Secondary Logo

Share this article on:

The Instruction of Balance and Its Measurement in Professional Physical Therapy Education Programs

Oates, Alison R., PhD; Santoro, Regan, BSc; Arnold, Catherine, PT, PhD; Sibley, Kathryn M., PhD

Journal of Physical Therapy Education: December 2018 - Volume 32 - Issue 4 - p 360–367
doi: 10.1097/JTE.0000000000000061
Research Report

Introduction. Physical therapists (PTs) have an important role in identifying and treating individuals with balance impairments to help modify fall risk; however, gaps in comprehensive assessment of balance among practicing PTs have been consistently identified. As academic preparation influences clinical practice, identifying the balance measurement tools included in entry-level training for PTs is important. In particular, exploring their underlying content in relationship to recognized components of balance described in the Systems Framework for Postural Control can highlight strengths and may identify opportunities to advance training and future practice. The objective of this study was to examine how balance and its measurement are included in entry-level physical therapy education programs.

Methods. Faculty from 110 physical therapy programs in Canada and the United States were surveyed on the inclusion of balance components and validated balance measures using an online survey.

Results. Descriptive analysis of 95 completed responses illustrated that instructors reported including detailed instruction and practical experience for most balance components. Almost all (26/27) measures included in the survey were included in course content with practical experience by at least one participant. Years of instructing had minimal effect on how the components and/or measures were included in course content. The measures reported to be included with practical experience most often do not assess all components of balance.

Discussion and Conclusions. Overall, instructors in participating physical therapy education programs reported providing detailed and practical instruction of commonly used balance measures and multiple components of balance. There is opportunity to enhance instruction by incorporating currently available measures that assess most and/or all balance components to ensure newly educated PTs are equipped to comprehensively assess and treat balance to improve fall prevention efforts.

Alison R. Oates, College of Kinesiology, University of Saskatchewan, Saskatoon, SK, S7N 5B2, Canada (alison.oates@usask.ca). Please address all correspondence to Alison R. Oates.

Santoro Regan, College of Kinesiology, University of Saskatchewan, Saskatoon, SK, Canada.

Arnold Catherine, School of Rehabilitation Science, College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada.

Kathryn M. Sibley, Centre for Healthcare Innovation and Department of Community Health Sciences, University of Manitoba, Winnipeg, MB, Canada.

The authors declare no conflicts of interest.

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.aptaeducation.org).

Received December 18, 2017

Accepted April 23, 2018

Back to Top | Article Outline

INTRODUCTION

Educators in physical therapy education programs aim to prepare their students for entry into practice. Future clinicians want training to apply theory in clinical practice to provide effective care.1 One major component of physical therapy practice is the assessment and treatment of balance impairments. Identifying balance impairment is a critical and essential role in light of the well-recognized burden of falls around the world and potential for balance exercise as an effective fall prevention intervention.2 The evaluation of balance is included as one of the minimum skills outlined by the American Physical Therapy Association for entry-level physical therapists (PTs). In the description of physical therapy in Canada, balance is identified as a core assessment skill.3 In addition, balance assessment and standardized measurement is a key component of clinical practice guidelines to screen for fall risk, as assessment is important for detecting impairments, identifying fall risk, planning treatment, and evaluating change over time.4

Recent investigations of clinical practice have determined that PTs do not regularly comprehensively assess balance and often omit important components related to fall avoidance.5,6 For example, reactive balance (the ability to recover balance after an external perturbation7) is one of the least-assessed components of balance but is independently related to falls and is well recognized as the most critical component of balance for fall avoidance.6 There is also evidence that PTs recognize these gaps: One study that assessed clinical perceptions of balance assessment found that 79% of participants wanted to improve their practice as it relates to assessment with lack of knowledge presented as one of the main barriers to improving assessment.8

One opportunity to improve balance assessment practice may lie in the entry-to-practice training; however, balance assessment instruction and practice are complicated by several issues. Balance is multifactorial9 and involves a complex interaction between several biological systems and their responses to varying task and environmental demands. While no universally recognized theory or model exists, the different elements important for balance control (hereafter referred to as “components”) are often explained using the Systems Framework for Postural Control9 and subsequent adaptations.7 The Systems Framework for Postural Control was used as the guiding framework for this study. It considers balance control as the result of the body mechanics and sensory inputs, their integration within the central nervous system, and interaction with a changing environment.7,9 (Refer to Table 1 for the description of balance components of this framework used in this study). An additional challenge is the substantial quantity of balance measures that are available.5,7,10,11 Despite an abundance of measures, the most commonly used tools used are not comprehensive and do not assess all components of balance.5,12 Indeed, a recent review found that, of 66 measures examined, only one evaluated all balance components, and only 15% of the measures included reactive balance.7

