed standing position proprioception,
in children vestibular mechanisms,
and motor planning
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K.M. Sibley et al
www.archives-pmr.org

Components of pediatric balance measures

Table 2 (continued )
Initial
No. of Pediatric
Components of Balance Target Pediatric No. of Items Scoring Graded Age Range
Measure Reference Stated Purpose of Measure Purportedly Assessed Population Development Methods in Test Evaluation Parameters Categories Progression Validated
Ghent Developmental De Kegel et al27 Evaluate balance in Static and dynamic Children developing Not specified 35 Categorical, norm 3 Yes 18moe5y
Balance Test children from moment balance typically, children referenced (test
of independent walking diagnosed with starts from
until age of 5y mental retardation level of 3
consecutive
scores of 2 in
developmental
order,
continues
until 3
consecutive
failures in
developmental
order of test)
High-Level Mobility Kissane et al28 Quantify the mobility Not specified Young adults with Developed in adult 13 Categorical, criterion 5 or 6 No 6e16y
Assessment Tool requirements of young moderate to severe population referenced
adults with traumatic traumatic brain (Williams)55,56
brain injury for social, injury
leisure, sporting, and
employment activities
Limits of Stability Alsalaheen Not specified Dynamic postural stability Adolescents Developed in adult 1 Continuous (reaction N/A No 9th to 12th
Test et al35 population time, movement grade
velocity, center of (boys,
gravity excursion and 16.11.7y;
endpoint, directional girls,
control), criterion 15.71.4y)
referenced
Modified Star Calatayud et al40 Identify dynamic balance Dynamic balance Primary school Developed in adult 3 tasks, performed Continuous (distance), N/A N/A 10e12y
Excursion Balance deficits and students in school population, for each leg 7 criterion referenced
Test improvements, predict setting administered according times (4 practice
risk of lower extremity to recommendations by trials, 3
injury Gribble et al.57 measurement
trials)
One Leg Standing Atwater et al29 Not specified Static posture Not specified Developed in adult 1 Continuous (time), N/A No 3e14y
Balance Test population criterion referenced
Pediatric Balance Franjoine et al32 Measure of functional Functional balance Children developing Modified Berg Balance 14 Categorical, criterion 5 No 4e12y
Scale balance for children typically, children Scale58 by reordering referenced
with known test items, reducing
balance time standards,
impairments clarifying directions;
conducted pilot
reliability testing
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2071
 2072
Table 2 (continued )
Initial
No. of Pediatric
Components of Balance Target Pediatric No. of Items Scoring Graded Age Range
Measure Reference Stated Purpose of Measure Purportedly Assessed Population Development Methods in Test Evaluation Parameters Categories Progression Validated
Pediatric Reach Test Bartlett Measure balance in Not specified Children developing Primary author consulted 6 Continuous (distance), N/A No 2e12y
and children with cerebral typically, children with 3 experienced criterion referenced
Birmingham43 palsy with cerebral palsy pediatric physical
therapists to reach
agreement for content
and protocol for
modifying Functional
Reach Test
Pediatric Version of Crowe et al44 Assess the influence of Sensory interaction Children developing Developed in adult 12 (6 sensory Continuous (stance, N/A No 4e9y
Clinical Test of sensory interaction on typically population (Shumway- conditions, 2 duration, peak to peak
Sensory balance Cook and Horak)59 feet positions) amount of sway,
Interaction for qualityd type of
Balance movement strategy),
criterion referenced
Posture and Postural Rodby- Assess postural control Alignment, stability in Children with cerebral Developed in adult 4 tasks, 53 items Categorical, criterion 7 categories No 6e16y
Ability Scale Bousquet and asymmetries in static and dynamic palsy population (Rodby- referenced for postural
et al34 people with severe situations Bosquet)60 ability, 2
disabilities in 4 basic categories
body positions (supine for quality
and prone lying, of posture
sitting, and standing)
Sensory Organization Christy et al36 Determine how vestibular Not specified Children with Developed in adult 6 Continuous (amount of N/A No 6e12y
Test information is used to sensorineural population sway), criterion
control posture hearing loss referenced
Sensory Test Gabriel and Mu25 Examine organization of Relative contributions of Children developing Developed in adult 4 Continuous (sway N/A No 5e9y
sensory inputs the visual, typically population velocity), criterion
necessary to maintain somatosensory, and (Ford-Smith et al.)61 referenced
postural stability and vestibular systems to
aspects of the maintain postural
vestibule-spinal reflex stability
Timed Up and Down Zaino et al41 Measure of functional Anticipatory and reactive Children developing Not specified 1 Continuous (time), N/A No 8e14y
Stairs Test mobility and balance postural control typically, children criterion referenced
with cerebral palsy
Timed Up and Go test Williams et al31 Assess basic or functional Dynamic balance Children developing Developed in adult 1 Continuous (time), N/A No 3e9y
ambulatory mobility of typically, children population (Podsiadlo criterion referenced
62
dynamic balance with physical and Richardson) ,
disability because modified based on pilot
of cerebral palsy or tests
spina bifida
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K.M. Sibley et al
Components of pediatric balance measures 2073

