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Dev Neurorehabil, Early Online: 19

! 2013 Informa UK Ltd. DOI: 10.3109/17518423.2013.827755

ORIGINAL ARTICLE

Development and validity of the early clinical assessment of balance for

young children with cerebral palsy
Sarah W. McCoy1, Doreen J. Bartlett2, Allison Yocum3, Lynn Jeffries4, Alyssa L. Fiss5, Lisa Chiarello6,
& Robert J. Palisano6
1
Department of Rehabilitation Medicine, University of Washington, Seattle, WA, USA, 2School of Physical Therapy, Faculty of Health Sciences,
Western University, Hamilton, Ontario, Canada, 3Waypoint Pediatric Therapies, Issaquah, WA, USA, 4Department of Rehabilitation Sciences,
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University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA, 5Department of Physical Therapy, Mercer University, Atlanta, GA, USA,
and 6Programs in Physical Therapy and Rehabilitation Sciences, Drexel University, Philadelphia, PA, USA

Abstract Keywords
Objectives: Validity of the Early Clinical Assessment of Balance (ECAB), to monitor postural Balance, cerebral palsy, measurement,
stability in children with cerebral palsy (CP), was evaluated. preschool children, validity
Methods: 410 children with CP, 1.5 to 5 years old, participated. Physical therapists scored
children on the Movement Assessment of Infants Automatic Reactions section and Pediatric History
Balance Scale. Through consensus, researchers selected items from both measures to create the
ECAB. Content and construct validity were examined through item correlations, comparison of Received 29 May 2013
ECAB scores among motor ability, age and gender groups and correlations with the Gross Revised 17 July 2013
Accepted 18 July 2013
For personal use only.

Motor Function Measure 66 basal and ceiling (GMFM-66-B&C).

Results: Internal consistency was high (Cronbachs alpha 0.92). ECAB differed significantly Published online 1 October 2013
among motor ability, children 531 months old scored lower than older children, but there was
no difference between boys and girls. ECAB and GMFM-66-B&C scores correlated strongly
(r 0.97).
Conclusion: Validity of the ECAB was supported. Reliability and responsiveness need study.

