Sports Related Concussions. The King-Devick Test: the Science & Implementation

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1 Sports Related Concussions The King-Devick Test: the Science & Implementation

2 King-Devick Test: the Today Show CLICK HERE for Video: King-Devick Test on the Today Show

Concussion by the Numbers Highest rates: Boy s football & Girl s soccer Epidemiology: 1.6 3.

Encephalopathy (CTE) 20-30% of Alzheimer s patients report head trauma vs.

Thurman et al., 1998; Guskiewicz et al., 2000; Langlois et al.

3 Concussion by the Numbers Highest rates: Boy s football & Girl s soccer Epidemiology: million annually Concussions drawing national attention NFL interest in Chronic Traumatic Encephalopathy (CTE) 20-30% of Alzheimer s patients report head trauma vs. 8-10% of controls Estimated 85% go undiagnosed Need for validated, rapid screening tests Thurman et al., 1998; Guskiewicz et al., 2000; Langlois et al., 2006; American College of Sports Medicine 2006; Guskiewicz et al., 2003; Collins et al., 2003; Mitka 2010; Halstead & Walter, 2010; Meehan et al., 2011;

4 Concussion Biomechanics Concussion or mtbi (mild traumatic brain injury) CLICK HERE for Video: Dr. Doug Smith explaining Concussion Linear & rotational accelerations cause: Axonal shearing & stretching Ionic imbalance, Biochemical cascade events Disrupted neurotransmission Meaney & Smith, 2011; Maruta et al, 2010

5 Signs & Symptoms Emotion: Irritability Anxiety Depression Extreme emotions Cognitive: Concentration Processing speed Memory Thinking Sleep: Abnormal sleep Difficulty sleeping Excessive sleep Physical: Saccadic dysfunction Headache Nausea Balance Vision/Diplopia Sensitivity to noise and light US Dept of Health & Human Services CDC, 2012

6 Complications of Concussion SHORT-TERM Increased risk of subsequent concussion 3-4x more likely to sustain another concussion within 7-10days Risk of Second Impact Syndrome Sustaining a second concussion before recovery from first concussion Rare complication Majority in pediatric/adolescent populations (<20 years) Enhancement of cerebrovascular congestion Diffuse cerebral edema Catastrophic outcome, Death within minutes in majority of cases Guskiewicz et al., 2003; Holsinger et al., 2002; Plassman et al., 2000; Gavett et al. 2011, Meehan & Bachur, 2009, Putukian et al. 2011

Complications of Concussion LONG-TERM Post-Concussion Syndrome Prolonged concussion symptoms >3mos Correlation to neuro-degenerative Chronic Traumatic Encephalopathy (CTE) Guskiewicz et al.

7 Complications of Concussion LONG-TERM Post-Concussion Syndrome Prolonged concussion symptoms >3mos Correlation to neuro-degenerative Chronic Traumatic Encephalopathy (CTE) Guskiewicz et al., 2003; Holsinger et al., 2002; Plassman et al., 2000; Gavett et al. 2011, Meehan & Bachur, 2009, Putukian, 2011; Scherwath et al., 2011; Mitka et al., 2010; McKee et al. 2009; Guskiewicz et al., 2005

8 Complications of Concussion LONG-TERM Correlation to neuro-degenerative disease Alzheimer s Disease 20-30% Alzheimer s patients report history of head trauma vs. 8-10% of controls Cognitive Impairment 15% have cognitive impairment even after just ONE concussion Retired professional football players with history of concussion 5x diagnosed with MCI (mild cognitive impairment) Guskiewicz et al., 2003; Holsinger et al., 2002; Plassman et al., 2000; Gavett et al. 2011, Meehan & Bachur, 2009, Putukian, 2011; Scherwath et al., 201; Mitka et al., 2010; McKee et al. 2009; Guskiewicz et al., 2005

