Validity and Reliability of the Vestibular/Ocular Motor Screening and Associations With Common Concussion Screening Tools

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.

Comparing the Impact of High-Intensity Exercise on Vestibular-Oculomotor Function Between Sex, Sport, and Activity Level

OBJECTIVE

To investigate the impact of high-intensity exercise on the vestibular and oculomotor systems in a group of sedentary and active males and females.

DESIGN

Prospective observational study.

SETTING

Performance laboratory; Institute of Sport, Exercise and Health, London.

PARTICIPANTS

Forty-five collegiate athletes and 30 age-matched sedentary participants.

INTERVENTIONS

A baseline Vestibular and Oculomotor Screening (VOMS) test was performed on all participants before undertaking a self-paced 5-minute treadmill run maintaining an intensity of 17/20 on the Borg scale. Post-run, participants were tested using the VOMS tool a further 3 times with each test 30 seconds apart.

MAIN OUTCOME MEASURES

Symptom provocation on testing of the VOMS tool.

RESULTS

At baseline testing, 25.3% of participants had 1 or more positive VOMS domains although there was no significant differences between sex, sport, or activity level. At postrun testing, 62.5% of participants had 1 or more positive VOMS domains; this was a significant change from baseline with large effect size (Z = 6.12, r = 0.72, P < 0.001).

CONCLUSIONS

High-intensity exercise has a deleterious impact on vestibular and oculomotor function. This change in function is consistent across all groups when considering activity level, sex, and sporting participation. These findings have implications when considering the timing of VOMS in relation to sporting participation and clinical testing that involves exercise.

Effect of Mild and Moderate Exertion on the Sideline Assessment of Concussion: A Randomized Controlled Trial

OBJECTIVE

Identify the effect size of mild and moderate levels of exertion on common sideline concussion assessment tool scores in healthy adolescent athletes.

DESIGN

Three arm randomized controlled trial.

SETTING

High school training rooms.

PARTICIPANTS

Forty-seven healthy adolescents who participate in school sports and have not had a concussion within the past month.

INTERVENTIONS

Participants performed the Sport Concussion Assessment Tool 5 (SCAT5) and Vestibular Ocular Motor Screen (VOMS) at rest. Participants were randomized to perform No Exertion (n = 16, 15-minute seated rest), Mild Exertion [n = 16, 50%-55% of heart rate (HR) max for 15 minutes on a treadmill], or Moderate Exertion (n = 15, 70%-75% of HR max). Participants then repeated the SCAT5 and VOMS immediately after a 2-minute cool down.

MAIN OUTCOME MEASURES

Effect size of change after exertion.

RESULTS

Few differences were seen after mild and moderate levels of exertion. In the combined sample, there was a small increase in the number of modified balance error scoring system errors [d = -0.17 (-0.52, 0.19)], a medium degree of improvement in symptoms [d = 0.38 (0.01, 0.74)], and a small degree of improvement in cognitive scores [d = 0.20 (-0.16, 0.55)] after exercise. No differences on VOMS testing were observed.

CONCLUSIONS

The SCAT5 and VOMS seem to be consistent measures even after mild and moderate levels of exertion (HR <75% of age-appropriate maximum). A future study should aim to identify the effect of maximal exertion.

The Role and Benefits of Physical Therapy Following Sport-Related Concussions

CONTEXT

Sport-related concussion management often requires referral to physical therapy (PT).

OBJECTIVES

To (1) outline the role of PT in the management of sport-related concussion, (2) describe patients who underwent PT, and (3) discuss outcomes of athletes who underwent PT.

DESIGN

Retrospective cohort study.

SETTING

Single institution.

METHODS

Adolescent athletes aged 14-19 years old who sustained a sport-related concussion from November 2017 to April 2022 were evaluated. The cohort was dichotomized into 2 groups: PT versus no PT. The outcomes were days from initial PT visit to symptom resolution (SR) and return-to-play. Subgroup analyses compared recovery metrics between those initiating PT before and after 30 (1 mo) and 90 days (3 mo) of injury. A univariable and multivariable regression was used to determine predictors of recovery.

RESULTS

Of 1010 concussed athletes, 205 (20.3%) received referral for rehabilitation, and 58 (28.3%) patients received PT at the parent institution. Those who received PT had a higher number of prior concussions compared with those who did not (PT: 1.0 [1.2]; non-PT: 0.6 + 1.0; χ2 = 19.37, P = .007). A large proportion of PT recipients reported headache (n = 45, 81.0%); visual disturbances (n = 32, 65.5%); and vestibular (n = 37, 63.8%), cervical (n = 25, 43.1%), or oculomotor dysfunction (n = 25, 43.1%). Most patients received exertional therapy (n = 32, 55.1%), vestibular therapy (n = 31, 53.4%), and/or cervical therapy (n = 30, 51.7%). Those initiating PT before 1 and 3 months had significantly shorter median times to SR compared with those initiating after 1 and 3 months, respectively. Multivariable regression showed that a shorter time between injury and the initial PT visit was predictive of faster SR (β = 1.66, P = .048).

CONCLUSIONS

Headache, dizziness, and visual disturbances were commonly reported symptoms by patients who received PT. Cervical, vestibular, and oculomotor deficits were common objective findings by physical therapists, and cervical, vestibular, and exertional therapy were common interventions. Delayed time to PT was independently associated with a longer time to SR.

Comparison of Vestibular/Ocular Motor Screening (VOMS) and Computerized Eye-tracking to Identify Exposure to Repetitive Head Impacts

INTRODUCTION

Military service members (SMs) are exposed to repetitive head impacts (RHIs) in combat and training that are purported to adversely affect brain health, including cognition, behavior, and function. Researchers have reported that RHI from blast-related exposure may affect both vestibular and ocular function, which in turn may be related to symptomology. As such, an examination of the effects of RHI on exposed military SMs should incorporate these domains. To date, researchers have not compared groups of exposed special operations forces (SOF) operators on combined clinical vestibular/ocular and eye-tracker-based outcomes. Therefore, the primary purpose of this study was to compare participant-reported symptoms and performance on the Vestibular/Ocular Motor Screening (VOMS) tool with performance on the computerized RightEye tracking system between SOF operators exposed to blast-related RHI and healthy controls without blast-related exposure. In addition, the study aimed to compare subgroups of snipers and breachers exposed to RHI to controls on the preceding metrics, as well as identify a subset of individual (demographic) factors, participant-reported symptoms, and performance metrics on VOMS and RightEye that best identify SOF operators exposed to RHI from unexposed controls.

MATERIALS AND METHODS

The study involved a cross-sectional design including 25 Canadian SOF SMs comprised of breachers (n = 9), snipers (n = 9), and healthy, unexposed controls (n = 7). The former 2 groups were combined into an RHI group (n = 18) and compared to controls (n = 7). Participants provided demographics and completed a self-reported concussion-related symptom report via the Military Acute Concussion Evaluation 2, the VOMS, and RightEye computerized eye-tracking assessments. Independent samples t-tests and ANOVAs were used to compare the groups on the outcomes, with receiver operating characteristic curve and area under the curve (AUC) analyses to identify predictors of blast exposure. This study was approved by the Defence Research Development Canada Human Research Ethics Committee and the Canadian Forces Surgeon General/Special Forces Command.

RESULTS

The results from t-tests supported group differences for age (P = .012), participant-reported symptoms (P = .006), and all VOMS items (P range = <.001-.02), with the RHI group being higher than healthy controls on all variables. ANOVA results supported group differences among snipers, breachers, and controls for age (P = .01), RightEye saccades (P = .04), participant-reported total symptom severity (P = .03), and VOMS total scores (P = .003). The results of the receiver operating characteristic curve analyses supported age (AUC = 0.81), Military Acute Concussion Evaluation 2 participant-reported total symptom severity (AUC = 0.87), and VOMS total scores (AUC = 0.92) as significant predictors of prior blast exposure.

CONCLUSIONS

Participant-reported concussion symptoms, VOMS scores, and age were useful in identifying SOF operators exposed to RHI from controls. RightEye metrics were not useful in differentiating RHI groups from controls. Differences between snipers and breachers warrant further research. Overall, the findings suggest that VOMS may be a useful tool for screening for the effects of exposure to RHI in SOF operators. Future investigations should be conducted on a larger sample of military SMs, consider additional factors (e.g., RHI exposure levels, medical history, and sex), and include additional assessment domains (e.g., balance, cognitive, and psychological).

Testing the Validity and Reliability of a Standardized Virtual Examination for Concussion

Background and Objectives

We determined inter-modality (in-person vs telemedicine examination) and inter-rater agreement for telemedicine assessments (2 different examiners) using the Telemedicine Buffalo Concussion Physical Examination (Tele-BCPE), a standardized concussion examination designed for remote use.

Methods

Patients referred for an initial evaluation for concussion were invited to participate. Participants had a brief initial assessment by the treating neurologist. After a patient granted informed consent to participate in the study, the treating neurologist obtained a concussion-related history before leaving the examination room. Using the Tele-BCPE, 2 virtual examinations in no specific sequence were then performed from nearby rooms by the treating neurologist and another neurologist. After the 2 telemedicine examinations, the treating physician returned to the examination room to perform the in-person examination. Intraclass correlation coefficients (ICC) determined inter-modality validity (in-person vs remote examination by the same examiner) and inter-rater reliability (between remote examinations done by 2 examiners) of overall scores of the Tele-BCPE within the comparison datasets. Cohen's kappa, κ, measured levels of agreement of dichotomous ratings (abnormality present vs absent) on individual components of the Tele-BCPE to determine inter-modality and inter-rater agreement.

Results

For total scores of the Tele-BCPE, both inter-modality agreement (ICC = 0.95 [95% CI 0.86-0.98, p < 0.001]) and inter-rater agreement (ICC = 0.88 [95% CI 0.71-0.95, p < 0.001]) were reliable (ICC >0.70). There was at least substantial inter-modality agreement (κ ≥ 0.61) for 25 of 29 examination elements. For inter-rater agreement (2 telemedicine examinations), there was at least substantial agreement for 8 of 29 examination elements.

