star excursion balance test vs y balance test

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Star Excursion Balance Test (SEBT)

The Star Excursion Balance Test (SEBT) is a test of dynamic balance, using in a single-leg stance that requires strength, flexibility, core control and proprioception. The test requires participants to balance on one leg and reach as far as possible in eight different directions. The similar Y-Balance Test was derived from this test.

purpose : To assess active balance and core control

equipment required: A flat, smooth, non-slip surface, measuring tape, marking tape. To prepare for the test, four 120cm lengths of marking tape are placed on to the floor, intersecting in the middle, and with the lines placed at 45-degree angles.

pre-test: Explain the test procedures to the subject. Perform screening of health risks and obtain informed consent. Prepare forms and record basic information such as age, height, body weight, gender, test conditions. Perform an appropriate warm-up. See more details of pre-test procedures .

procedure: The subject should be wearing lightweight and non-restrictive clothing and no footwear. The subject stands on one foot in the center of the star with their hands on their hips. They then reach with one foot as far as possible in one direction and lightly touch the line before returning back to the starting position. The support foot must stay flat on the ground. This is repeated for a full circuit, touching the line in every reach direction. The assessor should mark the spot on the line where the subject was able to reach. The test should be repeated three times for each foot. The trial is invalid if the subject cannot return to the starting position, the foot makes too heavy of a touch, or if the subject loses balance. see video .

Scoring : After the test all the reached distances are recorded to the nearest 0.5cm. Calculate Average distance in each direction (average of the three measurements) and 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 a total of 16 scores per athlete.

Comments: this test has been used as an indicator of lower limb injury risk in a variety of populations

advantages: this is a simple test to perform with simple and inexpensive equipment.

disadvantages: the test can be time-consuming if it needs to be performed on a large group of individuals.

The Test in Action

• See a video description of the star excursion balance test

Similar Tests

• A similar test, the y-balance test

Related Pages

• See a video about the Y Balance test
• About balance testing
• Other balance tests

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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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The Star Excursion Balance Test: An Update Review and Practical Guidelines

2021, International Journal of Athletic Therapy and Training

The Star Excursion Balance Test (SEBT) is a reliable, responsive, and clinically relevant functional assessment of lower limbs’ dynamic postural control. However, great disparity exists regarding its methodology and the reported outcomes. Large and specific databases from various population (sport, age, and gender) are needed to help clinicians when interpreting SEBT performances in daily practice. Several contributors to SEBT performances in each direction were recently highlighted. The purpose of this clinical commentary is to (a) provide an updated review of the design, implementation, and interpretation of the SEBT and (b) propose guidelines to standardize SEBT procedures for better comparisons across studies.

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Riley Kenney

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Performance Differences Between the Modified Star Excursion Balance Test and the Y-Balance Test in Individuals With Chronic Ankle Instability

• PMID: 31629325
• DOI: 10.1123/jsr.2018-0078

Context: The modified Star Excursion Balance Test (mSEBT) and Y-Balance Test (YBT) are common dynamic postural stability assessments for individuals with chronic ankle instability (CAI). However, the reach distance measurement technique and movement strategy used during the mSEBT and YBT differ. To date, no studies have compared task performance differences on these tests in CAI patients.

Objective: To determine whether individuals with CAI perform the mSEBT and YBT differently.

Design: Cross-sectional.

Setting: Biomechanics laboratory.

Participants: Of 97 consented participants, 86 (43 females, 43 males; age 21.5 [3.3] y, height 169.8 [10.3] cm, mass 69.5 [13.4] kg), who reported ≤25 on the Cumberland Ankle Instability Tool, ≥11 on the Identification of Functional Ankle Instability, and had a history of a moderate to severe ankle sprain(s) participated.

Interventions: Participants were instructed to perform the mSEBT and YBT in a predetermined counterbalanced order. Three anterior, posteromedial, and posterolateral trials of each test were completed on the involved limb after 4 practice trials. Test direction order was randomized for each participant.

Main outcome measures: Normalized (expressed in percentage) reach distance in each direction. Paired sample t tests were performed to compare each of the 3 directions between the mSEBT and YBT.

Results: Significantly shorter reach distances in the anterior (58.9% [5.8%] vs 61.4% [5.4%], P = .001) and the posteromedial (98.8% [8.6%] vs 100.8% [8.1%], P = .003) directions were noted on the mSEBT relative to the YBT. No differences in the posterolateral directions were observed.

Conclusions: Within those with CAI, mSEBT and YBT normalized reach distances differ in the anterior and posteriomedial directions. As a result, clinicians and researchers should not directly compare the results of these tests.

Keywords: ankle sprain; assessment; balance; dynamic postural stability test.

Publication types

• Comparative Study
• Ankle Injuries / physiopathology*
• Exercise Test / methods*
• Joint Instability / physiopathology*
• Postural Balance / physiology*
• Young Adult

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Systematic Review and Meta-Analysis of the Y-Balance Test Lower Quarter: Reliability, Discriminant Validity, and Predictive Validity

• Citation (BibTeX)

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Deficits in dynamic neuromuscular control have been associated with post-injury sequelae and increased injury risk. The Y-Balance Test Lower Quarter (YBT-LQ) has emerged as a tool to identify these deficits.

To review the reliability of the YBT-LQ, determine if performance on the YBT-LQ varies among populations (i.e., sex, sport/activity, and competition level), and to determine the injury risk identification validity of the YBT-LQ based on asymmetry, individual reach direction performance, or composite score.

Study Design

Systematic Review

A comprehensive search was performed of 10 online databases from inception to October 30, 2019. Only studies that tested dynamic single leg balance using the YBT-LQ were included. Studies were excluded if the Y-Balance Test kit was not utilized during testing or if there was a major deviation from the Y-Balance test procedure. For methodological quality assessment, the modified Downs and Black scale and the Newcastle-Ottawa Scale were used.

Fifty-seven studies (four in multiple categories) were included with nine studies assessing reliability, 36 assessing population differences, and 16 assessing injury prediction were included. Intra-rater reliability ranged from 0.85-0.91. Sex differences were observed in the posteromedial direction (males: 109.6 [95%CI 107.4-111.8]; females: 102.3 [95%CI 97.2-107.4; p = 0.01]) and posterolateral direction (males: 107.0 [95%CI 105.0-109.1]; females: 102.0 [95%CI 97.8-106.2]). However, no difference was observed between sexes in the anterior reach direction (males: 71.9 [95%CI 69.5-74.5]; females: 70.8 [95%CI 65.7-75.9]; p=0.708). Differences in composite score were noted between soccer (97.6; 95%CI 95.9-99.3) and basketball (92.8; 95%CI 90.4-95.3; p <0.01), and baseball (97.4; 95%CI 94.6-100.2) and basketball (92.8; 95%CI 90.4-95.3; p=0.02). Given the heterogeneity of injury prediction studies, a meta-analysis of these data was not possible. Three of the 13 studies reported a relationship between anterior reach asymmetry reach and injury risk, three of 10 studies for posteromedial and posterolateral reach asymmetry, and one of 13 studies reported relationship with composite reach asymmetry.

