American Speech-Language-Hearing Association

Guidelines

Role of Audiologists in Vestibular and Balance Rehabilitation: Guidelines

ASHA Ad Hoc Committee on Vestibular Rehabilitation


About this Document

Guidelines

These guidelines are an official statement of the American Speech-Language-Hearing Association (ASHA). They provide guidance on the role of audiologists in vestibular and balance rehabilitation but are not official standards of the Association. These guidelines were adopted by the ASHA Executive Board (EB 64-98) in November 1998. These guidelines, which were developed from current literature and a course, Vestibular Rehabilitation: A Competency-Based Course, hosted by the Division of Physical Therapy, University of Miami School of Medicine, were recognized as being applicable to the profession of audiology. Members of the committee include Nancy P. Garrus; Eric B. Hecker; Kenneth G. Henry; Susan Herdman, PhD, PT, consultant; Neil T. Shepard, chair; Charles Stockwell, and Maureen Thompson, ex-officio. Richard Nodar, vice president for professional practices in audiology, served as monitoring vice president.



Introduction

These guidelines were developed from current literature and from a course offered to physical and occupational therapists, Vestibular Rehabilitation: A Competency-Based Course, sponsored by the University of Miami School of Medicine, Division of Physical Therapy and held March 12–14, 1998, in Miami, FL. The course director, Susan J. Herdman, PhD, PT, served as a consultant to this committee. The course consisted of three days of lecture, laboratory sessions, and self-study sessions. In order to successfully complete the course, participants were expected to demonstrate the following assessment skills: oculomotor examination, with emphasis on the identification of nystagmus and canal involvement; balance and gait; fall risk; and functional assessments. Participants were also expected to demonstrate appropriate treatment procedures for benign paroxysmal positional vertigo (BPPV) affecting posterior, anterior, and horizontal canals for both cupulolithiasis and canalithiasis, for unilateral and bilateral peripheral vestibular disorders, and for central vestibular disorders, including traumatic brain injury and stroke. Members of the ASHA Ad Hoc Committee on Vestibular Rehabilitation recognized that these competencies were applicable to the profession of audiology.

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Background

Historically, audiologists have been involved in the assessment of patients with balance disorders and/or dizziness and imbalance utilizing procedures such as electronystagmography (ENG), rotational tests, oculomotor tests, and dynamic posturography. These assessment procedures have expanded the role and responsibilities of the audiologist to include participation on the rehabilitation team for patients identified with balance system dysfunction. Vestibular and balance rehabilitation therapy (VBRT) encompasses a formulation of exercise activities, preferably customized to the needs of the patient, designed to promote the system's natural central compensation process that reduces and, in some cases, eliminates symptoms for the patient with chronic balance disorders and/or dizziness. Audiologists may be involved in the administration of canalith repositioning procedures (CRP), a portion of a full VBRT program, and as consultants on multidisciplinary teams providing overall management to these patients.

These guidelines are designed to serve as a model for audiologists who are interested in (a) performing canalith repositioning maneuvers, and (b) serving as consultants to or members of multidisciplinary teams managing the patient with balance disorders and/or dizziness. The guidelines specify the knowledge and skills required to perform these tasks and the manner in which these skills may be acquired.

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Education and Training

The education and practical experience for the broader area of full vestibular rehabilitation (i.e., providing full clinical assessment of patients and developing rehabilitation activities including but not limited to CRP, gait and balance, adaptation and habituation exercise, as discussed in ASHA's Technical Report on Vestibular & Balance Rehabilitation Programs) is not typically available in audiology educational training programs or in typical postgraduate audiology courses. This type of extensive education involves graduate level work in physical and/or occupational therapy or other disciplines in addition to postgraduate course work in these other disciplines.

At this time, academic programs in audiology do offer a limited education and practicum experience in balance system assessment and canalith repositioning techniques. A limited portion of the required knowledge and skills may be obtained from graduate level studies in the anatomy and physiology of the balance system. Therefore, audiologists typically obtain most knowledge and skills through postgraduate continuing education courses in audiology and other disciplines (e.g., physical or occupational therapy, neurotology).

