Functional evaluation of hemineglect by means of a semistructured scale: Personal extrapersonal differentiation

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

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

Reduced Visuospatial Attention in Personal Space is Not Limited to the Affected Limb in Complex Regional Pain Syndrome

Purpose

Alterations in spatial attention have been reported in people with chronic pain and may be relevant to understanding its cortical mechanisms and developing novel treatments. There is conflicting evidence as to whether people with Complex Regional Pain Syndrome (CRPS) have reduced visuospatial attention to their affected limb and/or its surrounding space, with some evidence that these deficits may be greater in personal (bodily) space. We aimed to test the competing hypotheses of whether the visuospatial attentional bias is specific to the personal space of the affected limb or generalizes to the personal space of other parts of the affected side of the body.

Patients and Methods

Using visual Temporal Order Judgement tasks, we measured spatial attention in the personal space of the hands and feet of patients with upper (n=14) or lower (n=14) limb CRPS and pain-free controls (n=17). Participants judged the order of two light flashes presented at different temporal offsets on each of their hands or feet. Slower processing of the flash on one side relative to the other reflects reduced attention to that side of space.

Results

Controls prioritized stimuli on the non-dominant (left) relative to dominant side, consistent with the well-documented normal leftward bias of attention (ie "pseudoneglect"). Regardless of the location (upper or lower limb) of the pain or visual stimuli, people with CRPS showed no such asymmetry, representing reduced attention to the affected side (compared to the greater attention of controls to their non-dominant side). More severe CRPS symptoms were associated with a greater tendency to deprioritize stimuli on the affected side.

Conclusion

Our findings suggest that relative visuospatial bias in CRPS is generalized to the personal space of the affected side of the body, rather than being specific to the personal space of the CRPS-affected limb.

Key constructs of body awareness impairments post-stroke: a scoping review of assessment tools and interventions

PURPOSE

To summarise body awareness assessment tools and interventions relevant for stroke rehabilitation using a framework that categorises key body awareness constructs, disorders and impairments.

MATERIALS AND METHODS

Online electronic databases and trial registries were searched from inception until July 2021, in addition to hand searching reference lists of included studies and reviews. Study selection included any study design where the investigation involved assessing and/or intervening in body awareness following stroke. Data were extracted based on predefined criteria by two independent reviewers and mapped to the emergent framework.

RESULTS

The final analysis included 144 papers that reported 43 assessment tools and 8 types of interventions for body awareness. Consensus was reached on a synthesised body awareness framework. This comprised specific impairments and disorders, constructs, sub-categories and main categories leading to the overarching term of body awareness. Clinical and psychometric properties of the assessment tools were not reported or poorly evaluated, and the interventions lacked robust study designs and rigorous methods.

CONCLUSIONS

The framework produced will enable future research and clinical practice to be based on consistent concepts and definitions. Clinicians can also use this information to cautiously select assessment tools and/or interventions but are reminded of the limitations identified in this review.Implications for rehabilitationThere is limited understanding, compounded by inconsistent terminology and definitions regarding body awareness after stroke.A synthesized framework to define key constructs and definitions of body awareness is proposed.Assessment tools and interventions reported in the literature are mapped to the proposed framework.Psychometric properties of available tools are reported.Significant work remains to refine concepts of body awareness, develop and evaluate assessment tools and interventions.

Spatial neglect encompasses impaired verticality representation after right hemisphere stroke

Spatial neglect after right hemisphere stroke (RHS) was recently found to encompass lateropulsion, a deficit in body orientation with respect to gravity caused by altered brain processing of graviception. By analogy, we hypothesized that spatial neglect after RHS might encompass an altered representation of verticality. We also assumed a strong relation between body neglect and impaired postural vertical, both referring to the body. To tackle these issues, we performed contingency and correlation analyses between two domains of spatial neglect (body, extra-body) and two modalities of verticality perception (postural, visual) in 77 individuals (median age = 67) with a first-ever subacute RHS (1-3 months). All individuals with a transmodal (postural and visual) tilt in verticality perception (n = 26) had spatial neglect, but the reverse was not found. Correlation and multivariate analyses revealed that spatial neglect (and notably body neglect) was associated more with postural than visual vertical tilts. These findings indicate that after RHS, an impaired verticality representation results from a kind of graviceptive neglect, bearing first on somaesthetic graviception and second on vestibular graviception. They also suggest that the human brain uses not only a mosaic of 2D representations but also 3D maps involving a transmodal representation of verticality.

