BBS TP

Domiciliary Care

Berg Balance Scale Training Package →(Department for Communities and Social Inclusion 2014).

22

AbbreviationsAbbreviation Word Abbreviation Word Abbreviation Word

Abd Abductor FIM Functional Independence Measure

Quad Quadricep

Add Adductor Gastroc Gastrocnemius ROM Range of Motion

ADL Activity of Daily Living ICC Intraclass Correlation RR Relative Reliability

Ax Assessment Intra-R Intra-rater Reliability SBA Stand-by Assist

BBS Berg Balance Scale Inter-R Inter-rater Reliability SCI Spinal Cord Injury

BI Barthel Index IR Internal Rotation SLS Single Leg Stance

BOS Base of Support Jt Joint T/F Transfer

COG Centre of Gravity LA Light Assist TP Training Package

COP Centre of Pressure LL Lower Limb TUG Timed Up & Go

DC Domiciliary Care MS Multiple Sclerosis UL Upper Limb

DF Dorsiflexor Mvt Movement

F Flexion PT Physiotherapist

→←

3

Introduction to the Project

3

Aim: To develop a BBS TP for PTs to consistently measure balance to inform clinical decision making, thereby improving quality of care that is evidence informed at DC.

Objectives: •Design a TP that is relevant to the DC clientele so the BBS can be delivered in a home based setting.•Create a list of possible variations to implementation of the BBS for PTs.•Design a systematic and standardised method of undertaking the BBS.

Target Group: 6000 DC clients, generally over 65 years old, but also younger adults whom benefit from ongoing PT. Clients are frequently frail, with multiple medical conditions and most require assistance with at least one ADL. DC services assist clients to improve their quality of life in the community, and provide respite and support for their caregivers (Burdon 2013).

Stakeholders: 35 PT employed by DC in clinical roles with varying years of clinical experience (new graduates to 20+ years) looking to build upon the organisation’s current knowledge and protocols.

→←

44

Users Are Encouraged To Read the package provided

Follow links to full text articles and Word Documents/PDF summaries at the end of each section if further detail is required

Complete the Self-directed Quiz to test own knowledge

→←

55

Topics Covered1.General BBS Information2.Statistics – Reliability

2.1 Statistics – Validity3.Minimal Detectable Change (MDC) in Different Population Groups4.General Interpretation of BBS Scores

4.1 Interpretation of BBS Scores for Different Age Groups5.BBS for Predicting Falls – Cut-off Scores

5.1 BBS for Predicting Falls – Cut-off Scores for Different Populations1.BBS for Intervention Guidance2.Falls Prevention Program

6.1 Falls Prevention Program Resources3.Limitations of the BBS

7.1 Limitations of the BBS – Different Population Groups•Instructions for Administering the BBS at DC•Self Directed Quiz

→←

(Department for Communities and Social Inclusion 2014).

66

1.0: General BBS Information

→←

Developed by Katherine Berg (Berg et al. 1989):“The BBS is an objective performance-based measure of balance abilities. It has been used to identify and evaluate balance impairment in the elderly.” “The items test the client's ability to maintain positions or movements of increasing difficulty by diminishing the BOS from sitting, standing to single leg stance. The ability to change position is also assessed. The test is simple, easy to administer and safe for the evaluation of elderly patients,” (University of South Australia 2015).

The BBS includes:•14-items designed to assess static balance, limited dynamic balance and fall risk in adult populations•Static and dynamic activities of varying difficulty•Items scored on a 0-4 ordinal scale:

• 0 = lowest level of function• 4 = highest level of function

•Maximum Score = 56 (item scores are summed)•Time to administer = 15-20 minutes (Rehab Measures 2014).

77

2.0: Statistics – Reliability

→←

(Mackintosh 2015; Blum & Korner-Bitensky 2008; Cattaneo, Jonsdottir & Repetti 2007; Quinn et al 2013).

Population Inter-R ICC Intra-R ICC Test-retest ICC Interpretation

All 0.97 (0.96 to 0.98) 0.98 (0.97 to 0.99)BBS as an OM is generally consistent & free from error across all populations

Stroke 0.95-0.98 0.97 0.98

MS 0.96 0.96

Huntington’s 0.90-0.97

• With regard to balance, intra-R refers to the reproducibility of the BBS score when tested and retested by the same assessor

• Inter-R refers to the reproducibility of a balance score when measured by different assessors• Relative Reliability (RR) provides information about the variation in a score due to measurement

error relative to variation within a population. This measure of reliability is commonly expressed as ICC, where a score of 1 represents perfect agreement and a score of 0 represents no relationship (Downs, Marquez & Chiarelli 2013)

88

2.1: Statistics – ValidityValidity Results Interpretation

Criterion-related • BI (Pearson r = 0.67)• Fugl-Meyer Test motor and balance

subscales (Pearson r = 0.62)• TUG scores (Pearson r = -0.76)• Tinetti Balance Test (Pearson r = 0.91)• Emory Functional Ambulation Profile

(Pearson r = -0.60) (Steffen, Hacker & Mollinger 2002)

Generally high correlations between BBS scores & other functional OM in a variety of older adults with disability (Steffen, Hacker & Mollinger 2002)

Predictive • Elderly population with Dynamic Gait Index (r=0.67) (Shumway-Cook et al. 1997)

Generally high correlations between BBS & other functional OM in the elderly population (Shumway-Cook et al. 1997)

Practicality: BBS can be used either individually or in conjunction with other OM to assess disability in older adults

→←

99

→←9

3.0: Minimal Detectable Change (MDC) in Different Population Groups• Little guidance on how confident you can be that a real change in balance has occurred between tests across time

for individual patients• If a score on the BBS was between 20-56 and a change between 3-7 points occurred, then you can be 95%

confident that a real change in balance has occurred (Downs, Marquez & Chiarelli 2013)• In an inpatient setting, patients with a score of 20 had a 30% chance of being discharged to a nursing home,

whereas patients with a score of 25 had a 20% chance, further highlighting the usefulness of clinically meaningful data (Downs Maequez & Chiarelli 2013; Mackintosh 2015)

Score Population MDC – Minimal detectable change provides a confidence interval, within which one can be confident that a change in balance is real change

0-2425-3435-4445-56

Elderly 4.66.34.93.3 (Donoghue & Strokes 2009)

Parkinsonism 5 (Steffen & Seney 2008)

Stroke (Acute) 6.9 (Stevenson 2001)

Stroke (Chronic) 2-5 4.66 (Liston & Brouwer 1996; Hiengkaew, Kitaree & Chiayawat 2012; Flansbjer, Blom & Brogardh 2012)For more information regarding MDC in Stroke, please see Word Summary: Blum & Korner-Bitensky 2008

(Rehab Measures 2014).

