Visuo-haptic interactions in unilateral spatial neglect: the cross modal judd illusion

Validation of "Neurit.Space": Three Digital Tests for the Neuropsychological Evaluation of Unilateral Spatial Neglect

Patients suffering from Unilateral Spatial Neglect (USN) fail to pay attention to, respond to, and report sensory events occurring in the contralesional side of space. The traditional neuropsychological assessment of USN is based on paper-and-pencil tests, whose data recording and scoring may be subjected to human error. The utilization of technological devices can be expected to improve the assessment of USN. Therefore, we built Neurit.Space, a modified digital version of three paper-and-pencil tests, widely used to detect signs of USN, namely: Bells Cancellation, Line Bisection and Five Elements Drawing Test. Administration and data processing is fully automatic. Twelve right brain-damaged patients (six with and six without USN) and 12 age- and education-balanced healthy participants were enrolled in the study. All participants were administered both the computerized and the paper-and-pencil versions of the tests. The results of this preliminary study showed good sensitivity, specificity, and usability of Neurit.Space, suggesting that these digital tests are a promising tool for the evaluation of USN, both in clinical and in research settings.

Spatial Neglect Subtypes, Definitions and Assessment Tools: A Scoping Review

Objective: The objective of this scoping review was to capture the reported definitions for the subtypes of neglect post stroke and map the range of assessment tools employed for each neglect subtype.

Methods: EMBASE, Emcare, Medline, and psychINFO were searched from database inception. Searching included all allied terms and mesh headings for stroke, spatial neglect, measurement, screening tools, psychometric properties. Two reviewers independently screened studies for inclusion. Primary studies with documented protocols of a spatial neglect tool for adults post stroke, with some aspect of validity or reliability were included. Two reviewers independently reviewed the documented protocols of each tool to determine the underlying subtypes and disagreements were resolved through discussion.

Results: There were 371 articles included with 292 tools used for the screening or diagnosis of neglect. The majority of studies (67%) included a tool that did not specify the neglect subtype being assessed, therefore an analysis of the underlying subtypes for each tool is presented.

Conclusions: There is no consistency with the terms used to refer to the syndrome of spatial neglect with over 200 different terms used within the included studies to refer to the syndrome as a whole or one of its subtypes. It is essential to unify the terminology and definition for each neglect subtype. There are hundreds of neglect tools available, however many are not able to differentiate presenting subtypes. It is important for clinicians and researchers to critically evaluate the neglect tools being used for the screening and diagnosis of neglect.

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.

A novel computerized assessment of manual spatial exploration in unilateral spatial neglect

Unilateral spatial neglect is a neuropsychological syndrome commonly observed after stroke and defined by the inability to attend or respond to contralesional stimuli. Typically, symptoms are assessed using clinical tests that rely upon visual/perceptual abilities. However, neglect may affect high-level representations controlling attention in other modalities as well. Here we developed a novel manual exploration test using a touch screen computer to quantify spatial search behaviour without visual input. Twelve chronic stroke patients with left neglect and 27 patients without neglect (based on clinical tests) completed our task. Four of the 12 "neglect" patients exhibited clear signs of neglect on our task as compared to "non-neglect" patients and healthy controls, and six other patients (from both groups) also demonstrated signs of neglect compared to healthy controls only. While some patients made asymmetrical responses on only one task, generally, patients with the strongest neglect performed poorly on multiple tasks. This suggests that representations associated with different modalities may be affected separately, but that severe forms of neglect are more likely related to damage in a common underlying representation. Our manual exploration task is easy to administer and can be added to standard neglect screenings to better measure symptom severity.

Current practice and challenges in screening for visual perception deficits after stroke: a qualitative study

PURPOSE

We document current clinical practice and needs in screening for visual perception problems after stroke to inform development of new screening tools.

MATERIALS AND METHODS

We interviewed 12 occupational therapists and 13 orthoptists. Interviews were thematically analysed using the Value Proposition Canvas, a model which establishes challenges and facilitators in what people want to achieve.