The Certificate of Clinical Competence in Audiology (CCC-A) from ASHA ensures that audiologists have met the entry level education, knowledge, and experience requirements established by the Association for providing clinical services in the profession of audiology. In order to perform the clinical procedures discussed in this document, audiologists typically possess knowledge and skills beyond those obtained through “entry level” education. All audiologists who are interested in performing CRP and serving as consultants to and/or members of multidisciplinary teams managing patients with balance disorders and/or dizziness should ensure that they have acquired the general and specific knowledge and skills outlined below.

  • The ASHA Code of Ethics (ASHA, 1994) states:

    Individuals shall honor their responsibility to achieve and maintain high standards of professional competence. (Principle of Ethics II)

  • The Code of Ethics also states:

    Individuals shall only engage only in those aspects of their profession that are within the scope of their competence, considering their level of education, training, and experience. (Principle of Ethics II, Rule B)

The extent to which audiologists may be involved in the CRP portion of vestibular and balance rehabilitation programs is dependent on their current knowledge and skill level, privileges granted within a specific job setting, state licensure requirements, and the type of vestibular/balance assessment and rehabilitation management program available.

Other professionals in related fields also may be involved with the rehabilitation of patients with balance disorders and/or dizziness and it is not ASHA's intent to exclude or influence their participation.

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Knowledge and Skills

Outlined below are the general and specific objectives and skills required by audiologists who intend to develop and/or administer CRP and/or intend to serve as consultants on multidisciplinary teams managing patients who have balance disorders and/or dizziness:

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General Knowledge and Skills

  1. Objective: Knowledge of the anatomy and physiology of the subsystems necessary for balance maintenance.

    Knowledge/skills needed: General knowledge of the anatomy and physiology of the peripheral and central vestibular, visual and somatosensory/proprioceptive systems and their relative interactions.

  2. Objective: Knowledge of the pathophysiology of the balance system and the subjective and somatic complaints that lead to imbalance and/or dizziness.

    Knowledge/skills needed: Knowledge of various pathological processes that can affect the sensory and motor subsystems responsible for normal balance and equilibrium.

  3. Objective: Understanding of the general management techniques used for the treatment of vestibular and balance disorders.

    Knowledge/skills needed: In addition to the requisite skills and knowledge necessary for the management of CRP, the audiologist should be familiar with other management techniques and when these might be used to include other activities in the area of vestibular and balance rehabilitation, medical, surgical or dietary strategies for the patient with a balance disorder and/or dizziness.

  4. Objective: Ability to determine appropriate candidacy for vestibular and balance rehabilitation.

    Knowledge/skills needed: The audiologist should possess the ability to determine potential candidacy for vestibular rehabilitation based on the patient's presenting history and symptoms supplemented by presenting signs (e.g., nystagmus), laboratory tests, functional assessment and rule out alternative methods of treatment or contraindication to vestibular rehabilitation by the patient's managing physician.

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Specific Knowledge/Skills — Assessment

  1. Objective: Interpretation and integration of diagnostic vestibular tests and other laboratory data for diagnostic and functional assessment.

    Knowledge/skills needed: Possess the ability to interpret and integrate various laboratory studies for the purposes of diagnostic evaluation as well as to establish a baseline for outcome measures to assess the efficacy of rehabilitation and other management techniques. These tests may include but are not limited to: ENG including extensive oculomotor evaluation; rotational chair; head and body rotation; postural control assessment; audiological evaluation; electrocochleography; auditory brainstem evoked potentials.

  2. Objective: Possess the ability to perform and interpret a variety of direct clinical evaluations designed for diagnostic assessment of the patient with disorders of the balance system.

    Knowledge/skills needed: Skill with techniques for direct clinical examinations for diagnostic and rehabilitative assessments. These may include but not be limited to:

    • Oculomotor examinations with and without visual fixation (ocular alignment; spontaneous and gaze-holding nystagmus; ocular range of motion; vergence; pursuit and saccade eye movements; vestibulo-ocular reflex (VOR) cancellation; VOR to slow head rotation; VOR to head thrusts; head-shaking nystagmus; pressure-induced nystagmus; hyperventilation-induced nystagmus; dynamic visual acuity testing; vertebral artery compression test; Dix-Hallpike); and

    • Balance and gait evaluation (Romberg; tandem Romberg; modified clinical test for sensory interaction and balance (CTSIB); Fukuda stepping test; gait analysis; tandem walk).

