Spatial Neglect in Stroke: Identification, Disease Process and Association with Outcome During Inpatient Rehabilitation

Recovery of Visuospatial Neglect With Standard Treatment: A Systematic Review and Meta-Analysis

BACKGROUND

Visuospatial neglect is a common consequence of stroke and is characterized by impaired attention to contralesional space. Currently, the extent and time course of recovery from neglect are not clearly established. This systematic review and meta-analysis aimed to determine the recovery trajectory of poststroke neglect with standard treatment.

METHODS

PsycInfo, Embase, and MEDLINE were searched for articles reporting recovery rates of neglect after stroke. Time since stroke was categorized into early (0-3 months), mid (3-6 months), and late (>6 months) recovery phases. Random-effects models for pooled prevalence were generated for each phase, and potential sources of heterogeneity were explored with metaregressions. Methodological quality of each study was assessed using the Joanna Briggs Institute checklist, with low-quality studies excluded in sensitivity analyses.

RESULTS

The search captured 4130 articles including duplicates, and 111 full-text reviews were undertaken. A total of 27 studies reporting data from 839 stroke survivors with neglect were included for review. Meta-analyses indicated a recovery rate of 42% in the early phase, which increased to 53% in the mid-recovery phase. Additional recovery in the late phase was minimal, with an estimated 56% recovery rate. Heterogeneity of studies was high (I2>75%) in all 3 phases of recovery. Estimates were robust to sensitivity analyses. Metaregressions showed significantly greater recovery in studies that included patients with left-hemisphere lesions (β=0.275, P<0.05, I2=84%).

CONCLUSIONS

Most recovery from neglect occurs in the first 3 months, although additional gains can be expected up to 6 months poststroke. While a large proportion of patients recover from neglect, over 40% show persistent symptoms. Further research is needed on effective rehabilitation interventions, particularly focusing on patients most at risk of chronic visuospatial neglect.

REGISTRATION

URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42023388763.

Using mechanistic knowledge to appraise contemporary approaches to the rehabilitation of upper limb function following stroke

It is a paradox of neurological rehabilitation that, in an era in which preclinical models have produced significant advances in our mechanistic understanding of neural plasticity, there is inadequate support for many therapies recommended for use in clinical practice. When the goal is to estimate the probability that a specific form of therapy will have a positive clinical effect, the integration of mechanistic knowledge (concerning 'the structure or way of working of the parts in a natural system') may improve the quality of inference. This is illustrated by analysis of three contemporary approaches to the rehabilitation of lateralized dysfunction affecting people living with stroke: constraint-induced movement therapy; mental practice; and mirror therapy. Damage to 'cross-road' regions of the structural (white matter) brain connectome generates deficits that span multiple domains (motor, language, attention and verbal/spatial memory). The structural integrity of these regions determines not only the initial functional status, but also the response to therapy. As structural disconnection constrains the recovery of functional capability, 'disconnectome' modelling provides a basis for personalized prognosis and precision rehabilitation. It is now feasible to refer a lesion delineated using a standard clinical scan to a (dis)connectivity atlas derived from the brains of other stroke survivors. As the individual disconnection pattern thus obtained suggests the functional domains most likely be compromised, a therapeutic regimen can be tailored accordingly. Stroke is a complex disorder that burdens individuals with distinct constellations of brain damage. Mechanistic knowledge is indispensable when seeking to ameliorate the behavioural impairments to which such damage gives rise.

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

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

[Interindividual variability in patients with visuospatial neglect: a retrospective study]

INTRODUCTION

Patients who have suffered a stroke may present with visuospatial neglect (VSN). In clinical practice, different degrees of impairment can be observed among patients with VSN; however, there is no consensus regarding the criteria and tests used to determine them.

AIM

This study aims to classify patients with VSH based on their level of impairment and to study their response to computerized cognitive training.

PATIENTS AND METHODS

The sample consisted of 34 patients (19 men and 15 women) with a mean age of 47.59 ± 8.39 years. All patients underwent a neuropsychological exploration protocol composed of specific tests that assess visuospatial attention and others to evaluate multiple cognitive domains. All participants underwent computerized cognitive training consisting of 15 one-hour sessions.

RESULTS

A cluster analysis was performed that divided the sample into three groups: group 1: mildly affected VSN (n = 17), group 2: moderately affected VSN (n = 11), and group 3: severely affected VSN (n = 6). Statistically significant differences were found in all tests of the visuospatial attention protocol, both in the pre-treatment and post-treatment evaluation.

CONCLUSIONS

There are different levels of impairment among patients with VSN, differences that persist after applying computerized cognitive training. These results suggest that the evolution of VSN follows a homogeneous pattern linked to the initial level of impairment. These findings, although preliminary, may be relevant to neurorehabilitation professionals.

Spatial Neglect: An Exploration of Clinical Assessment Behaviour in Stroke Rehabilitation

OBJECTIVE

There is a large gap between evidence-based recommendations for spatial neglect assessment and clinical practice in stroke rehabilitation. We aimed to describe factors that may contribute to this gap, clinician perceptions of an ideal assessment tool, and potential implementation strategies to change clinical practice in this area.

DESIGN

Qualitative focus group investigation. Focus group questions were mapped to the Theoretical Domains Framework and asked participants to describe their experiences and perceptions of spatial neglect assessment.

