The Indiana Soccer Olympic Development concussion remove-from-play protocol incorporates the King-Devick test to establish a baseline and post event test, and incorporates the CDC’s concussion signs and symptoms checklist.
As coaches and administrators, we have an obligation to provide a safe environment for players to train and to play. This obligation extends to the implementation of injury prevention efforts as well as to remove from play, a player who is injured so as not to expose the player to further injury. Some injuries such as lacerations, broken bones, torn ligaments, sprains, etc. can be readily observed due to their immediate symptoms, and are easily identified, assessed and address. However, concussion, is a concealed injury, that frequently has delayed symptoms, and requires a more clinical investigation in order to properly identify, assess and address this injury.
Concussion, due to the concealment of the injury and the sometimes delayed observable symptoms associated with the injury, requires a more clinical approach to suitably identify, assess and address the injury. One proven method of assessing concussion begins with the establishment of a pre-injury baseline score [baseline]. A practical method of obtaining a baseline that can be administered by parents, coaches, athletic trainers, managers and medical professionals, is the King-Devick test. Once a baseline has been established using the King-Devick test, a post-event test can be administered immediately after a suspected concussion event. The post-event test results are then compared to the player’s pre-event baseline, to assist the available decision maker in determining if the player should be removed from play.
It is crucial to remove a concussed player from play in order to prevent further damage. It is also extremely important to keep the athlete from returning to play until they have made a full recovery. The King-Devick test, as a remove from play tool has been validated by the Mayo Clinic.
How does the King-Devick test work?
“Concussions are a complex type of brain injury that is not visible on routine scans of the brain, yet are detectable when important aspects of brain function are measured. King-Devick Test (K-D Test) is a two-minute test that requires an athlete to read single digit numbers displayed on cards or on an iPad. After suspected head trauma, the athlete is given the test and if the time required to complete the test is any longer than the athlete’s baseline test-time, or if the athlete makes any uncorrected errors in reading the numbers, the athlete should be removed from play and should be evaluated by a licensed professional.
The King-Devick Test Screens For:
· Saccades (eye movements)
· Other correlates of sub-optimal brain function
The eyes are actually part of the brain and the planning and execution of eye movement 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
· Superior Colliculus
· Brainstem Structures
· Eye movements relate closely to the functional integrity of the injured brain and eye movement function is impaired acutely in post-mTBI ”
· Impaired eye movements are an indicator of suboptimal brain function
The King-Devick concussion screening test establishes a best speed [baseline] that the tested player can read and articulate accurately, a series of numbers on three cards; See below:
Should the player be exposed to an event that results in observable concussion-like symptoms or should the player be exposed to an event that brings into question the players brain condition, the King-Devick test can be administered. Should the time required for the player to accurately complete the test INCREASE, or if the player makes any uncorrected errors in reading the numbers, remove the player from activity.
Process/Protocol for using the King-Devick Test:
1. Train athletic trainers, school nurses, coaches, managers, etc. on how to administer the King-
2. Baseline each athlete prior to their respective season [baselines are conducted yearly. [Athletes
under 10 years-old should establish a new baseline every six months due to their rapidly improving brain function.
3. Keep a King-Devick Test, score sheets, and team baselines available for practices and games.
4. Administer King-Devick Test immediately or shortly after suspected brain trauma occurs
· [According to published reports, waiting longer than 60 hours can increase the possibility of test related defects]
· [On a post-injury test, if the athlete’s baseline is faster than his/her preseason baseline, the faster time becomes their new baseline.]
5. Remove athlete from play due to increased King-Devick Test baseline score or errors reading the
6. Contact a physician and initiate “return-to-play” protocol
Frequently Asked Questions
Can I use the King-Devick Test without a baseline?
No. The results are compared to an individual’s performance, not comparative data. An established preseason baseline must be used.
How much time should I allocate to baseline all my athletes?
The good news is once you get the hang of it, the baseline process takes about four minutes an athlete. You can schedule King-Devick baseline testing with other baseline testing or during preseason physicals, equipment handout, and practice. It’s also quite simple to train people within your organization to help baseline your athletes, allowing you to have multiple people testing.