1010

4.0: General Interpretation of BBS Scores 41-56 = Independent21-40 = Walking with assistance0-20 = Wheelchair bound (Berg et al. 1992; Lusardi, Pellecchia & Schulman 2004).

→←

1111

4.1: Interpretation of BBS Scores for Different Age Groups

→←(Falls Prevention in SA 2012; Lusardi, Pellecchia & Schulman 2004).

Conclusion: Based on the available evidence, the older the client, the more likely they are to have a lower BBS score

1212

→←

5.0: BBS for Predicting Falls – Cut-off Scores

To date, the BBS is the most effective clinical Ax of balance used by DC. Because of the alarmingly high falls rate among DC clients – 30% every six months, double the rate of community dwelling adults, an accurate, repeatable assessment of falls risk is of paramount importance (Burdon 2013).

Cut-off Scores:•A score of less than 45 was shown to be a predictor of recurrent falls, and predictive of a future fall (University of South Australia 2015)•Cut off score of 45/56 for independent safe ambulation:

• Sensitivity = 64% (Correctly predicts fallers; 64% of subjects who were true fallers had a positive BBS (scores of <45))

• Specificity = 90% (Correctly predicts non-fallers; 90% of subjects who were non-fallers had a negative BBS (a scores of ≥45) (Riddle & Stratford 1999)

•History of falls and BBS ≤ 51 or no history of falls and BBS ≤ 42 predictive of falls (91% sensitivity, 82% specificity)•Score of ≤ 40 on BBS associated with almost 100% fall risk (Shumway-Cook et al. 1997)

Conclusion: <45/56 indicates the need for balance re-training!

1313

5.1 – BBS for Predicting Falls – Cut-off Scores for Different Populations

BBS Cut off Score Population Sensitivity /Specificity

< 45 Older residents in residential care (Berg, 1992) – Participants scoring <45 were the most impaired and had adopted strategies to minimise the risk of falling, including the use of an assistive device and/or companion during mobility

48.5 Elderly stroke 85% / 49% (Asburn et al)

49 stroke 83% / 95% (Mackintosh et al) – <49 is a predictor of 2 or more falls in the 6 months after discharge from stroke rehabilitation

49 stroke 92% / 65% (Mackintosh et al)

53 older, community 69% / 57% (Muir et al) – Author recommended higher cut-off to identify participants with history of multiple falls

(Mackintosh 2015; Neuls et al. 2011).

→←

• Table is the recommended cut-off score for predicting falls in the elderly , and its associated sensitivity and specificity for different population groups

• Sensitivity represents the ability to identify whether the BBS was able to identify history of falls• Specificity represents the ability to identify a history of no falls

1414

6.0: Falls Prevention Program•Sensorimotor systems involved in the maintenance of PC decline with age, which leads to an increased risk of falls among older adults. To prevent this, older adults are encouraged to maintain LL muscle strength and power, reaction time and balance with exercise

•A BBS score of <45 indicates that the client is at risk of falls. As PTs, we need to to look at the full clinical picture, not just improvements in each item of the BBS to prevent future falls

•Cochrane review of interventions to prevent falls in community dwelling older people concluded that exercise interventions is the most cost-effective method, and can reduce the risk and rate of falls in older people by 17%-34% (Tiedemann et al. 2011; Mazzeo et al. 1998)

•Exercise prescription should be guided by clinical skills and National Guidelines. Please see next slide for more resources

→←

1515

Resources – Exercise Prescription Guidelines:

Australian Falls Prevention Guidelines – Community

American College of Sports Medicine Guidelines – Older Adults

Please see link for an example of a Falls Prevention – Home Exercise Program:

http://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0008/258542/11a-and-11b-falls-prevention-home-exe

rcises.pdf

→←

6.1: Falls Prevention Program Resources

1616

7.0: Limitations of the BBSLimitations for Administration Limitations for Interpretation

Technique affects balance Floor or ceiling effects occur when a significant proportion of a tested population achieve the lowest or highest possible score on a test, respectively (Downs, Marquez & Chiarelli 2013). Ceiling effects: Insensitive to differences among clients with very high levels of balance ability (Bogle-Thorbahn & Newton 1996)

BBS may take longer than other balance OMs to administer (Rehab Measures 2014)

Few dynamic items and does not include gait items (Falls Prevention in SA 2012)

Rating scales associated with each item, while numerically identical, have different operational definitions for each number or score. E.g. a score of 2 is defined differently & has a different associated level of difficulty from item to item. Use of an overall score that adds together rating with different meanings with no common reference point may not be appropriate as interpretation is difficult & very little functional information is provided about the individual client (Kornetti et al. 2004)

No common interpretation exists for the BBS scores, their relationship to mobility status & the use gait aids (Wee, Wong & Palepu 2003)

Declines in performance with increasing age in both men and women (Rehab Measures 2014)

Fullerton Advanced Balance Scale for more higher function (Downs, Marquez & Chiarelli 2013)

BBS score are based on the patient mobilising without the assistance of a gait aid, therefore, does not take into account other falls risk factors (St Vincent’s Hospital 2015)

→←

1717

7.1: Limitations of the BBS – Different Population Groups

Population Limitation

SCI BBS scores are not associated with the number of falls & not able to discriminate fallers from non-fallers (Wirz, Muller & Bastiaenen 2010)

Vestibular dysfunction

BBS may not be the best OM to identify individuals at risk of falling (Whitney, Wrisley & Furman 2003)

Parkinson’s disease

Limited in Hoehn & Yahr Stages 2-3 due to ceiling effects (Leddy, Crowner & Earhart 2011); stages 4-5 unable to complete the test as an assistive device cannot be used during the BBS (Rehab Measures 2014)

