Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder and a leading cause of dizziness in primary care [1]. It is estimated to account for up to 20% - 30% of all vertigo cases, with a lifetime prevalence of approximately 2% - 3% in the general population [1][2]. Although BPPV is considered a benign and highly treatable condition, it is frequently associated with significant functional impairment, increased risk of falls, particularly in older adults, and reduced quality of life [3].

In most healthcare systems, patients with dizziness initially present to general practitioners (GPs), who act as the primary gatekeepers of care; however, the management of BPPV in primary care is often suboptimal. Studies have shown that BPPV is underdiagnosed or misdiagnosed, leading to unnecessary imaging, inappropriate pharmacological treatment, and delayed referral to specialists or physiotherapists [4]. This traditional referral-based pathway may result in increased GP workload, inefficient use of healthcare resources, and prolonged patient suffering despite the availability of effective, low-cost, and rapid treatments [5][6].

Vestibular physiotherapy, particularly through canalith repositioning maneuvers such as the Epley or Semont techniques, is highly effective in resolving symptoms of BPPV. These interventions are non-invasive, can often be delivered in a single or a limited number of sessions, and demonstrate high success rates with minimal risk. Given these characteristics, vestibular physiotherapists are well-positioned to play an important role in the early assessment and management of BPPV within primary and acute care pathways [7][8].

In recent years, the concept of expanded physiotherapy roles, including first-contact and early-access models, has gained increasing attention. In musculoskeletal care, these models have been associated with reduced GP workload, decreased imaging and medication use, comparable clinical outcomes, and potential cost savings. Such findings have supported the integration of physiotherapists as part of multidisciplinary and physiotherapy-led care pathways in primary care settings [9].

Despite the growing evidence supporting direct access models in musculoskeletal conditions [8], their application to vestibular disorders, particularly within structured primary care pathways, remains limited and insufficiently investigated. While vestibular physiotherapy is well established as an effective treatment for BPPV, its role as a first-contact or direct access service has not been adequately explored. Given the distinct clinical characteristics of BPPV, namely its well-defined diagnostic criteria, rapid response to repositioning maneuvers, and generally limited need for advanced investigations, it represents a highly suitable condition for evaluating the potential impact of direct access vestibular physiotherapy. The gap, therefore, lies not in the effectiveness of treatment, but in how patients access it [10]-[12].

Therefore, this systematic review aims to systematically evaluate the available evidence regarding the diagnosis, treatment pathways, healthcare resource utilization, and the role of vestibular physiotherapy in the management of BPPV across primary and acute care settings. Particular emphasis is placed on diagnostic pathways, vestibular physiotherapy interventions, healthcare resource utilization, and the integration of physiotherapy within existing models of care. By synthesizing the current evidence, this review seeks to identify potential benefits, implementation challenges, and future directions for physiotherapy-led care pathways in patients with BPPV.

A total of 18 studies were included in the final synthesis, encompassing research conducted across emergency department (ED), primary care, family practice, outpatient, ENT, and specialized vestibular care settings. To clarify the scope of the evidence, the included studies were categorized as evaluating either patients with confirmed benign paroxysmal positional vertigo (BPPV) or broader populations presenting with dizziness, vertigo, imbalance, or acute vestibular syndromes. The studies examined diagnostic pathways, guideline adherence, implementation of vestibular physiotherapy, healthcare resource utilization, vestibular rehabilitation, and the effectiveness of canalith repositioning maneuvers.

CharacteristicsofIncludedStudies

The included studies demonstrated substantial heterogeneity in both design and clinical focus. Ten studies were conducted primarily in emergency department settings and investigated diagnostic accuracy, imaging utilization, vestibular physiotherapy implementation, and clinical pathway development among patients presenting with dizziness or vertigo [12][14]-[22]. Several studies focused specifically on patients with confirmed BPPV and evaluated implementation of evidence-based BPPV care, guideline adherence, physiotherapy involvement, and canalith repositioning maneuvers in primary care, family practice, and emergency department settings [17][18][21][23]-[30]. Additional studies examined broader vestibular care pathways and first-contact physiotherapy services for patients with vestibular disorders or suspected vestibulopathy [20]-[22].

