Use of the King-Devick test for the identification of concussion in an amateur domestic women's rugby union team over two competition seasons in New Zealand

  • D. King
    Corresponding author at: Emergency Department, Hutt Valley District Health Board, Private Bag 31-907, Lower Hutt, New Zealand.
    Sport Performance Research Institute New Zealand (SPRINZ), Faculty of Health and Environment Science, Auckland University of Technology, Auckland, New Zealand

    School of Science and Technology, University of New England, Armidale, NSW, Australia

    School of Sport, Exercise and Nutrition, Massey University, New Zealand
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  • P.A. Hume
    School of Science and Technology, University of New England, Armidale, NSW, Australia

    National Institute of Stroke and Applied Neuroscience (NISAN), Faculty of Health and Environment Science, Auckland University of Technology, Auckland, New Zealand
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  • T.N. Clark
    International College of Management Sydney, Manly, New South Wales, Australia
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  • A.J. Pearce
    College of Science, Health and Engineering, La Trobe University, Bundoora, Melbourne, Victoria, Australia
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Published:September 28, 2020DOI:


      • The match concussion injury rate for women's amateur rugby union was 16.1 (95% CI: 8.4 to 31.0) per 1000 match hrs.
      • There was good reliability between tests for K-D test baseline establishment in 2018 (ICC: 0.88 [95% CI: 0.75 to 0.94]).
      • Post season analysis of the test scores for the K-D test showed a mean improvement of 9.8 [5.6 to 15.2] s in 2018 and 8.8 [5.5 to 14.9] s in 2019.
      • There was good reliability between the K-D test baseline and post-season K-D test scores (ICC: 0.83 [95%CI: 0.71–0.90]).



      To investigate the use of the King-Devick (K-D) test for sideline assessment of concussive injuries in a New Zealand amateur women's rugby union team.


      Prospective cohort observational.


      All players were K-D tested during pre-season using a tablet (iPad; Apple Inc., Cupertino, CA). Differences in K-D scores and test-retest reliability were calculated for baseline test scores, baseline, and post-injury (concussion) sideline assessment and baseline and post-season testing scores for tests by year and as a combined score.


      One training-related (0.3 per 1000 training-hrs) and nine match-related (16.1 per 1000 match-hrs) concussions were recorded. The K-D post-injury (concussion) sideline test score were significantly slower than established baseline (−4.4 [−5.8 to −3.4] s; χ2(1) = 42.2; p < 0.0001; t(9) = −4.0; p = 0.0029; d = −0.8). There was good-to-excellent reliability of the K-D test for baseline (ICC: 0.84 to 0.89), post-injury (concussion) sideline assessment (ICC: 0.82 to 0.97) and post-season evaluation (ICC: 0.79 to 0.83).


      By utilising the baseline to post-injury (concussion) assessment comparisons, any player with a post-injury (concussion) assessment slowing of their K-D test time, regardless of whether the player has, or has not had a witnessed insult, should be withheld from any further participation until they are evaluated by a medical professional trained in the management of concussion.


      This study has provided additional evidence to support the use of the K-D test as a frontline method of assessing concussion with good to excellent reliability of the test for baseline, side-line assessment and post-season evaluation.


