Guidelines, Knowledge and Skills, Position Statement

Balance System Assessment

Ad Hoc Committee on Advances in Clinical Practice

About this Document

This policy statement was prepared by the American Speech-Language-Hearing Association (ASHA) Ad Hoc Committee on Advances in Clinical Practice: Donald E. Morgan, chair; Carol M. Frattali, ex officio; Zilpha T. Bosone; David G. Cyr; Deborah Hayes; Krzysztof Izdebski; Paul Kileny; Neil T. Shepard; Barbara C. Sonies; Jaclyn B. Spitzer; and Frank B. Wilson. Diane L. Eger, 1991–1993 vice president for professional practices, and Teris K. Schery, 1988–1990 vice president for clinical affairs, served as monitoring vice presidents. The contributions of the Executive Board, and select and widespread peer reviewers are gratefully acknowledged. The Legislative Council approved the document as official policy of the Association at its November 1991 meeting (LC 51A-91).

I. Introduction

Speech-language pathology and audiology are dynamic and expanding professions with constantly developing technological and clinical advances. Before conducting procedures involving such advances, practitioners must have acquired the knowledge, skills, education, and experience necessary to perform them competently. This policy statement is one of seven documents [1] developed by the Ad Hoc Committee on Advances in Clinical Practice. Each statement expresses the position of the American Speech- Language-Hearing Association (ASHA) concerning specific clinical procedures within the scope of practice of speech-language pathology or audiology, most of which have developed only within the last few years. Each statement further provides guidelines for practitioners performing these procedures. The guidelines consider the knowledge and skills normally associated with the required competencies, the clinical settings recommended for the procedure, and the appropriate involvement of personnel from other disciplines.

Clinical certification by ASHA ensures that practitioners have met the education, knowledge, and experience requirements established by the Association for providing basic clinical services in the professions of speech-language pathology or audiology. Certification in the appropriate profession is necessary, but not sufficient to perform the specific clinical procedure(s) discussed in this statement. The procedure(s) addressed in this document requires the practitioner to obtain education and training beyond that necessary for ASHA certification. Practitioners are bound by the ASHA Code of Ethics to maintain high standards of professional competence. Therefore, practitioners should engage only in those aspects of the professions that are within the scope of their competence, considering their level of education, training, and experience.

In promulgating this policy statement, there is no intention to imply that the practitioner holding ASHA Certification is prepared to conduct the procedure(s); nor is it incumbent on any certified professional to provide the procedure(s) merely because the practitioner holds certification.

The following document is intended as guidelines for the practitioner to ensure the quality of care, welfare, safety, and comfort of those served by our professions.

Return to Top

II. Background

Audiologists, historically, have been involved in the assessment of patients with dizziness and imbalance. Recent surveys have indicated that a significant number of audiologists are continuing this trend (Martin & Morris, 1989). The improvement and expansion of balance function assessment (e.g., computerized electronystagmography (ENG)/ocular motor tests, rotational tests of the vestibular-ocular reflex (VOR), and dynamic posturography) have expanded the role and responsibilities of audiologists involved in this area of assessment. In addition, the emergence of state-of-the-art assessment procedures has led to a relatively new area of interest dealing with (re)habilitation of patients identified with balance system dysfunction.

“Balance system assessment” refers to a series of procedures designed to evaluate patients presenting with dizziness and/or imbalance. These procedures enable the practitioner to detect and monitor dysfunction within the vestibular, visual and somatosensory systems of balance-disordered patients, and in some cases, provide suggestions for (re)habilitation to the appropriate personnel.

Return to Top

III. Purpose

Although it is recognized that not all audiologists are or will be involved in the assessment of balance-disordered patients, this document provides guidelines for those audiologists who are or may be involved. The purpose of this position statement is to: (a) inform audiologists that performing balance assessment procedures is within the scope of practice of audiology; (b) identify the collection of procedures known as balance system assessment; (c) advise audiologists of the education, training, circumstances, and precautions that should be considered prior to undertaking the procedures; (d) provide guidance for audiologists as to the knowledge and skills that are required to perform balance system assessment; and (e) ultimately, to educate health care professionals, consumers, and members of the general public of the services offered by audiologists as qualified health care providers.

The spirit of this document is not to mandate a single method of education and training. The intention is to delineate the role of audiologists related to balance system assessment and to suggest minimum knowledge and skills required to begin work in this area.

