"For every one concussion that you see we identified, there were six concussions that were not seen and were not being reported."
The results took him by surprise. Mr King tested more than 100 Wellington premier rugby and league players over three years using what's called a saccadic reading test, which he calls his number-one tool. Players do a baseline reading pre-season and again after the games.
“For decades, optometrists have used the King-Devick test to aid in the diagnosis of ocular motor dysfunction and a need for vision therapy,” says Marc Taub, OD, MS, FAAO, FCOVD, chief of vision therapy and rehabilitation and supervisor of the residency program in pediatrics and vision therapy at Southern College of Optometry. “It is reliable and easy to perform in patients of any age or cognitive ability.
“It’s about that Jell-O within that cranium,” says Dennis Cardone, an associate professor of orthopedic surgery at Langone Medical Center, and co-director of NYU’s Concussion Center. “How it moves around, and how it collides with the cranium itself.” Because a significant proportion of our brains is used to process visual information, many of the symptoms that can be used to diagnose concussions affect vision. Cardone uses a screening test called the King-Devick test, which was developed in 1976 to measure deficiencies in eye movement during reading.
The King-Devick Test is one method Clugston and his team have used since 2011. The test is a two-minute challenge that requires an athlete to read single-digit numbers displayed on cards or on an iPad. UF collects baseline data for the King-Devick Test as with all of its concussion tests, and if an athlete is suspected of suffering head trauma, he or she is re-tested. If the time needed to complete the test is any longer than their baseline result, the athlete is removed from play and further evaluated.
UF and the University of Pennsylvania were the first schools to implement the King-Devick Test as part of their concussion management programs. “That’s something we feel is important to add in to the other concussions tests that we already do,’’ Clugston said. “It’s the only one of the simple tests that really looks at vision, and vision is a big component of the brain.”
Dr. Kurt Miceli, Medical Director of Bancroft, a neurological rehabilitation facility says it could prevent more injuries. “I’ve seen numbers one and a half million up to three million concussions a year, tremendous amounts of folks who are undergoing these concussions and the concern is to really have our kids or whoever it is not to suffer a second one.”
Video: A simple test can be done after a head injury and is a reliable way to quickly diagnose a concussion.
The simple assessment, which doesn't require medical knowledge to conduct or evaluate, may be especially useful in the youth sports arena where trainers and team physicians are few and far between. The rapid, low-tech evaluation may also help keep injured athletes from re-entering play and risking second impact syndrome, which can be fatal.
“We want to make sure that those communities that have very few resources for sideline detection can get some,” Robert said. “If we can do that for our schools — have a quick way to perform the test and have it interface seamlessly with a report to this office and perfect permanent record — then we have really made a contribution to detection and aftercare of our students.”
Don't Blink. The King-Devick Test: A Rapid, Sideline Visual Assessment Tool to Assist in Detection of Concussion
Take Home Message: The King-Devick test is a quick and reliable method to assess vision, eye movements, language function, and attention. An athlete with a concussion tends to complete the test slower than his/her preseason assessment while other athletes improve over time.
"In the youth leagues in particular, when there may not be doctors or athletic trainers on the sidelines when a kid gets hit, this enables parents with proper training to participate in the preliminary assessment of concussions," said study author Dr. Steven Galetta, a researcher at New York University Langone Concussion Center. "It's so affordable and easy to administer that any coach or parent could use it to determine when an injured child can return to the game and when they need to sit out."
Watch Jenna Lee talk about Head Injury with Laura Balcer, MD, from NYU.
"A vision test absolutely needs to be added," Dr Galetta told Medscape Medical News. "This one has been the most rigorously tested on the sidelines, and it's easy to administer by parents and others."
Overall, the King-Devick test had by far the greatest accuracy and lowest risk of false positives. The upshot, Dr. Galetta believes, is that parents and coaches “should absolutely consider” familiarizing themselves with the King-Devick test and administering it to young athletes before the season starts, then having those baseline numbers and the test itself handy on the sidelines.
Simple as it may sound, the K-D test actually does a better job of detecting concussions (with a 92 percent success rate) than two better-known methods: a "timed tandem gait test" similar to a walk-the-line test (87 percent), and a cognitive test known as the Standardized Assessment of Concussion (68 percent).