Conclusions

There was moderate to high quality evidence demonstrating that the YBT-LQ is a reliable dynamic neuromuscular control test. Significant differences in sex and sport were observed. If general cut points (i.e., not population specific) are used, the YBT-LQ may not be predictive of injury. Clinical population specific requirements (e.g., age, sex, sport/activity) should be considered when interpreting YBT-LQ performance, particularly when used to identify risk factors for injury.

Level of Evidence

Introduction.

Despite increased evidence on injury prevention and identification, injuries ranging from minor to career-limiting continue to rise. 1 , 2 Deficits in lower extremity dynamic neuromuscular control have been implicated as an injury risk factor and have been observed after lower extremity injury. 3–6 Interventions to improve lower extremity dynamic neuromuscular control have been utilized as a component in multiple injury prevention programs. Specifically, researchers have observed that athletes who participated in an injury prevention program displayed improved lower extremity dynamic neuromuscular control. 7 , 8 One study observed that the intervention group who was most compliant demonstrated the greatest lower extremity dynamic neuromuscular control improvement, and sustained lower extremity injuries at decreased rates. 8 Additionally, health care practitioners frequently utilize dynamic neuromuscular control as an outcome measure for return to sport criterion. Thus, there is a need for a lower extremity dynamic neuromuscular control test that identifies athletes at increased injury risk, captures changes that may occur with intervention, and evaluates return to sport readiness (i.e., ensure motor control deficits that occur after injury have normalized). In order to be useful in a sports setting the test would need to be valid and easy to use.

The Star Excursion Balance Test (SEBT) and Y-Balance Test Lower Quarter (YBT-LQ) have been studied and used extensively for the determination of physical readiness and injury risk identification, return to sport testing, and pre-post intervention measurement. 6 , 9 The SEBT, through a systematic review, has been found to be reliable, valid, and responsive to specific dynamic neuromuscular control training for injured and healthy athletic populations. 6 The advantage of the SEBT and YBT-LQ is that they test neuromuscular control at the limits of stability, which may allow for identification and magnification of subtle deficits and asymmetry. 6

The YBT-LQ was developed from the SEBT in order to improve the reliability and field expediency of the SEBT. 9 The YBT-LQ was simplified to use only the most reliable three reach directions (compared to eight reach directions with the SEBT). While both tests require dynamic neuromuscular control at the limits of stability, there are differences between the tests. The YBT-LQ uses a standardized approach via a testing kit and revised protocol to improve the reliability and testing speed. Protocol revisions include: heel of stance foot is allowed to raise, no touch down is allowed with reaching limb, and kit incorporates a standard reach height off the ground is used. 9

While the efficiency of the test may have been improved, these differences in test procedures can alter performance, leading researchers to conclude that the SEBT and YBT-LQ are not interchangeable. 10 , 11 Coughlan et al. 10 compared the performance on the SEBT and YBT-LQ, and found that healthy males reached farther on the SEBT in the anterior direction, but had similar reach distances in the posterior directions. 10 Fullam et al. 11 examined the kinematic differences between the SEBT and YBT-LQ. It was confirmed that healthy males reached farther in the anterior direction, and from a kinematic perspective, the YBT-LQ anterior reach had greater hip flexion. 11 These differences may be due to procedural differences or the use of a standardized YBT-LQ test kit. In addition to the differences in results between the YBT-LQ and SEBT, researchers have found that there may be differences in performance based on sex, sport and competition level in both tests. 3 , 4 Differences have been reported between subject performance on the YBT-LQ based on country of origin, 12 as well as, competition level. 13 , 14 However, it is uncertain whether these findings are isolated to these populations or represent a true difference in performance among populations.

While a systematic review has been performed on the reliability and discriminant validity of the SEBT, the YBT-LQ has not undergone a similar rigorous analysis regarding its effectiveness regarding injury risk identification. 6 In the SEBT systematic review, the YBT-LQ was described as reliable, but only one study was available; thus, there is a need to investigate and summarize the YBT-LQ literature. 6 The purpose of this systematic review and meta-analysis was to review the reliability of the YBT-LQ, determine if performance on the YBT-LQ varies among populations (i.e., sex, sport/activity, and competition level), and to determine the injury risk identification validity of the YBT-LQ based on asymmetry, individual reach direction performance, or composite score.

Study design

A systematic review was performed on the reliability, validity, and population differences of the YBT-LQ. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to conduct and report this review. 15 This review was prospectively registered with Prospero CRD42018090102.

Search strategy

A comprehensive computerized search was performed, employing online databases (MEDLINE, CINAHL, Cochrane, Embase, SPORTDiscus, Health Source-Consumer Edition, Health Source: Nursing/Academic Edition, SocINDEX, and Social Sciences), from inception to October 30, 2019. Medical subject headings (MeSH) and keywords were utilized for “ dynamic balance ,” “ Y-Balance Test ,” “ Star Excursion Balance Test ,” and “ single leg balance .” The full search strategy entailed “y balance test*”[All Fields] OR “star excursion balance test*”[All Fields] OR YBT[All Fields] OR SEBT[All Fields]. References were tracked in Covidence systematic review software (Veritas Health Innovation, Melbourne, Australia).

Eligibility criteria

Studies examining the YBT-LQ were included if they met the following criteria: 1) tested dynamic single leg balance using the YBT-LQ; 2) full-text articles were written in English. Study exclusion criteria consisted of 1) studies that did not use the Y-Balance Test kit during testing; 2) major deviation from the Y-Balance Test procedure (e.g., stance foot heel kept down); 3) the Y-Balance Test Upper Quarter procedure was utilized instead of the YBT-LQ; 4) conference abstracts or non-peer-reviewed papers.

Study selection

Four reviewers (GB, MG, BH, KS) were split into pairs, and each pair independently assessed half of the selected studies. Title and abstracts were first screened using inclusion and exclusion criteria. Four reviewers independently, who were all physical therapists and specialized in sports medicine, executed full-text review following title and abstract screening. Any conflicts were first discussed within the four reviewers. If a consensus could not be reached, another reviewer (PJ), who is a physical therapist, athletic trainer, PhD, with over twenty years’ experience in sports medicine, was utilized to determine final study eligibility. Following full-text review, a hand search was performed for any studies missed within the initial search.

Data extraction

Data were extracted into a customized Excel spreadsheet (Version 2013, Microsoft, Redmond, Washington, United States) in three domains: reliability, population differences, and injury prediction. Two reviewers verified data for each domain. Disagreements concerning data domain placement were resolved by a third reviewer (PJ). Data elements included study characteristics (e.g., publication data, study design, and population), YBT-LQ methodology, and results (number of injuries, reach distance, reach asymmetry, and reliability).

