The scope of this page includes balance system disorders across the life span.
See the Balance System Disorders Evidence Map for summaries of the available research on this topic.
A functioning balance system allows a person to move through the environment without falling and to be aware of one’s physical position in relation to gravity. The human balance system is complex. It includes input from and coordination of three sensory systems: vestibular, visual, and somatosensory. Disturbances to one or more of these systems may result in a balance system disorder, which can have a negative impact on balance and/or cause symptoms such as dizziness.
The term “dizziness” is nonspecific and can refer to a range of symptoms, such as light-headedness or vertigo (sensation of motion, such as spinning, swaying, or rocking). Symptoms of balance system disorders can be uncomfortable, inconvenient, and limiting to activities of daily living (Ten Voorde et al., 2012) and can increase fall risk (Graafmans et al., 1996; O’Loughlin et al., 1994; Rubenstein, 2006).
Assessment and management of balance system disorders and their symptoms is an interprofessional endeavor, at times involving audiology, behavioral health, cardiology, neurology, neuro-ophthalmology, neurotology, occupational therapy, otolaryngology, otology, physical therapy, and/or a primary care provider. Audiologists and speech-language pathologists may interact with individuals of all ages who complain of dizziness and/or imbalance. See the American Speech-Language-Hearing Association (ASHA) resource on interprofessional education/interprofessional practice (IPE/IPP) for more information on interprofessional collaborative practice.
The incidence of a disorder or condition refers to the number of new cases identified in a specified time period. Prevalence refers to the number of individuals who are living with the disorder or condition in a given time period.
Approximately 33.4 million adults in the United States report a dizziness or balance problem during the past 12 months (National Institute on Deafness and Other Communication Disorders, 2017). The true incidence and prevalence of balance system disorders in adults and children are unknown. This may be due, in part, to the wide range of symptoms attributable to balance disorders, the underlying cause(s), the length or frequency of the disorder, and the varied diagnostic techniques used for detection.
An epidemiological study conducted in the United States using data from the 2001–2004 National Health and Nutrition Examination Survey (Centers for Disease Control and Prevention, n.d.-a, n.d.-b) suggests that 35% of adults aged 40 years or older—approximately 69 million Americans—demonstrate some form of vestibular dysfunction when tested with a postural metric (Agrawal et al., 2009). A 2008 Balance and Dizziness Supplement to the U.S. National Health Interview Survey showed that 27.7% of adults aged 75 years and older experienced vestibular problems in the past year (Ward et al., 2013). A systematic review of the research by Murdin and Schilder (2015) identified that the rate of vestibular dysfunction increases with age, and women are more likely to experience dizziness and vertigo symptoms than men. Balance difficulties are a significant risk factor that contribute to falling injuries (Centers for Disease Control and Prevention, 2016), and more than 28% of adults over the age of 65 years reported falling at least once in the past 12 months (Bergen et al., 2016).
Statistics for balance system disorders can vary by type of disorder and how long it lasts. One study reported a 12-month prevalence of vestibular vertigo in adults to be roughly 5% and an incidence to be 1.4% (Neuhauser, 2007). From the 2008 Balance and Dizziness Supplement to the U.S. National Health Interview Survey, 20.6% of people reporting vestibular problems in the past 12 months demonstrated the features of benign paroxysmal positional vertigo (BPPV), and 1.4% of the same dizziness population presented with features of Ménière’s disease (Kerber et al., 2017).
Dizziness and balance disorders can also occur in children (Rine, 2009; Wiener-Vacher et al., 2018). Reponses to the 2016 Balance Supplement to the U.S. National Health Interview Survey for children revealed dizziness or imbalance symptoms in 5.6% of children ages 3–17 years, of which 40% had visited a health care provider to evaluate their symptoms (Brodsky et al., 2020). The rate of dizziness and vertigo in adolescents reaches adult levels (Langhagen et al., 2015). Children with hearing difficulties are more at risk for dizziness and balance problems (Li et al., 2016).
Signs and symptoms of balance system disorders vary due to a wide range of underlying causes. Signs and symptoms may be episodic, acute, or chronic and may include the following:
Accompanying auditory symptoms may include the following:
Functional modifications that may be observed include the following:
Identifying children with balance disorders, vestibular deficits, or dizziness can pose additional challenges when compared to adults. The process of acquiring information from a pediatric patient will be different, as will the testing strategies. Often, children will not report symptoms and may be incapable of verbalizing the abnormal sensations that they are experiencing (McCaslin et al., 2011; Wiener-Vacher, 2008). Distinct differences may exist in symptoms of dizziness and balance disorders in the pediatric population as compared with adults. Vestibular system impairments in children may present as developmental delay in activities such as walking. Working with this population requires additional education and training.
The underlying causes of balance disorders and the resulting symptoms are many and varied. They include causes related to the vestibular system and causes related to other body systems and conditions. Conditions and events resulting in imbalance and/or dizziness may resolve spontaneously or may become chronic.
Causes of balance system disorders may include, but not be limited to, the following:
A review of current literature indicates that the most common causes of dizziness in children are otitis media, migraine headache, benign paroxysmal vertigo of childhood, trauma, and vestibular neuritis (Gioacchini et al., 2014; O’Reilly et al., 2010). Numerous reports have detailed common disorders, illnesses, and injuries that cause vertigo and imbalance in children (Balatsouras et al., 2007; Blayney & Colman, 1984; Jahn et al., 2011; Master et al., 2020; McCaslin et al., 2011; Russell & Abu-Arafeh, 1999; Szirmai, 2010; Wiener-Vacher, 2008). Even though these reports originate from different clinics and regions of the world, there is substantial agreement regarding the primary causes of dizziness in the pediatric population. A 2014 systematic review found the causes of vestibular disorders in children to parallel those in adults (Gioacchini et al., 2014). The authors found BPPV (19%) and migraine-associated vertigo (18%) to be the most common causes of vertigo and dizziness in children.
