The BESS is an objective measure for assessing static postural stability (designed for the mild head injury population, to assist in return to sports play decisions).
3
10 minutes
10 minutes or less
Initially reviewed by Katie Hays, PT, DPT and the TBI EDGE task force of the Neurology Section of the APTA in 5/2012. Updated by Karen Lambert, PT, MPT, NCS and the Vestibular EDGE task force of the Neurology Section of the APTA 6/2013.
Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (PD EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.
For detailed information about how recommendations were made, please visit:
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Abbreviations: |
|
|
HR |
Highly Recommend |
|
R |
Recommend |
|
LS / UR |
Reasonable to use, but limited study in target group / Unable to Recommend |
|
NR |
Not Recommended |
Recommendations for use based on acuity level of the patient:
|
|
Acute (CVA < 2 months post) (SCI < 1 month post) (Vestibular < 6 weeks post) |
Subacute (CVA 2 to 6 months) (SCI 3 to 6 months) |
Chronic (> 6 months) (Vestibular > 6 weeks post) |
|
VEDGE |
LS |
NR |
NR |
Recommendations based on level of care in which the assessment is taken:
|
|
Acute Care |
Inpatient Rehabilitation |
Skilled Nursing Facility |
Outpatient Rehabilitation |
Home Health |
|
TBI EDGE |
LS |
LS |
NR |
R |
LS |
Recommendations for use based on ambulatory status after brain injury:
|
|
Completely Independent |
Mildly dependant |
Moderately Dependant |
Severely Dependant |
|
TBI EDGE |
R |
LS |
NR |
NR |
Recommendations based on vestibular diagnosis
|
|
Peripheral |
Central |
Benign Paroxysmal Positional Vertigo (BPPV) |
Other |
|
VEDGE |
NR |
LS |
NR |
NR |
Recommendations for entry-level physical therapy education and use in research:
|
|
Students should learn to administer this tool? (Y/N) |
Students should be exposed to tool? (Y/N) |
Appropriate for use in intervention research studies? (Y/N) |
Is additional research warranted for this tool (Y/N) |
|
TBI EDGE |
No |
Yes |
No |
Not reported |
|
VEDGE |
No |
Yes |
No |
Yes |
The Balance Error Scoring System was developed as a means of providing a quick and efficient balance assessment along the sidelines following sports concussion This tool may add value to the balance assessment of other populations (vestibular/ non-sports related concussion) however it has not been evaluated in these populations to date The mCTSIB has been assessed in the vestibular population. The mCTSIB requires similar training, time to administer and equipment and is, therefore, recommended as a superior test to the BESS at this time. Significant learning effect noted with tandem stance, especially with single leg stance and foam items (Valovich et al, 2003; Valovich et al, 2004) Exertion adversely affects BESS scores, with the greatest effect on single leg stance and tandem stance conditions. (Susco et al, 2004) Distracting environment may negatively affect scores (most noted on single leg foam condition, but also on total score and tandem leg foam conditions). Revised version of the test has been performed with four conditions: single-leg stance on firm and foam, and tandem stance on firm and foam) (Hunt, TN et al (2009)) with improved reliability. Intraclass reliability coefficient of 0.84 using conditions 2 and 3 Balance Error Scoring System translations: Spanish (on page 3 item 6): http://www.urba.org.ar/useruploads/notas/archivonota_923.pdf These translations, and links to them, are subject to the Terms and Conditions of Use of the Rehab Measures Database. RIC is not responsible for and does not endorse the content, products or services of any third-party website, and does not make any representations regarding its quality, content or accuracy. If you would like to contribute a language translation to the RMD, please contact us at rehabmeasures@ric.org.
Do you see an error or have a suggestion for this instrument summary? Please e-mail us!
