Mini-BESTest

Mini Balance Evaluation Systems Test

Authors
Affiliations

Doctor of Physical Therapy

B.S. in Kinesiology

Doctor of Physical Therapy

B.A. in Neuroscience

Keywords

Mini BEST Test, MiniBESt, Mini Balance Evaluation Systems Test

The Mini Balance Evaluation Systems Test also known as the Mini-BESTest consists of 14 items that evaluate different aspects of balance:

Each item is scored from 0 (worst) to 2 (best/normal) for a maximum of 28 total points.

The Mini-BEStest is most notably used in pathological populations, such as: Stroke, Parkinson’s disease, Multiple sclerosis (MS), Peripheral neuropathy secondary to Type 2 diabetes

Psychometrics

MCID 4 points- Early subacute stroke (Tamura et al, 2024) 4 points - Parkinson’s (Godi, 2020)

Population MCID
Early subacute stroke 4pts1
Parkinson’s disease 4pts2

Parkinson’s Disease

King et al3 attempted to find a cut-off points of the Mini-BESTest to differentiate patients with and without postural response deficits3. When using a a cutoff of >21/28 pts, postural response deficits could be differentiated with a sensitivity of 0.89 and a specificity of 0.813.

In patients with mild PD, the results of the Mini-BESTest are highly correlated with the Berg Balance Scale (BBS) (r = 0.79, P < 0.001), while experiencing less significant ceililng effects that the BBS suffers from3.

Mini-BESTest is more effective than the Berg for predicting the motor score on the Unified Parkinson’s Disease Rating Scale (UPDRS) and for discriminating between those with and without postural response deficits as measured by the Hoehn and Yahr (H&Y) scale3.

Indications

Clinicians are saturated with potential measures of balance, so how does the Mini-BESTest fit into one’s toolkit?

In studies on patients with Parkinson’s disease3, multiple sclerosis4 and spinal cord injuries5, the Mini-BESTest had a less significant ceiling effect and higher sensitivity in detecting balance improvements compared to other balance scales like the Berg Balance Scale. This means that it is more difficult to reach the max score (ceiling) on the Mini-BESTest compared to the BBS4,5.

Thus, this test excels at finding balance impairments for higher functioning populations than the Berg Balance Scale.

Setup

Subject Conditions

Subject should be tested with flat-heeled shoes OR shoes and socks off.

Equipment

  1. Temper® foam (also called T-foamTM 4 inches thick, medium density T41 firmness rating)
  2. chair without arm rests or wheels
  3. Incline ramp
  4. Stopwatch
  5. A box (9” height)
  6. 3 meter distance measured out and marked on the floor with tape [from chair]

Scoring

The test consists of 14 items which can be scored from 0-2 points. Therefore the test has a minimum score of 0/28 and a maximum score of 28/28.

For each item, “0” indicates the lowest level of function and “2” the highest level of function.

  • Assistive devices: If a subject must use an assistive device for an item, score that item one category lower.
  • Physical assistance: If a subject requires physical assistance to perform an item, score “0” for that item.

Form

Anticipatory

Anticipatory subsection consists of 3 items with a maximum score of 6 points.

  1. Sit-to-stand
  2. Rise to toes
  3. Single leg static balance

1 Sit-to-stand

Instruction: “Cross your arms across your chest. Try not to use your hands unless you must. Do not let your legs lean against the back of the chair when you stand. Please stand up now.”

Note

“Note the initiation of the movement, and the use of the subject’s hands on the seat of the chair, the thighs, or the thrusting of the arms forward.”

Score Level Criteria
2 Normal Comes to stand without use of hands and stabilizes independently
1 Moderate Comes to stand WITH use of hands on first attempt
0 Severe Unable to stand up from chair without assistance, OR needs several attempts with use of hands

Item 1 Score: Not tested

2 Rise to toes

Instruction: “Place your feet shoulder width apart. Place your hands on your hips. Try to rise as high as you can onto your toes. I will count out loud to 3 seconds. Try to hold this pose for at least 3 seconds. Look straight ahead. Rise now.”

