Predictors of discharge to home during the first year after right hemisphere stroke

Application of immersive virtual reality for assessing chronic neglect in individuals with stroke: the immersive virtual road-crossing task

BACKGROUND

Neglect can be a long-term consequence of chronic stroke that can impede an individual's ability to perform daily activities, but chronic and discrete forms can be difficult to detect. We developed and evaluated the "immersive virtual road-crossing task" (iVRoad) to identify and quantify discrete neglect symptoms in chronic stroke patients.

METHOD

The iVRoad task requires crossing virtual intersections and placing a letter in a mailbox placed either on the left or right. We tested three groups using the HTC Vive Pro Eye: (1) chronic right hemisphere stroke patients with (N = 20) and (2) without (N = 20) chronic left-sided neglect, and (3) age and gender-matched healthy controls (N = 20). We analyzed temporal parameters, errors, and head rotation to identify group-specific patterns, and applied questionnaires to measure self-assessed pedestrian behavior and usability.

RESULTS

Overall, the task was well-tolerated by all participants with fewer cybersickness-induced symptoms after the VR exposure than before. Reaction time, left-sided errors, and lateral head movements for traffic from left most clearly distinguished between groups. Neglect patients committed more dangerous crossings, but their self-rated pedestrian behavior did not differ from that of stroke patients without neglect. This demonstrates their reduced awareness of the risks in everyday life and highlights the clinical relevance of the task.

CONCLUSIONS

Our findings suggest that a virtual road crossing task, such as iVRoad, has the potential to identify subtle symptoms of neglect by providing virtual scenarios that more closely resemble the demands and challenges of everyday life. iVRoad is an immersive, naturalistic virtual reality task that can measure clinically relevant behavioral variance and identify discrete neglect symptoms.

When stroke survivors' self-ratings are inconsistent with the ratings of others: a cohort study examining biopsychosocial factors associated with impaired self-awareness of functional abilities

Background Stroke survivors' self-ratings of functional abilities are often inconsistent with ratings assigned by others (e.g. clinicians), a phenomenon referred to as 'impaired self-awareness' (ISA). There is limited knowledge of the biopsychosocial contributors and consequences of post-stroke ISA measured across the rehabilitation journey. This multi-site cohort study explored biopsychosocial correlates of ISA during subacute rehabilitation (inpatient) and at 4 months post-discharge (community-dwelling). Methods Forty-five subacute stroke survivors participated (Age M (s.d.) =  71.5 (15.6), 56% female), and 38 were successfully followed-up. Self-assessments were compared to those of an independent rater (occupational therapist, close other) to calculate ISA at both time points. Survivors and raters completed additional cognitive, psychological and functional measures. Results Multivariate regression (multiple outcomes) identified associations between ISA during inpatient admission and poorer outcomes at follow-up, including poorer functional cognition, participation restriction, caregiver burden, and close other depression and anxiety. Regression models applied cross-sectionally, including one intended for correlated predictors, indicated associations between ISA during inpatient admission and younger age, male sex, poorer functional cognition, poorer rehabilitation engagement and less frequent use of non-productive coping (adjusted R 2  = 0.60). ISA at community follow-up was associated with poorer functional cognition and close other anxiety (adjusted R 2  = 0.66). Conclusions Associations between ISA and poorer outcomes across the rehabilitation journey highlight the clinical importance of ISA and the value of assessment and management approaches that consider the potential influence of numerous biological and psychosocial factors on ISA. Future studies should use larger sample sizes to confirm these results and determine the causal mechanisms of these relationships.

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.

The process by which patients become aware of unilateral spatial neglect: A qualitative study

Unilateral spatial neglect (USN), which can occur post-stroke, significantly impacts patients' daily lives. We explored the process by which patients become aware of the facets of their USN from the acute to subacute phase using a qualitative method. Participant observations, semi-structured interviews, and medical-record surveys were conducted with eight patients with USN and thirty healthcare professionals. We identified three themes regarding the patients' USN awareness process: inconsistency between present symptoms and perception of the left side, reconsidering the reasons for a vagueness on the left side, and acceptance of neglecting the left side. Additionally, healthcare professionals' support consisted of four strategies: assessing patients' perception of stimuli on their left side, compensating for patients' behaviours, promoting awareness of USN, and promoting activities that involve the use of residual functions after a cerebrovascular accident. Patients with USN gradually became aware of their deficits through interactions with others, and they responded by creating and practicing their own self-developed management strategies. These findings indicate that recovery from USN requires a series of experiences and social interactions. A comprehensive understanding of the process of awareness and adaption to USN from onset to recovery can help provide support for patients with USN.

Assessment tools for differential diagnosis of neglect: Focusing on egocentric neglect and allocentric neglect

BACKGROUND

There are very few studies on the differential diagnosis between egocentric neglect (EN) and allocentric neglect (AN).

AIM

To investigate the overall trend of the previously developed assessment tools by conducting a descriptive review of the studies on assessment tools that can perform a differential diagnosis of EN and AN.

METHODS

The data were collected by using databases such as Google Scholar, PubMed, and ScienceDirect. The most commonly used search terms were “neglect”, “stroke”, “egocentric neglect”, and “allocentric neglect”.

