Complex Tandem Gait and VVE application Part 4 of 4

- Our ninth and final maneuver is complex tandem gait, where we'll have our patient walk for five steps each forward and backward, eyes open and closed with their feet in tandem. So I'll instruct Dr. Master to begin walking with one foot in front of the other as if she's walking on a tightrope, keeping her hands at her sides for five steps with her eyes open in the forward direction. I'll then have her close her eyes for five more steps. Pause, open her eyes, and begin walking backwards for five steps with eyes open, and then five steps with eyes closed. As she does this again, we'll talk about abnormalities. So two kinds of abnormalities. For each step our patient takes, it can either be on or off the straight line, and then they can also have presence or absence of sway. Where sway is, if we imagine a vertical line going from the crown of our patient's head to between their feet, a sway of more than 30 degrees in either direction or widening of their gait as they walk. So we can have five errors steps off the line or sway for each of the four conditions. We sum that up on a 0 to 24 scale. Anything more than five combined abnormalities on that 0 to 24 scale is an abnormal test. Alternatively, if our patient cannot perform one of the four elements of the complex tandem gait, that is also an abnormal complex tandem gait. So why take the two to three minutes to perform a visio-vestibular examination? First, this can help assist in our diagnosis. So for the patient who comes in following head trauma, who has a mild symptom burden, but has a significant number of visio-vestibular deficits, that visio-vestibular exam can help cinch the diagnosis for you. And we found that in the emergency department, earlier concussion diagnosis leads to earlier recovery. Secondly, it can help with risk stratification. So we found a really strong correlation between a large number of visio-vestibular examination element deficits and prolonged recovery times. So if you have a patient in the ED who has a large visio-vestibular deficit burden, you can think about earlier referral to a concussion specialist. And these are a therapeutic target. So there exists vestibular rehabilitation strategies. And finally, and perhaps most importantly, this exam is a functional assessment of our concussion patients. So we all use the visio-vestibular exam elements thousands of times a day, particularly those patients who are in school. For example, horizontal saccades is reading, vertical saccades is looking up at a board and taking notes. A near point of convergence is reading small font print. We can think about prescribing relevant accommodations related to the deficits that we identify in the ED. For example, that child that's struggling with vertical saccades may be able to get back into school more expeditiously within accommodation for pre-printed notes. And we found that an earlier return to school can really help augment recovery times and get the child, adolescent, or young adults back to their baseline most expeditiously. It's really important to remember that less than half of both pediatric and adult concussion patients who are diagnosed in the emergency department will ever see another provider again. So if you as the emergency department clinician may be the only one who is able to provide concussion specific anticipatory guidance for your patient. For more information on the VVE, including a step-by-step detailed instruction on how to perform each exam element, you can check out CHOP's Acute Head Trauma Pathway, or the Minds Matter website.