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Abstract
Background
Objectives:
To translate Berg Balance scale (BBS) to the Arabic
language (A-BBS) and to evaluate its reliability
and validity.
Methods:
Two persons proficient in English independently
translated the original scale into Arabic and
a consensus version was generated. Two translators
performed a back transformation. Discrepancies
were discussed and solved by a panel. The final
Arabic version was then tested on sixty elderly,
60 years and more, male and female, were interviewed.
Reliability of the measure was assessed twice
by one researcher (with a one-week interval between
assessment) and once by another researcher.
Results:
The Arabic version of BBS shows high internal
consistency with Cronbach's a
of the total scale of 0.91. The correlation
coefficient values for intra-rater and inter-rater
reliability of the total score are 0.97 and 0.95,
respectively. The intra-rater correlation of different
score items ranges from 0.0.75 to 0.96 and the
inter-rater correlation of different items ranges
from 0.71 to 0.98. Factor analysis revealed that
the total matrix variance was 72.9% of the three
factors (factor 1, 49.3%, factor 2, 13.0% and
factor 3, 10.6%).
Conclusion:
Despite the sample size of our study population
(n=60), the Arabic version of BBS appears to be
a reliable and valid instrument with high internal
consistency to be used in elderly living in a
community setting.
Keywords: Berg
Balance Scale, Reliability, Validity, Arabic Version.
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INTRODUCTION
The performance of all
activities of daily living requires good balance control
while at rest or when moving from one position to another.
Maintenance of balance requires the coordination of
sensory, neural and musculoskeletal systems.(1,2) Many
of these systems undergo deterioration as people age
and this has the potential to affect balance, restrict
safe mobility, increase the likelihood of a fall and
adversely affect quality of life.(1,3,4) Falls in older
people are a major public health concern in terms of
morbidity, mortality and health care costs.(5) Fear
of falls may discourage the elderly from being active
and the inactivity, in turn, may reduce their functional
abilities.(6) Therefore, the multi-factorial assessment
of balance is important to direct appropriate interventions
to improve balance performance and to reduce the risk
of falling.(7-9)
The Berg Balance Scale (BBS) was developed as a performance-oriented
measure of balance in elderly individuals, and to predict
multiple falls in community-dwelling and institutionalized
older adults. It is also widely used in many fields
of rehabilitation. (1,10,11) The scale comprises 14
items assessing the static sitting and standing balance,
as well as anticipatory balance during activities commonly
performed in daily function, including transfers, turning,
and retrieving objects from the floor.(1) The scoring
is done on a 5-point scale, that considers whether the
elderly can perform the task safely and independently,
often based on a definite time span. Normal performances
are graded from 0 (unable to perform) to 4 points (normal
performance). Scores on individual items are summed
for a total score, with a maximum of 56 points.(1) The
assessment takes 20-30 minutes, depending upon the sensorimotor
and cognitive function of the subjects. The scale has
been shown to possess very good inter-rater and intra-rater
interclass correlation coefficients and very good internal
consistency. Prognostic and concurrent validities have
demonstrated moderate statistical correlations.(1,10-14)
The ease with which the BBS can be administered makes
it an attractive measure for clinicians; it involves
minimal equipment (chair, stopwatch, ruler, and step)
and space and requires no specialized training.(15)
The BBS has been translated into many languages e.g.
Norwegian (16), Italian (17), Brazilian (18-20), Chinese
(21), Korean (22), Turkish (23), and Farsi. (24) To
the best of the authors' knowledge BBS has not been
translated into Arabic language. The objectives of the
present study were to translate BBS to Arabic and to
test the reliability of its scores among rural community-dwelling
elderly.
POPULATION AND METHODS
This study was done in Met Kamise village, about 5 km
away from Mansoura city, Egypt.
The study subjects included sixty elderly of both sexes
with a history of fall within the last year, living
in Met Kamise village. The exclusion criteria are: chronic
diseases (e.g. cardiac, respiratory, neurologic, severely
limiting arthritis, severe psychiatric diseases, and
cancer), surgery, limb amputation, chemotherapy or radiotherapy
within the past year; and acute illness on the days
of the assessment.
