Community Balance and Mobility Scale

Last Updated

February 19, 2013

Purpose

The CB&M detects ‘high level’ balance and mobility deficits based on tasks that are commonly encountered in community environments.

Link to Instrument

Instrument Details

Acronym CB&M

Area of Assessment

Balance – Vestibular

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Diagnosis/Conditions

Brain Injury Recovery
Cerebral Palsy
Stroke Recovery

Stroke

Older Adults and Geriatric Care

Cerebral Palsy

Brain Injury

A performance measure composed of 13 challenging tasks with six tasks performed on both sides.
Scaling is specific to the task being measured.
Scoring is done using the first trial for each item.
Maximum possible score of 96.
Item scores range from 0 to 5 and reflect progressive task difficulty.
A score of "0" = complete inability to perform the task.
A score of "5" = the most successful completion of the item possible.
All tasks are performed without ambulation aides, with the exception of item 12 (descending stairs) for which a cane can be used.
Patients are permitted to wear an orthotic.

Number of Items

An 8-m track is used in the evaluation of the various tasks performed
Stopwatch
Laundry basket
2lb and 7lb weights
Visual target (a paper circle 20cm in diameter with a 5cm diameter black circle in the middle)
Bean bag

20-30 minutes

Required Training

Reading an Article/Manual

Adolescent

13 - 17

years

Adult

18 - 64

years

Instrument Reviewers

Initially reviewed by the Rehabilitation Measures Team; Updated with references from the TBI population by Tammie Keller Johnson, PT, DPT, MS and the TBI EDGE task force of the Neurology Section of the APTA in 2012; Updated by Minu M. Nair, PT in 10/2012.

ICF Domain

Body Structure
Body Function

Measurement Domain

Motor

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

HR	Highly Recommend
R	Recommend
*LS / UR*	Reasonable to use, but limited study in target group / Unable to Recommend
NR	Not Recommended

Recommendations based on level of care in which the assessment is taken:

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

Recommendations for use based on ambulatory status after brain injury:

	Completely Independent	Mildly dependant	Moderately Dependant	Severely Dependant
TBI EDGE	R	R	NR	NR

Recommendations for entry-level physical therapy education and use in research:

	Students should learn to administer this tool? (Y/N)	Students should be exposed to tool? (Y/N)	Appropriate for use in intervention research studies? (Y/N)	Is additional research warranted for this tool (Y/N)
TBI EDGE	Yes	Yes	Yes	Not reported

Considerations

In patients with mild to moderate neurologic deficits secondary to stroke, the CB&M was superior to either the TUG or BBS five months after stroke onset
Designed for ambulatory individuals living in the community.
The CB&M is a valid outcome measure for detecting dynamic instability and for evaluating the ability of patients of TBI to successfully return to community living (Inness, 2011)
“Clinical feedback and preliminary evidence indicates that the scale is also appropriate for clients with diagnoses other than traumatic brain injury. The items of the CB&M encompass challenging balance and mobility tasks and, therefore, the CB&M may be more appropriate for patients in the rehabilitation and community setting rather than acute care.” (Toronto rehab CB&M pdf document)
Since the tool has not been specifically studied in community dwelling elderly population, the psychometric properties of the other studies can be considered which have included the age group of more than 60 years of age.
The studies which have taken the community dwelling elderly group into consideration are as follows:
- Knorr et al, 2010: For community dwelling elderly group with stroke, the available psychometric properties include convergent validity, sensitivity to change, and floor and ceiling effects as detailed above.
- Clegg et al, 2009 (healthy individuals aged 20-79 years: normative data): The age related reference values for community dwelling elderly show that the CB&MS score decline after the age of 50 indicating that balance is affected significantly in healthy elderly population.

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Standard Error of Measurement (SEM)

Traumatic Brain Injury (TBI): (Howe et al, 2006; phase 1: n=36; mean age(SD)= 31(9) years; mean time post-injury (SD)= 11(23) months; phase 2: n=32; mean age(SD)=34(12) years; mean time post-injury (SD)= 4(6) months) • SEM = 4.1 (calculated using Cronbach’s α value 0.96) • SEM = 3.2 (calculated using test-retest ICC 0.975)

Minimal Detectable Change (MDC)

Traumatic Brain Injury (TBI): (Howe et al, 2006)

MDC90 = 9.6 (calculated using SEM and Cronbach’s α value)
MDC90 = 7.5 (calculated using SEM and test-retest ICC values)

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

MDC90 = 13.5% points (established)
MDC95=14.6% points (established)

Normative Data

Traumatic Brain Injury: (Howe, 2006; n = 32; participants were able to ambulate with or without aid, participants drawn from 3 locations including acute care, inpatient, day hospital and outpatient; 5 days between assessments)

Care Setting Norms*:

Population	Mean	Standard Deviation
Acute care	30.39	11.7
Outpatients	41.69	18.0
Inpatient rehabilitation	53.59	21.2
Day hospital setting	62.49	17.1

