Relationship of the brief-balance evaluation systems test with physical functioning and activities of daily living: A cross-sectional study among hospitalized acute stroke patients

Abstract

BACKGROUND:

The Brief-Balance Evaluation Systems Test (Brief-BESTest) has the potential to be used effectively for interventions on specific balance components. However, it has not been utilized for acute stroke cases.

OBJECTIVE:

This study determined the characteristics of the distribution of the Brief-BESTest scores of patients who suffered acute stroke and examined its relationship with physical function and activities of daily living ability.

METHODS:

The Brief-BESTest, sub-items of Stroke Impairment Assessment Set (SIAS), and Functional Independence Measure (FIM) were conducted among 41 hospitalized acute stroke patients (71.3±9.5 years, 32 males). The skewness of the Brief-BESTest and Spearman’s rank correlation (ρ) between Brief-BESTest, SIAS, and FIM were analyzed.

RESULTS:

The skewness of the total score of the Brief-BESTest was -0.038. There were no ceiling or floor effects. The total score of the Brief-BESTest had a weak positive correlation with the SIAS lower extremity motor function (ρ= 0.457) and muscle tone (ρ= 0.374), and the total score on FIM (ρ= 0.365). Each sub-item of the Brief-BESTest was associated with different physical functions.

CONCLUSIONS:

The Brief-BESTest was unaffected by floor and ceiling functions among hospitalized acute stroke patients, and different physical functions were associated with each balance component.

Keywords

Balance validity stroke ADL

1 Introduction

Functional disability, such as spasticity, limitation of range of motion (ROM) (Lance, 1980), and muscle weakness in the limbs (Kim et al., 2003; Ng et al., 2005) and trunk (Karatas et al., 2004) that occurs after a stroke, is a factor that reduces the ability to perform activities of daily living (ADL). After discharge from the hospital, the prognosis of life is poor for those whose ADL ability deteriorates after the stroke (Boyd et al., 2008). Therefore, it is important to provide physical therapy interventions to maintain and improve physical functions and ADL ability during hospitalization.

Balance disorder is one of the most common problem that physical therapy intervention aims to improve. Balance disorders affect the quality and safety of ADL. The Balance Evaluation Systems Test (BESTest) is a rating scale designed to provide specific interventions for balance disorders and comprises six sections (I. Biomechanical constraints, II. Stability limits/verticality, III. Anticipatory postural adjustments, IV. Postural responses, V. Sensory orientation, and VI. Stability in gait) (Horak et al., 2009). The scoping review reported by Sibley et al. investigated the extent to which balance constructs were included for each of the 66 balance rating scales used internationally. The BESTest was the only rating scale that included all balance constructs (Sibley et al., 2015). However, it has been indicated that the BESTest requires about 50 minutes for measurement, which limits its use in clinical practice (Franchignoni et al., 2010; Padgett et al., 2012).

The Brief-BESTest is a balance assessment scale developed as a shortened version of the BESTest to specifically evaluate the six domains, while reducing the measurement time. The Brief-BESTest was constructed by calculating the correlation coefficient between the total score of the BESTest and all 36 sub-items, and then selecting one item from each section with the highest correlation coefficient. The feasibility study by Johns et al. reported that walking ability improved among sub-acute stroke patients through focused intervention on the sections that showed low scores on the Brief-BESTest (Johns et al., 2019). This suggests that the Brief-BESTest can be effectively used to intervene in specific balance components. However, while the Brief-BESTest has high reliability and criterion-related validity with existing balance assessment scales such as the Berg Balance Scale and the Postural Assessment Scale for Stroke Patients (Huang et al., 2017; Winairuk et al., 2019), the relationship between each section of the Brief-BESTest and the physical function and ADL ability has not been sufficiently verified (Winairuk et al., 2019). Furthermore, the Brief-BESTest score distribution characteristics and the floor/ceiling effect have been examined among sub-acute (Winairuk et al., 2019) and chronic (Huang et al., 2017) stroke patients but not in acute stroke patients.

The Brief-BESTest has been used to determine the effects of interventions among stroke patients (Haruyama et al., 2017). If physical function and ADL ability are found to be related to the balance components, it may provide clues to facilitate effective assessment and interventions for specific balance factors. This study identified the characteristics of the distribution of the Brief-BESTest scores of acute stroke in-patients and examined its relationship with physical function and ADL ability.

