Unilateral spatial neglect (USN) is:

Spatial neglect occurs after a stroke or degenerative disease and is a multifaceted and disabling condition (Andrade et al. 2010).

Incidence of neglect differs extensively in reported studies, and this variability is between 12% and 95% (Robertson & Halligan 1999). This variability of USN incidence is because of a plethora of factors such as the operational definition of USN, assessment type to identify USN and heterogeneity of USN presentation (Ting et al. 2011). In many patients post-stroke, the severity of neglect symptoms persist chronically (Farnè et al. 2004; Katz et al. 1999) with a negative affectation in almost every activity that contributes to daily living and rehabilitation outcomes such as postural balance (Gottlieb & Levine 1992; Pérennou 2006; Taylor, Ashburn & Ward 1994; Van Nes et al. 2009), functional mobility (Berti et al. 2002; Tromp, Dinkla & Mulder 1995), quality of life (Franceschini et al. 2010; Sobrinho et al. 2018), ADLs (Cherney et al. 2001; Jehkonen et al. 2000, 2001; Vossel et al. 2013) and hospital stay duration (Chen et al. 2015; Hammerbeck et al. 2019; Wee & Hopman 2008).

Several interventions to ameliorate USN have been proposed by researchers (Luauté et al. 2006; Umeonwuka, Roos & Ntsiea 2020). Strategies for USN symptom amelioration are broadly classified into bottom-up or top-down methods (Marshall 2009). Treatment options have metamorphosed in the last decades from a more conventional and conservative approach to the use of technology combining more than one treatment approach (Umeonwuka et al. 2020), and they include prism adaptation, combination therapy, constraint-induced movement therapy (CIMT), transcutaneous electrical nerve stimulation (TENS), transcranial magnetic stimulation, virtual reality, visual scanning exercise and trunk rotation exercise.

Current stroke treatment guidelines recommend the all-inclusive and timeous screening and diagnosis of USN as a critical part of post-stroke care (Bryer et al. 2010; National Stroke Foundation 2010; Royal College of Physicians 2012; Winstein et al. 2016). However, strict adherence to these protocols is not guaranteed, and translational gaps exist between theory and practice in the management of post-stroke USN (Checketts et al. 2020). Identified assessment currently utilised by rehabilitation experts in clinical practice includes cognitive, functional and neuro-imaging (Checketts et al. 2020).

In South Africa, a study by Ntsiea (2019), that collated South African physiotherapy stroke rehabilitation services and research, identified saccadic eye movement priming with visual scanning exercise as an effective physiotherapy intervention for USN. However, no study has examined the uptake of interventions identified as effective in the treatment of USN by South African neurorehabilitation physiotherapists.

An understanding of the therapists’ knowledge, practice and barriers they encounter in the treatment of USN will enable the neurorehabilitation team including the physiotherapy educators to better strategise and plan to achieve better outcomes in USN-specific treatment post-stroke. With the foregoing in mind, our study was conceptualised to evaluate physiotherapists’ knowledge, current practice and barriers and facilitators to the rehabilitation of USN in South Africa.

A cross-sectional national survey of the members of the neurology speciality interest group of the South African Society of Physiotherapists (SASP) was conducted from November 2018 to June 2019. Community service physiotherapists were not included. Community service physiotherapists were excluded because of their modest work experience in neurorehabilitation, given that they rotate through different departments and hospital wards during their community service year. A total sampling technique was used as all 277 members of the South African Society of Physiotherapy neurology special interest group were invited to participate in our study.

Physiotherapy is recognised as an autonomous profession in South Africa, accepting patients directly and as self-referrals (Bury & Stokes 2013). As such, physiotherapists practising in the South African health space are required to possess a sound theoretical, clinical and evidence-based knowledge of conditions they manage that includes post-stroke USN. Our study evaluated the knowledge on USN, current practice in the rehabilitation of USN and the barriers and enablers to USN rehabilitation amongst physiotherapists with a neurology bias in South Africa. Our study is the first to evaluate physiotherapists’ knowledge on USN, current practice in the rehabilitation of USN and the barriers and enablers to USN rehabilitation in South Africa.

