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Reliability of 16 balance tests in individuals with Down

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Article  in  Perceptual and Motor Skills · October 2010

DOI: 10.2466/03.10.15.25.PMS.111.5.530-542 · Source: PubMed

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 Perceptual and Motor Skills, 2010, 111, 2, 530-542. © Perceptual and Motor Skills 2010

RELIABILITY OF 16 BALANCE TESTS IN

INDIVIDUALS WITH DOWN SYNDROME1

ROMINA VILLAMONTE, PAT R. VEHRS, J. BRENT FELAND,

A. WAYNE JOHNSON, MATTHEW K. SEELEY, AND DENNIS EGGETT

Brigham Young University

Summary.—To assess test-retest reliability scores on 16 balance tests of 21 in-

dividuals with Down syndrome whose ages ranged from 5 to 31 yr., participants
performed a standing test on firm and soft surfaces with the eyes open and closed,
the balance subset of the Bruininks–Oseretsky test, full turn, timed-up-and-go test,
forward reach, and sit-to-stand. Each participant completed all 16 tests twice in one
day and then again on a subsequent day for a total of 4 sessions. The interclass
reliability correlation coefficients (ICC) value for each measure of balance varied
considerably by age and sex. Based on having an ICC > .50, only 3 tests were reliable
in young males and young females, whereas 5 tests could reliably be used in adult
females and 9 tests could reliably be used in adult males. The results of this study
raise suspicions as to the reliability of tests commonly used to assess balance and
differences in reliability due to age and sex. Results of balance tests should be inter-
preted with caution in males and females with Down syndrome across the age span.

Down syndrome is one of the most prevalent chromosomal disorders,

occurring in one out of every 800 births.2 Common characteristics of indi-
viduals with Down syndrome are that they have some intellectual disabili-
ty (Hayes & Batshaw, 1993) and poor dynamic and static balance (Boswell,
1991; Berg, Maki, Williams, Holliday, & Wood-Dauphinee, 1992). Individ-
uals with Down syndrome have a significant delay in motor skill and bal-
ance development that persists through adulthood (Connolly & Michael,
1986; Spano, Mercuri, Rando, Panto, Gagliano, Henderson, et al., 1999;
Wang & Ju, 2002), and rank lower on balance performance than the gen-
eral population or other mentally handicapped groups (Connolly & Mi-
chael, 1986; Tsimaras & Fotiadou, 2004). Hypotonia, strength deficits, liga-
mentous laxity, and a small cerebellum and brain stem contribute to poor
motor skills in individuals with Down syndrome (Wang & Ju, 2002). How-
ever, some researchers have suggested that poor motor performance in in-
dividuals with Down syndrome is secondary to defects in balance control
(Connolly, Morgan, Russell, & Fullerton, 1993). Children with Down syn-
drome score lower in balance tests compared to matched children with
and without intellectual disability (Le Blanc, French, & Shultz, 1977; Con-
nolly & Michael, 1986; Spano, et al., 1999; Vuillerme, Marin, & Debu, 2001).
1
Address correspondence to Pat Vehrs, Ph.D., Department of Exercise Sciences, Brigham
Young University, P.O. Box 22089, Provo, UT 84602 or e-mail (pat_vehrs@byu.edu)
2
National Down Syndrome Society. (2008) Down syndrome fact sheet. Retrieved October 4,
2010, at http://ndss.org/index.php?option=com_content&view=article&id=54&Itemid=74.

