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

Abstract

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.

How to identify and manage sports related concussions in primary care

“…If SRC is suspected, consider further assessment using a concussion assessment tool. Although no valid, office based primary care tool exists for concussion assessment, potential tools to consider include the Sports Concussion Assessment Tool 6 (SCAT 6), vestibular ocular motor screening, neuropsychological testing, or the Balance Error Scoring System 89…”

Multisensory integration and white matter pathology: Contributions to cognitive dysfunction

“…Dysfunctional unimodal sensory processing of visual ( 102 , 103 ), auditory ( 104 , 105 ), and vestibular ( 106 ) stimuli are found in persons with prior mTBI. In addition, altered central sensory processing of vestibular ( 107 , 108 ), visual, ( 101 , 107 , 108 ), and auditory ( 109 ) signals has been proposed as underlying persistent mTBI-related symptoms, including those indicating cognitive dysfunction. Moreover, multimodal sensory management requirements incur a greater processing demand for persons with prior mTBI ( 110 – 112 ).…”

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

“…Moreover, evidence indicates those with vestibular ocular reflex (VOR) or tandem gait abnormalities can experience protracted recovery times compared to those with no abnormalities [32,33]. Tools such as the vestibular ocular motor screening (VOMS) tool and balance error scoring system (BESS) may be useful at identifying potential areas requiring further in depth assessment; especially when they are used as part of a multimodal assessment approach [34][35][36]. Vestibular rehabilitation has been suggested to be beneficial in reducing dizziness and improving balance in individuals with persistent concussion symptoms although the randomised trial evidence base is yet very limited [13,37,38].…”