Table 1

Table 1

Practical knowledge and academic preparation influence clinical practice.13-15 Understanding which components and measures of balance are instructed can offer critical insights into factors influencing practice. Practical knowledge may come from experience while academic preparation may come from entry-level training like the Masters in Physical Therapy and Doctorate in Physical Therapy programs offered in Canada and the United States, respectively. Academic preparation designed to teach theory and provide experience with the breadth and complexity of balance and its measurement can develop clinical foundations16 and increase self-efficacy (confidence in one's ability to perform a skill) in future skill application. With improved self-efficacy comes a greater likelihood for the use of evidence-based approaches,17-19 which may then lead to more comprehensive balance assessment, a more focused treatment plan, and, in turn, a reduction in falls. Self-efficacy may also impact how different components and measures of balance are instructed and has shown to change with years of experience teaching.20,21 It is important to examine entry-level education programs to understand clinical practice and support efforts designed to improve patient care through evidence-based approaches.22,23 The purposes of this study were to examine 1) how balance and its measurement are being included in physical therapy education programs in the United States and Canada; 2) the relationship between years of experience of the instructor and the extent of inclusion of balance-related content in the course curriculum; and 3) the similarities and differences of balance-related course content in relationship to recognized components of balance described in the Systems Framework for Postural Control.9

Back to Top | Article Outline

METHODS

This cross-sectional study used an online survey (Fluid Surveys, Ottawa, ON) asking instructors in physical therapy education programs about the inclusion of balance and its measurement in their courses. Participants were eligible if they were instructors teaching in a Canadian or American physical therapy education program at the time of the study and if they included balance-related content in their course(s). This study was approved by the University of Saskatchewan, College of Kinesiology Research Ethics Committee (Kin-REC # 2015_16_05). Informed consent was described in the introduction of the survey and implied through survey completion (Appendix, Supplemental Digital Content 1, http://links.lww.com/JOPTE/A30).

To ensure the survey questions were appropriate for different types of institutions (e.g., traditional vs problem-based learning formats) and the different countries, the survey was piloted with 10 current instructors in a physical therapy education program (7 from Canada and 3 from the United States) who provided feedback only on survey content and structure and did not answer the questions directly. Piloting of the survey led to an additional component of balance (underlying sensory systems) being added to the survey to represent a modified Systems Framework for Postural Control (Table 1).7,9 The final version of the survey (relevant content appended) included questions about the instruction of balance components and balance measures using ordinal scales that measured characteristics of comprehensiveness and frequency of inclusion, general questions about the participant and their program, and questions about the participant's geographical location (Canada/United States [required] and province/state [optional]).

This survey was distributed using a chain-referral method of sampling outlined in Figure 1. A brief introduction and link to the survey was first sent to the program/curricular directors of 15 Canadian and 195 American nationwide physical therapy education programs identified from a web search. These individuals were asked to forward the invitation to instructors who met inclusion criteria. This initial round of recruitment occurred over 2 weeks (emails sent once per week). To increase response rate, a second round of recruitment targeted instructors from all 15 Canadian and 75 randomly selected American institutions, with 319 email invitations sent over 2 weeks (one email per week) directly to instructors listed on program Web sites.

The balance component question included operational definitions of 10 components of balance. Comprehensive instruction of a balance component was defined for analyses as having that component included in course content with detailed explanation and practical experience evaluating that balance component. This question asked if and how participants included each component in their course content through 4 options that increased in comprehensiveness: “No, never included,” “Yes, included but mentioned only briefly,” “Yes, included and explained in detail,” and “Yes, included and explained in detail and practical experience involving component is provided.” There was also an “other” option available included on the survey.

