The use of Optokinetic Stimulation in Rehabilitation of the Hemineglect Disorder

Gaze and attention: Mechanisms underlying the therapeutic effect of optokinetic stimulation in spatial neglect

Left smooth pursuit eye movement training in response to large-field visual motion (optokinetic stimulation) has become a promising rehabilitation method in left spatial inattention or neglect. The mechanisms underlying the therapeutic effect, however, remain unknown. During optokinetic stimulation, there is an error in visual localisation ahead of the line of sight. This could indicate a change in the brain's estimate of one's own direction of gaze. We hypothesized that optokinetic stimulation changes the brain's estimate of gaze. Because this estimate is critical for coding the locus of attention in the visual space relative to the body and across sensory modalities, its change might underlie the change in spatial attention. Here, we report that in healthy participants optokinetic stimulation causes not only a directional bias in the proprioceptive signal from the extraocular muscles, but also a corresponding shift of the locus of attention. Both changes outlasted the period of stimulation. This result forms a step in investigating a causal link between the adaptation in the sensorimotor gaze signals and the recovery in spatial neglect.

Comparison of uni- and multimodal motion stimulation on visual neglect: A proof-of-concept study

Spatial neglect is characterized by the failure to attend stimuli presented in the contralesional space. Typically, the visual modality is more severely impaired than the auditory one. This dissociation offers the possibility of cross-modal interactions, whereby auditory stimuli may have beneficial effects on the visual modality. A new auditory motion stimulation method with music dynamically moving from the right to the left hemispace has recently been shown to improve visual neglect. The aim of the present study was twofold: a) to compare the effects of unimodal auditory against visual motion stimulation, i.e., smooth pursuit training, which is an established therapeutical approach in neglect therapy and b) to explore whether a combination of auditory + visual motion stimulation, i.e., multimodal motion stimulation, would be more effective than unimodal auditory or visual motion stimulation. 28 patients with left-sided neglect due to a first-ever, right-hemispheric subacute stroke were included. Patients either received auditory, visual, or multimodal motion stimulation. The between-group effect of each motion stimulation condition as well as a control group without motion stimulation was investigated by means of a one-way ANOVA with the patient's visual exploration behaviour as an outcome variable. Our results showed that unimodal auditory motion stimulation is equally effective as unimodal visual motion stimulation: both interventions significantly improved neglect compared to the control group. Multimodal motion stimulation also significantly improved neglect, however, did not show greater improvement than unimodal auditory or visual motion stimulation alone. Besides the established visual motion stimulation, this proof-of-concept study suggests that auditory motion stimulation seems to be an alternative promising therapeutic approach to improve visual attention in neglect patients. Multimodal motion stimulation does not lead to any additional therapeutic gain. In neurorehabilitation, the implementation of either auditory or visual motion stimulation seems therefore reasonable.

Non-pharmacological interventions for spatial neglect or inattention following stroke and other non-progressive brain injury

BACKGROUND

People with spatial neglect after stroke or other brain injury have difficulty attending to one side of space. Various rehabilitation interventions have been used, but evidence of their benefit is unclear.

OBJECTIVES

The main objective was to determine the effects of non-pharmacological interventions for people with spatial neglect after stroke and other adult-acquired non-progressive brain injury.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched October 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; last searched October 2020), MEDLINE (1966 to October 2020), Embase (1980 to October 2020), the Cumulative Index to Nursing and Allied Health Literature (CINAHL; 1983 to October 2020), and PsycINFO (1974 to October 2020). We also searched ongoing trials registers and screened reference lists.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of any non-pharmacological intervention specifically aimed at spatial neglect. We excluded studies of general rehabilitation and studies with mixed participant groups, unless separate neglect data were available.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods. Review authors categorised the interventions into eight broad types deemed to be applicable to clinical practice through iterative discussion: visual interventions, prism adaptation, body awareness interventions, mental function interventions, movement interventions, non-invasive brain stimulation, electrical stimulation, and acupuncture. We assessed the quality of evidence for each outcome using the GRADE approach.

MAIN RESULTS

We included 65 RCTs with 1951 participants, all of which included people with spatial neglect following stroke. Most studies measured outcomes using standardised neglect assessments. Fifty-one studies measured effects on ADL immediately after completion of the intervention period; only 16 reported persisting effects on ADL (our primary outcome). One study (30 participants) reported discharge destination, and one (24 participants) reported depression. No studies reported falls, balance, or quality of life. Only two studies were judged to be entirely at low risk of bias, and all were small, with fewer than 50 participants per group. We found no definitive (phase 3) clinical trials. None of the studies reported any patient or public involvement. Visual interventions versus any control: evidence is very uncertain about the effects of visual interventions for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 55 participants) (standardised mean difference (SMD) -0.04, 95% confidence interval (CI) -0.57 to 0.49); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Prism adaptation versus any control: evidence is very uncertain about the effects of prism adaptation for spatial neglect based on measures of persisting functional ability in ADL (2 studies, 39 participants) (SMD -0.29, 95% CI -0.93 to 0.35); measures of immediate functional ability in ADL; persisting standardised neglect assessments; and immediate neglect assessments. Body awareness interventions versus any control: evidence is very uncertain about the effects of body awareness interventions for spatial neglect based on measures of persisting functional ability in ADL (5 studies, 125 participants) (SMD 0.61, 95% CI 0.24 to 0.97); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Mental function interventions versus any control: we found no trials of mental function interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of mental function interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Movement interventions versus any control: we found no trials of movement interventions for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of body awareness interventions on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments. Non-invasive brain stimulation (NIBS) versus any control: evidence is very uncertain about the effects of NIBS on spatial neglect based on measures of persisting functional ability in ADL (3 studies, 92 participants) (SMD 0.35, 95% CI -0.08 to 0.77); measures of immediate functional ability in ADL; persisting standardised neglect assessments; immediate neglect assessments; and adverse events. Electrical stimulation versus any control: we found no trials of electrical stimulation for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of electrical stimulation on spatial neglect based on immediate neglect assessments. Acupuncture versus any control: we found no trials of acupuncture for spatial neglect reporting on measures of persisting functional ability in ADL. Evidence is very uncertain about the effects of acupuncture on spatial neglect based on measures of immediate functional ability in ADL and immediate neglect assessments.

