Bilateral parietal lesions disrupt the beneficial effects of prism adaptation: evidence from a patient with optic ataxia

Neuropsychology of the parietal lobe: Luria's and contemporary conceptions

The parietal lobe, constituting approximately 20% of the human brain, comprises two main regions: the somatosensory cortex and the posterior parietal cortex. The former is responsible for receiving and processing information from the organism itself or its external environment, while the latter performs concurrent summaries and higher cognitive functions. The present study seeks to integrate modern research findings with Luria's previous discoveries in order to gain a nuanced understanding of the roles assigned to the parietal lobe as well as its lateralization differences.

Choosing Sides: Impact of Prismatic Adaptation on the Lateralization of the Attentional System

Seminal studies revealed differences between the effect of adaptation to left- vs. right-deviating prisms (L-PA, R-PA) in normal subjects. Whereas L-PA leads to neglect-like shift in attention, demonstrated in numerous visuo-spatial and cognitive tasks, R-PA has only minor effects in specific aspects of a few tasks. The paucity of R-PA effects in normal subjects contrasts with the striking alleviation of neglect symptoms in patients with right hemispheric lesions. Current evidence from activation studies in normal subjects highlights the contribution of regions involved in visuo-motor control during prism exposure and a reorganization of spatial representations within the ventral attentional network (VAN) after the adaptation. The latter depends on the orientation of prisms used. R-PA leads to enhancement of the ipsilateral visual and auditory space within the left inferior parietal lobule (IPL), switching thus the dominance of VAN from the right to the left hemisphere. L-PA leads to enhancement of the ipsilateral space in right IPL, emphasizing thus the right hemispheric dominance of VAN. Similar reshaping has been demonstrated in patients. We propose here a model, which offers a parsimonious explanation of the effect of L-PA and R-PA both in normal subjects and in patients with hemispheric lesions. The model posits that prismatic adaptation induces instability in the synaptic organization of the visuo-motor system, which spreads to the VAN. The effect is lateralized, depending on the side of prism deviation. Successful pointing with prisms implies reaching into the space contralateral, and not ipsilateral, to the direction of prism deviation. Thus, in the hemisphere contralateral to prism deviation, reach-related neural activity decreases, leading to instability of the synaptic organization, which induces a reshuffling of spatial representations in IPL. Although reshuffled spatial representations in IPL may be functionally relevant, they are most likely less efficient than regular representations and may thus cause partial dysfunction. The former explains, e.g., the alleviation of neglect symptoms after R-PA in patients with right hemispheric lesions, the latter the occurrence of neglect-like symptoms in normal subjects after L-PA. Thus, opting for R- vs. L-PA means choosing the side of major IPL reshuffling, which leads to its partial dysfunction in normal subjects and to recruitment of alternative or enhanced spatial representations in patients with hemispheric lesions.

Patients with lesions to the intraparietal cortex show greater proprioceptive realignment after prism adaptation: Evidence from open-loop pointing and manual straight ahead

Reaching toward a target viewed through laterally refracting prisms results in adaptation of both visual and (limb) proprioceptive spatial representations. Common ways to measure adaptation after-effect are to ask a person to point straight ahead with their eyes closed ("manual straight ahead", MSA), or to a seen target using their unseen hand ("open-loop pointing", OLP). MSA measures changes in proprioception only, whereas OLP measures the combined visual and proprioceptive shift. The behavioural and neurological mechanisms of prism adaptation have come under scrutiny following reports of reduced hemispatial neglect in patients following this procedure. We present evidence suggesting that shifts in proprioceptive spatial representations induced by prism adaptation are larger following lesions to the intraparietal cortex - a brain region that integrates retinotopic visual signals with signals of eye position in the orbit and that is activated during prism adaptation. Six healthy participants and six patients with unilateral intraparietal cortex lesions underwent prism adaptation. After-effects were measured with OLP and MSA. After-effects of control participants were larger when measured with OLP than with MSA, consistent with previous research and with the additional contribution of visual shift to OLP after-effects. However, patients' OLP shifts were not significantly different to their MSA shifts. We conclude that, for the patients, correction of pointing errors during prism adaptation involved proportionally more changes to arm proprioception than for controls. Since lesions to intraparietal cortex led to enhanced realignment of arm proprioceptive representations, our results indirectly suggest that the intraparietal cortex could be key for visual realignment.