The balance measures question included measures identified from a published scoping review7 and surveys of practicing clinicians,5,6 with the final 24 measures decided on through discussion and consensus within the research team. Comprehensive instruction of a balance measure was defined for analyses as having that measure included in the course with detailed explanation including the psychometric properties of the measure and how to interpret the scores and practical experience using that measure to evaluate balance. This question asked how instructors included different balance measures in their course content based on five categories that increased in comprehensiveness: “No, never included,” “Yes, mentioned but not explained (e.g., list of options given),” “Yes, explained briefly (e.g., general description provided),” “Yes, explained in detail including psychometric properties and interpretation of scores,” and “Yes, explained in detail including psychometric properties and interpretation of scores, and practical experience administering the test is provided.” Measures entered into the “other” option were included in the subsequent analyses.

Back to Top | Article Outline

Data Analysis

Analysis was composed of descriptive statistics, including count and percentages of responses. To examine how balance components were included in the respondent's instruction, preliminary analyses determined that, for 9 of 10 balance components, most (>60%) of the participants selected the most comprehensive option; therefore, responses were collapsed into three categories including “No, never included,” “Included,” or “Included with practical experience provided.” Similarly for the 10 most frequently included balance measures, the majority (>50%) of participants selected the most comprehensive level of instruction; therefore, responses were collapsed into three categories, including “No, never included,” “Included,” “Included with practical experience provided.” Note that the “Included” category for the balance measures included responses to both “Yes, explained briefly (e.g., general description provided)” and “Yes, explained in detail including psychometric properties and interpretation of scores.” Participant demographics, years of experience instructing, and detail about the instructor's program were grouped by country. Just over 50% of participants indicated they had more than 10 years of experience instructing in any physical therapy program; therefore, responses were collapsed into two categories: 0–10 and >10 years. To examine if the experience of the instructor had any influence on the level of instruction for the components of balance and balance measures, χ2 analyses compared the level of instruction (i.e., not included, included, included with practical experience) with the years of experience. Odds ratios were calculated for any significant results (α ≥ 0.05) with “included with practical experience” as the reference category.

Further analyses focused on the balance measures and components that were instructed in detail and with practical experience. First, researchers determined which components of balance were included in the most frequently reported balance measures, with the exception of movement observation. Data from a published scoping review that mapped the content of standardized balance measures using the Systems Framework for Postural Control9 were used to derive the components of balance addressed in each measure. The components included in the most frequently reported measures were compared, using descriptive analysis, to the reporting of the components included in instruction with practical experience provided.

Back to Top | Article Outline

RESULTS

A total of 111 responses were received, with 95 completed surveys (17 from Canada and 78 from the United States). The responses of incomplete surveys (surveys where some but not all questions were completed, n = 16) were included in the analysis when possible. Almost all participants (99%) identified as a PT and just over half (55%) reported having more than 10 years of experience instructing in any physical therapy program. Program lengths differed according to country: In Canada, most programs were 2 years in length (88%) and were at the Masters level (94%). In the United States, most programs were 3 years in length (99%) and were at the professional doctorate level (99%).

Back to Top | Article Outline

Balance Components

There were no “other” responses provided for the inclusion of balance components. More than 60% of participants reported providing detailed instruction with practical experience for all components of balance with the exception of verticality, which was instructed in detail with practical experience by 35% of participants (Table 2). Dynamic stability was the only balance component instructed at some level by all participants. Some participants reported never including verticality (10%), cognitive influences (4%), sensory integration (4%), stability limits (2%), anticipatory balance (1%), reactive balance (1%), static stability (1%), underlying motor systems (1%), and underlying sensory systems (1%) in balance-related course content.

Table 2

Table 2

Years of experience of the instructor did not affect the level of instruction for any balance components, except for sensory integration (P = .042). Participants were more likely to include this component of balance with practical experience compared to without practical experience if they had more than 10 years of teaching experience (OR: 1.61; 95% confidence interval [CI], 0.52–4.98). For participants who had been teaching for more than 10 years, sensory integration was always included at some level (i.e., 0 “Not included” responses); therefore, the odds ratio comparing “Included with practical experience” to “Not included” was not valid.

Back to Top | Article Outline

Balance Measures

Five additional measures were included under the “other” option, including the Functional Gait Assessment, Balance Error Scoring System, High-Level Mobility Assessment Tool, 6-minute walk test (6MWT), and the Activity-Specific Balance Confidence (ABC) Scale. As the 6MWT measures physical capacity and cardiovascular endurance24,25 and the ABC Scale measures balance self-efficacy,26 neither measures balance directly in accordance with the Systems Framework for Postural Control and were not included in the analysis. The remaining analysis included the 27 measures from survey responses. Most measures (26/27) were instructed in detail with practical experience by at least one participant. The top three balance measures instructed with practical experience were the Timed “Up and Go”27 (TUG) alone test (78%), Berg Balance Scale28 (76%), and the sit-to-stand test29 (76%). Table 3 highlights all the measures included in the analyses.

