Research Report

P.K. Pardasaney, PT, DPT, ScD, RTI

International, 1440 Main St, Suite
337, Waltham, MA 02451 (USA).
Conceptual Limitations of Balance Address all correspondence to Dr
Pardasaney at: pardasaney@rti.org.
Measures for Community-Dwelling At the time of the study, Dr Par-
dasaney was affiliated with the

Older Adults Department of Rehabilitation Sci-

ences, Sargent College of Health &

Downloaded from https://academic.oup.com/ptj/article/93/10/1351/2735540 by guest on 14 March 2024

Rehabilitation Sciences, and Health
Poonam K. Pardasaney, Mary D. Slavin, Robert C. Wagenaar,† Nancy K. Latham, & Disability Research Institute,
Pengsheng Ni, Alan M. Jette School of Public Health, Boston
University, Boston, Massachusetts.

M.D. Slavin, PT, PhD, Health &

Background. Psychometric limitations of balance measures for community- Disability Research Institute,
dwelling elderly may be related to gaps in task and environmental representation. School of Public Health, Boston
University.
Objective. The purposes of this study were: (1) to conduct item-level content R.C. Wagenaar, PhD, Department
analysis of balance measures for community-dwelling elderly people based on task of Physical Therapy and Athletic
and environmental factors and (2) to develop profiles of individual measures sum- Training, Sargent College of
marizing their task and environment representation. Health & Rehabilitation Sciences,
Boston University, and Rudolf
Magnus Institute of Neuroscience
Design. A systematic content analysis was conducted. and Department of Rehabilitation,
Nursing Sciences and Sports, Uni-
Methods. A literature search was conducted to identify balance measures. Item- versity Medical Center Utrecht,
level content analysis was based on 7 criteria related to task and environment: (1) task Utrecht, the Netherlands.
role, (2) environmental variation, (3) object interaction, (4) obstacle negotiation, N.K. Latham, PT, PhD, Health &
(5) external forces, (6) dual-tasking, and (7) moving people or objects in the Disability Research Institute,
environment. School of Public Health, Boston
University.
Results. Twenty-six measures, containing 167 items, were identified. Task role P. Ni, MD, MPH, Health & Disabil-
was fairly evenly distributed, with the majority of items examining gait tasks (32.3%), ity Research Institute, School of
followed by dynamic body stability (29.9%) and static body stability (25.1%). The Public Health, Boston University.
majority of items involved no environmental variation (58.1%), followed by variation A.M. Jette, PT, PhD, FAPTA, Health
of support surfaces (20.4%), visual conditions (13.2%), and both support and visual & Disability Research Institute,
conditions (8.4%). Limited task role variability was seen within measures, with 73.1% School of Public Health, Boston
University.
of measures examining only one task role. Environmental variation was present in
†
65.3% of measures, primarily during static body stability tasks. Few measures involved Dr Wagenaar passed away on
object interaction (23.1%), obstacle negotiation (38.5%), external forces (11.5%), February 13, 2013.
dual-tasking (7.7%), or moving people or objects (0%). [Pardasaney PK, Slavin MD, Wage-
naar RC, et al. Conceptual limita-
Limitations. The classification framework was not externally validated. tions of balance measures for
community-dwelling older adults.
Phys Ther. 2013;93:1351–1368.]
Conclusions. Existing measures focus on single-task assessment in static environ-
ments, underrepresenting postural control demands in daily-life situations involving © 2013 American Physical Therapy
dynamic changing environments, person-environment interactions, and multitasking. Association
New items better reflecting postural control demands in daily-life situations are Published Ahead of Print:
needed for more ecologically valid balance assessment. Individual balance measure May 23, 2013
profiles provided can help identify the most appropriate measure for a given purpose. Accepted: May 20, 2013
Submitted: February 4, 2013

