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Busis NA, Marolia D, Montgomery R, Balcer LJ, Galetta SL, Grossman SN. Navigating the U.S. regulatory landscape for neurologic digital health technologies. NPJ Digit Med 2024; 7:94. [PMID: 38609447 PMCID: PMC11014948 DOI: 10.1038/s41746-024-01098-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/29/2024] [Indexed: 04/14/2024] Open
Affiliation(s)
- Neil A Busis
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA.
| | | | - Robert Montgomery
- Clinical Affairs and Ambulatory Care, NYU Langone Health System, New York, NY, USA
| | - Laura J Balcer
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Population Health, NYU Grossman School of Medicine, New York, NY, USA
- Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY, USA
| | - Steven L Galetta
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
- Department of Ophthalmology, NYU Grossman School of Medicine, New York, NY, USA
| | - Scott N Grossman
- Department of Neurology, NYU Grossman School of Medicine, New York, NY, USA
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Kelly JT, Wilkes JR, Slobounov SM. An Examination of Visual Quality of Life and Functional Vision Among Collision and Non-Collision Athletes Over a Competitive Season. Arch Clin Neuropsychol 2023; 38:1115-1123. [PMID: 37097732 DOI: 10.1093/arclin/acad032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/29/2023] [Indexed: 04/26/2023] Open
Abstract
OBJECTIVE Repetitive head impacts (RHIs) experienced during sports are gaining attention due to potential long-term neurological dysfunction, absent of a diagnosed concussion. One area susceptible to dysfunction is vision. The goal of this study was to evaluate changes in visual quality of life (VQOL) and functional vision scores from pre- to post-season among collision and non-collision athletes. METHODS The Visual Functioning Questionnaire-25 and Neuro-Ophthalmic Supplement (NOS), as well as functional vision testing (Mobile Universal Lexicon Evaluation System - MULES) were completed pre- and post-season by three groups: collision athletes, non-collision athletes, and minimally active controls (MACs). RESULTS There were 42 participants, with 41 (21 male, 20 female) completing both testing sessions, with a mean (standard deviation [SD]) age of 21 (2.46) years (collision group, n = 14; non-collision group, n = 13, MACs, n = 14). Baseline analyses revealed no significant differences between groups for VQOL or MULES scores. However, those with a family history of psychiatric disorder scored significantly worse on NOS. Post-season/follow-up testing revealed no significant differences between groups for VQOL scores. Non-collision athletes significantly improved on the MULES test by 2.46 ± 3.60 (SD) s (35.0 [95% confidence interval, 0.29-4.63]; p = .03). Change score results from pre- to post-season were not significant. CONCLUSION Although the groups were not significantly different from one another, non-collision athletes significantly improved MULES scores, whereas collision athletes performed the worst, suggesting exposure to RHIs may impact functional vision. Thus, further evaluation of RHIs and their impact on vision is warranted.
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Affiliation(s)
- Jon T Kelly
- Department of Kinesiology, Penn State University, University Park, PA, USA
| | - James R Wilkes
- Department of Kinesiology, Penn State University, University Park, PA, USA
| | - Semyon M Slobounov
- Department of Kinesiology, Penn State University, University Park, PA, USA
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de Souza DN, Jarmol M, Bell CA, Marini C, Balcer LJ, Galetta SL, Grossman SN. Precision Concussion Management: Approaches to Quantifying Head Injury Severity and Recovery. Brain Sci 2023; 13:1352. [PMID: 37759953 PMCID: PMC10526525 DOI: 10.3390/brainsci13091352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/18/2023] [Accepted: 09/19/2023] [Indexed: 09/29/2023] Open
Abstract
Mitigating the substantial public health impact of concussion is a particularly difficult challenge. This is partly because concussion is a highly prevalent condition, and diagnosis is predominantly symptom-based. Much of contemporary concussion management relies on symptom interpretation and accurate reporting by patients. These types of reports may be influenced by a variety of factors for each individual, such as preexisting mental health conditions, headache disorders, and sleep conditions, among other factors. This can all be contributory to non-specific and potentially misleading clinical manifestations in the aftermath of a concussion. This review aimed to conduct an examination of the existing literature on emerging approaches for objectively evaluating potential concussion, as well as to highlight current gaps in understanding where further research is necessary. Objective assessments of visual and ocular motor concussion symptoms, specialized imaging techniques, and tissue-based concentrations of specific biomarkers have all shown promise for specifically characterizing diffuse brain injuries, and will be important to the future of concussion diagnosis and management. The consolidation of these approaches into a comprehensive examination progression will be the next horizon for increased precision in concussion diagnosis and treatment.
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Affiliation(s)
- Daniel N. de Souza
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Mitchell Jarmol
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Carter A. Bell
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Christina Marini
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
| | - Laura J. Balcer
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10017, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY 10017, USA
| | - Steven L. Galetta
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10017, USA
| | - Scott N. Grossman
- Department of Neurology, New York University Grossman School of Medicine, New York, NY 10017, USA; (D.N.d.S.); (M.J.); (C.A.B.); (C.M.); (L.J.B.); (S.L.G.)
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY 10017, USA
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Bell CA, Grossman SN, Balcer LJ, Galetta SL. Vision as a piece of the head trauma puzzle. Eye (Lond) 2023; 37:2385-2390. [PMID: 36801966 PMCID: PMC10397310 DOI: 10.1038/s41433-023-02437-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 12/07/2022] [Accepted: 01/31/2023] [Indexed: 02/19/2023] Open
Abstract
Approximately half of the brain's circuits are involved in vision and control of eye movements. Therefore, visual dysfunction is a common symptom of concussion, the mildest form of traumatic brain injury (TBI). Photosensitivity, vergence dysfunction, saccadic abnormalities, and distortions in visual perception have been reported as vision-related symptoms following concussion. Impaired visual function has also been reported in populations with a lifetime history of TBI. Consequently, vision-based tools have been developed to detect and diagnose concussion in the acute setting, and characterize visual and cognitive function in those with a lifetime history of TBI. Rapid automatized naming (RAN) tasks have provided widely accessible and quantitative measures of visual-cognitive function. Laboratory-based eye tracking approaches demonstrate promise in measuring visual function and validating results from RAN tasks in patients with concussion. Optical coherence tomography (OCT) has detected neurodegeneration in patients with Alzheimer's disease and multiple sclerosis and may provide critical insight into chronic conditions related to TBI, such as traumatic encephalopathy syndrome. Here, we review the literature and discuss the future directions of vision-based assessments of concussion and conditions related to TBI.
