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Research Reports |
PQ McGinnis, PT, PhD, is Associate Professor of Physical Therapy, Richard Stockton College of New Jersey, PO Box 195, Pomona, NJ 08240 (USA).
LM Hack, PT, DPT, PhD, MBA, FAPTA, is Professor, Department of Physical Therapy, Temple University, Philadelphia, Pennsylvania.
K Nixon-Cave, PT, PhD, PCS, is Associate Professor, University of the Sciences in Philadelphia, and Physical Therapy Manager, Children's Hospital of Philadelphia.
SL Michlovitz, PT, PhD, CHT, is Adjunct Associate Professor, Department of Rehabilitation Medicine, Columbia University, New York, New York.
Address all correspondence to Dr McGinnis at: Patricia.McGinnis{at}stockton.edu
Submitted May 1, 2008;
Accepted December 29, 2008
 | Abstract |
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Objectives: The aims of this study were: (1) to explore decision making during examination of patients with balance deficits, (2) to understand the selection and use of assessment methods from the clinician's perspective, and (3) to explore why specific methods were selected.
Design: A qualitative design using a grounded theory approach permitted exploration of clinical decision making.
Methods: Eleven therapists were purposefully selected (6 from outpatient offices, 5 from inpatient rehabilitation settings) to participate in repeated interviews. Credibility of the findings was established through low-inference data, member check, and triangulation among participants and multiple data sources.
Results: A highly individualized approach to patient examination based on therapists’ practical knowledge emerged from the data, with limited influence of the literature. Movement observation was the primary assessment and diagnostic tool. When selecting assessment approaches for specific patients, the perceived value of information gathered mattered more than testing time. A 3-stage model of assessment decision making portrayed both the process and reasons influencing therapists’ choices.
Conclusions: In the context of the complex and busy nature of clinical practice, therapists gathered data that they considered meaningful during patient examination. The findings provide insight into factors influencing assessment decisions and suggest mechanisms to foster translation of research into clinical practice.
| Introduction |
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 TopAbstract Introduction MethodResultsDiscussionConclusionsAppendix.References |
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Good practice is based on sound decision making incorporating the best available evidence. Evidence-based practice (EBP) has been identified as one of the key components of the Vision 2020 statement put forth by the American Physical Therapy Association (APTA).2 Using reliable and valid tests during examination of patients is one element of EBP.3 Several authors have recommended physical therapists use examination methods supported by research evidence4–6 and based on accepted standards for tests and measurements.7 Assessment is defined as quantifying a variable or placing a value on something.6 The professional literature provides a variety of balance assessment methods that physical therapists could choose to use. Many quantitative tests and measures meet these criteria, with numerous publications addressing the psychometric properties of various tests.5,8–12 Numerous studies have addressed the usefulness of specific balance assessment methods to help clinicians determine patients’ risk for falls11–14 or for particular populations such as patients with Parkinson disease,15,16 patients with multiple sclerosis,17,18 or community-dwelling older adults.12–14 Given this wealth of available literature, the question of interest is: What do therapists do in clinical practice?
Previous survey studies have identified balance tests used most frequently in clinical practice by therapists practicing in a particular state19 or by APTA section members.20,21 However, survey results did not fully explain how or why therapists selected specific balance assessment approaches during patient examination. Survey responses provided limited understanding of various factors influencing therapists’ choices. The primary aims of this study were: (1) to explore clinical decision making within the context of examination of patients with balance deficits, (2) to understand the selection and use of balance assessment methods from the clinician's perspective, and (3) to ascertain what therapists in the study knew about available options and explore why they selected the specific methods they chose.
An initial conceptual framework that served to bound and guide the study was developed from a review of the literature and pilot work (Fig. 1). There were 5 important elements contributing to choice of assessment methods: (1) therapist knowledge,22–25 (2) patient factors,25 (3) potential constraints,5,9,10,23,25–29 (4) therapists’ intended use of data gathered,5,9,10 and (5) available options for assessment of potential balance deficits.5,6,8–21 This framework represented our initial understanding of potential factors related to the research aims and served as the basis for interview questions.
