2014 Test-Retest Reliability of the Star Excursion Balance Test in Primary School Children

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C L I N I C A L F E AT U R E S

Test-Retest Reliability of the Star ExcursionBalance Test in Primary School Children

Joaquin Calatayud, MSc 1

Sebastien Borreani, PhD1

Juan Car los Colado, PhD1

Fernando Martin, PhD1

Jorge Flandez, PhD2

1Research Group in Sport andHealth, Laboratory of PhysicalActivity and Health, Departmentof Physical Education and Sports,University of Valencia, Valencia, Spain;2Austral University of Chi le, Facultyof Pedagogy in Physical Education,Sports, and Recreation, Valdivia, Chile

Correspondence: Juan Carlos Colado, PhD,Universidad de Valencia (FCAFE),Aulario Multiusos,C/ Gasco Oliag, 3,46010 Valencia, Spain.Tel: 00-34-963-983-470Fax: 00-34-963-864-353E-mail: [email protected]

DOI: 10.3810/psm.2014.11.2098

AbstractBackground: Dynamic balance has been considered a fundamental skill at all ages and is

required for normal daily tasks, such as walking, running, or other sports activities. The Star

Excursion Balance Test (SEBT) has been widely used in recent years to identify dynamic bal-

ance decits and improvements and to predict the risk of lower extremity injury. However, no

study has demonstrated the reliability of the SEBT in children while they are performing thetest in a physical education session. Reliability is needed in all measurement tools in order to

provide repeatable and consistent data. Objective: To evaluate the reliability of the SEBT in

primary school students in the school setting. Methods: Twenty-four healthy children with

typical development were tested twice, 2 weeks apart. The tests were conducted by the same

single rater and were performed during the physical education class. The test was performed

under standardized conditions during the 2 testing sessions and was performed by each subject

with both limbs in the 3 directions (anterior, posteromedial, and posterolateral). Four practice

trials were performed in each direction before selecting 3 additional distances reached. The best

value of these 3 additional measured trials was selected. The paired t test was used to ensure

the absence of any systematic bias. Intraclass correlation coefcient, standard error of measure-

ment, 95% condence intervals (CIs), and minimal change values were calculated to assess

reliability and measurement error. Results: The paired t tests revealed no signicant differences

between test–rest scores. Test–retest reliability for all distances reached was moderate to good.

Conclusions: Reliability values suggest that the SEBT is suitable for primary school students.

However, it may be more practical and feasible during extracurricular sports participation due

to the time constraints and difculties in using the test in the school setting.

Keywords: injury risk; school setting; reliability; dynamic balance

IntroductionDynamic balance has been considered a fundamental skill at all ages1 and is required

for normal daily tasks, such as walking, running, or other sports activities,1,2 especially

those activities that require dynamic movements while maintaining control.3

Since sports participation is one of the most frequent causes of injuries,4 and because

balance is a predictor of an increased risk to sustain a lower extremity injury such asankle sprains,5 a test that provides dynamic conditions is required in order to identify

balance decits and to assess fall risk and sports-related injury risk.6

The physical education classes may play an important role in identifying children

with poor tness7 and those at high risk of injuries. Because of their undeveloped

neuromuscular system,8 children’s injury rates related to falls and sports participation

are elevated.9


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SEBT Reliability in Primary School Children

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The Star Excursion Balance Test (SEBT) has been widely

used in recent years in both healthy and injured populations

to identify dynamic balance decits and improvements and

to predict the risk of lower extremity injury.10 Performing

the test requires strength, exibility, and coordination11 to

maintain a single leg stance on one leg while reaching as far

as possible with the contralateral leg.2

Reliability is needed in all measurement tools12 to provide

repeatable13,14 and consistent15,16 data. Therefore, a reliable

test is a precise measure14 that ensures similar results under

the same test conditions.15 Despite the fact that the intraclass

correlation coefcient (ICC) and standard error of measure-

ment (SEM) values have shown moderate2 to high16–18 reli-

ability for the SEBT in young adults and middle-aged adults,

no study has demonstrated the between-session reliability

of the SEBT in children who are performing the test in a

physical education class. To our knowledge, only 2 recent

investigations19,20 have tested the SEBT in schoolchildren,

although these were not conducted in order to evaluate thereliability of the test. Furthermore, the use of dynamic bal-

ance tests in children is limited to costly systems such as

balance platforms6 or the Biodex Balance System.21 Hence, a

reliable cost-effective test that could be performed anywhere

is needed to obtain dynamic balance measures and to provide

useful information to identify those with greater injury risk.