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Affiliation(s)
- Carter A Bell
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Scott N Grossman
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Laura J Balcer
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA
- Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Steven L Galetta
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
- Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA.
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5
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Patil SA, Grossman S, Kenney R, Balcer LJ, Galetta S. Where's the Vision? The Importance of Visual Outcomes in Neurologic Disorders: The 2021 H. Houston Merritt Lecture. Neurology 2023; 100:244-253. [PMID: 36522160 PMCID: PMC9931086 DOI: 10.1212/wnl.0000000000201490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 09/14/2022] [Indexed: 12/23/2022] Open
Abstract
Neurologists have long recognized the importance of the visual system in the diagnosis and monitoring of neurologic disorders. This is particularly true because approximately 50% of the brain's pathways subserve afferent and efferent aspects of vision. During the past 30 years, researchers and clinicians have further refined this concept to include investigation of the visual system for patients with specific neurologic diagnoses, including multiple sclerosis (MS), concussion, Parkinson disease (PD), and conditions along the spectrum of Alzheimer disease (AD, mild cognitive impairment, and subjective cognitive decline). This review highlights the visual "toolbox" that has been developed over the past 3 decades and beyond to capture both structural and functional aspects of vision in neurologic disease. Although the efforts to accelerate the emphasis on structure-function relationships in neurologic disorders began with MS during the early 2000s, such investigations have broadened to recognize the need for outcomes of visual pathway structure, function, and quality of life for clinical trials of therapies across the spectrum of neurologic disorders. This review begins with a patient case study highlighting the importance using the most modern technologies for visual pathway assessment, including optical coherence tomography. We emphasize that both structural and functional tools for vision testing can be used in parallel to detect what might otherwise be subclinical events or markers of visual and, perhaps, more global neurologic decline. Such measures will be critical because clinical trials and therapies become more available across the neurologic disease spectrum.
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Affiliation(s)
- Sachi A Patil
- From the Department of Ophthalmology (S.A.P., L.J.B, S.G.), New York University Grossman School of Medicine, NY; Department of Neurology (S.G., L.J.B., S. Galetta), New York University Grossman School of Medicine, NY; Department of Radiology and Radiological Sciences (R.K.), Vanderbilt University School of Medicine, Nashville, TN; Department of Population Health (L.J.B.), New York University Grossman School of Medicine, NY.
| | - Scott Grossman
- From the Department of Ophthalmology (S.A.P., L.J.B, S.G.), New York University Grossman School of Medicine, NY; Department of Neurology (S.G., L.J.B., S. Galetta), New York University Grossman School of Medicine, NY; Department of Radiology and Radiological Sciences (R.K.), Vanderbilt University School of Medicine, Nashville, TN; Department of Population Health (L.J.B.), New York University Grossman School of Medicine, NY
| | - Rachel Kenney
- From the Department of Ophthalmology (S.A.P., L.J.B, S.G.), New York University Grossman School of Medicine, NY; Department of Neurology (S.G., L.J.B., S. Galetta), New York University Grossman School of Medicine, NY; Department of Radiology and Radiological Sciences (R.K.), Vanderbilt University School of Medicine, Nashville, TN; Department of Population Health (L.J.B.), New York University Grossman School of Medicine, NY
| | - Laura J Balcer
- From the Department of Ophthalmology (S.A.P., L.J.B, S.G.), New York University Grossman School of Medicine, NY; Department of Neurology (S.G., L.J.B., S. Galetta), New York University Grossman School of Medicine, NY; Department of Radiology and Radiological Sciences (R.K.), Vanderbilt University School of Medicine, Nashville, TN; Department of Population Health (L.J.B.), New York University Grossman School of Medicine, NY
| | - Steven Galetta
- From the Department of Ophthalmology (S.A.P., L.J.B, S.G.), New York University Grossman School of Medicine, NY; Department of Neurology (S.G., L.J.B., S. Galetta), New York University Grossman School of Medicine, NY; Department of Radiology and Radiological Sciences (R.K.), Vanderbilt University School of Medicine, Nashville, TN; Department of Population Health (L.J.B.), New York University Grossman School of Medicine, NY
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6
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Bell CA, Rice L, Balcer MJ, Pearson R, Penning B, Alexander A, Roskelly J, Nogle S, Tomczyk CP, Tracey AJ, Loftin MC, Pollard-McGrandy AM, Zynda AJ, Covassin T, Park G, Rizzo JR, Hudson T, Rucker JC, Galetta SL, Balcer L, Kaufman DI, Grossman SN. MICK (Mobile Integrated Cognitive Kit) app: Feasibility of an accessible tablet-based rapid picture and number naming task for concussion assessment in a division 1 college football cohort. J Neurol Sci 2022; 442:120445. [PMID: 36208585 DOI: 10.1016/j.jns.2022.120445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Revised: 09/25/2022] [Accepted: 09/27/2022] [Indexed: 12/01/2022]
Abstract
Although visual symptoms are common following concussion, quantitative measures of visual function are missing from concussion evaluation protocols on the athletic sideline. For the past half century, rapid automatized naming (RAN) tasks have demonstrated promise as quantitative neuro-visual assessment tools in the setting of head trauma and other disorders but have been previously limited in accessibility and scalability. The Mobile Interactive Cognitive Kit (MICK) App is a digital RAN test that can be downloaded on most mobile devices and can therefore provide a quantitative measure of visual function anywhere, including the athletic sideline. This investigation examined the feasibility of MICK App administration in a cohort of Division 1 college football players. Participants (n = 82) from a National Collegiate Athletic Association (NCAA) Division 1 football team underwent baseline testing on the MICK app. Total completion times of RAN tests on the MICK app were recorded; magnitudes of best time scores and between-trial learning effects were determined by paired t-test. Consistent with most timed performance measures, there were significant learning effects between the two baseline trials for both RAN tasks on the MICK app: Mobile Universal Lexicon Evaluation System (MULES) (p < 0.001, paired t-test, mean improvement 13.3 s) and the Staggered Uneven Number (SUN) (p < 0.001, mean improvement 3.3 s). This study demonstrated that the MICK App can be feasibly administered in the setting of pre-season baseline testing in a Division I environment. These data provide a foundation for post-injury sideline testing that will include comparison to baseline in the setting of concussion.
