The Lighthouse Strategy: Improving the Functional Status of Patients with Unilateral Neglect After Stroke and Brain Injury Using a Visual Imagery Intervention

Virtual Reality and Eye-Tracking Assessment, and Treatment of Unilateral Spatial Neglect: Systematic Review and Future Prospects

Unilateral spatial neglect (USN) is a disorder characterized by the failure to report, respond to, or orient toward the contralateral side of space to a brain lesion. Current assessment methods often fail to discover milder forms, cannot differentiate between unilateral spatial neglect subtypes and lack ecological validity. There is also a need for treatment methods that target subtypes. Immersive virtual reality (VR) systems in combination with eye-tracking (ET) have the potential to overcome these shortcomings, by providing more naturalistic environments and tasks, with sensitive and detailed measures. This systematic review examines the state of the art of research on these technologies as applied in the assessment and treatment of USN. As we found no studies that combined immersive VR and ET, we reviewed these approaches individually. The review of VR included seven articles, the ET review twelve. The reviews revealed promising results. (1) All included studies found significant group-level differences for several USN measures. In addition, several studies found asymmetric behavior in VR and ET tasks for patients who did not show signs of USN in conventional tests. Particularly promising features were multitasking in complex VR environments and detailed eye-movement analysis. (2) No VR and only a few ET studies attempted to differentiate USN subtypes, although the technologies appeared appropriate. One ET study grouped USN participants using individual heatmaps, and another differentiated between subtypes on drawing tasks. Regarding (3) ecological validity, although no studies tested the prognostic validity of their assessment methods, VR and ET studies utilized naturalistic tasks and stimuli reflecting everyday situations. Technological characteristics, such as the field of view and refresh rate of the head-mounted displays, could be improved, though, to improve ecological validity. We found (4) no studies that utilized VR or ET technologies for USN treatment up until the search date of the 26th of February 2020. In conclusion, VR-ET-based systems show great potential for USN assessment. VR-ET holds great promise for treatment, for example, by monitoring behavior and adapting and tailoring to the individual person's needs and abilities. Future research should consider developing methods for individual subtypes and differential diagnostics to inform individual treatment programs.

Spatial exploration strategy training for spatial neglect: A pilot study

Spatial neglect is a syndrome due to impaired neural networks critical for spatial attention and related cognitive and motor functions. Affected individuals also have impaired self-awareness of their own neglect symptoms. The present randomized controlled study was the first proof-of-concept pilot examining the multi-context treatment approach using a protocol of spatial exploration strategy training in one brief session (20-30 minutes). The therapist provided supportive feedback and semi-structured guidance to promote strategy learning and self-discovery of omission errors. 40 patients with left-sided neglect after right brain stroke were included. The results showed that the treatment reduced lateralized bias toward the ipsilesional side of space but did not improve overall detection performance. Impaired general self-awareness of daily-life spatial difficulties was found independent of treatment outcome. This implies that judgment regarding responsiveness to treatment should not be made based on an awareness interview or the severity of neglect symptoms. Lastly, the treatment showed the potential of improving online contextual self-awareness of spatial abilities. A collaborative and interactive approach that focuses on helping the patient self-discover, monitor and self-manage their errors, appears to have a potential for decreasing neglect symptoms. Future studies are required to examine additional aspects of the multi-context treatment approach.

[Treatment of neglect: new therapy approaches]

Neglect is a supramodal, clinically relevant disorder, which occurs in the different sensory modalities as well as in the mental representation. The different manifestations of neglect show interindividual and intraindividual variation. Different spatial and attention-related interventions lead to varying degrees of improvement in neglect symptoms but are often not stable in time or transferable to activities of daily living. Representational deficits or body-related aspects to modify personal neglect are rarely a priority in current therapies. Because of the multisensory and motor deficits from our point of view the future of neglect rehabilitation lies in a combined therapy of visual exploration, motor imagery with intensive motor therapy of motor sensory deficits and probably best reinforced by continued neck muscle vibration or allocation of attention to the neglected side.

Effectiveness of Interventions to Address Visual and Visual–Perceptual Impairments to Improve Occupational Performance in Adults With Traumatic Brain Injury: A Systematic Review

OBJECTIVE. Visual and visual–perceptual impairments occur frequently with traumatic brain injury (TBI) and influence occupational performance. This systematic review examined the effectiveness of interventions within the scope of occupational therapy to improve occupational performance for adults with visual and visual–perceptual impairments as a result of TBI.

