The effect of voluntary trunk rotation and half-field eye-patching for patients with unilateral neglect in stroke: a randomized controlled trial

Stroke Rehabilitation: Synopsis of the 2024 U.S. Department of Veterans Affairs and U.S. Department of Defense Clinical Practice Guidelines

DESCRIPTION

In July 2024, the U.S. Department of Veterans Affairs (VA) and U.S. Department of Defense (DOD) released a joint update of their 2019 clinical practice guideline (CPG) for the management of stroke rehabilitation. This synopsis is a condensed version of the 2024 CPG, highlighting the key aspects of the guideline development process and describing the major recommendations.

METHODS

The VA/DOD Evidence-Based Practice Work Group convened a joint VA/DOD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy CPGs. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature (English-language publications from 1 July 2018 to 2 May 2023). The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was used to evaluate the evidence. The WG developed 47 recommendations along with algorithms for stroke rehabilitation in the inpatient and outpatient settings. Stakeholders outside the WG reviewed the CPG before approval by the VA/DOD Evidence-Based Practice Work Group.

RECOMMENDATIONS

This synopsis summarizes where evidence is strongest to support guidelines in crucial areas relevant to primary care physicians: transition to community (case management, psychosocial or behavioral interventions); motor therapy (task-specific practice, mirror therapy, rhythmic auditory stimulation, electrical stimulation, botulinum toxin for spasticity); dysphagia, aphasia, and cognition (chin tuck against resistance, respiratory muscle strength training); and mental health (selective serotonin reuptake inhibitor use, psychotherapy, mindfulness-based therapies for treatment but not prevention of depression).

The Effect of Mirror Visual Feedback on Spatial Neglect for Patients after Stroke: A Preliminary Randomized Controlled Trial

We investigated the effects of mirror visual feedback (MVF), with reference to using a glass wall or a covered mirror, on the reduction of spatial neglect for patients with stroke. A total of 21 subacute patients with left spatial neglect after right-hemispheric stroke were randomly assigned to 3 groups: MVF, sham 1 (viewing the hemiparetic arm through the transparent glass during bilateral arm movement) and sham 2 (using a covered mirror). The 3-week treatment program for all groups consisted of 12 sessions of movement tasks for the hemiparetic arm graded according to the severity of arm impairments. Blinded assessments were administered at pre/post and a three-week follow-up. The results showed that there was no significant advantage for MVF than sham 1; however, MVF was more beneficial than sham 2, as shown by the line crossing (p = 0.022). Improvement in discriminating the left-gap figures on the left and right side of the page in the Gap Detection Test was greater in MVF than using the covered mirror (p = 0.013; p = 0.010), showing a slight advantage of MVF in alleviating allocentric symptoms. Our study confirms that MVF was superior to using a covered mirror as a method for reducing spatial neglect and in alleviating its allocentric symptoms, but no significant advantage over bilateral arm movement through transparent glass was found. Further research in comparing their therapeutic effects is warranted.

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.

Disorders of higher visual processing in patients with acquired brain injury

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

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

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

Neglect syndrome in post-stroke conditions: assessment and treatment (scoping review)

There is no consensus about the definition or most effective treatment for neglect syndrome. The aim of this review was therefore to evaluate the results of trials that investigated different treatment methods for neglect syndrome. A systematic literature search in PubMed and Web of Science databases was performed to identify studies that investigated the effects of neglect therapies. Authors followed Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Studies were selected by two assayers, and disagreement was resolved by a third reviewer. The literature search identified 202 articles: 19 met the inclusion criteria and were included for data extraction. Thirty-five different kinds of assessments were used in these studies, and 17 treatment methods were applied. Successful treatments were reported at least in some parts of the assessments in 12 studies: mirror therapy (in two trials), transcranial magnetic stimulation, street crossing test in virtual reality, smooth pursuit eye movement training, saccadic eye movement therapy, direct current stimulation, eye patching therapy, prism adaptation treatment, socially assistive pet-type therapeutic robot (PARO), Kinesiological Instrument for Normal and Altered Reaching Movement robotic device therapy, transcutaneous electrical nerve stimulation, and optokinetic stimulation (the last two methods in the same trial). No success was shown in seven trials, which contained not only single treatments but combined ones also. Authors concluded that there are no convincing results for or against any of the different therapies used for neglect syndrome. The quality of the trials is questionable, and the numbers of included patients are small in the trials.

