Vestibular/Oculomotor Motor Screening (VOMS) Assessment

Original Editor - Megyn Robertson

Top Contributors - Simisola Ajeyalemi, Rachael Lowe, Mandy Roscher, Megyn Robertson and Samuel Adedigba  

Introduction

Impairments in the vestibulo-ocular system commonly manifest as symptoms of dizziness and visual instability. Nearly 30% of concussed athletes report visual problems during the first week after the injury.[1] Oculomotor impairments and symptoms may manifest as blurred vision, diplopia, impaired eye movements, difficulty in reading, dizziness, headaches, ocular pain, and poor visual-based concentration.[2] Dizziness, which may represent an underlying impairment of the vestibular and/or oculomotor systems, is reported by 50% of concussed athletes[1] and is associated with a 6.4-times greater risk, relative to any other on-field symptom, in predicting protracted (>21 days) recovery.[3]

Concussions can directly impair oculomotor function. Ocular issues (poor eye tracking) after concussion are common. Specifically cranial nerves (CN) III, IV and VI which innervate the eye muscles are susceptible to injury anywhere along the route from brainstem to eye muscles, so this needs to be assessed.

Objective

The Vestibular/Ocular Motor Screening (VOMS) Assessment is used as a brief 5-10 minute concussion screening tool. It has been proposed that it may serve as a single component of a comprehensive approach to the assessment of concussions[4].  

Intended population

The test is designed for use with subjects ages 9-40, when used with patients outside this age range, interpretation may vary. 

Method of Use

For this test you will need: a tape measure (cm), target with a 14 point font print and a metronome.

The test assesses vestibular and ocular motor impairments via patient-reported symptom provocation after each assessment[4].  The assessment includes a baseline measurement and 5 domains which are recorded in the table provided (see below). Patients verbally rate changes in headache, dizziness, nausea, and fogginess symptoms compared with their immediate pre-assessment state on a scale of 0 (none) to 10 (severe) after each VOMS assessment to determine if each assessment provokes symptoms.

Vestibular Ocular-Motor Screening.JPG

Baseline Measurement

Prior to performing the 5 domains of the VOMS screen, it is important to establish the patient's baseline symptoms. On a scale of 0-10, ask the patient to score their symptoms at rest for headache, dizziness, nausea & fogginess.

Record: Headache, Dizziness, Nausea & Fogginess ratings at rest.

Domain 1: Smooth Pursuit

Vertical Saccades.JPG

This tests the ability to follow a slowly moving target. The patient and the examiner are seated. The examiner holds a fingertip at a distance of 3 ft. from the patient. The patient is instructed to maintain focus on the target as the examiner moves the target smoothly in the horizontal direction 1.5 ft. to the right and 1.5 ft. to the left of midline. One repetition is complete when the target moves back and forth to the starting position, and 2 repetitions are performed. The target should be moved at a rate requiring approximately 2 seconds to go fully from left to right and 2 seconds to go fully from right to left. The test is repeated with the examiner moving the target smoothly and slowly in the vertical direction 1.5 ft. above and 1.5 ft. below midline for 2 complete repetitions up and down. Again, the target should be moved at a rate requiring approximately 2 seconds to move the eyes fully upward and 2 seconds to move fully downward.

Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. 

Domain 2: Saccades

Horizontal Saccades.JPG

This tests the ability of the eyes to move quickly between targets. The patient and the examiner are seated.

  • Horizontal Saccades: The examiner holds two single points (fingertips) horizontally at a distance of 3 ft. from the patient, and 1.5 ft. to the right and 1.5 ft. to the left of midline so that the patient must gaze 30 degrees to left and 30 degrees to the right. Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move back and forth to the starting position, and 10 repetitions are performed.

Record: Headache, Dizziness, Nausea & Fogginess ratings after the test.

  • Vertical Saccades: Repeat the test with 2 points held vertically at a distance of 3 ft. from the patient, and 1.5 feet above and 1.5 feet below midline so that the patient must gaze 30 degrees upward and 30 degrees downward. Instruct the patient to move their eyes as quickly as possible from point to point. One repetition is complete when the eyes move up and down to the starting position, and 10 repetitions are performed.

Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. 

Domain 3: Convergence

Convergence.JPG

Convergence is assessed by both symptom report and objective measurement of the near point of convergence (NPC).The NPC values are averaged across 3 trials, and normal NPC values are within 5 cm.[5]

Measure the ability to view a near target without double vision. The patient is seated and wearing corrective lenses (if needed). The examiner is seated in front of the patient and observes their eye movement during this test. The patient focuses on a small target (approximately 14 point font size) at arm’s length and slowly brings it toward the tip of their nose. The patient is instructed to stop moving the target when they see two distinct images (double vision) or when the examiner observes an outward deviation of one eye. Blurring of the image is ignored. The distance in centimetres between where the target is stopped, and the tip of nose, is measured and recorded using a tape measure. This is repeated a total of 3 times with measures recorded each time.