SETTING

Online stroke rehabilitation educational bootcamp.

PARTICIPANTS

A sample of 23 occupational therapists, three physiotherapists, and one orthoptist that attended the bootcamp.

INTERVENTION

Prior to their focus group, participants watched an hour-long educational session about spatial neglect.

MAIN MEASURES

A deductive analysis with the Theoretical Domains Framework was used to describe perceived determinants of clinical spatial neglect assessment. An inductive thematic analysis was used to describe perceptions of an ideal assessment tool and practice-change strategies in this area.

RESULTS

Participants reported that their choice of spatial neglect assessment was influenced by a belief that it would positively impact the function of people with stroke. However, a lack of knowledge about spatial neglect assessment appeared to drive low clinical use of standardised functional assessments. Participants recommended open-source online education involving a multidisciplinary team, with live-skill practice for the implementation of spatial neglect assessment tools.

CONCLUSIONS

Our results suggest that clinicians prefer functional assessments of spatial neglect, but multiple factors such as knowledge, training, and policy change are required to enable their translation to clinical practice.

Understanding Occupational Therapists' Knowledge and Confidence When Assessing for Spatial Neglect: A Special Issue Review

IMPORTANCE

Spatial neglect (SN)-failure to respond to stimuli on the side of the body contralateral to a poststroke lesion-is one of the most disabling impairments for stroke survivors, and 80% of stroke survivors may have undetected SN. Occupational therapists' evaluations should include determining the impact of poststroke SN.

OBJECTIVE

To investigate occupational therapists' confidence, knowledge, current practices, barriers, and facilitators when assessing for SN in adult stroke survivors.

DESIGN

A 30-item survey was created with guidance from stroke rehabilitation occupational therapists who reviewed the survey for face and content validity.

SETTING

Online survey.

PARTICIPANTS

Occupational therapist survey responders (N = 76).

OUTCOMES AND MEASURES

Self-report assessments were used to measure occupational therapists' confidence in identifying SN, SN assessment practices, and barriers to and facilitators of SN assessment. Knowledge of SN signs and symptoms, neuroanatomy, and clinical presentation were measured with a three-question quiz.

RESULTS

Eighty-one percent of the respondents reported a high level of confidence in identifying SN, and 70% reported routinely assessing for SN, with 81% using clinical observation rather than standardized tools as the primary assessment method. Barriers to SN assessment included time and resources.

CONCLUSIONS AND RELEVANCE

Most respondents, despite reporting high levels of confidence with routine SN assessments, did not use standardized SN measures and demonstrated suboptimal knowledge of SN. These results emphasize the need to increase clinical education about SN and its assessments. Plain-Language Summary: This study gathered baseline information on an underinvestigated topic-occupational therapists' education, confidence, current practices, barriers, and facilitators when assessing for spatial neglect in adult stroke survivors. The study results also contribute to future research on occupational therapists' current confidence and knowledge when assessing for spatial neglect.

Unilateral Spatial Neglect May Not Be Detected by Performance-Based Functional Neglect Assessment

IMPORTANCE

Unilateral spatial neglect (neglect) poststroke is disabling. It is critical that people with neglect are identified so that treatment can be provided to maximize independence. However, there is some evidence to suggest that existing assessments may not adequately measure neglect. It is unclear whether assessments also fail to identify people with neglect entirely.

OBJECTIVE

To determine whether there are stroke survivors who self-report neglect symptoms that are not detected by therapist-rated assessments and to compare self-report and therapist-ratings.

DESIGN

Cross-sectional study.

SETTING

U.S. university research center.

PARTICIPANTS

Unilateral stroke survivors (N = 133).

INTERVENTION

Not applicable.

OUTCOMES AND MEASURES

The Catherine Bergego Scale (CBS) was administered to participants and scored by a trained occupational therapist. The parallel self-evaluation anosognosia form was also administered to participants to self-report and rate neglect symptoms.

RESULTS

Forty-eight participants (36.1%) were classified as without neglect on the basis of therapist-rated total CBS scores, yet 30 (62.5%) of these 48 participants reported symptoms of neglect on the CBS self-evaluation anosognosia form. There was a significant difference (p < .001) between therapist-rated and self-rated total CBS scores.

CONCLUSIONS AND RELEVANCE

Our results indicate that many stroke survivors report some level of disability associated with neglect yet do not meet the criteria to be classified as having neglect according to a commonly used therapist-rated performance-based measure. Plain-Language Summary: The findings of this study contribute to the evidence that existing assessments used by occupational therapists to measure performance-based neglect may not always detect neglect symptoms comprehensively in people poststroke. The finding also suggest that we may be missing neglect symptoms entirely. Occupational therapists should consider using various methods to assess for neglect, including patient self-report and comprehensive occupational profiles. Clinicians should also thoroughly screen all clients with stroke for neglect, regardless of lesion location.

