Prisms and neglect: what have we learned?

Body ownership alterations in stroke emerge from reduced proprioceptive precision and damage to the frontoparietal network

BACKGROUND

Stroke patients often experience alterations in their subjective feeling of ownership for the affected limb, which can hinder motor function and interfere with rehabilitation. In this study, we aimed at disentangling the complex relationship between sensory impairment, body ownership (BO), and motor control in stroke patients.

METHODS

We recruited 20 stroke patients with unilateral upper limb sensory deficits and 35 age-matched controls. Participants performed a virtual reality reaching task with a varying displacement between their real unseen hand and a visible virtual hand. We measured reaching errors and subjective ownership ratings as indicators of hand ownership. Reaching errors were modeled using a probabilistic causal inference model, in which ownership for the virtual hand is inferred from the level of congruency between visual and proprioceptive inputs and used to weigh the amount of visual adjustment to reaching movements.

FINDINGS

Stroke patients were more likely to experience ownership over an incongruent virtual hand and integrate it into their motor plans. The model explained this tendency in terms of a decreased capability of detecting visuo-proprioceptive incongruences, proportionally to the amount of proprioceptive deficit. Lesion analysis further revealed that BO alterations, not fully explained by the proprioceptive deficit, are linked to frontoparietal network damage, suggesting a disruption in higher-level multisensory integration functions.

CONCLUSIONS

Collectively, our results show that BO alterations in stroke patients can be quantitatively predicted and explained in a computational framework as the result of sensory loss and higher-level multisensory integration deficits.

FUNDING

Swiss National Science Foundation (163951).

The effects of prior exposure to prism lenses on de novo motor skill learning

Motor learning involves plasticity in a network of brain areas across the cortex and cerebellum. Such traces of learning have the potential to affect subsequent learning of other tasks. In some cases, prior learning can interfere with subsequent learning, but it may be possible to potentiate learning of one task with a prior task if they are sufficiently different. Because prism adaptation involves extensive neuroplasticity, we reasoned that the elevated excitability of neurons could increase their readiness to undergo structural changes, and in turn, create an optimal state for learning a subsequent task. We tested this idea, selecting two different forms of learning tasks, asking whether exposure to a sensorimotor adaptation task can improve subsequent de novo motor skill learning. Participants first learned a new visuomotor mapping induced by prism glasses in which prism strength varied trial-to-trial. Immediately after and the next day, we tested participants on a mirror tracing task, a form of de novo skill learning. Prism-trained and control participants both learned the mirror tracing task, with similar reductions in error and increases in distance traced. Both groups also showed evidence of offline performance gains between the end of day 1 and the start of day 2. However, we did not detect differences between groups. Overall, our results do not support the idea that prism adaptation learning can potentiate subsequent de novo learning. We discuss factors that may have contributed to this result.

No short-term treatment effect of prism adaptation for spatial neglect: An inclusive meta-analysis

Despite 25 years of research on the topic, there is still no consensus on whether prism adaptation is an effective therapy for visuospatial neglect. We have addressed this question through a meta-analysis of the most well-controlled studies on the topic. Our main meta-analytic model included studies with a placebo/sham/treatment-as-usual control group from which data from right hemisphere stroke patients and left-sided neglect could be aggregated. The short-term treatment effects on the two commonly used standard tests for neglect, the conventional Behavioural Inattention Test (BIT-C) and cancellation test scores were combined into one random effect model justified by the fact that 89% of the BIT-C score is determined by cancellation tasks. With this approach, we were able to obtain a larger and more homogeneous dataset than previous meta-analyses: sixteen studies including 430 patients. No evidence for beneficial effects of prism adaptation was found. The secondary meta-analysis including data from the Catherine Bergego Scale, a functional measure of activities of daily living, also found no evidence for the therapeutic effects of prism adaptation, although half as many studies were available for this analysis. The results were consistent after the removal of influential outliers, after studies with high risk-of-bias were excluded, and when an alternative measure of effect size was considered. These results do not support the routine use of prism adaptation as a therapy for spatial neglect.

