The standard Berg Balance Scale (BBS) is designed to be performed without an assistive device. The original protocol asks patients to complete 14 balance tasks using their own body support, and relying on a cane, walker, or other aid during an item generally results in a lower score on that item. That said, the relationship between the BBS and assistive devices is more layered than a simple yes-or-no rule, and clinicians regularly use BBS results to make decisions about when a device is needed and when it can be retired.
How the Standard BBS Handles Assistive Devices
The Berg Balance Scale was developed as a way to measure functional balance in older adults. Each of its 14 items, from standing unsupported to turning 360 degrees, is scored on a 0-to-4 scale, for a maximum of 56 points. The scoring criteria for each item describe specific levels of independence. A score of 4 on most items means the person completed the task without any support. If someone needs to grab a table edge, lean on a railing, or use a cane, they score lower. If they require hands-on physical assistance from the therapist to avoid falling, they typically score a 0.
This makes sense when you consider what the test is trying to capture. The whole point of the BBS is to gauge how well a person can maintain balance on their own. If you let someone lean on a walker while standing on one foot, you are measuring a different thing than what the test was built to assess. So the standard approach is straightforward: complete the tasks without a device, and if you cannot, the scoring rubric accounts for that limitation.
In practice, though, therapists face a tension. Some patients simply cannot perform certain items safely without a device, and no responsible clinician will let someone fall during a test. The common clinical workaround is to allow the device for safety when absolutely necessary but to document the accommodation and score the item according to the level of support used. The score still reflects the person’s underlying balance ability, not their ability to use a walker effectively.
BBS Scores as a Guide to Device Prescription
One of the most practical uses of the BBS is helping clinicians figure out whether a patient needs an assistive device and, if so, what kind. Research has attempted to pin down specific score thresholds for this purpose. A secondary analysis of BBS data from elderly subjects identified a threshold score of 49 out of 56 for the ability to walk without any assistive device, and a score of 43 out of 56 for the ability to walk without a four-wheeled walker. In other words, patients scoring below 49 were more likely to need some form of walking aid, and those below 43 were more likely to need the extra stability of a rollator rather than just a cane.1PubMed Central. Threshold Berg balance scale scores for gait-aid use in elderly subjects: a secondary analysis
These thresholds come with a significant caveat: the accuracy was limited for guiding individual decisions. The percent agreement values for those threshold scores ranged from roughly half to about 87%, meaning that applying them as strict cutoffs would misclassify a substantial number of patients. The researchers concluded that while the thresholds offer a useful reference point, they should not be the sole basis for prescribing or discontinuing a walking aid.1PubMed Central. Threshold Berg balance scale scores for gait-aid use in elderly subjects: a secondary analysis
That said, a separate study looking specifically at hospitalized older adults recovering from hip fracture found the BBS useful for a more targeted question: when to discontinue a walker. In that population, BBS scores and certain sub-items helped clinicians judge readiness to transition away from walker use, suggesting that the test’s value for device-related decisions depends heavily on the clinical context and the specific question being asked.2PubMed. Cut-off values and sub-items of the Berg Balance Scale for walking-aid use in hospitalized older adults with a hip fracture: a retrospective analysis
Why Device Use Affects Your Score Even When You Are Not Being Tested With One
An interesting finding from early BBS research is that a person’s habitual use of an assistive device is itself a strong predictor of how they will perform on the test. One study examining the BBS as a predictor of falls in elderly persons found that whether or not someone used an assistive device in daily life was a powerful predictor of their Berg score.3Oxford Academic (Physical Therapy). Use of the Berg Balance Test to Predict Falls in Elderly Persons The original development and validation work for the scale confirmed this pattern: BBS scores could reliably discriminate between people who used mobility aids and those who did not.4eScholarship@McGill. Measuring balance in the elderly: development and validation of an instrument
This is worth understanding if you are a patient or caregiver. Your BBS score is not just a snapshot of your balance during those few minutes of testing. It correlates with your broader mobility profile, including the kind of support you rely on day to day. Someone who uses a rollator at home is, on average, going to score lower than someone who walks independently, even before considering whether a device is used during the test itself. That correlation is part of what makes the BBS clinically useful: it reflects real-world functional ability, not just lab performance.