The overall knowledge on the USN score of the respondents was moderate with only very few having poor knowledge of USN. Even though the general pooled knowledge score was adequate, item-by-item analysis of questions contained in the USN knowledge questionnaire showed some interesting results that might have some implications for training and practice. For instance, questions on pharmacological treatment for USN revealed that physiotherapists in South Africa had modest knowledge on the use of pharmacological agents in USN treatment. This may not be unrelated to the fact that physiotherapy training and legislation prohibit Physiotherapists to administer or prescribe medicines although many had a course in pharmacology during training. This is further corroborated by a study by Unger and Lochner (2006) that examined pharmacology practice amongst South African physiotherapists. In their study, respondents received theoretical training in pharmacology as part of their undergraduate qualification. This emphasises the need for a more in-depth integration of pharmacology in student training.

Respondents’ demographics and USN knowledge showed that there was a significant positive correlation between respondents’ age (r = 0.46; p = 0.016) and years of practice as a physiotherapist (r = 0.43; p = 0.026) and knowledge of USN. A previous study that investigated the knowledge of physiotherapists in South Africa on mental health (Hooblaul et al. 2020) found no association between knowledge of mental health and years of practice as a physiotherapist. However, a study by Taukobong et al. (2015) on knowledge of South African physiotherapists on health promotion identified age and work experience as associative factors to the knowledge of health promotion. Several reasons might explain this observation in our study, for instance, exposure to training facilities, access to learning facilities, location of practice (setting). This is evident in the higher knowledge level of a physiotherapist who practices in semi-urban areas as opposed to their counterparts in urban areas. The high load of patients encountered in urban areas may have constrained the therapist from utilising learning facilities, and this may have affected the therapist’s knowledge.

Also, respondents demonstrated a moderate knowledge on questions about incidences and occurrence of causes of USN and anatomy of neglect. Physiotherapists possess an in-depth understanding of gross anatomy necessary for safe and effective clinical practice. A study by Shead and colleagues in 2018 on anatomy education for South African undergraduate physiotherapy students reported that anatomy is taught in all eight schools that train physiotherapists in South Africa, and dissection, prosection, plastinated models, surface anatomy and e-learning were available across faculties (Shead et al. 2018). These learning environments might have positively influenced physiotherapists’ knowledge of the anatomy of neglect.

In South Africa, post-stroke rehabilitation typically commences immediately after the stroke survivor attains medical stability (Krakauer et al. 2012). Identification of post-stroke USN is reported as being modest as less than half of the therapists identified about two post-stroke patients with USN symptoms. This could be because of not having a routine assessment for the identification of USN or because of a low prevalence of USN in health facilities across South Africa. However, this is beyond the scope of our study and could only be substantiated in a future study. Interestingly, reported evaluation from time of admission for post-stroke USN is in line with clinical guidelines that recommend screening for visual perception and USN within 48 h of a patient re-gaining consciousness (National Stroke Foundation 2010; Robinson 2009). The association of USN with poor functional outcomes has been substantiated by previous authors (Jehkonen et al. 2000); it is, however, important to identify USN early in the rehabilitation process that can result in positive decision-making such as highlighting the importance for further perceptual assessment and commencing treatment interventions involving cognitive rehabilitation during hospitalisation (Bowen & Lincoln 2007).

We also showed that half of the physiotherapists reported using standardised outcome measures in the assessment/screening of post-stroke USN. This is in direct contrast with a Canadian study, where a paltry 13% of stroke survivors were assessed using a standardised outcome measure (Menon-Nair et al. 2006).

The use of standard outcome measures is a familiar discourse in the South African rehabilitation space. Inglis and colleagues in a cross-sectional survey of physiotherapists on awareness of outcome measures amongst physiotherapists in South Africa reported that 84% of responding therapists reported using standardised outcome measures frequently (Inglis, Faure & Frieg 2008). Our results are surprising given the previous report of high utilisation of standardised outcome measures by South African physiotherapists. This may be because of time constraints or reduced therapy time and lack of knowledge in the use of condition-specific outcome measures.

