Reliance on symptom reporting, delayed symptom onset, and possible overlap of symptoms with other health conditions make concussions challenging to diagnose in the fast-paced environment of the emergency department — especially among children.¹ However, a streamlined evaluation of a patient’s eye movements, vision, and balance may improve concussion diagnosis in the ED.

Researchers from Children’s Hospital of Philadelphia have fine-tuned a visio-vestibular examination (VVE) as a reliable way to augment acute concussion evaluation.^2-6 A VVE can be completed in two to three minutes and can be performed in children as young as 5.⁴ Furthermore, it facilitates more accurate concussion diagnosis in the ED, which is linked to better recovery.⁷

Recognizing Visio-vestibular Dysfunction

A VVE hones in on visio-vestibular dysfunction, which may be present in as many as nine out of 10 pediatric patients with a concussion.^8-10 Symptomatically, this may manifest as dizziness, headaches, problems with balance, blurred vision, nausea, and sensitivity to light or noise.¹¹ Visio-vestibular symptoms may only be present when provoked by stimuli or movement, and, therefore may be missed during an initial evaluation in the ED without use of VVE or other vestibular and oculomotor screening.^12,13

The table below provides step-by-step guidance on performing a VVE. ACEP has also created a series of 30-second instructional videos for emergency physicians. Although one abnormal testing element may be normal for a patient, as more abnormalities present, the more likely it is that a patient has a concussion.⁶ Elements of a VVE include:¹⁴

• nystagmus/smooth pursuit—the ability to track a moving object smoothly in a single plane,
• saccades—rapid, jumping eye movements that shift the gaze from one point to another,
• gaze stability (the vestibulo-ocular reflex)—ability of the eyes to maintain a clear and steady focus on a stationary object while the head is moving,
• near-point of convergence—closest distance at which two eyes can maintain single vision while focusing on a near object,
• monocular accommodation—eye’s ability to adjust its focus when viewing objects at different distances using only one eye, and
• complex tandem gait—assessing the presence of steps off a straight line or sway when walking forward and backward with eyes open and closed. 

Visio-Vestibular Examinations

Source: Children’s Hospital of Philadelphia
Emergency Department Clinical Pathway for Evaluation /Treatment of Children with Acute Head Trauma
Authors: Corwin D, Nadel F, Mittal M, Jacobstein C, Lavelle J, Scribano P, Chen S
Editors: Clinical Pathways Team
Last Revised: May 2025
Accessed: 26 Oct 2025

Visio-Vestibular Symptoms

Visio-vestibular symptoms may make daily activities (like reading and using a computer) a struggle, particularly as children are returning to school.¹⁵ Research also shows that pediatric patients with visio-vestibular dysfunction have more missed school days, experience more academic challenges, and are more likely to experience a prolonged recovery.^15-16 In fact, the more visio-vestibular symptoms a person has, the more likely they are to experience a prolonged recovery.^16,19

Guidelines recommend assessment of visio-vestibular symptoms and patient education by physicians because referral for interventions may mitigate the risk for adverse outcomes.^18,20-23 Findings from a VVE may also assist customizing return-to-activity guidance to a patient’s symptoms. For example, abnormal findings during an exam of horizontal saccades may result in challenges with reading, whereas abnormal findings on vertical saccades may mean that a child may have difficulty reviewing information on a whiteboard and taking notes. Simple accommodations, such as getting additional time to read and access to take-home notes, may make all the difference for children returning to school with a concussion.

For more information, including a step-by-step detailed instruction on how to perform each VVE element, check out CHOP’s Acute Head Trauma Pathway and the Minds Matter website.

The Brain Injury Association of America also offers training for health professionals on brain injury care through professional certifications, exceptional education, and innovative research initiatives. Learn more.

Ms. Sarmiento is Director of Outreach Programs at the Brain Injury Association of America.

Dr. Corwin is an attending physician and director of clinical and translational research in the Division of Emergency Medicine, and associate director and Emergency Department lead of the Minds Matter Concussion Program at Children’s Hospital of Philadelphia.

Dr. Master is a pediatrician and sports medicine specialist at Children’s Hospital of Philadelphia with expertise in primary care sports medicine and brain injury medicine.

References

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