Bálint syndrome

This chapter starts by reviewing the various interpretations of Bálint syndrome over time. We then develop a novel integrative view in which we propose that the various symptoms, historically reported and labeled by various authors, result from a core mislocalization deficit. This idea is in accordance with our previous proposal that the core deficit of Bálint syndrome is attentional (Pisella et al., 2009, 2013, 2017) since covert attention improves spatial resolution in visual periphery (Yeshurun and Carrasco, 1998); a deficit of covert attention would thus increase spatial uncertainty and thereby impair both visual object identification and visuomotor accuracy. In peripheral vision, we perceive the intrinsic characteristics of the perceptual elements surrounding us, but not their precise localization (Rosenholtz et al., 2012a,b), such that without covert attention we cannot organize them to their respective and recognizable objects; this explains why perceptual symptoms (simultanagnosia, neglect) could result from visual mislocalization. The visuomotor symptoms (optic ataxia) can be accounted for by both visual and proprioceptive mislocalizations in an oculocentric reference frame, leading to field and hand effects, respectively. This new pathophysiological account is presented along with a model of posterior parietal cortex organization in which the superior part is devoted to covert attention, while the right inferior part is involved in visual remapping. When the right inferior parietal cortex is damaged, additional representational mislocalizations across saccades worsen the clinical picture of peripheral mislocalizations due to an impairment of covert attention.

Visuomotor adaptation in the absence of input from early visual cortex

Prism adaptation is a time-honored tool for studying how the motor system adapts to sensory perturbations. Past research on the neural substrates of prism adaptation has implicated the posterior parietal cortex (PPC) and the cerebellum, under the assumption that these structures gain their visual input from the dominant retinogeniculate pathway to V1. Here we question whether this pathway is even required for visuomotor adaptation to occur. To investigate this, we examined prism adaptation in 'MC', someone who is blind to static stimuli following bilateral lesions that encompass much of her occipital cortex and the caudal-most areas of ventrotemporal cortex. Remarkably, MC shows evidence of prism adaptation that is similar to healthy control participants. First, when pointing with either the left or the right hand, MC shows spatial realignment; the classical after-effect exhibited by most people when adapting to displacing prisms. Second, MC demonstrates strategic recalibration - a reduction in her pointing error over time - that is similar in magnitude to healthy controls. These findings suggest that the geniculostriate pathway is not necessary for visuomotor adaptation to take place. Alternatively, we suggest that an extrageniculostriate pathway which provides visual inputs to the cerebellum from area MT and the PPC via the dorsolateral pons plays a significant and appreciable role in the guidance of unconscious automatic visuomotor adaptation.

Pushing attention to one side: Force field adaptation alters neural correlates of orienting and disengagement of spatial attention

Sensorimotor adaptation to wedge prisms can alter the balance of attention between left and right space in healthy adults, and improve symptoms of spatial neglect after stroke. Here we asked whether the orienting of spatial attention to visual stimuli is affected by a different form of sensorimotor adaptation that involves physical perturbations of arm movement, rather than distortion of visual feedback. Healthy participants performed a cued discrimination task before and after they made reaching movements to a central target. A velocity-dependent force field pushed the hand aside during each reach, and required participants to apply compensatory forces toward the opposite side. We used event-related potentials (ERPs) to determine whether electroencephalography (EEG) responses reflecting orienting (cue-locked N1) and disengagement (target-locked P1) of spatial attention are affected by adaptation to force fields. After adaptation, the cue-locked N1 was relatively larger for stimuli presented in the hemispace corresponding to the direction of compensatory hand force. P1 amplitudes evoked by invalidly cued targets presented on the opposite side were reduced. This suggests that force field adaptation boosted attentional orienting responses toward the side of hand forces, and impeded attentional disengagement from that side, mimicking previously reported effects of prism adaptation. Thus, remapping between motor commands and intended movement direction is sufficient to bias ERPs, reflecting changes in the orienting of spatial attention in the absence of visuo-spatial distortion or visuo-proprioceptive mismatch. Findings are relevant to theories of how sensorimotor adaptation can modulate attention, and may open new avenues for treatment of spatial neglect.

