R E SE AR C H R E PO R T

Pediatric Balance Scale: A Modified

Version of the Berg Balance Scale
for the School-Age Child with Mild
to Moderate Motor Impairment
Mary Rose Franjoine, MS, PT, PCS, Joan S. Gunther, PhD, PT, and Mary Jean Taylor, MA, PT, PCS
Physical Therapy Program, Daemen College, Amherst, New York

Purpose: The Pediatric Balance Scale (PBS), a modification of Berg’s Balance Scale, was developed as a balance
measure for school-age children with mild to moderate motor impairments. The purpose of this study was to
determine the test-retest and interrater reliability of the PBS. Methods: To determine test-retest reliability, 20
children (aged five to 15 years) with known balance impairments were tested by one examiner on the PBS. Ten
pediatric physical therapists independently scored 10 randomly selected videotaped test sessions.
Results: There was no significant difference in total test scores [intraclass correlation coefficient (ICC)
model 3,1
0.998] or individual items (Kappa Coefficients, k 0.87 to 1.0; Spearman Rank Correlation Coefficients, r
0.89 to 1.0) measured by one therapist on two occasions. No significant difference among ratings by different
physical therapists was found on the PBS for total test score (ICC 3,1 0.997). Conclusion: The PBS has been
demonstrated to have good test-retest and interrater reliability when used with school-age children with mild
to moderate motor impairments. (Pediatr Phys Ther 2003;15:114 –128) Key words: child, posture, equilibrium,
cerebral palsy, spinal dysraphism, mental retardation, activities of daily living, reproducibility of results,
physical therapy techniques/methods

INTRODUCTION AND PURPOSE postures, and standardized developmental measures of

Examination of balance is an important element of a
physical therapy evaluation for a school-age child. The cli-
nician must predict the ability of the child to safely and
independently function in a variety of environments (ie,
home, school, and community). Valid and reliable func-
tional balance measures are of critical importance if the
pediatric physical therapist is to justify that intervention is
warranted and demonstrate that improved balance func-
tion has occurred as a result of intervention.
Traditionally, pediatric physical therapists have ex-
amined balance through the observation of the underlying
elements of the balance response, timed measures of static
0898-5669/03/1502-0114
Pediatric Physical Therapy
Copyright © 2003 Lippincott Williams & Wilkins, Inc.
Address correspondence to: Mary Rose Franjoine, MS, PT, PCS, Physical
Therapy Program, Daemen College, 4380 Main St., Amherst, NY 14226.
Email: mfranjoi@daemen.edu
DOI: 10.1097/01.PEP.0000068117.48023.18
gross motor function.1– 4 The ability to describe the extent
to which a child demonstrates righting reactions, protec-
tive responses, and equilibrium reactions in response to a
therapist generated perturbation formed the foundation of
the “classic” balance assessment.1,2 Traditional balance as-
sessment also included timed measures of static sitting and
standing balance including single limb stance.4 Standard-
ized examination tools currently utilized by pediatric phys-
ical therapists for school-age children with mild to moder-
ate motor impairment include the Bruininks-Oseretsky
Test of Motor Proficiency,5 the Peabody Developmental
Motor Scale,6 and the Gross Motor Function Measure.7 In
addition, clinicians have developed their own non-stan-
dardized measures in an attempt to obtain information rel-
ative to the quality of performance during basic and instru-
mental activities of daily living, and higher-level gross
motor tasks.4 The standardized and non-standardized mea-
sures that currently exist provide clinicians with valuable
information, but may not fully meet their needs to assess a
child’s functional balance abilities.

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 Functional balance, for the purpose of this study,
has been defined as the element(s) of postural control

