Severity of Unilateral Spatial Neglect Is an Independent Predictor of Functional Outcome After Acute Inpatient Rehabilitation in Individuals With Right Hemispheric Stroke

Influence of postural control difficulty on changes in spatial orienting of attention after leftward prism adaptation

Prism adaptation (PA) affects visuospatial attention such as spatial orienting in both the right and left hemifields; however, the systematic after-effects of PA on visuospatial attention remain unclear. Visuospatial attention can be affected by non-spatial attentional factors, and postural control difficulty, which delays the reaction time (RT) to external stimulation, may be one such factor. Therefore, we aimed to investigate the influence of postural control difficulty on changes in spatial orienting of attention after leftward PA. Seventeen healthy young adults underwent 15-min and 5-min PA procedures for a leftward visual shift (30 diopters). Participants underwent the Posner cueing test immediately before (pre-evaluation) and in between and after the PA procedures (post-evaluations) while standing barefoot on the floor (normal standing condition) and on a balance-disc (balance standing condition). In the pre-evaluation, RTs in the balance standing condition were significantly longer compared to those in the normal standing condition for targets appearing in both the right and left hemifields. Leftward PA improved the RT for targets appearing in the right, but no left, hemifield in the balance standing condition, such that RTs for targets in the right hemifield in the post-evaluation were not significantly different between the two standing conditions. However, leftward PA did not significantly change RTs for targets in both hemifields in the normal standing condition. Therefore, postural control difficulty may enhance sensitivity to the features of the visuospatial cognitive after-effects of leftward PA.

The Neuropsychological Assessment of Unilateral Spatial Neglect Through Computerized and Virtual Reality Tools: A Scoping Review

Unilateral Spatial Neglect is a disabling neuropsychological deficit. Patients with spatial neglect fail to detect and report events, and to perform actions in the side of space contralateral to a hemispheric cerebral lesion. Neglect is assessed by evaluating the patients' abilities in daily life activities and by psychometric tests. Computer-based, portable and Virtual Reality technologies may provide more and precise data, and be more sensitive and informative, compared to current paper-and-pencil procedures. Studies since 2010, in which such technologies have been used, are reviewed. Forty-two articles meeting inclusion criteria are categorized according to their technological approaches (computer-, graphics tablet or tablet-, virtual reality-based assessment, and other). The results are promising. However, a definite golden standard, technologically based procedure cannot be still established. Developing technologically based tests is a laborious process, which requires technical and user experience improvements as well as normative data, to increase the evidence of efficacy for clinical evaluation of at least some of the tests considered in this review.

Feasibility and relevance of an immersive virtual reality cancellation task assessing far space in unilateral spatial neglect

Unilateral spatial neglect (USN) is a highly prevalent neuropsychological syndrome. However, its assessment in clinical practice, mainly based on paper-and-pencil tests, encounters limits as only near space, called peripersonal, is assessed. However, USN is a multicomponent syndrome that can also affect far space, called extrapersonal. This space is not assessed in current clinical assessment although it can be more impacted than peripersonal space. Immersive virtual reality (VR) allows developing tasks in far space to assess this heterogeneity. This study aimed to test the feasibility and the relevance of an immersive VR task to assess far space. A cancellation task, the Bells test, was used in its original paper-and-pencil version and was also adapted into a far immersive VR version. Ten patients with left USN and sixteen age-matched healthy participants were included. A single-case method was performed to investigate the performance of each patient. Although five patients showed very similar results between both versions, the five others exhibited a dissociation with a more severe impairment in the VR version. Three of these five patients significantly differed from the healthy participants only on the VR version. As USN in far space is not brought to light by paper-and-pencil tests, immersive VR appears as a promising tool to detect USN affecting this space.

Virtual reality gameplay classification illustrates the multidimensionality of visuospatial neglect

Brain injuries can significantly impact mental processes and lead to hidden disabilities not easily detectable. Traditional methods for assessing these impacts are imprecise, leading to unreliable prevalence estimates and treatments with uncertain effectiveness. Immersive virtual reality has shown promise for assessment, but its use as a standalone tool is rare. Our research focused on developing and validating a standalone immersive virtual reality classification system for unilateral spatial neglect, a condition common following brain injury characterized by inattention to one side of space. Our study involved 51 brain injury inpatients and 30 controls, all engaging with 'The Attention Atlas', an immersive virtual reality game for testing visual search skills. Our classification system aimed to identify patients with neglect, 'minor atypicality' (indicative of inattention not consistent enough to be labelled as neglect) or non-neglect. This categorization was based on a simple mathematical definition, utilizing gameplay to describe spatial orientation (to the left or right side) and attentional challenge (indicative of search inefficiency). These metrics were benchmarked against a normative model to detect atypical visual search, which refers to gameplay beyond the usual bounds. The combination of neglected side, orientation and challenge factors was used to categorize neglect. We discovered a strong correlation between atypical visual search patterns and neglect risk factors, such as middle cerebral artery stroke, parietal injuries and existing neglect diagnoses (Poisson regression incidence rate ratio = 7.18, 95% confidence interval = 4.41-11.90). In our study, immersive virtual reality-identified neglect in one-fourth of the patients (n = 13, 25.5%), minor atypicality in 17.6% (n = 9) and non-neglect in the majority, 56.9% (n = 29). This contrasts with standard assessments, which detected neglect in 17.6% (n = 9) of cases and had no intermediate category. Our analysis determined six categories of neglect, the most common being left hemispace neglect with above-median orientation and challenge scores. Traditional assessments were not significantly more accurate (accuracy = 84.3%, P = 0.06) than a blanket assumption of non-neglect. Traditional assessments were also relatively insensitive in detecting immersive virtual reality-identified neglect (53.8%), particularly in less severe cases and those involving right-side inattention. Our findings underline the effectiveness of immersive virtual reality in revealing various dimensions of neglect, surpassing traditional methods in sensitivity and detail and operating independently from them. To integrate immersive virtual reality into real-world clinical settings, collaboration with healthcare professionals, patients and other stakeholders is crucial to ensure practical applicability and accessibility.

Factors associated with independent ambulation at 3 months after putaminal hemorrhage: an observational study

[Purpose] This study was aimed at evaluating the clinical indicators for predicting ambulation at 3 months after putaminal hemorrhage. [Participants and Methods] The participants were 84 inpatients with putaminal hemorrhage. The patients' background characteristics and computed tomography findings at the time of the onset of putaminal hemorrhage were obtained from their medical records. Impaired consciousness, severity of hemiplegia, higher brain dysfunction, sensory impairment, activities of daily living, and ambulatory ability were evaluated. Logistic regression analysis was performed to identify factors associated with ambulation at 3 months, and receiver operating characteristic curve analysis was conducted to determine the predictive value of the identified factors and the optimal cut-off values. [Results] Ventricular rupture, severity of hemiplegia (determined using the 12-grade hemiplegia function test), and Functional Independence Measure cognitive score were found to be independent predictors of prognosis. Severity of hemiplegia was the strongest predictor of ambulation, with a sensitivity of 80.4% and specificity of 100% when the cut-off was set at grade 6 (the ability for coordinated movement of the extensor and flexor muscles of the hip joint). [Conclusion] The severity of hemiplegia, Functional Independence Measure cognitive score, and ventricular rupture were independently associated with ambulation in patients with putaminal hemorrhage. The ability of the hip joint movement is one of the most important factors in ambulation prognosis.

Effects of prism adaptation and visual scanning training on perceptual and response bias in unilateral spatial neglect

In some patients with unilateral spatial neglect, symptoms reflect impaired lateralized spatial attention and representation (perceptual bias) whereas in others the inability to respond to stimuli located in contralesional space (response bias). Here, we investigated whether prismatic adaptation (PA) and visual scanning training (VST) differentially affect perceptual and response bias and whether rehabilitation outcome depends on the type of bias underlying symptoms. Two groups of neglect patients in the subacute phase were evaluated before, immediately after, and two weeks following 10 days of PA (n = 9) or VST (n = 9). Standard neuropsychological tests (i.e., Behavioural Inattentional Test, Diller cancellation test, and Line Bisection test) were administered to assess neglect symptoms, while the Landmark task was used to disentangle perceptual and response biases. Performance on the Landmark task revealed that PA was more effective in improving the perceptual bias, while VST mainly modulated the response bias. Neuropsychological tests performance suggested that VST is better suited to modulate neglect in patients with response bias, while PA may be effective in patients with both types of bias. These findings may offer novel insights into the efficacy of PA and VST in the rehabilitation of perceptual and response biases in patients with neglect.

Immersive virtual reality gameplay detects visuospatial atypicality, including unilateral spatial neglect, following brain injury: a pilot study

BACKGROUND

In neurorehabilitation, problems with visuospatial attention, including unilateral spatial neglect, are prevalent and routinely assessed by pen-and-paper tests, which are limited in accuracy and sensitivity. Immersive virtual reality (VR), which motivates a much wider (more intuitive) spatial behaviour, promises new futures for identifying visuospatial atypicality in multiple measures, which reflects cognitive and motor diversity across individuals with brain injuries.