  3. Objective: Ability to determine presence of posterior canal BPPV or anterior and horizontal canal variants causing symptoms of dizziness.

    Knowledge/skills needed: Knowledge of and ability to perform a clinical assessment of maneuvers that provoke symptoms associated with posterior canal BPPV or its anterior and horizontal variants. The tools may include but not be limited to:

    • Dix-Hallpike maneuver to assess posterior and anterior canal BPPV;

    • Side-lying test for BPPV; and

    • Roll test for horizontal canal BPPV.

  4. Objective: Assess effects of ongoing medical conditions that might influence the CRP.

    Knowledge/skills needed: Ability to assess the impact of general medical conditions and knowledge of specific conditions that might compromise or contraindicate a CRP.

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Specific Knowledge/Skills — Treatment

  1. Objective: Perform, when indicated by diagnosis and direct examination, canalith repositioning procedures for canalithiasis or cupulolithiasis of the posterior, anterior or horizontal semicircular canals.

    Knowledge/skills needed: Knowledge of the theory, rationale and procedures necessary to successfully distinguish between posterior, anterior and horizontal canal BPPV and between canalithiasis and cupulolithiasis; and skill to administer a canalith repositioning procedure on patients with BPPV of posterior, anterior or horizontal canal origin.

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Precautions

Patient: CRP may result in patient discomfort or adverse reactions. It is the responsibility of the audiologist who conducts and supervises a CRP to develop specific protocols in conjunction with appropriate medical personnel to ensure patient safety and comfort. These protocols may include, but not be limited to:

  1. Assurances that balance system assessments as well as vestibular and balance rehabilitation techniques are performed in a safe and comfortable environment.

  2. Identification of personnel responsible for the administration and/or interpretation of balance system assessments as well as vestibular and balance rehabilitation programs.

  3. Identification of appropriate medical personnel to contact in the event that emergency medical assistance is needed.

  4. Provision of informed consent as required by the facility and/or regulatory bodies.

  5. Documentation of patient conditions before, during, and following test administration and/or CRP.

Audiologist: It is recommended that audiologists adhere to the Universal Precautions outlined in the Center for Disease Control Morbidity and Mortality Weekly report (June 24, 1988, Perspectives in Disease Prevention and Health Promotion, 37 (24), 377–388).

Audiologists also must understand the potential for professional liability for any procedure they conduct or supervise. Institutional and/or regulatory bodies, such as state licensure boards, should be informed that CRP is within the scope of practice for audiology. Audiologists should ensure, where applicable, that no limitations have been imposed on their scope of practice that would restrict the coverage of these procedures under their professional liability policy.

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Acquisition of Knowledge and Skills

Only a portion of the indicated knowledge and skills can be acquired through graduate level education on the anatomy and physiology of the balance system. Studies of pathophysiology of insults to the system that result in symptoms of vertigo, disequilibrium, lightheadedness and unsteadiness also may be obtained at the graduate school level in various disciplines and/or with independent programs of study.

The knowledge and skills indicated in the specific sections of assessment and treatment are currently available in postgraduate continuing education courses. It is recommended that audiologists desiring to acquire the knowledge and skills needed to perform CRP develop independent programs of study in centers recognized for their work in this area, in addition to postgraduate continuing education courses, in a variety of disciplines including physical and occupational therapy, in addition to audiology.

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Credentialing

At the present time, credentialing in the area of vestibular rehabilitation or the subarea of CRP is not available. A model for such activity was presented for physical and occupational therapists at the course, Vestibular Rehabilitation: A Competency-Based Course, which was sponsored in March, 1998, by the Division of Physical Therapy at the University of Miami School of Medicine.

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References

American Speech-Language-Hearing Association. (1994, March). Code of ethics. Asha, 36(Suppl. 13), 1–2.

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Index terms: balance, rehabilitation

Reference this material as: American Speech-Language-Hearing Association. (1999). Role of audiologists in vestibular and balance rehabilitation: guidelines [Guidelines]. Available from www.asha.org/policy.

© Copyright 1999 American Speech-Language-Hearing Association. All rights reserved.

Disclaimer: The American Speech-Language-Hearing Association disclaims any liability to any party for the accuracy, completeness, or availability of these documents, or for any damages arising out of the use of the documents and any information they contain.

doi:10.1044/policy.GL1999-00015

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