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TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendix.References |
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Participants
A purposeful sample of knowledgeable informants30 whom we believed would have knowledge of the topic of interest was selected. Participants were drawn from a large multisite suburban health system located in the northeastern United States, which included an 80-bed inpatient rehabilitation unit where patients with balance deficits from a variety of disorders were treated. Selection of this health system permitted exploration of factors proposed in the initial conceptual framework. For example, inclusion of therapists working in inpatient rehabilitation or outpatient settings within the system facilitated exploration of differences in clinical practice. Therapists with less than 1 year of clinical experience and former students of the researchers were excluded to reduce potential bias. Ten therapists in inpatient rehabilitation settings and 9 therapists in a hospital-based outpatient department were eligible for inclusion. The director of off-site centers identified 3 therapists from various satellite offices for possible inclusion based on the patient population seen at those sites. One therapist was excluded as a former student of one of the researchers. Participant recruitment continued until data saturation, or redundancy, was achieved. Data saturation is reached when the addition of subsequent participants no longer yields new findings.31,32
Eleven physical therapists who worked either in the inpatient rehabilitation settings (n=5) or in one of the outpatient offices (n=6) throughout the system (drawn from 4 sites) participated in the study. The average age of the participants was 34.2 years (range=27–43), with an average of 9.4 years (SD=4.2) of practice experience. Demographic information of the participants is provided in Table 1. Professional education represented 6 different academic institutions located in 3 northeastern states.
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Two sorting activities were designed to ascertain what the therapists being studied knew about available balance assessment approaches, which approaches they selected, and how they used them during examination. Participants identified all approaches they were aware of for examining patients with potential balance deficits and sorted them according to frequency of use, with a discussion of their choices and rationale. Participants then sorted the assessment approaches according to the following purposes: screening, identify impairments, identify functional limitations, establish diagnosis, establish prognosis, or measure outcomes. These categories were provided by the primary researcher, consistent with the patient management model described in the Guide to Physical Therapist Practice (Guide).6 Prior to the second interview, participants completed a demographic data form that included questions related to education, practice experience, certifications, memberships in professional organizations, continuing education, and identification of any resources used (eg, textbooks, journals) for balance assessment.
The primary investigator's background included courses and a laboratory rotation in qualitative research methods and conducting a pilot study to field test methods and refine necessary interviewing skills. Two of the coauthors (LMH, KNC) have extensive backgrounds in qualitative research methods, including peer-reviewed publications and presentations.
Data Analysis
Constant comparative analysis was used whereby data collection and analysis were ongoing. Data sources included interview transcripts, results of sorting activities, field notes, reflective memos, and comparison with expert opinion. Field notes were written during and immediately after each interview. They included descriptions of clinical sites and participants’ nonverbal expressions during interviews. Reflective memos included impressions and analytical insights written after each interview and throughout data analysis. Use of qualitative data analysis software (QSR NUD*IST 6 [N6]*) facilitated data management and analysis. Generation of code reports and identification of text units for specific codes within the data assisted identification of prominent factors influencing balance assessment decision making.
Data analysis consisted of comprehending, synthesizing, theorizing, and recontextualizing.31 Each transcript was reviewed line by line to gain an understanding of the raw data. This process of comprehensive content analysis is called "open coding." Codes were refined throughout data collection and analysis until mutually exclusive and exhaustive categories were defined. Open codes were grouped into categories of related concepts known as "axial codes." The second step of data analysis, synthesis, moved from concrete description of the data toward identification of common themes within and among interviews, sort results, field notes, and reflective memos.31 Interviewee summaries were developed, describing the factors influencing assessment decision making for each participant. An inductive process was used to derive conceptual elements and to develop a theory of balance assessment decision making that was grounded in the data. The conceptual framework was revised to depict findings. Contrast cases were used to elucidate and confirm emerging theory. Finally, emerging theory was compared with existing literature to recontextualize findings.
Verification Methods
There were several strategies to ensure scientific rigor and trustworthiness of the data.31 Multiple examples of low-inference data were used during analysis to support findings. Use of direct quotes from participants, with limited interpretation by the researcher, was an example of low-inference data. Another strategy, member check, consisted of sending each participant an interviewee summary that included data and the researcher's preliminary interpretations. Each summary identified factors influencing decision making for that participant, including sources of information used and descriptions of the decision-making process and reasons. In addition to direct quotes, sort results, excerpts from reflective memos, and demographic information were incorporated into each summary. After reviewing the interviewee summary, 3 participants requested minor additions to clarify or provide context for their original comments, which were included. The researcher's analysis and preliminary themes were confirmed by the participants, thus ensuring the "truth" of the findings.31,32
The consistency of the data was established by triangulation of the findings from various data sources. For example, answers to questions from the first interview and the second interview and results of the sorting activities were compared. If a participant identified time as an important factor influencing his or her selection of assessment approaches, examples of this were present in the discussion of patients in general and the specific patient case, and approaches listed in the sort as "frequently used" exhibited this characteristic. Similarly, the presence or absence of continuing education related to balance deficits on demographic forms of participants was a source of triangulation for this factor.
Confirmability, or neutrality, was established through identification and reflexive bracketing of biases about the research question during data collection and analysis. The investigator's bias was that evidence from the professional literature should shape clinical practice choices. To avoid the influence of this bias, interview questions were worded neutrally to solicit participants’ views. For example, we used the broad term "balance assessment methods" rather than "balance tests or measures" so that our questions did not limit participant responses to an implied acceptance of only standardized tests. Use of member checks and low-inference data during analysis ensured that findings were grounded in the data. In order to reduce potential researcher bias about how balance assessment approaches should be used, a panel of experts was used to establish content validity of the researcher's summary of the literature through a Delphi process.33
Interrater reliability of the coding scheme was established through use of an outside reader (80% agreement; kappa coefficient=.79 [>80% excellent agreement, 
60% represents substantial agreement]).34 Discussion of discrepancies and establishment of decision rules made the coding process explicit, enhancing trustworthiness. Finally, a record of activities and decisions made throughout data collection and analysis was maintained by the primary investigator. This audit trail was reviewed by the dissertation committee, whose members served as peer reviewers to verify the research findings and emerging themes.
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TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendix.References |
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Sources of Information
The first theme was the limited influence of the literature in guiding participants’ selection of a balance assessment method, with only 2 participants noting this as a consideration. Practical knowledge as the primary source of information guiding balance assessment decisions emerged as the second theme. Although participants identified a combination of factors contributing to their practical knowledge, all acknowledged the primary role of experience in influencing their decisions. Chris described how he relied on prior experience during assessment:
Your clinical experience, enough patients, if you put them in certain situations, this is generally what happens. Usually when I have people walk on their heels, actually their trunk will go. I've seen it so many times... . My walking-backward technique has told me everything I need to know.
Nine participants also noted that interactions with colleagues contributed to their practical knowledge.
Three participants stated that academic education contributed significantly to their balance assessment decisions. Nicky described how the following helped shape her assessment decisions:
From school you get the foundation, these are the things to look at when you're in an assessment. Then, after being in the clinic, you put it to use and get your own little system.
Two participants acknowledged that their academic education provided a foundation, but emphasized how clinical experience built on that. Andy, for instance, stated, "I was just trying to think, it's hard to pinpoint stuff that I do now, say there are 5 things that I do in a day. What did I learn in school, and what did I gather from here?" The remaining participants did not identify academic education as a primary influence when examining patients with balance deficits. All of the participants had attended continuing education on a variety of topics, but this did not emerge as a significant factor in thematic analysis.
Decision-Making Process
The most pronounced themes that emerged from the data were related to the decision-making process, or descriptions of how therapists made assessment decisions. Examples of both of these themes were found in all 22 interview transcripts.