DOI 10.2466/03.10.15.25.PMS.111.5.530-542 ISSN 0031-5125

 RELIABILITY OF BALANCE TESTS 531

Static and dynamic balance of individuals with Down syndrome are

important for the development of physical independence and the capac-
ity to participate in recreation, games, play, exercise, and social activities.
Balance test performance in children with Down syndrome has been com-
pared to that of children without intellectual disability and children with
intellectual disability but without any type of neuromuscular dysfunction
or genetic defect. The effectiveness of programs designed to improve mo-
tor skills and balance has also been evaluated in children with Down syn-
drome. Nevertheless, these studies failed to report the reliability of the as-
sessments used to measure balance in individuals with Down syndrome
(Le Blanc, et al., 1977; Connolly, Morgan, & Russell, 1984; Connolly & Mi-
chael, 1986; Connolly, et al., 1993; Wang & Ju, 2002). Bruininks (1978) re-
ported that the test-retest reliability of the balance subset of the Bruin-
inks–Oseretsky test was .56 in children 4 to 14 years of age. Boswell (1991)
reported that in children 8 to 13 years old with mild to moderate intellec-
tual disability (without Down syndrome), the test-retest reliability of the
balance beam walk and stabilometer were .81 to .89 and .99, respectively.
Tests must be reliable to evaluate accurately balance and changes in
balance resulting from interventions. Unreliable tests result in erroneous
assessments of balance, misrepresent the individual’s performance, and
compromise test interpretation. Unreliable tests also reduce the ability to
track progress in those who are trying to improve balance. As new re-
search topics receive an increasing amount of attention, the standards for
research methodology and reporting data often become more stringent.
The reliability of balance tests in individuals with Down syndrome is not
available in the current literature, perhaps due to the decreasing number
of investigations of balance since the 1980s (DePaepe & Ciccaglione, 1993).
The reliability of tests to assess balance in individuals with Down syn-
drome may not have been previously established due to the difficulty in
recruiting across the age span within this specific population. As a result,
the reliability of balance tests in individuals with Down syndrome either
may have been ignored or assumed to be similar to that of other popu-
lations. The validity and reliability of any assessment are compromised
when the assessment is used in individuals with characteristics that are
not similar to the population in which validity and reliability were origi-
nally established.
Determining the reliability of balance assessments in a Down syn-
drome population will clarify the interpretation of balance assessments,
provide guidelines for those who administer balance assessments and
plan programs, and aid those responsible for setting performance goals
for individuals who have motor impairments (Duger, Bumin, Uyanik,
Aki, & Kayihan, 1999; Tan, Parker, & Larkin, 2001). The purpose of this
532 R. VILLAMONTE, ET AL.

study was to assess the test-retest reliability of 16 balance tests in individ-

uals with Down syndrome.
Method
Participants
Sixteen balance tests were administered to a limited convenience
sample of 21 participants with Down syndrome. Participants ranged in
chronological age from 5 to 31 years. Four of the boys were 5 years old and
six boys ranged from 22 to 31 years of age. Seven of the girls ranged from
8 to 14 years of age, and four girls ranged from 22 to 29 years of age. All
participants had been diagnosed with Down syndrome with mild or mod-
erate cognitive impairment. Participants had no physical disability that
impaired mobility, were able to walk independently, could follow simple
instructions, and had no uncorrected visual or auditory disability. Par-
ticipants were recruited from communities in the states of Utah and Ne-
vada through the Utah Down Syndrome Association. Institutional review
board approval was obtained from Brigham Young University prior to
collection of data. A signed informed consent was obtained from the par-
ents of each participant before testing was performed.
Procedure
Each participant completed 16 different balance tests twice on one
day and then repeated the assessment twice on a subsequent day for a to-
tal of four assessments. During each assessment, participants completed
three trials of each balance test for a total of 12 trials of each balance test.
Each assessment lasted 25 to 60 minutes and the two assessments within
each day were separated by about 1 hr. The two days of testing were sepa-
rated by 1 to 7 days. The order of the 16 balance tests varied across the four
assessments. Each participant was tested individually. Participants were
tested in an open area relatively free of disturbances, noise, and distrac-
tions. Participants wore athletic shoes and comfortable clothes.
The preferred leg was identified by asking the participant to kick a
ball three times. The participant’s preferred leg was recorded as the leg
that was used to kick the ball. The preferred leg was used for all the one-
leg standing tests.
Tests
The 16 balance tests were selected because they have previously been
used by researchers to assess balance in individuals with Down syn-
drome. Each test is described below.
Center of Gravity Sway Tests
The overall center of gravity sway of each participant was measured
during four static tests performed on the NeuroCom Balance Master Sys-
 RELIABILITY OF BALANCE TESTS 533

