Reproducibility of the Kids Balance Evaluation Systems Test (Kids-BESTest) and the Kids-Mini-BESTest for children with cerebral palsy

To evaluate the reproducibility, including reliability and agreement, of the Kids Balance Evaluation Systems Test (Kids-BESTest) and short-form Kids-Mini-BESTest for measuring postural control in school-aged children with cerebral palsy.Psychometric study of intra-rater, inter-rater and test-retest reliability and agreement; SETTING: Clinical laboratory and home.Convenience sample of 18 children aged 8 to 17 years with ambulant cerebral palsy (Gross Motor Function Classification System I-II) with spastic or ataxic motor type.Not applicable.Postural control was assessed using the Kids-BESTest and the short-form Kids-Mini-BESTest. An experienced physiotherapist assessed all children in real-time and the testing session was videoed. The same physiotherapist viewed and scored the video twice, at least two weeks apart, to assess intra-rater reproducibility. Another experienced physiotherapist scored the same video to determine inter-rater reproducibility. Thirteen children returned for a repeat assessment with the first physiotherapist within 6 weeks and their test-retest performance was rated in real time and with video.Excellent reliability was observed for both the Kids-BESTest (ICC 0.96 to 0.99) and Kids-Mini-BESTest (ICC 0.79 to 0.98). The Smallest Detectable Change was good to excellent for all Kids-BESTest agreement analyses (5% to 9%), but poor to good for Kids-Mini-BESTest analyses (9% to 16%).The Kids-BESTest shows an excellent ability to discriminate postural control abilities of school-aged children with cerebral palsy and it has a low Smallest Detectable Change, suitable for use as a pre-post intervention outcome measure. Although the Kids-Mini-BESTest is 5-10 min shorter to administer, it has poorer reproducibility and focuses only on falls-related balance, which excludes two domains of postural control

Postural control in children with cerebral palsy: a comprehensive definition, framework and reproducible assessment.

Background: Cerebral Palsy (CP), the most common cause of childhood physical disability, results from a brain injury in utero or during infancy and presents as a primary impairment in movement and postural control. Impairment in postural control is known to have a significant impact on activity and participation of children with CP. Despite this, there is no current consensus on the most optimal assessments and interventions for this core deficit of CP.Aims: Thesis aims were in three parts: (Part 1) Evaluate current postural control assessments and interventions - Studies 1 and 2; (Part 2) Assess the reproducibility of a comprehensive clinical assessment of postural control in children with CP - Studies 3 and 4; (Part 3) Assess the validity of postural control assessment items in children with CP - Studies 5 and 6.Study 1 (Chapter 3), a systematic review of the efficacy and effectiveness of exercise interventions to improve postural control for children with CP, was performed using AACPDM and PRISMA methodology. Six databases were searched using (“cerebral palsy” OR “brain injury”) AND (postur* OR balance OR “Postural Balance” (MeSH)) AND (“intervention” OR “therapy” OR “exercise” OR “treatment”). Included were 45 articles describing 13 exercise interventions purported to improve postural control in children with CP. Evidence for interventions was moderate (five interventions), weak or conflicting (six interventions) or none (two interventions). No intervention reached a high level of evidence highlighting the need of a defining framework and a comprehensive postural control assessment.Study 2 (Chapter 4), a Delphi study was designed to identify consensus on a definition, a framework, and assessments and treatments for postural control dysfunction in children with CP. The perspective of 43 international researchers and/or clinicians with a mean of 20 years experience was gathered. Consensus was achieved for a postural control definition. A comprehensive postural control framework (Systems Theory) and multi-item assessment tool (Balance Evaluation Systems Test: BESTest) was identified. Further research was needed to determine whether this test could be applied for children with and without CP.Study 3 (Chapter 5) sought to establish the reproducibility of the BESTest and the Mini-BESTest in 34 typically developing (TD) school-aged children, seven to 17 years. Excellent reliability was observed for the BESTest (ICC >0.82) and fair to excellent for the Mini-BESTest (ICC 0.56 to 0.86). The Smallest Detectable Change (SDC) was good to excellent for all BESTest agreement analyses (2% to 6%), and for the Mini-BESTest (5% to 10%). Both the BESTest and the Mini-BEST shows an excellent ability to discriminate postural control abilities for school-aged children. We proposed minor modifications to improve reproducibility for children, the Kids-BESTest.Study 4 (Chapter 6) then investigated the reproducibility of the Kids-BESTest and the Kids-Mini-BESTest in 18 school-aged children with ambulant CP. Excellent reliability was observed for the Kids-BESTest (ICC 0.96 to 0.99) and for the Kids Mini-BESTest (ICC 0.79 to 0.98). The SDC was good to excellent for all Kids-BESTest agreement analyses (5% to 9%), but poor to good for the Kids Mini-BESTest (9% to 16%). The Kids-BESTest showed an excellent ability to discriminate postural control abilities and has good potential for use as an outcome measure in children with CP. Further research was needed on the validity of items in the Kids-BESTest.Study 5 (Chapter 7) evaluated the validity of the Kids-BESTest Clinical Test of Sensory Integration of Balance (CTSIB) criteria in 58 school-aged children including 17 ambulant children with CP and 41 TD. The ability to sustain postural control in standing was assessed using CTSIB while standing on force plate collecting centre-of-pressure (CoP) data. Face validity of Kids-BESTest CTSIB criteria was supported. Content and concurrent validity were partially supported. To improve Kids-BESTest scoring, new terms were added to the score sheet to better describe postural characteristics of ‘unstable’ and improve validity and reliability of scoring.Study 6 (Chapter 8) then evaluated the validity of the Kids-BESTest Functional Reach Test (FRT) in the same population. The ability to maintain postural control in standing using FRT forward and lateral was measured clinically, simultaneously collecting CoP and joint kinematic data. The FRTFORWARD demonstrated face, concurrent and content validity. The FRTLATERAL demonstrated concurrent validity, but partial face and content validity. To improve Kids-BESTest scoring, a new qualitative checklist was added to the score sheet to describe postural orientation and balance in the FRT.Summary: This thesis has produced a significant amount of new knowledge on postural control for children with CP. The six studies have provided clinicians and researchers working with children with CP with a number of outcomes including: (i) a clear consensus-driven definition for postural control, (ii) identifying the Systems Approach as a good contextual framework to base postural control assessment and intervention, and (iii) the Kids-BESTest, the first comprehensive postural control assessment that is reproducible in children with and without CP. The outcomes of this thesis will improve postural control assessment and future research for children with CP

