Rehabilitation of very severe unilateral neglect by visuo-spatio-motor cueing: Two single case studies

Consistency in Single-Case ABAB Phase Designs: A Systematic Review

The current article presents a systematic review of consistency in single-case ABAB phase designs. We applied the CONsistency of DAta Patterns (CONDAP) measure to a sample of 460 data sets retrieved from 119 applied studies published over the past 50 years. The main purpose was to (a) identify typical CONDAP values found in published ABAB designs and (b) develop interpretational guidelines for CONDAP to be used for future studies to assess the consistency of data patterns from similar phases. The overall distribution of CONDAP values is right-skewed with several extreme values to the right of the center of the distribution. The B-phase CONDAP values fall within a narrower range than the A-phase CONDAP values. Based on the cumulative distribution of CONDAP values, we offer the following interpretational guidelines in terms of consistency: very high, 0 ≤ CONDAP ≤ 0.5; high, 0.5 < CONDAP ≤ 1; medium, 1 < CONDAP < 1.5; low, 1.5 < CONDAP ≤ 2; very low, CONDAP > 2. We give examples of combining CONDAP benchmarks with visual analysis of single-case ABAB phase designs and conclude that the majority of data patterns (41.2%) in published ABAB phase designs is medium consistent.

Congruent movement training as a rehabilitation method to ameliorate symptoms of neglect-proof of concept

Stroke patients with visuospatial neglect (VSN) have difficulties responding to visual information located in the contralesional hemifield, affecting many daily life activities (ADL) such as eating, reading and mobility. Visual Scanning Therapy (VST) is widely used in clinical practice to ameliorate symptoms of VSN. Yet, not all patients benefit from this training and many training sessions are needed in order to achieve stable results. One potentially promising improvement to the VST is based on the theory that different effectors of the motor systems (e.g., eyes, hands) independently allocate attention during the programming of the movement (i.e., Pre Motor Theory of Attention (PMT)). Here, we studied this direct implementation of the PMT and tested whether a congruent movement training (CMT: congruent -i.e., executed at the same time to the same location-eye and pointing movements) is more effective to attenuate symptoms of neglect compared to VST. This study can be seen as a proof of concept. Attenuation of neglect symptoms was found in the CMT group after just 5 h of training in the subacute phase of neglect. In contrast, no training effects were found in the VST group. These findings indicate the potential of CMT which is a minimal -yet crucial-upgrade of the standard VST protocol that can be easily implemented in the clinic.

Single-Case Design, Analysis, and Quality Assessment for Intervention Research

BACKGROUND AND PURPOSE

The purpose of this article is to describe single-case studies and contrast them with case studies and randomized clinical trials. We highlight current research designs, analysis techniques, and quality appraisal tools relevant for single-case rehabilitation research.

SUMMARY OF KEY POINTS

Single-case studies can provide a viable alternative to large group studies such as randomized clinical trials. Single-case studies involve repeated measures and manipulation of an independent variable. They can be designed to have strong internal validity for assessing causal relationships between interventions and outcomes, as well as external validity for generalizability of results, particularly when the study designs incorporate replication, randomization, and multiple participants. Single-case studies should not be confused with case studies/series (ie, case reports), which are reports of clinical management of a patient or a small series of patients.

RECOMMENDATIONS FOR CLINICAL PRACTICE

When rigorously designed, single-case studies can be particularly useful experimental designs in a variety of situations, such as when research resources are limited, studied conditions have low incidences, or when examining effects of novel or expensive interventions. Readers will be directed to examples from the published literature in which these techniques have been discussed, evaluated for quality, and implemented.

Effect of Passive Limb Activation by Functional Electrical Stimulation on Wheelchair Driving in Patients with Unilateral Spatial Neglect: A Case Study

Background/Objective

Limb activation is one of the behavioural interventions to improve unilateral spatial neglect (USN). However, the effect of passive limb activation on activities of daily living (ADL) is not clear. This study examined the effect of passive limb activation by functional electrical stimulation (FES) on wheelchair driving for patients with USN, and to discuss the possibility of application of this treatment to occupational therapy.

Methods

A single subject design-baseline-intervention-baseline (ABA), was applied to 2 stroke patients with USN. Phase A' and A consisted of the wheelchair driving task only. Phase B consisted of the wheelchair driving task with FES. Each phase lasted for 2 weeks. The wheelchair driving task was maneuvering on a square passage in the clockwise and counter clockwise conditions for 8 minutes respectively, and four obstacles were set at each side. FES was applied to the affected forearm extensor muscles. Assessor recorded: 1) The distance participants drove wheelchair for 8 minutes, and 2) The number of collisions with obstacles and the wall, for 10 days.

Results

For one participant, the distance of maneuvering significantly increased in phase B (p < .05.), and USN on the cognitive test in the extrapersonal space indicated a tendency to improve after phase B.