Discussion

Our study demonstrates that the Tele-BCPE yielded consistent clinical results, whether conducted in-person or virtually by the same examiner, or when performed virtually by 2 different examiners. The Tele-BCPE is a valid indicator of neurologic examination findings as determined by an in-person concussion assessment. The Tele-BCPE may also be performed with excellent levels of reliability by neurologists with different training and backgrounds in the virtual setting. These findings suggest that a combination of in-person and telemedicine modalities, or involvement of 2 telemedicine examiners for the same patient, can provide consistent concussion assessments across the continuum of care.

The Unconsidered Pathway: Suggestions for Physical Therapists to Facilitate Student Reintegration to Physical Education after a Concussion

Background/Objectives: "Return-to-play" and "return-to-learn" after a concussion are familiar concepts due to guidelines proposed by the Concussion in Sport Group and Heads-Up Initiative. The purpose of this commentary is to expand upon the current consensus guidelines for treatment of concussed children and adolescents, as well as provide guidelines for returning to physical education (RT-PE) classes. Proposal: The authors propose one general and four subtype-specific guidelines post-concussion injury. This framework highlights the role of physical therapists in the management of children with prolonged recovery. The final RT-PE determination should occur with documented medical clearance from a licensed healthcare provider trained in the evaluation and management of a concussion. Conclusions: Despite significant gains regarding the management of concussed children and adolescents, confusion remains regarding RT-PE post-concussion. To eliminate ambiguity and promote adherence to a gradual return to activity protocols, the authors developed guidelines based on current evidence and recommendations.

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.

OculoMotor & Vestibular Endurance Screening (MoVES) Normative, Repeatability, and Reliability Data

This study aims to assess oculomotor and vestibular endurance by utilizing the Oculomotor and Vestibular Endurance Screening (MoVES) assessment in athletes' pre-season and post-season and after a suspected head injury to detect impairment. Athletes (N = 311, 19.4 ± 1.3 years) were recruited to perform the following seven tasks: (1) horizontal saccades, (2) vertical saccades, (3) vergence jumps, (4) horizontal vestibular-oculomotor reflex (VOR), (5) vertical VOR, (6) amplitude of accommodation (AoA), and (7) near point of convergence (NPC). At pre-season, the observed number of eye movements in 60 s are horizontal saccades (74 ± 13 initial 30 s; 67 ± 11 latter 30 s), vertical saccades (70 ± 13; 66 ± 10), vergence jumps (48 ± 12; 45 ± 13), horizontal VOR (38 ± 11; 38 ± 11), and vertical VOR (8 ± 11; 38 ± 11). These results establish a normative database for eye movements within the MoVES assessment and show consistency in the number of movements from pre-season to post-season. The initial results show a trending decrease in the number of eye movements in the initial days post-head injury, which improves to pre-season measures 14-21 days post-injury. This foundation can be used by future studies to explore the extent of binocular and vestibular endurance dysfunctions caused by head injuries that subside within two weeks.

Relationships Among Baseline Concussion Balance Test and Gaze Stability Test Scores in Division-I Collegiate Athletes

CONTEXT

Sports-related concussions are commonly occurring injuries as a result of sports and recreation that may cause alterations in brain functioning. It is important to be able to evaluate the impact of these injuries on function to manage the injury recovery and ensure recovery. Recent literature suggests the use of objective evaluation strategies in a multifaceted approach to evaluate and manage these injuries. It is important to understand the relationships between the assessments and how best to utilize each assessment. The purpose of this study was to investigate if relationships exist between measures of vestibular function at baseline in assessments that may be used following sports-related concussions. Additionally, a secondary purpose was to determine if self-reported symptoms were related to performance on the assessments. This study aimed to identify if these assessments measured independent functions of the vestibulo-ocular reflex or if some redundancy existed among the assessment strategies.

DESIGN

A cross-sectional study design was used in a cohort of collegiate athletes ages 18-24.

METHODS

Participants completed demographics questionnaires, the Post-Concussion Symptom Scale, Gaze Stabilization Test, and Concussion Balance Test. Spearman rho correlations were used to examine the relationships between the measures.

RESULTS

One hundred and thirty-five collegiate athletes (82 males and 53 females) were included, representative of 3 sports (cheerleading, soccer, and football) with a mean age of 19.77 (1.42) years old. There were weak to moderate, significant relationships between measures of Gaze Stabilization Test and Concussion Balance Test errors (r = .20-.31, P = .001-.03).

CONCLUSIONS

The direction of these relationships indicated that greater Concussion Balance Test errors were associated with greater Gaze Stabilization Test performance. These relationships may be attributed to the difficulty created by the foam conditions and the integration of more complex sensory tasks required to maintain balance during the more difficult conditions.

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.

Virtual Reality Application for Vestibular/Ocular Motor Screening: Current Clinical Protocol Versus a Novel Prototype

BACKGROUND

Virtual reality (VR) has been explored to improve baseline and postinjury assessments in sport-related concussion (SRC). Some experience symptoms related to VR, unrelated to concussion. This may deter use of vestibular/ocular motor screening (VOMS) using VR. Baseline VR VOMS symptomatology differentiates baseline from overall symptomatology.

HYPOTHESIS

There will be no difference between current clinical manual VOMS (MAN), a clinical prototype (PRO), and VR for symptom provocation change score (SPCS) and near point of convergence (NPC) average score in a healthy population and sex differences among the 3 modes of administration.

STUDY DESIGN

Cohort study.

LEVEL OF EVIDENCE

Level 3.

METHODS

A total of 688 National Collegiate Athletic Association Division I student-athletes completed VOMS using 3 methods (MAN, N = 111; female athletes, N = 47; male athletes, N = 64; average age, 21 years; PRO, N = 365; female athletes, N = 154; male athletes, N = 211; average age, 21 years; VR, N = 212; female athletes, N = 78; male athletes, N = 134; average age = 20 years) over a 3-year period (2019-2021) during annual baseline testing. Exclusion criteria were as follows: self-reported motion sickness in the past 6 months, existing or previous neurological insult, attention deficit hyperactivity disorder, learning disabilities, or noncorrected vision impairment. Administration of MAN followed the current clinical protocols, PRO used a novel prototype, and VR used an HTC Vive Pro Eye head mounted display. Symptom provocation was compared using Mann-Whitney U tests across each VOMS subtest with total SPCS and NPC average by each method.

RESULTS

MAN had significantly (P < 0.01) more baseline SPCS (MAN = 0.466 ± 1.165, PRO = 0.163 ± 0.644, VR = 0.161 ± 0.933) and significantly (P < 0.01) and more SPCS (MAN = 0.396 ± 1.081, PRO = 0.128 ± 0.427, VR = 0.48 ± 0.845) when compared with PRO and VR. NPC average measurements for VR (average, 2.99 ± 0.684 cm) were significantly greater than MAN (average, 2.91 ± 3.35 cm; P < 0.01; Cohen's d = 0.03) and PRO (average, 2.21 ± 1.81 cm; P < 0.01; Cohen's d = 0.57). For sex differences, female athletes reported greater SPCS with PRO (female athletes, 0.29 ± 0.87; male athletes, 0.06 ± 0.29; P < 0.01) but not in VR or MAN.

CONCLUSION

Using a VR system to administer the VOMS may not elicit additional symptoms, resulting in fewer false positives and is somewhat stable between sexes.

CLINICAL RELEVANCE

VOMS may allow for standardization among administrators and reduce possible false positives.

Temporal Changes in Fixational Eye Movements After Concussion in Adolescents and Adults: Preliminary Findings

Concussions often involve ocular impairment and symptoms such as convergence insufficiency, accommodative insufficiency, blurred vision, diplopia, eye strain, and pain. Current clinical assessments of ocular function and symptoms rely on subjective symptom reporting and/or involve lengthy administration time. More objective, brief assessments of ocular function following concussion are warranted. The purpose of this study was to evaluate changes in fixational eye movements (FEMs) and their association with clinical outcomes including recovery time, symptoms, cognitive and vestibular/ocular motor impairment. Thirty-three athletes (13-27 years of age; 54.5% female) within 21 days of a diagnosed concussion participated in the study. A tracking scanning laser ophthalmoscope (TSLO) evaluated FEMs metrics during fixation on a center and corner target. Participants completed symptom (Post-Concussion Symptom Scale [PCSS]), cognitive (Immediate Post-concussion Assessment and Cognitive Testing [ImPACT], and Vestibular/Ocular Motor Screening (VOMS) evaluations. All measures were administered at the initial visit and following medical clearance, which was defined as clinical recovery. Changes in FEMs were calculated using paired-samples t tests. Linear regression (LR) models were used to evaluate the association of FEMs with clinical recovery. Pearson product-moment correlations were used to evaluate the associations among FEMs and clinical outcomes. On the center task, changes across time were supported for average microsaccade amplitude (p = 0.005; Cohen's d = 0.53), peak velocity of microsaccades (p = 0.01; d = 0.48), peak acceleration of microsaccades (p = 0.02; d = 0.48), duration of microsaccade (p < 0.001; d = 0.72), and drift vertical (p = 0.017; d = -0.154). The LR model for clinical recovery was significant (R2 = 0.37; p = 0.023) and retained average instantaneous drift amplitude (β = 0.547) and peak acceleration of microsaccade (β = 0.414). On the corner task, changes across time were supported for drift proportion (p = 0.03; d = 0.43). The LR model to predict clinical recovery was significant (R2 = 0.85; p = 0.004) and retained average amplitude of microsaccades (β = 2.66), peak velocity of microsaccades (β = -15.11), peak acceleration of microsaccades (β = 12.56), drift horizontal (β = 7.95), drift vertical (β = 1.29), drift amplitude (β = -8.34), drift proportion (β = 0.584), instantaneous drift direction (β = -0.26), and instantaneous drift amplitude (β = 0.819). FEMs metrics were also associated with reports of nausea and performance within the domain of visual memory. The FEMs metric were also associated with PCSS, ImPACT, and VOMS clinical concussion outcomes, with the highest magnitude correlations between average saccade amplitude and VOMS symptoms of nausea and average instantaneous drift speed and ImPACT visual memory, respectively. FEMs metrics changed across time following concussion, were useful in predicting clinical recovery, and were correlated with clinical outcomes. FEMs measurements may provide objective data to augment clinical assessments and inform prognosis following this injury.