Effects of visual-motor illusion in stroke hemiplegic patients with left-side personal neglect: A report of two cases

Personal neglect is the neglect of self-body space, which often occurs in patients with unilateral spatial neglect (USN), but lacks a dedicated rehabilitation. The purpose of this study was to investigate the effects of visual-motor illusion (VMI) on two-stroke hemiplegic patients with left-side personal neglect. Case 1 was a 53-year-old man diagnosed with a right lenticulostriate artery infarction. Case 2 was a 76-year-old woman diagnosed with a right middle cerebral artery infarction. USN symptoms were not observed in either patient in the desk USN assessment, but personal neglect and USN symptoms in daily life were observed in both patients. Intervention effects were verified using an ABA design, comprising a 5-day three-phase (A1, B, A2). In phase B, VMI was performed on the paralyzed upper limb for 10 min in addition to conventional physical therapy. Outcomes measures were the Fluff test, Catherine Bergego Scale (CBS), Fugl-Meyer Assessment (FMA), and Functional Independence Measure (FIM). In both patients, no improvements were noted in FMA, but improvements were observed in the Fluff test, CBS, and FIM in phase B; these effects were retained in phase A2. Therefore, VMI may have contributed to improvements in Personal neglect and USN symptoms in daily life.

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.

Attention upturned: Bias toward and away from the affected side of the body and near space in a case of complex regional pain syndrome

People with Complex Regional Pain Syndrome (CRPS) following limb injury can show neuropsychological symptoms in the absence of observable brain pathologies. These can include sensory changes, distorted body representation, and inattention to their affected limb and its surrounding space, resembling post-stroke hemispatial neglect. The precise nature and mechanisms of these neuropsychological symptoms are unclear, however insights could be gained by testing for dissociations and associations that have been observed in stroke patients. Drawing from clinical and experimental methods for investigating spatial attention bias and related symptoms in stroke patients, we conducted a detailed investigation of neuropsychological symptoms in a woman with CRPS of her left arm who initially presented to us with pronounced inattention to her affected side. The patient showed visual and tactile neglect and extinction on her affected side on confrontation tests, but no attention deficits on "bedside" tests of neglect. On sensitive computer-based measures, attention biases were found in the patient's body and near space (in Temporal Order Judgements), but not far or imagined space (on the Greyscales task and Mental Number Line Bisection). Unique to the current literature, the patient showed a reversal in her Temporal Order Judgement bias across time, from inattention (first and second session) to hyperattention (third session) to her affected side. In contrast, pain and self-reported body representation distortion were similar across the three sessions. The patient had reduced central and peripheral visual acuity, however these deficits were near symmetrical and therefore could not explain her performance on the visual attention tasks. Given that spatial attention bias has been linked to imbalance in relative activation of the two cerebral hemispheres, we administered a Global-Local processing task to test for hemispheric asymmetry. This revealed no difference in global compared to local interference refuting any hemispheric imbalance. Instead, the patient showed impaired performance (compared to controls) on incongruent trials regardless of trial type, consistent with executive impairment. We conclude that spatial attention bias in CRPS can generalize across different sensory modalities and extend beyond the affected limb to the external space around it, independent of any low-level sensory disturbances. This bias is not necessarily directed away from the affected side or stable over time. People with CRPS can also demonstrate more generalized neuropsychological changes in sensory and executive functions. Our observations refute several existing theories about the mechanisms of attention bias in CRPS, and their relationship to pain, and have potential implications for treatment.

Systematic Review of Sensory Stimulation Programs in the Rehabilitation of Acquired Brain Injury

Abstract. Acquired Brain Injury (ABI) can lead to sensory deficits and compromise functionality. However, most studies have been focused on motor stimulation in stroke and traumatic brain injury (TBI). Sensory stimulation in stroke and mild/moderate TBI has received reduced interest. The main objective of this review is to know the methodological characteristics and effects of sensory programs in ABI. Studies with the purpose of testing the efficacy of those programs were identified through a literature search, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) and the Cochrane Collaboration Guidelines. Twenty-three studies were included in this review. The results show that in most studies sensory stimulation started within 12 months after injury and there is no consensus regarding frequency, duration and number of sessions, duration of intervention, and instruments used to assess outcomes. Most programs involved unisensory stimulation, and vision was the predominant target. The most used methods were compensation and somatosensory discrimination training. Most studies used a pre- and post-intervention assessment, with few studies comprising follow-up assessment. Regarding the studies revised, the interventions with positive outcomes in ABI are: compensation, cognitive training, vestibular intervention, somatosensory discrimination training, proprioceptive stimulation with muscle vibration, and sustained attention training with olfactory stimulation. Available findings suggest that sensory stimulation has positive results with immediate and long-term improvements in sensory functioning. This review provides useful information to improve rehabilitation and to design future investigation.

