Journal of Physical Medicine Rehabilitation & Disabilities Category: Medical Type: Research Article
Cross Cultural Adaptation of Berg Balance Scale in Greek for Various Balance Impairments
- Lampropoulou Sofia1*, Gizeli Anastasia2, Kalivioti Christina2, Billis Evdokia2, Gedikoglou Ingrid3, Nowicky Alexander4
- 1 Department Of Life And Health Sciences, Technological Educational Institute Of Western Greece, School Of Sciences And Engineering, University Of Nicosia, Nicosia, Cyprus
- 2 Department Of Physical Therapy, Technological Educational Institute Of Western Greece, Aigio, Greece
- 3 Physio Point, Alimos, Greece
- 4 Department Of Clinical Sciences, College Of Health And Life Sciences, Brunel University London, Uxbridge, United Kingdom
*Corresponding Author:Lampropoulou Sofia
Department Of Life And Health Sciences, Technological Educational Institute Of Western Greece, School Of Sciences And Engineering, University Of Nicosia, Nicosia, Cyprus
Received Date: May 13, 2016 Accepted Date: Jun 23, 2016 Published Date: Jul 07, 2016
Rationale, Aim & ObjectivesThe Berg Balance Scale (BBS) although widely used for assessing balance, it has not been officially adapted into Greek. The aim therefore, of this research is to translate and validate the cross cultural adaptation of the Greek BBS (BBS-GR).
Method The BBS was adapted according to international guidelines, (forward & backward translation, by four bilingual independent translators). The pre-final BBS-GR was piloted by 6 physiotherapists (1-5 years of experience) and 12 patients (5 men & 7 women, age 76Â±7 years) in the 1st pilot study and by 10 patients (7 men & 3 women, age 57Â±20 years) during the 2nd pilot study with balance impairments. After modifications, the final BBS-GR was undertaken to 112 patients (43 men, 69 women, age 67Â±19 years) for its psychometric testing. It was administered by two raters, twice over a 10 day period, to assess both inter- and test-retest reliability correspondingly. Bland-Altman analysis presented the levels of agreement between measurements. Validity was assessed by correlation of the BBS-GR with the mini-Balance Evaluation Systems Test (mini-BESTest-GR), the Functional Reach Test (FRT), the Timed Up and Go test (TUG) and the questionnaire of Falls Efficacy Scale-International (FES-I).
ResultsMinor modifications to one item were required for the final BBS-GR version, and showed: excellent inter-rater reliability (ICC=0.998), test-retest (ICC=0.976) reliability and internal consistency (Cronbach's alpha=0.830). Measurements showed a good level of agreement (meandif=0.126Â±0.7, p>0.05). Spearmanâ€™s correlations coefficient (rs) were strong between the BBS-GR and the mini-BESTest (rs=0.844, p<0.001), the TUG (rs=-0.781, p<0.001), the FRT (rs=0.650, p<0.001) and FES-I (rs=-0.501, p<0.001), indicating good validity properties. Responsiveness across fallers and non fallers showed a moderate effect size (0.54).
ConclusionThe excellent psychometric characteristics of the Greek BBS highly recommend its utility to the Greek clinical setting. Further research should be undertaken to evaluate responsiveness over treatment conditions.
The Berg Balance Scale (BBS)  constitutes a popular and well established clinical tool for the assessment of balance . It is mainly known as a tool for measuring balance in the elderly [1,3,4] but it has also been tested for its reliability and validity in assessing balance in patients with various neurological diseases, such as stroke [5-7], multiple sclerosis , traumatic brain injury  and Parkinsonâ€™s disease  with very good results. The BBS also predicts prospective falls in the elderly although it is highly recommended that it also be administered with other outcome measures [11,12].
