berg balance scale - welcome to exercisepd balance scale tests and measures: adult: 2012 do not copy...
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BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 1
Type of Test:
Time to administer: 15 – 20 minutes if all equipment prepared
Clinical Comments: With practice, this test can be done quickly. Keep blank scoring sheets & necessary equipment readily
available in the clinic. If a patient cannot complete all of the items, it is still worth doing as it provides good measure of
change over time.
Purpose/population for which tool was developed: The Berg Balance Scale (BBS) was developed as a performance-oriented
clinical measure of balance in elderly individuals. The focus of the measure was on the assessment of the performance of subjects
rather than the diagnosis of the origin of the impairment.1
When appropriate to use: Most of the research on this instrument has been done on the elderly. It can be used for clients with sitting
and standing balance impairments. Typically the test is done with the client wearing shoes. Scores on 100 women were 2.5 points
higher with shoes on than barefoot.2
Scaling: Each of the 14 items has its own ordinal scoring from 0-4. The total score range is 0-56. In 2004, a Rasch analysis was done
on the Berg, suggesting the need for changes in the scaling of most items.3 Another group has suggested rescoring the Berg with a 3-
point scale.4 A short form of the BBS for 226 people with stroke suggest a 7-item format was equivalent to the 14-item with the
exception of a much higher floor effect of 42% versus 24% for the original.5 These new scoring systems are not in widespread use
and therefore not yet recommended. In 2006 Chern 6 classified the static items as 2,3,6,7,13,14 and the dynamic items as
1,4,5,8,9,10,11,12. Item #3 in the Berg has a ceiling effect for 90% of patients in stroke rehab7.
Equipment needed:
stopwatch or watch with a second hand
ruler indicating 2, 5, and 10 inches
2 standard height chairs-approximately 46 cm (1 with, 1 without armrests; bed can substitute for chair without armrests)
footstool-approximately 21 cm
an object to pick up off the floor (e.g., shoe / slipper).
Directions: The directions for items are provided on the scoring sheet. (Appendix 2)
Reliability:
Reference N = Sample description Reliability Statistic
Internal Consistency: (how the items in the scale relate to each other and to the group of items as a whole). Reliability statistic =
Cronbach’s alpha In the studies looked at in the handout, range from .74 to 0.996. Berg, 1989
1 14 In 14 older adults with known balance impairments and a history of
falls, the item-to-total correlations ranged from .72 to .90.
The correlations among items ranged from .38 to .94. These values
indicate a strong degree of internal consistency, that is, the scale is
measuring one concept and the overall scale is providing more
information than any one item used alone
.96
Steffen, 20018 97 Community-dwelling older adults .74
Mao, 20029 112 People with stroke .92 to .98
Berg, 199510
113 Elderly living in a senior residence .83
Berg, 199510
69 Stroke patients < 14 days duration .97-.98
deFigueiredo, 200911
12 elderly individuals
reliability testing the Brazilian Portuguese version of BBS using
physiotherapists with no prior training and new graduates for inter-
rater reliability
.996
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 2
Intrarater and Interrater Reliability: These 2 reliabilities were high in all studies. In the studies looked at in this handout,
ICC range .88 to .99
Reference N = Sample description Reliability Statistic
Berg, 19891 14 People with balance impairment range .88-1.0
Berg, 199212
14 Residential care facility
Shumway Cook, 199713
5 Community dwelling with fall history
Bogle Thorbahn,
199614
66 Independent life-care communities
Mao, 20029 112 stroke
Berg, 199510
24 18 elderly, 6 stroke
Sackley, 200515
45 Individuals with a learning disability Kappa= .74-1.0
ICC=.99
Cattaneo, D, 200716
20 Multiple Sclerosis ICC = .96
de Figueriredo,200911
12 elderly individuals
reliability testing the Brazilian Portuguese version of BBS using
physiotherapists with no prior training and new graduates for inter-
rater reliability
ICC=0.996
Gan, Sue-Mae, 200817
30 children with cerebral palsy ICC=.99 (0.99-1.00)
Test-retest reliability& internal consistency (IC) (alpha) Test retest on the Berg was high for all studies except18
. This may have
occurred because that study involved a longer time period between the 2 tests. MDC(95) for the Berg are consistently 3-7 points with
the 7 occurring in residents of extended care facilities. ICC range .77 to .99 in the studies below
Reference N Mean (SD) Population Time
Between Test-Retest MDC IC
Berg,19891 14 65+ Not Given ICC=0.99 0.96
Berg, 199219
14 38.2 (9.8)
Residential care
facility, acute and
extended care
facility residents
Mean age=83
1 wk ICC=0.98 0.96
Berg, 199510
24 46 (11.0) 18 elderly, 6 stroke 1 wk ICC=0.97 5.28 0.98
Halsaa, 200720
83 44.4 (8.6)
Geriatric Rehab
Unit Average age:
82
0.87
Holbein-Jenny,
200518
26 41.3 (9.0)
Personal Care
Home Residents
Age 74-92
1-2 wks ICC(1,1)= .77 11.96
Liston, 1996 21
20 48.15
(6.467)
hemiparetic,
ambulatory 1 wk ICC(2,1)=.98 2.54
Mao, 20029 112 22.3 (22.2) 14 days post stroke 0.95
Newstead, 2005 22
5 44.9 (11.7)
Age 20-32
traditional living
community
residents post TBI
1 wk ICC(2,1)=.986 3.83
Sackley, 2005 15
34 Median =41
Learning disability
Age 19-86 1 wk ICC=.98
Steffen, T, 200823
37 50 (7) People with
Parkinsonism 7 days ICC(2,1) = .94 5 .86-.87
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 3
Reference N Mean (SD) Population Time
Between Test-Retest MDC IC
Lim, 200524
26 Parkinson Disease ICC=.87 2
Cattaneo, D25
25 Multiple sclerosis ICC = .96
Conradsson, 200726
45 30.1(15.9)
Elderly living in
residential care
facilities
1-3 days ICC(3,1)=97 MDC
7.48
Swanenburg,
200727
24 51.7(4.3)
elderly people with
decreased bone
mineral density
1,3,6,9,12
months ICC=0.90
MDC
3.79
Gan, Sue-Mae
200817
30
34.8(18.7)
children with
cerebral palsy 1 week
ICC=1.00 (0.99-
1.00)
MDC
5.13
Liaw, 200828
52
median
session 1
43.5(20.8-
53.0)
Clients s/p stroke 7days ICC(2,1)=.98
SEM =2.4
MDC 95) =
6.5
Validity:
Content Validity: The items were developed and refined through a 3-phase process involving 32 health care professionals working in
geriatric settings. Original items were tested on small groups of older adults (N= 12-14) with impairments of balance and a history of
falls.1
Construct / Concurrent Validity: It is difficult to always differentiate between these types of validity. Additionally, there is not
one definitive “gold standard” to serve as the criterion for the construct of “balance.”
