Vestibular rehab referral — what to look for before you send
A clinician-focused guide to recognising vestibular presentations that respond to physiotherapy, versus those that warrant further investigation first.
Dizziness is one of the more challenging presentations in primary care — the differential is broad, and the label "dizziness" covers everything from benign positional vertigo to cardiovascular and central causes. This guide focuses on recognising the presentations that respond well to vestibular physiotherapy, and the features that warrant investigation first.
Presentations that respond well
Several vestibular conditions have a strong evidence base for physiotherapy management:
- BPPV — positional, brief, episodic vertigo. Often responds well to canalith repositioning manoeuvres, frequently within a small number of treatments.
- Vestibular neuritis / labyrinthitis — post-acute, where graded vestibular rehabilitation supports compensation
- Unilateral vestibular hypofunction — responsive to customised adaptation exercises
- PPPD (persistent postural-perceptual dizziness) — benefits from a combined rehabilitation approach
The clinical pattern that suggests vestibular origin
Features pointing toward a peripheral vestibular cause amenable to physiotherapy include a clear positional or movement trigger, a sense of true rotational vertigo or motion sensitivity, and an absence of central or cardiovascular red flags.
Brief positional vertigo triggered by head position changes — rolling over in bed, looking up — is the classic BPPV pattern. It's common, frequently missed, and often resolves in a small number of sessions. Worth considering early, as the payoff for the patient is high.
Features that warrant investigation first
Some features suggest a cause that needs medical assessment before — or instead of — vestibular rehabilitation:
- Acute, severe, sustained vertigo with neurological signs (consider central causes)
- Associated symptoms such as new severe headache, diplopia, dysarthria, or focal weakness
- Dizziness with a clear cardiovascular or syncopal character
- Progressive unilateral hearing loss or tinnitus warranting ENT review
- Dizziness clearly attributable to medication or metabolic causes
Why precise assessment matters
Generic "balance exercises" are often unhelpful for vestibular presentations and can sometimes worsen symptoms if mismatched to the underlying mechanism. The value of vestibular physiotherapy lies in accurate assessment first — identifying the specific deficit, then prescribing accordingly. This is why a non-specific referral for "balance work" yields poorer results than a referral for vestibular assessment.
Practical referral summary
- Positional, episodic vertigo → strong candidate for vestibular physiotherapy, often BPPV
- Post-acute vestibular loss → graded rehabilitation supports recovery
- Central, cardiovascular, or progressive features → investigate first
If you're unsure whether a presentation is suitable, I'm happy to take a quick look or discuss before a formal referral — contact options below.
References
- 1. Vestibular Disorders Association. Canalith Repositioning Procedure (for BPPV). vestibular.org. [Link]
- 2. Comparative efficacy and safety of repositioning maneuvers for posterior canal benign paroxysmal positional vertigo: a network meta-analysis. Frontiers in Neurology. 2026. [Link]
This article provides general educational information and does not constitute individual medical advice. It is not a substitute for assessment by a qualified health professional. Always seek advice tailored to your specific circumstances from your treating practitioner.