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that allow a child to safely perform everyday tasks. A similar to “functional reach,” which has been studied in
child of school age is expected to function indepen- the pediatric population.13 The purpose of this
dently within his/her home and school environment study was
when performing self-help (basic activities of daily liv-
ing), locomotor (mobility), and gross motor activities,
including recreational activities/play (instrumental ac-
tivities of daily living). As the child approaches adoles-
cence and young adulthood increased proficiency in ba-
sic and instrumental activities of daily living is
anticipated. Balance, the ability to maintain a state of
equilibrium, is one of the critical underlying elements of
movement that facilitates the performance of functional
skills. Other critical elements for successful function
include cognition, vision, vestibular function, muscle
strength, and range of motion. The physical therapist
must determine if the child possesses adequate func-
tional balance to safely meet the demands of everyday
life at home, in school, and within the community.
School-age children with mild to moderate motor im-
pairment pose unique challenges for the pediatric physical
therapist. Generally, they have acquired basic motor abili-
ties. At first glance, these children appear to possess the
motor skills necessary for successful function within their
homes, schools, and communities. They are able to ambu-
late independently with or without assistive devices. It is
our observation, however, that a closer examination of
their abilities reveals that they have a limited movement
repertoire that allows for minimal variation of movement
strategies within a given environment. Examples of such
limitations include the ability to turn only in one direction
in preparation to sit in a chair, or the ability to initiate
single limb stance with only one limb in preparation for
stepping onto a curb. Strong preferences or limited options
may create movement strategies that are unique to given
environments and appear slow, precarious, or impulsive.
Children with mild to moderate motor impairment may
appear to lack endurance for long duration/distance activ-
ities, such as standing still while waiting in a line. Standard-
ized tests, such as the Bruininks-Oseretsky Test of Motor
Proficiency,5 often reveal a significant delay in motor func-
tion for children with mild to moderate impairments com-
pared to children of the same chronological age without
impairments.
Current standardized pediatric clinical measures may
not provide the clinician with adequate information to
fully assess a child with mild to moderate motor impair-
ment’s functional balance. A review of balance in the liter-
ature suggested that the Berg Balance Scale (BBS) might be
useful with the school-age population.8 –12 The 14 items
contained within BBS (see Table 1) assess many of the
functional activities a child must perform to safely and
independently function within his/her home, school, or
community: sitting balance, standing balance, sit to stand/
stand to sit, transfers, stepping, reaching forward, reaching
to the floor, turning, and stepping on and off of an elevated
surface. The test item “forward reaching” is conceptually

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threefold: 1) to pilot test BBS for use with children; 2) to pediatric version, items were reordered into functional se-
refine the instrument as needed for use with children; and quences with novel tasks placed at the end of the scale (see
3) to determine test-retest and interrater reliability of the
Balance Scale for school-age children with mild to moder-
ate motor impairments.

The BBS
The BBS has undergone extensive reliability and
validity testing within the geriatric patient popula-
tion. 8,10 The intraclass correlation coefficients (ICC) for
interrater and test-retest reliability for the test as a whole
were 0.98 and 0.99, respectively. The ICC for individual
test items ranged from 0.71 to 0.99. Berg has suggested
that for older persons the Balance Scale is an appropriate
screening tool with respect to functional balance, is pre-
dictive of future dysfunction, is sensitive to changes in
functional balance skills, and may be used to monitor a
patient’s status over time. 9,10 The BBS is easy to admin-
ister, does not require specialized equipment, and can be
completed in 20 minutes. A 0 to 4 grading scale pro-
vides a quantitative and qualitative measure of perfor-
mance. An overall numeric score is obtained at the con-
clusion of testing. 10

METHODS
Pilot Testing of the BBS with Children
The BBS (see Table 1) was administered to 13 children
who were typically developing who ranged in age from four to
12 years, on two separate occasions scheduled one week
apart. A physical therapist (M.R.F.), a clinical specialist in
pediatric physical therapy with 13 years of experience in
school-based therapy, administered the BBS per test proto- col
to all 13 participants during both test sessions. The same
test site was used for both test sessions. Preliminary results
revealed unsatisfactory test-retest reliability. For- mal
statistical analysis of this data could not be completed as nine
of the 13 participants (69%) had difficulty complet- ing two
or more of the test items that required prolonged
maintenance of static postures. Marked variation within
individual participant’s performance was noted from the
initial test session to the follow-up test session with total
test scores (TTS) decreasing by greater than six points in
eight of the 13 (62%) participants. Issues associated with
typical child behavior, attention span and following direc-
tions were consistently encountered throughout test ad-
ministration during both sessions.
On the basis of the results of pilot testing of the BBS
with children who were typically developing, the 14 items
contained within Berg’s scale were modified to create a
pediatric version of this tool. The modifications were mi- nor
and included: 1) reordering of test items; 2) reducing time
standards for maintenance of static postures; and 3)
clarifying directions. Test items within the BBS are orga-
nized by increasing difficulty of task (see Table 1). In the