Effective connectivity underlying neural and behavioral components of prism adaptation

Prism adaptation (PA) is a form of visuomotor training that produces both sensorimotor and cognitive aftereffects depending on the direction of the visual displacement. Recently, a neural framework explaining both types of PA-induced aftereffects has been proposed, but direct evidence for it is lacking. We employed Structural Equation Modeling (SEM), a form of effective connectivity analysis, to establish directionality among connected nodes of the brain network thought to subserve PA. The findings reveal two distinct network branches: (1) a loop involving connections from the parietal cortices to the right parahippocampal gyrus, and (2) a branch linking the lateral premotor cortex to the parahippocampal gyrus via the cerebellum. Like the sensorimotor aftereffects, the first branch exhibited qualitatively different modulations for left versus right PA, and critically, changes in these connections were correlated with the magnitude of the sensorimotor aftereffects. Like the cognitive aftereffects, changes in the second branch were qualitatively similar for left and right PA, with greater change for left PA and a trend correlation with cognitive aftereffects. These results provide direct evidence that PA is supported by two functionally distinct subnetworks, a parietal–temporal network responsible for sensorimotor aftereffects and a fronto-cerebellar network responsible for cognitive aftereffects.

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.

Age-related changes in visuo-proprioceptive processing in perceived body position

This study investigated age-related change in visuo-proprioceptive processing in the perceived body position using mirror hand/foot illusions, focusing on its temporal characteristics, its dependency on body parts, and its association with older adults’ fall risk. Either immediately or 15 s after the exposure to the mirror-induced inconsistency of visuo-proprioceptive signals regarding the right hand or foot position, participants performed a reaching task using the unseen, illusion-affected hand or foot. Results showed clear age group differences. Specifically, older adults exhibited larger reaching errors than younger adults in the hand condition, and after the 15 s delay in the foot condition. Further, the reaching errors were constant across time for older adults but decreased after the delay in young adults, regardless of the tested body part. Particularly, older adults’ risk of falling, which was assessed by the timed up-and-go test, was negatively correlated with the reduction of reaching error across time. This suggests that older adults, especially those with a high risk of falling, face difficulties in appropriately processing visual and proprioceptive information for body perception in accordance with their external environment.

Feasibility study of immersive virtual prism adaptation therapy with depth-sensing camera using functional near-infrared spectroscopy in healthy adults

Prism Adaptation (PA) is used to alleviate spatial neglect. We combined immersive virtual reality with a depth-sensing camera to develop virtual prism adaptation therapy (VPAT), which block external visual cues and easily quantify and monitor errors than conventional PA. We conducted a feasibility study to investigate whether VPAT can induce behavioral adaptations by measuring after-effect and identifying which cortical areas were most significantly activated during VPAT using functional near-infrared spectroscopy (fNIRS). Fourteen healthy subjects participated in this study. The experiment consisted of four sequential phases (pre-VPAT, VPAT-10°, VPAT-20°, and post-VPAT). To compare the most significantly activated cortical areas during pointing in different phases against pointing during the pre-VPAT phase, we analyzed changes in oxyhemoglobin concentration using fNIRS during pointing. The pointing errors of the virtual hand deviated to the right-side during early pointing blocks in the VPAT-10° and VPAT-20° phases. There was a left-side deviation of the real hand to the target in the post-VPAT phase, demonstrating after-effect. The most significantly activated channels during pointing tasks were located in the right hemisphere, and possible corresponding cortical areas included the dorsolateral prefrontal cortex and frontal eye field. In conclusion, VPAT may induce behavioral adaptation with modulation of the dorsal attentional network.

Long-lasting effects of a gaze-contingent intervention on change detection in healthy participants - Implications for neglect rehabilitation

Patients with spatial neglect show an ipsilesional exploration bias. We developed a gaze-contingent intervention that aims at reducing this bias and tested its effects on visual exploration in healthy participants: During a visual search, stimuli in one half of the search display are removed when the gaze moves into this half. This leads to a relative increase in the exploration of the other half of the search display - the one that can be explored without impediments. In the first experiment, we tested whether this effect transferred to visual exploration during a change detection task (under change blindness conditions), which was the case. In a second experiment, we modified the intervention (to an intermittent application) but the original version yielded more promising results. Thus, in the third experiment, the original version was used to test the longevity of its effects and whether its repeated application produced even stronger results. To this aim, we compared two groups: the first group received the intervention once, the second group repeatedly on three consecutive days. The change detection task was administered before the intervention and at four points in time after the last intervention (directly afterwards, + 1 hour, + 1 day, and +4 days). The results showed long-lasting effects of the intervention, most pronounced in the second group. Here the intervention changed the bias in the visual exploration pattern significantly until the last follow-up. We conclude that the intervention shows promise for the successful application in neglect patients.