A Systematic Review and Meta-Analysis of Rehabilitative Interventions for Unilateral Spatial Neglect and Hemianopia Poststroke From 2006 Through 2016

OBJECTIVE

To evaluate the effectiveness of activity-based, nonactivity-based, and combined activity- and nonactivity-based rehabilitative interventions for individuals presenting with unilateral spatial neglect (USN) and hemianopia.

DATA SOURCES

We searched CINAHL, Cochrane Library, EMBASE, MEDLINE, and PubMed from 2006 to 2016.

STUDY SELECTION

Randomized controlled trials (RCTs) with a score of 6 or more in the Physiotherapy Evidence Database Scale that examined the effects of activity-based and nonactivity-based rehabilitation interventions for people with USN or hemianopia. Two reviewers selected studies independently.

DATA EXTRACTION

Extracted data from the published RCTs. Mean differences (MD) or standardized mean differences (SMD), and 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using the I² statistic.

DATA SYNTHESIS

A total of 20 RCTs for USN and 5 for hemianopia, involving 594 and 206 stroke participants respectively, were identified. Encouraging results were found in relation to activity-based interventions for visual scanning training and compensatory training for hemianopia (MD=5.11; 95% confidence intervals [95% CI], 0.83-9.4; P=.019; I²=25.16% on visual outcomes), and optokinetic stimulation and smooth pursuit training for USN (SMD=0.49; 95% CI, 0.01-0.97; P=.045; I²=49.35%) on functional performance in activities of daily living, (SMD=0.96; 95% CI, 0.09-1.82; P=.031; I²=89.57%) on neglect.

CONCLUSIONS

Activity-based interventions are effective and commonly used in the treatment of USN and hemianopia. Nonactivity-based and combined approaches, for both impairments, have not been refuted, because more studies are required for substantiated conclusions to be drawn.

Therapeutic Intervention for Visuo-Spatial Neglect after Stroke: A Meta-Analysis of Randomized Controlled Trials

Objectives

The aims of this meta-analysis were to examine intervention methods of qualitatively, well-designed studies from the past 10 years for treating visuo-spatial neglect (VSN) in patients who had suffered a stroke, and to evaluate the combined effects of intervention.

Methods

Studies published between 2008 and 2017 on the theme of VSN were collected from PubMed, CINAHL, and MEDLINE, representative academic databases and search engines. The PEDro scale was used for evaluating the quality of methodology. The sample size, mean, and standard deviation of identified studies were used for meta-analysis.

Results

Eight studies were selected for analysis. The PEDro scores of the selected studies were ≥ 7, with 237 subjects analyzed. The results of intervention were classified into “mental function” and “activity and participation” based on the International Classification of Functioning, Disability and Health. The analyzed effect sizes for combined outcomes, mental function and, activity and participation, were 0.728 (medium effect size), 0.850 (large effect size), and 0.536 (medium effect size), respectively.

Conclusion

Intervention methods for treating VSN had a short-term effect on cognitive function (visual perception). In particular, non-invasive brain stimulation therapy showed a large effect size for VSN treatment.

Improved functions and reduced length of stay after inpatient rehabilitation programs in older adults with stroke: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

to examine the effects of inpatient rehabilitation programs on function and length of stay in older adults with strokeMETHODS: A total of five electronic databases were searched for relevant randomized controlled trials that examined the effects of inpatient rehabilitation programs on functional recovery, as measured by the functional independence measure and length of stay, which was measured in days. We included full-text articles written in English, and no time limit. The methodological quality and risk of bias were assessed using the Physiotherapy Evidence Database Scale and the Cochrane collaboration tools respectively. The effect sizes and confidence intervals were estimated using fixed-effect modelsRESULTS: Eight randomized controlled trials involving 1,910 patients with stroke were included in the meta-analysis showed that patients who participated in the inpatient rehabilitation programs had significantly (p less than 0.05) higher functional independence measure scores (effect size = 0.10; 95 percent confidence interval = 0.01, 0.22) and shorter length of stay (effect size = 0.14; 95 percent confidence interval = 0.03, 0.22).

