Effect of Eye Patching in Rehabilitation of Hemispatial Neglect

Hemispatial neglect is a common syndrome after stroke in which patients fail to report or respond or be aware of stimuli located ... ThisarticleispartoftheResearchTopic Novelinsightsinrehabilitationofneglect Viewall 30 Articles Articles Abstract Introduction RationaleofEyePatchinginHemispatialNeglect MaterialsandMethods Results Discussion Conclusion ConflictofInterestStatement References SuggestaResearchTopic> DownloadArticle DownloadPDF ReadCube EPUB XML(NLM) Supplementary Material Exportcitation EndNote ReferenceManager SimpleTEXTfile BibTex totalviews ViewArticleImpact SuggestaResearchTopic> SHAREON OpenSupplementalData REVIEWarticle Front.Hum.Neurosci.,02September2013 |https://doi.org/10.3389/fnhum.2013.00527 Effectofeyepatchinginrehabilitationofhemispatialneglect NicolaSmania*, CristinaFonte, AlessandroPicelli, MarialuisaGandolfiandValentinaVaralta DepartmentofNeurologicalandMovementSciences,NeuromotorandCognitiveRehabilitationResearchCenter,UniversityofVerona,Verona,Italy Eyepatching(EP;monocularorrighthemifield)hasbeenproposedtoimprovevisuospatialattentiontotheignoredfieldinpatientswithhemispatialneglect.TheaimofthispaperistoreviewtheliteratureontheeffectsofEPinhemispatialneglectafterstrokeinordertoconveyevidence-basedrecommendationstocliniciansinstrokerehabilitation.ThirteeninterventionstudieswereselectedfromtheMedline,EMBASE,Scopus,CochraneLibrary,CINAHL,PsychINFO,EBRSR,andHealthStardatabases.MethodologicalqualitywasdefinedaccordingtothePhysiotherapyEvidenceDatabase.Overall,sevenstudiesusedmonocularEP,fiveusedrighthemifieldpatching,andonecomparedrightmonocularwithrighthemifieldpatching.Sevenstudiescomparednormalviewingtomonocularorhemifieldpatchingconditions.Sixstudiesincludedaperiodoftreatment.AstothemonocularEP,fourstudiesreportedpositiveeffectsofrightmonocularpatching.Onestudyshowedanimprovementinhemispatialneglectwithleftmonocularpatching.Twostudiesfoundnosuperiorityofrightvs.leftmonocularpatching.Onestudyfoundnoeffectsofrightmonocularpatching.AstotherighthemifieldEP,onestudyshowedimprovementsinneglectafterrighthemifieldpatching.Threestudiesfoundthatrighthemifieldpatchingcombinedwithanotherrehabilitationtechniquewasmoreeffectivethanthattreatmentalone.Onestudyfoundnodifferencesbetweenrighthemifieldpatchingcombinedwithanothertreatmentandthattreatmentalone.Onestudyfoundthesameeffectbetweenrighthemifieldpatchingaloneandanotherrehabilitationtechnique.OurresultsgloballytendtosupporttheusefulnessofrighthemifieldEPinclinicalpractice.Inordertodefinealevelofevidencewiththestandardrehabilitationevidenceratingtools,furtherproperlypoweredrandomizedcontrolledtrialsormeta-analysisareneeded. Introduction Hemispatialneglectisacommonsyndromeafterstrokeinwhichpatientsfailtoreportorrespondorbeawareofstimulilocatedcontralateraltoabrainlesion(HeilmanandValenstein,1979;Kwonetal.,2012).Theincidenceofhemispatialneglectvariesbetween8and95%inindividualswithstroke(Bowenetal.,1999),withareasonableestimateof23%(Pedersenetal.,1997).Theseepidemiologicaldiscrepanciesarethoughttoresultfrominconsistenciesindefininghemispatialneglect,differencesinthetimingofexaminationafterstroke,theuseofdifferentteststodetectvisualhemispatialneglect,andtheuseofsmallandinsensitivetestbatteriesintheavailableliterature(Ogden,1985;Stoneetal.,1991). Lesionsinvolvingtherightinferiorfrontalgyrus,precentralgyrus,postcentralgyrus,superiortemporalgyrus,middletemporalgyrus,middleoccipitalgyrus,insula,andsurroundingwhitematterarethosemostfrequentlyassociatedwithhemispatialneglect(Chechlaczetal.,2012;Yueetal.,2012). Aslefthemispatialneglect(afterrightbraindamage)isthemostfrequentcaseinclinicalpractice,wewillrefertothisconditionthroughoutthewholepaper. Testingofhemispatialneglectshowsthatpatientsmisbisectlinestotherightoftruecenter,failtocanceltargetsontheleftsideofapage,andfailtodrawtheleftsideofobjectsandscenes(Kwonetal.,2012).Diagnosismustexcludethatthesebehavioralabnormalitiesarisefromaprimarysensoryormotordeficitsuchashemianopiaorparalysis(HeilmanandValenstein,1979). Anaccurateestimateoftheratesofhemispatialneglectrecoveryafterstrokecouldnotbederivedtodate(Bowenetal.,1999).However,arecentcohortstudyonasampleof101strokepatientsdescribedprogressoftimeasanindependentcovariatethatreflectsneurologicalrecoveryofhemispatialneglect(Nijboeretal.,2013).Theauthorsfoundthatat12weeksafterstroke,54%oftheinitialhemispatialneglectpatientsrecoverfromtheirimpairment,andapproximately60%after26upto52weeksfromtheonsetofstroke(Nijboeretal.,2013).Consequently,inclinicalpracticeitisnotunusualtohavecasesofchronichemispatialneglectmorethan1yearafterstroke. Thepresenceofhemispatialneglectincreasesposturalcontrolabnormalitiesinpatientswithstroke.Indeed,theyusuallyshowtrunkmisalignment(vanNesetal.,2009),posturalinstability(Pérennouetal.,2000),andincreasedriskoffalls(Paoluccietal.,2001;Jutaietal.,2003;Mackintoshetal.,2006).Hemispatialneglectisarecognizedpredictorofpoorfunctionaloutcome,withalowerlevelofindependenceinactivitiesofdailyliving(e.g.,dressing,bathing,eating,andmobility),prolongedhospitalstay,greaterneedofcare-giversupport(Katzetal.,1999;Cherneyetal.,2001;Buxbaumetal.,2004;Franceschinietal.,2010),andahigherriskoffunctionaldeteriorationat1yearpost-stroke(Paoluccietal.,2001).Thus,itisnotsurprisingthatoverthepast60yearsmorethan18differentrehabilitationtechniqueshavebeenputforwardtoalleviate,reduce,orremediateunilateralhemispatialneglect(Luautéetal.,2006;Ogourtsovaetal.,2010).ThemostrecentCochranereviewofcognitiverehabilitationforhemispatialneglectafterstroke(BowenandLincoln,2007)reportsthatalthoughseveraltypesofneglect-specificapproachescanimproveperformanceonsome,butnotall,standardizedneglecttests,evidencetosupport,orrefutetheireffectivenessinreducingdisabilityandimprovingindependenceisstillinsufficient. Eyepatching(EP)isaninterestingapproachtohemispatialneglectrehabilitationthathasbeenproposedsincetheearly1990sasamethodtoimprovevisual-scanningandattentiontowardtheneglectedfield(ButterandKirsch,1992).Fromaclinicalpointofview,EPmayhaveremarkablegainsoverothertreatmentmethodsbecauseofitshighfeasibilityandlowcost.However,theliteratureaboutEPreportsnon-uniqueevidencesofeffectiveness.Someofthesestudiesdisplayseveralmethodologicallimitations.Furthermore,confoundingfactorsinthisdebatearethatstudiesdifferinexperimentaldesignandthattwodifferenttypesofEPmethodshavebeenproposed. Althoughsomeliteraturereviewsdealingwiththeeffectsofhemispatialneglectrehabilitationhavebeenpublishedinthelastdecade(ButterandKirsch,1992;Diamond,2001;Manly,2002;PierceandBuxbaum,2002;Luautéetal.,2006;BowenandLincoln,2007;Ogourtsovaetal.,2010),nonehavebeenspecificallydedicatedtotheEPapproach. ThemainaimofthispaperistoreviewtheliteratureontheeffectsofEPinpost-strokehemispatialneglectinordertoconveyevidence-basedpracticerecommendationstocliniciansinstrokerehabilitation.Furthermore,giventhepotentialroleofthisapproachinclinicalpractice,weaimatgivingindicationsforguidingfuturestudiesinthisfieldofresearch. RationaleofEyePatchinginHemispatialNeglect AnumberofstudiesonEPtechniqueinpost-strokehemispatialneglectreferredtotheSpragueEffecttheory(seebelowfordetails)(SpragueandMeikle,1965;Sprague,1966a,b),whileothershaveinterpretedtheirresultsinlightofadifferentrationale(InterhemisphericbalancetheoryandVisualexplorationconstrainttheory)(Araietal.,1997;Beisetal.,1999;Ianesetal.,2012).Onthisbasis,wedecidedtoproposethreemaintheoriesinsupportofthepotentialbenefitofEPinthetreatmentofhemispatialneglectafterstroke. TheSpragueEffectTheory TheSpragueeffectwasfirstdescribedin1966bySprague.Inaremarkableseriesofstudiesonanimalmodels(cat),Spragueshowedthatvisuallyguidedbehaviorissubservedbyinteractionsinvolvingthemidbrainandcorticalpathways(SpragueandMeikle,1965;Sprague,1966a).Spraguereportedthathemianopiaresultingfromacontralateral,largeposteriorcorticallesioncouldbepartiallyalleviatedbyablationofthesuperiorcolliculuscontralateraltothecorticallesionortransectionofthecommissureofthesuperiorcolliculus.Heobservedthatcatswithcontralesionalorientingdeficitsimprovedtheirabilitytodetectstimuliinthecontralateralfieldaftersurgicalablationofthecontralesionalsuperiorcolliculus.Sprague’shypothesisthatablationofthecontralateralsuperiorcolliculusdisinhibitedtheipsilesionalcolliculusandimprovedorientationofcontralesionalattention(Sprague,1966b),metwithsomeskepticismandtheneuralbasisforthisphenomenoncontinuestofiredebatebetweensupportersandopponents(Sorokeretal.,1994;Walkeretal.,1996;Araietal.,1997;Barrettetal.,2001). WithregardtotheuseofEPinthetreatmentoflefthemispatialneglectinpatientswithrightbraindamage,PosnerandRafal(1987)suggestedthatinhibitingcontralesional(left)collicularactivitymightlessenorientingdeficits.Theyhypothesizedthatinputtothesuperiorcolliculifromtheeyesmaybepredominantlymonocularandcontralateralandthatarighteyepatchmaysensorydeprivetheleftcolliculus(Hubeletal.,1975). TheInterhemisphericBalanceTheory Beisetal.(1999)suggestedthatwearingpatchesoverbothrighthalf-fieldsinpatientswithlefthemispatialneglectafterrightbraindamageactivatestherighthemisphere,leadingtoanincreaseinthelevelofleftwardattention.UnlikerightmonocularEP(whichisthoughttocausesimultaneousactivationofbothhemispheres),coveringbothrighthalf-fieldsshouldactivateonlytherighthemisphere. Abalancebetweenthehemispheresmaybethusestablishedbetweenthe“overactivated”damagedrighthemisphereandthe“non-activated”healthylefthemisphere(Beisetal.,1999)(seeFigure1). FIGURE1 Figure1.Interhemisphericbalancetheory:(A)interhemisphericbrainactivationinindividualswithoutstroke;(B)interhemisphericimbalanceinindividualswithrighthemispherestrokewherethelefthemisphereisactivatedandrighthemisphereisunder-activated;(C)patchingbilateralrighthalf-fieldsinindividualswithlefthemineglectandrighthemispherestrokestimulatestherighthemisphereandreducesthestimulationofthelefthemisphereleadingtotheinterhemisphericre-balance.LVF,leftvisualfield;RVF,rightvisualfield;LH,lefthemisphere;RH,righthemisphere. TheVisualExplorationConstraintTheory Someauthors(Araietal.,1997;Ianesetal.,2012)suggestthattheuseofEPmightbeviewedasanapplicationofConstraint-InducedTherapy(CIT),awell-knownrehabilitationprograminpatientswithupperlimbparesis.Thistreatmentaimstoreversetheaffectedlimb“learnednon-use”phenomenon(Taubetal.,2006).Inhemispatialneglect,patientshaveastrongtendencytoorienttheirexploratoryeyemovementstowardtheipsilesionalspace.InkeepingwitharationalesimilartothatofCITinpatientswithhemispatialneglect,theuseofipsilesionalhemifieldEPmayhelppatientstovisuallyexploretheirneglectedspace(Araietal.,1997;Ianesetal.,2012). MaterialsandMethods Originalarticleswereselectedfromthefollowingelectronicdatabases:Medline(1950–March2013),EMBASE(1992–March2013),Scopus(1992–March2013),theCochraneLibrary(2008–March2013),CINAHL(1992–March2013),PsychINFO(1992–March2013),EBRSR(1992–March2013),andHealthStar(1992–March2013).Thefollowingkeywordswereused:stroke,neglect,visualneglect,unilateralspatialneglect,spatialneglect,hemispatialneglect,attention,eyepatching,viewing,patching,glassesneglect,monocular,binocular.Differentcombinationsofallthesetermswereusedtosourcethearticles. Twoindependentreviewers(ValentinaVaralta,CristinaFonte)reviewedallabstractsretrievedfromtheinitialsearch.StudieswereincludedwhichevaluatedtheeffectsofmonocularorhemifieldEPinpatientswithhemispatialneglect(interventionstudies)asaresultofrightbraindamage.Excludedwerenon-interventionstudies,animalstudies,non-Englishlanguagestudies,studiesenrollingonlyhealthysubjects,studiesinvolvingstrokepatientswithouthemispatialneglectandreviews.Thetworeviewersselectedtherelevantarticlesandperformedthequalityassessmentofthestudies.Theyindependentlyreadalltheselectedarticlesandlistedthedetailsinanappropriategrid(seeTable1).Inadditiontotheelectronicsearch,thereferencelistsoftheselectedfull-textarticleswerecheckedforfurtherarticles.Threeotherinvestigators(NicolaSmania,AlessandroPicelli,andMarialuisaGandolfi)readalltherelevantarticlesandprovidedfurtherassessmentofdataqualityandvalidity.Disagreementswereresolvedbydiscussion.Heterogeneityintheselectedstudiesprecludedformalreview.Thus,theresultspresentedherearequalitativeandrepresenttheviewsoftheinvestigators. TABLE1 