Pediatric Balance Scale

Instructions for examiners, as per original study

General instructions that accompany the Pediatric Balance Scale (Franjoine et al. 2003) include that the examiner should demonstrate each task and give instructions as below for each task. The child may also receive a practice trial on each item. If the child is unable to complete the task based on their ability to understand the directions, a second practice trial may be given. Verbal and visual directions may be clarified through the use of physical prompts.

The child’s performance should be scored based upon the lowest criteria, which describes the child’s best performance at the task, through the multiple trials (where task permits).

In addition to scoring items 4, 5, 6, 7, 8, 9, 10 and 13, the examiner may choose to record the exact time in seconds.

Equipment required: Adjustable height bench, chair with back support and arm rests, stopwatch or watch with a second hand, masking tape – 1 inch wide, a step stool 6 inches in height, chalkboard eraser, ruler or yardstick, a small level.

Optional equipment: 2 child-size footprints, blindfold, a brightly colored object of at least two inches in size, flash cards, 2 inches of adhesive-backed hook Velcro, two 1 foot strips of loop Velcro.

1. Sitting to Standing

Child is asked to “Hold arms up and stand up”.

Equipment required: a bench of appropriate height to allow the child’s feet to rest supported on the floor with the hips and knees maintained in 90 degrees of flexion.

2. Standing to Sitting

Child is asked to sit down slowly, without use of hands.

Same equipment from item 1.

Items 1 and 2 may be tested simultaneously if, in the determination of the examiner, it will facilitate the best performance of the child.

3. Transfers

The examiner should arrange chair(s) for a stand pivot transfer, touching at a forty-five degree angle and ask the child to transfer one way toward a seat with armrests and one way toward a seat without armrests.

Equipment required: Two chairs or one chair and one bench. One seating surface must have armrests. One chair/bench should be of standard adult size and the other should be of an appropriate height to allow the child to comfortably sit with feet supported on the floor and ninety degrees of hip and knee flexion.

4. Standing Unsupported

The child is asked to stand for 30 seconds without holding on or moving his/her feet. A taped line or footprints may be placed on the floor to help the child maintain a stationary foot position.

- The child may be engaged in non-stressful conversation to maintain attention span for thirty seconds.

- Weight shifting and equilibrium responses in feet are acceptable;

- Movement of the foot in space (off the support surface) indicates end of the timed trial.

Equipment required: A stopwatch or watch with a second hand, a twelve inch long masking tape line or two footprints placed shoulder width apart.

* If a subject is able to stand 30 seconds unsupported, score full points for item 5. “Sitting unsupported” and proceed to item 6.

5. Sitting with Back Unsupported and Feet Supported on the Floor

Instruct the child to: “Please sit with arms folded on your chest for 30 seconds.”

- Child may be engaged in non-stressful conversation to maintain attention span for thirty seconds.

- Time should be stopped if protective reactions are observed in trunk or upper extremities.

Equipment required: A stopwatch or watch with a second hand, a bench of appropriate height.

6. Standing Unsupported with Eyes Closed

The child is asked to stand still with feet shoulder width apart and close his/her eyes for ten seconds. “When I say close your eyes, I want you to stand still, close your eyes, and keep them closed until I say open.”. If necessary, a blindfold may be used.

- Weight shifting and equilibrium responses in the feet are acceptable;

- Movement of the foot in space (off the support surface) indicates end of timed trial.

- A taped line or footprints may be placed on the floor to help the child maintain a stationary foot position.

Equipment required: A stopwatch or watch with a second hand, a twelve inch long masking tape line or two footprints placed shoulder width apart, blindfold.

7. Standing Unsupported with Feet Together

The child is asked to place his/her feet together and stand still without holding on.

- The child may be engaged in non-stressful conversation to maintain attention span for thirty seconds.

- Weight shifting and equilibrium responses in feet are acceptable;

- Movement of the foot in space (off the support surface) indicates end of the timed trial.

- A taped line or footprints may be placed on the floor to help the child maintain stationary foot position.

Equipment required: A stopwatch or watch with a second hand, a twelve inch long masking tape line or two footprints placed shoulder width apart.

8. Standing Unsupported One Foot in Front

The child is asked to stand with one foot in front of the other, heel to toe. If the child cannot place feet in tandem position (directly in front), they should be asked to step forward far enough to allow the heel of one foot to be placed ahead of the toes of the stationary foot.

- A taped line and/or footprints may be placed on the floor to help the child maintain a stationary foot position. In addition to a visual demonstration, a single physical prompt (assistance with placement) may be given.

- The child may be engaged in non-stressful conversation to maintain attention span for thirty seconds.

- Weight shifting and equilibrium reactions in feet are acceptable.

- Timed trials should be stopped if either foot moves in space (leaves the support surface) and/or upper extremities support is utilized.

Equipment required: A stopwatch or watch with a second hand, a twelve inch long masking tape line or two footprints placed heel to toe.

