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Journal of Athletic Training 2013;48(3):000000

doi: 10.4085/1062-6050-48.3.03
by the National Athletic Trainers Association, Inc original research
www.nata.org/journal-of-athletic-training

Interrater Reliability of the Star Excursion Balance Test


Phillip A. Gribble, PhD, ATC, FNATA*; Sarah E. Kelly, BAppSci;
Kathryn M. Refshauge, PhD; Claire E. Hiller, PhD
*University of Toledo, OH; University of Sydney, Australia
Context: Dynamic postural control has gained popularity as Main Outcome Measure(s): Normalized and nonnormal-
a more useful assessment of function than static postural ized (leg-length) reaching distances were analyzed. Additionally,
control. One measurement of dynamic postural control that has the mean and maximum values from the 3 test trials were
increased in frequency of use is the Star Excursion Balance Test analyzed, producing a total of 16 variables.
(SEBT). Although the intrarater reliability of the SEBT is Results: For all 16 measures, the interrater reliability was

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excellent, few authors have determined interrater reliability. excellent. For the normalized maximum excursion distances, the
Preliminary evidence has shown poor reliability between intraclass correlation coefficients (1,1) ranged from 0.86 to 0.92.
assessors. Reliability for the nonnormalized measurements was stronger,
Objective: To determine interrater reliability using a group

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ranging from 0.89 to 0.94.
of investigators at 2 testing sites. A corollary purpose was to Conclusions: When the raters have been trained by an
examine the interrater reliability when using normalized and experienced rater, the SEBT is a test with excellent reliability
nonnormalized performance scores on the SEBT. eF when used across multiple raters in different settings. This
Design: Descriptive laboratory study.
information adds to the body of knowledge that exists regarding
Setting: University research laboratory.
the usefulness of the SEBT as an assessment tool in clinical and
Patients or Other Participants: A total of 29 healthy
participants between 18 and 50 years of age. research practice. Establishing excellent interrater reliability with
Intervention(s): Participants were evaluated by 5 raters at 2 normalized and nonnormalized scores strengthens the evidence
testing sites. After participants performed 4 practice trials, each for using the SEBT, especially at multiple sites.
rater assessed 3 test trials in the anterior, posteromedial, and Key Words: dynamic postural control, clinical balance tests,
in
posterolateral reaching directions of the SEBT. functional balance

Key Points
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 When multiple raters in different settings were trained by an experienced rater, the Star Excursion Balance Test had
excellent reliability.
 Whether the chosen outcome was average or maximum scored and used raw or normalized data, the anterior,
posteromedial, and posterolateral directions had excellent reliability.
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testing.9,1416 Kinzey and Armstrong15 were the rst to

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linicians often use postural-control assessments to
evaluate the risk of injury, initial decits resulting examine the reliability of the SEBT. A single investigator
from injury, and the level of improvement after conducted trials on 20 healthy participants, who performed
intervention for an injury. Dynamic postural control has reaches in 4 directions of the SEBT during 2 sessions, with
gained popularity in clinical and research settings as an moderate to strong intraclass correlation coefcient (ICC)
assessment of function. One measurement of dynamic scores ranging from 0.67 to 0.87.15 Hertel et al14 recruited
postural control that has increased in frequency of use is the 16 healthy women who performed all 8 directions of SEBT
Star Excursion Balance Test (SEBT). The measure of over 2 testing sessions, with 2 investigators evaluating each
dynamic postural control is inferred from how far a participant on each day. The range of interrater reliability
participant can reach while maintaining a base of support. for the 8 directions was wide (ICC 0.350.93), whereas
Widespread use of the SEBT in the clinical and research the range of intrarater reliability was more narrow with
settings has demonstrated its strong capability to differen- stronger reliability scores (ICC 0.780.96). The authors
tiate patients with lower extremity conditions such as ankle attributed the wide range in interrater reliability to lower
instability,18 anterior cruciate ligament reconstruction,9 scores that occurred on the rst day of testing and were a
and patellofemoral pain.10 Additionally, the SEBT can potential artefact of a learning effect. They recommended 6
assess improvements in dynamic postural control after practice trials to overcome the learning effect and
exercise interventions.4,11,12 consequently improve reliability of the measure. More
The limited literature available suggests that when a recently, Robinson and Gribble17 found that 4 practice trials
single investigator performs the assessments and the were sufcient to overcome the learning effect, with better
participant has had an adequate number of practice trials, consistency in subsequent test trials. Similarly, Munro and
the conventional categorization of reliability13 is consis- Herrington16 noted that reliability between test trials
tently moderate or better, even across multiple days of improved after a fourth consecutive trial, with excellent

