Introduction to the Community Balance and Mobility Scale

The Community Balance and Mobility Scale (CB&M) was developed in response to the needs of clinical practice to identify postural instability and evaluate change following intervention in the higher functioning ambulatory individual with TBI. Even those clients who are independent with walking and approaching normal values for gait velocity and endurance continue to experience balance and walking difficulties in more challenging environments (McFadyen et al, 2003; Niechiej-Szwedo et al, 2007; Chou et al, 2004) and/or age-appropriate activities such as work and sport, even many years post-injury (Hillier et al, 1997; Dean et al, 2000). These balance and mobility deficits are frequently not detected in commonly used clinical balance assessments or even in standard neurological examinations but are often only identified through the use of laboratory measures (McFadyen et al, 2003; Niechiej-Szwedo et al, 2007; Basford 2003). The CB&M therefore was designed for use in clinical settings to include sufficiently challenging items to detect persistent balance dyscontrol without the use of lab technology.

Most current balance measures were developed for a more impaired elderly population, therefore the population with TBI tends to score at the ceiling of these measures. Thus there is a risk of a false negative test, where patients are wrongly determined to have "perfect functioning" on an evaluation tool that was not sufficiently challenging. Our findings (in the following sections), as well as user reports, support that the CB&M is able to detect and quantify balance and mobility deficits in higher functioning individuals, and also demonstrate change after therapeutic intervention.

In early phases of the research, a literature search confirmed the paucity of measures to evaluate patients functioning at higher levels with regards to balance and mobility. To begin the process of item development for the new measure, interviews with physical and occupational therapists with expertise in neurorehabilitation probed the standardized and non-standardised methods they used for evaluating balance and mobility status in this patient group. Also, community-dwelling clients as well as the therapists were asked to describe the balance problems experienced by the individuals with TBI and the mobility tasks that elicited the difficulties. From this information, some common themes regarding balance problems within community mobility emerged and ultimately led to the development of the current CB&M items.

The CB&M has been proven reliable and valid, as presented in more detail in following sections. It is a performance-based measure with 13 items on a 6-point scale. Higher scores indicate better balance and mobility. Six of the items are performed on both right and left sides bringing the item total to 19 tasks. With the exception of the classic assessment of timed unilateral stance, all of the CB&M items evaluate 'dynamic balance.' This means that balance is evaluated during mobility making the scale and its items much more applicable to real-life community activity. The items are very challenging requiring speed, precision and recovery of stability after significant voluntary perturbations. The items test the postural control system using tasks which are representative of the motor skills necessary for function and participation within the community. Examples of items are:

• Walking & Looking - tests the ability to maintain a straight trajectory while keeping fixation on a visual target as would occur in walking and looking around any environment
• Running with Controlled Stop and Hopping Forward – these two items test the ability to generate significant power/momemtum and then stabilize in a final position without use of excessive balance reactions
• Lateral Foot Scooting – tests the ability to elicit and control a change-in-support balance reaction, pivoting the forefoot or heel, while traversing a 40 cm distance
• Forward to Backward Walking and Crouch & Walk – these two items test the ability to maintain walking while changing direction or position (to pick up an object), respectively, as would occur when maneuvering in the home or community environment

The CB&M was developed with the intent that any clinician would be able to apply the scale as needed in his/her practice. Consequently no formal training is required but a complete review of the scoring guidelines is required in order to ensure optimal use of the scale. Please review the Syllabus section and the guidelines provided for more information on scoring. Novice users usually require more time to administer the CB&M but once experienced with it, therapists are able to complete it in 20-30 minutes depending on familiarity with the scale and the patient's functional ability.

The CB&M has been adopted for use in clinical practice with other populations, for example people with multiple sclerosis, Parkinson's disease, acquired brain injury and stroke. Please see the Properties section for populations with whom the CB&M has been specifically validated.

Permission to use the CB&M is freely given but the co-investigators would appreciate hearing from users about the utility and application of the CB&M. Contact information is found in the left panel.

If you find the information in the COMBI useful, please mention it when citing sources of information. The information on the Community Balance and Mobility scale may be cited as:

Howe, J, Inness EL, & Wright, V. (2011). The Community Balance & Mobility Scale. The Center for Outcome Measurement in Brain Injury. http://www.tbims.org/combi/cbm ( accessed ).

REFERENCES FOR INTRODUCTION

1. McFadyen BJ, Swaine B, Dumas D, Durand A. Residual effects of a traumatic brain injury on locomotor capacity: A first study of spatiotemporal patterns during unobstructed and obstructed walking. J Head Trauma Rehabil 2003; 18: 512-25.

2. Niechiej-Szwedo E, Inness EL, Howe JA, Jaglal S, McIlroy WE, Verrier MC. Changes in gait variability during different challenges to mobility in patients with traumatic brain injury. Gait Posture. 2007; 25: 70-77

3. Chou LS, Kaufman KR, Walker-Rabatan AE, Brey RH, Basford JR. Dynamic instability during obstacle crossing following traumatic brain injury. Gait Posture 2004; 20; 245-54

4. Hillier SL, Sharpe MH, Metzer J. Outcomes 5 years post-traumatic brain injury with further reference to neurophysical impairment and disability. Brain Inj. 1997; 11: 661-75.

5. Dean S, Colantonio S, Ratcliff G, Chase S. Clients' perspectives on problems many years after traumatic brain injury. Psychol Rep. 2000; 86: 653-8.

6. Basford JR, Chou L, Kaufman K, Brey RH, Walker A, et al. An assessment of gait and balance deficits after traumatic brain injury. Arch Phys Med Rehabil. 2003; 84: 343-9

7. Colton T. Statistics in Medicine. Boston: Little, Brown and Company; 1974.