Recommendations for a Core Outcome Set for Measuring Standing Balance in Adult Populations: A Consensus-Based Approach
Identifieur interne : 000074 ( Pmc/Corpus ); précédent : 000073; suivant : 000075Recommendations for a Core Outcome Set for Measuring Standing Balance in Adult Populations: A Consensus-Based Approach
Auteurs : Kathryn M. Sibley ; Tracey Howe ; Sarah E. Lamb ; Stephen R. Lord ; Brian E. Maki ; Debra J. Rose ; Vicky Scott ; Liza Stathokostas ; Sharon E. Straus ; Susan B. JaglalSource :
- PLoS ONE [ 1932-6203 ] ; 2015.
Abstract
Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice.
To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults.
A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria.
The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS.
Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations.
Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate.
The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.
Url:
DOI: 10.1371/journal.pone.0120568
PubMed: 25768435
PubMed Central: 4358983
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PMC:4358983Le document en format XML
<record><TEI><teiHeader><fileDesc><titleStmt><title xml:lang="en">Recommendations for a Core Outcome Set for Measuring Standing Balance in Adult Populations: A Consensus-Based Approach</title><author><name sortKey="Sibley, Kathryn M" sort="Sibley, Kathryn M" uniqKey="Sibley K" first="Kathryn M." last="Sibley">Kathryn M. Sibley</name><affiliation><nlm:aff id="aff001"><addr-line>Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Howe, Tracey" sort="Howe, Tracey" uniqKey="Howe T" first="Tracey" last="Howe">Tracey Howe</name><affiliation><nlm:aff id="aff003"><addr-line>School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lamb, Sarah E" sort="Lamb, Sarah E" uniqKey="Lamb S" first="Sarah E." last="Lamb">Sarah E. Lamb</name><affiliation><nlm:aff id="aff004"><addr-line>Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lord, Stephen R" sort="Lord, Stephen R" uniqKey="Lord S" first="Stephen R." last="Lord">Stephen R. Lord</name><affiliation><nlm:aff id="aff005"><addr-line>Neuroscience Research Australia, University of New South Wales, Sydney, Australia</addr-line></nlm:aff></affiliation></author><author><name sortKey="Maki, Brian E" sort="Maki, Brian E" uniqKey="Maki B" first="Brian E." last="Maki">Brian E. Maki</name><affiliation><nlm:aff id="aff002"><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff006"><addr-line>University of Toronto, Toronto, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Rose, Debra J" sort="Rose, Debra J" uniqKey="Rose D" first="Debra J." last="Rose">Debra J. Rose</name><affiliation><nlm:aff id="aff007"><addr-line>California State University Fullerton, Fullerton, California, United States of America</addr-line></nlm:aff></affiliation></author><author><name sortKey="Scott, Vicky" sort="Scott, Vicky" uniqKey="Scott V" first="Vicky" last="Scott">Vicky Scott</name><affiliation><nlm:aff id="aff008"><addr-line>Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff009"><addr-line>British Columbia Injury Research and Prevention Unit and Ministry of Health, Victoria, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Stathokostas, Liza" sort="Stathokostas, Liza" uniqKey="Stathokostas L" first="Liza" last="Stathokostas">Liza Stathokostas</name><affiliation><nlm:aff id="aff010"><addr-line>Canadian Centre for Activity and Aging, Western University, London, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Straus, Sharon E" sort="Straus, Sharon E" uniqKey="Straus S" first="Sharon E." last="Straus">Sharon E. Straus</name><affiliation><nlm:aff id="aff006"><addr-line>University of Toronto, Toronto, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Jaglal, Susan B" sort="Jaglal, Susan B" uniqKey="Jaglal S" first="Susan B." last="Jaglal">Susan B. Jaglal</name><affiliation><nlm:aff id="aff002"><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff006"><addr-line>University of Toronto, Toronto, Canada</addr-line></nlm:aff></affiliation></author></titleStmt><publicationStmt><idno type="wicri:source">PMC</idno><idno type="pmid">25768435</idno><idno type="pmc">4358983</idno><idno type="url">http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4358983</idno><idno type="RBID">PMC:4358983</idno><idno type="doi">10.1371/journal.pone.0120568</idno><date when="2015">2015</date><idno type="wicri:Area/Pmc/Corpus">000074</idno><idno type="wicri:explorRef" wicri:stream="Pmc" wicri:step="Corpus" wicri:corpus="PMC">000074</idno></publicationStmt><sourceDesc><biblStruct><analytic><title xml:lang="en" level="a" type="main">Recommendations for a Core Outcome Set for Measuring Standing Balance in Adult Populations: A Consensus-Based Approach</title><author><name sortKey="Sibley, Kathryn M" sort="Sibley, Kathryn M" uniqKey="Sibley K" first="Kathryn M." last="Sibley">Kathryn M. Sibley</name><affiliation><nlm:aff id="aff001"><addr-line>Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff002"><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Howe, Tracey" sort="Howe, Tracey" uniqKey="Howe T" first="Tracey" last="Howe">Tracey Howe</name><affiliation><nlm:aff id="aff003"><addr-line>School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lamb, Sarah E" sort="Lamb, Sarah E" uniqKey="Lamb S" first="Sarah E." last="Lamb">Sarah E. Lamb</name><affiliation><nlm:aff id="aff004"><addr-line>Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom</addr-line></nlm:aff></affiliation></author><author><name sortKey="Lord, Stephen R" sort="Lord, Stephen R" uniqKey="Lord S" first="Stephen R." last="Lord">Stephen R. Lord</name><affiliation><nlm:aff id="aff005"><addr-line>Neuroscience Research Australia, University of New South Wales, Sydney, Australia</addr-line></nlm:aff></affiliation></author><author><name sortKey="Maki, Brian E" sort="Maki, Brian E" uniqKey="Maki B" first="Brian E." last="Maki">Brian E. Maki</name><affiliation><nlm:aff id="aff002"><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff006"><addr-line>University of Toronto, Toronto, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Rose, Debra J" sort="Rose, Debra J" uniqKey="Rose D" first="Debra J." last="Rose">Debra J. Rose</name><affiliation><nlm:aff id="aff007"><addr-line>California State University Fullerton, Fullerton, California, United States of America</addr-line></nlm:aff></affiliation></author><author><name sortKey="Scott, Vicky" sort="Scott, Vicky" uniqKey="Scott V" first="Vicky" last="Scott">Vicky Scott</name><affiliation><nlm:aff id="aff008"><addr-line>Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff009"><addr-line>British Columbia Injury Research and Prevention Unit and Ministry of Health, Victoria, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Stathokostas, Liza" sort="Stathokostas, Liza" uniqKey="Stathokostas L" first="Liza" last="Stathokostas">Liza Stathokostas</name><affiliation><nlm:aff id="aff010"><addr-line>Canadian Centre for Activity and Aging, Western University, London, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Straus, Sharon E" sort="Straus, Sharon E" uniqKey="Straus S" first="Sharon E." last="Straus">Sharon E. Straus</name><affiliation><nlm:aff id="aff006"><addr-line>University of Toronto, Toronto, Canada</addr-line></nlm:aff></affiliation></author><author><name sortKey="Jaglal, Susan B" sort="Jaglal, Susan B" uniqKey="Jaglal S" first="Susan B." last="Jaglal">Susan B. Jaglal</name><affiliation><nlm:aff id="aff002"><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></nlm:aff></affiliation><affiliation><nlm:aff id="aff006"><addr-line>University of Toronto, Toronto, Canada</addr-line></nlm:aff></affiliation></author></analytic><series><title level="j">PLoS ONE</title><idno type="eISSN">1932-6203</idno><imprint><date when="2015">2015</date></imprint></series></biblStruct></sourceDesc></fileDesc><profileDesc><textClass></textClass></profileDesc></teiHeader><front><div type="abstract" xml:lang="en"><sec id="sec001"><title>Background</title><p>Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice.</p></sec><sec id="sec002"><title>Objective</title><p>To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults.</p></sec><sec id="sec003"><title>Methodology</title><p>A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria.</p></sec><sec id="sec004"><title>Data sources</title><p>The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS.</p></sec><sec id="sec005"><title>Results</title><p>Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations.</p></sec><sec id="sec006"><title>Limitations</title><p>Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate.</p></sec><sec id="sec007"><title>Conclusions</title><p>The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.</p></sec></div></front><back><div1 type="bibliography"><listBibl><biblStruct><analytic><author><name sortKey="Shumway Cook, A" uniqKey="Shumway Cook A">A Shumway-Cook</name></author><author><name sortKey="Woollacott, Mh" uniqKey="Woollacott M">MH Woollacott</name></author></analytic></biblStruct><biblStruct><analytic><author><name sortKey="Howe, Te" uniqKey="Howe T">TE Howe</name></author><author><name sortKey="Rochester, L" uniqKey="Rochester L">L Rochester</name></author><author><name sortKey="Neil, F" uniqKey="Neil F">F Neil</name></author><author><name sortKey="Skelton, Da" uniqKey="Skelton D">DA Skelton</name></author><author><name sortKey="Ballinger, C" uniqKey="Ballinger C">C Ballinger</name></author></analytic></biblStruct><biblStruct><analytic><author><name 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<front><journal-meta><journal-id journal-id-type="nlm-ta">PLoS One</journal-id><journal-id journal-id-type="iso-abbrev">PLoS ONE</journal-id><journal-id journal-id-type="publisher-id">plos</journal-id><journal-id journal-id-type="pmc">plosone</journal-id><journal-title-group><journal-title>PLoS ONE</journal-title></journal-title-group><issn pub-type="epub">1932-6203</issn><publisher><publisher-name>Public Library of Science</publisher-name><publisher-loc>San Francisco, CA USA</publisher-loc></publisher></journal-meta><article-meta><article-id pub-id-type="pmid">25768435</article-id><article-id pub-id-type="pmc">4358983</article-id><article-id pub-id-type="doi">10.1371/journal.pone.0120568</article-id><article-id pub-id-type="publisher-id">PONE-D-14-49047</article-id><article-categories><subj-group subj-group-type="heading"><subject>Research Article</subject></subj-group></article-categories><title-group><article-title>Recommendations for a Core Outcome Set for Measuring Standing Balance in Adult Populations: A Consensus-Based Approach</article-title><alt-title alt-title-type="running-head">Standing Balance Core Outcome Set in Adults</alt-title></title-group><contrib-group><contrib contrib-type="author"><name><surname>Sibley</surname><given-names>Kathryn M.