The treatment of visual neglect using feedback of eye movements: a pilot study

Disorders of higher visual processing in patients with acquired brain injury

BACKGROUND: Disorders of higher visual processing often impact patients with acquired brain injury. Even with treatment, these vision conditions can cause chronic challenges for patients. Understanding these conditions and their management can help improve functional independence and quality of life. OBJECTIVES: To discuss the various disorders of higher visual processing that result from acquired brain injury. Discussion to include classification, evaluation, and treatment techniques available to clinicians. METHODS: Peer reviewed journal articles were searched, primarily through PubMed. Articles spanning several decades were included in the review for historical context of these conditions, however an emphasis was placed on more recent publications for purposes of a discussion regarding clinical management of these conditions. RESULTS: Peer-reviewed articles and clinical trials from across several disciplines were included to frame a discussion of this varied group of conditions. CONCLUSION: Visual processing disorders have debilitating impacts on both the rehabilitation process as well as functional independence. Varied approaches are utilized in the treatment of these conditions with limited success. Understanding the benefits and limitations of both restorative and compensatory treatments will better help clinicians manage patients with these conditions.

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

The treatment methods for post-stroke visual impairment: A systematic review

AIM

To provide a systematic overview of interventions for stroke related visual impairments.

METHOD

A systematic review of the literature was conducted including randomized controlled trials, controlled trials, cohort studies, observational studies, systematic reviews, and retrospective medical note reviews. All languages were included and translation obtained. This review covers adult participants (aged 18 years or over) diagnosed with a visual impairment as a direct cause of a stroke. Studies which included mixed populations were included if over 50% of the participants had a diagnosis of stroke and were discussed separately. We searched scholarly online resources and hand searched articles and registers of published, unpublished, and ongoing trials. Search terms included a variety of MESH terms and alternatives in relation to stroke and visual conditions. Article selection was performed by two authors independently. Data were extracted by one author and verified by a second. The quality of the evidence and risk of bias was assessed using appropriate tools dependant on the type of article.

RESULTS

Forty-nine articles (4142 subjects) were included in the review, including an overview of four Cochrane systematic reviews. Interventions appraised included those for visual field loss, ocular motility deficits, reduced central vision, and visual perceptual deficits.

CONCLUSION

Further high quality randomized controlled trials are required to determine the effectiveness of interventions for treating post-stroke visual impairments. For interventions which are used in practice but do not yet have an evidence base in the literature, it is imperative that these treatments be addressed and evaluated in future studies.

Rehabilitation of unilateral neglect: Evidence-based medicine

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Tracking Gaze of Patients with Visuospatial Neglect

Video eye-tracking appears to have great utility in the investigation and assessment of visuospatial neglect, and it may also have important benefits to intervention. Applications include the use of desktop eye-tracking to quantify neglect and its sensitivity to social cues, acquisition of eye-tracking data during performance of clinical and experimental assessment tasks, and trials of a wireless system to track the gaze of patients carrying out activities of daily living. Displays that provide differential feedback contingent on gaze locus may be particularly applicable to computer-aided training. If eye-tracking proves to be useful for monitoring and for automatic delivery of training, it can eventually be incorporated into telerehabilitation.

Ottawa Panel Evidence-Based Clinical Practice Guidelines for Post-Stroke Rehabilitation

BACKGROUND AND PURPOSE

The purpose of this project was to create guidelines for 13 types of physical rehabilitation interventions used in the management of adult patients (>18 years of age) presenting with hemiplegia or hemiparesis following a single clinically identifiable ischemic or hemorrhagic cerebrovascular accident (CVA).

METHOD

Using Cochrane Collaboration methods, the Ottawa Methods Group identified and synthesized evidence from comparative controlled trials. The group then formed an expert panel, which developed a set of criteria for grading the strength of the evidence and the recommendation. Patient-important outcomes were determined through consensus, provided that these outcomes were assessed with a validated and reliable scale.

RESULTS

The Ottawa Panel developed 147 positive recommendations of clinical benefit concerning the use of different types of physical rehabilitation interventions involved in post-stroke rehabilitation.

DISCUSSION AND CONCLUSION

The Ottawa Panel recommends the use of therapeutic exercise, task-oriented training, biofeedback, gait training, balance training, constraint-induced movement therapy, treatment of shoulder subluxation, electrical stimulation, transcutaneous electrical nerve stimulation, therapeutic ultrasound, acupuncture, and intensity and organization of rehabilitation in the management of post stroke.

