Balance Error Scoring System

Original Editor - Sinead Greenan Top Contributors - Sinead Greenan and Evan Thomas

Objective

The Balance Error Scoring System is an objective measure of assessing static postural stability (designed for the mild head injury population, to assist in return to sports play decisions).

Intended Population

Those diagnosed with concussion, mild traumatic brain injury, vestibular disorders

Method of Use

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:

  • 6 conditions each tested barefoot, eyes closed for 20 seconds each:
    • Double leg stance (feet together) – firm / foam surfaces
      Single leg stance (non-dominant foot) – firm / foam surfaces
    • Tandem stance (non-dominant foot in back) – firm / foam
  • Score of 0-60 (lower scores indicate better balance and less errors).
  • Each trial is scored by counting errors (deviations from the proper stance). If multiple errors occur at the same time, only one is counted. The maximum number of errors for a single condition is 10.
  • 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.
  • Number of errors in each trial are added together to obtain a total score (out of 60).
  • Read instructions to subject as they are written in the testing protocol.

Evidence

Reliability

Test-retest Reliability

  • Athletes: (Bell et al, 2011) [1]
  • Adequate test retest reliability in youth participants aged 9-14 (ICC = 0.70)


Interrater/Intrarater Reliability

  • Athletes (without neurological / orthopedic injury): (Susco et al, 2004; n = 34 subset of subjects) [2]
    • Adequate to Excellent intrarater reliability (ICC from 0.62-0.82)
    • Excellent: Double support / firm surface (ICC = 0.82)
    • Adequate: Double support / firm surface (ICC = 0.63)


  • Athletes: (Bell et al, 2011; n = 18 college athletes)[1]
    • Excellent interrater reliability (ICC = 0.78-0.96)
    • Adequate-excellent interrater reliability (ICC = 0.57-0.85 for total score (systematic review looking at 8 studies)
    • Adequate-excellent intrarater reliability for total score (ICC = 0.60-0.92)

Validity

Criterion Validity (Predictive/Concurrent)

  • Athletes: (Bell et al, 2011) [1]
    • Adequate-excellent correlations with target sway in male athletes
    • Significant correlations for 5 of the 6 stances (r = 0.31-0.79, p < 0.01)


  • Concussion: (Barlow et al, 2011 retrospective chart review of middle and high school students; n = 106; mean age = 15.38(1.7) years; mean days between testing = 15.5(14.1) days) [3]
    • Adequate correlation with ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing)Impulse control (r = -0.31)
    • Adequate correlation with ImPACT verbal score (r = 0.37)
    • Poor correlation with ImPACT visual motor speed change (r = -0.33)
    • Poor correlation with ImPACT reaction time (r = -0.02)
    • Poor correlation with PCSS (r = 0.15)


  • Athletes (controls without neurological / orthopedic injury): (Susco et al, 2004) [2]
    • Positive correlation with RPW score (r = 0.542)


Construct Validity (Convergent/Discriminant)

  • Athletes: (Bell et al, 2011) [1]
    • Convergent validity: BESS and sensory organization test (SOT), validated in a concussed population. More errors seen at day 1 post injury compared to healthy individuals, but returned to baseline at 3 and 5 days post injury. Average errors 9(4) for control, 15(8) for concussed, effect size 1.0.
    • Discriminant: BESS does not discriminate between concussed athletes with and without a headache (p = 0.87)
    • BESS performance worsens after 50 years of age (p < 0.01), r = 0.36
    • Increase in total BESS score (poorer performance) after whole-body or central fatigue (p < 0.01)
    • Barefoot BESS performance better than braced BESS (p = 0.04), before walking, better than braced (p=.03 or taped (p = 0.04) after walking. Differences not seen in SOT between conditions.


  • Healthy adults: (Iverson et al, 2008) [4]
    • Adequate correlation between BESS and age(r = 0.36)
    • Poor correlation between BESS and height (r = -0.03)
    • Poor correlation between BESS and weight (r = 0.16)
    • Poor correlation between BESS and waist circumference (r = 0.26)
    • Poor correlation between BESS and BMI (r = 0.23)

Responsiveness

Not established

Resources

References

  1. 1.0 1.1 1.2 1.3 Bell, D. R., Guskiewicz, K. M., et al. "Systematic review of the balance error scoring system." Sports Health 2011 3(3): 287-295
  2. 2.0 2.1 Susco, T. M., Valovich McLeod, T. C., et al. "Balance Recovers Within 20 Minutes After Exertion as Measured by the Balance Error Scoring System." J Athl Train 2004 39(3): 241-246
  3. Barlow, M., Schlabach, D., et al. "Differences in change scores and the predictive validity of three commonly used measures following concussion in the middle school and high school aged population." Int J Sports Phys Ther 2011 6(3): 150-157
  4. Iverson, G. L., Kaarto, M. L., et al. "Normative data for the balance error scoring system: implications for brain injury evaluations." Brain Inj 2008 22(2): 147-152