Ataxia Cannot reflect problems in the performance of daily living activities, which are caused by the effects of ataxia on the UL, as none of the items are designed to assess this (Physiopedia 2015)

Prosthesis Greater difficulty performing items with specific mvts, as constrained by ROM & prosthesis. Lack of sagittal plane jt control & ROM may limit the ability of forward reaching (item 8). Furthermore, most passive prostheses have limited frontal plane ROM & this may affect the ability to maintain tandem (item 13) and 360 degree turning (item 11), as it requires foot IR. Reduced sensory feedback that facilitates locating the COP under the prosthesis & its relationship with BOS may contribute to cautious performance & reduced BBS scores (Major, Fatone & Roth 2013)

→←

1818

8.0: Instructions for Administering the BBS at DC

→←

1919

General Instructions•Explicit Documentation next to the item where relevant e.g. equipment, technique•For the purpose of the BBS, follow the explicit instructions on the BBS sheet and in this TP but be aware of opportunities for clinical assessment (see next slide for more information)•Give instructions to the client as written in the BBS•Ensure no gait aids are used during the BBS•When scoring, record the lowest response category that applies for each item•Clients should understand that they must maintain their balance while attempting the tasks•Clients can choose their preferred leg to stand on or how far to reach. Poor judgment will adversely influence the performance and the scoring•PTs to always position themselves in a manner that is prepared to assist the client if needed that is safe for both the client and PT (Mackintosh 2015)

→←

2020

BBS as an OM vs. Clinical Ax•DC PTs perform the BBS as an OM but also perform other clinical Ax as part of an objective Ax•Recommend completing the BBS before undertaking other clinical Ax•However, in extenuating circumstances such as illnesses (e.g. fatigue, dizziness, SOB, etc) or lack of time, clinical Ax can be incorporated•Therefore, it is important to recognise the opportunity for the clinical Ax i.e. perform an item of the BBS, then move onto the clinical Ax, but not get the two results mixed up, as the BBS and other clinical Ax assess different things

→←

BBS OM Clinical Ax

2: Standing Unsupported6: Standing Unsupported With Eyes Closed7: Standing Unsupported With Feet Together10: Turning To Look Behind Over Left And Right Shoulders While Standing11: Turn 360 Degrees12: Standing Unsupported One Foot In Front14: Standing On One Leg

Balance:•Feet Together•SLS•180 Degree Turn•Tandem Steps

1: Sitting To Standing4: Standing To Sitting

Muscle Strength:•Sit To Stand Test

5: Transfers Home Environment•Access: Steps•T/Fs

2121

Equipment List

→←

For a systematic and repeatable approach, DOCUMENT the equipment and any other variations next to the item.

Please see Updated BBS Sheet for more information about documentation at DC

• Timing Device - Stopwatch: Wear it around your neck so you have 2 hands free for the client. All Physiotherapy Kits have a stopwatch in them

• Measuring Device - 30cm Metal Ruler: Recommend the introduction of a 30cm Metal Ruler to all Physiotherapy Kits, as that is the maximum required length for the BBS, is easy to handle and durable

• Chair - Dining Chair: Most commonly available and frequently used by the client. Use lounge chair or couch as the last option

• Step - Step in Client’s Home≤18cm Height (Australian Building Codes Board 2011): Most commonly available and frequently used by the client, and is often secured. If the client does not have a step in the home, bring a portable, wooden step next visit. These steps are available in the Restorative Team.

2222

Definitions that Appear in More than One Item

→←

Word Definition

Minimal aid/assist Verbal cues: Breaking the movement down in terms of body position &/orLA: Light physical cues for cueing

Minimal/minor use of hands There are no differences between having the hands on the chair or the knees. Minimal use means any pressure on the legs or chair

Several tries >2 tries

Supervision SBA; no touching of the client

2323

Item 1 – Sitting to Standing

→←

1. Sitting To Standing INSTRUCTIONS: Please stand up. Try not to use your hand for support.( ) 4 able to stand without using hands and stabilize independently( ) 3 able to stand independently using hands( ) 2 able to stand using hands after several tries( ) 1 needs minimal aid to stand or stabilize( ) 0 needs moderate or maximal assist to stand

Key points with performing the item:•Do not use any walking aid•Ask the client to stand without the use of arms and watch what they do with their arms. It needs to be clear to the client to not to use their arms•Starting position is comfortable sitting•Position of arms in sitting is hands rested on legs•Standing time is until the client is stabilised and balanced•Moderate or maximal assist is anything beyond LA; force is applied

2424

Item 2 – Standing Unsupported

→←

2. Standing UnsupportedINSTRUCTIONS: Please stand for two minutes without holding on.( ) 4 able to stand safely for 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.

Key points with performing the item:•Feet position is comfortable standing, shoulder width apart•Client is not required to have their feet together•Document variations with standing position e.g. BOS

2525

Item 3 – Sitting With Back Unsupported But Feet Supported On Floor Or On A Stool

→←

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 for 2 minutes( ) 3 able to sit 2 minutes under supervision( ) 2 able to able to sit 30 seconds( ) 1 able to sit 10 seconds( ) 0 unable to sit without support 10 seconds

Key points with performing the item:•For safety reasons, sitting position is feet flat on the floor and as much of the thigh supported as possible/comfortable sitting

2626

Item 4 – Standing to Sitting

→←

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 assist to sit

Key points with performing the item:•If client asks if they can use hands, ask if they can do without hands first•Controls descent by using hands is anytime the client takes weight through their hands•Uses back of legs against chair to control descent is using the back of the knees against the chair

2727

Item 5 – Transfers

→←

5. TransfersINSTRUCTIONS: Arrange chair(s) for pivot transfer. Ask subject to transfer one way toward a seat with armrests & one way toward a seat without armrests. You may use two chairs (one with & one without armrests) or a bed & 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 cuing and/or supervision( ) 1 needs one person to assist( ) 0 needs two people to assist or supervise to be safe