Preliminary Baseline Vestibular Ocular Motor Screening Scores in Pediatric Soccer Athletes

CONTEXT

The utility of baseline vestibular and ocular motor screening (VOMS) in high school and collegiate athletes is demonstrated throughout the literature; however, baseline VOMS data at the youth level are limited. In addition, with the recent adoption of the change scoring method, there is a need to document baseline VOMS total and change scores in a pediatric population.

OBJECTIVE

To document baseline VOMS total and change scores and to document the internal consistency of the VOMS in pediatric soccer athletes. We hypothesized that the VOMS would demonstrate strong internal consistency in pediatric soccer athletes.

DESIGN

Cross-sectional study.

METHODS

Pediatric soccer athletes (N = 110; range = 5-12 y) completed the VOMS at baseline. Descriptive statistics summarized demographic information, VOMS total scores, and VOMS change scores. Cronbach α assessed internal consistency for VOMS total scores and change scores.

RESULTS

Twenty-one (19.1%) participants had at least one total score above clinical cutoffs (≥2 on any VOMS component and ≥5 cm on average near point convergence). Forty (36.4%) participants had at least one change score above clinical cutoffs (≥1 on any VOMS component and ≥3 cm on average near point convergence). The internal consistency was strong for total scores with all VOMS components included (Cronbach α = .80) and change scores (Cronbach α = .89).

CONCLUSIONS

Although results suggest VOMS items measure distinct components of the vestibular and ocular motor systems, caution should be taken when interpreting VOMS total and change scores in pediatric athletes, as overreporting symptoms is common, thereby impacting the false-positive rate.

Automated Eye Tracking Enables Saccade Performance Evaluation of Patients with Concussion History

SIGNIFICANCE

Automated eye tracking could be used to evaluate saccade performance of patients with concussion history, providing quantitative insights about the degree of oculomotor impairment and potential vision rehabilitation strategies for this patient population.

PURPOSE

To evaluate the saccade performance of patients with concussion history based on automated eye-tracking test results.

METHODS

We conducted a retrospective study of patients with concussion history, primarily from sports participation, who underwent oculomotor testing based on an eye-tracking technology at the Duke Eye Center vision rehabilitation clinic between June 30, 2017, and January 10, 2022. Patients' saccade test results were reviewed, including saccade fixation and saccade speed/accuracy ratio. The outcomes were compared with age-matched normative population data derived from healthy individuals. Multiple linear regression analyses were performed to identify factors associated with saccade performance among patients with concussion history.

RESULTS

On hundred fifteen patients with concussion history were included in the study. Patients with concussion, on average, had fewer fixations on self-paced horizontal and vertical saccade tests and lower horizontal and vertical saccade speed/accuracy ratios compared with normative ranges. Among patients with concussion history, multiple linear regression analyses showed that older age was associated with fewer fixations on horizontal and vertical saccade tests, whereas male sex was associated with more fixations on horizontal and vertical saccade tests (all P < .01). In addition, older age was associated with lower horizontal saccade speed/accuracy ratio, after adjusting for sex, number of concussion(s), and time from most recent concussion to oculomotor testing ( P < .001).

CONCLUSIONS

Patients with concussion history had lower saccade performance based on eye tracking compared with healthy individuals. We additionally identified risk factors for lower saccade performance among patients with concussion history. These findings support the use of saccade test results as biomarkers for concussion and have implications for post-concussion rehabilitation strategies.

Maximizing the Accuracy of Adolescent Concussion Diagnosis Using Individual Elements of Common Standardized Clinical Assessment Tools

CONTEXT

Multiple clinical evaluation tools exist for adolescent concussion with various degrees of correlation, presenting challenges for clinicians in identifying which elements of these tools provide the greatest diagnostic utility.

OBJECTIVE

To determine the combination of elements from 4 commonly used clinical concussion batteries that maximize discrimination of adolescents with concussion from those without concussion.

DESIGN

Cross-sectional study.

SETTING

Suburban school and concussion program of a tertiary care academic center.

PATIENTS OR OTHER PARTICIPANTS

A total of 231 participants with concussion (from a suburban school and a concussion program) and 166 participants without concussion (from a suburban school) between the ages of 13 and 19 years.

MAIN OUTCOME MEASURE(S)

Individual elements of the visio-vestibular examination (VVE), Sport Concussion Assessment Tool, fifth edition (SCAT5; including the modified Balance Error Scoring System), King-Devick test (K-D), and Postconcussion Symptom Inventory (PCSI) were evaluated. The 24 subcomponents of these tests were grouped into interpretable factors using sparse principal component analysis. The 13 resultant factors were combined with demographic and clinical covariates into a logistic regression model and ranked by frequency of inclusion into the ideal model, and the predictive performance of the ideal model was compared with each of the clinical batteries using the area under the receiver operating characteristic curve (AUC).

RESULTS

A cluster of 4 factors (factor 1 [VVE saccades and vestibulo-ocular reflex], factor 2 [modified Balance Error Scoring System double-legged stance], factor 3 [SCAT5/PCSI symptom scores], and factor 4 [K-D completion time]) emerged. A model fit with the top factors performed as well as each battery in predicting concussion status (AUC = 0.816 [95% CI = 0.731, 0.889]) compared with the SCAT5 (AUC = 0.784 [95% CI = 0.692, 0.866]), PCSI (AUC = 0.776 [95% CI = 0.674, 0.863]), VVE (AUC = 0.711 [95% CI = 0.602, 0.814]), and K-D (AUC = 0.708 [95% CI = 0.590, 0.819]).

CONCLUSIONS

A multifaceted assessment for adolescents with concussion, comprising symptoms, attention, balance, and the visio-vestibular system, is critical. Current diagnostic batteries likely measure overlapping domains, and the sparse principal component analysis demonstrated strategies for streamlining comprehensive concussion assessment across a variety of settings.

Cortical and cerebellar structural correlates of cognitive-motor integration performance in females with and without persistent concussion symptoms

INTRODUCTION

Fifteen percent of individuals who sustain a concussion develop persistent concussion symptoms (PCS). Recent literature has demonstrated atrophy of the frontal, parietal, and cerebellar regions following acute concussive injury. The frontoparietal-cerebellar network is essential for the performance of visuomotor transformation tasks requiring cognitive-motor integration (CMI), important for daily function.

PURPOSE

We investigated cortical and subcortical structural differences and how these differences are associated with CMI performance in those with PCS versus healthy controls.

METHODS

Twenty-six age-matched  female participants (13 PCS, 13 healthy) completed four visuomotor tasks.  Additionally, MR-images were analyzed for cortical thickness and volume, and cerebellar lobule volume.

RESULTS

No statistically significant group differences were found in CMI performance. However, those with PCS demonstrated a significantly thicker and larger precuneus, and significantly smaller cerebellar lobules (VIIIa, VIIIb, X) compared to controls. When groups were combined, volumes of both the cerebellar lobules and cortical regions were associated with CMI task performance.

CONCLUSION

The lack of behavioral differences combined with the structural differences may reflect a compensatory mechanism for those with PCS. In addition, this study highlights the effectiveness of CMI tasks in estimating the structural integrity of the frontoparietal-cerebellar network and is among the first to demonstrate structural correlates of PCS.

Combined Neurocognitive and Exercise Tolerance Testing Improves Objectivity of Buffalo Concussion Treadmill Test

CONTEXT

The Buffalo Concussion Treadmill Test (BCTT) is a standard assessment of exercise tolerance utilized for exercise prescription following concussion and to inform decisions regarding return to play. One limitation of the BCTT is that interpretation of test results is dependent on individuals' self-report of symptom exacerbation with exertion. Symptoms following concussion are significantly underreported or unreported. Combining objective neurocognitive assessment with exercise tolerance testing may enable clinicians to objectively identify those requiring further assessment or rehabilitation before return to play. The purpose of this study was to investigate how performance on a neurocognitive assessment battery is affected by provocative exercise testing.

DESIGN

Prospective cohort study, pretest/posttest.

METHODS

A total of 30 participants included 13 women (43.3%), age 23.4 (1.93) years, height 173.56 (10) cm, weight 77.35 (16.3) kg, and 11 (36.7%) with history of concussion. All participants completed a neurocognitive assessment battery, including the Stroop Test and standardized assessments of working memory, attention, and information processing speed/accuracy in single-task (seated position) and dual-task conditions (walking on a treadmill at 2.0 miles per hour). The neurocognitive assessment battery was performed at baseline and after the standard BCTT test protocol.

RESULTS

BCTT: Average percentage of heart rate maximum (%HRmax) = 93.97% (4.8%); average maximum rating of perceived exertion = 18.6 (1.5). Time-based performance in single-task and dual-task conditions significantly improved from baseline (P < .05) following maximal exercise testing on the BCTT for the following neurocognitive assessments: concentration-reverse digits, Stroop congruent, and Stroop incongruent.

CONCLUSIONS

Healthy participants demonstrated improvements across multiple domains of neurocognitive performance following the exercise tolerance testing on the BCTT. Understanding normal responses in neurocognitive performance for healthy individuals following exercise tolerance testing may allow clinicians to more objectively monitor the trajectory of recovery following sports-related concussion.

Adults are not older adolescents: comparing physical therapy findings among adolescents, young adults and older adults with persistent post-concussive symptoms

OBJECTIVE

Individuals with persistent post-concussive symptoms (PPCS) may present with a myriad of physical symptoms. There is limited research available comparing the presence of examination findings among individuals with PPCS from different age groups.

METHODS

Retrospective case-control chart review of 481 patients with PPCS and 271 non-trauma controls. Physical assessments were categorized as ocular, cervical, and vestibular/balance. Differences in presentation were compared between PPCS and controls as well as between individuals with PPCS in three age groups: adolescents, young adults, and older adults.

RESULTS

All three PPCS groups had more abnormal oculomotor findings than their age-matched counterparts. When comparing PPCS patients from different age groups, no differences were seen in prevalence of abnormal smooth pursuits or saccades; however, adolescents with PPCS had more abnormal cervical findings and a lower prevalence of abnormal NPC, vestibular and balance findings.

CONCLUSION

Patients with PPCS presented with a different constellation of clinical findings based on their age. Adolescents were more likely to demonstrate evidence of cervical injury compared to younger and older adults, and adults were more likely to present with vestibular findings and impaired NPC. Adults with PPCS were more likely to present with abnormal oculomotor findings compared to adults with non-traumatic causes of dizziness.

