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Rehab Measures: Balance Error Scoring System

Link to instrument

Balance Error Scoring System here (other languages below) 

Title of Assessment

Balance Error Scoring System 

Acronym

BESS

Instrument Reviewer(s)

Initially reviewed by Katie Hays, PT, DPT and the TBI EDGE task force of the Neurology Section of the APTA in 5/2012. Updated by Karen Lambert, PT, MPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA 6/2013

Summary Date

4/6/2013 

Purpose

Objective measure of assessing static postural stability (designed for the mild head injury population, to assist in return to sports play decisions).

Description

  • 6 conditions each tested barefoot, eyes closed for 20 seconds each:
    • Double leg stance (feet together) – firm / foam surfaces
    • Single leg stance (non-dominant foot) – firm / foam surfaces
    • Tandem stance (non-dominant foot in back) – firm / foam
  • Score of 0-60 (lower scores indicate better balance and less errors).
  • Each trial is scored by counting errors (deviations from the proper stance). If multiple errors occur at the same time, only one is counted. The maximum number of errors for a single condition is 10.
  • Errors include moving hands off of iliac crests, opening eyes, step stumble or fall, abduction or flexion of the hip beyond 30 degrees, lifting forefoot or heel off testing surface, remaining out of the proper testing position for > 5 seconds.
  • Number of errors in each trial are added together to obtain a total score (out of 60).
  • Administration instructions found at above website. Read instructions to subject as they are written in the testing protocol.

Area of Assessment

Vestibular 

Body Part

 

ICF Domain

Activity 

Domain

 

Assessment Type

 

Length of Test

06 to 30 Minutes 

Time to Administer

< 10 minutes

Number of Items

3 test conditions on 2 different surfaces (6 separate trials) or 20 seconds each 

Equipment Required

Training Required

No training required, instructions available in test manual

Type of training required

No Training; Reading an Article/Manual 

Cost

Not Free 

Actual Cost

Cost of airex pad and stopwatch (< $100)

Age Range

 

Administration Mode

 

Diagnosis

Concussion; Traumatic Brain Injury 

Populations Tested

  • Concussion
  • Mild TBI
  • Ankle instability
  • Vestibular Disorders

Standard Error of Measurement (SEM)

Youth:
(Broglio et al, 2009; n = 48, age = 20.42(2.08)
  • SEM = 3.3

Youth:

(Valovich et al, 2004; n = 49; average age control group = 12.34(1.55) years; average age practice group = 11.77(1.82) years, healthy sports participants)

  • SEM = 1.01

Athletes (controls without neurological / orthopedic injury):

(Susco et al, 2004; n = 100; mean age = 21.4(2.7))

  • SEM for Double support/firm = 0.62
  • SEM for Double support/foam = 0.63

Minimal Detectable Change (MDC)

Athletes:
(Finnoff et al, 2009; n = 30 individuals videotaped performing BESS)
  • Mean intrarrater MDC = 7.3 points
  • Mean interrater MDC = 9.3 points

Minimally Clinically Important Difference (MCID)

Young Athletes :

(Valovich McLeod et al, 2006; n = 50, healthy community dwelling athletes, aged 9-14)

  • Reliable Change Index at 70% confidence interval = 3 points

Cut-Off Scores

Not Established

Normative Data

Healthy adults:
(Iverson et al, 2008; n = 589, healthy community dwelling adults, mean age = 49.75(10.81); Canadian sample)
  • Balance worsens with age—BESS score and age correlated
  • BESS performance worsened after 50 years of age 

Age (years)
Mean Score (points)
20-39
10.97 (5.05)
40-49
11.88 (5.40)
50-54
12.73 (6.07)
55-59
14.85 (7.32)
60-64
17.20 (7.83)
65-69
20.38 (7.87)

 
Mean Score (points)
AGE (years)
ALL
Men
Women
20-29
11.3
10.4
11.9
30-39
11.5
11.5
11.4
40-49
12.5
12.4
12.7
50-54
14.2
13.6
15.1
55-59
16.5
16.4
16.7
60-64
18.0
17.2
19.3
65-69
19.9
20.0
19.9

  • Women with BMI > 30
    • age 20-29; mean BESS score: 17.3
    • age 50-64; mean BESS score: 21.6

Test-retest Reliability

Athletes:
(Bell et al, 2011)
  • Adequate test retest reliability in youth participants aged 9-14 (ICC = 0.70)

Interrater/Intrarater Reliability

Athletes (without neurological / orthopedic injury):
(Susco et al, 2004; n = 34 subset of subjects)
  • Adequate to Excellent intrarater reliability (ICC from 0.62-0.82)
    • Excellent: Double support / firm surface (ICC = 0.82)
    • Adequate: Double support / firm surface (ICC = 0.63)

Athletes: 

(Bell et al, 2011; n  = 18 college athletes)