9. Standing On One Leg

The child is asked to stand on one leg for as long as he/she is able to, without holding on. If necessary the child can be instructed to maintain his/her arms (hands) on his/her hips (waist).

- A taped line and/or footprints may be placed on the floor to help the child maintain a stationary foot position.

- Weight shifting and equilibrium reactions in feet are acceptable.

- Timed trials should be stopped if the weight bearing foot moves in space (leaves the support surface), the up limb touches the opposite leg or the support surface and/or upper extremities are utilized for support.

Equipment required: A stopwatch or watch with a second hand, a twelve inch long masking tape line or two footprints placed heel to toe.

10. Turn 360 Degrees

The child is asked to turn completely around in a full circle, stop and then turn a full circle in the other direction.

Equipment required: A stopwatch or watch with a second hand.

11. Turning to Look Behind Left & Right Shoulders While Standing Still

The child is asked to stand with his/her feet still, fixed in one place. “Follow the object as I move it. Keep watching it as I move it, but don’t move your feet.”

Equipment required: A brightly colored object of at least two inches in size and a twelve inch long masking tape line or two footprints placed shoulder width apart.

12. Pick Up Object from the Floor from a Standing Position

The child is asked to pick up a chalkboard eraser placed approximately the length of his/her foot in front of his/her dominant foot.

Equipment required: A chalk board eraser and a taped line or footprints.

13. Placing Alternate Foot on Step Stool while Standing Unsupported

The child is asked to place each foot alternately on the step stool and to continue until each foot has touched the step/stool four times.

Equipment required: A step/stool of four inches in height and a stopwatch or watch with a second hand.

14. Reaching Forward with Outstretched Arm while Standing

A yardstick affixed to a wall via Velcro strips will be used as the measuring tool. A taped line and/or footprints are used to maintain a stationary foot position. The child will be asked to reach as far forward without falling, and without stepping over the line. The MCP joint of the child’s fisted hand will be used as the anatomical reference point for measurements.

- Assistance may be given to initially position the child’s arm at 90 degrees.

- Support may not be provided during the reaching process.

- If 90 degrees of shoulder flexion cannot be obtained, then this item should be omitted.

Equipment required: A yardstick or ruler, a taped line or footprints, and a level.

The final score of the Pediatric modified balance scale is obtained by summing the results from each of the 14 tasks, and ranges from 0 to 56. The greater the score, the better the functional balance of the child.

About the study

The Pediatric Balance Scale (PBS) is a 14-item measure of functional balance for children, developed through the modification of the Berg Balance Scale. Its purpose is to identify children with impairments in functional balance, which may be at risk for developmental delay. The scale has been validated and shows excellent psychometric properties.

The balance scale consists of 14 items with tasks for the child that vary in difficulty (common activities familiar to most children) and requires several pieces of equipment that are usually found in clinic anyways. For each of the tasks, the child’s performance is assessed on a scale from 0 to 4 points.

PBS typical performance values by age and gender have been reported, mapping out development in children aged from 2 to 13 years.

Psychometric characteristics

The PBS has shown the following reliability:

- Typically developing 5-7 y/o test-retest: 0.850

- Motor impairment 5-15 y/o interrater: 0.997 test-retest: 0.998

- Cerebral Palsy 6-13 y/o intrarater: 0.978-0.988 interrater: 0.905 test-retest: 0.958

With:

- Test-retest reliability: high [ICC (3,1) = 0.998]

- Interrater reliability: high [ICC (3,1) = 0.997]

The validation study conducted by Chen C-I et al. found good criterion-related concurrent and predictive validity with children with cerebral palsy and an ability of the PBS to predictor motor function and performance in activities of daily living (ADLs).

The pediatric balance scale introduces a standardized protocol for testing balance in children and requires very little equipment. Unfortunately, one of the limitations of the scale is that it does not assess locomotive balance nor does it include a task for measuring performance in overhead reaching.

References

Original reference

Franjoine MR, Gunther JS, Taylor MJ. Pediatric Balance Scale: A Modified Version of the Berg Balance Scale for the School Age Child with Mild to Moderate Motor Impairment. Pediatr Phys Ther. 2003; 15(2):114-128.

Validation

Chen C-I et al. Validity, responsiveness, minimal detectable change, and minimal clinically important change of Pediatric Balance Scale in children with cerebral palsy. Res Dev Disabil. 2013 Mar; 34(3):916-22.

Other references

Butz SM et al. Relationships among age, gender, anthropometric characteristics, and dynamic balance in children 5 to 12 years old. Pediatr Phys Ther. 2015 Feb 18; eprint PMID: 25695196.

Franjoine MR, Darr N, Held SL, Kott K, Young BL. The Performance of Children Developing Typically on the Pediatric Balance Scale. Pediatr Phys Ther. 2010; 22(4): 350-359.