UNILATERAL-SPATIAL INATTENTION

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$\ ICBO CONGRESS POMONA.$ CA APRIL 8, 2010 ROBERT B.

1 UNILATERAL-SPATIAL INATTENTION \ ICBO CONGRESS POMONA. CA APRIL 8, 2010 ROBERT B. SANET, O.D., F.C.O.V.D. San Diego Center for Vision Care 7898 Broadway Lemon Grove CA rsanet@cs.com

2 UNILATERAL SPATIAL INATTENTION (NEGLECT) GENERAL CHARACTERISTICS

3 UNILATERAL SPATIAL INATTENTION (NEGLECT) Many Names: Unilateral l 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 May or may not be accompanied by hemiplegia and homonymous hemianopsia

4 UNILATERAL 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 of the cortex Stroke is the most common cause Mechanism is not totally t clear May affect Personal Space (body image), Peri-Personal 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

5 UNILATERAL SPATIAL INATTENTION (NEGLECT) Competitive process Sometimes may only occur with simultaneous presentation (extinction phenomenon) May present with any combination of visual, auditory or tactile stimuli More devastating, but also more remediable than a visual field defect The presence of neglect more than 3 months post stroke is a major predictor of Activities for Daily Living (ADL) abilities

6 UNILATERAL SPATIAL INATTENTION (NEGLECT) PREDICTOR OF TREATEMENT OUTCOMES

7 VISUAL-SPATIAL SPATIAL INATTENTION AND 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 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

8 VISUAL-SPATIAL SPATIAL INATTENTION AND 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

9 UNILATERAL SPATIAL INATTENTION (NEGLECT) PROPOSED MECHANISMS

10 UNILATERAL SPATIAL INATTENTION (NEGLECT) Vallar & Perani, 1986 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 IPL receives inputs from subcortical structures that carry IPL receives inputs from subcortical structures that carry ocularmotor and attentional signals

11 UNILATERAL SPATIAL INATTENTION (NEGLECT) Vallar & Perani, 1986 IPL integrates t somatic, visual, and movement information IPL appears to be one of the primary cortical regions governing attention The IPL is thought to be part of the ventral stream

12 UNILATERAL SPATIAL INATTENTION (NEGLECT) Milner and Goodale, 1995: Superior parietal lobe is part of dorsal stream which mediates control of 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 p and cognitive representations which embody the enduring characteristics of objects and their significance

13 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 o and awareness a ess

14 UNILATERAL SPATIAL INATTENTION (NEGLECT) Karnath, 1997: 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 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

15 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

16 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

17 UNILATERAL SPATIAL INATTENTION (NEGLECT) 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 May present as problems with various functions and areas of space - Body image - Visuo-motor control - Cognition - Attention USI appears to manifest as a biased gradient of attention across the entire visual field

18 UNILATERAL SPATIAL INATTENTION (NEGLECT) EVALUATION

19 UNILATERAL SPATIAL INATTENTION (NEGLECT) Visual Field Defect-No Neglect-???

20 UNILATERAL SPATIAL INATTENTION (NEGLECT) Visual Field Defect-??? Neglect??? Both???

21 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 Auditory/tactile stimuli

22 FIGURE DRAWING TESTS

23 DRAW A CLOCK

24 FLOWER COPYING TEST

25 LINE BISECTION TEST

26 CANCELLATION TESTS

27 NAVON FIGURES Global vs. Local Features

28 Caution! LINE BISECTION TEST Study by Ferber & Karnath, 2001 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

29 Line Bisection Cross Out Task 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 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 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 overcompensate in the process

30 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

31 GRADIENT OF NEGLECT

32 UNILATERAL SPATIAL INATTENTION (NEGLECT) TREATMENT

33 TREATMENT OPTIONS FOR UNILATERAL SPATIAL INATTENTION Vestibular Stimulation i Hemi-Spatial Sun Rx Yoked Prisms Optokinetic Stimulation

34 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION VESTIBULAR TREATMENT

35 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION 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 minutes

36 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION HEMI-SPATIAL SUNGLASSES

37 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION HEMI-SPATIAL SUNGLASSES Study by Arai, Ohi, et. al patients with unilateral left neglect Used copying and line bisection tasks

38 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION 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

39 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION HEMI-SPATIAL SUNGLASSES Study by Arai, Ohi, et. al out of 10 patients showed some improvement One patient demonstrated dramatic and lasting improvement in functional activities iti

40 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION YOKED PRISM (PRISM ADAPTATION)

41 TREATMENT OPTIONS FOR VISUAL-SPATIALSPATIAL INATTENTION YOKED PRISM (PRISM ADAPTATION) TREATMENT Study by Rossetti, et. al patients with right brain damage, mean age 62 years All in neuro rehabilitation hospital for moderate to severe hemiplegia i and somatosensory dysfunction secondary to stroke

42 TREATMENT OPTIONS FOR VISUAL-SPATIALSPATIAL 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

43 YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

44 YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION

45 YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION Study by Rossetti, et. al 1998 continued In the study, using Yoked Prisms, the positive effect was a minimum of two hours, as compared to other treatments where the effects lasted no more than minutes Positive effect were found for both sensorimotor and cognitive 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 plasticity of sensorimotor correspondences by activating brain functions related to multisensory integration and space representation.

46 YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION Study by Rossetti, et. al 1998 continued Postulated mechanisms to account for the strong improvement in patients with neglect: Stimulation of short-term plasticity of brain functions related to spatial 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

47 YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION Study by Rossetti, et. al 1998 continued 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 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 in the neuropsychological l rehabilitation i of hemispatial i neglect.