RESULTS

A total of seven studies that met the inclusion criteria were selected and analyzed. We were able to confirm the research process, test method, and differential diagnosis criteria of the seven presented assessment tools from four studies on paper-based tests and three studies on computerized tests. The majority of the tests were carried out via the cancellation method using stimuli such as everyday objects or numbers. EN distinguished the left from right based on the test paper, while AN distinguished the left from right based on stimuli. In order to perform differential diagnosis, the difference in the number of left and right responses or non-responses was used based on the EN and AN criteria.

CONCLUSION

It was confirmed that all the seven assessment tools can effectively perform differential diagnosis of EN and AN. This study may provide important data that can be used in clinical practice for differential diagnosis and future intervention planning for neglect patients.

Using non-invasive transcranial direct current stimulation for neglect and associated attentional deficits following stroke

Neglect is a disabling neuropsychological syndrome that is frequently observed following right-hemispheric stroke. Affected individuals often present with multiple attentional deficits, ranging from reduced orienting towards contralesional space to a generalized impairment in maintaining attention over time. Although a degree of spontaneous recovery occurs in most patients, in some individuals this condition can be treatment-resistant with prominent ongoing non-spatial deficits. Further, there is a large inter-individual variability in response to different therapeutic approaches. Given its potential to alter neuronal excitability and affect neuroplasticity, non-invasive brain stimulation is a promising tool that could potentially be utilized to facilitate recovery. However, there are many outstanding questions regarding its implementation in this heterogeneous patient group. Here we provide a critical overview of the available evidence on the use of non-invasive electrical brain stimulation, focussing on transcranial direct current stimulation (tDCS), to improve neglect and associated attentional deficits after right-hemispheric stroke. At present, there is insufficient robust evidence supporting the clinical use of tDCS to alleviate symptoms of neglect. Future research would benefit from careful study design, enhanced precision of electrical montages, multi-modal approaches exploring predictors of response, tailored dose-control applications and increased efforts to evaluate standalone tDCS versus its incorporation into combination therapy.

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.

Prism Adaptation Treatment Improves Inpatient Rehabilitation Outcome in Individuals With Spatial Neglect: A Retrospective Matched Control Study

Objective

To determine whether prism adaptation treatment (PAT) integrated into the standard of care improves rehabilitation outcome in patients with spatial neglect (SN).

Design

Retrospective matched control study based on information extracted from June 2017-September 2019.

Setting

Inpatient rehabilitation.

Participants

Patients from 14 rehabilitation hospitals scoring >0 on the Catherine Bergego Scale (N=312). The median age was 69.5 years, including 152 (49%) female patients and 275 (88%) patients with stroke.

Interventions

Patients were matched 1:1 by age (±5 years), FIM score at admission (±2 points), and SN severity using the Catherine Bergego Scale (±2 points) and classified into 2 groups: treated (8-12 daily sessions of PAT) vs untreated (no PAT).

Main Outcome Measures

FIM and its minimal clinically important difference (MCID) were the primary outcome variables. Secondary outcome was home discharge.

Results

Analysis included the 312 matched patients (156 per group). FIM scores at discharge were analyzed using repeated-measures analyses of variance. The treated group showed reliably higher scores than the untreated group in Total FIM, F=5.57, P=.020, partial η²=0.035, and Cognitive FIM, F=19.20, P<.001, partial η²=0.110, but not Motor FIM, F=0.35, P=.553, partial η²=0.002. We used conditional logistic regression to examine the odds ratio of reaching MCID in each FIM score and of returning home after discharge. No reliable difference was found between groups in reaching MCID or home discharge.

Conclusions

Patients with SN receiving PAT had better functional and cognitive outcomes, suggesting that integrating PAT into the standard of care is beneficial. However, receiving PAT may not determine home discharge.

Is Discordance Between Recommended and Actual Postacute Discharge Setting a Risk Factor for Readmission in Patients With Congestive Heart Failure?

Background

Readmissions in patients with congestive heart failure are common and often preventable. Limited data suggest that patients discharged to a less intensive postacute care setting than recommended are likely to readmit. We examined whether postacute setting discordance (discharge to a less intensive postacute setting than recommended by a physical and occupational therapist) was associated with hospital readmission in patients with congestive heart failure. We also assessed sociodemographic and clinical predictors of setting discordance.

Methods and Results

Retrospective analysis of administrative claims and electronic health record data was conducted on 25 500 adults with a discharge diagnosis of congestive heart failure from 12 acute care hospitals in Western Pennsylvania. Generalized linear mixed models were estimated to examine the association between postacute setting discordance and 30‐day hospital readmission and to identify predictors of setting discordance. The 30‐day readmission and postacute setting discordance rates were high (23.7%, 20.6%). While controlling for demographic and clinical covariates, patients in discordant postacute settings were more likely to be readmitted within 30 days (adjusted odds ratio [OR], 1.12; 95% CI, 1.04–1.20). The effect was also seen in the subgroup of patients with low mobility scores (adjusted OR, 1.20; 95% CI, 1.08–1.33). Factors associated with setting discordance were lower‐income, higher comorbidity burden, therapist recommendation disagreement, and midrange mobility limitations.

