Kembhavi, Gayatri MScPT; Darrah, Johanna PhD; Magill-Evans, Joyce PhD; Loomis, Joan MEd
Reliable and valid outcome measures are needed in the field of rehabilitation to establish baseline measures, to demonstrate evidence for the efficacy of treatments, and to provide clients with feedback regarding their strengths and weaknesses. In the rehabilitation of persons with cerebral palsy, this need is especially important. Validated, standardized measures provide quantitative information about the child’s development and may identify problem areas not apparent through informal observation. 1 Not only must tools used in rehabilitation be reliable and valid, but they must also be appropriate for clinical use. Tools that are prohibitively expensive, time-consuming, or require laboratory testing have little clinical use. In addition, tools used in rehabilitation must be sensitive enough to detect clinically important changes in function.
Children with cerebral palsy experience muscle coordination problems, difficulties with the organization of sensory information and functional limitations that may be influenced by increased tone in their upper and lower extremities. These factors affect postural control. 2 Balance strategies of children with cerebral palsy are different than the strategies used by children without a neurological impairment. Children with cerebral palsy demonstrate increased co-contractions of distal and proximal muscles and do not have a smooth distal-to-proximal pattern of muscle activation. 3 Nashner et al. 4 found that, unlike subjects developing typically, children with cerebral palsy demonstrated a reversed order of activation of distal and proximal muscle synergies in response to a moving platform. In children with spastic hemiplegia, Nashner et al. 4 also found coordination problems in the noninvolved leg during platform perturbations that involved both legs. Children with a diagnosis of cerebral palsy also show increased antagonistic muscle coactivation as compared with children with typical motor development. 3,4
Balance skills are an integral part of gross motor abilities and poor balance causes difficulties with functional tasks involved in activities of daily living. Balance deficits in a functional context become an important issue in rehabilitation and are often the focus of intervention. Therefore, a reliable, valid and simple tool to measure functional balance in children with cerebral palsy would be valuable to clinicians involved in the rehabilitation of this population.
A review of current tools for use with children with cerebral palsy revealed a paucity of clinical tools to measure balance in this population. While several tools are used to measure balance in children, they are limited in their utility to assess functional balance with children with cerebral palsy. First, many motor developmental scales are used to assess balance abilities. The items on these scales represent typical motor development. As a result, children with motor disabilities can perform very few of the items. The tests are also unresponsive to small changes in functional balance. Second, some balance tools measure the balance deficit at the level of the impairment rather than function, particularly those impairments found in the vestibular and somatosensory systems. Third, some balance tests have to be administered in a laboratory setting, and involve using a moving platform and varying visual conditions. 5–7 These laboratory conditions are difficult to transfer to a clinical setting.
The Berg Balance Scale (BBS) is a functional measure of balance developed to measure balance in the elderly and the neurologically impaired individual in a clinical setting. The focus of the BBS is performance, rather than an underlying impairment of balance. 8 Administration requires little training, minimal equipment and only 15 to 20 minutes to administer. 8,9 The BBS is considered by some to be a gold standard of the evaluation of balance performance with the elderly. 10 It may have potential to be used with a pediatric population. Berg states, “. . .the scale may well apply to any population with balance impairment, regardless of age.”8 Unlike other balance measures for children, the BBS emphasizes function, and captures a wide range of functional abilities. These features of the BBS make it an appropriate measure to consider for use with a pediatric population.
The purpose of this study was to evaluate the use of the BBS to assess the balance abilities of children with cerebral palsy. Specifically, we evaluated the ability to use scores obtained on the BBS to distinguish among groups of children with varying balance abilities. The BBS was evaluated under two different classification methods: traditional diagnostic categories and the Gross Motor Function Classification Scheme (GMFCS). To compare the use of scores on the BBS to distinguish among groups with different balance abilities to an accepted pediatric measure, children were also evaluated on Dimensions D and E of the Gross Motor Function Measure (GMFM). 11
The categories of spastic hemiplegia, spastic diplegia—ambulatory without aids, and spastic diplegia—ambulatory with aids were considered to represent differing balance abilities. Because balance is considered an essential component for ambulation, the average age of independent walking can be used as one indicator of balance and motor abilities. The appearance of independent ambulation in children with spastic hemiplegia is considered to be “late normal” and is earlier than most children with spastic diplegia. 12 Studies indicate that the average age of independent ambulation in children with spastic diplegia, with or without ambulatory aids, varies between 36 and 47 months. 13 Because ambulatory aids such as walkers and crutches are provided to compensate for poor balance, it is reasonable to assume that children with spastic diplegia who walk without aids possess better balance abilities than those children who require aids. Thus, a hierarchy of balance abilities was hypothesized: 1) Children with no motor impairment will achieve higher BBS and GMFM group mean scores than children with spastic hemiplegia. 2) Children with spastic hemiplegia will achieve higher BBS and GMFM group mean scores than children with spastic diplegia who ambulate without aids. 3) Children with spastic diplegia who ambulate without aids will achieve higher BBS and GMFM group mean scores than children with spastic diplegia who ambulate with aids.
