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Harper BA, Soangra R. Assessing Brain Processing Deficits Using Neuropsychological and Vision-Specific Tests for Concussion. Sports (Basel) 2024; 12:125. [PMID: 38786994 PMCID: PMC11125887 DOI: 10.3390/sports12050125] [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: 03/31/2024] [Revised: 04/18/2024] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
INTRODUCTION Since verbal memory and visual processing transpire within analogous cerebral regions, this study assessed (i) if a visual function can predict verbal memory performance. It also hypothesized whether neurocognitive (e.g., ImPACT) tests focusing on the Visual Memory and Cognitive Efficacy Index will predict Verbal Memory scores and (ii) if vision metrics and age can identify individuals with a history of concussion. Finally, it also hypothesized that King-Devick and near point of convergence scores alongside age considerations will identify candidates with a prior reported history of concussion. MATERIALS AND METHODS This observational cohort assessed 25 collegiate ice hockey players prior to the competitive season considering age (19.76 ± 1.42 years) and BMI (25.9 ± 3.0 kg/cm2). Hypothesis 1 was assessed using a hierarchical (sequential) multiple regression analysis, assessing the predictive capacity of Visual Memory and Cognitive Efficacy Index scores in relation to Verbal Memory scores. Hypothesis 2 utilized a binomial logistic regression to determine if King-Devick and near point of convergence scores predict those with a prior history of concussion. RESULTS Hypothesis 1 developed two models, where Model 1 included Visual Memory as the predictor, while Model 2 added the Cognitive Efficacy Index as a predictor for verbal memory scores. Model 1 significantly explained 41% of the variance. Results from Model 2 suggest that the Cognitive Efficacy Index explained an additional 24.4%. Thus, Model 2 was interpreted where only the Cognitive Efficacy Index was a significant predictor (p = 0.001). For every 1 unit increase in the Cognitive Efficacy Index, Verbal Memory increased by 41.16. Hypothesis 2's model was significant, accounting for 37.9% of the variance in those with a history of concussion. However, there were no significant unique predictors within the model as age (Wald = 1.26, p = 0.261), King-Devick (Wald = 2.31, p = 0.128), and near point of convergence (Wald = 2.43, p = 0.119) were not significant predictors individually. CONCLUSIONS The conflicting findings of this study indicate that baseline data for those with a history of concussion greater than one year may not be comparable to the same metrics during acute concussion episodes. Young athletes who sustain a concussion may be able to overcompensate via the visual system. Future prospective studies with larger sample sizes are required using the proposed model's objective metrics.
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Affiliation(s)
- Brent A. Harper
- Department of Physical Therapy, Crean College of Health and Behavioral Sciences, Chapman University, Irvine, CA 92618, USA;
- Department of Physical Therapy, Radford University, Roanoke, VA 24013, USA
| | - Rahul Soangra
- Department of Physical Therapy, 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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Le RK, Ortega J, Chrisman SP, Kontos AP, Buckley TA, Kaminski TW, Meyer BP, Clugston JR, Goldman JT, McAllister T, McCrea M, Broglio SP, Schmidt JD. King-Devick Sensitivity and Specificity to Concussion in Collegiate Athletes. J Athl Train 2023; 58:97-105. [PMID: 34709396 PMCID: PMC10072097 DOI: 10.4085/1062-6050-0063.21] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
CONTEXT The King-Devick (K-D) test is used to identify oculomotor impairment after concussion. However, the diagnostic accuracy of the K-D test over time has not been evaluated. OBJECTIVES To (1) examine the sensitivity and specificity of the K-D test at 0 to 6 hours postinjury, 24 to 48 hours postinjury, the beginning of a return-to-play (RTP) protocol (asymptomatic), unrestricted RTP, and 6 months postconcussion and (2) compare outcomes between athletes with and those without concussion across confounding factors (sex, age, sport contact level, academic year, learning disorder, attention-deficit/hyperactivity disorder, migraine history, concussion history, and test administration mode). DESIGN Retrospective, cross-sectional design. SETTING Multiple institutions in the Concussion Assessment, Research