AUTHORS' CONCLUSIONS

The effectiveness of non-pharmacological interventions for spatial neglect in improving functional ability in ADL and increasing independence remains unproven. Many strategies have been proposed to aid rehabilitation of spatial neglect, but none has yet been sufficiently researched through high-quality fully powered randomised trials to establish potential or adverse effects. As a consequence, no rehabilitation approach can be supported or refuted based on current evidence from RCTs. As recommended by a number of national clinical guidelines, clinicians should continue to provide rehabilitation for neglect that enables people to meet their rehabilitation goals. Clinicians and stroke survivors should have the opportunity, and are strongly encouraged, to participate in research. Future studies need to have appropriate high-quality methodological design, delivery, and reporting to enable appraisal and interpretation of results. Future studies also must evaluate outcomes of importance to patients, such as persisting functional ability in ADL. One way to improve the quality of research is to involve people with experience with the condition in designing and running trials.

The effects of robot-assisted left-hand training on hemispatial neglect in older patients with chronic stroke: A pilot and randomized controlled trial

BACKGROUND

Even though a variety of rehabilitative technique have been implemented to ameliorate neglect symptoms of patients with stoke, the effects of limb activation using a robotic device are still unknown. The purpose of this study was to investigate the effects of the robot-assisted hand training on hemispatial neglect of older patients with chronic stroke.

METHODS

The participants were randomly allocated to the experimental group (EG) receiving robot-assisted left-hand training (n = 12) or the control group (CG) receiving conventional treatments for neglect symptoms (n = 12). All participants received 20 sessions for 4-week. To examine the effects on hemispatial neglect, the line bisection test (LBT), the Albert test, and the Catherine Bergego Scale (CBS) were utilized. The outcome measures were analyzed before and after the 20 training sessions.

RESULTS

After the intervention, improvements in the LBT, the Albert test, and the CBS were found in the EG whereas there were significant improvements in the LBT and the CBS but not the Albert test in the CG. In addition, the EG showed a significantly greater gain in all outcome measures compared to the CG (p < .05).

CONCLUSIONS

These results indicate that robot-assisted hand training was beneficial to improving the hemispatial neglect of elderly person with chronic stroke compared to the conventional treatments. Robot-assisted limb activation might be useful to ameliorate hemispatial neglect of the elderly with chronic stroke.

Combined virtual reality and haptic robotics induce space and movement invariant sensorimotor adaptation

Prism adaptation is a method for studying visuomotor plasticity in healthy individuals, as well as for rehabilitating patients suffering spatial neglect. We developed a new set-up based on virtual-reality (VR) and haptic-robotics allowing us to induce sensorimotor adaptation and to reproduce the effect of prism adaptation in a more ecologically valid, yet experimentally controlled context. Participants were exposed to an immersive VR environment while controlling a virtual hand via a robotic-haptic device to reach virtual objects. During training, a rotational shift was induced between the position of the participant's real hand and that of the virtual hand in order to trigger sensorimotor recalibration. The use of VR and haptic-robotics allowed us to simulate and test multiple components of sensorimotor adaptation: training either peripersonal or extrapersonal space and testing generalization for the non-trained sector of space, and using active versus robot-guided reaching movements. Results from 60 neurologically intact participants show that participants exposed to the virtual shift were able to quickly adapt their reaching movements to aim correctly at the target objects. When the shift was removed, participants showed a systematic deviation of their movements during open-loop tasks in the direction opposite to that of the shift, which generalized to un-trained portions of space and occurred also when their movements were robotically-guided during the adaptation. Interestingly, follow-up questionnaires revealed that when the adaptation training was robotically-guided, participants were largely unaware of the mismatch between their hand and the virtual hand's position. The stability of the aftereffects, despite the changing experimental parameters, suggests that the induced sensory-motor adaptation does not rely on low-level processing of sensory stimuli during the training, but taps into high-level representations of space. Importantly, the flexibility of the trained space and the option of robotically-guided movements open novel possibilities of fine-tuning the training to patients' level of spatial and motor impairment, thus possibly resulting in a better outcome.

Reward sensitivity predicts dopaminergic response in spatial neglect

It has recently been revealed that spatial neglect can be modulated by motivational factors including anticipated monetary reward. A number of dopaminergic agents have been evaluated as treatments for neglect, but the results have been mixed, with no clear anatomical or cognitive predictors of dopaminergic responsiveness. Given that the effects of incentive motivation are mediated by dopaminergic pathways that are variably damaged in stroke, we tested the hypothesis that the modulatory influences of reward and dopaminergic drugs on neglect are themselves related. We employed a single-dose, double-blind, crossover design to compare the effects of Co-careldopa and placebo on a modified visual cancellation task in patients with neglect secondary to right hemisphere stroke. Whilst confirming that reward improved visual search in this group, we showed that dopaminergic stimulation only enhances visual search in the absence of reward. When patients were divided into REWARD-RESPONDERs and REWARD-NON-RESPONDERs, we found an interaction, such that only REWARD-NON-RESPONDERs showed a positive response to reward after receiving Co-careldopa, whereas REWARD-RESPONDERs were not influenced by drug. At a neuroanatomical level, responsiveness to incentive motivation was most associated with intact dorsal striatum. These findings suggest that dopaminergic modulation of neglect follows an 'inverted U' function, is dependent on integrity of the reward system, and can be measured as a behavioural response to anticipated reward.