Because we felt that classification by function may produce more intra–group homogeneity and produce groups with more distinct balance abilities, the children were also classified using the Gross Motor Function Classification System (GMFCS) for children with cerebral palsy. 14 The GMFCS provides clinicians with an alternative method of classifying children with cerebral palsy. The five levels of classification represent meaningful distinctions in motor function, and are based on self-initiated movement. 14 Level I represents children who move without restriction, and only have limitations in advanced skills, while Level V represents children with severe movement restrictions. Only Levels I through III were used for the purposes of this study. Children in Level II walk without assistive devices, but have limitations walking outdoors and in the community, whereas children in Level III walk with assistive devices. The children were classified on the GMFCS by reviewing physical therapy notes and assessments, yearly reviews at clinics and notes from other health care professionals.
Design and Participants
Thirty-six children with cerebral palsy and 14 children with no identified motor impairment participated, for a total of 50 children between the ages of eight and 12 years (x = 10.46 years, SD = ±1.38). The subjects are described in Table 1. The children with cerebral palsy were recruited from clinics at a local rehabilitation hospital. The children with no identified motor impairment were identified from acquaintances of the investigators. The children with cerebral palsy comprised three diagnostic groups: spastic hemiplegia; children with spastic diplegia who ambulated without aids; and children with spastic diplegia who ambulated with aids. Walkers, forearm crutches, or canes were considered to be aids. All children were permitted to use orthotic devices if they used them regularly.
Exclusion criteria included severe behavioral problems, as identified by the clinic coordinator or the treating therapists, inasmuch as each test required that the children focus their attention on a task for at least 20 minutes. Children who had undergone orthopedic surgery in the previous six months were also excluded, because their motor performance may not have been indicative of their typical motor abilities. The gender of participants was not considered a confounding factor, as research into the balance of children with no motor impairment has not shown any significant difference between boys and girls. 15
The BBS has 14 items of increasing difficulty. These items are used to test functional skills relevant to everyday tasks, such as moving from sitting to standing, and reaching beyond one’s base of support. Items were designed to test a client’s ability to maintain a position within a decreasing base of support and to change positions. The items are performed within a specified time frame, or the positions are held for a specified amount of time. The items are scored on a five-point ordinal scale from zero to four, allowing for a maximum score of 56 points. 9 A higher score indicates better balance abilities. Interrater reliability using the BBS is reported to be extremely high, with an intraclass correlation coefficient of 0.98. 8,10 Similarly, intrarater reliability is high with a reported correlation coefficient of 0.99. 8 An additional validation study by Berg et al. 16 ascertained that by using scores attained on the BBS a therapist can predict falls in the elderly, and can discriminate between groups of subjects with differing levels of balance control, in particular, those subjects who require aids to ambulate, and those who do not. A copy of the BBS is included in the Appendix.
The GMFM is a widely used validated tool for the assessment of motor function in children with cerebral palsy. Although not designed specifically for the evaluation of balance, we hypothesized that Dimensions D (Standing) and E (Walking, Running, and Jumping) of the GMFM best reflect the construct of balance as a component of overall gross motor function. The GMFM is scored on a four-point ordinal scale from zero to three. A higher score indicates better gross motor function. Extensive testing of the GMFM by its developers indicates very high interrater and intrarater reliability, 11 and others have reported similar results. 17 Of the 37 items in Dimensions D and E of the GMFM, and the 14 items on the BBS, only three items are identical between the two tests. The three items are standing unsupported, standing on one leg, and picking up an object from the floor.
