it is a failure to report , respond to , or 
 orient towards stimuli located on the contralesional side .
it also occurs when converting 
 not only a visual landscape but also body schema to a visual image2 .
spatial neglect is caused by a disturbance of both 
 hemispheres after unilateral cortical lesions3 .
spatial neglect is more common after a right hemisphere lesion than after a left hemisphere 
 lesion4 . when the right hemisphere is 
 damaged , spatial neglect leads to visual perception problems such as asymmetrical division 
 of lines or failure to perceive the picture of the neglected side5 .
there are diverse methods that can be used to treat spatial 
 neglect such as perception retraining , visual scanning treatment , and cognitive therapy but 
 more effective and diverse interventions for the treatment of spatial neglect are 
 necessary6 .
neglect patients show multiple eye movement impairments , including reduced saccade 
 amplitude and difficulty in retaining spatial locations across saccades7 .
eye movements are increasingly being used as a tool for the 
 elucidation of relatively complex neuropsychological processes relating to attention , 
 spatial memory , motivation and decision - making8 .
oculo - motor exercise modulates many facets of neglect syndrome , and 
 pursuit eye movement especially represents an effective and easily applicable technique for 
 the treatment of neglect patients9 . 

karnath reported that oculo - motor exercise was effective at improving body orientation in 
 spatial neglect patients10 .
functional electrical stimulation ( fes ) has been developed as a method for artificially 
 activating the sensory motor system after central nervous system injury11 .
it is useful for activating muscle paralyzed by upper 
 motor neuron injury , and is used to strengthen weakened muscles , to decrease spasticity , and 
 to enhance the range of motion of joints12 .
rushton noted that fes activates motor and sensory nerve fibers 
 and promotes cortical reorganization through sensory stimulation of paralyzed muscle13 .
fes also activates a proprioceptive map 
 within the right parietal lobe , and alleviates unilateral spatial neglect14 .
most stroke patients experience loss of proprioceptive sensation , which results in body 
 sway increases , and failure to receive appropriate location information about the body 
 reduces their efficiency of movement15 . 

the proprioceptive neuromuscular facilitation ( pnf ) approach utilizes a typical diagonal 
 pattern to stimulate proprioceptive sensation16 .
the pnf patterns may permit muscles to act in ways that are close 
 to the actions and movements17 .
pnf can 
 also have a positive effect on the active and passive ranges of motion18 .
silva and johnson reported that proprioceptive afferent 
 input from the neck muscles plays an important role in postural control19 .
and kim and oh reported that the neck is an essential 
 component in the regulation of head and body orientation in space , and is necessary for 
 maintaining balance20 .
accordingly , this 
 study applied fes and pnf to the neck area , to increase the proprioceptive input to the neck 
 muscles and induce head movement . there have been many studies on balance and gait using oculo - motor exercise , fes , and pnf 
 with stroke patients as subjects , but studies analyzing the visual perception of neglect 
 patients are lacking .
accordingly , this study examined the effects of fes and pnf with 
 oculo - motor exercise on the visual perception of stroke patients with spatial neglect .
this study was conducted at the rusk rehabilitation hospital and lohas hospital located in 
 gyeonggi - do , and the subjects were 30 stroke patients with spatial neglect . in order to 
 select neglect patients , patients scoring 11 or higher on the catherine bergego scale ( cbs ) 
 were included21 .
the subjects did not 
 have visual or hearing disorder , and their score in the korean version of the mini - mental 
 state exam was 24 points or higher22 . 