Adaptation to Leftward Shifting Prisms Alters Motor Interhemispheric Inhibition

Adaptation to rightward shifting prisms (rightward prism adaptation, RPA) ameliorates neglect symptoms in patients while adaptation to leftward shifting prisms (leftward prism adaptation, LPA) induces neglect-like behaviors in healthy subjects. It has been hypothesized that prism adaptation (PA) modulates interhemispheric balance between the parietal cortices by inhibiting the posterior parietal cortex (PPC) contralateral to the prismatic deviation, but PA's effects on interhemispheric inhibition (IHI) have not been directly investigated. Since there are hyper-excitable connections between the PPC and primary motor cortex (M1) in the left hemisphere of neglect patients, we reasoned that LPA might mimic right hemisphere lesions by reducing parietal IHI, hyper-exciting the left PPC and PPC-M1 connections, and in turn altering IHI at the motor level. Namely, we hypothesized that LPA would increase IHI from the left to the right M1. We examined changes in left-to-right and right-to-left IHI between the 2 M1s using the ipsilateral silent period (iSP) (Meyer et al. 1995) before and after either LPA or RPA. The iSP was significantly longer after LPA but only from left-to-right and it did not change at all after RPA. This is the first physiological demonstration that LPA alters IHI in the healthy brain.

Multisensory and Modality-Specific Influences on Adaptation to Optical Prisms

Visuo-motor adaptation to optical prisms displacing the visual scene (prism adaptation, PA) is a method used for investigating visuo-motor plasticity in healthy individuals and, in clinical settings, for the rehabilitation of unilateral spatial neglect. In the standard paradigm, the adaptation phase involves repeated pointings to visual targets, while wearing optical prisms displacing the visual scene laterally. Here we explored differences in PA, and its aftereffects (AEs), as related to the sensory modality of the target. Visual, auditory, and multisensory - audio-visual - targets in the adaptation phase were used, while participants wore prisms displacing the visual field rightward by 10°. Proprioceptive, visual, visual-proprioceptive, auditory-proprioceptive straight-ahead shifts were measured. Pointing to auditory and to audio-visual targets in the adaptation phase produces proprioceptive, visual-proprioceptive, and auditory-proprioceptive AEs, as the typical visual targets did. This finding reveals that cross-modal plasticity effects involve both the auditory and the visual modality, and their interactions (Experiment 1). Even a shortened PA phase, requiring only 24 pointings to visual and audio-visual targets (Experiment 2), is sufficient to bring about AEs, as compared to the standard 92-pointings procedure. Finally, pointings to auditory targets cause AEs, although PA with a reduced number of pointings (24) to auditory targets brings about smaller AEs, as compared to the 92-pointings procedure (Experiment 3). Together, results from the three experiments extend to the auditory modality the sensorimotor plasticity underlying the typical AEs produced by PA to visual targets. Importantly, PA to auditory targets appears characterized by less accurate pointings and error correction, suggesting that the auditory component of the PA process may be less central to the building up of the AEs, than the sensorimotor pointing activity per se. These findings highlight both the effectiveness of a reduced number of pointings for bringing about AEs, and the possibility of inducing PA with auditory targets, which may be used as a compensatory route in patients with visual deficits.

