The Brunel Balance Assessment (BBA) is an activity-based outcome measure developed to quantify the reacquisition of balance post-stroke by using a hierarchical design that incorporates the progression of functional performance as a person recovers, which is thought to occur in a sequence across the 4 domains of (1) assisted balance, (2) independent balance, (3) static balance, and finally (4) dynamic balance. The BBA comprises 12 levels from sitting to standing, to altered base of support and eventual movement where the first and easiest skill to attain is static sitting balance with upper limb support and the hardest is advanced changes of the base of support. Thus, as a person’s perceived change in balance ability progresses or regresses to different levels of the hierarchy the BBA can document that change (Tyson, & DeSouza, 2004). The BBA has 3 sections: a sitting section (3 subtests), standing (3 subtests), and stepping (6 subtests). Each section can be used individually or in conjunction with each other for a complete assessment of the individual (Tyson, 2004). Each section is further divided into several levels, which are achieved by increasing the demand on balance ability (Tyson, 2004). Example items include sitting forward and reaching, standing with arms raised, and a 5-meter walk test with an aid. The BBA uses a 12-point ordinal scale (0 to 12) as well as some pass/fail items with lower scores indicative of decreased abilities. Time to complete the BBA is less than 30 minutes.
• Supported sitting
• Static sitting balance
• Dynamic sitting balance
• Supported standing balance
• Static standing balance
• Dynamic standing balance
• Static double stance balance
• Supported single stance
• Dynamic double stance
• Initial change of base of support
• Dynamic single stance
• Advanced change of the base of support
Adapted from Tyson, S. (2004). Brunel Balance Assessment (BBA) (1st ed., p. 5). Manchester, United Kingdom: Centre for Research and Human Performance Research, University of Salford.
During development, criterion validity was assessed by comparing the BBA with other accepted outcome measures and results showed that correlation coefficients were 0.83 when compared to the sitting section of the Motor Assessment Scale, 0.97 with the Berg Balance Test, and 0.95 with the Rivermead Mobility Index, indicating good validity relative to other established measures. The internal consistency Cronbach’s alpha coefficient for the measure was α = 0.93 (Tyson & DeSouza, 2004). The coefficients of reproducibility and scalability were 0.99 and 0.69 respectively. Lastly, test-retest and inter-rater reliability were both high with 100% agreement (Tyson & DeSouza, 2004). The BBA has also shown to have fair predictive value. Using balance disability as a predictor of future function Tyson, Hanley, Chillala, Selley, and Tallis (2007) found that at 3 months those with limited sitting balance (0% to 22%) and standing balance (25% to 50%) recovered independent functional mobility, whereas those people who could initially walk recovered independent functional mobility at a rate of 66% to 84%.
The BBA scale is easy to use and the clinical value of the test is increased by the ability to use all or part of the assessment by employing a hierarchical design where difficulty increases with each item; thus when a subject fails an item he or she can be assumed to fail all higher items and conversely, if the subject passes an item, it can be assumed that he or she would pass all of the lower items. This means that not all items need to be tested and testing can stop once the subject has failed an item reducing the time and effort required by both clinician and subject (Tyson & DeSouza, 2004). Another advantage to this type of assessment is that it gives information about what a patient can or cannot do, rather than how many activities they may able to do (Tyson & DeSouza, 2004).
The amount of peer-reviewed literature in support of its use outside of that authored or co-authored by its creator is limited. The BBA can also be a relatively complex if the clinician must test all levels, which could take up to 1 hour to complete. Its reliability is also thought to decrease with less-experienced health care professionals (Tyson, 2004). Finally, the assessment requires some set up and the use of various tools as well as an amount of space to perform all activities.
1. Supported sitting—30 seconds
2. Sitting arm raise test—3 or more arm lifts in 15 seconds
3. Sitting forward reach test—more than 7 cm
4. Supported standing test—30 seconds
5. Standing arm raise test—3 or more arm lifts in 15 seconds
6. Standing forward reach test—more than 5 cm
7. Timed step standing test—static step standing 30 seconds
8. Walk with aid—5 meters in 60 seconds
9. Weight shift test—3 or more shifts in 15 seconds
10. Walk without an aid—5-meters in 60 seconds
11. Tap test—2 or more taps in 60 seconds
12. Step-up test—1 or more in 15 seconds
Adapted from Tyson, S. (2004). Brunel Balance Assessment (BBA) (1st ed., p. 6). Salford, United Kingdom: Centre for Research and Human Performance Research, University of Salford.