</given-names></name><xref ref-type="aff" rid="aff001"><sup>1</sup></xref><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref rid="cor001" ref-type="corresp">*</xref></contrib><contrib contrib-type="author"><name><surname>Howe</surname><given-names>Tracey</given-names></name><xref ref-type="aff" rid="aff003"><sup>3</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lamb</surname><given-names>Sarah E.</given-names></name><xref ref-type="aff" rid="aff004"><sup>4</sup></xref></contrib><contrib contrib-type="author"><name><surname>Lord</surname><given-names>Stephen R.</given-names></name><xref ref-type="aff" rid="aff005"><sup>5</sup></xref></contrib><contrib contrib-type="author"><name><surname>Maki</surname><given-names>Brian E.</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff006"><sup>6</sup></xref></contrib><contrib contrib-type="author"><name><surname>Rose</surname><given-names>Debra J.</given-names></name><xref ref-type="aff" rid="aff007"><sup>7</sup></xref></contrib><contrib contrib-type="author"><name><surname>Scott</surname><given-names>Vicky</given-names></name><xref ref-type="aff" rid="aff008"><sup>8</sup></xref><xref ref-type="aff" rid="aff009"><sup>9</sup></xref></contrib><contrib contrib-type="author"><name><surname>Stathokostas</surname><given-names>Liza</given-names></name><xref ref-type="aff" rid="aff010"><sup>10</sup></xref></contrib><contrib contrib-type="author"><name><surname>Straus</surname><given-names>Sharon E.</given-names></name><xref ref-type="aff" rid="aff006"><sup>6</sup></xref></contrib><contrib contrib-type="author"><name><surname>Jaglal</surname><given-names>Susan B.</given-names></name><xref ref-type="aff" rid="aff002"><sup>2</sup></xref><xref ref-type="aff" rid="aff006"><sup>6</sup></xref></contrib></contrib-group><aff id="aff001"><label>1</label><addr-line>Department of Community Health Sciences, University of Manitoba, Winnipeg, Canada</addr-line></aff><aff id="aff002"><label>2</label><addr-line>Toronto Rehabilitation Institute- University Health Network, Toronto, Canada</addr-line></aff><aff id="aff003"><label>3</label><addr-line>School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, United Kingdom</addr-line></aff><aff id="aff004"><label>4</label><addr-line>Centre for Rehabilitation Research, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom</addr-line></aff><aff id="aff005"><label>5</label><addr-line>Neuroscience Research Australia, University of New South Wales, Sydney, Australia</addr-line></aff><aff id="aff006"><label>6</label><addr-line>University of Toronto, Toronto, Canada</addr-line></aff><aff id="aff007"><label>7</label><addr-line>California State University Fullerton, Fullerton, California, United States of America</addr-line></aff><aff id="aff008"><label>8</label><addr-line>Faculty of Medicine, School of Population and Public Health, University of British Columbia, Vancouver, Canada</addr-line></aff><aff id="aff009"><label>9</label><addr-line>British Columbia Injury Research and Prevention Unit and Ministry of Health, Victoria, Canada</addr-line></aff><aff id="aff010"><label>10</label><addr-line>Canadian Centre for Activity and Aging, Western University, London, Canada</addr-line></aff><contrib-group><contrib contrib-type="editor"><name><surname>Bayer</surname><given-names>Antony</given-names></name><role>Academic Editor</role><xref ref-type="aff" rid="edit1"></xref></contrib></contrib-group><aff id="edit1"><addr-line>Cardiff University, UNITED KINGDOM</addr-line></aff><author-notes><fn fn-type="conflict" id="coi001"><p><bold>Competing Interests: </bold>The authors have declared that no competing interests exist.</p></fn><fn fn-type="con" id="contrib001"><p>Conceived and designed the experiments: KMS BEM SES SBJ. Performed the experiments: KMS TH SEL SRL DJR VS LS SBJ. Analyzed the data: KMS TH SEL SRL BEM DJR VS LS SES SBJ. Contributed reagents/materials/analysis tools: KMS SBJ. Wrote the paper: KMS TH SEL SRL BEM DJR VS LS SES SBJ.</p></fn><corresp id="cor001">* E-mail: <email>kathryn.sibley@umanitoba.ca</email></corresp></author-notes><pub-date pub-type="epub"><day>13</day><month>3</month><year>2015</year></pub-date><pub-date pub-type="collection"><year>2015</year></pub-date><volume>10</volume><issue>3</issue><elocation-id>e0120568</elocation-id><history><date date-type="received"><day>5</day><month>11</month><year>2014</year></date><date date-type="accepted"><day>24</day><month>1</month><year>2015</year></date></history><permissions><copyright-year>2015</copyright-year><copyright-holder>Sibley et al</copyright-holder><license xlink:href="http://creativecommons.org/licenses/by/4.0/"><license-p>This is an open access article distributed under the terms of the <ext-link ext-link-type="uri" xlink:href="http://creativecommons.org/licenses/by/4.0/">Creative Commons Attribution License</ext-link>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited</license-p></license></permissions><self-uri content-type="pdf" xlink:type="simple" xlink:href="pone.0120568.pdf"></self-uri><abstract><sec id="sec001"><title>Background</title><p>Standing balance is imperative for mobility and avoiding falls. Use of an excessive number of standing balance measures has limited the synthesis of balance intervention data and hampered consistent clinical practice.</p></sec><sec id="sec002"><title>Objective</title><p>To develop recommendations for a core outcome set (COS) of standing balance measures for research and practice among adults.</p></sec><sec id="sec003"><title>Methodology</title><p>A combination of scoping reviews, literature appraisal, anonymous voting and face-to-face meetings with fourteen invited experts from a range of disciplines with international recognition in balance measurement and falls prevention. Consensus was sought over three rounds using pre-established criteria.</p></sec><sec id="sec004"><title>Data sources</title><p>The scoping review identified 56 existing standing balance measures validated in adult populations with evidence of use in the past five years, and these were considered for inclusion in the COS.</p></sec><sec id="sec005"><title>Results</title><p>Fifteen measures were excluded after the first round of scoring and a further 36 after round two. Five measures were considered in round three. Two measures reached consensus for recommendation, and the expert panel recommended that at a minimum, either the Berg Balance Scale or Mini Balance Evaluation Systems Test be used when measuring standing balance in adult populations.</p></sec><sec id="sec006"><title>Limitations</title><p>Inclusion of two measures in the COS may increase the feasibility of potential uptake, but poses challenges for data synthesis. Adoption of the standing balance COS does not constitute a comprehensive balance assessment for any population, and users should include additional validated measures as appropriate.</p></sec><sec id="sec007"><title>Conclusions</title><p>The absence of a gold standard for measuring standing balance has contributed to the proliferation of outcome measures. These recommendations represent an important first step towards greater standardization in the assessment and measurement of this critical skill and will inform clinical research and practice internationally.</p></sec></abstract><funding-group><funding-statement>The project was funded by a Canadian Institutes of Health Research (CIHR) planning grant (# MAG133935) - <ext-link ext-link-type="uri" xlink:href="http://www.cihr-irsc.gc.ca/e/193.html">http://www.cihr-irsc.gc.ca/e/193.html</ext-link>. KMS was supported by a STIHR-CIHR Fellowship from Knowledge Translation Canada and the Toronto Rehabilitation Institute. SEL is supported by the NIHR Oxford CLARHC and BRU awards. SES holds a Canada Research Chair in Knowledge Translation and Quality of Care. SBJ holds the Toronto Rehabilitation Institute Chair in Rehabilitation Research at the University of Toronto. Infrastructure support was provided by the Toronto Rehabilitation Institute, with grants from the Canadian Foundation for Innovation, the Ontario Innovation Trust and the Ministry of Research and Innovation. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.</funding-statement></funding-group><counts><fig-count count="2"></fig-count><table-count count="4"></table-count><page-count count="20"></page-count></counts><custom-meta-group><custom-meta id="data-availability"><meta-name>Data Availability</meta-name><meta-value>All relevant data are within the paper and its Supporting Information files.</meta-value></custom-meta></custom-meta-group></article-meta><notes><title>Data Availability</title><p>All relevant data are within the paper and its Supporting Information files.</p></notes></front><body><sec sec-type="intro" id="sec008"><title>Introduction</title><p>Standing balance, defined as the ability to keep the center of mass within the base of support [<xref rid="pone.0120568.ref001" ref-type="bibr">1</xref>], is a prerequisite for many functional activities such as mobility and fall avoidance [<xref rid="pone.0120568.ref002" ref-type="bibr">2</xref>, <xref rid="pone.0120568.ref003" ref-type="bibr">3</xref>]. Balance impairment is common across multiple populations and leads to the greatest losses in years of healthy life and quality of life in people living with stroke [<xref rid="pone.0120568.ref004" ref-type="bibr">4</xref>], brain injury [<xref rid="pone.0120568.ref005" ref-type="bibr">5</xref>], arthritis [<xref rid="pone.0120568.ref006" ref-type="bibr">6</xref>], and up to 75% of people of advancing age (≥70 years) [<xref rid="pone.0120568.ref007" ref-type="bibr">7</xref>]. Exercise is postulated to improve balance and is associated with increased mobility and reduced falls in many of these populations [<xref rid="pone.0120568.ref008" ref-type="bibr">8</xref>–<xref rid="pone.0120568.ref011" ref-type="bibr">11</xref>]. However, synthesizing evidence on the effects of interventions for improving balance has been hampered by the extensive variation in the use of balance outcome measures among studies [<xref rid="pone.0120568.ref002" ref-type="bibr">2</xref>, <xref rid="pone.0120568.ref012" ref-type="bibr">12</xref>]. For example, a systematic review on the effectiveness of exercise interventions to improve balance in older adults identified 95 eligible studies [<xref rid="pone.0120568.ref002" ref-type="bibr">2</xref>] but was able to pool less than 50% of included studies because over 25 different measures were used to assess balance. Varied use of balance measures is also seen in clinical practice, as illustrated in one survey of balance assessment practices among Canadian physiotherapists that reported use of over 20 different measures [<xref rid="pone.0120568.ref013" ref-type="bibr">13</xref>].