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Components of Standing Postural Control Evaluated in Pediatric Balance Measures: A Scoping Review

Open AccessPublished:April 21, 2017DOI:https://doi.org/10.1016/j.apmr.2017.02.032

      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.

      Keywords

      List of abbreviations:

      BESTest (Balance Evaluation Systems Test), BOT-2 (Bruininks-Oseretsky Test of Motor Proficiency, Second Edition), PDMS-2 (Peabody Developmental Motor Scales, Second Edition)
      Balance is defined as the ability to control the center of mass relative to the base of support.
      • Shumway-Cook A.
      • Woollacott M.H.
      Motor control translating research into clinical practice.
      Described as both a structure/function and activity within the International Classification of Functioning, Disability and Health framework,
      • Atkinson H.L.
      • Nixon-Cave K.
      A tool for clinical reasoning and reflection using the international classification of functioning, disability and health (ICF) framework and patient management model.
      the ability to achieve and maintain balance in upright stance is a critical and complex lifelong skill. Commonly observed impairments in postural control among pediatric populations, traditionally defined as those ≤18 years, are associated with delayed motor development and mobility function.
      • Saether R.
      • Helbostad J.L.
      • Riphagen II,
      • Vik T.
      Clinical tools to assess balance in children and adults with cerebral palsy: a systematic review.
      • Zylka J.
      • Lach U.
      • Rutkowska I.
      Functional balance assessment with pediatric balance scale in girls with visual impairment.
      Fortunately, impairments in standing balance can be effectively treated through therapeutic exercise.
      • Katz-Leurer M.
      • Rotem H.
      • Keren O.
      • Meyer S.
      The effects of a ‘home-based' task-oriented exercise programme on motor and balance performance in children with spastic cerebral palsy and severe traumatic brain injury.
      • Majlesi M.
      • Farahpour N.
      • Azadian E.
      • Amini M.
      The effect of interventional proprioceptive training on static balance and gait in deaf children.
      • Cheldavi H.
      • Shakerian S.
      • Shetab Boshehri S.N.
      • Zarghami M.
      The effects of balance training intervention on postural control of children with autism spectrum disorder: role of sensory information.
      Accordingly, assessment of postural control in standing is important for monitoring development, diagnosing impairments, planning treatment programs, and evaluating change in pediatric populations.
      The assessment of standing balance in pediatric populations is complicated both by its multicomponent structure and by the influence of development on postural control. The multicomponent nature of balance is reflected in contemporary postural control theory, which has adopted a systems perspective that conceptualizes balance as the product of interaction among multiple biologic systems in a continuously changing environment.
      • Bernstein N.
      Co-ordination and regulation of movements.
      • Horak F.B.
      • Macpherson J.M.
      Postural orientation and equilibrium.
      • Woollacott M.H.
      • Shumway-Cook A.
      Changes in postural control across the life span- a systems approach.
      • Horak F.B.
      • Wrisley D.M.
      • Frank J.
      The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits.
      Although no unified description of a systems perspective to postural control has been ratified, the approach is supported by evidence from multiple laboratories demonstrating how imposed constraints or deficits in ≥1 underlying systems impair balance and affect development of postural control.
      • Horak F.B.
      Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls?.
      Commonly described balance components in pediatric and adult populations include underlying motor system elements (eg, strength, coordination), static stability during quiet standing, limits of stability affecting the ability to move the center of mass as far as possible within the base of support, orienting relative to gravity, postural reactions to recover stability, anticipatory adjustments prior to discrete voluntary movements, dynamic stability when the base of support changes, integrating sensory information, and influence of cognitive processing on the maintenance of stability (table 1).
      • Woollacott M.H.
      • Shumway-Cook A.
      Changes in postural control across the life span- a systems approach.
      • Horak F.B.
      Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls?.
      • Gaertner C.
      • Bucci M.P.
      • Obeid R.
      • Wiener-Vacher S.
      Subjective visual vertical and postural performance in healthy children.
      • Boonyong S.
      • Siu K.C.
      • van Donkelaar P.
      • Chou L.S.
      • Woollacott M.H.
      Development of postural control during gait in typically developing children: the effects of dual-task conditions.
      • Girolami G.L.
      • Shiratori T.
      • Aruin A.S.
      Anticipatory postural adjustments in children with typical motor development.
      A systems perspective to postural control highlights the importance of considering each component individually because each can independently lead to balance impairment. Furthermore, development of each of these components takes place over multiple years, with neurophysiologic and biomechanical evidence suggesting that adult-like postural control requires approximately 7 years from birth to mature.
      • Shumway-Cook A.
      • Woollacott M.H.
      Motor control translating research into clinical practice.
      As such, there is much diversity regarding how pediatric balance may be expected to present within this time frame.
      Table 1Components of balance operational definitions
      • Sibley K.M.
      • Beauchamp M.K.
      • Van Ooteghem K.
      • Straus S.E.
      • Jaglal S.B.
      Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review.
      ComponentDefinition/Example
      1. Functional stability limitsAbility 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 systemsFor example, strength or coordination
      3. Static stabilityAbility 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, tandem—any standing condition)
      4. VerticalityAbility to orient appropriately with respect to gravity (eg, evaluation of lean)
      5. Reactive postural controlAbility 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 controlAbility to shift the center of mass prior to a discrete voluntary movement (eg, stepping—lifting leg, arm raise, head turn)
      7. Dynamic stabilityAbility to exert ongoing control of center of mass when the base of support is changing (eg, during gait, postural transitions)
      8. Sensory integrationAbility to reweigh sensory information (vision, vestibular, somatosensory) when input altered
      9. Cognitive influencesAbility to maintain stability while responding to commands during the task or attend to additional tasks (eg, dual-tasking)
      The intersection of systems and developmental considerations on postural control emphasizes the need for assessment of each component and tailored treatment on a case-by-case basis. Choosing an appropriate measure of balance has important implications for diagnosis, prognosis, and treatment, and content validity should be a primary consideration given the recognized absence of a criterion standard for evaluating balance.
      • Tyson S.F.
      • Connell L.A.
      How to measure balance in clinical practice. A systematic review of the psychometrics and clinical utility of measures of balance activity for neurological conditions.
      However, evidence based on adult data suggests that commonly used measures of standing balance do not comprehensively assess postural control. A 2015 scoping review of 66 standing balance measures validated in adult populations showed that most did not examine all relevant balance components for functional mobility and fall avoidance.
      • Sibley K.M.
      • Beauchamp M.K.
      • Van Ooteghem K.
      • Straus S.E.
      • Jaglal S.B.
      Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review.
      Although recent reviews of postural control assessment and functional balance tests in pediatric populations have focused on specific impairments,
      • Pavao S.L.
      • dos Santos A.N.
      • Woollacott M.H.
      • Rocha N.A.
      Assessment of postural control in children with cerebral palsy: a review.
      psychometric properties, and some components of balance,
      • Verbecque E.
      • Lobo Da Costa P.H.
      • Vereeck L.
      • Hallemans A.
      Psychometric properties of functional balance tests in children: a literature review.
      none have explored the content of the measures using a comprehensive systems perspective. Furthermore, to our knowledge, no reviews to date have examined the stage of postural development considered in the development of pediatric balance measures.
      Systematically examining the underlying constructs in pediatric balance measures is critical to improving understanding of the strengths and limitations of balance measures, and for facilitating selection of optimal measures for clinical use and future research. The primary objectives of this study were (1) to identify measures of standing balance for pediatric populations, and (2) to determine the components of standing postural control captured in each measure using a systems perspective. A secondary objective was to examine how developmental considerations for balance were accounted for in the development or initial pediatric testing of each measure. The review was guided by the following question: Which components of standing postural control are evaluated in balance measures whose validity or reliability are established in pediatric populations (≤18y)? The findings may be useful in developing recommendations for more standardized use of balance outcome measures in pediatric rehabilitation research and clinical practice.