Treatment of Visual Perceptual Disorders Post Stroke

Visual perceptual disorders are a common clinical consequence of stroke. They include unilateral neglect, which has a major impact on rehabilitation outcome. The nature of the behavioral deficits associated with neglect has suggested that behavioral modification strategies may improve performance. This article presents a critical review and synthesis of published research evidence for the effectiveness of treatments for visual perceptual disorders after stroke. The strongest evidence for rehabilitation effectiveness was for the following: (a) specific treatment for perceptual disorders; and (b) specific training for neglect (including visual scanning). Findings also suggest that more research is needed into how the assessment of specific features of visual perceptual disorders might lead to improved methods for rehabilitation, including the use of assistive devices for mobility and activities of daily living.

The Lighthouse Strategy: Improving the Functional Status of Patients with Unilateral Neglect After Stroke and Brain Injury Using a Visual Imagery Intervention

This study extends the work of J. Niemeier (1998) by using visual imagery for amelioration of the devastating impact of visual inattention or neglect on recovery from stroke or other brain injuries. Ten individuals with unilateral visual neglect who were undergoing acute physical rehabilitation after brain injury were cued by their interdisciplinary treatment team members to "be like" horizon-illuminating lighthouses and turn their heads left and right during functional and therapy training tasks. These treatment group patients, in comparison with waiting list controls, performed significantly better and more safely on route finding (p <.001), walking or wheelchair (p <.05), and problem solving (p <.05) tasks. The use of visual imagery techniques in rehabilitation of brain injuries is discussed.

Hearing and music in unilateral spatial neglect neuro-rehabilitation

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

Rehabilitation for post-stroke cognitive impairment: an overview of recommendations arising from systematic reviews of current evidence

BACKGROUND

Although cognitive impairments are common following stroke, there is considerable uncertainty about the types of interventions that can reduce activity restrictions and improve quality of life. Indeed, a recent project to identify priorities for research into life after stroke determined that the top priority for patients, carers and health professionals was how to improve cognitive impairments.

OBJECTIVE

To provide an overview of the evidence for the effectiveness of cognitive rehabilitation for patients with stroke and to determine the main gaps in the current evidence base.

METHODS

Evidence was synthesised for the six Cochrane reviews relating to rehabilitation for post-stroke cognitive impairment and any subsequently published randomized controlled trials to February 2012.

RESULTS

Data arising from 44 trials involving over 1500 patients was identified. Though there was support for the effectiveness of cognitive rehabilitation for some cognitive impairments, significant gaps were found in the current evidence base. All of the Cochrane reviews identified major limitations within the evidence they identified.

CONCLUSIONS

There is currently insufficient research evidence, or evidence of insufficient quality, to support clear recommendations for clinical practice. Recommendations are made as to the research required to strengthen the evidence base, and so facilitate the delivery of effective interventions to individuals with cognitive impairment after stroke.

The effect of visual scanning exercises integrated into physiotherapy in patients with unilateral spatial neglect poststroke: a matched-pair randomized control trial

BACKGROUND

Unilateral spatial neglect (USN) is a visual-perceptual disorder that entails the inability to perceive and integrate stimuli on one side of the body, resulting in the neglect of one side of the body. Stroke patients with USN present with extensive functional disability and duration of therapy input.

OBJECTIVE

To determine the effect of saccadic eye movement training with visual scanning exercises (VSEs) integrated with task-specific activities on USN poststroke.

METHODS

A matched-pair randomized control trial was conducted. Subjects were matched according to their functional activity level and allocated to either a control (n = 12) or an experimental group (n = 12). All patients received task-specific activities for a 4-week intervention period. The experimental group received saccadic eye movement training with VSE integrated with task specific activities as an "add on" intervention. Assessments were conducted weekly over the intervention period.

RESULTS

Statistical significant difference was noted on the King-Devick Test (P = .021), Star Cancellation Test (P = .016), and Barthel Index (P = .004).

CONCLUSION

Intensive saccadic eye movement training with VSE integrated with task-specific activities has a significant effect on USN in patients poststroke. Results of this study are supported by findings from previously reviewed literature in the sense that the effect of saccadic eye movement training with VSE as an intervention approach has a significant effect on the visual perceptual processing of participants with USN poststroke. The significant improved visual perceptual processing translate to significantly better visual function and ability to perform activities of daily living following the stroke.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Evidence-based cognitive rehabilitation after acquired brain injury: a systematic review of content of treatment

We reviewed all randomised trials on cognitive rehabilitation in order to determine the effective elements in terms of patients' and treatment characteristics, treatment goals and outcome. A total of 95 random controlled trials were included from January 1980 until August 2010 studying 4068 patients in total. Most studies had been conducted on language (n = 25), visuospatial functioning (n = 24), and memory (n = 14). Stroke patients were the commonest subjects (57%; overall mean age = 52.2, SD = 15.0 years). Of the interventions 39% were offered more than 12 months after onset and 23% were offered within two months of onset. The mean (SD) number of hours of treatment actually delivered was 4.1 (3.6) per week; treatment was mostly offered individually. No papers gave specific information on the expertise or competences of the staff involved. With 95 RCTs there is a large body of evidence to support the efficacy of cognitive rehabilitation, and the current study can serve as a database for clinicians and researchers. But most studies have given little information about the actual content of the treatment which makes it difficult to use the studies when making treatment decisions in daily clinical practice. We suggest developing an international checklist to make standardised description of non-pharmacological complex interventions possible.