The children were each tested once on the BBS and the GMFM. Pediatric physical therapists who were unaware of the hypotheses of the study administered the BBS and the GMFM. The BBS rater underwent training to achieve 80% or greater agreement with gold-standard training videotapes. The GMFM rater was formally trained in the administration of the GMFM and had achieved acceptable reliability. Testing on the BBS took approximately 10 to 15 minutes. The children were offered a rest break of up to 15 minutes between tests. The majority declined this rest and did both tests without a break. Administration of the GMFM took 15 to 20 minutes per child. As per the test administration guidelines, the children were permitted to wear their orthoses (if any), and shoes, but were not permitted to use ambulatory aids. The order of testing on the BBS and the GMFM was randomly determined for each child.
Scores attained on both BBS and the GMFM were described using means and standard deviations. Both parametric and nonparametric analyses were performed to determine if a significant mean difference was present among the four groups of children we hypothesized to represent different balance abilities. Nonparametric analysis was conducted using the Kruskal-Wallis analysis of variance, and parametric analysis was performed using the one-way analysis of variance (ANOVA). Parametric post-hoc analyses using a Tukey’s Honestly Significant Difference test (Tukey’s HSD) were conducted to determine the location of the pair-wise differences if the ANOVA result was significant. Similar analyses were performed on GMFM scores to determine if a significant mean difference was present among the four groups. For all statistical analyses, an alpha level of 0.05 was used.
The mean scores and standard deviations (SD) achieved on the BBS and the GMFM when the children were classified by traditional diagnostic groups are reported in Table 2. All GMFM values are reported as raw scores.
The results of the nonparametric and parametric analyses using the Kruskal-Wallis analysis of variance and the ANOVA were identical. Post-hoc analysis was performed using a parametric test (Tukey’s HSD). Although the data in this study were measured on an ordinal level, we decided to use the results of the parametric tests. The ANOVA revealed significant differences among the mean BBS scores of the four diagnostic groups (F =41.18, df = 3, p ≤ 0.01). Significant differences were also found among the mean GMFM scores of the four groups (F = 58.53, df = 3, p ≤ 0.01). Post-hoc analysis for the mean BBS scores revealed significant pair-wise differences among the group of children with spastic diplegia who used aids to ambulate and all other diagnostic groups. There were no other significant differences in the mean BBS scores among any of the other groups.
Post-hoc analysis for the mean GMFM scores also revealed significant pair-wise differences between children with spastic diplegia who used aids and all other groups, as well as between children with spastic diplegia who did not use aids and children with no identified motor impairment.
After classification using the GMFCS, all except one child with a diagnosis of spastic hemiplegia was classified in Level I on the GMFCS. The remaining child was classified in Level II. All children with a diagnosis of spastic diplegia who used aids to ambulate were classified in Level III because of their gross motor abilities and their reliance on an ambulatory aid. Of the 12 children with a diagnosis of spastic diplegia who did not use aids to ambulate, seven were classified in Level I, and the remaining five were classified in Level II. Children with no motor impairment (NMI) could not be classified using the GMFCS and have been designated as NMI in Figures 1 and 2. An illustration of the reclassification can be found in Figure 1.
Statistical analyses were performed for the mean BBS and GMFM scores using the groups based on functional classification. The ANOVA for mean BBS scores was significant (F = 59.53, df = 3, p ≤ 0.01), as was the ANOVA for mean GMFM scores (F = 135.32, df = 3, p ≤ 0.01). Post-hoc analysis for the mean BBS scores revealed significant pair-wise differences among all groups of children except between children in Level I and children with no motor impairment. Post-hoc analysis performed for the mean GMFM scores also revealed significant differences among all groups of children except those children in Level I and those with no motor impairment. Thus, the ability to use scores attained on both the BBS and the GMFM to distinguish among groups of children with varying balance abilities was greater when using functional classification than when using medical diagnosis. Figure 2 provides a summary of the findings using both traditional medical diagnosis and functional classification using the GMFCS.
The purpose of the study was to evaluate the use of the BBS to assess the balance abilities of children with cerebral palsy. When the children were classified using medical diagnostic categories, the ability to use scores on the GMFM to distinguish among groups of children with differing balance abilities was slightly better than that of scores on the BBS, showing one more significant pair-wise difference. This difference was between the children with spastic diplegia who ambulated without aids and the children with no motor impairment (Fig. 2). When functional classification was used to categorize the children, the ability to use scores on both tests to distinguish among the groups improved and was identical. These results suggest that both test characteristics and the method of classification influenced the ability to use the tests to distinguish among groups of children with different balance abilities.
