DISCUSSIONThe original BESTest is composed of a comprehensive batteryo terjemahan - DISCUSSIONThe original BESTest is composed of a comprehensive batteryo Bahasa Indonesia Bagaimana mengatakan

DISCUSSIONThe original BESTest is c

DISCUSSION
The original BESTest is composed of a comprehensive battery
of 36 balance tasks, developed to analyse 6 different postural
control systems that may contribute to poor functional balance in
adults of any age (7). Thus, it is not surprising that this test failed
to meet a unidimensionality assumption (i.e. that a single dimension
underlies all item responses), when applied to 115 patients
with a wide range of diagnoses and severity of disease.
Our dimensionality assessment extracted from the test battery
24 item assumed to define “dynamic balance”. On these items we performed an analysis of category and item properties
using Rasch psychometric methods, which led to the definition
of the 14 most psychometrically useful and practical items: the
refined mini-BESTest measures the unidimensional construct
of “dynamic balance” without redundant items or significant
ceiling/floor effects (26) and takes 10–15 min to administer.
The rating scale diagnostics (21) performed on the 24 items retained
after EFA showed that the original 4 levels were redundant
(23). This finding was expected, since some BESTest items were
borrowed (with modifications) from the BBS and the Dynamic
Gait Index. These 2 well-known balance and mobility scales have
been shown to include sub-optimal category
functioning (27,
28) when strict diagnostic criteria are applied (20). In addition,
it has already been demonstrated that the BBS (and other balance
scales) show essentially identical psychometric properties,
including responsiveness, when used with a 3-category, instead
of a 4- or 5-category rating scale (29). Appropriate combination
of levels 0–1 or 1–2 eliminated underutilized rating categories,
and ensured that each rating category was distinct from the others
in representing a distinct balance ability.
After collapsing the categories to 3 distinct levels, the data
from the 24-item set were reanalysed to calculate fit statistics
and the PCA of the residuals. This analysis enabled us to
eliminate 10 misfitting or redundant items without loss of
measurement information and with the great advantage of
improving test acceptability and feasibility. For the remaining
14-item (the mini-BESTest), we calculated fit statistics,
extracted Rasch-modelled parameters of ability and difficulty,
and then examined internal validity and test reliability. The
average ability of this group of patients was very similar to
the mean value of 0 logits (+0.15): this means that the test is
well targeted to the sample. Moreover, the person-ability and
item-difficulty mapped logit scale showed a broad range for
both person-ability and item-difficulty (Fig. 1). The 1.7% of
subjects (2/115) with extreme maximum scores, the 2 “×” at the
top of the left-hand column in Fig. 1, constituted a minor trend
toward a ceiling effect in very highly functioning subjects No floor effect was found. However, one should interpret the
extreme results with caution, since these person measures have
the least precision due to the larger errors of measurement. On
the other hand, the high item separation reliability indicates
that great confidence can be placed in the consistency of item
difficulty estimate across future samples.
Content validity of the dynamic mini-BESTest is high, since
many items included in the test are part of well-known balance
batteries: (i) “Sit to stand” is from the Berg Balance Scale (30)
and the Performance-Oriented Mobility Assessment (31); (ii)
“Stand on one leg” is from the Ataxia Test Battery (32) and
the Berg Balance Scale; (iii) “Stance – eyes open” and “Stance
on foam – eyes closed” are from the modified Clinical Test of
Sensory Integration of Balance (33, 34); (iv) Gait when balance
is challenged by changing speed, head rotations, pivot turns, or
stepping over obstacles comes from the Dynamic Gait Index
(35); (v) the “Get Up and Go” test (36) and the “Get Up and Go
with a simultaneous cognitive task” (37) are stand-alone tests.
In the BESTest, Horak et al. (7) made only minor modifications
to some of the above original items, in order to increase their
challenge and improve their consistency and reliability. Novel
items in the mini-BESTest have been adapted from laboratory
tests where they were shown to distinguish different types of
balance disorders: (i) postural reactions to external perturbations
(38); (ii) rise to toes (39); and (iii) stance on an inclined
surface with eyes closed (40).
