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Berg Balance Scale – Measuring tool for assessing patient balance

BBS

What is the Berg Balance Scale?

The Berg Balance Scale (BBS) is a measuring instrument used to assess a patient's balance. BBS is generally used to measure the balance level of the elderly population. BBS can also be used to assess the level of balance in patients with several conditions, such as stroke, spinal injuries, vestibular disorders, pulmonary disease, lower extremity amputation, brain injury, Alzheimer's and progressive dementia, intellectual disability, and Parkinson's.

The Berg Balance Scale (BBS) is a test used to assess functional balance. The BBS was created by Katherine Berg in 1989 to evaluate balance abilities in the elderly, with the initial target population having an average age of 73 years. BBS evaluates dynamic and static balance through 14 tests related to patient mobility. The Berg Balance Scale is useful in predicting a patient's risk of falling. BBS is a short test that can be performed relatively quickly under different environments. This test can be performed by nurses, physical therapists, occupational therapists, and doctors.

Indication

The Berg balance scale can be used in several conditions such as:

  • Stroke
  • Multiple sclerosis (MS)
  • Traumatic brain injury
  • Parkinson's disease
  • Peripheral neuropathy
  • Other conditions that can affect gait, such as lower extremity amputation.

Equipment required

It takes approximately 15-20 minutes to complete this test. There are several tools needed to carry out this test, such as:

  • Stopwatch
  • Ruler or measuring tape
  • Chair
  • Stairs
  • Objects that can be lifted

Measurement technique

The Berg Balance Scale consists of 14 mobility tests, with the tests varying in difficulty. The  BBS test is divided into 3 domains, namely sitting balance, standing balance and dynamic balance. In sitting balance, the test is to evaluate sitting without support. Standing balance consists of standing without support, standing with eyes closed, standing with feet together, standing on one foot, looking back, reaching for an object from the floor, reaching forward with arms outstretched, and placing one foot in front of the other. In the final domain, dynamic balance is evaluated with the individual shifting from sitting to standing, standing to sitting, transferring, turning 360 degrees, placing one foot on a step.

Each task is rated on a 5-point ordinal scale ranging from 0 to 4 with a maximum score of 56. In general, a score of 0 is given when the individual is unable to perform the task, and a score of 4 is given. when able to complete assigned tasks independently. Other factors that influence the points awarded are the time required to complete the task, the time the position can be maintained, and the amount of supervision or assistance required. The more time or supervision required or the need to use assistive devices affects the points awarded.

The 14 tasks each come with specific instructions on how to do them. For example, when testing unsupported standing with eyes closed, the instructions are “close your eyes and stand still for 10 seconds.” If the patient is able to stand for 10 seconds safely, a score of 4 is given, if he is able to stand for 10 seconds with supervision, a score of 3, able to stand for 3 seconds, a score of 2, unable to close his eyes for 3 seconds but still safe gives a score of 1, and a score of 0 given if the patient needs help to prevent falling.

Download the Berg Balance Scale instrument here:

Score Interpretation

  • A score of 56 indicates functional balance
  • A score < 45 indicates an individual has a high risk of falling

Reliability of the Berg Balance Scale

POPULATIONCRITERIAMARK
ElderlyTest-retest reliabilityICC = 0.77 (general elderly) ICC = 0.886 (elderly in nursing homes)
 Interater/Intrarater reliabilityCommunity Elderly ITA : ICC = 0.98ITE : ICC = 0.98 Institutional Elderly ITA : ICC = 0.97ITE : ICC = 0.88 Elderly in Nursing Homes ITE : ICC = 0.993   *ITA : intrarater reliability, ITE : interrater reliability
Brain TraumaTest-retest reliabilityICC = 0.99
ParkinsonTest-retest reliabilityICC = 0.94 (common Parkinson's) ICC = 0.80 (idiopathic Parkinson's in the community)
 Interater/Intrarater reliabilityITE : ICC = 0.84 – 0.95   *ITA : intrarater reliability, ITE : interrater reliability
 Internal consistencyCronbach Alpha : 0.86 – 0.95
Spinal InjuriesInterater/Intrarater reliabilityITE : ICC = 0.95   *ITA : intrarater reliability, ITE : interrater reliability
 Internal consistency0.84-0.98, p < 0.001) and for the total score (ICC = 0.95, 95% confident interval = 0.910-0.975)
StrokeTest-retest reliabilityICC = 0.72 – 0.99
 Interater/Intrarater reliabilityITE : ICC = 0.95 – 0.98 ITA : ICC = 0.97 – 0.98   *ITA : intrarater reliability, ITE : interrater reliability
 Internal consistencyCronbach alpha : 0.92 – 0.98
AmputationInterater/Intrarater reliabilityITE : ICC = 0.945   *ITA : intrarater reliability, ITE : interrater reliability
 Internal consistencyCronbach alpha : 0.26 – 0.27
Intellectual disorder (Adults with learning disabilities)Test-retest reliabilityICC = 0.98
 Interater/Intrarater reliabilityITE : ICC = 0.99   *ITA : intrarater reliability, ITE : interrater reliability
Alzheimer's and progressive dementiaTest-retest reliabilityICC = 0.995
 Interater/Intrarater reliabilityITE : ICC = 0.83 – 1   *ITA : intrarater reliability, ITE : interrater reliability
 Internal consistencyCronbach alpha : 0.948

