R E S E A R C H A R T I C L E

Functional Balance Assessment

With Pediatric Balance Scale in Girls
With Visual Impairment
Justyna Żyłka, MS, PT; Urszula Lach, MS, PT; Izabela Rutkowska, PhD, PT
Comprehensive Rehabilitation Center (Ms Zylka), Konstancin, Poland; Rehabilitation Department (Ms Lach), Educational
Center for Blind Children, Laski, Poland; Department of Theory and Methodology of Physical Education for People with
Disabilities (Dr Rutkowska), Faculty of Rehabilitation, Józef Piłsudski University of Physical Education, Warsaw, Poland.

Purpose: To examine functional balance abilities in girls with visual impairment (VI) and to investi-
gate the correlation between stabilography and clinical balance assessment using the Pediatric Balance
Scale (PBS) in girls with VI. Methods: The PBS and stabilography were administered to 26 girls with VI
aged 10 to 15 years. The association between PBS scores and sway parameters was examined using the
Spearman correlation coefficient. Results: The range of PBS scores was 47 to 56. Balance difficulties ap-
peared in single-leg stance, tandem stance, and reaching forward. The PBS scores correlated with all but
2 sway parameters, with r values ranging from −0.18 to −0.58. Conclusions: Girls with VI present difficulties
in upright stance when the size of the base of support is narrowed and in situations where the center of
gravity approaches the edge of the base of support. There is a need to provide interventions to improve
balance abilities in girls with VI. (Pediatr Phys Ther 2013;25:460–466) Key words: adolescent, child, female,
functional assessment, human, postural balance, visual impairment, validity

INTRODUCTION AND PURPOSE
Balance refers to the dynamics of body posture aimed
at preventing falls and is a requisite for execution of move-
ment and successful completion of functional activities.1
As the postural control system requires information from
the visual, vestibular, and proprioceptive systems, a lack
or insufficiency of visual input influences the ability to
maintain balance.1,2 Therefore, people with visual impair-
0898-5669/110/2504-0460
Pediatric Physical Therapy
Copyright C 2013 Wolters Kluwer Health | Lippincott Williams &
Wilkins and Section on Pediatrics of the American Physical Therapy
Association
Correspondence: Izabela Rutkowska, PhD, PT, Department of
Theory and Methodology of Physical Education for People with
Disabilities, Faculty of Rehabilitation, Józef Piłsudski University
of Physical Education, Marymoncka 34, 01-813 Warsaw, Poland
(izarutkowska7@tlen.pl).
The first author was a student in the Master of Physical Therapy degree
program of the Faculty of Rehabilitation of Józef Piłsudski University of
Physical Education in Warsaw at the time this work was undertaken.
The authors declare no conflicts of interest.
DOI: 10.1097/PEP.0b013e31829ddbc8
ment (VI) have been reported to have deficient balance
compared with individuals without VI.3-12
Some earlier studies indicate that the lack of visual
information can be partially compensated by the increased
use of residual sensory systems to maintain balance in in-
dividuals with vision loss.3,7 In a study by Ribadi et al,3
adolescents with congenital blindness outperformed their
blindfolded peers without VI in dynamic balance tasks. An-
other study revealed that in adolescents with total blind-
ness, postural control is better than in subjects who are
legally blind and individuals who are blindfolded but with-
out VI, which may indicate that people with total blindness
develop superior proprioceptive and vestibular reactions.7
However, in other research, the outcomes of individuals
without VI being blindfolded during balance tasks did not
differ from that of subjects with VI or were even better
than that in people with vision loss.5,6,8,11,12
People with blindness and low vision use different
strategies to stabilize the body in space than those used
by individuals without VI. However, it remains unclear
whether those behaviors are related to an adaptive compen-
satory strategy or inefficiency of movements increasing the
risk of fall in subjects with blindness and low vision.8,11,13
For example, Schmid et al8 noted significantly larger body
displacement with a stronger coupling between segments