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Table 1). Time standards for BBS item 2, “standing unsup-
ported,” item 3, “sitting unsupported,” and item 7, “stand-
ing unsupported feet together” were decreased to 30 sec-
onds. In the BBS, a maximal score of “4” is earned in items
2 and 3 by maintaining a static posture for two minutes and
in item 7 by maintaining a static posture for one minute.
The scoring criteria to earn a “0” to “3” for each of these
items were also modified. Directions and suggested equip-
ment were modified throughout the balance scale. Exam-
ples include the use of footprints or a taped line to facilitate
task completion in BBS items 2, 6 –10, 13, and 14. Equip-
ment modification also included the use a child-size bench
for BBS items 3–5, the use of a chalkboard eraser for BBS
item 8, the use of a flash card for BBS item 10, and the use
of a 6-inch step for BBS item 12. Care was taken to ensure
that the intent of the items was not altered by the modifi-
cations. The Pediatric Balance Scale (PBS) and instructions
for administration are presented in the Appendix.
Pilot Testing of the PBS with Children
The PBS, the revised version of the BBS, was adminis-
tered per the protocol detailed in the Appendix, to 40 chil-
dren aged five to seven years who were developing typi-
cally. They were recruited from two local elementary
schools and participated in two separate test sessions
scheduled two weeks apart for the purpose of determining
test-retest reliability. Two entry-level physical therapy stu-
dents (K.K. and J.L.) under the advisement of an experi-
enced pediatric physical therapist (S.H.) administered and
scored the test. Before test administration, the clinical spe-
cialist in pediatric physical therapy (M.R.F.) who partici-
pated in the initial pilot testing of the BBS with children
who were typically developing and in the revision process
to create the PBS, trained the two examiners. They partic-
ipated in two three-hour training sessions, which con-
cluded one week before their initial data collection session.
Before the examiners completed their training, they dem-
onstrated the ability to accurately administer and score the
PBS for three children of varying ages. Their results re-
vealed no significant difference for total test and retest
scores of the 40 children who were developing typically on
TABLE 1.
The Berg Balance Scale and the Pediatric Balance Scale
Berg’s Balance Scale Items
1 Sitting to standing
2 Standing unsupported
3 Sitting unsupported
4 Standing to sitting
5 Transfers
6 Standing with eyes closed
7 Standing with feet together
8 Reaching forward with outstretched arm
9 Retrieving object from floor
10 Turning to look behind
11 Turning 360 degrees
12 Placing alternate foot on stool
13 Standing with one foot in front
14 Standing on one foot
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118 Franjoine al
the PBS (p 0.2489, Wilcoxon Matched Pairs Signed
Ranks Test; r 0.931, Spearman Signed Rank Correla-
tion).14 The test-retest reliability was extremely high (ICC
3,1 0.850).
Reliability of the PBS with Children with Mild to
Moderate Motor Impairment
Sample. Twenty children (12 boys and eight girls)
ranging in age from five to 15 years (mean age nine years)
with mild to moderate motor impairments were recruited
for participation in this study from local elementary
schools (see Table 2). The children were referred for par-
ticipation in this study by their community-based physical
therapist or their parent(s) or legal guardian(s). Informed
consent was obtained before participation from the child’s
parent(s) or legal guardian(s). A formal medical diagnosis
was not considered essential for inclusion in this study. All
children had a known functional limitation and/or disabil-
ity that presented, clinically, as an impaired state of balance
(disequilibrium). Etiologies of balance deficits varied
among the participants and included neurological, muscu-
loskeletal, and/or unknown causes (see Table 2). For in-
clusion in this sample, children had to be able to stand
independently without upper extremity support for four
seconds. All children who participated in this study were
receiving physical therapy at the time of this study, al-
though the amount of intervention varied from educational
consult (one to three times per school year) to intensive
outpatient physical therapy four times per week. (See Table
2) The children’s level of motor impairment also varied.
Descriptions of the children provided by their physical
therapists identified mobility skills, which ranged from in-
dependent community ambulation, without external assis-
tive devices, to wheelchair dependent, able to ambulate for
short distances. Children with a mental age of less than two
years, attention deficit disorder, pervasive developmental
delay, or a severe receptive language disorder were ex-
cluded from this study. The decision to exclude children
from this study with significant cognitive, attention, be-
havioral, and/or language disorders was necessary because
these disorders may severely compromise a child’s ability
Pediatric Balance Scale Items
1 Sitting to standing
2 Standing to sitting
3 Transfers
4 Standing unsupported
5 Sitting unsupported
6 Standing with eyes closed
7 Standing with feet together
8 Standing with one foot in front
9 Standing on one foot
10 Turning 360 degrees
11 Turning to look behind
12 Retrieving object from floor
13 Placing alternate foot on stool
14 Reaching forward with outstretched arm
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 TABLE 2.
Characteristics of children participating in this study and their total test scores for test and retest