Rehabilitation of unilateral neglect: Evidence-based medicine

BACKGROUND

In the last decades, several rehabilitation methods have been developed to improve spatial neglect. These can be classified according to their theoretical basis: (i) enhance awareness of neglect behaviour through a top-down mechanism; (ii) low-level bottom-up sensory stimulation; (iii) modulation of inhibitory processes; (iv) increase arousal.

OBJECTIVE

The purpose of this study was to provide an overview of the evidence on the effectiveness of rehabilitation procedures for unilateral neglect.

METHOD

A systematic search was performed to look for all randomised controlled trials aimed at reducing left spatial neglect that included a functional assessment. In addition, recent review papers and meta-analyses were analysed.

RESULTS

Thirty-seven randomized controlled trials were found (12 bottom-up; 12 top-down; 1 interhemispheric competition; 12 combination of approaches) that included 1027 patients with neglect. Although there are some encouraging results, overall, the level of evidence remains low. Poor methodological quality and small sample sizes are major limitations in many published trials.

CONCLUSION

There is a need for well-conducted, large-scale randomised controlled trials that incorporate blinded assessments, evaluation of the generalization to activities of daily living and long-term follow-up.

Stroke Rehabilitation 2007: What Should it Be?

Background

There are an estimated 62 million stroke survivors worldwide. The majority will have long-term disability. Despite this reality, there have been few large, high-quality randomized controlled trials of stroke rehabilitation interventions.

Summary of review

There is excellent evidence for the effectiveness of a number of stroke rehabilitation interventions, notably care of stroke patients in inpatient stroke units and stroke rehabilitation units providing organized, goal-focused care via a multidisciplinary team. Stroke units (in comparison with care on general medical wards) effectively reduce death and disability with the number needed to treat to prevent one person from failing to regain independence being 20. Unfortunately, only a minority of stroke patients have access to stroke unit care. The key principles of effective stroke rehabilitation have been identified. These include ( 1 ) a functional approach targeted at specific activities e.g. walking, activities of daily living, ( 2 ) frequent and intense practice, and ( 3 ) commencement in the first days or weeks after stroke.

Conclusion

The most effective approaches to restoration of brain function after stroke remain unknown and there is an urgent need for more high-quality research. In the meantime, simple, broadly applicable stroke rehabilitation interventions with proven efficacy, particularly stroke unit care, must be applied more widely.

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Cognitive Impairment and Rehabilitation Strategies After Traumatic Brain Injury

Traumatic brain injury (TBI) is among the significant causes of morbidity and mortality in the present world. Around 1.6 million persons sustain TBI, whereas 200,000 die annually in India, thus highlighting the rising need for appropriate cognitive rehabilitation strategies. This literature review assesses the current knowledge of various cognitive rehabilitation training strategies. The entire spectrum of TBI severity; mild to severe, is associated with cognitive deficits of varying degree. Cognitive insufficiency is more prevalent and longer lasting in TBI persons than in the general population. A multidisciplinary approach with neuropsychiatric evaluation is warranted. Attention process training and tasks for attention deficits, compensatory strategies and errorless learning training for memory deficits, pragmatic language skills and social behavior guidance for cognitive-communication disorder, meta-cognitive strategy, and problem-solving training for executive disorder are the mainstay of therapy for cognitive deficits in persons with TBI. Cognitive impairments following TBI are common and vary widely. Different cognitive rehabilitation techniques and combinations in addition to pharmacotherapy are helpful in addressing various cognitive deficits.

Effects of lateralized light flash and color on unilateral neglect

PURPOSE

Bottom-up-based sensory stimulation has been useful in promoting recovery from post-stroke neglect. Light and color are salient stimuli for guiding our orienting behaviors and influence the degree of spatial bias. This study evaluated the effects of lateralized light flash and color on spatial bias in unilateral neglect (UN).

METHOD

We enrolled 15 individuals with UN as a consequence of a right hemispheric stroke of less than 65 d. This was a 3 × 3 design study with three conditions of lens color (colorless, red, and blue) and three conditions of flash light locations (no flash, left, and right).

RESULTS

All participants showed a decrease in ipsilesional spatial bias under left-side light flash and a red lens. Right-side light flash and a blue lens induced more rightward bias than other conditions.

CONCLUSIONS

This evidence confirms the use of sensory stimulation to complement post-stroke UN remediation. Lateralized light flash to the contralesional space and red-colored lenses have beneficial effects on amelioration of UN, whereas ipsilesional light flash and the color blue may exacerbate ipsilesional spatial bias in stroke survivors with UN. Implications for Rehabilitation Contralesional light flash and the color red may ameliorate ipsilesional spatial bias in stroke survivors with unilateral neglect (UN). Ipsilesional flash of light and the color blue may worsen ipsilesional spatial bias in stroke survivors with UN.

Hearing and music in unilateral spatial neglect neuro-rehabilitation

Unilateral spatial neglect (USN) is an attention deficit in the contralesional side of space which occurs after a cerebral stroke, mainly located in the right hemisphere. USN patients are disabled in all daily activities. USN is an important negative prognostic factor of functional recovery and of socio-professional reinsertion. Thus, patient rehabilitation is a major challenge. As this deficit has been described in many sensory modalities (including hearing), many sensory and poly-sensory rehabilitation methods have been proposed to USN patients. They are mainly based on visual, tactile modalities and on motor abilities. However, these methods appear to be quite task-specific and difficult to transfer to functional activities. Very few studies have focused on the hearing modality and even fewer studies have been conducted in music as a way of improving spatial attention. Therefore, more research on such retraining needs is neccessary in order to make reliable conclusions on its efficiency in long-term rehabilitation. Nevertheless, some evidence suggests that music could be a promising tool to enhance spatial attention and to rehabilitate USN patients. In fact, music is a material closely linked to space, involving common anatomical and functional networks. The present paper aims firstly at briefly reviewing the different procedures of sensory retraining proposed in USN, including auditory retraining, and their limits. Secondly, it aims to present the recent scientific evidence that makes music a good candidate for USN patients’ neuro-rehabilitation.

