Vestibular Ocular Motor Screening and Its Importance In The Management of Concussed Athletes

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1 Vestibular Ocular Motor Screening and Its Importance In The Management of Concussed Athletes March 15, 2018 Scott Euype, PT, DPT APTA Board Certified Orthopaedic Specialist Education Director, Cleveland Clinic Rehabilitation Sports Therapy

2 CONGRATULATIONS!!

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4 The Cleveland Clinic 4

5 The Cleveland Clinic 5 DOS Course 2018

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7 I have no disclosures or apparent conflict of interest Exercise and Concussions

8 OBJECTIVES Understand the value in performing the vestibular ocular motor screen (VOMS) in the assessment of an athlete with post concussion Know the components of the VOMS and what is indicative of positive findings of each component in the management of an athlete with post concussion Have an understanding of rehabilitation principles of vestibular rehabilitation as to it relates to the vestibular ocular system and cervical spine for the athlete with post concussion.

9 Dizziness and Concussion Dizziness has been reported in up to 80% of those suffering from traumatic brain injury within the first few days of injury. Maskell et al. Dizziness after traumatic brain injury: overview and measurement in the clinical setting. Brain Inj.2006;20: Subtypes of Dizziness: - Vertigo - Presyncope - Disequilibrium - Other dizziness Borg-Stein 2001, Froehling 1994, Drachman pic.jpg

10 Dizziness and Concussion More than 23% of patients with acute concussion due to sport report dizziness Stewert GS et al. Int J Sport Phys Ther % dizziness is reported in first few days after injury Alsalaheen et al. J Neuro Phys Ther. 2010;34: 87 93) 2010

11 Commonly Reported Symptoms in High School and College Athletes Within 3 days of Concussion Ranking Symptom % with symptom 1 Headaches Fatigue Feeling Slowed Down Difficulty Concentrating Fogginess Dizziness Light Sensitivity Memory Dysfunction Balance Problems Blurred or Double Vision 29.6 Lovell et al. App Neuropsychology. 2006;13:

12 Dizziness and Concussion Specific information to ask about dizziness: - Tempo Episodes: sec->min->hours->days? - Onset After incident was it gradual or sudden? - Type of dizziness? Vertigo, imbalance, Light Headed, falls, N/V, palpitations, or *5 D s (diplopia, dysphagia, dysarthria, dysmetria, drop attacks) * RED FLAGS

13 Dizziness and Concussion Additional Questions to ask: - Description Spinning Off-balanced - Aggravating /Relieving factors Positional Activity / Rest - Rule out Inner Ear Peripheral or Central vestibular

14 Which Signs /Symptoms Predict Protracted Recovery? Protracted recovery> 21 days - On field signs and symptoms If dizziness present: 6.34 odds ratio of a protracted recovery - No other on-field sings/symptoms had risk of protracted recovery Lau et al. Am J Sport Med.2011

15 Dizziness and Concussion Consider ruling out positional vertigo (Post traumatic BPPV) Episodic spinning with positional changes Rolling over Bending down Looking up Nystagmus present Torsional, vertical or horizontal Incidence is low: - 5% Alsalaheen et al Review study found BPPV: 15.6% Akin FW et al. Brain Inj.2017;31: How much Cervical Spine movement is needed?

16 How to Measure Dizziness Dizziness Handicap Inventory (DHI) 25 questions Yes (4), no (0), Sometimes (2) Scores are categorized by: Emotional Physical Functional Total score /100 points Can also look at specific questions to guide assessment 1, 13, 25

17 How to Measure Dizziness Dizziness Handicap Inventory - Has 3 separate subscales to distinguish between the patient s perception of physical, functional, and emotional disability - Test-reliability to be Statistically significant correlation coefficient with the functional (r=0.94), emotional (r=0.97), and physical (r=0.92) components - MDC = 18 points Jacobsen GP, Newman CW Arch Otolaryngol Head Surg. 1990;116: Appropriate for younger concussion population? - Some questions do not apply to younger patients - Reported that it is a sensitive measure for subtle balance disorders of concussionup to 4 weeks Gottshall K et al. Laryngoscope. 2003