METHODS

In this pilot study, we had 9 clinician controls (mean age 43 years; 4 males) and 13 neurorehabilitation inpatients (mean age 59 years; 9 males) recruited a mean of 41 days post-injury play a VR visual search game. Primary injuries included 7 stroke, 4 traumatic brain injury, 2 other acquired brain injury. Three patients were identified as having left sided neglect prior to taking part in the VR. Response accuracy, reaction time, and headset and controller raycast orientation quantified gameplay. Normative modelling identified the typical gameplay bounds, and visuospatial atypicality was defined as gameplay beyond these bounds.

RESULTS

The study found VR to be feasible, with only minor instances of motion sickness, positive user experiences, and satisfactory system usability. Crucially, the analytical method, which emphasized identifying 'visuospatial atypicality,' proved effective. Visuospatial atypicality was more commonly observed in patients compared to controls and was prevalent in both groups of patients-those with and without neglect.

CONCLUSION

Our research indicates that normative modelling of VR gameplay is a promising tool for identifying visuospatial atypicality after acute brain injury. This approach holds potential for a detailed examination of neglect.

Prism adaptation therapy in spatial neglect: The importance of connectional anatomy

The meta-analysis conducted by Székely et al. described the lack of beneficial effect of prism adaptation in neglect patients. The authors concluded that the results did "not support the routine use of prism adaptation as a therapy for spatial neglect". However, a possible nuance to this conclusion could be that the response (or lack thereof) of neglect patients to prism adaptation may actually depend on the connectional anatomy of their lesion. We develop this idea in our commentary, in order to offer a more balanced perspective on the implications of the findings obtained by Székely et al.

Innovative Therapy Combining Neck Muscle Vibration and Transcranial Direct Current Stimulation in Association with Conventional Rehabilitation in Left Unilateral Spatial Neglect Patients: HEMISTIM Protocol for a Randomized Controlled Trial

Unilateral spatial neglect (USN) rehabilitation requires the development of new methods that can be easily integrated into conventional practice. The aim of the HEMISTIM protocol is to assess immediate and long-term recovery induced by an innovative association of left-side neck-muscle vibration (NMV) and anodal transcranial Direct Current Stimulation (tDCS) on the ipsilesional posterior parietal cortex during occupational therapy sessions in patients with left USN. Participants will be randomly assigned to four groups: control, Left-NMV, Left-NMV + sham-tDCS or Left-NMV + anodal-tDCS. NMV and tDCS will be applied during the first 15 min of occupational therapy sessions, three days a week for three weeks. USN will be assessed at baseline, just at the end of the first experimental session, after the first and third weeks of the protocol and three weeks after its ending. Our primary outcome will be the evolution of the functional Catherine Bergego Scale score. Secondary outcome measures include five tests that investigate different neuropsychological aspects of USN. Left NMV, by activating multisensory integration neuronal networks, might enhance effects obtained by conventional therapy since post-effects were shown when it was combined with upper limb movements. We expect to reinforce lasting intermodal recalibration through LTP-like plasticity induced by anodal tDCS.

Prism adaptation combined with eye movement training for unilateral spatial neglect after stroke: Study protocol for a single-blind prospective, randomized controlled trial

Background

Unilateral spatial neglect (USN) is a complex neurological syndrome that often reduces rehabilitation outcomes, prolongs patients' hospital stays, and decreases their quality of life. However, the current therapies for USN have varying efficacy. We will explore a new treatment option that combines prism adaptation (PA) with eye movement training (EMT) for the treatment of USN after stroke.

Methods

We will conduct a single-blind, prospective, randomized controlled trial to assess the efficacy of the combined intervention (PA & EMT) on USN in an inpatient rehabilitation setting. The study aims to recruit 88 patients with USN after an ischemic or hemorrhagic stroke. Participants will be randomly assigned to the following four groups: (1) PA group (n = 22), (2) EMT group (n = 22), (3) PA and EMT group (n = 22), and (4) control group (n = 22). All groups will receive 10 sessions of interventions over 2 weeks, 5 times per week. Blinded assessors will conduct a baseline assessment, a post-intervention assessment, and a follow-up assessment (2 weeks post-intervention). The primary outcome measure will use the Behavioral Inattention Test-Conventional Subset (BIT-C) and Catherine Bergego Scale (CBS) to assess the levels of USN. Secondary outcome measures will assess the patient's ability to perform activities of daily living using the Modified Barthel Index (MBI). Patients who completed all treatment and assessment sessions will be included in the final analysis.

Discussion

This study will explore the effects of 10 sessions of combined interventions (PA & EMT) on USN and functional capacity. This study has the potential to identify a new, evidence-based treatment option and provide new ideas for the treatment of USN.

Ethics and dissemination

The study protocol has been approved by the Nanchong Central Hospital. Written informed consent will be obtained from all the participants. The results of this study will be disseminated to the public through scientific conferences and a peer-reviewed journal.

Trial registration

ChiCTR, ChiCTR2100049482. Registered on 2 August 2021, http://www.chictr.org.cn/showproj.aspx?proj=130823.

Relationship between daily rehabilitation time and functional gain in inpatient rehabilitation medicine of hospitalized older adults with subacute stroke

Igarashi T, Hayashi S, Ogawa K, Matsui S, Nishimatsu T. Relationship between daily rehabilitation time and functional gain in inpatient rehabilitation medicine of hospitalized older adults with subacute stroke. Jpn J Compr Rehabil Sci 2022; 13: 56-63.

Objective

Although there have been reports examining the relationship between daily rehabilitation time and functional gain, few have fully considered background factors such as severity of motor paralysis and comorbidities. This study aimed to examine the relationship between the daily rehabilitation time and improvement in functional status, longitudinally in hospitalized older adults with subacute stroke.

Method

From the results of the Functional Independence Measure (FIM), we calculated the FIM gain and FIM effectiveness, a measure that is less sensitive to the ceiling effect of FIM. Adjusted for covariates, multiple regression analysis was performed for daily rehabilitation time and FIM gain and effectiveness.

Results

This study enrolled 298 hospitalized older adults with subacute stroke (mean age, 78.1 ± 8.1 years, 112 females). The total scores of functional independence measure gain and effectiveness were 31.6 ± 22.5 points and 54.4 ± 35.2%, respectively. There was an association between FIM gain (total score) and total rehabilitation time (β = 0.29, p < 0.01) and between FIM effectiveness (total score) and total rehabilitation time (β = 0.22, p < 0.01).

Conclusions

Although prognosis after stroke is poorer in older adults than in young adults, this study shows that increased daily rehabilitation time may improve functional status.

The process by which patients become aware of unilateral spatial neglect: A qualitative study

Unilateral spatial neglect (USN), which can occur post-stroke, significantly impacts patients' daily lives. We explored the process by which patients become aware of the facets of their USN from the acute to subacute phase using a qualitative method. Participant observations, semi-structured interviews, and medical-record surveys were conducted with eight patients with USN and thirty healthcare professionals. We identified three themes regarding the patients' USN awareness process: inconsistency between present symptoms and perception of the left side, reconsidering the reasons for a vagueness on the left side, and acceptance of neglecting the left side. Additionally, healthcare professionals' support consisted of four strategies: assessing patients' perception of stimuli on their left side, compensating for patients' behaviours, promoting awareness of USN, and promoting activities that involve the use of residual functions after a cerebrovascular accident. Patients with USN gradually became aware of their deficits through interactions with others, and they responded by creating and practicing their own self-developed management strategies. These findings indicate that recovery from USN requires a series of experiences and social interactions. A comprehensive understanding of the process of awareness and adaption to USN from onset to recovery can help provide support for patients with USN.

White matter tracts involved in subcortical unilateral spatial neglect in subacute stroke

Background

Unilateral spatial neglect (USN) is common and associated with poor motor and cognitive outcomes as well as impaired quality of life following stroke. Traditionally, the neural substrates underlying USN have been thought to be cortical areas, such as the posterior parietal cortex. However, patients with stroke involving only subcortical structures may also present with USN. While only a few studies have reported on USN in subcortical stroke, the involvement of white matter tracts related to brain networks of visuospatial attention is one possible explanation for subcortical neglect. Therefore, this study aimed to investigate which specific white matter tracts are neural substrates for USN in patients with subcortical stroke.

Methods

Twenty-two patients with subcortical stroke without cortical involvement who were admitted to the Department of Rehabilitation Medicine at Seoul National University Bundang Hospital were retrospectively enrolled. Nine subjects were subclassified into a “USN(+)” group, as they had at least two positive results on three tests (the Schenkenberg line bisection test, Albert's test, and house drawing test) and a score of 1 or higher on the Catherine Bergego scale. The remaining 13 subjects without abnormalities on those tests were subclassified into the “USN(–)” group. Stroke lesions on MRI were manually drawn using MRIcron software. Lesion overlapping and atlas-based analyses of MRI images were conducted. The correlation was analyzed between the overlapped lesion volumes with white matter tracts and the severity of USN (in the Albert test and the Catherine Bergego scale).