tem. The center of gravity sway (°/sec.) was recorded when the participant
held the position for 10 sec.
Standing test—firm surface with eyes open and eyes closed.—The partic-
ipant stood on a firm surface with the feet parallel and shoulder-width
apart, and hands at the sides of the body. Participants were instructed to
hold as still as possible without taking any steps for 10 sec. The total time
(sec.) the participant could hold the position and center of gravity sway
was recorded. The test was performed with the eyes open and again with
the eyes closed.
Standing test—soft surface with eyes open and eyes closed.—The partici-
pant stood on a standard foam block, 50 × 50 × 15 cm with the feet paral-
lel and shoulder-width apart, and hands at the sides of the body. Partici-
pants were instructed to hold as still as possible without taking any steps
for 10 sec. The total duration (sec.) the participant could hold the position
and center of gravity sway was recorded. The test was performed with the
eyes open and again with the eyes closed.
Other Tests
Standing on preferred leg on the floor with eyes open (Bruininks, 1978).—
Looking forward, the participant stood on his preferred leg with hands at
his sides; the knee of the nonpreferred leg was bent so the lower leg was
parallel to the floor. The participant was instructed to maintain this posi-
tion for as long as possible. The total time (sec.) the participant could hold
the position was recorded. The maximum score was 10 sec.
Standing on preferred leg on a balance beam with eyes open (Bruininks,
1978).—Looking forward, with hands at his sides, the participant stood
on the preferred leg on a 4-in. wide balance beam as long as he could. The
knee of the nonpreferred leg was bent so the lower leg was parallel to the
beam. The total time (sec.) the participant could hold the position was re-
corded in seconds. The maximum score was 10 sec.
Standing on preferred leg on a balance beam with eyes closed (Bruininks,
1978).—The participant stood on the preferred leg on a 4-in. wide balance
beam with eyes closed and hands at his sides while the knee of the non-
preferred leg was bent so the lower leg was parallel to the balance beam.
The participant was instructed to maintain this position for as long as pos-
sible. The total time the participant could hold the position was recorded
in seconds.
Walking forward on a balance beam (Bruininks, 1978).—The participant
was instructed to walk forward on a 10-ft. long, 4-in. wide balance beam
with a normal walking stride. The number of consecutive steps complet-
ed on the balance beam was recorded. The maximum score was six steps.
Walking forward on a walking line (Bruininks, 1978).—The participant
was instructed to walk forward on a walking line with a normal walk-
534 R. VILLAMONTE, ET AL.

ing stride and with hands at their sides. The walking line was made us-
ing 5-cm wide masking tape taped to the floor. The number of consecutive
steps completed on the walking line was recorded. The maximum score
was six steps.
Walking forward heel-to-toe on a balance beam (Bruininks, 1978).—The
participant was instructed to walk forward on a 10-ft. long, 4-in. wide bal-
ance beam heel-to-toe with hands at his sides. The number of consecutive
steps completed on the balance beam was recorded. The maximum score
was six heel-to-toe steps.
Walking forward heel-to-toe on a walking line (Bruininks, 1978).—The
participant was instructed to walk forward on the walking line, heel-to-
toe with the hands at his sides. The walking line was made using 5-cm
wide masking tape taped to the floor. The number of consecutive steps
completed on the walking line was recorded. The maximum score was six
heel-to-toe steps.
Stepping over response speed stick on a balance beam (Bruininks, 1978).—
The participant walked forward on a 4-inch wide balance beam, stepping
over a response speed stick (broomstick) held in the middle of the beam
by the examiner. The height of the response stick was 1 inch below the
participant’s patella. The participant walked on the beam with a normal
stride with hands at his sides. The participant’s score was recorded as pass
(score of 1) or fail (score of 0). A passing score was given if the partici-
pant stepped over the response stick without touching it and placed the
next step on the balance beam. A failing score was given if the participant
touched the response stick or if the participant went around the stick.
Timed get-up and go test (Mathias, Nayak, & Isaacs, 1986; Carmeli, Bar-
Chad, Lotan, Merrick, & Coleman, 2003).—This test was used to measure
a mixture of four different locomotor tasks. Participants began in the seat-
ed position. Participants stood, walked 9 m, turned around, returned to
the chair, turned around, and sat down. Time to complete the task was re-
corded in seconds.
Full turn (Carmeli, et al., 2003).—The 360° turn test measured perfor-
mance of a full turn, made twice, once in each direction. The number of
steps taken and the amount of time in seconds to complete a full turn in
place were recorded.
Forward reach (Duncan, Weiner, Chandler, & Studenski, 1990; Car-
meli, et al., 2003).—The forward reach test measured margin of stabili-
ty, or the ability to shift one’s center of mass by reaching forward as far
as possible without taking a step. The participant was asked to stand up
straight, make a fist holding a dry erase marker, and extend the right or
left arm forward parallel to the whiteboard. The white board was fixed on
the wall and used to make the measurements. The participant was asked
 RELIABILITY OF BALANCE TESTS 535