Effectiveness of Interventions to Improve Occupational Performance of People With Cognitive Impairments After Stroke: An Evidence-Based Review

This evidence-based review was conducted to determine which interventions are effective in improving occupational performance after stroke. Forty-six articles met the inclusion criteria and were examined. Interventions for the following impairments were reviewed: general cognitive deficits, executive dysfunction, apraxia, memory loss, attention deficits, visual field deficits (included because of their close relationship with neglect), and unilateral neglect. Evidence is available from a variety of clinical trials to guide interventions regarding general cognition, apraxia, and neglect. The evidence regarding interventions for executive dysfunction and memory loss is limited. There is insufficient evidence regarding impairments of attention and mixed evidence regarding interventions for visual field deficits. The effective interventions have some commonalities, including being performance focused, involving strategy training, and using a compensatory as opposed to a remediation approach. The implications of the findings for practice, research, and education are discussed.

Bisecting or not bisecting: this is the neglect question. Line bisection performance in the diagnosis of neglect in right brain-damaged patients

In the present study we analysed the bisecting behaviour of 287 chronic right brain-damaged patients by taking into account the presence and severity of extrapersonal and/or personal neglect diagnosed with the hemineglect battery. We also analysed right brain-damaged patients who had (or did not have) neglect according to their line bisection performance. Our results showed that performance of the line bisection task correlates with performance of cancellation tasks, reading and perceptual tasks, but not with the presence of personal neglect. Personal neglect seems to be unrelated to line bisection behaviour. Indeed, patients affected by extrapersonal and personal neglect do not show more severe neglect in line bisection than patients with only extrapersonal neglect. Furthermore, we observed that 20.56% of the patients were considered affected or not by neglect on the line bisection task compared with the other spatial tasks of the hemineglect battery. We conclude that using a battery with multiple tests is the only way to guarantee a reliable diagnosis and effectively plan for rehabilitative training.

Reducing chronic visuo-spatial neglect following right hemisphere stroke through instrument playing

Unilateral visuo-spatial neglect is a neuropsychological syndrome commonly resulting from right hemisphere stroke at the temporo-parietal junction of the infero-posterior parietal cortex. Neglect is characterized by reduced awareness of stimuli presented on patients' contralesional side of space. Inspired by evidence of increased spatial exploration of patients' left side achieved during keyboard scale-playing, the current study employed a music intervention that involved making sequential goal-directed actions in the neglected part of space, in order to determine whether this would bring about clinically significant improvement in chronic neglect. Two left neglect patients completed an intervention comprising four weekly 30-min music intervention sessions involving playing scales and familiar melodies on chime bars from right to left. Two cancellation tests [Mesulam shape, Behavioral Inattention Test (BIT) star], the neglect subtest from the computerized TAP (Test of Attentional Performance) battery, and the line bisection test were administered three times during a preliminary baseline phase, before and after the four intervention sessions during the intervention phase to investigate short-term effects, and 1 week after the last intervention session to investigate whether any changes in performance would persist. Both patients demonstrated significant short-term and longer-lasting improvements on the Mesulam shape cancellation test. One patient also showed longer-lasting effects on the BIT star cancellation test and scored in the normal range 1 week after the intervention. These findings provide preliminary evidence that active music-making with a horizontally aligned instrument may help neglect patients attend more to their affected side.

Outcomes of neuropsychological interventions of stroke

The reported prevalence of cognitive deficits within the first month of stroke ranges widely from 10% to 82%, depending primarily on the criteria used to define cognitive impairment and on the selected patient population. These cognitive defects progress toward impairment over a course of time if left untreated. Among the most common cognitive deficits are the attentional, the visuoperceptual, the memory and executive function deficits. As these impairments are being increasingly recognized in the scientific communities, more and more studies are being devoted to the outcomes of various therapies for these disorders. In this review, we focus on the outcomes of various therapies for these cognitive disorders over time. We reviewed all the possible medical databases using key words for individual cognitive deficit treatment outcomes. All the possible studies including randomized controlled trials, pre-post design studies, case series and single case reports were included in this study. On the basis of present literature review, we conclude that the evidence is definitively positive only for outcomes of attentional and visuoperceptive skill deficits. On the other hand, there have been very few studies to conclude for effectiveness of various therapies for memory and executive function outcomes.

Is two better than one? Limb activation treatment combined with contralesional arm vibration to ameliorate signs of left neglect

In the present study, we evaluated the effects of the Limb Activation Treatment (LAT) alone and in combination with the Contralateral Arm Vibration (CAV) on left neglect (LN) rehabilitation. We conceived them as techniques that both prompt the activation of the lesioned right hemisphere because of the activation (with the LAT as an active technique) and the stimulation (with the CAV as a passive technique) of the left hemibody. To test the effect of the simultaneous use of these two techniques (i.e., LAT and CAV) on visuo-spatial aspects of LN, we described the case of an LN patient (GR), who showed high intra-individual variability (IIV) in performance. Given the high IIV of GR, we used an ABAB repeated-measures design to better define the effectiveness of the combined application of LAT and CAV, as a function of time. The results showed an improvement of GR's performance on the Bells test following the combined application of LAT and CAV, with respect to the application of LAT alone. We did not find, however, significant effects of treatment on two other LN tests (i.e., Line bisection and Picture scanning). We propose that the combined application of LAT and CAV can be beneficial for some aspects of LN.