18 Dizziness is common after concussion and is associated with prolonged recovery This article attempted to identify clinical tests that differentiate between cervicogenic and other forms of dizzy after concussion 25 experts in dizziness and concussion participated in 3 rounds of questioning Tests ID as having strong utility were those to ID dizziness from CNS and from vestibular system No clinical tests specific for the cervical spine achieved consensus

19 20% of university athletes (n=260) diagnosed with concussion reported symptom of neck pain. Shahata et al. Sport concussion assessment tool: baseline values for varsity collision sport athletes. Br J Sports Med Oct;43(10):730-4 CONCUSSIONS Neck Involvement Case report of high school athlete with a concussion also reporting neck pain. Zafonte R. Diagnosis and management of sports-related concussion. JAMA. 2011;306:79-86

20 Assess the Cervical Spine An athlete with post concussion syndrome with dizziness Did you check the neck? Much evidence for Cervicogenic component to post concussion - WAD?

21 The neck is cleared, and the athlete is still dizzy What Next?

22 Exertional Testing? Is it alright to do this if the patient is having symptoms? How much rest is too much?

23 Exertion Testing Buffalo Concussion Treadmill Test Used for protracted concussion symptoms - > 3 weeks Protocol progression MPH 0% incline - Increase incline by 1% for 1- minute intervals Until max obtained, or patient can not continue - Increase speed by 0.4 MPH for each minute - Maximum of 21 minutes Every Minute, check: - BORG Every 2-minutes, check: - Heart Rate - BP Stop, if: - Increase in symptoms by > 3 points on VAS - RPE > 18, or at Exhaustion Leddy et al. Clin J Sport Med. 2010;20: Exercise and Concussions

24 Use of Exertion For Post Concussion Management Time to pass BCTT( mean) - Boys: 22.0 days - Girls: 33.0 days - Total Average: 24.0 days All athletes returned to play in the week following completion of the BCCT Buffalo Concussion Treadmill Test in combination with the Zurich consensus guidelines seems to be safe for RTP Darling et al. Clin J Sport Med. 2014;24: Exercise and Concussions

25 Evidence for Aerobic Exercise for Post Concussion Multiple studies support graded aerobic treadmill testing Cordingley D et al. J Neurosurg Pediatr. 2016;18: Systematic Review - Physical Exercise improves PCSS - Improved reaction time Lal et al. Am J Sport Med (3): Moderate evidence to support sub-symptomatic aerobic exercises - Symptoms > 4 weeks Ritter KG et al. J Sport Rehabil. 2017; Sep 27:1-14 Exercise and Concussions

26 Still Dizzy?

27 Oculomotor Assessments Symptom Checklists Standardized Assessment of Concussion - Orientation, concentration, and memory - Good sideline Balance and Gait - BESS - Tandem Gait Test ( TGT) - C-3 App ( I-Pad)

28 Oculomotor Assessments Sport Concussion Assessment Tool - SCAT symptoms checklist Cognitive and sensorimotor assessments minutes King-Devick ( KD-T) - Visual function ( use of 3 cards) - Good if used in conjunction with SAC or Tandem Gait Test

29 Oculomotor Assessments No accepted definition of diagnostic criteria for concussion There is NO 100% sensitive and specific concussion screening tool. Sussman ES et al. Neurosurg Focus.2016;40:E7-E11

30 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Screening Tools - Smooth Pursuit - Saccades Horizontal Vertical - Convergence ( Near Point ) - VOR Horizontal Vertical - Visual Motion Sensitivity VOR and VMS most predictive of being concussion - > 2 points - 96% rate of identifying concussion NPC - > 5 cm - 84% rate of identifying concussion Positive prediction rate of 0.89 Mucha A, Collins M et al. Am J Sports Med 2014;42:

31 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Smooth Pursuit - Ability to follow a slowly moving target - Finger 3-feet - Move 1.5 feet Right to Left Up and Down - 2-seconds to go fully from right to left

32 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Saccades - Ability to move eyes quickly between targets - Horizontal 3-feet away 1.5 feet to right, and to left Perform 10 reps - Vertical 3-feet away 1.5 feet up, and down Gaze 30 degrees up/down Perform 10 reps

