A Survey of Israeli Physical Therapists Regarding Perturbation-Based Balance Training

doi:10.21203/rs.3.rs-2099657/v1

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Research Article

A Survey of Israeli Physical Therapists Regarding Perturbation-Based Balance Training

https://doi.org/10.21203/rs.3.rs-2099657/v1

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Journal Publication

published 13 Oct, 2023

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Background: ‘Perturbation-based balance training’ was developed to improve balance reactions to unexpected losses of balance. Although this training method is effective, its practical usage in the field of physical-therapy in Israel and world-wide is still unclear.

Aims: This study aimed to evaluate the extent of perturbation-based balance training use in physical-therapy clinics in Israel, to identify the significant barriers to/facilitators for implementing perturbation-based balance training in clinical practice among physical therapists, and to determine which aspects of perturbation-based balance training most interest physical therapists in Israel.

Methods: Physical therapists in Israel completed a survey using a questionnaire regarding their knowledge and use of perturbation-based balance training in their clinical practices. We compared the specific use of perturbation-based balance training among users; non-users; and open-to-use physical therapists. The odds ratios of the facilitators and barriers were calculated using univariate and multivariate logistic regression models.

Results: Four-hundred and two physical therapists responded to a yes/no question regarding their use of perturbation-based balance training. Three-quarters (75.4%) of physical therapists reported using perturbation-based balance training in their practices. The most prevalent barrier cited was insufficient space for setting up equipment and most prevalent facilitator was having a colleague who uses perturbation-based balance training. Most of the respondents wanted to learn more about perturbation-based balance training, and most of the non-users wanted to expand their knowledge and mastery of perturbation-based balance training principles.

Conclusions: There are misconceptions and insufficient knowledge about perturbation-based balance training among physical therapists in Israel. Reliable information may help to improve general knowledge regarding perturbation-based balance training, and to facilitate the more widespread implementation of perturbation-based balance training as an effective fall-prevention intervention method.

Accidental Falls

Perturbation-based training

Physical Therapy

Survey

Knowledge translation

Postural balance

As life expectancy rises, there are more older adults who are at risk of falling. Older adults have sensorimotor deficits that may affect balance control (1–3), voluntary step abilities (4–6) and reactive balance control in standing and walking (7, 8), indicating a growing fall risk that may require intervention. Falls may have life-threatening consequences that can seriously affect the lives of older adults such as physical injuries (9, 10), psychological influences including fear of falling (11, 12) and serious financial burden (13). In Israel, every day about 1000 older adults visit emergency departments due to a fall, and the total direct costs of hip fracture in the elderly population in Israel in 2013 were about 200 million USD (14).

Fall-prevention programs were found to be effective to reduce fall rates in older adults. Systematic reviews (15–17) that examined fall-prevention randomized control trials (RCTs) found that participating in ‘conventional’ balance and functional training reduced fall rates by 23–25% and improved health outcomes in older adults. These exercises mostly involve voluntary preplanned movements and maintaining balance during static postures or during movement balance. Many falls in older adults however, occur when they fail to adequately respond to a loss of balance i.e., unexpected perturbation (18). Therefore, training to improve the quality of reactions to a loss of balance may be particularly effective for preventing falls (19). Perturbation-Based Balance training (PBBT) is a specific type of balance training where participants repeatedly experience unannounced balance loss, and need to execute balance reactions to avoid a fall (20). Several previous studies have found that PBBT can improve reactive balance control and prevent falls in daily life (19, 21–25). In a meta-analysis of RCT's, PBBT was found to reduce the rate of falls by 46% compared to other exercise interventions (19); this is almost twice the effect of ‘conventional’ balance and functional training (15–17). Thus, PBBT seems to simulate and closely mimic unexpected, real-life perturbations for preventing falls in daily life. As such, it is an optimal method that forces and trains the body’s reactive balance control system to safely prevent falls.

Although PBBT has been shown to be effective as a fall-prevention program, the extent of its use in physical therapy (PT) clinics is unknown. Translating new knowledge into practice requires time and effort, and healthcare professionals experience barriers implementing new evidence-based practices (26); therefore, it is likely that PTs experience challenges implementing PBBT into practice. Our aim was to explore whether there is an evidence-practice gap for PBBT and to determine what barriers and challenges exist, delaying the implementation of such PBBT programs in PT clinics (27). Mansfield et al. (28) explored those barriers and facilitators, and tried to determine the scope of PBBT usage among clinicians in Canada. They found that over 75% of the respondents answered that they are using PBBT. They also found that the most significant barrier preventing the use of PBBT was the lack of knowledge about/and familiarity with PBBT. Facilitators for PBBT use were being able to complete PBBT easily in the practice settings, having colleagues who use PBBT, having access to resources for PBBT, and having sufficient training and mastery of PBBT. Replication of the Canadian study (28) in a different context is valuable since most of the resources available for PBBT are published in English, so those who do not read English at all or read English as a second language would have difficulty accessing these resources. Also, differences in the academic studies and clinical rotations in different countries may drive clinical practice and decisions, and differences in the health-care systems in different countries may affect clinical practice. The purpose of the current research was to estimate the extent of PBBT use in PT clinics in Israel and to identify existing barriers and facilitators. The collected data allows reliable and detailed analysis of the relationship between existing barriers and facilitators and the use of PBBT among Israeli PT's. The identified factors potentially influencing the relationship may contribute to a better understanding the cross-sectional interactions and may help to develop a focused educational program that provides scientifically based rehabilitation program for balance control for nationwide use.