Consultations with pediatric physical therapists highlighted the

Alberta Infant Motor Scale,47 Bruininks-Oseretsky Test of Motor
Age Range
Proficiency, Second Edition (BOT-2),48 and Peabody Develop-
Validated
Pediatric

1.5e5y
Initial

mental Motor Scales, Second Edition (PDMS-2)46 as commonly

used to assess balance, particularly in toddlers and preschool age
children. Although not explicit measures of balance and therefore
Progression

not included in the full review findings, conceptual mapping

(table 4) revealed that all 3 measures included at least 4 compo-
Graded

nents of balance: static stability, underlying motor systems,

No

anticipatory postural control, and dynamic stability. The BOT-2

also included sensory integration, and the PDMS-2 also
Categories
Scoring

included cognitive contributions. Two of these measures (Alberta

No. of

Infant Motor Scale and BOT-2) were initially tested in children

Categorical, converted to 5

developing postural control (study age, <7y), and 1 (PDMS-2)

criterion referenced
points with various
Evaluation Parameters

was tested with individuals across the postural develop-

weights attached,

ment continuum.

Discussion
Synthesizing the published literature on validated balance
measures for children and analyzing their content with respect to
No. of Items

contemporary postural control theory is useful for summarizing

in Test

the current state of pediatric balance measurement, and for iden-

Children with cerebral Combination of Movement 13

tifying opportunities for continued development. Furthermore,

e Automatic Reactions

engaging frontline physical therapists in vetting included

Assessment of Infants

selected by consensus
Section and Pediatric

therapist researchers
of pediatric physical
Balance scale, items
Development Methods

measures enhances the clinical utility of the results, and in this

and study team

case also identified potentially relevant measures that would not

otherwise have been included. Although >20 validated balance
measures were identified, they were not comprehensive and
assessed only some key components of balance. None of the
currently validated pediatric balance measures examine all
9 components of balance studied in this review. Although some
components were included in a high proportion of measures
Target Pediatric

(eg, underlying motor systems, anticipatory postural control, and

Population

static stability in at least 60% of measures), most measures

palsy

evaluated a limited number of balance components (3). This

finding is perhaps not unexpected given that such issues were also
identified in a previous review of balance measures for adult
Components of Balance
Stated Purpose of Measure Purportedly Assessed

populations.24 However, a critically important addition to this

Postural stability

body of literature is the finding that that pediatric balance

measures are even more restricted in their analysis of postural
control. This is exemplified by the fnding that some components,
including functional stability limits, cognitive contributions, and
verticality, were not included in most measures (less than one
quarter). Most importantly, not a single measure included an
stability in children
with cerebral palsy
across all levels of
To estimate postural

functional ability

evaluation of reactive postural control. The absence of this

component is a major limitation of existing pediatric balance
measures because reactive postural control is well recognized as
the most critical component of balance for fall avoidance.63
Impaired reactive control is independently associated with falls
in adults,64 and in children, mastery of rapid compensatory steps
Abbreviation: N/A, not available.

in walking is viewed as a key milestone during development of

McCoy et al45

effective balance recovery strategies.65 Similarly, cognitive

Reference

contributions and verticality were both underrepresented in

existing measures and are important precursors for safe mobility
(cognitive contributions) and establishing appropriate orientation
Table 2 (continued )

