Mobile Universal Lexicon Evaluation System (MULES) test: A new measure of rapid picture naming for 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.
Traumatic brain injury results in altered physiologic, but not subjective, responses to emotional stimuli [Meeting Abstract]
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
Different lateral amygdala outputs mediate reactions and actions elicited by a fear-arousing stimulus
Fear-arousing stimuli elicit innate reactions and can reinforce acquisition of new responses. We tested whether mechanisms mediating these conditioned stimulus (CS) properties were isomorphic or dissociable within the amygdala. Rats trained on a fear-conditioning task (CS paired with footshock) were then trained on an escape-from-fear task (EFF) in which the CS reinforced a locomotor response terminating the CS. Lateral nucleus (LA) lesions blocked acquisition of both conditioned freezing responses and the CS's reinforcement of a new response in the EFF task. Central nucleus (CE) lesions blocked conditioned freezing but not the EFF, whereas basal nucleus (B) lesions blocked the EFF but not conditioned freezing. Thus, activation of the LA by a CS seems to trigger conditioned reactions via CE and conditioned aversion via B activation, reduction of which reinforces new actions
Challenges and Lessons Learned for Acute Inpatient Rehabilitation of Persons With COVID-19: Clinical Presentation, Assessment, Needs, and Services Utilization
OBJECTIVE:The aim of the study was to present: (1) physiatric care delivery amid the SARS-CoV-2 pandemic, (2) challenges, (3) data from the first cohort of post-COVID-19 inpatient rehabilitation facility patients, and (4) lessons learned by a research consortium of New York and New Jersey rehabilitation institutions. DESIGN:For this clinical descriptive retrospective study, data were extracted from post-COVID-19 patient records treated at a research consortium of New York and New Jersey rehabilitation inpatient rehabilitation facilities (May 1-June 30, 2020) to characterize admission criteria, physical space, precautions, bed numbers, staffing, employee wellness, leadership, and family communication. For comparison, data from the Uniform Data System and eRehabData databases were analyzed. The research consortium of New York and New Jersey rehabilitation members discussed experiences and lessons learned. RESULTS:The COVID-19 patients (N = 320) were treated during the study period. Most patients were male, average age of 61.9 yrs, and 40.9% were White. The average acute care length of stay before inpatient rehabilitation facility admission was 24.5 days; mean length of stay at inpatient rehabilitation facilities was 15.2 days. The rehabilitation research consortium of New York and New Jersey rehabilitation institutions reported a greater proportion of COVID-19 patients discharged to home compared with prepandemic data. Some institutions reported higher changes in functional scores during rehabilitation admission, compared with prepandemic data. CONCLUSIONS:The COVID-19 pandemic acutely affected patient care and overall institutional operations. The research consortium of New York and New Jersey rehabilitation institutions responded dynamically to bed expansions/contractions, staff deployment, and innovations that facilitated safe and effective patient care.
Altered Relationship between Working Memory and Brain Microstructure after Mild Traumatic Brain Injury
BACKGROUND AND PURPOSE/OBJECTIVE:Working memory impairment is one of the most troubling and persistent symptoms after mild traumatic brain injury (MTBI). Here we investigate how working memory deficits relate to detectable WM microstructural injuries to discover robust biomarkers that allow early identification of patients with MTBI at the highest risk of working memory impairment. MATERIALS AND METHODS/METHODS:Multi-shell diffusion MR imaging was performed on a 3T scanner with 5 b-values. Diffusion metrics of fractional anisotropy, diffusivity and kurtosis (mean, radial, axial), and WM tract integrity were calculated. Auditory-verbal working memory was assessed using the Wechsler Adult Intelligence Scale, 4th ed, subtests: 1) Digit Span including Forward, Backward, and Sequencing; and 2) Letter-Number Sequencing. We studied 19 patients with MTBI within 4 weeks of injury and 20 healthy controls. Tract-Based Spatial Statistics and ROI analyses were performed to reveal possible correlations between diffusion metrics and working memory performance, with age and sex as covariates. RESULTS:= .04), mainly present in the right superior longitudinal fasciculus, which was not observed in healthy controls. Patients with MTBI also appeared to lose the normal associations typically seen in fractional anisotropy and axonal water fraction with Letter-Number Sequencing. Tract-Based Spatial Statistics results also support our findings. CONCLUSIONS:Differences between patients with MTBI and healthy controls with regard to the relationship between microstructure measures and working memory performance may relate to known axonal perturbations occurring after injury.
MULES on the sidelines: A vision-based assessment tool for sports-related concussion
OBJECTIVE:The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming under investigation. Measures of rapid automatic naming (RAN) have been used for over 50â€¯years to capture aspects of vision and cognition. MULES was designed as a series of 54 grouped color photographs (fruits, random objects, animals) that integrates saccades, color perception and contextual object identification. We examined MULES performance in youth, collegiate and professional athletes at pre-season baseline and at the sidelines following concussion. METHODS:Our study teams administered the MULES to youth, collegiate and professional athletes during pre-season baseline testing. Sideline post-concussion time scores were compared to pre-season baseline scores among athletes with concussion to determine degrees and directions of change. RESULTS:Among 681 athletes (age 17â€¯Â±â€¯4â€¯years, range 6-37, 38% female), average test times at baseline were 41.2â€¯Â±â€¯11.2â€¯s. The group included 280 youth, 357 collegiate and 44 professional athletes; the most common sports were ice hockey (23%), soccer (17%) and football (11%). Age was a predictor of MULES test times, with longer times noted for younger participants (Pâ€¯<â€¯.001, linear regression). Consistent with other timed performance measures, significant learning effects were noted for the MULES during baseline testing with trial 1 test times (mean 49.2â€¯Â±â€¯13.1â€¯s) exceeding those for trial 2 (mean 41.3â€¯Â±â€¯11.2â€¯s, Pâ€¯<â€¯.0001, paired t-test). Among 17 athletes with concussion during the sports seasons captured to date (age 18â€¯Â±â€¯3â€¯years), all showed increases (worsening) of MULES time scores from pre-season baseline (median increase 11.2â€¯s, range 0.6-164.2, Pâ€¯=â€¯.0003, Wilcoxon signed-rank test). The Symptom Severity Score from the SCAT5 Symptom Evaluation likewise worsened from pre-season baseline following injury among participants with concussion (Pâ€¯=â€¯.002). CONCLUSIONS:Concussed athletes demonstrate worsening performance on the MULES test compared to their baseline time scores. This test samples a wide network of brain pathways and complements other vision-based measures for sideline concussion assessment. The MULES test demonstrates capacity to identify athletes with sports-related concussion.