Conclusion

Passive limb activation by FES improved wheelchair driving and cognitive performance for patients with USN. It can be used with instruction from occupational therapists to enhance the performance on ADL.

A rehabilitation program based on music practice for patients with unilateral spatial neglect: a single-case study

Two major limitations of unilateral spatial neglect (USN) rehabilitation methods are actually reported: a lack of long-term efficiency and a lack of generalization to daily life. The aim of our case study was to underline how a multisensory method-music practice-could avoid these limitations. Mrs BV suffered from a chronic severe USN. She had rehabilitation sessions of music practice over 8 weeks. An improvement of her USN was found on paper-pencil tests but also in daily activities. Benefits subsisted 4 months after rehabilitation. Music practice seemed to avoid the major limitations of USN rehabilitations and could represent a promising tool.

The ecological assessment of unilateral neglect

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

Integrity of medial temporal structures may predict better improvement of spatial neglect with prism adaptation treatment

Prism adaptation treatment (PAT) is a promising rehabilitative method for functional recovery in persons with spatial neglect. Previous research suggests that PAT improves motor-intentional "aiming" deficits that frequently occur with frontal lesions. To test whether presence of frontal lesions predicted better improvement of spatial neglect after PAT, the current study evaluated neglect-specific improvement in functional activities (assessment with the Catherine Bergego Scale) over time in 21 right-brain-damaged stroke survivors with left-sided spatial neglect. The results demonstrated that neglect patients' functional activities improved after two weeks of PAT and continued improving for four weeks. Such functional improvement did not occur equally in all of the participants: Neglect patients with lesions involving the frontal cortex (n = 13) experienced significantly better functional improvement than did those without frontal lesions (n = 8). More importantly, voxel-based lesion-behavior mapping (VLBM) revealed that in comparison to the group of patients without frontal lesions, the frontal-lesioned neglect patients had intact regions in the medial temporal areas, the superior temporal areas, and the inferior longitudinal fasciculus. The medial cortical and subcortical areas in the temporal lobe were especially distinguished in the "frontal lesion" group. The findings suggest that the integrity of medial temporal structures may play an important role in supporting functional improvement after PAT.

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

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

Cognitive rehabilitation with right hemifield eye-patching for patients with sub-acute stroke and visuo-spatial neglect: a randomized controlled trial

OBJECTIVE

To assess whether, following a right-hemisphere stroke, the combined administration of computer-based cognitive rehabilitation and right hemifield eye-patching in patients with visuo-spatial neglect is more effective than computer-based cognitive rehabilitation alone.

METHODS

Twelve patients were randomized into two treatment groups: a single treatment group (n = 7) and a combination treatment group (n = 5). In both cases, the treatment consisted of a mean number of 15 sessions, each lasting 1 hour. Visuo-spatial neglect was assessed using a specific exploration protocol (Bell Cancellation Test, Figure Copying of Odgen, Line Bisection, Baking Tray Task and Reading Task). The functional effects of the treatment were assessed using the Catherine Bergego Scale.

RESULTS

Significant between-group differences were observed when comparing the pre- and post-treatment scores for the Reading Task. No differences were observed in either group in the Catherine Bergego Scale administered at baseline and at the final intervention.

CONCLUSION

The results obtained do not allow one to conclude that the combination treatment with cognitive rehabilitation and right hemifield eye-patching is more effective than cognitive rehabilitation alone. Although partial improvement in the performance of neuropsychological tests was observed, this improvement is not present at functional level.

Permutation Tests in the Educational and Behavioral Sciences

Over the past two decades, permutation tests (PTs) have received much attention in the educational and behavioral sciences. The aim of this article is to review the theoretical developments of PTs, the active areas in the educational and behavioral research using PTs, and the types of analysis under which PTs have been applied. We obtained 224 published articles, which included 141 theoretical articles and 83 application articles. After scrutinizing each article, we are happy to see that (1) some researchers began to advocate introducing PTs into basic statistics training; (2) computing load for PTs may be reduced dramatically by some intelligent algorithms; (3) PTs began to be applied in new areas such as studies on the relationship between brain and behavior and the relationship between gene and behavior; (4) besides simple types of analysis such as independent two-group comparison, PTs can also be carried out under more complex situations such as multivariate analysis. However, we should also notice that PTs are still mostly used for simple analyses (e.g., randomness analysis).

Functional assessment of spatial neglect: a review of the Catherine Bergego scale and an introduction of the Kessler foundation neglect assessment process

Spatial neglect is a debilitating poststroke neurocognitive disorder associated with prolonged hospitalization and poor rehabilitation outcomes. The literature suggests a high prevalence of this disorder, but clinicians have difficulty reliably identifying affected survivors. This discrepancy may result from suboptimal use of validated neglect assessment procedures. In this article, we suggest use of a validated assessment tool that is sensitive to identification of neglect and its functional consequences - the Catherine Bergego Scale (CBS). We provide detailed item-by-item instructions for observation and scoring - the Kessler Foundation Neglect Assessment Process (KF-NAP). Rehabilitation researchers may be able to use the CBS via the KF-NAP to measure ecological outcomes and specific, separable perceptual-attentional and motor-exploratory spatial behaviors.