The downsized hand in personal neglect

Introduction: Personal neglect (PN) refers to a form of hemi-inattention toward the contralesional body space and it usually occurs following a right brain lesion. Recent studies suggest that PN indicates a disorder of body representation. Specifically, patients with PN show difficulties in identifying differences between left and right hands and have an altered visuospatial body map, which is associated with disrupted mental body representations. However, the metric representation of the body, and in particular the hands, has not been systematically addressed in patients showing this form of neglect. Method: In the present study, we have investigated this representation by testing the perceived hands' width of 11 hemiplegic patients with right hemisphere cerebral lesions (5 with PN) and 12 healthy controls on a judgment of passability task. Patients and controls were asked to imagine inserting their hand (left and right) through a series of vertical apertures of different sizes and to judge whether their hand could fit through. Due to the heterogeneity of the data, both parametric and non-parametric approaches were used. Furthermore, additional single-case analyses were conducted. Results: Study findings showed that patients with PN showed a significant underestimation of the left hand compared with their right hand. In contrast, whilst the right hand was equally distorted in both patients' groups, the hemiplegic patients with no evidence of PN tended to perceive the affected hand as larger than their ipsilesional one. Conclusions: In line with the literature, our findings confirm an underlying distorted body representation following right brain damage. However, for the first time, we report both a quantitative and qualitative difference in impact of hemiplegia and PN on body representation of the contralesional body space.

The 'Neglected' Personal Neglect

A review of patients with brain injury showing personal neglect is presented. The aim is to shed light on this aspect of neglect often unresearched or only indirectly investigated, and to discuss recent findings concerning the methods used to assess personal neglect, its neural correlates and its association with the more often explored aspect of extrapersonal neglect. The review was performed using PubMed and PsychInfo databases to search for papers published in the last 123 years (until January 2018). We reviewed 81 papers describing either single or group studies for a total of 2247 patients. The results of this review showed that various aspects of personal neglect are still controversial and outcomes potentially contradictory. Despite the data reported in the present review suggest that personal neglect is more frequently associated with lesions of the right hemisphere, the left hemisphere may also play an important role. Not surprisingly, personal neglect and extrapersonal neglect seem to co-occur. However double dissociations of these two forms of neglect have been reported, and they seem to dissociate both from a functional and an anatomical perspective. More recent interpretations of personal neglect suggest that it may result from a disrupted body representation. The development of reliable psychometric tools with shared diagnostic criteria is essential to identify different degrees of personal neglect for different body parts and to better refine personal neglect in comparison to extrapersonal neglect and disorders related to distortions of personal domain.

Unilateral spatial neglect after posterior parietal damage

Unilateral spatial neglect is a disabling neurologic deficit, most frequent and severe after right-hemispheric lesions. In most patients neglect involves the left side of space, contralateral to a right-hemispheric lesion. About 50% of stroke patients exhibit neglect in the acute phase. Patients fail to orient, respond to, and report sensory events occurring in the contralateral sides of space and of the body, to explore these portions of space through movements by action effectors (eye, limbs), and to move the contralateral limbs. Neglect is a multicomponent higher-level disorder of spatial awareness, cognition, and attention. Spatial neglect may occur independently of elementary sensory and motor neurologic deficits, but it can mimic and make them more severe. Diagnostic tests include: motor exploratory target cancellation; setting the midpoint of a horizontal line (bisection), that requires the estimation of lateral extent; drawing by copy and from memory; reading, assessing neglect dyslexia; and exploring the side of the body contralateral to the lesion. Activities of daily living scales are also used. Patients are typically not aware of neglect, although they may exhibit varying degrees of awareness toward different components of the deficit. The neural correlates include lesions to the inferior parietal lobule of the posterior parietal cortex, which was long considered the unique neuropathologic correlate of neglect, to the premotor and to the dorsolateral prefrontal cortices, to the posterior superior temporal gyrus, at the temporoparietal junction, to subcortical gray nuclei (thalamus, basal ganglia), and to parietofrontal white-matter fiber tracts, such as the superior longitudinal fascicle. Damage to the inferior parietal lobule of the posterior parietal cortex is specifically associated with the mainly egocentric, perceptual, and exploratory extrapersonal, and with the personal, bodily components of neglect. Productive manifestations, such as perseveration, are not a correlate of posterior parietal cortex damage.

