The new Mobile Universal Lexicon Evaluation System (MULES): A test of rapid picture naming for concussion sized for the sidelines

Omar Akhand, Matthew S. Galetta, Lucy Cobbs, Lisena Hasanaj, Nikki Webb, Julia Drattell, Prin Amorapanth, John Ross Rizzo, Rachel Nolan, Liliana Serrano, Janet C. Rucker, Dennis Cardone, Barry D. Jordan, Arlene Silverio, Steven L. Galetta, Laura J. Balcer

Research output: Contribution to journalArticlepeer-review


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.

Original languageEnglish (US)
Pages (from-to)199-204
Number of pages6
JournalJournal of the Neurological Sciences
StatePublished - Apr 15 2018


  • Concussion
  • Mobile Universal Lexicon Evaluation System (MULES)
  • Picture naming
  • Saccades
  • Sports
  • Vision
  • Brain Concussion/diagnosis
  • Humans
  • Middle Aged
  • Male
  • Athletic Injuries/complications
  • Names
  • Neuropsychological Tests
  • Young Adult
  • Mobile Applications
  • Semantics
  • Adolescent
  • Adult
  • Female
  • Saccades/physiology
  • Photic Stimulation
  • Child

ASJC Scopus subject areas

  • Clinical Neurology
  • Neurology


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