Journal of Athletic Training 0


reliability (ICC 0.840.92) in the subsequent 3 trials. tionnaire and was free of any known musculoskeletal injury
Thus, repeated testing using the SEBT is reliable after 4 or other condition that would preclude completion of the
trials are implemented to effectively account for the test. Before the study, all participants read and signed an
learning effect associated with the test. informed consent form approved by the Human Research
Although the intrarater reliability of the SEBT is Ethics Committee at each university.
excellent, few investigators have determined interrater
reliability; preliminary evidence is for poor reliability Protocol
between assessors.14 Plisky et al18 showed that the SEBT
may be a useful, inexpensive tool to screen athletes for risk Before the test sessions at each laboratory, an investigator
of lower extremity musculoskeletal injury and reported with more than 11 years of experience (P.A.G.) with the
strong intrarater reliability (ICC 0.840.87) and test-retest SEBT instructed the raters at the test site using a script and
reliability (ICC 0.890.93). Their work demonstrates a a standardized demonstration. This investigator then served
likely underused purpose for the SEBT: assessment of as the practice model for the other raters at each site and
dynamic postural control in the clinical and research established that the raters were properly instructed and
could take measures independently. Participants were
settings. This could lead to large-scale, collaborative efforts
scheduled for the day after the raters were trained. On
to establish appropriate screening methods for injury
testing days, 3 raters (the supervising investigator and 2
prevention.
trained raters) each assessed the SEBT performance of each
However, we rst need to determine whether multiple
participant.
assessors at different sites can provide strong consistency in

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A total of 29 individuals volunteered to participate in the
SEBT measures. To date, no authors have had more than 2
trial: 19 at 1 test site and 10 at the other site. At each site,
assessors examine interrater reliability; a larger number of participants reported to the laboratory for a single testing
assessors is paramount to strengthening interrater reliability

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session. The stance leg was determined by randomization.
and expanding the use of this inexpensive tool to multi-site The length of the stance leg was measured from the
applications in which a number of individuals may be anterior-superior iliac spine to the most distal point of the
sharing information about patient screening. Interrater
eF ipsilateral medial malleolus, using a standard tape measure
reliability is also essential to underpin the development of while participants lay supine on a plinth.
prevention and intervention strategies for lower extremity Each participants performance on the SEBT was rated
injury. Additionally, since the rst reliability studies were by all 3 raters in the manner described in the Performance
performed, the now-accepted practice is to use normalized of the SEBT section, with the order of raters being
reach distances (reach distance / leg length).19 Therefore, randomized. A verbal and visual demonstration of the
we must revisit the reliability of the SEBT using SEBT was given to participants by the rst rater, and the
in
normalized, rather than absolute, reach distances. constraints of the test were explained. The participants then
The primary purpose of our study was to determine underwent the same protocol, and their SEBT performance
interrater reliability using a group of investigators at 2 was measured by the 3 raters. Participants performed 4
testing sites. The raters were all trained by the same
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practice trials of the SEBT, in any order in each direction,


instructor. This approach to determining reliability was with the rater with whom they were initially randomly
used to establish whether the SEBT can be applied in large- assigned to minimize any learning effects.17 The participant
scale assessments of dynamic postural control. then performed 3 test trials in each direction for each of the
A corollary purpose was to examine the interrater
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3 raters, sitting in a chair to rest for 5 minutes between


