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Applying Knowledge Translation Theory to Physical Therapy Research and Practice in Balance and Gait Assessment: Case Report Kathryn M. Sibley, Nancy M. Salbach
Background and Purpose. Knowledge translation (KT) is an emerging dis- cipline with a focus on implementing health evidence in decision making and clinical practice. Knowledge translation theories provide conceptual frameworks that can direct research focused on optimizing best practice. The objective of this case report is to describe one prominent KT theory—the knowledge-to-action (KTA) frame- work—and how it was applied to research on balance and gait assessment in physical therapist practice.
Case Description. Valid and reliable assessment tools are recommended to evaluate balance and gait function, but gaps in physical therapy practices are known. The KTA framework’s 2-pronged approach (knowledge creation phase and action cycle) guided research questions exploring current practices in balance and gait assessment and factors influencing practice in Ontario, Canada, with the goal of developing and evaluating targeted KT interventions.
Outcomes. Results showed the rate at which therapists use standardized balance and gait tools was less than optimal and identified both knowledge-to-practice gaps and individual and organizational barriers to implementing best assessment practices. These findings highlighted the need for synthesis of evidence to address those gaps prior to the development of potential intervention strategies.
Discussion. The comprehensive KTA framework was useful in guiding the direc- tion of these ongoing research programs. In both cases, the sequence of the individ- ual KTA steps was modified to improve the efficiency of intervention development, there was a need to go back and forth between the 2 phases of the KTA framework, and additional behavior change and barrier assessment theories were consulted. Continued research is needed to explicitly evaluate the efficacy of applying KT theory to best practice in health care.
K.M. Sibley, PhD, Toronto Reha- bilitation Institute–University Health Network, Toronto, Ontario, Canada, and Physical Therapy, University of Toronto, Toronto, Ontario, Canada.
N.M. Salbach, PT, PhD, Depart- ment of Physical Therapy, Univer- sity of Toronto, 500 University Ave, Room 160, Toronto, Ontario, Canada M5G 1V7, and Toronto Rehabilitation Institute–University Health Network, Toronto, Ontario, Canada. Address all cor- respondence to Dr Salbach at: nancy.salbach@utoronto.ca.
[Sibley KM, Salbach NM. Applying knowledge translation theory to physical therapy research and practice in balance and gait assessment: case report. Phys Ther. 2015;95:579 –587.]
© 2015 American Physical Therapy Association
Published Ahead of Print: June 26, 2014
Accepted: June 15, 2014 Submitted: October 15, 2013
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Delivery of high-quality healthcare that is evidence-based,cost-effective, individually tai- lored, and sustainable requires a coordinated strategy. To facilitate the consideration of research evi- dence in clinical practice, a focus on “knowledge translation” (KT) has emerged in health care. A commonly used definition developed by the Canadian Institutes of Health Research (CIHR), the primary funder of health research in Canada, describes KT as “a dynamic and itera- tive process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, pro- vide more effective health services and products and strengthen the health care system.”1 Physical therapist prac- tice has traditionally incorporated a strong focus on evidence-based prac- tice (EBP), defined as “integrating indi- vidual clinical expertise with the best available external clinical evidence from systematic research.”2 Adoption of a KT perspective expands the clinician-focused EBP approach, as KT may involve implementing research at the system, organization, team, or indi- vidual level. Although the exercise of translating knowledge to new situa- tions, applications, or patients is not new, the evolution of a field dedicated to systematically optimizing the imple- mentation of knowledge into practice, and supported by a body of evidence, represents a paradigm shift in science and health care.
Central to the rise of KT as a distinct discipline is the development of the- oretical models for moving research into practice. The use of theory, defined as “a coherent and noncon- tradictory set of statements, con- cepts or ideas that organizes, pre- dicts and explains phenomena, events, behavior, etc,”3 is recom- mended in KT because it provides generalizable frameworks for devel- oping research questions and inter- ventions, allowing for an incremental
accumulation of knowledge.4 The purpose of this case report is to describe the application of KT the- ory in research focused on best practice in physical therapy. The theory used is the knowledge-to- action (KTA) framework.5,6 It was selected because it is a pragmatic model that provides step-by-step direction for implementation. It also has been applied to other health care settings, such as osteoporosis management.7
The examples presented focus on balance and gait assessment in phys- ical therapist practice. Balance is required for many functional activi- ties such as mobility and fall avoid- ance, and impairment is common in older adults and people living with chronic conditions.8 –10 Gait impair- ment is also common across health conditions, particularly after stroke, where patients identify improve- ment in walking as a primary goal of rehabilitation.11 Assessment is important for diagnosing impair- ments, informing treatment plans, and evaluating change over time, and use of valid and reliable tests is a recognized component of EBP.12
However, there is evidence of a gap in incorporating balance and gait assessments into clinical prac- tice.13,14 As such, there is a need for innovation to implement best bal- ance and gait assessment approaches into practice and for targeted research to inform the development of interventions and their evaluation in pragmatic settings.