How Does Attention Alter Length Perception? A Prism Adaptation Study

How perceived size (length) of an object is influenced by attention is in debate. Prism adaptation (PA), as a type of sensory motor adaptation, has been shown to affect performance on a variety of spatial tasks in both neglect patient and healthy individuals. It has been hypothesized that PA's effects might be mediated by attentional mechanisms. In this study, we used PA to laterally shift spatial attention, and employed a precise psychophysical procedure to examine how the perceptual length of lines was influenced by this attentional shifting. Participants were presented with two separate lines in the left and right visual fields, and compared the length of the two lines. Forty-five healthy participants completed this line-length judgment task before and after a short period of adaptation to either left- (Experiment 1) or right-shifting (Experiment 2) prisms, or control goggles that did not shift the visual scene (Experiment 3). We found that participants initially tended to perceive the line presented in the left to be longer. This leftward bias of length perception was reduced by a short period of visuomotor adaptation to the left-deviating PA. However, for the right-shifting PA and plain glass goggles conditions, the initial length perception bias to the left line was unaffected. Mechanisms of this asymmetric effect of PA was discussed. Our results demonstrate that the length perception of a line can be influenced by a simple visuomotor adaptation, which might shift the spatial attention. This finding is consistent with the argument that attention can alter appearance.

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.

Left-shifting prism adaptation boosts reward-based learning

Visuospatial cognition has an inherent lateralized bias. Individual differences in the direction and magnitude of this bias are associated with asymmetrical D2/3 dopamine binding and dopamine system genotypes. Dopamine level affects feedback-based learning and dopamine signaling asymmetry is related to differential learning from reward and punishment. High D2 binding in the left hemisphere is associated with preference for reward. Prism adaptation (PA) is a simple sensorimotor technique, which modulates visuospatial bias according to the direction of the deviation. Left-deviating prism adaptation (LPA) induces rightward bias in healthy subjects. It is therefore possible that the right side of space increases in saliency along with left hemisphere dopaminergic activity. Right-deviating prism adaptation (RPA) has been used mainly as a control condition because it does not modulate behavior in healthy individuals. Since LPA induces a rightward visuospatial bias as a result of left hemisphere modulation, and higher dopaminergic activity in the left hemisphere is associated with preference for rewarding events we hypothesized that LPA would increase the preference for learning with reward. Healthy volunteers performed a computer-based probabilistic classification task before and after LPA or RPA. Consistent with our predictions, PA altered the preference for rewarded versus punished learning, with the LPA group exhibiting increased learning from reward. These results suggest that PA modulates dopaminergic activity in a lateralized fashion.

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.

Neuroanatomical and behavioural factors associated with the effectiveness of two weekly sessions of prism adaptation in the treatment of unilateral neglect

Among the different interventions to alleviate the symptoms of unilateral neglect, prism adaptation (PA) appears especially promising. To elucidate the contribution of some neuroanatomical and behavioural factors to PA's effectiveness, we conducted a study combining neuropsychological and lesion mapping methods on a group of 19 neglect patients who underwent two sessions of PA during one week and assessed their improvement relative to the baseline until the following week (7-8 days later). Correlation analyses revealed a significant positive relationship between the magnitude of the proprioceptive after-effect and the improvement at the follow-up session in two perceptual tasks requiring motor responses. Conversely, no correlation was found between the proprioceptive after-effect and the improvement in a perceptual task with no motor involvement. This finding suggests that patients' potential to show a prism-related improvement in motor-related tasks might be indicated by the strength of their proprioceptive response (proprioceptive after-effect). As for the neuroanatomical basis of this relationship, subtraction analyses suggested that patients' improvement in perceptual tasks with high motor involvement might be facilitated by the integrity of temporo-parietal areas and the damage of frontal and subcortical areas.

