UNILATERAL-SPATIAL INATTENTION \ ICBO CONGRESS POMONA. CA APRI - - PowerPoint PPT Presentation

UNILATERAL-SPATIAL INATTENTION

\

ICBO CONGRESS

• POMONA. CA

APRI 8 2010 APRIL 8, 2010

ROBERT B. SANET, O.D., F.C.O.V.D. San Diego Center for Vision Care g 7898 Broadway Lemon Grove CA 91945 rsanet@cs.com

UNILATERAL SPATIAL INATTENTION (NEGLECT)

GENERAL CHARACTERISTICS

UNILATERAL SPATIAL INATTENTION (NEGLECT)

M N U il t l S ti l N l t H i N l t

 Many Names: Unilateral Spatial Neglect, Hemi-Neglect,

Unilateral Spatial Inattention

 Involuntary failure, or reduced ability to attend or respond

to meaningful sensory stimuli presented in the affected hemi-field

 As opposed to a hemianopsia, it is not caused by a defect

in the Geniculo-Striate pathway p y

 May or may not be accompanied by hemiplegia and

homonymous hemianopsia y p

UNILATERAL SPATIAL INATTENTION (NEGLECT)

 Usually the result of a right parietal lobe lesion, but it can

• ccur as a result of damage in many other areas of the

cortex

 Stroke is the most common cause

M h i i t t t ll l

 Mechanism is not totally clear  May affect Personal Space (body image), Peri-Personal

Space (within arms reach) or Extra Personal Space Space (within arms reach) or Extra Personal Space (outside of arms reach)

 Neglect may be complete or relative stimulus/intensity  Neglect may be complete or relative-stimulus/intensity

dependant

UNILATERAL SPATIAL INATTENTION (NEGLECT)

C titi

 Competitive process  Sometimes may only occur with simultaneous presentation

( ti ti h ) (extinction phenomenon)

 May present with any combination of visual, auditory or tactile

stimuli stimuli

 More devastating, but also more remediable than a visual field

defect defect

 The presence of neglect more than 3 months post stroke is a

major predictor of Activities for Daily Living (ADL) abilities major predictor of Activities for Daily Living (ADL) abilities

UNILATERAL SPATIAL INATTENTION (NEGLECT)

PREDICTOR OF TREATEMENT OUTCOMES PREDICTOR OF TREATEMENT OUTCOMES

VISUAL SPATIAL INATTENTION VISUAL-SPATIAL INATTENTION AND ACTIVITIES FOR DAILY LIVING (ADL) ACTIVITIES FOR DAILY LIVING (ADL)

 Study by Katz , Hartman-Maeir, et. al, 1999  Conducted at the School of Occupational Therapy, Hebrew University

• f Jerusalem, Israel

 Objective was to evaluate the impact of unilateral spatial neglect

(USN) on the rehabilitation outcome and long-term functioning in activities of daily living (ADL) in right hemisphere damaged stroke activities of daily living (ADL) in right hemisphere damaged stroke patients

 Assessed sensory motor and cognitive impairment and functional  Assessed sensory-motor and cognitive impairment and functional

disability upon admission to rehabilitation, upon discharge from rehabilitation hospital and 6 months after discharge

VISUAL SPATIAL INATTENTION VISUAL-SPATIAL INATTENTION AND ACTIVITIES FOR DAILY LIVING (ADL) ACTIVITIES FOR DAILY LIVING (ADL)

Results:

 Neglect is associated with lower performance on measures of

impairment (sensory-motor and cognitive), as well as on measures

• f disability in ADL

 Differences were significant in all testing periods admission,

discharge, and 6 months post discharge

 The recovery pattern for patients with USN is slower and more

attenuated

 USN is the major predictor of rehabilitation o tcome from admission  USN is the major predictor of rehabilitation outcome from admission

to follow-up

UNILATERAL SPATIAL INATTENTION (NEGLECT)

