star excursion balance mat

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The MegaMAT TM   was designed by Movement Assessment Technologies TM   to help you improve your assessment and 3-dimensional training of your clients and athletes. 

With the MegaMAT TM  you can perform all of the same game-changing assessments that you can with the  MAT TM   , including:

• Star Excursion Balance Test (SEBT)
• Y-Balance test (YBT)
• Weight Bearing Lunge Test (WBLT)
• Hop + Jump tests
• Squats tests
• Lunge tests
• Closed Kinetic Chain Upper Extremity Test (CKCUET)
• Upper Quarter Y-Balance Test (UQYBT)
• Star Excursion Sitting Test (SEST)
• Standing Long Lump
• and many, many more Functional Performance Tests

However, the MegaMAT TM  is not only an amazing assessment tool, but a unique training environment to enhance the way your clients move.

It has been designed to allow you to train your clients in all 3-dimensions, giving you endless movement and exercise prescription options.

The MegaMAT TM  has many built-in elements to enhance neuroplasticity, balance, reaction, decision making to help improve movement variability and adaptability. Get instant biofeedback and train with more specificity each rep with full 360-degree measurement.

Build more robust individuals and take your client and athlete training to the next level by purchasing a  MegaMAT TM today. 

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Star Excursion Balance Test & Dynamic Postural Control

• Anterior (ANT), posteromedial (PM) and posterolateral (PL) lines.
• Stand on the central point.
• Hands on hips. 
• Reach as far as you can along the line and gently tap the line.
• Do not come to rest on the line.
• Do not transfer your body weight onto the reaching leg.

FACTORS AFFECTING PERFORMANCE 

• Vastus medialis is most active in anterior reach. 
• Vastus lateralis is least active in lateral reach.
• Medial hamstring is most active during anterolateral reach.
• Bicep femoris was most active during posterior and posterolateral reach. 

WHAT DOES THE SEBT TELL US?

Chronic ankle instability (cai):.

• In CAI, all three directions have the ability to identify reach deficits in participants compared to healthy controls, however, the PM is the most representative of the overall performance (Hertel, Braham, Hale & Olmsted-Kramer., 2006). 
• Anterior reach is more impacted by dorsiflexion ROM and plantar cutaneous sensation, meaning that mechanical restrictions and sensory deficits impact this movement.
• DF ROM is best evaluated with the knee to wall weight bearing lunge test compared to non weight bearing AROM (Dill et al., 2014). 
• Posteromedial and posterolateral reach is more impacted by eversion strength and balance control. 
• De la Motte, Arnold & Ross (2015) studied the movement pattern differences in trunk rotation and found that patients with CAI are more likely to use increased trunk flexion during anterior reach which suggests a compensation strategy for reduced ankle control is to manipulate the pelvis and trunk. 

ANTERIOR CRUCIATE LIGAMENT RECONSTRUCTION (ACLR):

• The same authors (De la Motte, Arnold & Ross., 2015, p.358) also studied trunk movements in ACL patients and found that following an ACLR, when reaching forward, patients are more likely to rotate their trunk away (backwards) from the reach leg and externally rotate the pelvis on the stance leg. 
• In a different study following ACLR, researchers found that when looking above the ankle and at the knee, patients with reduced quadricep strength have reduced reach capacity in the anterior directions (Clagg, Daterno, Hewett & Schmitt., 2015). 
• These same authors also found that hip abductions strength impacts all 3 directions, telling us that dynamic balance has contributions from the foot, ankle, knee, hip and trunk and our assessment of movement patterns should try consider all these areas too. 

PATELLOFEMORAL PAIN SYNDROME (PFPS):

IMPLEMENTATION INTO REHAB

REFERENCES:

Erson Religioso III, DPT, FAAOMPT

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Star Excursion Balance Test

The Star Excursion Balance Test (SEBT) is a dynamic test that requires strength, flexibility, and proprioception. It is a measure of dynamic balance that provides a significant challenge to athletes and physically active individuals.

The test can be used to assess physical performance, but can also be used to screen deficits in dynamic postural control due to musculoskeletal injuries (e.g. chronic ankle instability), to identify athletes at greater risk for lower extremity injury, as well as during the rehabilitation of orthopedic injuries in healthy active adults (1)

Research has suggested to use this test as a screening tool for sport participation as well as a post-rehabilitation test to ensure dynamic functional symmetry. 

Figure (physiopedia)

How to perform The SEBT:

Conducting the Test (science for sport)

• The athlete should be wearing lightweight clothing and remove their footwear. After doing so, they are the required to stand in the centre of the star, and await further instruction.
• When using the right foot as the reaching foot, and the left leg to balance, the athlete should complete the circuit in a clockwise fashion. When balancing on the right leg, the athlete should perform the circuit in an anti-clockwise fashion.
• With their hands firmly placed on their hips, the athlete should then be instructed to reach with one foot as far as possible and lightly touch the line before returning back to the starting upright position.
• With a pencil, the test administrator should mark the spot at which the athlete touched the line with their toe. This can then be measured from the centre spot after the test to calculate the reach distance of each reach direction. Reach distances should be recorded to the nearest 0.5cm (22).
• They should then repeat this with the same foot for all reach directions before changing foot.
• After they have completed a full circuit (every reach direction) with each foot, they should then repeat this process for a total of three times per leg. For example, they should have three anterior reach performances for both their right and left leg.
• Once the athlete has performed 3 successful reaches with each foot in all directions, they are then permitted to step away from the testing area.
• The test administrator should have recorded the reach distance of each successful attempt, with a pencil, in order to calculate the athlete’s SEBT score after the test.

Scoring System

With the test complete and all performances measured and recorded, the test administrator can then calculate the athlete’s SEBT performance scores using the following simple equations:

• Average distance in each direction (cm) = Reach 1 + Reach 2 + Reach 3 / 3
• Relative (normalised) distance in each direction (%) = Average distance in each direction / leg length * 100

These calculations should be performed for both the right and left leg in each direction, providing you with a total of 16 scores per athlete.