Population N = Support for validity
Older adults in
residential facilities
BBS is correlated with: Barthel index (.67), Fugl-Meyer motor and balance subscales
(.62-.94), Timed Up and Go scores (-.76), Tinetti’s balance subscale (.91),12, 19
28 Emory Functional Ambulation Profile (-.60).29
Older adults 105 BBS is correlated with: Dynamic Gait index (.67)30
; caregiver ratings of balance (.47-
.61),
20 gait speed (.81)21
,
31 center of pressure measures of body sway during still and perturbed standing (-.40 to -
.67),19, 21
36 upper thoracic slope (-.44) and knee joint angle (-.38)31
54 Environmental Analysis of Mobility Questionnaire (EAMQ) encounter score (.73) and
EAMQ avoidance score (-.72)32
Adults with stroke 25 BBS is correlated with: 6MWT (.78), 12MWT (.80), gait speed (.76),33
23 BBS and COP excursion (10 and 30% of body height); .48 and .41 (p<.05)
123 BBS is correlated with postural assessment scale for stroke (.92) and Fugl-Meyer
(.90), 9
26 BBS is correlated with improvement on Modified Emory Functional Ambulation
Profile (-.53),34
38 BBS is correlated with the Rivermead Mobility Index (.8),35
30 BBS is correlated with laboratory balance assessments,36
37 BBS is correlated with FIM motor and mobility (.72),37
28 BBS is correlated with trunk control test (-.72)38
48 BBS is correlated with sitting arm raises (.54), sitting forward reach (.54), standing arm
raise (.36), standing forward reach (.7), 5-m walk (-.64), tap test (.74)39
48 BBS is correlated with Brunel Balance Assessment (BBA)39
75 BBS is correlated with Functional Reach (.78)40
70 BBS is able to detect change of the same magnitude as the Barthel Index in the first 12
weeks post stroke and it was able to do this better than the Fugl-Meyer. The effect size
of the BBS over the 12 weeks immediately following stroke is large (.97)41
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 4
Population N = Support for validity
Persons s/p hip fracture 73 BBS correlates with: gait speed (.59), modified Barthel Index (.68), London Handicap
Scale (.76)42
;
120 BBS correlates with SF-36 subscales (.27 to .57), FIM (.67),43
20 BBS correlates with FIM (.60)44
s/p LE amputation 120 BBS correlates with: Frenchay ADL Index (.75)43
[Jongjit, 2003 #691]
Community-dwelling
older adults
30 BBS correlates with: movement times on the Timed Movement Battery (-.67 to -.83)45
Persons with Parkinson
disease
38 BBS correlates with UPDRS motor score (-.58), Hoehn and Yahr Scale staging (-.45),
the Modified Schwab and England capacity for Daily living (S&E ADL) (.55).46
,
30 BBS correlates with walking (.74) and walking while completing a dual motor task
(.55)47
.
persons following
stroke
20 BBS correlates with mean velocity of center of pressure r=-.5, in maintaining a
position48
.
older adults 21 BBS correlates with accelerometer with sway responses while standing on a foam mat
with eyes open (.83) but not with eyes closed using an accelerometer. It is correlated to
TUG (-.77)49
Patients with
Huntington’s Disease
30 BBS correlates with gait velocity (.49) and cadence (.54) but not with stride length,
balance measures of double support percent or support base. It correlates with falls –
(.49), step time (.54) and with measures of functional limitation HD-ADL (-.48) and d
total functional capacity ( .60)50
Children with cerebral
palsy
30 BBS correlation with dimension E and total score of GMFM-.88 rs.97, Sit to stand
(.79), walking speed (.84), TUG (-.88) and Forward Functional reach (.84)17
.
