Continuing Education Activity

The Berg Balance Scale is a testing tool with high validity and reliability used to measure balance. Balance gives an individual the ability to achieve physical movement and further carry out the activities of daily living. Balance can be classified as either static or dynamic. It was first created to be used in elderly individuals; however, it has been used in other individuals, such as amputees and persons with neurological conditions as Parkinson disease and strokes. This scale has also been used to assess the risk of falls and predict the length of stay during inpatient rehabilitation.

Objectives:

• Describe the clinical uses of the Berg Balance Scale.
• Explain the meaning of the numerical results.
• Explain what individuals benefit from performing this test.
• Explain what balance is and how it can affect an individual.

Introduction

The Berg Balance Scale is a test used to assess functional balance. It was created by Katherine Berg in 1989 to evaluate balance ability in the elderly, with the initial target population having an average age of 73.[1][2] It evaluates both dynamic and static balance through 14 tasks regarding mobility. In the beginning, it was mostly used to assess stroke patients; however, this test has shown high validity and reliability in various patient populations, including neurological conditions such as Parkinson disease, multiple sclerosis, traumatic brain injury, and acquired conditions as lower extremity amputees.[3] 

The scale has been useful in predicting the risk of falls and outcomes and even assessing the length of stay at inpatient rehabilitation.[4] It is a short test that can be performed relatively quickly under different environments. 

Anatomy and Physiology

Balance gives an individual the ability to achieve physical movement and further carry out the activities of daily living.[2]  Balance can be classified as either static or dynamic. In static balance, the body's center of gravity is maintained within the base of support. In dynamic balance, the center of gravity is maintained within the base support while in movement.[3] As balance is a skill that involves multiple body systems, including the musculoskeletal, cognitive, and somatosensory, it can be affected secondary to multiple conditions such as neurological diseases.[2] 

Many factors can lead to impaired balance depending on the individual's condition. Limiting factors include muscle strength, motor coordination, poor cognition, and poor sensory organization, all of which may be affected in some way with a neurological condition.[3]

In individuals with lower limb amputation, their gait is significantly affected. Studies have shown that balance strongly correlates with the gait performance of amputees. Hence, the better balance, the better walking ability, and better quality of life.[5]

For individuals with Parkinson disease, their postural instability is a major disease characteristic that worsens balance and can further lead to decreased independence and physical ability.[6] 

Indications

Balance dysfunction is commonly seen in individuals above the age of 65. Individuals that have had a stroke greatly benefit from having their balance performance tested. 

This test is indicated in the elderly, in neurological conditions such as stroke, multiple sclerosis, traumatic brain injury, Parkinson disease, peripheral neuropathies, and other conditions that may affect gait, such as lower extremity amputees.[4]

The Berg Balance Scale has been shown to have both high intra-rater and inter-rater reliability. Intra-rater reliability is when the same person who is administering the test can achieve the same results. Inter-rater reliability is when the test can be performed by different persons and achieve the same results. 

A systematic review conducted by Downs evaluated the Berg Balance Scale for individuals with various neurological conditions, including acute stroke, recent stroke, multiple sclerosis, cognitively impaired patients, and Parkinson disease patients, in different settings such as acute inpatient rehabilitation, outpatient rehabilitation, outpatient clinic, and home visits. The intra-rater relative reliability was found to be 0.98, with a 95% conference interval (CI).[7]

Contraindications

This test does not measure gait speed or quality of gait.[8] There is also evidence of both floor and ceiling effects with the test results. This can lead to the inability to detect changes in balance.[7] Another limitation to this test is that it can slightly differ in the way it is performed by the person administering it, for example, when explaining the actual tasks to be done.[7]

Equipment

The test takes around 15 to 20 minutes to complete and needs a few inexpensive pieces of equipment. It requires a stopwatch, a ruler or a measuring tape, a chair, a step, and an object that can be picked up.[8][9] The test has been adapted in different languages, including Italian, Turkish, French, and others.[3][10] 

