King-Devick Sensitivity and Specificity to Concussion in Collegiate Athletes

Rachel Khinh Le; Justus Ortega; Sara P Chrisman; Anthony P Kontos; Thomas A Buckley; Thomas W Kaminski; Briana P Meyer; James R Clugston; Joshua T Goldman; Thomas McAllister; Michael McCrea; Steven P Broglio; Julianne D Schmidt

doi:10.4085/1062-6050-0063.21

King-Devick Sensitivity and Specificity to Concussion in Collegiate Athletes

J Athl Train. 2023 Feb 1;58(2):97-105. doi: 10.4085/1062-6050-0063.21.

Authors

Affiliations

¹ Department of Kinesiology, University of Georgia, Athens.
² Department of Kinesiology and Recreation Administration, Humboldt University, Arcata, CA.
³ Seattle Children's Research Institute and Department of Pediatrics, University of Washington.
⁴ Department of Orthopaedic Surgery, University of Pittsburgh, PA.
⁵ Department of Kinesiology and Applied Physiology, University of Delaware, Newark.
⁶ Department of Neurosurgery, Medical College of Wisconsin, Wauwatosa.
⁷ Department of Community Health and Family Medicine, University Athletic Association, University of Florida, Gainesville.
⁸ Department of Neurology, University Athletic Association, University of Florida, Gainesville.
⁹ Division of Sports Health, University Athletic Association, University of Florida, Gainesville.
¹⁰ Department of Family Medicine, University of California Los Angeles.
¹¹ Department of Psychiatry, Indiana University School of Medicine, Indianapolis.
¹² Michigan Concussion Center, School of Kinesiology, University of Michigan, Ann Arbor.

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.

Keywords: baseline testing; diagnostic accuracy; mild traumatic brain injury; oculomotor performance; postconcussion assessment.

MeSH terms

Adolescent
Adult
Athletes
Athletic Injuries* / diagnosis
Brain Concussion* / diagnosis
Cross-Sectional Studies
Female
Humans
Male
Neuropsychological Tests
Retrospective Studies
Young Adult

Grants and funding

FINANCIAL DISCLOSURE This study was made possible, in part, by support from the Grand Alliance CARE Consortium, funded in part by the National Collegiate Athletic Association and the Department of Defense (Dr Kontos and S.P.B.). The US Army Medical Research Acquisition Activity, 820 Chandler Street, Fort Detrick, MD 21702-5014, USA, is the awarding and administering acquisition office. This work was supported by the Office of the Assistant Secretary of Defense for Health Affairs through the Psychological Health and Traumatic Brain Injury Program under award W81XWH-14-2-0151. Opinions, interpretations, conclusions, and recommendations are those of the authors and are not necessarily endorsed by the Department of Defense (Defense Health Program funds).