and Education Consortium. PATIENTS OR OTHER PARTICIPANTS A total of 320 athletes with a concussion (162 men, 158 women; age = 19.80 ± 1.41 years) were compared with 1239 total collegiate athletes without a concussion (646 men, 593 women; age = 20.31 ± 1.18 years). MAIN OUTCOME MEASURE(S) We calculated the K-D test time difference (in seconds) by subtracting the baseline from the most recent time. Receiver operator characteristic (ROC) curve and area under the curve (AUC) analyses were used to determine the diagnostic accuracy across time points. We identified cutoff scores and corresponding specificity at both the 80% and 70% sensitivity levels. We repeated ROC with AUC analyses using confounding factors. RESULTS The K-D test predicted positive results at the 0- to 6-hour (AUC = 0.724, P < .001), 24- to 48-hour (AUC = 0.701, P < .001), RTP (AUC = 0.640, P < .001), and 6-month postconcussion (AUC = 0.615, P < .001) tim points but not at the asymptomatic time point (AUC = 0.513, P = .497). The 0- to 6-hour and 24- to 48-hour time points yielded 80% sensitivity cutoff scores of -2.6 and -3.2 seconds (ie, faster), respectively, but 46% and 41% specificity, respectively. The K-D test had a better AUC when administered using an iPad (AUC = 0.800, 95% CI = 0.747, 0.854) compared with the spiral-bound card system (AUC = 0.646, 95% CI = 0.600, 0.692; P < .001). CONCLUSIONS The diagnostic accuracy of the K-D test was greatest at 0 to 6 hours and 24 to 48 hours postconcussion but declined across subsequent postconcussion time points. The AUCs did not differentiate between groups across confounding factors. Our negative cutoff scores indicated that practice effects contributed to improved performance, requiring athletes to outperform their baseline scores.
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Affiliation(s)
| | - Justus Ortega
- Department of Kinesiology and Recreation Administration, Humboldt University, Arcata, CA
| | - Sara P. Chrisman
- Seattle Children's Research Institute and Department of Pediatrics, University of Washington
| | | | - Thomas A. Buckley
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | - Thomas W. Kaminski
- Department of Kinesiology and Applied Physiology, University of Delaware, Newark
| | - Briana P. Meyer
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa
| | - James R. Clugston
- Department of Community Health and Family Medicine, University Athletic Association, University of Florida, Gainesville
- Department of Neurology, University Athletic Association, University of Florida, Gainesville
- Division of Sports Health, University Athletic Association, University of Florida, Gainesville
| | | | - Thomas McAllister
- Department of Psychiatry, Indiana University School of Medicine, Indianapolis
| | - Michael McCrea
- Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa
| | - Steven P. Broglio
- Michigan Concussion Center, School of Kinesiology, University of Michigan, Ann Arbor
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Validity Indices of the King-Devick Concussion Test in Hockey Players. Clin J Sport Med 2022; 32:e313-e315. [PMID: 34009786 DOI: 10.1097/jsm.0000000000000938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2020] [Accepted: 03/03/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To compare the validity indices of the King-Devick (KD) test in hockey players using any increase in test time over baseline to a 6-second increase as a positive concussion test. We hypothesized the KD test using the 6-second change would yield greater validity indices. DESIGN Prospective observational cohort study. SETTING Sports complex. PARTICIPANTS Sixty-five male hockey players aged 13 to 20 years. INDEPENDENT VARIABLE Concussion diagnosis. MAIN OUTCOME MEASURES Time to complete the KD test. Sensitivity (SN), specificity (SP), and the positive likelihood ratios (LRs+) were calculated using 2 thresholds for a positive test: (1) any increase in time and (2) an increase of 6 seconds or greater. RESULTS Eighteen players (27.7%) were diagnosed with a concussion. Using any increase in time as a positive test yielded the following: SN 72.2%, SP 78.7%, LR+ 3.4, and LR- 0.4. Using the 6-second threshold yielded the following: SN 44.4%, SP 93.6%, LR+ 7.0, and LR- 0.6. A receiver operator curve analysis confirmed 6.40 seconds or greater maximized the LR+. CONCLUSIONS A 6-second or greater increase in the KD test performance provides greater validity in diagnosing concussion as compared with any increase in performance time.
