Background: Sports-related concussion commonly affects the visual pathways. Current sideline protocols test cognition and balance but do not include assessments of visual performance. We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels.
Methods: Participants in this prospective study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Island University. Athletes underwent preseason baseline assessments using: 1) the King–Devick (K-D) test, a <2-minute visual performance measure of rapid number naming, 2) the Standardized Assessment of Concussion (SAC), a test of cognition, and 3) a timed tandem gait test of balance. The SAC and timed tandem gait are components of the currently used Sport Concussion Assessment Tool, 3rd Edition (SCAT3 and Child-SCAT3). In the event of a concussion during the athletic season, injured athletes were retested on the sideline/rink-side. Nonconcussed athletes were also assessed as control participants under the same testing conditions.
Results: Among 243 youth (mean age 11 ± 3 years, range 5–17) and 89 collegiate athletes (age 20 ± 1 years, range 18–23), baseline time scores for the K-D test were lower (better) with increasing participant age (P < 0.001, linear regression models). Among 12 athletes who sustained concussions during their athletic season, K-D scores worsened from baseline by an average of 5.2 seconds; improvement by 6.4 seconds was noted for the nonconcussed controls (n = 14). The vision-based K-D test showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury (receiver operating characteristic [ROC] curve areas from logistic regression models, accounting for age = 0.92 for K-D, 0.87 for timed tandem gait, and 0.68 for SAC; P = 0.0004 for comparison of ROC curve areas).
Conclusions: Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment. This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision.
Departments of Neurology (JM, NM, BM, LH, SLG, LJB), Population Health (LJB), Ophthalmology (SLG, LJB) and Sports Medicine/Orthopaedic Surgery (DAC), New York University School of Medicine, New York, New York; Department of Athletics (NW), New York University, New York, New York; Department of Athletics (CC), Long Island University, Brooklyn, New York; Departments of Emergency Medicine and Pediatrics (AS), Cohen Children's Medical Center of New York, Hofstra North Shore LIJ School of Medicine; and Departments of Neurology (KMG, SLG, LJB) and Epidemiology (LJB), University of Pennsylvania, Philadelphia, Pennsylvania.
Address correspondence to Laura J. Balcer, MD, MSCE, Department of Neurology, NYU School of Medicine, 240 East 38th Street, 20th Floor, New York, NY 10016; E-mail: firstname.lastname@example.org
S. L. Galetta has received honoraria for speaking from Biogen-Idec, Vaccinex, and Genzyme; L. J. Balcer has received honoraria for consulting from Biogen-Idec, Vaccinex, and Genzyme, and has served on a scientific advisory board for Biogen-Idec. The remaining authors report no conflicts of interest.