MEASUREMENT IN PHYSICAL EDUCATION AND EXERCISE SCIENCE, 5(2), 97108

Copyright 2001, Lawrence Erlbaum Associates, Inc.

Reliability of Biodex Balance System

Measures
Wendy J. C. Cachupe, Bethany Shifflett, Leamor Kahanov,
and Emily H. Wughalter
Department of Human Performance
San Jose State University

This study examined the reliability of measures of dynamic balance obtained using
the Biodex Balance System (BBS). Twenty male (n = 10) and female (n = 10) active
adults engaged in weight-bearing sports volunteered for this study. Dynamic balance
was assessed using measures obtained from the BBS at a spring resistance level of 2.
Spring resistance levels range from 1 (least stable) to 8 (most stable). The BBS uses a
circular platform that is free to move in the anteriorposterior and mediallateral axes
simultaneously, which permits three measures to be obtained: an overall stability index (OSI), an anteriorposterior stability index (APSI), and a mediallateral stability
index (MLSI). Measures were obtained from 20-sec trials during which participants
were asked to maintain an upright standing position on their dominant limb on the unstable surface of the BBS. An examination of measures obtained across 8 trials indicated that the BBS produced reliable measures as indicated by R = .94 (OSI), R = .95
(APSI), and R = .93 (MLSI). Based on findings in this study, the testing protocol recommended providing 2 practice trials (Trial 1 and Trial 2) followed by 2 test trials
(Trial 3 and Trial 4). Reliability estimates for Trials 3 and 4 were R = .90 (OSI), R = .86
(APSI), and R = .76 (MLSI). Replication of this protocol with a separate group of 27
collegiate athletes resulted in reliability estimates of R = .92 (OSI), R = .89 (APSI), R
= .93 (MLSI).
Keywords: Biodex Balance System, balance, dynamic balance

Ankle sprains are the most frequent injury in athletics (Grana, 1995). Trauma to
sensory nerve fibers associated with ankle sprains occurs along with ligament damage creating proprioceptive deficits (Docherty, Moore, & Arnold, 1998). Docherty
Requests for reprints should be sent to Bethany Shifflett, Human Performance Department, San Jose
State University, San Jose, CA 951920054. E-mail: bshifflett@geolog.com

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et al. explained that proprioceptive deficits can lead to ankle instability, causing
chronically recurring ankle sprains. The recurrence of ankle sprains may also predispose individuals to greater injury and instability. Given the frequency of injury
and associated problems, Lephart, Pincivero, Giraldo, and Fu (1997) suggested
the ability to quantify proprioceptive deficits is a vital component to the evaluation
of joint injury that may help answer a number of clinical research questions (p.
132), including the effects of injury, decision making for treatment, surgical reconstruction considerations, and rehabilitation.
Most researchers studying balance have measured static balance (Dayhoff,
Suhreinrich, Wigglesworth, Topp, & Moore, 1998; Fitzpatrick, Burke, &
Gandevia, 1996; Gatev, Thomas, Kepple, & Hallett, 1999; Winter, Patla, Prince,
Ishac, & Gielo-Perczak, 1998; Winter, Prince, Frank, Powell, & Zabjek, 1996),
but these measures are difficult to relate to activity requiring dynamic balance. In
addition, because static balance is obtained under stable conditions with no motion
involved, these measures are inadequate for rehabilitation purposes. Dynamic balance can be defined as the bodys maintenance of equilibrium under conditions
causing the center of gravity to move in response to muscular activity (Kinzey &
Armstrong, 1998). Drawing a distinction between static and dynamic balance,
Morrow, Jackson, Disch, and Mood (2000) noted that static balance entails maintaining equilibrium standing in one spot, whereas dynamic balance involves motion. With these definitions in mind, as Baier and Hopf (1998) noted, static
measures clearly do not resemble real-life movement. To maintain balance while
active requires dynamic balance due to the divergent effects of gravity, momentum, ground-reaction forces, and muscle forces on ankle motion from an unstable,
slanted, or irregular surface (Wilkerson & Nitz,1994). Therefore, measures of dynamic balance, rather than static balance, are needed to understand ankle instability and proprioceptive deficits better.
Kinzey and Armstrong (1998) used the star-excursion test, which involved
some motion. The test involves standing on one limb while manipulating the other.
Although motion is involved, Kinzey and Armstrong noted that the test involves a
type of movement that is not common to daily functional activity or sports.
Wilkerson and Nitz (1994) suggested that a multiaxial device be used to measure dynamic balance. They determined that such a device would increase the
proprioceptive input to the spinal cord by increasing the responsiveness and sensitivity of the mechanoreceptors. Wilkerson and Nitz noted that further development of instrumental tilting platforms may provide improved methods for
objective assessment of dynamic postural stability and may facilitate further scientific investigation of the role of proprioception in the maintenance of dynamic ankle stability (p. 52).
The Biodex Balance System (BBS; Biodex Medical Systems, 1999) is a
multiaxial device that objectively measures and records an individuals ability to stabilize the involved joint under dynamic stress. Unlike force plate systems, the BBS

