April 23, 2018April 10, 2018Free AccessThe New MULES: A Sideline-Friendly Test of Rapid Picture Naming for Concussion (P2.169)Omar Akhand, Matthew Galetta, Lisena Hasanaj, Lucy Cobbs, Nikki Webb, Julia Brandt, Prin Amorapanth, … Show All … , John-Ross Rizzo, Liliana Serrano, Rachel Nolan, Janet Rucker, Arlene Silverio, Barry Jordan, Steven Galetta, and Laura Balcer Show FewerAuthors Info & AffiliationsApril 10, 2018 issue90 (15_supplement)https://doi.org/10.1212/WNL.90.15_supplement.P2.169 Letters to the Editor

Objective: Measures of rapid automatized naming (RAN) have been used for over 50 years to capture vision based aspects of cognition. The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation for detection of concussion and other neurological disorders. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. Recent changes to the MULES test have been made to improve ease of use on the athletic sidelines. Originally an 11 x 17-inch single-sided paper, the test has been reduced to a laminated 8.5 x 11-inch double-sided version. We identified performance changes associated with transition to the new, MULES, now sized for the sidelines, and examined MULES on the sideline for sports-related concussion. Methods: We administered the new laminated MULES to a group of adult office volunteers as well as youth and collegiate athletes during pre-season baseline testing. Athletes with concussion underwent sideline testing after injury. Time scores for the new laminated MULES were compared to those for the larger version (big MULES). Results: Among 501 athletes and office volunteers (age 16 7 years, range 6-59, 29% female), average test times at baseline were 44.4 14.4 s for the new laminated MULES (n = 196) and 46.5 16.3 s for big MULES (n = 248). Both versions were completed by 57 participants, with excellent agreement (p < 0.001, linear regression, accounting for age). Age was a predictor of test times for both MULES versions, with longer times noted for younger participants (p < 0.001). Among 6 athletes with concussion thus far during the fall sports season (median age 15 years, range 11-21) all showed worsening of MULES scores from pre-season baseline (median 4.0 s, range 2.1-16.4). Conclusion: The MULES test has been converted to an 11 x 8.5-inch laminated version, with excellent agreement between versions across age groups. Feasibly administered at pre-season and in an office setting, the MULES test shows preliminary evidence of capacity to identify athletes with sports-related concussion.

Objective: The purpose of this investigation was to measure levels of agreement and quantitate the relative differences in baseline scores between the two versions of the K-D test. Background: Sports-related concussions are an increasingly recognized public health problem and may have serious neurologic implications for athletes. The vision-based King-Devick (K-D) test of rapid number naming has become an important tool to screen for concussion in athletes at the sidelines. Although the spiral-bound version of the K-D test has been tested in numerous research studies for this purpose, a computerized tablet-based version is now available. Methods: We recruited 85 participants into the study during sideline testing, and administered both the spiral and tablet versions of the K-D test to each participant. Version order was randomized to minimize the potential influences of learning effects on test differences. Results: There was excellent agreement (ICC=0.92, 95[percnt] CI: 0.82, 0.96) and strong linear correlations (r=0.94) between the two test versions. However, the tablet version had a significantly longer mean pre-season baseline test time compared to the spiral version (52.3 seconds vs. 48.6 seconds, p<0.001, paired t-test). A difference of 3.7 seconds between the two test modalities may be clinically significant since acutely concussed athletes in published studies and meta-analyses show average increases of 4 to 6 seconds in the K-D test time from baseline. Conclusions: The computerized tablet and spiral-bound versions of the K-D test have excellent agreement, suggesting that the tablet version should also be good predictor of concussion. However, alternating between the tablet and spiral versions of the K-D test may be inaccurate when screening for concussion during sideline testing.

