Berg Balance Scale (BBS)

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Tool Description

  • Performance based measure of balance with 14 tasks. Tasks progress in difficulty and include functional activities related to balance while reaching, bending, transferring, and standing.
  • Originally developed for use with the elderly, the scale has been used in a variety of populations including stroke, Parkinson’s, multiple sclerosis, and recently SCI. Some researchers have used the BBS as the gold standard for balance in measurement studies.

Availability:

The scale can be located at: http://utpjournals.metapress.com/content/t30n37061661184r/?p=a1d2af67d59249ce9f627967fc713f02&pi=0 [Table 3]

ICF Domain:

Activity – subcategory: Mobility.

Number of Items:

14

Brief Instructions for Administration & Scoring

Administration:

  • Clinician-administered; observer-rated performance measure
  • Time to administer is approximately 20 minutes (in relatively well functioning older adults). In general, the time required is inversely related to the lower extremity ability of the individual.

Equipment:

  • 2 standard chairs (1 with arms and 1 without)
  • Stopwatch
  • Step or stepstool
  • Ruler

Scoring:

  • Each of the 14 tasks are rated on a 5-point scale from 0 (cannot perform) to 4 (normal performance).
  • Task scores are summed to yield a total score.
  • Total scores range from 0 (severely impaired balance) to 56 (excellent balance).
  • Some tasks are rated according to the quality of the performance of the task, while others are evaluated by the time required to complete the task.

Interpretability

MCIDnot established for SCI
SEMnot established for the SCI population, but for a stroke population, SEM = 2.93 for individuals who ambulate with assistance (n=16) [Stevensen 2001, “Detecting change in patients with stroke using the Berg Balance Scale”, n=48, patients >65 yrs of age admitted to stroke rehabilitation unit after acute stroke]
MDC: not established for the SCI population, but for a stroke population, MDC = 8.1 for individuals who ambulate with assistance (n=16) [Stevensen 2001, see above for population and article details]

  • Results from studies of older adults suggest the follow cut points: 0-20 = wheelchair bound; 21-40 = walking with assistance; and 41-56 = independent.
  • Scores below 41 are suggested to indicate increased risk of falling.
  • Change scores >7 are said to be clinically relevant in studies of older adults. This interpretation has not been validated with SCI populations.
  • Published data for the SCI population is available for comparison (see the Interpretability section of the Study Details sheet).

Languages:

English, Italian, Turkish, Brazilian-Portuguese, German, Korean, and Dutch.

Training Required:

Raters are typically health professionals with knowledge of balance and trained to assign ratings.

Clinical Considerations

  • The BBS is generally well received among clinicians who specialize in the area of gait and balance training.
  • The tool is only applicable to individuals with incomplete SCI who retain some ability to stand and walk.
  • It has been found to be an appropriate assessment of standing balance for these individuals as shown by its strong associations with various clinical walking evaluations.

Measurement Property Summary

# of studies reporting psychometric properties: 8

Reliability:

  • High Inter-rater Reliability: ICC = 0.998(Srism et al. 2015; n=83, chronic SCI, mixed injury types, mean time since injury (multiple and non-multiple fallers) = 46.72-58.70 months)High Intra-rater Reliability: ICC = 0.97(Tamburella et al. 2014; n=23, 14 males, AIS D, time Since Injury (SD): 16.43 (19.03) months)

Validity:

  • Correlation of the Berg Balance Scale was High with:

o    WISCI (0.82-0.92)

o   WISCI II (0.816)

o   10 Meter Walk Test (0.78-0.86)

o   Functional Independence Measure (0.72-0.77)

o   Functional Independence Measure-Locomotor subscale (0.86-0.89)

o   Spinal Cord Independence Measure- Mobility subscale (0.89)

o   Timed Up and Go (-0.815)

o   SCI-Functional Ambulation Inventory- Mobility subscale (0.74).

[Wirz et al. 2010, Ditunno et al. 2007, Lemay & Nadeau 2010, Datta et al. 2009]

Low to Moderate correlation with ASIA Motor Scale:

UEMS = 0.30

LEMS = 0.79

ASIA Motor Score = 0.75

(Harkema et al. 2016; N=152, 123 male; mixed injury type; median (range) time post-SCI = 0.9 (0.1-45.2) years)

Responsiveness:

Floor/Ceiling Effect:
Significant ceiling effect; 37.5% of subjects reached maximal score
(Lemay & Nadeau 2010; N=32, 25 male, AIS D mixed injury types, mean time since injury (SD) = 77.2 (44.3) days)

Effect Size:
Standardized Response Mean:
All individuals: 0.59
AIS-A/B: 0.52
AIS-C: 0.65
AIS-D: 0.91
(Post locomotor training; Harkema et al. 2016; N=152, 123 male; mixed injury type; median (range) time post-SCI = 0.9 (0.1-45.2) years) Number of studies reporting responsiveness data: 2

Floor/ceiling effect:

  • A ceiling effect was reported (37.5% of subjects with incomplete (AIS D) tetraplegia and paraplegia reached maximal score of the Berg Balance score).

