Abstract
Background and Purpose Knowledge translation (KT) is an emerging discipline with a focus on implementing health evidence in decision making and clinical practice. Knowledge translation theories provide conceptual frameworks that can direct research focused on optimizing best practice. The objective of this case report is to describe one prominent KT theory—the knowledge-to-action (KTA) framework—and how it was applied to research on balance and gait assessment in physical therapist practice.
Case Description Valid and reliable assessment tools are recommended to evaluate balance and gait function, but gaps in physical therapy practices are known. The KTA framework's 2-pronged approach (knowledge creation phase and action cycle) guided research questions exploring current practices in balance and gait assessment and factors influencing practice in Ontario, Canada, with the goal of developing and evaluating targeted KT interventions.
Outcomes Results showed the rate at which therapists use standardized balance and gait tools was less than optimal and identified both knowledge-to-practice gaps and individual and organizational barriers to implementing best assessment practices. These findings highlighted the need for synthesis of evidence to address those gaps prior to the development of potential intervention strategies.
Discussion The comprehensive KTA framework was useful in guiding the direction of these ongoing research programs. In both cases, the sequence of the individual KTA steps was modified to improve the efficiency of intervention development, there was a need to go back and forth between the 2 phases of the KTA framework, and additional behavior change and barrier assessment theories were consulted. Continued research is needed to explicitly evaluate the efficacy of applying KT theory to best practice in health care.
Delivery of high-quality health care that is evidence-based, cost-effective, individually tailored, and sustainable requires a coordinated strategy. To facilitate the consideration of research evidence in clinical practice, a focus on “knowledge translation” (KT) has emerged in health care. A commonly used definition developed by the Canadian Institutes of Health Research (CIHR), the primary funder of health research in Canada, describes KT as “a dynamic and iterative process that includes synthesis, dissemination, exchange and ethically sound application of knowledge to improve the health of Canadians, provide more effective health services and products and strengthen the health care system.”1 Physical therapist practice has traditionally incorporated a strong focus on evidence-based practice (EBP), defined as “integrating individual clinical expertise with the best available external clinical evidence from systematic research.”2 Adoption of a KT perspective expands the clinician-focused EBP approach, as KT may involve implementing research at the system, organization, team, or individual level. Although the exercise of translating knowledge to new situations, applications, or patients is not new, the evolution of a field dedicated to systematically optimizing the implementation of knowledge into practice, and supported by a body of evidence, represents a paradigm shift in science and health care.
Central to the rise of KT as a distinct discipline is the development of theoretical models for moving research into practice. The use of theory, defined as “a coherent and noncontradictory set of statements, concepts or ideas that organizes, predicts and explains phenomena, events, behavior, etc,”3 is recommended in KT because it provides generalizable frameworks for developing research questions and interventions, allowing for an incremental accumulation of knowledge.4 The purpose of this case report is to describe the application of KT theory in research focused on best practice in physical therapy. The theory used is the knowledge-to-action (KTA) framework.5,6 It was selected because it is a pragmatic model that provides step-by-step direction for implementation. It also has been applied to other health care settings, such as osteoporosis management.7
The examples presented focus on balance and gait assessment in physical therapist practice. Balance is required for many functional activities such as mobility and fall avoidance, and impairment is common in older adults and people living with chronic conditions.8–10 Gait impairment is also common across health conditions, particularly after stroke, where patients identify improvement in walking as a primary goal of rehabilitation.11 Assessment is important for diagnosing impairments, informing treatment plans, and evaluating change over time, and use of valid and reliable tests is a recognized component of EBP.12 However, there is evidence of a gap in incorporating balance and gait assessments into clinical practice.13,14 As such, there is a need for innovation to implement best balance and gait assessment approaches into practice and for targeted research to inform the development of interventions and their evaluation in pragmatic settings.