Key points with performing the item:•Encourage the client to perform usual functional T/F•Document how the client performed the item•Direction of transfer is either left to right or right to left•Angle/distance of transfer is 90 degrees with corners touching where possible•Verbal cueing is anything beyond repeating the instructions and supervision is close SBA•Determine whether the client requires 1 or 2 assists to be safe by having an understanding of the client prior to Ax (e.g. by reading case notes, liasing with allied health, etc) and using clinical reasoning•Difference between pivoting and taking a step is pivoting is where one foot stays still and the other moves around. A few steps to sit does not change the scoring anyway•Use wheelchair as an arm chair as the last resort or if the client normally mobilises in it

2828

Item 6 – Standing Unsupported With Eyes Closed

→←

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 safely( ) 0 needs help to keep from falling

Key points with performing the item:•Starting position is comfortable standing•Counting out loud is possible but use your clinical reasoning to determine if it has an affect on the client’s performance•Score the client’s first attempt

2929

Item 7 – Standing Unsupported with Feet Together

7. Standing Unsupported With Feet TogetherINSTRUCTIONS: Place your feet together and stand without holding on.( ) 4 able to place feet together independently and stand 1 minute safely( ) 3 able to place feet together independently and stand 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

Key points with performing the item:•Clients who physically cannot get their feet together can attempt to get it as close as possible. It has to be an anatomical or physical reason, not just fear. Document the client’s impairment•Needs help to attain position is any external support from the PT or furniture or verbal cues that break the movement into individual components, excluding verbal cues to “Get your feet close together”. Document any external supports used or detailed instructions of how the client got into the position

→←

3030

Item 8: Reaching Forward With Outstretched Arm While Standing

8. Reaching Forward With Outstretched Arm While StandingINSTRUCTIONS: Lift arm to 90 degrees. Stretch out your fingers and reach forward as far as you can. (Examiner places a ruler at the end of fingertips when arm is at 90 degrees. 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 25 cm (10 inches)( ) 3 can reach forward 12 cm (5 inches)( ) 2 can reach forward 5 cm (2 inches)( ) 1 reaches forward but needs supervision( ) 0 loses balance while trying/requires external support

Key points with performing the item:•Assessor is required to demonstrate the movement•Instruct client to choose preferred arm and reach alongside the wall•Measure horizontal distance with no cheats e.g. shoulder elevation, scapular protraction, trunk rotation, diagonal reaching/dipping and stepping•Client to choose preferred arm but if they cannot get their preferred arm to 90 degrees, document the ROM achieved, reason for not getting to 90 degrees, which arm it is, and then attempt with the other arm•Always document which arm was tested

→←

3131

Item 8: Reaching Forward With Outstretched Arm While Standing

• Difficulties associated with performing this item safely are balance and position of the client, and position of the PT to best support the client. Suggested methods to overcome these difficulties include close SBA, use of rails or furniture where possible, have the correct level of assistance and perform the item in a corner of the room.

• New recommended method of using blu tac to stick the ruler to the wall so you have both hands to support the client

• Please see URL for video: https://www.youtube.com/watch?v=x2v6UflM18c

→←

3232

Item 9: Pick Up Object From The Floor From A Standing Position

9. Pick Up Object From The Floor From A Standing PositionINSTRUCTIONS: Pick up the shoe/slipper, which is place 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 2-5 cm (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

Key points with performing the item:•Any object can be used but avoid items that require fine motor mvt (e.g. pens, pins, cutlery). Document the object used next to the item. Recommended to have a prompt next to the item on the BBS sheet.•Position of object is anywhere in front of the foot within the client’s view, as long as it does not require the client to take a step•Document the technique, as it provides an indication of function, BOS, vision, vestibular function and balance. •Cannot assist the client to pick up the item by using cheats such as touching the PT’s hands on the way down and seeing how far they can go or holding onto external support e.g. chair, table

→←

3333

Item 10 – Turning To Look Behind Over Left And Right Shoulders While Standing

10. Turning To Look Behind Over Left And Right Shoulders While StandingINSTRUCTIONS: Turn to look directly behind you over toward the 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 side shows less weight shift( ) 2 turns sideways only but maintains balance( ) 1 needs supervision when turning( ) 0 needs assist to keep from losing balance or falling

Key points with performing the item:•Look to see if neck rotation only vs. trunk rotation, as the aim is to encourage trunk rotation & weight shift•Look to see if both sides are symmetrical•Starting position is feet facing forward comfortably apart •Trunk rotation to be a 4 is when the client can see an object behind on the wall at their shoulder height, and demonstrates both trunk and neck rotation•Document when there are differences between left and right and their limitations (e.g. pain, stiffness)

→←

3434

Item 11: Turn 360 Degrees11. Turn 360 DegreesINSTRUCTIONS: Turn completely around in a full circle. Pause then turn a full circle the other direction.( ) 4 able to turn 360 degrees safely in 4 seconds or less( ) 3 able to turn 360 degrees safely one side only 4 seconds or less( ) 2 able to turn 360 degrees safely but slowly( ) 1 needs close supervision or verbal cuing( ) 0 needs assistance while turning

Key points with performing the item:•Client is allowed 4 seconds to turn in each direction•Client is allowed to walk around or pivot, as item does not specify. Client should be encouraged to perform the task as they usually would•Needs assistance while turning is anything more than verbal cueing or SBA (i.e. any touching) is scored as a 0•If dizziness occurs during this item, allow the client to pause but not sit down, as the goal of the item is to test the ability to change directions and turning 360 degrees•If the client needs to sit down for safety or can only turn in one direction, score a 0

→←

3535

Item 12- Place Alternate Foot on Step Or Stool While Standing Unsupported

12. Place Alternate Foot On Step Or Stool While Standing UnsupportedINSTRUCTIONS: Place each foot alternately on the step/stool. Continue until each foot has touched the step four times.( ) 4 able to stand independently and safely and complete 8 steps in 20 seconds( ) 3 able to stand independently and complete 8 steps in > 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

Key points with performing the item:•Demonstrate the test•Secure the step if it is not (e.g. if phone book, portable step, stool etc), put it against a wall or a solid object•PT position is best to one side, one arm behind, other in front, and elbows in (safe guard position). Stand slightly behind if unable. Always be prepared to support the client if the client were to fall forwards or backwards•Starting position of the client is for the client to stand at a comfortable distance from the step so the client can easily reach the step but not catch their toe•Client is required to touch the ball of their foot on top of the step; not the edge

