upper extremity star excursion balance test

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• J Exerc Sci Fit
• v.21(2); 2023 Apr
• PMC10009542

Validity and reliability of upper extremity star excursion balance test in adolescent swimmers

a Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China

Yong-Hui Zhang

b Graduate School, Xi'an Physical Education University, Xi'an, China

Thanh Luan Ngo

Qiong zhang.

c Shanghai Changning Youth Amateur Sports School, Shanghai, China

Zhimin Feng

Xue-qiang wang.

d Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China

Associated Data

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Upper limb balance is one of the important physical fitness parameters for all populations, especially overhead athletes like swimmers. Upper extremity star excursion balance test (UESEBT) is a comprehensive dynamic balance assessment, this study aims to explore the reliability and validity of UESEBT among adolescent swimmers.

This cross-sectional study recruited 70 adolescent swimmers. All participants were required to complete UESEBT, upper quarter Y-balance test (UQYBT), maximal isometric strength (MIS) tests in upper limb, closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET). The intra- and inter-operator reliability and the correlation of UESEBT with other physical performances were conducted.

For reliability, the intra- and inter-operator reliability of all directions and composite score were high-to-excellent (ICC = 0.706−1.000) among all participants. For validity, the UESEBT has a moderate-to-strong correlation with UQYBT ( r  = 0.42−0.72, p  < 0.001), and a weak-to moderate one with CKCUEST ( r  = 0.25−0.42, p  < 0.05). Furthermore, the UESEBT performance showed weak-to-moderate correlations with MIS ( r  = 0.24−0.44, p  < 0.05). UESEBT was correlated to LTET ( r  = 0.24−0.33, p  < 0.05) whereas no relationship was found with TFET.

Conclusions

UESEBT was a reliable and valid tool to screen upper extremity dynamic balance among adolescent swimmers. UESEBT provides more detailed information in eight directions to assess the upper limb sport performance. Further study should explore the prediction ability of UESEBT for injury.

1. Introduction

Balance is defined as the ability to prevent body from falling, 1 which is essential for maintaining body posture, especially when executing complicated sport activities. Normally, balance could be classified into dynamic and static. To elaborate, static balance is the balance in stationary circumstances while dynamic balance accounts for the balance during motion and position transformation, 1 which is more frequently challenged among athletes. Better dynamic balance control could decline the deviations of center of mass during complex movement, thereby minimizing the possibility of potential injuries. 2 Therefore, the screening assessments evaluating the dynamic balance performance of athletes are demanding.

Different dynamic balance tests could also be categorized based on the targeted body part. In lower limb, lower quarter Y-balance test (LQYBT) and star excursion balance test (SEBT) are two primary tests used in clinical practice. LQYBT can validly predict lower limb injuries among volleyball players and runners 3 , 4 and it has been proven to be reliable among adults (ICC = 0.80−0.93), healthy adolescents (ICC = 0.40−0.96), and soccer players (ICC = 0.85−1.00). 5 , 6 Similarly, SEBT has been used to predict lower extremity injuries in basketball and soccer players. 7 , 8 The reliability of SEBT among adults (ICC = 0.86−0.92) and elite athletes (ICC = 0.90−0.95) has been demonstrated. 9 , 10 Meanwhile, the test targeting upper limb balance is fewer probably because the primary function of upper limb and lower limb differs. 11 That is to say, the upper limb requires more flexibility to account for technical and precise movement while the lower limb requires more stability for support. Nevertheless, stability is also essential for joints in upper limb when coping with perturbation, especially for the mobility-demanding one like glenohumeral. Lacking adequate stability, the joints could not return to its initial position, which might cause capsule laxity or further shoulder-related injury. 11 According to present research, Upper Quarter Y-Balance Test (UQYBT) is a frequently reported upper limb stability test among various populations and sports. 12 , 13 , 14 The UQYBT has been proved valid and reliable in healthy adolescents. 15 Considering swimming is a sport event requiring the full-range strength and endurance of upper limb 16 and that approximately 91% of professional swimmers experience shoulder injuries, 17 the assessments of upper limb dynamic stability is helpful to evaluate sport performance and predict future injuries for swimmers. 18 Nevertheless, UQYBT only contains information from three reach directions and the potential risks may not be fully screened. As a more comprehensive upper limb dynamic balance test, upper extremity star excursion balance test (UESEBT) could provide data in eight directions which enables clinicians and coaches to trace the deficits. However, the reliability and validity of UESEBT among adolescent swimmers has not been revealed.

The present study aimed to investigate the validity and reliability of UESEBT among 70 adolescent swimmers. The study purposed to report the inter- and intra-operator reliability of UESEBT and explore the criterion and construct validity (specifically convergent validity, a subtype of construct validity) of UESEBT. For criterion validity, the correlation between UESEBT and UQYBT was conducted. For construct validity, the correlation between UESEBT and other outcome measures, including maximal isometric strength (MIS), closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET), were measured.

Seventy adolescent swimmers were recruited in this cross-sectional study. Sample size was estimated based on Walter et al. 19 To match our study design, three replicates per subject, p 0  = 0.6, p 1  = 0.8, a = 0.05 and power = 0.8 were applied, then the sample size should be 26.1. The inclusion criteria were as follows: (1) training onsets more than 1-year and training at least three times a week (2) aged from 9 to 19 (3) no injury history within 3 months with irritating pain during the test. The exclusion criteria were as follows: (1) with any cardiac-related or mental-related conditions (2) disobedient behavior during the test. This study was approved by the local Human Ethics Committee (2018042). All willing participants and their legal guardians signed informed consent forms prior to the tests.

Prior to the test, basic and swimming-related information, injury history, and limb dominance were collected. In addition, the right upper limb length was measured and the average values of three assessments were used for analysis. 20 After that, a series of evaluation including UESEBT, UQYBT, MIS test, CKCUEST, TFET, and LTET were performed in random sequence. 21 In addition, the inter- and intra-operator reliability of the UESEBT were measured. For inter-operator reliability, participants performed one test procedure and operators A and B who were blinded to each other individually read and recorded the distances. For intra-rater reliability, participants repeated the same test procedure immediately and only operator A read and recorded the distances.

Eight directions including anterior, superomedial, medial, inferomedial, posterior, inferolateral, lateral, and superolateral were marked on floor by tapes with scale and the angle between each strip of tape were 45°. The minimum unit of the UESEBT was 0.5 cm. Before the formal test, a staff provided a comprehensive demonstration. One practice was required for each participant before formal tests. Participants stayed in a push-up position and placed the palm of the stance limb on the intersection of tapes. Then, maximal reach of free limb was performed. Hip flexion was permitted whereas stance limb flexion was not allowed. Distances for analysis were normalized by dividing the right upper limb length of every participant, and then multiplying by 100. Additionally, the composite score was calculated by summing up the normalized reach distances and dividing it by 8. The UESEBT included the maximal reach with dominant (D) and non-dominant (ND) limb as stance limb. The test was invalid and repeated if the substandard incidents were observed (1) foot was not contacted with floor; (2) distance between two feet exceed 12 inches; (3) unilateral stability was not maintained. One test procedure required the participants to repeat the UESEBT twice. The average values of the two UESEBTs in one test procedure were regarded as the outcome of this test procedure.

Detailed procedures of other physical performance including UQYBT, MIS test, CKCUEST, TFET, and LTET were depicted in Supplementary 1. For UQYBT, the average values of two measurements were determined for analysis. For MIS test and CKCUEST, the maximal values of two assessments were used for analysis. For TFET and LTET, only once performance was required.

