Translating knowledge into practice: Implementing perturbation-based balance training in a real-world rehabilitation setting

To describe and evaluate the implementation of a computerized PBT system in a real-world rehabilitation setting. 

The project was conducted at Loewenstein Rehabilitation Medical Center, Israel, using a computerized treadmill that delivers horizontal perturbations in multiple directions and intensities. The implementation followed a Knowledge Translation (KT) plan based on balance control and motor learning principles. Three key phases guided the process: 1) Adapting PBT to the local context: A team of physical therapists, researchers, and administrators tailored PTB to fit the local clinical environment, determined the training dosage, developed electronic forms for referrals and documentation, and established criteria for patient inclusion and exclusion. 2) Selecting and tailoring PBT interventions: Interventions were individualized to patient goals. 3) Monitoring knowledge use: Data were collected on adverse events, patient participation, session frequency, and pre-post outcome measures, including gait speed and the Activities-Specific Balance Confidence (ABC) scale.

The PBT was scheduled in addition to routine rehabilitation interventions, consisting of four 45-minute sessions over three weeks under a PT's supervision. Training included standing and walking practice, enhancing reactive step quality, and gradually increasing training difficulty through adjusted perturbation magnitude, unpredictability, gait speed, and dual task challenges. Out of 235 patients with diverse disorders (stroke, traumatic brain injury, spinal cord injury, orthopedic injury) 157 completed all four sessions. Participants experienced an average of 77.5±27.4 perturbations per session, with an average increase in perturbation translation magnitude of 7.2±3.4 cm and a treadmill gait speed increase of 0.53±0.4km/h. No adverse events were reported. Improvements in gait speed and ABC scores following the PBT program were observed.

This project successfully integrated perturbation-based balance training (PBT) into routine clinical practice using a structured, multicomponent implementation plan. Key factors contributing to the successful adoption included the careful selection and tailoring of interventions, ongoing support to staff, and alignment of the PBT program with routine rehabilitation care. Clinicians' readiness to embrace PBT and their engagement in the process were also crucial to its successful implementation. The improvements in patient outcomes, including gait speed and balance confidence, demonstrate the potential effectiveness of PBT in enhancing mobility and safety in neurological rehabilitation.

The successful implementation of PBT highlights the importance of adopting a structured approach when integrating novel technologies in clinical settings. This approach requires adapting interventions to local contexts, aligning with patient goals, and providing clinicians with training and support.