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RehabMeasures Instrument

Berg Balance Scale

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Purpose

The Berg Balance Scale (BBS) is a 14-item objective measure that assesses static balance and fall risk in adults.

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Instrument Details

Acronym BBS

Area of Assessment

Balance – Non-vestibular
Functional Mobility

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

Cost of equipment only

CDE Status

NINDS CDE Notice of Copyright
Berg Balance Scale (BBS)
Availability
Please click here for more information on the Pediatric Modification of the Berg Balance Scale.
Classification
Supplemental – Highly Recommended: Spinal Cord Injury (SCI); not recommended for youth < 18y.
Supplemental: Cerebral Palsy (CP), Multiple Sclerosis (MS) and Stroke
Exploratory: Unruptured Cerebral Aneurysms and Subarachnoid Hemorrhage (SAH)

Diagnosis/Conditions

  • Arthritis + Joint Conditions
  • Brain Injury
  • Multiple Sclerosis
  • Parkinson's Disease + Neurologic Rehabilitation
  • Spinal Cord Injury
  • Stroke Recovery

Key Descriptions

  • Items include static and dynamic activities of varying difficulty
  • Item-level scores range from 0-4, determined by ability to perform the assessed activity
  • Item scores are then summed
  • Maximum score = 56

Number of Items

14

Equipment Required

  • Stopwatch
  • Standard height chair (18-20 inches) with armrests
  • Standard height chair (18-20 inches) without armrests
  • Step or stool of average height (7.75 - 9 inch step stool)
  • Ruler
  • Slipper or a shoe
  • Ruler

Time to Administer

15-20 minutes

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

65 +

years

Instrument Reviewers

Initially reviewed by Jason Raad, MS, and Jennifer Moore, PT, DHS, NCS, and the Rehabilitation Measures Team in 2010; Updated in 2011; Updated with references for the SCI population by Phyllis Palma, PT, DPT, Christopher Newman, PT, MPT, NCS, Jennifer Kahn, PT, DPT, NCS and the SCI EDGE task force of the Neurology section of the APTA in 2012; Updated with references from the TBI population by Katie Hays, PT, DPT and the TBI EDGE task force of the Neurology Section of the APTA in 2012; Updated with references from the stroke, vestibular, cerebral palsy, and arthritis populations by Abby Lutz, SPT, Tiffanie Kimura, SPT, and Urvika Patel, SPT in 10/2012. Updated with references for individuals with vestibular disorders by Linda B. Horn, PT, DScPT, MHS, NCS, Karen H. Lambert, PT, MPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA (2013).

Body Part

Lower Extremity

ICF Domain

Activity

Measurement Domain

Motor

Professional Association Recommendation

Clinical Practice Guideline: Strong, level I evidence supports the use of the Berg Balance Scale to assess changes in static and dynamic sitting and standing balance (Moore et al. 2018)

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

For detailed information about how recommendations were made, please visit: http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks

SCI EDGE

R

R

R

StrokEDGE

R

HR

HR

VEDGE

LS

LS

LS

Recommendations Based on Parkinson Disease Hoehn and Yahr stage:

 

I

II

III

IV

V

PD EDGE

NR

HR

HR

NR

NR

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

MS EDGE

HR

HR

HR

HR

HR

StrokEDGE

R

HR

HR

HR

HR

TBI EDGE

LS

R

LS

R

LS

Recommendations based on SCI AIS Classification:

 

AIS A/B

AIS C/D

SCI EDGE

LS

R

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly Dependent

Moderately Dependent

Severely Dependent

TBI EDGE

LS

LS

LS

NR

Recommendations based on EDSS Classification:

 

EDSS 0.0 – 3.5

EDSS 4.0 – 5.5

EDSS 6.0 – 7.5

EDSS 8.0 – 9.5

MS EDGE

HR

HR

HR

NR

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

LS

LS

LS

LS

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

MS EDGE

Yes

Yes

Yes

No

PD EDGE

No

No

Yes

Not reported

SCI EDGE

Yes

Yes

Yes

Not reported

StrokEDGE

Yes

Yes

Yes

Not reported

TBI EDGE

Yes

Yes

Yes

Not reported

VEDGE

Yes

Yes

Yes

Yes

Considerations

  • May be better suited for use with acute stroke patients because the majority of these patients are not able to obtain the measures maximum scores at rehab admission.

  • No common interpretation of BBS scores currently exists.

  • May take longer than other balance measures to administer.

  • Declines in performance with increasing age observed in both men and women.

  • In SCI patients, scores are not associated with the number of falls and not able to discriminate fallers from non-fallers (Wirz et al., 2010).

  • May have limited utility in middle-stage Parkinson's Disease (Hoehn & Yahr stages 2-3) due to ceiling effects (Leddy et al., 2011).

  • Parkinson's Disease patients in Hoehn & Yahr stages 4-5 would be unable to complete the test since an assistive device cannot be utilized during testing; for vestibular dysfunction, the BBS may not be the best measure to identify individuals at risk for falling (Whitney et al., 2003).

  • Translations available:
    • Chinese (traditional): http://www.pt.ntu.edu.tw/mhh/course/neuro/BS/Basic%20assessment/2004%E4%BC%AF%E6%A0%BC%
    • Danish: http://fysio.dk/fafo/Maleredskaber/Maleredskaber-alfabetisk/Bergs-balanceskala/
    • French: http://www.csssvc.qc.ca/telechargement.php?id=559
    • German: http://www.patientensicherheit.ch/dms/de/themen/3121_sturz_berg_balance_scale_d/Berg%20Balance
    • Japanese: http://www.shiraume.or.jp/research/2013/01/10/121228 研究論文 大人見 リハ科 BBS%20HP原
    • Spanish (pp. 48-51): http://www.huntingtonargentina.com.ar/informacion_util/Guiafisioterapeutas.pdf
    • Finnish Version: http://www.thl.fi/toimia/tietokanta/mittariversio/51/

Brain Injury

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Standard Error of Measurement (SEM)

Traumatic Brain Injury (TBI): (Newstead et al., 2005; = 5; mean age = 24.4 (5.3) years; time post-injury ranged from 4-218 months, Rancho Los Amigo Scale > 6)
 

