ISSN (Print) : 0974-6846

ISSN (Online) : 0974-5645

Indian Journal of Science and Technology, Vol 9(35), DOI: 10.17485/ijst/2016/v9i35/101769, September 2016

The Effect of Balance Training based on the Berg

Balance Scale for the Balance Function in Patients
with Cerebellar Ataxia
Jun Su Ahn1, Chul Hoon Cho2, Jung Hoon Lee1, Wang Hun Ahn1*, Young Cheol Lee2,
Seon Ju Kim2 and Hyeun Seob Lee2
1
Department of Physical Medicine and Rehabilitation, ASAN Medical Center, Seoul, South Korea;
ahnjunsu@gmail.com, hooni8107@hanmial.net, amc-awh@hanmail.net
2
Department of Sport and Leisure Studies, Korea University, Seoul, South Korea;
whcjfgns@korea.ac.kr, eeyc2378@hanmail.net, redsune@naver.com, lhs.phd@gmail.com

Abstract
Objective: This paper aims to evaluate the effects of balance training on Berg balance scale on balance function in patients
with cerebellar ataxia. Methods/Statistical analysis: A total of 21 patients with cerebellar ataxia were randomly assigned
to the experimental group (n=14) for balance training based on Berg Balance Scale and to the control group (n=7) for
therapeutic exercise based on neurodevelopmental treatment. Each patient received 14 treatment sessions of 30 minutes
each. Patients were evaluated by physical therapist before and after treatment as well as 1-month post-treatment using
the Berg balance scale and Timed up and go test. Findings: At the end of treatment, the experimental and control groups
showed significant improvements in all outcome measures. Berg balance scale (BBS) group showed the better clinical out-
comes for balance training compared to neurodevelopmental treatment(NDT) group and NDT-BBS group. Improvements/
Applications: Balance training based on berg balance scale can improve balance ability in patients with cerebellar ataxia.

Keywords: Balance Training, Berg Balance Scale, Cerebellar Ataxia, Neurodevelopment Treatment, Physical Therapy,
Rehabilitation

1.Introduction But a risk of falling can be increased by decrease the

Previous studies were described with respect to balance
as follows. Balance is an ability to maintenance of body
equilibrium and affect the activities in daily living1,2 and
maintain the center of gravity3. Balance includes the sta-
bility can maintain posture with minimum unsteady,
symmetry can distribute weight and dynamic stability4.
In order to keep the balance during the gait, activities
must be able to response immediately to vestibular, pro-
prioceptive sense, visual sense, and external stimulation.
motor function and the balance by COPD (Chronic
Obstructive Pulmonary Disease), aging, etc. 55% of isch-
emic stroke patients are experienced a fall during a year
after discharge from hospital and 42% of them are itera-
tively experienced5. Also patients with problem of balance
after stroke have difficulty in recovery of ADL (activities
of daily living)6. Old people with lack of exercise were
experienced psychological atrophy and reduced exercise
ability because insufficient exercise accelerates the loss of
ADL due to reduced fitness such as muscle atrophy, lack

