Validating the Berg Balance Scale for Patients With
Parkinson’s Disease: A Key to Rehabilitation Evaluation
Abu A. Qutubuddin, MD, Phillip O. Pegg, PhD, David X. Cifu, MD, Rashelle Brown, BS,
Shane McNamee, MD, William Carne, PhD
ABSTRACT. Qutubuddin AA, Pegg PO, Cifu DX, Brown R,
McNamee S, Carne W. Validating the Berg Balance Scale for
patients with Parkinson’s disease: a key to rehabilitation evalua-
tion. Arch Phys Med Rehabil 2005;86:789-92.
Objective: To assess the criterion-related validity of the Berg
Balance Scale (BBS) in subjects with Parkinson’s disease (PD).
Design: Prospective, correlational analysis between the
BBS and accepted measures of PD motor and functional
Setting: The federally funded PD research center, an inter-
disciplinary center of excellence for people with PD within a
Veterans Affairs medical center.
Participants: Thirty-eight men (average ? standard devia-
tion, 71.1?10.5y) with confirmed PD. Their initial diagnosis
had been made on average 5.8?3.6 years earlier. All could
stand or walk unassisted and had mild to moderate disability.
Patients who could not ambulate without assistive devices were
Interventions: Not applicable.
Main Outcome Measures: Correlational analyses between
the BBS and the Unified Parkinson’s Disease Rating Scale
(UPDRS) motor scale, Modified Hoehn and Yahr Staging
(Hoehn and Yahr) Scale, and the Modified Schwab and
England Capacity for Daily Living Scale (S&E ADL Scale).
Results: BBS score showed significant correlations with
indicators of motor functioning, stage of disease, and daily
living capacity. BBS score was inversely associated with the
UPDRS motor score (–.58, P?.005), Hoehn and Yahr Scale
staging (–.45, P?.005), and S&E ADL Scale rating (.55,
P?.005). In all 3 correlations, lower scores on the BBS (indicat-
ing greater balance deficits) correlated with higher UPDRS scores
(indicating greater motoric or functional impairment).
Conclusions: Results support the criterion-related validity
of the BBS. Its utility in other balance conditions of older
adults has been established. Rehabilitation interventions have
been shown to improve the balance deficits associated with PD.
Early referral and periodic reassessment is vital to achieving
and maintaining improvements. Our research results agree with
other published research in suggesting that the BBS may be
used as a screening tool and ongoing assessment tool for
patients with PD.
Key Words: Balance; Parkinson disease; Rehabilitation;
Reliability and validity.
© 2005 by American Congress of Rehabilitation Medicine
and the American Academy of Physical Medicine and
independently at home and significant physical disability in this
patient population.1,2The progressive loss of dopaminergic
cells in the pars compacta of the substantia nigra in the mid-
brain and alterations in other brainstem sites are thought to
result in increased extremity and truncal tone, motor incoordi-
nation, and dysautonomia, which lead to the imbalance.3These
balance difficulties stem from a combination of deficits, includ-
ing loss of postural reflexes, abnormal changes in postural
adjustment, truncal and extremity rigidity, and akinesia. Once
a patient loses the ability to make rapid postural corrections, a
tendency to fall becomes evident. Despite the high prevalence
of, and significant functional limitations resulting from, bal-
ance deficits, there is little agreement among health care pro-
fessionals about the most appropriate tools with which to
evaluate this impairment.4
Visser et al5recently examined the available clinical tests for
postural instability in PD as part of their larger project to
develop Scales for Outcomes in Parkinson’s disease. They
noted that there is no criterion standard for a postural instability
evaluation. As part of their study, Visser suggested that the
most valid test for postural stability in PD was a retropulsion
test (ie, an unexpected shoulder pull).6,7Although the retropul-
sion test identifies an important facet of postural instability, it
cannot capture the full spectrum of potential contributing fac-
tors. Unfortunately, Visser excluded the more detailed, multi-
factorial balance measures typically used with the older adults,
such as the Berg Balance Scale (BBS),8the Tinetti Balance