460 Żyłka et al Pediatric Physical Therapy

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
 during dynamic posturography in adults with blindness.
The larger body displacement may be a means of getting
stronger vestibular input for balance control or a sign of in-
creased postural anxiety as a consequence of poor balance.
In other studies, Horvat et al13 and Ray et al11 reported
an increased use of the hip strategy in subjects with VI,
possibly related to difficulties in anticipatory balance ad-
justments, ankle muscles weakness, or simply cautiousness
in their movements.
Because studies reveal that the balance ability in peo-
ple with VI is generally worse than that in subjects with-
out visual deficits and apparently experience alone cannot
fully compensate for the lack or insufficiency of vi-
sual information,3-12 appropriate interventions may con-
tribute to the improvement of balance abilities in subjects
with VI.14
In the pediatric population, VI acts as a constraint on
overall development, affecting indirectly the acquisition of
gross motor skills because of reduced incentive and op-
portunities for movement, difficulties in learning through
imitation, as well as fear. Thus, children and adolescents
with VI often experience delays in various aspects of motor
development and are at risk for postural abnormalities.4
Therefore, the physical therapist is commonly a mem-
ber of the educational team for children and adolescents
with VI.
In childhood, VI leads to different motor problems,
and according to some authors, balance is most affected
in gross motor skills.4 Therefore, children and adolescents
with VI were reported to have worse performance in both
static and dynamic balance tasks than their peers without
VI.3,4,6,7,9,10 Those findings were based on laboratory bal-
ance measurements3,7 and norm-referenced tests of motor
proficiency, such as the Bruininks-Oseretsky Test of Mo-
tor Proficiency4 and the Movement Assessment Battery for
Children (MABC),9,10 or commonly used clinical balance
tests (Flamingo Balance Test).6 However, the functional
relevance of those measures is not directly interpretable.
Although comparative studies reveal that balance abilities
in children and adolescents with blindness and low vision
are inferior to that of their peers with typical development,
the studies do not reveal whether those findings imply
functional limitations. To our best knowledge, the only
attempt to relate the results of balance assessment in chil-
dren with VI to their performance of daily activities was
made by Engel-Yeger.9 In that study, the parents of chil-
dren with unilaterally reduced vision (aged 4-7 years) were
asked to rate the frequency of everyday situations that re-
flect the children’s balance and posture abilities as well as
intolerance or hypersensitivity to movement on a 5-point
Likert scale. Significant correlations were found between
some items on a parent’s questionnaire composed for the
study and mean balance scores of children on the MABC
and between mean score of items that evaluate static bal-
ance in the parent’s questionnaire and mean score of MABC
static balance items.9 Nevertheless, on the basis of previous
studies, the effect of balance deficits in subjects with VI on
carrying out activities of daily living cannot be determined.
Pediatric Physical Therapy
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
Identification of functional problems enables physi-
cal therapists and specialists in adapted physical education
to concentrate on the areas of particular need and to im-
plement adequate interventions. Thus, understanding the
level of functioning of children and adolescents with VI
may lead to more effective physical therapy and physical
education programs. Although the major problems affect-
ing everyday life of children and adolescents with VI, espe-
cially locomotor activities, are spatial orientation, locating
objects in space, and anticipation of danger, we suggest
that poor balance abilities may increase difficulties in in-
dependent mobility in this population. Moreover, identi-
fying the effects of VI on functional activities may give
some insight into treatment approaches for children and
adolescents with multiple disabilities. Since most children
and adolescents with VI have additional motor, sensory, or
cognitive impairments, they are commonly seen in physi-
cal therapy practice. Working with children with VI poses
a unique challenge; therefore, physical therapists should
be aware of problems related to the lack or insufficiency of
visual information. The purpose of this study was to exam-
ine functional balance abilities of girls with VI. Since there
are no specific tools to evaluate functional balance abilities
in children and adolescents with VI, the study also aimed
to compare the results of clinical balance assessment and
quantitative measurement of balance with stabilography.
METHODS
Participants
Twenty-six girls with VI aged 10 to 15 years (mean =
12.7, SD = 1.8) participated in this study. Following the
World Health Organization definition of VI, the inclusion
criterion was a best corrected visual acuity of less then
0.3 or 20/60, which means that the eye with better vi-
sual acuity provides vision from a distance of 20 ft that
is equal to what an individual without VI can see at 200
ft. For the World Health Organization International Clas-
sification of Diseases, Tenth Revision, classification of VI,
see Table 1.15 The degree of VI of each participant with
respect to the World Health Organization International
TABLE 1
WHO Categories of Visual Impairment15
Visual Acuity
WHO Category of VI Worse Than Equal or Better Than
0 (mild or no VI) 0.3 (20/70)
1 (moderate VI) 0.3 (20/70) 0.1 (20/200)
2 (severe VI) 0.1 (20/200) 0.05 (20/400)
3 (blindness) 0.05 (20/400) 0.02 (20/1200)
4 (blindness) 0.02 (20/1200) Light perception
5 (blindness) No light
perception
9 Undetermined or
unspecified
Abbreviations: VI, visual impairment; WHO, World Health Organiza-
tion.
Balance in Girls With Visual Impairment 461
 Classification of Diseases, Tenth Revision, classification is
reported in Table 2. The visual status ranged from severe
VI to total blindness. The cause of VI included retinopa-
thy of prematurity, optic nerve abnormalities, congenital
cataract, anophthalmia, and retinoblastoma. Visual impair-
ment was congenital or acquired (see Table 2). Children
and adolescents with physical and/or intellectual disabil-
ity were excluded from this study. Data concerning visual
status were extracted from medical records.
The study protocol was approved by the local
bioethics committee. Written informed consent was ob-
tained from each participant’s parent or guardian before
data collection.
abilities in the context of everyday tasks and requires only
minimal use of specialized equipment. The scale is com-
posed of 14 items that are scored on a criterion-based
0 to 4 scale (see Table 3). The range of scores in the
PBS is 0 to 56. The test-retest and interrater reliability
of the PBS was found to be high (intraclass correlation co-
efficient = 0.998 and 0.997, respectively) in school-aged
children with mild to moderate motor impairment.16 As,
to our knowledge, the PBS has not yet been used to assess
TABLE 3
Pediatric Balance Scale16
Pediatric Balance Scale Items