(verticality).12
Assessment of
Early Clinical

Although measures that evaluate a restricted subset of balance

Balance

components may be appropriate for balance screening or fall risk

Measure

assessment, a comprehensive approach is ideal for identifying

impairment and treatment planning. Currently, no combination of

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 2074
Table 3 Components of balance in measures used in pediatric populations
Underlying Functional Reactive Anticipatory Other Constructs
Static Motor Stability Postural Postural Dynamic Sensory Cognitive Not Included in
Measure Stability Systems Limits Verticality Control Control Stability Integration Influences Systems Framework
Balance Error Scoring System Yes Yes No No No No No Yes No N/A
Modified Balance Error Scoring System Yes Yes No No No No No Yes No N/A
Community Balance and Mobility Scale Yes Yes No No No Yes Yes Yes Yes N/A
Dynamic Gait Index No Yes No No No Yes Yes Yes Yes N/A
Five Times Sit to Stand Test No Yes No No No Yes Yes No No N/A
Four Square Step Test No Yes No No No Yes Yes No No N/A
Functional Reach Test No Yes Yes No No Yes No No No N/A
Ghent Developmental Balance Test Yes Yes No No No Yes Yes Yes Yes N/A
High-level Mobility Assessment Tool No Yes No No No Yes Yes No No N/A
Limits of Stability Test No Yes Yes No No Yes No No No N/A
One Leg Standing Balance Test Yes Yes No No No No No Yes No N/A
Pediatric Balance Scale Yes Yes Yes No No Yes Yes Yes No Sitting balance
Pediatric Reach Test Yes Yes Yes No No Yes No No No N/A
Pediatric Version of Clinical Test of Yes Yes No No No No No Yes No N/A
Sensory Interaction for Balance
Posture and Postural Ability Scale Yes Yes No Yes No Yes No No No Sitting balance
Sensory Organization Test Yes Yes No No No No No Yes No N/A
Sensory Test Yes Yes No No No No No Yes No N/A
Star Excursion Balance Test Yes Yes Yes Yes No Yes No No No N/A
Timed Up and Go test No Yes No No No Yes Yes No Yes N/A
Timed Up and Down Stairs Test No Yes No No No Yes Yes No No N/A
Early Clinical Assessment of Balance Yes Yes No No No Yes Yes Yes Yes Sitting balance
Abbreviation: N/A, not available.
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K.M. Sibley et al
Components of pediatric balance measures 2075

validated balance measures can provide a comprehensive assess-

Systems Framework
ment in pediatric populations. Interestingly, 2 comprehensive

Other Constructs
Not Included in
measuresdthe Balance Evaluation Systems Test (BESTest)11 and
Mini-BESTest66dhave published use in children despite no
accompanying pyschometric evaluation. The BESTest is the only
currently validated measure (for any population) containing all

N/A
N/A
N/A
9 components of balance examined in this review, and is the only
existing measure developed with the goal of helping clinicians
identify underlying postural control systems that may be respon-
Influences
Cognitive
sible for poor functional balance. First published in 2009, in 2011,
it was used in 5 children with cerebral palsy with Gross Motor

Yes
No
No Function Classification System scores between levels II and III
participating in a study of lower body positive pressureesupported
treadmill training.67 In 2012, Pickett et al68 used the Mini-
Integration

BESTest, a shortened version of the original BESTest, in a

Sensory

study of balance impairment in 9 children between the ages of

Yes
No

No

6 and 17 years with Wolfram syndrome, a rare neurodegenerative

disorder characterized by early onset diabetes, optic atrophy,
Dynamic
Stability

deafness, and neurologic abnormalities. The Mini-BESTest

includes 8 components of balance, missing only functional sta-
Yes
Yes
Yes

bility limits.24 It was recently recommended by an international

expert panel as suitable for a core outcome set or minimum data
set for research and practice in adult populations.69 Neither of
Anticipatory

