Berg Scale: Assessment of balance and risk of falls in patients with acquired brain injury

Nombre: Id: Date ___ /___ / ___

FROM SEDENTATION TO BIPEDALISM

INSTRUCTIONS: Please stand up. Try not to use your hands for support.

4 capable of getting up without using hands and stabilizing independently

3 capable of getting up independently using hands

Able to get up using hands after several attempts.

needs minimal assistance to get up or stabilize

( ) 0 needs moderate to maximum assistance to get up

2. BIPEDALISM WITHOUT HELP

INSTRUCTIONS: Please stand for two minutes without holding on.

Able to stand for 2 minutes safely

Able to stand for 2 minutes with supervision

( ) 2 able to stand for 30 seconds without holding on

1 needs several attempts to stand for 30 seconds without falling.

to hold on

0 unable to stand for 30 seconds without assistance

3. SITTING WITHOUT BACK SUPPORT, BUT WITH FEET ON THE GROUND OR ON A STOOL OR STEP

INSTRUCTIONS: Please sit with your arms at your sides for 2 minutes.

( ) able to sit safely for 2 minutes

3 able to remain seated for 2 minutes under supervision

able to sit for 30 seconds

1 capable of remaining seated for 10 seconds

0 unable to stay seated without assistance for 10 seconds

4. FROM BIPEDALISM TO SEDENTARISM

INSTRUCTIONS: Please, have a seat.

( ) 4 sits securely with minimal use of hands

( ) 3 controls the descent using the hands

Use the back of your thighs against the chair to control the descent.

( ) 1 sits independently, but does not control the descent

0 needs help to sit down

5. TRANSFERS

INSTRUCTIONS: Prepare the chairs for a pivot transfer. Ask the patient to first move to a seat with armrests and to
continuation to another seat without armrests. Two chairs can be used (one with and one without armrests) or a bed and a chair.
4 capable of transferring securely with minimal use of hands

3 capable of transferring securely with the help of hands

2 capable of transferring with verbal instructions and/or supervision

1 needs a person to assist him/her

( ) needs two people to assist or supervise the transfer so that

safe sea.

6. SITTING POSITION WITHOUT HELP WITH EYES CLOSED

INSTRUCTIONS: Please close your eyes and stand still for 10 seconds.

capable of standing for 10 seconds safely

( ) 3 able to stand for 10 seconds with supervision

able to stand for 3 seconds

1 unable to keep the eyes closed for 3 seconds but able to

remain firm

0 needs help not to fall

7. STAND UP WITHOUT HOLDING ON WITH FEET TOGETHER

INSTRUCTIONS: Please bring your feet together and stand without holding on.

( ) 4 able to stand with feet together safely and

independent for 1 minute

( ) 3 able to stand with feet together independently for

1 minute with supervision

( ) 2 able to stand on one's own with feet together independently, but

unable to maintain the position for 30 seconds

1 needs help to achieve the posture, but is able to remain standing.

for 15 seconds with feet together

0 needs help to achieve the posture and is unable to maintain it for 15 seconds.

8. EXTENDING THE ARM FORWARD IN BIPEDAL STANDING

INSTRUCTIONS: Raise your arm to 90º. Stretch your fingers and extend it forward as much as you can. The examiner places a ruler at the end of
the fingers when the arm is at 90º. The fingers should not touch the ruler while bringing the arm forward. The distance from the finger is measured.
reaches while the subject is leaning forward as much as possible. When possible, the patient is asked to use both arms to avoid the
trunk rotation

( ) can comfortably lean forward more than 25 cm

It can safely tilt forward more than 12 cm.

( ) 2 can lean forward safely > 5 cm

( ) leans forward but requires supervision

He/She loses his/her balance while trying to lean forward or requires help.
9. IN BIPEDAL STANCE, PICK UP AN OBJECT FROM THE FLOOR

INSTRUCTIONS: Pick up the object (shoe/sneaker) located in front of your feet.

able to pick up the object comfortably and safely

3 capable of picking up the object but requires supervision

Unable to grasp the object but approaches 2 to 5 cm (1-2 inches) from the object and

maintains balance independently

1 unable to pick up the object and needs supervision when trying to do so

0 unable to attempt it or needs assistance to avoid losing balance or falling

10. IN BIPEDAL STANCE, TURN AROUND TO LOOK BACK

INSTRUCTIONS: Turn to look back to the left. Do the same to the right.

The examiner can hold an object behind the patient for them to look at to encourage a better turn.

( ) 4 look back to both sides and shift your weight well

3 looks back from one side, on the other side it presents a lesser

body weight displacement

2 tilts to one side but maintains balance

1 needs supervision when turning

0 needs assistance to avoid losing balance or falling

11. TURN 360 DEGREES

INSTRUCTIONS: Make a complete turn of 360 degrees. Pause. Next, repeat the same thing in the other direction.

Able to spin 360 degrees safely in 4 seconds or less

( ) capable of rotating 360 degrees safely in one direction only in 4

seconds or less

2 capable of turning 360 degrees safely, but slowly

1 needs close supervision or verbal instructions

( ) 0 needs assistance when turning

12. ALTERNATELY LIFT THE FEET TO A STEP OR STOOL IN BIPEDAL STANCE WITHOUT HOLDING ON

INSTRUCTIONS: Alternate placing each foot on a step/stool. Repeat the operation 4 times for each foot.

4 capable of standing safely and independently and completing 8

steps in 20 seconds

3 able to stand independently and complete 8 steps

in more than 20 seconds

2 able to complete 4 steps without help or with supervision

1 able to complete more than 2 steps with minimal assistance

( ) 0 needs assistance to avoid falling or is unable to attempt it

INSTRUCTIONS: Demonstrate to the patient. Place one foot in front of the other. If you think you won't be able to place it right in front, try taking a step.
forward so that the heel of the foot is positioned in front of the shoe of the other foot (to score 3 points, the length of the step should
should be longer than the length of the other foot and the base of support should approach the normal step width of the subject.

able to place the foot in tandem independently and hold it for 30

seconds

able to place one foot in front of the other independently and

hold it for 30 seconds

able to take a small step independently and hold it for

30 seconds

1 needs help to take the step, but can hold it for 15 seconds.

( ) 0 loses balance when taking a step or standing.

14. BIPEDALISM ON ONE FOOT

INSTRUCTIONS: Support on one foot without holding on

( ) 4 able to lift the leg independently and hold it for more than 10 seconds.

3 able to lift the leg independently and hold it for 5-10 seconds.

able to lift the leg independently and hold it for 3 or more

seconds

( ) 1 tries to lift the leg, unable to hold it for 3 seconds, but remains

standing independently

0 unable to try it or needs help to prevent a fall

( ) PUNTUACIÓN TOTAL (Máximo= 56)

Specifically, the results are interpreted as:

0-20: high risk of falling

-21-40: moderate risk of falling

–41-56: low risk of falling

On average, patients with scores lower than 40 are almost twelve times more likely to fall than those with
scores above 40. Scores below 45 out of 56 are generally accepted as indicators of disturbance
balance. Various articles establish a cutoff point of 45 out of 56 for safe independent ambulation.

According to the scores obtained on the Berg scale, it also allows us to gain information about their motor and functional capacity.
We can establish 5 groups:

–Group for the onset of bipedalism (33-39)

Start march group (40-44)

March with/without technical aids (45-49)

Independent march (50-54)

Functional march (55-56)

Berg Ko, Wood-Dauphine Sl., Williams J.I., Maki B. Measuring balance in the elderly: Validation of an instrument 1992