Quality assessment

All three domains (reliability, population differences, and injury prediction) were each analyzed by two independent reviewers (GB, MG, BH, KS). A third reviewer (PJ) resolved any quality assessment disagreements. The Oxford Centre for Evidence-Based Medicine (OCEBM) levels of evidence (Level I to IV) 16 was used to discern study design. The YBT-LQ methodology was specifically assessed for uniformity. 6 The YBT-LQ protocol factors that were assessed included the use of shoes during testing, the use of the average or maximum reach for each reach direction, hand placement during testing, number of practice trials, and number of data collection trials. 6 The modified Downs and Black tool was utilized for methodological assessment for studies within the reliability and population differences domains. 17 , 18 The modified Downs and Black tool has been shown to be reliable and valid. 17 This methodological tool was scored on a scale of 0 to 15. The scoring system has a stratified ranking, with a score of 12 or greater deemed high quality, a score of 10 to 11 deemed moderate quality, and a score at or below 9 deemed low quality. 18 The Newcastle-Ottawa Scale (NOS) was utilized for methodological assessment for studies within the injury prediction domain. The NOS incorporates a ‘star system’ for three broad perspectives: the selection of the study groups (four questions); the comparability of the groups (one question); and the ascertainment of outcome of interest (three questions). Multiple questions can have more than one star, which may result in the number of stars totaling greater than total number of questions. 19

Statistical analyses

Percentage agreement and Cohen Kappa statistics were calculated to provide absolute agreement between raters in SPSS 23 (SPSS Inc, IBM, Chicago, Illinois). The extracted data were aggregated into three domains: reliability, population differences, and injury prediction. Reliability data were summarized in a narrative fashion. The population differences domain data were analyzed by pooling the study means through a random effects inverse variance approach, originally described by DerSimonian and Laird. 20 Studies that reported more than one individual cohort were each calculated as individual studies. Heterogeneity was assessed with the Cochrane Q and I 2 with high heterogeneity designated by a Q p-value <0.10 and I 2 >50%. Meta-analysis was used to combine and summarize the data. In outcomes related meta-analysis, high heterogeneity indicates that there is large variation in study outcomes between studies and that results should not be pooled or combined. In this meta-analysis, high heterogeneity was observed indicating that there indeed may be differences in performance on the YBT-LQ among populations (i.e., age, sex, sport, activity, occupation, and injury status). Through an abundance of caution, a random effects model was used assuming that even within populations, results fall in a normal distribution. Data subdivisions were first grouped by sex for each YBT-LQ reach and composite score then analyzed through a series of z-tests (p<0.05). Due to the differences found between sexes, and the paucity of female studies, only males were assessed for further subdivisions. Additionally, competition level was not able to be compared as there were no greater than two subgroups at each competition level. Male sports differences (for all three YBT-LQ reaches and composite scores) were analyzed through one-way ANOVA with Tukey-Kramer Q tests to localize pair-wise differences based on pooled study means and variances (p<0.05). 21 All meta-analyses were performed in R version 3.5.1 (R Core Team (2013). R: A language and environment for statistical computing (R Foundation for Statistical Computing, Vienna, Austria. URL http://www.R-project.org/ ), using the meta package. 22 Given the heterogeneity in study design and data reporting, injury prediction data were summarized in a narrative fashion.

A total of 982 titles were identified through the initial database and hand searches. After removal of duplicate articles, 732 abstracts were reviewed for relevance. Substantial agreement was demonstrated in title and abstract screening (k=0.976, p<0.01). Full text eligibility assessment of the remaining 411 articles resulted in 57 articles with 4 in multiple categories ( Figure 1 ). 3 , 9 , 12–14 , 23–50 Nine studies 9 , 25 , 33 , 40 , 46 , 51–54 assessed reliability, 36 studies 12–14 , 23–30 , 32 , 35 , 37 , 38 , 41–45 , 47 , 49 , 54–67 examined differences in the performance on the YBT-LQ in different populations or reported mean performance on the YBT-LQ in a specific population, and 16 studies 3 , 31 , 34 , 36 , 39 , 48 , 50 , 57 , 64 , 68–74 examined injury prediction (see Table 1 ). Substantial agreement was also observed for full text review (k=0.84, p<0.01).

*A higher score on the Downs and Black and the Newcastle-Ottawa Scale indicates lower risk of bias

The NOS was used to assess quality of the included cohort studies (n=16). For the remaining 41 articles, the Downs and Black tool was used to assess quality. The scores of the included studies on the NOS ranged from 6-9 out of a possible 9, while the scores on the Downs and Black tool ranged from 7-13 out of a possible 15 (see summary in Table 1 ).

Reliability

Nine studies 9 , 25 , 33 , 40 , 46 , 51–54 assessed reliability of YBT-LQ (see Table 1 ). Intraclass correlation coefficients (ICCs) for intrarater reliability ranged from 0.57-0.82 in adolescent populations, 40 and 0.85-0.91 in adult populations. 9 Interrater reliability ICCs ranged from 0.81-1.00. 9 , 33 , 46 , 51 Test-retest reliability was assessed in five studies with ICCs ranging from 0.63-0.93. 25 , 33 , 52–54

Sex differences

When sex was considered alone, differences were observed in the posteromedial direction (Male: 109.6 95% CI 107.4-111.8; Female: 102.3 95% CI 97.2-107.4; p < 0.01) and posterolateral direction (Male: 107.0 95% CI 105.0-109.1; Female: 102.0 95% CI 97.8-106.2; p=0.036). 12–14 , 25 , 27 , 37 , 43 , 44 , 58–61 , 63–66 However, no difference was observed between sexes in the anterior reach direction (Male: 71.9 95% CI 69.5-74.5; Female: 70.8 95% CI 65.7-75.9; p=0.708) 12–14 , 25 , 27 , 37 , 44 , 54 , 57–61 , 63 , 65–67 or in composite score (Male: 95.8 95% CI 94.5-97.2; Female: 95.3 95% CI 92.9-97.8; p=0.75) (Figure 2). 12–14 , 24–30 , 32 , 37 , 38 , 42–44 , 55–57 , 59–66 However, there were significant differences based on sex, competition level, and sport throughout Figure 2 . To illustrate, male Rwandan high school soccer players have a mean composite reach of 105.6 (95% CI 102.99-108.21), 12 while male professional basketball players have a mean composite reach of 92.0 (95% CI 90.16-93.84). 27 These scores also differ from female collegiate athletes, where a mean composite reach of 100.0 (95% CI 98.87-101.13) was observed. 30

Competition Level Differences

When competition level was considered alone (middle school, high school, college, professional), no differences were observed for the anterior (p = 0.05), posteromedial (p = 0.69), posterolateral (p = 0.62), or composite score (p = 0.15) ( Figure 3 , 4 , 5 , 6 ). 12–14 , 23–30 , 32 , 35 , 37 , 38 , 41–45 , 47 , 49 , 54–67

