We investigated the clinical effectiveness of Eye-Search, a web-based therapy app designed to improve visual search times, in a large group of patients with either hemianopia, neglect or both hemianopia and neglect. A prospective, interventional cohort design was used. For the main, impairment-based outcome measure (average visual search time), the within-subject control was affected vs. unaffected side. Four hundred and twenty-six participants who fitted the inclusion criteria completed all 4 time points (1200 therapy trials). We found a significant three-way interaction between therapy, side and group. Eye-Search therapy improved search times to the affected visual field of patients with either hemianopia alone or neglect and hemianopia, but not those with neglect alone. Effect sizes were moderate to large and consistent with previous studies. We found a similar significant interaction between therapy and group for the patient-reported outcome measure “finding things” that most closely matched the impairment-based outcome (visual search). Eye-Search therapy improves both impairment-based and patient-reported outcome measures related to visual search in patients with hemianopia alone or hemianopia and neglect.
Hemianopia and neglect are the two most common visual disorders complicating posterior brain injury (Corbetta et al., 2005; Rowe et al., 2019). While neglect is more likely to spontaneously improve over the first year post-injury than hemianopia, both have long-term effects on patients’ activities of daily living (Warren, 2009; Wee & Hopman, 2008). Several behavioural approaches to treating patients with persistent hemianopia have been successfully trialled. The most consistently effective therapies promote retraining of compensatory eye movements, by practising voluntary guided saccades (e.g., patients have to find a visual target amongst distractors, or find a target that has “jumped” to a new location in their blind field (Jacquin-Courtois et al., 2013; Schuett et al., 2012)). Eye-movement therapies have also been shown to be effective in treating the symptoms of neglect, although these rely on stimuli that induce smooth-pursuit eye movements (e.g., patients have to focus on targets that move towards their neglected side at a constant velocity (Hopfner et al., 2015; Kerkhoff et al., 2014)). We have previously reported on the clinical efficiency of Eye-Search (https://www.eyesearch.ucl.ac.uk/), a web-based therapy that improves visual search in patients with hemianopia, but in that study (n = 78) we left out patients with neglect (Ong et al., 2015). As hemianopia and neglect can co-occur (Muller-Oehring et al., 2003), the aim of this study was to investigate whether Eye-Search therapy works in patients with either neglect alone (“pure neglect” group) or hemianopia and neglect. We also extended the criteria for length of participation in the study from three time points (patients completed 800 therapy trials), to four (1200 therapy trials completed).
Materials and methods
All subjects’ data were collected using the Eye-Search browser-based app. This study was approved by the UCL Research Ethics Committee: 2681/001, and all participants consented to the use of their data. All data were anonymized and held securely on a UCL server. The Eye-Search app has five main data collecting components:
A test to identify hemianopia
A test to identify visual neglect
The therapy: a ramp-step paradigm, embedded in a game, that delivers the trial-by-trial eye-movement practice
An impairment-based outcome measure: a visual search task
A patient-reported outcome measure (PROM): a visual analogue scale for rating difficulty performing six activities of daily life
Subjects re-tested themselves on the two visual tests and two outcome measures before they started therapy (baseline) and then every time that they completed a block of 400 trials (T1 = after 400 trials, T2 after 800 and T3 after 1200).
Study population and selection criteria
The therapy took place at the discretion of the patient and on their personal computers. Due to the nature and delivery modality of the therapy, the patients are considered to be self-enrolled, rather than traditionally recruited. The data analysed in this study were collected from participants who used the Eye-Search website between July 2012 and February 2019. In this period, 1407 participants took part, out of which 426 fitted the inclusion criteria (see consort diagram Figure 1). Of these, 302 (71%) were male. The mean participant age was 60 years [SD 14.6]. Causative diagnosis was self-reported with 6% leaving the section blank. The remaining patients were divided as follows: 84% stroke; 5% head injury; 3% surgery; and, 2% reported other causes such as an abscess, CO poisoning and encephalitis. Time between the cause of their visual impairment and starting therapy was positively skewed, median 85 days [IQR = 44–210 days]. Progress through the therapy was self-paced. The time to get from baseline to T1 and T3 was also positively skewed with subjects taking a median time of 5 days [IQR = 2–12 days] and 20 days [IQR = 9–33 days], respectively.