When using diagnostic classification, the ability to use scores on the GMFM to distinguish among the groups was greater than when using scores on the BBS. This result was most likely because the GMFM has more items at a higher level of difficulty than the BBS. For example, there are more items in Dimension E of the GMFM that require single-leg stance, such as hopping on one leg in a circle. Administration of these items distinguished between the balance abilities of children with no motor impairment and children with spastic diplegia who did not use aids to ambulate. The most challenging items on the BBS include such items as reaching forward with an outstretched arm (No. 8), turning in a full circle in both directions (No. 11), alternately lifting each foot to touch a stool (No. 12), standing in tandem stance (No. 13), and standing on one leg (No. 14). During the initial development of the BBS, Berg stated that, “the lack of an item that requires a postural response to an external stimulus or uneven support surface…will likely limit the utility of the scale when assessing very active persons with minimal deficits.”8 Items on the GMFM could be considered as more challenging than items on the BBS. However, items on the BBS and the GMFM were not discrete enough to enable a therapist to distinguish between the balance abilities of children with no motor impairment and children with spastic hemiplegia by using test scores.
After functional classification using the GMFCS, the ability to use scores on both the BBS and the GMFM to distinguish among the groups was identical. Functional classification resulted in more homogeneous groups in terms of balance abilities. Despite an improved ability to distinguish among the groups, it was still not possible to differentiate between children in Level I and children with no motor impairment by using test scores. This finding may be due to a lack of items on either test that are discrete enough to identify subtle deficits in balance in children who have a mild motor impairment. Items that are more challenging to balance, such as items requiring speed, or movement over uneven terrain, may distinguish between children in Level I and children with no motor impairment. Neither test has such items.
The inability to use scores on the BBS to distinguish between children with no motor impairment and children with mild balance deficits may also have been influenced by the method of administration of the BBS. The BBS does not specify which side the subject must use when performing items such as single leg stance. Thus, the children with spastic hemiplegia were able to use the non–involved side to perform these activities. The administration protocol, as recommended by Berg, may have masked their balance deficits.
These results suggest that neither the BBS nor the GMFM are appropriate tests to measure balance deficits in children with mild functional limitations. The results also indicate that classification of children clearly affects the ability to use scores on the BBS and the GMFM to differentiate among groups of children with differing balance abilities. This finding contributes to the growing belief that the traditional classification of cerebral palsy by tonus and distribution provides an incomplete reflection of a child’s functional abilities.
Using the International Classification of Functioning and Disability (ICIDH 2) drafted by the World Health Organization (WHO), 18 traditional classification of children with cerebral palsy is at the level of impairment. Traditional classification using medical diagnosis provides an incomplete indication of the child’s gross motor abilities, except that it is assumed that the more severe the impairment, the more limited the child’s function. Because rehabilitation professionals should be addressing client issues at the functional level of activity, clients should be classified in terms of function. Only then will measurement of treatment intervention truly capture the effect of intervention on aspects of function. 19
Classification schemes based more on function than on impairment in cerebral palsy have only recently been developed. The GMFCS, developed by Palisano et al. 14 is a major departure of philosophy in the classification of children with cerebral palsy. This classification scheme is based on self-initiated movements, emphasizing sitting and walking. 14 The system includes descriptors of function at various ages, and children can change from one functional level to another as they mature. Researchers in Sweden have found that the GMFCS correlates highly with the ICIDH handicap code, with the highest correlation being with the dimension of mobility (r = 0.95, P < 0.0001). 20
Clinically, these results suggest that the BBS has limited use with children who have minimal motor deficits or mild balance impairments. There is a danger of a ceiling effect when the BBS is used with this population of children. This preliminary evaluation suggests that the BBS has potential to be used with ambulatory children with a diagnosis of cerebral palsy with moderate balance impairments, for example, children who were classified in either Levels II or III of the GMFCS. The test-retest and interrater reliability of the BBS needs to be examined in a pediatric population before it can be used widely with this population. The results do, however, suggest that by using test scores on the BBS, a therapist has the ability to distinguish balance abilities in children with cerebral palsy who are classified in Levels II or III of the GMFCS. The ability to use the GMFM and the BBS to distinguish among groups of children with differing functional abilities were identical when the GMFCS classification scheme was used. The BBS has fewer items and requires less time to administer than Dimensions D and E of the GMFM, and thus, may be more appealing to use in a clinical setting.