IBM SPSS Statistics 25.0 was applied to analyze the data. All 70 participants were divided into two groups based on gender, median age or median training onsets, respectively. The reliability of UESEBT were processed by conducting intraclass correlation coefficients (ICC) 3.1 . The different level of ICCs was interpreted based on the research of Domholdt et al., 22 where 0.90–1.00 meant “excellent reliability,” 0.70–0.89 meant “high reliability,” 0.50–0.69 meant “moderate reliability,” 0.26–0.49 meant “low reliability,” and 0.00–0.25 meant “little reliability.” The level of agreement and systematic error of reliability was indicated by Bland–Altman plots. For validity, two-tailed Spearman test was applied to determine the correlation between UESEBT with CKCUEST, TFET, LTET and ipsilateral MISs. In addition, the correlation between UESEBT and UQYBT in the corresponding three directions was also carried out. The outcome of Spearman test was interpreted as follows: 0.80–1.00 meant “very strong,” 0.60–0.79 meant “strong,” 0.40–0.59 meant “moderate,” 0.20–0.39 meant “weak,” and 0.00–0.19 meant “very weak.”

The personal characteristics and swimming performance of all, male, and female participants are demonstrated in Table 1 . The mean age and body mass index (BMI) of all participants was 12.32 years old and 17.55 kg/m 2 , respectively. Their mean training onsets and volume were 4.83 years and 24.73 km per week, respectively. Among the 70 participants, 19 reported injury history (Knee: 6, ankle: 5, wrist and hand: 6, elbow: 1, scoliosis: 1).

Table 1

Demographics and characteristics of all participants.

Note: All participants were divided into two groups based on gender. Data were presented as Mean ± SD or as the number of participants (%).

Abbreviations: BMI: Body Mass Index; CKCUEST: Closed Kinetic Chain Upper Extremity Stability Test; TFET: Trunk Flexor Endurance Test; LTET: Lateral Trunk Endurance Test.

Detailed information about intra- and inter-operator reliability of UESEBT in all participants were provided in Table 2 and the reliability in participants with different gender was demonstrated in Table 3 . The Bland–Altman plots for reliability were also provided from Figs. S1–S9 (Supplementary 2). Overall, the composite intra-operator reliability of UESEBT was excellent (D ICC = 0.923, ND ICC = 0.905). To narrow down in eight directions, the intra-operator reliability of every direction ranged from high to excellent regardless of the dominance of stance limb (ICC = 0.706−0.937). Of interest, it was observed that there was a drop in intra-operator reliability from anterior (D ICC = 0.780, ND ICC = 0.788) to superomedial (D ICC = 0.737, ND ICC = 0.743), followed by a successive increase. Once it reached the peak at posterior (D ICC = 0.937, ND ICC = 0.892), it started to decline. Furthermore, a similar pattern can also be witnessed when observing intra-operator reliability of participants with different gender. The intra-operator reliability of UESEBT among male and female participants was also high-to-excellent (ICC = 0.703−0.949) except for the one in the inferomedial direction on ND side of male (ICC = 0.675).

Table 2

Inter- and Intra-operator reliability of Upper Extremity Star Excursion Balance Test in all swimmers.

Abbreviations: A1: the first measurement outcome of operator A; A2: the second measurement outcome of operator A; B: the measurement outcome of operator B; SEM: standard error of measurement; MDC: minimum detectable change; ICC: intraclass correlation coefficient; CI: confidence interval.

Table 3

ICC values with 95% CI for inter- and intra-operator reliability of Upper Extremity Star Excursion Balance Test in swimmers with different gender.

Abbreviations: ICC: intraclass correlation coefficient; CI: confidence interval.

Whether side and gender factor influence reliability are detected by comparing the frequencies. As for side factor, the composite intra-operator reliability was slightly higher on D side than that on ND side among all participants and participants in different gender. Breaking into eight directions, the reach distances in 4 out of 8 directions on D side were higher among all participants. In addition, the intra-operator reliability in 5 out of 8 directions on D side were higher among male and female participants. With regard to gender factor, the composite intra-operator reliability of in female was higher than that in male regardless the dominance of stance limb. Breaking into directions, the intra-reliability in 10 out of 16 directions in female participants was higher than that in male. Above all, no obvious gender and side difference in number was observed, indicating that gender and side might not be influential factors for reliability in adolescent swimmers. Similarly, the results of age and training onsets subgroups showed that they did not have obvious impact on reliability and relative information was demonstrated in Supplementary 2 ( Table S1 and Table S2 ).

As for inter-operator reliability, all results stated a high level of agreement. The directional and composite inter-operator reliability among all participants were excellent (ICC >0.958). In terms of participants with different gender, the inter-operator reliability among male and female was also excellent (ICC >0.980).

For construct validity, the correlations with statistical significance between UESEBT and other outcome measures were illustrated in Fig. 1 . For criterion validity, the correlations between the performance of UESEBT and UQYBT were demonstrated in Fig. 2 and Fig. 3 .

Correlation Matrix of UESEBT and other outcomes

Note: Outcomes with statistical significance ( p  < 0.05) were labeled by r -values and those without were marked by ‘X’. Abbreviations: CKCUEST: Closed Kinetic Chain Upper Extremity Stability Test; TFET: Trunk Flexor Endurance Test; N -LTET: Lateral Trunk Endurance Test on non-dominant side; D-LTET: Lateral Trunk Endurance Test on dominant side.

Correlation Coefficient between UESEBT and UQYBT on dominant side

Note: Spearman test was applied to carry out r -value and it is labeled on the top left of each graph. Abbreviations: UESEBT: upper extremity star excursion balance test; UQYBT: upper quarter Y-balance test.

Correlation Coefficient between UESEBT and UQYBT on non-dominant side

The UESEBT and UQYBT were correlated in all directions ( p  < 0.001). On D side, a moderate correlation was found between the medial ( r  = 0.49), inferolateral ( r  = 0.42), superolateral ( r  = 0.54), and composite ( r  = 0.51) distances of UESEBT and the equivalent distances of UQYBT. On ND side, a moderate correlation was found between the medial ( r  = 0.48) and inferolateral ( r  = 0.54) distances of UESEBT and the equivalent distances of UQYBT. Furthermore, the superolateral ( r  = 0.60) and composite ( r  = 0.72) distances of UESEBT were strongly correlated with same distances of UQYBT.

Some significant correlations were discovered between UESEBT and MISs, basically in superomedial, medial, and inferomedial directions ( p  < 0.05). Specifically, there was weak correlations ( r  = 0.24−0.29) between the superomedial distance and 4 MISs on D side. The medial distance was weakly to moderately ( r  = 0.27−0.41) correlated with 5 MISs. A weak correlation ( r  = 0.26−0.27) was found between the inferomedial distance and 3 MISs. On ND side, the superomedial distance was weakly to moderately correlated with 8 MISs ( r  = 0.24−0.42). The medial distance had weak to moderate correlations with 9 MISs ( r  = 0.28−0.44). There was a weak correlation between the inferomedial distance and 8 MISs ( r  = 0.24−0.39).

UESEBT was significantly correlated with the following performances ( p  < 0.05). CKCUEST was weakly to moderately correlated with 8 distances on D side ( r  = 0.25−0.42). Furthermore, there was a weak correlation between CKCUEST and 5 distances on ND side ( r  = 0.25−0.32). Nevertheless, no significant relationship was discovered between UESEBT and TEFT. In terms of the relationship of UESEBT on D side and LTET, 4 distances had a weak correlation with the performance of dominant LTET ( r  = 0.27−0.33). Three distances were weakly correlated with the performance of non-dominant LTET ( r  = 0.24). With regard to the relationship between UESEBT on ND side and LTET, 3 distances ( r  = 0.27−0.30) and 3 distances ( r  = 0.24−0.26) had a weak correlation with the performance of dominant and non-dominant LTET, respectively.

4. Discussion

The overall intra- and inter-operator reliability was excellent and high-to-excellent. Furthermore, no obvious gender, side, age and training onsets difference were found in reliability. As for criterion validity, the performance of UESEBT was correlated with corresponding distance of UQYBT (moderate-to-strong). For construct validity, the better performance of UESEBT in superomedial, medial, and inferomedial directions were associated with more upper limb strength on both sides (weak-to-moderate). UESEBT had a close correlation with CKCUEST (weak-to-moderate) and LTET (weak) but not TFET.