Patients with
Parkinsons Disease
34 BBS correlates with disability (OARS) and disease severity(UPDRS and H & Y stage)
measures (.55-0.74).51
women with forward
head posture
203 BBS correlated with the FHP(forward head posture (-.51)52
Discriminate validity:
Population N = Support for validity
Older adults 113 BBS discriminates between: mean score (SD)
persons requiring a walker 33.1(8.4) versus a cane 45.3(3.4) for indoor ambulation
persons requiring no assistive devices 49.6 (5.6) versus a cane 48.3 (3.2) for outdoor
ambulation12
84 Discriminates between levels of frailty as judged by scores on the PPT: mean score (SD)
not frail (32-36 on PPT) BBS=52.5 (2.7)
mildly frail (25-31 on PPT)BBS=50.1(2.6); moderately frail (17-24 on PPT) BBS=45(3.9) 53
s/p stroke 33 Discriminates between: (mean score)
persons requiring physical assist to ambulation (FIM 4); (29) versus persons independent
without device to ambulate (FIM 6); (46)54
238 In study of 238 pts on stroke rehab unit:
Fallers tended to have lower BBS scores (50% of patients with a score <30 fell vs. 18% with
a score >30, p<.01).55
Persons with ↓ vision 66 Discriminates between levels of vision impairment:
no impairment (51); mild (46); moderate (39)56
s/p hip fracture 120 Discriminates between controls (54) versus persons with hip fx (46) (age & gender matched)43
Homebound persons 30 BBS did not discriminate those classified as fallers versus non-fallers57
Females over 65 48 BBS median scores:
fallers 45; non-fallers 5531
Patients with
Huntingtons disease
30 BBS discriminates between disease severity HD stage 1 51(6), HD stage 2 39(9). HD stage 3
36(15)50
Children with cerebral
palsy
30 BBS scores were significantly different among the 4 GMFCS levels (F=30, df =3, p<.001)17
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 5
Predictive Validity:
Older adults Several studies have shown that baseline BBS score contributes to prediction of falls.13,
31,14,19
(see Sensitivity / Specificity).
100 Others have found it does not predict fallers among community dwelling elderly58
pts admitted to stroke
rehab unit
313 Initial BBS scores help predict length of stay;59
104 Initial BBS scores help predict discharge destination.60
Pts s/p hip fx 90 Individuals who reported falls in the 6 months after hospitalization for hip fx had significantly
lower BBS scores than those who did not fall.61
Subjects with CVA 56 Fallers with low BBS scores were more likely to fall in the morning, to restrict their activity after
a fall and to sustain an injury after a fall. Subjects with higher physical function were more
likely to fall at night and were more able to get up within 5 min after a fall.62
s/p acquired brain injury 40 Low Berg (≤42) compared to High Berg (≥43) grps
strong correlation admission BBS and admission FIM (r=.86; p<.000)
moderate correlation admission BBS and admission MMSE (r=.6;p<.000)
moderate correlation admission BBS and discharge Total FIM (r=.56, p<.000)
moderate negative correlation admission BBS and LOS (r=-.55;p<.000)
No significant relationship between admission BBS and age or time after injury63
Patients with
Huntington’s disease
24 BBS scores help predict frequency of falls increased risk of falls occurred if BBS score was˂ 14
seconds64
Older adults 138 BBS scores predict higher SPPB (Short Physical Performance Battery)performance: as score ≥54
on BBS was associated with a higher SPPB score(>9)65
Older male veterans
attending balance
disorders clinic
95 Regression showed pain, baseline Berg and program completion were all predictors of final
BBS66
.
patients with acute stroke
(5 days) in county
hospital in Sweden
60 Correlation with FES (Falls Efficacy Scale)and BBS, (group 1) (0.55), and between BBS and
TUG (group 1 & 2)(-0.68 & -.72)67
Sensitivity/specificity: The cutoff scores used to predict people who will fall runs from 45-50 with no consensus in the
literature. As the cutoff score rises the sensitivity rises but the specificity decreases. When using sensitivity to predict the
probability of future falls therapists should compare their individual clients to similar data on like populations and report:
Berg Balance: 40/56 [cutoff of ≤ 50 suggests ↑ fall risk with sensitivity = 83%]68
Population N = Cutoff Score and Description Results
Predicting falls, multiple
falls and injurious falls
community dwelling
elderly
210
Muir, 200871
Cutoff score of 45 for any fall
Cutoff score of 54 for any fall
Cutoff score of 45 for multiple falls
Cutoff score of 54 for multiple falls
Cutoff score of 45 for injurious falls
Cutoff score of 55 for injurious falls
Sensitivity =.25%
Specificity = 87%
Sensitivity = 61%
Specificity = 53%
Sensitivity = 42%
Specificity = 87%
Sensitivity =69%
Specificity =57%
Sensitivity = 29%
Specificity = 86%
Sensitivity = 62%
Specificity = 51%
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 6
BBS as a screening test
for community-dwelling
elderly requiring referral
to physical therapy
53
Cutoff score of 48:
Harada, 199570
In combination with gait speed (cutoff score of .57m/s)
sensitivity increases but specificity decreases.70
Sensitivity = 84% ;
Specificity = 78%
Identifying fallers 110 Cutoff score of 45:
In studies by Riddle & Stratford,68
Shumway Cook et al,13
and
Bogle Thorbahn & Newton,14
Sensitivity = 64%
(combined results)
Specificity = 90%
(combined results)
Identifying fallers 110 Cutoff score of 50:
Riddle and Stratford68
used combined data of Shumway Cook
et al13
and Bogle Thorbahn & Newton,14
for this result
Sensitivity = 83%;
Specificity = 73%
Identifying fallers 125 Cutoff of 46:
In study of 45 fallers and 80 non-fallers.69
Sensitivity = 83%;
Specificity = 93%
predicting falls in clients
with Parkinson’s disease
49 Landers, 200872
Cutoff score of 43.5 for any falls
sensitivity =68%
specificity =96%
NOTE: Clinicians need to choose a cut-off score based on the specific purpose for which the test is used
Responsiveness / sensitivity to change: [Reminder: studies below indicate only amount of BBS change after treatment; other
outcome measures may have had a different responsiveness]
The Berg has been used most often with people with neurological disorders. It is more responsive in the earlier stages post
onset stroke where there is no ceiling effect.