</p><p>Such inconsistency in use of balance measures reflects the absence of a gold standard method for evaluating standing balance [<xref rid="pone.0120568.ref014" ref-type="bibr">14</xref>] and subsequent prolific development of measures [<xref rid="pone.0120568.ref015" ref-type="bibr">15</xref>]. This plethora highlights the complex multifactorial nature of balance; measures vary in purpose, specific components of balance evaluated, measurement techniques, target population and extent of psychometric evaluation. However, given the importance of standing balance in fall prevention and mobility enhancement, there is a need for greater consistency in standing balance measurement across studies and for individual assessments [<xref rid="pone.0120568.ref016" ref-type="bibr">16</xref>]. One approach to achieve a more standardized practice is to identify and recommend a core outcome set for measuring standing balance. A core outcome set (COS) is defined as a recommended minimum set of outcomes or outcome measures for a particular health construct, condition, or population, the results of which should be reported for all trials pertaining to that issue [<xref rid="pone.0120568.ref017" ref-type="bibr">17</xref>]. In all cases, COS recommendations do not imply that measurement of the construct should be restricted to the COS; rather, the purpose is to advocate that the COS forms a consistent component of measurement and it is expected that additional measures may also be used.</p><p>The objective of this project was to propose recommendations for a COS of standing balance measures for research and practice settings in adult populations. Although core outcome sets were originally developed for clinical trials, including health care practice in the scope of a COS offers the opportunity to expand the utility of recommendations and potential for broad uptake. Recommendation of a few representative and feasible measures that can be widely used across a range of populations and settings can facilitate evaluating the efficacy of interventions to improve standing balance, and thus a recommended COS for standing balance will directly and substantially inform clinical research and practice internationally. In turn, this will optimize the development and implementation of evidence-based exercise programs for mobility enhancement and fall prevention worldwide.</p></sec><sec sec-type="materials|methods" id="sec009"><title>Methods</title><sec id="sec010"><title>Design</title><p>We used a consensus-based approach incorporating a modified Nominal Group Technique based on the RAND/UCLA Appropriateness Method [<xref rid="pone.0120568.ref018" ref-type="bibr">18</xref>], involving a combination of anonymous rating and face-to-face group discussion [<xref rid="pone.0120568.ref019" ref-type="bibr">19</xref>]. These techniques have been used to develop COSs for other health outcome measures [<xref rid="pone.0120568.ref020" ref-type="bibr">20</xref>, <xref rid="pone.0120568.ref021" ref-type="bibr">21</xref>], and published guidelines for reporting the development of COSs [<xref rid="pone.0120568.ref017" ref-type="bibr">17</xref>] were followed. The project was funded by a Canadian Institutes of Health Research (CIHR) planning grant (# MAG133935), and was registered on the COMET (Core Outcome Measures in Effectiveness Trials) Initiative database (available at <ext-link ext-link-type="uri" xlink:href="http://www.comet-initiative.org/studies/details/244?result=true">http://www.comet-initiative.org/studies/details/244?result=true</ext-link>). Given the secondary nature of the data extraction, analysis, and recommendations, and as is common practice in COS development work, research ethics approval was not sought.</p></sec><sec id="sec011"><title>Expert panel sampling and recruitment</title><p>A purposive and iterative approach was used to identify individuals to sit on an international panel of experts for the consensus process. “Experts” were operationally defined as individuals who have national or international recognition in the fields of balance, mobility, exercise or fall prevention, and who regularly evaluate balance in their work. Within this context, individuals were strategically identified to represent a range of 1) related expertise (postural control, fall prevention, geriatrics, neurology, orthopedics, health service delivery, knowledge translation); 2) professional backgrounds (bioengineering, epidemiology, kinesiology, medicine, nursing, physiotherapy); and 3) practice settings (primary care, rehabilitation, nursing homes, homecare, community). The four members of the research team who initiated the project (KMS, SBJ, BEM, SES) have established track records in postural control, fall prevention, geriatrics, and hip fracture. They worked together to identify potential panel members who collectively represented all of the target expertise, professional backgrounds and practice settings identified as relevant to balance measurement. An initial cohort of individuals identified by the research team were contacted through email by the principal investigator (KMS), informed about the project, and invited to participate. Those who declined where asked to recommend other appropriate individuals, and any suggestions were discussed by the research team prior to invitation. Individuals were not excluded if they were the developer of one of the measures under consideration, but all panel members declared at the meeting whether they had any conflicts of interest related to participating in balance COS recommendations (including authorship) of measures under consideration for the balance COS. A panel size between twelve and eighteen individuals was sought, which falls within recommended ranges for consensus panels to provide good validity without excessively affecting group processes [<xref rid="pone.0120568.ref022" ref-type="bibr">22</xref>]. Consent was implied when individuals agreed to join the expert panel.</p></sec><sec id="sec012"><title>Identification of measures for consideration</title><p>A scoping review identifying published standing balance measures for adult populations [<xref rid="pone.0120568.ref023" ref-type="bibr">23</xref>] formed the pool of measures to be considered for the COS recommendations. Full details of the review are available. In brief, electronic searches of Medline, Embase, and CINAHL databases up to March 2014 were conducted using key word combinations of postural balance/ equilibrium, psychometrics/ reproducibility of results/ predictive value of tests/ validation studies, instrument construction/ instrument validation, geriatric assessment/ disability evaluation, as well as grey literature [<xref rid="pone.0120568.ref024" ref-type="bibr">24</xref>] and hand searches. Inclusion criteria were measures with a stated objective to assess balance, adult populations (aged 18 years and over), at least one psychometric evaluation, one standing balance task, a standardized protocol and evaluation criteria, and published in English. Two research assistants independently identified studies for inclusion and extracted characteristics (levels of measurement, scoring properties etc.), and psychometric properties for each measure. Two reviewers independently coded components of balance evaluated in each measure using the Systems Framework for Postural Control [<xref rid="pone.0120568.ref025" ref-type="bibr">25</xref>], a widely recognized model of balance. To avoid considering obsolete measures, electronic searches of Pubmed and Google Scholar were conducted on all identified measures published prior to 2009, and those with no references in peer-reviewed publications since 2009 or reported in a 2011 Canadian survey of balance assessment practices [<xref rid="pone.0120568.ref013" ref-type="bibr">13</xref>] were excluded.</p></sec><sec id="sec013"><title>Consensus process</title><p>The consensus process is summarized in <xref rid="pone.0120568.g001" ref-type="fig">Fig. 1</xref>.</p><fig id="pone.0120568.g001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0120568.g001</object-id><label>Fig 1</label><caption><title>Overview of consensus process</title></caption><graphic xlink:href="pone.0120568.g001"></graphic></fig><sec id="sec014"><title>Round One</title><p>Round one scoring took place online. To inform their scores, members of the expert panel were provided with background information, including: (i) the original publication and test items for each measure; (ii) a description of the established psychometric properties for each measure, downloaded from the Rehabilitation Measures Database, a searchable website containing evidence-based summaries of more than 250 rehabilitation measures (<ext-link ext-link-type="uri" xlink:href="http://www.rehabmeasures.org/">www.rehabmeasures.org</ext-link>), or a psychometric summary prepared by KMS if one was not available; (iii) results of the scoping review findings including measure characteristics and components of balance evaluated in each measure [<xref rid="pone.0120568.ref023" ref-type="bibr">23</xref>]; and (iv) a publication of balance assessment practices among Canadian physiotherapists [<xref rid="pone.0120568.ref013" ref-type="bibr">13</xref>].</p><p>Each measure was scored on a 5-point Likert scale (1- lowest, 5- highest) on three dimensions: (i) <italic>psychometric properties (</italic>validity, reliability etc.); (ii) <italic>feasibility</italic> of use on a large scale (practicality of administration, time, cost, equipment needs); and (iii) overall impression as a potential balance COS measure for adult populations. To manage workload, each measure was scored by half of the panel members, and to reduce bias, each participant had a different, randomly assigned set of measures to score. Panel members were invited to propose additional measures they felt warranted consideration.