Assessment of Knowledge and Clinical Competency in Vestibular Rehabilitation Among Physical Therapists in Karachi: A Cross-Sectional Study

Abstract

Background: Vestibular disorders disrupt the inner-ear balance system and manifest as vertigo, dizziness, and imbalance, impairing daily function and increasing fall risk. Their annual global incidence is approximately 7.4%, rising to over 30% in adults older than 65 years, while in Pakistan vestibular complaints account for an estimated 3-24.7% of neurological presentations, with a disproportionate burden reported in Karachi. Vestibular rehabilitation (VR), originating from the Cawthorne-Cooksey exercise program and later refined by Herdman, employs habituation, adaptation, and substitution strategies-including gaze-stabilization exercises and canalith repositioning maneuvers such as the Epley maneuver-to achieve symptom resolution in 70-80% of patients within 4-6 weeks.

Objective: To evaluate the level of knowledge and clinical competency in vestibular rehabilitation among physical therapists practicing in Karachi.

Methods: An observational cross-sectional study was conducted among physical therapists practicing in Karachi (Liaquat National Hospital, Ziauddin Hospital, and Saifee Hospital), recruited through non-probability convenience sampling. A minimum sample of 250 was targeted (WHO OpenEpi, 5% margin of error, 95% CI; minimum required n = 149). Physical therapists with prior specialist certification in vestibular rehabilitation or those not currently managing dizzy patients were excluded. Data were collected using a 22-item, Delphi-developed questionnaire spanning awareness, assessment-test knowledge, rehabilitation-maneuver knowledge, clinical competency, and training/practice exposure, validated by three vestibular rehabilitation specialists (Cronbach's alpha = 0.77 in the study sample). Data were analyzed in IBM SPSS (v29.0) following STROBE reporting guidelines, using descriptive statistics, Pearson correlation, chi-square tests of association, and diagnostic checks (multicollinearity, normality, homogeneity of variance).

Results: Of 265 questionnaires distributed, 249 were included in the final analysis (94.0% valid response). Respondents were predominantly young and early-career (89.6% aged 25-28 years; 35.7% with under one year of clinical practice). Overall knowledge and competency was poor in 171 respondents (68.7%), moderate in 56 (22.5%), and good in only 22 (8.8%). By domain, knowledge of assessment tests was poor in 70.3% and knowledge of rehabilitation maneuvers was poor in 78.7% (the weakest domain overall), whereas general awareness of vestibular rehabilitation was good in 94.4% and reported training/practice exposure was good in 85.5%. Clinical-competency scores were more evenly distributed (30.1% good, 30.5% moderate, 39.4% poor). Competency improved with increasing age and years of clinical experience, and respondents who learned through workshops or self-study showed slightly higher rates of good knowledge than those relying on formal curricula alone. The questionnaire demonstrated satisfactory internal consistency (Cronbach's alpha = 0.77) and no problematic multicollinearity among predictors (all VIF < 2). Chi-square analysis showed significant associations between knowledge level and age (p = 0.01) and between knowledge level and years of clinical practice (p = 0.02), whereas the source through which vestibular rehabilitation was learned was not significantly associated with knowledge (p = 0.12).

Conclusion: Physical therapists in Karachi report high awareness of vestibular rehabilitation but demonstrate a substantial deficit in the practical knowledge and clinical skills required to assess and treat vestibular disorders, particularly in diagnostic testing and repositioning maneuvers. This awareness-competency gap indicates an urgent need for structured, hands-on, competency-based training-including supervised clinical practice and standardized skills assessment-integrated into physiotherapy curricula and continuing professional development, with support from academic institutions and professional bodies to standardize training and embed vestibular rehabilitation competencies into licensing and re-certification requirements.