The number of physical therapists in the United States who treat persons with vestibular disorders via telehealth is unknown. Werenke et al. (15) reported that 37% of their physical therapists from their outpatient clinics (n = 222, 680 patients) provided telehealth care during the second and third quarters of 2020. There are 1,589 members of the Neurology Academy's Vestibular Special Interest (VSIG) group (personal communication, Sara Oxborough, 9/7/2021), but not all VSIG members treated persons via telehealth. It is unclear how many of the subjects were recruited from the VSIG vs. from other recruitment mechanisms.

Most of the respondents (66%) had between 6 months to 1 years' experience treating persons via telehealth with only 8% having >2 years of experience. Eighty-three percent of the physical therapists had 15 or less years of experience. It is unclear how many physical therapists were required to use telehealth technology to conduct telehealth visits.

Werneke et al. reported that patients who received physical therapy care via telehealth were younger and were more likely to live in a metropolitan area (15). The use of technology is a consideration for both the patient and the physical therapist. Sixty-four percent of our physical therapist sample were ≥35 years of age, suggesting that physical therapists were able to adapt to telehealth platforms and the technology requirements to treat patient's virtually (see Table 1). Outpatient physical therapist practices were the most common practice setting (85%), which is not surprising since outpatient practices are the most common employment setting for physical therapists in the US (16).

Eighty-six percent of the physical therapist respondents felt that telehealth was effective for the delivery of vestibular physical therapy. Cottrell et al. have suggested that telehealth can be effective for the treatment of musculoskeletal conditions (8). Others have reported that patients (n = 222,680) were satisfied with their out-patient care for both orthopedic, non-orthopedic, and vestibular physical therapy care via telehealth (15). Per their study, the satisfaction ratings of persons seen in the clinic was only 3% higher than those who were treated via telehealth (15). Others have reported a 95% patient satisfaction rating in persons seen in outpatient rehabilitation locations (17). Our result of physical therapist satisfaction with telehealth mirrors the satisfaction of patients with their care.

Fifty-six percent of the physical therapists thought that there was enhanced attendance at physical therapy sessions via telehealth. Others have reported that attendance might be positively affected with the use of telehealth (18).

Related to whether physical therapists thought that the patient achieved similar outcomes, 68% agree and 19% disagreed and felt that the outcomes were not as good with telehealth. The 19% who reported that they felt that patient had worse outcomes might be related to bandwidth and connection issues, issues related to patients having difficulty with their telecommunication devices, and resistance to change (18).

BPPV is the most common condition seen in vestibular clinics (19). Physical therapists were generally comfortable using telehealth to treating persons with posterior and horizontal canal BPPV as described by Barreto and Yacovino (1). Barreto and Yacovino (1) utilized cell phones to observe eye movements during the Dix-Hallpike and the roll test. They suggested that it is imperative to utilize telecommunication devices that incorporate both audio and video in the examination and treatment of persons with BPPV via telehealth.

However, there were both experienced and less experienced physical therapists who were uncomfortable treating posterior or horizontal canal BPPV via telehealth. The survey question did not ask about what lead the physical therapist to be uncomfortable. A possible scenario could be whether the patient had a caregiver at home to assist in the telehealth visit which may have modified their responses as to their level of comfort in treating persons with BPPV.

Persons with BPPV can experience a Tumarkin like event upon resuming the sitting position during the treatment of posterior canal BPPV (20). With older persons, it may be important to have an additional person in the home to avoid a fall after the repositioning maneuver. Barreto and Yacovino suggest that the diagnosis can be made via telehealth first, followed by a decision to treat via telehealth or in the clinic (1). Clinicians may be more willing to treat persons with BPPV who have previously experienced BPPV in the past (1), as voiced during the focus group meeting. If the person's BPPV symptoms do not resolve with telehealth visits, Shaikh et al. suggest that persons be seen in the clinic (3).

The number of people reporting that they had treated persons with bilateral vestibular loss (BVL) was low and most reported that they were “somewhat comfortable” treating persons with BVL. It is known that persons with BVL fall frequently (21), thus care is required with challenging balance activities in the home.

Unlike BVL, all physical therapists were comfortable with treating persons with Meniere's disease and vestibular neuritis. These two diagnostic groups of the 7 discussed were the only diagnoses where all respondents felt comfortable treating via telehealth.

The pandemic reduced sports related concussions by 60% (22). Persons with mild traumatic brain injury were treated later by an average of 26 days compared to pre pandemic time from accident to presentation to the clinic (22). Thus, persons with mild traumatic brain injury seen during the pandemic via telehealth may have been more chronic in our survey as well. Generally, participants were comfortable treating persons with mild traumatic brain injury and vestibular migraine via telehealth. It may be more difficult to determine if persons post pandemic with mild traumatic brain injury will respond to physical therapy via telehealth in a similar manner to those who were seen during the pandemic because of the differences in chronicity.

Overall, physical therapists were comfortable with treating vestibular migraine via telehealth.

