What is the Vestibular Ocular Motor Screen (VOMS)?

VOMS Testing

The vestibular ocular motor screen (VOMS) is a screening tool that was designed by experts at the University of Pittsburgh Medical Centre (UPMC) to test for the signs and symptoms of concussion after a head injury (1). It is performed by a trained healthcare provider during the physical examination of a patient to determine the extent and severity of concussion symptoms.

The VOMS consists of a variety of tests that challenge the visual and vestibular systems of the brain. Based on the results of these tests, clinicians gain a better understanding of the deficits in brain function that may be occurring after a head injury, and what specific brain systems are leading to the symptoms of a concussion.

Common symptoms that may be experienced by patients during the VOMS include headache, dizziness, lightheadedness, brain fog, fatigue and nausea.

Clinically, the VOMS is used to confirm the diagnosis of a concussion, guide the rehabilitation process for a patient who is experiencing prolonged symptoms of a concussion, and is a component of the return to sport protocol that an athlete must pass in order to return to contact sports.

Note that you can also download our free VOMS screening template by clicking the button below!

DOWNLOAD FREE VOMS SCREENING TEMPLATE

Research note:

Research has shown that in athletes who have sustained a concussion, nearly 30% report visual problems during the first week after the head injury (2).

Furthermore, up to 50% of concussed athletes report dizziness after their head injuries which may represent underlying dysfunction of the visual or vestibular systems (3).

Therefore, it is important to conduct tests like the VOMS after the initial head injury to accurately assess the source of your patient’s symptoms and how these symptoms may be provoked.

What is a Concussion or Mild Traumatic Brain Injury (mTBI)?

mild Traumatic Brain Injury

A concussion is a traumatic brain injury caused by a blow to the head or body that negatively affects brain function by altering the ability of brain cells to communicate with one another.

We commonly associate concussions with contact sports, but any circumstance where your head or body undergoes high levels of acceleration and deceleration have the potential to cause a concussion.

Common situations that cause concussions include sports-related head injuries, motor vehicle accidents, slips and falls, and other activities causing head injury.

The International Consensus statement for Concussion in Sport defines a concussion as a “traumatic brain injury that is caused by biomechanical forces”. These biomechanical forces induce a sudden acceleration-deceleration movement of the brain inside of the skull cavity.

The rapidly changing biomechanical forces during the impact stretch the brain’s nerve cells to the point where they all begin to fire at the same time. The activation of all of these nerve cells at the same time causes a rapid depletion of the brain’s energy systems, and the brain enters a state of “fatigue”.

This energy depletion alters the nerves’ ability to communicate effectively with one another, leading to many of the signs and symptoms that we commonly associate with mild traumatic brain injuries.

While there is a temporary reduction in brain function, the vast majority of concussions will resolve within a 30-day recovery period, provided that the concussed person seeks appropriate medical care from a trained healthcare provider.

Signs of a more severe head injury include a loss of consciousness duration greater than 30 minutes, a Glasgow Coma Scale (GCS) of less than 13 longer than 30 minutes post-injury, post-traumatic amnesia greater than 24 hours, any sign of a skull fracture, signs of severe cervical spine injury or any progressive deterioration in mental status.

In these instances, patients should seek medical assistance immediately for emergency medical care.

For an in-depth explanation of concussions, how they occur and the brain physiology behind concussions, please see our post “What is a Concussion” here.

Common Concussion Symptoms

Common physical signs of concussion include loss of consciousness, altered mental state, and memory loss.

Common symptoms include neck pain, headache, dizziness, changes in sleep patterns, trouble concentrating, irritability, decreased mental processing, and other cognitive symptoms.

Concussion Treatment

The specific treatment that a patient will receive after a concussion is dependent on what areas of the brain are affected, and what activities are causing their concussion symptoms.

Treatment can include a combination of mental rest, physical therapy, vision therapy, vestibular therapy, light physical activity, patient education, and a progressive return to normal activities.

The VOMS can be used to guide the treatment of a concussion patient by highlighting the various functional deficits that the patient is experiencing, and providing a basis for the rehabilitation of these deficits.