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Affiliation(s)
- Carter A Bell
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
| | - Lionel Rice
- Michigan State University, East Lansing, MI, USA.
| | | | | | | | | | | | - Sally Nogle
- Michigan State University, East Lansing, MI, USA.
| | | | | | | | | | | | | | - George Park
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
| | - John-Ross Rizzo
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA; Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA.
| | - Todd Hudson
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA; Department of Rehabilitation Medicine, New York University Grossman School of Medicine, New York, NY, USA.
| | - Janet C Rucker
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA.
| | - Steven L Galetta
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA.
| | - Laura Balcer
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA; Department of Population Health, New York University Grossman School of Medicine, New York, NY, USA.
| | | | - Scott N Grossman
- Department of Neurology, New York University Grossman School of Medicine, New York, NY, USA.
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7
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Master CL, Bacal D, Grady MF, Hertle R, Shah AS, Strominger M, Whitecross S, Bradford GE, Lum F, Donahue SP. Vision and Concussion: Symptoms, Signs, Evaluation, and Treatment. Pediatrics 2022; 150:188533. [PMID: 35843991 DOI: 10.1542/peds.2021-056047] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 01/24/2023] Open
Abstract
Visual symptoms are common after concussion in children and adolescents, making it essential for clinicians to understand how to screen, identify, and initiate clinical management of visual symptoms in pediatric patients after this common childhood injury. Although most children and adolescents with visual symptoms after concussion will recover on their own by 4 weeks, for a subset who do not have spontaneous recovery, referral to a specialist with experience in comprehensive concussion management (eg, sports medicine, neurology, neuropsychology, physiatry, ophthalmology, otorhinolaryngology) for additional assessment and treatment may be necessary. A vision-specific history and a thorough visual system examination are warranted, including an assessment of visual acuity, ocular alignment in all positions of gaze, smooth pursuit (visual tracking of a moving object), saccades (visual fixation shifting between stationary targets), vestibulo-ocular reflex (maintaining image focus during movement), near point of convergence (focusing with both eyes at near and accommodation (focusing with one eye at near because any of these functions may be disturbed after concussion. These deficits may contribute to difficulty with returning to both play and the learning setting at school, making the identification of these problems early after injury important for the clinician to provide relevant learning accommodations, such as larger font, preprinted notes, and temporary use of audio books. Early identification and appropriate management of visual symptoms, such as convergence insufficiency or accommodative insufficiency, may mitigate the negative effects of concussion on children and adolescents and their quality of life.
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Affiliation(s)
- Christina L Master
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine.,Minds Matter Concussion Program.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Darron Bacal
- Department of Ophthalmology and Visual Science, Yale University, New Haven, Connecticut.,Eye Physicians and Surgeons, PC, New Haven, Connecticut
| | - Matthew F Grady
- Department of Pediatrics, University of Pennsylvania Perelman School of Medicine.,Pediatric and Adolescent Sports Medicine, Division of Pediatric Orthopaedics, Karabots Center, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Richard Hertle
- Department of Surgery, College of Medicine, Northeast Ohio Medical College, Rootstown, Ohio.,Department of Specialty Medicine, Ohio University College of Osteopathic Medicine, Athens, Ohio; and Akron Children's Hospital Vision Center, Akron, Ohio
| | - Ankoor S Shah
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts.,Massachusetts Eye and Ear, Boston, Massachusetts
| | - Mitchell Strominger
- Departments of Surgery.,Ophthalmology.,Pediatrics.,Clinical Internal Medicine, University of Nevada Reno School of Medicine, Renown Medical Center, Reno, Nevada
| | - Sarah Whitecross
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Geoffrey E Bradford
- Departments of Ophthalmology.,Pediatrics, West Virginia University, Morgantown, West Virginia
| | - Flora Lum
- Quality and Data Science Division, American Academy of Ophthalmology, San Francisco, California
| | - Sean P Donahue
- Department of Ophthalmology and Visual Sciences, Vanderbilt University Medical Center, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee
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Rapid Automatized Picture Naming in an Outpatient Concussion Center: Quantitative Eye Movements during the Mobile Universal Lexicon Evaluation System (MULES) Test. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2022. [DOI: 10.3390/ctn6030018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Number and picture rapid automatized naming (RAN) tests are useful sideline diagnostic tools. The main outcome measure of these RAN tests is the completion time, which is prolonged with a concussion, yet yields no information about eye movement behavior. We investigated eye movements during a digitized Mobile Universal Lexicon Evaluation System (MULES) test of rapid picture naming. A total of 23 participants with a history of concussion and 50 control participants performed MULES testing with simultaneous eye tracking. The test times were longer in participants with a concussion (32.4 s [95% CI 30.4, 35.8] vs. 26.9 s [95% CI 25.9, 28.0], t=6.1). The participants with a concussion made more saccades per picture than the controls (3.6 [95% CI 3.3, 4.1] vs. 2.7 [95% CI 2.5, 3.0]), and this increase was correlated with longer MULES times (r = 0.46, p = 0.026). The inter-saccadic intervals (ISI) did not differ between the groups, nor did they correlate with the test times. Following a concussion, eye movement behavior differs during number versus picture RAN performance. Prior studies have shown that ISI prolongation is the key finding for a number-based RAN test, whereas this study shows a primary finding of an increased saccade number per picture with a picture-based RAN test. Number-based and picture-based RAN tests may be complimentary in concussion detection, as they may detect different injury effects or compensatory strategies.
