Vestibulo-Ocular Workup for Persistent Post-Concussion Symptoms — Beyond VOMS [2026]

The acute VOMS — Vestibular/Ocular Motor Screening — is a 5-minute provocation screen across smooth pursuits, saccades, convergence, VOR (horizontal + vertical), and visual motion sensitivity. It produces a yes/no signal: is there vestibulo-ocular involvement worth pursuing? See our full guide: VOMS in Concussion Care.

For chronic cases, the answer is almost always yes — which is why VOMS alone is insufficient. The chronic workup characterises:

• Which subsystem(s) — vestibular, oculomotor (convergence), or both
• What severity — provoking threshold, symptom intensity, recovery time
• What treatment-responsive — does sub-threshold exercise produce adaptation, or does it provoke without progress?
• What's missed — BPPV, vestibular hypofunction, ocular motor disease unrelated to concussion

Convergence insufficiency is a common and treatable chronic driver. It's easy to miss on the acute VOMS because the patient may converge once or twice without obvious failure — but with sustained reading or screen use it produces headache, blurred vision, and fatigue.

Workup:

• NPC measurement — patient focuses on a target moving toward the nose. Record distance at which fusion breaks (double vision appears) and recovery distance.
• Normal NPC: <6 cm break, <8 cm recovery. Persistent NPC >6 cm break indicates convergence insufficiency.
• Repeated measure — assess once, rest, repeat 3-5 times. Worsening over repeats suggests fatigue contribution.

Treatment: pencil push-ups, Brock string, near-far focus training. 5-10 minutes 2-3 times daily. Most patients improve in 4-6 weeks.

BPPV after head trauma is common, treatable, and routinely missed. Otoliths get dislodged into the semicircular canals during the impact, producing position-provoked vertigo that the patient may not connect to the original injury.

Every PPCS dizziness workup needs:

• Dix-Hallpike test (both sides) — for posterior canal BPPV, the most common type
• Supine roll test — for horizontal canal BPPV
• If positive: Epley manoeuvre (posterior) or Lempert / Gufoni (horizontal). Effective in 80%+ of cases on first treatment.

Don't assume the patient's chronic dizziness can't be BPPV because it's been months. BPPV doesn't spontaneously resolve in everyone — repositioning treatment can produce dramatic improvement in patients who've been managed unsuccessfully for months as “chronic concussion dizziness.”

If VOMS provokes symptoms with VOR testing (horizontal or vertical), the patient needs vestibular adaptation work — not symptom avoidance.

Structured prescription:

• VOR ×1 — fixed target, head moves. Start at the velocity the patient tolerates without symptom flare for 2 minutes.
• VOR ×2 — target moves opposite to head (more demanding). Add once VOR ×1 is symptom-free at 2 minutes.
• Symptom-threshold prescription — exercise to the point of mild provocation, recover, repeat. Avoid both the “never provoke” trap and the “push through severe symptoms” trap.
• Weekly progression — increase velocity, duration, and complexity (standing → walking, eyes-open → eyes-closed transitions).

Expected timeframe to substantial improvement: 4-8 weeks of consistent practice. If no improvement at 8 weeks, escalate to vestibular specialist for instrumented testing.

Most vestibulo-ocular PPCS responds to structured rehab by a competent generalist clinician with the workup framework. Refer when:

• BPPV-negative persistent vertigo — Dix-Hallpike and supine roll tests negative, but vertigo continues
• Suspected vestibular hypofunction — positive head-impulse test, persistent gaze-evoked nystagmus, asymmetric VOR
• No improvement after 6-8 sessions of structured vestibulo-ocular rehab
• Complex bilateral involvement — bilateral hypofunction, oscillopsia
• Need for instrumented testing — video head-impulse test (vHIT), caloric testing, posturography
• Ocular motor findings unrelated to concussion — internuclear ophthalmoplegia, persistent nystagmus types not consistent with peripheral vestibular pathology — these warrant neurology referral, not vestibular specialist

A typical PPCS vestibulo-ocular assessment session takes 40-60 minutes:

• 10 min — history, prior treatment, current functional impact
• 5 min — acute VOMS (smooth pursuits, saccades, NPC, VOR, visual motion sensitivity)
• 10 min — BPPV screening (Dix-Hallpike both sides, supine roll)
• 5 min — quantified NPC, repeated measures
• 10 min — gaze stability exercise tolerance benchmark (VOR ×1 starting prescription)
• 5 min — home program prescription, written instructions, expected timeframe
• 5 min — review at 2 weeks, adjust prescription

Don't skip steps. Each is high-yield in a different subset of patients, and the workup is what separates effective PPCS care from “keep doing VOR exercises and see how you go.”