2 Materials and methods

2.1 Study design

This was a single-center, cross-sectional observational study. Data was collected from consecutive acute stroke patients admitted to the general wards of the Numata Neurosurgery and Cardiovascular Hospital between January and July 2019. This study was conducted with the approval of the Ethics Committees at Numata Neurosurgery and Cardiovascular Hospital, Japan, in accordance with the Declaration of Helsinki and the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) (von Elm et al., 2014). Written informed consent was obtained from all patients before participation.

2.2 Study population

Participants were required to meet all of the following inclusion criteria: 1) those undergoing hospitalization for cerebral infarction or cerebral hemorrhage, 2) those with motor paralysis in the lower limb on one side, and 3) those who were able to walk, regardless of the use of a walking aid. Exclusion criteria were as follows: 1) those who were unable to walk independently before the disease, 2) those who had difficulty understanding the content of the test due to aphasia or dementia, and 3) those who experienced pain that affected their ADL. The sample size for determining the correlation coefficient was calculated using G *Power ver. 3.1.9.3 (Heinrich-Heine-University, Düsseldorf, Germany) before enrolling the participants. The sample size based on effect size 0.5, α error prob 0.05, and 1-β error prob 0.8 was 26, sufficient to confirm the correlation.

2.3 Data collection

Patient demographics and clinical characteristics, including the type of stroke, gender, age, height, weight, body mass index (BMI), history of diseases, were collected from medical records. The clinical assessment consisted of the Brief-BESTest (Padgett et al., 2012) as an index of each balance component, motor function of the lower extremity, muscle tone, ROM, and trunk control among the sub-items of the Stroke Impairment Assessment Set (SIAS) (Chino et al., 1994; Liu et al., 2002) was an index of physical function, and Functional Independence Measure (FIM) (Data management service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research, 1990) was an index of ADL ability. Each assessment was conducted on the same day during hospitalization.

2.3.1 Brief-balance evaluation systems test (Brief-BESTest)

The Brief-BESTest is a shortened version of the BESTest with six sections (I. Biomechanical constraints, II. Stability limits/verticality, III. Anticipatory postural adjustments, IV. Postural responses, V. Sensory orientation, VI. Stability in gait). Each section consists of Functional Reach (Duncan et al., 1990), one-footed Standing Duration, a part of the modified clinical tests of sensory interaction in balance (Wrisley et al., 2004), the Timed Up and Go test (TUG) (Podsiadlo et al., 1991), etc. Four items (I, II, V, and VI) are assigned scores of 0–3, and two items (III and IV) are assigned scores of 0–6 because they include left and right ratings. The total score is distributed on a scale of 0–24, with higher scores indicating better balance ability. The BESTest is evaluated in 50–60 minutes, while the Brief-BESTest is evaluated in 10–15 minutes. Intra-class and inter-class correlation coefficients of the Brief-BESTest in sub-acute stroke patients were 0.91–0.99 with high relative reliability. It had criterion-related validity with the existing balance assessment scales, the Berg Balance Scale, and the BESTest (Winairuk et al., 2019). The measurements were taken by physical therapists who had practiced well in advance by watching the video of the evaluation method published by the developers of the BESTest.

2.3.2 Stroke impairment assessment set (SIAS)

The SIAS assesses comprehensive functional impairment in stroke patients and covers various aspects of impairment, including motor, sensory, movement, and other impairments (Chino et al., 1994). In this study, motor function of the lower limbs, muscle tone, ROM, and trunk control were assessed using the SIAS. Each item was scored on a scale of 0–15 points for motor function of the lower extremities, 0–12 points for muscle tone, 0–6 points for ROM, and 0–6 points for trunk control; the lower the score, the more severe the functional impairment. The SIAS has been validated for reliability and validity among stroke patients (Liu et al., 2002).

2.3.3 Functional independence measure (FIM)

The FIM is a scale for observing the degree of performance of instrumental activities of daily living, consisting of 13 motor items and five cognitive items. Each item is scored on a scale of 1–7, with the total score distributed on a scale of 18–126. A lower score indicates less independence in instrumental activities of daily living, while a higher score indicates greater independence (Data management service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research, 1990).