In this study, the intra-operator reliability was high-to-excellent, similar to previous findings. Gorman et al. concluded that the instant test-retest reliability of UQYBT in young adult ranged from 0.80-0.99 13 . Notably, the intra-operator reliability of superomedial direction was the lowest among eight directions. The possible explanation might be the reach in this direction required more dynamic stability in diagonal. 23 When the center of gravity shifting towards the contralateral side, the lateral shear force of the stance limb might significantly increase. Furthermore, the center of gravity shifts toward the cranial side synchronously, which generates great pressure on the top front of the shoulder capsule. These challenges might account for the fluctuation of reach distance between trials. On the other hand, the intra-operator reliability in posterior direction was the highest. The possible explanation is the application of hip flexion strategy during performance could significantly decrease the pressure and provide more stability. With regard to the potential factors affecting intra-operator reliability, we found the dominance of stance limb in UESEBT may not affect the intra-operator reliability, which is consistent with previous findings. 15

The inter-operator reliability of UESEBT in adolescent swimmers was excellent. Similarly, the excellent inter-operator reliability of UQYBT in young adult was reported by Gorman et al. with the ICC value at 1.00 13 . Another research revealed that the inter-operator reliability of SEBT among healthy adults was high-to-excellent (ICC = 0.86–0.92), 24 which was slightly lower. This possible reason is their inter-operator reliability was derived from three independent test sessions completed by three individuals, which might add more uncertainty between operators.

The UESEBT was found moderately to strongly related to UQYBT. UQYBT has been proved to be reliable and valid in many populations, including adults and swimming athletes. 12 , 13 , 14 The UESEBT shares some similar advantages to UQYBT because they both require the engagement of the entire kinetic chain, including scapular stability, coordination ability, thorax flexibility, and core stability. Considering that the absence of any certain parts could increase the risk of upper limb injuries among overhead athletes, 25 the outcomes of UESEBT and UQYBT enable clinicians to verify the potential weakness. Furthermore, the UESEBT owns more advantages compared to UQYBT. Specifically, it can provide more information in eight directions. Comprehensive information about upper limb stability is significant, since adequate stability provided by shoulder surrounding tissues were foundation to obtain more mobility. 11 As a mobility-demanding stability test, UESEBT evaluates performance throughout the entire range, which further discovered the undetected deficits. Moreover, eight reach directions in the UESEBT challenge the dynamic stability within a longer period, which is closer to real swimming situation. Given that the average duration in Olympic pool events ranges from 21 s to 15 min, 26 UESEBT is more proper and valid among swimmers working for endurance event.

The UESEBT performance in superomedial, medial, and inferomedial direction was extensively correlated with ipsilateral upper limb strength. The possible explanation is that the distal reach in these 3 directions requires weight to lean toward the contralateral side. Adequate engagements of these muscles are necessary to provide posture stability. By contrast, Westrick et al. found no relationship between the performance of UQYBT and isometric strength, seemingly inconsistent with our findings. 21 This could be interpreted by the different body positions during the MIS test. Besides, their study only assessed the strength of shoulder muscles whereas this study measured that of most large muscles in the upper limbs.

The performance of UESEBT was widely correlated with that of CKCUEST. Previous research has revealed the close correlation between UQYBT and CKCUEST, 21 which is consistent with our findings. CKCUEST was the first developed closed kinetic chain (CKC) dynamic stability test. 27 Although both CKCUEST and UESEBT aim to measure the upper limb performance in CKC situations, the former requires bilateral limb supporting alternatively, whereas the latter demands unilateral limb supporting. In addition, the CKCUEST is carried out bidirectionally at a high speed, 28 whereas the UESEBT is executed multi-directionally at a low speed. We suggest researchers and coaches should select the more suitable tests or the combination of these two tests to match the characteristics of specific sports event. With regard to trunk endurance, the study found nearly no results indicating a relationship between UESEBT and TFET, in line with the findings of Westrick et al. 21 Additionally, a few correlations were discovered between the performances of some directions in UESEBT and LTET. Previous studies have indicated LTET can effectively activate some core muscles, including lateral musculature and anterolateral flexors. 29 , 30 , 31 Adequate strength of these muscles guarantees further reach distance in unstable posture during UESEBT.

Dynamic balance is an important fitness parameter for overhead athletes, which is strongly associated with physical performance and the risk of injury. At present, limited assessments focused on the dynamic balance in upper limb. This study is the first to apply star excursion balance test in upper limb and prove that UESEBT is reliable and valid to screen upper limb dynamic balance among adolescent swimmers. This assessment could provide more information in eight directions for clinicians and coaches to detect the potential deficits. Also, this study has some limitations. First, we did not find the impact of injury history on the UESEBT even though 19 participants reported injury history. The small samples and low consistency of injury position and pathology limited the discovery of injury impact. Second, only one practice was required before the formal test of UESEBT, whereas another research has mentioned 6 reps of practice were needed in SEBT to demonstrate stable performance. 23 Considering the participants are adolescent whose physical ability may be limited, over-practice could result in poor performance during six-time formal test and other physical tests, which may not truly reflect their abilities.

5. Conclusion

The intra- and inter-operator reliability of all reach directions and composite score was basically high-to-excellent, and gender, side, age and training onsets might not affect the reliability. Moreover, the outcome of UESEBT was closely correlated with the dynamic balance assessed by UQYBT and CKCUEST, as well as the muscle strengths in upper limb, indicating good construct and criterion validity. Therefore, this study suggested that UESEBT is a reliable and valid tool to assess upper limb dynamic stability among adolescent swimmers and provide more information in eight directions for clinicians and coaches to detect the potential deficits. Future research is expected to focus on the prediction of upper limb injuries applying UESEBT.

Ethics approval and consent to participate

This study was approved by the Human Ethics Committee of Shanghai University of Sport (2018042). All willing participants and their legal guardians signed informed consent forms prior to the tests.

Availability of data and materials

Funding information.

The work was supported by the scientific and technological research program of the Shanghai Science and Technology Committee (grant numbers: 19080503100; 21S31902400); the Shanghai Key Lab of Human Performance (Shanghai University of Sport) (grant numbers: 11DZ2261100); Talent Development Fund of Shanghai Municipal (grant numbers: 2021081); Shanghai Clinical Research Center for Rehabilitation Medicine (grant numbers: 21MC1930200).

This work is following the ethical standards of the institutional research committee and with the Helsinki Declaration. This study was approved by the local Human Ethics Committee (2018042). All willing participants and their legal guardians signed informed consent forms.

Authors statement

Conceptualization, X.-Q.W.; investigation, H.-R.X., Y.-H.Z., Q.Z., G.H., Z.M.F., and W.J.S.; data curation and analysis, H.-R.X., Y.-H.Z., T.L.N., Y.M.; validation, H.-R.X., Y.-H.Z., and T.L.N.; writing—original draft preparation, H.-R.X., Y.-H.Z., and Y.M.; writing—review and editing, H.-R.X., Y.-H.Z. and X.-Q.W.; supervision, X.-Q.W. All authors have read and agreed to the published version of the manuscript.

Declaration of interest statement

This article is an original research which has not been published and is not under consideration for publication elsewhere. The authors declare that they have no competing interests and this work has been approved for publication by all author.

Acknowledgments

The authors would like to thank the individuals who volunteered to participate in this study and the physiotherapists who assisted in participants recruitment.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.jesf.2023.02.003 .

Appendix A. Supplementary data

The following are the Supplementary data to this article.

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Hand reach star excursion balance test: An alternative test for dynamic postural control and functional mobility

Affiliations.

