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Diagnostic accuracy and reliability of sideline concussion evaluation: a prospective, case-controlled study in college athletes comparing newer tools and established tests
  1. Kimberly G Harmon1,
  2. Bridget M Whelan1,
  3. Douglas F Aukerman2,
  4. Adam D Bohr3,
  5. J Matthew Nerrie4,
  6. Heather A Elkinton5,
  7. Marissa Holliday6,
  8. Sourav K Poddar7,
  9. Sara P D Chrisman8,9,
  10. Matthew B McQueen3
  1. 1Family Medicine, University of Washington, Seattle, Washington, USA
  2. 2Department of Family Medicine, Oregon State University, Corvallis, Oregon, USA
  3. 3Department of Integrative Physiology, University of Colorado Boulder, Boulder, Colorado, USA
  4. 4Intercollegiate Athletics, University of Washington, Seattle, Washington, USA
  5. 5Intercollegiate Athletics, Oregon State University, Corvallis, Oregon, USA
  6. 6Intercollegiate Athletics, University of Colorado Boulder, Boulder, Colorado, USA
  7. 7Department of Family Medicine, University of Colorado - Anschutz Medical Campus, Aurora, Colorado, USA
  8. 8Center for Child Health, Behavior and Development, Seattle Children's Research Institute, Seattle, Washington, USA
  9. 9Harborview Injury Prevention and Research Center, Seattle, Washington, USA
  1. Correspondence to Dr Kimberly G Harmon, Family Medicine, University of Washington, Seattle WA 98195 USA, Washington, USA; kharmon{at}


Objective To assess diagnostic accuracy and reliability of sideline concussion tests in college athletes.

Methods Athletes completed baseline concussion tests including Post-Concussion Symptom Scale, Standardised Assessment of Concussion (SAC), modified Balance Error Scoring System (m-BESS), King-Devick test and EYE-SYNC Smooth Pursuits. Testing was repeated in athletes diagnosed acutely with concussion and compared to a matched teammate without concussion.

Results Data were collected on 41 concussed athletes and 41 matched controls. Test–retest reliability for symptom score and symptom severity assessed using control athletes was 0.09 (−0.70 to 0.88) and 0.08 (−1.00 to 1.00) (unweighted kappa). Intraclass correlations were SAC 0.33 (−0.02 to 0.61), m-BESS 0.33 (−0.2 to 0.60), EYE-SYNC Smooth Pursuit tangential variability 0.70 (0.50 to 0.83), radial variability 0.47 (0.19 to 0.69) and King-Devick test 0.71 (0.49 to 0.84). The maximum identified sensitivity/specificity of each test for predicting clinical concussion diagnosis was: symptom score 81%/94% (3-point increase), symptom severity score 91%/81% (3-point increase), SAC 44%/72% (2-point decline), m-BESS 40%/92% (5-point increase), King-Devick 85%/76% (any increase in time) and EYE-SYNC Smooth Pursuit tangential variability 48%/58% and radial variability 52%/61% (any increase). Adjusted area under the curve was: symptom score 0.95 (0.89, 0.99), symptom severity 0.95 (95% CI 0.88 to 0.99), SAC 0.66 (95% CI 0.54 to 0.79), m-BESS 0.71 (0.60, 0.83), King-Devick 0.78 (0.69, 0.87), radial variability 0.47 (0.34, 0.59), tangential variability 0.41 (0.30, 0.54)

Conclusion Test–retest reliability of most sideline concussion tests was poor in uninjured athletes, raising concern about the accuracy of these tests to detect new concussion. Symptom score/severity had the greatest sensitivity and specificity, and of the objective tests, the King-Devick test performed best.

  • Concussion
  • Adolescent
  • Injury
  • Diagnosis

Data availability statement

Data are available on reasonable request. Data requests may be made to

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Data availability statement

Data are available on reasonable request. Data requests may be made to

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  • Twitter @DrKimHarmon, @SPDChrismanMD

  • Contributors All authors contributed to study design, data collection, and writing and review of the manuscript. KGH, ADB, BMW, SPDC and MBM contributed to data analysis as well.

  • Funding Funding for this study was provided by a generous donation from University of Washington alumni Jack and Luellen Charneski.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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