Berg Balance Scale Flashcards
(7 cards)
Used to assess sitting and standing, static and dynamic balance
BBS consists of 14 functional balance items that focus on the ability to maintain a position and perform postural adjustments to complete functional movements
Each item is scored on a 5 point ordinal scale ranging from 0 to 4, w/ 0 indicating an intability to complete the task entirely and 4 indicating an ability to complete the task criterion
Items are scored relative to time, level of independence or supervision required. Points are deducted for requiring supervision, assistance and/or taking more than the allotted time to complete the task. The lowest category that applies should be marked
Supervision is required in the event of excessive sway or safety concerns
Item 1: Sitting to Standing
* Patient is seated in a free standing, standard height chair with arm rests (this seems to be the only one w/ arm rests)
* Instructions: Please stand up, try not to use your hands for support
Scoring:
4) Able to stand w/o using hands, stabilizes 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 max assist to stand
Item 2: Standing unsupported
* Pt is standing quietly with feet shoulder width apart on a solid surface
* Examiner has stopwatch in hand
* Instructions: plase stand for 2 minutes w/o holding on
Scoring: - if a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item 4
4) able to stand safely for 2 minutes
3) Able to stand 2 minutes w/ supervision
2) Able to stand 30 seconds unsupported
1) Needs several tries to stand 30 seconds unsupported
0) Unable to stand 30 seconds unsupported
Item 3: Sitting w/ back unsupported
* Pt is seated, back unsupported but feet supported on floor or a stool
* Examiner has stopwatch in hand
* Instructions: Please sit w/ arms folded for 2 minutes
* Scoring:
4) Able to sit safely and securely for 2 minutes
3) Able to sit 2 minutes udner supervision
2) Able to sit 30 seconds
1) Able to sit 10 seconds
0) Unable to sit w/o support 10 seconds
Item 4: Standing to sitting
* Patient is standing quietly in front of a chair with arm rests
* Instructions: Please sit down
* Scoring:
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 assitance to sit
Item 5: Transfers:
* Arrange two chairs at approximately 90 degrees for a pivor transfer. You may use tow chairs or a bed and a chair with arm rests
* Ensure that the pt will transfer both directions and that they will be transferring from one surace w/o arm rests and one surface w/ arm rests
* Instructions: Please transfer from this chair, with arm armrests, to that chair, without arm rests, and back again
Scoring:
4) able to transfer safely with minor use of hands
3) Able to transfer safely with definite need of hands
2) Able to transfer with verbal cueing and/or supervision
1) Needs one person assist
0) Needs two person assistance or supervision for safety
Item 6: Standing unsupported w/ eyes clsoed
* pt is standing quietly
* Examiner has stopwatch in hand
* Instructions: please close your eyes and stand still for 10 seconds
Scoring:
4) Able to stand 10 seconds safely
3) Able to stand 10 seconds w/ supervision
2) Unable to stand 3 seconds
1) Unable to keep eyes closed 3 seconds byt stays safely
0) Needs help to keep from falling
Item 7: Standing unsupported w/ feet togther
* Patient is standing quietly with feet together
* Examiner has stopwatch in hand
* instructions: Place your feet together and stand without holding on
Scoring:
4) Able to place feet together independently and stand 1 minute safely
3) able to place feet together independetly 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 able to stand 15 seconds feet together
0) Needs help to attain position and unable to hold 15 seconds
Item 8: reaching forward w/ outstretched arm while standing
* pt is standing queitly with both arms lifted to 90 degrees of shoulder flexion with fingers extended. If the pt has a shoulder impairment limiting the ability to lift arms symmetrically, use only the arm that can be lifted to 90 degrees easily and painlessly. Examiner is holding a ruler at the end of the fingertips. If the pt is unable to extend fingers, utilize the metacarapal phalangeal joint instead of the fingertips.
* Instructions: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can
* Fingers are not touching the ruler at any point during the test. Both arms are utilized by the pt to avoid trunk rotation during the forward reach. If one arm is utilized provide verbal curing to the pt to limit trunk rotation
* Examiner measures how far the pt can reach in the most forward lean position, w/o trunk rotation or losing balance
Scoring
4) Can reach forward confidently 25 cm (10 inches)
3) Can reach forward 12 cm safely (5 inches)
2) Can reach forward 5 cm safely (2 in)
1) reaches forward but needs supervision
9( loses balance while trying/requires external support
Item 9: Pick up object from the floor from a standing position
* A slipper or shoe is palced in front of the pt, close to the pts feet
* The pt should be able to bend and easily reach the slipper. This is not a test for forward reach or limits of stability
* Do not substitute with any object that is shorter or taller than a slipper toe box or shoe as this will make the subject bend lower or not as far as inteded for this this criteria
* Instructions: pick up the shoe/slipper which is placed in front of your feet
* Examiner pays attention to how close the pt is able to get to the object
* Examiner also ensures that the pt is not using the back of the legs against a bed or chair during the reach
Scoring:
4) Able to pick ip slipper safely and easily
3) Able to pick up slipper but needs superision
2) Unable to pick ip reaches 2-5 cm (1-2 inches) from slipper and keeps balance independently
1) Unable to pick ip and needs supervision while trying
0) Unable to try/needs assist to keep from losing balance or falling
Item 10: Turning to look behind over left and right shoulders
* patient is standing quietly
* Examiner is standing in front of the pt to accurately assess rotation and weight shift
* INstructions: Turn to look directly behind you over toward the left shoulder and repeat to the right
* Reaminer may pick an object to look at directly behind the subject to encourage a better twist turn
* Examiner asses the amount of trunk rotation
Scoring:
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
tem 11: Turn 360 degrees
Patient is standing quietly
Examiner has stopwatch in hand
Instructions: Turn completely around in a full circle. Pause. Then turn a full circle in the
other direction
Examiner times the time it takes to complete each full turn
Scoring:
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 cueing
0: needs assistance while turning
o Item 12: Placing alternate foot on step or stool while standing unsupported
Patient is standing quietly
Examiner places a 7¾ - 9 inch step stool in front of the patient, or the patient is able to
stand in front of a flight of steps3
Examiner stands close by to provide assistance if needed
Examiner has stopwatch in hand
Instructions: Place each foot alternately on the step/stool. Continue until each foot has
touched the step/stool four times
Examiner times how long it takes to complete task
Scoring:
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
Item 13: Standing unsupported one foot in front
Patient is standing quietly
Examiner has stopwatch in hand
Instructions: (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
Scoring:
4: able to place foot tandem independently and hold 30 seconds
3: able to place foot ahead of other independently and hold 30 seconds
§Foot must completely pass the other foot7
§Step width should be no wider than shoulders
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
o Item 14: Standing on one leg
Patient is standing quietly
Examiner has stopwatch in hand
Instructions: Stand on one leg as long as you can without holding on with your hands.
Do not let your lifted leg touch your standing leg.
Scoring:
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 leg unable to hold 3 seconds but remains standing independently
0: unable to try or needs assist to prevent fall
What does a cuttoff score </ 40 mean?
almost 100% fall risk
What does a cutoff score </50 mean?
increased fall risk
can you use assitive devices while doing the berg?
Nope
This is like the only one