What is the King-Devick testing criteria for removing an athlete from play?
If a subject performs any slower compared to their baseline time or makes any uncorrected errors reading the numbers, the subject should be “removed-from-play”.
How accurate is the King-Devick Test?
According to over 50 research studies, the King-Devick Test has accurately and reliably correlated with athletes subsequently diagnosed with concussions. There have also been instances in research where athletes have had increased baseline times on the King-Devick Test despite passing all other sideline tests administered by a physician.
How can I tell if an athlete is cheating/sandbagging when trying to establish their baseline?
The onus is on the person recording the baseline to make sure the athlete understands the expectations before a baseline attempt is started. Once the timer starts, if the person recording the baseline believes the athlete isn’t reading the numbers as quickly as they can, the test should stop and the expectations explained again. If the issue still exists, the person recording the baseline should contact the athlete’s coach or parent and explain the athlete will not participate in their sport until the baseline is recorded properly. (The importance of the role of the person recording the baseline cannot be stressed enough for the program to be successful.)
What do I do if an athlete’s memorizes the numbers on the cards?
With 120 numbers on three test cards, this is highly unlikely. However, if you believe this is a possibility, the King-Devick Online System and K-D Test Pro app are equipped with a Version 2, which is the same test with different numbers.
What if my younger athletes struggle reading the numbers on the third card?
With athletes five to nine years-old, it’s recommended that you establish a baseline using the first two cards. You can try to see how your eight and nine year-olds fare on the third card, but don’t feel it necessary to include the third card if they are struggling. Score the time required to complete the first two cards and that time becomes the athlete’s baseline. Any athlete 10 years-old and older should establish a baseline using all three cards.
What if one of my athletes has a reading or learning disability?
Keep in mind the King-Devick Test is based upon individual results, so athletes with any type of learning disability should read the cards as quickly as they are able.
Can I use the King-Devick Test for “return-to-play”?
No! Although it’s tempting to continually test an athlete post-concussion until their baseline time improves to what it was before they were concussed, the King-Devick Test is only validated as a “remove-from-play” screening tool. There is research being done in this area or return to play, but it’s in its infant stages.
What’s preventing me from photocopying the test and passing it around for others to use?
The King-Devick Test is protected with several patents and copyrights. Anyone choosing to copy and distribute the test illegally will be prosecuted to the full extent of the law.
What happens if I decide not to renew my yearly subscription?
If a decision is made to not renew your yearly subscription, once your remaining subscription expires you will no longer have access to the King-Devick Online System or the K-D Pro iPad App.
The Indiana Soccer Olympic Development Concussion Protocol also includes the CDC’s recommended signs and symptoms check list. A player does not need to fail both the King-Devick test and display any of the items on the CDC Checklist. If a player satisfies either portion (the King-Devick portion or the CDC check list portion) of the protocol, remove the player from play.
Players who experience one or more of the following signs or symptoms of concussion after a bump, blow, or jolt to the head should be removed from play and referred to a health care professional with experience in evaluating for concussion.
The CDC concussion signs and symptoms checklist:
· Appears dazed or stunned
· Is confused about events
· Repeats questions
· Answers questions slowly
· Can’t recall events prior to the hit, bump, or fall
· Can’t recall events after the hit, bump, or fall
· Loses consciousness (even briefly)
· Shows behavior or personality changes
· Forgets class schedule or assignments
· Headache or “pressure” in head
· Nausea or vomiting
· Balance problems or dizziness
· Fatigue or feeling tired
· Blurry or double vision
· Sensitivity to light
· Sensitivity to noise
· Numbness or tingling
· Does not “feel right”
· Difficulty thinking clearly
· Difficulty concentrating
· Difficulty remembering
· Feeling more slowed down
· Feeling sluggish, hazy, foggy, or groggy
· More emotional than usual
The player should only be returned to play when released by a health care professional.
Executive Director, Indiana Soccer Association