Sports-related concussion: assessing the comprehension, collaboration, and contribution of chiropractors

Over the last 2 decades, sports-related concussion (SRC) awareness and management have evolved from an emphasis on complete cognitive and physical rest to evidence-based protocols and interventions. Chiropractors are primary care providers with exposure to athletes and teams in collision sports and, in addition, manage patients with concussion-like symptoms including neck pain, dizziness, and headache. With SRC frequently occurring in the absence of a medical practitioner, the role of allied health practitioners like chiropractors should be emphasised when it comes to the recognition, assessment, and management of SRC. This commentary discusses the potential contribution of chiropractors in SRC and the specific role their expertise in the cervical spine may play in symptom evaluation and management. A PubMed and Google scholar review of the chiropractic SRC literature suggests that the chiropractic profession appears under-represented in concussion research in athletic populations compared to other medical and allied health fields. This includes an absence of chiropractic clinicians with a focus on SRC participating in the Concussion in Sport Group (CISG) and the International Consensus Conferences on Concussion. Furthermore, with evolving evidence suggesting the importance of cervicogenic manifestations in SRC, there is an opportunity for chiropractors to participate in SRC diagnosis and management more fully and contribute scientifically to an area of specialised knowledge and training. With a dearth of chiropractic orientated SRC science, clinical SRC expertise, and clinical chiropractic representation in the CISG; it is incumbent on chiropractic clinicians and scientists to take up this opportunity through meaningful contribution and involvement in the SRC field.

Symptom Provocation Following Post-concussion Computerized Neurocognitive Testing and Its Relationship to Other Clinical Measures of Concussion

OBJECTIVE

The objective of this study was to document the prevalence of post-computerized neurocognitive test (post-CNT) increases in symptoms in athletes with sport-related concussion, and to examine the effect of post-CNT symptom increases on concussion neurocognitive and vestibular/ocular motor clinical outcomes.

METHODS

This was a retrospective analysis of medical records from a concussion specialty clinic. Two hundred and three athletes (M = 16.48 ± 1.97 years; 44% [90/203] female) completed a clinical visit for concussion within 30 days of injury (M = 7.73 ± 5.54 days). Computerized neurocognitive testing (the Immediate Post-concussion Assessment and Cognitive Testing: ImPACT), the Post-Concussion Symptom Scale (PCSS), and the Vestibular Ocular Motor Screening (VOMS) were the main outcome measures for the current study.

RESULTS

Sixty-nine percent (141/203) of the sample did not report significant increases in PCSS scores following post-concussion CNT and were classified into a No Provocation (NO PROV) group. Thirty-one percent (62/203) of participants did report a significant increase in symptoms following post-concussion CNT and were classified into a Provocation (PROV) group. Neurocognitive performance was similar between groups. However, the PROV group reported significantly higher scores on the VOMS symptom items than the NO PROV group.

CONCLUSIONS

The majority of adolescent athletes can complete a post-concussion CNT without experiencing significant increases in concussion symptoms. Individuals that report symptom increases from completing a post-concussion CNT are more likely to exhibit increased vestibular/ocular motor symptoms. These findings underscore the relationship between the clinical findings from both CNT and vestibular/ocular motor measures following concussion.

Optimizing VOMS for identifying acute concussion in collegiate athletes: Findings from the NCAA-DoD CARE consortium

The Vestibular/Ocular-Motor Screening (VOMS), an important component in acute (<72 h) sport-related concussion (SRC) assessment, is increasingly used alongside the Sport Concussion Assessment Tool (SCAT) and as part of the Military Acute Concussion Evaluation 2 (MACE2). VOMS demonstrates clinically useful diagnostic accuracy for acute SRC and improves the overall utility when added to the SCAT3. However, potential overlap among VOMS's vestibular and oculomotor items suggests the possibility of a more efficient version. VOMS and SCAT3 scores were analyzed for 3,958 preseason (47.8% female) and 496 acute-SRC (37.5% female) NCAA-DoD Concussion Assessment, Research, and Education (CARE) consortium collegiate athlete evaluations. Analyses revealed very large effect sizes (d = 2.39-2.45) and high correlations (rho = 0.95-0.99) among all VOMS items except near point of convergence distance (d = 0.79, rho ≤ 0.341). Receiver operating characteristic (ROC) curve analyses showed clinically useful discriminative utility for VOMS Total (AUC = 0.85) and the VOMS Total change score, where pretest symptoms were incorporated (AUC = 0.81). A modified VOMS (mVOMS) consisting of four items (smooth pursuits, horizontal saccades, horizontal vestibulo-ocular reflex, visual motion sensitivity) yielded identical AUCs to VOMS Total. Integer cutoff analyses suggest a score of ≥4 for VOMS Total and ≥4 for mVOMS Total optimizes concussion identification. Incorporating VOMS or mVOMS into SCAT3 (AUC = 0.79) significantly improved the combined tool's acute utility for acute concussion identification by a maximum of 4% (SCAT3+VOMS AUC = 0.84, SCAT3+mVOMS AUC = 0.83). Future versions of SCAT or MACE may want to consider incorporating a more parsimonious VOMS for the purpose of identifying acute concussion.

Exploring Vestibular Ocular Motor Screening in Adults With Persistent Complaints After Mild Traumatic Brain Injury

OBJECTIVE

The purpose of this study was to (1) explore differences in vestibular ocular motor screening (VOMS) symptoms between healthy adults and adults with persistent symptoms after mild traumatic brain injury (mTBI), and (2) explore the relationships between VOMS symptoms and other measures (self-reported vestibular symptoms, clinical measures of balance and gait, and higher-level motor ability tasks).

SETTING

Research laboratory setting.

PARTICIPANTS

Fifty-three persons with persistent symptoms (>3 weeks) following mTBI and 57 healthy controls were recruited. Eligibility for participation included being 18 to 50 years of age and free of medical conditions that may affect balance, with the exception of recent mTBI for the mTBI group.

DESIGN

Cross-sectional.

MAIN MEASURES

The primary outcomes were the VOMS symptom scores and near point of convergence (NPC) distance. Secondary outcomes included the Dizziness Handicap Inventory (DHI) total and subdomain scores, sway area, Functional Gait Analysis total score, gait speed, and modified Illinois Agility Task completion time, and Revised High-Level Mobility Assessment Tool total score.

RESULTS

The mTBI group reported more VOMS symptoms ( z range, -7.28 to -7.89) and a further NPC ( t = -4.16) than healthy controls (all P s < .001). DHI self-reported symptoms (total and all subdomain scores) were strongly associated with the VOMS symptom scores (rho range, 0.53-0.68; all P s < .001). No significant relationships existed between VOMS symptoms and other measures.

CONCLUSION

Significant group differences support the relevance of the VOMS for mTBI in an age-diverse sample with persistent symptoms. Furthermore, strong association with DHI symptoms supports the ability of the VOMS to capture vestibular complaints in this population.

The University of Kansas Health System Outpatient Clinical Concussion Comprehensive Protocol: An Interdisciplinary Approach

Objective:

The concussion team at The University of Kansas Health System outpatient rehabilitation spine center is comprised of experienced multi-disciplinary experts including physical therapists and a speech language pathologist. The team set forth with a purpose of creating and organizing an internal physical therapy clinical recommendation protocol for initial evaluations and subsequent treatments for the concussed patient. The aim of this paper is to share these recommendation protocols with other therapy teams and provide a foundational layout for treating the patient with post-concussion symptoms in an outpatient physical therapy clinical setting.

Study design:

Clinical recommendation protocol provides guidance for patients ages 10+ from initial evaluation through discharge with emphasis on evidence-based research in the areas of: oculomotor, cervical, vestibular, post-concussion migraine influence, mood disorders(such as anxiety and depression), exertion, and cognitive communicative dysfunction.

Results:

Finding a written, comprehensive clinical resource protocol for post-concussion outpatient evaluation(s) and treatment strategies can be difficult. This document serves as a resource for other outpatient concussion rehabilitation clinics, providing rationale, and objective measurement tools, for assessing and treating concussion patients. To the authors’ knowledge, no other research has produced a practical, efficient evaluation tool to be utilized at bed side, condensing evidence-based research into an easy-to-use form.

Conclusion:

The University of Kansas Health System outpatient concussion rehabilitation center developed clinical recommendation protocols for concussion care. The intent was to standardize assessment and treatment for concussion patients and to share these objective measurement tools and procedures, focused on a team approach of concussion providers, as a clinical outline for both the novice and seasoned clinician specializing in the field of concussion work in an outpatient rehabilitation setting.

An assessment of current concussion identification and diagnosis methods in sports settings: a systematic review

BACKGROUND

Concussion in sport is an ongoing global concern. The head injury assessment (HIA) by the field of play is acknowledged as the first step in recognising and identifying concussion. While previous systematic literature reviews have evaluated the sensitivity of side-line screening tools and assessment protocols, no systematic review has evaluated the research designs and assessments used in a field setting. This systematic review investigated existing screening and diagnostic tools used in research as part of the HIA protocol to identify concussion that are currently used in professional, semi-professional and amateur (club) sports settings.

METHODS

A systematic searching of relevant databases was undertaken for peer-reviewed literature between 2015 and 2020.

RESULTS

Twenty-six studies met the inclusion criteria. Studies were of moderate to good quality, reporting a variety of designs. The majority of studies were undertaken in professional/elite environments with medical doctors and allied health practitioners (e.g., physical therapists) involved in 88% of concussion assessments. While gender was reported in 24 of the 26 studies, the majority of participants were male (77%). There was also a variety of concussion assessments (n = 20) with the sports concussion assessment tool (SCAT) used in less than half of the included studies.

CONCLUSION

The majority of studies investigating concussion HIAs are focused on professional/elite sport. With concussion an issue at all levels of sport, future research should be directed at non-elite sport. Further, for research purposes, the SCAT assessment should also be used more widely to allow for consistency across studies.

Visio-Vestibular Deficits in Healthy Child and Adolescent Athletes

OBJECTIVE

To determine the relationship between patient characteristics and performance on the visio-vestibular examination (VVE) in a cohort of healthy youth athletes and explore the potential association between the VVE and other standardized concussion batteries.