*Author for correspondence

 The Effect of Balance Training based on the Berg Balance Scale for the Balance Function in Patients with Cerebellar Ataxia
of balance and endurance7. Over 35% of 65 years later
were experienced a fall at least once a year, and 20~30%
of them have difficulty in independent living by moderate
or serious damage by the fall8,9. Another studies reported
that 29%~33% of old people10, 25%~51% of COPD
patients11, 35%~90% of patients of parkinsons disease12,
and 40%~73% of stoke patients13 have been experienc-
ing a fall. As such, the fall is problem to various people
as well as specific patients. Generally, factors associated
with the fall are elderly, gait disturbance, balancing abil-
ity, fear of falling etc. And there are external factors such
as drug, environmental factors, walking aids etc.14. The
training for improvement the balance is required in order
to prevent a falling, and the self-confidence to daily living
without stumbling is as important as the actual balance.
People have no fear of falling was higher balance-confi-
dence, and higher balance-confidence was investigated
with high quality of life. In 15,16 Cerebellar ataxia can occur
as a result of many diseases and presents with symptoms
of an inability to coordinate balance, gait, and extremity17.
As while studies have been done with respect to preven-
tion of the fall, importance of balance ability in daily
living, effect of balance training and necessity, there has
not been study conducted on balance training specifying
which training methods were used for it. Therefore, this
study was performed on whether it has treatment effect
when Berg Balance Scale (BBS) testing the balance as
evaluation methods applied as treatment for patients of
balance disorder.
2.Methods
2.1Subjects
Participants in study were patients with disturbance of
gait and dynamic balance by cerebellar ataxia who are
being admitted to Asan Medical Center. The participants
with grade 1 or more to Functional Ambulation Category
could maintain a static balance in standing posture
independently. Subjects who can walking over 10m
regardless use of walking aids independently, understand
and follow the instructions exactly and average score
24 points or more considering the level of education to
Mini Mental Examination-Korea version were selected.
2 Vol 9 (35) | September 2016 | www.indjst.org
People with following disorders was excluded: cognitive
impairment, visual and perceptual disorder, high risk
of cardiovascular disease, severity of medical illness,
orthopedic diseases to lower limb. Also participants not
attending for more than 3 times continuously or not
reached the 80% of treatment process were excluded.
Participants were given a detailed description about the
study and consented to participation.
2.2Evaluation
Evaluators for all evaluation consist of 3 physical thera-
pists with over 10 years of experience. Both pre and post
test was performed by the same evaluator.
2.1.2 Physical therapy intervention
2.2.1.1 Physical Therapy Program and Methods
Participants consisted of nine males and 12 females in
a total 21 people were divided into three groups. The
three groups were carried out a program with each time
by 30 minutes, 5 times per week for 4 weeks. All pro-
cesses were supervised by physical therapist. The first
group was performed therapeutic exercise based on
NeuroDevelopmental Treatment (NDT), and the second
group was performed balance training based on BBS. The
third group was performed NDT and balance training by
every other day alternately. Evaluators for all evaluation
consist of 3 physical therapists with over 10 years of expe-
rience. Both pre and post test was performed by the same
evaluator.
2.2.1.2 Configuration of Balance Training
Balance training was comprised of the following 14 ele-
ments: perform the sitting position and standing position
without anything support, moving from a sitting position
to a standing position and backward, moving to chair
and bed for medical treatment, maintain a standing posi-
tion with closed eye, maintain a standing position with
collect both feet, Extend the arm and maintain a stand-
ing position, raise up things on the floor, view back over
both shoulder in standing position, 360 degree rotation
both direction alternately, raise up both feet on footboard
alternately, maintain standing position with stick feet
back and forth, maintain standing position lifting one leg.
Indian Journal of Science and Technology
 Jun Su Ahn, Chul Hoon Cho, Jung Hoon Lee, Wang Hun Ahn, Young Cheol Lee, Seon Ju Kim and Hyeun Seob Lee

2.2.2Evaluation for Balance and Gait Ability 2.3Analysis

2.2.2.1 Berg Balance Scale (BBS)
BBS considering posture keep, posture control due to vol-
untary exercise, response to external sway as functional
balance test is used for the purpose of evaluating the
dynamic balance ability of old people with high risk of
fall and neurological diseases patients. It consists of a total
14 items with applied activities of daily living and an easy
assessment. Scale of BBS consist of 0-4 points of a 5-point
scale and perfect score is 56 points. The high score reflects
a good balance, and required 45 points or more for inde-
pendent and safe move.
2.2.2.2 Time Up and Go (TUG)
TUG is simple test that can assess basic mobility and
balance. TUG measure the amount of time between sit
in a chair and sit again after a round ahead 3m point.
Measured time by stopwatch in this study obtained three
times and recorded the average value.
Statistical analyses were performed with SPSS package.
Paired t-test was used for analysis of pre-post test within
group. One-way ANOVA was used for analysis between
group and was used the Scheffe method for post-hoc.
Statistical significant level was set at .05.
3.Result
3.1Anthropometric Data of Participants
Average age of participants was 59.311.56 and duration
a diseases averaged 1.233.29 months Table 1.
3.2 Pre-post Test within Group
When analyzed for ability of balance within groups, sta-
tistical significant difference appeared in all groups. BBS
group was the highest and BBS-NDT group was higher
than NDT group Tables 2 to 4.

