Preseason Vestibular Ocular Motor Screening in Children and Adolescents

Utility of the Vestibular/Ocular Motor Screening in Military Medicine: A Systematic Review

INTRODUCTION

The Vestibular/Ocular Motor Screening (VOMS) was created as a brief clinical screening tool for identifying vestibular and ocular motor symptoms and impairments post-concussion. It was found to have predictive validity in correctly identifying concussed athletes from healthy controls. In 2018, the Military Acute Concussion Evaluation 2 (MACE2) replaced the original Military Acute Concussion Evaluation (MACE); the most prominent change between the MACE and MACE2 was the addition of the VOMS. Despite its adoption into military medicine, it is not known if the addition of the VOMS to the MACE2 is acutely helpful, and if it provides additional information for diagnosis, prognosis, and/or management. The purposes of this systematic review were: (1) to determine the utility of the VOMS in correctly identifying concussed individuals, particularly as it pertains to military medicine; (2) to explore the extent to which the VOMS can inform concussion prognosis; and (3) to establish the value of the VOMS as a measure for monitoring the evolution of symptoms throughout a service member's course of care.

MATERIALS AND METHODS

A comprehensive search of PubMed was performed from January 1, 2014 through August 16, 2023. Articles were included if they researched concussion or a related health condition or healthy controls and administered the VOMS. Articles were excluded if they discussed health conditions other than concussion; did not administer the VOMS; or were written in languages other than English. The tools used to assess methodological quality and risk of bias varied according to study design. Articles were classified into three primary domains: diagnosis, prognosis, and/or rehabilitation/recovery over time.

RESULTS

A total of 231 articles were retrieved and 3 were duplicates, leaving 228 articles for review. Of the 228 articles screened, 100 relevant full-text articles were assessed for eligibility. Fifty-nine articles met our inclusion and exclusion criteria while the other 41 articles were rejected. Thirty-two articles helped to inform diagnosis, 15 prognosis, and 16 rehabilitation/recovery over time.

CONCLUSIONS

The VOMS had excellent internal consistency and moderate to good test-retest reliability; however, a false-positive rate of 21.9% was found. Most studies indicated that a positive VOMS was associated with a delayed recovery. Several studies indicated that VOMS scores improved with targeted, active interventions and/or a symptom-guided progressive return to activity. The greatest limitation was the paucity of published evidence in the military population. More research is needed on the use of the VOMS in service members.

Clinical Utility of Ocular Assessments in Sport-Related Concussion: A Scoping Review

Background/objectives: Ocular tools and technologies may be used in the diagnosis of sport-related concussions (SRCs), but their clinical utility can vary. The following study aimed to review the literature pertaining to the reliability and diagnostic accuracy of such assessments. Methods: The preferred reporting items for systematic reviews and meta-analysis (PRISMA) extension for scoping reviews was adhered to. Reference standard reliability (RSR ≥ 0.75) and diagnostic accuracy (RSDA ≥ 0.80) were implemented to aid interpretation. Results: In total, 5223 articles were screened using the PCC acronym (Population, Concept, Context) with 74 included in the final analysis. Assessments included the King-Devick (KD) (n = 34), vestibular-ocular motor screening (VOMs) and/or near point of convergence (NPC) (n = 25), and various alternative tools and technologies (n = 20). The KD met RSR, but RSDA beyond amateur sport was limited. NPC met RSR but did not have RSDA to identify SRCs. The VOMs had conflicting RSR for total score and did not meet RSR in its individual tests. The VOMs total score did perform well in RSDA for SRCs. No alternative tool or technology met both RSR and RSDA. Conclusion: Ocular tools are useful, rapid screening tools but should remain within a multi-modal assessment for SRCs at this time.

An Exploratory Analysis of Physical Examination Subtypes in Pediatric Athletes With Concussion

OBJECTIVE

Pediatric athletes with concussion present with a variety of impairments on clinical assessment and require individualized treatment. The Buffalo Concussion Physical Examination is a brief, pertinent clinical assessment for individuals with concussion. The purpose of this study was to identify physical examination subtypes in pediatric athletes with concussion within 2 weeks of injury that are relevant to diagnosis and treatment.

DESIGN

Secondary analysis of a published cohort study and clinician consensus.

