Physical & Occupational Therapy in Pediatrics, 32(4):416–429, 2012

C 2012 by Informa Healthcare USA, Inc.
Available online at http://informahealthcare.com/potp
DOI: 10.3109/01942638.2012.705418

Performance of Children on the Community

Balance and Mobility Scale

Marilyn J. Wright, BSc PT, MEd, MSc & Cecily Bos, BA, MSc PT

McMaster Children’s Hospital, McMaster University, Hamilton, Ontario, Canada

ABSTRACT. This study describes the performance of children 8–11 years of age on
the Community Balance and Mobility Scale (CB&M) and associations between per-
formance and age, body mass index (BMI), and sex. A convenience sample of 84 was
recruited. The CB&M was administered using instructions we developed for children.
Mean CB&M total scores (95% confidence intervals) for age groups were 8: 70.1 (64.2,
76.1); 9: 72.8 (68.7, 76.8); 10: 79.2 (76.6, 81.7); and 11: 82.9 (79.2, 86.5). None of the chil-
dren achieved the maximum score. Scores increased with age, and overweight/obese
children had relatively lower scores. There were no significant differences between
males and females. A regression analysis found 28.1% of the variation in the CB&M
total scores was explained by age (p < .001), BMI (p < .01), and sex (p = .25) sug-
gesting that other factors contribute to variation in balance and mobility proficiency.
The modified instructions and scoring patterns from this study can assist in using the
CB&M in children of ages 8–11 years.

KEYWORDS. Balance, children, mobility, outcome measure, pediatric, postural

control

Balance and mobility provide a foundation for children to safely and efficiently en-
joy participation in activities of daily living, play, sports, and fitness. Impairments
in balance and limitations in mobility are characteristics of children with neurode-
velopmental diagnoses, such as cerebral palsy (CP), developmental coordination
disorder, acquired brain injuries (ABIs), developmental delay, and hearing impair-
ment. The development of balance and mobility skills is complex and involves the
maturation of multiple physiological systems within the child in combination with
demands placed on children by the environment and task-related experiences
(Westcott & Burtner, 2004). Effective postural control reflects the development
and coordination of the sensory, motor, and musculoskeletal systems for func-
tional activity. More specifically, these three systems underlie static and dynamic
postural control through the integration of the visual, vestibular, and somatosen-
sory systems; neuro-motor anticipatory and reactive postural adjustments; and

Address correspondence to: Marilyn J. Wright, BSc PT, MEd, MSc, Hamilton Health Sciences, Box
2000, Children’s Developmental Rehabilitation Programme, Chedoke Campus, Hamilton, Ontario, Canada
(E-mail: wrightm@hhsc.ca).
(Received 20 December 2011; accepted 11 June 2012)