In relation to other scales of assessing static and dynamic balance, such as the Performance Oriented Mobility Assessment (POMA) or the Balance Evaluation Systems Test (BESTest), the BBS has the advantage of being an easy and quickly administered physical performance test that does need no training or special equipment . The BBS consists of 14 balance tasks such as sitting-to-standing, standing-to sitting, transferring from bed to chair, sitting and standing unsupported, standing with eyes closed, standing with feet together, tandem standing, single limb standing, reaching forward, picking up an object from the floor, alternating foot on stool, looking over the shoulders, and turning 360Â° . Every task is scored in a 5-point ordinal scale (0-4) and total score ranges from 0 to 56 with higher scores indicating better performance and greater independence . A cut off point of 45/56 has been suggested for independent and safe ambulation . All tasks take no more than 15 minutes to be delivered whereas the BESTest usually takes more than 40 minutes to administer . In addition, compared to single balance tests such as the Rombergâ€™s Test, the Functional Reach Test (FRT) or the Timed Up and Go test (TUG), BBS, with the 14 aforementioned functional tasks that it includes, offers a thorough assessment of balance [15,16]. Finally, it is freely available and inexpensive. Thus, the BBS offers several advantages for international adoption for balance assessment .
BBS has been adapted into several languages, including Italian , Brazilian-Portuguese , German , Korean , Swedish , Norwegian , Turkish , French , and Persian [24,25]. Most translations to the target language have been undertaken according recommendations of using double directed (forward and backward) translation process [17-21]. Psychometric characteristics of reliability and validity of the adapted versions are shown in table 1. Almost all adapted versions showed high intra- and inter-rater reliability and internal consistency [4,18,20,22,24,25]. The Italian , Turkish , Brazilian-Portuguese  and French  versions presented good construct and criterion validity in correlation with other balance measurements.
|Adapted version||Study||Sample||Reliability||Validity (correlation with BBS)|
|Italian||Ottonello et al. ||N=85
Miyamoto et al. Scalzo et al. 
|Korean||Jung et al. ||N=18
Inter-rater (ICCC=0.97 physio)
|Norwegian||Halsaa et al. ||N=83
|Swedish||Conradsson et al. ||N=45
|Turkish||Sahin et al. ||N=60
|French||Lemay & Nadeau ||N=32
|-||WISCI II (r=0.816*)
SCI-FAIassistive devices (0.714*)
|Persian||Azad et al. 
Salavati et al. 
Table 1: Psychometric characteristics of adapted versions of Berg Balance Scale (BBS).
HY: Hoehn & Yahr Staging Scale
FIM: Functional Independence Measure
MBI: Modified Barthel Index
MS: Multiple Sclerosis
2MWT: 2-min walk test
10MWT: 10-min walk test
PD: Parkinson Disease
S & E: Schwab and England Scale
SCI-FAI: Spinal Cord Injury Functional Ambulation Inventory
TBS: Tinetti Balance Scale
TUG: Timed Up and Go
UPDRS II & III: Unified Parkinsonâ€™s Disease Rating Scale (Subscales II & III)
WISCI II: Walking Index for Spinal Cord Injury (Version II)
Despite its popularity, BBS has not been cross culturally adapted into the Greek language and setting. A Greek study of Chatzitheodorou et al.,  tested its reliability regarding gender and the fallsâ€™ history in 60 elderly with very good results, but this study did not refer to any kind of official translation of the scale with consideration of cross cultural adaptation guidelines and no evaluation of cross cultural validation in Greek has been undertaken. Therefore, the aim of this study is to cross culturally adapt and validate the BBS in Greek adults with balance impairments. An officially translated and scientifically adapted tool would be of great value for a valid balance assessment in Greek patients.
MATERIAL AND METHODS
This study followed three phases. Firstly, a translation of the BBS into Greek was conducted after receiving permission of the original instrumentâ€™s developer, Dr. Berg. Secondly, a piloting testing of the pre-final version (derived in the initial phase) of the Greek BBS (BBS-GR) followed. Finally, full psychometric evaluation of the final BBS-GR was undertaken including reliability, validity and responsiveness of the measurement tool. The study was approved by ethics review board of the Scientific Committee of the Technological Educational Institute (TEI) of Western Greece.