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The MICK (Mobile integrated cognitive kit) app: Digital rapid automatized naming for visual assessment across the spectrum of neurological disorders. J Neurol Sci 2022; 434:120150. [PMID: 35038658 DOI: 10.1016/j.jns.2022.120150] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2021] [Revised: 12/31/2021] [Accepted: 01/06/2022] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Rapid automatized naming (RAN) tasks have been utilized for decades to evaluate neurological conditions. Time scores for the Mobile Universal Lexicon Evaluation System (MULES, rapid picture naming) and Staggered Uneven Number (SUN, rapid number naming) are prolonged (worse) with concussion, mild cognitive impairment, multiple sclerosis and Parkinson's disease. The purpose of this investigation was to compare paper/pencil versions of MULES and SUN with a new digitized format, the MICK app. METHODS Participants (healthy office-based volunteers, professional women's hockey players), completed two trials of the MULES and SUN tests on both platforms (tablet, paper/pencil). The order of presentation of the testing platforms was randomized. Between-platform variability was calculated using the two-way random-effects intraclass correlation coefficient (ICC). RESULTS Among 59 participants (median age 32, range 22-83), no significant differences were observed for comparisons of mean best scores for the paper/pencil versus MICK app platforms, counterbalanced for order of administration (P = 0.45 for MULES, P = 0.50 for SUN, linear regression). ICCs for agreement between the MICK and paper/pencil tests were 0.92 (95% CI 0.86, 0.95) for MULES and 0.94 (95% CI 0.89, 0.96) for SUN, representing excellent levels of agreement. Inter-platform differences did not vary systematically across the range of average best time score for either test. CONCLUSION The MICK app for digital administration of MULES and SUN demonstrates excellent agreement of time scores with paper/pencil testing. The computerized app allows for greater accessibility and scalability in neurological diseases, inclusive of remote monitoring. Sideline testing for sports-related concussion may also benefit from this technology.
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Blacker M. Response to Khokhar et al., Military Acute Concussion Evaluation: A Report on Clinical Usability, Utility, and User's Perceived Confidence (DOI: 10.1089/neu.2020.7176). J Neurotrauma 2021; 39:1013-1014. [PMID: 34915743 DOI: 10.1089/neu.2021.0492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mason Blacker
- New York University Grossman School of Medicine, New York, New York, USA; Portsmouth Naval Medical Center, Portsmouth, Virginia, USA
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11
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Vergence, accommodation, and visual tracking in children and adolescents evaluated in a multidisciplinary concussion clinic. Vision Res 2021; 184:30-36. [PMID: 33838503 DOI: 10.1016/j.visres.2021.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 02/22/2021] [Accepted: 03/03/2021] [Indexed: 11/23/2022]
Abstract
Many patients with concussion experience visual symptoms following injury that lead to a diagnosis of convergence insufficiency, accommodative insufficiency, or saccadic dysfunction. However, these diagnostic categories are based on aggregates of clinical tests developed from a non-concussed population and therefore may not accurately describe visual deficits in the concussed population. Thus, we sought to understand individual metrics of visual dysfunction in chronically symptomatic post-concussion patients. This retrospective cross-sectional study included patients examined at the multidisciplinary concussion clinic (MDCC) at Boston Children's Hospital over four years. Patients aged 5-21 years who had a complete assessment of eye alignment, vergence, accommodation, and visual tracking, and had visual acuity better than or equal to 20/30 in each eye were included. Patients with history of amblyopia, strabismus, or ocular pathology were excluded. Chart review yielded 116 patients who met inclusion criteria (median age 15 years, 64% female). The majority of patients (52%) experienced a single concussion and most were sports-related (50%). Clinical data show vergence, accommodation, or visual tracking deficits in 95% of patients. A receded near point of convergence (NPC, 70/116) and reduced accommodative amplitude (63/116) were the most common deficits. Both NPC and accommodative amplitude were significantly correlated with one another (r = -0.5) and with measures of visual tracking (r = -0.34). Patients with chronic post-concussion symptoms show deficits in individual metrics of vergence, accommodation and visual tracking. The high incidence of these deficits, specifically NPC and accommodative amplitude, highlights the need for a detailed sensorimotor evaluation to guide personalized treatment following concussion.
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Conway J, Moretti L, Nolan-Kenney R, Akhand O, Serrano L, Kurzweil A, Rucker JC, Galetta SL, Balcer LJ. Sleep-deprived residents and rapid picture naming performance using the Mobile Universal Lexicon Evaluation System (MULES) test. eNeurologicalSci 2021; 22:100323. [PMID: 33604461 PMCID: PMC7876539 DOI: 10.1016/j.ensci.2021.100323] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 12/31/2020] [Accepted: 01/31/2021] [Indexed: 12/03/2022] Open
Abstract
Objective The Mobile Universal Lexicon Evaluation System (MULES) is a rapid picture naming task that captures extensive brain networks involving neurocognitive, afferent/efferent visual, and language pathways. Many of the factors captured by MULES may be abnormal in sleep-deprived residents. This study investigates the effect of sleep deprivation in post-call residents on MULES performance. Methods MULES, consisting of 54 color photographs, was administered to a cohort of neurology residents taking 24-hour in-hospital call (n = 18) and a group of similar-aged controls not taking call (n = 18). Differences in times between baseline and follow-up MULES scores were compared between the two groups. Results MULES time change in call residents was significantly worse (slower) from baseline (mean 1.2 s slower) compared to non-call controls (mean 11.2 s faster) (P < 0.001, Wilcoxon rank sum test). The change in MULES time from baseline was significantly correlated to the change in subjective level of sleepiness for call residents and to the amount of sleep obtained in the 24 h prior to follow-up testing for the entire cohort. For call residents, the duration of sleep obtained during call did not significantly correlate with change in MULES scores. There was no significant correlation between MULES change and sleep quality questionnaire score for the entire cohort. Conclusion The MULES is a novel test for effects of sleep deprivation on neurocognition and vision pathways. Sleep deprivation significantly worsens MULES performance. Subjective sleepiness may also affect MULES performance. MULES may serve as a useful performance assessment tool for sleep deprivation in residents. MULES is a rapid picture naming test that captures extensive brain networks. MULES performance is impaired in sleep deprived residents. Subjective sleepiness may also affect MULES performance. MULES may serve as an assessment tool for sleep deprivation in residents.