Rehabilitation, Disability, and Participation Research: Are Occupational Therapy Researchers Addressing Cognitive Rehabilitation After Stroke?

I reviewed articles published in the American Journal of Occupational Therapy (AJOT) in 2009 and 2010 to assess (1) whether research was published in the practice area of rehabilitation, disability, and participation and (2) the evidence being produced in an underdeveloped subcategory of this practice area: cognitive rehabilitation after stroke. The review revealed one intervention effectiveness study that addressed cognitive rehabilitation poststroke published in the 2-year period. Further analysis of outside repositories of evidence in this area revealed that although some evidence supports rehabilitation approaches for people with cognitive dysfunction after a stroke, little research has been devoted to this practice area. The poststroke cognitive intervention approaches in use have been shown to have little or no effect on improving everyday life activity. Occupational therapy has a key research and practice role with the poststroke population, and occupational therapists should be at the forefront in developing the science to support the effectiveness of their services.

Reported quality of randomized controlled trials in neglect rehabilitation

The aim of this study is to assess the reported quality of randomized controlled trials (RCTs) on the effectiveness of neglect rehabilitation using a standardized scale. A search of seven electronic databases was carried out. Selected articles were scored using the PEDro scale and classified as high or low quality study both with the original cut off of 6 and a modified cut off of 5. A linear regression analysis between year of publication and quality rate was used to test whether the quality of the studies improved with time. A total of 18 RCTs were selected. Six articles (33.3%) and 10 articles (55.56%) were classified as having high quality when the original cut off or the modified cut off of the PEDro scale were used, respectively. Analysis shows no time-related changes in PEDro scores. The results show that reported quality is moderate for RCTs in neglect rehabilitation.

Rehabilitation approaches to hemineglect

BACKGROUND

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

REVIEW SUMMARY

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

CONCLUSIONS

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

Visual Deficit Interventions in Adult Stroke and Brain Injury

Visual deficits after cerebral injury are common. The variability in the types of injury sustained as well as their impact on function in the environment have produced multiple approaches at corrective intervention. To assess the effectiveness of these vision interventions, an extensive literature search was completed. The analysis of this review revealed some success with visual neglect disorders, but not enough evidence to comment definitively on interventions for hemianopsia, quadrantonopsia, diplopia, or convergence insufficiency. A lack of follow-up also limited efforts to assess the durability of documented gains. Additional research is necessary to clarify, quantify, and measure treatment outcomes for acquired visual dysfunction as well as to link laboratory testing to improvement in actual functioning for individuals in their environment.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH STRATEGY

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Improving outcome in stroke patients with visual problems

BACKGROUND

stroke is a common condition, frequently with significant effects on a patient's ability to live an active and independent life. Anything that may potentially have a beneficial effect on the rehabilitation of such patients should therefore be explored, and as ocular and visual problems are common in patients with stroke, it is important that their implications are understood.

OBJECTIVE

this article aims at providing a broad overview of the literature relating to visual problems in stroke patients, looking particularly at the impact on, and the potential for, recovery and rehabilitation.

METHODS

the online database PubMed was searched for literature relating to visual and ocular problems in stroke. The resulting abstracts and articles were then reviewed to extract clinically relevant information. Findings are summarised and discussed.

CONCLUSIONS

visual problems in stroke are associated with problems with activities of daily living (ADL), falls and rehabilitation. Because many visual problems are easily corrected or improve with intervention, there may be a role for formal screening for visual problems in stroke patients in a rehabilitation setting. The orthoptist has an important role to play in stroke rehabilitation, and links between the stroke and orthoptic departments should be established in all units.

Cognitive Rehabilitation Interventions for Neglect and Related Disorders: Moving from Bench to Bedside in Stroke Patients

The spatial neglect syndrome, defined by asymmetric attention and action not attributed to primary motor or sensory dysfunction and accompanied by functional disability, is a major cause of post-stroke morbidity. In this review, we consider the challenges and obstacles facing scientific researches wishing to evaluate the mechanisms and effectiveness of rehabilitation interventions. Spatial neglect is a heterogeneous disorder, for which consensus research definitions are not currently available, and it is unclear which of the deficits associated with the syndrome causes subsequent disability. We review current opinion about methods of assessment, suggest a rational approach to selecting therapies which requires further study, and make systems-level and theoretical recommendations for building theory. We lastly review some creative questions for consideration in future research.

