Advertisement

Validity and Reliability of the Berg Balance Scale for Community-Dwelling Persons With Lower-Limb Amputation

  • Matthew J. Major
    Correspondence
    Corresponding author Matthew J. Major, PhD, Northwestern University Prosthetics-Orthotics Center, 680 N Lake Shore Dr, Suite 1100, Chicago, IL 60611.
    Affiliations
    Northwestern University Prosthetics-Orthotics Center, Northwestern University Feinberg School of Medicine, Chicago, IL

    Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL
    Search for articles by this author
  • Stefania Fatone
    Affiliations
    Northwestern University Prosthetics-Orthotics Center, Northwestern University Feinberg School of Medicine, Chicago, IL

    Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL
    Search for articles by this author
  • Elliot J. Roth
    Affiliations
    Department of Physical Medicine and Rehabilitation, Northwestern University Feinberg School of Medicine, Chicago, IL

    Rehabilitation Institute of Chicago, Chicago, IL
    Search for articles by this author

      Abstract

      Objective

      To evaluate the validity and reliability of the Berg Balance Scale (BBS) for use in people with lower-limb amputation.

      Design

      Cross-sectional study.

      Setting

      Research laboratory.

      Participants

      Individuals (N=30; age, 54±12y; 20 men) with unilateral transtibial (n=13), unilateral transfemoral (n=14), or bilateral (n=3) lower-limb amputation of dysvascular (n=7), traumatic (n=14), infectious (n=6), or congenital (n=3) origin.

      Interventions

      Not applicable.

      Main Outcome Measures

      BBS, 2-minute walk test, L test, Prosthesis Evaluation Questionnaire-Mobility Subscale, Activities-specific Balance Confidence Scale, and Frenchay Activities Index; self-reported descriptors were also collected, including frequency of prosthesis use, number of falls in 12 months before the visit, fear of falling, and daily mobility aid use.

      Results

      The BBS had high interrater reliability (intraclass correlation coefficient =.945) and internal consistency (α=.827). Relations between the BBS scores and those of other outcome measures were all statistically significant (P≤.001). Significant group differences in BBS scores were observed for fear of falling (P=.008) and mobility aid use (P<.001), but not for multiple (≥2) falls in the previous 12 months (P=.381). BBS items involving reaching forward, turning 360°, tandem standing, and standing on 1 leg had relatively greater frequencies of lower scores across participants.

      Conclusions

      The BBS appears to be a valid and reliable clinical instrument for assessing balance in individuals with lower-limb amputation, but it may not be able to discriminate between individuals with greater or lesser fall risk. Limitations in prosthetic motion and control may be responsible for the challenges experienced on items of lower performance. Future studies would be useful to assess the responsiveness of the BBS to interventions aimed at improving balance in individuals with lower-limb amputation.

      Keywords

      List of abbreviations:

      ABC (Activities-specific Balance Confidence), BBS (Berg Balance Scale), FAI (Frenchay Activities Index), LLA (lower-limb amputation), PEQ-MS (Prosthesis Evaluation Questionnaire-Mobility Subscale), ROM (range of motion), 2MWT (2-minute walk test)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Archives of Physical Medicine and Rehabilitation
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Pauley T.
        • Devlin M.
        • Heslin K.
        Falls sustained during inpatient rehabilitation after lower limb amputation: prevalence and predictors.
        Am J Phys Med Rehabil. 2006; 85 (quiz 33-5): 521-532
        • Miller W.C.
        • Speechley M.
        • Deathe B.
        The prevalence and risk factors of falling and fear of falling among lower extremity amputees.
        Arch Phys Med Rehabil. 2001; 82: 1031-1037
        • Kulkarni J.
        • Wright S.
        • Toole C.
        • Morris J.
        • Hirons R.
        Falls in patients with lower limb amputations: prevalence and contributing factors.
        Physiotherapy. 1996; 82: 130-136
        • Blake A.J.
        • Morgan K.
        • Bendall M.J.
        • et al.
        Falls by elderly people at home: prevalence and associated factors.
        Age Ageing. 1988; 17: 365-372
        • Campbell A.J.
        • Reinken J.
        • Allan B.C.
        • Martinez G.S.
        Falls in old age: a study of frequency and related clinical factors.
        Age Ageing. 1981; 10: 264-270
        • Miller W.C.
        • Deathe A.B.
        • Speechley M.
        • Koval J.
        The influence of falling, fear of falling, and balance confidence on prosthetic mobility and social activity among individuals with a lower extremity amputation.
        Arch Phys Med Rehabil. 2001; 82: 1238-1244
        • Norvell D.C.
        • Turner A.P.
        • Williams R.M.
        • Hakimi K.N.
        • Czerniecki J.M.
        Defining successful mobility after lower extremity amputation for complications of peripheral vascular disease and diabetes.
        J Vasc Surg. 2011; 54: 412-419
        • Pedrinelli A.
        • Saito M.
        • Coelho R.F.
        • Fontes R.B.
        • Guarniero R.
        Comparative study of the strength of the flexor and extensor muscles of the knee through isokinetic evaluation in normal subjects and patients subjected to trans-tibial amputation.
        Prosthet Orthot Int. 2002; 26: 195-205
        • Nadollek H.
        • Brauer S.
        • Isles R.
        Outcomes after trans-tibial amputation: the relationship between quiet stance ability, strength of hip abductor muscles and gait.
        Physiother Res Int. 2002; 7: 203-214
        • Kavounoudias A.
        • Tremblay C.
        • Gravel D.
        • Iancu A.
        • Forget R.
        Bilateral changes in somatosensory sensibility after unilateral below-knee amputation.
        Arch Phys Med Rehabil. 2005; 86: 633-640
        • Geurts A.C.
        • Mulder T.W.
        • Nienhuis B.
        • Rijken R.A.
        Postural reorganization following lower limb amputation: possible motor and sensory determinants of recovery.
        Scand J Rehabil Med. 1992; 24: 83-90
        • Quai T.M.
        • Brauer S.G.
        • Nitz J.C.
        Somatosensation, circulation and stance balance in elderly dysvascular transtibial amputees.
        Clin Rehabil. 2005; 19: 668-676
        • Hermodsson Y.
        • Ekdahl C.
        • Persson B.M.
        • Roxendal G.
        Standing balance in trans-tibial amputees following vascular disease or trauma: a comparative study with healthy subjects.
        Prosthet Orthot Int. 1994; 18: 150-158
        • Hof A.L.
        • van Bockel R.M.
        • Schoppen T.
        • Postema K.
        Control of lateral balance in walking: experimental findings in normal subjects and above-knee amputees.
        Gait Posture. 2007; 25: 250-258
        • Buckley J.G.
        • O'Driscoll D.
        • Bennett S.J.
        Postural sway and active balance performance in highly active lower-limb amputees.
        Am J Phys Med Rehabil. 2002; 81: 13-20
        • Vanicek N.
        • Strike S.
        • McNaughton L.
        • Polman R.
        Postural responses to dynamic perturbations in amputee fallers versus nonfallers: a comparative study with able-bodied subjects.
        Arch Phys Med Rehabil. 2009; 90: 1018-1025
        • Vrieling A.H.
        • van Keeken H.G.
        • Schoppen T.
        • et al.
        Balance control on a moving platform in unilateral lower limb amputees.
