Understanding the Pediatric Balance Scale: Guide Assessment Tool for Children's Balance

Balance is a fundamental skill that children need to navigate their daily lives—from walking and playing to participating in classroom activities. For children with motor impairments, assessing balance abilities is crucial for developing effective treatment plans and tracking progress over time. The Pediatric Balance Scale (PBS) has emerged as the gold standard tool for evaluating functional balance in school-aged children.

What Is the Pediatric Balance Scale?

The Pediatric Balance Scale is a modified version of the Berg Balance Scale, specifically adapted to assess functional balance skills in school-aged children with mild to moderate motor impairments. The scale consists of 14 balance-related test items that mimic everyday living experiences, with each item scored from 0 points (lowest function) to 4 points (highest function), yielding a maximum total score of 56 points.

Originally developed and pilot-tested on children aged 5 to 15 years, the PBS has become widely adopted in clinical and research settings worldwide. A second-generation version (PBS-2) with updated administrative directions and score sheets is now available, reflecting three decades of research and refinement.

Why the Pediatric Balance Scale Was Developed

The Berg Balance Scale was originally designed for assessing balance in elderly populations, but pilot studies revealed questionable reliability when applied to children. This led researchers to modify all 14 items of the scale to better suit the pediatric population, creating a tool that uses age-appropriate language, adjusted time requirements, and tasks more relevant to children's daily activities.

The 14 Assessment Items

The PBS evaluates balance through a diverse set of functional tasks that children encounter regularly. While the specific tasks include activities ranging from simple sitting positions to complex movements, they generally encompass:

• Static balance tasks: Sitting unsupported, standing with eyes closed, standing on one foot
• Dynamic balance activities: Sitting to standing transitions, turning 360 degrees, retrieving objects from the floor
• Functional reach tasks: Forward reach while standing
• Narrow base of support challenges: Tandem stance (heel-to-toe position), single-limb stance

Each task is scored based on the time a position can be maintained, the distance the upper limb can reach forward, or the time needed to complete the activity. The child performs each task while clothed and may use their habitual braces or gait-assistance devices.

Key Advantages of Single-Task Screening

Research has revealed an important clinical efficiency finding. For children with disabilities, the single-limb stance item alone explained 64.5% of the variance in total PBS scores, making it a useful first indicator when assessment time is limited. This suggests that accomplishing balance tasks with a narrowed base of support, such as tandem stance and single-limb stance, are necessary precursors to developing more complex balance abilities and are essential for everyday functional activities like walking and stair negotiation.

Clinical Applications and Populations

The PBS has been validated for use with various pediatric populations, particularly:

Cerebral Palsy

Studies demonstrate excellent validity when correlated with the Gross Motor Function Measurement (GMFM-66), with correlation coefficients ranging from 0.89 to 0.95. The PBS shows positive correlation with the mobility dimension of the Pediatric Evaluation Disability Inventory, regardless of motor impairment severity, demonstrating that balance is a prerequisite for independent gait performance.

Traumatic Brain Injury

Children who have experienced brain injuries often face balance challenges. Research shows that functional balance abilities in children post-traumatic brain injury are significantly limited compared to typically developing children, making the PBS a valuable assessment tool for this population.

Typically Developing Children

The PBS also provides valuable benchmarks for typically developing children. Performance on the scale is significantly affected by age and gender, with scores increasing with age—particularly between ages six and seven—and females demonstrating significantly higher scores than males across all age groups.

Administration and Equipment

The test takes approximately 15-20 minutes to complete and requires minimal equipment commonly found in clinical settings:

• Adjustable height bench or chair with armrests
• Stopwatch or watch with second hand
• Masking tape (1 inch wide)
• Step stool (6 inches in height)
• Small objects (chalkboard eraser, ruler)
• Optional items: child-size footprints, blindfold, brightly colored objects, flash cards

The tester demonstrates each task to the child, who receives up to three attempts at performing each item. The final score derives from calculating the sum of the three trial scores.