Conclusions

Postacute setting discordance was associated with an increased readmission risk in patients hospitalized with congestive heart failure. Maximizing concordance between therapist recommended and actual postacute discharge setting may decrease readmissions. Understanding factors associated with post‐acute setting discordance can inform strategies to improve the quality of the discharge process.

The Korean Version of the Fugl-Meyer Assessment: Reliability and Validity Evaluation

Objective

To systematically translate the Fugl-Meyer Assessment (FMA) into a Korean version of the FMA (K-FMA).

Methods

We translated the original FMA into the Korean version with three translators and a translation committee, which included physiatrists, physical therapists, and occupational therapists. Based on a test-retest method, each of 31 patients with stroke was assessed by two evaluators twice, once on recruitment, and again after a week. Analysis of intra- and inter-rater reliabilities was performed using the intra-class correlation coefficient, whereas validity was analysed using Pearson correlation test along with the Motricity Index (MI), Motor Assessment Scale (MAS), and Berg Balance Scale (BBS).

Results

The intra- and inter-rater reliabilities were significant for the total score, and good to excellent reliability was noted in all domains except for the joint range of motion of the lower extremity domain of the K-FMA. The MI and MAS scores were significantly correlated with all domains, all with p<0.01. The results for the MI ranged from r=0.639 to r=0.891 and those for the MAS from r=0.339 to r=0.555. However, the BBS was not significantly correlated with any domain, as the K-FMA lacks balance evaluation items.

Conclusion

The K-FMA was found to have high reliability and validity. Additionally, the newly developed manual for the K-FMA may help minimise errors that can occur during evaluation and improve the reliability of motor function evaluation.

Barriers and Facilitators to Rehabilitation Care of Individuals With Spatial Neglect: A Qualitative Study of Professional Views

Objective

To identify barriers and facilitators to achieving optimal inpatient rehabilitation outcome among individuals with spatial neglect (SN).

Design

Cross-sectional, semistructured focus group discussions.

Setting

Rehabilitation hospitals.

Participants

A total of 15 occupational therapists and 14 physical therapists treating patients with SN on 3 campuses of a rehabilitation hospital system (N=29). Six focus group sessions were conducted and audio-recorded for transcription.

Interventions

Not applicable.

Main Outcome Measures

Not applicable.

Results

Participants identified several patient-related characteristics that posed barriers to treatment, including the symptoms of SN itself, cognitive issues, physical weakness, comorbidities, and reduced therapy engagement. Supportive family members were considered a key facilitator, but lack of preparedness to assume caregiving roles, poor understanding of SN and rehabilitation goals, and inadequate levels of involvement were family-related barriers to successful treatment. Participants expressed that having resources and technologies available at their center to support SN treatment facilitated positive outcomes and perceived limited staff knowledge and skills and poor interclinician communication as barriers to treatment. At the health care system level, barriers included a lack of responsive measures of SN progress and insurer-related issues. Strong continuity of care between transitions was considered an important factor for enabling effective treatment.

Conclusions

Barriers and facilitators to the current practice of SN care were identified from occupational and physical therapists’ point of view. Opportunities exist to promote identified facilitators and minimize barriers to improve SN rehabilitation. The present study makes a unique contribution in identifying specific needs for innovative interventions that involve family support and training, promotion of interdisciplinary collaboration, development of interprofessional vocabulary, and continuous treatment and follow-up assessment for SN through care transitions.

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.

Spatial exploration strategy training for spatial neglect: A pilot study

Spatial neglect is a syndrome due to impaired neural networks critical for spatial attention and related cognitive and motor functions. Affected individuals also have impaired self-awareness of their own neglect symptoms. The present randomized controlled study was the first proof-of-concept pilot examining the multi-context treatment approach using a protocol of spatial exploration strategy training in one brief session (20-30 minutes). The therapist provided supportive feedback and semi-structured guidance to promote strategy learning and self-discovery of omission errors. 40 patients with left-sided neglect after right brain stroke were included. The results showed that the treatment reduced lateralized bias toward the ipsilesional side of space but did not improve overall detection performance. Impaired general self-awareness of daily-life spatial difficulties was found independent of treatment outcome. This implies that judgment regarding responsiveness to treatment should not be made based on an awareness interview or the severity of neglect symptoms. Lastly, the treatment showed the potential of improving online contextual self-awareness of spatial abilities. A collaborative and interactive approach that focuses on helping the patient self-discover, monitor and self-manage their errors, appears to have a potential for decreasing neglect symptoms. Future studies are required to examine additional aspects of the multi-context treatment approach.

Speech-Language Pathology Practices for Adults With Right Hemisphere Stroke: What Are We Missing?