33 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Convergence - Ability to view a near target without double vision - Patient focuses pm small target 14-point font - Move from arms length to tip of nose - Stop when target is seen as two distinct images

34 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Vestibular-Ocular Reflex (VOR) - Ability to stabilize vision as the head moves - Hold target 3 feet distance 14-point font - Horizontal Patient rotates head horizontally while maintaining focus on target Head moves at speed of 20 degrees to each side Metronome 180 beats/minute One beat in each direction - Vertical Patient moves head up and down while maintaining focus on target Head moves at speed of 20 degrees to each side Metronome 180 beats/minute One beat in each direction

35 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Visual Motion Sensitivity (VMS) Test - Ability to inhibit vestibular-induced eye movements using vision - Patient holds out arm and focuses on their thumb - Patient rotates ( head, eyes, and trunk) - 80 degrees to right / left - Metronome 50 beats/min - 5 Repetitions

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37 VESTIBULAR OCULAR MOTOR SCREENING (VOMS) Video of VOMS - Anzalone et al. Am J Sport Med. 2016;45:

38 Follow-up Research on VOMS Patients presenting without symptom provocation on VOMS returned to play faster than those with symptoms on at least 1 VOMS domain All domains of VOMS that had symptoms provocation delayed recovery except Near Point Convergence ** VOMS may serve as a predictor of recovery time in patients with Sports Related Concussions Anzalone AJ et al. Am J Sport Med.2016;45:

39 Is the VOMS Valid and Reliable? Healthy subjects completed the VOMS, BESS, and King Devick ( K-D) tests - Median VOMS score: 0 - VOMS did NOT show a significant relationship with the BESS or K-D. - VOMS had high agreement Found measurement of NPC >4cm considered a real change Authors summarized that the VOMS should be a part of a comprehensive concussion assessment if vestibular impairment is suspected. Yorke AM et al. Sport Health. 2017

40 Is the VOMS Valid and Reliable? VOMS studied in youth athletes (8-14) - 60% of athletes reported no symptoms - Only 9-13% reported over the cut-off score > 2 - High internal consistency Crobach 0.97 Moran RN et al. Am J Sport Med. 2018

41 Is the VOMS Valid and Reliable? Studies on collegiate athletes - 89% of athletes scored below the cutoff levels - Found female athletes and those with motion sickness were more likely to have > 1 VOMS above cutoff levels Kontos AP et al. Am J Sport Med. 2016;44:

42 Is the VOMS Valid and Reliable? VOMS has a high internal consistency - Cronbach = 0.97 Majority of athletes do not score above the cutoff scores Should be considered as a tool for post concussion and suspicion of vestibular issue

43 King Devick (K-D) and Concussions Developed in 1976 by Alan King O.D. and Steven Devick O.D. for assessment of reading abilities One Practice Card and Three progressively more difficult Testing Cards Score the sum time of three test cards

44 Other Oculomotor Exam Components It can get complicated Why the VOMS has value!!!

45 Oculomotor Dysfunctions Symptoms Headaches Pressure in Head Neck Pain Dizziness Blurred Vision Balance Problems Sensitivity to light Light/Heavy Headed Faint Feeling slowed down Feeling like in a fog Don t feel right Difficulty concentrating Difficulty remembering Fatigue Drowsiness

46 Clinical Observations (CI) One eye drifts or points in different direction Turns to see Head tilt Squinting or covering eye Increased blinking Poor hand-eye coordination Bumps into things Fatigues easily Difficulty reading / Avoids doing homework

47 Oculomotor Exam Components With fixation: - Observations of ocular alignment Look for skew eye deviation, ocular tilt reaction - Spontaneous nystagmus - Smooth pursuit - Gaze evoked nystagmus - Vergence - VOR cancellation - Head thrust

48 Oculomotor Exam Components Without fixation - Spontaneous nystagmus - Gaze evoked nystagmus - Cervical rotation - Head shake nystagmus - Pressure testing

49 Observation Spontaneous nystagmus Observe Ocular alignment - Skew Eye Deviation vertical misalignment of the eyes due to abnormalities in the vestibular periphery, brainstem, cerebellum may find with raised ICP due to supratentorial tumors and psuedotumors Central causes are more common

50 Eye Misalignments Definitions Tropia - The relative deviation of a visual axis during Binocular viewing of a single target. Phoria - The relative deviation of a visual axis during Monocular viewing of a single target.