PROPOSED MECHANISMS

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Vallar & Perani, 1986

 Considerable evidence that damage to the inferior parietal  Considerable evidence that damage to the inferior parietal

lobule (IPL), more than any other brain region, produces the classic symptoms of neglect

 Region of the IPL appears to be at the apex of a multistage

cortical processing stream cortical processing stream

 IPL receives inputs from subcortical structures that carry

IPL receives inputs from subcortical structures that carry

• cularmotor and attentional signals

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Vallar & Perani, 1986 IPL i t t ti i l d t i f ti

 IPL integrates somatic, visual, and movement information  IPL appears to be one of the primary cortical regions  IPL appears to be one of the primary cortical regions

governing attention

 The IPL is thought to be part of the ventral stream

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Milner and Goodale, 1995:

• Superior parietal lobe is part of dorsal stream which mediates control

Superior parietal lobe is part of dorsal stream which mediates control

• f goal directed actions
• Lesions restricted to the superior parietal lobe lead to disturbances

in visuomotor control (optic ataxia)

• Lesions of the inferior parietal lobe lead to spatial neglect
• Due to damage to areas which deals with abstract spatial reasoning,

based on input from the ventral stream which permits the formation of perceptual and cognitive representations which embody the enduring p p g p y g characteristics of objects and their significance

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Perenin, 1997:

• Superior part of the parietal cortex is involved with direct

coding of space for action

• Inferior part or parietal lobe is responsible for more

enduring and conscious representations underlying spatial cognition and awareness cog t o a d a a e ess

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Karnath, 1997:

• The brain uses inputs from various afferent channels to
• The brain uses inputs from various afferent channels to

elaborate a unitary representation of egocentric space Neglect due to an altered representation of body centered

• Neglect due to an altered representation of body-centered

space I l t th di t t f ti h t ti

• In neglect the coordinate transformation has a systematic

error that results in deviation of the spatial reference to the ipsilateral side

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Kinsbourne, 1987:

• Orientation is not intact in in either right or left hemispace
• A lateral gradient of attention sweeps across both

hemispheres

• There a gradient of severity of the neglect across the entire

visual field

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Rizzolatti and Berti, 1990:

• Neglect results from a lesion in higher order spatial maps
• There is gradient of severity across the visual field with a
• There is gradient of severity across the visual field with a

maximum severity in the in the extreme contralateral hemifield to a minimum severity in the extreme ipsilateral field

UNILATERAL SPATIAL INATTENTION (NEGLECT)

Summary of Research: Summary of Research:

• Many varied presentations of USI depending on the specific brain

area(s) involved ( )

• Inferior parietal lobule (IPL), more than any other brain region,

produces the classic symptoms of neglect. However, it must be remembered that many different cortical areas may produce neglect remembered that many different cortical areas may produce neglect

• May present as problems with various functions and areas of space
• Body image

Body image

• Visuo-motor control
• Cognition
• Attention
• USI appears to manifest as a biased gradient of attention across the

entire visual field

UNILATERAL SPATIAL INATTENTION (NEGLECT)

O EVALUATION

UNILATERAL SPATIAL INATTENTION (NEGLECT) UNILATERAL SPATIAL INATTENTION (NEGLECT)

Visual Field Defect-No Neglect-???

UNILATERAL SPATIAL INATTENTION (NEGLECT) UNILATERAL SPATIAL INATTENTION (NEGLECT)

Visual Field Defect-??? Neglect??? Both???

OPTOMETRIC EVALUATION OPTOMETRIC EVALUATION OF THE ABI PATIENT WITH VISUAL SPATIAL NEGLECT

PROBES:



Questions to patient/caregiver regarding behavior



Patient’s awareness of problem



Observe Behavior



Drawing tests: Clock, Flowers, etc.