Table 1. Anthropometric data

Group Age Duration

NDT group (n=7) 58.4 33.29 1.0 54.39

BBS group (n=7) 59.7 21.46 1.1 14.27

NDT-BBS group (n=7) 60.8 31.23 1.4 33.50

Values are mean standard deviation

Table 2. Paired t-test for NDT group

Pre Post

BBS 35.9 11.23 42.9 12.34*

TUG (sec) 19.0 10.21 14.7 8.53*

Values are mean standard deviation. BBS: Berg balance scale, TUG: Timed up and go test, *p<0.05.

Vol 9 (35) | September 2016 | www.indjst.org Indian Journal of Science and Technology 3
 The Effect of Balance Training based on the Berg Balance Scale for the Balance Function in Patients with Cerebellar Ataxia

Table 3. Paired t-test for BBS group (n = 7)

Pre Post

BBS 35.9 11.23 42.9 12.34*

TUG (sec) 19.0 10.21 14.7 8.53*

Values are mean standard deviation. BBS: Berg balance scale, TUG: Timed up and go test, *p<0.05.

Table 4. Paired t-test for NDT-BBS group (n = 7)

Pre Post

BBS 35.9 11.23 42.9 12.34*

TUG (sec) 19.0 10.21 14.7 8.53*

Values are mean standard deviation. BBS: Berg balance scale, TUG: Timed up and go test, *p<0.05.

3.3Results of Post-hoc about Ability of 4.Discussion

Balance between Groups
Results of post-hoc about ability of balance between
groups showed that BBS group was the highest and 9.6
higher than NDT-BBS group. Also BBS group was 4.89
higher than NDT group. NDT-BBS group was 4.69 higher
than NDT group. Statistical significant difference was
observed between all pairs of groups (p<.001) Table 5.
This study performed balance training based on contents
of BBS (Berg balance scale) which is one of the assessment
tools. Balance deficiency is main cause of injury by fall-
ing of old age people as well as patients, and the balance
score often associated with older people18. The dominant
reasons falling older people are balance strategical prob-
lem by reduced muscle strength, lack of agility, input of

Table 5. Results of one-way ANOVA and post-hoc (n = 7)