Clinical and demographic predictors of unilateral spatial neglect recovery after prism therapy among stroke survivors in the sub-acute phase of recovery

BACKGROUND AND AIMS: Unilateral Spatial Neglect (USN) affects the rehabilitation process and leads to poor outcomes after stroke. Factors that influence USN recovery following prism adaptation therapy have not been investigated. This study investigated predictors of USN recovery after prism therapy at the sub-acute phase of recovery. METHODS: This study was a randomized controlled trial. USN was assessed with the Behavioural Inattention Test and Catherine Bergego scale. Seventy-four patients with USN were divided into control and intervention group (prism). The prism group used 20 dioptre prism lenses for repeated aiming for 12 sessions while the control group used neutral lenses for aiming training. Regression analysis was conducted to establish clinical and sociodemographic factors that influence USN recovery. RESULTS: Gender, age, years of education, race, employment status, handedness, type of stroke, time since stroke and site of stroke (p > 0.005) showed no significant influence on USN recovery following PA treatment. Higher Cognitive function (OR  = 1.52, CI = 1.08-2.14, p =  0.016) and group allocationng (being in the prism group) (OR = 63.10, CI =  9.70-410.59, P < 0.001) were found to significantly influence USN recovery following PA treatment session. CONCLUSIONS: A significant modulating effect on general cognitive ability was found in this study. This suggests that prism adaptation therapy's effect on neural activity and spatial neglect depends on the cognitive function of stroke survivors.Trial registration: Pan African Clinical Trial Registry identifier: PACTR201903732473573.

Prevalence, Severity and Impact of Visuospatial Neglect in Geriatric Stroke Rehabilitation, a Cross-Sectional Study

OBJECTIVES

Visuospatial neglect (VSN) is a common cognitive deficit of lateralized attention after stroke and can have a negative influence on patients' daily activities, community participation, and caregiver burden. VSN prevalence has been investigated in several mixed-age populations, but rarely in only an older population. As the population in geriatric rehabilitation (GR) is understudied and VSN may influence rehabilitation goals in GR (return home), we examined the prevalence of VSN as well as associations between VSN (severity) and population characteristics and the impact of VSN on functioning, length of stay, and discharge destination after GR.

DESIGN

Multicenter cross-sectional study.

SETTING AND PARTICIPANTS

Stroke patients admitted to GR.

METHODS

Three VSN tests (Star cancelation task, Line bisection task, and Catherine Bergego Scale) were administered in the first 2 weeks of GR admission. To examine VSN severity, a composite score was calculated based on scores of the 3 tests.

RESULTS

A total of 114 stroke patients were included [55.3% female; mean age 80.2 (SD 8.0) years]. VSN prevalence was 47.4%, in which allocentric and egocentric neglect were more prevalent than VSN during activities of daily living. Participants with VSN spent more days in GR compared to participants without VSN (median 68.5 vs 35.5 days) and had fewer home returns. In addition, VSN participants showed less mobility, lower cognitive functioning, and less independence during self-care compared to participants without VSN. Mobility, self-care, cognition, duration of rehabilitation, and home return were negatively associated with VSN severity.

CONCLUSIONS AND IMPLICATIONS

VSN is very prevalent in the GR stroke population. VSN severely hampers older people during daily activities and their rehabilitation process and, therefore, has a major personal and societal impact. Accordingly, systematic assessment of VSN in the early phase of geriatric rehabilitation with multiple VSN screening tests is recommended.

Sensitivity and Specificity of the Brentano Illusion Test in the Detection of Visual Hemi-Field Deficits in Patients with Unilateral Spatial Neglect

Stroke survivors with right-brain damage (RBD) often present with attentional deficits such as left unilateral spatial neglect. Some patients also present with contralesional visual hemi-field deficits. A late detection of visual hemi-field deficits (VHFD) contributes to hampering neurorehabilitation and functional outcome of patients with neglect. The Brentano Illusion Test (BRIT) may be used for an early detection of VHFD during the neuropsychological assessment. In the present study, we determined the sensitivity and specificity of the BRIT for screening VHFD in patients with neglect. Sixty-four consecutive RBD patients were examined. Forty-five presented with neglect. Of these, 23 presented with VHFD (hemianopia or quadrantanopia) as detected by the Humphrey automated static visual field testing (reference standard). Consecutive patients also included 19 participants without neglect, who did not have any VHFD. The sensitivity and specificity of the BRIT for neglect patients were 78.3% (95% CI: 61.4-95.1) and 90.9 (95% CI: 78.9-100.0), respectively. Positive predictive value (PPV) was 89.6% (95% CI: 76.4-100.0); negative predictive value (NPV) 80.7% (95% CI: 65.2-96.2). No false positives in the group without neglect were identified. We conclude that the BRIT is an effective tool for clinical neuropsychologists to screen for possible VHFD in neglect patients during the neuropsychological assessment, allowing the refinement of the clinical picture in the neuropsychological report. An early detection of VHFD also allows referring the patient to standard diagnostics for a formal visual field examination, right from the first neuropsychological assessment.

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

OBJECTIVE

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

DESIGN

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

SETTING

Ten hospital sites providing in-patient stroke services.

PARTICIPANTS

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

INTERVENTION

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

MAIN MEASURES

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

RESULTS

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

CONCLUSIONS

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

CLINICAL TRIAL REGISTRATION

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

The Effect of Trunk Position on Attentional Disengagement in Unilateral Spatial Neglect

Unilateral spatial neglect (USN) causes difficulties in disengaging attention from the right side to unexpected targets on the left. However, the relationship between egocentric spatial position and attentional disengagement remains unclear. Therefore, this study aimed to clarify the relationship between trunk position and attentional disengagement. Thirty-eight patients with early stroke onset were classified as follows: USN (n = 18), right brain damage without USN (n = 10), and left brain damage (n = 10). The primary outcome was reaction time (RT) in the modified Posner task (MPT). The MPT comprised a condition in which the preceding cue and target direction were the same (valid condition) and a condition in which the directions were opposite (invalid condition). RT to the target was calculated. The MPT was performed in three different trunk positions (trunk midline, left, and right). In each group, the RT was compared on the basis of the stimulus conditions and trunk position. The RT was delayed in the valid and invalid left conditions, especially in the invalid left condition. The RT of the trunk right condition was significantly reduced compared with that of trunk midline and left conditions in the invalid left condition. Thus, trunk position influences attentional disengagement. This study contributes to the rehabilitation of patients with neglect symptoms.