Designing rehabilitation programs for neglect: could 2 be more than 1+1?

Unilateral neglect is a multimodal neuropsychological disorder that has puzzled scientists for a long time. Many interventions have been developed, but only a handful has proven to be effective. This review examines whether applying different therapeutic techniques in combination will increase therapeutic benefits. Studies were reviewed where therapies are applied sequentially or in combination with other techniques. The results indicate that combining different interventions leads to increased general improvement compared with other noncombined designs, even when the number of treatment sessions is not constant. Practical and theoretical aspects of different treatments are discussed. The combined approach to treatment may have direct relevance to disorders other than neglect. This report introduces a new classification scheme for different interventions with the aim of facilitating more focused therapy. Finally, suggestions are made as to what the focus of future studies of neglect therapy should be and how therapeutic benefits might be maximized.

Rehabilitation approaches to hemineglect

BACKGROUND

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

REVIEW SUMMARY

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

CONCLUSIONS

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

Characterisation of unilateral neglect by physiotherapists

PURPOSE

It is not known how clinicians characterise unilateral neglect (ULN) or whether they consider the different types of ULN during their evaluation and management of patients with this condition. The purpose of this study was to gain insight into physiotherapists' understanding of ULN and to identify the terminology used by clinicians to characterise neglect behaviour.

METHOD

Qualitative research design employing focus groups and one-to-one interviews. Thirty-three experienced neurological and novice physiotherapists from one Australian state were asked to discuss how they characterise ULN and to explain what they meant by the terms they used. Data analysis involved preparation of verbatim transcripts followed by coding, data reduction, and identification of major themes. Data management was facilitated using NVivo computer software.

FINDINGS

Terms such as sensory neglect, visual neglect, extinction, inattention, and functional neglect were used to characterise neglect behaviour but there was considerable confusion between many of these terms. Motor neglect was an unfamiliar concept to many participants. Functional implications of ULN were considered important. Characterisations of neglect according to the spatial distribution of the behaviour were uncommon.

CONCLUSIONS

Despite awareness of many types of neglect, the physiotherapists in this study did not have a clear understanding of how to accurately characterise the different types of ULN. Education to address the issue is required.

Evidence-based cognitive rehabilitation: updated review of the literature from 1998 through 2002

OBJECTIVE

To update the previous evidence-based recommendations of the Brain Injury Interdisciplinary Special Interest Group of the American Congress of Rehabilitation Medicine for cognitive rehabilitation of people with traumatic brain injury (TBI) and stroke, based on a systematic review of the literature from 1998 through 2002.

DATA SOURCES

PubMed and Infotrieve literature searches were conducted using the terms attention, awareness, cognition, communication, executive, language, memory, perception, problem solving, and reasoning combined with each of the terms rehabilitation, remediation, and training. Reference lists from identified articles were reviewed and a bibliography listing 312 articles was compiled.

STUDY SELECTION

One hundred eighteen articles were initially selected for inclusion. Thirty-one studies were excluded after detailed review. Excluded articles included 14 studies without data, 6 duplicate publications or follow-up studies, 5 nontreatment studies, 4 reviews, and 2 case studies involving diagnoses other than TBI or stroke.

DATA EXTRACTION

Articles were assigned to 1 of 7 categories reflecting the primary area of intervention: attention; visual perception; apraxia; language and communication; memory; executive functioning, problem solving and awareness; and comprehensive-holistic cognitive rehabilitation. Articles were abstracted and levels of evidence determined using specific criteria.

DATA SYNTHESIS

Of the 87 studies evaluated, 17 were rated as class I, 8 as class II, and 62 as class III. Evidence within each area of intervention was synthesized and recommendations for practice standards, practice guidelines, and practice options were made.

CONCLUSIONS

There is substantial evidence to support cognitive-linguistic therapies for people with language deficits after left hemisphere stroke. New evidence supports training for apraxia after left hemisphere stroke. The evidence supports visuospatial rehabilitation for deficits associated with visual neglect after right hemisphere stroke. There is substantial evidence to support cognitive rehabilitation for people with TBI, including strategy training for mild memory impairment, strategy training for postacute attention deficits, and interventions for functional communication deficits. The overall analysis of 47 treatment comparisons, based on class I studies included in the current and previous review, reveals a differential benefit in favor of cognitive rehabilitation in 37 of 47 (78.7%) comparisons, with no comparison demonstrating a benefit in favor of the alternative treatment condition. Future research should move beyond the simple question of whether cognitive rehabilitation is effective, and examine the therapy factors and patient characteristics that optimize the clinical outcomes of cognitive rehabilitation.