Virtual Environment Rehabilitation for Patients with Motor Neglect Trial (VERMONT): A Single-Center Randomized Controlled Feasibility Trial

Background: Motor neglect occurs in patients with chronic pain conditions. Virtual environments (VE) help rehabilitation through biofeedback and improving motivation. Aim: To assess the feasibility of a VE for patients with motor neglect with chronic pain. Methods: 10 subjects with chronic pain (Fibromyalgia, Sciatica, and Complex Regional Pain Syndrome) underwent a treadmill task three times per week for two weeks. Groups were randomized to receive real-time biofeedback from the VE (intervention) or shown still images (control). Primary outcomes were: (i) distance walked at baseline compared to the final 5 min cycle of week 2; (ii) the Lower Extremity Functional Index (LEFI) questionnaire. A satisfaction questionnaire was used. Follow up was to 24 weeks. Results: Total distance walked was significantly higher in the intervention group (p < 0.05), and 33% (2/6) of the intervention group had a clinically important LEFI improvement compared to 0/4 in the control group at week 2. No secondary outcome measures demonstrated any significant differences. The intervention received high satisfaction scores, significantly greater than the control group at week 24. No harms were recorded. Discussion: This feasibility study showed that VE and treadmill-walking improved walking distances and function for subjects with motor neglect. This is a promising novel approach and requires further validation through larger study.

Quantitative Assessment of Motor Neglect

Background and Purpose: We used differential actigraphy as a novel, objective method to quantify motor neglect (a clinical condition whereby patients mimic hemiplegia even in the absence of sensorimotor deficits), whose diagnosis is at present highly subjective, based on the clinical observation of patients’ spontaneous motor behavior. Methods: Patients wear wristwatch-like accelerometers, which record spontaneous motor activity of their upper limbs during 24 hours. Asymmetries of motor behavior are then automatically computed offline. On the basis of normal participants’ performance, we calculated cutoff scores of left/right motor asymmetry. Results: Differential actigraphy showed contralesional motor neglect in 9 of 35 patients with unilateral strokes, consistent with clinical assessment. An additional patient with clinical signs of motor neglect obtained a borderline asymmetry score. Lesion location in a subgroup of 25 patients was highly variable, suggesting that motor neglect is a heterogenous condition. Conclusions: Differential actigraphy provides an ecological measure of spontaneous motor behavior, and can assess upper limb motricity in an objective and quantitative manner. It thus offers a convenient, cost-effective, and relatively automatized procedure for following-up motor behavior in neurological patients and to assess the effects of rehabilitation.

Quantitative assessment of motor neglect

Objectives. Patients with unilateral brain damage may avoid moving the limbs contralateral to their lesion, even in the absence of sensorimotor deficits. However, when asked to move their limbs these patients typically show normal strength and dexterity. In their seminal 1983 article on the Journal of Neurology, Neurosurgery and Psychiatry, Laplane and Degos dubbed this condition Motor Neglect (MN). MN can mimic hemiplegia, with severe clinical consequences. Its assessment has thus important clinical implications. However, MN diagnosis is at present highly subjective, because it is based on the clinical observation of patients' spontaneous motor behaviour. Here we introduce differential actigraphy as a novel, objective method to quantify MN. Methods. Patients wear wristwatch-like accelerometers, which record spontaneous motor activity of their upper limbs during 24 hours. Asymmetries of motor behaviour are then automatically computed offline. On the basis of normal participants' performance, we calculated cut-off scores of left/right motor asymmetry. Results. Differential actigraphy showed contralesional MN in nine of 35 patients with unilateral strokes, consistent with clinical assessment. An additional patient with clinical signs of MN obtained a borderline asymmetry score. Lesion location in a subgroup of 25 patients was highly variable, suggesting that MN is a heterogenous condition. Conclusions. Differential actigraphy provides an ecological measure of spontaneous motor behaviour, and can assess upper limb motricity in an objective and quantitative manner. It thus offers a convenient, cost-effective, and relatively automatized procedure for following-up motor behaviour in neurological patients, and to assess the effects of rehabilitation.

Prisms to Shift Pain Away: Pathophysiological and Therapeutic Exploration of CRPS with Prism Adaptation

Complex Regional Pain Syndrome (CRPS) is an invalidating chronic condition subsequent to peripheral lesions. There is growing consensus for a central contribution to CRPS. However, the nature of this central body representation disorder is increasingly debated. Although it has been repeatedly argued that CRPS results in motor neglect of the affected side, visual egocentric reference frame was found to be deviated toward the pain, that is, neglect of the healthy side. Accordingly, prism adaptation has been successfully used to normalize this deviation. This study aimed at clarifying whether 7 CRPS patients exhibited neglect as well as exploring the pathophysiological mechanisms of this manifestation and of the therapeutic effects of prism adaptation. Pain and quality of life, egocentric reference frames (visual and proprioceptive straight-ahead), and neglect tests (line bisection, kinematic analyses of motor neglect and motor extinction) were repeatedly assessed prior to, during, and following a one-week intense prism adaptation intervention. First, our results provide no support for visual and motor neglect in CRPS. Second, reference frames for body representations were not systematically deviated. Third, intensive prism adaptation intervention durably ameliorated pain and quality of life. As for spatial neglect, understanding the therapeutic effects of prism adaptation deserves further investigations.