CARROLL UNIVERSITY

Doctor of Physical Therapy Program

Critically Appraised Topic

VESTIBULAR/OCULAR MOTOR SCREENING DOMAINS PREDICT RECOVERY

DURATION IN POST-SPORT RELATED CONCUSSION ADOLESCENTS
Clinician’s Topic:
What is best practice for treating patients with oculomotor dysfunction following concussion or mild TBI? Include recommendations
for screen time following concussion, as well as the factors that contribute to or slow recovery (i.e., prognostic factors).

Specific focus: Do ocular motor tests predict recovery time?

Clinical Bottom Line:

Yes, the vestibular/ocular motor screening (VOMS) is associated with increased recovery duration from sport related concussions in
adolescents. Patients with positive VOMS scores are likely to return to sport after a longer recovery period than patients without
positive VOMS scores. I recommend clinicians utilize the VOMS in conjunction with other assessments to accurately predict
recovery time in adolescents with sport related concussions. This will ensure that other factors not accounted for in the VOMS are
considered in order to provide patients with the most accurate prognosis for their recovery.

Limit text to this space. This is your answer to the clinical question based on the literature appraised, clinical relevance and
Refresh Date:
experience andMarch perspectives. You should not simply repeat author’s findings verbatim but consider all aspects of EBP
2019
patient
(research finding, clinical relevance /experiences and patient situations/values). Your bottom line may agree or disagree with the
research reviewed based on quality of evidence and relevance to clinical application. You may not be able to give definitive
recommendation but you should give a bottom line statement that specifically answers your clinical question.

Author(s): Paige Lyford Date Created: 2/22/18

Reviewer(s): Date Updated:
Key Findings
 General Summary
o Overall, the breadth of literature in regard to ocular motor testing predicting recovery time after a concussion is limited.
More evidence was available regarding ocular motor testing as a tool for assessing dysfunction post-concussion rather than
as a prognostic tool.
 Research Quality
o The quality of evidence is moderate. The validity of the evidence is moderate for patients who are younger and sustain
concussions from sport related injuries. However, the designs of these studies include numerous threats to validity
pertaining to adults and patients who sustain non-sport related concussions.
 Level of Evidence
o The level of evidence for the literature was moderate due to the limited number of articles being cohort studies and,
therefore, level 2 evidence.
 General Limitations
o The articles focus on sport related concussions in adolescents, with the majority being males. Therefore, the evidence is
limited to young athletes rather than adults who sustain concussions while playing sports or with other mechanisms of
injury, such as falls or motor vehicle accidents. Additional limiting factors include small sample sizes, not accounting for
intervention differences, not accounting for differences in injury mechanism, and lacking baseline measurements.
 Take Home Findings
o Overall, a positive VOMS score for any domain, except NPC and accommodation, is associated with delayed recovery
from a sport related concussion in adolescents. Smooth pursuit, horizontal saccade, and vertical saccade are most predictive
of a 15-29 day recovery period. However, smooth pursuit is most predictive of a 30-90 day recovery period.
 Clinical Relevance
o Use of VOMS to predict recovery period after sport related concussion should be utilized as a baseline for therapists to
guide treatment. However, therapists should not rely on the VOMS as the sole predictor of return to sport since many
variables were not controlled for in the literature.

Author(s): Paige Lyford Date Created: 2/22/18

Reviewer(s): Date Updated:
Search Methodology:
Search Resources Search Terms Limits # of Articles
PubMed Concussion AND oculomotor tests - No limits applied 2
1 AND prognosis

PubMed Concussion AND oculomotor AND - No limits applied 9

2
prognosis
PsychINFO Concussion AND prognosis AND - No limits applied 0
3
oculomotor
SPORTDiscus Concussion prognosis AND - No limits applied 0
4 oculomotor AND prognosis or
predictors
SPORTDiscus Concussion AND prognosis or - No limits applied 2
5
predictors AND ocular motor
CINAHL Plus Concussion AND prognosis AND - No limits applied 1
6
oculomotor
CINAHL Plus Concussion AND prognosis AND - No limits applied 2
7
ocular motor

Search Results Summary:

Results Reasons for Inclusion Reasons for Exclusion # of Articles
Included
- Prospective cohort (1) -Specific interventions - No mention of prognostic 0
- Case report (1) outcomes
1 - Vision therapy intervention
- Oculomotor tests for mild TBI
diagnostic purposes
- Prospective cohort (2) N/A (no articles included) - No mention of prognostic 0
- Retrospective cohort (1) outcomes
- Case report (2) - Rehabilitation interventions
2
- Review (2) - Prism correction
- Systematic review (1)
- Pilot study (1)
Author(s): Paige Lyford Date Created: 2/22/18
Reviewer(s): Date Updated:
 3 No search results N/A (no search results) N/A (no search results) 0
4 No search results N/A (no search results) N/A (no search results) 0
Cohort study (2) - Vestibular, ocular motor screening - N/A (included both articles) 2
recovery time
5 - Vestibular, ocular motor,
neurocognitive, and symptom
impairments recovery time
6 Poster presentation (1) N/A (no articles included) - Poster presentation 0
Cohort study (2) - Vestibular, ocular motor screening - N/A (included both articles) Both articles
recovery time included are
7 - Vestibular, ocular motor, identified in
neurocognitive, and symptom search #5
impairments recovery time

Author(s): Paige Lyford Date Created: 2/22/18

Reviewer(s): Date Updated:
Research Participant and Study Characteristics:
Reference Participant Key Clinical
Characteristics
Anzalone et al - Diagnosed with sport related
2017 concussion (assessed within
14 days of initial injury date)
- Age range: 11-19 years
(mean = 15 years)
- 98 males; 69 females
- 50 subjects had prior
concussion
Author(s): Paige Lyford
Reviewer(s):
Prognostic Factors Outcome Measurement Level of
Evidence
Vestibular/Ocular Motor Recovery time: number of Level 2
Screening (VOMS) days from initial injury date to
assessment at first date cleared to begin
appointment graduated return to play (RTP)
- smooth pursuits, protocol
horizontal saccades, - Symptom free for
vertical saccades, minimum of 48 hours,
horizontal vestibular normal physical exam,
ocular reflex, vertical normal VOMS,
vestibular ocular neurocognitive scores
reflex, near point of > baseline or within
convergence (NPC), normal limits
accommodation
- Symptom provocation
(headache, dizziness,
nausea, fogginess) and
abnormal findings
(NPC > 6 cm,
abnormal smooth
pursuits, abnormal
saccadic eye
movements) reported
as yes/no
Date Created: 2/22/18
Date Updated:
 Sufrinko et al - Diagnosed with sport related
2017 concussion within past 7 days
- Average time from injury to
examination: 3.6 days
- Average age: 15.3 years
- 51 males; 18 females
Vestibular/Oculomotor Recovery: total number of Level 2
Screening (VOMS) days from injury to receiving
- Smooth pursuit, full medical clearance for
horizontal saccade, return to sports
vertical saccade, - Symptom free at rest
horizontal vestibular and with physical
ocular reflex, vertical exertion and normal
vestibular ocular clinical evaluation
reflex, visual motion
sensitivity (VMS),
near point convergence
(NPC)
- After each component,
patient rates symptoms
of headache, dizziness,
nauseam and fogginess
on scale of 0-10

Outcomes:
Reference Event/Outcome Time to reach Outcome/Extracted Info ES &/or NNT
Measured outcome
Anzalone et al Return to graduated - Average of 13.4 - All patients returned to play Unable to
2017 RTP protocol days to return - Delayed recovery associated with symptom calculate
when present provocation from each VOMS domain except NPC
without symptom and accommodation
provocation or - Number of positive domains exhibited at
clinical examination is positively correlated with recovery
abnormalities time (r = 0.31)
- Average of 23.0
days to return
when present with
> 1 VOMS
domain
Author(s): Paige Lyford Date Created: 2/22/18
Reviewer(s): Date Updated:
 Sufrinko et al Recovery days - < 14 days - 30-90 day recovery time predicted by all VOMS Unable to
2017 - 15-29 days scores but strongest association with smooth calculate
- 30-90 days pursuit
- 15-29 day recovery time predicted by smooth
pursuit, horizontal saccade, vertical saccade
- VOMS scores did not independently predict
recovery duration
- NPC distance did not predict recovery time
period

References:
Anzalone AJ, Blueitt D, Case T, et al. A positive vestibular/ocular motor screening (VOMS) is associated with increased recovery
time after sports-related concussion in youth and adolescent athletes. Am J Sports Med. 2017;45(2):474-479.
doi:10.1177/0363546516668624.

Sufrinko AM, Marchetti GF, Cohen PE, et al. Using acute performance on a comprehensive neurocognitive vestibular, and ocular
motor assessment battery to predict recovery duration after sport-related concussions. Am J Sports Med. 2017;45(5):1187-1194
doi:10.1177/0363546516685061.

Author(s): Paige Lyford Date Created: 2/22/18

Reviewer(s): Date Updated: