Concussions detectable on the sidelines in children as young as 5

A vision test that can be done on sidelines to detect concussions was shown effective in children as young as 5 years old.

New research from the NYU Langone Concussion Center finds that a simple eye test, which can be administered in less than two minutes, can effectively diagnose a concussion and help determine whether a student athlete as young as 5 years old should return to a game.

The new study, published online in the Journal of Neuro-Ophthalmology, was conducted on 89 NCAA athletes and a younger subset of 243 youth athletes under age 17, and shows how the eye test, known as the King-Devick test, could help mitigate the problems that face concussion diagnosis in youth sports.

Study author Steven Galetta, MD, the Philip K. Moskowitz, MD Professor and Chair of Neurology at NYU Langone Medical Center, says the test can easily be administered on the sidelines by parents and non-health care professionals when athletic trainers and doctors are not available to monitor sidelines at youth sports games.

"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."

As part of the King-Devick test, athletes read numbers off of three pieces of paper while being timed with a stopwatch. A worsened performance from a baseline reading suggests a concussion has occurred.

"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-director of the NYU Langone Concussion Center, and a professor of neurology, ophthalmology and population health at NYU Langone.

Some sideline tests only measure cognition and balance, but visual testing is rarely performed, despite longstanding evidence that vision is commonly affected by concussion, according to a review article published by Dr. Galetta and Dr. Balcer in the March 3 print issue of Journal of Neuro-Ophthalmology. Previous research suggests about 50 percent of the brain's pathways are tied to vision.

The King-Devick test was developed in 1976 by optometrists Dr. Alan King and Steven Devick. Previous studies have looked at the test for neurological conditions that can affect vision like multiple sclerosis, before the researchers began testing it on athletes.

While earlier studies by the NYU Langone researchers looked at the King-Devick test on college athletes, this is the first to administer the test in children.

For the new study, researchers recruited 243 male and female athletes between the ages of 5 and 17 years old participating in a local youth hockey and lacrosse leagues, and 89 athletes who played these sports at the collegiate level. All of them underwent a baseline King-Devick test before the start of the sports season.

As part of the test, participants read numerical on cards from left to right as quickly as possible. Times for all three reading cards are added together, and then that number is compared with the baseline score: higher testing times suggest a worsening of performance consistent with a concussion.

All the student athletes were also given a brief cognitive test called the Standardized Assessment of Concussion (SAC) which measures memory, concentration and recall, and a Timed Tandem Gait Test, which is a timed walking trial.

Researchers determined 12 athletes sustained a concussion during the season. After matching them to control subjects of the same age and sport who did not experience a head injury, the study showed the King-Devick test outperformed the other two tests in distinguishing a concussed athlete versus an uninjured control subject with 92 percent accuracy (compared to 87 percent for Tandem Gait and 68 percent for SAC test).

Among concussed athletes, K-D scores worsened by an average of 5.2 seconds compared to baseline scores, while non-concussed athletes improved their times by 6.4 seconds compared with baseline.

Up to 3.9 million sports-related mild traumatic brain injuries, or concussions, occur annually in the United States, according to the Centers for Disease Control and Prevention, but researchers say that number is likely higher since the CDC only tracks emergency room visits.

Experiencing a concussion in a game increases an athlete's risk for sustaining a second condition in the same season by three times. Other complications include the dangerous second impact syndrome, or other short- and long-term side effects.

The group next plans to study the underlying mechanisms of the fast eye movements required for rapid number naming using electronic quantitative eye movement recordings in collaboration with Janet Rucker, MD, the Bernard A. and Charlotte Marden Associate Professor of Neurology and J.R. Rizzo, MD, director of the Visuomotor Integration Lab at Rusk Rehabilitation. According to Dr Balcer, these observations may permit more precise anatomical correlations of performance data and concussive symptoms.

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Vision tests may help spot concussions

Research shows that a vision testing on the sidelines at games can help determine if a player has had a concussion or not. Caution if the athlete has a reading disorder. JR

A simple vision test given on the sidelines can help identify athletes who've suffered a concussion, a new study finds.