Table 3

Table 3

Tandem standing/walking (P = .048) and the TUG (dual task) (P = .038) were the only measures where type of instruction was affected by years of experience. For tandem standing/walking, participants were more likely to include tandem standing/walking with practical experience compared to including it without practical experience if they had more than 10 years of teaching experience (OR: 1.28; 95% CI, [0.42–3.96]). Participants were also more likely to include tandem standing/walking with practical experience compared to not including it at all if they had more than 10 years of experience (OR: 5.45; 95% CI, [1.77–16.86]). For the TUG (dual task), participants were slightly less likely to include the TUG (dual task) with practical experience compared to including without practical experience if they had more than 10 years of teaching experience (OR: 0.94; 95% CI, [0.31–2.91]). Participants were also less likely to include the TUG (dual task) with practical experience compared to not including it at all if they had more than 10 years of experience (OR: 0.19; 95% CI, [0.06–0.58]).

Back to Top | Article Outline

Comparison Between Components Instructed and Components Assessed in Instructed Measures

Table 4 highlights which of the 10 components of balance are assessed by those measures reported to be instructed in detail with practical experience by >50% of participants. Underlying motor systems (10/10) and anticipatory balance (7/10) are the 2 balance components included in most balance measures. The balance components least included were assessment of stability limits (2/10), cognitive influences (1/10), verticality (1/10), reactive balance (0/10), and underlying sensory systems (0/10). None of the measures in Table 4 assess all 10 components of balance provided in the survey.

Table 4

Table 4

Back to Top | Article Outline

DISCUSSION

These study findings illustrate how balance and its measurement are included in physical therapy education programs across Canada and the United States. Nine of the 10 balance components were reported to be instructed in detail with practical experience by more than 60% of participants, with the exception of verticality. The only balance component that was included differently according to years of experience of the instructor was sensory integration, which was more likely to be included in course content with practical experience if the instructor had more than 10 years of teaching experience. Instructors also reported providing detailed instruction and practical experience in 26 balance measurement tools with the TUG27 alone test, Berg Balance Scale,28 and the sit-to-stand test29 as the three most frequently included measures included in instruction with practical experience. While tandem standing/walking was more likely to be included with practical experience by participants with more than 10 years of teaching experience, the TUG (dual task) was less likely to be included with practical experience by that same group. None of the measures reported to be instructed in detail with practical experience by >50% of participants assess more than six balance components creating a disparity between the reporting of balance component inclusion with practical experience and the components assessed by those measures reported to be most frequently instructed with practical experience.

Comprehensive assessment of all balance components is important as each component has distinct constructs individually related to mobility and falls.9,30 The reported instruction of balance components in this study corresponds to previous research into clinical practice, which found that 80% of participants regularly assessed static stability, dynamic stability, and underlying motor systems, while the rest of the components were regularly assessed by just over half of the participants.5 These results, although not direct comparisons between educational experience and clinical practice, support the relationship between academic preparation and clinical decision making.14,19 One exception is verticality, defined as the ability to orient appropriately with respect to gravity, support surface, and visual surround (e.g., evaluation of lean), which was included less frequently in instruction than previous reports on clinical practice.5,6 It is possible that the operational definition for verticality may have overlapped with other balance components: Verticality can be affected by sensory systems, including vestibular, vision, and proprioception. Participants may have considered verticality as part of another balance component response such as underlying sensory systems. Not including the component of verticality in instruction would limit the opportunity to learn how the ability to properly orient with gravity, support, and/or visual surround is important for balance control.9,30