        Gait Posture. 2008; 28: 222-228
        • Nederhand M.J.
        • Van Asseldonk E.H.
        • der Kooij H.V.
        • Rietman H.S.
        Dynamic Balance Control (DBC) in lower leg amputee subjects: contribution of the regulatory activity of the prosthesis side.
        Clin Biomech (Bristol, Avon). 2012; 27: 40-45
        • Viton J.M.
        • Mouchnino L.
        • Mille M.L.
        • et al.
        Equilibrium and movement control strategies in trans-tibial amputees.
        Prosthet Orthot Int. 2000; 24: 108-116
        • Major M.J.
        • Stine R.L.
        • Gard S.A.
        The effects of walking speed and prosthetic ankle adapters on upper extremity dynamics and stability-related parameters in bilateral transtibial amputee gait.
        Gait Posture. 2013 May 13; ([Epub ahead of print])
        • Major M.J.
        • Kenney L.P.
        • Twiste M.
        • Howard D.
        Stance phase mechanical characterization of trans-tibial prostheses distal to the socket: a review.
        J Rehabil Res Dev. 2012; 49: 815-829
        • van Velzen J.M.
        • van Bennekom C.A.
        • Polomski W.
        • Slootman J.R.
        • van der Woude L.H.
        • Houdijk H.
        Physical capacity and walking ability after lower limb amputation: a systematic review.
        Clin Rehabil. 2006; 20: 999-1016
        • Hislop H.J.
        • Montgomery J.
        Daniels and Worthingham's muscle testing: techniques of manual examination.
        8th ed. Saunders, St. Louis1995
        • Norkin C.C.
        • White D.J.
        Measurement of joint motion: a guide to goniometry.
        3rd ed. F.A. Davis Company, Philadelphia2003
        • Deathe A.B.
        • Wolfe D.L.
        • Devlin M.
        • Hebert J.S.
        • Miller W.C.
        • Pallaveshi L.
        Selection of outcome measures in lower extremity amputation rehabilitation: ICF activities.
        Disabil Rehabil. 2009; 31: 1455-1473
        • Miller W.C.
        • Speechley M.
        • Deathe A.B.
        Balance confidence among people with lower-limb amputations.
        Phys Ther. 2002; 82: 856-865
        • Berg K.
        • Wood-Dauphinee S.
        • Williams J.I.
        • Gayton D.
        Measuring balance in the elderly: validation of an instrument.
        Physiother Canada. 1989; 41: 304-311
        • Berg K.O.
        • Maki B.E.
        • Williams J.I.
        • Holliday P.J.
        • Wood-Dauphinee S.L.
        Clinical and laboratory measures of postural balance in an elderly population.
        Arch Phys Med Rehabil. 1992; 73: 1073-1080
        • Berg K.O.
        • Wood-Dauphinee S.L.
        • Williams J.I.
        • Maki B.
        Measuring balance in the elderly: validation of an instrument.
        Can J Public Health. 1992; 83: S7-11
        • Berg K.
        • Wood-Dauphinee S.
        • Williams J.I.
        The Balance Scale: reliability assessment with elderly residents and patients with an acute stroke.
        Scand J Rehabil Med. 1995; 27: 27-36
        • Sahin F.
        • Yilmaz F.
        • Ozmaden A.
        • Kotevolu N.
        • Sahin T.
        • Kuran B.
        Reliability and validity of the Turkish version of the Berg Balance Scale.
        J Geriatr Phys Ther. 2008; 31: 32-37
        • Halsaa K.E.
        • Brovold T.
        • Graver V.
        • Sandvik L.
        • Bergland A.
        Assessments of interrater reliability and internal consistency of the Norwegian version of the Berg Balance Scale.
        Arch Phys Med Rehabil. 2007; 88: 94-98
        • Liston R.A.
        • Brouwer B.J.
        Reliability and validity of measures obtained from stroke patients using the Balance Master.
        Arch Phys Med Rehabil. 1996; 77: 425-430
        • Mao H.F.
        • Hsueh I.P.
        • Tang P.F.
        • Sheu C.F.
        • Hsieh C.L.
        Analysis and comparison of the psychometric properties of three balance measures for stroke patients.
        Stroke. 2002; 33: 1022-1027
        • Wee J.Y.
        • Wong H.
        • Palepu A.
        Validation of the Berg Balance Scale as a predictor of length of stay and discharge destination in stroke rehabilitation.
        Arch Phys Med Rehabil. 2003; 84: 731-735
        • Blum L.
        • Korner-Bitensky N.
        Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review.
        Phys Ther. 2008; 88: 559-566
        • Wirz M.
        • Muller R.
        • Bastiaenen C.
        Falls in persons with spinal cord injury: validity and reliability of the Berg Balance Scale.
        Neurorehabil Neural Repair. 2010; 24: 70-77
