Perceptual Disorders After Stroke: A Scoping Review of Interventions

Perceptual disorders relating to hearing, smell, somatosensation, taste, touch, and vision commonly impair stroke survivors’ ability to interpret sensory information, impacting on their ability to interact with the world. We aimed to identify and summarize the existing evidence for perceptual disorder interventions poststroke and identify evidence gaps. We searched 13 electronic databases including MEDLINE and Embase and Grey literature and performed citation tracking. Two authors independently applied a priori–defined selection criteria; studies involving stroke survivors with perceptual impairments and interventions addressing those impairments were included. We extracted data on study design, population, perceptual disorders, interventions, and outcomes. Data were tabulated and synthesized narratively. Stroke survivors, carers, and clinicians were involved in agreeing definitions and organizing and interpreting data. From 91 869 records, 80 studies were identified (888 adults and 5 children); participant numbers were small (median, 3.5; range, 1–80), with a broad range of stroke types and time points. Primarily focused on vision (34/80, 42.5%) and somatosensation (28/80; 35.0%), included studies were often case reports (36/80; 45.0%) or randomized controlled trials (22/80; 27.5%). Rehabilitation approaches (78/93; 83.9%), primarily aimed to restore function, and were delivered by clinicians (30/78; 38.5%) or technology (28/78; 35.9%; including robotic interventions for somatosensory disorders). Pharmacological (6/93; 6.5%) and noninvasive brain stimulation (7/93; 7.5%) approaches were also evident. Intervention delivery was poorly reported, but most were delivered in hospital settings (56/93; 60.2%). Study outcomes failed to assess the transfer of training to daily life. Interventions for stroke-related perceptual disorders are underresearched, particularly for pediatric populations. Evidence gaps include interventions for disorders of hearing, taste, touch, and smell perception. Future studies must involve key stakeholders and report this fully. Optimization of intervention design, evaluation, and reporting is required, to support the development of effective, acceptable, and implementable interventions. Registration: URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42019160270.


List of Supplemental material
Study selection processes implemented were in line with scoping review guidance, using the following criteria: Participants: of any age (adults and children) with stroke-related disorders of perception Studies which combine stroke and non-stroke populations were included and coded to indicate whether they are a stroke-only or mixed population.
Studies that combine perceptual disorders with sensory or cognitive disorders, or where the precise nature of the disorder could be determined were included and coded to indicate this.
Intervention: all interventions that expressly address a perceptual disorder. We envisioned these may include rehabilitation, pharmacological, screening/ assessment interventions and possibly surgical. We included and coded all interventions that addressed perceptual disorders across more than one sense.
Study Design: all quantitative, qualitative and mixed-methods primary research studies, exploring clinical effectiveness, economic outcomes or implementation of interventions.
Setting: all settings, including hospital, community and out-patients, and any geographical location Date and Language: All published and unpublished studies in any language, with no date limitations Titles were assessed for eligibility by one reviewer (KM) with remaining abstracts and subsequent full texts evaluated by two reviewers (KM, CH). Third reviewers were consulted with areas of uncertainty or disagreement.
*In our original protocol, we had planned to search the following databases: Applied Social Sciences Index and Abstracts (ASSIA), PsycLIT database and Latin American and Carribean Health Services Literature (LILACS). Following the inception meeting with key stakeholders to develop the search strategy, it was clear that there was potentially significant overlap across these databases and in line with the publication of Bramer WM, Rethlefson ML, Kleijnen J, Franco OH (2017) Optimal database combinations for literature searches in systematic reviews: a prospective exploratory study. Systematic Reviews, 6, 245, we decided to include the Web of Science Core Collection instead.

Definition of perception
Our definitions of perception, and how to apply these, were developed and agreed through a full-day consensus process at the start of our project. The meeting was attended by the researcher team, and the stakeholder group of stroke survivors, carers and specialist clinicians in the field of perception. Each term was discussed in depth, definitions co-produced, and confirmed through a voting process.
The definition of perception agreed was: "specific mental functions of recognizing and interpreting sensory stimuli".
The included senses, and their agreed definitions were: Vision (visual) Processing and understanding visual (vision) information.
This may include the mental functions of being able to distinguish, discriminate, recognise and interpret visual information.

Hearing (auditory)
Processing and understanding auditory (hearing) information.
This may include the mental functions of being able to distinguish, discriminate, recognise and interpret auditory information.
This may include the mental functions of being able to distinguish, discriminate, recognise and interpret gustatory information.
This may include the mental functions of being able to distinguish, discriminate, recognise and interpret olfactory information

Touch
Processing and understanding tactile information*. This may include the mental functions of being able to distinguish, discriminate, recognise and interpret tactile information.
*Tactile is described as "understanding information from the skin" Somatosensation (including proprioception) Processing and understanding somatosensory information. This may include the mental functions of being able to distinguish, discriminate, recognise, and interpret somatosensory information.
NB somatosensation and touch were treated separately. Although tactile sensation can be considered a component of somatosensation, it was the decision of the group (after discussion) to present these individually, as they were considered separate -and distinguishable -functions. It also was felt this would aid understanding by stroke survivors and carers, for whom touch is well-recognised as one of the five "traditional" senses.
We did not include studies related to pain.