EmergencyDepartmentDiagnosticPathwaysandResourceUtilization

Several studies evaluated patients presenting to emergency departments with dizziness, vertigo, imbalance, or acute vestibular syndromes rather than confirmed BPPV cohorts [14]-[16][18]. Diagnostic uncertainty was common, with many patients receiving nonspecific or incorrect diagnoses [15]. Diagnostic accuracy studies demonstrated the value of structured bedside vestibular assessments, including the HINTS examination, for differentiating peripheral from central vestibular disorders [16]. Furthermore, studies reported frequent use of neuroimaging despite limited diagnostic yield in patients without focal neurological deficits, highlighting opportunities to reduce unnecessary imaging through improved clinical assessment pathways [14]. In studies specifically addressing BPPV care, the implementation of evidence-based diagnostic pathways was associated with increased use of Dix-Hallpike testing and canalith repositioning maneuvers and improved adherence to guideline-recommended care [18].

VestibularPhysiotherapyinEmergencyCare

Most studies evaluating vestibular physiotherapy in emergency settings involved broader dizziness populations rather than exclusively patients with confirmed BPPV [12][19][20][22]. Specialized vestibular physiotherapy was consistently reported as feasible and safe and was associated with increased use of Dix-Hallpike testing and canalith repositioning maneuvers, as well as reduced rates of undifferentiated dizziness diagnoses and brain imaging [19][22]. Structured emergency department vertigo pathways incorporating vestibular physiotherapists improved assessment quality, diagnostic specificity, and operational efficiency, including reductions in assessment delays and emergency department length of stay [12]. Statewide analyses further highlighted the underutilization of vestibular-trained physiotherapists despite their potential contribution to bedside assessment, repositioning treatment, and healthcare resource stewardship [21].

PrimaryCareManagementandGuidelineAdherence

Evidence from primary care studies demonstrated persistent gaps between guideline recommendations and real-world practice. Several investigations reported underutilization of positional diagnostic testing and canalith repositioning maneuvers, accompanied by continued reliance on vestibular suppressant medications and diagnostic imaging [25][26]. Educational interventions targeting physiotherapists significantly improved clinician knowledge, confidence, and practical skills in BPPV management, supporting the feasibility of physiotherapy-led vestibular care models in primary care settings [23]. Additionally, first-contact vestibular physiotherapy reduced the need for specialist ENT review, suggesting a potential role for physiotherapists in triage and early management of vestibular disorders [24].

EffectivenessofRepositioningManeuvers

Four studies directly evaluated canalith repositioning maneuvers in patients with posterior canal BPPV [27]-[30]. Randomized controlled trials conducted in family practice and primary care settings demonstrated that the Epley maneuver can be effectively delivered outside specialist clinics, resulting in greater symptom resolution and higher rates of conversion to a negative Dix-Hallpike test compared with control interventions [27][28]. Comparative clinical studies consistently identified the Epley maneuver as the most effective treatment strategy when compared with Semont and Brandt-Daroff maneuvers [29][30]. Across studies, the Epley maneuver produced superior improvements in vertigo symptoms, nystagmus resolution, and dizziness-related quality of life outcomes, further supporting its role as the preferred first-line treatment for posterior canal BPPV.

MethodologicalQualityAssessment

Quality appraisal using Joanna Briggs Institute (JBI) critical appraisal tools demonstrated generally favorable methodological quality across the included studies. Ten studies were rated as high quality, including randomized controlled trials, cohort studies, implementation studies, and large database analyses [12][14][17][18][20][21][25]-[28]. Most remaining studies were classified as moderate quality, largely due to limitations inherent to observational, feasibility, qualitative, diagnostic accuracy, or quasi-experimental designs [15][16][19][22]-[24][29][30]. No study was rated as low quality. Overall, the body of evidence provides moderate-to-high confidence in the reported findings regarding vestibular physiotherapy implementation, clinical pathway development, and the effectiveness of repositioning maneuvers for BPPV management.