Visuomotor adaptation needs a validation of prediction error by feedback error

The processes underlying short-term plasticity induced by visuomotor adaptation to a shifted visual field are still debated. Two main sources of error can induce motor adaptation: reaching feedback errors, which correspond to visually perceived discrepancies between hand and target positions, and errors between predicted and actual visual reafferences of the moving hand. These two sources of error are closely intertwined and difficult to disentangle, as both the target and the reaching limb are simultaneously visible. Accordingly, the goal of the present study was to clarify the relative contributions of these two types of errors during a pointing task under prism-displaced vision. In “terminal feedback error” condition, viewing of their hand by subjects was allowed only at movement end, simultaneously with viewing of the target. In “movement prediction error” condition, viewing of the hand was limited to movement duration, in the absence of any visual target, and error signals arose solely from comparisons between predicted and actual reafferences of the hand. In order to prevent intentional corrections of errors, a subthreshold, progressive stepwise increase in prism deviation was used, so that subjects remained unaware of the visual deviation applied in both conditions. An adaptive aftereffect was observed in the “terminal feedback error” condition only. As far as subjects remained unaware of the optical deviation and self-assigned pointing errors, prediction error alone was insufficient to induce adaptation. These results indicate a critical role of hand-to-target feedback error signals in visuomotor adaptation; consistent with recent neurophysiological findings, they suggest that a combination of feedback and prediction error signals is necessary for eliciting aftereffects. They also suggest that feedback error updates the prediction of reafferences when a visual perturbation is introduced gradually and cognitive factors are eliminated or strongly attenuated.

Rehabilitation of spatial neglect by prism adaptation: a peculiar expansion of sensorimotor after-effects to spatial cognition

Unilateral neglect is a neurological condition responsible for many debilitating effects on everyday life, poor functional recovery, and decreased ability to benefit from treatment. Prism adaptation (PA) to a right lateral displacement of the visual field is classically known to directionally bias visuo-motor and sensory-motor correspondences. One longstanding issue about this visuo-motor plasticity is about its specificity to the exposure condition. In contrast to very poor transfer to unexposed effectors classically described in healthy subjects, therapeutic results obtained in neglect patients suggested that PA can generate unexpected "expansion". Prism adaptation affects numerous levels of neglect symptomatology, suggesting that its effects somehow expand to unexposed sensory, motor and cognitive systems. The available body of evidence in support for this expansion raises important questions about the mechanisms involved in producing unexpected cognitive effects following a simple and moderate visuo-motor adaptation. We further develop here the idea that prism adaptation expansion to spatial cognition involves a cerebello-cortical network and review support for this model. Building on the basic, therapeutical and pathophysiological knowledge accumulated over the last 15 years, we also provide guidelines for the optimal use of prism adaptation in the clinic. Although further research and clinical trials are required to precisely define the ideal regime for routine applications, the current state of the art allows us to outline practical recommendations for therapeutical use of prisms.

Prism adaptation alters spatial remapping in healthy individuals: evidence from double-step saccades

The visual system is able to represent and integrate large amounts of information as we move our gaze across a scene. This process, called spatial remapping, enables the construction of a stable representation of our visual environment despite constantly changing retinal images. Converging evidence implicates the parietal lobes in this process, with the right hemisphere having a dominant role. Indeed, lesions to the right parietal lobe (e.g., leading to hemispatial neglect) frequently result in deficits in spatial remapping. Research has demonstrated that recalibrating visual, proprioceptive and motor reference frames using prism adaptation ameliorates neglect symptoms and induces neglect-like performance in healthy people - one example of the capacity for rapid neural plasticity in response to new sensory demands. Because of the influence of prism adaptation on parietal functions, the present research investigates whether prism adaptation alters spatial remapping in healthy individuals. To this end twenty-eight undergraduates completed blocks of a double-step saccade (DSS) task after sham adaptation and adaptation to leftward- or rightward-shifting prisms. The results were consistent with an impairment in spatial remapping for left visual field targets following adaptation to leftward-shifting prisms. These results suggest that temporarily realigning spatial representations using sensory-motor adaptation alters right-hemisphere remapping processes in healthy individuals. The implications for the possible mechanisms of the amelioration of hemispatial neglect after prism adaptation are discussed.

