A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: Preliminary Findings
Mucha A., Collins M.W., Elbin R.J., Furman J.M., Troutman-Enseki C., DeWof R.M., Marchetti G., Kontos A.P. Am J Sport Med; 2014;ahead of print
Take Home Message: The vestibular/ocular motor screening (VOMS) is valid assessment to identify young patients with concussions.
Vestibular impairments (e.g., dizziness) are commonly reported following a sports-related concussion, and have been associated with prolong recovery. Despite the growing evidence of vestibular-related impairments there are no validated concussion assessments to evaluate this aspect of the concussion injury. Therefore, the authors described and provided initial data for the internal consistency and validity of a new brief clinical screening tool for vestibular and ocular motor impairment and symptoms following a sports-related concussion. The authors administered the Vestibular/Ocular Motor Screening (VOMS) assessment and post-concussion symptom scale to 64 patients who sustained a sports-related concussion (36 males, 28 females; ~14 years of age; ~5.5 days after injury) and 78 healthy controls (57 males, 21 females; ~13 years of age). The VOMS is a 5-10 minute test that consists of 5 domains (smooth pursuits, horizontal and vertical saccades, near point convergence, horizontal vestibular ocular reflex, and vision motion sensitivity). The patients verbally rate changes in headache, dizziness, nausea, and fogginess of symptoms after each assessment compared with their immediate preassessment state on a scale from 0 (no change) to 10 (severe change). Near point convergence was measured subjectively as well as an objectively (a mean score recorded from 3 measurements). The internal consistency for the VOMS total symptom score and the near point convergence was high, which indicates that the VOMS items are measuring related things but they are not identical. All VOMS tests had a small to moderate relationship with the post-concussion symptom scale total score. Patients who sustained a concussion had higher mean total symptoms score for all of the VOMS tests compared with the healthy controls. Patients reporting symptom provocation during the vestibular ocular reflex and vision motion sensitivity were nearly 4 times and 3 times more likely to be in the concussed group, respectively. The authors determined that a positive VOMS test could be defined as reporting 2 or more symptoms during the smooth pursuit, saccade tests, horizontal vestibular ocular reflex, or visual motion sensitivity. Additionally, a patient with a near point convergence distance of 5 cm or more was also a positive sign for a concussion.
This is an important study because it is the first study to release preliminary findings for assessing a potentially concussed athlete based on the VOMS assessment. The VOMS assessment is cheap, easy, and quick to perform. The cutoff scores are also easy to identify; however, the medial personnel are still relying on the patient to report symptom provocation. The authors demonstrated that the VOMS evaluation has excellent internal consistency and validity for identifying young concussed athletes. It will be interesting to see if these tests will also perform well in older athletes (e.g., college-age athletes). A concussion is a complex injury; therefore, it is necessary to use a multifaceted protocol to assess this condition. VOMS may be a useful tool to add to the concussion assessment protocol to verify and manage sports-related concussion injuries.
Questions for Discussion: Do you use any head/eye movement tests to assess for a concussion? Will you begin to implement VOMS in your concussion assessment protocol?
Written by: Jane McDevitt, PhD
Reviewed by: Jeffrey Driban
Related Posts:
Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, & Kontos AP (2014). A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. The American Journal of Sports Medicine, 42 (10), 2479-86 PMID: 25106780
This study was very interesting mainly because (as it states) the common practices for vestibular impairments following a concussion do not address ALL aspects of the system itself. There were however a few things that I felt this study should have accounted for in it's subjects. First, was that in the exclusion criteria, to be a healthy participant it did not state you had to be free of any vestibular disease that may affect balance. I feel this should have been a key component because it can ultimately affect the reliability. Another problem with the exclusion criteria was that they did not specify if healthy controls needed to be free of a concussion at least 6 months (or more) prior to participation in the study. In the results, the authors even state that 12% of the controls reported a history of concussion, yet they did not state whether they took into consideration the time at which it happened.
Hello,
I am a second year AT graduate student that has been taught to test the cranial nerves while testing for a concussion. As I am typically utilizing the cranial nerve tests as part of a wholistic head injury assessment I would say I do utilize head/eye movements as part of my approach to test for a concussion. In fact, correct me if I am wrong but I believe the smooth pursuits test is just a modified the CN III test while the near point convergence is a modified CN IV test.
I like the idea of adding the VOMS assessment into my sideline arsenal, if the studies are accurate, and a positive test has a strong specificity and correlation to a concussion. If the VOMS test meets these criteria I would happily add the VOMS into my concussion testing approach. This test would help save time getting an athlete back into the game and ensure my assessment utilizes a tried and true method for accurate diagnosis. If I could eliminate the need to test the additional cranial nerves on the sideline and still have confidence in my testing methods I would do so.
While we have never been taught the VOMS method in grad school, the tests appear to be fairly simple to learn and implement on the sideline. All my rotations have been at the collegiate level, so I would be eager to see if the correlation held true with older athletes. I will bring this method up with my remaining preceptors and see if they have any experience utilizing this method of concussion testing. I hope to hear more on this subject soon, I look forward to testing the method out, and I’ll be waiting eagerly for updates on the subject!