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.

Home and family in cognitive rehabilitation after brain injury: Implementation of social reserves

The focus of the present article is the home and family environment of patients suffering acquired brain injury. In order to obtain the optimal outcome of posttraumatic cognitive rehabilitation it is important (a) to obtain a sufficient intensity of rehabilitative training, (b) to achieve the maximum degree of generalization from formalized training to the daily environment of the patient, and (c) to obtain the best possible utilization of "cognitive reserves" in the form of cognitive abilities and "strategies" acquired pretraumatically. Supplementing the institution-based cognitive training with (potentially computer-based) home-based training these three goals may more easily be met. Home-based training supports a higher intensity of training. Training in the home environment also allows better utilization of cognitive strategies acquired pretraumatically and more direct transfer of training results from formalized training to activities of daily living of the patient.

The asymmetrical effect of leftward and rightward prisms on intact visuospatial cognition

Rightward prismatic adaptation (RPA) can reduce neglect symptoms in patients whereas adaptation to leftward deviating prisms (LPA) can induce neglect-like behavior in healthy subjects. One influential anatomo-functional model of prismatic adaptation (PA) postulates that it inhibits activity of the posterior parietal cortex (PPC) contralateral to the prismatic deviation. By hypo-activating the PPC and thus eventually acting on interhemispheric balance, both LPA and RPA could possibly affect visuospatial perception in healthy subjects, however, such behavioral modulation has seldom been reported after RPA. In the light of recent evidence showing that LPA-induced visuospatial shift need time to develop we hypothesized that RPA might induce significant changes in visuospatial cognition on a longer time scale. We thus assessed the Landmark task, as well as sensorimotor aftereffects, several times over 8 h after a single session of either LPA or RPA. In agreement with previous reports, sensorimotor effects were symmetrical and long-lasting, with both LPA and RPA inducing shifts of comparable amplitudes in the direction opposite to the deviation that lasted up to 8 h. Visuospatial cognition assessed by Landmark performance, was also significantly modulated for up to 8 h, but only after LPA. Interestingly, the timing and direction of this modulation differed according to participants' baseline bias. An initial leftward bias led to a rapid, but short-lasting rightward shift, whereas an initial rightward bias led to a slower-developing and longer-lasting leftward shift. These findings shed new light on a so-far relatively overlooked feature of spatial cognition that may interact with the effect of PA: the state of the visuospatial system prior to PA should be taken into account when attempting to understand and modulate visuospatial cognition in healthy and brain-damaged populations. This highlights the need for refining current models of PA's mechanisms of action.

Use of virtual reality in improving poststroke neglect: Promising neuropsychological and neurophysiological findings from a case study

After experiencing a stroke in the right hemisphere, almost 50% of patients show unilateral spatial neglect (USN). Virtual Reality technologies offer impressive opportunities for both the rehabilitation and assessment of different cognitive deficits, including USN. A 57-year-old woman, affected by subarachnoid hemorrhage presented a severe left hemiparesis with severe cognitive and behavioral alterations, including temporal and spatial disorientation, reduction of attention and memory process, slowing ideation, USN, and depression of mood. She underwent two different rehabilitation trainings, including standard cognitive training (SCT) in addition to semi-immersive virtual training with her shadow (S-IVT_s) and SCT in addition to a Semi- immersive virtual training, without her shadow (S-IVT). The patient was assessed before and after each of the two different trainings, by using a specific psychometric battery and the event related potential, P300. Only at the end of the use of the S-IVT, we observed a significant improvement in the motor and cognitive function, with regard to USN. SCT in addition to S-IVT with Bts-Nirvana System may be a promising approach in improving attention process, spatial cognition, and mood in patients with post stroke USN, as also demonstrated by the electrophysiological parameters.