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Neurosensory Screening and Symptom Provocation in Pediatric Mild Traumatic Brain Injury. J Head Trauma Rehabil 2021; 35:270-278. [PMID: 32108710 DOI: 10.1097/htr.0000000000000560] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To evaluate diagnostic/prognostic implications of neurosensory testing during the subacute stage in patients with pediatric mild traumatic brain injury (pmTBI). SETTING Recruitment from pediatric emergency department and urgent care clinics, assessment in a controlled environment. PARTICIPANTS In total, 146 pmTBI patients evaluated 7.4 ± 2.3 days and approximately 4 months postinjury; 104 age/sex-matched healthy controls (HCs) at equivalent time points. DESIGN Prospective cohort study. MAIN MEASURES Neurosensory examination based on sequence of 10 established tests of vestibular-ocular, oculomotor, vestibulospinal, and visual functioning. RESULTS The amount of symptom provocation (positive change from pretest symptomatology) was significantly increased in pmTBI relative to HCs on every subtest 1 week postinjury, as were deficits in monocular accommodative amplitude and King-Devick Test errors. However, symptom provocation did not meaningfully alter diagnostic sensitivity/specificity relative to more easily obtained pretest symptom ratings. Evidence of clinically significant symptom provocation 1 week postinjury improved sensitivity (Δ = +12.9%) of identifying patients with persistent postconcussive symptoms 4 months postinjury on an independent symptom measure. CONCLUSIONS The diagnostic sensitivity/specificity of neurosensory testing in acutely concussed youth may be limited at 1 week postinjury as a function of natural recovery occurring in most emergency department cohorts. Neurosensory screening may have greater utility for identifying patients who experience delayed recovery.
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Establishing Test-Retest Reliability and Reliable Change for the King-Devick Test in High School Athletes. Clin J Sport Med 2021; 31:e235-e239. [PMID: 31842057 DOI: 10.1097/jsm.0000000000000772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/31/2019] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To establish test-retest reliability in nonconcussed high school athletes and compare absolute change, reliable change indices (RCIs), and minimal detectable change (MDC) methods for classifying impairment after sport-related concussion. DESIGN Prospective, repeated measures. SETTING High schools from the Midwest and Central regions of the United States. PARTICIPANTS A convenience sample of 772 nonconcussed high school athletes (n = 546 men) completed preseason K-D testing. In addition, 69 athletes completed a second postseason K-D test, and 54 athletes sustained a concussion and completed postconcussion K-D tests. INTERVENTION K-D test. MAIN OUTCOME MEASURES Data for age, sex, and concussion history were determined using preseason K-D test outcomes. Test-retest reliability, RCIs, and MDCs were calculated using postseason K-D tests (M = 98.9, SD = 9.1 days). Postinjury K-D assessments within 5 days of injury (M = 1.5, SD = 1.5 days) were used to classify impairment on K-D using absolute change, RCI, and MDC methods. RESULTS Significant effects for age (P < 0.001) and history of concussion (P = 0.001) were supported on baseline K-D time, with no sex differences (P = 0.21). Preseason to postseason reliability for K-D times was 0.60 (intraclass correlation coefficient, 95% CI, 0.43-0.73), although 38% of athletes exhibited slower postseason K-D times compared with baseline. Impairment on K-D exhibited for 72% of the concussed sample using absolute change, 48% using MDC, and 44% using RCI methods. CONCLUSIONS K-D exhibited moderate test-retest reliability across 1 season. Absolute change yielded the highest sensitivity for preinjury to postinjury impairment on the K-D compared with RCI and MDC methods.
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Weise KK, Galt SJ, Hale MH, Springer DB, Swanson MW. Pre-participation Vision Screening and Comprehensive Eye Care in National Collegiate Athletic Association Athletes. Optom Vis Sci 2021; 98:764-770. [PMID: 34328455 DOI: 10.1097/opx.0000000000001738] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Pre-participation physical evaluation and its vision screenings have been the mainstay of medical clearance for competitive play for decades. The ability of screening to address athlete's sports-specific vision needs is unknown. METHODS Fifty-eight intercollegiate football players consented to participate in a comprehensive, sports-specific eye examination in addition to the standard pre-participation vision screening. Sensitivity, specificity, and positive and negative predictive values were determined for screening's ability to detect athletes whose vision might improve with correction, athletes who had significant ocular findings that impact safety, and either of the two conditions together. The effect no recent eye examination added to pre-participation vision screening results was evaluated for change in screening yield. Descriptive statistics of the cohort and associations with no recent comprehensive eye examination were generated. RESULTS The pre-participation vision screening was able to identify three athletes not meeting visual acuity requirements for medical clearance to play without a comprehensive assessment. A failed screening was poorly able to identify athletes who might benefit from improved acuity (sensitivity, 9.1%; specificity, 100%), have sports-specific significant ocular findings (sensitivity, 10.5%; specificity, 97.3%), or have either together (sensitivity, 7.5%; specificity, 100%). Sixty percent (33/55) of athletes reported never having a comprehensive examination or one within the last 10 years. Fifty-eight percent (34/58) had improved best-corrected visual acuity after comprehensive examination, and 81% (47/58) had improved acuity or a sports-specific significant finding. CONCLUSIONS The pre-participation vision screening was largely able to identify athletes meeting the minimum visual acuity requirement for athlete clearance. It poorly identified those who might benefit from improved vision with refractive correction and those in whom sport-specific significant eye findings were noted. Comprehensive eye care had a clear benefit for the majority of athletes tested. This benefit needs to be balanced with the potential added costs and time constraints to players and athletic department staff.