CONCLUSIONS

This systematic review provided evidence that inpatient rehabilitation programs have beneficial effects, improving functionality and reducing length of stay for older adults with stroke.

Neglected-Field Eye Patching Improves Visual Inattention in Hemispatial Neglect: A Case Study

Objective

Recently, eye patching has been used as a technique for adjusting visual information. However, there are differing opinions regarding the influence of eye patching on visual attention in hemispatial neglect. Studies on eye patching do not usually consider the effects of differences in task difficulty or reaction space. Moreover, to date, no trial has used neglected-field eye patching. We investigated the effect on hemispatial neglect of hemi-visual field eye-patching glasses in a patient with left spatial neglect.

Methods

The patient was an 86-year-old woman who had suffered a stroke. She had severe left hemiparesis and left spatial neglect. Three types of eye-patching glasses were used: right-field patching, left-field patching, and no patching. The line bisection test, the line crossing test, the star cancellation test, and the letter cancellation test were carried out for the three eye-patching conditions.

Results

The line bisection test results showed rightward deviations for both left and right patching compared to no patching. For the line crossing test, there were no omission errors for any patching condition. In the star cancellation test, there were small differences between the three patching conditions. However, in the letter cancellation test, the fewest omission errors occurred during left-field patching, with the most notable improvement on the right half of the test paper.

Conclusion

The results suggest that neglected-field eye patching for hemispatial neglect might improve visual attention, especially the non-spatial aspects.

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

AIM

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

METHOD

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

RESULTS

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

CONCLUSION

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

Rehabilitation of unilateral neglect: Evidence-based medicine

BACKGROUND

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

OBJECTIVE

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

METHOD

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

RESULTS

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

CONCLUSION

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

Guidelines for Adult Stroke Rehabilitation and Recovery: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association

PURPOSE

The aim of this guideline is to provide a synopsis of best clinical practices in the rehabilitative care of adults recovering from stroke.

METHODS

Writing group members were nominated by the committee chair on the basis of their previous work in relevant topic areas and were approved by the American Heart Association (AHA) Stroke Council's Scientific Statement Oversight Committee and the AHA's Manuscript Oversight Committee. The panel reviewed relevant articles on adults using computerized searches of the medical literature through 2014. The evidence is organized within the context of the AHA framework and is classified according to the joint AHA/American College of Cardiology and supplementary AHA methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive AHA internal and external peer review, Stroke Council Leadership review, and Scientific Statements Oversight Committee review before consideration and approval by the AHA Science Advisory and Coordinating Committee.

RESULTS

Stroke rehabilitation requires a sustained and coordinated effort from a large team, including the patient and his or her goals, family and friends, other caregivers (eg, personal care attendants), physicians, nurses, physical and occupational therapists, speech-language pathologists, recreation therapists, psychologists, nutritionists, social workers, and others. Communication and coordination among these team members are paramount in maximizing the effectiveness and efficiency of rehabilitation and underlie this entire guideline. Without communication and coordination, isolated efforts to rehabilitate the stroke survivor are unlikely to achieve their full potential.

CONCLUSIONS

As systems of care evolve in response to healthcare reform efforts, postacute care and rehabilitation are often considered a costly area of care to be trimmed but without recognition of their clinical impact and ability to reduce the risk of downstream medical morbidity resulting from immobility, depression, loss of autonomy, and reduced functional independence. The provision of comprehensive rehabilitation programs with adequate resources, dose, and duration is an essential aspect of stroke care and should be a priority in these redesign efforts. (Stroke.2016;47:e98-e169. DOI: 10.1161/STR.0000000000000098.).

Pharmacological interventions for unilateral spatial neglect after stroke

BACKGROUND

Unilateral spatial neglect (USN) is characterized by the inability to report or respond to people or objects presented on the side contralateral to the lesioned side of the brain and has been associated with poor functional outcomes and long stays in hospitals and rehabilitation centers. Pharmacological interventions (medical interventions only, use of drugs to improve the health condition), such as dopamine and noradrenergic agonists or pro-cholinergic treatment, have been used in people affected by USN after stroke, and effects of these treatments could provide new insights for health professionals and policy makers.

OBJECTIVES

To evaluate the effectiveness and safety of pharmacological interventions for USN after stroke.