The objective of this case report is to describe: (1) the KTA framework and (2) how it informed our research focused on optimizing balance and gait assessment practices. In both cases, the KTA framework was used from the beginning of the research process, guiding the research ques- tions. This work is ongoing; efforts to date have addressed the early components of the model, working
toward the development of a KT intervention. Implications and limita- tions of applying the KTA framework are discussed.
The Knowledge-to-Action Framework The KTA framework (Figure) divides KT into 2 phases: (1) the knowledge creation phase and (2) the action cycle. The knowledge creation phase acts as a funnel that tailors knowledge into usable units, begin- ning with the “knowledge inquiry” stage that refers to the range of health research literature. The next stage, “knowledge synthesis,” includes systematic reviews and meta-analyses that analyze the body of evidence on a particular topic and are the basis for the “knowledge products/tools” stage that refines the knowledge into manageable units. These units could include, but are not limited to, best practice guide- lines, clinical pathways, or decision algorithms.
The action cycle identifies the steps required for a unit of knowledge to reach widespread use. Although this cycle is dynamic and can be per- formed in any order (reflected by multidimensional arrows between stages), in general, the first step involves “identifying the problem/ selecting, reviewing, and identifying the knowledge” to be translated. Once a gap is identified, there is a need to “adapt knowledge to the local context,” such as an individual practice setting or particular patient. Such adaptation may occur in con- junction with “assessing barriers to knowledge use” in that particular sit- uation. These KTA components inform the “selection, tailoring, and implementation of interventions” designed to facilitate uptake of the knowledge by adapting interven- tions to individual settings and patients. Such tailoring can be informed by an emerging knowledge base on the efficacy of various imple-
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mentation interventions.15 “Monitor- ing knowledge use” is required to evaluate the extent to which the intervention was implemented, along with “evaluation of outcomes” to assess the impact of the interven- tion. A unique feature of the KTA framework is the need to “sustain knowledge use” by ensuring that continued processes and reviews are implemented. However, it also is noted that this issue is addressed the least in the academic literature, as it may be considered beyond the realm of traditional research and fall out- side of the scope of funding windows.7
Applying KTA to Physical Therapy Research and Practice Case 1: Balance Assessment The long-term objective of this research is to optimize clinical bal- ance assessment practices and, in turn, maximize the effectiveness of interventions to improve balance and reduce falls in high-risk popula- tions. Case 1 (balance assessment) is summarized in Table 1.
Identify, review, and select knowledge. The first step was to identify the components that should be considered in an “optimal” bal- ance assessment approach. There is no best practice guideline for evalu- ating balance, nor is there a univer- sally accepted gold standard mea- sure. Thus, in the absence of such benchmarks, we selected content validity as the primary factor for con- sideration. Contemporary postural control theory views balance as the product of integrated inputs and the body as a mechanical system that interacts with the nervous system in a continuously changing environ- ment.16 –18 Based on this view, the “systems framework for postural control” was proposed (Tab. 2)19,20
and was identified as the “knowl- edge” guiding the consideration of
theoretical constructs that should be included in an optimal balance assessment approach.
Identify problem. The next objective was to understand current balance assessment practices, which served as a baseline indicator of strengths and weaknesses in existing approaches. We conducted a cross- sectional survey of 369 randomly selected physical therapists practic- ing in Ontario, Canada.21,22 Ninety percent of the respondents reported using at least one standardized bal- ance measure in their assessment, and although most components of balance were regularly assessed by the majority of respondents, reactive postural control was regularly assessed by only 41% of the respon- dents. Reactive control refers to rapid recovery responses following a loss of balance, and the low fre-
quency of assessment represents a knowledge-to-practice gap because this is the component of balance most related to fall avoidance.23
The survey also revealed gaps in how reactive control is assessed: most respondents reported using nonstandardized perturbations to evaluate it, and some reported using standardized balance mea- sures for reactive control assess- ment, which did not contain a spe- cific evaluation of it.