Purpose Limited evidence exists to guide the assessment and treatment of cognitive-communication disorders associated with right hemisphere stroke. The purpose of this study was to obtain information about speech-language pathologists' (SLPs') clinical practices and decision making for this population to understand what practices are being used and identify gaps in clinical practice. Method A survey was distributed via online ASHA Communities for the Special Interest Groups and other social media platforms. Respondents included 143 SLPs from across the United States representing 3-50 years of experience and a wide range of practice settings. Survey questions probed assessment practices including how tests are selected, what tests are used to diagnose specific deficits, and how confident SLPs were in their diagnoses. Treatment decisions were queried for a small set of disorders. Results SLPs routinely assess cognitive disorders using standardized tests. Communication disorders are less likely to be formally assessed. Three core right cerebral hemisphere deficits-anosognosia, aprosodia, and pragmatic deficits-are either not assessed or assessed only through observation by 80% of SLPs. Evidence-based treatments are commonly used for disorders of attention, awareness, and aprosodia. Conclusion Communication disorders are less likely to be formally assessed than cognitive disorders, creating a critical gap in care that cannot be filled by other allied health professionals. Suggestions for free or low-cost resources for evaluating pragmatics, prosody, and awareness are provided to aid SLPs in filling this gap. Supplemental Material https://doi.org/10.23641/asha.12159597.

Factors associated with successful home discharge after inpatient rehabilitation in frail older stroke patients

Background

Stroke is a highly prevalent disease among older people and can have a major impact on daily functioning and quality of life. When community-dwelling older people are hospitalized due to stroke, discharge to an intermediate care facility for geriatric rehabilitation is indicated when return to the previous living situation is expected but not yet possible. However, a substantial proportion is still unable to return home after discharge and has to be admitted to a residential care setting. This study aims to identify which factors are associated with home discharge after inpatient rehabilitation among frail and multimorbid older stroke patients.

Methods

This study is a longitudinal cohort study among 92 community-dwelling stroke patients aged 65 years or over. All patients were admitted to one of eight participating intermediate care facilities for geriatric rehabilitation, under the expectation to return home after rehabilitation. We examined whether 16 potentially relevant factors (age; sex; household situation before admission; stroke history; cardiovascular disorders; diabetes mellitus; multimorbidity; cognitive disability; neglect; apraxia; dysphagia; urinary and bowel incontinence; emotional problems; sitting balance; daily activity level; and independence in activities of daily living) measured at admission were associated with discharge to the former living situation. Logistic regression analysis was used for statistical analysis.

Results

Mean age of the patients was 79.0 years (SD 6.4) and 51.1% was female. A total of 71 patients (77.1%) were discharged to the former living situation within 6 months after the start of geriatric rehabilitation. Of the 16 factors analysed, only a higher level of independence in activities of daily living at admission was significantly associated with home discharge.

Conclusions

Our study shows that the vast majority of previously identified factors predicting home discharge among stroke patients, could not predict home discharge among a group of frail and multimorbid older persons admitted to geriatric rehabilitation. Only a higher level of independence in activities of daily living at admission was significantly related to home discharge. Additional insight in other factors that might predict home discharge after geriatric rehabilitation among this specific group of frail older stroke patients, is needed. Trial registration: ISRCTN ISRCTN62286281. Registered 19-3-2010.

Conventional and functional assessment of spatial neglect: Clinical practice suggestions

OBJECTIVE

Spatial neglect (SN) constitutes a substantial barrier to functional recovery after acquired brain injury. However, because of its multimodal nature, no single test can capture all the signs of SN. To provide a clinically feasible solution, we used conventional neuropsychological tests as well as the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP). The goal was to add evidence that a global approach should detect better even subtle signs of SN.

METHOD

Fourteen individuals with lesions located in the right cerebral hemisphere participated in the study. Participants were assessed with a comprehensive battery of neuropsychological tests, comprising a set of visuospatial tests to evaluate several spatial domains. In addition, patients underwent functional assessment with the Barthel Index, the Functional Independence Measure (FIM), and the CBS via KF-NAP.

RESULTS

The CBS via KF-NAP was associated with the visuospatial paper-based tests (p = .004) as well as the Motor FIM (p = .003), and was more sensitive than the Behavioral Inattention Test-Conventional in detecting SN (p = .014).

CONCLUSIONS

We showed that the CBS via KF-NAP was able: (a) to detect functional impairment, especially motor, related to SN; (b) to selectively measures spatial rather than nonspatial dysfunctions; and (c) to be highly sensitive in detecting SN signs especially in those patients with mild severity, covering several aspects of SN manifestations. The patient's SN diagnosis based on the CBS via KF-NAP is clinically important and directly relevant to care planning and goal setting. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Spatial cognitive rehabilitation and motor recovery after stroke

PURPOSE OF REVIEW

Stroke rehabilitation needs to take major steps forward to reduce functional disability for survivors. In this article, we suggest that spatial retraining might greatly increase the efficiency and efficacy of motor rehabilitation, directly addressing the burden and cost of paralysis after stroke.

RECENT FINDINGS

Combining motor and cognitive treatment may be practical, as well as addressing the needs after moderate-to-severe stroke. Spatial neglect could suppress motor recovery and reduce motor learning, even when patients receive appropriate rehabilitation to build strength, dexterity, and endurance. Spatial neglect rehabilitation acts to promote motor as well as visual-perceptual recovery. These findings, and the previous underemphasized studies, make a strong case for combining spatial neglect treatment with traditional exercise training. Spatial neglect therapies might also provide motor stimulation if people cannot participate in intensive movement therapies because of limited strength and endurance after stroke.