Induced sensorimotor cortex plasticity remediates chronic treatment-resistant visual neglect

Right brain injury causes visual neglect - lost awareness of left space. During prism adaptation therapy, patients adapt to a rightward optical shift by recalibrating right arm movements leftward. This can improve left neglect, but the benefit of a single session is transient (~1 day). Here we show that tonic disinhibition of left motor cortex during prism adaptation enhances consolidation, stabilizing both sensorimotor and cognitive prism after-effects. In three longitudinal patient case series, just 20 min of combined stimulation/adaptation caused persistent cognitive after-effects (neglect improvement) that lasted throughout follow-up (18–46 days). Moreover, adaptation without stimulation was ineffective. Thus stimulation reversed treatment resistance in chronic visual neglect. These findings challenge consensus that because the left hemisphere in neglect is pathologically over-excited it ought to be suppressed. Excitation of left sensorimotor circuits, during an adaptive cognitive state, can unmask latent plastic potential that durably improves resistant visual attention deficits after brain injury.

Paired-Pulse Parietal-Motor Stimulation Differentially Modulates Corticospinal Excitability across Hemispheres When Combined with Prism Adaptation

Rightward prism adaptation ameliorates neglect symptoms while leftward prism adaptation (LPA) induces neglect-like biases in healthy individuals. Similarly, inhibitory repetitive transcranial magnetic stimulation (rTMS) on the right posterior parietal cortex (PPC) induces neglect-like behavior, whereas on the left PPC it ameliorates neglect symptoms and normalizes hyperexcitability of left hemisphere parietal-motor (PPC-M1) connectivity. Based on this analogy we hypothesized that LPA increases PPC-M1 excitability in the left hemisphere and decreases it in the right one. In an attempt to shed some light on the mechanisms underlying LPA's effects on cognition, we investigated this hypothesis in healthy individuals measuring PPC-M1 excitability with dual-site paired-pulse TMS (ppTMS). We found a left hemisphere increase and a right hemisphere decrease in the amplitude of motor evoked potentials elicited by paired as well as single pulses on M1. While this could indicate that LPA biases interhemispheric connectivity, it contradicts previous evidence that M1-only MEPs are unchanged after LPA. A control experiment showed that input-output curves were not affected by LPA per se. We conclude that LPA combined with ppTMS on PPC-M1 differentially alters the excitability of the left and right M1.

Brain aerobic glycolysis and motor adaptation learning

Ten percent to 15% of glucose used by the brain is metabolized nonoxidatively despite adequate tissue oxygenation, a process termed aerobic glycolysis (AG). Because of the known role of glycolysis in biosynthesis, we tested whether learning-induced synaptic plasticity would lead to regionally appropriate, learning-dependent changes in AG. Functional MRI (fMRI) before, during, and after performance of a visual-motor adaptation task demonstrated that left Brodmann area 44 (BA44) played a key role in adaptation, with learning-related changes to activity during the task and altered resting-state, functional connectivity after the task. PET scans before and after task performance indicated a sustained increase in AG in left BA 44 accompanied by decreased oxygen consumption. Intersubject variability in behavioral adaptation rate correlated strongly with changes in AG in this region, as well as functional connectivity, which is consistent with a role for AG in synaptic plasticity.

Prismatic Adaptation Induces Plastic Changes onto Spatial and Temporal Domains in Near and Far Space

A large literature has documented interactions between space and time suggesting that the two experiential domains may share a common format in a generalized magnitude system (ATOM theory). To further explore this hypothesis, here we measured the extent to which time and space are sensitive to the same sensorimotor plasticity processes, as induced by classical prismatic adaptation procedures (PA). We also exanimated whether spatial-attention shifts on time and space processing, produced through PA, extend to stimuli presented beyond the immediate near space. Results indicated that PA affected both temporal and spatial representations not only in the near space (i.e., the region within which the adaptation occurred), but also in the far space. In addition, both rightward and leftward PA directions caused opposite and symmetrical modulations on time processing, whereas only leftward PA biased space processing rightward. We discuss these findings within the ATOM framework and models that account for PA effects on space and time processing. We propose that the differential and asymmetrical effects following PA may suggest that temporal and spatial representations are not perfectly aligned.

