Rehabilitation of visuospatial neglect by prism adaptation: effects of a mild treatment regime. A randomised controlled trial

A study of prisms and therapy in attention loss after stroke (SPATIAL): A feasibility randomised controlled trial

OBJECTIVE

Investigate feasibility and acceptability of prism adaptation training for people with inattention (spatial neglect), early after stroke, during usual care.

DESIGN

Phase II feasibility randomised controlled trial with 3:1 stratified allocation to standard occupational therapy with or without intervention, and nested process evaluation.

SETTING

Ten hospital sites providing in-patient stroke services.

PARTICIPANTS

Screened positive for inattention more than one-week post-stroke; informal carers. Occupational therapists participated in qualitative interviews.

INTERVENTION

Adjunctive prism adaptation training at the start of standard occupational therapy sessions for three weeks.

MAIN MEASURES

Feasibility measures included recruitment and retention rates, intervention fidelity and attrition. Outcomes collected at baseline, 3 weeks and 12 weeks tested measures including Nottingham Extended Activities of Daily Living Scale. Acceptability was explored through qualitative interviews and structured questions.

RESULTS

Eighty (31%) patients were eligible, 57 (71%) consented, 54 randomised (40:13, +1 exclusion) and 39 (74%) completed 12-week outcomes. Treatment fidelity was good: participants received median eight intervention sessions (IQR: 5, 12) lasting 4.7 min (IQR: 4.1, 5.0). All six serious adverse events were unrelated. There was no signal that patients allocated to intervention did better than controls. Twenty five of 35 recruited carers provided outcomes with excellent data completeness. Therapists, patients and carers found prism adaptation training acceptable.

CONCLUSIONS

It is feasible and acceptable to conduct a high-quality definitive trial of prism adaptation training within occupational therapy early after stroke in usual care setting, but difficult to justify given no sign of benefit over standard occupational therapy.

CLINICAL TRIAL REGISTRATION

https://www.isrctn.com/ Ref ISRCTN88395268.

Unilateral Spatial Neglect Recovery Poststroke

Unilateral spatial neglect (USN) is a common and disabling cognitive consequence of stroke wherein individuals demonstrate decreased response to contralesional information. Here, we provide an updated narrative review of studies that shed light on the neural mechanisms and predictors of recovery of USN. Additionally, we report a rapid review of randomized controlled trials focusing on USN intervention, both nonpharmacological and pharmacological, published in the last 5 years. Randomized controlled trials are reviewed within the context of systematic reviews and meta-analyses of USN interventions published within the same time frame. The quality of randomized controlled trials of treatment is higher compared to quality reported in previous reviews and meta-analyses. However, remaining weaknesses in participant demographic reporting, as well as small, heterogenous samples, render generalizability and cross-study interpretation a challenge. Nevertheless, evidence regarding neural mechanisms underlying USN recovery and regarding the effectiveness of targeted USN interventions is accumulating and strengthening, setting the foundation for future investigations into patient-specific factors that may influence treatment response. We identify gaps and provide suggestions for future USN intervention research.

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.

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.

Effect of motor tasks with left monocular eyeglasses on visual search and line-bisection performance in people with left unilateral spatial neglect

Training with an eyepatch or eyeglasses is one of the effective approaches for unilateral spatial neglect (USN), and it usually uses a device that covers the right side. However, few approaches are available for the left side. In this study, we examine the effect of motor tasks with left/right monocular eyeglasses on visual search and line-bisection performance in people with left USN. Seven participants with left USN admitted to convalescent hospitals were included. We conducted the Bells test, line-crossing test, and line-bisection test of the behavioral inattention test before/after the motor task. Our analyses focused on the improvement or decline in these assessment scores and the achievement/errors/non-smoothness scores of the motor task. When using the left monocular eyeglasses, the percentages of participants categorized as "improvement," "unchanged," and "decline" were 71.4%, 28.6%, and 0%, respectively (when using the right one they were 14.3%, 85.7%, and 0%). In the motor task, when using the left monocular eyeglasses, total achievement scores in five of seven participants were greater than those when using the right one, and they performed efficiently with fewer movement errors. These results suggest that training with left monocular eyeglasses might improve visual search performance in people with left USN.