</p><p>Measures that received scores ≥ 4/ 5 on both psychometric <underline>and</underline> feasibility dimensions by 70% of scorers in round one were retained in the pool of potential COS measures and forwarded for discussion in round three. Measures that received scores ≤ 2/ 5 on the psychometric properties dimension by 70% of scorers were excluded. The remaining measures that received a range of scores across both dimensions were held for discussion in round two.</p></sec><sec id="sec015"><title>Round Two</title><p>Subsequent rounds took place at face-to-face meetings held in Toronto, Canada on May 29<sup>th</sup> and 30<sup>th</sup>, 2014. One week prior to the meeting, panel members received a report of the round one results, including detailed reports of the scoring distribution and comments for each measure (<xref rid="pone.0120568.s001" ref-type="supplementary-material">S1 File</xref>). The proceedings were led by a professional facilitator with a background in physiotherapy, and were audio recorded and transcribed verbatim along with detailed notes taken by a recorder. One panel member (TH) published meeting status updates throughout the proceedings via Twitter, which are archived and available online (<ext-link ext-link-type="uri" xlink:href="https://storify.com/MSK_Elf/recommending-a-core-outcome-set-for-standing-balan">https://storify.com/MSK_Elf/recommending-a-core-outcome-set-for-standing-balan</ext-link>). In round two, measures that received a range of scores across both dimensions were discussed by the expert panel, and then each member scored each of those measures on a single 5-point Likert scale rating the <italic>overall suitability</italic> for inclusion in the balance COS. A discussion of the constructs important for overall suitability of a balance COS was undertaken using the OMERACT filter (Outcome Measures in Rheumatology) filter framework to guide the discussion (<xref rid="pone.0120568.t001" ref-type="table">Table 1</xref>). The OMERACT filter is a framework of constructs developed for rheumatology core outcome sets that emphasizes the concepts of “truth”, “discrimination”, and “feasibility” [<xref rid="pone.0120568.ref026" ref-type="bibr">26</xref>]. Following the discussion, panel member scored each measure electronically using a web-based tool, and were blind to each other’s scores. At this phase, measures receiving scores ≥ 4/5 on overall suitability by 70% of panel members were retained in the pool of potential balance COS measures and discussed in round three.</p><table-wrap id="pone.0120568.t001" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0120568.t001</object-id><label>Table 1</label><caption><title>OMERACT (Outcome Measures in Rheumatology) filter to determine applicability of a measurement instrument in a setting.</title></caption><alternatives><graphic id="pone.0120568.t001g" xlink:href="pone.0120568.t001"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Construct</th><th align="left" rowspan="1" colspan="1">Explanation</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Truth</td><td align="left" rowspan="1" colspan="1">Is the measure truthful, does it measure what is intended? Is the result unbiased and relevant? The word “truth” captures issues for face, content, and construct validity (As gold standards are often not available, criterion validity is mostly not tested)</td></tr><tr><td align="left" rowspan="1" colspan="1">Discrimination</td><td align="left" rowspan="1" colspan="1">Does the measure discriminate between situations of interest? The situations can be states at one time (for classification or prognosis) or states at different times (to measure change). The word “discrimination” captures issues of reliability and sensitivity to change</td></tr><tr><td align="left" rowspan="1" colspan="1">Feasibility</td><td align="left" rowspan="1" colspan="1">Can the measure be applied easily, given constraints of time, money, and interpretability? The word “feasibility” captures an essential element in the selection of measure, one that may be decisive in determining a measure’s success</td></tr></tbody></table></alternatives></table-wrap></sec><sec id="sec016"><title>Round Three</title><p>In round three, panel members discussed the measures forwarded from rounds one and two. They also discussed and agreed that any panel members who developed measures under consideration in round three would abstain from the discussion and final vote. In round three, panel members responded to the following yes/ no statement for each measure: “This measure should be included in a COS of balance measures for adult populations”. Measures required support by a minimum of 70% of the panel members to be included in the final balance COS recommendations.</p></sec></sec></sec><sec sec-type="results" id="sec017"><title>Results</title><sec id="sec018"><title>Expert panel membership</title><p>Twenty individuals were invited to join the expert panel in the consensus exercise. Two declined the invitation, and four who accepted the invitation withdrew prior to the beginning of consensus activities due to scheduling conflicts. Fourteen individuals (70% of those invited) joined the expert panel—13 in person and one via teleconference (KV). One co-investigator participated in discussions via teleconference but did not vote (BEM). Expert panel characteristics are described in <xref rid="pone.0120568.t002" ref-type="table">Table 2</xref>. Four panel members declared that they developed measures under consideration for the balance COS (KB, FH, EI, DR).</p><table-wrap id="pone.0120568.t002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0120568.t002</object-id><label>Table 2</label><caption><title>Expert panel participant characteristics.</title></caption><alternatives><graphic id="pone.0120568.t002g" xlink:href="pone.0120568.t002"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Participant</th><th align="left" rowspan="1" colspan="1">Country</th><th align="left" rowspan="1" colspan="1">Primary Appointment</th><th align="left" rowspan="1" colspan="1">Affiliation Setting</th><th align="left" rowspan="1" colspan="1">Academic Background</th><th align="left" rowspan="1" colspan="1">Subject area expertise</th><th align="left" rowspan="1" colspan="1">Population expertise</th><th align="left" rowspan="1" colspan="1">Setting expertise</th><th align="left" rowspan="1" colspan="1">Years of experience</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1"><bold><xref rid="t002fn001" ref-type="table-fn">*</xref>K. Berg</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Chair, Department of Physical Therapy</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Epidemiology, Physical Therapy</td><td align="left" rowspan="1" colspan="1">Fall prevention, health service delivery</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Acute care, nursing home, home care</td><td align="left" rowspan="1" colspan="1">40</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold><xref rid="t002fn001" ref-type="table-fn">*</xref>F. Horak</bold></td><td align="left" rowspan="1" colspan="1">USA</td><td align="left" rowspan="1" colspan="1">Professor of Neurology</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Physical Therapy, Neurophysiology</td><td align="left" rowspan="1" colspan="1">Postural control, outcome measures</td><td align="left" rowspan="1" colspan="1">Neurology</td><td align="left" rowspan="1" colspan="1">Rehabilitation</td><td align="left" rowspan="1" colspan="1">40</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>T. Howe</bold></td><td align="left" rowspan="1" colspan="1">UK</td><td align="left" rowspan="1" colspan="1">Professor of Rehabilitation Sciences</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Physical Therapy</td><td align="left" rowspan="1" colspan="1">Exercise, postural control, outcome measures</td><td align="left" rowspan="1" colspan="1">Geriatrics, neurology, musculoskeletal</td><td align="left" rowspan="1" colspan="1">Rehabilitation</td><td align="left" rowspan="1" colspan="1">30</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>E. Inness</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Clinic Leader—Balance, Mobility & Falls Clinic</td><td align="left" rowspan="1" colspan="1">Rehabilitation Hospital</td><td align="left" rowspan="1" colspan="1">Physical Therapy</td><td align="left" rowspan="1" colspan="1">Falls prevention, postural control, outcome measures</td><td align="left" rowspan="1" colspan="1">Neurology</td><td align="left" rowspan="1" colspan="1">Rehabilitation</td><td align="left" rowspan="1" colspan="1">25</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>S. Jaglal</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Professor and Chair in Rehabilitation Research</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Epidemiology</td><td align="left" rowspan="1" colspan="1">Health service delivery, hip fracture, knowledge translation</td><td align="left" rowspan="1" colspan="1">Musculoskeletal</td><td align="left" rowspan="1" colspan="1">Rehabilitation</td><td align="left" rowspan="1" colspan="1">20</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>S. Lamb</bold></td><td align="left" rowspan="1" colspan="1">UK</td><td align="left" rowspan="1" colspan="1">Professor of Rehabilitation Sciences</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Physical Therapy</td><td align="left" rowspan="1" colspan="1">Falls prevention, health service delivery, knowledge translation, postural control</td><td align="left" rowspan="1" colspan="1">Geriatrics, musculoskeletal</td><td align="left" rowspan="1" colspan="1">Acute care, rehabilitation, primary care, community</td><td align="left" rowspan="1" colspan="1">25</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>S. Lord</bold></td><td align="left" rowspan="1" colspan="1">Australia</td><td align="left" rowspan="1" colspan="1">Senior Principal Research Fellow</td><td align="left" rowspan="1" colspan="1">Medical Research Institute</td><td align="left" rowspan="1" colspan="1">Epidemiology, Physiology, Psychology</td><td align="left" rowspan="1" colspan="1">Falls prevention, knowledge translation, postural control</td><td align="left" rowspan="1" colspan="1">Geriatrics, neurology, musculoskeletal</td><td align="left" rowspan="1" colspan="1">Acute care, rehabilitation, community</td><td