This presentation includes 11 balance assessment scales

1. Submitted to: Dr. Richa Rai
Submitted by: Aditi
Pre PhD Student
03/pre PhD DPSRU/2021
Balance Scales

2. Contents
 Activity Specific Balance Confidence Scale
 Balance Evaluation Scale
 Berg Balance Scale
 Performance Oriented Mobility Assessment
 Tinetti Fall Efficacy Scale
 Modified Fall Efficacy Scale
 Fullerton Advanced Balance Scale
 Balance Evaluation System Test
 Mini BEStest
 Brief BEStest
 Community Balance And Mobility Scale
 Dynamic Gait Index

3. What and Why ?

4. ACTIVITY SPECIFIC BALANCE
CONFIDENCE SCALE
 SELF REPORT TOOL used to gather information about
the patient’s confidence with performing various activities.
 16 items are included
 Percentages are added and divided by 16 to give an
overall confidence %
 0% = no confidence
 100% = completely confidence
 Instrument format:
 Questionnaire/ Survey
 Reliability/validity:
 Good

6.  Article: Measuring balance confidence after spinal cord injury: the reliability
and validity of the Activities-specific Balance Confidence Scale
 Authors: Garima Shah, Alison R. Oates, Tarun Arora, et al.
 Journal: the journal of spinal cord medicine
 Year: 2017
 Type of study: Prospective cross sectional study
 Sample size: 26 individuals with iSCI and 26 able bodied individuals
 Results: The ABC scale demonstrated high test-retest reliability (intra class
correlation coefficient = 0.93) among participants with iSCI. The minimal detectable
change was 14.87%. ABC scale scores correlated with performance on all clinical
measures (ρ=0.60-0.80, P<0.01), with the exception of proprioception and cutaneous
pressure sensitivity (P=0.20–0.70), demonstrating convergent validity. ABC scale
scores also correlated with overall COP velocity (ρ=-0.69, P<0.001) and COP
velocity in the anterior-posterior direction (ρ=-0.71, P<0.001). Participants with
iSCI scored significantly lower on the ABC scale than the AB participants
(P<0.001), and the area under the receiver operating characteristic curve was 0.95,
demonstrating discriminative validity.
 Conclusion: The ABC scale is a reliable and valid measure of balance confidence in
community dwelling, ambulatory individuals with chronic iSCI.

7. BALANCE EVALUATION SCALE
 BES is a self-report measure that examines how
confident an individual feels while performing 10
items of ADL and functional mobility.
 The ADL items on the test include both basic ADL
(getting dressed and undressed, taking a bath or
shower) and instrumental ADL (cleaning house,
preparing simple meals, simple shopping).
 The functional mobility items include getting in
and out of a car, going up and down stairs,
walking around the neighbourhood, reaching, and
hurrying to answer the phone.
 Individuals are asked to consider how confident
they feel in doing each of the activities listed
without falling.

8.  The individual is asked to rate his or her
confidence level on a 0 (not at all) to 10
(completely confident) scale.
 The highest score is 100 (completely
confident on all 10 items) and represents high
self efficacy whereas the bottom score of 0
represents low self-efficacy

9. BERG BALANCE SCALE
 It is a multi task test 14 balance task (6 static & 8 dynamic)
 Focused on:
 Maintenance of position
 Postural adjustment to voluntary movement
 Simple and easy to administer
 Patient should be able to stand
 Provide baseline and outcome data; score of 45 or below are
predictive falls in the elderly

10.  Reliability:
 inter = 0.98
 Intra = 0.99
 Scoring:
 5 point ordinal scale with specific task criteria
 Limitations:
 It has very high ceiling effect
 Lack of items requiring postural response to external stimuli
or uneven support surfaces
 The use of the BBS as an outcome measure is compromised
when participants score high on initial trials