The objective of this case report is to describe: (1) the KTA framework and (2) how it informed our research focused on optimizing balance and gait assessment practices. In both cases, the KTA framework was used from the beginning of the research process, guiding the research questions. This work is ongoing; efforts to date have addressed the early components of the model, working toward the development of a KT intervention. Implications and limitations of applying the KTA framework are discussed.
The Knowledge-to-Action Framework
The KTA framework (Figure) divides KT into 2 phases: (1) the knowledge creation phase and (2) the action cycle. The knowledge creation phase acts as a funnel that tailors knowledge into usable units, beginning with the “knowledge inquiry” stage that refers to the range of health research literature. The next stage, “knowledge synthesis,” includes systematic reviews and meta-analyses that analyze the body of evidence on a particular topic and are the basis for the “knowledge products/tools” stage that refines the knowledge into manageable units. These units could include, but are not limited to, best practice guidelines, clinical pathways, or decision algorithms.
The knowledge-to-action framework. Reprinted with permission of John Wiley & Sons from: Straus SE, Tetroe J, Graham ID, eds. Knowledge Translation in Health Care: Moving From Evidence to Practice. 2nd ed. Chichester, United Kingdom: John Wiley & Sons Ltd; 2013.
The action cycle identifies the steps required for a unit of knowledge to reach widespread use. Although this cycle is dynamic and can be performed in any order (reflected by multidimensional arrows between stages), in general, the first step involves “identifying the problem/selecting, reviewing, and identifying the knowledge” to be translated. Once a gap is identified, there is a need to “adapt knowledge to the local context,” such as an individual practice setting or particular patient. Such adaptation may occur in conjunction with “assessing barriers to knowledge use” in that particular situation. These KTA components inform the “selection, tailoring, and implementation of interventions” designed to facilitate uptake of the knowledge by adapting interventions to individual settings and patients. Such tailoring can be informed by an emerging knowledge base on the efficacy of various implementation interventions.15 “Monitoring knowledge use” is required to evaluate the extent to which the intervention was implemented, along with “evaluation of outcomes” to assess the impact of the intervention. A unique feature of the KTA framework is the need to “sustain knowledge use” by ensuring that continued processes and reviews are implemented. However, it also is noted that this issue is addressed the least in the academic literature, as it may be considered beyond the realm of traditional research and fall outside of the scope of funding windows.7
Applying KTA to Physical Therapy Research and Practice
Case 1: Balance Assessment
The long-term objective of this research is to optimize clinical balance assessment practices and, in turn, maximize the effectiveness of interventions to improve balance and reduce falls in high-risk populations. Case 1 (balance assessment) is summarized in Table 1.
Case 1 (Balance Assessment): Aligning Research Steps With the Knowledge-to-Action Framework
Identify, review, and select knowledge.
The first step was to identify the components that should be considered in an “optimal” balance assessment approach. There is no best practice guideline for evaluating balance, nor is there a universally accepted gold standard measure. Thus, in the absence of such benchmarks, we selected content validity as the primary factor for consideration. Contemporary postural control theory views balance as the product of integrated inputs and the body as a mechanical system that interacts with the nervous system in a continuously changing environment.16–18 Based on this view, the “systems framework for postural control” was proposed (Tab. 2)19,20 and was identified as the “knowledge” guiding the consideration of theoretical constructs that should be included in an optimal balance assessment approach.
Domains in the Systems Framework for Postural Control20
Identify problem.
The next objective was to understand current balance assessment practices, which served as a baseline indicator of strengths and weaknesses in existing approaches. We conducted a cross-sectional survey of 369 randomly selected physical therapists practicing in Ontario, Canada.21,22 Ninety percent of the respondents reported using at least one standardized balance measure in their assessment, and although most components of balance were regularly assessed by the majority of respondents, reactive postural control was regularly assessed by only 41% of the respondents. Reactive control refers to rapid recovery responses following a loss of balance, and the low frequency of assessment represents a knowledge-to-practice gap because this is the component of balance most related to fall avoidance.23 The survey also revealed gaps in how reactive control is assessed: most respondents reported using nonstandardized perturbations to evaluate it, and some reported using standardized balance measures for reactive control assessment, which did not contain a specific evaluation of it.