align="left" rowspan="1" colspan="1">30</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>S. MacKay</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Manager, Research & Evaluation</td><td align="left" rowspan="1" colspan="1">Home Care</td><td align="left" rowspan="1" colspan="1">Kinesiology</td><td align="left" rowspan="1" colspan="1">Falls prevention, health service delivery</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Home care</td><td align="left" rowspan="1" colspan="1">8</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold><xref rid="t002fn002" ref-type="table-fn">**</xref>B. Maki</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Senior Scientist</td><td align="left" rowspan="1" colspan="1">Rehabilitation Hospital</td><td align="left" rowspan="1" colspan="1">Kinesiology, Biomechanics, Biomedical Engineering</td><td align="left" rowspan="1" colspan="1">Falls prevention, postural control,</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Rehabilitation, community</td><td align="left" rowspan="1" colspan="1">30</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>D. Rose</bold></td><td align="left" rowspan="1" colspan="1">USA</td><td align="left" rowspan="1" colspan="1">Director, Institute of Gerontology and Center for Successful Aging</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Kinesiology</td><td align="left" rowspan="1" colspan="1">Fall prevention, knowledge translation, postural control</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Rehabilitation, community, home care</td><td align="left" rowspan="1" colspan="1">29</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>V. Scott</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Senior Advisor, Fall and Injury Prevention, BC Injury Research & Prevention Unit and Ministry of Health</td><td align="left" rowspan="1" colspan="1">Research Institute</td><td align="left" rowspan="1" colspan="1">Nursing, Health Policy</td><td align="left" rowspan="1" colspan="1">Fall prevention, health service delivery, knowledge translation</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Primary care, nursing homes, community, home care</td><td align="left" rowspan="1" colspan="1">20</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>K. Sibley</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Postdoctoral Fellow</td><td align="left" rowspan="1" colspan="1">Research Institute</td><td align="left" rowspan="1" colspan="1">Kinesiology</td><td align="left" rowspan="1" colspan="1">Fall prevention, knowledge translation, postural control</td><td align="left" rowspan="1" colspan="1">Geriatrics, neurology, musculoskeletal</td><td align="left" rowspan="1" colspan="1">Rehabilitation</td><td align="left" rowspan="1" colspan="1">10</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>D. Skelton</bold></td><td align="left" rowspan="1" colspan="1">UK</td><td align="left" rowspan="1" colspan="1">Professor of Ageing and Health</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Exercise Physiology</td><td align="left" rowspan="1" colspan="1">Fall prevention, health services delivery, postural control, exercise interventions</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Primary care, nursing homes, community</td><td align="left" rowspan="1" colspan="1">24</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>L. Stathokostas</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Researcher</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Kinesiology</td><td align="left" rowspan="1" colspan="1">Aging, exercise</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">community</td><td align="left" rowspan="1" colspan="1">15</td></tr><tr><td align="left" rowspan="1" colspan="1"><bold>K. Van Ooteghem</bold></td><td align="left" rowspan="1" colspan="1">Canada</td><td align="left" rowspan="1" colspan="1">Postdoctoral Fellow</td><td align="left" rowspan="1" colspan="1">University</td><td align="left" rowspan="1" colspan="1">Kinesiology</td><td align="left" rowspan="1" colspan="1">Postural control</td><td align="left" rowspan="1" colspan="1">Geriatrics</td><td align="left" rowspan="1" colspan="1">Nursing home, community</td><td align="left" rowspan="1" colspan="1">7</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t002fn001"><p>* Did not participate in round three discussion and vote.</p></fn><fn id="t002fn002"><p>** Did not vote.</p></fn></table-wrap-foot></table-wrap></sec><sec id="sec019"><title>COS development</title><p>The results are summarized in <xref rid="pone.0120568.g002" ref-type="fig">Fig. 2</xref>. The scoping review identified 66 measures. Of these, ten measures published at least five years earlier with no evidence of use since then were excluded. Fifty-six measures were considered in the pool of potential balance COS measures (<xref rid="pone.0120568.t003" ref-type="table">Table 3</xref>) and scored in round one. Following round one, 15 measures were excluded, two measures were forwarded to round three (Berg Balance Scale (BBS) [<xref rid="pone.0120568.ref027" ref-type="bibr">27</xref>] and Timed Up-and-Go (TUG) Test [<xref rid="pone.0120568.ref028" ref-type="bibr">28</xref>]), and 39 measures were held for discussion in round two.</p><fig id="pone.0120568.g002" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0120568.g002</object-id><label>Fig 2</label><caption><title>Overview of standing balance COS development results.</title></caption><graphic xlink:href="pone.0120568.g002"></graphic></fig><table-wrap id="pone.0120568.t003" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0120568.t003</object-id><label>Table 3</label><caption><title>Measures considered for standing balance COS (n = 56).</title></caption><alternatives><graphic id="pone.0120568.t003g" xlink:href="pone.0120568.t003"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1">Measure</th><th align="left" rowspan="1" colspan="1">Result</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Activity-based Balance Level Evaluation (ABLE) Scale [Ardolino et al. Phys Ther. 2012]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Balance Computerized Adaptive Testing (CAT) System [Hsueh et al. Phys Ther. 2010]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, specific to stroke)</td></tr><tr><td align="left" rowspan="1" colspan="1">Hierarchical Balance Short Forms (HBSF) [Hou et al. Arch Phys Med Rehabil. 2011]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Balance Error Scoring System (BESS) [Riemann et al. J Sport Rehabil. 1999]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Modified Balance Error Scoring System (M-BESS) [Hunt et al. Clin Journal Sport Med. 2009]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Balance Evaluation Systems Test (BESTest) [Horak et al. Phys Ther. 2009]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Brief Balance Evaluation Systems Test (Brief BESTest) [Padgett et al. Phys Ther 2012]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Mini Balance Evaluation Systems Test (Mini BESTest) [Franchignoni et al. J Rehabil Med 2010]</td><td align="left" rowspan="1" colspan="1">Included in balance COS recommendations</td></tr><tr><td align="left" rowspan="1" colspan="1">Balance Outcome Measure for Elder Rehabilitation (BOOMER) [Haines et al. Arch Phys Med Rehabil. 2007]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">BDL Balance Scale [Lindmark et al. Advances in Physiotherapy. 2012]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Berg Balance Scale (BBS) [Berg et al. Physiotherapy Canada. 1989]</td><td align="left" rowspan="1" colspan="1">Included in balance COS recommendations</td></tr><tr><td align="left" rowspan="1" colspan="1">Short Form of the Berg Balance Scale (SFBBS) [Chou et al. Phys Ther. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Short Berg Balance Scale [Hohtari-Kivimaki et al. Aging-Clinical & Experimental Research. 2012]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Brunel Balance Assessment (BBA) [Tyson et al. Clin Rehabil. 2004]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Clinical Gait and Balance Scale (GABS) [Thomas et al. J Neurol Sci. 2004]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Clinical Test of Sensory Interaction in Balance (CTSIB)</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Community Balance and Mobility Scale (CB&M) [Howe et al. Clin Rehabil. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Dynamic Balance Assessment (DBA) [Desai et al Phys Ther. 2010]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Dynamic Gait Index [Shumway-Cook et al. Phys Ther. 1997]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Four-item Dynamic Gait Index (4-DGI) [Marchetti et al. Phys Ther. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Functional Gait Assessment (FGA) [Wrisley et al. Phys Ther. 2004]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Five Times Sit-to-Stand Test (5-STS) [Whitney et al. Phys Ther. 2005]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Four Square Step Test (FSST) [Dite and Temple. Arch Phys Med Rehabil. 2002]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Fullerton Advanced Balance (FAB) Scale [Rose et al. Arch Phys Med Rehabil. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Functional Reach Test [Duncan et al. J Gerontol. 1990]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Multidirectional Reach Test [Newton. J Gerontol A Biol Sci Med Sci. 2001]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Hierarchical Assessment of Balance and Mobility (HABAM) [MacKnight and Rockwood. Age & Ageing 1995]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Limits of Stability Test (LOS) [Clark et al. Arch Phys Med Rehabil. 1997]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Modified Figure of Eight Test [Jarnlo and Nordell. Phys Theor Pract. 2003]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Parallel Walk Test (PWT) [Johansson et al. Phys Theor Pract. 1991]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Performance Oriented Mobility Assessment (POMA) [Tinetti. J Am Geriatr Soc. 1986]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Modified Performance Oriented Mobility Assessment [Fox et al. Arch Phys Med Rehabil. 1996]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Postural Assessment Scale for Stroke Patients (PASS) [Benain et al. Stroke. 1999]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Short Form of Postural Assessment Scale for Stroke Patients (SFPASS) [Chien et al. Neurorehabil Neur Repair. 