• 1 Department of Physical Performance, Norwegian School of Sports of Science, Oslo, Norway.
• 2 Department of Sport Science, University of Innsbruck, Innsbruck, Austria.
• PMID: 29738557
• PMCID: PMC5940230
• DOI: 10.1371/journal.pone.0196813

Tests of dynamic postural control eliciting full-body three-dimensional joint movements in a systematic manner are scarce. The well-established star excursion balance test (SEBT) elicits primarily three-dimensional lower extremity joint movements with minimal trunk and no upper extremity joint movements. In response to these shortcomings we created the hand reach star excursion balance test (HSEBT) based on the SEBT reach directions. The aims of the current study were to 1) compare HSEBT and SEBT measurements, 2) compare joint movements elicited by the HSEBT to both SEBT joint movements and normative range of motion values published in the literature. Ten SEBT and HSEBT reaches for each foot were obtained while capturing full-body kinematics in twenty recreationally active healthy male subjects. HSEBT and SEBT areas and composite scores (sum of reaches) for total, anterior and posterior subsections and individual reaches were correlated. Total reach score comparisons showed fair to moderate correlations (r = .393 to .606), while anterior and posterior subsections comparisons had fair to good correlations (r = .269 to .823). Individual reach comparisons had no to good correlations (r = -.182 to .822) where lateral and posterior reaches demonstrated the lowest correlations (r = -.182 to .510). The HSEBT elicited more and significantly greater joint movements than the SEBT, except for hip external rotation, knee extension and plantarflexion. Comparisons to normative range of motion values showed that 3 of 18 for the SEBT and 8 of 22 joint movements for the HSEBT were within normative values. The findings suggest that the HSEBT can be used for the assessment of dynamic postural control and is particularly suitable for examining full-body functional mobility.

Publication types

• Comparative Study
• Biomechanical Phenomena
• Cross-Sectional Studies
• Joints / physiology*
• Postural Balance*
• Range of Motion, Articular / physiology*
• Young Adult

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Reliability and Validity of the Star Excursion Balance Test for Evaluating Dynamic Balance of Upper Extremities. Sports Health . 2024 Jan 16 [Online ahead of print] SH

Upper extremity (UE) dynamic balance is a significant physical fitness ability, which includes high-level neuromuscular proprioception, joint mobility, force, and coordination. The evaluation methods of UE dynamic balance are insufficient and lack experimental support. The Star Excursion Balance Test (SEBT) is a reliable assessment of dynamic balance and injury risk of the lower extremity.

The UE-SEBT is a reliable and reproducible approach for evaluating dynamic balance of UEs.

STUDY DESIGN

Observational study.

LEVEL OF EVIDENCE

This cross-sectional study recruited 65 healthy adults. All participants were required to complete UE-SEBT, UE Y-balance test (UE-YBT), maximal voluntary isometric contraction (MVIC) of UE, closed kinetic chain UE stability test (CKCUEST), trunk flexor endurance test (TFET), trunk extensor endurance test (TEET), and lateral trunk endurance test (LTET). Intra- and inter-rater reliability and the correlation of UE-SEBT with other outcomes were measured.

Among the participants, the intra- and interoperator reliability of UE-SEBT in all directions and composite score achieved a moderate-to-excellent (intraclass correlation coefficients [ICC], 0.729-0.946) reliability. For validity, the UE-SEBT had a moderate to very strong correlation with UE-YBT (r = 0.315-0.755, P < 0.01) and a strong correlation with CKCUEST (r = 0.4-0.67, P < 0.01). Furthermore, the UE-SEBT performance showed weak-to-strong correlations with MVIC (r = 0.26-0.43, P < 0.05). UE-SEBT was also correlated with LTET, TEET, and TFET to varying degrees.

UE-SEBT has good reliability and validity to assess UE dynamic balance compared with other tests.

CLINICAL RELEVANCE

UE-SEBT can be used as a clinical assessment method to evaluate UE dynamic balance and injury prevention.

Authors +Show Affiliations

Pub type(s).

• Publisher Full Text (DOI)

Related Citations

• Validity and reliability of upper extremity star excursion balance test in adolescent swimmers.
• THE RELIABILITY OF THE STAR EXCURSION BALANCE TEST AND LOWER QUARTER Y-BALANCE TEST IN HEALTHY ADULTS: A SYSTEMATIC REVIEW.
• Reliability of the Star Excursion Balance Test and Two New Similar Protocols to Measure Trunk Postural Control.
• Relationships between core endurance, hip strength, and balance in collegiate female athletes.
• EXPLORATION OF SCORE AGREEMENT ON A MODIFIED UPPER QUARTER Y-BALANCE TEST KIT AS COMPARED TO THE UPPER QUARTER Y-BALANCE TEST.
• Clinical observation and analysis of movement quality during performance on the star excursion balance test.
• Kinematic analysis of selected reach directions of the Star Excursion Balance Test compared with the Y-Balance Test.
• Hand reach star excursion balance test: An alternative test for dynamic postural control and functional mobility.
• Comparison of Functional Movement Screen, Star Excursion Balance Test, and Physical Fitness in Junior Athletes with Different Sports Injury Risk.
• Test of intrarater and interrater reliability for the star excursion balance test.

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This tour is a perfect choice for those who wish to get to know Moscow in depth. One of the highlights of this package is the KGB history tour which gives an interesting perspective on the Cold War. You will also have time for exploring the city on your own or doing extra sightseeing.

Weekend in Moscow

This tour is a great way to get acquainted with the capital of Russia if you are short of time. You will see all the main attractions of the city, the most important of which is the Kremlin - the heart of Russia. The tour starts on Friday and can be combined with a business trip.

Group Tour Moscow Break by Intourist

Russia's capital has so much to offer, from the Kremlin and the Metro to the Old Arbat street and the Tretyakov Gallery. Besides these sites, you will also visit a fascinating country estate which today is quite off the beaten path, Gorky Estate, where the Soviet leader Lenin spent the last months of his life.

Kolomenskoye Tour with transport

The history of Kolomenskoye stretches back for centuries. In 1380, Dmitri Donskoi’s army passed through Kolomenskoye on their way to the Kulikovo battlefield, and it was...

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Kremlin, Red Sq., Cathedrals & Armory Tour

The Kremlin is truly a fascinating structure, at the same time it is an ancient tower, the city’s former military fortification, a palace, an armory, the sovereign treasury...

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Kremlin, Red Sq., Cathedrals, Armory, Diamond Fund Tour

Old Arbat walking tour

You will be told of the street’s interesting history and view the street’s artisan culture. You will also have the opportunity to view and purchase souvenirs from the...

Tour to Sergiev Posad with transport

Considered by some to be the Russian Vatican, Sergiev Posad is the temporary residence of the Patriarch of the Russian Orthodox Church. The Trinity St. Sergius Monastery (Lavra)...

Tour to Kuskovo with transport

The Kuskovo Estate often called the Moscow Versailles due to its perfectly preserved French park, is an example of an 18th century, luxurious Moscow summer residence. Its history...

Tour to Tsaritsyno with transport

The Tsaritsyno Estate is located in the southern part of Moscow. The estate was constructed for Catherine the Great by the Russian architects Bazhenov and Kazakov in a romantic...

Moscow Metro and Old Arbat Tour

The Moscow Metro is one of the largest and most grandly built metro systems in the world. It was meant to be a showcase of the Soviet Union’s achievements for both the Russians...

Vodka Museum Tour with transport (excursion and vodka tasting)

Vodka is an important component of Russian life, an element of national identity and everyday culture. We invite you to visit the Vodka Museum and feel the atmosphere of long-gone...

Mikhail Bulgakov Apartment Museum

This apartment museum located close to Patriarch Ponds became the prototype of the "bad apartment" described in the novel "The Master and Margarita." Currently the museum's...