METHOD. Medline, PsycINFO, CINAHL, OTseeker, and the Cochrane Database of Systematic Reviews were searched, and 66 full text articles were reviewed. Sixteen articles were included in the review.

RESULTS. Strong evidence supports the use of scanning, limited evidence supports the use of adaptive strategies, and mixed evidence supports the use of cognitive interventions to improve occupational performance for adults with TBI. Evidence related to vision therapy varies on the basis of the specific intervention implemented.

CONCLUSION. Although the strength of the research varied, implications are discussed for practice, education, and research.

Implications of CI therapy for visual deficit training

We address here the question of whether the techniques of Constraint Induced (CI) therapy, a family of treatments that has been employed in the rehabilitation of movement and language after brain damage might apply to the rehabilitation of such visual deficits as unilateral spatial neglect and visual field deficits. CI therapy has been used successfully for the upper and lower extremities after chronic stroke, cerebral palsy (CP), multiple sclerosis (MS), other central nervous system (CNS) degenerative conditions, resection of motor areas of the brain, focal hand dystonia, and aphasia. Treatments making use of similar methods have proven efficacious for amblyopia. The CI therapy approach consists of four major components: intensive training, training by shaping, a "transfer package" to facilitate the transfer of gains from the treatment setting to everyday activities, and strong discouragement of compensatory strategies. CI therapy is said to be effective because it overcomes learned nonuse, a learned inhibition of movement that follows injury to the CNS. In addition, CI therapy produces substantial increases in the gray matter of motor areas on both sides of the brain. We propose here that these mechanisms are examples of more general processes: learned nonuse being considered parallel to sensory nonuse following damage to sensory areas of the brain, with both having in common diminished neural connections (DNCs) in the nervous system as an underlying mechanism. CI therapy would achieve its therapeutic effect by strengthening the DNCs. Use-dependent cortical reorganization is considered to be an example of the more general neuroplastic mechanism of brain structure repurposing. If the mechanisms involved in these broader categories are involved in each of the deficits being considered, then it may be the principles underlying efficacious treatment in each case may be similar. The lessons learned during CI therapy research might then prove useful for the treatment of visual deficits.

Prism adaptation for spatial neglect after stroke: translational practice gaps

Spatial neglect increases hospital morbidity and costs in around 50% of the 795,000 people per year in the USA who survive stroke, and an urgent need exists to reduce the care burden of this condition. However, effective acute treatment for neglect has been elusive. In this article, we review 48 studies of a treatment of intense neuroscience interest: prism adaptation training. Due to its effects on spatial motor 'aiming', prism adaptation training may act to reduce neglect-related disability. However, research failed, first, to suggest methods to identify the 50-75% of patients who respond to treatment; second, to measure short-term and long-term outcomes in both mechanism-specific and functionally valid ways; third, to confirm treatment utility during the critical first 8 weeks poststroke; and last, to base treatment protocols on systematic dose-response data. Thus, considerable investment in prism adaptation research has not yet touched the fundamentals needed for clinical implementation. We suggest improved standards and better spatial motor models for further research, so as to clarify when, how and for whom prism adaptation should be applied.

Comparison of virtual wheelchair driving performance of people with traumatic brain injury using an isometric and a conventional joystick

Cooper RA. Comparison of virtual wheelchair driving performance of people with traumatic brain injury using an isometric and a conventional joystick.

OBJECTIVE

To compare wheelchair driving performance in a driving simulator using a conventional joystick and an isometric joystick.

DESIGN

Randomized, cohort study.

SETTING

A research facility based in a hospital or in an independent living center.

PARTICIPANTS

Participants (N=20; 12 men, 8 women; mean age ± SD, 30.62±10.91 y) who were at least 1 year post-TBI.

INTERVENTIONS

Driving performance using an isometric joystick compared with a conventional movement joystick.

MAIN OUTCOME MEASURES

Average trial completion time, and trajectory-specific measures measured orthogonal to the center of driving tasks: root mean squared error, movement offset, movement error, and number of significant changes in heading.

RESULTS

After statistically controlling for driving speed, participants were able to complete the driving tasks faster with an isometric joystick than while using a conventional movement joystick. Compared with the conventional joystick, an isometric joystick used for driving forward demonstrated fewer driving errors. During reverse driving the conventional joystick performed better.

CONCLUSIONS

The customizable isometric joystick seems to be a promising interface for driving a powered wheelchair for individuals with TBI.