→←

3636

Item 13: Standing Unsupported One Foot In Front

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 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

Key points with performing the item:•Demonstrate tandem stance•Tandem stance is heel to toe, both feet touching in a straight line with client’s preferred combination•If the client assumes the position independently without prompting (may take more than 1 mvt), the client may score a 4, otherwise a 3 or 2. If the client can get their feet into tandem stance but with a gap between heel and toe, the client can adjust to score a 4, otherwise a 3 or 2•Foot ahead: When the heel of the front foot does not touch the toe of the back foot, <1 foot width apart•Small step: A step with a length less than a foot

→←

3737

Item 13: Standing Unsupported One Foot In Front

→←

3838

Item 14 – Standing On One Leg14. Standing On One LegINSTRUCTIONS: Stand on one leg as long as you can without holding on.( ) 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 ≥ 3 seconds( ) 1 tries to lift leg unable to hold 3 seconds but remains standing independently.( ) 0 unable to try of needs assist to prevent fall

Key points with performing the item:•Client to choose preferred leg and record first try•Legs can touch but are not allowed to lock their non-weightbearing leg around the stance leg

→←

3939

6.0: BBS for Intervention Guidance

→←*Full text not available, See References (Rose 2010).

Item Possible Impairments Recommended Exercises

1. Sitting to standing

• LL &/or UL weakness• Poor dynamic COG control• Abnormal weight

distribution

• Wall sits; UL & LL exercises with resistance (quad, biceps/triceps, hip abd/add)• Seated/Standing balance activities emphasising forward weight shifts• Standing balance activities with eyes closed (controlled swap in A-P & lateral

directions)

2. Standing unsupported

• Poor gaze stabilisation• LL weakness• Abnormal weight

distribution in standing

• Teach gaze fixation & stabilisation techniques• Wall sits; LL exercises with resistance• COG standing balance

3. Sitting with back unsupported but feet supported on floor or on a stool

• Poor trunk stabilisation &/or UL weakness

• Abnormal perception of true vertical

• UL exercises with resistance (own body); seated balance activities on compliant surfaces

• Standing against wall with eyes closed; somatosensory cues

4. Standing to sitting

• Poor dynamic COG control• LL &/or UL weakness• Poor trunk flexibility

• Seated/standing balance activities emphasising backward weight shifts• UL & LL exercises with resistance (own body/resistance band; emphasise

eccentric component)• Flexibility exercises emphasising trunk rotation/F; seated & standing

5. T/F • Poor dynamic control of COG• LL &/or UL weakness

• Seated/standing balance activities emphasising multidirectional weight shifts• UL & LL exercises with resistance

4040

6.0: BBS for Intervention Guidance ContinueItem Possible Impairments Recommended Exercises

6. Standing unsupported with eyes closed

• Poor use of somatosensory inputs; visual dependency &/or fear of falling

• LL weakness

• Seated/standing balance activities with eyes closed• Verbally emphasise use of surface cues• Wall sits; LL exercises with resistance

7. Standing unsupported with feet together

• Poor COG control• Weak hip abd/add

• Standing balance activities with reduced BOS• Lateral leg raises/weight shifts against resistance

8. Reaching forward with outstretched arm while standing

• Poor dynamic COG control (reduced limits of stability)

• LL body weakness• Reduced ankle ROM

• Seated/standing COG activities emphasising leaning away from & back to midline• LL exercises with resistance (body/resistance band); emphasise DF, gastroc/soleus

muscles)• Flexibility exercises (emphasise DF)

9. Pick up object from the floor from a standing position

• Poor dynamic COG control• Poor UL & LL flexibility• LL weakness• Vestibular impairment

(dizziness)

• Seated/standing COG activities emphasising leaning away from & back to midline• Selected exercises to improve UL & LL F• LL exercises with resistance (body/resistance band)• Head & eye mvts; habitual exercises

10. Turning to look behind over left & right shoulders while standing

• Poor dynamic COG control• Poor neck &/or trunk

flexibility• LL weakness

• Standing weight shifts in lateral direction• Selected exercises emphasising rotation of neck, shoulders & hips• LL exercises with resistance; ball mvt exercises in standing position

→←(Rose 2010). *Full text not available, See References

(Department for Communities and Social Inclusion 2014).

4141

6.0: BBS for Intervention Guidance ContinueItem Possible Impairments Recommended Exercises

11. Turn 360 degrees

• Poor dynamic COG control• Possible vestibular

impairment (dizziness)• LL weakness

• Standing weight T/F activities; gait pattern enhancement (turns, directional changes)

• Head & eye mvt coordination exercises• LL exercises with resistance; emphasise hip & knee F; hip abd/add

12. Place alternate foot on step or stool while standing unsupported

• Poor dynamic COG control• LL weakness

• Standing weight shifts in lateral/A-P directions• LL exercises with resistance; emphasise hip & knee F; hip abd/add

13. Standing unsupported one foot in front

• Poor static & dynamic COG control

• LL weakness• Poor gaze stabilisation

• Standing A-P weight shifts & T/Fs; reduced BOS activities• LL exercises with resistance (body/resistance band); emphasise hip abd/add• Practice focusing on visual targets in front of & at head height during standing &

moving activities

14. Standing on one leg

• Poor static & dynamic COG control

• LL weakness• Poor gaze stabilisation

• Standing A-P weight shifts & T/Fs; reduced BOS activities• LL exercises with resistance (body/resistance band); emphasise hip abd/add• Practice focusing on visual targets during standing & moving activities

→←

*Full text not available, See References (Rose 2010).

4242

9.0: Self-directed QuizA series of four multiple choice questions has been designed to assist you in reflecting on your own knowledge gained using this training package.

To use the quiz, simply click on the LETTER corresponding to your answer.

The questions have been derived from the content presented in the TP and links provided

Begin the QuizReturn to Previous Restart TP

4343

Question 11. What is the purpose of the BBS?