SETTING

Three university-affiliated sports medicine centers.

PARTICIPANTS

Two hundred seventy children (14.9 ± 1.9 years).

INDEPENDENT VARIABLES

Orthostatic intolerance, horizontal and vertical saccades, smooth pursuits, vestibulo-ocular reflex, near-point convergence, complex tandem gait, neck range of motion, neck tenderness, and neck spasm.

MAIN OUTCOME MEASURES

Correlations between independent variables were calculated, and network graphs were made. k -means and hierarchical clustering were used to identify clusters of impairments. Optimal number of clusters was assessed. Results were reviewed by experienced clinicians and consensus was reached on proposed subtypes.

RESULTS

Physical examination clusters overlapped with each other, and no optimal number of clusters was identified. Clinician consensus suggested 3 possible subtypes: (1) visio-vestibular (horizontal and vertical saccades, smooth pursuits, and vestibulo-ocular reflex), (2) cervicogenic (neck range of motion and spasm), and (3) autonomic/balance (orthostatic intolerance and complex tandem gait).

CONCLUSIONS

Although we identified 3 physical examination subtypes, it seemed that physical examination findings alone are not enough to define subtypes that are both statistically supported and clinically relevant, likely because they do not include symptoms, assessment of mood or cognitive problems, or graded exertion testing.

What are the Protocols and Resources for Sport-Related Concussion Among Top National Collegiate Athletic Association Football Programs? A Cross-Sectional Survey of A5 Schools

OBJECTIVE

This study summarizes findings from a cross-sectional survey conducted among National Collegiate Athletic Association (NCAA) Division 1 football programs, focusing on sport-related concussion (SRC) protocols for the 2018 season.

DESIGN

Cross-sectional survey study.

SETTING

65 football programs within the Autonomy Five (A5) NCAA conferences.

PARTICIPANTS

Athletic trainers and team physicians who attended a football safety meeting at the NCAA offices June 17 to 18, 2019, representing their respective institutions.

INTERVENTION

Electronic surveys were distributed on June 14, 2019, before the football safety meeting.

MAIN OUTCOME MEASURES

Results for 16 unique questions involving SRC protocols and resources were summarized and evaluated.

RESULTS

The survey garnered responses from 46 of 65 programs (response rate = 71%). For baseline testing, 98% measured baseline postural stability and balance, 87% used baseline neurocognitive testing, while only 61% assessed baseline vestibular and/or ocular function. Regarding concussion prevention, 51% did not recommend additional measures, while 4% and 24% recommended cervical compression collars and omega-3 supplementation, respectively. In postconcussion treatment, 26% initiated aerobic exercise 1 day postconcussion if symptoms were stable, 24% waited at least 48 hours, 4% waited for the athlete to return to baseline, 11% waited until the athlete became asymptomatic, and 35% determined procedures on a case-by-case basis.

CONCLUSIONS

Most institutions assessed postural stability/balance and neurocognitive functioning at baseline and introduced light aerobic exercise within 48 h postconcussion. There was variation in baseline assessment methods and concussion prevention recommendations. These survey findings deepen our understanding of diverse SRC protocols in NCAA football programs.

False-Positive Rates, Risk Factors, and Interpretations of the Vestibular/Ocular Motor Screening in Collegiate Athletes

CONTEXT

Biological sex and history of motion sickness are known modifiers associated with a false-positive baseline Vestibular/Ocular Motor Screening (VOMS). However, other factors may be associated with a false-positive VOMS in collegiate athletes.

OBJECTIVE

To identify contributing factors to false-positive VOMS assessments using population-specific criteria. We also critically appraised previously reported interpretation criteria.

DESIGN

Descriptive laboratory study.

SETTING

Single-site collegiate athletic training clinic.

PATIENTS OR OTHER PARTICIPANTS

National Collegiate Athletic Association Division I athletes (n = 462 [41% female]) aged 18.8 ± 1.4 years.

