Data were collected from 06 January 2021 to 31 July 2021. A modified 3-point Likert-type questionnaire (yes, not sure, no) was used to collect data. The questionnaire consisted of two sections and comprised of six closed-type and four open-type questions. The questionnaire was developed (Willits et al. 2016) using information from literature then tested using a pilot study with a sample of six. Questions were validated against the objective of the study, which was to determine current practice in the treatment of vestibular hypofunction following stroke in poorly-resourced areas. Therefore, the aim of the pilot study was to establish feasibility, as well as to determine participants’ understanding of the questions and the amount of time required to complete the questionnaire. Based on the pilot study findings, some questions which were considered repetitive were removed to reduce the amount of time taken to complete the questionnaire. The final questionnaire was sent to all physiotherapy departments in the North West province through the physiotherapy department heads. Heads of physiotherapy department collected responses which were either sent via email or WhatsApp. The responses received via email and WhatsApp were captured on Microsoft^® Excel for analysis and summarisation.

Heads of physiotherapy department distributed the questionnaire, information leaflet and the consent forms to consented participants. However, participants who had not received the questionnaire through their group WhatsApp portals were sent emails. Respondents had until the 28th week to submit their responses.

Data were captured on Microsoft^® Excel and cleaned. Cleaned data were further transferred to Stata 18.5 for descriptive statistical analysis. The data were categorical and were presented as frequencies and percentages.

Ethical approval to conduct this study was obtained from the Sefako Makgatho Health Sciences University Research Ethics Committee (No. SMUREC/H/291/2020: PG). Participation in this study was voluntary. Permission was obtained from Sefako Makgatho Health Sciences University Research Ethics Committee to conduct research study in any public hospital in the North West province. Permission was also granted by the hospitals where data were collected. Codes instead of names of participants were used to ensure confidentiality. WhatsApp application employed in the distribution of the questionnaire had a device encryption screen-lock on and a fingerprint unlocking ability. Auto backup capability was disabled to enhance cybersecurity. The questionnaire form had non-sensitive questions except about general services and awareness of VRT. Anonymity was upheld by non-identity linked questions and forms were randomly filed in the same folder to improve anonymity.

The study explored current practice of stroke rehabilitation physiotherapists in the management of central vestibular system disorders. The demographics showed females being a predominant gender (Felman et al. 2023). This gender distribution underscores the prominence of female physiotherapists in this particular sample, which reflects broader trends within the profession, where women are often more represented (World Physiotherapy Survey 2019). The majority of the participants had work experience of less than 9 years with only one having Master’s degree indicating a predominantly early-career cohort. These factors may influence the scope and quality of care provided, particularly in more specialised or complex areas of physiotherapy practice and advanced techniques such as VRT (Fonarow et al. 2010).

All physiotherapists in this study treated patients with stroke; however, the responses are more varied when identifying central vestibular system disorders among their patients. A majority, 57.7% (n = 15), indicated that they do encounter patients with these disorders, while 26.9% (n = 7) do not and 15.4% (n = 4) are unsure. This variability suggests that while many physiotherapists are aware of and treat central vestibular disorders, a considerable portion still do not encounter these conditions or are uncertain about their presence. This could point to a potential gap in knowledge or diagnostic capability within the cohort. Furthermore, the data reveal that none of the physiotherapists have received training specifically in vestibular system rehabilitation. This finding is particularly concerning, as it highlights a significant educational gap that could directly impact on the quality and effectiveness of the care provided. The lack of specialised training may also explain the absence of standardised rehabilitation programmes, as physiotherapists may not feel equipped to develop or adhere to such protocols without appropriate education and training (Albalwi et al. 2023).

The study outcomes indicate that most of the physiotherapists in this study do not use VRT (Albalwi et al. 2023) and this is similar to the findings by Polensek, Tusa and Sterk (2019), which may be as a result of limitation of specialised knowledge in VRT (Kao et al. 2010). Furthermore, the data reveal that none of the physiotherapists have received training specifically in vestibular system rehabilitation. This finding is particularly concerning, as it highlights a significant educational gap that could directly impact the quality and effectiveness of the care provided. The awareness of VRT among physiotherapists is still quite low, discouraging further training in VRT (Smolka et al. 2020). A study conducted in Saudi Arabia revealed that unavailability of resources for VRT and the lack of knowledge hampered physiotherapists from successfully managing vestibular hypofunction (Albalwi et al. 2023). Contrary to that, a study conducted in Europe portrayed a different picture. The percentage of therapists who were knowledgeable about VRT was high; however, the majority supported a notion of a possibility of having an accredited postgraduate certificate in VRT (Meldrum et al. 2020). Also, majority of therapists did not use standard outcome measures (Meldrum et al. 2020). The lack of specialised training may also explain the absence of standardised rehabilitation programmes and VRT specific outcome measures reflected in the study.

Overall, the distribution of traditional methods employed in vestibular hypofunction post-stroke highlighted a wide range of rehabilitation strategies, with a clear preference for the Bobath approach. However, the data also suggest considerable variability in the methods used, potentially reflecting differences in training, clinical experience and patient demographics. The significant reliance on traditional methods such as Bobath and strengthening exercises, alongside the underutilisation of vestibular system-related techniques, indicates areas where further training or standardisation could enhance the effectiveness and consistency of stroke rehabilitation practices for vestibular dysfunctions. The minimal use of specialised vestibular rehabilitation methods further underscores a potential area for professional development. Enhancing training and increasing awareness of the benefits of vestibular rehabilitation could help integrate these approaches more consistently into stroke rehabilitation programmes, potentially improving patient outcomes. The data suggest that while there is some recognition of these methods, their application could be more widespread, pointing to a significant opportunity for growth in this area of physiotherapy.