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        • King D.
        • Brughelli M.
        • Hume P.
        • Gissane C.
        Concussions in amateur rugby union identified with the use of a rapid visual screening tool.
        J. Neurol. Sci. 2013; 326: 59-63
        • Brooks J.
        • Fuller C.
        • Kemp S.
        • Reddin D.
        Epidemiology of injuries in English professional rugby union: part 1 match injuries.
        Br. J. Sports Med. 2005; 39: 757-766
        • Kemp S.
        • Hudson Z.
        • Brooks J.
        • Fuller C.
        The epidemiology of head injuries in English professional rugby union.
        Clin. J. Sport Med. 2008; 18: 227-234
        • Whitehouse T.
        • Orr R.
        • Fitzgerald E.
        • Harries S.
        • McLellan C.P.
        The epidemiology of injuries in Australian professional rugby union 2014 super rugby competition.
        Orthop. J. Sports Med. 2016; 4
        • Roberts S.
        • Trewartha G.
        • Higgitt R.
        • El-Abd J.
        • Stokes K.
        The physical demands of elite English rugby union.
        J. Sports Sci. 2008; 26: 825-833
        • Davidson R.
        Schoolboy rugby injuries, 1969-1986.
        Med. J. Aust. 1987; 147: 119-120
        • Marshall S.
        • Spencer R.
        Concussion in rugby: the hidden epidemic.
        J. Athl. Train. 2001; 36: 334-338
        • McIntosh A.
        • McCrory P.
        Effectiveness of headgear in a pilot study of under 15 rugby union football.
        Br. J. Sports Med. 2001; 35: 167-169
        • Kirkwood G.
        • Parekh N.
        • Ofori-Asenso R.
        • Pollock A.
        Concussion in youth rugby union and rugby league: a systematic review.
        Br. J. Sports Med. 2015; 49: 506-510
        • Gardner A.
        • Shores E.
        • Batchelor J.
        Reduced processing speed in rugby union players reporting three or more previous concussions.
        Arch. Clin. Neuropsychol. 2010; 25: 174-181
        • Pearce A.
        • Rist B.
        • Fraser C.
        • Cohen A.
        • Maller J.
        Neurophysiological and cognitive impairment following repeated sports concussion injuries in retired professional rugby league players.
        Brain Inj. 2018; 32: 498-505
        • Pearce A.J.
        • Tommerdahl M.
        • King D.A.
        Neurophysiological abnormalities in individuals with persistent post-concussion symptoms.
        Neuroscience. 2019; 408: 272-281
        • Guskiewicz K.
        • Marshall S.
        • Bailes J.
        • McCrea M.
        • Cantu R.
        • Randolph C.
        • et al.
        Association between recurrent concussion and late-life cognitive impairment in retired professional football players.
        Neurosurgery. 2005; 57: 719-726
        • Guskiewicz K.
        • Marshall S.
        • Bailes J.
        • McCrea M.
        • Harding Jr., H.
        • Matthews A.
        • et al.
        Recurrent concussion and risk of depression in retired professional football players.
        Med. Sci. Sports Exerc. 2007; 39: 903-909
        • McCrory P.
        • Meeuwisse W.
        • Aubry M.
        • Cantu R.
        • Dvořák J.
        • Echemendia R.
        • et al.
        Consensus statement on concussion in sport: the 4th international conference on concussion in sport held in Zurich, November 2012.
        Br. J. Sports Med. 2013; 47: 250-258
        • Talavage T.
        • Nauman E.
        • Breedlove E.
        • Yoruk U.
        • Dye A.
        • Morigaki K.
        • et al.
        Functionally-detected cognitive impairment in high school football players without clinically-diagnosed concussion.
        J. Neurotrauma. 2014; 31: 327-338
        • Ciuffreda K.
        • Kapoor N.
        • Rutner D.
        • Suchoff I.
        • Han M.
        • Craig S.
        Occurrence of oculomotor dysfunctions in acquired brain injury: a retrospective analysis.
        Optometry. 2007; 78: 155-161
        • Goodrich G.
        • Flyg H.
        • Kirby J.
        • Chang C.
        • Martinsen G.
        Mechanisms of TBI and visual consequences in military and veteran populations.
        Optom. Vis. Sci. 2013; 90: 105-112
        • Heitger M.
        • Anderson T.
        • Jones R.
        Saccade sequences as markers for cerebral dysfunction following mild closed head injury.
        in: DPMWH J. Hyona Radach R. Progress in Brain Research. Elsevier, 2002: 433-448
      1. A new approach to predicting postconcussion syndrome after mild traumatic brain injury based upon eye movement function.