While the success rate of the King-Devick test is impressive, Balcer emphasized to HuffPost that if possible, parents should have their child perform all three of the above-mentioned concussion tests when he or she takes a hard hit. The reason could not be more clear. In tandem, the three tests can detect concussions at a rate that is truly hard to believe -- 100 percent.
“Given that concussions may cause devastating short and long-term cognitive effects, tools like vision testing that can objectively diagnose a concussion are critical,” says Laura Balcer, MD, co-author of the study.
“Our findings in children and collegiate athletes show how a simple vision test can aid in diagnosis of concussion at all levels of sport,” says Dr. Galetta, who is also a professor of ophthalmology at NYU Langone. “Adding the King-Devick test to the sideline assessment of student athletes following a head injury can eliminate the guesswork for coaches and parents when deciding whether or not a student should return to play.”
But without tell-tale signs, the clinician must turn to concussion detection tools to help guide the decision about returning the athlete back to gameplay.
LISTEN: As researchers learn more about the often crippling effects on sports-related concussions, legislators across the country worked to establish protocols and procedures for student athletes. We host Senator Dan Kotowski and Dr. Steve Devick to dig deeper into the issue and what lawmakers and schools can do to address it. Begins at 33:45.
Dr. Patrick Kersey, Medical Director for USA Football, couldn't have been more impressed with the implementation process and overall results. "The implementation process was a total breeze," Kersey said. "Very quick and easy to understand and administer, and can be done in almost any environment - optimal for the sports world."
"The actual science behind it and it being a potential valuable tool that fills a much needed void in the sideline management and evaluation of head injuries was my initial attraction," Kersey stated. "This test can provide some near immediate and important information to the medical provider, athlete, and coaches about head injuries and help answer the challenging question of 'does he/she have a concussion' and 'is it safe for them to return to play?'"
Kersey also pointed out the King-Devick Test would complement some of the more popular concussion tools that many organizations are already using, such as ImPACT.
"Studies have indicated that the King-Devick test is an effective tool for the real-time evaluation of concussion because it looks at rapid eye movement and attention, both of which are affected by concussions," said Dr. David Dodick, a neurosurgeon and the director of the Mayo Clinic's concussion program in Phoenix.
"It has now emerged as a gold standard, I think, for sideline diagnosis for concussions," Dodick said. "So it's only a matter of time, I believe, once the word gets out, where there's going to have to be a very good reason for them not to use it."
“Studies have indicated that the King-Devick test is an effective tool for the real-time evaluation of concussion because it looks at rapid eye movement and attention - both are affected by concussions,” says David Dodick, M.D., Mayo Clinic neurologist and director of Mayo Clinic’s concussion program.
Tests administered on the sidelines, such as the King-Devick and the Standardized Assessment of Concussions (SAC), require athletes to quickly read numbers or words, or to recall words. Athletes must equal or better their previous baseline test score in a set amount of time to get back into a game — and that is if they are otherwise asymptomatic. "Kids are still not honest. They want to work through it," Herceg said.
Injury liaisons such as Shaman do not need medical training to perform a series of simple assessments to check if a player may be suffering a concussion, Schmidt said. Each injury liaison performs a King-Devick test, a two-minute test conducted on the sidelines that requires a player to read single digit numbers displayed on cards, to check to see if there are any symptoms of head injuries.
“More than 50 percent of brain pathways are responsible for controlling eye movement, so injuries to the brain almost universally affect eye movement,” said Dr. David Dodick of the Mayo Clinic, who is also the Director of the Sport Neurology and Concussion Program.
Chasan’s team has provided the league with the King-Devick Test, a reading assessment tool that they’ve taught the coaches to use. Essentially, the King-Devick tool allows the coaches to compare a player’s typical brain function – as each player is baseline-tested before the season – with the player’s function directly after a suspected concussion.
Some surveys suggest there are 10-times as many concussions that are undetected than are detected. Along a similar line, Doug King, MD, and colleagues, wrote a recent paper showing that in rugby players undetected concussions are quite common. He routinely tested his rugby players with the King-Devick test and found that undetected concussions were three to four times more common compared to detected concussions.