A

B

D

C

The BBS is a treatment tool used to improve balance in the elderly population

The BBS is an OM designed to assess static balance, limited dynamic balance and fall risk in adult populations

The BBS is a subjective Ax tool used to determine falls risk in adult populations

The BBS is an OM designed to assess vestibular function and fall risk in the elderly population

Please click on the corresponding letter

4444

Incorrect

Try again!

Revisit “General BBS Information”

Return to Previous Restart TP Next question

4545

Correct! The BBS is an OM designed to assess static balance, limited dynamic balance and

fall risk in adult populations

The BBS has good reliability and validity with other OMs, therefore, the BBS should be used in conjunction with other OMs, in order to gain a full clinical picture of the client.

Next questionRestart TPReturn to Previous

4646

Question 22. What is general interpretation of the BBS score?

A

B

D

C

41-56 = Walking with assistance21-40 = Wheelchair bound0-20 = Independent

41-56 = Wheelchair bound21-40 = Walking with assistance0-20 = Independent

A client can only be independent if they score a 56

41-56 = Independent21-40 = Walking with assistance0-20 = Wheelchair bound


4747

Incorrect

Try again!

Revisit “General Interpretation of BBS Scores”

Next QuestionReturn to Previous Restart TP

4848

Correct! 41-56 = Independent21-40 = Walking with assistance0-20 = Wheelchair bound

A BBS score of <45/56 requires the PT to consider prescribing a gait aid. Use clinical Ax skills to determine which gait aid is best for the client. Gait aids may be different for indoors, outdoors and in the community.


4949

Question 33. A score of less than ___ was shown to be a predictor of _______________?

A

B

D

C

A score of less than 45 was shown to be a predictor of recurrent falls, and predictive of a future fall

A score of less than 45 was shown to be a predictor of poor balance

A score of less than 45 was shown to be a predictor of the client’s ability to perform ADLs

A score of less than 40 was shown to be a predictor of recurrent falls, and predictive of a future fall


5050

Incorrect

Try again!

Revisit “BBS for Predicting Falls – Cut-off Scores”


5151

Correct! A score of less than 45 was shown to be a predictor of recurrent falls, and

predictive of a future fall Although cut-off scores vary for clients depending on age and health condition, the

general consensus is that a score of less than 45 implies that the client is at falls risk.


5252

Question 44. Is the minimal detectable change (MDC) for the BBS the same in different populations?

A

B

D

C

MDC is the same for acute and chronic stroke

MDC is the same for the elderly for any BBS score range

No, MDC is different for different populations

Yes, it is the same all the time


5353

Incorrect

Try again!

Revisit “Minimal Detectable Change (MDC) in Different

Population Groups”


5454

Correct! No, MDC is different for different populations

When interpreting the BBS scores, we should be aware of the MDC for different populations.


5555

Question 55. Which of the following is NOT a limitation of the BBS?

A

B

D

C

Does not assess gait

Does not measure balance

Takes longer than other OMs

Floor/ceiling effects occur


5656

Incorrect

Try again!

Revisit “Limitations of the BBS”


5757

Correct! Does not measure balance

Although the BBS is the gold standard with good reliability and validity, there are many limitations to the administration and interpretation of the BBS that we should be aware of.


5858

Question 66. What equipment is recommended to use when performing the BBS?

A

B

D

C

Stopwatch, shower chair, 30cm metal ruler and phonebook

Wrist watch, dining chair, 1m ruler and >18cm step

Any stopwatch, chair, ruler and step

Stopwatch, dining chair, 30cm metal ruler and step in client’s home≤18cm height


5959

Incorrect

Try again!

Revisit “Equipment List”


6060

Correct! Stopwatch, dining chair, 30cm metal ruler and Step in client’s home≤18cm height

These equipment are recommended for DC PTs, as they are the agreed upon items due to their availability and safety in the home setting.


6161

Question 77. For “Item 8: Reaching Forward With Outstretched Arm While Standing”, what is the

new recommended method of administration to improve safety of the client and PT?

A

B

D

C

Use 2 pieces of blu tac so that the client can stick the first piece of blu tac at arms length and second piece for the distance reached. Measure the distance between the 2 points

PT places a ruler at the end of the fingertips when the arm is at 90 degrees. Client to reach forward. Record the distance

Client to reach forward as far as possible. PT to estimate the distance reached

Use blu tac to stick the ruler to the wall so you have both hands to support the client


6262

Incorrect

Try again!

Revisit “Item 8: Reaching Forward With Outstretched Arm While Standing”


6363

Correct! Use blu tac to stick the ruler to the wall so you have both hands to support the

client

The “Use 2 pieces of blu tac so that the client can stick the first piece of blu tac at arms length and second piece for the distance reached. Measure the distance between the 2 points” was another method discussed and can be considered


6464

Question 88. For “Item 9: Pick Up Object From The Floor From A Standing Position”, what object

should you use and where on the floor should you place it?

A

B

D

C

Any object can be used. The object should be to the side of the client

Any object can be used but avoid items that require fine motor mvt (e.g. pens, pins, cutlery). Position of object is anywhere in front of the foot within the client’s view, as long as it does not require the client to take a stepAny item can be used, as long as it does not require fine motor mvt (e.g. pens, pins, cutlery). The object should be as close to the client’s foot as possible

Only a slipper can be used, as stated by the BBT. The slipper should be in front of the client


6565

Incorrect

Try again!

Revisit “Item 9: Pick Up Object From The Floor From A Standing Position”


6666

Correct! Any object can be used but avoid items that require fine motor mvt (e.g. pens,

pins, cutlery). Position of object is anywhere in front of the foot within the client’s view, as long as it does not require the client to take a step

A slipper is not always available. Any other object that does not require fine motor skills will suffice. If you use an object that requires fine motor skills, a client with hand/finger pathology (e.g. rheumatoid arthritis) may score lower but this is not an indication of the client’s balance and falls risk.


6767

Question 99. For “Item 11: Turn 360 Degrees”, if the client experiences dizziness, what should you

do?

