Unilateral Neglect (25 Nov 07)

Unilateral Neglect 1

Unilateral Neglect: Assessment and Rehabilitation

Unilateral neglect is a brain disorder that is seen in a number of people who have

experienced damage to one hemisphere of their brain. These individuals do not respond normally

to objects, stimuli, and people located to their contralesional side, (i.e., the side opposite of the

lesion site) (Danckert & Ferber, 2006; Heilman, Watson, & Valenstein, 2003). This paper will

discuss the symptoms and possible causes of unilateral neglect, as well as the diagnostic testing

and rehabilitation therapies that are currently available to individuals who suffer from this

disability. Lastly, three case studies relating to neglect will be introduced, in order to exemplify

and personalize the individual experiences relating to unilateral neglect.

Unilateral neglect is a neurological condition in which the person fails to respond to

stimuli in the contralesional hemispace, which cannot be explained by primary sensory or motor

defects (Kim et al., 2007; Kolb & Whishaw, 2003). It is seen most frequently in patients who

have experienced damage to the right hemisphere of the brain, usually due to stroke, but

sometimes neglect may coincide with a traumatic brain injury (Zillmer & Spiers, 2001).

However, in some cases, unilateral neglect may be temporary and reversible when it occurs in

conjunction with seizures, electroconvulsive therapy, and intracarotid sodium amytal testing

(Wada testing) (Kolb & Whishaw, 2003; Lezak et al., 2004; Wenman, Bowen, Tallis, Gardner,

Cross, & Niven, 2003).

Individuals who experience neglect typically do not respond to stimuli located to their

left side. For example, they may not eat the food on the left side of their plate, shave only the

right side of their face, fail to read words on the left-hand side of a page, or when asked to draw

an object they are only able to reproduce the right side (Lezak et al., 2004; Wenman et al., 2003).

Zillmer and Spiers (2001) point out that “in one respect, neglect can be thought of as a forgetting

or lack of conscious attention to the left side, but even more so--it is as if awareness is being

pulled to the right” (p.134). In extreme cases, Mesulam (1985) comments that “when neglect is

severe, the patient may behave almost as if one half of the universe had abruptly ceases to exist

in any meaningful form” (p. 142). Although unilateral neglect can occur after damage to either


hemisphere, left-side neglect due to right-hemisphere damage is far more common, longer lasting

and severe than right-side neglect due to left-hemisphere damage (Danckert & Ferber, 2006;

Kleinman, Newhart, Davis, Heidler-Gary, Gottesman, & Hillis, 2007; Lezak et al., 2004).

Furthermore, research has indicated that the presence of neglect in stroke patients is considered

an adverse indicator of their prognosis for recovery (Wenman et al., 2003; Cassidy, Lewis, &

Gray, 1998).

In some cases, individuals with severe unilateral neglect fail to make eye movements

towards stimuli on the contralesional side. Instead, their eyes deviate towards the ipsilesional

side, (i.e., the side with the lesion) (Hillis et al., 2006; Ladavas & Zeloni, 1997; Mattingley &

Husain, 1998). However, the unilateral neglect response is not due to any loss of vision; instead

it is a cognitive inability to perceive what is in the visual field on the contralesional side.

According to Mesulam (1985), “neglect is not a defect of seeing, hearing, feeling, or moving but

one of looking listening, touching, and searching” (p. 142). Although neglect may be

demonstrated in more than one modality, it is usually confined to the visual performance,

indicating a significant relationship between spatial attention and movement (Hillis et al., 2006;

Punt & Riddoch, 2006).

Subtypes of Unilateral Neglect

Motor Neglect

Individuals who are suffering from motor neglect typically experience an absence of

spontaneous movement in the contralesional limb, which is not explained by damage to the

motor cortex (Hillis et al., 2006). For instance, when individuals are asked to raise both hands,

they frequently only elevate the ipsilateral hand to the lesion site (Punt & Riddoch, 2006). It is

important to note that motor neglect involves the contralateral side of the body and not the

contralateral environment, as is represented in the typical clinical presentation of unilateral

spatial neglect.

