Eye movements and visuoverbal descriptions exhibit heterogeneous and dissociated patterns before and after prismatic adaptation in unilateral spatial neglect

Ignoring space around a painful limb? No evidence for a body-related visuospatial attention bias in complex regional pain syndrome

BACKGROUND

Complex Regional Pain Syndrome (CRPS) is a disorder of severe chronic pain in one or more limb(s). People with CRPS report unusual perceptions of the painful limb suggesting altered body representations, as well as difficulty attending to their affected limb (i.e., a 'neglect-like' attention bias). Altered body representations and attention in CRPS might be related, however, existing evidence is unclear. We hypothesized that if there were a body-related visuospatial attention bias in CRPS, then any attention bias away from the affected side should be larger for or limited to circumstances when the (impaired) body representation is involved in the task versus when this is not the case.

METHODS

We included 40 people with CRPS, 40 with other limb pain conditions, and 40 pain-free controls. In half of the people with pain, their upper limb was affected, in the other half their lower limb. We administered computerized tasks of spatial attention, including free viewing of images, shape cancellation, temporal order judgement, and dot-probe. The degree to which different versions of each task involved body representation was manipulated by one or more of the following: (1) presenting stimuli nearer versus further away from the body, (2) using body related versus neutral stimuli, and (3) inducing mental rotation of body parts versus no mental rotation. In addition to perceptual judgements, eye movements were recorded as a sensitive index of spatial attention. Bayesian repeated measures analyses were performed.

RESULTS

We found no evidence for a (body-related) visuospatial attention bias in upper limb CRPS. Secondary analyses suggested the presence of a body-related visuospatial attention bias away from the affected side in some participants with lower limb CRPS.

DISCUSSION

Our results add to growing evidence that there might be no general visuospatial attention bias away from the affected side in CRPS.

Effect of prism adaptation on neglect hemianesthesia

Prism adaptation (PA) has proven to be effective in alleviating many signs of unilateral spatial neglect (USN). Generally, the principal improvement after PA treatment was found to be in the high-level cognitive function. Nevertheless, some evidence has also been found for it in somatosensory function. We have aimed to test the influence of PA on neglect hemianesthesia, a condition in which the high-level neglect-related deficit mimics hemianesthesia. Twenty-one USN patients were enrolled in the study. Each patient performed two sessions of PA, one with neutral glasses and one with prism glasses using a cross-over design. Sensitivity on the upper limb was tested using two methods. The first task was the sensibility subtest which was derived from the standard clinical examination. The second was the perceptual and motor electro-cutaneous threshold on the forearms using an electro-cutaneous stimulator. Four neuropsychological tests were used to diagnose USN and to check improvement: Star cancellation, Line bisection, Sentence reading and the Comb & Razor test. Comparing prism with sham conditions, our results show significant improvements in double extinction and in the electro-cutaneous perceptual threshold only for the contralesional hand. No improvement was found for the ipsilesional hand, for the motor threshold, and for neutral glasses. Significant improvement was found in personal neglect. Replication of the task in a subgroup of patients confirmed the primary results. The improvements in somatosensory perception together with the amelioration of personal neglect suggest that PA also has a specific effect on the neglect hemianesthesia.

Clinical versus Evidence-based Rehabilitation Options for Post-stroke Visual Impairment

The aim of this study was to identify which treatments for post-stroke visual impairment have a supportive evidence base, and which are being used in practice without supportive evidence. A systematic review of the literature reporting on the available treatment options was compared against the visual treatments used in the Vision In Stroke (VIS) study. Treatments were identified for visual field, visual neglect, visual perception and ocular motility disorders. Visual scanning therapies for hemianopia and neglect have an established evidence base. However, a number, such as typoscopes and advice options, have limited detail of their effectiveness and require further research.

The treatment methods for post-stroke visual impairment: A systematic review

AIM

To provide a systematic overview of interventions for stroke related visual impairments.

