Original article| Volume 95, ISSUE 2, P353-359, February 2014

Instrumenting the Balance Error Scoring System for Use With Patients Reporting Persistent Balance Problems After Mild Traumatic Brain Injury

Published:November 07, 2013DOI:



      To determine whether alterations to the Balance Error Scoring System (BESS), such as modified conditions and/or instrumentation, would improve the ability to correctly classify traumatic brain injury (TBI) status in patients with mild TBI with persistent self-reported balance complaints.


      Cross-sectional study.


      Outpatient clinic.


      Subjects (n=13; age, 16.3±2y) with a recent history of concussion (mild TBI group) and demographically matched control subjects (n=13; age, 16.7±2y; control group).


      Not applicable.

      Main Outcome Measures

      Outcome measures included the BESS, modified BESS, instrumented BESS, and instrumented modified BESS. All subjects were tested on the noninstrumented BESS and modified BESS and were scored by visual observation of instability in 6 and 3 stance conditions, respectively. Instrumentation of these 2 tests used 1 inertial sensor with an accelerometer and gyroscope to quantify bidirectional body sway.


      Scores from the BESS and the modified BESS tests were similar between groups. However, results from the instrumented measures using the inertial sensor were significantly different between groups. The instrumented modified BESS had superior diagnostic classification and the largest area under the curve when compared with the other balance measures.


      A concussion may disrupt the sensory processing required for optimal postural control, which was measured by sway during quiet stance. These results suggest that the use of portable inertial sensors may be useful in the move toward more objective and sensitive measures of balance control postconcussion, but more work is needed to increase sensitivity.


      List of abbreviations:

      AP (anterior-posterior), AUC (area under the curve), BESS (Balance Error Scoring System), ML (mediolateral), mTBI (mild traumatic brain injury), NIH (National Institutes of Health), OHSU (Oregon Health & Science University), RMS (root-mean-square), ROC (receiver operating characteristic), TBI (traumatic brain injury)
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