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Affiliation(s)
| | - Sarah J Galt
- Department of Optometry and Vision Science, School of Optometry, University of Alabama at Birmingham, Birmingham, Alabama
| | - M Heath Hale
- Department of Athletics, School of Medicine, University of Alabama at Birmingham, Birmingham, Alabama
| | - Daniel B Springer
- Department of Athletics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark W Swanson
- Department of Optometry and Vision Science, School of Optometry, University of Alabama at Birmingham, Birmingham, Alabama
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Harper B, Aron A, John E. The role of pre-season health characteristics as injury risk factors in female adolescent soccer players. J Phys Ther Sci 2021; 33:439-443. [PMID: 34083885 PMCID: PMC8165364 DOI: 10.1589/jpts.33.439] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 02/27/2021] [Indexed: 11/24/2022] Open
Abstract
[Purpose] Determine if female adolescent soccer players with a history of concussion, impaired K-D scores, and pre-season subjective complaints of neck pain, dizziness, and headache were predisposed to additional risk of musculoskeletal or concussive injury during 10-weeks of competitive play. [Participants and Methods] Twenty-three female high school soccer athletes provided concussion history and reported pre-season subjective complaints. K-D testing was performed pre and postseason. During the 10-week season, all injuries, preventing participation in practice or game, were recorded. [Results] Six reported a history of concussion. Of those six, three injuries were reported, including two concussions and a hamstring strain. Baseline K-D scores were worse in athletes that had two or more pre-season subjective factors compared to those that did not have any. Moderate positive correlations were found between a history of concussion and the number of injuries and a history of concussion and K-D post-test scores. [Conclusion] Findings indicate that pre-season subjective factors of neck pain, dizziness and headache, history of concussion, and K-D potentially increased injury risk. Combining pre-season metrics both at baseline and during the course of the season may assist in better injury risk screening in-season or indicate suboptimal function due to cumulative effects.
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Affiliation(s)
- Brent Harper
- Department of Physical Therapy, Crean College of Health
& Behavioral Sciences, Rinker Health Science Campus in Irvine, Chapman University:
9401 Jeronimo Rd, Irvine, CA 92618, USA
| | - Adrian Aron
- Department of Physical Therapy, Radford University,
USA
| | - Emmanuel John
- Department of Physical Therapy, Crean College of Health
& Behavioral Sciences, Rinker Health Science Campus in Irvine, Chapman University:
9401 Jeronimo Rd, Irvine, CA 92618, USA
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Gunasekaran P, Fraser CL, Hodge C. The learning effect of the King-Devick test in semi-professional rugby union athletes. J Neurol Sci 2020; 419:117168. [PMID: 33038568 DOI: 10.1016/j.jns.2020.117168] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Revised: 09/21/2020] [Accepted: 09/30/2020] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Abnormalities of eye movement and visual processing are common in traumatic brain injury. The King-Devick test (KDT) has been widely used in the detection and recovery of concussion. Current recommendations propose performing the initial test at baseline and then repeating annually to account for potential learning effects. In practice, this may still account for large deviations. The aim of this study was to determine the number of trials needed for a player to achieve a ceiling effect and to determine the validity of the existing protocol requiring two tests at baseline. METHODS One hundred and eighty-three semi-professional male rugby union players (median age = 22.5 (21.0-25.3) years) were recruited. Over the duration, all athletes performed the KDT on an iPad, under standardised baseline procedures and then repeated the test based on availability during weekly in-season training. RESULTS The improvement through each repeated trial was 0.60 ± 0.1 s (P < 0.001). The ceiling effect was determined at 30 trials. A median difference of 4.2 s (range 0-14.9) was calculated between the initial and best trial overall, although the greatest difference occurred within the first eight attempts. There was a significant positive correlation between the initial test value and the difference between first and fastest time (P < 0.001, r = 0.455). CONCLUSION We have shown continuous improvement with repeated attempts which suggests that administrators ideally should continue to perform the KDT over the duration of the season to optimise the value of the test.
