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Using The SEBT To Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury
Using The SEBT To Assess Dynamic Postural-Control Deficits and Outcomes in Lower Extremity Injury
doi: 10.4085/1062-6050-47.3.08
g by the National Athletic Trainers Association, Inc
http://www.nata.org/journal-of-athletic-training
systematic review
Context: A dynamic postural-control task that has gained Study Selection: The criteria for article selection were (1)
notoriety in the clinical and research settings is the Star The study was original research. (2) The study was written in
Excursion Balance Test (SEBT). Researchers have suggested English. (3) The SEBT was used as a measurement tool.
that, with appropriate instruction and practice by the individual Data Extraction: Specific data extracted from the articles
and normalization of the reaching distances, the SEBT can be included the ability of the SEBT to differentiate pathologic
used to provide objective measures to differentiate deficits and conditions of the lower extremity, the effects of external
improvements in dynamic postural-control related to lower influences and interventions, and outcomes from exercise
extremity injury and induced fatigue, and it has the potential to intervention and to predict lower extremity injury.
predict lower extremity injury. However, no one has reviewed Data Synthesis: More than a decade of research findings has
this body of literature to determine the usefulness of the SEBT in established a comprehensive portfolio of validity for the SEBT,
clinical applications. and it should be considered a highly representative, noninstru-
Objective: To provide a narrative review of the SEBT and its mented dynamic balance test for physically active individuals.
implementation and the known contributions to task perfor- The SEBT has been shown to be a reliable measure and has
mance and to systematically review the associated literature to validity as a dynamic test to predict risk of lower extremity injury,
address the SEBTs usefulness as a clinical tool for the to identify dynamic balance deficits in patients with a variety of
quantification of dynamic postural-control deficits from lower lower extremity conditions, and to be responsive to training
extremity impairment. programs in both healthy people and people with injuries to the
Data Sources: Databases used to locate peer-reviewed lower extremity. Clinicians and researchers should be confident
articles published from 1980 and 2010 included Derwent in employing the SEBT as a lower extremity functional test.
Innovations Index, BIOSIS Previews, Journal Citation Reports, Key Words: clinical balance, functional tests, dynamic
and MEDLINE. balance tests, dynamic postural-control tasks
Key Points
N The Star Excursion Balance Test should be considered a highly representative noninstrumented dynamic balance test for
physically active people.
N The Star Excursion Balance Test is a reliable measure and a valid dynamic test to predict risk of lower extremity injury, to
identify dynamic balance deficits in patients with lower extremity conditions, and to be responsive to training programs in
healthy participants and those with lower extremity conditions.
C
linicians often use postural-control assessments to measures of postural-control provide useful clinical infor-
evaluate risk of injury, initial deficits resulting from mation, the underlying task of standing as still as possible
injury, and level of improvement after intervention might not translate necessarily to movement tasks during
for an injury. Postural-control and balance can be grouped physical activity.
into static and dynamic categories.16 Static postural- Conversely, dynamic postural-control involves some
control tasks require the individual to establish a stable level of expected movement around a base of support.
base of support and maintain this position while minimiz- This might involve tasks, such as jumping or hopping to a
ing segment and body movement during the assessment. new location and immediately attempting to remain as
These assessments can be conducted with instrumented motionless as possible or attempting to create purposeful
equipment, such as a force platform, or valid, reliable segment movements (reaching) without compromising the
clinical scales, such as the Balance Error Scoring Sys- established base of support. Although these dynamic
tem13,5,720 or Berg Balance Scale.1,21 Whereas static measures of postural stability do not exactly replicate
sport participation, they more closely mimic demands of and after an intervention to quantify deficits or improve-
physical activity than assessments of static postural ments in dynamic postural-control. The body of literature
stability. Therefore, discovering assessment techniques that that exists suggests that, with appropriate instruction and
can provide reliable, sensitive, and, if possible, cost- practice by the participant and normalization of the
effective information about dynamic movement is impor- reaching distances, the SEBT can provide objective
tant. measures to differentiate deficits and improvements in
One such task that has gained notoriety in the clinical dynamic postural-control related to lower extremity injury
and research settings is the Star Excursion Balance Test and induced fatigue, and it has the potential to predict
(SEBT). Originally described by Gray22 as a rehabilitative injury to the lower extremity. However, no one has
tool, the SEBT is a series of single-limb squats using the reviewed this body of literature to determine the usefulness
nonstance limb to reach maximally to touch a point along of the SEBT in clinical applications. Therefore, the 2
1 of 8 designated lines on the ground.23 The lines are purposes of our study were to (1) provide a narrative
arranged in a grid that extends from a center point and are review of the SEBT and its implementation and the known
456 from one another (Figure 1). Each reaching direction contributions to task performance and (2) systematically
offers different challenges and requires combinations of review the associated literature to address the usefulness of
sagittal, frontal, and transverse movements. The reaching the SEBT as a clinical tool for the quantification of
directions are named in orientation to the stance limb as dynamic postural-control deficits from lower extremity
anterior, anteromedial, anterolateral, medial, lateral, pos- impairment.
