1Berg Balance Scale Overview
• 14-point scale: Highest score of 56
• Includes static sitting and standing balance, transfers, standing with eyes closed, Romberg and sharpened Romberg, standing reach, picking up an object from the floor, turns, step taps, SLS
• The greater the score, the better the performance
• No DME allowed
2 Functional Gait Assessment Overview
• 10-point scale: Highest score of 30
• Includes ambulation across walkway and analyzes balance, need for DME and veering off path
• Includes gait speed, speed variations, head turns, stepping over obstacles, backward walking, tandem walking, walking with eyes closed, quick pivot turns and stairs
• DME is allowed
3
ABC scale Overview
• Self-report measure including 16 items
• Pt answers how confident they are completing specific tasks
• Tasks included are more community and home based, so may not be great to use in the inpatient setting
• The higher the score, the more confident the patient is
4
10 meter walk test Overview
• Measures walking speed in meters per second
• Patient walks across a 10 meter walk way with 2 meters at beginning and end for acceleration/deceleration with the middle 6 meters being the distance during time measuring
• Calculation: the distance walked (6 meters) divided by time recorded (x seconds)
5
6 min walk test Overview
• Endurance measure using heart rate, pulse oximetry and BORG RPE scale
• Patient is allowed to take as many rests as needed but time does not stop
• Score is the distance they walk within the 6 minutes
6
5x sit to stand test Overview
• Measures the amount of time patient needs to complete 5 sit to stand transfers from chair without arm rests
• If the patient cannot perform 5 repetitions, they receive a score of 0 with documentation of why they are unable to perform
7Berg Balance Scale Cut off
< 50/56 may indicate high fall risk
< 40/56 almost 100% fall risk
8 Functional Gait Assessment Cut off
< 22/30 indicates high fall risk
<15/30 indicates high fall risk for Parkinsons
9 ABC Scale Cut off
< 67% indicates high fall risk
< 69% is predictive of recurrent falls in PD
> 81% indicates relative certainty that patient does not have a history of falls in chronic stroke pts
10 10 Meter Walk Test Cut off
< 1.0 m/s indicates high fall risk
Cut off for stroke
< 0.4 household ambulator
0.4 – 0.8 limited community ambulator
> 0.8 community ambulator
11 5x sit to stand Cut off
> 12 seconds indicates need to assess fall risk
> 15 seconds indicates risk of falls
> 12 seconds discriminates indviduals with stroke from those without
16 seconds discriminates fallers from nonfallers for patients with PD
> 16 seconds indicates high fall risk for patients with PD
> 13 seconds identifies patients with balance dysfunction in balance and vestibular cases