Resident Balance Scale

Total Page:16

File Type:pdf, Size:1020Kb

Resident Balance Scale

RESIDENT BALANCE SCALE

RESIDENT NAME:______DATE:______

LOCATION:______EVALUATED BY:______

(Please see instructions on back.) 1. Sitting to Standing Score Please stand up. Try not to use your hands 4 – able to 3 – able to 2 – able to 1 – needs 0 – needs for support stand without stand stand using minimal aid to moderate or using hands independently hands after stand or to maximal assist and stabilize using hands several tries stabilize to stand independently 2. Standing Unsupported Please stand for two minutes without 4 – able to 3 – able to 2 – able to 1 – needs 0 – unable to holding. stand safely 2 stand 2 minutes stand 30 several tries to stand 30 minutes with supervision seconds stand 30 seconds unsupported seconds unassisted unsupported NOTE: If a resident is able to stand 2 minutes unsupported, score full points for sitting unsupported. Proceed to item #4. 3. Sitting with Back Unsupported but Feet Supported on Floor or on a Stool Please sit with arms folded for 2 minutes. 4 – able to sit 3 – able to sit 2 2 – able to sit 1 – able to sit 0 – unable to sit safely and minutes under 30 seconds 10 seconds without support securely 2 supervision 10 seconds minutes 4. Standing to Sitting Please sit down. 4 – sits safely 3 – controls 2 – uses back 1 – sits 0 – needs with minimal descent by of legs against independently assistance to sit use of hands using hands chair to control but has descent uncontrolled descent 5. Transfers Arrange chair(s) for a pivot transfer. Ask 4 – able to 3 – able to 2 – able to 1 – needs one 0 – needs two resident to transfer one way toward a seat transfer safely transfer safely transfer with person to assist people to assist with armrests and one way toward a seat with minor use definite need of verbal cueing or supervise to without armrests. You may use two chairs of hands hands and/or be safe (one with and one without armrests) or a supervision bed and a chair. 6. Standing Unsupported with Eyes Closed Please close your eyes and stand still for 10 4 – able to 3 – able to 2 – able to 1 – unable to 0 – needs help seconds. stand 10 stand 10 stand 3 keep eyes to keep from seconds safely seconds with seconds closed 3 falling supervision seconds but stays steady 7. Standing Unsupported with Feet Together Place your feet together and stand without 4 – able to 3 – able to 2 – able to 1 – needs help 0 – needs help holding. place feet place feet place feet to attain to attain together together together position but position and independently independently independently able to stand 15 unable to hold and stand 1 and stand for 1 and to hold for seconds feet for 15 seconds minute safely minute with 30 seconds together supervision 8. Reaching Forward with Outstretched Arm While Standing Lift arm to 90 degrees. Stretch out your 4 – can reach 3 – can reach 2 – can reach 1 – reaches 0 – loses fingers and reach forward as far as you can. forward forward >12.5 forward >5 cm forward but balance while (Examiner places a ruler at end of fingertips confidently >25 cm safely (5 safely (2 needs trying/ requires when arm is at 90 degrees. Fingers should cm (10 inches) inches) inches) supervision external support not touch the ruler while reaching forward. The recorded measure is the distance forward that the finger reaches while the resident is in the most forward leaning position. When possible, ask resident to use both arms when reaching to avoid rotation of the trunk. 9. Pick-up Object From the Floor From a Standing Position Score Pick up the shoe/slipper which is placed in 4 – able to pick 3 – able to pick 2 – unable to 1 – unable to 0 – unable to front of your feet. up slipper up slipper but pick up but pick up and try/needs assist safely and needs reaches 2-5cm needs to keep from easily supervision (1-2 inches) supervision losing balance from slipper and while trying or falling keeps balance independently 10. Turning to Look Behind Over Left and Right Shoulders While Standing Turn to look directly behind you over 4 – looks 3 – looks 2 – turns 1 – needs 0 – needs toward left shoulder. Repeat to the right. behind from behind one side sideways only supervision assist to keep Examiner may pick an object to look at both sides and only other side but maintains when turning from losing directly behind the resident to encourage a weight shifts shows less balance balance or better twist turn. well weight shift falling 11. Turn 360 Degrees Turn completely around in a full circle. 4 – able to turn 3 – able to turn 2 – able to turn 1 – needs close 0 – needs Pause. Then turn a full circle in the other 360 degrees 360 degrees 360 degrees supervision or assistance direction. safely in 4 safely one side safely but verbal cueing while turning seconds or less only in 4 slowly seconds or less 12. Placing Alternate Foot on Step or Stool While Standing Unsupported Place each foot alternately on the 4 – able to 3 – able to 2 – able to 1 – able to 0 – needs step/stool. Continue until each foot has stand stand complete 4 complete >2 assistance to touched the step/stool four times. independently independently steps without steps/needs keep from and safely and and complete 8 aid with minimal assist falling/unable to complete 8 steps >20 supervision try steps in 20 seconds seconds 13. Standing Unsupported One Foot in Front (Demonstrate to resident) Place one foot 4 – able to 3 – able to 2 – able to take 1 – needs help 0 – loses directly in front of the other. If you feel that place foot place foot small step to step but can balance while you cannot place your foot directly in front, tandem ahead of other independently hold 15 stepping or try to step far enough ahead that the heel of independently independently and hold 30 seconds standing your forward foot is ahead of the toes of the and hold 30 and hold 30 seconds other foot. (To score 3 points, the length of seconds seconds the step should exceed the length of the other foot and the width of the stance should approximate the resident’s normal stride width.) 14. Standing on One Leg Stand on one leg as long as you can 4 – able to lift 3 – able to lift 2 – able to lift 1 – tries to lift 0 – unable to try without holding. leg leg leg leg unable to or needs assist independently independently independently hold 3 seconds to prevent fall and hold <10 and hold 5-10 and hold = or but remains seconds seconds >3 seconds standing independently

