VOMS Assessment: A Healthy Balance

Why do we check balance and vision with concussions?

Recent research has shown that vestibular symptoms were common after a concussion and could slow down the recovery process. Furthermore, dizziness was reported by 50% of concussed athletes, which can be due to vestibulo-ocular system impairment. The human balance system is complex and involves the sensory and motor control systems. A person’s sense of balance is influenced by vestibular (motion, equilibrium, spatial orientation), visual (sight), and proprioceptive (touch) systems. Any damage to these systems can disrupt one’s sense of balance.

What is Vestibular/Ocular Motor Screening (VOMS) Assessment?

VOMS is a clinical tool used to assess vestibulocular-related impairments and symptoms following a concussion. According to University of Pittsburgh study, a positive VOMS test was very accurate in identifying sports-related concussion.
This includes 5 domains: (1) smooth pursuit, (2) horizontal and vertical saccades, (3) near point of convergence (NPC) distance, (4) horizontal vestibular ocular reflex (VOR), and (5) visual motion sensitivity (VMS). Current studies show the importance of the ocular motor components of the VOMS, especially near point convergence distance. Clinically, convergence insufficiency can mimic many of the signs/symptoms attributed to concussions such as headache, difficulty in reading, difficulty in focusing, and blurred vision. Ocular motor components (smooth pursuit, vertical/ horizontal saccades, convergence) of the VOMS provoked symptoms in 33% to 42% of patients in the current sample of concussed patients.

Why is it used?

Each individual and concussion injury is different so it is important to diagnose and identify the problem accurately in order to treat appropriately.

What are all of the different tests?

EOMI bilaterally with smooth pursuits:

Patient to follow a moving target while the patient and the examiner are seated. Examiner holds a target 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 1.5ft to the left of midline.
Record for each direction: Headache, Dizziness, Nausea, Fogginess ratings after each test

Near point convergence

Measure the ability to view a near target without double vision. The patient is seated and wearing corrective lenses (if needed)
Abnormal: Near Point of convergence ≥ 6 cm from the tip of the nose.

Horizontal and vertical saccades

Patient to follow a target between two points as quickly as possible
Record for each direction: Headache, Dizziness, Nausea, Fogginess ratings after each test

VOR – vestibular ocular reflex

Assess the ability to stabilize vision as the head moves. The patient and the examiner is seated. The examiner holds a target of approximately 14 point font size in front of the patient in midline at a distance of 3 ft. Use a metronome to help with speed at about 180 beats/min.
Record after each test (Horizontal and Vertical VOR): Headache, Dizziness, Nausea and Fogginess ratings.

VMS – vestibular motion sensitivity

Test visual motion sensitivity and the ability to inhibit vestibular –induced eye movements using vision. Patient stands with feet shoulder width apart. Patient holds arm outstretched and focuses on their thumb. 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 left and 80 degrees to the right. Use a metronome to ensure the speed of rotation is maintained at 50 beats/min (one beat in each direction).
Record: Headache, Dizziness, Nausea and Fogginess ratings

BESS testing – Balance Error Scoring System

Published studies have identified acute postural stability deficits lasting approximately 72 h following sports-related concussion. It appears that postural stability testing provides a useful tool for objectively assessing the motor domain of neurological functioning, and should be considered as a reliable and valid addition to the assessment of athletes suffering from concussion, particularly where the symptoms or signs indicate a balance component.

Double leg stance: Patient has feet together with hands on hips and eyes closed

Single leg stance: Patient stands on non-dominant foot with opposite leg and knee flexed. Patient has hands on hips and eyes closed.

Tandem stance: Patient stands heel to toe on a firm surface with dominant foot forward. Dominant foot heel should be touching non-dominant toe. Patient’s hands are on the hips and eyes are closed.