Berg Balance Scale

Berg Balance Scale Assessment Patient Name: Sarah Johnson Date of Birth: 15/03/1965 Date of Assessment: 01 November 2024 Assessor: Dr. Emily White, Physiotherapist Purpose of Assessment: To evaluate the patient's balance and fall risk following a recent hip replacement. Instructions to Patient: "I will be asking you to perform various tasks to assess your balance. Please do your best, and let me know if you feel unsteady at any point." Observation: Patient demonstrated good understanding of instructions and was cooperative throughout the assessment. Some apprehension noted during single-leg standing. Items Scored (0-4 scale): 1. Sitting to standing: 4 2. Standing unsupported: 4 3. Sitting unsupported: 4 4. Standing to sitting: 3 5. Transfers: 3 6. Standing with eyes closed: 2 7. Standing with feet together: 3 8. Reaching forward with outstretched arm: 3 9. Picking up object from floor: 2 10. Turning to look behind: 3 11. Turning 360 degrees: 2 12. Placing alternate foot on stool: 2 13. Standing with one foot in front: 1 14. Standing on one leg: 1 Total Score: 37/56 Interpretation: A score of 37 out of 56 indicates a moderate risk of falls. The patient demonstrates good balance with static tasks but experiences some instability with dynamic tasks, particularly those requiring single-leg support or changes in base of support. Recommendations/Plan: * Initiate a progressive balance training programme, focusing on dynamic balance and strengthening of lower extremity muscles. * Recommend home exercises including standing on one leg with support, heel-to-toe walking, and tandem stance. * Educate patient on fall prevention strategies, including removing tripping hazards at home and using appropriate footwear. * Referral to occupational therapy for home safety assessment. * Re-assess Berg Balance Scale in 4 weeks to monitor progress. Patient Toleration: Patient tolerated the assessment well with no adverse events. Reported mild fatigue towards the end of the assessment. Signature: Dr. Emily White, Physiotherapist Date: 01 November 2024