Approximately 85% of sports-related concussions

Study of Traumatic Encephalopathy Boston

9 Approximately 85% of sports-related concussions go undiagnosed CLICK HERE for Video: Chris Nowinski Chris Nowinski Executive Director, Sports Legacy Institute Co-Director, Center for Study of Traumatic Encephalopathy Boston University School of Medicine Source: American College of Sports Medicine

10 Challenges: Recognition and Management of Concussion 1. Wide variety of symptoms: easily missed by coaches, medical staff 1. Denial of symptoms ( I feel fine ) Metabolically-mediated euphoria (McKee 2010) 2. Most evaluation & management protocols not evidencebased 3. Traditional neurological / radiological studies (CT, MRI, EEG) normal with mtbi Metabolic vs. structural changes There is a need for objective, validated sideline Remove-From-Play concussion screening tools

11 Levels of Evidence Expert Opinion and Clinical Observation are the LOWEST forms of scientific evidence

12 Concussion Testing Two types of tests: 1. Remove from Play (Screening/Diagnosis) Sport Concussion Assessment Tool (SCAT2), Standardized Assessment of Concussion (SAC) King-Devick Test (K-D test) Hit Accelerometers (X2, Check Light) 2. Return to Play/School (Management) REST (cognitive & physical) Neurocognitive tests CDC Return to Play Protocol Ocular Motor Integrated training Guskiewicz & Broglio, 2011; Dziemianowicz et al, Curr Neurol Neurosci Rep, 2012

Remove from Play King-Devick Test for Concussions Test of rapid number naming & eye movements Speed & error compared to baseline time Best of 2 trials to determine Baseline Time (learning effect)

13 Remove from Play King-Devick Test for Concussions Test of rapid number naming & eye movements Speed & error compared to baseline time Best of 2 trials to determine Baseline Time (learning effect) Retest after suspected head injury: INCREASED time or ERRORS Concussion *Can be administered by coaches/parents (non-medical professional) *May help coaches/trainers with game time decisions Galetta et al., 2011

of Pennsylvania Laura Balcer, MD, MSCE CLICK HERE for Video: King-Devick on

14 King-Devick Test: On The Sidelines Eric Laudano, MHS, ATC Head Athletic Trainer Univ. of Pennsylvania Laura Balcer, MD, MSCE CLICK HERE for Video: King-Devick on Sidelines Vice Chair of Neurology, NYU Langone Medical Center Professor of Neurology, Ophthalmology, Epidemiology at NYU School of Medicine

Neurology of Concussion Many symptoms not captured by cognitive testing Vision alone accounts for >55% of the brain s pathways Planning and execution of saccades involves a wide network of anatomical

15 Neurology of Concussion Many symptoms not captured by cognitive testing Vision alone accounts for >55% of the brain s pathways Planning and execution of saccades involves a wide network of anatomical structures in the brain: Frontal eye field (Frontal Cortex) Dorsolateral prefrontal cortex Supplementary motor area Posterior parietal cortex Middle temporal Area Occipital Lobe, Striate cortex Thalamus Superior Colliculus Brainstem structures Impaired eye movements are an indicator of suboptimal brain function (Heitger et al, 2002) Heitger et al, 2002; Heitger et al, 2010; Maruta et al, 2010; Pierrot-Deseilligny et al., 2005; Gaymard et al., 1998

16 King-Devick Test in Scientific Literature Neurology Apr 26;76(17): Epub 2011 Feb 2. The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters J Neurol Sci Oct 15;309(1-2):34-9. Epub 2011 Aug 16. The King-Devick test and sports-related concussion: Study of a rapid visual screening tool in a collegiate cohort Curr Neurol Neurosci Rep Oct;12(5): Sports Concussion Testing J Neurol Sci Sep 15;320(1-2): Epub 2012 Jun 12. Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: A pilot study The King-Devick Test is an accurate and reliable method for identifying athletes with head trauma, and is a strong candidate rapid sideline screening test for concussion. addresses the need for a quick, reliable test that can accurately identify concussion and thus reduces the potentially devastating effects of second impact syndrome and recurrent neurological injury. Because the K-D test does not require a medical professional and can be administered in 1-2min, it is practical for sideline use at all levels of sports. The K-D test has the potential to capture brain impairment not observed in standard neurocognitive testing able to identify players with a suspected concussion, players with a concussion that was not reported or witnessed. the ease-of-use made it more acceptable to team management and players and, as it provided immediate feedback to the player and coach. the K-D test served to provide support for the decision made by the team medic to rule out the player from further match participation.