Age in Physical Therapy Number of Days Test Session 1 Test Session 2

Subject Years Gender Diagnosis Sessions per Week Between Test-Retest Functional Level TTS TTS
1 9 Female PWS 2 7 Mild 45 45
2 6 Male LD/SI 2 14 Mild 45 41
3 7 Male CP-Hypo 2 7 Mild 46 41
4 13 Male SB CONSULT 7 Mild 48 48
5 9 Male CP-SD 2 7 Mild 47 46
6 13 Male MR 1 9 Mild 52 52
7 5 Male Autistic 2 7 Mild 44 46
8 11 Female CP-SD 2 7 Moderate 42 42
9 7 Male MR 3 7 Mild 49 49
10 8 Male CP-ATHD 4 7 Moderate 31 31
11 7 Female CP-SD 3 7 Mild 46 46
12 8 Male SP BT 2 7 Mild 52 52
13 10 Female CP-SD 4 7 Moderate 34 34
14 15 Male CP-SD 3 10 Moderate to Severe 19 19
15 14 Female CP-SD 4 8 Moderate to Severe 8 8
16 5 Female CP-Hemi 2 7 Moderate 14 14
17 5 Male LD/SI 2 10 Moderate 30 30
18 14 Female CP-SD 3 7 Moderate to Severe 13 13
19 9 Female CP-SD 2 7 Moderate to Severe 13 13
20 10 Male CP-Hemi 2 7 Moderate to Severe 5 5
PWS Prader-Willi syndrome; LD/SI learning disabled and speech-language impaired; MR mental retardation; SB spina bifida; SP BT
status post-brain tumor resection; CP cerebral palsy; Athd. athetoid; Hemi hemiplegia; Hypo hypotonia; SD spastic diplegia; TTS total test
score.

to comprehend and comply with test instructions in the
standardized manner necessary for determining the reli-
ability of a tool.
Procedure
Test-retest reliability. The PBS was administered to
all 20 participants following the criteria set forth in Appen-
dix 1. The same physical therapist (M.R.F.) tested all chil-
dren at both test sessions. She was responsible for direct
interaction with the child, administration of the test, scor-
ing of the test, and ensuring the child’s safety during test-
ing. An assistant was responsible for videotaping. Each
item was scored on the criterion-based 0 to 4 scale. Only
one practice trial per item was allowed. Verbal, visual, and
physical cues were provided to ensure the child under-
stood the requested task. If a child successfully completed
the task (ie, scored a four on the first trial), additional trials
were not administered. It took approximately 15 minutes
to administer and score the PBS.
A variety of test sites within the community were uti-
lized in this study, including the child’s home, school, and
private physical therapy clinic. For each child, the location
of the test site for test one and two were the same. Selection
of the test site was determined according to child, caretaker
or clinician convenience.
All children who participated in the study were sched-
uled for two test sessions that occurred within 14 days.
Whenever possible, the day of the week and time of day
were kept consistent. Scheduling of the test session was at
the convenience of the child, their parent(s) or legal guard-
ian(s), and/or the facility. Before each test session, a brief
introductory period occurred. This period did not exceed 5
minutes, and was designed to put the child at ease, allow-
ing the examiner to develop effective communication strat-
egies with the child. The child’s parent(s) and the referring
therapist(s) were invited to attend the test sessions.
Interrater Reliability
Interrater reliability of the PBS for total test score was
determined by using the videotapes created during the test
and retest data collection. Item 14, “forward reach,” was
omitted from videotape analysis because a two-dimen-
sional videotape does not adequately record test perfor-
mance.13 To ensure a range of performance scores, video-
taped test sessions were subdivided into three categories:
TTS 20, TTS 20 and 40, and TTS 40. Three to four
videotapes were randomly selected from the tapes in each
category. Ten pediatric physical therapists with a mini-
mum of two years of clinical experience participated in the
interrater reliability phase of this study. All therapists were
volunteers and were recruited from the local therapeutic
community. Their level of pediatric clinical experience var-
ied, ranging from two to 25 years (mean experience 9.4
years). All participating therapists were involved in pedi-
atric clinical practice, although their practice setting var-
ied: school-based, five therapists; outpatient hospital
based, three therapists; outpatient private practice, two
therapists. Each therapist participated in a single, 45-
minute training session on scoring of the PBS before scor-
ing of the videotapes. The 10 therapists independently
viewed and scored the 10 videotaped test sessions within
one week of their training session.