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Affiliation(s)
- Jenna Conway
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Luke Moretti
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Rachel Nolan-Kenney
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Departments of Population Health, New York University Grossman School of Medicine, New York, NY, USA
| | - Omar Akhand
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Liliana Serrano
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Arielle Kurzweil
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA
| | - Janet C Rucker
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Departments of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA
| | - Steven L Galetta
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Departments of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA
| | - Laura J Balcer
- Departments of Neurology, New York University Grossman School of Medicine, New York, NY, USA.,Departments of Ophthalmology, New York University Grossman School of Medicine, New York, NY, USA.,Departments of Population Health, New York University Grossman School of Medicine, New York, NY, USA
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13
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Rizzo JR, Hudson TE, Martone J, Dai W, Ihionu O, Chaudhry Y, Selesnick I, Balcer LJ, Galetta SL, Rucker JC. How sandbag-able are concussion sideline assessments? A close look at eye movements to uncover strategies. Brain Inj 2021; 35:426-435. [PMID: 33529094 DOI: 10.1080/02699052.2021.1878554] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Background: Sideline diagnostic tests for concussion are vulnerable to volitional poor performance ("sandbagging") on baseline assessments, motivated by desire to subvert concussion detection and potential removal from play. We investigated eye movements during sandbagging versus best effort on the King-Devick (KD) test, a rapid automatized naming (RAN) task.Methods: Participants performed KD testing during oculography following instructions to sandbag or give best effort.Results: Twenty healthy participants without concussion history were included (mean age 27 ± 8 years). Sandbagging resulted in longer test times (89.6 ± 39.2 s vs 48.2 ± 8.5 s, p < .001), longer inter-saccadic intervals (459.5 ± 125.4 ms vs 311.2 ± 79.1 ms, p < .001) and greater numbers of saccades (171.4 ± 47 vs 138 ± 24.2, p < .001) and reverse saccades (wrong direction for reading) (21.2% vs 11.3%, p < .001). Sandbagging was detectable using a logistic model with KD times as the only predictor, though more robustly detectable using eye movement metrics.Conclusions: KD sandbagging results in eye movement differences that are detectable by eye movement recordings and suggest an invalid test score. Objective eye movement recording during the KD test shows promise for distinguishing between best effort and post-injury performance, as well as for identifying sandbagging red flags.
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Affiliation(s)
- John-Ross Rizzo
- Department of Physical Medicine & Rehabilitation, NYU School of Medicine, New York, NY, United States.,Department of Neurology, NYU School of Medicine, New York, NY, United States.,Department of Mechanical & Aerospace Engineering, NYU Tandon School of Engineering, New York, NY, United States.,Department of Biomedical Engineering, NYU Tandon School of Engineering, New York, NY, United States
| | - Todd E Hudson
- Department of Physical Medicine & Rehabilitation, NYU School of Medicine, New York, NY, United States.,Department of Neurology, NYU School of Medicine, New York, NY, United States
| | - John Martone
- Department of Neurology, NYU School of Medicine, New York, NY, United States
| | - Weiwei Dai
- Department of Electrical & Computer Engineering, NYU Tandon School of Engineering, New York, NY, United States
| | - Oluchi Ihionu
- Department of Neurology, NYU School of Medicine, New York, NY, United States
| | - Yash Chaudhry
- Department of Neurology, NYU School of Medicine, New York, NY, United States
| | - Ivan Selesnick
- Department of Electrical & Computer Engineering, NYU Tandon School of Engineering, New York, NY, United States
| | - Laura J Balcer
- Department of Neurology, NYU School of Medicine, New York, NY, United States.,Department of Population Health, NYU School of Medicine, New York, NY, United States.,Department of Ophthalmology, NYU School of Medicine, New York, NY, United States
| | - Steven L Galetta
- Department of Neurology, NYU School of Medicine, New York, NY, United States.,Department of Ophthalmology, NYU School of Medicine, New York, NY, United States
| | - Janet C Rucker
- Department of Neurology, NYU School of Medicine, New York, NY, United States.,Department of Ophthalmology, NYU School of Medicine, New York, NY, United States
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14
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Dahan N, Moehringer N, Hasanaj L, Serrano L, Joseph B, Wu S, Nolan-Kenney R, Rizzo JR, Rucker JC, Galetta SL, Balcer LJ. The SUN test of vision: Investigation in healthy volunteers and comparison to the mobile universal lexicon evaluation system (MULES). J Neurol Sci 2020; 415:116953. [DOI: 10.1016/j.jns.2020.116953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 05/14/2020] [Accepted: 05/26/2020] [Indexed: 01/12/2023]
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15
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Rigamonti L, Albrecht UV, Lutter C, Tempel M, Wolfarth B, Back DA. Potentials of Digitalization in Sports Medicine: A Narrative Review. Curr Sports Med Rep 2020; 19:157-163. [PMID: 32282462 DOI: 10.1249/jsr.0000000000000704] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Digital transformation is becoming increasingly common in modern life and sports medicine, like many other medical disciplines, it is strongly influenced and impacted by this rapidly changing field. This review aims to give a brief overview of the potential that digital technologies can have for health care providers and patients in the clinical practice of sports medicine. We will focus on mobile applications, wearables, smart devices, intelligent machines, telemedicine, artificial intelligence, big data, system interoperability, virtual reality, augmented reality, exergaming, or social networks. While some technologies are already used in current medical practice, others still have undiscovered potential. Due to the diversity and ever changing nature of this field, we will briefly review multiple areas in an attempt to give readers some general exposure to the landscape instead of a thorough, deep review of one topic. Further research will be necessary to show how digitalization applications could best be used for patient treatments.