Translation of the scale
Psychometric testing of the final Greek version of BBS
Outcome measures: Balance assessment tools were selected for comparison with the BBS to test its validity. The mini-Balance Evaluation Systems Test (mini-BESTest) is a recently developed balance tool, and it is the short version of the original BESTest . It was chosen because, similarly to BBS, it consists of 14 functional balance tasks of static and dynamic balance, and it takes 15 minutes to be delivered. Its advantage to other functional balance scales is that its tasks are divided into five balance testing systems (anticipatory adjustments, reactive control, compensatory stepping corrections, sensory orientation and dynamic balance during gait) offering the benefit of identification of the system responsible for the balance deficit [33,34]. Its excellent reliability, its strong correlation with the BBS and other balance measures [30,31,34,35] and its availability to Greek language (www.bestest.us) makes it one of the best choices for comparison with the Greek version of the BBS. The Timed Up and Go Test (TUG) [13,36] and the Functional Reach Test (FRT)  are simple balance tests which were chosen due to their high correlation with the BBS, their reliability, their ability to predict falls and because these are of the most frequently simple tests used in clinical and similar research settings [15,38,39]. Additionally to observational assessment tools, balance was self-reported by the participants through the Falls Efficacy Scale-International (FES-I) questionnaire . Its excellent psychometric characteristics in exploring the chance of fall in everyday living activities as well as its availability in the Greek language  made its selection the best choice for the validity assessment of the Greek version of the BBS.
Procedure: All measurements administered in outpatients settings, including patientâ€™s homes, quiet environment to avoid attention disturbance, and at a convenient time for them, but not close to meals or close to medication times. Patients had been advised in advance to wear comfortable clothes and flat shoes. Apart from the demographic characteristics, patients were asked about how often they had fallen during the last year with answer choices of â€œneverâ€, â€œonceâ€, â€œtwiceâ€, â€œmore than two timesâ€. At the same time, the FES-I was also completed by the patient. The functional balance tests (BBS, mini-BESTest, TUG, FRT) were then undertaken. After completion of the BBS a 10 minutes break was taken before the administration of the mini-BESTest to eliminate fatigue from the tasks.
Reliability: Reliability concerns the degree of similarity/stability in answers taken in repeated measures (41). To evaluate the test-retest reliability, measurements were repeated 7-10 days after the first testing. During the first session two observers scored the patient performance independently, to examine the inter-rater reliability. Raters for psychometric testing of the BBS-GR were two physiotherapists of those participating to the 1st pilot study. These procedures (7-10 days between tests time-interval and at least two raters) for reliability assessment were followed by other BBS cross cultural adaptation studies . The internal consistency reliability, which measures the degree that the items of the scale are correlated and thus measuring the same concept was also evaluated .
Validity: Validity is referred to the degree to which an instrument measures what it is intended to measure . Criterion validity is used to demonstrate the instrumental validity by comparing the scale being tested with a criterion measure of a same construct that has been established as valid . For the criterion validity, the BBS-GR was correlated with the Greek version of mini-BESTest, previously assessed as having very good (construct) validity with Greek patients with balance disorders . The BBS-GR was also tested for its construct validity (specifically the convergent validity) through the agreement among ratings that have been selected independently by other measurement scales that theoretically should be related . For the convergent validity the final Greek version of BBS was correlated with the TUG, the FRT, and the Greek FES-I.
Responsiveness: BBS-GR was also assessed for its responsiveness, meaning its ability to detect a clinically significant change . However, in the absence of intervention, responsiveness could be used to assess the ability of a measurement tool to reflect change according to an external standard (i.e., to classify patients in two categories) . Responsiveness was assessed through the differences between the two big categories, of â€œfallersâ€ and â€œnon fallersâ€, where as â€œfallersâ€ are characterized those who experienced at least one unexplained fall during the last year and â€œnon fallersâ€ those who had not one fall .
Ceiling & floor effects: Ceiling and floor effects of the BBS-GR were examined to assure that no great proportion of the testing sample have scores at the bottom (floor) or top (ceiling) of the scale and thus the measurement outcome is able to detect change in performance and does not limit sensitivity .
