Received date: August 2, 2017; Accepted date: August 10, 2017; Published date: August 15, 2017
Citation: Jang HY, Kim YL, Oh JL, Lee SM (2017) Barriers to Using Balance and Gait Assessment Tools by Physical Therapists in Patients with Neurological Impairments: A Systematic Review. J Clin Res Bioeth 8:309. doi:10.4172/2155-9627.1000309
Copyright: © 2017 Jang HY, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Introduction: The balance disability and pathological gait caused by neurological impairments deter activities of everyday living and social participation, deteriorate the quality of life, and increase the risk of falling. Physical therapeutic intervention plays a critical role in improving the balance disability and pathological gait. For effective physical therapy, accurate assessment of a patient is a priority.
Objective: This study aimed to identify the barriers regarding the use of the balance and gait assessment tests in patients with neurological impairments.
Method: Two reviewers used Electronic databases (Cochrane Library, MEDLINE, PEDro and RISS) to assess the titles and abstracts from the literature published until Dec. 2016 with the use of keywords, including "balance or posture or postural control or postural stability", "gait or walking or locomotion or ambulation", "test or assessment or measurement or outcome measure or assessment tool or measurement tool", "barriers", and "facilitators", read the full texts of identified articles, selected the publications related to the purpose of our study, and then analyzed materials from the literature.
Result: Independent reviewers and one analyst selected six materials from the literature relevant to the purpose of our study, and identified several barriers to using the balance and gait assessment tools by physical therapists, including therapists and patients’ individual factors (lack of knowledge, low priority, and patients’ functional ability), environmental factors (time, cost, space, and low organizational support), and measure-specific factors of the assessment tools (reliability, validity, and assessment tools appropriate for population).
Conclusion: Our study revealed the barriers to the use of the balance and gait assessment tool. Overcoming the barriers is essential to make it possible for physical therapists to efficiently use the tool for balance and gait assessment.
Physical therapist; Neurological impairment; Balance; Gait; Assessment; Barriers
Balance and gait are the basic abilities of physical activity required to perform activities of everyday life and social participation. Balance is the ability to control the center of mass relative to the base of support , to maintain a posture without falling, to achieve a motion in the stable condition, or to restore the body stability after external perturbation. It was reported that balance was influenced by the motor and sensory systems, and the physical properties of the individual . Gait uses a repetitious sequence of limb motion to move the body forward while simultaneously maintaining stance stability, and is divided into stance phases and swing phases which are more specifically classified into Initial contact, Loading response, Mid stance, Terminal stance, Pre swing, Initial swing, Mid swing, and Terminal swing . Balance and gait are influenced by the harmonized inherent action of the musculoskeletal and the neuromuscular systems and external environmental factors such as the shoe type, walking surface, lighting, the use of an assistive device, and gravity.
Patients with neurological impairments including stroke, traumatic brain injury, spinal cord injury, cerebral palsy, and Parkinson’s disease, those with musculoskeletal system impairments including fracture, amputation, arthritis, and polio, those with medical diseases including diabetes, heart disease, and respiratory disease, and elderly persons experience changes in their balance disability, pathological gait, and gait pattern. These disabilities deter activities of everyday life and social participation. As a result, their quality of life deteriorates, and the risk of falling increases [4-12].
Physical therapy is a method to improve the balance disability and pathological gait and enhance the physical abilities. Intervention techniques such as neurophysiological approaches (Bobath), moving platform, biofeedback, electrostimulation, physical fitness training, high-intensity therapy, repetitive task-specific training, gait training using visual cues, treadmill training plus body weight support, roboticassisted body weight supported treadmill training and aquatic gait training are applied [13-17].
To render a physical therapy course effective, it is essential to accurately assess the patient's condition. Assessment is required to identify the causes of balance and gait problems, establish a treatment plan, and predict the outcome of the therapy. In addition, it helps provide the information necessary to educate patients and their caregivers and to equip them with confidence. Furthermore, assessment enables rehabilitation experts to share information, and is a critical part of evidence-based practice [18-20]. There are various methods of assessing the balance and gait ability of the patients with neurological impairments. For example, Romberg test, Single-Leg Stance test, Step test, Functional Reach test, 10 meter walk test, 6 minute walk test, and timed up & go (TUG) test are assessment methods based on functional performance; Berg balance scale (BBS), postural assessment scale for stroke patients (PASS), activities-specific balance confidence (ABC) scale, motor assessment scale (MAS), trunk impairment scale (TIS), Brunel balance assessment (BBA), Fugl-Meyer assessment (FMA), Dynamic Gait Index (DGI), Rivermead Mobility Index (RMI), Functional Ambulation Classification (FAC), Functional Independent Measure (FIM), Chedoke-McMaster Stroke Assessment, and Balance evaluation systems test (BESTest) are methods using the assessment tool of ordinal scale; and there are other methods using tooled measurement tools, such as the body control ability for postural sway, weight distribution, and external perturbation, and the kinetic or kinematic based tools [3,21-35].