      Methods

      A scoping review was conducted.
      • Arksey H.
      • O'Malley L.
      Scoping studies: towards a methodological framework.
      Scoping reviews are rigorous knowledge syntheses that comprehensively summarize evidence to inform policy, practice, and future research.
      • Colquhoun H.L.
      • Levac D.
      • O'Brien K.K.
      • Straus S.
      • Tricco A.C.
      • Perrier L.
      • et al.
      Scoping reviews: time for clarity in definition, methods, and reporting.
      We applied Arksey and O'Malley's 5-stage framework for scoping reviews
      • Arksey H.
      • O'Malley L.
      Scoping studies: towards a methodological framework.
      and incorporated recent recommendations for enhancing this methodology
      • Levac D.
      • Colquhoun H.
      • O'Brien K.
      Scoping studies: advancing the methodology.
      • Daudt H.M.
      • van Mossel C.
      • Scott S.J.
      Enhancing the scoping study methodology: a large, inter-professional team's experience with Arksey and O'Malley's framework.
      (eg, using an iterative approach to develop the research question with stakeholder involvement, defining relevant concepts, including quality indicators in the eligibility criteria). Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations for systematic review conduct and reporting
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      also informed the methodology, and were adopted where appropriate.

      Data sources and searches

      A professional librarian developed the search strategy, which was reviewed by a second librarian. Published literature indexed in MEDLINE (1946 to December 1, 2015), Embase (1974 to December 1, 2015), and CINAHL (1981 to December 1, 2015) was searched. Combinations of the following terms were used: postural balance/equilibrium, psychometrics/reproducibility of results/predictive value of tests, and child/pediatrics. A sample search strategy for MEDLINE is presented in supplemental table S1 (available online only at http://www.archives-pmr.org/). A comprehensive hand search was also conducted to identify measures not captured by database searches, including a search of published narrative review articles describing balance measures identified in the database search, the Health and Psychosocial Instruments database, and a search for pediatric validation of measures identified in a previous scoping review of balance measures for adult populations.
      • Sibley K.M.
      • Beauchamp M.K.
      • Van Ooteghem K.
      • Straus S.E.
      • Jaglal S.B.
      Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review.
      In addition, a local team of practicing pediatric physical therapists were consulted to identify additional measures commonly used to assess balance potentially not identified by the search.

      Study selection

      Level one title and abstract screening criteria included descriptive studies which (1) focused on balance measurement, (2) included pediatric populations (≤18y), and (3) were published in the English language. Screening criteria were piloted on a random 10% sample of abstracts and clarified where necessary. The search was specific for index publications—a measure's first publication presenting its development and/or initial psychometric evaluation—and/or initial psychometric evaluation in pediatric 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 from the abstract, the names of all balance measures identified in the abstract screen were recorded for manual cross-checking and hand search for the index publication. Teams of 2 research assistants with health sciences backgrounds and graduate research training independently screened abstracts of studies identified in the database search using the screening criteria. The principal investigator, who also reviewed the list of all measures identified in the abstract screening, resolved disagreements and flagged relevant abstracts for follow-up hand search. The principal investigator had an educational background in kinesiology with graduate training in rehabilitation and medical sciences focused on fundamental and clinical research in postural control.
      Level 2 full-text screening criteria included (1) index publication in pediatric population, (2) have a stated objective or commonly used to assess balance, (3) include at least 1 standing task, (4) have both a standardized testing protocol and standardized evaluation criteria, and (5) evaluate a minimum of 1 psychometric property (validity or reliability). The last criterion (minimum of 1 psychometric property evaluated) was included for quality assessment purposes to prevent inclusion of measures with no 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 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. Full-text screening was performed by teams of 2 research assistants, with disagreements resolved by the principal investigator. The preliminary list of included measures was reviewed and discussed by a local team of practicing pediatric physical therapists to confirm inclusion of all known relevant measures.

      Data extraction and quality assessment

      Descriptive data abstraction was performed by teams of 2 research assistants and reviewed by the principal investigator. A standardized template was used to extract the measures' stated purpose and development methods, characteristics (evaluation parameters and number of items), and results of preliminary psychometric testing (pediatric population and age range, and reliability and/or validity).
      The components of balance evaluated in each measure were explored by coding the individual test items and tasks using a systems perspective to postural control. Operational definitions for 9 components of balance were applied from a previous review of standing balance measures in adult populations
      • Sibley K.M.
      • Beauchamp M.K.
      • Van Ooteghem K.
      • Straus S.E.
      • Jaglal S.B.
      Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review.
      after confirming that all components were identified as relevant to pediatric populations in the literature.
      • Woollacott M.H.
      • Shumway-Cook A.
      Changes in postural control across the life span- a systems approach.
      • Gaertner C.
      • Bucci M.P.
      • Obeid R.
      • Wiener-Vacher S.
      Subjective visual vertical and postural performance in healthy children.
      • Boonyong S.
      • Siu K.C.
      • van Donkelaar P.
      • Chou L.S.
      • Woollacott M.H.
      Development of postural control during gait in typically developing children: the effects of dual-task conditions.
      • Girolami G.L.
      • Shiratori T.
      • Aruin A.S.
      Anticipatory postural adjustments in children with typical motor development.
      Several pediatric balance measures were identical to the adult version (with respect to test items, evaluation criteria, and referenced associated index publication for adult populations), and the coding scheme from the previous scoping review of adult balance measures
      • Sibley K.M.
      • Beauchamp M.K.
      • Van Ooteghem K.
      • Straus S.E.
      • Jaglal S.B.
      Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: a scoping review.
      was adopted for these pediatric measures. For all other pediatric measures, 2 investigators independently reviewed the tasks and scoring criteria of each measure and identified on a binary scale (yes/no) which balance components were included in each measure. Individual components were defined as included if they were integral to task performance, even if not explicitly part of the measure's evaluation criteria. Shumway-Cook and Woollacott's reference
      • Shumway-Cook A.
      • Woollacott M.H.
      Motor control translating research into clinical practice.
      of 7 years to reach postural maturity was used to determine whether each measure's initial development and psychometric testing occurred in children who were in the development phase of postural control (study age, <7y), fully matured (study age, 7–18y), or crossed the postural development continuum. Disagreements were resolved through consensus discussion with a third investigator.