1 Sitting to standing
Measures 2 Standing to sitting
3 Transfers
The Pediatric Balance Scale (PBS), which is a modi- 4 Standing unsupported
fication of Berg Balance Scale (BBS) designed for children 5 Sitting unsupported
and adolescents aged 5 to 15 years, was chosen to assess 6 Standing with eyes closed
7 Standing with feet together
functional balance abilities in girls with VI. The PBS exam-
8 Standing with one foot in front
ines various activities that a child must perform to safely 9 Standing on one foot
and independently function at home, at school, and in the 10 Turning 360◦
community. The scale was developed to assess both static 11 Turning to look behind
and dynamic balance, including tasks requiring anticipa- 12 Retrieving object from floor
13 Placing alternate foot on stool
tory balance and self-induced challenge to limits of stand-
14 Reaching forward with outstretched arm
ing stability.16,17 The PBS enables an assessment of balance

TABLE 2
Characteristics of the Study Sample and Pediatric Balance Scale Total Test Scores

Degree of PBS
VI (WHO Total Test
Subject Age, y Categorya ) Cause of VI Onset Score

1 10.0 5 ROP Con 54

2 10.0 5 Optic nerve dysplasia Con 53
3 10.1 5 Anophthalmia Con 47
4 10.2 5 Cataract Con 51
5 10.5 5 Optic nerve hipoplasia Con 51
6 10.5 5 Retinoblastoma Aq 56
7 10.6 5 ROP Con 49
8 10.9 2 optic nerve atrophy Aq 53
9 11.6 5 ROP Con 51
10 12.2 5 ROP Con 50
11 12.2 5 ROP Con 54
12 12.9 4 Optic nerve atrophy Con 53
13 13.1 4 Optic nerve hipoplasia Con 52
14 13.1 5 Optic nerve hipoplasia Con 51
15 13.4 4 Optic nerve atrophy Aq 56
16 13.8 2 Optic nerve atrophy Aq 53
17 14.0 5 ROP Con 52
18 14.0 5 ROP Con 54
19 14.1 4 ROP Con 52
20 14.2 5 Optic nerve atrophy Con 55
21 14.3 5 ROP Con 54
22 14.5 4 ROP Con 52
23 14.9 4 Optic nerve atrophy Con 50
24 15.0 4 ROP Con 53
25 15.1 3 Optic nerve atrophy Aq 56
26 15.2 5 ROP Con 55

Abbreviations: Aq, acquired; Con, congenital; PBS, Pediatric Balance Scale; ROP, retinopathy of prematurity; VI, visual impairment; WHO, World
Health Organization.
a For WHO International Classification of Diseases, Tenth Revision, categories of visual impairment, see Table 1.

462 Żyłka et al Pediatric Physical Therapy

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
 balance in children with sensory impairments, we used sta-
bilography to examine concurrent validity of the scale for
assessment of balance abilities in children and adolescents
with VI. Postural stability was measured during 30-second
quiet stance in a natural posture on a force platform (80
cm × 80 cm). The force platform was linked to a personal
computer via a 4-channel amplifier with a 12-bit analog-
to-digital converter. The signals from the load cells were
amplified and converted from analog to digital form and
then recorded on the computer using a software program
that calculated the center-of-pressure trajectory in relation
to the platform coordinates. Data were sampled at 20 Hz.
The calculated parameters were sway path and average
sway velocity, as well as mediolateral and anterioposterior
sway path, average sway amplitude, and velocity.
Procedures
At the beginning of the test session, height and
weight were measured and recorded for each participant.
Stabilography and the PBS were performed by each subject
in random order during a single test session that lasted ap-
proximately 30 minutes. The PBS was administered to each
girl individually, using a protocol and scoring described
by Franjoine et al.16 Although the scale was developed for
children with motor impairment, the items clearly relate to
activities of daily life and the examiner is authorized to use
verbal and physical prompts to clarify tasks, so adaptations
were not needed for children and adolescents with VI.
Moreover, each girl was allowed to feel the test materials
before the test was administered. The stabilometric mea-
surement was performed during 30 seconds of quiet stance
with feet hip-width apart and arms freely hanging on both
sides. Assistance was given to enable each child to achieve
a proper position in the center of the force platform.
The participant was asked to stand as still as possible.
