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Wethe JV, Bogle J, Dodick DW, Howard MD, Gould AR, Butterfield RJ, Buras MR, Adler J, Talaber A, Soma D, Starling AJ. Baseline Normative and Test-Retest Reliability Data for Sideline Concussion Assessment Measures in Youth. Diagnostics (Basel) 2024; 14:1661. [PMID: 39125537 PMCID: PMC11311299 DOI: 10.3390/diagnostics14151661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/25/2024] [Accepted: 07/30/2024] [Indexed: 08/12/2024] Open
Abstract
Tools used for the identification, evaluation, and monitoring of concussion have not been sufficiently studied in youth or real-world settings. Normative and reliability data on sideline concussion assessment measures in the youth athlete population is needed. Pre-season normative data for 515 athletes (93.5% male) aged 5 to 16 on the Standardized Assessment of Concussion (SAC/SAC-Child), modified Balance Errors Scoring System (mBESS), Timed Tandem Gait (TTG), and the King-Devick Test (KDT) are provided. A total of 212 non-injured athletes repeated the measures post-season to assess test-retest reliability. Mean performance on the SAC-C, mBESS, TTG, and KDT tended to improve with age. KDT was the only measure that demonstrated good to excellent stability across age ranges (ICC = 0.758 to 0.941). Concentration was the only SAC/SAC-C subtest to demonstrate moderate test-retest stability (ICC = 0.503 to 0.706). TTG demonstrated moderate to good (ICC = 0.666 to 0.811) reliability. mBESS demonstrated poor to moderate reliability (ICC = -0.309 to 0.651). Commonly used measures of concussion vary regarding test-retest reliability in youth. The data support the use of at least annual sport concussion baseline assessments in the pediatric population to account for the evolution in performance as the child ages. Understanding the variation in the stability and the evolution of baseline performance will enable improved identification of possible injury.
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Affiliation(s)
- Jennifer V. Wethe
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
| | - Jamie Bogle
- Department of Otolaryngology-Head and Neck Surgery, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
| | - David W. Dodick
- Department of Neurology, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
| | - Marci D. Howard
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
| | - Amanda Rach Gould
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
| | - Richard J. Butterfield
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Scottsdale, AZ 85259, USA
| | - Matthew R. Buras
- Division of Biostatistics and Clinical Trials, Department of Quantitative Health Sciences, Scottsdale, AZ 85259, USA
| | - Jennifer Adler
- Department of Psychiatry and Psychology, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
| | | | - David Soma
- Department of Pediatric and Adolescent Medicine, Department of Orthopedic Surgery, Mayo Clinic School of Medicine and Science, Rochester, MN 55905, USA
| | - Amaal J. Starling
- Department of Neurology, Mayo Clinic School of Medicine and Science, Scottsdale, AZ 85259, USA
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Harper B, Shiraishi M, Soangra R. Reliability and Validity of Inertial Sensor Assisted Reaction Time Measurement Tools among Healthy Young Adults. SENSORS (BASEL, SWITZERLAND) 2022; 22:8555. [PMID: 36366253 PMCID: PMC9656344 DOI: 10.3390/s22218555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/21/2022] [Accepted: 11/02/2022] [Indexed: 06/16/2023]
Abstract
The assessment of movement reaction time (RT) as a sideline assessment is a valuable biomarker for mild TBI or concussion. However, such assessments require controlled laboratory environments, which may not be feasible for sideline testing during a game. Body-worn wearable devices are advantageous as being cost-effective, easy to don and use, wirelessly transmit data, and ensure unhindered movement performance. This study aimed to develop a Drop-stick Test System (DTS) with a wireless inertial sensor and confirm its reliability for different standing conditions (Foam versus No Foam) and task types (Single versus Dual), and postures (Standing versus sitting). Fourteen healthy young participants (seven females, seven males; age 24.7 ± 2.6 years) participated in this study. The participants were asked to catch a falling stick attached to the sensor during a drop test. Reaction Times (RTs) were calculated from data for each trial from DTS and laboratory camera system (gold standard). Intraclass correlation coefficients (ICC 3,k) were computed to determine inter-instrument reliability. The RT measurements from participants using the camera system and sensor-based DTS showed moderate to good inter-instrument reliability with an overall ICC of 0.82 (95% CI 0.78-0.85). Bland-Altman plots and 95% levels of agreement revealed a bias where the DTS underestimated RT by approximately 50 ms.