A limitation of the survey was that it relied on self-report data, which is known to overestimate perfor- mance. Thus, we conducted a follow-up retrospective chart review to objectively validate the findings.24
The review was conducted on a ran- dom sample of charts from 250 indi- viduals aged 65 years and over who were admitted to an Ontario urban
Figure. The knowledge-to-action framework. Reprinted with permission of John Wiley & Sons from: Straus SE, Tetroe J, Graham ID, eds. Knowledge Translation in Health Care: Moving From Evidence to Practice. 2nd ed. Chichester, United Kingdom: John Wiley & Sons Ltd; 2013.
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specialized rehabilitation hospital with a diagnosis associated with bal- ance impairment. Standardized bal- ance measures were used in 73% of the charts reviewed. Reactive con- trol was not assessed with any of the standardized measures documented, and it was assessed with nonstan- dardized methods in only 2% of
charts. These results confirmed and strengthened indications of a gap in balance assessment in Ontario.
Assess barriers to knowledge use. A secondary focus of the sur- vey was to explore factors influenc- ing current balance assessment prac- tices.25 Multiple barriers were noted,
reflecting individual (eg, lack of knowledge, low priority), environ- mental (eg, lack of time and person- nel), and measure-specific (eg, tools not available, tools not appropriate for population) issues. Some barriers suggested that there is an education need—for example, the perception that standardized measures for reac- tive control do not exist, when in fact several clinical measures are available. In contrast, other barri- ers—such as a lack of psychometric data for particular populations and measures— highlighted a need for additional research evidence.
Knowledge synthesis. Reflection on the survey and chart review find- ings highlighted that one potential factor influencing the gap in balance assessment related to the compo-
Table 1. Case 1 (Balance Assessment): Aligning Research Steps With the Knowledge-to-Action Framework
KTA Phase Case Study Step Findings Implications
Identify, review, and select knowledge
Identified “systems framework for postural control”20 as contemporary theory of balance describing components and systems involved
This framework views postural control as the result of the integration of inputs from several underlying physiological systems
The systems framework provided a guide for the theoretical components of postural control that should be included in a comprehensive assessment of balance
Identify problem 1. Cross-sectional survey of 369 practicing Ontario physical therapists exploring self-reported use of standardized balance measures and components of balance assessed21,22
2. Retrospective chart review of 250 inpatient charts at one Ontario rehabilitation hospital24
1. More than 90% of the respondents reported using at least one standardized balance measure
2. Not all components of balance were regularly assessed: reactive postural control (responses to external perturbations) were regularly assessed by only 41% of the survey respondents
3. Among respondents who assessed reactive control, most used a nonstandardized technique, and some reported using standardized measures to assess reactive control that did not contain an explicit evaluation of it
4. Standardized balance measures were used in 73% of charts reviewed; in no charts were all components of balance assessed
A gap in balance assessment practice exists: reactive postural control, the component of balance most directly associated with avoiding falls, is not regularly formally assessed by Ontario physical therapists.
Assess barriers to knowledge use
Analysis of additional Ontario balance assessment survey data (n�369) exploring satisfaction with current practices and factors influencing satisfaction25
Individual (eg, lack of knowledge, low priority), environmental (eg, lack of time and personnel), and measure-specific (eg, tools not available, tools not appropriate for population) barriers were identified
The identified barriers highlight potential intervention strategies (ie, education and coaching on potential measures) and knowledge gaps requiring additional evidence (ie, the validity of a particular measure in a specific population)
Knowledge synthesis
Scoping review identifying existing standardized balance measures and components of balance evaluated29
66 standardized measures identified The scoping review results will be useful for informing the selection of standardized balance measures that can comprehensively assess all relevant components of balance
Table 2. Domains in the Systems Framework for Postural Control20
Domain No. Domain
1. Biomechanical constraints: degrees of freedom, strength, limits of stability
2. Orientation in space: perception of gravity, verticality
3. Movement strategies: reactive, anticipatory, voluntary
4. Control of dynamics: gait, proactive
5. Sensory strategies: integration, reweighting
6. Cognitive processing: attention, learning
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nents of balance included in stan- dardized measures themselves and that selection of measurement tools had a direct impact on information acquired during assessment. These findings suggested a need to better understand the nature of existing standardized balance measures and where there may be conceptual gaps in individual measures. This need entailed going back to the knowl- edge creation phase of the KTA framework to synthesize information
on existing balance measures by identifying all existing measures and analyzing the components of balance they evaluate. A scoping review—a variation of a systematic review intended to scope and identify gaps in the literature26 –28—was con- ducted, and 66 standardized mea- sures of balance were identified.29
The results will be useful in identify- ing which measures can fill the prac- tice gap in assessment of reactive postural control.