table 1table 1.general characteristics and cbs values of the subjectsomefomepomegendermale4 75female635age ( years)60.27.856.77.761.18.1time after stroke ( months)22.210.228.612.123.37.0stroke typeinfarction563hemorrhage547affected sideleft101010right000cbs ( score)13.11.612.71.413.11.6ome : oculo - motor exercise group , fome : fes with oculo - motor exercise group , pome : pnf 
 with oculo - motor exercise group , cbs : catherine bergego scale outlines the general characteristics and cbs values of the subjects .
ome : oculo - motor exercise group , fome : fes with oculo - motor exercise group , pome : pnf 
 with oculo - motor exercise group , cbs : catherine bergego scale this study complied with the ethical principles of the declaration of helsinki .
the 
 subjects agreed to participate in the study after receiving explanations regarding the 
 purpose and procedures of the experiment , and signed an informed consent statement before 
 participation .
the protocol for this study was approved by the local ethics committee of 
 yongin university ( 2 - 1040966-ab - n-01 - 201503-hsr-025 - 1 ) .
the subjects were equally and randomly divided into three groups : an oculo - motor exercise 
 ( ome ) group , a fes with oculo - motor exercise ( fome ) group , and a pnf with oculo - motor 
 exercise ( pome ) group .
the intervention was conducted five times per week , for a total of 
 six weeks .
schematic diagram of the study the oculo - motor exercise was designed according to the method used by morimoto et al23 .
a total of four different exercises were 
 performed ( saccadic eye movement , smooth pursuit exercise , and the adaptation 1 & 2 
 exercises ) .
the saccadic eye movement exercise is a movement of the eyes horizontally 
 between two stationary targets while keeping the head still .
the smooth pursuit exercise 
 involves moving the targets horizontally and tracking them with the eyes while keeping the 
 head still .
the adaptation 1 exercise involves moving the head horizontally while keeping 
 the stationary target in focus .
the adaptation 2 exercise requires movement of the head and 
 a target in opposite horizontal directions while tracking the target with the eyes ( fig .
2.oculo-motor exercise ( 1 : saccadic eye exercise , 2 : smooth pursuit exercise , 3 : 
 adaptation 1 exercise , 4 : adaptation 2 exercise))23 .
those in the ome group each 
 conducted two sets of each exercise , with each exercise performed 10 times per set . oculo - motor exercise ( 1 : saccadic eye exercise , 2 : smooth pursuit exercise , 3 : 
 adaptation 1 exercise , 4 : adaptation 2 exercise ) the fome group performed the oculo - motor exercise program and fes
was additionally applied 
 to the neck area of the paretic side , to induce movement of the head .
the fes equipment used 
 was a microstim ( medel gmbh , germany ) was used and two electrodes were attached to the 
 origin and insertion of the paretic splenius capitis of the neck extensor .
fes was applied 
 for a total of 15 minutes and the electricity on - time and off - time were six and two seconds , 
 respectively .
the frequency was set at 30  hz , and the stimulation intensity was less than 
 15v , to avoid muscle contraction .
the pome group performed the oculo - motor exercise program , and pnf additionally was applied 
 to the neck area , to induce movement of the head .
the pnf pattern used was a neck extensor 
 pattern , and the technique used was a contract - relax technique .
the starting posture was 
 neck flexion , followed by right rotation , and left lateral flexion .
the last posture was 
 neck extension , followed by left rotation , and right lateral flexion . the subjects conducted 
 exercises for a total of three sets , 10 exercises per set .
the pnf training was conducted by 
 a therapist who had completed pnf courses at levels iand ii .
anova was used to evaluate the 
 change in balance and head alignment . in all analyses ,
this study involved thirty subjects : 10 subjects in the ome group , 10 subjects in the fome 
 group , and 10 subjects in the pome group .
the line bisection test ( lbt ) , motor free visual 
 test ( mvpt ) , and catherine bergego scale ( cbs ) were used as outcome measures .
changes in visual perception within each group are shown in table 2table 2.comparison of the pre - test and post - test visual perception tests resultspre - testpost - testome grouplbt ( mm)15.12.613.23.0*mvpt ( score)17.72.218.71.8*cbs ( score)13.11.611.31.4*fome grouplbt ( mm)16.11.315.71.5mvpt ( score)16.51.316.81.2cbs ( score)12.71.411.71.4*pome grouplbt ( mm)15.22.513.32.5*mvpt ( score)17.82.218.51.9*cbs ( score)13.11.611.81.7**p<0.05 .
lbt : line bisection test , mvpt : motor - free visual perception test , cbs : catherine 
 bergego scale . in the ome and pome groups ,
significant differences were found in the lbt , 
 mvpt and cbs results ( p<0.05 ) . in the fome group ,
no significant differences were found 
 in the lbt and mvpt results ( p>0.05 ) .
however , a significant difference was found in the 
 cbs results ( p<0.05 ) . *
lbt : line bisection test , mvpt : motor - free visual perception test , cbs : catherine 
 bergego scale table 3table 3.comparison of the groups visual perception tests resultsmsdduncanlbt ( mm)ome13.23.0b < a , c*fome15.71.5pome13.32.5mvpt ( score)ome18.71.8b < a , c*fome16.81.2pome18.51.9cbs ( score)ome11.31.4fome11.71.4pome11.81.7*p<0.05 . a : ome group , b : fome group , c : pome group presents a comparison of the results of the groups . in the ome and pome 
 groups ,
the lbt and mvpt results were significantly different from those of the fome group 
 ( p<0.05 ) .
however , according to the cbs test , there were no significant differences among 
 the three groups .
spatial neglect is characterized by a lack of awareness of sensory events located towards 
 the contralesional side of space .
indeed , neglect patients often behave as if half of their 
 world is no longer in existence24 . 