SUMMARY

Spatial retraining, currently used selectively after right-brain stroke, may be broadly useful after stroke to promote rapid motor recovery.

Is two better than one? Limb activation treatment combined with contralesional arm vibration to ameliorate signs of left neglect

In the present study, we evaluated the effects of the Limb Activation Treatment (LAT) alone and in combination with the Contralateral Arm Vibration (CAV) on left neglect (LN) rehabilitation. We conceived them as techniques that both prompt the activation of the lesioned right hemisphere because of the activation (with the LAT as an active technique) and the stimulation (with the CAV as a passive technique) of the left hemibody. To test the effect of the simultaneous use of these two techniques (i.e., LAT and CAV) on visuo-spatial aspects of LN, we described the case of an LN patient (GR), who showed high intra-individual variability (IIV) in performance. Given the high IIV of GR, we used an ABAB repeated-measures design to better define the effectiveness of the combined application of LAT and CAV, as a function of time. The results showed an improvement of GR's performance on the Bells test following the combined application of LAT and CAV, with respect to the application of LAT alone. We did not find, however, significant effects of treatment on two other LN tests (i.e., Line bisection and Picture scanning). We propose that the combined application of LAT and CAV can be beneficial for some aspects of LN.

Rehabilitation Interventions for Unilateral Neglect after Stroke: A Systematic Review from 1997 through 2012

A systematic review of the effectiveness of rehabilitation for persons with unilateral neglect (UN) after stroke was conducted by searching the computerized databases from 1997 through 2012. Randomized controlled trials (RCTs) of neglect treatment strategies for stroke patients which used the Behavioral Inattention Test (BIT) as the primary outcome measure were eligible for inclusion. Out of 201 studies initially identified, 12 RCTs covering 277 participants were selected for analysis. All had the same weakness of low power with smaller samples and limitation in the blinding of the design. Prism Adaptation (PA) was the most commonly used intervention while continuous Theta-burst stimulation (cTBS) appeared to be a new approach. Meta-analysis showed that for immediate effects, the BIT conventional subscore had a significant and large mean effect size (ES = 0.76; 95% CI 0.28-1.23; p = 0.002) whereas the BIT total score showed a modestly significant mean ES (ES = 0.55; 95% CI 0.16-0.94; p = 0.006). No significant mean ES in sensitivity analysis was found for long-lasting effects across all BIT outcomes. PA appeared to be the most effective intervention based on the results of pooled analysis. More rigorous studies should be done on repetitive transcranial magnetic stimulation (rTMS) before it can be concluded that it is a promising treatment for UN.

An evidence-based systematic review on communication treatments for individuals with right hemisphere brain damage

PURPOSE

The purpose of this review is to evaluate and summarize the research evidence related to the treatment of individuals with right hemisphere communication disorders.

METHOD

A comprehensive search of the literature using key words related to right hemisphere brain damage and communication treatment was conducted in 27 databases (e.g., PubMed, CINAHL). On the basis of a set of pre-established clinical questions, inclusion/exclusion criteria, and search parameters, studies investigating sentence- or discourse-level treatments were identified and evaluated for methodological quality. Data regarding participant, intervention, and outcome variables were reported.

RESULTS

Only 5 studies were identified, each representing a different sentence- or discourse-level treatment approach and reporting a wide range of prosodic, expressive, receptive, and pragmatic outcomes.

CONCLUSION

Although the state of the evidence pertaining to right hemisphere communication treatments is at a very preliminary stage, some positive findings were identified to assist speech-language pathologists who are working with individuals with right hemisphere brain damage. Clinical implications and recommendations for future research are explored.

The nonspatial side of spatial neglect and related approaches to treatment

In addition to deficits in spatial attention, individuals with persistent spatial neglect almost universally exhibit nonspatially lateralized deficits in sustained and selective attention, and working memory. However, nonspatially lateralized deficits in neglect have received considerably less attention in the literature than deficits in spatial attention. This is in spite of the fact that nonspatially lateralized deficits better predict the chronicity and functional disability associated with neglect than spatially lateralized deficits. Furthermore, only a few treatment studies have specifically targeted nonspatially lateralized deficits as a means to improve spatial neglect. In this chapter, we will briefly review several models of spatial attention bias in neglect before focusing on nonspatial deficits and the mechanisms of nonspatial-spatial interactions and implications for treatment. Treatment approaches that more completely address nonspatial deficits and better account for their interactions with spatial attention will likely produce better outcomes.

Driving ability in stroke patients with residual visual inattention: a case study

Driving ability of three patients having a right hemisphere infarct and residual visual inattention was examined. The neuropsychological examination included the Peripheral Perception Test and the Signal Detection Test from the Vienna Test System, and the Behavioural Inattention Test (BIT). Driving ability was assessed with an on-road evaluation. The patients had no neglect based on the BIT and had normal visual fields, but they showed slightly poorer visual search on the left side. All patients passed the official on-road driving test and were considered capable of driving. This study raises the question if acute neglect can recover to a degree in which driving may be possible.

Factors associated with functional recovery and home discharge in stroke patients admitted to a convalescent rehabilitation ward

AIMS

This study aimed to determine the predictive factors for functional recovery and home discharge in stroke patients receiving in-hospital rehabilitation.

