Frontiers in neurology · 2026
How reliable are clinical balance and ataxia scales in healthy children aged 4-12 years? An inter-rater reliability and construct validity study of the PBS, SARA, and BARS.
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Arslan Elif Acar, Gültekin Ece, Umut Gülsena Utku, Güney İrem, Parlayan Cüneyd, Sert Abdullah, Turanlı Güzide
Аннотация
BACKGROUND: No study has evaluated the Pediatric Balance Scale (PBS), the Scale for the Assessment and Rating of Ataxia (SARA), and the Brief Ataxia Rating Scale (BARS) together in a healthy pediatric sample.
OBJECTIVE: This study aimed to determine the inter-rater reliability, measurement error, and construct validity of the PBS, SARA, and BARS in healthy children aged 4-12 years and to compare scores between physiotherapists and pediatric neurologists.
METHODS: Thirty-four healthy children (18 girls and 16 boys; mean age 8.2 ± 1.8 years) were each scored from standardized video recordings by five independent, mutually blinded raters (two physiotherapists and three pediatric neurologists). Inter-rater reliability was quantified using two-way random-effects and absolute-agreement intraclass correlation coefficients (ICCs), reported as single-rater [ICC (2,1)] and average-of-five-raters [ICC (2, k)] measures. Standard error of measurement (SEM), minimal detectable change (MDC95), Cronbach's α, Bland-Altman agreement, Spearman inter-scale correlations, and Kruskal-Wallis tests of rater differences were calculated.
RESULTS: Average-measure reliability was good for the PBS (ICC2k = 0.89, 95% CI 0.81-0.94) and the SARA (0.85, 0.74-0.92) but moderate for the BARS (0.64, 0.41-0.80). Single-rater reliability was moderate for the PBS (0.61) and the SARA (0.53) but poor for the BARS (0.27). The BARS was attenuated by a floor effect (20.6% scored zero) rather than rater disagreement, which Bland-Altman confirmed to be small. Construct validity was supported: The PBS negatively correlated with the SARA (ρ = -0.76) and the BARS (ρ = -0.59), and the SARA positively correlated with the BARS (ρ = 0.87; all p < 0.001), which remained unchanged in the non-zero-BARS subgroup. No sex differences emerged.
CONCLUSION: In healthy children, the PBS, the SARA, and the BARS are reliable when averaged across raters and show coherent construct validity. Single-rater use is adequate for the PBS and the SARA but limited for the BARS in this floor-dominated population. Age-referenced interpretation of the PBS is warranted. Establishing the reliability and normative characteristics of these scales in typically developing children will facilitate more accurate interpretation of pediatric ataxia and balance assessments in both clinical practice and research.
OBJECTIVE: This study aimed to determine the inter-rater reliability, measurement error, and construct validity of the PBS, SARA, and BARS in healthy children aged 4-12 years and to compare scores between physiotherapists and pediatric neurologists.
METHODS: Thirty-four healthy children (18 girls and 16 boys; mean age 8.2 ± 1.8 years) were each scored from standardized video recordings by five independent, mutually blinded raters (two physiotherapists and three pediatric neurologists). Inter-rater reliability was quantified using two-way random-effects and absolute-agreement intraclass correlation coefficients (ICCs), reported as single-rater [ICC (2,1)] and average-of-five-raters [ICC (2, k)] measures. Standard error of measurement (SEM), minimal detectable change (MDC95), Cronbach's α, Bland-Altman agreement, Spearman inter-scale correlations, and Kruskal-Wallis tests of rater differences were calculated.
RESULTS: Average-measure reliability was good for the PBS (ICC2k = 0.89, 95% CI 0.81-0.94) and the SARA (0.85, 0.74-0.92) but moderate for the BARS (0.64, 0.41-0.80). Single-rater reliability was moderate for the PBS (0.61) and the SARA (0.53) but poor for the BARS (0.27). The BARS was attenuated by a floor effect (20.6% scored zero) rather than rater disagreement, which Bland-Altman confirmed to be small. Construct validity was supported: The PBS negatively correlated with the SARA (ρ = -0.76) and the BARS (ρ = -0.59), and the SARA positively correlated with the BARS (ρ = 0.87; all p < 0.001), which remained unchanged in the non-zero-BARS subgroup. No sex differences emerged.
CONCLUSION: In healthy children, the PBS, the SARA, and the BARS are reliable when averaged across raters and show coherent construct validity. Single-rater use is adequate for the PBS and the SARA but limited for the BARS in this floor-dominated population. Age-referenced interpretation of the PBS is warranted. Establishing the reliability and normative characteristics of these scales in typically developing children will facilitate more accurate interpretation of pediatric ataxia and balance assessments in both clinical practice and research.