A limitation of the survey was that it relied on self-report data, which is known to overestimate performance. Thus, we conducted a follow-up retrospective chart review to objectively validate the findings.24 The review was conducted on a random sample of charts from 250 individuals aged 65 years and over who were admitted to an Ontario urban specialized rehabilitation hospital with a diagnosis associated with balance impairment. Standardized balance measures were used in 73% of the charts reviewed. Reactive control was not assessed with any of the standardized measures documented, and it was assessed with nonstandardized methods in only 2% of charts. These results confirmed and strengthened indications of a gap in balance assessment in Ontario.
Assess barriers to knowledge use.
A secondary focus of the survey was to explore factors influencing current balance assessment practices.25 Multiple barriers were noted, reflecting individual (eg, lack of knowledge, low priority), environmental (eg, lack of time and personnel), and measure-specific (eg, tools not available, tools not appropriate for population) issues. Some barriers suggested that there is an education need—for example, the perception that standardized measures for reactive control do not exist, when in fact several clinical measures are available. In contrast, other barriers—such as a lack of psychometric data for particular populations and measures—highlighted a need for additional research evidence.
Knowledge synthesis.
Reflection on the survey and chart review findings highlighted that one potential factor influencing the gap in balance assessment related to the components of balance included in standardized measures themselves and that selection of measurement tools had a direct impact on information acquired during assessment. These findings suggested a need to better understand the nature of existing standardized balance measures and where there may be conceptual gaps in individual measures. This need entailed going back to the knowledge creation phase of the KTA framework to synthesize information on existing balance measures by identifying all existing measures and analyzing the components of balance they evaluate. A scoping review—a variation of a systematic review intended to scope and identify gaps in the literature26–28—was conducted, and 66 standardized measures of balance were identified.29 The results will be useful in identifying which measures can fill the practice gap in assessment of reactive postural control.
Case 2: Gait Assessment
Case 2 (gait assessment) is summarized in Table 3. Among people with stroke with some ambulatory capacity, more time is spent on gait retraining than on any other activity during physical therapy.30 Thus, physical therapists are primary end-users of recommendations to implement reliable and valid measures of walking poststroke. The long-term aim of this research program is to advance physical therapists' effectiveness in using standardized, valid measures of walking ability poststroke.
Case 2 (Gait Assessment): Aligning Research Steps With the Knowledge-to-Action Framework
Identify, review, and select knowledge.
The first step was to conceptualize standardized assessment as a critical element of EBP. Health measurement frameworks31 were used to identify that walking measures could serve 4 primary goals (provide a description of the magnitude of deficit, evaluate change due to a therapeutic intervention, help formulate a prognosis for walking recovery, and evaluate readiness for discharge), and a number of valid and reliable tools that involved an evaluation of walking capacity existed. Clinical practice guidelines32,33 and systematic reviews34 that emerged over the course of this research have reinforced these goals and provide guidance for the selection of stroke-related outcome measures for clinical practice, research, and education. What remained unknown early in this research program was the extent to which physical therapists were using: (1) standardized measures to describe and monitor walking capacity, predict walking recovery, or assess readiness for discharge and (2) specific measures of walking with evidence of reliability and validity in people with stroke.
Identify problem.
We conducted a cross-sectional survey of 270 physical therapists who were providing services to people with stroke in Ontario.35–38 The percentage of respondents reporting use of a walking measure to evaluate, monitor change, determine prognosis, and assess readiness for discharge in the majority of patients was 45%, 43%, 19%, and 28%, respectively. Given theoretical knowledge outlining best practices for using standardized measures to identify deficits, monitor effects of treatment, formulate a prognosis, and evaluate readiness for discharge, the low rates of use were interpreted as a knowledge-to-practice gap.
Assess barriers to knowledge use.