      Data synthesis and analysis

      Figure 1 illustrates the study selection process. The MEDLINE, CINAHL, and Embase searches yielded a total of 1405 records. The hand search and Health & Psychosocial Instruments search yielded an additional 59 records. After removing duplicates, 1283 abstracts were identified for screening. Of these, 155 articles were selected for full-text review. After full-text screening, 21 measures met the inclusion criteria.
      • Gabriel L.S.
      • Mu K.
      Computerized platform posturography for children: test-retest reliability of the sensory test of the VSR System.
      • Kumban W.
      • Amatachaya S.
      • Emasithi A.
      • Siritaratiwat W.
      Five-times-sit-to-stand test in children with cerebral palsy: reliability and concurrent validity.
      • De Kegel A.
      • Baetens T.
      • Peersman W.
      • Maes L.
      • Dhooge I.
      • Van Waelvelde H.
      Ghent developmental balance test: a new tool to evaluate balance performance in toddlers and preschool children.
      • Kissane A.L.
      • Eldridge B.J.
      • Kelly S.
      • Vidmar S.
      • Galea M.P.
      • Williams G.P.
      High-level mobility skills in children and adolescents with traumatic brain injury.
      • Atwater S.W.
      • Crowe T.K.
      • Deitz J.C.
      • Richardson P.K.
      Interrater and test-retest reliability of two pediatric balance tests.
      • Lubetzky-Vilnai A.
      • Jirikowic T.L.
      • McCoy S.W.
      Investigation of the Dynamic Gait Index in children: a pilot study.
      • Williams E.N.
      • Carroll S.G.
      • Reddihough D.S.
      • Phillips B.A.
      • Galea M.P.
      Investigation of the timed ‘up & go' test in children.
      • Franjoine M.R.
      • Gunther J.S.
      • Taylor M.J.
      Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment.
      • Valovich McLeod T.C.
      • Barr W.B.
      • McCrea M.
      • Guskiewicz K.M.
      Psychometric and measurement properties of concussion assessment tools in youth sports.
      • Rodby-Bousquet E.
      • Persson-Bunke M.
      • Czuba T.
      Psychometric evaluation of the Posture and Postural Ability Scale for children with cerebral palsy.
      • Alsalaheen B.
      • Haines J.
      • Yorke A.
      • Broglio S.P.
      Reliability and construct validity of limits of stability test in adolescents using a portable forceplate system.
      • Christy J.B.
      • Payne J.
      • Azuero A.
      • Formby C.
      Reliability and diagnostic accuracy of clinical tests of vestibular function for children.
      • Bandong A.N.
      • Madriaga G.O.
      • Gorgon E.J.
      Reliability and validity of the Four Square Step Test in children with cerebral palsy and Down syndrome.
      • Wright F.V.
      • Ryan J.
      • Brewer K.
      Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury.
      • Hunt T.N.
      • Ferrara M.S.
      • Bornstein R.A.
      • Baumgartner T.A.
      The reliability of the modified Balance Error Scoring System.
      • Calatayud J.
      • Borreani S.
      • Colado J.C.
      • Martin F.
      • Flandez J.
      Test-retest reliability of the Star Excursion Balance Test in primary school children.
      • Zaino C.A.
      • Marchese V.G.
      • Westcott S.L.
      Timed up and down stairs test: preliminary reliability and validity of a new measure of functional mobility.
      • Donahoe B.
      • Turner D.
      • Worrell T.
      The use of functional reach as a measurement of balance in boys and girls without disabilities ages 5 to 15 years.
      • Bartlett D.
      • Birmingham T.
      Validity and reliability of a pediatric reach test.
      • Crowe T.K.
      • Deitz J.C.
      • Richardson P.K.
      • Atwater S.W.
      Interrater reliability of the pediatric clinical test of sensory interaction for balance.
      • McCoy S.W.
      • Bartlett D.J.
      • Yocum A.
      • et al.
      Development and validity of the early clinical assessment of balance for young children with cerebral palsy.
      During review and consultation with the local team of practicing pediatric physical therapists, an additional 3 measures were identified that included a clinically relevant standing balance component within a broader developmental motor measure.
      • Folio M.
      • Fewell R.
      Peabody Developmental Motor Scales – second edition.
      • Piper M.C.
      • Pinnell L.E.
      • Darrah J.
      • Maguire T.
      • Byrne P.J.
      Construction and validation of the Alberta Infant Motor Scale (AIMS).
      • Bruininks R.H.
      • Bruininks B.D.
      Bruininks-Oseretsky test of motor proficiency.
      Although these measures did not meet the criteria of a balance measure for this review, because clinicians conceived these measures as useful tools for assessing balance, they were also coded against the Systems Framework for Postural Control as an addendum to the full review. Data abstraction and mapping results were tabulated, and descriptive statistics were calculated for all variables.
      Figure thumbnail gr1
      Fig 1Study flow diagram. Abbreviation: HAPI, Health and Psychosocial Instruments.