  • Excellent interrater reliability (ICC = 0.78-0.96)
  • Adequate-excellent interrater reliability (ICC = 0.57-0.85 for total score (systematic review looking at 8 studies)
  • Adequate-excellent intrarater reliability for total score (ICC = 0.60-0.92)

Athletes:

(Finnoff et al, 2009)

Item
Interrater Reliability (ICC)
Intrarater Reliability (ICC)
Firm Double Log
**
**
Firm Single Leg
Excellent (0.83)
Excellent (0.88)
Firm Tandem
Adequate (0.44)
Excellent (0.77)
Foam Double Leg
Adequate (0.46)
Excellent (0.83)
Foam Single Leg
Adequate (0.53)
Adequate (0.50)
Foam Tandem
Adequate (0.57)
Adequate (0.73)
Total Score
Adequate (0.57)
Adequate (0.74)
** Unable to report due to errors made by subjects

(Valovich et al, 2004)

  • Excellent interrater reliability for all testing conditions (ICC = 0.87-0.98)
  • Excellent interrater reliability for total score (ICC = 0.98)

Internal Consistency

Not Established

Criterion Validity (Predictive/Concurrent)

Athletes:
(Bell et al, 2011)
  • Adequate-excellent correlations with target sway in male athletes
  • Significant correlations for 5 of the 6 stances (r = 0.31-0.79, p < 0.01)

Concussion:

(Barlow et al, 2011 retrospective chart review of middle and high school students; n = 106; mean age = 15.38(1.7) years; mean days between testing = 15.5(14.1) days)

  • Adequate correlation with ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)Impulse control (r = -0.31)
  • Adequate correlation with ImPACT verbal score (r = 0.37)
  • Poor correlation with ImPACT visual motor speed change (r = -0.33)
  • Poor correlation with ImPACT reaction time (r = -0.02)
  • Poor correlation with PCSS (r = 0.15)

Athletes (controls without neurological / orthopedic injury):

(Susco et al, 2004)

  • Positive correlation with RPW score (r = 0.542)

Construct Validity (Convergent/Discriminant)

Athletes:
(Bell et al, 2011)
  • Convergent validity: BESS and sensory organization test (SOT), validated in a concussed population. More errors seen at day 1 post injury compared to healthy individuals, but returned to baseline at 3 and 5 days post injury. Average errors 9(4) for control, 15(8) for concussed, effect size 1.0.
  • Discriminant: BESS does not discriminate between concussed athletes with and without a headache (p = 0.87)
  • BESS performance worsens after 50 years of age (p < 0.01), r = 0.36
  • Increase in total BESS score (poorer performance) after whole-body or central fatigue (p < 0.01)
  • Barefoot BESS performance better than braced BESS (p = 0.04), before walking, better than braced (p=.03 or taped (p = 0.04) after walking. Differences not seen in SOT between conditions.

Healthy adults:

(Iverson et al, 2008)

  • Adequate correlation between BESS and age(r = 0.36)
  • Poor correlation between BESS and height (r = -0.03)
  • Poor correlation between BESS and weight (r = 0.16)
  • Poor correlation between BESS and waist circumference (r = 0.26)
  • Poor correlation between BESS and BMI (r = 0.23)

Content Validity

Athletes (controls without neurological / orthopedic injury):
(Susco et al, 2004)
  • After 20 min of activity, BESS scores were significantly higher (worse) than pre-test scores; also significantly higher than controls who did not perform any activity (rested for 20 and then repeated BESS)
  • The following time points were significantly different (worse) than pre-test:
    • Immediately following exertion
    • 5 min after exertion
    • 10 min after exertion
    • 15 min after exertion

(Bell et al, 2011)

  • Excellent content validity for identifying balance deficits in functional ankle instability (Effect size = 2.69-3.14)
  • Excellent content validity for identifying fatigue (ES = 0.89-2.12 across various studies)

(Onate et al, 2007 n = 21 uninjured NCAA baseball players; mean age = 20.1(1.4) years; no history of head injury or lower extremity injury in the last 12 months)

  • Single leg foam condition significantly different when tested in controlled locker room vs uncontrolled sideline environment (p = 0.001, ES d = 1.03)
  • Moderate to large effect sizes (0.53-1.03) found for single-leg foam, tandem foam, and total BESS scores when comparing above two noted environments

Face Validity

Not Established

Floor/Ceiling Effects

Not Established

Responsiveness

Not Established

Professional Association Recommendations

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (VEDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

 

For detailed information about how recommendations were made, please visit:  http://www.neuropt.org/go/healthcare-professionals/neurology-section-outcome-measures-recommendations

 

Abbreviations:

HR

Highly Recommend

R

Recommend

LS / UR

Reasonable to use, but limited study in target group  / Unable to Recommend

NR

Not Recommended

 

