Predictive Accuracy of the Sport Concussion Assessment Tool 3 and Vestibular/Ocular-Motor Screening, Individually and In Combination: A National Collegiate Athletic Association–Department of Defense Concussion Assessment, Research and Education Consortium Analysis

Abstract

Background: Vestibular and ocular symptoms in sport-related concussions are common. The Vestibular/Ocular-Motor Screening (VOMS) tool is a rapid, free, pen-and-paper tool that directly assesses these symptoms and shows consistent utility in concussion identification, prognosis, and management. However, a VOMS validation study in the acute concussion period of a large sample is lacking. Purpose: To examine VOMS validity among collegiate student-athletes, concussed and nonconcussed, from the multisite National Collegiate Athletic Association–Department of Defense Concussion Assessment, Research and Education (CARE) Consortium. A secondary aim was to utilize multidimensional machine learning pattern classifiers to deduce the additive power of the VOMS in relation to components of the Sport Concussion Assessment Tool 3 (SCAT3). Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: Preseason and acute concussion assessments were analyzed for 419 student-athletes. Variables in the analysis included the VOMS, Balance Error Scoring System, Standardized Assessment of Concussion, and SCAT3 symptom evaluation score. Descriptive statistics were calculated for all tools, including Kolmogorov-Smirnov significance and Cohen d effect size. Correlations between tools were analyzed with Spearman r, and predictive accuracy was evaluated through an Ada Boosted Tree machine learning model’s generated receiver operating characteristic curves. Results: Total VOMS scores and SCAT3 symptom scores demonstrated significant increases in the acute concussion time frame (Cohen d = 1.23 and 1.06; P < .0001), whereas the Balance Error Scoring System lacked clinical significance (Cohen d = 0.17). Incorporation of VOMS into the full SCAT3 significantly boosted overall diagnostic ability by 4.4% to an area under the curve of 0.848 ( P < .0001) and produced a 9% improvement in test sensitivity over the existing SCAT3 battery. Conclusion: The results from this study highlight the relevance of the vestibular and oculomotor systems to concussion and the utility of the VOMS tool. Given the 3.8 million sports-related and 45,121 military-related concussions per year, the addition of VOMS to the SCAT3 is poised to identify up to an additional 304,000 athletes and 3610 servicemembers annually who are concussed, thereby improving concussion assessment and diagnostic rates. Health care providers should consider the addition of VOMS to their concussion assessment toolkits, as its use can positively affect assessment and management of concussions, which may ultimately improve outcomes for this complex and common injury.

Utility of VOMS, SCAT3, and ImPACT Baseline Evaluations for Acute Concussion Identification in Collegiate Athletes: Findings From the NCAA-DoD Concussion Assessment, Research and Education (CARE) Consortium

“…38 It is increasingly being used alongside other tools such as the Sport Concussion Assessment Tool (SCAT) and the Immediate Post-concussion Assessment and Cognitive Testing (ImPACT) tool for concussion assessment and management, including during preseason baseline testing. 36 These tools have been shown to improve the accuracy of concussion identification in acute evaluations, 11,18,41 and they are commonly conducted in mandatory preseason concussion evaluation settings and at the acute phase of injury. 36 However, controversy has arisen over the comparative diagnostic value of using raw postinjury scores alone versus considering change scores based on the difference between the postinjury performance and the most recent preseason baseline test.…”

“…32 The use of ROCs to evaluate concussion assessment utility is increasing, with results aiding clinicians' understanding of the diagnostic value that various tools offer. 11,18,41 Clinicians understandably face significant pressure to maximize accurate and timely concussion detection. Yet, conducting preseason baseline evaluation assessments on every athlete places significant resource burdens, in terms of time and costs, on both athletes and organizations.…”

Factors Associated With a Prolonged Time to Return to Play After a Concussion

“…Most athletes will demonstrate clinical recovery from a concussion within 2 to 4 weeks. 6,8,18 However, some athletes take longer, and a small subset can have symptoms for months after the initial injury. 4,8,10,[16][17][18] Identifying athletes who are at risk for delayed recovery is crucial, not only for prognostication and early intervention but also to mitigate the emotional and physical toll associated with prolonged RTP times.…”

“…8,18 However, much of this same literature has reported inconsistent results regarding the correlation of female sex, a history of migraines, or a history of attention-deficit/hyperactivity disorder (ADHD) with prolonged RTP times after a concussion. 1,4,9,10,12,13,16,18 Furthermore, several systematic reviews 6,9,13 have investigated these as well as other risk factors associated with prolonged recovery from a concussion but with inconsistent findings. The recent 2019 American Medical Society for Sports Medicine position statement on concussions specifically called for further research to identify risk factors for prolonged recovery and identified this as a key area for future studies.…”

“…7 The most consistent postinjury predictor of prolonged RTP times is the number and severity of acute symptoms on initial evaluation. [6][7][8]18 However, the literature is mixed regarding whether specific symptoms can be predictive of prolonged recovery. Many studies have sought to identify specific self-reported symptoms or symptom patterns that are correlated with prolonged RTP times, but findings have been inconsistent.…”