Kremlin, Red Sq., Cathedrals & Diamond Fund Tour

The State Museum of Lev Tolstoy Tour

Take this opportunity to learn more about the Russian writer Lev Tolstoy. During the visit to the museum you will see part of a vast collection of exhibits connected to Tolstoy...

Novodevichy Convent Tour with transport

Tour of the Novodevichy Monastery. Founded in 1524 by Grand Prince VasiliIoanovich, the original convent was enclosed by fortified walls and contained 12 towers. The structure...

City Tour with Visit to St. Basils & Red Sq. with transport

Panoramic City Tour. This Moscow tour is a great start to your trip and the best way to get acquainted with many of the city’s major highlights. Our professional guide will...

City Tour of Moscow

Head to the heart of Moscow with a professional guide on a 4-hour private walk through the city center. See Tverskaya and Old Arbat streets, Theatre Square with the world-famous...

Moscow Metro walking tour

Kremlin, Red Square and Cathedrals Tour

KGB Tour with transport

This is a very interesting and insightful tour. You will visit places connected with Stalin’s terror - a time of great repression and fear. You will be shown monuments to...

Soviet and Post-Soviet Moscow Tour

The tour begins with a drive or walk down Tverskaya Street – a Soviet masterpiece. In the years of Soviet power, Tverskaya began to undergo a transformation: it was widened...

Tretyakov State Gallery Tour

This world-famous gallery contains masterpieces of Russian art beginning in the 10th century up until today. You will view exquisite Russian icons and paintings from the 18th and...

Jewish Heritage of Moscow Tour

This tour offers a detailed look into the history and present-day life of the Jewish community of Moscow. On the tour, you will visit sites connected with the cultural and religious...

Vodka Museum Tour with transport (excursion only)

Lena, our guide in Moscow was excellent. She was very knowledgable and could answer any question we had for her. We liked that she could pick up on our interests and take us places we might not have thought of to go. When we realized that one of the places we had chosen to see would probably not be that interesting to us, she was able to arrange entry to the Diamond Fund and the Armoury for us. Riding the Metro with Lena was a real adventure and a lot of fun. In Saint Petersburg we found Anna well versed in the history of the Tsars and in the Hermitage collection. Arkady in Veliky Novgorod was a very good guide and answered all of our questions with ease. Novgorod was perhaps a long way to go for a day trip, but we did enjoy it. Vasily was a great driver to have and kept us safe with good humour and skill. We enjoyed ourselves so much, my daughter says she is already planning to return. We would both have no hesistation to recommend ExpresstoRussia to anyone we know.

Just wanted to let you know that My grandson Bruno and I couldn´t have been more pleased with our week in Moscow (6/15 - 6/21). We were absolutely enchanted with the whole experience, including getting lost a couple of times in the Metro during our free time. Although both our guides (both Eleanas) were excellent, I would particularly commend the first one (she took us to the Tatiakov, the KGB tour, and to that beautiful cemetery where so many great Russian artists, authors, composers, musicians, militarists, and politicians are buried). Her knowledge is encyclopedic; and her understanding of today´s Russia as a product of its past was, for us, truly enlightening. I will be taking another tour in Russia, with my wife, within the next two or three years. I will be in touch with you when the time comes. Meanwhile, I will refer you to other potential visitors to Russia as I meet them.

Tours to Moscow

Our Moscow tours are land only meaning that you arrange your own air travel to Russia and our expert staff meets you at the airport and handles everything else from there. Our online Airline Ticket booking system offers some of the most competitive rates to Russia available on the web so if you need tickets, please visit our Russian air ticket center . Rest assured that you will be taken great care of on one of our Moscow tours. Express to Russia has a fully staffed office in Moscow that will help to make your visit fun, informative and unforgettable. Please remember that of all these tours are private and can be adjusted to your taste. You can add, replace or skip some sights; you can add more days to the package or cut the tour short. Our specialists will be glad to help you create the tour of your dreams!

Moscow, a City Like No Other

Moscow is Russia’s largest city with a population of between 12 and 13 million. It is also Europe’s largest city and when you visit Moscow, you can feel it. The layout and architecture of the city is eclectic, ranging from crooked, ancient streets and alleyways to wide, bustling boulevards, from medieval churches to Stalin skyscrapers and to modern, glass buildings towering over everything and of course in the center of it all is the Kremlin and the magnificent Red Square. Moscow is also home to a fantastic, efficient and very beautiful metro system – each station having its own special design. In fact, Express to Russia’s Moscow metro tours and excursions are some of our most popular attractions that we offer. On our Moscow tours, you will see this and more.

Moscow Tours centering on Russian History

Moscow has a long and interesting history and has been the capital of Russia in many of its different iterations – capital of the Grand Duchy of Moscow , the Russian Empire and of course the Soviet Union (who could ever forget the Soviet Union?). Moscow, was founded in the 12th century by Prince Yuri Dolgaruki (Yuri of the long arms – he really did have long arms!). From that time on, it was home to the Russian Tsars until Peter the Great moved the capital to St. Petersburg in 1703. The city has survived invasions and sieges from the Mongols, the Tartars, the Poles, Lithuanians and Napoleon but has always persevered. Our Moscow tours will enlighten you on this great history and give you insights into Muscovites and their unique culture. Our Moscow tours show you what the city is like today but also brings to life the past. Moscow never seems to sleep and is bursting with energy. A Moscow tour with Express to Russia is truly the best way of getting to know Russia’s largest and most vibrant city.

Frequently Asked Questions From Our Travelers

What is the best time to visit moscow.

Any time of year is fine depending on what you plan to do. Summertime is pleasantly warm, ideal for exploring the city and its vibrant atmosphere, but Moscow will be much busier and accommodation is more expensive. Winter can be quite cold but beautiful nonetheless, and this is unproblematic if you intend to spend most of your trip in museums and galleries. There are also various festivals and events organised throughout the year. For more information about the best time to visit, read our guide

How many days are enough in Moscow?

If you plan your itinerary strategically and aren’t averse to a packed schedule, you can cover Moscow’s main sights over a long weekend. Most popular attractions are in the city centre, and the Moscow Metro allows you to cover much ground in a small amount of time. Ensure that your accommodation is fairly central and book tickets in advance, so that you can make the most of your days. For an informative and well-organised day out, check out our Moscow day tours with options to suit all interests.

Do they speak English in Moscow?

As Russia’s capital city, tourists are well accommodated in Moscow. There should be English-speaking staff in restaurants, bars, hotels, shops and attractions in tourist hotspots, and there are also English-speaking tourist police. Transport services have English translations on their maps and English announcements via intercom; alternatively, order taxis from the Yandex Taxi app (Russian Uber), though it’s unlikely that your taxi driver will speak English. If you get stuck and cannot communicate, it’s fine to use Google Translate.

Is it safe to travel to Moscow?

It is no less safe to travel to Moscow than to any European city if you exercise common sense and look after your belongings. As with every city some regions can be more unsavoury than others, but no tourist attractions are located there. The traffic in Moscow is notorious, so exercise caution when crossing roads. Do not take unlicensed taxis; book in advance or take public transport, which is widespread and perfectly safe. If you encounter any problems, look for the special tourist police who can help you. For more information, read our guide about staying safe in Russia .

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Validity and reliability of upper extremity star excursion balance test in adolescent swimmers.

Author information, affiliations, orcids linked to this article.