Note

“Allow the subject two attempts. Score the best attempt. (If you suspect that subject is using less than full height, ask the subject to rise up while holding the examiners’ hands.) Make sure the subject looks at a non-moving target 4-12 feet away”

Score Level Criteria
2 Normal Stable for 3s with maximum height
1 Moderate Heels up, but not full range (smaller than when holding hands), OR noticeable instability for 3s
0 Severe <3s

Item 2 Score: Not tested

3 Single leg static balance

Instruction: “Look straight ahead. Keep your hands on your hips. Lift your leg off of the ground behind you without touching or resting your raised leg upon your other standing leg. Stay standing on one leg as long as you can. Look straight ahead. Lift now.”

To score each side separately use the trial with the longest time. To calculate the sub-score and total score use the side [left or right] with the lowest numerical score [i.e. the worse side].

Score Level Criteria
2 Normal 20s
1 Moderate < 20s
0 Severe Unable
LLE RLE
Trial 1 — s — s
Trial 2 — s — s
Final Time — s — s
Final Score

Item 3 Score: 0

Note

Include the best score from the worst side.

“Allow the subject two attempts and record the times. Record the number of seconds the subject can hold up to a maximum of 20 seconds. Stop timing when the subject moves hands off of hips or puts a foot down. Make sure the subject looks at a non-moving target 4-12 feet ahead. Repeat on other side.”

Example
You have a patient who scores the following:

    | Trial | Right | Left |
    |-|-|-|
    | Trial 1 | 17s | 19s |
    | Trial 2 | 20s| 15s |

    When scoring **both** legs, you would report the best score from the two trials:

    | Right | Left |
    |-|-|
    | 20s (2/2 pt) | 19s (1/2 pt) |

    When calculating the subscore or the overall score, you cannot include both legs, since each item can only be worth 2 points.
    Thus, you must choose the leg with the *worse* score, in this case, it would be the left leg.
    You would report this items score as follows:

    | Item | Time | Score | Level |
    |-|-|-|-|
    | Item 3 | 19s | 1/2 pt | Moderate |

Reactive postural control

Reactive postural control subsection consists of 3 items with a maximum score of 6 points.

4 Compensatory stepping correction - Forward

Instruction: “Stand with your feet shoulder width apart, arms at your sides. Lean forward against my hands beyond your forward limits. When I let go, do whatever is necessary, including taking a step, to avoid a fall.”

Score Level Criteria
2 Normal Recovers independently with a single, large step (second realignment step is allowed)
1 Moderate More than one step used to recover equilibrium
0 Severe No step, OR would fall if not caught, OR falls spontaneously

Current Score4: 0

“Stand in front of the subject with one hand on each shoulder and ask the subject to lean forward (Make sure there is room for them to step forward). Require the subject to lean until the subject’s shoulders and hips are in front of toes. After you feel the subject’s body weight in your hands, very suddenly release your support. The test must elicit a step. NOTE: Be prepared to catch subject.”

5 Compensatory stepping correction - Backward

Instruction: “Stand with your feet shoulder width apart, arms at your sides. Lean backward against my hands beyond your backward limits. When I let go, do whatever is necessary, including taking a step, to avoid a fall.”

Caution

Be prepared to catch subject!

Score Level Criteria
2 Normal Recovers independently with a single, large step
1 Moderate More than one step used to recover equilibrium
0 Severe No step, OR would fall if not caught, OR falls spontaneously

Item 5 score: 0

“Stand behind the subject with one hand on each scapula and ask the subject to lean backward (Make sure there is room for the subject to step backward.) Require the subject to lean until their shoulders and hips are in back of their heels. After you feel the subject’s body weight in your hands, very suddenly release your support. Test must elicit a step”

6 Compensatory stepping correction - Lateral

Instruction: “Stand with your feet together, arms down at your sides. Lean into my hand beyond your sideways limit. When I let go, do whatever is necessary, including taking a step, to avoid a fall.”

Caution

Be prepared to catch subject!

Score Level Criteria
2 Normal Recovers independently with a single, large step
1 Moderate More than one step used to recover equilibrium
0 Severe No step, OR would fall if not caught, OR falls spontaneously

Item 6 Score: 0

Note

Only include the score for the worst side.

Stand to the side of the subject, place one hand on the side of the subject’s pelvis, and have the subject lean their whole body into your hands. Require the subject to lean until the midline of the pelvis is over the right (or left) foot and then suddenly release your hold

Sensory orientation

Sensory orientation is a subsection with a subscore of 6 points.