Results

Lesions were more widespread in the USN(+) group than in the USN(–) group, although their locations in the right hemisphere were similar. The atlas-based analyses identified that the right cingulum in the cingulate cortex, the temporal projection of the superior longitudinal fasciculus, and the forceps minor significantly overlapped with the lesions in the USN(+) group than in the USN(–) group. The score of the Catherine Bergego scale correlated with the volume of the involved white matter tracts.

Conclusion

In this study, white matter tracts associated with USN were identified in patients with subcortical stroke without any cortical involvement. Our study results, along with previous findings on subcortical USN, support that USN may result from damage to white matter pathways.

Transcranial direct current stimulation in neglect rehabilitation after stroke: a systematic review

Hemispatial neglect is one of the most frequent attention disorders after stroke. The presence of neglect is associated with longer hospital stays, extended rehabilitation periods, and poorer functional recovery. Transcranial direct current stimulation (tDCS) is a new technique with promising results in neglect rehabilitation; therefore, the objective of this systematic review, performed following the PRISMA guidelines, is to evaluate the effectiveness of tDCS on neglect recovery after stroke. The search was done in MEDLINE (PubMed), Web of Science, Scopus, Cochrane Library, and BioMed Central databases. A total of 311 articles were found; only 11 met the inclusion criteria, including 152 post-stroke patients in total. Methodological quality and risk of bias were assessed for all the studies, and methodological characteristics of the studies, sample sizes, methods, main results, and other relevant data were extracted. tDCS intervention ranged from one to twenty sessions distributed in 1 day to 4 weeks, with intensity ranged from 1 to 2 mA. We found moderate evidence for the efficacy of tDCS in the rehabilitation of hemispatial neglect after a stroke, being more effective in combination with other interventions. Nonetheless, the limited number of studies and some studies' design characteristics makes it risky to draw categorical conclusions. Since scientific evidence is still scarce, further research is needed to determine the advantage of this treatment in acute, sub-acute and chronic stroke patients. Future studies should include larger samples, longer follow-ups, and broader neurophysiological assessments, with the final aim of establishing the appropriate use of tDCS as an adjuvant intervention in neurorehabilitation settings.

Transcranial alternating brain stimulation at alpha frequency reduces hemispatial neglect symptoms in stroke patients

Background/Objective

Non-invasive brain stimulation techniques such as transcranial alternating current stimulation (tACS) may help alleviate attention deficits in stroke patients with hemispatial neglect by modulating oscillatory brain activity. We applied high-definition (HD)-tACS at alpha frequency over the contralesional hemisphere to support unilateral oscillatory alpha activity and correct for the pathologically altered attention bias in neglect patients.

Methods

We performed a within-subject, placebo-controlled study in which sixteen stroke patients with hemispatial neglect underwent 10 Hz (alpha) as well as sham (placebo) stimulation targeting the contralesional posterior parietal cortex. Attentional bias was measured with a computerized visual detection paradigm and two standard paper-and-pencil neglect tests.

Results

We revealed a significant shift of attentional resources after alpha-HD-tACS, but not sham tACS, toward the ipsilateral and thus contralesional hemifield leading to a reduction in neglect symptoms, measured with a computerized visual detection paradigm and a widely used standard paper and pencil neglect tests.

Conclusions

We showed a significant alpha-HD-tACS-induced shift of attentional resources toward the contralesional hemifield, thus leading to a reduction in neglect symptoms. Importantly, HD-tACS effects persisted after the stimulation itself had ended. This tACS protocol, based on intrinsic oscillatory processes, may be an effective and well-tolerated treatment option for neglect.

Virtual reality for the assessment and rehabilitation of neglect: where are we now? A 6-year review update

Unilateral spatial neglect (USN) is a frequent repercussion of a cerebrovascular accident, typically a stroke. USN patients fail to orient their attention to the contralesional side to detect auditory, visual, and somatosensory stimuli, as well as to collect and purposely use this information. Traditional methods for USN assessment and rehabilitation include paper-and-pencil procedures, which address cognitive functions as isolated from other aspects of patients' functioning within a real-life context. This might compromise the ecological validity of these procedures and limit their generalizability; moreover, USN evaluation and treatment currently lacks a gold standard. The field of technology has provided several promising tools that have been integrated within the clinical practice; over the years, a "first wave" has promoted computerized methods, which cannot provide an ecological and realistic environment and tasks. Thus, a "second wave" has fostered the implementation of virtual reality (VR) devices that, with different degrees of immersiveness, induce a sense of presence and allow patients to actively interact within the life-like setting. The present paper provides an updated, comprehensive picture of VR devices in the assessment and rehabilitation of USN, building on the review of Pedroli et al. (2015). The present paper analyzes the methodological and technological aspects of the studies selected, considering the issue of usability and ecological validity of virtual environments and tasks. Despite the technological advancement, the studies in this field lack methodological rigor as well as a proper evaluation of VR usability and should improve the ecological validity of VR-based assessment and rehabilitation of USN.

Prism Adaptation Treatment of Spatial Neglect: Feasibility During Inpatient Rehabilitation and Identification of Patients Most Likely to Benefit

Objective

Spatial Neglect is prevalent among stroke survivors, yet few treatments have evidence supporting efficacy. This study examines the feasibility of Prism Adaptation Treatment (PAT) within an inpatient rehabilitation facility and the degree by which PAT improves symptoms of spatial neglect and functional independence among sub-acute survivors of right hemispheric stroke.

Design

In this retrospective cohort study, 37 right hemispheric stroke patients were identified as having received at least 4 PAT sessions during their inpatient stay. Spatial neglect and functional independence levels of patients in the PAT cohort were compared to a matched active control group comprised of rehabilitation patients receiving alternative therapies to address neglect admitted during the same time period.

Results

Most patients received the full recommended 10 sessions of PAT (average sessions completed = 8.6). A higher percentage of severe neglect patients receiving PAT (69%) displayed clinically significant gains on FIM (≥22 points) compared to those receiving alternative treatments (6%). Patients with mild or moderate neglect in the PAT cohort did not exhibit greater benefit than controls.

Conclusion

Provision of PAT for treatment of spatial neglect in right hemispheric stroke patients was feasible during the inpatient rehabilitation admission. Patients with severe neglect showed the most benefit from PAT.

Clinical Trial Registration

This study was registered as a retrospective observational study on Itab Clinical Trials.gov. NCT04977219.

Predicting home discharge after inpatient rehabilitation of stroke patients with aphasia

The early identification of the discharge setting from Inpatient Rehabilitation Facilities is a primary goal in stroke-related research because of its clinical and socio-economic relevance. Several features have been identified as significant predictors of the discharge setting. Within cognitive deficits, aphasia is known to be a common and disabling condition that could influence rehabilitation outcome. However, it is often set as an exclusion criterion in stroke research. This study aims to investigate the predictive power of clinical variables, in particular specific language disturbances and nonlinguistic cognitive deficits, for discharge setting in post-acute stroke patients with aphasia after intensive multidisciplinary rehabilitation. In a sample of 158 patients, demographic, motor, language, and nonverbal cognitive data were retrospectively considered for the prediction of the discharge to home vs. another institutional setting. Univariate analysis identified relevant differences between groups and the significant variables were included in a logistic regression model. The results showed that better functional motor status, absence of dysphagia and unimpaired nonlinguistic cognitive profile independently predict the discharge to home. In particular, nonverbal cognitive functioning seemed to be specifically relevant within the aphasic population. The findings could be helpful for setting up the rehabilitation priorities and an adequate discharge arrangement.

Spatial Neglect Subtypes, Definitions and Assessment Tools: A Scoping Review

Objective: The objective of this scoping review was to capture the reported definitions for the subtypes of neglect post stroke and map the range of assessment tools employed for each neglect subtype.

Methods: EMBASE, Emcare, Medline, and psychINFO were searched from database inception. Searching included all allied terms and mesh headings for stroke, spatial neglect, measurement, screening tools, psychometric properties. Two reviewers independently screened studies for inclusion. Primary studies with documented protocols of a spatial neglect tool for adults post stroke, with some aspect of validity or reliability were included. Two reviewers independently reviewed the documented protocols of each tool to determine the underlying subtypes and disagreements were resolved through discussion.

Results: There were 371 articles included with 292 tools used for the screening or diagnosis of neglect. The majority of studies (67%) included a tool that did not specify the neglect subtype being assessed, therefore an analysis of the underlying subtypes for each tool is presented.