Figure 1. Consort diagram showing the identification of participants in the study.
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The aim of this review was to summarize the evidence for the effectiveness of low-frequency (LF) repetitive transcranial magnetic stimulation (rTMS) over the unaffected hemisphere in promoting functional recovery after stroke. We performed a systematic search of the studies using LF-rTMS over the contralesional hemisphere in stroke patients and reviewed the 67 identified articles. The studies have been gathered together according to the time interval that had elapsed between the stroke onset and the beginning of the rTMS treatment. Inhibitory rTMS of the contralesional hemisphere can induce beneficial effects on stroke patients with motor impairment, spasticity, aphasia, hemispatial neglect and dysphagia, but the therapeutic clinical significance is unclear. We observed considerable heterogeneity across studies in the stimulation protocols. The use of different patient populations, regardless of lesion site and stroke aetiology, different stimulation parameters and outcome measures means that the studies are not readily comparable, and estimating real effectiveness or reproducibility is very difficult. It seems that careful experimental design is needed and it should consider patient selection aspects, rTMS parameters and clinical assessment tools. Consecutive sessions of rTMS, as well as the combination with conventional rehabilitation therapy, may increase the magnitude and duration of the beneficial effects. In an increasing number of studies, the patients have been enrolled early after stroke. The prolonged follow-up in these patients suggests that the effects of contralesional LF-rTMS can be long-lasting. However, physiological evidence indicating increased synaptic plasticity, and thus, a more favourable outcome, in the early enrolled patients, is still lacking. Carefully designed clinical trials designed are required to address this question. LF rTMS over unaffected hemisphere may have therapeutic utility, but the evidence is still preliminary and the findings need to be confirmed in further randomized controlled trials.
Source: Low-frequency rTMS of the unaffected hemisphere in stroke patients: A systematic review – Sebastianelli – 2017 – Acta Neurologica Scandinavica – Wiley Online Library
- motor function,
- repetitive transcranial magnetic stimulation,
We recorded gaze positions during visual imagery in patients with HLH or neglect.
Spatially consistent mental imagery was possible in all hemianopic patients.
Neglect patients had a representational disability for the left side of the map.
Hemianopic patients positioned their gaze contralesionally-Neglect patients positioned their gaze ipsilesionally.
Occipital and fronto-parietal cortices are involved in visual imagery.
Spontaneous eye movements during imagery are not random and can be used to study and reveal mental visualization processes (Fourtassi et al., 2013; Johansson et al. 2006). For example, we previously showed that during memory recall of French towns via imagery healthy individuals looks straight ahead when recalling Paris and their subsequent gaze positions are significantly correlated with the real GPS coordinates of the recalled towns. This correlation suggests that memory retrieval is done via depictive representations as it is never found when the towns are recalled using verbal fluency. In the present paper we added to this finding by showing that the mental image is spontaneously centered on the head or body midline.
In order to investigate the capacities of visual imagery in patients, and by extension, the role of primary visual cortex and fronto-parietal cortex in spatial visual imagery, we recorded gaze positions during memory recall of French towns in an imagery task, a non-imagery task (verbal fluency), and a visually-guided task in five patients with left or right hemianopia and in four patients with hemineglect (two with left hemianopia and two without).
The correlation between gaze position and real GPS coordinates of the recalled towns was significant in all hemianopic patients, but in patients with hemineglect this was only the case for towns located on the right half of the map of France. This suggests hemianopic patients can perform spatially consistent mental imagery despite direct or indirect unilateral lesions of the primary visual cortex. In contrast, the left-sided towns recalled by hemineglect patients, revealed that they have some spatial inconsistency or representational difficulty.
Hemianopic patients positioned and maintained their gaze in their contralesional hemispace, suggesting that their mental map was not centered on their head or body midline. This contralesional gaze positioning appeared to be a general compensation strategy and was not observed in patients with neglect (with or without hemianopia). Instead, neglect patients positioned their gaze in their ipsilesional hemispace and only when performing the visual imagery task.