How the Mini-BESTest Handles Assistive Devices Differently
The BBS is not the only balance assessment out there, and some alternatives take a more explicit approach to assistive device use. The Mini-BESTest (a shortened version of the Balance Evaluation Systems Test) includes a specific scoring rule: if a person must use an assistive device to complete an item, that item is scored one category lower than it would otherwise be. If the person needs physical assistance from the examiner, the item scores a zero.5PubMed Central. Using psychometric techniques to improve the Balance Evaluation Systems Test: the mini-BESTest
This approach is more flexible for clinicians working with patients who genuinely cannot attempt certain tasks without a device. Rather than simply saying “no devices allowed,” the Mini-BESTest builds device use into its scoring framework. A patient who performs a task well with a cane still gets some credit, just less than someone who performed the same task unaided. The result is a score that captures a broader range of balance ability, including among people who would score very low on the standard BBS simply because they could not safely attempt several items without support.
For patients with moderate to severe balance impairments, this difference matters. The BBS has well-documented floor and ceiling effects in certain populations. A systematic review of the BBS in stroke rehabilitation found that several studies reported floor effects (patients scoring so low that the test cannot distinguish among them) and ceiling effects (patients scoring so high that further improvements go undetected). The review’s authors recommended using the BBS alongside other balance measures to get a fuller picture.6Oxford Academic (Physical Therapy). Usefulness of the Berg Balance Scale in Stroke Rehabilitation: A Systematic Review The Mini-BESTest’s device-accommodating scoring helps address the floor effect problem by allowing lower-functioning patients to participate more fully in the assessment.
Modified Versions of the BBS for Specific Populations
Beyond the standard BBS and the Mini-BESTest, researchers have developed modified versions of the Berg scale for populations where the original test does not fit well. One example is a modified Berg Balance Scale (mBBS) designed for adults with both intellectual and visual disabilities. This version adjusts the test administration to accommodate the communication and sensory challenges these individuals face, though research on its validity is still in relatively early stages.7PubMed Central. Validity of the modified Berg Balance Scale in adults with intellectual and visual disabilities
These adaptations highlight an important broader point: the BBS was originally validated with community-dwelling older adults, and its rules about assistive devices were designed with that population in mind. When the test is used with people who have spinal cord injuries, stroke, developmental disabilities, or other conditions that affect balance in distinct ways, the standard device rules may not capture what clinicians need to know. In these cases, the therapist’s clinical judgment, not just the test manual, drives decisions about whether and how to accommodate a device.
What This Means if You Are Being Tested
If your physical therapist is about to administer the BBS, here is what to expect regarding assistive devices. You will likely be asked to attempt each item without your cane, walker, or other aid. The therapist will stay close enough to catch you or stabilize you if needed, and they will not ask you to do anything they consider genuinely unsafe. If you cannot complete a task without support, the therapist will note that and score accordingly. You do not “fail” the test by needing support; the scoring system simply reflects the level of independence you demonstrated.
You should tell your therapist about any devices you use at home, even if you did not bring them to the appointment. As noted earlier, habitual device use correlates with BBS scores and helps the therapist put your results in context. If you normally use a cane outdoors but not indoors, mention that. If you recently started using a walker after a surgery, that context matters. The BBS score is most useful when combined with everything else the therapist knows about how you move in daily life.
If you are tracking your own progress over time, consistency matters more than the absolute score. Being tested with a device one session and without it the next will produce scores that are not comparable. Make sure the testing conditions stay the same across sessions so that any change in your score reflects a real change in your balance rather than a change in how the test was administered.