 Normative data

Figure ( Miller, T., 2012).

• According to Hertel, Miller, and Deneger (2000), the reliability of the SEBT ranges between r = 0.85-0.96
• According to Plisky et al (2006), the reliability of this test ranges between 0.82-0.87 and scores 0.99 for the measurement of limb length
• Chaiwanichsiri et al (2005) concluded that the Star Excursion Balance training was more effective than a conventional therapy program in improving functional stability of a sprained ankle
• Plisky et al (2009) concluded that the intra-rater reliability of the SEBT as being moderate to good (ICC 0.67- 0.97) and inter-rater reliability as being poor to good (0.35-0.93) [2]

Supporting Articles/text

Advanced fitness assessment and exercise prescription. Heyward V. Human kinetics, 6th edition: 303 (5)

Miller, T. (2012). National Strength and Conditioning Association. Test and Assessment. Human Kinetics. Champagne, IL.

Bressel E, Yonker JC, Kras J, Heath EM. Comparison of Static and Dynamic Balance in Female Collegiate Soccer, Basketball, and Gymnastics Athletes. Journal of Athletic Training 2007;42(1):42–46.

Chaiwanichsiri D., Lorprayoon E., Noomanoch L. (2005). Star Excursion Balance Training : Effects on Ankle Functional Stability after Ankle Sprain. Journal of Medical Association Thailand 88(4): 90-94 (1B)

Plisky P., Rauh M., Kaminski T., Underwood F (2006) Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. Journal of Orthopaedic and Sports Physical Therapy. 36 (12) (1B)

Plisky P et al. (2009). The Reliability of an Instrumented Device for Measuring Components of the Star Excursion Balance Test.  American Journal of Sports Physical Therapy. 4(2): 92–99. (2B)

Star Excursion Balance Test

My favourite dynamic postural control objective outcome measure.

Firstly, thanks for checking out the video. I hope that it was helpful and if you are not already using the Star Excursion Balance Test you will now.  This is the information that I felt was too ‘nitty gritty’ to include in the video.

Reliability of the Star Excursion Balance Test

The reliability of the SEBT components utilised (i.e. the anterior, posteromedial and posterolateral) ranged from 0.82 to 0.87 (ICC3,1) (Plisky et al. 2006). To put this in perspective, it is of similar reliability to assessing knee flexion ROM with a universal goniometer (Brosseau et al. 1997).

Clinical Implications of This Measure

Assessing Intervention Effectiveness: as a reliable measure, you can use it to gauge an athletes improvements in dynamic postural control over time.

Injury Prediction: Plisky et al. (2006) showed that athletes with anterior left/right reach differences greater than 4 cm were 2.5 times more likely to sustain a lower limb injury over the course of a season. They also found that female athletes with a composite reach distance less than 94.0% of their limb length (measured from ASIS to lateral malleolus) were 6.5 times more likely to have a lower extremity injury!

Relevant to Athletic Population: the SEBT is sensitive enough to show dynamic postural control in a number of athletic populations including ACL deficient and Chronic Ankle Instability patients (Herrington et al. 2009; Hertel et al. 2006).

Conclusions

My conclusion is that is a sweet test. If you want to objectively assess an athlete’s responses to neuromuscular and postural control training (and honestly why would you not) this is your go-to. This can be a massive motivational tool, and also proves how helpful your exercises are. Also, if you want to “pre-screen” for injury this can also be used as a helpful predictor and should be a component of your assessment.

Go set it up right now, and enjoy your new favourite outcome measure.

Brosseau L, Tousignant M, Budd J, Chartier N, Duciaume L, Plamondon S, O’Sullivan JP, O’Donoghue S, Balmer S. Intratester and intertester reliability and criterion validity of the parallelogram and universal goniometers for active knee flexion in healthy subjects. Physiotherapy Research International 1997; 2(3):150-166

Herrington L, Hatcher J, Hatcher A,  McNicholas M. A comparison of Star Excursion Balance Test reach distances between ACL defiient patients and asymptomatic controls. The Knee 16 (2009) 149–152

Hertel J, Braham RA, Hale SA, Olmsted Kramer LC. Simplifying the Star Excursion Balance Test: Analyses of Subjects With and Without Chronic Ankle Instability. J Orthop Sports Phys Ther 2006;36:131-137.

Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a Predictor of Lower Extremity Injury in High School Basketball Players. J Orthop Sports Phys Ther 2006;36(12):911-919

Related Posts

hey fellow profession,

im a brazilian academic of physiotherapy and my work of completion of course is about a star test balance in injury of ACL and I don’t have found articles about SEBT, so you can send me your references on this post???

i really need… thanks

Natália Goulart ( [email protected] )

Hi Natália,

Thanks for your interest. Unfortunately, I am not able to distribute PDF documents of articles given this is digital piracy. You can, however, access these articles via each Journal’s website e.g. Journal of Orthopaedic Sports and Physical Therapy: http://www.jospt.org/ .

Hope this helps you out!

I currently using SEBT for my dissertation and I am at the point of putting the results into microsoft excel. What I wanted to know was what is the correct equation for measuring the composite scores?

Hope you can answer this Thanks

Seti ( [email protected] )

[…] This post was mentioned on Twitter by The Sports PT, The Sports PT. The Sports PT said: My favourite dynamic postural control measure – The Star Excursion Balance Test. http://bit.ly/9Eo7GN #physiotherapy #physicaltherapy […]

Star Excursion Balance Test

The Star Excursion Balance Test (SEBT) is a simple, but time intensive, test used to measure dynamic balance/dynamic postural control.

By Owen Walker Last updated: February 29th, 2024 8 min read

Contents of Article

What is the Star Excursion Balance Test?

Why is balance important in sports, how do you conduct the star excursion balance test, what is the star excursion balance test scoring system, is the star excursion balance test valid and reliable, further reading.