to reach forward as far as possible without taking a step, losing balance,

or touching the white board. As the participant reached, the white board
was marked with the dry erase pen. Functional reach was defined as the
length between starting and ending positions.
Sit-to-stand test (Carmeli, et al., 2003).—From a seated position, the
participant rose to standing from an armless chair and then sat down
again. The height of the chair depended on the individual’s height. Four
chair heights were available for the test, 30 cm, 35 cm, 41 cm, and 46 cm.
The participant sat on the chair with the feet flat on the ground and knees
bent at a 90° angle. The feet did not change position during the test. This
was repeated for 20 sec. The test measures the ability to transfer body
weight upright and then down by use of the knee extensor and lower back
muscles. The number of sit-to-stands completed in 20 sec. was recorded.
Analysis
Three trials of each test were performed during each of the four as-
sessments. For each assessment, the best value (maximum or minimum)
of the three trials was used as the observed value. This method of report-
ing test scores is consistent with the methodology of Wang and Ju (2002).
An analysis of variance indicated no significant differences in means for
the four assessments for each of the 16 balance tests within subjects. There-
fore, these values were pooled to establish within- and between-subjects
variance to compute interclass reliability coefficients (ICC). The ICC esti-
mates reliability based on the amount of variance within participants rela-
tive to the variance between participants. The smaller the within-subject
variance relative to the between-subjects variance shows that the partici-
pant was consistent across trials of the test. Generally, tests with ICCs of
less than .5, between .5 and .75, and greater that .75 can be considered as
having poor, moderate, and good reliability, respectively (Portney & Wat-
kins, 2000).
The underlying objective of calculating ICCs for each of the measures
of balance was to identify a battery of tests that had ICCs greater than
.5 and could therefore be recommended to assess balance in individuals
with Down syndrome. Balance tests that had an ICC less than .5 could not
be recommended for assessing balance. Likewise, balance tests that had
ICCs that were not meaningful or could not be calculated (e.g., ICC > 1
or ICC < 0), because all participants achieved the maximum score on the
test could not be recommended for assessing balance. ICCs that were not
meaningful are simply reported in this paper as ICC = 0. ICCs were initial-
ly calculated for each measure of balance for all participants combined as
well as all males combined and all females combined. ICCs were also cal-
culated for boys (n = 4; age = 5 years), men (n = 6; age = 22 to 31 years), girls
(n = 7; age = 8 to 14 years), and women (n = 4; age = 22 to 29 years).
536 R. VILLAMONTE, ET AL.

Results
Means and standard deviations for age, weight, height, and Body
Mass Index for the 10 males and 11 females who participated in this
study are shown in Table 1. The estimates of reliability for the 16 balance
TABLE 1
Participants’ Physical Characteristics
Males (n = 10) Females (n = 11) Total (N = 21)
M SD Range M SD Range M SD Range
Age, yr. 17.8 11.3 5–31 16.0 7.0 8–29 16.8 9.1 5–31
Weight, kg 56.9 34.6 15.9–104.4 48.6 23.3 21.8–111.0 52.5 28.8 15.9–111.0
Height, m 1.36 0.32 0.94–1.65 1.39 0.11 1.12–1.54 1.38 0.23 0.94–1.65
Body Mass Index,
kg/m2 26.4 8.1 16.2–40.8 24.4 9.5 17.4–51.4 25.4 8.7 16.2–51.4

tests are shown in Table 2. Two measurements (time and center of grav-
ity sway) were recorded for the four static tests (Items 1−4, Table 2). Two
measurements (time and steps taken) were recorded for the full turn to the
right and full turn to the left tests (Items 13−14, Table 2). Standing on the
TABLE 2
Interclass Reliability Coefficients For 16 Balance Tests
Test Item and Measure Interclass Reliability Coefficients (ICC)
Boys Men Girls Women
1. Standing test—firm surface with eyes closed, sec. 0 0 0 0
Standing test—firm surface with eyes closed,
°/sec. 0.51 0.75 0 0.37
2. Standing test—soft surface with eyes closed, sec. 0 0 0 0
Standing test—soft surface with eyes closed,
°/sec. 0.09 0 0.23 0.91
3. Standing test—soft surface with eyes opened,
sec. 0 0 0 0
Standing test—soft surface with eyes opened,
°/sec. 0.12 0.53 0 0.88
4. Standing test—firm surface with eyes opened,
sec. 0 0 0 0
Standing test—firm surface with eyes opened,
°/sec. 0 0 0 0.73
5. Standing on preferred leg on a balance beam
with eyes open, sec.* 0 0.88 0.62 0
Standing on preferred leg on a balance beam
with eyes closed, sec.* 0 0.76 0.01 0
6. Standing on preferred leg on the floor, sec.* 0.63 0.94 0.57 0
(continued on next page)
Note.—Boys (n = 4, 5 years old); men (n = 6, 22−31 years old); girls (n = 7, 8–14 years old); wom-
en (n = 4, 22−29 years old). ICCs that were not meaningful (e.g., ICC > 1 or ICC < 0) or could
not be calculated are recorded as 0. *This test is included in the balance subset of the Bruin-
inks–Oseretsky test (Bruininks, 1978).
 RELIABILITY OF BALANCE TESTS 537