When the BBS Is Not the Right Test for Device Decisions
The BBS is one of the most widely used balance assessments in rehabilitation, but it is not always the best tool for deciding whether someone needs a walking aid. A scoping review of objective assessments for walking-aid prescription identified a range of tests that may be better suited for that specific question, including combinations of the Timed Up and Go test, walking speed tests, and confidence scales like the Activities-specific Balance Confidence scale.8Taylor & Francis Online (Disability and Rehabilitation: Assistive Technology). Objective assessments for walking aid prescription in balance impairment and falls risk: a scoping review of current evidence The BBS was among the tools identified, but it appeared alongside many others, underscoring that no single test comprehensively answers the device-prescription question.
Part of the reason is that the BBS was designed to measure balance, not mobility. Balance and mobility overlap, but they are not the same thing. You can have adequate balance for standing tasks and still struggle with walking endurance, or you can have decent static balance but poor reactive balance when you trip or get bumped. A person’s need for a walking aid depends on all of these factors plus environmental considerations like terrain, distance, and fatigue. The BBS captures one piece of the puzzle well, but clinicians who rely on it alone for device decisions are working with incomplete information.
The threshold score research reinforces this point. Even with carefully derived cutoff values, the BBS alone misclassifies a meaningful proportion of patients when used as the sole guide for prescribing or removing an assistive device.1PubMed Central. Threshold Berg balance scale scores for gait-aid use in elderly subjects: a secondary analysis A good clinician uses the BBS as one input among several, combining it with walking tests, patient-reported confidence levels, and direct observation of how you move in realistic conditions.
How Assistive Device Type Interacts With Balance Training Goals
A subtle but important question that comes up around BBS testing and assistive devices is whether using a device too early or for too long might slow balance recovery. This is a legitimate concern in rehabilitation. If you always walk with a walker, you may not challenge your balance system enough to improve. On the other hand, if you ditch the walker too soon, you risk a fall that sets recovery back dramatically.
This is where serial BBS testing becomes genuinely valuable. By administering the test at regular intervals, always under the same conditions, a therapist can track whether your unassisted balance is improving. If your BBS score rises from 38 to 45 over several weeks of therapy, that is objective evidence that you may be ready to trial a less supportive device, such as moving from a rollator to a single-point cane, or from a cane to independent walking. Conversely, if the score plateaus or drops, the device stays or gets upgraded.
The hip fracture study mentioned earlier illustrates this approach in action. In that clinical setting, the BBS helped therapists make the specific decision about when to stop using a walker, giving patients and their families something more concrete than just a gut feeling about readiness.2PubMed. Cut-off values and sub-items of the Berg Balance Scale for walking-aid use in hospitalized older adults with a hip fracture: a retrospective analysis The test cannot tell you everything, but it gives rehabilitation a measurable anchor, and that anchor is most reliable when devices are handled consistently each time the test is given.
Common Misunderstandings About BBS Scoring and Devices
One misconception patients sometimes have is that they should try to perform the BBS without their device to get a “better” score that will impress their therapist or satisfy an insurance requirement. This is counterproductive and potentially dangerous. The BBS is a diagnostic tool, not a performance review. A score that reflects your actual balance ability is far more useful clinically than one inflated by risk-taking. If you need a device, using it during the test (and accepting the lower score) gives your therapist accurate information to plan your treatment.
Another misunderstanding is that a low BBS score automatically means you need a specific type of device. As the threshold research showed, the score ranges for different device categories overlap considerably, and individual variation is large. Two people with a BBS score of 44 might have very different mobility profiles: one might be safe with a cane, while the other genuinely needs a rollator, depending on factors like leg strength, vision, cognitive status, and the home environment they are navigating. The BBS score points the conversation in the right direction, but it does not end it.
Finally, some people assume the BBS is the definitive test for fall risk and that scoring above a certain number means they will not fall. The evidence is more modest than that. While BBS scores are associated with fall risk and the test was validated partly on its ability to predict subsequent falls, no single balance test perfectly predicts whether a given person will fall in the coming months.4eScholarship@McGill. Measuring balance in the elderly: development and validation of an instrument Falls are influenced by medications, lighting, footwear, home hazards, blood pressure changes, and dozens of other variables the BBS cannot capture. The test is a strong contributor to risk assessment, not a crystal ball.