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Neuropsychological rehabilitation of visuospatial skills

Visuospatial skills

Visuospatial skills are an innate process for any human being and therefore it is important its evaluation and intervention before any congenital or acquired brain damage. On many occasions this ability is often confused with perception or praxis and is evaluated by copying drawings, such as the King figure test, or by replicating models, such as the Kohs cubes or the Wechsler scales. But then, what are visuospatial skills? And does their intervention only involve copying and assembling objects…? Throughout this text we will try to answer these two questions in order to understand the visuospatial process and provide strategies that allow the improvement of these skills in the face of brain damage.

Definition and components of visuospatial skills

Visuospatial skills are more complex than making a copy of a figure or assembling a model; this process is a set of cognitive skills associated with brain areas that are responsible for the spatial analysis of elements in order to be able to replicate them accurately, even if they are in motion (Stiles et al., 2020). When we talk about a set of cognitive skills, we mainly refer to two processes: visuospatial perception and motor skills.

One of the main components of visuospatial skills is visuospatial perception, which must be differentiated from visual perception or gnosia. The ability to identify and recognize an object is better known as visual perception and is associated with occipito-temporal networks; while the ability to analyze how different components relate in space to achieve a whole is known as visuospatial perception and is associated with occipito-parietal networks (Atkinson, 2002; Roselli, 2015; Stiles et al., 2020).

In the clinic, patients can be found who preserve the ability to recognize visual stimuli but fail to perform replications of drawings or models. Some clinical samples such as Williams syndrome, schizophrenia and/or autism have demonstrated adequate ability to copy the local elements of a figure but with significant difficulties in putting them together in space (Doniger et al., 2002; D’Souza et al., 2016). In visuospatial skills, motor function allows for fine tracing with adequate pitch. In this case, the cerebellum plays an important role as it is in charge of the coordination between the eye and the hand to perform an adequate stroke and the fronto-striatal networks are involved in motor control.

The dorsal stream and visuospatial skills

Visual stimuli have been found to take two routes to reach the occipital cortex and originate in the retina of the eyes. The magnocellular pathway originates in the large retinal ganglion cells and continues its path through the ventral lateral geniculate nucleus, ascends to the primary visual cortex (V1) and projects to areas V5 and V7A, intraparietal sulcus and inferior parietal area (Labos et al., 2008; Stiles et al., 2020); whereas, the parvocellular pathway originates in the smaller retinal cells, continues through the thalamus, projects to the primary visual cortex and from there to areas V2 and V4 and inferotemporal cortex (Labos et al., 2008; Stiles et al., 2020).

The networks that make up the magnocellular pathway and the occipito-parietal cortex are known as the dorsal stream and are associated with where and how objects are located in space; while the parvocellular networks and the occipito-temporal cortex are identified as the ventral pathway and are associated with which object is being observed. Therefore, damage to the dorsal pathway would result in alterations in visuospatial skills, while the other would lead to alterations in identifying and recognizing objects.

Dorsal stream vulnerability

The term “dorsal stream vulnerability” refers to patients and populations where brain damage has been found in these areas and they present alterations in visuospatial skills (Atkinson & Braddick, 2011). In addition, it has been identified that the dorsal stream is then divided into three other networks: the parietoprefrontal, associated with visuospatial working memory; the parieto-premotor, related to eye movement and visual tracking; and the parietotemporal, which is associated with spatial navigation (Kravitz et al., 2011; van der Ham & Ruotolo, 2017). Therefore, patients with dorsal stream vulnerability are also likely to have impairments in visual selective attention, visuospatial working memory, and in topographic orientation.

Development of visuospatial skills

The neural networks involved in visuospatial skills begin to develop in the first months of life.

The model of Atkinson and Nardini (2008) reveals that visuospatial skills begin around 1 month, when the child begins to have voluntary control of his eyes; at 3 months with the attempt to reach objects; between 5 and 6 months with grasping objects; at 8 months with manual grasping; at 12 months with the manual exchange of objects; and at 12 to 18 months with the manual exchange of objects; between 12 and 18 months he begins to assemble towers; between 3 to 4 years he creates two-dimensional models and between 5 to 6 years he makes copies of figures; moreover, by this age a right hemispheric dominance and asymmetry has already been established for these skills (Roselli, 2015; van der Ham & Ruotolo, 2017). Therefore, a delay in the acquisition of these developmental milestones could be a risk factor or alarm symptoms of an alteration of visuospatial skills.

Neuropsychological rehabilitation of visuospatial skills.

Neuropsychological rehabilitation is a procedure that aims to improve, to the greatest extent possible, the affected cognitive abilities of the patient in order to achieve an optimal adaptation to his psychological, emotional, social, family and school/work life (Peña-Casanova et al., 1984). One of the objectives of the rehabilitation of visuospatial skills is that the patient manages to make copies and assemble objects with the most accurate precision to their models, this implies not only to put him to copy but also to stimulate previous processes and give strategies that allow a better consolidation of the visuospatial skill.

Some articles (Blázquez-Alisente et al., 2004; Serrano-Juárez et al., 2018) where the intervention of visuospatial skills has been worked on have used activities involving selective attention, eye movement, figure-ground, mental rotation, among others.

Activities for the neuropsychological intervention of visuospatial skills.

