Optokinetic stimulation modulates neglect for the number space: evidence from mental number interval bisection

Combined optokinetic stimulation and cueing-assisted reading therapy to treat hemispatial neglect: A randomized controlled crossover trial

BACKGROUND

Hemispatial neglect is a disabling cognitive disorder following stroke and effective therapies are required.

OBJECTIVES

To evaluate the effects of combined optokinetic stimulation (OKS) and cueing-assisted reading therapy (READ) on the remission of hemispatial neglect following stroke.

METHODS

Randomized, controlled, two-period, crossover trial conducted at a German neurorehabilitation center. Twenty participants with left neglect following right hemispheric stroke (mean age 66 years (SD 11), mean time since stroke 50 days (SD 33)) finished the trial (12 received OKSREAD first, 8 CONTROL first). The intervention consisted of 15 daily sessions of OKS (20 min) and text reading assisted by a therapist providing cues (20 min). The control treatment was a same-number, same-length neuropsychological treatment not targeting visuospatial attention. Primary outcomes were the change in performance of a customized neuropsychological test battery for neglect (0% worst - 100% best) and a test of neglect-related functional disability (Catherine Bergego Scale, 0 no impairment - 30 severest impairment), assessed before and after each treatment period. Secondary outcomes were performance in the 6 single tests composing the battery (e.g., omissions in text reading, center of cancellation in the Bells test, spatial bias of fixations when freely viewing photographs) and a clinical test of anosognosia.

RESULTS

Overall performance in the neglect test battery improved slightly more after OKSREAD than after CONTROL (d=6%; p=0.002). The remission of neglect-related functional disability did not differ between treatments (d=-2; p=0.291). Ipsilesional fixation bias during free viewing was the only secondary outcome that was improved by OKSREAD as compared to CONTROL (d= -2.8°; p=0.005).

CONCLUSION

At the applied intensity, the combined OKSREAD intervention slightly attenuated the ipsilesional attention bias in persons with neglect, but it did not improve neglect-related functional disability, anosognosia, or other neglect symptoms to a clinically meaningful degree.

CLINICAL TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT04273620.

Effects of attentional shifts along the vertical axis on number processing: An eye-tracking study with optokinetic stimulation

Previous studies suggest that associations between numbers and space are mediated by shifts of visuospatial attention along the horizontal axis. In this study, we investigated the effect of vertical shifts of overt attention, induced by optokinetic stimulation (OKS) and monitored through eye-tracking, in two tasks requiring explicit (number comparison) or implicit (parity judgment) processing of number magnitude. Participants were exposed to black-and-white stripes (OKS) that moved vertically (upward or downward) or remained static (control condition). During the OKS, participants were asked to verbally classify auditory one-digit numbers as larger/smaller than 5 (comparison task; Exp. 1) or as odd/even (parity task; Exp. 2). OKS modulated response times in both experiments. In Exp.1, upward attentional displacement decreased the Magnitude effect (slower responses for large numbers) and increased the Distance effect (slower responses for numbers close to the reference). In Exp.2, we observed a complex interaction between parity, magnitude, and OKS, indicating that downward attentional displacement slowed down responses for large odd numbers. Moreover, eye tracking analyses revealed an influence of number processing on eye movements both in Exp. 1, with eye gaze shifting downwards during the processing of small numbers as compared to large ones; and in Exp. 2, with leftward shifts after large even numbers (6,8) and rightward shifts after large odd numbers (7,9). These results provide evidence of bidirectional links between number and space and extend them to the vertical dimension. Moreover, they document the influence of visuo-spatial attention on processing of numerical magnitude, numerical distance, and parity. Together, our findings are in line with grounded and embodied accounts of numerical cognition.