Data recording started once the subject was stable in the re-
quired posture and stated that she was ready. All data were
collected in a quiet room free from external distractions at
the Educational Center for Blind Children in Laski.
Data Analysis
To describe the study group, means and standard de-
viations were calculated for age, height, and weight. The
mean, standard deviation, and range of the PBS total test
scores, as well as the percentage of participants attaining
scores from 0 to 4 in each PBS item were reported. Spear-
man rank correlation analyses were performed to deter-
mine the associations between PBS total test scores and all
of the sway parameters. The α level was set at .05. The sta-
tistical analyses were performed using Statistica software
(version 9.0).
RESULTS
The age, degree, cause, and onset of VI, as well as PBS
total point scores for all of 26 girls who participated in this
Pediatric Physical Therapy
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
study are presented in Table 2. The mean height in study
sample was 151.8 cm (SD = 11.7 cm) and the mean weight
45.3 kg (SD = 11.9 kg). The range of point scores on the
PBS was 47 to 56 (mean = 52.6, SD = 2.2). Although
all participants (n = 26) demonstrated mastery in 9 of 14
PBS items, the maximal score on the scale was achieved
only by 11.5% (n = 3) of the study sample. As seen in
Table 4, the greatest difficulties in maintaining balance
appeared in single-limb stance; 88.5% of participants (n =
23) were not able to hold the position for 10 seconds or
more, and in 46.2% of participants (n = 12), single-limb
stance time was less than 3 seconds. Fifteen (57.7%) of the
subjects demonstrated difficulty in reaching forward with
an outstretched arm in standing, and 53.8% of participants
(n = 14) could not maintain tandem stance for 30 seconds.
In 2 cases (7.7%), some difficulties occurred in dynamic
balance tasks such as turning 360◦ and alternately placing
a foot on a step stool while standing unsupported.
The results of stabilography are presented in Table 5,
whereas Table 6 provides Spearman rank correlation co-
efficients between total point scores in the PBS and sway
parameters. There was a statistically significant correlation
(P < .05) between PBS total point scores and sway path,
average sway velocity, sway path in the anterioposterior
direction, as well as average sway velocity in the mediolat-
eral direction, with r values ranging from −0.44 to −0.48.
The strongest relationship was found between PBS scores
and sway path in the mediolateral direction (r = −0.58,
P < .005), as well as average sway amplitude in the medi-
olateral direction (r = −0.57, P < .005). The correlation
between PBS scores and stabilographic parameters in the
anterioposterior direction, such as average sway amplitude
and velocity, was weak and not significant.
DISCUSSION
In previous studies, balance abilities of children and
adolescents with VI were compared with those of their
peers with no impairments. The main finding was that
children and adolescents with VI perform worse than their
peers with typical development on both static and dynamic
balance tasks.3,4,6,7,9,10 However, those deficits have not
been analyzed in the context of activities of daily living.
Therefore, the difference compared to the groups without
VI may not imply that this discrepancy affects everyday
functioning of children and adolescents with VI.
Although all participants aged 10 to 15 years demon-
strated mastery in 9 of 14 items of the PBS, only 11.5% of
the group achieved the maximal score on the scale. Results
of previous studies indicate that the PBS reflects develop-
ment of balance control in children with typical develop-
ment and that they achieve the maximal score by the age of
9 years.18 According to Franjoine et al,17 30.3% of children
without impairments achieve the maximal point score on
the PBS by the age of 5 years, and in children and adoles-
cents aged 7 to 13 years, this percentage reaches 69.1%.
Thus, the present study seems to provide further evidence
Balance in Girls With Visual Impairment 463
 TABLE 4
Percentage of Participants Attaining Scores From 0 to 4 in 5 Pediatric Balance Scale Items (n = 26)

