A comparison of prism adaptation with terminal versus concurrent exposure on sensorimotor changes and spatial neglect

The Effect of Cognitive Style on Individual Differences in Prismatic Adaptation: A Pilot Study

Prism adaptation (PA) is a well-known and widely used technique for rehabilitating unilateral spatial neglect and studying sensory-motor plasticity. However, there is conflicting evidence in the literature regarding its effectiveness which may arise from differences in the type of prisms used, clinical characteristics of the patients, and the procedure used in training. Individual differences may play a role in PA effectiveness in rehabilitating neglect, affecting both its development and its effects. Field-dependent/independent cognitive style is a pervasive characteristic of individual functioning, affecting how environmental information is processed. Here, we tested the hypothesis that cognitive style plays a role in PA efficacy by submitting to a protocol of prism adaptation to 38 health participants, who were classified as field-dependent (FD, N = 19) or field-independent (FI, N = 19), by using the Embedded Figure Test. Results show that during the exposure phase, FI individuals needed a lesser number of pointing movements to reduce the deviation error than FD individuals. However, there are no differences in the extinction of sensory-motor and cognitive after-effects. These results suggest that prismatic adaptation is affected by individuals' cognitive style since FI individuals will need fewer trials to reach adaptation and this could explain why using this rehabilitation technique with a unique, standard protocol is not always effective.

Prism adaptation in patients with unilateral lesion of the parietal or cerebellar cortex: A pilot study on two single cases using a concurrent exposure procedure

Neuroimaging studies showed that prism adaptation (PA), a widely used tool for the rehabilitation of neglect, involves a wide network of brain regions including the parietal cortex and the cerebellum. In particular, the parietal cortex has been suggested to mediate the initial stage of PA through conscious compensatory mechanisms as a reaction to the deviation induced by PA. The cerebellum, on the other side, intervenes in sensory errors prediction to update internal models in later stages. It has been suggested that two mechanisms may underlie PA effects: recalibration, a strategic cognitive process occurring in the initial stages of PA, and realignment, a fully automatic reorganization of spatial maps emerging later and more slowly in time. The parietal lobe has been proposed to be involved mainly in the recalibration whereas the realignment would be carried over by the cerebellum. Previous studies have investigated the effects of a lesion involving either the cerebellum or the parietal lobe in PA taking into account both realignment and recalibration processes. Conversely, no studies have compared the performance of a patient with a cerebellar lesion to that of a patient with a parietal lesion. In the present study, we used a recently developed technique for digital PA to test differences in visuomotor learning after a single session of PA in a patient with parietal and a patient with cerebellar lesions, respectively. The PA procedure, in this case, includes a digital pointing task based on a concurrent exposure technique, which allows patients to fully see their arm during the pointing task. This procedure has been shown to be as effective as the terminal exposure condition in neglect rehabilitation albeit different processes take place during concurrent exposure condition compared to the most used terminal exposure (allowing to see only the final part of the movement). Patients' performances were compared to that of a control group. A single session of PA was administered to 1) a patient (BC) with left parieto-occipital lesion involving SPL and IPL, 2) a patient (TGM) with a stroke in the territory sub-served by the SCA in the cerebellum, and 3) 14 healthy controls (HC). The task included three conditions: before wearing prismatic goggles (pre-exposure), while wearing prisms (exposure) and after removing the goggles (post-exposure). Mean deviations were calculated for the following phases: pre-exposure, early-exposure, late-exposure, post-exposure. The presence of after-effect was calculated as the difference between pre-exposure and post-exposure conditions. For each of these conditions, patients' performance was compared to that of the control group by using a modified Crawford t-test. We found that the patient with the parietal lesion had a significantly different performance in the late-exposure and in the post-exposure compared to both HC and the patient with the cerebellar lesion. Conversely, no differences were observed between TGM and HC across all the conditions. Our results show an increase in the magnitude of the adaptation during the late stage of PA in the patient with the parietal lesion whereas no differences in the performance between the cerebellar patient and the controls were found. These results confirm previous studies suggesting that the parietal cortex is an important node of a wider network involved in PA effect. Furthermore, results in the cerebellar patient suggest that visuomotor learning is not affected by lesions of the SCA territory when a concurrent exposure is used as, in such case, it less relies on sensory errors prediction to update internal models. Results are discussed considering the novelty of the applied PA technique.