Vestibular and Multi-Sensory Influences Upon Self-Motion Perception and the Consequences for Human Behavior

In this manuscript, we comprehensively review both the human and animal literature regarding vestibular and multi-sensory contributions to self-motion perception. This covers the anatomical basis and how and where the signals are processed at all levels from the peripheral vestibular system to the brainstem and cerebellum and finally to the cortex. Further, we consider how and where these vestibular signals are integrated with other sensory cues to facilitate self-motion perception. We conclude by demonstrating the wide-ranging influences of the vestibular system and self-motion perception upon behavior, namely eye movement, postural control, and spatial awareness as well as new discoveries that such perception can impact upon numerical cognition, human affect, and bodily self-consciousness.

Spatial grounding of symbolic arithmetic: an investigation with optokinetic stimulation

Growing evidence suggests that mental calculation might involve movements of attention along a spatial representation of numerical magnitude. Addition and subtraction on nonsymbolic numbers (numerosities) seem to induce a “momentum” effect, and have been linked to distinct patterns of neural activity in cortical regions subserving attention and eye movements. We investigated whether mental arithmetic on symbolic numbers, a cornerstone of abstract mathematical reasoning, can be affected by the manipulation of overt spatial attention induced by optokinetic stimulation (OKS). Participants performed additions or subtractions of auditory two-digit numbers during horizontal (experiment 1) or vertical OKS (experiment 2), and eye movements were concurrently recorded. In both experiments, the results of addition problems were underestimated, whereas results of subtractions were overestimated (a pattern that is opposite to the classic Operational Momentum effect). While this tendency was unaffected by OKS, vertical OKS modulated the occurrence of decade errors during subtractions (i.e., fewer during downward OKS and more frequent during upward OKS). Eye movements, on top of the classic effect induced by OKS, were affected by the type of operation during the calculation phase, with subtraction consistently leading to a downward shift of gaze position and addition leading to an upward shift. These results highlight the pervasive nature of spatial processing in mental arithmetic. Furthermore, the preeminent effect of vertical OKS is in line with the hypothesis that the vertical dimension of space–number associations is grounded in universal (physical) constraints and, thereby, more robust than situated and culture-dependent associations with the horizontal dimension.

Reassessing lateralization in calculation

The role of the left hemisphere in calculation has been unequivocally demonstrated in numerous studies in the last decades. The right hemisphere, on the other hand, had been traditionally considered subsidiary to the left hemisphere functions, although its role was less clearly defined. Recent clinical studies as well as investigations conducted with other methodologies (e.g. neuroimaging, transcranial magnetic stimulation and direct cortical electro-stimulation) leave several unanswered questions about the contribution of the right hemisphere in calculation. In particular, novel clinical studies show that right hemisphere acalculia encompasses a wide variety of symptoms, affecting even simple calculation, which cannot be easily attributed to spatial disorders or to a generic difficulty effect as previously believed. The studies reported here also show how the right hemisphere has its own specific role and that only a bilateral orchestration between the respective functions of each hemisphere guarantees, in fact, precise calculation. Vis-à-vis these data, the traditional wisdom that attributes to the right hemisphere a role mostly confined to spatial aspects of calculation needs to be significantly reshaped. The question for the future is whether it is possible to precisely define the specific contribution of the right hemisphere in several aspects of calculation while highlighting the nature of the cross-talk between the two hemispheres.This article is part of a discussion meeting issue 'The origins of numerical abilities'.

Number line estimation and complex mental calculation: Is there a shared cognitive process driving the two tasks?

It is widely accepted that different number-related tasks, including solving simple addition and subtraction, may induce attentional shifts on the so-called mental number line, which represents larger numbers on the right and smaller numbers on the left. Recently, it has been shown that different number-related tasks also employ spatial attention shifts along with general cognitive processes. Here we investigated for the first time whether number line estimation and complex mental arithmetic recruit a common mechanism in healthy adults. Participants' performance in two-digit mental additions and subtractions using visual stimuli was compared with their performance in a mental bisection task using auditory numerical intervals. Results showed significant correlations between participants' performance in number line bisection and that in two-digit mental arithmetic operations, especially in additions, providing a first proof of a shared cognitive mechanism (or multiple shared cognitive mechanisms) between auditory number bisection and complex mental calculation.