Concussion Treatment

What Does the VOMS Test Include?

The VOMS test is composed of 5 different procedures that can give clinicians insight into the function, or lack of function, of the visual and vestibular systems. These 5 tests include:

Smooth pursuits

Rapid eye movements

Near point of convergence

Vestibular-ocular reflex

Visual motion sensitivity

During each of these tests, patients will be asked to rate their perceived symptom intensity of headache, dizziness, nausea, fogginess or any other symptom that may be provoked with testing.

If VOMS testing makes symptoms worse in a patient with a suspected concussion, it is evidence that a traumatic brain injury has occurred. This helps to confirm the diagnosis of a concussion in combination with a clinical interview, baseline symptom assessment, computerized neurocognitive testing and other physical testing such as the balance error scoring system (BESS).

Current research suggests that the VOMS has a sensitivity of over 90% in accurately diagnosing mild traumatic brain injuries (mTBI).

What Brain Systems is the VOMS Testing?

The two main systems that are tested by the VOMS are the oculomotor system and vestibular system. Head injuries that lead to concussion can alter the oculomotor and vestibular systems ability to function independently and synchronously, and can cause patients to experience concussion symptoms.

The Oculomotor system

The oculomotor system is a sub-system of the visual system that spans many brain areas. Its function is dependent on the integration of these pathways to produce many different visual functions including stabilizing the visual field, coordinating eye movements, and visual processing.

Here is a basic summary of the structures involved:

  1. Frontal Eye Fields: The frontal eye field is located in the frontal cortex and plays a crucial role in initiating and controlling voluntary eye movements.
  2. Superior Colliculus: The superior colliculus is a structure located in the midbrain that integrates sensory information and coordinates eye movements.
  3. Pontine Reticular Formation: The PRF is a region in the brainstem involved in the generation and control of smooth pursuit eye movements. It receives input from the FEF and projects to the oculomotor nuclei. The PRF is responsible for coordinating eye movements with visual stimuli.
  4. Oculomotor Nuclei: The superior colliculus sends signals to the oculomotor nuclei in the brainstem of cranial nerves III (superior rectus, inferior rectus, medial rectus, inferior oblique), IV (superior oblique) and VI (lateral rectus). These nuclei control the movement of the eye muscles through the visual field.
  5. Cerebellum: The cerebellum plays a crucial role in the coordination and fine-tuning of eye movements. The cerebellum receives input from the visual cortex, superior colliculus, and vestibular system, and sends output to the oculomotor nuclei to adjust eye movements during eye pursuit.
  6. Visual Cortex: The visual cortex processes visual motion information and contributes to the initiation and maintenance of eye movements.

Dysfunction in the visual system can lead to a variety of symptoms including blurry vision, double vision, trouble focusing, light sensitivity, eye tracking and coordination problems, eye fatigue and visual motion sensitivity (4).

The Vestibular System

The vestibular system is located within the brain, brain stem and inner ear, and is primarily responsible for coordinating balance and spatial orientation.

Here is a basic summary of the structures involved:

  1. Semicircular canals: The semicircular canals are three fluid-filled structures located within the inner ear. The main function of the semicircular canals is to detect angular acceleration and provide information about the body’s orientation in space.The information from the semicircular canals is processed by the brain to maintain balance, coordination, and spatial orientation. It helps us maintain visual stability by coordinating eye movements (via the vestibulo-ocular reflex) and provides input to other motor control systems to adjust body posture and movements.
  2. Vestibular Nuclei: The vestibular nuclei, located in the brainstem, receive input from the visual system as well as the vestibular system. They integrate information from both systems to adjust eye movements and maintain visual stability during head and body movements.
  3. Vestibulo-ocular Reflex (VOR) Pathway: The VOR is responsible for generating eye movements that stabilize vision during head movements. The VOR works by generating eye movements that are equal and opposite to the head movements, thereby stabilizing the visual image on the retina. When the head rotates, the semicircular canals in the inner ear detect the rotational movement and send signals to the brainstem, specifically the vestibular nuclei. The vestibular nuclei integrate the signals and transmit them to the cranial nerve nuclei responsible for controlling eye movements.