Case 2: Gait Assessment Case 2 (gait assessment) is summa- rized in Table 3. Among people with stroke with some ambulatory capac- ity, more time is spent on gait retraining than on any other activity during physical therapy.30 Thus, physical therapists are primary end- users of recommendations to imple- ment reliable and valid measures of walking poststroke. The long-term aim of this research program is to advance physical therapists’ effec-
Table 3. Case 2 (Gait Assessment): Aligning Research Steps With the Knowledge-to-Action Framework
KTA Phase Case Study Step Findings Implications
Identify, review, and select knowledge
The literature was reviewed to aid conceptualization of an evidence- based practice approach to using standardized assessment
1. Measurement frameworks31 describe the use of standardized assessment tools for discriminative, evaluative, and predictive purposes
2. Walking measures with evidence of reliability and validity poststroke are available39
We decided to investigate use of: standardized tools to assess walking for the purposes of evaluation, monitoring change, formulating a prognosis, and assessing readiness for discharge
Identify problem Cross-sectional survey of 270 Ontario physical therapists exploring self- reported use of standardized walking measures among people with stroke38
The percentage of respondents reporting consistent use of a walking measure to evaluate, monitor change, determine prognosis, and assess readiness for discharge was 45%, 43%, 19%, and 28%, respectively; use of a measure of walking speed or distance was below 35%
A knowledge-to-practice gap in the use of standardized measures of walking poststroke exists. The rate of using tests of walking speed and distance after stroke is particularly low.
Assess barriers to knowledge use
1. Analysis of additional Ontario survey data (n�270) exploring practitioner-level barriers to the use of standardized measures35–38
2. Qualitative study of 23 Ontario physical therapists examining their experiences implementing evidence-based practice poststroke40,41
1. 40% of respondents were unsure that reliable and valid measures of walking exist
2. Among respondents not using walking measures consistently, barriers included lack of time, uncertainty that measures are useful to quantify severity of deficit, and beliefs that measures do not reflect the home or community environment, are difficult to administer, lack sensitivity to change, are a low priority, and lack normative values
Insufficient knowledge is a primary barrier to use of standardized measures of walking in physical therapist practice; other barriers include negative perceptions of the quality and clinical utility of standardized measures of walking
Knowledge synthesis Systematic reviews to synthesize evidence of the quality and interpretability of measures of walking speed and distance poststroke42,43
1. Findings provided an overview of distances required to walk at 24 community sites, speeds required to walk across the street in the time of a walk signal, and walk test norms
2. Reporting of additional findings related to quality is ongoing
1. Distance and speed requirements to walk in the community and test norms provide reference values for interpreting the results of scores on time measures of walking speed and distance
2. Review findings will be used to develop a knowledge tool
Adapt knowledge to local context
Analysis of additional data from the qualitative study to understand preferences for resources and educational interventions that would help to facilitate evidence- based practice40,41
1. Participants described a preference for synthesized online resources to facilitate quick access to preappraised and summarized information
2. Participants described a preference for learning sessions that are led by an expert, case-based, and provide opportunities to practice new skills to achieve practice change
Findings will inform the design of knowledge translation strategies to facilitate the clinical use of measures of walking speed and distance poststroke
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tiveness in using standardized, valid measures of walking ability poststroke.
Identify, review, and select knowledge. The first step was to conceptualize standardized assess- ment as a critical element of EBP. Health measurement frameworks31
were used to identify that walking measures could serve 4 primary goals (provide a description of the magnitude of deficit, evaluate change due to a therapeutic inter- vention, help formulate a prognosis for walking recovery, and evaluate readiness for discharge), and a num- ber of valid and reliable tools that involved an evaluation of walking capacity existed. Clinical practice guidelines32,33 and systematic reviews34 that emerged over the course of this research have rein- forced these goals and provide guid- ance for the selection of stroke- related outcome measures for clinical practice, research, and edu- cation. What remained unknown early in this research program was the extent to which physical thera- pists were using: (1) standardized measures to describe and monitor walking capacity, predict walking recovery, or assess readiness for dis- charge and (2) specific measures of walking with evidence of reliability and validity in people with stroke.
Identify problem. We conducted a cross-sectional survey of 270 phys- ical therapists who were providing services to people with stroke in Ontario.35–38 The percentage of respondents reporting use of a walk- ing measure to evaluate, monitor change, determine prognosis, and assess readiness for discharge in the majority of patients was 45%, 43%, 19%, and 28%, respectively. Given theoretical knowledge outlining best practices for using standardized mea- sures to identify deficits, monitor effects of treatment, formulate a prognosis, and evaluate readiness for
discharge, the low rates of use were interpreted as a knowledge-to- practice gap.