2007]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, specific to stroke)</td></tr><tr><td align="left" rowspan="1" colspan="1">Pull/ Retropulsion Test [Visser et al. Arch Phys Med Rehabil. 2003]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Push and Release Test [Jacobs et al. J Neurol. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Rapid Step Test (RST) [Medell et al. J Geron A Biol Sci Med Sci. 2000]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Sensory Organization Test (SOT) [Ford-Smith et al. Arch Phys Med Rehabil. 1995]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Head-Shake Sensory Organization Test (HS-SOT) [Pang et al. Phys Ther. 2011]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Short Physical Performance Battery (SPPB) [Guralnik et al. J Gerontol. 1994]</td><td align="left" rowspan="1" colspan="1">Excluded in round three (insufficient consensus)</td></tr><tr><td align="left" rowspan="1" colspan="1">Side-Step Test [Fujisawa et al. Clin Rehabil. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Single Leg Hop Stabilization Test [Riemann et al. J Sport Rehabil. 1999]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Single leg Stance Test [Bohannon. Topics Geri Rehabil. 2006]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9</td></tr><tr><td align="left" rowspan="1" colspan="1">Spring Scale Test (SST) [DePasquale and Toscano. J Geri Phys Ther. 2009]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Standing Test for Imbalance and Disequilibrium (SIDE) [Teranishi et al. Jap J Comp Rehabil Sci. 2010]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Star Excursion Balance Test (SEBT) [Hertel et al. J Sport Rehabil. 2000]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Step Test (ST) [Hill et al. Physiotherapy Canada. 1996]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Tandem Stance [Hile et al. Phys Ther 2012]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Timed Up-and-Go Test (TUG) [Podsiadlo et al. J Am Geriatr Soc. 1991]</td><td align="left" rowspan="1" colspan="1">Excluded in round three (forwarded directly from round one)</td></tr><tr><td align="left" rowspan="1" colspan="1">Expanded Timed Up-and-Go Test (ETUG) [Botolfsen et al. Phys Res Int. 2008]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">TURN180 [Simpson et al. Physiotherapy. 2002]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (not discussed, mean psychometric score < 2.9)</td></tr><tr><td align="left" rowspan="1" colspan="1">Unified Balance Scale [La Porta et al. J Rehabil Med. 2011]</td><td align="left" rowspan="1" colspan="1">Excluded in round three (insufficient consensus)</td></tr><tr><td align="left" rowspan="1" colspan="1">Timed Up-and-Go Assessment of Biomechanical Strategies (TUG-ABS) [Faria et al. J Rehabil Med. 2013</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">Posture and Posture Ability Scale (PPAS) [Rodby-Bousquet et al. Clin Rehab. 2012]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr><tr><td align="left" rowspan="1" colspan="1">High Level Mobility Assessment Tool (HiMAT) [Williams et al. Brain Inj. 2005]</td><td align="left" rowspan="1" colspan="1">Excluded in round two (insufficient consensus on overall suitability)</td></tr><tr><td align="left" rowspan="1" colspan="1">Cross Step Moving on Four Spots Test (CSFT) [Yamaji & Demura Arch Phys Med Rehabil 2013]</td><td align="left" rowspan="1" colspan="1">Excluded in round one (consensus on low psychometric score)</td></tr></tbody></table></alternatives></table-wrap><p>At the meeting, initial discussions focused on the parameters of the COS and feasibility of making one recommendation applicable to research and practice in all adult populations. The advantages and disadvantages of both broad and narrow-scoped recommendations were debated, and the decision was made to maintain the objective to recommend a COS for measuring standing balance in research and practice in adult populations. Subsequent discussions addressed the constructs necessary for a COS for standing balance. There was general agreement regarding the application of the OMERACT framework principles within the consideration of “overall suitability”, and the need to consider the many components that comprise the balance “system” [<xref rid="pone.0120568.ref001" ref-type="bibr">1</xref>].</p><p>Once these parameters were defined, the group considered the 39 measures held for discussion in round two. While these measures did not meet either of the <italic>a priori</italic> criteria for exclusion or forwarding, in order to expedite the consensus process the expert panel agreed to exclude 21 measures with either a mean psychometric properties score < 2.9 or validated in only one adult population. As a result of this discussion, 21 measures were excluded and 18 were individually discussed and scored (<xref rid="pone.0120568.s002" ref-type="supplementary-material">S2 File</xref>). Following the round two vote, only one measure (Mini Balance Evaluation Systems Test [Mini BESTest] [<xref rid="pone.0120568.ref029" ref-type="bibr">29</xref>]) reached the 70% threshold for forwarding to round three. However, to promote discussion the group agreed to forward two additional measures that achieved sufficient scores by at least 50% of panel members (the Short Physical Performance Battery [<xref rid="pone.0120568.ref030" ref-type="bibr">30</xref>] and Unified Balance Scale [<xref rid="pone.0120568.ref031" ref-type="bibr">31</xref>]). As such, three measures were forwarded to round three and fifteen measures were excluded.</p><p>Five measures were discussed in round three: two that were forwarded directly from round one, and three that were forwarded from round two. The five measures considered in round three were: BBS, Mini BESTest, Short Physical Performance Battery, TUG Test, and Unified Balance Scale. Two panel members were developers of two of the measures under consideration, and abstained from the discussion and vote. As such, twelve panel members participated and voted in round three. In the round three discussion, comments centered on whether a single measure could achieve all the objectives of the standing balance COS in research and practice in adult populations. Comments suggested that the group thought that while a single measure would be ideal from a minimum dataset perspective, one measure could not address the full spectrum of abilities among the adult population, and that a small number of measures—less than three—would be a permissible compromise. Of the five measures considered in round three, two achieved consensus on being included in COS recommendations for measuring standing balance in research and practice in adult populations: Berg Balance Scale [<xref rid="pone.0120568.ref027" ref-type="bibr">27</xref>] and Mini Balance Evaluation Systems Test [<xref rid="pone.0120568.ref029" ref-type="bibr">29</xref>] (<xref rid="pone.0120568.s003" ref-type="supplementary-material">S3 File</xref>).</p></sec></sec><sec sec-type="conclusions" id="sec020"><title>Discussion</title><p>The need for increased consistency and psychometric rigor in the evaluation of standing balance in adult populations in order to advance understanding and implementation of optimal interventions to improve mobility and decrease falls is well-recognized. The expert panel convened in the current project recommends that at a minimum, either the Berg Balance Scale or the Mini Balance Evaluation Systems Test should be used when measuring standing balance for research and practice in adult populations.</p><p>Both the face-to-face panel meeting and anonymous scoring were integral to the development of the recommendations. The interactive discussions allowed for debate and reflection, while anonymous voting allowed individual panel members to make a full and equal contribution to the recommendations even if they did not share the opinion of the majority. This novel project represents the first attempt to make COS recommendations for the field of balance research and practice, and as such should be both viewed as a starting point and revisited in the future.</p><sec id="sec021"><title>Two recommended measures in the standing balance COS</title><p>Two measures gained consensus for recommendation by the panel. Characteristics of both measures are presented in <xref rid="pone.0120568.t004" ref-type="table">Table 4</xref>, and readers are encouraged to consult the Rehabilitation Measures Database for a more detailed description of the psychometric properties of each measure. Comparisons of the two measures have noted that they are highly correlated (correlation coefficients ranging from 0.79–0.94 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>–<xref rid="pone.0120568.ref036" ref-type="bibr">36</xref>], and in one study directly comparing the psychometric properties of the Mini BESTest and BBS, both measures performed similarly on the majority of characteristics [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>].</p><table-wrap id="pone.0120568.t004" orientation="portrait" position="float"><object-id pub-id-type="doi">10.1371/journal.pone.0120568.t004</object-id><label>Table 4</label><caption><title>Characteristics of measures included in standing balance COS.