terior, posteromedial, and posterolateral (Figure 1). The
goal of the task is to have the individual establish a stable PART I: IMPLEMENTATION OF THE SEBT AND
base of support on the stance limb in the middle of the KNOWN CONTRIBUTIONS TO PERFORMANCE
testing grid and maintain it through a maximal reach A NARRATIVE REVIEW
excursion in 1 of the prescribed directions.22,23 While
standing on a single limb, the participant reaches as far as
Development of Measurement Properties
possible with the reaching limb along each reaching line;
lightly touches the line with the most distal portion of the The first report of the SEBT in the research literature
reaching foot without shifting weight to or coming to rest was a reliability study published in 1998.25 Test-retest
on this foot of the reaching limb; and then returns the reliability estimates were reported for the 4 diagonal reach
reaching limb to the beginning position in the center of the directions of the test (anteromedial, anterolateral, postero-
grid, reassuming a bilateral stance (Figure 2). If the medial, and posterolateral). Intratester reliability estimates
individual touches heavily or comes to rest at the touch- (intraclass correlation coefficients [ICC]) for the different
down point, has to make contact with the ground with the directions ranged from 0.67 to 0.87.25 In another reliability
reaching foot to maintain balance, or lifts or shifts any part study,26 the intratester and intertester reliability of all 8
of the foot of the stance limb during the trial, the trial is not reach directions of the SEBT in healthy young adults were
considered complete.23,24 These stipulations should be established. These included anterior, posterior, medial, and
applied during rehabilitation, injury evaluation, and lateral reach directions in addition to the 4 diagonal
research applications of the SEBT. directions previously mentioned.22 Participants performed
The measurement or outcome from the SEBT perfor- 12 trials in each direction on 2 days: 3 trials in each
mance is how far the participant can reach without direction while 1 examiner measured reaching distance as
violating any of the described stipulations. The reach the performance variable. Intratester reliability estimates
distance values are used as an index of dynamic postural- (ICCs) for the different directions ranged from 0.78 to 0.96,
control (ie, a farther distance reached indicates better and the intertester reliability ranged from 0.35 to 0.84 on
dynamic postural-control). These assessments can be day 1 and from 0.81 to 0.93 on day 2. The relatively poor
compared between injured and uninjured limbs or before intertester reliability reported on day 1 was likely an
artifact of a practice effect. The investigators found a practice product, the Y Balance Test (functionalmovement.com,
effect, with participants reaching farther as they performed Danville, VA), to further improve the efficiency of SEBT
more trials until a plateau occurred during trials 7 through 9. measures. This device comprises a stance platform from
Therefore, they recommended having participants perform 6 which 3 pieces of polyvinylchloride pipe extend in the
practice trials in each direction before recording reaching anterior, posteromedial, and posterolateral reach direc-
distances for clinical or research purposes.26 tions. Each pipe is marked in 5-mm increments. The
More recently, Robinson and Gribble27 demonstrated participant pushes a target (reach indicator) along the pipe
that, in most reach directions, the maximum reaching with the foot of his or her reach limb, and the target
distances and associated kinematic displacement values of remains over the tape measure after performance of the test
the stance limb stabilized by the fourth trial. Thus, they to allow for easy measurement. Intratester reliability (ICC)
recommended that only 4 practice trials need to be using this device ranged from 0.85 to 0.89, whereas
performed before measuring reaching distances for clinical intertester reliability was nearly perfect, ranging from