• Ngo TL | 0000-0003-2736-3170

Journal of Exercise Science and Fitness , 27 Feb 2023 , 21(2): 210-217 https://doi.org/10.1016/j.jesf.2023.02.003   PMID: 36923209  PMCID: PMC10009542

Abstract 

Conclusions, free full text , validity and reliability of upper extremity star excursion balance test in adolescent swimmers.

a Department of Sport Rehabilitation, Shanghai University of Sport, Shanghai, China

Yong-Hui Zhang

b Graduate School, Xi'an Physical Education University, Xi'an, China

Thanh Luan Ngo

Qiong zhang.

c Shanghai Changning Youth Amateur Sports School, Shanghai, China

Zhimin Feng

Xue-qiang wang.

d Department of Rehabilitation Medicine, Shanghai Shangti Orthopaedic Hospital, Shanghai, China

Associated Data

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Upper limb balance is one of the important physical fitness parameters for all populations, especially overhead athletes like swimmers. Upper extremity star excursion balance test (UESEBT) is a comprehensive dynamic balance assessment, this study aims to explore the reliability and validity of UESEBT among adolescent swimmers.

This cross-sectional study recruited 70 adolescent swimmers. All participants were required to complete UESEBT, upper quarter Y-balance test (UQYBT), maximal isometric strength (MIS) tests in upper limb, closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET). The intra- and inter-operator reliability and the correlation of UESEBT with other physical performances were conducted.

For reliability, the intra- and inter-operator reliability of all directions and composite score were high-to-excellent (ICC = 0.706−1.000) among all participants. For validity, the UESEBT has a moderate-to-strong correlation with UQYBT ( r  = 0.42−0.72, p  < 0.001), and a weak-to moderate one with CKCUEST ( r  = 0.25−0.42, p  < 0.05). Furthermore, the UESEBT performance showed weak-to-moderate correlations with MIS ( r  = 0.24−0.44, p  < 0.05). UESEBT was correlated to LTET ( r  = 0.24−0.33, p  < 0.05) whereas no relationship was found with TFET.

UESEBT was a reliable and valid tool to screen upper extremity dynamic balance among adolescent swimmers. UESEBT provides more detailed information in eight directions to assess the upper limb sport performance. Further study should explore the prediction ability of UESEBT for injury.

1. Introduction

Balance is defined as the ability to prevent body from falling, 1 which is essential for maintaining body posture, especially when executing complicated sport activities. Normally, balance could be classified into dynamic and static. To elaborate, static balance is the balance in stationary circumstances while dynamic balance accounts for the balance during motion and position transformation, 1 which is more frequently challenged among athletes. Better dynamic balance control could decline the deviations of center of mass during complex movement, thereby minimizing the possibility of potential injuries. 2 Therefore, the screening assessments evaluating the dynamic balance performance of athletes are demanding.

Different dynamic balance tests could also be categorized based on the targeted body part. In lower limb, lower quarter Y-balance test (LQYBT) and star excursion balance test (SEBT) are two primary tests used in clinical practice. LQYBT can validly predict lower limb injuries among volleyball players and runners 3 , 4 and it has been proven to be reliable among adults (ICC = 0.80−0.93), healthy adolescents (ICC = 0.40−0.96), and soccer players (ICC = 0.85−1.00). 5 , 6 Similarly, SEBT has been used to predict lower extremity injuries in basketball and soccer players. 7 , 8 The reliability of SEBT among adults (ICC = 0.86−0.92) and elite athletes (ICC = 0.90−0.95) has been demonstrated. 9 , 10 Meanwhile, the test targeting upper limb balance is fewer probably because the primary function of upper limb and lower limb differs. 11 That is to say, the upper limb requires more flexibility to account for technical and precise movement while the lower limb requires more stability for support. Nevertheless, stability is also essential for joints in upper limb when coping with perturbation, especially for the mobility-demanding one like glenohumeral. Lacking adequate stability, the joints could not return to its initial position, which might cause capsule laxity or further shoulder-related injury. 11 According to present research, Upper Quarter Y-Balance Test (UQYBT) is a frequently reported upper limb stability test among various populations and sports. 12 , 13 , 14 The UQYBT has been proved valid and reliable in healthy adolescents. 15 Considering swimming is a sport event requiring the full-range strength and endurance of upper limb 16 and that approximately 91% of professional swimmers experience shoulder injuries, 17 the assessments of upper limb dynamic stability is helpful to evaluate sport performance and predict future injuries for swimmers. 18 Nevertheless, UQYBT only contains information from three reach directions and the potential risks may not be fully screened. As a more comprehensive upper limb dynamic balance test, upper extremity star excursion balance test (UESEBT) could provide data in eight directions which enables clinicians and coaches to trace the deficits. However, the reliability and validity of UESEBT among adolescent swimmers has not been revealed.

The present study aimed to investigate the validity and reliability of UESEBT among 70 adolescent swimmers. The study purposed to report the inter- and intra-operator reliability of UESEBT and explore the criterion and construct validity (specifically convergent validity, a subtype of construct validity) of UESEBT. For criterion validity, the correlation between UESEBT and UQYBT was conducted. For construct validity, the correlation between UESEBT and other outcome measures, including maximal isometric strength (MIS), closed kinetic chain upper extremity stability test (CKCUEST), trunk flexor endurance test (TFET) and lateral trunk endurance test (LTET), were measured.

Seventy adolescent swimmers were recruited in this cross-sectional study. Sample size was estimated based on Walter et al. 19 To match our study design, three replicates per subject, p 0  = 0.6, p 1  = 0.8, a = 0.05 and power = 0.8 were applied, then the sample size should be 26.1. The inclusion criteria were as follows: (1) training onsets more than 1-year and training at least three times a week (2) aged from 9 to 19 (3) no injury history within 3 months with irritating pain during the test. The exclusion criteria were as follows: (1) with any cardiac-related or mental-related conditions (2) disobedient behavior during the test. This study was approved by the local Human Ethics Committee (2018042). All willing participants and their legal guardians signed informed consent forms prior to the tests.

Prior to the test, basic and swimming-related information, injury history, and limb dominance were collected. In addition, the right upper limb length was measured and the average values of three assessments were used for analysis. 20 After that, a series of evaluation including UESEBT, UQYBT, MIS test, CKCUEST, TFET, and LTET were performed in random sequence. 21 In addition, the inter- and intra-operator reliability of the UESEBT were measured. For inter-operator reliability, participants performed one test procedure and operators A and B who were blinded to each other individually read and recorded the distances. For intra-rater reliability, participants repeated the same test procedure immediately and only operator A read and recorded the distances.

Eight directions including anterior, superomedial, medial, inferomedial, posterior, inferolateral, lateral, and superolateral were marked on floor by tapes with scale and the angle between each strip of tape were 45°. The minimum unit of the UESEBT was 0.5 cm. Before the formal test, a staff provided a comprehensive demonstration. One practice was required for each participant before formal tests. Participants stayed in a push-up position and placed the palm of the stance limb on the intersection of tapes. Then, maximal reach of free limb was performed. Hip flexion was permitted whereas stance limb flexion was not allowed. Distances for analysis were normalized by dividing the right upper limb length of every participant, and then multiplying by 100. Additionally, the composite score was calculated by summing up the normalized reach distances and dividing it by 8. The UESEBT included the maximal reach with dominant (D) and non-dominant (ND) limb as stance limb. The test was invalid and repeated if the substandard incidents were observed (1) foot was not contacted with floor; (2) distance between two feet exceed 12 inches; (3) unilateral stability was not maintained. One test procedure required the participants to repeat the UESEBT twice. The average values of the two UESEBTs in one test procedure were regarded as the outcome of this test procedure.

Detailed procedures of other physical performance including UQYBT, MIS test, CKCUEST, TFET, and LTET were depicted in Supplementary 1. For UQYBT, the average values of two measurements were determined for analysis. For MIS test and CKCUEST, the maximal values of two assessments were used for analysis. For TFET and LTET, only once performance was required.

