The Test–Retest Reliability and Limits of Agreement of the Balance Evaluation Systems Test (BESTest) in Youth with Intellectual Disabilities—A Pilot Study

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The Test–Retest Reliability and Limits of Agreement of the Balance Evaluation Systems Test (BESTest) in Youth with Intellectual Disabilities—A Pilot Study

https://doi.org/10.21203/rs.3.rs-2572578/v1

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published 25 Sep, 2023

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Clinical tests for the assessment of postural balance in people with intellectual disabilities have been the most commonly used single-item tests or multi-item tests, but new tests have been developed, such as the BESTest. The purpose of the study was to evaluate the test–retest reliability and limits of agreement of the Balance Evaluation Systems Test (BESTest) in youth with intellectual disabilities. A descriptive cross-sectional study was conducted with 65 youth (ages 16–25 years) with intellectual disabilities. The BESTest (27 items) was completed twice by the participants. Intraclass correlation coefficients (ICC), 95% confidence intervals (CIs), and standard error of measurement (SEM) were calculated to determine the test–retest reliability of the BESTest. The BESTest overall scores' test-retest reliability was rated as excellent (0.75). Stability limits/verticality, reactive fair to good (≥ 0.40–<0.75) and biomechanical constraints, transitions/anticipatory, transitions/anticipatory, sensory orientation, and stability in gait excellent (≥ 0.75). Current evidence suggests that children with intellectual disabilities have impaired postural balance. However, there appears to be a lack of assessment tools that reliably evaluate the postural balance of this population. The results from this investigation suggest that the BESTest provides "excellent reliability" (≥ 0.75) to assess postural balance in youth with intellectual disabilities.

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BESTest

Reliability

Intellectual Disability

Intellectual disabilities (IDs) are a type of neurodevelopmental disorder that is characterized by limitations in both intellectual and adaptive functioning behaviors ¹. Adaptive behavior is defined as the conceptual, social, and practical skills involving tasks performed by persons in their everyday lives ². Youth with IDs mostly show, to a greater or lesser extent, delays in maturation and motor growth, which limits their functional levels. Among the motor skills, postural control is one in which people with IDs present more limitations ^3,4. This phenomenon can be explained by the physiopathology of IDs, which usually involves some degree of incomplete development of the central nervous system (CNS), which controls motor and cognitive functions ⁵. Furthermore, these people age prematurely, and, as in the case of healthy people, their postural control deteriorates with age due to the decline of the various postural control subsystems (primarily the somatoaesthetic, vestibular, and visual subsystems) ⁶. Studies have exhibited that gait deceleration can be an early indicator of balance decline ^7,8. In youth with IDs, a variety of evaluation tools for motor development and skill are commonly used.

The clinical tests for the evaluation of balance and gait that has been most commonly used in this population are: the Berg Balance Scale (BBS) ⁹, the Tinetti Scale ³, Single-leg Stance ¹⁰, the Functional Reach Test (FRT) ^10,11, the Lateral Reach Test (LRT) ^10,11, the Biodex Balance System (BBS) ^12,13, the Force Plate, and the Timed Up and Go (TUG) ^10,11. These functional balance scales are useful in reporting the presence of balance disorders, but they cannot identify the type of disorders underlying balance disorders. However, performance balance tests usually examine the performance in a series of tests; in evaluating the functional balance, single-item tests or multi-item tests are usually applied ¹⁴. Tests including items such as tandem standing and standing on one foot provide less information about balance disorders. On the contrary, multi-item tests can provide much more useful information ¹⁵. Postural control will no longer be considered as one system or group of balance and postural reflexes. Postural control is a complicated skill that is composed of a compromise between sensorimotor processes ¹⁶. According to these cases, recently, the Balance Evaluation Systems Test (BESTest) has been developed based on a conceptual model of balance control in which six different systems or domains contribute to balance control. The BESTest evaluates the following systems: biomechanical constraints, stability limits, and verticality; anticipatory postural adjustments; automatic postural responses; sensory organization; and stability in gait ^2,17.

