Berg Balance Scale

Assess balance and predict fall risk. Please select one option for each item.

Item 1. SITTING TO STANDING

INSTRUCTIONS: Please stand up. Try not to use your hand for support.

Item 2. STANDING UNSUPPORTED

INSTRUCTIONS: Please stand for two minutes without holding on.

Item 3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL

INSTRUCTIONS: Please sit with arms folded for 2 minutes.

Item 4. STANDING TO SITTING

INSTRUCTIONS: Please sit down.

Item 5. 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.

Item 6. STANDING UNSUPPORTED WITH EYES CLOSED

INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.

Item 7. STANDING UNSUPPORTED WITH FEET TOGETHER

INSTRUCTIONS: Place your feet together and stand without holding on.

Item 8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING

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.)

Item 9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION

INSTRUCTIONS: Pick up the shoe/slipper, which is place in front of your feet.

Item 10. 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.

Item 11. TURN 360 DEGREES

INSTRUCTIONS: Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.

Item 12. PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED

INSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touch the step/stool four times.

Item 13. STANDING UNSUPPORTED ONE FOOT IN FRONT

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.)

Item 14. STANDING ON ONE LEG

INSTRUCTIONS: Stand on one leg as long as you can without holding on.

Assessment Summary

TOTAL SCORE: 0 / 56  (0 of 14 items)

Score Interpretation:
41–56 = Independent
21–40 = Walking with assistance
0–20 = Wheelchair bound

A score less than 45 may indicate a greater risk of falling.
BBS less than 51 with a history of falls and BBS less than 42 without a history of falls have been used as a sensitive predictor of fall risk.
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