416
 Community and Balance Mobility Scale in Pediatrics 417

biomechanics of musculoskeletal structures impacted by anthropometric charac-

teristics, such as height, weight, and body mass index (BMI; Westcott & Burtner,
2004). Performance of balance and mobility may also be associated with variables,
such as behavior, attention, motivation, fatigue, and apprehension (Buderath et al.,
2009; Ghanizadeh, 2009; Mickle, Munro, & Steele, 2011; Westcott & Burtner, 2004).
Various measures have been used to document proficiency and measure
change in the balance and mobility skills of children. Some, including the
Bruininks–Oseretsky Test of Motor Proficiency (BOTMP, Bruininks & Bruininks,
2005) and the Gross Motor Function Measure (Russell et al., 1989), were devel-
oped specifically for pediatric populations. Others, such as the Functional Reach
Test (Duncan, Weiner, Chandler, & Studenski, 1990), Timed Up and Go (Pod-
siadlo & Richardson, 1991), and the Dynamic Gait Index (Whitney, Hudak, &
Marchetti, 2000), were developed initially for adults and subsequently used in pe-
diatric populations. Other measures have been adapted from use in adults to use in
children, such as the Pediatric Balance Scale (Franjoine, Darr, Held, Kott, & Young,
2010), which is an adaptation of the Berg Balance Scale (Berg, Wood-Dauphinee,
Williams, & Gayton, 1989).
Many of these outcome measures demonstrate a ceiling effect for certain popu-
lations. When tested using the Pediatric Balance Scale, for example, most children
older than 6 years of age obtained maximum scores, thus limiting its usefulness in
school-aged children (Franjoine et al., 2010). A ceiling effect was also observed
when the psychometric properties of the Dynamic Gait Index were studied in chil-
dren 8–15 years of age (Lubetzky-Vilnai, Jirlowic, & McCoy, 2011). When a ceiling
level exists, an outcome measure may not be useful in identifying children who may
appear to be high functioning on the basis of performance of basic skills, but have
deficits in the complex skills required for independent participation in community
and recreational pursuits. There remains a need for a measure of balance and mo-
bility that demonstrates no ceiling effect, enabling the measurement of change in
complex or higher-level skills.
There is a need for valid and reliable norm-referenced measures of balance and
mobility for ambulatory children that are feasible for use in clinical practice for the
purposes of goal stetting, program planning, and outcome measurement. Cost and
ease of administration are important considerations in the selection of measure-
ment tools. Those that require expensive or complicated instrumentation may not
be feasible for clinical or field settings.
The Community Balance and Mobility Scale (CB&M) was developed at the
Toronto Rehab Institute as a clinical tool to assess postural stability and dynamic
balance, and to evaluate change in high-level balance skills of ambulatory adults
with ABIs (Howe, Inness, Venturini, Williams, & Verrier, 2006). High-level bal-
ance skills are defined as static and dynamic balance and mobility skills that re-
quire precision, speed, timing, sequencing of movements, and the ability to multi-
task (Inness et al., 2011). The CB&M is a 13-item measure that includes tasks that
are representative of the motor skills thought to be necessary for everyday func-
tioning in community settings, many of which have a higher degree of complexity
than some pediatric outcome measures. Examples of items include: running with
an abrupt stop, transitioning from forward to backward walking, and walking while
looking laterally. Items are scored on a 6-point ordinal scale, with a higher score
418 Wright and Bos

representing better performance. The test does not require specialized equipment
and can be administered in clinical or community settings. The CB&M and detailed
description of scoring procedures are accessible via Internet at no cost (Toronto Re-
hab, 2011).
The psychometric properties of the CB&M have been well established in adults
with acquired brain injury (ABI) and demonstrate high degrees of validity and re-
liability (Howe et al., 2006). Construct validity was established by clinicians and
patients with traumatic brain injury (TBI), and discriminant validity was demon-
strated by the scale’s ability to differentiate patients along a continuum of care, from
acute care to community settings (Inness et al., 2011). The CB&M demonstrates
intra-rater reliability (ICC = 0.98), inter-rater reliability (ICC = 0.98), test–retest
reliability (ICC = 0.98), and internal consistency (alpha coefficient = 0.96) in adults
(Howe et al., 2006). It has also been shown to have excellent (ICCs ≥ 0.90) intra-
rater, inter-rater, and test–retest reliability in children with ABIs (Wright, Ryan, &
Brewer, 2010).
Research in typically functioning adults has confirmed the high level of difficulty
and lack of a ceiling effect based on only 3 of 90 participants achieving a perfect
score (Rocque, Bartlett, Brown, & Garland, 2005). Response to change has been
demonstrated by a mean change of 23.8% from baseline to discharge in pediatric
brain injured clients (Wright, Brewer, & Wannamaker, 2007). The CB&M demon-
strated moderate magnitude correlations with both Community Integration Ques-
tionnaire (r = 0.54, p < .001) and the Activities-specific Balance Confidence Scale
(r = 0.60, p = .01) in adult populations (Inness et al., 2011). These measures reflect
ability, self-efficacy, and participation in the community studies, which have docu-
mented the CB&M reference values in adults between the ages of 20 and 69 years
(Rocque et al., 2005; Williams, Howe, & Inness, 2005).
The inter-rater, intra-rater, and test–retest reliability of the CB&M has been ex-
amined in children with ABI (Wright et al., 2010), however, there are no known
studies describing the scoring of the CB&M in school-aged children without motor
impairments. The objectives of the study were to describe the testing and perfor-
mance of children 8–11 years of age on the CB&M, and to explore associations
among the CB&M scoring patterns with age, weight, and sex. It was hypothesized
that CB&M scores would improve with age, that children who were overweight or
obese would have poorer scores, and that sex differences in scoring may exist as
females demonstrate earlier maturation of the neurological, visual, vestibular, and
proprioceptive systems (Franjoine et al., 2010; Mickle et al., 2011).

