Unilateral Spatial Neglect

Evidence Reviewed as of before: 04-06-2015
Author(s): Anita Menon, PhD OT; Anita Petzold, MSc OT; Angela Kim, BSc OT; Tatiana Ogourtsova, MSc OT; Annabel McDermott, OT; Nicol Korner-Bitensky, PhD OT
Patient/Family Information Table of contents

Introduction

Unilateral spatial neglect (USN) is one of the disabling features of a stroke, and is defined as a failure to attend to the side opposite a brain lesion. Clinically, the presence of severe USN is apparent when a patient often collides into his/her surroundings, ignores food on one side of the plate, and attends to only one side of his/her body. Many terms are used interchangeably in the literature to describe USN, such as unilateral neglect, hemi-inattention, visual neglect and hemi spatial neglect. It is estimated that as many as 30% of patients experience USN following a stroke.

A client with USN is unable to attend to either one side of his/her body (personal neglect), the space within reaching distance (near extrapersonal neglect), the space beyond reaching distance (far extrapersonal neglect), or to a combination of these three spaces in the environment. USN continues to be commonly associated with a right stroke, but evidence from the literature suggests that all patients with stroke might benefit from USN screening.

The presence of USN has been strongly associated with an increased risk for injury and with poor functional outcomes. The effects of USN extend beyond the basic skills for self-care (bathing, dressing, walking, etc.) to instrumental activities of daily living (IADL) that are crucial for successful reintegration into community life.

When refering to the figure below “Typically, right hemisphere patients with left neglect omit elements to their left when copying simple objects (A), drawing a clock face (B), and cancelling targets among distractors (C). They also tend to err to the right when asked to bisect a horizontal line (D). When asked to name objects in their surroundings, they will tend to name only those on the right. Crosses in (E) mark the locations of reported objects with respect to the patient.” (page 14 from Parton, A et al. J Neurol Neurosurg Psychiatry 2004; 75:13-21 reproduced with permission from the BMJ Publishing Group).

INTRO_Parton et al. JNNP 2004

Patient/Family Information

What is unilateral spatial neglect?

Unilateral spatial neglect (USN) is the inability to pay attention to people and things on the side that is affected by the stroke. For example, someone with left-sided paralysis may also have left-sided USN. This problem is sometimes called unilateral visual neglect.

Picture of the Clock Drawing Test of a normal individual (right) and a patient with left neglect (left)

Patients with severe USN have obvious symptoms in that they may:

  1. Collide into their surroundings on one side (usually the left) when trying to wheel a wheelchair,
  2. Ignore food on one side of the plate, usually the left half,
  3. Ignore one side of their body, usually the left.

For example, you might notice that a person with USN shaves only one half of his face, typically the right, while ignoring the left.

Family members often become frustrated in the early days after the stroke because they do not understand why the patient is not looking at them when they stand on the side affected by the stroke. It is because the person is unaware of that side, not because they are ignoring you.

A patient can also have mild symptoms of USN that are not as obvious. For example, he may be able to notice food on both the left and right side, and may look at you if you are on his affected side, but may have difficulty with more complex daily tasks, such as driving a car or crossing a busy street.

Because USN can result in falls and other problems when doing daily activities, and because it is treatable, it is important that all patients who have had a stroke receive at least a quick assessment to test for USN.

How frequent is USN after a stroke?

About 30% of patients have either hemianopsia (blindness on one side of both eyes) or USN following stroke. USN is found more often in those who have had a stroke in the right side of the brain. However, studies show that all patients with stroke should receive testing for USN. USN can occur in three ways:

  1. A person may have USN that results in neglect of one side of their body. For example, you may notice a person whose hand is hanging over into the wheelchair spokes but he doesn’t realize it.
  2. A person may have USN in the space within reaching distance. For example, you may notice that the person does not know where the telephone is, even when it is fairly close by, because it is on the side affected by the stroke.
  3. A person may have USN in the space beyond reaching distance. This type of USN is often missed while the patient is in the hospital, but it is serious because when walking and driving, the person is missing important visual information from one half of the environment.

Neglect can occur in all of these three ways or in a combination of these.

What are the potential consequences of having USN after a stroke?

Those with USN are more at risk to fall and usually have lower functional ability than those without USN. USN can affect the ability to take care of basic skills such as bathing, dressing, and walking.

Can USN caused by a stroke be treated?

There are four types of treatment for USN:

  1. Visual Scanning: During this treatment the person with USN is encouraged to explore the neglected visual field (usually the left side) by performing a task on that side. The treatment often includes a visual target that the patient uses as an anchor while scanning.
  2. Sensory Stimulation: The therapist uses different types of sensory stimulation to encourage the person to pay attention to their neglected side. These include:
    • Visual/Verbal/Auditory Cues: The use of a visual cue (i.e. use of red tape or flashing lights), verbal cue (i.e. the voice of the therapist or a family member) or auditory cue (i.e. horn or bell) on the neglected side to improve awareness of that space.
    • Limb Activation: When doing this treatment the patient makes movements of the affected arm and hand on the neglected side to encourage scanning of that space (usually the left hand and arm towards the left). The person receiving treatment can do these movements alone or with help from the therapist.
    • Caloric Stimulation: This treatment uses either cold or warm water that is put into the patient’s ear (external ear canal) to encourage scanning of the neglected side. Cold water seems to encourage scanning toward the stimulated ear. Warm water encourages scanning of the field opposite to the stimulated ear.
    • Eye Patching/Hemiglasses: This treatment uses standard eyeglass frames with half of both lenses blacked out on the same side (usually the right half). This forces the patient to look through the side of the lens that represents the side that he is ignoring (usually the left side).
    • Fresnel Prisms: This treatment involves putting prisms over regular eyeglass frames. The prisms cause a shift of the visual field. So, if there is neglect on the right side, these prisms will cause what is seen to the right to be shifted farther to the right in order to encourage visual scanning of the right visual field. When first wearing these glasses, patients initially reach too far for objects on the right side because their vision is further deviated toward the right. After repeated treatments, clients can correct how far they reach and can accurately grasp the object, despite the distorted visual input they receive with their glasses.
    • Neck/Hand Vibration or Stimulation: This intervention consists of the use of vibration or stimulation on the neck or hand of the side affected by the stroke to encourage the patient to look to that side.
    • Trunk Rotation: This strategy involves twisting the trunk toward the side affected by USN to improve visual scanning of that space.
    • Visuo-motor Imagery: Visual imagery involves mental imaging tasks where the patient is required to describe details of a familiar room, environment, or geographic area. Motor imagery consists of the patient imagining a body movement or posture and describing this sequence. This type of imagery treatment may stimulate areas of the brain that can activate those actual movements during daily activities in order to improve neglect symptoms.
    • Constraint-Induced Therapy: This treatment involves restraining the arm that is not affected by the stroke (for example with a sling) to encourage use of the arm affected by the stroke. While used primarily to encourage use of the arm, this intervention will also encourage visual scanning of the side being used.
    • Optokinetic Stimulation: This is the observation of moving visual targets from left to right. This treatment is used to encourage visual scanning of the side that is neglected.
  3. video Feedback: This treatment involves filming the patient while he does specific activities. The therapist and patient then watch the video together. The therapist points out to the client how they are neglecting their body or the space on the side of their body. They then discuss strategies to encourage attention to the patient’s body and the space he is neglecting.
  4. Pharmacological Therapy: This involves the use of specific medications (dopamine-agonist drugs) to improve visual attention skills. A physician must prescribe these medications.

Which treatment for USN works?

The benefits of various interventions to treat USN symptoms have been carefully studied post-stroke. Research studies have reported that the use of visual scanning, limb activation, trunk rotation, as well as cueing (visual, verbal, auditory) during treatment has led to improvements in USN symptoms and in some cases, improvements in performing daily activities. Patients receiving eye patching and prism therapy have also shown some progress in attending to the neglected side, however, these benefits were only temporary, lasting a few hours after treatment. The other treatments described in the section above require further research before their effectiveness can be confirmed.

Who provides the treatment?

Occupational therapists (OT) typically provide therapy for USN at an acute care hospital, rehabilitation centre, or private clinic.

Clinician Information

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The effectiveness of the various interventions in the management of unilateral spatial neglect (USN) has been examined with individuals post-stroke. This review presents 16 high quality RCTs, 14 fair quality RCTs, 4 poor quality RCTs and several non-randomized studies that evaluate the benefits of different treatment interventions for USN.

Results Table

View results table

Outcomes

Acute phase

Eye patching
Not effective
1b

One high quality RCT (Ianes et al., 2012) examined the effects of right hemifield eye patching on USN symptoms in patients with acute stroke. This high quality RCT randomized patients with acute stroke and left USN to receive right half-field patching or visual scanning training over a 15 day period. There were no significant between-group differences in USN (Line Crossing Test, Bells Test, Line Bisection Test) at post-treatment. At one-week follow-up there was a significant between-group difference in Line Crossing Test scores only, in favor of half-field patching compared to visual scanning training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that eye patching is not more effective than comparative interventions (visual scanning training) for improving USN among patients with acute stroke. However, note that one high quality RCT found a significant between group difference in favour of eye patching for one measure of USN at follow up.

Family participation
Effective
2b

One quasi-experimental study (Osawa & Maeshima, 2010) examined the effects of family participation on USN in patients with acute stroke. This quasi-experimental study allocated patients with acute stroke and left USN to receive conventional rehabilitation with family participation or conventional rehabilitation alone. There were significant between-group differences in USN (Behavioral Inattention Test- BIT) at post-treatment (3 weeks), favoring family participation compared to the control group.
Note: There was no significant between-group difference reported for a measure of hemispheric dominance (Laterality Index).

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that conventional rehabilitation with family participation is more effective than conventional rehabilitation alone for improving USN in patients with acute stroke.

Limb Activation
Effective
1b

One high quality RCT (Kalra et al., 1997) investigated the impact of a limb activation intervention on USN among patients with acute stroke. This high quality RCT randomly assigned patients with acute stroke and visual neglect to receive spatiomotor cueing based on the ‘attentional motor integration’ model or conventional rehabilitation. At 12 weeks there were significant between-group differences in visual perceptual abilities (Rivermead Perceptual Assessment Battery – Body Image and Cancellation subtests only), in favour of spatiomotor cueing intervention compared to conventional rehabilitation.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that limb activation interventions (spatiomotor cueing) are more effective than conventional rehabilitation for improving USN in patients with acute stroke.

Mirror Therapy
Effective
1b

One high quality RCT (Pandian et al., 2014) investigated the effect of mirror therapy on hemineglect in patients with acute stroke. This high quality RCT randomized patients with acute stroke to an intervention group that received mirror therapy or a control group that performed the same exercises using a nonreflecting mirror. There was a significant between-group difference in USN (Star Cancellation Test, Line Bisection Test, Picture Identification Task) at 1, 3, and 6 months, in favor of mirror therapy compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mirror therapy is more effective than a control intervention for improving USN in patients with acute stroke.

Prism adaptation
Effective
1b

One high quality RCT (Nys et al., 2008) investigated the effect of prism adaptation on USN among patients with acute stroke. This high quality RCT randomized patients with acute stroke to wear prism goggles with 10° rightward deviation or neutral goggles with 0° deviation while performing pointing exercises for 30 minutes/day for 4 consecutive days. At 4 days (post- treatment) there was a significant between-group difference in USN (Schenkenberg Line Bisection Task, BIT Letter Cancellation Task, Scene Copying Task), in favour of prism goggles compared to neutral goggles.
Note: No significant between-group differences were observed on four subscales of the BIT (Star Cancellation, Figure Copying, Representational Drawing, and Line Bisection) at 1-month follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT (Nys et al, 2008) that prisms are more effective than neutral glasses in improving USN in patients with acute stroke, in the short term.

Repetitive Transcranial Magnetic Stimulation (rTMS)
Not effective
1b

One high quality RCT (Kim et al., 2013) investigated the effect of repetitive transcranial magnetic stimulation (rTMS) on USN among patients with acute stroke. This high quality RCT randomly assigned patients with acute stroke and visuospatial neglect to receive low frequency (1Hz) repetitive transcranial magnetic stimulation (rTMS) to the non-affected posterior parietal cortex (PPC), high frequency (10Hz) rTMS to the affected PPC, or sham stimulation. Patients received their respective intervention for 10 sessions over 2 weeks. At post-treatment (2 weeks) there was a significant between-group difference on only one measure of USN (Line Bisection Test), in favour of high frequency rTMS compared to sham stimulation. There were no significant between-group differences on other measures of USN (Motor-Free Visual Perception Test, Star Cancellation Test, Catherine Bergego Scale).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that rTMS is not more effective than sham stimulation for improving USN among patients with acute stroke.
Note
: High frequency rTMS was more effective than sham stimulation on one measure of USN (Line Bisection Test).

Virtual Reality
Effective
2b

One poor quality RCT (Kim et al., 2011) investigated the effect of virtual reality training on USN among patients with acute stroke. This poor quality RCT randomized patients with acute stroke to receive virtual reality (VR) USN training or conventional USN training. Both groups showed a significant improvement in USN (Star Cancellation Test, Line Bisection Test, Catherine Bergego Scale) at 3 weeks (post-treatment); the VR USN group demonstrated significantly greater improvement than the control group on the Star Cancellation Test and Catherine Bergego Scale from baseline to post-treatment.

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that virtual reality training is more effective than conventional rehabilitation for improving USN among patients with acute stroke.

Visual imagery
Not effective
2b

One quasi-experimental study (Niemeier et al., 2001) investigated the effect of visual imagery on USN among patients with stroke. This pre-post repeated measures study assigned patients with acute stroke to receive visual imagery training and conventional rehabilitation or conventional rehabilitation alone. Visual imagery training promoted visual scanning. There were no significant between-group differences in USN (Mesulam Verbal Cancellation Test, Rancho Los Amigos Cognitive and Behavioural Scale) at post-treatment. However, there was a significant between-group difference on the Functional Independence Measure (FIM) for the subscales Walking/Wheelchair Task and Problem-Solving Task as well as for a Route-Finding Task at discharge.
Note: There were no reported differences on the FIM grooming, dressing upper body, dressing lower body, feeding, toileting, safety judgement, attention, bathing, reading or writing subtests.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that visual imagery to promote visual scanning is not more effective than conventional rehabilitation alone for improving USN among patients with acute stroke.

Visual scanning
Not effective
1b

One high quality RCT (Ianes et al., 2012) investigated the effect of visual scanning training on USN among patients with acute stroke. This high quality RCT randomized patients with acute stroke and left USN to receive right half-field patching or visual scanning training over a 15 day period. There were no significant between-group differences in USN (Line Crossing Test, Bells Test, Line Bisection Test) at post-treatment. At one-week follow-up there was a significant between-group difference in Line Crossing Test scores only, in favor of half-field patching compared to visual scanning training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that visual scanning training is not more effective than a comparative intervention (half-field patching) for improving USN among patients with acute stroke.
Note: in fact, half-field patching was more effective than visual scanning training on one measure of USN.

Subacute phase

Computer training
Not effective
2a

One fair quality RCT (Modden et al., 2012) has investigated the effect of computer training on USN among patients with subacute stroke. This fair quality RCT randomly assigned patients with subacute stroke and homonomous hemianopia to receive Restorative Computerized Training (RT), Compensatory Therapy (CT) or conventional occupational therapy (OT) in addition to standard inpatient rehabilitation. Participants in the RT group were required to respond to stimuli as they appeared on the computer screen, and eye movements were not permitted. Participants in the CT group performed an ‘exploration task’ that promoted visual exploration in the hemianopic field. At post-treatment (3 weeks) there were no significant between-group differences on measures of USN (Test of Attentional Performance (TAP) Visual Field Test, Phasic Alertness and visual scanning tests; Behavioral Inattention Test (BIT) Line Cancellation, Star Cancellation and Letter Cancellation Tasks; Weschler Memory Test standardized reading texts).

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that computer training is not more effective than conventional occupational therapy for improving USN among patients with subacute stroke.
Note: Results from one fair quality RCT also indicate no significant difference in efficacy between two types of computer training.

Limb activation
Insufficient evidence
5

No known RCTs have investigated the effect of limb activation interventions on USN among patients with subacute stroke. One non-randomized study (Bailey et al., 2002) is reviewed. This non-randomized study assigned 2 patients with subacute stroke and USN to perform contralesional limb activation training using functional, goal-oriented upper limb activities in the neglected hemispace, for ten 1-hour sessions conducted over approximately 3 weeks. Both patients demonstrated a significant improvement on one or more tests of USN (measured using the BIT Star Cancellation Test, Line Bisection Test and the Baking Tray Task) at post-treatment, and maintained results at follow-up (approximately three weeks later).

Conclusion: There is insufficient evidence (level 5) regarding the effect of limb activation interventions on USN among patients with subacute stroke. However, one non-randomized study reported improvement on one or more tests of USN following limb activation interventions.

