The Relationship Between Human-rated Errors and Tablet-based Postural Sway During the Balance Error Scoring System in Military Cadets

Abstract

Background: The Balance Error Scoring System (BESS) is commonly accepted as a valid measure of postural stability. However, reliability values have varied, and subtle changes undetectable with the human eye may exist postinjury. The inertial measurement unit in commercially available tablets has been used to quantify postural sway (instrumented Balance Error Scoring System [iBESS] volume). However, iBESS has not been validated in a military population, and the stability of the tests beyond 1 week is unknown. Hypothesis: iBESS volume is capable of objectively measuring postural sway during the traditional BESS. Study Design: Prospective repeated-measures study. Level of Evidence: Level 3. Methods: Eighty-three cadets (40.96% women; age 20.0 ± 1.44 years; height 68.7 ± 4.1 inches; weight 166.7 ± 30.2 lb) with no history of concussion or lower extremity injury agreed to participate. All participants completed the BESS at baseline and 6 months post baseline. During testing, a tablet equipped with an inertial measurement unit was positioned on the participant’s sacrum to capture postural sway. Results: Moderate to strong correlations were exhibited between baseline measurements for single-limb (SL)-firm ( r = 0.84; P < 0.01), tandem (TAN)-firm ( r = 0.85; P < 0.01), double-limb (DL)-foam ( r = 0.50; P < 0.01), SL-foam ( r = 0.59; P < 0.01), and TAN-foam ( r = 0.79; P < 0.01). Balance improved significantly at 6 months for SL-firm human-rated errors (Effect Size [ES] = 0.32) and for SL-firm (ES = 0.38), DL-foam (ES = 0.21), and SL-foam iBESS volume (ES = 0.35). Moderate to strong correlations were exhibited between human-rated and iBESS change scores for SL-firm ( r = 0.71; P < 0.01), TAN-firm ( r = 0.75; P < 0.01), and TAN-foam ( r = 0.71; P < 0.01), and a weak correlation was exhibited for DL-foam ( r = 0.29; P < 0.01) and SL-foam ( r = 0.40; P < 0.01). Conclusion: Moderate to strong correlations existed between human-rated BESS errors and iBESS volume at baseline and between change scores. In addition, iBESS volume may be more sensitive to balance changes than the human-rated BESS. Clinical Relevance: This evidence supports the use of iBESS volume as a valid measure of postural stability in military cadets. iBESS volume may provide clinicians with an objective and more sensitive measure of postural stability than the traditional human-rated BESS.