We expected that same barriers and facilitators would be found among the PT professionals in Israel vs. Canadian clinicians: 1) Although in a previous study about 75% of the Canadian cohort used PBBT in their clinical practice we expect that due to the English barriers, PBBT is used less frequent by the Israeli PT's (< 50% of respondents); 2) the lack of relevant knowledge and skill are the most prevalent barriers to the implementation of PBBT; 3) having the relevant scientific knowledge and the ability to complete PBBT easily at the workplace are the most prevalent facilitators for PBBT implementation; and 4) physical therapists are most interested in learning the principles of practical PBBT.

Participants

In a cross-sectional survey we distributed via a link sent by Email with the help of the Israeli Physical Therapy Society (IPTS), to 7,105 registered Israeli physical therapists. The study was approved by the Ethics Committee of the Faculty of Health Sciences at Ben-Gurion University of the Negev (Ethics Committee approval number 38-2020). Only after indicating their consent by reading a consent form (using √), the participants filled out the questionnaire via Email and social networks. We included only registered PT's who stated that they practice clinical therapy intended to improve their patients’ balance or mobility. The inclusion and exclusion processes appear in figure 1.

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Questionnaire

We used an existing questionnaire developed by a Canadian team of investigators (28). This questionnaire was developed based on a previous questionnaire (29). A member of our research team translated the questionnaire into Hebrew (NM). Then, another team member, who had not seen the original questionnaire, translated it back into English (IK). Finally, a third member (IM) compared the original English version of the questionnaire to the retranslated English version, to assess its congruence, or lack of it. We did not find any major differences between the original questionnaire and the retranslated one. To ensure that all the items are culturally appropriate i.e., validate its content for Israeli physical therapists, the drafted questionnaire was given to a convenience sample of fifteen PT graduate students currently studying master's degree at Ben-Gurion University of the Negev. They were tasked with critiquing the appropriateness of the individual items, to provide feedback on clarity and the overall survey length; the wording of some items was modified on the basis of this feedback. For example, one of the questions asked about PBBT improving sensation, which can also be perceived as emotional feeling in Hebrew. We changed the term to clarify that we refer to physical rather than emotional sensation. All fifteen physical therapists agreed that the survey suited its purpose. The final questionnaire included five parts: 1) eligibility; 2) demographic information; 3) approaches for treating balance; 4) knowledge of PBBT, including facilitators and barriers to its use; and 5) frequency of PBBT use.

Study protocol

The translated questionnaire was sent as a digital link to registered Israeli physical therapists with the help of the IPTS. Prior to accessing the questionnaires, the participants were sent a Consent Affidavit, dealing with the research data, the researchers’ contact information, a privacy statement, and a statement confirming voluntary participation. The participants were required to click that they consent to participate to continue as part of this study. Submitted questionnaires were anonymous and accepted from October 2020 to April 2021; once a questionnaire was submitted, no further changes could be made. As instructed, the participants were not to put any personal, identifying information (i.e., name, address, etc.) on the questionnaires. After gathering all data from the questionnaires, the results were analyzed.

Data and statistical analyses

Only those participants who met the eligibility criteria and had answered the questions regarding their general and specific use of PBBT were included in the analysis. We calculated the descriptive statistics for each item in the questionnaire. We tested the first hypothesis by calculating the 95% confidence interval of the question regarding the general use of PBBT. Respondents were then divided into three groups: 1) users (those who have either used PBBT with more than one client to treat balance impairment, or use PBBT regularly in their practice); 2) non-users (those who either never heard of PBBT, or had previously heard about PBBT, but were currently using other strategies to treat their clients’ balance impairments); and 3) Open-to-use (those who know about PBBT and are open to its use in their practice, but still have barriers to its practical implementation). The second and third hypotheses were tested by comparing the frequency of ‘agree’ and ‘disagree’ responses to the set of questions related to the barriers/facilitators experienced by the respondents at their workplace. Those answers were compared among the three groups using the chi-square test, and post-hoc pairwise comparisons were conducted using Fisher’s exact test. Additionally, we calculated the odds ratios (ORs) of chosen variables that showed significant differences between the users and the non-users in the post-hoc analysis. Those variables were categorized into three groups: 1) properties; 2) barriers; and 3) facilitators. We disproved collinearity between those variables by using the Spearman's rank correlation coefficient (r<0.7) and calculated the ORs for each group by using multivariate logistic regression models. We also calculated the combined OR for each of the variables in the barriers group and in the facilitators group with univariate logistic regression models. Regarding the combined barriers, we took the variables from the barriers' multivariate logistic regression model and calculated the combined OR of an individual who has not experienced the following barriers: unsure of when to use PBBT; it takes too much time to set-up for PBBT; PBBT is unsafe for patients; inability to conduct PBBT without assistance. Regarding the combined facilitators, we took the variables from the facilitators' multivariate logistic regression model and calculated the combined OR of an individual who appreciates the following facilitators: ease of use of PBBT at the clinic; encouraged by colleagues to use PBBT; have managerial support and/or encouragement; and have access to necessary resources for using PBBT). The fourth hypothesis was tested using the same methods as for the second and third hypotheses, regarding the questions on the learning needs around PBBT. An alpha of 0.05 defined statistical significance in all the analyses.

Participants

Six-hundred and forty-seven physical therapists consented to participate, filled out and submitted their questionnaires. Seventeen participants answered that they do not treat patients for balance or mobility problems, and forty-one participants did not answer this question; these 58 PT's were excluded from this study. One-hundred and eighty-seven participants did not complete the question regarding the specific use of PBBT and so were also excluded. Therefore, responses from 352 participants were included in the analysis. The participants’ characteristics are presented in Table 1.