Test characteristics and issues of client classification affect the use of the BBS and the GMFM to distinguish among groups of children with differing balance abilities. Children with spastic diplegia who ambulated independently demonstrated more variability of balance abilities than the other diagnostic groups. Children with this diagnosis seemed to be grouped more homogeneously when the functional classification scheme was used.
The BBS has potential for use with children as a measure of functional balance. Its ease of use makes it an appealing clinical measure. More research is needed to evaluate its reliability with a pediatric population and its use with a younger age group. Because it would be valuable to use as an evaluative index with children with cerebral palsy, future research should also include evaluation of its responsiveness with a pediatric population.
This research was conducted in partial fulfillment of the requirements for a Master of Science degree in Physical Therapy at the University of Alberta for the first author. We would like to thank the children and their families who participated in the study, and the physical therapists at the Glenrose Hospital who assisted with recruitment of subjects and data collection.
1. Campbell SK. Quantifying the effects of interventions for movement disorders resulting from cerebral palsy. J Child Neurol. 1996; 11: S61–S70.
2. Liao H-F, Jeng S-F, Lai J-S, et al. The relation between standing balance and walking function in children with spastic diplegic cerebral palsy. Dev Med Child Neurol. 1997; 39: 106–112.
3. Woollacott M, Burtner P. Neural and musculoskeletal contributions to the development of stance balance control in typical children and in children with cerebral palsy. Acta Paediatr. 1996; 416: S58–S62.
4. Nashner L, Shumway-Cook A, Marin O. Stance posture control in select groups of children with cerebral palsy: deficits in sensory organization and muscular coordination. Exp Brain Res. 1983; 49: 393–409.
5. Berg K. Balance and its measure in the elderly: a review. Physiother Can. 1989; 41: 240–246.
6. Berg KO, Maki BE, Williams JI, et al. Clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil. 1992; 73: 1073–1083.
7. Westcott SL, Lowes LP, Richardson PK. Evaluation of postural stability in children: current theories and assessment tools. Phys Ther. 1997; 77: 629–645.
8. Berg K, Wood-Dauphinee S, Williams JI, et al. Measuring balance in the elderly: preliminary development of an instrument. Physiother Can. 1989; 41: 304–311.
9. Cole B, Finch E, Gowland C, et al. Physical Rehabilitation Outcome Measures. 2nd ed. Toronto: Canadian Physiotherapy Association; 1994.
10. Liston R, Brouwer B. Reliability and validity of measures obtained from stroke patients using the Balance Master. Arch Phys Med Rehabil. 1996; 77: 425–430.
11. Russell D, Rosenbaum P, Gowland C. Gross Motor Function Measure Manual. 2nd ed. Hamilton, Ontario: McMaster University; 1993.
12. Scrutton D, Rosenbaum P. The locomotor development of children with cerebral palsy. In: Connolly KJ, Forssberg H, eds. Neurophysiology & Neuropsychology of Motor Development. London: MacKeith Press; 1997: 101–123.
13. Montgomery PC. Predicting potential for ambulation in children with cerebral palsy. Pediatr Phys Ther. 1998; 10: 148–155.
14. Palisano R, Rosenbaum P, Walter S, et al. Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997; 39: 214–223.
15. Richardson PK, Atwater SW, Crowe TK, et al. Performance of preschoolers on the pediatric clinical test of sensory interaction for balance. Am J Occup Ther. 1992; 46: 793–800.
16. Berg KO, Wood-Dauphinee SL, Williams JI, et al. Measuring balance in the elderly: validation of an instrument. Can J Public Health. 1992; 83 (Suppl 2): S7–S11.
17. Nordmark E, Hägglund G, Jarnlo GB. Reliability of the gross motor function measure in cerebral palsy. Scand J Rehabil Med. 1997; 29: 25–28.
18. WHO. ICIDH-2: International Classification of Impairments, Activities, and Participation. A Manual of Dimensions of Disablement and Health. Beta-1 draft for field trials. Geneva: World Health Organization; 1997; 14–16.
19. Fetters L. Measurement and treatment in cerebral palsy: an argument for a new approach. Phys Ther. 1991; 71: 244–247.
20. Beckung E, Hagberg G. Correlation between ICIDH handicap code and Gross Motor Function Classification System in children with cerebral palsy. Dev Med Child Neurol 2000; 42: 669–673.