Mirror Therapy
Effective
1b

One high quality RCT (Dohle et al., 2009) investigated the effect of mirror therapy on USN in patients with stroke. This high quality RCT randomized patients with subacute stroke to a mirror therapy group that performed upper limb exercises while watching the unaffected limb in a mirror, or a control group that performed the same exercises while watching the affected limb. There was a significant between-group difference in hemineglect (measured using a 5-point rating scale derived from the Behavioural Inattention Test and the Test of Attentional Performance), in favour of the mirror therapy group compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mirror therapy is more effective than a control therapy in improving USN in patients with subacute stroke.

Neck/Hand Vibration
Effective
2b

One quasi-experimental study (Kamada et al.,2011) has investigated the effect of neck/hand vibration on USN among patients with subacute stroke. This multiple-baselines study assigned patients with subacute stroke and USN to receive neck-muscle vibration before occupational therapy (OT) in an A1-B-A2 format. Neck vibration treatment (session B) consisted of left posterior neck muscle vibration for 5 minutes using a handheld vibrator; and conventional OT (sessions A1 and A2) consisted of ADLs, vocational, perceptual and functional activities. Significant improvements in USN (BIT conventional and behavioral scores) were noted compared to baseline after sessions B and A2.
Note: Significant improvements in USN (not compared to baseline) were noted after session B (BIT conventional and behavioral scores) and after sessions A2 (BIT behavioral scores).

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that the use of neck vibration stimulation with conventional occupational therapy may improve USN symptoms in patients with subacute stroke shortly following treatment.

Optokinetic stimulation
Effective
1a

One high quality RCT (Kerkhoff et al., 2012) investigated the effect of optokinetic stimulation on USN among patients with subacute stroke. This high quality RCT randomly assigned patients with subacute stroke and left visual neglect and left auditory neglect to receive optokinetic stimulation (OKS) or conventional visual scanning training. At post-treatment (4 weeks) there was a significant between-group difference in visual neglect (horizontal line bisection task, number cancellation task, reading task), in favour of OKS compared to visual scanning training. Between-group differences did not remain significant at follow-up (2 months later).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that optokinetic stimulation is more effective than a comparison intervention (conventional visual scanning training) for improving USN among patients with subacute stroke, in the short term.

Prism Adaptation
Not effective
1a

Two high quality RCTs (Turton et al., 2010; Mizuno et al., 2011), one fair quality RCT (Rossi et al., 1990) and a single subject repeated measures study (Pisella et al., 2002) have investigated the effect of prism adaptation interventions on USN among patients with subacute stroke.

The first high quality RCT (Turton et al., 2010) randomized patients with subacute stroke and left USN to receive prism adaptation training using prismatic lenses of 6° or sham treatment using neutral glasses. There were no significant between-group differences in USN (BIT) at post treatment (2 weeks) or follow-up (8 weeks).

The second high quality RCT (Mizuno et al., 2011) randomized patients with subacute stroke and left USN to a prism adaptation group or a control group that wore neutral glasses. Prism glasses shifted the visual field 12 degrees to the right. Patients were also grouped according to mild or severe USN. There were no significant between-group differences in USN (Catherine Bergego Scale, BIT-B, BIT-C) at post-treatment (2 weeks) or on discharge from hospital.

The fair-quality RCT (Rossi et al., 1990) randomly assigned patients with subacute stroke and homonymous hemianopia or unilateral visual neglect to an intervention group that received treatment using Fresnel prisms or a control group that received no additional treatment. Fresnel prisms were 15-diopter plastic press-on prisms that were worn during all daytime activities. There were significant between-group differences in measures of USN (Motor Free Visual Perception Test, Line Bisection Task, Line Cancellation Task, Harrington Flocks Visual Field Screener, Tangent Screen Examination) at 4 weeks, in favour of the intervention group compared to the control group.

A single subject repeated measures study (Pisella et al., 2002) assigned two patients with subacute stroke and USN to receive one session of prism adaptation treatment. One patient demonstrated improved USN (Line Bisection Test) at post-treatment, and sustained improvements up to 4 days post-treatment.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that prisms are not more effective than neutral glasses in improving USN symptoms in patients with subacute stroke. However, one fair quality RCT noted an improvement in USN using Fresnel prisms and a single subject repeated measures study noted improvement in USN for one patient following prism adaptation treatment.

Transcranial Magnetic Stimulation - Theta-burst Stimulation (TBS)
Effective
1a

Two high quality RCTs (Cazzoli et al., 2012; Koch et al., 2012) examined the effects of theta-burst stimulation (TBS) transcranial magnetic stimulation (TMS) over the left posterior parietal cortex on unilateral spatial neglect (USN) symptoms in patients with subacute stroke and left USN.

The first high quality RCT (Cazzoli et al., 2012) randomly assigned patients with subacute stroke and left spatial neglect to receive continuous theta burst stimulation followed by sham stimulation (TBS1), sham stimulation followed by continuous theta burst stimulation (TBS2), or no stimulation (control). There were significant between-group differences in USN (Catherine Bergego Scale, Vienna Test System, Random Shape Cancellation Test, Two-Part Picture Test) between groups that received cTBS and the group that received no stimulation immediately following stimulation and at follow-up (1-2 weeks later).
Note: There were no differences between groups on another measure of USN (Munich Reading Texts) at either time point. This study did not compare cTBS and sham stimulation.

The second high quality RCT (Koch et al., 2012) randomized patients to receive real continuous (cTBS) or sham TBS over the left posterior parietal cortex in addition to conventional therapy. There was a significant between-group difference in USN symptoms (Behavioral Inattention Test) at post-treatment (2 weeks) and at follow-up (4 weeks) in favour of real cTBS compared to sham TBS.

Conclusion: There is strong evidence (level 1a) from two high-quality RCTs that theta-burst stimulation over the left posterior parietal cortex is more effective than comparison interventions (no stimulation, sham stimulation) for improving USN symptoms on the left visual field in patients with subacute stroke and USN.

Virtual Reality
Not effective
2b

No RCTs have investigated the use of virtual reality in the management of USN among patients with subacute stroke. A quasi-experimental study (Katz et al., 2005) is reviewed. This quasi-experimental study allocated patients with subacute stroke to received computer-based virtual reality street crossing USN training or computer-based visual scanning USN training. There were no significant between-group differences in USN measures (BIT Star Cancellation Test, Mesulam Symbol Cancellation Test) at 4 weeks (post-treatment).
Note: At post-treatment the control group demonstrated a significant improvement in BIT Star Cancellation Test scores, whereas no significant improvement was seen in the VR group. Both groups demonstrated a significant improvement in scores on the Mesulam Symbol Cancellation Test at post-treatment.

Conclusion: There is limited evidence (level 2b) that virtual reality is not more effective than comparison interventions (computer-based visual scanning training) for improving USN among patients with subacute stroke.
Note: The virtual reality treatment group presented with more severe USN at baseline than the computer-based visual scanning group, which might have contributed to the lack of significant between-group findings at post-treatment.

Visual scanning
Conflicting evidence
4

Two high quality RCTs (Fanthome et al., 1995; Kerkhoff et al., 2012), three fair quality RCTs (Weinberg et al., 1977, Weinberg et al., 1979, Antonucci et al., 1995), one poor quality RCT(Paolucci et al., 1996) and one non-randomized study (Bailey et al., 2002) have investigated the effect of visual scanning training on USN among patients with subacute stroke.

The first high quality RCT (Fanthome et al., 1995) randomly assigned patients with subacute stroke and USN to receive auditory feedback of eye movements or no treatment for visual inattention. The intervention group were required to wear glasses that provided an auditory reminder beep if the patient failed to move their eyes to the left in a 15 second interval. There were no significant between-group differences in eye movements or USN (measured using the Behavioural Inattention Test) at post-treatment (4 weeks) or follow-up (8 weeks).

The second high quality RCT (Kerkhoff et al., 2012) randomly assigned patients with subacute stroke and left visual neglect and left auditory neglect to receive visual scanning training or optokinetic stimulation. At post-treatment (4 weeks) there was a significant between-group difference in visual neglect (Horizontal Line Bisection Task, Number Cancellation Task, Reading Task), in favour of optokinetic stimulation compared to visual scanning training. Between-group differences did not remain significant at follow-up (2 months later).