or research purposes.27 Similarly, Munro and Herrington28 0.97 to 1.00.31
found that performance on the SEBT stabilized after 4 To compare performance within limbs of an individual,
trials among healthy participants. Furthermore, those comparisons in the absolute reaching distance can be made
authors examined the test-retest reliability among 3 between reaching distances attained on each limb. Howev-
additional trials and found strong reliability (ICC 5 er, to make valid comparisons of SEBT reaching distances
0.840.92),28 which was consistent with previous reliability among individuals or groups, reaching distances need to be
studies.25,26 normalized to each participants limb length.24 This
Based on the results of a factor analysis study,29 great recommendation is based on limb length, as measured
from the anterosuperior iliac spine to the medial malleolus,
redundancy has been found in participant performance in
being correlated with reach performance.24 Whereas
the 8 reach directions. A tremendous amount of shared
overall body height also was correlated with reaching
variance was present across the 8 reach directions. In other
distance, limb length was more strongly correlated.24 When
words, an individuals reaching distance in a given
normalizing reaching distances to limb length, performance
direction was highly correlated with his or her reaching
typically is expressed as a percentage of limb length.
distance in the other 7 directions.29 This has led to the
recommendation that only 3 reach directions (anterior,
posteromedial, and posterolateral) should be performed Other Contributing Factors to SEBT Performance
(Figure 2).30 This modification substantially reduces the In addition to limb length and height, several other
time necessary to perform the SEBT. anthropometric and physiologic characteristics have been
Building on the reduction in the number of reach studied to assess their association with SEBT performance.
directions, Plisky et al31 proposed a commercially available Several researchers have investigated if SEBT performance
Ankle Instability. The first and most common joint that comparisons, demonstrating that participants with CAI
has been addressed with SEBT testing is the ankle. Various performed worse on the total score in all 8 directions when
balance and other sensorimotor deficits have been associ- using their affected limbs as the stance limbs compared
ated with ankle instability.10,12,46,48 Consistently in the with their unaffected limbs, as well as compared with the
literature, people with acute ankle instability and CAI performance of matched limbs of the control group
perform worse on the SEBT than people with uninjured participants (P 5 .05). Akbari et al47 compared the injured
limbs (Table 1). Olmsted et al45 were the first to make these and uninjured sides of participants with unilateral ankle
346
Normalized to
Authors Main Comparison N Leg Length? Result P Value Effect Size (95% CI)
Akbari et al,47 2006 Unknown direction for injured and uninjured 30 No Injured limb 5 84.97 6 10.26 cm .03 0.19 (20.32, 0.69)
limbs Uninjured limb 5 86.8 6 9.34 cm
Gribble et al,2 2004 Anterior direction for CAI-IS and CAI-US 15 Yes CAI-IS 5 78.4% 6 6.2% .03 0.53 (20.21, 1.24)
CAI-US 5 81.8% 6 6.6%
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Medial direction for CAI-IS and CAI-US 15 Yes CAI-IS 5 87.5% 6 5.8% .02 0.39 (20.34, 1.10)
CAI-US 5 90.0% 6 7.0%
Posterior direction for CAI-IS and CAI-US 15 Yes CAI-IS 5 89.0% 6 9.3% .01 0.20 (20.52, 0.92)
CAI-US 5 90.9% 6 9.3%
Hale et al,7 2007a Posteromedial direction for IS and US 29 Yes IS 5 80.0% 6 12.5% .047 0.29 (20.23, 0.80)
US 5 83.5% 6 11.5%
Posterolateral direction for IS and US 29 Yes IS 5 73.5% 6 10.5% .007 0.38 (20.14, 0.90)
US 5 77.5% 6 10.5%
Lateral direction for IS and US 29 Yes IS 5 65.5% 6 10.0% .03 0.44 (20.09, 0.95)
US 5 70.0% 6 10.5%
Hertel et al,29 2006 Anteromedial direction for CAI-IS and CAI 5 48 Yes CAI-IS 5 80.0% 6 10.0% .005 Within groups 5 0.21 (20.22, 0.63)