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Affiliation(s)
- Brent Harper
- Crean College of Health and Behavioral Sciences, Chapman University, Irvine, CA 92618, USA
| | - Michael Shiraishi
- Crean College of Health and Behavioral Sciences, Chapman University, Irvine, CA 92618, USA
| | - Rahul Soangra
- Crean College of Health and Behavioral Sciences, Chapman University, Irvine, CA 92618, USA
- Fowler School of Engineering, Chapman University, Orange, CA 92866, USA
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King-Devick testing and concussion recovery time in collegiate athletes. J Sci Med Sport 2022; 25:930-934. [DOI: 10.1016/j.jsams.2022.08.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Revised: 04/28/2022] [Accepted: 08/25/2022] [Indexed: 11/21/2022]
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Harmon KG, Whelan BM, Aukerman DF, Bohr AD, Nerrie JM, Elkinton HA, Holliday M, Poddar SK, Chrisman SPD, McQueen MB. Diagnostic accuracy and reliability of sideline concussion evaluation: a prospective, case-controlled study in college athletes comparing newer tools and established tests. Br J Sports Med 2021; 56:144-150. [PMID: 33883170 DOI: 10.1136/bjsports-2020-103840] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess diagnostic accuracy and reliability of sideline concussion tests in college athletes. METHODS Athletes completed baseline concussion tests including Post-Concussion Symptom Scale, Standardised Assessment of Concussion (SAC), modified Balance Error Scoring System (m-BESS), King-Devick test and EYE-SYNC Smooth Pursuits. Testing was repeated in athletes diagnosed acutely with concussion and compared to a matched teammate without concussion. RESULTS Data were collected on 41 concussed athletes and 41 matched controls. Test-retest reliability for symptom score and symptom severity assessed using control athletes was 0.09 (-0.70 to 0.88) and 0.08 (-1.00 to 1.00) (unweighted kappa). Intraclass correlations were SAC 0.33 (-0.02 to 0.61), m-BESS 0.33 (-0.2 to 0.60), EYE-SYNC Smooth Pursuit tangential variability 0.70 (0.50 to 0.83), radial variability 0.47 (0.19 to 0.69) and King-Devick test 0.71 (0.49 to 0.84). The maximum identified sensitivity/specificity of each test for predicting clinical concussion diagnosis was: symptom score 81%/94% (3-point increase), symptom severity score 91%/81% (3-point increase), SAC 44%/72% (2-point decline), m-BESS 40%/92% (5-point increase), King-Devick 85%/76% (any increase in time) and EYE-SYNC Smooth Pursuit tangential variability 48%/58% and radial variability 52%/61% (any increase). Adjusted area under the curve was: symptom score 0.95 (0.89, 0.99), symptom severity 0.95 (95% CI 0.88 to 0.99), SAC 0.66 (95% CI 0.54 to 0.79), m-BESS 0.71 (0.60, 0.83), King-Devick 0.78 (0.69, 0.87), radial variability 0.47 (0.34, 0.59), tangential variability 0.41 (0.30, 0.54) CONCLUSION: Test-retest reliability of most sideline concussion tests was poor in uninjured athletes, raising concern about the accuracy of these tests to detect new concussion. Symptom score/severity had the greatest sensitivity and specificity, and of the objective tests, the King-Devick test performed best.