Scanning Tests



Line Bisection Cross Out Task (Suter analysis)



Two Penlights-Extinction



Read Hart Chart



Read Hart Chart



Auditory/tactile stimuli

FIGURE DRAWING TESTS

DRAW A CLOCK

FLOWER COPYING TEST

LINE BISECTION TEST

CANCELLATION TESTS

NAVON FIGURES

Global vs. Local Features

LINE BISECTION TEST

Caution! Caution!

 Study by Ferber & Karnath, 2001  Examined validity of a line bisection test and four cancellation tests  Examined validity of a line bisection test and four cancellation tests  Found that the line bisection test missed 40% of the neglect patients  Cancellation tests only missed 6% of the subjects  Deviations in line bisection may be indicative of other conditions,

such as hemianopia

 Conclusions: Result calls into question line bisection tests as a valid

assessments tool and confirmed the use of cancellation tests

Li Bi ti C O t T k Line Bisection Cross Out Task

The Line Bisection Cross Out Task (by Suter) The Line Bisection Cross Out Task (by Suter)

 In deep neglect, the patient will neglect to bisect the lines on one

side of the paper side of the paper

 In lesser neglect, the patient will bisect all of the lines, but the lines

greater than 5 cm in length will be bisected away from the neglected greater than 5 cm in length will be bisected away from the neglected field

 A patient with a hemianopsia without neglect tends to bisect the line

p p g toward the blind field, as if they are aware of the defect and

• vercompensate in the process

C O Line Bisection Cross Out Task

The Line Bisection Cross Out Task (by Suter)

 There is a caveat to the right-left bisection bias… a patient with a

hemianopsia plus neglect may bisect the lines accurately

 Do not get out your ruler to score. Healthy normal subjects seem to

show a slight bias to left side, so if you score with a ruler, everyone will be a neglect suspect

 If truly present, the differences should be easily discerned by

“eyeballing” the sheet

GRADIENT OF NEGLECT

UNILATERAL SPATIAL INATTENTION (NEGLECT)

TREATMENT

TREATMENT OPTIONS FOR UNILATERAL SPATIAL INATTENTION

V ib l S i l i

 Vestibular Stimulation  Hemi-Spatial Sun Rx  Yoked Prisms  Optokinetic Stimulation

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

VESTIBULAR TREATMENT VESTIBULAR TREATMENT

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

VESTIBULAR TREATMENT VESTIBULAR TREATMENT

 Neglect temporarily improved by caloric stimulation,

Neglect temporarily improved by caloric stimulation, neck vibration and optokinetic stimulation, but effects are transitory-lasting no more than 10-12 minutes

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

HEMI SPATIAL SUNGLASSES HEMI-SPATIAL SUNGLASSES

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

HEMI SPATIAL SUNGLASSES HEMI-SPATIAL SUNGLASSES Study by Arai, Ohi, et. al 1997 Study by Arai, Ohi, et. al 1997

 10 patients with unilateral left neglect  Used copying and line bisection tasks

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

HEMI-SPATIAL SUNGLASSES HEMI-SPATIAL SUNGLASSES Study by Arai, Ohi, et. al 1997

 Used Hemi-Spatial Sun Rx  Using spectrometer:

90% light penetration in the unshaded half 08% light penetration in the shaded half 08% light penetration in the shaded half

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

HEMI SPATIAL SUNGLASSES HEMI-SPATIAL SUNGLASSES Study by Arai, Ohi, et. al 1997 Study by Arai, Ohi, et. al 1997

 4 out of 10 patients showed some improvement  One patient demonstrated dramatic and lasting

i t i f ti l ti iti improvement in functional activities

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

YOKED PRISM YOKED PRISM (PRISM ADAPTATION) (PRISM ADAPTATION)

TREATMENT OPTIONS TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION VISUAL SPATIAL INATTENTION

YOKED PRISM (PRISM ADAPTATION) TREATMENT YOKED PRISM (PRISM ADAPTATION) TREATMENT

Study by Rossetti, et. al 1998

 12 patients with right brain damage, mean age 62 years  All in neuro rehabilitation hospital for moderate to severe

h i l i d t d f ti d t t k hemiplegia and somatosensory dysfunction secondary to stroke