Neuropsychology of Aesthetic Judgment of Ambiguous and Non-Ambiguous Artworks

Several affective and cognitive processes have been found to be pivotal in affecting aesthetic experience of artworks and both neuropsychological as well as psychiatric symptoms have been found to affect artistic production. However, there is a paucity of studies directly investigating effects of brain lesions on aesthetic judgment. Here, we assessed the effects of unilateral brain damage on aesthetic judgment of artworks showing part/whole ambiguity. We asked 19 unilaterally brain-damaged patients (10 left and 9 right brain damaged patients, respectively LBDP and RBDP) and 20 age- and education-matched healthy individuals (controls, C) to rate 10 Arcimboldo's ambiguous portraits (AP), 10 realistic Renaissance portraits (RP), 10 still life paintings (SL), and 10 Arcimboldo's modified portraits where only objects/parts are detectable (AO). They were also administered a Navon task, a facial recognition test, and evaluated on visuo-perceptual and visuo-constructional abilities. Patients included in the study did not show any deficits that could affect the capability to explore and enjoy artworks. SL and RP was not affected by brain damage regardless of its laterality. On the other hand, we found that RBDP liked AP more than the C participants. Furthermore, we found a positive correlation between aesthetic judgment of AP and visuo-perceptual skills even if the single case analyses failed to find a systematic association between neuropsychological deficits and aesthetic judgment of AP. On the whole, the present data suggest that a right hemisphere lesion may affect aesthetic judgment of ambiguous artworks, even in the absence of exploration or constructional deficits.

Unilateral Neglect and Functional Significance among Patients with Stroke

The purpose of this study was to investigate the impact of unilateral neglect on activities of daily living (ADL). Participating in the study were 46 right-brain stroke patients evaluated on the Klein-Bell ADL Scale, the Draw-A-Man-Test, the Random Chinese Word Cancellation Test, and physical variables. Based on the results of the Draw-A-Man Test, and of the Random Chinese Word Cancellation Test, patients were divided into groups. The results showed that patients demonstrating concurrent personal and extrapersonal neglect were significantly lower in ADL performance than patients with extrapersonal neglect and patients with test results within normal range, but that the latter two groups did not differ from each other statistically. ADL performance was found to be related to physical variables. However, after controlling the effects of these physical variables by a partial correlation, the presence of concurrent personal and extrapersonal neglect was significant as it related to ADL performance.

The ecological assessment of unilateral neglect

Conventional paper-and-pencil tests of unilateral neglect are of limited ecological validity. To address this issue, a number of assessment procedures have been proposed to provide clinicians and researchers with more ecologically valid assessments of unilateral neglect, which may be useful to plan rehabilitation and to measure the generalization of the effects of rehabilitation to daily life. We present here an overview of the different assessment measures available in the literature. The most widely used scales are the Behavioural Inattention Test (BIT), the semi-structured scales for assessment of personal and extra-personal neglect, the Subjective Neglect Questionnaire, the Baking Tray Task, the wheelchair obstacle course, the ADL-based neglect battery, and the Catherine Bergego Scale (CBS). The CBS is probably, to date, the most widely used behavioural assessment instrument for unilateral neglect. It has been found to be reliable, valid, and sensitive to change during rehabilitation. It also enables the assessment of awareness of the consequences of unilateral neglect in daily life skills.

Evaluating Unilateral Spatial Neglect Post Stroke: Working Your Way Through the Maze of Assessment Choices

This study identified, using a comprehensive review of the literature, 62 standardized and nonstandardized assessment tools that exist to evaluate unilateral spatial neglect (USN). Each standardized tool was critically appraised according to its purpose (hemispace assessed), psychometric properties, and client appropriateness. The findings on the 28 standardized tools were compiled into a USN Assessment Summary Guide to facilitate clinical decision-making regarding the standardized USN assessments that are appropriate for specific clients at different phases of their recovery post stroke.

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.

Posterior parietal cortex and visuospatial control in near and far space

Neuropsychological studies of patients with visuospatial neglect have shown differences in perceptual deficits for information in near space (i.e. near to the body) and information in far space. It has been suggested that among the many areas of the human brain, a number of areas are associated with a set of spatial maps specialized for visuospatial control related to this spatial distinction. This paper reviews how parietal cortex is thought to be involved in visuospatial neglect in relation to its control of visuospatial attention in the left and right visual fields and at different viewing distances. In particular, the importance of regions of the parietal cortex in the pathogenesis of neglect and in spatial attention and perception is discussed. Parietal cortex may control different distributions of attention across space by allocating specific attentional resources in near and far space while also showing attentional asymmetry across visual fields. Transcranial magnetic stimulation (TMS) as a technique offers the advantage of examining the direct behavioral effect of disruption of many of these areas with excellent temporal and spatial resolution. We discuss the use of TMS and the insights it may offer regarding the roles of these areas in neglect as well as normal visuospatial perception.