instability and reported that the performance of the injured SEBT, authors of 2 studies have presented conflicting
side was worse than that of the uninjured side (P 5 .03). It results. Sefton et al12 reported no differences in participants
is unclear which direction or directions were used in this with and without CAI using the anteromedial, medial, and
study and how much time had passed since participants posteromedial directions. However, how the participants
had sustained the ankle injuries. In both studies, the with CAI were selected raises concerns. The authors used
reported reaching distances were not normalized, and we the Foot and Ankle Disability Index (FADI) and the
have discussed the importance of this procedure. FADI-Sport to differentiate the level of functional deficits
Using normalized reaching distances, Gribble et al2 in the identified participants with a history of ankle
reported decreased performance of the CAI group on their sprains. Although the FADI instruments commonly are
injured sides in the anterior (P 5 .03), medial (P 5 .02), used for this purpose, the range of scores for the FADI
and posterior (P 5 .01) directions. Similarly, Hertel et al29 (37%) and FADI-Sport (56.2%) and the reported standard
reported group-by-side interactions that demonstrated deviations for the combined score (75.35%) of the CAI
decreased normalized reaching distances on the injured group were quite large, which could have jeopardized the
sides of participants with CAI for the anteromedial (P 5 homogeneity of the sample of injured participants. In
.005), medial (P , .001), and posteromedial (P 5 .03) addition, the normalized scores that Sefton et al12 reported
directions. Additionally, Hale et al7 confirmed the deficit in for the CAI group were much larger than those reported in
task performance in participants with CAI at baseline the body of work we have reviewed. Similarly, Martinez-
before implementation of a rehabilitation protocol, with Ramirez et al11 did not report differences between groups
injured limbs producing worse dynamic postural-control with and without CAI among the anterior, posteromedial,
than the uninjured limbs for the posteromedial (P 5 .047), and posterolateral reaching directions, but they found close
posterolateral (P 5 .007), and lateral (P 5 .03) directions. to a strong effect size for the anterior direction (Cohen d 5
Finally, Nakagawa and Hoffman37 reported better total 0.74). The authors stated that their inclusion criteria for
score performance in healthy control participants than CAI might not have been specific enough, raising concerns
participants with CAI (P 5 .01). Whereas their data were similar to those noted in the study by Sefton et al.12 This
normalized, they used a variation of the procedure by issue has been discussed further in a recent investigation by
multiplying rather than dividing the reaching distances by Delahunt et al.49
height. Anterior Cruciate Ligament Reconstruction. Anterior
Although the authors of these studies consistently cruciate ligament injuries also are very common among
showed that ankle instability is associated with a dimin- lower extremity pathologic conditions, and authors of
ished level of dynamic postural-control measured with the many studies that are too numerous to discuss here have
Table 3. Ability of the Star Excursion Balance Test to Differentiate Pathologic Lesions: Patellofemoral Paina
Normalized to
Authors Main Comparisons N Leg Length? Results P Value Effect Size (95% CI)
Aminaka and Anterior direction for PFP IL 5 20 Yes PFP IL 5 62.8% 6 1.2% .03 2.33 (1.49, 3.08)
Gribble,9 2008 PFP IL and CML Control 5 20 Control 5 65.6% 6 1.2%
Abbreviations: CML, control matched limb; IL, injured limb; PFP, patellofemoral pain.
a
Level of evidence for all entries is 2b. Phillips B, Ball C, Sackett D, et al. The Oxford Centre for Evidence-Based Medicine: Levels of Evidence
(March 2009) [updated by Howick J in March 2009]. Oxford Centre for Evidence-Based Medicine. http://www.cebm.net/index.aspx?o51025.
Accessed November 29, 2011.