The first fair quality RCT (Weinberg et al., 1977) randomly assigned patients with subacute stroke and left USN to receive visual scanning training or conventional therapy. There were significant between-group differences in improvements on a comprehensive neuropsychological battery (including the Wide Range Reading Achievement Test, Paragraph Reading, Wide Range Arithmetic, Single Letter Cancellation Test, Double Letter Cancellation Test) at post-treatment (4 weeks), in favour of visual scanning training compared to conventional therapy

The second fair quality RCT (Weinberg et al., 1979) randomly assigned patients with subacute stroke and left USN to receive visual scanning training with spatial and sensory awareness or conventional therapy. There were significant between-group differences in improvements on a comprehensive neuropsychological battery (including the Wide Range Reading Achievement Test, Paragraph Reading, Wide Range Arithmetic, Single Letter Cancellation Test, Double Letter Cancellation Test) at post-treatment (4 weeks), in favour of visual scanning training compared to conventional therapy.
Note: Further analysis revealed that participants in the experimental group with severe impairments had significantly greater improvements following treatment as compared to those with mild impairments.

The third fair quality RCT (Antonucci et al., 1995) randomized patients with subacute stroke to receive immediate or delayed specific neglect training that included visual scanning, reading and copying, drawing and figure description tasks. There were significant within-group improvements in neglect (measured by the Letter Cancellation test, Albert’s Barrage Test, Sentence Reading Test, Wundt-Jastrow Area Illusion Test and Functional Neglect Scale) following specific neglect training.
Note: The study did not report between-group differences. The delayed training group received nonspecific cognitive training while waiting for specific training; no significant improvements in measures of neglect were reported following nonspecific cognitive training.

The poor quality cross-over study (Paolucci et al., 1996) randomly assigned patients with subacute stroke and left USN to receive immediate specific neglect training (visual scanning exercises, reading and copying tasks, copying line drawings and description of scene tasks) or delayed specific neglect training, during which time participants received general cognitive training. There was a significant between-group difference in measures of USN (Letter Cancellation Test, Wundt-Jastrow Area Illusion Test and the Sentence Reading Test) at 8 weeks (post-treatment 1), in favour of the group that received immediate specific neglect training compared to those who received general cognitive training. At 16 weeks (post-treatment 2), by which time the second group had also received specific neglect training, there were no longer any significant between-group differences in USN.
Note: However, there were no significant between-group differences in a fourth measure of USN (Barrage Test) at both measurement times.

A non-randomized study (Bailey et al., 2002) assigned 5 patients with subacute stroke and USN to perform scanning and cueing training during reading and copying tasks and games. Three of the five patients demonstrated a significant improvement on one or more tests of USN (measured using the BIT Star Cancellation Test, the Line Bisection Test and the Baking Tray Task) at post-treatment (3 weeks), and maintained results at follow-up (approximately three weeks later).

Conclusion: There is conflicting evidence (level 4) regarding the effect of visual scanning training on USN among patients with subacute stroke. Differences in the type and duration of visual scanning training, comparison treatments, and USN measures used, are likely to account for discrepancies among studies.

Visual scanning with trunk rotation
Effective
2a

One fair quality RCT (Wiart et al., 1997) examined the use of trunk rotation to encourage visual scanning of the neglected hemispace in patients with subacute stroke and USN. This fair quality RCT randomized patients with subacute stroke and USN to receive visual scanning training with voluntary trunk rotation using the Bon Saint Come method or conventional neurorehabilitation. There were significant between-group differences in improvements on measures of USN (Line Bisection Test, Line Cancellation Test, Bell Test) at post-treatment (day 30) and follow-up (day 60), in favour of the experimental group compared to the control group.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that visual scanning training using trunk rotation is more effective than conventional rehabilitation for improving USN among patients with subacute stroke.

Chronic phase

Virtual Reality
Effective
2b

Two non-randomised studies (Webster et al., 2001; Sedda et al., 2013) have investigated the effect of virtual reality on USN among patients with chronic stroke.

A quasi-experimental study (Webster et al., 2001) allocated patients with chronic stroke to receive virtual reality (VR) USN training focusing on wheelchair navigation/obstacle avoidance course tasks or conventional USN intervention. Significant between-group differences were found on all measures of USN (number of errors in real and virtual wheelchair obstacle crossing tasks, fall reports during hospitalization, obstacle hits on a video obstacle course task) at post-treatment, in favour of VR USN training compared to conventional USN intervention.

A pre-post single design study (Sedda et al., 2013) assigned one patient with chronic stroke and left USN to receive VR training using the Sony PS3 “EyeToy” to grasp virtual objects among distractors using the unaffected hand. Significant* improvements on measures of USN (Line Bisection Test, Albert’s Cancellation Test) at post-treatment (4 weeks) and gains were maintained at follow-up (5 months).
*Note: Statistical data was not provided.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that virtual reality USN training is more effective than conventional USN intervention for improving USN among patients with chronic stroke. Also, a pre-post single design study noted improvements on USN measures after a VR training.

Visual scanning
Insufficient evidence
5

One non-randomized study (Ladavas et al., 1994) has examined the effect of visual scanning intervention on USN among patients with chronic stroke. This non-randomized study assigned patients with chronic stroke and left USN to receive covert computerized visual scanning and attention training, overt computerized visual scanning and attention training, or no computerized visual scanning and attention training. Both training groups demonstrated significant improvements in measures of USN (Letter Cancellation Test, Line Cancellation Test, Bells Test, Object Pointing Task) and a non-standardized measure of visual extinction and neglect at post-treatment (6 weeks).
Note: Improvements in detecting targets were specific to the left space; there was no significant improvement in a test of tactile extinction and neglect within any group at post-treatment.

Conclusion: There is insufficient evidence (level 5) regarding the effect visual scanning on USN among patients with chronic stroke. However, a non-randomized study reported significant improvements in measures of USN after computerized visual scanning and attention training.

Phase of stroke recovery not specific to one period

Eye patching
Effective
2b

One poor quality RCT (Zeloni et al., 2002) has investigated the effect of eye patching on USN among patients with stroke (time since stroke not specific to one period). This poor quality RCT randomized patients with subacute or chronic stroke and left USN to receive hemiblinding using goggles or no hemiblinding. A significant between group difference was found in favour of the goggles group for the Albert’s Test at at 1 week (post-treatment) or 2 weeks (follow-up). However, there were no significant between-group differences in other measures of USN (Line Cancellation Test, Letter Cancellation Test, Bell’s Test, Copying A Drawing, Line Bisection Test) at both measurement times.

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that eye patching is more effective than a control intervention (no eye patching) for improving USN among patients with stroke.

Limb activation
Conflicting evidence
4

Two high quality RCTs (Robertson et al., 2002; Luukkainen-Markkula et al., 2009) and one fair quality RCT (Harvey et al., 2003) investigated the effect of limb activation exercises on USN among patients with stroke (time since stroke not specific).

The first high quality RCT (Robertson et al., 2002) randomised patients with subacute to chronic stroke and left unilateral visual neglect to receive perceptual training + limb activation treatment or perceptual training alone. There were no significant between-group differences in unilateral neglect (Behavioural Inattention Test – BIT, Comb and Razor Test, Landmark Test) at 12 weeks (post-treatment) or at 3 months, 6 months or 18-24 months (follow-up).

The second high quality RCT (Luukkainen-Markkula et al., 2009) randomly assigned patients with acute or subacute stroke and left hemispatial neglect to receive left arm activation therapy or visual scanning training, in addition to conventional rehabilitation. The arm activation therapy group demonstrated significant improvements in visual neglect (BIT conventional subtest) at 3 weeks (post-treatment) and 6 months later (follow-up). There was no significant improvement in behavioural neglect (Catherine Bergego Scale) at either time point.
Note: Between-group differences were not reported.

The fair quality RCT (Harvey et al., 2003) pseudorandomly assigned patients with subacute or chonic stroke and USN to an intervention group that performed centre-lifting rod exercises or a control group that performed right-lifting rod exercises. There was a significant between-group difference in one measure of USN (Landmark Test) at 3 days (post-treatment stage 1), in favour of the intervention group compared to the control group. There were no significant between-group differences in other measures of USN (Line Bisection Test, Real Objects Test, BIT, Balloons Test) at 10 days (post-treatment stage 2) or 1 month (follow-up).

Conclusion: There is conflicting evidence (level 4) from 2 high quality RCTs and one fair quality RCT regarding the effect of limb activation on USN. A first, high quality RCT found no significant between-group differences on USN when comparing a perceptual training + limb activation treatment and perceptual training alone. On the other hand, a second high quality RCT found significant improvements in USN after an arm activation therapy group as compared to a visual scanning training. Finally, a fair quality RCT noted a significant improvement in one measure of USN post-treatment but not on the other three measures at post-treatment and follow up.