From Patient to Musician: A Multi-Sensory Virtual Reality Rehabilitation Tool for Spatial Neglect

Unilateral Spatial Neglect (USN) commonly results from a stroke or acquired brain injury. USN affects multiple modalities and results in failure to respond to stimuli on the contralesional side of space. Although USN is a heterogeneous syndrome, present-day therapy methods often fail to consider multiple modalities. Musical Neglect Therapy (MNT) is a therapy method that succeeds in incorporating multiple modalities by asking patients to make music. This research aimed to exploit the immersive and modifiable aspect of VR to translate MNT to a VR therapy tool. The tool was evaluated in a 2-week pilot study with four clinical users. These results are compared to a control group of four non-clinical users. Results indicated that patients responded to triggers in their entire environment and performance results could be clearly differentiated between clinical and non-clinical users. Moreover, patients increasingly corrected their head direction towards their neglected side. Patients stated that the use of VR increased their enjoyment of the therapy. This study contributes to the current research on rehabilitation for USN by proposing the first system to apply MNT in a VR environment. The tool shows promise as an addition to currently used rehabilitation methods. However, results are limited to a small sample size and performance metrics. Future work will focus on validating these results with a larger sample over a longer period. Moreover, future efforts should explore personalisation and gamification to tailor to the heterogeneity of the condition.

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.

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.

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.

Prism adaptation treatment to address spatial neglect in an intensive rehabilitation program: A randomized pilot and feasibility trial

Spatial neglect (SN) is a common cognitive disorder after brain injury. Prism adaptation treatment (PAT) is one of the promising interventions for SN albeit inconsistent results from previous studies. We carried out a comparison intervention (PAT vs. Sham) and aimed to evaluate the efficacy of PAT on visuospatial symptoms of SN in an inpatient rehabilitation setting that offered a highly intensive comprehensive brain injury rehabilitation program. A total of 34 patients with moderate-to-severe SN secondary to stroke or traumatic brain injury were randomized to the PAT group and the Sham group (an active control group). Both groups received 10 sessions of treatment, over two weeks, in addition to the rehabilitation therapies provided by their rehabilitation care teams. Outcomes were measured using an ecological instrument (the Catherine Bergego Scale) and paper-and-pencil tests (the Bells Test, the Line Bisection Test and the Scene Copying Test). Patients were assessed at baseline, immediately after treatment, two weeks after treatment, and four weeks after treatment. 23 (67.6%) patients completed treatment and all the assessment sessions and were included in the final analyses using mixed linear modeling. While SN symptoms reduced in both groups, we found no difference between the two groups in the degree of improvement. In addition, the average SN recovery rates were 39.1% and 28.6% in the PAT and Sham groups, respectively, but this discrepancy did not reach statistical significance. Thus, the present study suggests that PAT may contribute little to SN care in the context of a highly intensive inpatient rehabilitation program. Further large-scale investigation is required to uncover the mechanisms underlying PAT and Sham in order to refine the treatment or create new interventions.

Virtual prism adaptation for spatial neglect: A double-blind study

ABSTRACTPrismatic adaptation (PA) with wedge prisms is a non-invasive technique used in the rehabilitation of patients suffering from spatial neglect. Unfortunately, as for many behavioural intervention techniques, it is nearly impossible to achieve adequate blinding using wedge prisms, and the potential benefit of PA in the rehabilitation of neglect remains controversial. In order to study an alternative to wedge prism, we examine whether virtual PA at different degrees of deviation may alleviate signs of neglect in a double-blind design. Fifteen neglect patients participated in three adaptation sessions, which differed by the degree of deviation (0°, 15°, or 30°). Performance in line bisection and item cancellation tasks was measured in virtual reality immediately before and after adaptation. Session allocation was concealed from patients and the examiner. Despite the presence of robust, dose-dependent effects of virtual PA on Open-Loop Pointing (OLP), no transfer to line bisection and item cancellation tests were observed. None of the patients were aware of differences between sessions. Virtual PA did not result in visuo-motor transfer effects despite inducing significant adaptation effects in OLP. Together with recent negative findings of randomized-controlled trials, these findings cast doubt on the general efficacy of PA as a rehabilitation method of spatial neglect.

Applications of Functional Magnetic Resonance Imaging in Determining the Pathophysiological Mechanisms and Rehabilitation of Spatial Neglect

Functional magnetic resonance imaging (fMRI) is a neuroimaging tool which has been applied extensively to explore the pathophysiological mechanisms of neurological disorders. Spatial neglect is considered to be the failure to attend or respond to stimuli on the side of the space or body opposite a cerebral lesion. In this review, we summarize and analyze fMRI studies focused specifically on spatial neglect. Evidence from fMRI studies have highlighted the role of dorsal and ventral attention networks in the pathophysiological mechanisms of spatial neglect, and also support the concept of interhemispheric rivalry as an explanatory model. fMRI studies have shown that several rehabilitation methods can induce activity changes in brain regions implicated in the control of spatial attention. Future investigations with large study cohorts and appropriate subgroup analyses should be conducted to confirm the possibility that fMRI might offer an objective standard for predicting spatial neglect and tracking the response of brain activity to clinical treatment, as well as provide biomarkers to guide rehabilitation for patients with SN.

