• 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

The BBS 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 an 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 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)

  • High internal consistency: (α = 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 with the Walking Index for SCI: r = 0.89-0.92
  • High correlation with the Functional Independence Measure (FIM): r = 0.72-0.77
  • High correlation with the FIM Locomotor Score: 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 with the ASIA Motor Scale:  r = 0.30 – UEMS; r = 0.79 – LEMS; 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 with the Mini-BESTest scale:  r = 0.899, (p<0.001)
  • High correlation with the Timed Up and Go (TUG) assessment: r = -0.75, (p<0.001)
  • High correlation with the Spinal Cord Independence Measure version III (SCIM): r = 0.88, (p<0.001)
  • High correlation with the Walking Index for Spinal Cord Injury Version II (WISCI): r = 0.63, (p<0.001)
  • High correlation with the Fall Efficiency Scale – International (FES-I): r = -0.68, (p<0.001)
  • Low correlation with participants’ fear of falling: r = -0.32, (p=0.83)
  • Low correlation with the Quality of Life (QOL) questionnaire: 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

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

Significant ceiling effects (28.3%-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; Jørgensen et al. 2017; n=46; 32 males, 14 females; ASIA A-D (AIS D = 85%); duration of injury (range): 6.5 years (1-41); Morooka et al. 2024; n=20; 14 males, 6 females; mean age: 64.3 years; ASIA A; mean time since injury: 19.6 days)

Reviewers

Dr. William Miller, Dr. Carlos L. Cano-Herrera

Date Last Updated

December 31, 2024

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