  • Calculated from statistics in paper, SEM = 1.65

Test/Retest Reliability

TBI: (Newstead et al., 2005)
 

  • Excellent test-retest reliability (ICC = 0.99)

Older Adults and Geriatric Care

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Standard Error of Measurement (SEM)

Older Adults: (Donoghue et al., 2009; = 118 people over 65 years of age without a history of stroke; mean age = 85 (6.6) years)

BBS Initial Score

SEM

0 - 24

1.7

25 - 34

2.3

35 - 44

1.8

45 - 56

1.2

 

Older Adults Living in Nursing Homes: (Viveiro et al., 2019, n=49; mean age = 77.8 (7.2) years)

  • SEM for entire group (n = 49): 3.8

Minimal Detectable Change (MDC)

Older Adults: (Donoghue et al., 2009)

BBS Initial Score

MDC

0 - 24

4.6

25 - 34

6.3

35 - 44

4.9

45 - 56

3.3

Institutionalized Older Adults: (Conradsson et al., 2007; n = 45 institutionalized older adults from 3 residential care facilities; mean age = 82.3 (6.6) years; mean Mini-Mental Status Exam scores = 17.5 (6.3) points)

  • MDC = 8 points

Older Adults Living in Nursing Homes: (Viveiro et al., 2019)

  • MDC for entire group (n = 49): 10.5

Cut-Off Scores

Older Adults: (Berg et al., 1992; = 70 acute stroke patients; mean age = 71.6 (10.1) years; n = 113 individuals from a home for the elderly; mean age = 83.5 (5.3) years; n = 31 elderly individuals who agreed to participate in a laboratory study; mean age = 83.0 (6.9) years)

  • Score of 56 indicates functional balance

  • Score of < 45 indicates individuals may be at greater risk of falling

Older Adults: (Shumway-Cook et al., 1997, n = 44; mean age = 74.6 (5.4) years for non-fallers, 77.6 (7.8) for fallers)

  • History of falls and BBS < 51 or no history of falls and BBS < 42 predictive of falls (91% sensitivity, 82% specificity)

  • Score of < 40 on BBS associated with almost 100% fall risk

Older Adults Living in Nursing Homes: (Viveiro et al., 2019)

  • <47 indicates a patient is at risk for falls (Sensitivity 94.4%; Specificity 54.8%)

Normative Data

Community-Dwelling Elderly People:

(Steffen et al, 2002; = 96 community-dwelling elderly people; mean age = 73 (8) years; participants had a mean of 1.8 (1.2) medical diagnoses including high blood pressure (= 35), arthritis (= 34), low back pain (n= 29), cancer and heart disease (= 14), thyroid disease (= 10) and diabetes (= 9); Community-Dwelling Elderly People)

Berg Balance Score for Community-Dwelling Adults:

Age

Gender

N

Mean

SD

95% CI

60-69

Male

15

55

1

55-56

 

Female

22

55

2

54-56

70-79

Male

14

54

3

52-56

 

Female

22

53

4

52-55

80-89

Male

8

53

2

51-54

 

Female

15

50

3

49-52

Institutionalized Older Adults:

(Conradsson et al, 2007; Institutionalized Older Adults)

  • Mean score = 30.1 (15.9) points

Older Adults Living in Nursing Homes: (Viviero et al., 2019)

  • balance scores of participants; Brazilan sample

 

Characteristics

Total (n=49)

Nonfallers (n=30)

Fallers (n=18)

P

Age, Mean (SD), Y

77.8 (7.2)

77.7 (7.9)

78.0 (6.0)

.89a

Sex, n (%)

 

 

 

 

Female

30 (61.2)

18 (58.1)

12 (66.7)

.55b

Male

19 (38.8)

13 (41.9)

6 (33.3)

 

BMI, mean (SD) kg/m

26.4 (5.9)

26.4 (6.4)

26.2 (5.2)

.98a

Schooling, mean (SD)

4.8 (3.9)

4.8 (4.0)

4.7 (3.7)

.88a

Medications, mean

8.4 (3.6)

8.6 (3.7)

8.0 (3.5)

.59a

Comorbidties, mean (SD)

6.7 (2.9)

6.6 (2.8)

7.1 (3.1)

.49a

Frailty phenotype, n

 

 

 

 

Frail

17 (34.7)

6 (19.3)

12 (66.7)

.01b

Prefrail

14 (28.6)

12 (38.7)

5 (27.8)

 

Frailty risk

9 (18.4)

7 (22.7)

1 (5.6)

 

Non-frail

6 (12.2)

6 (19.3)

0 (0)

 

Institutionalization, mean (SD) y

6.3 (5.5)

6.5 (5.6)

5.9 (5.5)

.70a

Cognition - MMSE (total score), mean SD

22.4 (4.8)

23.4 (5.1)

20.8 (3.9)

.06a

Walking aids, n

 

 

 

 

None

30 (61.2)

22 (71)

8 (44.4)

 

Walker

11 (22.5)

6 (19.3)

5 (27.8)

 

Candian crutch

2 (4.1)

1 (3.2)

1 (5.6)

 

Simple cane

6 (12.2)

2 (6.5)

4 (22.2)

 

Falls, n

0.8 (1.6)

0 (0)

2.2 (1.9)

<.001a

BBS (total score), mean (SD)

40.4 (11.3)

43.9 (10.8)

34.3 (9.5)

.003a

Test/Retest Reliability

Institutionalized Older Adults: (Holbein-Jenny et al., 2005; = 26; mean age = 85.3 (4.9) years; inclusion criteria = able to stand without an assistive device; mean BBS score = 41.3 (9) points; mean ABC = 54.0 (24.9))

  • Excellent test-retest reliability (ICC = 0.77)

Older Adults Living in Nursing Homes: (Viveiro et al., 2019)

  • Excellent test-retest reliability: (ICC = .886)

Interrater/Intrarater Reliability

Community-Dwelling Older Adults: (Berg, Maki et al., 1992)

  • Excellent intrarater reliability (ICC = 0.98)
  • Excellent interrater reliability (ICC = 0.98) 

