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Berg Balance Scale Cheat Sheet by

Measure balance of old people with impairments
assessment     medical     nurse     balance     berg

Sitting to Standing

4 able to stand without using hands & 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
Instru­ctions: Please stand up. Try not to use your hand for support.

Standing Unsupp­orted

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
Instru­ctions: Please stand for two minutes without holding on. If a subject is able to stand 2 minutes unsupp­orted, score full points for sitting unsupp­orted. Proceed to item #4.

Sitting: Back Unsupp­orted but Feet Supported

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
Instru­ctions: Please sit with arms folded for 2 minutes. Feet supported on floor or stool.

Standing to Sitting

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
Instru­ctions: Please sit down.

Transfers

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
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.

Standing Unsupp­orted 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 stays safely
0 needs help to keep from falling
Instru­ctions: Please close your eyes and stand still for 10 seconds.

Staanding Unsupp­orted 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 able to stand 15 seconds feet together
0 needs help to attain position and unable to hold for 15 seconds
Instru­ctions: Place your feet together and stand without holding on.

Reaching Forward w/Outs­tre­tched Arm Standing

4 can reach forward confid­ently 25 cm (10 inches)
3 can reach forward 12 cm (5 inches)
2 can reach forward 5 cm (2 inches)
1 reaches forward but needs superv­ision
0 loses balance while trying­/re­quires external support
Instru­ctions: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. Fingers should not touch the ruler while reaching forward. The recorded measure is the distance forward that the fingers reach while the subject is in the most forward lean position. When possible, ask subject to use both arms when reaching to avoid rotation of the trunk.)
 

Pickup Object from Floor while Standing

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 2-5 cm(1-2 inchs) from slipper & keeps balance indepe­ndently
1 unable to pick up and needs superv­ision while trying
0 unable to try/needs assist to keep from losing balance or falling
Instru­ctions: Pick up the shoe/s­lipper, which is in front of your feet.

Turning to Look Behind Over Left/Right Shoulders

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
Turning to Look Behind Over Left/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.)

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 cuing
0 needs assistance while turning
Instru­ctions: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.

Place Alternate Foot on Step 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
Place Alternate Foot on Step or Stool While Standing Unsupp­orted:
Instru­ctions: Place each foot altern­ately on the step/s­tool. Continue until each foot has touched the step/stool four times.

Standing Unsupp­orted 1 Foot in Front

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 small step indepe­ndently and hold 30 seconds
1 needs help to step but can hold 15 seconds
0 loses balance while stepping or standing
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. (To score 3 points, the length of the step should exceed the length of the other foot and the width of the stance should approx­imate the subject’s normal stride width.)

Standing on One Leg

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 L 3 seconds
1 tries to lift leg unable to hold 3 seconds but remains standing indepe­nde­ntly.
0 unable to try of needs assist to prevent fall
Instru­ctions: Stand on one leg as long as you can without holding on.

Berg Balance Scale

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.
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 (max)
Inte­rpr­eta­tion:
41-56 = low fall risk
21-40 = medium fall risk
0 –20 = high fall risk
A change of 8 points is required to reveal a genuine change in function between 2 assess­ments.

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