REFERENCE · DIAGNOSTIC TECHNIQUE

Vestibular and Differential Assessment for PPPD

Clinician-focused educational reference; select assessment within professional competence, consent and an individual clinical plan.

Purpose and Suitability
Anatomy and Physiology
Preparation and Safety
Performing the Assessment
Interpreting Findings
Explaining the Result
Evidence and Limitations
Media and Accessibility
Research and Sources

Purpose and Suitability

Use this guide to plan the clinical questions that vestibular, neurological and cardiovascular assessment should answer in someone being considered for PPPD. It is a selection-and-interpretation guide, not a training protocol for examination manoeuvres.

Differential assessment: Comparing plausible explanations for symptoms and checking which are supported.

The original inventory identifies vestibular/positional examinations and orthostatic/neurological assessment as differential investigations. Neither group supplies a positive PPPD test. [1]

Anatomy and Physiology

Keep the system being tested explicit: an eye-movement or head-impulse assessment, a positional examination, standing vital signs and a neurological examination address different questions. Record what each can contribute rather than labelling the whole battery “the PPPD test.”

Orthostatic: Related to being upright, commonly used when discussing changes after standing.

The anatomical finding, the reported symptom and the proposed explanation belong in separate parts of the record. A laboratory result should not be converted into an assumption about community mobility or endurance.

Preparation and Safety

First decide whether this is appropriate for routine assessment. New severe dizziness, new focal neurological symptoms, fainting, chest pain or new hearing loss belongs to the relevant urgent assessment pathway; an existing PPPD diagnosis must not override it.

Explain the purpose and likely symptom burden of each proposed assessment. Check mobility, neck restrictions, pain, hearing/vision access, relevant medication and ability to transfer safely. Plan support, rest and stopping conditions. If examination cannot be completed safely, record the limitation and arrange an appropriate alternative or referral. Do not stop prescribed medication simply to complete this educational page.

This guide does not teach a home head-impulse test, a positional manoeuvre or an acute-stroke screening examination.

Performing the Assessment

Select by clinical question

Use the original inventory’s investigation groups below within a qualified clinician’s usual protocols. This is an authored planning table, not a mandatory battery.

Inventory group	Question for the clinician	Documentation prompt
Vestibular and positional examinations	Could a vestibular condition account for some or all symptoms?	Why this test was selected; findings; whether it sampled the relevant problem; referral or treatment implications
Orthostatic assessment	Could a cardiovascular or autonomic condition contribute?	Symptoms, posture, timing and measurements under the chosen clinical protocol
Neurological assessment	Are there findings requiring a neurological explanation?	Relevant examination, existing diagnoses, new changes and investigation plan

Head-impulse, nystagmus and positional examinations investigate alternative or coexisting vestibular causes; standing blood pressure/heart rate and neurological examination are selected where indicated. This restates the original inventory, not a claim that everyone requires every test. [1]

Nystagmus: Repetitive involuntary eye movement assessed as part of some balance examinations.

After assessment, return to the five-criteria history. Identify what the results explain, what they leave unanswered and whether another clinician needs to review them.

Interpreting Findings

An abnormal vestibular result does not automatically exclude PPPD; a normal result does not confirm it. Consider residual vestibular impairment, episodic conditions such as vestibular migraine or positional vertigo, autonomic conditions, medication effects and neurological disease according to the presentation. Coexistence requires attribution of each symptom pattern, not choosing one label for everything. [1]

Separate persistent background symptoms from a distinct new attack. Avoid calling a completed examination “normal” without naming its scope and any constraints. “No abnormality found on this examination” and “all relevant alternatives excluded” are different statements.

For daily-function decisions, add the person’s account of repeated activity, environment, support and recovery. A short safe corridor walk cannot establish how a crowded journey or a full shift will go.

Explaining the Result

Authored explanation example: “This assessment was looking for another balance problem. I will explain what it found and what it cannot tell us. We can consider PPPD and another condition together when the evidence supports both. Your day-to-day difficulties need their own assessment, even if a particular test is reassuring.”

Name the relevant finding and next step; do not offer this generic wording in place of an individual explanation. Ask the person to describe their understanding and agree who will communicate results across the team.

Evidence and Limitations

The consensus supports clinical history with indicated testing; there is no pathognomonic examination or laboratory finding for PPPD. It is not a diagnostic-accuracy study of the selection table above. [1]

Pathognomonic: A finding sufficiently specific to identify a particular disease or disorder.

This page does not provide accuracy estimates for individual vestibular tests, positional protocols, standing thresholds or imaging. Those require their own indication-specific guidance and training. An incomplete assessment remains incomplete; lack of access to a specialist does not convert an uncertain result into a positive diagnosis.

Record unresolved questions and who will review them. The purpose is to make clinical reasoning visible and prevent either normal or abnormal tests from being overinterpreted.

Media and Accessibility

A static table showing “clinical question → selected assessment → interpretation and next step” is preferable to a provocative demonstration. Use fictional records and clearly mark them as authored examples. Do not film head movements or standing challenges as instructions for viewers to reproduce.

Provide captions and transcripts for any later clinician explanation. Avoid autoplay, moving backgrounds and flashing visual patterns; offer the same information in plain text.

Research and Sources

The original vestibular and orthostatic/neurological inventory entries are preserved in the inventory. The clinical planning table is an authored aid. The Bárány paper supplies the diagnostic and coexistence framework, not a complete manual for every differential examination.

Citation	Figure	Full citation
[1]	—	Staab JP, Eckhardt-Henn A, Horii A, Jacob R, Strupp M, Brandt T, Bronstein A. Diagnostic criteria for persistent postural-perceptual dizziness (PPPD): consensus document of the Committee for the Classification of Vestibular Disorders of the Bárány Society. Journal of Vestibular Research. 2017;27(4):191–208. FND-CIT-0027. https://doi.org/10.3233/VES-170622

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