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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


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


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



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:


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


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


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


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


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


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


Yes

initially

but not at

follow-up

Exp initial: 37(12)

End: 43(11)

p 4wks: 42(11)


End: 38(13)

p 4 wks: 38(14)

Exp>Control

P<.001

Effect disappeared at 1 year

follow-up.

BERG BALANCE SCALE


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


yes Grp1 initial: 49(6)

Grp2 initial: 46(9)


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


Balance exercises with a computerized force

platform visual feedback training

Control group (n=7)

Yes Exp initial: 49(5)

End: 52(4), p=.001


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


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


High force eccentric training

Control (n=10):

Traditional weight training

yes

Exp initial: 50(1)

End: 53(.64), p<.05


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


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


at 8 weeks 41.4(10.65)

change -1.42(±0.23)

p<0.01

BERG BALANCE SCALE


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)


final score 54.50( 2.45)

change 7.25(4.35-10.15)


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

BERG BALANCE SCALE


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 3 months 55.3(1.5)



BBS 12 months 55.6(0.7)

Change 0/12 mos 3.9(4.0)





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)

BERG BALANCE SCALE


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


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


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


( ) 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)

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