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99

uses a circular platform that is free to move in the anteriorposterior and mediallateral axes simultaneously (Arnold & Schmitz, 1998). The BBS allows up to 20 of foot
platform tilt, which permits the ankle joint mechanoreceptors to be stimulated maximally (Biodex Medical Systems, 1999). The BBS measures, in degrees, the tilt about
each axis during dynamic conditions and calculates a mediallateral stability index
(MLSI), anteriorposterior stability index (APSI), and an overall stability index
(OSI). These indexes represent fluctuations around a zero point established prior to
testing when the platform is stable (Arnold & Schmitz, 1998). For example, an OSI of
5 would be interpreted to mean that on average, the displacement from center is 5.
The stability of the platform can be varied by adjusting the level of resistance of
the springs under the platform (Arnold & Schmitz, 1998). Eight springs, made of
music wire, are located at the perimeter of the balance platform. Each spring, uncompressed, is 13.97 cm long, the outside diameter is 3.11 cm, and the wire diameter is .24 cm (Arnold & Schmitz, 1998). The spring is compressed to 7.52 cm and
has a spring rate of 13.81 N/cm. When the spring is compressed, it creates 88.9 N
of force (Arnold & Schmitz, 1998).
Currently, only a few studies using the BBS have been published. Pincivero,
Lephart, and Henry (1995) found the BBS to be a reliable assessment device
across multiple test trials (20 sec) in healthy college students (N = 20). At Level 2
resistance (out of 8 possible), the intraclass correlation coefficient for the OSI
measures was R = .60 for testing on the dominant and the nondominant limb. At
Level 8, the intraclass correlation coefficient was R = .95 for the dominant limb,
and R = .78 for the nondominant limb. Pincivero et al. (1995) recommended two
practice trials. With respect to the other two indexes available when using the BBS
(mediallateral and anteriorposterior), Schmitz and Arnold (1998) found with a
decreasing stability protocol (from Level 8 to Level 1 over 30 sec; N = 19),
intratester reliability of R = .80 for the anteriorposterior stability index and R =
.43 for the mediallateral stability index. The intratester reliability was reported as
R = .82 for the overall stability index. Intertester reliability for the overall stability
index was reported as R = .70. Schmitz and Arnold (1998) concluded that the overall stability index measures were the most reliable. With just two studies (using
different protocols) reporting reliability information, additional work is needed to
examine reliability so that recommendations with respect to the number of practice
trials and test trials can be made. A study attending to these issues would be both
timely and valuable.
Medical and sport professionals (i.e., athletic trainers, physicians, coaches)
working with athletes experiencing ankle sprains and often recurring ankle
sprains understand particularly well the time and energy invested in treatment
of this injury. Given the resources consumed by ankle injuries among athletes,
studying dynamic balance, as opposed to static balance, is particularly important to increase the understanding of balance deficits, ankle instability, and the
effectiveness of rehabilitation techniques. Accompanying this need is the im-

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portance of assessing the accuracy of techniques such as the BBS for measuring dynamic balance. Therefore, this study was designed to assess the
reliability of measures obtained from the BBS.

METHODS
Instrumentation
The BBS was designed to measure and record an individuals ability to maintain
stability under dynamic stress. As noted, the BBS uses a circular platform that is
free to move in the anteriorposterior and medial lateral axes simultaneously.
The BBS allows up to 20 of foot platform tilt and calculates three separate measures: MLSI, APSI, and OSI. The stability of the platform can be varied by adjusting the level of resistance given by the springs under the platform. In this
study, a spring resistance level of two (out of eight) was used because the lower
the resistance level the less stable the platform and the intention was to examine
the reliability of BBS measures under dynamic conditions. In addition, using
this setting (and the same trial length) allowed comparisons to the findings of
Pincivero et al. (1995).