Test,9single-limb stance timed test (eyes open and closed),10
Romberg test, modified sit-reach test,11and computerized pos-
turography.12Our literature search indicated that initial re-
search to develop a PD-specific balance measure is presently
The BBS was designed to measure changes in functional
standing balance over time. It is a 14-item scale that rates each
function from 0 (worst) to 4 (best) along a dependence-inde-
pendence continuum. This summative scale measures balance
abilities seen during tasks involving sitting, standing, and po-
sitional changes. Total scores are indicative of overall balance
abilities, with scores interpreted in the following manner: 0 to
20, wheelchair bound; 21 to 40, walking with assistance; and
41 to 56, independent.8,14The BBS is relatively safe and simple
to administer. It uses a quantitative scale format that has strong
internal consistency and good inter- and intrarater reliability
with different patient populations, including brain injury,
OSTURAL INSTABILITY IS A hallmark of Parkinson’s
disease (PD) and the major cause of falls, inability to live
From Southeastern Parkinson’s Disease Research, Education, and Clinical Center
(Qutubuddin, Pegg, Cifu, Brown, McNamee, Carne) and Defense and Veterans Brain
Injury Center (Pegg), McGuire Veterans Medical Center, Richmond, VA; and De-
partment of Rehabilitation Medicine, Virginia Commonwealth University, Richmond,
VA (Qutubuddin, Cifu, Carne).
Supported by the Veterans Health Administration Southeastern Parkinson’s Dis-
ease Research, Education, and Clinical Center (PADRECC) and the Veterans Health
Administration Defense and Veterans Brain Injury Center (DVBIC). The content of
this article is solely the responsibility of the authors and does not represent the official
views of PADRECC or DVBIC.
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit upon the authors(s) or upon any
organization with which the author(s) is/are associated.
Reprint requests to Abu A. Qutubuddin, MD, PADRECC/Dept of Rehabilitation
Medicine, McGuire VA Medical Center, 1201 Broad Rock Blvd, Rm 2C-144,
Richmond, VA 23249, e-mail: firstname.lastname@example.org.
Arch Phys Med Rehabil Vol 86, April 2005
stroke, and geriatric patients.4,15,16Although the BBS has been
used to measure balance deficits in different patient population,
no study to date has focused on people with PD. In this
prospective demonstration study, we evaluated consecutive
patients with PD using the BBS. We obtained additional clin-
ical information, including motor functioning, stage of disease,
and daily living skills. These indicators of functioning let us
examine the criterion-related validity of the BBS for people
with PD. We hypothesized that the BBS provides a unique and
meaningful determinant of balance difficulties in these patients.
Our purpose was to affirm its utility in measuring the unique
balance deficits in this patient population.
The Hunter Holmes McGuire Veterans Affairs Medical
Center in Richmond, VA, is 1 of 6 Veterans Health System
centers of excellence for the treatment of PD. Patients referred
to Parkinson’s Disease Research, Education, and Clinical Cen-
ter (PADRECC) undergo a comprehensive interdisciplinary
evaluation that includes examinations by a neurologist, neuro-
psychologist, and physiatrist. Eligible participants in this study
were consecutively evaluated by the PADRECC physiatrist
between August 2003 and January 2004. The diagnosis of PD
was confirmed by the PADRECC neurologist (ie, appropriate
clinical findings, and confirmed responsiveness to dopamine or
dopamine-agonists), and all participants were ambulatory with-
out any assistive device or physical assistance during their
initial clinic evaluation. Physiatrists experienced with PD pro-
spectively collected and documented demographic data from
patients’ medical records and clinical interviews.
Among the demographic variables collected for this inves-
tigation was subject age at study entry.
One single physician evaluated each subject by using mul-
tiple assessment instruments to determine motor functioning,
stage of disease, daily living skills, and balance. All measure-
ments were taken during a 60-minute examination. The fol-
lowing instruments were used.
