A left attentional bias in chronic neglect: a case study using temporal order judgments

Attention upturned: Bias toward and away from the affected side of the body and near space in a case of complex regional pain syndrome

People with Complex Regional Pain Syndrome (CRPS) following limb injury can show neuropsychological symptoms in the absence of observable brain pathologies. These can include sensory changes, distorted body representation, and inattention to their affected limb and its surrounding space, resembling post-stroke hemispatial neglect. The precise nature and mechanisms of these neuropsychological symptoms are unclear, however insights could be gained by testing for dissociations and associations that have been observed in stroke patients. Drawing from clinical and experimental methods for investigating spatial attention bias and related symptoms in stroke patients, we conducted a detailed investigation of neuropsychological symptoms in a woman with CRPS of her left arm who initially presented to us with pronounced inattention to her affected side. The patient showed visual and tactile neglect and extinction on her affected side on confrontation tests, but no attention deficits on "bedside" tests of neglect. On sensitive computer-based measures, attention biases were found in the patient's body and near space (in Temporal Order Judgements), but not far or imagined space (on the Greyscales task and Mental Number Line Bisection). Unique to the current literature, the patient showed a reversal in her Temporal Order Judgement bias across time, from inattention (first and second session) to hyperattention (third session) to her affected side. In contrast, pain and self-reported body representation distortion were similar across the three sessions. The patient had reduced central and peripheral visual acuity, however these deficits were near symmetrical and therefore could not explain her performance on the visual attention tasks. Given that spatial attention bias has been linked to imbalance in relative activation of the two cerebral hemispheres, we administered a Global-Local processing task to test for hemispheric asymmetry. This revealed no difference in global compared to local interference refuting any hemispheric imbalance. Instead, the patient showed impaired performance (compared to controls) on incongruent trials regardless of trial type, consistent with executive impairment. We conclude that spatial attention bias in CRPS can generalize across different sensory modalities and extend beyond the affected limb to the external space around it, independent of any low-level sensory disturbances. This bias is not necessarily directed away from the affected side or stable over time. People with CRPS can also demonstrate more generalized neuropsychological changes in sensory and executive functions. Our observations refute several existing theories about the mechanisms of attention bias in CRPS, and their relationship to pain, and have potential implications for treatment.

Neuropsychological Changes in Complex Regional Pain Syndrome (CRPS)

Complex Regional Pain Syndrome (CRPS) is a poorly understood chronic pain condition of multifactorial origin. CRPS involves sensory, motor, and autonomic symptoms primarily affecting one extremity. Patients can also present with neuropsychological changes such as reduced attention to the CRPS-affected extremity, reminiscent of hemispatial neglect, yet in the absence of any brain lesions. However, this "neglect-like" framework is not sufficient to characterise the range of higher cognitive functions that can be altered in CRPS. This comprehensive literature review synthesises evidence of neuropsychological changes in CRPS in the context of potential central mechanisms of the disorder. The affected neuropsychological functions constitute three distinct but not independent groups: distorted body representation, deficits in lateralised spatial cognition, and impairment of non-spatially-lateralised higher cognitive functions. We suggest that many of these symptoms appear to be consistent with a broader disruption to parietal function beyond merely what could be considered "neglect-like." Moreover, the extent of neuropsychological symptoms might be related to the clinical signs of CRPS, and rehabilitation methods that target the neuropsychological changes can improve clinical outcomes in CRPS and other chronic pain conditions. Based on the limitations and gaps in the reviewed literature, we provide several suggestions to improve further research on neuropsychological changes in chronic pain.

Biased temporal order judgments in chronic neglect influenced by trunk position

Numerous studies have reported that temporal order perception is biased in neurological patients with extinction and neglect. These individuals tend to perceive two objectively simultaneous stimuli as occurring asynchronously, with the ipsilesional item being perceived as appearing prior to the contralesional item. Likewise, they report that two stimuli occurred simultaneously in situations where the contralesional item is presented substantially prior to the ipsilesional item. Therefore, they exhibit a biased point of subjective simultaneity (PSS). Here we demonstrate that the magnitude of this effect is modulated by the relative position of the stimuli with respect to the patient's trunk. This effect was only observed in patients who still exhibited neglect symptoms, and neither the pathological bias nor substantial modulation were observed in individuals who had recovered from neglect, those who never had neglect or neurologically healthy controls. Crucially, our design kept the retinal and head-centered coordinates of these stimuli constant, providing a pure measure for the influence of egocentric trunk position. This finding emphasizes the interaction of egocentric spatial position on the temporal symptoms observed in these individuals.

The time course of alerting effect over orienting in the attention network test

In the present experiment we used a version of the attention network test (ANT) similar to that of Callejas et al. (Exp Brain Res 167:27-37, 2005) to assess the Posner's attention networks (alerting, orienting and conflict), and their interactions. We observed shorter reaction times with alerting tone than with no alerting tone trials (the alerting effect); with cued than with uncued trials (the orienting effect); and with congruent than with incongruent trials (the conflict effect). These results replicate previous findings with the ANT. We also manipulated cue-target interval at five stimulus onset asynchrony (SOA) values (100, 300, 500, 800, and 1,200 ms) to trace the alerting network influence over the orienting network. The SOA manipulation showed that cuing effects peaked at 300 ms SOA irrespective of whether an alerting tone was present or not, and the alerting tone improved the cuing effect equally for 100-500 SOAs, but it did not at the longest 800-1,200 ms SOAs. These results suggest that alerting improves rather than accelerates orienting effects, a result that agrees with data from neuropsychological rehabilitation of parietal patients with spatial bias.

Comparing temporal order judgments and choice reaction time tasks as indices of exogenous spatial cuing

Attentional disorders are common in individuals with neurological or psychiatric conditions and impact on recovery and outcome. Thus, it is critical to develop theory-based measures of attentional function to understand potential mechanisms underlying the disorder and to evaluate the effect of intervention. The present study compared two alternative methods to measure the effects of attentional cuing that could be used in populations of individuals who may not be able to make manual responses normally or may show overall slowing in responses. Spatial attention was measured with speeded and unspeeded methods using either manual or voice responses in two standard attention paradigms: the cued target discrimination reaction time (RT) paradigm and the unspeeded temporal order judgment (TOJ) task. The comparison of speeded and unspeeded tasks specifically addresses the concern about interpreting RT differences between cued and uncued trials (taken as a proxy for attention) in the context of drastically different baseline RTs. We found significant cuing effects for both tasks (speeded RT and untimed TOJ) and both response types (vocal and manual) giving clinicians and researchers alternative methods with which to measure the effects of attention in different populations who may not be able to perform the standard speeded RT task.