“I don't think about a specific framework for exercise prescription” - Is there a more thoughtful approach to prescribing balance exercise?

This study aimed to explore the professional challenges posed by clinical reasoning related to balance exercise prescription across years of experience, clinical settings, and geographical regions. 

An online survey, hosted on REDCap, was distributed via health professional conferences, social media, and researcher networks to reach physiotherapists and other practitioners who prescribe balance exercises. The survey collected data on participant demographics, clinical reasoning, and training related to balance exercise prescription including awareness of the Balance Intensity Scale. Clinical reasoning questions focused on evidence-based frameworks, thought processes, and decision-making, using open-ended questions to elicit detailed responses.  Descriptive statistics summarised demographic data, while qualitative content analysis synthesised data describing the respondents' approaches to balance exercise prescription and related parameters.

Of 142 respondents, most were from Australia (n=68, 47.9%) and the USA (n=56, 39.4%), with 79.6% identifying as physiotherapists (n=113) and 55.6% working in outpatient settings (n=79). Years of prescribing balance exercise ranged from 1 to 40 years (median 11.5). Most respondents (n=93, 65.5%) had completed further training in balance exercise prescription. Prescription decisions were reported to be largely based on frameworks, guidelines, and educational resources (n=118, 83.1%), with the most confirming they used the FITT (frequency, intensity, type, time) framework (n=106, 74.6%). Nearly one in four respondents (n=35, 24.6%) reported considering client assessments when prescribing balance exercises, with client physical and balance capacity being the most mentioned factor (n=20, 14.1%). Only five respondents (3.5%) reported using objective measures to guide balance exercise prescription. Additional factors included client goals and preferences (n=12, 8.5%), client response (n=8, 5.6%), ease of implementation and enjoyment (n=5, 3.5%), and access to exercise equipment (n=2, 1.4%). 

This study identified that prescription decisions were loosely connected to evidence-based guidelines and highly variable.  Objective assessments were rarely incorporated into exercise prescribing decisions. The FITT framework was the primary prescribing model used by physiotherapists to guide dosage decisions across levels of experience, setting, and geographic regions.

This study indicates that physiotherapists across levels of experience, setting, and geographic regions use highly variable evidence and approaches to make decisions when prescribing balance exercises. This highlights a lack of consistency that may indicate a gap in evidence-based practice in the field of balance exercise prescription. Importantly, this study builds on existing conceptual frameworks and offers insights that can be used to advance education and training that promotes evidence informed balance exercise prescribing.