C L I N I C A L F E AT U R E S

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Test-Retest Reliability of the Star Excursion

Balance Test in Primary School Children

DOI: 10.3810/psm.2014.11.2098

Joaquin Calatayud, MSc 1

Sebastien Borreani, PhD 1
Juan Carlos Colado, PhD 1
Fernando Martin, PhD 1
Jorge Flandez, PhD 2
1
Research Group in Sport and
Health, Laboratory of Physical
Activity and Health, Department
of Physical Education and Sports,
University of Valencia, Valencia, Spain;
2
Austral University of Chile, Faculty
of Pedagogy in Physical Education,
Sports, and Recreation, Valdivia, Chile

Abstract

Background: Dynamic balance has been considered a fundamental skill at all ages and is
required for normal daily tasks, such as walking, running, or other sports activities. The Star
Excursion Balance Test (SEBT) has been widely used in recent years to identify dynamic balance deficits and improvements and to predict the risk of lower extremity injury. However, no
study has demonstrated the reliability of the SEBT in children while they are performing the
test in a physical education session. Reliability is needed in all measurement tools in order to
provide repeatable and consistent data. Objective: To evaluate the reliability of the SEBT in
primary school students in the school setting. Methods: Twenty-four healthy children with
typical development were tested twice, 2 weeks apart. The tests were conducted by the same
single rater and were performed during the physical education class. The test was performed
under standardized conditions during the 2 testing sessions and was performed by each subject
with both limbs in the 3 directions (anterior, posteromedial, and posterolateral). Four practice
trials were performed in each direction before selecting 3 additional distances reached. The best
value of these 3 additional measured trials was selected. The paired t test was used to ensure
the absence of any systematic bias. Intraclass correlation coefficient, standard error of measurement, 95% confidence intervals (CIs), and minimal change values were calculated to assess
reliability and measurement error. Results: The paired t tests revealed no significant differences
between testrest scores. Testretest reliability for all distances reached was moderate to good.
Conclusions: Reliability values suggest that the SEBT is suitable for primary school students.
However, it may be more practical and feasible during extracurricular sports participation due
to the time constraints and difficulties in using the test in the school setting.
Keywords: injury risk; school setting; reliability; dynamic balance

Introduction

Correspondence: Juan Carlos Colado, PhD,

Universidad de Valencia (FCAFE),
Aulario Multiusos,
C/ Gasco Oliag, 3,
46010 Valencia, Spain.
Tel: 00-34-963-983-470
Fax: 00-34-963-864-353
E-mail: juan.colado@uv.es

120

Dynamic balance has been considered a fundamental skill at all ages1 and is required
for normal daily tasks, such as walking, running, or other sports activities,1,2 especially
those activities that require dynamic movements while maintaining control.3
Since sports participation is one of the most frequent causes of injuries,4 and because
balance is a predictor of an increased risk to sustain a lower extremity injury such as
ankle sprains,5 a test that provides dynamic conditions is required in order to identify
balance deficits and to assess fall risk and sports-related injury risk.6
The physical education classes may play an important role in identifying children
with poor fitness7 and those at high risk of injuries. Because of their undeveloped
neuromuscular system,8 childrens injury rates related to falls and sports participation
are elevated.9

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SEBT Reliability in Primary School Children

The Star Excursion Balance Test (SEBT) has been widely

used in recent years in both healthy and injured populations
to identify dynamic balance deficits and improvements and
to predict the risk of lower extremity injury.10 Performing
the test requires strength, flexibility, and coordination11 to
maintain a single leg stance on one leg while reaching as far
as possible with the contralateral leg.2
Reliability is needed in all measurement tools12 to provide
repeatable13,14 and consistent15,16 data. Therefore, a reliable
test is a precise measure14 that ensures similar results under
the same test conditions.15 Despite the fact that the intraclass
correlation coefficient (ICC) and standard error of measurement (SEM) values have shown moderate2 to high1618 reliability for the SEBT in young adults and middle-aged adults,
no study has demonstrated the between-session reliability
of the SEBT in children who are performing the test in a
physical education class. To our knowledge, only 2 recent
investigations19,20 have tested the SEBT in schoolchildren,
although these were not conducted in order to evaluate the
reliability of the test. Furthermore, the use of dynamic balance tests in children is limited to costly systems such as
balance platforms6 or the Biodex Balance System.21 Hence, a
reliable cost-effective test that could be performed anywhere
is needed to obtain dynamic balance measures and to provide
useful information to identify those with greater injury risk.
Moreover, it has been established that motor fitness, which
includes balance and coordination, is a physical health-related
component in childhood and adolescence.22 Thus, this study
evaluated the relative and absolute testretest reliability of
the SEBT in primary school students in the school setting.
We hypothesized that the SEBT would be a reliable measure
to assess dynamic balance in this population.