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Use of PBBT

For clarity, the definition of PBBT was included in the questionnaire, so that the respondents might be more confident when answering the yes/no question regarding their use of this method. Three hundred and three participants (out of 402) ,75.4%, stated that they use PBBT, with a 95% confidence interval (72.4, 77.8). Regarding its specific use, 11.2% of the participants (45/402) reported they had not heard about PBBT before; and 15.2% of the participants (61/402) reported they had heard of PBBT before, but are using other treatment options for balance and mobility dysfunction; 18.9% of the participants (76/402) stated they are familiar with PBBT, but experience barriers when using this method in their practice; 39.6% (159/402) stated they had used PBBT in their practice with more than one patient; and 15.2% (61/402) stated that they are using PBBT on a regular basis.

Several participants had contradictions in responses to the yes/no question about PBBT use and the specific use question; 33 participants responded that they had used PBBT, but had not heard of it; 14 participants reported that they are using PBBT, but stated that they are using other treatment strategies to treat balance and mobility problems; and 3 participants stated that they did not use PBBT, but had used it with more than one patient. Those respondents with conflicting answers were removed from the analysis. The remining 352 participants were divided into three using groups, based on their responses to the specific use question: 1) user group (n=217); 2) non-user group (n=59); 3) Open-to-use group (n=76). Treatment strategies for balance and mobility problems are shown in Table 2.

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Prior experiences, knowledge, and attitudes about PBBT

Having received a PBBT education in an entry-to-practice program was significantly different between the non-users’ and users’ groups, and between the non-users and the open-to-use group (P<0.001 and P=0.022, respectively, Table 3). The non-users were the least likely to have received PBBT education in their entry-to-practice program, and there was no significant difference between the users’ group and the open-to-use group. In all the groups, most of participants stated they first heard about PBBT during their bachelor’s studies. In all three groups, there was little agreement with the statement: “Tried PBBT but found it to be ineffective;” with no statistically significant difference between the groups. The users were more likely than the non-users and the open-to-use group to agree that their patients acknowledged that PBBT improved their balance (P=0.015 and P<0.001, respectively). Also, the users were more likely to state that they feel confident doing PBBT, compared to the non-users and the open-to-use group (P<0.001 and P<0.001, respectively), and they were less likely to prefer other methods than PBBT (P<0.001 and P<0.001, respectively). There was no statistically significant difference between the groups regarding whether they would like to use PBBT more; 78.9%-92.4% of respondents in all the groups agreed with this statement. The non-users indicated that they are less familiar with PBBT research, compared to the users’ group and open-to-use group (P<0.001 and P=0.012, respectively). There was no significant difference between the users and the open-to-use regarding their knowledge of scientific research evidence on PBBT.

insert table 3

Barriers to implementing PBBT

The responses to the set of questions about barriers to the use of PBBT were categorized and grouped into themes as follow: 1) practice setting, 2) equipment, 3) knowledge/training, 4) client characteristics, 5) time and 6) human resources. The answers to the set questions about barriers are presented in Table 4.

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Practice setting

Most participants in all 3 groups (>50%) agreed that they have limited space in which to set up the PBBT equipment. There was no significant difference between the groups regarding this issue. The non-users were more likely than the users to agree that their clients’ length of stay is too short for conducting PBBT (P=0.002).

Equipment

The open-to-use were more likely than the users and non-users to state that they do not have the authority to purchase PBBT equipment (P=0.004 and P=0.047, respectively). All three groups equally agreed with the statement that delivering effective manual perturbations can be fatiguing.

Knowledge/training

The users were significantly more likely to disagree about being unsure of when to use PBBT than the non-users and the open-to-use (P<0.001 and P<0.001, respectively), with approximately 20% of participants acknowledging they are unsure of when to use this method. In the non-users’ group, half the participants stated they are unsure of when to use PBBT and 41.5% of the open-to-use agreed.

Client characteristics

Significantly more non-users stated that there is weak evidence to justify PBBT use with their clients, than in the users’ group (P=0.006). There was no significant difference among the groups regarding patients being apprehensive about PBBT and, in all three groups, less than half of the physical therapists agreed with this statement. There were, however, significant differences between the users and the non-users, and also between the users and the open-to-use group in regard to PBBT patient safety (P<0.001 and P<0.001, respectively). The majority of the users’ group (93.2%) disagreed that PBBT is unsafe for their clients, while around one-third of the non-user physical therapists and the open-to-use group agreed with this statement. Moreover, fewer physical therapists in the users’ group stated that their client population is too cognitively impaired to practice PBBT than among the non-users and in the open-to-use group (P=0.028 and P=0.045, respectively).

Time

The users were less likely than the non-users and the open-to-use to state that setting up PBBT takes too much time, with only ~17% agreement (P<0.001 and P<0.001, respectively). Fifty-two percent of the non-user physical therapists agreed with this statement, with no significant difference between non-users and open-to-use group.

Human resources

Similar results are seen regarding the human resources barriers. The users were less likely to state that they need assistance to do PBBT, with only 18.5% agreeing with this statement, compared to ~50% agreement in the non-users’ and open-to-use groups (P<0.001 and P<0.001, respectively).

Facilitators for implementing PBBT

Responses to set questions about facilitators for implementing PBBT were categorized by themes as follow: 1) practice setting, 2) equipment, 3) knowledge/training. The answers to the set questions about facilitators are presented in Table 5.