Dr. Leong called a recent article published in The Lancet Neurology a must-read. "It highlights the important role of optometry, saying that vision-based testing is vital in managing all forms of traumatic brain injury (TBI) and provides a sensitive approach for sideline or post-injury concussion screening."
Mary Medina, the school’s head athletic trainer gave him the concussion standard ‘King-Devick’ test. “That is a short 32 second test where they read numbers and Oscar was off by a couple seconds,” said Medina. The test measured his ability to think and respond to a series of questions that he’d already taken in the past. Since he already knew the answers, he shouldn’t have had any difficulty; but that wasn’t the case. “We pulled him!” said Medina.
The King-Devick is a simple test that can be administered on the sidelines in less than two minutes, explains Troy Buchanan Principal Dr. Jerry Raines “It’s a very fast, two minute, sideline examination. We’re making database decisions instead of subjective decisions. In the past it was ‘What’s today? What did you have first hour?’ Those are more subjective. We always subscribe to ‘When in doubt, sit ‘em out,’ but this allows us to have data behind that decision. Ultimately it’s for the safety of our kids.”
Concussion Head Games - Why brain research and baseline testing should inspire a public cry for action
Visual tracking problems and silent concussions - WHY parents, the public and Optometrists need to know
Participants will take the King-Devick Test, which provides an objective measure of reaction time, eye movement and mental clarity.
The King-Devick test may be a more objective and accurate method for sideline evaluation of sports-related concussion than the Standardized Concussion Assessment Tool 3 (SCAT3), which is the current standard, according to research reported at the 56th Annual Scientific Meeting of the American Headache Society.
In the new study, Mayo Clinic researchers tested the feasibility of using a portable eye-tracking device [King-Devick Test] in a simulated environment as a way to detect the early phases of hypoxia.
In an article published this month in the journal “Neurology: Clinical Practice,” the researchers report that adding one simple vision test detected 100 percent of concussions that occurred during games or in practice.
“This is the first study that has shown that adding a vision test helps to identify more athletes with concussion and shows the vision-based King-Devick test is very effective in a college setting,” said Dr. Laura Balcer, a professor of neurology and population health at NYU.
About 1,200 students at Loyola High School, including non-athlete students, are being given a series of tests, known as baseline concussion test, designed to measure brain function.
Bert Vargas, MD, compares two tools for evaluating sports-related concussion on the sidelines.
Patients who are dealing with symptoms such as balance issues and vision problems are often referred to a neurologist such as Dr. Laura Balcer, who has done pioneering research on the link between eye movement and brain function.
CMCC & Rugby Ontario Partner to Administer Baseline Concussion Measures For More Than 235 Junior Provincial Athletes
Canadian Memorial Chiropractic College in Toronto volunteered their day to aid in the administration of baseline concussion measures with seven different Rugby Ontario junior provincial teams for over 235 athletes.
"The results of this pilot study suggest that the King-Devick remediation software may be effective in significantly improving reading fluency through rigorous practice of eye movements," Amaal Starling, MD, Mayo Clinic neurologist and a co-author of the study, said in the release.
“The results of this pilot study suggest that the King-Devick remediation software may be effective in significantly improving reading fluency through rigorous practice of eye movements,” says Dr. Starling. “What our study also found was that there was an even greater improvement between first and third grade versus third and fourth graders, which means there may be a critical learning period that will determine reading proficiency.”
“Given the many brain pathways involved in concussion, we think that a combination of cognitive, balance and vision tests may be best to improve diagnosis of concussion in athletes,” says Laura Balcer, MD, Fellow of AAN, professor and vice chair of neurology at New York University Langone Medical Center.
Dr. Devick is committed to making reliable and objective sideline concussion testing for all athletes accessible and affordable. "The King-Devick Test helps provide a safer sporting environment for youth athletes by accurately screening for concussion," he says. "It's our responsibility as parents, coaches and clinicians to identify concussions in order to remove them from play and allow children the proper time to recover from concussion so they can safely return to learn and play."
Dr. Amaal Starling of the Mayo Clinic is co-author of the study. She said for youth athletes, "This is really the first accurate, rapid, cost effective, removal-from-play tool that is available for concussion screen."