MSD F value post hoc

15.51 a-b, a-c, b-c

NDT group 9.15 2.23

BBS group 18.75 1.78

NDT-BBS group 13.86 1.74

Values are mean Standard Deviation

4 Vol 9 (35) | September 2016 | www.indjst.org Indian Journal of Science and Technology
 Jun Su Ahn, Chul Hoon Cho, Jung Hoon Lee, Wang Hun Ahn, Young Cheol Lee, Seon Ju Kim and Hyeun Seob Lee
inaccurate information, slow determination and reduced
proprioceptive ability19. To prevent these, Long-term reg-
ular exercise or activity is required to elderly because it
improves the ability to maintain dynamic posture. Muscle
strength and muscle endurance are closely related to the
ability of balance and gait20. Specially, older people or
patients are influenced by the quality of life and activities
of daily living due to muscle weakness21. In by applying
the combined exercise program for a year to the elderly
woman showed a 5.41% increase in knee extension22. In
by applying the exercise program combined with muscle
strength, muscle endurance, moving and balance for 12
weeks to the elderly man showed a 8.86% increase in knee
joint extension and 26.2% increase in muscle endurance.
Various combined exercise program performed for the
purpose of improving the muscle strength, muscle endur-
ance, move, balance, and coordination, and most studies
were performed for the purpose of improving the balance
ability23. In previous studies applying combined exercise
program, the change of muscle strength did not show any
appreciable effect, but balance was significantly improved.
In a study on applying the muscle strength, balance, com-
mon activity training through a home program for six
months showed an improvement of 84.70% in stand on
one foot24, and showed that stand on one foot of elderly
woman improved 75.74% when applied combine exer-
cise program for a year. The human body in unstable
state while walking requires a continuous adjustment of
the balance between both legs and between the upper
extremity and lower extremity on changing basal plane25.
Also walking in the daily living not occur only toward
one direction and is performed with different speeds and
directions. The change of the waling direction reduces the
movement in the forward direction and occur movement
of the new direction. For these new direction and speed,
the control of balance was required for continually stable
walking without falling26,27. Many studies have applied
the various exercise program in order to improve the bal-
ance, but this study was applied the contents in BBS in
the treatment was able to improve the balance ability. The
result show that sufficiently iterative movement with the
contents is effective.
Vol 9 (35) | September 2016 | www.indjst.org
5.Conclusions
This study subjects who are balance disorder patients
receiving treatment of physiotherapy exercise was divided
into 3 groups that are balance training group based on
BBS, therapeutic exercise group base on NDT, and com-
plex group with balance training and therapeutic exercise.
The treatment term was 4 weeks. Collected data were
analyzed in order to determine whether or not there are
a significant difference between pre and post after treat-
ment within group and a significant difference between
groups.
The conclusions are as follows:
1. Significant improvement of the balance ability
appears after 4 weeks in all within groups (BBS,
NDT, and BBS-NDT group).
2. Improvement of the balance ability in BBS
group was the highest. Next was the order of the
NDT-BBS group, NDT group.
3. Statistically significant difference was observed
between all pairs of groups with respect to
improvement of the balance ability.
Taken together, BBS itself to evaluate the balance
ability can help to improve the balance of patients with
disorders of gait and balance. It can be quite a positive
effect for treating patients with balance disorder If uti-
lized appropriately in parallel with traditional balance
treatment or other balance treatment.
6.References
1. Cohen H, Blatchly CA, Gombash LL. A study of the clini-
cal test of the sensory integration and balance. Physical
Therapy. 1993 Jun; 73(6):34651.
2. Cohen J. Statistical power analysis for the behavioral sci-
ences. 2nd (edn), Academic Press: New York; 1988.
3. Nashner LM. Sensory, neuromuscular and biomechani-
cal contributions to human balance. Proceedings of the
Forum of the American Physical Therapy Association:
Nashville;1989 Jun. p. 1315.
4. Goldie PA, Evans O, Matyas TA. Performance in the stabil-
ity limits test during rehabilitation. Gait and Posture. 1996
Oct; 4(4):31522.
Indian Journal of Science and Technology 5
 The Effect of Balance Training based on the Berg Balance Scale for the Balance Function in Patients with Cerebellar Ataxia