Return to Top

IV. Scope of Practice

It is ASHA's position that balance system assessment is within the scope of practice of audiologists. Practice in this area requires that audiologists possess sufficient knowledge and skills to conduct and interpret the range of vestibular, ocular motor, and balance function tests (Cyr, 1991; Kileny, 1985; Stockwell, 1986; Stockwell, 1990). Audiologists should possess knowledge of anatomy, physiology, and pathophysiology of the balance and auditory systems, medical conditions that affect test results, electrophysiologic and biomedical techniques, management of sick patients in accordance with local medical policy, and physical or occupational therapy procedures related to the assessment and (re)habilitation of balance-disordered patients (Shepard, Telian, & Smith-Wheelock, 1990). Clinical experience and proficiency in conducting basic and advanced balance test procedures are required.

It is noted that the level of experience, skills, and knowledge may differ greatly among audiologists working actively in the area of balance assessment. It is recognized that other professions or related fields also may be involved with assessment and/or (re)habilitation of balance-disordered patients. As a result, there is no intention to exclude or influence their participation. This document recognizes further that the area of balance system assessment is changing rapidly and there is no intention to preclude future procedures within the scope of practice.

If practitioners choose to perform these procedures, indicators should be developed, as part of a continuous quality improvement process, to monitor and evaluate the appropriateness, efficacy, and safety of the procedure conducted.

Return to Top

V. Education and Training

Depending on factors such as individual job setting, local practice policy and the type of vestibular/balance assessment procedures available, audiologists may function on a continuum from basic test administration through test interpretation. As a result, education and training may vary. Education should be obtained through the audiologist's academic program or through a clinical program structured to cover all aspects of balance assessment. Training should take place in a clinical setting affiliated with medical personnel and should include exposure to a number of diverse patients. In addition, all practitioners must determine whether or not they have obtained a sufficient degree of education and training to be competent to perform and interpret the various tests of balance function.

Return to Top

VI. Precautions

Patient: Some procedures may result in patient discomfort or adverse reactions. It is the responsibility of practitioners who conduct or supervise such procedures to develop specific protocols in conjunction with appropriate medical personnel to ensure patient safety and comfort. The protocols should address:

  1. Facilities, equipment, and protocols necessary to perform the tests in a safe and comfortable manner;

  2. Identification of personnel responsible for the tests;

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

  4. Informed consent, including known risks of the tests, in conjunction with institutional and/or regulatory bodies;

  5. Documentation of patient condition before, during, and following the tests.

Practitioner: Some procedures may introduce the possibility of practitioner exposure to bloodborne pathogens. It is recommended that the practitioner follow the Universal Precautions contained 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) or ASHA's AIDS/HIV Update ( Asha, 1990). In addition, practitioners must determine the potential professional liability for any procedure they conduct or supervise. Institutional and/or regulatory bodies, such as state licensure boards, should be informed about these procedures as within the scope of practice. In addition, they should be consulted to determine policies related to professional responsibility and liability, and to ensure that there are no limitations imposed on the scope of audiology practice that restricts the performance of these procedures or their insurance coverage.

Return to Top

VII. Definitions

“Balance assessment” refers to the evaluation of vestibular and extravestibular (visual and somatosensory) systems using a variety of vestibular or balance tests. Those tests include but are not limited to electronystagmography (ENG), rotation and posturography. Electronystagmography includes tests of the gaze, optokinetic, ocular saccade and pursuit systems, spontaneous, positional and positioning nystagmus, and caloric irrigation. Tests of rotation might include the rotary chair test (sinusoidal, pseudorandom, off-axis, low and high frequency) or autorotation test. Posturography includes static and dynamic conditions along with accessory tests (ear canal pressure, EMG recording, etc.).

“Balance (re)habilitation” refers to nonmedical therapy for balance-disordered patients. Audiologists working with such patients should be aware of the various (re)habilitative therapies employed. It is not the intent of these guidelines to prepare audiologists for the (re)habilitative aspects of balance dysfunction. However, based on their training background and experience, they should be prepared to use their knowledge of balance system assessment for the purpose of interacting with rehabilitation professionals (when appropriate) by integrating balance test results into (re)habilitation programs.

Return to Top

VIII. Knowledge and Skills

All audiologists who intend to perform these procedures must ensure that they have acquired the knowledge and skills necessary to do so accurately and effectively. Outlined below are objectives and the basic knowledge and skills necessary to become proficient in balance system assessment techniques.

  1. Objective: To conduct calibration and function checks on equipment.

    Knowledge/skills needed:

    1. Knowledge of general electrophysiological techniques and bioelectrical recording procedures.

    2. Fundamental and practical knowledge of electronic instrumentation used in eye movement recording procedures.

  2. Objective: To develop normative values for each test administered, when necessary.

    Knowledge/skills needed:

    1. Familiarity with and proficiency in performing each individual test.

    2. Knowledge of basic statistical design.

  3. Objective: To administer routine vestibular and ocular motor tests and possess the ability to change the test protocol when required.