Application of definitions within the review process
To apply our eligibility criteria two independent reviewers considered whether a disorder was perceptual, based on a study's description of the function/impairment being studied, and our agreed definitions. A third a relevant topic expert was consulted where necessary: for somatosensory and tactile disorders (where decision making was often found to be difficult), a stroke-specialist physiotherapist was involved in decision-making.
Participant populations with complex disorders (including disorders of balance and Pusher Syndrome) proved challenging. A third topic expert was involved in all decisions, which were pragmatic, but considering relevant theory. Studies focused on balance were excluded, as balance was considered to (i) frequently incorporate a broad range of non-perceptual input, (ii) be a stage 'after' perception (analogous to reading and vision) and (iii) has an evidence base that often takes a physical function approach, and whose inclusion could make the results less meaningful. Studies of Pusher Syndrome, defined as "a clinical disorder following left or right brain damage in which patients actively push away from the nonhemiparetic side, leading to a loss of postural balance" 37 were included. Whilst the aetilogy and mechanism of the disorder are not fully understood, it was fundamentally as disorder of perception, where "perception of body posture in relation to gravity is altered" 37 and thus eligible for inclusion.
Disorders purely of sensation, such as visual field loss, and those purely of attention, such as visual neglect, were not included, as they were fell outside the definition of perception used in this review.

Methods S2: GRIPP2 summary of stakeholder involvement GRIPP2 short form
Section and topic Item Reported on page No

Report the aim of PPI in the study
The key aim of PPI was to maximise the quality, relevance and accessibility of our work. Specific aims included:  Agree definitions on key terms of relevance to the review (including "perception" and related terms)  Agree, and prioritise, outcomes of relevance to the review  Contribute to decisions on inclusion / exclusion of papers  Contribute to interpretation of findings  Support dissemination In Methods + additional information here

Provide a clear description of the methods used for PPI in the study
We had three key PPI strategies: 1. CO-PRODUCTION. Author DJN (a stroke survivor with a related perceptual problem) was a co-applicant on the funding application, and has a shared responsibility for this research. DJN has contributed to decisions around the design, conduct, interpretation and reporting of this research, and taken a lead role in the involvement of the Lived Experience Group (see below). 2. LIVED EXPERIENCE GROUP. This group comprises 5 individuals (including 2 stroke survivors, 2 carers of stroke survivors, and 1 parent of a child with perceptual problems after stroke). 3. CLINICAL EXPERT GROUP. This group comprises 4 clinicians with expertise relating to different areas of perception (vision, hearing, smell/taste).
Led by DJN, and our evidence synthesis PPI expert (AP), these groups had one face-to-face meeting at the start of the project, and then had four video-conference meetings, plus additional communication via email. Methods used within meetings comprised facilitated discussion, informed by participatory methods, to ensure all opinions were heard and represented. We used the nominal group technique, and experience of James Lind Alliance consensus methods, to reach consensus on key points, as this provides a structured format which is democratic, fosters equal participation and can facilitate generation of new ideas. Key stages to reach consensus involved (i) generation of ideas, (ii) sharing ideas, (iii) group discussion, (iv) voting and ranking.
In Methods + additional information here

3: Study results
Outcomes-Report the results of PPI in the study, including both positive and negative outcomes Definitions were agreed and outcomes identified and prioritised, and are Reported here. Manuscript Section and topic Item Reported on page No reported within this paper.
After each meeting all PPI contributors completed a record of involvement. This record captures each member's perception of their role at that stage (including the degree of control / influence that the felt they had over the review), what they felt they influenced, what was good / not so good, and any additional comments.
The results of these records of involvement will be fully reported within a separate paper (after completion of all stages of the project, which includes a Cochrane review in addition to this reported scoping review).
reporting the details of this in preparation.

4: Discussion and conclusions
Outcomes-Comment on the extent to which PPI influenced the study overall. Describe positive and negative effects PPI was central to decision making for this scoping review. The PPI input into this scoping review:  provided clear definitions of key terms which have been used to inform and structure the scoping review  provided a list of important outcomes of interest which informed the data extraction and presentation of results from the scoping review  influenced decisions on the presentation of results within this paper Reported here. Manuscript reporting the details of this in preparation.

5: Reflections/ critical perspective
Comment critically on the study, reflecting on the things that went well and those that did not, so others can learn from this experience Careful planning at the protocol stage provided us with a clear preplanned strategy and process for PPI. We have followed our pre-planned methods as fully as possible (moving to more online meetings than anticipated due to COVID restrictions), and successfully met our aims. Our PPI in this study is ongoing, as the PPI groups are continuing to contribute to a subsequent review (Cochrane review) and to other dissemination activities based on the results of our work. We plan to produce a critical reflection, including data from feedback forms provided by all PPI members after each meeting, at the end of this project.
Reported here. Manuscript reporting the details of this in preparation.

PPI=patient and public involvement
Whilst GRIPP uses the term PPI, we used the term stakeholder in this review, to denote the involvement of clinical specialists, as well as stroke survivors and carers

Rationale 3
Describe the rationale for the review in the context of what is already known. Explain why the review questions/objectives lend themselves to a scoping review approach.

4-5
Objectives 4 Provide an explicit statement of the questions and objectives being addressed with reference to their key elements (e.g., population or participants, concepts, and context) or other relevant key elements used to conceptualize the review questions and/or objectives.

Protocol and registration 5
Indicate whether a review protocol exists; state if and where it can be accessed (e.g., a Web address); and if available, provide registration information, including the registration number.

2, 5
Eligibility criteria 6 Specify characteristics of the sources of evidence used as eligibility criteria (e.g., years considered, language, and publication status), and provide a rationale.

5-6
Information sources* 7 Describe all information sources in the search (e.g., databases with dates of coverage and contact with authors to identify additional sources), as well as the date the most recent search was executed. Describe the methods of charting data from the included sources of evidence (e.g., calibrated forms or forms that have been tested by the team before their use, and whether data charting was done independently or in duplicate) and any processes for obtaining and confirming data from investigators 6 Data items 11 List and define all variables for which data were sought and any assumptions and simplifications made.
Supplementary If done, provide a rationale for conducting a critical appraisal of included sources of evidence; describe the methods used and how this information was used in any data synthesis (if appropriate).