Procedures
Twenty active college-aged men (n = 10) and women (n = 10) from a large metropolitan university volunteered for this study. The average age of the participants
was 27 years with a range of 23 years to 34 years. All participants were right-foot
dominant. Thirty percent (n = 6) of the participants had not previously sprained
their dominant ankle, although the remaining 70% had. Participants were full
weight bearing without a limp, had no ankle pain, and were able to stand comfortably on one limb.
Prior to the collection of data, Human Subjects Institutional Review Board
approval was obtained for the study. All participants read and signed a written
agreement to participate in the study. In addition, prior to balance testing the
BBS was calibrated and each participant completed an information sheet to obtain information on gender, age, height, weight, sports participation, foot dominance, and ankle sprain information. All participants were tested in low-top
athletic shoes.
To begin, participants stood on their dominant leg on the BBSs locked platform. The platform was then unlocked to allow motion. Participants were instructed to adjust the position of the supporting foot until they found a position
where they could maintain platform stability. The platform was then locked. Next,

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101

testing began as the platform was released for a 20-sec trial and participants were
asked to maintain an upright standing position on their dominant limb. The unsupported leg was in a comfortable knee-flexed position. Participants were instructed
to put their unsupported foot down on the back corner of the BBS if they lost balance. Those who did put their foot down started over and no information was recorded for that trial. For the trial to be complete, balance needed to be maintained
for 20 sec. The handrails to the BBS were up only between trials and participants
were permitted to move their arms to assist in maintaining balance. Testing was repeated for eight trials or until the individual reported they were fatigued and did
not wish to continue. The instrument panel was covered to prevent participants
from obtaining performance feedback from the BBS.

Analysis of Data
OSI scores were summarized for each trial, and central tendency and variability
measures at each trial were obtained to aid in assessing the pattern of performance
across trials. The Statistical Package for the Social Sciences for Windows 9.0
(SPSS, 1999) was used for all statistical analyses.
From data collected, intraclass reliability of the measures from the BBS was assessed. Intraclass reliability estimates (one-way analysis of variance or ANOVA)
were obtained across all measures followed by reliability estimates dropping one
trial each time so that estimates were obtained across 8, 7, 6, 5, 4, 3, and 2 trials.
Reliability was then assessed working back in pairs (7 and 8, 6 and 7, etc.) to assist
in determining where scores stabilized. In addition, 95% confidence intervals were
constructed around the OSI estimates of reliability.

Replication of Testing
A second group comprising 27 volunteer male (n = 10) and female (n = 17) college-aged athletes from a Division I university was obtained. In-season or currently training athletes were recruited via announcements at team meetings by
one of the authors. Sports targeted were those where movement of quick directional changes (i.e., cutting, contact, or both) are common. This population was
sampled because of the high incidence of ankle sprains associated with sudden
changes of direction, contact, and unplanned lateral motion. With the exception
of four rather than eight trials, all procedures and interactions with this group
were the same as those employed with the first group. Intraclass reliability estimates across Trials 3 and 4 for this group were obtained for the OSI, APSI, and
MLSI measures. Finally, the data from both groups were combined to examine
reliability estimates for Trials 3 and 4.

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RESULTS
The study was designed to assess the reliability of measures from the BBS. Multiple trials were used to assess where OSI scores stabilized to determine which trials
provided the most reliable measure of dynamic balance.
Ten out of 20 participants were able to complete eight trials on the BBS. Seventeen individuals completed six trials; 2 participants could not complete any trials
without losing their balance. The overall range for the OSI scores was 2.2 to
17.7. These values represent overall deviation in degrees from the stable zero
point established prior to the release of the platform for testing. The lower the
number, the greater the BBS stability.
Trial 1 had the highest mean (M = 8.15) and Trial 6 had the lowest mean (M =
5.86). Table 1 provides a summary of all trials. Although a pattern (improvement
across trials) did begin to emerge, it was not maintained. Performance first improved, reflecting gains most likely related to learning, followed by a decline with
Trials 4 and 5; however, the decline was not sustained. Not all participants were
able to complete eight trials on the BBS due to fatigue or loss of balance. Therefore, the participants who were able to complete the eight trials were most likely
different from those who completed fewer trials. A possible difference, which
would explain the lower (better) scores, is that those completing eight trials were
stronger, possessed greater dynamic balance skill, or both, thereby enabling them
to complete more trials without fatigue.
When OSI scores were examined separately for those who were able to complete all eight trials a more consistent pattern emerged (see Table 2). Based on
means, performance generally improved through Trial 3, then remained fairly stable near a score of 6. In addition, no statistically significant difference (p = .098)
was observed when a one-way repeated measures ANOVA was conducted to test
for differences in mean OSI scores across the eight trials.
With respect to estimates of reliability, the intraclass reliability for the overall
stability index (OSI) measures for eight trials was R = .94. Table 3 gives intraclass
TABLE 1
Summary Measures (in Degrees) for Overall Stability Index (OSI) Scores
Trial