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Analysis of Test-Retest Reliability TABLE 3.
Test retest reliability item analysis
To determine test-retest reliability of the PBS, scores
on the initial administration of the PBS were compared PBS Test Items Kappa Spearman
with those obtained by the same investigator on the second 1. Sit-Stand 1.00 1.00
administration of the PBS. Scores on the PBS are ordinal 2. Stand-Sit 1.00 1.00
level data; therefore, the nonparametric Wilcoxon 3. Transfers 1.00 1.00
Matched Pairs Signed Ranks Test (alpha 0.05) was used 4. Standing Balance 0.92 0.89
5. Sitting Balance 1.00 1.00
to test for significant difference between total test and total
6. Stand Eyes Closed 1.00 1.00
retest scores. The Kappa statistic, k, was used to evaluate 7. Stand Feet Together 0.91 0.99
the agreement of test and retest scores on individual test 8. Stand One Foot in 0.92 0.96
items. Each ordinal score from 0 to 4 was considered to be Front-Tandem
a category. The kappa corrects for the proportion of agree- 9. Stand on One Foot 0.87 0.95
10. Turn 360 Degrees 0.91 0.99
ments between test and retest scores that occur as a result
15 11. Turn and Look Behind 0.93 1.00
of chance. Correlation coefficients evaluate the corre- 12. Pick Up Object 1.00 0.93
spondence between measurements. The correlation be- 13. Stepping 0.93 1.00
Spearman
tween test Rank Correlation
and retest scores coefficient. This test
was determined reflects
using the 14.PBS Functional
pediatric Reachscale.
balance 1.00 1.00
the consistency of ranks of data, but not the degree of
similarity between repeated test scores.15 An ICC model 3,1
[ICC(3,1)], which is a reliability coefficient based on an 1.574; p 0.1087) (see Table 5) and high interrater reli-
analysis of variance, was also determined. ability was demonstrated via an ICC(3,1) 0.997.

DISCUSSION
Analysis of Interrater Reliability
Preliminary testing of the PBS reveals very high test-
A single-factor repeated-measure analysis of variance retest and interrater reliability for children five to 15 years of
(alpha 0.05) and an ICC(3,1) were used to evaluate age with mild to moderate motor impairments. The PBS may
interrater reliability of total test score (exclusive of item therefore provide clinicians with an additional, reliable means
14) on the PBS. of assessing a child’s balance. The PBS also affords clinicians a
standardized protocol for test administration and scoring.
RESULTS Our preliminary work does not specifically address the valid-
Test-Retest Reliability ity of the PBS as a pediatric balance measure, nor does it
provide normative information. Clinical observations sup-
The age, gender, diagnosis, and frequency of physical
port the content (face) validity of the PBS, because items con-
therapy services as well as time between initial test and
tained within are routinely performed by children throughout
follow-up test are presented in Table 2 for all 20 children
the day and are frequently examined by pediatric physical
who participated in this study. The distribution of the TTS
therapist as a component of assessment. Examples of such
for test and retest data is also shown in Table 2. Individual
tasks include the following: item 1, sit to stand; item 2, stand
TTS scores ranged from 5 to 52. The maximal possible TTS
to sit; item 10, turning around; item 11, turning to look be-
for the PBS is 56. There was no significant difference be-
hind; and item 12, picking an object up from the floor (see the
tween total test and retest scores on the PBS (p 0.2733,
Appendix and Table 1).
Wilcoxon Matched Pairs Signed Ranks Test). The test-re-
The PBS incorporates a 0 to 4 grading scale to assess
test reliability for individual items is presented in Table 3.
performance. The scoring criterion within an item incor-
k ranged from 0.87 to 1.0. The Spearman Signed Ranked
porates qualitative and quantitative measures that allow for
Correlation, r, ranged from 0.89 to 1.0 for individual items.
Test-retest reliability was extremely high [ICC(3,1)
0.998]. TABLE 4.
Median, mode and range of TTS on PBS for 10 subjects evaluated by 10
pediatric physical therapists
Interrater Reliability
Ten pediatric physical therapists with varied clinical Subjects Median Mode Range
background, including years of experience and practice 1 5 5 1
setting, independently viewed and scored the videotaped 2 12 12 0
performance of 10 children. The median, mode, and range 3 12 12 0
4 27 27 0
of TTS on the PBS for each of the videotaped subjects are 5 11 11 0
presented in Table 4. The total test scores of the subjects 6 31 31 1
examined by the 10 therapists ranged from five to 49 with 7 49 49 2
only a zero-to-two point difference in the total test scores 8 45 45 1
for each subject. There was no significant difference among 9 40 40 1
10 43 43 0
ratings by different physical therapists on PBS TTS (F

