HQ BaselineBalance testing
BESS vs. mBESS vs. Instrumented BESS: When Low-Tech Meets High-Tech in Balance Assessment
The balance assessment spectrum — from free clinical observation to laboratory-grade force plates.
Balance testing in concussion management exists on a spectrum from simple clinical observation to sophisticated laboratory instrumentation. Understanding the options — their strengths, limitations, and costs — helps organizations choose the right approach for their setting.
Traditional BESS
Traditional BESS uses six conditions: three stances (double leg, single leg, tandem) performed on two surfaces (firm floor and medium-density foam pad), each held for 20 seconds with eyes closed and hands on hips. A clinician counts errors using a standardized list: opening eyes, lifting hands off hips, stepping, stumbling, falling, lifting the forefoot or heel, or remaining out of position for more than 5 seconds. It’s free to administer, requires minimal equipment, and takes about 10 minutes. Originally developed at UNC and incorporated into the SCAT assessment tools, BESS has the largest evidence base of any clinical balance assessment in concussion management.
Modified BESS (mBESS)
The mBESS eliminates the foam pad conditions, testing three stances on firm surface only. Research suggests it may be equally or more sensitive to concussion-related balance deficits while being faster and simpler to administer. The mBESS is the version embedded in the SCAT6.
Instrumented BESS
Instrumented BESS uses technology to remove human judgment from the equation entirely. Force plate systems like Tekscan’s MobileMat (with SportsAT software) and the BTrackS Balance Plate measure center-of-pressure displacement with millimeter precision during each stance. Research by Caccese and Kaminski at the University of Delaware, comparing observational BESS to Tekscan’s automated scoring module in 111 NCAA Division-I athletes, found good agreement between methods — validating that the automated approach captures what clinicians observe while adding measurement precision.
Smartphone-based systems like Sway Medical use built-in accelerometers to quantify postural sway, providing an objective numerical score rather than a subjective error count.
Choosing the right tool
The cost differential is significant: traditional BESS is essentially free, a Sway Medical subscription runs a few dollars per athlete, and force plate systems range from $1,500–$5,000 for the hardware. The choice depends on your organization’s resources, volume of testing, and clinical needs.
At Headquarters, we select the appropriate balance assessment based on the setting and population. Clinical baselines in our facilities use instrumented measurement for maximum precision. Field-based and large-volume testing events use mBESS for speed and portability. The goal is always the same: objective, reliable balance data that supports clinical decision-making.