Institutionalized Older Adults: (Conradsson et al., 2007)

  • Excellent intrarater reliability (ICC = 0.97)

Institutionalized Older Adults: (Holbein-Jenny et al., 2005)

  • Excellent Interrater reliability (ICC = 0.88)

Older Adults Living in Nursing Homes: (Viveiro et al, 2019)

  • Excellent interrater reliability: (ICC = .993)

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Older Adults: (Shumway-Cook et al., 1997)

  • Excellent correlation with Dynamic Gait Index (= .67)

Older Adults: (Bogle et al., 1996; n = 66; mean age = 79.2 (6.2) years; irrespective of age, gender or disability)*

  • High specificity (96%) for predicting non-fallers

  • Low sensitivity (53%) in positive prediction of falls

*In a 1996 PT Journal Letter to the Editor, Raymond Tsang challenged the results of this study. Instead, he suggested the sensitivity and specificity should actually be 82% and 85%, respectively. (Tsang, Raymond; PT Journal; Volume 76, Number 10, October 1996)

Older Adults Living in a Nursing Home: (Viveiro et al, 2019)

  • Excellent predictive validity of the BBS to identify fall status (AUC = 0.762)

Construct Validity

Convergent validity:

Older Adults Living in a Nursing Home: (Viveiro et al, 2019)

  • Excellent correlation of the BBS compared to the Balance Evaluation Systems Test, Mini- BEStest, and brief Brief BESTest (individuals with fall risk = 0.679-0.957;
  • Poor correlation of the BBS compared to individuals with no fall risk = 0.135-0.143)

Osteoarthritis

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Normative Data

Osteoarthritis: (Jogi et al., 2010; n = 54 patients, 26 with total hip arthroplasty (THA) and 28 with total knee arthroplasty (TKA); mean age for THA = 68 (8) years; mean age for TKA = 64 (10) years)

  • Mean BBS score 1 week post-operative = 34 (8) points

  • Mean BBS score 5-7 weeks post-operative = 50 (6) points

Construct Validity

Osteoarthritis: (Jogi et al., 2010)

  • Correlation Coefficients between original and reduced versions of the BBS:

    • 1 week post-operative: r = 0.92 (0.86, 0.95)

    • 5-7 weeks post-operative: r = 0.97 (0.95, 0.98)

Parkinson's Disease

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Minimal Detectable Change (MDC)

Parkinsonism: (Steffen and Seney, 2008; n = 37; mean age = 71 years; mean Hoehn & Yahr classification = 2, scores ranged from 1-4)

  • MDC = 5 points

Cut-Off Scores

Parkinson’s Disease and Fall Risk: (Schlenstedt et al., 2016; n=66; nonfallers n=33; fallers n=33; nonfallers mean age= 66.0 (11.6); fallers mean age= 68.1 (7.5); diagnosed with idiopathic PD)

  • ≤52/56 (sensitivity=0.64, specificity=0.7067)
    • BBS cut-off score to assess fall rates prospectively

Normative Data

Parkinsonism: (Steffen and Seney, 2008)

  • Mean BBS score = 50 (7); range = 47-52

Parkinson’s Disease: (Qutubuddin et al., 2005; = 38; mean age = 71.1 (10.5) years; standing or walking unassisted and have mild to moderate disability)

  • Mean BBS score = 40.22 (8.48); range = 21-53

Community-dwelling individuals with Parkinson's Disease: (Brusse et al., 2005; n = 15; n = 11 female, n = 4 male; age range = 76 (7) years)

  • Mean BBS score: 46 (7) points; range = 43–49.

Parkinson’s Disease and Fall Risk: (Schlenstedt et al., 2016)

Parkinson Disease Nonfallers Mean BBS= 52.0
Parkinson Disease Fallers Mean BBS= 47.6

Participant Characteristics

Characteristic

Nonfallersb (n=33)

Fallersc (n=33)

P

Age (y)

66.0 (11.6)

68.1 (7.5)

.63

      Median (range)

67 (40-82)

69 (51-82)

N/A

Sex(female), n(%)

8 (24)

13 (39)

N/A

Fall historyd

7 (21)

23 (70)

N/A

BMI (kg/m2)

25.5 (3.8)

26.8 (5.0)

.48

Disease duration (y)

6.9 (5.2)

9.3 (6.5)

.15

       Median (range)

5 (1-18)

7 (1-23)

N/A

H&Y Stage

 

 

 

1-4

2.5 (0.8)

2.8 (0.7)

.17

1

3

1

N/A

1.5

1

0

N/A

2

7

3

N/A

2.5

9

14

N/A

3

9

9

N/A

4

4

6

N/A

UPDRS

 

    Total Score

40.2 (17.3)

44.0 (16.0)

.37

    Part II

11.4 (6.1)

14.5 (7.6)

.03*

    Part III

23.9 (12.0)

23.3 (9.7)

.89

PIGD score

3.8 (3.0)

4.4 (3.2)

.50

FAB scale

27.8 (8.8)

21.8 (9.7)

.01*

Mini-BESTest

21.2 (5.0)

17.1 (7.2)

.04*

BBS

52.0 (5.8)

47.6 (8.7)

.001*

a Values are mean (SD) or as otherwise indicated. BMI=body mass index, H&Y= Hoehn and Yahr, UPDRS= United Parkinson’s Disease Rating Scale, PIGD= postural instability and gait disorder, FAB= Fullerton Advanced Balance, Mini-BESTest= Mini-Balance Evaluation Systems Test, BBS= Berg Balance Scale, N/A= not applicable. *P<0.5.

b Patients without any fall during prospective 6-month follow-up assessment.

c Patients with one or more falls during prospective 6-month follow-up assessment.

d Number of patients (%) with one or more falls during the previous 6 months; P value of independent-samples Mann-Whitney U test.