The third theme that emerged was that therapists use patient factors to initiate decision making and to contribute to expected patient presentation based on their experience, as seen in the following: "His diagnosis was CVA [cerebrovascular accident] and ataxia, so we had a pretty good idea what was going on before he came in." (Jordi) Patient factors contributing to examination decisions most commonly identified by participants were medical diagnosis (n=11), age (n=9), and history (n=8).
The fourth theme was that physical therapists rely on movement observation to guide assessment decisions. Lee stated, "As I start walking with them, generally, I'll just make an overall observation and decide where to start, if they need balance (assessment), and where to start with that." Jackie described using movement observation to select specific tests: "I chose that one (the Berg Balance Scale) because, by watching her walk I knew she was going to get 4's on some and zeros on the others." Jordi described how the patient's initial presentation and early movements influenced his decisions about what to include in his examination:
I guess as soon as they walk in, you notice. You tell them to come back to the table, and you see them struggling to get out of the chair. You see them struggling with their walker, and they're not transferring well. Then you're like "Wait a minute, we need to look at his balance or gait." As soon as they get up you pretty much know exactly what kind of things you should be honing into.
Movement observation was used by participants for many purposes: preliminary observation, screening, determining areas to include in the examination, as a diagnostic tool, and as an outcome measure.
Decision-Making Reasons
The fifth theme that emerged from the data was therapists’ perspective that the primary advantage of using standardized balance tests was to have quantitative data for documentation purposes. Participants noted the usefulness of balance assessment approaches with numeric scoring to assist with specific purposes such as goal setting or demonstrating patient progress in response to therapy:
But honestly, a lot of this stuff is necessary for paperwork purposes and not so much for my treatment. I could treat this guy perfectly fine without doing any Berg balance assessment, but then later on I have nothing objectively to compare it back to. (Jordi)
Only 2 participants (Randy and Casey) indicated that the psychometric properties of reliability or validity were a primary consideration in their selection of balance assessment approaches.
The sixth theme that emerged was that the therapists’ views of the perceived value of information gathered from a particular balance assessment approach mattered more than the testing time when selecting methods during examination of patients. They considered both aspects and selected an approach that they valued or considered relevant. Participants who considered information gained from the Berg Balance Scale as useful, described it as a quick and easy-to-administer test. Jackie described her reasons for using the Berg Balance Scale to assess a specific patient: "I chose that one for ease. It's very specific, there's 1, 2, 3, 4, and you can grade them, and you can get a real quick general assessment." Jackie preferred the Berg Balance Scale over the Timed "Up & Go" Test (TUG), which was shorter but, in her view, did not provide useful information: "I can show improvement with the TUG, but it doesn't necessarily, for me as a clinician, show me what I need to work on." Chris had a different point of view regarding the Berg Balance Scale:
So if that takes me a long time to do, to get the tape measure to do the measurements and those steps to it, and I don't believe it, in that sense I'll go with my clinical judgment, which doesn't make it right or better, but that's the decision I make.
Chris mentioned time, but the underlying reason for his choice was that he valued information gained from his observations more than the Berg Balance Scale scores.
Perceived relevance of information also depended on the circumstances. All therapists working in the inpatient rehabilitation setting described examples of using the Berg Balance Scale score to assist with discharge planning in situations of uncertainty, even though 4 of the 5 therapists did not use it frequently. All participants selected methods that provided information that they considered meaningful.
Professional Role
The final theme was difficulty with the concept of physical therapists as diagnosticians, which emerged during the second sorting activity. Nicky noted that the medical diagnosis was provided in the patient's chart: "Usually here, I have my diagnosis already, so I don't really have to diagnose anything." The concept of physical therapists as diagnosticians was discussed by only 3 of the participants (Randy, Jamie, and Terry). Based on examination data, Randy established a diagnosis that was consistent with the Guide. "It's going to help me put them in one practice pattern versus another. And that's what I consider diagnosis." Jamie made the distinction between a patient's medical diagnosis and the diagnosis made by the physical therapist in the following example:
I have a patient who has a brain tumor, absent proprioception, kinesthesia, poor coordination, poor endurance, good strength, some range-of-motion limitations, decreased ankle strategies. He had his medical diagnosis, but his physical therapy diagnosis was the deconditioned component for balance, decreased coordination. I use all of these as my diagnosis.
