Objective. This update of a 2008 guideline from the American Academy of Otolaryngology-Head and Neck Surgery Foundation provides evidence-based recommendations to benign paroxysmal positional vertigo (BPPV), defined as a disorder of the inner ear characterized by repeated episodes of positional vertigo. Changes from the prior guideline include a consumer advocate added to the update group; new evidence from 2 clinical practice guidelines, 20 systematic reviews, and 27 randomized controlled trials; enhanced emphasis on patient education and shared decision making; a new algorithm to clarify action statement relationships; and new and expanded recommendations for the diagnosis and management of BPPV.Purpose. The primary purposes of this guideline are to improve the quality of care and outcomes for BPPV by improving the accurate and efficient diagnosis of BPPV, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing such as radiographic imaging, and increasing the use of appropriate therapeutic repositioning maneuvers. The guideline is intended for all clinicians who are likely to diagnose and manage patients with BPPV, and it applies to any setting in which BPPV would be identified, monitored, or managed. The target patient for the guideline is aged ≥18 years with a suspected or potential diagnosis of BPPV. The primary outcome considered in this guideline is the resolution of the symptoms associated with BPPV. Secondary outcomes considered include an increased rate of accurate diagnoses of BPPV, a more efficient return to regular activities and work, decreased use of inappropriate medications and unnecessary diagnostic tests, reduction in recurrence of BPPV, and reduction in adverse events associated with undiagnosed or untreated BPPV. Other outcomes considered include minimizing costs in the diagnosis and treatment of BPPV, minimizing potentially unnecessary return physician visits, and maximizing the health-related quality of life of individuals afflicted with BPPV.Action Statements. The update group made strong recommendations that clinicians should (1) diagnose posterior semicircular canal BPPV when vertigo associated with torsional, upbeating nystagmus is provoked by the Dix-Hallpike maneuver, performed by bringing the patient from an upright to supine position with the head turned 45° to one side and neck extended 20° with the affected ear down, and (2) treat, or refer to a clinician who can treat, patients with posterior canal BPPV with a canalith repositioning procedure. The update group made a strong recommendation against postprocedural postural restrictions after canalith repositioning procedure for posterior canal BPPV. The update group made recommendations that the clinician should (1) perform, or refer to a clinician who can perform, a supine roll test to assess for lateral semicircular canal BPPV if the patient has a history compatible with BPPV and the Dix-Hallpike test exhibits horizontal or no nystagmus; (2) differentiate...

The American Academy of Otolaryngology-Head and Neck Surgery Foundation has published a supplement to this issue of Otolaryngology-Head and Neck Surgery featuring the "Clinical Practice Guideline: Benign Paroxysmal Positional Vertigo (Update)." To assist in implementing the guideline recommendations, this article summarizes the rationale, purpose, and key action statements. The 14 recommendations developed emphasize diagnostic accuracy and efficiency, reducing the inappropriate use of vestibular suppressant medications, decreasing the inappropriate use of ancillary testing, and increasing the appropriate therapeutic repositioning maneuvers. An updated guideline is needed due to new clinical trials, new systematic reviews, and the lack of consumer participation in the initial guideline development group.

Purpose of review Rehabilitation for persons with vertigo and balance disorders is becoming commonplace and the literature is expanding rapidly. The present review highlights recent findings of both peripheral and central vestibular disorders and provides insight into evidence related to new rehabilitative interventions. Risk factors will be reviewed to create a better understanding of patient and clinical characteristics that may effect recovery among persons with vestibular disorders. Recent findings Clinical practice guidelines have recently been developed for peripheral vestibular hypofunction and updated for benign paroxysmal positional vertigo. Diagnoses such as persistent postural-perceptual dizziness (PPPD) and vestibular migraine are now defined, and there is growing literature supporting the effectiveness of vestibular rehabilitation as a treatment option. As technology advances, virtual reality and other technologies are being used more frequently to augment vestibular rehabilitation. Clinicians now have a better understanding of rehabilitation expectations and whom to refer based on evidence in order to improve functional outcomes for persons living with peripheral and central vestibular disorders. Summary An up-to-date understanding of the evidence related to vestibular rehabilitation can assist the practicing clinician in making better clinical decisions for their patient and hopefully result in optimal functional recovery.

Purpose The purpose of this article is to review the advancing understanding, differential diagnosis, and integral role of vestibular rehabilitation (VR) in the relatively new but very common diagnosis, persistent postural-perceptual dizziness (PPPD). PPPD is a functional vestibular disorder characterized by chronic and persistent nonspinning dizziness, visual/motion hypersensitivities, and perceived unsteadiness that is often triggered from a definable peripheral vestibular disorder. PPPD is being found to be more common than many well-known peripheral vestibular disorders such as Ménière's disease or bilateral vestibular hypofunction. Early and correct identification of PPPD, including appropriately prescribed VR, is being found essential not only to promote optimal recovery but also to prevent more refractory engrained PPPD. Conclusion PPPD management is steadily advancing, and treating clinicians are now able to access internationally sanctioned diagnostic criteria, World Health Organization International Classification of Diseases , 11th Revision (WHO, 2018) classification, and advancing treatment protocols. Treatment protocols integrate not only medications and cognitive behavioral therapy but also the crucial role of VR, including education, visual/optokinetic motion desensitization, graded habitation, balance retraining, and integrated relaxation/mindfulness.

