Dynamic assessment of visual neglect: The Mobility Assessment Course as a diagnostic tool

Evaluation of driving fitness using driving simulators in patients with right-hemisphere damage: an unmatched case-control study

BACKGROUND

Patients with right hemisphere damage (RHD) may exhibit mild unilateral spatial neglect (USN), which is difficult to detect in general assessments performed during driving rehabilitation.

OBJECTIVES

We compared driving simulator performance, practical driving performance, and neuropsychological test results between patients with RHD who were able and unable to return to driving to predict driving fitness based on driving simulator performance.

METHODS

This unmatched case-control study included 29 patients with RHD who were able (return-to-driving group, n = 16) and unable (non-return-to-driving group, n = 13) to return to driving. Patient demographics, motor function, attention, driving simulator performance (participants' reaction time and rate to green lamps appearing in any of the three displays and average lane position), and practical driving performance were compared between the groups. Receiver operating characteristic (ROC) analysis was performed to examine the predictive performance of driving fitness in reaction rate and paper-and-pencil tests.

RESULTS

The non-return-to-driving group had a significantly lower reaction rate than the return-to-driving group (p = 0.027; 95% confidence interval [CI], 0-7; r = 0.407). No significant difference in reaction time or lane position in either the left or right lane during driving simulation was observed. ROC analysis of the reaction rate in the driving simulator task showed sensitivity of 0.692, specificity of 0.812, and area under the curve of 0.738 [95% CI, 0.541-0.935].

CONCLUSIONS

Decreases in reaction rates during simulated driving assessments are associated with an inability to resume driving in patients with RHD. Such assessments may aid in predicting fitness for driving in these patients.

Does visuospatial neglect contribute to standing balance within the first 12 weeks post-stroke? A prospective longitudinal cohort study

BACKGROUND

Visuospatial neglect (VSN) has been suggested to limit standing balance improvement post-stroke. However, studies investigating this association longitudinally by means of repeated within-subject measurements early post-stroke are lacking. This prospective longitudinal cohort study evaluates the longitudinal association of egocentric and allocentric VSN severity with 1) standing balance independence and 2) postural control and weight-bearing asymmetry (WBA) during quiet standing, in the first 12 weeks post-stroke.

METHODS

Thirty-six hemiplegic individuals after a first-ever unilateral stroke were evaluated at weeks 3, 5, 8 and 12 post-stroke. Egocentric and allocentric VSN severity were evaluated using the Broken Hearts Test. The standing unperturbed item of the Berg Balance Scale (BBS-s) was used to clinically evaluate standing independence. Posturographic measures included measures of postural control (mediolateral (ML)/anteroposterior (AP) net center-of-pressure velocities (COPvel)) and WBA during quiet standing. A linear mixed model was used to examine longitudinal associations between egocentric and allocentric VSN, and BBS-s, COPvel-ML, COPvel-AP and WBA within the first 12 weeks post-stroke.

RESULTS

Egocentric (β = -0.08, 95%CI[-0.15;-0.01], P = .029) and allocentric VSN severity (β = -0.09, 95%CI[-0.15; -0.04], P = .002) were significant independent factors for BBS-s scores in the first 12 weeks post-stroke. Egocentric and allocentric VSN were no significant independent factors for COPvel-ML, COPvel-AP and WBA in the first 12 weeks post-stroke.

CONCLUSIONS

Allocentric and egocentric VSN severity were significantly associated with decreased standing independence, but not impaired postural control or greater asymmetric weight-bearing, in the early subacute post-stroke phase. This may involve traditional VSN measures being not sensitive enough to detect fine-grained VSN deficits due to a ceiling effect between 5 and 8 weeks post-stroke, once the individual regains standing ability. Future studies may require more sensitive VSN measurements to detect such deficits. Trial registration Clinicaltrials.gov. unique identifier NCT05060458.

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

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

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

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

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

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

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

Adaptation to post-stroke homonymous hemianopia - a prospective longitudinal cohort study to identify predictive factors of the adaptation process

PURPOSE

To determine any factors that predict how an individual will adapt to post-stroke hemianopic visual field loss, with close monitoring of the adaptation process from an early stage.