Assess barriers to knowledge use. An additional objective of the survey was to identify barriers to the use of standardized measures of walking. Insufficient knowledge emerged as a primary barrier to respondents’ use of standardized walking measures given that 40% of the physical ther- apists were unsure of the existence of reliable and valid measures.38
Respondents reported a number of negative perceptions of walking measures related to a lack of ability to quantify deficit severity, relate to the home and community environ- ment, and respond to change in capacity. A subsequent qualitative study40,41 of 23 survey respondents revealed that another challenge related to the lack of adequate description in the literature of how to administer standardized assess- ment tools in clinical practice. Because these barriers pointed to an insufficient knowledge of existing lit- erature on the quality, interpretabil- ity, and administration of walking measures, a systematic review that would inform education was proposed.
Knowledge synthesis. A system- atic review of the quality and inter- pretability of measures of walking speed and distance in people with stroke was conducted.42,43 Measures of walking speed and distance were selected because versions of these tests were recommended in emerg- ing clinical practice guidelines for stroke14 and had demonstrated sen- sitivity to change as outcome mea- sures in numerous clinical trials. Using an “integrated KT” approach,1
we included 2 knowledge users who would use the research findings to inform decision making (a physical therapy educator and clinician) on the research team. Their involve- ment, from the development of the
research objectives to reporting of the findings, helped optimize the clinical relevance of the research. Findings described the distances required to walk at 24 community sites, the speeds required to walk across the street in the time of a walk signal,42 and walk test norms.43
These reference values will be useful for interpreting the results of tests of walking distance and speed. Results from this knowledge synthesis will be used to develop a knowledge tool for use by physical therapists in peo- ple with stroke.
Adapt knowledge to local context. Additional findings from the qualitative study showed that physical therapists prefer synthe- sized online resources to facilitate quick access to preappraised and summarized information.41 When practice change is the goal, partici- pants described a preference for learning sessions that are led by an expert, case-based, and provide opportunities to practice new skills.40 This information will inform development of an intervention to facilitate access to review and appli- cation of the knowledge tool to clin- ical practice in ongoing research.
Discussion The cases described in this report outline the process involved in operationalizing the KTA framework into focused research questions in physical therapist practice. Applica- tion of the KTA framework to bal- ance and gait assessment was associ- ated with both direct implications for the research programs under study and broader implications for applying KT theory to best practice research. In general, the guidance of the KTA framework was helpful in presenting the implementation pro- cess in totality and serves as a road- map for potential users. Both research programs began with the problem identification step, and the ensuing results clearly identified
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knowledge-to-practice gaps and fac- tors influencing current practice, all of which were not apparent prior to this research and will be of use in developing interventions. The KTA framework effectively communi- cates the need to create knowledge tools based on research syntheses that are tailored to the end-user to facilitate consideration of research evidence in clinical practice. The goal of basing health care decisions on a consistent demonstration of effi- cacy (for interventions) and of psy- chometric strength (for assessment tools) in the literature, as opposed to individual studies, is a strength of the model. Indeed, a key outcome of the present application of the KTA framework was the need in both cases to move from the early action cycle components back into the knowledge creation phase for addi- tional knowledge synthesis before advancing to the design of a poten- tial intervention. Although such a progression is accounted for in the description of the KTA framework, it is not emphasized. Our cases present the first example we are aware of that demonstrate the practice of such reciprocal movement between knowledge creation and action phases in the literature, highlighting the iterative nature of the KT process.
Variations in Application of the KTA Framework to Balance and Gait Assessment In addition to moving between phases of the KTA framework, there were other notable variations in our application of this theory to balance and gait assessment. First, the bal- ance case represents an example of how to translate an established unit of knowledge even in the absence of a clinical practice guideline. Second, in both cases, we assessed barriers to knowledge use before adapting to the local context. The model advo- cates identifying the problem, adapt- ing to the local context, and assess-
ing the relevant barriers to using the knowledge, with the provision that there may be feedback (and presum- ably modifications) between compo- nents. We modified the recom- mended order of steps in an effort to optimize efficiency by first identify- ing relevant barriers to incorporate them into our adaptation of the knowledge to the local context. By doing so, we identified individual, organizational, and systemic factors that would influence the success of any potential intervention, and we identified knowledge gaps (such as a lack of psychometric data for some standardized balance measures) in need of additional data. Moreover, one challenge encountered in apply- ing the KTA framework was the lim- ited information provided on barrier assessment, when it is a critical com- ponent of translating knowledge for widespread implementation. The lack of explicit description of a con- ceptual framework for understand- ing the types of barriers at the indi- vidual, group, organization, and policy levels is a limitation of the KTA framework, one that required us to consult additional theories for guidance. Other authors also have used the KTA framework in conjunc- tion with other theories,7 emphasiz- ing that no single model may serve all necessary purposes.