        • Lemay J.F.
        • Nadeau S.
        Standing balance assessment in ASIA D paraplegic and tetraplegic participants: concurrent validity of the Berg Balance Scale.
        Spinal Cord. 2010; 48: 245-250
        • Ditunno Jr., J.F.
        • Barbeau H.
        • Dobkin B.H.
        • et al.
        Validity of the walking scale for spinal cord injury and other domains of function in a multicenter clinical trial.
        Neurorehabil Neural Repair. 2007; 21: 539-550
        • Learmonth Y.C.
        • Paul L.
        • McFadyen A.K.
        • Mattison P.
        • Miller L.
        Reliability and clinical significance of mobility and balance assessments in multiple sclerosis.
        Int J Rehabil Res. 2012; 35: 69-74
        • Cattaneo D.
        • Jonsdottir J.
        • Repetti S.
        Reliability of four scales on balance disorders in persons with multiple sclerosis.
        Disabil Rehabil. 2007; 29: 1920-1925
        • Cattaneo D.
        • Regola A.
        • Meotti M.
        Validity of six balance disorders scales in persons with multiple sclerosis.
        Disabil Rehabil. 2006; 28: 789-795
        • Newstead A.H.
        • Hinman M.R.
        • Tomberlin J.A.
        Reliability of the Berg Balance Scale and balance master limits of stability tests for individuals with brain injury.
        J Neurol Phys Ther. 2005; 29: 18-23
        • Feld J.A.
        • Rabadi M.H.
        • Blau A.D.
        • Jordan B.D.
        Berg Balance Scale and outcome measures in acquired brain injury.
        Neurorehabil Neural Repair. 2001; 15: 239-244
        • Rao A.K.
        • Muratori L.
        • Louis E.D.
        • Moskowitz C.B.
        • Marder K.S.
        Clinical measurement of mobility and balance impairments in Huntington's disease: validity and responsiveness.
        Gait Posture. 2009; 29: 433-436
        • Leddy A.L.
        • Crowner B.E.
        • Earhart G.M.
        Functional gait assessment and balance evaluation system test: reliability, validity, sensitivity, and specificity for identifying individuals with Parkinson disease who fall.
        Phys Ther. 2011; 91: 102-113
        • Scalzo P.L.
        • Nova I.C.
        • Perracini M.R.
        • et al.
        Validation of the Brazilian version of the Berg Balance Scale for patients with Parkinson's disease.
        Arquivos De Neuro-Psiquiatria. 2009; 67: 831-835
        • Qutubuddin A.A.
        • Pegg P.O.
        • Cifu D.X.
        • Brown R.
        • McNamee S.
        • Carne W.
        Validating the Berg Balance Scale for patients with Parkinson's disease: a key to rehabilitation evaluation.
        Arch Phys Med Rehabil. 2005; 86: 789-792
        • Steffen T.
        • Seney M.
        Test-retest reliability and minimal detectable change on balance and ambulation tests, the 36-item short-form health survey, and the unified Parkinson disease rating scale in people with parkinsonism.
        Phys Ther. 2008; 88: 733-746
        • Franchignoni F.
        • Martignoni E.
        • Ferriero G.
        • Pasetti C.
        Balance and fear of falling in Parkinson's disease.
        Parkinsonism Relat Disord. 2005; 11: 427-433
        • Lim L.I.
        • van Wegen E.E.
        • de Goede C.J.
        • et al.
        Measuring gait and gait-related activities in Parkinson's patients own home environment: a reliability, responsiveness and feasibility study.
        Parkinsonism Relat Disord. 2005; 11: 19-24
        • Bogle Thorbahn L.D.
        • Newton R.A.
        Use of the Berg Balance Test to predict falls in elderly persons.
        Phys Ther. 1996; 76 (discussion 84-5): 576-583
        • Muir S.W.
        • Berg K.
        • Chesworth B.
        • Speechley M.
        Use of the Berg Balance Scale for predicting multiple falls in community-dwelling elderly people: a prospective study.
        Phys Ther. 2008; 88: 449-459
        • Persson C.U.
        • Hansson P.O.
        • Sunnerhagen K.S.
        Clinical tests performed in acute stroke identify the risk of falling during the first year: postural stroke study in Gothenburg (POSTGOT).
        J Rehabil Med. 2011; 43: 348-353
        • Alzayer L.
        • Beninato M.
        • Portney L.G.
        The accuracy of individual Berg Balance Scale items compared with the total Berg score for classifying people with chronic stroke according to fall history.
        J Neurol Phys Ther. 2009; 33: 136-143
        • Andersson A.G.
        • Kamwendo K.
        • Seiger A.
        • Appelros P.