Most participants focused on the "medical diagnosis" or the pathology-based diagnosis and did not view establishing a diagnosis as part of their role as physical therapists. Further analysis revealed that therapists being studied clearly used balance assessment approaches to identify patient problems and to develop a plan of care. Chris described using observations to identify patient problems to address: "So there comes a decision, is this a weakness issue? Is it a vision issue? You have to, the main thing is pinpointing the real problem." Thus, participants engaged in a diagnostic process even though they did not view it as such.
Balance Assessment Approaches Used by Participants
A highly individualized approach to examining patients with balance deficits emerged from the data collected with open-ended interview questions (Tab. 2). Participants identified components of a neuromuscular examination, such as strength (force-generating capacity) or range-of-motion tests, that are consistent with the Guide. Many participants used standardized balance tests consistent with recommendations from literature. In addition, they used these approaches for other purposes, including using numeric scores as outcome measures (regardless of the psychometric properties). Participants also used a wide range of approaches based on movement observation and description.
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| Discussion |
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TopAbstractIntroductionMethodResultsDiscussionConclusionsAppendix.References |
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I guess the script, before they come in, I have an idea. OK, I have a patient with total knee replacement. I can tell he's 3 weeks out. I have a picture of the person. And he comes in, and he's either that or he's not, or I notice something that I didn't expect. So in that little walk back in to the office, my picture starts changing. (Jordi)
Preliminary decisions about which assessment tools to include in patient examination were made at this point.
Stage 2: Data Gathering
Items in Figure 4 are listed in descending order based on the prominence of the findings in the data. During the data-gathering stage, therapists engaged in back and forth consideration of how and why choices when selecting assessment approaches, as depicted by back and forth arrows between the decision-making process and reasons. Therapists combined procedural knowledge of how to conduct a neuromuscular examination with their observations of a patient's movements and engaged in a matching process for selection of assessment approaches for a specific patient. The patient's level of function also contributed to therapists’ choices as they matched assessment approaches to the patient.
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I probably have a repertoire of things, but depending on what's appropriate for this person's cognition and their physical ability. Someone who is 20 and someone who is 80, you look at a little bit differently. (Casey)
If they're higher-level patients, I have them walk on unlevel surfaces. I might even put them on, not just the foam but have them walk on the grass, have them walk on the rocks outside. I use that a lot for some of the higher-level brain injury patients that I see. (Dana)
Dana's comments also provide an example of the overlap between assessment and treatment whereby participants used intervention activities as part of their examination.
Participants described why they chose assessment approaches for specific patients. At times, assessment tools were selected to address documentation concerns. Tools with numeric scores were used by therapists to describe balance ability, identify expected outcomes, and report patient progress. At other times, standardized balance assessment tools such as the Berg Balance Scale were selected to assist with discharge planning. Rehabilitation therapists who did not use this method frequently noted that the numeric score was useful in situations where decisions about patient safety were less clear-cut. Finally, 9 of the participants described the influence of practice setting on their selection of assessment approaches. Jackie, an outpatient therapist, noted, "I find that you're not putting inpatients on the Balance Master
because they have so many other things that are more important. Let's get them standing."
Stage 3: Diagnosis and Treatment Planning
Although the focus of this study was clinical reasoning during examination, therapists described how they began treatment planning during the initial encounter with patients. Data gathering (stage 2) and diagnosis and treatment planning (stage 3) were overlapping, iterative processes. The final component of the model was implementing the plan of care and reassessment (Fig. 2). Although this was not specifically explored in this study, analysis of interview transcripts revealed the link between these aspects of clinical reasoning. When participants described specific patient cases, they easily moved from their thought process at initial examination to subsequent interventions and reexamination.