Moreover, it has been established that motor tness, which

includes balance and coordination, is a physical health-related

component in childhood and adolescence.22 Thus, this study

evaluated the relative and absolute test–retest reliability of

the SEBT in primary school students in the school setting.

We hypothesized that the SEBT would be a reliable measure

to assess dynamic balance in this population.

Materials and MethodsParticipantsTwenty-four children (12 girls and 12 boys; age 11.0 ± 0.8

years, height 152.4 ± 8.7 cm, weight 45.4 ± 8.1 kg, body mass

index 19.46 ± 2.63) volunteered to take part in this study.

They were required to be free from lower extremity injury for

at least 6 months prior to testing and to have no history of hip,

knee, or ankle surgery.17 A complete life-screening was not

performed, but the children did not report any injury (at leastin the 6 months prior to testing) that could affect dynamic

balance and thus the performance of the test. The children

were required to be in primary school (their ages ranged from

10 to 12 years) and to be physically active, because they were

required to be participating in some organized sport before

the study started.

All the children and their parents signed an institutional

informed consent form before starting the protocol, and the

study was approved by the institutional review board at the

authors’ institutions. All procedures described in this section

comply with the requirements listed in the 1975 Declaration

of Helsinki and its 2008 amendment.

ProtocolHeight and body mass index were measured according to the

protocol used in a previous studies.23

Participants were tested twice, 2 weeks apart, and mea-

surements were performed at the same time of the day by the

same single rater, according to the protocol established in a

previous reliability study.13 The rater was a researcher with

some experience in performing SEBT studies at a university.

To avoid possible distractions that could inuence the results,

the children were individually tested in the sports facility

while the other subjects waited outside.

The SEBT was performed with both limbs, following therecommendations by Gribble et al,10 and was performed in

3 directions (anterior, posteromedial, and posterolateral, in

this order). This modication reduces the time necessary to

perform the SEBT10 and thus is a more practical way to use

the test in a school setting.

Four practice trials were performed in each direction

before selecting 3 additional distances reached in order to

minimize practice effects.17,24 The best value of the 3 mea-

sured trials was selected, as in previous studies.11,17 The

subjects performed all the reaching distances with 1 leg and

then with the contralateral leg in a counterbalanced order.

After nishing the practice trials, the subjects had 30 seconds

to rest before performing the next 3 trials.

The subjects performed the test barefoot, with the stance

foot aligned at the most distal aspect of the toes for anterior

direction and the most posterior aspect of the heel for the back-

ward directions.10 During the trials, the hands were placed on

the hips, and minimal stance foot movement was allowed.10

The test started from a bipedal position. Then the par-

ticipants were asked to maintain a single leg stance on 1 leg

while reaching as far as possible with the opposite leg to

touch as far as possible along the chosen line with the most

distal part of their foot.10,17

The subjects then returned to theinitial stance.10,17 The point at which the subject touched the

line was marked by the examiner and measured manually

using a measuring tape.17

Leg length was measured, quantifying the distance from

the anterosuperior iliac spine to the center of the ipsilateral

medial malleolus with the participant lying supine.25 This


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measure was used to normalize the distances reached,

dividing the distance reached by leg length and then multiply-

ing by 100.25 A trial was discarded and repeated if participants

used the reaching leg for a substantial amount of support at

any time, removed the foot from the center of the grid, were

unable to maintain balance,25 lifted their heel off the ground,

lifted their hands off the hips, or did not follow the previously

mentioned instructions in performing the test.

Data AnalysisStatistical analysis was carried out using SPSS version 17

(SPSS Inc., Chicago, IL). The level of signicance was set

at P 0.05 for all statistical tests.

Means and standard deviations were calculated for the

maximum distance reached in each direction for both limbs.