      Results

      Measure characteristics

      Table 2 presents selected characteristics of each measure. The 21 measures were published or first used in pediatric populations between 1990 and 2015. Most measures (17/21, 81%) were developed in adult populations and subsequently validated for use with pediatric populations. The remaining measures were developed specifically for children either through consultation with clinicians (n=2; Pediatric Reach Test
      • Bartlett D.
      • Birmingham T.
      Validity and reliability of a pediatric reach test.
      and Early Clinical Assessment of Balance
      • McCoy S.W.
      • Bartlett D.J.
      • Yocum A.
      • et al.
      Development and validity of the early clinical assessment of balance for young children with cerebral palsy.
      ) or by unreported methods (n=2; Ghent Developmental Balance Test
      • De Kegel A.
      • Baetens T.
      • Peersman W.
      • Maes L.
      • Dhooge I.
      • Van Waelvelde H.
      Ghent developmental balance test: a new tool to evaluate balance performance in toddlers and preschool children.
      and Timed Up and Down Stairs Test
      • Zaino C.A.
      • Marchese V.G.
      • Westcott S.L.
      Timed up and down stairs test: preliminary reliability and validity of a new measure of functional mobility.
      ). The number of items in each measure ranged between 1 and 35, with a median of 4 items. One measure included graded progression in which participants must meet specific criteria to complete additional items. Fourteen measures (67%) were evaluated on a continuous scale, and the remaining 7 measures used a categorical scale with 2 to 7 categories. One measure (Ghent Developmental Balance Test
      • De Kegel A.
      • Baetens T.
      • Peersman W.
      • Maes L.
      • Dhooge I.
      • Van Waelvelde H.
      Ghent developmental balance test: a new tool to evaluate balance performance in toddlers and preschool children.
      ) was criterion-referenced, whereas the other 20 measures were norm-referenced. Both reliability and validity statistics were presented in the original report for 10 measures (48%), whereas 9 (43%) presented reliability only, and 2 (9%) presented validity only in the original report. Detailed psychometric data published with the index pediatric publication are presented in supplemental table S2.
      Table 2Selected characteristics of balance measures validated in pediatric populations
      MeasureReferenceStated Purpose of MeasureComponents of Balance Purportedly AssessedTarget Pediatric PopulationDevelopment MethodsNo. of Items in TestEvaluation ParametersNo. of Scoring CategoriesGraded ProgressionInitial Pediatric Age Range Validated
      Balance Error Scoring SystemValovich McLeod et al
      • Valovich McLeod T.C.
      • Barr W.B.
      • McCrea M.
      • Guskiewicz K.M.
      Psychometric and measurement properties of concussion assessment tools in youth sports.
      Not specifiedNot specifiedYouth sport participantsDeveloped in adult population (Riemann)
      • Riemann B.L.
      • Guskiewicz K.M.
      • Shields E.W.
      Relationship between clinical and forceplate measures of postural stability.
      6 (3 stances, 2 surfaces)Continuous (no. of errors), criterion referencedN/ANo9–14y
      Modified Balance Error Scoring SystemHunt et al
      • Hunt T.N.
      • Ferrara M.S.
      • Bornstein R.A.
      • Baumgartner T.A.
      The reliability of the modified Balance Error Scoring System.
      Evaluate postural stability after concussionNot specifiedHigh school athletesModified from adult version adult population (Riemann)
      • Riemann B.L.
      • Guskiewicz K.M.
      • Shields E.W.
      Relationship between clinical and forceplate measures of postural stability.
      4 (2 stances, 2 surfaces)Continuous (no. of errors), criterion referencedN/ANo13–19y
      Community Balance and Mobility ScaleWright et al
      • Wright F.V.
      • Ryan J.
      • Brewer K.
      Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury.
      Assess high-level balance that mimics requirements underlying community mobility skillsNot specifiedChildren with acquired brain injuryDeveloped in adult population (Howe)
      • Howe J.A.
      • Inness E.L.
      • Venturini A.
      • Williams J.I.
      • Verrier M.C.
      The community balance and mobility scaled a balance measure for individuals with traumatic brain injury.
      20 (13 items, 6 performed bilaterally)Categorical, criterion referenced4No7–18y
      Dynamic Gait IndexLubetzky-Vilnai et al
      • Lubetzky-Vilnai A.
      • Jirikowic T.L.
      • McCoy S.W.
      Investigation of the Dynamic Gait Index in children: a pilot study.
      Quantify dynamic balance abilities and evaluate individual's ability to modify gait in response to changing task demandsMobility function and dynamic balance in walking and stair-climbingChildren developing typically, children with fetal alcohol spectrum disorderDeveloped in adult population (Shumway-Cook and Woollacott)
      • Shumway-Cook A.
      • Baldwin M.
      • Polissar N.L.
      • Gruber W.
      Predicting the probability for falls in community-dwelling older adults.
      8Categorical, criterion referenced4No8–15y
      Five Times Sit to Stand TestKumban et al
      • Kumban W.
      • Amatachaya S.
      • Emasithi A.
      • Siritaratiwat W.
      Five-times-sit-to-stand test in children with cerebral palsy: reliability and concurrent validity.
      Measure lower limb strength and balance abilityNot specifiedChildren with mild to moderate cerebral palsyDeveloped in adult population (Whitney et al.)
      • Whitney S.L.
      • Wrisley D.M.
      • Marchetti G.F.
      • Gee M.A.
      • Redfern M.S.
      • Furman J.M.
      Clinical measurement of sit-to-stand performance in people with balance disorders: validity of data for the Five-Times- Sit-to-Stand Test.
      1Continuous (time), criterion referencedN/ANo6–18y
      Four Square Step TestBandong et al
      • Bandong A.N.
      • Madriaga G.O.
      • Gorgon E.J.
      Reliability and validity of the Four Square Step Test in children with cerebral palsy and Down syndrome.
      Assess balance in the presence of task and environmental constraintsNot specifiedChildren with developmental disabilitiesDeveloped in adult population (Dite and Temple)
      • Dite W.
      • Temple V.A.
      A clinical test of stepping and change of direction to identify multiple falling older adults.
      1Continuous (time), criterion referencedN/ANo5–12y
      Functional Reach TestDonahoe et al
      • Donahoe B.
      • Turner D.
      • Worrell T.
      The use of functional reach as a measurement of balance in boys and girls without disabilities ages 5 to 15 years.
      Measure distance reached beyond arm's length while maintaining a fixed standing position in childrenDynamic balance, strength, biomechanics, proprioception, vestibular mechanisms, and motor planningChildren developing typicallyDeveloped in adult population (Duncan)
      • Duncan P.W.
      • Weiner D.K.
      • Chandler J.
      • Studenski S.
      Functional reach: a new clinical measure of balance.
      1Continuous (distance), criterion referencedN/ANo5–15y
      Ghent Developmental Balance TestDe Kegel et al
      • De Kegel A.
      • Baetens T.
      • Peersman W.
      • Maes L.
      • Dhooge I.
      • Van Waelvelde H.
      Ghent developmental balance test: a new tool to evaluate balance performance in toddlers and preschool children.
      Evaluate balance in children from moment of independent walking until age of 5yStatic and dynamic balanceChildren developing typically, children diagnosed with mental retardationNot specified35Categorical, norm referenced3Yes (test starts from level of 3 consecutive scores of 2 in developmental order, continues until 3 consecutive failures in developmental order of test)18mo–5y
      High-Level Mobility Assessment ToolKissane et al
      • Kissane A.L.
      • Eldridge B.J.
      • Kelly S.
      • Vidmar S.
      • Galea M.P.
      • Williams G.P.
      High-level mobility skills in children and adolescents with traumatic brain injury.