</title></caption><alternatives><graphic id="pone.0120568.t004g" xlink:href="pone.0120568.t004"></graphic><table frame="hsides" rules="groups"><colgroup span="1"><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col><col align="left" valign="middle" span="1"></col></colgroup><thead><tr><th align="left" rowspan="1" colspan="1"></th><th align="left" rowspan="1" colspan="1">Berg Balance Scale</th><th align="left" rowspan="1" colspan="1">Mini Balance Evaluation Systems Test</th></tr></thead><tbody><tr><td align="left" rowspan="1" colspan="1">Year of publication</td><td align="left" rowspan="1" colspan="1">1989</td><td align="left" rowspan="1" colspan="1">2010</td></tr><tr><td align="left" rowspan="1" colspan="1">Number of items</td><td align="left" rowspan="1" colspan="1">14</td><td align="left" rowspan="1" colspan="1">14</td></tr><tr><td align="left" rowspan="1" colspan="1">Number of categories</td><td align="left" rowspan="1" colspan="1">5</td><td align="left" rowspan="1" colspan="1">3</td></tr><tr><td align="left" rowspan="1" colspan="1">Equipment required</td><td align="left" rowspan="1" colspan="1">Stop watch, chair with arm rests, measuring tape or ruler, object to pick up off the floor (e.g. pencil), step stool</td><td align="left" rowspan="1" colspan="1">60 cm x 60 cm block of 4" medium density Tempur foam, incline ramp of 10 degree slope, chair without arm rests or wheels, firm chair with arms, 23 cm high box, stop watch, masking tape marked on floor at 3 m from front of chair</td></tr><tr><td align="left" rowspan="1" colspan="1">Time to administer</td><td align="left" rowspan="1" colspan="1">15–20 minutes</td><td align="left" rowspan="1" colspan="1">10–15 minutes</td></tr><tr><td align="left" rowspan="1" colspan="1">Populations used with</td><td align="left" rowspan="1" colspan="1">Older adults [<xref rid="pone.0120568.ref037" ref-type="bibr">37</xref>, <xref rid="pone.0120568.ref038" ref-type="bibr">38</xref>], multiple sclerosis [<xref rid="pone.0120568.ref039" ref-type="bibr">39</xref>], osteoarthritis [<xref rid="pone.0120568.ref040" ref-type="bibr">40</xref>], Parkinson’s Disease [<xref rid="pone.0120568.ref041" ref-type="bibr">41</xref>, <xref rid="pone.0120568.ref042" ref-type="bibr">42</xref>], spinal cord injury [<xref rid="pone.0120568.ref043" ref-type="bibr">43</xref>, <xref rid="pone.0120568.ref044" ref-type="bibr">44</xref>], stroke [<xref rid="pone.0120568.ref045" ref-type="bibr">45</xref>–<xref rid="pone.0120568.ref048" ref-type="bibr">48</xref>], brain injury [<xref rid="pone.0120568.ref049" ref-type="bibr">49</xref>], vestibular dysfunction [<xref rid="pone.0120568.ref050" ref-type="bibr">50</xref>]</td><td align="left" rowspan="1" colspan="1">People with neurological impairments [<xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0120568.ref051" ref-type="bibr">51</xref>], people with age-related balance disorders [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>], community-dwelling older adults [<xref rid="pone.0120568.ref052" ref-type="bibr">52</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Psychometric properties evaluated</td><td align="left" rowspan="1" colspan="1">Minimal detectable change, minimal clinically important difference, test-retest reliability, inter-rater reliability, intra-rater reliability, internal consistency, criterion validity, construct validity, responsiveness</td><td align="left" rowspan="1" colspan="1">Minimal detectable change, minimal clinically important difference, test-retest reliability, inter-rater reliability, intra-rater reliability, internal consistency, criterion validity, construct validity, responsiveness</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported Standard Error of Measurement (SEM) range</td><td align="left" rowspan="1" colspan="1">SEM = 1.2–2.9 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref037" ref-type="bibr">37</xref>, <xref rid="pone.0120568.ref039" ref-type="bibr">39</xref>, <xref rid="pone.0120568.ref045" ref-type="bibr">45</xref>, <xref rid="pone.0120568.ref053" ref-type="bibr">53</xref>, <xref rid="pone.0120568.ref054" ref-type="bibr">54</xref>]</td><td align="left" rowspan="1" colspan="1">SEM = 1.3 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported minimal detectable change (MDC) range</td><td align="left" rowspan="1" colspan="1">MDC = 3.3–8.1 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref037" ref-type="bibr">37</xref>, <xref rid="pone.0120568.ref039" ref-type="bibr">39</xref>, <xref rid="pone.0120568.ref045" ref-type="bibr">45</xref>, <xref rid="pone.0120568.ref053" ref-type="bibr">53</xref>–<xref rid="pone.0120568.ref056" ref-type="bibr">56</xref>]</td><td align="left" rowspan="1" colspan="1">MDC = 3–3.5 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported minimal clinically important difference (MCID) range</td><td align="left" rowspan="1" colspan="1">n/a</td><td align="left" rowspan="1" colspan="1">MCID = 4 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported test-retest reliability range</td><td align="left" rowspan="1" colspan="1">ICC = 0.72–0.99 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref039" ref-type="bibr">39</xref>, <xref rid="pone.0120568.ref049" ref-type="bibr">49</xref>, <xref rid="pone.0120568.ref053" ref-type="bibr">53</xref>, <xref rid="pone.0120568.ref054" ref-type="bibr">54</xref>, <xref rid="pone.0120568.ref056" ref-type="bibr">56</xref>–<xref rid="pone.0120568.ref061" ref-type="bibr">61</xref>]</td><td align="left" rowspan="1" colspan="1">ICC = 0.80–0.96 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0120568.ref051" ref-type="bibr">51</xref>, <xref rid="pone.0120568.ref060" ref-type="bibr">60</xref>, <xref rid="pone.0120568.ref062" ref-type="bibr">62</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported inter-rater reliability range</td><td align="left" rowspan="1" colspan="1">ICC = 0.84–0.98 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref044" ref-type="bibr">44</xref>, <xref rid="pone.0120568.ref047" ref-type="bibr">47</xref>, <xref rid="pone.0120568.ref048" ref-type="bibr">48</xref>, <xref rid="pone.0120568.ref055" ref-type="bibr">55</xref>, <xref rid="pone.0120568.ref057" ref-type="bibr">57</xref>–<xref rid="pone.0120568.ref061" ref-type="bibr">61</xref>, <xref rid="pone.0120568.ref063" ref-type="bibr">63</xref>]</td><td align="left" rowspan="1" colspan="1">ICC = 0.72–0.98 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0120568.ref051" ref-type="bibr">51</xref>, <xref rid="pone.0120568.ref060" ref-type="bibr">60</xref>, <xref rid="pone.0120568.ref062" ref-type="bibr">62</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported internal consistency range</td><td align="left" rowspan="1" colspan="1">Chronbach’s alpha = 0.92–0.98 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref044" ref-type="bibr">44</xref>, <xref rid="pone.0120568.ref047" ref-type="bibr">47</xref>, <xref rid="pone.0120568.ref048" ref-type="bibr">48</xref>, <xref rid="pone.0120568.ref056" ref-type="bibr">56</xref>, <xref rid="pone.0120568.ref063" ref-type="bibr">63</xref>–<xref rid="pone.0120568.ref065" ref-type="bibr">65</xref>]</td><td align="left" rowspan="1" colspan="1">Chronbach’s alpha = 0.89–0.93 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported criterion validity ranges</td><td align="left" rowspan="1" colspan="1">r = 0.90–0.95 with Fugl Meyer Assessment and Postural Assessment for Stroke Scale [<xref rid="pone.0120568.ref047" ref-type="bibr">47</xref>], r = 0.67–0.85 with other balance tests [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>, <xref rid="pone.0120568.ref038" ref-type="bibr">38</xref>, <xref rid="pone.0120568.ref060" ref-type="bibr">60</xref>]</td><td align="left" rowspan="1" colspan="1">r = 0.79–0.94 with Berg Balance Scale [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>–<xref rid="pone.0120568.ref036" ref-type="bibr">36</xref>], r = 0.55–0.83 with other balance tests [<xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0120568.ref034" ref-type="bibr">34</xref>, <xref rid="pone.0120568.ref066" ref-type="bibr">66</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported construct validity ranges</td><td align="left" rowspan="1" colspan="1">Convergent with the Barthel index r = 0.87–0.94 [<xref rid="pone.0120568.ref047" ref-type="bibr">47</xref>, <xref rid="pone.0120568.ref067" ref-type="bibr">67</xref>]</td><td align="left" rowspan="1" colspan="1">Discriminates between stroke vs. healthy [<xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>], faller vs. non-faller [<xref rid="pone.0120568.ref033" ref-type="bibr">33</xref>, <xref rid="pone.0120568.ref051" ref-type="bibr">51</xref>], balance deficits vs. not [<xref rid="pone.0120568.ref035" ref-type="bibr">35</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Reported responsiveness ranges</td><td align="left" rowspan="1" colspan="1">Effect size = 0.26–1.11 [<xref rid="pone.0120568.ref047" ref-type="bibr">47</xref>, <xref rid="pone.0120568.ref065" ref-type="bibr">65</xref>, <xref rid="pone.0120568.ref068" ref-type="bibr">68</xref>], area under ROC curve = 0.91 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>]</td><td align="left" rowspan="1" colspan="1">Area under ROC curve = 0.92 [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>]</td></tr><tr><td align="left" rowspan="1" colspan="1">Component of balance evaluated (23)</td><td align="left" rowspan="1" colspan="1">Underlying motor systems, static stability, dynamic stability, functional stability limits, anticipatory postural control, sensory integration</td><td align="left" rowspan="1" colspan="1">Underlying motor systems, static stability, dynamic stability, anticipatory postural control, sensory integration, reactive postural control, cognitive influences on balance, verticality</td></tr></tbody></table></alternatives><table-wrap-foot><fn id="t004fn001"><p>ICC = Intra-class correlation; ROC = Receiver Operating Characteristic.</p></fn></table-wrap-foot></table-wrap><p>The BBS was recommended because it is both well-validated in a number of adult populations and widely used in both research and practice settings. It was published in 1989, with the objective to develop a valid measure of balance that was appropriate for geriatric patients (aged 60 years and older) and for use in a clinical setting [<xref rid="pone.0120568.ref027" ref-type="bibr">27</xref>]. It has been widely evaluated subsequent to its initial development, and tested in a number of populations. It is commonly used in physiotherapy practice [<xref rid="pone.0120568.ref013" ref-type="bibr">13</xref>] and has been translated into several languages. These factors contribute to the suitability of the BBS for standing balance COS recommendations and potential for broad implementation.</p><p>A limitation of the BBS is that ceiling effects have been well-documented in higher functioning individuals [<xref rid="pone.0120568.ref043" ref-type="bibr">43</xref>, <xref rid="pone.0120568.ref056" ref-type="bibr">56</xref>, <xref rid="pone.0120568.ref065" ref-type="bibr">65</xref>, <xref rid="pone.0120568.ref069" ref-type="bibr">69</xref>], restricting its suitability for all adult populations. Moreover, while it includes some components of balance, including underlying motor systems, static and dynamic stability, functional stability limits, anticipatory postural control and sensory integration, it does not evaluate verticality, reactive postural control, or cognitive influences on balance [<xref rid="pone.0120568.ref023" ref-type="bibr">23</xref>], which are all important for avoiding falls.