Paired t tests of the differences of scores obtained at test

and retest sessions were used to ensure the absence of any

systematic bias.26

The ICC (3,1) was calculated for each reaching directionto assess the relative between-session reliability, normal-

izing the measurement error relative to the heterogeneity

of the subjects.14 The SEM (pooled standard deviation of

all scores multiplied by the square root of 1 – ICC) 14 and

the 95% CIs were computed to estimate the amount of error

associated with the measurement. In addition, the mini-

mum difference (MD) was calculated (SEM * 1.96 * √2)

to determine the minimum threshold of measurement to

ensure that differences between measurements were real and

outside the error range.14

Criteria ranges for ICC reliability were as follows: 0.50,

poor; 0.50 to 0.75, moderate; and 0.75, good.27

ResultsPaired t tests revealed no signicant differences between the

scores of the 2 testing sessions for all directions reached in

both limbs ( P 0.05).

Mean, standard deviation, and P values of the paired t

test for normalized maximum distances reached in both limbs

are reported in Table 1.

The ICC values for normalized scores showed moderate

to good reliability (0.51 to 0.93), and the SEM values for

normalized scores ranged from 3.03 to 12.32. Table 2 showsthe mean, standard deviation, 95% CI, SEM, MD, and ICC

values for normalized reaching distances.

DiscussionIn accordance with the hypothesis, SEBT showed moderate

to high reliability scores (0.51 to 0.93) in primary school

children. Similar intratester ICC results have been reported

previously in healthy young adults, where SEBT ICCs ranged

from 0.84 to 0.92,17 0.67 to 0.87,2 0.78 to 0.96,16 and 0.82 to

0.87.11 In addition, intertester ICCs have ranged from 0.35

to 0.9316 and from 0.86 to 0.92.18

Although the ICC provides a relative measure of reli-

ability, the SEM provides an absolute reliability index14

and quanties the scores’ precision.28 Relative reliabilityaddresses the consistency of the position or the rank of the

subjects in the group relative to others, whereas absolute reli-

ability addresses the consistency of the subjects’ scores.14

In our study, the SEM values for normalized scores

ranged from 3.03 to 12.32. Concretely, the lowest SEM

result was found in the anterior reach direction with the

right stance, also showing the lowest minimal distance value

(8.39). Previous SEM values ranged from 1.77 to 3.38,16

3.43 to 4.78,2 and 1.95 to 2.54,17 whereas the only study

reporting MD data during the SEBT performance showed

values ranging from 6.13 to 8.15.17 A possible explanation for

the highest SEM value in our study (12.32) and the lowest

ICC value (0.51) across all the SEBT reliability studies is

that primary school children might need a greater number

of demonstrations and practice trials in order to improve

their technique. However, this value pertains to a specic

reach (posteromedial direction with left stance), and the

other results in our study are in accordance with the range

of values previously reported.

It should be pointed out that the different results from

different studies could be due to the different testing proce-

dures performed. For example, our study was the rst that

conducted a 2-session model with 2 weeks between tests,whereas the subjects in the other studies has at most 1 week

between tests.17 In addition, some SEBT reliability studies

performed the 8 reaching directions,2,16,17 whereas other

studies performed only 3 reaching directions.18 Differences

in the number of trials, the familiarization sessions, and

other aspects of the performance (eg, hands placed on hips,

Table 1. Mean, SD, and P Values for Normalized Maximum

Excursion Distancesa

Test Retest P value

Anterior Left stance 67.43 (8.75) 65.88 (15.27) 0.536

Right stance 69.17 (8.96) 70.23 (8.14) 0.249

Posteromedial Left stance 84.80 (11.89) 82.54 (22.40) 0.541

Right stance 84.51 (14.32) 86.11 (15.33) 0.178

Posterolateral Left stance 75.83 (12.43) 75.89 (11.82) 0.957

Right stance 74.78 (13.93) 76.33 (16.23) 0.219

aValues are mean ± SD for normalized maximum excursion distance. P values are

for the paired t test on test–retest differences.


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SEBT Reliability in Primary School Children

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barefoot or not, and foot alignment) also could inuence the

results and thus the reliability of the studies. We are condent

that additional familiarization sessions and additional prac-

tice trials might have helped to improve the reliability in

our study, and thus these factors are the main limitations.