Neglect Dyslexia

People who are experiencing the symptoms of neglect dyslexia will characteristically fail


to read the left part of sentences or single words (Hillis, Newhart, Heidler, Marsh, Barker, &

Degoankar, 2005). For example, “smile” is read as “mile” or “belief” as “grief.” Omissions

usually consist of the initial letter or substitutions of the original letter to form a grammatically

correct word. The opposite effect has also been reported with left hemisphere lesions (Lezak et

al., 2004). For example, “south” is read as “soup” or “modern” as “modest.” When asked to read

a complete sentence or a passage, patients often begin reading at the middle of the sentence and

read the entire passage in this manner despite the meaningless of the text (Hillis et al., 2005).

Neglect Dysgraphia

The symptoms of neglect dysgraphia usually involve a preference for the right page of a

document, which causes the individual to produce crowded handwriting with an inflated left

margin (Lezak et al., 2004). It is certainly not out of the ordinary for people with neglect

dysgraphia to have difficulty writing horizontally, as well as leaving large spaces between words

and committing graphic errors (Rode, Klos, Jacquin, Rossetti, & Pisella, 2006).

In both neglect dysgraphia and neglect dyslexia the pattern of errors may vary widely

between patients (Lezak et al., 2004). It is important to note that both conditions do not always

co-occur (Halligan & Marshall, 1993; Heilman et al., 2003).

Facial Neglect

People struggling with facial neglect show a defect in the recognition of normal faces and

in some instances only recognize half faces (Vuilleumier & Schwartz, 2001). Young, DeHann,

Newcombe, and Hay (1990) describe this as a domain-specific form of unilateral neglect. In their

research the deficit was present with the representation of both internal and external facial

features. Indeed, research indicated that the judgment of facial expressions and the resemblance

between faces also suffered from neglect. The authors believe this phenomenon occurs from a

failure to attend to the left side of faces, due to the injury of the right hemisphere that produces a

right-sided cognitive preference.

Auditory Neglect

Although a few studies have reported the presence of auditory neglect, it remains


complicated to validate (Eramudugolla, Irvine, & Mattingley, 2007; Spierer, Meuli, & Clarke,

2007). This difficulty arises from the fact that the auditory system is not nearly as lateralized as

the visual system. Therefore, testing with unilateral stimuli cannot be accurately controlled. For

instance, past studies have utilized the presentation of bilateral auditory stimulus and defined the

failure to respond to the stimulus in the left hemispace as auditory neglect (Lezak et al., 2004).

Due to the bilateral nature of the auditory system, this form of neglect is often referred to as

inattention This type of deficiency in aural functioning is also known as extinction; however, it

has been argued that extinction is nothing more than an attenuated form of neglect (Punt &

Riddoch, 2006).

Related Disorders and Causation

Unilateral neglect has also been associated with a number of other disorders. These

include: (a) anosognosia--which refers to the loss of ability to recognize or to acknowledge an

illness or body defect (Appelros, Karlsson, & Hennerdal, 2007); (b) anosodiaphoria--an

awareness of the contralateral defect despite an apparent lack of concern about the impairment

(Morin, Thibierge, & Perrigot, 2001); (c) allesthesia or allochiria--a failure to detect unilateral

stimuli (Heilman et al., 2003); (d) extinction--a failure to identify both stimuli in the presentation

of bilateral simultaneous presentation (Heilman et al., 2003; Punt & Riddoch, 2006).

The area of the brain most commonly affected by unilateral neglect is the posterior region

of the inferior parietal lobe in the right hemisphere (Heilman et al., 2003; Lezak et al., 2004).

The condition has also been associated with damage to sub cortical structures including the

thalamus. These three areas are interrelated and believed to comprise an important "neural

circuit." Therefore, damage to any one of them may affect the functioning of the others (Kolb &

Whishaw, 2003; Rode et al., 2006).

There are two general types of theories regarding the cause of unilateral neglect

symptoms: Attention theories and representational theories (Heilman et al., 2003). Advocates of

awareness theories hold that individuals with unilateral neglect have damage to areas of the brain

that control attention orienting. For example, people with neglect focus their attention on the


ipsilesional side of space and fail to shift their attention to the contralesional side of space,

thereby not noticing stimuli on that side. Some proponents of attention theories believe that

damage occurs to a neural circuit that generates saccadic (fast eye) movements, which are an

important component of visual attention. Advocates of representational theories believe that

patients are unable to "construct a complete mental representation" of space on the contralesional

side. In this case the damage is believed to be to a neural circuit that controls spatial

representation and conscious awareness in the brain. Within these two general theories, there are

a variety of opinions regarding the specific mechanisms and brain functions that account for the

symptoms seen in individuals with unilateral neglect, which can vary in severity and scope from

person to person (Humphreys & Riddoch, 1993; Punt & Riddoch, 2006; Rizzolatti & Berti,

1993). For example, different sensory modes (visual, auditory, and tactile) and spatial

dimensions (horizontal, radial, and vertical) can be affected to different degrees. In fact, neglect

symptoms may be task specific, which may create difficulty in individual awareness and therapy

(Appelros, Nydevik, Karlsson, Thorwalls, & Seiger, 2004; Lezak et al., 2004).