Table1.Shortdescriptionofthestudiesconsideredforreview. MethodologicalqualityoftheinterventionstudieswasdefinedaccordingtothePhysiotherapyEvidenceDatabase(PEDro)scoreasreportedinthePhysiotherapyEvidenceDatabase(1999).Themainauthor(NicolaSmania)verifiedallthescores. Results Atotalof83paperswerereviewed.Sixty-ninestudieswereexcludedaccordingtotheabove-mentionedcriteria.Thirteeninterventionstudieswereincludedinthereview. Fivewerecase-series/case-controlstudies(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Walkeretal.,1996;Araietal.,1997),twoweresingle-casestudies(Barrettetal.,2001;Khurshidetal.,2009),andsixwererandomizedcontrolledtrials(RCTs)(Beisetal.,1999;Zelonietal.,2002;Fongetal.,2007;Tsangetal.,2009;Ianesetal.,2012;Wuetal.,2013). SevenstudiesinvestigatedtheeffectsofrightmonocularEP(fivealsoanalyzedtheeffectsofleftmonocularEP)(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Walkeretal.,1996;Barrettetal.,2001;Khurshidetal.,2009;Wuetal.,2013)andfiveassessedtheeffectsofrighthemifieldEP(Araietal.,1997;Zelonietal.,2002;Fongetal.,2007;Tsangetal.,2009;Ianesetal.,2012).OnlyonestudyinvestigatedtheeffectofrightmonocularEPandthatofrighthemifieldEP(Beisetal.,1999). Sevenstudiescomparedpatientperformanceonneglecttestingundertwoexperimentalconditions:normalviewingandviewingduringEP(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Walkeretal.,1996;Araietal.,1997;Barrettetal.,2001;Khurshidetal.,2009).SixcomparedtheeffectsofarehabilitationtechniquewiththesamekindoftreatmentcombinedwithEP(Beisetal.,1999;Zelonietal.,2002;Fongetal.,2007;Tsangetal.,2009;Wuetal.,2013)orEPtreatmentappliedalone(Ianesetal.,2012). Threestudieswereperformedinpatientsintheearlystageafterstroke(Fongetal.,2007:meandays=11.9;Tsangetal.,2009:meandays=21.8;Ianesetal.,2012:meandays=12.9),whileninestudieswereconductedinpatientsinthesub-acute-chronicphaseofillness(Sorokeretal.,1994:meandays=135;Serfatyetal.,1995:meandays=67.2;Walkeretal.,1996:meandays=506;Araietal.,1997:meandays=255;Barrettetal.,2001:notspecified;Khurshidetal.,2009:days=365;Beisetal.,1999:meandays=49.2;Zelonietal.,2002:meandays=236.2;Wuetal.,2013:meandays=368).Onestudy(ButterandKirsch,1992)testedpatientsat<1monthaftertheonsetofstroke(meandays=29.6)andpatientsinthechronicphase(meandays=112). Thestudiesaresummarizedasfollows(seealsoTable1formethodologicalissues): (1)ButterandKirsch(1992)conductedtwodifferentexperiments.Inthefirstone,theytestedtheperformanceof13strokepatientswithhemispatialneglect(co-morbidity:8patientswithhemianopia;11patientswitheyemovementdisturbances;3patientswithvisualextinction)duringnormalviewingandrightmonocularEPbymeansofthefollowingtest:LineCancelation,LetterCancelation,Reading,LineBisection,andClockDrawing.TheauthorsobservedthatundertheEPcondition,11patientshadmodestclinicalimprovementinatleastoneofthefiveoutcomes,notingstatisticallysignificantimprovementsonlyintheLineBisectionTest.Intheirsecondexperiment,ButterandKirschtested18patientswithhemispatialneglect(co-morbidity:13patientswithhemianopia;11patientswitheyemovementdisturbances;1patientwithvisualextinction)bymeansofacomputerizedtest.Patientswererequiredtobisectalinepresentedonthevideoscreenatbaselineandduringpresentationofvisualwarningstimuliontheleftendoftheline(warningcondition).BoththeseconditionswerecarriedoutundernormalviewingandunderrightmonocularEP.Theauthorsreportedthatpatientsperformedsignificantlybetterunderwarningconditionscomparedtothebaselineevaluation.Furthermore,theyobservedasmallerbeneficialeffectofrightmonocularEPcomparedtopresentationofvisualwarningstimuliontheleftendofthelineduringnormalviewing(ButterandKirsch,1992). (2)Sorokeretal.(1994)analyzedtheseverityofhemispatialneglectinsixstrokepatients(co-morbidity:threepatientswithhemianopia;threepatientswithvisualextinction)bymeansofaLineBisectionTestperformedunderthreetestingconditions:normalviewing;rightmonocularEP;andleftmonocularEP.TheauthorsobservedasignificantimprovementundertherightmonocularEPconditioninonepatient.Furthermore,threepatientsshowedasignificantworseningundertheleftmonocularEPcondition(Sorokeretal.,1994). (3)Serfatyetal.(1995)analyzed26strokepatientswithhemispatialneglect(co-morbidity:10patientswithlefthemianopiaand2withleftquadrantanopia)bymeansoftheStarCancelationTestperformedunderthesameconditionsusedbySorokeretal.(1994).TheauthorsnotedasignificantimprovementduringrightmonocularEPcomparedtothenormalviewingconditionin13patients.Furthermore,twopatientsshowednon-statisticallysignificantimprovementsduringleftmonocularEP(Serfatyetal.,1995). (4)Walkeretal.(1996)testedthepresenceandseverityofhemispatialneglectinninestrokepatients(co-morbidity:allpatientswithlefthemianopia)underthesameconditionsusedbySorokeretal.(1994)bymeansofthefollowingtests:LetterCancelation,LineBisection,LetterStringReading,TextReading,andChimericFaceRecognition.TheauthorsobservedthatintherightEPconditionthreepatientsimprovedonatleastonetestandfivepatientsworsened.IntheleftEPcondition,fivepatientswerefoundtoworsenonatleastonetest,whereastwopatientsimproved(Walkeretal.,1996). (5)Barrettetal.(2001)examinedtheeffectsofmonocularEPonperceptual-attentionandmotor-intentionaldeficitsinonestrokepatientwithhemispatialneglect(co-morbidity:leftlowerquadrantanopia)bymeansofavideoLineBisectionTestperformeddirectly(left/rightonthevideoscreencorrespondedwithworkspaceleft/right)andindirectly(a180°changeincameraperspectivereversedtheimage)underthreetestingconditions:normalviewing;rightmonocularEP;andleftmonocularEP.Paradoxically,undertherightmonocularEPcondition,patientperceptual-attentiondeficitwasfoundtosignificantlyworsen,whereastherewasasignificantimprovementundertheleftmonocularEPcondition(Barrettetal.,2001). (6)Khurshidetal.(2009)analyzedtheeffectsofmonocularEPinonestrokepatientwithhemispatialneglect(co-morbidity:lefthomonymoushemianopia)bymeansofthevideoLineCancelationTestperformedunderthesameconditionsusedbyBarrettetal.