However, the number of trials performed was enough to

minimize practice effects in previous reliability studies.17,24

Furthermore, a mean score of the 3 measured trials could

provide higher reliability values as has been recently dem-

onstrated.18 Because we recorded only the best value, futurestudies should include this variation to improve the reliability

of the test in this population.

Field-based tests in the school setting must be time-

efcient and inexpensive, must require only minimal equip-

ment, and must be easily administered to a large number of

children simultaneously.29 For example, it took 3 physical

education sessions of approximately 55 minutes each for

a single tester to administer a validated battery of 6 tness

tests to 20 children.29 However, 6 physical education sessions

were needed in our study to perform all the measurements.

The time required to perform the practice trials and ensure

the correct performance of the test may be excessive if the

purpose is to measure a large number of participants in a

single physical education session. Thus, the time needed to

perform the SEBT is a limitation in some settings. Another

limitation is that 2 examiners may be required to observe

and ensure an adequate testing technique and to mark the

distances reached.

The performance of the SEBT in the school setting may

have additional limitations. In our study, the children were

tested individually to avoid the distraction of having their

peers present. Moreover, the number of subjects involved

and time constraints may represent further limitationsto performing the SEBT during the physical education

classes. Because this is the rst SEBT reliability investiga-

tion that was conducted in the school setting, our results

provide a rst s tep for future studies that can attempt to

nd optimal methods and procedures to provide more

reliable results.

ConclusionsThe moderate to good absolute and relative reliability values

show that the SEBT is a repeatable measure for primary

school students in different testing sessions. Thus, the SEBT

may be used to assess dynamic balance in children. How-

ever, the difculty and time needed for a single examiner

to conduct the testing might prove impractical in the school

setting. The SEBT might be more appropriate in extracur-

ricular sports where there are fewer time constraints.

AcknowledgmentsThe authors thank the children who participated in this study

as well as their teachers at the Padre Moreno School for

their cooperation. In addition, we thank Craig Denegar and

Germán Martín for their assistance.

Conict of Interest Statement

Joaquin Calatayud, MSc, Sebastien Borreani, PhD,

Juan Carlos Colado, PhD, Fernando Martin, PhD, and

Jorge Flandez, PhD, have no conicts of interest to declare.

Table 2. Mean, SD, 95% CI, SEM, MD, and ICC Values for Normalized Excursion Distances

Mean SD 95% CI SEM MD ICC

Anterior Left stance 66.65 12.20 63.11 73.29 8.36 23.19 0.53

Right stance 69.69 8.39 66.78 70.48 3.03 8.39 0.87

Posteromedial Left stance 83.67 17.60 78.39 93.48 12.32 34.15 0.51

Right stance 85.31 14.53 81.32 86.09 3.85 10.66 0.93

Posterolateral Left stance 75.86 11.87 73.58 78.02 3.56 9.88 0.91

Right stance 75.55 14.83 71.47 76.53 4.20 11.63 0.92

Abbreviations: ICC, intraclass correlation coefcient; MD, minimal difference; SEM, standard error of measurement.

References

1. Gallahue DL. Understanding Motor Development: Infants, Children,

Adolescents, Adults. New York: McGraw-Hill; 2011.

2. Kinzey SJ, Armstrong CW. The reliability of the Star-Excursion

test in assessing dynamic balance. J Orthop Spor ts Phys Ther.

1998;27(5):356–360.

3. Miller MG, Herniman JJ, Ricard MD, Cheatham CC, Michael TJ. The

effects of a 6-week plyometric training program on agility. J Sport Sci

Med . 2006;5(3):459–465.

4. Fong DT, Hong Y, Chan LK, Yung PS, Chan KM. A systematic

review on ankle injury and ankle sprain in sports. Sports Med .

2007;37(1):73–94.

5. Witchalls J, Blanch P, Waddington G, Adams R. Intrinsic functional

decits associated with increased risk of ankle injuries: a systematic

review with meta-analysis. Br J Sports Med. 2012;46(7):515–523.

6. Granacher U, Gollhofer A. Is there an association between variables of

postural control and strength in prepubertal children? J Strength Cond

Res. 2012;26(1):210–216.