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)
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)
Youth:
(Broglio et al, 2009; n = 48, age = 20.42(2.08)
SEM = 3.3
Youth:
(Valovich et al, 2004; n = 49; average age control group = 12.34(1.55) years; average age practice group = 11.77(1.82) years, healthy sports participants)
SEM = 1.01
Athletes (controls without neurological / orthopedic injury):
(Susco et al, 2004; n = 100; mean age = 21.4(2.7))
SEM for Double support/firm = 0.62
SEM for Double support/foam = 0.63
Athletes:
(Finnoff et al, 2009; n = 30 individuals videotaped performing BESS)
Mean intrarrater MDC = 7.3 points
Mean interrater MDC = 9.3 points
Young Athletes :
(Valovich McLeod et al, 2006; n = 50, healthy community dwelling athletes, aged 9-14)
Reliable Change Index at 70% confidence interval = 3 points
Healthy adults:
(Iverson et al, 2008; n = 589, healthy community dwelling adults, mean age = 49.75(10.81); Canadian sample)
|
Age (years) |
Mean Score (points) |
|
20-39 |
10.97 (5.05) |
|
40-49 |
11.88 (5.40) |
|
50-54 |
12.73 (6.07) |
|
55-59 |
14.85 (7.32) |
|
60-64 |
17.20 (7.83) |
|
65-69 |
20.38 (7.87) |
|
|
Mean Score (points) |
||
|
AGE (years) |
ALL |
Men |
Women |
|
20-29 |
11.3 |
10.4 |
11.9 |
|
30-39 |
11.5 |
11.5 |
11.4 |
|
40-49 |
12.5 |
12.4 |
12.7 |
|
50-54 |
14.2 |
13.6 |
15.1 |
|
55-59 |
16.5 |
16.4 |
16.7 |
|
60-64 |
18.0 |
17.2 |
19.3 |
|
65-69 |
19.9 |
20.0 |
19.9 |
Athletes:
(Bell et al, 2011)
Adequate test retest reliability in youth participants aged 9-14 (ICC = 0.70)
Athletes (without neurological / orthopedic injury):
(Susco et al, 2004; n = 34 subset of subjects)
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)
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)
Athletes:
(Finnoff et al, 2009)
|
Item |
Interrater Reliability (ICC) |
Intrarater Reliability (ICC) |
|
Firm Double Log |
** |
** |
|
Firm Single Leg |
Excellent (0.83) |
Excellent (0.88) |
|
Firm Tandem |
Adequate (0.44) |
Excellent (0.77) |
|
Foam Double Leg |
Adequate (0.46) |
Excellent (0.83) |
|
Foam Single Leg |
Adequate (0.53) |
Adequate (0.50) |
|
Foam Tandem |
Adequate (0.57) |
Adequate (0.73) |
|
Total Score |
Adequate (0.57) |
Adequate (0.74) |
** Unable to report due to errors made by subjects
(Valovich et al, 2004)
Excellent interrater reliability for all testing conditions (ICC = 0.87-0.98)
Excellent interrater reliability for total score (ICC = 0.98)
Athletes:
(Bell et al, 2011)
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)
Athletes (controls without neurological / orthopedic injury):
(Susco et al, 2004)
Positive correlation with RPW score (r = 0.542)
Athletes:
(Bell et al, 2011)
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)
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)
Athletes (controls without neurological / orthopedic injury):
(Susco et al, 2004)
After 20 min of activity, BESS scores were significantly higher (worse) than pre-test scores; also significantly higher than controls who did not perform any activity (rested for 20 and then repeated BESS)
The following time points were significantly different (worse) than pre-test:
Immediately following exertion
5 min after exertion
10 min after exertion
15 min after exertion
(Bell et al, 2011)
Excellent content validity for identifying balance deficits in functional ankle instability (Effect size = 2.69-3.14)
Excellent content validity for identifying fatigue (ES = 0.89-2.12 across various studies)
(Onate et al, 2007 n = 21 uninjured NCAA baseball players; mean age = 20.1(1.4) years; no history of head injury or lower extremity injury in the last 12 months)
Single leg foam condition significantly different when tested in controlled locker room vs uncontrolled sideline environment (p = 0.001, ES d = 1.03)
Moderate to large effect sizes (0.53-1.03) found for single-leg foam, tandem foam, and total BESS scores when comparing above two noted environments
Barlow, M., Schlabach, D., et al. (2011). "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 6(3): 150-157.
Bell, D. R., Guskiewicz, K. M., et al. (2011). "Systematic review of the balance error scoring system." Sports Health 3(3): 287-295.
Broglio, S. P., Zhu, W., et al. (2009). "Generalizability theory analysis of balance error scoring system reliability in healthy young adults." J Athl Train 44(5): 497-502.
Finnoff, J. T., Peterson, V. J., et al. (2009). "Intrarater and interrater reliability of the Balance Error Scoring System (BESS)." PM R 1(1): 50-54.
Hunt, T. N., Ferrara, M. S., et al. (2009). "The reliability of the modified Balance Error Scoring System." Clin J Sport Med 19(6): 471-475.
Iverson, G. L., Kaarto, M. L., et al. (2008). "Normative data for the balance error scoring system: implications for brain injury evaluations." Brain Inj 22(2): 147-152.
Koehle, M. S. (2013). "Normative Data for the Balance Error Scoring System in Adults." Rehabilitation research and practice 2013.
Onate, J. A., Beck, B. C., et al. (2007). "On-field testing environment and balance error scoring system performance during preseason screening of healthy collegiate baseball players." J Athl Train 42(4): 446-451.
Susco, T. M., Valovich McLeod, T. C., et al. (2004). "Balance Recovers Within 20 Minutes After Exertion as Measured by the Balance Error Scoring System." J Athl Train 39(3): 241-246.
Valovich McLeod, T. C., Perrin, D. H., et al. (2004). "Serial administration of clinical concussion assessments and learning effects in healthy young athletes." Clin J Sport Med 14(5): 287-295.
Valovich, T. C., Perrin, D. H., et al. (2003). "Repeat administration elicits a practice effect with the Balance Error Scoring System but not with the Standardized Assessment of Concussion in high school athletes." J Athl Train 38(1): 51-56.
We have reviewed more than 500 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.