Visuomotorische Imaginationstherapie in der Neglektrehabilitation – Grundlagen, Vorgehen und Falldarstellungen

Mentales Training findet vermehrt in der neurologischen Rehabilitation Einsatz. Neglekpatienten mit repräsentationalen Störungen, u. a. des eigenen Körpers, könnten von einer visuomotorischen Imaginationstherapie profitieren. Das therapeutische Vorgehen für die praktische Anwendung in der Neglektrehabilitation wird vorgestellt bezüglich (1) Patientenauswahl, (2) Testdiagnostik, (3) Messung der Imaginationsfähigkeit, (4) Psychoedukation, (5) Setting, (6) Therapiemanual, (7) Frequenz und Komplexitätsgrade, (8) Therapieprotokoll, (9) Elektromyographie sowie (10) Eigentraining. Zwei Fallbeispiele verdeutlichen wie eine visuomotorische Imaginationstherapie selbst im chronischen Krankheitsstadium zu Funktionsverbesserungen führen und bei subakutem personalem Neglekt die Körperwahrnehmung beeinflusst werden kann.

Rehabilitation approaches to hemineglect

BACKGROUND

Hemineglect is a difficult neurologic condition to rehabilitate. It arises predominantly from right brain injury, and manifests heterogeneously in clinical deficits such as poor visual exploration to the left, inaccurate assessment of the midpoint of a line, left limb hypokinesis, and anosognosia. Most of the cognitive dysfunction produced by hemineglect is because of an asymmetric distribution of attention, either with respect to extrapersonal space or to an object being viewed. Many treatments draw on hemineglect theory to attempt to mediate the basic asymmetry of attention.

REVIEW SUMMARY

Treatment approaches can be divided into 2 main categories. Extrinsic or "top-down" approaches require active participation of the patient under the guidance of a therapist. The most common approach of this type is visual scanning therapy in which the patient is continually instructed to move the gaze leftward into the neglected space. Intrinsic or "bottom-up" approaches manipulate stimulus characteristics, sensory input, or the brain directly in an attempt to alter the interhemispheral attentional imbalance. Examples of this approach include vestibular stimulation of the left side, sensory activation of the left limb, and transcranial magnetic stimulation of the overactive left hemisphere. Combined approaches such as prism adaptation have also shown good results.

CONCLUSIONS

Hemineglect is a complicated disorder that poses challenges to treatment. A paucity of clinical trial evidence limits our ability to extrapolate experimental mediation of hemineglect to globally improved functioning. Nonetheless, many treatment approaches appear promising. Underlying neuroscience may help guide future treatment approaches.

Visual Deficit Interventions in Adult Stroke and Brain Injury

Visual deficits after cerebral injury are common. The variability in the types of injury sustained as well as their impact on function in the environment have produced multiple approaches at corrective intervention. To assess the effectiveness of these vision interventions, an extensive literature search was completed. The analysis of this review revealed some success with visual neglect disorders, but not enough evidence to comment definitively on interventions for hemianopsia, quadrantonopsia, diplopia, or convergence insufficiency. A lack of follow-up also limited efforts to assess the durability of documented gains. Additional research is necessary to clarify, quantify, and measure treatment outcomes for acquired visual dysfunction as well as to link laboratory testing to improvement in actual functioning for individuals in their environment.

Motor imagery in physical therapist practice

Motor imagery is the mental representation of movement without any body movement. Abundant evidence on the positive effects of motor imagery practice on motor performance and learning in athletes, people who are healthy, and people with neurological conditions (eg, stroke, spinal cord injury, Parkinson disease) has been published. The purpose of this update is to synthesize the relevant literature about motor imagery in order to facilitate its integration into physical therapist practice. This update also will discuss visual and kinesthetic motor imagery, factors that modify motor imagery practice, the design of motor imagery protocols, and potential applications of motor imagery.

The adjunctive role of imagery on the functional rehabilitation of a grade II ankle sprain

The purpose of the present study was to examine the effectiveness of imagery on muscular endurance, dynamic balance, and functional stability in athletes who sustained a grade II ankle sprain. The sample consisted of 20 active athletes (aged from 18 to 30 years) with a grade II ankle sprain, as confirmed by ultrasound testing. The participants were randomly divided into two groups of 10 participants each; one experimental and one control group. The experimental group received 12 individual sessions of imagery rehearsal in addition to a normal course of physical therapy, while the control group followed only the physical therapy treatment. Results revealed significant differences only in the variable of muscular endurance. This study partly supports the contribution of imagery to the functional rehabilitation of grade II ankle sprain. Further research should be conducted to examine the effect of imagery on the functional rehabilitation of sport injuries using other tests of functional rehabilitation along with larger sample sizes.