One of the most consistent findings across the included studies was the persistent overreliance on diagnostic imaging for dizziness presentations, particularly in emergency departments. Several studies included in this review evaluated dizziness management pathways in emergency department settings and were not limited to patients with confirmed BPPV. While these studies were not restricted to patients with confirmed BPPV, they provide important contextual evidence regarding dizziness management pathways in emergency settings and help contextualize the role of physiotherapy-led assessment, diagnostic accuracy, and healthcare resource utilization in patients presenting with dizziness. Large-scale investigations demonstrated frequent use of CT and MRI despite relatively low diagnostic yield in patients without focal neurological deficits [14][18]. These findings are supported by recent reviews emphasizing that imaging often contributes little to the diagnosis of peripheral vestibular disorders and should not replace careful clinical examination [31][32]. Given the significant economic burden associated with vertigo-related healthcare utilization [33], reducing unnecessary imaging through improved bedside assessment represents an important opportunity to enhance both clinical effectiveness and resource stewardship.

Several studies highlighted the importance of structured vestibular assessment pathways in improving diagnostic accuracy. Emergency physicians frequently encounter difficulties distinguishing peripheral from central vestibular disorders, resulting in diagnostic uncertainty and potential misclassification [15]. The HINTS examination has demonstrated strong diagnostic utility in differentiating central from peripheral causes of acute vestibular syndromes when performed by appropriately trained clinicians [16]. Similarly, implementation studies showed that structured BPPV pathways increased the use of Dix-Hallpike testing and canalith repositioning procedures while reducing undifferentiated dizziness diagnoses and unnecessary imaging [17][24]. These findings suggest that improving clinician confidence and competency in vestibular assessment may represent one of the most impactful interventions for dizziness management.

A particularly important observation emerging from this review is the growing role of vestibular physiotherapy across the continuum of care. Traditionally, vestibular disorders have been managed primarily by otolaryngologists or neurologists; however, several included studies demonstrated that physiotherapists can successfully contribute to assessment, triage, and treatment processes [19][24]. Training programs significantly improved physiotherapists’ knowledge and practical skills in BPPV management [23], while first-contact vestibular physiotherapy was associated with a reduced need for specialist ENT review [24]. Similar findings have been reported in broader physiotherapy literature, where direct-access physiotherapy models consistently reduce physician workload and healthcare utilization without compromising patient outcomes [9]. Collectively, these findings support the integration of vestibular-trained physiotherapists into both primary care and emergency care pathways.

The effectiveness of canalith repositioning maneuvers was another prominent theme throughout the review. Multiple randomized controlled trials and systematic reviews have consistently demonstrated the superiority of repositioning maneuvers over observation or medication-based approaches [7][8][27]-[35]. Notably, studies conducted in family practice and primary care settings confirmed that the Epley maneuver can be delivered effectively outside specialist clinics, resulting in significant symptom resolution and conversion to negative Dix-Hallpike testing [27][28]. Comparative studies further demonstrated that the Epley maneuver consistently outperformed Semont and Brandt-Daroff interventions in terms of symptom resolution, quality of life improvement, and nystagmus reduction [29]-[31]. These findings align closely with previous meta-analyses and Cochrane reviews, which have identified the Epley maneuver as the most effective first-line treatment for posterior canal BPPV [8][34].

Despite the strength of the evidence supporting repositioning maneuvers, guideline adherence remains suboptimal. Studies evaluating real-world clinical practice revealed persistent underuse of Dix-Hallpike testing and canalith repositioning procedures, alongside continued reliance on vestibular suppressants and diagnostic imaging [25][26]. Recent qualitative research has further identified barriers, including lack of clinician confidence, insufficient training, time constraints, and uncertainty regarding maneuver performance [5]. These findings suggest that dissemination of evidence alone may be insufficient to change practice. Instead, successful implementation likely requires structured educational initiatives, organizational support, and integrated referral pathways similar to those described in successful emergency department implementation studies [17][19][22].