Dissociating perceptual and motor effects of prism adaptation in neglect

Prism adaptation reduces some symptoms of neglect; however the mechanisms underlying such changes are poorly understood. We suggest that prisms influence neglect by acting on dorsal stream circuits subserving visuomotor control, with little influence on perceptual aspects of neglect. We examined prism adaptation in three neglect patients and a group of healthy controls on line bisection and landmark tasks. Neglect patients showed a dramatic reduction in the rightward bias for line bisection, but absolutely no change in their leftward bias on the landmark task, which is a perceptual equivalent to bisection. However, in controls, prisms produced 'neglect-like' deficits on both the line bisection and landmark tasks. These data suggest that prisms influence visually guided actions more so than perception in neglect.

Impairments in tactile search following superior parietal damage

The superior parietal cortex is critical for the control of visually guided actions. Research suggests that visual stimuli relevant to actions are preferentially processed when they are in peripersonal space. One recent study demonstrated that visually guided movements towards the body were more impaired in a patient with damage to superior parietal cortex. Whereas past studies have explored disordered movement in optic ataxic patients, there has been less exploration of space perception in terms of search capacity in this population. In addition, there is some debate concerning the relationship between deficits of visuomotor control and impaired attention/perception in optic ataxia. Given that the dorsal stream has been implicated in the spatial processing of stimuli in peripersonal space, and damage to this region is known to cause optic ataxia, we felt that further investigation was warranted. We examined tactile search behavior in the fronto-parallel and radial planes in a patient with right superior parietal damage and optic ataxia. We used a pegboard with removable cylindrical pegs that allowed for the reorganization of targets between trials. To better characterize three-dimensional search behavior, we included both horizontal and vertical search conditions. Results showed that the patient spent more time searching, was more accurate and revisited more targets in right versus left space. Interestingly, the patient spent the majority of her time specifically searching the lower right quadrant of the stimulus array. Further analysis revealed lower target detection rates along the outer borders of the pegboard on all sides. The search pattern observed here is unusual considering that all targets were within arm's reach. The present experiment demonstrates that damage to superior parietal cortex impairs tactile search and biases exploration towards lower right peripersonal space.

Proprioceptive pathways to posterior parietal areas MIP and LIPv from the dorsal column nuclei and the postcentral somatosensory cortex

The posterior parietal cortex (PPC) serves as an interface between sensory and motor cortices by integrating multisensory signals with motor-related information. Sensorimotor transformation of somatosensory signals is crucial for the generation and updating of body representations and movement plans. Using retrograde transneuronal transfer of rabies virus in combination with a conventional tracer, we identified direct and polysynaptic somatosensory pathways to two posterior parietal areas, the ventral lateral intraparietal area (LIPv) and the rostral part of the medial intraparietal area (MIP) in macaque monkeys. In addition to direct projections from somatosensory areas 2v and 3a, respectively, we found that LIPv and MIP receive disynaptic inputs from the dorsal column nuclei as directly as these somatosensory areas, via a parallel channel. LIPv is the target of minor neck muscle-related projections from the cuneate (Cu) and the external cuneate nuclei (ECu), and direct projections from area 2v, that likely carry kinesthetic/vestibular/optokinetic-related signals. In contrast, MIP receives major arm and shoulder proprioceptive inputs disynaptically from the rostral Cu and ECu, and trisynaptically (via area 3a) from caudal portions of these nuclei. These findings have important implications for the understanding of the influence of proprioceptive information on movement control operations of the PPC and the formation of body representations. They also contribute to explain the specific deficits of proprioceptive guidance of movement associated to optic ataxia.

Cerebellar inputs to intraparietal cortex areas LIP and MIP: functional frameworks for adaptive control of eye movements, reaching, and arm/eye/head movement coordination