348
Normalized to Level of
Authors Main Comparisons N Leg Length? Results P Value Effect Size (95% CI) Evidencea
Aminaka and Anterior direction for patellofemoral 20 Yes No tape 5 62.88% 6 1.2% .03 0.50 (20.14, 1.11) 2b
Gribble,9 2008 pain syndrome group in no-tape Tape 5 63.5% 6 1.3%
and tape conditions
Anterior direction for healthy group 20 Yes No tape 5 65.6% 6 1.2% .03 0.64 (20.01, 1.26) 2b
Volume 47
in no-tape and tape conditions Tape 5 64.8% 6 1.3%
Hardy et al,13 Semirigid, lace-up, and no-brace 36 Yes No differences All comparisons . .05 All comparisons , 0.25 3b
2008 conditions among healthy
participants
Olmsted and Within-session anterolateral, 7 Yes Anterolateral-O 5 81% 6 3% Condition-by-direction-by- Anterolateral 5 0.4 (20.68, 1.43) 2b
Hertel,4 2004 posterolateral, and lateral group interaction 5 .03
directions for participants with Anterolateral-NO 5 79% 6 4%
cavus feet in orthoses and no- Posterolateral-O 5 95% 6 5% Posterolateral 5 0.4 (20.68, 1.43)
orthoses conditions Posterolateral-NO 5 93% 6 5%
Lateral-O 5 81% 6 5% Lateral 5 0.57 (20.54, 1.59)
Lateral-NO 5 79% 6 4%
lateral direction no orthoses condition; Lateral-O, lateral direction orthoses condition; Posterolateral-NO, posterolateral direction no orthoses condition; Posterolateral-O, posterolateral direction
Abbreviations: Anterolateral-NO, anterolateral direction no orthoses condition; Anterolateral-O, anterolateral direction orthoses condition; CI, confidence interval; D1, day 1; D2, day 2; Lateral-NO,
Phillips B, Ball C, Sackett D, et al. The Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009) [updated by Howick J in March 2009]. Oxford Centre for Evidence-Based
and functional performance deficits that exist among
Evidencea
Level of
populations with ACL reconstruction and deficiency
3b
3b
3b
(ACL-D). However, in only 1 study, the investigators3
appear to have used the SEBT as a screening tool to
examine dynamic postural-control deficits in participants
with ACL-D (range, 5 months to 2 years after injury). The
Effect Size (95% CI)
performance of the ACL-D group in all 8 directions of the
SEBT while standing on the injured limb was compared
with performances of the uninjured limb and the matched
limb of a group of healthy control participants. In the
0.32 (20.31, 0.94)
.001
Yes
Yes
20
20
95% of the time, replication of the study would not yield an condition. In the future, determining the minimal clinically
effect size of zero or would yield the potential for no effect. important difference when using the SEBT to screen for
If the interval does cross zero, one should consider whether these conditions also might be valuable to further elucidate
a true difference actually was detected and how reliable the the effectiveness of this test as an outcome tool.
effect size would be if the study was repeated. Therefore,
studies with significant results or large effect sizes and
Ability of the SEBT to Differentiate Effects of External
small CIs that do not cross zero have the greatest clinical
Influences and Interventions
importance.
In the ankle literature, all of the calculated CIs crossed In addition to identifying the deficits in dynamic postural-
zero. In the single ACL-D and PFPS studies that were control that lower extremity conditions can create, the SEBT
reviewed, the CIs did not cross zero. Although this could also can be used to display the influence of external
be a surprising outcome, it might be explained by interventions and influences on dynamic postural-control.
considering how these 3 conditions are defined. Definitions The external influences that have been investigated include
of ACL-D and PFPS might be more consistent than taping, bracing, orthoses, and induced fatigue, all of which can
definitions of ankle instability. Herrington et al3 defined affect physical performance or risk of injury. These compar-
ACL-D through physical examination and either arthros- isons have implications for how the SEBT might be used to
copy or magnetic resonance imaging (MRI). Aminaka and address effective intervention and prevention strategies for
Gribble9 categorized PFPS based on specific criteria of the lower extremity injuries in clinical and laboratory settings.