Background: Dizziness is a very challenging condition to diagnose and treat. Patients with dizziness are increasingly consulting physical therapists in direct access clinics, and commonly require vestibular rehabilitation exercises (VREs). To optimize the effect of VREs, physical therapists should be able to determine whether the patient with dizziness is appropriate for VREs or should be referred to other healthcare providers. Objectives: The purpose of this paper is to describe a screening procedure that will assist physical therapists in the clinical decision-making process for the person presenting with dizziness in direct access clinics. Major Findings: Patients with dizziness can be classified into three subgroups: red flags, yellow flags, and green flags. Red flags are patients with dizziness for whom VRE intervention is not appropriate unless a physician has already cleared them. Yellow flags are patients with dizziness who can benefit from a VRE intervention, however, they present with comorbid disorders that warrant consultation with other healthcare practitioners in order to maximize the effect of the VRE intervention. Green flags are patients who will benefit from VRE intervention without referral. Conclusions: The screening procedure classifies patients with dizziness into three subgroups: red flags, yellow flags, and green flags. Red flags are patients with dizziness for whom VRE intervention is not appropriate unless a physician has already cleared them. Yellow flags are patients with dizziness who can benefit from a VRE intervention, however, they present with comorbid disorders that warrant consultation with other healthcare practitioners in order to maximize the effect of the VRE intervention. Green flags are patients who will benefit from VRE intervention without referral.

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This document presents the initiative of the Bárány Society to improve diagnosis and care of patients presenting with vestibular symptoms worldwide. The Vestibular Medicine (VestMed) concept embraces a wide approach to the potential causes of vestibular symptoms, acknowledging that vertigo, dizziness, and unsteadiness are non-specific symptoms that may arise from a broad spectrum of disorders, spanning from the inner ear to the brainstem, cerebellum and supratentorial cerebral networks, to many disorders beyond these structures. The Bárány Society Vestibular Medicine Curriculum (BS-VestMed-Cur) is based on the concept that VestMed is practiced by different physician specialties and non-physician allied health professionals. Each profession has its characteristic disciplinary role and profile, but all work in overlapping areas. Each discipline requires good awareness of the variety of disorders that can present with vestibular symptoms, their underlying mechanisms and etiologies, diagnostic criteria and treatment options. Similarly, all disciplines require an understanding of their own limitations, the contribution to patient care from other professionals and when to involve other members of the VestMed community. Therefore, the BS-VestMed-Cur is the same for all health professionals involved, the overlaps and differences of the various relevant professions being defined by different levels of detail and depth of knowledge and skills. The BS-VestMed-Cur defines a Basic and an Expert Level Curriculum. The Basic Level Curriculum covers the VestMed topics in less detail and depth, yet still conveys the concept of the wide net approach. It is designed for health professionals as an introduction to, and first step toward, VestMed expertise. The Expert Level Curriculum defines a Focused and Broad Expert. It covers the VestMed spectrum in high detail and requires a high level of understanding. In the Basic and Expert Level Curricula, the range of topics is the same and runs from anatomy, physiology and physics of the vestibular system, to vestibular symptoms, history taking, bedside examination, ancillary testing, the various vestibular disorders, their treatment and professional attitudes. Additionally, research topics relevant to clinical practice are included in the Expert Level Curriculum. For Focused Expert proficiency, the Basic Level Curriculum is required to ensure a broad overview and additionally requires an expansion of knowledge and skills in one or a few specific topics related to the focused expertise, e.g. inner ear surgery. Broad Expert proficiency targets professionals who deal with all sorts of patients presenting with vestibular symptoms (e.g. ORL, neurologists, audiovestibular physicians, physical therapists), requiring a high level of VestMed expertise across the whole spectrum. For the Broad Expert, the Expert Level Curriculum is required in which the minimum attainment targets for all the topics go beyond the Basic Level Curriculum. The minimum requirements regarding knowledge and skills vary between Broad Experts, since they are tuned to the activity profile and underlying specialty of the expert.   The BS-VestMed-Cur aims to provide a basis for current and future teaching and training programs for physicians and non-physicians. The Basic Level Curriculum could also serve as a resource for inspiration for teaching VestMed to students, postgraduate generalists such as primary care physicians and undergraduate health professionals or anybody wishing to enter VestMed.   VestMed is considered a set of competences related to an area of practice of established physician specialties and non-physician health professions rather than a separate clinical specialty. This curriculum does not aim to define a new single clinical specialty.   The BS-VestMed-Cur should also integrate with, facilitate and encourage translational research in the vestibular field.

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