Another limitation of the KTA frame- work is that it does not explicitly describe the need for end-users (eg, clinicians) to appraise whether knowledge applies to the local con- text. Physical therapists have described the challenge of applying research evidence derived from a rel- atively homogeneous population to diverse patients seen in everyday practice.40 Physical therapist profes- sional programs should provide edu- cation on the role of and opportuni- ties to practice clinical reasoning in the context of applying clinical prac- tice recommendations. This educa- tion will provide students with a
foundation for exercising clinical judgment when deciding whether a recommended practice will be suit- able to apply.
Future Directions Although this report is limited in that neither case has completed the action cycle, this comprehensive approach has been advocated in the literature44 and emphasizes the importance of not “rushing” to the intervention phase. An advantage of applying the KTA framework to our research program is that we have a clear direction for next steps. With respect to balance assessment, much of the variation in clinical practice reflects the variation in options for standardized measurement and high- lights the need for greater consis- tency in balance assessment across the continuum from research to practice. Accordingly, we are con- ducting an ongoing project to develop recommendations for mini- mum data sets for measuring bal- ance. This activity will serve as pre- cursor to implementing an optimized assessment approach that includes a focus on appropriate assessment of reactive postural con- trol. There is a need for data on how to implement knowledge tools, as there is a dearth of such information in the literature. With respect to gait assessment, findings from the sys- tematic review are being used to develop a knowledge tool that will have application to gait assessment poststroke. Examples of tailoring, evaluating, and sustaining interven- tions in physical therapist practice are scarce, and we refer readers to published examples in osteoporosis management incorporating these steps.7
We noted some limitations in apply- ing the KTA framework. In particu- lar, there is a need for additional work to optimize the ability to apply KT theory to best practice research and implementation science. There
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is little consideration for the role of clinical reasoning in the framework. Our work has attempted to address this gap by incorporating clinical judgment. For example, reactive pos- tural control assessment may not be appropriate for every patient, so the KT intervention would be to ensure that physical therapists actively con- sider assessing reactive balance and document reasons when it is not per- formed. Though emphasizing the importance of knowledge tools, the current KTA framework provides lit- tle direction for their creation and how to tailor them to the end-user, nor does the description of the action cycle refer to theories of behavior change at the individual, group, or organizational level that may optimize intervention effective- ness. One key finding in the balance assessment case was that respon- dents overwhelmingly expressed a desire to improve assessment prac- tices.25 Although the consideration of end-user readiness-for-change is commonly recognized in the litera- ture, it is not addressed in the KTA framework. Moreover, evidence for effective KT interventions in rehabil- itation is scarce,45 and the efficacy of the application of KT frameworks themselves has not been empirically evaluated.46
Conclusions The KTA framework is a broad con- ceptual model for translating research evidence into practice, and we have demonstrated how it can be applied to research focusing on best practice in physical therapy. Although useful for shaping research questions and providing a general direction for moving from research to action, in order to be truly com- prehensive, there may be a need to consult additional models of behav- ior change and barriers to behavior. Continued research is warranted to evaluate the efficacy of specific implementation strategies, and the KT process, more broadly.
Both authors provided concept/idea/project design, writing, and data collection and analysis.
A podium presentation of a portion of the manuscript content was given at the 2014 Canadian Falls Prevention Conference; May 27, 2014; Toronto, Ontario, Canada.
Dr Sibley was supported by fellowships from the Canadian Institutes of Health Research (CIHR) and KT Canada. Dr Salbach holds a New Investigator Award in Knowledge Translation from CIHR.
DOI: 10.2522/ptj.20130486
References 1 Canadian Institutes of Health Research.
About knowledge translation. Available at: http://www.cihr-irsc.gc.ca/e/29418.html. Accessed July 10, 2014.
2 Sackett DL, Rosenberg WM, Gray JA, et al. Evidence based medicine: what it is and what it isn’t. BMJ. 1996;312:71–72.
3 Eccles MP, Grimshaw J, Walker A, et al. Changing the behavior of healthcare pro- fessionals: the use of theory in promoting the uptake of research findings. J Clin Epi- demiol. 2005;58:107–112.