• About the Author

The Star Excursion Balance Test was developed to be a reliable measure of dynamic stability. Since then, it has proven to be a sensitive indicator of lower limb injury risk in a variety of populations. To add to this, the Star Excursion Balance Test has been shown to have high levels of intra-rater test-retest reliability , though no validity coefficients have been studied.

The Star Excursion Balance Test (SEBT) is a relatively simple, but somewhat time-intensive, test used to measure dynamic balance, otherwise known as dynamic postural control (1). It measures dynamic balance by challenging athletes to balance on one leg and reach as far as possible in eight different directions (2). Though the SEBT is very similar to the Y Balance Test TM , it is important to understand that these are in fact different, with the Y Balance Test TM being a newer and condensed version of the SEBT.

Performance on the SEBT has been shown to differentiate between individuals with lower limb conditions such as chronic ankle instability (3-10), patellofemoral pain (11), and anterior cruciate ligament reconstruction (12). To add to this, the SEBT is even capable of assessing improvements in dynamic balance following training interventions (13, 14).

Perhaps the SEBT’s greatest talent is its ability to identify athletes with a higher risk of lower limb injury. For example, an anterior reach asymmetry of greater than 4cm during the SEBT has been suggested to predict which individuals are at higher risk of lower limb injury (15). However, other researchers have found that only female athletes with a composite score of less than 94 % of limb length were at greater risk of injury (15). More recent research in collegiate American football players has shown that athletes with a composite score of less than 90 % are 3.5 times more likely to sustain an injury (16).

All of this information suggests that each sport and population (e.g. gender) appear to have their own injury risk cut-off point (15, 16).

Balance, otherwise known as ‘postural control’, can be defined statically as the ability to maintain a base of support with minimal movement, and dynamically as the ability to perform a task while maintaining a stable position (17, 18). In a chaotic sporting environment, the ability to maintain a stable position is vital not only for successful application of the skill but to also reduce the likelihood of injury (15, 16, 19).

As dynamic balance is an integral part of performance, and poor balance is related to a higher risk of injury (20, 21, 15), then it may be of great interest to test and monitor an athlete’s dynamic stability.

It is important to understand that whenever fitness testing is performed, it must be done so in a consistent environment (e.g. facility) so it is protected from varying weather types, and with a dependable surface that is not affected by wet or slippery conditions. If the environment is not consistent, the reliability of repeated tests at later dates can be substantially hindered and result in worthless data.

Required Equipment Before the start of the test, it is important to ensure you have the following items:

• Reliable and consistent testing facility (minimum 2×2 metres (m)).
• Test administrator(s)
• Sticky tape (minimum 8m)
• Measuring tape
• Performance recording sheet

Test Configuration Video 1 displays the test configuration for the SEBT. This setup must be adhered to if accurate and reliable data is desired. The test administrator should stick four 120 cm lengths of sticky tape onto the floor, intersecting in the middle, and with the lines placed at 45°   angles (2).

Participants should thoroughly warm up prior to the commencement of the test. Warm-ups should correspond to the biomechanical and physiological nature of the test. In addition, sufficient recovery (e.g. 3-5 minutes) should be administered following the warm-up and prior to the commencement of the test.

Conducting the test

• The athlete should be wearing lightweight clothing and remove their footwear. After doing so, they are then required to stand in the centre of the star and await further instruction.
• When using the right foot as the reaching foot, and the left leg to balance, the athlete should complete the circuit in a clockwise fashion. When balancing on the right leg, the athlete should perform the circuit in an anti-clockwise fashion.
• With their hands firmly placed on their hips, the athlete should then be instructed to reach with one foot as far as possible and lightly touch the line before returning back to the starting upright position.
• With a pencil, the test administrator should mark the spot at which the athlete touched the line with their toe. This can then be measured from the centre spot after the test to calculate the reach distance of each reach direction. Reach distances should be recorded to the nearest 0.5cm (22).
• They should then repeat this with the same foot for all reach directions before changing foot.
• After they have completed a full circuit (every reach direction) with each foot, they should then repeat this process for a total of three times per leg. For example, they should have three anterior reach performances for both their right and left leg.
• Once the athlete has performed three successful reaches with each foot in all directions, they are then permitted to step away from the testing area.
• The test administrator should have recorded the reach distance of each successful attempt, with a pencil, in order to calculate the athlete’s SEBT score after the test.

NOTE: Failed attempts include the following:

• The athlete cannot touch their foot down on the floor before returning back to the starting position. Any loss of balance will result in a failed attempt.
• The athlete cannot hold onto any implement to aid their balance.
• The athlete must keep their hands on their hips at all times throughout the test.
• The athlete must lightly touch their toe on the reach line whilst staying in full control of their body. Any loss of balance resulting in a heavy toe/foot contact with the floor should be regarded as a failed attempt.

With the test complete and all performances measured and recorded, the test administrator can then calculate the athlete’s SEBT performance scores using the following simple equations (17):

• Average distance in each direction (cm) = Reach 1 + Reach 2 + Reach 3 / 3
• Relative (normalised) distance in each direction (%) = Average distance in each direction / leg length * 100

These calculations should be performed for both the right and left leg in each direction, providing you with a total of 16 scores per athlete.

Though no validity coefficients are available for the SEBT, authors (23) have provided evidence that the SEBT is sensitive for screening various musculoskeletal injuries (17). Furthermore, high intratester reliability has been found for the SEBT (intraclass correlation coefficients = 0.78 – 0.96) (24).

We suggest you now check out this article on The Landing Error Scoring System (LESS).

All information provided in this article is for informational and educational purposes only. We do not accept any responsibility for the administration or provision of any testing conducted, whether that results in any positive or negative consequences. As an example, we do not take any responsibility for any injury or illness caused during any test administration. All information is provided on an as-is basis.