METHOD

A systematic review of the literature was conducted including randomized controlled trials, controlled trials, cohort studies, observational studies, systematic reviews, and retrospective medical note reviews. All languages were included and translation obtained. This review covers adult participants (aged 18 years or over) diagnosed with a visual impairment as a direct cause of a stroke. Studies which included mixed populations were included if over 50% of the participants had a diagnosis of stroke and were discussed separately. We searched scholarly online resources and hand searched articles and registers of published, unpublished, and ongoing trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. Article selection was performed by two authors independently. Data were extracted by one author and verified by a second. The quality of the evidence and risk of bias was assessed using appropriate tools dependant on the type of article.

RESULTS

Forty-nine articles (4142 subjects) were included in the review, including an overview of four Cochrane systematic reviews. Interventions appraised included those for visual field loss, ocular motility deficits, reduced central vision, and visual perceptual deficits.

CONCLUSION

Further high quality randomized controlled trials are required to determine the effectiveness of interventions for treating post-stroke visual impairments. For interventions which are used in practice but do not yet have an evidence base in the literature, it is imperative that these treatments be addressed and evaluated in future studies.

Using brain potentials to understand prism adaptation: the error-related negativity and the P300

Prism adaptation (PA) is both a perceptual-motor learning task as well as a promising rehabilitation tool for visuo-spatial neglect (VSN)—a spatial attention disorder often experienced after stroke resulting in slowed and/or inaccurate motor responses to contralesional targets. During PA, individuals are exposed to prism-induced shifts of the visual-field while performing a visuo-guided reaching task. After adaptation, with goggles removed, visuomotor responding is shifted to the opposite direction of that initially induced by the prisms. This visuomotor aftereffect has been used to study visuomotor learning and adaptation and has been applied clinically to reduce VSN severity by improving motor responding to stimuli in contralesional (usually left-sided) space. In order to optimize PA's use for VSN patients, it is important to elucidate the neural and cognitive processes that alter visuomotor function during PA. In the present study, healthy young adults underwent PA while event-related potentials (ERPs) were recorded at the termination of each reach (screen-touch), then binned according to accuracy (hit vs. miss) and phase of exposure block (early, middle, late). Results show that two ERP components were evoked by screen-touch: an error-related negativity (ERN), and a P300. The ERN was consistently evoked on miss trials during adaptation, while the P300 amplitude was largest during the early phase of adaptation for both hit and miss trials. This study provides evidence of two neural signals sensitive to visual feedback during PA that may sub-serve changes in visuomotor responding. Prior ERP research suggests that the ERN reflects an error processing system in medial-frontal cortex, while the P300 is suggested to reflect a system for context updating and learning. Future research is needed to elucidate the role of these ERP components in improving visuomotor responses among individuals with VSN.

Impaired oculo-motor behaviour affects both reading and scene perception in neglect patients

Unilateral spatial neglect (USN) is a common neuropsychological disorder following a right-sided brain lesion. Although USN is mostly characterized by symptoms involving the left hemispace, other symptoms are not left lateralized. Recently, it was shown that patients with neglect dyslexia, a reading disturbance that affects about 40% of USN patients, manifest a non-lateralized impairment of eye movement behaviour in association with their reading deficit when they read aloud and perform non-verbal saccadic tasks (Primativo et al., 2013). In the present paper, we aimed to demonstrate that the eye movement impairment shown by some USN patients reflects a more general oculo-motor disorder that is not confined to orthographic material, the horizontal axis or constrained saccadic tasks. We conjectured that inaccurate oculo-motor behaviour in USN patients indicates the presence of a reading deficit. With this aim we evaluated 20 patients, i.e., 10 right-sided brain-damaged patients without neglect and 10 patients affected by USN. On the basis of the patients' eye movement patterns during a scene exploration task, we found that 4 out of the 10 USN patients presented an abnormal oculo-motor pattern. These same four patients (but not the others) also failed in performing 5 different saccadic tasks and produced neglect dyslexia reading errors in both single words and texts. First, we show that a large proportion of USN patients have inaccurate eye movement behaviour in non-reading tasks. Second, we demonstrate that this exploratory deficit is predictive of the reading impairment. Thus, we conclude that the eye movement deficit prevents reading and impairs the performance on many other perceptual tests, including scene exploration. The large percentage of patients with impaired eye-movement pattern suggests that particular attention should be paid to eye movement behaviour during the diagnostic phase in order to program the best rehabilitation strategy for each patient.