Mental practice
Not effective
2a

One fair quality RCT (Ferreira et al., 2011) investigated the effect of mental practice on USN among patients with stroke (time since stroke not specific to one period). This fair quality RCT randomly assigned patients with subacute or chronic stroke and left hemispatial neglect to receive mental practice training, visual scanning training, or physiotherapy alone (control). There were no significant differences in neglect (BIT conventional scores) between mental practice and visual scanning, or between mental practice and the control group, at post-treatment (5 weeks) or follow-up (3 months later).

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that mental practice is not more effective than comparison interventions (visual scanning training, conventional rehabilitation) for improving USN among patients with subacute or chronic stroke.

Optokinetic stimulation
Conflicting evidence
4

One fair quality RCT (Schroder et al., 2008) and one poor quality RCT (Pizzamiglio et al., 2004) examined the use of optokinetic stimulation in patients with stroke and USN (time since stroke not specific).

The fair quality RCT (Schroder et al., 2008) randomly assigned patients with acute to subacute stroke and left neglect to receive optokinetic stimulation + exploration (scanning) training, TENS + exploration training, or exploration training alone. There were significant between-group differences in neglect (measured using the NET Line Cancellation, Star Cancellation, Line Bisection, Figure Copying and Freehand Drawing Subtests and the Test of Attentional Performance (TAP) Neglect Subtest) and reading and writing skills (measured using reading test A from the ELEX manual and a writing dictation task) after 10 sessions (mid-treatment), 20 sessions (post-treatment) and 1 week post-treatment (follow-up), in favour of optokinetic stimulation + exploration training compared to exploration training alone. There were no significant differences between optokinetic stimulation + exploration training or TENS + exploration training at any time point.

The poor quality RCT (Pizzamiglio et al., 2004) randomized patients with subacute or chronic stroke to receive specific USN training and optokinetic stimulation (a leftward-moving background of black dots on a computer screen) or specific USN training alone. At post-treatment (6 weeks) there were no significant between-group differences in measures of USN (Albert’s Test, Letter Cancellation Test, Reading Task, Wundt-Jastrow Area Illusion Test, BIT Line Cancellation Test), the functional impact of USN (Semi-structured Scale for the Functional Evaluation of Personal Neglect, Semi-structured Scale for the Functional Evaluation of Extrapersonal Neglect), or functional independence (Barthel Index).

Conclusion: There is conflicting evidence (level 4) between studies regarding the effectiveness of optokinetic stimulation on neglect among patients with stroke. Discrepancies in results arise from differences in control treatments and stage of stroke of study participants.

Prism adaptation
Effective
1b

One high quality RCT (Serino et al., 2009), two fair quality RCTs (Rossetti et al., 1998; Mancuso et al., 2012) and one non-randomized study (Frassinetti et al., 2002) investigated the effect of prism adaptation on USN among patients with stroke (time since stroke not specific to one period).

The high quality RCT (Serino et al., 2009) pseudorandomized patients with acute to chronic stroke and left USN to an intervention group that performed scanning treatment wearing prismatic goggles deviating the visual field 10 degrees to the right, or a control group that performed scanning treatment with neutral goggles. At post-treatment (2 weeks) there was a significant between-group difference* on measures of USN (BIT, BIT Star and Letter Cancellation subtests, Bell Cancellation Test, Reading Test), in favour of prismatic goggles compared to neutral goggles. At the end of treatment the control group also received 2 weeks of prismatic adaptation training. This group demonstrated significant improvement on measures of USN (BIT, Cancellation Tests, Reading Task). At follow-up (1 month post-treatment), both groups demonstrated significant improvements compared to baseline (but not compared to post-treatment) on measures of USN (BIT, Cancellation Tests, Reading Task). There were no significant between-group differences at follow-up.
*differences reflect change in scores from baseline to post-treatment.

The first fair quality RCT (Rossetti et al., 1998) randomized patients with acute to chronic stroke and left hemispatial neglect to an intervention group that received prism adaptation training using goggles with wedge prisms with 10-degree optical deviation to the right or a control group that wore neutral goggles. Immediately post-treatment (5 minutes) and at follow-up (2 hours later), there were significant between-group differences on all measures of USN (Line Bisection Task, Line Cancellation Task, Copying A Drawing, Drawing From Memory, Reading Simple Text) in favour of the prism adaptation training group.

The second fair quality RCT (Mancuso et al., 2012) randomized patients with subacute or chronic stroke and left USN to an intervention group that performed pointing exercises wearing prismatic lenses deviating the visual field 5 degrees to the right or a control group that performed pointing exercises with neutral lenses. There were no significant between-group differences on measures of USN (Albert Test, Bells Cancellation Test, Line Orientation Test, and four BIT subtests: line bisection, copying drawings, finding objects, dealing playing cards) at post-treatment (1 week).

A non-randomized study (Frassinetti et al., 2002) provided patients with subacute or chronic stroke and left USN with prism adaptation training during pointing tasks. Participants demonstrated significant improvements on measures of USN (BIT, Bell’s Test, Reading Test, Objects Reaching Test and Room Description Test) at post-treatment (2 days) and follow-up (1 week post-treatment, 5 weeks post-treatment).
Note: there was no significant improvement in performance on a modified version of the Fluff Test at any time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT one fair quality RCTs and one non randomized study that training with prism adaptation is more effective than control interventions (neutral glasses) for improving USN among patients with stroke . However, another fair quality RCT did not find any significant difference on USN after wearing prismatic lenses while performing pointing exercises.

Sensory cueing
Not effective
1b

One high quality RCT (Fong et al., 2013) has investigated the use of sensory cueing in the treatment of USN among patients with stroke (time since stroke not specific to one period). This high quality RCT randomly assigned patients with acute or subacute stroke and left USN to receive contralesional sensory cueing and limb activation or sham cueing. There was a significant between-group difference in one measure of USN (BIT Drawing Tasks) overall (i.e. from measures taken at post-treatment and follow-up), in favour of the intervention group compared to the control group. There were no significant between-group differences in other measures of USN (BIT Cancellation Tasks) at post-treatment (3 weeks) or follow-up (6 weeks).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that sensory cueing and limb activation training is not more effective than a control intervention (sham cueing) for improving USN among patients with stroke.
Note
: Significant between-group differences were found on one measure of USN.

Sensory stimulation
Effective
1b

One high quality RCT (Polanowska et al., 2009) investigated the effect of sensory stimulation to the affected arm on USN among patients with stroke (time since stroke not specific to one period). This high quality RCT randomised patients with acute to subacute stroke and left visual hemineglect to receive visual scanning training with somatosensory electrical stimulation or visual scanning training with sham stimulation. Stimulation comprised 30 minutes of transcutaneous electrical stimulation to the left hand in the experimental group and sham (no current) stimulation in the control group. At post-treatment (4 weeks) there was a significant between-group difference in scanning accuracy and scanning range (measured using the BIT Line Crossing and Star Cancellation Tests and a Letter Reading Task), in favour of electrical stimulation compared to sham stimulation.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that somatosensory electrical stimulation is more effective than sham stimulation for improving USN among patients with acute/subacute stroke.

Transcutaneous Electrical Nerve Stimulation (TENS)
Effective
2a

One fair quality RCT (Schroder et al., 2008) investigated the effect of TENS on neglect among patients with stroke (time since stroke not specific to one period). This fair quality RCT randomly assigned patients with acute to subacute stroke and left neglect to receive TENS + exploration (scanning) training, optokinetic stimulation + exploration training, or exploration training alone. Compared to the control group, the TENS group demonstrated significantly better improvement in neglect (measured using the NET Line Cancellation, Star Cancellation, Line Bisection, Figure Copying and Freehand Drawing subtests and the Test of Attentional Performance (TAP) neglect subtest) after 20 sessions (post-treatment), and in reading/writing (measured using reading test A from the ELEX manual and a writing dictation task) at 10 sessions (mid-treatment), 20 sessions (post-treatment) and 1 week post-treatment (follow-up). There were no significant differences between TENS + exploration training or optokinetic stimulation + exploration training at any time point.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that TENS + exploration (scanning) training is more effective than conventional scanning training for improving neglect among patients with acute to subacute stroke.

Virtual Reality
Not effective
2b

One poor quality RCT (van Kessel et al., 2013) investigated the effect of virtual reality on USN among patients with stroke (time since stroke not specific to one period). This poor quality RCT semi-randomized patients with subacute or chronic stroke and left USN to receive dual task virtual reality (VR) training (driving simulation and response to visual scanning task) or single task VR training. There were no significant between-group differences in USN measure (Line Cancellation Test, Letter Cancellation Test, Bells Test, Line Bisection Test, Word Reading task, Grey Scales, Baking Tray Task, Semi-Structured Scale for the Evaluation of Extrapersonal and Personal Neglect, Subjective Neglect Questionnaire) at post-treatment (6 weeks).