Vestibular dysfunction can lead to symptoms that include dizziness, balance problems, motion sensitivity, nausea and vomiting.

What Equipment is Needed to Conduct the VOMS Test?

In order to conduct the VOMS test, you need 6 pieces of equipment:

  1. A tape measure
  2. A metronome
  3. The VOR checkerboard
  4. Size 14 font visual target
  5. A pen
  6. A copy of the VOMS test template that can be found below.

How do you Perform the Test?

Before beginning the test, make sure that you download the CCMI VOMS scoring sheet by clicking the Download button below.

  1. Have your patient comfortably seated facing you. Explain to them the purpose of the test, that it may provoke and/or exacerbate their concussion symptoms, and answer any questions that they have prior to administering the test.
  2. While the patient is comfortably resting, assess the symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 (with 10 being the maximum).
  3. Proceed through each of the 8 tests (explained below), assessing and recording any increases to the patients’ symptoms when conducting the tests, as well as any relevant notes about each test (nystagmus, visual symptoms, inability to maintain the correct pace, etc

DOWNLOAD FREE VOMS SCREENING TEMPLATE

 

Smooth Pursuits

  1. The patient and the examiner should be seated 3 feet apart. The patient should be looking straight ahead and should not move their head for the duration of the test.
  2. The midpoint of this test is at the patient’s nose. Using the practitioner’s finger as the target, the practitioner should move their finger 1.5 feet horizontally to the left, then in a smooth continuous motion back to the midline and then 1.5 feet horizontally to the right. It should take 2 seconds to complete 1 full revolution (midline–> left–> right–> midline).
  3. Repeat for 2 revolutions.
  4. Switch the motion to the vertical plane. Using the practitioner’s finger as the target, the practitioner should move their finger 1.5 feet vertically upward, then in a smooth continuous motion back to the midline and then 1.5 feet vertically downward. It should take 2 seconds to complete 1 full revolution (midline–> up–> down–> midline).
  5. Repeat for 2 revolutions
  6. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.

Horizontal Saccades

  1. The patient and the examiner should be seated 3 feet apart. The patient should be looking straight ahead and should not move their head for the duration of the test.
  2. The practitioner holds their fingers 3 feet apart, 1.5 feet to the left and right of the midline respectively.
  3. The patient is instructed to look from side to side, back and forth between the fingers, for a total of 10 repetitions while only moving their eyes and keeping their head still. The patient should perform this as fast as they can.
  4. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.

Vertical Saccades

  1. The patient and the examiner should be seated 3 feet apart. The patient should be looking straight ahead and should not move their head for the duration of the test.
  2. The practitioner holds their fingers 3 feet apart, 1.5 feet vertically upward and downward of the midline respectively.
  3. The patient is instructed to look from up to down, back and forth between the fingers, for a total of 10 repetitions while only moving their eyes and keeping their head still. The patient should perform this as fast as they can.
  4. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.

Horizontal Vestibulo-ocular Reflex (VOR)

  1. The patient and the examiner should be seated 3 feet apart. The patient should be looking straight ahead.
  2. The practitioner holds the checkerboard printout 3 feet in front of the patient. The patient should fixate on the centre dot in the middle of the checkerboard.
  3. The patient is instructed to turn their head from right to left, 20 degrees to each side, back and forth, while maintaining their gaze on the centre dot.
  4. The patient completes 10 reps of this movement at the pace of 180 bpm (use metronome).
  5. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.

Vertical Vestibulo-ocular Reflex (VOR)

  1. The patient and the examiner should be seated 3 feet apart. The patient should be looking straight ahead.
  2. The practitioner holds the checkerboard printout 3 feet in front of the patient. The patient should fixate on the centre dot in the middle of the checkerboard.
  3. The patient is instructed to nod their head upward to downward, 20 degrees in each direction, back and forth, while maintaining their gaze on the centre dot.
  4. The patient completes 10 reps of this movement at the pace of 180 bpm (use metronome).
  5. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.