Not done, noted in methods
Synthesis of results 13 Describe the methods of handling and summarising the data that were charted. 7

Selection of sources of evidence 14
Give numbers of sources of evidence screened, assessed for eligibility, and included in the review, with reasons for exclusions at each stage, ideally using a flow diagram.

Figure 1
Characteristics of sources of evidence 15 For each source of evidence, present characteristics for which data were charted and provide the citations.

Summary of evidence 19
Summarize the main results (including an overview of concepts, themes, and types of evidence available), link to the review questions and objectives, and consider the relevance to key groups.

11
Limitations 20 Discuss the limitations of the scoping review process. 14-15 Conclusions 21 Provide a general interpretation of the results with respect to the review questions and objectives, as well as potential implications and/or next steps.

Funding 22
Describe sources of funding for the included sources of evidence, as well as sources of funding for the scoping review. Describe the role of the funders of the scoping review.

15-16
Supplemental Tables Year of publication iii.
Type of publication iv.
Study title v.
Reference vi.
Country vii.
Author correspondence details vi. Country -continent category added (Asia, Africa, Europe, N. America, S. America, Australia)

Study characteristics
i.
Study aims ii.
Study design iii.
Recruitment method iv.
Number of recruitment sites (single vs multiple) v.
PPI involvement (yes, not reported) ii. Study design -categorized (RCT, case report, case series, case-controlled, cross sectional, controlled trial, other)

Participants
i. Selection criteria ii.
Total study population (n=) iii.
Lost to follow-up (n=) v.
Age -measures of age/distribution vi.
Adult or child (adult/child) vii.
Stroke characteristics ix.
Stroke severity x.
Type of stroke xi.
Presence of other stroke related impairment xiii.
Time since stroke xiv.
Just Name of intervention iv.
Materials access details reported (yes, partial yes, no*) ix.
Mode of delivery reported (yes, partial yes, no*), description xi.
Location of delivery reported (yes, partial yes, no*), description xii.
When and how much reported (yes, partial yes, no*, description xiii. Intervention tailored (yes, partial yes, no*) xiv.
Was evaluation of adherence or fidelity planned (yes, partial yes, no*) xv.
Were any other interventions tested? (yes/no) xvi.
Was the intervention delivered alongside usual care (yes, no, unclear) ii. Approach classified (pharmacological, noninvasive brain stimulation, rehabilitation). Rehabilitation was further classified as restitution (direct training of impaired function), compensation (compensation of deficit by a training/using a spared function) substitution (use of an external device or modification e.g. optic or prosthetic devices, environmental redesign) 1 , or a mix of these. Non-invasive brain stimulation includes transcranial magnetic stimulation (rTMS), theta burst stimulation (TBS), and transcranial direct current stimulation (tDCS). vi. Materials categorized (health care professional led, technology (machinery, computer, robotics), brain stimulation, equipment (specialised equipment that does not come under technology), pharmacological, not reported) ix. intervention provider categorised (physiotherapist, occupational therapist, researcher, medical doctor (medic), other, not reported, unclear) x. mode of delivery categorised (one-to-one, self-delivery, group, not reported, unclear) xi. location of delivery categorised (hospital inpatient, hospital outpatient, hospital in-or out-patient, home, not reported) xiii. duration of intervention delivery classified (less than one week, one month or less, between one and three months, more than three months, not reported, unclear) xv. Other intervention type categorised (active, sham, unclear),

Results
i. ii. Measurement timepoint -categorized based on longest follow-up timepoint (Immediate (same day as intervention), Medium term (1-3 months), Long term (> 3 months), not reported) * Partial yes -where some detail is given, but it lacks enough detail for a clinician to be able to deliver the intervention   1970-1974 1980-1984 1985-1989 1990-1994 1995-1999 2000-2004 2005-2009   Auditory processing disorder A hearing problem that affects how the brain interprets sound rather than how sound is carried through the ear to the brain Charles Bonnet syndrome Visual hallucinations, which may be simple patterns, or detailed images of events, people or places Hearing deficit/disorder A problem in recognizing and interpreting sensory information from the hearing (auditory) system Proprioceptive deficit/disorder A problem in recognizing and interpreting sensory information relating to proprioception, or body/joint location and movement Pusher syndrome Is characterized by leaning and active pushing toward the contralesional side, affecting posture and possibly leading to instability and loss of balance Somatosensory deficit/disorder A problem in recognizing and interpreting sensory information relating to somatosensation, including pressure, temperature or body position.
Tactile deficit/disorder A problem in recognizing and interpreting sensory information relating touch and information from the skin.
Visual agnosia A condition in which a person can see but cannot recognize or interpret visual information e.g. an inability to name or describe the use for an object being viewed Visual hallucination The visual perception of an object or event in the absence of an external stimulus.
Visual perceptual deficit/disorder A problem in recognizing and interpreting sensory information from the eyes and visual system Visual spatial deficit/disorder A problem in recognizing and interpreting visual information relating to the position of objects, their relation to other objects, and relation to the body, both when at rest and in motion.