Tests of all data for normality by use of Kolmogorov-Smirnov test were significant so nonparametric tests were used. Criterion and construct validity were investigated by using Spearmanâ€™s correlation coefficient (rs). Correlation between 0.0-0.25 indicates little if any association, 0.26-0.49 low association, 0.50-0.69 moderate association, 0.70-0.89 high association and 0.90-1.00 very high association . Relative reliability was assessed by computing the consistency of the two measurements using Intraclass Correlation Coefficient (ICC2,2) where values 0.75 excellent reliability [8,45]. The Bland Altman Analysis for absolute reliability was also used to plot the differences between the two measurements against the means for each subject and to show the â€˜biasâ€™ (mean difference) of the measurements and the 95% Limits of Agreement (LoA) [49,50]. One Sample t-test for the differences was used to find whether these measurements significantly differed from 0. The internal consistency reliability was measured with the Cronbach's alpha coefficient with accepted value of 0.70 (or 70%), values between 0.70 and 0.80 to demonstrate good internal consistency and values above 0.80 to indicate very good internal consistency [32,48]. Responsiveness of the BBS-GR was calculated as the ratio between the mean difference of the scores between â€œfallersâ€ and â€œnon fallersâ€ divided by the standard deviation of the baseline score (total score of â€œfallersâ€ and â€œnon fallersâ€ together) [32,46]. That ratio was considered as the effect size with the value of 0.2 to 0.5 to indicate a small effect, value from 0.5 to 0.8 a moderate and above 0.8 a large effect . Percentage more than 20% of the participants at the highest and lowest score was considered as ceiling and floor effects, accordingly. Skewness of scores distribution, as further estimator of ceiling & floor effect, was presented at total scores . All data were presented as mean Â± standard deviation (meanÂ±SD), and statistical significance was set at pâ‰¤0.05. Statistical analysis was performed with SPSS (version 17.0, SPSS for Windows, Chicago, SPSS Inc).
Translation and adaptation of the scale
|Stages||Translation Procedure||Words/Phrases that needed attention/modification||Final Wording (Meaning in English)|
|1Î¿||Forward Translation (English-Greek)||Without Difficulties|
Î›ÎµÎ¹Ï„Î¿Ï…ÏÎ³Î¹ÎºÎ® Î”ÏÎ±ÏƒÏ„Î·ÏÎ¹ÏŒÏ„Î·Ï„Î±(Functional task)
Î¤ÎÎ½Ï„Ï‰Î¼Î± Ï€ÏÎ¿Ï‚ Ï„Î± ÎµÎ¼Ï€ÏÏŒÏ‚ (Stretching forward)
First Greek BBS
|3Î¿||Backward Translation Greek- English||Î¤ÎµÎ½Ï„Ï‰Î¸ÎµÎ¹Ï„Îµ Î¼Ï€ÏÎ¿ÏƒÏ„Î± (Stretch forward)
Î“Ï…ÏÎ¹ÏƒÏ„Îµ Î½Î± ÎºÎ¿Î¹Ï„Î¬Î¾Ï„Îµ ÎºÎ±Ï„ÎµÏ…Î¸ÎµÎ¯Î±Î½ Ï€Î¯ÏƒÏ‰ (Turn to look directly behind)
ÎšÎ¬Î½Ï„Îµ Î¼Î¹Î± Ï€Î»Î®ÏÎ· Ï€ÎµÏÎ¹ÏƒÏ„ÏÎ¿Ï†Î® (Doafullturn)
Turn around to look straight behind
Perform a full rotation
|4Î¿||Synthesis II||Turn back
|Î“Ï…ÏÎ¯ÏƒÏ„Îµ Ï€ÏÎ¿Ï‚ Ï„Î± Ï€Î¯ÏƒÏ‰ (Turnback)
Î Î±Ï„Î®Î¼Î±Ï„Î± (Touch)
1st pre-final Greek BBS
|5Î¿||1st Pilot Testing
2nd Pilot Testing
Difficulty in understanding “turn back” & “rotate 360Â°” (from patients)All clear and comprehensive
|Item 10 Instructions: Turn to look directly behind over your left shoulder, without moving your feet from floor (Underlined phrase added in Greek version after permission)
Item 11 Instructions:Turn completely around in a full circle, with small steps (Underlined phrase added in Greek version after permission)
2nd pre-final Greek BBS
No more modifications needed
Final Greek BBS (BBS-GR)
Psychometric testing of the final Greek version of BBS
Mean Score Â± SD(Range)
|Male||38% (43)||48Â±9 (23-56)|
|Female||62% (69)||47Â±9 (6-56)|
|Condition causing Balance Impairment|
|Imbalance (Age related)||37% (42)||50Â±5 (37-56)|
|Musculoskeletal||19% (21)||46Â±8 (23-56)|
|Stroke||15% (18)||44Â±14 (6-56)|
|Multiple Sclerosis||8% (9)||49Â±5 (41-56)|
|Parkinson||8% (9)||47Â±5 (39-53)|
|Traumatic Brain Injury||4% (4)||55Â±3 (50-56)|
|Cerebellum Inflammation||3% (3)||33Â±18 (20-53)|
|Blindness||2% (2)||51Â±0 (51-51)|
|Cerebrum Inflammation||2% (2)||54Â±3 (52-56)|
