Impact of spatial neglect on stroke rehabilitation: evidence from the setting of an inpatient rehabilitation facility

Advancements in brain-computer interfaces for the rehabilitation of unilateral spatial neglect: a concise review

This short review examines recent advancements in neurotechnologies within the context of managing unilateral spatial neglect (USN), a common condition following stroke. Despite the success of brain-computer interfaces (BCIs) in restoring motor function, there is a notable absence of effective BCI devices for treating cerebral visual impairments, a prevalent consequence of brain lesions that significantly hinders rehabilitation. This review analyzes current non-invasive BCIs and technological solutions dedicated to cognitive rehabilitation, with a focus on visuo-attentional disorders. We emphasize the need for further research into the use of BCIs for managing cognitive impairments and propose a new potential solution for USN rehabilitation, by combining the clinical subtleties of this syndrome with the technological advancements made in the field of neurotechnologies.

Spatial Neglect: An Exploration of Clinical Assessment Behaviour in Stroke Rehabilitation

OBJECTIVE

There is a large gap between evidence-based recommendations for spatial neglect assessment and clinical practice in stroke rehabilitation. We aimed to describe factors that may contribute to this gap, clinician perceptions of an ideal assessment tool, and potential implementation strategies to change clinical practice in this area.

DESIGN

Qualitative focus group investigation. Focus group questions were mapped to the Theoretical Domains Framework and asked participants to describe their experiences and perceptions of spatial neglect assessment.

SETTING

Online stroke rehabilitation educational bootcamp.

PARTICIPANTS

A sample of 23 occupational therapists, three physiotherapists, and one orthoptist that attended the bootcamp.

INTERVENTION

Prior to their focus group, participants watched an hour-long educational session about spatial neglect.

MAIN MEASURES

A deductive analysis with the Theoretical Domains Framework was used to describe perceived determinants of clinical spatial neglect assessment. An inductive thematic analysis was used to describe perceptions of an ideal assessment tool and practice-change strategies in this area.

RESULTS

Participants reported that their choice of spatial neglect assessment was influenced by a belief that it would positively impact the function of people with stroke. However, a lack of knowledge about spatial neglect assessment appeared to drive low clinical use of standardised functional assessments. Participants recommended open-source online education involving a multidisciplinary team, with live-skill practice for the implementation of spatial neglect assessment tools.

CONCLUSIONS

Our results suggest that clinicians prefer functional assessments of spatial neglect, but multiple factors such as knowledge, training, and policy change are required to enable their translation to clinical practice.

A systematic review of vestibular stimulation in post-stroke visual neglect

Unilateral visual neglect is a condition that negatively impacts the lives of many stroke survivors. Studies have investigated different forms of vestibular stimulation as a potential therapy, but evidence is yet to be systematically reviewed. We therefore reviewed the effects of vestibular stimulation on outcomes of neglect and activities of daily living (ADL) for people with visual neglect. We searched relevant databases up until September 2022. Eligible articles included any form of vestibular stimulation, study design, or control condition. Included participants were 18 years or older, presenting with neglect following a haemorrhagic or ischaemic stroke. Relevant outcomes were clinically validated measures of neglect and ADL. Cochrane risk of bias tools were used to assess study quality. Meta-analyses and narrative methods were used to synthesize the data. Our search returned 17 relevant studies comprising 180 participants. Meta-analyses showed no difference between galvanic vestibular stimulation and sham conditions on outcomes, whereas caloric vestibular stimulation led to improvement compared to pre-stimulation scores. Narrative syntheses showed mixed results. Clinical and methodological heterogeneity was found both within and between studies. Overall, results were inconsistent regarding the effects of vestibular stimulation as a treatment for neglect. Further trials are warranted but require more careful methodological planning.

A bibliometric review of unilateral neglect: Trends, frontiers, and frameworks

BACKGROUND

Owing to the adverse effects of unilateral neglect (UN) on rehabilitation outcomes, fall risk, and activities of daily living, this field has gradually got considerable interest. Notwithstanding, there is presently an absence of efficient portrayals of the entire research field; hence, the motivation behind this study was to dissect and evaluate the literature published in the field of UN following stroke and other nonprogressive brain injuries to identify hotspots and trends for future research.

MATERIALS AND METHODS

Original articles and reviews related to UN from 1970 to 2022 were retrieved from the Science Citation Index Expanded of the Web of Science Core Collection. CiteSpace, VOSviewer, and Bibliometrix software were used to observe publication fields, countries, and authors.

RESULTS

A total of 1,202 publications were incorporated, consisting of 92% of original articles, with an overall fluctuating upward trend in the number of publications. Italy, the United Kingdom, and the United States made critical contributions, with Neuropsychologia being the most persuasive academic journal, and Bartolomeo P. ranked first in both the quantity of publications and co-citations. Keywords were divided into four clusters, and burst keyword detection demonstrated that networks and virtual reality might additionally emerge as frontiers of future development and warrant additional attention.

CONCLUSIONS

UN is an emerging field, and this study presents the first bibliometric analysis to provide a comprehensive overview of research in the field. The insights and guidance garnered from our research on frontiers, trends, and popular topics could prove highly valuable in facilitating the rapid development of this field while informing future research directions.

Identifying Spatial Neglect in Chronic Right Hemisphere Stroke Survivors Using the RHDBank Outcomes

PURPOSE

The chronicity of spatial neglect (SN) and the utility of existing diagnostic measures used by speech-language pathologists remain poorly understood. In this retrospective study, we examined how the RHDBank test battery informs the identification of SN after right hemisphere brain damage (RHD) during the chronic phase of recovery.

METHOD

Data from 29 right hemisphere stroke survivors were extracted from the RHDBank, including SN tests, for which we performed laterality index scoring: a 51-item demographic survey, the Apples Test, the Indented Paragraph Test, and the clock drawing task from the Cognitive Linguistic Quick Test (CLQT). Two groups (SN+ and SN-) were identified using the Apples Test. A hierarchical cluster analysis explored CLQT performance clusters in association with SN, and group comparisons of demographic variables and test scores were conducted.

RESULTS

Ten patients were identified as having SN+ (34%) using the Apples Test. The Indented Paragraph Test and the CLQT's clock drawing test identified only two of the 20 stroke survivors with SN+. Cluster analyses showed that domain and task scores on the CLQT carried information to classify participants into SN+ and SN- in concordance with performance on the Apples Test. Participants in the SN+ cluster had moderately impaired attention and executive function skills and mildly impaired visuospatial skills.

CONCLUSIONS

The Apples Test differentiated SN in a group of chronic right hemisphere stroke survivors. Using multiple measures from the CLQT seemed to capture a greater range of problems than clock drawing and paragraph reading tests alone. Therefore, the RHDBank test battery as a whole-and in part the CLQT, Apples Test, and Indented Paragraph Test-can detect certain subtypes of SN in the chronic deficit profile after RHD and is a starting point for diagnostic integration by speech-language pathologists.

An immersive virtual reality tool for assessing left and right unilateral spatial neglect

The reported rate of the occurrence of unilateral spatial neglect (USN) is highly variable likely due to the lack of validity and low sensitivity of classical tools used to assess it. Virtual reality (VR) assessments try to overcome these limitations by proposing immersive and complex environments. Nevertheless, existing VR-based tasks are mostly focused only on near space and lack analysis of psychometric properties and/or clinical validation. The present study evaluates the clinical validity and sensitivity of a new immersive VR-based task to assess USN in the extra-personal space and examines the neuronal correlates of deficits of far space exploration. The task was administrated to two groups of patients with right (N = 28) or left (N = 11) hemispheric brain lesions, also undergoing classical paper-and-pencil assessment, as well as a group of healthy participants. Our VR-based task detected 44% of neglect cases compared to 31% by paper-and-pencil tests in the total sample. Importantly, 30% of the patients (with right or left brain lesions) with no clear sign of USN on the paper-and-pencil tests performed outside the normal range in the VR-based task. Voxel lesion-symptom mapping revealed that deficits detected in VR were associated with lesions in insular and temporal cortex, part of the neural network involved in spatial processing. These results show that our immersive VR-based task is efficient and sensitive in detecting mild to strong manifestations of USN affecting the extra-personal space, which may be undetected using standard tools.

Impact of Spatial Neglect on Activity and Participation: A Mixed-Methods Study

Post-stroke neglect is disabling, yet it is unclear whether existing assessments capture the extent neglect affects activity and participation. The objective of the study is to explore stroke survivor and caregiver perspectives on how neglect affects activity and participation and to compare their experiences to neglect assessments items. We conducted an explanatory sequential mixed-methods study by conducting semi-structured interviews with stroke survivors (n = 7) and caregivers (n = 7) analyzed using thematic analysis. Stroke survivors completed the Catherine Bergego Scale (CBS) and Behavioral Inattention Test (BIT). Descriptive analyses characterized participant's neglect. The standardized CBS and BIT tests indicated that stroke survivors demonstrated mild-to-moderate (CBS) or no-to-mild (BIT) neglect. In contrast, the qualitative data revealed serious safety concerns and significant ongoing difficulties participating in school, work, and family activities because of neglect. Current assessments may not measure the impact of neglect on activity or participation in life for stroke survivors.

Clinical and demographic predictors of unilateral spatial neglect recovery after prism therapy among stroke survivors in the sub-acute phase of recovery

BACKGROUND AND AIMS: Unilateral Spatial Neglect (USN) affects the rehabilitation process and leads to poor outcomes after stroke. Factors that influence USN recovery following prism adaptation therapy have not been investigated. This study investigated predictors of USN recovery after prism therapy at the sub-acute phase of recovery. METHODS: This study was a randomized controlled trial. USN was assessed with the Behavioural Inattention Test and Catherine Bergego scale. Seventy-four patients with USN were divided into control and intervention group (prism). The prism group used 20 dioptre prism lenses for repeated aiming for 12 sessions while the control group used neutral lenses for aiming training. Regression analysis was conducted to establish clinical and sociodemographic factors that influence USN recovery. RESULTS: Gender, age, years of education, race, employment status, handedness, type of stroke, time since stroke and site of stroke (p > 0.005) showed no significant influence on USN recovery following PA treatment. Higher Cognitive function (OR  = 1.52, CI = 1.08-2.14, p =  0.016) and group allocationng (being in the prism group) (OR = 63.10, CI =  9.70-410.59, P < 0.001) were found to significantly influence USN recovery following PA treatment session. CONCLUSIONS: A significant modulating effect on general cognitive ability was found in this study. This suggests that prism adaptation therapy's effect on neural activity and spatial neglect depends on the cognitive function of stroke survivors.Trial registration: Pan African Clinical Trial Registry identifier: PACTR201903732473573.

Prevalence, Severity and Impact of Visuospatial Neglect in Geriatric Stroke Rehabilitation, a Cross-Sectional Study

OBJECTIVES

Visuospatial neglect (VSN) is a common cognitive deficit of lateralized attention after stroke and can have a negative influence on patients' daily activities, community participation, and caregiver burden. VSN prevalence has been investigated in several mixed-age populations, but rarely in only an older population. As the population in geriatric rehabilitation (GR) is understudied and VSN may influence rehabilitation goals in GR (return home), we examined the prevalence of VSN as well as associations between VSN (severity) and population characteristics and the impact of VSN on functioning, length of stay, and discharge destination after GR.

DESIGN

Multicenter cross-sectional study.

SETTING AND PARTICIPANTS

Stroke patients admitted to GR.

METHODS

Three VSN tests (Star cancelation task, Line bisection task, and Catherine Bergego Scale) were administered in the first 2 weeks of GR admission. To examine VSN severity, a composite score was calculated based on scores of the 3 tests.

RESULTS

A total of 114 stroke patients were included [55.3% female; mean age 80.2 (SD 8.0) years]. VSN prevalence was 47.4%, in which allocentric and egocentric neglect were more prevalent than VSN during activities of daily living. Participants with VSN spent more days in GR compared to participants without VSN (median 68.5 vs 35.5 days) and had fewer home returns. In addition, VSN participants showed less mobility, lower cognitive functioning, and less independence during self-care compared to participants without VSN. Mobility, self-care, cognition, duration of rehabilitation, and home return were negatively associated with VSN severity.

CONCLUSIONS AND IMPLICATIONS

VSN is very prevalent in the GR stroke population. VSN severely hampers older people during daily activities and their rehabilitation process and, therefore, has a major personal and societal impact. Accordingly, systematic assessment of VSN in the early phase of geriatric rehabilitation with multiple VSN screening tests is recommended.

Association of delirium and spatial neglect in patients with right-hemisphere stroke

BACKGROUND

Delirium, an acute and fluctuating decline in cognitive functioning, increases mortality and length of hospital stays (LOS) and adversely affects functional outcomes. Previous studies suggested that the incidence of delirium may be increased in right-hemisphere strokes. Similarly, spatial neglect, a disabling deficit in unilateral spatial processing, is more common and more severe following a right-sided stroke. Spatial neglect has been established as a risk factor for delirium.

OBJECTIVE

It was hypothesized that functionally relevant spatial neglect and delirium are associated in patients with right-hemisphere stroke during acute inpatient rehabilitation. Data were examined from consecutive unilateral stroke patients evaluated with the 3-minute diagnostic interview for confusion assessment method (3D-CAM) and the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP).

DESIGN

A retrospective, cohort study.

SETTING

Data collected in an acute inpatient rehabilitation facility.

PARTICIPANTS

Six hundred twenty six patients with stroke were included.

MAIN OUTCOME MEASURES

The measures were the relative risk of patients with right-hemisphere stroke having delirium when also positive for spatial neglect compared to patients with right-hemisphere stroke without spatial neglect, the incidence of 3D-CAM positive results by stroke hemisphere, and the effect of spatial neglect and delirium on functional outcomes for patients with right-brain stroke patients.

RESULTS

There was a significantly higher risk of delirium in patients with right-hemisphere stroke with spatial neglect compared to patients with right-hemisphere stroke without spatial neglect. The rates of 3D-CAM positive results were not statistically different for left- compared to right-hemisphere strokes. Both delirium and spatial neglect had significant adverse effects on right-hemisphere stroke patients' functional independence.

CONCLUSIONS

The results demonstrate an association between spatial neglect and delirium in patients with right hemisphere stroke in the acute inpatient rehabilitation setting. Because of the negative effect of these impairments on functional outcomes after stroke, prevention, early detection, and targeted treatments should be prioritized for these patients.

Treating Visual Inattention in Acute Stroke Survivors Using a Therapy Scanning Wall: A Proof-of-Concept Study

Background

Visual inattention is common following right hemisphere stroke, with up to 80% of patients being affected. Visual inattention following stroke is linked to poorer outcomes. There is no clear evidence for how visual inattention should be treated in the hospital inpatient setting.

Objective

To explore the practical implications and possible benefits of using a visual scanning wall in a stroke rehabilitation unit as an assessment and treatment tool for visual inattention.

Methods

This proof-of-concept study recruited stroke survivors with visual inattention. Participants used the scanning wall for scanning training five days a week for two weeks. Assessments using the scanning wall and modified Albert's test were conducted at baseline and at day 14. Both participants and staff delivering the training were asked to complete an acceptability questionnaire.

Results

All participants demonstrated an improvement in the number of pictures identified from baseline to day 14. There was a mean improvement of 9.20 (95% CI 4.77 to 13.63) in the 14 days. This is a statistically significant improvement in the scanning wall score between baseline line and day 14 (p = 0.01). All participants and staff reported the scanning wall as acceptable to use.

Conclusion

This proof-of-concept study has demonstrated the scanning wall could be used to assess for visual inattention in extra personal space. Also, it could be beneficial and is acceptable for the treatment of visual inattention within a hospital inpatient setting for acute stroke survivors.

Standardization of apple cancellation test for neglect patients in Korea: An observational study

BACKGROUND

Neglect can be divided into two types using apple cancellation test (apple test): Egocentric neglect (EN) and allocentric neglect (AN). However, in South Korea, apple test results and decision criteria are still largely dependent on tests by foreign countries.

AIM

To establish a new South Korea standard and improve the accuracy of neglect assessment, the apple experiment was standardized in this study.

METHODS

This study was conducted on 223 healthy subjects for a total of 7 mo from August 2021 to February 2022. Standardization was carried out using the original apple test developed by Bickerton in 2011. In scoring for the apple test, total omission error refers to the number of missed targets (full apple) in the entire test sheet (left, middle, and right area). The score for EN is the difference between the cor-rect number of right area and the correct number of left area (excluding the middle area). For AN, the score is difference between the number of left opening apples and number of right opening apples (including the middle area). Linear regression analysis was used for standardization using the general characteristics of subjects and the results of the apple test.

RESULTS

The cut-off score, which is the standard value indicating the pathological condition by combining the results of all subjects, is as follows: Total omission error (5), error for EN (2), and error for AN (2). Also, differences in cut-off score according to age were found.

CONCLUSION

This study will be helpful in facilitating a more accurate differential diagnosis of neglect.

Standardization of apple cancellation test for neglect patients in Korea: An observational study

BACKGROUND

Neglect can be divided into two types using apple cancellation test (apple test): Egocentric neglect (EN) and allocentric neglect (AN). However, in South Korea, apple test results and decision criteria are still largely dependent on tests by foreign countries.

AIM

To establish a new South Korea standard and improve the accuracy of neglect assessment, the apple experiment was standardized in this study.

METHODS

This study was conducted on 223 healthy subjects for a total of 7 mo from August 2021 to February 2022. Standardization was carried out using the original apple test developed by Bickerton in 2011. In scoring for the apple test, total omission error refers to the number of missed targets (full apple) in the entire test sheet (left, middle, and right area). The score for EN is the difference between the cor-rect number of right area and the correct number of left area (excluding the middle area). For AN, the score is difference between the number of left opening apples and number of right opening apples (including the middle area). Linear regression analysis was used for standardization using the general characteristics of subjects and the results of the apple test.

RESULTS

The cut-off score, which is the standard value indicating the pathological condition by combining the results of all subjects, is as follows: Total omission error (5), error for EN (2), and error for AN (2). Also, differences in cut-off score according to age were found.

CONCLUSION

This study will be helpful in facilitating a more accurate differential diagnosis of neglect.

Digital Therapeutics for the Egocentric and Allocentric Neglects in Patients with Brain Injury: A Mini Review

Various therapeutic approaches have been developed for neglect. Many studies have demonstrated the effect of digital therapeutics (DTx) on neglect. However, few studies have reported the effects of DTx on egocentric and allocentric neglect. The differentiation of types of neglect and separate interventions is crucial in the rehabilitation process. In this article, seven studies on DTx on egocentric and allocentric neglect were reviewed. DTx, which was employed in these studies, could be classified as follows: (1) software adaptation in traditional treatment, (2) VR game using the head-mount display as treatment, and (3) the development of a new digital program like ReMoVES. In addition, more studies and more effective results were reported for egocentric neglect than for allocentric neglect. In future studies, each effect on egocentric and allocentric neglect should be identified in detail with the appropriate use of differential evaluation and long-term application of independent DTx.

Recombination of the right cerebral cortex in patients with left side USN after stroke: fNIRS evidence from resting state

Objective

Unilateral spatial neglect (USN) is an impaired contralesional stimulus detection, response, or action, causing functional disability. After a stroke, the right hemisphere experiences USN more noticeably, severely, and persistently than the left. However, few studies using fNIRS have been reported in cases of USN. This study aimed to confirm weaker RSFC in USN and investigate the potential inherent features in hemodynamic fluctuations that may be associated with USN. Furthermore, these features were combined into a mathematical model for more accurate classification.

Methods

A total of 33 stroke patients with right-sided brain damage were chosen, of whom 12 had non-USN after stroke, and 21 had USN after stroke (the USN group). Graph theory was used to evaluate the hemodynamic signals of the brain's right cerebral cortex during rest. Furthermore, a support vector machine model was built to categorize the subjects into two groups based on the chosen network properties.

Results

First, mean functional connectivity was lower in the USN group (0.745 ± 0.239) than in the non-USN group (0.843 ± 0.254) (t = -4.300, p < 0.001). Second, compared with the non-USN group, USN patients had a larger clustering coefficient (C) (t = 3.145, p < 0.001), local efficiency (LE) (t = 3.189, p < 0.001), and smaller global efficiency (GE) (t = 3.047, p < 0.001). Notably, there were differences in characteristic path length (L) and small worldness (σ) values between the two groups at certain thresholds, mainly as higher L (t = 3.074, p < 0.001) and lower small worldness (σ) values (t = 2.998, p < 0.001) in USN patients compared with non-USN patients. Finally, the classification accuracy of the SVM model based on AUC aC (t = -2.259, p = 0.031) and AUC aLE (t = -2.063, p = 0.048) was 85%, the sensitivity was 75%, and the specificity was 89%.

Conclusion

The functional network architecture of the right cerebral cortex exhibits significant topological alterations in individuals with USN following stroke, and the sensitivity index based on the small-world property AUC may be utilized to identify these patients accurately.

Predicting Falls in Rehabilitation: A Comparison of Three Instruments Including Hester Davis

PURPOSE

The aim of this study was to evaluate the ability of the Hester Davis Scale (HDS), Section GG, and facility fall risk assessment scores to predict patients who fall during inpatient rehabilitation.

DESIGN

This study is an observational quality improvement project.

METHODS

Nurses administered the HDS in parallel to the facility's current fall risk assessment and Section GG of the Centers for Medicare & Medicaid Services Inpatient Rehabilitation Facility Patient Assessment Instrument. Receiver operating characteristic curves were compared in 1,645 patients. Relationships of individual scale items to falls were also assessed.

RESULTS

The HDS (area under the curve [AUC] = .680, 95% CI [.626, .734]), facility fall risk assessment (AUC = .688, 95% CI [.637, .740]), and Section GG scores (AUC = .687, 95% CI [.638, .735]) adequately identified patients who fell. AUCs did not significantly differ between assessments. HDS scores of ≥13, facility scores of ≥14, and Section GG scores of ≤51 resulted in the highest sensitivity/specificity balance.

CONCLUSIONS

HDS, facility fall risk assessment, and Section GG scores adequately and similarly identified patients of mixed diagnoses at risk of falling in inpatient rehabilitation.

CLINICAL RELEVANCE TO THE PRACTICE OF REHABILITATION NURSING

Rehabilitation nurses have several options including the HDS and Section GG to identify patients at greatest risk of falling.

Gait asymmetry in stroke patients with unilateral spatial neglect

The recovery of independent gait represents one of the main functional goals of the rehabilitative interventions after stroke but it can be hindered by the presence of unilateral spatial neglect (USN). The aim of the paper is to study if the presence of USN in stroke patients affects lower limb gait parameters between the two body sides, differently from what could be expected by the motor impairment alone, and to explore whether USN is associated to specific gait asymmetry. Thirty-five stroke patients (right or left lesion and ischemic or hemorrhagic etiology) who regained independent gait were assessed for global cognitive functioning and USN. All patients underwent a gait analysis session by using a wearable inertial system, kinematic parameters were computed. Enrolled patients presented altered motion parameters. Stroke patients with USN showed specific asymmetries in the following parameters: stance phase, swing phase, and knee range of motion. No differences in the clinical scores were found as the presence of USN. The presence of USN was associated with a specific form of altered gait symmetry. These findings may help clinicians to develop more tailored rehabilitative training to enhance gait efficacy of patients with motor defects complicated by the presence of selected cognitive impairments. Overview of the experiment setup. The workflow shows: diagnosis of unilateral spatial neglect by the neuropsychologist, sensors placement, gait analysis protocol and evaluation of the gait asymmetry together with the statistically significant features.

Combined optokinetic stimulation and cueing-assisted reading therapy to treat hemispatial neglect: A randomized controlled crossover trial

BACKGROUND

Hemispatial neglect is a disabling cognitive disorder following stroke and effective therapies are required.

OBJECTIVES

To evaluate the effects of combined optokinetic stimulation (OKS) and cueing-assisted reading therapy (READ) on the remission of hemispatial neglect following stroke.

METHODS

Randomized, controlled, two-period, crossover trial conducted at a German neurorehabilitation center. Twenty participants with left neglect following right hemispheric stroke (mean age 66 years (SD 11), mean time since stroke 50 days (SD 33)) finished the trial (12 received OKSREAD first, 8 CONTROL first). The intervention consisted of 15 daily sessions of OKS (20 min) and text reading assisted by a therapist providing cues (20 min). The control treatment was a same-number, same-length neuropsychological treatment not targeting visuospatial attention. Primary outcomes were the change in performance of a customized neuropsychological test battery for neglect (0% worst - 100% best) and a test of neglect-related functional disability (Catherine Bergego Scale, 0 no impairment - 30 severest impairment), assessed before and after each treatment period. Secondary outcomes were performance in the 6 single tests composing the battery (e.g., omissions in text reading, center of cancellation in the Bells test, spatial bias of fixations when freely viewing photographs) and a clinical test of anosognosia.

RESULTS

Overall performance in the neglect test battery improved slightly more after OKSREAD than after CONTROL (d=6%; p=0.002). The remission of neglect-related functional disability did not differ between treatments (d=-2; p=0.291). Ipsilesional fixation bias during free viewing was the only secondary outcome that was improved by OKSREAD as compared to CONTROL (d= -2.8°; p=0.005).

CONCLUSION

At the applied intensity, the combined OKSREAD intervention slightly attenuated the ipsilesional attention bias in persons with neglect, but it did not improve neglect-related functional disability, anosognosia, or other neglect symptoms to a clinically meaningful degree.

CLINICAL TRIAL REGISTRATION

URL: http://www.

CLINICALTRIALS

gov. Unique identifier: NCT04273620.

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.

A validity study to consult on a protocol of a home hazard management program for falls prevention among community dwelling stroke survivors

OBJECTIVE

A fall after a stroke is common but the consequences can be devastating not only for the stroke survivors, but also for caregivers, healthcare, and the society. However, research on falls prevention among the stroke population are limited, particularly on home hazards assessment and home modifications, demanding for a study to be conducted. The aim of the study is to validate the protocol and content of a home hazard management program guided by the Person-Environment-Occupation (PEO) Model for falls prevention among community dwelling stroke survivors.

METHOD

Researchers developed their own questionnaire for content validation which consist of 23 items that covers two domains, namely justification for telehealth home hazard management practice and the protocol's overall methodology. Occupational therapists with at least one year of experience in conducting a home hazard assessment were consulted for the content validation of a two-group clinical controlled trial protocol utilizing a home hazard assessment, home modifications and education over the usual care. Written consent was obtained prior to the study. The occupational therapists were given a Google Form link to review the protocol and intervention based on the questionnaire and rated each item using a four-point Likert scale for relevance and feasibility. Open-ended feedback was also recorded on the google form. Content Validity Index (CVI), Modified Kappa Index and Cronbach's Alpha was calculated for the content validity and reliability analysis.

RESULTS

A total of sixteen occupational therapists participated in the study. 43.7% of participants had a master's degree, 93.7% worked in the government sector and 56.2% had six years and more experience on conducting home hazard assessments. Content validity of the protocol is satisfactory for relevancy and feasibility (CVI = 0.84, ranging from 0.5 to 1.00), and for the reliability (α = 0.94 (relevance) and α = 0.97 (feasibility), respectively. The Modified Kappa ranged from 0.38 to 1.00 for all items. Feedback was also received regarding the design and procedure of the study protocol which included participant's selection criteria, sample size, equipment provided, cost, location, and care for the participants during the intervention.

CONCLUSIONS

Introducing a home hazard management program to prevent falls among the stroke population is viewed relevant and feasible. Practical suggestions from the consultation panel were adopted, and minor adjustments were required to strengthen the protocol's overall methodology. This study established a rigorous and robust experimental protocol for future undertaking.

Anosognosia for Hemiplegia and Falls After Stroke: A Prospective Correlational Study

PURPOSE

The aim of this study was to explore the association between the presence and severity of anosognosia for hemiplegia (AHP) and falls in stroke survivors.

DESIGN

A prospective, correlational research design was utilized.

METHODS

Primary instrumentation included demographic information and the Visual-Analogue Test for Anosognosia for motor impairment (VATA-m). Correlational and regression analyses were performed between a priori variables.

RESULTS

There was no statistically significant relationship found between AHP and falls. An incidental finding included that clinicians erroneously charted that their patients were aware of their physical limitations 100% of the time, which indicates that there is discord between clinicians and patients regarding physical limitations.

CONCLUSIONS

Though no statistically significant relationship was found between AHP and falls, the incidental finding of dissonance between the patient and the clinician has important clinical implications.

RELEVANCE

The relationship between AHP and stroke rehabilitation outcomes is still not understood, and incorporating part of the VATA-m into patient assessment could improve clinician understanding of patient awareness.

Prism adaptation treatment improves spatial neglect after severe traumatic brain injury: A case series

BACKROUND

Spatial neglect (SN) after traumatic brain injury (TBI) is common, hindering rehabilitation progress and functional outcomes. Most research has focused on SN treatment after stroke with few published instances of post-TBI SN treated using prism adaptation treatment (PAT) in inpatient rehabilitation.

OBJECTIVE

This case series characterizes the dose, after-effect, and treatment response of PAT in patients with SN after severe TBI.

METHODS

Six patients exhibiting severe (n = 2), moderate (n = 2), or mild (n = 2) SN after severe TBI received 5 to 10 PAT sessions during their inpatient rehabilitation stay. Functional improvement in SN was measured by the Catherine Bergego Scale (CBS).

RESULTS

Patients presented with a mean initial CBS score of 16.8 (range: 8.8-24.3). Prism after-effect was present after PAT. Following 5-10 sessions, the mean CBS score improved by 11.6 points to 5.2 (range: 7.8-21.8); the change in initial versus final CBS scores was significant (P = 0.031).

CONCLUSION

This study is the first to demonstrate prism after-effect and functional SN improvement in individual patients with TBI. Patients showed a clinically meaningful improvement in mild, moderate, and severe SN following 5 to 10 PAT sessions. Additional studies are needed to assess tolerability, benefit, and optimal PAT dose for SN after TBI.

Effects of standing and walking training using a laser pointer based on stimulus-driven attention for behavioural outcome in spatial neglect: A single-case study

The therapy for unilateral spatial neglect (USN) is unclear. This case report investigated the effect of standing and walking training using a laser pointer based on stimulus-driven attention for USN. The patient was a right-handed 79-year-old man with cardiogenic cerebral embolism in the right middle and posterior cerebral arteries. Initially, we evaluated the absence of hemiparalysis in the lower limb and sensory disorder; almost all daily activities were performed independently. Intervention effects were verified using the BABA method. The course of the four phases (B1, A1, B2, A2) was conducted for 5 days. In the B1 and B2 phases, standing and walking training using a laser pointer was performed additionally to conventional physical therapy. Outcomes were measured using the Behavioural Inattention Test conventional subtest (BIT-c), Catherine Bergego Scale (CBS), and modified Posner task (MPT). The BIT-c remained unchanged in each phase. CBS scores improved after B1 and B2. In the MPT, the reaction time in the left space reduced after B1 and B2 compared with those in the A1 and A2 control phases. In this case, training may have contributed to the improvement in the response to the neglected space and behavioural assessment of USN.

Exploring the Potential of Immersive Virtual Reality in the Treatment of Unilateral Spatial Neglect Due to Stroke: A Comprehensive Systematic Review

The present review aims to explore the use of Immersive Virtual Reality (IVR) in the treatment of visual perception in Unilateral Spatial Neglect (USN) after a stroke. PubMed, Scopus, Embase and Pedro databases were searched, from inception to 1 February 2022. All studies that investigated the effect of IVR on USN, such as outcome in the stroke population, have been included. The current comprehensive systematic review was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations and was registered in the PROSPERO database [CRD42022311284]. Methodological quality was assessed through JBI critical appraisal tool. A total of 436 articles were identified through the database searches. A total of 10 articles, with a heterogeneous study design, which involved 77 patients with USN with low-to-moderate methodological quality, have been selected. Five out the included studies tested usability of IVR for assessed or treated visual perception deficits in USN, comparing the results with 134 healthy subjects. In the rest of studies that tested IVR such as treatment, three showed statistical positive results (p < 0.05) in visual perception outcome. To date, the literature has suggested the potential benefits in the use of IVR for the treatment of visual perception disorders in USN. Interestingly, IVR motivates patients during the rehabilitation process improving compliance and interest. The heterogeneity in the studies’ design and in IVR treatments indicate the need of future investigations in the consideration of potentiality and low-cost of this technology.

Development and 5-year Evaluation of Diagnosis-Specific Protocols for Visual Neuro-Rehabilitation in a Multicenter Inpatient Rehabilitation Network

Objective

To provide a retrospective evaluation of a new eye and vision rehabilitation care pathway in a U.S. multi-site inpatient rehabilitation network involving the occupational therapy (OT) staff and a consulting doctor of optometry (OD) specializing in vision rehabilitation.

Design

Retrospective study.

Setting

Two Inpatient Rehabilitation Facilities (IRFs) and 1 Long Term Acute Care Hospital (LTACH).

Participants

There were 2083 records reviewed (44% women, avg. age 59 years). The most common diagnoses were hemispatial neglect (19.2%), homonymous field defects (18.5%), and oculomotor cranial nerve palsies (16.7%) (N=2083).

Interventions

Clinical care was reviewed where diagnosis-specific protocols were developed and training was provided to OTs in order to reinforce OD-prescribed interventions during daily treatment sessions, including (1) third, fourth, and sixth ocular cranial nerve palsies (OCNPs) with prisms fitted for full time, postural adaptation training, and oculomotor re-education using pursuits, saccades, head-rotations, and binocular vision exercises including alternate cover and vergence; (2) homonymous hemianopia with training awareness of field loss, eccentric viewing, and fitting of Peli lens for optical field expansion; and (3) prism adaptation therapy (PAT) for left hemispatial neglect.

Main Outcome Measures

Frequency of diagnoses.

Hypothesis

Diagnoses with developed protocols were most common. Secondarily, feasibility and efficacy by anonymous OT survey.

Results

2083 vision consults were performed over 5 years. The most common diagnoses were hemispatial neglect (n=399, 19.2%), homonymous field defects (n=386, 18.5%), and OCNPs (n=347, 16.7%). None of the OTs reported the protocols were infeasible and 63% (IQR 38%-69%) reported their patients benefited from the interventions. The survey suggested prism for OCNPs helped in 42%, and Peli lens and PAT both helped in 38%.

Conclusions

Data support the feasibility of this inpatient eye and vision rehabilitation care pathway which may be used as a foundation for creating or refining similar programs elsewhere. Uniform administration of IRF-based visual neuro-rehabilitation care could provide a substrate for future clinical trials to evaluate efficacy.

Right Unilateral Spatial Neglect Improves with Intrinsic Motivation

Background. In the acute phase of stroke, it is well known that the incidence and severity of unilateral spatial neglect (USN) are more significant in the right hemisphere injuries. Still, the detection of USN in left hemisphere injuries has been increasing in recent years. This trend is because behavioral assessments have prevented the exclusion of patients who are difficult to assess for USN or apathy using conventional paper-and-pencil tests (e.g., aphasia). Right USN and post-stroke apathy share many common lesions. Therefore, clinical symptoms may overlap, but little validation considers this. Case Study. A man (62 years old) determined to have the right USN and apathy was treated for six weeks in 3 terms. In the first term (weeks 1 to 2), the patient was treated for the right USN by conventional therapy. In the second term (3–4 weeks), treatment for right USN and apathy by goal-directed therapy based on affinity behavior was implemented. In the third term (5–6 weeks), goal-directed therapy based on affinity behavior was discontinued, and treatment was returned to conventional therapy only. In the second term (goal-directed therapy based on affinity behavior), the improvement in patients' apathy (clinical assessment for spontaneity) was more significant than the effect size in the third term (conventional therapy). There were no significant differences in USN (catherine bergego scale) and intrinsic motivation (pittsburgh rehabilitation participation scale). However, the effect size in the second term tended to be larger than in the third term (conventional therapy). Clinical Rehabilitation Impact. This report aims to demonstrate the limitations of current treatment for cases determined to have both right USN and apathy. Second, to assess the extent to which this new intervention can complement the limitations of current treatment.

Prism Adaptation Treatment Predicts Improved Rehabilitation Responses in Stroke Patients with Spatial Neglect

Spatial neglect (SN) impedes functional recovery after stroke, leading to reduced rehabilitation gains and slowed recovery. The objective of the present study was to investigate whether integrating prism adaptation treatment (PAT) into a highly intensive rehabilitation program eliminates the negative impact of spatial neglect on functional and motor recovery. We examined clinical data of the 355 consecutive first-time stroke patients admitted to a sub-acute inpatient neurorehabilitation program that integrated PAT. The 7-item Motor Functional Independence Measure, Berg Balance Scale, and Motor Activity Log were used as main outcome measures. We found that 84 patients (23.7%) had SN, as defined by a positive score on the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (KF-NAP^®). Although 71 patients (85%) received PAT, the presence of SN at baseline, regardless of PAT completion, was associated with lower functional independence, higher risk of falls, and a lower functional level of the affected upper limb both at admission and at discharge. The severity of SN was associated with inferior rehabilitation outcomes. Nonetheless, patients with SN who received PAT had similar rehabilitation gains compared to patients without SN. Thus, the present study suggests that integrating PAT in an intensive rehabilitation program will result in improved responses to regular therapies in patients with SN.

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.

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.

The unilateral hemispatial neglect phenomenon in right hemiplegia

One of the most important perceptual function disorders following a cerebrovascular accident (CVA) is the unilateral hemispatial neglect phenomenon (UHNP). In this case report, we present a 73-year-old male patient with UHNP accompanying right hemiplegia, which was identified with detailed examination. Clinical picture was characterized by right-sided hemiparesis in the upper right shoulder and relative weakness in the right leg. Patient was tested on hemineglect (HN) with star cancellation test and detailed neuropsychological evaluation. This article highlight the latest findings regarding the cognitive–behavioral syndrome of neglect for hemiplegia that occur following left hemisphere stroke.

Assessment tools for differential diagnosis of neglect: Focusing on egocentric neglect and allocentric neglect

BACKGROUND

There are very few studies on the differential diagnosis between egocentric neglect (EN) and allocentric neglect (AN).

AIM

To investigate the overall trend of the previously developed assessment tools by conducting a descriptive review of the studies on assessment tools that can perform a differential diagnosis of EN and AN.

METHODS

The data were collected by using databases such as Google Scholar, PubMed, and ScienceDirect. The most commonly used search terms were “neglect”, “stroke”, “egocentric neglect”, and “allocentric neglect”.

RESULTS

A total of seven studies that met the inclusion criteria were selected and analyzed. We were able to confirm the research process, test method, and differential diagnosis criteria of the seven presented assessment tools from four studies on paper-based tests and three studies on computerized tests. The majority of the tests were carried out via the cancellation method using stimuli such as everyday objects or numbers. EN distinguished the left from right based on the test paper, while AN distinguished the left from right based on stimuli. In order to perform differential diagnosis, the difference in the number of left and right responses or non-responses was used based on the EN and AN criteria.

CONCLUSION

It was confirmed that all the seven assessment tools can effectively perform differential diagnosis of EN and AN. This study may provide important data that can be used in clinical practice for differential diagnosis and future intervention planning for neglect patients.

Computer-based assessment of unilateral spatial neglect: A systematic review

Background

To date, no gold standard exists for the assessment of unilateral spatial neglect (USN), a common post-stroke cognitive impairment, with limited sensitivity provided by currently used clinical assessments. Extensive research has shown that computer-based (CB) assessment can be more sensitive, but these have not been adopted by stroke services yet.

Objective

We conducted a systematic review providing an overview of existing CB tests for USN to identify knowledge gaps and positive/negative aspects of different methods. This review also investigated the benefits and barriers of introducing CB assessment tasks to clinical settings and explored practical implications for optimizing future designs.

Methodology

We included studies that investigated the efficacy of CB neglect assessment tasks compared to conventional methods in detecting USN for adults with brain damage. Study identification was conducted through electronic database searches (e.g., Scopus), using keywords and standardized terms combinations, without date limitation (last search: 08/06/2022). Literature review and study selection were based on prespecified inclusion criteria. The quality of studies was assessed with the quality assessment of diagnostic accuracy studies tool (Quadas-2). Data synthesis included a narrative synthesis, a table summarizing the evidence, and vote counting analysis based on a direction of effect plot.

Results

A total of 28 studies met the eligibility criteria and were included in the review. According to our results, 13/28 studies explored CB versions of conventional tasks, 11/28 involved visual search tasks, and 5/28 other types of tasks. The vote counting analysis revealed that 17/28 studies found CB tasks had either equal or higher sensitivity than conventional methods and positive correlation with conventional methods (15/28 studies). Finally, 20/28 studies showed CB tasks effectively detected patients with USN within different patient groups and control groups (17/28).

Conclusions

The findings of this review provide practical implications for the implementation of CB assessment in the future, offering important information to enhance a variety of methodological issues. The study adds to our understanding of using CB tasks for USN assessment, exploring their efficacy and benefits compared to conventional methods, and considers their adoption in clinical environments.

Neural substrates in patients with visual-spatial neglect recovering from right-hemispheric stroke

Visual-spatial attention disorder after stroke seriously affects recovery and quality of life in stroke patients. Previous studies have shown that some patients recovery rapidly from visual-spatial neglect (VSN), but the brain networks underlying this recovery are not well understood. Using functional magnetic resonance imaging, we aimed to identify network differences between patients who rapidly recovered from VSN and those with persistent VSN. The study included 30 patients with VSN who suffered subacute stroke. Patients were examined 2–4 weeks after stroke onset and 4 weeks after the initial assessment. At the last evaluation, patients in the persistent VSN (n = 15) and rapid recovery (n = 15) groups underwent paper-and-pencil tests. We defined the bilateral frontal eye fields, bilateral intraparietal sulcus in the dorsal attention network, and right temporoparietal junction and ventral frontal cortex areas in the ventral attention network as regions of interest (ROI) and measured whole-brain ROI-based functional connectivity (FC) and amplitude of low-frequency fluctuations (ALFF) in subacute right-hemisphere stroke patients. VSN recovery was associated with changes in the activation of multiple bilateral attentional brain regions. Specifically, persistent VSN was associated with lower FC in the right superior frontal gyrus, right inferior temporal gyrus, right medial orbitofrontal cortex, left precuneus, right inferior parietal gyrus, right medial frontal gyrus, right rectus gyrus, left superior frontal gyrus, left middle cingulate gyrus, right superior temporal pole, right postcentral gyrus, and right posterior cingulate gyrus compared to that in those with rapid recovery, whereas ALFF in the left cerebellum were decreased in patients with persistent VSN. Our results demonstrate that the DAN rather than the VAN, plays a more important role in recovery from VSN, and that the cerebellum is involved in recovery. We believe that our results supplement those of previous studies on recovery from VSN.

Resting-state electroencephalography changes in poststroke patients with visuospatial neglect

Background

This study aimed to explore the electrophysiological characteristics of resting-state electroencephalography (rsEEG) in patients with visuospatial neglect (VSN) after stroke.

Methods

A total of 44 first-event sub-acute strokes after right hemisphere damage (26 with VSN and 18 without VSN) were included. Besides, 18 age-matched healthy participants were used as healthy controls. The resting-state electroencephalography (EEG) of 64 electrodes was recorded to obtain the power of the spectral density of different frequency bands. The global delta/alpha ratio (DAR), DAR over the affected hemispheres (DAR_AH), DAR over the unaffected hemispheres (DAR_UH), and the pairwise-derived brain symmetry index (pdBSI; global and four bands) were compared between groups and receiver operating characteristic (ROC) curve analysis was conducted. The Barthel index (BI), Fugl-Meyer motor function assessment (FMA), and Berg balance scale (BBS) were used to assess the functional state of patients. Visuospatial neglect was assessed using a battery of standardized tests.

Results

We found that patients with VSN performed poorly compared with those without VSN. Analysis of rsEEG revealed increased delta and theta power and decreased alpha and beta power in stroke patients with VSN. Compared to healthy controls and poststroke non-VSN patients, patients with VSN showed a higher DAR (P < 0.001), which was significantly positively correlated with the BBS (DAR: r = –0.522, P = 0.006; DAR_AH: r = –0.521, P = 0.006; DAR_UH: r = –0.494, P = 0.01). The line bisection task was positively correlated with DAR (r = 0.458, P = 0.019) and DAR_AH (r = 0.483, P = 0.012), while the star cancellation task was only positively correlated with DAR_AH (r = 0.428, P = 0.029). DAR_AH had the best discriminating value between VSN and non-VSN, with an area under the curve (AUC) of 0.865. Patients with VSN showed decreased alpha power in the parietal and occipital areas of the right hemisphere. A higher parieto-occipital pdBSI_alpha was associated with a worse line bisection task (r = 0.442, P = 0.024).

Conclusion

rsEEG may be a useful tool for screening for stroke patients with visuospatial neglect, and DAR and parieto-occipital pdBSI_alpha may be useful biomarkers for visuospatial neglect after stroke.

Impacts of Prism Adaptation Treatment on Spatial Neglect and Rehabilitation Outcome: Dosage Matters

We examined whether number of prism adaptation treatment (PAT) sessions in regular clinical practice would predict spatial neglect (SN) improvement and rehabilitation outcomes. We reviewed clinical records from 16 U.S. rehabilitation hospitals where neurological patients were assessed for SN using the Catherine Bergego Scale (CBS) and if SN was detected, and may have received PAT. Multiple linear regression was used to predict CBS Change (indicating SN improvement) in 520 patients who received PAT while considering age, sex, diagnosis, time post diagnosis, CBS at baseline, neglected side of space, and length of stay. Another set of regression models including the same variables and adding Function Independent Measure (FIM®) at admission was used to predict FIM Gains (indicating rehabilitation outcomes) in 1720 patients receiving PAT or not. We found that greater number of PAT sessions predicted greater CBS Change, especially in patients with moderate-to-severe neglect. Number of PAT sessions also positively correlated with Total FIM, Motor FIM, and Cognitive FIM Gains regardless of SN severity classification at baseline. Furthermore, number of PAT sessions predicted CBS Change and FIM Gains among patients completing ≤8 PAT sessions but not among patients with ≥8 sessions, who however, showed greater CBS Change with increased PAT frequency (i.e., fewer days between two consecutive sessions). Receiving more once-daily PAT sessions predicted greater improvement in SN and rehabilitation outcomes. Receiving PAT at a higher frequency for 8 or more sessions predicted better SN improvement. Thus, dosage matters. The study provides practice-based evidence that PAT is appropriate for inpatient rehabilitation.