*Statistically different across all settings (p < 0.03)

Test/Retest Reliability

Traumatic Brain Injury: (Howe, 2006)

Test-retest Reliability:

Item	Test-retest (5 days apart)	Test-retest (Immediate)
Unilateral stance left	0.81	0.76
Unilateral stance right	0.44	0.8
Tandem walking	0.59	0.85
1808 tandem pivot	0.53	0.9
Lateral foot scooting left	0.54	0.74
Lateral foot scooting right	0.58	0.92
Hopping forward left	0.68	0.85
Hopping forward right	0.6	0.87
Crouch and walk	0.45	0.92
Lateral dodging	0.61	0.61
Walking & looking left	0.3	0.86
Walking & looking right	0.35	0.87
Running with controlled stop	0.58	0.85
Forward to backward walking	0.64	0.77
Walk, look & carry left	0.69	N/A
Walk, look & carry right	0.77	N/A
Descending stairs	0.77	0.96
Step-ups X 1 step left	0.6	0.98
Step-ups X 1 step right	0.51	0.94

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

Excellent test re-test reliability (3–10-day re-test interval) (ICC=0.90)

Interrater/Intrarater Reliability

Traumatic Brain Injury: (Howe, 2006; n = 13 Physical Therapist raters, mean practice experience = 5.89 (4.4) years)

Intra-rater = 0.977 (CI = 0.957-0.986)
Inter-rater = 0.977 (CI = 0.972-0.988)

Inter and Intra-rater Reliability:

Item	Intra-rater	Inter-rater
Unilateral stance left	0.89	0.87
Unilateral stance right	0.92	0.98
Tandem walking	0.71	0.85
1808 tandem pivot	0.64	0.59
Lateral foot scooting left	0.84	0.78
Lateral foot scooting right	0.62	0.88
Hopping forward left	0.81	0.81
Hopping forward right	0.76	0.86
Crouch and walk	0.64	0.7
Lateral dodging	0.53	0.78
Walking & looking left	0.34	0.53
Walking & looking right	0.72	0.64
Running with controlled stop	0.78	0.67
Forward to backward walking	0.76	0.71
Walk, look & carry left	0.58	0.75
Walk, look & carry right	0.71	0.8
Descending stairs	0.85	0.78
Step-ups X 1 step left	0.71	0.84
Step-ups X 1 step right	0.82	0.85

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

Excellent interrater reliability (ICC=0.93)

Internal Consistency

Excellent internal consistency (Cronbach's alpha > 0.95)

Acquired Brain Injury in school-aged children and adolescents: (Wright et al, 2010)

Excellent internal consistency (Cronbach’s alpha=0.89) for the primary assessors’ baseline CB&M scores.

Construct Validity

Traumatic Brain Injury: (Howe, 2006)

Adequate: self-paced gait velocity (r = 0.53; p = 0.001)
Excellent: maximal gait velocity (r = 0. 64; p = 0.001)

Traumatic Brain Injury : (Inness, 2011 n= 35 patients with TBI; 13 in-patients, 22 outpatients)

Adequate : a moderate to good magnitude (r =0.54, p < 0.001) was demonstrated between the CB&M and the CIQ. This was obtained by combining current study data with a prior study for n=47
Excellent : a significant relationship between CB&M and ABC scores emerged (r = 0.60, p = 0.011)

Content Validity

TBI patients and clinicians experienced in neurorehabilitation were involved in item generation. A group of PT's then rated items for relevance (Howe, 2006).

Face Validity

Traumatic Brain Injury: (Howe, 2006; n = 32; participants were able to ambulate with or without aid, participants drawn from 3 locations including acute care, inpatient, day hospital and outpatient; 5 days between assessments)

Items for the CB&M scale were derived from a series of interviews and discussions with individuals with traumatic brain injury living in the community, students in physical therapy with experience in neurological rehabilitation and therapists. Items were added or eliminated based on expert opinion on relevance to key constructs of balance and mobility.

Criterion Validity (Predictive/Concurrent)

Acute Stroke: (Knorr et al, 2010)

Chedoke McMaster Stroke Assessment (CMSA) and Lower-Limb Strength Results across measures~:

Variables	CB&M (n = 44)	BBS (n = 44)	TUG (n = 42)
CMSA leg	0.63*	0.54*	-0.70*
CMSA foot	0.61*	0.50†	-0.69*
Paretic limb	0.67*	0.50*	-0.71*
Nonparetic limb	0.46†	0.28	-0.44†

~Spearman correlation coefficients
Adjusted level of significance = p < .01
* p < .001
† p < .01

Floor/Ceiling Effects

Acute Stroke: (Knorr et al, 2010; n = 44; time post stroke (baseline assessment) 98.6 (52.6) days; Mean FIM scores, Motor = 82.0 (range = 20 to 91) Cog = 33.0 (range = 23 to 35) points)

Scores on the CB&M covered the scale’s range; the maximum score was not achieved by any of the participants.