Conceptual Framework Revisions
Although the initial conceptional framework depicted a linear process with a specific endpoint, findings revealed that therapists engaged in a series of assessment decisions during examination of patients with potential balance deficits. Initial impressions and findings from data gathering, in turn, triggered additional choices of assessment activities. Clinical reasoning was a complex, ongoing process influenced by many factors that therapists considered as they conducted their initial examination. The iterative or cyclical nature of clinical reasoning during examination of patients with balance deficits was similar to models proposed by Jones22 and Edwards et al.35 Likewise, the clinical reasoning process described by the participants was similar to that described by previous authors.24,36
Movement observation was a central focus of the initial examination among the participants interviewed. This feature was found in all 22 interview transcripts, and it also accounted for the greatest percentage of data coded. The central role of movement evaluation is consistent with previous reports.24,37,38 Embrey et al38 proposed that movement scripts were used by pediatric physical therapists in clinical decision making. The prevalence of movement observation and description during examination may be due, in part, to participants’ organization of practical knowledge. Patients’ movements were an important source of knowledge for participants, as they compared their observations with their knowledge of normal and atypical movement. If tacit or practical knowledge gained through experience is stored in the form of movement scripts, this explains the inherent relevance of movement observation and description as an assessment approach. The primary importance placed by therapists being studied on movement observation during examination of patients was articulated by Casey: "I think what really separates a good clinician from the average clinician is their observation skills." Six of the participants described using pattern recognition, or the ability to quickly recognize common patterns of movement problems, during examination of patients.
Limited Influence of Constraints
An unexpected finding was the limited influence of various constraints, such as time or resources, on assessment decisions among participants. Time often is presented as a barrier to implementing research evidence into clinical practice.26,27,39–44 In the current study, item analysis revealed that testing time was mentioned as a consideration in choosing balance assessment approaches in only 8 of the 22 interviews. Two of the participants did not identify time as a consideration in assessment decisions in either interview, and issues of time did not figure prominently for 5 of the participants. When time was mentioned by participants, it was a secondary issue to the perceived value of information resulting from various balance assessment approaches. Therapists who valued the information took the time to gather it. This is an important consideration influencing translation of knowledge into clinical practice.
Limited access to resources also has been identified as a barrier to incorporating evidence into practice.27,40–43 Participants in the current study had access to specialized equipment, various standardized tests, and a knowledgeable colleague to answer clinical questions. It became clear that participants did not view their choices as limited by constraints; rather, they selected approaches that they considered best suited for specific patients, as noted in the following:
I don't feel like I'm limited at all. I feel like there's so much I could choose from and evaluate the patient and get a good picture of what the patient looks like. And then get a good picture of where I would like to take the patient. (Lee)
Canadian studies examining utilization of outcome measures in clinical practice27–29 cited time and lack of knowledge as primary barriers to their widespread implementation. However, study participants’ choices of balance assessment tools cannot be ascribed to a knowledge gap. A regional continuing education program by a nationally known speaker on examination and treatment of balance disorders had been offered by the health system. Participants in this study were aware of a variety of balance assessment approaches and were clearly choosing some options over others.
The critical component to translating research information into clinical use was individual therapists’ perceptions of the value of the information provided by different assessment approaches. The final participant interviewed at the hospital-based outpatient site indicated that the health system had identified preferred balance tests: "It was sort of a global health system thing. They wanted us to stick with certain standard tests, the Berg Balance Scale preferably, then the Tinetti." (Terry) The health system recommendation may have been based on the literature supporting these standardized tests. As such, research evidence may have indirectly influenced clinical practice. Specifically, this organizational guideline may have had some impact on therapist behavior because the Berg Balance Scale was the most frequently used standardized balance test among participants. However, there still was considerable variability among staff in the selection of balance assessment approaches, and none of the other participants mentioned this guideline as a factor influencing their choices.
