Visuomotor adaptation to optical prisms: a new cure for spatial neglect?

Neurobiology of Unilateral Spatial Neglect

Hemispatial neglect is a common and disabling consequence of stroke. Earlier studies aimed to identify a single area of the brain where damage caused neglect and sought a single disrupted process that could account for the symptoms. Recent studies have shifted toward identifying component processes and representations underlying spatial attention required for various tasks and identifying areas of the brain responsible for each component that together constitute the network of regions responsible for neglect. This review focuses on recent insights into the mechanisms of neglect, regions of neural dysfunction that cause disruption of particular components or forms of neglect, and potential means of ameliorating neglect. Converging evidence supporting these insights comes from new imaging modalities in acute stroke, functional imaging, transcranial magnetic stimulation, electrophysiological studies in humans, and single-cell recording studies in nonhuman primates.

Visual Scanning Training, Limb Activation Treatment, and Prism Adaptation for Rehabilitating Left Neglect: Who is the Winner?

WE COMPARED, FOR THE FIRST TIME, THE OVERALL AND DIFFERENTIAL EFFECTS OF THREE OF THE MOST WIDELY USED LEFT NEGLECT (LN) TREATMENTS: visual scanning training (VST), limb activation treatment (LAT), and prism adaptation (PA). Thirty-three LN patients were assigned in quasi-random order to the three groups (VST, LAT, or PA). Each patient received only one type of treatment. LN patients' performance on everyday life tasks was assessed four times (over a period of 6 weeks): A1 and A2 (i.e., the two pre-treatment assessments); A3 and A4 (i.e., the two post-treatment assessments). LN patients in each of the three treatment conditions were treated for the same number of sessions (i.e., 20). The results showed that improvements were present in the majority of the tests assessing the peripersonal space in everyday life activities. Our findings were independent of unspecific factors and lasted for at least 2 weeks following the end of the treatments. There were no interactions, however, between LN treatments and assessments. We suggest that all three treatments can be considered as valid rehabilitation interventions for LN and could be employed for ameliorating LN signs.

Motor extinction in distinct reference frames: a double dissociation

OBJECTIVE

Test the hypothesis that right hemisphere stroke can cause extinction of left hand movements or movements of either hand held in left space, when both are used simultaneously, possibly depending on lesion site.

METHODS

93 non-hemiplegic patients with acute right hemisphere stroke were tested for motor extinction by pressing a counter rapidly for one minute with the right hand, left hand, or both simultaneously with their hands held at their sides, or crossed over midline.

RESULTS

We identified two distinct types of motor extinction in separate patients; 20 patients extinguished left hand movements held in left or right space (left canonical body extinction); the most significantly associated voxel cluster of ischemic tissue was in the right temporal white matter. Seven patients extinguished either hand held in left space (left space extinction), and the most significantly associated voxel cluster of ischemic tissue was in right parietal white matter.

CONCLUSIONS

There was a double dissociation between left canonical body extinction and left space motor extinction. Left canonical body extinction seems to be associated with more dorsal (parietal) ischemia, and left canonical body extinction seems to be associated with more ventral (temporal) ischemia.

Mechanisms underlying embodiment, disembodiment and loss of embodiment

Bodily experience is a complex, mostly unconscious, process that requires the integration of multiple sensory inputs. This paper reviews the sensory systems involved in internal representations of the body--primarily the proprioceptive, motor, vestibular, and visual systems. Various neurological disorders are defined by aberrations in bodily experience--including the perceptual ablation or disembodiment of body parts, "filling in" of amputated body parts, or reduplication of body parts. These perceptual aberrations are discussed and their implications for the central and peripheral systems involved in updating and retrieving internal representations of the body are highlighted. Bodily perception and egocentric frames of reference can be experimentally manipulated through visual capture (e.g., using rubber limbs), functional adaptation and embodiment of tools and prostheses, and changes in afferent sensory feedback (e.g., through stimulation of muscle spindles). These perceptual illusions are described, and discussed for their implications for the mechanisms underlying bodily perception.

Négligence spatiale unilatérale : une conséquence dramatique mais souvent négligée des lésions de l’hémisphère droit

INTRODUCTION

Unilateral Spatial Neglect (USN) is a common consequence of right brain damage. In the most severe cases, behavioral signs of USN can last several years and compromise patients' autonomy and social rehabilitation. These clinical facts stress the need for reliable procedures of diagnosis and rehabilitation.

STATE OF THE ART

The last 3 decades have witnessed an explosion of studies on USN, which raises issues related to complex cognitive activities such as mental representation, spatial attention and consciousness. USN is probably a heterogeneous syndrome, but some of its underlying mechanisms might be understood as an association of disorders of spatial attention. A bias of automatic orienting towards right-sided objects seems typical of left USN. Afterwards, patients find it difficult to disengage their attention in order to explore the rest of the visual scene. Neglected objects are sometimes processed in an "implicit" way.

PERSPECTIVES

The development of behavioural paradigms and of neuroimaging techniques and their application to the study of USN has advanced our understanding of the functional mechanisms of attention and spatial awareness, as well as of their neural bases. A number of new procedures for rehabilitation have recently been proposed.

CONCLUSION

The present review describes the clinical presentation of USN, its anatomical basis and some of possible accounts of different aspects of neglect behavior. Results of computer simulations and of rehabilitation techniques are also presented with implications for the functioning of normal neurocognitive systems.

Rehabilitation of Unilateral Spatial Neglect: New Insights From Magnetic Resonance Perfusion Imaging

OBJECTIVE

To illustrate how magnetic resonance perfusion imaging has provided insights regarding rehabilitation of different forms of hemispatial neglect.

