Smooth pursuit eye movement training promotes recovery from auditory and visual neglect: a randomized controlled study.

BACKGROUND: No treatment for auditory neglect and no randomized controlled trial evaluating smooth pursuit eye movement therapy (SPT) for multimodal neglect are available. OBJECTIVE: To compare the effects of SPT and visual scanning therapy (VST) on auditory and visual neglect in chronic stroke patients with neglect. METHODS: A randomized, prospective trial was conducted. Fifty patients with left auditory and visual neglect were randomly assigned. Twenty-four patients completed SPT therapy and 21 patients VST. Five patients (4 VST, 1 SPT) were lost. Each group received 1-hour sessions of neglect therapy for 5 consecutive days totaling 5 hours. Outcome measures in visual neglect (digit cancellation, visuoperceptual- and motor line bisection, paragraph reading) and auditory neglect (auditory midline) were assessed twice before therapy, thereafter, and at 2-week follow-up. The SPT group practiced smooth pursuit eye movements while tracking stimuli moving leftward. The VST group systematically scanned the same but static stimuli. Both groups were divided into subgroups, and effects were separately investigated for mild and severe neglect. RESULTS: Both groups did not differ before therapy in clinical/demographic variables or neglect severity (auditory/visual). After treatment, the SPT group showed significant and lasting improvements in all visual measures and normal performance in the auditory midline. Neither visual nor auditory neglect impairments changed significantly after VST. Moreover, the treatment effect sizes (Cohen's d) were considerably higher for visual and auditory neglect after SPT versus VST, both for mild and severe neglect. CONCLUSIONS: Repetitive contralesional, smooth pursuit training induces superior, multimodal therapeutic effects in mild and severe neglect.

Differential effects of galvanic vestibular stimulation on arm position sense in right- vs. left-handers.

The human brain is organized asymmetrically in two hemispheres with different functional specializations. Left- and right-handers differ in many functional capacities and their anatomical representations. Right-handers often show a stronger functional lateralization than left-handers, the latter showing a more bilateral, symmetrical brain organization. Recent functional imaging evidence shows a different lateralization of the cortical vestibular system towards the side of the preferred hand in left- vs. right-handers as well. Since the vestibular system is involved in somatosensory processing and the coding of body position, vestibular stimulation should affect such capacities differentially in left- vs. right-handers. In the present, sham-stimulation-controlled study we explored this hypothesis by studying the effects of galvanic vestibular stimulation (GVS) on proprioception in both forearms in left- and right-handers. Horizontal arm position sense (APS) was measured with an opto-electronic device. Second, the polarity-specific online- and after-effects of subsensory, bipolar GVS on APS were investigated in different sessions separately for both forearms. At baseline, both groups did not differ in their unsigned errors for both arms. However, right-handers showed significant directional errors in APS of both arms towards their own body. Right-cathodal/left-anodal GVS, resulting in right vestibular cortex activation, significantly deteriorated left APS in right-handers, but had no detectable effect on APS in left-handers in either arm. These findings are compatible with a right-hemisphere dominance for vestibular functions in right-handers and a differential vestibular organization in left-handers that compensates for the disturbing effects of GVS on APS. Moreover, our results show superior arm proprioception in left-handers in both forearms.

Galvanic vestibular stimulation improves arm position sense in spatial neglect: a sham-stimulation-controlled study.

BACKGROUND: Disturbed arm position sense (APS) is a frequent and debilitating condition in patients with hemiparesis after stroke. Patients with neglect, in particular, show a significantly impaired contralesional APS. Currently, there is no treatment available for this disorder. Galvanic vestibular stimulation (GVS) may ameliorate neglect and extinction by activating the thalamocortical network. OBJECTIVE: The present study aimed to investigate the immediate effects and aftereffects (AEs; 20 minutes) of subsensory, bipolar GVS (M = 0.6 mA current intensity) on APS in stroke patients with versus without spatial neglect and matched healthy controls. METHODS: A novel optoelectronic arm position device was developed, enabling the precise measurement of the horizontal APS of both arms. In all, 10 healthy controls, 7 patients with left-sided hemiparesis and left-spatial neglect, and 15 patients with left hemiparesis but without neglect were tested. Horizontal APS was measured separately for both forearms under 4 experimental conditions (baseline without GVS, left-cathodal/right-anodal GVS, right-cathodal/left-anodal GVS, sham GVS). The immediate effects during GVS and the AEs 20 minutes after termination of GVS were examined. RESULTS: Patients with neglect showed an impaired contralateral APS in contrast to patients without neglect and healthy controls. Left-cathodal/right-anodal GVS improved left APS significantly, which further improved into the normal range 20 minutes poststimulation. GVS had no effect in patients without neglect but right-cathodal/left-anodal GVS worsened left APS in healthy participants significantly. CONCLUSIONS: GVS can significantly improve the impaired APS in neglect. Multisession GVS can be tested to induce enduring therapeutic effects.

Rotation or translation of auditory space in neglect? A case study of chronic right-sided neglect.

Egocentric models of neglect explain the lateralised omission of stimuli in neglect patients by an ipsilesional shift of a subjective reference frame. However, they differ in the direction of shift (rotation around the midsagittal plane versus translation in front/back space). We tested this hypothesis in a patient (AJ) with persistent right-sided neglect following a left temporo-parieto-occipital and hypoxic lesion and in six age-matched healthy subjects. AJ showed visual neglect in line bisection, size matching, reading and visual search. Auditory localization was tested by using two different psychophysical techniques based on binaurally simulated stimuli for the horizontal plane in front and back space. Eye position was continuously monitored during stimulus presentation in all subjects. AJ revealed a significant ipsilesional, leftward shift of his auditory subjective median plane (ASMP) in front space (mean: -22.6 degrees), and a rightward shift of the ASMP in back space (+14.5 degrees). This pattern of results was replicated with a different psychophysical technique in a retest 10 months later. The rotational shift of AJ's ASMP contrasted with normal performance in the healthy subjects. Monaural hearing deficits can not account for these differential findings as all subjects (including AJ) performed normally. In conclusion, a rotation of the egocentric spatial reference frame may occur in the auditory modality for right-sided neglect.