Introduction clinically feasible measurement of impairments in postural

stability is important for describing when and how postural
Postural stability is defined as the ability to control the bodys
stability is impaired and monitoring change in childrens
center of mass in relationship to the persons base of support
balance across time. This should lead to amelioration as much
for maintenance of balance [1]. Impairments in postural
as possible via specific interventions.
stability have been documented in children with cerebral
For a larger study to identify determinants of gross motor
palsy (CP) during both static (maintaining a posture) and
function, self-care and play in young children with CP (entitled
dynamic (changing positions and moving through the envir-
Move & PLAY: Movement and Participation in Life Activities
onment) activities [25]. Depending on the type of CP
of Young Children) [12, 13], we wanted a clinically feasible
(spastic, dystonic, ataxic), children may show primary
measure of balance ability from pre-sitting to standing and
impairments in postural stability due to variations in
walking that is valid for young children with CP across all
biomechanical alignment and musculoskeletal structures [6],
Gross Motor Function Classification System (GMFCS) [14
sensory cueing for postural adjustments [1] and temporal and
16] levels. Available clinical measures of balance for young
spatial aspects of motor coordination patterns triggered to
children with CP that include early balance ability of the head,
control posture [79]. Balancing difficulty can also be
the trunk in sitting and standing balance are sections of
observed among children with CP in the control of the head
developmental diagnostic motor tests such as the Peabody
alone [10], the head and trunk for sitting activities [11] or the
Developmental Motor Scales, 2nd edition (PDMS-2) [17] and
head, trunk and legs for standing and walking activities [2, 5].
Movement Assessment of Infants (MAI) [18], and tests focused
The relationship between postural stability or balancing
specifically on sitting and standing balance such as the
ability (used as a synonymous term) and gross motor ability in
Pediatric Reach Test (PRT) [19] and the Pediatric Balance
children with CP has been demonstrated in many research
Scale (PBS) [20]. Each of these tests was reviewed from the
studies [1, 2, 10]. Given the importance of balance ability for
perspective of our research purpose with the following
functional movement in children with CP, a valid, reliable and
conclusions.
The PDMS-2 has been shown to have high testretest and
inter-rater reliability on children 17 months and younger [17]
Correspondence: Sarah Westcott McCoy, Department of Rehabilitation
Medicine, University of Washington, Seattle, WA 98195, USA. E-mail: and on 410-year-old children with CP [21] (correlations or
westcs@uw.edu ICCs40.80). The stationary sub-test has a limited number of
 2 S. W. McCoy et al.
items related to balance ability development, making it
potentially unresponsive to small changes in functional
balance [17]. The MAI [18] has one section (Automatic
Reactions section) devoted to equilibrium development,
which offers a detailed and systematic way to examine and
monitor emerging balance ability of the head and trunk in
supine, prone and sitting. Psychometrics on the MAI have
been completed in infants with positive results (inter-rater
reliability r 0.72, testretest reliability r 0.76, significant
predictive validity for early MAI to assessment 12 years
later) [2224] but have not been completed on young children
with CP or on the Automatic Reactions Section. Our
assumption, however, was that these items were clearly
written and could conceivably be measured reliably.
The PRT assesses the distance a child can reach from a
sitting and/or standing posture [19] and was developed so it
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could be used with children with CP across all GMFCS levels.
However, it is limited to a measurement of balance due to an
internal perturbation (reaching) and does not encompass
balance in response to external perturbations (reactive postural
adjustments) or sensory perturbations (altered vision or support
surface). The PBS [20], adapted from the Berg Balance Scale
(BBS) [25], includes static, dynamic and anticipatory balance
items that are considered integral parts of everyday functional
tasks. The PBS presents as a more comprehensive postural
stability test for childrens sitting and standing balance.
Reliability was found to be high (inter-rater ICC 0.997;
For personal use only.
testretest ICC 0.998) in a mixed group of children with mild
to moderate motor impairments, many of whom had a
diagnosis of CP [20]. Validity has been demonstrated via
verification of increased scores as children age and differences
in scores of children with and without disability [26].
Based on our review, we did not find one measure that
adequately examined balance for head control through body
control during static (prone, sitting, standing) and dynamic
(moving while sitting and standing) activities. Therefore,
within the Move & PLAY study, we collected data using
several balance measures. We chose to use the items and
scoring mechanism within the Automatic Reactions section of
the MAI to measure balance ability within the head and trunk
during lying and sitting in children with CP who had limited
functional movement (GMFCS levels IIIV) and we used the
PBS to measure balance during more challenging sitting and
standing activities in children with CP who had greater
functional movement ability (GMFCS levels I and II and
potentially III). Our research team combined items from the
two measures to represent the continuum of balance ability
from head control in prone and supported sitting to whole body
control in standing while moving through space to create the
Early Clinical Assessment of Balance (ECAB). The ECAB is a
13-item test that estimates postural stability and is intended for
children with CP across all levels of functional ability. Ease of
administration in clinical practice and low burden on the child
were high priorities during the creation of the test.
The purpose of this study was to describe the creation of the
ECAB and our examination of content and construct validity
[27] within our Move & PLAY sample of young children with
CP. The primary research questions and our hypotheses were:
(1) Does the ECAB have content validity (internal consist-
ency of test items)?
Dev Neurorehabil, Early Online: 19
We hypothesized that internal consistency would be
0.80, indicating that items are measuring similar types
of balance behaviors.
(2) Does the ECAB demonstrate construct validity?
(a) Using a known groups method:
(i) Do ECAB scores differ among children with CP
by GMFCS level? We hypothesized that ECAB
scores would differ based on childrens GMFCS
level; children with higher gross motor function
would demonstrate higher ECAB scores demon-
strating better balance ability.
(ii) Do ECAB scores differ among children with CP
by age? We hypothesized that older children
would have higher ECAB scores than younger
children (children older than 42 months4chil-
dren 3142 months4children less than 31
months).
(iii) Do ECAB scores differ among children with CP