48 YOKED PRISM (PRISM ADAPTATION) FOR VISUAL-SPATIAL INATTENTION Study by Rossetti, et. al 1998 continued Rossetti s s work had been replicated by many researchers, in most cases with with similar results: Mcintosh, et. al., 2002 Farne, et. al., 2002 Frassinetti, et. al., 2002 Rode, et. al., 2003 Luate, et. al., 2006 Sumitani, et. al., 2007 Seriano, et. al., 2007

49 UNILATERAL SPATIAL INATTENTION EXCELLENT REFERENCE ON PRISM ADAPTATION!!! Published in Journal of Behavioral a Optometry, 2009 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 Behav Optom 2009; 20:

50 TREATMENT OPTIONS FOR VISUAL-SPATIAL INATTENTION OPTOKINETIC STIMULATION

51 OPTOKINETIC O STIMULATION Study by Kerkhoff, Keller, et., al Published in Restorative Neurology and Neuroscience Evaluated pre and post treatment t t using line bisection tests t and cancellation tests in two matched groups Transfer was assessed using paragraph reading tests

52 OPTOKINETIC O STIMULATION Study by Kerkhoff, Keller, et., al Performed 5 treatment sessions of repetitive OKN stimulation Used the PC based EYEMOVE program: Visual displays of objects all moving coherently toward the neglected side

53 OPTOKINETIC O STIMULATION Study by Kerkhoff, Keller 2006 Control group did conventional scanning training Found positive in all of the tests t administered i d and transfer to paragraph reading Effect from OKN occurred in both high and low velocity movement and with large and small sized displays

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

55 OPTOKINETIC O 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 p areas, pre-cuneus and the posterior cingulate gyrus

56 UNILATERAL SPATIAL INATTENTION (NEGLECT) CONCLUSION

57 Conclusion: VISUAL-SPATIAL INATTENTION Visual Spatial Inattention (Neglect) is a major source of stroke-related long-term disability 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 to remediate unilateral spatial inattention

58 THANK YOU

59 UNILATERAL SPATIAL INATTENTION

60 UNILATERAL SPATIAL INATTENTION REFERENCES: Kinsbourne, : Mechanisms of unilateral neglect. In: Neurophysiological and neuropsychological aspects of spatial neglect (ed: M. Jennerod) Amsterdam, North Holland pp , 1987 Rizzolatti and Berti, Neglect as a neural representational deficit. Rev. Neurol. 146, , 1990 Rossetti, et. al Prism adaptation to a rightward optical deviation 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:

61 UNILATERAL SPATIAL INATTENTION REFERENCES: N.Katz, A.Hartman-Maeir, H.Ring, N.Soroker Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect. Archives of Physical Medicine and Rehabilitation 1999; 80 (4), Katz H-M., Ring H., Soroker, N. Arch Phy. Med. Rehab. 80(4)April 1999, pp Perenin MT, Optic Ataxia and unilateral neglect: clinical evidence for dissociable i spatial functions in posterior parietal cortex. In: Parietal lobe contributions to orientation in 3D space (ed. P. Their + H-O Karnath, Heidelberg: Springer pp 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

62 UNILATERAL SPATIAL INATTENTION REFERENCES: Karnath, Neural coding of space in egocentric coordinates. Evidence for Lmits of a hypothesis derived from patients with parietal lesions and neglect. In: Parietal lobe contributions to orientation in 3D space space (ed. P. Their+H-O Karnath, Heidelberg:Springer pp pp Vallar G, Perani D. The anatomy of unilateral neglect after right-hemisphere stroke lesions. A clinical/ct-scan correlation study in man. Neuropsychologia. 1986;24(5): Ferber S., Karnath H.O. (2001) How to assess spatial neglect - Line bisection or cancellation tasks? Journal of Clinical and Experimental Neuropsychology, 23: Mcintosh R., Rossetti Y. Milner A.D. Prism adaptation improves chronic, p p visual and haptic neglect: A single case study. Cortex 2002, 3:

63 UNILATERAL SPATIAL INATTENTION REFERENCES: Farne A. Rossetti Y., Toniolo S. Ladavas E. Ameliorating neglect with prism adaptation: visio-manual and visuo-verbal verbal measures. Neurophysiologica 2002;40: Frassinetti F., Angeli V., Menegrello F., Avanzi S., Long-lasting ameioration of visuospatial neglect by prism adaptation. Brain 2002, 125: 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: 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:

64 UNILATERAL SPATIAL INATTENTION REFERENCES: Sumitani M., Rossetti Y., Shibata M., Matsuda N., Prism adaptation to optical deviation alieviates pathological pain. Neurol. 2007; 68: Seriano A., Bonifazi S., Pierfederici., Ladavas E., Neglect treatment by prism adaptation: What recovery and for how long. Neuropsychol. Rehabil. 2007; 17: Arai T; Ohi H; Sasaki H; Nobuto, H Tanaka, K. Hemispatial Sunglasses: Effect on unilateral spatial neglect. Arch Phys Med Rehabil. 1997; Kerkhoff G., Keller I., Ritter V. Marquardt C., Repetitive optokinetic stimulation induces lasting recovery from visual neglect. Restor Neruol and Neurosci 24 (2006)

65 UNILATERAL SPATIAL INATTENTION REFERENCES: Strum W., Thimm M., Fink, GR. Alertness training in neglect- Behavioural and imagining results. Restor Neruol and Neurosci, 2006;24(4-6): Vallar G., Guariglia C., Nico D., Pizzamiglio L. Motor deficits and optokinetic ti stimulation in patients t with left hemineglect, Neurology :

Unilateral Spatial Neglect USN

Unilateral Spatial Neglect USN 86 214 28 2 Behavioural Inattention Test Catherine Bergego Scale 28 2 214 223 2008 Key Words unilateral spatial neglect language disturbance mechanism priming rehabilitation Unilateral Spatial Neglect