Recommendations for use based on acuity level of the patient:

 

Acute

(CVA < 2 months post)

(SCI < 1 month post)

(Vestibular < 6 weeks post)

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

(Vestibular > 6 weeks post)

VEDGE

LS

NR

NR

 

Recommendations based on level of care in which the assessment is taken:

 

Acute Care

Inpatient Rehabilitation

Skilled Nursing Facility

Outpatient

Rehabilitation

Home Health

TBI EDGE

LS

LS

NR

R

LS

 

Recommendations for use based on ambulatory status after brain injury:

 

Completely Independent

Mildly dependant

Moderately Dependant

Severely Dependant

TBI EDGE

R

LS

NR

NR

 

Recommendations based on vestibular diagnosis

 

Peripheral

Central

Benign Paroxysmal Positional Vertigo (BPPV)

Other

VEDGE

NR

LS

NR

NR

 

 

Recommendations for entry-level physical therapy education and use in research:

 

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

TBI EDGE

No

Yes

No

Not reported

VEDGE

No

Yes

No

Yes


Considerations

  • The Balance Error Scoring System was developed as a means of providing a quick and efficient balance assessment along the sidelines following sports concussion
  • This tool may add value to the balance assessment of other populations (vestibular/ non-sports related concussion) however it has not been evaluated in these populations to date
  • The mCTSIB has been assessed in the vestibular population.  The mCTSIB requires similar training, time to administer and equipment and is, therefore, recommended as a superior test to the BESS at this time.
  • Significant learning effect noted with tandem stance, especially with single leg stance and foam items (Valovich et al, 2003; Valovich et al, 2004)
  • Exertion adversely affects BESS scores, with the greatest effect on single leg stance and tandem stance conditions. (Susco et al, 2004)
  • Distracting environment may negatively affect scores (most noted on single leg foam condition, but also on total score and tandem leg foam conditions).
  • Revised version of the test has been performed with four conditions: single-leg stance on firm and foam, and tandem stance on firm and foam) (Hunt, TN et al (2009)) with improved reliability. Intraclass reliability coefficient of 0.84 using conditions 2 and 3

Balance Error Scoring System translations:

Spanish (on page 3 item 6):
http://www.urba.org.ar/useruploads/notas/archivonota_923.pdf 

These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.

Do you see an error or have a suggestion for this instrument summary? Please e-mail us!

Bibliography

Barlow, M., Schlabach, D., et al. (2011). "Differences in change scores and the predictive validity of three commonly used measures following concussion in the middle school and high school aged population." Int J Sports Phys Ther 6(3): 150-157. Find it on PubMed

Bell, D. R., Guskiewicz, K. M., et al. (2011). "Systematic review of the balance error scoring system." Sports Health 3(3): 287-295. Find it on PubMed

Broglio, S. P., Zhu, W., et al. (2009). "Generalizability theory analysis of balance error scoring system reliability in healthy young adults." J Athl Train 44(5): 497-502. Find it on PubMed

Finnoff, J. T., Peterson, V. J., et al. (2009). "Intrarater and interrater reliability of the Balance Error Scoring System (BESS)." PM R 1(1): 50-54. Find it on PubMed

Hunt, T. N., Ferrara, M. S., et al. (2009). "The reliability of the modified Balance Error Scoring System." Clin J Sport Med 19(6): 471-475. Find it on PubMed

Iverson, G. L., Kaarto, M. L., et al. (2008). "Normative data for the balance error scoring system: implications for brain injury evaluations." Brain Inj 22(2): 147-152. Find it on PubMed

Koehle, M. S. (2013). "Normative Data for the Balance Error Scoring System in Adults." Rehabilitation research and practice 2013.

Onate, J. A., Beck, B. C., et al. (2007). "On-field testing environment and balance error scoring system performance during preseason screening of healthy collegiate baseball players." J Athl Train 42(4): 446-451. Find it on PubMed

Susco, T. M., Valovich McLeod, T. C., et al. (2004). "Balance Recovers Within 20 Minutes After Exertion as Measured by the Balance Error Scoring System." J Athl Train 39(3): 241-246. Find it on PubMed

Valovich McLeod, T. C., Perrin, D. H., et al. (2004). "Serial administration of clinical concussion assessments and learning effects in healthy young athletes." Clin J Sport Med 14(5): 287-295. Find it on PubMed

Valovich, T. C., Perrin, D. H., et al. (2003). "Repeat administration elicits a practice effect with the Balance Error Scoring System but not with the Standardized Assessment of Concussion in high school athletes." J Athl Train 38(1): 51-56. Find it on PubMed

 

Year published

 

Instrument in PDF Format

No 
Approval Status Approved 
 
Attachments
Created at 11/15/2012 3:04 PM  by Jason Raad 
Last modified at 11/1/2016 12:19 PM  by Jason Raad