These numerous assessments are used for academic or clinical purposes; therefore, it is difficult for therapists to apply an assessment method properly in line with a patient’s functional level [36,37]. Van Peppen et al. found that, changing routines, time investment and financial compensation constituted significant barriers to assessment in a clinical setting . In a different study, the lack of knowledge about assessment tools was the main barrier to balance and gait assessment [39,40]. In other studies, the floor & ceiling effect of assessment tools make it difficult to assess patients with various physical activity levels , and assessment methods using equipment are limited owing to spatial restriction, difficult security of experts, and expensive equipment . Assessment tools are not equally recognized among therapists owing to disparate medical insurance systems among countries, the lack of time caused by busy clinical settings, and various education system worldwide . These barriers make it difficult for therapists to apply appropriate assessment methods to clinics in relation to patient’s functional levels. Nevertheless, there is not sufficient systematic research regarding the potential barriers to the assessment of balance and gait in patients with neurological impairments.
Therefore, this study aims to identify, through a systematic review of the literature the barriers faced by physical therapists working in a clinical setting while performing balance and gait assessments, and to develop a strategy to overcome these barriers. The result of our study will contribute to the more effective use of assessment tools by physical therapists.
This study was approved by the Institutional Review Board of Sahmyook University in January 2017.
For a systematic review, studies were searched using, Cochrane Library, MEDLINE, PEDro and RISS electronic databases to identify the materials published from December 2011 to December 2016. Various search keywords were used, including, "balance or posture or postural control or postural stability" AND "gait or walking or locomotion or ambulation" AND "test or assessment or measurement or outcome measure or assessment tool or measurement tool" AND "barriers" AND "facilitators". The searched keywords were divided into four work groups: balance group, gait group, assessment group, and barriers group. Two reviewers (Jang HY, Kim YL) entered more than two word-groups to search for the titles and abstracts from the materials found, for instance, "Balance and Gait", "Balance and Walking", "Balance and Assessment and Barriers", or "Balance and Gait and Assessment and Barriers". To select studies appropriate for our study, the reviewers read the full texts checked the references from selected articles and subsequently. read the full texts from the selected references. The reviewers agreed in the selection publications that met the purpose of our study. Data were analyzed by one analyst (Oh JL), who classified the selected materials based on methodology and results. 9 full-text articles excluded with reasons (same author or barriers factor unclear). Subsequently, two reviewers and one analyst completed the analysis (Figure 1).
Each reviewer checked the titles and abstracts from the selected studies, read the full texts from 15 publications, selected six articles relevant to the purpose of our study, and subsequently identified barriers to physical therapists’ balance and gait assessment in patients with neurological impairments (Table 1).
|Sibley KM and Salbach NM (2015)||Case report||Lack of knowledge
Lack of time
Tools not appropriate for population
|Pattison KM, et al. (2015)||Qualitative descriptive study
(28 Physical therapists)
|Validity and reliability
|Duncan E and Murray J (2012)||Systematic review||Knowledge
Low organizational support
|McGinnis PQ, et al. (2009)||Qualitative design
(11 Physical therapists)
|Tyson SF and Connell LA (2009)||Systematic review||Validity and reliability
Lack of time
|Van Peppen, et al. (2008)||41 Item Survey
(167 Physical therapist)
Table 1: Six publications relevant to the objective of this study.
Sibley and Salbach had identified significant barriers to balance and gait assessment. Based on the study regarding the Canadian physical therapists’ perceptions and use of balance and gait assessment [39,40,43], the authors suggested that individual (lack of knowledge and low priority), environmental (lack of time), and measure-specific (tools not available, tools not appropriate for population) factors contribute as barriers to balance assessment; reliable and valid measures, 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 as gait assessment .