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Affiliation(s)
- Premkumar Gunasekaran
- Discipline of Orthoptics, Graduate School of Health, University of Technology Sydney, NSW, Australia.
| | - Clare L Fraser
- Save Sight Institute, Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, NSW, Australia.
| | - Christopher Hodge
- Discipline of Orthoptics, Graduate School of Health, University of Technology Sydney, NSW, Australia; Save Sight Institute, Discipline of Ophthalmology, Faculty of Health and Medicine, The University of Sydney, NSW, Australia.
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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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Socioeconomic status and race as social determinants of health to be considered in clinical use of pre-season vestibular and oculomotor tests for concussion. J Clin Transl Res 2020; 6:168-178. [PMID: 33501387 PMCID: PMC7821747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 08/08/2020] [Accepted: 09/24/2020] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Aside from racial and socioeconomic disparities in computerized neurocognitive testing and symptomology, there is a scarcity of research representing more diverse populations on other widely used tests for concussion, including vestibular and visual assessment. AIM The aim of the study was to investigate if racial and socioeconomic differences exist on baseline vestibular/ocular motor screening (VOMS) and King-Devick (K-D) test performance in high school student-athletes. METHODS A total of 670 participants (66.1% White, 33.9% Black) with a mean age of 15.43±1.2 years were administered a baseline VOMS, average Near Point of Convergence (NPC) distance, and K-D test. The exposure variables included race (White or Black) and socioeconomic status (SES), defined as free and reduced lunch status (FRL or No-FRL). FRL status was determined by each participant's school SES. The outcome variables consisted of baseline VOMS item symptom provocation scores, average NPC distance, and K-D baseline time. A series of Mann-Whitney U tests were performed for K-D baseline time, NPC distance, and VOMS items with FRL status or race as a between-subject factor. Two multivariable linear regressions were run to assess the association of (1) K-D baseline times using FRL, race, sex, and corrected vision as variables in the model and (2) average NPC distance using FRL, race, sex, and corrected vision as variables in the model. RESULTS When adjusting for multiple comparisons, FRL athletes had slower (worse) K-D times (P<0.001) than non-FRL athletes. Black athletes had significantly lower mean NPC distance compared to White athletes at baseline (P=0.02) and FRL status athletes reported a significantly greater (worse) mean symptom provocation following the visual motion sensitivity item on the VOMS (P=0.02); however, these findings were no longer significant following adjustments for multiple comparisons. No differences were noted for any remaining VOMS items. The first model explained 3.9% of the total variance of K-D baseline times, whereas the second model was not significant. CONCLUSIONS Racial and SES differences existed on average NPC distance and the K-D test at baseline. Possible explanations for group differences may be neurobiological, anatomical, and/or disparity in nature. With a higher probability of undiagnosed and uncorrected vision impairment, vestibular dysfunction, and saccadic eye tracking deficits likely to be more apparent as a consequence of poverty or health inequities, it is important that healthcare providers, especially those that diagnose and treat concussions, understand that performance on the VOMS and K-D tests at baseline may be subject to sociodemographic factors of SES and race. RELEVANCE FOR PATIENTS To provide the most culturally competent care, clinicians should consider sociodemographic variables of race and SES as social determinants of health worthy of attention on objective and subjective measures of baseline concussion assessment.
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Abstract
OBJECTIVE To explore differences in baseline King-Devick Test (KD) completion time between 2 testing modalities: (1) spiral-bound paper cards (cards) and (2) iPad application (iPad). DESIGN Cross-sectional cohort analysis. SETTING National Collegiate Athlete Association (NCAA) institutions. PARTICIPANTS Student athletes from 13 women's and 11 men's collegiate sports who completed KD baseline testing as part of their first year in the Concussion Assessment, Research and Education (CARE) Consortium from 2014 to 2016 (n = 2003, 52.2% male). INDEPENDENT VARIABLES King-Devick Test modalities; cards or iPad. MAIN OUTCOME MEASURE Baseline KD completion time (seconds). RESULTS Mean baseline KD completion time of the iPad modality group [42.8 seconds, 95% confidence interval (CI), 42.1-43.3] was 2.8 seconds (95% CI, 2.1-3.4) greater than the cards group (40.0 seconds, 95% CI, 39.7-40.3) (t(1, 1010.7) = -8.0, P < 0.001, Cohen's d = 0.41). CONCLUSIONS Baseline KD performance is slower when tested on an iPad than when tested on spiral-bound paper cards. The 2 KD modalities should not be used interchangeably in concussion assessments because differences in the modalities can lead to time differences similar in magnitude to those used to indicate concussion. From a research perspective, modality may influence interpretation and/or synthesis of findings across studies.
