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Reliability of the visio-vestibular examination for concussion among providers in a pediatric emergency department

  • Daniel J. Corwin
    Correspondence
    Corresponding author at: The Children's Hospital of Philadelphia, Roberts Center for Pediatric Research, 2716 South St, Philadelphia, PA 19103, United States of America.
    Affiliations
    Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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  • Kristy B. Arbogast
    Affiliations
    Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Center for Injury Research and Prevention, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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  • Casey Swann
    Affiliations
    Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
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  • Rebecca Haber
    Affiliations
    Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America
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  • Matthew F. Grady
    Affiliations
    Sports Medicine and Performance Center, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
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  • Christina L. Master
    Affiliations
    Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Sports Medicine and Performance Center, The Children's Hospital of Philadelphia, Philadelphia, PA, United States of America

    Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States of America
    Search for articles by this author

      Abstract

      Background

      Visio-vestibular examination (VVE) deficits are common following pediatric concussion. Guidelines recommend assessing these deficits on all potentially concussed youth given their diagnostic and prognostic value, however test psychometrics of the VVE in the emergency department (ED) setting are unknown. Our objective was to determine the inter-rater (IRR) and test-retest reliability (TRR) of the VVE in a pediatric ED.

      Methods

      We enrolled 155 patients (112 IRR; 43 TRR) age 6–18 years with head injury presenting to the ED of a tertiary care children's hospital. Exams were performed by a group of 65 attending/fellow physicians, pediatricians, and advanced practice providers. The VVE consisted of 9 maneuvers (smooth pursuits, horizontal/vertical saccades and gaze stability, binocular convergence, left/right monocular accommodation, complex tandem gait). Cohen's kappa was calculated for IRR and TRR for each element.

      Results

      For IRR, 5/9 kappas (saccades, gaze stability, monocular accommodation) were in the moderate agreement range (0.40 to 0.60); remaining kappas showed fair agreement. For TRR, 6/9 maneuvers (saccades, horizontal gaze stability, monocular accommodation, tandem gait) showed substantial agreement (0.60 to 0.80). Kappas of 7/9 elements for subjects age 15–18 showed improved IRR and TRR.

      Conclusions

      The individual elements of the VVE show fair to moderate agreement between providers and moderate to substantial agreement among the same provider in the ED setting. These findings suggest a role in the VVE in evaluating concussion acutely, particularly given its previously demonstrated ability to assist in risk stratification of concussed youth and the importance of early diagnosis for improved outcomes.

      Abbreviations:

      ED (emergency department), IR (inter-rater), TR (test-retest), VOMS (vestibular/oculomotor screening), VVE (visio-vestibular examination)

      Keywords

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