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 TABLE 5.
Summary table for single-factor repeated-measures analysis of variance: PBS total scores of 10 videotaped subjects scored by 10 pediatric physical
therapists
df Sum of Squares
Subjects (S) 9 24430.800
Therapists (T) 9 1.600
Error (S T) 81 8.600
normal variability in performance. This aspect of the grad-
ing scale is extremely important, in that variability is a
hallmark of typical motor development. PBS item 8,
“standing one foot in front” (see Appendix) illustrates the
use of qualitative measures, quantitative measures and
variability within the scoring criteria of a single item. This
item examines a child’s ability to assume and maintain a
tandem posture. To obtain the maximal score of four the
child must be able to independently assume a tandem foot
placement position and maintain it for 30 seconds. A lesser
score is earned if the child requires assistance to step, can
maintain a stride stance, but not tandem stance, or main-
tains the tandem posture for 30 seconds.
Extreme care was taken during the modification pro-
cess of the BBS to ensure that the intent of the task was not
altered. The reduction in time parameters for static stance
in BBS items 2, 3, and 7 was necessary to ensure the mea-
sure of elements of postural control vs attention span. The
reduction to 30 seconds may limit the ability of this tool to
assess the underlying element of muscle strength/postural
stability as a component of functional balance. The time
parameter of 30 seconds was chosen based in part upon
clinical observation during pilot testing of the BBS and
1,4
current clinical research in the area of pediatric balance.
Care was taken to limit the effects of learning during
the test-retest phase of this study. Verbal, visual, and tactile
feedback, for each item, was provided during test session
one and two during the practice trial only. Qualitative per-
formance feedback, positive or negative, was not provided
during test administration and/or scoring. Additional feed-
back relative to individual item(s) or overall task perfor-
mance was also not provided. At the conclusion of each test
the child received a small toy of their choice as a thank you
for participating. The test and retest session were sched-
uled at least seven days apart and no longer than 14 days to
minimize the effects of leaning, retention, and develop-
mental-based changes.
The PBS has limitations. For example, the PBS does
not examine a child’s ability to reach overhead. If one con-
siders the strategies that children use as they interact with
their environment, we have observed that items which are
out of reach are frequently overhead. Additionally, the PBS
does not examine issues associated with balance during
locomotion. Inclusion of such items in the PBS would re-
quire further investigation.
Several questions remain with respect to the validity
of the PBS. Does the TTS have meaning, and if so, what
does it mean? Do age, height, weight, or gender influence
test performance? Is the PBS sensitive to functional
Pediatric PhysicaletTherapy
121 Franjoine al
Mean Square F Value p Value
2714.533
0.178 1.674 0.109
0.106
change? Is it capable of documenting skill progression or
regression over time? Do the criteria used in the grading
scale reflect different levels of motor proficiency? Are the
scale increments (zero to four) reflective of an overall
change in function? Ongoing investigation with the PBS
includes collection of normative data on children who are
typically developing. Preliminary results suggest that chil-
dren who are typically developing by the age of seven years
can successfully complete all items within the PBS, obtain-
ing the maximal score of 56. Additionally, three subjects
have been tested using the PBS for a period of two years in
conjunction with their ongoing clinical intervention pro-
grams. Trends in their data suggest that the PBS may be
sensitive to changes in a child’s functional balance abilities
over time. It is hoped that the PBS can be used clinically to
screen for functional balance deficits, identify a need for
physical therapy intervention, and to monitor progress
within a therapeutic program.
CONCLUSION
Preliminary data supports the use of the PBS as a reli-
able measure of functional balance for use with the school-
age child with mild to moderate motor impairment. It is
quick to administer and is easily scored. Total test admin-
istration and scoring time is 15 minutes. The PBS does
not require the use of specialized equipment. It provides
clinicians with a standardized format for measurement of
functional balance tasks which are routine components of
physical therapy examination for the school-age child with
mild to moderate motor impairments.
ACKNOWLEDGMENTS
The authors thank the children, their families, and the
community clinicians who participated in this study. The
authors acknowledge and thank Sharon L. Held, MS, PT,
PCS, Kim Kobes, PT, and Jeff Lach, PT, for their contribu-
tions to this study. A special thank you is extended to
Katherine Carey Carney, Theresa Kolodziej, Deborah Sc-
heider, and Jane Montgomery for their assistance and
support.
This study is dedicated in loving memory of Gregory
James Heiser (November 9, 1988 to August 23, 1996).
Sleep well my little angel.
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ual, 2nd ed. Hamilton, Ontario, Canada: Gross Motor Measure
Group; 1993.
8. Berg K, Maki BE, Williams JI, et al. Clinical and laboratory measures
of postural balance in an elderly population. Arch Phys Med Rehabil.
1992;73:1073–1080.
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9. Berg K. Balance and its measure in the elderly: a review. Phys Canada
1989;41:240 –246.
10. Berg K, Wood-Dauphinee S, Williams JI, et al. Measuring balance in
the elderly: preliminary development of an instrument. Phys Canada.
1990;41:304 –311.
11. Di Fabio RP, Badke MB. Relationship of sensory organization to balance
function in patients with hemiplegia. Phys Ther. 1990;70:542–548.
12. Shumway-Cook A, Horak FB. Assessing the influence of sensory in-
teraction on balance. Phys Ther. 1986;66:1548 –1550.
13. Donahoe B, Turner D, Worrell T. The use of functional reach as a
measurement of balance in boys and girls without disabilities ages 5
to 15 years. Pediatr Phys Ther. 1994;6:190 –193.
14. Kobes K, Lach J. Determining the Intertester and Intratester Reliability
of the Pediatric Balance Scale for Normal Developing Children. Am-
herst, NY: Daemen College, 1997. Bachelor’s Thesis.
15. Portney LG, Watkins MP. Foundations of Clinical Research. Norwalk,
Conn: Appleton & Lange; 1993.
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6. Standing Unsupported With Eyes Closed