reliability when using normalized and nonnormalized raters. The 3 reach directions tested were anterior (ANT),
scores of SEBT performance. Until now, the reliability of posteromedial (PM), and posterolateral (PL). The order of
normalized scores has not been examined. We also wished the reach directions was randomized for each participant
to examine the intertester reliability when using average and kept constant across all 3 raters.
and maximum performance scores on the SEBT. Tradi-
tionally, average scores are used, but when the SEBT is Performance of the SEBT
conducted in clinical and research practices, the largest
distance from a series of test trials may be more Participants performed the SEBT by standing in the
appropriate; however, reliability has not yet been estab- middle of a testing grid with strips of tape placed at 458
lished for this approach. A tertiary purpose was to establish angles, reaching with 1 foot as far as possible along the
the interrater reliability of measures of leg length. These different grid lines, and then returning to the starting
measures are essential when normalizing the SEBT position.20,21 The goal was to have the individual establish a
performance, so it was necessary to examine this measure stable base of support on the stance limb at the apex of the
as we examined the reliability of normalized SEBT values. testing grid and maintain support through a maximal reach
excursion in multiple directions.20,21 While standing
Methods barefoot or in socks on a single limb and keeping the
hands on the hips, the participant made an effort to reach as
far as possible with the reaching limb along each tape
Participants
measure; touch lightly on the tape measure with the most
A total of 29 participants (19 women, 10 men, age distal portion of the reaching foot, without shifting weight
31.72 6 10.8 years, height 169.52 6 8.8 cm, mass to or coming to rest on the foot of the reaching limb; and
65.58 6 12.3 kg) from the University of Toledo (Ohio) and return the reaching limb to the start position at the apex of
the University of Sydney (Australia) volunteered for the the grid, resuming a stable bilateral stance. Standardized
study. Each participant completed an injury-history ques- oral instructions were given to every participant (Table 1).

0 Volume 48  Number 3  June 2013


Table 1. Oral Instructions Given for Star Excursion Balance Test Statistical Analysis
Performance
Interrater reliability refers to variation between 2 or
1. Keep your stance foot flat on the floor with your hands on your
hips.
more assessors who measure the same group of partici-
2. Make a reach with your other leg as far as possible and make a
pants.13,23 We used a conservative interpretation of
light tap on the measuring tape. interrater reliability by pooling data from 2 testing sites
3. Without pushing off the ground with your reaching leg, return it to determine whether consistent SEBT assessments could
back to the center of the testing grid and place this foot on the be achieved by multiple raters, all instructed by the same
ground next to the foot of the stance leg. source. Using an ICC (1,1) model, we examined the
4. You may make any movements you wish to reach as far as reliability of a single assessment by a rater, wherein
possible, as long as you keep your stance foot planted, your hands different sets of raters assessed different groups of
on your hips. participants.13,23,24 The interrater reliability of the SEBT
5. If you tap more than once or slide the reaching foot during the
reach, miss the tape measure with your tap, push off the floor with
was determined by calculating ICCs (1,1) with 95%
the reaching foot, lift your heel or your hands from the testing condence intervals for each of the 4 primary variables
position, or are unable to return the reaching foot back to the (ANT, PM, PL, and composite) for both normalized and
starting position, we will repeat that trial. nonnormalized measurements. Within the groupings of
normalized and nonnormalized measurements, an ICC (1,1)
was calculated for the average and maximum score from
A trial was not considered complete if the participant the 3 trials for each of the 4 primary variables.

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touched heavily or came to rest at the touchdown point, had Additionally, this model was applied to the leg-length
to make contact with the ground with the reaching foot to measure. The data from the 2 sites were pooled, and an ICC
maintain balance, or lifted or shifted any part of the foot of (1,1) was used because participants were rated by different

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the stance limb during the trial.19,21 sets of 3 raters. An ICC (1,1) of ,0.4 represents poor
Although the SEBT consists of 8 directions, conventional reliability; 0.4 to 0.75, fair to good reliability; and .0.75,
testing procedures have adopted a condensed version of the excellent reliability.25
test, using the ANT (Figure 1), PM (Figure 2), and PL
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(Figure 3) reaching directions.11,18,22 For the ANT reach,
the stance-foot position is to place the toes at the 0 mark
Results

position of the anterior reach direction line. For the PM and For all 16 measures, the interrater reliability was
PL reaches, the heel is placed at the 0 mark position of the excellent. For the normalized maximum excursion distanc-
es, the ICC (1,1) ranged from 0.86 to 0.92 (Table 2).
anterior reach direction line. At the rst testing station, 4
Reliability for the nonnormalized measurements was
in
practice trials were required in each direction.17 Participants
stronger, ranging from 0.89 to 0.94 (Table 3). The interrater
were afforded 5 minutes rest between the practice and test
reliability of the leg-length measurement was excellent
trials.
(ICC [1,1] 0.92, 95% condence interval 0.86, 0.96).
The ICC (1,1) and 95% condence interval for the average,
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Data Reduction maximum, and composite scores in each direction, for both
From each reaching direction (ANT, PM, and PL), the normalized and nonnormalized measurements, are shown in
excursion distances were recorded (cm) and considered the Tables 2 and 3, respectively.
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nonnormalized data. Additionally, the results from the 3