13. Article: Characteristics that affect score reliability in the Berg Balance Scale: a
meta-analytic reliability generalization study
Authors: Ana-Belén MESEGUER-HENAREJOS , María RUBIO-A et. Al
Journal: European Journal of Physical and Rehabilitation Medicine
Year : 2019
Type of study: systematic review & meta-analytic study
Sample size: 65 studies
Result: Coefficient alpha ranged from 0.62 to .98, with a mean of 0.92. For
intra-rater agreement, the mean intra class correlation was ICC=0.957, and
for inter-rater agreement ICC+=0.97. The SD of the Berg Balance Scale
scores presented statistically significant relationships with the coefficient
alpha and with ICC (intra-rater).
Conclusion: The alpha coefficient and intra- and inter-rater agreement for Berg
Balance Scale scores was very satisfactory. Several characteristics of the
studies were statistically associated to the alpha coefficient and with intra-
rater reliability

14. PERFORMANCE ORIENTED
MOBILITY ASSESSMENT
 It is a multi level task : have 2 parts
 It is a test to measure balance and mobility skills in older adults and to
determine the likelihood for falls and mobility scale, which rates
performance on a three-point scale. The maximum score is 28 points.
 Focused on:
 Maintenance of position
 Postural response to perturbation
 Gait mobility
 Equipment needed:
 Chair, walk way, patient can use usual walking aid

15.  It takes 10-15 minutes to complete the assessment with good
reliability
 Scoring:
 Some items graded can/cannot perform; some 3 point scale with
specific criteria
 Simple and easy to administer
 Provide baseline data; predictive of fall in elderly
 >24 low risk
 19-24 moderate risk
 <18 high risk
 Reliability:
 Inter = .85
 Requirements:
 should be able to stand and walk independently

17.  Article: Predictive accuracy of performance oriented mobility assessment for fall in
older adults: A systematic review
 Authors: saifullah jahantabi-nejad , akram azad
 Journal: medical journal of Islamic republic of Iran
 Year: 2019
 Type of study: systematic review
 Sample size: 12
 Results: sensitivity and specificity of POMA ranged from 24-91 to 37-97, respectively.
 Conclusion: due to heterogeneity of the studies, it was not possible to determine a
specific cutoff point for POMA .

18. TINETTI FALL EFFICACY SCALE
 It measures level of confidence in doing each of the activities
without falling (0 = not at all, 10 = completely confident).
 Total score is sum of 10 individual scores (range: 0 [low self-
efficacy] to 100 [high self- efficacy]).
 Time to administer : 10-15 minutes
 Equipment Required:
 Pen
 Paper
 A total score greater than 70 indicates the fear of fall
 Reliability :
 Adequate Test- retest reliabilty is 0.71
 Internal consistency : excellent (Cronbach’s alpha 0.91)

19.  Excellent correlation(0.84) but adequate predictive validity
(0.55) with ABC scale
 Construct validity :
 Excellent correlation with balance (r=0.66)
 Poor correlation with age(r=0.23)
 Excellent correlation with gait(r=0.67)
 Excellent correlation with mobility (r=0.71)
 Adequate correlation with history of falling (r= 0.47)
 Adequate correlation with self- rated health status (r=0.36)
 Poor correlation with medical history (r= 0.18)

20. MODIFIED FALL EFFICACY
SCALE
 MFES is a 14 activity questionnaire that is an expanded
version of original 10 activity fall efficacy scale(FES)
 The MEFS includes outdoor activities, which the FES does
not cover
 Scoring: each item is scored on a 10 point visual analogue
scale.
 0= not confident/not sure at all
 5= fairly confident/fairly sure
 10= completely confident/ completely sure
 Scores can fall between 0,5 and10

21. Reliability and validity
 Cronbach’s alpha was used to demonstrate
internal consistency of the items on the
questionnaire and the result was 0.95.
 The lowest ICC was 0.54 for the individual items
and the overall ICC was .93
 In order to validate MFES, subjects from two
separate groups were scored. The sample
consisted of healthy elderly and other group
included patients from fall and balance clinic
(FBC).
 Significant differences were found between the
two groups using multivariate analysis of
variance(MANOVA) with post hoc univariate
ANOVA.