Post a Rapid Response to

this article at:
ptjournal.apta.org

October 2013 Volume 93 Number 10 Physical Therapy f 1351

Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
B
alance, or postural control,
depends on interaction of mul-
tiple body systems, with pos-
tural control demands being influ-
enced by the complexity of the task
and the environment in which the
task is performed.1–3(pp157–186) Task
and environmental conditions influ-
ence postural control by affecting
associated biomechanical and
information-processing demands.1,4
The ability to maintain balance is
context-dependent, and different
people can become unstable in differ-
ent task and environmental condi-
tions, depending on the particular
body systems impaired.2 To identify
balance deficits in people with vary-
ing types and degrees of impairment,
a balance measure would need to
assess balance under task and envi-
ronmental conditions of varying
complexity.
Performance-based balance mea-
sures typically assess balance by sys-
tematically varying aspects of the
task or environment to challenge
performance. Balance measures are
extensively used to assess balance
ability, monitor change, determine
fall risk, and classify type of balance
dysfunction. A psychometrically
strong balance measure would be
expected to have adequate reliabil-
ity, validity, and measurement
breadth; minimal floor or ceiling
effects for the intended purpose and
population; adequate sensitivity and
specificity when used for diagnosis;
and adequate sensitivity to change
and responsiveness when used for
assessment of change.5–7 To achieve
precision and sensitivity to change
Available With
This Article at
ptjournal.apta.org
• eTable 1: Operational Definitions
of Classification Criteria
• eTable 2: Balance Measures and
Abbreviations
1352 f Physical Therapy Volume 93
uniformly across people of varying
balance ability, a balance test would
need to include tasks of a wide range
of difficulty in order to cover the full
spectrum of ability from low to high.
With regard to the ability to measure
balance and assess change, existing
measures have important limitations
in community-dwelling elderly peo-
ple, who typically represent a
higher-functioning population com-
pared with institutionalized elderly
or clinical populations with balance
deficits. Well-recognized psycho-
metric limitations include limited
comprehensiveness in assessing the
multiple aspects of balance, ceiling
effects, and limited sensitivity to
change and responsiveness.8 –10 These
limitations may contribute to fre-
quent use of multiple tests for bal-
ance assessment, increasing testing
burden.11–13
From a conceptual perspective, psy-
chometric limitations of balance mea-
sures may be related to gaps in repre-
sentation of essential task and
environmental components within
their items.1 Previous authors have
expressed concern that most existing
measures assess balance in static, pre-
dictable environments, inadequately
representing postural control
demands in daily life situations that
involve complex and dynamically
changing environments.1,3(pp257–295)
Focus on static environments ren-
ders measures susceptible to inaccu-
rately underestimating deficits and
reduces their ability to predict peo-
ple’s performance outside of clini-
cal environments.1,3(pp257–295) As a
result, individuals who could benefit
from balance interventions may not
be identified. Furthermore, although
balance intervention strategies com-
monly incorporate dynamic, chang-
ing environments and person-
environment interaction,3(pp257–295)
balance assessment in primarily
static environments can limit ability
to capture improvement resulting
from intervention.
Number 10
Given that psychometric limitations
of balance measures may be related
to gaps in task and environment
representation, a systematic content
analysis of existing measures would
be valuable in understanding the
degree to which essential task and
environmental factors are examined.
Content analysis of existing mea-
sures prior to development of new
measures is recommended when
several measures relevant to the out-
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come of interest already exist.14 A
systematic analysis would identify
task and environmental factors that
are well-represented in existing mea-
sures, reveal content gaps, and guide
new measure development, reduc-
ing redundant item development
and ensuring that new measures
successfully overcome any content
gaps. Additionally, given the vast
array of balance measures available
to clinicians and researchers, devel-
oping profiles of measures based on
a systematic analysis would allow
content comparison across mea-
sures, guiding selection of the most
appropriate measure for a given pur-
pose. Although a global critique of
task and environmental complexity
of some balance measures has previ-
ously been reported,1 to our knowl-
edge, a systematic item-level content
analysis of balance measures for
community-dwelling elderly people
is lacking.
The first aim of this study was to
conduct a systematic item-level con-
tent analysis of balance measures for
community-dwelling elderly people
based on task and environmental
factors that influence balance perfor-
mance and can be systematically
varied for balance assessment. The
second aim was to develop profiles
of balance measures describing the
extent to which different aspects of
the task and environment are repre-
sented within their items.
October 2013
 Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults

Table.
Classification Criteriaa

Object Obstacle External Moving

Role of Task* Environmental Variation Interaction* Negotiation Forces Dual-Tasking People/Objects*