Researchers found that the test -- known as the King-Devick, or K-D -- was able to detect 79 percent of concussions among college athletes who were followed over a season. When the results were combined with those of two other screening tests, all of the concussions were caught.

The findings were released Wednesday by the American Academy of Neurology (AAN), ahead of its annual meeting this spring.

Experts said the study bolsters evidence that the K-D is a reliable way to help spot athletes' head injuries -- though the test, by itself, is not enough.

"People have been looking for quick, on-the-field screening tests," said Steven Broglio, an athletic trainer and director of the NeuroSport Research Laboratory at the University of Michigan in Ann Arbor.

The new findings suggest the K-D is "one option," said Broglio, who was not involved in the study. "But it's not definitive, and you wouldn't want to rely on this alone," he added.

The K-D takes a minute or two, and it can be given by an athletic trainer, coach or even a parent right on the sidelines. It requires test-takers to read a few rows of single-digit numbers that are unevenly spaced, as quickly and accurately as possible. If they are slower to finish than they were on their "baseline" test -- taken before the season starts -- that's a potential sign of a concussion.

There are other sideline screening tests already in use, including ones that test balance and short-term memory.

But the K-D test "fills a gap" by looking for vision-related problems, explained study co-author Dr. Steven Galleta, chair of neurology at NYU Langone Medical Center in New York City.

Concussions can cause a wide range of symptoms that are often subtle at first. Symptoms like worsening headache, dizziness, nausea, fatigue and confusion might not become obvious until hours after the knock to the head. Plus, even when athletes are suffering immediate problems, they might not tell anyone.

"Some athletes don't recognize the symptoms, and some try to hide them because they want to stay in the game," Galleta said.

A number of professional groups, such as the AAN and National Athletic Trainers' Association, say that athletes who've potentially suffered a concussion should be taken out of the game or practice immediately.

For the new study, Galleta and his colleagues followed 217 athletes at the University of Florida -- including male football players, and female lacrosse and soccer players.

At the start of the season, they all took the K-D, as well as two other sideline screening tests: the BESS, which measures balance; and the SAC, which measures abilities such as short-term memory (asking the athlete to memorize and recall five words) and "orientation" (asking the player to name the day, month and year).

Over one season, 30 athletes were diagnosed with a concussion. And when the researchers looked at their sideline test results, 79 percent showed slower times on the K-D, compared with their pre-season performance. Adding the SAC and BESS results improved the detection rate to 100 percent.

Part of the appeal of the K-D is its simplicity; it can be used by "laypeople," including coaches and parents, Galleta noted. That raises the question of whether it can be used in high school and youth sports -- where there is often no athletic trainer or other health professional on the sidelines.

Studies are currently testing the K-D's usefulness for kids as young as 6, said Dr. Laura Balcer, a professor of neurology at NYU Langone who also worked on the study.

But regardless of what the K-D or other screening test shows on the sidelines, Balcer said there is "no substitute" for parents' judgment. If they notice any potential signs of concussion after a game or practice, they should take their child to the doctor immediately, she said.

"Parents know their kids best," Broglio agreed. "If you notice a change in their behavior, it's probably worth it to have them evaluated."

According to the U.S. Centers for Disease Control and Prevention, more than 173,000 U.S. children and teens land in the ER each year because of a concussion suffered during sports or recreational activities, like bike riding.

But the overall number -- including kids not seen in the ER -- is probably much larger: the CDC estimates that across age groups, up to 3.8 million Americans sustain a sports-related concussion each year.

In general, experts say kids with concussions should be symptom-free and get a doctor's OK before returning to sports. The biggest concern is that, if they sustain another knock to the head while they are still recovering from the first concussion, they could suffer so-called second-impact syndrome -- which can cause potentially fatal bleeding inside the skull and brain swelling.

The data and conclusions of research presented at meetings should be viewed as preliminary until published in a peer-reviewed journal.

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