02 Bob Sanet Newest Sanet.pdfUNILATERAL SPATIAL INATTENTION (NEGLECT) Usually the result of a right parietal lobe lesion, but it can occur as a result of damage in many other areas

UNILATERAL-SPATIAL INATTENTION\

ICBO CONGRESSPOMONA. CAAPRI 8 2010APRIL 8, 2010

ROBERT B. SANET, O.D., F.C.O.V.D.San Diego Center for Vision Careg

7898 BroadwayLemon Grove CA 91945

[email protected]

UNILATERAL SPATIAL INATTENTION (NEGLECT)

GENERAL CHARACTERISTICS


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 pathwayp y

May or may not be accompanied by hemiplegia and homonymous hemianopsiay p


Usually the result of a right parietal lobe lesion, but it can occur 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 SpaceSpace (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


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 stimulistimuli

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

The presence of neglect more than 3 months post stroke is a major predictor of Activities for Daily Living (ADL) abilitiesmajor predictor of Activities for Daily Living (ADL) abilities


PREDICTOR OF TREATEMENT OUTCOMESPREDICTOR OF TREATEMENT OUTCOMES

VISUAL SPATIAL INATTENTIONVISUAL-SPATIAL INATTENTIONAND

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 of 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 strokeactivities 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 INATTENTIONVISUAL-SPATIAL INATTENTIONAND

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 of 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


PROPOSED MECHANISMS


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 streamcortical processing stream

IPL receives inputs from subcortical structures that carryIPL receives inputs from subcortical structures that carry ocularmotor and attentional signals


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


Milner and Goodale, 1995:

• Superior parietal lobe is part of dorsal stream which mediates controlSuperior parietal lobe is part of dorsal stream which mediates control of goal directed actions

• Lesions restricted to the superior parietal lobe lead to disturbancesin 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 gcharacteristics of objects and their significance


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 awarenesscog t o a d a a e ess


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


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


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 contralateralhemifield to a minimum severity in the extreme ipsilateralfield


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 neglectremembered that many different cortical areas may produce neglect

• May present as problems with various functions and areas of space- Body imageBody image- Visuo-motor control- Cognition- Attention

• USI appears to manifest as a biased gradient of attention across the entire visual field


OEVALUATION

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 EVALUATIONOPTOMETRIC EVALUATIONOF

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 FIGURESGlobal vs. Local Features

LINE BISECTION TESTCaution!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 kLine Bisection Cross Out TaskThe 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 paperside 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 neglectedgreater 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 gtoward the blind field, as if they are aware of the defect and overcompensate in the process

C OLine Bisection Cross Out TaskThe 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 toshow 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


TREATMENT

TREATMENT OPTIONSFOR

UNILATERAL SPATIAL INATTENTION

V ib l S i l i Vestibular Stimulation

Hemi-Spatial Sun Rx

Yoked Prisms

Optokinetic Stimulation


VISUAL-SPATIAL INATTENTION

VESTIBULAR TREATMENTVESTIBULAR TREATMENT



VESTIBULAR TREATMENTVESTIBULAR 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



HEMI SPATIAL SUNGLASSESHEMI-SPATIAL SUNGLASSES




Study by Arai, Ohi, et. al 1997Study by Arai, Ohi, et. al 1997

10 patients with unilateral left neglect

Used copying and line bisection tasks



HEMI-SPATIAL SUNGLASSESHEMI-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 half08% light penetration in the shaded half




Study by Arai, Ohi, et. al 1997Study 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 itiimprovement in functional activities



YOKED PRISMYOKED PRISM (PRISM ADAPTATION)(PRISM ADAPTATION)

TREATMENT OPTIONSTREATMENT OPTIONSFOR

VISUAL-SPATIAL INATTENTIONVISUAL SPATIAL INATTENTION

YOKED PRISM (PRISM ADAPTATION) TREATMENTYOKED 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 khemiplegia and somatosensory dysfunction secondary to stroke

TREATMENT OPTIONSTREATMENT OPTIONSFOR

VISUAL-SPATIAL INATTENTIONVISUAL 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



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

In the study, using Yoked Prisms, the positive effect was a minimum of t o ho rs as compared to other treatments here the effectsof 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 functionsspatial 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 thecan be seen as stimulating active processes involved in the plasticity of sensorimotor correspondences by activating brain functions related to multisensory integration and space representation.”