Personnel

The test can be administered by any individual in healthcare who has been trained. Nurses, physical therapists, occupational therapists, and physicians are able to perform the test with good reliability.[2]

Technique or Treatment

Little training is needed for administering this test. The scale can be downloaded or filled out online. It involves 14 mobility tasks, with the tasks varying in degrees of difficulty. The tasks are divided into 3 domains: sitting balance, standing balance, and dynamic balance. In the sitting balance, the task is the evaluation of sitting unsupported. Standing balance consist of standing unsupported, standing with eyes closed, standing with feet together, standing on one foot, turning to look behind, grabbing an object from the floor, reaching forward with outstretched arms, and placing one foot in front of the other.  In the last domain, the dynamic balance is evaluated with the individual going from sitting to standing, standing to sitting, transferring, turning 360 degrees, placing one foot on a step.[1][2][11]

Each task is graded on a 5-point ordinal scale that ranges from 0 to 4 for a maximum score of 56. In general, a score of 0 is given when the individual is unable to perform the task, and a score of 4 is given when able to complete the given task independently. Other factors that affect the points given are the time it takes to complete the task, the time a position can be maintained, and the amount of supervision or assistance required. The more time or supervision required or the need to use assistive devices affects the points given.[12] 

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

Complete Detailed Scale:[13][14][12]

Sitting Balance

Task 1: Sitting Unsupported

___ 4   able to sit safely and securely for 2 minutes

___ 3   able to sit 2 minutes under supervision

___ 2   able to able to sit 30 seconds

___ 1   able to sit 10 seconds

___ 0   unable to sit  without support 10 seconds

Standing Balance

Task 2: Standing Unsupported

___ 4   able to sit safely and securely for 2 minutes

___ 3   able to sit 2 minutes under supervision

___ 2   able to able to sit 30 seconds

___ 1   able to sit 10 seconds

___ 0   unable to sit  without support 10 seconds

Task 3: Standing with eyes closed

___ 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 stands safely

___ 0   needs help to keep from falling

Task 4: Standing with feet together

___ 4   able to place feet together independently and stand 1 minute safely

___ 3   able to place feet together independently and stand 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 is able to stand 15 seconds feet together