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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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Wallace J, Moran R, Beidler E, McAllister Deitrick J, Shina J, Covassin T. Disparities on Baseline Performance Using Neurocognitive and Oculomotor Clinical Measures of Concussion. Am J Sports Med 2020; 48:2774-2782. [PMID: 32804545 DOI: 10.1177/0363546520946753] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND Given the high participation of Black/African American individuals in high school sports, especially high-risk sports for concussion, it is important to note if racial and socioeconomic status (SES) differences exist in baseline performance on clinical measures of concussion. PURPOSE To explore the association between race and SES on baseline concussion assessments of neurocognitive performance and oculomotor function in adolescent athletes. STUDY DESIGN Cohort study (Diagnosis); Level of evidence, 3. METHODS A total of 564 high school athletes (mean ± SD age, 15.33 ± 1.1 years) completed the baseline Immediate Post-Concussion Assessment and Cognitive Test and King-Devick (KD) battery before the start of their competitive season. Race was defined as either White/non-Hispanic or Black/African American. SES status was determined by whether the individual's participating high school was a Title I or non-Title I school. A series of multivariable linear regression analyses were conducted to evaluate the association of computerized neurocognitive test scores (verbal memory, visual memory, motor processing speed, and reaction time), symptom severity scores, and KD scores by race and SES. RESULTS White/non-Hispanic individuals performed significantly better than Black/African American individuals on verbal memory (P < .01), visual memory (P < .01), visual motor processing speed (P < .01), and reaction time (P < .01) and had a lower symptom score (P < .01). Regarding SES, individuals from non-Title I schools performed better on visual memory (P = .05) and reaction time (P = .02) than individuals from Title I schools. Examination of cumulative KD test reading time revealed that there was no association between race on baseline reading times (P = .12). There was a significant association between cumulative reading time and SES (P = .02). Individuals from non-Title I schools performed significantly faster than individuals from Title I schools on KD test time. CONCLUSION Overall, race and SES influence neurocognitive and oculomotor concussion baseline performance in high school athletes. These findings add to the growing literature on the influence of race and SES on neurocognitive and oculomotor function baseline concussion assessments; they highlight the necessity for individualized concussion baseline measurements or race-specific normative reference values.
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Affiliation(s)
- Jessica Wallace
- Department of Health Science, University of Alabama, Tuscaloosa, Alabama, USA.,Department of Epidemiology, T.H. Chan School of Public Health, Harvard University, Boston, Massachusetts, USA
| | - Ryan Moran
- Department of Health Science, University of Alabama, Tuscaloosa, Alabama, USA
| | - Erica Beidler
- Department of Athletic Training, Duquesne University, Pittsburgh, Pennsylvania, USA
| | | | - James Shina
- Youngstown State University, Youngstown, Ohio, USA
| | - Tracey Covassin
- Department of Kinesiology, Michigan State University, East Lansing, Michigan, USA
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14
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A Review of the Use of Confidence Intervals for Bland-Altman Limits of Agreement in Optometry and Vision Science. Optom Vis Sci 2020; 97:3-8. [PMID: 31895271 DOI: 10.1097/opx.0000000000001465] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
SIGNIFICANCE Confidence intervals are still seldom reported for Bland-Altman 95% limits of agreement. When they are reported, 50% of articles use approximate methods and 50% use exact methods. PURPOSE Bland-Altman limits of agreement can be unreliable estimates, especially for small sample sizes. However, authors seldom use confidence intervals for limits of agreement. This article reviews their use in Optometry and Vision Science. METHODS A keyword search for "Bland," "Altman," "Bland-Altman," "LoA," and "limits of agreement" was conducted on the Optometry and Vision Science website within a time range from January 2016 to December 2018. RESULTS Fifty articles were reported or were judged to use Bland-Altman analysis; sample sizes ranged from 3 to 2072. Eight of these article reported confidence limits for limits of agreement, four of which used exact methods and four used Bland and Altman's approximate method. CONCLUSIONS Use of confidence intervals for limits of agreement has increased in Optometry and Vision Science but is far from universal. To assist researchers in calculating exact confidence limits for Bland-Altman limits of agreement, spreadsheets are included for performing the calculations and generating Bland-Altman plots with the confidence intervals included.