Point Score

PBS Item 4 3 2 1 0

8 Standing with one foot in front 46.2% (n = 12) 53.8% (n = 14) ... ... ...
9 Standing on one foot 11.5% (n = 3) 26.9% (n = 7) 15.4% (n = 4) 46.2% (n = 12) ...
10 Turning 360◦ 92.3% (n = 24) 7.7% (n = 2) ... ... ...
13 Placing alternate foot on stool 92.3% (n = 24) 3.8% (n = 1) 3.8% (n = 1) ... ...
14 Reaching forward with outstretched arm 42.3% (n = 11) 42.3% (n = 11) 11.5% (n = 3) 3.8% (n = 1) ...

Abbreviation: PBS, Pediatric Balance Scale.

TABLE 5 Thus, results of correlation analysis between the PBS and

Descriptive Statistics for Sway Parameters Recorded During 30-Second stabilography seem to provide some evidence of concurrent
Quiet Stance (n = 26) validity of the PBS in balance assessment of girls with VI.
Parameter Mean SD Range However, the relationship between PBS total point score
and sway parameters in the anterioposterior direction such
Sway path, mm 311.23 129.85 200.00-804.00
as average sway amplitude and velocity was not significant.
Average sway velocity, 10.40 4.33 6.70-26.80
mm/s Since, to our best knowledge, there were no studies that
ML sway path, mm 176.92 83.07 108.00-475.00 compared results of the PBS with that of stabilography in
AP sway path, mm 224.65 92.05 138.00-559.00 children with typical development, it is not clear whether
ML average sway 5.52 3.22 2.64-16.80 those results are specific for the population of the children
velocity, mm/s
and adolescents with VI or are because of the construction
AP average sway 7.22 3.33 4.05-19.10
velocity, mm/s of the scale itself, which may be more sensitive in identify-
ML average sway 4.66 2.00 2.04-9.80 ing balance deficits in the frontal plane. However, the com-
amplitude, mm parisons of static posturography and the BBS, which was
AP average sway 6.60 2.17 3.97-14.20 a basis for development of the PBS, revealed that the BBS
amplitude, mm
correlates better with anterioposterior parameters and the
Abbreviations: AP, anterioposterior; ML, mediolateral. speed of anterioposterior sway differentiates among sub-
jects walking with and without aids.19 Thus, the fact that in
the present study, the correlation between PBS scores and
TABLE 6 most of the stabilographic parameters in the sagittal plane
Spearman Rank Correlation Coefficients Between Pediatric Balance was not observed may be attributed to the characteristics
Scale Total Test Scores and Sway Parameters
of the sample, which was relatively homogenous with re-
PBS Total Test Scores (n = 26) spect to balance abilities, being composed of subjects who
walked independently.
Sway path −0.45a
Average sway velocity −0.46a
Another finding was that functional balance abilities
ML sway path −0.58b in girls with VI correlate most with stabilographic param-
AP sway path −0.44a eters in the frontal plane, such as mediolateral sway path
ML average sway velocity −0.48a and average sway amplitude. Some evidence in the liter-
AP average sway velocity −0.35 ature indicates that postural control in the frontal plane
ML average sway amplitude −0.57b
AP average sway amplitude −0.18
depends more on proprioceptive information, whereas in
the sagittal plane, we rely more on visual cues.2,12 More-
Abbreviations: AP, anterioposterior; ML, mediolateral; PBS, Pediatric over, mediolateral stability in blind athletes was found to
Balance Scale. be better than in people with blindness who were not in-
a P < .05.
b P < .005. volved in sports activities.5 Therefore, we can hypothesize
that appropriate interventions could contribute to the im-
provement of functional balance abilities in children and
that children and adolescents with VI have deficits in bal- adolescents with VI. Nevertheless, results of the present
ance control compared with their peers with no VI. study should be interpreted with caution, given the small
In this study, a moderate negative correlation (corre- sample size that may not be representative of children and
lation coefficients between −0.4 and −0.6) was found be- adolescents with VI.
tween the PBS total point scores of girls with VI and most The study highlights functional problems of children
of the stabilographic parameters. Correlation between sta- and adolescents with VI by using the PBS to examine the
bilographic and clinical measurement of balance with the abilities that are crucial to safely and independently meet
BBS, considered as the reference standard for functional the demands of everyday tasks, that is, changing positions,
balance assessment in adults, with an average value of maintaining position within a decreasing base of support,
−0.55,19 is similar to that obtained in the present study. and reaching beyond one’s base of support. Moreover, this

