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Hemispatial Neglect The prognosis for recovery of independent function in
patients with persisting spatial neglect is worse than inthose with seemingly more disabling deficits (e.g.hemiparesis)
Although patients may recover from spatial neglect,
they often remain severely disabled.
Linked to longer hospitalisation and worse rehaboutcomes
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Incidence Reported incidence of neglect in stroke patients has varied
from as low as 8% of patients to as high as 90%.
Luukainen-Makkula report 30% of all acute stroke patients
suffer from neglect, while 2% suffer chronically More common in injuries affecting right cortical
hemisphere
Causes of spatial neglect include stroke, traumatic brain
injury, brain tumors, and aneurysm. Rarely,neurodegenerative diseases can cause neglect symptoms
This disorder is under-recognized in clinical practices,which may result from the failure to document its presence(Chen et al 2013)
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Mechanisms Many different cognitive deficits have been identified
in patients with neglect.
Led to a range of hypotheses about the mechanismsunderlying the condition
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Mechanisms
attention Perception Attention disordered awareness
(Heilman 2003)
Deficit in directing spatial attention, specificallyin disengaging attention from ipsilesional objects andshifting it contralesionally towards the neglected sideof space
Cueing attention towards the neglected side of spacecan help to reduce spatial biases
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Mechanisms - Spatial working
memory Imagery/representation unable to maintain an
internal map or spatial knowledge of the environment
Patients have difficulty in keeping track of spatiallocations across saccadic eye movements
Suggests limitations in visual short term memory(Malholtra et al 2004)
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Symptoms Deficits in attention to the area within reaching space
(peripersonal neglect) and beyond (extrapersonal neglect)
Personal neglect- deficit in grooming or dressing thecontralesional side.
Anosognosia- unaware of the deficit that is present (Occursin 20-58% of patients)
Deficits in attending to or perceiving contralesional space.
Motor neglect fail to use contralesional limbs even ifthere is little weakness
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Neglect vs. hemianopia Hemianopia primary sensory deficit visual field
loss, pt is aware of deficit will turn head to see
Patients with neglect are unaware of their deficit ofthe missing information on one side. Vision is intact,attention is disrupted.
Once their attention is drawn to the missinginformation, they become aware of it.
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Prognosis Most patients with neglect show early recovery, particularly
within the first month,and marked improvement may beseen within 3 months.
Patients with neglect need to be monitored because theymay be more prone to falls or left-sided wheelchaircollisions.Patients may require sitters, vest restraints, gaitbelts, or other interventions to prevent falling out of bed,for which they are at high risk.
Spatial neglect may greatly increase morbidity and the riskof acute and chronic complications of stroke (eg, hipfracture). It is associated with a longer acute hospital stay.
Neglect patients who were not detected clinically stayed inrehab longer than those who were (Chen et al 2013)
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Copying
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Catherine Bergego Scale
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Rx Prism Adaptation
Motor bias rehabilitation/Constraint-induced therapy
Visual Scanning Cueing
Trunk rotation
Vibration of contralesional neck muscles
Bed Placement/ Room rearrangement
Caloric stimulation
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Rx Interventions which simply attempt to improve
exploration of contralesional space (e.g. directinggaze) are effective in reducing neglect on those tasks,but have little transfer to functional benefits ineveryday life
However when combined with vibration ofcontralateral neck muscles, there is evidence forsignificant improvement in functional outcomemeasures at 2 months follow up (Schindler et al., 2002)
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Prism Adaptation Prism adaptation causes an optical deviation of the visual field
to the Right, so objects appear farther to the subjects right thanis actually the case.
After repeated exposure, it forces patients to correct their reachtrajectory to accurately grasp objects, thus overriding the visualimpairment. (A recalibration of visuomotor hand-eyecoordination.)
Significant improvements in neglect tests, but not functionalperformance.
Some have reported improvements in representational neglect,haptic neglect, neglect dyslexia, postural imbalance inhemiparesis
Mcintosh et al reported benefits for chronic neglect patients
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Contralesional Limb ActivationActive and passive movement to reduce visual and
behavioural neglect
Passive movement was also induced by functionalelectrical stimulation
Experimental groups appeared to have statisticallysignificant improvements on BIT, CBS and FIMmeasures during rehabilitation, however had ratherlarge standard deviations
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Constraint-Induced Therapy Based on principle of learned non-use - Causes reduced
neural representation of that limb, diminishing theirpotential to return to function
Mechanically forces patient to use their affected limb
van de Lee et al. (1999) compared CIT againsttraditional therapy
66 Stroke patients 7 with neglect
Showed significant improvements vs normal rehab
But no proper neglect measures used!
Requires active + functional wrist and hand movement
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Conclusion There have been numerous studies on various treatments
for neglect that have shown statistically significantimprovements both immediately and in the long-term.
Daily life functions are often performed under morechallenging conditions than is the case for formalneuropsychological testing/treatment environments
According to Cochrane review by Bowen and Lincoln(2007) it is difficult to correlate an improvement instandardised neglect tests, as they say little about thepersons ability to function in complex everyday activitiesthat are relevant to their life
More research is required on the various techniques andthe long-term effects
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References Luukkainen-Markkula, I.M. Tarkka, K. Pitkanen, J. Sivenius, and H. Hamalainen. Rehabilitation ofhemispatial neglect: A randomized study using either arm activation or visual scanning training.Restorative Neurology and Neuroscience.(2009); 27: 665-674.
Schindler I, Kerkhoff G, Karnath HO, Keller I, Goldenberg G. Neck muscle vibration induces lastingrecovery in spatial neglect. J Neurol Neurosurg Psychiatry 2002;73(4):412-9.
Nicole Y. H. Yang, Dong Zhou, Raymond C. K. Chung, Cecilia W. P. Li-Tsang, and Kenneth N. K.
Fong. Rehabilitation interventions for Unilateral Negelct after stroke: A systematic review from 1997through 2012. Frontiers in Human Neuroscience. (2013); 7: 187. van de Lee, J., Wagenaar, R., Lankhorst, G., Vogelaar, T., Deville, W., Bouter, L. Forced Use of the
Upper Extremity in Chronic Stoke Patients. Stroke. (1999); 30: 2369-2375. Bowen, A. & Lincoln, N. Cognitive Rehabilitation for Spatial Neglect Following Stroke. Cochrane
Database of Systematic Reviews. (2007); 2. Heilman KM, Watson RW, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E,
eds. Clinical neuropsychology. 4thed. New York, NY: 2003:296-346. Ringman JM, Saver JL, Woolson RF, Clarke WR, Adams HP. Frequency, risk factors, anatomy, and course of
unilateral neglect in an acute stroke cohort. Neurology. Aug 10 2004;63(3):468-74. Malhotra, P., Jager, H.R., Parton, A., Greenwood, R., Playford, E.D., Brown, M., Driver, J., and Husain, M. (2005). Spatial
working memory capacity in unilateral neglect. Brain 128, 424-435.
Chen, P., Pasquale, G.F. & Barret, A.M. Evidence of under-documentation of spatial neglect after stroke. DisabilRehabil. 2013 Jun;35(12):1033-8