(2001).TheauthorsshowedthatleftmonocularEPhadnoeffect,whereasrightmonocularEPreducedleft-sidedomissionsascomparedwiththeun-patchedcondition(Khurshidetal.,2009). (7)Araietal.(1997)analyzedtheperformanceof10strokepatientswithhemispatialneglect(co-morbidity:9patientswithvisualfielddeficits)undernormalviewingorduringrighthemifieldEPbymeansofthefollowingtests:LineBisection,LineCancelation,andFigureCopying.TheauthorsfoundthatninepatientsshowedimprovementinhemispatialneglectonatleastoneofthethreetestsusedduringrighthemifieldEPascomparedtothenormalviewingcondition(itwasnotspecifiedifimprovementswerestatisticallysignificant).Noeffectswereseenintheothertwopatients(Araietal.,1997). (8)Beisetal.(1999)randomized22strokepatients(co-morbiditynotspecified)intothreegroups:Group1(n=7)receivedVisual-ScanningTraining(VST)plusrighthemifieldEP;Group2(n=7)underwentVSTplusrightmonocularEP;Group3(n=8)performedVSTalone.Allpatientsunderwent12-weektraining.TheywereevaluatedbeforeandaftertreatmentbymeansoftheFunctionalIndependenceMeasure(FIM)andananalyticaltestrecordedbyphoto-oculography(numberoftimesthesubjectlookedattheleftzone;timespentlookingatleftzone).Aftertreatment,significantimprovementswerefoundontheFIMandthenumberoftimesthesubjectlookedattheleftzoneinGroup1vs.Group3.NodifferencewasfoundbetweenGroups2and3.Statisticsforwithin-groupcomparisonswerenotreported(Beisetal.,1999). (9)Zelonietal.(2002)randomized11strokepatients(co-morbidity:11patientswithlefthemiplegia;9patientswithvisualfielddeficits)intotwogroups:Group1(n=5)receivedVSTplusrighthemifieldEP;Group2(n=6)underwentVSTalone.Allpatientsunderwent1-weektraining.Theywereevaluatedbefore,immediatelyafterand1weekpost-treatmentbymeansofthefollowingtests:LineCancelation,LetterCancelation,BellCancelation,CopyofDrawing,andLineBisection.Aftertreatment,asignificantimprovementofvisualspatialneglectwasfoundinGroup1vs.Group2asmeasuredbytheabove-mentionedtests.Improvementsweremaintainedatthefollow-upevaluation.Within-groupcomparisonsshowedsignificantimprovementonlyinGroup1atalltimepoints(Zelonietal.,2002). (10)Fongetal.(2007)randomized60strokepatients(co-morbidity:allpatientswithlefthemiplegia)intothreegroups:Group1(n=20)receivedvoluntarytrunkrotationtreatmentplusrighthemifieldEP;Group2(n=20)underwentvoluntarytrunkrotationtreatmentalone;Group3(n=20)receivedoccupationaltherapy.Allpatientsunderwent6-weektraining.Theywereevaluatedbefore,immediatelyafterand1monthpost-treatmentbymeansoftheBehavioralInattentionTest(BIT),ClockDrawingTest,andFIM.Aftertreatmentandatthefollow-upevaluation,nosignificantdifferenceforanyoutcomemeasurewasfoundbetweengroups.Statisticsforwithin-groupcomparisonswerenotreported(Fongetal.,2007). (11)Tsangetal.(2009)randomized34strokepatients(co-morbiditynotspecified)intotwogroups:Group1(n=17)performedoccupationaltherapyplusrighthemifieldEP;Group2(n=17)performedoccupationaltherapyalone.Allpatientsunderwent4-weektraining.TheywereevaluatedbeforeandimmediatelyaftertreatmentbymeansoftheBIT(conventionalsubtest)andFIM.Aftertreatment,asignificantimprovementwasfoundinGroup1vs.Group2ontheBIT.Within-groupcomparisonsshowedsignificantimprovementsforalloutcomemeasuresinbothgroups(Tsangetal.,2009). (12)Ianesetal.(2012)randomized18patients(co-morbiditynotspecified)intotwogroups:Group1(n=10)receivedrighthemifieldEP;Group2(n=8)underwentVST.Allpatientsunderwent2-weektraining.Theywereevaluatedbefore,immediatelyafterand1weekpost-treatmentbymeansofthefollowingtests:LineCancelation,BellCancelation,andLineBisection.Aftertreatment,nosignificantdifferencewasfoundbetweengroups.Atthefollow-upevaluation,asignificantimprovementwasfoundinGroup1vs.Group2ontheLineCancelationtest.Within-groupcomparisonsshowedsignificantimprovementsforalloutcomemeasuresinbothgroups(Ianesetal.,2012). (13)Wuetal.(2013)randomized27strokepatients(co-morbidity:allpatientswithlefthemiplegiaand8patientswithvisualextinction)intothreegroups:Group1(n=9)receivedpareticarmCITplusrightmonocularEP;Group2(n=9)underwentCITalone;Group3(n=9)receivedoccupationaltherapy.Allpatientsunderwent3-weektraining.TheywereevaluatedbeforeandimmediatelyaftertreatmentbymeansoftheCatherineBergegoScale(CBS),EyeMovements(namely:thefixationamplitudefromleftmosttorightmostfixationpoints,thenumberoffixationpoints,andthefixationtimeintheleftarea),andArmKinematicAnalysis.Inparticular,theauthorsusedaneyetrackersystemtorecordeyemovementbydetectingthesubject’spupilduringtheLineBisection,aswellasaseven-cameramotionanalysissystemtoevaluatereactiontime,durationofthereachingmovement,totaldistance(thepathofthehandinthree-dimensionalspace),plannedcontrolofthereachingmovement(percentageofmovementusedfortheaccelerationphase),andtrunklateralshifttoleft.Aftertreatment,asignificantimprovementwasfoundinGroup1andGroup2vs.Group3fortheCBS.Furthermore,asignificantimprovementwasfoundinGroup2andGroup3vs.Group1fortheleftfixationpoint.AsfortheArmKinematicAnalysis,asignificantimprovementinthepre-plannedcontrolofthereachingmovementswasfoundinGroup1vs.Groups2and3andintrunklateralshifttoleftinGroup1vs.Group2.Furthermore,asignificantimprovementinthereactiontimewasfoundinGroup2vs.Group3.Statisticsforwithin-groupcomparisonswerenotreported(Wuetal.,2013). Overall,sevenstudiesusedmonocularEP(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Walkeretal.,1996;Barrettetal.,2001;Khurshidetal.,2009;Wuetal.,2013),fiveusedrighthemifieldEP(Araietal.,1997;Zelonietal.,2002;Fongetal.,2007;Tsangetal.,2009;Ianesetal.,2012),andonecomparedtheeffectsofrightmonocularEPwithrighthemifieldEP(Beisetal.,1999).Thedurationofintervention,thefrequencyandthedurationofeachsessionvariedacrossstudies.Sixstudies(Beisetal.,1999;Zelonietal.,2002;Fongetal.,2007;Tsangetal.,2009;Ianesetal.,2012;Wuetal.,2013)comparedoutcomesbeforeandafteraperiodoftreatment,whilesevenstudiescomparedtheperformancesonneglecttestsduringnormalviewingandwearingmonocular(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Walkeretal.,1996;Barrettetal.,2001;Khurshidetal.,2009)orhemifieldEP(Araietal.,1997).Onlythreestudiesincludedfollow-upevaluations(Zelonietal.,2002;Fongetal.,2007;Ianesetal.,2012). AstothemonocularEP,fourstudiesreportedpositiveeffectsofrightmonocularEP(ButterandKirsch,1992;Serfatyetal.,1995;Khurshidetal.,2009;Wuetal.,2013)andonestudy(Barrettetal.,2001)showedaclearimprovementinhemispatialneglectduringleftmonocularEP.Twostudiesfoundnoclearsuperiorityofrightvs.leftmonocularEP(Sorokeretal.,1994;Walkeretal.,1996)andonestudyfoundnoeffectsofrightmonocularEP(Beisetal.,1999). AstohemifieldEP,onestudyshowedaclearimprovementinhemispatialneglectduringrighthemifieldEP(Araietal.,1997)andthreestudiesfoundthatthecombinationofrighthemifieldEPwithanotherrehabilitationtechniquewasmoreeffectivethanthesametreatmentappliedalone(Araietal.,1997;Zelonietal.,2002;Tsangetal.,2009).OnestudyfoundnodifferencesbetweenthecombinationofrighthemifieldEPwithanothertreatmentandthesametreatmentappliedalone(Fongetal.,2007),whileonestudyfoundthesameeffectbetweenEPappliedaloneandanotherrehabilitationtechnique(Ianesetal.,2012). Withregardtodatainterpretation,threestudiesshowedresultsthatwereinconsistentwiththepresenceofaSpragueeffectduringmonocularEP(Sorokeretal.,1994;Walkeretal.,1996;Barrettetal.,2001).Indeed,accordingtoSprague’scollicularhypothesis(Sprague,1966b),patchingtherighteyeshouldhavedecreasedthetendencytomakeeyemovementstotherightandthereforereducelefthemispatialneglect.However,theresultsofthesethreestudiesshowednoclearincreaseinleftwardeyemovementsafterrightmonocularEP.Ontheotherhand,twostudies(Araietal.,1997;Ianesetal.,2012)suggestedthattheirobservationswereconsistentwiththe“forceduse”intervention(Visualexplorationconstrainttheory),andonestudysuggestedthatthefindingswereconsistentwiththeInterhemisphericbalancetheory(Beisetal.,1999). Finally,sevenstudiesfailedtointerpretresultsinlightofaspecifictheory(ButterandKirsch,1992;Serfatyetal.,1995;Zelonietal.,2002;Fongetal.,2007;Khurshidetal.,2009;Tsangetal.,2009;Wuetal.,2013). Discussion TheresultsofthepresentreviewshowedthatEPisapromisingprocedureintherehabilitationofpatientswithhemispatialneglectduringtheacute,subacute,orchronicphaseofstroke.AstothetypeofEP,thedatatendtofavorrighthemifieldEPovermonocularEP.ThedataavailabletodateareinsufficienttosupportorrefutetheeffectivenessofEPatreducingdisabilityandimprovingpatientindependence.FewstudiesinvestigatedmaintenanceofimprovementsafterEPbyshort-termfollow-upevaluations.Theeffectivenessofthisprocedureshouldbefurtherevaluatedbyfutureresearch. EffectsofMonocularEP RightmonocularEPwasthefirstapproachtobeexaminedinpatientswithhemispatialneglect.Itseffectshavebeentestedmostlyincase-controlsandsingle-casestudies,whichreportedhighlyconflictingresults.AfewstudiesfoundthatrightmonocularEPhassomeeffectsonimprovingpatientperformanceduringneglectvisualsearchtests(ButterandKirsch,1992;Serfatyetal.,1995;Khurshidetal.,2009).Otherstudiesfoundnoclearsuperiorityofrightvs.leftmonocularEP(Sorokeretal.,1994;Walkeretal.,1996)andonestudydescribedunexpectedimprovementinhemispatialneglectafterleftmonocularEP(Barrettetal.,2001).OnlytwostudiestestedtheeffectsofrightmonocularEP(Beisetal.,1999;Wuetal.,2013)bymeansofanRCTdesign.Theyusedspecificanalyticalinstrumentstotesttheseeffects.TheearlierstudycomparedtheeffectsofrightmonocularEPwiththoseofrighthemifieldEPusingphoto-oculographyandshowedthatthemonocularEPapproachwaslesseffectivethantherighthemifieldEPapproachinregainingvoluntarycontroloverthedeficit(Beisetal.,1999).TherighthemifieldEPindeedincreasedthenumberoftimesthesubjectlookedattheleftzone(Beisetal.,1999).ThisstudyreachedaPEDroscoreof2/10,thusindicatingthatithassomemethodologicalshortcomings.ThelaterstudyattemptedtocomparetheeffectsofrightmonocularEPpluspareticarmCITwiththoseofCIToroccupationaltherapyalone.ThemainoutcomewasthatCITcombinedwithmonocularEPandCITaloneleadtosimilarbeneficialeffectsonfunctionalperformanceinpatients’everydaylife(Wuetal.,2013).However,theseapproacheshaddifferentialeffectsoneyemovementandreachingkinematics.Indeed,whileCITaloneimprovedeyemovementsandlimbinitiation,CITplusEPfacilitatedpre-plannedcontroloflimbmovement,andtrunkcontrol(seeResultsfordetails).ThisstudyreachedaPEDroscoreof7/10indicatingafairmethodologicalquality. Takentogether,thestudiesexaminingtheeffectofrightmonocularEP(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Walkeretal.,1996;Beisetal.,1999;Barrettetal.,2001;Khurshidetal.,2009;Wuetal.,2013)onhemispatialneglectarenotveryconvincing;whencomparedwiththerighthemifieldEPapproach,theytendtofavorthesecondtechnique(Beisetal.,1999).Indeed,themajoritywerecase-controlorsingle-casestudies(ButterandKirsch,1992;Sorokeretal.,1994;Serfatyetal.,1995;Barrettetal.,2001;Khurshidetal.,2009),oneRCThadmethodologicaldrawbacks(Beisetal.,1999),whileanothergoodqualityRCTdidnotdisplayanysignificantadditionaleffectofmonocularEPwhencombinedwithCIT(Wuetal.,2013).Moreover,thepuzzlingevidencethatleftmonocularEPmayoccasionallyleadtoanimprovementinhemispatialneglecthasledsomeauthorstosuggestthatthereisnoclearrationaleforrightmonocularEPinhemispatialneglectrehabilitation(Sorokeretal.,1994;Walkeretal.,1996;Barrettetal.,2001). EffectsofRightHemifieldEP Araietal.(1997)werethefirsttoexaminetheeffectsofrighthemifieldEPinpatientswithhemispatialneglectafterstroke.Inthisstudy,10patientswithhemispatialneglectweretestedundernormalviewingorwhilewearingglassesinwhichtherightportionofthelenseswasobscured.DuringrighthemifieldEP,8outof10patientsimprovedtheirabilitytoexplorethelefthemispace(Araietal.,1997).Thisstudygavenewinsightsintothepotentialeffectsofthistechniqueonreducinghemispatialneglect.FollowingonthestudybyAraietal.(1997),fiveRCTstestedtheeffectsofrighthemifieldEPinhemispatialneglect(Beisetal.,1999;Zelonietal.,2002;Fongetal.,2007;Tsangetal.,2009;Ianesetal.,2012).ThesestudiestestedtheeffectofrighthemifieldEPinconjunctionwithotherrehabilitationprocedures(VST,TrunkRotation,OccupationalTherapy,CIT),exceptforthestudybyIanesetal.(2012)thatcomparedtheeffectivenessofrighthemifieldEPwithaconventionalVSTforhemispatialneglect(Ianesetal.,2012). Astomethodologicalquality,threeoftheseRCTs(Beisetal.,1999;Fongetal.,2007;Tsangetal.,2009)wereratedbymeansofthePEDroscale(PhysiotherapyEvidenceDatabase,1999),reachingascoreof2/10,6/10,and7/10,respectively.Twootherstudies(Zelonietal.,2002;Ianesetal.,2012)couldnotberatedwiththePEDroscorebecausetheywerenotconsideredasphysiotherapyinterventions. Beisetal.