Berg Balance Scale PDF
Berg Balance Scale PDF
Berg Balance Scale PDF
The Berg Balance Scale (BBS) was developed to measure balance among older people with
impairment in balance function by assessing the performance of functional tasks. It is a valid
instrument used for evaluation of the effectiveness of interventions and for quantitative
descriptions of function in clinical practice and research. The BBS has been evaluated in several
reliability studies. A recent study of the BBS, which was completed in Finland, indicates that a change
of eight (8) BBS points is required to reveal a genuine change in function between two assessments
among older people who are dependent in ADL and living in residential care facilities.
Description:
14-item scale designed to measure balance of the older adult in a clinical setting.
Equipment needed: Ruler, two standard chairs (one with arm rests, one without),
footstool or step, stopwatch or wristwatch, 15 ft walkway
Completion:
Time: 15-20 minutes
Scoring: A five-point scale, ranging from 0-4. 0 indicates the lowest level
of function and 4 the highest level of function. Total Score = 56
Sitting to standing 3
________
Standing unsupported ________
4
Sitting unsupported 4
________
Standing to sitting ________
3
Transfers ________
3
Standing with eyes closed ________
3
Standing with feet together ________
2
Reaching forward with outstretched arm ________
1
Retrieving object from floor ________
1
Turning to look behind ________
2
Turning 360 degrees ________
2
Placing alternate foot on stool ________
2
Standing with one foot in front ________
3
Standing on one foot ________
1
Total 34
________
GENERAL INSTRUCTIONS
Please document 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
the subjects performance warrants supervision
the subject touches an external support or receives assistance from the examiner
Subject 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 is 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.
Berg Balance Scale
SITTING TO STANDING
INSTRUCTIONS: Please stand up. Try not to use your hand 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 stabilize
( )0 needs moderate or maximal assist to stand
STANDING UNSUPPORTED
INSTRUCTIONS: Please stand for two minutes without holding on.
( )4 able to stand safely for 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 unsupported
If a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #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 assist to sit
TRANSFERS
INSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests and one way
toward a seat without armrests. You may use two chairs (one with and one without armrests) 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
TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING
INSTRUCTIONS: Turn to look directly behind you over toward the 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