these pediatric studies reported any adverse events in using either

Postural
Control

version of the BESTest. Given their inclusion of missing

Yes
Yes
Yes

components in existing pediatric balance measures, comprehen-

siveness, and endorsed use in adult populations, one or both
Components of balance in motor development measures identified by pediatric physical therapists

represent good candidates for initial validation in pediatric

Postural Control

populations.
The analysis of developmental considerations in the develop-
ment of pediatric balance measures demonstrated that >50% of
Reactive

measures were developed and/or initially validated among

No
No
No

pediatric participants across a large age range that spanned the

postural development continuum. Given the progressive develop-
ment of balance in the first 7 years, in contrast to the relative
Verticality

stabilization of development in typically developing children

around the age of 7 years, the lack of developmental specificity
No
No
No

among these measures warrants additional examination into

appropriateness for pediatric subpopulations. In particular, the
Functional

absence of dedicated standing balance measures targeted at chil-

Stability

dren between 1 and 5 years is noteworthy. Our clinician partners

Limits

identified 3 measures failing to meet the inclusion criteria because

No
No
No

they did not expressly aim to evaluate only balance, but included a
significant balance component within the context of a motor
Underlying

development framework. In some cases, the balance section was

Systems

just as comprehensive as some standalone balance measures

Motor

Yes
Yes
Yes

included in the review. However, similar to included balance

measures, none included an assessment of reactive postural con-
trol or functional stability limits or verticality. Although consul-
Stability

ting with practicing pediatric physical therapists did not identify

Static

any superior measures, the process served to increase the clinical

Yes
Yes
Yes

utility of the results by facilitating analysis of clinically relevant

Abbreviation: N/A, not available.

tools or measures that might not be flagged with common search

Alberta Infant Motor Scale

terms, strategies, or keywords.

Study limitations
Limitations to this review include the following: (1) restricting
consideration of theoretical constructs to standing postural
Measure
Table 4

PDMS-2

control (ie, framework did not include, for example, seated

BOT-2

balance), which is only 1 measure characteristic and only

1 aspect of pediatric balance; (2) no specific examination of

www.archives-pmr.org
2076 K.M. Sibley et al

evaluation parameters which might provide more precise disability and health (ICF) framework and patient management
information than observed behaviors; and (3) lack of model. Phys Ther 2011;91:416-30.
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rigorous operational definition development and duplicate balance performance in children with spastic cerebral palsy and
coding, specific codes may still be open to interpretation. For severe traumatic brain injury. Clin Rehabil 2009;23:714-24.
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contributions. However, the pediatric version had administra- deaf children. Res Dev Disabil 2014;35:3562-7.
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assessment in research and practice to facilitate individualized 13. Sibley KM, Beauchamp MK, Van Ooteghem K, Straus SE, Jaglal SB.
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components of balance evaluated in standardized balance measures:
programs in the clinical setting.
a scoping review. Arch Phys Med Rehabil 2015;96:122-132.e29.
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2010;205:153-65.
Kathryn M. Sibley, PhD, 379-753 McDermot Ave, Winnipeg, MB, 17. Tyson SF, Connell LA. How to measure balance in clinical practice.
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Components of pediatric balance measures 2078.e1

