MULES on the sidelines: A vision-based assessment tool for sports-related concussion

Samuel Fallon, Omar Akhand, Christopher Hernandez, Matthew S. Galetta, Lisena Hasanaj, John Martone, Nikki Webb, Julia Drattell, Prin Amorapanth, John Ross Rizzo, Rachel Nolan-Kenney, Liliana Serrano, Janet C. Rucker, Dennis Cardone, Steven L. Galetta, Laura J. Balcer

Research output: Contribution to journalArticlepeer-review

8 Scopus citations


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 50 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 17 ± 4 years, range 6–37, 38% female), average test times at baseline were 41.2 ± 11.2 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 (P < .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 49.2 ± 13.1 s) exceeding those for trial 2 (mean 41.3 ± 11.2 s, P < .0001, paired t-test). Among 17 athletes with concussion during the sports seasons captured to date (age 18 ± 3 years), all showed increases (worsening) of MULES time scores from pre-season baseline (median increase 11.2 s, range 0.6–164.2, P = .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 (P = .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.

Original languageEnglish
Pages (from-to)52-56
Number of pages5
JournalJournal of the Neurological Sciences
StatePublished - 15 Jul 2019
Externally publishedYes


  • Concussion
  • Mobile Universal Lexicon Evaluation System (MULES)
  • Picture naming
  • Sports
  • Vision


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