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that dual task VR training is not more effective than single task VR training for improving USN among patients with stroke.

Visual scanning
Not effective
1a

Two high quality RCTs (Roberston et al., 1990; Luukkainen-Markkula et al., 2009) and one fair quality RCT (Ferreira et al., 2011) examined the effect of visual scanning on USN among patients with stroke (time since stroke not specific).

The first high quality RCT (Robertson et al., 1990) randomly assigned patients with acquired head injury (n=33 subacute/chronic stroke) and left USN to receive computerized scanning and attentional training or recreational computing. There were no significant between-group differences on measures of USN (BIT, Rey-Osterreith Complex Figure Copy Test, Neale Reading Test Accuracy Score, Letter Cancellation Test, WAIS-R Block Design Subtest, an observer’s report of neglect) at post-treatment (approximately 9 weeks) or follow-up (6 months later). There was a significant between-group difference on one measure of USN (WAIS-R Picture Completion Subtest) at post-treatment but this was not maintained at follow-up.

The second high quality RCT (Luukkainen-Markkula et al., 2009) randomly assigned patients with acute or subacute stroke and left hemispatial neglect to receive left arm activation therapy or visual scanning training, in addition to conventional rehabilitation. The visual scanning group demonstrated no significant improvement in visual neglect (BIT conventional scores) at 3 weeks (post-treatment), but improvements were significant 6 months later (follow-up). There was no significant improvement in behavioural neglect (Catherine Bergego Scale) at either time point.
Note: Between-group differences were not reported.

The fair quality RCT (Ferreira et al., 2011) randomly assigned patients with subacute or chronic stroke and left hemispatial neglect to receive visual scanning training, mental practice training, or physiotherapy alone (control). There were significant between-group differences in neglect (BIT conventional scores) at post-treatment (5 weeks), in favour of visual scanning training compared to the control group. Differences did not remain significant at follow-up (3 months later). There were no significant differences in neglect between visual scanning training and mental practice training at either time point.

Conclusion: There is moderate evidence (level 1a) from two high quality RCTs that visual scanning is not more effective than a control intervention (recreational computing or conventional rehabilitation) for improving USN among patients with stroke . However, one fair quality RCT noted improvements in neglect at post-treatment but that difference did not remain significant at follow up.

Clinician How-To

USN e-learning module

Please visit our USN e-learning module: http://elearning.strokengine.org/module.php

What is USN?

Unilateral spatial neglect (USN) is most typically characterized by the inability to orient or respond to stimuli appearing on the contralateral side/hemispace of the brain lesion1. Terms including unilateral neglect, hemi-inattention, visual neglect and hemi-spatial neglect are used to describe USN. Over 30% of patients will have post-stroke USN2. USN is more frequent in those with a right hemisphere stroke, such that symptoms of USN commonly appear on the left hemispace. Research has shown that damage to the following brain areas leads to USN: right parieto-temporal junction3, the angular gyrus, the right inferior parietal lobe, the parahippocampal region4 and the right superior temporal cortex5. Depending on the brain area affected, there are three different types of USN and patients can have one or a combination of the three types with varying degrees of severity1:

Personal neglect: Neglect of one side of his/her body (e.g. patients shave/apply makeup to half of their face, usually the left half); acquired from damage to the parietal lobe (post-central and supramarginal gyri)6;

Near extrapersonal neglect: Neglect of the environment within reaching distance (e.g. patients ignore food on one side of the plate, usually the left half);

Far extrapersonal neglect: Neglect of the space beyond reaching distance (e.g. patients collide into their surroundings, usually the left, when trying to wheel a wheelchair).

*Extrapersonal neglect arises from damage to the frontal lobe (ventral premotor and dorsolateral prefrontal cortex) and the temporal lobe (middle and anterior superior temporal gyrus, and the superior temporal sulcus)6

Why is it critical to assess for USN?

Patients with USN are at an increased risk for falls and related injuries, usually have longer rehabilitation stays as well as poorer functional recovery post-stroke1. Given that USN can result in falls and lack of independence in daily activities, and that it is treatable, all patients must be quickly screen or assessed for USN during the acute phase post-stroke. Patients identified with the presence of USN must receive effective interventions aimed at reducing impairment and maximizing function.

Who should be assessed?

Perceptual deficits, including USN, are more common in individuals with right hemisphere lesions (RHD). Thus, routine screening for USN in those with RHD is very important. Research has shown that the left hemisphere modulates arousal and attention for the right visual field, whereas the right hemisphere controls these processes in both right and left visual fields. This may be a partial explanation for why USN is not typical in persons with left hemisphere damage (LHD); the intact right hemisphere is capable of compensating for perceptual deficits that result from LHD7. It also substantiates why individuals with RHD experience more severe and longer lasting symptoms of USN compared to those with LHD. The Opponent–processor model argues that each hemisphere attends to the contralateral visual hemispace by inhibiting the other hemisphere. It goes on to propose that with a right hemisphere lesion the left hemisphere is not inhibited, and this results in exaggerated attentional shift to the right (i.e. left USN)3. USN continues to be commonly associated with a right stroke, but evidence from the literature suggests that all patients with stroke might benefit from USN screening.

Can USN be treated?

Yes, below is an overview of four different types of treatment categories that exist for USN8:

  1. Visual Scanning: The patient with USN is encouraged to explore the neglected visual field (usually the left side) by performing tasks on that side. The treatment often includes a visual target that the patient uses as an anchor while scanning.
  2. Sensory Stimulation: The therapist uses various types of sensory stimulation to encourage the patient to pay attention to their neglected side. These include:
    • Visual/Verbal/Auditory Cues: The use of a visual cue (i.e. red tape or flashing lights), verbal cue (i.e. the voice of the therapist or a family member) or auditory cue (i.e. horn or bell) on the neglected side to improve awareness of that space.
    • Limb Activation: The patient actively moves their arm/hand on the neglected side to encourage scanning of that space (usually the left upper extremity towards the left). The patient receiving treatment can do these movements alone or with help from the therapist.
    • Caloric Stimulation: The therapist uses a syringe to put either cold or warm water into the patient’s ear (external ear canal) to encourage scanning of the neglected side. Cold water seems to encourage scanning toward the stimulated ear. Warm water encourages scanning of the field opposite to the stimulated ear.
    • Eye Patching/Hemiglasses: This treatment uses standard eyeglass frames with either monocular patches (entire eye) or half of both lenses blacked out on the same side (usually the right half). This forces the patient to look through the side of the lens and scan the neglected side (usually the left side).
    • Fresnel Prisms: This treatment involves placing prisms over regular eyeglass frames which cause a shift of the visual field. If there is neglect on the left side, these prisms will cause what is seen on the left to be shifted to the right to encourage visual scanning of the left visual field.
    • Neck/Hand Vibration or Stimulation: Vibration or stimulation is applied to the side of the neck or hand affected by USN to encourage scanning of the neglected side.
    • Trunk Rotation: This strategy involves twisting the trunk toward the neglected side in order to improve visual scanning and awareness of that hemispace.
    • Visuo-motor Imagery: Visual imagery involves mental tasks where the patient is required to describe details of a familiar room, environment, or geographic area from their memory. Motor imagery consists of the patient imagining a body movement or posture and describing this sequence. This type of imagery treatment may stimulate areas of the brain that can activate those actual movements during daily activities in order to improve neglect symptoms.
    • Constraint-Induced Movement Therapy: This treatment involves restraining the unaffected arm with a sling in order to encourage use of the affected arm. While used primarily to encourage motor return in the affected arm, this intervention will also encourage visual scanning of the patient’s neglected side.
    • Optokinetic Stimulation: This involves observation of moving visual targets from left to right, in order to encourage visual scanning of the neglected side
  3. Video Feedback: This treatment involves filming the patient while he/she does specific activities. The therapist and patient then watch the video together. The therapist points out to the client how they are neglecting their body or the space on the side of their body. They then discuss strategies to encourage the patient to attend to their body and their neglected hemispace.
  4. Pharmacological Therapy: This involves the use of specific medications (dopamine-agonist drugs) to improve visual attention skills. A physician must prescribe these medications.

Which types of treatments are most effective for post-stroke USN?

The benefits of various interventions to treat post-stroke USN symptoms have been carefully studied9.