2.4 Statistical analysis

All statistical analyses were conducted using SPSS Statistics 25.0 (IBM Corp., Armonk, NY) and Microsoft Excel (Microsoft Corp). For statistical analysis, the mean±standard deviation and median, and interquartile range (1st–3rd quartiles) of each measurement were calculated as descriptive statistics. To examine the characteristics of the score distribution and the floor and ceiling effects, the Brief-BESTest histogram of the total score and the skewness (γ1) of the score distribution were calculated. Values of γ1 greater than +1 indicated a substantial floor effect, and values less than -1 indicated a substantial ceiling effect (Chan et al., 2015). Furthermore, the number and percentage of those with perfect scores and zero scores were calculated among the total scores, and if each percentage was greater than 15%, it was determined that the floor or ceiling effect existed (Terwee et al., 2007). To examine the relationship between each balance component and the functional impairment and ADL, correlation coefficient was calculated between the Brief-BESTest’s total score and score on each section, sub-items of SIAS, and the FIM total score. Since each data was measured on an ordinal scale, Spearman’s rank correlation (ρ) was used.

The strength of the coefficient was determined as follows: 0.00 to 0.25 indicated little if any correlation, 0.26 to 0.49 indicated weak correlation, 0.50 to 0.69 indicated moderate correlation,.70 to.89 indicated strong correlation, and 0.90 to 1.00 indicated very strong correlation (Domholdt, 2000).

3 Results

Table 1 shows the clinical characteristics of participants. There were 41 patients, most of whom were male and diagnosed with cerebral infarction. Those who were able to walk independently accounted for 53.7%. The mean and standard deviation of age were 71.3±9.5 years.

Table 1
Clinical characteristics of the subjects

All participants (n = 41)

Age (years), (SD) 71.3 (9.5)

Male, n (%) 32 (78.0)

Body Mass Index (kg/m²), (SD) 23.9 (4.1)

Time since stroke (days), (SD) 6.5 (5.9)

Walking independence, n (%) 22 (53.7)

Type of stroke, n (%)

Cerebral infarction 39 (95.1)

Intra-cerebral hemorrhage 2 (4.9)

Affected side, n (%)

Right 20 (48.8)

Left 21 (51.2)

History of diseases, n (%)

Hypertension 35 (85.4)

Diabetes mellitus 11 (26.8)

Cardiovascular disease 9 (22.0)

Cerebral infarction 4 (9.8)

Lipidemia 4 (9.8)

Orthopedic disease 4 (9.8)

Kidney disease 3 (7.3)

Pulmonary disease 1 (2.4)

	All participants (n = 41)
Age (years), (SD)	71.3 (9.5)
Male, n (%)	32 (78.0)
Body Mass Index (kg/m²), (SD)	23.9 (4.1)
Time since stroke (days), (SD)	6.5 (5.9)
Walking independence, n (%)	22 (53.7)
Type of stroke, n (%)
Cerebral infarction	39 (95.1)
Intra-cerebral hemorrhage	2 (4.9)
Affected side, n (%)
Right	20 (48.8)
Left	21 (51.2)
History of diseases, n (%)
Hypertension	35 (85.4)
Diabetes mellitus	11 (26.8)
Cardiovascular disease	9 (22.0)
Cerebral infarction	4 (9.8)
Lipidemia	4 (9.8)
Orthopedic disease	4 (9.8)
Kidney disease	3 (7.3)
Pulmonary disease	1 (2.4)

Note: Values are mean±SD or n (%). SD; standard deviation.

Figure 1 shows the score distribution of the balance function. The percentage of perfect scores and zero scores were both 0%. γ1 was –0.038, and neither ceiling effect nor floor effect was observed.

Fig. 1

Score distribution of the balance function. Frequency distributions of scores on the Brief-Balance Evaluation Systems Test are shown.

The distribution of scores on clinical assessment is shown in Table 2. The mean and standard deviation for each section of Brief-BESTest were 1.3±0.9 points for I, 2.2±0.6 points for II, 2.6±1.7 points for III, 3.5±2.0 points for IV, 1.3±0.9 points for V, and 2.3±1.0 points for VI. The total score of the Brief-BESTest was 13.2±4.7 points. The mean and standard deviation of each sub-item of the SIAS were 13.6±1.7 points for motor function of the lower extremity, 11.2±1.4 points for muscle tone, 5.6±0.6 points for ROM, and 5.5±0.6 points for trunk control. The mean and standard deviation of the total score on FIM were 106.8±17.4 points.