(32.3)
28 (30.1) 13 (14.0) 9 (9.7) 6 (6.5) 6 (6.5) 1 (1.    Comparison of the pre-and post-intervention assessment results showed that both interventions led to the following significant changes: decreased severity of PB scores and increased PASS, BPR, and K-MBI scores (p<.05). In particular, statistical analysis between the two groups, the BLS score was significantly decreased in the GPVT group (p<.05). And PASS, BPR, and K-MBI scores were significantly improved in the GPVT group than in the CPVT group (p<.01, respectively)

NIBS -Non invasive Brain Stimulation
An 2020 For the primary outcome, after training, BLS scores were decreased more for the experimental than control group ( At day four post-stroke, none of the eight patients were able to sit unsupported. All eight patients showed severe contraversive pushing on each of the Scale for Contraversive Pushing sub-scales. Within three weeks, pushing behaviour improved significantly. When we compared the overall score of the scale for Contraversive Pushing between days four and 24 post-stroke, we found significant improvement (Wilcoxon's Z = -2.23; p = 0.026). Further, at day 24, six of the patients (75%) had recovered sufficiently that they could sit unsupported (McNemar test; p= 0.031). These patients were able to keep a stable upright body position even when distracted; for example, when they did not concentrate on their body orientation. Moreover, 18 days post-stroke all eight patients were able to stand erect while being supported by a physiotherapist. The average degree of pushing behaviour while standing at day 18 was 0.79 on the 'posture' subscale, 0.72 on the 'extension' sub-scale and 1.0 on the 'resistance' sub-scale Brunsdon 2007 Clear benefits from treatment were evident. The assessment and treatment methods employed provide practical and useful ideas for management of this condition in other children. The results clearly indicate a specific treatment effect for both landmark recognition training and specific route-finding training. In other words, constant exposure to the target routes on a day-to-day level did not impact significantly on route finding even over an extended time period, but specific training resulted in significant improvements. In addition, improvements were not restricted to route finding success but were also evident in efficiency of route finding. Although CA had a documented visual agnosia and had difficulty recognising school buildings and landmarks, improving his visual recognition skills was not sufficient for treatment success in actual route finding and orientation Burr 1970 Mr W appears brighter and more confident in himself and his abilities. His wife reports that he is continuing to do everything for himself at home and although she still does supervise him while getting in and out of the bath, she was not needed to offer any manual assistance Carey 1993 Graphic and statistical interrupted time-series analyses indicated that treatment produced improvements in seven of eight tactile time series and all four proprioceptive time series. Baseline improvement in one tactile time series prevented unequivocal evaluation of treatment effect. Improvements were clinically significant, discrimination in the affected hand becoming comparable to the other hand and normal performance. Therapeutic effects were maintained at 3-month to S-month follow-up tests

Carey 2005a
Stimulus-specific training was successful for trained texture and proprioceptive discriminations, but it failed to show spontaneous transfer to related untrained stimuli in the same modality in seven of eight experiments in which this was possible. In contrast, intramodality transfer was obtained with stimulus-generalization training in four of five experiments that investigated stimulus-generalization training of texture discrimination. Findings were confirmed by meta-analysis Carey 2011 Between-group comparisons revealed a significantly greater improvement in sensory capacity following sensory discrimination training, t(47) = 2.75, P = .004, 1-tailed; mean between-group change = 11.1 SSD; confidence interval 3.0 to 19.2. Improvements were maintained at 6 weeks and 6 months. Sensory discrimination training can achieve significant improvements in functional sensory discrimination capacity after stroke. The clinically oriented training achieved transfer of training effects to novel stimuli. Our findings provide support for introducing sense discrimination training in rehabilitation of sensory deficits after stroke Carey 2016 Improved touch discrimination of a magnitude similar to previous clinical studies and approaching normal range was found. Patients with thalamic/capsular somatosensory lesions activated pre intervention in left ipsilesional supramarginal gyrus, and post intervention in ipsilesional insula and supramarginal gyrus. In contrast, those with S1/S2 lesions did not show common activation pre intervention, only deactivation in contralesional superior parietal lobe, including S1, and cingulate cortex post intervention. The S1/S2 group did, however, show significant change over time involving ipsilesional precuneus. This change was greater than for the thalamic/capsular group (P = .012; d = −2.43; CI = −0.67 to −3.76)

Chen 2011
After 3 weeks, the symptoms of hallucinations and anxiety were relieved. Although some CBS patients might be self-limited without discomfort, low-dose aripiprazole can be considered as a safe medication for significantly anxious patients with CBS Chen 2012a indicated that treatment produced improvements in seven of eight tactile time series and all four proprioceptive time series. Baseline improvement in one tactile time series prevented unequivocal evaluation of treatment effect. Improvements The result demonstrated that the Global Processing Training significantly improved visuospatial memory deficits after a right-brain stroke. On the other hand, rote practice without a step-by-step guidance limited the degree of memory improvement. The treatment effect was observed both immediately after the training procedure and 24 h posttraining

Cho 2015
Both groups showed significant differences in their relative beta wave values and attention concentration quotients. Moreover, the NFB group showed a significant difference in MVPT visual discrimination, form constancy, visual memory, visual closure, spatial relation, raw score, and processing time. This study demonstrated that NFB training is more effective for increasing concentration and visual perception changes than traditional rehabilitation Choi 2018 After completion of training, the WVRT group showed significant improvements of+7 (8.25) in theMVPT-3 score, +3.00 (5.25) in the BBS score, and -1.92 (6.33) s in the TUG test, with all results being significantly better than those of the GBT group (P<0.05)

Cogan 1973
These subjective phenomena would come and go with unpredictable intermittency but would lessen in a dimly lit room and would disappear when he closed his eyes or made an attempt to look at them on his left side. They continued for two months but were said to be relieved by Librium Colombo 2015 Range of motion during shoulder and wrist flexion improved, but only wrist flexion remained improved at 3-month follow-up. These preliminary results suggest that intensive robot-aided rehabilitation may play an important role in the recovery of sensory function. However, further studies are required to confirm these data Dutton 2017 After a few weeks her simultanagnostic visual dysfunction had regressed almost entirely. She regained her reading skills and visual detection in her peripheral visual field, and returned to full time schooling