TREATMENT OPTIONS TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION VISUAL SPATIAL INATTENTION

YOKED PRISM (PRISM ADAPTATION) TREATMENT

Study by Rossetti, et. al 1998

 Study took place 3 weeks->14 months post stroke (average 9 weeks)  Used 10 degree (18 prism diopter) Base Left prisms  Performed simple pointing task

YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

Study by Rossetti et al 1998 continued Study by Rossetti, et. al 1998…continued

 In the study, using Yoked Prisms, the positive effect was a minimum

• f t o ho rs as compared to other treatments

here the effects

• f two hours, as compared to other treatments where the effects

lasted no more than 10-12 minutes

 Positive effect were found for both sensorimotor and cognitive

spatial functions spatial functions

 “The prisms do not merely act as a passive modifier of sensory

afferents (like caloric, vibrational, or optokinetic stimulation), but can be seen as stimulating active processes involved in the can be seen as stimulating active processes involved in the plasticity of sensorimotor correspondences by activating brain functions related to multisensory integration and space representation.”

YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

Study by Rossetti, et. al 1998…continued Postulated mechanisms to account for the strong improvement in Postulated mechanisms to account for the strong improvement in patients with neglect:

 Stimulation of short-term plasticity of brain functions related to spatial

p y p transformations and spatial representation may favor the neural restoration of the right hemispheric functions when they have been impaired by a lesion

 Exposure alters the coordinate transformations used by the nervous

system to represent extrapersonal space

YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

Study by Rossetti, et. al 1998…continued Some conclusions by the authors of the study: Some conclusions by the authors of the study:



“The dramatic improvement induced by prism adaptation suggests that a signal is given to the brain that stimulates the recovery process” g g y p

 “An attractive aspect of the prism exposure lies in it’s non-invasive

nature, acceptability to patients, and ease of use”

 “The duration of the effects, owing to central active process being

activated, indicates that this technique may come top have a major role i h h l i l h bili i f h i i l l ” in the neuropsychological rehabilitation of hemispatial neglect.”

YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

Study by Rossetti, et. al 1998…continued

 Rossetti’s work had been replicated by many researchers,

Rossetti s work had been replicated by many researchers, in most cases with with similar results:

• M i t

h t l 2002

• Mcintosh, et. al., 2002
• Farne, et. al., 2002
• Frassinetti, et. al., 2002
• Frassinetti, et. al., 2002
• Rode, et. al., 2003
• Luate, et. al., 2006
• Sumitani, et. al., 2007
• Seriano, et. al., 2007

UNILATERAL SPATIAL INATTENTION

EXCELLENT REFERENCE ON PRISM ADAPTATION !!!

 Published in Journal of Behavioral Optometry, 2009

ub s ed Jou a o e a

• a Opto

et y, 009

 Author: Maura E. Massucci, OD  Title: Prism Adaptation in the Rehabilitation of

Patients with Unilateral Spatial Inattention Massucci, ME. Prism adaptation in the rehabilitation

• f patients with unilateral spatial inattention. J Behav

Optom 2009; 20:101 105 Optom 2009; 20:101-105

TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION

OPTOKINETIC STIMULATION OPTOKINETIC STIMULATION

O O C S O OPTOKINETIC STIMULATION

Study by Kerkhoff, Keller, et., al. 2006

 Published in Restorative Neurology and Neuroscience

E l t d d t t t t i li bi ti t t d

 Evaluated pre and post treatment using line bisection tests and

cancellation tests in two matched groups

 Transfer was assessed using paragraph reading tests

O O C S O OPTOKINETIC STIMULATION

Study by Kerkhoff, Keller, et., al. 2006

 Performed 5 treatment sessions of repetitive OKN stimulation

Performed 5 treatment sessions of repetitive OKN stimulation

 Used the PC based EYEMOVE program: Visual displays of

• bjects all moving coherently toward the neglected side
• bjects all moving coherently toward the neglected side