METHODS

Subjects
The subjects were a convenience sample of 84 children from 8 to 11 years of age who
were independent in walking and able to follow basic instructions. Children were
recruited from a local school and scout troop in a community with varying socioe-
conomic levels. The study was approved by the Research Ethics Board of Hamil-
ton Health Sciences/McMaster University Faculty of Health Sciences. Informed
consent was obtained from all parents/guardians of participants, and the children
 Community and Balance Mobility Scale in Pediatrics 419

TABLE 1. Participant Characteristics and CB&M Total Scores

Age group (N) %Overweight/%obese CB&M total scores: mean (SD) [95% CI]

Total group (84) 18.1/14.5 75.57 (10.50) [73.29, 77.85]

Male (44) 13.6/11.4 74.50 (10.75) [71.33, 77.77]
Female (40) 17.5/15.0 76.75 (10.23) [73.48, 80.02]
8 years: total (20) 20.0/15.0 70.10 (12.71) [64.15, 76.05]
Male (9) 22.2/11.1 64.56 (2.03) [54.33, 74.78]
Female (11) 18.2/18.2 74.64 (10.72) [67.44, 81.84]
9 years: total (28) 21.4/25.0 72.75 (10.37) [68.73, 76.77]
Male (17) 23.5/27.3 73.00 (8.35) [68.71, 77.29]
Female (11) 18.2/36.4 72.36 (13.36) [63.39, 81.34]
10 years: total (20) 15.0/10.0 79.15 (5.40) [76.62, 81.68]
Male (8) 0/25.0 78.88 (6.20) [73.69, 84.06]
Female (12) 25.0/0 79.33 (5.09) [76.10, 82.57]
11 years: total (16) 12.5/0 82.88 (6.83) [79.24, 86.51]
Male (10) 0/0 82.50 (7.04) [77.46, 87.54]
Female (6) 33.0/0 83.50 (7.06) [76.09, 90.91]

provided written and verbal assent. An attempt was made to recruit similar dis-
tributions of males and females in age groupings by year. The majority of the
participants were Caucasian. Thirty-two percent of the participants were over-
weight or obese. Age and BMI category descriptions are included in Table 1.

Measure
The CB&M is comprised of a total of 13 tasks with 6 items measured bilaterally
(Table 2). Each task is rated on a 6-point scale (0–5), with one item allowing for a
bonus point. The highest possible score is 96. A score of “0” denotes the inability to
perform the task. The criteria for scores 1–5 are progressively demanding with re-
gards to time, distance, and quality of performance (Howe et al., 2006). The scoring
administration guidelines available on the Internet provide a detailed description
of scoring for each task (Toronto Rehab, 2011).
The CB&M was administered to each child individually using the CB&M guide-
lines with modifications described below. Prior to data collection the CB&M was
piloted on six children between the ages of 6 and 11 years. During testing, the 6-
and 7-year-old children demonstrated signs of frustration with certain items of the
CB&M (tandem pivot, lateral foot scooting, etc.). Given that the basics of adult
gait patterns, the skills upon which the CB&M items are based, are achieved by the
age of 7 years (Sutherland, Olshen, Cooper, & Woo, 1980), it was decided that the
minimum age for this study would be 8 years.
All children reported and demonstrated signs of difficulty understanding the
complexity of the standardized instructions. A revised script was developed using
more simplistic terminology and additional cueing instructions to increase partic-
ipant comprehension of each task (see Appendix). In addition to the changes in
instruction, the weights in the bags used in the “walk, look, and carry” items were
reduced from 7.5 pounds to 5 pounds in order to account for the smaller size and
strength of the child participants as compared with the adult participants for which
the CB&M was designed.
420 Wright and Bos

