Background: Benign paroxysmal positional vertigo (BPPV) is the most common peripheral vestibular disorder and a frequent cause of dizziness. Despite the availability of effective bedside diagnostic and therapeutic maneuvers, BPPV remains underdiagnosed and is frequently associated with unnecessary healthcare utilization, including excessive imaging and specialist referrals. Objective: To systematically evaluate the evidence regarding vestibular physiotherapy and care pathways in the management of BPPV across primary and acute care settings. Methods: A systematic review was conducted in accordance with PRISMA 2020 guidelines. MEDLINE, Embase, Cochrane Library, CINAHL, PEDro, Web of Science, and Scopus were searched through April 2026. Studies evaluating vestibular physiotherapy, canalith repositioning maneuvers, diagnostic pathways, or physiotherapy-led models of care in adults with BPPV were included. Methodological quality was assessed using the Joanna Briggs Institute (JBI) critical appraisal tools. Results: Eighteen studies met the inclusion criteria. Evidence consistently demonstrated persistent diagnostic challenges, frequent neuroimaging utilization, and suboptimal adherence to BPPV clinical practice guidelines. The Epley maneuver showed the strongest evidence for symptom resolution and improvement in dizziness-related outcomes. Physiotherapy-led care pathways were associated with improved diagnostic processes, increased use of evidence-based vestibular assessments, reduced imaging utilization, and decreased demand for specialist consultations. Across studies, vestibular physiotherapy was found to be feasible in both primary and acute care settings and may facilitate earlier diagnosis and treatment. Conclusion: The principal challenge in contemporary BPPV care is not the lack of effective interventions, but their inconsistent implementation across healthcare settings. Vestibular physiotherapy appears to be a promising strategy for addressing this evidence-to-practice gap through improved 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. Further prospective studies are needed to evaluate long-term clinical and economic outcomes.
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