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Berg Balance Scale

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Introduction

The Berg Balance Scale (BBS) is the best-known clinical measure of balance in adults.[1] Berg and colleagues first described the scale in 1989 to measure balance in older adults.[2] It consists of a list of 14 predetermined tasks, resembling real-life daily activities.[2] Each item uses an ordinal scale from 0 to 4, so the total score ranges from 0 to 56.[2] With 0 indicating the lowest level of function and 4 the highest level of function.[2] The BBS is a balance tool used to assess balance performance during functional activities, with high-quality evidence for both validity and reliability in older people.[3]

Purpose

The Scale serves to measure static and dynamic balance in every day functional activites.[1][2] Balance deficits restrict functional independence and elevate the risk of fall-related incidents.[2] Consequently, once a patient's balance abilities have been objectively assessed, addressing balance impairments becomes an essential component of rehabilitation.[2]

Intended Population

The Berg Balance Scale (BBS) was originally designed for older adults; since then, research has investigated its use across several clinical populations.

  • Older adults: Berg and colleagues designed the scale for older people.[2] Researchers have studied it in community-dwelling adults aged 65 years or older in Taiwan.[4] They have also studied it in older adults living in residential care.[5]
  • People with stroke: The BBS is a common choice in stroke rehabilitation.[6] Even people in the acute phase of stroke, many of whom cannot sit or stand, can complete it.[1]
  • People with other neurological conditions: Studies support its use in people with Parkinson's disease, [7] and in people with spinal cord injury.[8] Trials have also used it as an outcome measure in people with cerebellar ataxia.[9]
  • Younger people with balance problems: The scale shows a ceiling effect in people younger than 75 years who have balance problems.[1] A ceiling effect means that many people achieve near-maximum scores. Clinicians should therefore choose the measure with care in this group.[1]

Method of Use

This part sets out the general instructions for the scale and lists its 14 items.

General Instructions

The assessor rates each of the 14 items on an ordinal scale from 0 to 4.[2] A score of 0 indicates the lowest level of function, and a score of 4 indicates the highest level.[2] The assessor adds the 14 item scores to obtain a total score out of 56.[2] The tasks start with static positions, later items reduce the base of support and then move on to dynamic activities.[2] The items resemble daily activities.[2] The authors of the original scale described it as easy to administer and to score.[2]

[10]

Required Equipment

  • A ruler
  • 2 standard chairs (one with arm rests, one without)
  • A footstool or step
  • 15 ft walkway
  • Stopwatch or wristwatch

The Scale

Name: __________________________________ Date: ___________________

Location: ________________________________ Rater: ___________________

Item Task Score
1 Sitting to standing 0 to 4
2 Sitting unsupported 0 to 4
3 Sitting unsupported 0 to 4
4 Standing to sitting 0 to 4
5 Transfers 0 to 4
6 Standing with eyes closed 0 to 4
7 Standing with feet together 0 to 4
8 Reaching forward with an outstretched arm 0 to 4
9 Retrieving an object from the floor 0 to 4
10 Turning to look behind 0 to 4
11 Turning through 360 degrees 0 to 4
12 Placing alternate feet on a step or stool 0 to 4
13 Standing with one foot in front (tandem stance) 0 to 4
14 Standing on one leg 0 to 4

Interpretation of the Scale

A higher total score indicates better balance, and a lower score indicates a higher risk of falls.[1][2]

Cut-off scores for the elderly were reported by Berg et al as follows:[2]

  • A score of 56 indicates functional balance.
  • A score of < 45 indicates individuals may be at greater risk of falling.
  • A score of ≤49 indicates a risk of falls in individuals with stroke.

The evidence for fixed fall-risk bands is limited. A systematic review of eight studies found fall-prediction cut-off scores between 45 and 51 points.[11] The same review judged the evidence for predicting falls with the BBS to be insufficient.[11] Clinicians are advised not to use the BBS alone to decide a person's risk of falling.[11] An umbrella review, reached a similar conclusion for gait, balance and mobility tests in general.[12]

The total score helps to estimate rehabilitation outcomes.[1] Scores at admission relate inversely to length of hospital stay and help to predict discharge decisions.[1] In people with stroke, scores also predicted discharge destination and later disability.[6]

Evidence

Reliability

Reliability describes how consistent a score is. Researchers express it with the intraclass correlation coefficient (ICC), which measures agreement between raters or repeated tests. Values close to 1.0 indicate strong consistency.