Pattison conducted a qualitative descriptive study regarding the factors that influence the use of standardized gait assessment tools by interviewing 28 physical therapists. As a result, he suggested that familiarity, patient, colleagues, guidelines, ease of use, time, space, validity, reliability, and cost are contributing factors that influence the use of gait assessment tools in patients with stroke .
Duncan and Murray examined the barriers and facilitating factors in routine outcome measurement with allied health professionals and identified four higher level issues: first, the therapists’ knowledge, education, and value recognition of measurement tools; second, the support and priority for measurement tools; third, practical considerations including time and cost; fourth, patient considerations .
In a qualitative study with 11 participating physical therapists, McGinnis analyzed the factors influencing the selection of a balance assessment tool. According to their study, the barriers to the use of assessment tools were time required for initial examination and that required to complete tests as physical therapists’ view of constraints; age, diagnosis, and functional ability as patient factors; screening and diagnoses as physical therapists’ intended use of information; formal knowledge and practical experience as physical therapists’ knowledge; and other sources of information (colleagues, the literature, continuing education, etc.) .
Tyson studied how to perform balance and gait assessment in a clinical setting. He determined barriers to assessment in the categories of psychometrics properties and clinical utility. Psychometrics properties included reliability, validity and sensitivity. Clinical utility included time, cost, specialist equipment, training to use, and tool portable .
Van Peppen conducted a questionnaire- based survey consisting of 41 questions with 167 physical therapists. According to the survey, changing routines, time investment and financial compensation were recognized as barriers to the use of assessment tools in a clinical setting .
Based on the results of the data analysis, we found that three categories were significant. First, therapists and patients’ individual factors that included lack of knowledge, low priority, and patients’ functional ability. Second, environmental factors that included lack of time, excessive or low assessment cost, spatial restriction, and lack of organizational support. Third, measure-specific factors that included reliability, validity, and assessment tools appropriate for population. In addition, the existence of numerous assessment tools became a barrier to the use of assessment tools (Figure 2).
The balance disability and pathological gait caused by neurological impairments deter activities of everyday living and social participation, lower quality of life, and increase the risk of falling [10-12]. Physical therapeutic intervention plays a critical role in improving the balance disability and pathological gait . For effective physical therapy, accurate assessment of a patient is a priority [18-20]. Unfortunately, barriers to balance and gait assessment make it difficult for therapists to use assessment tools. Therefore, these researchers conducted a systematic review of the literature on the barriers to physical therapists’ balance and gait assessment in patients with neurological impairments in a clinical setting, and devised a strategy for overcoming them.
Barriers to balance and gait assessment
Independent reviewers checked the titles and abstracts from published articles, reviewed the full text from 15 publications from the literature, and selected and analyzed six publications relevant to the purpose of this study. As a result, we identified barriers classified into three categories: individual factors, environmental factors, and measure-specific factors. Individual factors were divided into therapists’ and patients-related barriers, and included lack of knowledge about assessment tools, low priority, and patients’ functional ability. Regarding to environmental factors, barriers included lack of time, excessive or low assessment cost, spatial restriction, and low organizational support. Regarding measurespecific factors, barriers were reliability and validity of assessment tools, and the application of an assessment tool appropriate for population [38,44-48].
Individual factors were analyzed in accordance with the therapist’s or patients’ view. Regarding therapists’, barriers to the use of assessment tools included lack of knowledge and low priority [44,46,47]. Sibley and Salbach examined the Canadian physical therapists’ recognition of balance and gait assessment and actual conditions, and reported that lack of knowledge was the most critical barrier to the use of assessment tools . According to a systematic literature review by Duncan and Murray, 11 of 15 publications revealed that therapists’ knowledge was related to their use of assessment tools . A study by McGinnis et al. also reported that therapists’ knowledge was a critical determinant in the application of an assessment tool . Sibley and Salbach reported that therapists’ low priority of assessment tools was also a barrier . Regarding patients’, consideration factors in the use of assessment tools included age, diagnosis, and functional ability , and barriers were patients’ physical ability for assessment, linguistic communication, and ethical or cultural barriers .