Mobile Universal Lexicon Evaluation System (MULES) in MS: Evaluation of a new visual test of rapid picture naming
OBJECTIVE:The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming that is under investigation for concussion. MULES captures an extensive visual network, including pathways for eye movements, color perception, memory and object recognition. The purpose of this study was to introduce the MULES to visual assessment of patients with MS, and to examine associations with other tests of afferent and efferent visual function. METHODS:We administered the MULES in addition to binocular measures of low-contrast letter acuity (LCLA), high-contrast visual acuity (VA) and the King-Devick (K-D) test of rapid number naming in an MS cohort and in a group of disease-free controls. RESULTS:Among 24 patients with MS (median age 36â€¯years, range 20-72, 64% female) and 22 disease-free controls (median age 34â€¯years, range 19-59, 57% female), MULES test times were greater (worse) among the patients (60.0 vs. 40.0â€¯s). Accounting for age, MS vs. control status was a predictor of MULES test times (Pâ€¯=â€¯.01, logistic regression). Faster testing times were noted among patients with MS who had greater (better) performance on binocular LCLA at 2.5% contrast (Pâ€¯<â€¯.001, linear regression, accounting for age), binocular high-contrast VA (Pâ€¯<â€¯.001), and K-D testing (Pâ€¯<â€¯.001). Both groups demonstrated approximately 10-s improvements in MULES test times between trials 1 and 2 (Pâ€¯<â€¯.0001, paired t-tests). CONCLUSION/CONCLUSIONS:The MULES test, a complex task of rapid picture naming involves an extensive visual network that captures eye movements, color perception and the characterization of objects. Color recognition, a key component of this novel assessment, is early in object processing and requires area V4 and the inferior temporal projections. MULES scores reflect performance of LCLA, a widely-used measure of visual function in MS clinical trials. These results provide evidence that the MULES test can add efficient visual screening to the assessment of patients with MS.
White Matter Tract Integrity: An Indicator Of Axonal Pathology After Mild Traumatic Brain Injury
We seek to elucidate the underlying pathophysiology of injury sustained after mild traumatic brain injury (MTBI) using multi-shell diffusion MRI, deriving compartment-specific WM tract integrity (WMTI) metrics. WMTI allows a more biophysical interpretation of WM changes by describing microstructural characteristics in both intra- and extra-axonal environments. Thirty-two patients with MTBI within 30 days of injury and twenty-one age- and sex-matched controls were imaged on a 3T MR scanner. Multi-shell diffusion acquisition was performed with 5 b-values (250 - 2500 s/mm<sup>2</sup>) along 6 - 60 diffusion encoding directions. Tract-based spatial statistics (TBSS) was used with family-wise error (FWE) correction for multiple comparisons. TBSS results demonstrate focally lower intra-axonal diffusivity (D<sub>axon</sub>) in MTBI patients in the splenium of the corpus callosum (sCC) (p < 0.05, FWE-corrected). The Area Under the Curve (AUC)-value for was 0.76 with low sensitivity of 46.9%, but 100% specificity. These results indicate that D<sub>axon</sub> may be a useful imaging biomarker highly specific for MTBI-related WM injury. The observed decrease in D<sub>axon</sub> suggests restriction of the diffusion along the axons occurring shortly after injury.
The new Mobile Universal Lexicon Evaluation System (MULES): A test of rapid picture naming for concussion sized for the sidelines
OBJECTIVE:Measures of rapid automatized naming (RAN) have been used for over 50â€¯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 11â€¯Ã—â€¯17-inch single-sided paper, the test has been reduced to a laminated 8.5â€¯Ã—â€¯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 16â€¯Â±â€¯7â€¯years, range 6-59, 29% female), average test times at baseline were 44.4â€¯Â±â€¯14.4â€¯s for the new laminated MULES (nâ€¯=â€¯196) and 46.5â€¯Â±â€¯16.3â€¯s for big MULES (nâ€¯=â€¯248). Both versions were completed by 57 participants, with excellent agreement (pâ€¯<â€¯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 (pâ€¯<â€¯0.001). Among 6 athletes with concussion thus far during the fall sports season (median age 15â€¯years, range 11-21) all showed worsening of MULES scores from pre-season baseline (median 4.0â€¯s, range 2.1-16.4). CONCLUSION/CONCLUSIONS:The MULES test has been converted to an 11â€¯Ã—â€¯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.
Mobile Universal Lexicon Evaluation System (MULES) in MS: Evaluation of a New Visual Test of Rapid Picture Naming [Meeting Abstract]