Floor and Ceiling Effects:

Baseline (n = 44)

Follow-Up (n = 44)

Scale	Floor Effect	Ceiling Effect	Floor Effect	Ceiling Effect
CB&M	4 (9.1)	0 (0.0)	3 (6.8)	0 (0.0)
BBS	0 (0.0)	15 (34.1)*	0 (0.0)	21 (47.7)*
TUG	2 (4.5)	10 (22.7)*	0 (0.0)	16 (36.4)*

*Significant effect (> 20%)

Responsiveness

Acute Stroke: (Knorr et al, 2010)

The Standardized Response Mean (SRM) suggests a large effect size for the CB&M and small effect sizes for the BBS and TUG.

Standardized Response Mean Across Measures:

Variable	Metric	Baseline*	Follow-Up*	p	SRM
CB&M	96 points	42.7 (22.6)	51.3 (24.6)	<.001	0.83
BBS	56 points	48.9 (12.4)	50.4 (11.0)	<.010	0.42
TUG	Seconds	16.7 (17.1)	13.7 (16.0)	<.010	0.34

*Mean (SD)
p = between the baseline and follow-up

Responsiveness

Cerebral Palsy: (Bien et al, 2011; n = 4; mean age = 16 (2.25) years; The study span 5 days and used a 90 minute virtual reality balance intervention)

True change from the mean CB&M score were achieved in 3 of 4 participants
In a follow-up, these improvements were maintained and true change was observed in all participants

Normative Data

Older Women With Low Bone Mass: (Liu-Ambrose et al, 2006; n = 98; mean age = 79.3 (2.7) years)

CB&M Norms:

Measure	Scale	Mean (SD)	Range
CB & M	max. 85 pts	42 (19)	0–81
MMSE	max. 30 pts	29 (2)	24–30
ABC	max. 100 pts	77 (20)	5–100
PASE		85.8 (40.6)	17.9–224.1
Fast-paced gait (m/s)		1.38 (0.30)	0.51–2.24

MMSE = Mini-Mental State Examination
ABC = Activities-Specific Balance Confidence
PASE = Physical Activity Scale for the Elderly

Healthy individuals aged 20-79 years (Clegg et al, 2009; n=54)

Age group	N	Mean*	SD	95% CI
20-29	24	88.71	3.53	87.2-90.2
30-39	27	86.33	5.78	84.1-88.6
40-49	23	84.35	4.03	82.6-86.1
50-59**	26	77.43	6.55	75.0-79.9
60-69**	17	64.94	8.22	60.7-69.2
70-79**	4	49.75	6.95	38.7-60.8

Construct Validity

Community-dwelling persons after stroke: (Knorr et al, 2010)

Excellent (ρ=.70 to .83, P=.001) correlation were observed among the CB&M, BBS, and TUG

Bibliography

Brien, M. and Sveistrup, H. (2011). "An intensive virtual reality program improves functional balance and mobility of adolescents with cerebral palsy." Pediatr Phys Ther 23(3): 258-266. Find it on PubMed

Clegg, H., Fernande, S., et al. (2009). "Community balance and mobility scale: age-related reference values."

Howe, J. A., Inness, E. L., et al. (2006). "The Community Balance and Mobility Scale--a balance measure for individuals with traumatic brain injury." Clin Rehabil 20(10): 885-895. Find it on PubMed

Inness, E. L., Howe, J. A., et al. (2011). "Measuring Balance and Mobility after Traumatic Brain Injury: Validation of the Community Balance and Mobility Scale (CB&M)." Physiotherapy Canada 63(2): 199-208.

Knorr, S., Brouwer, B., et al. (2010). "Validity of the Community Balance and Mobility Scale in community-dwelling persons after stroke." Arch Phys Med Rehabil 91(6): 890-896. Find it on PubMed

Liu-Ambrose, T., Khan, K. M., et al. (2006). "Falls-related self-efficacy is independently associated with balance and mobility in older women with low bone mass." J Gerontol A Biol Sci Med Sci 61(8): 832-838. Find it on PubMed

Wright, F. V., Ryan, J., et al. (2010). "Reliability of the Community Balance and Mobility Scale (CB&M) in high-functioning school-aged children and adolescents who have an acquired brain injury." Brain Inj 24(13-14): 1585-1594. Find it on PubMed

Last Updated

Purpose

Link to Instrument

Area of Assessment

Assessment Type

Administration Mode

Cost

Diagnosis/Conditions

Number of Items

Required Training

Instrument Reviewers

ICF Domain

Measurement Domain

Professional Association Recommendation

Considerations

Standard Error of Measurement (SEM)

Minimal Detectable Change (MDC)

Normative Data

Test/Retest Reliability

Interrater/Intrarater Reliability

Inter and Intra-rater Reliability:

Internal Consistency

Construct Validity

Content Validity

Face Validity

Criterion Validity (Predictive/Concurrent)

Floor/Ceiling Effects

Responsiveness

Responsiveness

Normative Data

Construct Validity

Bibliography

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