Conclusions: There is no consistency with the terms used to refer to the syndrome of spatial neglect with over 200 different terms used within the included studies to refer to the syndrome as a whole or one of its subtypes. It is essential to unify the terminology and definition for each neglect subtype. There are hundreds of neglect tools available, however many are not able to differentiate presenting subtypes. It is important for clinicians and researchers to critically evaluate the neglect tools being used for the screening and diagnosis of neglect.

Theta-burst transcranial magnetic stimulation for the treatment of unilateral neglect in stroke patients: A systematic review and best evidence synthesis

BACKGROUND

Unilateral neglect (UN) is a common and disabling disorder after stroke. UN is a strong and negative predictor of functional rehabilitative outcome. Non-invasive brain stimulation, such as theta-burst transcranial magnetic stimulation (TBS), is a promising rehabilitation technique for treating stroke-induced UN.

OBJECTIVE

To systematically review the available literature, researching whether TBS of the contra-lesional hemisphere is more effective than standard rehabilitation in improving symptoms of UN in patients with right hemisphere stroke.

REVIEW METHODS

A systematic review was conducted to retrieve randomized controlled trials (RCTs) that were relevant to the objective of this review. PubMed, Ovid and Cochrane Library electronic databases were comprehensively searched from inception up to February 2021. Of the included studies, methodological quality was assessed using the PEDro scale, whereafter a best evidence synthesis (BES) was conducted to summarize the results.

RESULTS

Nine RCTs investigating the effects of TBS on stroke-induced UN symptoms were included in this review. Seven studies assessing continuous TBS (cTBS) found significantly greater amelioration of UN symptoms in the TBS intervention group when compared to the control group; one study assessing cTBS found no such significant difference. One study assessing intermittent TBS (iTBS) found significant between-group differences in favor of the intervention. The BES yielded strong evidence in favor of cTBS, and limited evidence in favor of iTBS.

CONCLUSIONS

The included studies in the present review allow the conclusion that TBS can have favorable effects on UN recovery in stroke patients. Its clinical use is recommended in conjunction with cognitive rehabilitation and occupational or physical rehabilitation as needed. However, many aspects for optimal usage of TBS therapy in clinical settings, such as exact TBS protocols, number of sessions, and treatment duration, are not clear.

Role of S100B Serum Concentration as a Surrogate Outcome Parameter After Mechanical Thrombectomy

Background and Objectives

To establish serum concentration of protein S100B as an objective biomarker surrogate for astroglial tissue damage after mechanical thrombectomy in patients with acute ischemic stroke.

Methods

This prospective 2-center study recruited patients with acute middle cerebral artery infarctions caused by large vessel occlusion treated with mechanical thrombectomy. Blood samples were collected at day 2 after intervention and analyzed for S100B serum concentrations using ELISA techniques. Infarct size was determined on follow-up brain imaging and functional outcome according to modified Rankin Scale (mRS) was assessed at 90 days.

Results

A total of 171 patients were included (mean age ± SD: 70 ± 14 years, 42% female). S100B levels correlated with infarct size. Median S100B concentrations at day 2 after intervention were lower in patients with favorable outcome (mRS score 0–1) at 90 days compared to patients with unfavorable outcome (mRS score 2–6) (median 0.10 µg/L [interquartile range 0.07–0.14] vs 0.20 µg/L [0.11–0.48], p < 0.001). Younger age (odds ratio [OR] 1.120 [confidence interval (CI) 1.068–1.174]; p < 0.001), lower National Institutes of Health Stroke Scale score 24 hours after symptom onset (OR 1.232 [CI 1.106–1.372]; p < 0.001), and lower S100B serum concentrations (OR 1.364 [CI 1.105–1.683]; p = 0.004) were independently associated with a favorable outcome. S100B was able to eliminate the lateralization bias associated with the use of mRS for functional outcome assessment at 90 days after stroke.

Discussion

S100B serum concentrations after mechanical thrombectomy indicate the extent of ischemic tissue damage. This can be assessed rapidly, independent of brain imaging and clinical outcome scales. Following prospective validation in further studies, this may provide an objective surrogate outcome measure both in clinical routine and interventional trials.

Classification of Evidence

This study provides Class I evidence that S100B 2 days following mechanical thrombectomy for acute ischemic stroke accurately distinguishes favorable from unfavorable functional outcome.

Audiospatial evoked potentials for the assessment of spatial attention deficits in patients with severe cerebrovascular accidents

INTRODUCTION

Neuropsychological assessment of spatial orientation in post-acute patients with large brain lesions is often limited due to additional cognitive disorders like aphasia, apraxia, or reduced responsiveness.

METHODS

To cope with these limitations, we developed a paradigm using passive audiospatial event-related potentials (pAERPs): Participants were requested to merely listen over headphones to horizontally moving tones followed by a short tone ("target"), presented either on the side to which the cue moved or on the opposite side. Two runs of 120 trials were presented and we registered AERPs with two electrodes, mounted at C3 and C4. Nine sub-acute patients with large left hemisphere (LH) or right hemisphere (RH) lesions and nine controls participated.

RESULTS

Patients had no problems completing the assessment. RH patients showed a reduced N100 for left-sided targets in all conditions. LH patients showed a diminished N100 for invalid trials and contralesional targets.

CONCLUSION

Measuring AERPs for moving auditory cues and with two electrodes allows investigating spatial attentional deficits in patients with large RH and LH lesions, who are often unable to perform clinical tests. Our procedure can be implemented easily in an acute and rehabilitation setting and might enable investigating spatial attentional processes even in patients with minimal conscious awareness.

Independence in Daily Activities after Stroke among Occupational Therapy Patients and Its Relationship with Unilateral Neglect

More research is needed to better understand the impact of occupational therapy (OT) in stroke patients and syndromes of unilateral neglect (UN) and anosognosia. A prospective, observational, longitudinal design was conducted on a sample of 27 OT patients. The objectives were to examine: (1) the presence of UN and anosognosia; (2) the functional outcomes; and (3) the association of UN at baseline with functional status at discharge from OT. The outcomes were Barthel (functional independence) and the Rivermead Mobility Index (RMI). The baseline proportion of participants with UN was 33% according to the Star Cancellation Test (STC), and 48.1% according to the Catherine Bergego Scale (CBS) therapist-version. There was a significant difference between the therapist and participant-rated CBS scores (p = 0.004). Functional independence improved significantly between the initial and final assessments (p < 0.001); the effect size (r) was large (r = 0.61). There was a significant improvement in RMI scores (p < 0.001), which was large in size (r = 0.59). Both the STC and CBS-therapist scores were significantly correlated with the Barthel (p < 0.001, p = 0.005, respectively) and with the RMI (p = 0.004, p = 0.028, respectively). The participants substantially enhanced their functional status skills. UN and anosognosia were common problems, and neglect was associated with worse OT program outcomes.

Efficacy of Repetitive Transcranial Magnetic Stimulation Combined With Visual Scanning Treatment on Cognitive-Behavioral Symptoms of Unilateral Spatial Neglect in Patients With Traumatic Brain Injury: Study Protocol for a Randomized Controlled Trial

Left hemispatial neglect (LHSN) is a frequent and disabling condition affecting patients who suffered from traumatic brain injury (TBI). LHSN is a neuropsychological syndrome characterized clinically by difficulties in attending, responding, and consciously representing the right side of space. Despite its frequency, scientific evidence on effective treatments for this condition in TBI patients is still low. According to existing literature, we hypothesize that in TBI, LHSN is caused by an imbalance in inter-hemispheric activity due to hyperactivity of the left hemisphere, as observed in LHSN after right strokes. Thus, by inhibiting this left hyperactivity, repetitive Transcranial Magnetic Stimulation (rTMS) would have a rebalancing effect, reducing LHSN symptoms in TBI patients. We plan to test this hypothesis within a single-blind, randomized SHAM controlled trial in which TBI patients will receive inhibitory i-rTMS followed by cognitive treatment for 15 days. Neurophysiological and clinical measures will be collected before, afterward, and in the follow-up. This study will give the first empirical evidence about the efficacy of a novel approach to treating LHSN in TBI patients.

Clinical Trial Registration:https://www.clinicaltrials.gov/ct2/show/NCT04573413?cond=Neglect%2C+Hemispatial&cntry=IT&city=Bologna&draw=2&rank=2, identifier: NCT04573413.

How We Assess Spatial Neglect Matters: Prevalence of Spatial Neglect as Measured by the Catherine Bergego Scale and Impact on Rehabilitation Outcomes

OBJECTIVE

The aim of this study was to determine the prevalence and functional impact of unilateral spatial neglect on right hemisphere stroke patients in an inpatient rehabilitation facility using a multidimensional, functionally based behavioral measure (Catherine Bergego Scale [CBS]).

DESIGN

This was a retrospective cohort study of 742 consecutive admissions of patients with right hemispheric stroke to an inpatient rehabilitation facility. Spatial neglect was assessed using the CBS. Functional impact of neglect was measured by hospital length of stay, Functional Independence Measure change per day, discharge destination, and number of falls.