Veterans Affairs/Department of Defense Clinical Practice Guideline for the Management of Adult Stroke Rehabilitation Care: executive summary

BACKGROUND

A panel of experts developed stroke rehabilitation guidelines for the Veterans Health Administration and Department of Defense Medical Systems.

METHODS

Starting from previously established guidelines, the panel evaluated published literature through 2002, using criteria developed by the US Preventive Services Task Force. Recommendations were based on evidence from randomized clinical trials, uncontrolled studies, or consensus expert opinion if definitive data were lacking.

RESULTS

Recommendations with Level I evidence include the delivery of poststroke care in a multidisciplinary rehabilitation setting or stroke unit, early patient assessment via the NIH Stroke Scale, early initiation of rehabilitation therapies, swallow screening testing for dysphagia, an active secondary stroke prevention program, and proactive prevention of venous thrombi. Standardized assessment tools should be used to develop a comprehensive treatment plan appropriate to each patient's deficits and needs. Medical therapy for depression or emotional lability is strongly recommended. A speech and language pathologist should evaluate communication and related cognitive disorders and provide treatment when indicated. The patient, caregiver, and family are essential members of the rehabilitation team and should be involved in all phases of the rehabilitation process. These recommendations are available in their entirety at http://stroke.ahajournals.org/cgi/content/full/36/9/e100. Evidence tables for each of the recommendations are also in the full document.

CONCLUSIONS

These recommendations should be equally applicable to stroke patients receiving rehabilitation in all medical system settings and are not based on clinical problems or resources unique to the Federal Medical System.

Quality of the stroke rehabilitation research

The Stroke Rehabilitation Evidence-Based Review revealed a wide range of quality scores across primary studies. The aim of this section is to determine what differences there are across studies and to provide a detailed examination of methodological issues in the stroke rehabilitation literature. Methodology of each article was assessed using the Physiotherapy Evidence Database (PEDro) quality scale. Mean PEDro scores and percentage of studies meeting individual PEDro criteria were determined for all studies, for therapy-based studies only, and for drug-based studies only. It was noted that the stroke rehabilitation literature lacked rigor in the area of concealed allocation, blinding of the assessor, and intention-to-treat analysis. Investigation of the methodological quality of stroke rehabilitation literature emphasizes the need for improved treatment protocols, taking into account previous deficits, during research.

An evidence-based review of stroke rehabilitation

A comprehensive evidence-based review of stroke rehabilitation was created to be an up-to-date review of the current evidence in stroke rehabilitation and to provide specific conclusions based on evidence that could be used to help direct stroke care at the bedside and at home. A literature search using multiple data-bases was used to identify all trials from 1968 to 2001. Methodological quality of the individual randomized controlled trials was assessed using the Physiotherapy Evidence Database (PEDro) quality assessment scale. A five-stage level-of-evidence approach was used to determine the best practice in stroke rehabilitation. Over 403 treatment-based articles investigating of various areas of stroke rehabilitation were identified. This included 272 randomized controlled trials.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

Unilateral spatial neglect is a failure to attend to one side of space. Various strategies have been used to treat these problems but evidence of their benefit has been lacking.

OBJECTIVES

To determine the effects of cognitive rehabilitation for spatial neglect following stroke as measured on impairment and disability level assessments, and destination on discharge from hospital. To determine whether any effects persist at follow-up assessment.

SEARCH STRATEGY

We searched the Cochrane Stroke Group Trials Register (last searched February 2001), MEDLINE (1966-December 2000), EMBASE (1980-February 2001), CINAHL (1983-January 2001), PSYCLIT and CLINPSYCH (1974-February 2001). We handsearched relevant journals, screened reference lists from relevant articles and tracked citations using SCISEARCH.

SELECTION CRITERIA

Controlled trials of cognitive rehabilitation for spatial neglect in stroke. Studies with mixed patient groups were excluded unless more than 75% of their sample were stroke patients or separate stroke data were available for stroke patients.

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

We included 15 studies with 400 participants. A large number of different outcome measures were reported. Only six studies included a measure of disability and only four (111 participants) investigated persisting effects on any outcome. There was evidence that cognitive rehabilitation resulted in significant and persisting improvements in performance on impairment level assessments, although this varied depending on the test used. There was insufficient evidence to confirm or exclude an effect of cognitive rehabilitation at the level of disability or on destination following discharge from hospital.

REVIEWER'S CONCLUSIONS

There is some evidence that cognitive rehabilitation for spatial neglect improves performance on some impairment level tests but its effect on disability is unclear. Further well-designed RCTs are warranted as well as basic research to develop valid outcome measures.