TABLE 2 (cont’d)
Interclass Reliability Coefficients For 16 Balance Tests
Test Item and Measure Interclass Reliability Coefficients (ICC)
Boys Men Girls Women
7. Walking forward on a walking line, no. of steps* 0.04 0 0 0
8. Walking forward on a balance beam, no. of steps* 0.67 0 0.26 0.64
9. Walking forward heel-to-toe on a walking line,
no. of steps* 0 0.63 0 0
10. Walking forward heel-to-toe on a balance beam,
no. of steps* 0 0.91 0 0
11. Stepping over response stick on a balance beam,
0 or 1* 0 0 0 0
12. Timed get-up and go test, sec. 0 0.22 0.24 0
13. Full-turn—left, no. of steps 0 0 0 0
Full-turn—left, sec. 0 0.44 0.68 0
14. Full-turn—right, no. of steps 0.51 0 0
Full-turn—right, sec. 0 0 0 0
15. Forward reach, cm 0.73 0.64 0 0.25
16. Sit-to-stand test, total no. 0 0.54 0 0.76
Note.—Boys (n = 4, 5 years old); men (n = 6, 22−31 years old); girls (n = 7, 8–14 years old); wom-
en (n = 4, 22−29 years old). ICCs that were not meaningful (e.g., ICC > 1 or ICC < 0) or could
not be calculated are recorded as 0. *This test is included in the balance subset of the Bruin-
inks–Oseretsky test (Bruininks, 1978).

preferred leg on a balance beam was completed with the eyes open and
closed (Item 5, Table 2). Therefore, for the 16 balance tests, reliability coef-
ficients are reported for a total of 23 measures of balance (Table 2).

TABLE 3
Balance Tests With Acceptable Reliability in Males with Down Syndrome
Test Item and Measure Interclass Reliability
Coefficients (ICC)
Boys Men
1. Standing test—firm surface with eyes closed, °/sec. 0.51 0.75
3. Standing test—soft surface with eyes opened, °/sec. 0.53
5. Standing on preferred leg on a balance beam with eyes open,
sec.* 0.88
Standing on preferred leg on a balance beam with eyes
closed, sec.* 0.76
6. Standing on preferred leg on the floor, sec.* 0.63 0.94
8. Walking forward on a balance beam, no. of steps * 0.67
9. Walking forward heel-to-toe on a walking line, no. of steps* 0.63
10. Walking forward heel-to-toe on a balance beam, no. of steps* 0.91
14. Full-turn—right, no. of steps 0.51
16. Sit-to-stand test, total no. 0.54
Note.—Unrecorded ICC values indicate that they were low (ICC < .5), not meaningful (e.g.,
ICC > 1 or ICC < 0), or could not be calculated. *This test is included in the balance subset of
the Bruininks–Osteretsky test (Bruininks, 1978).
538 R. VILLAMONTE, ET AL.