RESULTS

As measured by the CBS, 86% of the right hemisphere stroke patients had symptoms of spatial neglect. Moderate and severe neglect was associated with less Functional Independence Measure change per day and lower rates of community discharge. The presence of neglect was not significantly associated with fall rate or length of hospital stay after controlling for admission Functional Independence Measure scores and age. The "difficulty looking left" CBS item had the strongest relationship with total CBS scores and effectively predicted Functional Independence Measure change per day and discharge destination.

CONCLUSIONS

Using a sensitive measure, the CBS, rates of spatial neglect are extremely high in right hemisphere stroke patients entering inpatient rehabilitation. Both identification and determination of neglect severity are extremely important given their significant relationship to rehabilitation outcomes and discharge destinations.

TO CLAIM CME CREDITS

Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME.

CME OBJECTIVES

Upon completion of this article, the reader should be able to (1) describe why carefully assessing spatial neglect in right hemisphere stroke patients is important; (2) identify multiple dimensions of spatial neglect assessed by the Catherine Bergego Scale and how this approach differs from traditional paper and pencil assessment methods; and (3) describe the relationship between spatial neglect as measured by the Catherine Bergego Scale and functional outcomes of right hemisphere stroke patients in inpatient rehabilitation settings.

LEVEL

Advanced.

ACCREDITATION

The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

Effect of Prism Adaptation Therapy on the Activities of Daily Living and Awareness for Spatial Neglect: A Secondary Analysis of the Randomized, Controlled Trial

BACKGROUND

Rehabilitation for unilateral spatial neglect (USN) using prism adaptation (PA) is one of the most widely used methods, and the effectiveness of PA is well-evidenced. Although the effect of PA generalized various neglect symptoms, the effectiveness for some aspects of neglect is not fully proven. The Catherine Bergego Scale (CBS) was developed to identify problems with the activities of daily living (ADL) caused by USN. The CBS is composed of 10 observation assessments and a self-assessment questionnaire. To assess the self-awareness of USN, the anosognosia score is calculated as the difference between the observational scores and the self-assessment scores. To investigate how PA affects ADL and self-awareness in subacute USN patients during rehabilitation, we analyzed each item of the CBS and self-awareness from a randomized, controlled trial (RCT) that we previously conducted (Mizuno et al., 2011).

METHODS

A double-masked randomized, controlled trial was conducted to evaluate the effects of a 2-week PA therapy on USN in 8 hospitals in Japan. We compared each item of the CBS, anosognosia score, and absolute value of the anosognosia score between the prism group and the control group.

RESULTS

Two of ten items (gaze orientation and exploration of personal belongings) were significantly improved in the prism group compared with those in the control group. The absolute value of the anosognosia score was significantly improved by PA.

CONCLUSIONS

Improvement of oculomotor exploration by PA may generalize the behavioral level in a daily living environment. This study suggested that PA could accelerate the self-awareness of neglect during subacute rehabilitation.

Behavioral Assessment of Unilateral Spatial Neglect with the Catherine Bergego Scale (CBS) Using the Kessler Foundation Neglect Assessment Process (KF-NAP) in Patients with Subacute Stroke during Rehabilitation in Japan

The Kessler Foundation Neglect Assessment Process (KF-NAP) is an assessment tool for unilateral spatial neglect (USN), which is the scoring method for the Catherine Bergego Scale (CBS) based on detailed instructions. This study is aimed at determining the reliability and validity of the Japanese version of the KF-NAP (KF-NAP-J), evaluating the improvement of neglect assessment with KF-NAP-J, and comparing it with the original CBS for subacute stroke patients. We assessed subacute stroke patients admitted to our intensive rehabilitation hospital. Two KF-NAP-trained occupational therapists (OTs) assessed 22 patients. Before implementing the KF-NAP at the hospital, two other OTs assessed the other 23 patients using the CBS. We evaluated the interrater reliability of the KF-NAP and CBS using intraclass correlation coefficients (ICC) for the total scores, weighted kappa statistics for each subscale, and internal consistency using Cronbach's alpha. We assessed the validity of the KF-NAP against the Behavioral Inattention Test (BIT) and Functional Independence Measure (FIM) using Spearman's correlation coefficient. The reliability of both the KF-NAP and CBS was excellent. The weighted kappa results demonstrated that each subscale was in better agreement with the KF-NAP than with the CBS. In the KF-NAP, all eight subscales in which weighted kappa could be calculated were in significant agreement, and two were almost in perfect agreement. The KF-NAP moderately correlated with the subscales of BIT and FIM representing USN and activities of daily living. The USN detection rates of KF-NAP and BIT in the KF-NAP group were 63.6% and 22.7%, respectively. These results suggest that the KF-NAP, as well as the CBS, is useful to assess USN, which strongly impacts the rehabilitation outcomes in subacute stroke patients.

Efficacy of repetitive transcranial magnetic stimulation combined with visual scanning treatment on cognitive and behavioral symptoms of left hemispatial neglect in right hemispheric stroke patients: study protocol for a randomized controlled trial

BACKGROUND

Left hemispatial neglect (LHN) is a neuropsychological syndrome often associated with right hemispheric stroke. Patients with LHN have difficulties in attending, responding, and consciously representing the right side of space. Various rehabilitation protocols have been proposed to reduce clinical symptoms related to LHN, using cognitive treatments, or on non-invasive brain stimulation. However, evidence of their benefit is still lacking; in particular, only a few studies focused on the efficacy of combining different approaches in the same patient.

METHODS

In the present study, we present the SMART ATLAS trial (Stimolazione MAgnetica Ripetitiva Transcranica nell'ATtenzione LAteralizzata dopo Stroke), a multicenter, randomized, controlled trial with pre-test (baseline), post-test, and 12 weeks follow-up assessments based on a novel rehabilitation protocol based on the combination of brain stimulation and standard cognitive treatment. In particular, we will compare the efficacy of inhibitory repetitive-transcranial magnetic stimulation (r-TMS), applied over the left intact parietal cortex of LHN patients, followed by visual scanning treatment, in comparison with a placebo stimulation (SHAM control) followed by the same visual scanning treatment, on visuospatial symptoms and neurophysiological parameters of LHN in a population of stroke patients.

DISCUSSION

Our trial results may provide scientific evidence of a new, relatively low-cost rehabilitation protocol for the treatment of LHN.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04080999 . Registered on September 2019.

Proprioceptive impairment in unilateral neglect after stroke: A systematic review

Introduction:

Unilateral neglect is a debilitating condition that can occur after stroke and can affect a variety of domains and modalities, including proprioception. Proprioception is a sensorimotor process essential to motor function and is thus important to consider in unilateral neglect. To date, there has not been a comprehensive review of studies examining the various aspects of proprioceptive impairment in unilateral neglect after stroke. This review aimed to determine if people with unilateral neglect have more severe proprioceptive impairments than those without unilateral neglect after stroke.

Methods:

The MEDLINE, Embase, Scopus, CINAHL and Web of Science databases were searched from inception to September 2019 using an a priori search strategy. Two independent reviewers screened abstracts and full texts, and extracted data from the included full texts. A third reviewer resolved disagreements at each step. Risk of bias was assessed using the AXIS Quality Assessment tool.

Results:

A total of 191 abstracts were identified, with 56 eligible for full-text screening. A total of 18 studies were included in the review and provided evidence that people with unilateral neglect have more severe proprioceptive impairment than people without unilateral neglect. This impairment is present in multiple subtypes of unilateral neglect and aspects of proprioception. Most studies had a moderate risk of bias.

Conclusion:

People with unilateral neglect after stroke are more likely to have impaired processing of multiple types of proprioceptive information than those without unilateral neglect. However, the available evidence is limited by the large heterogeneity of assessment tools used to identify unilateral neglect and proprioception. Unilateral neglect and proprioception were rarely assessed comprehensively.

PROSPERO Registration: CRD42018086070.

A Retrospective Cohort Comparing Left and Right Middle Cerebral Artery Ischemic Stroke Functional Outcomes in Acute Inpatient Rehabilitation

BACKGROUND

To date, no large population studies compare left and right middle cerebral artery (MCA) strokes and corresponding patient performance in acute rehabilitation as measured by the Functional Independence Measure (FIM).

OBJECTIVE

To compare granular performance data using the six FIM subcategories between left and right MCA territory strokes. This may foster development of individualized rehabilitation programs and affect rehabilitation policy based on phenotypic variations.

DESIGN

Retrospective cohort study.

SETTING

Inpatient rehabilitation facilities, using Uniform Data System for Medical Rehabilitation data from 2015 to 2017.

PATIENTS

Individuals with MCA strokes admitted to inpatient rehabilitation facilities (n = 38 812).

MAIN OUTCOME MEASURES

Mean FIM efficiency and FIM gain within the six FIM subcategories (self-care, sphincter control, transfers, locomotion, communication, and social cognition) were compared between left and right MCA strokes. All were stratified by admission FIM severity categories (<40, 40-80, >80). The study also examined length of stay and percentage discharged to home.