Record: Headache, Dizziness, Nausea & Fogginess ratings after the test. Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose

Domain 4: Vestibular-Ocular Reflex (VOR) Test

Vertical VOR Test.JPG

Assess the ability to stabilise vision as the head moves. The patient and the examiner are seated. The examiner holds a target of approximately 14 point font size in front of the patient in the midline at a distance of 3 ft.

Horizontal VOR Test: The patient is asked to rotate their head horizontally while maintaining focus on the target. Using a metronome set at 180 beats per minute (bpm), the head is moved at an amplitude of 20 degrees to each side with the beat. One repetition is complete when the head moves back and forth to the starting position, and 10 repetitions are performed.

Record: Headache, Dizziness, Nausea and Fogginess ratings after the test.

Vertical VOR Test: The test is repeated with the patient moving their head vertically while maintaining focus on the target. Using a metronome set at 180 bpm, the head is moved in an amplitude of 20 degrees up and 20 degrees down with the beat. One repetition is complete when the head moves up and down to the starting position, and 10 repetitions are performed.

Record: Headache, Dizziness, Nausea and Fogginess ratings after the test. 

Domain 5: Visual Motion Sensitivity (VMS) Test

Visual Motion Sensitivity (VMS) Test.JPG

Assess visual motion sensitivity and the ability to inhibit vestibular-induced eye movements using vision.

The patient stands with feet shoulder width apart, facing a busy area of the clinic. The examiner stands next to and slightly behind the patient, so that the patient is guarded but the movement can be performed freely. The patient holds arm outstretched and focuses on their thumb. Set the metronome to 50 bpm. Maintaining focus on their thumb, the patient rotates, together as a unit, their head, eyes and trunk at an amplitude of 80 degrees to the right and 80 degrees to the left, to the beat of the metronome. One repetition is complete when the trunk rotates back and forth to the starting position, and 5 repetitions are performed.

Record: Headache, Dizziness, Nausea & Fogginess ratings after a 10 second pause to allow for latent symptoms after the test.

Reference

Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. The American journal of sports medicine. 2014 Oct;42(10):2479-86.

Evidence

The VOMS has demonstrated internal consistency as well as sensitivity in identifying patients with concussions[4][6][7].  

Mucha et al[4] found that the test demonstrates internal consistency and basic validity compared with the Post-Concussion Symptom Scale (PCSS). They also suggest that it may "provide preliminary evidence for the use of the VOMS to identify patients with sport-related concussions from healthy controls". 

Moran et al[6] supported the implementation of the VOMS baseline assessment into clinical practice, due to a high internal consistency, strong relationships between VOMS items, and a low false-positive rate at baseline in youth athletes. 

Anzalon et al[8] suggest that the VOMS can serve as a predictor of recovery time in patients with sports-related concussion.  

Resources

Vestibular/Ocular-Motor Screening (VOMS) for Concussion

References

  1. 1.0 1.1 Kontos AP, Elbin RJ, Schatz P, et al. A revised factor structure for the Post-Concussion Symptom Scale: baseline and postconcussion factors. Am J Sports Med. 2012;40(10):2375-2384.
  2. Ciuffreda KJ, Ludlam D, Thiagarajan P. Oculomotor diagnostic protocol for the mTBI population. Optometry. 2011;82(2):61-63.
  3. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39(11):2311-2318.
  4. 4.0 4.1 4.2 4.3 Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. The American journal of sports medicine. 2014 Oct;42(10):2479-86.
  5. Scheiman M, Gallaway M, Frantz KA, et al. Nearpoint of convergence: test procedure, target selection, and normative data. Optom Vis Sci80(3) 2003:214-225
  6. 6.0 6.1 Moran RN, Covassin T, Elbin RJ, Gould D, Nogle S. Reliability and normative reference values for the Vestibular/Ocular Motor Screening (VOMS) tool in youth athletes. The American journal of sports medicine. 2018 May;46(6):1475-80.
  7. Moran RN, Covassin T, Elbin RJ. Sex Differences on Vestibular and Ocular Motor Assessment in Youth Athletes. Journal of athletic training. 2019 Apr;54(4):445-8.
  8. Anzalone AJ, Blueitt D, Case T, McGuffin T, Pollard K, Garrison JC, Jones MT, Pavur R, Turner S, Oliver JM. A positive vestibular/ocular motor screening (VOMS) is associated with increased recovery time after sports-related concussion in youth and adolescent athletes. The American journal of sports medicine. 2017 Feb;45(2):474-9.