Study by Rossetti, et. al 1998…continued

Postulated mechanisms to account for the strong improvement inPostulated mechanisms to account for the strong improvement in patients with neglect:

Stimulation of short-term plasticity of brain functions related to spatial p y ptransformations 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



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.”



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


EXCELLENT REFERENCE ON PRISM ADAPTATION !!!

Published in Journal of Behavioral Optometry, 2009ub s ed Jou a o e a o 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 of patients with unilateral spatial inattention. J BehavOptom 2009; 20:101 105Optom 2009; 20:101-105



OPTOKINETIC STIMULATIONOPTOKINETIC STIMULATION

O O C S OOPTOKINETIC STIMULATIONStudy 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 OOPTOKINETIC STIMULATIONStudy by Kerkhoff, Keller, et., al. 2006

Performed 5 treatment sessions of repetitive OKN stimulationPerformed 5 treatment sessions of repetitive OKN stimulation

Used the PC based EYEMOVE program: Visual displays of objects all moving coherently toward the neglected sideobjects all moving coherently toward the neglected side

O O C S OOPTOKINETIC STIMULATIONStudy 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 OOPTOKINETIC STIMULATIONStudy by Kerkhoff, Keller 2006

Kerkhoff and associates offered two compatible hypothesis forKerkhoff 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 attentioninfluencing spatial perception and attention

O O C S OOPTOKINETIC STIMULATIONAdditional 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 ggyrus


CONCLUSION


Conclusion:Conclusion:

Visual Spatial Inattention (Neglect) is a major source of p ( g ) jstroke-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 pto remediate unilateral spatial inattention

THANK YOU



REFERENCES:

• Kinsbourne, : Mechanisms of unilateral neglect. In: Neurophysiological and neuropsychological aspects of spatialNeurophysiological 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 pNeurol. 146, 626-634, 1990

• Rossetti, et. al Prism adaptation to a rightward optical deviation rehabilitates left hemispatial neglect Nature 395/10 September 1998rehabilitates 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; 20:101-105unilateral spatial inattention. J Behav Optom 2009; 20:101-105


REFERENCES:

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


REFERENCESREFERENCES:

• Karnath, 1997- Neural coding of space in egocentric coordinates. Evidence for Lmits of a hypothesis derived from patients with parietal lesions and yp p pneglect. 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 pstroke 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 gor cancellation tasks? Journal of Clinical and Experimental Neuropsychology, 23:599-607

• Mcintosh R. , Rossetti Y. Milner A.D. Prism adaptation improves chronic , p pvisual and haptic neglect: A single case study. Cortex 2002, 3:309-320


C SREFERENCES:

• Farne A. Rossetti Y., Toniolo S. Ladavas E. Ameliorating neglect with prism adaptation: visio manual and visuo verbal measureswith 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 sensorymotor plasticity to recovery of spatial cognition: Visuomotoradaptation 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



• Sumitani M., Rossetti Y., Shibata M., Matsuda N., Prism adaptation to optical deviation alieviates pathological pain. Neurol. 2007; 68:128 13368:128-133

• Seriano A., Bonifazi S., Pierfederici ., Ladavas E., Neglect treatment by prism adaptation: What recovery and for how long. Neuropsychol Rehabil 2007; 17: 657 687Neuropsychol. Rehabil. 2007; 17: 657-687

• Arai T; Ohi H; Sasaki H; Nobuto, H Tanaka, K. HemispatialSunglasses: 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 pstimulation induces lasting recovery from visual neglect. RestorNeruol and Neurosci 24 (2006) 357-369



• 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 toptokinetic stimulation in patients with left hemineglect,

Neurology1991 49: 1364-1370

Documents

02 Bob Sanet Newest Sanet.pdfUNILATERAL SPATIAL INATTENTION (NEGLECT) Usually the result of a right parietal lobe lesion, but it can occur as a result of damage in many other areas