Berg Balance Scale.
The BBS is an objective measure of
balance abilities. It has been used to identify and evaluate
balance impairment. The scale consists of 14 tasks common in
everyday life. The items test a subject’s ability to maintain
positions or movements of increasing difficulty by diminishing
the base of support from sitting and standing to single-leg
stance. One’s ability to change positions is also assessed.
Unified Parkinson’s Disease Rating Scale.
Parkinson’s Disease Rating Scale (UPDRS) is currently the
most widely accepted scale for measuring the different com-
ponents of PD. It is used in clinical research and drug trials to
follow the longitudinal course of PD.17,18Its major strength is
that it provides a detailed and accurate assessment of PD in
different respects. It is divided into 6 sections. In the Discus-
sion section later, we only use the scale’s motor component.
This is a detailed motor examination that evaluates 14 items
with 27 distinct functions. Each item is scored on a scale from
0 to 4. A total of 108 points is possible, with 108 representing
maximal (or total) disability and 0 representing no disability.19
Modified Schwab and England Capacity for Daily Living
The Modified Schwab and England Capacity for Daily
Living Scale (S&E ADL Scale) is widely used to assess dis-
ability in performing activities of daily living for people with
PD. It is a percentage scale divided into deciles, with 100%
representing completely normal function and 0% representing
Modified Hoehn and Yahr Staging Scale.
Hoehn and Yahr Staging Scale (Hoehn and Yahr Scale) is de-
signed to give an estimate of PD disease staging (appendix 1).20
Data were analyzed with SPSS, 10.0a
for Windows. Means and standard deviations (SDs) were cal-
culated for each of the measures, as well as for continuous
demographic variables (eg, age). Bivariate correlations among
all the various measures except age were calculated, with the
degree of relation between the indicators assessed by using the
Spearman rank correlation coefficient. Bivariate correlations
between age and other measures were calculated by using
Pearson correlations. Tests of significance for all correlation
were 2-tailed (P?.05). The criterion-related validity of the
BBS was determined by the directionality and strength of
the relation between total BBS scores and measures of motor
functioning, disease staging, and daily living skills.
Participants were 38 male patients at the PADRECC clinic.
Thirty (77%) identified themselves as white and the remainder
as African American. Thirty patients (77%) lived with their
wives only or with their families, while 3 lived alone, 2 lived
with a nonfamily member, 1 lived in a nursing home, and the
living arrangements of 2 participants were not reported. For the
27 patients who had complete information about how long
since they were diagnosed with PD, the average time was
5.4?3.58 years (range, 1–13y). The average age of patients at
study initiation was 71.1?10.5 years (range, 39–85y; see table
1). The mean Mini-Mental Status Examination (MMSE)21total
score of participants was 27.11?3.35 (range, 18–30). On the
basis of their performance on the MMSE, 5 participants (14%)
were classified as having dementia (ie, MMSE total score,
?24). The modal MMSE total score was the maximum possi-
ble score of 30, and was attained by 10 patients (26%).
The average BBS score for all subjects was 40.22?8.48
(range, 21–53) (table 1). The average score on the UPDRS
motor examination was 23.05?8.48 (range, 9–43). The Hoehn
and Yahr Scale disease staging (range, 1.5–4.0) showed gen-
erally mild-to-moderate disease involvement, with 4 patients
(13%) having ratings of 1.5 and 26 patients (86%) having
ratings of between 2.0 and 3.0. The mean Hoehn and Yahr
Scale staging was 3, with 12 patients (39%) receiving that
rating. Percentile ratings on the S&E ADL Scale likewise
suggest the relatively high and generally independent function-
ing of the participants; the average rating was 76.15?14.07
(range, 20–90%). The mean S&E ADL Scale rating, attained
by 19 participants (54%), was 80%, indicating complete inde-
pendence in most activities of daily living, while acknowledg-
Table 1: Demographic and Clinical Variables of Study Subjects
VariablesMean ? SDRange
BBS total score
UPDRS motor score
Modified Hoehn and Yahr score
Modified S&E ADL rating
VALIDATING THE BERG BALANCE SCALE, Qutubuddin
Arch Phys Med Rehabil Vol 86, April 2005
ing slowness and difficulty in performing the activities. Seven
patients (20%) were given an S&E ADL Scale rating of 90%,
indicating complete independence in daily activities even if
they had some difficulty with certain activities. Only 9 partic-
ipants (26%) received S&E ADL Scale ratings of 70% or
lower, with only 1 patient receiving a score below 60%.