Assessment / Testing

The presence of visuospatial unilateral neglect can be detected using some simple

screening tests that are quickly and easily administered at the individual’s bedside. The most

common are line bisection, figure cancellation, figure copying, and representational drawing

(Heilman et al., 2003; Lezak et al., 2004). These are subtests of a standard neuropsychological

test battery called the Behavioral Inattention Test, which is commonly used to test for unilateral

neglect in people who have experienced brain damage (Jehkonen, Ahonen, Dastidar, Koivisto,

Laippala, & Vilkki, 1998; Ptarmigan & West, 2000).

Line Bisection Test

The line bisection test is the most widely used diagnostic test for unilateral neglect

(Lezak, et al., 2004; Rizzolatti & Berti, 1993). In its most common version, the individual is

presented with a thin long horizontal line drawn in the center of a piece of paper and asked to

bisect the line, either by pointing to the line's midpoint or by quickly making a mark across the


line at its midpoint. Typically, persons with left-sided unilateral neglect bisect the line to the

right of the actual midpoint of the line. Likewise, right-sided neglect is associated with a leftward

shift in people’s mark from the midpoint. In either case, the distance from the actual midpoint

(called the displacement) is an indicator of the severity of the client’s neglect (Lezak et al., 2004;

Marshall, 1998).

Although there is a general consensus among clinicians that poor performance on the test

is a reliable indicator of the presence of unilateral neglect, its specific merits for showing the

severity or particular manifestations of neglect are less understood (Heilman et al., 2003; Lezak

et al., 2004). The test has been conducted using various line lengths, orientations, backgrounds,

and positions on the paper. Numerous studies performed by several researchers (as cited in

Halligan & Marshall, 1993), during the late 1980s and early 1990s, found that all of these

variables have "reliable effects on the measured severity of neglect" (Mozer & Halligan, 1997, p.

187). The effects of other individual and test administration factors on line bisection performance

have been studied to various degrees, individual age, reading habits (left-to-right or right-to-left),

viewing distance, gender, and handedness (i.e., whether the patient is left handed or right

handed).

Figure Cancellation Tests

In the cancellation tests, a person is presented with a piece of paper containing various

drawn figures, either short lines, letters of the alphabet, or stars scattered around the page (Lezak

et al., 2004). The patient is asked to draw a line through each figure on the page or, for the letter

test, through a particular letter. Typically, clients with left-sided neglect cross out figures on the

right side of the page and fail to notice the ones on the left side of the page (Cassidy et al., 1998).

Omission of more than 5 percent of the figures is considered the usual criterion indicating

unilateral spatial neglect (Mark & Heilman, 1998).

Studies have also indicated that there is a diagonal bias among unilateral neglect patients

during the performance of cancellation tasks. Mark and Heilman (1998) found that stroke

patients commonly indicate diagonal neglect (a corner-based spatial bias) on the cancellation


tests, i.e., they omit targets toward one corner of the page, usually the bottom left quadrant.

The cancellation tests assess a client’s ability to ignore distracting stimuli and use visual

discrimination. Because letters are more complex and require greater control over information

processing, the letter cancellation test is considered the most demanding of the three tests and has

the greatest distraction factor (Cassidy et al., 1998).

Another visual inattention test with a high distraction factor is referred to as the balloons

test (Lezak et al., 2004). In this cancellation test, the patient must search and cross out particular

shapes scattered amongst a background of very similar and distracting shapes, viz., circles and

circles with a line adjoining (balloons). This test battery can distinguish between attention and

visual field deficits.

Figure Copying Test

In this test, the individual is asked to copy a simple drawn figure, such as a daisy (Lezak

et al., 2004). Clients with left-sided unilateral neglect typically copy only the right side of the

figure, leaving the left side of their drawing blank, unfinished, or distorted in some way. Ishiai,

Seki, Koyama, and Izumi (1997) found that unilateral neglect patients shown a complete drawing

of a daisy (a large central circle surrounded by many side-by-side smaller circular petals)

correctly identified the figure as a daisy and did not mention any missing petals. However, when

asked to copy the daisy, the patients consistently drew a daisy that was correct on the right side

only, with large gaps between petals on its left side. Interestingly, the same patients were able to

arrange a large circle and many smaller circles into the shape of a daisy, when asked specifically

to do that task.