TOTAL SCORE (MAX=56) Instructions: Please give instructions as written and/or demonstrate each task. When scoring, please record the lowest response category that applies for each item. In most items, the resident is asked to maintain a given position for a specific time. Progressively more points are deducted if the time or distance requirements are not met, if the resident’s performance warrants supervision, or if the resident touches an external support or receives assistance from the examiner. Residents should understand that they must maintain their balance while attempting the tasks. The choices of which leg to stand on or how far to reach are left to the resident. Poor judgment will adversely influence the performance and the scoring. Equipment required for testing are a stopwatch or watch with a second hard, and a ruler or other indicator of 2, 5, and 10 inches (5, 12.5 and 25 cm). Chairs used during testing should be of reasonable height. Either a step or a stool (of average step height) may be used for item #12.

References: 1. Wood-Dauphinee S, Berg K, Bravo G, Williams JI: The Balance Scale: Responding to clinically meaningful changes. Canadian Journal of Rehabilitation 10: 35-50,1997 2. Berg K, Wood-Dauphinee S, Williams JI: The Balance Scale: Reliability assessment for elderly residents and residents with an acute stroke. Scand J Rehab Med 27:27-36, 1995 3. Berg K, Maki B, Williams JI, Holliday P, Wood-Dauphinee S: A comparison of clinical and laboratory measures of postural balance in an elderly population. Arch Phys Med Rehabil 73: 1073-1083, 1992 4. Berg K, Wood-Dauphinee S, Williams JI, Maki, B: Measuring balance in the elderly: validation of an instrument. Can. J. Pub. Health July/August supplement 2:S7-11, 1992 5. Berg K, Wood-Dauphinee S, Williams JI, Gayton D: Measuring balance in the elderly: preliminary development of an instrument. Physiotherapy Canada 41:304-311, 1989

MO-03-04-NHAD April 2003 This material was prepared by Primaris under contract with the Centers for Medicare & Medicaid Services (CMS). The contents presented do not necessarily reflect CMS policy.

Recommended publications