Berg Balance Scale
Test information Chart #: DOS:
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 subject’s 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.

# Patient Instruction and Result
1 SITTING TO STANDING:
Please stand up. Try not to use your hand for support.
2 STANDING UNSUPPORTED:
Please stand for two minutes without holding on.
3 SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOL:
Please sit with arms folded for 2 minutes.
4 STANDING TO SITTING:
Please sit down.
5 TRANSFERS:
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.
6 STANDING UNSUPPORTED WITH EYES CLOSED:
Please close your eyes and stand still for 10 seconds.
7 STANDING UNSUPPORTED WITH FEET TOGETHER:
Place your feet together and stand without holding on.
8 REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDING:
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.)
9 PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITION:
Pick up the shoe/slipper, which is in front of your feet.
10 TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDING:
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.)
11 TURN 360 DEGREES:
Turn completely around in a full circle. Pause. Then turn a full circle in the other direction.
12 PLACE ALTERNATE FOOT ON STEP OR STOOL WHILE STANDING UNSUPPORTED:
Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool four times.
13 STANDING UNSUPPORTED ONE FOOT IN FRONT:
(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.)
14 STANDING ON ONE LEG:
Stand on one leg as long as you can without holding on.
Scoring
Score: 0 Scoring Criteria
41-56 = low fall risk
21-40 = medium fall risk
0 –20 = high fall risk