METHODS

This study included a consecutive series of 174 stroke patients (average age 73.0 ± 10.8) admitted to the convalescent rehabilitation ward at Azumino Red Cross Hospital in Japan after acute rehabilitation. The main outcome measures were functional recovery (functional independence measure [FIM] at discharge and Montebello rehabilitation factor score [MRFS]) and home discharge.

RESULTS

Total FIM improved from 72.6 ± 27.6 to 87.7 ± 29.9 during the hospital stay (P < 0.001). The average MRFS was 0.30 ± 0.28. Of the 174 patients, 151 were discharged home (87%). Age, stroke type, premorbid independence, motor FIM, and cognitive FIM at admission showed a significant association with FIM at discharge, while age, premorbid independence, motor FIM at admission, and cognitive FIM at admission were statistically significant predictors of MRFS. Female sex, not living with family, premorbid independence, and neglect were negatively associated with home discharge.

CONCLUSIONS

Premorbid disability and cognitive dysfunction at admission were both negatively associated with functional recovery and home discharge in patients undergoing inpatient stroke rehabilitation.

Predictors of discharge to home after thrombolytic treatment in right hemisphere infarct patients

BACKGROUND

The aim of the study was to assess the association between thrombolysis and length of hospital stay after right hemisphere (RH) infarct, and to identify which cognitive functions were predictive of discharge.

METHODS

The study group consisted of 75 acute RH patients. Thirty-three patients had thrombolysis. Neuropsychological examinations were performed within 11 days of stroke onset. The cognitive predictors were visual neglect, visual memory, visual search and reasoning and visuoconstructive abilities. The outcome variable was time from stroke to discharge to home.

RESULTS

Thrombolysis emerged as a statistically significant predictor of discharge time in patients with moderate/severe stroke (NIHSS ≥5). In the total series of patients and in patients with mild stroke (NIHSS <5), thrombolysis was not significantly associated with discharge time. Milder visuoconstructive defects shortened the hospital stay of the whole patient group and of patients with moderate/severe stroke. In all patient groups, independence in activities of daily living (ADL) was a significant single predictor of a shorter hospital stay. The best combination of predictors for discharge was independence in ADL in the total series of patients and in patients with mild stroke, and thrombolysis and independence in ADL in patients with moderate/severe stroke.

CONCLUSIONS

Thrombolytic treatment was a significant predictor of earlier discharge to home in patients with moderate/severe RH infarct, while cognitive functions had less predictive power.

Compensatory strategies following visual search training in patients with homonymous hemianopia: an eye movement study

A total of 29 patients with homonymous visual field defects without neglect practised visual search in 20 daily sessions, over a period of 4 weeks. Patients searched for a single randomly positioned target amongst distractors displayed for 3 s. After training patients demonstrated significantly shorter reaction times for search stimuli (Pambakian et al. in J Neurol Neurosurg Psychiatry 75:1443-1448, 2004). In this study, patients achieved improved search efficiency after training by altering their oculomotor behaviour in the following ways: (1) patients directed a higher proportion of fixations into the hemispace containing the target, (2) patients were quicker to saccade into the hemifield containing the target if the initial saccade had been made into the opposite hemifield, (3) patients made fewer transitions from one hemifield to another before locating the target, (4) patients made a larger initial saccade, although the direction of the initial saccade did not change as a result of training, (5) patients acquired a larger visual lobe in their blind hemifield after training. Patients also required fewer saccades to locate the target after training reflecting improved search efficiency. All these changes were confined to the training period and maintained at follow-up. Taken together these results suggest that visual training facilitates the development of specific compensatory eye movement strategies in patients with homonymous visual field defects.

The frequency, clinical correlates, and mechanism of anosognosia after stroke

OBJECTIVE

To review the frequency, clinical correlates, and mechanism of anosognosia after stroke.

METHODS

We searched the most recent relevant literature on anosognosia after stroke and carried out a critical analysis of the main findings.

RESULTS

Anosognosia is present in about 10% of acute stroke patients and its diagnosis is relatively simple. Nevertheless, a valid and reliable standardization of diagnostic instruments and criteria for research purposes is more difficult to achieve. This limitation may partially account for various instruments available to assess anosognosia and the different strategies used to diagnose this phenomenon. Anosognosia is a fleeting phenomenon and chronic cases are infrequent. There is a robust association between anosognosia and right-hemisphere lesions involving cortical (insular, temporal, and parietal lobes) and subcortical structures (thalamus and basal ganglia). The main clinical correlates of anosognosia are the presence of neglect, cognitive deficits, previous strokes, and older age. Anosognosia has a negative impact on the rehabilitation of stroke patients. The mechanism of anosognosia remains unknown but was explained as owing to psychological denial, disconnection between left and right hemispheres, and dysfunction of a system that monitors the intention to move and actual movements.

CONCLUSION

Anosognosia is a relatively frequent complication of acute stroke and may become an excellent model to understand the mechanism of human awareness.

Paediatric arterial ischaemic stroke: functional outcome and risk factors

AIM

To study functional outcome in children aged 1 month to 18 years after paediatric arterial ischaemic stroke (PAIS) and to identify risk factors influencing their quality of life.