As an additional demonstration of the internal construct
validity of the scale, the general hierarchical arrangement
found by Rasch analysis (Table II) is consistent with clinical
expectations. For example, the maintenance of feet-together
stance, eyes open on a firm surface (“Stance EO”) is the easiest
task and “Stand on one leg” the most difficult task item (28). In
fact, “Stance EO” makes few sensory demands and requires low
effort, whereas “Stand on one leg” is very challenging because
of the narrow base of support and musculoskeletal demands.
In addition, the results of Rasch analysis of the mini-BESTest
show a hierarchical order of item difficulty: “Gait with horizontal head turns”, “Stand on one leg”, and “Lateral stepping
responses” were the most difficult items, whereas “Stance EO”
and “Sit to Stand” were the easiest items. The high difficulty of
the item “Gait with horizontal head turns” may be attributed to
vestibular influences (35) and is in line with the results of the
two Rasch studies on the Dynamic Gait Index (28, 41).
The mini-BESTest contains 14 items belonging evenly to 4
of the 6 sections from the original BESTest (Table I): section
III “Anticipatory Postural Adjustments” (sit to stand, rise to
toes, stand on 1 leg); section IV “Postural Responses” (stepping
in 4 different directions); section V “Sensory Orientation”
(stance – eyes open; foam surface – eyes closed; incline – eyes
closed); and section VI “Balance during Gait” (gait during
change speed, head turns, pivot turns, obstacles; cognitive
“Get Up and Go” with dual task).
Our factor analysis procedure (42) isolated a number of
items, primarily in the first 2 sections of the BESTest, that did
not contribute to the dominant trait (dynamic balance), suggesting
that parts I “Biomechanical constraints” and II “Stability
limits” of the BESTest warrant separate psychometric studies.
Biomechanical constraints (such as orthopaedic limitations on
the base of foot support, postural alignment and strength) and
stability limits (ability to lean to perceived limits of stability
and perception of verticality) are also important facets of
postural control, but appear to be independent of the construct
“dynamic balance”.
This study has several limitations, which restrict the generalization
of our results to different groups or settings, and
raters. In particular, the selection criteria of our convenience
sample (recruited with a consecutive sampling method) may
represent a threat to external validity. Our sample was a crosssection
of adults drawn from a single rehabilitation facility and
with balance disorders of very different origins and severities.
Moreover, we used only one rater, but to improve the reliability
of results he participated in a one week training course on
BESTest, held by one of its developers (FBH).
In conclusion, the new mini-BESTest offers a unique, brief
clinical rating scale for dynamic balance that has excellent
psychometric characteristics. The potential interest of the mini-
BESTest in clinical settings is high, but further studies are needed.
They should include: (i) analysis of the actual performance of
the new 3-level response structure; and (ii) a study of differential
item functioning, i.e. the stability of item hierarchy across subsamples
defined according to potentially relevant clinical criteria;
(iii) relation of the scores to fall risk and to other clinical tests of
balance; and (iv) age-related normative values.
