Asynchronous Stimulation Research Articles

Comparing the force ripple during asynchronous and conventional stimulation

Asynchronous stimulation has been shown to reduce fatigue during electrical stimulation; however, it may also exhibit a force ripple. We quantified the ripple during asynchronous and conventional single-channel transcutaneous stimulation across a range of stimulation frequencies. The ripple was measured during 5 asynchronous stimulation protocols, 2 conventional stimulation protocols, and 3 volitional contractions in 12 healthy individuals. Conventional 40 Hz and asynchronous 16 Hz stimulation were found to induce contractions that were as smooth as volitional contractions. Asynchronous 8, 10, and 12 Hz stimulation induced contractions with significant ripple. Lower stimulation frequencies can reduce fatigue; however, they may also lead to increased ripple. Future efforts should study the relationship between force ripple and the smoothness of the evoked movements in addition to the relationship between stimulation frequency and NMES-induced fatigue to elucidate an optimal stimulation frequency for asynchronous stimulation.

Currents induced by fast movements inside the MRI room may cause inhibition in an implanted pacemaker.

The static magnetic field generated by MRI systems is highly non-homogenous and rapidly decreases when moving away from the bore of the scanner. Consequently, the movement around the MRI scanner is equivalent to an exposure to a time-varying magnetic field at very low frequency (few Hz). If people with an implanted pacemaker (PM) enter the MRI room, fast movements may thus induce voltages on the loop formed by the PM lead, with the potential to modify the correct behavior of the stimulator. In this study, we performed in-vitro measurements on a human-shaped phantom, equipped with an implantable PM and with a current sensor, able to monitor the activity of the PM while moving the phantom in the MRI room. Fast rotational movements in close proximity of the bore of the scanner caused the inappropriate inhibition of the PM, programmed in VVI modality, maximum sensitivity, unipolar sensing and pacing. The inhibition occurred for a variation of the magnetic field of about 3 T/s. These findings demonstrate that great care must be paid when extending PM MRI compatibility from patients to healthcare personnel, since the safety procedures and the MRI-conditional PM programming (e.g. asynchronous stimulation or bipolar sensing) used for patients cannot be applied.

Neural correlates of finger gnosis.

Neuropsychological studies have described patients with a selective impairment of finger identification in association with posterior parietal lesions. However, evidence of the role of these areas in finger gnosis from studies of the healthy human brain is still scarce. Here we used functional magnetic resonance imaging to identify the brain network engaged in a novel finger gnosis task, the intermanual in-between task (IIBT), in healthy participants. Several brain regions exhibited a stronger blood oxygenation level-dependent (BOLD) response in IIBT than in a control task that did not explicitly rely on finger gnosis but used identical stimuli and motor responses as the IIBT. The IIBT involved stronger signal in the left inferior parietal lobule (IPL), bilateral precuneus (PCN), bilateral premotor cortex, and left inferior frontal gyrus. In all regions, stimulation of nonhomologous fingers of the two hands elicited higher BOLD signal than stimulation of homologous fingers. Only in the left anteromedial IPL (a-mIPL) and left PCN did signal strength decrease parametrically from nonhomology, through partial homology, to total homology with stimulation delivered synchronously to the two hands. With asynchronous stimulation, the signal was stronger in the left a-mIPL than in any other region, possibly indicating retention of task-relevant information. We suggest that the left PCN may contribute a supporting visuospatial representation via its functional connection to the right PCN. The a-mIPL may instead provide the core substrate of an explicit bilateral body structure representation for the fingers that when disrupted can produce the typical symptoms of finger agnosia.

Exploring the specific time course of interhemispheric inhibition between the human primary sensory cortices

The neurophysiological mechanism of interhemispheric inhibition (IHI) between the human primary sensory cortices (S1s) is poorly understood. Here we used a paired median nerve somatosensory evoked potential protocol to observe S1-S1 IHI from the dominant to the nondominant hemisphere with electroencephalography. In 10 healthy, right-handed individuals, we compared mean peak-to-peak amplitudes of five somatosensory evoked potential components (P14/N20, N20/P25, P25/N30, N30/P40, and P40/N60) recorded over the right S1 after synchronous versus asynchronous stimulation of the right and left median nerves. Asynchronous conditioning + test stimuli (CS+TS) were delivered at interstimulus intervals of 15, 20, 25, 30, and 35 ms. We found that, in relation to synchronous stimulation, when a CS to the left S1 preceded a TS to the right S1 at the short intervals (15 and 20 ms) the amplitude of the cortical N20/P25 complex was significantly depressed, whereas at the longer intervals (25, 30, and 35 ms) significant inhibition was observed for the thalamocortical P14/N20 as well as the cortical N20/P25 components. We conclude that the magnitude of S1 IHI appears to depend on the temporal asynchrony of bilateral inputs and the specific timing is likely reflective of a direct transcallosal mechanism. Employing a method that enables direct S1 IHI to be reliably quantified may provide a novel tool to assess potential IHI imbalances in individuals with neurological damage, such as stroke.