Exercise interventions improve postural control in children with cerebral palsy: a systematic review

AimThe aim of this study was to evaluate the efficacy and effectiveness of exercise interventions that may improve postural control in children with cerebral palsy (CP)

Evaluating validity of the Kids-Balance Evaluation Systems Test (Kids-BESTest) Clinical Test of Sensory Integration of Balance (CTSIB) criteria to categorise stance postural control of ambulant children with CP

Purpose: Evaluate the validity of the Clinical Test of Sensory Integration of Balance (CTSIB) scored using Kids-Balance Evaluation Systems Test (Kids-BESTest) criteria compared to laboratory measures of postural control. Method: Participants were 58 children, 7–18 years, 17 with ambulant cerebral palsy (CP) (GMFCS I–II), and 41 typically developing (TD). Postural control in standing was assessed using CTSIB items firm and foam surfaces, eyes open (EO) then closed (EC). Face validity was evaluated comparing clinical Kids-BESTest scores between groups. Correlating force plate centre-of-pressure (CoP) data and clinical scores allowed evaluation of concurrent and content validity. Results: Face validity: TD children scored higher for all CTSIB conditions when compared to children with CP. Concurrent validity: the agreement between clinical and CoP derived scores was poor to excellent (Firm-EO = 76%, Firm-EC = 76%, Foam-EO = 59%, Foam-EC = 94%). Clinical scores of “2-unstable” and “3-stable” were not distinguished reliably by force plate measures. Content validity: significant correlations were found between clinical scores and CoP data for the two intermediate conditions (Firm-EC: rs −0.40 to −0.72; Foam-EO: rs −0.12 to −0.50), but not the easier (Firm-EO: rs −0.41 to −0.36) or harder conditions (Foam-EC: rs −0.25 to −0.27). Conclusion: Face validity of Kids-BESTest CTSIB criteria was supported. Content and concurrent validity were partially supported. Improved Kids-BESTest scoring terms were recommended to describe postural characteristics of “2-unstable.IMPLICATIONS FOR REHABILITATION  - Face validity of the Kids-BESTest criteria for the CTSIB was confirmed.  - The Kids-BESTest criteria for the CTSIB can identify children with atypical postural control.  - Concurrent validity and content validity were partially supported, since children with CP resorted to a range of different balance strategies when “unstable.”  - To improve CTSIB Kids-BESTest criteria, new terms were recommended to better describe postural characteristics of “2-unstable.”.</p