Representational Drawing Test

In this test, the patient is asked to draw a simple diagram of a common object. A clock is

often used, because it requires the placing of numerals around the face (Ishiai, Sugishita,

Ichikawa, Gono, & Watabiki, 1993; Lezak et al., 2004). Patients with left-sided unilateral neglect

may confine their drawings to the right side of the paper and distort or even omit the left side of

the object in their drawings (Lezak et al., 2004).


Rehabilitation

Research indicates that the symptoms of unilateral neglect will typically stabilize two

months after a stroke event (Heilman et al., 2003; Lezak et al., 2004). In some cases the

condition may resolve itself, however in most instances the effects are enduring. Unilateral

neglect has been associated with poor performance of daily motor activities, such as writing,

poor sitting balance, crossing the street, or recognizing an object that exits on the contralesional

side of the visional field. Studies have shown that as visual neglect improves so will functional

motor skills. Unfortunately, there has been less than an optimal response to the various therapies,

due to the inability to maintain the positive effects of the various treatments that are currently

available (Pizzamiglio, Guariglia, Antonucci, & Zoccolotti, 2006; Punt & Riddoch, 2006;

Wenman, et al., 2003).

The symptoms of unilateral neglect are heterogeneous, which may affect an individual’s

limb movement, vision, hearing, or balance. In some instances, the neglect may be task-specific,

such as the involvement of inattention to far away space when attempting to cross the street

(Lezak et al., 2004). Due to this neurological phenomenon, the rehabilitation programs are

various and typically involve a top-down or bottom-up approach to therapy. The top-down

technique focuses on improving both the perceptional and behavioral biases by stimulating the

individual’s higher cognitive levels, through such methods as visual scanning. The bottom-up

practice is an attempt at modifying the sensorimotor level by initiating passive sensory

stimulation, as is used in Transcutaneous Electrical Nerve Stimulation (TENS) (Appelros et al.,

2004; Punt & Riddoch, 2006; Rode et al., 2006).


Constraint and Bilateral Therapies

Constraint – Induced Movement Therapy (CIMT) is a cognitive method of therapy that

involves the conscious protecting of the unaffected side as a means of training the contralesional

side to respond with increased normality (Punt & Riddoch, 2006). In contrast, Bilateral

Movement Training (BMT) encourages the individual to utilize the unaffected limb or body side

as a technique to effectively guide the affected bodily area. BMT was recently endorsed by the

Royal College of Physicians’ National Clinical Guidelines for Stroke.

According to the guidelines, these lower level cognitive exercises aid in the development

of bilateral activities that include coordination, postural control, and gait. However, studies have

indicated that this particular therapy is difficult when the individual is involved in bilateral

environmental conditions, such as crossing the street when road traffic is present. It is

hypothesized by many researchers that compensation by the individual’s ipsilateral side is

compromised due to the increased stimuli to which the person must respond in a more complex

environment (Punt & Riddoch, 2006).

Transcutaneous Electrical Nerve Stimulation (TENS)

TENS is a therapy that involves the application of nerve stimulation to the contralesional

side of the neck, in order to improve balance and restore a symmetric gait in people who

experience neglect. The TENS bottom-up therapy method has received contradictory scholarly

reviews, with regard to the technique’s effectiveness and client comfort.

According to Punt and Riddoch (2006), TENS has the ability to dramatically improve the

balance in people suffering from neglect. In addition, these researchers found that if clients

directed their vision towards the contralesional side during the treatment their gait showed a


significant improvement in symmetry. Those researchers who favor TENS assert that balance is

enhanced by improving the activation of the neurological processor that is injured; thereby

allowing the undamaged side to function more efficiently. On the other hand, Wenman et al.

(2003) found clients who received electrical stimulation in combination with self-instructional

training showed no benefit from the treatment. In addition, the therapy was not well tolerated by

a least two of the participants. Further research by Pizzamiglio et al. (2006), suggested that

TENS has the ability to temporarily improve or worsen the condition of unilateral neglect.

According to Pizzamiglio et al, eight weeks of TENS treatment did not result in positive changes

for all participants who took part in their study.