Test/Retest Reliability

Parkinsonism: (Steffen & Seney, 2008)

  • Excellent test-retest reliability (ICC = 0.94)

Community-dwelling Individuals with Idiopathic Parkinson's Disease: (Leddy et al., 2011; = 80; mean age = 68.2 (9.3) years; mean disease duration = 8.5 (0.54) years; mean H & Y stage = 2.45 (0.64); test-retest sample, n = 24)

  • Excellent test-retest reliability (ICC = 0.80)

Interrater/Intrarater Reliability

Parkinson's Disease: (Leddy et al., 2011; interrater sample, n = 15)

  • Excellent interrater reliability (ICC = 0.95)

Parkinson's Disease: (Scalzo et al., 2009; = 53; mean age = 62 (7.9) years; UPDRS scores = 41.6 (17.8) points; BBS mean score = 47.2 (8.2) points; median Hoehn and Yahr Staging Scale = 2.5; Brazilian sample)

  • Excellent interrater reliability (ICC = 0.84)

Internal Consistency

Parkinsonism: (Steffen & Seney, 2008)

  • Excellent Internal consistency (Cronbach's alpha, day 1 = 0.86; day 2 = 0.87)

Ambulatory Patients with Parkinson’s Disease: (Franchignoni et al., 2005; = 70; mean age = 71 (range = 41-81) years; mean duration of disease = 7 (1-21) years; Mean H & Y score = 3 (1.5 - 4); mean Berg scores = 46.5 (34-54) points; mean TUG scores = 13.5 (9-27) points)

  • Excellent internal consistency (Cronbach's alpha = 0.95)

Parkinson's Disease: (Scalzo et al., 2009)

  • Excellent internal consistency (Cronbrach’s alpha = 0.92)

Criterion Validity (Predictive/Concurrent)

Predictive Validity:

Parkinson's Disease: (Brusse et al., 2005; n = 25; mean age = 76 (7) years)

 

UPDRS total

FFR

BFR

TUG

Comfortable gait speed

Fast gait speed

BBS

Excellent

-0.64

Excellent

0.50

Excellent

0.51

Excellent

-0.78

Excellent

0.73

Excellent

0.64

BBS = Berg Balance Scale

FFR = Forward Functional Reach

BFR = Backward Functional Reach

TUG = Timed Up and Go

p < 0.05

 

Predictive Validity:

Parkinson’s Disease and Fall Risk: (Schlenstedt et al., 2016)

ROC-AUC (95% CI)

  • Poor AUC (0.69 (0.56, 0.82))

Sensitivity (95% CI)

  • 0.64 (0.47, 0.78)

Specificity (95% CI)

  • 0.67 (0.50, 0.80)

LR+ (95% CI)

  • 1.91 (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

Floor/Ceiling Effects

Parkinson Disease: (Leddy et al., 2011)

  • Poor ceiling effects in which 10% of those tested had perfect scores including 1 faller and 46% had scores in the top 10% of the test including 5 fallers; scores were significantly left skewed (Komogorov-Smirnov test, p = 0.035)

  • Hoehn and Yahr stage 4 are usually reliant on assistive devices and would likely exhibit floor effects

  • Hoehn and Yahr stage 5 cannot be tested

Spinal Injuries

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Cut-Off Scores

SCI within One Year of Assessment: (Wirz et al., 2010; = 42; mean age = 49.3 (11.5) years; ASIA A, n = 2; ASIA B, n = 2; ASIA C, n = 35; ASIA D, n = 3; Swiss sample)

  • No significant relationship between total falls and obtained BBS scores

  • No cutoff score effectively discriminated fallers

Normative Data

Individuals with ASIA D SCI walking 10m independently with or without Walking Assistive Devices: (Lemay & Nadeau, 2010; = 32; mean age = 47.9 (12.8); mean time post lesion = 77.2 (44.3) days)

  • Mean BBS score = 47.9 (10.7) points; range = 17-56

  • Mean BBS score for Paraplegia = 44.8 (13.0) points; range = 17-56

  • Mean BBS score for Tetraplegia = 50.7 (7.5) points; range = 31-56

Interrater/Intrarater Reliability

Chronic SCI: (Wirz et al., 2010)

  • Excellent interrater reliability (ICC = 0.95)

Internal Consistency

Chronic SCI: (Wirz et al., 2010)

  • Excellent for both single items (0.84-0.98, p < 0.001) and for the total score (ICC = 0.95, 95% confidence interval = 0.910-0.975)

Criterion Validity (Predictive/Concurrent)

SCI: (Ditunno et al., 2007; = 146; ASIA B, n = 36; ASIA C, n = 90; ASIA D, n = 20; mean age = 32 (range = 16 - 69); mean Berg score = 4.85 (range = 0-42)) 

Predictors of the Walking Index for Spinal Cord Injury at 12 Months:*

 

Baseline

3 months

6 months

Berg Balance Scale

0.47

0.84

0.89

Lower Extremity Motor Score

0.73

0.81

0.86

FIM Locomotor

0.30

0.79

0.85

FIM Total

0.12

0.63

0.69

Speed

 

0.71

0.81

Distance

 

0.77

0.80

FIM = Functional Independence Measure

*Spearman's rho

(Wirz et al, 2010; Chronic SCI)

 

SCIM

mobility

WISCI

Speed,

10MWT

FES-I

AIS Motor

Scores

BBS

Excellent: 0.89

Excellent: 0.82

Excellent: 0.93

Excellent:0.81

Excellent; 0.62

Spearman correlation coefficients, all p < 0.001

BBS = Berg Balance Scale

WISCI = Walking Index for Spinal Cord Injury

FES-I = Falls Efficacy Scale-International

AIS = ASIA Impairment Scale

SCIM = Spinal Cord Injury Independence Measure

 

Construct Validity

 Convergent Validity:

SCI: (Lemay & Nadeau, 2010)

Measure

2MWT

10MWT

TUG

BBS

0.781**

0.792**

-0.815**

2MWT

 

0.932 a**

-0.623 a**

10MWT

 

 

-0.646 a**

a = Pearson’s product moment correlation; other coefficients are Spearman’s r 

**Significant at p < 0.01

Convergent Validity Evidence:

Measure

SCI-FAI

SCI-FAI

assistive devices

SCI-FAI

mobility

BBS

0.747**

0.714**

0.740**

Spearman’s r

SCI-FAI – Spinal Cord Injury Functional Ambulation Inventory

**Significant at p < 0.01

 