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Affiliation(s)
- Lia Rigamonti
- Center of Sport Medicine, Department of Sport and Health Science, University of Potsdam, University Outpatient Clinic, Potsdam, GERMANY
| | - Urs-Vito Albrecht
- Hannover Medical School, Peter L Reichertz Institute for Medical Informatics, Hannover, GERMANY
| | - Christoph Lutter
- Department of Orthopedic and Trauma Surgery, Sports Orthopedics and Sports Medicine, Klinikum Bamberg, Bamberg, GERMANY
| | - Mathias Tempel
- Department of Sports Medicine, Humboldt University, Charité University Medicine Berlin, Berlin, GERMANY
| | - Bernd Wolfarth
- Department of Sports Medicine, Humboldt University, Charité University Medicine Berlin, Berlin, GERMANY
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16
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Rapid picture naming in Parkinson's disease using the Mobile Universal Lexicon Evaluation System (MULES). J Neurol Sci 2020; 410:116680. [PMID: 31945624 DOI: 10.1016/j.jns.2020.116680] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 12/30/2019] [Accepted: 01/08/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVE The Mobile Universal Lexicon Evaluation System (MULES) is a test of rapid picture naming that captures extensive brain networks, including cognitive, language and afferent/efferent visual pathways. MULES performance is slower in concussion and multiple sclerosis, conditions in which vision dysfunction is common. Visual aspects captured by the MULES may be impaired in Parkinson's disease (PD) including color discrimination, object recognition, visual processing speed, and convergence. The purpose of this study was to compare MULES time scores for a cohort of PD patients with those for a control group of participants of similar age. We also sought to examine learning effects for the MULES by comparing scores for two consecutive trials within the patient and control groups. METHODS MULES consists of 54 colored pictures (fruits, animals, random objects). The test was administered in a cohort of PD patients and in a group of similar aged controls. Wilcoxon rank-sum tests were used to determine statistical significance for differences in MULES time scores between PD patients and controls. Spearman rank-correlation coefficients were calculated to examine the relation between MULES time scores and PD motor symptom severity (UPDRS). Learning effects were assessed using Wilcoxon rank-sum tests. RESULTS Among 51 patients with PD (median age 70 years, range 52-82) and 20 disease-free control participants (median age 67 years, range 51-90), MULES scores were significantly slower (worse performance) in PD patients (median 63.2 s, range 37.3-296.3) vs. controls (median 53.9 s, range 37.5-128.6, P = .03, Wilcoxon rank-sum test). Slower MULES times were associated with increased motor symptom severity as measured by the Unified Parkinson's Disease Rating Scale, Section III (rs = 0.37, P = .02). Learning effects were greater among patients with PD (median improvement of 14.8 s between two MULES trials) compared to controls (median 7.4 s, P = .004). CONCLUSION The MULES is a complex test of rapid picture naming that captures numerous brain pathways including an extensive visual network. MULES performance is slower in patients with PD and our study suggests an association with the degree of motor impairment. Future studies will determine the relation of MULES time scores to other modalities that test visual function and structure in PD.
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17
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Heckmann JG, Vachalova I, Lang CJG, Pitz S. Neuro-Ophthalmology at the Bedside: A Clinical Guide. J Neurosci Rural Pract 2019; 9:561-573. [PMID: 30271051 PMCID: PMC6126320 DOI: 10.4103/jnrp.jnrp_145_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Neuro-ophthalmological signs and symptoms are common in the emergency department but are a frequent source of diagnostic uncertainties. However, neuro-ophthalmological signs often allow a precise neuro-topographical localization of the clinical problem. A practical concept is presented how to perform a neuro-ophthalmological examination at the bedside and to interpret key findings under the aspect of emergency medicine with limited resources.
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Affiliation(s)
- Josef G Heckmann
- Department of Neurology, Municipal Hospital, Landshut, Bavaria, Germany
| | - Ivana Vachalova
- Department of Neurology, Municipal Hospital, Landshut, Bavaria, Germany
| | - Christoph J G Lang
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | - Susanne Pitz
- Orbital Center, Bürgerhospital, Frankfurt, Germany
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18
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Fallon S, Akhand O, Hernandez C, Galetta MS, Hasanaj L, Martone J, Webb N, Drattell J, Amorapanth P, Rizzo JR, Nolan-Kenney R, Serrano L, Rucker JC, Cardone D, Galetta SL, Balcer LJ. MULES on the sidelines: A vision-based assessment tool for sports-related concussion. J Neurol Sci 2019; 402:52-56. [DOI: 10.1016/j.jns.2019.04.036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 04/03/2019] [Accepted: 04/26/2019] [Indexed: 10/26/2022]
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19
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Akhand O, Rizzo JR, Rucker JC, Hasanaj L, Galetta SL, Balcer LJ. History and Future Directions of Vision Testing in Head Trauma. J Neuroophthalmol 2019; 39:68-81. [DOI: 10.1097/wno.0000000000000726] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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21
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Seay M, Akhand O, Galetta MS, Cobbs L, Hasanaj L, Amorapanth P, Rizzo JR, Nolan R, Serrano L, Rucker JC, Galetta SL, Balcer LJ. Mobile Universal Lexicon Evaluation System (MULES) in MS: Evaluation of a new visual test of rapid picture naming. J Neurol Sci 2018; 394:1-5. [PMID: 30193154 DOI: 10.1016/j.jns.2018.08.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 08/02/2018] [Accepted: 08/21/2018] [Indexed: 10/28/2022]
Abstract
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 36 years, range 20-72, 64% female) and 22 disease-free controls (median age 34 years, range 19-59, 57% female), MULES test times were greater (worse) among the patients (60.0 vs. 40.0 s). Accounting for age, MS vs. control status was a predictor of MULES test times (P = .01, logistic regression). Faster testing times were noted among patients with MS who had greater (better) performance on binocular LCLA at 2.5% contrast (P < .001, linear regression, accounting for age), binocular high-contrast VA (P < .001), and K-D testing (P < .001). Both groups demonstrated approximately 10-s improvements in MULES test times between trials 1 and 2 (P < .0001, paired t-tests). CONCLUSION 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.