This tool is a special assessment for any age and any severity of the following: Parkinson's disease, cerebral ataxia disorders, vestibular disorders, neuropathy, brain damage, multiple sclerosis, brain stroke, cerebral palsy, intellectual and recognition disorders (IDs and Down syndrome), and other balance disorders ^18,19.

However, in previous studies, just some aspects of postural control have been taken into consideration, and that's due to the lack of a comprehensive clinical evaluation for IDs people. For example, in children with a nervous disorder, measuring the probable disorders in all the systems involved with postural control is important. For example, children with cerebral palsy have demonstrated disorders in anticipatory mechanisms (feed-forward postural adjustments), musculoskeletal systems (muscular strength and the joint range of motion required for static balance), and sensory systems (visual functions and proprioception). This study shows how a population can experience a wide range of postural control conditions and also how a lack of a comprehensive clinical evaluation exists for the so-called people with IDs. Out of the present clinical evaluations for measuring model postural disorders in people, none evaluates all the systems involved with postural control, and a large amount of the data is limited ^19,20.

However, the test-retest reliability of the BESTest for youth with IDs remains unclear. Thus, the purpose of this investigation was to evaluate the test-retest reliability of the BESTest for measuring postural balance in youth with IDs.

Participants

Sixty-five youths with IDs (25 females and 40 males), ages 16 to 25 years old, volunteered to participate in the investigation. IDs with IQs ranging from 50 to 70 were chosen from intellectual disability centers and special education schools in the provinces of Guilan and Ardabil (Table 1). The inclusion criteria were (a) age 16–25 years; (b) a diagnosis of ID defined by a full-scale IQ < 70 obtained on an individually administered test of intelligence, and (c) being able to follow simple commands cognitively. individuals with coexisting neurologic or cardiovascular impairments were excluded. Individuals who had received any physical or exercise training during the study period were also excluded.

Procedures

All participants came to the research laboratory for three visits. During the first visitation, a detailed explanation of the study protocol was provided to the participants as well as their parents and/or educators. After the explanation of the study, parents, and educators provided informed satisfaction, and the participants signed an agreement. Anthropometric assessments of each participant’s height and weight were completed. Parents and guardians reported the date of birth and IQ of their children. Finally, the BESTest was completed by the participants. Only on the second and third visits did the participants complete the BESTest. To account for any training effect, all visits were separated by at least two weeks. No intervention or other testing by the current researchers was implemented between the visits. The participant's parents or guardians did not report any other intervention or testing during this time, and participants were encouraged to maintain their typical activity behaviors. Before each assessment, a trained researcher performed a demonstration.

Ethics statement and consent to participate. This study was approved by the Ethics Review Committee of the Guilan University of Medical Sciences and all participants signed informed consent (No. IR. GUMS.REC.1397.021) and follows the guidelines of the declaration of Helsinki 2013.

Balance Evaluation Systems Test (BESTest)

BESTest is a quantitative evaluation method aimed at detecting the faulty systems underpinning postural control responsible for the poor functional balance. 2009 saw the development of BESTest. It has 27 activities (items), which are broken up into six divisions and grouped to show how well a particular balancing control system works (biomechanical constraints, stability limits or verticality, anticipatory postural adjustments, postural responses, sensory orientation, and stability in gait). Which balance control system is malfunctioning may be determined, which helps to target the therapy. The ABC scale has been used to assess concurrent validity (r = 0/636, p = 0.01). The examination's durability was 0.91, while each system's durability ranged from 0.79 to 0.96 ^18,21. This item may receive a maximum score of 15 to 21. NHS domain 0 performs the poorest, whereas domain 3 performs the best. Each of these tests must be completed in 30 minutes for each examinee. Please refer to the Supplementary Material (Appendix 1) for further details regarding the instructions for the test, the required tools, and the performance.