Static body stability No variation Present Present Present Present Present

Dynamic body stability Variation of support surfaces Absent Absent Absent Absent Absent

Transfers Variation of visual conditions

Gait Variation of support surfaces

and visual conditions

Transfers and gait

a
Each item was coded on each of the 7 classification criteria listed. Asterisk indicates item was adapted from: Gentile AM. Skill acquisition: action,

Downloaded from https://academic.oup.com/ptj/article/93/10/1351/2735540 by guest on 14 March 2024

movement, and neuromotor processes. In: Carr J, Shepherd R, eds. Movement Science: Foundations for Physical Therapy in Rehabilitation. 2nd ed.
Gaithersburg, MD: Aspen Publishers Inc; 2000.

Method to identify further appropriate arti- balance measures,1 describes 4 catego-

Search Strategy
An extensive literature search was
conducted in consultation with a
medical librarian to identify balance
measures used in community-
dwelling elderly people. Functional
mobility measures primarily designed
as indicators of fall risk were not
included. The electronic databases
PubMed (MEDLINE) and CINAHL
were searched from their earliest
records until September 2012. In
PubMed, the following search terms
were used: (“Postural Balance”
[MeSH] AND “Geriatric Assessment”
[MeSH]) AND (“Aged” [MeSH] OR
“Aged, 80 and over” [MeSH]) AND
((“residence characteristics” [MeSH
Terms] OR (“residence” [All Fields]
AND “characteristics” [All Fields])
OR “residence characteristics” [All
Fields] OR “community” [All Fields])
AND dwelling [All Fields]). In
CINAHL, the following search terms
were used: (“balance scales” AND
“aged” AND “aged 80 and over” AND
“community-dwelling”). Titles and
abstracts of search results were
reviewed to identify articles report-
ing development or application of
balance measures. When abstracts
reporting balance measures were
identified, a further search was con-
ducted, as needed, to determine
whether the measures were used in
community-dwelling elderly people.
For relevant abstracts, related cita-
tions were reviewed within PubMed
cles. Relevant article bibliographies,
a rehabilitation measures database,15
and rehabilitation textbook3 also
were searched to identify balance
measures.
Data Extraction
Individual items from each balance
measure were extracted. To obtain
individual item content, the full text
of original articles reporting measure
development was obtained. When
the original article could not be
found, measure content was
obtained from secondary sources.
When the content of a measure
could not be obtained electronically,
in the university library, or in reha-
bilitation textbooks, the measure
was not included in the analysis.
Classification Criteria for
Item-Level Content Analysis
An extensive literature search was
conducted to determine classifica-
tion criteria for content analysis.
Conceptual literature discussing the
construct of balance was reviewed,
as were studies examining factors
that influence postural control
demands.1–3(pp157–186,257–295),16 –26 In
addition to literature directly related
to balance, Gentile’s taxonomy of
tasks,4 a framework for analyzing
movement and action based on task
and environmental complexity, was
reviewed. Gentile’s taxonomy, which
has been applied to globally examine
ries each of task and environmental
factors that influence biomechanical
and information-processing demands
of movement. Gentile’s definitions of
task role and motion in the environ-
ment4 were modified to increase
their applicability to postural control
and adapted within our classification
criteria, as described below. How-
ever, Gentile’s concept of intertrial
variability, which is more relevant to
practice and skill acquisition, was
not included.
From the above literature review, 7
factors related to task and environ-
ment that can influence balance per-
formance and be systematically var-
ied for balance assessment were
extracted: (1) task role,3(pp157–186),4
(2) variation of support surface and
visual conditions in the environ-
ment,1,2,16,21,23–27 (3) interaction
with objects,4 (4) obstacle negotia-
tion,1,22,25 (5) external forces,20
(6) dual-tasking,3(pp157–186),17–19,25 and
(7) moving people or objects in the
environment.1,4 These classification
criteria and their operational defini-
tions are provided in the Table and
eTable 1 (available at ptjournal.
apta.org), reflecting varying degrees
of task and environment complexity.
Initially, a modified 4-level definition
of task role was adapted from Gen-
tile’s taxonomy, which dichotomizes