O O C S O OPTOKINETIC STIMULATION

Study by Kerkhoff, Keller 2006

 Control group did conventional scanning training

F d iti i ll f th t t d i i t d d t f t

 Found positive in all of the tests administered and transfer to

paragraph reading

 Effect from OKN occurred in both high and low velocity

movement and with large and small sized displays

O O C S O OPTOKINETIC STIMULATION

Study by Kerkhoff, Keller 2006 Kerkhoff and associates offered two compatible hypothesis for Kerkhoff and associates offered two compatible hypothesis for effect of OKN on Neglect

• OKN facilitates the directing of attention toward the neglected
• OKN facilitates the directing of attention toward the neglected

regions of space. The improved attention allocation leads to improved exploration of leftward space

• Leftward OKN facilitates more accurate egocentric space

representation by providing visual directional input thereby influencing spatial perception and attention influencing spatial perception and attention

O O C S O OPTOKINETIC STIMULATION

Additional studies on OKN and Neglect

 Vallar, et., al 1997 found positive effects from OKN visual

displays on arm position and other arm and hand functions

 Sturm et., al. 2006, using the EYEMOVE program found

reactivation of cortical regions including angular gyrus, temporal-occipital areas, pre-cuneus and the posterior cingulate p p , p p g gyrus

UNILATERAL SPATIAL INATTENTION (NEGLECT)

CONCLUSION

VISUAL-SPATIAL INATTENTION Conclusion: Conclusion:

 Visual Spatial Inattention (Neglect) is a major source of

p ( g ) j stroke-related long-term disability

 Yoked prisms (prism adaptation) optokinetic stimulation  Yoked prisms (prism adaptation), optokinetic stimulation

and hemispatial sun Rx’s, appear to be useful tools to remediate unilateral spatial inattention

 The profession of Optometry has the potential to play an

important role in applying these therapeutic modalities p pp y g p to remediate unilateral spatial inattention

THANK YOU

UNILATERAL SPATIAL INATTENTION

UNILATERAL SPATIAL INATTENTION

REFERENCES:

• Kinsbourne, : Mechanisms of unilateral neglect. In:

Neurophysiological and neuropsychological aspects of spatial Neurophysiological and neuropsychological aspects of spatial neglect (ed: M. Jennerod) Amsterdam, North Holland pp. 69-86, 1987

• Rizzolatti and Berti, Neglect as a neural representational deficit. Rev.

g p

• Neurol. 146, 626-634, 1990
• Rossetti, et. al Prism adaptation to a rightward optical deviation

rehabilitates left hemispatial neglect Nature 395/10 September 1998 rehabilitates left hemispatial neglect. Nature, 395/10 September, 1998

• Massucci, ME. Prism adaptation in the rehabilitation of patients with

unilateral spatial inattention J Behav Optom 2009; 20:101-105 unilateral spatial inattention. J Behav Optom 2009; 20:101-105

UNILATERAL SPATIAL INATTENTION

REFERENCES:

• N.Katz, A.Hartman-Maeir, H.Ring, N.Soroker Functional disability

, , g, y and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect. Archives of Physical Medicine and Rehabilitation 1999; 80 (4),379-384 S ( )

• Katz H-M. , Ring H., Soroker, N. Arch Phy. Med. Rehab. 80(4)April

1999, pp. 379-384

• Perenin MT, Optic Ataxia and unilateral neglect: clinical evidence for

di i bl i l f i i i i l I P i l , p g dissociable spatial functions in posterior parietal cortex. In: Parietal lobe contributions to orientation in 3D space (ed. P. Their + H-O Karnath, Heidelberg: Springer pp.289-308 1997 Mil AD d G d l MA Th i l b i i ti O f d

• Milner , AD. and Goodale MA. The visual brain in action. Oxford

University Press,1995

UNILATERAL SPATIAL INATTENTION

REFERENCES REFERENCES:

• Karnath, 1997- Neural coding of space in egocentric coordinates. Evidence

for Lmits of a hypothesis derived from patients with parietal lesions and yp p p

• neglect. In: Parietal lobe contributions to orientation in 3D space space (ed. P.