Sport differences

In the anterior reach direction, a significant difference was observed between soccer and basketball athletes (Soccer: 76.0 95% CI 73.6-78.4; Basketball: 70.5 95% CI 67.7-73.2; p < 0.01). 12–14 , 27 In the posteromedial reach direction, a significant difference was observed between soccer and basketball athletes (Soccer: 114.8 95% CI 111.6-118.3; Basketball: 105.6 95% CI 101.9-109.4; p < 0.01), and baseball and basketball athletes (Baseball: 113.8 95% CI 109.5- 118.1; Basketball 105.6 95% CI 101.9-109.4; p < 0.01). 12–14 , 27 In the posterolateral reach direction, a significant difference was observed between soccer and basketball athletes(Soccer: 111.8, 95%CI 108.5-115.0; Basketball: 102.0 95% CI 101.3-104.4; p < 0.01), and baseball and basketball athletes (Baseball: 107.7 95% CI 105.7-106.1; Basketball: 102.0 95% CI 101.3-104.4; p < 0.01). 12–14 , 27 For composite score, there was a significant difference between soccer and basketball athletes (Soccer: 97.6 95% CI 95.9-99.3; Basketball: 92.8 95% CI 90.4-95.3; p < 0.01) and baseball and basketball athletes (Baseball: 97.4 95% CI 94.6-100.2; Basketball: 92.8 95% CI 90.4-95.3; p = 0.02). 12–14 , 27

Injury prediction

A total of 16 studies 3 , 31 , 34 , 36 , 39 , 48 , 50 , 57 , 64 , 68–74 investigated the association between YBT-LQ performance and injury risk: 12 investigated anterior reach asymmetry, 10 investigated asymmetries in the posteromedial and posterolateral directions, five studied individual reach directions, and 13 utilized composite scores. Populations studied include collegiate athletes 3 , 36 , 39 , 50 , 57 , 68 , 70 (n=1,493), elite female basketball players 73 (n=169), male high school athletes 72 (n=156), professional and amateur soccer athletes 34 (n=74), rugby players 71 (n=109), high school cross country runners 64 (n=148), military personnel 31 , 48 , 69 (n=1919), and firefighters 74 (n=39).

Anterior Reach Asymmetry

Twelve studies 34 , 36 , 39 , 48 , 50 , 57 , 64 , 68 , 69 , 72–74 investigated the injury prediction ability of the YBT-LQ anterior reach asymmetry (Subjects: n=3,986). Five of these studies 34 , 50 , 57 , 64 , 68 examined anterior reach asymmetry using a cut off of ≥4 cm; three 34 , 57 , 64 reported raw numbers of subjects falling above and below this cut off score. Due to the high level of methodological and reporting discrepancies in the available data, a meta-analysis was not able to be completed.

Smith et al. 68 utilized the 4 cm threshold and found a relationship with future injury risk, reporting an OR of 2.20 (95% CI 1.09-4.46). The remaining seven studies varied in interpretation of anterior reach performance. Five studies 39 , 48 , 69 , 72 , 74 utilized anterior asymmetry cut off values varying from 2-3cm; of these, Valuerin et al. 74 found an asymmetry of ≥2cm was predictive of ankle sprains. Siupsinksaks et al. 73 reported only limb difference scores and did not find an association to injury in elite female basketball players. Hartley et al. 36 created a reach distance cut off of 54.5 %LL for the anterior reach and found a significant difference between injured and uninjured collegiate athletes. Populations and definition of injury and asymmetry varied between studies, however, the three studies identifying a relationship between injury risk and anterior reach all included collegiate or professional athletes.

Posteromedial and Posterolateral Asymmetry

Ten studies 3 , 34 , 36 , 39 , 57 , 64 , 68 , 72–74 examined the relationship between posteromedial and/or posterolateral reach asymmetry and future injury risk. Gonell et al. 34 reported an OR of 3.86 (95%CI 1.46-10.95) for male soccer players with a posteromedial asymmetry of 4cm or greater. No relationship was observed with posterolateral asymmetry. Four studies 57 , 64 , 68 , 72 used the same 4cm or greater asymmetry threshold for both the posteromedial and posterolateral directions, and found no relationship to future non-contact injuries in collegiate basketball players, high school cross country runners, collegiate athletes, or musculoskeletal injuries in male high school athletes, respectively. Hartley et al. 36 also reported a significant difference in posteromedial reach asymmetry, with injured female athletes having a significantly reduced asymmetry compared to uninjured counterparts. Lai et al. 39 reported asymmetries of 9cm in the posteromedial reach direction and 3cm in the posterolateral direction resulted in a sensitivity of 17.1% and 54.9% (respectively), while specificity was reported as 89.9% and 54.6% (respectively). Valuerin et al. 74 and Siupsinskas et al. 73 reported varying values for asymmetry in reach directions or limb differences, though no relationships to future injury risk were noted. Finally, Butler et al. 3 did not observe significant differences in reach asymmetry between injured and uninjured football players.

Individual Reach Directions Distance

Five studies 34 , 36 , 50 , 69 , 71 described the relationship between injury and individual reach directions. Four of these studies 34 , 36 , 50 , 69 reported normalized reach distances for all reach directions, with no significant difference noted between injured and uninjured subjects.

Johnston et al. 71 examined the relationship between the anterior reach and future concussions. Using an inertial sensor, rugby players with increased sample entropy when reaching in the anterior direction were found to be 3 times more likely to sustain a concussion. No association between posteromedial and posterolateral reaches to concussion was noted.

One 3 of 13 studies 3 , 31 , 34 , 39 , 48 , 50 , 57 , 64 , 68 , 69 , 72–74 found a relationship between composite score and future injury. Butler et al. 3 reported an odds ratio of 3.5 (95%CI 2.4-5.3) when using a cutoff of 89.6% (SN=100%, SP=71.7%) in football players. Wright et al. 50 and Brumitt et al. 57 utilized different composite cutoffs for athletic teams, ranging from 89-94%, all yielding non-significant likelihood ratios (ranges 0.55-1.32 and 0.50-1.70, respectively). Nine studies 31 , 34 , 39 , 48 , 68 , 69 , 72–74 did not report significant relationships between composite scores and future injury.

Three studies 34 , 64 , 69 examined the relationship between composite score asymmetry and future injury. Gonell et al. 34 and Ruffe et al. 64 both utilized 12cm or greater threshold for asymmetry and no relationship to injury was noted. De la Motte et al. 69 found no significant differences in composite asymmetry between injured and uninjured military personnel (p=0.50).

Testing is an important function for researchers, health care providers, and performance professionals. Many decisions hinge on test results, and it is essential to have validated tests in this process. While commonly used, the YBT-LQ has not been rigorously studied via systematic review and meta-analysis. This systematic review observed that the YBT-LQ is a highly reliable test. Dynamic balance differences were observed between sex, sport, and competition level, and asymmetry in the anterior reach demonstrated increased risk of lower extremity injury.