Visual Scanning Training for Neglect after Stroke with and without a Computerized Lane Tracking Dual Task

Neglect patients typically fail to explore the contralesional half-space. During visual scanning training, these patients learn to consciously pay attention to contralesional target stimuli. It has been suggested that combining scanning training with methods addressing non-spatial attention might enhance training results. In the present study, a dual task training component was added to a visual scanning training (i.e., Training di Scanning Visuospaziale - TSVS; Pizzamiglio et al., 1990). Twenty-nine subacute right hemisphere stroke patients were semi-randomly assigned to an experimental (N = 14) or a control group (N = 15). Patients received 30 training sessions during 6 weeks. TSVS consisted of four standardized tasks (digit detection, reading/copying, copying drawings, and figure description). Moreover, a driving simulator task was integrated in the training procedure. Control patients practiced a single lane tracking task for 2 days a week during 6 weeks. The experimental group was administered the same training schedule, but in weeks 4-6 of the training, the TSVS digit detection task was combined with lane tracking on the same projection screen, so as to create a dual task (computerized visual reaction time task designed for training). Various neglect tests and driving simulator tasks were administered before and after training. No significant group and interaction effects were found that might reflect additional positive effects of dual task training. Significant improvements after training were observed in both groups taken together on most assessment tasks. Ameliorations were generally not correlated to post-onset time, but spontaneous recovery, test-retest variability, and learning effects could not be ruled out completely, since these were not controlled for. Future research might focus on increasing the amount of dual task training, the implementation of progressive difficulty levels in driving simulator tasks, and further exploration of relationships between dual task training and daily functioning.

Neglecting the left side of a city square but not the left side of its clock: prevalence and characteristics of representational neglect

Representational neglect, which is characterized by the failure to report left-sided details of a mental image from memory, can occur after a right hemisphere lesion. In this study, we set out to verify the hypothesis that two distinct forms of representational neglect exist, one involving object representation and the other environmental representation. As representational neglect is considered rare, we also evaluated the prevalence and frequency of its association with perceptual neglect. We submitted a group of 96 unselected, consecutive, chronic, right brain-damaged patients to an extensive neuropsychological evaluation that included two representational neglect tests: the Familiar Square Description Test and the O'Clock Test. Representational neglect, as well as perceptual neglect, was present in about one-third of the sample. Most patients neglected the left side of imagined familiar squares but not the left side of imagined clocks. The present data show that representational neglect is not a rare disorder and also support the hypothesis that two different types of mental representations (i.e. topological and non-topological images) may be selectively damaged in representational neglect.

Visual Scanning Training, Limb Activation Treatment, and Prism Adaptation for Rehabilitating Left Neglect: Who is the Winner?

WE COMPARED, FOR THE FIRST TIME, THE OVERALL AND DIFFERENTIAL EFFECTS OF THREE OF THE MOST WIDELY USED LEFT NEGLECT (LN) TREATMENTS: visual scanning training (VST), limb activation treatment (LAT), and prism adaptation (PA). Thirty-three LN patients were assigned in quasi-random order to the three groups (VST, LAT, or PA). Each patient received only one type of treatment. LN patients' performance on everyday life tasks was assessed four times (over a period of 6 weeks): A1 and A2 (i.e., the two pre-treatment assessments); A3 and A4 (i.e., the two post-treatment assessments). LN patients in each of the three treatment conditions were treated for the same number of sessions (i.e., 20). The results showed that improvements were present in the majority of the tests assessing the peripersonal space in everyday life activities. Our findings were independent of unspecific factors and lasted for at least 2 weeks following the end of the treatments. There were no interactions, however, between LN treatments and assessments. We suggest that all three treatments can be considered as valid rehabilitation interventions for LN and could be employed for ameliorating LN signs.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

Unilateral spatial neglect causes difficulty attending to one side of space. Various rehabilitation interventions have been used but evidence of their benefit is lacking.

OBJECTIVES

To assess whether cognitive rehabilitation improves functional independence, neglect (as measured using standardised assessments), destination on discharge, falls, balance, depression/anxiety and quality of life in stroke patients with neglect measured immediately post-intervention and at longer-term follow-up; and to determine which types of interventions are effective and whether cognitive rehabilitation is more effective than standard care or an attention control.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (last searched June 2012), MEDLINE (1966 to June 2011), EMBASE (1980 to June 2011), CINAHL (1983 to June 2011), PsycINFO (1974 to June 2011), UK National Research Register (June 2011). We handsearched relevant journals (up to 1998), screened reference lists, and tracked citations using SCISEARCH.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) of cognitive rehabilitation specifically aimed at spatial neglect. We excluded studies of general stroke rehabilitation and studies with mixed participant groups, unless more than 75% of their sample were stroke patients or separate stroke data were available.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected studies, extracted data, and assessed study quality. For subgroup analyses, review authors independently categorised the approach underlying the cognitive intervention as either 'top-down' (interventions that encourage awareness of the disability and potential compensatory strategies) or 'bottom-up' (interventions directed at the impairment but not requiring awareness or behavioural change, e.g. wearing prisms or patches).

MAIN RESULTS

We included 23 RCTs with 628 participants (adding 11 new RCTs involving 322 new participants for this update). Only 11 studies were assessed to have adequate allocation concealment, and only four studies to have a low risk of bias in all categories assessed. Most studies measured outcomes using standardised neglect assessments: 15 studies measured effect on activities of daily living (ADL) immediately after the end of the intervention period, but only six reported persisting effects on ADL. One study (30 participants) reported discharge destination and one study (eight participants) reported the number of falls.Eighteen of the 23 included RCTs compared cognitive rehabilitation with any control intervention (placebo, attention or no treatment). Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation, compared with control, for persisting effects on either ADL (five studies, 143 participants) or standardised neglect assessments (eight studies, 172 participants), or for immediate effects on ADL (10 studies, 343 participants). In contrast, we found a statistically significant effect in favour of cognitive rehabilitation compared with control, for immediate effects on standardised neglect assessments (16 studies, 437 participants, standardised mean difference (SMD) 0.35, 95% confidence interval (CI) 0.09 to 0.62). However, sensitivity analyses including only studies of high methodological quality removed evidence of a significant effect of cognitive rehabilitation.Additionally, five of the 23 included RCTs compared one cognitive rehabilitation intervention with another. These included three studies comparing a visual scanning intervention with another cognitive rehabilitation intervention, and two studies (three comparison groups) comparing a visual scanning intervention plus another cognitive rehabilitation intervention with a visual scanning intervention alone. Only two small studies reported a measure of functional disability and there was considerable heterogeneity within these subgroups (I² > 40%) when we pooled standardised neglect assessment data, limiting the ability to draw generalised conclusions.Subgroup analyses exploring the effect of having an attention control demonstrated some evidence of a statistically significant difference between those comparing rehabilitation with attention control and those with another control or no treatment group, for immediate effects on standardised neglect assessments (test for subgroup differences, P = 0.04).

AUTHORS' CONCLUSIONS

The effectiveness of cognitive rehabilitation interventions for reducing the disabling effects of neglect and increasing independence remains unproven. As a consequence, no rehabilitation approach can be supported or refuted based on current evidence from RCTs. However, there is some very limited evidence that cognitive rehabilitation may have an immediate beneficial effect on tests of neglect. This emerging evidence justifies further clinical trials of cognitive rehabilitation for neglect. However, future studies need to have appropriate high quality methodological design and reporting, to examine persisting effects of treatment and to include an attention control comparator.

Rehabilitation Interventions for Unilateral Neglect after Stroke: A Systematic Review from 1997 through 2012

A systematic review of the effectiveness of rehabilitation for persons with unilateral neglect (UN) after stroke was conducted by searching the computerized databases from 1997 through 2012. Randomized controlled trials (RCTs) of neglect treatment strategies for stroke patients which used the Behavioral Inattention Test (BIT) as the primary outcome measure were eligible for inclusion. Out of 201 studies initially identified, 12 RCTs covering 277 participants were selected for analysis. All had the same weakness of low power with smaller samples and limitation in the blinding of the design. Prism Adaptation (PA) was the most commonly used intervention while continuous Theta-burst stimulation (cTBS) appeared to be a new approach. Meta-analysis showed that for immediate effects, the BIT conventional subscore had a significant and large mean effect size (ES = 0.76; 95% CI 0.28-1.23; p = 0.002) whereas the BIT total score showed a modestly significant mean ES (ES = 0.55; 95% CI 0.16-0.94; p = 0.006). No significant mean ES in sensitivity analysis was found for long-lasting effects across all BIT outcomes. PA appeared to be the most effective intervention based on the results of pooled analysis. More rigorous studies should be done on repetitive transcranial magnetic stimulation (rTMS) before it can be concluded that it is a promising treatment for UN.

Multi-input/output alarming system for patients with inattention caused by higher cortical function disorder

Background

Method

Results

Conclusion

Long-term effects of prism adaptation in chronic visual neglect: A single case study

We investigated the effects of long-term training using prism adaptation on a patient with chronic neglect. A positive effect of prism adaptation was apparent on tests of visuo-spatial processing (cancellation, bisection, and grasping), but there was no benefit for neglect on the detection of errors on the contralesional side of words or on the detection the left side of chimeric faces. Across training sessions, the benefit of adaptation on immediate performance decreased, but it increased across sessions and within sessions when performance was tested up to 90 minutes after adaptation. The beneficial effect was maintained up to 1 year posttraining. In later sessions there were also increased negative after-effects following prism adaptation, as training progressed. There was no improvement on tests of mathematical cognition, which comprised an independent deficit in this patient. The data suggest that prolonged prism training can induce long-term adaptive spatial realignment of visuo-motor mappings, ameliorating some aspects of neglect. We discuss the implications for the rehabilitation of neglect and for understanding the neglect syndrome more generally.

Functional assessment of spatial neglect: a review of the Catherine Bergego scale and an introduction of the Kessler foundation neglect assessment process

Spatial neglect is a debilitating poststroke neurocognitive disorder associated with prolonged hospitalization and poor rehabilitation outcomes. The literature suggests a high prevalence of this disorder, but clinicians have difficulty reliably identifying affected survivors. This discrepancy may result from suboptimal use of validated neglect assessment procedures. In this article, we suggest use of a validated assessment tool that is sensitive to identification of neglect and its functional consequences - the Catherine Bergego Scale (CBS). We provide detailed item-by-item instructions for observation and scoring - the Kessler Foundation Neglect Assessment Process (KF-NAP). Rehabilitation researchers may be able to use the CBS via the KF-NAP to measure ecological outcomes and specific, separable perceptual-attentional and motor-exploratory spatial behaviors.

Rehabilitation of neglect: an update

Spatial neglect is a characteristic sign of damage to the right hemisphere and is typically characterized by a failure to respond to stimuli on the left side. With about a third of stroke victims showing initial signs of neglect, it is a frequent but also one of the most disabling neurological syndromes. Despite partial recovery in the first months after stroke one third of these patients remain severely disabled in all daily activities, have a poor rehabilitation outcome and therefore require specific treatment. The last decades have seen an intensive search for novel, more effective treatments for this debilitating disorder. An impressive range of techniques to treat neglect has been developed in recent years. Here, we describe those techniques, review their efficacy and identify gaps in the current research on neglect therapy.

Evidence-based cognitive rehabilitation: updated review of the literature from 2003 through 2008

OBJECTIVE

To update our clinical recommendations for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 2003 through 2008.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognitive, communication, executive, language, memory, perception, problem solving, and/or reasoning combined with each of the following terms: rehabilitation, remediation, and training for articles published between 2003 and 2008. The task force initially identified citations for 198 published articles.