      Quantify the mobility requirements of young adults with traumatic brain injury for social, leisure, sporting, and employment activitiesNot specifiedYoung adults with moderate to severe traumatic brain injuryDeveloped in adult population (Williams)
      • Williams G.P.
      • Robertson V.
      • Greenwood K.M.
      • Goldie P.A.
      • Morris M.E.
      The high-level mobility assessment tool (HiMAT) for traumatic brain injury, part 2: content validity and discriminability.
      • Williams G.
      • Robertson V.
      • Greenwood K.
      • Goldie P.
      • Morris M.E.
      The high-level mobility assessment tool (HiMAT) for traumatic brain injury, part 1: item generation.
      13Categorical, criterion referenced5 or 6No6–16y
      Limits of Stability TestAlsalaheen et al
      • Alsalaheen B.
      • Haines J.
      • Yorke A.
      • Broglio S.P.
      Reliability and construct validity of limits of stability test in adolescents using a portable forceplate system.
      Not specifiedDynamic postural stabilityAdolescentsDeveloped in adult population1Continuous (reaction time, movement velocity, center of gravity excursion and endpoint, directional control), criterion referencedN/ANo9th to 12th grade (boys, 16.1±1.7y; girls, 15.7±1.4y)
      Modified Star Excursion Balance TestCalatayud et al
      • Calatayud J.
      • Borreani S.
      • Colado J.C.
      • Martin F.
      • Flandez J.
      Test-retest reliability of the Star Excursion Balance Test in primary school children.
      Identify dynamic balance deficits and improvements, predict risk of lower extremity injuryDynamic balancePrimary school students in school settingDeveloped in adult population, administered according to recommendations by Gribble et al.
      • Gribble P.A.
      • Hertel J.
      • Plisky P.
      Using the Star Excursion Balance Test to assess dynamic postural-control deficits and outcomes in lower extremity injury: a literature and systematic review.
      3 tasks, performed for each leg 7 times (4 practice trials, 3 measurement trials)Continuous (distance), criterion referencedN/AN/A10–12y
      One Leg Standing Balance TestAtwater et al
      • Atwater S.W.
      • Crowe T.K.
      • Deitz J.C.
      • Richardson P.K.
      Interrater and test-retest reliability of two pediatric balance tests.
      Not specifiedStatic postureNot specifiedDeveloped in adult population1Continuous (time), criterion referencedN/ANo3–14y
      Pediatric Balance ScaleFranjoine et al
      • Franjoine M.R.
      • Gunther J.S.
      • Taylor M.J.
      Pediatric balance scale: a modified version of the berg balance scale for the school-age child with mild to moderate motor impairment.
      Measure of functional balance for childrenFunctional balanceChildren developing typically, children with known balance impairmentsModified Berg Balance Scale
      • Berg K.
      • Wood-Dauphinee S.
      • Williams J.I.
      • Gayton D.
      Measuring balance in the elderly: preliminary development of an instrument.
      by reordering test items, reducing time standards, clarifying directions; conducted pilot reliability testing
      14Categorical, criterion referenced5No4–12y
      Pediatric Reach TestBartlett and Birmingham
      • Bartlett D.
      • Birmingham T.
      Validity and reliability of a pediatric reach test.
      Measure balance in children with cerebral palsyNot specifiedChildren developing typically, children with cerebral palsyPrimary author consulted with 3 experienced pediatric physical therapists to reach agreement for content and protocol for modifying Functional Reach Test6Continuous (distance), criterion referencedN/ANo2–12y
      Pediatric Version of Clinical Test of Sensory Interaction for BalanceCrowe et al
      • Crowe T.K.
      • Deitz J.C.
      • Richardson P.K.
      • Atwater S.W.
      Interrater reliability of the pediatric clinical test of sensory interaction for balance.
      Assess the influence of sensory interaction on balanceSensory interactionChildren developing typicallyDeveloped in adult population (Shumway-Cook and Horak)
      • Shumway-Cook A.
      • Horak F.B.
      Assessing the influence of sensory interaction of balance: suggestion from the field.
      12 (6 sensory conditions, 2 feet positions)Continuous (stance, duration, peak to peak amount of sway, quality— type of movement strategy), criterion referencedN/ANo4–9y
      Posture and Postural Ability ScaleRodby-Bousquet et al
      • Rodby-Bousquet E.
      • Persson-Bunke M.
      • Czuba T.
      Psychometric evaluation of the Posture and Postural Ability Scale for children with cerebral palsy.
      Assess postural control and asymmetries in people with severe disabilities in 4 basic body positions (supine and prone lying, sitting, and standing)Alignment, stability in static and dynamic situationsChildren with cerebral palsyDeveloped in adult population (Rodby-Bosquet)
      • Rodby-Bousquet E.
      • Agústsson A.
      • Jónsdóttir G.
      • Czuba T.
      • Johansson A.-C.
      • Hägglund G.
      Interrater reliability and construct validity of the Posture and Postural Ability Scale in adults with cerebral palsy in supine, prone, sitting and standing positions.
      4 tasks, 53 itemsCategorical, criterion referenced7 categories for postural ability, 2 categories for quality of postureNo6–16y
      Sensory Organization TestChristy et al
      • Christy J.B.
      • Payne J.
      • Azuero A.
      • Formby C.
      Reliability and diagnostic accuracy of clinical tests of vestibular function for children.
      Determine how vestibular information is used to control postureNot specifiedChildren with sensorineural hearing lossDeveloped in adult population6Continuous (amount of sway), criterion referencedN/ANo6–12y
      Sensory TestGabriel and Mu
      • Gabriel L.S.
      • Mu K.
      Computerized platform posturography for children: test-retest reliability of the sensory test of the VSR System.
      Examine organization of sensory inputs necessary to maintain postural stability and aspects of the vestibule-spinal reflexRelative contributions of the visual, somatosensory, and vestibular systems to maintain postural stabilityChildren developing typicallyDeveloped in adult population (Ford-Smith et al.)
      • Ford-Smith C.D.
      • Wyman J.F.
      • Elswick Jr., R.K.
      • Fernandez T.
      • Newton R.A.
      Test-retest reliability of the Sensory Organization Test in noninstitutionalized older adults.
      4Continuous (sway velocity), criterion referencedN/ANo5–9y
      Timed Up and Down Stairs TestZaino et al
      • Zaino C.A.
      • Marchese V.G.
      • Westcott S.L.
      Timed up and down stairs test: preliminary reliability and validity of a new measure of functional mobility.
      Measure of functional mobility and balanceAnticipatory and reactive postural controlChildren developing typically, children with cerebral palsyNot specified1Continuous (time), criterion referencedN/ANo8–14y
      Timed Up and Go testWilliams et al
      • Williams E.N.
      • Carroll S.G.
      • Reddihough D.S.
      • Phillips B.A.
      • Galea M.P.
      Investigation of the timed ‘up & go' test in children.
      Assess basic or functional ambulatory mobility of dynamic balanceDynamic balanceChildren developing typically, children with physical disability because of cerebral palsy or spina bifidaDeveloped in adult population (Podsiadlo and Richardson)
      • Podsiadlo D.
      • Richardson S.
      The timed “Up & Go”: a test of basic functional mobility for frail elderly persons.
      , modified based on pilot tests
      1Continuous (time), criterion referencedN/ANo3–9y
      Early Clinical Assessment of BalanceMcCoy et al
      • McCoy S.W.
      • Bartlett D.J.
      • Yocum A.
      • et al.
      Development and validity of the early clinical assessment of balance for young children with cerebral palsy.
      To estimate postural stability in children with cerebral palsy across all levels of functional abilityPostural stabilityChildren with cerebral palsyCombination of Movement Assessment of Infants – Automatic Reactions Section and Pediatric Balance scale, items selected by consensus of pediatric physical therapist researchers and study team13Categorical, converted to points with various weights attached, criterion referenced5No1.5–5y
      Abbreviation: N/A, not available.