23. FULLERTON ADVANCED BALANCE
SCALE
 The FAB Scale is developed for higher-functioning older adults which
tests both static and dynamic balance under varying sensory conditions.
 The FAB includes 10 items which are scored between 0 to 4, with a
score range of 0 (poor balance) to 40 (good balance).
 It takes 10-12 minutes to administer this scale
 Excellent test- retest reliability for fall (r=0.96)
 Adequate reliability for individual test items (r= 0.55 to 0.82)
 Excellent internal consistency (r= 0.9555 to 0.999)
 Criterion validity is excellent in correlation with BBS (r= 0.75)
 in 7/10 cases who scores 25 or less than 25 is at a high risk for falls
 Construct validity is excellent in correlation with BBS (r=0.75)
 Ceiling effect: item 1 may have the ceiling effect for independent
functioning older adults

26. BALANCE EVALUATION
SYSTEMS TEST
 (BESTest) was developed by Horak and colleagues (2009) to
examine multiple aspects of postural control.
 The BESTest consists of 36 items, grouped into six systems:
- Biomechanical Constraints,
- Stability Limits
- Verticality,
- Anticipatory Postural Adjustments
- Postural Responses,
- Sensory Orientation, and
- Stability in gait

27. Mini-BESTest
 The Mini-BESTest is a shortened version of the
original BESTest.
 It has 14 items scored from 0 to 2 with a maximum
score of 28.The items chosen had the highest
correlation with the overall /complete score of the
BESTest using a Rasch analysis.
 The Mini version can be administered in 15 to 20
minutes and is as reliable and capable of detecting
fall status as the original version.
 The construct differs from the BESTest as it only
considers dynamic balance by omitting items related
to mechanical constraints and limits of stability.
 The Mini-BESTest has similar clinometric properties
as the BESTest.

28. Brief BESTest
 The brief version of the BESTest was developed to
improve the clinical utility of the BESTest and to
preserve the construct validity of the BESTest.
 The Brief BESTest included the most representative
item from each of the six domain sections of the
original BESTest for a total of 8 items scored 0 to 3
with a maximum score of 24.
 The Brief-BESTest has similar clinometric properties
as the BESTest and Mini BESTest.

29.  Equipment required:
 Stopwatch, 36” ruler, 4” foam pad (12” x12”), 10-
degree-incline ramp, 6” stair step, two stacked shoe
boxes, 5-lb free weight, and chair with arms. The
authors emphasize that only the worst performance
in items “stand on one leg” and “lateral stepping”
are to be scored. Item 14 (Mini-BESTest) is clarified
by the authors as “if a person’s gait slows >10%
between the TUG with and without a dual task, the
score should be decreased by a point.”

32.  Article: Reliability and Fall risk Detection for the BESTest and miniBESTest in
Older Adults
 Authors: Eric Anson, Elizabeth Thompson, Lei Ma, et al.
 Journal: Journal of Geriatric Physical Therapy
 Year: 2019
 Type of study: Observational
 Sample size : 58
 Results: —Balance scores did not significantly change over a 4 week period. Test-
retest reliability for the BESTest (.86) and mini-BEST (.84) was good to excellent.
MDC95 scores were identified for the BESTest (8.9) and mini-BEST.
 Conclusion : —The BESTest and mini-BEST scores were stable and reliable over a
period of 4 weeks for a population of older adults with self-reported balance
problems or a history of falling. MDC95 scores allow interpretation of change in
BESTest and mBEST scores following rehabilitation.

33. COMMUNITY BALANCE AND
MOBILITY SCALE
 The Community Balance and Mobility Scale (CBM)
assesses higher level balance and mobility skills through
performance of tasks that are common to community
environments.
 The purpose of the CBM is to reflect balance and mobility
skills necessary for full participation in the community.
 13 tasks make up the test scored from 0 (inability) to 5 for
a maximum score of 96. Item arrangement reflects
progressive task difficulty.
 The test takes 20 to 30 minutes to administer. It is reliable,
valid, and responsive to change in community-dwelling
older adults, those with arthritis, those in cardiac
rehabilitation, and those with stroke.
 The CBM does not have the ceiling effects of other
measures of balance (e.g., BBS) and correlates with the
FAB; therefore, it may be more useful for healthy, higher-
functioning, younger community-dwelling older adults.