51 Directional Terms to Describe a Tropia or Phoria Eso Inward Deviation Exo Outward Deviation Hyper Upward Deviation Hypo Downward Deviation

52 Tests for Skew Eye Deviation Cover Test Uncover Test Alternate Cross Cover Test

53 Cover Test How to perform test - When focusing on target, one eye is covered - Look for movement of the uncovered eye - If there is movement this is the problematic side - Skew deviation named by the elevated side (lower side is side of defect) Identifies tropia of uncovered eye

54 Maddox Rod for Vertical Phoria Assessment No horizontal deviation Esodeviation Exodeviation

55 Maddox Rod for Horizontal Phoria Assessment No vertical deviation Right hyperdeviation Right hypodeviation

56 Uncover Test How to perform test - Observe for movement of occluded eye when cover is removed - Perform with cover test Identifies phoria if cover test is negative

57 Cross Cover Test Occuluder must remain over the eye for several seconds to allow the eye to establish resting position Occuluder is quickly moved from one eye to the other to prevent binocular viewing (breaking fusion) A correctional movement is observed under the uncovered eye is noted Repeated several times back and forth

58 VESTIBULAR OCULAR REFLEX Head Thrust Headshaking Dynamic Visual Acuity Do not recommend during acute recovery or if limitations from neck pain exist **Very provocative!

59 Head Thrust Tests patient s ability to hold visual fixation with quick head movements How to perform test - Hold patient s head firmly and tilt forward 30 degrees - Patient looks at your nose - Quickly move patients head in small ROM 1 direction - Observe patients ability to maintain visual fixation Positive test: - Corrective saccade observed - Indicates unilateral vestibular deficit and the side of the problem

60 Head Thrust

61 Dynamic Visual Acuity Static and Dynamic visual acuity Patient sit in front of an eye chart approximately 2-4 meters ( feet depending on type of chart used) Note the lowest level that the patient is able to read while seated still Then tilt their head down 30 degrees and gently turn their head side to side at 2 Hz (2 complete cycles side to side per sec) Note the lowest line the patient is able to read with the head moving Abnormal DVA is 3 or more Herdman SJ. Vestibular Rehabilitation 3rd Ed 2000

62 When to Refer for Specialist Visual Field loss Abnormal Smooth Pursuit, Saccades, VOR cancellation Double Vision Vertical Phoria Any new Tropia Large Phoria When Small issues do not resolve with therapy Issues with eye health or eye trauma Decreasing Acuity Limitation in ocular ROM Nystagmus? Large convergence insufficiency

63 Eye Movement Exercises for Post Concussion Good or Bad? Probably not for early onset symptoms Good for protracted?

64 Brock Strings Start with first bead 8 inches, remaining 12 inches apart for remaining beads. Slow progress beads inward Progress to divided attention with math problems, standing balance on compliant surface, or with head turned to different position. Convergence Training

65 What your patient should see You should only see a single target bead The Strings should cross at the target bead There should be two strings before and after the target bead (physiological diplopia) If you only see one string there may be suppression of one eye

66 Saccades Presentation Title l March 15, 2018 l 66

67 Saccades Level 1 1 H X P N 9 4 F L E J W 8 T 9 Y

68 Saccades Level 2 1 H X P N 9 4 F L E J W 8 T 9 Y

69 Saccades Level 3 1 D 5 7 X N 4 9 N Y D F L V 2 E R 6 C 2 0 H 5 J 1 Z W 8 I B T Y

70 Conclusion VOMS is a valid and reliable test and should be A PART of a comprehensive concussion assessment if vestibular impairment is suspected. Vestibular rehabilitation is multifaceted and should be done by a vestibular trained clinician Vision therapy may be needed - Optometrist / Vision Therapy specialist Consider assessing the Cervical Spine Consider Exertional testing / rehabilitation for protracted recovery

71 Thank you! GLATA Programming Committee Chris Schommer Bob Gray

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