All of the participants selected assessment approaches that they deemed useful or meaningful. They did not use assessment approaches that they considered to be of little value. As one example, Dana did not consider information from standardized balance tests relevant to the inpatient rehabilitation initial examination, based on her perspective of reimbursement issues: "I generally don't use the Berg or Tinetti (Mobility Assessment) scales, just because I find when you do the evaluation, all the insurance company seems to care about is function, function, function." Higgs and Titchen noted the importance of personal knowledge in clinical reasoning:
The individual's behavior is highly influenced by his/her frame of reference. Within this frame of reference, scientific knowledge and professional knowledge are translated into decisions for practice, which are influenced by the individual's convictions and judgments about the worth of this knowledge and its relevance to the current situation.45(p528)
A person's values influence his or her development of practical knowledge. This perspective helps explain why therapists working in identical settings had opposing points of view about a particular balance assessment approach. Each therapist made judgments about his or her arsenal of balance assessment approaches and deemed some approaches more useful than others. This was part of developing tacit knowledge of how to examine patients and using experience to determine what worked. "Learning what works best for me" is one component of tacit knowledge.46 In essence, each participant had determined his or her own view of what constitutes "best practice."
Greenhalgh et al47 explored the role of tacit knowledge and standardized outcome measures in decision making by multidisciplinary teams. In situations of agreement between outcome measure scores and tacit knowledge, scores were used to reinforce, rather than determine, clinical opinions. When scores and tacit knowledge differed, clinicians relied on their clinical experience and intuition. Greenhalgh et al concluded that standardized outcome measures supported, rather than determined, clinical judgments. Likewise, participants in the current study noted that the primary advantage of standardized balance tests was for documenting what they already knew about patients.
Implications for Clinical Practice
Evidence-based practice integrates clinical experience, patient values, and the best available evidence from systematic research.3 It also has been described as a philosophy whereby clinicians consistently consider evidence in every aspect of practice.48 Participants in the current study relied on clinical experience as their primary source of information during patient examination. It is possible that research evidence supporting various balance tests indirectly influenced clinical practice choices. For example, participants may have learned about specific tests through educational experiences that were based on the presenter's knowledge of the literature. However, the limited influence of research evidence in clinical practice described by the participants is consistent with the literature in physical therapy, nursing, and medicine. In a survey of APTA members, physical therapists reported positive attitudes toward EBP, but infrequent use of the literature to guide clinical decisions.26 Salbach et al44 found similar disparities between attitudes and actual use of research findings in clinical decision making when they surveyed Canadian physical therapists about the use of research findings in stroke rehabilitation. High self-efficacy and positive attitudes regarding usefulness of research findings promoted the physical therapists’ use of research findings in making clinical decisions for patients with stroke. Salbach et al44 suggested enhancing therapists’ self-efficacy through continuing education to develop skills needed to search and evaluate research literature. These strategies, although important, do not fully address the complex factors influencing clinician choices of examination tools or interventions.
In her invited commentary on the article by Salbach et al,44 Duncan49 called upon researchers to evaluate the feasibility of research-based interventions for clinical practice and select clinically relevant outcomes. Current findings offer insights into clinicians’ views of relevance. We agree that both researchers and clinicians have responsibilities to consider and address to foster translation of research evidence into practice. The open-ended nature of questions used in this study elicited perspectives of clinicians not captured by surveys. We expected participants to identify many of the barriers previously presented in the literature related to EBP. Although issues of time or access to resources were mentioned by some of the participants, these issues were secondary to the importance of therapists’ perspectives on the relevance or value of information gained from various tools when selecting balance assessment approaches during examination.
Two of the participants studied (Casey and Randy) were contrast cases. Although movement observation helped guide their assessment decisions, they also made a point of selecting tests and measures supported by research evidence, as seen in the following:
Tinetti, I never use. I think more of the research supports the Berg Balance Scale. And it's more functional, so that to me makes more sense. And for observation skills, there are many more components you can look at. It's quick and easy, and the reliability piece is greater, at least from what I've read. (Casey)
Casey and Randy differed from other participants in their espoused commitment to using research evidence to support their clinical practice. These values were formed early in their careers, and their practice choices were based, in part, on their personal convictions. They also differed from other participants as APTA members. Although this factor was noted on the demographic forms, neither mentioned it in either interview. Unlike previous studies26,44 where the most recent graduates were more likely to use the literature to guide clinical decisions, Casey and Randy were among the study participants with the greatest number of years of practice experience.