Prism Adaptation Treatment Predicts Improved Rehabilitation Responses in Stroke Patients with Spatial Neglect

Spatial neglect (SN) impedes functional recovery after stroke, leading to reduced rehabilitation gains and slowed recovery. The objective of the present study was to investigate whether integrating prism adaptation treatment (PAT) into a highly intensive rehabilitation program eliminates the negative impact of spatial neglect on functional and motor recovery. We examined clinical data of the 355 consecutive first-time stroke patients admitted to a sub-acute inpatient neurorehabilitation program that integrated PAT. The 7-item Motor Functional Independence Measure, Berg Balance Scale, and Motor Activity Log were used as main outcome measures. We found that 84 patients (23.7%) had SN, as defined by a positive score on the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (KF-NAP^®). Although 71 patients (85%) received PAT, the presence of SN at baseline, regardless of PAT completion, was associated with lower functional independence, higher risk of falls, and a lower functional level of the affected upper limb both at admission and at discharge. The severity of SN was associated with inferior rehabilitation outcomes. Nonetheless, patients with SN who received PAT had similar rehabilitation gains compared to patients without SN. Thus, the present study suggests that integrating PAT in an intensive rehabilitation program will result in improved responses to regular therapies in patients with SN.

Assess and rehabilitate body representations via (neuro)robotics: An emergent perspective

The perceptions of our own body (e.g., size and shape) do not always coincide with its real characteristics (e.g., dimension). To track the complexity of our perception, the concept of mental representations (model) of the body has been conceived. Body representations (BRs) are stored in the brain and are maintained and updated through multiple sensory information. Despite being altered in different clinical conditions and being tightly linked with self-consciousness, which is one of the most astonishing features of the human mind, the BRs and, especially, the underlying mechanisms and functions are still unclear. In this vein, here we suggest that (neuro)robotics can make an important contribution to the study of BRs. The first section of the study highlights the potential impact of robotics devices in investigating BRs. Far to be exhaustive, we illustrate major examples of its possible exploitation to further improve the assessment of motor, haptic, and multisensory information building up the BRs. In the second section, we review the main evidence showing the contribution of neurorobotics-based (multi)sensory stimulation in reducing BRs distortions in various clinical conditions (e.g., stroke, amputees). The present study illustrates an emergent multidisciplinary perspective combining the neuroscience of BRs and (neuro)robotics to understand and modulate the perception and experience of one's own body. We suggest that (neuro)robotics can enhance the study of BRs by improving experimental rigor and introducing new experimental conditions. Furthermore, it might pave the way for the rehabilitation of altered body perceptions.

Computer-based assessment of unilateral spatial neglect: A systematic review

Background

To date, no gold standard exists for the assessment of unilateral spatial neglect (USN), a common post-stroke cognitive impairment, with limited sensitivity provided by currently used clinical assessments. Extensive research has shown that computer-based (CB) assessment can be more sensitive, but these have not been adopted by stroke services yet.

Objective

We conducted a systematic review providing an overview of existing CB tests for USN to identify knowledge gaps and positive/negative aspects of different methods. This review also investigated the benefits and barriers of introducing CB assessment tasks to clinical settings and explored practical implications for optimizing future designs.

Methodology

We included studies that investigated the efficacy of CB neglect assessment tasks compared to conventional methods in detecting USN for adults with brain damage. Study identification was conducted through electronic database searches (e.g., Scopus), using keywords and standardized terms combinations, without date limitation (last search: 08/06/2022). Literature review and study selection were based on prespecified inclusion criteria. The quality of studies was assessed with the quality assessment of diagnostic accuracy studies tool (Quadas-2). Data synthesis included a narrative synthesis, a table summarizing the evidence, and vote counting analysis based on a direction of effect plot.

Results

A total of 28 studies met the eligibility criteria and were included in the review. According to our results, 13/28 studies explored CB versions of conventional tasks, 11/28 involved visual search tasks, and 5/28 other types of tasks. The vote counting analysis revealed that 17/28 studies found CB tasks had either equal or higher sensitivity than conventional methods and positive correlation with conventional methods (15/28 studies). Finally, 20/28 studies showed CB tasks effectively detected patients with USN within different patient groups and control groups (17/28).

Conclusions

The findings of this review provide practical implications for the implementation of CB assessment in the future, offering important information to enhance a variety of methodological issues. The study adds to our understanding of using CB tasks for USN assessment, exploring their efficacy and benefits compared to conventional methods, and considers their adoption in clinical environments.

Resting-state electroencephalography changes in poststroke patients with visuospatial neglect

Background

This study aimed to explore the electrophysiological characteristics of resting-state electroencephalography (rsEEG) in patients with visuospatial neglect (VSN) after stroke.