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Affiliation(s)
| | - Bridget M Whelan
- Family Medicine, University of Washington, Seattle, Washington, USA
| | - Douglas F Aukerman
- Department of Family Medicine, Oregon State University, Corvallis, Oregon, USA
| | - Adam D Bohr
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
| | - J Matthew Nerrie
- Intercollegiate Athletics, University of Washington, Seattle, Washington, USA
| | - Heather A Elkinton
- Intercollegiate Athletics, Oregon State University, Corvallis, Oregon, USA
| | - Marissa Holliday
- Intercollegiate Athletics, University of Colorado Boulder, Boulder, Colorado, USA
| | - Sourav K Poddar
- Department of Family Medicine, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
| | - Sara P D Chrisman
- Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA.,Harborview Injury Prevention and Research Center, Seattle, Washington, USA
| | - Matthew B McQueen
- Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
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Yue JK, Phelps RRL, Chandra A, Winkler EA, Manley GT, Berger MS. Sideline Concussion Assessment: The Current State of the Art. Neurosurgery 2021; 87:466-475. [PMID: 32126135 DOI: 10.1093/neuros/nyaa022] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 12/15/2019] [Indexed: 02/03/2023] Open
Abstract
More than 200 million American adults and children participate in organized physical activity. Growing awareness has highlighted that concussion, especially when repeated, may be associated with prolonged neurological, cognitive, and/or neuropsychiatric sequelae. Objective diagnosis of concussion remains challenging. Although some concussion symptoms may be apparent even to nonmedical observers, diagnosis and removal from play for evaluation depend on validated assessment tools and trained, vigilant healthcare personnel. Over the past 2 decades, sideline concussion measures have undergone significant revision and augmentation to become more comprehensive batteries in order to detect a wide spectrum of symptomatology, eg, neurocognitive function, postconcussive symptoms, gait/balance, and saccadic eye movements. This review summarizes the current state-of-the-art concussion evaluation instruments, ranging from the Sports Concussion Assessment Tool (SCAT) and tools that may enhance concussion detection, to near-term blood-based biomarkers and emerging technology (eg, head impact sensors, vestibulo-ocular/eye-tracking, and mobile applications). Special focus is directed at feasibility, utility, generalizability, and challenges to implementation of each measure on-field and on the sidelines. This review finds that few instruments beyond the SCAT provide guidance for removal from play, and establishing thresholds for concussion detection and removal from play in qualification/validation of future instruments is of high importance. Integration of emerging sideline concussion evaluation tools should be supported by resources and education to athletes, caregivers, athletic staff, and medical professionals for standardized administration as well as triage, referral, and prevention strategies. It should be noted that concussion evaluation instruments are used to assist the clinician in sideline diagnosis, and no single test can diagnose concussion as a standalone investigation.
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Affiliation(s)
- John K Yue
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ryan R L Phelps
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ankush Chandra
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Ethan A Winkler
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, California
| | - Mitchel S Berger
- Department of Neurological Surgery, University of California, San Francisco, California
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A COMPARISON OF THE PAPER AND COMPUTERIZED TABLET VERSION OF THE KING-DEVICK TEST IN COLLEGIATE ATHLETES AND THE INFLUENCE OF AGE ON PERFORMANCE. Int J Sports Phys Ther 2020; 15:688-697. [PMID: 33110687 DOI: 10.26603/ijspt20200688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Background Sport-related concussion is a public concern with between 1.6 and 3.8 million sport- and recreation-related injuries occurring annually. An estimated 65% to 90% of concussed athletes show oculomotor disruption such as difficulty with saccades, accommodation, smooth pursuit, and fixation. A rapid number-naming saccade test, the King-Devick (K-D) test, has shown promising results as part of a multifaceted concussion assessment tool. Purpose The purpose of the current study was to evaluate the two versions of the K-D in collegiate aged (18-24) athletes to determine the agreement between versions. A secondary purpose was to investigate the association of K-D scores with sport, sex, use of glasses or contacts, and age of the athlete. Study design Descriptive laboratory study. Methods Division 1 NCAA collegiate athletes across ten sports were recruited to participate in baseline concussion assessments at the beginning of their respective athletic season. Correlations and multivariable logistic regression analyses were used to investigate the association of K-D scores with sex and age. Results One-hundred and nine athletes (69 males, 40 females; mean age = 20.40 ± 1.38 years) were baseline tested. There was excellent agreement (ICC=0.93, 95% CI: 0.90, 0.95) between the paper and computer version. Preseason K-D scores were statistically different (r2=0.873, p<0.05) with athletes scoring a mean of 37.58 seconds on the paper version (95% CI, 36.21, 38.96) and athletes scoring a mean of 41.48 seconds for the computerized tablet version (95% CI, 40.17, 42.91). There were no significant differences in sex, sport, or use of glasses noted for both versions. Age differences were identified; eighteen-year-old athletes took statistically longer than their peers for both K-D versions. Pairwise comparisons showed statistically significant differences between 18-year olds up to the age of 21-year-olds (p<0.05) for the computer version and statistically significant differences between 18-year olds up to 22-year-olds (p<0.05) for the paper version. Conclusion This study supports the use of either version of the K-D test as a potential part of a multifaceted concussion assessment. The age of the athlete influences scores and therefore a K-D baseline should be repeated annually for collegiate athletes. Clinicians should not substitute K-D versions (computer vs. paper) in comparing baseline to a post-concussion K-D score as the scores are quite different. Level of evidence Level 3.
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Bretzin AC, Anderson M, Moran RN, Covassin T. Long-term test-retest evaluation of the King-Devick test in youth soccer athletes. J Neurol Sci 2020; 416:116951. [DOI: 10.1016/j.jns.2020.116951] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 05/12/2020] [Accepted: 05/26/2020] [Indexed: 11/25/2022]
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Breedlove KM, Ortega JD, Kaminski TW, Harmon KG, Schmidt JD, Kontos AP, Clugston JR, Chrisman SPD, McCrea MA, McAllister TW, Broglio SP, Buckley TA. King-Devick Test Reliability in National Collegiate Athletic Association Athletes: A National Collegiate Athletic Association-Department of Defense Concussion Assessment, Research and Education Report. J Athl Train 2019; 54:1241-1246. [PMID: 31618072 DOI: 10.4085/1062-6050-219-18] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The King-Devick (KD) test has received considerable attention in the literature as an emerging concussion assessment. However, important test psychometric properties remain to be addressed in large-scale independent studies. OBJECTIVE To assess (1) test-retest reliability between trials, (2) test-retest reliability between years 1 and 2, and (3) reliability of the 2 administration modes. DESIGN Cross-sectional study. SETTING Collegiate athletic training facilities. PATIENTS OR OTHER PARTICIPANTS A total of 3248 intercollegiate student-athletes participated in year 1 (male = 55.3%, age = 20.2 ± 2.3 years, height = 1.78 ± 0.11 m, weight = 80.7 ± 21.0 kg) and 833 participated in both years. MAIN OUTCOME MEASURE(S) Time, in seconds, to complete the KD error free. The KD test reliability was assessed between trials and between annual tests over 2 years and stratified by test modality (spiral-bound cards [n = 566] and tablet [n = 264]). RESULTS The KD test was reliable between trials (trial 1 = 43.2 ± 8.3 seconds, trial 2 = 40.8 ± 7.8 seconds; intraclass correlation coefficient [ICC] (2,1) = 0.888, P < .001), between years (year 1 = 40.8 ± 7.4 seconds, year 2 = 38.7 ± 7.7 seconds; ICC [2,1] = 0.827, P < .001), and for both spiral-bound cards (ICC [2,1] = 0.834, P < .001) and tablets (ICC [2,1] = 0.827, P < .001). The mean change between trials for a single test was -2.4 ± 3.8 seconds. Although most athletes improved from year 1 to year 2, 27.1% (226 of 883) of participants demonstrated worse (slower) KD times (3.2 ± 3.9 seconds) in year 2. CONCLUSIONS The KD test was reliable between trials and years and when stratified by modality. A small improvement of 2 seconds was identified with annual retesting, likely due to a practice effect; however, 27% of athletes displayed slowed performance from year 1 to year 2. These results suggest that the KD assessment was a reliable test with modest learning effects over time and that the assessment modality did not adversely affect baseline reliability.