Errors of somatosensory localisation in a patient with right-hemisphere stroke

Following a right-hemisphere stroke, Patient NG could detect somatosensory stimulation that she was unable to localise. With vision precluded, NG systematically mislocalized touch on the little and ring finger of her affected left hand, and reported feeling this touch on the neighbouring rightward finger. This pattern of mislocalization occurred not only when the Examiner administered touch but also when touch was self-administered. We manipulated the relative position of NG's two hands during sensory assessment of the affected hand. When NG's right hand was positioned to the left of her affected hand, NG exhibited improved localisation. Theoretical and clinical implications are discussed.

Selective visual neglect in right brain damaged patients with splenial interhemispheric disconnection

Left unilateral neglect is frequently reported after right hemispheric lesions of the middle cerebral artery (MCA) damaging the parietal-frontal cortical-subcortical network subserving space representation and awareness. However, accumulating evidence shows that neglect can also follow lesions of the posterior cerebral artery (PCA) that do not directly affect this parietal-frontal network. Surgical studies in the monkeys have demonstrated that complete callosal resection combined with lesion of the right optic tract entirely deprives the right hemisphere of visual inputs from the left hemispace provoking severe left unilateral neglect. Here, through the detailed study of two patients we show, for the first time, that PCA lesions selectively affecting the splenium of the corpus callosum and the adjacent right primary visual cortex provoke severe neglect selectively restricted to the visual domain. No trace of personal, motor or representational-imagery neglect was found. Also at variance with previous case studies in which neglect followed lesion of the trunk or the genu of the corpus callosum, no restriction of neglect to tasks performed with the right hand, no left hemispatial limb akinesia, no tactile extinction for the left hand and no tactile anomia for stimuli explored with the left hand were observed. These findings demonstrate that brain lesions depriving intact parietal and frontal attentional areas from specific sensory inputs can yield spatial neglect limited to specific sensory modalities or sectors of space.

Recovery from unilateral neglect after right-hemisphere stroke

PURPOSE

To show the recovery process for different forms of unilateral neglect (UN)--including personal neglect and neglect of far space--in relationship to impairment, disability, cognition and mood.

METHOD

Patients were tested at 2-4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

RESULTS

Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

CONCLUSIONS

For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.

Pure representational neglect and navigational deficits in a case with preserved visuo-spatial working memory

We describe a patient who, after right hemisphere damage, showed severe, persistent, pure representational neglect but no evidence of perceptual neglect and no deficits in spatial working memory when evaluated with a traditional clinical test (Corsi Block Tapping test). This finding provides evidence against a full explanation of representational neglect within the context of visuo-spatial working memory. Indeed, this patient showed a peculiar deficit in navigational tasks requiring re-orientation in a novel environment by means of his mental representation of the environment. Since no representational neglect was observed in tests requiring mental representation of single or multiple objects (i.e., o'clock test) we suggest that in our patient representational neglect is caused by damage to the cognitive system involved in coding and storing environmental information to be used during navigation.

Clinical assessment of hemispatial neglect: evaluation of different measures and dimensions

The multidimensional nature of the neglect syndrome constitutes a challenge for clinical assessments. This study evaluates the sensitivity of different clinical measures to detect neglect and explores ways to evaluate the diversity of the syndrome in a clinical sample. An extensive battery of tests was used to examine aspects of visuospatial, representational, and personal neglect. A total of 31 normal control participants and 34 patients with right hemisphere stroke were examined 16.8 days post-stroke, on average. Of the patients, 24 showed neglect in at least one task. The Random shape cancellation test, Star cancellation, and two line bisection tasks appeared to be the most sensitive tests of visuospatial neglect. Personal neglect and neglect in far space occurred only together with extrapersonal neglect. Besides near space, other spatial aspects of neglect are important to consider in clinical assessments, but standardized methods are needed. In this patient group a minimum of 10 tests were needed to cover various aspects of detection, dissociations, and severity of neglect. A multifactorial approach in clinical testing of neglect is recommended.

Négligence spatiale unilatérale : une conséquence dramatique mais souvent négligée des lésions de l’hémisphère droit

INTRODUCTION

Unilateral Spatial Neglect (USN) is a common consequence of right brain damage. In the most severe cases, behavioral signs of USN can last several years and compromise patients' autonomy and social rehabilitation. These clinical facts stress the need for reliable procedures of diagnosis and rehabilitation.