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Affiliation(s)
- Meagan Seay
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Omar Akhand
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Matthew S Galetta
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Lucy Cobbs
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Lisena Hasanaj
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Prin Amorapanth
- Physical Medicine and Rehabilitation, New York University School of Medicine, New York, NY, USA.
| | - John-Ross Rizzo
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA; Physical Medicine and Rehabilitation, New York University School of Medicine, New York, NY, USA.
| | - Rachel Nolan
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Liliana Serrano
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA.
| | - Janet C Rucker
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA; Ophthalmology, New York University School of Medicine, New York, NY, USA.
| | - Steven L Galetta
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA; Ophthalmology, New York University School of Medicine, New York, NY, USA.
| | - Laura J Balcer
- Departments of Neurolog, New York University School of Medicine, New York, NY, USA; Population Health, New York University School of Medicine, New York, NY, USA; Ophthalmology, New York University School of Medicine, New York, NY, USA.
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22
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Akhand O, Galetta MS, Cobbs L, Hasanaj L, Webb N, Drattell J, Amorapanth P, Rizzo JR, Nolan R, Serrano L, Rucker JC, Cardone D, Jordan BD, Silverio A, Galetta SL, Balcer LJ. The new Mobile Universal Lexicon Evaluation System (MULES): A test of rapid picture naming for concussion sized for the sidelines. J Neurol Sci 2018; 387:199-204. [PMID: 29571863 PMCID: PMC6022286 DOI: 10.1016/j.jns.2018.02.031] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2018] [Revised: 02/17/2018] [Accepted: 02/19/2018] [Indexed: 11/28/2022]
Abstract
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 × 17-inch single-sided paper, the test has been reduced to a laminated 8.5 × 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 × 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.
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Affiliation(s)
- Omar Akhand
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
| | - Matthew S Galetta
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
| | - Lucy Cobbs
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
| | - Lisena Hasanaj
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
| | - Nikki Webb
- Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA.
| | - Julia Drattell
- Department of Recreation and Athletics, New York University, New York, NY, USA.
| | - Prin Amorapanth
- Department of Physical Medicine and Rehabilitation, New York University School of Medicine, New York, NY, USA.
| | - John-Ross Rizzo
- Department of Neurology, New York University School of Medicine, New York, NY, USA; Department of Physical Medicine and Rehabilitation, New York University School of Medicine, New York, NY, USA.
| | - Rachel Nolan
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
| | - Liliana Serrano
- Department of Neurology, New York University School of Medicine, New York, NY, USA.
| | - Janet C Rucker
- Department of Neurology, New York University School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University School of Medicine, New York, NY, USA.
| | - Dennis Cardone
- Department of Emergency Medicine, New York University School of Medicine, New York, NY, USA.
| | | | - Arlene Silverio
- Department of Orthopaedics, Primary Care Sports Medicine, New York University School of Medicine, New York, NY, USA
| | - Steven L Galetta
- Department of Neurology, New York University School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University School of Medicine, New York, NY, USA.
| | - Laura J Balcer
- Department of Neurology, New York University School of Medicine, New York, NY, USA; Department of Population Health, New York University School of Medicine, New York, NY, USA; Department of Ophthalmology, New York University School of Medicine, New York, NY, USA.
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23
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Debacker J, Ventura R, Galetta SL, Balcer LJ, Rucker JC. Neuro-ophthalmologic disorders following concussion. HANDBOOK OF CLINICAL NEUROLOGY 2018; 158:145-152. [PMID: 30482342 DOI: 10.1016/b978-0-444-63954-7.00015-x] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Visual symptoms, such as photophobia and blurred vision, are common in patients with concussion. Such symptoms may be accompanied by abnormalities of specific eye movements, such as saccades and convergence, or accommodation deficits. The high frequency of visual involvement in concussion is not surprising, since more than half of the brain's pathways are dedicated to vision and eye movement control. These areas include many that are most vulnerable to head trauma, including the frontal and temporal lobes. Vision and eye movement testing is important at the bedside and on the sidelines of athletic events, where brief performance measures that require eye movements, such as rapid number naming, are reliable and sensitive measures for concussion detection. Tests of vision and eye movements are also being explored clinically to identify and monitor patients with symptoms of both sport- and nonsport-related concussion. Evaluation of vision and eye movements can assist in making important decisions after concussion, including the prognosis for symptom recovery, and to direct further visual rehabilitation as necessary.
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Affiliation(s)
- Julie Debacker
- Department of Neurology, NYU School of Medicine, New York, NY, United States
| | - Rachel Ventura
- Department of Neurology, NYU School of Medicine, New York, NY, United States
| | - Steven L Galetta
- Department of Neurology, NYU School of Medicine, New York, NY, United States; Ophthalmology, NYU School of Medicine, New York, NY, United States
| | - Laura J Balcer
- Department of Neurology, NYU School of Medicine, New York, NY, United States; Ophthalmology, NYU School of Medicine, New York, NY, United States; Population Health, NYU School ofMedicine, New York, NY, United States
| | - Janet C Rucker
- Department of Neurology, NYU School of Medicine, New York, NY, United States; Ophthalmology, NYU School of Medicine, New York, NY, United States.