RESULTS

Mean FIM efficiency was significantly higher for left MCA strokes compared to right MCA strokes. Left MCA strokes with admission FIM <40 and 40-80 had significantly higher FIM efficiencies within the majority of FIM subcategories. However, left and right MCA strokes with admission FIM > 80 did not display any significant differences. Overall, patients with left MCA strokes were discharged to home at a significantly higher percentage. Patients with left MCA strokes with admission FIM 40-80 had on average a 2-day shorter length of stay than those with right MCA strokes.

CONCLUSIONS

Overall, patients with left MCA ischemic strokes had shorter length of stays, higher FIM efficiencies, and larger FIM gains than those with right MCA strokes. These results allow clinicians to counsel patients regarding functional gains based on diagnosis and to tailor rehabilitation programs to impairments encountered in left and right MCA territories. Including laterality of stroke and admission functional status would also improve algorithms for determining reimbursement.

Influence of right versus left unilateral spatial neglect on the functional recovery after rehabilitation in sub-acute stroke patients

Unilateral spatial neglect (USN) may lead to poor functional rehabilitation outcomes. However, studies investigating the rehabilitation outcomes of right-sided USN are lacking. We aimed to investigate (1) the clinical impacts of USN, including right-sided USN, for stroke patients in sub-acute rehabilitation, and (2) evaluate the differences in clinical characteristics and rehabilitation outcomes between right- and left-sided USN patients. We retrospectively screened the medical records of 297 inpatients at the Tokyo-Bay Rehabilitation Hospital who experienced a cerebrovascular accident with supratentorial lesions between January 1st, 2014 and December 31st, 2016. We performed independent multiple regression analysis in patients with left and right hemisphere damage. The Behavioral Inattention Test was a significant independent variable for predicting the motor, cognitive, and total functional independence measure (FIM), compared to the Stroke Impairment Assessment Set and Mini-Mental State Examination. USN affects motor FIM recovery more than cognitive FIM recovery regardless of the damaged hemisphere. Our study results confirm that both right- and left-sided USN influence the functional recovery of stroke patients. USN occurs, slightly less frequently, following a left hemisphere stroke. However, USN negatively affected rehabilitation outcomes, regardless of the neglected side. Therefore, USN treatment is necessary for patients with left and right hemisphere damage.

Multisensory stimulation for the rehabilitation of unilateral spatial neglect

Unilateral spatial neglect (USN) is a neuropsychological syndrome, typically caused by lesions of the right hemisphere, whose features are the defective report of events occurring in the left (contralesional) side of space and the inability to orient and set up actions leftwards. Multisensory integration mechanisms, largely spared in USN patients, may temporally modulate spatial orienting. In this pilot study, the effects of an intensive audio-visual Multisensory Stimulation (MS) on USN were assessed, and compared with those of a treatment that ameliorates USN, Prismatic Adaptation (PA). Twenty USN stroke patients received a 2-week treatment (20 sessions, twice per day) of MS or PA. The effects of MS and PA were assessed by a set of neuropsychological clinical tests (target cancellation, line bisection, sentence reading, personal neglect, complex drawing) and the Catherine Bergego Scale for functional disability. Results showed that MS brought about an amelioration of USN deficits overall comparable to that induced by PA; personal neglect was improved only by MS, not by PA. The clinical gains of the MS treatment were not influenced by duration of disease and lesion volume, and they persisted up to one month post-treatment. In conclusion, MS represents a novel and promising rehabilitation procedure for USN.

How is carer strain related to the recovery of stroke survivors with right hemisphere dysfunction? Implications for practice

Aim: Right hemisphere strokes are associated with neuro-behavioural impairments including hemi-inattention, impulsiveness and anosognosia, which can impede stroke recovery and adversely affect carer health. This study explored the impact of associated impairments on carer strain and depression through a mixed methods approach.Method: Fifty-one carer-survivor dyads were recruited from inpatient rehabilitation units and followed-up for 6 months. Validated measures assessed survivors' physical and cognitive function and carers' strain and depression levels. Survey methods captured qualitative experiences of the caring role. Data collection occurred at baseline, discharge, 6 weeks post-discharge and 6 months. Multilevel-modelling and thematic data analysis, were employed.Results: Carer strain median scores were within normal ranges of the Caregiver Strain Index scale. Carer strain was positively linked to carer depression, number of carers' concerns reported and survivors' anosognosia levels. Carer strain was negatively linked to the survivors' functional and cognitive abilities. Carers' experiences differed qualitatively with caring concerns increasing over time.Conclusion: Carer strain worsens with increases in significant concerns about the rehabilitation process and poor survivor functioning skills, which potentially increase risk of depression in carers. Consequently, improving right-hemisphere stroke survivors' recovery and nurturing the carer-survivor relationship are likely to enhance overall outcomes and caring experiences.IMPLICATIONS FOR REHABILITATIONIn the context of right hemisphere stroke: Carer assessment should be comprehensive and include a measure of perceived ability to care.Less strained carers tend to report fewer caring concerns and have lower depression levels.Education, training and practical support should be tailored to carer identified needs, abilities and the caring context.

Transcranial electric stimulation optimizes the balance of visual attention across space

OBJECTIVE

Transcranial direct current stimulation (tDCS) provides a way to modulate spatial attention by enhancing the ratio of neural activity between the left and right hemispheres, with a potential benefit for the rehabilitation of visual neglect.

METHODS

We tested the effect of bilateral tDCS in healthy individuals performing a visual detection task. This protocol consists in the positioning of the anode and cathode on mirror positions over the left and right parietal areas. The stimulation was repeated over three days to maximize the chance to observe a bias to the hemispace controlateral to the anode.

RESULTS

Compared to a sham treatment, left anodal - right cathodal stimulation enhanced attention across the full range of space, since the first day with no build-up effect on the next days, and modified the balance of left-right omissions when stimuli appeared at the same time.

CONCLUSION

Bilateral tDCS improved detection in both visual fields, with no privileged processing of one side, except when concurrent stimuli were presented. The results provide partial support to the hemispheric rivalry hypothesis.

SIGNIFICANCE

The technique has the potential to boost attention in neglect patients but should be used as an adjuvant rather than as an alternative to functional rehabilitation.

Noninvasive brain stimulation in rehabilitation of hemispatial neglect after stroke

BACKGROUND

Noninvasive brain stimulation can modulate neural processing within the motor cortex and thereby might be beneficial in the rehabilitation of hemispatial neglect after stroke.

METHODS

We review the pertinent literature regarding the use of transcranial direct current stimulation (tDCS) and transcranial magnetic stimulation in order to facilitate recovery of hemispatial neglect after stroke.

RESULTS

Twenty controlled trials (including 443 stroke patients) matched our inclusion criteria. Methodology and results of each study are presented in a comparative approach. Current data seem to indicate a better efficiency of repetitive transcranial magnetic stimulation, compared to tDCS to ameliorate hemispatial neglect after stroke.

CONCLUSIONS

Noninvasive brain stimulation has the potential to facilitate recovery of hemispatial neglect after stroke, but until today, there are not enough data to claim its routine use.

Unilateral Spatial Neglect After Stroke: Current Insights

INTRODUCTION

Unilateral spatial neglect (USN) is a disorder of contralesional space awareness which often follows unilateral brain lesion. Since USN impairs awareness of contralesional space/body and often of concomitant motor disorders, its presence represents a negative prognostic factor of functional recovery. Thus, the disorder needs to be carefully diagnosed and treated. Here, we attempted to present a clear and concise picture of current insights in the comprehension and rehabilitation of USN.

METHODS

We first provided an updated overview of USN clinical and neuroanatomical features and then highlighted recent progresses in the diagnosis and rehabilitation of the disease. In relation to USN rehabilitation, we conducted a MEDLINE literature research on three of the most promising interventions for USN rehabilitation: prismatic adaptation (PA), non-invasive brain stimulation (NIBS), and virtual reality (VR). The identified studies were classified according to the strength of their methods.

RESULTS

The last years have witnessed a relative decrement of interest in the study of neuropsychological disorders of spatial awareness in USN, but a relative increase in the study of potential interventions for its rehabilitation. Although optimal protocols still need to be defined, high-quality studies have demonstrated the efficacy of PA, TMS and tDCS interventions for the treatment of USN. In addition, preliminary investigations are suggesting the potentials of GVS and VR approaches for USN rehabilitation.

CONCLUSION

Advancing neuropsychological and neuroscience tools to investigate USN pathophysiology is a necessary step to identify effective rehabilitation treatments and to foster our understanding of neurofunctional bases of spatial cognition in the healthy brain.