October 2013 Volume 93 Number 10 Physical Therapy f 1353

Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
tasks into body stability and body
transport. A fifth level of task role—
transfers and gait— had to be created
to accommodate some items that
included both transfers and gait. A
4-level definition of environmental
variation was operationalized to
reflect variation of support surfaces
and visual conditions.16 Interaction
with objects and obstacle negotia-
tion were defined to reflect different
aspects of person-environment inter-
action that can influence balance
performance.1,4,22,25 External forces
was included as a criterion, as the
ability to respond to external forces
is a crucial strategy for postural sta-
bility and fall prevention.20,22 Dual-
tasking was included as a criterion,
as postural instability and fall risk are
manifested to a greater extent in
dual-task conditions and reduced bal-
ance performance under dual-task
conditions is highly predictive of
falls in older adults.28,29 Based on
Gentile’s taxonomy, moving people
or objects in the environment was
included as a criterion, as the pres-
ence of such motion, which is out-
side the individual’s control, can
increase information-processing and
postural control demands.4 Interac-
tion with objects, obstacle negotia-
tion, external forces, dual-tasking,
and moving people or objects in the
environment were operationalized
as being present or absent.
Item-Level Classification
Individual items were coded on each
of the 7 classification criteria. Coding
was conducted independently by the
first author (P.K.P.) and the second
author (M.D.S.). Both raters are phys-
ical therapists who are familiar with
the use of standardized balance mea-
sures in the elderly population. Both
raters underwent standardized train-
ing on application of classification
criteria. The 2-hour training session
included extensive discussion of
operational definitions to ensure
consistency in understanding and
application and coding of 15 items
1354 f Physical Therapy Volume 93
selected from the balance measures
identified. At the end of training,
both raters were in full agreement on
coding of practice items. The third
author (R.C.W.) was available for tie-
breaking in the event of any coding
discrepancies.
Data Analyses
Data analyses were conducted in
Microsoft Excel 2010 (Microsoft Cor-
poration, Redmond, Washington)
using pivot tables. To address the
first aim of conducting an item-level
content analysis, frequency analyses
were conducted for each classifica-
tion criterion. To address the second
aim of describing profiles of mea-
sures, frequency analyses of classifi-
cation criteria were summarized by
balance measure and are presented
as radar plots. All results are reported
as percentages.
Results
A total of 217 articles were initially
identified from PubMed and CINAHL
searches, and their titles and
abstracts were examined. A review
of relevant full text articles, related
citations, article bibliographies, and
the rehabilitation measures database
and rehabilitation textbook identi-
fied 27 balance measures used in
community-dwelling elderly people.
The content of one measure, the
Balance Screen Test,30 could not be
obtained and was not included.
Twenty-six balance measures, com-
prising a total of 167 items, were
included in the analysis; a list of
these measures and their abbrevia-
tions is provided in eTable 2 (avail-
able at ptjournal.apta.org). The num-
ber of items within a measure ranged
from 1 to 20. Of the 26 measures,
30.8% were single-item measures
(Four Square Step Test [FSST], Func-
tional Reach Test [FRT], TURN180,
single-leg stance [SLS], tandem
stance, tandem walk, Romberg test,
step test); 19.2% were multidirec-
tional assessments of leaning, step-
Number 10
ping, or reaching tasks (Limits of Sta-
bility [LOS], Maximum Step Length
[MSL], Rapid Step Test [RST], Multi-
directional Reach Test [MDRT], and
Lateral Reach Test [LRT]); 19.2%
were multi-item measures examining
different aspects of balance (Berg
Balance Scale [BBS], Mini-Balance
Evaluation Systems Test [Mini-
BESTest], Fullerton Advanced Bal-
ance Scale [FAB], Performance-
Oriented Mobility Assessment–
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Balance Scale [POMA-B], and Frailty
and Injuries: Cooperative Studies of
Intervention Techniques– 4 [FICSIT-
4]); 11.5% were focused on assessing
sensory systems underlying balance
(Dynamic Balance Assessment [DBA],
Sensory Organization Test [SOT], and
Clinical Test of Sensory Interaction on
Balance [CTSIB]); 7.7% were func-
tional mobility-based assessments
(Sensory-Oriented Mobility Assess-
ment Instrument [SOMAI] and Func-
tional Obstacle Course [FOC]); 7.7%
were gait-based assessments (Func-
tional Gait Assessment [FGA] and
Dynamic Gait Index [DGI]); and 3.8%
were dual-task balance assessments
(Multiple Tasks Test [MTT]).
There were no disagreements
between the 2 raters on item coding,
and tie-breaking from the third rater