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DISCUSSIONThe original BESTest is composed of a comprehensive batteryof 36 balance tasks, developed to analyse 6 different posturalcontrol systems that may contribute to poor functional balance inadults of any age (7). Thus, it is not surprising that this test failedto meet a unidimensionality assumption (i.e. that a single dimensionunderlies all item responses), when applied to 115 patientswith a wide range of diagnoses and severity of disease.Our dimensionality assessment extracted from the test battery24 item assumed to define “dynamic balance”. On these items we performed an analysis of category and item propertiesusing Rasch psychometric methods, which led to the definitionof the 14 most psychometrically useful and practical items: therefined mini-BESTest measures the unidimensional constructof “dynamic balance” without redundant items or significantceiling/floor effects (26) and takes 10–15 min to administer.The rating scale diagnostics (21) performed on the 24 items retainedafter EFA showed that the original 4 levels were redundant(23). This finding was expected, since some BESTest items wereborrowed (with modifications) from the BBS and the DynamicGait Index. These 2 well-known balance and mobility scales havebeen shown to include sub-optimal categoryfunctioning (27,28) when strict diagnostic criteria are applied (20). In addition,it has already been demonstrated that the BBS (and other balancescales) show essentially identical psychometric properties,including responsiveness, when used with a 3-category, insteadof a 4- or 5-category rating scale (29). Appropriate combinationof levels 0–1 or 1–2 eliminated underutilized rating categories,and ensured that each rating category was distinct from the othersin representing a distinct balance ability.After collapsing the categories to 3 distinct levels, the datafrom the 24-item set were reanalysed to calculate fit statisticsand the PCA of the residuals. This analysis enabled us toeliminate 10 misfitting or redundant items without loss ofmeasurement information and with the great advantage ofimproving test acceptability and feasibility. For the remaining14-item (the mini-BESTest), we calculated fit statistics,extracted Rasch-modelled parameters of ability and difficulty,and then examined internal validity and test reliability. Theaverage ability of this group of patients was very similar tothe mean value of 0 logits (+0.15): this means that the test iswell targeted to the sample. Moreover, the person-ability anditem-difficulty mapped logit scale showed a broad range forboth person-ability and item-difficulty (Fig. 1). The 1.7% ofsubjects (2/115) with extreme maximum scores, the 2 “×” at thetop of the left-hand column in Fig. 1, constituted a minor trendtoward a ceiling effect in very highly functioning subjects No floor effect was found. However, one should interpret theextreme results with caution, since these person measures havethe least precision due to the larger errors of measurement. Onthe other hand, the high item separation reliability indicatesthat great confidence can be placed in the consistency of itemdifficulty estimate across future samples.Content validity of the dynamic mini-BESTest is high, sincemany items included in the test are part of well-known balancebatteries: (i) “Sit to stand” is from the Berg Balance Scale (30)and the Performance-Oriented Mobility Assessment (31); (ii)“Stand on one leg” is from the Ataxia Test Battery (32) andthe Berg Balance Scale; (iii) “Stance – eyes open” and “Stanceon foam – eyes closed” are from the modified Clinical Test ofSensory Integration of Balance (33, 34); (iv) Gait when balanceis challenged by changing speed, head rotations, pivot turns, orstepping over obstacles comes from the Dynamic Gait Index(35); (v) the “Get Up and Go” test (36) and the “Get Up and Gowith a simultaneous cognitive task” (37) are stand-alone tests.In the BESTest, Horak et al. (7) made only minor modificationsto some of the above original items, in order to increase theirchallenge and improve their consistency and reliability. Novelitems in the mini-BESTest have been adapted from laboratorytests where they were shown to distinguish different types ofbalance disorders: (i) postural reactions to external perturbations(38); (ii) rise to toes (39); and (iii) stance on an inclinedsurface with eyes closed (40).As an additional demonstration of the internal constructvalidity of the scale, the general hierarchical arrangementfound by Rasch analysis (Table II) is consistent with clinicalexpectations. For example, the maintenance of feet-togetherstance, eyes open on a firm surface (“Stance EO”) is the easiesttask and “Stand on one leg” the most difficult task item (28). Infact, “Stance EO” makes few sensory demands and requires loweffort, whereas “Stand on one leg” is very challenging