TABLE 2. CB&M Item Scores and Analyses Based on Age and Obesity Categories

CB&M item Median (interquartile range) Agea Obesity categorya

1a. Unilateral stance — left 4 (1) 10.032, p = .018 NS

1b. Unilateral stance — right 4 (1) NS NS
2. Tandem walking 5 (1) 8. 45, p = .038 7.878, p = .019
3. 180◦ Tandem pivot 4 (2) 12.875, p = .005 NS
4a. Lateral foot scooting — left 4 (1) 11.48, p = .011 NS
4b. Lateral foot scooting — right 4 (1) NS NS
5a. Hopping forward — left 4 (2) 18.933, p < .001 14.016, p = .001
5b. Hopping forward — right 4 (1) NS 16.488, p < .001
6. Crouch and walk 4 (2) NS NS
7. Lateral dodging 4 (1) NS NS
8a. Walking and looking — left 4 (1) NS NS
8b. Walking and looking — right 4 (1) NS NS
9. Running with controlled stop 4 (1) NS 7.705, p = .021
10. Forward to backward walking 4 (2) 8.892, p = .031 10.079, p = .006
11a. Walk, look, and carry — left 4 (0) 9.069, p = .028 NS
11b. Walk, look, and carry — right 4 (1) NS NS
12. Descending stairs 6 (0) NS NS
13a. Step-ups × 1 step — left 5 (3) 8.528, p = .036 NS
13b. Step-ups × 1 stop — right 5 (1) 13.778, p = .003 NS
a
Analyses based on Kruskul—Wallis one-way ANOVA.

Procedures
Testing was conducted in local church or school hallways and gymnasiums with
minimal distractions. Data were collected by two pediatric physiotherapists, both
with over 5 years of experience, and four physiotherapy students in their final year
of training who received standardized training in the administration and scoring
of the CB&M from the developers of the scale. Practice trials were conducted to
ensure agreement on scoring among testers. Student assessors collected data un-
der the supervision of a physiotherapist. All children were able to complete testing
safely and indicated that they enjoyed performing the CB&M. In addition, some
children noted that items such as lateral dodging were similar to movements per-
formed in dance or hockey practices. Testing time was 15–20 min per child. The
CB&M administrators observed that children were able to understand the modi-
fied instructions, enjoyed performing the test items, and those who were inattentive
to instructions performed less optimally than those who were attentive to instruc-
tions.
Following the CB&M administration, children were invited to give comments
regarding their experience. They were asked whether they enjoyed participating or
not, and were then asked to volunteer any other comments. Heights and weights of
all participants were measured.

Data Analysis
The BMI was calculated by the Centers for Disease Control and Prevention (CDC)
BMI Percentile Calculator for Child and Teen Metric Version, which uses the equa-
tion weight/height2 and determines BMI percentile for age and gender based on
normative data (Centers for Disease Control and Prevention, 2011). Children less
than the 5th percentile are classified as underweight, those between the 85th and
 Community and Balance Mobility Scale in Pediatrics 421

95th percentiles are considered overweight, those above the 95th percentile are
classified as obese, and all others are considered to have a healthy BMI.
The CB&M total scores were analyzed as interval data representing a contin-
uum from poor to excellent, and reported as means with standard deviations (SDs)
and 95% confidence intervals. Scores of individual items were treated as ordinal
data as they range from 0 to 6 and reported as medians and interquartile ranges.
The Kruskal–Wallis one-way analysis of variance (ANOVAs) and Mann–Whitney
U-tests were used to determine the effect of age, BMI, and gender on individual
items. A regression analysis was conducted to investigate the associations of age in
months, BMI category, and sex with total CB&M scores. Underweight and healthy
children were combined into one group. A probability level of .05 or less was con-
sidered statistically significant.