Practice setting

The results show that the user physical therapists generally have more facilitators to implement PBBT, and a more supportive workplace environment. The users were more likely to claim that they can easily complete PBBT at their clinical practices with agreement rates of over 90%, while only about 40% of the participants in non-users’ group and in the open-to-use group claimed the same (P<0.001 and P<0.001, respectively). In all groups most physical therapists declared that they have one or more colleagues that use PBBT, but there was a statistically significant difference in favor of the users’ group compared to non-users and the open-to-use group (P<0.001 and P<0.001, respectively). There was no significant difference between the non-users’ group and the open-to-use group regarding this matter. Results reveal that the users’ group also has more encouragement in their workplace; users were more encouraged by colleagues to use PBBT than the non-users and the open-to-use groups (P<0.001 and P<0.001, respectively), with almost 60% of users agreed to receive this encouragement compared to 15% in the non-users’ group and 29% in the open-to-use group. Significant difference was also seen in the users’ group who were more likely to agree that they are encouraged by their manager compared to the non-users and the open-to-use group (P<0.001 and P<0.001, respectively) with almost 84% of agreement in the users’ group compared to the non-user's group (35%) and to the open-to-use group (31%). The users’ group was also more likely to agree that they have budget to purchase PBBT equipment in their workplace compared to the non-users and to the open-to-use group (P=0.023 and P<0.001, respectively).

Equipment

More than half of the user participants stated that they have access to PBBT resources and were significantly more likely to agree than 35% of the non-users’ group and 22% of the open-to-use group (P=0.023 and P<0.001, respectively).

Knowledge/training

Table 5 shows that the users’ group were more likely to agree that they have sufficient training in PBBT than the non-users and the open-to-use group (P<0.001 and P<0.001, respectively) and that the users know what equipment is required to complete PBBT, compared to the non-users and the open-to-use group (P=0.007 and P<0.001, respectively). No statistically significant difference was found between the non-users and the open-to-use group. Also, there was no statistically significant difference between all 3 groups regarding to the statement that with more hands-on training participants will be more inclined to use PBBT. Note that there was a general agreement with the statement in the 3 groups.

insert table 5 here

Odds ratios of properties, barriers, and facilitators

To understand the amount of the variables' impact on the use of PBBT, we calculated the OR using multivariate logistic regression models; we included variables that were statistically significant at the post-hoc pairwise comparisons of the users’ group and the non-user's group. We chose variables in which we had the most interest with and categorized them into three themes: 1) properties, 2) barriers, and 3) facilitators. After ruling out variable's collinearity, we created a multivariate logistic regression model for each theme. Variables and results for the properties, barriers and facilitators regression models are presented in tables 6-8 respectively.

Odds ratios of properties

Properties table shows that individuals who agreed they have confidence in their ability to conduct PBBT are 11.36 times more likely to be PBBT users than those who declared they do not have confidence (95% CI=4.40, 29.33; p<0.001). Other variables did not attain statistical significance (table 6).

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Odds ratios of barriers

Physical therapists who agree that PBBT is unsafe for their patients are 7.69 times less likely to use PBBT than those who disagree (95% CI=0.03, 0.52; p=0.004). Other variables did not reach statistical significance (table 7).

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Odds ratios of facilitators

Considering facilitators, two variables attained statistically significance. Individuals who agree they can conduct PBBT easily at their clinics are 41.53 times more likely to use PBBT than those who disagree (95% CI=6.64, 259.97; p<0.001), and those who are encouraged by their colleagues to use PBBT are 8.16 times more likely to be a PBBT user than those who are not (95% CI=1.73, 38.49; p=0.008; table 8).

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Odds ratios of combined barriers and combined facilitators

In addition to the OR of each of the chosen variables, we wanted to calculate the OR of the combined barriers and combined facilitators of the users’ group. We did two univariate logistic regression models, one for combined barriers and another for combined facilitators. For the combined barrier model, we calculated the OR for those individuals who met the following criteria: i) sure of when to use PBBT; ii) disagree that it takes too much time to set-up for PBBT; iii) disagree that PBBT is unsafe for clients; and iv) disagree that they cannot conduct PBBT without assistance. For the combined facilitator model, we calculated the OR for those individuals who met the following criteria: i) agreed they can easily do PBBT at their clinics; ii) are encouraged by their colleagues to use PBBT; iii) have their managers’ support and/or encouragement; and iv) have access to the necessary resources for using PBBT. For each model, we sought the ORs of those who met the above criteria. The results of the combined barrier and combined facilitator regression models appear in Table 9.

insert Table 9 here

Results show that those who meet the combined barrier criteria mentioned above are 10.9 times more likely to use PBBT than those who do not meet them (95% CI=3.30, 36.00; p<0.001). Moreover, those who meet the combined facilitator criteria mentioned above are 4.5 times more likely to use PBBT than those missing even one of those prerequisites (95% CI=1.06, 19.72; p=0.042). These results were statistically significant.

Learning needs for promoting the use of PBBT

The responses regarding preferred methods for learning about PBBT were categorized by topics. Physical therapists stated whether, or not, they would like to know more about a certain topic and how they would prefer to learn (Table 10).

There were high rates of interest (80.4%-95.6%) in all the 3 groups, without significant differences between them indicating that most of the participating PTs (from all the groups) wanted more knowledge of/and familiarity with PBBT. Among the users and non-users, most of the PTs answered that they would like to learn more about the principles of training for PBBT, while in the open-to-use group, most of the PTs stated they are interested in learning more about identifying patients’ reactive balance control impairments and about specific approaches for treating such impairments. High interest (64%-93.3%) was also reported regarding the various learning options in PT education. In each group, the highest scores (90.2%-93.3%) were given for learning by means of watching instructional videos. Among the users, this choice was followed by attending practical ‘hands on’ workshops. The second choice of the open-to-use group was the reading of training manuals, while in the non-users’ group, it was followed by webinars/teleconferences.

insert table 10 here

Similarly to the previous study with health-care professionals in Canada who use PBBT (28), most of Israeli PTs who participated in the research claim they use PBBT in their clinical practice (76.3% versus 75.4%). Also, in the Israeli cohort there were contradictions in responses, thus it is possible that some of the participants who declared using PBBT are, in fact, not challenging reactive balance control, indicate a misunderstanding or confusion of the meaning of reactive balance control, although the definition was included in our questionnaire. It seems that participants in the Israeli cohort referred to an incidental loss of balance during practice rather than directed and specific training for reactive balance control. Interestingly, almost 40% of the PTs declared to have over 20 years of experience in their profession. This raises the possibility that these PT's have a limited knowledge regarding PBBT. The PBBT is clinically evident to prevent falls and to improve reactive balance control only around the past 10–15 years (23, 30, 31), thus it is possible that time from graduation is a factor that may influence their response.