Fallers and Non-fallers with Chronic SCI: (Wirz et al., 2010)

  • Poor ROC Area Under the Curve: (-0.48)

 

SCI: (Ditunno et al., 2007)

BBS

50FW-S

LFIM

FIM

WISCI

3mo

Excellent

0.81*

Excellent

0.89

Excellent

0.76

Excellent

0.91*

6mo

Excellent

0.86

Excellent

0.86

Excellent

0.72

Excellent

0.89*

12mo

Excellent

0.78

Excellent

0.86

Excellent

0.77

Excellent

0.92*

p < 0.001

BBS = Berg Balance Scale

50FW-S = 50 foot walking speed

LFIM = Locomotor Functional Independence Measure

FIM = Functional Independence Measure

WISCI = Walking Index for Spinal Cord Injury

Floor/Ceiling Effects

SCI: (Lemay & Nadeau, 2010)

  • Poor ceiling effects (37.5%)

Stroke

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Standard Error of Measurement (SEM)

Stroke:

(Stevensen, 2001; = 48 medically stable individuals over the age of 65 who were admitted to a stroke unit for rehabilitation following an acute stroke; mean age = 73.5 (7.0) years; mean time post CVA = 30.3 (23.3) days; Acute Stroke)

  • SEM for entire group (= 48) = 2.49
  • SEM for individuals who ambulate with assistance (= 16) = 2.93
  • SEM for individuals who ambulate with stand-by-assist (= 17) = 2.15
  • SEM for individuals who ambulate independently (= 15) = 2.26

(Liston and Brouwer, 1996; = 22 subjects with hemiparesis associated with unilateral stroke; mean age = 64.0 (8.5) years; 6 months to 17 years post-stroke; Chronic Stroke)

  • SEM = 1.79 points

(Hiengkaew et al, 2012; = 61; mean age = 63.5 (10) years; Chronic Stroke)

  • SEM = 1.68

(Flansbjer et al, 2012; = 50; mean age = 58 (6) years; Chronic Stroke)

  • SEM = 1.49

Chronic Stroke: (Alghadir et al., 2018; n=56; age = 58.6 (7.0) years; Mean Time Post CVA = 3 months)
●    SEM for entire group (n=56): 0.98

Minimal Detectable Change (MDC)

Stroke:

(Stevensen, 2001; during inpatient rehabilitation; Acute Stroke)

  • MDC for entire group (= 48): 6.9
  • MDC for individuals who ambulate with assistance (= 16): 8.1
  • MDC for individuals who ambulate with stand-by-assist (= 17): 6.0
  • MDC for individuals who ambulate independently (= 15): 6.3

(Liston and Brouwer, 1996; Chronic Stroke)

  • MDC = 2.5 points

(Hiengkaew et al, 2012; = 61; mean age = 63.5 (10) years; Chronic Stroke)

  • MDC = 4.66

(Flansbjer et al, 2012; = 50; mean age = 58 (6) years; Chronic Stroke)

  • MDC = 4.13

Chronic Stroke: (Alghadir et al,. 2018)

  • MDC for entire group (n=56): 2.7

Cut-Off Scores

Stroke:

(Doggan et al, 2011; = 51; mean age = 60.7 (12.5) years; Hemiparetic Stroke)

  • Cut-off score = 45 out of 56

Chronic Stroke: 

  • ≤44 indicates high risk of falling (Alghadir et al,. 2018)
  • ≤47.5 indicates slow walker status (Sensitivity 81% specificity 56%) (Madhavan et al, 2017)

Normative Data

Chronic Stroke: 

  • Mean (SD) Berg Balance Scale (BBS) score; 41.4 (10.9), range = 5 to 56 (Alghadir et al,. 2018)
  • Mean (SD) BBS score: 48.51 (4.84) (Madhavan, et al, 2017; n = 41; mean age = 59.4 (9.05) years; mean time post CVA = 5.68 (4.29); lower limb Fugl-Meyer Motor score between 20 and 30)

 

Test/Retest Reliability

Stroke:

(Liston and Brouwer, 1996; Chronic Stroke)

  • Excellent test-retest reliability (ICC = 0.98)

(Hiengkaew et al, 2012; = 61; mean age = 63.5 (10) years; Chronic Stroke)

  • Excellent test-retest reliability (ICC = 0.95)

(Flansbjer et al, 2012; = 50; mean age = 58 (6) years; Chronic Stroke)

  • Excellent test-retest reliability (ICC = 0.72)

Chronic Stroke:  (Alghadir et al., 2018)

  • Excellent test-retest reliability: (ICC = .99)

Interrater/Intrarater Reliability

Stroke:

(Mao et al, 2002; = 123 stroke patients, 32 with cerebral hemmorhage, 74 with cerebral infarction, and 17 others; sex = 66 males, 57 females; mean age = 69.3(11.2) years; Acute Stroke)

  • Excellent interrater reliability in individuals 14 days post (ICC = 0.95)

(Berg et al, 1995; = 113 elderly residents and 70 stroke patients; mean age = 84.4(5.0) years; Acute Stroke)

  • Excellent interrater and intrarater reliability in individuals 2,4,6 & 12 weeks post onset (ICC = 0.98; ICC = 0.97) (n = 18 residents and 6 stroke patients)

Chronic Stroke: (Alghadir et al., 2018)

  • Excellent interrater reliability: (ICC=0.97)
  • Excellent intra-rater reliability: (ICC=0.98)
     

Internal Consistency

Stroke:

(Berg et al, 1995; Acute Stroke)

  • Excellent internal consistency 2,4,6 & 12 weeks post onset (Cronbach's alphas > 0.97)

(Mao et al, 2002; Acute Stroke)

 

  • Excellent internal consistency 14, 30, 90, & 180 weeks post onset (Cronbach's alphas =  0.92-0.98)

(Chou et al, 2006; n = 226 individuals with acute stroke; mean age = 68.2 (10.1) for the development of the BBS shortform; mean age = 68.1 (11.3) for the testing of the BBS short form; Taiwanese sample; Acute Stroke)

  • Excellent internal consistency 14 days post onsent (Cronbach's alpha = 0.98)

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Stroke:

(Mao et al, 2002; = 123; mean age = 69.3 (11.2) years; Acute Stroke)

  • Excellent correlations with the balance subscale of the Fugl-Meyer at 14, 30, 90 and 180 days post stroke (= 0.90 to 0.92)
  • Excellent correlations with Postural Assessment Scale for Stroke patients (PASS) (= 0.92 to 0.95)

Predictive validity:

Stroke:

(Mao et al, 2002; Acute Stroke)

  • Excellent predictive validity of the BBS at 14, 30 and 90 days at predicting Motor Assessment Scale (MAS) scores at 180 days post stroke (= 0.82, 0.84, 0.91 respectively)

(Liston and Brouwer, 1996; Chronic Stroke) 

  • Excellent predictive validity of the BBS at 14 and 30 days to the Barthel Index at 90 days (= 0.76 and 0.81 respectively)

(Wang et al, 2004; = 226; mean age = 59.8 (11.9) years; Taiwanese sample; Acute Stroke)

  • Dynamic Balance Master test variables correlated with the Berg Scores as follows:
    • Excellent Correlation with: forward and backward (FB) 3sec (= -0.62), Limits of stability path sway (LOSP) (= -0.61)
    • Adequate Correlation with: eyes open (EO) sway (= -0.39), Target Sway (TAR) (= -0.45), Left to right (LR) 3sec(= -0.51*), Left to right 2sec (= 0.48*), Forward and backward 2sec (= -0.53*), Limits of stability movement time (LOSM) (= -0.55*)
    • Poor Correlation with: eyes closed sway (= -0.10)
  • Excellent correlation with 10-meter walk test self selected velocity (= 0.81)

Construct Validity

Stroke:

(Wee et al, 1999; = 128; mean age = 69.9 (11.6) years; retrospective study; Acute Stroke)

  • Excellent correlations between Admission BBS and Admission FIM (= 0.76)

(Berg et al, 1992; = 70 elderly participants; Acute Stroke)

  • Adequate to excellent correlation with global ratings of balance provided by a carer (= 0.47 to 0.61)
  • Adequate correlation with self-ratings of balance (= 0.39 to 0.41)
  • Adequate correlation with Timed Up and Go scores (= -0.48)
  • Excellent correlation with mobility items of the Barthel Index (= 0.67)

 (Mao et al, 2002; Acute Stroke)

  • Excellent convergent validity with Barthel Index at
    • 14 days after stroke (r= 0.89)
    • 30 days after stroke (r= 0.94)
    • 90 days after stroke (r= 0.90)
    • 180 days after stroke (r= 0.91)
  • Excellent predictive validity with Motor Assessment Scale (administered at 180 days):
    • 14 days after stroke (r= 0.82)
    • 30 days after stroke (r= 0.84)
    • 90 days after stroke (r= 0.91)

(Wang et al, 2004; Acute Stroke)

  • Excellent convergent validity with Barthel Index (= 0.85)

Convergent validity:

Chronic Stroke:

  • Excellent correlation between BBS and DGI (r = 0.75 and 0.77 for first and second reading, respectively) (Alghadir et al,. 2018)
  • Adequate correlation between BBS and TUG (r = -0.52 and -0.53 for first and second reading, respectively) (also from Alghadir et al,. 2018)

 

 

DGI vs BBS

TUG vs BBS

First Reading

0.75**

-0.52**

Second Reading

0.77**

-0.53**

 

**Significant at p<0.01

DGI = Dynamic Gait Index

BBS = Berg Balance Scale

TUG = Timed Up and Go Test

 

  • Excellent correlation between BBS and the Mini-BESTest (r = 0.720) (p ≤0.001) (Madhavan et al, 2017)
  • Poor correlation between BBS and 10-Minute Walk Test (10MWT) (r = 0.303) (p>0.05) (also Madhavan et al, 2017)

 

Discriminant Validity:

Chronic Stroke: (Madhavan et al, 2017)

  • Poor discriminative validity to classify participants into slow and fast walkers (AUC = 0.671 (0.08) (p = 0.06)

 

Content Validity

Chronic Stroke: (Alghadir et al., 2018)

  • Content validity of the BBS was determined by a senior physical therapist. The expert ranked items quantitatively on a scale from 0-4.

Floor/Ceiling Effects

Acute Stroke: (Mao et al., 2002)

  • Poor floor effects at 14 days post stroke (35%)

  • Patients who experience floor effects may be more accurately assessed with the Postural Assessment Scale for Stroke Patients (PASS)

Acute Stroke: (Chou et al., 2006)

  • Poor floor effects 14 days post stroke (23.9%)

Acute Stroke & Residual Gait Deficits: (Salbach et al., 2001; = 50; n = 31 men, n = 19 women; mean age = 68 (13) years)

  • Poor floor effects 38 days post stroke (26%)

Responsiveness

Acute Stroke: (Mao et al., 2002)

  • Moderate responsiveness at detecting changes < 90 days of stroke onset; greatest responsiveness between 14-30 days

Acute Stroke: (Chou et al., 2006)

  • Large responsiveness (Effect Size (ES) = 0.85)

Acute Stroke: (Wood-Dauphinee et al., 1996; = 70)

  • Moderate responsiveness from 2-6 weeks (ES = 0.66)
  • Moderate responsiveness from 6-12 weeks (ES = 0.25)
  • Large responsiveness from 2-12 weeks (ES = 0.97)

Chronic Stroke: (Alghadir et al., 2018)

  • The magnitude of responsiveness was recorded as large but stated as moderate overall responsiveness (SRM=0.81).

