Balance Error Scoring System

Original Editor - Sinead Greenan Top Contributors - Sinead Greenan, Lucinda hampton, Evan Thomas, Oyemi Sillo, 127.0.0.1, WikiSysop and Kim Jackson

Objective

The balance error scoring system (BESS) is a brief, easily administered test of static balance. It is often used in the population of athletes with concussion or mild traumatic brain injury.

Information obtained from this clinical balance tool can be used to assist clinicians in making return to play decisions following mild head injury. The BESS can be performed in nearly any environment and takes approximately 10 minutes to conduct.

Intended Population

Problems with balance and postural stability can arise from injuries or diseases affecting the vestibular system and/or brain. eg sport-related concussion, stroke, Parkinson's disease, multiple sclerosis, traumatic brain injury, blast exposure in the military. Blunt trauma to the head can cause persistent problems with dizziness and balance.

Equipment Required

• Foam pad
• Stopwatch
• An assistant to act as a spotter
• BESS testing protocol (instructions to be read to subject during testing)
• BESS score card

Description

The balance testing consists of three stances on two different surfaces. The three stances are double leg stance, single leg stance and tandem stance. The two different surfaces include both a firm (ground) and foam surface.

The athlete will stand with hands on hips and eyes closed with a consistent foot position depending on the stance. Shoes should not be worn. In the double leg stance, the feet are flat on the testing surface approximately pelvic width apart. In the single leg stance position, the athlete is to stand on the non-dominant leg with the contralateral limb held in approximately 20° of hip flexion, 45° of knee flexion and neutral position in the frontal plane.

In the tandem stance, one foot is placed in front of of the other with heel of the anterior foot touching the toe of the posterior foot. The athlete’s non-dominant leg is in the posterior position. Leg dominance should be determined by the athlete’s kicking preference.

Administration

Establish baseline score prior to the start of the athletic season. After a concussive injury, re-assess the athlete and compare to baseline score. Only consider return to activity if scores are comparable to baseline score.

Scoring

Trial is 20 seconds. Count the number ofd errors from the proper stance. The examiner should begin counting errors only after the individual has assumed the proper testing position. If multiple errors occur at the same time, only one is counted. The maximum number of errors for a single condition is 10.

Score of 0-60 (lower scores indicate better balance and less errors). Number of errors in each trial are added together to obtain a total score (out of 60).

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.

Read instructions to subject as they are written in the testing protocol.

Normative Data

Normative reference values for the BESS stratified by age.

Age	N	Mean	Median	SD	Superior	Above average	Broadly normal	Below average	Poor	Very poor
20–29	65	11.3	11.0	4.8	0–5	6-7	8–14	15–17	18–23	24+
30–39	173	11.5	11.0	5.5	0–4	5–7	8–15	16–18	19–26	27+
40–49	352	12.5	11.5	6.2	0–5	6–8	9–16	17–20	21–28	29+
50–54	224	14.2	12.0	7.5	0–6	7-8	9–18	19–24	25–33	34+
55–59	197	16.5	15.0	7.6	0–7	8–10	11–20	21–28	29–35	36+
60–64	148	18.0	16.5	7.8	0–8	9–12	13–22	23–28	29–40	41+
65-69	77	19.9	18.0	7.1	0–12	13–15	16–24	25–32	33–38	39+

Conclusion

The BESS is a clinical evaluation of balance that usually has moderate to good reliability. The BESS correlates with laboratory-based measures for criterion-related validity and has construct validity. Scores increase with concussion, functional ankle instability, external ankle bracing, fatigue, and age. Scores should improve after completing a comprehensive neuromuscular training program.

Resources

• Balance Error Scoring System (BESS)