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The Effectiveness of the Y Balance Test Compared to the Star

Excursion Balance Test: A Critically Appraised Topic
Heidi Krueger, Nikki German, PhD, ATC
Department of Health, Nutrition and Exercise Sciences, Fargo ND, USA
Abstract Characteristics of Included Studies
Clinical Scenario: Dynamic neuromuscular control and unilateral balance are
important requirements for sports and essential daily living activities as we age.
Study Design Coughlan et al. (2012)1
Cohort Study
Evaluating these components has been a way many clinicians are able to
identify individuals at a greater risk for injury.1- 4 The Star Excursion Balance Participants 20 healthy male participants volunteered.
Test incorporates eight reach directions while standing on each foot separately. Inclusion criteria: required 18 30 years of
age, and active three times a week. No
The intra rater reliability of the Star Excursion Balance Test is found to be
history of lower limb injury, neurologic or
moderate to good, while the inter rate reliability is found to be poor to good.3 balance disorder, or fracture in the past
The Y Balance Test was developed to improve the Star Excursion Balance Test three months.
by defining questionable variables of the Star Excursion Balance Test. More
evidence is needed to ensure that the new instrument assesses dynamic Intervention Participants were randomized for test,
neuromuscular control and unilateral balance is effective and useful in the Investigated testing leg and direction each session.
clinical setting. Summary of Search, Best Evidence Appraised and Key All testing was performed barefoot to
Findings: The literature was searched for studies of level 3 evidence or higher eliminate additional stabilization and
that investigated the effectiveness of the Y Balance Test compared to the Star balance.
Demonstration was performed for each
Excursion Balance Test in physically active males and females. The literature participant.
search resulted in two articles comparing the tests and two articles concerning Four practice trials each direction on each
test reliability. All four quality articles were included. leg then two minutes rest. After the rest,
three test trials were conducted in each
direction.
Clinical Question Testing sessions were completed the same
time to minimize the diurnal variation in
North Dakota State University
Implications for Practice, Education
and Future Research
Gribble et al. (2013)2
Cohort Study
29 healthy participants volunteered.
10 men and 19 women
21 41 years old
No musculoskeletal injuries or any other
condition that would preclude completion of the
tests.
Each rater was instructed how to perform the
SEBT . A script and a standardized
demonstration were used. The investigator was
the model for each rater to establish proper
instructing and measurements.
Each participant was tested by all three of the
raters on the SEBT. Test order and stance leg
was randomized. A verbal and visual
demonstration was given from the first rater.
Four practice trials in each direction followed by
three test trials for each rater in all three
directions. Five minute break between each
rater was given. Reach directions were anterior,
Plisky et al. (2009)3
Cohort Study
15 male collegiate soccer players 17 21 years
old
Exclusion criteria: vestibular disorder, lack of
medical clearance, injury, undergoing treatment
for inner ear, sinus, upper respiratory infection or
head cold, or cerebral concussion within the
previous three months.
Instructional video was shown for demonstration
and explanation. Six practice trials on each leg
in all three directions. The subjects were tested
within 20 minutes of practicing. All participants
wore athletic shoes during the test.
Three trials were performed in each direction
with the right foot in the anterior direction then
the left foot. Then the right foot was tested in
the posteromedial direction, followed by the left
foot. This repeated for the posterolateral
direction.
All testing was observed and scored by two
raters. Once three trials were performed, the
Fullam et al. (2014)4
Cohort Study
15 healthy male and 14 healthy females
volunteered. Inclusion criteria: 18 30
years old, no history of a lower limb
injury in the past three months and no
history of neurological, balance disorder,
or lower limb fracture.
Participants were randomized to perform
the Star Excursion Balance Test (SEBT)
or the Y Balance Test (YBT) first.
Participants were instructed to reach with
their non-dominant leg and test
directions randomized for both tests.
All testing was conducted barefoot . Test
was demonstrated before the four
practice trials in each direction while
standing on the dominant leg, with a two
minute break. Then three test trials were
performed for the three directions.