“The King-Devick test represents a rapid, accurate, and cost-effective tool to identify concussion on the sideline and make appropriate game-time, remove-from-play decisions,” Dr. Amaal Starling says.
Balancing fun and competition with safety, Ernest Murdukhayev, a director of SB4U Soccer Academy and the Jewish Community Center programs, is using the King-Devick test to assess the seriousness of any head bangs his players encounter.
"I do think this is enough to recommend this vision test be used routinely," Dr. Clugston commented. "This test is less subjective than some of the other tests used currently. An assessment of balance is always very subjective, and cognition tests can be too. But the vision test just involves reading numbers from a screen as fast you can. It is very simple and less easily manipulated by the athlete. But it is best used in combination with the standard tests."
Researchers found the time to complete the test was longer for 79-percent of players who were later found to have a concussion. When combined with other assessments, the sideline test helped diagnose 100-percent of concussions. Experts say using a vision based test on the sidelines may help detect concussions more quickly ... and keep athletes from getting injured further.
The King-Devick test capitalizes on a subtle but important symptom of brain injury: a disruption in the eyes' ability to travel smoothly across a page, and to shift direction upon the brain's command.
The study provides more evidence that the King-Devick test, a one-minute test where athletes read single-digit numbers on index cards, can be used in addition to other tests to increase the accuracy in diagnosing concussion.
New research presented at the American Academy of Neurology's 66th Annual Meeting in Philadelphia indicates that a quick vision test, known as the King-Devick test, combined with a series of other simple tests, could yield near-perfect concussion detection rates on the sidelines of a game.
Many sports medicine professionals suggest that those coaches who do not have immediate access to an athletic trainer use easy and reliable screening tools. One of the most effective screening tools is the King-Devick test. Personally, I recommend every high school and youth coach to use this screening tool. It is very easy to learn and does not require a medical professional to administer. The King-Devick test can be easily implemented into an existing concussion management protocol.
PracticeUpdate: Would you sum up in a single sentence why you chose this development as the top story of the past year?
Dr. Press: The merging of technology available to administer tests such as the King-Devick saccade test, and how to dovetail this information with batteries such as the ImPACT Test, represent a significant advancement in clinical concepts as well as tools.
One of the main benefits of this concussion program is the donation of an effective and reliable concussion screening device known as the King-Devick Test, an objective, rapid sideline screening test for concussions that can be administered by coaches, athletic trainers, and athletic support personnel.
The NYU Cover Story, notes: “Drs. Galetta and Balcer believe the King-Devick test works because at least 50 percent of the brain’s circuits are involved in vision. Thus the test can pick up deficiencies occurring across a wide range of neurological geography.
“Right now, these tests — King-Devick, SCAT2, balance, computerized assessment — are considered the standard of care, or the best procedure, for diagnosing concussions,” head Notre Dame University Physician Dr. Jim Moriarty said. “The key for us is if you’re a physician on the sidelines, you’d like to know the tests you’re running are reliable. There are symptoms that confirm concussions, but most people don’t have that. Most people have the lesser symptoms which cause you to have doubts whether you’re making the right choice or not.”
The Mayo Clinic study team used the King-Devick neurocognitive performance test, which is commonly used to identify cognitive changes related to sports-related concussions, and to assess cognitive function under conditions of low oxygen-simulating altitude. The King-Devick test assesses the time in viewing, identifying and reading aloud a series of numbers on three consecutive test cards. Based on test times of 25 participants, the study concluded that the King-Devick test is an effective tool to detect "impairment of cognitive performance at a presymptomatic stage of hypoxia."