        in: Heitger M. Jones R. Anderson T. Conference Proceedings of the IEEE Engineering in Medicine and Biology Society. 2008 (Vancouver, BC)
        • McCrory P.
        • Meeuwisse W.
        • Dvořák J.
        • Aubry M.
        • Bailes J.
        • Broglio S.
        • et al.
        Consensus statement on concussion in sport - the 5th international conference on concussion in sport held in Berlin, October 2016.
        Br. J. Sports Med. 2017; 51: 838-847
        • Galetta K.
        • Morganroth J.
        • Moehringer N.
        • Mueller B.
        • Hasanaj L.
        • Webb N.
        • et al.
        Adding vision to concussion testing: a prospective study of sideline testing in youth and collegiate athletes.
        J. Neuroophthalmol. 2015; 35: 235-241
        • Ventura R.
        • Balcer L.
        • Galetta S.
        The neuro-ophthalmology of head trauma.
        Lancet Neurol. 2014; 13: 1006-10016
        • Felleman D.J.
        • Van Essen D.C.
        Distributed hierarchical processing in the primate cerebral cortex.
        Cereb. Cortex. 1991; 1: 1-47
        • Galetta K.
        • Brandes L.
        • Maki K.
        • Dziemianowicz M.
        • Laudano E.
        • Allen M.
        • et al.
        The King-Devick test and sports-related concussion: study of a rapid visual screening tool in a collegiate cohort.
        J. Neurol. Sci. 2011; 309: 34-39
        • Galetta M.
        • Galetta K.
        • McCrossin J.
        • Wilson J.
        • Moster S.
        • Galetta S.
        • et al.
        Saccades and memory: baseline associations of the King–Devick and SCAT2 SAC tests in professional ice hockey players.
        J. Neurol. Sci. 2013; 328: 28-31
        • Leong D.
        • Balcer L.
        • Galetta S.
        • Liu Z.
        • Master C.
        The King-Devick test as a concussion screening tool administered by sports parents.
        J. Sports Med. Phys. Fit. 2014; 54: 70-77
        • Arca K.N.
        • Starling A.J.
        • Acierno M.D.
        • Demaerschalk B.M.
        • Marks L.
        • O’Carroll C.B.
        Is King-Devick testing, compared with other sideline screening tests, superior for the assessment of sports-related concussion? A critically appraised topic.
        Neurologist. 2020; 25: 33-37
        • Mujika I.
        • Taipale R.S.
        Sport science on women, women in sport science.
        Int. J. Sports Phys. Perform. 2019; 14: 1013
        • Cummins C.
        • Melinz J.
        • King D.
        • Sanctuary C.
        • Murphy A.
        Call to action: a collaborative framework to better support female rugby league players.
        Br. J. Sports Med. 2020;
        • Seidman D.
        • Burlingame J.
        • Yousif L.
        • Donahue X.
        • Krier J.
        • Rayes L.
        • et al.
        Evaluation of the King–Devick test as a concussion screening tool in high school football players.
        J. Neurol. Sci. 2015; 356: 97-101
        • Dessy A.M.
        • Yuk F.J.
        • Maniya A.Y.
        • Gometz A.
        • Rasouli J.J.
        • Lovell M.R.
        • et al.
        Review of assessment scales for diagnosing and monitoring sports-related concussion.
        Cureus. 2017; 9 (e1922-e)
        • King D.
        • Gissane C.
        • Hume P.
        • Flaws M.
        The King–Devick test was useful in management of concussion in amateur rugby union and rugby league in New Zealand.
        J. Neurol. Sci. 2015; 351: 58-64
        • Galetta K.
        • Barrett J.
        • Allen M.
        • Madda F.
        • Delicata D.
        • Tennant A.
        • et al.
        The King-Devick test as a determinant of head trauma and concussion in boxers and MMA fighters.
        Neurology. 2011; 76: 1456-1462
        • Galetta K.
        • Liu M.
        • Leong D.
        • Ventura R.
        • Galetta S.
        • Balcer L.
        The King-Devick test of rapid number naming for concussion detection: meta-analysis and systematic review of the literature.
        Concussion. 2015; 1: CNC8
        • Yue J.K.
        • Phelps R.R.L.
        • Chandra A.
        • Winkler E.A.
        • Manley G.T.
        • Berger M.S.
        Sideline concussion assessment: the current state of the art.
        Neurosurgery. 2020;
        • Tjarks B.
        • Dorman J.
        • Valentine V.
        • Munce T.
        • Thompson P.
        • Kindt S.
        • et al.