directions were averaged to create a composite non- Discussion
normalized score. Assessment of dynamic postural control with the SEBT
For the 4 dependent variables (ANT, PM, PL, and had excellent interrater reliability, as per the classication
composite), the nonnormalized scores (cm) were recorded of Fleiss.25 For each type of measure (average and
and analyzed. Additionally, the excursion distances in each maximum) and for both normalized and nonnormalized
direction (cm) were normalized by dividing by a partici- data, our results demonstrate strong consistency of
pants leg length (cm) and multiplying by 100 (normalized measurements by multiple investigators for the ANT, PM,
maximum excursion distance) for the percentage score.19 PL, and composite scores. This information adds to the
Finally, using the nonnormalized and normalized scores body of knowledge regarding the usefulness of the SEBT as
from the 4 dependent variables, we determined 2 measures: an assessment tool in clinical and research practice.
the average and the maximum score. For the average score Establishing excellent interrater reliability with normalized
of each direction, the means and standard deviations from and nonnormalized scores supports the use of the SEBT,
the 3 trials were used. For the maximum score, the especially at multiple sites.
maximum reach distance of the 3 trials was used. This is the rst study in which more than 2 raters
In addition to the SEBT analyses, the interrater reliability evaluated the interrater reliability of the SEBT. Five
of the single trial of leg-length measures needed to be investigators measured the participants overall; however,
established because this value is used in the normalized each participant was assessed by 3 investigators, and testing
version of SEBT performance reporting. Therefore, this took place at 2 sites. Experience varied among the
measure was included as a separate variable for analysis. investigators, but each was trained by the same SEBT
Thus, in total, 16 SEBT variables and 1 leg-length expert before testing. Despite the varied experience of the
variable were available for our analyses. All variables were investigators, the interrater reliability results were excel-
analyzed for 1 randomly selected limb from each lent. This allows us to conclude that the SEBT can be used
participant. with condence across raters of different experience levels

Journal of Athletic Training 0


Table 2. Interrater Reliability for Normalized Reach Distances on the Star Excursion Balance Test
Reach Distance, Intraclass Correlation Coefficient (1,1) (95% Confidence Interval)
Distance Anterior Posteromedial Posterolateral Composite
Average 0.88 (0.80, 0.94) 0.91 (0.83, 0.95) 0.88 (0.80, 0.94) 0.92 (0.85, 0.96)
Maximum 0.86 (0.77, 0.93) 0.88 (0.79, 0.94) 0.90 (0.83, 0.95) 0.91 (0.84, 0.95)

without compromising the reliability of results, provided the nonnormalized data seemed to be slightly higher, all
each rater is initially trained in the measurement of the values had excellent reliability with small 95% condence
SEBT by an experienced rater. This nding has promising intervals. Therefore, it is logical that SEBT performance
clinical and research implications: consistent, reliable data should continue to include normalized reaching distances as
can be collected when multiple investigators at multiple previously established,19 and we can be condent that the
sites are trained and then assess participants performing the associated reliability will be excellent.
SEBT. A limitation to the application of our ndings is that A secondary purpose of this study was to establish
an expert provided the training and was involved in rating interrater reliability of the leg-length measurements.
the participants. The next needed step is to determine Because this measurement is critical to the normalization
whether similar levels of reliability can be obtained with of the SEBT reaches, it was imperative that this be reliable

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the use of written or video instructions (or both) that could across our group of investigators. We demonstrated
be distributed to clinicians and researchers. excellent interrater reliability using the selected leg-length
In the only previous report of interrater reliability of the measurement technique. This technique was chosen based