Press Release: ImPACT® Partners with King-Devick Test in Support of Multifaceted Approach to Concussion Management
|The King-Devick Test is widely supported by published neurological research as an accurate and reliable method for identifying athletes with concussion. "The partnership between King-Devick Test and ImPACT highlights the need for schools and organizations to utilize both remove-from-play and return-to-play concussion management tools to ensure the safety of all athletes," said Steve Devick chief executive officer of King-Devick Test.|
The need for sideline rapid assessment of mild head injury is fundamental to limiting the deleterious effects of repeated impacts to the head. The great majority of athletes are at the youth sports level and not in collegiate or professional sports, which leaves many important decisions to be made by parents and coaches on the sideline. This structural element of sport is unlikely to change since allocating medically trained people to youth sports will require unavailable financial resources. Accordingly, empowering adults to administer a simple, rapid, yet effective test is paramount to preventing repeated head injury. As increasing evidence suggests that even mild impact to the head can lead to accruing neuropathology, it may be prudent to routinely perform sideline testing for players involved in even modest collisions. This could help avoid return to play of athletes with sub-concussive impacts as knowledge about head injury continues to evolve.
Steve Devick and Chris Nowinski discuss concussions and football with the University of Miami.
With help from an Association of Applied Sport Psychology (AASP) grant and King-Devick, the Academy has made presentations to more than 50 coaches about concussions and given training on how to use the King-Devick test to quickly and accurately determine on the sideline if any player has suffered head trauma. In addition, each coach and team received a comprehensive manuals about concussion safety, fact sheets, and King-Devick Playbooks that included the tests to administer on players.
The latest episode of Raising Canes continues the showcase of Miami's industry-leading concussion testing procedures utilized by the sports medicine staff.
Dr. Rahul Jandial demonstrates King-Devick Test on the Today Show!
The King-Devick Test (KD) is one solution that is relatively low-tech but has high-tech abilities and research supporting its use for TBI/concussion and sports. This test has been available for more than 25 years to assess oculomotor dysfunction.
The K-D measures the time it takes for an athlete to read a series of single digit numbers displayed on index-sized cards. Previous studies of boxers and mixed martial arts (MMA) fighters (2), collegiate athletes in contact sports (3), and in a New Zealand rugby league (4,5) found that an increase (worsening) in the time needed to complete the one-minute K-D was predictive of concussion. While K-D detects fast eye (i.e. saccadic) movements, it also captures language and concentration, all of which have been shown to be impaired as a result of concussion.
The King-Devick Test has the benefit of providing objective baseline and post-injury data for rapid comparison. This may help athletic trainers and coaches determine whether players should be removed from games.
Last year he introduced to the club the King-Devick test, a screening that can help determine whether a player has suffered a concussive incident during the game.
A player does an initial test in the preseason to record a baseline score. The players are then tested after every game, and if anyone is three-seconds slower than his baseline score, he is deemed to have suffered a concussion. Because the test is calculated on an iPad, it can even be used during a game if a concussion is suspected.
Last year there were five concussions witnessed on the field, but another 17 were diagnosed through the King-Devick test (which is named after another King, not Doug).
Major League Lacrosse will become the first professional sports organization to mandate the King-Devick test -- an objective rapid sideline screening test of concussions that a growing body of studies show is an effective test for concussion -- as an additional sideline assessment tool.
The K-D Test serves as a “remove from play” test and is actually more suited to a sports role than one might think. Since players can only be on the sidelines for a few minutes between plays or drives, time is of the essence. The player has to be assessed immediately; continued play with head trauma can be increasingly dangerous. “We do know that if you put a kid back in with concussive symptoms, he’s at really high risk to get hit again,” says Dr. Gillian Hotz of the University of Miami’s Miller School of Medicine.
“As a direct result of the findings using the King-Devick Test, the club has implemented a wider concussion awareness program to assist in identification and management of concussion for the upcoming season,” Dr. Doug King, the senior author of the study, said in a news release.
The advantage of the King-Devick is that it’s much more straightforward for an inexperienced physician or coach to grade than the SCAT-2, which relies on subjective analysis of symptoms and test results. Many concussed athletes in the team’s trials have passed the SCAT-2 exam but failed the King-Devick Test.
The King-Devick Test has emerged as one of the most promising tools for rapid sideline concussion diagnosis.
Steve Devick became involved in the concussion issue because of a graduate school thesis he co-wrote in 1976. That project—now known as the King-Devick Test—has emerged as one of the most promising tools for rapid sideline concussion diagnosis. What’s both beautiful and confounding about the test is its simplicity: it’s administered on three spiral-bound laminated cards, takes less than a minute to complete, and is simply pass/fail.