• Nelson, Brian D., “Using the Star Excursion Balance test as a predictor of lower extremity injury among high school basketball athletes” (2012).Theses and Dissertations. Paper 389. [Link]
• Gribble PA, Kelly SE, Refshauge KM, Hiller CE. Interrater Reliability of the Star Excursion Balance Test. Journal of Athletic Training 2013;48(5):621–626. [PubMed]
• Akbari M, Karimi H, Farahini H, Faghihzadeh S. Balance problems after unilateral lateral ankle sprains. J Rehabil Res Dev. 2006;43(7): 819–824. [PubMed]
• Gribble PA, Hertel J, Denegar CR. Chronic ankle instability and fatigue create proximal joint alterations during performance of the Star Excursion Balance Test. Int J Sports Med. 2007;28(3):236–242. [PubMed]
• Gribble PA, Hertel J, Denegar CR, Buckley WE. The effects of fatigue and chronic ankle instability on dynamic postural control. J Athl Train. 2004;39(4):321–329. [PubMed]
• Hale SA, Hertel J, Olmsted-Kramer LC. The effect of a 4-week comprehensive rehabilitation program on postural control and lower extremity function in individuals with chronic ankle instability. J Orthop Sport Phys Ther. 2007;37(6):303–311. [PubMed]
• Hertel J, Braham RA, Hale SA, Olmsted-Kramer LC. Simplifying the Star Excursion Balance Test: analyses of subjects with and without chronic ankle instability. J Orthop Sport Phys Ther. 2006;36(3):131– 137. [PubMed]
• Martinez-Ramirez A, Lecumberri P, Gomez M, Izquierdo M. Wavelet analysis based on time-frequency information discriminate chronic ankle instability. Clin Biomech (Bristol, Avon). 2010;25(3): 256–264. [PubMed]
• Nakagawa L, Hoffman M. Performance in static, dynamic, and clinical tests of postural control in individuals with recurrent ankle sprains. J Sport Rehabil. 2004;13(3):255–268. [Link]
• Olmsted LC, Carcia CR, Hertel J, Shultz SJ. Efficacy of the Star Excursion Balance Tests in detecting reach deficits in subjects with chronic ankle instability. J Athl Train. 2002;37(4):501–506. [PubMed]
• Aminaka N, Gribble PA. Patellar taping, patellofemoral pain syndrome, lower extremity kinematics, and dynamic postural control. J Athl Train. 2008;43(1):21–28. [PubMed]
• Herrington L, Hatcher J, Hatcher A, McNicholas M. A comparison of Star Excursion Balance Test reach distances between ACL deficient patients and asymptomatic controls. Knee. 2009;16(2):149–152. [PubMed]
• McKeon PO, Ingersoll CD, Kerrigan DC, Saliba E, Bennett BC, Hertel J. Balance training improves function and postural control in those with chronic ankle instability. Med Sci Sports Exerc. 2008; 40(10):1810–1819. [PubMed]
• McLeod TC, Armstrong T, Miller M, Sauers JL. Balance improvements in female high school basketball players after a 6- week neuromuscular-training program. J Sport Rehabil. 2009;18(4): 465–481. [PubMed]
• Plisky PJ, Rauh MJ, Kaminski TW, Underwood FB. Star Excursion Balance Test as a predictor of lower extremity injury in high school basketball players. J Orthop Sports Phys Ther. 2006;36(12):911–919. [PubMed]
• Butler RJ, Lehr ME, Fink ML, Kiesel KB, Plisky PJ. Dynamic balance performance and noncontact lower extremity injury in college football players: an initial study. Sports Health. 2013;5(5): 417–422. [PubMed]
• Bressel E, Yonker JC, Kras J, Heath EM. Comparison of Static and Dynamic Balance in Female Collegiate Soccer, Basketball, and Gymnastics Athletes. Journal of Athletic Training 2007;42(1):42–46. [PubMed]
• Winter DA, Patla AE, Frank JS. Assessment of balance control in humans. Med Prog Technol. 1990;16:31–51. [PubMed]
• Zazulak B, Cholewicki J, and Reeves NP. Neuromuscular control of trunk stability: Clinical implications for sports injury prevention. J Am Acad Orthop Surg 16: 497–505, 2008. [PubMed]
• de Noronha M, Franca LC, Haupenthal A, Nunes GS. Intrinsic predictive factors for ankle sprain in active university students: a prospective study [published online January 20, 2012]. Scan J Med Sci Sports. doi:10.1111/j.1600-0838.2011.01434. [PubMed]
• McGuine T. Sports injuries in high school athletes: a review of injury-risk and injury-prevention research. Clin J Sports Med. 2006;16:488-499. [PubMed]
• Shaffer SW, Teyhen DS, Lorenson CL, Warren RL, Koreerat CM, Straseske CA, Childs JD. Y-Balance Test: a reliability study involving multiple raters. Mil Med. 2013;178(11):1264-70. [PubMed]
• Olmstead L, Carcia C, Hertel J, Shultz S. Efficacy of star excursion balance test in detecting reach deficits in subjects with chronic ankle instability. Journal of Athletic Training. 2002;37(4):501-507. [PubMed]
• Hertel J, Miller S, Denegar C. Intratester and intertester reliability during the star excursion balance test. Journal of Sport Rehabilitation. 2000;9(1):104-116. [Link]

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Owen is the Founder of Science for Sport and has a Master’s degree in Strength & Conditioning and a Bachelor’s degree in Sports Conditioning & Rehabilitation from Cardiff Metropolitan University. Before founding Science for Sport, he was the Head of Academy Sports Science at Cardiff City Football Club, and an interim Sports Scientist for the Welsh Football Association.

He’s published research on the ‘Practical Applications of Water Immersion Recovery Modalities for Team Sports’ in the Strength & Conditioning Journal by the NSCA (National Strength & Conditioning Association). He has also been featured in the Sports Business Journal and The Roar, Australia’s leading sports opinion website.

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Description of the Star Excursion Balance Test (SEBT)

March 22nd, 2018 · no comments · balance.