SEARCH METHODS

We searched the Cochrane Stroke Group Trials Register (April 2015), the Cochrane Central Register of Controlled Trials (April 2015), MEDLINE (1946 to April 2015), the Cumulative Index to Nursing and Allied Health Literature (CINAHL) (1982 to April 2015), EMBASE (1980 to April 2015), PsycINFO (1806 to April 2015) and Latin American Caribbean Health Sciences Literature (LILACS) (1982 to April 2015). We also searched trials and research registers, screened reference lists, and contacted study authors and pharmaceutical companies (April 2015).

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-randomized controlled trials (quasi-RCTs) of pharmacological interventions for USN after stroke.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed risk of bias in the included studies and extracted data.

MAIN RESULTS

We included in the review two studies with a total of 30 randomly assigned participants. We rated the quality of the evidence as very low as the result of study limitations, small numbers of events, and small sample sizes, with imprecision in the confidence interval (CI). We were not able to perform meta-analysis because of heterogeneity related to the different interventions evaluated between included studies. Very low-quality evidence from one trial (20 participants) comparing effects of rivastigmine plus rehabilitation versus rehabilitation on overall USN at discharge showed the following: Barrage (mean difference (MD) 0.30, 95% confidence interval (CI) -0.18 to 0.78); Letter Cancellation (MD 10.60, 95% CI 2.07 to 19.13); Sentence Reading (MD 0.20, 95% CI -0.69 to 1.09), and the Wundt-Jastrow Area Illusion Test (MD -4.40, 95% CI -8.28 to -0.52); no statistical significance was observed for the same outcomes at 30 days' follow-up. In another trial (10 participants), study authors showed statistically significant reduction in omissions in the three cancellation tasks under transdermal nicotine treatment (mean number of omissions 2.93 ± 0.5) compared with both baseline (4.95 ± 0.8) and placebo (5.14 ± 0.9) (main effect of treatment condition: F (2.23) = 11.06; P value < 0.0001). One major adverse event occurred in the transdermal nicotine treatment group, and treatment was discontinued in the affected participant. None of the included trials reported data on several of the prespecified outcomes (falls, balance, depression or anxiety, poststroke fatigue, and quality of life).

AUTHORS' CONCLUSIONS

The quality of the evidence from available RCTs was very low. The effectiveness and safety of pharmacological interventions for USN after stroke are therefore uncertain. Additional large RCTs are needed to evaluate these treatments.

Midline Body Actions and Leftward Spatial "Aiming" in Patients with Spatial Neglect

Spatial motor–intentional “Aiming” bias is a dysfunction in initiation/execution of motor–intentional behavior, resulting in hypokinetic and hypometric leftward movements. Aiming bias may contribute to posture, balance, and movement problems and uniquely account for disability in post-stroke spatial neglect. Body movement may modify and even worsen Aiming errors, but therapy techniques, such as visual scanning training, do not take this into account. Here, we evaluated (1) whether instructing neglect patients to move midline body parts improves their ability to explore left space and (2) whether this has a different impact on different patients. A 68-year-old woman with spatial neglect after a right basal ganglia infarct had difficulty orienting to and identifying left-sided objects. She was prompted with four instructions: “look to the left,” “point with your nose to the left,” “point with your [right] hand to the left,” and “stick out your tongue and point it to the left.” She oriented leftward dramatically better when pointing with the tongue/nose, than she did when pointing with the hand. We then tested nine more consecutive patients with spatial neglect using the same instructions. Only four of them made any orienting errors. Only one patient made >50% errors when pointing with the hand, and she did not benefit from pointing with the tongue/nose. We observed that pointing with the tongue could facilitate left-sided orientation in a stroke survivor with spatial neglect. If midline structures are represented more bilaterally, they may be less affected by Aiming bias. Alternatively, moving the body midline may be more permissive for leftward orienting than moving right body parts. We were not able to replicate this effect in another patient; we suspect that the magnitude of this effect may depend upon the degree to which patients have directional akinesia, spatial Where deficits, or cerebellar/frontal cortical lesions. Future research could examine these hypotheses.

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.