Methods

A total of 44 first-event sub-acute strokes after right hemisphere damage (26 with VSN and 18 without VSN) were included. Besides, 18 age-matched healthy participants were used as healthy controls. The resting-state electroencephalography (EEG) of 64 electrodes was recorded to obtain the power of the spectral density of different frequency bands. The global delta/alpha ratio (DAR), DAR over the affected hemispheres (DAR_AH), DAR over the unaffected hemispheres (DAR_UH), and the pairwise-derived brain symmetry index (pdBSI; global and four bands) were compared between groups and receiver operating characteristic (ROC) curve analysis was conducted. The Barthel index (BI), Fugl-Meyer motor function assessment (FMA), and Berg balance scale (BBS) were used to assess the functional state of patients. Visuospatial neglect was assessed using a battery of standardized tests.

Results

We found that patients with VSN performed poorly compared with those without VSN. Analysis of rsEEG revealed increased delta and theta power and decreased alpha and beta power in stroke patients with VSN. Compared to healthy controls and poststroke non-VSN patients, patients with VSN showed a higher DAR (P < 0.001), which was significantly positively correlated with the BBS (DAR: r = –0.522, P = 0.006; DAR_AH: r = –0.521, P = 0.006; DAR_UH: r = –0.494, P = 0.01). The line bisection task was positively correlated with DAR (r = 0.458, P = 0.019) and DAR_AH (r = 0.483, P = 0.012), while the star cancellation task was only positively correlated with DAR_AH (r = 0.428, P = 0.029). DAR_AH had the best discriminating value between VSN and non-VSN, with an area under the curve (AUC) of 0.865. Patients with VSN showed decreased alpha power in the parietal and occipital areas of the right hemisphere. A higher parieto-occipital pdBSI_alpha was associated with a worse line bisection task (r = 0.442, P = 0.024).

Conclusion

rsEEG may be a useful tool for screening for stroke patients with visuospatial neglect, and DAR and parieto-occipital pdBSI_alpha may be useful biomarkers for visuospatial neglect after stroke.

Body and peripersonal space representations in chronic stroke patients with upper limb motor deficits

The continuous stream of multisensory information between the brain and the body during body–environment interactions is crucial to maintain the updated representation of the perceived dimensions of body parts (metric body representation) and the space around the body (the peripersonal space). Such flow of multisensory signals is often limited by upper limb sensorimotor deficits after stroke. This would suggest the presence of systematic distortions of metric body representation and peripersonal space in chronic patients with persistent sensorimotor deficits. We assessed metric body representation and peripersonal space representation in 60 chronic stroke patients with unilateral upper limb motor deficits, in comparison with age-matched healthy controls. We also administered a questionnaire capturing explicit feelings towards the affected limb. These novel measures were analysed with respect to patients’ clinical profiles and brain lesions to investigate the neural and functional origin of putative deficits. Stroke patients showed distortions in metric body representation of the affected limb, characterized by an underestimation of the arm length and an alteration of the arm global shape. A descriptive lesion analysis (subtraction analysis) suggests that these distortions may be more frequently associated with lesions involving the superior corona radiata and the superior frontal gyrus. Peripersonal space representation was also altered, with reduced multisensory facilitation for stimuli presented around the affected limb. These deficits were more common in patients reporting pain during motion. Explorative lesion analyses (subtraction analysis, disconnection maps) suggest that the peripersonal space distortions would be more frequently associated with lesions involving the parietal operculum and white matter frontoparietal connections. Moreover, patients reported altered feelings towards the affected limb, which were associated with right brain damage, proprioceptive deficits and a lower cognitive profile. These results reveal implicit and explicit distortions involving metric body representation, peripersonal space representation and the perception of the affected limb in chronic stroke patients. These findings might have important clinical implications for the longitudinal monitoring and the treatments of often-neglected deficits in body perception and representation.

Exploring the use of dopaminergic medication to treat hemispatial inattention during in-patient post-stroke neurorehabilitation

Hemispatial inattention (HSI), a lateralised impairment of spatial processing, is a common consequence of stroke. It is a poor prognostic indicator for functional recovery and interferes with the progress during in-patient neurorehabilitation. Dopaminergic medication has shown promise in improving HSI in the chronic post-stroke period but is untested in more acute settings, e.g. during in-patient neurorehabilitation. We audited the use of dopaminergic medication in ten sequential patients with post-stroke HSI, on an open-label exploratory basis. Patients' response to medication was assessed individually, using a three-week Off-On-Off protocol. We employed a mixture of bedside and functional measures, and made a multidisciplinary judgement of efficacy in individual patients. In six out of 10 patients, there was a convincing improvement of HSI while on medication, which reversed when it was paused. There was a mean 57% relative increase in target detection in the star cancellation test on the most affected side (on vs. off medication). In the six responders, medication was therefore continued throughout their admission without adverse effects. The star cancellation test was sensitive to HSI in most patients but in two cases failed to detect changes that were picked up by a functional assessment (Kessler Functional Neglect Assessment Protocol). We found this multidisciplinary approach to be feasible in an in-patient neurorehabilitation setting. We suggest further research to explore the efficacy of dopaminergic medication in improving neurorehabilitation outcomes for patients with post-stroke HSI. We suggest that more detailed N-of-1 assessments of treatment response, with internal blinding, may be a productive approach.

Current knowledge and practice of post-stroke unilateral spatial neglect rehabilitation: A cross-sectional survey of South African neurorehabilitation physiotherapists

Background

Unilateral spatial neglect (USN) affects the rehabilitation process leading to poor functional outcomes after stroke. South African physiotherapists' level of uptake of available evidence in USN rehabilitation and the barriers they encounter are not known.

Objectives

To evaluate knowledge, current practice enablers and barriers to USN management in stroke survivors amongst physiotherapists in South Africa.

Methods

Our cross-sectional survey used a total sampling technique. Questionnaires were sent to neurorehabilitation physiotherapists in South Africa. Descriptive and inferential statistics analysed the data.

Results

The overall knowledge score of USN was 14.11 ± 5.23 of a total of 25. The knowledge was good for definitions of USN; moderate for incidences, causes, screening, diagnosis and prognosis of USN and poor for pharmacological approaches to the management of USN. A significant low positive correlation between respondents' age (r = 0.46; p = 0.016) and years of practice as a physiotherapist (r = 0.43; p = 0.026) and knowledge of USN was found. The most frequently utilised intervention was constraint-induced movement therapy; the commonly utilised assessment tool was the comb and razor test. 'Inadequate therapy time' (55.56%) and 'lack of relevant equipment for rehabilitation of USN' (38.89%) were identified as major barriers to USN rehabilitation. Major enablers to USN rehabilitation were the 'presence of multidisciplinary stroke team in clinical practice' (83.35%) and 'availability of adequate staff' (76.47%).

Conclusion

Physiotherapists demonstrated a fair knowledge of USN although knowledge about pharmacological management of USN was modest. Current practice in post-stroke USN by South African neuro-physiotherapists follows current evidence and practice guidelines.

Clinical implication

Our study shows the level of knowledge and current practice of post-stroke USN rehabilitation. The demonstrated fair knowledge of USN may be improved through training, curriculum modifications or continuing professional development. Identified barriers to the rehabilitation of post-stroke USN can assist health policy, managers and clinicians to improve stroke-specific care.

Virtual Reality and Eye-Tracking Assessment, and Treatment of Unilateral Spatial Neglect: Systematic Review and Future Prospects

Unilateral spatial neglect (USN) is a disorder characterized by the failure to report, respond to, or orient toward the contralateral side of space to a brain lesion. Current assessment methods often fail to discover milder forms, cannot differentiate between unilateral spatial neglect subtypes and lack ecological validity. There is also a need for treatment methods that target subtypes. Immersive virtual reality (VR) systems in combination with eye-tracking (ET) have the potential to overcome these shortcomings, by providing more naturalistic environments and tasks, with sensitive and detailed measures. This systematic review examines the state of the art of research on these technologies as applied in the assessment and treatment of USN. As we found no studies that combined immersive VR and ET, we reviewed these approaches individually. The review of VR included seven articles, the ET review twelve. The reviews revealed promising results. (1) All included studies found significant group-level differences for several USN measures. In addition, several studies found asymmetric behavior in VR and ET tasks for patients who did not show signs of USN in conventional tests. Particularly promising features were multitasking in complex VR environments and detailed eye-movement analysis. (2) No VR and only a few ET studies attempted to differentiate USN subtypes, although the technologies appeared appropriate. One ET study grouped USN participants using individual heatmaps, and another differentiated between subtypes on drawing tasks. Regarding (3) ecological validity, although no studies tested the prognostic validity of their assessment methods, VR and ET studies utilized naturalistic tasks and stimuli reflecting everyday situations. Technological characteristics, such as the field of view and refresh rate of the head-mounted displays, could be improved, though, to improve ecological validity. We found (4) no studies that utilized VR or ET technologies for USN treatment up until the search date of the 26th of February 2020. In conclusion, VR-ET-based systems show great potential for USN assessment. VR-ET holds great promise for treatment, for example, by monitoring behavior and adapting and tailoring to the individual person's needs and abilities. Future research should consider developing methods for individual subtypes and differential diagnostics to inform individual treatment programs.

Spatial Neglect Midline Diagnostics From Virtual Reality and Eye Tracking in a Free-Viewing Environment

Purpose: Virtual reality (VR) and eye tracking may provide detailed insights into spatial cognition. We hypothesized that virtual reality and eye tracking may be used to assess sub-types of spatial neglect in stroke patients not readily available from conventional assessments.

Method: Eighteen stroke patients with spatial neglect and 16 age and gender matched healthy subjects wearing VR headsets were asked to look around freely in a symmetric 3D museum scene with three pictures. Asymmetry of performance was analyzed to reveal group-level differences and possible neglect sub-types on an individual level.

Results: Four out of six VR and eye tracking measures revealed significant differences between patients and controls in this free-viewing task. Gaze-asymmetry between-pictures (including fixation time and count) and head orientation were most sensitive to spatial neglect behavior on a group level analysis. Gaze-asymmetry and head orientation each identified 10 out of 18 (56%), compared to 12 out of 18 (67%) for the best conventional test. Two neglect patients without deviant performance on conventional measures were captured by the VR and eyetracking measures. On the individual level, five stroke patients revealed deviant gaze-asymmetry within-pictures and six patients revealed deviant eye orientation in either direction that were not captured by the group-level analysis.