In the original study, the ICC was 0.98 for agreement between raters and 0.99 for agreement within the same rater.[2] In 268 community-dwelling older adults in Taiwan, the interrater ICC was 0.87.[4]

A more recent review of 156 studies reported ICC values of 0.83 to 0.97 for the BBS after stroke.[13] A review of diagnostic tests found excellent interrater and intrarater reliability and high internal consistency in people with spinal cord injury.[14]

Validity

Content Validity

Content validity describes whether items cover the relevant areas of the concept.

  • The developers of the scale drew the items for the scale from the views of 38 older adults and 32 health care professionals who were experts working in geriatric settings.[2]
  • The tasks represent everyday activites and progress from static positions, to dynamic activities, which covers a range of balance demands.[1][2]

Criterion Validity

Criterion validity describes how closely a score agrees with an established measure.

  • In community-dwelling older adults, BBS scores showed moderate correlations with the Timed Up and Go (TUG) test.[4]
  • In people with stroke, scores correlated strongly with other measures of function and mobility.[6]

Construct Validity

Construct validity describes whether a score reflects the concept that it intends to measure, which here is balance.

  • A review reported good construct validity in people with spinal cord injury,[8] and a second review described the BBS as valid and reliable in this group.[15]
  • The BBS is one of six measures with strong psychometric properties in people with Parkinson's disease.[7]

Limitations

  • The scale does not measure the quality or speed of gait.[1]
  • The scale does not predict falls reliably when used alone.[6][11][12]
  • In people with spinal cord injury, the Mini-BESTest is the more comprehensive measure, and no single measure combined high clinical utility, strong psychometric properties and comprehensiveness.[15]

Practical Applications for Clinicians

  1. Select the appropraite measure. Use the BBS to assess balance in adults, including people with stroke, Parkinson's disease and spinal cord injury.[1][7][8][15] Consider a more comprehensive measure, such as the Mini-BESTest, for people with spinal cord injury.[15]
  2. Do not rely on the BBS alone for fall risk prediction. Combine it with other balance measures and with gait speed.[6][11][12]
  3. Plan treatment. Evidence supports task-oriented training, exercise programmes and virtual reality training as ways to improve balance.[9][5][16][17]