Edmans 1991
The results showed little evidence of effective treatment or individual perceptual deficits. Perceptual stimulation alone may have produced some general improvements Edmans 2000a There was no significant difference between the treatment groups on patient characteristics or impairments. The results also showed no significant difference between the treatment groups before and after treatment on perceptual ability total scores, individual perceptual subtest scores, or functional ability total scores (Mann-Whitney U 642.5-798.0, p > 0.05). Wilcoxon matched pairs signed ranks tests showed a significant improvement in both groups after treatment on perceptual and functional

Enders 2013
Vibrotactile noise of all intensities and locations instantaneously and significantly improved Monofilament scores of the index fingertip and thumb tip (p < .01). No significant effect of the noise was seen for the Two-Point Discrimination Test scores. Remote application of subthreshold (imperceptible) vibrotactile noise at the wrist and dorsal hand instantaneously improved stroke survivors' light touch sensation, independent of noise location and intensity. Vibrotactile noise at the wrist and dorsal hand may have enhanced the fingertips' light touch sensation via stochastic resonance and interneuronal connections. While long-term benefits of noise in stroke patients warrants further investigation, this result demonstrates potential that a wearable device applying vibrotactile noise at the wrist could enhance sensation and grip ability without interfering with object manipulation in everyday tasks

Fechtelpeter 1990
The stimulation of conscious auditory analysis proved to be increasingly effective over a 4-week period of therapy. We were able to show that the patient's improvement was not only a simple effect of practicing, but it was stable and carried over to non-trained items

Fifer 1993
The most remarkable finding associated with this case is the presence of a unilateral auditory processing disorder when presenting speech materials to the left ear. Intervention for this patient is described in addition to a discussion of possible explanations for the unique pattern of auditory dysfunction

Flint 2005
The positive symptoms abated over a week. The hallucinations may have resulted from infarction, with disinhibition of higher visual centers, or from simple partial seizures not detected by surface EEG. The prolonged symptoms and finding of hypoperfusion by SPECT during the phenomena argue against an epileptiform etiology

Freitas 2017
There is a considerable improvement in FM scores -sensory function and in FIM. The improvement of hemi negligence and SP was also observed by the applied tests. BSE scores and FM, upper limb and lower limb section had minimal differences in the comparison before and after treatment Fujimoto 2016 We found that GOT thresholds for the affected index finger during and 10 min after the S1 and S2conditions were significantly lower compared with each sham condition. GOT thresholds were not significantly different between the S1 and S2 conditions at any time point

Fujino 2016
At the baseline phase, both scores were poor. Both scores improved after the intervention and follow-up phases, and all the patients could sit independently

Fujino 2019
In both patients, electromyography of the non-paretic triceps brachii muscle revealed excessive activity. To inhibit the excessive activity, ES was applied to the non-paretic biceps muscle. All scores improved after the intervention and follow-up phases

Funk 2013
The authors found (a) rapid improvements in trained but also in nontrained spatial orientation tests in all 13 participants, partially up to a normal level; (b) stability of the obtained improvements at 2-month follow-up; (c) interocular transfer of training effects to the nontrained eye in 2 participants suggesting a central, postchiasmatic locus for this perceptual improvement; and (d) graded transfer of improvements to related spatial tasks, such as horizontal writing, analog clock reading, and visuoconstructive capacities but no transfer to unrelated measures of visual performance. Conclusions. These results suggest the potential for treatmentinduced improvements in visuospatial deficits by feedback-based, perceptual orientation training as a component of rehabilitation after stroke

Gillen 2003
The child and his family reported that simply having the deficits recognized had been beneficial. The commonsense strategies suggested were incorporated easily into everyday life and school. He is able to attend mainstream school with the help of a support teacher for less than two hours a week. He has achieved greater independence and his self-esteem has improved. Behavioural problems arising from frustration are less frequent. The patient is able to ride his bicycle safely near his rural home. He appeared, therefore, to have the same condition but had adapted to it much more effectively Gillespie 2019 A standing frame protocol was implemented into standard care to improve CoP. The patient was assisted into a standing frame daily, and the Burke Lateropulsion Scale and Functional Independence Measure were tracked. Improvements in both outcome measures were greater than normative data.

Gottlieb 1991
The role of blinking in reviving the visual percept may be explained accordingly as causing a re-fixation of the target under visual fixation or as resetting the visual pathways for visual processing. When he intentionally blinked the faded visual percept reappeared

Hayashi 2004
We encountered a patient recovering from a right temporal hemorrhage who suddenly developed olfactory illusions and hallucinations in response to certain foods or situations. We discuss the likely mechanism of olfactory hallucinations in this case. About 3 months after the hemorrhage the olfactory episodes had nearly ceased. the patient recovered his appetite and returned to his job Jahn 2017 The case shows, for the first time, that specific training of disturbed verticality perception can be performed using the Spacecurl and that improvement of SPV (not SVV, which remained unchanged) parallels with the improvement of established measures and with clinical progress. The training method supports active participation of the patient and can be used before the patient is able to stand without or with only limited support. This is limited evidence from a single subject. Currently, a larger series of stroke patients are receiving the same training protocol in a randomized trial