OSI M

OSI SD

1
2
3
4
5
6
7
8

18
18
17
18
18
16
12
10

8.15
7.51
6.75
7.25
6.64
5.86
6.03
6.28

3.35
2.92
3.45
3.45
2.77
2.93
3.30
2.30

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103

TABLE 2
Summary Measures (in Degrees) for Overall Stability Index (OSI) Scores for Participants
Completing All Trials
Trial
1
2
3
4
5
6
7
8
Note.

OSI M

OSI SD

7.28
7.15
5.65
6.36
6.27
5.65
6.20
6.28

3.29
3.10
2.51
2.67
2.56
2.40
3.34
2.30

N = 10.

reliability estimates across combinations of 7, 6, 5, 4, 3, and 2 trials. Table 4 gives

estimates from pairs of trials. In addition, 95% confidence intervals around reliability estimates, which Morrow and Jackson (1993) recommend, provide valuable information on the range within which true reliability can be expected to be
found (see Tables 3 and 4).
Reliability estimates were also obtained for the anteriorposterior and mediallateral measures (see Tables 3 and 4). For pairs of measures, the reliability estimates for the APSI measures are more spread out (.56 through .90) than the
reliability estimates for the MLSI measures (.76 through .88). In addition, the reliability estimates for the OSI measures are comparable to or greater than (although
not significantly) the reliability estimates for both the MLSI and APSI measures in
all cases.
Comparison of confidence intervals revealed a pattern. Although the 95%
confidence intervals overlapped, the lower limits of the reliability estimates for
the OSI measures were higher than those for the MLSI and APSI in all but a few
cases.
Finally, reliability was examined again following replication of testing
with a group of athletes (N = 27). Based on the pattern of reliability estimates
and the 95% confidence intervals around the reliability estimates obtained
from the first group, four trials were used with this second group. The first
two were practice trials and reliability was examined for the measures from
Trials 3 and 4. The intraclass reliability estimates for this second group were
R = .92 (OSI), R = .89 (APSI), and R = .93 (MLSI). Combining data obtained
from both groups, reliability estimates for the BBS measures from Trials 3
and 4 were R = .91 (OSI, N = 44), R = .89 (APSI, N = 39), and R = .92
(MLSI, N = 39). Table 5 gives the 95% confidence intervals for these
intraclass reliability estimates.

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TABLE 3
Intraclass Reliability Estimates and 95% Confidence Intervals (CI) for BBS (Biodex Balance System) Measures
OSI

APSI

MLSI

Trials

95% CI

95% CI

95% CI

1 through 8
1 through 7
1 through 6
1 through 5
1 through 4
1 through 3
1 and 2

10
12
15
17
17
17
18

.94
.92
.93
.92
.88
.83
.81

.85.98
.83.97
.86.98
.84.97
.76.95
.62.93
.53.93

6
8
9
10
10
11
12

.95
.93
.89
.86
.80
.73
.81

.86.99
.83.98
.73.97
.65.96
.49.94
.26.92
.36.94

6
7
9
10
10
11
12

.93
.94
.92
.90
.84
.81
.71

.81.99
.85.99
.81.98
.75.97
.58.95
.47.94
.03.91

Note. N for MLSI and APSI differ from OSI measures due to printer difficulties encountered during testing; OSI = overall stability index; APSI =
anteriorposterior stability index; MLSI = mediallateral stability index.