34.  List of Items:
1. Unilateral Stance
2. Tandem Walking
3. 180 Tandem Pivot
4. Lateral Foot Scooting
5. Hopping Forward
6. Crouch and Walk
7. Lateral Dodging
8. Walking & Looking
9. Running with Controlled Stop
10. Forward to Backward Walking
11. Walk, Look and Carry
12. Descending Stairs
13. Step-Ups x 1 Step

35.  Directions:
 The CB&M is completed using a set 8-meter measured track
and a full flight of stairs is required. This test requires
approximately 20-30 minutes to administer. It is recommended
that the assessor instructs the patient verbally as well as
demonstrates all of the items to ensure proper understanding.
 In brief, tasks 1 through 11 are performed on an 8-m track
outlined on the floor and tasks 12 and 13 are performed on a
flight of ≥8 steps ( Figure 1 ). All tasks are scored on a scale of 0
to 5 (0 = unable to perform, 5 = able to perform independently).
Thus, 13 tasks are performed, 6 bilaterally, for a maximum of 95
points. Of note, any participant who receives a score of ≥4 for
task 12 (descending stairs) can reattempt the task carrying a
weighted laundry basket. If the participant is able to complete
the modified task in a coordinated manner without continually
watching his or her feet, he or she is awarded a bonus point.
Thus, the maximum score achievable for the CBMS is 96. [1]
 Equipment needed includes a laundry basket, 2- and 7-lb
weights, a bean bag, a visual target, and stairs. Tasks are
conducted on an 8-m track that is 2 m wide (Fig. 7.8). The test is
to be done without a mobility aid and is tested on both sides.

36.  Article: Concurrent validity and reliability of the Community Balance
and Mobility scale in young-older adults
 Authors: Michaela Weber1 , Jeanine Van Ancum2 , Ronny Bergquist4 et al.
 Journal: BMC Geriatrics
 Year: 2018
 Type of study: Cross Sectional
 Sample size: 51
 Results: The CBM significantly correlated with the FAB (ρ = 0.75; p <
.001), 3MTW errors (ρ = − 0.61; p < .001), 3MTW time (ρ = − 0.35; p =
.05), the 8-level balance scale (ρ = 0.35; p < .05), the TUG (ρ = − 0.42; p <
.01), and 7-m habitual gait speed (ρ = 0.46, p < .001). Inter- (ICC2,k =
0.97), intra rater reliability (ICC3,k = 1.00) were excellent, and internal
consistency (α = 0.88; ρ = 0.28–0.81) was good to satisfactory. The CBM
did not show ceiling effects in contrast to other scales.
 Conclusion: Concurrent validity of the CBM was good when compared to
the FAB and moderate to good when compared to other measures of balance
and mobility. Based on this study, the CBM can be recommended to
measure balance and mobility performance in the specific population of
young-older adults.

37.  Article: Validity and Reliability of the Community Balance and Mobility Scale
in Individuals With Knee Osteoarthritis
 Authors: Judit Takacs, S. Jayne Garland, Mark G. Carpenter, et al.
 Journal: Physical Therapy Journal APTA
 Year: 2014
 Type of study: Cross-Sectional Study
 Sample size: 50
 Results: Scores on the CB&M were significantly correlated with all measures of
balance and mobility for those with knee OA. There were significant differences in
CB&M scores between groups. Scores on the CB&M were highly reliable in people
with knee OA (ICC.95, 95% confidence interval [95% CI]0.70 to 0.99; SEM3, 95%
CI2.68 to 4.67).
 Conclusion: The CB&M displayed moderate convergent validity, excellent known-
groups validity, and high test-retest reliability. The CB&M can be used as a valid
and reliable tool to assess dynamic balance and mobility deficits in people with knee
OA