was not required. Item-level analysis
of task role across the 167 items is
presented in Figure 1. Task role was
fairly evenly distributed, with the
majority of items examining gait
tasks, followed by dynamic body
stability and static body stability.
Although transfers were examined
by only 7.2% of items, the opera-
tional definition of transfers was
restricted to a narrow range of items
such as sit-stand and chair-chair
transfers. The category of transfers
and gait was created to accurately
classify 9 items from the Mini-
BESTest and MTT that examined
both transfers and gait.
The majority of items involved no
environmental variation (Fig. 2).
October 2013
 Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
Figure 1.
Distribution of task roles across the 167 items.
Figure 2.
Distribution of environmental variations across the 167 items.
Variation of support surface was the
most common type of environmen-
tal variation, followed by variation of
visual conditions and variation of
both support surface and visual con-
ditions. Of 48 items incorporating
support surface variations, 41.7%
involved base of support variations
such as narrow base of support;
52% involved compliant, sway-
October 2013
referenced, or inclined surfaces with
or without base of support varia-
tions; and 6.3% simulated a slippery
surface. Of 70 items incorporating
any type of environmental variation,
48.6% represented static body stabil-
ity tasks; 35.7% represented gait
tasks, 8.6% represented dynamic
body stability tasks, 4.3% repre-
sented transfer and gait tasks, and
Volume 93
2.9% represented transfers. A very
small proportion of items examined
interaction with objects (8.4%),
obstacle negotiation (14.4%), exter-
nal forces (3.0%), and dual-task bal-
ance (4.8%). No item incorporated
moving people or objects in the
environment.
Distributions of the different content
areas across measures are summa-
rized in Figures 3, 4, and 5. In terms
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of task role, 73.1% of the tests exam-
ined only one type of task; these
tests included the 18 measures con-
taining 8 items or less, and the
10-item FGA (Fig. 3). The remaining
26.9% of tests examined different
task roles to varying extents, with
the Mini-BESTest being the only mea-
sure to examine all 5 task roles. Envi-
ronmental variation was present in
65.3% of tests to varying extents
(Fig. 4). Of the 17 tests incorporating
environmental variation, 47.1% var-
ied environmental conditions during
static body stability tasks (BBS,
POMA-B, SOT, CTSIB, FICSIT-4, SLS,
tandem stance, and Romberg test),
23.5% during gait tasks (FOC, FGA,
DGI, and tandem walk), and 29.4%
during more than one type of task
role (SOMAI, Mini-BESTest, DBA,
FAB, and MTT). Of the 16 tests incor-
porating support surface variations,
50% consisted uniquely of base-of-
support variations (BBS, FGA,
POMA-B, FICSIT-4, SLS, tandem
stance, tandem walk, and Romberg
test); 43.7% consisted of compliant,
sway-referenced, or inclined surfaces
with or without base-of-support varia-
tions (SOMAI, Mini-BESTest, DBA,
FOC, FAB, SOT, and CTSIB); and 6.3%
simulated a slippery surface (MTT). A
minority of measures incorporated
interaction with objects (23.1%),
obstacle negotiation (38.5%), external
forces (11.5%), and dual-task balance
(7.7%) (Fig. 5).
Profiles of individual balance mea-
sures are presented as radar plots in
the Appendix, summarizing the dif-
Number 10 Physical Therapy f 1355
Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
Figure 3.
Distribution of task roles across the 26 measures. See eTable 2 for balance measures and abbreviations.
ferent content areas represented
within each measure. For instance,
the Mini-BESTest radar plot shows
incorporation of all but one content
area including static body stability
(35.7%), dynamic body stability
(21.4%), transfers (7.1%), gait (28.6%),
transfers and gait (7.1%), variation of
support surfaces (21.4%), variation
of visual conditions (7.1%), variation
of support surface and visual condi-
tions (14.3%), obstacle negotiation
(7.1%), external forces (21.4%), and
dual-tasking (7.1%). In contrast, the
DGI radar plot shows incorporation
of only 3 content areas including
gait (100%), variation of visual con-
ditions (25%), and obstacle negotia-
tion (37.5%). The CTSIB and SOT
radar plots show incorporation of all
3 types of environmental variations
within each measure, including vari-
ation of support surfaces (16.7%),
1356 f Physical Therapy Volume 93
visual conditions (33.3%), and sup-
port surface and visual conditions
(33.3%); however, these environ-
mental variations occur in the con-
text of static body stability tasks
(100%) only. Other radar plots can
be similarly interpreted to determine
the extent to which different con-
tent areas are encompassed within
each measure. The category of mov-
ing people or objects is not included
in these radar plots, as no measure
incorporated moving people or