Spatial Neglect in Stroke: Identification, Disease Process and Association with Outcome During Inpatient Rehabilitation

We established spatial neglect prevalence, disease profile and amount of therapy that inpatient stroke survivors received, and outcomes at discharge using Sentinel Stroke National Audit Programme (SSNAP) data. We used data from 88,664 National Health Service (NHS) admissions in England, Wales and Northern Ireland (July 2013–July 2015), for stroke survivors still in hospital after 3 days with a completed baseline neglect National Institute for Health Stroke Scale (NIHSS) score. Thirty percent had neglect (NIHSS item 11 ≥ 1) and they were slightly older (78 years) than those without neglect (75 years). Neglect was observed more commonly in women (33 vs. 27%) and in individuals with a premorbid dependency (37 vs. 28%). Survivors of mild stroke were far less likely to present with neglect than those with severe stroke (4% vs. 84%). Those with neglect had a greatly increased length of stay (27 vs. 10 days). They received a comparable amount of average daily occupational and physiotherapy during their longer inpatient stay but on discharge a greater percentage of individuals with neglect were dependent on the modified Rankin scale (76 vs. 57%). Spatial neglect is common and associated with worse clinical outcomes. These results add to our understanding of neglect to inform clinical guidelines, service provision and priorities for future research.

Influence of Motor Deficiency and Spatial Neglect on the Contralesional Posterior Parietal Cortex Functional and Structural Connectivity in Stroke Patients

The posterior parietal cortex (PPC) is a key structure for visual attention and upper limb function, two features that could be impaired after stroke, and could be implied in their recovery. If it is well established that stroke is responsible for intra- and interhemispheric connectivity troubles, little is known about those existing for the contralesional PPC. In this study, we aimed at mapping the functional (using resting state fMRI) and structural (using diffusion tensor imagery) networks from 3 subparts of the PPC of the contralesional hemisphere (the anterior intraparietal sulcus), the posterior intraparietal sulcus and the superior parieto-occipital cortex to bilateral frontal areas and ipsilesional homologous PPC parts in 11 chronic stroke patients compared to 13 healthy controls. We also aimed at assessing the relationship between connectivity and the severity of visuospatial and motor deficiencies. We showed that interhemispheric functional and structural connectivity between PPCs was altered in stroke patients compared to controls, without any specificity among seeds. Alterations of parieto-frontal intra- and interhemispheric connectivity were less observed. Neglect severity was associated with several alterations in intra- and interhemispheric connectivity, whereas we did not find any behavioral/connectivity correlations for motor deficiency. The results of this exploratory study shed a new light on the influence of the contralesional PPC in post-stroke patients, they have to be confirmed and refined in further larger studies.

Visuospatial Neglect - a Theory-Informed Overview of Current and Emerging Strategies and a Systematic Review on the Therapeutic Use of Non-invasive Brain Stimulation

Visuospatial neglect constitutes a supramodal cognitive deficit characterized by reduction or loss of spatial awareness for the contralesional space. It occurs in over 40% of right- and 20% of left-brain-lesioned stroke patients with lesions located mostly in parietal, frontal and subcortical brain areas. Visuospatial neglect is a multifaceted syndrome - symptoms can be divided into sensory, motor and representational neglect - and therefore requires an individually adapted diagnostic and therapeutic approach. Several models try to explain the origins of visuospatial neglect, of which the "interhemispheric rivalry model" is strongly supported by animal and human research. This model proposes that allocation of spatial attention is balanced by transcallosal inhibition and both hemispheres compete to direct attention to the contralateral hemi-space. Accordingly, a brain lesion causes an interhemispheric imbalance, which may be re-installed by activation of lesioned, or deactivation of unlesioned (over-activated) brain areas through noninvasive brain stimulation. Research in larger patient samples is needed to confirm whether noninvasive brain stimulation can improve long-term outcomes and whether these also affect activities of daily living and discharge destination.

Noninvasive Brain Stimulation and Noninvasive Peripheral Stimulation for Neglect Syndrome Following Acquired Brain Injury

OBJECTIVE

Hemispatial neglect is a frequent condition usually following nondominant hemispheric brain injury. It strongly affects rehabilitation strategies and everyday life activities. It is associated with behavioral and cognitive disability with a strong impact on patient's life.

METHODS

We reviewed the published literature on the use of noninvasive brain stimulation, including repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS), and of noninvasive peripheral muscle stimulation, as therapeutic strategies for rehabilitation of neglect after acquired brain injury, such as in stroke or in traumatic injuries. The studies were grouped as controlled or uncontrolled studies in each stimulation techniques.

RESULTS

Thirty-four studies were identified and 16 on rTMS, 10 on tDCS, and 8 on vibration. All studies were conducted in adult patients who suffered a stroke, except for one that was conducted in a patient suffering traumatic acquired brain injury and another that was conducted in a patient with brain tumor. In spite of significant variability in treatment protocols, patients' features and assessment of neglect, improvement was reported in almost all studies with no side-effects.

CONCLUSIONS

Noninvasive brain stimulation and neuromuscular vibration are promising therapeutic neuromodulatory approaches for neglect. Further randomized-controlled studies are needed to corroborate their effectiveness as separate and combined techniques.

Functional recovery and blood pressure on acute post-stroke setting

Objectives

This study aims to evaluate the effects of blood pressure (BP) on functional recovery and length of stay (LOS) in post-stroke patients in an acute rehabilitation facility (ARF).

Patients and methods

A total of 116 ischemic stroke patients (60 males, 56 females; mean age 70.0±12.8 years; range, 37 to 93 years) who were admitted to the ARF between January 2012 and September 2012 were included. Daily BP measurements with mean systolic and diastolic BP values and Functional Independent Measure (FIM) scores at the time of admission and discharge were measured. The LOS and systolic and diastolic BP ranges were also recorded.

Results

There was no significant correlation between the BP and FIM scores. The mean diastolic BP was positively correlated with admission (rs=0.316, p=0.01) and discharge (rs=0.287, p=0.002), FIM scores, and FIM effectiveness (rs=0.185, p=0.047) and negatively correlated with age (r=-0.449, p<0.001) and LOS (rs=-0.189, p=0.042). The LOS in hospital was negatively correlated with FIM scores at admission (rs=-0.585, p<0.001) and discharge (rs=-0.352, p<0.001) and positively correlated with FIM score changes (rs=0.414, p<0.001).

Conclusion

Our study results show that diastolic BP in the subacute phase of stroke does not have a major impact on the functional recovery and LOS in post-stroke patients. However, there is a significant correlation between diastolic BP values and FIM efficiency.

Impact of visuospatial neglect post-stroke on daily activities, participation and informal caregiver burden: A systematic review

OBJECTIVES

Visuospatial neglect (VSN) is a common cognitive disorder after stroke. The primary aim of this systematic review was to provide an overview of the impact of VSN in 3 aspects: (1) activities of daily living (ADL), (2) participation, and (3) caregiver burden. The second aim was to investigate the differences in studies focusing on populations with mean age<65 versus≥65 years.

METHODS

PubMed, EMBASE, Web of Science, Cochrane Library, Emcare, PsychINFO, Academic Search Premier and CENTRAL were searched systematically. Quality was assessed with the Mixed Methods Appraisal Tool.

RESULTS

Of the 115 included studies, 104 provided outcomes on ADL, 15 on participation (4 studies with mean age≥65), and 2 on caregiver burden (1 study with mean age≥65). Quality assessment yielded scores ranging from 0 to 100%. VSN had a negative impact on ADL (i.e., independence during ADL and performance in self-care, household tasks, reading, writing, walking, wheelchair navigation) and participation (i.e., driving, community mobility, orientation, work). The impact of VSN on fulfilling social roles was unclear. VSN had a negative effect on caregiver burden. We found no clear age-related differences.

CONCLUSIONS AND IMPLICATIONS

VSN has a negative impact not only on patients' independence but particularly on the performance of ADL. Despite the far fewer studies of VSN as compared with ADL, VSN also seems to hamper participation and increase caregiver burden, but further research is needed. Because of the large impact, VSN should be systematically and carefully assessed during rehabilitation. A considerable number of different instruments were used to diagnose VSN. Diagnosing VSN at more than one level [function (i.e., pen-and-paper test), activities, and participation] is strongly recommended. Consensus is needed on how to assess VSN and its negative impact for research and rehabilitation practice.

SYSTEMATIC REVIEW REGISTRATION NO

PROSPERPO Registration No. CRD42018087483.

Impact of heart failure on functional recovery after hip fracture

[Purpose] Heart failure has been identified as a risk factor for reduced physical function and falls; however, the impact of heart failure on functional recovery after a hip fracture is unclear. This study aimed to examine how heart failure and pre-fracture physical function affect recovery after a hip fracture. [Participants and Methods] The study population consisted of 122 patients with sub-acute hip fracture (mean age 81.7 ± 9.7 years, 18.9% male) who were divided into two groups: heart failure and non-heart failure. The outcome measurement was the functional independence measure effectiveness. A two-way analysis of variance was performed to investigate how heart failure and ambulatory ability prior to hip fracture were related to the functional independence measure effectiveness. [Results] Seventeen patients (13.9%) had a history of heart failure. The two-way analysis of variance showed the two independent variables (heart failure and ambulatory ability before fracture) had significant main effects; however, their interaction effect was not significant. [Conclusion] Heart failure affects functional recovery after hip fracture independent of the pre-fracture physical function, and vice versa. Further research on rehabilitation in hip fracture patients with heart failure is required to develop strategies to overcome poor functional recovery in such patients.