38. DYNAMIC GAIT INDEX
 DGI examines a patient’s ability to perform variations in
walking on command. Items include changing speed (walk
at normal speed and at fast speed), walk with head turns
(look right or left, look up or down), walk and pivot turn,
step over or around an obstacle, and climb stairs (up and
down).
 A four-point scale (0 to 3) includes specific descriptors of
normal control (3), mild impairment (2), moderate
impairment (1), and severe impairment (0), with a
maximum possible score of 24. The DGI app pears to be
sensitive in predicting likelihood for falls with older adults
(a score below 19 is indicative of increased fall risk).
 It has also been used with individuals with vestibular
dysfunction, chronic stroke, and multiple sclerosis.
 Whitney et al., found a moderate correlation between the
Dynamic Gait Index and the Berg Balance Scale when
testing individuals with vestibular and balance dysfunction.

39.  Directions:
 The scoring system for the original 8 item DGI was
modified and expanded in 2013.The new scoring
system, called the modified DGI, includes time, level of
assistance, and gait pattern for each task to attempt to
avoid the ceiling effect noted with the original DGI. The
test allows the use of an assistive device but results in a
loss of points.
 Floor and ceiling effects is The number of respondents
who achieved the lowest or highest possible score
 Interpretation:
 A score of 19 or less on the original DGI indicates an
increased risk of falling in older adults and in patients
with vestibular disorders.
 It is reliable and valid as well as responsive.
 Fall risk is indicated on the 4-item DGI with a score of
<10.

41.  Article: Reliability, validity, and responsiveness of three scales for measuring
balance in patients with chronic stroke
 Authors: Ahmad H. Alghadir1 , Einas S. Al-Eisa1 , Shahnawaz Anwer et al.
 Journal: BMC Neurology
 Year: 2018
 Type of Study: ?
 Results: The reliability of the TUG (intra class correlation coefficient [ICC2,1] =
0.98), DGI (ICC2,1 = 0.98) and BBS (ICC2,1 = 0.99) were excellent. The standard
error of measurement (SEM) of the TUG, DGI, and BBS were 1.16, 0.71, and 0.98,
respectively. The minimal detectable change (MDC) of the TUG, DGI, and BBS
were 3.2, 1.9, and 2.7, respectively. There was a significant correlation found
between the DGI and BBS (first reading [r] = 0. 75; second reading [r] = 0.77), TUG
and BBS (first reading [r] = −.52; second reading [r] = −.53), and the TUG and DGI
(first reading [r] = 0.45; second reading [r] = 0.48), respectively.
 Conclusion: The test-retest reliability of the TUG, BBS, and DGI was excellent.
The DGI demonstrated better responsiveness than TUG and BBS. The results of the
present study support the use of these scales for measuring balance and mobility in
patients with chronic stroke

42.  Article: The Frail'BESTest. An Adaptation of the "Balance Evaluation System Test"
for Frail Older Adults. Description, Internal Consistency and Inter-Rater Reliability
 Authors: A Kubicki1,2 M Brika2 L Coquisart3 et al.
 Journal: Dove Press journal: Clinical Interventions in Aging
 Year: 2020
 Type of study: ?
 Sample size: 64
 Results: : The internal consistency was moderate to good for five systems and limited for
“biomechanical constraints”. The distribution of the Frail’BESTest was more centered
than that of the Tinetti and Mini-Motor tests. The Kendall’s tau showed strong
concordance in center 1 for all systems and only for 4 on 6 systems in center 2
 Discussion: Completing a systemic evaluation, the therapist may prioritize the patient’s
needs identifying the most challenging systems. This paper presents the Frail’BESTest
and confirms the psychometric properties at a first step level

43. References
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44.  Weber M, Van Ancum J, Bergquist R, Taraldsen K, Gordt K, Mikolaizak AS, Nerz C,
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45. THANK YOU