Methods

This narrative review aims to explore the importance of the BBS in the context of its translation and psychometric evaluation across various cultural and linguistic settings. The BBS, a widely used tool to assess balance and fall risk in older adults and other populations, has undergone several translations and cross-cultural adaptations. To understand the global applicability and reliability of the BBS, this review evaluates translations into languages such as Portuguese, Persian, Korean, Norwegian and others, as well as psychometric properties in diverse patient populations. The review synthesizes studies that address the translation process, cross-cultural validation, and psychometric testing of the BBS.

Results

From all the research databases such as EBSCOhost, Scopus, PubMed, Lilacs, IBECS, CENTRAL, Web of Science (WOS), SciELO and Google Scholar databases, a total of 17 articles were found with special interest in translation, cross-cultural adaptation, validity, and reliability.

The results summarized in Supplementary Table SI A highlight the global effort to validate and adapt the BBS across diverse populations, languages, and clinical conditions. Most studies adopted cross-sectional or validation designs, focusing on psychometric evaluation such as reliability, validity, and cultural adaptation of the BBS. The included countries ranging from Hungary, Pakistan, Brazil, and Iran to Japan, Norway, and Greece demonstrate widespread interest in ensuring the scale’s applicability beyond its original context [17–23]. Participants varied widely in number and characteristics, with most studies involving older adults or individuals with Parkinson’s disease, dementia, or stroke. Where reported, participant ages generally ranged from 60 to 70, reflecting the BBS’s relevance for aging populations. Gender was consistently mixed, although specific breakdowns were often omitted. Several studies, like those from Brazil and Italy, reported strong psychometric properties, supporting the BBS’s use for balance assessment across settings [5, 9]. Notably, studies emphasized inter-rater reliability and construct validity, critical components for clinical tools. The general consistency in findings supports the BBS as a robust instrument across cultures, though variability in reporting sample size, age, disease duration suggests a need for standardized methodologies in future validation efforts. Overall, the BBS proves adaptable and clinically useful across a spectrum of international contexts.

The findings in Supplementary Table SI B illustrate that most studies used a cross-sectional or validation design, focusing on the translation, cultural adaptation, and psychometric assessment of the BBS. The BBS was the primary tool used, with minimal implementation of additional assessments. Frequency of testing was generally a single administration, with few studies conducting test-retest evaluations. Only Jung et al. clearly reported a test-retest interval of 10 days [20]. Overall, the findings show that while BBS validation is widely conducted, standardized reporting of intervention frequency and test-retest intervals is limited, indicating a need for more consistent methodological transparency.

The extended Table I A presents a comprehensive synthesis of studies evaluating the validity and reliability of the BBS across different cultural contexts and populations. Most studies confirmed high inter- and intra-rater reliability, with ICCs ranging from 0.95 to 0.99, indicating excellent consistency across raters and test sessions. Internal consistency, measured by Cronbach’s α, was also strong in several translations (α = 0.98 in Turkish, α = 0.90 in the Fear of Falling Avoidance Behavior Questionnaire (FFABQ-B) context). Correlational analyses, where available, further reinforced construct validity. For example, moderate to strong correlations were reported between BBS and other functional assessments, such as the Timed Up and Go Test (TUG) (r = –0.75), Modified Barthel Index (MBI) (r = 0.67), and Unified Parkinson’s Disease Rating Scale III (UPDRS-III) (r = –0.78), supporting BBS’s relevance in assessing balance and motor function in elderly and Parkinson’s populations. Some studies also reported significant correlations with age, as seen in the Norwegian version (r = –0.36). However, despite the strong psychometric support, several articles lacked detailed statistical reporting on validity measures or did not assess correlations. Overall, the findings confirm the BBS as a robust, reliable tool for cross-cultural clinical use, though further standardization in reporting and broader psychometric evaluations would enhance its global applicability.