464 Żyłka et al Pediatric Physical Therapy

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
 study seems to provide some evidence on the validity of
the PBS as an assessment tool in this population. However,
before the scale is recommended for use in screening, as
well as in planning and evaluating the effectiveness of in-
terventions, other psychometric properties of the PBS in
this population need to be examined.
Girls with VI aged 10 to 15 years appear to have no
difficulties in balance control in the sitting position, dur-
ing transfers, and quiet standing. Nevertheless, problems
occur in the standing position when the size of the base of
support is narrowed, as well as in situations where the cen-
ter of gravity is approaching the edge of the base of support.
This situation occurs in 1 of the items of the PBS consisting
of reaching forward with an outstretched arm. Identifica-
tion of those deficits in an isolated clinical setting, using a
scale based on everyday tasks, suggests that these may ap-
pear in situations of daily living, when people with VI are
confronted with an environment that is constantly chang-
ing. As vision is a basic and the most accessible source
of information about the environment, which enables an
ongoing process of updating environmental information,
as well as calibration of other sensory systems, children
and adolescents with VI are more adversely affected by
changing conditions.20 Thus, difficulties in maintaining
balance that were identified in this study can be enhanced
by lowered illumination, the presence of motion, as well
as an unfamiliar environment, when walking on uneven
surfaces or while negotiating common indoor and outdoor
obstacles.
The results of this study demonstrate that VI itself
can lead to balance problems, which may affect every-
day functioning. This is an important issue that should
be taken into consideration by physical therapists, given
the high prevalence of VI among children and adolescents
with motor impairments or intellectual disability. It seems
that VI would further enhance motor problems in these
populations.
The present study has some limitations that must be
taken into consideration when interpreting the results.
One limitation of the study is the small sample size, which
is because of the low incidence of blindness and low vi-
sion among children and adolescents. Furthermore, as in
most studies on VI, subjects were not homogenous in their
level of vision and type of eye condition. In future studies,
factors such as age, gender, physical fitness level, as well
as the degree and cause of VI should be included in the
analysis of functional balance abilities in children and ado-
lescents with blindness and low vision to determine which
of those variables should be taken into account when de-
veloping and implementing interventions to improve their
everyday functioning. Moreover, the efficiency of different
interventions in improving functional abilities in children
and adolescents with VI should be verified.
CONCLUSIONS
The level of balance of girls with VI is sufficient for
independent sitting, standing, and transfers. Nevertheless,
Pediatric Physical Therapy
Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.
girls with VI have difficulties in balance control in the
standing position when the base of support is narrowed
as well as in situations where the center of gravity is ap-
proaching the edge of base of support. Those deficits in
balance control may appear in more complex activities
of daily life and in unfamiliar environments, which indi-
cates a need to provide interventions to improve the func-
tional balance abilities of children and adolescents with