7 Feet together, Eyes open, static balance

Instruction: “Place your hands on your hips. Place your feet together until almost touching. Look straight ahead. Be as stable and still as possible, until I say stop.”

“Record the time the subject was able to stand with feet together up to a maximum of 30 seconds. Make sure subject looks at a non-moving target 4-12 feet away.”

Score Level Criteria
2 Normal ≥30s
1 Moderate <30s
0 Severe Unable

— s

Item 7 Score: 0

8 Feet together, Eyes closed, static balance

Instruction: “Step onto the foam. Place your hands on your hips. Place your feet together until almost touching. Be as stable and still as possible, until I say stop. I will start timing when you close your eyes.”

“Use medium density Temper® foam, 4 inches thick. Assist subject in stepping onto foam. Record the time the subject was able to stand in each condition to a maximum of 30 seconds. Have the subject step off of the foam between trials. Flip the foam over between each trial to ensure the foam has retained its shape.”

Score Level Criteria
2 Normal ≥30s
1 Moderate <30s
0 Severe Unable

— s

Item 8 Score: 0

9 Incline (DF) Eyes closed static balance

Instruction: “Step onto the incline ramp. Please stand on the incline ramp with your toes toward the top. Place your feet shoulder width apart and have your arms down at your sides. I will start timing when you close your eyes.”

Score Level Criteria
2 Normal ≥30s
1 Moderate <30s
0 Severe Unable

— s

Item 9 Score: 0

“Aid the subject onto the ramp. Once the subject closes eyes, begin timing and record time. Note if there is excessive sway.”

Dynamic gait

The dynamic gait subsection consists of 5 items and a maximum of 10 points.

10 Change in Gait Speed

Instruction: “Begin walking at your normal speed, when I tell you ‘fast’, walk as fast as you can. When I say ‘slow’, walk very slowly.”

“Allow the subject to take 3-5 steps at normal speed, and then say “fast”. After 3-5 fast steps, say “slow”. Allow 3-5 slow steps before the subject stops walking.”

Score Level Criteria
2 Normal Significantly changes walking speed without imbalance
1 Moderate Unable to change walking speed or signs of imbalance
0 Severe Unable to achieve significant change in walking speed AND signs of imbalance

Item 10 Score: 0

11 Walk + Horizontal Head Turns

Instruction: “Begin walking at your normal speed, when I say “right”, turn your head and look to the right. When I say “left” turn your head and look to the left. Try to keep yourself walking in a straight line.”

“Allow the subject to reach normal speed, and give the commands “right, left” every 3-5 steps. Score if you see a problem in either direction. If subject has severe cervical restrictions allow combined head and trunk movements.”

Score Level Criteria
2 Normal Performs head turns with no change in gait speed and good balance
1 Moderate Performs head turns with reduction in gait speed
0 Severe Performs head turns with imbalance

Item 11 Current: 0

12 Gait + Pivot turns

Instruction: “Begin walking at your normal speed. When I tell you to ‘turn and stop’, turn as quickly as you can, face the opposite direction, and stop. After the turn, your feet should be close together.”

“Demonstrate a pivot turn. Once the subject is walking at normal speed, say “turn and stop.” Count the number of steps from “turn” until the subject is stable. Imbalance may be indicated by wide stance, extra stepping or trunk motion. ”

Score Level Criteria
2 Normal Turns with feet close FAST (< 3 steps) with good balance
1 Moderate Turns with feet close SLOW (>4 steps) with good balance
0 Severe Cannot turn with feet close at any speed without imbalance

Item 12 Current: 0

13 Step over obstacles

Instruction: “Begin walking at your normal speed. When you get to the box, step over it, not around it and keep walking.”