      Components of balance evaluated and postural development considerations in each measure

      Of the 21 included pediatric balance measures, 12 were identical to the adult-validated version and the codes were adopted from the previous adult review.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      Among the 9 newly coded measures, coding agreement by the 2 independent reviewers was 94%. Total agreement was achieved after consensus discussion with a third reviewer. Coding results identifying the components of balance included in each measure are presented in table 3. Underlying motor systems were evaluated in all 21 measures, anticipatory postural control in 15 measures (72%), static stability in 13 measures (62%), sensory integration in 11 measures (52%), dynamic stability in 10 measures (48%), functional stability limits in 5 measures (24%), cognitive influences in 5 measures (24%), verticality in 2 measures (9%), and reactive postural control in 0 measures. All measures included between 3 and 6 components of balance; no measures included all 9 components.
      Table 3Components of balance in measures used in pediatric populations
      MeasureStatic StabilityUnderlying Motor SystemsFunctional Stability LimitsVerticalityReactive Postural ControlAnticipatory Postural ControlDynamic StabilitySensory IntegrationCognitive InfluencesOther Constructs Not Included in Systems Framework
      Balance Error Scoring SystemYesYesNoNoNoNoNoYesNoN/A
      Modified Balance Error Scoring SystemYesYesNoNoNoNoNoYesNoN/A
      Community Balance and Mobility ScaleYesYesNoNoNoYesYesYesYesN/A
      Dynamic Gait IndexNoYesNoNoNoYesYesYesYesN/A
      Five Times Sit to Stand TestNoYesNoNoNoYesYesNoNoN/A
      Four Square Step TestNoYesNoNoNoYesYesNoNoN/A
      Functional Reach TestNoYesYesNoNoYesNoNoNoN/A
      Ghent Developmental Balance TestYesYesNoNoNoYesYesYesYesN/A
      High-level Mobility Assessment ToolNoYesNoNoNoYesYesNoNoN/A
      Limits of Stability TestNoYesYesNoNoYesNoNoNoN/A
      One Leg Standing Balance TestYesYesNoNoNoNoNoYesNoN/A
      Pediatric Balance ScaleYesYesYesNoNoYesYesYesNoSitting balance
      Pediatric Reach TestYesYesYesNoNoYesNoNoNoN/A
      Pediatric Version of Clinical Test of Sensory Interaction for BalanceYesYesNoNoNoNoNoYesNoN/A
      Posture and Postural Ability ScaleYesYesNoYesNoYesNoNoNoSitting balance
      Sensory Organization TestYesYesNoNoNoNoNoYesNoN/A
      Sensory TestYesYesNoNoNoNoNoYesNoN/A
      Star Excursion Balance TestYesYesYesYesNoYesNoNoNoN/A
      Timed Up and Go testNoYesNoNoNoYesYesNoYesN/A
      Timed Up and Down Stairs TestNoYesNoNoNoYesYesNoNoN/A
      Early Clinical Assessment of BalanceYesYesNoNoNoYesYesYesYesSitting balance
      Abbreviation: N/A, not available.
      Two of the 21 measures (9%) were initially tested in children developing postural control (study age, <7y), 7 (33%) were initially tested in individuals with mature postural control (study age, 7–18y) only, and 12 (57%) were initially tested with individuals across the postural development continuum.
      Consultations with pediatric physical therapists highlighted the Alberta Infant Motor Scale,
      • Piper M.C.
      • Pinnell L.E.
      • Darrah J.
      • Maguire T.
      • Byrne P.J.
      Construction and validation of the Alberta Infant Motor Scale (AIMS).
      Bruininks-Oseretsky Test of Motor Proficiency, Second Edition (BOT-2),
      • Bruininks R.H.
      • Bruininks B.D.
      Bruininks-Oseretsky test of motor proficiency.
      and Peabody Developmental Motor Scales, Second Edition (PDMS-2)
      • Folio M.
      • Fewell R.
      Peabody Developmental Motor Scales – second edition.
      as commonly used to assess balance, particularly in toddlers and preschool age children. Although not explicit measures of balance and therefore not included in the full review findings, conceptual mapping (table 4) revealed that all 3 measures included at least 4 components of balance: static stability, underlying motor systems, anticipatory postural control, and dynamic stability. The BOT-2 also included sensory integration, and the PDMS-2 also included cognitive contributions. Two of these measures (Alberta Infant Motor Scale and BOT-2) were initially tested in children developing postural control (study age, <7y), and 1 (PDMS-2) was tested with individuals across the postural development continuum.
      Table 4Components of balance in motor development measures identified by pediatric physical therapists
      MeasureStatic StabilityUnderlying Motor SystemsFunctional Stability LimitsVerticalityReactive Postural ControlAnticipatory Postural ControlDynamic StabilitySensory IntegrationCognitive InfluencesOther Constructs Not Included in Systems Framework
      Alberta Infant Motor ScaleYesYesNoNoNoYesYesNoNoN/A
      BOT-2YesYesNoNoNoYesYesYesNoN/A
      PDMS-2YesYesNoNoNoYesYesNoYesN/A
      Abbreviation: N/A, not available.