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15
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Mrazik M, Naidu D, Borza C, Kobitowich T, Shergill S. King Devick computerized neurocognitive test scores in professional football players with learning and attentional disabilities. J Neurol Sci 2019; 399:140-143. [DOI: 10.1016/j.jns.2019.02.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Revised: 02/08/2019] [Accepted: 02/10/2019] [Indexed: 11/16/2022]
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16
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Lawrence JB, Haider MN, Leddy JJ, Hinds A, Miecznikowski JC, Willer BS. The King-Devick test in an outpatient concussion clinic: Assessing the diagnostic and prognostic value of a vision test in conjunction with exercise testing among acutely concussed adolescents. J Neurol Sci 2019; 398:91-97. [PMID: 30690413 PMCID: PMC7038786 DOI: 10.1016/j.jns.2018.12.020] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Revised: 12/13/2018] [Accepted: 12/15/2018] [Indexed: 01/16/2023]
Abstract
OBJECTIVE This study investigated the diagnostic and prognostic value of the King-Devick (K-D) test in conjunction with treadmill testing in adolescents after sport-related concussion (SRC) in an outpatient concussion management clinic without baseline measures. DESIGN Prospective cohort. METHODS The K-D test was administered pre- and post-exercise on a graded treadmill test to acutely concussed (AC, <10 days from injury, n = 46, 15.4 ± 2.1 years) participants for 2 clinic visits (1 week apart) and to matched controls (MC, n = 30, 15.8 ± 1.4 years) for 2 visits (1 week apart). Initial K-D test times were compared between MC and AC. Changes in times from pre- to post- exercise during a treadmill test were compared for MC and AC and from Visit 1 to Visit 2. Smooth pursuits and repetitive saccades were compared with initial visit K-D test performance. RESULTS Comparison of pre-exercise K-D test times at Visit 1 distinguished MC from AC (46.1 ± 9.2 s vs. 53.7 ± 13.0 s, p = .007). Comparison of pre- and post-exercise K-D test times revealed significant improvements for MC (46.1 ± 9.2 s vs. 43.1 ± 8.5 s, p < .001) and AC who recovered by Visit 2 (Fast Recovery Group [FRG], n = 23, 50.4 ± 10.0 s vs. 47.3 ± 9.8 s, p = .002). No significant difference was seen in pre- and post-exercise K-D test times on Visit 1 for AC who took longer than 2 weeks to recover (Slow Recovery Group [SRG], n = 23, 57.0 ± 15.0 s vs. 56.0 ± 16.3 s, p = .478). At Visit 1, AC had more abnormal smooth pursuits than MC (17% vs. 3%, non-significant, p = .064). AC, however, had significantly more abnormal repetitive saccades than MC (37% vs. 3%, p = .001) and AC with abnormal repetitive saccades took significantly longer to complete the Visit 1 pre-exercise K-D test than AC with normal repetitive saccades (58.6 ± 16.0 s vs 50.8 ± 10.2 s, p = .049). CONCLUSION The study supports utility of the K-D test as part of outpatient concussion assessment. Lack of improvement in K-D test performance after an exercise test may be an indicator of delayed recovery from SRC.
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Affiliation(s)
- Justine B Lawrence
- Department of Neuroscience, University at Buffalo, SUNY, Buffalo, NY 14214, United States.
