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Research Reports: Patricia Q McGinnis, Laurita M Hack, Kim Nixon-Cave, and Susan L Michlovitz Factors That Influence the Clinical Decision Making of Physical Therapists in Choosing a Balance Assessment Approach PHYS THER 2009; 89: 233-247 [Abstract] [Full text] [PDF]

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In Support of Clinicians' Decision Making on Balance

David J Smyntek   (11 March 2009)

In Support of Clinicians' Decision Making on Balance 11 March 2009
David J Smyntek, Physical Therapist Vienna, Ohio Send rapid response to journal: Re: In Support of Clinicians' Decision Making on Balance davesmyntek{at}yahoo.com David J Smyntek	As a clinician, I was considerably reassured by the clinicians' approaches to balance assessment described in the study by McGinnis and colleagues.1 As described in the "themes" reported in the study, it seems that therapists wisely and appropriately used and valued "patient factors" in making decisions about balance assessment. The uniqueness of each patient cannot be overstated--it may be the primary determining factor when choosing how to evaluate balance or what standardized test to use. The theme of "practical knowledge" seems genuinely appropriate as well. I interpret the phrase “practical knowledge” broadly to imply that, to some real extent, a clinician relies on considerations such as safety, feasibility, and simplicity versus complexity in deciding how to assess balance. Additionally, the notion of "reliance" on observation in the assessment of balance seems truly self-evident to me and presumably to this group of clinicians. Finally, the perceived value of the balance test is certainly an appropriate criterion for any clinician to use. It is only logical for a clinician to have "selected assessment approaches deemed useful or meaningful." The paragraph above is my support for the clinicians and their approaches documented in this study. I am truly interested in knowing how else to approach balance assessment. It seems reasonable to be aware of tests and select them based on some legitimate rationale (eg, "useful or meaningful"), which is the clinician's prerogative and responsibility. The available standardized tests have strengths and weaknesses, appeal and lack of appeal. The results are often--too often--very difficult to interpret and apply to a given patient. I now have a patient who is 84 years old and performed the Timed “Up & Go” (TUG) test in 11 seconds. According to the test results, he is at "low risk" for falling; however, does that mean he can safely walk at home on his own? Aren’t there other factors involved? I have another patient who walked 16 meters in 2 minutes and 20 seconds without loss of balance. Is he safe to walk on his own? Should I use the TUG test with him? What would the results tell me? Would I be able to tell him confidently that he cannot be alone or walk alone and that he will in fact lose his independence in walking and must be restricted to a wheelchair? I am simply trying to provide examples to highlight the unavoidable difficulties in balance assessment and in the standardized tests. Finally, by sheer coincidence, this year, the Combined Sections Meeting sent an e-mail indicating topics for discussion. One discussion topic was: “It's a Matter of Balance: In Search of a Consensus Definition.” Does that mean that there is no consensus at present? Another topic was: “The Balance and Falls SIG [Special Interest Group] Roundtable: How Should I Measure Balance Control and Fall Risk?” Does that mean that there is controversy and it is unclear and unresolved? I am intending to emphasize the complexity of balance assessment. Given that complexity and lack of "consensus" (even in the definition of balance), I think that the clinicians included in this study did a reasonable, if not admirable, job of balance assessment. I would be interested to know how it could be improved upon and somehow give evidence of being "evidence-based." I am hoping there will be other responses, as this seems like a topic that should inspire some reaction. Dave Smyntek, PT Reference 1 McGinnis PQ, Hack LM, Nixon-Cave K, Michlovitz SL. Factors that influence the clinical decision making of physical therapists in choosing a balance assessment approach. Phys Ther. 2009;89:233-247.