Tool Description
- The BBS is a 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.
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.
ICF Domain
Activity ▶ Mobility
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.
Number of Items
14
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.
Languages
English, Italian, Turkish, Brazilian-Portuguese, German, Korean, Spanish and Dutch.
Training Required
Raters are typically health professionals with knowledge of balance and trained to assign ratings.
Availability
Worksheet can be found here.
Measurement Property Summary
Number of studies reporting psychometric properties: 11
Interpretability
- Results from studies of older adults suggest the following 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).
MCID: not established for SCI
SEM = 0.66 (Srism et al. 2015; n=83, mean age 44.21 years, ASIA C; mean time since injury of multiple and non-multiple fallers; 58.7 and 46.7 months, respectively)
MDC95 = 5.74, %MDC = 17.2% (Lemay & Nadeau 2010; n=32, 25 male, AIS D mixed injury types, mean time since injury (SD) = 77.2 (44.3) days).
Reliability – High
Number of studies reporting reliability data: 5
High Inter-rater consistency:
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 consistency
ICC = 0.97 (Tamburella et al. 2014; n = 23, 14 males, AIS D, time Since Injury (SD): 16.43 (19.03) months).
High Internal consistency
(Information Coefficient = 0.94) (Jørgensen et al. 2017; n = 46 (32 males); AIS D = 85%, duration of injury (range): 6.5 years (1-41)).
Validity – Low to High
Number of studies reporting validity data: 8
High correlation between the BBS and the Walking Index for SCI (Pearson’s r = 0.89-0.92).
High correlation between the BBS and the Functional Independence Measure (FIM) (Pearson’s r = 0.72-0.77).
High correlation between the BBS and the FIM Locomotor Score (Pearson’s r = 0.86-0.89).
(Ditunno et al. 2007: n = 146, 114 males, inpatient, incomplete SCI, within 1 year post-injury)
Low to High correlations between the BBS and the ASIA Motor Scale (ranging from Pearson’s r = 0.30 – UEMS, to Pearson’s r = 0.79 – LEMS, to Pearson’s r = 0.75 – ASIA Motor Score).
(Harkema et al. 2016: N=152, 123 male; mixed injury type, median (range) time post-SCI = 0.9 (0.1-45.2) years)
High correlation between the BBS and the Mini-BESTest scale (Pearon’s r = 0.899, P<0.001).
High correlation between the BBS and the Timed Up and Go (TUG) assessment (Pearson’s r = -0.75, P<0.001).
High correlation between the BBS and Spinal Cord Independence Measure version III (SCIM) (Pearson’s r = 0.88, P<0.001).
High correlation between the BBS and the Walking Index for Spinal Cord Injury version II (WISCI) (Pearson’s r = 0.63, P<0.001).
High correlation between the BBS and the Fall Efficiency Scale – International (FES-I) (Pearson’s r = -0.68, P<0.001).
Low correlation between the BBS and the participants’ fear of falling (Pearson’s r = -0.32, P=0.83).
Low correlation between the BBS and the Quality of Life (QOL) questionnaire (Pearson’s r = -0.75, P = 0.20).
(Jørgensen et al. 2017: n = 46, 32 males; AIS D = 85%, duration of injury (range) = 6.5 years (1-41))
Responsiveness
Number of studies reporting responsiveness data: 3
Floor/Ceiling Effect
Significant ceiling effects (37.5% of subjects reached maximal score) and no floor effects have been reported in the Berg Balance Scale for the SCI population (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
Reviewers
Dr. William Miller, Carlos L. Cano Herrera
Date Last Updated
December 31, 2024
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
Jorgensen V, Opheim A, Halvarsson A, Franzen E, Skavberg Roaldsen K. Comparison of the berg balance scale and the mini-BESTest for assessing balance in ambulatory people with spinal cord injury: A validation study. Physical Therapy 2017;97: 677-687.
Lemay JF, Nadeau S. Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale. Spinal Cord. 2010;48(3):245-50.
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
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