INSTRUCTIONS: The child is asked to stand still with feet shoulder width apart and close
his/her eyes for ten seconds. Direction: "When I say close your eyes, I want you to stand
still, closeyour eyes, and keep them closed until I say open." If necessary, a blindfold may
be used. Weight shifting and equilibrium responses in the feet are acceptable; movement of the
foot in space (off the support surface) indicates end of timed trial. A taped line or footprints may
be placed on the floor to help the child maintain a stationary foot position.

EQUIPMENT: a stop watch or watch with a second hand

a twelve-inch long masking tape line or two footprints placed
shoulder width apart
blindfold

Best Of 3 Trials,
( )4 able to stand 10 seconds safely
( )3 able to stand 10 seconds with supervision (spotting)
( )2 able to stand 3 seconds
( ) 1 unable to keep eyes closed 3 seconds but stays steady
( )0 needs help to keep from falling

Time in seconds

7. Standing Unsupported With Feet Together

INSTRUCTIONS: The child is asked to place his/herfeet togetherand stand still

withoutholdingon. The child may be engaged in non-stressful conversation to maintain
attention span for thirty seconds. Weight shifting and equilibrium responses in feet are
acceptable; movement of the foot in space (off the support surface) indicates end of timed trial. A
taped line or footprints may be placed on the floor to help the child maintain stationary foot
position.

EQUIPMENT: a stop watch or watch with a second hand

a twelve inch long masking tape line or two footprints placed together
Best Of 3 Trials

)4 able to place feet together independently and stand 30 seconds safely

)3 able to place feet together independently and stand for 30 seconds with
supervision (spotting)
)2 able to place feet together independently but unable to hold for 30
seconds
) 1 needs help to attain position but able to stand 30 seconds with feet
together
( )0 needs help to attain position and I or unable to hold for 30 seconds
Time in seconds

