Kategorie: Blog

In the world of implementation science, we often focus on frameworks, strategies, and outcomes—but rarely do we pause to examine the power dynamics shaping every step of the process. Yet, understanding who holds power, how it’s distributed, and how it influences implementation success is essential for creating meaningful and equitable change.

What Do We Mean by “Power Dynamics”?

Power dynamics refer to the ways authority, influence, and decision-making are distributed between people or groups. In implementation, this includes:

• Who gets to decide which problems matter
• Whose knowledge is valued
• Who benefits from interventions—and who might be left out

A New Typology of Power

A 2022 paper by Stanton and colleagues introduced a powerful (pun intended) framework that breaks power down into three categories:

• Discursive Power: Who frames the narrative? For example, labeling a community as “hard to reach” shapes how we design solutions.
• Epistemic Power: Whose knowledge counts? Is clinical expertise valued as much as academic credentials?
• Material Power: Who controls the money, time, staff, and resources that make implementation possible?

These forms of power show up across every phase of implementation—from exploring the problem to sustaining a solution.

Why This Matters

Another insightful article by Douglas et al. (2022) highlights how a longstanding power differential between researchers and clinicians contributes to the “research-to-practice gap.” Researchers often generate knowledge without clinician input, while clinicians are left to implement solutions that may not align with their real-world context. This imbalance can lead to frustration, poor adoption, and missed opportunities for improvement.

What Practitioners Can Do

Whether you’re a facilitator, clinician, or implementation lead, here are a few actions you can take:

• Ask who’s at the table—and who’s missing
• Value diverse expertise, especially from those with lived or frontline experience
• Create feedback loops that center the voices of those most affected
• Use frameworks like EPIS alongside questions that interrogate power

Final Thoughts

If implementation is about getting evidence into practice, we must also address who defines the evidence and who shapes the practice. When we ignore power, we risk reinforcing the very inequities we’re trying to solve.

Let’s shift the focus—not just to what gets implemented, but how and with whom we implement it.

Are you interested in learning more about how to navigate power dynamics during implementation?  Consider the Essential Skills for the Knowledge Translation Practitioner offered by the Institute for Knowledge Translation.

References

Douglas, N., Hinckley, J., Grandbois, K., Schliep, M., Wonkka, A., Oshita, J., & Feuerstein, J. (2022). How a power differential between clinicians and researchers contributes to the research-to-practice gap. American Journal of Speech-Language Pathology, 32(2), 803–810. https://doi.org/10.1044/2022_AJSLP-22-00207

Roura, M. (2021). The social ecology of power in participatory research. Qualitative Health Research, 31(2), 203–214. https://doi.org/10.1177/1049732320941838

Stanton, M. C., Ali, S. B., & the SUSTAIN Center Team. (2022). A typology of power in implementation: Building on the exploration, preparation, implementation, sustainment (EPIS) framework to advance mental health and HIV health equity. Implementation Research and Practice, 3, 1–16. https://doi.org/10.1177/26334895211064250

At the Institute for Knowledge Translation (iKT), our mission is to advance evidence-based rehabilitation and support clinicians in implementing best practices that improve patient outcomes. A recent question from one of our course participants highlights a foundational concept in gait training:

“Does emphasizing energy efficiency always result in effective gait? Specifically, we are asking about these concepts as they relate to the definitions below. 

Energy efficiency in gait refers to achieving movement with the least possible energy expenditure. 

Effectiveness in gait, on the other hand, is about how well the movement fulfills its intended purpose.

In clinical practice, we’ve encountered patients who are unable to sufficiently shorten their leg during swing due to spasticity or issues with the ankle. In such cases, these patients might compensate by intentionally activating their knee flexors to achieve effective toe clearance. While this strategy promotes effectiveness, it introduces additional energy expenditure due to the intentional use of the knee flexors, making it less energy-efficient”

High-intensity gait training (HIT) protocols, as taught in our Walk the Walk course, address this balance by focusing on both the biomechanical subcomponents of gait, including propulsion, stance, swing, and postural stability, and the energy demands of each phase. HIT encourages therapists to analyze why patients walk the way they do, target interventions to improve both efficiency and effectiveness, and use clinical reasoning to optimize outcomes for each individual. It is important to note that we’re thinking about the definition of effectiveness a little differently.  We think of “effectiveness” of getting from one place to another in the home and community.  That definition means they can walk faster and further and in different terrains/environments they must negotiate in the community.

With these definitions in mind, let’s dive into a Q&A with our HIT experts to explore this important topic further.

Q: How does HIT address this balance efficiency and effectiveness?

A: HIT gait training is designed to improve gait speed, walking endurance, and adaptability which all essential for functional independence. To achieve these goals, HIT challenges patients to walk faster and farther, encouraging them to adopt strategies that are both effective and, over time, more energy efficient. Research demonstrates that HIT improves gait patterns and optimizes functional mobility, supporting better patient outcomes.

Q: Should therapists focus on helping patients achieve “normal” gait patterns?

A: Focusing solely on “normal” gait mechanics is not always realistic or beneficial, especially for patients with significant neurologic or orthopedic impairments. Evidence shows that traditional approaches aimed at normalizing gait don’t always lead to improved outcomes. Instead, interventions like HIT prioritize outcomes that impact functional independence and community reintegration, including walking speed, endurance, and balance.

Q: What role does clinical reasoning play in gait training?

A: Clinical reasoning is essential in gait training. Therapists must consider each patient’s unique impairments, functional goals, and real-world environments to deliver a personalized, effective HIT program. HIT provides a structured framework for addressing impairments in biomechanical subcomponents while integrating intensity (>75% of age predicted heart rate), task-specificity, and motor learning principles. It’s not a one-size-fits-all solution, and successful implementation of this evidence-based practice relies on skilled clinical judgment and individualized care.

In Summary

Effective gait training focuses on outcomes that enhance a patient’s functional mobility and independence. High-intensity gait training is an evidence-based approach that helps clinicians achieve both energy efficiency and effectiveness and is grounded in strong clinical reasoning and science.

If you’re a clinician looking to master high-intensity gait training, our flagship Walk the Walk course is built for you. This comprehensive program empowers physical therapists to implement HIT, improve patient outcomes, and join a vibrant community of evidence-driven practitioners.

Learn more about Walk the Walk and enroll today!