The findings of this review also have important implications for healthcare system design. Referral systems function most effectively when patients receive appropriate management at the lowest effective level of care [6]. The evidence synthesized in this review suggests that many patients with BPPV can be accurately diagnosed and effectively treated in primary care without specialist referral [4][27][28]. Early management may reduce symptom duration, improve quality of life, decrease unnecessary investigations, and reduce demand on specialist services [24][25][33]. Such an approach aligns with contemporary models of integrated healthcare delivery that emphasize early intervention, interdisciplinary collaboration, and efficient resource utilization.

Taken together, the evidence supports a shift toward more structured, physiotherapy-integrated vestibular care pathways. Emergency departments, primary care clinics, and ENT services reported potential benefits from incorporating vestibular-trained physiotherapists and standardized assessment protocols [12][17][20]-[24]. The consistent effectiveness of repositioning maneuvers, particularly the Epley maneuver, combined with the documented limitations of current practice, suggests that substantial improvements in BPPV management remain achievable through targeted implementation effort [36][37].

Perhaps the most important finding of this review is that the major barrier to optimal BPPV care is not the absence of effective interventions, but rather their inconsistent implementation across primary and acute care settings. Although the diagnostic criteria for BPPV are well established and repositioning maneuvers have demonstrated high success rates for decades, substantial gaps remain between guideline recommendations and routine clinical practice. The persistence of diagnostic uncertainty, excessive imaging utilization, underuse of positional testing, and low adoption of canalith repositioning maneuvers suggests that future efforts should focus less on developing new treatments and more on improving implementation of existing evidence-based care. In this context, vestibular physiotherapy may help bridge this evidence-to-practice gap because it directly addresses the major barriers identified across the included studies, including limited clinician expertise, delayed access to treatment, overreliance on imaging, and inefficient referral pathways.

A major strength of this review is the inclusion of studies from multiple healthcare settings, including emergency departments, primary care, family medicine, ENT services, and specialized vestibular clinics, providing a comprehensive overview of current BPPV management pathways. Additionally, methodological quality was generally moderate to high across the included studies.

However, several limitations should be acknowledged. Considerable heterogeneity existed regarding study designs, outcome measures, healthcare settings, and intervention strategies, limiting direct comparisons across studies. Several implementation and feasibility studies included relatively small sample sizes and lacked long-term follow-up [19][20][23]. Furthermore, some evidence originated from observational or quasi-experimental studies, which may be subject to selection bias and confounding. Finally, healthcare systems differ substantially between countries, potentially affecting the generalizability of implementation findings.

Future research should focus on large-scale implementation studies evaluating vestibular physiotherapy pathways across diverse healthcare systems. Additional investigation is needed to determine the most effective educational strategies for improving guideline adherence among primary care and emergency clinicians. Economic evaluations examining cost savings associated with reduced imaging, decreased specialist referrals, and earlier treatment are also warranted. Finally, future studies should assess long-term patient outcomes following physiotherapy-led vestibular care models and explore optimal integration of vestibular physiotherapists within multidisciplinary dizziness pathways.

Overall, the available evidence strongly supports earlier recognition of BPPV, wider adoption of evidence-based bedside assessment techniques, greater use of canalith repositioning maneuvers, and expanded integration of vestibular physiotherapy throughout the healthcare continuum. These strategies have the potential to improve patient outcomes while simultaneously reducing unnecessary healthcare utilization and costs.

This review demonstrates that the principal challenge in contemporary BPPV management is not the lack of effective diagnostic or therapeutic interventions, but rather their inconsistent implementation across healthcare settings. Although evidence strongly supports the use of positional testing and canalith repositioning maneuvers, these interventions remain underutilized in both primary care and emergency departments. Vestibular physiotherapy appears to be a promising strategy for supporting the implementation of evidence-based assessment and treatment approaches. The available evidence suggests that physiotherapy-integrated care pathways may facilitate earlier diagnosis and treatment while potentially reducing unnecessary healthcare utilization.

Future research should focus on implementation strategies, workforce training, and health system integration to ensure that evidence-based BPPV care is consistently delivered in routine clinical practice.