Right half-field eye patching may not be an effective approach for chronic hemispatial neglect--a two-case investigation

Right half-field eye-patched glasses intervention was performed in two chronic stroke patients with unilateral spatial neglect. Eye movement on the neglect side, the center of gravity as an index of the internal midline bias, neglect sign tests, and the regional cerebral blood flow (rCBF) were measured before and after intervention. The improvement of eye movement was not shown clearly after intervention. The center of gravity shifted significantly to the right and backward. Letter and star cancellation tests were improved in both the cases. Line bisection test showed improvement in one patient. However, line cancellation and line bisection tests were worsened in the other. The rCBF was not changed after intervention. This case study suggests that right half-field eye patching might not be an effective intervention.

Effectiveness of Interventions to Improve Occupational Performance of People With Cognitive Impairments After Stroke: An Evidence-Based Review

This evidence-based review was conducted to determine which interventions are effective in improving occupational performance after stroke. Forty-six articles met the inclusion criteria and were examined. Interventions for the following impairments were reviewed: general cognitive deficits, executive dysfunction, apraxia, memory loss, attention deficits, visual field deficits (included because of their close relationship with neglect), and unilateral neglect. Evidence is available from a variety of clinical trials to guide interventions regarding general cognition, apraxia, and neglect. The evidence regarding interventions for executive dysfunction and memory loss is limited. There is insufficient evidence regarding impairments of attention and mixed evidence regarding interventions for visual field deficits. The effective interventions have some commonalities, including being performance focused, involving strategy training, and using a compensatory as opposed to a remediation approach. The implications of the findings for practice, research, and education are discussed.

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

BACKGROUND

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Effect of eye patching in rehabilitation of hemispatial neglect

Eye patching (EP; monocular or right hemifield) has been proposed to improve visuospatial attention to the ignored field in patients with hemispatial neglect. The aim of this paper is to review the literature on the effects of EP in hemispatial neglect after stroke in order to convey evidence-based recommendations to clinicians in stroke rehabilitation. Thirteen intervention studies were selected from the Medline, EMBASE, Scopus, Cochrane Library, CINAHL, PsychINFO, EBRSR, and Health Star databases. Methodological quality was defined according to the Physiotherapy Evidence Database. Overall, seven studies used monocular EP, five used right hemifield patching, and one compared right monocular with right hemifield patching. Seven studies compared normal viewing to monocular or hemifield patching conditions. Six studies included a period of treatment. As to the monocular EP, four studies reported positive effects of right monocular patching. One study showed an improvement in hemispatial neglect with left monocular patching. Two studies found no superiority of right vs. left monocular patching. One study found no effects of right monocular patching. As to the right hemifield EP, one study showed improvements in neglect after right hemifield patching. Three studies found that right hemifield patching combined with another rehabilitation technique was more effective than that treatment alone. One study found no differences between right hemifield patching combined with another treatment and that treatment alone. One study found the same effect between right hemifield patching alone and another rehabilitation technique. Our results globally tend to support the usefulness of right hemifield EP in clinical practice. In order to define a level of evidence with the standard rehabilitation evidence rating tools, further properly powered randomized controlled trials or meta-analysis are needed.

Cognitive rehabilitation for spatial neglect following stroke

BACKGROUND

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

OBJECTIVES

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

SEARCH METHODS

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

SELECTION CRITERIA

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

DATA COLLECTION AND ANALYSIS

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

MAIN RESULTS

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

AUTHORS' CONCLUSIONS

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

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.

Effects of Constraint-Induced Therapy Combined With Eye Patching on Functional Outcomes and Movement Kinematics in Poststroke Neglect

OBJECTIVE. We investigated the effect of constraint-induced therapy (CIT) plus eye patching (EP), CIT alone, and conventional treatment on functional performance, eye movement, and trunk–arm kinematics in stroke patients with neglect syndrome.

METHOD. Twenty-four participants were recruited and randomly allocated to three intervention groups. All participants received intervention 2 hr/day, 5 days/wk, for 3 wk. Outcome measures included the Catherine Bergego Scale, eye movement, and trunk–arm kinematic analysis.

RESULTS. The CIT + EP and CIT groups demonstrated larger improvements in functional performance than the control group. The CIT group showed better performance with left fixation points than the CIT+EP group and shorter reaction time than the control group. The CIT + EP group improved more in preplanned control and leftward trunk shift than the other two groups.

CONCLUSION. CIT + EP and CIT were more effective interventions than conventional treatment of patients with neglect syndrome in daily functional performance.

Combined effects of sensory cueing and limb activation on unilateral neglect in subacute left hemiplegic stroke patients: a randomized controlled pilot study

Objective:

To compare the effects of contralesional sensory cueing and limb activation with that of sham control in the treatment of unilateral neglect after stroke.

Design:

A randomized, single-blinded, sham-controlled pilot study.

Setting:

Two rehabilitation hospitals.

Subjects:

Forty subacute left hemiplegic stroke inpatients with unilateral neglect.

Interventions:

Participants were assigned randomly to 1 of 2 groups. The experimental group wore a wristwatch cueing device over the hemiplegic arm for three hours a day, five days per week, for three weeks, and also underwent conventional rehabilitation. Patients were encouraged to move their hemiplegic arm five consecutive times after each prompt. The sham group underwent the same rehabilitation process, except they wore a sham device.

Main measures:

Neglect, arm motor performance, and overall functioning were assessed pre- and posttraining, and at follow-up.

Results:

There were no significant differences between groups in outcome measures except the neglect drawing tasks ( p = 0.034) (the mean gain score from baseline to follow-up assessment was 5.2 (3.7) in the experimental group and 1.9 (3.5) in the sham group), across three time intervals. The experimental group showed greater improvement in arm motor performance than did the sham group.

Conclusion:

The results did not confirm that sensory cueing and limb activation treatment is effective when compared with those receiving placebo to reduce unilateral neglect, but it might be useful for promoting hemiplegic arm performance in stroke patients.

Effects of primary caregiver participation in vestibular rehabilitation for unilateral neglect patients with right hemispheric stroke: a randomized controlled trial

INTRODUCTION

The current study aims to investigate the effects of primary caregiver participation in vestibular rehabilitation (VR) on improving the measures of neglect, activities of daily living (ADL), balance, and falls of unilateral neglect (UN) patients.

METHODS

This study is a single-blind randomized controlled trial. Both experimental (n = 24) and control groups (n = 24) received conventional rehabilitation. The experimental group undertook VR for a month. During the first and second weeks, a registered nurse trained the experimental group in VR. The primary caregivers in the experimental group supervised and guided their patients in VR during the third and fourth weeks. The outcome measures were neglect, ADL, balance, and falls.

RESULTS

The two groups of UN patients showed a significant improvement in neglect, ADL, and balance over time. Based on the generalized estimating equations model, an interaction was observed between groups and times. Significant interactions were observed between the VR group at days 14 and 28 in the areas of neglect, ADL, and balance. No significant difference was observed between the two groups in the number of falls.

CONCLUSION

Neglect, ADL, and balance among UN patients with right hemispheric stroke can be improved through the participation of primary caregivers in VR. Trained informal caregivers were recommended to provide VR guidance and supervision to patients who suffer from UN.

Clock drawing in spatial neglect: a comprehensive analysis of clock perimeter, placement, and accuracy

Clock drawings produced by right-brain-damaged (RBD) individuals with spatial neglect often contain an abundance of empty space on the left while numbers and hands are placed on the right. However, the clock perimeter is rarely compromised in neglect patients' drawings. By analysing clock drawings produced by 71 RBD and 40 healthy adults, this study investigated whether the geometric characteristics of the clock perimeter reveal novel insights to understanding spatial neglect. Neglect participants drew smaller clocks than either healthy or non-neglect RBD participants. While healthy participants' clock perimeter was close to circular, RBD participants drew radially extended ellipses. The mechanisms for these phenomena were investigated by examining the relation between clock-drawing characteristics and performance on six subtests of the Behavioral Inattention Test (BIT). The findings indicated that the clock shape was independent of any BIT subtest or the drawing placement on the test sheet and that the clock size was significantly predicted by one BIT subtest: the poorer the figure and shape copying, the smaller the clock perimeter. Further analyses revealed that in all participants, clocks decreased in size as they were placed farther from the centre of the paper. However, even when neglect participants placed their clocks towards the centre of the page, they were smaller than those produced by healthy or non-neglect RBD participants. These results suggest a neglect-specific reduction in the subjectively available workspace for graphic production from memory, consistent with the hypothesis that neglect patients are impaired in the ability to enlarge the attentional aperture.

