[ARTICLE] Rehabilitation of hemianopia and visuospatial hemineglect with a mixed intervention including adapted boxing therapy: An exploratory case study – Full Text

ABSTRACT

Visual field loss and visuospatial neglect are frequent consequences of cerebral stroke. They often have a strong impact on independence in many daily activities. Rehabilitation aiming to decrease these disabilities is therefore important, and several techniques have been proposed to foster awareness, compensation, or restitution of the impaired visual field. We here describe a rehabilitation intervention using adapted boxing therapy that was part of a pluridisciplinary intervention tailored for a particular case. A 58-year-old man with left homonymous hemianopia (HH) and mild visuospatial hemineglect participated in 36 sessions of boxing therapy six months after a right temporo-occipital stroke. Repeated stimulation of his blind and neglected hemifield, and training to compensate for his deficits through improved use of his healthy hemifield were performed through boxing exercises. The patient showed a stable HH before the beginning of the training. After six months of boxing therapy, he reported improved awareness of his visual environment. Critically, his HH had evolved to a left superior quadrantanopia and spatial attention for left-sided stimuli had improved. Several cognitive functions and his mood also showed improvement. We conclude that boxing therapy has the potential to improve the compensation of visuospatial impairments in individual patients with visual field loss.

Introduction

Visual field loss and neglect are distinct, yet often concomitant sequelae of unilateral brain damage. The former is considered a perceptual defect of the visual field and is caused by damage to the visual cortex or pathways (Zihl, Citation1995). Homonymous hemianopia (HH) is the contralesional loss of one-half of the visual field in both eyes. It is the most common visual disorder after stroke, with a prevalence of 20–57% (Rowe et al., Citation2009). Visuospatial neglect is the contralesional reduction of awareness for the spatial side opposite to the lesioned area. The prevalence is on average 30% after unilateral lesion in stroke patients (Esposito et al., Citation2021).

The consequences of HH and visuospatial neglect on patients’ autonomy in daily activities, such as reading, cooking, driving, spatial navigation, or simply moving within their homes, are often substantial. Because of these handicaps, the quality of life is obviously reduced, and patients present subjective complaints even years after injury (Papageorgiou et al., Citation2007). Only 10% of patients with HH fully recover within the first two weeks (Gray et al., Citation1989). Visual recovery is partial in the subacute phase and becomes negligible after 10–12 weeks (Gray et al., Citation1989; Tiel & Kolmel, Citation1991; Zhang et al., Citation2006). Spontaneous recovery of visuospatial hemineglect occurs within the first six months and is still present at three months in 17% of patients with right brain lesions (Ringman et al., Citation2004).

With time, some patients with remaining visual field difficulties spontaneously use strategies to compensate for their blind and/or neglected hemifield (Fellrath & Ptak, Citation2015; Zihl, Citation1995). However, some compensation strategies are not functional, and many patients continue to show impairment in everyday life. Rehabilitation of both HH and visuospatial hemineglect is therefore highly recommended and should start early for a positive prognosis. Some interventions for these disorders are similar and often involve visual field training (e.g., Kerkhoff et al., Citation2021; Leitner & Hawelka, Citation2021). There are four different forms of intervention (Schofield & Leff, Citation2009), which are sometimes combined (Bowen et al., Citation2013).

1. Substitutive compensation with external aids to help the patient interact with his visual environment. The best known is the prism goggle, an optical device that induces a deviation of the blind/neglected field towards the healthy side of the visual field. Optical aids may be efficient though not when patients present visual attentional symptoms (Ptak, Citation2017), but are unfortunately prone to cause diplopia and visuospatial confusion in certain patients (Trauzettel-Klosinski, Citation2010).
2. Behavioural compensation is the training to use the normal hemifield for contralesional visual perception and attentional focus instead of the blind and neglected hemifield respectively. Head and eye movements towards the blind/neglected hemifield are trained in order to create an automatic behaviour (Hill et al., Citation2015; Pambakian et al., Citation2004; Zihl, Citation1995).
3. Restoration and increased awareness of the problematic hemifield via passive repeated sensory stimulation. This approach is based on the idea that recurrent administration of visual stimuli in the blind and/or neglected hemifield of patients promotes neural plasticity. However, this approach is highly controversial (see Das & Huxlin, Citation2010; Huxlin et al., Citation2009; Kasten et al., Citation1998; Melnick et al., Citation2016; against: Schreiber et al., Citation2006).
4. Multisensory stimulation: combining visual and auditory stimulation in order to activate multisensory integration for visual restoration and improved awareness of the visual field (Bolognini et al., Citation2005; Rowland et al., Citation2023; Zigiotto et al., Citation2021).

We here report the outcome of an interdisciplinary and complex intervention including physical, occupational, and neuropsychological therapies in a 58-year-old man six months after a posterior ischaemic stroke. The neuropsychological programme aimed to train visual attention, compensate for the blind hemifield and improve visual function in the blind hemifield by repeated stimulation. To this aim we applied adapted boxing therapy (ABT), which was previously used to improve mobility, balance, and quality of life in patients with Parkinson’s disease (Combs et al., Citation2011; Morris et al., Citation2019). Boxing training has also been applied to improve balance, motor ability, and cognitive functions in stroke patients (Ersoy & Iyigun, Citation2021; Park et al., Citation2017). Park et al. (Citation2017) found that boxing therapy even enhanced quality of life to a greater extent than physical therapy alone.

To our knowledge, this is the first case report of boxing therapy in the rehabilitation of visual field loss and impaired visuospatial attention. Boxing movements require motor activation and advanced coordination of the upper body, as well as visuomotor coordination when patients are instructed to hit visual targets. If the targets are moving from one hemifield to another, it also trains the detection of and reaction to stimuli in the blind or neglected hemifield. Stimulation is not only visual, but also auditory and tactile (when the glove hits the target), and requires high degrees of balance and postural control. Because of the multisensory nature of ABT, we hypothesized that this method may improve the active compensation of visual field defects and visuospatial neglect. […]

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Figure 1. Brain MRI of the patient performed at two weeks. Axial view fluid-attenuated inversion recovery T2-weighted MR image shows hyperintense lesions in the right temporo-occipital area.
Axial view of the patient’s brain showing lesion in the right temporo-occipital lobe.