RESULTS
Median values and interquartile ranges for each item are listed in Table 2. Figure
1 illustrates the age grouping scores by gender. The minimum total CB&M score
was 44 and the maximum 93 (out of a possible 96). Mean, SD, and 95% confidence
intervals are listed in Table 1. There were no significant differences in the CB&M
total scores between males and females, however, there was a nonsignificant trend
for females to perform better than males in the 8-year-old group.
Multiple regressions explained 28.1% of the variance in the CB&M total scores
(Table 3). Age (older children scored higher) and BMI category (overweight/obese

FIGURE 1. Interval plot of CB&M Total scores by Age and Gender. 144 mm × 96 mm
(101 × 101 DPI).
422 Wright and Bos

TABLE 3. Regression Analysis Results

Unstandardized coefficients

Variable B Standard error Standardized coefficients beta t p

Age 0.306 0.076 0.382 4.025 <.001

BMI −4.556 1.360 −0.319 −3.349 .001
Gender −2.995 1.952 −0.143 −1.534 .129

scored lower) were significant predictors of the CB&M total scores. Sex was not a
significant contributor to the regression equation.
Kruskal–Wallis one-way ANOVAs were performed to determine which items
were significantly different among ages (Table 2). The analysis indicated a signif-
icant age effect for left unilateral stance, tandem walk, tandem pivot, left lateral
foot scooting, left hopping forward, forward to backward walking, and left walk,
look and carry, and left and right step-ups. Overweight and obese children had rel-
atively lower CB&M total scores (Figure 2). The CB&M items that accounted for
the poorer performance of children who were overweight or obese based on the
Kruskal–Wallis one-way ANOVAs were the tandem walk, hopping forward left and
right, run with a controlled stop, and forward to backward walk (Table 2). No par-
ticular subtest was responsible for the discrepancy between 8-year-old males and
females based on Mann–Whitney U-test analyses.

FIGURE 2. Interval plot of CB&M Total Scores by BMI category. 144 mm × 96 mm (101 ×
101 DPI).
 Community and Balance Mobility Scale in Pediatrics 423

DISCUSSION
This study provides information about the administration and performance of a
sample of 84 children, 8–11 years of age with typical development (TD) on the
CB&M. Administration of the test was safe, efficient, economical, and enjoyable,
suggesting it is a feasible tool to use in clinical or community settings for children
8–11 years of age. The CB&M total scores varied from 44 to 93, demonstrating the
ability of the CB&M to detect variability in balance and mobility skills in children
in this age group. No child achieved a perfect score of 96, demonstrating the ab-
sence of a ceiling effect. The lowest score of 44 suggests there is ample latitude to
document variance in children with motor difficulties. This has been demonstrated
by relatively lower scores and greater variability in a study by Wright et al. (2010)
who investigated the use of the CB&M with original script in a group of 32 chil-
dren/adolescents from 8 to 18 years of age with acute brain injuries. Their total
CB&M scores ranged from 23 to 96 with a mean of 64.7 and a SD of 17.4.
There is a progressive improvement and refinement of postural control through
childhood and adolescence (Cumberworth, Patel, Rogers, & Kenyon, 2006; Fran-
joine et al., 2010). Maturation of the sensory, motor, and musculosketal systems
continues through the age span of subjects in the current study (Westcott & Burt-
ner, 2004). This maturation was reflected in the current study where the CB&M
scores showed a significant positive relationship with age demonstrating that the
test measures age-related changes in balance and mobility skills. Franjoine et al.
(2010) reported similar findings of improved balance with age using the Pediatric
Berg Scale, however, a ceiling effect was observed in children older than 6 years
of age. The positive association found between the CB&M total scores and age in
this study reflects the ability of the tool to show the expected increase in balance
abilities from ages 8 through 11 years, adding construct validity for the use of this
measure in children.
Most left-sided bilateral items were performed significantly poorer by the
younger children relative to the older children. Information about dominance was
not collected. Assuming that the majority of children were right dominant, this find-
ing could suggest that skills develop earlier on a child’s dominant side due possibly
to the impact of more frequent use.
The effect of previous experience could also be reflected in the relative difficulty
of items. The lateral dodging item was most difficult for adults (Rocque et al., 2005)
but not for children who likened it to activities they perform in dance or hockey
activities.
Studies have documented the CB&M reference values in adults between the ages
of 20 and 69 years, where a significant and inverse relationship was demonstrated
between CB&M scores and age with progressive decline in CB&M score across
decades (Rocque et al., 2005; Williams et al., 2005). The same age effect with a
progressive decline from the age of 20 can be seen using other static and dynamic
measures of balance including the Romberg test, One Leg Standing test, Timed Up
and Go test, Tandem Gait test, and Dynamic Gait Index (Vereeck, Wuyts, Truijen,
& Van de Heyning, 2008). While, there remains debate in the literature regarding
the age at which age related changes plateau, the combination of studies involv-
ing subjects with typical development suggests that balance continues to develop
424 Wright and Bos