Statistical Analysis

Data were analyzed using SPSS version 22. Participants' descriptive characteristics are presented as mean standard deviation (SD). Because all participants completed each assessment in the BESTest, data from all participants (n = 65) were analyzed. The best score for each trial of the assessments was used in the analysis. To determine the test–retest reliability of the BESTest, intraclass correlation coefficients (ICCs) and 95% confidence intervals (CIs) were calculated. A two-way mixed model approach, mean rating of 1 (k = 1) ,and absolute agreement were used. The single-measure ICC and 95% CIs are reported. Reliability was classified based on Shrout and Fleiss (1979) standards, in which an ICC < 0.40 was considered to have "poor" reliability, 0.40 to 0.75 was considered to have "fair to good" reliability, and > 0.75 was considered to have "excellent" reliability ²². The formula (SEM = SD _{1st Test} × √ (1-ICC)) was used to calculate the standard error of measurement (SEM). These statistics indicate the error associated with the specific assessments. We then calculated the minimal detectable change (MDC) based on the SEM, as follows: MDC = 1.96 ×SEM×√2. Significance was set at an alpha level of P < 0.05.

Fifteen youths participated in the study. Demographic information for the participants is presented in Table 1. BEST overall scores and test-retest reliability were rated excellent (ICC = 0.92, 95% CI: 0.87 to 0.95, p < 0.001, SEM = 2.48, MDC: 6.87). The test–retest reliability results are presented for each of the subtests in Table 2. Eight assessments were considered to have “fair to good” reliability (Stability Limits/Verticality and Reactive) (n = 8) and the remaining assessments (Biomechanical Constraints, Transitions/Anticipatory, Sensory Orientation ,and Stability in Gait) had excellent reliability (n = 19) (Table 2). The SEM for the subtest assessments ranged from 1.95 to 7.23; specific values for the individual assessments are included in Table 2. Also, the MDC for the subtest assessments ranged from 5.40 to 20.04; specific values for the individual assessments are included in Table 2.

Table 1

Descriptive characteristics (n = 65; mean + SD; range).
Characteristics	Mean + SD; (range)
Age (years)	21.20 ± 4.81(16–25)
Weight (kg)	65.73 ± 15.86(41.60–97.50)
Height (cm)	161.13 ± 8.34(151–176)
BMI (kg/m2)	25.12 ± 4.79(18.01–31.84)
Male Female	61% 39%
IQ	50–70