DESIGN

Cross-sectional.

SETTING

Suburban middle and high school.

PATIENTS

One hundred ninety subjects age 11 to 18 enrolled before their respective scholastic sport season between August 2017 and March 2020.

ASSESSMENT OF INDEPENDENT VARIABLES

Patient age, sex, concussion history, comorbidities, hours of weekly exercise, Sport Concussion Assessment Tool, 5th edition (SCAT-5), King-Devick (K-D), Postconcussion Symptom Inventory (PCSI).

MAIN OUTCOME MEASURES

Visio-vestibular examination abnormalities (smooth pursuit, horizontal and vertical saccades, horizontal and vertical gaze stability, convergence, right and left monocular accommodation, complex tandem gait).

RESULTS

Overall, 29.5% of subjects had at least one of 9 VVE elements abnormal, 7.9% at least 2, and 3.2% at least 3. None of 72 comparisons of the VVE elements, when stratified by age, sex, concussion history, history of headaches, attention deficit hyperactivity disorder, learning issues, psychiatric problems, motion sickness, or weekly hours of exercise, reached significance using the Benjamini-Hochberg procedure at a false discovery rate of 5%. There were no significant associations between VVE elements and the SCAT-5, K-D, or PCSI.

CONCLUSIONS

The VVE is robust across multiple patient characteristics. Although healthy subjects may have one abnormal element, multiple abnormal elements are a less common feature, making multiple abnormal elements more indicative of concussion, highlighting the use of this assessment in the setting of injury. The VVE tests unique domains when compared with the PCSI, SCAT-5, and K-D.

Do Sideline Tests of Vestibular and Oculomotor Function Accurately Diagnose Sports-Related Concussion in Adults? A Systematic Review and Meta-analysis

BACKGROUND

Sports-related concussion (SRC) assessment tools are primarily based on subjective assessments of somatic, cognitive, and psychosocial/emotional symptoms. SRC symptoms remain underreported, and objective measures of SRC impairments would be valuable to assist diagnosis. Measurable impairments to vestibular and oculomotor processing have been shown to occur after SRC and may provide valid objective assessments.

PURPOSE

Determine the diagnostic accuracy of sideline tests of vestibular and oculomotor dysfunction to identify SRC in adults.

STUDY DESIGN

Systematic review; Level of evidence, 4.

METHODS

Electronic databases and gray literature were searched from inception until February 12, 2020. Physically active individuals (>16 years of age) who participated in sports were included. The reference standard for SRC was a combination of clinical signs and symptoms (eg, the Sport Concussion Assessment Tool [SCAT]), and index tests included any oculomotor assessment tool. The QUADAS tool was used to assess risk of bias, with the credibility of the evidence being rated according to GRADE.

RESULTS

A total of 8 studies were included in this review. All included studies used the King-Devick test, with no other measures being identified. Meta-analysis was performed on 4 studies with a summary sensitivity and specificity of 0.77 and 0.82, respectively. The overall credibility of the evidence was rated as very low.

CONCLUSION

Caution must be taken when interpreting these results given the very low credibility of the evidence, and the true summary sensitivity and specificity may substantially differ from the values calculated within this systematic review. Therefore, we recommend that clinicians using the King-Devick test to diagnose SRC in adults do so in conjunction with other tools such as the SCAT.

PROSPERO REGISTRATION

CRD42018106632.

Association Between Fear of Pain and Sports-Related Concussion Recovery in a Pediatric Population

OBJECTIVE

To determine whether an association exists between fear of pain and recovery time from sports-related concussion in a pediatric population.

DESIGN

Prospective observational study.

SETTING

Primary outpatient sports medicine clinic of a large pediatric hospital.

PATIENTS

One hundred twenty-eight pediatric patients aged 8 to 18 years who presented to clinic with a primary diagnosis of concussion from September 2018 to March 2020. Inclusion criteria included presentation within 2 weeks of injury and symptomatic on initial visit. Patients who sustained a concussion because of motor vehicle collisions or assault were excluded.

INDEPENDENT VARIABLES

There was no intervention. Study participants who met inclusion criteria were administered the Fear of Pain Questionnaire (FOPQ) at their initial visit.

MAIN OUTCOME MEASURES

Time to clinical recovery was the main outcome measure and was determined by the fellowship-trained sports medicine physician based on resolution of concussion symptoms, resumption of normal physical and cognitive daily activities, no use of accommodations or medications, and normalization of physical exam.

RESULTS

There was a significant difference in FOPQ scores for those with prolonged recovery (M = 33.12, SD = 18.36) compared with those recovering in fewer than 28 days (M = 26.16, SD = 18.44; t [126] = -2.18, P = 0.036).

CONCLUSIONS

Consistent with the adult literature, we found that pediatric patients are more likely to have a prolonged recovery from concussion when they have higher fear of pain.

Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management – A review

BACKGROUND: Individuals who have suffered a concussion/mild traumatic brain injury (mTBI) frequently report symptoms associated with vestibular and/or oculomotor dysfunction (VOD) like dizziness, nausea, fatigue, brain fog, headache, gait and neurocognitive impairments which are associated with the development of chronic symptoms. The Vestibular/Ocular Motor Screening (VOMS) tool has been established as a reliable and clinically relevant complement to use alongside a battery of post-concussion tests to improve screening and referral for further evaluation and treatment of VOD. OBJECTIVES: This paper will review the pathoanatomy and symptomatology of common vestibular and oculomotor disorders after concussion, as well as the utility of the VOMS to assist in diagnosis, referral, and management. METHODS: Primary articles were identified using a search via PubMed, Google Scholar, OneSearch, and CINAHL. Search key terms were combinations of “mild traumatic brain injury” or “concussion” or “pursuit” or “accommodation” or “vergence” or “convergence insufficiency” or “saccades” or “vestibulo-ocular reflex” or “vestibular ocular motor screen” or “vestibular rehabilitation”, or “vision rehabilitation” including adult and pediatric populations that were published in print or electronically from 1989 to 2021 in English. Classic papers on anatomy of eye movements, vestibular system and pathological changes in mTBI were also included, regardless of publication date. RESULTS: Objective impairments are commonly found during testing of smooth pursuit, saccades, vergence, accommodation, vestibular ocular reflex, and visual motion sensitivity after mTBI. These deficits can be actively treated with vestibular physical therapy and oculomotor/neuro-optometric vision therapy. VOMS is an efficient and reliable tool that can be used by all healthcare and rehabilitation providers to aid in diagnosis of post-concussion VOD, to help facilitate the decision to refer for further evaluation and treatment to expedite symptomatic post-concussion recovery. CONCLUSIONS: VOD is common after concussion in acute, post-acute, and chronic phases. Once areas of impairments are identified through proper assessment, clinicians can maximize recovery by referring to vestibular physical therapy and/or neuro-optometry to design a targeted treatment program to address individual deficits.

Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

BACKGROUND

The Vestibular/Ocular-Motor Screening (VOMS) is a valuable component of acute (<72 hours) sports-related concussion (SRC) assessments and is increasingly used with the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) instrument and the third edition of the Sport Concussion Assessment Tool (SCAT3). Research has suggested that VOMS acute postinjury scores are useful in identifying acute concussion. However, the utility of preseason baseline measurements to improve diagnostic accuracy remains ambiguous. To this end, there is a need to determine how reliable VOMS baseline assessments are across years and whether incorporating individuals' baseline performance improves diagnostic yield for acute concussions.

PURPOSE

To analyze VOMS, SCAT3, and ImPACT to evaluate the test-retest reliability of consecutive-year preseason baseline assessments to directly compare the diagnostic utility of these tools when incorporating baseline assessments versus using postinjury data alone to identify acute SRC.

STUDY DESIGN

Cohort study (diagnosis); Level of evidence, 2.

METHODS

Preseason and postinjury VOMS, SCAT3, ImPACT Post-Concussion Symptom Scale (PCSS), and ImPACT composite scores were analyzed for 3958 preseason (47.7% female) and 496 acute (≤48 hours) SRC (37.5% female) collegiate athlete evaluations in the National Collegiate Athletic Association-Department of Defense Concussion Assessment Research and Education Consortium. Descriptive statistics, Kolmogorov-Smirnov significance, and Cohen d effect size were calculated. Consecutive-year baseline reliability was evaluated for a subset of 447 athlete encounters using Pearson r, Cohen κ, Cohen d, and 2-way mixed intraclass correlation coefficients (ICCs). Wilcoxon signed rank tests were used to determine the statistical significance between population performances, and the 90% reliable change index (RCI) was calculated from the test-retest results. Preseason to postinjury change scores were then calculated from each tool's RCI. Finally, receiver operating characteristic (ROC) curve analyses were conducted, and DeLong method was used to compare the area under the curve (AUC) of raw postinjury scores versus change scores from preseason baseline assessments. Potential effects of sex, medical history (learning disorders or attention-deficit/hyperactivity disorder), and outlier data were also explored.

RESULTS

Effect sizes were large, and overall predictive utilities were clinically useful for postinjury VOMS Total (d = 2.44; AUC = 0.85), the SCAT3 Symptom Evaluation total severity score (d = 1.74; AUC = 0.82), and the ImPACT PCSS total severity score (d = 1.67; AUC = 0.80). Comparatively, effect sizes were small and predictive utilities were poor for Standardized Assessment of Concussion (SAC), modified Balance Error Scoring System (mBESS), and all ImPACT composites (d = 0.11-0.46; AUC = 0.48-0.59). Preseason baseline test-retest reliability was poor to moderate (r = 0.23-0.52; κ = 0.32-0.36; ICC = 0.36-0.68) for all assessments except ImPACT Visual Motion Sensitivity (r = 0.73; ICC = 0.85). Incorporating baseline scores for VOMS Total, SCAT3 (Symptom Evaluation, SAC, mBESS), ImPACT PCSS, or ImPACT composites did not significantly improve AUCs.

CONCLUSION

VOMS Total and symptom severity (SCAT3, PCSS) total scores had large effect sizes and clinically useful AUCs for identifying acute concussion. However, all tools demonstrated high within-patient test-retest variability, resulting in poor reliability. The findings in this sample of collegiate athletes suggest that incorporating baseline assessments does not significantly increase diagnostic yield for acute concussion.