As shown in table 2, total BBS scores showed significant
correlations with indicators of motor functioning, stage of disease,
and daily activities. BBS scores were inversely associated
(r?–.58) with the most recent UPDRS motor examination, sug-
gesting that higher performance on the BBS is related to lower
UPDRS motor functioning scores. Notably, higher ratings on the
UPDRS suggest a lower level of patient functioning. Similarly,
stage of disease, such that higher scores on the BBS were related
to lower Hoehn and Yahr Scale staging. Analogous to the UPDRS
ratings, lower standing on the Hoehn and Yahr staging indicates
fewer signs of disease. Also in a manner consistent with our
hypothesis, total BBS scores were positively associated with S&E
ADL Scale percentage scores (at .55), indicating that higher per-
formance on the BBS is related to better ratings of adult daily
living. All correlations were significant at P less than .005.
Total BBS scores did not correlate significantly with patient
age. To address concerns about a potential relation between age
using partial correlations and controlling for patient age. We used
these analyses to examine whether either the direction or the
statistical significance of any of the relationships between the
ratings of patient performance on the BBS (and indicators of
motor functioning, disease staging, or daily activities) would be
changed as a result. In agreement with the previously noted
finding that age showed no significant correlations with any of the
variables of interest, none of the relationships between the vari-
ables we included in our analysis changed after controlling for the
effect of age.
Intact balance is a key building block for all functional activi-
ties, from upright sitting tasks to transfer skills to ambulation.
Although a range of rehabilitation interventions have improved
motor skills that affect activities of daily living and ambulation in
people with PD,22,23specific improvements in PD-related balance
have been less well demonstrated. A key factor accounting for this
is the lack of a well-accepted, standardized balance measure for
people with PD. Although such a measurement tool must be
simple enough to be feasible for clinic use, it must also be
sophisticated enough to objectively screen for subtle balance def-
icits and to detect even small improvements in balance. This study
has shown the criterion-related validity of the BBS use with
people with PD.
Several unidimensional and multidimensional balance assess-
ment scales have been developed that have primarily focused on
older adults.5-11,15The retropulsion test offers a “rapid screen” for
people with PD at risk for falls; however, the limited nature of this
test is likely to result in a significant rate of “false-negative”
assessments.5A recently proposed scale13using components of
the PD-specific UPDRS, S&E ADL Scale, and the Hoehn and
Yahr Scale, as well as components of other balance and gait
measures, may be a promising functional measure. However,
initial application of this measurement tool failed to show the
validity of the overall score obtained. The BBS, on the other hand,
is a well-accepted, multidimensional measure of balance that has
excellent reliability and validity with older adults.24,25It also has
significant correlations with responsiveness to rehabilitation out-
comes in select stroke and brain injury patient populations.4,15,26
older adults who benefit from rehabilitation interventions. Clearly,
the characteristics and clinical relevance of the BBS make it an
excellent candidate as an assessment tool in the PD patient pop-
The UPDRS motor score, Modified Hoehn and Yahr Scale,
and Modified S&E ADL Scale are the established measures of
motor functioning, stage of disease, and daily living skills for
people with PD.17-20They have been adopted by both the
PADRECC and the American Parkinson’s Disease Associa-
tion’s Centers of Excellence programs as required elements of
a comprehensive assessment for patients with PD. These 3
measures provide a multimodal evaluation of physical and
functional status. Critical to the criterion-related validity of the
BBS for people with PD is its relation to indicators of related
functioning noted earlier.