objects in the environment.
Discussion
To our knowledge, this is the first
study to report an extensive, system-
atic content analysis of balance
measures for community-dwelling
elderly people based on task and
environmental factors. Our study
raises awareness of the breadth of
Number 10
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task and environment factors that
influence postural control demands
and are important to incorporate
in balance assessments. A striking
observation of the study was the
plethora of balance measures avail-
able for community-dwelling elderly
people, with considerable overlap
in content noted across several mea-
sures. Important content gaps were
observed across most measures,
with limited comprehensiveness in
content areas represented and lim-
ited incorporation of environmental
variations. Most measures focused on
single-task assessment in static envi-
ronments, underrepresenting pos-
tural control demands in daily-life
situations, which frequently involve
changing environments, person-
environment interactions, unexpected
external forces, and multitasking. No
measure incorporated environments
October 2013
 Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
Figure 4.
Distribution of environmental variations across the 26 measures. See eTable 2 for balance measures and abbreviations.
with moving people or objects, an
important limitation for assessment
of community-dwelling elderly peo-
ple. These content gaps may contrib-
ute to the ceiling effects and reduced
sensitivity to change of balance mea-
sures in the community-dwelling
elderly population. The content gaps
also provide important insights into
areas that should be incorporated
in new items for more comprehen-
sive and ecologically valid balance
assessment.
The detailed and comprehensive
profiles of balance measures have
significant practical applications, as
they summarize the content areas
examined by each measure within
a simple, easily interpretable format.
These profiles depict the strengths
and limitations in content coverage
of individual measures and serve as
a valuable guide to clinicians and
researchers seeking to identify the
October 2013
most appropriate measure for a given
purpose. An important strength of
the balance measure profiles is their
development based on systematic
item-level analysis using standard-
ized, comprehensive criteria.
The identified content gaps across
measures may partly result from lack
of application of a conceptual frame-
work clearly outlining essential
task and environment components
during measure development. A
strong conceptual model has been
described as a key attribute in devel-
oping sound health outcome mea-
sures.31 Although balance assess-
ment in physical therapy has
historically been based on strong
conceptual frameworks of postural
control systems, a systems
approach—albeit necessary—may
be insufficient for developing psy-
chometrically strong balance mea-
sures. A task and environment
Volume 93
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approach is additionally needed to
develop improved and ecologically
valid assessments that are adequately
challenging for the community-
dwelling elderly population.
The importance of incorporating
task and environmental conditions of
varying complexity in balance assess-
ments due to their varying influence
on postural control demands has pre-
viously been emphasized.1,3(pp257–295)
Evaluating patients using a broad
range of activities based on a frame-
work of task and environment com-
plexity also has been suggested so
functional assessments are more rep-
resentative of people’s performance
in daily-life situations.4,32 From a
broader perspective, the widely
adopted International Classifica-
tion of Functioning, Disability and
Health33 has highlighted the impor-
tant interaction among the person,
task, and environment in determin-
Number 10 Physical Therapy f 1357
Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
Figure 5.
Distribution of object interaction, obstacle negotiation, external forces, and dual tasks across the 26 measures. See eTable 2 for
balance measures and abbreviations.
ing an individual’s function and dis-
ability levels. Application of a com-
prehensive conceptual framework
of task and environment would be
a crucial step toward developing
improved balance measures and
achieving standardization across
measures. Although a framework of
postural control systems underlies
the recently developed BESTest,21,34
given its diagnostic purpose of iden-
tifying disordered postural control
systems, the framework does not
comprehensively outline task and
environment factors that can be sys-
tematically varied for balance assess-
ment. The classification criteria com-
piled for this study can serve as a
preliminary framework when devel-
oping new measures, to ensure that
items along the entire spectrum of
task and environment complexity
are represented.
1358 f Physical Therapy Volume 93