In a clinical setting, barriers included lack of time, too high or too low assessment cost, spatial restriction, and low organizational support [38,44-48]. All six publications that these researchers identified explained clinical environmental barriers. Among the barriers, lack of time was described in all articles. Previous studies revealed that, lack of time was a critical barrier in a clinical setting. The time of initial examination, and the time of completion of the test were critical factors that determined an assessment tool [46,47]. In addition, in a busy clinical setting with too many patients, time limitations impair proper assessment . In three studies, too high or too low assessment cost was identified as barrier [38,46,48]. In other articles, cost was a low priority in decision-making . This seems to be related to disparities in medical insurance systems among countries. Spatial restriction and low organizational support were also barriers in a clinical setting [45,46,48].
Regarding measure-specific factors, barriers were reliability and validity of assessment tools, and recognition of an assessment tool appropriate for population [44,45,46,48]. Subjective assessment can yield measurement errors therefore, it is necessary to use assessment tools with reliability and validity [44-46,48]. In addition, it was found that one barrier was the selection of an assessment tool appropriate for population [44,46,48]. For accurate assessment, it is important to select an assessment tool appropriate for a patient’s physical ability however, this is challenging.
In addition to those barriers, the fact that there are numerous assessment tools used for clinical or academic purposes, was a barrier. In some countries, multiple assessment tools were recommended for balance and gait assessment.
Efforts to overcome barriers
To overcome these barriers, it is necessary to provide better education and suggest standardized clinical environmental criteria to properly use assessment tools with reliability and validity, understand the various medical insurance systems among countries and make changes, and propose unified guidelines to select only one out of numerous assessment tools.
It is important to use an assessment tool with reliability and validity in patients with neurological impairments to achieve proper clinical assessment. In fact, assessment tools are inherently limited. Therefore, it is necessary to select a wide range assessment tool , or it may be more efficient to use multiple assessment tools in a way of using both PASS and ABC scale to improve the limited range of BBS, than to use only one assessment tool . In Tyson’s study regarding the selection of a balance and gait assessment tool for patients with neurological impairments, functional and ordinal-scale assessment tools were recommended [48,49]. In a recent systematic review aimed at enhancing the general use of assessment tools, education for the use of assessment tools has been emphasized . It is also important to include reliability and validity of assessment tools when the tools are translated to a native language [51,52]. In addition, it is important to resolve the knowledge gaps between various university courses among countries .
To apply an assessment tool, it is significant to recommend standardized clinical environmental criteria appropriate for assessment. Time is the most significant barrier to the application of an assessment tool in a clinical setting. To address this issue, various assessment tools have been developed. In addition, in the country the number of patients that therapists care for during the day, is inversely correlated with the time they spend performing assessment. Therefore, it is necessary to make a change in the point . Among countries, there are various medical insurance systems; thus, so there are various medical payments depending on the use of an assessment tool. Too high or too low assessment cost for therapists and patients is directly correlated with the use of an assessment tool . Therefore, it is necessary to suggest a reasonable medical payment for therapist and patient assessment.
Guidelines that recommend one assessment tool appropriate for patients versus other assessment tools can be effective at overcoming barriers. However, in some countries, different assessment tools are recommended according to guidelines [48,49,55-57]. Therefore, it is necessary to develop a consensus regarding the use of only one assessment tool.
Our study has the following limitations. Although studies were selected through a review of the literature, only those published in English were considered. Hence, it was not possible to identify all relevant publications. The electronic databases were only limited to Cochrane Library, MEDLINE, PEDro and RISS. This study failed to review the literature published after December 2016, the literature not registered, and gray literature. Even though the reviewers and analyst were experts in this field, the process of agreeing and selecting six articles was subjective. Moreover, only one of the six publications was a systematic review, and the remaining were qualitative design and survey therefore, there was low objectivity.
In conclusion, essential barriers to the use of assessment tools were individual factors (lack of knowledge, low priority, and patients’ functional ability), environmental factors (lack of time, too high or low assessment cost, spatial restriction, and organizational support), and measure-specific factors (reliability, validity, and an assessment tool appropriate for population). To overcome these barriers, it is necessary to provide education of standardized assessment, change of clinical settings and medical insurance systems, and to recommend appropriate guidelines. Thus, it is possible for physical therapists to perform balance and gait assessment efficiently and accurately. As part of the effort to overcome the barriers and make general use of assessment tools, it is necessary to conduct a comparative study regarding the different types of assessment education, clinical settings, medical insurance systems, and guidelines in various countries.