Contribution of visuospatial attention, short-term memory and executive functions to performance in number interval bisection

Number interval bisection consists of estimating the mid-number within a pair (1-9=>5). Healthy adults and right-brain damage patients can show biased performance in this task, underestimating and overestimating the mid-number, respectively. The role of visuospatial attention during this task, and its interplay with other cognitive abilities (e.g., working memory) is still object of debate. In this study we explored the relation between visuospatial attention and individual differences in working memory and executive functions during number interval bisection. To manipulate the deployment of visuospatial attention, healthy participants tracked a dot moving to the left or moving to the right while bisecting numerical intervals. We also collected information concerning verbal and visuospatial short-term memory span, and concerning verbal and visuospatial fluency scores. Beside replicating what is typically observed in this task (e.g., underestimation bias), a correlation was observed between verbal short-term memory and bisection bias, and an interesting relation between performance in the number interval bisection, verbal short-term memory, and visuospatial attention. Specifically, performance of those participants with low verbal span was affected by the direction of the moving dot, underestimating at a larger extent when the dot moved leftward than rightward. Finally, it was also observed that participants' verbal fluency ability contributed in the generation of biases in the numerical task. The finding of the involvement of abilities belonging to the verbal domain contributes to unveil the multi-componential nature of number interval bisection. Considering the debate on the nature of number interval bisection and its use in the clinical assessment of deficits following brain damage, this finding may be interesting also from a clinical perspective.

Acute peripheral vestibular deficit increases redundancy in random number generation

Unilateral peripheral vestibular deficit leads to broad cognitive difficulties and biases in spatial orientation. More specifically, vestibular patients typically show a spatial bias toward their affected ear in the subjective visual vertical, head and trunk orientation, fall tendency, and walking trajectory. By means of a random number generation task, we set out to investigate how an acute peripheral vestibular deficit affects the mental representation of numbers in space. Furthermore, the random number generation task allowed us to test if patients with peripheral vestibular deficit show evidence of impaired executive functions while keeping the head straight and while performing active head turns. Previous research using galvanic vestibular stimulation in healthy people has shown no effects on number space, but revealed increased redundancy of the generated numbers. Other studies reported a spatial bias in number representation during active and passive head turns. In this experiment, we tested 43 patients with acute vestibular neuritis (18 patients with left-sided and 25 with right-sided vestibular deficit) and 28 age-matched healthy controls. We found no bias in number space in patients with peripheral vestibular deficit but showed increased redundancy in patients during active head turns. Patients showed worse performance in generating sequences of random numbers, which indicates a deficit in the updating component of executive functions. We argue that RNG is a promising candidate for a time- and cost-effective assessment of executive functions in patients suffering from a peripheral vestibular deficit.

Hemispatial Neglect Shows That "Before" Is "Left"

Recent research has led to the hypothesis that events which unfold in time might be spatially represented in a left-to-right fashion, resembling writing direction. Here we studied fourteen right-hemisphere damaged patients, with or without neglect, a disorder of spatial awareness affecting contralesional (here left) space processing and representation. We reasoned that if the processing of time-ordered events is spatial in nature, it should be impaired in the presence of neglect and spared in its absence. Patients categorized events of a story as occurring before or after a central event, which acted as a temporal reference. An asymmetric distance effect emerged in neglect patients, with slower responses to events that took place before the temporal reference. The event occurring immediately before the reference elicited particularly slow responses, closely mirroring the pattern found in neglect patients performing numerical comparison tasks. Moreover, the first item elicited significantly slower responses than the last one, suggesting a preference for a left-to-right scanning/representation of events in time. Patients without neglect showed a regular and symmetric distance effect. These findings further suggest that the representation of events order is spatial in nature and provide compelling evidence that ordinality is similarly represented within temporal and numerical domains.