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Affiliation(s)
- Katherine M Breedlove
- Center for Clinical Spectroscopy, Brigham and Women's Hospital and Department of Radiology, Harvard Medical School, Boston, MA
| | - Justus D Ortega
- Department of Kinesiology and Recreation Administration, Humboldt State University, Arcata, CA
| | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | | | | | | | - James R Clugston
- Department of Community Health and Family Medicine, Department of Neurology, and Division of Sports Health, University Athletic Association, University of Florida, Gainesville
| | - Sara P D Chrisman
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | | | | | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
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Clugston JR, Houck ZM, Asken BM, Boone JK, Kontos AP, Buckley TA, Schmidt JD, Chrisman SPD, Hoffman NL, Harmon KG, Kaminski TW, Collins MW, McAllister TW, McCrea MA, Broglio SP, Ortega JD. Relationship Between the King-Devick Test and Commonly Used Concussion Tests at Baseline. J Athl Train 2019; 54:1247-1253. [PMID: 31584854 DOI: 10.4085/1062-6050-455-18] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT Comprehensive assessments are recommended to evaluate sport-related concussion (SRC). The degree to which the King-Devick (KD) test adds novel information to an SRC evaluation is unknown. OBJECTIVE To describe relationships at baseline among the KD and other SRC assessments and explore whether the KD provides unique information to a multimodal baseline concussion assessment. DESIGN Cross-sectional study. SETTING Five National Collegiate Athletic Association institutions participating in the Concussion Assessment, Research and Education (CARE) Consortium. PATIENTS OR OTHER PARTICIPANTS National Collegiate Athletic Association student-athletes (N = 2258, age = 20 ± 1.5 years, 53.0% male, 68.9% white) in 11 men's and 13 women's sports. MAIN OUTCOME MEASURE(S) Participants completed baseline assessments on the KD and (1) the Symptom Inventory of the Sport Concussion Assessment Tool-3rd edition, (2) the Brief Symptom Inventory-18, (3) the Balance Error Scoring System, (4) the Standardized Assessment of Concussion (SAC), (5) the Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) test battery, and (6) the Vestibular/Ocular Motor Screening tool during their first year in CARE. Correlation coefficients between the KD and the 6 other concussion assessments in isolation were determined. Assessments with ρ magnitude >0.1 were included in a multivariate linear regression analysis to evaluate their relative association with the KD. RESULTS Scores for SAC concentration, ImPACT visual motor speed, and ImPACT reaction time were correlated with the KD (ρ = -0.216, -0.276, and 0.164, respectively) and were thus included in the regression model, which explained 16.8% of the variance in baseline KD time (P < .001, Cohen f2 = 0.20). Better SAC concentration score (β = -.174, P < .001), ImPACT visual motor speed (β = -.205, P < .001), and ImPACT reaction time (β = .056, P = .020) were associated with faster baseline KD performance, but the effect sizes were small. CONCLUSIONS Better performance on cognitive measures involving concentration, visual motor speed, and reaction time was weakly associated with better baseline KD performance. Symptoms, psychological distress, balance, and vestibular-oculomotor provocation were unrelated to KD performance at baseline. The findings indicate limited overlap at baseline among the CARE SRC assessments and the KD.
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Affiliation(s)
- James R Clugston
- Department of Community Health and Family Medicine, Department of Neurology, and Division of Sports Health, University Athletic Association, University of Florida, Gainesville
| | - Zachary M Houck
- Department of Clinical Psychology, University of Florida, Gainesville
| | - Breton M Asken
- Department of Clinical Psychology, University of Florida, Gainesville
| | - Jonathan K Boone
- Department of Athletic Training, Miami Dolphins, National Football League, Davie, FL
| | | | - Thomas A Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | | | - Sara P D Chrisman
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington, Seattle
| | - Nicole L Hoffman
- School of Kinesiology and Recreation, Illinois State University, Normal
| | | | - Thomas W Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | | | - Thomas W McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Michael A McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee
| | | | - Justus D Ortega
- Department of Kinesiology and Recreation Administration, Humboldt State University, Arcata, CA
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