7. España-Romero V, Artero EG, Jimenez-Pavón D, et al. Assessing health-

related tness tests in the school setting: reliability, feasibility and safety;

the ALPHA Study. Int J Sports Med . 2010;31(7):490–497.

8. Williams HG, Pfeiffer KA, O’Neill JR, et al. Motor skill per -

formance and physical activity in preschool children. Obesity.

2008;16(6):1421–1426.


5/5

Calatayud et al



9. Schneider S, Yamamoto S, Weidmann C, Brühmann B. Sports injuries

among adolescents: incidence, causes and consequences. J Paediatr

Child Health. 2012;48(10):E183–E189.

10. Gribble PA, Hertel J, Plisky P. Using the Star Excursion Balance Test

to assess dynamic postural-control decits and outcomes in lower

extremity injury: a literature and systematic review. J Athl Training.

2012;47(3):339–357.

11. Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star excursion

balance test as a predictor of lower extremity injury in high school

basketball players. J Orthop Sports Phys Ther. 2006;36(12):911–919. 12. Currell K, Jeukendrup AE. Validity, reliability and sensitivity of mea-

sures of sporting performance. Sports Med . 2008;38(4);297–316.

13. Ortega FB, Artero EG, Ruiz JR, et al. Reliability of health-related

physical tness tests in European adolescents. The HELENA Study.

Int J Obesity. 2008;32(5):49–57.

14. Weir JP. Quantifying test-retest reliability using the intraclass correlation

coefcient and the SEM. J Strength Cond Res. 2005;19(1):231–240.

15. Hopkins WG. Measures of reliability in sports medicine and science.

Sports Med . 2000;30(1):1–15.

16. Hertel J, Miller SJ, Denegar CR. Intratester and intertester reliability

during the star excursion balance tests. J Sport Rehabil . 2000;9:

104–116.

17. Munro AG, Herrington LC. Between-session reliability of the star

excursion balance test. Phys Ther Sport . 2010;11(4):128–132.

18. Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater reliability

of the star excursion balance test. J Athl Train. 2013;48(5):621–626. 19. Gorman PP, Butler RJ, Rauh MJ, Kiesel K, Plisky PJ. Differences in

dynamic balance scores in one sport versus multiple sport high school

athletes. Int J Sports Phys Ther . 2012;7(2):148–153.

20. Sandrey MA, Mitzel JG. Improvement in dynamic balance and core

endurance after a 6-week core-stability-training program in high school

track and eld athletes. J Sport Rehabil . 2013;22(4):264–271.

21. Houghton KM, Guzman J. Evaluation of static and dynamic postural

balance in children with juvenile idiopathic arthritis. Pediatr Phys Ther .

2013;25(2):150–157.

22. Ruiz JR, Castro-Piñero J, Artero EG, et al. Predictive validity of

health-related tness in youth: a systematic review. Br J Sports Med.

2009;43(12):909–923.

23. García-Massó X, Colado JC, González LM, et al. Myoelectric activationand kinetics of different plyometric push-up exercises. J Strength Cond

Res. 2011;25(7):2040–2047.

24. Robinson RH, Gribble PA. Support for a reduction in the number of

trials needed for the Star Excursion Balance Test. Arch Phys Med Rehab.

2008;89(2):364–370.

25. Gribble PA, Hertel J. Considerations for normalising measures

of the star excursion balance test. Meas Phys Educ Exerc Sci .

2003;7(2):89–100.

26. Atkinson G, Nevill AM. Statistical methods for assessing measurement

error (reliability) in variables relevant to sports medicine. Sports Med .

1998;26(4):217–238.

27. Portney LG, Watkins MP. Foundations of Clinical Research: Appli-

cations to practice. Upper Saddle River, NJ: Prentice Hall Health;

1999.

28. Harvill LM. Standard error of measurement. Educ Meas. 1991;

10(2):33–41. 29. Ruiz JR, Castro-Piñero J, España-Romero V, et al. Field-based tness

assessment in young people: the ALPHA health-related tness test battery

for children and adolescents. Br J Sports Med . 2011;45(6):518–524.

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2014 Test-Retest Reliability of the Star Excursion Balance Test in Primary School Children