Their+H-O Karnath, Heidelberg:Springer pp.289-308 1997 pp. 497-520

• Vallar G, Perani D. The anatomy of unilateral neglect after right-hemisphere

, y g g p stroke lesions. A clinical/CT-scan correlation study in man.

• Neuropsychologia. 1986;24(5):609–622
• Ferber S., Karnath H.O. (2001) How to assess spatial neglect - Line bisection

, ( ) p g

• r cancellation tasks? Journal of Clinical and Experimental Neuropsychology,

23:599-607

• Mcintosh R. , Rossetti Y. Milner A.D. Prism adaptation improves chronic

, p p visual and haptic neglect: A single case study. Cortex 2002, 3:309-320

UNILATERAL SPATIAL INATTENTION

C S REFERENCES:

• Farne A. Rossetti Y., Toniolo S. Ladavas E. Ameliorating neglect

with prism adaptation: visio manual and visuo verbal measures with prism adaptation: visio-manual and visuo-verbal measures. Neurophysiologica 2002;40:718-729

• Frassinetti F., Angeli V., Menegrello F., Avanzi S., Long-lasting

ameioration of visuospatial neglect by prism adaptation. Brain 2002, 125:608-623

• Rode G., Pisella I., Rossetty Y., Farne A..Bottom up transfer of sensory-

Rode G., Pisella I., Rossetty Y., Farne A..Bottom up transfer of sensory motor plasticity to recovery of spatial cognition: Visuomotor adaptation and spatial neglect.Prog. Brain Res. , 2003; 142: 273-287

• Luate J

Michael C Rode G Pisella L Functional anatomy of the

• Luate J., Michael C., Rode G. Pisella L. Functional anatomy of the

therapeutic effects of prism adaptation on left neglect. Neurol 2006; 66: 1859-1867

UNILATERAL SPATIAL INATTENTION

REFERENCES REFERENCES:

• Sumitani M., Rossetti Y., Shibata M., Matsuda N., Prism adaptation

to optical deviation alieviates pathological pain. Neurol. 2007; 68:128 133 68:128-133

• Seriano A., Bonifazi S., Pierfederici ., Ladavas E., Neglect treatment

by prism adaptation: What recovery and for how long. Neuropsychol Rehabil 2007; 17: 657 687

• Neuropsychol. Rehabil. 2007; 17: 657-687
• Arai T; Ohi H; Sasaki H; Nobuto, H Tanaka, K. Hemispatial

Sunglasses: Effect on unilateral spatial neglect. Arch Phys Med Rehabil 1997;

• Rehabil. 1997;

78 230-232

• Kerkhoff G., Keller I., Ritter V. Marquardt C., Repetitive optokinetic

ti l ti i d l ti f i l l t R t q p p stimulation induces lasting recovery from visual neglect. Restor Neruol and Neurosci 24 (2006) 357-369

UNILATERAL SPATIAL INATTENTION

REFERENCES REFERENCES:

• Strum W., Thimm M., Fink, GR. Alertness training in neglect-

Behavioural and imagining results. Restor Neruol and Neurosci, Behavioural and imagining results. Restor Neruol and Neurosci, 2006;24(4-6):371-84

• Vallar G., Guariglia C., Nico D., Pizzamiglio L. Motor deficits and

t ki ti ti l ti i ti t ith l ft h i l t

• ptokinetic stimulation in patients with left hemineglect,

Neurology1991 49: 1364-1370