The BBS was initially independently translated by two
researchers proficient in English, whose native language
was Arabic. The two translations were compared and when
differences were identified, the texts were modified
to obtain consensus between the two translations regarding
the initial translation. The consensus Arabic version
was again translated back into English by the other
two researchers who were unaware of the original version.
The two English versions were compared with the original
English version. The differences were analyzed, and
questions and/or response choices were rewritten when
necessary, thus approving a second Arabic version. All
the items involving misunderstanding were replaced and
discrepancies were resolved by the four authors (see
appendix).
The participants were interviewed and tested in their
own homes or in the corridor outside their rooms. They
were informed that they could stop the testing session
whenever they wanted and that they were allowed to rest
between tasks, if necessary. They also were told to
wear stable and comfortable shoes.
To test the reliability of the Arabic BBS, the final
version was applied to the 60 elderly during three assessments.
The first two assessments were performed consecutively
on the same day by two observers (inter-observer reliability),
at an interval of approximately 15 minutes, with either
observer 1 or observer 2 applying the first assessment,
thus preventing a habituation bias in terms of the tasks
performed. The third assessment was applied after seven
days by observer 1 (intra-observer reliability).
The study was approved by the College of Nursing and
the local Directorate of Health. An official letter
was declared to the director of Met Kamise Health Center.
Before the interview the elderly were informed about
the objective of the study and assured about confidentiality
of data. The participation was voluntary.
Data was analyzed using SPSS (Statistical Package for
Social Sciences, version 16). Descriptive statistics
(minimum, maximum, mean and standard deviation) were
carried out for the total score and its items. The internal
consistency of the total score was assessed using Cronbach's
? coefficient. To confirm internal consistency, a correlation
was done between each item and the total score, using
Pearson's correlation coefficients and their 95% confidence
intervals. The correlation coefficients and their 95%
confidence intervals were used to calculate the intra-
and inter-rater correlations for each item and for the
total BBS scale. Factor analysis with varimax rotation
was used to evaluate construct validity and dimensionality
of the BBS. P < 0.05 was considered to be
statistically significant.
RESULTS
The
age of the elderly who participated in the study ranged
from 60 to 77 years with a mean of 67.95±5.4
years. The majority of them were males (61.7%), currently
married (60.0%) and either illiterate (48.3%) or could
just read and write (41.7%). Only 10% had attended the
primary level of education.
Table 1: Descriptive statistics of the test, retest
and second rater of Berg Balance Scale Items
Table (1) shows the mean and SD of the total BBS and
each item the test, retest and second rater. The total
score was 20.4, 20.0 and 20.3 in the test, retest and
second rater, respectively.
CI = Confidence Interval
Table 2: Intra-and inter-rater and item/total score
correlation coefficients of items and the total score
The Arabic version of BBS shows high internal consistency
with Cronbach's a of the
total scale of 0.91. The results of the intra-and inter-rater
reliability tests related to total BBS and its items
are shown in Table 2. The correlation coefficient values
for intra-rater and inter-rater reliability of the total
score are 0.97 and 0.95, respectively. The intra-rater
correlation of different score items ranges from 0.0.75
to 0.96 and the inter-rater correlation of different
items ranges from 0.71 to 0.98. The correlation coefficients
of different items and the total score ranged from 0.31
to 0.89. All the correlation coefficients are statistically
significant.
Table 3: Results of factor analysis of each Arabic
BBS item
Construct validity: Factor analysis of the 14
items of the Arabic BBS revealed 3 factors above Eigen
value 1 were more prominent. The total matrix variance
was 72.9% of the three factors (factor 1, 49.3%, factor
2, 13.0% and factor 3, 10.6%). Factor 1 involved mostly
static activities where feet were motionless such as
standing unsupported, sitting unsupported, standing
with eyes closed, standing with feet together, retrieving
object from floor, turning to look behind, placing alternate
foot on stool, standing with one foot in front and standing
on one foot. However, factors 2 and 3 were usually related
to dynamic activities involving sitting to standing,
standing to sitting, transfers and turning 360 degrees
(Table 3).