The Role of the Cerebellum in Dynamic Changes of the Sense of Body Ownership: A Study in Patients with Cerebellar Degeneration

The sense of the body is deeply rooted in humans, and it can be experimentally manipulated by inducing illusions in at least two aspects: a subjective feeling of ownership and a proprioceptive sense of limb position. Previous studies mapped these different aspects onto anatomically distinct neuronal regions, with the ventral premotor cortex processing subjective experience of ownership and the inferior parietal lobule processing proprioceptive calibration. Lines of evidence suggest an involvement also of the cerebellum, but its precise role is not clear yet. To investigate the contribution of the cerebellum in the sense of body ownership, we applied the rubber-hand illusion paradigm in 28 patients affected by neurodegenerative cerebellar ataxia, selectively involving the cerebellum, and in 26 age-matched control participants. The rubber hand illusion is established by synchronous stroking of the participants' real unseen hand and a visible fake hand. Short asynchronous stroking does not bring about the illusion. We tested the subjective experience of the illusion, evaluated through a questionnaire and the proprioceptive drift of the real unseen hand toward the viewed rubber hand. In patients with cerebellar ataxia, we observed reduced sense of the subjective illusory experience specifically after synchronous stroking. In contrast, the proprioceptive drift was enhanced after synchronous and after asynchronous stimulation. These findings support the contention that the mechanisms underlying the presence of the illusion and the proprioceptive drift may be differently affected in different conditions. Impairment of the subjective sense of the illusion in cerebellar patients might hint at an involvement of cerebellar-premotor networks, whereas the proprioceptive drift typically associated with synchronous stroking appears to rely on other circuits, likely involving the cerebellum and the parietal regions.

Measuring the Effects through Time of the Influence of Visuomotor and Visuotactile Synchronous Stimulation on a Virtual Body Ownership Illusion

Previous studies have examined the experience of owning a virtual surrogate body or body part through specific combinations of cross-modal multisensory stimulation. Both visuomotor (VM) and visuotactile (VT) synchronous stimulation have been shown to be important for inducing a body ownership illusion, each tested separately or both in combination. In this study we compared the relative importance of these two cross-modal correlations, when both are provided in the same immersive virtual reality setup and the same experiment. We systematically manipulated VT and VM contingencies in order to assess their relative role and mutual interaction. Moreover, we present a new method for measuring the induced body ownership illusion through time, by recording reports of breaks in the illusion of ownership ('breaks') throughout the experimental phase. The balance of the evidence, from both questionnaires and analysis of the breaks, suggests that while VM synchronous stimulation contributes the greatest to the attainment of the illusion, a disruption of either (through asynchronous stimulation) contributes equally to the probability of a break in the illusion.

Surface‐distributed low‐frequency asynchronous stimulation delays fatigue of stimulated muscles

One important reason why functional electrical stimulation (FES) has not gained widespread clinical use is the limitation imposed by rapid muscle fatigue due to non-physiological activation of the stimulated muscles. We aimed to show that asynchronous low-pulse-rate (LPR) electrical stimulation applied by multipad surface electrodes greatly postpones the occurrence of muscle fatigue compared with conventional stimulation (high pulse rate, HPR). We compared the produced force vs. time of the forearm muscles responsible for finger flexion in 2 stimulation protocols, LPR (fL = 10 Hz) and HPR (fH = 40 Hz). Surface-distributed low-frequency asynchronous stimulation (sDLFAS) doubles the time interval before the onset of fatigue (104 ± 80%) compared with conventional synchronous stimulation. Combining the performance of multipad electrodes (increased selectivity and facilitated positioning) with sDLFAS (decreased fatigue) can improve many FES applications in both the lower and upper extremities.

