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Table 2 Physiotherapists’ perceptions, barriers and strategies to delivering balance training within Pulmonary Rehabilitation

From: Minimizing the evidence-practice gap – a prospective cohort study incorporating balance training into pulmonary rehabilitation for individuals with chronic obstructive pulmonary disease

Themes Quotes Key message
Perceptions of balance training within PR Benefits Balance training is effective at improving patients’ balance but distracts from the usual PR program.
PT4: “It’s definitely beneficial. I mean you see the difference just through the … through the weeks that we trained them and the patients do notice and they comment that they notice a big difference.”
Disadvantages
PT2: “I know it’s supposed to be as an adjunct to their normal one [PR program] but it actually did impact their normal programme.”
PT1: “if it’s … some of those sessions are balance where they need supervision. They are not going to be taking home very much [balance exercises which require supervision] and you want them to have a good comprehensive home programme.”
Barriers to balance training within PR PT5: “That’s complicated. Remember those are geriatric patients. Their memories are not that great. Okay? Some they even repeat for weeks still doesn’t stick.” Barriers to balance training include:
PT2: “We were limited just because first off the … the time restraints. A lot of them [patients] wanted to work on their core exercise programmes.” 1. Time restraints
PT3: “if they were in the balance programme sometimes I was putting their sheets in a chart at the end of their … their six week programme and they would have done something [hand therapy] only two or three times the whole time there were here” 2. Space
PT1: “the space, the monitoring both, the group you have in there already plus the close supervision you need to do the balance properly.” 3. Staffing due to the unpredictability of patients’ balance and patients inability to perform the exercises independently.
PT3: “their balance really varied from session to session.”
Support for therapists PT2: “I think yeah, I mean, it’s nice to see all the equipment that you are planning to use…” Support consisting of familiarisation with the equipment and practical demonstrations is necessary for the first few sessions.
PT3: “I felt it was helpful that you were there for the first few sessions to kind of get it going in our environment.”
PT2: “Yeah it’s always good for a … kind of a observation demonstration.”  
The sustainability of balance training within PR. PT4: “Since… sorry, since the study too I tend… I’m more prone to ask them in terms of falls too versus before I wasn’t really, you know, focusing on whether they have previous falls.” Aspects of balance training are sustainable but following completion of the study balance training was being delivered fewer times per week.
PT5: “And then what we’re doing the TUG and their sit and stand balance……as a part of the assessment.”
PT1: “I did it with one lady. She gets in and out of a boat so we did some balance exercises and I sent her home with a mini programme.”
PT3: “We’re not doing balance three times a week. ….as we see there’s a goal of theirs or something that they require”
Strategies to improve the sustainability of balance training with PR PT1: “Has to be incorporated [into an interval training program] cause we don’t have the staff to do it the other way.” Strategies to maintain the delivery of balance training include:
PT2: “for the lower level people you want to provide the … the one to one for safety in terms of spotting just because their balance is so bad.” 1. Deliver balance training twice a week.
PT5:“You have with the pictures. And that they can do it with parallels [bars]. 2. Deliver as an interval training program to everyone enrolled in PR.
PT3: “you kind of have to educate people to become independent in their exercises.” 3. Provide visual aids.
PT5: “Have to be simple…Functional. And easy.” 4. Promote independence by providing a set program consisting of simple balance exercises.
PT3: “if we had an extra person like if there were no follow ups or something we had… we had extra help, then we would have that extra person just to deal with the other patients” 5. Consider the environment (i.e. use of parallel bars) if staffing is not available.
PT3: “And so when we changed the sheets I found that was a … at least cause I knew had a sort of a set programme and then the primary therapist could progress it as they wanted to.” 6. Introduce a home-based program early.
PT3: “where everyone is doing it and its circuit based I think is one thing versus just have it incorporated into the IT [interval training] programme and then they do it whenever they’re doing their IT.”
PT4 “balance class and having other people within the room doing exercise it gets chaotic so it’s just having two sets of balance class where everybody does balance and everybody has their own programmes we can have a bit more supervise from the staff”
PT2: “you’d have to really focus in on where their impairment is.”
PT2: “maybe it’s advantageous to pick … pick early on which ones are you going to be doing while you… when they go home.”