A single measure encompassing all
content areas was not identified,
with nearly three fourths of mea-
sures examining only one type of
task role. The Mini-BESTest was the
most comprehensive measure, fol-
lowed by the FAB. Nevertheless,
the Mini-BESTest has demonstrated
a ceiling effect trend even in inpa-
tients with neurological disorders,34
and the FAB has been found to have
very few items to assess community-
dwelling elderly people with above-
average balance ability.35 Method-
ologically, the ceiling effect trend in
these measures may be related to the
difficulty in selecting a reasonably
small number of items that can dis-
criminate across a wide range of bal-
ance abilities. Conceptually, 2 impor-
tant reasons may explain the ceiling
effect trend. First, environmental
variation, though present in these
Number 10
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tests, primarily occurs in the context
of less challenging, static body stabil-
ity tasks. Second, neither measure
assesses balance in environments
involving moving people or objects,
which are more representative of
dynamic, real-world environments
such as pedestrian crossings or
crowded supermarkets.1,4 Compared
with stationary environments, pos-
tural control demands increase con-
siderably in moving environments
due to the changing amount and
nature of sensory information, and
the need to predict and respond to
changing paths of people and
objects in a timely manner.1,4 Previ-
ous authors have expressed concern
that until balance measures can
incorporate dynamic, moving envi-
ronments, their ability to measure
balance and predict performance
October 2013
 Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
outside of clinical environments is
likely to remain limited.1
To truly develop more challenging
items, environmental variation
across the spectrum of task roles,
from static body stability to gait, is
recommended. Additionally, incor-
porating object interactions, obsta-
cle negotiations, and dual-tasking
across varied environmental condi-
tions is recommended to replicate
complex, real-world environments.
Although the majority of support sur-
face variations comprised base-of-
support changes, balance assess-
ment on compliant surfaces also is
encouraged to challenge sensory
inputs in addition to biomechanical
constraints. Response to external
forces and dual-tasking are other
essential areas that were minimally
examined by measures. The ability
to respond to unexpected external
forces using reactive strategies has
long been acknowledged as a critical
aspect of postural control,22 as a sig-
nificant proportion of falls in elderly
people are related to inadequate
responses to external disturbances.20
Given the evidence that information-
processing demands and postural
instability increase with secondary
task performance, balance assess-
ment under dual-task conditions
also is critical to isolate deficits not
apparent in single-task paradigms.
Dual-task assessment is particularly
important in older adults because
attentional capacity has been found
to decline with aging25 and impaired
performance of one or both tasks
has been noted in older adults in
dual-task paradigms where attention
is divided.36,37 Although the MTT
was specifically developed as a mea-
sure of balance under multiple task
conditions,38 very limited applica-
tion of the measure was found dur-
ing the literature search.
The lack of incorporation of moving
people and objects in balance assess-
ments may be related to the chal-
October 2013
lenge in incorporating such motion
in a standardized, practical, and
reproducible manner. Virtual reality
systems may offer promising mecha-
nisms to overcome this challenge
and systematically assess balance in
dynamic, moving environments.39
Virtual reality has been described as
an immersive and interactive system
that provides users with the illusion
of entering and exploring a virtual
world that can be responsive to
actions of the user.40 Virtual reality
environments have been suggested
as ideal, ecologically valid environ-
ments to understand postural con-
trol strategies.39 Although effective-
ness of virtual reality systems in
delivering balance interventions has
been examined,41– 43 their applica-
tion as balance assessment tools
remains limited. Applying virtual
reality environments to balance
assessments may be a potential
mechanism to reduce ceiling effects
of balance measures.
When advocating the importance of
comprehensive balance assessment,
it is equally important to underscore
the practical challenges of adminis-
tering a lengthy, comprehensive
measure in the traditional, fixed-
form format. Traditional fixed-form
measures require administration of
all items in the measure to every per-
son.44 A comprehensive fixed-form
balance measure will be associated
with increased testing burden on
both administrators and elderly peo-
ple due to the large number of items
needed to cover the full spectrum
of balance ability and components.