Visual and Spatial Scanning

The procedures used for visual and spatial scanning therapy are considered to be higher

cognitive training that utilizes the top-down approach to treatment (Pizzamiglio et al., 2006). The

technique that is utilized encourages the client to actively and sequentially scan various parts of a

simulated visual field, in order to produce the answers to various questions. These inquiries may

include information pertaining to: Reading, copying, copying of line drawings on a dot matrix,

and figure description.

Pizzamiglio et al. (2006) found overall that the group benefited from the therapy;

however, individual differences were reported. It was hypothesized that treatment duration or

lesion size and dimension may have been factors in these recorded differences. Follow-up

interviews with the participants indicated improved scanning ability many months after the

therapy was discontinued. Throughout the treatment process the participants’ exhibited

significant attitude changes relating to their disability. For instance, when the clients noticed

improvement in their respective skills they became more aware of the deficit, which aided them


in their ability to create compensatory tactics. In addition, the therapy allowed the clients to

actively participate in their rehabilitation process, which appears to contribute to their expressed

feelings of positive self-worth and efficacy. It is important to note that some of the clients who

were initially indifferent to the disability experienced some depression when they began to

understand the severity of their impairment.

Virtual Environment Training System

This newly developed bottom-up approach to therapy was created to assist those

individuals who suffer from the symptoms of unilateral spatial neglect (Kim et al., 2007). This

new technology aids the person in everyday tasks, such as crossing the street. The virtual reality

equipment encourages attention to the contralesional visual area by creating visual cueing. The

theory behind this system is to enable people with spatial neglect to use their ipsilateral site as

compensation for the injury demonstrated by the contralesional area. Through training this

technology has the ability to reduce asymmetry between the left and right side in cases of

unilateral neglect. In a three-month follow-up study, the positive effects of the training remained,

although there was a small degree of neglect symptom increase in some clients. It is

hypothesized that this method of training is more beneficial than the traditional therapies. For

instance, scanning therapy must be provided in a variety of living situations for the method not to

become task-oriented, which would inhibit the actual improvement of neglect. Conversely, the

virtual reality therapy permits flexible usage in the least restrictive environment, which aids the

client in using this method as a way of creating independence when performing the functions of

everyday life.

Prism Therapy


According to recent research, Prismatic Adaptation (PA) may significantly reduce the

behavioral prejudices due to neglect, using a bottom-up process. Rode et al. (2006), used prisms

that displaced the visual field by 10° in a rightward direction. After a two to five minute

exposure to the prism the participants’ manual straight ahead pointing shifted significantly to the

left side. Prior to the prism therapy the participants were identified as manually pointing 9° to the

right, therefore there was a 70% compensation for the 10° optical displacement. Six of the clients

who were exposed to PA showed significant improvement in symptoms for both spatial and

object neglect. In addition, PA has been found to improve visual-spatial deficits, such as spatial

dysgraphia (right page preference, graphic errors, and failure to write horizontally), as well as

audio insufficiency. In fact, PA appears to aid in the ability to create and investigate symmetrical

inner representations.

Equally impressive is the length of improvement time that is offered by this therapy.

Research has indicated that a five-minute session lasts much longer than any other form of

therapy (e.g., two hours and one day respectively). In fact, there have been some case studies that

show a marked improvement for as long as four days. Further research has demonstrated that

repeated sessions of PA exposure, such as two times daily for a period of two weeks, will bring

about noteworthy improvement that lasts for a five week period (Rode et al., 2006).

Researchers are unsure whether PA is a recovery therapy or a form of selective

compensation. However, it is hypothesized that PA may activate the network between the

cerebellum, thalamus, and cortical areas of the brain, causing the positive effects of PA therapy.

More importantly, PA appears to be the only treatment that focuses on the right cortical

hemisphere, as opposed to the traditional training that stimulates the ipsilesional side of the brain

(Rode et al., 2006).


Case Studies

Case Example One

Mr. L. is a seventy-seven-year-old, right-handed male, who was referred to the Kessler

Institute for Rehabilitation (KIR) for evaluation, following a verbal assault toward staff members

at a residential nursing facility, where he has resided for the past two years. Mr. L became

abusive during dinner when he claimed, “Everyone else is getting steak except me.” A review of

his medical records revealed that Mr. L. experienced a CVA (cerebrovascular accident) 12

months previously, with damage to the parietotemporal cortex (Brodman 39/40) and cingulate

gyrus, which caused Mr. L. to suffer from deficits in spatial awareness.