Audiologists play a role in the screening, assessment, diagnosis, and management of persons with balance system disorders, often as part of an interprofessional collaborative team. Professional roles and activities in audiology include clinical and educational services (diagnosis, assessment, planning, and management); prevention and advocacy; and education, administration, and research. See ASHA’s Scope of Practice in Audiology (ASHA, 2018).
Appropriate roles and responsibilities for audiologists include, but are not limited to, the following:
As indicated in the ASHA Code of Ethics (ASHA, 2016a), audiologists who serve this population should be specifically educated and appropriately trained to do so.
Speech-language pathologists may encounter individuals with complaints of dizziness and/or imbalance within the populations they serve. See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles and responsibilities for speech-language pathologists include, but are not limited to, providing referrals for patients who complain of dizziness and/or balance disorders.
See the Assessment section of the Balance System Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. For guidance and considerations on infection control practices during the assessment process, see ASHA’s resource on infection control resources for audiologists and speech-language pathologists.
The assessment of a patient with dizziness and/or imbalance complaints includes aspects of the central and peripheral vestibular system as well as sensory and motor balance components. Balance system assessment is an interprofessional endeavor, with audiologists serving as experts in hearing and vestibular function testing. Balance system evaluation by an audiologist may be prompted by results of a case history and/or a medical referral.
The process (whether in a screening or a comprehensive assessment) always begins with a thorough case history.
Case history information may indicate a need for modification of screening or evaluation procedures. Because the term “dizziness” can describe varying symptoms and each patient may have a different idea of what dizziness means, a thorough case history is vital (Dye, 2008).
A case history specific to balance may include the following:
Pediatric case histories may differ in the type of information gathered as well as the strategies used to obtain the information. Documenting the age that developmental milestones are reached and making note of a child’s performance on gross and fine motor tasks are important. Children who are deaf or hard of hearing may exhibit certain predictive factors of a co-occurring vestibular loss (Janky et al., 2018). Information regarding these factors can be used to identify children who may benefit from an age-appropriate vestibular evaluation.
For information regarding gathering a case history, see ASHA’s Practice Portal page on Cultural Responsiveness.
Performing appropriate screening measures may determine the need for further assessment, referrals, and/or a management plan. Screening a patient with balance complaints may assist in triaging, ruling out emergencies, and determining the probability of a central (brain/brainstem) versus a peripheral (vestibular labyrinth, eighth cranial nerve) origin. Vestibular and balance screening may be performed by audiologists as well as other trained medical professionals. Some screening measures may be affected by the patient’s understanding of the task(s), their eye muscle function and visual acuity, and their current levels of fatigue and attention.
Screening of vestibular function and vestibular ocular reflexes (VORs) may be completed at a patient’s bedside or in an office setting with little or no equipment. Normal VOR responses allow for clear vision during head and/or eye movement.
A vestibular and balance screening battery may include the following:
Reflexive eye movements in response to head movement and position involve input from peripheral vestibular organs. These organs include the semicircular canals (horizontal, anterior, and posterior) and the otolith organs (utricle and saccule). Nystagmus is a reflexive eye movement characterized by two components: the slow phase, in which the eyes drift away from center, and the fast phase, in which the eyes quickly move back toward center. Nystagmus can be observed under various conditions (normal [physiologic] and abnormal [pathophysiologic]), which are named accordingly: spontaneous, positional, evoked, congenital, and gaze. Some level of spontaneous nystagmus may be seen in healthy individuals (Levo et al., 2004).
The presence and direction of nystagmus as well as the response to visual fixation may provide important information for differentiating between a peripheral and a central etiology of vertigo. In general, “nystagmus of peripheral origin is horizontal, and direction fixed . . . and decreases with visual fixation . . . Central signs include direction-changing nystagmus, pure vertical or torsional nystagmus and/or enhancement with fixation” (Slattery et al., 2011, p. 145).
A screening of nystagmus may include noninstrumented tests, such as direct observation using a penlight or otoscope light. The specificity of these findings will likely be reduced in comparison to those obtained with instrumented measures, such as videonystagmography (VNG) or electronystagmography (ENG; Guidetti et al., 2006).
Nystagmus can be observed using both static and dynamic measures. An example of a dynamic measure is the head-shake test. During the head-shake test, the patient tilts their head down slightly, and then, the patient or examiner shakes the head quickly back and forth for 30 s (often with fixation removed), after which the eyes are examined for the presence or absence of nystagmus. Presence of head-shake nystagmus may indicate asymmetric peripheral vestibular function (e.g., semicircular canal function).
The head thrust test or head impulse test assesses the VOR. It involves observing whether the patient can maintain visual fixation on a target after brief and rapid head thrusts in the planes of the semicircular canals or whether the patient requires corrective eye movements to regain eye contact with the target, which may indicate asymmetric semicircular canal function. Results of this test, taken in context, may give an indication of abnormal peripheral function versus abnormal central nervous system function.
The dynamic visual acuity test assesses the VOR by having the patient read a Snellen eye chart first in a static position and then while the head is rotated back and forth. The lowest line on the eye chart where 50% of the characters are correctly identified may be used to compare static versus dynamic visual acuity results. The possibility of VOR deficit depends on how many lines are lost in this comparison. The difference between static and dynamic visual acuity may indicate peripheral vestibular loss as related to gaze stabilization. Computerized systems are also available for the measurement of dynamic visual acuity.