Two recently developed compre-
hensive fixed-form balance measures
have limited practicality due to their
testing burden, with the BESTest
containing 36 items and the Unified
Balance Scale containing 27 items.21,45
Contemporary measurement meth-
ods of item response theory and
computerized adaptive testing offer
promising approaches to overcome
methodological challenges associ-
Volume 93
ated with fixed-form testing and
develop precise and efficient bal-
ance measures.44 Item response the-
ory and computerized adaptive test-
ing methods require development of
a comprehensive item pool measur-
ing the construct of interest46 – 49; rel-
evant and tailored item subsets from
the item pool then are administered
to individuals based on their ability
level. Qualitative review and classifi-
cation of collective items from exist-
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ing measures is the recommended
first step toward developing compre-
hensive item pools.14
In the future, it is conceivable that
a comprehensive item response
theory– calibrated balance item pool
could be developed for the
community-dwelling elderly popula-
tion, which can be used to adminis-
ter tailored balance assessments. Our
analyses, by providing qualitative
understanding of items contained
in existing measures, represent an
important first step toward building
an improved, expanded item pool
that fills existing content gaps.
Recent unpublished research by our
group has demonstrated the superior
validity of a preliminary computer-
ized adaptive balance measure over
3 traditional, fixed-form measures in
discriminating between community-
dwelling elderly fallers and nonfall-
ers. Continued investigation of item
response theory and computerized
adaptive testing methods for balance
assessment is encouraged.
Limitations
Our study had some limitations.
First, although we conducted an
extensive literature search in consul-
tation with a medical librarian to
identify balance measures for
community-dwelling elderly people,
it is possible that some measures
were not identified. Second, although
the classification criteria for our con-
tent analysis were based on an exten-
sive literature review that included
examination of existing postural
Number 10 Physical Therapy f 1359
Conceptual Limitations of Balance Measures for Community-Dwelling Older Adults
control frameworks, our classifica-
tion framework was not externally
validated. Validation of the classifica-
tion framework by external experts
in the field of balance assessment as
well as clinician focus groups would
strengthen its validity for future
application. Nevertheless, our frame-
work is timely in raising awareness
of task and environment influences,
given the proliferation of balance
measures that fail to adequately
represent the spectrum of task and
environment components important
for balance assessment. Finally,
although we recognize that our clas-
sification framework is not diagnos-
tic of disordered postural control sys-
tems, developing a single framework
of postural control systems, task,
and environment is challenging. The
classification framework used in our
study can be integrated with pos-
tural control system frameworks to
develop items of varying complexity
targeted to specific systems.
Conclusions
The majority of balance measures
used in the community-dwelling
elderly population are deficient in
incorporating important task and
environmental variations, showing
limited variability in types of task
roles examined. These content gaps
may contribute to the ceiling effects
and reduced sensitivity to change of
balance measures in this population.
New measures should include items
of greater task and environmental
complexity to better replicate pos-
tural control demands in real-world
environments. The most critical and
underrepresented task and environ-
ment components recommended for
inclusion in new measures include
support surface and visual variations,
obstacle negotiation, external forces,
dual-tasking, and moving people or
objects in the environment.
Dr Pardasaney, Dr Slavin, Dr Wagenaar, and
Dr Latham provided concept/idea/research
design. Dr Pardasaney, Dr Slavin, Dr Wage-
1360 f Physical Therapy Volume 93
naar, Dr Latham, and Dr Jette provided writ-
ing. Dr Pardasaney and Dr Slavin provided
data collection. Dr Pardasaney, Dr Slavin, Dr
Ni, and Dr Jette provided data analysis. Dr
Pardasaney provided project management.
Dr Slavin and Dr Wagenaar provided consul-
tation (including review of manuscript
before submission).
DOI: 10.2522/ptj.20130028
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Appendix.
Profiles of Individual Balance Measuresa

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Appendix.
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Appendix.
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a
See eTable 2 for balance measures and abbreviations.

1368 f Physical Therapy Volume 93 Number 10 October 2013