We noticed that barriers related to practice setting (i.e., the limited space to set up equipment) and not having the authority to purchase PBBT equipment were the most prevalent, indicating that PTs may falsely believe that PBBT requires large and expansive equipment. This is not always the case since perturbations can be acquired with simple and small equipment such as 'balance Swiss ball' exercises or water-based perturbation exercises (32–35). We also found that the non-users were the least likely to receive PBBT education in their entry-to-practice program, and the least familiar with PBBT research studies compare to other groups. The non-users were also less sure than the users of when to use PBBT, indicating on a gap in knowledge between these two groups. These findings are similar to the results of Mansfield et al. (28), who found lack of knowledge to be the most significant barrier for those who do not use PBBT. Other interesting findings were related to the patients' properties. The non-users’ group seemed to have more patients than the users’ group who were reportedly too cognitively impaired to treat with PBBT. This finding fits with the multivariate logistic regression model that show that the non-users’ group tended to believe more than the users’ group that PBBT is unsafe for their patients, although there was no difference regarding thinking their patients are apprehensive of PBBT. Additionally, compared to users, the non-users also tended to agree that their patients do not stay long enough in order to imply PBBT.

Regarding the facilitators to implement PBBT the most frequent facilitator was having at least one PT colleague that uses PBBT. Generally, the users group seemed to have more supportive workplace environment to use PBBT since they were more likely to have a user colleague, had more encouragement from their colleagues, and had more encouragement from their manager to use PBBT. Other facilitators were access to resources, budget for equipment, sufficient PBBT training, knowledge of required equipment and being able to easily complete PBBT in practice. These results match with previous research that tried to identify facilitators to implement rehabilitation methods in practice (28, 29).

Similarly to the Canadian cohort (28) the majority of PTs in our cohort reported high interest to learn all the different topics of PBBT. The two topics that garnered the most interest was identifying patients’ reactive balance control impairments, specific approaches for treating such impairments and to know more about principals of PBBT training. The most preferred way to increase knowledge and familiarity with PBBT was by watching instructional videos, which was also the most favored way in the Canadian research (28).

The current study has several limitations; first, we used a questionnaire that was distributed via several channels, such as Email and social networks. Using the format of a ‘convenient study’ enabled us to reach a relatively large number of PTs, but there is an accompanying risk of incurring bias. In our sample the entire population of PTs were eligible to participate, but it might be that those PTs who chose to respond were more interested in PBBT. Also, there was a possibility that only physical therapists who think they use PBBT would complete our questionnaires, which might result in an over-representation of PTs reporting the use of PBBT in their clinical practices (75.4%) and skewing the results, as if more PTs are using PBBT than actually do so and thus, are likely not capturing the perspectives of those who have the most challenges or less interest with PBBT. We also considered the possibility that some PTs might feel as if they are being evaluated/examined and, as such, might provide insincere responses. To avoid such imprecisions, we emphasized that the survey is anonymous, hoping that the participants would feel more comfortable giving us honest answers. Another limitation was discovered in some of the answers themselves; there were several internal contradictions in certain questionnaires, perhaps implying a misunderstanding of ‘reactive balance control’. In an attempt to overcome such contradictions, we excluded those responders from the affected analysis; a similar observation was made by Mansfield et al. (28) raising the possibility that this misunderstanding is quite common. This possible confusion regarding ‘reactive balance control’ and the false beliefs regarding PBBT (such as the necessity for the use of large and cumbersome equipment), had led us to conclude that some misconceptions still surround this topic.

In conclusion, continued effort is necessary to increase the implementation of PBBT in practice. We believe that there is a definite need to improve the knowledge and familiarity of clinicians regarding PBBT therapy, in order to widely implement this highly effective method for preventing falls in the older population in Israel. Creating reliable information sources for PBBT should help to reduce such doubt and hesitation by expanding the physical therapists’ practical knowledge, along with facilitating the implementation of instructional and therapeutic programs, that will hopefully reduce the risk of future falls and their costly consequences.

CI – Confidence Interval

IPTS - Israeli Physical Therapy Society

OR - odds ratios

PBBT – Perturbation-Based Balance Training

PT - Physical Therapy

RCT - Randomized Control Trials

Ethics approval and consent to participate

Ethics approvals have been obtained by Ethics Committees in the faculty of health sciences at Ben-Gurion University (Ethics Committee approval number 38-2020). All methods were carried out in accordance with relevant guidelines and regulations (declaration of Helsinki). All participants informed consent before answering the study questionnaire.

Consent for publication

Not applicable.

Availability of data and materials

The datasets used and/or analyzed in the current study are available from the corresponding author upon reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The work reported in this publication was granted by the Recanati school of community health professions at the faculty of health sciences, Ben-Gurion University if the Negev, Israel.

Authors' contributions

N.M. and I.M., participated in data collection, data management and statistical analyses, manuscript drafting and revision. N.M., A.M., I.M., I.K.., and O.W., participated in study protocol design and manuscriptdrafting and revision N.M., A.M, I.M., I.K., participated in translating the questionnaire to Hebrew and back translation to English.

Acknowledgements

We thank the PTs who participated in this study and the management of IPTS for helping us to distribute the questionnaires.