Spatial displacement of numbers on a vertical number line in spatial neglect

Previous studies that investigated the association of numbers and space in humans came to contradictory conclusions about the spatial character of the mental number magnitude representation and about how it may be influenced by unilateral spatial neglect. The present study aimed to disentangle the debated influence of perceptual vs. representational aspects via explicit mapping of numbers onto space by applying the number line estimation paradigm with vertical orientation of stimulus lines. Thirty-five acute right-brain damaged stroke patients (6 with neglect) were asked to place two-digit numbers on vertically oriented lines with 0 marked at the bottom and 100 at the top. In contrast to the expected, nearly linear mapping in the control patient group, patients with spatial neglect overestimated the position of numbers in the lower middle range. The results corroborate spatial characteristics of the number magnitude representation. In neglect patients, this representation seems to be biased towards the ipsilesional side, independent of the physical orientation of the task stimuli.

Extra-powerful on the visuo-perceptual space, but variable on the number space: Different effects of optokinetic stimulation in neglect patients

We studied the effects of optokinetic stimulation (OKS; leftward, rightward, control) on the visuo-perceptual and number space, in the same sample, during line bisection and mental number interval bisection tasks. To this end, we tested six patients with right-hemisphere damage and neglect, six patients with right-hemisphere damage but without neglect, and six neurologically healthy participants. In patients with neglect, we found a strong effect of leftward OKS on line bisection, but not on mental number interval bisection. We suggest that OKS influences the number space only under specific conditions.

When time is space: evidence for a mental time line

Time and space are tightly linked in the physical word. Recently, several lines of evidence have suggested that the mental representation of time might be spatial in nature. For instance, time-space interactions have been described as a strong preference to associate the past with the left space and the future with the right space. Here we review the growing evidence of interactions between time and space processing, systematized according to the type of interaction being investigated. We present the empirical findings supporting the possibility that humans represent the subjective time flow on a spatially oriented "mental time line" that is accessed through spatial attention mechanisms. The heterogeneous time-space interactions are then compared with the number-space interactions described in the numerical cognition literature. An alternative hypothesis, which maintains a common system for magnitude processing, including time, space, and number, is also discussed. Finally, we extend the discussion to the more general issue of how the representation of these concepts might be grounded into the cortical circuits that support spatial attention and sensorimotor transformations.

Neglect impairs explicit processing of the mental number line

Converging evidence suggests that visuospatial attention plays a pivotal role in numerical processing, especially when the task involves the manipulation of numerical magnitudes. Visuospatial neglect impairs contralesional attentional orienting not only in perceptual but also in numerical space. Indeed, patients with left neglect show a bias toward larger numbers when mentally bisecting a numerical interval, as if they were neglecting its leftmost part. In contrast, their performance in parity judgments is unbiased, suggesting a dissociation between explicit and implicit processing of numerical magnitude. Here we further investigate the consequences of these visuospatial attention impairments on numerical processing and their interaction with task demands. Patients with right hemisphere damage, with and without left neglect, were administered both a number comparison and a parity judgment task that had identical stimuli and response requirements. Neglect patients’ performance was normal in the parity task, when processing of numerical magnitude was implicit, whereas they showed characteristic biases in the number comparison task, when access to numerical magnitude was explicit. Compared to patients without neglect, they showed an asymmetric distance effect, with slowing of the number immediately smaller than (i.e., to the left of) the reference and a stronger SNARC effect, particularly for large numbers. The latter might index an exaggerated effect of number-space compatibility after ipsilesional (i.e., rightward) orienting in number space. Thus, the effect of neglect on the explicit processing of numerical magnitude can be understood in terms of both a failure to orient to smaller (i.e., contralesional) magnitudes and a difficulty to disengage from larger (i.e., ipsilesional) magnitudes on the number line, which resembles the disrupted pattern of attention orienting in visual space.