Indices of responsiveness

TUG

DGI

BBS

Baseline

20.1 (8.3)

14.9 (5.3)

41.4 (10.9)

Discharge

16.9 (7.9)

17.4 (4.8)

45.7 (8.6)

Mean Difference

3.11

2.52

4.34

Pooled Standard Deviation

8.18

5.02

9.85

Standard Deviation of paired differences

5.87

2.82

5.37

*Effect size (ES) using pooled SD (95% CI)

0.38 (-0.57 - -0.08)

0.50 (0.31 – 0.73)

0.44 (0.23 – 0.67)

Standardized response mean (SRM) (95% CI)

0.53 (-1.01 - -0.03)

0.89 (0.47 – 1.30)

0.81 (0.47 – 1.01)

 

*Cohen’s d

Vestibular Disorders

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Cut-Off Scores

Community-dwelling Veterans with Balance Deficits: (Kornetti et al., 2004; = 100; n = 99 males, n = 1 female; age range = 64-88 years)

  • Score of 45/56 indicates functional ability

  • 100% of subjects with a score > 45 succesfully completed alternating foot

  • 55% of subjects with a score > 45 succesfully completed standing on one leg

  • 76% of subjects with a score > 45 succesfully completed look behind

 

Criterion Validity (Predictive/Concurrent)

Predictive validity:

Vestibular Dysfunction: (Whitney et al., 2003; = 70; mean age = 64.9 (17.0) years)

  • Adequate correlation with Dynamic Gait Index (r = .71)

Responsiveness

Vestibular Dysfunction: (Cohen et al., 2008; n = 80 (n = 40 controls; n = 40 patients); mean age = 38.1 (12.9) years for controls and 57.4 (13.7) years for patients)

Using a cut-off score of 45 to identify balance impairments in individuals with vestibular dysfunction:

  • Sensitivity (95% CI): .75 (.58-.87)

  • Specificity (95% CI): .75 (.58-.87)

  •  Likelihood ratio: 3.00

  • Post-test probability: 0.75

Limb Loss and Amputation

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Normative Data

Transfemoral Amputees: (Azuma et al., 2019; n = 30; Mean Age = 54 (19); Mean Time Post Amputation = 10 months for initial hospitalization, 192 months for re-hospitalization, and 106 months for outpatient)

 

Use of Ambulatory Aids (n= 12)

No aids (n=18)

P Value

Age

70 ± 5  (62-78)

44 ± 18  (18-68)

< .001

BBS Score

41 ± 5  (43-49)

52 ± 3  (47-56)

< .001

TUG-t

23.1 ± 11.6  (10.6-49.3)

10.3 ± 4.2  (4.7-15.4)

< .0030

6MWT

285 ± 90  (142-421)

497 ± 108  (342-660)

< .0001

BBS = Berg Balance Scale

TUG-t = Timed Up and Go test

6MWT = 6-Minute Walk Test

Interrater/Intrarater Reliability

Lower Limb Amputees: (Major et al., 2013; n = 30; Mean age = 54 (12); Mean time since most recent major amputation = 21 (15) years; unilateral transtibial (n=13), unilateral transfemoral (n=14), or bilateral (n=3) lower-limb amputation of dysvascular (n=7), traumatic (n=14), infectious (n=6), or congenital (n=3) origin)

  • Excellent interrater reliability (ICC=.945)

Internal Consistency

Lower Limb Amputees: (Major et al., 2013)

  • Excellent Internal Consistency (𝛂=.827 and .826 for rater A and rater B, respectively)

Construct Validity

Convergent Validity:

Transfemoral Amputees: (Azuma et al., 2019)

  • Excellent correlation with Timed Up and Go test (r = -0.66)
  • Adequate correlation with use of ambulatory aids (r = -0.56)
  • Adequate correlation with 6-Minute Walk Test (r = 0.57)

 

r = age-corrected Spearman rank partial correlation coefficient

Lower Limb Amputees: (Major et al., 2013)

  • Excellent correlations with Activities-specific Balance Confidence (ABC) Scale, Frenchay Activities Index (FAI), 2-Minute Walk Test (2MWT), and L Test
  • Adequate correlation with Prosthesis Evaluation Questionnaire-Mobility Subscale (PEQ-MS)

 

Outcome Measure Correlated With the BBS

Spearman ρ

P

ABC Scale

.634

<.001

PEQ-MS

.584

.001

FAI

.607

<.001

2MWT

.675

<.001

L Test

−.802

<.001

*Significant comparisons

 

Floor/Ceiling Effects

Transfemoral Amputees: (Azuma et al., 2019)

  • Adequate ceiling effect (3.3%) However, no ceiling effect was stated to be observed due to not being able to reach a clear conclusiosn about the adaptation range of BBS

 

Lower Limb Amputees: (Major et al., 2013)

  • Adequate Ceiling effects (10% of the participants achieved the maximum score of 56)

 

Pulmonary Diseases

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Standard Error of Measurement (SEM)

Chronic Obstructive Pulmonary Disease: (Jácome, 2016; n= 46 mean age: 75.9 (7.1) years; clinically stable for 1 month prior to study)

  • The SEM for the entire group (n=46): 2.1

Minimal Detectable Change (MDC)

Chronic Obstructive Pulmonary Disease: (Jácome, 2016)

  • The MDC for the entire group (n=46):  5.9

Cut-Off Scores

Chronic Obstructive Pulmonary Disease: (Jácome, 2016)

  • < 52.5 indicates a risk for falls (Sensitivity 73%; Specificity 77%)

Normative Data

Characteristic

Total

Participants Without a History of Falls (n=23)

Participants Without a History of Falls (23)

P

Age (y)

75.9 (7.1)

74.6 (5.9)

77.2 (8)

.21

Sex

 

 

 

 

Male

24 (52.2%)

14 (60.9%)

10 (43.5%)

.38

Female

22 (47.8%)

9 (39.1%)

13 (56.5%)

 

BMI (kg/m2)

28.4 (4.7)

28.4 (4.8)

28.3 (4.8)

.91

mMRC, M (IQR)

2 (1-2)

2 (1-2)

2 (1-3)

.28

Exacerbations in the previous year

 

 

 

 

0

28 (60.9%)

16 (69.6%)

12 (52.2%)

.18

>1

18  (39.1%)

7 (30.4%)

11 (47.8%)

 

Comorbidities, M (IQR)

2 (1-3)

2 (0-3)

2 (1-3.75)

.40

FEv (% predicted)

69.4 (19.9)

68.8 (21)

70.1 (19.2)

.83

GOLD spirometric classification

 

 

 

 

Mild

13 (28.3%)

8 (34.8%)

5 (21.7%)

 

Moderate

21. 47%)