In this study, we hypothesized that BBS total score would be
most strongly associated with the UPDRS motor functioning
examination scores because of the close association of motor
functioning and balance. Because higher total BBS scores indicate
better balance whereas, conversely, higher UPDRS scores suggest
greater impairment in motor functioning, we expected the nega-
tive correlation between the 2 measures. Because the balance
difficulties attendant on movement disorders can reasonably be
expected to adversely affect daily living skills, we further hypoth-
esized that total BBS scores would correlate significantly with the
Modified S&E ADL Scale rating. Because Modified S&E ADL
Scale percentage ratings are indicative of better daily living ad-
aptation, the relation between total BBS scores and Modified S&E
ADL percentages should be positive. Second, because the broad
focus of daily living skills are less explicitly related to balance
between total BBS scores and Modified S&E ADL percentages
would be of a lower order than that obtained between total BBS
scores and UPDRS motor examination scores. Our findings sup-
port this hypothesis. Third, with the increases in postural instabil-
ity and balance difficulties typically seen as PD progresses, we
expected that total BBS scores would also be correlated signifi-
cantly with Modified Hoehn and Yahr staging. Because a higher
Modified Hoehn and Yahr staging is related to more PD-related
impairment, we anticipated that the relation between total BBS
score and disease staging would be negative. Because a measure
of disease staging is expected to be less closely related to balance
abilities than is a rating of motor functioning, we also hypothe-
sized that the correlation between total BBS scores and Modified
the level of the association between total BBS scores and UPDRS
Table 2: Correlations of BBS Total Scores With UPDRS Motor
Functioning, Modified Hoehn and Yahr Scale, Modified S&E ADL
Scale, Age, and Patient Self-Rating of Pain
and Yahr staging
Modified ADL Scale
Age of patient
VALIDATING THE BERG BALANCE SCALE, Qutubuddin
Arch Phys Med Rehabil Vol 86, April 2005
motor functioning. Moreover, because disease staging falls into a Download full-text
more limited spectrum of values than the S&E ADL Scale, the
association between total BBS scores and disease staging will
likely be less than the association shown by total BBS scores and
S&E ADL percentage ratings. In summary, we found that total
in the following order of magnitude: UPDRS motor functioning,
then Modified S&E ADL Scale percentage, and then Modified
Hoehn and Yahr disease staging.
The consistent correlations found in this study support the
clinical validity of the BBS in the PD population. Its increased use
in this subpopulation of older adults may serve as both a useful
screening test for balance deficits and a sensitive measure of
changes in balance skills. This may provide for a better under-
standing of the specific effects of therapeutic interventions (eg,
medications, deep brain stimulation, rehabilitation) on balance
deficits in people with PD. The prospective, consecutive design of
this investigation; the uniform patient population resulting from
strict inclusion criteria; the presence of a single, trained examiner;
and the use of well-established clinical and disease staging mea-
sures for correlation adds to the generalizability of the study’s
findings. The significant diversity of the PD patient population,
presence of concomitant medical conditions, may all have ad-
versely affected the assessment procedures. Additionally, the lack
of women in the study sample may have resulted in a biased
subject selection. Larger, multicenter investigations with a more
sex-diverse population are recommended. Finally, a prospective
evaluation of the utility of the BBS as a screening tool for
determining fall risk and the need for rehabilitation intervention is
APPENDIX 1: MODIFIED HOEHN AND YAHR
No evidence of disease
1.0 Unilateral disease only
1.5 Unilateral disease plus axial involvement
2.0 Bilateral mild disease, without impairment of balance
2.5 Mild bilateral disease with recovery on pull test
3.0 Mild-to-moderate bilateral disease, with some postural
instability but physically independent
4.0 Severe disease, but still able to walk or stand unassisted
5.0 Wheelchair bound or bedridden unless aided
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