Of the 21 participants, one did not complete the forward reach test.
Data from one person was dropped for the full-turn test due to recording
errors. The center of gravity sway for the first five participants was based
on a Biodex Balance System, but values varied depending on how close
to the center of the plate the participant was standing. As participants did
not always stand on the center of the plate, the NeuroCom Balance Master
System was used in testing the center of gravity sway for the other 16 par-
ticipants. Only the scores for the four static measurements using the Neu-
roCom Balance Master System were used.
The ICCs for the 23 measures of balance varied considerably by sex
and age. Based on having ICC greater than .5, fewer tests could reliably
assess balance in the boys and girls compared to adult men and women,
respectively (Table 4). Only three measures of balance were reliable in the
boys and girls, whereas five tests were reliable in the women and nine
tests were reliable in the men. The ICCs for the combined group of males,
combined group of females, and overall combined group are not report-
ed because doing so erroneously depicts the reliability of the individual
groups.
TABLE 4
Balance Tests With Acceptable Reliability in Females with Down Syndrome
Test Item and Measure Interclass Reliability
Coefficients (ICC)
Girls Women
2. Standing test—soft surface with eyes closed, °/sec. 0.91
3. Standing test—soft surface with eyes opened, °/sec. 0.88
4. Standing test—firm surface with eyes opened, °/sec. 0.73
5. Standing on preferred leg on a balance beam with eyes open,
sec.* 0.62
6. Standing on preferred leg on the floor, sec.* 0.57
8. Walking forward on a balance beam, no. of steps* 0.64
13. Full-turn—left, sec. 0.68
16. Sit-to-stand test, total no. 0.76
Note.—Unrecorded ICC values indicate that they were low (ICC < .5), not meaningful (e.g.,
ICC > 1 or ICC < 0), or could not be calculated. *This test is included in the balance subset of
the Bruininks–Oseretsky test (Bruininks, 1978).

Discussion
Apparently, this is the first study to evaluate the reliability of tests
commonly used to assess balance in individuals with Down syndrome.
The results of this study describe the test-retest performance of individu-
als 5 to 31 yr. of age with a potentially broad range of skills and abilities.
Due to a relatively small sample size, the interpretation of the results of
this study should be made with caution. Nevertheless, the contribution
of this study to the current body of knowledge should not be overlooked
 RELIABILITY OF BALANCE TESTS 539

due to the small sample size. The results of this study raise suspicions as
to the reliability of balance tests that are commonly used in this popula-
tion. Most of the 23 measures of balance were not reliable in either males
or females who participated in this study. Balance tests that had low or
otherwise meaningless reliability coefficients should not be used to assess
balance in individuals with Down syndrome.
A variety of factors may have contributed to the poor reliability (i.e.,
large within-subjects variance relative to between-subjects variance) of
most of the balance tests. Balance may be related to mental age and cog-
nitive impairment as well as chronological age and physical development
(Block, 1991). Since there was no screen for cognitive impairment, as mea-
sured by IQ, inconsistent test performance could have been due to intel-
lectual disability.
Postural control involves the integration of somatosensory, visual,
and vestibular sensory information regarding body position and motion
with the ability to generate forces to control body position (Vuillerme, et
al., 2001). Visual inputs appear to be dominant in the control of balance
prior to ages 6 or 7 years, after which there is a shift toward multimodal
control (Vuillerme, et al., 2001). There is some evidence to suggest that the
shift from visual to multimodal control of stance is delayed in individuals
with Down syndrome, thereby decreasing stability (Wade, Van Emmerik,
& Kernosek, 2000; Vuillerme, et al., 2001). It is also likely that the timing
of the shift from visual to multimodal control of stance varies between in-
dividuals. Thus, individual differences in sensory-motor integration may
contribute to the variance within and between participants. The fact that
in this study, fewer balance tests were reliable in males and females under
the age of 14 years compared to adults may be related to the timing of the
shift from visual to multimodal control of stance. In addition, early and
regular involvement in programs designed to improve motor skills and
balance in individuals with Down syndrome can influence motor perfor-
mance. More tests may have been reliable measures of balance in adult
males and females simply because they have had more experience and
time to develop motor skills and attention span.
Inconsistent performance on a balance test may be related to fear of
falling or the necessity to perform multiple tasks. For example, when par-
ticipants performed the timed get-up and go and the full-turn tests, they
would sometimes walk or turn quickly and other times they would per-
form the tests very slowly. In the full-turn test, participants often varied
the number of steps taken during the turn. During the sit-to-stand test,
young participants often stopped during the test because they were tired
of sitting or standing. Although the forward reach test had an acceptable
reliability in both age groups of males, its use cannot be recommended in
540 R. VILLAMONTE, ET AL.