A

B

D

C

Allow the client to pause but not sit down, as the goal of the item is to test the ability to change directions and turning 360 degrees. If the client needs to sit down for safety or can only turn in one direction, score a 0

Tell the client to sit down and stop the BBS immediately

Allow the client to pause and sit down, as the goal of the item is to reproduce any dizziness that may affect balance

Tell the client dizziness is normal and ask them to continue


6868

Incorrect

Try again!

Revisit “Item 11: Turn 360 Degrees”


6969

Correct! Allow the client to pause but not sit down, as the goal of the item is to test the

ability to change directions and turning 360 degrees. If the client needs to sit down for safety or can only turn in one direction, score a 0

Document the dizziness.


7070

Question 1010. For “Item 13: Standing Unsupported One Foot In Front”, what is the difference

between tandem, foot ahead and a small step?

A

B

D

C

Tandem stance is when the heel of the front foot is touching the toe of the back foot. Foot ahead is when the heel of the front foot is not past the toes of the back foot but there is a gap between both feet. A small step is when the foot is ahead. Tandem stance is when the heel of the front foot is touching the toe of the back foot. Foot ahead is when the heel of the front foot is past the toe of the back foot. A small step is when the heel does not pass the toe.

Tandem stance is any position with the foot in front. Foot ahead is another way of saying tandem. A small step is when one foot moves forward.

Tandem stance is feet apart with one foot in front. Foot ahead is when you point your toe with your front foot. A small step is when the dominant foot moves forwards.


7171

Incorrect

Try again!

Revisit “Item 13: Standing Unsupported One Foot In Front”

FinishReturn to Previous Restart TP

7272

Correct! Tandem stance is when the heel of the front foot is touching the toe of the back

foot. Foot ahead is when the heel of the front foot is past the toe of the back foot. A small step is when the heel does not pass the toe.

When a client performs this item verbal cues to attain the position include any verbal assistance. Physical cues include any physical assistance.

FinishReturn to Previous Restart TP

7373

Congratulations on completing the Berg Balance Scale Training

Package!*Please be advised that this is a basic TP only and does not account for competencies outside of DC

Restart TP ReferencesRestart Quiz

7474

References

→←

Australian Building Codes Board 2011, Proposal to revise the BCA to reduce the risk of slips, trips and falls in buildings, Australian Government, States and Territories of Australia, Canberra.Australian Commission on Safety and Quality in Health Care 2009, Preventing Falls and Harm From Falls in Older People: Best Practice Guidelines for Australian Community Care, Government of Australia, <http://www.safetyandquality.gov.au/wp-content/uploads/2012/01/Guidelines-COMM.pdf>.Berg, K, Wood-Dauphine, S, Williams, JI, Gayton, D 1989, ‘Measuring balance in the elderly: preliminary development of an instrument’, Physiotherapy Canada, vol. 41, no. 6, pp. 304-311. Berg K, Wood-Dauphinee S, Williams JI & Maki, B 1992, ‘Measuring balance in the elderly: validation of an instrument,’ Canadian Journal of Public Health (Canadian Public Health Association), vol. 83, no. 2, pp. S7-11.Blum, L & Korner-Bitensky, N 2008, ‘Usefulness of the Berg Balance Scale in stroke rehabilitation: a systematic review’, Physical Therapy, vol. 88, no. 5, pp. 559-566.Bogle-Thorbahn, LD & Newton, RA 1996, ‘Use of the Berg Balance Test to Predict Galls in Elderly Persons’, Physical Therapy, vol. 76, no. 6, pp. 576-583.Burdon, M 2013, A Clinical Audit of Domiciliary Care Physiotherapy Clinical Practice and Use of the Mobility Assessment Tool, Government of South Australia.Cattaneo, D, Jonsdottir, J & Repetti, S 2007, ‘Reliability of four scales on balance disorders in persons with multiple sclerosis’, Disability & Rehabilitation, vol. 29, no. 24, pp. 1920-1925.Chodzko-Zajko, WJ, Proctor, DN, Singh, MAF, Minson, CT, Nigg, CR, Salem, GJ & Skinner, JS, 2009, ‘American College of Sports Medicine position stand. Exercise and physical activity for older adults’, Medicine & Science in Sports & Exercise, vol. 41, no. 7, pp. 1510-1530.Department for Communities and Social Inclusion 2014, Domiciliary Care, Government of South Australia, viewed 25 April 2015, <https://www.sa.gov.au/__data/assets/pdf_file/0020/35507/DCSI-428-DIS-Domcare-brochure-2014_WEB2.pdf>.Donoghue, D & Stokes, EK 2009, ‘How much change is true change? The minimal detectable of the Berg Balance Scale in elderly people’, Journal of Rehabilitation Medicine, vol. 41, no. 5, pp. 343-346.