Conclusion: This study is a first step in using VR in combination with eye tracking measures as individual differential neglect subtype diagnostics. This may pave the way for more sensitive and elaborate sub-type diagnostics of spatial neglect that may respond differently to various treatment approaches.

Spatial Neglect and Anosognosia After Right Brain Stroke

PURPOSE OF REVIEW

Up to 80% of survivors of right brain stroke leave acute care without being diagnosed with a major invisible disability. Studies indicate that a generic cognitive neurologic evaluation does not reliably detect spatial neglect, nor does it identify unawareness of deficit after right brain stroke; this article reviews the symptoms, clinical presentation, and management of these two cognitive disorders occurring after right brain stroke.

RECENT FINDINGS

Stroke and occupational therapy practice guidelines stress a quality standard for spatial neglect assessment and treatment to reduce adverse outcomes for patients, their families, and society. Neurologists may attribute poor outcomes associated with spatial neglect to stroke severity. However, people with spatial neglect are half as likely to return to home and community, have one-third the community mobility, and require 3 times as much caregiver supervision compared with similar stroke survivors. Multiple randomized trials support a feasible first-line rehabilitation approach for spatial neglect: prism adaptation therapy; more than 20 studies reported that this treatment improves daily life independence. Evidence-based treatment of anosognosia is not as developed; however, treatment for this problem is also available.

SUMMARY

This article guides neurologists' assessment of right brain cognitive disorders and describes how to efficiently assemble and direct a treatment team to address spatial neglect and unawareness of deficit.

Rescue of Neglect and Language Impairment After Stroke Thrombectomy

BACKGROUND AND PURPOSE

Although National Institutes of Health Stroke Scale scores provide an objective measure of clinical deficits, data regarding the impact of neglect or language impairment on outcomes after mechanical thrombectomy (MT) is lacking. We assessed the frequency of neglect and language impairment, rate of their rescue by MT, and impact of rescue on clinical outcomes.

METHODS

This is a retrospective analysis of a prospectively collected database from a comprehensive stroke center. We assessed right (RHS) and left hemispheric strokes (LHS) patients with anterior circulation large vessel occlusion undergoing MT to assess the impact of neglect and language impairment on clinical outcomes, respectively. Safety and efficacy outcomes were compared between patients with and without rescue of neglect or language impairment.

RESULTS

Among 324 RHS and 210 LHS patients, 71% of patients presented with neglect whereas 93% of patients had language impairment, respectively. Mean age was 71±15, 56% were females, and median National Institutes of Health Stroke Scale score was 16 (12-20). At 24 hours, MT resulted in rescue of neglect in 31% of RHS and rescue of language impairment in 23% of LHS patients, respectively. RHS patients with rescue of neglect (56% versus 34%, P<0.001) and LHS patients with rescue of language impairment (64 % versus 25%, P<0.01) were observed to have a higher rate of functional independence compared to patients without rescue. After adjusting for confounders including 24-hour National Institutes of Health Stroke Scale, rescue of neglect among RHS patients was associated with functional independence (P=0.01) and lower mortality (P=0.01). Similarly, rescue of language impairment among LHS patients was associated with functional independence (P=0.02) and lower mortality (P=0.001).

CONCLUSIONS

Majority of LHS-anterior circulation large vessel occlusion and of RHS-anterior circulation large vessel occlusion patients present with the impairment of language and neglect, respectively. In comparison to 24-hour National Institutes of Health Stroke Scale, rescue of these deficits by MT is an independent and a better predictor of functional independence and lower mortality.

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.

Impact of Multidisciplinary Stroke Post-Acute Care on Cost and Functional Status: A Prospective Study Based on Propensity Score Matching

Few papers discuss how the economic burden of patients with stroke receiving rehabilitation courses is related to post-acute care (PAC) programs. This is the first study to explore the economic burden of stroke patients receiving PAC rehabilitation and to evaluate the impact of multidisciplinary PAC programs on cost and functional status simultaneously. A total of 910 patients with stroke between March 2014 and October 2018 were separated into a PAC group (at two medical centers) and a non-PAC group (at three regional hospitals and one district hospital) by using propensity score matching (1:1). A cost-illness approach was employed to identify the cost categories for analysis in this study according to various perspectives. Total direct medical cost in the per-diem-based PAC cohort was statistically lower than that in the fee-for-service-based non-PAC cohort (p < 0.001) and annual per-patient economic burden of stroke patients receiving PAC rehabilitation is approximately US $354.3 million (in 2019, NT $30.5 = US $1). Additionally, the PAC cohort had statistical improvement in functional status vis-à-vis the non-PAC cohort and total score of each functional status before rehabilitation and was also statistically significant with its total score after one-year rehabilitation training (p < 0.001). Early stroke rehabilitation is important for restoring health, confidence, and safe-care abilities in these patients. Compared to the current stroke rehabilitation system, PAC rehabilitation shortened the waiting time for transfer to the rehabilitation ward and it was indicated as an efficient policy for treatment of stroke in saving medical cost and improving functional status.

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

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

Prevalence of spatial neglect post-stroke: A systematic review

OBJECTIVE

Spatial neglect (SN) impedes stroke rehabilitation progress, slows functional recovery, and increases caregiver stress and burden. The estimation of SN prevalence varies widely across studies.

BACKGROUND

We aimed to establish the prevalence of SN based on the injured cerebral hemisphere, recovery stage post-stroke, and diagnostic methodology.