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Table 1. Participant characteristics. Values presented as number of responses in each category, with percentage of the group in parentheses.
	Non-users	Users	Open-to-use	Total
Number	59	217	76	352
Gender
Male	16 (27.1)	69(31.8)	7(9.2)	92(26.1)
Female	43(72.9)	148(68.2)	69(90.8)	260(73.9)
Highest level of education
Bachelor's	35(59.3)	122(56.5)	45(60)	202(57.7)
Professional master's	13(22)	41(19)	16(21.3)	70(20)
Thesis-based master's	10(16.9)	46(21.3)	13(17.3)	69(19.7)
PhD	1(1.7)	7(3.2)	1(1.3)	9(2.6)
Missing	0(0)	1(0.4)	1(1.3)	2(0.5)
Professional experience
5 years or less	9(15.3)	43(19.8)	22(28.9)	74(21)
6-10 years	10(16.9)	40(18.4)	16(21.1)	66(18.8)
11-15 years	5(8.5)	38(17.5)	9(11.8)	52(14.8)
16-20 years	10(16.9)	14(6.5)	3(3.9)	27(7.7)
More than 20 years	25(42.4)	82(37.8)	26(34.2)	133(37.8)
Time spent treating clients with balance problems (per week)
0-1 work day	23(40.4)	54(25.1)	15(19.7)	92(26.4)
1-2 work days	19(33.3)	89(41.4)	34(44.7)	142(40.8)
2-3 work days	8(14)	37(17.2)	17(22.4)	62(17.8)
3-4 work days	2(3.5)	25(11.6)	5(6.6)	32(9.2)
4-5 work days	5(8.8)	10(4.7)	5(6.6)	20(5.7)
Missing	2(3.5)	2(0.9)	0(0)	4(1.1)
Healthcare setting
Acute care	11(19.3)	19(8.8)	9(11.8)	39(11.2)
Inpatient rehabilitation	7(12.3)	34(15.8)	13(17.1)	54(15.5)
Outpatient rehabilitation	1(1.8)	15(7)	2(2.6)	18(5.2)
Private practice	7(12.3)	21(9.8)	4(5.3)	32(9.2)
Home/community care	18(31.6)	73(34)	24(31.6)	115(33)
Long term care	3(5.3)	11(5.1)	8(10.5)	22(6.3)
Other	10(17.5)	42(19.5)	16(21.1)	68(19.5)
Missing	2(3.5)	2(0.9)	0(0)	4(1.1)
Area of practice
Neurological	7(12.1)	53(24.8)	9(11.8)	69(19.8)
Orthopedic	26(44.8)	82(38.3)	34(44.7)	142(40.8)
Cardiorespiratory	1(1.7)	2(0.9)	0(0)	3(0.9)
Geriatric	7(12.1)	28(13.1)	15(19.7)	50(14.4)
Pediatric	7(12.1)	10(4.7)	7(9.2)	24(6.9)
Other	10(17.2)	39(18.2)	11(14.5)	60(17.2)
Missing	1(1.7)	3(1.4)	0(0)	4(1.1)

Table 2. Treatment strategies for balance and mobility problems. The values presented indicate the number of responses in each category, with percentage of the group in parentheses.
		Non-users	Users	Open-to-use	Total
Number		59	217	76	352
Client's admitting diagnosis
	Stroke	32(54.2)	129(59.4)	40(52.6)	201(57.1)
	Movement disorder including Parkinson disease	28(47.5)	131(60.4)	48(63.2)	207(58.8)
	Spinal cord injury	7(11.9)	57(26.3)	19(25)	83(23.6)
	Cerebral palsy	9(15.3)	31(14.3)	13(17.1)	53(15.1)
	Acquired brain injury excluding stroke	10(16.9)	68(31.3)	14(18.4)	92(26.1)
	Multiple sclerosis	7(11.9)	58(26.7)	15(19.7)	80(22.7)
	Vestibular conditions	23(39)	68(31.3)	30(39.5)	121(34.4)
	Dementia/cognitive impairment	19(32.2)	91(41.9)	33(43.4)	143(40.6)
	Musculoskeletal conditions	43(72.9)	174(80.2)	59(77.6)	276(78.4)
	COPD/respiratory conditions	12(20.3)	35(16.1)	16(21.1)	63(17.9)
	Cardiac conditions	9(15.3)	34(15.7)	12(15.8)	55(15.6)
	Geriatric	39(66.1)	152(70)	55(72.4)	246(69.9)
Treatment strategies
	Task-oriented training	37(62.7)	156(71.9)	55(72.4)	248(70.5)
	Bobath/neurodevelopmental training	13(22)	66(30.4)	17(22.4)	96(27.3)
	Overground walking practice	49(83.1)	177(81.6)	56(73.7)	282(80.1)
	Body weight supported treadmill training	11(18.6)	56(25.8)	11(14.5)	78(22.2)
	Functional electrical stimulation	1(1.7)	10(4.6)	1(1.3)	12(3.4)
	Strength training	38(64.4)	158(72.8)	53(69.7)	249(70.7)
	Aerobic/cardiorespiratory training	19(32.2)	92(42.4)	33(43.4)	144(40.9)
	Perturbation-based balance training	14(23.7)	185(85.3)	40(52.6)	239(67.9)
	Video game-based interventions/exergaming	15(25.4)	72(33.2)	17(22.4)	104(29.5)
	Specific exercise program (e.g., FaME, Otago etc.)	3(5.1)	24(11.1)	6(7.9)	33(9.4)