The YBT-LQ demonstrated high reliability over time and between raters. The high YBT-LQ reliability is comparable to the SEBT, which highlights the ability of the YBT-LQ to accurately measure dynamic neuromuscular control. 9 Higher variability in single session performance on the YBT-LQ in children may be due to the greater variability of balance performance seen in children. 75

Difference in YBT-LQ by sex, sport, and competition level

When sex was considered alone, differences were observed in the posteromedial and posterolateral directions, but no differences were observed between sexes in the anterior reach direction or in composite score. While it may appear that there was not a difference between sexes in composite score, it is important to note that there was large variability in each sex, sport, and age/competition level in YBT-LQ performance. This was confirmed by the high heterogeneity observed indicating that there indeed may be differences in performance on the YBT-LQ among populations (i.e., age, sex, sport, activity, occupation, and injury status). This overall heterogeneity helped confirm that sex, sport, and competition level differences may exist. Thus, when the pooled means were analyzed, no differences were noted. Composite reach scores varied by as much as 13 %LL depending on the sex, sport, and competition level. These differences may point to the differences seen in injury rate and type by sex. 76

There were significant differences observed between baseball and basketball in the posteromedial, posterolateral reach directions, and overall composite reach, with baseball demonstrating greater reach distances normalized to limb length. There were also differences observed between soccer and basketball in the anterior, posteromedial, posterolateral reach directions, and overall composite reach, with soccer demonstrating greater reach distances normalized to limb length. This may be due to sport specific adaptations in dynamic balance based on the demands and environment of the sport. For example, while both sports spend time running, soccer spends more time in unilateral stance at the limit of stability (e.g., kicking the ball) compared to basketball. 77 While these differences may be due to sport specific adaptations, or limb dominance, specifically greater dynamic balance strategies on the stance leg during the kicking motion, it is also worth noting that dynamic neuromuscular control differences could be due to disparate anthropometric body types in athletes. For example, basketball players may in general have longer femurs than soccer players, which may make single limb squatting (i.e., anterior reach) biomechanically more difficult for basketball players.

Population differences summary

There were significant differences across populations by sex and sport in YBT-LQ reach distance. There were not enough studies to analyze all the possible sex, sport, competition level permutations; however, it was clear that differences exist. For example, when male Rwandan high school soccer players were compared to male high school soccer players from the United States, the posteromedial and posterolateral reach distances were not different. 12 However, there was a significant difference in anterior reach and composite score. This shows YBT-LQ performance can potentially be affected by environment factors (e.g., in Rwanda there is less frequent wearing of athletic shoes and more frequent deep squatting for activities of daily living compared to the United States). 12

It is interesting to note, that not only sex, sport, and environment might influence YBT-LQ performance, but also biological maturation. Researchers have found that YBT-LQ reach distance was significantly associated with the total Balance Error Scoring System score as YBT-LQ anterior and posteromedial reach distances. 78

Injury prediction validity of the YBT-LQ

Since there were sport and gender differences in YBT-LQ, predictive studies could only be analyzed if they used a population specific cut point or examined homogeneous populations (e.g., male collegiate football players). Cut points for asymmetry and composite score varied

between studies. Due to these differences, composite score was found to be predictive of future injury in one study. 3 More research is needed to develop these population-specific cut points to more accurately determine future injury risk.

Lehr et al. 5 used population specific cut points across multiple sports. The researchers found that accurate injury risk identification was possible when multiple risk factors, including the YBT-LQ, were combined. The authors used age, sex, and sport specific risk cut points to place athletes in risk categories. These cut points were based on previously published injury prediction studies and normative databases. 5 Thus, it is important to include age, sex, and sport cut points for injury risk identification. This study was not included in the meta-analysis since the researchers included multiple risk factors and the YBT-LQ was not able to be isolated as a risk factor. Further, Teyhen et al. 79 found using a multifactorial model in soldiers that included YBT-LQ: Anterior Reach ≤ 72% limb length as one of the risk factors in the model. This study further illustrates the point that YBT cut points are population specific but also that the YBT should be used as part of a multifactorial model rather than a single risk factor in isolation.

Six studies 34 , 36 , 39 , 48 , 50 , 68 examined reach asymmetry as a predictor of injury. Four of the studies found a positive relationship between injury risk and reach asymmetry. However, there was variability in the definition of “asymmetry” with a wide cut point range and different risk reporting methods (e.g., odds ratios, likelihood ratio, sensitivity, and specificity). Thus, there may be an association with reach asymmetry and injury risk, but this was difficult to quantify given the variability of data reporting and analysis. Given that sport and sex differences were observed, it is likely that tolerance for asymmetry and direction of asymmetry may differ by sport or population. While asymmetry is an absolute value that is relative to the individual, it also may need population specific cut points, like composite score. A meta-analysis was not performed and definitive conclusions could not be drawn.

Limitations

While 57 articles were included in this review, there were not enough studies (even when combined) to provide enough power to compare populations by the different combinations of sex, sport, and competition levels. A meta-analysis on the YBT-LQ predictive ability was not completed because only two studies were found that used homogeneous methodology and reporting measures. YBT-LQ reach asymmetry as a predictive factor was not analyzed due to the highly variable reported risk cut points. Two studies 9 , 40 were low quality, while the rest were moderate and high quality. Furthermore, some of the studies had high heterogeneity in the specific YBT-LQ methodology (hands free versus hands on hip, maximum versus average reach, etc.). Due to the study risk of bias stratification, and the methodological heterogeneity, these findings need to be taken with some caution. The YBT-LQ is a controlled dynamic balance test. As many sport injuries are sustained at high velocities and forces, the YBT-LQ does not mimic some sport mechanisms of injury, which decreases the transferability of these results to the sport setting. Finally, this systematic review investigated athletic and active populations; thus, these findings cannot be generalized to all adult populations (inactive adults, geriatrics, etc.).

RECOMMENDATIONS FOR FUTURE RESEARCH

From this meta-analysis, it is clear that populations when stratified by sex and sport perform significantly differently on the YBT-LQ. This has two large implications. First, future research needs to establish normative data for a wide range of populations that utilize this test. Second, injury predictive studies need to use population specific (e.g., age, sex, sport/activity) cut points for composite score and reach asymmetry. For asymmetry, these cut points should be greater than the standard error of measure (3.2cm), 9 so that meaningful asymmetry, beyond the error of measure, can be identified. Further, given the findings of Lehr et al. 5 and Teyhen et al. 79 it may be most appropriate to combine the YBT-LQ asymmetry and composite score specific to age, sex, and sport, along with other testing to accurately determine injury risk. Interestingly, country of origin seemed to impact performance; thus, cut points may need to specify beyond the aforementioned factors to include geographical location. Future research should use adequately powered and homogenous age, sex, and sport/activity specific analysis to determine if composite score is related to injury risk.

The YBT-LQ is a reliable tool for capturing dynamic single leg neuromuscular control at the limits of stability. Performance on the YBT-LQ differs based on age, sex, and sport, therefore clinicians should consider these factors when interpreting results to ensure accurate clinical decision-making. The relationship between the YBT-LQ and future injury risk remains unclear; future studies should utilize population specific cut points and homogenous samples to determine utility in injury prediction.

Data sharing statement

This study is registered with PROSPERO, and the protocol can be found at https://www.crd.york.ac.uk/prospero/ with the identifier Prospero CRD42018090102.

Conflicts of Interest

Funding for payment of a graduate research assistant was made possible through the Ridgeway 488 Student Research Award from the University of Evansville.