Voluntary and reflexive eye movements can include saccadic tracking (shift in gaze from one point to another) and smooth pursuit (following a slowly moving target across the visual field). If a patient shows significant abnormalities in these functions, they may require a referral to neurology or neuro-ophthalmology for assessment of central nervous system function.
This specific positioning maneuver is often used to observe nystagmus and/or vertigo associated with benign paroxysmal positional vertigo (BPPV). The patient is moved somewhat briskly from sitting to supine position with their head hanging below their shoulders and turned 30°–45° to the left or right (Dix & Hallpike, 1952). After the maneuver, the examiner observes whether nystagmus is present and, if so, notes the duration and direction of nystagmus. They also consider whether nystagmus intensity is reduced with repeated maneuvers. Abnormal results may indicate the need for canalith repositioning procedures.
One screening objective is to differentiate between peripheral causes (e.g., vestibular neuritis) and central causes (e.g., acute cerebellar stroke) when a patient presents with acute vestibular syndrome—a term used to describe the presence of “severe vertigo, nausea and vomiting, spontaneous nystagmus, and postural instability” (Hotson & Baloh, 1998, p. 680). One review of the literature (1966–1996) determined that etiologies for dizziness included 35%–55% peripheral vestibulopathies, 10%–25% psychiatric disorders, 5% cerebrovascular disease, and less than 1% brain tumor, while also noting that the symptom of dizziness can be multifactorial (Hoffman et al., 1999).
HINTS, which can be helpful in this differentiation, is a three-step oculomotor/VOR test protocol that includes (a) the Head Impulse test, (b) interpretation of Nystagmus, and (c) Test of Skew (Kattah et al., 2009). Skew deviation is a vertical misalignment of the eyes that can be tested by covering the patient’s eyes, one at a time, while they focus on a fixed target.
When screening for dizziness and/or imbalance, the following considerations are important:
Accurate differential diagnosis of balance system disorders relies partly on the audiologist’s interpretation of a test battery within the context of the individual’s medical history. Comprehensive assessment of dizziness and/or balance complaints will include a case history (as outlined above), results from any number of screening tests (described above), as well as an audiologic assessment, in-depth vestibular assessments (described below), and information from outside referrals or sources (as part of an interprofessional collaborative team).
Comprehensive assessment of a patient with dizziness, vertigo, or imbalance includes an audiometric assessment. There is a close relationship between hearing and balance in relation to inner ear organs. Some patients with dizziness and imbalance symptoms will have coexisting auditory symptoms. For example, the combination of vertigo and audiologic symptoms is a classic presentation in a patient with labyrinthitis and may also be seen in patients after they experience head trauma. Audiologic assessment can provide information about possible retrocochlear or middle ear pathologies that may need to be addressed prior to further vestibular testing and follow-up.
Audiometric assessment in a patient with dizziness, vertigo, or imbalance complaints may include, but not be limited to,
See the Assessment section of ASHA’s Practice Portal page on Hearing Loss in Adults and the Joint Audiology Committee Clinical Practice Statements and Algorithms for detailed information on audiologic assessment.
A comprehensive balance system evaluation will include a combination of tests. Results and combinations of results from vestibular tests require complex interpretation and can indicate various deficits. The audiologist’s goal is differential diagnosis and differentiation of unilateral versus bilateral vestibular disorders.
Depending on the age of a pediatric patient, as well as their levels of cooperation and comprehension, it may not be possible to complete a comprehensive balance function examination. However, as with pediatric hearing assessment, experts in the assessment of pediatric dizziness have the skills necessary to adjust testing methods to collect useful information regarding the status of a child’s vestibular function and overall balance.
In interprofessional practice (IPP) settings, vital signs such as blood pressure and oxygen saturation may be measured prior to patients receiving a full balance assessment (Dye, 2008). These measurements are important because symptoms of dizziness stem from a variety of etiologies and may be multifactorial.
VNG and ENG are techniques used to measure and record a patient’s eye movements, including nystagmus, during a variety of tasks and conditions. Both VNG and ENG include computer analysis of eye movements. ENG is a process of recording eye movement indirectly through the electrical potential difference between the front and back of the eye. Electrodes are placed around the eyes during ENG. VNG, which has become standard in balance assessment, uses infrared video technology to record eye movement.
VNG and ENG technology enables enhanced assessment and recording of nystagmus (e.g., gaze-evoked, spontaneous) and allows for measurement of nystagmus intensity and direction. Measurements of nystagmus may be taken without fixation (i.e., in complete darkness), thus minimizing the possibility that nystagmus will be suppressed by visual fixation.
VNG and ENG technology may be used when conducting oculomotor tests, positional and positioning tests, and/or caloric tests.
Oculomotor tests measure eye movement and can be useful in identifying abnormalities of the VOR and/or the presence of spontaneous nystagmus. An oculomotor test battery may include tests of the following:
Static and dynamic position tests are used to observe the vestibular system response to a change in head and/or body position as compared with neutral head and/or body position. Measurements can be taken with or without fixation. The examiner considers the presence or absence of nystagmus and/or changes in nystagmus as well as the patient’s subjective report of symptoms.
Positional tests are most often used to elicit signs and symptoms of BPPV and to aid in diagnosing this disorder. The Dix–Hallpike maneuver is one positional test that can be used, depending on the characteristics of the patient and determination of risk factors. Symptoms of BPPV occur when otoconia moves into one of the semicircular canals. Movement of a patient from one position to another elicits or exacerbates these symptoms.