(1999),Zelonietal.(2002),andTsangetal.(2009)showedthattheeffectofrighthemifieldEPincombinationwithothertreatmentsproducedbetterimprovementinhemispatialneglectdeficit,thanthesametreatmentsappliedalone.OnlyonestudycomparedtheeffectsofrighthemifieldEPtreatmentaloneagainstanotherhemispatialneglecttreatment(VST)andfoundthattherighthemifieldEPwasaseffectiveasconventionalneglecttreatment(I31).TakingintoaccountthatthehemifieldEPprocedureisfarlessexpensivethanVST,whichrequiresone-on-onepatient-therapistinvolvement,theresultsofthisstudyareveryrelevantfortheclinicalpractice. AlthoughtheavailableliteratureonrighthemifieldEPisencouraging,someclearmethodologicallimitationsofthestudiesmeritattention:smallpatientsamplesize(Araietal.,1997;Beisetal.,1999;Zelonietal.,2002;Ianesetal.,2012),lackofpower,andsamplesizecalculation(Araietal.,1997;Beisetal.,1999;Zelonietal.,2002;Ianesetal.,2012),lackoffollow-upevaluations(Beisetal.,1999;Tsangetal.,2009),inclusionofpatientswithvisualfielddeficits(becausehemifieldpatchingmaybetoopenalizinginsuchcases)(Araietal.,1997;Zelonietal.,2002),useofunchallengingneglecttests(Araietal.,1997;Ianesetal.,2012),lackofsamplesizehomogeneityintermsoftimefromstroke(Araietal.,1997;Zelonietal.,2002),andseverityofhemispatialneglect(Zelonietal.,2002).Allinall,giventhepotentialoftherighthemifieldEPapproachinremediatinghemispatialneglectafterstroke,futureresearchwithimprovedmethodologicalqualityiswarranted. AnotherpotentiallyinterestingresearchareaisthebasisoftheeffectsofrighthemifieldEP.Ontheonehand,theseeffectscouldbeexplainedbytheInterhemisphericbalancetheoryaccordingtowhichrighthemifieldEPmayalloworincreasedetectionandselectionofvisualinputsfromtheneglectedfield.Theseinputsmayenhanceactivationofthedamaged(right)hemisphere,allowingare-balancebetweenthedirectionalorientationprocessorsoftherightandlefthemispheres.WemaysuggestthattestingtheeffectsofrighthemifieldEPinafunctionalMagneticResonanceImaging(MRI)orEEGmappingstudyinhealthysubjectsandinpatientswithhemispatialneglectmayhelpfurtherourunderstandingoftheneuralbasisofthisrehabilitationapproach. Ontheotherhand,righthemifieldEPmightbeviewedasanotherapplicationofsuch“forceduse”intervention(Araietal.,1997).Followingthisconceptualmodel,useofarighthemifieldEPmayinducepatientstovisuallyexploretheirneglectedspaceaccordingtotheVisualexplorationconstrainttheory(Ianesetal.,2012). AdvantagesofEP SeveraladvantagesofEPapproachesshouldbeacknowledged.First,itisaninexpensiveandeasilyapplicableprocedurethatrequiresthatpatientssimplywearspectaclescontainingmonocularorrighthemifieldEP.Itmaybeusedformanyhoursadayandprovidelong-termstimulation,aconditionnotapplicabletoconventionalhemispatialneglecttreatments.Second,patientsmaynotbeactivelyinvolvedinone-on-onetreatmentsessions.Thisisparticularlyrelevantinpatientsinwhomtheclinicalconditionmayinterferewithactivelyparticipatingintreatmentsessionsduetomedicalreasonsortoalackofsittingtolerance.Finally,EPapproachesmaybeeasilycoupledwithotherrehabilitationtechniquesorperformedathomeduringdailyactivitieswiththesupportofacaregiver. AllthesefeaturesmaketheEPparticularlysuitableforpatientsintheacute-sub-acutestageafterstroke(Ianesetal.,2012).Thislastpointisespeciallyimportantbecauseduringthefirstpost-strokeperiodpatientsmaybeunabletoactivelyparticipateinrehabilitationtreatmentsessions,andcouldbenefitfromatreatmentregimeinwhichtheyarepassivebeneficiaries(Ianesetal.,2012).Inaddition,trunkmisalignmentoralackoftrunkposturalcontrolintheearlystageafterstrokemaynotallowthepatienttoreceiveconventionaltreatment. RecommendationstoClinicians Takentogether,theresultsofthepresentreviewshowthatrighthemifieldEPmightbeapromisingprocedureintreatinghemispatialneglect.However,providingclearrecommendationstocliniciansisdifficultforseveralreasons. First,twoRCTsrated6/10and7/10bythePEDrodatabasedisplayedpartiallyconflictingresultsontheeffectivenessofrighthemifieldEPintheearlyphasesafterstroke(Fongetal.,2007;Tsangetal.,2009).However,thepowerofthesestudieswasinadequatebecauseofthesmallsamplesize.Theauthors,whosuggestedthatareplicationofthestudieswithanappropriatepatientsampleiswarranted,admittedthis.ItisworthnotingherethatthispointhighlightsalimitofthePEDroscale,inthatthepresenceofanadequatepatientsamplesizeisnotconsideredasacriterionforratingmethodologicalquality(Gehaetal.,2013). Second,twoRCTsrelevanttoourreviewwerenotfoundtobeeligibleforPEDroratingbecausetheywerenotconsideredasphysiotherapyinterventions(Zelonietal.,2002;Ianesetal.,2012).ThisprecludedthepossibilitytoratetheRCTsbyZelonietal.(2002)andIanesetal.(2012)whoshowedthatrighthemifieldEPcombinedwithanothertreatment(Zelonietal.,2002)orappliedalone(Ianesetal.,2012)ismoreeffectiveoratleastaseffectiveasastandardVST. Tosummarize,theresultsofthepresentreviewgloballytendtosupporttheusefulnessofrighthemifieldEPinclinicalpractice.Inordertodefinealevelofevidencebymeansofthestandardrehabilitationevidenceratingtools,however,furtherresearchiswarrantedbymeansofadequatelypoweredRCTsand/orameta-analysisofthepresentliteraturedata. DirectionsforFutureResearch Futurestudiesinthisfieldarerecommended.ThesestudiesshouldbedirectedtoinvestigatetheeffectsofEPonreducinghemispatialneglectseverity,disability,andtoimprovepatientindependence.Itisalsodesirablethatthelimitationsofthecurrentliteraturearetakenintoconsideration.First,RCTsinlargepatientsamplesandwithmultipleandlong-termfollow-upevaluationsessions(atleastat1and3monthsaftertreatment)arewarranted.ThisiscrucialtohavereliableevidenceabouttheroleofEPinstrokerehabilitationinordertoconveyause/notusemessagetoclinicians.Second,studiesinvolvingsub-acutepatientsshouldbeimplemented,wherespontaneousrecoverywillneedtobeconsideredasapotentialconfoundingfactor.Themostsuitablemethodtocontrolfortheeffectsofspontaneousrecoverywouldbetoincludeanuntreatedgroup.However,theinclusioninthestudyofanuntreatedgroupisdifficulttojustify,becausewithholdingtreatmentforhemispatialneglectfromapatientisunethical.Instead,aspecificstudydesignsuchas“delayedtreatment”shouldbeapplied(Paoluccietal.,2000).Third,patientswithhemianopiashouldbeexcludedor,ifincluded,theyshouldbeanalyzedseparately.Finally,theassessmentproceduresshouldincludebothstandardizedbatteriesfortheevaluationofhemispatialneglectseverity,suchasBIT,andtheevaluationofdisability. Conclusion Toconclude,theresultsofthepresentreviewshowthatEPisapromisingprocedureinthetreatmentofhemispatialneglectafterstrokeandthatfurtherresearchintheevaluationofEPisneeded. ConflictofInterestStatement Theauthorsdeclarethattheresearchwasconductedintheabsenceofanycommercialorfinancialrelationshipsthatcouldbeconstruedasapotentialconflictofinterest. References Arai,T.,Ohi,H.,Sasaki,H.,Nobuto,H.,andTanaka,K.