P 183. Long term depression: A study with rapid-rate PAS

Introduction In a previous paper we showed that sub-motor threshold 5 Hz rENS of the right median nerve when synchronized with sub-motor threshold 5 Hz rTMS of the left M1 at a constant interval of 25 ms for 2 min caused a somatotopically specific increase in cortical excitability (5 Hz PAS LTP ). Objective In this study we used a similar protocol with a different interstimulus interval (ISI) to evaluate if an asynchronous paired stimulation could cause a somatotopically specific reduction of motor cortical excitability (5 Hz PAS LTD ). We also study the effect of 5 Hz PAS LTD on intracortical paired-pulse excitability and sensorimotor intracortical inhibition. Material and methods 5 Hz rPAS consisted of 600 pairs of stimuli which were continuously delivered to the left M1 at a rate of 5 Hz for 2 min in 20 healthy volunteers. Each pair of stimuli consisted of an electrical conditioning stimulus given to the right median nerve followed by a biphasic transcranial magnetic stimulus given to the left M1 controlling APB at 15 ms interval. Before and after rPAS (T0–T30–T60), we measured the amplitude of MEP, intracortical inhibition (ICI) and facilitation (ICF), short (SAI 20) and long latency (LAI 200 ms) afferent inhibition. We also recorded the MEP amplitudes at rest from first dorsal interosseus (FDI) and extensor carpi radialis (ECR) muscle at baseline and up to 1 h after 5 Hz rPAS 15 ms conditioning. Results The 5 Hz PAS LTD protocol caused a significant and somatotopically specific decrease in mean MEP amplitudes in the APB muscle that lasted for at least 1 h which was paralleled by a reduction of SAI. Conclusions These findings show that 2 min of 5 Hz rPAS at 15 ms can induce a long-lasting and somatotopically specific reduction in the excitability of the corticospinal output from the stimulated M1 for 60 min.

Spatial limits on the nonvisual self-touch illusion and the visual rubber hand illusion: Subjective experience of the illusion and proprioceptive drift

The nonvisual self-touch rubber hand paradigm elicits the compelling illusion that one is touching one's own hand even though the two hands are not in contact. In four experiments, we investigated spatial limits of distance (15 cm, 30 cm, 45 cm, 60 cm) and alignment (0°, 90° anti-clockwise) on the nonvisual self-touch illusion and the well-known visual rubber hand illusion. Common procedures (synchronous and asynchronous stimulation administered for 60s with the prosthetic hand at body midline) and common assessment methods were used. Subjective experience of the illusion was assessed by agreement ratings for statements on a questionnaire and time of illusion onset. The nonvisual self-touch illusion was diminished though never abolished by distance and alignment manipulations, whereas the visual rubber hand illusion was more robust against these manipulations. We assessed proprioceptive drift, and implications of a double dissociation between subjective experience of the illusion and proprioceptive drift are discussed.

Termination of Chemoconvulsant-Induced Seizures by Synchronous and Asynchronous Electrical Stimulation of the Hippocampus In-Vivo

BackgroundNeurostimulation has been proposed as a potential new treatment modality for pharmacoresistant epilepsy. Yet the effect of the different stimulation parameters on the efficacy of stimulation is not sufficiently known. ObjectiveInvestigate the effect of different stimulation parameters on the efficacy of neurostimulation in terminating acute chemoconvulsant-induced hippocampal seizures in-vivo. MethodsSeizures were induced in rats in-vivo either by systemic or local intra hippocampal application of chemoconvulsants, and bipolar electrical stimulation was applied during seizures by stimulating the perforant pathway of the hippocampus. The stimulus intensity, frequency, and duration were altered. ResultsIncreasing the stimulus intensity and train duration increased the probability for seizure termination. The efficacy of stimulus intensity peaked at 250–300 μA. Low stimulation frequencies (≤13 Hz) were inefficient in terminating seizures. Increasing the stimulation frequency (up to 250 Hz) enhanced seizure termination, reaching a plateau effect at frequencies of 50–100 Hz. When we simultaneously applied the same stimulation frequency in two adjacent electrodes (synchronous stimulation) the probability for seizure termination did not significantly change. In contrast when the two stimulating electrodes were simultaneously activated with different asynchronous stimulation frequencies (30 and 100 Hz or 60 and 200 Hz, asynchronous stimulation) the probability for terminating seizures more than doubled. Similar results were also observed with local intra hippocampal-induced seizures. ConclusionsAsynchronous stimulation paradigms enhanced the antiepileptic efficacy of neurostimulation, possibly by desynchronizing and functionally subdividing the network.