Caloric tests stimulate the vestibular system in the ear by creating a temperature difference relative to body temperature. Methods used to create a temperature change include heated or cooled air introduced into the ear canal, heated or cooled water introduced directly into the ear canal (open-loop), and heated or cooled water introduced into the ear canal inside of a balloon (closed-loop). Only a few closed-loop systems are still used in clinical practice. Testing typically includes presenting either cool and warm air or cool and warm water into each ear canal in succession. The examiner measures the presence, strength, and direction of any nystagmus that exists during and following the introduction of each stimulus. This technique allows the examiner to evaluate each labyrinth independently by comparing the strength of nystagmus that results from stimulating the left and right sides. Fitzgerald and Hallpike (1942) provided a description of one widely used caloric technique.
Considerations with caloric testing include the following:
Other tests that can be included in a VNG or an ENG battery are hyperventilation testing, vibration testing, and head-shake testing:
Rotary chair testing can be helpful in detecting bilateral and uncompensated unilateral vestibular disorders. Results may be more accurate when used in conjunction with VNG or ENG. Testing involves whole-body rotation, with the patient seated and restrained in a motorized rotary chair. Eye movements are recorded in darkness using electrodes, as in ENG, or video-oculography goggles, as in VNG. The patient’s head is properly secured so that the chair and head movements correspond. It is important to record baseline spontaneous nystagmus and gaze nystagmus prior to rotary chair testing. A rotary chair test battery may include sinusoidal harmonic acceleration tests, visual–vestibular interaction tests (i.e., visual–vestibular ocular reflex and visual–vestibular fixation), and step velocity tests, as follows:
Rotary chair testing assesses both ears simultaneously, rather than independently. A natural stimulus allows for VOR measurements to be taken during physiologically relevant stimulation (i.e., head rotation) at a variety of frequencies. Rotational testing provides important information about residual vestibular function in individuals with bilateral vestibular weakness on caloric testing. This information is critical in selecting appropriate rehabilitative strategies.
CDP is a method of assessing an individual’s functional balance and the contribution of visual, vestibular, and somatosensory inputs. CDP does not provide information regarding possible location of lesion or possible etiology of balance disorders. Equipment required for CDP includes a movable support surface (a force platform) within a movable enclosure.
Subtests include the following:
VEMP offers an electrophysiological method of testing otolith (saccule and utricle) function and potentially both branches of the vestibular nerve. VEMP testing involves measuring a motor response to sound stimulation of the otolith organs.
There are two types of VEMP testing. The cervical VEMP (cVEMP) measures a relaxation response in the SCM coincident with presentation of sound or vibration. Electrodes are placed in a specified configuration on the SCM and on the forehead. Because the cVEMP is a relaxation response, the SCM must be activated (contracted) either unilaterally or bilaterally through intentional head positioning by the patient. The ocular VEMP (oVEMP) uses electrode placement under the eyes and on the forehead and measures an activation response from those muscles. For both types of VEMP testing, clicks and/or tone bursts are introduced via earphones or a bone-conduction oscillator. Recordings of waveforms are taken, and asymmetries can be identified between responses generated by stimulating the right and left ears.
Results of VEMP testing may provide insight into pathologies that affect balance and/or cause dizziness, such as superior semicircular canal dehiscence and vestibular neuritis. The use of one of these tests as opposed to the other (i.e., oVEMP or cVEMP) may be preferred for certain patients and/or situations. As with any vestibular test, VEMP results must be interpreted by a knowledgeable clinician and in the context of the patient’s personal history and characteristics. For example, patient age may impact VEMP results (Janky & Shepard, 2009; Ochi & Ohashi, 2003).
In addition to VEMP testing, other tests are available to measure otolith function. The subjective visual vertical test is one in which a patient is asked to adjust an illuminated straight line against a featureless background until it appears to be completely vertical to them. Abnormalities in this test may reflect the presence of vestibular (otolith) dysfunction.
The vHIT is an instrumented version of the head impulse test using infrared video recording of eye movements in response to short, brisk head turns or impulses in the planes of the semicircular canals. This allows for objective measurement of eye movements rather than subjective clinician observations. The vHIT also enables evaluation of each semicircular canal independently (Hougaard & Abrahamsen, 2019). The patient is instructed to maintain visual contact on a stationary target during head impulses. Eye movements are analyzed to determine whether the eyes (a) moved in the same direction as the head during impulses and then made a corrective refixation back to the target (abnormal) or (b) moved in the opposite direction of the head during impulses and maintained fixation on the target (normal). Results may demonstrate a problem with semicircular canal function on the same side to which the head was turned prior to the corrective refixation response. This procedure is noninvasive, is relatively short, and utilizes stimuli in the physiological range of everyday head movement.
IPP occurs when two or more professions collaborate with each other to improve health outcomes for a patient. This approach is vital in the assessment and management of balance and vestibular disorders. In addition to tests and services offered by a trained audiologist, the patient may require input from other medical professionals both to complete a comprehensive evaluation and to conduct management planning. For example, the patient may require medical imaging studies, a gait assessment by a vestibular physical therapist, or a review of medications by their primary care physician. See ASHA’s resources on interprofessional education/interprofessional practice (IPE/IPP) for more information on this topic.
Interpretation and integration of comprehensive balance assessment results may indicate normal or abnormal balance system function. Abnormal results may indicate reason or origin, such as unilateral or bilateral peripheral vestibular hypofunction or central vestibular origin (e.g., incomplete central compensation or abnormal visual–vestibular interaction). Finally, an awareness of how dizziness and/or disequilibrium functionally impacts the patient may be obtained with dizziness scales or questionnaires.
Recommendations from the audiologist may include, but not be limited to, referral to other professionals, referral to a vestibular/balance rehabilitation program, routine follow-up, and/or discharge from audiologic services.
See the Treatment section of the Balance System Disorders Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. For guidance and considerations on infection control practices during the treatment process, see ASHA’s resource on infection control resources for audiologists and speech-language pathologists.