Supplemental Table S1 Sample search strategy (Ovid MEDLINE, 1946 to December Week 1, 2015)
No. Searches Results Search Type
1 Postural Balance/ 15,295 Advanced
2 ((balanc* or imbalanc* or equilibrium or disequilibrium) and (body or postur* or musculoskeletal or 3204 Advanced
disorder* or trunk or gait or walk* or abilit* or disabilit* or instabil*)).ti,kw.
3 1 or 2 17,027 Advanced
4 in.fs. 210,835 Advanced
5 mt.fs. 2,759,598 Advanced
6 Validation Studies/ 70,783 Advanced
7 exp Psychometrics/ 56,268 Advanced
8 psychometr*.ti,ab,kw. or clinimetr*.tw,kw. or clinometr*.tw,kw. 25,970 Advanced
9 exp Observer Variation/ 32,881 Advanced
10 exp “Reproducibility of Results”/ 285,816 Advanced
11 reproducib*.tw,kw. 105,188 Advanced
12 exp “Sensitivity and Specificity”/ 432,013 Advanced
13 predictive value of tests/ 148,365 Advanced
14 exp severity of illness index/ 176,797 Advanced
15 exp disability evaluation/ 40,828 Advanced
16 or/4-15 3,496,247 Advanced
17 exp Child/ 1,568,972 Advanced
18 exp Pediatrics/ 44,983 Advanced
19 exp Infant/ 950,073 Advanced
20 exp Adolescent/ 1,640,983 Advanced
21 exp minors/ 2201 Advanced
22 exp puberty/ 14,872 Advanced
23 exp School/ 83,196 Advanced
24 (Infan* or Newborn* or new-born* or Baby* or Babies or Neonat* or neo-nat* or Prenat* or pre-nat* or 1,942,667 Advanced
Preterm* or pre-term* or Prematur* or pre-matur* or Postmatur* or Post-matur* or Child* or Schoolchild*
or School age* or Preschool* or Kid or kids or Toddler* or Adoles* or Teen* or Boy* or Girl* or Minor or
Minors or Pubert* or Pubescen* or juvenil* or youth* or Prepubescen* or Paediatric* or Paediatric* or
Peadiatric* or Nursery school* or Kindergar* or Primary school* or Secondary school* or Elementary
school* or High school* or Highschool*).tw,kw.
25 or/17-24 3,585,444 Advanced
26 3 and 16 and 25 779 Advanced
27 exp animals/not (exp animals/and exp humans/) 4,003,250 Advanced
28 26 not 27 774 Advanced

www.archives-pmr.org
 Supplemental Table S2 Preliminary psychometric characteristics evaluated in index publication of included measures

2078.e2
Measure Reliability Tested Reliability Type Reliability Score Validity Tested Validity Type Validity Sample Size Validity Score
Balance Error Scoring Yes Test-retest ICCZ.75 (boys), No N/A N/A N/A
System ICCZ.61 (girls)
Modified Balance Error Yes Intraclass rZ.84 when No N/A N/A N/A
Scoring System administering 3 trials
and scoring the second
and third trials
Community Balance and Yes 1. Interrater, 2. Test- 1. ICCZ.93, 2. ICCZ.90 No N/A N/A N/A
Mobility Scale retest
Dynamic Gait Index Yes 1. Interrater, 2. Test- 1. ICCZ.82, 2. ICCZ.71 Yes Construct 20 children (10 Significantly lower score
retest developing typically, in children with FASD
10 with FASD) compared with those
with typical
development (PZ.01)
Five Times Sit to Stand Yes 1. Interrater, 2. Test- 1. ICCZ.88, 2. ICCZ.912 Yes Concurrent 33 children with cerebral 1. rZ.552 with TUG
Test retest palsy, 3 pediatric PTs (P<.01), 2. rZ.561
with BBS (P<.01)
Four Square Step Test Yes 1. Interrater, 2. Test- 1. ICCZ.79, 2. ICC range, Yes Concurrent 30 children (16 with RZ.74 with TUG (P<.01)
retest .54e.89 cerebral palsy, 14 with
down syndrome)
FRT Yes 1. Interrater, 2. 1. ICCZ.98, 2. ICCZ.83, No N/A N/A N/A
Intrarater, 3. Test- 3. ICCZ.75
retest
Ghent Developmental Yes 1. Interrater, 2. Test- 1. ICCZ.98, 2. ICCZ.99 Yes 1. Known-group, 2. 74 normally developing 1. Known-group t38Z
Balance Test retest Convergent and children and 20 .142, PZ.888;
discriminant, and 3. diagnosed with mental 2. Convergent and
Construct retardation discriminant: rZ.80
with BOT-2, rZ.60
with PDMS-2, rZ.69
with balance subscale,
and rZ.66 with M-ABC-
2; 3. Construct: rZ.92
with age
High-Level Mobility Yes 1. Interrater, 2. Test- 1. ICCZ.93, 2. ICCZ.98 Yes Concurrent 52 children with Spearman rZ.68 with
Assessment Tool retest traumatic brain injury PEDI functional skills
mobility domain
Limits of Stability Test Yes Test-retest ICCZ.73 Yes Construct (divergent and 36 adolescents No significant
www.archives-pmr.org

discriminant) correlations with BESS

total score (P>.05)