The specific test identified for screening for USN was the Comb and Razor test, Draw-a-Man test and the Behavioural Inattention test. The previous multidisciplinary international survey had identified the Line Cancellation test as the most popular test used in the screening for USN (Checketts et al. 2020). However, we did not investigate the factors that influence the selection of specific screening tools. It might be because of the ease of administration of the Comb and Razor test, the reduced time in administering and no cost implication in obtaining the test as the Comb and Razor test takes approximately 5 min to administer (McIntosh et al. 2000). Another probable explanation for the popularity of the Comb and Razor test amongst South African neurological physiotherapists could be an institutional preference. Anecdotally, most physiotherapy practice centres in South Africa have a battery of recommended outcome measures institutionalised in those centres although McGinnis et al. (2009) had in a previous study reported that patients’ medical diagnosis and history could inform the choice of assessment tool selection for balance assessment post-stroke.

Constraint-induced movement therapy, mirror therapy, visual scanning exercise and limb activation were the top four popular interventions for USN identified. This observation is similar to a previous study by Chen et al. (2018) that identified visual scanning, active limb activation, sustained attention training and prism adaptation therapy as the top four popular interventions for USN. Similarly, a systematic literature review by Luauté et al. (2006) recommended, based on available evidence, the use of visual scanning exercise, trunk rotation, mental imagery and muscle neck vibration. The CIMT was the top intervention of choice in our study. This is not surprising as CIMT is currently considered to be the most effective treatment regimen in physiotherapy for improving upper paretic limb rehabilitation outcomes (Langhorne, Bernhardt & Kwakkel 2011; Veerbeek et al. 2014). It has been reported that increased mobility of the affected limb, especially in the affected hemispace, could reduce the manifestations of visual-spatial neglect (Robertson & North 1993). The reasons for selecting these interventions were not explored here. However, physiotherapist preference, patient profile information and alternating to other effective treatment have been pinpointed to be reasons for the selection of a particular intervention.

Finally, we investigated the enablers and barriers faced by South African neuro-physiotherapist in the treatment of USN. Identified major barriers included inadequate therapy time and lack of relevant equipment for rehabilitation of USN in clinical practice. This is similar to reports by Checkett and colleagues that highlighted various barriers to USN rehabilitation as time and equipment shortages, sub-optimal MDT collaboration and lack of knowledge (Checketts et al. 2020). A major challenge in the South African context is that there are few public rehabilitation facilities leading to overcrowding and long waiting times and delays (Sokhela et al. 2013). The overload may ripple to the shortening of individualised therapy time. Treatment for USN is usually tailored to individual’s needs and needs ample time for a one-on-one session with the therapist. Also, the other major barrier identified is not alien to the African region; poor facilities and equipment have been an age-long challenge for the African health landscape (African Development Bank 2013). In contrast, perceived major enablers included: presence of a multidisciplinary stroke team, therapists’ belief that USN greatly enhances stroke patients’ quality of life (QoL) and availability of staff. These identified barriers and enablers are critical in understanding how to plan for better USN rehabilitation outcomes in the South African rehabilitation space.

The small sample size could affect the reliability of the survey results. Moreover, most of the respondents completed this survey questionnaire in urban areas. This limits the generalisation of the findings in semi-urban and rural settings.

A probable reason for the low response rate may be that physiotherapists may have missed the emails (as the emails may have been delivered to their spam because the questionnaire was sent in bulk to all SASP neurology interest group members). Another possible reason for the low response rate may be because physiotherapists as a result of their workload spend minimal time at their desks or in front of a computer or smart devices and missed emails containing the survey questionnaire.

Physiotherapists surveyed demonstrated a fair knowledge of USN although knowledge about pharmacological management of USN appears to be modest. Current practice in post-stroke USN by South African neuro-physiotherapists is based on current evidence and practice guidelines.