17 King-Devick Test in Scientific Literature J Neurol Sci. 2013;326(1-2):59-63 Concussions in amateur rugby union identified with the use of a rapid visual screening tool able to identify players that had not shown, or reported, any signs or symptoms of a concussion but who had meaningful head injury. suitable for rapid assessment in a limited time frame on the sideline such as a five-minute window to assess and review suspected concussed players in rugby union. Poster Presentation at ARVO 2013 Annual Meeting Concussion Screening in High School Football Using the King-Devick Test Three football players whose concussion diagnosis was confirmed by a neurologist did in fact demonstrate diminished KD test performances times. J Neurol Sci. 2013;328(1-2):28-31 Saccades and Memory: Baseline associations of the King-Devick and SCAT2 SAC tests in professional hockey players Two players tested rink-side immediately following concussion had KD scores worsened from baseline. These athletes had no differences found for SCAT2 SAC components, but reported symptoms of concussion. The K-D test was associated with reductions in Immediate Memory Scores and the overall SAC score.

King-Devick Test: -10 30 40 50 60 70 10 20 30 0-10 30 40 50 60 70 10 20 30 0

18 King-Devick Test: Boxers & MMA Fighters Study Boston, MA P =.02 P <.0001 P =.02 P <.0001 No head trauma (n = 31) Head trauma (n = 8) No LOC (n = 4) LOC (n = 4) K-D scores worse after head trauma K-D scores worse with loss of consciousness Galetta et al. Neurology. 2011

King-Devick Test: Penn Collegiate Athlete Study Football, Basketball, Soccer 30 40 50 60 70 p=0.009 vs. baseline following concussion 30 40 50 60 70 p=0.0003 vs.

19 King-Devick Test: Penn Collegiate Athlete Study Football, Basketball, Soccer p=0.009 vs. baseline following concussion p= vs. baseline following exercise Baseline K-D (sec) Sideline K-D (sec) n = 10 n = 10 Baseline (sec) n = 18 n = 18 K-D scores worse after concussion Post-scrimmage (sec) K-D scores not worse after exercise Galetta et al. J Neurol Sci p< vs. controls p< vs. controls

King-Devick Test: Amateur Rugby Studies New Zealand Pilot Study: Participants: 50 athletes over 12 matches Concussions: 5 3 witnessed/self reported 2 incidental, un-witnessed (detected on post-game

20 King-Devick Test: Amateur Rugby Studies New Zealand Pilot Study: Participants: 50 athletes over 12 matches Concussions: 5 3 witnessed/self reported 2 incidental, un-witnessed (detected on post-game assessment with King-Devick test) Follow-up Study: Participants: 37 athletes over 24 matches Concussions: 22 5 witnessed/self reported 17 incidental, un-witnessed (detected on post-game assessment with King-Devick test) King, D et al. J Neurol Sci. 2012; King D et al., J Neurol Sci. 2013

Saccades & Memory Professional Ice Hockey: Philadelphia Flyers 27

SCAT2 SAC Memory score Lower overall SAC score 2 concussed athletes

memory and saccades share closely related anatomical structures,

21 Saccades & Memory Professional Ice Hockey: Philadelphia Flyers 27 athletes, season Worse KD scores associated with: Lower SCAT2 SAC Memory score Lower overall SAC score 2 concussed athletes exhibited: Abnormal KD test Normal SCAT2 SAC test +Symptoms Working memory and saccades share closely related anatomical structures, including the dorsolateral prefrontal cortex (DLPFC) Galetta MS, et al. J Neurol Sci 2013