MAIN OUTCOME MEASURE(S)

Participants completed the Athlete Sleep Behavior Questionnaire, the 7-Item Generalized Anxiety Index, the Immediate Postconcussion Assessment and Cognitive Testing battery, the Patient Health Questionnaire-9, the Revised Head Injury Scale, the Sensory Organization Test, and the VOMS as part of a multidimensional baseline concussion assessment. Participants were classified into 2 groups based on whether they had a total symptom score of greater than or equal to 8 after VOMS administration, excluding the baseline checklist. We used χ2 and independent t tests to compare group demographics. A binary logistic regression with adjusted odds ratios (ORs) was used to evaluate the influence of sex, corrected vision, attention-deficit/hyperactivity disorder, Immediate Postconcussion Assessment and Cognitive Testing composite scores, concussion history, history of treatment for headache and/or migraine, Generalized Anxiety Index scores, Patient Health Questionnaire-9 scores, Athlete Sleep Behavior Questionnaire scores, and Sensory Organization Test equilibrium scores and somatosensory, visual, and vestibular sensory ratios on false-positive rates.

RESULTS

Approximately 9.1% (42 of 462 [30 females]) met criteria for a false-positive VOMS. A significantly greater proportion of females had false positives (χ21 = 18.37, P < .001). Female sex (OR = 2.79; 95% CI = 1.17, 6.65; P = .02) and history of treatment for headache (OR = 4.99; 95% CI = 1.21, 20.59; P = .026) were the only significant predictors of false-positive VOMS. Depending on cutoff interpretation, false-positive rates using our data ranged from 9.1% to 22.5%.

CONCLUSIONS

Our results support the most recent interpretation guidelines for the VOMS in collegiate athletes due to a low false-positive rate and ease of interpretation. Biological sex and history of headaches should be considered when administering the VOMS in the absence of a baseline.

The Vestibular/Ocular Motor Screening-Child (VOMS-C) tool for concussion evaluation in 5- to 9-year-old pediatric patients: preliminary evidence

OBJECTIVE

Vestibular and ocular motor dysfunction occurs in an estimated 60%-90% of concussion patients. The Vestibular/Ocular Motor Screening (VOMS) tool is validated for use in concussion patients older than 9 years. The goal of the current study was to adapt the current VOMS tool for a pediatric sample of children aged 5-9 years and establish its clinical utility in this patient population.

METHODS

In this case-control study, 80 symptomatic concussion patients (n = 33 [41%] female) aged 5-9 years (mean age 7.40 ± 1.09 years) and 40 (n = 18 [45%] female) age- and sex-matched uninjured controls (mean age 7.10 ± 1.26 years) completed the VOMS-Child (VOMS-C), a version of the VOMS adapted for younger patients. Differences in binary "yes" or "no" symptom provocation for headache, dizziness, and nausea/"tummy ache" across the 7 items of the VOMS-C, and near point of convergence (NPC) distance, were examined. Logistic regression (LR) models were built to classify concussion and controls. Predicted probabilities were generated from the LR model and entered into receiver operating characteristic (ROC) curve models to generate area under the curve (AUC) values.

RESULTS

VOMS-C item provocation ranged from 13% to 30% for concussed patients and 3% to 20% for controls. The LR model distinguished concussed participants from controls (R2 = 0.39; p < 0.001), with significant predictors being smooth pursuits, family depression history, and NPC distance. The ROC analysis had an AUC of 0.81 (95% CI 0.73-0.89; p < 0.001) in the good range.

CONCLUSIONS

Accurate diagnosis of concussion in the clinic setting requires comprehensive evaluation in multiple domains, including detailed clinical interview, neurocognitive testing, and vestibular/ocular motor assessment, regardless of patient age. Our results provide preliminary support for the VOMS-C as a developmentally appropriate tool for concussion management.

Evaluation of the vestibular/ocular motor screening assessment in active combat sport athletes: an exploratory study

OBJECTIVE

The first aim of this study was to compare the results of the vestibular/ocular motor screening (VOMS) in combat sport athletes with a healthy control population. Second, to explore differences between athletes with and without a concussion history. Third, to examine the relationship between VOMS and the Post-Concussion Symptom Scale (PCSS) in combat sport athletes.

PARTICIPANTS

Forty active male combat sport athletes and 40 healthy male control participants were recruited from 4 clubs and a University in Australia.

METHODS

Participants completed the VOMS in a primary care physiotherapy clinic. Participants completed an injury questionnaire and the PCSS.