Management of balance and vestibular disorders may include medical, surgical, and/or rehabilitative approaches. Interprofessional collaborative practice is a vital part of the management process. Coordination and communication between and among balance professionals will assist the patient in achieving the best outcomes. Involved professionals may include an audiologist, a physical and/or an occupational therapist with balance expertise, a primary care physician, an otolaryngologist, a neurologist, and other medical professionals.
Depending on the etiology of the patient’s vestibular disorder and/or the underlying cause(s) of their balance symptoms, a variety of medical and surgical options may be recommended by appropriate medical professionals. Medications may be provided to suppress the vestibular symptoms or to treat the underlying pathology (e.g., migraine, multiple sclerosis). Dietary and/or lifestyle changes may be suggested. Surgical intervention may be considered in specific cases (e.g., excision of vestibular schwannoma [benign tumor]).
Vestibular and balance rehabilitation therapy involves activities specific to the diagnosis and individual needs of each patient. This therapy promotes the central nervous system’s natural compensation process to reduce or eliminate problematic symptoms that come with chronic balance disorders and/or dizziness.
Goals of vestibular rehabilitation may include
Adaptation exercises target the vestibular ocular reflexes (VORs) and involve the patient performing specific head movements while keeping a visual target in focus. The clinician carefully monitors the patient’s performance for accuracy and for appropriateness of progression in difficulty. Variations are made to patient positioning, distance from target, and speed of movement. A typical adaptation exercise program may last between 6 and 8 weeks (Dye, 2008).
The goal of habituation exercises is long-term reduction of negative responses (e.g., dizziness) to particular stimuli (e.g., motion) by repeated exposure to those stimuli. The patient will be guided to perform specific symptom-inducing movements repeatedly. Monitored progression of habituation exercises may be appropriate for a patient who has dizziness or other vestibular symptoms caused by motion or visual field sensitivity.
The patient learns to substitute and actively control eye movements during head movement to reduce vestibular symptoms. For example, smooth pursuit and/or corrective saccades may be used to reduce dizziness. Substitution skills can be mastered with repetitive exercises using visual targets.
Balance exercises challenge the patient by removing or disturbing visual input or using uneven surfaces. These exercises can focus on static and/or dynamic balance. An exercise program focusing on balance may be appropriate for a person experiencing symptoms from general vestibular hypofunction.
In some cases, muscle weakness may be found to be a contributing factor to a patient’s balance difficulties. These patients may benefit from traditional strength and conditioning exercises. This aspect of vestibular rehabilitation will require input and collaboration with a physical and/or an occupational therapist.
In addition to exercise programs, the balance management team also considers the patient’s functional performance. For example, an occupational therapist may do a home assessment to ensure that fall risk is reduced, a physical therapist may recommend gait activities, or an audiologist may provide education on how specific vestibular and balance disorders can impact a person’s daily activities.
Canalith repositioning procedures (CRPs) are maneuvers used in the management of benign paroxysmal positional vertigo (BPPV). BPPV is caused by otoconia detaching from the utricle and/or saccule and collecting in the semicircular canals. Typical symptoms of BPPV include dizziness, vertigo, imbalance, and nausea. The goal of repositioning maneuvers is to move otoconia out of the semicircular canals to reduce dizziness and/or other vestibular symptoms. CRPs involve specific sequences of head and body movements guided by a trained professional. Eye movements are monitored during each guided head and body movement sequence.
Patients may be instructed to follow limitations and restrictions (e.g., posture, head movements, activities) for some time after the maneuver. However, use of postmaneuver restrictions generally does not improve the efficacy of the procedure or the patient outcomes (Casqueiro et al., 2008; Hunt et al., 2012; McGinnis et al., 2009; Roberts et al., 2005).
One management option for posterior semicircular canal BPPV is the Epley maneuver, which assists in the migration of otoconia (Epley, 1992). Medication may be given to reduce nausea during the procedure.
The Semont maneuver, also called the Liberatory maneuver, manages BPPV in conditions with free-floating otoconia and with otoconia that are attached to the cupula in the posterior semicircular canal. Movements undertaken with this maneuver are done with more speed than required with the Epley maneuver.
Techniques such as the “barbeque roll,” Lempert maneuver, and Gufoni maneuver all target the lateral semicircular canal variant of BPPV. These techniques involve variations of rotating and tilting movements performed by the patient.
Anterior semicircular canal BPPV is rare and is sometimes diagnosed after a head injury or recovery from surgical procedures. Less information is available on effective management. In some cases, the Epley maneuver or Semont maneuver may be helpful. Another technique called prolonged forced position procedure has been described (Crevits, 2004).
Each patient with dizziness and/or imbalance concerns will require education and counseling specific to the etiology, symptomology, and characteristics of their disorder. Ensuring a patient’s health literacy regarding their diagnosis and management options will allow them to make informed decisions and to be an active participant in their care. A patient with chronic balance issues can use a variety of strategies to remain active, reduce fall risk, and cope with symptoms. See ASHA’s Practice Portal page on Counseling For Professional Service Delivery for more information on this topic.
Untreated vestibular system impairments in children can lead to problems with coordination and delays in developmental milestones (Rine et al., 2004). Once a child has had a medical evaluation by a physician (e.g., pediatrician, neurologist, otolaryngologist) and a thorough diagnostic assessment, an effective management plan can be developed. Outcome measures may include the use of tools related to dizziness-related quality of life and dizziness symptoms (McCaslin et al., 2015).
