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Vestibular

Physio Nexus Academy · Clinical Treatment Framework

Benign Paroxysmal Positional Vertigo (BPPV)

Canalith repositioning is the primary treatment after confirming the affected canal and excluding central or vascular warning signs.

Assess → classifyTreat → reassessLoad → progress

Clinical decision pathway

A structured plan, not a recipe

Clinician-led · Individualised
01

Understand

Screen safety, identify the likely clinical pattern and agree meaningful goals.

02

Select

Choose only interventions that match the patient's impairments and preferences.

03

Reassess

Repeat the same comparable sign or functional task after key interventions.

04

Progress

Build capacity and participation using measurable response, not session count.

Before choosing an intervention

Clinical reasoning

  1. 1Classic BPPV is treated with canalith repositioning after identifying the involved canal/side.
  2. 2Atypical nystagmus or neurological signs require a different diagnostic pathway.
  3. 3Do not substitute generic balance exercises for correct repositioning in clear BPPV.

A practical starting sequence

First-session workflow

  1. 1Take a detailed vertigo history: duration, triggers and associated neurological symptoms.
  2. 2Perform oculomotor/neurological screening if presentation is not classic.
  3. 3Use Dix-Hallpike or supine roll testing as appropriate.
  4. 4Choose the maneuver based on canal and side.

Assessment & examination

  1. 1History of brief position-triggered vertigo
  2. 2Dix-Hallpike or roll test as appropriate
  3. 3Observe nystagmus pattern
  4. 4Neurological/oculomotor screen when presentation is atypical

Red flags & safety screen

  1. 1New focal neurological signs
  2. 2Severe new headache
  3. 3Continuous spontaneous vertigo with central signs
  4. 4Syncope or vascular warning symptoms

Indication · dosage · response

Manual therapy application

  1. 1Posterior-canal BPPV: use an appropriate canalith repositioning sequence such as Epley when indicated.
  2. 2Move the head/body through each position carefully and observe symptom/nystagmus response.
  3. 3Cervical limitations may require modified maneuvers.

Adapt to irritability and capacity

Exercise prescription & dosage

  1. 1No generic strengthening dosage is required for isolated BPPV.
  2. 2If residual imbalance remains, add balance/gaze-stability work based on findings.

Modalities & adjuncts

  1. 1Electrotherapy has no routine role.

Progression & regression rules

  1. 1Re-test after treatment when appropriate.
  2. 2If positional tests normalize but imbalance persists, treat residual vestibular deficits.
  3. 3If repeated maneuvers fail, reconsider diagnosis/canal.

Home programme

  1. 1Educate about recurrence and safe movement
  2. 2Home maneuver only when diagnosis and technique have been taught correctly

Outcome measures

  1. 1Positional test response
  2. 2Dizziness Handicap Inventory
  3. 3Balance/function

Common clinical mistakes

  1. 1Treating dizziness without identifying the canal.
  2. 2Missing central neurological signs.
  3. 3Doing repeated maneuvers despite no diagnostic fit.
  4. 4Forcing cervical extension in a patient who cannot tolerate it.

Patient education & self-management

  1. 1Explain that BPPV can recur.
  2. 2Teach a home maneuver only after diagnosis and correct technique are established.
  3. 3Explain warning signs that are not typical of BPPV.

Referral & escalation

  1. 1Urgent medical evaluation for central neurological features or atypical persistent symptoms

Clinical use & safety note

This is an educational clinical framework, not an individual prescription or a substitute for diagnosis, medical assessment, local protocols or professional judgement. Exercise dose, manual techniques and adjuncts must be adapted to examination findings, irritability, comorbidities, precautions, patient goals and response. Obtain informed consent, work within training and scope, and refer when indicated. Do not apply every intervention listed to every patient.

The PNA treatment principle

The best plan is not the one with the most techniques. It is the one that identifies the patient's main problem, selects a defensible intervention, measures the response and steadily restores meaningful function.