Detection of Stroke-Induced Visual Neglect and Target Response Prediction Using Augmented Reality and Electroencephalography

We aim to build a system incorporating electroencephalography (EEG) and augmented reality (AR) that is capable of identifying the presence of visual spatial neglect (SN) and mapping the estimated neglected visual field. An EEG-based brain-computer interface (BCI) was used to identify those spatiospectral features that best detect participants with SN among stroke survivors using their EEG responses to ipsilesional and contralesional visual stimuli. Frontal-central delta and alpha, frontal-parietal theta, Fp1 beta, and left frontal gamma were found to be important features for neglect detection. Additionally, temporal analysis of the responses shows that the proposed model is accurate in detecting potentially neglected targets. These targets were predicted using common spatial patterns as the feature extraction algorithm and regularized discriminant analysis combined with kernel density estimation for classification. With our preliminary results, our system shows promise for reliably detecting the presence of SN and predicting visual target responses in stroke patients with SN.

Principal Component Analysis of Oxford Cognitive Screen in Patients With Stroke

Cognitive deficits occur in most patients with stroke and are the important predictors of adverse long-term outcome. Early identification is fundamental to plan the most appropriate care, including rehabilitation and discharge decisions. The Oxford Cognitive Screen (OCS) is a simple, valid, and reliable tool for the assessment of cognitive deficits in patients with stroke. It contains 10 subtests, providing 14 scores referring to 5 theoretically derived cognitive domains: attention, language, number, praxis, and memory. However, an empirical verification of the domain composition of the OCS subtests in stroke data is still lacking in the literature. A principal component analysis (PCA) was performed on 1,973 patients with stroke who were enrolled in OCS studies in the UK and in Italy. A number of six main components were identified relating to the domains of language and arithmetic, memory, visuomotor ability, orientation, spatial exploration, and executive functions. Bootstrapped split-half reliability analysis on patients and comparison between patients and 498 healthy participants, as that between patients with left and right hemisphere damage, confirmed the results obtained by the principal component analysis. A clarification about the contribution of each score to the theoretical original domains and to the components identified by the PCA is provided with the aim to foster the usability of OCS for both clinicians and researchers.

Rehabilitation interventions of unilateral spatial neglect based on the functional outcome measure: A systematic review and meta-analysis

ABSTRACTThis review aimed to examine the bottom-up and top-down rehabilitation intervention effectiveness based on the functional outcome measure as immediate effect and long-term effect for unilateral spatial neglect conditions. The RCT studies were collected by searching in three databases J-Stage, PubMed, and PEDro from 2008 through 2018. The studies which used the following instruments: BI, CBS, FMA, and FIM, as the functional outcome with the PEDro score of six and above, were eligible for inclusion. A total of 492 participants in 13 studies included from 291 studies initially identified. The meta-analysis for overall ES revealed that BI and CBS had a significant mean of SMD = 0.65 (95% CI, 0.23-1.07; p = 0.003; I2 = 65%), and SMD = -0.23 (95% CI, -0.45 to -0.01; p = 0.04; I2 = 35%) respectively, while FMA and FIM had an insignificant mean of SMD = 0.14 (95% CI, -0.08-0.37; p = 0.22; I2 = 0%), and SMD = -0.22 (95% CI, -0.69-0.25; p = 0.37; I2 = 0%) respectively. Based on the results, although indicated the heterogeneity representation across studies, it showed that the top-down intervention approach of high-frequency rTMS was more effective in enhancing the functional abilities and ADL of unilateral spatial neglect patients on the immediate effects but not necessarily in the long-term effects.

The mobility assessment course: A ready-to-use dynamic measure of visuospatial neglect

The Mobility Assessment Course (MAC) is a tool to measure visuospatial neglect in a dynamic fashion. Although the MAC has been shown to dissociate between patients with and without neglect, it remains unclear whether it is applicable in clinical settings. We evaluated the MAC regarding its (1) feasibility as a diagnostic tool as part of standard care, (2) construct validity, and (3) underlying constructs and potential confounders. A consecutive sample of stroke patients admitted to inpatient rehabilitation completed the MAC, shape cancellation, line bisection, and/or Catherine Bergego Scale (CBS) as part of the standard assessment. To assess feasibility, we computed the percentage of patients who completed the MAC. Construct validity was tested by evaluating MAC performance between patients with and without neglect and controls. Finally, a regression analysis was conducted to assess underlying constructs and potential confounders of MAC performance (i.e., level of mobility and lesion side). The MAC was completed by 82% of patients (N = 182/223; of whom 145 completed all tasks). Patients with neglect performed worse on the MAC (indicating more severe neglect) compared to patients without neglect and controls. The MAC had a lower sensitivity and higher specificity than paper-and-pencil tasks and the CBS. Performance on shape cancellation, line bisection, and CBS were predictors of MAC performance. Level of mobility and lesion side did not predict MAC scores, indicating that these factors do not confound its reliability. To conclude, the MAC is an easy-to-implement tool to evaluate neglect in a dynamic manner, which can be administered in addition to conventional paper-and-pencil tasks.

Current knowledge and practice of post-stroke unilateral spatial neglect rehabilitation: A cross-sectional survey of South African neurorehabilitation physiotherapists

Background

Unilateral spatial neglect (USN) affects the rehabilitation process leading to poor functional outcomes after stroke. South African physiotherapists’ level of uptake of available evidence in USN rehabilitation and the barriers they encounter are not known.

Objectives

To evaluate knowledge, current practice enablers and barriers to USN management in stroke survivors amongst physiotherapists in South Africa.

Methods

Our cross-sectional survey used a total sampling technique. Questionnaires were sent to neurorehabilitation physiotherapists in South Africa. Descriptive and inferential statistics analysed the data.

Results

The overall knowledge score of USN was 14.11 ± 5.23 of a total of 25. The knowledge was good for definitions of USN; moderate for incidences, causes, screening, diagnosis and prognosis of USN and poor for pharmacological approaches to the management of USN. A significant low positive correlation between respondents’ age (r = 0.46; p = 0.016) and years of practice as a physiotherapist (r = 0.43; p = 0.026) and knowledge of USN was found. The most frequently utilised intervention was constraint-induced movement therapy; the commonly utilised assessment tool was the comb and razor test. ‘Inadequate therapy time’ (55.56%) and ‘lack of relevant equipment for rehabilitation of USN’ (38.89%) were identified as major barriers to USN rehabilitation. Major enablers to USN rehabilitation were the ‘presence of multidisciplinary stroke team in clinical practice’ (83.35%) and ‘availability of adequate staff’ (76.47%).

Conclusion

Physiotherapists demonstrated a fair knowledge of USN although knowledge about pharmacological management of USN was modest. Current practice in post-stroke USN by South African neuro-physiotherapists follows current evidence and practice guidelines.

Clinical implication

Our study shows the level of knowledge and current practice of post-stroke USN rehabilitation. The demonstrated fair knowledge of USN may be improved through training, curriculum modifications or continuing professional development. Identified barriers to the rehabilitation of post-stroke USN can assist health policy, managers and clinicians to improve stroke-specific care.

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.

Functional Independence Measure Subtypes among Inpatients with Subacute Stroke: Classification via Latent Class Analysis

Objectives:

Using Functional Independence Measure (FIM) records, this study used latent class analysis (LCA) to clarify the structure of activities of daily living (ADL) status in patients following stroke.

Methods:

In this retrospective, single-center study, we extracted the medical records of patients with stroke who were admitted to a rehabilitation hospital in Japan between April 2018 and March 2020. LCA was used to determine classes of ADL status based on response patterns in FIM items converted from the original seven levels to three levels: Complete Dependence, FIM1–2; Modified Dependence, FIM3–5; Independence, FIM6–7. We compared the length of stay and discharge destinations among subgroups of patients with different ADL status at admission.

