Comparison of 3 short-form BESTests in stroke
Fig. 1. Receiver operating characteristic (ROC) plot of the S-BESTest,
the Brief-BESTest, the Mini-BESTest, and the BESTest scores using the
Berg Balance Scale (BBS) as reference, measured at (a) 0–2 weeks (b)
2–4 weeks, in people with subacute stroke. Arrow depicts cut-off score
(minimal clinically important difference; MCID).
DISCUSSION
This study compared the reliability, validity and
responsiveness of 3 different short versions of the
BESTest (S-BESTest, the Brief-BESTest and the Mini-
BESTest) with the original BESTest in patients with
subacute stroke. Our findings showed that all short
forms of the BESTest were reliable and valid in this
group of the population, but only the S-BESTest de-
monstrated no significant floor-ceiling effect with high
external responsiveness in accurately identification of
balance improvement similar to the original BESTest,
689
suggesting that the S-BESTest was more appropriate as
a short version of the BESTest for assessing postural
control in patients with subacute stroke.
Excellent intra-rater and inter-rater reliability of the
S-BESTest, the Brief-BESTest, and the Mini-BESTest
in patients with subacute stroke were consistent with
a previous study in people with balance disorders, in-
cluding patients with subacute stroke (12). In patients
with subacute stroke, excellent concurrent validity of
the S-BESTest, Brief-BESTest, Mini-BESTest and
original BESTest with the BBS, the clinical gold
standard of balance tests, suggest that all versions of
the BESTest assess the same balance constructs as the
BBS. Our finding of a strong correlation between the
BESTest and the BBS (r = 0.96) was also in agreement
with previous findings (12).
This study confirmed that the original BESTest had no
floor and ceiling effect similar to those reported in the
previous studies (12). Although the S-BESTest did not
reach significant floor effect (<20%), the magnitude of
floor effect at baseline of the S-BESTest was still high
(18.6%) compared with the original BESTest (5.7%),
suggesting that the original BESTest outperformed
other shortened versions, including S-BESTest, Brief-
BESTest and Mini-BESTest. We recommended the use
of original BESTest in assessing balance impairment
in patients with subacute stroke when there is no time
constraint. However, when there is the need for redu-
cing assessment time or the need to identify patients
with balance improvement, the S-BESTest is the most
appropriate choice for balance assessment in patients
with subacute stroke. In contrast, the Brief-BESTest
and the Mini-BESTest may be more suitable for asses-
sing postural control in patients with chronic stroke,
as previous studies found no floor effect in patients
with chronic stroke using the Brief-BESTest and the
Mini-BESTest (15, 17). The floor effect of the Brief-
BESTest and Mini-BESTest in subacute stage may be
due to the fact that these 2 scales contain items that
are more difficult for patients with subacute stroke to
perform. For example, the items of compensatory step-
ping correction in a backward direction, standing with
eyes closed on a foam surface and walking with pivot
turn showed no change in score when measured at 0–2
weeks. A previous study showed that protective steps in
a backward direction require more supraspinal control
than protective steps in a forward direction; thus, this
backward protective mechanism could be more impaired
in patients with stroke (35). In the same way, patients
with stroke showed larger postural sway velocity while
standing on foam with eyes closed, compared with other
conditions of sensory orientation testing (36).
The S-BESTest, the Mini-BESTest, the Brief-
BESTest, and the BESTest demonstrated good internal
J Rehabil Med 51, 2019