The measures reportedly instructed in detail with practical experience also align well with previous research evaluating clinical practice.5 In particular, the TUG test and the Berg Balance Scale were also the measures most commonly used by PTs in a clinical context.5 There is a mismatch; however, between what participants reported for components of balance included with practical experience and the actual content of the top measures reported. For example, 71% of participants reported providing detailed instruction and practical experience of reactive balance yet none of the measures reportedly taught most frequently with detailed instruction and practical experience include reactive balance. It is unclear why this finding occurred, but may be due to several reasons, including uncertainty how to include reactive balance in instruction to PT students, limited knowledge of the more comprehensive standardized balance measures, or lack of time or resources.8 It is also possible that reactive balance assessment was instructed using observation as a measurement tool, which was reported as instructed with detail and practical experience by 57% of participants. Of the measures provided as options in the current study, the Balance Evaluation Systems Test (BESTest), Fullerton Advanced Balance (FAB) Scale, Performance Oriented Mobility Assessment, and Push and Release Test are all measures that include evaluation of reactive balance,7 yet they were reported to be instructed in detail with practical experience by less than 45% of participants and were not in the top 10 most frequently included measures. It is possible that the measures above that do provide comprehensive balance measurement were instructed without practical experience. Responses do suggest that measures that are more comprehensive are being included with practical experience more frequently in academic preparation than in recent reports of clinical practice.5 Efforts by instructors in physical therapy education programs to support more comprehensive clinical balance assessment should be continued to support more comprehensive balance instruction. For example, instructors could include the most comprehensive measures available (e.g., BESTest and its variations) and/or include a variety of measures to ensure all balance components are captured in the tools used.

Years of experience instructing in a physical therapy education program affected how one component of balance (sensory integration) and two measures of balance (tandem standing/walking and TUG [dual task]) were included, suggesting years of experience had minimal impact on how balance-related content is included. Instructors with more years of experience may be providing a more thorough explanation of how sensory integration relates to balance control, thereby preparing students better than their less-experienced colleagues. It is possible that sensory integration-related content could be included under the component described as underlying sensory systems. As these two components are similar in nature, examining course curricula would be helpful in clarifying under which balance component specific curricular content would lie. The results describing the effect of experience on the inclusion of the TUG (dual task) may be linked to evidence promoting the TUG (alone or dual-task) as predictive of falls in older adults31; however, the timing of research evidence does not support the same argument for tandem standing/walking32 nor does it support the lack of difference for the TUG (alone) test. In addition, while participants were asked about their years of experience instructing, they were not asked about their years of experience in clinical practice and/or their area of specialty. It could be that some instructors who graduated from entry-to-practice programs more than 10 years ago have less than 10 years of instructional experience and, as such, linking the timing of the measures to the years of instructional experience would not take that clinical experience and its influence on the inclusion of certain balance measures in their courses into account. Similarly, the specialty of a PT may influence their instructional practices to reflect their experience (e.g., a PT with more experience working with a population with increased fall risk may have more experience and/or knowledge related to balance assessment and may provide a more comprehensive instruction in their course). In addition, some research suggests that the use of evidence-based practice is negatively correlated with experience instructing,33 suggesting that more information is needed to understand the differences in teaching practice related to teaching experience.

There are some limitations to be aware of when interpreting the results from this study, including calculating the actual response rate. It is impossible to know how many instructors received the survey link from their curricular directors nor if the recipients of the individual email invitations were still instructors in a physical therapy education program; therefore, it is not possible to determine a valid response rate. The survey relied on self-report measurements, which may overestimate/underestimate any of these findings.34 While “practical experience” was intended to mean hands-on, in-class experience under the instructor's supervision, there was no operational definition provided, which may have led to varied interpretation by participants. In addition, it is possible that participants who perceived they were already providing comprehensive balance-related instruction responded while others did not respond, leading to a potential source of bias in the data. Responses were collapsed into fewer categories, thereby simplifying the results and limiting the sensitivity to different levels of instruction. Importantly, the survey results cannot identify the quality and/or method of the instruction provided. Examining how responses correlate with course curricula and in which type of courses (e.g., foundational, neuro-rehabilitation) balance and its measurement are included would be helpful in further detailing the inclusion of balance-related content in these programs of study. The options provided for balance measures were based on a published scoping review7 and recent surveys of clinical practice5,6 and was not exhaustive; however, participants had the option of including other measures in an open-ended format. Future versions of the survey could target more measures that include both dynamic and reactive balance components. In addition, the components of balance included may not have been independent from each other, which could have resulted in overestimation/underestimation in the responses toward other components. The balance components listed were based on the Systems Framework for Postural Control,9 recent adaptations,7 and feedback during the pilot phase of this study. Despite operational definitions being provided within the survey questions, participants may not have been familiar with this framework, and as such, the analyses based on this framework may contain some bias. Also, the comparison between the components reported to be instructed and the components included in the top measures does not include observation which may account for the differences between the two constructs. Although observation is not a standardized measure, it is clearly important to clinical practice as it remains popular in both instruction and practice.5 Finally, this analysis combined responses from instructors teaching in both Canada and the United States. Program lengths and entry-to-practice degrees are notably different between the 2 countries: A longer program length and relatively higher level of an entry-to-practice degree may provide more opportunity for more comprehensive balance instruction. These and other country-specific factors, such as differences in health care systems, may be interesting to investigate; however, a Canada/US comparison would not be feasible, given the difference in number of programs and being outside of the scope of this study.