The bias assessment of the psychometric studies included in Table I B reveals an overall moderate to low risk of bias across the selected research. Most studies reported appropriate sample sizes for psychometric evaluations, with several exceeding 60 participants a number generally considered sufficient for basic reliability and validity testing [3, 4, 19]. However, a few studies, such as those by Scalzo et al. and Sahin et al., had relatively smaller samples (< 50), which may affect the generalizability and stability of their psychometric estimates [5, 10].

Regarding statistical methods, almost all studies applied robust and recognized techniques such as Intraclass Correlation Coefficient (ICC), Cronbach’s α, and Pearson correlations to assess reliability and validity. Some studies, like Salavati et al. and Viveiro et al., also included Standard Error of Measurement (SEM) and Receiver Operating Characteristic (ROC) curves, enhancing their methodological rigor [6, 7].

Clarity of reporting was generally strong. Most studies provided detailed descriptions of their translation, adaptation, and validation procedures. Nevertheless, a few older studies [5, 16] offered less comprehensive methodological explanations, potentially leading to moderate interpretative bias.

While minor concerns related to sample size and reporting detail exist in some studies, the majority of the reviewed research demonstrates high methodological quality, reinforcing the reliability and validity of the BBS across diverse cultural contexts.

Discussion

The BBS has been extensively validated across a variety of populations, languages, and cultural settings, emerging as one of the most reliable and widely used tools for assessing balance impairments, especially among older adults and individuals with neurological conditions such as Parkinson’s disease and stroke. The present review of international literature provides compelling evidence supporting the scale’s psychometric robustness, while also highlighting a significant gap the absence of an Albanian version of the BBS. Considering the growing elderly population and increasing burden of age-related balance disorders in Albania, the development and validation of a culturally adapted BBS is both timely and necessary.

The validation of the BBS across various linguistic and clinical contexts has consistently shown strong inter-rater and intra-rater reliability. For instance, studies conducted in Turkey, Brazil, Norway, and Korea indicated almost perfect reliability [10, 18, 20, 21]. Similarly, Cronbach’s α values, which assess internal consistency, were frequently above 0.90, suggesting that the items within the scale are measuring a coherent construct.

The Urdu version validated by Kashif et al. in people with Parkinson’s disease showed excellent reliability (α = 0.81; ICC = 0.99) and strong correlations with established Parkinson’s measures, demonstrating both reliability and construct validity [4]. Likewise, the Turkish study [10] confirmed convergent validity through significant correlations with the MBI (r = 0.67) and TUG (r = –0.75). These correlations are crucial because they demonstrate that the BBS is not only internally consistent but also meaningfully related to other functional mobility measures.

Successful adaptation of the BBS has occurred in a variety of linguistic and cultural contexts, including Hungarian, Persian, Japanese, and Brazilian-Portuguese [3, 5, 7, 8, 22]. These studies followed standardized cross-cultural adaptation procedures, which typically involve translation, back-translation, expert committee reviews, and pilot testing. Despite differences in health systems, rehabilitation practices, and socio-cultural norms, the scale demonstrated strong measurement equivalence, reinforcing its versatility and applicability across different countries.

This context strengthens the argument for an Albanian translation and validation of the BBS. Albania currently lacks a standardized and validated balance assessment tool. The introduction of the BBS, following cross-cultural adaptation protocols, such as those outlined by Beaton et al., would offer clinicians and researchers in Albania/would provide clinicians and researchers in Albania with a validated, internationally recognized instrument for use in clinical and research settings [13]. Moreover, considering the BBS’s widespread usage, an Albanian version would facilitate international collaboration, comparative research, and evidence-based rehabilitation practices.

The clinical utility of the BBS is underscored in studies such as Viveiro et al., who compared the BBS with other balance assessments (BESTest, Mini-BESTest, Brief-BESTest) in older nursing home residents [6]. While all tools were reliable, the BBS demonstrated solid validity in identifying fall status (ICC = 0.94), though slightly less sensitive than the more dynamic BESTest. Nevertheless, its brevity, simplicity, and minimal equipment requirements make the BBS particularly suitable for resource-limited settings such as many areas in Albania.

