Effects of a Stimulus Response Task Using Virtual Reality on Unilateral Spatial Neglect: A Randomized Controlled Trial.

OBJECTIVE: To investigate the effects of a stimulus response task using virtual reality (VR) for unilateral spatial neglect (USN). DESIGN: Double-blind randomized controlled trial. SETTING: Acute phase hospital where stroke patients are hospitalized. PARTICIPANTS: The participants were 42 patients (N=42) with right-hemisphere cerebral damage who had been experiencing USN in their daily lives. They were randomly assigned to 3 groups: a stimulus response task with a background shift (SR+BS group), a stimulus response task without a background shift (SR group), and an object gazing task (control group). INTERVENTIONS: The stimulus response task was to search for balloons that suddenly appeared on the VR screen. A background shift was added to highlight the search in the neglected space. The control task was to maintain a controlled gaze on a balloon that appeared on the VR screen. The intervention period was 5 days. MAIN OUTCOME MEASURES: The primary outcome was the participants' scores on a stimulus-driven attention test (SAT) using the reaction time. The stimuli of the SAT were divided into 6 blocks of 3 lines on each side (-3 to +3). The secondary outcomes were their scores on the Behavioral Intention Test conventional, Catherine Bergego Scale, and straight ahead pointing tests. RESULTS: In the SAT, there were significant interaction effects of reaction time between time and group factors in left-2, right+2, and right+3. The SR+BS and SR groups showed significant improvements in the reaction time of left-2 and right+3 compared with the control group. Moreover, the SR+BS group showed a significant improvement in the reaction time of left-2, which was the neglected space, compared with the SR group. However, there were no significant interaction effects of Behavioral Intention Test conventional, Catherine Bergego Scale, and straight ahead pointing. CONCLUSIONS: Our results suggest that the use of stimulus response tasks using VR combined with background shifts may improve left-sided USN.

Effects of a visual search task in a virtual reality space with a moving background on spatial cognition and standing balance in patients with left hemiparetic stroke.

We examined effects of a visual search task (VST) in virtual reality (VR) with a moving background on spatial cognition and standing balance in left hemiparetic strokes. The VST with background deviation was allocated to Case A. In Case B, the VST without the deviation was performed. As a results, in Case A, the reaction time of VST was shortened in the paretic space and ability of weight-shift to the paretic side was improved. In conclusion, the VST in the VR with a spatial manipulation may improve spatial cognition and standing balance in left hemiparetic strokes.

Effect of stimulation-driven attention in virtual reality balloon search training of patients with left unilateral spatial neglect after stroke: A randomized crossover study.

Patients with unilateral spatial neglect (USN) commonly experiences stimulus-driven attention deficit characterized by unexpected stimuli detection. We investigated whether virtual reality (VR) balloon search training with the screen background shifted to left space could improve stimulus-driven attention in patients with USN. The participants were divided into two groups: immediate VR group (n = 14) and delayed VR group (n = 14). The immediate VR group first received VR balloon search training, followed by control training, for two weeks each. Delayed VR group received the same training in reverse order. Outcomes were changes in scores on Catherine Bergego Scale (CBS) and reaction time on the modified Posner task (MPT). There was significant improvement in CBS score change after VR balloon retrieval training (all F > 2.71; P < 0.002). In the invalid condition of MPT, significant improvements were shown after VR balloon search training in left-sided reaction time (improvement of stimulation-driven attention). This study shows that VR balloon search training can improve neglect symptoms by using an intensive intervention lasting 2 weeks.

Effects of visual-motor illusion in stroke hemiplegic patients with left-side personal neglect: A report of two cases.