</p><p>The second recommended measure in the standing balance COS, the Mini BESTest, addresses some of the limitations in the BBS. The Mini BESTest was published in 2010. It was developed as a shorter version of a more comprehensive test [<xref rid="pone.0120568.ref070" ref-type="bibr">70</xref>], using factor and Rasch analyses [<xref rid="pone.0120568.ref029" ref-type="bibr">29</xref>]. Documented ceiling effects were less than the BBS in a sample of inpatients (mean age 66 years) with balance disorders [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>], however one study noted a minor ceiling effect in very high functioning neurological patients [<xref rid="pone.0120568.ref029" ref-type="bibr">29</xref>]. It evaluates most components of postural control: underlying motor systems; verticality; static and dynamic stability; anticipatory and reactive postural control; integration of sensory information; and cognitive influences on balance; but not functional stability limits [<xref rid="pone.0120568.ref023" ref-type="bibr">23</xref>].</p><p>However, as with the BBS, there are also limitations to the Mini BESTest in the context of standing balance COS recommendations. It has been evaluated considerably less than the BBS, likely related to its more recent emergence in the literature. Responsiveness has been demonstrated in prospective descriptive studies [<xref rid="pone.0120568.ref032" ref-type="bibr">32</xref>], but the Mini BESTest has yet to be published in a clinical trial. Moreover, there is no published evidence of its uptake in clinical or community practice. Panel members acknowledged that the Mini BESTest requires more population testing, and its applicability across care settings and functional abilities needs to be demonstrated.</p><p>These two measures received the votes required for recommendation because they collectively best represent the objectives of the standing balance COS. They have unique features that make them suitable for COS recommendations and it is recommended that users choose at least one of these measures based on their particular needs. In considering which of the two measures to use in research or practice, readers may wish to consider a number of factors highlighted by the panel. The BBS may be considered more suitable for lower functioning adults, while preliminary data suggests the Mini BESTest may cover the continuum of balance abilities. If ability to perform the test is not an issue, the Mini BESTest evaluates more components of postural control than the BBS, and may be considered a more comprehensive measure.</p></sec><sec id="sec022"><title>Measures not included in the balance COS recommendations for adult populations</title><p>The very definition of a core outcome set restricts the number of measures that can be recommended. Many well-developed balance measures were excluded from the current COS recommendations because they were too narrow in scope of target population or feasibility on a broad scale. Readers are cautioned not to infer that the current recommendations constitute best practice recommendations for balance assessment, but instead are recommended as a minimum standard for standing balance measurement. In fact, adoption of the COS measurement should not be construed as a comprehensive assessment of balance, and the panel recommends that additional population-specific measures be used, particularly when designing balance training programs.</p><p>Of the 56 measures considered for the balance COS, five reached the final round of discussion. While only two of these measures were included in the final recommendations, the three excluded measures each warrant a specific comment. The TUG test received high scores in round one and was forwarded directly to round three. In those discussions; the panel recognized its psychometric properties, feasibility and widespread clinical utility, but questioned in regards to variability in methods of application and as to whether it genuinely reflected the construct of ‘balance’. Moreover, the TUG test is also included in the Mini BESTest which was recommended in the balance COS. The Unified Balance Scale and Short Physical Performance Battery were both included in the round three discussions as a result of slightly relaxed criteria modified during the meeting, but neither achieved consensus on recommendation for the final COS. As such, the relaxed criteria did not unduly influence the outcome of the recommendations. The Unified Balance Scale, a recent scale combining items from the Balance Evaluation Systems Test [<xref rid="pone.0120568.ref070" ref-type="bibr">70</xref>], Fullerton Advanced Balance Scale [<xref rid="pone.0120568.ref071" ref-type="bibr">71</xref>], and Performance Oriented Mobility Assessment [<xref rid="pone.0120568.ref072" ref-type="bibr">72</xref>] also received high scores from the panel in rounds one and two, and discussions noted its comprehensive nature and appropriateness for a wide range of physical abilities [bed to community]. Its potential for future COS recommendation was noted, but the panel recognized it is not currently appropriate due to insufficient psychometric evaluation and high number of test items [<xref rid="pone.0120568.ref027" ref-type="bibr">27</xref>]. Finally, the Short Physical Performance Battery was discussed in round three and its psychometric properties and utility for large clinical trials was recognized. Although it did not reach consensus for inclusion in the standing balance COS recommendations, its use as a quick measure of lower extremity function that includes a standing balance item and appropriateness for large cohort and intervention studies where balance and mobility were not primary outcome measures was recognized.</p></sec><sec id="sec023"><title>Limitations</title><p>The current standing balance COS recommendations are not without limitations, and should be interpreted in this context. First, it is acknowledged that the consensus process is not a completely objective exercise. The panel members, while invited with the goal of being representative, may not share the opinions of all potential users of the standing balance COS recommendations. While attempting to account for practice-related issues, the panel’s expertise was skewed towards research-related issues. Although attempts were made to control for conflicts of interest (such as developers of measures in contention in round three not participating in the final vote), there is no guarantee that they were eliminated. Second, the broad aims of the current standing balance COS objectives are both a strength and a weakness. There may still be some questions about applicability in some populations and/ or settings. Future iterations of balance COS recommendations may elect to narrow the scope of populations and settings included in the review, but would risk losing the ability to make meaningful comparisons across groups. Third, no single measure met all the intended objectives for the COS recommendations. As such, variation in reporting is still going to be an issue and may impact the ability to synthesize balance intervention data. The panel acknowledged this limitation, but felt the tradeoff of recommending a single balance measure was impractical and would limit successful uptake. Another consequence of the decision to recommend two measures in the standing balance COS is that the decision on what measure to use becomes more complicated and requires some discretion. Fifth, there will be a number of challenges for implementation of the recommendations. It is acknowledged that both measures require both a significant investment of time, as well as some training and equipment, which have implications for implementation. If users are not currently using one of the recommended measures, adoption of the COS recommendations will require changing their behavior, which also has implications for implementation. In particular, the Mini BESTest is less widely known, which may skew uptake towards the more familiar BBS.</p></sec></sec><sec sec-type="conclusions" id="sec024"><title>Conclusions</title><p>The lack of a gold standard measure and subsequent disparate quantity and nature of existing approaches for the measurement of standing balance are an important factor limiting the ability to advance the optimization of exercise interventions for fall prevention and mobility enhancement, and may be related to clinicians’ frustrations with outcome measures [<xref rid="pone.0120568.ref073" ref-type="bibr">73</xref>] and challenges prescribing exercise programs [<xref rid="pone.0120568.ref074" ref-type="bibr">74</xref>]. These COS recommendations for evaluating standing balance reflect an attempt to find ‘common ground’ that can meet the needs of a broad range of users. Our recommended COS for standing balance will directly and substantially inform clinical research and practice internationally. However, continued efforts to promote uptake and implementation of the COS will be required to maximize its utility.</p></sec><sec sec-type="supplementary-material" id="sec025"><title>Supporting Information</title><supplementary-material content-type="local-data" id="pone.0120568.s001"><label>S1 File</label><caption><title>Round One Results.</title><p>This file contains the round one ranking results by measure, organized by decision. It contains basic information about each measure, the scoring distribution for the psychometric and feasibility categories, and comments noted by the panel.</p><p>(PDF)</p></caption><media xlink:href="pone.0120568.s001.pdf"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="pone.0120568.s002"><label>S2 File</label><caption><title>Round Two Results.</title><p>This file contains the results of the second round of voting, including the criterion calculations for moving to round three.</p><p>(PDF)</p></caption><media xlink:href="pone.0120568.s002.pdf"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material><supplementary-material content-type="local-data" id="pone.0120568.s003"><label>S3 File</label><caption><title>Round Three Results.</title><p>This file contains the number of votes received for each measure and the decision.</p><p>(PDF)</p></caption><media xlink:href="pone.0120568.s003.pdf"><caption><p>Click here for additional data file.</p></caption></media></supplementary-material></sec></body><back><ack><p>We gratefully acknowledge the helpful contributions of all the expert panel members who participated in the development of the standing balance core outcome set. 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