DISCUSSION
BBS is frequently
used to evaluate postural control and estimate risk
of falling in older adults both community dwelling and
in residential care facilities.(10,16,19,21-26) The
BBS was originally written in English with questions
pertaining to the Canadian culture.(10) The English
and other non-Arabic versions of the measure have been
examined for use in assessing individuals with stroke
(27-30); brain injury (31,32), rheumatology patients
(18), hemiplegia and diplegia (33,34) and Parkinson's
disease.(20,35,36) Up to now there has been no validated
Arabic version of BBS to be tested in different diagnoses.
In this work we translated the BBS into Arabic language
and validated it in the elderly of rural residences.
The BBS was originally written in English; therefore,
in order to apply the scale to the Arab population,
we translated it into the Arabic language in terms that
could be well interpreted by both the elderly and the
examiner.
The determination of the reliability of the Arabic version
of BBS indicates that it has high internal consistency
with Cronbach's a coefficient
high (0.91) for the BBs total score. The Cronbach's
a coefficient provides us
with the internal consistency of the scale tested where
the values over 0.80 are accepted as a higher index
of consistency.(26) Higher values of Cronbach's a
were reported for the other versions of BBS e.g.
0.96 for the original version (1), 0.98 for the Turkish
version (23), 0.95 for the Italian version (17), 0.9
for the Iranian version.(24) On the other hand some
versions of the BSS showed lower Cronbach's a
e.g. 0.87 for Norwegian version (16), 0.77 for
the Taiwan version.(21)
The test-retest (or intra-rater) and inter-rater reliability
are used to assess the consistency of a measure from
one time to another and from one observer to another,
respectively. Correlation coefficients above 0.80 are
indicators of higher reliability.(37) The intra-rater
and inter-rater correlation coefficient of the total
score were 0.95 and 0.98, respectively. This is consistent
with previous findings evaluating the original scale
(1,10) as well as Turkish (23), Brazilian (18,19), Taiwan
(Chinese) (21), Norwegian (16), Italian (17), Iranian
(24) translated versions. Strong Cronbach's ? and correlations
of the Arabic version of BBS imply the homogeneity of
variables and reproducibility of the items like the
original scale.(10,11)
The intra-rater correlation of different score items
ranges from 0.0.75 to 0.96. These high correlation coefficients
are consistent with previous results evaluating the
original (1) as well as other versions of the scale
e.g. Turkish (23), Korean (22), Brazilian (18,19), and
Iranian (33,34) versions.
The inter-rater correlation of different items ranged
from 0.71 to 0.98. These high correlation coefficients
are consistent with previous results evaluating the
original (1,6,36) as well as other versions of the scale
e.g. Turkish (23), Korean (22), Brazilian.(18,19) Furthermore,
the correlation coefficients of different items with
the total score ranged from 0.31 to 0.89. In the Iranian
version item-to-total correlations for all items were
higher than 0.6.(33,34)
Factor analysis revealed that three factors had a 72.9%
matrix variance. Factor 1 involved in mostly static
activities where feet were motionless, such as standing
unsupported, sitting unsupported, standing with eyes
closed, standing with feet together, retrieving object
from floor, turning to look behind, placing alternate
foot on stool, standing with one foot in front and standing
on one foot. However, factors 2 and 3 were usually related
to dynamic activities involving sitting to standing,
standing to sitting, transfers and turning 360 degrees.
Factors with similar constructs were reported in studies
of Norwegian (3 factors) (16), Turkish (2 factors) (23),
Italian (2 factors) (17) versions of the BBS.
In conclusion the Arabic version of BBS is a reproducible,
reliable and valid measure of postural control for Arabic
speaking rural elderly in community settings. However,
this version needs further evaluation in large scale
study community settings, in residential care facilities,
and clinical settings as well as in rehabilitation of
patients with disabling diseases.
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