The Star Excursion Balance Test (SEBT) is a test of dynamic balance, which requires subjects to balance on one leg and reach as far as possible in eight different directions. This test has been used as an indicator of lower limb injury risk. Read about the Star Excursion Balance Test , and the similar Y-Balance Test  which was derived from this test.

Tags: balance

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Validity and reliability of upper extremity star excursion balance test in adolescent swimmers

a Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China

Yong-Hui Zhang

b Graduate School, Xi'an Physical Education University, Xi'an, China

Thanh Luan Ngo

Qiong zhang.

c Shanghai Changning Youth Amateur Sports School, Shanghai, China

Zhimin Feng

Xue-qiang wang.

d Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China

Associated Data

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Upper limb balance is one of the important physical fitness parameters for all populations, especially overhead athletes like swimmers. Upper extremity star excursion balance test (UESEBT) is a comprehensive dynamic balance assessment, this study aims to explore the reliability and validity of UESEBT among adolescent swimmers.

This cross-sectional study recruited 70 adolescent swimmers. All participants were required to complete UESEBT, upper quarter Y-balance test (UQYBT), maximal isometric strength (MIS) tests in upper limb, closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET). The intra- and inter-operator reliability and the correlation of UESEBT with other physical performances were conducted.

For reliability, the intra- and inter-operator reliability of all directions and composite score were high-to-excellent (ICC = 0.706−1.000) among all participants. For validity, the UESEBT has a moderate-to-strong correlation with UQYBT ( r  = 0.42−0.72, p  < 0.001), and a weak-to moderate one with CKCUEST ( r  = 0.25−0.42, p  < 0.05). Furthermore, the UESEBT performance showed weak-to-moderate correlations with MIS ( r  = 0.24−0.44, p  < 0.05). UESEBT was correlated to LTET ( r  = 0.24−0.33, p  < 0.05) whereas no relationship was found with TFET.

Conclusions

UESEBT was a reliable and valid tool to screen upper extremity dynamic balance among adolescent swimmers. UESEBT provides more detailed information in eight directions to assess the upper limb sport performance. Further study should explore the prediction ability of UESEBT for injury.

1. Introduction

Balance is defined as the ability to prevent body from falling, 1 which is essential for maintaining body posture, especially when executing complicated sport activities. Normally, balance could be classified into dynamic and static. To elaborate, static balance is the balance in stationary circumstances while dynamic balance accounts for the balance during motion and position transformation, 1 which is more frequently challenged among athletes. Better dynamic balance control could decline the deviations of center of mass during complex movement, thereby minimizing the possibility of potential injuries. 2 Therefore, the screening assessments evaluating the dynamic balance performance of athletes are demanding.

Different dynamic balance tests could also be categorized based on the targeted body part. In lower limb, lower quarter Y-balance test (LQYBT) and star excursion balance test (SEBT) are two primary tests used in clinical practice. LQYBT can validly predict lower limb injuries among volleyball players and runners 3 , 4 and it has been proven to be reliable among adults (ICC = 0.80−0.93), healthy adolescents (ICC = 0.40−0.96), and soccer players (ICC = 0.85−1.00). 5 , 6 Similarly, SEBT has been used to predict lower extremity injuries in basketball and soccer players. 7 , 8 The reliability of SEBT among adults (ICC = 0.86−0.92) and elite athletes (ICC = 0.90−0.95) has been demonstrated. 9 , 10 Meanwhile, the test targeting upper limb balance is fewer probably because the primary function of upper limb and lower limb differs. 11 That is to say, the upper limb requires more flexibility to account for technical and precise movement while the lower limb requires more stability for support. Nevertheless, stability is also essential for joints in upper limb when coping with perturbation, especially for the mobility-demanding one like glenohumeral. Lacking adequate stability, the joints could not return to its initial position, which might cause capsule laxity or further shoulder-related injury. 11 According to present research, Upper Quarter Y-Balance Test (UQYBT) is a frequently reported upper limb stability test among various populations and sports. 12 , 13 , 14 The UQYBT has been proved valid and reliable in healthy adolescents. 15 Considering swimming is a sport event requiring the full-range strength and endurance of upper limb 16 and that approximately 91% of professional swimmers experience shoulder injuries, 17 the assessments of upper limb dynamic stability is helpful to evaluate sport performance and predict future injuries for swimmers. 18 Nevertheless, UQYBT only contains information from three reach directions and the potential risks may not be fully screened. As a more comprehensive upper limb dynamic balance test, upper extremity star excursion balance test (UESEBT) could provide data in eight directions which enables clinicians and coaches to trace the deficits. However, the reliability and validity of UESEBT among adolescent swimmers has not been revealed.

The present study aimed to investigate the validity and reliability of UESEBT among 70 adolescent swimmers. The study purposed to report the inter- and intra-operator reliability of UESEBT and explore the criterion and construct validity (specifically convergent validity, a subtype of construct validity) of UESEBT. For criterion validity, the correlation between UESEBT and UQYBT was conducted. For construct validity, the correlation between UESEBT and other outcome measures, including maximal isometric strength (MIS), closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET), were measured.

Seventy adolescent swimmers were recruited in this cross-sectional study. Sample size was estimated based on Walter et al. 19 To match our study design, three replicates per subject, p 0  = 0.6, p 1  = 0.8, a = 0.05 and power = 0.8 were applied, then the sample size should be 26.1. The inclusion criteria were as follows: (1) training onsets more than 1-year and training at least three times a week (2) aged from 9 to 19 (3) no injury history within 3 months with irritating pain during the test. The exclusion criteria were as follows: (1) with any cardiac-related or mental-related conditions (2) disobedient behavior during the test. This study was approved by the local Human Ethics Committee (2018042). All willing participants and their legal guardians signed informed consent forms prior to the tests.