Jamal 2017
In the post-test, a significant reduction in WBA was established in the RBD (P = 0.009) and was maintained at D + 15 (P = 0.01) and D + 22 (P = 0.05), no effect was observed in the LBD. In addition, no significant modification was found on the spatial frame in both groups. A significant improvement was found for the Motricity and time up and go in the RBD Jang 2018 Four months after onset, left leg motor function (Motricity Index [MI] = 51) did not show significant recovery from that at two months after onset (MI = 41); however, in the same period, Nottingham Sensory Assessment and scale for contraversive pushing significantly improved. At four months, the patient was able to stand independently but required manual contact of one person during independent walking on an even floor. At seven months after onset, he was able to walk independently on an even floor Jo 2012 First, the difference in visual perception function before and after CoTras treatment was analyzed using a paired t-test. As a result of the analysis, there was a statistically significant difference (0.000, p <.05). Second, the average AMPS motor skill score increased from 0.90 to 1.11, but there was no statistically significant difference. The average treatment technique score increased from 0.08 to 0.46 points, but there was no statistically significant difference, and clinically the ability to perform daily activities was significantly improved (logit >0.3) Jokelainen 2000 In the light of the example case, we describe the pusher syndrome that exists previously dealt with only briefly in the Finnish medical literature. A typical cause is a pyramidal tract infarction or bleeding in the brain capsules in the area of the internal crus posterus. The syndrome is characterized by continuous, strong pushing and tilting of the body towards the paralyzed side. Syndrome it is important to identify; it complicates and slows down rehabilitation, especially in the early stages but does not necessarily affect the outcome of rehabilitation. After more than a month and a half, pushing syndrome was so relieved that the patient received permission move in your own room independently without aids Dangerous situations still arose during the turns, stopping and as he walked through the doors -especially if tired. In the doorways he could collide with his left doorstep or get stuck on the left hand to the doorway. Gradually, as walking became more confident, the patient began move outside your room without an assistant. On the way home, score in Berg's balance test (Berg et al. 1989) was 42/56 and on the FIM performance indicator 102/126 and the ten-meter walking time was 8.5 seconds.

Kang 2009
After training, the mean (SD) Motor-free Visual Perception Test score increased significantly in both experimental group (from 65.8 (19.5) to 77.8 (28.7)) and control group (from 68.3 (11.4) to 74.1 (14.8)) (P50.01). Modified Barthel Index score increased significantly in both groups, with the experimental group recording a higher increase. Mean (SD) interest scale score was greater in the experimental group (2.2 (0.8)) than in the control group (1.3 (0.7) (P50.01)

Kim 2011
The intervention group showed significant improvement in visual attention (p＜ 0.05). There was no significant difference in visual memory, visuomotor coordination nd K-DRS (p＞0.05). Both groups showed significant increase in K-MMSE and K-MBI scores (p＜0.05), but there was no significant difference between the two groups (p＞0.05)

Kim 2015a
Experimental groups (group 1 and group 2) showed significant differences in PE, FRT, TUG, and 10-MWT compared to the control group (p <0.05). Group 2 (PSPT on an unstable surface) was significantly different in PE, FRT, and 10-MWT from group 1 (p <0.05). No significant differences were observed for other measures. Pressure sense perception training on an unstable surface might be a significantly more effective method for improving somatosensory function, balance, and walking ability, than PSPT on a stable surface

Kim 2016
The Lokomat group produced significantly better outcomes in SCP (p =0.046), BBS (p =0.046), FI (p =0.038), and TUG (p =0.038) compared with the control group after 4 weeks of intervention. In addition, there were significant correlations between SCP and BBS (p =0.024), FI (p =0.039), and TUG (p =0.030). Lokomat with VR more effectively aided recovery from PS after stroke, and restoration of PS symptoms was related with improvement of balance and gait function Kitisomprayoonkul 2012 Mean (SD) age of control and tDCS groups were 54.7(8.6) and 58. 0(11.9) years, consecutively. Mean (SD) onset were 5.3(1.8) and 9.7(17.8) days. When compared with the control group, the tDCS group significantly improved sensation of hypesthetic hand immediately after tDCS and 30 minutes after cessation (P 0.05). Immediately after stimulation, 50% and 60-70% of tDCS group improved light touch and pinprick sensation, consecutively. Thirty minutes after tDCS cessation, 40% and 50% of the tDCS group improved light touch and pinprick sensation, consecutively. 40-70% of patients have an improvement in 5 out of 7 SWM-tested sites. Most patients in tDCS group had sensation improvement at least 1-level. Most patients in control group had no sensation improvement. Anodal tDCS improves hand sensation in acute stroke immediately after 20-min stimulation. This effect remains at least 30 minutes after stimulation Ko 2018 Patients in both groups showed significant improvements on the kinesthetic and tactile sensation subscale of the NSA for the lower limb, the K-BBS, the FAC, and the K-MBI, but not the MI, from baseline to post-intervention at 3 weeks. When compared between the two groups, significant improvements were only seen in the kinesthetic sensation subscale of the NSA for the lower limb and the K-BBS (p<0.05). Frenkel's exercise improves sensory and balance recovery among subacute ischemic stroke patients with impaired proprioception and minimal lower limb motor weakness