Population
Descriptor
N = Reference and intervention Responsive
Yes/No Data Supporting Responsiveness
s/p stroke
20 Duncan, 1998
73
23 treatments and 4 weeks of a home program
Experimental group (n=10)
Detailed program to improve strength, balance,
endurance and encourage use of affected extremity
Control group (n=10)
Receiving traditional therapy
no Treatment: 38.3 to 46.1
Control: 40.8 to 45.8
NS
13 Geiger, 200174
4 weeks; 2-3x/week for 50 minutes
(Exp- 35 min/session standard PT with 15 min
Balance Master)
Experimental group (n=7):
Standard PT plus training on Balance Master
Control (n=6):
Standard PT
no
Experimental: gain of 6.6
Control: gain of 7.5 on BBS
No difference between groups
46 Walker, 200075
Until discharge; mean=36-39 weeks
Group 1: 22 training sessions
Group 2: 23 training sessions
All groups: Received PT and OT 2hr/day
Experimental group 1(n=16):
Balance Master training with visual feedback (30
min/day)
Experimental group 2 (n=16):
Conventional balance training (30 min/day)
Control group (n=14):
PT and OT 2 hrs/day
no Initial
Group 1: 36
Group 2: 37
Control: 36
End
Group 1: 47
Group 2: 49
Control: 46
NS
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 7
s/p Stroke 50 Nilsson, 200176
30 min/day; 5 days per week
Experimental group (N=28):
Treadmill training with body weight support
Control group (N=32 patients with hemiparesis):
Walking training on ground
no At 10 month follow-up:
Treatment: 24 to 48 (p<.001)
Control: 23 to 48 (p<.001)
NS between groups
7 Weiss, 200077
2x/week for 12 weeks
Individuals 1 year post stroke
Progressive resistance training at 70% of 1 RM
yes Baseline: 46.9 (1.9)
End: 52.6 (.8)
(p=.003)
12% improvement
132 Duncan, 200378
36, 90 min/session; 12-14 weeks
Experimental group (N=44):
Structured, progressive exercise program targeting
strength, endurance, balance and UE use
Control group (N=48)
Usual care
yes Exp group change: 4.36 (.71)
Control group change: 1.70 (.52)
Exp group increased > control group
(p<.01)
37 Hellstrom, 2003 37
Not standardized or controlled
Unspecific rehab program
yes Admission: 36
D/C: 40
10 mo. Follow-up: 45
Admission vs. discharge (p<.001)
Discharge vs. follow-up (p=.001) 12 Chu, 2004
79
8 weeks, 3d/wk, 1h/session
Experimental (n=6):
Water-based exercise program
Control (n=6):
Arm exercise group
no Exp initial: 52(5)
End: 52(3)
Control initial: 50(4)
End: 52(4), NS
25 Eng, 200380
8 weeks, 60 minutes, 3x/week
Training focusing on balance and mobility
yes Baseline 1: 44.7 (6)
Baseline 2: 45.9 (5)
End 1: 48 (5)
End 2: 48.3 (4.3)
P<.05
27 Garland, 2003 81
1 month
Rehabilitation
yes 14 (7) point improvement
P<.001
24 Pomeroy, 200182
6 weeks
Experimental group (n=12):
Weighted garments worn on paretic side
Control (n=12):
No weighted garments
no Exp initial: 52
End: 51
Control initial: 50
End: 50
NS
123 Mao, 2002 9
Assessed at 14-30 days after stroke onset and in
later stages 90 to 180 days post stroke
BBS was less responsive than the
Fugl-Meyer and the Postural
Assessment Scale
48 Stevenson, 2001 83
Reassessed after 1-2 weeks of intervention
(N=48) Inpatient rehabilitation
Only 25/45 subjects showed agreement between
statistical change and clinicians’ perceptions of
change.
Yes/no Minimal detectable change
estimated to be + 6 BBS points
(90% confident of genuine change)
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 8
s/p Stroke 42 Wang, 200584
40 min sessions, 5/wk; 20 sessions total
Spastic group:
Bobath tx vs. orthopedic tx
Pts with relative recovery:
Bobath tx vs. orthopedic tx
no Spastic grp:
Bobath pre=6
Post=20.5 (p=.001)
Ortho
pre=10.7
Post=20.4 (p=.000)
Rel recov grp:
Bobath
pre=16
post=35 (p=.001)
Ortho
Pre=33
Post=40.3 (p=.000)
Change scores between Bobath and
Ortho grps are not significant for
either spastic or relative recovery
grp.
20 Leroux, 2005 85
1 hr, 2x/week for 8 weeks pre/post measures
Intervention:
Group sessions aimed at strengthening UEs and
LEs, balance, mobility, coordination
yes Pre: 45 (7)
Post: 49(5)
(p<.008)
91 Salbach, 2004 86
]
3x/week for 6 weeks Experimental Group (N=44):
Functional task activities to increase LE strength,
balance, speed and walking distance
Control Group (N=47):
UE activities
no Control:
Pre: 40
Post: 41
Exp:
Pre: 42
Post: 44,
NS
91 Salbach, 2006 87
3x/week for 6 weeks
Grp 1 (N=47):
UE intervention
Grp 2 (N=44):
Task-oriented interventions targeting walking
Low correlation between BBS and
ABC scale after interventions:
-.05 walking grp
-.06 UE grp
Predictive model research
18 Hart, 2004
88
1 h, 2x/wk for 12 wks
Experimental Group (N=9):
Tai Chi exercise
Control Group (N=9):
Physiotherapy exercises focusing on balance
no Control grp showed improved
balance (p=.01), Exp grp did not
show change in balance
103 Wang, 2005 89
(N=42) symptoms of short duration (<6 mo.)
(N=61) symptoms of long duration (>12 mo.)