MATERIALS AND METHODS

All journal articles published up to February 27, 2019 from CINAHL, PsycINFO, PubMed and Web of Science were searched. We selected original research articles that described observational studies, included both individuals with left brain damage (LBD) and those with right brain damage (RBD) post-stroke, and reported specific diagnostic methods for SN. All authors reached consensus for the final selection of 41 articles. Time post-stroke, patient selection criteria, study setting, SN diagnostic methods were extracted.

RESULTS

A total of 6324 participants were included: 3411 (54%) with RBD and 2913 (46%) with LBD. Without considering time post-stroke or diagnostic methods, the occurrence rate of SN was 29% (38% after RBD and 18% after LBD). Using ecological assessments resulted in higher prevalence than using tests not directly related to daily life activities (53% vs. 24%). Using methods based on a single-cutoff criterion led to lower occurrence of SN than using multi-test methods (27% vs. 33%). The prevalence decreased from the acute to chronic stage post-stroke.

CONCLUSIONS

The estimated prevalence of SN after unilateral stroke is 30%. SN is more common after RBD than after LBD, but SN after LBD is still quite common. Using ecological assessments and multi-test methods to detect SN is preferred to using a single-cutoff criterion of a test that is not directly related to daily function. The decrease in SN prevalence over time is evident, but the exact prevalence in later stages cannot be estimated. More research is needed to better understand chronic SN.

Proprioceptive impairment in unilateral neglect after stroke: A systematic review

Introduction:

Unilateral neglect is a debilitating condition that can occur after stroke and can affect a variety of domains and modalities, including proprioception. Proprioception is a sensorimotor process essential to motor function and is thus important to consider in unilateral neglect. To date, there has not been a comprehensive review of studies examining the various aspects of proprioceptive impairment in unilateral neglect after stroke. This review aimed to determine if people with unilateral neglect have more severe proprioceptive impairments than those without unilateral neglect after stroke.

Methods:

The MEDLINE, Embase, Scopus, CINAHL and Web of Science databases were searched from inception to September 2019 using an a priori search strategy. Two independent reviewers screened abstracts and full texts, and extracted data from the included full texts. A third reviewer resolved disagreements at each step. Risk of bias was assessed using the AXIS Quality Assessment tool.

Results:

A total of 191 abstracts were identified, with 56 eligible for full-text screening. A total of 18 studies were included in the review and provided evidence that people with unilateral neglect have more severe proprioceptive impairment than people without unilateral neglect. This impairment is present in multiple subtypes of unilateral neglect and aspects of proprioception. Most studies had a moderate risk of bias.

Conclusion:

People with unilateral neglect after stroke are more likely to have impaired processing of multiple types of proprioceptive information than those without unilateral neglect. However, the available evidence is limited by the large heterogeneity of assessment tools used to identify unilateral neglect and proprioception. Unilateral neglect and proprioception were rarely assessed comprehensively.

PROSPERO Registration: CRD42018086070.

Current clinical practice in the screening and diagnosis of spatial neglect post-stroke: Findings from a multidisciplinary international survey

Spatial neglect has profound implications for quality of life after stroke, yet we lack consensus for screening/diagnosing this heterogeneous syndrome. Our first step in a multi-stage research programme aimed to determine which neglect tests are used (within four categories: cognitive, functional, neurological and neuroimaging/neuromodulation), by which stroke clinicians, in which countries, and whether choice is by professional autonomy or institutional policy. 454 clinicians responded to an online survey: 12 professions (e.g., 39% were occupational therapists) from 33 countries (e.g., 38% from the UK). Multifactorial logistic regression suggested inter-professional differences but fewer differences between countries (Italy was an outlier). Cognitive tests were used by 82% (particularly by psychologists, cancellation and drawing were most popular); 80% used functional assessments (physiotherapists were most likely). 20% (mainly physicians, from Italy) used neuroimaging/ neuromodulation. Professionals largely reported clinical autonomy in their choices. Respondents agreed on the need for a combined approach to screening and further training. This study raises awareness of the translation gap between theory and practice. These findings lay an important foundation to subsequent collaborative action between clinicians, researchers and stroke survivors to reach consensus on screening and diagnostic measures. The immediate next step is a review of the measures' psychometric properties.

Assessment of spatial neglect in clinical practice: A nationwide survey

This study was part of a nationwide, anonymous, open Internet survey conducted amongst healthcare professionals in Denmark on the assessment and treatment of spatial neglect (SN). The objective was to describe knowledge and practices in the assessment of SN in current clinical practice across different healthcare sectors and professions. Data included the perceived prevalence, assessment methods and observations, subtypes and differential diagnostics of SN. A total of 525 professionals participated in the survey. The vast majority (81.5%) reported that assessment of SN was provided by their workplace. The median of perceived prevalence of SN was 35% (IQR 22-51) but major differences were found between professions. Occupational therapists and psychologists appeared to be most involved in assessment, whilst nursing staff and speech therapists were least involved. Subjective observations were the most common assessment method (90%). Conversely, systematic ADL observations, paper-and-pencil tests, confrontational tests and computerized tests were less common. The survey revealed large differences in the assessment methods and awareness of various aspects of SN symptoms (subtypes and differential diagnostics) between different healthcare professions. The results emphasize the need for international multidisciplinary clinical guidelines on how to assess SN and distinguish between different subtypes and differential diagnoses.