Recommendations
The participants primarily made decisions based on their clinical judgment drawn from practical experience. They used observations of gait, posture, and functional activities to identify balance problems. They selected standardized balance tests for specific reasons such as documentation purposes or to assist with decision making in situations where clinical judgment alone was insufficient. In most cases, participants based examination and diagnostic decisions on their observations and then selected additional assessment approaches to meet their needs.
Given these clinical realities, efforts to foster increased utilization of research evidence into clinical practice must move beyond dissemination of the psychometric properties of various tests and measures. Insights gained from this study demonstrate that aspects of clinical relevance or utility also must be addressed. Several authors26,39,41,44 have noted clinicians’ views that research findings have limited application to specific patients seen in their practice, which poses a significant barrier to translating research evidence into practice. Among the participants in our study, perceived clinical usefulness was the determining factor in selection of balance assessment approaches for specific patient cases. Researchers should consider the practical knowledge of clinicians and address their concerns of perceived value when recommending various tests and measures for use during examination of patients. Ideally, EBP is a blending of clinical experience and the best available evidence.
Finally, current emphasis in physical therapist education to integrate concepts of EBP into clinical decision making may help influence development of this core value in students. Opportunities for explicit discussion of how personal and professional values influence clinical reasoning in specific patient cases would be a useful component of the curriculum. We believe that educators who provide context, as well as content knowledge, may better prepare students for the realities of clinical practice and foster development of high-quality decision making.
Limitations
With qualitative research small numbers of participants are studied in greater depth. Reader generalizability is the important construct, meaning that sufficient description is provided to permit readers to determine whether the findings apply to their situation. In the present study, certain groups were not represented (ie, therapists with less than 4 years of clinical experience, therapists with Doctor of Physical Therapy-level professional education). Each of these areas would be recommended for future study.
Participants were recruited from multiple sites within a large health system to explore a variety of clinical experiences. Low staff turnover and the culture of the environment may have been factors influencing assessment decisions. Organizational expectations may influence patterns of practice27,44 as well as the development of tacit knowledge.46 Thus, future studies should include specific questions to explore organizational influences on clinical reasoning.
Suggestions for Future Study
The intent of this study was to describe balance assessment decisions made by generalist clinicians. A follow-up study exploring the factors influencing assessment decisions of clinical specialists is strongly recommended.
Finally, the 3-stage model of assessment decision making should be tested in other areas of practice in order to confirm or further refine theory elements. Although we focused on examination of patients with balance deficits, the themes that emerged likely have more universal application. In particular, exploration of factors influencing assessment decisions in patients with other multidimensional problems such as low back disorders or complex cardiopulmonary disorders is recommended. Previous authors26–29,39–44 have described the challenges of implementing evidence into clinical practice. Our model is useful in thinking about how to address challenges and implement known evidence into practice.
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The authors express their sincere appreciation to the 11 physical therapists who generously offered their time and clinical wisdom. Graduate assistants supported by Richard Stockton College of New Jersey's School of Graduate and Continuing Studies provided assistance with data transcription. The Richard Stockton College of New Jersey Physical Therapy Foundation provided support to offer small tokens of appreciation to participants in the study.
This research was completed by Dr McGinnis in partial fulfillment of the requirements for the Doctor of Philosophy in Physical Therapy degree at Temple University. Dr Hack served as Chair and Dr Nixon-Cave and Dr Michlovitz served as members of the Dissertation Advisory Committee.
This project was approved by the Office for Human Subjects Protections Institutional Review Board of Temple University.
An abstract of this work was presented at the 15th International Congress of the World Confederation for Physical Therapy; June 2–6, 2007; Vancouver, British Columbia, Canada, and at the Combined Sections Meeting of the American Physical Therapy Association; February 14–18, 2007; Boston, Massachusetts.
* QSR International (Americas) Inc, 90 Sherman St, Cambridge, MA 02140. 
NeuroCom International Inc, 9570 SE Lawnfield Rd, Clackamas, OR 97015.
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