Prior to the test, basic and swimming-related information, injury history, and limb dominance were collected. In addition, the right upper limb length was measured and the average values of three assessments were used for analysis. 20 After that, a series of evaluation including UESEBT, UQYBT, MIS test, CKCUEST, TFET, and LTET were performed in random sequence. 21 In addition, the inter- and intra-operator reliability of the UESEBT were measured. For inter-operator reliability, participants performed one test procedure and operators A and B who were blinded to each other individually read and recorded the distances. For intra-rater reliability, participants repeated the same test procedure immediately and only operator A read and recorded the distances.

Eight directions including anterior, superomedial, medial, inferomedial, posterior, inferolateral, lateral, and superolateral were marked on floor by tapes with scale and the angle between each strip of tape were 45°. The minimum unit of the UESEBT was 0.5 cm. Before the formal test, a staff provided a comprehensive demonstration. One practice was required for each participant before formal tests. Participants stayed in a push-up position and placed the palm of the stance limb on the intersection of tapes. Then, maximal reach of free limb was performed. Hip flexion was permitted whereas stance limb flexion was not allowed. Distances for analysis were normalized by dividing the right upper limb length of every participant, and then multiplying by 100. Additionally, the composite score was calculated by summing up the normalized reach distances and dividing it by 8. The UESEBT included the maximal reach with dominant (D) and non-dominant (ND) limb as stance limb. The test was invalid and repeated if the substandard incidents were observed (1) foot was not contacted with floor; (2) distance between two feet exceed 12 inches; (3) unilateral stability was not maintained. One test procedure required the participants to repeat the UESEBT twice. The average values of the two UESEBTs in one test procedure were regarded as the outcome of this test procedure.

Detailed procedures of other physical performance including UQYBT, MIS test, CKCUEST, TFET, and LTET were depicted in Supplementary 1. For UQYBT, the average values of two measurements were determined for analysis. For MIS test and CKCUEST, the maximal values of two assessments were used for analysis. For TFET and LTET, only once performance was required.

IBM SPSS Statistics 25.0 was applied to analyze the data. All 70 participants were divided into two groups based on gender, median age or median training onsets, respectively. The reliability of UESEBT were processed by conducting intraclass correlation coefficients (ICC) 3.1 . The different level of ICCs was interpreted based on the research of Domholdt et al., 22 where 0.90–1.00 meant “excellent reliability,” 0.70–0.89 meant “high reliability,” 0.50–0.69 meant “moderate reliability,” 0.26–0.49 meant “low reliability,” and 0.00–0.25 meant “little reliability.” The level of agreement and systematic error of reliability was indicated by Bland–Altman plots. For validity, two-tailed Spearman test was applied to determine the correlation between UESEBT with CKCUEST, TFET, LTET and ipsilateral MISs. In addition, the correlation between UESEBT and UQYBT in the corresponding three directions was also carried out. The outcome of Spearman test was interpreted as follows: 0.80–1.00 meant “very strong,” 0.60–0.79 meant “strong,” 0.40–0.59 meant “moderate,” 0.20–0.39 meant “weak,” and 0.00–0.19 meant “very weak.”

The personal characteristics and swimming performance of all, male, and female participants are demonstrated in Table 1 . The mean age and body mass index (BMI) of all participants was 12.32 years old and 17.55 kg/m 2 , respectively. Their mean training onsets and volume were 4.83 years and 24.73 km per week, respectively. Among the 70 participants, 19 reported injury history (Knee: 6, ankle: 5, wrist and hand: 6, elbow: 1, scoliosis: 1).

Table 1

Demographics and characteristics of all participants.

Note: All participants were divided into two groups based on gender. Data were presented as Mean ± SD or as the number of participants (%).

Abbreviations: BMI: Body Mass Index; CKCUEST: Closed Kinetic Chain Upper Extremity Stability Test; TFET: Trunk Flexor Endurance Test; LTET: Lateral Trunk Endurance Test.

Detailed information about intra- and inter-operator reliability of UESEBT in all participants were provided in Table 2 and the reliability in participants with different gender was demonstrated in Table 3 . The Bland–Altman plots for reliability were also provided from Figs. S1–S9 (Supplementary 2). Overall, the composite intra-operator reliability of UESEBT was excellent (D ICC = 0.923, ND ICC = 0.905). To narrow down in eight directions, the intra-operator reliability of every direction ranged from high to excellent regardless of the dominance of stance limb (ICC = 0.706−0.937). Of interest, it was observed that there was a drop in intra-operator reliability from anterior (D ICC = 0.780, ND ICC = 0.788) to superomedial (D ICC = 0.737, ND ICC = 0.743), followed by a successive increase. Once it reached the peak at posterior (D ICC = 0.937, ND ICC = 0.892), it started to decline. Furthermore, a similar pattern can also be witnessed when observing intra-operator reliability of participants with different gender. The intra-operator reliability of UESEBT among male and female participants was also high-to-excellent (ICC = 0.703−0.949) except for the one in the inferomedial direction on ND side of male (ICC = 0.675).

Table 2

Inter- and Intra-operator reliability of Upper Extremity Star Excursion Balance Test in all swimmers.

Abbreviations: A1: the first measurement outcome of operator A; A2: the second measurement outcome of operator A; B: the measurement outcome of operator B; SEM: standard error of measurement; MDC: minimum detectable change; ICC: intraclass correlation coefficient; CI: confidence interval.

Table 3

ICC values with 95% CI for inter- and intra-operator reliability of Upper Extremity Star Excursion Balance Test in swimmers with different gender.

Abbreviations: ICC: intraclass correlation coefficient; CI: confidence interval.

Whether side and gender factor influence reliability are detected by comparing the frequencies. As for side factor, the composite intra-operator reliability was slightly higher on D side than that on ND side among all participants and participants in different gender. Breaking into eight directions, the reach distances in 4 out of 8 directions on D side were higher among all participants. In addition, the intra-operator reliability in 5 out of 8 directions on D side were higher among male and female participants. With regard to gender factor, the composite intra-operator reliability of in female was higher than that in male regardless the dominance of stance limb. Breaking into directions, the intra-reliability in 10 out of 16 directions in female participants was higher than that in male. Above all, no obvious gender and side difference in number was observed, indicating that gender and side might not be influential factors for reliability in adolescent swimmers. Similarly, the results of age and training onsets subgroups showed that they did not have obvious impact on reliability and relative information was demonstrated in Supplementary 2 ( Table S1 and Table S2 ).