An additional objective of the survey was to identify barriers to the use of standardized measures of walking. Insufficient knowledge emerged as a primary barrier to respondents' use of standardized walking measures given that 40% of the physical therapists were unsure of the existence of reliable and valid measures.38 Respondents reported a number of negative perceptions of walking measures related to a lack of ability to quantify deficit severity, relate to the home and community environment, and respond to change in capacity. A subsequent qualitative study40,41 of 23 survey respondents revealed that another challenge related to the lack of adequate description in the literature of how to administer standardized assessment tools in clinical practice. Because these barriers pointed to an insufficient knowledge of existing literature on the quality, interpretability, and administration of walking measures, a systematic review that would inform education was proposed.
Knowledge synthesis.
A systematic review of the quality and interpretability of measures of walking speed and distance in people with stroke was conducted.42,43 Measures of walking speed and distance were selected because versions of these tests were recommended in emerging clinical practice guidelines for stroke14 and had demonstrated sensitivity to change as outcome measures in numerous clinical trials. Using an “integrated KT” approach,1 we included 2 knowledge users who would use the research findings to inform decision making (a physical therapy educator and clinician) on the research team. Their involvement, from the development of the research objectives to reporting of the findings, helped optimize the clinical relevance of the research. Findings described the distances required to walk at 24 community sites, the speeds required to walk across the street in the time of a walk signal,42 and walk test norms.43 These reference values will be useful for interpreting the results of tests of walking distance and speed. Results from this knowledge synthesis will be used to develop a knowledge tool for use by physical therapists in people with stroke.
Adapt knowledge to local context.
Additional findings from the qualitative study showed that physical therapists prefer synthesized online resources to facilitate quick access to preappraised and summarized information.41 When practice change is the goal, participants described a preference for learning sessions that are led by an expert, case-based, and provide opportunities to practice new skills.40 This information will inform development of an intervention to facilitate access to review and application of the knowledge tool to clinical practice in ongoing research.
Discussion
The cases described in this report outline the process involved in operationalizing the KTA framework into focused research questions in physical therapist practice. Application of the KTA framework to balance and gait assessment was associated with both direct implications for the research programs under study and broader implications for applying KT theory to best practice research. In general, the guidance of the KTA framework was helpful in presenting the implementation process in totality and serves as a roadmap for potential users. Both research programs began with the problem identification step, and the ensuing results clearly identified knowledge-to-practice gaps and factors influencing current practice, all of which were not apparent prior to this research and will be of use in developing interventions. The KTA framework effectively communicates the need to create knowledge tools based on research syntheses that are tailored to the end-user to facilitate consideration of research evidence in clinical practice. The goal of basing health care decisions on a consistent demonstration of efficacy (for interventions) and of psychometric strength (for assessment tools) in the literature, as opposed to individual studies, is a strength of the model. Indeed, a key outcome of the present application of the KTA framework was the need in both cases to move from the early action cycle components back into the knowledge creation phase for additional knowledge synthesis before advancing to the design of a potential intervention. Although such a progression is accounted for in the description of the KTA framework, it is not emphasized. Our cases present the first example we are aware of that demonstrate the practice of such reciprocal movement between knowledge creation and action phases in the literature, highlighting the iterative nature of the KT process.
Variations in Application of the KTA Framework to Balance and Gait Assessment
In addition to moving between phases of the KTA framework, there were other notable variations in our application of this theory to balance and gait assessment. First, the balance case represents an example of how to translate an established unit of knowledge even in the absence of a clinical practice guideline. Second, in both cases, we assessed barriers to knowledge use before adapting to the local context. The model advocates identifying the problem, adapting to the local context, and assessing the relevant barriers to using the knowledge, with the provision that there may be feedback (and presumably modifications) between components. We modified the recommended order of steps in an effort to optimize efficiency by first identifying relevant barriers to incorporate them into our adaptation of the knowledge to the local context. By doing so, we identified individual, organizational, and systemic factors that would influence the success of any potential intervention, and we identified knowledge gaps (such as a lack of psychometric data for some standardized balance measures) in need of additional data. Moreover, one challenge encountered in applying the KTA framework was the limited information provided on barrier assessment, when it is a critical component of translating knowledge for widespread implementation. The lack of explicit description of a conceptual framework for understanding the types of barriers at the individual, group, organization, and policy levels is a limitation of the KTA framework, one that required us to consult additional theories for guidance. Other authors also have used the KTA framework in conjunction with other theories,7 emphasizing that no single model may serve all necessary purposes.