beyond 11 years of age and peaks in late adolescence or the twenties. Decreased
muscle strength, slowness in reaction time, and slow speed of performance were
suggested as possible reasons for the decline in scores with increasing age in adults
(Rocque et al., 2005).
The percentages of children who were overweight or obese (18.1% and 14.5%,
respectively) in this sample were slightly greater than the national estimates of
15.5% for overweight and 12.4% for obese based on CDC cut-points (Shields &
Tremblay, 2010). These figures reflect the increases in body weight in children ob-
served in Canada and other countries. There was a significant relationship between
BMI categories and CB&M total scores as overweight and obese children per-
formed more poorly. The CB&M items that accounted for the differences in the
BMI categories were the tandem walk, hopping forward, run with a controlled stop,
and forward to backward walk.
Similar findings were found in studies investigating the impact of body weight on
balance and mobility skills. D’Hondt, Deforche, Bourdeaudhuij, and Lenoir (2009)
found poorer general motor skill performance in obese children as measured by
the Movement Assessment Battery for Children (MABC), but no differences be-
tween healthy-weight children and children who were overweight. The scores dif-
fered most for the MABC static and dynamic balance cluster (p < .01), which would
be more reflective of the skills tested in the CB&M and less so for the ball skills
(p < .05) and manual dexterity items (p < .10), which would be less similar to
CB&M items.
Deforche et al. (2009) studied associations between percent body fat and multi-
ple balance and mobility skills in normal and overweight prepubertal boys. Higher
percent fat was significantly associated with poorer scores in sit to stand activities
and some aspects of walking heel to toe on a line. Similar to our study, Deforche
et al. noted performance of step-up skills, unilateral stance, and basic walking pa-
rameters (other than step width) were not associated with weight status.
The mechanism behind the poorer performance in overweight and obese chil-
dren in our study is most likely multifactorial. Children with a higher BMI could
have increased difficulty with motor skills due to the biomechanics associated with
moving larger body segments. It is possible that they present with lower strength
relative to mass, have trouble decelerating the body once moving, or need a wider
base of support due to greater adipose tissues between the lower extremities. These
could contribute to inferior performance on balance and mobility tests requiring
propulsion, controlled sudden deceleration, or a narrow base of support (D’Hondt
et al., 2009).
The relationships between motor skills and BMI could also be mediated by alter-
native and possibly multidirectional mechanisms (D’Hondt et al., 2009). Children
who are overweight tend to be less physically active and prefer sedentary pastimes
contributing further to lack of experience and practice, and therefore poorer mo-
tor skill performance. Conversely, children who are not proficient in motor skills
may not pursue physical activities and become overweight or obese (Wrontniak,
Epstein, Dorn, Jones, & Kondilis, 2006).
There were no significant differences between males and females on the CB&M
total scores in the combined sample, however, when age groups were considered
separately there was a trend among the 8-year-old children for females to score
 Community and Balance Mobility Scale in Pediatrics 425