As for inter-operator reliability, all results stated a high level of agreement. The directional and composite inter-operator reliability among all participants were excellent (ICC >0.958). In terms of participants with different gender, the inter-operator reliability among male and female was also excellent (ICC >0.980).

For construct validity, the correlations with statistical significance between UESEBT and other outcome measures were illustrated in Fig. 1 . For criterion validity, the correlations between the performance of UESEBT and UQYBT were demonstrated in Fig. 2 and Fig. 3 .

Correlation Matrix of UESEBT and other outcomes

Note: Outcomes with statistical significance ( p  < 0.05) were labeled by r -values and those without were marked by ‘X’. Abbreviations: CKCUEST: Closed Kinetic Chain Upper Extremity Stability Test; TFET: Trunk Flexor Endurance Test; N -LTET: Lateral Trunk Endurance Test on non-dominant side; D-LTET: Lateral Trunk Endurance Test on dominant side.

Correlation Coefficient between UESEBT and UQYBT on dominant side

Note: Spearman test was applied to carry out r -value and it is labeled on the top left of each graph. Abbreviations: UESEBT: upper extremity star excursion balance test; UQYBT: upper quarter Y-balance test.

Correlation Coefficient between UESEBT and UQYBT on non-dominant side

The UESEBT and UQYBT were correlated in all directions ( p  < 0.001). On D side, a moderate correlation was found between the medial ( r  = 0.49), inferolateral ( r  = 0.42), superolateral ( r  = 0.54), and composite ( r  = 0.51) distances of UESEBT and the equivalent distances of UQYBT. On ND side, a moderate correlation was found between the medial ( r  = 0.48) and inferolateral ( r  = 0.54) distances of UESEBT and the equivalent distances of UQYBT. Furthermore, the superolateral ( r  = 0.60) and composite ( r  = 0.72) distances of UESEBT were strongly correlated with same distances of UQYBT.

Some significant correlations were discovered between UESEBT and MISs, basically in superomedial, medial, and inferomedial directions ( p  < 0.05). Specifically, there was weak correlations ( r  = 0.24−0.29) between the superomedial distance and 4 MISs on D side. The medial distance was weakly to moderately ( r  = 0.27−0.41) correlated with 5 MISs. A weak correlation ( r  = 0.26−0.27) was found between the inferomedial distance and 3 MISs. On ND side, the superomedial distance was weakly to moderately correlated with 8 MISs ( r  = 0.24−0.42). The medial distance had weak to moderate correlations with 9 MISs ( r  = 0.28−0.44). There was a weak correlation between the inferomedial distance and 8 MISs ( r  = 0.24−0.39).

UESEBT was significantly correlated with the following performances ( p  < 0.05). CKCUEST was weakly to moderately correlated with 8 distances on D side ( r  = 0.25−0.42). Furthermore, there was a weak correlation between CKCUEST and 5 distances on ND side ( r  = 0.25−0.32). Nevertheless, no significant relationship was discovered between UESEBT and TEFT. In terms of the relationship of UESEBT on D side and LTET, 4 distances had a weak correlation with the performance of dominant LTET ( r  = 0.27−0.33). Three distances were weakly correlated with the performance of non-dominant LTET ( r  = 0.24). With regard to the relationship between UESEBT on ND side and LTET, 3 distances ( r  = 0.27−0.30) and 3 distances ( r  = 0.24−0.26) had a weak correlation with the performance of dominant and non-dominant LTET, respectively.

4. Discussion

The overall intra- and inter-operator reliability was excellent and high-to-excellent. Furthermore, no obvious gender, side, age and training onsets difference were found in reliability. As for criterion validity, the performance of UESEBT was correlated with corresponding distance of UQYBT (moderate-to-strong). For construct validity, the better performance of UESEBT in superomedial, medial, and inferomedial directions were associated with more upper limb strength on both sides (weak-to-moderate). UESEBT had a close correlation with CKCUEST (weak-to-moderate) and LTET (weak) but not TFET.

In this study, the intra-operator reliability was high-to-excellent, similar to previous findings. Gorman et al. concluded that the instant test-retest reliability of UQYBT in young adult ranged from 0.80-0.99 13 . Notably, the intra-operator reliability of superomedial direction was the lowest among eight directions. The possible explanation might be the reach in this direction required more dynamic stability in diagonal. 23 When the center of gravity shifting towards the contralateral side, the lateral shear force of the stance limb might significantly increase. Furthermore, the center of gravity shifts toward the cranial side synchronously, which generates great pressure on the top front of the shoulder capsule. These challenges might account for the fluctuation of reach distance between trials. On the other hand, the intra-operator reliability in posterior direction was the highest. The possible explanation is the application of hip flexion strategy during performance could significantly decrease the pressure and provide more stability. With regard to the potential factors affecting intra-operator reliability, we found the dominance of stance limb in UESEBT may not affect the intra-operator reliability, which is consistent with previous findings. 15

The inter-operator reliability of UESEBT in adolescent swimmers was excellent. Similarly, the excellent inter-operator reliability of UQYBT in young adult was reported by Gorman et al. with the ICC value at 1.00 13 . Another research revealed that the inter-operator reliability of SEBT among healthy adults was high-to-excellent (ICC = 0.86–0.92), 24 which was slightly lower. This possible reason is their inter-operator reliability was derived from three independent test sessions completed by three individuals, which might add more uncertainty between operators.