Beyond the Sensorimotor Plasticity: Cognitive Expansion of Prism Adaptation in Healthy Individuals

Sensorimotor plasticity allows us to maintain an efficient motor behavior in reaction to environmental changes. One of the classical models for the study of sensorimotor plasticity is prism adaptation. It consists of pointing to visual targets while wearing prismatic lenses that shift the visual field laterally. The conditions of the development of the plasticity and the sensorimotor after-effects have been extensively studied for more than a century. However, the interest taken in this phenomenon was considerably increased since the demonstration of neglect rehabilitation following prism adaptation by Rossetti et al. (1998). Mirror effects, i.e., simulation of neglect in healthy individuals, were observed for the first time by Colent et al. (2000). The present review focuses on the expansion of prism adaptation to cognitive functions in healthy individuals during the last 15 years. Cognitive after-effects have been shown in numerous tasks even in those that are not intrinsically spatial in nature. Altogether, these results suggest the existence of a strong link between low-level sensorimotor plasticity and high-level cognitive functions and raise important questions about the mechanisms involved in producing unexpected cognitive effects following prism adaptation. Implications for the functional mechanisms and neuroanatomical network of prism adaptation are discussed to explain how sensorimotor plasticity may affect cognitive processes.

Assessment and rehabilitation of neglect using virtual reality: a systematic review

After experiencing a stroke in the right hemisphere, almost 50% of patients showed Unilateral Spatial Neglect (USN). In recent decades, Virtual Reality (VR) has been used as an effective tool both for the assessment and rehabilitation of USN. Indeed, this advanced technology allows post-stroke patients to interact with ecological and engaging environments similar to real ones, but in a safe and controlled way. To provide an overview of the most recent VR applications for the assessment and rehabilitation of USN, a systematic review has been carried out. Since 2010, 13 studies have proposed and tested innovative VR tools for USN. After a wide description of the selected studies, we discuss the main features of these VR tools in order to provide crucial indications for future studies, neurorehabilitation interventions, and clinical practice.

Prisms for pain. Can visuo-motor rehabilitation strategies alleviate chronic pain?

BACKGROUND AND AIMS

Prism adaptation (PA) is a non-invasive procedure in which participants perform a visuo-motor pointing task while wearing prism goggles inducing a lateral displacement of the visual field and a mismatch between the seen and felt position of the pointing hand. PA is thought to induce a reorganization of sensorimotor coordination, and has been used successfully to rehabilitate neglect following right-hemisphere lesions. Because studies have shown that complex regional pain syndrome (CRPS) is associated with neglect-like symptoms, it was proposed that PA could be used to alleviate pain in these patients.

DATABASE

A search for peer-reviewed articles on neglect-like symptoms in CRPS and on the use of prisms in CRPS was conducted using the PubMed database.

RESULTS

There is still no agreement as to whether CRPS patients really present neglect symptoms and, if they do, what it is that they neglect. Furthermore, there is insufficient data to determine whether PA exerts an effect on CRPS symptoms. Finally, it remains unknown whether neglect can be observed in other types of lateralized pain, or whether PA could be useful for these patients.

CONCLUSION

By highlighting open issues, our review provides guidelines for future studies on the use of prisms in pain. The assessment of neglect in patients with CRPS as well as other types of lateralized chronic pain should be characterized using a combination of neuropsychological methods assessing the multiple aspects of neglect in a more refined manner. In addition, further studies should investigate the mechanisms through which PA may modulate pain.

Integrity of medial temporal structures may predict better improvement of spatial neglect with prism adaptation treatment

Prism adaptation treatment (PAT) is a promising rehabilitative method for functional recovery in persons with spatial neglect. Previous research suggests that PAT improves motor-intentional "aiming" deficits that frequently occur with frontal lesions. To test whether presence of frontal lesions predicted better improvement of spatial neglect after PAT, the current study evaluated neglect-specific improvement in functional activities (assessment with the Catherine Bergego Scale) over time in 21 right-brain-damaged stroke survivors with left-sided spatial neglect. The results demonstrated that neglect patients' functional activities improved after two weeks of PAT and continued improving for four weeks. Such functional improvement did not occur equally in all of the participants: Neglect patients with lesions involving the frontal cortex (n = 13) experienced significantly better functional improvement than did those without frontal lesions (n = 8). More importantly, voxel-based lesion-behavior mapping (VLBM) revealed that in comparison to the group of patients without frontal lesions, the frontal-lesioned neglect patients had intact regions in the medial temporal areas, the superior temporal areas, and the inferior longitudinal fasciculus. The medial cortical and subcortical areas in the temporal lobe were especially distinguished in the "frontal lesion" group. The findings suggest that the integrity of medial temporal structures may play an important role in supporting functional improvement after PAT.