MATERIALS AND METHODS

The Hemianopia Adaptation Study (HAST) is a prospective observational longitudinal cohort clinical study. Adult stroke survivors (n = 144) with new onset homonymous hemianopia were monitored using standardised mobility assessment course (MAC) as the primary outcome measure of adaptation.

RESULTS

Several baseline variables were found to be good predictors of adaptation. Three variables were associated with adaptation status at 12-weeks post-stroke: inferior % visual field, % total MAC omissions, and MAC completion time (seconds). Baseline measurements of these variables can predict the adaptation at 12 weeks with moderate to high accuracy (area under ROC curve, 0.82, 95% CI 0.74-0.90). A cut-off score of ≤25% target omissions is suggested to predict which individuals are likely to adapt by 12-weeks post-stroke following gold standard care.

CONCLUSIONS

Adaptation to hemianopia is a personal journey with several factors being important for prediction of its presence, including MAC outcomes and extent of inferior visual field loss. A clinical recommendation is made for inclusion of the MAC as part of a functional assessment for hemianopia.Implications for rehabilitationThe mobility assessment course (MAC) should be considered as an assessment of mobility/scanning in the rehabilitation of patients with homonymous hemianopia.A cut-off score of ≤25% omissions on MAC could be employed to determine those likely to adapt to hemianopia long-term.Targeted support and therapy for patients with significant visual loss in the inferior visual field area should be considered.

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 association between visuospatial neglect and balance and mobility post-stroke onset: A systematic review

BACKGROUND

Although previous narrative reviews have highlighted a potential association between visuospatial neglect (VSN) and balance disorders, to what extent different areas of balance and mobility could be affected is still unclear.

OBJECTIVES

This systematic review updates previous literature findings and systematically reviews sitting balance, standing balance and mobility outcomes.

METHODS

PubMed, Web of Science, ScienceDirect, Naric-Rehabdata, PEDro and the Cochrane Trials Library were systematically searched. Methodological quality was assessed by the National Heart, Lung, and Blood Institute Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. The association between VSN and sitting balance, standing balance and mobility (walking, stair climbing/descending and transfers) was investigated.

RESULTS

In total, 48 studies were included (4595 stroke survivors): at least 1319 (29%) showed symptoms of VSN. VSN was associated with less independence during sitting, with an asymmetric posture toward the affected body side. For standing balance, we revealed a significant negative association between VSN and mediolateral stability and weight shifting, whereas only activities of daily living-related VSN was associated with weight-bearing asymmetry during static stance. While walking, patients with VSN laterally deviated from their path. Results were inconclusive regarding other aspects of mobility. The association between VSN and balance/mobility seemed to decrease over time.

CONCLUSIONS

Despite great heterogeneity in results, this study suggests that stroke survivors with VSN show specific deviations in posture and movement in the mediolateral direction. Although the association between VSN and balance/mobility has been extensively investigated, explanatory studies evaluating underlying mechanisms of the frequently present association are lacking. Future studies should address this by combining clinical and instrumented assessment of balance and gait performance, preferably longitudinally to investigate the associations over time.

The Visual Scanning Test: a newly developed neuropsychological tool to assess and target rehabilitation of extrapersonal visual unilateral spatial neglect

PURPOSE

Visual unilateral spatial neglect (VUSN) is a neuropsychological condition commonly experienced after stroke whereby patients are unable to attend to stimuli on the controlesional side of their space. VUSN can occur in the personal, peripersonal, and/or extrapersonal portion of patient's space. Traditional paper-and-pencil neuropsychological tests are widely used to evaluate VUSN, but they assess peripersonal VUSN. Instead, personal and extrapersonal neglect are less easily evaluated. The aim of this study was to present normative values for the Visual Scanning Test (VST), a new neuropsychological tool to quantitatively assess the extrapersonal VUSN.

METHODS

Eighty-six healthy subjects took part in the study (61 female), with a mean age of 52.8 years (SD = 17.0) and a mean of 14.0 years of education (SD = 5.2). The VST involved a visual search for a target between similar visual distractors, projected in the far space. The test was administered twice to each participant, with an interval of 2 weeks. From the recorded data, it was possible to obtain indexes related to the reaction times and to the accuracy of the performance on the VST.