better than males. This was not attributable to any individual items. Various studies
have suggested that males may lag behind in their development of postural control
compared to girls, particularly in skills requiring static control, but not for those
requiring anticipatory control (Franjoine et al., 2010, Geldhof et al., 2006; Mickle
et al., 2011). Sex differences in certain motor skills may also be indicative of differ-
ences in muscle strength, attention span, and sex-role development (Mickle et al.,
2011). Some of these attributes that may be less sex-specific for the age group stud-
ied. These studies demonstrate the importance of analyzing balance and mobility
separately for males and females.
Although, a significant amount of variability was attributable to age and obesity,
other factors not measured in the current study must contribute to the variability
in the CB&M scores. These could include impairments of body function and struc-
tures, such as attention, strength, joint contracture, laxity, or alignment, hypo or hy-
pertonicity; sensory problems including pain or visual, auditory or tactile deficits;
environmental influences, such as peers, family, facilities, or socioeconomic status
(SES); or personal factors, such as motivation.
It was observed that children who appeared to have trouble paying attention to
the testing protocol performed more poorly on the CB&M. It was difficult to de-
termine if their poor performance was because they did not fully pay attention to
the instructions, and therefore did not attend to the specific details, or whether an
association between attention problems and balance impairments impacted per-
formance. Studies analyzing the impact of attention on balance have found that
children with attention deficits have significant challenges in balance testing and
proposed that deviations in gait and posture in children with attention deficit hyper-
activity disorder may be indicative of an underlying cerebellar or central nervous
system circuitry dysfunction contributing to balance deficits (Buderath et al., 2009;
Ghanizadeh, 2009).
Participants were not screened for mild neurological findings, orthopedic prob-
lems, or fitness levels. Although, these factors could potentially impact perfor-
mance, the intent of this study was to measure balance and mobility abilities in
sample representative of ambulatory children with a spectrum of demographics,
health status, and other capacities. However, the reference values from this study
are based on children who live in an urban setting, have variable SES, and are mostly
Caucasian. Therefore, the CB&M scores described in this sample may not be gener-
alizable to dissimilar populations, and cannot be considered to be normative data.
The cross-sectional design of this study does not allow for determination of cause
and effect. Questions such as “does obesity lead to poor motor function?” or “do
poor motor skills contribute to obesity due to lack participation in physical activ-
ity?” remain unanswered. Explanations for variation in the CB&M scores most
likely vary among children and in many cases associations are multifactorial and
multidirectional. Therefore, it is important to interpret the CB&M scores within the
context of examination of other potential impairments or environmental factors.

CONCLUSIONS
Children 8–11-years old were able to perform the items on the CB&M when a re-
vised script and lighter weights were used. The revised script has not been used in
426 Wright and Bos

other pediatric studies. It was feasible to conduct the test in community settings.
Older children had higher scores, however, there was no ceiling effect. The posi-
tive associations between the CB&M total scores and age demonstrated the abil-
ity of the tool to track the maturation of high-level balance abilities from ages 8
through 11 years. Overweight or obese classification impacted scores negatively.
These findings contribute to the construct validity for use of this measure in chil-
dren. Although, age and BMI were significant predictors of the CB&M scores, the
regression analysis suggested other factors not measured in this study contribute to
the variation in balance and mobility proficiency.
The modified instructions and scoring patterns from this study can assist in ad-
ministering the measure and interpreting the scores for 8–11-year-old children with
or without motor impairments. The ability to identify problems with balance and
mobility in children who walk but lack the skills necessary for safe and efficient in-
tegration into the community, may justify and promote services for this population.
The CB&M can also be used for research in this age group.

ACKNOWLEDGMENTS
The authors wish to acknowledge Jo-Anne Howe and Liz Inness for providing
training in the use of the CB&M and the participants, Earl Kitchener School staff,
49th Scout Group, Melrose United Church, Robyn Synnott, Jenna Weck, Lesley
Minich, Jennifer Rochefort, Erin Sturch, Rose-Marie Bos, Timothy Bentley, and
Micha Bentley for assistance with testing sessions.