Majority of physiotherapists demonstrated little knowledge of VRT and therefore could not attest to its effectiveness in treating stroke survivors with central vestibular system disorders (Kao et al. 2010). Also, a degree of uncertainty or a lack of clarity among physiotherapists about the specific difficulties associated with these conditions, could reflect the complex nature of vestibular disorders and the need for more targeted education and support for physiotherapists in managing these challenges effectively. Furthermore, vestibular system has been ignored for years as a primary system for balance control (Britton & Qadeer 2019). Continuous training and discussions may stimulate interest among physiotherapists to learn more about vestibular system function and always take it into consideration during assessment and treatment (Albalwi et al. 2023).

Traditional methods such as Bobath, NDT, strengthening and balance exercises, were mentioned as modalities of choice by participants, in an open-ended questions section. Overall, the distribution of these traditional methods highlights a wide range of rehabilitation strategies, with a clear preference for the Bobath approach (Alqahtani, Faizan & Ahmad 2018). Variability may demonstrate differences in training, clinical experience, and patient demographics, as well as underutilisation of standardised vestibular rehabilitation techniques. Application of standardised guidelines and VRT principles has been proven to enhance the effectiveness of VRT post-stroke (Bush & Dougherty 2015; Hall et al. 2016; Sulway & Whitney 2019; Sullivan et al. 2013; Gebhardt et al. 2021; Marioni et al. 2012; Sana et al. 2022). Thompson & Amedee (2009) provide a clinician-friendly overview of dizziness applicable to stroke settings.

Vestibular rehabilitation therapy treatment protocols are underutilised (Alahmari et al. 2014) and there is therefore a tendency among majority of physiotherapists, at least 75%, to avoid the use of central VRT in the treatment of patients with stroke. This suggests that physiotherapists need more effective VRT protocols and outcome-based treatment options (Agrawal et al. 2011). The minimal use of specialised vestibular rehabilitation methods further underscores a potential area for professional development. Enhancing training and increasing awareness of the benefits of vestibular rehabilitation could help integrate these approaches more consistently into stroke rehabilitation programmes, potentially improving patient outcomes. The data suggest that while there is some recognition of these methods, their application could be more widespread, pointing to a significant opportunity for growth in this area of physiotherapy. Training in VRT may assist therapists to offer best practices and improve outcomes of patients with vestibular system disorders (Almohiza et al. 2016). This means physiotherapists would benefit from the knowledge of commonly used VRT modalities such as the Brandt-Darrof which are suitable for both peripheral and central vestibular disorders.

Most of the physiotherapists (68%) did not assess patients for specific treatment efficacy but they did use generic measures such as the Berg Balance Scale and the Barthel Index. Recommended assessment tools include the Dizziness Handicap Inventory, Dynamic Gait Index, Functional Gait Assessment, Dynamic Visual Acuity, and Activities-Specific Balance Confidence Scale (Karmali et al. 2017; Hall et al. 2016). Karmali et al. (2017) further explore vestibular thresholds with implications for assessment selection and interpretation. The level of uncertainty suggests that many physiotherapists may not have the tools or methods to effectively measure and evaluate the success of their interventions, which could be a direct consequence of the lack of standardised programmes and specialised training. This indicates that there is a need for more consistent and standardised practices in evaluating treatment outcomes. Enhancing the consistency and comprehensiveness of assessment practices could contribute to more effective and measurable rehabilitation outcomes even for VRT.

Cost-effective assessment tools used in VRT are better for resource-constrained areas. Giray et al. (2009) demonstrated short-term improvements with structured VRT programme. Individualised VRT programmes have also shown to be effective (Black et al. 2000). Abarghuei et al. (2018) highlighted Cawthorne-Cooksey viability as low-tech (Hilton & Pinder 2014 and Teixidó et al. 2021). The head-shake, eye-tracking and cover-and-uncover tests, are effective and yet affordable tests used to confirm vestibular hypofunction, as well as distinguish between central and peripheral vestibular causes.

The survey showed low response than expected, which introduced a certain degree of response bias. This response bias may have negatively impacted on the overall outcomes of the study results. Hard to reach locations in the rural areas, overload and poor internet connection, were some of the reasons for poor response rates. The study findings cannot be generalised for entire North West province or general South African population of physiotherapists but can be used as a reminder to all rehabilitation professionals that there is a need to always assess and treat vestibular-related hypofunction.

Addressing the VRT knowledge and service gaps through targeted education and developing evidence-based protocols may enhance the quality of care provided and lead to better patient outcome. Furthermore, increased awareness among all clinicians may enhance VRT programmes. To improve generality of the study, perhaps electronic web-based surveys to all other mainly rural provinces which are also under-resourced would have a positive impact on the outcomes of the study. The study can also serve as a reminder for academic institutions to emphasise the need for the inclusion of VRT into the curriculum considering that some of the graduates may be deployed in resource-constrained areas where they may be the only available rehabilitation professionals to offer VRT.