Materials and Methods

Participants

Twenty-four children (12girls and 12 boys; age 11.0 0.8

years, height 152.4 8.7cm, weight 45.4 8.1kg, body mass
index 19.46 2.63) volunteered to take part in this study.
They were required to be free from lower extremity injury for
at least 6months prior to testing and to have no history of hip,
knee, or ankle surgery.17 A complete life-screening was not
performed, but the children did not report any injury (at least
in the 6months prior to testing) that could affect dynamic
balance and thus the performance of the test. The children
were required to be in primary school (their ages ranged from
10 to 12 years) and to be physically active, because they were
required to be participating in some organized sport before
the study started.

All the children and their parents signed an institutional

informed consent form before starting the protocol, and the
study was approved by the institutional review board at the
authors institutions. All procedures described in this section
comply with the requirements listed in the 1975 Declaration
of Helsinki and its 2008 amendment.

Protocol

Height and body mass index were measured according to the

protocol used in a previous studies.23
Participants were tested twice, 2 weeks apart, and measurements were performed at the same time of the day by the
same single rater, according to the protocol established in a
previous reliability study.13 The rater was a researcher with
some experience in performing SEBT studies at a university.
To avoid possible distractions that could influence the results,
the children were individually tested in the sports facility
while the other subjects waited outside.
The SEBT was performed with both limbs, following the
recommendations by Gribble etal,10 and was performed in
3 directions (anterior, posteromedial, and posterolateral, in
this order). This modification reduces the time necessary to
perform the SEBT10 and thus is a more practical way to use
the test in a school setting.
Four practice trials were performed in each direction
before selecting 3 additional distances reached in order to
minimize practice effects.17,24 The best value of the 3measured trials was selected, as in previous studies.11,17 The
subjects performed all the reaching distances with 1 leg and
then with the contralateral leg in a counterbalanced order.
After finishing the practice trials, the subjects had 30seconds
to rest before performing the next 3 trials.
The subjects performed the test barefoot, with the stance
foot aligned at the most distal aspect of the toes for anterior
direction and the most posterior aspect of the heel for the backward directions.10 During the trials, the hands were placed on
the hips, and minimal stance foot movement was allowed.10
The test started from a bipedal position. Then the participants were asked to maintain a single leg stance on 1 leg
while reaching as far as possible with the opposite leg to
touch as far as possible along the chosen line with the most
distal part of their foot.10,17 The subjects then returned to the
initial stance.10,17 The point at which the subject touched the
line was marked by the examiner and measured manually
using a measuring tape.17
Leg length was measured, quantifying the distance from
the anterosuperior iliac spine to the center of the ipsilateral
medial malleolus with the participant lying supine.25 This

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Calatayud etal

measure was used to normalize the distances reached,

dividing the distance reached by leg length and then multiplying by 100.25 A trial was discarded and repeated if participants
used the reaching leg for a substantial amount of support at
any time, removed the foot from the center of the grid, were
unable to maintain balance,25 lifted their heel off the ground,
lifted their hands off the hips, or did not follow the previously
mentioned instructions in performing the test.

Table 1. Mean, SD, and P Values for Normalized Maximum

Excursion Distancesa
Anterior
Posteromedial
Posterolateral

Left stance
Right stance
Left stance
Right stance
Left stance
Right stance

Test

Retest

P value

67.43 (8.75)
69.17 (8.96)
84.80 (11.89)
84.51 (14.32)
75.83 (12.43)
74.78 (13.93)

65.88 (15.27)
70.23 (8.14)
82.54 (22.40)
86.11 (15.33)
75.89 (11.82)
76.33 (16.23)

0.536
0.249
0.541
0.178
0.957
0.219

Values are mean SD for normalized maximum excursion distance. P values are
for the paired t test on testretest differences.

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Data Analysis

Statistical analysis was carried out using SPSS version 17

(SPSS Inc., Chicago, IL). The level of significance was set
at P,0.05 for all statistical tests.
Means and standard deviations were calculated for the
maximum distance reached in each direction for both limbs.
Paired t tests of the differences of scores obtained at test
and retest sessions were used to ensure the absence of any
systematic bias.26
The ICC (3,1) was calculated for each reaching direction
to assess the relative between-session reliability, normalizing the measurement error relative to the heterogeneity
of the subjects.14 The SEM (pooled standard deviation of
all scores multiplied by the square root of 1 ICC)14 and
the 95% CIs were computed to estimate the amount of error
associated with the measurement. In addition, the minimum difference (MD) was calculated (SEM * 1.96 * 2)
to determine the minimum threshold of measurement to
ensure that differences between measurements were real and
outside the error range.14
Criteria ranges for ICC reliability were as follows:,0.50,
poor; 0.50 to 0.75, moderate; and.0.75, good.27

Results

Paired t tests revealed no significant differences between the

scores of the 2 testing sessions for all directions reached in
both limbs (P.0.05).
Mean, standard deviation, and P values of the paired t
test for normalized maximum distances reached in both limbs
are reported in Table1.
The ICC values for normalized scores showed moderate
to good reliability (0.51 to 0.93), and the SEM values for
normalized scores ranged from 3.03 to 12.32. Table2shows
the mean, standard deviation, 95% CI, SEM, MD, and ICC
values for normalized reaching distances.