Tested with and without an AFO on hemiparetic
side
no Short duration:
With AFO=51
Without=51
Long duration:
With AFO=52
Without=51
No significant differences between
conditions
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 9
S/P stroke in
rehabilitation
unit
15 Allison, 200790
Intervention group n= 7 conventional treatment
plus additional session of standing practice
Control group n=10 conventional treatment
yes in
change
scores
Intervention group median
week 1 8 (2.5-21.75)
week 2 24 (7.25-45)
week 12 47 (11.25-51.5)
difference from week 1-12 37
(6.5-42)
Control group median
week 1 16.5 (2 – 26.5)
week 2 28 (8-44)
week 12 44 (11-52)
difference from week 1-12 20.5
(1.5-31)
Status post
stroke before
and after
rehabilitation
10 Cikazjlo, 200991
stroke rehab intervention
yes
Initial score 23(15) following
treatment39(11)
P<0.001
status post
stroke before
and after
rehabilitation
51 Amusat 20097
stroke rehabilitation
no BBS admission score 25(16)
discharge score 36(13)
p= NS
status post
stroke
68 Yelnik, 200892
both groups received 20 sessions in 4 weeks
group 1 n=35 –- a conventional
neurodevelopmental theory based treatment (NDT)
that used a general approach for sensorimotor
rehabilitation
group 2 n=33- a multisensorial approach based on
higher intensity of balance tasks and exercise
during visual deprivation
no
BBS Score (95% CI)
day 0 47(39;53)
day 30 53(43;55)
day 90 51(44;55)
day 0 49(42;53)
day 30 53(48;55)
day 90 53(49;55)
p<,.06 at day 90
Status post
stroke,
community
dwelling
individuals
50 Hamzat, 200893
Group 1 – those walking with a cane (N=25)
group 2 - those walking without a cane (N=25)
yes
BBS score39.72(9.19)
BBS score 53.68(2.81)
P<.001
Clients with
chronic stroke
30 Wing, 200894
Intervention was whole body intensive training 3-6
hours per day, 4-5 days per week,≥ 2weeks,
yes mean ±SEM
pretest 46.5(2.3) seconds
post test 47.2(1.9) seconds
Older adults 77 Wolf, 200195
12 sessions over 4-6 weeks
Persons with functional balance problems, > 75
years old living independently or in a residential
care facility
Experimental (n=37):
Individualized balance training
Control group (n=40)
Yes
initially
but not at
follow-up
Exp initial: 37(12)
End: 43(11)
p 4wks: 42(11)
Control initial: 34(13)
End: 38(13)
p 4 wks: 38(14)
Exp>Control
P<.001
Effect disappeared at 1 year
follow-up.
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 10
Older adults 34 Shimada, 200396
2-3 times/week for 12 weeks; 40 min/session
Ambulatory persons attending a geriatric health
facility; average age 81
Experimental 1(n=12):
Exercise group with balance emphasis
Experimental 2 (n=12):
Exercise group with emphasis on gait re-education
Control group (n=10)
yes Grp1 initial: 49(6)
Grp2 initial: 46(9)
Control initial: 50(6)
Grp1 End: 51(5), p<.01
Grp2 End: 48(8), p<.01
Control end: 50(5)
Grp 1 (balance) improved over
control, p<.05
27
Sihvonen, 2004
97
3x/wk for 4 weeks
Frail elderly women
Experimental (n=20):
Balance exercises with a computerized force
platform visual feedback training
Control group (n=7)
Yes Exp initial: 49(5)
End: 52(4), p=.001
Control initial: 45(9)
End: 45(10)
Exp improved over control, p=.003
41
Malone, 2002
98
At least 5 visits
Rehab at a geriatric day hospital
Yes but
not at
follow-up
5 point improvement from
admission to discharge; not
sustained at 3 month follow-up
156 Li, 2004 99
60 min sessions, 3x/wk for 6 months
Tx grp (N=125):
Tai Chi
Control grp (N=131):
stretching, deep breathing and relaxation
techniques
Yes Tai Chi grp showed greater change
in BBS scores (p<.001)
Control showed no change in
score; Tai Chi grp showed increase
(p<.001)
6 mo. Follow-up: Tai Chi showed
less decline in scores (p=.04)
Subjects with
gait deviations
50 Salbach, 2001 100
4 weeks
Post stroke
Prospective study
General rehabilitation services focusing on
improving function and gait
Yes Initial: 37(18)
End: 47(11)
Responsiveness to change,
measured by SRM (standardized
response mean (mean change / SD
change scores), was high (1.04)
Long term care 20 Baum, 2003101
]
12 months; 3x/week, 1 hour
Experimental (n=11):
Group exercise program
Control (n=9):
Recreational activity
Yes Increase of 4.8 with effect size of
0.32
Frail elderly 21 LaStayo, 2003102
11 wks, 3x/week, 10-20 min; both groups focused
on LE
Experimental (n=11):
High force eccentric training
Control (n=10):
Traditional weight training
yes
Exp initial: 50(1)
End: 53(.64), p<.05
Control initial: 42(2)
End: 44(1)
elderly people
with decreased
bone mineral
density
24 Swanenburg, 200727
Intervention group N=12 baseline, 3 months
N=11, 6 and 12 months N=10
12 weeks of exercise and balance training, three
sessions per week for 70 minutes each and
nutritional protein supplementation and
calcium/vitamin D supplementation
Control group N=12 at baseline, 3 months N=11, 6
and 12 months N=10
Calcium /vitamin D supplementation only
Intervention group
baseline51.7(4.3)
3 months 55.3(1.5)
6 months 55.5(0.8)
12 months 55.6(3.8)
Control group
baseline 53.2(2.4)
3 months 52.9(2.2)
6 months 52.7 (2.2)
12 months 51.9(4.5)
BERG BALANCE SCALE
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s/p hip fracture 20 Mendelsohn, 200344
Approx 80 min/session, 5x/wk, 3-5 wks
Inpatient rehab program
yes Initial: 30(8)
d/c: 44(5.5)
p<.01
90 Binder, 2004103
3 sessions/wk for 6 mo.