“Place the box (9 inches or 23 cm height) 10 feet away from where the subject will begin walking. Two shoeboxes taped together works well to create this apparatus”

Score Level Criteria
2 Normal Able to step over box with minimal change of gait speed and with good balance
1 Moderate Steps over box but touches box OR displays cautious behavior by slowing gait
0 Severe Unable to step over box OR steps around box

Item 13 Score: 0

14 Timed Up & Go with Dual-task

  • 3 meter walk
  • Instruction TUG: “When I say ‘Go’, stand up from chair, walk at your normal speed across the tape on the floor, turn around, and come back to sit in the chair.” Instruction TUG with Dual Task: “Count backwards by threes starting at ___. When I say ‘Go’, stand up from chair, walk at your normal speed across the tape on the floor, turn around, and come back to sit in the chair. Continue counting backwards the entire time.”
Score Level Criteria
2 Normal No noticeable change in sitting, standing or walking while backward counting when compared to TUG without Dual Task
1 Moderate Dual Task affects either counting OR walking (>10%) when compared to the TUG without Dual Task
0 Severe Stops counting while walking OR stops walking while counting

Item 14 TUG Time: Not tested

Item 14 Cognitive TUG Time: Not tested

Item 14 Score: Not tested

Item 14 TUG + TUG Cog: Not tested (TUG: , Cog-TUG: , )

Note

If the patient’s gait speed decreases more than 10% when adding the Dual Task, the score should be ↓decreased by a point.

“Use the TUG time to determine the effects of dual tasking. The subject should walk a 3 meter distance. TUG: Have the subject sitting with the subject’s back against the chair. The subject will be timed from the moment you say “Go” until the subject returns to sitting. Stop timing when the subject’s buttocks hit the chair bottom and the subject’s back is against the chair. The chair should be firm without arms. TUG With Dual Task: While sitting determine how fast and accurately the subject can count backwards by threes starting from a number between 100-90. Then, ask the subject to count from a different number and after a few numbers say “Go”. Time the subject from the moment you say “Go” until the subject returns to the sitting position. Score dual task as affecting counting or walking if speed slows (>10%) from TUG and or new signs of imbalance.”

Final Results

Item 1 STS: Not tested
Item 2 Heel Raise: Not tested
Item 3 SLB: Not tested
Anticipatory Subtotal: 0

Item 4 Forward compensatory step: Not tested
Item 5 Backward compensatory step: Not tested
Item 6 Lateral compensatory step: Not tested
Reactive Postural Control Subtotal: 0

Item 7 Static balance (Feet together + EO): Not tested (NA)
Item 8 Static balance (Feet together + EC + FOAM): Not tested (NA)
Item 9 Incline + EC Balance: Not tested (NA)
Sensory Orientation Subtotal: 0

Item 10 Change in gait speed: Not tested
Item 11 Gait + Horizontal head turns: Not tested
Item 12 Gait + Pivot: Not tested
Item 13 Step over Obstacle: Not tested
Item 14 TUG + TUG Cog: Not tested (TUG: , Cog-TUG: , %Δ: )
Dynamic Gait Subtotal: 0

Total: 0

References

1.
Tamura S, Miyata K, Hasegawa S, Kobayashi S, Shioura K, Usuda S. Pooled Minimal Clinically Important Differences of the Mini-Balance Evaluation Systems Test in Patients With Early Subacute Stroke: A Multicenter Prospective Observational Study. Physical Therapy. 2024;104(4):pzae017. doi:10.1093/ptj/pzae017
2.
Godi M, Arcolin I, Giardini M, Corna S, Schieppati M. Responsiveness and minimal clinically important difference of the Mini-BESTest in patients with Parkinson’s disease. Gait & Posture. 2020;80:14-19. doi:10.1016/j.gaitpost.2020.05.004
3.
King LA, Priest KC, Salarian A, Pierce D, Horak FB. Comparing the Mini-BESTest with the Berg Balance Scale to Evaluate Balance Disorders in Parkinson’s Disease. Parkinson’s Disease. 2012;2012:1-7. doi:10.1155/2012/375419
4.
Ross E, Purtill H, Uszynski M, et al. Cohort Study Comparing the Berg Balance Scale and the Mini-BESTest in People Who Have Multiple Sclerosis and Are Ambulatory. Physical Therapy. 2016;96(9):1448-1455. doi:10.2522/ptj.20150416
5.
Jørgensen V, Opheim A, Halvarsson A, Franzén E, Roaldsen KS. Comparison of the Berg Balance Scale and the Mini-BESTest for Assessing Balance in Ambulatory People With Spinal Cord Injury: Validation Study. Physical Therapy. 2017;97(6):677-687. doi:10.1093/ptj/pzx030

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