A total of 476 responses were received from 22 countries (Fig. 1). The English language version was completed by 64%. Five non-European respondents (n = 3 from Australia and n = 2 from Argentina) were excluded, but 14 responses from Israel were included. Therefore, a total of 471 surveys from 20 countries were included in the analysis.
The frequency distribution of responses per country is shown in Fig. 1, 50% of countries had 14 or more responses, Germany had the highest number (n = 124), followed by the UK (n = 69). The median age of respondents was 41 years (range 23–68 years). Demographic data are shown in Table 1. Respondents were mostly female (73.4%) and the predominant profession was physiotherapy (89%). Close to half (50.7%) described themselves as “competent”, 36.3% as “novice”, and 12.9% as “expert” at VR. The median length of time working in VR was 4 years (range < 1–35 years). The majority (62.7%) spent less than 25% of working time in VR with only 11.6% spending greater than 75%. Those who self-reported as “expert” were not qualified longer (i.e., post-registration), but had worked for longer number of years in VR, spent a higher percentage of their working week in VR, and treated more patients per week (Table 2).
Work environments and specialities
The vast majority of respondents (82.5%) worked in two or less work environments (Table 1). A hospital setting (29.7% in-patient; 28.5% out-patient) predominated but private practice accounted for 53.5%. Over a fifth (21.4%) indicated that they worked at least part of the time in a specialist VR service. The percentage working in private practice varied across countries: 86.3% of French respondents worked in private practice, followed by 60% of Belgians and 57.2% of Germans. Respondents worked in a median of three specialities, most commonly in neurology (62.2%) followed by care of the elderly (43.4) and ENT (42.0%; Fig. 2).
Respondents predominantly received referrals from consultant physicians (67.5%) but also from family doctors (63.1%), other health care professionals (52.4%) and less commonly reported that they accepted patient self-referral (13.5%) as an access route to VR. Regarding consultation times, a median of 40 (IQR, 30) minutes for an initial assessment and 30 (IQR, 5) for a follow-up consultation was reported. A majority (92%) “always” used an individual mode of treatment and telerehabilitation was used by only 4.5%.
Infrequent access to the results of vestibular function assessment was evident, with most reporting they “sometimes” had access (55.5%), and only 27% reporting “always”. The majority (62%) had no vestibular function testing available in their workplace. There was wide variation in access and use of specialised equipment for vestibular assessment (Table 3). Only 40% indicated they “sometimes” or “always” used either Frenzel’s lenses or infrared goggle systems (Table 3). The two most frequently used pieces of equipment were high-density foam and a marked-out distance for gait testing (which were used sometimes or always by > 75%). Computerised posturography (e.g., Balance Master, Equitest, Framiral) was inaccessible to all but 20%. However, 21% sometimes or always used a static force plate. A marked-out Fukuda/Unterberger test (68%), dynamic visual acuity (DVA) testing (58%) and the rotatory chair (40%) were the next most ubiquitously used tests (Table 3).
BPPV was reported as known by the vast majority (98.9%) and treated by 87.5% (Table 4). Use of canal repositioning procedures is shown in Fig. 3. The next most commonly treated conditions were unilateral vestibular loss (including vestibular neuritis), dizziness in the elderly (presbystasis), persistent postural-perceptual dizziness (PPPD), and cervicogenic dizziness. The least commonly treated conditions were perilymphatic fistula and vestibular paroxysmia (Table 4).
Types of VR exercises
Beside BPPV manoeuvres, in order of frequency, balance training, adaptation, habituation, and gait retraining exercises were utilised most frequently. Brandt–Daroff exercises, virtual reality, and visual retraining exercises were the least frequently used (Table 5).
Physical and patient-reported outcome measures
A wide variation and total of 48 published physical outcome measures appeared in the top three listed by respondents. The top three reported as most frequently used were Romberg (or Tandem Romberg), the Clinical Test of Sensory Interactions on Balance (CTSIB or mCTSIB), and gait analysis in the form of Dynamic Gait Index (DGI) or Functional Gait Assessment (FGA). The single leg stance test or variant was the next most frequently used followed by the Berg Balance Scale, the Dix–Hallpike test, dynamic visual acuity (DVA) test and Fukuda/Unterberger. Computerised posturography was not used frequently. A detailed list of the physical outcome measures is shown in the supplementary material.
Concerning patient-reported outcome measures (PROMs), respondents were first asked to list the top three PROMs they used and thereafter were provided a list of published PROMs and asked to indicate their usage on a Likert Scale. The most frequently used PROMs cited by respondents were the Dizziness Handicap Inventory (DHI), Vertigo/Dizziness Visual Analogue Scales (VAS) and the Activities Balance Confidence Scale (ABC). An excess of 30 published PROMs were used (see supplementary material). Only two PROMs from the provided list were used “always” or “sometimes” by greater than 50% of respondents. These were the DHI and Dizziness/Vertigo VAS. The next most commonly used PROMs were the ABC, Vertigo Symptom Scale and Falls Efficacy Scale, but were used by less than 30%.