Per Table 2A, our respondents did not believe that all examination techniques could be effectively administered via telehealth. Items endorsed by <30% of the respondents included the cross-cover test, gait speed, coordination testing, sensory testing, and the head impulse test. Green et al. (23) suggested that tests of skew and the alternate cover test could be performed via a virtual exam with a cell phone. They suggest that the head impulse test can be performed with active participation of the patient under the direction of the clinician to implement the head impulse test (23). No data is provided to report the reliability or validity of testing the test of skew, nystagmus or head impulse test via telehealth (23). The telehealth exam may be hampered by an inadequate frame rate, the ability of the patient or caregiver to hold the phone in the correct position with adequate light to visualize the eyes, or an unstable internet signal (1, 23, 24).

Recording gait speed is a challenge as it is often impossible to accurately determine distances in a person's home to calculate velocity. With cell phones or other technologic devices, it may be difficult to assess coordination and timing of both upper and lower extremity movements.

Sensory testing is a challenge via telehealth, yet sensory testing is a vital aspect of the exam that can help guide which balance tests can be performed safely. With loss of distal sensation, performing the Romberg test with eyes closed while a person holds a telecommunication device would not be advised.

Forty-eight percent of the examination procedures utilized in telehealth were rated as not being effective by the physical therapists. There is much work that needs to be done to improve the use of examination procedures commonly utilized by physical therapists in the assessment of persons with balance and vestibular disorders via telehealth.

The use of exercises (see Table 2B) had higher efficacy ratings by the physical therapists when compared to the overall ratings of the examination procedures in Table 2A. Although most exercises were endorsed as being able to perform in the home, challenging gait exercises, virtual reality exercises and the remembered or imaginary target exercises had the lowest confidence ratings by the physical therapists. The eye exercises were rated at 50% or greater except for the remembered or imaginary target exercise, which is often difficult to teach and challenging for patients to remember how to perform the exercise correctly regardless of setting.

Participants may have rated the gait exercises low for fear of the patient falling, the difficulty locating a walkway in the home where the device can transmit their gait clearly, or the lack of a caregiver to guard the patient while performing the exercises. It will remain challenging to work on advanced postural skills during gait without having someone nearby to guard the patient. Making decisions to progress based on performance may also be challenging because small nuances in postural control may not be easy to visualize over a telecommunication device. However, remote cell phone monitoring is being done and demonstrates promise in enhancing decision making about fall risk (25, 26). The in-home utilization of cell phones to monitor sit to stand abilities and walking will assist in future telehealth decision making (25, 26). In summary, examination of the client in the home appears to be more challenging than providing exercises for rehabilitation via telehealth.

As reported in Table 3, the primary concern was treating the patient without a caregiver present followed by an inconsistent internet signal and the ability to see the correct body part to make a sound clinical judgement (3, 12). Others have reported that familiarity with the use of technology is a barrier, as did our respondents (18). There were concerns about the ability of persons to walk with a telecommunication device if their gait was impaired and concerns about a person's balance. The other concern was that with the lighting (too much or too little) the physical therapist was challenged in conducting an adequate exam to make clinical decisions (3). Although not asked in our survey, persons who are hearing challenged may have more difficulty communicating via telecommunications (12, 27) and is something to consider with persons with both vestibular and audiologic impairments.

Only 29% of the physical therapists felt that telehealth was as effective as in person care (see Figure 4). With enhanced video streaming, greater comfort with the technology, and virtual mechanisms to better assess posture and gait, these effectiveness ratings may improve with time.

The survey was active during March-May 2021. It is impossible to know how robust our response rate was since it is unknown how many physical therapists in the United States treated persons via telehealth with balance and vestibular disorders. The response rate of 198 is most likely low. However, Dahl-Popolizio et al. (14) had 230 surveys returned about occupational therapists' experiences with telehealth from 137,000 members. The study was mainly distributed through state chapters, academies of the American Physical Therapy Association and social media. Our methods of survey distribution may have limited access to the survey and could have potentially biased sample. Another limitation to the study includes the inability to complete any follow-up after the initial survey. We were unable to determine if physical therapist's perception of telehealth during the pandemic changed as the pandemic progressed.

Only 8% of the respondents had 2 years or more of experience conducting telehealth visits, yet most of the physical therapists were positive in their responses. It is possible that only those physical therapists who liked performing telehealth visits responded to the survey request biasing the findings. Not all out-patient physical therapists performed telehealth during the shutdowns in the United States (15). It appears that some form of telehealth will continue in most areas of the world long after the pandemic has stabilized (28–34).

It appears that there is a promising future for the telehealth delivery of vestibular physical therapy. Improved technology may assist with some of the technological issues revealed by this study (i.e., eye movement examination). The assessment of balance and postural control will be a more challenging issue for telehealth users, although with recent advances in technology the examination of postural control and gait is improving. Developing guidelines or rules to help determine when it is safe to test people in challenging positions will need to be determined and shared to prevent falls during telehealth visits. Overall physical therapist satisfaction appeared high with telehealth, yet physical therapists continued to feel that person to person visits yielded more effective visits.