Personal neglect is the neglect of self-body space, which often occurs in patients with unilateral spatial neglect (USN), but lacks a dedicated rehabilitation. The purpose of this study was to investigate the effects of visual-motor illusion (VMI) on two-stroke hemiplegic patients with left-side personal neglect. Case 1 was a 53-year-old man diagnosed with a right lenticulostriate artery infarction. Case 2 was a 76-year-old woman diagnosed with a right middle cerebral artery infarction. USN symptoms were not observed in either patient in the desk USN assessment, but personal neglect and USN symptoms in daily life were observed in both patients. Intervention effects were verified using an ABA design, comprising a 5-day three-phase (A1, B, A2). In phase B, VMI was performed on the paralyzed upper limb for 10 min in addition to conventional physical therapy. Outcomes measures were the Fluff test, Catherine Bergego Scale (CBS), Fugl-Meyer Assessment (FMA), and Functional Independence Measure (FIM). In both patients, no improvements were noted in FMA, but improvements were observed in the Fluff test, CBS, and FIM in phase B; these effects were retained in phase A2. Therefore, VMI may have contributed to improvements in Personal neglect and USN symptoms in daily life.

Intra- and inter-rater reliability of angle assessment for righting reaction from a tilted sitting position in healthy participants.

[Purpose] Lateral balance and the righting reaction are related to trunk function and many activities of daily living. However, there are no studies evaluating the assessment of the righting reaction while ensuring safety. This study aimed to clarify the reliability of assessments for the righting reaction from a tilted sitting position in healthy participants. [Participants and Methods] The participants of this study included 28 healthy young adults. Before the start of the study, markers were attached to the participants for data collection. Participants were asked to sit on a vertical board, tilted 10 degrees, and were asked to perform the righting reaction. This test was repeated four times on each side. The actions were recorded with a video camera, and two analysts used the Image J software to calculate the angles of the righting reaction of the neck, trunk, and left and right lower legs. [Results] High reliability was obtained regardless of the tilt direction and site of righting reaction. In addition, no adverse events occurred. [Conclusion] It was possible to evaluate the righting reaction while ensuring safety, and reproducibility was confirmed.

Predictive factors for walking in acute stroke patients: a multicenter study using classification and regression tree analysis.

[Purpose] Walking ability should be predicted as early as possible in acute stroke patients. The purpose is to construct a prediction model for independent walking from bedside assessments using classification and regression tree analysis. [Participants and Methods] We conducted a multicenter case-control study with 240 stroke patients. Survey items included age, gender, injured hemisphere, the National Institute of Health Stroke Scale, the Brunnstrom Recovery Stage for lower extremities, and "turn over from a supine position" from the Ability for Basic Movement Scale. The National Institute of Health Stroke Scale items, such as language, extinction, and inattention, were grouped under higher brain dysfunction. We used the Functional Ambulation Categories to classify patients into independent (four or more the Functional Ambulation Categories; n=120) and dependent (three or fewer the Functional Ambulation Categories; n=120) walking groups. A classification and regression tree analysis was used to create a model to predict independent walking. [Results] The Brunnstrom Recovery Stage for lower extremities, "turn over from a supine position" from the Ability for Basic Movement Scale, and higher brain dysfunction were the splitting criteria for classifying patients into four categories: Category 1 (0%), severe motor paresis; Category 2 (10.0%), mild motor paresis and could not turn over; Category 3 (52.5%), with mild motor paresis, could turn over, and had higher brain dysfunction; and Category 4 (82.5%), with mild motor paresis, could turn over, and no higher brain dysfunction. [Conclusion] We constructed a useful prediction model for independent walking based on the three criteria.

Reaction time analysis in patients with mild left unilateral spatial neglect employing the modified Posner task: vertical and horizontal dimensions.

Unilateral spatial neglect (USN) is a common neurological syndrome that develops after a right hemisphere lesion. By examining the performance of the modified Posner task added to the vertical dimensions of the left and right visual fields, we studied whether the lower left area had different neglect symptoms than the other locations. 41 patients with right hemisphere damage were classified into those with mild USN (USN+ ; n = 20) and without USN (USN- ; n = 21). Twenty older participants made up the healthy control (HC; n = 20) group. All participants recorded deficits in the paper-and-pencil tests established for neglect and reaction times in the modified Posner task. In the paper-and-pencil tests, there was no difference in deficit between the upper and lower left visual fields in any of the groups. According to the modified Posner task, the USN+ group exhibited delays in reaction time in the lower left visual field rather than the upper left visual field. Importantly, reaction times were delayed, and USN symptoms persisted, particularly for the lower left quadrant. Our findings imply that the modified Posner task can accurately uncover neglect symptoms in the case of mild USN.

