The Utility of Vestibular and Ocular Assessment Tools in Diagnosing a Sports-Related Concussion: A Critically Appraised Topic Powers C 1 , Nosker A 1 , Beidler E 2 1 Student, 2 Assistant Professor; Duquesne University, Pittsburgh, PA • The overall average Sport-related concussion (SRC) incidence rate is 26.1 SRCs per 100,000 athlete-exposures. 1 • A multi-faceted evaluative approach to SRC management is recommended that includes assessments of self-reported symptoms, motor control, mental status, and neurocognition. 2 • Dizziness and balance problems occur in 50% of concussed athletes and vision problems occur in 30%. 3,4 • Many current diagnostic assessments fail to take into consideration vestibular and ocular deficits. • High sensitivity and internal consistency are important components for determining the clinical utility of sideline SRC assessment tools. The studies reviewed were identified as the “best evidence” and met all the inclusion criteria (Table 1). There were 5 articles identified; 4 studies 4,5,7 demonstrated that vestibular and ocular assessments have a high internal consistency and three studies 4,5,7 showed high sensitivities for diagnosing SRCs. Combining near point convergence (NPC), smooth pursuits, and vestibular-ocular reflex increased the accuracy of vestibular and ocular assessment tools to 87.5%. 5 The sensitivity of adding NPC to the diagnostic process is 0.83 and stands out as being a beneficial tool in diagnosing a sports-related concussion. 5 METHODS Do vestibular and ocular assessments have suitable levels of internal consistency and sensitivity for diagnosing sport-related concussions? INTRODUCTION CLINICAL QUESTION RESULTS DISCUSSION REFERENCES Balaban et al. (2016) Cohort Study Kontos et al. (2016) Cohort Study McDevitt et al. (2016) Cross-Sectional Study Mucha et al. (2014) Cross-Sectional Study Pearce et al. (2015) Cross-Sectional Study Participants 200 athletes (50 concussed) 394 NCAA student-athletes 72 active collegiate student-athletes 142 athletes (mean age = 13.9 y/o ± 2.5 y) 78 athletes (mean age = 14.31 y/o) Intervention Symptom profile, functional gait index, dizziness handicap inventory, battery of oculomotor, vestibular, and reaction time (OVRT) reflexes Vestibular and ocular motor screening (VOMS) test Sensory organization test (SOT), Balance error scoring system, VOMS components 5 domains of VOMS: smooth pursuit, horizontal/vertical saccades, near point convergence, horizontal vestibular ocular reflex, vision motion sensitivity Near point convergence (NPC) testing, neurocognitive and symptom assessments (3 trials) Outcome Measures Sensitivity Internal consistency Internal consistency Internal consistency & sensitivity Internal consistency Main Findings 2 cohorts (different time frames) did not differ in functional test results. Sensitivity: 88-92% Specificity: 98-99% High internal consistency (0.97) High Sensitivity False positive (11%) due to history of motion sickness. Best exam consists of: sensory organization tests, sensory ratios, NPC, and optokinetic stimulation signs/symptoms score. High sensitivity and accuracy (98.6%) 61% of patients reported symptoms after 1 VOMS test. Vestibular ocular reflex & visual motion sensitivity were most predictive. Internal consistency = 0.95-0.98 Patients in convergence insufficiency group had NPC 12.64±8.97cm compared to 1.53cm of the normal group. Level of Evidence 2b 2b 2b 2b 3 Conclusions Does not require a baseline, just past medical history. Sensitivity of saccade testing showed significance during diagnosis. Efficient test for determining if an athlete is concussed. False positive rate is acceptable. Important to have a baseline exam to determine relevant risk factors (e.g. motion sickness, migraines). Near point convergence-sensitive assessment models should be used to determine if a patient has a concussion. If patients present with 2 symptoms: increases the chance of correct diagnosis by 50%. High internal consistency (0.92) High sensitivity VOMS may serve as a single component of a comprehensive assessment. Scores ≥2 total symptoms