The Inter-Rater and Intra-Rater Reliability of the Balance Error Scoring System in Acutely Concussed Individuals

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Context: The Balance Error Scoring System (BESS) is the recommended postural stability test and is the most commonly utilized test by Certified Athletic Trainers (ATC). The reliability of BESS ranges from poor (0.80) in healthy, non-injured individuals but has yet to be assessed in acutely concussed individuals. Furthermore, minimal detectable change (MDC) scores for the BESS have only been determined in healthy, non-injured individuals and are higher than the average increase in errors following concussion. Objective: We aim to determine the interrater and intrarater reliability of BESS in acutely concussed individuals. Secondly, we aim to investigate MDC scores in this population. Design: Prospective study. Setting: Large public university in southeast Georgia. Participants: We recruited 16 practicing ATCs from a single university. Main Outcome Measure: Reliability was determined by calculating intra-class correlations (ICCs), reported with 95% confidence intervals (CIs), for each stance and total BESS. The MDC will be determined by calculating the standard error of the measurement (SEM) and will be reported with 95% CIs. Results: The interrater and intrarater reliability ICCs for the total BESS scores were 0.75 and 0.86 respectively. The interrater reliability ICCs for the individual stances ranged from 0.00 to 0.74, and the intrarater reliability ICCs ranged from -0.01 to 0.89. The MDC scores for interrater and intrarater were 11.3 points and 8.6 points respectively. Discussion: This study suggests that for interrater reliability, no individual stance or the total BESS score reached clinically acceptable reliability; but, for intrarater reliability certain stances and the total BESS score demonstrated sufficient reliability to be used in the evaluation of postural stability. This indicates that for serial administration of the BESS the same rater should be used to achieve clinically acceptable levels of reliability. Additionally, a change in total BESS score of greater than 11.3 (interrater) or 8.6 (intrarater) points is required to ensure the change in score represents impairments in postural stability rather than variability in rater scoring. This is a potential problem considered the average increase in score following concussion was 4.87 points.


National Athletic Training Association National Conference (NATA)


St. Louis, MO