RESULTS

Multiple linear regression analysis revealed that age and education significantly influenced VST-derived indexes. From the regression analysis, a correction grid for raw scores was built. Adjusted scores were then ranked, and by means of a non-parametric procedure, tolerance limits (both outer and inner one-sided) were defined.

CONCLUSIONS

The present study provided normative data for the VST in an Italian population useful for both clinical and research purposes.

TRIAL REGISTRATION

ClinicalTrials.gov ID: NCT03931798.

Peripheral Prisms Improve Obstacle Detection during Simulated Walking for Patients with Left Hemispatial Neglect and Hemianopia

SIGNIFICANCE

The first report on the use of peripheral prisms (p-prisms) for patients with left neglect and homonymous visual field defects (HVFDs).

PURPOSE

The purpose of this study was to investigate if patients with left hemispatial neglect and HVFDs benefit from p-prisms to expand the visual field and improve obstacle detection.

METHODS

Patients (24 with HVFDs, 10 of whom had left neglect) viewed an animated, virtual, shopping mall corridor and reported if they would have collided with a human obstacle that appeared at various offsets up to 13.5° from their simulated walking path. There were 40 obstacle presentations on each side, with and without p-prisms. No training with p-prisms was provided, and gaze was fixed at the center of expansion.

RESULTS

Detection on the side of the HVFD improved significantly with p-prisms in both groups, from 26 to 92% in the left-neglect group and 43 to 98% in the non-neglect group (both P < .001). There was a tendency for greater improvement in the neglect patients with p-prisms. For collision judgments, both groups exhibited a large increase in perceived collisions on the side of the HVFD with the prisms (P < .001), with no difference between the groups (P = .93). Increased perceived collisions represent a wider perceived safety margin on the side of the HVFD.

CONCLUSIONS

Within the controlled conditions of this simulated, collision judgment task, patients with left neglect responded well to initial application of p-prisms exhibiting improved detection and wider safety margins on the side of the HVFD that did not differ from non-neglect patients. Further study of p-prisms for neglect patients in free-gaze conditions after extended wear and in real-world mobility tasks is clearly warranted.

Lower Tinetti scores can support an early diagnosis of spatial neglect in post-stroke patients

BACKGROUND

Neglect represents a severe complication of stroke, which impairs patients' daily activities. An early diagnosis of neglect is fundamental for management decisions.

AIM

The aim of this study is to evaluate the usefulness of the Tinetti Test as an outcome of spatial neglect in post-stroke patients.

DESIGN

Observational retrospective data analysis.

SETTING

Rehabilitation Hospital.

POPULATION

Cohort of post-stroke adults admitted in our Rehabilitation Unit.

METHODS

One hundred and sixty stroke patients were evaluated between the 1st of January 2015 and the 31st of December 2016 at our Department. Eighty-nine inpatients matched the inclusion criteria. Their scores of the Tinetti Test for balance condition and gait function were compared with Bells Test and line bisection task for spatial neglect. Global independence activity was also assessed using Barthel Index and global cognitive functioning by means of the Mini-Mental State Examination.

RESULTS

Twenty-two patients between the 89 patients included in this study were affected by spatial neglect at admission. A high statistical significant correlation was observed between lower Tinetti scores and neglect presence (mean Tinetti Score: 2.36 neglect; 7.82 non-neglect; P<0.001).

CONCLUSIONS

The Tinetti Test is a well-established assessment scale to measure balance ability and gait function in post-stroke patients. Results from this study suggest that Tinetti Test may be considered as an early ecological screening tool for the diagnosis of neglect in post-stroke patients.

CLINICAL REHABILITATION IMPACT

The alternative use of the Tinetti Test for the diagnosis of spatial neglect.

