Using visio-vestibular examination in the emergency department helps with earlier, more accurate concussion diagnosis
By Sravya Valiveti. This article was initially published in the 2/26/26 Edition of our Concussion Update newsletter; please consider subscribing.
A recent article published in the Children’s Hospital of Philadelphia’s (CHOP’s) Research in Action blog by Dr. Daniel Corwin emphasizes the importance of using CHOP’s visio-vestibular examination (VVE) as a part of first-line concussion management in the emergency department. Due to the fast-paced environment of the emergency department, clinicians may miss subtle signs of acute concussion. This can lead to delayed diagnosis and patient care, and, in turn, prolonged recovery and worse outcomes. Dr. Corwin emphasizes that emergency room physicians play a crucial role in diagnosis, patient education, and referral, so timely and accurate diagnosis is crucial. The VVE, which takes only 2-3 minutes to perform, can aid in diagnosis, risk stratification, and functional assessment. Dr. Corwin joined Dr. Master and Kelly Sarmiento to author a related article for ACEP Now, noting that the VVE facilitates a “more accurate concussion diagnosis in the ED, which is linked to better recovery.”
The VVE is a series of maneuvers that can be quickly administered in an acute care setting to evaluate for concussion. The examination was first developed and used at CHOP to identify initial signs associated with concussion and assist with accurate diagnosis. It works by testing changes in vision, oculomotor tracking, and balance. Symptoms such as dizziness, headaches, blurred vision, nausea, and sensitivity to light or noise can all point to visio-vestibular dysfunction. However, these symptoms may only show up with provocation, so they can be easy to miss if a physical exam does not actively test for these abnormalities during initial evaluation. The VVE can be used in pediatric patients as young as five years of age and can be especially useful to evaluate concussions in pediatric patients as the data shows that 9 times out of 10 children present with visual and vestibular dysfunction when they have a concussion.
Dr. Corwin notes that “Over the past decade, the exam has been incorporated into the routine workflow of clinicians practicing in CHOP EDs, to where now nearly 80% of our patients with concussion will have a VVE performed upon diagnosis.” The American College of Emergency Physicians (ACEP) has made short, step-by-step instructional videos on performing the VVE available to emergency medicine physicians to make the training process more seamless. In VVE video #4, Dr. Corwin explains that the VVE provides risk stratification: “We found a really strong correlation between a higher number of VVE deficits and prolonged recovery times.” With patients with a high burden of VVE deficits, clinicians can consider earlier referral to a concussion specialist for vestibular rehabilitation.
When clinicians take an extra few minutes to evaluate and diagnose a concussion using the VVE, it helps them identify any limitations to visual and vestibular function that patients need care for. This knowledge can help providers work more effectively with patients to find the most appropriate treatment approach to address a patient’s symptoms, which can allow them to recover and return to their usual activities faster. For functional deficits identified with the VVE, Dr. Corwin says, “We can think about prescribing relevant accommodations relative to the deficits that we identify in the ED. For example, that child that is struggling with vertical saccades may be able to get back into school more expeditiously with an accommodation for preprinted notes.”