Restoring abnormal aftereffects of prismatic adaptation through neuromodulation

Adaptation to optical prisms displacing the visual scene laterally is a widely investigated instance of visuo-motor plasticity, also because prism adaptation (PA) has been extensively used as a treatment for right-brain-damaged patients suffering from left spatial neglect. The lateral visual displacement brought about by prisms, as indexed by a pointing error in the direction of the displacement, is progressively corrected through repeated pointings: after prism removal, a shift in the direction opposite to the prism-induced deviation occurs in visual, proprioceptive, and visuo-proprioceptive straight-ahead tasks (aftereffects, AEs). The cerebellum and the posterior parietal cortex (PPC) are key components of the bilateral cerebral network subserving the AEs, and the reduction of the pointing error during prism exposure in PA. We report the experimental study of a patient with bilateral occipital and left cerebellar damage, who showed a preserved reduction of the pointing errors to rightward displacing prisms, but not the leftward AEs in the proprioceptive straight-ahead task; instead, visual-proprioceptive and visual AEs were preserved. Anodal transcranial Direct Current Stimulation (tDCS) over the left PPC restored the leftward proprioceptive AEs, and anodal tDCS over the left cerebellum abolished the rightward deviation. Conversely, stimulation over the right PPC or the right cerebellum was ineffective. These results provide novel evidence for neuromodulatory effects of tDCS on defective AEs, through the stimulation over dedicated cortical regions.

Modelling the differential effects of prisms on perception and action in neglect

Damage to the right parietal cortex often leads to a syndrome known as unilateral neglect in which the patient fails to attend or respond to stimuli in left space. Recent work attempting to rehabilitate the disorder has made use of rightward-shifting prisms that displace visual input further rightward. After a brief period of adaptation to prisms, many of the symptoms of neglect show improvements that can last for hours or longer, depending on the adaptation procedure. Recent work has shown, however, that differential effects of prisms can be observed on actions (which are typically improved) and perceptual biases (which often remain unchanged). Here, we present a computational model capable of explaining some basic symptoms of neglect (line bisection behaviour), the effects of prism adaptation in both healthy controls and neglect patients and the observed dissociation between action and perception following prisms. The results of our simulations support recent contentions that prisms primarily influence behaviours normally thought to be controlled by the dorsal stream.

Prism adaptation in the healthy brain: the shift in line bisection judgments is long lasting and fluctuates

Rightward prism adaptation has been shown to ameliorate visuospatial biases in right brain-damaged patients with neglect, and a single session of prism adaptation can lead to improvements that last up to several hours. Leftward prism adaptation in neurologically healthy individuals induces neglect-like biases in visuospatial tasks. The duration of these effects in healthy individuals, typically assumed to be ephemeral, has never been investigated. Here we assessed the time-course of the adaptation-induced modifications in a classical perceptual line bisection task that was repeatedly administered for approximately 40min after a single session of adaptation to either a leftward or rightward prismatic deviation. Consistent with previous reports, only adaptation to leftward-deviating prisms induced a visuospatial shift on perceptual line bisection judgments. The typical pattern of pseudoneglect was counteracted by a rightward shift in midline judgments, which became significant between 5 and 10 min after adaptation, fluctuated between being significant or not several times in the 40 min following adaptation, and was present as late as 35 min. In contrast, the sensorimotor aftereffect was present immediately after adaptation to both rightward and leftward deviating prisms, decayed initially then remained stable until 40 min. These results demonstrate that both the sensorimotor and visuospatial effects last for at least 35 min, but that the visuospatial shift needs time to fully develop and fluctuates. By showing that the effects of prism adaptation in the undamaged brain are not ephemeral, these findings reveal the presence of another, so-far neglected dimension in the domain of the cognitive effects induced by prism adaptation, namely time. The prolonged duration of the induced visuospatial shift, previously considered to be a feature of prism adaptation unique to brain-damaged subjects, also applies to the normal brain.