VI. The present findings need to be confirmed by further
studies.
ACKNOWLEDGMENTS
The authors thank all the girls who participated in
this study and their families.
REFERENCES
1. Winter DA. Human balance and posture control during standing and
walking. Gait Posture. 1995;3:193-214.
2. Day BL, Streiger MJ, Thompson PD, et al. Effect of vision and stance
width on human body motion when standing: implications for affer-
ent control of lateral sway. J Physiol. 1993;469:479-499.
3. Ribadi H, Rider RA, Toole T. A comparison of static and dynamic
balance in congenitally blind, sighted, and sighted blindfolded ado-
lescents. Adapt Phys Activ Q. 1987;4:220-225.
4. Bouchard D, Tetreault S. The motor development of sighted children
and children with moderate low vision aged 8-13. J Vis Impair Blind.
2000;94:564-573.
5. Aydog E, Aydog ST, Cakci A, Doral MN. Dynamic postural stability
in blind athletes using the biodex stability system. Int J Sports Med.
2006;27:415-418.
6. Häkkinen A, Holopainen E, Kautiainen H, et al. Neuromuscular func-
tion and balance of prepubertal and pubertal blind and sighted boys.
Acta Paediatr. 2006;95:1277-1283.
7. Juodzbaliene V, Muckus K. The influence of degree of visual im-
pairment on psychomotor reaction and equilibrium maintenance of
adolescents. Medicina (Kaunas). 2006;42:49-56.
8. Schmid M, Nardone A, De Nunzio AM, et al. Equilibrium during
static and dynamic tasks in blind subjects: no evidence of cross-modal
plasticity. Brain. 2007;130:2097-2107.
9. Engel-Yeger B. Evaluation of gross motor abilities and self perception
in children with amblyopia. Disabil Rehabil. 2008;30:243-248.
10. Houwen S, Visscher C, Kemmink KAPM, et al. Motor skill perfor-
mance of school-age children with visual impairments. Dev Med Child
Neurol. 2008;50:139-145.
11. Ray C, Horvat M, Croce R, et al. The impact of vision loss on postural
stability and balance strategies in individuals with profound vision
loss. Gait Posture. 2008;28:58-61.
12. Giagazoglou P, Amiridis IG, Zafeiridis A, et al. Static balance control
and lower limb strength in blind and sighted women. Eur J Appl
Physiol. 2009;107:571-579.
13. Horvat M, Ray C, Ramsey VK, et al. Compensatory analysis and
strategies for balance in individuals with visual impairments. J Vis
Impair Blind. 2003;97:695-703.
14. Aki E, Atasavun S, Turan A, et al. Training motor skills of children
with low vision. Percept Mot Skills. 2007;104:1328-1336.
15. World Health Organization. International Classification of Diseases,
version 2010. http://apps.who.int/classifications/icd10/browse/2010/
en#/H54. Accessed March 1, 2012.
16. Franjoine MR, Gunther JS, Taylor MJ. Pediatric Balance Scale: a mod-
ified version of the Berg Balance Scale for the school-age child with
mild to moderate motor impairment. Pediatr Phys Ther. 2003;15:114-
128.
Balance in Girls With Visual Impairment 465
 17. Franjoine MR, Darr N, Held SL, et al. The performance of children
developing typically on the Pediatric Balance Scale. Pediatr Phys Ther.
2010;22:350-359.
18. Abraham A, Ravindra S. Assessment of age or attainment of bal-
ance in children using Pediatric Balance Scale (PBS). Childhood Dis-
ablity Update 2005—Conference Abstracts [serial online] . Pediatric
Oncall. 2006;(suppl 1):3. http://www.pediatriconcall.com/fordoctor/
conference abstracts/paediatric Balance Scale.asp. Accessed July 10,
2011.
19. Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures
of postural balance in an elderly population. Arch Phys Med Rehabil.
1992;73:1073-1080.
20. Kalloniatis M, Johnson AW. Visual environmental adaptation prob-
lems of partially sighted children. J Vis Impair Blind. 1994;88:234-243.