Visual Motion Sensitivity (VMS or VOR cancellation test)

  1. The patient should stand in the room with enough space around them to freely move their arms. The practitioner is standing behind the patient to spot them in case of dizziness, but is not to impede their free movement.
  2. The patient extends their arms in front of them, interlocking their fingers and pointing their thumbs to the ceiling.
  3. With their trunk, head and eyes moving as a unit, the patient is going to rotate 80 degrees to the right and then 80 degrees to the left of the midline, while maintaining their gaze on their extended thumbs.
  4. The patient completes 10 reps at a pace of 50 bpm (use metronome).
  5. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.

Accommodation

  1. The patient should be comfortably seated. The practitioner should obtain a visual target (size 14 font) and a rule/ tape measure.
  2. The patient begins by gently covering their right eye with their hand and holding the visual target in their left hand.
  3. The patient slowly moves the visual target toward their nose while focusing on the target with their left eye. The patient reports when the target becomes blurry and the practitioner measures the distance from the tip of the nose to the target at that point.
  4. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.
  5. Repeat covering the left eye and holding the target in the right hand.
  6. Normal accommodation is less than 10 cm.

Convergence

  1. The patient should be comfortably seated. The practitioner should obtain a visual target (size 14 font) and a rule/ tape measure
  2. With both eyes open, the patient slowly moves the visual target toward their nose while focusing on the target with both eyes. The patient reports when the target becomes double and the practitioner measures the distance from the tip of the nose to the target at that point.
  3. Ask the patient to report their symptoms of headache, dizziness, nausea, and fogginess on a scale of 1-10 and record.
  4. Normal convergence is less than 5 cm.

When Should you use the VOMS Test?

The VOMS test is a vital component of the comprehensive diagnosis and treatment of traumatic brain injuries. It can give insight into brain function that is not well challenged with other standard concussion testing.

Therefore, the VOMS should be performed on all concussion patients during the initial examination in order to fully appreciate the extent of the patient’s physical symptoms (5).

Clinically, the VOMS test can be used to:

a. Confirm the diagnosis of concussion,

b. Guide the rehabilitation of a concussed patient, and

c. Clear athletes for return to sport post-concussion. We will walk you through each of those scenarios below.

Confirmation of the Diagnosis of an Acute Concussion

According to the most recent published guidelines by the American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury, the diagnosis of a concussion needs a biomechanically plausible mechanism plus one or more of the following (6):

  1. One or more clinical signs attributable to brain injury.
  2. Two or more acute symptoms attributable to brain injury plus at least one laboratory or clinical finding.*
  3. Neuroimaging evidence of TBI (structural magnetic resonance imaging, computed tomography).

And confounding factors do not fully account for the clinical signs, acute symptoms, and clinical examination and laboratory findings that are necessary for the diagnosis.

*The VOMS test would be used to see if challenging the vestibular and/or ocular systems exacerbate the baseline symptoms. If symptoms are increased during VOMS testing, this is a positive clinical finding and confirms the diagnosis of an acute concussion.

Guiding the Rehabilitation of the Concussion Patient

Once the diagnosis of a concussion has been made, the VOMS test is used to guide the rehabilitation of patients with persistent concussion symptoms (PCS).

If the VOMS test continues to be positive longer than 14 days post-impact, the patient would be diagnosed with vestibulo-ocular post- concussion syndrome. Based on the findings of the VOMS, you would prescribe the corresponding rehabilitation exercises to address the headache, dizziness, nausea, or fogginess associated with the use of the vestibular and/or oculomotor systems.

Clearing Athletes for Return to Sport

Lastly, the  VOMS test can be used to clear athletes for return to high risk sports after sustaining a concussion. In order for an athlete to be granted medical clearance for the safe return to sport, they must pass both the Chicago Blackhawks test and the VOMS test with no symptom exacerbation, in addition to passing the prior 4 stages.

If the athlete is not able to pass the VOMS test without an increase in symptoms, the athlete is not cleared to return to sport and they are returned back to the previous stage of non-contact sport-specific training.