STUDY SELECTION

One hundred forty-one articles were selected for inclusion after our initial screening. Twenty-nine studies were excluded after further detailed review. Excluded articles included 4 descriptive studies without data, 6 nontreatment studies, 7 experimental manipulations, 6 reviews, 1 single case study not related to TBI or stroke, 2 articles where the intervention was provided to caretakers, 1 article redacted by the journal, and 2 reanalyses of prior publications. We fully reviewed and evaluated 112 studies.

DATA EXTRACTION

Articles were assigned to 1 of 6 categories reflecting the primary area of intervention: attention; vision and visuospatial functioning; language and communication skills; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 112 studies, 14 were rated as class I, 5 as class Ia, 11 as class II, and 82 as class III. Evidence within each area of intervention was synthesized and recommendations for Practice Standards, Practice Guidelines, and Practice Options were made.

CONCLUSIONS

There is substantial evidence to support interventions for attention, memory, social communication skills, executive function, and for comprehensive-holistic neuropsychologic rehabilitation after TBI. Evidence supports visuospatial rehabilitation after right hemisphere stroke, and interventions for aphasia and apraxia after left hemisphere stroke. Together with our prior reviews, we have evaluated a total of 370 interventions, including 65 class I or Ia studies. There is now sufficient information to support evidence-based protocols and implement empirically-supported treatments for cognitive disability after TBI and stroke.

Designing rehabilitation programs for neglect: could 2 be more than 1+1?

Unilateral neglect is a multimodal neuropsychological disorder that has puzzled scientists for a long time. Many interventions have been developed, but only a handful has proven to be effective. This review examines whether applying different therapeutic techniques in combination will increase therapeutic benefits. Studies were reviewed where therapies are applied sequentially or in combination with other techniques. The results indicate that combining different interventions leads to increased general improvement compared with other noncombined designs, even when the number of treatment sessions is not constant. Practical and theoretical aspects of different treatments are discussed. The combined approach to treatment may have direct relevance to disorders other than neglect. This report introduces a new classification scheme for different interventions with the aim of facilitating more focused therapy. Finally, suggestions are made as to what the focus of future studies of neglect therapy should be and how therapeutic benefits might be maximized.

Galvanic vestibular stimulation reduces the pathological rightward line bisection error in neglect-a sham stimulation-controlled study

Patients with right hemisphere lesions often show left spatial neglect and the typical rightward deviation in horizontal line bisection. Previous studies have shown that sensory stimulation modulates line bisection. A less well-known but promising sensory stimulation method is galvanic vestibular stimulation (GVS). This non-invasive technique leads to activation of the vestibular cortices and adjacent cortical areas in the temporo-parietal cortex via polarization effects of the vestibular nerves. This is accomplished by application of weak direct currents, delivered by two electrodes attached to the mastoids. Despite the relative benefits of GVS its effects on line bisection have not yet been studied in neglect patients. Thus, the present study investigated the impact of GVS on performance in a modified line bisection task in right-brain damaged patients with versus without leftsided visual neglect. In neglect patients, but not in control patients, left-cathodal and right-cathodal GVS significantly reduced the rightward line bisection error as compared to Baseline (without GVS) and sham stimulation. A larger decrease of the rightward line bisection error was observed during right-cathodal GVS. Sham stimulation showed no specific effects on line bisection. The beneficial effects of GVS might be due to activation of preserved structures of the lesioned right posterior parietal cortex which is known to be involved in line bisection.

Rehabilitation approaches to hemineglect

BACKGROUND

Hemineglect is a difficult neurologic condition to rehabilitate. It arises predominantly from right brain injury, and manifests heterogeneously in clinical deficits such as poor visual exploration to the left, inaccurate assessment of the midpoint of a line, left limb hypokinesis, and anosognosia. Most of the cognitive dysfunction produced by hemineglect is because of an asymmetric distribution of attention, either with respect to extrapersonal space or to an object being viewed. Many treatments draw on hemineglect theory to attempt to mediate the basic asymmetry of attention.

REVIEW SUMMARY

Treatment approaches can be divided into 2 main categories. Extrinsic or "top-down" approaches require active participation of the patient under the guidance of a therapist. The most common approach of this type is visual scanning therapy in which the patient is continually instructed to move the gaze leftward into the neglected space. Intrinsic or "bottom-up" approaches manipulate stimulus characteristics, sensory input, or the brain directly in an attempt to alter the interhemispheral attentional imbalance. Examples of this approach include vestibular stimulation of the left side, sensory activation of the left limb, and transcranial magnetic stimulation of the overactive left hemisphere. Combined approaches such as prism adaptation have also shown good results.

CONCLUSIONS

Hemineglect is a complicated disorder that poses challenges to treatment. A paucity of clinical trial evidence limits our ability to extrapolate experimental mediation of hemineglect to globally improved functioning. Nonetheless, many treatment approaches appear promising. Underlying neuroscience may help guide future treatment approaches.

Combination of Pursuit Eye Movement Training With Prism Adaptation and Arm Movements in Neglect Therapy: A Pilot Study

Objective. The aim of the present study was to determine if a combination of pursuit eye movement training to optokinetic stimulation (OKSP) and prism adaptation leads to greater improvement of neglect symptoms than a single application of OKSP. Additionally, the effect of ipsilesional arm movements during OKSP was tested. Methods. Ten patients with left-sided neglect due to unilateral right-sided vascular brain lesions were studied between 2 and 4.5 months after their stroke. Each patient received 4 different single-session treatments (each lasting 30 minutes): visual scanning treatment (control condition), OKSP, OKSP in conjunction with wearing base-left prisms inducing a shift of the visual field to the right by 10°, and OKSP in conjunction with the right to the left side. Severity of visuospatial neglect was assessed before and directly after each treatment with 4 standard neglect tests. Results. Visual scanning training improved neglect symptoms only slightly. Single OKSP stimulation led to significant improvements in all tests. OKSP in conjunction with prism adaptation was superior to the control condition in the cancellation task. The treatment condition requiring arm movements aggravated neglect symptoms in all tests. A comparison between treatments indicates best improvements may be achieved with OKSP without any additional treatment. Conclusions . The present results give evidence that OKSP significantly reduces symptoms of visuospatial neglect within 1 treatment session. The results suggest that patients should be prevented from performing ipsilesional movements during OKSP.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

Unilateral spatial neglect causes difficulty attending to one side of space. Various rehabilitation strategies have been used but evidence of their benefit is lacking.