TABLE 4
Intraclass Reliability Estimates and 95% Confidence Intervals (CI) for pairs of BBS (Biodex Balance System) Measures
OSI

APSI

MLSI

Trials

95% CI

95% CI

95% CI

1 and 2
2 and 3
3 and 4
4 and 5
5 and 6
6 and 7
7 and 8

18
17
17
18
16
12
10

.81
.80
.90
.85
.93
.86
.80

.53.93
.51.92
.73.96
.63.94
.67.97
.59.96
.35.95

12
12
12
13
13
11
9

.81
.56
.86
.66
.90
.89
.83

.36.94
.48.87
.54.96
.07.90
.67.97
.63.97
.29.96

12
12
12
13
13
11
9

.71
.81
.76
.82
.88
.81
.80

.03.91
.37.94
.20.93
.43.94
.63.96
.34.95
.18.95

Note. N for MLSI and APSI differ from OSI measures due to printer difficulties encountered during testing; OSI = overall stability index; APSI =
anteriorposterior stability index; MLSI = mediallateral stability index.

105

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TABLE 5
Intraclass Reliability Estimates and 95% Confidence Intervals (CI) of BBS (Biodex Balance
System) Measures for Trials 3 and 4
Group 1

Group 2

Combined

Measure

95% CI

95% CI

95% CI

OSI
APSI
MLSI

17
12
12

.90
.86
.76

.73.96
.54.96
.20.93

27
27
27

.92
.89
.93

.83.96
.75.95
.86.97

44
39
39

.91
.89
.92

.84.95
.79.94
.85.96

Note. OSI = overall stability index; APSI = anteriorposterior stability index; MLSI = mediallateral
stability index.

DISCUSSION
As more performance information is obtained on any variable, reliability typically
increases. Therefore, as would be expected, the highest reliability estimate was obtained across eight trials and quite uniformly decreased as the number of trials decreased (see Table 3). Because most participants in the first group either reported fatigue or needed to end testing prior to eight trials due to fatigue, the question becomes
how to obtain the best measure possible while keeping the length of testing minimal.
Based on information obtained, the recommended test length would be four trials
with the Trials 1 and 2 being practice trials and Trials 3 and 4 the test trials.
Reliability estimates obtained in this study for the OSI measures were higher
than those reported by Pincivero et al. (1995). In addition, a pattern was observed
across the three measures produced by the BBS. The reliability estimates of the
OSI measures in this study were comparable or higher (although confidence intervals overlapped) than the reliability estimates of both the APSI and MLSI measures supporting the conclusion drawn by Schmitz and Arnold (1998) that the
overall stability index measures may be more reliable than the other two indexes.
The more important observation, however, was that for the protocol of two test trials preceded by two practice trials, all of the measures provided by the BBS had
similar, and good, reliability estimates.
Generalizability of the findings from this study is limited due to a small sample
size. However, the reliability estimates observed for all three measures suggest
that at least among healthy, athletic adults, BBS measures of dynamic balance at a
spring resistance level of two are reliable.
Additional constraints on generalizability include the fact that only one protocol, replicating testing in the Pincivero et al. (1995) study (single-leg balance,
20-sec trial length at a spring resistance level of two), was used. In addition, the validity of measures from the BBS has yet to be assessed (other than logically). This
may be due to difficulty in determining to what criterion measure of dynamic balance the BBS should be compared.

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107

Continued study of the BBS, as well as dynamic balance utilizing the BBS, is
recommended. Although the movement of the BBS does not resemble all daily
activities and sport involving dynamic balance, it does involve angular perturbations of the ankle. Real-life examples involving angular perturbations at the ankle include landing on a shoe (e.g., basketball, volleyball), losing balance across
an uneven patch of grass (e.g., field sports), or turning an ankle while stepping
across a curb or sidewalk (e.g., track, cross country) or a base (e.g., softball,
baseball).
To extend the work completed in this study, future researchers might pursue examining (a) the validity of BBS measures; (b) the reliability of BBS measures
among groups of varying ages, height, health, history of injury, activity levels,
functional capacity, or a combination thereof; (c) the reliability of BBS measures
among athletes in various sports; (d) the reliability of BBS measures at different
stability levels and for different length trials; and (e) the reliability of BBS measures while varying the visual, sensory, or vestibular inputs of balance (e.g., handrails up vs. down).

ACKNOWLEDGMENTS
We would like to thank Mike London for his technical support and the Physical Performance Institute for the use of their facility and BBS.

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