Back to Top | Article Outline

SUMMARY

This research shows that instructors in entry-level physical therapy education programs in Canada and the United States reported providing comprehensive instruction of balance components and the inclusion of a variety of balance measures in their course content. Further work is needed to understand the factors influencing the inclusion of balance components and measures in the instruction of physical therapy programs. Balance measures already exist (e.g., BESTest and FAB) for clinicians to use in practice to comprehensively assess balance. Entry-level education programs for PTs could include these more comprehensive standardized balance measures, or a combination of measures,5 to enhance fall prevention efforts.6,30,35 Physical therapists play an important role in balance assessment, and academic preparation helps form foundations16 and impacts clinical practice.18 Future work could examine the relationship between course curricula and clinical practices as well as how instructional methodology affects perception of preparedness, confidence, and self-efficacy for comprehensive balance assessment in recent graduates of physical therapy education programs.

Back to Top | Article Outline

ACKNOWLEDGMENTS

The authors would like to acknowledge the instructors who provided valuable feedback during the pretesting of the survey instrument.

Back to Top | Article Outline

REFERENCES

1. Prince KJAH, Boshuizen HPA, Van Der Vleuten CPM, Scherpbier AJJA. Students' opinions about their preparation for clinical practice. Med Educ. 2005;39:704–712.
2. Berg WP, Alessio HM, Mills EM, Tong C. Circumstances and consequences of falls in independent community-dwelling older adults. Age Ageing. 1997;26:261–268.
3. NPAG Competency Profile for Physiotherapists in Canada (2017). https://physiotherapy.ca/sites/default/files/competency_profile_final_en_0.pdf. Accessed April 2, 2018.
4. Drootin M. Summary of the updated American geriatrics society/british geriatrics society clinical practice guideline for prevention of falls in older persons. J Am Geriatr Soc. 2011;59:148–157.
5. Sibley KM, Straus SE, Inness EL, Salbach NM, Jaglal SB. Balance assessment practices and use of standardized balance measures among ontario physical therapists. Phys Ther. 2011;91:1583–1591.
6. Oates A, Arnold C, Walker-Johnston J, et al. Balance assessment practices of saskatchewan physiotherapists: A brief report of survey findings. Physiother Can. 2017:69. doi:10.3138/ptc.2016-47.
7. Sibley KM, Beauchamp MK, Van Ooteghem K, Straus SE, Jaglal SB. Using the systems framework for postural control to analyze the components of balance evaluated in standardized balance measures: A scoping review. Arch Phys Med Rehabil. 2015;96:122–132.e29.
8. Sibley KM, Straus SE, Inness EL, Salbach NM, Jaglal SB. Clinical balance assessment: Perceptions of commonly-used standardized measures and current practices among physiotherapists in Ontario, Canada. Implement Sci. 2013;8:33.
9. Horak FB. Postural orientation and equilibrium: What do we need to know about neural control of balance to prevent falls? Age Ageing. 2006(Suppl 2):35. doi:10.1093/ageing/afl077.
10. Woollacott MH, Tang PF. Balance control during walking in the older adult: Research and its implications. Phys Ther. 1997;77:646–660.
11. Orr R, Raymond J, Fiatarone Singh M. Efficacy of progressive resistance training on balance performance in older adults : A systematic review of randomized controlled trials. Sports Med. 2008;38:317–343.
12. Andrews AW, Folger SE, Norbet SE, Swift LC. Tests and measures used by specialist physical therapists when examining patients with stroke. J Neurol Phys Ther. 2008;32:122–128.
13. 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.
14. Salbach NM, Jaglal SB, Korner-Bitensky N, Rappolt S, Davis D, Duncan PW. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke … includes commentary by Duncan PW, and author response by Salbach NM and Korner-Bitensky N. Phys Ther. 2007;87:1284–1305 22p.