7575

References

→←

Downs, S, Marquez J & Chiarelli, P 2013, ‘The Berg Balance Scale has high intra- and inter-rater reliability but absolute reliability varies across the scale: a systematic review’, Journal of Physiotherapy (Australian Physiotherapy Association, vol. 59, no. 2, pp. 93-99.Falls Prevention in SA 2012, Berg Balance Scale, Active Ageing Australia, viewed 20 April 2015, <http://www.fallssa.com.au/documents/hp/Berg_Balance_Scale.pdf>.Flansbjer, UB, Blom, J & Brogardh, C 2012, ‘The reproducibility of Berg Balance Scale and the Single-leg Stance in chronic stroke and the relationship between the two tests’, PM&R, vol. 4, no. 3, pp. 165-170. Hiengkaew, V, Kitaree, K & Chiayawat, P 2012, ‘Minimal detectable changes of the Berg Balance Scale, Fugl-Meyer Assessment Scale, Timed "Up & Go" Test, gait speeds, and 2-minute walk test in individuals with chronic stroke with different degrees of ankle plantarflexor tone’, Archives of Physical Medicine and Rehabilitation, vol. 93, no. 7, pp. 1201-1208.Kornetti, DL, Fritz, SL, Chiu, Y, Light, KE & Velozo, CA 2004, ‘Rating Scale Analysis of the Berg Balance Scale’, Archives of Physical Medicine and Rehabilitation, vol. 85, no. 7, pp. 1128-1135.Leddy, AL,Crowner, BE & Earhart 2011, ‘Functional Gait Assessment and Balance Evaluation System Test: Reliability, Validity, Sensitivity, and Specificity for Identifying Individuals With Parkinson Disease Who Fall’, Physical Therapy, vol. 91, no, 1, pp. 102-113.Liston, R & Brouwer, B 1996, ‘Reliability and validity of measures obtained from stroke patients using the balance master’, Archives of Physical Medicine and Rehabilitation, vol. 77, no. 5, pp. 425-430.Lusardi, MM, Pellecchia, GL & Schulman, M 2004, ‘Functional Performance in Community Living Older Adults’, Journal of Geriatric Physical Therapy, vol. 26, no. 3, pp. 14-22. Mackintosh, S 2015, ‘Berg Balance Scale’, Oral Presentation with Lecture Notes, University of South Australia, Adelaide, February. Major, MJ, Fatone, S & Roth, EJ 2013, ‘Validity and Reliability of the Berg Balance Scale for Community-Dwelling Persons With Lower-Limb Amputation’, Archives of Physical Medicine and Rehabilitation, vol. 94, no. 1, pp. 2194-2202.Mazzeo, RS, Cavanagh, P, Evans, WJ, Fiatarone, M, Hagberg, J, McAuley, E & Startzell, J 1998, ‘ACSM Position Stand: Exercise and Physical Activity for Older Adults’, Medicine & Science in Sports & Exercise, vol. 30, no. 6, pp. 992-1008.Nelson, ME, Rejeski, WJ, Blair, SN, Duncan, PW, Judge, JO, King, AC, Macera, CA & Castaneda-Sceppa, C 2007, ‘Physical activity and public health in older adults: recommendation from the American College of Sports Medicine and the American Heart Association’, Medicine and Science in Sports and Exercise, vol. 39, no. 8, pp. 1423-1434.

7676

References

→←

Neuls, PD, Clark, TL, Van Heuklon, NC, Proctor, JE, Kilker, BJ, Bieber, ME, Donlan, AV, Carr-Jules, SA, Neidel, WH & Newton, RA 2011, ‘Usefulness of the Berg Balance Scale to Predict Falls in the Elderly’, Journal of Geriatric Physical Therapy, vol. 34, no. 1, pp. 3-10.NSW Falls Prevention Program 2012, Falls Prevention – Home exercises, Clinical Excellence Commission, viewed 28 April 2015, <http://www.cec.health.nsw.gov.au/__documents/programs/falls-prevention/one-page-flyers/11a-and-11b-falls-prevention-home-exercises.pdf>.Physiopedia 2015, Berg Balance Scale, Physiopedia, viewed 21 April 2015, <http://www.physio-pedia.com/Berg_Balance_Scale>.Quinn, L, Khalil, H, Fritz, NE, Kegelmeyer, D, Kloos, AD, Gillard, JW & Busse, M 2013, ‘Reliability and Minimal Detectable Change of Physical Performance Measures in Individuals With Pre-manifest and Manifest Huntington Disease’, Physical Therapy, vol. 93, no. 7, pp. 942-956.Rehab Measures 2014, Rehab Measures: Berg Balance Scale, Rehabilitation Institute of Chicago, viewed 20 February 2015, <http://www.rehabmeasures.org/Lists/RehabMeasures/DispForm.aspx?ID=888>.Riddle, DL & Stratford, PW 1999, ‘Interpreting Validity Indexes for Diagnostic Tests: An Illustration Using the Berg Balance Test’, Physical Therapy, vol. 79, no. 10, pp. 939-948.Rose, D 2010, Fall Proof!: A comprehensive Balance and Mobility Training Program, 2nd edn, Sheridan Books, United States of America.Shumway-Cook, A, Baldwin, M, Polissar, NL & Gruber, W 1997, ‘Predicting the Probability for Falls in Community-Dwelling Older Adults’, Physical Therapy, vol. 77, no. 8, pp. 812-819.St Vincent’s Hospital 2015, Berg Balance Scale, St Vincent’s Hospital, viewed 25 April 2015, <http://webcache.googleusercontent.com/search?q=cache:ThxRwMmSMIIJ:www.stvincents.ie/dynamic/File/Berg%2520balance%2520scale_SVUH_MedEL_tool.doc+&cd=1&hl=en&ct=clnk&gl=au>.Steffen, T & Seney, M 2008, ‘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’’, Physical Therapy, vol. 88, no. 6, pp. 733-746.

7777

References

→←

Steffen, TM, Hacker, TA & Mollinger, L 2002, ‘Age- and Gender-Related Test Performance in Community-Dwelling Elderly People: Six-Minute Walk Test, Berg Balance Scale, Timed Up & Go Test, and Gait Speed’, Physical Therapy, vol. 82, no. 2, pp. 128-137.Stevenson, TJ 2001, ‘Detecting change in patients with stroke using the Berg Balance Scale’, Australian Journal of Physiotherapy, vol. 47, no. 1 pp. 29-38.Tiedemann, A, Sherrington, C, Close, JCT, Lord, SR 2011, ‘Exercise and Sports Science Australia Position Statement on exercise and falls prevention in older people’, Journal of Science and Medicine in Sport, vol. 4, no. 16, pp. 489-495.University of South Australia 2015, iCAHE Outcome Calculators, University of South Australia, viewed 10 th April 2015, <http://www.unisa.edu.au/research/sansom-institute-for-health-research/research-at-the-sansom/research-concentrations/allied-health-evidence/resources/oc/>.Wee, JY, Wong, H & Palepu, A 2003, ‘Validation of the Berg Balance Scale as a Predictor of Length of Stay and Discharge Destination in Stroke Rehabilitation’, Archives of Physical Medicine and Rehabilitation, vol. 84, no. 5, pp. 731-735.Whitney, S, Wrisley, D & Furman J 2003, ‘Concurrent validity of the Berg Balance Scale and the Dynamic Gait Index in people with vestibular dysfunction’, Physiotherapy Research International, vol. 8, no. 4, pp. 178-186.Wirz, M, Muller, R & Bastiaenen C 2010, ‘Falls in Persons With Spinal Cord Injury: Validity and Reliability of the Berg Balance Scale’, Neurorehabilitation and Neural Repair, vol. 24, no. 1, pp. 70-77.