duration of pain and which activities caused pain. In the Taping, Bracing, and Orthoses. Externally applied
ankle literature, the definition of ankle instability differs devices, such as taping, bracing, and orthoses, are used to
considerably, with researchers reporting varying numbers enhance joint stability and mechanics. The intended
of previous sprain incidences, times since last substantial improvements in joint congruency and efficient arthrokine-
sprain, residual mechanical and functional instabilities, and matics often are considered avenues to heighten postural-
levels of pain. Even with some of these criteria, contem- control. Specific to performance on the SEBT, the
porary theory is that subsets of copers who do not exhibit literature appears to be mixed on the optimization of
functional limitations despite similar histories and symp- dynamic postural-control with such interventions.
toms related to their ankle injuries might exist.49,50 Olmsted and Hertel4 examined the use of custom-made
Therefore, a history of ankle injury possibly can create a orthoses in uninjured participants with pes cavus, pes
deficit in dynamic postural-control that the SEBT is planus, or pes rectus feet. Participants performed all 8
sensitive enough to detect, as evidenced by the differences directions of the SEBT during 2 testing sessions that were
observed in these studies. However, because of the 2 weeks apart. During each session, the participants were
potential variability in the level of ankle instability within evaluated with and without the orthoses to examine the
a group of injured participants under the criteria used in immediate effects of the orthoses. In the 2-week period
the studies we have reviewed, this possibly contributed to between testing sessions, they were instructed to wear the
higher group standard deviations that resulted in smaller orthoses, which provided an outcome on the continued use
effect sizes and 95% CIs that crossed zero. Researchers are for this intervention. For the first purpose, a condition-by-
encouraged to define ankle instability as succinctly as group-by-direction interaction (P 5 .03) supported that,
possible to determine the sensitivity of the SEBT for among the participants with pes cavus, immediate appli-
screening dynamic postural-control deficits related to this cation of the orthoses improved reaching distances in 3 of
352
Normalized to Level of
Authors Main Comparisons N Leg Length? Results P Value Effect Size (95% CI) Evidencea
Bouillon et al,15 Anterolateral direction for PostE PostE 5 10 Yes PostE 5 80.71% 6 5.9% .07 1.01 (20.06, 1.98) 1b
2009 and PC PC 5 7 PC 5 73.0% 6 9.6%
Anterior direction for PostE and PC PostE 5 10 Yes PostE 5 94.1% 6 9.0% .006 1.46 (0.31, 2.46) 1b
PC 5 7 PC 5 82.2% 6 6.7%
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Anteromedial direction for PostE PostE 5 10 Yes PostE 5 92.3% 6 6.98% .03 1.19 (0.09, 2.17) 1b
and PC PC 5 7 PC 5 83.9% 6 7.12%
Medial direction for PostE and PC PostE 5 10 Yes PostE 5 92.1% 6 9.26% .005 1.49 (0.33, 2.49) 1b
PC 5 7 PC 5 80.0% 6 6.1%
Posteromedial for PostE and PC PostE 5 10 Yes PostE 5 89.1% 6 8.14% .005 1.68 (0.49, 2.70) 1b
PC 5 7 PC 5 76.6% 6 6.2%
Posterior direction for PostE and PC PostE 5 10 Yes PostE 5 86.7% 6 4.7% .001 1.97 (0.72, 3.02) 1b
PC 5 7 PC 5 77.2% 6 5.0%
Posterolateral direction for PostE PostE 5 10 Yes PostE 5 78.3% 6 7.5% .07 1.02 (20.05, 1.99) 1b
and PC PC 5 7 PC 5 70.7% 6 7.4%
Lateral direction for PostE and PC PostE 5 10 Yes PostE 5 72.7% 6 3.4% .06 1.37 (0.24, 2.37) 1b
Phillips B, Ball C, Sackett D, et al. The Oxford Centre for Evidence-Based Medicine: Levels of Evidence (March 2009) [updated by Howick J in March 2009]. Oxford Centre for Evidence-Based
Evidencea
CAI and variances in knee flexion and hip flexion angle. An
Level of
additional important point of this analysis was that of the 4
1b
1b
2b
2b
fatigue protocols, continuous lunging was the most dynam-
ic, and it produced the strongest predictive models for
decline in SEBT performance. Therefore, the authors
concluded that SEBT performance might provide a useful
Effect Size (95% CI)
.04
5 .001
Yes
Yes
Yes
Exercise Intervention
A typical goal of clinicians is to return athletes and
patients to a desired level of functional activity. Innumer-
able intervention protocols and functional assessment tools
exist, but unfortunately, too few are validated either
independently or in combination. As we have demonstrat-
20
20
13
13
N
control group and a CAI group that did not perform the
protocol. These differences were observed in the postero-
2010
5 .03). The mean change scores rather than means and sizes that were greater than 1.0, and only 2 had CIs
standard deviations from the pretesting and posttesting crossing zero (Table 6).