Experimental Group (N=46):
Supervised PT and exercise training
Phase 1 (3 mo): grp PT focusing on flexibility,
balance, coordination, strength
Phase 2 (3 mo): progressive resistance training
Control (N=44):
Home exercise program
yes Exp grp increased > control
(p=.009)
Exp grp:
Base: 43
3 mo: 48
6 mo: 49 (p=.02)
Control:
Base: 41
3 mo: 44
6 mo: 43
elderly women
age 65and over
with
osteoporosis
60 Madureira, 2007104
Control group (n=30) no intervention
Experimental Group (n=30) 1 hour weekly
treatment session and home exercise program with
home exercises 3 times per week for 30 minutes
Yes
Control group loss of -0.5 (4.88)
Experimental group gain of 5.5(
5.67)
Postmeno-
pausal women
with
osteoporosis
51 Gunendi, 2008105
Both groups received 4 weeks of submaximal
aerobic exercise
Group 1 n=26 postmenopausal women with
osteoporosis
Group2 n=25 postmenopausal women without
osteoporosis
No
initial BBS score 53.8(1.6)
final BBS score54.7(1.0)
p < 0.001
initial BBS score 54.1(1.5)
final BBS score 54.2(1.5) p =NS
Parkinsons
patients living
at home, repeat
fallers
142 Ashburn, 2007106
personalized home program of exercises and
strategies
Intervention group n=70 (at start)
individualized treatment program, weekly visits
from physical therapist, 6 weeks initial treatment
period
Control group n=72 (at start) contact with nurse,
advice about exercises at the end of follow-up.
No at 8
weeks and
6 months
intervention group
baseline 44.3 (9.8) n=70
8 weeks 45.8 (9.2) n=67
6 months 45.3 (10.0) n=64
control group
baseline 43.6 (10.5) n=72
8 weeks 45.2 (9.9) n=66
6 months 44.6 (11.0) n=64
p=N.S.
Clients with
Parkinsons
disease
31 Cakit, 2007107
Training Group (n=21) 8 week exercise program
using incremental speed dependent treadmill
training
Control group n=10 no intervention
yes
BBS baseline 37.0(9.41)
at 8 weeks 44.09(7.11)
change 7.09(1.27)
p<0.01
BBS baseline 42.6(9.37)
at 8 weeks 41.4(10.65)
change -1.42(±0.23)
p<0.01
BERG BALANCE SCALE
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Community
dwelling older
adults
429 Shumway-Cooke, 2007108
experimental group n=212
multifaceted interventionincluding3x/wk group
exercise, 6 hours of fall prevention education
control group n=217
received brochures on fall prevention
yes Experimental group
Initial score50.3(5.6)
Final score 51.1(6.2)
Control group
Initial score 50.2 (6.0)
Final score 49.4 (7.4)
Adjusted mean difference 1.5
points(95%CI, 0.8-2.3)
p<.001
Community
dwelling
elderly at high
risk for falls
56 Sze, 2008109
Intervention was 12 sessions of once a week falls
prevention clinic, including fall evaluation, balance
training, home hazard management program, and
medical referrals for the first 3 months, followed
by community step-down program including falls
prevention education, a weekly exercise class and 2
home visitations in the following 9 months
yes
Baseline 48.1(6.9)
posttest 51.3(5.2)
p<.001
Older adults
with balance
impairment
scoring less
than 52 on the
BBS and/or
CGS less than
1.1m/s
23 Silsupadol, 2009110
Patients trained 45 minutes individual, 3 times per
week for 4 weeks.
single task balance training group n=7
Dual task training with fixed priority instruction
n=8
Dual task training with variable-priority
instruction n=6
no
Initial score 50.00(4.85)
final score 55.29(1.25)
change 5.29(2.19-8.39)
Initial score 47.25(6.61)
final score 54.50( 2.45)
change 7.25(4.35-10.15)
Initial score 49.00(4.90)
final score 54.00( 2.76)
Change 5.00(1.65-8.35)
P=NS, effect size .07
Older Women 37 Eyigor, 2009111
Experimental group n=19
Dance based exercise in group setting one hour,
three times per week for 8 weeks
Control Group n=18 no exercise
yes experimental group pretest
score 54.1(2.2)
posttest score 55.3(0.85)
control group pretest score
53.6(2.1)
posttest score 53.9(1.7) Between
group difference p<.05
non-
ambulatory
clients after
stroke, spinal
cord and brain
injury
6 Freivogel, 2008112
intervention was a electromechanical gait device
(LokoHelp) for locomotion training for patients
with impaired walking ability
This does
meet the
MDC of
5/56 for
stroke
clients
BBS at start 20(23)
BBS at finish 25(23)
p=NS
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healthy older
volunteers
100 Melzer, 2007115
application of voluntary step
execution test
fallers n=11
nonfallers n=71
no
50,6(4.6) seconds
52.5(3.4) seconds p=0.079
elderly patients
with decreased
bone mineral
density
24 Swanenburg, 200727
Both groups received mineral supplementation
according to physician’s assessment at baseline
Intervention group n=10
participated in a 12 week training program aimed
at improvement of balance abilities and reduction
of the risk of falling 3 sessions per week of 70
minutes each. This group also received protein
drink supplement
Control group n=10
Received a leaflet about home exercises. Did not
receive protein supplementation
yes
BBS baseline 51.7(4.3)
BBS 3 months 55.3(1.5)
BBS 6 months 55.5(0.8)
BBS 9 months 55.3(1.1)
BBS 12 months 55.6(0.7)
Change 0/12 mos 3.9(4.0)
BBS baseline 53.2(2.4)
BBS 3 months 52.9(2.2)
BBS 6 months 52.7(2.2)
BBS 9 months 52.7(2.8)
BBS 12 months 51.9(4.5)
Change 0/12 mos -1.3(2.7)
ANOVA F=8.90p=0.008
clients in
inpatient
rehabilitation
165 Gosselin, 2008113
Comparison of outcomes for older vs. younger
patients
patients < 65 years old n=50
patients > 65 years old n=115
No but
yes with
follow-up
mean differences between
admission and discharge/discharge
and 3 mos follow-up11.2(11.0)/4.0
(7.9)
11.0(9.3)/-1.2(6.9)
p = NS between groups from d/c to
admission but p<.004 discharge to
3 mos follow up.