METHOD

In a consecutive series of 76 children (35 males 41 females, median age at diagnosis 2y 6mo, range 1mo-17y 2mo; median length of follow-up 2y 4mo, range [7mo-10y 6mo]) with PAIS diagnosed at the Erasmus Medical Centre Sophia Children's Hospital between 1997 and 2006, we collected clinical, biochemical, and radiological data prospectively. In 66 children surviving at least 1 year after PAIS, functional outcome could be evaluated with the World Health Organization's International Classification of Impairments, Disabilities and Handicaps.

RESULTS

Significant risk factors at presentation for a poor neurological outcome were young age, infarction in the right middle cerebral artery territory, and fever at presentation. Fifty-four % of children had severe neurological impairments at 12 months after PAIS, and at last follow-up more than half needed remedial teaching, special education, or institutionalization. Health-related quality of life (HRQOL) questionnaires showed a significantly lower HRQOL in all age groups. Children with a longer follow-up had a lower HRQOL in the cognitive functioning domain.

INTERPRETATION

Our study shows significant morbidity and mortality and a reduced HRQOL after PAIS depending on age, fever at presentation, and infarction in the right middle cerebral artery territory.

Prognostic social factors in the subacute phase after a stroke for the discharge destination from the hospital stroke-unit. A systematic review of the literature

PURPOSE

The objective of our study was to identify prognostic social factors in the subacute phase after stroke for the discharge destination from the hospital stroke-unit.

METHODS

A systematic literature search was performed, designed in accordance with the Cochrane Collaboration criteria. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria.

RESULTS

Characteristics of the social situation that proved to be important for prediction of the discharge destination are marital status and social support. Quantity and methodological quality of the research studies were insufficient, and the number of possible social prognostic factors investigated was limited by the absence of a conceptual framework of social subdomains in the studies, including an unambiguous definition of the prognostic social factors within these subdomains.

CONCLUSIONS

A great need exists for research into the prognostic qualities of the following social factors: the ability to provide support, presence, and readiness of the homefront; the availability of professional care, personal financial means, membership of societies and clubs, frequency of contacts with close relatives and friends; the quality of the patient's residence with regard to the adaptation to the needs and abilities of the patient. A commitment about the aforementioned conceptual framework is mandatory.

Perspectives on treatment for communication deficits associated with right hemisphere brain damage

PURPOSE

To describe the current treatment research for communication (prosodic, discourse, and pragmatic) deficits associated with right hemisphere brain damage and to provide suggestions for treatment selection given the paucity of evidence specifically for this population.

METHOD

The discussion covers (a) clinical decision processes and evidence-based practice; (b) a review of right hemisphere communication deficits and existing treatment studies; (c) accounts of right hemisphere function, right hemisphere deficits, and theoretically motivated treatments; and (d) a guide for exploring and selecting treatments based on deficits rather than etiology.

CONCLUSIONS

Controlled treatment studies for communication deficits specifically for adults with right hemisphere brain damage are limited to aprosodia. For other communication deficits, clinicians may select treatments based on current theories of right hemisphere function and right hemisphere deficits, and/or treatments developed for other etiologies for which deficits are similar to those associated with right hemisphere damage.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

The impact of neuropsychological deficits on functional stroke outcomes

This review examines the available literature on neuropsychological outcomes of stroke and the literature on the ability of specific areas of neuropsychological deficit to predict functional stroke outcome. The literature reviewed indicates that post-stroke deficits in executive function, memory, language, and speed of processing are common, with those identified as having progressive 'post-stroke dementia' presenting with a similar, though more impaired profile, with increased impairments particularly noted in the area of memory. It is clear that some aspects of neuropsychological functioning (e.g., presence of neglect, aphasia, anosognosia; and verbal memory and attention deficits) show promise as a means of predicting post-stroke functional outcomes. Examining the available literature, it becomes evident that there is a need for long-term, large scale (i.e., population based) follow-up studies, evaluating likely long-term neuropsychological outcomes of stroke and their prognostic utility.

The Orpington Prognostic Scale for patients with stroke: reliability and pilot predictive data for discharge destination and therapeutic services

PURPOSE

To determine the inter-rater and test-retest reliability of the Orpington Prognostic Scale (OPS) in patients with stroke. Pilot data were gathered to evaluate its predictive validity for discharge destination and therapeutic services required on discharge.

METHOD

Ninety-four consecutive patients, admitted to hospital due to stroke participated. Pairs of physiotherapists (PT) and occupational therapists (OT) assessed patients using the OPS on days 7 and 14 post stroke. For inter-rater reliability, one rater performed the OPS while the other observed, each scoring the scale independently. For test-retest reliability, two different raters tested the subjects separately within the same day. Data were gathered on the discharge destination and the number of follow-up services prescribed.

RESULTS

The inter-rater reliability as measured by the intraclass correlation coefficient (ICC) was 0.99 (95% CI 0.97 - 0.99). For test-retest reliability, the ICC was 0.95 (95% CI 0.90 - 0.98). The accuracy for predicting discharge to home using OPS 5.0 was 65% (95% CI 0.52 - 0.76). OPS scores were not related to number of follow-up services prescribed.