Assessment of Saccades and Gaze Stability in the Diagnosis of Pediatric Concussion

OBJECTIVE

To evaluate the discriminatory ability of different repetition increments of saccades and gaze stability testing for diagnosing concussion in adolescents.

DESIGN

Cross-sectional.

SETTING

Suburban high school and academic pediatric tertiary care center.

PARTICIPANTS

Sixty-nine adolescent athletes within 28 days of a sports- or recreation-related concussion and 69 adolescent athletes without recent concussion.

ASSESSMENT OF INDEPENDENT VARIABLES

Symptom provocation with horizontal and vertical saccades and gaze stability testing performed up to 30 repetitions.

MAIN OUTCOME MEASURES

Sensitivity and specificity at 10-repetition increments (≤10, ≤20, ≤30) and area under the receiver operating characteristic curves (AUC) of a visio-vestibular examination (VVE) subscore, scored 0 to 4 based on the number of assessments with symptom provocation, at each repetition increment.

RESULTS

Sensitivity improved when increasing from ≤10 to ≤20 to ≤30 repetitions for horizontal (25% to 50% to 69%) and vertical (32% to 52% to 74%) saccades and horizontal (19% to 45% to 71%) and vertical (23% to 45% to 72%) gaze stability. Specificity was comparable at ≤10 and ≤20 repetitions, but decreased at ≤30 repetitions across assessments. For a VVE subscore (0-4) based on the number of symptomatic assessments, the discriminatory ability of the test was highest at ≤20 repetitions (AUC of 0.79) with an optimal subscore of one (sensitivity 59%, specificity 96%).

CONCLUSIONS

A VVE including a higher threshold level of repetitions for saccades and gaze stability has improved discriminatory ability for concussion, with an optimized AUC of 0.79 at ≤20 repetitions.

CLINICAL RELEVANCE

The findings in this study suggest that a higher threshold level of repetitions of 2 commonly used visio-vestibular assessments enables clinicians to more accurately diagnose youth concussion.

Cervicovestibular Rehabilitation in Adults with Mild Traumatic Brain Injury: A Randomised Clinical Trial

The objective of this study was to compare the effects of a cervicovestibular rehabilitation program combined with symptom-limited aerobic exercise (SLAE) program to a SLAE program alone in adults with persistent symptoms following mild traumatic brain injury (mTBI) on severity of symptoms and other indicators of clinical recovery. In this single-blind, parallel-group randomised clinical trial, 60 adults with persistent symptoms following mTBI were randomly assigned to: 1) a 6-week SLAE program or 2) a 6-week cervicovestibular rehabilitation program combined with SLAE program. All participants took part in 4 evaluation sessions (baseline, week 6, 12 and 26) performed by a blinded evaluator. The primary outcome was the Post-Concussion Symptoms Scale (PCSS). The secondary outcomes were Numerical Pain Rating Scale (NPRS), Neck Disability Index (NDI), Headache Disability Inventory (HDI), Dizziness Handicap Inventory (DHI), time to return to function, and physical cervical and vestibular measures. Nonparametric analysis for longitudinal data was used to evaluate the effect of interventions on outcomes. For PCSS, NPRS, NDI, HDI, DHI and return to function, there were no group-by-time interactions at any time-points follow-up (p>0.05); clinically significant time effects were however observed (p0.05). There were group-by-time interactions at weeks 6 and 12 for vestibulo-ocular reflex (p0.003) and the cranio-vertebral mobility (p0.001) measures in favor of the cervicovestibular rehabilitation group. The study indicates that a cervicovestibular rehabilitation program combined with SLAE was not superior to a SLAE program alone in term of symptoms and functional level improvement but resulted in improved physical cervical and vestibular function. Keywords: mild traumatic brain injury, rehabilitation, neck pain, dizziness, headache.

Sensorimotor system changes in adolescent rugby players post-concussion: A prospective investigation from the subacute period through to return-to-sport

BACKGROUND

The pathophysiology of concussion is complex. Altered sensorimotor function post-concussion may contribute to the wide range of symptoms and impairments reported. There is currently limited evidence documenting changes in sensorimotor function during the recovery period. The aim of this study was to investigate the effect of concussion on the sensorimotor system in adolescents post-concussion using a multifaceted approach.

STUDY DESIGN

Prospective nested case-control study.

METHODS

A total of 285 male adolescent rugby players underwent assessment of sensorimotor function during preseason. Players who sustained a concussion during the season and control players, matched for age and playing position, were assessed in the subacute period (3-5 days) and after return-to-sport (3 weeks). Tests of sensorimotor function included balance, cervical spine and vestibulo-ocular function, and measurement of the size and contraction of lumbopelvic muscles (ultrasound imaging).

RESULTS

Twenty-three players (8%) sustained a concussion. Of these, 20 players were assessed during the subacute period and 17 players following return-to-sport. The prevalence of vestibulo-ocular dysfunction increased from 38.9% to 72.2% during the subacute period and dysfunction was present in 83.3% of players after return-to-sport (p = 0.01). Changes in lumbar multifidus muscle size (p = 0.002) and thickness (p = 0.05) at the L5 vertebral level were observed. No statistically significant changes in balance, cervical spine proprioception, or contraction of lumbopelvic muscles were found (p > 0.05).

CONCLUSION

Changes in sensorimotor function were observed in the subacute period post-concussion, with some persisting after return-to-sport. Using symptom-based criteria for return-to-sport may not adequately reflect the sequelae of concussion on the sensorimotor system.

Vestibular/Ocular Motor Screening is Independently Associated With Concussion Symptom Severity in Youths

OBJECTIVE

To examine the independent contributions of the Vestibular/Ocular Motor Screening (VOMS) to concussion symptom severity in youths while controlling for computerized neurocognitive screening performance, demographics, and medical history.

STUDY DESIGN

Cross-sectional.

SETTING

Concussion specialty clinic.

PARTICIPANTS

A retrospective review of 278 concussed youths clinical charts resulted in a total of 158 participants (16.5 ± 2.8 years, 46.8% women, 4.3 ± 3.3 days post-injury) when exclusionary criteria (ie, neurological or substance use disorders, age >21, >14 days since injury, and missing/incomplete data) were applied.

INDEPENDENT VARIABLES

Vestibular/Ocular Motor Screening items and computerized neurocognitive test scores.

MAIN OUTCOME MEASURES

Standardized postconcussion symptom scale scores.

RESULTS

At the univariate level, all VOMS items were positively associated with concussion symptom severity at small to medium effect sizes (r range 0.26-0.42). Women and individuals with a concussion history and/or Attention Deficit Disorder/Attention Deficit Hyperactivity Disorder diagnosis reported higher VOMS item scores (Ps < 0.10). In a multiple hierarchical regression, the contribution of VOMS item scores was significant and explained 9.6% of the variance in concussion symptom severity after adjustment for sex, baseline VOMS symptom ratings, and ImPACT scores [F(6, 141) = 3.90, P = 0.001]. Vertical saccades (b = 2.22, P = 0.003) and vertical vestibulo-ocular reflex (VOR; b = -1.46, P = 0.004) VOMS items significantly contributed to concussion symptom severity in the multivariable model.

CONCLUSIONS

Findings from this study provide support for the independent contributions of the VOMS items, particularly vertical saccades and vertical VOR, to acute concussion symptom severity in youths. Further work is warranted for a comparison of the VOMS to the full gold standard of concussion testing (ie, clinical interview, physical examination, balance testing, and neurocognitive assessment).

Evaluating the Vestibulo-Ocular Reflex Following Traumatic Brain Injury: A Scoping Review

Purpose:To identify the tests and tools used to evaluate vestibulo-ocular reflex (VOR) function after traumatic brain injury (TBI) in all age groups and across TBI severity.Methods: An electronic search was conducted to include relevant peer-reviewed literature published up to November 2019. Studies included those done with humans, of all ages, and had assessments of oculomotor and/or vestibulo-ocular function in TBI.Results: Of the articles selected (N = 48), 50% were published in 2018/2019. A majority targeted mild TBI, with equal focus on non-computerized versus computerized measures of VOR. Computerized assessment tools used were videonystagmography, dynamic visual acuity/gaze stability, rotary chair, and caloric irrigation. Non-computerized tests included the head thrust, dynamic visual acuity, gaze stability, head shaking nystagmus, rotary chair tests and the vestibular/oculomotor screening tool. High variability in administration protocols were identified. Namely: testing environment, distances/positioning/equipment used, active/passive state, procedures, rotation frequencies, and variables observed.Conclusions: There is a rapid growth of literature incorporating VOR tests in mild TBI but moderate and severe TBI continues to be under-represented. Determining how to pair a clinical test with a computerized tool and developing standardized protocols when administering tests will help in developing an optimal battery assessing the VOR in TBI.

Influence of Sleep Dysfunction on Concussion Assessment Outcomes Among Adolescent Athletes After Concussion and Healthy Controls

BACKGROUND

Sleep dysfunction (SD) is associated with a high symptom burden and lower neurocognitive performance after concussion and on baseline testing without injury. However, few studies have compared concussed athletes and controls with and without SD on clinical outcomes.

OBJECTIVE

To evaluate differences in clinical outcomes among both concussed athletes and matched controls with and without SD.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Participants aged 12 to 20 years were recruited from a concussion clinic (n = 50 patients) and research registry/flyers (n = 50 healthy age-/sex-matched controls). Participants were categorized by self-reported SD into one of 4 groups: sport-related concussion (SRC) + SD, SRC only, SD only, and controls.

MAIN OUTCOME MEASURES

Post-Concussion Symptom Scale (PCSS), Vestibular/Oculomotor Screening (VOMS), and neurocognitive testing (Immediate Postconcussion Assessment Cognitive Test).

RESULTS

Compared with the SRC only group, the SRC + SD group performed worse on all neurocognitive domains, had a higher total symptom score, and endorsed more symptoms on most VOMS items. In addition, the SRC + SD group was at an increased likelihood of having at least 1 abnormal VOMS item compared with SRC only group. The SRC only group had neurocognitive test scores and symptom reports statistically similar to the SD only group.