These findings are discussed in the context of the role of occipital and fronto-parietal cortices in the neuroanatomical model of visual imagery developed by Kosslyn et al. (2006).
Source: Spontaneous ocular positioning during visual imagery in patients with hemianopia and/or hemineglect
The aim of this systematic review was to integrate and assess evidence for the effectiveness of multisensory stimulation (i.e., stimulating at least two of the following sensory systems: visual, auditory, and somatosensory) as a possible rehabilitation method after stroke. Evidence was considered with a focus on low-level, perceptual (visual, auditory and somatosensory deficits), as well as higher-level, cognitive, sensory deficits. We referred to the electronic databases Scopus and PubMed to search for articles that were published before May 2015. Studies were included which evaluated the effects of multisensory stimulation on patients with low- or higher-level sensory deficits caused by stroke. Twenty-one studies were included in this review and the quality of these studies was assessed (based on eight elements: randomization, inclusion of control patient group, blinding of participants, blinding of researchers, follow-up, group size, reporting effect sizes, and reporting time post-stroke). Twenty of the twenty-one included studies demonstrate beneficial effects on low- and/or higher-level sensory deficits after stroke. Notwithstanding these beneficial effects, the quality of the studies is insufficient for valid conclusion that multisensory stimulation can be successfully applied as an effective intervention. A valuable and necessary next step would be to set up well-designed randomized controlled trials to examine the effectiveness of multisensory stimulation as an intervention for low- and/or higher-level sensory deficits after stroke. Finally, we consider the potential mechanisms of multisensory stimulation for rehabilitation to guide this future research.
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Front Psychiatry. 2015 Aug 26
BACKGROUND: Traumatic brain injury (TBI) is a common cause of physical,psychological, and cognitive impairment, but many current treatments for TBI are ineffective or produce adverse side effects. Non-invasive methods of brain stimulation could help ameliorate some common trauma-induced symptoms.
OBJECTIVE: This review summarizes instances in which repetitive Transcranial Magnetic Stimulation (rTMS) and transcranial Direct Current Stimulation (tDCS) have been used to treat symptoms following a TBI. A subsequent discussion attempts to determine the value of these methods in light of their potential risks.
METHODS: The research databases of PubMed/MEDLINE and PsycINFO were electronically searched using terms relevant to the use of rTMS and tDCS as a tool to decrease symptoms in the context of rehabilitation post-TBI.
RESULTS: Eight case-studies and four multi-subject reports using rTMS and sixmulti–subject studies using tDCS were found. Two instances of seizure are discussed.
CONCLUSION: There is evidence that rTMS can be an effective treatment option for some post-TBI symptoms, such as depression, tinnitus, and neglect. Although the safety of this method remains uncertain, the use of rTMS in cases of mild TBI without obvious structural damage may be justified. Evidence on the effectiveness of tDCS is mixed, highlighting the need for additional investigations.
Source: Traumatic Brain Injury Resource Guide – Research Reports – Non-invasive brain stimulation for the treatment of symptoms following traumatic brain injury
One prominent deficit resulting from stroke is visuo-spatial neglect, which has been associated with slower and more attenuated recovery patterns of sensory-motor impairment as well as limitations in activities of daily living (ADL). The aim of the current study was to further specify the relationship between neglect and recovery of different domains of ADL. One hundred eighty four patients were assessed with the Functional Independence Measure in the first week of inpatient rehabilitation, and again at 6, 12, and 36months post-stroke. On average, neglect patients scored significantly lower on Self-care, Transfers, and Locomotion compared to non-neglect patients, but these differences became smaller with progress of time. Overall, no differences between groups were found for Sphincter control and Cognition. Patients with more severe neglect scored significantly lower on Self-care and Transfers compared to patients with mild neglect. During rehabilitation, it would be of importance to test for independence in ADL domains in neglect in order to define realistic treatment goals. The current findings could be taken into account in early multidisciplinary intervention planning in the sub-acute phase, to optimize regaining ADL…
via Predicting Functional Outcome after Stroke: The Influence of Neglect on Basic Activities in Daily Living.