becauseof the narrow base of support and musculoskeletal demands.In addition, the results of Rasch analysis of the mini-BESTestshow a hierarchical order of item difficulty: “Gait with horizontal head turns”, “Stand on one leg”, and “Lateral steppingresponses” were the most difficult items, whereas “Stance EO”and “Sit to Stand” were the easiest items. The high difficulty ofthe item “Gait with horizontal head turns” may be attributed tovestibular influences (35) and is in line with the results of thetwo Rasch studies on the Dynamic Gait Index (28, 41).The mini-BESTest contains 14 items belonging evenly to 4of the 6 sections from the original BESTest (Table I): sectionIII “Anticipatory Postural Adjustments” (sit to stand, rise totoes, stand on 1 leg); section IV “Postural Responses” (steppingin 4 different directions); section V “Sensory Orientation”(stance – eyes open; foam surface – eyes closed; incline – eyesclosed); and section VI “Balance during Gait” (gait duringchange speed, head turns, pivot turns, obstacles; cognitive“Get Up and Go” with dual task).Our factor analysis procedure (42) isolated a number ofitems, primarily in the first 2 sections of the BESTest, that didnot contribute to the dominant trait (dynamic balance), suggestingthat parts I “Biomechanical constraints” and II “Stabilitylimits” of the BESTest warrant separate psychometric studies.Biomechanical constraints (such as orthopaedic limitations onthe base of foot support, postural alignment and strength) andstability limits (ability to lean to perceived limits of stabilityand perception of verticality) are also important facets ofpostural control, but appear to be independent of the construct“dynamic balance”.This study has several limitations, which restrict the generalizationof our results to different groups or settings, andraters. In particular, the selection criteria of our conveniencesample (recruited with a consecutive sampling method) mayrepresent a threat to external validity. Our sample was a crosssectionof adults drawn from a single rehabilitation facility andwith balance disorders of very different origins and severities.Moreover, we used only one rater, but to improve the reliabilityof results he participated in a one week training course on
BESTest, held by one of its developers (FBH).
In conclusion, the new mini-BESTest offers a unique, brief
clinical rating scale for dynamic balance that has excellent
psychometric characteristics. The potential interest of the mini-
BESTest in clinical settings is high, but further studies are needed.
They should include: (i) analysis of the actual performance of
the new 3-level response structure; and (ii) a study of differential
item functioning, i.e. the stability of item hierarchy across subsamples
defined according to potentially relevant clinical criteria;
(iii) relation of the scores to fall risk and to other clinical tests of
balance; and (iv) age-related normative values.
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Hasil (Bahasa Indonesia) 2:[Salinan]
Disalin!
PEMBAHASAN
bestest asli terdiri dari baterai yang komprehensif
dari 36 tugas keseimbangan, dikembangkan untuk menganalisis 6 postural yang berbeda
sistem kontrol yang dapat menyebabkan keseimbangan fungsional miskin di
orang dewasa dari segala usia (7). Jadi, tidak mengherankan bahwa tes ini gagal
memenuhi asumsi unidimensionality (yaitu bahwa dimensi tunggal
mendasari semua tanggapan item), bila diterapkan pada 115 pasien
dengan berbagai diagnosa dan keparahan penyakit.
Penilaian dimensi kami diekstrak dari tes baterai
24 item yang diasumsikan untuk menentukan "keseimbangan dinamis". Pada item ini kita melakukan analisa dari kategori dan item yang sifat
menggunakan Rasch metode psikometri, yang menyebabkan definisi
dari 14 item yang paling psychometrically berguna dan praktis:
halus mini-bestest mengukur konstruk unidimensional
dari "keseimbangan dinamis" tanpa item berlebihan atau signifikan
efek langit-langit / lantai (26) dan membutuhkan waktu 10-15 menit untuk mengelola.
diagnostik skala rating (21) dilakukan pada 24 item ditahan
setelah EFA menunjukkan bahwa asli 4 tingkat yang berlebihan
(23). Temuan ini diharapkan, karena beberapa item Bestest yang
dipinjam (dengan modifikasi) dari BBS dan Dinamis
Indeks Kiprah. 2 skala ini keseimbangan dan mobilitas terkenal telah
terbukti termasuk kategori sub-optimal
berfungsi (27,
28) ketika kriteria diagnostik yang ketat diterapkan (20). Selain itu,
ia telah menunjukkan bahwa BBS (dan keseimbangan lainnya
timbangan) menunjukkan sifat psikometrik dasarnya identik,
termasuk tanggap, bila digunakan dengan 3-kategori, bukan
dari rating skala 4 atau 5-kategori (29). Kombinasi yang tepat
dari tingkat 0-1 atau 1-2 dieliminasi kurang dimanfaatkan kategori rating,
dan memastikan bahwa setiap kategori Peringkat itu berbeda dari yang lain
dalam mewakili kemampuan keseimbangan yang berbeda.