Listed below are 6 activities that can be used for neuropsychological intervention of visuospatial skills:

Visual scanning tasks

Eye movement is important for adequate scanning to detect all the components that make up a figure. The patient is asked to follow the tip of a pencil by moving only his eyes; or on a computer a stimulus is created that moves randomly across the screen and the patient is asked to follow it only with his eyes.

Visuomotor coordination tasks

A task similar to the previous one is performed but in this case the patient is asked to follow it with his eyes and with the index finger of his dominant hand; later, he can be asked to do it with a pencil. Make different paths with different shapes; straight and curved, and of different thickness, wide and thin. To make figures by joining dots.

Selective attention tasks

Perform cancellation tasks by teaching the child to trace from right to left and from top to bottom; in severe cases, the child’s finger can be used as a guide. Perform figure-background tasks where he is asked to go over all the figures he finds with a different color.

Visual closure tasks

In order for a patient to begin to identify incomplete figures, he/she must first identify them in a complete way, so activities are done where he/she relates objects and/or complete figures and degrades them as he/she progresses. Strategies such as completing the figure are used to train visual closure.

Spatial relationship tasks

To improve the notion of laterality, a blue bracelet is placed on the right hand and a red one on the left. You can also play the game “Simon says…” asking him to take steps forward, backward, left or right. Draw a line down the middle of the sheet and ask him to place different objects above, below, to the left or right of it. Put three objects at different distances and different number of circles between each of them, then ask him to mention which are closer and which are farther away; you can help him with the number of circles between each object.

Copying drawings

Ask the patient to make copies of figures but following a strategy taught by the therapist. For example, first start by identifying and copying the largest figures, then the medium-sized ones and finally add the details; each step can also be done with a different color until copies similar to the model are made. Assembling and assembling the puzzle.


The adequate development of visuospatial skills is important for any individual since they have been associated to other processes such as calculation and writing; therefore, the early identification and evaluation of these skills will allow the creation of programs, strategies and intervention activities that achieve early improvement, which could also impact other skills, processes and even adaptive behavior.


Atkinson, J. (2002). The Developing Visual Brain. Oxford University Press.

Atkinson, J., & Braddick, O. (2011). Chapter 15—From genes to brain development to phenotypic behavior: “Dorsal-stream vulnerability” in relation to spatial cognition, attention, and planning of actions in Williams syndrome (WS) and other developmental disorders. En O. Braddick, J. Atkinson, & G. M. Innocenti (Eds.), Progress in Brain Research (Vol. 189, pp. 261–283). Elsevier.

Atkinson, J., & Nardini, M. (2008). The neuropsychology of visuospatial and visuomotor development. Child neuropsychology: Concepts, theory and practice, 183–217.

Blázquez-Alisente, J., Paúl-Lapedriza, N., & Muñoz-Céspedes, J. (2004). Atención y funcionamiento ejecutivo en la rehabilitación neuropsicológica de los procesos visuoespaciales [Attention and executive functioning in the neuropsychological rehabilitation of visuospatial processes]. Rev Neurol38(5), 487–495.

Doniger, G. M., Foxe, J. J., Murray, M. M., Higgins, B. A., & Javitt, D. C. (2002). Impaired Visual Object Recognition and Dorsal/Ventral Stream Interaction in Schizophrenia. Archives of General Psychiatry59(11), 1011.

D’Souza, D., Booth, R., Connolly, M., Happé, F., & Karmiloff-Smith, A. (2016). Rethinking the concepts of ‘local or global processors’: Evidence from Williams syndrome, Down syndrome, and Autism Spectrum Disorders. Developmental Science19(3), 452–468.

Kravitz, D. J., Saleem, K. S., Baker, C. I., & Mishkin, M. (2011). A new neural framework for visuospatial processing. Nature Reviews Neuroscience12(4), 217–230.

Más referencias sobre la rehabilitación de las habilidades visoespaciales

Labos, E., Slachevsky, A., Fuentes, P., & Manes, F. (2008). Tratado de neuropsicología clínica [Treatment of clinical neuropsychology]. Buenos Aires: Akadia.

Peña-Casanova, J., Pamies, M. P., García, J. S., & Pulido, J. H. (1984). Rehabilitación de la afasia y trastornos asociados [Rehabilitation of aphasia and associated disorders]. Masson.

Roselli, M. (2015). Desarrollo neuropsicológico de las habilidades visoespaciales y visoconstruccionales [Neuropsychological development of visuospatial and visoconstructional skills]. Revista Neuropsicología, Neuropsiquiatría y Neurociencias15(1), 175–200.

Serrano-Juárez, C. A., Prieto-Corona, D. M. B., & Yáñez-Téllez, M. G. (2018). Intervención Neuropsicológica en un caso de una niña con Síndrome de Williams [Neuropsychological intervention in a case of a girl with Williams Syndrome]. Cuadernos de Neuropsicología/Panamerican Journal of Neuropsychology12(2).

Stiles, J., Akshoomoff, N. A., & Haist, F. (2020). Chapter 17—The development of visuospatial processing. En J. Rubenstein, P. Rakic, B. Chen, & K. Y. Kwan (Eds.), Neural Circuit and Cognitive Development (Second Edition) (pp. 359–393). Academic Press.

van der Ham, I. J. M., & Ruotolo, F. (2017). On inter- and intrahemispheric differences in visuospatial perception. En Neuropsychology of space: Spatial functions of the human brain. (pp. 35–76). Elsevier Academic Press.

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