periods were reported, preventing us from calculating effect Other researchers have found consistent improvements
sizes from this study. in SEBT performance after exercise-intervention programs
Similarly, McKeon et al52 implemented a 4-week that focused on balance16,19,53 or neuromuscular17,18
protocol using balance-training exercises for participants training exercises. Eisen et al16 reported that 4 weeks of
with CAI and used the SEBT as an outcome measure, this balance training using either a rocker board or DynaDisc
time focusing on the anterior, posteromedial, and postero- (Exertools, Inc, Petaluma, CA) resulted in an average
lateral directions. They reported a favorable outcome on improvement in SEBT performance of 3.8%. Using a
the SEBT performance after the rehabilitation protocol for combination of balance training and gluteal strengthening,
the posteromedial (P 5 .01) and posterolateral (P 5 .03) Leavey et al19 noted improvements in SEBT performance
directions, with moderate to strong effect sizes (range, after 6 weeks that ranged from 2.85% to 6.22% across the 8
0.671.07; Table 5). reaching directions. Although these researchers showed
Improvements in Healthy People. Dynamic postural- improvements in dynamic postural-control with balance
control is also important in healthy individuals and might training, the effect sizes were low to moderate, ranging
be an outcome measure of interest after an exercise from 0.25 to 0.61, with all 95% CIs crossing zero (Table 6).
intervention to improve performance and reduce the risk Valovich McLeod et al53 also found improved SEBT
of injury. Kahle and Gribble5 were interested in the performance after a 6-week balance-training program, but
influence of core stability on improvement of dynamic they did not provide any means or point estimates to
stability. Using a 6-week intervention training program, support the reported differences, preventing us from
healthy, physically active young adults demonstrated calculating effect sizes and appreciating the magnitude of
improvements in SEBT performance compared with a the differences from the intervention.
control group. Specifically, in the anteromedial direction, Similar to balance-training interventions, neuromuscular
the exercise group improved their scores by more than 4% (P control exercise programs seem to encourage improved
5 .001; Table 6). In the medial direction, after rehabilita- dynamic postural-control measured with the SEBT.
tion, the exercise group had improved 6% from baseline and Fitzgerald et al18 reported improvements of 2.95% to
was more than 6% better than the control group at the 9.4% in the anterior, posteromedial, and posterolateral
posttesting (P , .001). These differences produced moderate directions after 12 exercise sessions of wobble board
to strong effect sizes, with the moderate effect sizes having exergaming or postural-stability training. Similarly,
CIs that did cross zero (Table 6). Filipa et al17 found that 8 weeks of neuromuscular control
Bouillon et al15 used the SEBT and other clinical balance training in young female athletes improved performance in
indices to compare 2 cycle-ergometer protocols among the same 3 directions by 1.75% to 9.5%. Support for the
middle-aged women. The exercise group improved their use of neuromuscular control training is provided by
dynamic stability compared with the control group in 6 of mostly moderate to strong effect sizes that ranged from
8 reaching directions with the exception of the anterolateral 0.58 to 1.00 (Table 6). In the study by Filipa et al,17 only
(P 5 .07) and posterolateral (P 5 .07) directions, which performance in the anterior direction was associated with a
had a relationship that was not different. Upon request, the low effect size.
authors of the original study provided the means and This literature demonstrates that the SEBT can be used
standard deviations of their results so we could calculate to identify improvements in dynamic stability after exercise
effect sizes. In all 8 directions, we discovered large effect intervention among healthy individuals and those with
Address correspondence to Phillip A. Gribble, PhD, ATC, 2801 W Bancroft, University of Toledo, Mailstop #119, Toledo, OH 42606.
Address e-mail to phillip.gribble@utoledo.edu.