Another limitation of the KTA framework is that it does not explicitly describe the need for end-users (eg, clinicians) to appraise whether knowledge applies to the local context. Physical therapists have described the challenge of applying research evidence derived from a relatively homogeneous population to diverse patients seen in everyday practice.40 Physical therapist professional programs should provide education on the role of and opportunities to practice clinical reasoning in the context of applying clinical practice recommendations. This education will provide students with a foundation for exercising clinical judgment when deciding whether a recommended practice will be suitable to apply.
Future Directions
Although this report is limited in that neither case has completed the action cycle, this comprehensive approach has been advocated in the literature44 and emphasizes the importance of not “rushing” to the intervention phase. An advantage of applying the KTA framework to our research program is that we have a clear direction for next steps. With respect to balance assessment, much of the variation in clinical practice reflects the variation in options for standardized measurement and highlights the need for greater consistency in balance assessment across the continuum from research to practice. Accordingly, we are conducting an ongoing project to develop recommendations for minimum data sets for measuring balance. This activity will serve as precursor to implementing an optimized assessment approach that includes a focus on appropriate assessment of reactive postural control. There is a need for data on how to implement knowledge tools, as there is a dearth of such information in the literature. With respect to gait assessment, findings from the systematic review are being used to develop a knowledge tool that will have application to gait assessment poststroke. Examples of tailoring, evaluating, and sustaining interventions in physical therapist practice are scarce, and we refer readers to published examples in osteoporosis management incorporating these steps.7
We noted some limitations in applying the KTA framework. In particular, there is a need for additional work to optimize the ability to apply KT theory to best practice research and implementation science. There is little consideration for the role of clinical reasoning in the framework. Our work has attempted to address this gap by incorporating clinical judgment. For example, reactive postural control assessment may not be appropriate for every patient, so the KT intervention would be to ensure that physical therapists actively consider assessing reactive balance and document reasons when it is not performed. Though emphasizing the importance of knowledge tools, the current KTA framework provides little direction for their creation and how to tailor them to the end-user, nor does the description of the action cycle refer to theories of behavior change at the individual, group, or organizational level that may optimize intervention effectiveness. One key finding in the balance assessment case was that respondents overwhelmingly expressed a desire to improve assessment practices.25 Although the consideration of end-user readiness-for-change is commonly recognized in the literature, it is not addressed in the KTA framework. Moreover, evidence for effective KT interventions in rehabilitation is scarce,45 and the efficacy of the application of KT frameworks themselves has not been empirically evaluated.46
Conclusions
The KTA framework is a broad conceptual model for translating research evidence into practice, and we have demonstrated how it can be applied to research focusing on best practice in physical therapy. Although useful for shaping research questions and providing a general direction for moving from research to action, in order to be truly comprehensive, there may be a need to consult additional models of behavior change and barriers to behavior. Continued research is warranted to evaluate the efficacy of specific implementation strategies, and the KT process, more broadly.
Footnotes
Both authors provided concept/idea/project design, writing, and data collection and analysis.
A podium presentation of a portion of the manuscript content was given at the 2014 Canadian Falls Prevention Conference; May 27, 2014; Toronto, Ontario, Canada.
Dr Sibley was supported by fellowships from the Canadian Institutes of Health Research (CIHR) and KT Canada. Dr Salbach holds a New Investigator Award in Knowledge Translation from CIHR.
- Received October 15, 2013.
- Accepted June 15, 2014.
- © 2015 American Physical Therapy Association
References
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