older adults
with hip
fracture
20 Mendelsohn, 2008114
Training group n=10 patients used an arm crank
ergometer 3 times a week for 4 weeks in addition
to physical therapy and occupational therapy 5
times per week
Control group n=10 patients received physical and
occupational therapy 5 times per week
yes change score
60.3(47.4)
48.7(19.2)
p<0.05
older male
veterans
95 Bishop, 200766
subjects who did or did not complete the program
program completed
program not completed
no
39.8(7.4)
37.5(7.7)
p=NS
Clients with
chronic stroke
14 Yen, 2008116
Control group n=7
received general stroke physical therapy
yes pretest 50.57
(3.55)
posttest 51.57(3.1)
p=NS
pretest 50.29(3.25)
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experimental group n=7
received bodyweight supported treadmill training
in addition to general stroke physical therapy
posttest52.43(2.88)
p=.016
Clients with
stroke, living
at home
63 Pang, 2007117
Intervention group n=32
Underwent a fitness and mobility exercise(FAME)
program - 1 hour sessions, three sessions/week for
19 weeks
Control group n=31
Underwent a seated upper extremity program
No
Intervention group
pretest 47.6 (6.7)
post test 49.6 (4.4)
change (95% CI) 2.1 (0.8-3.3)
Control group
pretest 47.3 (6.1)
post test 49.2 ( 5.8)
change (95%CI) 1.9 (0.8-3.0)
Ceiling & floor effect: Ceiling effects are reported in clients with minimal hemiparesis.9, 118, 119
. This means the BBS will not
capture balance impairments in patients with minimal hemi paresis, as they will achieve a high score while still possessing
balance impairments. Mao (2002)9 reports floor effects in 35% of participants 14 days post stroke. Those not able to sit
independently score the lowest score on this test.
Reference data:
Subjects N = BBS
60 – 95 years (mean, 74.3; SD, 7.7 years); Inner city older adults; majority were African-
American or Hispanic and women; all lived independently in the community but 12%
used an assistive device for ambulation and 22% reported falling in the past 6 months;120
251 Mode = 53 (range, 29-56)
60-89 years;
Community-dwelling adults 121
96 See Table 2
Community-dwelling individuals with stroke33
25 Mean, 49.25 SD, 3.5
8-12 yrs; Ambulatory children with cerebral palsy and 14 children with no motor
impairment122
36 See reference
66-101 years; Community dwelling elderly123
66 See reference
Increasing age was not shown to correlate with decreasing BBS scores in one study.14
but
was correlated in another (n=53) r= -.63105
Age group comparisons established declines in BBS with age124
Screening: The BBS with a 45 cut off was used in screening of 68 individuals in a community health fair. Twenty one percent of
participants scored below 45; of these 9 had experienced falls during the prior year.125
Interpreting results: The 14 items included on the test were judged by health care professionals to measure various dimensions of
balance. It is commonly used as a performance-based measure of balance and a predictor of fall-risk among older adults. Based on
personal clinical experience, Berg et al12
suggested that a score of 45 could serve as a cut-off point between individuals who are safe
in independent ambulation and those who may require assistive devices or supervision. Subsequent studies suggest that this cut-off
point is better at identifying non-fallers than fallers.14
68
(see Sensitivity / Specificity) A study by Daubney and Culham (1999).126
reports dorsiflexion and subtalar evertor force account for 58% of the score on Berg Balance Scale in 39 people (age 65-91) reporting
no fall history.
Berg Balance Score*: Means and Standard Deviation by Age and Gender
of Community Dwelling Elderly
121
Age (yrs) Gender N X SD CI
50-59 Male 9 56 0 56-56
Female 15 55 1 55-56
60-69 Male 9 55 1 54-56
Female 10 55 2 54-56
70-79 Male 10 53 2 52-55
Female 14 52 4 50-54
80+ Male 4 52 5 45-59
Female 12 48 7 44-53
TOTAL SAMPLE 83 53 4 52-54
BERG BALANCE SCALE
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BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 20
Name: __________________________________ Date: _____________________
Location: ________________________________ Rater: _____________________
ITEM DESCRIPTION SCORE (0-4)
1. Sitting to standing ________
2. Standing unsupported ________
3. Sitting unsupported ________
4. Standing to sitting ________
5. Transfers ________
6. Standing with eyes closed ________
7. Standing with feet together ________
8. Reaching forward with outstretched arm ________
9. Retrieving object from floor ________
10. Turning to look behind ________
11. Turning 360 degrees ________
12. Placing alternate foot on stool ________
13. Standing with one foot in front ________
14. Standing on one foot ________
Total ________
GENERAL INSTRUCTIONS
Please demonstrate each task and/or give instructions as written. When scoring, please record the lowest response category that
applies for each item.
In most items, the subject is asked to maintain a given position for a specific time. Progressively more points are deducted if the time
or distance requirements are not met, if the subject’s performance warrants supervision, or if the subject touches an external support or
receives assistance from the examiner. Subjects should understand that they must maintain their balance while attempting the tasks.
The choices of which leg to stand on or how far to reach are left to the subject. Poor judgment will adversely influence the
performance and the scoring.
Equipment required for testing are a stopwatch or watch with a second hand, and a ruler or other indicator of 2, 5, and 10 inches.
Chairs used during testing should be a reasonable height. Either a step or a stool (of average step height) may be used for item #12.
