Is the Berg Balance Scale an internally valid and reliable measure of balance across different etiologies in neurorehabilitation? A revisited Rasch analysis study.

OBJECTIVES: To assess, within the context of Rasch analysis, (1) the internal validity and reliability of the Berg Balance Scale (BBS) in a sample of rehabilitation patients with varied balance abilities; and (2) the comparability of the BBS measures across different neurologic diseases. DESIGN: Observational prospective study. SETTING: Rehabilitation ward of an Italian district hospital. PARTICIPANTS: Consecutively admitted inpatients and outpatients (N=217); for 85 participants, data were collected both on admission and discharge, giving a total sample of 302 observations. INTERVENTION: Not applicable. MAIN OUTCOME MEASURE: BBS. RESULTS: Most of the BBS items had to be rescored, and 2 items (static sitting and standing balance) had to be deleted, to attain adequate internal construct validity (χ(2)(24)=35.68; P=.059). The reliability of the Rasch-modified BBS (BBS-12) (total score, 0-35) was high (.957), indicating precision of measurement at the individual level. The analysis of differential item functioning (DIF) showed invariance of the item calibrations across patients' sex, age, and etiology. After adjusting for the possible effect of repeated measurements on person estimates, the analysis of DIF by timing of assessment confirmed the stability of the item hierarchy across time. A practical ruler was provided to convert item raw scores into Rasch estimates of balance ability. CONCLUSIONS: This study supports the internal validity and reliability of the BBS-12 as a measurement tool independent of the etiology of the neurologic disease causing the balance impairment. In view of some sample-related issues and that not all possible etiologies encountered in the neurorehabilitation settings were tested, a larger multicenter study is warranted to confirm these findings.

Clinical relevance of action observation in upper-limb stroke rehabilitation: a possible role in recovery of functional dexterity. A randomized clinical trial.

OBJECTIVE: A randomized controlled observer-blind trial was designed to evaluate the effectiveness of action observation as an add-on treatment to the standard rehabilitation of upper-limb function, early after stroke. METHODS: Stroke survivors (N = 102) were consecutively recruited from 13 centers 30 days (±7) after a first-ever stroke and randomly assigned to the experimental (EG) or control group (CG). EG participants watched video footage of daily routine tasks (actions) carried out with the upper limb in order to prepare to imitate the presented action. At the end of each sequence, a therapist prompted the patient to perform the same movement for 2 minutes, providing help when needed. Static images without animals or human beings were shown to the CG. At the end of each sequence, the CG executed movements that simulated the shoulder and elbow joint mobilization activities performed by the EG. RESULTS: for the Fugl-Meyer test, Frenchay Arm test, Box and Block test (BBT), Modified Ashworth Scale, and Functional Independence Measure Motor items were recorded before treatment (T0), after 4 weeks of treatment (T1), and at the follow-up visit 4 to 5 months after the conclusion of treatment (T2). Results. An improvement over time was appreciated on all measures of impairment and functional ability with both treatment programs. A Time × Treatment interaction emerged from the generalized estimating equations analysis of BBT, showing significant T0-T1 and T0-T2 differences in favor of EG. CONCLUSION: This multicenter trial endorses the use of action observation in upper-extremity rehabilitation, along with a role for the mirror neuron system in poststroke recovery.

Unified Balance Scale: an activity-based, bed to community, and aetiology-independent measure of balance calibrated with Rasch analysis.

OBJECTIVE: To build a new activity-based, "bed to community", aetiology-independent measure of balance within the neurological rehabilitation setting by merging some existing scales. METHODS: Balance scales were selected using a conceptual framework and subsequently administered to a convenience sample of adult patients with balance problems due to different neurological aetiologies. Data were then processed using classical psychometric analyses and Rasch analysis in order to construct a new balance measurement tool. RESULTS: The Berg Balance Scale, the Tinetti Scales and the Fullerton Advanced Balance Scale were selected and administered to a sample of patients, giving 302 observations. Classical psychometric analyses (item and scale analysis; confirmatory factor analysis) were undertaken on the pooled 40-item set with confirmation of unidimensionality. The subsequent Rasch analysis allowed the identification of a 27-item set satisfying the Rasch Model's requirements for fundamental measurement, with further confirmation of unidimensionality by post-hoc confirmatory factor analysis. CONCLUSION: The new scale (Unified Balance Scale) holds proven measurement properties and may be a candidate tool for "bed to community" balance measurement for patients with balance problems within the neuro-rehabilitation setting. Future studies are warranted to explore further its external validity and other clinical properties, as well as to improve its usability.

Unified Balance Scale: classic psychometric and clinical properties.

OBJECTIVE: To evaluate the classic psychometric and clinical profile of the Unified Balance Scale, a novel Rasch-based measure of balance. METHODS: The Unified Balance Scale was administered to 219 neurological patients (providing 302 observations) admitted to rehabilitation, together with: Timed Up & Go, 10-meters walking test, Functional Ambulation Classification (FAC), Walking Handicap Scale, FIM™, Trunk Control Test, Motricity Index, and posturographic indexes. Analyses included: concurrent validity, external construct validity (convergent, divergent and discriminant validity), responsiveness, interpretability, predictive validity and usability. RESULTS: External construct validity (e.g. correlation with FAC: rho=0.80; with the motor FIM™: rho=0.55), adequate responsiveness (effect size 1.13), interpretability (the relationship of Unified Balance Scale scores with those of the originating scales and, indirectly, with the risk of falling), and, finally, predictive validity (e.g. relative risk of nursing home admission: 4.33 (95% confidence interval 2.43-7.73) for Unified Balance Scale scores ≤ 2 on admission) were demonstrated for the Unified Balance Scale. Analysis of usability suggested a mean administration time of 20-30 min. CONCLUSION: Although further studies are needed to generalize these results to different samples, to confirm its fall risk estimation capabilities and to improve its usability, the Unified Balance Scale presents itself as a psychometrically sound outcome measurement tool to evaluate the effectiveness both of fall reduction plans and of rehabilitation interventions aimed at improving balance.