|Hydrocephalus||1% (1)||49Â±0 (49-49)|
|Drop Foot||1% (1)||56Â±0 (56-56)|
|Falls over last year|
|0||61% (69)||50Â±6 (6-56)|
|1||37% (41)||45Â±9 (20-56)|
|â‰¥2||2% (2)||46Â±3 (44-48)|
Table 3: Demographic characteristics of the Greek sample (n=112).
|Intraclass Correlation Coefficient|
Figure 1: Bland Altman Plot of the difference scores of the two raters measurements in total BBS scores of the sample (n=112) during the first assessment. LoA as the mean differenceÂ±1.96SD are presented.
|Measurement Outcome||Spearman’s rho (r)|
*Statistically Significant Correlation at p<0.001
Ceiling & floor effects
|BBS||48Â±8||-2.072||0% (0)||9% (10)|
|Mini-BESTest||18Â±6||-0.594||0.9% (1)||2.7% (3)|
|FES||33Â±12||0.793||1.8% (2)||3.6% (4)|
This study aimed to cross culturally adapt and validate the BBS into Greek for patients with balance impairments. The main findings in regards the translation and the validation process are discussed and interpreted below.
Psychometric Testing of the Greek version of BBS
In this part of the study the psychometric properties of the BBS-GR for people with various balance deficits were examined. The first results showed that the BBS-GR has high criterion validity and moderate to high convergence validity. Its ability in giving stable results over time and between raters was proved by the excellent test-retest and inter-rater reliability. No ceiling or floor effects were revealed thus arguing towards the ability of the scale to detect changes in performance. The negative skewness in the distribution of the scores in combination with the moderate responsiveness of the scale may be explained by the sample used in the present study, which consisted of ambulatory patients.
The BBS-GR showed high criterion validity with the Greek mini-BESTest. Other language translations of the BBS have not been correlated with the mini-BESTest probably because this scale has only recently been developed . However, similar results of high correlation between the two scales have been recorded in other validity studies for the mini-BESTest. Specifically, in the studies of Bergstorm et al., , Godi et al., , Tsang et al.,  correlations of 0.86, 0.85 and 0.83 respectively, were reported when the scales have been administered to patients with stroke and balance impairments. Our lower correlation of the BBS-GR with the TUG is similar to correlations for the Persian  and Turkish study , which reported a correlation value of 0.74 and 0.75 respectively. The moderate correlation of the BBS-GR with the FRT that yielded in our study, is not in agreement with the study of Smith et al., , which was conducted in 75 patients with stroke (r=0.78). The results may be explained by the differences between our study which included participants with varied neurological conditions, and the Smith et al study  which used a more homogeneous sample consisting of stroke patients. Our results were more similar to that of Kuruka et al.,  who showed a more moderate correlation (r=0.48) based on a sample of 30 healthy elderly woman. A moderate correlation of BBS-GR with the FES-I questionnaire, which was revealed in the present study, may be expected due to the indirect way that the FES-I assesses balance, which in contrary to the BBS that assesses it via tasks performance, FES-I is based on subjective reports from the patient. Moderate correlations between BBS and other scales, such as the Modified Barthel Index , the Modified Hoehn and Yahr Staging Scale  or the Schwab & England Activities of Daily Living (ADL) Scale , have been attributed to less closely relation of these scales with balance performance. The high correlation between BBS and FES-I scales in the study of Wirz et al.,  may be attributed to homogeneity of their sample which consisted of spinal cord injured patients only. The moderate and high correlations of the BBS-GR with the TUG, FRT and FES-I balance tools that have been revealed in the present study indicate a moderate to high convergence validity of the BBS-GR.