K.M. Sibley et al
Modified Star Excursion Yes Test-retest ICC range, .51e.93 No N/A N/A N/A
Balance Test
(continued on next page)
www.archives-pmr.org

Components of pediatric balance measures

Supplemental Table S2 (continued )
Measure Reliability Tested Reliability Type Reliability Score Validity Tested Validity Type Validity Sample Size Validity Score
One Leg Standing Balance Yes 1. Interrater, 2. Test- 1. Eyes open rZ1.00, No N/A N/A
Test retest eyes closed rZ.96;
2. Eyes open rZ.91
e1.00; eyes closed
rZ.59e.77
Pediatric Balance Scale Yes 1. Interrater, 2. Test- 1. ICCZ.997, No N/A N/A N/A
retest 2. ICCZ.998
PRT Yes 1. Interrater, 2. Test- 1. ICC range, .50e.93, Yes 1. Concurrent, 29 children (19 1. Construct: rZ.79 with
retest 2. ICC range, .54e.88 2. Construct developing typically, a laboratory test of
10 with CP) steadiness in quiet
stance and rZ.83 with
age, Spearman rZ0.8
with GrossMotor
Function Classification
System among the
sample of children with
cerebral palsy;
2. Concurrent: rZ.42
e.77 between the
standing section of the
PRT and laboratory
tests of limits of
stability
Pediatric Version of Yes Interrater Spearman r range, .69 No N/A N/A N/A
Clinical Test of Sensory (feet together) to .92
Interaction for Balance (heel-toe)
Posture and Postural Yes 1. Interrater, 2. Internal 1. ICCZ.77, 2. Cronbach Yes Construct 29 children with cerebral Significantly
Ability Scale consistency aZ.95e.96 palsy differentiated between
Gross Motor Function
Classification System
scores (P<.009)
Sensory Organization Test No N/A N/A Yes Discriminant 20 children with sever to Discriminated between
profound sensorineural children with
hearing loss, 23 sensorineural hearing
children developing loss and those with
typically typical development
(sensitivity, .75;
specificity, .86)
Sensory Test Yes 1. Test-retest ICC range, .76e.90 No N/A N/A N/A

2078.e3
(continued on next page)
 2078.e4
Supplemental Table S2 (continued )
Measure Reliability Tested Reliability Type Reliability Score Validity Tested Validity Type Validity Sample Size Validity Score
Timed Up and Down Stairs Yes 1. Interrater, 2. Test- 1. ICCZ.99, 2. ICCZ.94 Yes 1. Concurrent, 47 children (20 with 1. Concurrent: rZ.78
Test retest 2. Construct cerebral palsy and 27 with TUG, rZ .57 with
developing typically) FRT and rZ .77 with
TOLS; 2. Construct:
moderate correlation
with age (r range,
.61e.41; PZ.001 and
PZ.018, respectively)
TUG Yes Test-retest ICCZ.83 for children Yes Concurrent Subgroup of 22 young Moderate negative
without physical adults with cerebral correlation between
disabilities, ICCZ.099 palsy concurrently TUG scores and the
same-day retest for tested using the GMFM GMFM (rZ.524,
children with PZ.012)
disabilities
Early Clinical Assessment Yes 1. Content; 2. Construct 410 children with 1. Content: test item
of Balance cerebral palsy across all correlation range,
GMFCS Levels; age, .32e.94 (P<.0001);
1.5e5y Cronbach aZ.92;
2. Construct:
significant differences
in test scores between
GMFCS groups
(c2Z365.11, P<.001)
Abbreviations: BESS, balance error scoring system; FASD, fetal alcohol spectrum disorder; FRT, Functional Reach Test; GMFCS, gross motor function classification system; GMFM, Gross Motor Function Measure;
ICC, intraclass correlation coefficient; N/A, not available; M-ABC-2, movement assessment battery for children, second edition; PEDI, pediatric evaluation of disability inventory; PRT, Pediatric Reach Test; PT,
physical therapist; TUG, Timed Up and Go test; TOLS, timed one leg stance test.
www.archives-pmr.org

K.M. Sibley et al