| | - Mohammad N Haider
- Department of Neuroscience, University at Buffalo, SUNY, Buffalo, NY 14214, United States; UBMD Department of Orthopedics and Sports Medicine, University at Buffalo, SUNY, Buffalo, NY 14214, United States
| | - John J Leddy
- UBMD Department of Orthopedics and Sports Medicine, University at Buffalo, SUNY, Buffalo, NY 14214, United States
| | - Andrea Hinds
- UBMD Department of Orthopedics and Sports Medicine, University at Buffalo, SUNY, Buffalo, NY 14214, United States
| | | | - Barry S Willer
- Department of Psychiatry, University at Buffalo, SUNY, Buffalo, NY 14214, United States
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17
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Mayer AR, Wertz C, Ryman SG, Storey EP, Park G, Phillips J, Dodd AB, Oglesbee S, Campbell R, Yeo RA, Wasserott B, Shaff NA, Leddy JJ, Mannix R, Arbogast KB, Meier TB, Grady MF, Master CL. Neurosensory Deficits Vary as a Function of Point of Care in Pediatric Mild Traumatic Brain Injury. J Neurotrauma 2018; 35:1178-1184. [PMID: 29336197 DOI: 10.1089/neu.2017.5340] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Neurosensory abnormalities are frequently observed following pediatric mild traumatic brain injury (pmTBI) and may underlie the expression of several common concussion symptoms and delay recovery. Importantly, active evaluation of neurosensory functioning more closely approximates real-world (e.g., physical and academic) environments that provoke symptom worsening. The current study determined whether symptom provocation (i.e., during neurosensory examination) improved classification accuracy relative to pre-examination symptom levels and whether symptoms varied as a function of point of care. Eighty-one pmTBI were recruited from the pediatric emergency department (PED; n = 40) or outpatient concussion clinic (n = 41), along with matched (age, sex, and education) healthy controls (HC; n = 40). All participants completed a brief (∼ 12 min) standardized neurosensory examination and clinical questionnaires. The magnitude of symptom provocation upon neurosensory examination was significantly higher for concussion clinic than for PED patients. Symptom provocation significantly improved diagnostic classification accuracy relative to pre-examination symptom levels, although the magnitude of improvement was modest, and was greater in the concussion clinic. In contrast, PED patients exhibited worse performance on measures of balance, vision, and oculomotor functioning than the concussion clinic patients, with no differences observed between both samples and HC. Despite modest sample sizes, current findings suggest that point of care represents a critical but highly under-studied variable that may influence outcomes following pmTBI. Studies that rely on recruitment from a single point of care may not generalize to the entire pmTBI population in terms of how neurosensory deficits affect recovery.
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Affiliation(s)
- Andrew R Mayer
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico.,2 Neurology Department, University of New Mexico School of Medicine , Albuquerque, New Mexico.,3 Psychiatry Department, University of New Mexico School of Medicine , Albuquerque, New Mexico.,4 Psychology Department, University of New Mexico , Albuquerque, New Mexico
| | - Christopher Wertz
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico
| | - Sephira G Ryman
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico
| | - Eileen P Storey
- 5 Division of Orthopedic Surgery, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Grace Park
- 6 Emergency Medicine, University of New Mexico Hospital , Albuquerque, New Mexico
| | - John Phillips
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico.,4 Psychology Department, University of New Mexico , Albuquerque, New Mexico
| | - Andrew B Dodd
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico
| | - Scott Oglesbee
- 6 Emergency Medicine, University of New Mexico Hospital , Albuquerque, New Mexico
| | - Richard Campbell
- 3 Psychiatry Department, University of New Mexico School of Medicine , Albuquerque, New Mexico
| | - Ronald A Yeo
- 4 Psychology Department, University of New Mexico , Albuquerque, New Mexico
| | - Benjamin Wasserott
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico
| | - Nicholas A Shaff
- 1 The Mind Research Network/Lovelace Biomedical and Environmental Research Institute , Pete & Nancy Domenici Hall, Albuquerque, New Mexico
| | - John J Leddy
- 7 Department of Orthopaedics, University at Buffalo , Buffalo, New York
| | - Rebekah Mannix
- 8 Division of Emergency Medicine, Boston Children's Hospital , Boston, Massachusetts
| | - Kristy B Arbogast
- 9 Center for Injury Research and Prevention, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Timothy B Meier
- 10 Department of Neurosurgery, Medical College of Wisconsin , Milwaukee, Wisconsin.,11 Department of Cell Biology, Neurobiology and Anatomy, Medical College of Wisconsin , Milwaukee, Wisconsin
| | - Matthew F Grady
- 5 Division of Orthopedic Surgery, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.,9 Center for Injury Research and Prevention, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
| | - Christina L Master
- 5 Division of Orthopedic Surgery, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania.,9 Center for Injury Research and Prevention, The Children's Hospital of Philadelphia , Philadelphia, Pennsylvania
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18
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Barker F, Cockerham G, Goodrich G, Hartwick A, Kardon R, Mick AB, Swanson M. Brain Injury Impact on the Eye and Vision. Optom Vis Sci 2017; 94:4-6. [PMID: 28009763 DOI: 10.1097/opx.0000000000001001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Felix Barker
- Rock Hill, South Carolina Palo Alto, California Union City, California Columbus, Ohio Iowa City, Iowa San Francisco, California Birmingham, Alabama
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