15. Korner-Bitensky N, Menon-Nair A, Thomas A, Boutin E, Arafah AM. Practice style traits: Do they help explain practice behaviours of stroke rehabilitation professionals? J Rehabil Med. 2007;39:685–692.
16. Wainwright SF, Shepard KF, Harman LB, Stephens J. Factors that influence the clinical decision making of novice and experienced physical therapists. Phys Ther. 2011;91:87–101.
17. Salbach NM, Guilcher SJ, Jaglal SB, Davis DA. Determinants of research use in clinical decision making among physical therapists providing services post-stroke: A cross-sectional study. Implement Sci. 2010;5:77.
18. Stajkovic AD, Luthans F. Self-efficacy and work-related performance: A meta-analysis. Psychol Bull. 1998;124:240–261.
19. Straus SE, Ball C, Balcombe N, Sheldon J, McAlister FA. Teaching evidence-based medicine skills can change practice in a community hospital. J Gen Intern Med. 2005;20:340–343.
20. Tschannen-Moran M, Hoy AW. The differential antecedents of self-efficacy beliefs of novice and experienced teachers. Teach Teach Educ. 2007;23:944–956.
21. Klassen RM, Chiu MM. Effects on teachers' self-efficacy and job satisfaction: Teacher gender, years of experience, and job stress. J Educ Psychol. 2010;102:741–756.
22. Salbach NM, Jaglal SB, Korner-Bitensky N, Rappolt S, Davis D. Practitioner and organizational barriers to evidence-based practice of physical therapists for people with stroke. Phys Ther. 2007;87:1284–1303.
23. Slavin MD. Teaching evidence-based practice in physical Therapy: Critical competencies and necessary conditions. J Phys Ther Educ. 2004;18:4–11.
24. Care PE-R. The Six-Minute Walk Test. 2003. http://rc.rcjournal.com/content/48/8/783.short. Accessed March 12, 2018.
25. Harada N, Chiu V; Medicine AS-A of Physical. Mobility-related function in older adults: Assessment with a 6-minute walk test. 1999. http://www.archives-pmr.org/article/S0003-9993(99)90236-8/abstract. Accessed March 12, 2018.
26. Powell L, A AM-TJ of GS. The activities-specific balance confidence (ABC) scale. 1995. https://academic.oup.com/biomedgerontology/article-abstract/50A/1/M28/616764. Accessed March 12, 2018.
27. Podsiadlo D, Richardson S. The timed “Up & Go”: A test of basic functional mobility for frail elderly persons. J Am Geriatr Soc. 1991;39:142–148.
28. Berg KO, Wood-Dauphinee SL, Williams JI, Maki B. Measuring balance in the elderly: Validation of an instrument. In: Canadian Journal of Public Health. Vol 83. 1992. doi:10.1016/j.archger.2009.10.008.
29. Bohannon RW. Sit-to-stand test for measuring performance of lower extremity muscles. Percept Mot Ski. 1995;80:163–166.
30. Shumway-Cook A, Woollacott M, Kerns KA, Baldwin M. The effects of two types of cognitive tasks on postural stability in older adults with and without a history of falls. J Gerontol A Biol Sci Med Sci. 1997;52:M232–M240.
31. Shumway-Cook A, Brauer S, Woollacott M. Predicting the probability for falls in community-dwelling older adults using the Timed Up & Go Test. Phys Ther. 2000;80:896–903.
32. Lord SR, Rogers MW, Howland A, Fitzpatrick R. Lateral stability, sensorimotor function and falls in older people. J Am Geriatr Soc. 1999;47:1077–1081.
33. Manspeaker SA, Van Lunen BL, Turocy PS, Pribesh S, Hankemeier D. Student knowlege, attitudes, and use of evidence-based concepts following and educational intervention. Athl Train Educ J. 2011;6:88–98.
34. Davis DA, Mazmanian PE, Fordis M, Van Harrison R, Thorpe KE, Perrier L. Accuracy of physician self-assessment compared with observed measures of competence: A systematic review. JAMA. 2006;296:1094–1102.
35. Horak FB, Shupert CL, Mirka A. Components of postural dyscontrol in the elderly: A review. Neurobiol Aging. 1989;10:727–738.
Keywords:

Balance; Measurement; Education

Supplemental Digital Content

Back to Top | Article Outline
Copyright 2018 Education Section, APTA