IBM SPSS Statistics 25.0 was applied to analyze the data. All 70 participants were divided into two groups based on gender, median age or median training onsets, respectively. The reliability of UESEBT were processed by conducting intraclass correlation coefficients (ICC) 3.1 . The different level of ICCs was interpreted based on the research of Domholdt et al., 22 where 0.90–1.00 meant “excellent reliability,” 0.70–0.89 meant “high reliability,” 0.50–0.69 meant “moderate reliability,” 0.26–0.49 meant “low reliability,” and 0.00–0.25 meant “little reliability.” The level of agreement and systematic error of reliability was indicated by Bland–Altman plots. For validity, two-tailed Spearman test was applied to determine the correlation between UESEBT with CKCUEST, TFET, LTET and ipsilateral MISs. In addition, the correlation between UESEBT and UQYBT in the corresponding three directions was also carried out. The outcome of Spearman test was interpreted as follows: 0.80–1.00 meant “very strong,” 0.60–0.79 meant “strong,” 0.40–0.59 meant “moderate,” 0.20–0.39 meant “weak,” and 0.00–0.19 meant “very weak.”

The personal characteristics and swimming performance of all, male, and female participants are demonstrated in Table 1 . The mean age and body mass index (BMI) of all participants was 12.32 years old and 17.55 kg/m 2 , respectively. Their mean training onsets and volume were 4.83 years and 24.73 km per week, respectively. Among the 70 participants, 19 reported injury history (Knee: 6, ankle: 5, wrist and hand: 6, elbow: 1, scoliosis: 1).

Table 1

Demographics and characteristics of all participants.

Note: All participants were divided into two groups based on gender. Data were presented as Mean ± SD or as the number of participants (%).

Abbreviations: BMI: Body Mass Index; CKCUEST: Closed Kinetic Chain Upper Extremity Stability Test; TFET: Trunk Flexor Endurance Test; LTET: Lateral Trunk Endurance Test.

Detailed information about intra- and inter-operator reliability of UESEBT in all participants were provided in Table 2 and the reliability in participants with different gender was demonstrated in Table 3 . The Bland–Altman plots for reliability were also provided from Figs. S1–S9 (Supplementary 2). Overall, the composite intra-operator reliability of UESEBT was excellent (D ICC = 0.923, ND ICC = 0.905). To narrow down in eight directions, the intra-operator reliability of every direction ranged from high to excellent regardless of the dominance of stance limb (ICC = 0.706−0.937). Of interest, it was observed that there was a drop in intra-operator reliability from anterior (D ICC = 0.780, ND ICC = 0.788) to superomedial (D ICC = 0.737, ND ICC = 0.743), followed by a successive increase. Once it reached the peak at posterior (D ICC = 0.937, ND ICC = 0.892), it started to decline. Furthermore, a similar pattern can also be witnessed when observing intra-operator reliability of participants with different gender. The intra-operator reliability of UESEBT among male and female participants was also high-to-excellent (ICC = 0.703−0.949) except for the one in the inferomedial direction on ND side of male (ICC = 0.675).

Table 2

Inter- and Intra-operator reliability of Upper Extremity Star Excursion Balance Test in all swimmers.

Abbreviations: A1: the first measurement outcome of operator A; A2: the second measurement outcome of operator A; B: the measurement outcome of operator B; SEM: standard error of measurement; MDC: minimum detectable change; ICC: intraclass correlation coefficient; CI: confidence interval.

Table 3

ICC values with 95% CI for inter- and intra-operator reliability of Upper Extremity Star Excursion Balance Test in swimmers with different gender.

Abbreviations: ICC: intraclass correlation coefficient; CI: confidence interval.

Whether side and gender factor influence reliability are detected by comparing the frequencies. As for side factor, the composite intra-operator reliability was slightly higher on D side than that on ND side among all participants and participants in different gender. Breaking into eight directions, the reach distances in 4 out of 8 directions on D side were higher among all participants. In addition, the intra-operator reliability in 5 out of 8 directions on D side were higher among male and female participants. With regard to gender factor, the composite intra-operator reliability of in female was higher than that in male regardless the dominance of stance limb. Breaking into directions, the intra-reliability in 10 out of 16 directions in female participants was higher than that in male. Above all, no obvious gender and side difference in number was observed, indicating that gender and side might not be influential factors for reliability in adolescent swimmers. Similarly, the results of age and training onsets subgroups showed that they did not have obvious impact on reliability and relative information was demonstrated in Supplementary 2 ( Table S1 and Table S2 ).

As for inter-operator reliability, all results stated a high level of agreement. The directional and composite inter-operator reliability among all participants were excellent (ICC >0.958). In terms of participants with different gender, the inter-operator reliability among male and female was also excellent (ICC >0.980).

For construct validity, the correlations with statistical significance between UESEBT and other outcome measures were illustrated in Fig. 1 . For criterion validity, the correlations between the performance of UESEBT and UQYBT were demonstrated in Fig. 2 and Fig. 3 .

Correlation Matrix of UESEBT and other outcomes

Note: Outcomes with statistical significance ( p  < 0.05) were labeled by r -values and those without were marked by ‘X’. Abbreviations: CKCUEST: Closed Kinetic Chain Upper Extremity Stability Test; TFET: Trunk Flexor Endurance Test; N -LTET: Lateral Trunk Endurance Test on non-dominant side; D-LTET: Lateral Trunk Endurance Test on dominant side.

Correlation Coefficient between UESEBT and UQYBT on dominant side

Note: Spearman test was applied to carry out r -value and it is labeled on the top left of each graph. Abbreviations: UESEBT: upper extremity star excursion balance test; UQYBT: upper quarter Y-balance test.

Correlation Coefficient between UESEBT and UQYBT on non-dominant side

The UESEBT and UQYBT were correlated in all directions ( p  < 0.001). On D side, a moderate correlation was found between the medial ( r  = 0.49), inferolateral ( r  = 0.42), superolateral ( r  = 0.54), and composite ( r  = 0.51) distances of UESEBT and the equivalent distances of UQYBT. On ND side, a moderate correlation was found between the medial ( r  = 0.48) and inferolateral ( r  = 0.54) distances of UESEBT and the equivalent distances of UQYBT. Furthermore, the superolateral ( r  = 0.60) and composite ( r  = 0.72) distances of UESEBT were strongly correlated with same distances of UQYBT.

Some significant correlations were discovered between UESEBT and MISs, basically in superomedial, medial, and inferomedial directions ( p  < 0.05). Specifically, there was weak correlations ( r  = 0.24−0.29) between the superomedial distance and 4 MISs on D side. The medial distance was weakly to moderately ( r  = 0.27−0.41) correlated with 5 MISs. A weak correlation ( r  = 0.26−0.27) was found between the inferomedial distance and 3 MISs. On ND side, the superomedial distance was weakly to moderately correlated with 8 MISs ( r  = 0.24−0.42). The medial distance had weak to moderate correlations with 9 MISs ( r  = 0.28−0.44). There was a weak correlation between the inferomedial distance and 8 MISs ( r  = 0.24−0.39).

UESEBT was significantly correlated with the following performances ( p  < 0.05). CKCUEST was weakly to moderately correlated with 8 distances on D side ( r  = 0.25−0.42). Furthermore, there was a weak correlation between CKCUEST and 5 distances on ND side ( r  = 0.25−0.32). Nevertheless, no significant relationship was discovered between UESEBT and TEFT. In terms of the relationship of UESEBT on D side and LTET, 4 distances had a weak correlation with the performance of dominant LTET ( r  = 0.27−0.33). Three distances were weakly correlated with the performance of non-dominant LTET ( r  = 0.24). With regard to the relationship between UESEBT on ND side and LTET, 3 distances ( r  = 0.27−0.30) and 3 distances ( r  = 0.24−0.26) had a weak correlation with the performance of dominant and non-dominant LTET, respectively.

4. Discussion

The overall intra- and inter-operator reliability was excellent and high-to-excellent. Furthermore, no obvious gender, side, age and training onsets difference were found in reliability. As for criterion validity, the performance of UESEBT was correlated with corresponding distance of UQYBT (moderate-to-strong). For construct validity, the better performance of UESEBT in superomedial, medial, and inferomedial directions were associated with more upper limb strength on both sides (weak-to-moderate). UESEBT had a close correlation with CKCUEST (weak-to-moderate) and LTET (weak) but not TFET.