Table 3. Prior experiences, attitudes, and knowledge of PBBT.
		Non-users		Users		Open-to-use
		n	Responses	n	Responses	n	Responses	P-value
Prior experiences with PBBT
Received PBBT education in entry-to-practice program		58	17(29.3)	216	124(57.4)	75	37(49.3)	0.001	*	†
First heard about PBBT
	Bachelor's degree	49	19(38.8)	213	90(42.3)	74	32(43.2)	0.005
	Master's degree		3(6.1)		12(5.6)		8(10.8)
	Workplace/Colleagues		7(14.3)		52(24.4)		12(16.2)
	Continuing education		2(4.1)		32(15)		7(9.5)
	Physiotherapy conference		14(28.6)		17(8)		12(16.2)
	Physical therapist acquaintance		4(8.2)		10(4.7)		3(4.1)
Tried PBBT, but found it to be ineffective		39	1(2.6)	199	3(1.5)	64	2(3.1)	0.695
Clients acknowledge that balance improves with PBBT		10	7(70)	157	150(95.5)	35	26(74.3)	<0.001		†	‡
Confident in ability to conduct PBBT with clients		46	22(47.8)	198	185(93.4)	63	30(47.6)	<0.001		†	‡
Prefer to use other treatment options besides PBBT		46	34(73.9)	177	72(40.7)	69	45(65.2)	<0.001		†	‡
Would like to use PBBT more		38	30(78.9)	191	157(82.2)	66	61(92.4)	0.096
Familiar with PBBT research		58	15(25.9)	212	112(52.8)	73	35(47.9)	0.001	*	†
Research evidence that PBBT can improve sensation		6	6(100)	51	44(86.3)	17	17(100)	0.175
Research evidence that PBBT can improve walking function performance		8	8(100)	77	75(97.4)	23	22(95.7)	0.799
Research evidence that PBBT can improve lower-limb muscle strength/endurance		5	5(100)	58	38(65.5)	18	16(88.9)	0.056
Research evidence that PBBT can improve anticipatory balance control		8	8(100)	75	72(96)	22	20(90.9)	0.495
Research evidence that PBBT can improve reactive balance control		8	8(100)	82	82(100)	23	23(100)
Research evidence that PBBT can improve coordination		4	4(100	57	53(93)	20	19(95)	0.827
Research evidence that PBBT can improve spatial awareness		5	4(80)	60	56(93.3)	18	16(88.9)	0.528
Research evidence that PBBT can reduce falls in daily life		8	8(100)	80	78(97.5)	24	24(100)	0.665
Research evidence that PBBT can improve balance confidence		8	8(100)	79	78(98.7)	25	25(100)	0.810
* Significant difference between the Non-user and Open-to-use groups (P < 0.0056 for nine pairwise comparisons). †Significant difference between the Non-user and User groups (P < 0.0056 for nine pairwise comparisons). ‡ Significant difference between the Open-to-use and User groups (P < 0.0056 for nine pairwise comparisons). Only those who answered that they have practical knowledge about PBBT were invited to answer questions regarding research evidence.

Table 4. Barriers to implementing PBBT. Data presented are the total number of non-missing responses (n) and the number of responses in each category, for each item for each group, with the percentage of non-missing responses in parenthesis. The p-value is for the item chi-square test, comparing response rates between groups and categories of response. The symbols indicate results of pairwise comparisons.
	Non-users		Users		Open-to-use
	n	Responses	n	Responses	n	Responses	P-value
Barriers related to practice setting
Limited space to set up equipment for PBBT	32	24(75)	157	102(65)	52	38(73.1)	0.368
Clients' length of stay is too short to include PBBT in treatment plans	35	14(40)	184	28(15.2)	64	17(26.6)	0.002		†
Barriers related to equipment
Do not have the authority to purchase equipment for PBBT	41	23(56.1)	156	86(55.1)	56	43(76.8)	0.015	*		‡
Delivering effective manual perturbations can be fatiguing	35	16(45.7)	191	85(44.5)	64	37(57.8)	0.177
Barriers related to knowledge/training
Unsure of when to use PBBT	42	21(50)	202	40(19.8)	65	27(41.5)	<0.001		†	‡
Barriers related to client characteristics
Weak evidence to justify the use of PBBT with client population	31	7(22.6)	163	9(5.5)	51	4(7.8)	0.006		†
Clients have communicated that they are apprehensive about PBBT	26	10(38.5)	193	76(39.4)	57	27(47.4)	0.539
PBBT is not safe for my clients	31	11(35.5)	190	13(6.8)	59	21(35.6)	<0.001		†	‡
Clients are too cognitively impaired to take part in PBBT	36	4(11.1)	181	4(2.2)	60	5(8.3)	0.023		†	‡
Barriers related to time
Takes too much time to set-up for PBBT	25	13(52)	166	28(16.9)	44	16(36.4)	<0.001		†	‡
Barriers related to human resources
Cannot conduct PBBT without having someone else to assist	27	15(55.6)	173	32(18.5)	43	21(48.8)	<0.001		†	‡
*Significant difference between the Non-user and Open-to-use groups (P < 0.0056 for nine pairwise comparisons). †Significant difference between the Non-user and User groups (P < 0.0056 for nine pairwise comparisons). ‡ Significant difference between the Open-to-use and User groups (P < 0.0056 for nine pairwise comparisons).