* Static items as classified by Chern in 2006 6; all other items are considered dynamic items
1. SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hands for support.
( ) 4 able to stand without using hands and stabilize independently
( ) 3 able to stand independently using hands
( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or to stabilize
( ) 0 needs moderate or maximal assist to stand
2.* STANDING UNSUPPORTED
INSTRUCTORS: Please stand for two minutes without holding.
( ) 4 able to stand safely 2 minutes
( ) 3 able to stand 2 minutes with supervision
( ) 2 able to stand 30 seconds unsupported
( ) 1 needs several tries to stand 30 seconds unsupported
( ) 0 unable to stand 30 seconds unassisted
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 21
If a subject is able to stand 2 minutes unsupported, score full points for unsupported. Proceed to item #4.
3.* SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL.
INSTRUCTIONS: Please sit with arms folded for 2 minutes.
( ) 4 able to sit safely and securely 2 minutes
( ) 3 able to sit 2 minutes under supervision
( ) 2 able to sit 30 seconds
( ) 1 able to sit 10 seconds
( ) 0 unable to sit without support 10 seconds
4.* STANDING TO SITTING
INSTRUCTIONS: Please sit down.
( ) 4 sits safely with minimal use of hands
( ) 3 controls descent by using hands
( ) 2 uses back of legs against chair to control descent
( ) 1 sits independently but has uncontrolled descent
( ) 0 needs assistance to sit
5. TRANSFERS
INSTRUCTIONS: Arrange chairs(s) for a pivot transfer. Ask subject to transfer one way toward a seat with armrests and one
way toward a seat without arm/rests. You may use two chairs (one with one without arm/rests) or a bed and a chair.
( ) 4 able to transfer safely with minor use of hands
( ) 3 able to transfer safely definite need of hands
( ) 2 able to transfer with verbal cuing and/or supervision
( ) 1 needs one person to assist
( ) 0 needs two people to assist or supervise to be safe
6.* STANDING UNSUPPORTED WITH EYES CLOSED,
INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
( ) 4 able to stand 10 seconds safely
( ) 3 able to stand 10 seconds with supervision
( ) 2 able to stand 3 seconds
( ) 1 unable to keep eyes closed 3 seconds but stays steady
( ) 0 needs help to keep from falling
7.* STANDING UNSUPPORTED WITH FEET TOGETHER
INSTRUCTIONS: Place your feet together and stand without holding.
( ) 4 able to place feet together independently and stand 1 minute safely
( ) 3 able to place feet together independently and stand for 1 minute with supervision
( ) 2 able to place feet together independently but unable to hold for 30 seconds
( ) 1 needs help to attain position but able to stand 15 seconds feet together
( ) 0 needs help to attain position and unable to hold for 15 seconds
8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING
INSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a
ruler at end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded
measure is the distance forward that the finger reaches while the subject is in the most forward lean position. When possible,
ask subject to use both arms when reaching to avoid rotation of the trunk.)
( ) 4 can reach forward confidently > 10 inches
( ) 3 can reach forward >5 inches safely
( ) 2 can reach forward > 2 inches safely
( ) 1 reaches forward but needs supervision
( ) 0 loses balance with trying/requires external support
9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION
INSTRUCTIONS: Pick up the shoe/slipper which is placed in front of your feet.
BERG BALANCE SCALE
Tests and Measures: Adult: 2012 Do not copy without permission of Teresa Steffen BBS Page 22
( ) 4 able to pick up slipper safely and easily
( ) 3 able to pick up slipper but needs supervision
( ) 2 unable to pick up but reaches 1-2 inches from slipper and keeps balance independently
( ) 1 unable to pick up and needs supervision while trying
( ) 0 unable to try/needs assist to keep from losing balance or falling
10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE
STANDING
INSTRUCTIONS: Turn to look directly behind you over left shoulder. Repeat to the right. Examiner may pick an object to
look at directly behind the subject to encourage a better twist turn.
( ) 4 looks behind from both sides and weight shifts well
( ) 3 looks behind one side only other side shows less weight shift
( ) 2 turns sideways only but maintains balance
( ) 1 needs supervision when turning
( ) 0 needs assist to keep from losing balance or falling
11. TURN 360 DEGREES
INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.
( ) 4 able to turn 360 degrees safely in 4 seconds or less
( ) 3 able to turn 360 degrees safely one side only in 4 seconds or less
( ) 2 able to turn 360 degrees safely but slowly
( ) 1 needs close supervision or verbal cuing
( ) 0 needs assistance while turning
12. PLACING ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED
INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool four times.
( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds
( ) 3 able to stand independently and complete 8 steps > 20 seconds
( ) 2 able to complete 4 steps without aid with supervision
( ) 1 able to complete > 2 steps needs minimal assist
( ) 0 needs assistance to keep from falling/unable to try
13. STANDING UNSUPPORTED ONE FOOT IN FRONT
INSTRUCTION: (DEMONSTRATE TO SUBJECT)
Place one foot directly in front of the other. If you feel that you cannot place your foot directly in front, try to step far enough
ahead that the heel of your forward foot is ahead of the toes of the other foot. (To score 3 points, the length of the step should
exceed the length of the other foot and the width of the stance should approximate the subject’s normal stride width)
( ) 4 able to place foot tandem independently and hold 30 seconds
( ) 3 able to place foot ahead of other independently and hold 30 seconds
( ) 2 able to take small step independently and hold 30 seconds
( ) 1 needs help to step but can hold 15 seconds
( ) 0 loses balance while stepping or standing
14. * STANDING ON ONE LEG
INSTRUCTIONS: Stand on one leg as long as you can without holding
( ) 4 able to lift leg independently and hold > 10 seconds
( ) 3 able to lift leg independently and hold 5-10 seconds
( ) 2 able to lift leg independently and hold = or > 3 seconds
( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently
( ) 0 unable to try or needs assist to prevent fall
( ) TOTAL SCORE (Maximum=56)