Concussions in High School Football Participants: 47 high school football players, 2012 season Concussions: 3 Concussion confirmed by neurologist ALL abnormal KD scores Student 1: 41% worse Student

22 Concussions in High School Football Participants: 47 high school football players, 2012 season Concussions: 3 Concussion confirmed by neurologist ALL abnormal KD scores Student 1: 41% worse Student 2: 100% worse Student 3: 143% worse Test-retest Reliability: ICC = (p<0.05) Poster Presentation at the Association for Research in Vision and Ophthalmology Annual Meeting 2013 Yevsyenkov V, et al. Unpublished data 2013

25 30 35 40 45 25 30 35 40 45 20 30 40 50 60 King-Devick Test: Wheaton College Football K-D Time Scores (seconds) K-D Time Scores (seconds) K-D Time Scores (seconds) P = 0.

23 King-Devick Test: Wheaton College Football K-D Time Scores (seconds) K-D Time Scores (seconds) K-D Time Scores (seconds) P = vs Baseline P = 0.01 vs. Baseline P = 0.03 vs. Baseline Baseline Concussion Baseline Post-Workout Baseline Post-Season n = 11 n = 25 n = 43 Evans, G et al., unpublished data 2012

24 King-Devick Test: Sports Parents Study -- Pending Publication n=34 amateur boxers Ringside physician using MACE 6 Layperson testers in off-ringside testing room Single boxer sustained concussion (per ringside physician) Accurately identified by layperson K-D tester 3.2s worsening compared to baseline In the absence of concussion, post-fight K-D scores better than baseline scores Fatigue does not worsen K-D test performance High test-retest reliability: ICC 0.90 K-D test Reliably & Effectively Administered by Sports Parents

25 King-Devick Test, ImPACT & Symptoms N=35 (12-19yo) concussed patients Evaluated with KD, ImPACT and Post-Concussion Symptom Scale (PCSS) over 4 clinical visits KD times improved with each visit and paralleled improvements in PCSS KD test is effective in objectively monitoring concussion recovery and symptom resolve Tjarks B et al. 2013

26 Practice Management: Incorporating King-Devick into your practice Educational Outreach Educate communities about sports concussions and the science behind the K-D test Teach coaches/parents to administer the test and implement on sidelines Create Brand Awareness for your Practice Offer K-D baseline testing at annual exam or at a pre-season practice K-D baselines take 2 minutes, Technician can administer during pre-testing Patient capture & retention: K-D baselines required EVERY year, encourages YEARLY office visit

King-Devick Test for Neurological Function KD test for Neurological

Life indicator Parkinson s disease MAYO clinic: Rapid tool for

Deprivation Penn: KD is sensitive to effects of sleep deprivation on

27 King-Devick Test for Neurological Function KD test for Neurological functions: Multiple Sclerosis Penn & NYU: Disability and Quality of Life indicator Parkinson s disease MAYO clinic: Rapid tool for quantifying visual & cognitive function in Parkinson s Sleep Deprivation Penn: KD is sensitive to effects of sleep deprivation on cognitive functioning Hypoxia MAYO: KD test is an early indicator of hypoxia incapacitation

28 King-Devick Test Baseline: Normoxia

29 King-Devick Test: Under Hypoxic Condition

30 MAYO/Tobii/KD Tracking Click Here: Mayo/Tobii/KD eye tracking video demonstration

32 Practice Management Enhance your practice with evidence based science & technology Annual K-D Baselines in your office Post-injury evaluations & coordinated management Ocular Motor Integration Reading Remediation Neurological function testing and monitoring with MAYO/Tobii/KD technology

Clinical Practice of a Vision Based Concussion Tool MATT FRANTZ, M.ED., LAT, ATC LAFAYETTE COLLEGE

Clinical Practice of a Vision Based Concussion Tool MATT FRANTZ, M.ED., LAT, ATC LAFAYETTE COLLEGE Disclosure No financial COI No non-financial COI No corporate bias or sponsorship Your Concussion Toolbag