CONCLUSION

Sleep dysfunction after concussion is related to worse neurocognitive performance and higher concussion symptom reporting. This study extended findings to suggest vestibular symptomology is worse among athletes with SD after injury compared to injured athletes without SD. Similar performances on concussion assessments for the SRC only and SD only groups suggest SD may appear similar to clinical presentation of concussion, even at baseline in the absence of SRC.

Potential Mechanisms of Acute Standing Balance Deficits After Concussions and Subconcussive Head Impacts: A Review

Standing balance deficits are prevalent after concussions and have also been reported after subconcussive head impacts. However, the mechanisms underlying such deficits are not fully understood. The objective of this review is to consolidate evidence linking head impact biomechanics to standing balance deficits. Mechanical energy transferred to the head during impacts may deform neural and sensory components involved in the control of standing balance. From our review of acute balance-related changes, concussions frequently resulted in increased magnitude but reduced complexity of postural sway, while subconcussive studies showed inconsistent outcomes. Although vestibular and visual symptoms are common, potential injury to these sensors and their neural pathways are often neglected in biomechanics analyses. While current evidence implies a link between tissue deformations in deep brain regions including the brainstem and common post-concussion balance-related deficits, this link has not been adequately investigated. Key limitations in current studies include inadequate balance sampling duration, varying test time points, and lack of head impact biomechanics measurements. Future investigations should also employ targeted quantitative methods to probe the sensorimotor and neural components underlying balance control. A deeper understanding of the specific injury mechanisms will inform diagnosis and management of balance deficits after concussions and subconcussive head impact exposure.

Minimum detectable change and false positive rates of the vestibular/ocular motor screening (VOMS) tool: an NCAA-DoD care consortium analysis

OBJECTIVE

To derive minimum detectable change (MDC) across individual Vestibular-Ocular Motor Screening (VOMS) items and VOMS overall score in 17-25 years old collegiate athletes and to examine false positive rates.

METHOD

Participants (n = 378) completed VOMS pre-season for two consecutive years. MDC was identified for individual VOMS symptom items and NPC distance (cm). Both total and change methods of VOMS scoring were included in analysis.

RESULTS

Regarding total scoring, MDC for ocular VOMS symptom items was 1 and MDC for vestibular VOMS symptoms items was 2. MDC for NPC was 4 cm and for VOMS overall score was 10. Regarding change scoring, MDC for each VOMS symptom item was 1, and for VOMS overall score was 8. False positives ranged from 5.3% to 15.9%.

CONCLUSIONS

This study presents MDCs for each VOMS item and overall VOMS score, using total and change scoring. These values can be considered true change outside measurement error with 95% confidence in a 17-25 year old collegiate athlete population.

Neurosensory Screening and Symptom Provocation in Pediatric Mild Traumatic Brain Injury

OBJECTIVE

To evaluate diagnostic/prognostic implications of neurosensory testing during the subacute stage in patients with pediatric mild traumatic brain injury (pmTBI).

SETTING

Recruitment from pediatric emergency department and urgent care clinics, assessment in a controlled environment.

PARTICIPANTS

In total, 146 pmTBI patients evaluated 7.4 ± 2.3 days and approximately 4 months postinjury; 104 age/sex-matched healthy controls (HCs) at equivalent time points.

DESIGN

Prospective cohort study.

MAIN MEASURES

Neurosensory examination based on sequence of 10 established tests of vestibular-ocular, oculomotor, vestibulospinal, and visual functioning.

RESULTS

The amount of symptom provocation (positive change from pretest symptomatology) was significantly increased in pmTBI relative to HCs on every subtest 1 week postinjury, as were deficits in monocular accommodative amplitude and King-Devick Test errors. However, symptom provocation did not meaningfully alter diagnostic sensitivity/specificity relative to more easily obtained pretest symptom ratings. Evidence of clinically significant symptom provocation 1 week postinjury improved sensitivity (Δ = +12.9%) of identifying patients with persistent postconcussive symptoms 4 months postinjury on an independent symptom measure.

CONCLUSIONS

The diagnostic sensitivity/specificity of neurosensory testing in acutely concussed youth may be limited at 1 week postinjury as a function of natural recovery occurring in most emergency department cohorts. Neurosensory screening may have greater utility for identifying patients who experience delayed recovery.

The development and the inter-rater agreement of a treatment protocol for vestibular/oculomotor rehabilitation in children and adolescents post-moderate-severe TBI

Introduction:There is limited evidence investigating the effect of vestibular/oculomotor rehabilitation programs in children and adolescents post moderate-severe TBI at the sub-acute stage.Objective:To describe the development of a treatment protocol for vestibular/oculomotor interventions in this population, and to assess the inter-rater agreement of this protocol as an initial step of a clinical trial.Method:The protocol was developed by 10 health professionals, address the high variability of balance performance, the high prevalence of vestibular/oculomotor abnormalities and the low prevalence of symptoms reported in this population.Results:The protocol enables the clinician to use the assessment during the treatment exercise selection. The training position was defined by the Pediatric Balance Scale. Vestibular/oculomotor exercises were selected using a quantified version of the Vestibular/Ocular Motor Screening. The exercise protocol was selected based on impairment in function or reproduction of symptoms. The protocol planning was implemented by two assessors in 27 children and adolescents post-moderate-severe TBI (median age 14.1 [6-18.4] years) in the sub-acute stage (median 40 [14-162] days since injury). Very high agreement was found (k > 0.72) in all the parameters.Conclusion: This protocol could reliably be used in a randomized control trial that assesses the effect of vestibular/oculomotor rehabilitation program in children and adolescents post moderate-severe TBI at the sub-acute stage.

Eye tracking to assess concussions: an intra-rater reliability study with healthy youth and adult athletes of selected contact and collision team sports

Eye movements that are dependent on cognition hold promise in assessing sports-related concussions but research on reliability of eye tracking measurements in athletic cohorts is very limited. This observational test-retest study aimed to establish whether eye tracking technology is a reliable tool for assessing sports-related concussions in youth and adult athletes partaking in contact and collision team sports. Forty-three youth (15.4 ± 2.2 years) and 27 adult (22.2 ± 2.9 years) Rugby Union and soccer players completed the study. Eye movements were recorded using SMIRED250mobile while participants completed a test battery twice, with a 1-week interval that included self-paced saccade (SPS), fixation stability, memory-guided sequence (MGS), smooth pursuit (SP), and antisaccades (AS) tasks. Intra-class correlation coefficient (ICC), measurement error (SEM) and smallest real difference (SRD) were calculated for 47 variables. Seventeen variables achieved an ICC > 0.50. In the adults, saccade count in SPS had good reliability (ICC = 0.86, SRD = 146.6 saccades). In the youth, the average blink duration in MGS had excellent reliability (ICC = 0.99, SRD = 59.4 ms); directional errors in AS tasks and gain of diagonal SP had good reliability (ICC = 0.78 and 0.77, SRD = 25.3 and 395.1%, respectively). Four metrics were found in this study to be reliable candidates for further biomarker validity research in contact and collision sport cohorts. Many variables failed to present a sufficient level of robustness for a practical diagnostic tool; possibly, because athletic cohorts have higher homogeneity, along with latent adverse effects of undetected concussions and repetitive head impacts. Since reliability of a measure can influence type II error, effect sizes, and confidence intervals, it is strongly advocated to conduct dedicated reliability evaluations prior to any validity studies.

Establishing Test-Retest Reliability and Reliable Change for the King-Devick Test in High School Athletes

OBJECTIVE

To establish test-retest reliability in nonconcussed high school athletes and compare absolute change, reliable change indices (RCIs), and minimal detectable change (MDC) methods for classifying impairment after sport-related concussion.

DESIGN

Prospective, repeated measures.

SETTING

High schools from the Midwest and Central regions of the United States.

PARTICIPANTS

A convenience sample of 772 nonconcussed high school athletes (n = 546 men) completed preseason K-D testing. In addition, 69 athletes completed a second postseason K-D test, and 54 athletes sustained a concussion and completed postconcussion K-D tests.

INTERVENTION

K-D test.

MAIN OUTCOME MEASURES

Data for age, sex, and concussion history were determined using preseason K-D test outcomes. Test-retest reliability, RCIs, and MDCs were calculated using postseason K-D tests (M = 98.9, SD = 9.1 days). Postinjury K-D assessments within 5 days of injury (M = 1.5, SD = 1.5 days) were used to classify impairment on K-D using absolute change, RCI, and MDC methods.

RESULTS

Significant effects for age (P < 0.001) and history of concussion (P = 0.001) were supported on baseline K-D time, with no sex differences (P = 0.21). Preseason to postseason reliability for K-D times was 0.60 (intraclass correlation coefficient, 95% CI, 0.43-0.73), although 38% of athletes exhibited slower postseason K-D times compared with baseline. Impairment on K-D exhibited for 72% of the concussed sample using absolute change, 48% using MDC, and 44% using RCI methods.

CONCLUSIONS

K-D exhibited moderate test-retest reliability across 1 season. Absolute change yielded the highest sensitivity for preinjury to postinjury impairment on the K-D compared with RCI and MDC methods.

Test Order Does Not Affect Vestibular/Ocular Motor Screening Item Scores in High School Athletes

OBJECTIVE

To compare VOMS item scores between a fixed and randomized administration order in a sample of nonconcussed high school athletes.

DESIGN

Post-test only, quasi-experimental design.

SETTING

Local high schools in a mid-west region of the United States.

PATIENTS

Fifty nonconcussed high school athletes (M = 15.64; SD = 1.12 years) completed the VOMS in a randomized testing order (RANDOM), and 49 (M = 15.64; SD = 1.12 years) completed the VOMS in the fixed testing order (FIXED). The groups were matched on age, sex, learning disorder, attention-deficit/hyperactivity disorder, concussion history, and baseline concussion symptoms.

INTERVENTIONS

The Vestibular/Ocular Motor Screening (VOMS) tool comprises pretest symptoms, smooth pursuit (SP), horizontal/vertical saccade (HSAC/VSAC), average near-point of convergence (NPC) distance, convergence symptoms, horizontal/vertical vestibular ocular reflex (HVOR/VVOR), and visual motion sensitivity (VMS).

