Advances
in the medical field are rapid. What may be true today can
be outdated within a few years. To travel the field of
physical therapy is similar particularly in the practice of
balance and coordination therapy.
For so many years, physical therapist have been using
established evaluation tools for screening balance and
coordination disorders such as Berg (1).
We have good reason to use it since it is simple to
administer and has been extensively researched and
validated. It involves 14 items that focus on tasks
performed by patients in their performance of daily function
like standing from seated position and reaching forward.
However, in spite of its well-correlated reliability in
assessing Parkinson's Disease, it has inherent limitations
particularly the well-reported ceiling effects and its failure
to identify mild or subtle neurologic deficits.
We might dismiss this as our avoidance of the panacea in
assessment tools—we can't have everything, afterall. The more
pragmatic response may be to just use another tool to
supplement what Berg or other tools lack.
Fortunately, some more comprehensive tools have been
developed in recent years. The field might have been paved with
the publication of the Balance Evaluation Systems Test (BESTest)
in 2009 (2). In recent years, we have seen its offshoot such
as the Mini-BESTest and the Brief-BESTest.
The forerunner BESTest was developed and published by
physical therapists Fay Horak, Diane Wrisley and James
Frank. They wanted to have an assessment tool that would
help "identify the particular postural control systems
responsible for poor functional balance" (2).
Horak and her colleagues contended that by identifying which
system is deficient, a particular treatment option and
rehabilitation program can be initiated to address the
specific problem.
The six balance control systems they focused on are:
stability limits and verticality; biomechanical constraints;
anticipatory postural adjustments, transitions; reactive
postural responses; sensory orientation; and dynamic balance
during gait and cognitive effects.
Their research revealed that the BESTEst has good intrarater
reliability and good validity for identifying fallers and
non-fallers (among patients with Parkinsons disease).
The biggest drawback of this evaluation tool is its
impracticality for use in busy clinical setting because of
its comprehensive nature. It is quite lengthy to administer.
Gaining grounds on the limitation of the BESTest, the Mini-BESTest
was developed by Franchignoni and colleagues in 2010 (3).
This 14-item test for dynamic balance eliminated what was
deemed redundant in the BESTest. Thus, it was as short as
the Berg Test.
The scoring system was also simplified with a maximum score
of 28 (out of the 0 or 2 scoring for those who are able and
unable to perform a task, respectively).
The main advantage of this test is it has excellent
interrater and test-retest reliability. Unfortunately, there
is limited research available to establish its place in the
clinical setting. Padgett deemed the
Mini-BESTest as "theoretically inconsistent with the BESTest".
Another test that stemmed from the original BESTest is the
Brief-BESTest proposed by Padgett and colleauges (2012) (4).
It selected one test item from each of the BESTest
categories plus two items that require performance
bilaterally.
Method for testing and scoring was the same as the full
BESTest. The six items selected were derived from those with
the highest correlation to the complete score in the
original BESTest.
Padgett concluded that the Brief-BESTest was consistent with
the sections included in the full BESTest.
In several published research studies, they also demonstrated high
specificity in identifying non-fallers.
One research study on the comparative utility of the two BESTest
versions that came out recently was published by Duncan and
colleagues (2013) (5). They noted that "all versions have
consistent high sensitivity in identifying future fallers".
They suggested that clinicians can rely on the Brief-BESTest
for predicting falls especially when time and equipment are
limited.
The progenitor assessment tool will eventually become a
benchmark for clinical utility as more physical therapists
utilize this assessment tool and researchers further
evaluate its various versions.
Refining our approach to patient care is important as
advancements in the medical field is geared towards more
personalized treatment. Having a clearer distinction of
clinically-significant subtleties through validated
assessment tools will ultimately benefit the patient and the
physical therapy profession.
