Concussion Vestibulo-Ocular PCS Form

Cervicogenic PCS
Patient Name*

First NameLast Name
Today's Date*

MonthDayYear
Date
Subjective
Please explain below
Vestibular-Oculomotor Screen (VOMS)
Purpose: The VOMS testing was developed to assess vestibular and ocular motor impairments via patient reported symptom provocation after each assessment. The VOMS consists of 5 domains: Smooth Pursuits (0-10), Horizontal and Vertical Saccades (0-10), Convergence (0-10), Horizontal and Vertical Vestibular Reflex (VOR)(0-10), and Visual Motion Sensitivity (0-10). Baseline symptoms are taken in reference to Headaches, Dizziness, Nausea, and Fogginess. The symptoms are reassessed after each test. The testing is looking for provocation of symptoms (2 point increase in any symptom from baseline (Mucha et al. 2015; Elbin et al. 2018). The VOMS test is designed to help establish vestibular / oculomotor dysfunction and help guide rehabilitation and potentially academic accommodations. If positive, initial rehabilitation corresponds to VOMS findings.
Additional Vestibular Testing (VOMS Passed)
VOR Cancellation: The VOR Cancellation Test (Cerebellar Test) evaluates the cerebellar inhibition on the Vestibulo-Occular Reflex (VOR). The test is performed by having the patient lock both arms in front of them with the fingers laced and the thumbs up (Visual Motion Sensitivity Test). The patient rotates back and forth with the head and arms moving together. Result: The patient’s eyes were able to remain fixed on the thumbs without slippage which indicates the cerebellum is functioning properly.

Yes No*
Dynamic Visual Acuity: The patient stands 10' from a wall with the Snellen Eye Chart. Patient reads the chart with their head stationary; the last line read correctly is the "reference line". The examiner manually oscillates the patient's head 20 degrees in each direction at a rhythmic frequency of 2 Hz. The patient reads the chart while the head is being moved and the last line read correctly is the "Test Line".

Calculating Score: Subtract "Test Line" from "Reference Line" to find DVA Score.

DVA = 0; visual acuity is the same with and without head movements.

DVA => 2; dynamic visual acuity is abnormal. If abnormal, management is Gaze Stabilization / Vestibulo-Ocular Rehab.

Reference Line:      Reference Line Numeric Value 0-20

Test Line:      Test Line Numeric Value 0-20

Dynamic Visual Acuity:      Dynamic Visual Acuity Numeric Value 0-20
Benign Positional Paroxysmal Vertigo (BPPV)
Purpose: Benign Positional Paroxysmal Vertigo (BPPV) is one of the most common causes of vertigo -- the sudden sensation that a patient is spinning or the inside of the head is spinning. BPPV causes brief episodes of mild to intense vertigo which is usually triggered by specific changes in head position.
Dix-Hallpike: Dix-Hallpike tests for otoliths affecting the posterior
canals (85%-90% of BPPV cases). The test is performed by the patient
performing 30° of neck extension and 45° of neck rotation. The patient
is quickly laid down on their back (unaffected side first). The
examiner observes for nystagmus/vertigo (upbeating nystagmus). There
may be a latency so the patient is held in the position for up to 30
seconds.

Right Side (Yes) Right Side (No) Left Side (Yes) Left Side (No)*
Supine Roll Test: If Dix-Hallpike normal but still suspecting BPPV, the Supine Roll Test is performed for Horizontal Canal BPPV. The Supine Roll Test is performed with the patient supine and the head in slight flexion. The head is rotated quickly to the left 90° looking for lateral nystagmus and/or vertigo sensation. The head is brought back to neutral and then quickly rotated to the right 90° and observed for nystagmus and/or vertigo. When present, we will likely be positive bilaterally; however, the effected side will be the side that presents the greatest symptoms.

Right Side (Yes) Right Side (No) Left Side (Yes) Left Side (No)*
DIAGNOSES (ICD-10)
Concussion W/O LOC (Subsequent Visit) S06.0X0D*

YesNo
Concussion W/ LOC < 30 Min (Subsequent Visit) S06.0X1D*

YesNo
Concussion W/ LOC Unspecified Duration (Subsequent Visit) S06.0X9D*

YesNo
Persistent Concussive Symptoms (PCS) AKA Post Concussion Syndrome F07.81*

YesNo
Convergence Insufficiency H51.11*

YesNo
Dizziness R42*

YesNo
BPPV H81.10*

YesNo
Any additional diagnoses?
PLAN / RECOMMENDATIONS
Vestibulo-Ocular PCS Testing*

PassedFailed
Vestibulo-Ocular Rehab Prescribed: When prescribed, each exercise is reviewed with the patient in detail. The patient is also given a detailed instruction handout. It is important the patient performs the exercises 3-4x/day. The patient indicated any understanding.*

Vestibulo-Ocular Rehab Level 1Vestibulo-Ocular Rehab Level 2Vestibulo-Ocular Rehab Level 3Accommodation InsufficiencyConvergence InsufficiencyBrock String Rehab ExercisesVisual Motion Sensitivity Exercises
Schedule:*

Physiologic Testing (BCTT / BCBT)Vestibulo-Ocular EvalCervicogenic EvalBESS Testing
Neurocognitive Testing Reviewed*

YesNo
Neurologic Co-Management Reviewed*

YesNo
Psychological Complicating Factors Present*

YesNo
Time: Today, I spent * minutes reviewing the patient’s current status, outcome measures, performing a Vestibulo-Ocular evaluation, discussing my recommendations, documenting my findings and completing the chart note. The patient indicated an understanding of our discussion and we will implement the above treatment plan.
Tests Reviewed*

99203 (New Patient; 30-44 Min)99204 (New Patient; 45-59 Min)99211 (Est Patient; Brief OV)99212 (Est Patient; 10-19 Min)99213 (Est Patient; 20-29 Min)99214 (Est Patient; 30-39 Min)99215 (Est Patient; 40-54 Min)97112 (Neuromuscular Re-education)
Doctors Notes:*
Provider Signature*

Clear
Date*

MonthDayYear
Date
C 2022 First Care Concussion Clinic, LLC
Should be Empty:

Cervicogenic PCS

Subjective

Vestibular-Oculomotor Screen (VOMS)

Additional Vestibular Testing (VOMS Passed)

Benign Positional Paroxysmal Vertigo (BPPV)

DIAGNOSES (ICD-10)

PLAN / RECOMMENDATIONS