Results:

From 373 patients, 1592 FIM records were analyzed. These were classified into six ADL status classes based on “Complete Dependence,” “Modified Dependence,” and “Independence” in the motor and cognitive domains. Significant differences were observed among the six admission ADL subgroups for the length of stay (median values in patient subgroups based on admission ADL status: 126, 146, 90, 65, 44, and 29 days in the Motor Complete/Cognitive Complete, Motor Complete/Cognitive Modified, Motor Modified/Cognitive Modified, Motor Modified/Cognitive Independent, Motor Independent/Cognitive Modified, and Motor Independent/Cognitive Independent groups, respectively) and discharge destinations (patients discharged home: 27%, 62%, 81%, 92%, 95%, and 98%, respectively, and to acute care hospitals: 18%, 14%, 8%, 8%, 2%, and 2%, respectively).

Conclusions:

LCA successfully stratified ADL status in patients with stroke undergoing rehabilitation and may aid in determining an appropriate treatment regimen.

The Implementation Process of Two Evidence-Based Protocols: A Spatial Neglect Network Initiative

Introduction

Spatial neglect, a neurocognitive disorder of lateralized spatial attention, is prevalent among stroke survivors especially in inpatient rehabilitation facilities (IRFs). The ultimate goal of the project was to improve spatial neglect care in inpatient rehabilitation and trained as many OTs as possible using both tools in their regular practices as the means to achieve our overall objective. Therefore, we conducted a project aimed at implementing two evidence-based protocols, one for assessment (KF-NAP®) and the other for treatment (KF-PAT®), and share the implementation process, which included barriers and facilitators identified during and after the process, and implementation outcomes.

Methods

Sixteen IRFs were involved. The Knowledge-To-Action Cycle was used to describe the process of knowledge inquiry (training), translating knowledge (implementation) and evaluating the use of knowledge in clinical practice (outcomes). Barriers and strategies were reported using the Consolidated Framework for Implementation Research and identified through a survey, after the study concluded.

Results

Thirty-two therapists at the participating sites were trained to some level of the KF-NAP and KF-PAT. Throughout the project and also once after it finished, different barriers were identified by researchers and clinicians, who then determined together actions to eliminate or minimize the barriers. For example, multiple sites reported: "not having time to train other staff at their hospital due to high patient volume and other responsibilities."

Discussion

The project shared our implementation process which demonstrated the importance of using implementation methods and incorporating a researcher-clinician partnership, not only for knowledge generation but also knowledge translation. Frequent communications and exchanging information with stakeholders at different levels, may be determinant to the success of each implementation phase. Further research is needed.

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.

Spatial Neglect and Anosognosia After Right Brain Stroke

PURPOSE OF REVIEW

Up to 80% of survivors of right brain stroke leave acute care without being diagnosed with a major invisible disability. Studies indicate that a generic cognitive neurologic evaluation does not reliably detect spatial neglect, nor does it identify unawareness of deficit after right brain stroke; this article reviews the symptoms, clinical presentation, and management of these two cognitive disorders occurring after right brain stroke.

RECENT FINDINGS

Stroke and occupational therapy practice guidelines stress a quality standard for spatial neglect assessment and treatment to reduce adverse outcomes for patients, their families, and society. Neurologists may attribute poor outcomes associated with spatial neglect to stroke severity. However, people with spatial neglect are half as likely to return to home and community, have one-third the community mobility, and require 3 times as much caregiver supervision compared with similar stroke survivors. Multiple randomized trials support a feasible first-line rehabilitation approach for spatial neglect: prism adaptation therapy; more than 20 studies reported that this treatment improves daily life independence. Evidence-based treatment of anosognosia is not as developed; however, treatment for this problem is also available.

SUMMARY

This article guides neurologists' assessment of right brain cognitive disorders and describes how to efficiently assemble and direct a treatment team to address spatial neglect and unawareness of deficit.

Neural Mechanisms of Prism Adaptation in Healthy Adults and Individuals with Spatial Neglect after Unilateral Stroke: A Review of fMRI Studies

Functional disability due to spatial neglect hinders recovery in up to 30% of stroke survivors. Prism adaptation treatment (PAT) may alleviate the disabling consequences of spatial neglect, but we do not yet know why some individuals show much better outcomes following PAT than others. The goal of this scoping review and meta-analysis was to investigate the neural mechanisms underlying prism adaptation (PA). We conducted both quantitative and qualitative analyses across fMRI studies investigating brain activity before, during, and after PA, in healthy individuals and patients with right or left brain damage (RBD or LBD) due to stroke. In healthy adults, PA was linked with activity in posterior parietal and cerebellar clusters, reduced bilateral parieto-frontal connectivity, and increased fronto-limbic and sensorimotor network connectivity. In contrast, RBD individuals with spatial neglect relied on different circuits, including an activity cluster in the intact left occipital cortex. This finding is consistent with a shift in hemispheric dominance in spatial processing to the left hemisphere. However, more studies are needed to clarify the contribution of lesion location and load on the circuits involved in PA after unilateral brain damage. Future studies are also needed to clarify the relationship of decreasing resting state functional connectivity (rsFC) to visuomotor function.

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.

Prism Adaptation Treatment Improves Inpatient Rehabilitation Outcome in Individuals With Spatial Neglect: A Retrospective Matched Control Study

Objective

To determine whether prism adaptation treatment (PAT) integrated into the standard of care improves rehabilitation outcome in patients with spatial neglect (SN).

Design

Retrospective matched control study based on information extracted from June 2017-September 2019.

Setting

Inpatient rehabilitation.

Participants

Patients from 14 rehabilitation hospitals scoring >0 on the Catherine Bergego Scale (N=312). The median age was 69.5 years, including 152 (49%) female patients and 275 (88%) patients with stroke.

Interventions

Patients were matched 1:1 by age (±5 years), FIM score at admission (±2 points), and SN severity using the Catherine Bergego Scale (±2 points) and classified into 2 groups: treated (8-12 daily sessions of PAT) vs untreated (no PAT).

Main Outcome Measures

FIM and its minimal clinically important difference (MCID) were the primary outcome variables. Secondary outcome was home discharge.

Results

Analysis included the 312 matched patients (156 per group). FIM scores at discharge were analyzed using repeated-measures analyses of variance. The treated group showed reliably higher scores than the untreated group in Total FIM, F=5.57, P=.020, partial η²=0.035, and Cognitive FIM, F=19.20, P<.001, partial η²=0.110, but not Motor FIM, F=0.35, P=.553, partial η²=0.002. We used conditional logistic regression to examine the odds ratio of reaching MCID in each FIM score and of returning home after discharge. No reliable difference was found between groups in reaching MCID or home discharge.

Conclusions

Patients with SN receiving PAT had better functional and cognitive outcomes, suggesting that integrating PAT into the standard of care is beneficial. However, receiving PAT may not determine home discharge.

Mirror therapy for unilateral neglect after stroke: A systematic review

BACKGROUND AND PURPOSE

The effect of mirror therapy for unilateral neglect after stroke currently remains uncertain.

METHODS

This systematic review investigated the effect of mirror therapy on neglect and daily living activities in patients with unilateral neglect after stroke when compared with no treatment, sham mirror therapy, or routinely applied therapies only. We performed a systematic electronic search of PubMed, Embase, Web of Science, Cochrane Central Register of Controlled Trials, China National Knowledge Infrastructure, and Wanfang Data to identify relevant randomized control trials (RCTs).

RESULTS

We included five RCTs in the data synthesis. Mirror therapy (combined or not with other treatments) was more effective in improving neglect as compared with sham mirror therapy or no treatment (combined or not with the other therapies; standard mean difference [SMD] = 1.62, 95% confidence interval [CI] = 1.03-2.21, p < 0.00001). Mirror therapy (combined or not with other therapies) was effective in improving daily living activities as compared with sham mirror therapy or no treatment (combined or not with the other therapies; SMD = 2.09, 95% CI = 0.63-3.56, p = 0.005).

CONCLUSIONS

Our results show that mirror therapy effectively improves neglect and daily living activities in patients with unilateral neglect after stroke. Future trials with high methodological quality and larger sample sizes are needed to determine the immediate and long-term effect of appropriate mirror therapy protocol for unilateral neglect.