MAIN OUTCOME MEASURES

Mann-Whitney U tests were performed to examine differences between FIXED and RANDOM groups on VOMS items. RANDOM scores were rearranged in order of administration and combined with the FIXED group scores, and a Freidman test was performed for repeated measures.

RESULTS

There were no significant differences between FIXED and RANDOM groups on VOMS pretest symptoms (U = 1171, P = 0.57), SP (U = 1122.5, P = 0.35), HSAC (U = 1128.5, P = 0.44), VSAC (U = 1055.5, P = 0.16), convergence symptoms (U = 1129.0, P = 0.41), average NPC distance (U = 979.0, P = 0.06), HVOR (U = 1085.0, P = 0.25), VVOR (U = 1126.0, P = 0.41), and VMS scores (U = 1101.0, P = 0.32). When VOMS items were rearranged and the sample was combined, there were no differences for repeated measures [χ2 (6) = 9.92, P = 0.13].

CONCLUSIONS

There were no significant differences on VOMS items between FIXED and RANDOM groups for repeated measures. The testing order of VOMS items does not affect VOMS scores in nonconcussed high school athletes.

Does Exercise Increase Vestibular and Ocular Motor Symptom Detection After Sport-Related Concussion?

BACKGROUND AND PURPOSE

Postconcussive vestibular and ocular motor symptoms are common and contribute to longer recovery. The Vestibular/Ocular Motor Screening (VOMS) is used to detect such symptoms, but a VOMS performed at rest may miss symptoms that are only provoked by exertion. Supervised exercise challenges (SECs) have been shown to detect concussion-related symptoms provoked by physical exertion. The purpose of this study was to determine whether athletes undergoing an SEC will exhibit greater symptom provocation with the VOMS compared to a VOMS performed at rest prior to an SEC.

METHODS

Thirty-six athletes (58.3% male) between ages 10 and 18 years and within 30 days of concussion were included. All participants completed VOMS assessments at rest and immediately after an SEC. VOMS total symptom score increases were calculated for both pre- and post-SEC assessments compared using Wilcoxon ranked sum tests. The frequencies of positive assessments for each VOMS item were compared using McNemar's test.

RESULTS

There were significant increases in post-SEC symptom provocation scores compared with pre-SEC scores for all VOMS items. The post-SEC VOMS identified 29 participants (80.6%) as positive in at least 1 VOMS item compared with 21 participants (58.3%) identified as positive pre-SEC (P = 0.008). For all VOMS items, the post-SEC VOMS identified participants who were previously negative on a pre-SEC VOMS but became positive after the SEC.

DISCUSSION AND CONCLUSIONS

An SEC performed prior to a VOMS assessment may increase the detection of vestibular and ocular motor symptoms that may be missed if the VOMS was performed only at rest.Video Abstract available for more insight from the authors (see the Video Supplemental Digital Content 1, available at: http://links.lww.com/JNPT/A342).

Preseason Vestibular Ocular Motor Screening in Children and Adolescents

OBJECTIVES

The primary purpose of this study was to examine vestibular/ocular motor screening (VOMS) test performance in a sample of healthy youth ice hockey players. A particular focus was to investigate the potential effects of age and pre-existing health conditions, including concussion history, attention-deficit/hyperactivity disorder (ADHD), learning disability (LD), headaches/migraines, and depression/anxiety on preseason baseline VOMS performance, including the near point of convergence (NPC) distance.

DESIGN

Cross-sectional cohort.

SETTING

Outpatient physiotherapy clinic.

PARTICIPANTS

Three hundred eighty-seven male youth hockey players, with an average age of 11.9 years (SD = 2.2, range = 8-17), completed the VOMS and responded to self- or parent-reported demographic and medical history questionnaires during preseason baseline assessments.

INDEPENDENT VARIABLES ASSESSED

Age, sex, and mental and physical health history including ADHD, headaches, depression, anxiety, migraine, and LD.

OUTCOME MEASURE

Vestibular/ocular motor screening.

RESULTS

The large majority of boys scored within normal limits on the VOMS, ie, they reported no symptom provocation of more than 2 points on any VOMS subset (89%) and had a normal NPC distance, ie, <5 cm (78%). The individual VOMS subtests had low abnormality rates, and demographic and pre-existing health conditions, such as age, headache or migraine history, previous neurodevelopmental conditions, or mental health problems, were not associated with clinically meaningful symptom provocation during the VOMS.

CONCLUSIONS

There was a low rate of abnormal findings for the individual VOMS subtests, with the exception of NPC distance, among male youth hockey players during preseason assessment.

The Current Status of Concussion Assessment Scales: A Critical Analysis Review

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Concussion is a complex pathophysiologic process that affects the brain; it is induced by biomechanical forces, with alteration in mental status with or without loss of consciousness.

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Concussion assessment tools may be broadly categorized into (1) screening tests such as the SAC (Standardized Assessment of Concussion), the BESS (Balance Error Scoring System), and the King-Devick (KD) test; (2) confirmatory tests including the SCAT (Sport Concussion Assessment Tool), the ImPACT (Immediate Post-Concussion Assessment and Cognitive Testing), and the VOMS (Vestibular Oculomotor Screening); and (3) objective examinations such as brain network activation (BNA) analysis, imaging studies, and physiologic markers.

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The KD, child SCAT3 (cSCAT3), child ImPACT (cImPACT), and VOMS tests may be used to evaluate for concussion in the pediatric athlete.

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Future work with BNA, functional magnetic resonance imaging, diffusion tensor imaging, and serum biomarkers may provide more objective assessment of concussion, neurologic injury, and subsequent recovery.

OculoMotor Assessment Tool Test Procedure and Normative Data

SIGNIFICANCE

This study establishes normative data and a testing procedure for the oculomotor assessment tool. The oculomotor assessment tool standardizes visual targets for the Vestibular/OculoMotor Screening assessment and provides additional metrics that may aid in the differentiation between those with normal and those with abnormal oculomotor function potentially caused by a concussion.

PURPOSE

This study aimed to assess the oculomotor endurance of healthy participants with no self-reported history of concussions using the oculomotor assessment tool.

METHODS

Healthy participants (n = 376, average age of 20.4 years, range of 11 to 34 years, with no self-reported history of concussions) were recruited to perform the following three tasks for 60 seconds each: (1) horizontal saccades, (2) vertical saccades, and (3) vergence jumps. The participants were instructed to alternate visual fixation between two targets for each of the tasks as fast as they could without overshooting or undershooting the visual target. The differences in the number of eye movements between the initial and latter 30 seconds of the 1-minute test were analyzed.

RESULTS

A statistical difference (P < .001) was observed in the number of eye movements for all three tasks (horizontal saccades [70 ± 15 for initial 30 seconds, 63 ± 13 for latter 30 seconds], vertical saccades [68 ± 14, 63 ± 13], and vergence jumps [43 ± 11, 39 ± 10]) between the initial and latter 30 seconds. No significant differences were identified in the number of eye movements or the change in eye movements between the initial and latter 30 seconds based on sex.

CONCLUSIONS

These results establish a normative database for various eye movements. These data could potentially be used to compare different patient populations who have binocular endurance dysfunctions potentially due to traumatic brain injury, such as patients with concussion(s).

Does Vestibular-Ocular-Motor (VOM) Impairment Affect Time to Return to Play, Symptom Severity, Neurocognition and Academic Ability in Student-Athletes following acute Concussion?

Introduction: Research indicates Sports-Related Concussion (SRC) impairs Vestibular-Ocular-Motor (VOM) function. The aim was to explore if VOM impairment correlates with longer Return To Play (RTP), symptom burden, neurocognitive performance and academic capability.Participants: 40 (61.4% male) Loughborough University, UK, rugby union student-athletes who sustained 42 SRCs.Methods: Student-athletes completed an assessment battery during pre-season (baseline), 2, 4, 8 and 14 days post-SRC and prior to RTP and were managed according to the rugby Football Union' community pathway.Outcome measures: Vestibular Ocular-Motor Screening (VOMS), Immediate Post-Concussion Assessment and Cognitive Test, Post-Concussion Symptom Scale, Perceived Academic Impairment Tool questionnaire and percentage of academic activities specifically missed due to SRC.Results: VOMS scores were significantly (p < 0.005) greater than baseline at all time points except RTP. Presence of VOM dysfunction at 14 days post-SRC significantly correlated with a longer RTP, greater symptom burden and increased odds ratio at 2, 4 and 8 days and academic time loss at 2, 4 and 8 days post-SRC.Conclusion: VOM impairment is associated with an increased symptom burden and impaired academic capability, and a longer time to RTP when present at 14 days post-SRC.

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.

Is near point of convergence associated with symptom profiles or recovery in adolescents after concussion?

Our purpose was to compare the clinical and injury characteristics of concussion patients with a receded near point of convergence (NPC) vs those without a receded NPC. Concussion patients were seen within 14 days of injury. We compared those with receded a NPC (>6 cm) break point distance and those with a normal NPC distance on symptom, behavioral, and clinical assessments. We also compared NPC break points between those who did/did not recover within 28 days of injury. 123 patients completed the assessment. 77/123 (63%) of participants demonstrated a receded NPC when tested within 14 days of injury. Those with receded a NPC break point (n = 77; mean = 14.9, SD = 1.5 years; 47% female) were significantly younger than those with a normal NPC break point (n = 46; mean = 15.7, SD = 1.7 years; 46% female). The receded NPC break point group had a significantly greater proportion of patients reporting headaches (86% vs. 61%), as well as significantly greater cognitive (mean = 13.4, SD = 8.7 vs. mean = 8.8, SD = 8.6), somatic (mean = 10.0, SD = 5.9 vs. mean = 6.9, SD = 6.6), and overall (mean = 23.7, SD = 13.6 vs. mean = 15.8, SD = 14.4) symptom severity. Our multivariable model indicated among all potential predictor variables, more severe somatic symptoms were significantly associated with a greater NPC break point (β = 0.26; 95% CI = 0.01, 0.52). The group who went onto experience persistent symptoms had a significantly greater NPC break point at initial evaluation than those without persistent symptoms (mean = 9.7, SD = 7.5 cm vs. mean = 7.0, SD = 4.0 cm). Those with a receded NPC break point at initial evaluation showed an increased symptom burden, most notable with somatic symptoms, compared with those without a receded NPC break point.