Rehabilitation interventions of unilateral spatial neglect based on the functional outcome measure: A systematic review and meta-analysis.

ABSTRACTThis review aimed to examine the bottom-up and top-down rehabilitation intervention effectiveness based on the functional outcome measure as immediate effect and long-term effect for unilateral spatial neglect conditions. The RCT studies were collected by searching in three databases J-Stage, PubMed, and PEDro from 2008 through 2018. The studies which used the following instruments: BI, CBS, FMA, and FIM, as the functional outcome with the PEDro score of six and above, were eligible for inclusion. A total of 492 participants in 13 studies included from 291 studies initially identified. The meta-analysis for overall ES revealed that BI and CBS had a significant mean of SMD = 0.65 (95% CI, 0.23-1.07; p = 0.003; I2 = 65%), and SMD = -0.23 (95% CI, -0.45 to -0.01; p = 0.04; I2 = 35%) respectively, while FMA and FIM had an insignificant mean of SMD = 0.14 (95% CI, -0.08-0.37; p = 0.22; I2 = 0%), and SMD = -0.22 (95% CI, -0.69-0.25; p = 0.37; I2 = 0%) respectively. Based on the results, although indicated the heterogeneity representation across studies, it showed that the top-down intervention approach of high-frequency rTMS was more effective in enhancing the functional abilities and ADL of unilateral spatial neglect patients on the immediate effects but not necessarily in the long-term effects.

Effects of standing and walking training using a laser pointer based on stimulus-driven attention for behavioural outcome in spatial neglect: A single-case study.

The therapy for unilateral spatial neglect (USN) is unclear. This case report investigated the effect of standing and walking training using a laser pointer based on stimulus-driven attention for USN. The patient was a right-handed 79-year-old man with cardiogenic cerebral embolism in the right middle and posterior cerebral arteries. Initially, we evaluated the absence of hemiparalysis in the lower limb and sensory disorder; almost all daily activities were performed independently. Intervention effects were verified using the BABA method. The course of the four phases (B1, A1, B2, A2) was conducted for 5 days. In the B1 and B2 phases, standing and walking training using a laser pointer was performed additionally to conventional physical therapy. Outcomes were measured using the Behavioural Inattention Test conventional subtest (BIT-c), Catherine Bergego Scale (CBS), and modified Posner task (MPT). The BIT-c remained unchanged in each phase. CBS scores improved after B1 and B2. In the MPT, the reaction time in the left space reduced after B1 and B2 compared with those in the A1 and A2 control phases. In this case, training may have contributed to the improvement in the response to the neglected space and behavioural assessment of USN.

Effects of kinesthetic illusion induced by visual stimulation on the ankle joint for sit-to-stand in a hemiparesis stroke patient: ABA' single-case design.

[Purpose] The purpose of this study was to investigate the effect of kinesthetic illusion induced by visual stimulation to the paralyzed side ankle joint on the sit-to-stand of a hemiparesis stroke patient. [Participant and Methods] A 33-year-old male with left hemiparesis due to a right putamen hemorrhage participated. This study used the ABA' single-case design. Phase A and A' conducted only conventional physiotherapy. Phase B conducted kinesthetic illusion induced by visual stimulation and conventional physiotherapy. To create a kinesthetic illusion, a video image of the patient's ankle joint dorsiflexion movement on the non-paralyzed side was inverted and placed on the patient's paralyzed ankle. The patient observed this display for 5 min. We evaluated weight-bearing symmetry values during sit-to-stand, duration of sit-to-stand, trunk and ankle joint movement on the paralyzed side during sit-to-stand, active ankle dorsiflexion angle on the paralyzed side, and the composite spasticity score. [Results] The weight-bearing symmetry values, movement of the ankle dorsiflexion during sit-to-stand, active ankle dorsiflexion angle, and composite spasticity score were significantly improved in phase B as compared with phase A and the effect was sustained in phase A'. [Conclusion] Kinesthetic illusion induced by visual stimulation for a hemiparesis stroke patient affected the ankle dorsiflexion function, resulting in an improved asymmetry during sit-to-stand as assessed by weight-bearing symmetry values.

Immediate effects of head-mounted display adaptation in cases of unilateral spatial neglect: study of straight-ahead pointing.