by gender? While the conclusion by many is that
postural control matures earlier in girls than in
boys in typically developing children younger
than 10 years [2832], we could find no research
that had examined this within young children with
CP. We therefore hypothesized that there would
be no differences between boys and girls.
(b) Does the ECAB correlate with the Gross Motor
Function Measure 66 basal & ceiling version
(GMFM-66-B&C) [33] in children with CP? We
hypothesized correlations of moderate to high
magnitude (r 0.600.80) between ECAB and
GMFM-66-B&C scores, given that the GMFM-
66-B&C reports on overall gross motor activity, not
just balance ability, but does include assessment of
pre-sitting to standing gross motor movements.
Methods
Design
For content validity, an informal consensus process and a
correlation design was employed. To evaluate construct
validity of the ECAB, a known groups and correlation
design was used [34].
Participants
A convenience sample of 410 children with CP who
participated in the Move & PLAY study across all GMFCS
levels, age 1.55 years, was recruited through therapist
referral and word of mouth from four regions across the
United States (Greater Seattle, WA; Greater Philadelphia, PA;
Greater Oklahoma City, OK; Greater Atlanta, GA) and six
provinces across Canada (British Columbia, Saskatchewan,
Manitoba, Ontario, Nova Scotia, and Newfoundland and
Labrador). Institutional Review Boards at all participating
institutions approved the study. Parents provided informed
consent for their childrens participation in the study.
The children included 231 boys and 179 girls (mean age
38 mo, SD 11 mo): 9 children with monoplegia, 90 with
hemiplegia, 97 with diplegia, 24 with triplegia, and 188 with
quadriplegia, (n 2 unclassified). For age comparisons, the
 DOI: 10.3109/17518423.2013.827755
Table I. Characteristics of children participating in the study.
Age groups n, (%)
Total participants Male gender n, (%) 531 3142 442
410 231 (56) 116 (28) 131 (32) 163 (40)
*GMFCS Gross Motor Function Classification System.
children were divided into three age groups:531 months; 31
42 months; 442 months. These age divisions were chosen to
divide the sample into three relatively equal groups of 2
years old, 3 years old and 45 years old. Table I
summarizes the characteristics of the children who partici-
pated in the study.
Instrumentation
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Gross Motor Function Classification System (GMFCS)
The GMFCS is a 5-level system used to classify children with
CP on present abilities and limitations in motor function with
emphasis on sitting and walking [14]. The GMFCS has
evidence of reliability and validity [14, 15] and has been used
in many studies [16].
Movement Assessment of Infants Automatic Reactions
section (MAI-AR)
For personal use only.
The Movement Assessment of Infants (MAI) is a criterion-
referenced tool used to evaluate infants at risk for develop-
mental delay [18]. Test items used within our study included
the eight items within the MAIs Automatic Reactions
section, including assessment of reactive postural adjustments
of the head to tilting, trunk reactions when rolling, trunk
balance reactions in sitting and reactions to fast perturbations
(protective extension) in sitting [18]. Inter-rater reliability of
the MAI items used was assessed on 16 children within the
Move & PLAY study. One of the study raters administered
and scored the test while a second study rater or investigator
observed and scored. Inter-rater reliability was found to be
high, ICC(2,1) 0.96, (95% CI: 0.900.99), p50.001.
Pediatric Balance Scale (PBS)
The PBS is a 14-item criterion referenced screening tool for
functional balance in children age 36 years that assesses
static, dynamic and anticipatory balance [20]. The PBS starts
with bench sitting balance ability and then moves to more
difficult standing balance tasks such as standing with eyes
closed and completing dynamic tasks in standing such as
alternately tapping feet on a 600 step [20]. Adequate testretest,
inter-rater and intra-rater reliability have been established and
beginning norms have been compiled [20, 28]. Convergent
validity of the BBS [25] (same items as PBS, but directions
are not modified for children) to the GMFM-66-B&C,
walking speed and 10-second sit-to-stand test has been
demonstrated in children with CP [35].
Gross Motor Function Measure 66 basal & ceiling
(GMFM-66-B&C)
The basal and ceiling approach of the GMFM-66-B&C was
used to measure motor function in as succinct a manner as
Early Clinical Assessment of Balance for children with CP 3
GMFCS* level n, (%)
White race/ethnicity n, (%) I II III IV V
288 (70) 138 (34) 49 (12) 51 (12) 76 (19) 96 (23)
appropriate to reduce the burden of testing on the children and
because our sample age matched previous research that
validated this procedure [33]. The GMFM-66-B&C is based
on sequencing the 66 items in terms of difficulty level,
established using Rasch analysis [36]. The 66 items are the
same as the GMFM-66, in which each item is graded on a 4-
point ordinal scale (from 0 does not initiate to 3
completes). Using the basal and ceiling version of the
GMFM, therapists can obtain a very accurate estimate of the
GMFM-66 score with as few as 15 items. An adapted score
sheet provides an entry point for testing children based on
their GMFCS level and age, and therapists need to score items
that fall between a basal level of three consecutive scores of
3 and a ceiling of three consecutive scores of 0. The
second version of the Gross Motor Ability Estimator (GMAE)
is used to calculate a GMFM-66 score using the basal and
ceiling approach (available at www.canchild.ca search
GMAE-2 for a free download of the software). Concurrent
validity is supported with strong correlations between the
GMFM-66-B&C and the GMFM-66 (ICC 0.987; 95% CI:
0.9720.994) and testretest reliability is also high
(ICC 0.994; 95% CI: 0.9870.997 [33].
Procedures
Rater training
As a part of the Move & PLAY study, 61 licensed, practicing,
pediatric physical and occupational therapists attended one-
day training courses held in each data collection site. During
the training, investigators used the same presentations to
explain the study and the tests. Within the training, therapists
achieved 80% agreement on rating of the GMFCS using video
segments of children with CP. After the course, therapists
observed and scored MAI, PBS and GMFM-66-B&C
items from videotapes of children. Before testing any
children in the study, the therapists had to reach 80%
agreement with investigators scores for the videotaped
children on all tests.
Data collection
Therapists collected data during home or clinic visits,
dependent upon families preferences. Within a single test
session, the therapists scored the children on the GMFM-66-
B&C and the MAI and/or PBS and established the childrens
GMFCS level. Children in GMFCS levels IIII were scored
on all items from the PBS. Children in GMFCS levels IIIV
were scored on the Automatic Reactions section of the MAI.
Intentionally, children in GMFCS level III were assessed
using both tools because it was thought that their balance
ability would potentially fall between the two scales.
 4 S. W. McCoy et al. Dev Neurorehabil, Early Online: 19