RESULTS

Participants' understanding of visual perception varied and often included sensory and cognitive deficits. Occupational therapists commonly screened for visual field deficits and hemispatial neglect, while other aspects of visual cognition were rarely assessed. A positive screening result triggered an orthoptic referral. Screening generally occurred during functional assessments and/or with in-house developed tools. Challenges to practice were: lack of time, lack of training, environmental and stroke survivor factors (e.g., aphasia), insufficient continuation of care, and test characteristics (e.g., not evidence-based). Facilitators were: quick and practical tools, experienced staff or tools with minimal training requirements, a streamlined care pathway.

CONCLUSIONS

Screening employs non-standardised assessments and rarely covers higher visual perceptual deficits. We demonstrates the need for an evidence-based visual perception screen, which should ideally be 15 min or less, be portable, and require minimal equipment. The screen should be suitable for bedside testing and aphasia-friendly.Implications for rehabilitationThere is a high demand for training on what visual perception deficits are and how to screen for them.Building local relationships between orthoptists and occupational therapists is perceived as highly beneficial for providing good vision and visual perception care for stroke survivors.Occupational therapists should be alert for visual perceptual deficits in their patients preferably through systematic screening with standardised assessments such as the shortened version of the Rivermead Perceptual Assessment Battery or Occupational Therapy Adult Perceptual Screening Test.

Multisensory stimulation for the rehabilitation of unilateral spatial neglect

Unilateral spatial neglect (USN) is a neuropsychological syndrome, typically caused by lesions of the right hemisphere, whose features are the defective report of events occurring in the left (contralesional) side of space and the inability to orient and set up actions leftwards. Multisensory integration mechanisms, largely spared in USN patients, may temporally modulate spatial orienting. In this pilot study, the effects of an intensive audio-visual Multisensory Stimulation (MS) on USN were assessed, and compared with those of a treatment that ameliorates USN, Prismatic Adaptation (PA). Twenty USN stroke patients received a 2-week treatment (20 sessions, twice per day) of MS or PA. The effects of MS and PA were assessed by a set of neuropsychological clinical tests (target cancellation, line bisection, sentence reading, personal neglect, complex drawing) and the Catherine Bergego Scale for functional disability. Results showed that MS brought about an amelioration of USN deficits overall comparable to that induced by PA; personal neglect was improved only by MS, not by PA. The clinical gains of the MS treatment were not influenced by duration of disease and lesion volume, and they persisted up to one month post-treatment. In conclusion, MS represents a novel and promising rehabilitation procedure for USN.

Altered visual feedback from an embodied avatar unconsciously influences movement amplitude and muscle activity

Evidence suggests that the sense of the position of our body parts can be surreptitiously deceived, for instance through illusory visual inputs. However, whether altered visual feedback during limb movement can induce substantial unconscious motor and muscular adjustments is not known. To address this question, we covertly manipulated virtual body movements in immersive virtual reality. Participants were instructed to flex their elbow to 90° while tensing an elastic band, as their virtual arm reproduced the same, a reduced (75°), or an amplified (105°) movement. We recorded muscle activity using electromyography, and assessed body ownership, agency and proprioception of the arm. Our results not only show that participants compensated for the avatar’s manipulated arm movement while being completely unaware of it, but also that it is possible to induce unconscious motor adaptations requiring significant changes in muscular activity. Altered visual feedback through body ownership illusions can influence motor performance in a process that bypasses awareness.

Extinction as a deficit of the decision-making circuitry in the posterior parietal cortex

Extinction is a common neurologic deficit that often occurs as one of a constellation of symptoms seen with lesions of the posterior parietal cortex (PPC). Although extinction has typically been considered a deficit in the allocation of attention, new findings, particularly from nonhuman primate studies, point to one potential and important source of extinction as damage to decision-making circuits for actions within the PPC. This new understanding provides clues to potential therapies for extinction. Also the finding that the PPC is important for action decisions and action planning has led to new neuroprosthetic applications using PPC recordings as control signals to assist paralyzed patients.