BERG BALANCE SCALE WORKSHEET AND INSTRUCTIONS
Please demonstrate 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, if the subject’s performance warrants supervision, or if the subject touches an external support or receives assistance from the examiner. Subjects 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 the testing are 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 of reasonable height. Either a step or a stool (of average step height) may be used for item # 12.
1. SITTING TO STANDINGINSTRUCTIONS: Please stand up. Try not to use your hands for support.
( ) 4 able to stand without using hands and stabilize independently
( ) 3 able to stand independently using hand
( ) 2 able to stand using hands after several tries
( ) 1 needs minimal aid to stand or to stabilize
( ) 0 needs moderate or maximal assist to stand
2. STANDING UNSUPPORTEDINSTRUCTIONS: Please stand for 2 minutes without holding.
( ) 4 able to stand safely 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 unsupportedIf a subject is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item # 4.
3. SITTING WITH BACK UNSUPPORTED BUT FEET SUPPORTED ON FLOOR OR ON A STOOLINSTRUCTIONS: Please sit with arms folded for 2 minutes.
( ) 4 able to sit safely and securely 2 minutes
( ) 3 able to sit 2 minutes under supervision
( ) 2 able to sit 30 seconds
( ) 1 able to sit 10 seconds
( ) 0 unable to sit without support 10 seconds
4. STANDING TO SITTINGINSTRUCTIONS: Please sit down.
( ) 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 assistance to sit
5. TRANSFERSINSTRUCTIONS: Arrange chair(s) for a 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.
( ) 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 cueing and/or supervision
( ) 1 needs one person to assist
( ) 0 need two people to assist or supervise to be safe
6. STANDING UNSUPPORTED WITH EYES CLOSEDINSTRUCTIONS: Please close your eyes and stand still for 10 seconds.
( ) 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 steady
( ) 0 needs help to keep from falling
7. STANDING UNSUPPORTED WITH FEET TOGETHERINSTRUCTIONS: Place your feet together and stand without holding.
( ) 4 able to place feet together independently and stand 1 minute safely
( ) 3 able to place feet together independently and stand for 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
8. REACHING FORWARD WITH OUTSTRETCHED ARM WHILE STANDINGINSTRUCTIONS: Lift arm 90°. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at end of fingertips when arm in at 90°. 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.)
( ) 4 can reach forward confidently > 10 inches
( ) 3 can reach forward > 5 inches safely
( ) 2 can reach forward > 2 inches safely
( ) 1 reaches forward but needs supervision
( ) 0 loses balance while trying/requires external support
9. PICK UP OBJECT FROM THE FLOOR FROM A STANDING POSITIONINSTRUCTIONS: Pick up the shoe/slipper which is placed in front of your feet.
( ) 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 1–2 inches from slipper and 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
10. TURNING TO LOOK BEHIND OVER LEFT AND RIGHT SHOULDERS WHILE STANDINGINSTRUCTIONS: Turn to look directly behind you over your left shoulder. Repeat to the right. Examiner may pick an object to look at directly behind the subject to encourage a better twist turn.
( ) 4 looks behind from both sides and weight shifts well
( ) 3 looks behind one side only other sides shows less weight shift
( ) 2 turns sideways only but maintains balance
( ) 1 needs supervision when turning
( ) 0 needs assistance while turning
11. TURNS 360 DEGREESINSTRUCTIONS: Turn completely around in a full circle. Then turn a full circle in the other direction.
( ) 4 able to turn 360° safely in 4 seconds or less
( ) 3 able to turn 360° safely one side only in 4 seconds or less
( ) 2 able to turn 360° safely but slowly
( ) 1 needs close supervision or verbal cueing
( ) 0 needs assistance while turning
12. 12.PLACING ALTERNATE FOOT ON THE STEP OR STOOL WHILE STANDING UNSUPPORTEDINSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touched the step/stool 4 times.
( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds
( ) 3 able to stand independently and complete 8 steps > 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
13. STANDING UNSUPPORTED ONE FOOT IN FRONTINSTRUCTIONS: (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.)
( ) 4 able to place foot tandem independently and hold 30 seconds
( ) 3 able to place foot ahead of other 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
14. STANDING ON ONE LEGINSTRUCTIONS: Stand on one leg as long as you can without holding.
( ) 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 = or > 3 seconds
( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently
( ) 0 unable to try or needs assist to prevent fall ( ) TOTAL SCORE (Maximum 56)
© 2002 Lippincott Williams & Wilkins, Inc.