PT Classroom - A Brief Guide for Physiotherapists on the BESTTest for Balance  ׀ by Richard Philip Kochoa, PT, MD


Dr. Richard Philip Kochoa is a registered physiotherapist in the State of Texas. He is currently working with Avant Healthcare Professionals. He received his medical degree as a Shonee Henry Scholar at the University of St. La Salle College of Medicine and earned his pre-medicine course at the Riverside College, Philippines. He is an accomplished writer who maintains a column in a weekly magazine and international news organization.


A Brief Guide for Physiotherapists on the BESTTest for Balance

Advances in the medical field are rapid. What may be true today can be outdated within a few years. To travel the field of physical therapy is similar particularly in the practice of balance and coordination therapy.

For so many years, physical therapist have been using established evaluation tools for screening balance and coordination disorders such as Berg (1).

We have good reason to use it since it is simple to administer and has been extensively researched and validated. It involves 14 items that focus on tasks performed by patients in their performance of daily function like standing from seated position and reaching forward.

However, in spite of its well-correlated reliability in assessing Parkinson's Disease, it has inherent limitations particularly the well-reported ceiling effects and its failure to identify mild or subtle neurologic deficits.

We might dismiss this as our avoidance of the panacea in assessment tools—we can't have everything, afterall. The more pragmatic response may be to just use another tool to supplement what Berg or other tools lack.

Fortunately, some more comprehensive tools have been developed in recent years. The field might have been paved with the publication of the Balance Evaluation Systems Test (BESTest) in 2009 (2). In recent years, we have seen its offshoot such as the Mini-BESTest and the Brief-BESTest.

The forerunner BESTest was developed and published by physical therapists Fay Horak, Diane Wrisley and James Frank. They wanted to have an assessment tool that would help "identify the particular postural control systems responsible for poor functional balance" (2).

Horak and her colleagues contended that by identifying which system is deficient, a particular treatment option and rehabilitation program can be initiated to address the specific problem.

The six balance control systems they focused on are: stability limits and verticality; biomechanical constraints; anticipatory postural adjustments, transitions; reactive postural responses; sensory orientation; and dynamic balance during gait and cognitive effects.

Their research revealed that the BESTEst has good intrarater reliability and good validity for identifying fallers and non-fallers (among patients with Parkinsons disease).

The biggest drawback of this evaluation tool is its impracticality for use in busy clinical setting because of its comprehensive nature. It is quite lengthy to administer.

Gaining grounds on the limitation of the BESTest, the Mini-BESTest was developed by Franchignoni and colleagues in 2010 (3). This 14-item test for dynamic balance eliminated what was deemed redundant in the BESTest. Thus, it was as short as the Berg Test.

The scoring system was also simplified with a maximum score of 28 (out of the 0 or 2 scoring for those who are able and unable to perform a task, respectively).

The main advantage of this test is it has excellent interrater and test-retest reliability. Unfortunately, there is limited research available to establish its place in the clinical setting. Padgett deemed the
Mini-BESTest as "theoretically inconsistent with the BESTest".

Another test that stemmed from the original BESTest is the Brief-BESTest proposed by Padgett and colleauges (2012) (4). It selected one test item from each of the BESTest categories plus two items that require performance bilaterally.

Method for testing and scoring was the same as the full BESTest. The six items selected were derived from those with the highest correlation to the complete score in the original BESTest.

Padgett concluded that the Brief-BESTest was consistent with the sections included in the full BESTest.

In several published research studies, they also demonstrated high specificity in identifying non-fallers.

One research study on the comparative utility of the two BESTest versions that came out recently was published by Duncan and colleagues (2013) (5). They noted that "all versions have consistent high sensitivity in identifying future fallers". They suggested that clinicians can rely on the Brief-BESTest for predicting falls especially when time and equipment are limited.

The progenitor assessment tool will eventually become a benchmark for clinical utility as more physical therapists utilize this assessment tool and researchers further evaluate its various versions.

Refining our approach to patient care is important as advancements in the medical field is geared towards more personalized treatment. Having a clearer distinction of clinically-significant subtleties through validated assessment tools will ultimately benefit the patient and the physical therapy profession.

Last revised: May 23, 2013
by Richard Philip Kochoa, PT, MD


1.Berg, K, Wood-Dauphinee S. And Williams JI (1995). The Balance Scale: Reliability Assessment for Elderly Residents and Patients with Acute Stroke. Scandinavian Journal of Rehabilitation Medicine.
2.Horak FB, Wrisley DM, Frank J (2009). The Balance Evaluation Systems Test (BESTest) to Differentiate Balance Deficits. Physical Therapy.
3.Franchignoni F, Horak F, Godi M, Nardone A, Giordano A (2010). Using Psychometric Techniques to Improve the Balance Evaluation Systems Test: The Mini-BESTest. Journal of Rehabilitation Medicine.
4.Padgett PK, Jacobs JV, Kasser SL (2012). Is the BESTest at its best? A Suggested Brief Version Based on Interrater Reliability, Validity, Internal Consistency and Theoretical Construct. Physical Therapy.
5.Duncan, RP, et al (2013). Comparative Utility of the BESTest, Mini-BESTest, and Brief-BESTest for Predicting Falls in Individuals With Parkinson Disease: A Cohort Study.
6.King LA, Priest KC, Salarian A, Pierce D, and Horak F (2012). Comparing the Mini-BESTest with the Berg Balance Scale to Evaluate Balance Disorders in Parkinson's Disease. Parkinson's Disease.

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