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 F

8. Standing Unsupported One Foot In Front

INSTRUCTIONS: The child is asked to stand with one foot in front of the other, heel
to toe. If the child cannot place feet in a tandem position (directly in front), they should be asked
to step forward far enough to allow the heel of one foot to be placed ahead of the toes of the
stationary foot. A taped line and/or footprints may be placed on the floor to help the child
maintain a stationary foot position. In addition to a visual demonstration, a single physical prompt
(assistance with placement) may be given. The child may be engaged in non-stressful
conversation to maintain his/her attention span for 30 seconds. Weight shifting and/or equilibrium
reactions in the feet are acceptable. Timed trials should be stopped if either foot moves in space
(leaves the support surface) and/or upper extremities support is utilized.
EQUIPMENT: a stop watch or watch with a second hand
a twelve inch long masking tape line or two footprints placed heel to toe
Best Of Three Trials
( )4 able to place feet tandem independently and hold 30 seconds
( )3 able to place foot ahead of other independently and hold 30 seconds. Note:
The length of the step must exceed the length of the stationary foot and
the width of the stance should approximate the subject's normal stride
width.
)2 able to take small step independently and hold 30 seconds, or required
assistance to place foot in front, but can stand for 30 seconds.
) 1 needs help to step, but can hold 15 seconds
)0 loses balance while stepping or standing
Time in seconds

9. Standing On One Leg

INSTRUCTIONS: The child is asked to stand on one leg for as long as he/she is able
to without holding on. If necessary the child can be instructed to maintain his/her arms (hands)
on his/her hips (waist). A taped line or footprints may be placed on the floor to help the child
maintain a stationary foot position. Weight shifting and/or equilibrium reactions in the feet are
acceptable. Timed trials should be stopped if the weight-bearing foot moves in space (leaves the
support surface), the up limb touches the opposite leg or the support surface and/or upper
extremities are utilized for support.

EQUIPMENT: a stop watch or watch with a second hand

a twelve inch long masking tape line or two footprints placed heel to toe
3 Trials Average Score
( )4 able to lift leg independently and hold 10 seconds
( )3 able to lift leg independently and hold 5 to 9 seconds
( )2 able to lift leg independently and hold 3 to 4 seconds
( ) 1 tries to lift leg; unable to hold 3 seconds but remains standing
( )0 unable to try or needs assist to prevent fall

126 Franjoine et al Pediatric Physical Therapy

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 G

10. Turn 360 Degrees

INSTRUCTIONS: The child is asked to turn completely around in a full circle, STOP,
and then turn a full circle in the other direction.

EQUIPMENT: A stop watch or watch with a second hand

)4 able to turn 360 degrees safely in 4 seconds or less each way (total of
less than eight seconds)
)3 able to turn 360 degrees safely in one direction only in 4 seconds or less
completes turn in other direction requires more than four seconds
)2 able to turn 360 degrees safely but slowly
) 1 needs close supervision (spotting) or constant verbal cueing
)0 needs assistance while turning
Time in seconds

11. Turning To Look Behind Left & Right Shoulders While Standing Still
INSTRUCTIONS: The child is asked to stand with his/her feet still, fixed in one
place. "Follow this object as I move it. Keep watching it as I move it, but don't move your
feet."
EQUIPMENT: a brightly colored object of at least two inches in size, or flash
cards
a twelve inch long masking tape line or two footprints placed
shoulder width apart
( )4 looks behind/over each shoulder; weight shifts include trunk rotation
( )3 looks behind/over one shoulder with trunk rotation; weight shift in the
opposite direction is to the level of the shoulder; no trunk rotation
)2 turns head to look to level of shoulder; no trunk rotation
) 1 needs supervision (spotting) when turning; the chin moves greater than
half the distance to the shoulder
)0 needs assist to keep from losing balance or falling; movement of the chin
is less than half the distance to the shoulder

12. Pick Up Object From The Floor From A Standing Position

INSTRUCTIONS: The child is asked to pick up a chalkboard eraser placed

approximately the length of his/her foot in front of his/her dominant foot. In children, where
dominance is not clear, ask the child which hand they want to use and place the object in front of
that foot.
EQUIPMENT: a chalkboard eraser
a taped line or footprints
( )4 able to pick up an eraser safetly and easily
( )3 able to pick up eraser but needs supervision (spotting)
( )2 unable to pick up eraser but reaches 1 to 2 nches from eraser and keeps
balance independently
( )1 unable to pick up eraser; needs supervision (spotting)while attempting
( )0 unable to try, needs assist to keep from losing balance or falling

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128 Franjoine et al Pediatric Physical Therapy