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.
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.
Am J Emerg Med. 2020 Sep;38(9):1847-1853. doi: 10.1016/j.ajem.2020.06.020. Epub 2020 Jun 11.
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.
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.
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.
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.
儿科脑震荡后常出现视-前庭检查（VVE）缺陷。指南建议对所有可能出现脑震荡的青少年进行这些缺陷评估，因为它们具有诊断和预后价值，但是 VVE 在急诊（ED）环境中的测试心理测量学尚不清楚。我们的目的是确定儿科 ED 中 VVE 的观察者间（IRR）和测试-重测可靠性（TRR）。
我们招募了 155 名年龄在 6-18 岁之间因头部受伤到三级儿童医院 ED 就诊的患者（112 名 IRR；43 名 TRR）。检查由一组 65 名主治医生/研究员、儿科医生和高级实践提供者进行。VVE 由 9 项测试组成（平滑追踪、水平/垂直扫视和凝视稳定性、双眼会聚、左眼/右眼单眼调节、复杂串联步态）。计算了每项元素的 IRR 和 TRR 的 Cohen's kappa。
对于 IRR，5/9 个 kappas（扫视、凝视稳定性、单眼调节）处于中度一致范围（0.40 至 0.60）；其余的 kappas 显示出公平的一致性。对于 TRR，6/9 个动作（扫视、水平凝视稳定性、单眼调节、串联步态）显示出实质性一致（0.60 至 0.80）。15-18 岁受试者的 7/9 个动作的 kappas 显示出更好的 IRR 和 TRR。
VVE 的各个元素在提供者之间表现出公平到中度的一致性，在 ED 环境中同一提供者之间表现出中度到实质性的一致性。这些发现表明 VVE 在急性评估脑震荡方面具有作用，特别是考虑到其先前显示出有助于对脑震荡青少年进行风险分层的能力以及早期诊断对改善结果的重要性。