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24
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Rizzo JR, Hosseini M, Wong EA, Mackey WE, Fung JK, Ahdoot E, Rucker JC, Raghavan P, Landy MS, Hudson TE. The Intersection between Ocular and Manual Motor Control: Eye-Hand Coordination in Acquired Brain Injury. Front Neurol 2017; 8:227. [PMID: 28620341 PMCID: PMC5451505 DOI: 10.3389/fneur.2017.00227] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Accepted: 05/11/2017] [Indexed: 11/13/2022] Open
Abstract
Acute and chronic disease processes that lead to cerebral injury can often be clinically challenging diagnostically, prognostically, and therapeutically. Neurodegenerative processes are one such elusive diagnostic group, given their often diffuse and indolent nature, creating difficulties in pinpointing specific structural abnormalities that relate to functional limitations. A number of studies in recent years have focused on eye-hand coordination (EHC) in the setting of acquired brain injury (ABI), highlighting the important set of interconnected functions of the eye and hand and their relevance in neurological conditions. These experiments, which have concentrated on focal lesion-based models, have significantly improved our understanding of neurophysiology and underscored the sensitivity of biomarkers in acute and chronic neurological disease processes, especially when such biomarkers are combined synergistically. To better understand EHC and its connection with ABI, there is a need to clarify its definition and to delineate its neuroanatomical and computational underpinnings. Successful EHC relies on the complex feedback- and prediction-mediated relationship between the visual, ocular motor, and manual motor systems and takes advantage of finely orchestrated synergies between these systems in both the spatial and temporal domains. Interactions of this type are representative of functional sensorimotor control, and their disruption constitutes one of the most frequent deficits secondary to brain injury. The present review describes the visually mediated planning and control of eye movements, hand movements, and their coordination, with a particular focus on deficits that occur following neurovascular, neurotraumatic, and neurodegenerative conditions. Following this review, we also discuss potential future research directions, highlighting objective EHC as a sensitive biomarker complement within acute and chronic neurological disease processes.
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Affiliation(s)
- John-Ross Rizzo
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States.,Department of Neurology, New York University Langone Medical Center, New York, NY, United States
| | - Maryam Hosseini
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Eric A Wong
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Wayne E Mackey
- Department of Psychology and Center for Neural Science, New York University, New York, NY, United States
| | - James K Fung
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Edmond Ahdoot
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Janet C Rucker
- Department of Neurology, New York University Langone Medical Center, New York, NY, United States.,Department of Ophthalmology, New York University Langone Medical Center, New York, NY, United States
| | - Preeti Raghavan
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States
| | - Michael S Landy
- Department of Psychology and Center for Neural Science, New York University, New York, NY, United States
| | - Todd E Hudson
- Department of Rehabilitation Medicine, New York University Langone Medical Center, New York, NY, United States.,Department of Neurology, New York University Langone Medical Center, New York, NY, United States
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25
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Hainline C, Rizzo JR, Hudson TE, Dai W, Birkemeier J, Raynowska J, Nolan RC, Hasanaj L, Selesnick I, Frohman TC, Frohman EM, Galetta SL, Balcer LJ, Rucker JC. Capturing saccades in multiple sclerosis with a digitized test of rapid number naming. J Neurol 2017; 264:989-998. [PMID: 28389741 DOI: 10.1007/s00415-017-8484-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2017] [Revised: 04/01/2017] [Accepted: 04/03/2017] [Indexed: 01/25/2023]
Abstract
The King-Devick (K-D) test of rapid number naming is a visual performance measure that captures saccadic eye movements. Patients with multiple sclerosis (MS) have slowed K-D test times associated with neurologic disability and reduced quality of life. We assessed eye movements during the K-D test to identify characteristics associated with slowed times. Participants performed a computerized K-D test with video-oculography. The 25-Item National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25) and its 10-Item Neuro-Ophthalmic Supplement measured vision-specific quality of life (VSQOL). Among 25 participants with MS (age 37 ± 10 years, range 20-59) and 42 controls (age 33 ± 9 years, range 19-54), MS was associated with significantly longer (worse) K-D times (58.2 ± 19.8 vs. 43.8 ± 8.6 s, P = 0.001, linear regression models, accounting for age). In MS, test times were slower among patients with higher (worse) Expanded Disability Status Scale scores (P = 0.01). Average inter-saccadic intervals (ISI) were significantly longer in MS participants compared to controls (362 ± 103 vs. 286 ± 50 ms, P = 0.001), and were highly associated with prolonged K-D times in MS (P = 0.006). MS participants generated greater numbers of saccades (P = 0.007). VSQOL scores were reduced in MS patients with longer (worse) K-D times (P = 0.04-0.001) and longer ISI (P = 0.002-0.001). Patients with MS have slowed K-D times that may be attributable to prolonged ISI and greater numbers of saccades. The K-D test and its requisite eye movements capture VSQOL and make rapid number naming a strong candidate efferent visual performance measure in MS.
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Affiliation(s)
- Clotilde Hainline
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
| | - John-Ross Rizzo
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Todd E Hudson
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
| | - Weiwei Dai
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
- Department of Rehabilitation Medicine, New York University School of Medicine, New York, NY, USA
- Department of Electrical and Computer Engineering, New York University Tandon School of Engineering, New York, NY, USA
| | - Joel Birkemeier
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
| | - Jenelle Raynowska
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
| | - Rachel C Nolan
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
| | - Lisena Hasanaj
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
| | - Ivan Selesnick
- Department of Electrical and Computer Engineering, New York University Tandon School of Engineering, New York, NY, USA
| | - Teresa C Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Elliot M Frohman
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Steven L Galetta
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
- Department of Ophthalmology, New York University School of Medicine, New York, NY, USA
| | - Laura J Balcer
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA
- Department of Ophthalmology, New York University School of Medicine, New York, NY, USA
- Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Janet C Rucker
- Department of Neurology, New York University School of Medicine, 240 East 38th Street, 20th Floor, New York, NY, 10016, USA.
- Department of Ophthalmology, New York University School of Medicine, New York, NY, USA.
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