The nursing staff reported that this type of behavior was out of character for Mr. L; he

had never acted aggressively in the past. Mr. L. was administered a variety of

neuropsychological tests and it was apparent that he suffered from neglect. He scored below the

first percentile on tasks involving line cancellation, clock drawing, and hemi-attention. There is

also evidence of early dementia and he will be referred for a complete neurological and

neuropsychological evaluation.

Meanwhile, Mr. L. has to be assisted by staff in negotiating obstacles in his left visual

field. In addition, Mr. L. showed significant signs of anosognosia for the visual field deficits

until he was made aware of his difficulty. Through rehabilitation therapy Mr. L. will learn to

acknowledge the visual and spatial difficulties, which will enable him to strengthen his ipsilateral

side to compensate for the deficit in cognitive functioning from the lesion that is located in the

right hemisphere of Mr. L.’s brain (R. P. Conti, personal communication, October 3, 2007).


Case Example Number Two

Mr. W is a 62-year-old married, right-handed, African-American male who was admitted

to KIR following his release from _______ hospital. Mr. W. is a physical education teacher who

suffered a fall during class from a CVA. Upon evaluation, he was wheelchair bound and alert,

but under aroused and sluggish in his responses to various stimuli. In addition, he complained of

a headache and fatigue. Mr. W. was oriented to both person and time but disoriented to place.

Mr. W. was only able to provide a partial explanation for his hospitalization and rehabilitation

(“I fell”). His previous medical history indicated that he suffered from hypertension and

experienced several head injuries from playing contact sports.

Throughout his neuropsychological evaluation, Mr. W. sustained attention for brief tasks.

His working memory was intact but he presented significant visual field deficits. Mr. W. is aware

of his difficulties but demonstrates impulsivity and a lack of understanding for safety precautions

(e.g., wheelchair seatbelt). He was referred to the cognitive remediation program, in order to

implement an approach to rehabilitation (R. P. Conti, personal communication, October 3, 2007).

Case Example Number Three

Ms. M. is a 71-year-old, right-handed, white female who was seen for neurobehavioral

assessment following her release from ______ hospital. She was admitted to the hospital

following a fall in her home. Family members reported changes in her behavior during the past

year. Her previous medical history was unremarkable. Ms. M. is a retired schoolteacher who is

widowed and lives alone. She complained to family members of “balance problems” during the


past year. For example, she stated that when she was driving “cars come out of nowhere and pass

her.”

Ms. M. suffered a minor cerebrovascular incident (CVA) to the posterior right

hemisphere with a focal neurological deficit. She is aware of her condition and follow-up

neuropsychological testing has indicted minor neglect to the left hemi-space (R. P. Conti,

personal communication, October 3, 2007).

Discussion

The mysteries surrounding neglect are numerous, due to the heterogeneity of the

disability. For instance, it is not uncommon to have difficulty in diagnosing neglect because it is

often somewhat compensated for by the client, it may be modality specific, or its existence is

denied. Due to these complications, a full battery of testing should be implemented, so both the

client and therapist are able to recognize the disorder and its severity. In many cases, individuals

who suffer from neglect will respond accurately to unilateral stimuli while missing stimuli that is

contralesional during bilateral representations. This phenomenon in cognitive functioning may

encourage the client to not understand and recognize the issue as one of cognitive significance,

which can cause personal frustration and anger, which was illustrated by the case study of Mr. L.

From a clinical perspective, it is important for the clinician during the interview process to

recognize and appreciate the body movements of clients, as well as their ability to perceive

various stimuli when asked to concentrate on a specific task (Appelros et al., 2004; Punt &

Riddoch, 2006).

The signs of neglect are typically apparent two to four weeks after a CVA. Research

indicates that the disturbances of neglect are usually stabilized two months following the CVA.

Therefore, the time to properly assess for neglect would be at least two weeks after the stroke


event. However, there appears to be no time constraints on assessment because neglect

symptoms do not seem to depreciate. It is important to note that some clients continue to decline

after the acute phase of neglect. Many researchers contend that this small difference in a

population of individuals with neglect may be due to continued silent infarcts, or persistent

cognitive decline, due to dementia. Of course, cognitive complications such these make any

sustained improvement in neglect therapy sub-optimal (Appelros et al., 2004; Pizzamiglio et al.,

2006; Wenman et al., 2003).