Treatment type
Effective (Yes/No)
Level of Evidence
Prisms
Yes
Strong (1a)
Eye patching
Yes
Limited (2a)
Trunk rotation
Yes
Limited (2a)
Limb activation
Yes
Limited (2a)
Visual-motor imagery
Yes
Limited (2b)
Neck/Hand Vibration
Yes
Consensus (3)
Caloric Stimulation
Yes
Consensus (3)
Visual scanning
Unsure
Conflict (4)
Verbal/Visual/Auditory Cues
No
Limited (2a)
Optokinetic Stimulation
No
Limited (2a)
The other treatments methods described in the section above such as constraint-induced movement therapy, video feedback and pharmacological therapy require further research before their effectiveness can be confirmed.

How are these USN treatments administered?

Fresnel Prisms:
To administer fresnel prism therapy, the patient must wear the prisms (deviates their visual field 10º to the right) on their glasses or on goggles. Next, the therapist must engage the patient in a visual scanning task where they repetitively point or reach for two different targets located at each side of their field of vision. According to the studies, the intensity of repetitions varied from 30 to 100 per treatment. The frequency of treatment also varied from 5 sessions of 10 minutes over 2 weeks, to two 20 minute treatments per day for 2 weeks or 30 minutes of scanning performed daily, 5 times per week for 2 weeks 10-13.
Eye Patching:
To administer eye patching treatment, the therapist must apply right half patches to both lenses of the patient’s glasses or on goggles for those who do not wear glasses. Patients should wear the glasses/goggles during their waking hours and while doing all tasks. Duration of the eye patching treatment varied from 1 week to 3 months with improved results according to the length of time worn 14-15.
Trunk Rotation:
Trunk rotation treatments require the use of a thoracolumbosacral orthosis (e.g. Bon Saint Come’s device) to which a metal bar is attached. The bar is designed to project forward horizontally just above the patients head. The therapist then sets up some visual targets on the patient’s neglected side and asks the patient to repetitively rotate their body towards the target and touch it with the metal bar. This encourages visual scanning of the neglected area. The movements can be performed in a seated or standing position. In the study of the effectiveness of this intervention, patients received 1 hour of trunk rotation per day, every week day for 1 month (total of 20 hours) 16.
Visual/Motor Imagery:
In visual imagery, the therapist guides the patient to mentally visualize scenes that encourage scanning of all areas including the neglected side. For example, the patient imagines that they are a lighthouse and their eyes are the sweeping light at the top scanning the surrounding area. Or, the patient describes a specific room or geographical area. For the motor imagery tasks, the patient is asked to imagine specific postures which they later have to reproduce, as well as specific sequences of movements that would involve the right arm followed by the left arm. Treatment intensities and frequencies ranged from three 30-minute sessions per week for an average of 3 weeks to 40 trials of 50 minute sessions 17-18.
 
Limb Activation:
For limb activation, the therapist instructs the patient to actively move their upper extremity on the neglected side. The therapist can provide verbal or physical cues to guide the patient during this task. The goal is to use active voluntary movements of the upper extremity to promote scanning of the neglected hemispace. For example, the patient can repetitively lift a rod on the left side or displace cones from the right to the left side. Recommended frequency of limb activation therapy is 1 hour per day, for 10 days over a 2-week period 19-20.
 
Visual Scanning:
Visual scanning treatment involves a wide range of activities that encourage the patient to attend to their neglected side. Therapists can engage patients in reading, copying, describing figures or scenes, computer tasks (finding digits on the screen) etc. All of the studies agreed upon an intensity and frequency of 1 hour of treatment per day on a daily basis (5 days per week). However, duration varied from 2, 4 or 8 weeks of treatments 21-25. Positive effects of the visual scanning treatments did not increase according to the duration of treatments.

When is the best time to receive treatments for USN?

USN interventions can be provided during the acute, sub-acute, and chronic stages post-stroke.

What type of client is USN treatment for?

USN treatments can be offered to individuals of all ages but should be tailored to the client’s specific level of functioning. Clients with either mild or no cognitive deficits can benefit from therapy (i.e. score ≥22 on the Mini-Mental State Examination is recommended) as they must be able to follow simple commands. Clients must have receptive language abilities in order to be able to understand instructions; however expressive language is not a requirement. Last, patients may have other post-stroke visual impairments such as hemianopsia and it is important o differentiate between the two when assessing treatment benefits.

Who offers these treatments?

Occupational therapists (OTs) typically assess for and provide treatment for USN in an acute care hospital, rehabilitation center, or private clinic 8.

Special considerations for OTs

There are minimal equipment costs (e.g. prism therapy, eye patching, limb activation) and training required for providing USN treatments. Therapists need to consider that clients with USN may be unable to attend to either one side of his/her body (personal neglect), the space within reaching distance (near extrapersonal neglect), the space beyond reaching distance (far extrapersonal neglect), or to a combination of these three spaces in their environment. Therefore the assessment and treatment of USN within these hemispaces must be considered. It is also important to explain to the patient and their family what USN is and to provide them with safety recommendations such as remembering to put on the wheelchair brake on the left side, and ensuring that the patient does not trip over obstacles on the left. Therapists can also engage the family members aiding with therapy by instructing them to allow the patient to search and find objects in their room which are located on the left side instead of placing all objects within the patient’s field of view.

 

Screening Tool Administration Procedures
Comb and Razor Test: Patients are required to groom themselves using common objects. For males, this consists of combing and mock shaving (shaving with a shield on) each for 30 seconds. Female patients are asked to comb and demonstrate the use of a facial compact for 30 seconds each. During the 30 second intervals, the evaluator categorizes each “stroke” or touch as having occurred on the left side of the head, the right side of the head, or as ambiguous 26.
To score the test, observational data is plugged into a formula (% left = left strokes/total strokes x 100), which yields a % value. This value indicates the degree to which the individual being tested has neglected the left side of their head. Left personal neglect is diagnosed when an individual’s mean% left score is less than 35%. The test takes approximately 5 minutes and requires no specialized training to administer 26.
Albert’s Test: Patients are required to cross through the center of 41 randomly oriented lines, each about 2 cm long, arranged on a sheet of paper. The test sheet is presented to the patient at their midline. The examiner asks the patient to cross out all of the lines, and demonstrates what is required by crossing out the 5 central lines him/herself. The patient is encouraged to cross out all the lines until he/she is satisfied that they have all been crossed 26.
The presence or absence of USN is based on the number of lines left uncrossed on each side of the test sheet. If any lines are left uncrossed, and more than 70% of uncrossed lines are on the same side as the brain lesion or motor deficit, USN is suspected. This may be quantified in terms of the percentage of lines left uncrossed. The test takes approximately 5 minutes and requires no specialized training to administer 26.
Baking Tray Task:This test requires that the patient pick-up 16 “buns” and spread them as evenly as possible on a 75×100 cm board. Cubes can be used to represent the “buns”. The therapist must note how the “buns” are spread out and USN can be easily detected depending on their arrangement on the board (i.e. if they are placed on the right side of the board only, left USN is suspected). Patients do not usually exceed 3-5 minutes to complete the task and no specialized training is required to administer the test 7.
Balloons Test: This bedside test was developed to screen for USN and contains 2 subtests. Subtest A requires the client to cross out the 22 target balloons of the 202 circles that appear on a page within the fixed time limit of 3 minutes. In subtest B, the number and position of balloons is exactly reverse from subtest A, where the client is asked to cross out 10 target circles from the 90 balloons that appear on a page within the fixed time limit of 3 minutes. No specialized training is required to administer the test 27.
Bells Test: In the Bells Test, the patient is asked to circle with a pencil all 35 bells embedded within 280 distracters (houses, horses, etc.) on an 11 x 8.5 – inch page. The objects are actually equally distributed in 7 columns containing 5 targets and 40 distracters each. Of the 7 columns, 3 are on the left side of the sheet, 1 is in the middle, and 3 are on the right. To administer the test, the examiner must sit facing the patient and place the page at the patient’s midline. The examiner gives the following instructions: “Your task will consist of circling with the pencil all the bells that you will find on the sheet that I will place in front of you without losing time. You will start when I say “go” and stop when you feel you have circled all the bells. I will also ask you to avoid moving or bending your trunk if possible.” If the patient stops before all the bells are circled, the examiner gives only one warning by saying “are you sure all the bells are now circled? Verify again.” 26
To score the Bell’s test, the total number of circled bells is recorded as well as the time taken to complete. The maximum score is 35. An omission of 6 or more bells on the right or left half of the page indicates USN. Judging by the spatial distribution of the omitted targets, the evaluator can then determine the severity of the visual neglect and the hemispace affected (i.e. left or right) 26.
Clock Drawing Test (CDT): There are a few variations to the CDT:
Free drawn clock: the individual is given a blank sheet of paper and asked first to draw the face of a clock, place the numbers on the clock, and then draw the hands to indicate a given time. To successfully complete this task, the patient must first draw the contour of the clock, then place the numbers 1 through 12 inside, and finally indicate the correct time by drawing in the hands of the clock. A markedly abnormal clock is an important indication that the individual may have a cognitive deficit, warranting further investigation.;
Pre-drawn clock: alternatively, some clinicians prefer to provide the individual with a pre-drawn circle and the patient is only required to place the numbers and the hands on the face of the clock. Copying a clock: the individual is given a fully drawn clock with a certain time pre-marked and is asked to replicate the drawing as closely as possible. The successful completion of the copy command requires less use of language and memory functions but requires greater reliance on visuospatial and perceptual processes.
Clock reading test: a modified version of the copy command CDT simply asks the patient to read aloud the indicated time on a clock drawn by the examiner 26.
The time setting “10 after 11” is an ideal setting as it forces the patient to attend to both sides of the clock and requires the recoding of the command “10” to the number “2” on the clock.
The scores are used to evaluate any errors or distortions such as neglecting to include numbers, putting numbers in the wrong place, or having incorrect spacing. Scoring systems may be simple or complex, quantitative or qualitative in nature. The CDT should take approximately 1-2 minutes to complete and requires no specialized training to administer 26.
Double Letter Cancellation Test (DLCT): The patient is asked to put a mark through all the letters C and E on presented 105 times a sheet of paper containing 6 lines with 52 letters per line. To begin the DLCT, the therapist places the test sheet at the patient’s midline, secures it with tape, and points to the trial line, asking the patient to mark the Cs and Es. If the patient is unable to perform the trial, further instruction is given. If the trial is correctly performed, the therapist will then proceed to give instructions as follows: “Look at the letters on this page. Put one line through each C and E. Ready, begin here”. The therapist points to the first letter in the first row. The time taken to complete the test is recorded 26.
The score is calculated by subtracting the number of omissions (Cs and Es that were not crossed out) from the possible perfect score of 105. Higher scores indicate better performance. The timing and total number of errors should be noted. The test requires less than 5 minutes to complete and requires no specialized training to administer 26.
Draw-A-Man Test: This test was initially designed to measure intelligence levels in children, however, has good reliability in detecting USN. To administer the test, the therapist asks the patient to complete three individual drawings (draw a man, a woman, and themselves) on separate pieces of paper. No further instructions are given. There is no right or wrong type of drawing, although the patient must make a drawing of a whole person each time – i.e. head to feet, not just the face. The test has no time limit, however, it is rare that someone takes longer than 10 or 15 minutes to complete all three drawings 26. Specific scoring instructions for USN can be found in an article by Chen-Sea MJ. Validating the Draw-A-Man Test as a personal neglect test. Am J Occup Therap. 2000;54:391–397.
Line Bisection Test: This is a quickly administered test that requires the patient to mark a line through the center of a series of 17 horizontal lines on an 11x 8.5-inch page. The test is scored by measuring the deviation of the bisection (in centimetres or millimetres) from the true center of the line. A deviation of more than 6 mm from the midpoint indicates USN 26.
Most testers utilize a formula that divides the deviation by half the length of the line and then multiplies this quotient by 100 to yield a percentage. Omission of two or more lines on one half of the page indicates USN. This test takes less than 5 minutes to complete and requires no specialized training to administer 26.
Single Letter Cancellation Test: The test consists of one 8.5″x11″ sheet of paper containing 6 lines with 52 letters per line. The stimulus letter “H” is presented 104 times. The page is placed at the patient’s midline. The therapist instructs the patient to put a line through each “H” that is found on the page. The time taken to complete the test is recorded 26.