Rehabilitation of spatial neglect by prism adaptation: a peculiar expansion of sensorimotor after-effects to spatial cognition

Unilateral neglect is a neurological condition responsible for many debilitating effects on everyday life, poor functional recovery, and decreased ability to benefit from treatment. Prism adaptation (PA) to a right lateral displacement of the visual field is classically known to directionally bias visuo-motor and sensory-motor correspondences. One longstanding issue about this visuo-motor plasticity is about its specificity to the exposure condition. In contrast to very poor transfer to unexposed effectors classically described in healthy subjects, therapeutic results obtained in neglect patients suggested that PA can generate unexpected "expansion". Prism adaptation affects numerous levels of neglect symptomatology, suggesting that its effects somehow expand to unexposed sensory, motor and cognitive systems. The available body of evidence in support for this expansion raises important questions about the mechanisms involved in producing unexpected cognitive effects following a simple and moderate visuo-motor adaptation. We further develop here the idea that prism adaptation expansion to spatial cognition involves a cerebello-cortical network and review support for this model. Building on the basic, therapeutical and pathophysiological knowledge accumulated over the last 15 years, we also provide guidelines for the optimal use of prism adaptation in the clinic. Although further research and clinical trials are required to precisely define the ideal regime for routine applications, the current state of the art allows us to outline practical recommendations for therapeutical use of prisms.

Prism adaptation alters spatial remapping in healthy individuals: evidence from double-step saccades

The visual system is able to represent and integrate large amounts of information as we move our gaze across a scene. This process, called spatial remapping, enables the construction of a stable representation of our visual environment despite constantly changing retinal images. Converging evidence implicates the parietal lobes in this process, with the right hemisphere having a dominant role. Indeed, lesions to the right parietal lobe (e.g., leading to hemispatial neglect) frequently result in deficits in spatial remapping. Research has demonstrated that recalibrating visual, proprioceptive and motor reference frames using prism adaptation ameliorates neglect symptoms and induces neglect-like performance in healthy people - one example of the capacity for rapid neural plasticity in response to new sensory demands. Because of the influence of prism adaptation on parietal functions, the present research investigates whether prism adaptation alters spatial remapping in healthy individuals. To this end twenty-eight undergraduates completed blocks of a double-step saccade (DSS) task after sham adaptation and adaptation to leftward- or rightward-shifting prisms. The results were consistent with an impairment in spatial remapping for left visual field targets following adaptation to leftward-shifting prisms. These results suggest that temporarily realigning spatial representations using sensory-motor adaptation alters right-hemisphere remapping processes in healthy individuals. The implications for the possible mechanisms of the amelioration of hemispatial neglect after prism adaptation are discussed.

Adaptation to leftward-shifting prisms reduces the global processing bias of healthy individuals

When healthy individuals are presented with peripheral figures in which small letters are arranged to form a large letter, they are faster to identify the global- than the local-level information, and have difficulty ignoring global information when identifying the local level. The global reaction time (RT) advantage and global interference effect imply preferential processing of global-level information in the normal brain. This contrasts with the local processing bias demonstrated following lesions to the right temporo-parietal junction (TPJ), such as those that lead to hemispatial neglect (neglect). Recent research from our lab demonstrated that visuo-motor adaptation to rightward-shifting prisms, which ameliorates many leftward performance deficits of neglect patients, improved the local processing bias of patients with right TPJ lesions (Bultitude, Rafal, & List, 2009). Here we demonstrate that adaptation to leftward-shifting prisms, which can induce neglect-like performance in neurologically healthy individuals, also reduces the normal global processing bias. Forty-eight healthy participants were asked to identify the global or local forms of hierarchical figures before and after adaptation to leftward- or rightward-shifting prisms. Prior to prism adaptation, both groups had greater difficulty ignoring irrelevant global information when identifying the local level (global interference) compared to their ability to ignore irrelevant local-level information when identifying the global level (local interference). Participants who adapted to leftward-shifting prisms showed a significant reduction in global interference, but there was no change in the performance of the rightward-shifting Prism Group. These results show, for the first time, that in addition to previously demonstrated effects on lateralised attention, prism adaptation can influence non-lateralised spatial attention in healthy individuals.