Construction of the Early Clinical Assessment of Balance retained included: (1) two sitting items: one static sitting item
(ECAB) (bench-sitting), one dynamic sitting item (movement from sit
to stand), (2) two static standing items: one with decreased
After collection of the MAI and PBS data, we reviewed the
sensory information (balance in standing with feet together
eight items from the MAI and 14 items from the PBS in order
and with eyes closed) and (3) two dynamic standing items
to merge the items into one comprehensive test of balance, the
requiring anticipatory postural control (turning 360 degrees
ECAB. Consensus between two researchers (SWM, DJB:
and tapping alternate feet on a 600 step).
pediatric physical therapists with greater than 30 years
We hypothesized that the MAI and PBS items could be
experience) and approval of the Move & PLAY study team
merged together as an overall measure of the developmental
was conducted to: (1) reduce clinician and respondent burden
progression of postural stability, given that the MAI items we
by decreasing the number of items, (2) maintain items which
selected test early postural stability via reactive and antici-
measured postural stability due to internal, external and
patory head stability and trunk stability in floor sitting while
sensory perturbations and (3) cover balance of the childs
the PBS items we selected test anticipatory postural stability
head, trunk in sitting and overall body in standing to allow
starting with bench sitting, then transfers and static and
measurement of all functional levels among children with CP.
dynamic standing. One external verification of our merging
Seven items from the MAI and six from the PBS were
assumption comes from examination of the mean difficulty
retained for the ECAB. (Table II lists the test items.) One item
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estimates for items on the GMFM-66 [29]. GMFM-66 Item