Setelah runtuh kategori untuk 3 tingkat yang berbeda, data
dari 24-item set yang menganalisis ulang untuk menghitung fit statistik
dan PCA dari residual. Analisis ini memungkinkan kita untuk
menghilangkan 10 misfitting atau item berlebihan tanpa kehilangan
informasi pengukuran dan dengan keuntungan besar
meningkatkan tes penerimaan dan kelayakan. Untuk sisanya
14-item (the-bestest mini), kita menghitung fit statistik,
diekstrak parameter Rasch-model dari kemampuan dan kesulitan,
dan kemudian diperiksa validitas internal dan reliabilitas. The
kemampuan rata-rata dari kelompok pasien ini sangat mirip dengan
nilai rata-rata 0 logits (0,15): ini berarti bahwa tes ini
juga ditargetkan untuk sampel. Selain itu, orang-kemampuan dan
item-kesulitan skala dipetakan logit menunjukkan berbagai untuk
kedua orang-kemampuan dan item-kesulitan (Gbr. 1). 1,7% dari
subyek (2/115) dengan skor maksimum ekstrim, 2 "x" di
atas kolom kiri pada Gambar. 1, merupakan tren minor
terhadap efek langit-langit dalam mata pelajaran yang sangat sangat berfungsi Tidak ada efek lantai ditemukan. Namun, salah satu harus menginterpretasikan
hasil yang ekstrim dengan hati-hati, karena tindakan orang ini memiliki
sedikit presisi karena kesalahan yang lebih besar dari pengukuran. Di
sisi lain, item tinggi kehandalan pemisahan menunjukkan
bahwa keyakinan besar dapat ditempatkan dalam konsistensi item
kesulitan perkiraan seluruh sampel masa depan.
Validitas Isi dinamis mini-Bestest tinggi, karena
banyak item yang termasuk dalam tes adalah bagian dari baik Saldo-dikenal
baterai: (i) "Duduk untuk berdiri" adalah dari Balance Scale Berg (30)
dan Kinerja Berorientasi Mobilitas Assessment (31); (ii)
"Berdiri dengan satu kaki" adalah dari Ataksia Uji Baterai (32) dan
Neraca Skala Berg; (iii) "Stance - mata terbuka" dan "Sikap
pada busa - mata tertutup" berasal dari Uji Klinis modifikasi dari
Sensory Integrasi Balance (33, 34); (iv) Kiprah bila saldo
ditantang dengan mengubah kecepatan, kepala rotasi, poros ternyata, atau
melangkahi hambatan berasal dari Indeks Kiprah Dinamis
(35); (v) "Get Up and Go" test (36) dan "Get Up and Go
dengan tugas kognitif simultan" (37) adalah tes yang berdiri sendiri.
Dalam Bestest, Horak dkk. (7) dibuat hanya modifikasi kecil
untuk beberapa item asli di atas, dalam rangka meningkatkan mereka
tantangan dan meningkatkan konsistensi dan kehandalan mereka. Novel
item dalam mini-bestest telah diadaptasi dari laboratorium
tes di mana mereka ditampilkan untuk membedakan berbagai jenis
gangguan keseimbangan: (i) reaksi postural untuk gangguan eksternal
(38); (ii) naik ke jari-jari kaki (39); dan (iii) sikap pada miring
permukaan dengan mata tertutup (40).