Vibrotactile Sensory Substitution Elicits Feeling of Ownership of an Alien Hand

Tactile feedback plays a key role in the attribution of a limb to the self and in the motor control of grasping and manipulation. However, due to technological limits, current prosthetic hands do not provide amputees with cutaneous touch feedback. Recent findings showed that amputees can be tricked into experiencing an alien rubber hand as part of their own body, by applying synchronous touches to the stump which is out of view, and to the rubber hand in full view. It was suggested that similar effects could be achieved by using a prosthesis with touch sensors that provides synchronous cutaneous feedback through an array of tactile stimulators on the stump. Such a prosthesis holds the potential to be easily incorporated within one’s body scheme, because it would reproduce the perceptual illusion in everyday usage. We propose to use sensory substitution – specifically vibrotactile – to address this issue, as current haptic technology is still too bulky and inefficient. In this basic study we addressed the fundamental question of whether visuo-tactile modality mismatch promotes self-attribution of a limb, and to what extent compared to a modality-matched paradigm, on normally-limbed subjects. We manipulated visuo-tactile stimulations, comprising combinations of modality matched, modality mismatched, synchronous and asynchronous stimulations, in a set of experiments fashioned after the Rubber Hand Illusion. Modality mismatched stimulation was provided using a keypad-controlled vibrotactile display. Results from three independent measures of embodiment (questionnaires, pointing tests and skin conductance responses) indicate that vibrotactile sensory substitution can be used to induce self-attribution of a rubber hand when synchronous but modality-conflicting visuo-tactile stimulation is delivered to the biological finger pads and to the equivalent rubber hand phalanges.

Auditory MEG mismatch responses modified by visual stimulation accompanying auditory stimulation

We investigated the effects of visual stimulation on auditory mismatch responses using a magnetoencephalography (MEG) system. Mismatch magnetic fields (MMNms, equivalents of EEG mismatch negativity, MMN) were recorded in 10 healthy subjects under three audio-visual conditions, which consisted of auditory stimulation with a static visual stimulation (A-0), auditory + synchronous visual stimulation (AV-S), and auditory + asynchronous visual stimulation (AV-R). Clear MMNms were obtained from eight subjects. The amplitude of the root mean square (r.m.s.) value, as well as the global field power, under AV-S conditions were greater compared to those recorded under other conditions in the right hemisphere (P = 0.0087, ANOVA). The latency difference of the N1ms, equivalents of the N1 ERP component recorded in the right hemisphere 100 msec after stimulation and elicited by standard and deviant stimuli, was significantly smaller under AV-S conditions than under other conditions (P = 0.016). There was no difference in the dipole localization for MMNm among the conditions. The results indicate that simultaneous visual stimulation enhances auditory MMNm. The mismatch response can be determined not only by the physical amount of deviated stimulation but also by a deviated feature produced due to accompanying stimulation of a different modality.

Interpersonal multisensory stimulation and emotion: The impact of threat-indicative facial expressions on enfacement

Prior studies have identified an ‘enfacement effect’ in which participants incorporate another’s face into their self-face representation after observing that face touched repeatedly in synchrony with touch on their own face (Sforza et al., 2010; Tsakiris, 2008). The degree of self-face/other-face merging is positively correlated with participants’ trait-level empathy scores (Sforza et al., 2010) and affects judgments of the other’s personality (Paladino et al., 2010), suggesting that enfacement also modulates higher-order representations of ‘self’ and ‘other’ involved in social and emotional evaluations. To test this hypothesis, we varied not only whether visuo-tactile stimulation was synchronous or asynchronous but also whether the person being touched in the video displayed an emotional expression indicative of threat, either fear or anger. We hypothesized that participants would incorporate the faces of fearful others more than the faces of angry others after a shared visuo-tactile experience because of a potentially stronger representation of the sight of fear in somatosensory cortices compared to the sight of anger (Cardini et al., 2012). Instead, we found that the enfacement effect (i.e., greater self-face/other-face merging following synchronous compared to asynchronous visuo-tactile stimulation) was abolished if the other person displayed fear but remained if they expressed anger. This nonetheless suggests that enfacement operates on an evaluative self-representation as well as a physical one because the effect changes with the emotional content of the other’s face. Further research into the neural mechanism behind the enfacement effect is needed to determine why sight of fear diminishes it rather than enhancing it.