Is Unilateral Spatial Neglect Associated With Motor Recovery of the Affected Upper Extremity Poststroke? A Systematic Review

BACKGROUND AND PURPOSE

Individuals with stroke often present symptoms of multiple domains, such as weakness of the affected upper extremity (UE) and unilateral spatial neglect (USN), which are both associated with poor functional outcome. The aims of this systematic review were to search and review studies that investigated (1) the relationship between USN and affected UE sensorimotor recovery poststroke and (2) the effectiveness of sensorimotor interventions to improve the affected UE in patients with USN.

METHODS

An electronic search of databases (MEDLINE, EMBASE, CINAHL and Cochrane CENTRAL) was conducted using a combination of the following terms: stroke, USN, and affected UE. Studies meeting the inclusion criteria were rated using a modified version of the Quality Index, and relevant data were extracted.

RESULTS

A total of 850 studies were identified, and 14 were included; 13 studies assessed correlations between USN and the affected UE capacity/recovery, and 1 study assessed an intervention to improve the UE of individuals with USN. An association between presence of USN and UE capacity/recovery was found in most studies and USN did not interfere with recovery of the affected UE in the single experimental study.

CONCLUSIONS

USN is associated with poor UE motor capacity and less UE recovery poststroke. Therefore, these impairments should be considered when planning rehabilitation and discharge. Because USN is a well-researched phenomenon, the lack of studies and insufficient evidence related to UE interventions in individuals with USN was unexpected. These interventions should be developed and researched to improve UE and overall functional outcome poststroke.

Ventral attention and motor network connectivity is relevant to functional impairment in spatial neglect after right brain stroke

Emerging research suggests spatial neglect after right stroke is linked to dysfunctional attention and motor networks. Advanced functional connectivity analysis clarified brain network recovery, however we need to know how networks participate in adaptive motor performance. We need to verify network changes associated with validated functional measures and spatial-motor performance in spatial neglect, especially in patients with large brain lesions and significant disability. This study tested whether disability-relevant spatial neglect associates with different patterns of resting state functional connectivity between motor, dorsal and ventral attention networks (MN, DAN and VAN). Right stroke patients had spatial neglect (n = 8) or not (n = 10) on the Behavioural Inattention Test-conventional. Spatial neglect patients had weaker intranetwork VAN connectivity, and reduced internetwork connectivity between VAN and left frontal eye field (DAN), and between VAN and the left primary motor area (MN). These network impairments might explain the co-occurrence of attention and motor deficits in spatial neglect, and open a path to assessing functional connectivity in clinical trials of combined spatial retraining and motor rehabilitation after stroke.

The effect of theta-burst stimulation on unilateral spatial neglect following stroke: a systematic review

OBJECTIVE:

To evaluate the effectiveness of theta-burst stimulation for the treatment of stroke-induced unilateral spatial neglect.

DATA SOURCES:

A systematic literature search was conducted from the inception of each database to 30 June 2018 using CINAHL, EMBASE, PubMed, PsycINFO, and Scopus.

REVIEW METHODS:

Articles were included if theta-burst stimulation was used to treat neglect following a stroke. The additional a priori inclusion criteria were as follows: (1) ⩾3 adult (⩾18 years) participants, (2) ⩾50% stroke population, and (3) peer-reviewed journal articles published in English. Extracted data included study and treatment characteristics, results, and adverse events.

RESULTS:

Nine studies met the inclusion criteria, generating a total of 148 participants. Eight studies evaluated a continuous stimulation protocol and one study investigated an intermittent stimulation protocol. Overall, both protocols significantly improved neglect severity when compared against placebo or active controls ( P < 0.05). Adding smooth pursuit training to theta-burst stimulation did not improve neglect relative to when the stimulation was delivered alone ( P > 0.05). There was inconsistent reporting of neglect terminology, outcome measures, and adverse events. The treatment characteristics were heterogeneous among the trials.

CONCLUSION:

This systematic review found that theta-burst stimulation seems to improve post-stroke unilateral spatial neglect, but because the evidence is limited to a few small studies with varied and inconsistent protocols and use of terminology, no firm conclusion on effectiveness can be drawn.

Occurrence and Recovery of Different Neglect-Related Symptoms in Right Hemisphere Infarct Patients during a 1-Year Follow-Up

OBJECTIVES

To examine the occurrence of and recovery from visual neglect-related symptoms with the focus on neglect laterality, ipsilateral orienting bias, and slowed processing speed in right hemisphere (RH) infarct patients during a 1-year follow-up. Furthermore, to propose guidelines for assessing processing speed alongside the Behavioural Inattention Test (BIT).

METHODS

We studied three RH patient groups: neglect (N+), mild left inattention (MLI+), and non-neglect (N-) patients, and healthy controls. The BIT with some additional analyses was conducted at the acute phase and at 6 and 12 months.

RESULTS

The N+ group's BIT score increased and originally lateralized omissions became more evenly distributed during the follow-up. The N+ and MLI+ groups' starting points were more rightward located than the healthy group's at the acute phase and at 6, and partly at 12 months. Patient groups were slower than the controls in performing cancellation tests at the acute phase. The N+ and MLI+ groups remained slower than the controls throughout the follow-up.

CONCLUSIONS

During the first year after RH infarct, originally left-sided manifestation of neglect shifted toward milder non-lateralized attentional deficit. Ipsilateral orienting bias and slowed processing speed appeared to be rather persistent neglect-related symptoms both in neglect patients and patients with initially milder inattention. We propose some effortless, tentative ways of examining processing speed and ipsilateral orienting bias alongside the BIT to better recognize these neglect-related symptoms, and highlight the need to assess and treat patients with initially milder inattention, who have been under-recognized and under-treated in clinical work. (JINS, 2018, 24, 617-628).

Neuroanatomical and behavioural factors associated with the effectiveness of two weekly sessions of prism adaptation in the treatment of unilateral neglect

Among the different interventions to alleviate the symptoms of unilateral neglect, prism adaptation (PA) appears especially promising. To elucidate the contribution of some neuroanatomical and behavioural factors to PA's effectiveness, we conducted a study combining neuropsychological and lesion mapping methods on a group of 19 neglect patients who underwent two sessions of PA during one week and assessed their improvement relative to the baseline until the following week (7-8 days later). Correlation analyses revealed a significant positive relationship between the magnitude of the proprioceptive after-effect and the improvement at the follow-up session in two perceptual tasks requiring motor responses. Conversely, no correlation was found between the proprioceptive after-effect and the improvement in a perceptual task with no motor involvement. This finding suggests that patients' potential to show a prism-related improvement in motor-related tasks might be indicated by the strength of their proprioceptive response (proprioceptive after-effect). As for the neuroanatomical basis of this relationship, subtraction analyses suggested that patients' improvement in perceptual tasks with high motor involvement might be facilitated by the integrity of temporo-parietal areas and the damage of frontal and subcortical areas.

Unilateral spatial neglect in the acute phase of ischemic stroke can predict long-term disability and functional capacity

OBJECTIVE

The aim of this study was to assess the relationship between the degree of unilateral spatial neglect during the acute phase of stroke and long-term functional independence.

METHODS

This was a prospective study of right ischemic stroke patients in which the independent variable was the degree of spatial neglect and the outcome that was measured was functional independence. The potential confounding factors included sex, age, stroke severity, topography of the lesion, risk factors, glycemia and the treatment received. Unilateral spatial neglect was measured using the line cancellation test, the star cancellation test and the line bisection test within 48 hours of the onset of symptoms. Functional independence was measured using the modified Rankin and Barthel scales at 90 days after discharge. The relationship between unilateral spatial neglect and functional independence was analyzed using multiple logistic regression that was corrected for confounding factors.

RESULTS

We studied 60 patients with a median age of 68 (34-89) years, 52% of whom were male and 74% of whom were Caucasian. The risk for moderate to severe disability increased with increasing star cancellation test scores (OR=1.14 [1.03-1.26], p=0.01) corrected for the stroke severity, which was a confounding factor that had a statistically positive association with disability (OR=1.63 [1.13-2.65], p=0.01). The best chance of functional independence decreased with increasing star cancellation test scores (OR=0.86 [0.78-0.96], p=0.006) corrected for the stroke severity, which was a confounding factor that had a statistically negative association with independence (OR=0.66 [0.48-0.92], p=0.017).

CONCLUSION

The severity of unilateral spatial neglect in acute stroke worsens the degree of long-term disability and functional independence.