this 
 study conducted fes and pnf with oculo - motor exercises , and compared their results in order 
 to verify their effects on the visual perception of spatial neglect patients .
the ome group showed significant improvements according to the lbt , mvpt , and cbs results . 

noted that saccadic eye movement and pursuit eye movement are 
 organized in the cerebral cortex and play an important role in spatial memory and 
 concentration8 .
kerkhoff et al . reported 
 that oculo - motor exercise activates multiple brain regions ( temporo - parietal cortex , basal 
 ganglia , brainstem , cerebellum ) involved in auditory and visual space coding9 . therefore ,
the physiological effects of 
 oculo - motor exercise are considered to have positively affected the visual perception of the 
 spatial neglect patients in this study . in the fome group
, there were no significant improvements according to the lbt and mvpt 
 results , but there was a significant difference according to the cbs result .
reported that fes can enhance the recovery of upper extremity function in stroke 
 patients25 .
fes has been developed to 
 restore function to the upper extremity , lower extremity , bladder , bowel , and respiratory 
 system26 . however , in this study , fes 
 with oculo - motor exercise did not have an effect on the visual perception of the spatial 
 neglect patients .
the pome group showed significant improvements according to the lbt , mvpt , and cbs results . 

karnath reported that visual input , together with vestibular and neck proprioceptive input 
 has a positive effect on the body orientation of spatial neglect patients10 .
this supports the notion that pnf 
 training applied to the neck area has a positive effect on visual perception .
furthermore , 
 hindle et al . reported that the contract - relax technique of pnf is effective at improving 
 and maintaining range of motion18 .
it is 
 considered that the contract - relax technique applied to the neck area in this study 
 increased the range of motion of the neck , positively affecting visual perception .
reported that head movement triggered coordination of the arms and legs , positively 
 affecting postural balance27 .
therefore , 
 head movement through the pnf technique is considered to have had a positive effect on 
 postural adjustment as well as visual perception . in the comparison of the three groups
however , the lbt and mvpt results showed there were significant differences 
 between the ome and pome groups and the fome group .
this indicates that the intensive 
 application of oculo - motor exercises or pnf with oculo - motor exercise is more effective than 
 fes with oculo - motor exercises in the improvement of the visual perception of spatial 
 neglect patients .
the number of subjects included in this study was insufficient for the generalization of 
 the results to all spatial neglect patients .
however , the results indicate that head 
 movement through oculo - motor exercise and pnf is effective and more diverse interventions 
 should be developed for spatial neglect patients .
 [ purpose ] the purpose of this study was to identify the effects of oculo - motor exercise , 
 functional electrical stimulation ( fes ) , and proprioceptive neuromuscular facilitation 
 ( pnf ) on the visual perception of spatial neglect patients . 
 [ subjects and methods ] the 
 subjects were randomly allocated to 3 groups : an oculo - motor exercise ( ome ) group , a fes 
 with oculo - motor exercise ( fome ) group , and a pnf with oculo - motor exercise ( pome ) group . 
 
 the line bisection test ( lbt ) , motor free visual test ( mvpt ) , and catherine bergego scale 
 ( cbs ) were used to measure visual perception . 
 these were performed 5 times per week for 6 
 weeks . 
 [ results ] the ome group and pome group showed significant improvements according to 
 the lbt and mvpt results , but the fome group showed no significant improvement . according 
 to the cbs , all 3 groups showed significant improvements . 
 the ome and pome groups showed 
 improvement over the fome group in the lbt and mvpt . 
 however , there was no significant 
 difference among the three groups according to the cbs . 
 [ conclusion ] these results 
 indicate that oculo - motor exercise and pnf with oculo - motor exercise had more positive 
 effects than fes with oculo - motor exercise on the visual perception of spatial neglect 
 patients . 
INTRODUCTION
SUBJECTS AND METHODS
RESULTS
DISCUSSION