What is the recommended balance testing protocol for a child with suspected concussion?

Balance Testing in Pediatric Concussion

Balance testing should be performed using validated tools as part of a multimodal assessment, with the specific approach varying by age: use the modified Balance Error Scoring System (mBESS) as part of the SCAT6/Child SCAT6 in the acute period, and incorporate tandem gait variants (standard, timed, complex, and dual-task) along with visio-vestibular examination in the subacute period, particularly for adolescent athletes. 1, 2

Age-Specific Approach

For Adolescents (13+ years)

The 2024 Amsterdam Consensus provides the most current framework 2:

• Acute assessment (0-72 hours): Use the SCAT6 tool, which includes the modified Balance Error Scoring System (mBESS). The SCAT6 demonstrates strong discriminatory ability within the first 72 hours but utility diminishes by 7 days 2.

• Subacute assessment (office setting): Use the SCOAT6, which includes:

  • Standard balance assessment
  • Timed tandem gait
  • Complex tandem gait
  • Dual-task tandem gait
  • Visio-vestibular examination 2

For Children (8-12 years)

• Acute period: Use the Child SCAT6 with age-appropriate modifications 2
• Subacute period: Use the Child SCOAT6 with developmentally appropriate versions of balance tests 2

Specific Balance Testing Components

Modified Balance Error Scoring System (mBESS)

The mBESS involves three stances, though it exhibits variability in reliability 2:

• Double-leg stance
• Single-leg stance
• Tandem stance

Important caveat: The mBESS alone shows only moderate correlation with gold-standard force plate measurements. Research demonstrates that dual-task gaze stabilization with tandem stance correlates more strongly (rs = 0.77) with objective sway area than standard mBESS positions 3.

Enhanced Balance Testing

The evidence supports augmenting standard balance testing with:

1. Tandem gait variants 2:

   • Standard tandem gait
   • Timed tandem gait
   • Complex tandem gait (part of Visio-Vestibular Examination)
   • Dual-task tandem gait (combining balance with cognitive or vestibular tasks)

2. Dual-task assessments: Combining balance testing with either cognitive tasks or vestibular-oculomotor function (gaze stabilization) enhances diagnostic sensitivity 2, 3. The "sharpened BESS" (sBESS) - dual-task gaze stabilization with tandem stance - shows stronger association with objective balance deficits than mBESS alone 3.

3. Romberg test: When combined with PCSS and BESS, identifies additional patients with balance deficits (approximately 80% of concussed children show balance difficulties when using this comprehensive approach) 4.

Clinical Application Algorithm

Step 1 - Acute Setting (0-72 hours):

• Use SCAT6 (ages 13+) or Child SCAT6 (ages 8-12)
• Perform mBESS as part of the standardized tool
• Consider adding dual-task gaze stabilization with tandem stance if resources permit

Step 2 - Subacute Setting (Office visit):

• Use SCOAT6 (ages 13+) or Child SCOAT6 (ages 8-12)
• Include all tandem gait variants
• Perform visio-vestibular examination
• Add Romberg test for comprehensive assessment

Step 3 - Ongoing Monitoring: Balance testing is recommended as one component of recovery assessment in adolescent athletes, though it should not be used in isolation 1. The CDC guideline specifies that health care professionals may use balance testing to assess recovery in adolescent athletes with mTBI (moderate evidence, level C) 1.

Critical Limitations and Pitfalls

1. Age considerations: Most evidence comes from adolescent populations, with limited data in children under 12 years 2. The Amsterdam Consensus emphasizes the need for more research in the under-12 age group 2.

2. No single tool is sufficient: Balance testing alone is not strongly predictive of outcome 1. The 2018 CDC guideline explicitly recommends using a combination of tools including validated symptom scales, cognitive testing, and balance testing 1.

3. Timing matters: Balance deficits are most apparent acutely. The SCAT tools show diminishing utility by 7 days post-injury 2.

4. Baseline testing: Routine mandatory baseline testing is not recommended in children due to rapid developmental changes, though it may be considered for older competitive athletes if resources and trained personnel are available 2.

5. Training requirements: The mBESS shows improved reliability with systematic training methods 2. Ensure personnel are properly trained in administration and scoring.

6. Symptom exacerbation: Brief, mild symptom increases (≤2 points on 0-10 scale for ≤1 hour) during testing are not harmful and do not delay recovery 2.

Practical Considerations

For children too dizzy to complete testing (approximately 18% in one study), document this finding as it represents clinically significant balance impairment 5. Simple double-leg stance with eyes open may be the only feasible test acutely and can still discriminate concussed from non-concussed children 5.

The evidence strongly supports that balance testing provides unique information not captured by symptom reporting alone - approximately 30% of children with balance difficulties on objective testing do not report balance problems or dizziness on symptom scales 4.