UNILATERAL-SPATIAL INATTENTION

Transcription

UNILATERAL-SPATIAL INATTENTION
\
ICBO CONGRESS
POMONA. CA
APRI 8,
APRIL
8 2010
ROBERT B. SANET, O.D., F.C.O.V.D.
g Center for Vision Care
San Diego
7898 Broadway
Lemon Grove CA 91945
[email protected]
UNILATERAL SPATIAL INATTENTION (NEGLECT)
GENERAL CHARACTERISTICS
 Many
Names:
Unilateral
M
N
U il t l Spatial
S ti l Neglect,
N l t Hemi-Neglect,
H iN l t
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
p
y
in the Geniculo-Striate pathway
 May or may not be accompanied by hemiplegia and
y
hemianopsia
p
homonymous
 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
M h i
is
i nott totally
t t ll clear
l
 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
relative-stimulus/intensity
stimulus/intensity
dependant
 Competitive
C
titi process
 Sometimes may only occur with simultaneous presentation
( ti ti
(extinction
phenomenon)
h
)
 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
PREDICTOR OF TREATEMENT OUTCOMES
VISUAL SPATIAL INATTENTION
VISUAL-SPATIAL
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
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
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
outcome
tcome from admission
to follow-up
PROPOSED MECHANISMS
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
ocularmotor and attentional signals
Vallar & Perani, 1986
 IPL integrates
i t
t somatic,
ti visual,
i
l and
d movementt information
i f
ti
 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 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
p
and cognitive
g
representations
p
which embody
y the enduring
g
characteristics 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
cog
t o and
a d awareness
a a e ess
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
body-centered
centered
space
• In
I neglect
l t the
th coordinate
di t transformation
t
f
ti
has
h a systematic
t
ti
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
maximum severity in the in the extreme contralateral
hemifield to a minimum severity in the extreme ipsilateral
field
Summary of Research:
• Many varied presentations of USI depending on the specific brain
( ) involved
area(s)
• 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
EVALUATION
O
Visual Field Defect-No
Neglect-???
Visual Field Defect-???
Neglect???
Both???
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
FIGURE DRAWING TESTS
DRAW A CLOCK
FLOWER COPYING TEST
LINE BISECTION TEST
CANCELLATION TESTS
NAVON FIGURES
Global vs. Local Features
LINE BISECTION TEST
Caution!
 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
Li Bi
ti
C
O t Task
T k
Line
Bisection
Cross
Out
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
 Ap
patient with a hemianopsia
p
without neglect
g
tends to bisect the line
toward the blind field, as if they are aware of the defect and
overcompensate 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
TREATMENT
TREATMENT OPTIONS
FOR
UNILATERAL SPATIAL INATTENTION
 Vestibular
V ib l Stimulation
Si l i
 Hemi-Spatial Sun Rx
 Yoked Prisms
 Optokinetic Stimulation
TREATMENT OPTIONS
FOR
VISUAL-SPATIAL INATTENTION
VESTIBULAR TREATMENT
TREATMENT OPTIONS
FOR
VESTIBULAR TREATMENT
 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
HEMI SPATIAL SUNGLASSES
HEMI-SPATIAL
TREATMENT OPTIONS
FOR
HEMI-SPATIAL
Study by Arai, Ohi, et. al 1997
 10 patients with unilateral left neglect
 Used copying and line bisection tasks
TREATMENT OPTIONS
FOR
HEMI-SPATIAL SUNGLASSES
 Used Hemi-Spatial Sun Rx
 Using spectrometer:
90% light penetration in the unshaded half
08% light penetration in the shaded half
TREATMENT OPTIONS
FOR
HEMI-SPATIAL
 4 out of 10 patients showed some improvement
 One patient demonstrated dramatic and lasting
i
improvement
t in
i functional
f
ti
l activities
ti iti
TREATMENT OPTIONS
FOR
YOKED PRISM
(PRISM ADAPTATION)
TREATMENT OPTIONS
FOR
VISUAL
SPATIAL INATTENTION
VISUAL-SPATIAL
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 and
hemiplegia
d somatosensory
t
dysfunction
d f
ti
secondary
d
to
t stroke
t k
TREATMENT OPTIONS
FOR
VISUAL
SPATIAL INATTENTION
VISUAL-SPATIAL
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,
Rossetti et.
et al 1998…continued
1998 continued
 In the study, using Yoked Prisms, the positive effect was a minimum
of two
t o hours,
ho rs as compared to other treatments where
here the effects
lasted no more than 10-12 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.”
Study by Rossetti, et. al 1998…continued
Postulated mechanisms to account for the strong improvement in
patients with neglect:
 Stimulation of short-term p
plasticity
y of brain functions related to spatial
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
Some conclusions by the authors of the study:
 “The dramatic improvement induced by prism adaptation suggests
g
is given
g
to the brain that stimulates the recovery
y process”
p
that a signal
 “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 the
in
h neuropsychological
h l i l rehabilitation
h bili i off hemispatial
h i
i l neglect.”
l
”
 Rossetti
Rossetti’s
s work had been replicated by many researchers,
in most cases with with similar results:







Mcintosh,
M
i t h et.
t al.,
l 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
EXCELLENT REFERENCE ON PRISM ADAPTATION !!!
 Published
ub s ed in Journal
Jou a of
o Behavioral
e a o a Opto
Optometry,
et y, 2009
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 Behav
Optom 2009; 20:101-105
20:101 105
TREATMENT OPTIONS
FOR
OPTOKINETIC STIMULATION
O O
C STIMULATION
S
O
OPTOKINETIC
Study by Kerkhoff, Keller, et., al. 2006
 Published in Restorative Neurology and Neuroscience
 Evaluated
E l t d pre and
d postt treatment
t
t
t using
i
line
li bisection
bi
ti tests
t t and
d
cancellation tests in two matched groups
 Transfer was assessed using paragraph reading tests
O O
C STIMULATION
S
O
OPTOKINETIC
Study by Kerkhoff, Keller, et., al. 2006
 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
O O
C STIMULATION
S
O
OPTOKINETIC
Study by Kerkhoff, Keller 2006
 Control group did conventional scanning training
 Found
F
d positive
iti in
i all
ll off the
th tests
t t administered
d i i t
d and
d transfer
t
f to
t
paragraph reading
 Effect from OKN occurred in both high and low velocity
movement and with large and small sized displays
O O
C STIMULATION
S
O
OPTOKINETIC
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
O O
C STIMULATION
S
O
OPTOKINETIC
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
p
areas,, pre-cuneus
p
and the p
posterior cingulate
g
gyrus
CONCLUSION
Conclusion:
 Visual Spatial
p
Inattention (Neglect)
( g
) is a major
j source of
stroke-related long-term disability
 Yoked prisms (prism adaptation)
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
p
role in applying
pp y g these therapeutic
p
modalities
to remediate unilateral spatial inattention
THANK YOU
REFERENCES:
• Kinsbourne, : Mechanisms of unilateral neglect. In:
Neurophysiological and neuropsychological aspects of spatial
neglect (ed: M. Jennerod) Amsterdam, North Holland pp. 69-86, 1987
• Rizzolatti and Berti, Neglect
g
as a neural representational
p
deficit. Rev.
Neurol. 146, 626-634, 1990
• Rossetti, et. al Prism adaptation to a rightward optical deviation
rehabilitates left hemispatial neglect.
neglect Nature,
Nature 395/10 September
September, 1998
•
Massucci, ME. Prism adaptation in the rehabilitation of patients with
unilateral spatial inattention
inattention. J Behav Optom 2009; 20:101-105
REFERENCES:
• N.Katz,, A.Hartman-Maeir,, H.Ring,
g, N.Soroker Functional disability
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
• Katz H-M. , Ring H., Soroker,
S
N. Arch Phy. Med. Rehab. 80(4)April
( )
1999, pp. 379-384
• Perenin MT,, Optic
p Ataxia and unilateral neglect:
g
clinical evidence for
dissociable
di
i bl spatial
i l functions
f
i
in
i posterior
i parietal
i l cortex. In:
I Parietal
P i l
lobe contributions to orientation in 3D space (ed. P. Their + H-O
Karnath, Heidelberg: Springer pp.289-308 1997
• Milner
Mil
, AD.
AD and
d Goodale
G d l MA.
MA Th
The visual
i
l brain
b i in
i action.
ti
Oxford
O f d
University Press,1995
REFERENCES:
REFERENCES
• Karnath, 1997- Neural coding of space in egocentric coordinates. Evidence
for Lmits of a hypothesis
yp
derived from p
patients with parietal
p
lesions and
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
y of unilateral neglect
g
after right-hemisphere
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
p
neglect
g
- Line bisection
or cancellation tasks? Journal of Clinical and Experimental Neuropsychology,
23:599-607
• Mcintosh R. , Rossetti Y. Milner A.D. Prism adaptation
p
improves
p
chronic
visual and haptic neglect: A single case study. Cortex 2002, 3:309-320
REFERENCES:
C S
• Farne A. Rossetti Y., Toniolo S. Ladavas E. Ameliorating neglect
with prism adaptation: visio-manual
visio manual and visuo-verbal
visuo verbal measures
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 sensorysensory
motor plasticity to recovery of spatial cognition: Visuomotor
adaptation and spatial neglect.Prog. Brain Res. , 2003; 142: 273-287
• Luate J.,
J Michael C.,
C Rode G
G. Pisella L.
L Functional anatomy of the
therapeutic effects of prism adaptation on left neglect. Neurol 2006;
66: 1859-1867
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.
Neuropsychol.
Rehabil 2007; 17: 657
657-687
687
• Arai T; Ohi H; Sasaki H; Nobuto, H Tanaka, K. Hemispatial
Sunglasses: Effect on unilateral spatial neglect. Arch Phys Med
Rehabil 1997;
Rehabil.
78 230-232
• Kerkhoff G., Keller I., Ritter V. Marquardt
q
C., Repetitive
p
optokinetic
p
stimulation
ti l ti induces
i d
lasting
l ti recovery from
f
visual
i
l neglect.
l t Restor
R t
Neruol and Neurosci 24 (2006) 357-369
REFERENCES:
REFERENCES
• Strum W., Thimm M., Fink, GR. Alertness training in neglect-
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
optokinetic
t ki ti stimulation
ti l ti in
i patients
ti t with
ith left
l ft hemineglect,
h i
l t
Neurology1991 49: 1364-1370

UNILATERAL-SPATIAL INATTENTION

Transcription

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