Dr Phillip Plisky developed the Y-Balance Test Protocol and Test kit and receives royalties from the sale of the Y-Balance Test kit.

Submitted : December 09, 2020 CDT

Accepted : June 15, 2021 CDT

© The Author(s)

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• Int J Sports Phys Ther
• v.15(1); 2020 Feb

SCORING PERFORMANCE VARIATIONS BETWEEN THE Y-BALANCE TEST, A MODIFIED Y-BALANCE TEST, AND THE MODIFIED STAR EXCURSION BALANCE TEST

Kristen jagger.

1 Regis University, School of Physical Therapy, Denver, CO, USA

Amanda Frazier

2 Radford University, Department of Physical Therapy, Roanoke, VA, USA

Adrian Aron

Brent harper.

3 Chapman University, Department of Physical Therapy, Irvine, CA, USA

The Modified Star Excursion Balance Test (MSEBT) and the Y-Balance Test- Lower Quarter (YBT-LQ) are utilized to assess dynamic postural stability. These assessments cannot be used interchangeably secondary to kinematic variations and performance differences. A Modified Y-Balance Test-Lower Quarter (MYBT-LQ) was developed to determine if a modification allows performance scores to be directly compared to the MSEBT.

The purpose of this research was to determine if reach distances were similar for young, healthy individuals between three different balance tests: the YBT-LQ, the MYBT-LQ, and the MSEBT.

Study Design

Repeated measures, descriptive cohort study

Twenty-eight participants (17 males, 11 females) were recruited from a convenience sample of young, healthy adults. Participants completed all testing within a single session and performed three trials in each direction, on each leg, for all balance tests. Scoring performance was calculated for each balance test using the average normalized reach distance in the anterior, posterolateral, and posteromedial directions. A one-way ANOVA was used to compare between-subject posteromedial and posterolateral scores, while anterior scores were analyzed using a Kruskal Wallis test. The intraclass correlation coefficient (ICC) was used to determine within-subject participant performance reliability.

Analyses indicated significant differences in the posterolateral and posteromedial reach directions between the YBT-LQ and MSEBT and between the MYBT-LQ and MSEBT, while no significant difference was found between the YBT-LQ and MYBT-LQ in any direction. No anterior reach differences were noted between any of the tests. Within-subject ICCs showed a very strong level of agreement between right and left anterior and right posteromedial reaches between all three tests, while only the YBT-LQ and MYBT-LQ demonstrated very strong agreement in all directions.

Reach performance on the MSEBT differed from the performance on the YBT-LQ and MYBT-LQ in the anterior, posteromedial and posterolateral directions in this population. These findings further support the difference in motor control strategies used during these tests.

Levels of Evidence

Introduction.

The neuromuscular system plays an integral role in postural control during dynamic balance activities to limit the occurrence of loss of balance. 1 When there is a lack of coordination between the sensory and motor aspects of the neuromusculoskeletal system, balance is hindered, and postural instability may occur. Postural instability could lead to falls or uncoordinated and uncontrolled body movements that could ultimately produce injuries. 2 Previous research has shown that impairments within the neuromuscular system result in an increased risk for injury in young, active individuals, therefore warranting dynamic balance screening. 3 The Modified Star Excursion Balance Test (MSEBT) and the Y-Balance Test of the Lower Quarter (YBT-LQ) are reliable measures in the assessment of postural control within this population. 4 Gorman et al. 5 concluded that the YBT-LQ is a reliable derivation of the MSEBT, yet this could potentially lead clinicians to infer that these tests can be used interchangeably and that data collected during each test could be compared equally. Fullam et al. 6 identified kinematic variations and differences in performance scores on these tests, which has confirmed that they cannot be used interchangeably in the assessment of dynamic balance. 6 Specifically, authors of previous research have described significant differences have been identified in anterior reach distances comparing the SEBT and YBT-LQ. 6 , 7 The present study introduced and evaluated an alteration to the YBT-LQ that included a modification intended to counteract the physical alignment differences between the YBT-LQ and MSEBT.

The Star Excursion Balance Test (SEBT) utilizes an eight point star-shaped pattern, upon which an individual stands in the middle, balanced on one foot, while reaching as far as possible in each of the eight directions with the opposite leg. 8 The SEBT has been shown to be an effective assessment of dynamic postural control and is reliable at identifying risk for injury in individuals with chronic ankle instability, but limitations have also been discussed through extensive research. 9 - 11 Plisky and colleagues 8 determined that a difference in anterior reach distance of greater than four centimeters between each limb was associated with a higher risk of injury in high school basketball players. Robinson and Gribble 10 hypothesized that the eight reach directions within the SEBT were redundant in both healthy populations and in those with chronic ankle instability. 10 Reducing the number of reach directions tested, referred to as the Modified SEBT (MSEBT), has been a common suggestion for improving the administration and time efficiency of the SEBT, though the directions most appropriate to test for measurements continues to be debatable. 3 , 10 , 12 , 13 The directions that have been utilized for the MSEBT in other studies consist of anterior, posteromedial, and posterolateral directions. 6

The YBT-LQ was developed based on the MSEBT protocol, but instead of reaching and touching a taped line, the individual stands on a stance plate and slides a reach indicator along a static frame while maintaining balance on the opposite lower extremity ( Figure 1 ). 5 The YBT-LQ was developed to address some of the limitations of the SEBT to provide a more consistent dynamic balance assessment tool. 13 The YBT-LQ assesses dynamic limits of stability during single limb stance while the opposite leg reaches in the same three directions as the MSEBT: anterior, posteromedial, and posterolateral. 3 It can also be utilized to assess risk of injury from functional asymmetries associated with young, athletic populations. 13 , 14 As with the SEBT, the YBT-LQ reach distances are normalized to leg length. 5 The YBT-LQ has also been proposed to provide a better assessment of movement quality as compared to the SEBT, by allowing more focused attention to observing the subject and their technique during performance of the test, rather than primarily on marking the reach distance. 13

Y-Balance Test anterior reach direction .

Because the YBT-LQ was developed from the MSEBT, it was hypothesized that the results would be equivalent or very similar between the two dynamic balance assessments. 7 However, Fullam et al. 6 and Coughlan et al. 7 have shown differences between the MSEBT and YBT-LQ in the composite anterior reach score as well as the sagittal plane hip and knee angular displacements, while no significant differences were noted in the posteromedial and posterolateral directions. 6 , 7 Differences in the anterior reach direction impacts the overall composite score of the evaluation, which affects the interpretation of test results. 6 It was suggested that these discrepancies resulted from variations in dynamic neuromuscular demands and/or the use of different postural control strategies during the task of reaching in each direction. 6 , 7 Differences among the reach directions between the YBT-LQ and the MSEBT are clinically relevant because patients with neuromuscular control deficits, such as those with chronic ankle instability, will likely perform differently on one test versus the other. 6

During performance of the YBT-LQ, participants push a reach indicator slightly lateral to midline and inferior to the floor level of the stance foot, which varies from the midline and floor-level reach performed during the MSEBT. A modification to the reach indicator of the YBT-LQ was introduced by the current researchers in order to better match an individual's physical position and alignment during performance of the MSEBT and the YBT-LQ ( Figure 2 ). This modification allowed the reach indicator to be pushed from a central location, at stance foot level, similar to the physical parameters of the MSEBT. This modification of the YBT-LQ, the Modified YBT-LQ (MYBT-LQ), was intended to counteract the physical differences between testing parameters so that any additional discrepancies in performance could be attributed to other factors. As the MSEBT and YBT-LQ cannot be used interchangeably at this time, secondary to performance differences and kinematic variations, further research assessing the kinematics and postural strategies required to perform these tests have been deemed necessary. 6 The purpose of this research was to determine if reach distances were similar for young, healthy individuals between three different balance tests: the YBT-LQ, the MYBT-LQ, and the MSEBT.