[Purpose] This study aimed to clarify the effect of an adaptation of a deviation of the visual field in three axes on spatial cognition in patients with unilateral spatial neglect and distorted spatial perception in three dimensions. [Participants and Methods] Fifteen patients with cerebrovascular disease and symptoms of unilateral spatial neglect were included. Forty-eight pointing movements with a camera attached to a head-mounted display changed in three axes were compared with the control condition in which the camera was deflected only in the horizontal plane as with the prism adaptation. The main outcome measures were subjective straight-ahead pointing, line bisection, line cancellation, and star cancellation. [Results] The head-mounted display adaptive therapy was performed under conditions that varied in all three axes. The results indicated that it was possible to deflect the subjective straight-ahead pointing position to the lower left direction. [Conclusion] In contrast to the prism adaptation, which deflects the visual field in a single axis in the horizontal plane, the tri-axial adaptation corrected the median cognition in the left-right direction as well as the cognition of the body center, including the vertical direction.

Efficacy of sitting balance training with delayed visual feedback among patients with stroke: a randomized crossover clinical trial.

[Purpose] This study aimed to determine the effect of delayed visual feedback on the center of pressure and sitting balance in patients with stroke. [Participants and Methods] This was a single-blinded, randomized crossover trial. The duration of each intervention in real-time visual feedback and delayed visual feedback conditions while sitting on the platform was five days. We measured the center of pressure, function in sitting test, and functional independence measure for physiotherapy assessment. [Results] Twenty patients with stroke were included in this study. The delayed visual feedback condition improved the center of pressure for lateral distance, function in sitting test, and functional independence measure. The lateral center of pressure deviation increased significantly after 500 ms of intervention. The function in sitting test evaluated the interaction between pre- and post-training, and these conditions revealed that timing and condition factors contributed to the improvement. Sitting balance training affected the functional independence measure. [Conclusion] Sensory-motor and cognitive learning was facilitated through balance training with delayed visual feedback, and the internal model was updated with the efference copy of error correction. Sensory-motor feedback to visual stimulation can improve postural control, balance, and activities of daily living.

Effects of visual-motor illusion on functional connectivity during motor imagery.

This study aimed to verify whether visual-motor illusion changes the functional connectivity during kinesthetic motor imagery and the vividness of kinesthetic motor imagery. Twelve right-handed healthy adults participated in this study. All participants randomly performed both the illusion and observation conditions in 20 min, respectively. Illusion condition was induced kinesthetic illusion by viewing own finger movement video. Observation condition was observed own finger movement video. Before and after each condition, the brain activity of kinesthetic motor imagery was measured using functional near-infrared spectroscopy. The measure of brain activity under kinesthetic motor imagery was executed in five sets using block design. Under the kinesthetic motor imagery, participants were asked to imagine the movement of their right finger. Functional connectivity was analyzed during the kinesthetic motor imagery. In addition, after performing the task under kinesthetic motor imagery, the vividness of the kinesthetic motor imagery was measured using a visual analog scale. Furthermore, after each condition, the degree of kinesthetic illusion and sense of body ownership measured based on a seven-point Likert scale. Our results indicated that the functional connectivity during kinesthetic motor imagery was changed in the frontal-parietal network of the right hemisphere. The vividness of the kinesthetic motor imagery was significantly higher with the illusion condition compared with the observation condition. The degree of kinesthetic illusion and sense of body ownership were significantly higher with the illusion condition compared with the observation condition. In conclusion, the visual-motor illusion changes the functional connectivity during kinesthetic motor imagery and influences the vividness of kinesthetic motor imagery. The visual-motor illusion provides evidence that it improves motor imagery ability. VMI may be used in patients with impaired motor imagery.

Clinical course of left spatial neglect with a focus on the assessment of stimulus-driven attention.