Table 2

Distribution of clinical assessment scores

	Mean	SD	Minimum value	Maximum value	Median	IQR
			1st	3rd
Brief-BESTest
I. Hip/trunk lateral strength (0–3)	1.3	0.9	0.0	3.0	1.0	1.0	2.0
II. Functional reach forward (0–3)	2.2	0.6	0.0	3.0	2.0	2.0	3.0
III. Stand on one leg (0–6)	2.6	1.7	0.0	6.0	2.0	2.0	3.5
IV. Compensatory stepping (0–6)	3.5	2.0	0.0	6.0	3.0	2.0	6.0
V. Stand with eye closed on foam (0–3)	1.3	0.9	0.0	3.0	1.0	1.0	2.0
VI. Timed up and go (0–3)	2.3	1.0	0.0	3.0	3.0	2.0	3.0
Total score (0–24)	13.2	4.7	4.0	22.0	13.0	9.5	17.5
SIAS
Motor function of lower extremity (0–15)	13.6	1.7	9.0	15.0	14.0	12.0	15.0
Muscle tone (0–12)	11.2	1.4	8.0	12.0	12.0	10.5	12.0
ROM (0–6)	5.6	0.6	3.0	6.0	6.0	5.0	6.0
Trunk control (0–6)	5.5	0.6	4.0	6.0	6.0	5.0	6.0
FIM
Motor score (13–91)	73.2	15.2	29.0	91.0	77.0	63.5	83.5
Cognitive score (5–35)	33.6	3.8	15.0	35.0	35.0	34.0	35.0
Total score (18–126)	106.8	17.4	61.0	126.0	111.0	98.0	118.5

Note: Descriptive statistics of SIAS and FIM and Brief-BESTest are shown. Brief-BESTest; Brief-Balance Evaluation Systems Test, SIAS; Stroke Impairment Assessment Set, FIM; Functional Independence Measure, SD; standard deviation, IQR; interquartile range, ROM; Range of motion.

Bivariate correlations between the Brief-BESTest sections and the total score of functional disability and ADL ability measures are shown in Table 3. Section I showed a weak positive correlation with ROM, and section II showed a weak positive correlation with muscle tone, ROM, and trunk control. Section III showed a weak positive correlation with lower extremity motor function, and section IV showed a weak positive correlation with the total score on FIM. Section VI showed a weak positive correlation with all indices except trunk control. The total score of the Brief-BESTest had a weak positive correlation with lower extremity motor function, muscle tone, and the total score on FIM; no significant correlation was observed with section V.

Table 3

Bivariate correlations between Brief-BESTest sections and total score with physical function and ADL ability measures

		I. Hip/trunk lateral strength	II. Functional reach forward	III. Stand one leg	IV. Compensatory stepping	V. Stand with eyes closed on foam	VI. Timed up and go	Total score
SIAS	Motor function of lower extremity	0.269	0.136	0.373^*	0.280	0.187	0.437^**	0.457^**
	Muscle tone	0.199	0.359^*	0.151	0.305	0.137	0.378^*	0.374^*
	ROM	0.417^**	0.382^*	0.014	0.149	0.129	0.355^*	0.271
	Trunk control	0.260	0.332^*	0.042	0.009	–0.071	–0.071	0.072
FIM	Total score	0.084	0.186	0.151	0.333^*	0.275	0.493^**	0.365^*

Note: Spearman’s rank correlation (ρ) between SIAS and FIM and each section and total score of Brief-BESTest are shown. Brief-BESTest; Brief-Balance Evaluation Systems Test, SIAS; Stroke Impairment Assessment Set, FIM; Functonal Independence Measure, ROM; Range of motion. ^**p < 0.01, ^*p < 0.05.

4 Discussion

This study identified the distribution of the Brief-BESTest scores and its relationship with each balance component, physical function, and ADL ability of acute stroke in-patients. The Brief-BESTest showed no floor and ceiling effects, both in terms of γ1 and the percentage of patients with perfect and zero scores. The proportions of patients with zero and perfect scores in the Brief-BESTest were 4% and 0%, respectively, for chronic stroke patients (Huang et al., 2017), and 20% and 0%, respectively for sub-acute stroke patients (Winairuk et al., 2019), indicating a floor effect among sub-acute stroke patients. The γ1 value of the Brief-BESTest score was –0.038 in this study, –0.139 for chronic stroke patients (Huang et al., 2017), and –0.440 for patients with chronic obstructive pulmonary disease (Jácome et al., 2016), with no substantial ceiling or floor effect, respectively (Huang et al., 2017). In this study, we included participants who were able to walk regardless of the use of walking aids. The Brief-BESTest was suggested to be a suitable difficulty level for assessing postural control among acute stroke in-patients who were ambulatory.