RESULTS

An "abnormal" score in at least one subtest or near point convergence (NPC) was recorded in 45% of the combat group compared with 22.5% of the control group. All VOMS scores and NPC distance were greater in the combat group compared with control group (p < 0.05). The VOMS scores were found to be moderately positively correlated with the PCSS. There was no difference in VOMS between athletes with and without a history of concussion (p > 0.05).

CONCLUSION

VOMS scores differed between combat sport athletes and control participants. The PCSS may aid clinicians in identifying athletes who have underlying vestibular/oculomotor impairment.

Safety and Tolerability of an Innovative Virtual Reality-Based Deep Breathing Exercise in Concussion Rehabilitation: A Pilot Study

To examine the safety and tolerability of a virtual reality-based deep breathing exercise for children and adolescents who are slow to recover from concussion. Methods: Fifteen participants (ages 11 to 22; mean = 16.9 years) were recruited from a specialty concussion clinic within a tertiary care medical center. Participants completed a 5-min paced deep breathing exercise administered via a virtual reality headset. Results: Nearly all participants (93.3%) reported the experience was either positive or extremely positive. No participants reported significant discomfort or discontinued the exercise. Three participants reported a mild increase in headache, dizziness, or nausea. Participants reported significant decreases in stress (r =.57), tension (r =.73), fatigue (r =.73), and confusion (r =.67), with large effect sizes, following the deep breathing exercise. Conclusion: A brief, virtual reality-based deep breathing exercise is worthy of additional study as a rehabilitation component for children and adolescents with prolonged concussion recoveries.

Using change scores on the vestibular ocular motor screening (VOMS) tool to identify concussion in adolescents

OBJECTIVE

To develop clinical cutoffs using change scores for the VOMS individual items and an overall VOMS change score that identified concussion in adolescent athletes.

METHODS

Change score clinical cutoffs were calculated from a sample of adolescents (13-18 years) with SRC (n = 147) and a sample of uninjured adolescents CONTROL (n = 147). Receiver operating characteristic (ROC) curves, with area under the curve (AUC), based on Youden's J statistic were used to identify optimal cutoffs for identifying SRC from CONTROLS using VOMS individual item change scores, an overall VOMS change scores, and NPC distance (cm).

RESULTS

AUC values for VOMS item change scores ranged from .55 to .71. Optimal change score cutoffs were ≥1 for VOMS items and ≥3 for overall VOMS change score. The optimal cutoff for NPC distance was ≥3 cm. A ROC analysis revealed a three-factor model (AUC = .76) for identifying SRC that included vertical vesibular ocular reflex (VVOR), visual motion sensitivity (VMS), and NPC distance items. The AUC (.73) for the overall VOMS change score was higher than any individual VOMS AUC values.

CONCLUSIONS

This study supports an alternate scoring approach and clinical interpretation of VOMS items involving change scores that account for pretest symptoms.

Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department

BACKGROUND

Visio-vestibular examination (VVE) deficits are common following pediatric concussion. Guidelines recommend assessing these deficits on all potentially concussed youth given their diagnostic and prognostic value, however test psychometrics of the VVE in the emergency department (ED) setting are unknown. Our objective was to determine the inter-rater (IRR) and test-retest reliability (TRR) of the VVE in a pediatric ED.

METHODS

We enrolled 155 patients (112 IRR; 43 TRR) age 6-18 years with head injury presenting to the ED of a tertiary care children's hospital. Exams were performed by a group of 65 attending/fellow physicians, pediatricians, and advanced practice providers. The VVE consisted of 9 maneuvers (smooth pursuits, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, complex tandem gait). Cohen's kappa was calculated for IRR and TRR for each element.

RESULTS

For IRR, 5/9 kappas (saccades, gaze stability, monocular accommodation) were in the moderate agreement range (0.40 to 0.60); remaining kappas showed fair agreement. For TRR, 6/9 maneuvers (saccades, horizontal gaze stability, monocular accommodation, tandem gait) showed substantial agreement (0.60 to 0.80). Kappas of 7/9 elements for subjects age 15-18 showed improved IRR and TRR.

CONCLUSIONS

The individual elements of the VVE show fair to moderate agreement between providers and moderate to substantial agreement among the same provider in the ED setting. These findings suggest a role in the VVE in evaluating concussion acutely, particularly given its previously demonstrated ability to assist in risk stratification of concussed youth and the importance of early diagnosis for improved outcomes.