OBJECTIVES

To determine the persisting effects of cognitive rehabilitation specifically aimed at spatial neglect following stroke, as measured on impairment and disability level outcome assessments and on destination on discharge from hospital.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched 4 July 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005), CINAHL (1983 to July 2005), PsycINFO (1974 to July 2005), UK National Research Register (July 2005). We handsearched relevant journals, screened reference lists, and tracked citations using SCISEARCH.

SELECTION CRITERIA

We included randomised controlled trials of cognitive rehabilitation specifically aimed at spatial neglect. We excluded studies of general stroke rehabilitation and studies with mixed patient groups, unless more than 75% of their sample were stroke patients or separate stroke data were available.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials, extracted data, and assessed trial quality.

MAIN RESULTS

We included 12 RCTs with 306 participants. Only four had adequate allocation concealment, that is a low risk of selection bias. A large number of outcome measures were reported. Only six studies measured disability and two investigated whether the effects persisted. The overall effect (standardised mean difference) on disability had a wide confidence interval that included zero and was not statistically significant. For discharge destination there were clinically significant effects but in both directions and the confidence interval of the odds ratio included one. In contrast, cognitive rehabilitation did improve performance on some, but not all, standardised neglect tests. The number of cancellation errors made was reduced and the ability to find the midpoint of a line improved immediately and persisted at follow up. These effects appeared likely to generalise from the samples studied to the target population, but were based on a small number of studies.

AUTHORS' CONCLUSIONS

Several types of neglect specific approaches are now described but there is insufficient evidence to support or refute their effectiveness at reducing disability and improving independence. They can alter test performance and warrant further investigation in high quality randomised controlled trials. As we did not review whether patients with neglect benefit from rehabilitation input in general, such patients should continue to receive general stroke rehabilitation services.

Therapeutic effects of caloric stimulation and optokinetic stimulation on hemispatial neglect

Hemispatial neglect refers to a cognitive disorder in which patients with unilateral brain injury cannot recognize or respond to stimuli located in the contralesional hemispace. Hemispatial neglect in stroke patients is an important predictor for poor functional outcome. Therefore, there is a need for effective treatment for this condition. A number of interventions for hemispatial neglect have been proposed, although an approach resulting in persistent improvement is not available. Of these interventions, our review is focused on caloric stimulation and optokinetic stimulation. These lateralized or direction-specific stimulations of peripheral sensory systems can temporarily improve hemispatial neglect. According to recent functional MRI and PET studies, this improvement might result from the partial (re)activation of a distributed, multisensory vestibular network in the lesioned hemisphere, which is a part of a system that codes ego-centered space. However, much remain unknown regarding exact signal timing and directional selectivity of the network.

The neurological basis of visual neglect

PURPOSE OF REVIEW

A recent study has confirmed the enormous impact of visual neglect on the health services of the western world. Neglect was present in 48% of a sample of 166 right hemisphere stroke patients, and the severity of neglect predicted the extent of functional disability and family burden more accurately than did the extent of brain damage. Given the medical significance of neglect and its tantalizing relevance to understanding human conscious experience, it is unsurprising that the neuropsychological literature concerning the syndrome continues to grow rapidly.

RECENT FINDINGS

We include brief surveys of six topics currently attracting attention in the field: the anatomical focus of neglect; the visual input pathways implicated; impairments of spatial working memory; the nature of visual extinction; perceptual distortions in neglect; studies on healthy subjects using transcranial magnetic stimulation; and the use of prism adaptation for the rehabilitation of neglect.

SUMMARY

There is steady progress in understanding the essential components of neglect and their brain localization. Every step towards clarity, however, seems to be matched by a new discovery of the inherent complexity of the syndrome. The clinical expression of neglect may reflect the interaction of a variety of spatially lateralized and non-lateralized impairments, not all of which are present in all patients. The quest for an effective technique for the clinical rehabilitation of neglect continues, with prism adaptation emerging as the most promising approach to date.

EFNS guidelines on cognitive rehabilitation: report of an EFNS task force

Disorders of language, spatial perception, attention, memory, calculation and praxis are a frequent consequence of acquired brain damage [in particular, stroke and traumatic brain injury (TBI)] and a major determinant of disability. The rehabilitation of aphasia and, more recently, of other cognitive disorders is an important area of neurological rehabilitation. We report here a review of the available evidence about effectiveness of cognitive rehabilitation. Given the limited number and generally low quality of randomized clinical trials (RCTs) in this area of therapeutic intervention, the Task Force considered, besides the available Cochrane reviews, evidence of lower classes which was critically analysed until a consensus was reached. In particular, we considered evidence from small group or single cases studies including an appropriate statistical evaluation of effect sizes. The general conclusion is that there is evidence to award a grade A, B or C recommendation to some forms of cognitive rehabilitation in patients with neuropsychological deficits in the post-acute stage after a focal brain lesion (stroke, TBI). These include aphasia therapy, rehabilitation of unilateral spatial neglect (ULN), attentional training in the post-acute stage after TBI, the use of electronic memory aids in memory disorders, and the treatment of apraxia with compensatory strategies. There is clearly a need for adequately designed studies in this area, which should take into account specific problems such as patient heterogeneity and treatment standardization.