When to refer for vestibular rehabilitation: a clinician's guide

Who benefits from vestibular physical therapy

BPPV: key guideline statements

• Diagnose posterior canal BPPV with the Dix-Hallpike maneuver; perform a supine roll test if the Dix-Hallpike is negative or shows horizontal nystagmus.
• Treat posterior canal BPPV with canalith repositioning.
• Do not routinely obtain imaging or vestibular testing when diagnostic criteria are met without additional findings.
• Do not routinely treat BPPV with vestibular suppressants such as antihistamines or benzodiazepines.
• Do not recommend post-procedural postural restrictions.
• Reassess within one month after observation or initial treatment, and assess fall risk and comorbidities.¹

Red flags that need emergency evaluation first

• Acute, continuous vertigo with a normal head impulse test, direction-changing or vertical nystagmus, or skew deviation (central HINTS findings)¹⁰
• New neurologic deficits, a severe or unusual headache, or neck pain after trauma or manipulation (dissection risk)¹¹
• Sudden sensorineural hearing loss, which needs time-sensitive ENT care
• Syncope, chest pain or palpitations

What our evaluation includes

• A 60-minute, 1-on-1 evaluation with Dr. Manan Patel, PT, DPT, a Certified Vestibular Specialist
• Infrared video goggle oculomotor and positional testing (spontaneous, gaze-evoked, head-shake and positional nystagmus)
• Head impulse and dynamic visual acuity testing
• BioSway computerized balance testing, gait and fall-risk measures
• Cervical screen, including vascular safety considerations, before positional testing when indicated
• Standardized outcome measures such as the Dizziness Handicap Inventory

How to write the referral

A referral that reads "Physical therapy: evaluate and treat. Vestibular rehabilitation." with the working diagnosis (for example BPPV, vestibular hypofunction, PPPD or post-concussion dizziness) is all we need. Include relevant audiology, imaging or vestibular test results if available, and note any vascular or neurologic history. Our printable referral pad has check boxes for each.

Patients can be seen at our Cumming or Alpharetta clinic, usually within 48 hours for urgent needs. We are in-network with Traditional Medicare, BCBS / Anthem and Tricare, accept Workers' Compensation, Auto MedPay and attorney liens, and offer a $129 flat rate for self-pay and out-of-network plans, including Aetna, Cigna and UnitedHealthcare.

What your office receives

An evaluation summary faxed to your office within 48 hours of the first visit, with objective findings, the working diagnosis and the plan of care, followed by progress updates at key milestones and a discharge summary.

Keep reading

• The Epley maneuver: when it works, and why the side mattersHow canalith repositioning works, why home attempts fail, and what to expect afterward.4 min read · Patients
• Vertigo, dizziness or lightheadedness? How to tell the differenceWhat spinning, rocking, woozy and faint usually mean, and when dizziness is an emergency.4 min read · Patients
• All guidesBrowse the full learning center.

Related conditions we treat

References

1. Bhattacharyya N, et al. Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update). Otolaryngology–Head and Neck Surgery. 2017.
2. von Brevern M, et al. Benign paroxysmal positional vertigo: Diagnostic criteria. Journal of Vestibular Research. 2015.
3. Hall CD, et al. Vestibular Rehabilitation for Peripheral Vestibular Hypofunction: An Updated Clinical Practice Guideline. Journal of Neurologic Physical Therapy. 2022.
4. McDonnell MN, Hillier SL. Vestibular rehabilitation for unilateral peripheral vestibular dysfunction. Cochrane Database of Systematic Reviews. 2015.
5. Staab JP, et al. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD). Journal of Vestibular Research. 2017.
6. Lempert T, et al. Vestibular migraine: Diagnostic criteria (Update). Journal of Vestibular Research. 2022.
7. Patricios JS, et al. Consensus statement on concussion in sport: the 6th International Conference on Concussion in Sport, Amsterdam 2022. British Journal of Sports Medicine. 2023.
8. Quatman-Yates CC, et al. Physical Therapy Evaluation and Treatment After Concussion/Mild Traumatic Brain Injury: Clinical Practice Guidelines. Journal of Orthopaedic & Sports Physical Therapy. 2020.
9. Basura GJ, et al. Clinical Practice Guideline: Ménière's Disease. Otolaryngology–Head and Neck Surgery. 2020.
10. Kattah JC, et al. HINTS to diagnose stroke in the acute vestibular syndrome: three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke. 2009.
11. Newman-Toker DE, Edlow JA. TiTrATE: A Novel, Evidence-Based Approach to Diagnosing Acute Dizziness and Vertigo. Neurologic Clinics. 2015.

Clinically reviewed by Dr. Manan Patel, PT, DPT, TPSDoctor of Physical Therapy, Certified Vestibular Specialist and one of the few certified Therapeutic Pain Specialists in North Atlanta, with 15+ years of outpatient care. About Dr. Patel

This guide is general education, not a diagnosis or a substitute for an examination. If you have new or worsening symptoms, contact your doctor.