Using retrograde transneuronal transfer of rabies virus in combination with a conventional tracer (cholera toxin B), we studied simultaneously direct (thalamocortical) and polysynaptic inputs to the ventral lateral intraparietal area (LIPv) and the medial intraparietal area (MIP) in nonhuman primates. We found that these areas receive major disynaptic inputs from specific portions of the cerebellar nuclei, the ventral dentate (D), and ventrolateral interpositus posterior (IP). Area LIPv receives inputs from oculomotor domains of the caudal D and IP. Area MIP is the target of projections from the ventral D (mainly middle third), and gaze- and arm-related domains of IP involved in reaching and arm/eye/head coordination. We also showed that cerebellar cortical "output channels" to MIP predominantly stem from posterior cerebellar areas (paramedian lobe/Crus II posterior, dorsal paraflocculus) that have the required connectivity for adaptive control of visual and proprioceptive guidance of reaching, arm/eye/head coordination, and prism adaptation. These findings provide important insight about the interplay between the posterior parietal cortex and the cerebellum regarding visuospatial adaptation mechanisms and visual and proprioceptive guidance of movement. They also have potential implications for clinical approaches to optic ataxia and neglect rehabilitation.

Through a prism darkly: re-evaluating prisms and neglect

Many studies have demonstrated that prism adaptation can reduce several symptoms of visual neglect: a disorder in which patients fail to respond to information in contralesional space. The dominant framework to explain these effects proposes that prisms influence higher order visuospatial processes by acting on brain circuits that control spatial attention and perception. However, studies that have directly examined the influence of prisms on perceptual biases inherent to neglect have revealed very few beneficial effects. We propose an alternative explanation whereby many of the beneficial effects of prisms arise via the influence of adaptation on circuits in the dorsal visual stream controlling attention and visuomotor behaviors. We further argue that prisms have little influence on the pervasive perceptual biases that characterize neglect.

Implications of prism adaptation asymmetry for unilateral visual neglect: theoretical note

Asymmetry in intermanual transfer of proprioceptive and visual prism adaptation is reviewed, which suggests asymmetric hemispheric representation of left and right space, directional connection from right to left visual hemispheres, and lateralization of limb motor control. Damage to the right visual hemisphere source of the directional connection could produce the general features of unilateral visual neglect.

Dynamic changes in brain activity during prism adaptation

Prism adaptation does not only induce short-term sensorimotor plasticity, but also longer-term reorganization in the neural representation of space. We used event-related fMRI to study dynamic changes in brain activity during both early and prolonged exposure to visual prisms. Participants performed a pointing task before, during, and after prism exposure. Measures of trial-by-trial pointing errors and corrections allowed parametric analyses of brain activity as a function of performance. We show that during the earliest phase of prism exposure, anterior intraparietal sulcus was primarily implicated in error detection, whereas parieto-occipital sulcus was implicated in error correction. Cerebellum activity showed progressive increases during prism exposure, in accordance with a key role for spatial realignment. This time course further suggests that the cerebellum might promote neural changes in superior temporal cortex, which was selectively activated during the later phase of prism exposure and could mediate the effects of prism adaptation on cognitive spatial representations.

Prism adaptation improves visual search in hemispatial neglect

Visuomotor prism adaptation has been found to induce a lateral bias of spatial attention in chronic hemispatial neglect patients. Here, two experiments were conducted to explore the effects of 10 degrees prism adaptation on visual search tasks and standard visual inattention tests. Baselines and intervention effects were measured on separate days for all patients. The first experiment explored whether prism adaptation affects performance on a time restricted visual search task (maximum 3500ms presentation followed by visual and auditory feedback). No positive effects of prism adaptation were found on accuracy in visual search nor on traditional neglect tests. These results accord well with previous studies showing that increased cognitive load can lead to prism de-adaptation or unchanged performance following prism adaptation. Response times in visual search became faster following intervention but this was not the case for the standard neglect tests. In the second experiment, the same single-featured search task was used, but the participants had unlimited search time and received no feedback on their response. This time, the patients showed accuracy improvements in visual search and all four on regular neglect tests. Therapeutic effects lasted for at least 90-120min. Response times on all tasks became faster after prism adaptation. The results are consistent with studies showing effects of prism adaptation on neuropsychological neglect tests and other attentional tasks that are not speeded or time restricted, where feedback is not provided, or are performed following non-feedback-based tasks. The current findings show that prism adaptation improves visual search in neglect and that these beneficial effects can disappear with feedback.