STATE OF THE ART

The last 3 decades have witnessed an explosion of studies on USN, which raises issues related to complex cognitive activities such as mental representation, spatial attention and consciousness. USN is probably a heterogeneous syndrome, but some of its underlying mechanisms might be understood as an association of disorders of spatial attention. A bias of automatic orienting towards right-sided objects seems typical of left USN. Afterwards, patients find it difficult to disengage their attention in order to explore the rest of the visual scene. Neglected objects are sometimes processed in an "implicit" way.

PERSPECTIVES

The development of behavioural paradigms and of neuroimaging techniques and their application to the study of USN has advanced our understanding of the functional mechanisms of attention and spatial awareness, as well as of their neural bases. A number of new procedures for rehabilitation have recently been proposed.

CONCLUSION

The present review describes the clinical presentation of USN, its anatomical basis and some of possible accounts of different aspects of neglect behavior. Results of computer simulations and of rehabilitation techniques are also presented with implications for the functioning of normal neurocognitive systems.

Efficacy of visuo-spatial training in right-brain damaged patients with spatial hemineglect and attention disorders

Several rehabilitative approaches have been used to reduce neglect disorders. Some studies tried to demonstrate that hemineglect can be ameliorated by using tasks promoting attentional activation towards the neglected hemispace (Robertson et al., 1995, 2001). As a consequence, a functional link between level of attention and disorders of space exploration has been proposed. For this reason we tried to explore the possible role of attentional deficits on the efficacy of a standard neglect treatment based on visuo spatial rehabilitation. In this study we then examined the performances of a selected group of seven right brain damaged patients, suffering from both severe hemineglect and attentional deficits (of both phasic and tonic components of attention), to several tasks before and after a visuo-spatial training (VST) whose efficacy has been already demonstrated (Pizzamiglio et al., 1992). Results showed that VST induces a significant remission of hemineglect symptoms independently from disorders of attention. Moreover, after visuo-spatial rehabilitation, no improvement of attentional deficits is detectable.

Anosognosia versus unilateral neglect. Coexistence and their relations to age, stroke severity, lesion site and cognition

The aim of this study was to examine the association between anosognosia and unilateral neglect (UN), with special focus on age, stroke severity, lesion location and pre-stroke dementia. The basis of this investigation was a population-based stroke incidence study. Anosognosia was assessed using a questionnaire, and UN using a three-item version of the Behaviour Inattention Test, the Baking Tray Task and a test of personal neglect. Stroke severity was assessed using the NIH stroke scale. Patients with anosognosia were older, and they more often had pre-stroke dementia than patients having UN only. No particular lesion localization was associated with anosognosia, while UN was strongly associated with previously defined lesion sites, often in the parietal lobe. There was a borderline significance regarding stroke severity in patients having anosognosia compared with those with UN only. Patients with anosognosia had higher mortality than patients without, but when controlled for age and stroke severity, this effect was not independent. While UN is closely associated with 'classical' lesion sites, anosognosia is a condition that more often occurs in a previously impaired brain. For anosognosia, lesion location appears to be less important. Anosognosia also tends to occur with larger strokes.

Anosognosia after stroke: assessment, occurrence, subtypes and impact on functional outcome reviewed

PURPOSE

This review provides an update on recent research findings concerning the methods used in the assessment of anosognosia, the occurrence and subtypes of anosognosia, the association between anosognosia and neglect, and the impact of anosognosias on functional outcome.

METHODS

A systematic review covering the period from 1995 to 2005 was carried out on reports drawn from electronic databases (MEDLINE, PSYCHLIT) and identified from the references in these reports. Twenty-seven articles met the selection criteria.

RESULTS

The results of this review are in line with previous findings in the following respects: anosognosia was more often associated with right hemisphere damage, neglect and anosognosia co-occurred, and anosognosia had predictive value on poor functional outcome. The variation in the methods used in the assessment of anosognosia, patient samples and assessment times influence the occurrence rates and the predictive value of anosognosia, which might undermine the generalizability of the results.

CONCLUSIONS

More homogeneous patient samples and consistency in the assessment methods and evaluation times would facilitate comparisons of the occurrence and the impact of anosognosia on functional outcome. New methods need to be developed for the assessment of anosognosia. These new methods should take account of the subtypes of anosognosia both at verbal and at non-verbal levels.