(1997).Hemispatialsunglasses:effectonunilateralspatialneglect.J.Neurol.Neurosurg.Psychiatr.78,230–232. Barrett,A.M.,Crucian,G.P.,Beversdorf,D.Q.,andHeilman,K.M.(2001).Monocularpartchingmayworsensensory-attentionalneglect:acasereport.Arch.Phys.Med.Rehabil.82,516–518.doi:10.1053/apmr.2001.21973 PubmedAbstract|PubmedFullText|CrossRefFullText Beis,J.,Andre,J.,Baumgarten,A.,andChallier,B.(1999).Eyepatchinginunilateralspatialneglect:efficacyoftwomethods.Arch.Phys.Med.Rehabil.80,71–76.doi:10.1016/S0003-9993(99)90310-6 PubmedAbstract|PubmedFullText|CrossRefFullText Bowen,A.,andLincoln,N.B.(2007).Cognitiverehabilitationforspatialneglectfollowingstroke.CochraneDatabaseSyst.Rev.18:CD003586. Bowen,A.,McKenna,K.,andTallis,R.C.(1999).Reasonsforvariabilityinthereportedrateofoccurenceofunilateralspatialneglectafterstroke.Stroke30,1196–1202.doi:10.1161/01.STR.30.6.1196 CrossRefFullText Butter,C.,andKirsch,N.(1992).Combinedandseparateeffectsofeyepatchingandvisualstimulationonunilateralneglectfollowingastroke.Arch.Phys.Med.Rehabil.73,1133–1139. PubmedAbstract|PubmedFullText Buxbaum,L.J.,Ferraro,M.K.,Veramonti,T.,Farne,A.,Whyte,J.,Ladavas,E.,etal.(2004).Hemispatialneglect:subtypes,neuroanatomy,anddisability.Neurology62,749–756.doi:10.1212/01.WNL.0000113730.73031.F4 PubmedAbstract|PubmedFullText|CrossRefFullText Chechlacz,M.,Rotshtein,P.,andHumphreys,G.W.(2012).Unilateralvisualneglectsymptoms:ALEmeta-analysisoflesion-symptommapping.Front.Hum.Neurosci.6:230.doi:10.3389/fnhum.2012.00230 PubmedAbstract|PubmedFullText|CrossRefFullText Cherney,L.R.,Halper,A.S.,Kwasnica,C.M.,Harvey,R.L.,andZhang,M.(2001).Recoveryoffunctionalstatusafterrighthemispherestroke:relationshipwithunilateralneglect.Arch.Phys.Med.Rehabil.82,322–328.doi:10.1053/apmr.2001.21511 PubmedAbstract|PubmedFullText|CrossRefFullText Diamond,P.T.(2001).Rehabilitativemanagementofpost-strokevisuospatialinattention.Disabil.Rehabil.23,407–412.doi:10.1080/09638280010008834 PubmedAbstract|PubmedFullText|CrossRefFullText Fong,K.N.,Chan,M.K.,Tsang,M.H.,Chow,K.K.,Lau,C.W.,Chan,F.S.,etal.(2007).Theeffectofvoluntarytrunkrotationandhalf-fieldeye-patchingforpatientswithunilateralneglectinstroke:arandomizedcontrolledtrial.Clin.Rehabil.21,729–741.doi:10.1177/0269215507076391 PubmedAbstract|PubmedFullText|CrossRefFullText Franceschini,M.,LaPorta,F.,Agosti,M.,andMassucci,M.(2010).Ishealth-related-qualityoflifeofstrokepatientsinfluencedbyneurologicalimpairmentsatoneyearafterstroke?Eur.J.Phys.Rehabil.Med.46,389–399. PubmedAbstract|PubmedFullText Geha,N.N.,Moseley,A.M.,Elkins,M.R.,Chiavegato,L.D.,Shiwa,S.R.,andCosta,L.O.(2013).Thequalityandreportingofrandomizedtrialsincardiothoracicphysicaltherapycouldbesubstantiallyimproved.Respir.Care.doi:10.4187/respcare.02379 PubmedAbstract|PubmedFullText|CrossRefFullText Heilman,K.M.,andValenstein,E.(1979).Mechanismunderlyinghemispatialneglect.Ann.Neurol.5,166–170.doi:10.1002/ana.410050210 CrossRefFullText Hubel,D.H.,LeVay,S.,andWiesel,T.N.(1975).Modeofterminationofretinotectalfibersinmacaquemonkey:anautoradiographicstudy.BrainRes.96,25–40.doi:10.1016/0006-8993(75)90567-3 PubmedAbstract|PubmedFullText|CrossRefFullText Ianes,P.,Varalta,V.,Gandolfi,M.,Picelli,A.,Corno,M.,DiMatteo,A.,etal.(2012).Stimulatingvisualexplorationoftheneglectedspaceintheearlystageofstrokebyhemifieldeye-patching:arandomizedcontrolledtrialinpatientswithrightbraindamage.Eur.J.Phys.Rehabil.Med.48,189–196. PubmedAbstract|PubmedFullText Jutai,J.,Bhogal,K.,Foley,N.,Bayley,M.,Teasell,W.,andSpeechley,M.(2003).Treatmentofvisualperceptualdisorderspoststroke.Top.StrokeRehabil.10,77–107.doi:10.1310/07BE-5E1N-735J-1C6U PubmedAbstract|PubmedFullText|CrossRefFullText Katz,N.,Hartman-Maeir,A.,Ring,H.,andSoroker,N.(1999).Functionaldisabilityandrehabilitationoutcomeinrighthemispheredamagedpatientswithandwithoutunilateralspatialneglect.Arch.Phys.Med.Rehabil.80,379–384.doi:10.1016/S0003-9993(99)90273-3 PubmedAbstract|PubmedFullText|CrossRefFullText Khurshid,S.,Longin,H.,Crucian,G.P.,andBarrett,A.M.(2009).Monocularpatchingaffectsinattentionbutnotperseverationinspatialneglect.Neurocase15,311–317.doi:10.1080/13554790902776888 PubmedAbstract|PubmedFullText|CrossRefFullText Kwon,J.C.,Ahn,S.,Kim,S.,andHeilman,K.M.(2012).Ipsilesional“where”withcontralesional“what”neglect.Neurocase18,415–423.doi:10.1080/13554794.2011.627340 PubmedAbstract|PubmedFullText|CrossRefFullText Luauté,J.,Halligan,P.,Rode,G.,Rossetti,Y.,andBoisson,D.(2006).Visuo-spatialneglect:asystematicreviewofcurrentinterventionsandtheireffectiveness.Neurosci.Biobehav.Rev.30,961–982.doi:10.1016/j.neubiorev.2006.03.001 PubmedAbstract|PubmedFullText|CrossRefFullText Mackintosh,S.F.,Hill,K.D.,Doss,K.J.,Goldie,P.A.,andCulham,E.G.(2006).Balancescoreandahistoryoffallsinhospitalpredictrecurrentfallsinthe6monthsfollowingstrokerehabilitation.Arch.Phys.Med.Rehabil.87,1583–1589.doi:10.1016/j.apmr.2006.09.004 PubmedAbstract|PubmedFullText|CrossRefFullText Manly,T.(2002).Cognitiverehabilitationforunilateralneglect:review.Neuropsychol.Rehabil.12,289–310.doi:10.1080/0960201044000101 CrossRefFullText Nijboer,T.C.,Kollen,B.J.,andKwakkel,G.(2013).Timecourseofvisuospatialneglectearlyafterstroke:alongitudinalcohortstudy.Cortex.doi:10.1016/j.cortex.2012.11.006 PubmedAbstract|PubmedFullText|CrossRefFullText Ogden,J.A.