Links

References

  1. ↑ 1.00 1.01 1.02 1.03 1.04 1.05 1.06 1.07 1.08 1.09 1.10 Joa KL. Outcome Measurement in Balance Problems: Berg Balance Scale. Ann Rehabil Med. 2024 Apr;48(2):103-104. Epub 2024 Apr 23.PMID: 38649325; PMCID: PMC11058368.
  2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 2.11 2.12 2.13 2.14 2.15 2.16 2.17 2.18 Berg, K. (1989). Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada, 41, 304-311.
  3. ↑ Honvo G, Sabico S, Veronese N, Bruyère O, Rizzoli R, Amuthavalli Thiyagarajan J, Mikton C, Diaz T, Cooper C, Reginster JY. Measures of attributes of locomotor capacity in older people: a systematic literature review following the COSMIN methodology. Age Ageing. 2023 Oct 28;52(Suppl 4):iv44-iv66. doi: 10.1093/ageing/afad139. PMID: 37902521; PMCID: PMC10615073.
  4. ↑ 4.0 4.1 4.2 Wang CY, Hsieh CL, Olson SL, Wang CH, Sheu CF, Liang CC. Psychometric properties of the Berg Balance Scale in a community-dwelling elderly resident population in Taiwan. J Formos Med Assoc. 2006 Dec;105(12):992-1000. doi: 10.1016/S0929-6646(09)60283-7. PMID: 17185241.
  5. ↑ 5.0 5.1 Valenzuela PL, Saco-Ledo G, Morales JS, Gallardo-Gómez D, Morales-Palomo F, López-Ortiz S, Rivas-Baeza B, Castillo-García A, Jiménez-Pavón D, Santos-Lozano A, Del Pozo Cruz B, Lucia A. Effects of physical exercise on physical function in older adults in residential care: a systematic review and network meta-analysis of randomised controlled trials. Lancet Healthy Longev. 2023 Jun;4(6):e247-e256. Epub 2023 May 11. PMID: 37182530.
  6. ↑ 6.0 6.1 6.2 6.3 6.4 Blum L, Korner-Bitensky N. Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review. Phys Ther. 2008 May;88(5):559-66. Epub 2008 Feb 21. PMID: 18292215.
  7. ↑ 7.0 7.1 7.2 Winser SJ, Kannan P, Bello UM, Whitney SL. Measures of balance and falls risk prediction in people with Parkinson's disease: a systematic review of psychometric properties. Clin Rehabil. 2019 Dec;33(12):1949-1962. Epub 2019 Oct 1. PMID: 31571503; PMCID: PMC6826874.
  8. ↑ 8.0 8.1 8.2 Arsh A, Darain H, Ullah I, Shakil-Ur-Rehman S. Diagnostic tests to assess balance in patients with spinal cord injury: a systematic review of their validity and reliability. Asian Biomed (Res Rev News). 2021 Jun 30;15(3):111-118.PMID: 37551368; PMCID: PMC10388767.
  9. ↑ 9.0 9.1 Winser S, Chan HK, Chen WK, Hau CY, Leung SH, Leung YH, Bello UM. Effects of therapeutic exercise on disease severity, balance, and functional Independence among individuals with cerebellar ataxia: A systematic review with meta-analysis. Physiother Theory Pract. 2023 Jul 3;39(7):1355-1375. Epub 2022 Feb 25. PMID: 35212247.
  10. ↑ Kembe Frederick. 5253 Assessment Process Berg Balance Scale F.H.F. Available from: http://www.youtube.com/watch?v=i_Jlc5kL6KU[last accessed 08/02/13]
  11. ↑ 11.0 11.1 11.2 11.3 11.4 Lima CA, Ricci NA, Nogueira EC, Perracini MR. The Berg Balance Scale as a clinical screening tool to predict fall risk in older adults: a systematic review. Physiotherapy. 2018 Dec;104(4):383-394. Epub 2018 Feb 15. PMID: 29945726.
  12. ↑ 12.0 12.1 12.2 Beck Jepsen D, Robinson K, Ogliari G, Montero-Odasso M, Kamkar N, Ryg J, Freiberger E, Masud T. Predicting falls in older adults: an umbrella review of instruments assessing gait, balance, and functional mobility. BMC Geriatr. 2022 Jul 25;22(1):615.PMID: 35879666; PMCID: PMC9310405.
  13. ↑ Pise O, Kamble S, Ghorpade A. Assessment of multidimensional functional recovery post-stroke: a systematic review of outcome measures and their psychometric properties. BMC Neurol. 2026 Apr 24;26(1):376. PMID: 42032558; PMCID: PMC13248328.
  14. ↑ Arsh A, Darain H, Ullah I, Shakil-Ur-Rehman S. Diagnostic tests to assess balance in patients with spinal cord injury: a systematic review of their validity and reliability. Asian Biomed (Res Rev News). 2021;15(3):111.
  15. ↑ 15.0 15.1 15.2 15.3 Arora T, Oates A, Lynd K, Musselman KE. Current state of balance assessment during transferring, sitting, standing and walking activities for the spinal cord injured population: A systematic review. J Spinal Cord Med. 2020 Jan;43(1):10-23.Epub 2018 Jun 5. PMID: 29869951; PMCID: PMC7006707.
  16. ↑ Krohn M, Rintala A, Immonen J, Sjögren T. The Effectiveness of Therapeutic Exercise Interventions With Virtual Reality on Balance and Walking Among Persons With Chronic Stroke: Systematic Review, Meta-Analysis, and Meta-Regression of Randomized Controlled Trials. J Med Internet Res. 2024 Dec 2;26:e59136.PMID: 39621381; PMCID: PMC11650088.
  17. ↑ Kwon SH, Park JK, Koh YH. A systematic review and meta-analysis on the effect of virtual reality-based rehabilitation for people with Parkinson's disease. J Neuroeng Rehabil. 2023 Jul 20;20(1):94.PMID: 37475014; PMCID: PMC10360300.


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