Contraversive Pushing and Inattention of the Contralesional Hemispace

The aim of this study was to investigate, in 114 stroke patients, the frequency of occurrence of a largely unknown neurological disorder, characterized by a postural imbalance due to a 'pushing away' reaction of the body towards the contralesional side of space, in function of hemispheric lesion localization and gender. The study also investigate the relation of this contraversive pushing with active movement, somatosensory perception deficits and, in particular, inattention of contralesional hemispace and body. The similarity of the presence of contraversive pushing and the syndrome of spatial hemineglect together with a gender-related differentiation suggest the existence of a "pusher syndrome", in which the pathophysiology points in the direction of a spatial higher-order processing deficit, related to spatial inattention, underlying the higher frequency and severity of contraversive pushing after right brain lesions.

Influence of unilateral neglect on independence in activities of daily living after stroke

This article summarizes a systematic literature review conducted to establish whether the phenomenon of unilateral neglect (UN) has a substantial impact upon an individual's independence in activities of daily living after stroke. The literature was scrutinized to ensure compatibility with pre-established inclusion criteria and to generate themes for discussion. Consistency of critique methodology was structured through the use of set questions.

Findings of the review were more complex than anticipated, not least because of the influence of additional perceptual and cognitive deficits existing alongside UN. Activities conducted outside personal space were found to be less impaired by UN than those within it, despite agreement not being reached over whether neglect can exist in different areas of space. It has also been suggested that load and familiarity have a strong influence upon ability, which leads existing rehabilitation techniques to be brought into question.

Inconsistencies are great throughout defining, detecting and treating UN. Decreasing these would go a long way towards improving effective and integrated stroke services, as required by the National Service Framework for Older People. Recommendations have been made for areas in need of research and implications for future practice are discussed.

Évaluation des incapacités et de la qualité de vie des patients présentant des troubles cognitifs

OBJECTIVE

To identify disability, handicap and quality of life questionnaires available for patients with cognitive impairment.

MATERIALS AND METHODS

We systematically reviewed the literature in Medline using the keywords assessment, evaluation, deficiency, disability, disadvantage, handicap, quality of life, scale, index, questionnaire, ICIDH-1, and ICIDH-2, combined with the cognitive deficits dysexecutive syndrome, memory deficits, attention deficits, neglect, apraxia, aphasia, agnosia and mood disorders. We focused on validated scales and distinguished scales dedicated to assess disability, handicap and quality of life.

RESULTS

At the level of disability, global and specific scales are available. Specific scales exist for dysexecutive syndrome, memory deficits, attention deficits, unilateral neglect, aphasia and mood disorders. French adaptations of foreign language tests and original tests developed in French have been validated in these areas. No specific tool is available for isolated apraxia or agnosia. Generic scales and pathology-specific scales (for stroke, traumatic brain injury, and multiple sclerosis) are available for quality of life. For aphasia, specific tools are available for incapacity handicap and quality of life.

CONCLUSION

Previous results show the impact of the ICIDH-1 framework on functional outcome assessment of cognitive impairments. This approach is often limited by the lack of theoretical background and by the difficulty to assess the involvement of environment and anosognosia.

Developing functional outcome measures for unilateral neglect: A pilot study

Stroke patients may develop personal neglect, peripersonal neglect or both. Four new measures were tested in a sample of 42 right-handed inpatients (25 male; 17 female, median age 72 years). Participants removed keys from a rack, identified grocery items, washed their face, and cleaned a tray. Prior to this, they were classified as: no neglect (15), personal neglect (8), peripersonal neglect (7), and both personal and peripersonal neglect (12). The sensitivity and specificity of each new measure was determined by agreement with the classification. Test-retest reliability was determined using weighted kappa statistics or limits of agreement. Four occupational therapists (OTs) rated videos of the face and tray measures, and software was developed to measure objectively time spent and area covered on Face and Tray. Keys and Grocery had high specificity, good reliability but poor sensitivity. For the OTs' video ratings, there was good and moderate inter-rater reliability on Tray and Face respectively for area covered, but not time spent. Intra-rater reliability was also better for area than time on Tray. However, the validity of Face and Tray themselves is currently inadequate. A longitudinal study is proposed to modify the measures, increase their sensitivity and evaluate their ability to monitor change over time.

The use of Optokinetic Stimulation in Rehabilitation of the Hemineglect Disorder

The aim of this study was to investigate whether it is possible to strengthen the rehabilitation of spatial hemineglect by combining standard training for spatial scanning with optokinetic stimulation. A simple randomized design was used: one group of neglect patients was treated with a combination of the two techniques, and a second group received only the standard treatment. Both treatments were given for six consecutive weeks and produced significant improvements. However, addition of the optokinetic stimulation did not improve the patients' performance. Also, none of the independent variables (i.e., presence/absence of hemianopia) predicted the positive effect occasionally observed in individual patients.