Further support comes from the systematic review by Lima et al., which evaluated the BBS’s ability to predict fall risk [11]. While the review acknowledged moderate predictive validity, it also pointed out some limitations, such as ceiling effects in high-functioning individuals and lower sensitivity to subtle balance deficits. These findings imply that while the BBS is a reliable screening tool, it should be complemented with additional assessments for more comprehensive balance evaluation, especially in individuals with higher functional levels.

From a methodological perspective, many studies employed rigorous psychometric analyses, including test-retest reliability, construct validity, and correlation with established scales. For example, Gillespie et al. compared in-person and telerehabilitation BBS scoring in stroke survivors, highlighting the scale’s adaptability to telehealth applications, an increasingly relevant consideration in post-pandemic rehabilitation [15].

However, some articles lacked complete psychometric reporting. Several studies, such as those by Scalzo et al. and Babaei-Ghazani et al., affirmed reliability but omitted detailed correlation analyses or construct validity measures [5, 8]. This variation in reporting standards underscores the need for more uniform methodology and comprehensive data presentation, especially when developing a new cultural adaptation such as an Albanian version.

Although numerous studies included in this review reported psychometric indicators such as ICC, Cronbach’s α, and correlation coefficients, a meta-analysis was not undertaken. This decision was driven by the substantial heterogeneity across the available evidence, which varied in cultural and linguistic adaptations, clinical populations, sample sizes, measurement procedures, and statistical approaches. Such variability limits the comparability of results and challenges the assumptions required for valid data pooling. Conducting a meta-analysis under these conditions could lead to misleading summary estimates that overlook important contextual nuances. Instead, the narrative synthesis applied here allows for a more critical appraisal of the evidence, highlighting methodological differences, population-specific findings, and the broader implications for the cross-cultural applicability of the BBS.

This review was restricted to studies published in English, a decision taken to ensure accurate interpretation of methodological procedures and psychometric results. However, this choice inevitably introduces the possibility of language and publication bias, as relevant evidence from other high-output languages such as Chinese, Spanish, and Portuguese may not have been captured. Future reviews would benefit from adopting a multilingual approach to provide a more comprehensive overview of the cross-cultural performance of the BBS. In addition, it is important to acknowledge the limitations of the instrument itself. While the BBS is widely used and supported by strong psychometric evidence, it is subject to ceiling effects in high-functioning or community-dwelling individuals, which can reduce its sensitivity to change in these populations. These limitations should be taken into account when interpreting results and when selecting outcome measures for research and clinical practice.

Despite the robust global evidence base, no validated version of the BBS currently exists in the Albanian language. This absence limits clinicians’ ability to objectively assess and monitor balance deficits among Albanian-speaking populations, both within Albania and in diaspora communities. As the country’s population ages and the burden of falls, Parkinson’s disease, stroke, and frailty increases, the need for standardized, evidence-based assessment tools becomes urgent.

An Albanian version of the BBS would support early detection of balance impairments, guide individualized rehabilitation planning, and facilitate outcome monitoring. Moreover, a culturally adapted tool could account for local language nuances, health beliefs, and environmental challenges that may influence balance, such as uneven terrain in rural areas or lack of accessibility infrastructure.

The process of translation and validation should follow internationally accepted protocols to ensure content validity and reliability. This would typically include: forward translation by bilingual experts; back-translation into the original language; review by an expert committee for semantic and conceptual equivalence; pilot testing on a sample of older Albanian adults and full psychometric evaluation including factor analysis, test-retest reliability, and construct validity.

Given Albania’s limited access to sophisticated rehabilitation technologies, the simplicity, cost-effectiveness, and portability of the BBS make it an ideal candidate for widespread use in both urban clinics and rural health posts.