Faculty Bibliography

OBJECTIVE:To determine if native English speakers (NES) perform differently compared to non-native English speakers (NNES) on a sideline-focused rapid number naming task. A secondary aim was to characterize objective differences in eye movement behaviour between cohorts. BACKGROUND:The King-Devick (KD) test is a rapid number-naming task in which numbers are read from left-to-right. This performance measure adds vision-based assessment to sideline concussion testing. Reading strategies differ by language. Concussion may also impact language and attention. Both factors may affect test performance. METHODS:Twenty-seven healthy  NNES and healthy NES performed a computerized KD test under high-resolution video-oculography.  NNES also performed a Bilingual Dominance Scale (BDS) questionnaire to weight linguistic preferences (i.e., reliance on non-English language(s)). RESULTS:Inter-saccadic intervals were significantly longer in  NNES (346.3 ± 78.3 ms vs. 286.1 ± 49.7 ms, p = 0.001), as were KD test times (54.4 ± 15.1 s vs. 43.8 ± 8.6 s, p = 0.002). Higher BDS scores, reflecting higher native language dominance, were associated with longer inter-saccadic intervals in  NNES. CONCLUSION/CONCLUSIONS:These findings have direct implications for the assessment of athlete performance on vision-based and other verbal sideline concussion tests; these results are particularly important given the international scope of sport. Pre-season baseline scores are essential to evaluation in the event of concussion, and performance of sideline tests in the athlete's native language should be considered to optimize both baseline and post-injury test accuracy.

BACKGROUND:While the cognitive sequelae of traumatic brain injury (TBI) are well known, emotional impairments after TBI are suboptimally characterized. Lack of awareness of emotional difficulties can make self-report unreliable. However, individuals with TBI demonstrate involuntary changes in heart rate variability which may enable objective quantification of emotional dysfunction. METHODS:Sixteen subjects with chronic TBI and 10 age-matched controls were tested on an emotional function battery during which they watched a series of film clips normed to elicit specific positively and negatively valenced emotions: amusement, sexual amusement, sadness, fear and disgust. Subjective responses to the emotional stimuli were also obtained. Additionally, surface electrodes measured cardiac and respiratory signals to compute heart rate variability (HRV), from which measures of parasympathetic activity, the respiratory frequency area (RFA) and sympathetic activity, the low frequency area (LFA), of the HRV frequency spectrum were derived. The Neurobehavioral Rating Scale-Revised (NRS-R) and the King-Devick (KD) test were administered to assess neurobehavioral dysfunction. RESULTS:The two groups showed no differences in subjective ratings of emotional intensity. Subjects with TBI showed significantly decreased sympathetic activity when viewing amusing stimuli and significantly increased sympathetic activity when viewing sad stimuli compared to controls. Most of the subjects did not show agitation, anxiety, depression, blunted affect, emotional withdrawal, decreased motivation or mental fatiguability on the NRS-R. However, 13/16 subjects with TBI demonstrated attention difficulty on the NRS-R which was positively correlated with the increased sympathetic activity during sad stimuli. Both attention difficulty and abnormal autonomic responses to sad stimuli were correlated with the timing on the KD test, which reflected difficulty with visual attention shifting. CONCLUSIONS:The HRV spectrum may be useful to identify subclinical emotional dysfunction in individuals with TBI. Attention difficulites, specifically impairment in visual attention shifting, may contribute to abnormal reactivity to sad stimuli that may be detected and potentially treated to improve emotional function.

Objective: This study introduces the Mobile Universal Lexicon Evaluation System (MULES), a new vision-based test of rapid picture naming, in a cohort of youth and collegiate athletes at pre-season concussion testing. Background: Vision-based measures of rapid number naming (King-Devick [K-D]) have improved the sensitivity of sports-related concussion screening. K-D requires saccades and vergence, measuring aspects of frontal, parietal and brainstem centers. We developed the MULES to capture a more extensive vision network, integrating saccades, color perception, and object identification. Design/Methods: We administered MULES and K-D to youth and collegiate athletes during pre-season baseline testing. Sports for 2016-17 included ice hockey, football, soccer, volleyball and wrestling. Test administration order was randomized. Results: Among 165 athletes (age 14+/-5 years, range 6-24, 25% female), average K-D times (59.9+/-29.7 seconds) were similar to MULES (57.9+/-20.4 seconds). Higher K-D times predicted greater MULES times, accounting for age (p<0.001, linear regression). Age was itself a predictor of K-D and MULES time scores, with longer times noted for younger participants (p<0.001). Faster times with increasing age were noted primarily among athletes <16 years for K-D and <15 years for MULES. MULES showed greater degrees of improvement between two baseline trials (57.9 vs. 51.2 seconds, p<0.0001, paired t-test), vs. K-D (59.9 vs. 58.3 seconds, p=0.01). Conclusions: A complex task, the MULES test of rapid picture naming involves a more extensive visual network that captures not only rapid saccades but color perception and the characterization of objects. Color recognition is early in object processing and requires area V4 and the inferior temporal projections. In contrast, rapid number naming appears to engage a specific area of the inferior temporal cortex. Both tests use the centers responsible for initiating and sequencing saccadic eye movements, and will be further examined in our youth and collegiate cohorts during this athletic season for their ability to detect concussion

OBJECTIVE: This study introduces a rapid picture naming test, the Mobile Universal Lexicon Evaluation System (MULES), as a novel, vision-based performance measure for concussion screening. The MULES is a visual-verbal task that includes 54 original photographs of fruits, objects and animals. We piloted MULES in a cohort of volunteers to determine feasibility, ranges of picture naming responses, and the relation of MULES time scores to those of King-Devick (K-D), a rapid number naming test. METHODS: A convenience sample (n=20, age 34+/-10) underwent MULES and K-D (spiral bound, iPad versions). Administration order was randomized; MULES tests were audio-recorded to provide objective data on temporal variability and ranges of picture naming responses. RESULTS: Scores for the best of two trials for all tests were 40-50s; average times required to name each MULES picture (0.72+/-0.14s) was greater than those needed for each K-D number ((spiral: 0.33+/-0.05s, iPad: 0.36+/-0.06s, 120 numbers), p<0.0001, paired t-test). MULES scores showed the greatest degree of improvement between trials (9.4+/-4.8s, p<0.0001 for trials 1 vs. 2), compared to K-D (spiral 1.5+/-3.3s, iPad 1.8+/-3.4s). Shorter MULES times demonstrated moderate and significant correlations with shorter iPad but not spiral K-D times (r=0.49, p=0.03). CONCLUSION: The MULES test is a rapid picture naming task that may engage more extensive neural systems than more commonly used rapid number naming tasks. Rapid picture naming may require additional processing devoted to color perception, object identification, and categorization. Both tests rely on initiation and sequencing of saccadic eye movements.

Research Objectives: To test the hypotheses that 1) emotional impairments in patients with traumatic brain injury (TBI) are characterized by alterations in autonomic activity, and 2) identify the relationship of these impairments to subjective responses. Design: This study was part of a larger randomized control study in which TBI patients and age-matched controls were tested on an emotional function battery where they watched a series of film clips normed to elicit specific emotions). Surface electrodes measured cardiac and respiratory signals to compute heart rate variability (HRV), from which measures of parasympathetic activity (RFA, Respiratory Frequency Area) and sympathetic activity (LFA, Low Frequency Area) were derived. The intensity of the emotional response to the film-clips was captured via questionnaires. Setting: Outpatient ambulatory care setting at an academic medical center. Participants: Twelve healthy subjects, ranging in age from 21 to 67 years (mean +/- SD = 35.8 +/- 13.5 years), with no history of psychiatric disease or complicating medical problems, such as uncontrolled hypertension, diabetes, neurological illness such as stroke, epilepsy, or demyelinating disease participated in the study. Six of the subjects were female. Sixteen subjects with traumatic brain injury (TBI), ranging in age from 25 to 81 participated in the study. 10 of the subjects were female. Interventions: N/A. Main Outcome Measure(s): Electrocardiographic and respiratory signals were sampled at 250 Hz and 50 Hz, respectively and collected using ANSAR ANX 3.0 software (ANSAR Medical Technologies, Inc., Philadelphia, PA). Heart rate variability (HRV) was computed every 0.25 seconds and time- frequency spectral analysis was performed to quantify ANS activity. The respiratory frequency area (RFA) measured parasympathetic activity from higher frequency areas of the HRV spectrum as determined from time-frequency analyses of respiratory activity (Aysin 2006). RFA represents the frequency ranges associated with Respiratory Sinus Arrhythmia, known to be a cardio-vagal response, reflecting parasympathetic activity (Akselrod 1981, Appelhans 2008). Low frequency area (LFA) is defined as the area under the heart rate spectral curve over the frequency range from 0.04 - 0.10 Hz, or the lower limit of RFA range (ANSAR Medical Technologies, 2005; Colombo 2008). By localizing and omitting the parasympathetic influence (e.g., from Respiratory Sinus Arrhythmia) from the low frequency range of HRV, LFA primarily corresponds to activity from the sympathetic nervous system (Aysin 2006; Colombo 2008). Results: TBI and control groups reported subjectively feeling similar intensities of emotion across all emotional film clips. The TBI group displayed sympathetic nervous system activity that was significantly decreased compared to controls when viewing amusing stimuli, but significantly increased when viewing sad stimuli. Conclusions: Despite being able to recognize positive emotions such as amusement explicitly, patients with TBI may have a more difficult time recruiting or accessing the appropriate autonomic outputs in response to these emotions. In the case of negative emotions such as sadness, it may be the case that once activated, autonomic outputs in response to these emotions are more difficult to control or regulate and so proceed unchecked. These differences may be present in TBI patients may reflect a dissociation between implicit and explicit emotional responses that is further affected by the valence of the particular emotions being processed. Future study will be required to further identify neural systems associated with differences in autonomic responding to emotional stimuli following traumatic brain injury

The World Health Organization, one of the leading authorities on pain management, stressed the need for further guidelines to help manage pain in patients with chronic disease. In light of the impact of pain on morbidity and quality of life, this article summarizes current knowledge about pain experienced by older adults in 3 advanced non-cancer-related chronic diseases (ie, congestive heart failure, end-stage renal disease, and stroke) in which pain is common but not typically a primary focus of disease management. This article examines the data on the prevalence of pain, co-occurring symptoms, and challenges in managing pain in these conditions.