        How to identify potential fallers in a stroke unit: validity indexes of 4 test methods.
        J Rehabil Med. 2006; 38: 186-191
        • Nilsagard Y.
        • Lundholm C.
        • Denison E.
        • Gunnarsson L.G.
        Predicting accidental falls in people with multiple sclerosis—a longitudinal study.
        Clin Rehabil. 2009; 23: 259-269
        • Medley A.
        • Thompson M.
        • French J.
        Predicting the probability of falls in community dwelling persons with brain injury: a pilot study.
        Brain Inj. 2006; 20: 1403-1408
        • McCulloch K.L.
        • Buxton E.
        • Hackney J.
        • Lowers S.
        Balance, attention, and dual-task performance during walking after brain injury: associations with falls history.
        J Head Trauma Rehabil. 2010; 25: 155-163
        • Busse M.E.
        • Wiles C.M.
        • Rosser A.E.
        Mobility and falls in people with Huntington's disease.
        J Neurol Neurosurg Psychiatry. 2009; 80: 88-90
        • Kerr G.K.
        • Worringham C.J.
        • Cole M.H.
        • Lacherez P.F.
        • Wood J.M.
        • Silburn P.A.
        Predictors of future falls in Parkinson disease.
        Neurology. 2010; 75: 116-124
        • Dibble L.E.
        • Lange M.
        Predicting falls in individuals with Parkinson disease: a reconsideration of clinical balance measures.
        J Neurol Phys Ther. 2006; 30: 60-67
        • Duncan R.P.
        • Leddy A.L.
        • Cavanaugh J.T.
        • et al.
        Accuracy of fall prediction in Parkinson disease: six-month and 12-month prospective analyses.
        Parkinsons Dis. 2012; 2012: 237673
        • Landers M.R.
        • Backlund A.
        • Davenport J.
        • Fortune J.
        • Schuerman S.
        • Altenburger P.
        Postural instability in idiopathic Parkinson's disease: discriminating fallers from nonfallers based on standardized clinical measures.
        J Neurol Phys Ther. 2008; 32: 56-61
        • Dite W.
        • Connor H.J.
        • Curtis H.C.
        Clinical identification of multiple fall risk early after unilateral transtibial amputation.
        Arch Phys Med Rehabil. 2007; 88: 109-114
        • Gosselin S.
        • Desrosiers J.
        • Corriveau H.
        • et al.
        Outcomes during and after inpatient rehabilitation: comparison between adults and older adults.
        J Rehabil Med. 2008; 40: 55-60
        • Yazicioglu K.
        • Taskaynatan M.A.
        • Guzelkucuk U.
        • Tugcu I.
        Effect of playing football (soccer) on balance, strength, and quality of life in unilateral below-knee amputees.
        Am J Phys Med Rehabil. 2007; 86: 800-805
        • Vincent C.
        • Demers E.
        • Moffet H.
        • Corriveau H.
        • Nadeau S.
        • Mercier C.
        Use of an innovative model to evaluate mobility in seniors with lower-limb amputations of vascular origin: a pilot study.
        BMC Geriatr. 2010; 10: 68
        • Sawatzky B.
        • Denison I.
        • Langrish S.
        • Richardson S.
        • Hiller K.
        • Slobogean B.
        The segway personal transporter as an alternative mobility device for people with disabilities: a pilot study.
        Arch Phys Med Rehabil. 2007; 88: 1423-1428
        • Cowley A.
        • Kerr K.
        Amputees and tightropes: a pilot study to measure postural control post-amputation.
        Phys Ther Rev. 2001; 6: 5-15
        • Ülger Ö
        • Topuz S.
        • Bayramlar K.
        Effects of a hydraulic knee joint on energy consumption, gait and patient satisfaction in trans-femoral amputees.
        Fizyoterapi Rehabilitasyon. 2009; 20: 169-177
        • Portney L.G.
        • Watkins M.P.
        Foundations of clinical research: applications to practice.
        3rd ed. Prentice-Hall, Upper Saddle River2009
        • Rougier P.R.
        • Bergeau J.
        Biomechanical analysis of postural control of persons with transtibial or transfemoral amputation.
        Am J Phys Med Rehabil. 2009; 88: 896-903
        • Miller W.C.
        • Deathe A.B.
        • Speechley M.
        Lower extremity prosthetic mobility: a comparison of 3 self-report scales.
        Arch Phys Med Rehabil. 2001; 82: 1432-1440
        • Walter S.D.
        • Eliasziw M.
        • Donner A.
        Sample size and optimal designs for reliability studies.
        Stat Med. 1998; 17: 101-110
      1. Cohen J. Statistical power analysis for the behavioral sciences. In: The t test for means. 2nd ed. Hillsdale: Erlbaum; 1988. p 19-74.

