Overview

The Vestibular/Ocular Motor Screening (VOMS) is a brief, clinician-administered screening tool used after a suspected concussion to identify vestibular and ocular-motor impairment — problems with eye movement control and the reflexes that keep vision stable during head movement. Unlike a purely self-report questionnaire, the VOMS combines a set of standardised eye- and head-movement tests with patient-reported symptom ratings taken immediately after each one.

Vestibular and ocular-motor dysfunction is present in a large proportion of concussions, yet it is easy to miss on standard concussion tools that focus mainly on symptom checklists and cognitive testing. The VOMS was built specifically to close that gap in under ten minutes, using equipment no more specialised than a tape measure and a target the patient can fix their gaze on.

History

The VOMS was developed by Anne Mucha, Michael Collins, R.J. Elbin, and colleagues at the University of Pittsburgh Medical Center (UPMC) Sports Concussion Program, and published in 2014 in the American Journal of Sports Medicine. It was designed in response to a clear clinical observation: vestibular and ocular-motor symptoms are extremely common after concussion, are strongly associated with a longer recovery, but were not being systematically captured by the assessment tools in widespread use at the time (such as symptom checklists and computerised cognitive testing alone).

The preliminary validation study found the VOMS could reliably distinguish concussed patients from healthy controls and demonstrated strong internal consistency across its component tests. It has since become a standard component of comprehensive post-concussion assessment, recommended alongside — not instead of — symptom inventories, balance testing, and cognitive assessment.

Indications

The VOMS is used in the assessment and management of:

Suspected acute concussion, in clinic or on the sideline, as part of a multi-domain assessment.
Persistent post-concussion symptoms, to identify whether a vestibular or ocular-motor component is contributing to ongoing headache, dizziness, or “fogginess.”
Return-to-play and return-to-learn decision-making, used alongside symptom scales, balance testing, and cognitive measures — not as a standalone clearance tool.
Referral triage for vestibular rehabilitation, since a positive VOMS is one of the more consistent predictors of which concussed patients are likely to benefit from targeted vestibular/ocular-motor therapy.
Monitoring recovery across a course of vestibular rehabilitation following concussion, by re-administering the screen and tracking whether provoked symptoms are reducing.

How It’s Scored

Administration starts with a baseline symptom rating: at rest, before any testing, the patient rates current headache, dizziness, nausea, and fogginess, each from 0 (none) to 10 (severe).

The clinician then guides the patient through seven tests:

Smooth pursuit
Horizontal saccades
Vertical saccades
Convergence (near point of convergence)
Horizontal vestibulo-ocular reflex (VOR)
Vertical vestibulo-ocular reflex (VOR)
Visual motion sensitivity (VMS)

After each test, the patient rates how much it provoked (worsened) any of the four symptoms, again on a 0–10 scale. A change score is calculated for each test by subtracting the baseline rating from the post-test rating.

The convergence test also includes an objective physical measurement: the near point of convergence (NPC), the closest distance (in centimetres) at which the patient can maintain a single, fused image of a target as it’s brought toward the bridge of the nose, typically averaged over three trials.

Interpretation

A test is generally considered positive (abnormal) if:

Any individual item’s change score is 2 points or greater, or
NPC distance is greater than roughly 5 cm.

A positive VOMS doesn’t diagnose a specific vestibular pathology on its own, but it flags that vestibular/ocular-motor impairment is likely contributing to the patient’s symptoms — information that has been associated in the research literature with a higher likelihood of a protracted recovery and a greater likelihood of benefiting from targeted vestibular rehabilitation.

What It Tells the Clinician

Localises the problem to a specific system. Because each of the seven tests probes a different oculomotor or vestibular pathway, item-level results point toward which rehabilitation exercises are likely to help — for example, prominent VOR provocation supports gaze-stabilisation exercises, while high visual motion sensitivity supports graded exposure to busy visual environments.
Adds objective signal to a subjective symptom picture. Two patients with similar total symptom-checklist scores can have very different VOMS profiles, changing the emphasis of their rehabilitation plan.
Supports return-to-play and return-to-learn conversations. A positive VOMS is one more piece of evidence that a patient isn’t yet ready for full activity, even if resting symptoms have settled.
Flags who is likely to need vestibular therapy early. Because vestibular/ocular-motor impairment is a consistent predictor of delayed recovery, a positive screen at initial assessment can prompt an earlier referral, rather than waiting for symptoms to fail to resolve on their own.
Provides a re-testable measure of recovery. Change scores on each of the seven tests can be tracked across a course of vestibular rehabilitation to document objective improvement, test by test.

References

Mucha A, Collins MW, Elbin RJ, et al. A Brief Vestibular/Ocular Motor Screening (VOMS) Assessment to Evaluate Concussions: Preliminary Findings. Am J Sports Med. 2014;42(10):2479-2486.
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. Am J Sports Med. 2016;44(6):1400-1406.
Elbin RJ, Sufrinko A, Anderson MN, et al. Prospective Changes in Vestibular and Ocular Motor Impairment After Concussion. J Neurol Phys Ther. 2018;42(3):142-148.