was dropped from the MAI, forward protection response, due
24 (SIT ON MAT: maintain arms free 3 seconds) has a
to the reported difficulty administering this item with larger
difficulty estimate of 30.1 and item 34 (SIT ON BENCH:
children. Also, therapists demonstrated uncertainty in scoring
maintains arms and feet free 3 seconds) has a difficulty
the item; because as the child is quickly lowered toward the
estimate of 36.6. This suggests that in children with CP, the
floor to score this item, the arms can extend slightly due to
ability to sit on the floor is slightly easier than the ability to sit
gravity. Eight items were dropped on the PBS for the
on a bench. Within the ECAB, postural stability during floor
following reasons: (1) problems with test administration and
testing is followed by postural stability in bench sitting.
measurement in the young children as reported by therapist
We then created a total ECAB score as the sum of the score
raters (turn to look behind, reaching forward while standing),
for each of the 13 items, which varied from 0 to 100. The
(2) redundancy in type of balance tested and desire for
response options for the seven items, originally from the MAI,
reducing burden of testing (stand to sit, stand unsupported,
For personal use only.

are scored from 0 (no response) to 3 (consistent full response).

pick up object from floor), (3) requirement of specified
Five of the seven items require a score for both the right and
equipment (transfers, the need for an appropriate size chair
left side, totaling 12 items to represent early postural stability.
with arm rests) and (4) items very difficult for this age range
Therefore, the maximum score for this section of the ECAB is
(tandem standing and one leg balance). The six PBS items
36. The written scoring criteria for the six items originally
from the PBS, which ranged from 0 (unable to complete task)
Table II. Early Clinical Assessment of Balance items*. to 4 (able to complete task at the noted criterion level) were
retained. However, the points awarded for these items were
PART I: Head and trunk postural control changed based on the fact that we had more early items (12)
(specific scoring criteria noted on score sheet)
and our judgment that there were small increments of postural
ECAB 1 Head righting lateral (Right and Left)
ECAB 2 Head righting extension stability difficulty item-to-item reflected in the early meas-
ECAB 3 Head righting flexion urements of head and trunk postural stability. Also, there were
ECAB 4 Rotation in trunk (Right and Left) larger increments of difficulty between items, that is, greater
ECAB 5 Equilibrium reactions in sitting (Right and Left)
ECAB 6 Protective extension side
changes in postural stability required for accomplishing these
ECAB 7 Protective extension backward later test items. We changed the points for the sitting items to
06 points, the static standing items to 010 points and the
PART II: Sitting and standing postural control:
(specific scoring criteria noted on score sheet) dynamic standing items to 016 points. Therefore, the
ECAB 8 Sitting with back unsupported but feet maximum score for this section of the ECAB is 64. The
supported on floor or on a stool full score sheet with details for testing is available online
ECAB 9 Sitting to standing
at http://www.canchild.ca/en/ourresearch/moveplay.asp. After
ECAB 10 Standing unsupported with eyes closed
ECAB 11 Standing unsupported with feet together the ECAB was created, we then used the data from the Move &
ECAB 12 Turns 360 degrees PLAY study to further evaluate the validity of the ECAB.
ECAB 13 Placing alternate foot on the step while standing
unsupported
(Items 8 & 9 are weighted  1.5; Items 10 & 11  2.5; and Items 12 & Data analysis
13  4 for total score.)
The Statistical Package for the Social Sciences (SPSS)
PART I: Head and trunk postural control total score part I (PASW, Version 18; IBM Corporation, Somers, NY) was
(max 36)
PART II: Sitting & standing postural control total score part II used for data analyses. The total ECAB test score was used for
(max 64) all data analyses, except item scores were used for examin-
Total ECAB score (max 100) ation of internal consistency. Descriptive statistics of each
*The full ECAB is available on the Move & PLAY website: http://
comparison group were run within SPSS to examine data
www.canchild.ca/en/ourresearch/moveplay.asp distributions (skewness and kurtosis). The distribution of
Copyright: Sarah W. McCoy, Doreen J. Bartlett, Lisa A. Chiarello, ECAB total scores was relatively normally distributed among
Robert J. Palisano, Lynn Jeffries, Alyssa Fiss. Unpublished work, 2010.
 DOI: 10.3109/17518423.2013.827755 Early Clinical Assessment of Balance for children with CP 5

all groupings (GMFCS levels, age groups and gender groups)
except one (ECAB score for GMFCS level II). Given this, and
the fact that the ECAB items are scored on ordinal scales, the
decision was made to use non-parametric statistics. The alpha
value used for all analyses was 0.05.
Content validity was analyzed by examining the bivariate
Spearman correlations between test items and Cronbachs
alpha to determine overall internal consistency. Construct
validity was first analyzed using the known groups method.
KruskalWallis ANOVA tests were used to determine if
ECAB scores differed among the five GMFCS levels and
among the three age groups of children. Post-hoc comparisons
between GMFCS levels and age groups were performed using
MannWhitney U tests. Differences between the ECAB
scores among girls and boys were analyzed using the
MannWhitney U test. As a second test of construct validity,
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Content validity
All bivariate correlations between test items were statistically
significant (p50.001) and varied in magnitude from
rs 0.320.94 (Table VI). Cronbachs alpha was 0.92,
indicating statistically, a high overall internal item
consistency.
Construct validity (known groups method)
For comparisons among GMFCS levels, KruskalWallis
ANOVA results were statistically significant (Chi-square
365.11, p50.001) (Figure 1 and Table III). Mann
Whitney U pairwise analyses indicated that median ECAB
scores differed significantly among children in all GMFCS
levels (p50.001). Children with GMFCS level I had the
highest median ECAB score, while children in level V had the
lowest median score.

the ECAB and the GMFM-66-B&C total scores were

compared using Spearmans correlation coefficients.
Results
Descriptive data on the ECAB and the GMFM-66-B&C for
children with CP, grouped by GMFCS level are presented in
Table III, grouped by age in Table IV and grouped by gender
in Table V.
For personal use only.
For comparisons among the three age groups, Kruskal
Wallis ANOVA results were statistically significant (Chi-
square 9.42, p 0.009). Children with CP who were less
than 31 months of age had lower median balance scores than
children 3142 months of age (p 0.01) and children 4360
months of age (p 0.006). Median balance scores did not
differ between children 3142 and 4360 months of age
(p 0.51) (Table IV).

Table III. Summary of scores on the Early Clinical Assessment of Balance for children with cerebral palsy across gross motor function classification
levels.

GMFCS I GMFCS II GMFCS III GMFCS IV GMFCS V

Mean (SD) Mean (SD) Mean (SD) Mean (SD) Mean (SD)
Median (min/max) Median (min/max) Median (min/max) Median (min/max) Median (min/max)
(n 138) (n 49) (n 51) (n 76) (n 96) Difference among GMFCS groups
ECAB 80.3 (17.2) 46.7 (7.7) 32.0 (8.1) 17.5 (6.2) 7.9 (5.4) p50.001
total score 85.8 (43.5/100) 43.5 (37.5/83.0) 31.5 (12.0/54.0) 17.5 (5.0/34.0) 7.0 (0/24.0)
GMFM 67.8 (7.8) 50.5 (5.1) 43.4 (5.2) 28.0 (8.3) 19.9 (7.1) p50.001
total score 66.7 (47.5/100) 50.9 (39.5/63.6) 44.2 (27.3/56.9) 26.0 (8.1/45.7) 20.5 (0/37.4)

GMFCS Gross Motor Function Classification System; CP cerebral palsy; SD standard deviation.

Table IV. Summary of scores for the Early Clinical Assessment of Balance for children with cerebral palsy grouped by age.

GMFCS level
Age
I II III IV V ALL
1831 Months
Mean score (SD) 61.4 (13.5) 43.9 (3.7) 26.0 (8.8) 16.9 (5.4) 7.5 (5.6) 31.7 (22.2)
Median 58.5 43.5 27.5 16.0 5.0 27.5
(min/max) (43.5/92.0) (39.0/53.0) (12.0/46.5) (6.0/28.0) (1.0/21.0) (1/92)
(n) (28) (22) (13) (28) (25) (116)
3242 Months
Mean score (SD) 81.0 (14.2) 45.4 (3.9) 32.9 (5.7) 16.1 (4.4) 8.1 (5.0) 44.1 (32.0)
Median 85.8 45.5 33.0 17.0 8.0 40.0
(min/max) (46.5/100) (37.5/52.5) (22.5/41.5) (5.0/23.0) (0/20.0) (0/100)
(n) (48) (16) (21) (12) (34) (131)
4360 Months
Mean score (SD) 88.4 (13.9) 54.2 (12.3) 35.6 (7.9) 18.4 (7.3) 7.9 (5.9) 46.9 (36.2)
Median 95.0 53.0 36.0 19.0 7.0 36.0
(min/max) (46/100) (40.5/83) (23.0/54.0) (8.0/34.0) (0/24.0) (0/100)
(n) (62) (11) (17) (36) (37) (163)
Difference among age groups 1831 months to 3242 months: p 0.01
1831 months to 4360 months: p 0.006
3242 months to 4360 months: p 0.51

GMFCS Gross Motor Function Classification System; SD standard deviation.

 6 S. W. McCoy et al. Dev Neurorehabil, Early Online: 19

Table V. Summary of scores on the Early Clinical Assessment of Balance for children with cerebral palsy grouped by gender.

GMFCS levels
Gender I II III IV V All
Boys
Mean score (SD) 78.7 (17.3) 45.4 (4.7) 31.9 (8.5) 16.3 (6.2) 8.3 (5.5) 40.3 (31.1)
Median (min/max) 84.0 (43.5/100) 43.5 (37.5/58.0) 31.75 (12.0/54.0) 15.0 (5.0/34.0) 8.0 (0/21.0) 34.5 (0/100)
(n) (75) (31) (26) (45) (54) (231)
Girls
Mean score (SD) 82.3 (17.0) 49.0 (11.0) 32.1 (7.8) 19.2 (5.9) 7.4 (5.4) 43.4 (33.1)
Median (min/max) 88.0 (43.5/100) 46.25 (39.0/83.0) 30.5 (16.0/49.0) 19.0 (10.0/34.0) 6.5 (0/24.0) 34.0 (0/100)
(n) (63) (18) (25) (31) (42) (179)
Difference between gender groups p 0.41

GMFCS Gross Motor Function Classification System; SD standard deviation.

Table VI. ECAB item-by-item correlations.

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1 4 5 6 7
Test items 2 3 8 9 10 11 12 13
Side tested* L R L R L R L R L R
1L 1.0
1R 0.90 1.0
2 0.77 0.79 1.0
3 0.78 0.78 0.73 1.0
4L 0.77 0.77 0.73 0.67 1.0
4R 0.76 0.77 0.74 0.68 0.95 1.0
5L 0.84 0.84 0.76 0.74 0.83 0.83 1.0
5R 0.81 0.82 0.77 0.72 0.83 0.85 0.94 1.0
6L 0.80 0.81 0.76 0.71 0.83 0.83 0.89 0.87 1.0
6R 0.74 0.77 0.76 0.68 0.80 0.83 0.88 0.89 0.91 1.0
For personal use only.