This athlete should then be prescribed rehabilitation exercises that correspond to any deficits in their VOMS test that may still be present.

It is critically important to make sure that athletes have recovered to normal brain function before being cleared for contact sport. Sustaining a second concussion before the previous concussion has healed greatly increases the risk of a severe concussion and serious long term complications. This can include worsening symptoms, permanent brain damage, and even death.

Conclusion.

This article has focused on the purpose of the Vestibular Ocular Motor Screen (VOMS) in a concussion patient’s recovery process. This test helps accurately measure and evaluate an individual’s oculomotor and vestibular systems in order to identify potential functional deficits that could be causing issues with balance, eye movements, gaze stability, and visual sensitivity.

The results of the VOMS can provide valuable information for creating a tailored treatment plan that will help the patient regain physical and cognitive abilities. Through its accurate assessment of a concussion patient’s oculomotor and vestibular systems, the VOMS is an invaluable tool in helping them to effectively recover and return to both sport and life.

Disclaimer

This is not intended as a substitute for the medical advice of doctors and/or healthcare professionals. Patients should consult their physician and/or healthcare providers in matters relating to their health, and in particular, with respect to any brain injury, concussion and/or symptoms that may require diagnosis or medical attention.

References 
  1. Mucha A, Collins MW, Elbin RJ, Furman JM, Troutman-Enseki C, DeWolf RM, Marchetti G, Kontos AP. A Brief Vestibular/Ocular Motor Screening (VOMS) assessment to evaluate concussions: preliminary findings. Am J Sports Med. 2014 Oct;42(10):2479-86. doi: 10.1177/0363546514543775. Epub 2014 Aug 8. PMID: 25106780; PMCID: PMC4209316.
  2. Kontos AP, Elbin RJ, Schatz P, et al. A revised factor structure for the Post-Concussion Symptom Scale: baseline and postconcussion factors. Am J Sports Med. 2012;40(10):2375-2384.
  3. Lau BC, Kontos AP, Collins MW, Mucha A, Lovell MR. Which on-field signs/symptoms predict protracted recovery from sport-related concussion among high school football players? Am J Sports Med. 2011;39(11):2311-2318.
  4. Ciuffreda KJ, Ludlam D, Thiagarajan P. Oculomotor diagnostic protocol for the mTBI population. Optometry. 2011;82(2):61-63.
  5.  Kaae C, Cadigan K, Lai K, Theis J. Vestibulo-ocular dysfunction in mTBI: Utility of the VOMS for evaluation and management. A review. NeuroRehabilitation. 2022 Jan 1(Preprint):1-8.
  6. Silverberg ND, Iverson GL; ACRM Brain Injury Special Interest Group Mild TBI Task Force and the ACRM Mild TBI Definition Expert Consensus Group, ACRM Brain Injury Special Interest Group Mild TBI Task Force members; Cogan A, Dams-O’Connor K, Delmonico R, Graf MJP, Iaccarino MA, Kajankova M, Kamins J, McCulloch KL, McKinney G, Nagele D, Panenka WJ, Rabinowitz AR, Reed N, Wethe JV, Whitehair V; ACRM Mild TBI Diagnostic Criteria Expert Consensus Group; Anderson V, Arciniegas DB, Bayley MT, Bazarian JJ, Bell KR, Broglio SP, Cifu D, Davis GA, Dvorak J, Echemendia RJ, Gioia GA, Giza CC, Hinds SR 2nd, Katz DI, Kurowski BG, Leddy JJ, Sage NL, Lumba-Brown A, Maas AIR, Manley GT, McCrea M, Menon DK, Ponsford J, Putukian M, Suskauer SJ, van der Naalt J, Walker WC, Yeates KO, Zafonte R, Zasler ND, Zemek R. The American Congress of Rehabilitation Medicine Diagnostic Criteria for Mild Traumatic Brain Injury. Arch Phys Med Rehabil. 2023 May 19:S0003-9993(23)00297-6. doi: 10.1016/j.apmr.2023.03.036. Epub ahead of print. PMID: 37211140.