      Discussion

      Synthesizing the published literature on validated balance measures for children and analyzing their content with respect to contemporary postural control theory is useful for summarizing the current state of pediatric balance measurement, and for identifying opportunities for continued development. Furthermore, engaging frontline physical therapists in vetting included measures enhances the clinical utility of the results, and in this 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 (eg, underlying motor systems, anticipatory postural control, and static stability in at least 60% of measures), most measures 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 populations.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      However, a critically important addition to this 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 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.
      • Maki B.E.
      • McIlroy W.E.
      Postural control in the older adult.
      Impaired reactive control is independently associated with falls in adults,
      • Hilliard M.J.
      • Martinez K.M.
      • Janssen I.
      • et al.
      Lateral balance factors predict future falls in community-living older adults.
      and in children, mastery of rapid compensatory steps in walking is viewed as a key milestone during development of effective balance recovery strategies.
      • Roncesvalles M.N.
      • Woollacott M.H.
      • Jensen J.L.
      The development of compensatory stepping skills in children.
      Similarly, cognitive contributions and verticality were both underrepresented in existing measures and are important precursors for safe mobility (cognitive contributions) and establishing appropriate orientation (verticality).
      • Horak F.B.
      Postural orientation and equilibrium: what do we need to know about neural control of balance to prevent falls?.
      Although measures that evaluate a restricted subset of balance components may be appropriate for balance screening or fall risk assessment, a comprehensive approach is ideal for identifying impairment and treatment planning. Currently, no combination of validated balance measures can provide a comprehensive assessment in pediatric populations. Interestingly, 2 comprehensive measures—the Balance Evaluation Systems Test (BESTest)
      • Horak F.B.
      • Wrisley D.M.
      • Frank J.
      The Balance Evaluation Systems Test (BESTest) to differentiate balance deficits.
      and Mini-BESTest
      • Franchignoni F.
      • Horak F.
      • Godi M.
      • Nardone A.
      • Giordano A.
      Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest.
      —have published use in children despite no accompanying pyschometric evaluation. The BESTest is the only currently validated measure (for any population) containing all 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 responsible for poor functional balance. First published in 2009, in 2011, it was used in 5 children with cerebral palsy with Gross Motor Function Classification System scores between levels II and III participating in a study of lower body positive pressure–supported treadmill training.
      • Kurz M.J.
      • Corr B.
      • Stuberg W.
      • Volkman K.G.
      • Smith N.
      Evaluation of lower body positive pressure supported treadmill training for children with cerebral palsy.
      In 2012, Pickett et al
      • Pickett K.A.
      • Duncan R.P.
      • Paciorkowski A.R.
      • et al.
      Balance impairment in individuals with Wolfram syndrome.
      used the Mini-BESTest, a shortened version of the original BESTest, in a study of balance impairment in 9 children between the ages of 6 and 17 years with Wolfram syndrome, a rare neurodegenerative disorder characterized by early onset diabetes, optic atrophy, deafness, and neurologic abnormalities. The Mini-BESTest includes 8 components of balance, missing only functional stability limits.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
      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.
      • Sibley K.M.
      • Howe T.
      • Lamb S.E.
      • et al.
      Recommendations for a core outcome set for measuring standing balance in adult populations: a consensus-based approach.
      Neither of these pediatric studies reported any adverse events in using either version of the BESTest. Given their inclusion of missing components in existing pediatric balance measures, comprehensiveness, and endorsed use in adult populations, one or both represent good candidates for initial validation in pediatric populations.
      The analysis of developmental considerations in the development of pediatric balance measures demonstrated that >50% of measures were developed and/or initially validated among pediatric participants across a large age range that spanned the postural development continuum. Given the progressive development of balance in the first 7 years, in contrast to the relative stabilization of development in typically developing children around the age of 7 years, the lack of developmental specificity among these measures warrants additional examination into appropriateness for pediatric subpopulations. In particular, the absence of dedicated standing balance measures targeted at children between 1 and 5 years is noteworthy. Our clinician partners identified 3 measures failing to meet the inclusion criteria because they did not expressly aim to evaluate only balance, but included a significant balance component within the context of a motor development framework. In some cases, the balance section was just as comprehensive as some standalone balance measures included in the review. However, similar to included balance measures, none included an assessment of reactive postural control or functional stability limits or verticality. Although consulting with practicing pediatric physical therapists did not identify any superior measures, the process served to increase the clinical utility of the results by facilitating analysis of clinically relevant tools or measures that might not be flagged with common search terms, strategies, or keywords.

      Study limitations

      Limitations to this review include the following: (1) restricting consideration of theoretical constructs to standing postural control (ie, framework did not include, for example, seated balance), which is only 1 measure characteristic and only 1 aspect of pediatric balance; (2) no specific examination of evaluation parameters which might provide more precise information than observed behaviors; and (3) lack of consideration of the difficulty of individual items related to a particular balance component (eg, whether static stability was assessed by normal or narrow stance, tandem stance, or single-leg stance). Given the complexities of standardized balance measurement, we suggest readers interpret these findings in conjunction with previous reviews addressing some of these issues,
      • Verbecque E.
      • Lobo Da Costa P.H.
      • Vereeck L.
      • Hallemans A.
      Psychometric properties of functional balance tests in children: a literature review.
      • Westcott S.L.
      • Lowes L.P.
      • Richardson P.K.
      Evaluation of postural stability in children: current theories and assessment tools.
      and available Internet resources.
      • Berg K.O.
      • Wood-Dauphinee S.L.
      • Williams J.I.
      • Maki B.
      Measuring balance in the elderly: validation of an instrument.
      Further, despite rigorous operational definition development and duplicate coding, specific codes may still be open to interpretation. For example, in our previous review, the commonly used Timed Up and Go test was unanimously coded as not involving cognitive contributions. However, the pediatric version had administration modifications (touching a wall target prior to turning) requiring the measure be recoded, and cognitive contributions were identified in this review. On discussion, the study team reflected that cognitive contributions could also be associated with the adult Timed Up and Go test.

      Conclusions

      The theoretical components of postural control included in standardized balance measures for children vary greatly, and do not provide a comprehensive evaluation of all the key elements of standing postural control. Additional balance measures validated in adult populations (eg, BESTest, Mini-BESTest) address some of the existing gaps in pediatric measures, and warrant consideration for validation in children. This review demonstrates continued work is necessary to identify and validate comprehensive balance assessment in research and practice to facilitate individualized identification of balance deficits and customization of training programs in the clinical setting.

      Acknowledgments

      We thank Jessica Babineau, BA MLIS and Hal Loewen, MLIS for developing and validating the search strategy. We thank the Knowledge Synthesis Platform at the Centre for Healthcare Innovation for study screening and data abstraction.

      Supplementary data

      Supplemental Table S1Sample search strategy (Ovid MEDLINE, 1946 to December Week 1, 2015)
      No.SearchesResultsSearch Type
      1Postural Balance/15,295Advanced
      2((balanc* or imbalanc* or equilibrium or disequilibrium) and (body or postur* or musculoskeletal or disorder* or trunk or gait or walk* or abilit* or disabilit* or instabil*)).ti,kw.3204Advanced
      31 or 217,027Advanced
      4in.fs.210,835Advanced
      5mt.fs.2,759,598Advanced
      6Validation Studies/70,783Advanced
      7exp Psychometrics/56,268Advanced
      8psychometr*.ti,ab,kw. or clinimetr*.tw,kw. or clinometr*.tw,kw.25,970Advanced
      9exp Observer Variation/32,881Advanced
      10exp “Reproducibility of Results”/285,816Advanced
      11reproducib*.tw,kw.105,188Advanced
      12exp “Sensitivity and Specificity”/432,013Advanced
      13predictive value of tests/148,365Advanced
      14exp severity of illness index/176,797Advanced
      15exp disability evaluation/40,828Advanced
      16or/4-153,496,247Advanced
      17exp Child/1,568,972Advanced
      18exp Pediatrics/44,983Advanced
      19exp Infant/950,073Advanced
      20exp Adolescent/1,640,983Advanced
      21exp minors/2201Advanced
      22exp puberty/14,872Advanced
      23exp School/83,196Advanced
      24(Infan* or Newborn* or new-born* or Baby* or Babies or Neonat* or neo-nat* or Prenat* or pre-nat* or 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.1,942,667Advanced
      25or/17-243,585,444Advanced
      263 and 16 and 25779Advanced
      27exp animals/not (exp animals/and exp humans/)4,003,250Advanced
      2826 not 27774Advanced
      Supplemental Table S2Preliminary psychometric characteristics evaluated in index publication of included measures
      MeasureReliability TestedReliability TypeReliability ScoreValidity TestedValidity TypeValidity Sample SizeValidity Score
      Balance Error Scoring SystemYesTest-retestICC=.75 (boys), ICC=.61 (girls)NoN/AN/AN/A
      Modified Balance Error Scoring SystemYesIntraclassr=.84 when administering 3 trials and scoring the second and third trialsNoN/AN/AN/A
      Community Balance and Mobility ScaleYes1. Interrater, 2. Test-retest1. ICC=.93, 2. ICC=.90NoN/AN/AN/A
      Dynamic Gait IndexYes1. Interrater, 2. Test-retest1. ICC=.82, 2. ICC=.71YesConstruct20 children (10 developing typically, 10 with FASD)Significantly lower score in children with FASD compared with those with typical development (P=.01)
      Five Times Sit to Stand TestYes1. Interrater, 2. Test-retest1. ICC=.88, 2. ICC=.912YesConcurrent33 children with cerebral palsy, 3 pediatric PTs1. r=.552 with TUG (P<.01), 2. r=.561 with BBS (P<.01)
      Four Square Step TestYes1. Interrater, 2. Test-retest1. ICC=.79, 2. ICC range, .54–.89YesConcurrent30 children (16 with cerebral palsy, 14 with down syndrome)R=.74 with TUG (P<.01)
      FRTYes1. Interrater, 2. Intrarater, 3. Test-retest1. ICC=.98, 2. ICC=.83, 3. ICC=.75NoN/AN/AN/A
      Ghent Developmental Balance TestYes1. Interrater, 2. Test-retest1. ICC=.98, 2. ICC=.99Yes1. Known-group, 2. Convergent and discriminant, and 3. Construct74 normally developing children and 20 diagnosed with mental retardation1. Known-group t38= .142, P=.888; 2. Convergent and discriminant: r=.80 with BOT-2, r=.60 with PDMS-2, r=.69 with balance subscale, and r=.66 with M-ABC-2; 3. Construct: r=.92 with age
      High-Level Mobility Assessment ToolYes1. Interrater, 2. Test-retest1. ICC=.93, 2. ICC=.98YesConcurrent52 children with traumatic brain injurySpearman ρ=.68 with PEDI functional skills mobility domain
      Limits of Stability TestYesTest-retestICC=.73YesConstruct (divergent and discriminant)36 adolescentsNo significant correlations with BESS total score (P>.05)
      Modified Star Excursion Balance TestYesTest-retestICC range, .51–.93NoN/AN/AN/A
      One Leg Standing Balance TestYes1. Interrater, 2. Test-retest1. Eyes open r=1.00, eyes closed r=.96; 2. Eyes open r=.91–1.00; eyes closed r=.59–.77NoN/AN/A
      Pediatric Balance ScaleYes1. Interrater, 2. Test-retest1. ICC=.997, 2. ICC=.998NoN/AN/AN/A
      PRTYes1. Interrater, 2. Test-retest1. ICC range, .50–.93, 2. ICC range, .54–.88Yes1. Concurrent, 2. Construct29 children (19 developing typically, 10 with CP)1. Construct: r=.79 with a laboratory test of steadiness in quiet stance and r=.83 with age, Spearman ρ=0.8 with GrossMotor Function Classification System among the sample of children with cerebral palsy; 2. Concurrent: r=.42–.77 between the standing section of the PRT and laboratory tests of limits of stability
      Pediatric Version of Clinical Test of Sensory Interaction for BalanceYesInterraterSpearman ρ range, .69 (feet together) to .92 (heel-toe)NoN/AN/AN/A
      Posture and Postural Ability ScaleYes1. Interrater, 2. Internal consistency1. ICC=.77, 2. Cronbach α=.95–.96YesConstruct29 children with cerebral palsySignificantly differentiated between Gross Motor Function Classification System scores (P<.009)
      Sensory Organization TestNoN/AN/AYesDiscriminant20 children with sever to profound sensorineural hearing loss, 23 children developing typicallyDiscriminated between children with sensorineural hearing loss and those with typical development (sensitivity, .75; specificity, .86)
      Sensory TestYes1. Test-retestICC range, .76–.90NoN/AN/AN/A
      Timed Up and Down Stairs TestYes1. Interrater, 2. Test-retest1. ICC=.99, 2. ICC=.94Yes1. Concurrent, 2. Construct47 children (20 with cerebral palsy and 27 developing typically)1. Concurrent: r=.78 with TUG, r=−.57 with FRT and r= −.77 with TOLS; 2. Construct: moderate correlation with age (r range, .61–.41; P=.001 and P=.018, respectively)
      TUGYesTest-retestICC=.83 for children without physical disabilities, ICC=.099 same-day retest for children with disabilitiesYesConcurrentSubgroup of 22 young adults with cerebral palsy concurrently tested using the GMFMModerate negative correlation between TUG scores and the GMFM (ρ=.524, P=.012)
      Early Clinical Assessment of BalanceYes1. Content; 2. Construct410 children with cerebral palsy across all GMFCS Levels; age, 1.5–5y1. Content: test item correlation range, .32–.94 (P<.0001); Cronbach α=.92; 2. Construct: significant differences in test scores between GMFCS groups (χ2=365.11, 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.

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