Kinematic data was acquired at 200 Hz
Two studies in this CAT evaluated the differences between the Star Excursion Balance
Test and the Y Balance Test on physically active males and females. Both studies
found that the anterior reach direction had a significant difference between the two
tests. There was no significant difference between the other two reach directions.
Therefore, the two tests cannot be used interchangeably. The other two studies
evaluated the reliability for the two balance tests. The Star Excursion Balance Test was
shown to have good reliability as long as the tester has been trained and practiced
administering the test. The Y Balance Test was shown to have good to excellent
reliability due standardized protocol and testing instrument. However, all four studies
have limited quality, and as such, conclusions should be interpreted with caution.
Each study suggested that both the Star Excursion Balance Test and the Y Balance
Test were effective and reliable. There are positives and negatives for both balance
tests, but evidence has found that the two tests cannot be used interchangeably.
Choosing one test is the best way to compare dynamic neuromuscular control
deficiencies for prevention, or improvements after injury. The Star Excursion Balance
Test has eight original reach directions, a varying start position, and varying protocols.
1,3,4 The Y Balance Test has three reach directions, a clear starting position, a clear,

postural stability.
Is the Star Excursion Balance Testing data interchangeable with the Y Balance
Testing data in physically active males and females?
Clinical Bottom Line
Outcome The reach distances for all testing trials for Normalized and non-normalized (leg length)
Measures the right and left legs were recorded for the reach distances were recorded for each leg and
three directions of the Y Balance Test and each reach direction for the two raters.
There is supporting evidence to indicate a significant difference between the the Star Excursion Balance Test.
anterior reach direction for the Star Excursion Balance Test compared to the Y
Balance Test. Evidence also supports that the protocol for the Y Balance Test is
Main Findings Differences were found when comparing
more definitive. The reliability of the Y Balance Test is found to be good to the SEBT to the YBT in the anterior reach
excellent while the Star Excursion Balance Test is found to have good reliability. direction . The right leg had a P value =
Ultimately, it is the clinicians choice on which test to use when evaluating 0.003 while the left had a P value = 0.0002.
dynamic neuromuscular control and unilateral balance. Based on these The Bland-Altman analysis showed that the
95% limit of agreement between the two
findings, the strength of the recommendation is listed as a grade two.
balance tests in the anterior direction
Strength of Recommendation: Although all four of these studies are cohorts,
ranging from -4.69% to 14.85% for the left
two studies compare the balance tests and two studies look at the reliability of leg.
each test. Therefore, the strength of evidence is a grade two. The two studies
comparing the balance tests show a significant difference in the anterior reach
direction, determining the tests should not be used interchangeably.
Level of Evidence 2b
Inclusion and Exclusion Criteria Validity Score N/A
Inclusion
Studies that compared Y Balance Test and Star Excursion Test Conclusion In this study, there was a difference in
reach distance with the anterior direction of
Limited to English language
Limited to humans
the test between the SEBT and the YBT.
There were no differences with the
Limited to the last ten years (2006 2016) posterolateral or posteromedial directions
Level 3 evidence or higher between the tests. Postural control
strategies influenced the testing outcomes
when completing the two tests. Since a
Exclusion
difference was found in one direction, the
If not Y Balance Test reach distances are not transferrable
If not Star Excursion Balance Test between tests.
Non-physically-active subjects
posteromedial, and posterolateral.
Testing was performed either barefoot or in
socks.
The inter rater reliability was excellent for all 16
measurements taken in this study.
The data that was divided by the leg length, or
normalized, had an intra class correlation
coefficient (ICC) that ranged from 0.86 to 0.92.
The data that wasnt divided by the leg length,
or the non-normalized, was stronger and had an
ICC ranging from 0.89 to 0.94.
The inter rater reliability of the leg length
measurement was excellent.
2b
N/A
Multiple trained and experienced raters have
shown that the SEBT is a reliable test. This is a
reliable and inexpensive tool in the clinical and
research settings as long as the clinician has
received instruction and practice with the SEBT.
participant would move to a different direction if
both raters had at least one successful trial.