Virtual reality-based sensorimotor adaptation shapes subsequent spontaneous and naturalistic stimulus-driven brain activity

Our everyday life summons numerous novel sensorimotor experiences, to which our brain needs to adapt in order to function properly. However, tracking plasticity of naturalistic behavior and associated brain modulations is challenging. Here, we tackled this question implementing a prism adaptation-like training in virtual reality (VRPA) in combination with functional neuroimaging. Three groups of healthy participants (N = 45) underwent VRPA (with a shift either to the left/right side, or with no shift), and performed functional magnetic resonance imaging (fMRI) sessions before and after training. To capture modulations in free-flowing, task-free brain activity, the fMRI sessions included resting-state and free-viewing of naturalistic videos. We found significant decreases in spontaneous functional connectivity between attentional and default mode (DMN)/fronto-parietal networks, only for the adaptation groups, more pronouncedly in the hemisphere contralateral to the induced shift. In addition, VRPA was found to bias visual responses to naturalistic videos: Following rightward adaptation, we found upregulation of visual response in an area in the parieto-occipital sulcus (POS) only in the right hemisphere. Notably, the extent of POS upregulation correlated with the size of the VRPA-induced after-effect measured in behavioral tests. This study demonstrates that a brief VRPA exposure can change large-scale cortical connectivity and correspondingly bias visual responses to naturalistic sensory inputs.

Prism Adaptation and Optokinetic Stimulation Comparison in the Rehabilitation of Unilateral Spatial Neglect

Prism adaptation (PA) is one of the most effective treatments for the rehabilitation of unilateral spatial neglect. Optokinetic stimulation (OKS) has also been demonstrated to be effective in ameliorating symptoms of neglect. The aim of this study is to compare the effectiveness of these two methods in a group of neglect patients using a crossover design. A group of 13 post-acute brain-damaged patients with unilateral spatial neglect, who had never been rehabilitated, were treated using PA and OKS. Each treatment was applied for 10 sessions, twice a day, to all patients with both treatments in crossed order (i.e., PA followed by OKS or vice versa). Neuropsychological assessments were performed: before the first (T1), at the end of the first/beginning of the second (T2) and at the end of the second training sessions (T3), and two weeks after the end of treatment (T4). Both procedures produced a significant improvement in clinical tests at T2, independent of the type of training. The results suggest that either PA or OKS induces a significant amelioration of neglect in right brain-damaged patients, mainly in the first block of treatment. Since no differences between treatments were found, they could be applied in clinical practice, according to the requirements of the individual patient.

Neural Mechanisms of Prism Adaptation in Healthy Adults and Individuals with Spatial Neglect after Unilateral Stroke: A Review of fMRI Studies

Functional disability due to spatial neglect hinders recovery in up to 30% of stroke survivors. Prism adaptation treatment (PAT) may alleviate the disabling consequences of spatial neglect, but we do not yet know why some individuals show much better outcomes following PAT than others. The goal of this scoping review and meta-analysis was to investigate the neural mechanisms underlying prism adaptation (PA). We conducted both quantitative and qualitative analyses across fMRI studies investigating brain activity before, during, and after PA, in healthy individuals and patients with right or left brain damage (RBD or LBD) due to stroke. In healthy adults, PA was linked with activity in posterior parietal and cerebellar clusters, reduced bilateral parieto-frontal connectivity, and increased fronto-limbic and sensorimotor network connectivity. In contrast, RBD individuals with spatial neglect relied on different circuits, including an activity cluster in the intact left occipital cortex. This finding is consistent with a shift in hemispheric dominance in spatial processing to the left hemisphere. However, more studies are needed to clarify the contribution of lesion location and load on the circuits involved in PA after unilateral brain damage. Future studies are also needed to clarify the relationship of decreasing resting state functional connectivity (rsFC) to visuomotor function.

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.