Table 5. Facilitators for implementing PBBT. Data presented are the total number of non-missing responses (n) and the number of responses in each category, for each item for each group, with the percentage of non-missing responses in parenthesis. The p-value is for the item chi-square test, comparing response rates between groups and categories of response. The symbols indicate results of pairwise comparisons.
	Non-users		Users		Open-to-use
	n	Responses	n	Responses	n	Responses	P-value
Facilitators related to practice setting
Can easily complete PBBT at place of practice	46	17(37)	205	187(91.2)	71	29(40.8)	<0.001	†	‡
One or more colleagues has used PBBT	35	20(57.1)	164	159(97)	52	32(61.5)	<0.001	†	‡
Colleagues have encouraged use of PBBT	39	6(15.4)	156	91(58.3)	59	17(28.8)	<0.001	†	‡
Manager supports and/or encourages use of PBBT	26	9(34.6)	117	98(83.8)	35	18(51.4)	<0.001	†	‡
Purchasing equipment for PBBT is within workplace budget	25	6(24)	132	76(57.6)	34	7(20.6)	<0.001	†	‡
Facilitators related to equipment
Have access to resources necessary to use PBBT	40	14(35)	173	96(55.5)	64	14(21.9)	<0.001	†	‡
Facilitator related to knowledge/training
Have sufficient training in PBBT	46	9(19.6)	174	89(51.1)	66	9(13.6)	<0.001	†	‡
With more hands-on training would be more inclined to use PBBT	32	18(56.3)	162	88(54.3)	64	42(65.6)	0.299
Know what equipment is required to administer PBBT	38	13(34.2)	167	99(59.3)	50	15(30)	<0.001	†	‡
*Significant difference between the Non-user and Open-to-use groups (P < 0.0056 for nine pairwise comparisons). †Significant difference between the Non-user and User groups (P < 0.0056 for nine pairwise comparisons). ‡ Significant difference between the Open-to-use and User groups (P < 0.0056 for nine pairwise comparisons).

Table 6. Users' properties, with a multivariate logistic regression model.
p-value	95% CI	OR
0.107	0.863-4.496	1.970	I have received education on PBBT in my entry-to-practice healthcare-professional program
0.726	0.501-2.696	1.162	I am familiar with some research evidence surrounding PBBT
<0.001	4.402-29.331	11.363	I am confident in my ability to conduct PBBT with my clients
0.088	0.187-1.122	0.458	I prefer to use other treatment options besides PBBT
OR=odds ratio, represents the odds ratio to use PBBT if agreeing with the matching sentence above. CI=confidence interval.

Table 7. Users' barriers, with a multivariate logistic regression model.
p-value	95% CI	OR
0.742	0.182-3.362	0.783	I am unsure of when to use PBBT in my practice
0.113	0.092-1.288	0.345	It takes too much time to set-up for PBBT
0.004	0.033-0.521	0.130	PBBT is not safe for my clients
0.152	0.110-1.412	0.393	I cannot conduct PBBT with my clients without having someone else to assist me
OR=odds ratio, represents the odds ratio to use PBBT if agreeing with the matching sentence above. CI=confidence interval.

Table 8. Users' facilitators, with a multivariate logistic regression model.
p-value	95% CI	OR
<0.001	6.636-259.969	41.535	I can easily complete PBBT at my place of practice
0.008	1.728-38.490	8.156	My colleagues have encouraged me to use PBBT
0.234	0.526-13.767	2.692	My manager supports and/or encourages use of PBBT in my practice
0.051	0.020-1.008	0.144	I have access to resources necessary to use PBBT in my practice
OR=odds ratio, represents the odds ratio to use PBBT if agreeing with the matching sentence above. CI=confidence interval.

Table 9. Combined barrier and combined facilitator univariate logistic regression models.
p-value	95% CI	OR
<0.001	3.304-35.966	10.900	Combined barriers
0.042	1.060-19.722	4.572	Combined facilitators
Combined barriers represent individuals that are sure of when to use PBBT, disagree that it takes too much time to set-up for PBBT, disagree that PBBT is unsafe for clients, and disagree that they cannot conduct PBBT without assistance. Combined facilitators represent individuals that agree they can easily do PBBT at their clinics, are encouraged by colleagues to use PBBT, have managerial support and/or encouragement, and have access to the necessary resources for doing PBBT. OR=odds ratio, represents the odds ratio for the use of PBBT, in accordance with the aforementioned criteria. CI=confidence interval.

Table 10. Learning needs for promoting the use of PBBT. The data presented are the total number of non-missing responses (n) and the number of responses in each category, for each item in each group, with the percentage of non-missing responses in parenthesis. The p-values represent each item in the chi-square test, comparing response rates among the three groups and the various response categories.
		Non-users		Users		Open-to-use
		n	Responses	n	Responses	n	Responses	P-value
Interested in learning more about
	Theoretical background of PBBT	56	45(80.4)	206	172(83.5)	73	63(86.3)	0.664
	Principles of training for PBBT	58	53(91.4)	206	197(95.6)	74	68(91.9)	0.319
	Identifying clients' reactive balance control impairments	56	50(89.3)	204	195(95.6)	73	69(94.5)	0.197
	Specific approaches for clients' reactive balance control impairments	56	51(91.1)	206	196(95.1)	73	69(94.5)	0.503
Interested in learning more about PBBT through
	'Hands on' workshop	49	38(77.6)	195	150(76.9)	70	54(77.1)	0.996
	Reviewing case studies	45	30(66.7)	171	119(69.6)	65	46(70.8)	0.896
	Having access to an expert to answer questions	47	36(76.6)	178	139(78.1)	66	52(78.8)	0.961
	Reading scientific literature	46	35(76.1)	183	126(68.9)	64	46(71.9)	0.610
	Reading training manual	46	35(76.1)	182	137(75.3)	67	57(85.1)	0.249
	Watching instructional videos	55	51(92.7)	194	175(90.2)	75	70(93.3)	0.661
	Webinar/teleconference	52	41(78.8)	180	135(75)	69	54(78.3)	0.778
	An in-person lecture	50	32(64)	188	139(73.9)	63	46(73)	0.373
* Significant difference between the Non-user and Open-to-use groups (P < 0.0056 for nine pairwise comparisons). †Significant difference between the Non-user and User groups (P < 0.0056 for nine pairwise comparisons). ‡ Significant difference between the Open-to-use and User groups (P < 0.0056 for nine pairwise comparisons).

No competing interests reported.

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A Survey of Israeli Physical Therapists Regarding Perturbation-Based Balance Training

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