7L 0.72 0.74 0.69 0.62 0.83 0.83 0.87 0.87 0.87 0.86 1.0
7R 0.70 0.72 0.70 0.61 0.83 0.84 0.86 0.87 0.85 0.89 0.98 1.0
8 0.72 0.73 0.70 0.63 0.79 0.79 0.84 0.83 0.86 0.86 0.87 0.88 1.0
9 0.64 0.65 0.63 0.56 0.75 0.75 0.77 0.79 0.79 0.79 0.85 0.86 0.86 1.0
10 0.50 0.51 0.50 0.44 0.61 0.61 0.64 0.65 0.63 0.65 0.73 0.73 0.73 0.86 1.0
11 0.38 0.38 0.37 0.32 0.45 0.45 0.47 0.48 0.47 0.48 0.55 0.55 0.53 0.66 0.79 1.0
12 0.48 0.49 0.46 0.41 0.58 0.58 0.60 0.62 0.60 0.61 0.69 0.70 0.68 0.82 0.89 0.78 1.0
13 0.37 0.37 0.37 0.32 0.44 0.44 0.46 0.47 0.46 0.47 0.53 0.56 0.52 0.65 0.78 0.82 0.78 1.0

L left side; R right side.

For comparisons between genders, there was no significant 100.00

effect of gender (MannWhitney U 19 684.0, p 0.41)
(Table V).
80.00

Construct validity (correlation method)

ECAB Total Score

The Spearman correlation between the ECAB and GMFM- 60.00

66-B&C was 0.97 (p50.001). The explained variance

between ECAB and GMFM-66-B&C scores (R2) was 94.1%. 40.00

Discussion 20.00

Content validity
Content validity was supported by the high internal consist- .00