___ 0   needs help to attain position and is unable to hold for 15 seconds

Task 5: Standing on one foot

___ 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 ≥ 3 seconds

___ 1   tries to lift a leg, unable to hold 3 seconds but remains standing independently.

___ 0   unable to try of needs assist to prevent fall

Task 6: Turning to look behind

___ 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 assistance to keep from losing balance or falling

Task 7:  Grab an object from the floor

___ 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 assistance to keep from losing balance or falling

Task 8: Reaching forward with outstretched arms while standing

___ 4   can reach forward confidently 10 inches

___ 3   can reach forward 5 inches

___ 2   can reach forward 2 inches

___ 1   reaches forward but needs supervision

___ 0   loses balance while trying/requires external support

Task 9: Placing one foot in front of the other

___ 4   able to place foot tandem independently and hold 30 seconds

___ 3   able to place foot ahead independently and hold 30 seconds

___ 2   able to take a small step independently and hold 30 seconds

___ 1   needs help to step but can hold 15 seconds

___ 0   loses balance while stepping or standing

Dynamic Balance

Task 10: Going from sitting to standing

___ 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 stabilize

___ 0   needs moderate or maximal assist to stand

Task 11: Going from standing to sitting

___ 4   sits safely with minimal use of hands

___ 3   controls descent by using hands

___ 2   uses the back of their legs against the chair to control their descent

___ 1   sits independently but has uncontrolled descent

___ 0   needs assistance to sit

Task 12: Transfer from a seat with an armrest to a seat without an armrest

___ 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 cueing and/or supervision

___ 1   needs one person to assist

___ 0   needs two people to assist or supervise to be safe

Task 13:  Turn 360 degrees

___ 4   able to turn 360 degrees safely in 4 seconds or less

___ 3   able to turn 360 degrees safely one side only 4 seconds or less

___ 2   able to turn 360 degrees safely but slowly

___ 1   needs close supervision or verbal cueing

___ 0   needs assistance while turning

Task 14: Place alternating foot on a step or stool while standing unsupported    

___ 4   able to stand independently and safely and complete 8 steps in 20 seconds

___ 3   able to stand independently and complete 8 steps in > 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

Clinical Significance

This scale can assist healthcare workers in determining outcomes. It can help assess the increased risk of falls and further help prevent complications such as fractures or infections that can commonly occur after falls, especially in the elderly.[2] It has been studied and validated as a tool to predict the length of stay during inpatient rehabilitation as well as help determine the type of rehabilitation center an individual can benefit from.[11]

Impaired balance leads to a decreased quality of life and inability or difficulty to carry out activities of daily living. It can also lead to an increased risk of falls.

The total score after performing the test determines the predicted risk of falls. Overall, total scores below 45 are associated with a higher risk of falls. An individual with a history of falls and a total score below 51 is highly predictive of falls. A score of less than 40 is associated almost with a 100% fall risk.[15]

Furthermore, the test can allow practitioners to assess the need for an assistive device for ambulation, such as a cane, walker, or wheelchair. A total score of 0-20 reflects mobility by wheelchair, 21 to 40 walking with assistance, and a score of 41 to 56 walking independently. [6] This can be helpful in both the outpatient and inpatient setting when evaluating an individual to determine the equipment needed and a complete treatment plan focused on what skills the individual will be able to accomplish. Individuals with lower scores will benefit from more training on wheelchairs and safe transfers.

As with neurological conditions, studies have supported using the Berg Balance Scale for lower extremity amputees. There is a high risk of falls in individuals with amputations, with studies showing more than 50% of amputees experiencing falls within the prior 12 months. The results of the Berg testing have been shown to be comparable to the ones when testing for neurological conditions affecting balance.  However, at times they may present with lower scores than expected as prosthetic devices, if present, can interfere with results, especially if there is no proper control of the prosthetic yet.[16]

It is important to consider an individual's risk of fall, as it has been shown that it can lead to lower scores on the scale.[16]

Enhancing Healthcare Team Outcomes

Balance is an ability we have to carry out motion and mobility throughout our daily activities effectively. It is composed of different factors, including but not limited to somatosensory, vestibular, and postural responses, among others. 

Neurological conditions such as stroke, traumatic brain injury, Parkinson disease, multiple sclerosis, and other studied populations as lower extremity amputees can lead to impaired balance, which can, in turn, lead to an increased risk of falls and a further decline in daily function and performance of ADLs.

Maintaining proper balance can further prevent falls, a common health issue with possible serious complications, especially in the elderly. 

The Berg Balance Scale is a test that can be performed during an inpatient rehabilitation stay as part of the goals and treatment plan for the individual affected. The goals set are then further assessed during interdisciplinary team rounds that can include the occupational therapist, physical therapist, nursing staff, social worker, and physiatrist to conjunctively come up with a plan and prepare the patient for discharge. The entire team is responsible for assessing the patients' needs as they spend the most time with the patient and can further predict what the patient will need after discharge. This is why the scale is useful, as durable medical equipment (DME) and family training can be done for a safe discharge. 

Furthermore, when performing this test, the nursing staff can monitor for any changes in vital signs during the testing if the patient is unable to tolerate and becomes hemodynamically unstable.

The multidisciplinary team, composed of the healthcare workers, also needs the ability to communicate with the family member and/or caregivers, that is aware of the risks of falls, and aware of expectations with test score results can further improve outcomes as even after discharge from inpatient rehabilitation the patient needs to continue treatment at home.