Y-Balance Test reach indicator (A) and Modified Y-Balance Test reach indicator (B) .

Prior to recruitment of participants, approval was obtained from the university's Institutional Review Board (IRB). A convenience sample of twenty-eight participants (11 females, 17 males, mean age = 25.0 ± 2.2 years) was recruited from a pool of healthy, young individuals located in Roanoke, VA. Inclusion criteria for the study required participants to be healthy adults aged 18-35 years who self-reported that they were free of any lower extremity injuries in the prior six months and did not have any diagnosed neurological or balance disorders. Participants were excluded from the study if any of the following were present: lower extremity amputation, history of lower extremity fracture, vestibular disorders, undergoing current treatment for inner ear/sinus/upper respiratory infection, concussion within the prior three months, past medical history of surgery for a lower extremity injury within the prior six months, currently pregnant, or medically prohibited from participating in physical activities. Prior to engaging in any formal data collection, participants read a description of the study and signed a consent form.

Participants completed a total of three different balance tests during a single testing session, including the YBT-LQ (Functional Movement Systems™, Danville, VA), the MSEBT, and the MYBT-LQ. Performances were normalized using leg length, and maximal reach distances for anterior, posterolateral, and posteromedial directions. Prior to testing, each participant received an orientation to the balance assessments, and bilateral lower extremity leg lengths were measured. Leg length data were collected by the same researcher for all participants for consistency of measurements. The order of the three balance tests was randomized to account for the impact of fatigue and learning effect. Each test was demonstrated and scored by the same researcher who was certified to administer the Y-Balance Test through Functional Movement Systems™ (Danville, VA). Prior researchers have demonstrated good to excellent intra-rater reliability (0.85-0.91), 13 and good 3 to excellent 13 interrater reliability (0.80-0.85 and 0.99-1.0, respectively) when the YBT-LQ was performed by trained examiners. Participants were allotted three practice trials per lower extremity and direction prior to testing. A two-minute rest period was required after completion of all practice trials prior to initiation of testing.

Participants performed all versions of the tests barefoot in order to decrease external stability of the ankle provided by shoes. During YBT-LQ testing, the foot was placed on the center of the stance plate while the other remained free for reaching. Per the Y-Balance Test protocol, participants were instructed to stand on the center of the stance plate with toes behind the pre-set line and to push the reach indicator in the red target area toward the direction being tested. The reach distance was measured at the trailing edge of the reach indicator to the nearest 0.5 cm. Additionally, per Y-Balance Test protocol, trials were discarded and repeated if the participant failed to maintain unilateral stance on the stance plate (i.e. reach foot touched the floor), failed to maintain reach foot contact with the reach indicator on the target area while in motion (i.e. kicked the reach indicator), used the reach indicator for stance support, failed to keep the entire plantar aspect of the stance foot in contact with the stance plate (i.e. lifting the heel), or failed to return the reach foot to the starting position in a controlled manner (i.e. loss of balance).

In contrast to the YBT-LQ, during the MYBT-LQ participants pushed the reach indicator by using an additional fabricated tab that was centered on the superior surface of the reach indicator and flush with the trailing edge ( Figure 2 ). The fabricated tab was attached to the top of the Y Balance reach indicator such that the reach foot was centered over the reach indicator and was not effectively reaching below the stance surface or lateral to midline, which is physically more similar to the MSEBT.

To perform the MSEBT, the participants stood on the YBT stance plate and followed the same protocol as the YBT-LQ, with the exception of sliding the reach indicator. Instead of pushing the reach indicator, participants reached out and lightly touched the YBT frame with the reach foot in each of the three testing directions ( Figure 3 ). Performance of the MSEBT on the YBT frame was deemed necessary to minimize the effect of perceptual differences associated with standing on a raised surface versus the floor. The distances were recorded in the same manner as for the YBT-LQ (within 0.5 cm). The trial was invalid if the participant did not maintain unilateral stance limb support throughout the trial (loss of balance), transferred body weight onto the reach foot, failed to keep the entire plantar surface of the stance foot in contact with the stance plate, and/or if the reach foot did not contact the YBT frame.

Modified Star Excursion Balance Test as performed atop the Y-Balance Test frame .

Statistical Methods

Prior to conducting this study, an a priori power analysis was conducted to determine the necessary sample size using G*Power 3.1 (© 2010-2019 Heinrich Heine Universität Düsseldorf). Calculations based on a similar study conducted by Fullam and colleagues 6 indicated that a sample size of 27 was necessary to achieve 80% power. A between- and within-subjects analysis was performed comparing the differences between the normalized reach distances on the YBT-LQ, MSEBT, and MYBT-LQ. Posterolateral and posteromedial reach distances for the YBT-LQ, MYBT-LQ, and MSEBT were analyzed utilizing a one-way ANOVA and Tukey's HSD post hoc tests, while anterior reach distances were analyzed using a Kruskal Wallis test due to non-normality. Intraclass correlation coefficients (ICCs), using a consistency definition and a two-way mixed model, were analyzed to determine the reliability of individual participant performance among the three tests. All participants served as their own controls. Statistical analysis was completed using IBM SPSS Statistics for Windows, Version 24.0. (Armonk, NY: IBM Corp) with an alpha value of 0.05 utilized to determine any statistically significant different results were found among the variables.

The normalized reach distances of the YBT-LQ, MYBT-LQ, and MSEBT were analyzed for the 28 participants. A significant main effect was found between subjects for the average reach distances for the posterolateral [right: F (2) = 4.816, p = 0.011, left: F (2) = 5.455, p = 0.006] and posteromedial [right: F (2) = 3.425 , p = 0.037, left: F (2) = 3.121, p = 0.049] reach directions between the three tests. The average anterior reach distances were not found to be significantly different [right: X ( 2 ) 2 = 0.779, p = 0.677, left: X ( 2 ) 2 = 1.869, p = 0.393] between any of the three tests ( Figure 4 ). Tukey's HSD post-hoc analyses indicated significant differences in the right posteromedial reach direction between the MYBT-LQ and MSEBT ( Figure 5 and Table 1 ), and significant differences in bilateral posterolateral reach directions between the YBT-LQ and MSEBT and between the MYBT-LQ and MSEBT ( Figure 6 and Table 1 ). There was no significant difference between the YBT-LQ and MYBT-LQ in any reach direction (p = 0.23), no significant difference between any of the three tests in the left posteromedial reach direction (p = 0.51), and no significant difference between the YBT-LQ and MSEBT in the right posteromedial reach direction (p = 0.14) ( Table 1 ).