Bivariate correlations between the Brief-BESTest sections and the total score of functional disability showed that different physical functions were associated with each section. Section VI showed a weak positive correlation with all items except trunk control. TUG time assessed in section VI tended to decrease in those with better lower extremity motor function. Better muscle strength in the paralyzed side of the lower limb is associated with higher walking speed and TUG performance, and the results of this study supported the previous studies (Ng et al., 2005; Huang et al., 2017; Kim et al., 2003). TUG consists of elemental tasks such as “standing,” “sitting,” and “changing direction” (Podsiadlo et al., 1991), and each movement is frequently required in ADL. TUG performance, even when scored on the Brief-BESTest, partially reflected lower limb motor function and ADL ability.

Section II showed a weak positive correlation with muscle tone, ROM, and trunk control. The distance of functional reach assessed in section II was related to the amount of movement of the Center of Pressure (COP) (Duncan et al., 1990). To move the center of gravity forward, it was necessary to maintain the center of gravity within the base of support through adequate ROM of each joint, including the ankle joint and coordinated trunk control. Spastic movement disorder after stroke is a condition in which coordination of muscle activity is impaired (Nielsen et al., 2020). The coordination of muscle activity affected the stability of gait as well as the limits of stability of postural control.

Section I showed a weak positive correlation with ROM. The biomechanical constraints assessed in section I measured the verticality of the posture and the holding time of one hip in the standing position (Padgett, 2012). Mobility of the lower limbs was one of the factors to maintain stable alignment in the standing posture. Section III showed a weak positive correlation with lower extremity motor function. One-legged holding time assessed in section III had predictive validity for falls and could be easily assessed in clinical practice (Vellas et al., 1997). It has been reported that people who are able to hold one leg for a longer period of time have stronger muscles in their lower limbs, and the results of this study supported previous studies (Serra-Prat et al., 2019). Lower extremity motor function affected anticipatory postural adjustments with postural changes, even when scored in the Brief-BESTest. Section IV showed a weak positive correlation with FIM. ADLs include a variety of tasks that require fixing the base of support or changing the base of support. In such application tasks, unexpected events such as “slipping” or “stumbling” may occur, and the risk of falling is high (Berg et al., 1997). Therefore, reactive joint strategies and compensatory steps to regain equilibrium against disturbances play an important role (Maki et al., 2006). It was suggested that the assessment and intervention of postural responses related to balance ability would improve ADL ability. None of the correlations in section V were significant. As a compensatory strategy for postural control, the use of hip and ankle joint strategies changed and automatically adapted to environmental conditions, even in the presence of visual and somatosensory loss (Horak et al., 1990). In this study, patients with mild strokes maintained their ADL abilities by applying other compensatory postural strategies, even when their somatosensory perception was impaired.

There were several limitations in this study. First, this was a cross-sectional study, and the causal relationship of the results needs to be examined in the future. Second, this was a single-center study and had not been validated for generalization to other centers. Third, the results were limited to the population with mild motor paralysis because of the inclusion of those with high walking independence. In the future, the results of studies from a more general population should be used to verify the external validity.

5 Conclusion

The study revealed that Brief-BESTest had no floor or ceiling effect in acute stroke in-patients and different physical functions were associated with each balance component. Furthermore, section VI of the Brief-BESTest was found to be the most associated with ADL ability. It has been suggested that the six sections of the Brief-BESTest can be used to identify balance deficits and effectively intervene in specific balance components. Identifying the sections of the Brief-BESTest that affect the ADL ability of stroke patients is highly applicable in clinical practice for effective balance interventions. Our findings suggest that the Brief-BESTest is suitable for assessing postural control in patients who suffered acute strokes. Further studies with stroke patients of different stages and severity are needed to validate the usefulness of the Brief-BESTest.

Footnotes

Acknowledgments

The authors would like to thank all participants for their time, effort, and contribution without financial compensation.

Conflict of interest

None to report.

Funding

This study received no financial support.

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