and ≥5cm on NPC resulted in high rates on identifying concussions (96% and 84% respectively) Convergence insufficiency is common in athletes following concussion (45%). Athletes with convergence insufficiency are at risk for greater impairments and higher symptom scores. Search Strategy Terms Used to Guide Search Strategy (PIO): - Patient: Athletes - Intervention: Vestibular/Ocular assessment tools - Outcome: Internal Consistency & Sensitivity Sources of Evidence Searched: - PubMed - Google Scholar - Cinahl - SPORTDiscus - Global Health Library Inclusion and Exclusion Criteria Inclusion: Exclusion: - Studies that investigated SRC - Non-athletes - Athletes - Specified outcomes - Outcomes of internal consistency not measured and/or sensitivity - Published in the last decade (2006-2016) - Limited to English Language Vestibular and ocular deficits following a SRC are contributed to the impact mechanism occurring on the occipital and temporal regions of the brain. With the increasing number of vision and balance problems reported in patients, it is important to take these into consideration during the multi-faceted SRC evaluation process. 3,4 Research shows that dizziness and visual problems are becoming more prevalent in concussed athletes. 3-8 The 4 th International Consensus Statement on Concussion in Sport states that there is a need for a standardized assessment tool for on-field evaluations that takes into consideration the rapidly changing signs and symptoms; such as those affecting the vestibulo-ocular system. 2 Clinical Importance: • Vestibular and ocular assessments should be incorporated as a component of the systematic approach to diagnosing a SRC. • They are cost effective and easily accessible compared to computerized assessment tools. • They are simple and are an effective use of time during the acute SRC assessment and management period. Future research should be completed to differentiate between the multiple vestibular and ocular assessments. Research should also be conducted to understand the long-lasting deficits to the vestibulo-ocular system following a SRC to emphasize the importance of considering them in the clinical examination. 1. Marshall SW, Guskiewicz KM, Shankar V, McCrea M, & Cantu RC. Epidemiology of sports-related concussion in seven US high school and collegiate sports. Injury epidemiology, 2015;2(1). 2. McCrory P, Meeuwisse W, Aubry M, et al. Consensus statement on concussion in sport: the 4th International Conference on Concussion in Sport held in Zurich, November 2012. Br J Sport Med. 2013;47(5):250–258. 3. Kontos AP, Sufrinko A, Elbin RJ, Puskar A, Collins MW. Reliability and associated risk factors for performance on the vestibular/ocular motor screening (VOMS) tool in healthy collegiate athletes. The American journal of sports medicine. 2016;44(6):1400-1406. 4. Mucha A, Collins MW, Elbin RJ, et al. A brief vestibular/ocular motor screening (VOMS) assessment to evaluate concussions: preliminary findings. The American Journal of Sports Medicine. 2014;42(10):2479-2486. 5. McDevitt J, Appiah-Kubi KO, Tierney R, Wright WG. Vestibular and oculomotor assessments may increase accuracy of subacute concussion assessment. International Journal of Sports Medicine. 2016;37(9):738-747. 6. Pearce KL, Sufrinko A, Lau BC, Henry L, Collins MW, Kontos AP. Near point of convergence after a sport-related concussion: measurement reliability and relationship to neurocognitive impairment and symptoms. The American journal of sports medicine. 2015;43(12):3055-306. 7. Balaban C, Hoffer ME, Szczupak M, et al. Oculomotor, vestibular, and reaction time tests in mild traumatic brain injury. Janigro D, ed. PLoS ONE. 2016;11(9). doi:10.13710162168. 8. Master CL, Scheiman M, Gallaway M, et al. Vision diagnoses are common after concussion in adolescents. Clinical Pediatrics. 2016;55(3):260-267. Table 1- Characteristics of Included Studies Figure 1- Demonstrations of vestibular/ocular assessment components Near Point Convergence Vertical Saccades Horizontal Saccades Horizontal Vestibulo-Ocular Reflex Visual Motion Sensitivity