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Boubée scale: the 6 stages of sitting balance
The Boubée test scores sitting balance in motor-complete paraplegia, from 0 to 6. Here is the full grid, the starting position to respect, a tool to score during a session, and what the score does not tell you.
Grid reproduced from A. Collot, Annales de Kinésithérapie 1979;6:283, as published in Kinésithérapie la Revue 2011;(114):19-32.
Who this test is for
The test is restricted to motor-complete paraplegia. This is not a stylistic caveat: the higher scores assume abilities that a complete lesion makes unlikely, and the score loses its meaning outside this population. It is sometimes applied to incomplete tetraplegia to document a balance disorder, but it is then only a descriptor, with no prognostic value.
Sitting balance underpins a large share of everyday actions after a spinal cord injury: transfers, dressing, wheelchair propulsion, the ability to catch oneself. Assessing it means indirectly assessing part of functional independence.
Starting position
It is standardised, and it is what makes two measurements comparable:
- patient seated on the edge of the examination couch, on a firm surface;
- no backrest, no posterior support;
- feet on the floor.
Not to be confused with the ELST
The Évaluation ludique de la stabilité du tronc is another sitting-balance scale, also scored through successive positions of the upper limbs. Two differences are enough to tell them apart: in the ELST, the feet do not touch the floor, and the posture does not have to be held. The ELST covers everyone with a complete spinal cord injury, paraplegic and tetraplegic alike, and by extension frail patients; it is a national scale that has not been validated. The two grids look alike enough to be swapped for one another in a patient record.
The grid, stage by stage
The score is the most difficult stage performed correctly. Each task starts from the starting position and requires the patient to hold the posture, which sets this test apart from simple reaching scales.
Scoring a patient
Select the most difficult stage the patient performs correctly. Nothing is sent or recorded: everything happens in your browser.
Boubée score: – / 6
Select a stage above.
| Score | Task |
|---|
The threshold of 3
The benchmark most used in practice is that a score of at least 3 goes with wheelchair independence and limits the risk of a forward fall. It is a field benchmark, and it helps to know where it comes from: from clinical use and from the French-language professional literature, not from a validation study that established sensitivity and specificity against an external standard.
What the score does not tell you
A 3 does not authorise a return home, a 2 does not rule it out. The test describes a postural ability in a standardised position, at one point in time. It says nothing about the environment, the equipment, fatigability across the day, or transfers, which are tested directly.
Three limits worth knowing
Stages 5 and 6 are physiologically debatable
The two highest scores call for trunk rotation, theoretically impossible when the abdominal muscles are paralysed. In high-level complete paraplegia, the top of the scale therefore describes performances that the lesion itself puts out of reach. A ceiling at 4 is not necessarily a rehabilitation ceiling.
The ceiling effect depends on the level of the lesion
Collot recommends the test for high-level paraplegia, where the range of possible variation is wider and the test more sensitive; the ceiling is reached sooner in low-level paraplegia. For longitudinal follow-up in low-level paraplegia, the scale is liable to stop moving while rehabilitation is still progressing.
A painful shoulder distorts the test
Every task goes through upper-limb elevation. A painful shoulder limits the movement for a reason that has nothing to do with balance: the score then underestimates postural ability. That is grounds for setting the test aside, not a simple confounder.
What to pair it with
The recommendation is consistently not to use it on its own, but to pair it with the modified Functional Reach Test (mFRT). The two complement each other well:
| Tool | Population | What it adds |
|---|---|---|
| Boubée test | Motor-complete paraplegia | Static balance in a held posture. Ordinal scoring, read at once, no equipment. |
| mFRT | Paraplegia or tetraplegia, complete or not | Maximum reach distance, hence a continuous measure, more sensitive to change. Reliability studied in spinal cord injury (Lynch, 1998). |
In practice
- Record the starting position along with the score: firm surface, no backrest, feet on the floor.
- Record the stage and the date: it is the progression that informs, not the isolated figure.
- In low-level paraplegia, expect a quick ceiling: pair it with the mFRT from the outset.
- Set the test aside if the shoulder is painful, or read the score as a floor.
- Do not turn the threshold of 3 into a discharge decision on its own.
References
- Collot A. L'équilibre assis du paraplégique de niveau lésionnel élevé. Annales de Kinésithérapie 1979;6:283. Primary source of the grid.
- Les outils de mesure pour l'évaluation fonctionnelle du blessé médullaire. Kinésithérapie la Revue 2011;(114):19-32. Overview review: population, procedure, grid in figure 1, comparison with the ELST, recommendation to pair with the mFRT.
- Viel E, Plas F. Méthodologie du diagnostic kinésithérapique : les examens et les bilans en théorie et en pratique. Annales de Kinésithérapie 1997;24:306-18.
- Lynch SM, Leahy P, Barker SP. Reliability of measurements obtained with a modified functional reach test in subjects with spinal cord injury. Physical Therapy 1998;78:128-33.
- Duncan PW, Weiner DK, Chandler J, Studenski S. Functional reach: a new clinical measure of balance. Journal of Gerontology 1990;45:192-7.
- Sprigle S, Maurer C, Holowka M. Development of valid and reliable measures of postural stability. Journal of Spinal Cord Medicine 2007;30:40-9.
- Shirado O, Kawase M, Minami A, Strax TE. Quantitative evaluation of long sitting in paraplegic patients with spinal cord injury. Archives of Physical Medicine and Rehabilitation 2004;85:1251-6.