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SEBT, Hertel et al14 reported ICCs between 0.35 and 0.93 on the original article19 describing normalizing SEBT reach
when 16 healthy females performed all 8 directions of the distances. It should be noted that all the investigators were
SEBT over 2 testing sessions and 2 investigators evaluated either credentialed clinicians or students in clinician
each participant on each day. Lower estimates of preparation programs, and all had experience using this
reliability were found on day 1 of testing: ICCs were
0.76, 0.58, and 0.80 for the ANT, PL, and PM directions,
eF technique. Therefore, we must conclude that this result
would be applicable to similar populations of individuals
respectively, less than demonstrated in our study. Hertel et with clinical backgrounds.
al14 included the initial published recommendation for a An additional secondary purpose of the study was to
specic number of requisite practice trials before SEBT compare the reliability of the SEBT assessments when
assessment because of higher ICC values on a second day using the average of 3 trials versus the maximum reach
in
of testing. The interrater reliability scores in our study distance among 3 trials. In more than half of the
might be higher because we included 4 practice trials in assessments, the average normalized value had higher
each direction before the test was performed, based on a associated ICC values than the maximum values. However,
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more recent study17 examining the learning effect during for all the assessments, the ICC values were strong (.0.81).
SEBT performance. Common practice is to use an average of 3 or more trials on
Furthermore, although it is not stated in their testing the SEBT. These data could be interpreted to show that if
protocol, Figure 1 in the investigation of Hertel et al14 reliability is strong when maximum trials are used, perhaps
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shows a participant performing the test wearing footwear. greater time efciency could be gained from only recording
Our participants performed the test barefoot, potentially the maximum trial. When working with large sample sizes,
allowing for a more accurate measurement of excursion this reduction may be advantageous. Additional investiga-
distance along the tape measure. Additionally, Hertel et al14 tion will be needed to determine how much time is saved
did not normalize reaching distances. One purpose of our when using only the maximum of 3 trials.
investigation was to establish the interrater reliability using Each investigator in our study was trained in the
the normalized procedures that are now standard for the measurement of the SEBT before the testing sessions. An
SEBT.19 Both normalized and nonnormalized reaching investigator with more than 11 years of experience in SEBT
distances were associated with stronger interrater reliability performance and measurement provided instruction to the
than previously reported.14 Again, this is likely because we raters at each site before deeming them competent to take
afforded participants a specic number of practice trials, measures independently. The Hertel et al14 reliability study
which was a recommendation from the initial reliability was conducted early in the initial development of the
study by Hertel et al.14 SEBT. Since this time, the evidence base surrounding the
Little difference was observable in the strength of the SEBT has been well established, and the test has become
reliability between the normalized and nonnormalized widely used in both clinical and research settings. The
reaching data. Although the ICC values associated with pretesting training of raters in the current study by an

Table 3. Interrater Reliability for Nonnormalized Reach Distances on the Star Excursion Balance Test
Reach Distance, Intraclass Correlation Coefficient (1,1) (95% Confidence Interval)
Distance Anterior Posteromedial Posterolateral Composite
Average 0.92 (0.86, 0.96) 0.92 (0.85, 0.96) 0.92 (0.86, 0.96) 0.91 (0.85, 0.96)
Maximum 0.89 (0.82, 0.94) 0.90 (0.82, 0.95) 0.93 (0.88, 0.96) 0.94 (0.88, 0.97)

0 Volume 48  Number 3  June 2013


individual with expertise using the SEBT may have been implementation, yet our results support the strong reliabil-
responsible for greater consistency of measurement among ity in using the SEBT, as we have discussed in previous
raters and may provide an explanation for the higher sections.
interrater reliability we obtained. We cannot conclude from
our study exactly how much experience is needed to ConclusionS
adequately train other individuals to ensure excellent
interrater reliability. Future authors should investigate this The SEBT is a reliable test when used across multiple
factor to further strengthen the use of the SEBT in multi- raters in different settings when raters are trained by an
site testing designs. experienced rater. Reaching in the ANT, PM, and PL
It is commonly accepted that in order to obtain accurate directions has excellent reliability, whether the chosen
estimates of reliability in research, data should be collected outcome is the average or maximum score using raw or
from a wide range of participants. Where previous trials normalized data. Therefore, researchers, especially with
may have been limited in participant characteristics of clinical backgrounds, should be able to use this tool for
either sex16 or age,17 the participants in our study ranged assessing dynamic postural control after receiving instruc-
widely in age, height, and mass: women predominated, the tion and practice, making it a suitable and inexpensive tool
age range was 21 to 57 years, the height range was 152 to in clinical and research settings.
190 cm, and the mass range was 42 to 112 kg. Despite the
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Address correspondence to Phillip A. Gribble, PhD, ATC, FNATA, 2801 W Bancroft, University of Toledo, Mailstop #119, Toledo, OH
43606. Address e-mail to phillip.gribble@utoledo.edu.

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0 Volume 48  Number 3  June 2013