(1985).Anterior-posteriorinterhemisphericdifferencesinthelocioflesionsproducingvisualhemineglect.BrainCogn.4,59–75.doi:10.1016/0278-2626(85)90054-5 PubmedAbstract|PubmedFullText|CrossRefFullText Ogourtsova,T.,Korner-Bitensky,N.,andPtito,A.(2010).Contributionofthesuperiorcolliculitopost-strokeunilateralspatialneglectandrecovery.Neuropsychologia48,2407–2416.doi:10.1016/j.neuropsychologia.2010.06.001 PubmedAbstract|PubmedFullText|CrossRefFullText Paolucci,S.,Antonucci,G.,Grasso,G.,andPizzamiglio,L.(2001).Theroleofunilateralspatialneglectinrehabilitationofrightbrain-damagedischemicstrokepatients:amatchedcomparison.Arch.Phys.Med.Rehabil.82,743–749.doi:10.1053/apmr.2001.23191 PubmedAbstract|PubmedFullText|CrossRefFullText Paolucci,S.,Antonucci,G.,Grasso,M.G.,Morelli,D.,Troisi,E.,Coiro,P.,etal.(2000).Earlyversusdelayedinpatientstrokerehabilitation:amatchedcomparisonconductedinItaly.Arch.Phys.Med.Rehabil.81,695–700.doi:10.1053/apmr.2000.5583 PubmedAbstract|PubmedFullText|CrossRefFullText Pedersen,P.M.,Jørgensen,H.S.,Nakayama,H.,Raaschou,H.O.,andOlsen,T.S.(1997).Hemineglectinacutestroke:incidenceandprognosticimplications.Am.J.Phys.Med.Rehabil.76,122–127.doi:10.1097/00002060-199703000-00007 PubmedAbstract|PubmedFullText|CrossRefFullText Pérennou,D.A.,Leblond,C.,Amblard,B.,Micallef,J.P.,Rouget,E.,andPélissier,J.(2000).Thepolymodalsensorycortexiscrucialforcontrollinglateralposturalstability:evidencefromstrokepatients.BrainRes.Bull.53,359–365.doi:10.1016/S0361-9230(00)00360-9 PubmedAbstract|PubmedFullText|CrossRefFullText PhysiotherapyEvidenceDatabase.(1999).Missenden(RD):TheGeorgeInstituteforGlobalHealth.Availableat:http://www.pedro.org.au/[Internet]. Pierce,S.R.,andBuxbaum,L.J.(2002).Treatmentsofunilateralneglect:areview.Arch.Phys.Med.Rehabil.83,256–268.doi:10.1053/apmr.2002.27333 PubmedAbstract|PubmedFullText|CrossRefFullText Posner,M.I.,andRafal,R.D.(1987).“Cognitivetheoriesofattentionandtherehabilitationofattentionaldeficits,”inNeuropsychologicalRehabilitation,edsM.J.Meier,A.Benton,andL.Diller(NewYork:Guilford),182–201. Serfaty,C.,Soroker,N.,Glicksohn,J.,Sepkuti,J.,andMyslobodsky,M.S.(1995).Doesmonocularviewingimprovetargetdetectioninhemispatialneglect?Restor.Neurol.Neurosci.9,77–83.doi:10.3233/RNN-1995-9202 PubmedAbstract|PubmedFullText|CrossRefFullText Soroker,N.,Cohen,T.,Baratz,C.,Glicksohn,J.,andMyslobodsky,M.S.(1994).Isthereaplaceforipsilesionaleyepatchinginneglectrehabilitation?Behav.Neurol.7,159–164. Sprague,J.M.(1966a).“Visual,acoustic,andsomestheticdeficitsinthecataftercorticalandmidbrainlesions,”inTheThalamus,edsD.P.PurpuraandM.D.Yahr(NewYork:ColumbiaUniversityPress),391–417. Sprague,J.M.(1966b).Interactionofcortexandsuperiorcolliculusinmediationofvisuallyguidedbehaviorinthecat.Science153,1544–1547.doi:10.1126/science.153.3743.1544 CrossRefFullText Sprague,J.M.,andMeikle,T.H.(1965).Theroleofthesuperiorcolliculusinvisuallyguidedbehavior.Exp.Neurol.11,115–146.doi:10.1016/0014-4886(65)90026-9 CrossRefFullText Stone,S.P.,Wilson,B.,Wroot,A.,Halligan,P.W.,Lange,L.S.,Marshall,J.,etal.(1991).Theassessmentofvisuo-spatialneglectafteracutestroke.J.Neurol.Neurosurg.Psychiatr.54,345–350.doi:10.1136/jnnp.54.4.345 PubmedAbstract|PubmedFullText|CrossRefFullText Taub,E.,Uswatte,G.,Mark,V.W.,andMorris,D.M.(2006).Thelearnednonusephenomenon:implicationsforrehabilitation.Eura.Medicophys.42,241–256. PubmedAbstract|PubmedFullText Tsang,M.H.,Sze,K.H.,andFong,K.N.(2009).Occupationaltherapytreatmentwithrighthalf-fieldeye-patchingforpatientswithsubacutestrokeandunilateralneglect:arandomizedcontrolledtrial.Disabil.Rehabil.31,630–637.doi:10.1080/09638280802240621 PubmedAbstract|PubmedFullText|CrossRefFullText vanNes,I.J.,vanderLinden,S.,Hendricks,H.T.,vanKuijk,A.A.,Rulkens,M.,Verhagen,W.I.,etal.(2009).Isvisuospatialhemineglectreallyadeterminantofposturalcontrolfollowingstroke?Anacute-phasestudy.Neurorehabil.NeuralRepair23,609–614.doi:10.1177/1545968308328731 PubmedAbstract|PubmedFullText|CrossRefFullText Walker,R.,Young,A.,andLincoln,N.(1996).Eyepatchingandtherehabilitationofvisualneglect.Neuropsychol.Rehabil.3,219–231.doi:10.1080/713755508 CrossRefFullText Wu,C.Y.,Wang,T.N.,Chen,Y.T.,Lin,K.C.,Chen,Y.A.,Li,H.T.,etal.(2013).Effectsofconstraint-inducedtherapycombinedwitheyepatchingonfunctionaloutcomesandmovementkinematicsinpoststrokeneglect.Am.J.Occup.Ther.67,236–245.doi:10.5014/ajot.2013.006486 PubmedAbstract|PubmedFullText|CrossRefFullText Yue,Y.,Song,W.,Huo,S.,andWang,M.(2012).Studyontheoccurrenceandneuralbasesofhemispatialneglectwithdifferentreferenceframes.Arch.Phys.Med.Rehabil.93,156–162.doi:10.1016/j.apmr.2011.07.192 PubmedAbstract|PubmedFullText|CrossRefFullText Zeloni,G.,Farnè,A.,andBaccini,M.(2002).Viewinglesstoseebetter.J.Neurol.Neurosurg.Psychiatr.73,195–198.doi:10.1136/jnnp.73.2.195 PubmedAbstract|PubmedFullText|CrossRefFullText Keywords:hemispatialneglect,rehabilitation,perceptualdisorders,treatment,stroke,visualstimulation,superiorcolliculus,eyepatching Citation:SmaniaN,FonteC,PicelliA,GandolfiMandVaraltaV(2013)Effectofeyepatchinginrehabilitationofhemispatialneglect.Front.Hum.Neurosci.7:527.doi:10.3389/fnhum.2013.00527 Received:16March2013;Accepted:14August2013;Publishedonline:02September2013. Editedby: TanjaNijboer,UtrechtUniversity,Netherlands Reviewedby: TanjaNijboer,UtrechtUniversity,NetherlandsTatianaOgourtsova,McGillUniversityHealthCenter,Canada Copyright:©2013Smania,Fonte,Picelli,GandolfiandVaralta.Thisisanopen-accessarticledistributedunderthetermsoftheCreativeCommonsAttributionLicense(CCBY).Theuse,distributionorreproductioninotherforumsispermitted,providedtheoriginalauthor(s)orlicensorarecreditedandthattheoriginalpublicationinthisjournaliscited,inaccordancewithacceptedacademicpractice.Nouse,distributionorreproductionispermittedwhichdoesnotcomplywiththeseterms. *Correspondence:NicolaSmania,DepartmentofNeurologicalandMovementSciences,NeuromotorandCognitiveRehabilitationResearchCenter,UniversityofVerona,PiazzaleLAScuro10,37134,Verona,Italye-mail:[email protected] COMMENTARY ORIGINALARTICLE Peoplealsolookedat SuggestaResearchTopic>