The BBS-GR showed both excellent test-retest and inter-rater reliability as it was assessed by the ICC of the scores between repeated measurements and scores between observers. In addition to excellent relative reliability, BBS-GR showed absolute reliability as this was proved by the Bland Altman Analysis. The mean difference between the measurements of the two raters were close to 0 and 95% of the cases were lying between the limits of agreement proving the absence of proportional bias in the measurements . The high correlation and the agreement between the measurements indicate that the scale is reliable in presenting stable repeated results. These excellent results are in agreement with many of the other language versions of the BBS [18,20,22,25]. In addition, a systematic review of 11 studies that assessed intra- and inter-rater reliability of the English BBS in a variety of clinical populations revealed a value of 0.98 for the intra-rater reliability and 0.97 for inter-rater reliability . Our findings with the BBS-GR also have very similar correlations. An excellent correlation was presented not only in the total score of the scale but also in the score of every item. The inter-rater reliability for each item ranged from 0.972 to 1.00 and the test-retest reliability ranged from 0.786 to 0.99, values that are close enough to those reported in the Brazilian BBS , the Iranian BBS , the Norwegian BBS  and in the original BBS [1,5]. The high internal consistency of the BBS-GR (0.83) indicates the homogeneity of the scale and is in line with the Norwegian (0.87) , the Italian (0.95) , and the Turkish versions (0.98 at total score) . The Iranian scale has presented lower internal consistency (0.62) .
The Greek BBS-GR did not present any ceiling or floor effects, but compared to other scales it showed the biggest percentage in people at highest score. In a systematic review of 21 studies in people with stroke three studies reported a ceiling or/and floor effect of the BBS . In addition, the study of Tsang et al.  did also report a larger ceiling effect of 32% for BBS. The negative skew, reported to our study, with more scores gathered to the higher levels, agree with the studies of Sahin et al.,  and Tsang et al., (35). These results may be explained by the characteristics of the sample in which all patients were ambulant, as the inclusion criteria required, which however may skew the scores towards higher levels. The same characteristics may also explain the moderate responsiveness also presented here. Nevertheless, the mean total BBS-GR score in the group of â€œfallersâ€ did not differ too much from the â€œnon fallersâ€ BBS-GR score (Table 3), thus leading to moderate effect size. Additionally, the variability in the sample characteristics may have masked the responsiveness results. This finding implies that the BBS-GR of scores equal or above 20/56 in various balance impairments cannot actually distinguish â€œfallersâ€ from â€œnon-fallersâ€. Further application of the BBS-GR to a less varied sample according to neurological conditions, and including non-ambulant patients as well, may give more concluding results regarding the skewness and the responsiveness of the scale.
Implications for further research
Part of the results have been orally presented to 24Î¿ Panhellenic Scientific Conference of Physiotherapy, PSF, Athens, Greece (5-7 Dec. 2014).
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Appendix I: Berg Balance Scale translated into Greek.
Citation:Lampropoulou S, Gizeli A, Kalivioti C, Billis E, Gedikoglou IA, et al. (2016) Cross Cultural Adaptation of Berg Balance Scale in Greek for Various Balance Impairments. J Phys Med Rehabil Disabil 2: 011.
Copyright: © 2016 Lampropoulou Sofia, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.