Unilateral spatial neglect after posterior parietal damage

Unilateral spatial neglect is a disabling neurologic deficit, most frequent and severe after right-hemispheric lesions. In most patients neglect involves the left side of space, contralateral to a right-hemispheric lesion. About 50% of stroke patients exhibit neglect in the acute phase. Patients fail to orient, respond to, and report sensory events occurring in the contralateral sides of space and of the body, to explore these portions of space through movements by action effectors (eye, limbs), and to move the contralateral limbs. Neglect is a multicomponent higher-level disorder of spatial awareness, cognition, and attention. Spatial neglect may occur independently of elementary sensory and motor neurologic deficits, but it can mimic and make them more severe. Diagnostic tests include: motor exploratory target cancellation; setting the midpoint of a horizontal line (bisection), that requires the estimation of lateral extent; drawing by copy and from memory; reading, assessing neglect dyslexia; and exploring the side of the body contralateral to the lesion. Activities of daily living scales are also used. Patients are typically not aware of neglect, although they may exhibit varying degrees of awareness toward different components of the deficit. The neural correlates include lesions to the inferior parietal lobule of the posterior parietal cortex, which was long considered the unique neuropathologic correlate of neglect, to the premotor and to the dorsolateral prefrontal cortices, to the posterior superior temporal gyrus, at the temporoparietal junction, to subcortical gray nuclei (thalamus, basal ganglia), and to parietofrontal white-matter fiber tracts, such as the superior longitudinal fascicle. Damage to the inferior parietal lobule of the posterior parietal cortex is specifically associated with the mainly egocentric, perceptual, and exploratory extrapersonal, and with the personal, bodily components of neglect. Productive manifestations, such as perseveration, are not a correlate of posterior parietal cortex damage.

Multisensory integration in hemianopia and unilateral spatial neglect: Evidence from the sound induced flash illusion

Recent neuropsychological evidence suggests that acquired brain lesions can, in some instances, abolish the ability to integrate inputs from different sensory modalities, disrupting multisensory perception. We explored the ability to perceive multisensory events, in particular the integrity of audio-visual processing in the temporal domain, in brain-damaged patients with visual field defects (VFD), or with unilateral spatial neglect (USN), by assessing their sensitivity to the 'Sound-Induced Flash Illusion' (SIFI). The study yielded two key findings. Firstly, the 'fission' illusion (namely, seeing multiple flashes when a single flash is paired with multiple sounds) is reduced in both left- and right-brain-damaged patients with VFD, but not in right-brain-damaged patients with left USN. The disruption of the fission illusion is proportional to the extent of the occipital damage. Secondly, a reliable 'fusion' illusion (namely, seeing less flashes when a single sound is paired with multiple flashes) is evoked in USN patients, but neither in VFD patients nor in healthy participants. A control experiment showed that the fusion, but not the fission, illusion is lost in older participants (>50 year-old), as compared with younger healthy participants (<30 year-old). This evidence indicates that the fission and fusion illusions are dissociable multisensory phenomena, altered differently by impairments of visual perception (i.e. VFD) and spatial attention (i.e. USN). The occipital cortex represents a key cortical site for binding auditory and visual stimuli in the SIFI, while damage to right-hemisphere areas mediating spatial attention and awareness does not prevent the integration of audio-visual inputs in the temporal domain.

