Balance Error Scoring System

What is postural stability?

Postural stability, also known as balance, refers to maintaining the body’s center of mass over its support base. This ability is crucial for performing everyday activities, such as walking, standing, and sitting, without falling. Postural stability is a complex process involving sensory information from the visual, vestibular, and proprioceptive systems to produce appropriate motor responses.

Several factors can affect postural stability, including age, injury, and neurological conditions. For example, older adults often experience a decline in balance due to age-related changes in the sensory systems and muscle strength. Injuries, such as sprained ankles or concussions, can also disrupt postural stability by causing balance deficits and affecting the proprioceptive feedback from the injured area. Additionally, neurological conditions like Parkinson’s disease or multiple sclerosis can impair the neural pathways involved in balance control.

To check for postural stability, healthcare professionals use various assessments and tools. One commonly used tool is measured by the Balance and Error Scoring System (BESS), which evaluates static balance through different stances and surfaces. The total BESS score is instrumental in assessing athletes following concussions or a mild head injury to determine their readiness to return to play.

What is the Balance Error Scoring System?

The Balance Error Scoring System is a brief and easily administered test to assess static balance. It is widely used in sports medicine to evaluate athletes, particularly following concussions or mild traumatic brain injuries, and to assist clinicians in making return-to-play decisions. The BESS provides a standardized method to measure balance errors in different stances and surfaces, offering a reliable assessment of an individual’s postural stability and BESS performance in clinical sports-related concussion and assessments.

The BESS consists of three stances (double leg, single leg, and tandem stance) performed on both firm and foam surfaces. The test measures the number of balance errors made during each 20-second trial, with a lower score indicating better balance and fewer errors. The BESS is versatile and can be performed in nearly any environment, making it a practical tool for clinicians and researchers alike (Iverson & Koehle, 2013).

How to perform the BESS

Performing the BESS involves a series of balance tests conducted under specific conditions. Barefoot BESS performance can provide additional insights into natural postural stability. The subject is instructed to remove their shoes and stand in a designated testing area. The clinician explains the testing positions and the scoring criteria to ensure the subject understands the procedure. The balance testing includes three positions on both a firm surface and foam surfaces: double-leg stance, single-leg stance, and tandem stance.

In the double leg stance, the subject stands with their feet together, hands on hips, and eyes closed. For the single-leg stance, the subject stands on their non-dominant foot with the dominant leg held in approximately 30° hip flexion and 45° knee flexion. In the tandem stance, the subject stands heel-to-toe with the non-dominant foot in the back. Each trial lasts for 20 seconds, and the clinician records the number of balance errors, such as moving hands off hips, lifting the forefoot, opening eyes, or lifting the forefoot or heel of the testing surface. The BESS comprehensively evaluates postural stability by assessing balance under various conditions (Bell et al., 2011).

How does our Balance Error Scoring System template work?

Our BESS template is designed to streamline the assessment process for healthcare professionals. The template provides a clear and structured format for conducting the BESS, ensuring consistency and accuracy in testing.

Step 1: Download the template

Download the BESS template from our website. Ensure you have all the necessary materials, including a foam pad and a stopwatch, ready for the test.

Step 2: Prepare the testing area

Set up a designated testing area where the subject can perform the balance tests without obstructions. Ensure the area is safe and free from distractions.

Step 3: Explain the procedure to the subject

Instruct the subject to remove their shoes and stand in the designated proper testing position and area. Explain the testing positions and scoring criteria clearly so the subject understands what is expected.

Step 4: Conduct the balance tests

Perform the balance tests according to the procedures outlined in the template. Record the number of errors made during each 20-second trial for each test position and surface. Ensure the subject maintains the correct posture throughout the test.

Step 5: Calculate the scores

Calculate the total score by summing the errors across all trials. Use the normative data provided in the template to interpret multiple errors in the results and assess the subject's postural stability.

Scoring and results

The BESS scoring involves counting the number of balance errors made during each 20-second trial for each of the six conditions: double leg stance, single leg stance, and tandem stance on both firm and foam surfaces. This method is crucial in brain injury evaluations and identifying balance deficits. Errors include moving hands off hips, opening eyes, stepping, stumbling, falling, abduction or flexion of the hip beyond 30 degrees, lifting the forefoot or heel of the testing surface, and remaining out of the proper testing position for more than 5 seconds. If multiple errors co-occur, only one is counted.

The total score is the sum of all errors across the six trials, with a maximum possible score of 60. Lower scores indicate better balance and fewer errors. After completing the test, the clinician records the number of errors for each stance and surface, calculates the total score, and compares it to the normative data provided in the template to determine the subject’s balance performance.

Interpretation and next steps

Interpreting the total BESS score results involves comparing the subject’s score to normative data stratified by age. Lower scores indicate better balance and postural stability, while higher scores suggest poorer balance and potential issues with postural control. The normative data allows clinicians to determine whether a subject’s balance performance is broadly normal, below average, poor, or very poor for their age group.

If a subject’s balance performance is below average or poor, clinicians may recommend targeted balance training exercises, further diagnostic testing, or a referral to a specialist for additional evaluation and treatment. Additionally, a comprehensive neuromuscular training program may be suggested to improve BESS scores, addressing factors like concussion, functional ankle instability, external ankle bracing, fatigue, and age.

References

Bell, D. R., Guskiewicz, K. M., Clark, M. A., & Padua, D. A. (2011). Systematic review of the balance error scoring system. Sports Health, 3(3), 287–295. https://doi.org/10.1177/1941738111403122

Iverson, G. L., & Koehle, M. S. (2013). Normative data for the balance error scoring system in adults. Rehabilitation Research and Practice, 2013, 1–5.https://doi.org/10.1155/2013/846418