Access to VR
VR was ranked as “hard” or “very hard” to access by 48% of respondents, “accessible” by 44% and easy to access by only 8%. Israel, Belgium, The Netherlands, and France were the countries with greatest perceived accessibility (> 65% ranked VR as “accessible” or “easy to access”).
Education in VR
A low percentage (19%) reported that they had pre-registration training in VR, but the large majority (90%) had completed post-registration VR training, with a median of two formats attended and the most common formats being basic and advanced courses in VR. There was broad agreement by 75% with the statement that “therapists should have professionally accredited post-graduate certification for practicing in the area of VR”. A blended learning approach combining web based, clinical and attendance at college/university was most commonly selected as the optimal mode of delivery (56%), followed by clinical training only (25%). Only half of respondents indicated their course tuition was paid and time off from work was supported.
Research activity and priorities
Just over a fifth of respondents (22.5%) stated they were research active. Of those that were research active, 61% expressed interest in becoming part of a European network on research and 42% indicated capacity to be a trial site. Being research active was significantly associated with increased levels of self-reported competence (χ2 = 62.1, p < 0.0001), interest in becoming part of a European research network (χ2 = 51.7, p < 0.0001) and capacity to be a trial site (χ2 = 65.4, p < 0.0001).
289 therapists out of 471 (61.3%) answered the open question related to research questions that should be prioritized. Some therapists gave multiple suggestions which resulted in 776 counts. Three major themes/research areas were identified: management of specific conditions (317 counts), effectiveness of VR (246 counts), and mechanisms/factors influencing vestibular compensation and dizziness (206 counts). These themes were divided into subthemes of which some were split up in second-order subthemes. The number of counts per subtheme is shown in Table 6.
The first theme concerned the management of specific diagnoses. Since some respondents only mentioned the name of the condition, it was not always clear what they meant to investigate. The most commonly reported conditions were chronic dizziness (62 counts), BPPV (45), vestibular migraine (42), and dizziness in the elderly (35).
The second theme concerned the study of the effectiveness of VR. Respondents not only reported a need to assess the effectiveness of VR in general (16 counts), but were also particularly interested in comparing different methods of VR in different diseases (61 counts). In addition, they were interested in the best way of delivering VR, to optimize exercise adherence and how to incorporate rehabilitation technology: timing of VR (11 counts), VR setting , VR parameters , and rehabilitation technology . Furthermore, they were looking for the optimal way to measure rehabilitation outcome (49 counts).
The third theme focussed on understanding vestibular compensation and dizziness. A large number of therapists expressed the need to better understand mechanisms, models, and aetiologies (83 counts). In addition, questions were asked with a view to improving both the multidisciplinary care (improving care pathways: 24 counts) and the diagnostic process (role of PT in diagnostics: 10 counts; developing diagnostic algorithms: 18 counts). Finally, therapists indicated the need for specific education as well as to finding the best way to improve VR knowledge (26 counts).
182 respondents did not answer the research-related questions. There was no difference between physiotherapists and other professions, but there were clear geographical differences, with a large percentage of French (91%) and British (88%) therapists answering, while only a minority of German (37%) and Austrian (17%) therapists answered this question. When compared to women, there were also more men who answered.
Other issues in VR
The final question in the survey invited participants to indicate any other relevant issues in VR. 64% (n = 303) of respondents provided a response. The responses aligned into three main themes.
Delivery of best practice: Training at all stages of pre- and post-graduate education, mentoring, consistency and identification of skilled VR therapists and recruitment opportunities; research into testing protocols and red flags, effective referral pathways, prevention, apps and internet resources/downloads, when to initiate VR and exercise specificity; guidance on condition and treatment knowledge, outcomes measures, condition-specific VR, benefit of clinical psychology, efficacy of methods of treatment delivery, e.g. low cost vs high tech, medication management and benefits of prevention strategies.
Delivery of patient services identified the need to improve awareness for vestibular symptoms and disorders among the public and all medical health care professionals. Better knowledge would reduce over testing and improve first contact diagnosis and treatment, e.g. in BPPV. Respondents also focused on improving team interaction (general practitioners, physiotherapists, occupational therapists, audiologists, and clinical psychologists), involvement in patient care (e.g. in emergency vertigo), and referral pathways (timely access, waiting times).
Cost implications for VR provision identified lack of evidence and accessibility of resources related to healthcare cost benefits of providing early VR intervention, the overall economic benefit of VR, and the cost of training.