Cognitive neuroscience of hemispatial neglect

INTRODUCTION

Patients with neglect often fail to be aware of stimuli located on their contralesional side--the side of space opposite their brain damage. Some patients show impairments in extrapersonal space; others within personal (body) space; and some in both. Although the neglect syndrome may be associated with a distorted perception of extrapersonal or personal space, recent investigations suggest that attentional, memory and motor deficits may be important additional components.

CONCLUSION

Better understanding of these cognitive impairments holds the key to offering effective treatment for neglect, as well as providing important insights into normal brain function.

Treatments of unilateral neglect: a review

OBJECTIVES

To review the existing literature on treatments of unilateral neglect, to synthesize findings, and to offer recommendations for future studies.

DATA SOURCES

Computerized databases including MEDLINE and PsychINFO.

STUDY SELECTION

All studies investigating treatment(s) of unilateral neglect.

DATA EXTRACTION

Authors reviewed design and other methodologic issues.

DATA SYNTHESIS

Unilateral neglect is a common consequence of right-hemisphere stroke. It is well recognized that the disorder is heterogeneous and has numerous subtypes. There have been numerous studies showing that arousal, hemispheric activation, and spatial attention treatments may all improve neglect, at least transiently. Despite these promising outcomes, little consensus exists as to whether 1 treatment is more efficacious than others, in part because cross-study differences in methodology render meta-analyses difficult, and in part because many studies fail to document duration of treatment effects or generalization to daily activities. One possibility is that these varied and diverse treatments may all be effective, reflecting redundancy in neural circuits devoted to attention and action in space, and consequent flexibility of the spatial processing system. It remains possible, however, that different subtypes of neglect may respond differentially to treatment of various sorts. Most existing studies of neglect have relied on very small populations of neglect patients, whose neglect is characterized only generally.

CONCLUSION

Methodologic shortcomings hinder assessment of the efficacy of various types of neglect treatment. In the future, these shortcomings could be addressed with larger studies of well-characterized patients that evaluate duration of treatment effects and include functional measures. In addition, the role of overarching variables, such as reduced arousal, requires consideration. The ultimate goal of these studies might be the development of triaging strategies wherein neglect patients are assigned to treatments of most likely benefit on the basis of neuroanatomic and behavioral profiles.

Asymmetries of visuospatial attention are modulated by viewing distance and visual field elevation: pseudoneglect in peripersonal and extrapersonal space

Many factors influence the degree of leftward error (pseudoneglect) that typifies the line bisection performance of normal subjects. We find that viewing distance also exerts a modulating influence on spatial attention in normal subjects, as it appears to do in neglect syndrome. Using forced-choice tachistoscopic line bisection, 38 right-handed subjects (15 male, 23 female) bisected horizontal lines (13.7 degrees w x 0.24 degrees h) presented in the midsagittal plane as a function of line elevation (- 3.6 degrees, 0 degrees, and 3.6 degrees relative to horizontal midline) and viewing distance (45 and 90 cm). We find a significant main effect of viewing distance, F (1, 37) = 10.04, p = .003, where pseudoneglect is larger in peripersonal (45 cm) than in extrapersonal (90 cm) space. We replicate an effect of line elevation, F (2, 74) = 4.40, p = .016, where pseudoneglect is greatest in the superior visual field (McCourt and Jewell, 1999). The interaction was not significant, p > .05. Thus, we find evidence for independent spatiotopic (viewing distance) and retinotopic (line elevation) effects on line bisection performance in normal observers, suggesting that the allocation of visuospatial attention is modulated within multiple frameworks.

Improving the clinical diagnosis of personal neglect: a reformulated comb and razor test

Beschin and Robertson (1997) devised a simple clinical test of left personal neglect, which characterises personal grooming behaviour according to the proportion of the total activity that is directed to the left side of the body. Although this test proved highly reliable, and more sensitive than prior diagnostic techniques, its formulation may yet be improved. The present paper reports a reanalysis of Beschin and Robertson's (1997) data, using additional control subjects, and a formula which characterises personal neglect as a lateral bias of behaviour rather than as a lateralised deficit. It is shown that this formula greatly enhances the test's sensitivity to the behavioural abnormalities of brain damaged patients, and it is recommended that this modification be adopted for the future diagnosis of personal neglect.