        Comparison and utility of King-Devick and ImPACT composite scores in adolescent concussion patients.
        J. Neurol. Sci. 2013; 334: 148-153
        • Legarreta A.D.
        • Mummareddy N.
        • Yengo-Kahn A.M.
        • Zuckerman S.L.
        On-field assessment of concussion: clinical utility of the King-Devick test.
        Open Access J. Sports Med. 2019; 10: 115-121
        • Howitt S.
        • Brommer R.
        • Fowler J.
        • Gerwing L.
        • Payne J.
        • DeGraauw C.
        The utility of the King-Devick test as a sideline assessment tool for sport-related concussions: a narrative review.
        J. Can. Chiropr. Assoc. 2016; 60: 322-329
        • Marinides Z.
        • Galetta K.
        • Andrews C.
        • Wilson J.
        • Herman D.
        • Robinson C.
        • et al.
        Vision testing is additive to the sideline assessment of sports-related concussion.
        Neurol. Clin. Pract. 2014; 5: 25-34
        • Nguyen M.Q.
        • King D.
        • Pearce A.J.
        A reliability and comparative analysis of the new randomized King-Devick test.
        J. Neuroophthalmol. 2020; 40: 207-212
        • Spradley B.
        • Wiriyanpinit S.
        • Magner A.
        Baseline concussion testing in different environments: A pilot study.
        Sport J. 2014; 55 ([Internet]. Mar-12 Available from:)
        • King D.
        • Clark T.
        • Gissane C.
        Use of a rapid visual screening tool for the assessment of concussion in amateur rugby league: a pilot study.
        J. Neurol. Sci. 2012; 320: 16-21
        • Koo T.K.
        • Li M.Y.
        A guideline of selecting and reporting intraclass correlation coefficients for reliability research.
        J. Chiropr. Med. 2016; 15: 155-163
        • Perinetti G.
        StaTips part IV: selection, interpretation and reporting of the intraclass correlation coefficient.
        South Eur. J. Orthod Dentofac. Res. 2018; 5: 3-5
        • Cohen J.
        Statistical Power Analysis for the Behavioural Sciences.
        2nd ed. Lawrence Erlbaum Associates, New York, New York1988
        • Zakzanis K.K.
        Statistics to tell the truth, the whole truth, and nothing but the truth: formulae, illustrative numerical examples, and heuristic interpretation of effect size analyses for neuropsychological researchers.
        Arch. Clin. Neuropsychol. 2001; 16: 653-667
        • Hubbard R.
        • Stringer G.
        • Peterson K.
        • Vaz Carneiro M.R.F.
        • Finnoff J.T.
        • Savica R.
        The King-Devick test in mixed martial arts: the immediate consequences of knock-outs, technical knock-outs, and chokes on brain functions.
        Brain Inj. 2019; 33: 349-354
        • Oberlander T.J.
        • Olson B.L.
        • Weidauer L.
        Test-retest reliability of the King-Devick test in an adolescent population.
        J. Athl. Train. 2017; 52: 439-445
        • Bretzin A.C.
        • Anderson M.
        • Moran R.N.
        • Covassin T.
        Long-term test-retest evaluation of the King-Devick test in youth soccer athletes.
        J. Neurol. Sci. 2020; 416: 116951
        • Eddy R.
        • Goetschius J.
        • Hertel J.
        • Resch J.
        Test-retest reliability and the effects of exercise on the King-Devick test.
        Clin. J. Sport Med. 2020; 30: 239-244
        • Gardner A.
        • Iverson G.
        • Williams W.
        • Baker S.
        • Stanwell P.
        A systematic review and meta-analysis of concussion in rugby union.
        Sports Med. 2014; : 1-15
        • Kara S.
        • Crosswell H.
        • Forch K.
        • Cavadino A.
        • McGeown J.
        • Fulcher M.
        Less than half of patients recover within 2 weeks of injury after a sports-related mild traumatic brain injury: a 2-year prospective study.
        Clin. J. Sport Med. 2020; 30: 96-101
        • Nordahl-Hansen A.
        • Øien R.A.
        • Volkmar F.
        • Shic F.
        • Cicchetti D.V.
        Enhancing the understanding of clinically meaningful results: a clinical research perspective.
        Psychiatry Res. 2018; 270: 801-806
        • Zakzanis K.K.
        • Yeung E.
        Base rates of post-concussive symptoms in a nonconcussed multicultural sample.
        Arch. Clin. Neuropsychol. 2011; 26 (Epub 2011/06/07): 461-465
        • King D.
        • Hume P.
        • Gissane C.
        • Clark T.
        Use of the King–Devick test for sideline concussion screening in junior rugby league.
        J. Neurol. Sci. 2015; 357: 75-79