Combined virtual reality and haptic robotics induce space and movement invariant sensorimotor adaptation

Prism adaptation is a method for studying visuomotor plasticity in healthy individuals, as well as for rehabilitating patients suffering spatial neglect. We developed a new set-up based on virtual-reality (VR) and haptic-robotics allowing us to induce sensorimotor adaptation and to reproduce the effect of prism adaptation in a more ecologically valid, yet experimentally controlled context. Participants were exposed to an immersive VR environment while controlling a virtual hand via a robotic-haptic device to reach virtual objects. During training, a rotational shift was induced between the position of the participant's real hand and that of the virtual hand in order to trigger sensorimotor recalibration. The use of VR and haptic-robotics allowed us to simulate and test multiple components of sensorimotor adaptation: training either peripersonal or extrapersonal space and testing generalization for the non-trained sector of space, and using active versus robot-guided reaching movements. Results from 60 neurologically intact participants show that participants exposed to the virtual shift were able to quickly adapt their reaching movements to aim correctly at the target objects. When the shift was removed, participants showed a systematic deviation of their movements during open-loop tasks in the direction opposite to that of the shift, which generalized to un-trained portions of space and occurred also when their movements were robotically-guided during the adaptation. Interestingly, follow-up questionnaires revealed that when the adaptation training was robotically-guided, participants were largely unaware of the mismatch between their hand and the virtual hand's position. The stability of the aftereffects, despite the changing experimental parameters, suggests that the induced sensory-motor adaptation does not rely on low-level processing of sensory stimuli during the training, but taps into high-level representations of space. Importantly, the flexibility of the trained space and the option of robotically-guided movements open novel possibilities of fine-tuning the training to patients' level of spatial and motor impairment, thus possibly resulting in a better outcome.

Visual Feedback Modulates Aftereffects and Electrophysiological Markers of Prism Adaptation

Prism adaptation (PA) is both a model for visuomotor learning and a promising treatment for visuospatial neglect after stroke. The task involves reaching for targets while prism glasses horizontally displace the visual field. Adaptation is hypothesized to occur through two processes: strategic recalibration, a rapid self-correction of pointing errors; and spatial realignment, a more gradual adjustment of visuomotor reference frames that produce prism aftereffects (i.e., reaching errors upon glasses removal in the direction opposite to the visual shift). While aftereffects can ameliorate neglect, not all patients respond to PA, and the neural mechanisms underlying successful adaptation are unclear. We investigated the feedback-related negativity (FRN) and the P300 event-related potential (ERP) components as candidate markers of strategic recalibration and spatial realignment, respectively. Healthy young adults wore prism glasses and performed memory-guided reaching toward vertical-line targets. ERPs were recorded in response to three different between-subject error feedback conditions at screen-touch: view of hand and target (Experiment 1), view of hand only (Experiment 2), or view of lines to mark target and hand position (view of hand occluded; Experiment 3). Conditions involving a direct view of the hand-produced stronger aftereffects than indirect hand feedback, and also evoked a P300 that decreased in amplitude as adaptation proceeded. Conversely, the FRN was only seen in conditions involving target feedback, even when aftereffects were smaller. Since conditions producing stronger aftereffects were associated with a phase-sensitive P300, this component may index a “context-updating” realignment process critical for strong aftereffects, whereas the FRN may reflect an error monitoring process related to strategic recalibration.

The Brentano Illusion Test (BRIT): An implicit task of perceptual processing for the assessment of visual field defects in neglect patients

In brain damaged patients with unilateral spatial neglect (USN), the differential diagnosis between the presence and absence of a unilateral visual half-field deficit (VHFD) is hampered by the similarity of their phenomenology. The absence of stimuli detection in the contralateral visual field, indeed, can be due to the co-occurrence of USN and VHFD or the sole presence of the USN. The disentangling of the two conditions is required to devise more specific rehabilitation programmes. Daini et al. [2002. Exploring the syndrome of spatial unilateral neglect through an illusion of length. Experimental Brain Research, 144(2), 224-237.] reported a difference in performance for the two conditions when the tasks required the bisection of Brentano illusory stimuli. Only when USN and VHFD co-occurred, the leftward illusory effect was disrupted. Based on previous findings, in this cross-sectional study, we developed the Brentano Illusion Test (BRIT), a clinical tool that helps the identification of VHFD in USN patients. The BRIT is a simple behavioural test of line bisection aimed at verifying the presence or absence of implicit processing in USN and thus helping the diagnosis of VHFD in USN patients; it also provides normative data for the line bisection task and the length effect.