Factors that may limit the success of vestibular rehabilitation include
Contraindications for canalith repositioning maneuvers include
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
Agrawal, Y., Carey, J. P., Della Santina, C. C., Schubert, M. C., & Minor L. B. (2009). Disorders of balance and vestibular function in US adults: Data from the National Health and Nutrition Examination Survey, 2001–2004. Archives of Internal Medicine, 169(10), 938–944. https://doi.org/10.1001/archinternmed.2009.66
American Speech-Language-Hearing Association. (2016a). Code of ethics [Ethics]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2016b). Scope of practice in speech-language pathology [Scope of practice]. www.asha.org/policy/
American Speech-Language-Hearing Association. (2018). Scope of practice in audiology [Scope of practice]. www.asha.org/policy/
Balatsouras, D. G., Kaberos, A., Assimakopoulos, D., Katotomichelakis, M., Economou, N. C., & Korres, S. G. (2007). Etiology of vertigo in children. International Journal of Pediatric Otorhinolaryngology, 71(3), 487–494. https://doi.org/10.1016/j.ijporl.2006.11.024
Bergen, G., Stevens, M. R., & Burns, E. R. (2016). Falls and fall injuries among adults aged ≥65 years—United States, 2014. Morbidity and Mortality Weekly Report, 65(37), 993–998. https://doi.org/10.15585/mmwr.mm6537a2
Blayney, A. W., & Colman, B. H. (1984). Dizziness in childhood. Clinical Otolaryngology & Allied Sciences, 9(2), 77–85. https://doi.org/10.1111/j.1365-2273.1984.tb01477.x
Brodsky, J. R., Lipson, S., & Bhattacharyya, N. (2020). Prevalence of pediatric dizziness and imbalance in the United States. Otolaryngology—Head and Neck Surgery, 162(2), 241–247. https://doi.org/10.1177/0194599819887375
Casqueiro, J. C., Ayala, A., & Monedero, G. (2008). No more postural restrictions in posterior canal benign paroxysmal positional vertigo. Otology & Neurotology, 29(5), 706–709. https://doi.org/10.1097/MAO.0b013e31817d01e8
Centers for Disease Control and Prevention. (n.d.-a). National Health and Nutrition Examination Survey Data: NHANES 2001–2002. National Center for Health Statistics. https://wwwn.cdc.gov/nchs/nhanes/continuousnhanes/default.aspx?BeginYear=2001
Centers for Disease Control and Prevention. (n.d.-b). National Health and Nutrition Examination Survey Data: NHANES 2003–2004. National Center for Health Statistics. https://wwwn.cdc.gov/nchs/nhanes/ContinuousNhanes/Default.aspx?BeginYear=2003
Centers for Disease Control and Prevention. (2016). Important facts about falls. https://www.cdc.gov/homeandrecreationalsafety/falls/adultfalls.html
Cohen, H. S., Sangi-Haghpeykar, H., Ricci, N. A., Kampangkaew, J., & Williamson, R. A. (2014). Utility of stepping, walking, and head impulses for screening patients for vestibular impairments. Otolaryngology—Head and Neck Surgery, 151(1), 131–136. https://doi.org/10.1177/0194599814527724
Crevits, L. (2004). Treatment of anterior canal benign paroxysmal positional vertigo by a prolonged forced position procedure. Journal of Neurology, Neurosurgery & Psychiatry, 75(5), 779–781. https://doi.org/10.1136/jnnp.2003.025478
Dix, M. R., & Hallpike, C. S. (1952). The pathology, symptomatology and diagnosis of certain common disorders of the vestibular system. Annals of Otology, Rhinology & Laryngology, 61(4), 987–1016. https://doi.org/10.1177/000348945206100403
Dye, D. (2008, July/August). Vestibular rehabilitation: Rehabilitation options for patients with dizziness and imbalance. ASHA Access Audiology, 7. www.asha.org/articles/vestibular-rehabilitation/
Epley, J. M. (1992). The Canalith Repositioning Procedure: For treatment of benign paroxysmal positional vertigo. Otolaryngology—Head and Neck Surgery, 107(3), 399–404. https://doi.org/10.1177/019459989210700310
Fitzgerald, G., & Hallpike, C. S. (1942). Studies in human vestibular function: I. Observations on the directional preponderance (“Nystagmusbereitschaft”) of caloric nystagmus resulting from cerebral lesions. Brain, 65(2), 115–137. https://doi.org/10.1093/brain/65.2.115
Formby, C., Kuntz, L. A., Rivera-Taylor, I. M., Rivera-Mraz, N., Weesner, D. R., Butler-Young, N. E., & Ahlers, A. E. (1992). Measurement, analysis, and modelling of the caloric response. 2.: Evaluation of mental alerting tasks for measurement of caloric-induced nystagmus. Acta Oto-Laryngologica, 112(Suppl. 498), 19–29. https://doi.org/10.3109/00016489209136855
Gioacchini, F. M., Alicandri-Ciufelli, M., Kaleci, S., Magliulo, G., & Re, M. (2014). Prevalence and diagnosis of vestibular disorders in children: A review. International Journal of Pediatric Otorhinolaryngology, 78(5), 718–724. https://doi.org/10.1016/j.ijporl.2014.02.009
Graafmans, W. C., Ooms, M. E., Hofstee, H. M. A., Bezemer, P. D., Bouter, L. M., & Lips, P. (1996). Falls in the elderly: A prospective study of risk factors and risk profiles. American Journal of Epidemiology, 143(11), 1129–1136. https://doi.org/10.1093/oxfordjournals.aje.a008690
Guidetti, G., Monzani, D., & Rovatti, V. (2006). Clinical examination of labyrinthine-defective patients out of the vertigo attack: Sensitivity and specificity of three low-cost methods. Acta Otorhinolaryngologica Italica, 26(2), 96–101.