OBJECTIVE: Vision encompasses nearly 50[percnt] of the brain's pathways, yet is not represented in current sideline testing protocols for sports-related concussion. We examined the King-Devick (K-D) test, a vision-based measure of rapid number naming, as a complement to the Sport Concussion Assessment Tool, 3rd Edition (SCAT3/Child-SCAT3) in youth and collegiate athletes. BACKGROUND: Identification of rapid yet simple diagnostic tests for concussion is critical. Rapid tests must be interpreted in the context of developmental status and age, and capture all relevant aspects of concussion, including vision. DESIGN/METHODS: Members of a youth ice hockey and football league and collegiate athletes from NYU and Long Island University (LIU) participated in a prospective study to examine sideline tests, including K-D, Standardized Assessment of Concussion, (SAC, cognitive component of SCAT3/Child-SCAT3) and timed-tandem-gait test (balance). RESULTS: Youth and collegiate athletes (n=342, age 14.7±4.9 years, range 5-23) underwent pre-season testing during the fall of 2014. Higher (worse) time scores for the vision-based K-D test were associated with lower (worse) scores for the SAC, particularly the Orientation (p=0.003) and Immediate Memory components (p=0.01, linear regression accounting for age). K-D scores correlated significantly yet moderately with scores for balance (p=0.003). Athlete age was most strongly correlated with K-D scores (r=-0.79, p<0.0001) compared to SAC (r=0.51, p<0.0001) and timed-tandem (r=-0.49, p<0.0001). CONCLUSIONS: The K-D test, a vision-based measure that requires saccades and other eye movements, captures aspects of brain function that are not entirely captured by current sideline testing for balance and cognition. At the same time, associations of K-D scores with working memory and orientation suggest that closely related anatomical structures, such as the dorsolateral prefrontal cortex, underlie saccades and memory. K-D scores showed the greatest associations with age in this young athlete cohort, suggesting that vision may a key domain for assessing developmental aspects of brain function.

Background:Sports-related concussion commonly affects the visual pathways. Current sideline protocols test cognition and balance but do not include assessments of visual performance. We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels.Methods:Participants in this prospective study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Island University. Athletes underwent preseason baseline assessments using: 1) the King-Devick (K-D) test, a <2-minute visual performance measure of rapid number naming, 2) the Standardized Assessment of Concussion (SAC), a test of cognition, and 3) a timed tandem gait test of balance. The SAC and timed tandem gait are components of the currently used Sport Concussion Assessment Tool, 3rd Edition (SCAT3 and Child-SCAT3). In the event of a concussion during the athletic season, injured athletes were retested on the sideline/rink-side. Nonconcussed athletes were also assessed as control participants under the same testing conditions.Results:Among 243 youth (mean age 11 3 years, range 5-17) and 89 collegiate athletes (age 20 +/- 1 years, range 18-23), baseline time scores for the K-D test were lower (better) with increasing participant age (P < 0.001, linear regression models). Among 12 athletes who sustained concussions during their athletic season, K-D scores worsened from baseline by an average of 5.2 seconds; improvement by 6.4 seconds was noted for the nonconcussed controls (n = 14). The vision-based K-D test showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury (receiver operating characteristic [ROC] curve areas from logistic regression models, accounting for age = 0.92 for K-D, 0.87 for timed tandem gait, and 0.68 for SAC; P = 0.0004 for comparison of ROC curve areas).Conclusions:Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment. This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision.

Sports-related concussion commonly affects the visual pathways. Current sideline protocols test cognition and balance but do not include assessments of visual performance. We investigated how adding a vision-based test of rapid number naming could increase our ability to identify concussed athletes on the sideline at youth and collegiate levels.Participants in this prospective study included members of a youth ice hockey and lacrosse league and collegiate athletes from New York University and Long Island University. Athletes underwent preseason baseline assessments using: 1) the King-Devick (K-D) test, a <2-minute visual performance measure of rapid number naming, 2) the Standardized Assessment of Concussion (SAC), a test of cognition, and 3) a timed tandem gait test of balance. The SAC and timed tandem gait are components of the currently used Sport Concussion Assessment Tool, 3rd Edition (SCAT3 and Child-SCAT3). In the event of a concussion during the athletic season, injured athletes were retested on the sideline/rink-side. Nonconcussed athletes were also assessed as control participants under the same testing conditions.Among 243 youth (mean age 11 ± 3 years, range 5-17) and 89 collegiate athletes (age 20 ± 1 years, range 18-23), baseline time scores for the K-D test were lower (better) with increasing participant age (P < 0.001, linear regression models). Among 12 athletes who sustained concussions during their athletic season, K-D scores worsened from baseline by an average of 5.2 seconds; improvement by 6.4 seconds was noted for the nonconcussed controls (n = 14). The vision-based K-D test showed the greatest capacity to distinguish concussed vs control athletes based on changes from preseason baseline to postinjury (receiver operating characteristic [ROC] curve areas from logistic regression models, accounting for age = 0.92 for K-D, 0.87 for timed tandem gait, and 0.68 for SAC; P = 0.0004 for comparison of ROC curve areas).Adding a vision-based performance measure to cognitive and balance testing enhances the detection capabilities of current sideline concussion assessment. This observation in patients with mild traumatic brain injury reflects the common involvement and widespread distribution of brain pathways dedicated to vision.