Table 2

BESTest subtest percent scores, intraclass correlations (95% CI), standard error of the measurement, minimal detectable change ,and subtest scores (N = 65)
BESTest subtest	Trial 1 Mean ± SD; (Range)	Trial 2 Mean ± SD; (Range)	Trial 3 Mean ± SD; (Range)	ICC (95% CI)	SEM	MDC	Classification of Subtest ICCs	No. of Subtests (%)	Absolute limits (95%)
Biomechanical Constraints Base of Support COM Alignment Ankle Strength & Range Hip/Trunk Lateral Strength Sit on Floor and Standup	59.18 ± 11.27; (46.67–80)	59.10 ± 11.54; (46.67–80)	58.36 ± 11.79; (46.67–80)	0.97 (0.98 to 0.96)	1.95	5.40	Excellent reliability (≥ 0.75)	5/27(18.52%)	0.10 (-8.06-8.26)
Stability Limits/Verticality Sitting Verticality and Lateral Lean Functional Reach Forward Functional Reach Lateral	69.67 ± 9.91; (47.62–85.71)	69.89 ± 10.28; (47.62–85.71)	69.81 ± 7.91; (47.62–85.71)	0.69 (0.54 to 0.81)	5.52	15.30	Fair to good reliability (≥ 0.40–<0.75)	3/27(11.11%)	-0.22 (-21.50-21.07)
Transitions/Anticipatory Sit to Stand Rise to Toes Stand on One Leg Alternate Stair Touching Standing Arm Raise	71.37 ± 7.75; (55.56–88.89)	71.62 ± 8.84; (71.62–83.33)	74.19 ± 8.12; (61.11–83.33)	0.85 (0.77 to 0.90)	2.99	8.29	Excellent reliability (≥ 0.75)	5/27(18.52%)	-0.26 (-12.34-11.83)
Reactive In Place Response- Forward In Place Response - Backward Compensatory Stepping Correction- Forward Compensatory Stepping Correction - Backward Compensatory Stepping Correction -lateral	60.34 ± 12.22; (33.33–83.33)	63.08 ± 12.44; (33.33–88.89)	62.31 ± 12.90; (33.33–83.33)	0.65 (0.47 to 0.77)	7.23	20.04	Fair to good reliability (≥ 0.40–<0.75)	5/27(18.52%)	-2.73 (-30.77-25.30)
Sensory Orientation Sensory Integration for Balance (Modified CTSIB) Incline- Eyes Closed	76.31 ± 8.42; (60.00–86.67)	77.84 ± 7.91; (60.00–86.67)	77.33 ± 8.15; (60.00–86.67)	0.85 (0.77 to 0.90)	3.26	9.04	Excellent reliability (≥ 0.75)	2/27(7.40%)	-1.54 (-16.65-13.57)
Stability in Gait Gait – Level Surface Change in Gait Speed Walk with Head Turns – Horizontal Walk with Pivot Turns Step over Obstacles Timed “Get UP & GO” Timed “Get Up & Go” With Dual Task	57.10 ± 7.64; (47.62–71.43)	57.73 ± 7.64; (47.62–71.43)	58.02 ± 6.46; (47.62–71.43)	0.82 (0.73 to 0.89)	3.24	8.98	Excellent reliability (≥ 0.75)	7/27(25.92%)	-0.66 (-14.25-12.93)
Percent Total Score	65.41 ± 8.76; (49.07–82.41)	66.28 ± 6.06; (53.70–77.78)	66.45 ± 5.94; (52.78–77.78)	0.92 (0.87 to 0.95)	2.48	6.87	Excellent reliability (≥ 0.75)	27/27(100%)	-0.87 (-10.46-8.72)

ICC, intraclass correlation coefficient; MDC, minimal detectable change; SEM, standard error of measurement agreement.

Figure 1 shows the differences between test and retest plotted against their means for each subject with 95% CI and 95% Limits of Agreement (LOA). The systematic errors (mean difference between test and retest) for the analyzed test were nearly zero, and the 95% limits of agreement were narrow, indicating good reliability of the measurement.

This study aimed to determine the test-retest reliability of the BESTest in youth with IDs. Overall, the BESTest appeared to be a reliable test for assessing postural control in youth with IDs for epidemiological research aimed at determining the effects of interventions designed to improve physical function in this population. To the authors’ knowledge, no studies have considered the test-retest reliability of the BESTest in youth with IDs. Postural control tests that have low or otherwise senseless reliability coefficients should not be used to assess postural control in people with IDs. Given that existing tools for assessing clinical balance cannot assist the therapist in diagnosing the underlying causes of balance disorder, BESTest can distinguish balance subsystems and can purposefully plan the treatment process.²¹.

Several statistical methods and indices have been proposed to test the reliability of outcome assessment, but it was forcefully suggested that both relative and absolute reliability should be introduced ²³. For relative reliability, the ICC is the most generally used statistical method because it shows the level of agreement among tests. For absolute reliability, the SEM can reflect the reliability of the response with a 95% CI, which provides useful information relevant to the actual value of real change²⁴.

Six subsystems underlying control of balance that are targeted in the new Balance Evaluation Systems Test (BESTest) involve the integration of biomechanical constraints, stability limits and verticality, anticipatory postural adjustments, postural responses, sensory orientation, and stability in gait regarding body position and motion with the ability to generate forces to control body position. Each system consists of neurophysiological mechanisms that control a particular aspect of postural control. Our results are consistent with findings from studies in other various populations, such as people with stroke, Parkinson’s disease, spinal cord injury, and multiple sclerosis, and also in people with balance disorders and people with an increased risk of falling ^25–30. These studies provide ICC values for total scores ranging from.80 to.97, measurement errors ranging from and MDC ranging from 2.4 to 5.2.