Declarations of interest: The authors report no conflicts of interest. The authors

alone are responsible for the content and writing of this article.

ABOUT THE AUTHORS

Marilyn J. Wright, BScPT, MEd, MSc, is Physiotherapist, McMaster Children’s Hos-
pital, and Assistant Clinical Professor, McMaster University, Hamilton, Ontario,
Canada. Cecily Bos, BA, MSc PT, is Physiotherapist, McMaster Children’s Hospi-
tal, and Professional Associate, McMaster University, Hamilton, Ontario, Canada.

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APPENDIX:

Revised CB&M Script for Children

For each station, start by saying: “Listen closely as we tell you what to do,” then
“Now, watch closely as we show you what to do.”
At the end of all instructions say: “Start when you’re ready.”

1. Unilateral Stance
• Stand on your right/left leg, as long as you can. Don’t stop until I say “stop.”
Look straight ahead.
• Cues: At most two times.
• “Keep your foot up”
• “Keep going.”
2. Tandem Walking
• Walk forward on the line, heel touching toes. Keep your feet pointing for-
ward. Look straight ahead, down the line.
• Don’t look at your feet.
• Don’t stop until I say stop.
• Cues: At most one time
• Keep going.
• Heels touching toes.
• Look straight ahead.
3. Tandem Pivot
• Stand with one foot in front of the other. Lift your heels a little and turn
around to face the other side. Do this without stopping. Put your heels down
and hold that position.
• Cues: At most one time
• “stay still”
• “hold that position.”
4. Lateral Foot Scooting
• Stand on your right/left leg. Lift your heel and move it over, now lift your
toes and move them over. Move sideways along the line until you reach the
other side. When you get there, stay on one leg.
• Cues: At most one time
• Try not to fall.
5. Hopping Forward
• Stand on your right/left foot, Hop two times, straight along the line. Pass
this mark with your foot. When you get there, stay on one leg.
 Community and Balance Mobility Scale in Pediatrics 429

• Cues: At most one time.

• Don’t leap, just hop.
6. Crouch and Walk
• What hand do you usually write with? (Place beanbag to on corresponding
side of 2 m mark) Walk forward quickly and bend to pick up the beanbag.
Keep walking down the line to the end. Do this without stopping.
• Cue with: At most two times.
• Keep going.
• Don’t stop.
7. Lateral Dodging
• Face the wall. Have your feet touch the line. Move sideways along the line
by crossing one foot in front of and over the other. Do this quickly but safely.
Change directions when we say CHANGE. You can look at your feet if you
need to.
• Cues: At most two times.
• Keep going
• Stay on the line.
8. Walking and Looking
• Walk quickly down the line. When we say “look at the circle,” we want you to
look at this circle (point to circle). Keep looking at the circle even when you
have walked past it. Don’t look forward until we tell you to. Keep walking
straight down the line the whole time.
• Cue with: cue throughout
• Look at the circle, look forward
• Keep going.
9. Running with Controlled Stop
• Run as fast as you can to the end of the track. Stop right away with both feet
on the finish line and freeze.
10. Forward to Backward Walking
• Walk forwards to the halfway mark where will be standing. Without
stopping, turn around and walk backward. Don’t stop until I say stop. Try to
stay on the line. Walk quickly but safely.
• Cues: at most one time
• Keep walking.
11. Walk, Look, and Carry
• As in #8, beginning with “Now you will walk with a 5 lb. bag in each hand.”
12. Descending Stairs
• Walk down the stairs. Try not to use the railing, but you can if you need to.
• Now, we’ll try the bonus. Walk down the stairs, carrying this basket. Try not
to look at your feet, but you can if you need to.
13. Step-Ups × 1 step
• Step up and down on this step as quickly as you can. Don’t stop until I say
stop. Step up with right foot first, then left foot. Step down with right foot
first, then left foot. Try not to look at your feet.
• Step up and down on this step as quickly as you can. Don’t stop until I say
stop. Step up with right foot first, then left foot. Step down with right foot
first, then left foot. Try not to look at your feet.
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