Unilateral Spatial Neglect After Stroke: Current Insights

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSION

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

The Effect of Continuous Theta-Burst Transcranial Magnetic Stimulation Combined with Prism Adaptation on the Neglect Recovery in Stroke Patients

OBJECTIVES

This study was designed to investigate the effect of prism adaptation (PA) combined with continuous theta-burst transcranial magnetic stimulation (cTBS) on the neglect recovery of stroke patients with unilateral neglect.

METHODS

A total of 14 stroke patients with unilateral neglect were randomly assigned to 2 groups including an intervention group undergone PA combined with cTBS over the left intact parietal cortex and a control group. PA combined with sham cTBS was perfomed for 2 weeks in 10 daily sessions. Before and after the intervention, patients were evaluated for visuospatial neglect measured using the Star Cancellation Test (SCT), Line Bisection Task (LBT), Figure Copying Test, and Clock Drawing Task. Neurological function was evaluated using the Modified Rankin Scale (MRS).

RESULTS

Both groups (PA alone and PA+ cTBS) showed improvement in their neglected symptoms (measured by SCT, LBT, Figure Copying Test, and Clock Drawing Task), and in their disability in the neurological function (measured by MRS) (P< .05).

CONCLUSIONS

The results of the present study showed that, transcranial magnetic stimulation did not increase the effect of PA on neglect symptoms in stroke patients.

Perceptual Postural Imbalance and Visual Vertigo

PURPOSE OF REVIEW

Disorders of posture and balance cause significant patient morbidity, with reduction of quality of life as patients refrain from critical activities of daily living such as walking outside the home and driving. This review describes recent efforts to characterize visual disorders that interact with the neural integrators of positional maintenance and emerging therapies for these disorders.

RECENT FINDINGS

Abnormalities of gait and body position sense may be unrecognized by patients but are correlated with focal neurological injury (stroke). Patients with traumatic brain injury can exhibit visual vertigo despite otherwise normal visual functioning. The effect of visual neglect on posture and balance, even in the absence of a demonstrable visual field defect, has been characterized quantitatively through gait analysis and validates the potential therapeutic value of prism treatment in some patients. In addition, the underlying neural dysfunction in visual vertigo has been explored further using functional imaging, and these observations may allow discrimination of patients with structural causes from those whose co-morbid psychosocial disorders may be primarily contributory.

Prism Adaptation in Rehabilitation? No Additional Effects of Prism Adaptation on Neglect Recovery in the Subacute Phase Poststroke: A Randomized Controlled Trial

Background. Patients with neglect ignore or respond slower to contralesional stimuli. Neglect negatively influences independence in activities of daily living (ADL). Prism adaptation (PA) is one of the most frequently studied treatments, yet there is little evidence regarding positive effects on neglect behavior in ADL. Objective. To assess whether PA in the subacute phase ameliorates neglect in situations of varying complexity. Methods. A total of 70 neglect patients admitted for inpatient stroke rehabilitation received either PA or sham adaptation (SA) for 2 weeks, with full access to standard treatment. There were 7 time-dependent measurements (baseline and 1-4, 6, and 14 weeks after start of treatment). The primary outcome was change of neglect as observed during basic ADL with the Catherine Bergego Scale (CBS). Secondary outcomes were changes in performance on a dynamic multitask (ie, the Mobility Assessment Course [MAC]) and a static paper-and-pencil task (ie, a shape cancellation task [SC]). Results. In all, 34 patients received PA and 35 SA. There were significant time-dependent improvements in performance as measured with the CBS, MAC, and SC (all F > 15.57; P < .001). There was no significant difference in magnitude of improvement between groups on the CBS, MAC, and SC (all F < 2.54; P > .113]. Conclusions. No beneficial effects of PA over SA in the subacute phase poststroke were observed, which was comparable for situations of varying complexity. Heterogeneity of the syndrome, time post–stroke onset, and the content of treatment as usual are discussed. Basic knowledge on subtypes and recovery patterns would aid the development of tailored treatment.