Visual map development depends on the temporal pattern of binocular activity in mice

Binocular competition is thought to drive eye-specific segregation in the developing visual system, potentially through Hebbian synaptic learning rules that are sensitive to correlations in afferent activity. Altering retinal activity can disrupt eye-specific segregation, but little is known about the temporal features of binocular activity that modulate visual map development. We used optogenetic techniques to directly manipulate retinal activity in vivo and identified a critical period before eye opening in mice when specific binocular features of retinal activity drive visual map development. Synchronous activation of both eyes disrupted segregation, whereas asynchronous stimulation enhanced segregation. The optogenetic stimulus applied was spatially homogenous, and accordingly retinotopy of ipsilateral projections was dramatically perturbed, but contralateral retinotopy was unaffected or even improved. These results provide direct evidence that the synchrony and precise temporal pattern of binocular retinal activity during a critical period in development regulates eye-specific segregation and retinotopy in the developing visual system.

Multiple-Input Single-Output Closed-Loop Isometric Force Control Using Asynchronous Intrafascicular Multi-Electrode Stimulation

Although asynchronous intrafascicular multi-electrode stimulation (IFMS) can evoke fatigue-resistant muscle force, a priori determination of the necessary stimulation parameters for precise force production is not possible. This paper presents a proportionally-modulated, multiple-input single-output (MISO) controller that was designed and experimentally validated for real-time, closed-loop force-feedback control of asynchronous IFMS. Experiments were conducted on anesthetized felines with a Utah Slanted Electrode Array implanted in the sciatic nerve, either acutely or chronically ( n = 1 for each). Isometric forces were evoked in plantar-flexor muscles, and target forces consisted of up to 7 min of step, sinusoidal, and more complex time-varying trajectories. The controller was successful in evoking steps in force with time-to-peak of less than 0.45 s, steady-state ripple of less than 7% of the mean steady-state force, and near-zero steady-state error even in the presence of muscle fatigue, but with transient overshoot of near 20%. The controller was also successful in evoking target sinusoidal and complex time-varying force trajectories with amplitude error of less than 0.5 N and time delay of approximately 300 ms. This MISO control strategy can potentially be used to develop closed-loop asynchronous IFMS controllers for a wide variety of multi-electrode stimulation applications to restore lost motor function.

Interference of remote magnetic catheter navigation and ablation with implanted devices for pacing and defibrillation

Remote magnetic catheter navigation (RMN) may facilitate catheter ablation. However, as the system uses permanent magnets, interference (INF) with devices for pacing [pacemaker (PM)], defibrillation [implantable cardioverter defibrillators (ICD)], or cardiac resynchronisation [cardiac resynchronization therapy (CRT)] may occur. We investigated the effects of the RMN system on implanted arrhythmia devices in a prospective series. Prior to RMN-guided electrophysiological procedures, devices were fully interrogated and programmed to VVI 40/min with tachycardia detection off (if applicable). Periprocedural device performance was monitored by 12-lead electrocardiogram, and duration and effect of asynchronous stimulation resulting from INF were evaluated. Following the procedure, devices were again interrogated and system integrity verified. A total of 21 procedures in 18 patients with implanted devices [PM n = 12, ICD n = 3, CRT-pacemaker (P) n = 1, CRT-defibrillation (D) n = 2] were evaluated. No relevant changes in lead parameters or device programming were observed after the procedure. No INF was noted in ICD/CRT-D devices (tachycardia detection off) and in 2 PMs, whereas 10 PMs and 1 CRT-P switched to asynchronous stimulation for 1.8 ± 0.3 h (63 ± 13% of RMN duration) without clinical adverse effects. In one patient, ventricular tachycardia (VT) degenerating in ventricular fibrillation occurred, but no causal relation between INF and VT initiation could be ascertained. This prospective data provide no evidence that using RMN in patients with implanted arrhythmia devices may cause persistent device dysfunction. Asynchronous PM stimulation is common without negative clinical consequences. Although a causal role of INF for the VT observed seems unlikely, risks and benefits of RMN utilization should carefully be weighed for each patient with an implanted arrhythmia device.