individuals with Down syndrome because the test was not timely to per-
form—participants preferred to draw on the board instead of reaching
forward, and they did not fully understand the concept of reaching for-
ward without taking a step.
The results of this study indicate that standing on firm or soft sur-
faces with the eyes open or closed were not sensitive balance assessments
since every participant achieved the maximum score (10 sec.). Because
there was no variance either within or between participants, it could be
assumed that the individuals in this study had well-developed balance
and motor control while standing on different surfaces with and without
visual stimulus. Increasing the duration of such simple tests may make
these static balance tests more effective measures of balance. However,
performance on simple balance tests of longer duration may reflect limita-
tions of attention rather than balance.
The balance subset of the Bruininks–Oseretsky Test (Bruininks, 1978)
has often been used to assess balance in children with Down syndrome
(Connolly & Michael, 1986; Connolly, et al., 1993; DePaepe & Ciccaglione,
1993). The test-retest reliability of the balance subset of the Bruininks–Os-
eretsky test was previously reported to be .56 in children 4 to 14 years old
(Bruininks, 1978). The overall test-retest reliability of the balance subset of
the Bruininks–Oseretsky test in all 21 individuals with Down syndrome
in this study was .50, yet the reliability of each test varied between sexes
(Table 2). Five of the eight tests included in the balance subset of the Bruin-
inks–Oseretsky test were reliable in adult males and only one of the eight
tests was reliable in adult females with Down syndrome in this study (Ta-
bles 3 and 4). In the boys and girls who participated in this study, only
two of the eight tests were reliable (Tables 3 and 4). Wang and Ju (2002)
eliminated standing on a balance beam with the eyes closed, walking for-
ward heel-to-toe on the floor and on the balance beam, and stepping over
a stick when assessing balance in children with Down syndrome because
the tests were too difficult to perform. Current results concur with Wang
and Ju (2002) in that stepping over a response stick on the balance beam
was not a reliable test for any of the participants. In this study, standing
on a balance beam with the eyes closed and walking forward heel-to-toe
on the floor and on the balance beam were highly reliable in adult males.
Based on ICCs greater than .5, the battery of tests that could reliably
assess balance varied with age and sex (Tables 3 and 4). Only two tests,
standing on a soft surface with eyes opened and sit-to-stand, were reliable
in both men and women (Tables 3 and 4). Only one test, standing on the
preferred leg on the floor, was reliable in both boys and girls (Tables 3 and
4). The differences in the number of tests that could reliably measure bal-
ance in different ages in males and females are likely related to topics dis-
 RELIABILITY OF BALANCE TESTS 541

cussed above. Although the causes for the sex differences in test reliability
are not known, the results raise pressing issues as to the sex differences in
reliability that have not previously been evaluated.
Considering the diversity of cognitive abilities and motor skills among
individuals with Down syndrome and the small sample size of this study,
the results of this study may not be generalizable to the population of in-
dividuals with Down syndrome. Nevertheless, the results of this study
contribute to the current body of knowledge concerning the assessment of
balance. Due to the limitations and results of this study, a specific battery
of balance tests that should universally be used in individuals with Down
syndrome cannot be recommended. The results of this study raise doubts
about the reliability of commonly used balance tests and indicate sex dif-
ferences in test reliability. The findings of this study have clinical relevance
to physical therapists as well as to those who teach adaptive physical edu-
cation or administer intervention programs. Only reliable tests should be
used to assess balance. Based on the preliminary results of this study, bal-
ance test results should be interpreted with caution. Until further research
findings are available, it is suggested that those assessing balance in indi-
viduals with Down syndrome perform multiple trials on their patients,
students, or program participants to identify tests providing meaningful
information. Results of a single trial may be misleading.
Larger sample sizes should be used in future research that evaluates
the reliability of selected balance tests in males and females within specif-
ic age groups and cognitive abilities. Eventually, future research will lead
to the recommendation of a standardized battery of reliable tests that are
easy for the participant to understand and timely to perform. Subsequent
research can determine the types of physical activities that improve bal-
ance in individuals with Down syndrome and the development of norma-
tive test scores by sex and age. Availability of a standardized battery of
reliable tests will allow adaptive physical educators, physical therapists,
and others to make appropriate decisions about interventions and pro-
gram placement and planning, and to track individual progress.
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Accepted October 6, 2010.

 RELIABILITY OF 16 BALANCE TESTS IN
INDIVIDUALS WITH DOWN SYNDROME

ROMINA VILLAMONTE, PAT R. VEHRS, J. BRENT FELAND,

A. WAYNE JOHNSON, MATTHEW K. SEELEY, AND DENNIS EGGETT

Brigham Young University

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