Normalized scores for all anterior reach directions. YBT-LQ = Y-Balance Test Lower Quarter; MYBT-LQ = Modified Y-Balance Test Lower Quarter; MSEBT = Modified Star Excursion Balance Test .

Normalized scores for all posteromedial reach directions. YBT-LQ = Y-Balance Test Lower Quarter; MYBT-LQ = Modified Y-Balance Test Lower Quarter; MSEBT = Modified Star Excursion Balance Test .

Normalized scores for all posterolateral reach directions. YBT-LQ = Y-Balance Test Lower Quarter; MYBT-LQ = Modified Y-Balance Test Lower Quarter; MSEBT = Modified Star Excursion Balance Test .

Tukey's HSD Post Hoc Results.

YBT-LQ = Y-Balance Test Lower Quarter; MYBT-LQ = Modified Y-Balance Test Lower Quarter; MSEBT = Modified Star Excursion Balance Test

Intraclass correlation coefficients comparing YBT-LQ and MYBT-LQ demonstrated very strong agreement for all reach directions, and all three tests demonstrated very strong agreement in the anterior reach direction ( Table 2 ). Reaches in the right posteromedial direction showed very strong agreement for MYBT-LQ and MSEBT and for YBT-LQ and MSEBT, while there was less strong agreement among the remaining tests and reach directions ( Table 2 ).

Intraclass Correlation Coefficients by Lower Extremity and Reach Direction.

The primary aim of the present study was to determine if there were differences between reach distances during performance of the YBT-LQ, the newly developed MYBT-LQ, and the MSEBT. Analyses revealed that participants performed more similarly on the YBT-LQ and MYBT-LQ, and less similarly on the MSEBT, indicating that the modification to the YBT-LQ did not significantly alter performance outcomes of the YBT-LQ. It has previously been proposed that differences occurred between performance in the YBT-LQ and SEBT due to variations in the position of the reach foot; the SEBT is performed by reaching directly in line and at floor level, while the YBT-LQ is performed by reaching slightly lateral to the position of the stance foot and at a level slightly below that of the stance foot. 7 The MYBT-LQ was specifically developed for the present study to evaluate these differences inferred by Coughlan and colleagues 7 . The YBT-LQ and MYBT-LQ showed very strong agreement in overall reach distance performance, which suggests that differences shown in previous research between the YBT-LQ and MSEBT should not be attributed to the foot position relative to the reach indicator or stance foot.

Variations in performance between the MSEBT and YBT-LQ have also been attributed to varying feedback and feedforward mechanisms of postural control. 7 In the YBT-LQ, it is proposed that a continuous feedback loop is present due to the proprioceptive input to the reach foot as it pushes the reach indicator during testing. This feedback loop is thought to assist participants in determining how far they have reached and when they are nearing the limits of their stability. In contrast, the MSEBT utilizes a feedforward mechanism of postural control as participants reach to their limits of stability prior to making contact with the support surface; this means that participants must rely heavily on anticipatory actions before they receive sensory input from the ground. 7 The present study appears to further support a difference in postural control mechanisms between these tests. The MYBT-LQ altered the physical alignment to more closely approximate the MSEBT, yet the reach distance outcomes remained similar to those of the YBT-LQ. Reaching out while utilizing proprioceptive feedback from the reach indicator may have provided an advantage during the YBT-LQ and MYBT-LQ that allowed for greater reach distances in the posteromedial and posterolateral directions. In the present study, participants displayed more difficulty locating the YBT frame while performing the MSEBT atop it, compared to the YBT-LQ and MYBT-LQ. This could be due to the role of the proprioceptive systems and a continuous feedback loop that is present during the YBT-LQ and MYBT-LQ.

Contrary to the findings of Coughlin and colleagues, 7 no statistically significant differences were noted between the three tests in the anterior direction. In order to perform these balance assessments, participants utilize three different sensory systems (visual, vestibular, and proprioceptive) to maintain postural control. 7 It is likely that participants performed similarly on the three tests in the anterior direction due to the increased visual input and awareness of their body position during completion of the anterior reach. In the posteromedial and posterolateral directions, the participants could not see the labeled frame, were unaware of their reach distances during the performance of each trial, and had to seek the rail positions during the MSEBT. Participants likely relied more heavily on vestibular and proprioceptive input to perform the posteromedial and posterolateral reaches which may have led to more variation between the overall group's performances in these directions. 7 In contrast, participants’ performance of the anterior direction likely utilized all three sensory systems, yielding a more uniform reach distance in this direction. Additionally, unlike participants in the Coughlan 7 study, the participants in the present study were not members of organized collegiate sports teams at the time of testing. This may have resulted in a group of participants who did not have the proprioceptive abilities typically demonstrated by collegiate athletes. These participants, however, may be more representative of average healthy active young adults, making the findings applicable to a larger subset of the population.

Clinical Relevance

The outcomes of this study support prior findings indicating that performance scores on the YBT-LQ and MSEBT are not equivalent and thus, the assessments should not be used interchangeably. A modification designed to align the physical parameters of the two tests (MYBT-LQ) did not result in significant differences in reach distances when compared to the MSEBT, and therefore is not suggested for future use of the YBT-LQ. Choosing between the MSEBT and the YBT-LQ should continue to be at the discretion of the sports or rehabilitation professional and should best match the needs of the professional and their athlete/patient, since both tests are reliable and have demonstrated injury prediction capabilities. Given that the primary difference between the two tests is the pattern associated with the reach, sports and rehabilitation professionals should select the test that best aligns with the individual's sports, recreation, or job duties. Those who are able to utilize environmental inputs during their movements may benefit from testing using the YBT, while those who are required to target in open space should choose the MSEBT.

A potential limitation in the present study is the method of testing during the MSEBT. Standing atop the YBT frame allowed for consistent positioning and measurement of reach distances, but it did not address the altered visual perception that may result from standing on a raised surface.

Results of the present study show strong correlations between performance on the YBT-LQ and the MYBT-LQ, suggesting that feedback from the reach indicator may be responsible for variations noted when comparing performance to the MSEBT. These findings also indicate that there is no need to modify the YBT-LQ reach indicator to more closely replicate the physical parameters of the MSEBT, as the reach distance outcomes do not differ significantly. Results of this study also indicate that healthy active young adults demonstrate performance variations in the posterolateral and posteromedial reach directions when performing the YBT-LQ, MYBT-LQ, and MSEBT, while anterior reach directions do not differ. Future research that investigates the effect of standing on a raised versus level surface during completion of the MSEBT (i.e., on the YBT frame) would be beneficial in helping determine the cause of variable findings on these balance tests.