Synchrony of audio–visual speech stimuli modulates left superior temporal sulcus

The superior temporal sulcus has been suggested to play a significant role in the integration of auditory and visual sensory information. Here, we presented vowels and short video clips of the corresponding articulatory gestures to healthy adult humans with two auditory-visual stimulus intervals during sparse sampling 3-T functional magnetic resonance imaging to detect which brain areas are sensitive to synchrony of speech sounds and associated articulatory gestures. The upper bank of the left middle superior temporal sulcus showed stronger activation during naturally asynchronous stimulation than during simultaneous stimulus presentation. It is possible that this reflects sensitivity of the left middle superior temporal sulcus to temporal synchrony of audio-visual speech stimuli.

Synchronous Multisensory Stimulation Blurs Self-Other Boundaries

In a study that builds on recent cognitive neuroscience research on body perception and social psychology research on social relations, we tested the hypothesis that synchronous multisensory stimulation leads to self-other merging. We brushed the cheek of each study participant as he or she watched a stranger’s cheek being brushed in the same way, either in synchrony or in asynchrony. We found that this multisensory procedure had an effect on participants’ body perception as well as social perception. Study participants exposed to synchronous stimulation showed more merging of self and the other than participants exposed to asynchronous stimulation. The degree of self-other merging was determined by measuring participants’ body sensations and their perception of face resemblance, as well as participants’ judgment of the inner state of the other, closeness felt toward the other, and conformity behavior. The results of this study show how multisensory integration can affect social perception and create a sense of self-other similarity.

Spatiotemporal Interactions in Retinal Prosthesis Subjects

Vision loss due to retinitis pigmentosa affects an estimated 15 million people worldwide. Through collaboration between Second Sight Medical Products, Inc., and the Doheny Eye Institute, six blind human subjects underwent implantation with epiretinal 4 x 4 electrode arrays designed to directly stimulate the remaining cells of the retina, with the goal of restoring functional vision by applying spatiotemporal patterns of stimulation. To better understand spatiotemporal interactions between electrodes during synchronous and asynchronous stimulation, the authors investigated how percepts changed as a function of pulse timing across the electrodes. Pulse trains (20, 40, 80, and 160 Hz) were presented on groups of electrodes with 800, 1600, or 2400 microm center-to-center separation. Stimulation was either synchronous (pulses were presented simultaneously across electrodes) or asynchronous (pulses were phase shifted). Using a same-different discrimination task, the authors were able to evaluate how the perceptual quality of the stimuli changed as a function of phase shifts across multiple electrodes. Even after controlling for electric field interactions, subjects could discriminate between spatiotemporal pulse train patterns based on differences of phase across electrodes as small as 3 ms. These findings suggest that the quality of the percept is affected not only by electric field interactions but also by spatiotemporal interactions at the neural level. During multielectrode stimulation, interactions between electrodes have a significant influence on the quality of the percept. Understanding how these spatiotemporal interactions at the neural level influence percepts during multielectrode stimulation is fundamental to the successful design of a retinal prosthesis.

Visual extinction: The effect of temporal and spatial bias

Unlike patients with neglect, neurological patients with extinction can detect a single event presented at any location. However, when shown two brief near-simultaneous stimuli they only report the ipsilesional item. The question of what inter-stimulus delay leads to maximal extinction has clear clinical and theoretical implications. di Pellegrino et al. [di Pellegrino, G., Basso, G., & Frassinetti, F. (1997). Spatial extinction on double asynchronous stimulation. Neuropsychologia, 35, 1215–1223] report that extinction is maximal when the two stimuli are presented simultaneously, with less extinction when either item has a slight temporal lead. This finding supports traditional clinical diagnosis (which only presents simultaneous events), and is in accord with theories of extinction that entail individuation of objects (e.g. “token” accounts). In contrast, Cate and Behrmann [Cate, A., & Behrmann, M. (2002). Spatial and temporal influences of extinction. Neuropsychologia, 40, 2206–2225] report that extinction is maximal when the ipsilesional item is presented slightly prior to the contralesional item. This finding appears to support disengage models of attention. Our aim was to reveal whether the difference between these studies reflects different patients, or different methods. Specifically, we note that the stimuli used by Cate and Behrmann were biased both temporally (more ipsilesional first trials) and spatially (more items presented in ipsilesional field). We examined the performance of nine individuals with extinction, and found that maximal extinction was not influenced by temporal biases, but extinction was modulated by the spatial location of stimuli. This finding reconciles previous studies and offers new insight into this syndrome.