The Effect of Noninvasive Brain Stimulation on Poststroke Cognitive Function: A Systematic Review

Introduction. Cognitive impairment after stroke has been associated with lower quality of life and independence in the long run, stressing the need for methods that target impairment for cognitive rehabilitation. The use of noninvasive brain stimulation (NIBS) on recovery of language functions is well documented, yet the effects of NIBS on other cognitive domains remain largely unknown. Therefore, we conducted a systematic review that evaluates the effects of different stimulation techniques on domain-specific (long-term) cognitive recovery after stroke. Methods. Three databases (PubMed, EMBASE, and PsycINFO) were searched for articles (in English) on the effects of NIBS on cognitive domains, published up to January 2018. Results. A total of 40 articles were included: randomized controlled trials (n = 21), studies with a crossover design (n = 9), case studies (n = 6), and studies with a mixed design (n = 4). Most studies tested effects on neglect (n = 25). The majority of the studies revealed treatment effects on at least 1 time point poststroke, in at least 1 cognitive domain. Studies varied highly on the factors time poststroke, number of treatment sessions, and stimulation protocols. Outcome measures were generally limited to a few cognitive tests. Conclusion. Our review suggests that NIBS is able to alleviate neglect after stroke. However, the results are still inconclusive and preliminary for the effect of NIBS on other cognitive domains. A standardized core set of outcome measures of cognition, also at the level of daily life activities and participation, and international agreement on treatment protocols, could lead to better evaluation of the efficacy of NIBS and comparisons between studies.

Simulated driving: The added value of dynamic testing in the assessment of visuo-spatial neglect after stroke

BACKGROUND

Visuo-spatial neglect (VSN) is generally assessed with neuropsychological paper-and-pencil tasks, which are often not sensitive enough to detect mild and/or well-compensated VSN. It is of utmost importance to develop dynamic tasks, resembling the dynamics of daily living.

OBJECTIVE

A simulated driving task was used to assess (1) differences in performance (i.e., position on the road and magnitude of sway) between patients with left- and right-sided VSN, recovered VSN, without VSN, and healthy participants; (2) the relation between average position and VSN severity; and (3) its diagnostic accuracy in relation to traditional tasks.

METHODS

Stroke inpatients were tested with a cancellation task, the Catherine Bergego Scale and the simulated driving task.

RESULTS

Patients with left-sided VSN and recovered VSN deviated more regarding position on the road compared to patients without VSN. The deviation was larger in patients with more severe VSN. Regarding diagnostic accuracy, 29% of recovered VSN patients and 6% of patients without VSN did show abnormal performance on the simulated driving task. The sensitivity was 52% for left-sided VSN. Right-sided VSN was not well detected, probably due to the asymmetric layout.

CONCLUSIONS

Based on these results, the simulated driving task should not be the only task to assess VSN, especially in its current form. Given the heterogenic nature of VSN, the assessment should always consist of several tasks varying in nature and complexity and include a dynamic task to detect mild and/or recovered VSN. A symmetric design should be used when designing novel tasks to assess right-sided VSN.

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.

The Mobility Assessment Course for the Diagnosis of Spatial Neglect: Taking a Step Forward?

Spatial neglect after stroke can be a challenging syndrome to diagnose under standard neuropsychological assessment. There is now sufficient evidence that those affected might demonstrate neglect behavior in everyday settings despite showing no signs of neglect during common neglect tasks. This discrepancy is attributed to the simplified and unrealistic nature of common pen and paper based tasks that do not match the demanding, novel, and complex environment of everyday life. As such, increasing task demands under more ecologically valid scenarios has become an important method of increasing test sensitivity. The main aim of the current study was to evaluate the diagnostic utility of the Mobility Assessment Course (MAC), an ecological task, for the assessment of neglect. If neglect becomes more apparent under more challenging task demands the MAC could prove to be more diagnostically accurate at detecting neglect than conventional methods, particularly as the time from initial brain damage increases. Data collected by Guide Dogs of SA/NT were retrospectively analyzed. The Receiver Operating Characteristic (ROC) curve, a measure of sensitivity and specificity, was used to investigate the diagnostic utility of the MAC and a series of paper and pencil tests in 67 right hemisphere stroke survivors. While the MAC proved to be a more sensitive neglect test (74.2%) when compared to the Star Cancellation (43.3%) and Line Bisection (35.7%) tests, this was at the expense of relatively low specificity. As a result, the ROC curve analysis showed no statistically discernable differences between tasks (p > 0.12), or between subacute and chronic groups for individual tasks (p > 0.45). It is concluded that, while the MAC is an ecologically valid alternative for assessing neglect, regarding its diagnostic accuracy, there is currently not enough evidence to suggest that it is a big step forward in comparison to the accuracy of conventional tests.