Validitas Berg Balance Scale

POPULATIONCRITERIAMARK
ElderlyCriterion Validity (Predictive/ConcurentPredictive validity : r = 0.67 Specificity = 96% (prediction at low fall risk Sensitivity = 53 % (positive fall prediction results)   Predictive validity : AUC = 0.762 (Elderly in nursing homes)
 Construct ValidityExcellent correlation of the BBS compared with the Balance Evaluation Systems Test, Mini-BESTest, and Brief BESTest (individuals with fall risk, r = 0.679-0.957 Poor BBS correlation compared with individuals without fall risk, r = 0.135-0.143)
ParkinsonCriterion Validity (Predictive/ConcurentROC-AUC (95% CI) Poor AUC (0.69 (0.56, 0.82)) Sensitivity (95% CI) 0.64 (0.47, 0.78) Specificity (95% CI) .67 (0.50, 0.80) LR+ (95% CI) . 91 (1.11, 3.30) LR- (95% CI) 0.55 (0.33, 0.91) *AUC= area under the curve, CI= confidence interval, LR+= positive likelihood ratio, LR-= negative likelihood ratio
Spinal InjuriesCriterion Validity (Predictive/Concurent)Excellent correlation of BBS compared to WISCI = Walking Index for Spinal Cord Injury, FES-I = Falls Efficacy Scale-International, AIS = ASIA Impairment Scale, SCIM = Spinal Cord Injury Independence Measure, r = 0.62-0.93
 Construct ValidityExcellent correlation of BBS compared to 50FW-S = 50 foot walking speed, LFIM = Locomotor Functional Independence Measure, FIM = Functional Independence Measure, WISCI = Walking Index for Spinal Cord Injury, r = 0.72-0.92
StrokeCriterion Validity (Predictive/Concurent)Concurrent validity Very good correlation with the balance subscale of the Fugl-Meyer (r= 0.90 – 09.2) Very good correlation with the Postural Assessment Scale for Stroke patients (PASS) (r = 0.92 to 0.95) Predictive validity Very good correlation with the Motor Assessment Scale (MAS) scores at 180 days post stroke (r = 0.82, 0.84, 0.91) Very good correlation of BBs  with Bhartel Index (r = 0.76 and 0.81)
 Construct ValidityExcellent correlation between BBS and Mini-BESTest (r = 0.720)
Vestibular disordersCriterion Validity (Predictive/Concurent)Adequate correlation with Dynamic Gait Index (r = 0.71)
AmputationConstruct ValidityVery good correlation with Timed Up and Go test (r = -0.66) Adequate correlation with use of walking aids (r = -0.56) Adequate correlation with 6MWT (r = 0.57)  
Intellectual disorder (Adults with learning disabilities)Construct ValidityVery good correlation between Barthel Activities of Daily Living Index (BI) and Berg Balance Scale (BBS) (r = 0.83 – 0.84) Very good correlation between Rivermead Mobility Index (RMI) and BBS (r = 0.88 – 0, 93)  

Also read: Parkinson's: What is it and what is the role of physiotherapy

Reference :

  1. Miranda-Cantellops N, Tiu TK. Berg Balance Testing. [Updated 2023 Feb 17]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK574518/
  2. Shirley Ryan Ability Lab. diakses pada 13 Agustus 2023 pada https://www.sralab.org/rehabilitation-measures/berg-balance-scale

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