Koo 2018
Although there was no clear significant difference between the two groups, when the changes from baseline to post treatment evaluation were compared between the groups, a partially significant improvement was observed in the anodal stimulation group compared with the sham stimulation group. Interestingly, the tactile sensation of the unaffected side also improved. Moreover, the greater improvement in activities of daily living function was observed in the anodal stimulation group too. Conclusion: Anodal transcranial direct current stimulation over the primary somatosensory cortex may be a useful adjuvant therapy for the recovery of somatosensation and activities of daily living function in patients with sensory deficits after stroke Koohi 2017 (a) The signal-to-noise-ratio (SNR) for 50% correct speech recognition performance was measured with speech presented from 0°azimuth and competing babble from ±90°azimuth. Spatial release from masking (SRM) was defined as the difference between SNRs measured with co-located speech and babble and SNRs measured with spatially separated speech and babble. The SRM significantly improved when babble was spatially separated from target speech, while the patients had the FM systems in their ears compared to without the FM systems Speech reception thresholds showed clinically and statistically significant improvements in intervention but not in standard care subjects at10 weeks in aided and unaided conditions Krewer 2013 Compared to PT-vf, Lokomat therapy had a significant effect on the BLS of pusher patients but no significant effect on the SCP values. GVS had no significant effect on these values on either scale. BLS is more useful than SCP to detect small changes for clinical trials and routine treatment. Forced control of the upright position during locomotion seems to be an effective method for immediately reducing the pushing behaviour of stroke patients, probably because it recalibrates a biased sense of verticality, via the somatic graviception. This finding, however, does not allow prediction of its long-term effects. Furthermore, it would be interesting to evaluate repetitive, multi-session DGO therapy and the amount of therapy needed to effectively reduce the pusher behaviour Lee 2017 Compared to the average score at baseline, the average SCP score for the SPV training without visual feedback decreased from 5.3 to 2.8, from 4.6 to 3, and from 3.5 to 2.7 for subjects 1, 2, and 3, respectively. However, the average score for the SPV training with visual feedback decreased from 5.3 to 3.1, from 4.6 to 3.5, and from 3.5 to 3.3 for subjects 1, 2, and 3, respectively Lincoln 1985 No significant differences were found between the groups either before or after 4 weeks of treatment on measures of visual perception or on ADL scales McDowell 2019 The patient suffered spontaneous left occipital lobe brain hemorrhage from a ruptured arteriovenous malformation. This was surgically excised. Short lived right upper limb intermittent jerking, with additional left sided weakness, ensued. Anomalous EEG recordings, with right-sided bias, arose from the posterior temporo parietal area. A right homonymous hemianopia was evident. During the ensuing 17 years she experienced multiple complex difficulties, until, at a lecture describing how to identify and support children with CVI, she realized she herself had many of the difficulties described. Visual assessment identified hemianopia and dorsal stream dysfunction. Discussion. Following identification, characterization, and explanation of the impact of her visual difficulties, she both gained greater awareness of her visual difficulties and their impact and developed a range of strategies leading to functional improvement of her visual field loss and amelioration of her dorsal stream dysfunction, with great improvement in quality of life. Following identification, characterization, and explanation of the impact of her visual difficulties, she both gained greater awareness of her visual difficulties and their impact and developed a range of strategies leading to functional improvement of her visual field loss and amelioration of her dorsal stream dysfunction, with great improvement in quality of life. Her new knowledge and understanding of her condition have considerably improved her quality of life because she can now use rational approaches to make the best use of her vision Meneghetti 2009 Aquatic physiotherapy consisted of two weekly sessions of one hour for two months, totaling 16 sessions, using the methods Bad Ragaz and Halliwick, to strengthen the musculature of the trunk and the upper limbs, respectively. In the evaluation after the intervention, important reduction in the head inclination angles (from 31.7º to 10.6º), the shoulders (from 10.3º to 1.7º) and the trunk (from 9.6º to 3.0º). The program of aquatic physiotherapy, therefore, provided the participant with the syndrome of sensitive pusher improves trunk symmetry and alignment

Mikola-jewska 2012
The author describes, on the basis of the literature and own research, symptoms and methods of the treatment of the little-known posterior pusher syndrome. After two weeks (ten sessions) of the therapy there was an observed extinction of symptoms of the posterior pusher syndrome (SCP score = 1.25, both sitting and standing, Table 2). Previously reported tendency to fall backwards could no longer be demonstrated

Morioka 2003
Twenty-six subjects completed the study. Data indicate that more parameters indicating postural sway were significantly decreased in the experimental group than in the control group. Also, there was a significant difference between the groups in change scores (pre-exercise minus post exercise) of length and enveloped area. The plantar perception exercise used as a method in this study is considered to be effective as a supplemental exercise for standing balance. The possibility of clinical application using the hardness discrimination task with rubber as a balance exercise is therefore suggested Nakagawa 1999 Hyperdynamic therapy relieved the visual hallucinations Nakamura 2014 In both patients, the SCP scores were reduced only during phase B2. Although the BLS scores improved at the A1 phase, a larger improvement was seen at the two B phases. Multisession GVS combined with physical therapy may have positive effects on PB in clinical setting

Nguyen 2011
The patient had previously presented to his ophthalmologist with visual acuity complaints and was diagnosed with hypertensive retinopathy and bilateral cataracts but neglected to mention these ongoing visual hallucinations for fear of being diagnosed with mental illness. As a diagnosis of exclusion, CBS was confirmed, and the patient was reassured but also treated temporarily with haloperidol nightly until immediate marked resolution of hallucinations O'Hare 1998 The progress of cognitive visual dysfunction over an 8-year period of a child who sustained bilateral occipital-lobe infarctions at the age of 2% years is described. She survived with normal intelligence and went on to attend mainstream school. She manifested many features of cognitive visual impairment and, in particular, developed a form of pure alexia without agraphia. She achieved some letter-byletter reading but no sight vocabulary development, including to her own name. She learned to write imaginatively employing phonetically true spelling but cannot read what she has written. Her progress and the dif5culties encountered during the management of her condition are discussed in this first case report of the evolution of pure alexia without agraphia in childhood. The features of this syndrome in the developing child who has never developed the capacity to read are contrasted with that seen in affected adults

Oppen-laender 2015
Both groups performed these tasks under three experimental conditions on three different days: a) sham GVS where electric current was applied only for 30 s and then turned off, b) left-cathodal GVS and c) right-cathodal GVS, for a period of20 min per session. Left-cathodal GVS, but not right-cathodal GVS significantly reduced all parameters in the SVV. Concerning STV GVS also reduced constant error and range numerically, though not significantly. These effects occurred selectively in the impaired patient group. In conclusion, we found that GVS rapidly influences post stroke verticality deficits in the visual and tactile modality, thus highlighting the importance of the vestibular system in the multimodal elaboration of the subjective vertical. Left-cathodal GVS, but not right-cathodal GVS significantly reduced all parameters in the SVV. Concerning STV GVS also reduced constant error and range numerically, though not significantly. These effects occurred selectively in the impaired patient group. In conclusion, we found that GVS rapidly influences post stroke verticality deficits in the visual and tactile modality, thus highlighting the importance of the vestibular system in the multimodal elaboration of the subjective vertical Papathan-asiou 1998 The neuropsychological nature of verbal auditory agnosia is not fully understood. This study aims to describe the language deficits and the remediation strategies used in a person with verbal auditory agnosia. In addition, it will address the theoretical issues concerning the nature of the phenomenon and the clinical implications in the management of people with this disorder