We developed Stimulus-driven Attention Tests (SAT) for a patient with unilateral spatial neglect (USN) and longitudinally investigated the results and compared them to two conventional assessments. The patient suffered a right putaminal hemorrhage resulting in left-side USN. On the 12th, 22nd, and 28th days from the onset, the Behavioral Inattention Test (BIT) and the Catherine Bergego Scale (CBS), which are conventional USN assessments, and our two Stimulus-driven Attention Tests (SAT-1 and SAT-2) were performed. Our assessment tests comprise two tasks in which participants respond to suddenly appearing stimuli and to a target stimulus among distractors. A longitudinal comparison of all assessments was performed to observe the clinical course of the USN. On the 12th day, scores were low on the BIT, CBS, and both SATs, but on the 22nd day, BIT improved above the cutoff; however, the CBS and SATs did not improve. On the 28th day, response to a target stimulus among distractors in the SAT remained low, and CBS scores did not change significantly. We were able to detect USN with the SAT when the participant showed improvement on the paper-and-pencil tests. Moreover, the number of distractors in the SAT was thought to reveal covert USN.

Examination and treatment of unilateral spatial neglect using virtual reality in three-dimensional space.

Here, we developed a method that randomly generates balloons in the left-right, up-down, and near-far spaces on a monitor using a head-mounted display. In this study, we evaluated a lack of stimulus-driven attention case that was undetected by conventional assessments such as the Behavioral Inattention Test. We could identify mild neglect with our virtual reality method, as later confirmed using the Catherine Bergego scale. After repeated practice under a tilted background space condition, the patient demonstrated a reduction in the time needed to perceive the appearing balloons, suggesting a therapeutic effect.

Examination of Rehabilitation Intensity According to Severity of Acute Stroke: A Retrospective Study.

OBJECTIVES: To investigate the intensity and effectiveness of rehabilitation in acute stroke patients according to the severity of functional impairments in them. MATERIALS AND METHODS: This retrospective cohort study included 294 patients with acute hemispheric stroke admitted to three acute-care hospitals who subsequently underwent an inpatient rehabilitation program. Stroke severity was classified according to neurological deficits and trunk dysfunction. The following data were obtained from medical records: age, sex, stroke type, lesion side, hospitalization duration, initial functional status determined using the National Institutes of Health Stroke Scale, rehabilitation start date, first day out of bed after admission, total treatment duration, total number of treatment sessions, rehabilitation implementation rate between start of rehabilitation and discharge, trunk control test and Barthel Index score on the first day out of bed after admission and discharge, and post-discharge outcomes. Hierarchical cluster analysis was performed with clusters categorized using the National Institutes of Health Stroke Scale and trunk control test scores. Variables were compared using the Kruskal-Wallis test, and Dunn's nonparametric comparison test was performed for post-hoc analysis to determine differences between clusters. RESULTS: The National Institutes of Health Stroke Scale and trunk control test showed a significant correlation (r = -0.816, p < 0.01) using which cluster analysis identified three clusters. Rehabilitation showed a ceiling effect in patients with mild stroke and a floor effect in patients with severe stroke. CONCLUSION: These results may guide the determination of rehabilitation intensity with reference to the severity of neurological deficits and trunk dysfunction.

Factors Influencing Sitting Ability During the Acute Post-Stroke Phase: A Multicenter Prospective Cohort Study in Japan.

OBJECTIVES: Sitting ability during the acute phase after stroke is a useful indicator of functional outcomes; however, factors that affect this ability have not been evaluated. Therefore, this study aimed to identify and evaluate factors that affect sitting ability in the acute phase after stroke. MATERIALS AND METHODS: This multicenter prospective cohort study included hemispheric stroke patients who underwent an inpatient rehabilitation program after acute stroke from five acute care hospitals. The effect of age, sex, lesion side, etiology, consciousness disorder, stroke and dementia history, stroke-related complications, National Institutes of Health Stroke Scale score, hemiparalysis, turn-over movement from the supine position and sit-up movement, and Scale for Contraversive Pushing on the "remain sitting" item in the revised version of the Ability of Basic Movement Scale at the time of acute hospital discharge were investigated. Factors affecting sitting ability were identified using binomial logistic regression analysis. RESULTS: We included 293 stroke patients. Age (odds ratio: 0.943, 95% confidence interval: 0.910-0.977, p=0.001), National Institutes of Health Stroke Scale score (odds ratio: 0.862, 95% confidence interval: 0.811-0.916, p<0.001), and Scale for Contraversive Pushing score (odds ratio: 0.543, 95% confidence interval: 0.419-0.705, p<0.001) were identified as independent predictors of sitting ability at the time of hospital discharge (median; 23.0 days). CONCLUSIONS: Older patients and those with high Scale for Contraversive Pushing and National Institutes of Health Stroke Scale scores experienced difficulties in regaining sitting ability. These results may guide physical therapy for patients with impaired sitting ability due to hemispheric stroke.