Sebagai demonstrasi tambahan konstruk internal yang
validitas skala, pengaturan hirarki umum
ditemukan oleh analisis Rasch (Tabel II) konsisten dengan klinis
harapan. Misalnya, pemeliharaan kaki-sama
sikap, mata terbuka pada permukaan perusahaan ("Stance EO") adalah yang paling mudah
tugas dan "Berdiri dengan satu kaki" item tugas yang paling sulit (28). Pada
kenyataannya, "Stance EO" membuat beberapa tuntutan sensorik dan membutuhkan rendah
usaha, sedangkan "Berdiri dengan satu kaki" sangat menantang karena
basis sempit dukungan dan tuntutan muskuloskeletal.
Selain itu, hasil analisis Rasch dari mini-bestest
menunjukkan urutan hirarkis item kesulitan: "Kiprah dengan kepala horisontal ternyata", "Berdiri dengan satu kaki", dan "loncatan Lateral
tanggapan" adalah item yang paling sulit, sedangkan "Stance EO"
dan "Sit ke Stand" adalah item paling mudah . Kesulitan tinggi
item "Kiprah dengan kepala horisontal ternyata" mungkin disebabkan
pengaruh vestibular (35) dan ini sejalan dengan hasil
dua studi Rasch pada Kiprah Indeks Dinamis (28, 41).
Mini-bestest mengandung 14 item milik merata ke 4
dari 6 bagian dari bestest asli (Tabel I): Bagian
III "antisipatif postural Penyesuaian" (duduk ke berdiri, naik ke
jari-jari kaki, berdiri di atas kaki 1); Bagian IV "Tanggapan postural" (melangkah
di 4 arah yang berbeda); Bagian V "Orientasi Sensory"
(sikap - mata terbuka; permukaan busa - mata tertutup; tanjakan - mata
tertutup); dan bagian VI "Balance selama Kiprah" (gait selama
kecepatan perubahan, kepala ternyata, poros ternyata, hambatan;
kognitif. "Get Up and Go" dengan tugas ganda)
prosedur analisis faktor kami (42) diisolasi sejumlah
item, terutama di pertama 2 bagian dari bestest, yang tidak
memberikan kontribusi pada sifat dominan (keseimbangan dinamis), menunjukkan
bahwa bagian-bagian saya "kendala biomekanik" dan II "Stabilitas
batas" dari surat perintah bestest studi psikometri terpisah.
kendala biomekanik (seperti keterbatasan ortopedi di
basis dukungan kaki, keselarasan postural dan kekuatan) dan
batas stabilitas (kemampuan untuk bersandar ke batas yang dirasakan dari stabilitas
dan persepsi vertikalitas) juga aspek penting dari
kontrol postural, tetapi tampaknya independen dari konstruk
"keseimbangan dinamis".
Ini Penelitian memiliki beberapa keterbatasan, yang membatasi generalisasi
dari hasil kami untuk kelompok atau pengaturan yang berbeda, dan
penilai. Secara khusus, kriteria pemilihan kenyamanan kita
sampel (direkrut dengan metode consecutive sampling) mungkin
merupakan ancaman terhadap validitas eksternal. Sampel kami adalah penampang
orang dewasa yang ditarik dari fasilitas rehabilitasi tunggal dan
dengan gangguan keseimbangan asal sangat berbeda dan severities.
Selain itu, kami menggunakan hanya satu penilai, tetapi untuk meningkatkan keandalan
dari hasil dia berpartisipasi dalam kursus pelatihan satu minggu pada
Bestest, yang diselenggarakan oleh salah satu pengembang (FBH).
Kesimpulannya, mini-Bestest menawarkan singkat, unik
skala penilaian klinis untuk keseimbangan dinamis yang memiliki baik
karakteristik psikometri. Kepentingan potensi mini
bestest dalam pengaturan klinis tinggi, namun studi lebih lanjut diperlukan.
Mereka harus mencakup: (i) analisis kinerja aktual dari
struktur respon 3-tingkat yang baru; dan (ii) studi diferensial
barang berfungsi, yaitu kestabilan hirarki barang di Subsamples
didefinisikan menurut kriteria klinis berpotensi relevan;
(iii) hubungan skor jatuh risiko dan tes klinis lain dari
keseimbangan; dan (iv) usia terkait nilai-nilai normatif.
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