Herdman, S. J., Tusa, R. J., Blatt, P., Suzuki, A., Venuto, P. J., & Roberts, D. (1998). Computerized dynamic visual acuity test in the assessment of vestibular deficits. Otology & Neurotology, 19(6), 790–796.
Hoffman, R. M., Einstadter, D., & Kroenke, K. (1999). Evaluating dizziness. The American Journal of Medicine, 107(5), 468–478. https://doi.org/10.1016/S0002-9343(99)00260-0
Hotson, J. R., & Baloh, R. W. (1998). Acute vestibular syndrome. The New England Journal of Medicine, 339(10), 680–685. https://doi.org/10.1056/NEJM199809033391007
Hougaard, D. D., & Abrahamsen, E. R. (2019). Testing of all six semicircular canals with video head impulse test systems. Journal of Visualized Experiments, 146, Article e59012. https://doi.org/10.3791/59012
Hunt, W. T., Zimmerman, E. F., & Hilton, M. P. (2012). Modifications of the Epley (canalith repositioning) manoeuvre for posterior canal benign paroxysmal positional vertigo (BPPV). Cochrane Database of Systematic Reviews, 4. https://doi.org/10.1002/14651858.CD008675.pub2
Jacobson, G. P., Newman, C. W., & Safadi, I. (1990). Sensitivity and specificity of the head-shaking test for detecting vestibular system abnormalities. Annals of Otology, Rhinology & Laryngology, 99(7), 539–542. https://doi.org/10.1177/000348949009900708
Jahn, K., Langhagen, T., Schroeder, A. S., & Heinen, F. (2011). Vertigo and dizziness in childhood—Update on diagnosis and treatment. Neuropediatrics, 42(4), 129–134. https://doi.org/10.1055/s-0031-1283158
Janky, K. L., & Shepard, N. (2009). Vestibular evoked myogenic potential (VEMP) testing: Normative threshold response curves and effects of age. Journal of the American Academy of Audiology, 20(8), 514–522. https://doi.org/10.3766/jaaa.20.8.6
Janky, K. L., Thomas, M. L., High, R. R., Schmid, K. K., & Ogun, O. A. (2018). Predictive factors for vestibular loss in children with hearing loss. American Journal of Audiology, 27(1), 137–146. https://doi.org/10.1044/2017_AJA-17-0058
Kattah, J. C., Talkad, A. V., Wang, D. Z., Hsieh, Y.-H., & Newman-Toker, D. E. (2009). HINTS to diagnose stroke in the acute vestibular syndrome: Three-step bedside oculomotor examination more sensitive than early MRI diffusion-weighted imaging. Stroke, 40(11), 3504–3510. https://doi.org/10.1161/STROKEAHA.109.551234
Kerber, K. A., Callaghan, B. C., Telian, S. A., Meurer, W. J., Skolarus, L. E., Carender, W., & Burke, J. F. (2017). Dizziness symptom type prevalence and overlap: A US nationally representative survey. The American Journal of Medicine, 130(12), 1465.E1–1465.E9. https://doi.org/10.1016/j.amjmed.2017.05.048
Langhagen, T., Albers, L., Heinen, F., Straube, A., Filippopulos, F., Landgraf, M. N., Gerstl, L., Jahn, K., & von Kries, R. (2015). Period prevalence of dizziness and vertigo in adolescents. PLOS ONE, 10(9), Article e0136512. https://doi.org/10.1371/journal.pone.0136512
Levo, H., Aalto, H., & Petteri Hirvonen, T. (2004). Nystagmus measured with video-oculography: Methodological aspects and normative data. ORL: Journal for Oto-Rhino-Laryngology and Its Related Specialties, 66(3), 101–104. https://doi.org/10.1159/000079327
Li, C. M., Hoffman, H. J., Ward, B. K., Cohen, H. S., & Rine, R. M. (2016). Epidemiology of dizziness and balance problems in children in the United States: A population-based study. The Journal of Pediatrics, 171, 240.E3–247.E3. https://doi.org/10.1016/j.jpeds.2015.12.002
Master, C. L., Curry, A. E., Pfeiffer, M. R., Metzger, K. B., Kessler, R. S., Haarbauer-Krupa, J., DePadilla, L., Greenspan, A., Breiding, M. J., & Arbogast, K. B. (2020). Characteristics of concussion in elementary school-aged children: Implications for clinical management. The Journal of Pediatrics, 223, 128–135. https://doi.org/10.1016/j.jpeds.2020.04.001
McCaslin, D. L., Jacobson, G. P., & Gruenwald, J. M. (2011). The predominant forms of vertigo in children and their associated findings on balance function testing. Otolaryngologic Clinics of North America, 44(2), 291–307. https://doi.org/10.1016/j.otc.2011.01.003
McCaslin, D. L., Jacobson, G. P., Lambert, W., English, L. N., & Kemph, A. J. (2015). The development of the vanderbilt pediatric dizziness handicap inventory for patient caregivers (DHI-PC). International Journal of Pediatric Otorhinolaryngology, 79(10), 1662–1666. https://doi.org/10.1016/j.ijporl.2015.07.017
McGinnis, P. Q., Nebbia, M., Saez, L., & Rudolph, K. (2009). Retrospective comparison of outcomes for patients with benign paroxysmal positional vertigo based on length of postural restrictions. Journal of Geriatric Physical Therapy, 32(4), 168–173. https://doi.org/10.1519/00139143-200932040-00005
Murdin, L., & Schilder, A. G. (2015). Epidemiology of balance symptoms and disorders in the community: A systematic review. Otology & Neurotology, 36(3), 387–392. https://doi.org/10.1097/MAO.0000000000000691
National Institute on Deafness and Other Communication Disorders. (2017). NIDCD strategic plan (FY 2017–2021). https://www.nidcd.nih.gov/sites/default/files/Documents/NIDCD-StrategicPlan2017-508.pdf
Neuhauser, H. K. (2007). Epidemiology of vertigo. Current Opinion in Neurology, 20(1), 40–46. https://doi.org/10.1097/WCO.0b013e328013f432
Ochi, K., & Ohashi, T. (2003). Age-related changes in the vestibular-evoked myogenic potentials. Otolaryngology—Head and Neck Surgery, 129(6), 655–659.