[Lemay & Nadeau 2010]

Reviewers

Dr. Janice Eng, John Zhu, Jeremy Mak

Date Last Updated:

Nov 1, 2016

Download the measure

Download Worksheet:

Worksheet Document

Video

Scoring

  • Each of the 14 tasks are rated on a 5-point scale from 0 (cannot perform) to 4 (normal performance).
  • Task scores are summed to yield a total score.
  • Total scores range from 0 (severely impaired balance) to 56 (excellent balance).
  • Some tasks are rated according to the quality of the performance of the task, while others are evaluated by the time required to complete the task.

Equipment Needed

  • 2 standard chairs (1 with arms and 1 without)
  • Stopwatch
  • Step or stepstool
  • Ruler

BBS:

Berg K, Wood-Dauphinee S, Williams JI, Gayton D. Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada 1989; 41(6): 304-311.
http://utpjournals.metapress.com/content/t30n37061661184r/

Datta S, Lorenz DJ, Morrison S, Ardolino E, Harkema SJ. A multivariate examination of temporal changes in Berg Balance Scale items for patients with ASIA Impairment Scale C and D spinal cord injuries. Arch Phys Med Rehabil 2009;90:1208-17.
http://www.ncbi.nlm.nih.gov/pubmed/19577035

Ditunno JF Jr, Barbeau H, Dobkin BH, Elashoff R, Harkema S, Marino RJ, Hauck WW, Apple D, Basso DM, Behrman A, Deforge D, Fugate L, Saulino M, Scott M, Chung J, Spinal Cord Injury Locomotor Trial Group. Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial. Neurorehabil Neural Repair 2007; 21: 539-550.
http://www.ncbi.nlm.nih.gov/pubmed/17507642

Harkema SJ, Shogren C, Ardolino E, Lorenz DJ. Assessment of functional improvement without compensation for human spinal cord injury: extending the Neuromuscular Recovery Scale to the upper extremities. J Neurotraum 2016. Ahead of print. doi:10.1089/neu.2015.4213.
http://online.liebertpub.com/doi/10.1089/neu.2015.4213

Lemay JF, Nadeau S. Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale. Spinal Cord advance online publication, 22 September 2009; doi: 10.1038/sc.2009.119.
http://www.ncbi.nlm.nih.gov/pubmed/19773797

Liston RA, Brouwer BJ. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil 1996; 77: 425-430.
http://www.ncbi.nlm.nih.gov/pubmed/8629916

Srisim K, Saengsuwan J, Amatachaya S. Functional assessments for predicting a risk of multiple falls in independent ambulatory patients with spinal cord injury. J Spinal Cord Med. 2015;38(4):439-45.
http://www.ncbi.nlm.nih.gov/pubmed/24621036

Tamburella F, Scivoletto G, Iosa M, Molinari M. Reliability, validity, and effectiveness of center of pressure parameters in assessing stabilometric platform in subjects with incomplete spinal cord injury: a serial cross-sectional study. J Neuroeng Rehabil. 2014;11:86.
http://www.ncbi.nlm.nih.gov/pubmed/24886312

Tester NJ, Lorenz DJ, Suter SP, Buehner JJ, Falanga D, Watson E, Velozo CA, Behrman AL, Michele Basso D. Responsiveness of the Neuromuscular Recovery Scale During Outpatient Activity-Dependent Rehabilitation for Spinal Cord Injury. Neurorehabil Neural Repair. 2016;30(6):528-38.
https://www.ncbi.nlm.nih.gov/pubmed/26359344

Tyson SF, DeSouza LH. Development of the Brunel Balance assessment: a new measure of balance disability post stroke. Clin Rehabil 2004; 18: 801-810.
http://www.ncbi.nlm.nih.gov/pubmed/15573837

Wirz M, Muller R, Bastiaenen C. Falls in persons with spinal cord injury: Validity and reliability of the Berg Balance Scale. Neurorehabil Neural Repair 2010;24: 70-77.
http://www.ncbi.nlm.nih.gov/pubmed/19675123