CLINICAL BOTTOM LINE

Commentary on “Functional Balance Assessment With Pediatric Balance Scale in Girls With Visual
Impairment”

“How should I apply this information?”

Physical therapy for children with visual impairment (VI) is important, as this population experiences gross
motor delays, which can lead to postural difficulties. An understanding of a child’s VI and its effect on functional
activities are factors to consider when establishing a therapy program to promote safe participation in daily roles.
For the sample of girls with VI recruited for this study, difficulties were seen in the dynamic standing activities
of the Pediatric Balance Scale. A significant negative correlation was found between Pediatric Balance Scale scores
and mediolateral sway amplitude and velocity measured using stabilography. Therefore, intervention that focuses
on functional standing tasks and improving stability in the mediolateral plane may be beneficial. The results may
also guide the physical therapist to address balance instability earlier in a child’s life, to possibly minimize or avert
the challenges identified in adolescence.
“What should I be mindful about when applying this information?”
A specific test measure has not been established to assess the functional capabilities of children and adolescents
with VI. While the study found correlations between Pediatric Balance Scale and stabilography, the generalizability
is limited because of the sample studied. The results were derived from a small sample size of adolescent girls
who had varying levels of VI and did not have physical or cognitive impairments. Further research is needed to
establish a broader research base of reference to measure balance for children and adolescents with VI.

Elissa Rynearson, PT, DPT

California Children’s Services, County of Los Angeles
Gardena, California
Stephanie Yu, PT, MSPT, PCS
California Children’s Services, County of Los Angeles
El Monte, California
The authors declare no conflict of interest.
DOI: 10.1097/PEP.0b013e31829de6ec

466 Żyłka et al Pediatric Physical Therapy

Copyright © 2013 Wolters Kluwer Health | Lippincott Williams & Wilkins and the Section on Pediatrics of the American Physical Therapy
Association. Unauthorized reproduction of this article is prohibited.