4 Eccles MP, Armstrong D, Baker R, et al. An implementation research agenda. Imple- ment Sci. 2009;4:108.
5 Graham ID, Logan J, Harrison MB, et al. Lost in knowledge translation: time for a map? J Contin Educ Health Prof. 2006;26: 13–24.
6 Straus SE, Tetroe J, Graham ID. Introduc- tion: knowledge translation—what it is and what it isn’t. In: Straus SE, Tetroe J, Graham ID, eds. Knowledge Translation in Health Care: Moving From Evidence to Practice. 2nd ed. Chichester, United King- dom: John Wiley & Sons Ltd; 2013.
7 Kastner M, Straus SE. Application of the Knowledge-to-Action and Medical Research Council frameworks in the development of an osteoporosis clinical decision support tool. J Clin Epidemiol. 2012;65:1163–1170.
8 Tyson SF, Hanley M, Chillala J, et al. Bal- ance disability after stroke. Phys Ther. 2006;86:30 –38.
9 Sturnieks DL, Tiedemann A, Chapman K, et al. Physiological risk factors for falls in older people with lower limb arthritis. J Rheumatol. 2004;31:2272–2279.
10 Dillon CF, Gu Quiping, Hoffman HJ, Ko Chia-Wen. National Center for Health Sta- tistics Data Brief, Number 31, April 2010. Vision, hearing, balance, and sensory impairments in Americans aged 70 years and older: United States, 1999 –2006. Available at: http://www.cdc.gov/nchs/ data/databriefs/db31.htm. Accessed July 10, 2014.
11 Bohannon RW, Andrews AW, Smith MB, Rehabilitation goals of patients with hemi- plegia. Int J Rehabil Res. 1988;11:181– 184.
12 Straus SE, Richardson WS, Gasziou P, Haynes B. Evidence-Based Medicine: How to Practice and Teach EBM. 3rd ed. Lon- don, United Kingdom: Elsevier, Churchill Livingstone; 2005.
13 McGinnis PQ, Hack LM, Nixon-Cave K, Michlovitz SL. Factors that influence the clinical decision making of physical thera- pists in choosing a balance assessment approach. Phys Ther. 2009;89:233–247.
14 Van Peppen RP, Maissan FJ, Van Genderen FR, et al. Outcome measures in physio- therapy management of patients with stroke: a survey into self-reported use, and barriers to and facilitators for use. Phys- iother Res Int. 2008;13:255–270.
15 Grimshaw JM, Thomas RE, MacLennan G, et al. Effectiveness and efficiency of guide- line dissemination and implementation strategies. Health Technol Assess. 2004;8; iii–iv, 1–72.
16 Bernstein N. Co-ordination and Regula- tion of Movements. New York, NY: Per- gamon Press Inc; 1967.
17 Horak FB, Macpherson JM. Postural orien- tation and equilibrium. In: Rowell LB, Shepherd JT, eds. Handbook of Physiol- ogy, Section 12, Exercise: Regulation and Integration of Multiple Systems. New York, NY: American Physiological Society; 1996:255–292.
18 Woollacott MH, Shumway-Cook A. Changes in postural control across the life span: a systems approach. Phys Ther. 1990;70:799 – 807.
19 Horak FB, Wrisley DM, Frank J. The Bal- ance Evaluation Systems Test (BESTest) to differentiate balance deficits. Phys Ther. 2009;89:484 – 498.
20 Horak FB. Postural orientation and equilib- rium: what do we need to know about neural control of balance to prevent falls? Age Ageing. 2006;35(suppl 2):ii, 7–11.
21 Sibley KM, Straus SE, Inness EL, et al. Bal- ance assessment practices and use of stan- dardized balance measures among Ontario physical therapists. Phys Ther. 2011;91: 1583–1591.
22 Sibley KM, Inness EL, Straus SE, et al. Clin- ical assessment of reactive postural con- trol among physiotherapists in Ontario, Canada. Gait Posture. 2013;38:1026 – 1031.
23 Maki BE, McIlroy WE. Postural control in the older adult. Clin Geriatr Med. 1996; 12:637– 658.
24 Gervais T, Burling N, Krull J, et al. Under- standing approaches to balance assess- ment in physical therapy practice for elderly inpatients of a rehabilitation hospi- tal. Physiother Can. 2014;66:6 –14.
25 Sibley KM, Straus SE, Inness EL, et al. Clin- ical balance assessment: perceptions of commonly-used standardized measures and current practices among physiothera- pists in Ontario, Canada. Implement Sci. 2013;8:33.