ency of the items. The bivariate correlations indicate that level I level II level III level IV level V
while all items were significantly related, there were differ- GMFCS level
ences in the magnitude of the relationships between individ-
ual items. The lowest correlations were between the first four Figure 1. Boxplots of the ECAB total scores plotted across GMFCS
levels of the children with CP are presented. The boxes represent the
items (head control laterally to right and left and in flexion 2575th percentile with the median indicated by the dark line within the
and extension) and the last two items (turning 360 degree in box. The high and low scores are indicated by the lines extending
standing and alternate toe tapping on a step). We suggest this from the boxes, with outliers noted by small circles, and extreme outliers
by stars.
supports that the items cover different aspects of postural
stability.
 DOI: 10.3109/17518423.2013.827755
Construct validity
The ECAB was significantly different across gross motor
function levels of children with CP, which provides evidence
of the construct validity of the test. As gross motor function
increased, balance ability increased. Children with the highest
motor ability, GMFCS level I, had the highest balance ability
among children with CP; on average their scores were 72%
higher than the scores for children in GMFCS level II. This
finding, that children in GMFCS level I stand apart compared
to children with CP in other GMFCS levels, is consistent with
previous research in older children on participation in leisure
and recreation activities and impairments [37]. However, it
should be noted that children in level I also had the highest
variability in their balance scores, in part due to age
variability within the sample.
We hypothesized that ECAB scores of children with
Dev Neurorehabil Downloaded from informahealthcare.com by Associacao Das Pioneiras on 11/03/14
CP531 months, 3142 months, and 4360 months of age
would be higher for each age group based on the assumption
of age related changes in postural stability during early
development [38]. We found that children 531 months had
the lowest median score, but the median scores of children in
the two older groups did not differ from each other. To
explore the interaction of age and GMFCS level, we ran a
2-way (Age  GMFCS) ANOVA. We found an interaction in
age and GMFCS level (Figure 2). The mean ECAB scores of
children in GMFCS level I differed significantly for each age
group, whereas there were smaller differences among children
For personal use only.
in levels II and III by age group and no significant differences
at GMFCS levels IV and V. In studies of children with typical
development, postural control, motor coordination patterns
and sensory integration during balancing were different
between 18 month to 3 years old and 4 to 6 years old [38,
39]. Further analysis of ECAB scores after collection of a
larger sample including older children (6 years old) with re-
grouping into two similar age levels (18 months3 years and
100.00
Estimated Marginal Means ECAB Total Score
80.00
60.00
40.00
20.00
.00
level I level II level III
GMFCS level
Figure 2. Plot of the interaction of ECAB scores among age and
GMFCS groups. The points plotted represent the mean ECAB scores by
age (separate lines) and GMFCS level (across X-axis).
Early Clinical Assessment of Balance for children with CP 7
46 years) may yield similar age differences on the ECAB.
Alternatively, improvement in postural stability behaviors in
children with CP has been shown to take longer to develop [1,
10, 40, 41], which may be affecting our age differences results
as compared to those from children with typical development.
Although research on children with typical development
shows gender differences in young children [2832], we could
not find reports of gender differences in balance in young
children with CP. Therefore, we hypothesized that there would
not be a significant difference in ECAB scores between the
young boys and girls in our study. Our results substantiated
this hypothesis. It is interesting to note, however, that for
every GMFCS level except level V, girls mean scores were
higher than boys.
The correlation between ECAB (a measure of body
functions) and GMFM-66-B&C (a measure of gross motor
activity) scores (r 0.97) was higher than anticipated. We
hypothesized a correlation of 0.60 to 0.80 based on the
perspective that although many items on the ECAB and
GMFM are similar, items on the ECAB were selected
specifically to assess postural stability. In retrospect, perhaps
this is not surprising, given the inclusion of some postural
control tasks within the GMFM-66-B&C items (e.g. prone,
lifts head upright; supine, pulls self to sitting with head
control) and the focus of measuring postural stability using
motor functions in the PBS that are also in the GMFM (e.g.
sitting on a bench or moving from sitting to standing).
Although the correlation is very strong, we propose that the
ECAB focuses specifically on functional balance tasks,
whereas the GMFM is a global measure of gross motor
function. In addition, the ECAB includes items for head and
trunk postural stability, specific balance reactions in sitting
and a dynamic standing balance task, which are not addressed
by the GMFM-66-B&C. Given the reduced time to administer
the GMFM-66-B&C, therapists might consider using both the
ECAB and GMFM-66-B&C to identify strengths and areas
for improvement and intervention planning. Research is
Age Group
recommended to determine if the ECAB and GMFM-66-
18 - 30 months B&C differ in measuring change over time.
31 - 42 months
43 - 60 months
Benefits of the ECAB
The ECAB provides an easy, inexpensive and low-burden way
to measure postural stability or balance in young children with
CP at all GMFCS levels. To our knowledge there are no other
tests for young children with CP across all functional levels in
this age range that are specific to balance ability. The ECAB
can be completed within approximately 15 minutes, making
the burden of administration low for therapists and research-
ers. It includes a broad and comprehensive range of balance
abilities, from early head and trunk balancing to balance in
standing while doing a dynamic activity. As the intent of the
ECAB is to succinctly measure overall postural stability, it
cannot be broken down into subscales associated with aspects
of postural control, but should direct implementation of
level IV level V physical therapy interventions. Utilization of the ECAB with
families of young children with CP should also facilitate
opportunities for discussion about the childs abilities across
time and the importance of balance within development of
movement ability.
 8 S. W. McCoy et al.
Limitations of the ECAB
Within our study, we acknowledge the limitations of the
assumptions we made in creating the test, the lack of complete
normal distribution and the different sample sizes within
some of the groupings for functional ability and age. Future
studies should include the use of different and larger samples
of children with CP to assist with statistical analysis (i.e.
Rasch analysis) to determine whether items represent a
univariate construct and to assess the difficulty of each item.
This will help substantiate or refute the scoring system and
determine the interval nature of the items. Reliability,
comparison of the ECAB with other measures of postural
stability and sensitivity-to-change also need to be completed.
An examination of the responsiveness of the ECAB in
children with CP after interventions focusing on improving
balance would be beneficial prior to the test being used as an
Dev Neurorehabil Downloaded from informahealthcare.com by Associacao Das Pioneiras on 11/03/14
outcome measure. This analysis is in progress. Following
children over time will also facilitate the development of
reference percentile curves across GMFCS levels for moni-
toring of developmental progression of postural stability and
recommendations for interventions for children with CP.
Finally, research on this test in children with other medical
diagnoses or motor disabilities is warranted.
Conclusion
The ECAB provides clinicians and researchers with a
For personal use only.
clinically feasible test of balance or postural stability for
1.5- to 5-year-old children with CP across all GMFCS levels.
Content and construct validity of the ECAB are supported for
children with CP. Further research examining test reliability,
the potential interval nature of the test items, describing
developmental trajectories of postural stability of children
with CP and examination of responsiveness (ability to detect
change) of the ECAB in the context of effective interventions
is needed prior to use as an outcome measure in clinical trials
and as an evaluative measure in clinical practice.
Acknowledgments
We wish to express our appreciation to all the children and
their families who participated in this study. We also want to
acknowledge all the rest of the Move & PLAY research team
including Peter Rosenbaum, MD; Barbara Stoskopf, RN,
MHSc; Audrey Wood, PT, MS; Barbara Sieck Taylor, parent
consultant; Tina Hjorngaard, parent consultant; and all the
therapist assessors and interviewers from the United States
and Canadian test sites.
Declaration of interest
The authors report no declarations of interest.
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