    Knowledge/Skills needed:

    1. Efficiency in performing the ENG test battery. Sufficient practicum should have been obtained on a number of patients, preferably during graduate training.

    2. Knowledge of the theory and rationale for each ENG subtest.

    3. Understanding of the interaction between each subtest and the medical conditions which may affect or alter the conduct of the tests or the results generated. Knowledge of other factors that may affect test results (e.g, patient alertness and medication).

    4. Knowledge of anatomy and physiology related to the type of eye movement recording and the system(s) being evaluated by each type.

    5. Knowledge of patient preparation including placing electrodes, verifying electrode contact, and providing clear and accurate patient instructions.

  4. Objective: To conduct otoscopic examinations (governed by local policy and training) to note cerumen obstruction and tympanic membrane integrity.

    Knowledge/Skills needed:

    1. Refer to ASHA Position Statement and Guidelines on External Auditory Canal Examination and Cerumen Management.

  5. Objective: To integrate all test results incorporating patient history, symptoms and other pertinent information into reports with recommendations.

    Knowledge/Skills needed:

    1. Knowledge of anatomy, physiology, and pathophysiology of the balance system. This might include, but not be limited to, the vestibular, vestibular-ocular, vestibular-spinal, visual and somatosensory systems, both peripheral and central, sensory and motor.

    2. Knowledge of the physiological and functional interaction among these systems.

    3. General medical background related to various conditions and events affecting the balance systems and the tests designed to evaluate those systems. This might include, but not be limited to, the effects of medication or specific medical entities causing test artifacts, such as extra-ocular muscle weakness, mental or emotional status of the patient, orthopedic or neurological deficits, and so forth. Exposure to medical specialties such as otolaryngology, neurology, and physical medicine is suggested.

    4. Knowledge and skill related to balance assessment procedures, both basic (ENG) and advanced (rotation and posturography), and an understanding of the interaction between test results and patient symptoms. Sufficient practicum should be obtained during their graduate program or at a “Center of Excellence” to prepare audiologists both for test administration and interpretation.

  6. Objective: To develop protocols for management of sick patients in conjunction with appropriate medical personnel.

    Knowledge/Skills needed:

    1. Demonstration of current certification in CPR and other lifesaving procedures (basic life support) for adult and pediatric patients.

    2. Knowledge of general medical conditions that may be present during the course of the testing.

  7. Objective: To interact with appropriate rehabilitation personnel (when appropriate) for the development of rehabilitation programs for balance-disordered patients.

    Knowledge/skills needed:

    1. Knowledge of therapy approaches and techniques as they relate to (re)habilitation of balance-disordered patients.

    2. Knowledge and understanding of the functional impact of vestibular and extra-vestibular system dysfunction on balance and equilibrium.

Return to Top


American Speech-Language-Hearing Association. (1990, December). Report update. AIDS/HIV: Implications for speech-language pathologists and audiologists. Asha, 32, 46–48.

Centers for Disease Control. (1988). Morbidity and mortality weekly report: Perspectives in disease prevention and health promotion. CDC, 37, 377–388.

Cyr, D. G. (1990). Vestibular system assessment. In W. Rintelmann (Ed.), Hearing assessment (pp. 739–803). Austin, TX: Pro-Ed.

Kileny, P. (1985). Evaluation of vestibular function. In J. Katz (Ed.), Handbook of clinical audiology (pp. 582–603). Baltimore, MD: Williams & Wilkins.

Marlin, F., & Morris, L. (1989). Current audiologic practices in the United States. Hearing Journal, 25–44.

Shepard, N., Telian, S., & Smith-Wheelock, M. (1990, May). Habituation and balance retraining therapy: A retrospective review. Neurology Clinics of North America, 459–475.

Stockwell, C. (1986). Vestibular function tests. In C. W. Cummings (Ed.), Otolaryngology head and neck surgery (Vol. 4, pp. 2743–2763). St. Louis, MO: C.V. Mosby.

Stockwell, C. (1990). Vestibular function testing: 4-year update. In C. W. Cummings (Ed.), Otolaryngology head and neck surgery, update II (pp. 39–53). St. Louis, MO: C.V. Mosby.

Return to Top


[1] The documents include position statements and guidelines for balance system assessment, electrical stimulation for cochlear implant selection and rehabilitation, evaluation and treatment for tracheoesophageal fistulization/puncture, external auditory canal examination and cerumen management, instrumental diagnostic procedures for swallowing, neurophysiologic intraoperative monitoring, vocal tract visualization and imaging.

Return to Top

Index terms: balance, assessment

Reference this material as: American Speech-Language-Hearing Association. (1992). Balance system assessment [Guidelines, Knowledge and Skills, Position Statement]. Available from

© Copyright 1992 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.


ASHA Corporate Partners