DATA SOURCES

Recent studies of different types of neglect and their neural substrates and of rehabilitation strategies that might be differentially effective for different types of neglect.

STUDY SELECTION

Author selected all articles on PubMed that were identified with the key words reference frame or perfusion-weighted imaging plus neglect plus rehabilitation and other relevant articles that were cited therein.

DATA EXTRACTION

An independent reviewer determined if the data presented provided evidence relevant to planning or developing rehabilitation for stroke patients with distinct forms of neglect.

DATA SYNTHESIS

Results from a number of studies converge on the hypothesis that hypoperfusion and/or infarct of right angular gyrus and intraparietal sulcus can cause viewer-centered neglect, whereas hypoperfusion and/or infarct of right superior temporal gyrus can lead to left stimulus-centered neglect. Distinct forms of rehabilitation might be differentially useful for distinct types of spatial neglect, even though an individual patient may have 2 or more types of neglect. Magnetic resonance perfusion imaging has also shown that fluctuations in neglect in the acute-subacute period after stroke are often due to changes in blood flow caused by changes in blood pressure.

CONCLUSIONS

Consideration of neglect type and status of cerebral blood flow can be useful in planning strategies to ameliorate each individual's deficits.

Eye movements and visuoverbal descriptions exhibit heterogeneous and dissociated patterns before and after prismatic adaptation in unilateral spatial neglect

This prospective study examined the effects of prismatic adaptation on visual exploration strategies in patients with left unilateral spatial neglect (USN). Photo-oculographic gaze recordings were obtained, as the subjects (28 brain-damaged; 15 control) performed a free visual exploration task before and after a session of prismatic adaptation. (i) Before prismatic adaptation, the pattern of visual exploration described two subgroups of patients (symmetrical exploration of hemispaces - similar to the control subjects, deficient exploration of left hemispace). Twelve of 20 patients failed to describe significant elements in the left part of the displayed image. Several visuoverbal patterns were observed, some dissociating visual exploration and verbal description. (ii) Immediately after prismatic adaptation, patients with asymmetrical visual exploration presented a significant increase in the number of point fixations and saccades in the left hemispace. Patients with symmetrical exploration presented the opposite pattern. Improved pattern of visual exploration contrasted with an absence of improved verbal description. Eye movements and visuoverbal descriptions exhibit heterogeneous and dissociated patterns before and after prismatic adaptation. This results demonstrate that prismatic adaptation has no effect in certain patients, suggesting that therapeutic indications and evaluation of prismatic test results should take into consideration the heterogeneous nature of USN.

Prism adaptation changes perceptual awareness for chimeric visual objects but not for chimeric faces in spatial neglect after right-hemisphere stroke

Prism adaptation can ameliorate some symptoms of left spatial neglect after right-hemisphere stroke. The mechanisms behind this remain unclear. Prism therapy may increase exploration towards the contralesional side, yet without improving perceptual awareness, as apparently for the left side of chimeric face stimuli (Ferber et al. 2003). However, other prism studies suggest that perceptual awareness might be improved (e.g., Maravita et al., 2003). We tested the impact of prism therapy on visual awareness for the left side of chimeric objects as well as chimeric faces, in three neglect patients. Prism therapy dramatically improved awareness for the identity of the left side of chimeric non-face objects, but had no effect on judging expressions for chimeric faces. The latter may thus be unique in showing no prism benefit.

Rebalancing parietal activation underlies resolution of hemispatial neglect after right frontal stroke

This study sought to identify changes in neural activation, revealed by functional magnetic resonance imaging (fMRI), associated with the recovery of left hemispatial neglect after a right frontal stroke. The investigators studied 11 subjects who had left neglect after strokes that included damage to the right frontal cortex (in many cases also involving the right parietal and/or temporal cortex) using traditional behavioral tests for hemispatial neglect and spatial attention tasks during fMRI in the acute and chronic stages of recovery. They found that patients showed abnormally increased left dorsal parietal activation and abnormally decreased right dorsal parietal activation in the acute stage, and that activation normalized (decreased on the left and increased on the right) when left neglect improved. Activation in the visual cortex was also acutely higher in the left than right ventral and dorsal occipital cortex, but became more balanced with recovery. Activation in the right superior temporal gyrus depended on the accuracy in reorienting to unexpected targets in the right or left visual field, and was influenced by the stage of recovery. The results were interpreted as providing additional support for a new model of the neuroanatomical basis of hemispatial neglect. This model leads to specific predictions regarding interventions that may be useful for reducing persistent hemispatial neglect after stroke. For example, suppressing hyperactivity in the left dorsal parietal cortex using transcranial magnetic stimulation may to help restore the balance of activation during spatial attention and improve directed attention to the left.

Prism adaptation and unilateral neglect: Review and analysis

Theory and data from normal prism adaptation are applied toward understanding the ameliorating effects of prism adaptation for left unilateral neglect patients. Neglect is proposed to be, at least in part, a dysfunction in selection of the region of space appropriate for the task at hand. Normally, a task-work space is strategically sized and positioned (calibrated) around the task-relevant objects. Patients show deficits in both strategic abilities: the task-work space is pathologically reduced in size and patients cannot strategically shift its position. Prism adaptation (spatial realignment) ameliorates dysfunctional positioning, but not sizing of the task-work space. Realignment shifts the egocentric coordinates of a sensory-motor reference frame, thereby bringing at least part of the neglected hemispace into the dysfunctional task-work space: prism adaptation substitutes for dysfunctional positioning, but not sizing of a task-work space. However, such amelioration of dysfunctional positioning may enable relearning of strategic processes (calibration), perhaps, even partially restoring the ability to appropriately size the task-space. Investigation of therapeutic prism adaptation requires methods that permit identification of both the calibration dysfunction and ameliorating realignment.