In this study, the intra-operator reliability was high-to-excellent, similar to previous findings. Gorman et al. concluded that the instant test-retest reliability of UQYBT in young adult ranged from 0.80-0.99 13 . Notably, the intra-operator reliability of superomedial direction was the lowest among eight directions. The possible explanation might be the reach in this direction required more dynamic stability in diagonal. 23 When the center of gravity shifting towards the contralateral side, the lateral shear force of the stance limb might significantly increase. Furthermore, the center of gravity shifts toward the cranial side synchronously, which generates great pressure on the top front of the shoulder capsule. These challenges might account for the fluctuation of reach distance between trials. On the other hand, the intra-operator reliability in posterior direction was the highest. The possible explanation is the application of hip flexion strategy during performance could significantly decrease the pressure and provide more stability. With regard to the potential factors affecting intra-operator reliability, we found the dominance of stance limb in UESEBT may not affect the intra-operator reliability, which is consistent with previous findings. 15

The inter-operator reliability of UESEBT in adolescent swimmers was excellent. Similarly, the excellent inter-operator reliability of UQYBT in young adult was reported by Gorman et al. with the ICC value at 1.00 13 . Another research revealed that the inter-operator reliability of SEBT among healthy adults was high-to-excellent (ICC = 0.86–0.92), 24 which was slightly lower. This possible reason is their inter-operator reliability was derived from three independent test sessions completed by three individuals, which might add more uncertainty between operators.

The UESEBT was found moderately to strongly related to UQYBT. UQYBT has been proved to be reliable and valid in many populations, including adults and swimming athletes. 12 , 13 , 14 The UESEBT shares some similar advantages to UQYBT because they both require the engagement of the entire kinetic chain, including scapular stability, coordination ability, thorax flexibility, and core stability. Considering that the absence of any certain parts could increase the risk of upper limb injuries among overhead athletes, 25 the outcomes of UESEBT and UQYBT enable clinicians to verify the potential weakness. Furthermore, the UESEBT owns more advantages compared to UQYBT. Specifically, it can provide more information in eight directions. Comprehensive information about upper limb stability is significant, since adequate stability provided by shoulder surrounding tissues were foundation to obtain more mobility. 11 As a mobility-demanding stability test, UESEBT evaluates performance throughout the entire range, which further discovered the undetected deficits. Moreover, eight reach directions in the UESEBT challenge the dynamic stability within a longer period, which is closer to real swimming situation. Given that the average duration in Olympic pool events ranges from 21 s to 15 min, 26 UESEBT is more proper and valid among swimmers working for endurance event.

The UESEBT performance in superomedial, medial, and inferomedial direction was extensively correlated with ipsilateral upper limb strength. The possible explanation is that the distal reach in these 3 directions requires weight to lean toward the contralateral side. Adequate engagements of these muscles are necessary to provide posture stability. By contrast, Westrick et al. found no relationship between the performance of UQYBT and isometric strength, seemingly inconsistent with our findings. 21 This could be interpreted by the different body positions during the MIS test. Besides, their study only assessed the strength of shoulder muscles whereas this study measured that of most large muscles in the upper limbs.

The performance of UESEBT was widely correlated with that of CKCUEST. Previous research has revealed the close correlation between UQYBT and CKCUEST, 21 which is consistent with our findings. CKCUEST was the first developed closed kinetic chain (CKC) dynamic stability test. 27 Although both CKCUEST and UESEBT aim to measure the upper limb performance in CKC situations, the former requires bilateral limb supporting alternatively, whereas the latter demands unilateral limb supporting. In addition, the CKCUEST is carried out bidirectionally at a high speed, 28 whereas the UESEBT is executed multi-directionally at a low speed. We suggest researchers and coaches should select the more suitable tests or the combination of these two tests to match the characteristics of specific sports event. With regard to trunk endurance, the study found nearly no results indicating a relationship between UESEBT and TFET, in line with the findings of Westrick et al. 21 Additionally, a few correlations were discovered between the performances of some directions in UESEBT and LTET. Previous studies have indicated LTET can effectively activate some core muscles, including lateral musculature and anterolateral flexors. 29 , 30 , 31 Adequate strength of these muscles guarantees further reach distance in unstable posture during UESEBT.

Dynamic balance is an important fitness parameter for overhead athletes, which is strongly associated with physical performance and the risk of injury. At present, limited assessments focused on the dynamic balance in upper limb. This study is the first to apply star excursion balance test in upper limb and prove that UESEBT is reliable and valid to screen upper limb dynamic balance among adolescent swimmers. This assessment could provide more information in eight directions for clinicians and coaches to detect the potential deficits. Also, this study has some limitations. First, we did not find the impact of injury history on the UESEBT even though 19 participants reported injury history. The small samples and low consistency of injury position and pathology limited the discovery of injury impact. Second, only one practice was required before the formal test of UESEBT, whereas another research has mentioned 6 reps of practice were needed in SEBT to demonstrate stable performance. 23 Considering the participants are adolescent whose physical ability may be limited, over-practice could result in poor performance during six-time formal test and other physical tests, which may not truly reflect their abilities.

5. Conclusion

The intra- and inter-operator reliability of all reach directions and composite score was basically high-to-excellent, and gender, side, age and training onsets might not affect the reliability. Moreover, the outcome of UESEBT was closely correlated with the dynamic balance assessed by UQYBT and CKCUEST, as well as the muscle strengths in upper limb, indicating good construct and criterion validity. Therefore, this study suggested that UESEBT is a reliable and valid tool to assess upper limb dynamic stability among adolescent swimmers and provide more information in eight directions for clinicians and coaches to detect the potential deficits. Future research is expected to focus on the prediction of upper limb injuries applying UESEBT.

Ethics approval and consent to participate

This study was approved by the Human Ethics Committee of Shanghai University of Sport (2018042). All willing participants and their legal guardians signed informed consent forms prior to the tests.

Availability of data and materials

Funding information.

The work was supported by the scientific and technological research program of the Shanghai Science and Technology Committee (grant numbers: 19080503100; 21S31902400); the Shanghai Key Lab of Human Performance (Shanghai University of Sport) (grant numbers: 11DZ2261100); Talent Development Fund of Shanghai Municipal (grant numbers: 2021081); Shanghai Clinical Research Center for Rehabilitation Medicine (grant numbers: 21MC1930200).

This work is following the ethical standards of the institutional research committee and with the Helsinki Declaration. This study was approved by the local Human Ethics Committee (2018042). All willing participants and their legal guardians signed informed consent forms.

Authors statement

Conceptualization, X.-Q.W.; investigation, H.-R.X., Y.-H.Z., Q.Z., G.H., Z.M.F., and W.J.S.; data curation and analysis, H.-R.X., Y.-H.Z., T.L.N., Y.M.; validation, H.-R.X., Y.-H.Z., and T.L.N.; writing—original draft preparation, H.-R.X., Y.-H.Z., and Y.M.; writing—review and editing, H.-R.X., Y.-H.Z. and X.-Q.W.; supervision, X.-Q.W. All authors have read and agreed to the published version of the manuscript.

Declaration of interest statement

This article is an original research which has not been published and is not under consideration for publication elsewhere. The authors declare that they have no competing interests and this work has been approved for publication by all author.

Acknowledgments

The authors would like to thank the individuals who volunteered to participate in this study and the physiotherapists who assisted in participants recruitment.

Appendix A Supplementary data to this article can be found online at https://doi.org/10.1016/j.jesf.2023.02.003 .

Appendix A. Supplementary data

The following are the Supplementary data to this article.

Full text links 

Read article at publisher's site: https://doi.org/10.1016/j.jesf.2023.02.003

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