Visual neglect following stroke: current concepts and future focus

Visual neglect is a common, yet frequently overlooked, neurological disorder following stroke characterized by a deficit in attention and appreciation of stimuli on the contralesional side of the body. It has a profound functional impact on affected individuals. A assessment and management of this condition are hindered, however, by the lack of professional awareness and clinical guidelines. Recent evidence suggests that the underlying deficit in visual attention is due to a disrupted internalized representation of the outer world rather than a disorder of sensory inputs. Dysfunction of the cortical domains and white-matter tracts, as well as inter-hemispheric imbalance, have been implicated in the various manifestations of visual neglect. Optimal diagnosis requires careful history-taking from the patient, family, and friends, in addition to clinical assessment with the line bisection test, the star cancellation test, and the Catherine Bergego Scale. Early recognition and prompt rehabilitation employing a multidisciplinary approach is desirable. Although no treatment has been definitively shown to be of benefit, those with promise include prism adaptation, visual scanning therapy, and virtual reality-based techniques. Further high quality research to seek optimum short- and long-term rehabilitative strategies for visual neglect is required.

Benefits of wellness interventions for persons with chronic and disabling conditions: a review of the evidence

BACKGROUND

Persons living with the effects of chronic and disabling conditions are often at increased risk for the development of secondary conditions and disabilities that can lead to further decline in health status, independence, functional status, life satisfaction, and overall quality of life.

OBJECTIVE

The purpose of this study was to review the evidence for the benefits of wellness/health promotion interventions for persons with chronic and disabling conditions.

METHODS

The authors conducted a Medline search (1990-2007) using terms related to wellness and health promotion cross-referenced with general terms for chronic and disabling conditions, as well as 15 specific chronic and/or disabling conditions (e.g., multiple sclerosis, spinal cord injury). Selection of studies was limited to those published in English that reported randomized controlled trails or prospective studies that involved adult human subjects with a chronic and/or disabling condition. All selected studies focused on some aspect of a wellness or health promotion intervention and involved a comparison or control group. Of the 5,847 studies initially identified in the search using medical subject heading terms, 190 met the criteria for full review. Data were extracted from these publications and summarized using descriptive statistics.

RESULTS

Almost all studies (95%) explored the effects of wellness intervention in a sample diagnosed with a single condition (e.g., cancer, stroke, arthritis). Although the mean sample size was 100, the range in sample size varied widely (6-688); 25% of the studies had sample of 30 or fewer. Almost all studies (89.5%) reported positive effects of the wellness intervention, although the delivery and content of interventions as well as the measurement of outcomes, varied greatly.

CONCLUSIONS

Our findings support an immediate post-intervention positive impact of wellness interventions across persons with a wide variety of chronic and disabling conditions. Future research that clearly specifies primary study outcomes and follows the CONSORT guidelines will strengthen future reviews of the evidence and facilitate application of the evidence of practice.

Rehabilitation in practice: Hemispatial neglect: approaches to rehabilitation

This series of articles for rehabilitation in practice aims to cover a knowledge element of the rehabilitation medicine curriculum. Nevertheless they are intended to be of interest to a multidisciplinary audience. The competency addressed in this article is 'The trainee consistently demonstrates a knowledge of the pathophysiology of various specific impairments including cognitive dysfunction including perception' and 'management approaches for specific impairments including cognitive dysfunction including perception'. The article focuses on hemispatial neglect as a common and difficult to manage problem in clinical practice.

Recent trends in rehabilitation interventions for visual neglect and anosognosia for hemiplegia following right hemisphere stroke

This article highlights the most recent findings regarding the rehabilitation interventions for the syndromes of visual neglect and anosognosia for hemiplegia that occur following right hemisphere stroke. We review papers published in the past 4 years pertaining to therapeutic approaches for these two syndromes in order to identify the trends in the development of effective interventions. Overall, it appears well recognized that visual neglect syndromes and awareness syndromes frequently co-occur and both include complex, multifaceted impairments leading to significant difficulties in daily life functioning following stroke. Thus, the interventions for these syndromes must be multifaceted in order to address the complex interplay of cognitive-behavioral-emotional components. There appears to be a trend for using combination therapeutic interventions that address these components.

Reported quality of randomized controlled trials in neglect rehabilitation

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