        • Faul F.
        • Erdfelder E.
        • Lang A.G.
        • Buchner A.
        G*Power 3: a flexible statistical power analysis program for the social, behavioral, and biomedical sciences.
        Behav Res Meth. 2007; 39: 175-191
        • Askham J.
        • Glucksman E.
        • Owens P.
        • Swift C.
        • Tinker A.
        • Yu G.
        A review of research on falls among elderly people.
        Age Concern Institute of Gerontology, King's College London, and Department of Trade and Industry, London, UK1990
        • Powell L.E.
        • Myers A.M.
        The Activities-specific Balance Confidence (ABC) Scale.
        J Gerontol A Biol Sci Med Sci. 1995; 50A: M28-M34
        • Miller W.C.
        • Deathe A.B.
        • Speechley M.
        Psychometric properties of the Activities-specific Balance Confidence Scale among individuals with a lower-limb amputation.
        Arch Phys Med Rehabil. 2003; 84: 656-661
        • Legro M.W.
        • Reiber G.D.
        • Smith D.G.
        • del Aguila M.
        • Larsen J.
        • Boone D.
        Prosthesis evaluation questionnaire for persons with lower limb amputations: assessing prosthesis-related quality of life.
        Arch Phys Med Rehabil. 1998; 79: 931-938
        • Schuling J.
        • de Haan R.
        • Limburg M.
        • Groenier K.H.
        The Frenchay Activities Index: assessment of functional status in stroke patients.
        Stroke. 1993; 24: 1173-1177
        • Holbrook M.
        • Skilbeck C.E.
        An activities index for use with stroke patients.
        Age Ageing. 1983; 12: 166-170
        • Miller W.C.
        • Deathe A.B.
        • Harris J.
        Measurement properties of the Frenchay Activities Index among individuals with a lower limb amputation.
        Clin Rehabil. 2004; 18: 414-422
        • Deathe A.B.
        • Miller W.C.
        The L test of functional mobility: measurement properties of a modified version of the timed “up & go” test designed for people with lower-limb amputations.
        Phys Ther. 2005; 85: 626-635
        • Brooks D.
        • Parsons J.
        • Hunter J.P.
        • Devlin M.
        • Walker J.
        The 2-minute walk test as a measure of functional improvement in persons with lower limb amputation.
        Arch Phys Med Rehabil. 2001; 82: 1478-1483
        • Brooks D.
        • Hunter J.P.
        • Parsons J.
        • Livsey E.
        • Quirt J.
        • Devlin M.
        Reliability of the two-minute walk test in individuals with transtibial amputation.
        Arch Phys Med Rehabil. 2002; 83: 1562-1565
        • Raya M.A.
        • Gailey R.S.
        • Fiebert I.M.
        • Roach K.E.
        Impairment variables predicting activity limitation in individuals with lower limb amputation.
        Prosthet Orthot Int. 2010; 34: 73-84