5. Ashburn A, Hyndman D, Pickering R, Yardley L, Harris
S. Predicting people with stroke at risk of falls. Age and
Ageing. 2008 May; 37(3):2706.
6. Lamb SE, Ferrucci L, Volapto S, Fried LP, Guralnik JM.
Risk factors for falling in home-dwelling older women with
stroke: The Womens Health and Aging Study. Stroke. 2003
Feb; 34(2):494501.
7. Tideiksaar R. Falling in old age: prevention and treatment.
2nd (edn), New York, Springer; 1997.
8. Alexander BH, Rivara FP, Wolf ME. The cost and frequency
of hospitalization for fall related injuries in older adults.
American Journal of Public Health. 1992 Jul; 82(7):10203.
9. Hausdorff JM, Rios DA, Edelberg HK. Gait variability
and fall risk in community living older adults: A 1-year
properctive study. Archives of Physical Medicine and
Rehabilitation. 2001 Aug; 82(8):10506.
10. Bongue B, Dupr C, Beauchet O, Rossat A, Fantino B, Colvez
A. A screening tool with five risk factors was developed for
fall-risk prediction in community-dwelling elderly. Journal
of Clinical Epidemiology. 2011 Oct; 64(10):115260.
11. Roig M, Eng JJ, MacIntyre DL, Road JD, FitzGerald JM,
Burnset J. Falls in people with chronic obstructive pulmo-
nary disease: An observational cohort study. Respiratory
Medicine. 2011 Mar; 105(3):4619.
12. Allen NE, Schwarzel AK, Canning CG. Recurrent falls
in Parkinsons disease: A systematic review. Parkinsons
Disease. 2013 Mar; 2013(2).
13. Weerdesteyn V, Mark de Niet, Hanneke JR, Alexander CH.
Falls in individuals with stroke. Journal of Rehabilitation
Research and Development. 2008 Mar; 45(8):1195214.
14. Juyeun K, Youngwhee L, Okkyung H. Factors related to
fall in elderly patients with osteoporosis. Journal of Korean
Academy Adult Nursing. 2009 Apr; 21(2):25767.
15. Junghee K, Oksoo K. Balance confidence and balance abil-
ity among community-residing stroke patients. Journal of
Korean Academy Adult Nursing. 2010 Aug; 22(4):4307.
16. Soongnang J, Sungil C, Sangwoo O, Eonsook L, Hyunwook
B. The validity and reliability of Korean Fall Efficacy Scale
(FES) and Activities-specific Balance Confidence Scale
(ABC). Journal of Korean Geriatrics Society. 2003 Dec;
7(4):25568.
17. Ferrarin M, Gironi M, Mendozzi L, Nemni R, Mazzoleni
P, Rabuffetti M. Procedure for the quantitative evaluation
of motor disturbances in cerebellar ataxic patients. Medical
6 Vol 9 (35) | September 2016 | www.indjst.org
and Biological Engineering and Computing. 2005 May;
43(3):34956.
18. Whitney SL, Marchetti GF, Schade A. The relationship
between falls history and computerized dynamic posturog-
raphy in persons with balance and vestibular disorder.
Archives of Physical Medicine and Rehabilitation. 2006
Mar; 87(3):4027.
19. Rogers ME, Rogers NL, Takeshima N, Islam M. Method to
assess and improve the physical parameters associated with
fall risk in older adults. Preventive Medicine. 2003 Mar;
36(3):25564.
20. Wolfson L, Judge J, Whipple R, King M. Strength is a major
factor in balance, gait, and the occurrence of falls. Journals
of Gerontology Series A: Biological Sciences and Medical
Sciences. 1995 Nov; 647.
21. Jette AM, Branch LG. The Framingham disability study: 2
physical disability among the aging. American Journal of
Public Health. 1981 Nov; 71(11):121116.
22. Rubenstein LZ, Josephson KR, Trueblood PR, Loy S, Harker
JO, Pietruszka FM, Robbins AS. Effects of a group exercise
program on strength, mobility, and falls among fall-prone
elderly men. Journal of Gerontology Series A Biological
Science and Medical Science. 2000 Jun; 55(6):M31721.
23. Binder EF, Schechtman KB, Ehsani AA, Steger-May K,
Brown M, Sinacore DR, Yarasheski KE, Holloszy JO. Effects
of exercise training on frailty in community-dwelling older
adults: results of a randomized, controlled trial. Journal of
the American Geriatrics Society. 2002 Dec; 50(12):19218.
24. Nelson ME, Layne JE, Bernstein MJ, Nuernberger A,
Castaneda C, Kaliton D, Hausdorff J, Judge JO, Buchner
DM, Roubenoff R, Singh MAF. The effects of multidimen-
sional home-based exercise on functional performance in
elderly people. Journal of Gerontology Series A: Biological
Science and Medical Science. 2004 Feb; 59(2):15460.
25. Mackinnon CD, Winter DA. Control of whole body bal-
ance on the frontal plane during human walking. Journal of
Biomechanical. 1993 Jun; 26(6):63344.
26. Hase K, Stein RB. Turning strategies during human walk-
ing. Journal of Neurophysiology. 1999 Jun; 81(6):291422.
27. Englund U, Littbrand H, Sondell A, Pettersson U, Bucht
G. A 1-year combined weight-bearing training program
is beneficial for bone mineral density and neuromuscular
function in older women. International Osteoporosis. 2005
Sep; 16(9):111723.
Indian Journal of Science and Technology