Psychometric Properties: Reliability and Validity

The PBS demonstrates robust psychometric properties that support its clinical utility:

Reliability

Studies with 20 children aged 5-15 years showed excellent test-retest reliability (ICC=0.998) and interrater reliability (ICC=0.997), with individual items showing Kappa coefficients ranging from 0.87 to 1.0.

Validity

Validity testing with 23 children aged 6-15 years with spastic cerebral palsy demonstrated a strong correlation (r=0.797) between the PBS and the Selective Control Assessment of Lower Extremity. The scale shows excellent convergent validity with motor capacity measures, including strong correlations with GMFM-88 total scores (r=0.926), GMFM-66 (r=0.902), and GMFM D (r=0.929).

Interpretation Guidelines and Age Considerations

Children who are seven years and older who are typically developing usually demonstrate mastery of PBS items, suggesting the scale may be most appropriate for detecting changes in children aged three to six years, whether typically developing or those with mild to moderate motor impairment.

Higher total scores indicate better balance ability and potentially lower fall risk. However, interpretation should consider:

• The child's age and developmental stage
• Specific diagnosis and severity of motor impairment
• Clinical examination findings
• Correlation with age (r=0.689) and height (r=0.650) in typically developing children

Limitations to Consider

While the PBS is an excellent assessment tool, clinicians should be aware of certain limitations:

1. Ceiling Effects: The scale may miss balance improvements in both typically developing children and those with mild to moderate physical impairments due to ceiling effects in the scoring system, particularly for children aged seven years and older with mild motor challenges.
2. Time Requirements: Some items may not accurately represent a child's balance abilities due to unrealistic time requirements for maintaining stationary postures, especially in young children or those with attention deficits secondary to neurologic conditions.
3. Scope Limitations: The PBS does not assess locomotive balance during walking or include tasks measuring overhead reaching performance.

Clinical Integration and Multidisciplinary Use

The PBS serves as more than just an assessment tool—it's a communication bridge between healthcare providers, educators, and families. Physical therapists, occupational therapists, and rehabilitation specialists use PBS scores to:

• Document baseline balance abilities
• Justify treatment necessity to insurers
• Track progress over treatment periods
• Modify intervention strategies based on objective data
• Establish realistic functional goals

Reliable measures of functional balance for children with cerebral palsy and other conditions are essential in clinical practice for determining appropriate therapy protocols and assessing treatment effectiveness.

The Future: PBS-2 and Normative Data

The field continues to evolve with the second-generation PBS-2 now available, featuring established age-based norms for children ages 2-13 years and supported by 30 years of research. These normative values provide crucial benchmarks that help clinicians distinguish between typical developmental variations and significant balance impairments requiring intervention.

Practical Tips for Implementation

For clinicians implementing the PBS in their practice:

1. Create a child-friendly environment: Use engaging language and demonstrate tasks in a playful manner
2. Allow adequate practice trials: Children may need visual, verbal, and physical prompts to understand tasks
3. Document environmental factors: Note any distractions, fatigue, or attention difficulties that may affect performance
4. Combine with clinical judgment: Use PBS scores alongside comprehensive clinical examination findings
5. Track longitudinal changes: Serial assessments every 4-6 months can reveal meaningful improvements or identify areas requiring additional focus

Conclusion

The Pediatric Balance Scale represents a sophisticated yet practical tool for evaluating functional balance in children with motor impairments. Its strength lies in its standardized approach, strong psychometric properties, and focus on activities that mirror real-world challenges children face daily.

Given realistic time constraints within healthcare and school-based therapy programs, identifying efficient evaluations to screen for balance control challenges is crucial not only for documenting underlying difficulties but also for justifying treatment necessity.

Whether used as a comprehensive 14-item battery or as a quick screening tool using single-limb stance, the PBS continues to serve as an invaluable resource for pediatric rehabilitation professionals worldwide. As research advances and normative databases expand, this assessment tool will undoubtedly remain central to helping children achieve their maximum functional potential.

Note: The Pediatric Balance Scale and PBS-2 are available for free download at pediatricbalancescale.com, making this evidence-based assessment accessible to clinicians globally.

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