Pardo 2019
All five participants demonstrated improvements in pushing behavior, balance and transfer status. These outcomes provide preliminary evidence of decreased pushing behavior, and improved balance and transfers following a program of interventions designed to improve the functional outcomes of patients with PS. Larger studies are needed to confirm these findings, and whether these interventions are effective for patients with less severe pushing behavior There is no literature regarding the treatment of asomatognosia, but the use of established cognitive rehabilitation techniques for neglect seemed reasonable and ultimately led to the complete resolution of the asomatognosia and the hallucinations and marked improvements in neglect Rafique 2016 Increased application of rTMS corresponded with a reduction in intensity of visual phosphene hallucinations and was reflected in altered blood oxygen leveldependent (BOLD) signal. fMRI revealed focal excitatory discharges at the border of the lesion, highlighting the origin of phosphenes. Post-rTMS, rTMS did not simply suppress activity in the patient but rather re-distributed the previously imbalanced cortical activity not only at the stimulation site but in remote cortical regions so that it more closely resembled that of controls

Roberts-Woodbury 2016
Charles Bonnet syndrome is a syndrome of release, or visual, hallucinations due to stroke or secondary to visual impairments, including cataracts, macular degeneration, and glaucoma. Patients with this syndrome usually realize that the hallucinations are not real. Many patients are afraid to mention the hallucinations to their doctors for fear of this symptom being mistaken for a psychiatric illness. Charles Bonnet syndrome should be considered in the differential diagnosis for visual hallucinations. It is, unfortunately, a diagnosis of exclusion. The visual hallucinations worsened during his hospitalization, and he was placed on a trial of Risperidone. This medication was stopped due to side effects, and over the next few days, the hallucinations began to improve without any other pharmacological intervention

Scheets 2007
Use of movement system diagnoses may have multiple benefits for patient care. The possible benefits include decreasing the variability in management of patients with neuromuscular conditions, minimizing the trial-and-error approach to treatment se-lection, improving communication among health care professionals, and advancing research by enabling creation of homogenous patient groupings Tanemura 1999 Measurable recovery of visual perception was achieved through activities planned to reorganize his visual perception with intact kinesthetic information Towle 1990 Treatment had no discernable effect on measures of cancellation or cube copy. In 3/6 patient there was some improvement in Rey complex figure scores, but in only one was this distinct and attributable to treatment Voos 2011 After treatment, the patient was reassessed and showed improvement in all scales. The assessment of the pushing symptom and the the manual Jebsen-Taylor function tests were those that registered the highest percentages improvement, 79% and 46%, respectively. The protocol used, even though it was started six months after the injury, provided perceptual and functional improvement, which suggests the importance of physical therapy in the recovery of SP Wang 2016a A comparison of pre and post treatment assessment revealed that the three experimental groups led to increase in the balance scores and Barthel Index, but the core stability training group hadn't obvious change in Pusher syndrome scores. Visual feedback training group, visual feedback and core stability training group had obvious decrease in Pushers syndrome scores (p<0.01) with no obvious difference between these two groups (p>0.05)

Weinburg 1981
The remaining 18 patients were re-examined after 1 month and served as controls. The design of the treatment program was based on the hypothesis that nonneglecting RBD patients fail to appreciate and synthesize elements of complex visual material due to a breakdown in compensation for a persistent lateral bias in visual-spatial attention. Upon post testing, it was found that those patients who received training exhibited significantly improved performance, as compared to controls, on a subgroup of visuo-cognitive tasks. These results are discussed in terms of: (1) offering indirect support for the argument that pathological asymmetries in attention play a significant role in the failure of RBD patients on many visuocognitive tasks; and (2) offering a basis for extending the treatment of perceptual problems in RBD patients. Upon post testing, it was found that those patients who received training exhibited significantly improved performance, as compared to controls, on a subgroup of visuo-cognitive tasks. These results are discussed in terms of: (1) offering indirect support for the argument that pathological asymmetries in attention play a significant role in the failure of RBD patients on many visuo-cognitive tasks; and (2) offering a basis for extending the treatment of perceptual problems in RBD patients

Woolf 2014
Group analyses showed no significant changes in tests of word and non-word discrimination as a result of therapy. One comprehension task improved following therapy, but two did not. There was also no indication that therapy improved the discrimination of treated words, as assessed by a priming task. The facilitation scores indicated that participants needed less support during tasks as therapy progressed, possibly as a result of improved listening. There was a significant effect of time on the telephone message task. Across all tasks there were few individual gains Yang 2015 A comparison of pre-and post-training assessment results revealed that both training programs led to the following significant changes: decreased severity of pusher syndrome scores (decreases of 4.0 ±1.1 and 1.4 ±1.0 in the experimental and control groups, respectively); improved balance scores (Increases of 14.7 ±4.3 and 7.2 ±1.6 in the experimental and control groups, respectively); and higher scores for lower extremity motor control (increases of 8.4 ±2.2 and 5.6 ±3.3 in the experimental and control groups, respectively). Furthermore, the computer-generated interactive visual feedback training program produced significantly better outcomes in the improvement of pusher syndrome (p < 0.01) and balance (p < 0.05) compared with the mirror visual feedback training program. Although both training programs were beneficial, the computer-generated interactive visual feedback training program more effectively aided recovery from pusher syndrome compared with mirror visual feedback training