An example of this type of problem can be seen in the case of Mr. L. Mr. L. is suffering

from neglect, as well as continued dementia. In addition, Mr. L. is in denial of his neglect

deficiency, which has begun to cause him increased stress and agitation. Perhaps cognitive

scanning will aid Mr. L. in his ability to cognitively perceive his left hemi-space. If some

improvement in cognitive functioning is experienced by Mr. L., he will most likely begin to

understand his deficit, which will aid in the development of his compensatory behaviors and

improve his agitated emotional state.

In addition, prism therapy may be helpful if Mr. L. is unable to recognize the neglect

deficit. This approach will passively treat the inattention and allow for a higher level of

functioning in the area of neglect, while the dementia will continue. Lastly, it is important to

appreciate that Mr. L.’s continued cognitive decline can not be compensated for by neglect

therapy. Therefore there will be limitations to his progress, which must be addressed in his

comprehensive therapy program.

Due to the relationship between spatial attention and movement the symptoms of neglect

will affect both individual perception and action. This idea is exemplified by case number three,

which introduces Ms. M. and her inability to see traffic in her left hemi-space when driving her


car. Ms. M. is aware of her disability and would largely profit from a form of therapy that will

increase her daily functioning.

If indeed there is minor neglect detected in Ms. M. she may find improvement through

the use of prism therapy. This therapy works from a bottom-up approach by passive sensory

stimulation. In this case, prism therapy would help Ms. M. in her ability to perform her daily

activities. In addition, this particular therapy offers an increase in the lasting effects of treatment.

Therefore, Ms. M. could receive therapy over a period of two weeks and reap the benefit for as

long as five weeks.

Cognitive scanning may also be utilized to aid Ms. M. This approach offers a top-down

design, due to the focus on higher cognitive stimulation. Again, Ms. M. who suffers from minor

neglect may benefit both physically and psychologically by participating in a therapy that is

based on client interaction and effort. This particular treatment has shown remarkable success,

and in a few cases of minor neglect, an improvement that lasted for months after therapy.

Ms. M. would possibly benefit from a therapy that is client motivated, due to her

understanding of the disability. This knowledge may encourage her to cultivate compensatory

behaviors that can be utilized within many living situations over time. Lastly, this treatment

allows Ms. M. to take control of the deficit, which will undoubtedly boost her self-esteem and

efficacy, due to the independence and self-pride that such a therapy has to offer.

In case number two, Mr. W. suffered both a CVA and past traumatic brain injuries from

contact sports. Neglect testing indicates that Mr. W. suffers from significant visual field

deficiencies. While this is undoubtedly true, it is important to understand that Mr. W. has also

presented behavior that indicates impulsivity, which must be evaluated in terms of the severe

head injuries and the CVA event. In addition, Mr. W. appears to be under aroused and sluggish,


these indications of a blunt affect must be considered in his continued neurological testing and

rehabilitation program.

It is possible that Mr. W. would profit from virtual reality therapy. Virtual reality

rehabilitation is interesting because it allows Mr. W. more freedom than perhaps the other

treatments, because of the continued left hemi-space stimulation. Due to Mr. W.’s under aroused

state, sluggish response system, disorientation to place, and the physical immobility that he must

endure, the virtual reality system may provide the least restrictive treatment and environmental

benefit for practical everyday living.

Clearly, the symptoms and diagnosis of unilateral neglect are diverse and difficult; this is

mostly due to the disability’s homogeneity. A clinical interview and neurological testing are

imperative when the clinician and the client are deciding upon a treatment regime to rehabilitate

the symptoms of neglect. All clients must be assessed based upon their respective physiological,

psychological, and environmental conditions. Only then can a successful plan for rehabilitation

be established.

Unilateral neglect appears to be elusive in its ability to be successfully treated. However,

as technology advances so does the capacity to treat the symptoms of hemi-neglect. This is

supported by the technologies of both prism treatment and virtual reality therapy, which illustrate

how equipment and expertise can significantly alter rehabilitation options for the individual.

Although unilateral neglect is an old and frustrating disability the promise for advancements in

therapies are abundant, which allows hope, self-satisfaction, and self-sufficiency in everyday

living for people dealing with neglect.

This type of research is necessary for the clinician to understand how assessment,

changing technology, and individual circumstance may affect the rehabilitation of neglect.


Further examination is suggested to test various therapies, such as virtual reality, for the

effectiveness and duration.

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