In our study, excellent reliability was found for both the biomechanical constraints, transitions and anticipatory, sensory orientation, and stability in gait sections, which is consistent with the results from studies in people with Parkinson’s disease ²⁷ and Multiple Sclerosis³⁰, and in people with increased risk of falling.

On the other hand, studies such as Villamonte et al. measured test-retest reliability scores on 16 balance tests in children, teenagers, and young adults with ID. Among the tests conducted are the STS (20 s long) and the TUG (9 m distance), the former being reliable (ICC > 50) only in young women and young men, while the latter is not reliable for any group of ID. Among the limitations of the study are its small sample (21 people) and very varied age range (5–31 years old)³¹.

PH Boer and S.J. Moss explored the test-retest reliability and minimal detectable change of selected functional fitness test items in adults with ID. The results indicated all tests showed excellent results (ICCs > 0.9). All SEM values demonstrated acceptable measurement precision (SEM < SD/2). Values for MDC90 are provided for all 12 tests ³².

The Consensus-Based Standards for the Selection of Health Measurement Instruments initiative defines domain reliability as "the degree to which the measurement is free from measurement error," which implies that scores for unchanged patients are constant in repeated measurements. Estimations of the MDC and limits of agreement (Fig. 1) are important to define the change and the boundaries that need to be exceeded to show a change beyond the measurement error, that is, a "true" change. The current study's findings indicate that a change of 10 points or more in the BESTest total score is required to determine a "true" change in balance control in IDs. However, if the sample consists of only IDs, a change of 10 points or more is needed.

In this study, the kappa values for all items except items 2 and 4 were considered excellent. The kappa value for items 2 and 4 included in the section on stability limits/ verticality, and reactive postural control was fair to good. This contributed to the lower reliability found in this section compared with the other BESTest sections. The assessment of items 2 and 4 on the first test occasion seemingly caused a learning effect that biased the assessment on the second test occasion; that is, the learning effect caused anticipation when the item was reassessed, which made the performance of the item less reactive and more proactive ³⁰.

The results of this investigation suggest that the BESTest is a reliable test that can be used to assess overall postural control in youth with IDs. This study has several strengths, including the use of a single researcher to collect all of the data to ensure the consistency of the assessments. Nevertheless, there are some limitations to this study. First, results from this study are valid for individuals with IDs; they cannot be generalized to subjects with other sub-types of IDs. Second, data were not collected on socioeconomic status or sports that the participants practiced. These factors may influence postural control levels. The average age of the participants was 21.1 years old, which may have influenced postural control as older youths may have performed better on the BESTest when compared to adults and individuals. Due to the potential impact that balance proficiency has on physical activity levels and the overall health of individuals, including those with IDs, it is paramount for clinicians and researchers to determine if these tests are reliable. The BESTest, which is often used in a variety of settings, might be a feasible assessment tool.

Data availability

The datasets generated during and analyzed during the current study are not publicly available due to privacy and restrictions but are available from the corresponding author upon reasonable request.

Author contributions

S.B. & E.H.: data acquisition and analysis. S.B.& E.H. & R.A.J.: data interpretation. S.B.: wrote the main manuscript text and prepared the figures. E.H. & R.A.J.: conception/design of the work. All authors reviewed and contributed to the manuscript.

Competing interests

The authors declare no conflict of interest.

Additional information

Supplementary Information

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No competing interests reported.

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The Test–Retest Reliability and Limits of Agreement of the Balance Evaluation Systems Test (BESTest) in Youth with Intellectual Disabilities—A Pilot Study

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Abstract

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Introduction

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Participants

Procedures

Balance Evaluation Systems Test (BESTest)

Statistical Analysis

Results

Discussion

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References

Additional Declarations

Supplementary Files

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