The UESEBT was found moderately to strongly related to UQYBT. UQYBT has been proved to be reliable and valid in many populations, including adults and swimming athletes. 12 , 13 , 14 The UESEBT shares some similar advantages to UQYBT because they both require the engagement of the entire kinetic chain, including scapular stability, coordination ability, thorax flexibility, and core stability. Considering that the absence of any certain parts could increase the risk of upper limb injuries among overhead athletes, 25 the outcomes of UESEBT and UQYBT enable clinicians to verify the potential weakness. Furthermore, the UESEBT owns more advantages compared to UQYBT. Specifically, it can provide more information in eight directions. Comprehensive information about upper limb stability is significant, since adequate stability provided by shoulder surrounding tissues were foundation to obtain more mobility. 11 As a mobility-demanding stability test, UESEBT evaluates performance throughout the entire range, which further discovered the undetected deficits. Moreover, eight reach directions in the UESEBT challenge the dynamic stability within a longer period, which is closer to real swimming situation. Given that the average duration in Olympic pool events ranges from 21 s to 15 min, 26 UESEBT is more proper and valid among swimmers working for endurance event.

The UESEBT performance in superomedial, medial, and inferomedial direction was extensively correlated with ipsilateral upper limb strength. The possible explanation is that the distal reach in these 3 directions requires weight to lean toward the contralateral side. Adequate engagements of these muscles are necessary to provide posture stability. By contrast, Westrick et al. found no relationship between the performance of UQYBT and isometric strength, seemingly inconsistent with our findings. 21 This could be interpreted by the different body positions during the MIS test. Besides, their study only assessed the strength of shoulder muscles whereas this study measured that of most large muscles in the upper limbs.

The performance of UESEBT was widely correlated with that of CKCUEST. Previous research has revealed the close correlation between UQYBT and CKCUEST, 21 which is consistent with our findings. CKCUEST was the first developed closed kinetic chain (CKC) dynamic stability test. 27 Although both CKCUEST and UESEBT aim to measure the upper limb performance in CKC situations, the former requires bilateral limb supporting alternatively, whereas the latter demands unilateral limb supporting. In addition, the CKCUEST is carried out bidirectionally at a high speed, 28 whereas the UESEBT is executed multi-directionally at a low speed. We suggest researchers and coaches should select the more suitable tests or the combination of these two tests to match the characteristics of specific sports event. With regard to trunk endurance, the study found nearly no results indicating a relationship between UESEBT and TFET, in line with the findings of Westrick et al. 21 Additionally, a few correlations were discovered between the performances of some directions in UESEBT and LTET. Previous studies have indicated LTET can effectively activate some core muscles, including lateral musculature and anterolateral flexors. 29 , 30 , 31 Adequate strength of these muscles guarantees further reach distance in unstable posture during UESEBT.

Dynamic balance is an important fitness parameter for overhead athletes, which is strongly associated with physical performance and the risk of injury. At present, limited assessments focused on the dynamic balance in upper limb. This study is the first to apply star excursion balance test in upper limb and prove that UESEBT is reliable and valid to screen upper limb dynamic balance among adolescent swimmers. This assessment could provide more information in eight directions for clinicians and coaches to detect the potential deficits. Also, this study has some limitations. First, we did not find the impact of injury history on the UESEBT even though 19 participants reported injury history. The small samples and low consistency of injury position and pathology limited the discovery of injury impact. Second, only one practice was required before the formal test of UESEBT, whereas another research has mentioned 6 reps of practice were needed in SEBT to demonstrate stable performance. 23 Considering the participants are adolescent whose physical ability may be limited, over-practice could result in poor performance during six-time formal test and other physical tests, which may not truly reflect their abilities.

5. Conclusion

The intra- and inter-operator reliability of all reach directions and composite score was basically high-to-excellent, and gender, side, age and training onsets might not affect the reliability. Moreover, the outcome of UESEBT was closely correlated with the dynamic balance assessed by UQYBT and CKCUEST, as well as the muscle strengths in upper limb, indicating good construct and criterion validity. Therefore, this study suggested that UESEBT is a reliable and valid tool to assess upper limb dynamic stability among adolescent swimmers and provide more information in eight directions for clinicians and coaches to detect the potential deficits. Future research is expected to focus on the prediction of upper limb injuries applying UESEBT.

Ethics approval and consent to participate

This study was approved by the Human Ethics Committee of Shanghai University of Sport (2018042). All willing participants and their legal guardians signed informed consent forms prior to the tests.

Availability of data and materials

Funding information.

The work was supported by the scientific and technological research program of the Shanghai Science and Technology Committee (grant numbers: 19080503100; 21S31902400); the Shanghai Key Lab of Human Performance (Shanghai University of Sport) (grant numbers: 11DZ2261100); Talent Development Fund of Shanghai Municipal (grant numbers: 2021081); Shanghai Clinical Research Center for Rehabilitation Medicine (grant numbers: 21MC1930200).

This work is following the ethical standards of the institutional research committee and with the Helsinki Declaration. This study was approved by the local Human Ethics Committee (2018042). All willing participants and their legal guardians signed informed consent forms.

Authors statement

Conceptualization, X.-Q.W.; investigation, H.-R.X., Y.-H.Z., Q.Z., G.H., Z.M.F., and W.J.S.; data curation and analysis, H.-R.X., Y.-H.Z., T.L.N., Y.M.; validation, H.-R.X., Y.-H.Z., and T.L.N.; writing—original draft preparation, H.-R.X., Y.-H.Z., and Y.M.; writing—review and editing, H.-R.X., Y.-H.Z. and X.-Q.W.; supervision, X.-Q.W. All authors have read and agreed to the published version of the manuscript.

Declaration of interest statement

This article is an original research which has not been published and is not under consideration for publication elsewhere. The authors declare that they have no competing interests and this work has been approved for publication by all author.

Acknowledgments

The authors would like to thank the individuals who volunteered to participate in this study and the physiotherapists who assisted in participants recruitment.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.jesf.2023.02.003 .

Appendix A. Supplementary data

The following are the Supplementary data to this article.

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