CONCLUSIONS

Despite high inter-rater and test-retest reliability, the OPS has limited predictive accuracy for discharge destination and is a poor predictor of follow-up services.

Functional Recovery After Hemiplegia in Patients With Neglect

Background and Purpose— The aim of this study was to verify whether the presence of anosognosia (A) affects the rehabilitative prognosis of hemiplegic subjects with neglect (N).

Methods— This study was carried out on 30 patients with left hemiplegia: 15 patients had neglect (group N) and 15 had neglect and anosognosia (group N+A). Mean age was 68.2±6.3 in group N (9 men and 6 women) and 72.1±6.4 in group N+A (7 men and 8 women). The average interval from onset of stroke to admission for rehabilitation was 23 and 23.6 days, respectively, in group N and in group N+A. Patients were assessed through the Mesulam test, Bisiach test, Wechsler Adult Intelligence Scale, Fugl-Meyer scale, Functional Independence Measure (FIM), and Rankin scale.

Results— Before rehabilitation, cognitive FIM scores of patients of group N were significantly higher than those of group N+A ( P =0.001), whereas motor FIM scores and total FIM scores did not differ between the 2 groups. After rehabilitation, cognitive FIM scores ( P =0.000) and even motor ( P =0.009) and total FIM scores ( P =0.000) were statistically higher in group N than in group N+A. Effectiveness ( P =0.005) and efficiency ( P =0.012) in the motor FIM scores of group N were significantly greater than those of group N+A. Disability was lower in group N ( P =0.040).

Conclusions— Our study shows that the presence of anosognosia worsens the rehabilitation prognosis in hemiplegic subjects who also have neglect.

Determinants of mortality in stroke patients with right brain damage

Stroke is the world's second leading cause of mortality and long-term disability. Damage to the nondominant right brain has distinct clinical characteristics. The resultant cardiovascular and autonomic dysfunction peculiar to right hemispheric stroke can adversely affect the short- and long-term outcome of stroke victims. Blood flow characteristics to the right hemisphere may also put the right brain at more risk for embolic and silent infarcts.

Prognostic factors in the subacute phase after stroke for the future residence after six months to one year. A systematic review of the literature

OBJECTIVE

To identify evidence-based prognostic factors in the subacute phase after a stroke for future residence at six months to one year post stroke.

DESIGN

Systematic literature search designed in accordance with the Cochrane Collaboration criteria with the following data sources: (1) MEDLINE, EMBASE, CINAHL, Current Contents, Cochrane Database of Systematic Reviews, PsycLIT and Sociological Abstracts. (2) Reference lists, personal archives and consultation of experts in the field. (3) Guidelines.

METHODS

Inclusion criteria were: (1) cohort studies of patients with an ischaemic or haemorrhagic stroke; (2) inception cohort with assessment of prognostic factors within the first two weeks after stroke; (3) outcome measures for future residence; and (4) a follow-up of six months to one year. Internal, statistical and external validity of the studies were assessed using a checklist with 11 methodological criteria in accordance with the recommendations of the Cochrane Collaboration.

RESULTS

From 1027 potentially relevant studies 10 studies involving a total of 3564 patients met the inclusion criteria. No prognostic factor was identified in at least two level A (i.e., a good level of scientific evidence according to the methodological score) studies, our standard for scientific proof. The following factors were found in at least one level A study: low initial ADL functioning, high age, cognitive disturbance, paresis of arm and leg, not alert as initial level of consciousness, old hemiplegia, homonymous hemianopia, visual extinction, constructional apraxia, no transfer to the stroke unit, nonlacunar stroke type, visuospatial construction problems, urinary incontinence and female gender.

CONCLUSIONS

At present there is insufficient evidence concerning possible predictors in the subacute stage of stroke to make an evidence-based prediction of the future residence. In the scientific research until now social factors and their contribution to the possibility of living independently have not been investigated, or at least less well. None of the studies in this review described a conceptual framework as basis for the choice of the examined prognostic factors.

Emotions, behaviours and mood changes in stroke

The brain mediates and integrates all cognitive activities, emotional experiences and finally behaviours. Stroke is undoubtedly a privileged disease for human behavioural studies, because of its high incidence. Recent advances in high-resolution magnetic resonance imaging techniques and functional neuroimaging allow both the precise localization of lesions and on-line visualization of the activity of cerebral areas and networks. Nevertheless, the neuropsychiatry of stroke remains uncertain in its relationship with brain dysfunction. Clinical studies on registry populations, single case studies, and functional neuroimaging data provide interesting findings, but differences in methods and great individual intervariability still prevent a complete understanding of emotional perception and behavioural responses in stroke. We adopted an anatomical-functional model as an operational framework in order to systematize the recent literature on emotional, behavioural and mood changes after stroke. The dysfunction of the areas subserving fundamental and executive functions induces behavioural and affective changes (such as depression, anxiety, apathy) that reflect the dysfunction of the whole system. Conversely, lesions in the system of instrumental functions induce signature syndromes (aphasia, anosognosia). At any delay from stroke, the diagnosis and treatment of mood and behavioural changes are a priority for clinicians and healthcare professionals to improve the quality of life of patients.