Balance Error Scoring System (BESS)
One Component of Sideline Evaluation for the Athlete with MTBI
By Teresa Schuemann, PT, SCS, ATC, CSCS
The Balance Error Scoring System (BESS) is a standardized balance testing system that was developed and described by Bryan Riemann and Kevin Guskiewicz from University of North Carolina at Chapel Hill.1 This system was designed for pre-season and post-injury balance testing as a part of the sideline evaluation that is recommended for athletes who have suffered trauma that may result in mild traumatic brain injury (MTBI). The balance-testing regime originally consisted of tests completed in three stances on two different surfaces.
The three stances are double stance, tandem stance and single leg stance. The two different surfaces include both a firm and foam surface (Table 1). Stance requirements include the hands on the iliac crests, eyes closed and a consistent foot position depending on the stance (Table 2). In double leg stance (Figure 1), the feet are flat on the testing surface approximately pelvic width apart. In the tandem stance testing position (Figure 2), one foot is placed in front of the other with heel of the anterior foot touching the toe of the posterior foot. The athlete’s non-dominant leg is in the posterior position. Leg dominance was determined by kicking preference. Finally, in the single leg stance position (Figure 3), the athlete is to stand on the non-dominant leg with the contralateral limb held in approximately 20° of hip flexion, 45° of knee flexion and neutral position in the frontal plane. As mentioned previously, the different surfaces include both a firm and foam surface (Figure 3). The foam utilized in the study had the specific dimensions of 45cm2 x 13 cm thick, Density of 60 kg/m3, and a load deflection of 80 - 90 newtons.1
Each stance is tested for 20 seconds with the examiner observing and noting errors. These errors could include hands coming off the iliac crests, eyes opening, steps/stumbles, moving the contralateral limb into more than 30° of hip flexion or abduction, lifting forefoot or heel from flat position, or remaining out of the test position for longer than 5 seconds (Table 3). Each error is counted as one and the examiner tallies the number of errors for each stance on each surface. The final score for the athlete’s BESS test is the total of all these errors. An example of a scoring sheet may be found in Table 4. Pre-season testing allows for a baseline to be established for each athlete so that when testing is completed post-injury, a comparison may be made and severity of balance impairment may be established.
Currently additional testing of the three stances on a third surface is being studied by the same group at University of North Carolina at Chapel Hill.2 The third surface is a dynamic surface called a Kinetic Stabilization device that moves in an anterior/posterior, lateral and rotational directions. The trade name of the device being utilized is called the Teton Tremor (Figure 4)3, and it is presently being speculated that this type of dynamic balance testing may better identify balance deficits especially in those athletes who perform his/her sport on a dynamic surface such as a skateboard, downhill ski or roller blades.
The BESS allows for standardized and objective balance testing for preseason and post-injury testing. I see implications for this testing ranging into other injury profiles such as post-knee surgery patients, athletes after ankle sprains and neurologically impaired patients with a few necessary modifications to the testing procedure. The research studies have not been completed on these types of patients however so reliability is still questionable in these cases. I would encourage the sports physical therapist, especially those completing athletic event sideline medical coverage, to further study this testing regime and implement the BESS in his/her practice.
References
1. Riemann BL, Guskiewicz KM, Effects of mild head injury on Postural stability as measured through clinical balance testing. J of Athl Train 2000:35(1): 19-25.
2. Guskiewicz, KM, Abstract presented at NATA Convention 2002.
3. Riemann BL, Guskiewicz KM, Shields E. Relationship between clinical and forceplate measures of postural stability. J Sport Rehabil. 1999;8:71-82.
4. Guskiewicz KM, Ross SE, Marshall SW. Postural Stability and Neuropsychological Deficits After Concussion Collegiate Athletes. J of Athl 2002:36(3): 263-273.
5. Guskiewicz K, Barth JT Head Injuries. Athletic Training and Sports Medicine Edited by Robert C. Schenck, Jr. MD. . 144 - 167.
6. Teton Tremor Information at www.exertools.com/tetontremor
7. Schuemann, TL, Lynch J, Innovations from the Field - Teton Tremor T & C 2002:12(8):42.
Table 1. BESS - Test Conditions
Stances
Surfaces
· Double Stance
· Single-Leg Stance (non-dominant)
· Tandem Stance
· Firm
· Foam
Table 2. BESS - Stance Requirements
All Stances
Double Stance
Tandem Stance
Single Leg Stance
· Hands on Iliac Crests
· Eyes Closed
· Consistent Foot Position
· Feet pelvic width apart
· Heel to toe positions
· Non-dominant leg posterior
· Standing on non-dominant leg
· Contralateral hip flexed 20°, neutral abduction
· Contralateral knee flexed 45°
Table 3.BESS Errors
· Hands off iliac crests
· Opening eyes
· Step or stumble
· Lifting forefoot or heel
· Contralateral hip over 30° of flexion and/or 20° abduction
· Staying out of test position > 5 seconds
Table 4. Balance Error Scoring System (BESS) Recording sheet
Scorecard
(No. of Errors)
Firm Surface
Foam Surface
Dynamic Surface
Teton Tremor
Double-leg Stance
Single-leg Stance (dominant leg)
Tandem Stance (dominant post.)
Total errors
TOTAL SCORE
Figure 1. BESS Double Stance position on Dynamic Surface
Figure 2. Tandem Stance on Firm Surface
Figure 3. Single Leg Stance on Foam Surface
Figure 4. Kinetic Stabilization Device/Teton Tremor
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