O’Loughlin, J. L., Boivin, J.-F., Robitaille, Y., & Suissa, S. (1994). Falls among the elderly: Distinguishing indoor and outdoor risk factors in Canada. Journal of Epidemiology & Community Health, 48(5), 488–489. https://doi.org/10.1136/jech.48.5.488
O’Reilly, R. C., Morlet, T., Nicholas, B. D., Josephson, G., Horlbeck, D., Lundy, L., & Mercado, A. (2010). Prevalence of vestibular and balance disorders in children. Otology & Neurotology, 31(9), 1441–1444. https://doi.org/10.1097/MAO.0b013e3181f20673
Rine, R. M. (2009). Growing evidence for balance and vestibular problems in children. Audiological Medicine, 7(3), 138–142. https://doi.org/10.1080/16513860903181447
Rine, R. M., Braswell, J., Fisher, D., Joyce, K., Kalar, K., & Shaffer, M. (2004). Improvement of motor development and postural control following intervention in children with sensorineural hearing loss and vestibular impairment. International Journal of Pediatric Otorhinolaryngology, 68(9), 1141–1148. https://doi.org/10.1016/j.ijporl.2004.04.007
Roberts, R. A., Gans, R. E., DeBoodt, J. L., & Lister, J. J. (2005). Treatment of benign paroxysmal positional vertigo: Necessity of postmaneuver patient restrictions. Journal of the American Academy of Audiology, 16(6), 357–366. https://doi.org/10.3766/jaaa.16.6.4
Rubenstein, L. Z. (2006). Falls in older people: Epidemiology, risk factors and strategies for prevention. Age and Ageing, 35(Suppl. 2), ii37–ii41. https://doi.org/10.1093/ageing/afl084
Russell, G., & Abu-Arafeh, I. (1999). Paroxysmal vertigo in children—An epidemiological study. International Journal of Pediatric Otorhinolaryngology, 49(Suppl. 1), S105–S107. https://doi.org/10.1016/S0165-5876(99)00143-3
Slattery, E. L., Sinks, B. C., & Goebel, J. A. (2011). Vestibular tests for rehabilitation: Applications and interpretation. NeuroRehabilitation, 29(2), 143–151. https://doi.org/10.3233/NRE-2011-0688
Szirmai, A. (2010). Vestibular disorders in childhood and adolescents. European Archives of Oto-Rhino-Laryngology, 267(11), 1801–1804. https://doi.org/10.1007/s00405-010-1283-2
Ten Voorde, M., van der Zaag-Loonen, H. J., & van Leeuwen, R. B. (2012). Dizziness impairs health-related quality of life. Quality of Life Research, 21(6), 961–966. https://doi.org/10.1007/s11136-011-0001-x
Ward, B. K., Agrawal, Y., Hoffman, H. J., Carey, J. P., & Della Santina, C. C. (2013). Prevalence and impact of bilateral vestibular hypofunction: Results from the 2008 US National Health Interview Survey. JAMA Otolaryngology—Head & Neck Surgery, 139(8), 803–810. https://doi.org/10.1001/jamaoto.2013.3913
Whitney, S. L., Marchetti, G. F., & Schade, A. I. (2006). The relationship between falls history and computerized dynamic posturography in persons with balance and vestibular disorders. Archives of Physical Medicine and Rehabilitation, 87(3), 402–407. https://doi.org/10.1016/j.apmr.2005.11.002
Wiener-Vacher, S. R. (2008). Vestibular disorders in children. International Journal of Audiology, 47(9), 578–583. https://doi.org/10.1080/14992020802334358
Wiener-Vacher, S. R., Quarez, J., & Le Priol, A. (2018). Epidemiology of vestibular impairments in a pediatric population. Seminars in Hearing, 39(3), 229–242. https://doi.org/10.1055/s-0038-1666815
Zamysłowska-Szmytke, E., Szostek-Rogula, S., & Śliwińska-Kowalska, M. (2015). Bedside examination for vestibular screening in occupational medicine. International Journal of Occupational Medicine and Environmental Health, 28(2), 379–387. https://doi.org/10.13075/ijomeh.1896.00514
Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Balance System Disorders page.
In addition, ASHA thanks the members of the Ad Hoc Committee on Vestibular Rehabilitation, whose work was foundational to the development of this content. Members of the committee were Nancy P. Garrus, Eric B. Hecker, Kenneth G. Henry, Susan Herdman (consultant), Neil T. Shepard (chair), Charles W. Stockwell, and Maureen E. Thompson (ex officio). Richard Nodar, ASHA vice president for professional practices in audiology (1998-2000), served as monitoring vice president.
In addition, ASHA thanks the members of the Ad Hoc Committee on Advances in Clinical Practice, whose work was foundational to the development of this content. Members of the committee were 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, vice president for professional practices (1991-1993), and Teris K. Schery, vice president for clinical affairs (1988-1990), served as monitoring vice presidents.
The recommended citation for the Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Balance System Disorders (Practice Portal). Retrieved from www.asha.org/Practice-Portal/Clinical-Topics/Balance-System-Disorders/.