Discussion

In accordance with the hypothesis, SEBT showed moderate

to high reliability scores (0.51 to 0.93) in primary school
122

children. Similar intratester ICC results have been reported

previously in healthy young adults, where SEBT ICCs ranged
from 0.84 to 0.92,17 0.67 to 0.87,2 0.78 to 0.96,16 and 0.82 to
0.87.11 In addition, intertester ICCs have ranged from 0.35
to 0.9316 and from 0.86 to 0.92.18
Although the ICC provides a relative measure of reliability, the SEM provides an absolute reliability index14
and quantifies the scores precision.28 Relative reliability
addresses the consistency of the position or the rank of the
subjects in the group relative to others, whereas absolute reliability addresses the consistency of the subjects scores.14
In our study, the SEM values for normalized scores
ranged from 3.03 to 12.32. Concretely, the lowest SEM
result was found in the anterior reach direction with the
right stance, also showing the lowest minimal distance value
(8.39). Previous SEM values ranged from 1.77 to 3.38,16
3.43 to 4.78,2 and 1.95 to 2.54,17 whereas the only study
reporting MD data during the SEBT performance showed
values ranging from 6.13 to 8.15.17 A possible explanation for
the highest SEM value in our study (12.32) and the lowest
ICC value (0.51) across all the SEBT reliability studies is
that primary school children might need a greater number
of demonstrations and practice trials in order to improve
their technique. However, this value pertains to a specific
reach (posteromedial direction with left stance), and the
other results in our study are in accordance with the range
of values previously reported.
It should be pointed out that the different results from
different studies could be due to the different testing procedures performed. For example, our study was the first that
conducted a 2-session model with 2 weeks between tests,
whereas the subjects in the other studies has at most 1 week
between tests.17 In addition, some SEBT reliability studies
performed the 8 reaching directions,2,16,17 whereas other
studies performed only 3 reaching directions.18 Differences
in the number of trials, the familiarization sessions, and
other aspects of the performance (eg, hands placed on hips,

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SEBT Reliability in Primary School Children

Table 2. Mean, SD, 95% CI, SEM, MD, and ICC Values for Normalized Excursion Distances
Anterior
Posteromedial
Posterolateral

Left stance
Right stance
Left stance
Right stance
Left stance
Right stance

Mean

SD

95% CI

66.65
69.69
83.67
85.31
75.86
75.55

12.20
8.39
17.60
14.53
11.87
14.83

63.11
66.78
78.39
81.32
73.58
71.47

73.29
70.48
93.48
86.09
78.02
76.53

SEM

MD

ICC

8.36
3.03
12.32
3.85
3.56
4.20

23.19
8.39
34.15
10.66
9.88
11.63

0.53
0.87
0.51
0.93
0.91
0.92

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Abbreviations: ICC, intraclass correlation coefficient; MD, minimal difference; SEM, standard error of measurement.

barefoot or not, and foot alignment) also could influence the

results and thus the reliability of the studies. We are confident
that additional familiarization sessions and additional practice trials might have helped to improve the reliability in
our study, and thus these factors are the main limitations.
However, the number of trials performed was enough to
minimize practice effects in previous reliability studies.17,24
Furthermore, a mean score of the 3measured trials could
provide higher reliability values as has been recently demonstrated.18 Because we recorded only the best value, future
studies should include this variation to improve the reliability
of the test in this population.
Field-based tests in the school setting must be timeefficient and inexpensive, must require only minimal equipment, and must be easily administered to a large number of
children simultaneously.29 For example, it took 3 physical
education sessions of approximately 55minutes each for
a single tester to administer a validated battery of 6 fitness
tests to 20 children.29 However, 6 physical education sessions
were needed in our study to perform all the measurements.
The time required to perform the practice trials and ensure
the correct performance of the test may be excessive if the
purpose is to measure a large number of participants in a
single physical education session. Thus, the time needed to
perform the SEBT is a limitation in some settings. Another
limitation is that $2 examiners may be required to observe
and ensure an adequate testing technique and to mark the
distances reached.
The performance of the SEBT in the school setting may
have additional limitations. In our study, the children were
tested individually to avoid the distraction of having their
peers present. Moreover, the number of subjects involved
and time constraints may represent further limitations
to performing the SEBT during the physical education
classes. Because this is the first SEBT reliability investigation that was conducted in the school setting, our results
provide a first step for future studies that can attempt to
find optimal methods and procedures to provide more
reliable results.

Conclusions

The moderate to good absolute and relative reliability values

show that the SEBT is a repeatable measure for primary
school students in different testing sessions. Thus, the SEBT
may be used to assess dynamic balance in children. However, the difficulty and time needed for a single examiner
to conduct the testing might prove impractical in the school
setting. The SEBT might be more appropriate in extracurricular sports where there are fewer time constraints.

Acknowledgments

The authors thank the children who participated in this study

as well as their teachers at the Padre Moreno School for
their cooperation. In addition, we thank Craig Denegar and
Germn Martn for their assistance.

Conflict of Interest Statement

Joaquin Calatayud, MSc, Sebastien Borreani, PhD,

Juan Carlos Colado, PhD, Fernando Martin, PhD, and
Jorge Flandez, PhD, have no conflicts of interest to declare.

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