The effect of a concomitant stroop task during sit-to-stand tasks on postural control.

[Purpose] This study aimed to explain the effect of a dual-task technology that utilizes motor and/or cognitive skills on the performance of major tasks, postural control, and gait consistency. [Participants and Methods] Eighteen healthy adults were divided into two groups: the single-word dual-task group and the control group (study 1). We enrolled 32 healthy adults to perform four-word Stroop (study 2) and sit-to-stand tasks simultaneously to determine the attentional demand for postural control and locomotion. [Results] The dynamic condition of postural control differed significantly between the single-task and single-word dual-task groups in Study 1. In Study 2, postural control in the four-word dual-task condition improved under both static and dynamic conditions. On comparing the results of studies 1 and 2, we found that during a four-word dual-task, healthy participants experienced a more significant decrease in postural sway than that experienced during the single-word dual-task. [Conclusion] Dual task of Stroop task with sit-to-stand could improve a postural control.

Immediate effect of adding mirror visual feedback to lateral weight-shifting training on the standing balance control of the unilateral spatial neglect model.

[Purpose] This study aimed to clarify the immediate effect of adding mirror visual feedback to lateral weight-shifting training on the standing balance control of the left unilateral spatial neglect model. [Participants and Methods] We included 64 healthy participants to create left unilateral spatial neglect models and divided them into four subgroups. Each subgroup received opposite lateral weight-shifting training with or without mirror visual feedback. We then evaluated the static and dynamic standing balance by measuring the center of pressure point alterations in the medial-lateral and anterior-posterior planes. We further evaluated the center of pressure length and bilateral load ratio. [Results] The center of pressure was significantly stable upon performing the eyes-open static standing balance test in the left weight-shifting training subgroup with mirror visual feedback. When participants performed the left dynamic standing balance test, the center of pressure moved significantly rightward and became significantly stable in the right weight-shifting training subgroup with mirror visual feedback. The left load ratio significantly decreased in the right weight-shifting training of subgroups that either did or did not receive mirror visual feedback upon performing the left dynamic standing balance test. [Conclusion] We concluded that adding mirror visual feedback to lateral weight-shifting training affected some measurements of standing balance control of the left unilateral spatial neglect model.

Starting position effects in the measurement of the postural vertical for pusher behavior.

Pusher behavior (PB) is a severe lateral postural disorder that involves a disturbed subjective postural vertical (SPV) in the frontal plane. SPV is measured by determining the mean value and standard deviation of several trials beginning on both the contralesional- and ipsilesional-tilted positions. However, the postural representation, when passively tilted to the contralesional versus ipsilesional position, is different between patients with and without PB. Therefore, we hypothesized that SPV dependence on the starting position will be influenced by PB. For 53 patients with hemispheric stroke enrolled, SPV was measured using a non-motorized vertical board with eyes closed. The mean value (tilt direction) and standard deviation (variability) were calculated in four trials, each from two positions, with the patient tilted to the contralesional position (SPV-CL condition) and then to the ipsilesional position (SPV-IL condition). Patients were categorized into the non-pusher (n = 29) and pusher (n = 24) groups. In the SPV-CL trials, the tilt direction was significantly tilted contralesionally for the pusher group (- 6.3° ± 1.6°) compared with that for the non-pusher group (- 2.2° ± 1.8°; p < 0.001), with no significant difference in variability between the groups. In the SPV-IL trials, the tilt direction was not significantly different between the groups, but the variability was significantly higher in the pusher group (4.8° ± 2.0°) than in the non-pusher group (2.2° ± 1.3°; p < 0.001). The dependence of tilt direction and variability of SPV on the starting position in patients with PB differed from those noted in patients without PB. These results may help explain this abnormal posture and optimize neurological rehabilitation strategies for PB.