26 Arksey H, O’Malley K. Scoping studies: towards a methodological framework. Int J Soc Res Methodol. 2005;8:19 –32.
27 Levac D, Colquhoun H, O’Brien K. Scop- ing studies: advancing the methodology. Implement Sci. 2010;5:69.
Research and Practice in Balance and Gait Assessment
586 f Physical Therapy Volume 95 Number 4 April 2015
28 Daudt HM, van Mossel C, Scott SJ. Enhanc- ing the scoping study methodology: a large, inter-professional team’s experience with Arksey and O’Malley’s framework. BMC Med Res Methodol. 2013;13:48.
29 Sibley KM, Beauchamp MK, Van Oote- ghem K, et al. Using the Systems Frame- work for Postural Control to analyze the components of balance evaluated in stan- dardized balance measures: a scoping review. Arch Phys Med Rehabil. 2015;96: 122–132.
30 Latham NK, Jette DU, Slavin M, et al. Phys- ical therapy during stroke rehabilitation for people with different walking abilities. Arch Phys Med Rehabil. 2005;86(12 suppl 2):S41–S50.
31 Kirshner B, Guyatt A. A methodological framework for assessing health indices. J Chronic Dis. 1985;38:27–36.
32 Lindsay MP, Gubitz G, Bayley M, et al. On behalf of the Canadian Stroke Best Prac- tices and Standards Writing Group. Cana- dian Best Practice Recommendations for Stroke Care (Update 2010). Ottawa, Ontario, Canada: Canadian Stroke Net- work; 2010.
33 Van Peppen RP, Hendriks HJ, van Meeteren NK, et al. The development of a clinical practice stroke guideline for phys- iotherapists in The Netherlands: a system- atic review of available evidence. Disabil Rehabil. 2007;29:767–783.
34 Sullivan JE, Crowner BE, Kluding PM, et al. Outcome measures for individuals with stroke: process and recommendations from the American Physical Therapy Asso- ciation Neurology Section Task Force. Phys Ther. 2013;93:1383–1396.
35 Salbach NM, Jaglal SB, Korner-Bitensky N, et al. Practitioner and organizational barri- ers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1284 –1303.
36 Salbach NM, Guilcher SJ, Jaglal SB, Davis DA. Factors influencing information seek- ing by physical therapists providing stroke management. Phys Ther. 2009;89:1039 – 1050.
37 Salbach NM, Guilcher SJ, Jaglal SB, Davis DA. Determinants of research use in clin- ical decision making among physical ther- apists providing services post-stroke: a cross-sectional study. Implement Sci. 2010;5:77.
38 Salbach NM, Guilcher SJ, Jaglal SB. Physi- cal therapists’ perceptions and use of stan- dardized assessments of walking ability post-stroke. J Rehabil Med. 2011;43:543– 549.
39 Finch E, Brooks D, Stratford PW, Mayo NE. Physical Rehabilitation Outcome Mea- sures: A Guide to Enhanced Clinical Deci- sion Making. 2nd ed. Baltimore, MD: Lip- pincott Williams & Wilkins; 2002.
40 Salbach NM, Veinot P, Rappolt S, et al. Physical therapists’ experiences updating the clinical management of walking reha- bilitation after stroke: a qualitative study. Phys Ther. 2009;89:556 –568.
41 Salbach NM, Veinot P, Jaglal SB, et al. From continuing education to personal digital assistants: what do physical thera- pists need to support evidence-based prac- tice in stroke management? J Eval Clin Pract. 2011;17:786 –793.
42 Salbach NM, O’Brien K, Brooks D, et al. Speed and distance requirements for com- munity ambulation: a systematic review. Arch Phys Med Rehabil. 2014;95:117– 128.
43 Salbach NM, O’Brien K, Brooks D, et al. Reference values for standardized tests of walking speed and distance: a systematic review. Gait Posture. 2014 Oct 12 [Epub ahead of print]. doi: 10.1016/j.gaitpost. 2014.10.002.
44 Hardeman W, Sutton S, Griffin S, et al. A causal modelling approach to the develop- ment of theory-based behaviour change programmes for trial evaluation. Health Educ Res. 2005;20:676 – 687.
45 Menon A, Korner-Bitensky N, Kastner M, et al. Strategies for rehabilitation profes- sionals to move evidence-based knowl- edge into practice: a systematic review. J Rehabil Med. 2009;41:1024 –1032.
46 Contandriopoulos D. Some thoughts on the field of KTE. Healthc Policy. 2012;7: 29 –37.
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