9 (39.1%)

12 (52.2%)

 

Severe-to-very-severe

12 (26.1%)

6 (26.1%)

6 (26.1%)

 

BBS

50.1 (5.5)

53.3 (4.3)

48.3 (5.4)

≤.001

Interrater/Intrarater Reliability

Chronic Obstructive Pulmonary Disease: (Jácome, 2016)

  • Excellent interrater reliability: (ICC = 0.94)
  • Adequate intrarater reliability: (ICC = .52)

Construct Validity

Convergent Validity

Chronic Obstructive Pulmonary Disease:(Jácome, 2016)

  • Excellent correlation with Activities-specific Balance Confidence (ABC) Scale: (r = .75)

Floor/Ceiling Effects

Chronic Obstructive Pulmonary Disease: (JacomeJácome, 2016)

  • Poor ceiling effect found for the score on the test (skewness=−1.31)

Responsiveness

Chronic Obstructive Pulmonary Disease: (Jácome, 2016)

  • Large Change (effect size = 1.02)

Intellectual Disability

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Test/Retest Reliability

Adults with a Learning Disability: (Sackley et al., 2005; n= 47; mean age= 43.1 (14.3) years; 23 males, 24 females; diagnoses including broad term of learning disability (n=27), cerebral palsy (n=7), microcephaly (n=1), autism (n=1), Down’s Syndrome (n=6), and variety of other named syndromes (n=5))

  • Excellent test-retest reliability (ICC= 0.98)
  • K=0.63-1.00
  • two items were an exception:
    • transfers K=0.58
    • turning in 360 degrees K=0.52

 

Test-retest reliability of the Berg Balance Scale (kappa scores and percentage agreement for each rater)

 

Rater #1 (n=36)

Rater #2 (n=36)

Item

Kappa

% agreement

Kappa

% agreement

1.Sitting to standing

0.78

86.8

0.83

89.5

2.Standing unsupported

0.70

85.0

0.70

85.0

3.Sitting unsupported

0.37

92.1

0.58

94.7

4.Standing to sitting

0.72

87.8

0.64

82.9

5.Transfers

0.58

75.0

0.88

92.5

6.Standing with eyes closed

0.71

83.3

0.75

86.1

7.Standing with feet together

0.66

78.4

0.76

81.6

8.Reaching forward with outstretched arm

0.63

73.0

0.70

78.4

9.Retrieving object from floor

1.00

100.0

1.00

100.0

10.Turning to look behind

0.65

73.7

0.76

81.6

11.Turning 360 degrees

0.52

64.9

0.56

67.6

12.Placing alternate foot on stool

0.70

78.4

0.74

81.1

13.Standing with one foot in front

0.64

73.0

0.67

75.7

14. Standing on one foot

0.63

76.3

0.71

81.6

Interrater/Intrarater Reliability

Adults with a Learning Disability: (Sackley et al., 2005)

  • Excellent interrater reliability (ICC= 0.99)
  • K= 0.74-1.00

Construct Validity

Convergent Validity:

Adults with a Learning Disability: (Sackley et al., 2005)

  • Excellent correlation between Barthel Activities of Daily Living Index (BI) and Berg Balance Scale (BBS) (r = 0.83 – 0.84)
  • Excellent correlation between Rivermead Mobility Index (RMI) and BBS (r = 0.88 – 0.93)

Alzheimer's Disease and Progressive Dementia

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Standard Error of Measurement (SEM)

Dementia: (Telenius et al., 2015; n= 33 (8 male and 25 female); Mean age= 82.7; Individuals residing in 4 different nursing homes, above the age of 55, having a mild to moderate degree of dementia according to the Dementia Rating Scale, able to stand up alone or with the help of one person, being able to walk 6 m with or without a walking aid).

●    SEM for entire group (n=33): 0.97

Minimal Detectable Change (MDC)

Dementia:  (Telenius et al., 2015), n=33; Mean age= 82.7
●    MDC for entire group (n = 33): 1.92
 

Normative Data

Dementia: (Telenius et al., 2015)

ICC of BBS
Test    Tester    Mean (SD)    Range    ICC    SEM    MDC    MDC%
BBS    Tester 1    38.0 (13.8)    0-51    0.995    0.97    1.92    7
BBS    Tester 2    38.0 (13.7)    0-51    0.995    0.97    1.92    7


Mean BBS score = 38 points
Excellent ICC reliability (.995)
 

Test/Retest Reliability

Dementia: (Telenius et al., 2015)

  • Excellent test-retest reliability  (ICC = .995)

Interrater/Intrarater Reliability

Dementia: (Telenius et al., 2015)

  • Excellent interrater reliability (between 0.83 and 1)

Internal Consistency

Dementia: (Telenius et al., 2015)

  • Excellent internal consistency (≥0.6 item-to-total correlation coefficients except for item 3).
  • Cronbach’s α coefficient of the BBS was 0.948. The item-to-total correlations were r>0.4 for all items except item 3.

Floor/Ceiling Effects

Dementia:  (Telenius et al., 2015)

  • Excellent ceiling effect- None of the participants scored the maximum amount of points on the BBS.
  • Excellent floor effect (only one participant scored 0 points)

Bibliography

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Au-Yeung, S., Ng, J., et al. (2003). "Does balance or motor impairment of limbs discriminate the ambulatory status of stroke survivors?" American Journal of Physical Medicine & Rehabilitation 82(4): 279. Find it on PubMed

Azuma, Y., Chin, T., & Miura, Y. (2019). The relationship between balance ability and walking ability using the Berg Balance Scale in people with transfemoral amputation. Prosthetics and Orthotics International, 43(4), 396–401. https://doi.org/10.1177/0309364619846364

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Brusse, Kevin J, Zimdars, Sandy, Zalewski, Kathryn R, & Steffen, Teresa M. (2005). Testing functional performance in people with Parkinson disease. Physical therapy, 85(2), 134-141.

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Conradsson, M., Lundin-Olsson, L., et al. (2007). "Berg balance scale: intrarater test-retest reliability among older people dependent in activities of daily living and living in residential care facilities." Physical Therapy 87(9): 1155-1163. Find it on PubMed

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