The greatest successful reach for each direction
and each rater was used for analysis. Also, a
composite score was analysis to determine
overall performance.
The intra rater reliability of the YBT for one tester
ranged from 0.85 to 0.91, with an anterior reach
reliability of 0.9, posteromedial of 0.85,
posterolateral of 0.90, and a composite score of
0.91.
Inter rater reliability between the two testers
ranged from 0.99 to 1.0. The anterior,
posteromedial, posterolateral, and the
composite score reach were all 0.99.
2b
N/A
According to this study, the YBT reliability
ranges from good to excellent due to the
standardized equipment and methods. Now that
the reliability of the test has been established,
clinicians can determine deficits and
asymmetries in patients more effectively and
confidently. The YBT may also assist clinicians
with the return to play process.
using three CODA cx1 units.
Kinematic profiles of the sagittal plane
lower limb were recorded using a 3D
motion analysis system. Along with reach
distances in all three directions for both
tests.
Significant difference in sagittal plane hip
joint angular displacement at maximum
reach between the SEBT and the YBT.
The SEBT angles were 20.37 18.63
and YBT angles were 28.32 13.19.
The Bland-Altman test showed that the
95% limit of agreement between the
balance test in the anterior direction
ranging from -0.35% to 14.97%.
2b
N/A
Based on the results of this study, there
are differences in the anterior direction
reach distance during the performance of
the SEBT and the YBT. There is also a
difference in the angle of the hip at
maximum reach. Looking at the sagittal-
plane, the angular displacement of the
hip is different between the two balance
tests. These differences indicate that the
SEBT and the YBT cannot be used
interchangeably.
standardized protocol; and a commercially crafted testing kit to improve reliability and
repeatability.1,2,4 Athletic Trainers and other health care providers value quality
information in a short amount of time. Y Balance can test dynamic neuromuscular
control and unilateral balance for preventing injury and also returning patients to
activity quickly and effectively.
The conclusion from the four studies in this CAT is that the Y Balance Test was
designed to improve the limitations of the Star Excursion Balance Test. It is noteworthy
that three of the four studies were not conducted within the United States; therefore, it
may limit the ability to generalize the outcomes and recommendations. The four
studies contained 20, 29, 15, and 15 participants making it difficult to generalize with a
limited number of studies conducted. All of the studies were conducted using university
participants suggesting that they were physically active. However, it is unclear how the
results translate to other age ranges regardless of physical activity level.
Future research should include determining which balance test is more clinically
appropriate when looking at the entire scope of determining injury risk, return to play,
and possibly concussion protocol. Longitudinal studies would provide data on the
usefulness of neuromuscular control screening before participation to address the
issues to decrease injuries and return to physical activity decisions making. In addition,
studies that include a greater sample of sports and age range would increase external
validity and overall ability to generalize the outcomes. Additionally, this CAT should be
reviewed in two years to determine whether additional best evidence has been
published that may change the clinical bottom line for this specific clinical question.
References
1. Coughlan GF, Fullam K, Delahunt E, Gissane C, Caulfield BM. A comparison
between performance on selected directions of the star excursion balance test
and the Y balance test. J Athl Train. 2012;47(4):366-71.
2. Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater reliability of the star
excursion balance test. J Athl Train. 2013;48(5):621-6.
3. Plisky PJ, Gorman PP, Butler RJ, Kiesel KB, Underwood FB, Elkins B. The reliability
of an instrumented device for measuring components of the star excursion

Search Strategy balance test. N Am J Sports Phys Ther. 2009;4(2):92-9.

4. Fullam K, Caulfield B, Coughlan GF, Delahunt E. Kinematic analysis of selected
reach directions of the Star Excursion Balance Test compared with the Y-
Terms Used to Guide Search Strategy Balance Test. J Sport Rehabil. 2014;23(1):27-35.
Patient/Client Group: Active females OR males
Intervention (or Assessment): Y Balance Test
Comparison: Star Excursion Balance Test
Outcome(s): Interchangeability between test data (reach distances for all three
directions)