Visual illusion and line bisection: a bias hypothesis revisited

It is generally accepted that visual illusions affect line bisection in the predicted direction. However, it has been reported an illusionary bias which seems questioning such general view. In a previous study, participants bisected lines flanked at both ends by two pairs of arrows, pointing in the same direction. The medialmost vertices of one pair converged on the line (converging arrows), whereas those of the other pair did not (non-converging arrows). Participants bisected lines toward the base of the arrows, i.e., toward the wider end of the stimulus and in the direction opposite to that predicted by the Baldwin illusion. However, the bisection bias was also directed away from the location of the converging arrows. We investigated what is the main factor affecting line bisection: arrows orientation, as previously suggested, or interference effects related to the location of converging arrows. In experiment 1, participants bisected lines flanked by converging versus non-converging arrows. Results confirmed the presence of a bisection bias directed not only toward the base of the converging arrows but also away from their location. In experiment 2, the arrows were located more internally, so that their medialmost vertices always converged on the line. Results showed that the bisection bias was directed away from the location of the arrows regardless of their orientation. It is suggested that the previously reported bisection bias did not depend on arrows orientation, but rather on interference effects related to converging arrows position. The theoretical implications of the results are discussed.

Visual and spatial modulation of tactile extinction: behavioural and electrophysiological evidence

Crossing the hands over the midline reduces left tactile extinction to double simultaneous stimulation in right-brain-damaged patients, suggesting that spatial attentional biases toward the ipsilesional (right) side of space contribute to the patients' contralesional (left) deficit. We investigated (1) whether the position of the left hand, and its vision, affected processing speed of tactile stimuli, and (2) the electrophysiological underpinnings of the effect of hand position. (1) Four right-brain-damaged patients with spatial neglect and contralesional left tactile extinction or somatosensory deficits, and eight neurologically unimpaired participants, performed a speeded detection task on single taps delivered on their left index finger. In patients, placing the left hand in the right (heteronymous) hemi-space resulted in faster reaction times (RTs) to tactile stimuli, compared to placing that hand in the left (homonymous) hemi-space, particularly when the hand was visible. By contrast, in controls placing the left hand in the heteronymous hemi-space increased RTs. (2) Somatosensory event-related potentials (ERPs) were recorded from one patient and two controls in response to the stimulation of the left hand, placed in the two spatial positions. In the patient, the somatosensory P70, N140, and N250 components were enhanced when the left hand was placed in the heteronymous hemi-space, whereas in controls these components were not modulated by hand position. The novel findings are that in patients placing the left hand in the right, ipsilesional hemi-space yields a temporal advantage in processing tactile stimuli, and this effect may rely on a modulation of stimulus processing taking place as early as in the primary somatosensory cortex, as indexed by evoked potentials. Furthermore, vision enhances tactile processing specifically when the left hand is placed in the hemi-space toward which the patients' attentional biases are pathologically directed, namely rightwards.

Bisecting real and fake body parts: effects of prism adaptation after right brain damage

The representation of body parts holds a special status in the brain, due to their prototypical shape and the contribution of multisensory (visual and somatosensory-proprioceptive) information. In a previous study (Sposito et al., 2010), we showed that patients with left unilateral spatial neglect exhibit a rightward bias in setting the midpoint of their left forearm, which becomes larger when bisecting a cylindrical object comparable in size. This body part advantage, found also in control participants, suggests partly different processes for computing the extent of body parts and objects. In this study we tested 16 right-brain-damaged patients, and 10 unimpaired participants, on a manual bisection task of their own (real) left forearm, or a size-matched fake forearm. We then explored the effects of adaptation to rightward displacing prism exposure, which brings about leftward aftereffects. We found that all participants showed prism adaptation (PA) and aftereffects, with right-brain-damaged patients exhibiting a reduction of the rightward bias for both real and fake forearm, with no overall differences between them. Second, correlation analyses highlighted the role of visual and proprioceptive information for the metrics of body parts. Third, single-patient analyses showed dissociations between real and fake forearm bisections, and the effects of PA, as well as a more frequent impairment with fake body parts. In sum, the rightward bias shown by right-brain-damaged patients in bisecting body parts is reduced by prism exposure, as other components of the neglect syndrome; discrete spatial representations for real and fake body parts, for which visual and proprioceptive codes play different roles, are likely to exist. Multisensory information seems to render self bodily segments more resistant to the disruption brought about by right-hemisphere injury.