The score is calculated by subtracting the number of omissions (H’s that were not crossed out) from the possible perfect score of 104 (0 to 53 on the left and 0 to 51 on the right). Higher scores indicate better performance. Presence of USN can be inferred by calculating the frequency of errors to the left or to the right from the center of the page. Omissions of 4 or more on one side have been found to be pathological 26.

Star Cancellation Test (SCT): In the Star Cancellation Test, the patient must cross out 56 small stars which are interspersed with 52 large stars, 13 letters, and 10 short words on a sheet of paper. Two small stars in the centre are used for demonstration. The therapist must place the page at the patient’s midline 26.

The maximum score that can be achieved on the test is 54 points (56 small stars in total minus the 2 used for demonstration). A cut-off of < 44 indicates the presence of USN. A Laterality Index or Star Ratio can be calculated from the ratio of stars cancelled on the left of the page to the total number of stars cancelled. Scores between 0 and 0.46 indicate USN in the left hemispace. Scores between 0.54 and 1 indicate USN in the right hemispace. The test takes under 5 minutes to administer and requires no specialized training for the tester 26.

National Institute of Health Stroke Scale (NIHSS): The NIHSS is a 15-item impairment scale, intended to evaluate neurologic outcome and degree of recovery for patients with stroke. The scale assesses various outcomes with the one item involving the assessment of USN for the personal space and near extrapersonal space. There are no specific instructions for assessing USN, however, the test states that sufficient information to detect neglect may be obtained from testing the prior items and is rated from 0 – 226.

Short Version – Rivermead Behavioral Inattention Test (RBIT): The short version of the RBIT involves three conventional subtests (line crossing, Star Cancellation Test, and figure copying) and five behavioural subtests (scanning a picture, reading a menu, eating a meal, reading an article, and sorting coins). Administration procedures and scoring methods can be found in the RBIT manual 7.

Semi-Structured Scale for the Functional Evaluation of Hemi-inattention in Extrapersonal Space: Patients are asked to perform different tasks with real objects. To assess personal neglect, patients must demonstrate the use of three common objects: comb, razor/powder compact, and eyeglasses. The objects are placed at the patient’s midline one at a time and he/she is asked to demonstrate how each are used. To assess extrapersonal neglect, patients must serve tea, deal cards, describe a picture, and describe an environment 26.

1. Serving tea: The patient is brought to a table with a tray containing 4 cups and saucers, a teapot, a sugar bowl, teaspoons, and paper napkins. Examiners are seated both on the right, in front, and to the left of the patient who is asked to serve tea for him/herself and for those who are with him/her, to distribute napkins and teaspoons, and also to serve the sugar. The examiner, who is seated in front of the patient asks: “Would you like to serve the tea?”. If the patient serves the tea but not the napkins and/or teaspoons, the examiner asks: “Would you like to give us the teaspoons (napkins)?”.

2. Card dealing.
The examiners and the patient are seated the same way as they were for the tea-serving situation. The patient is asked if he/she knows how to play “Scopa”. If necessary, he/she is reminded of the basic rules (3 cards for each player and 4 in the middle of the table). The examiner seated in front of the patient asks: “Would you like to deal the cards for a game of Scopa?”.

3. Picture description.
A picture is placed in front of the patient and he/she is asked: “Will you describe everything you see in this picture?”. Three pictures are used. Two are cards 3 and 6 of Set 1 of the Progressive Picture Compositions by Byrne (1967); one is Tissot’s painting ‘The dance on the ship’. The examiner indicates the persons and objects pointed out by the patient with progressive numbers on a photocopy of the stimulus figure in the order in which they are reported, without soliciting in any way.

4. Description of an environment.
The patient is placed in a

Info Pocket Booklet

USN-Pocket-Card

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Exlcuded Studies

Castiello, U., Lusher, D., Burton, C., et al. (2004). Improving left hemispatial neglect using virtual reality. Neurology, 62, 1958-62.
Reason for exclusion: feasibility study.

Dick, A. S., Raja Beharelle, A., Solodkin, A., & Small, S. L. (2013). Interhemispheric functional connectivity following prenatal or perinatal brain injury predicts receptive language outcome. J Neurosci., 33(13), 5612-5625.
Reason for exclusion: study participants were children.

Ertekin, A., Gelecek, N., Yildirim, Y., & Akdal, G. (2009). Supervised versus home physiotherapy outcomes in stroke patients with unilateral visual neglect: a randomized controlled follow-up study. Journal of Neurological Sciences, 26 (3), 325-34.
Reason for exclusion: Both groups were given the same exercise program to target USN, which was then performed under supervision or as a home program.

Hommel, M., Peres, B., Pollak, P., Memin, B., Besson, G., Gaio, J.M., & Perret, J. (1990). Effects of passive tactile and auditory stimuli on left visual neglect. Archives of Neurology, 47, 573-576.
Reason for exclusion: No control group.

Kim, J., Kim, K., Kim, D.Y., Chang, W.H., Park, C., Ohn, S.H., Han, K., Ku, J., Nam, S.W., Kim, I.Y., & Kim, S.I. (2007). Virtual reality training system for rehabilitation of stroke patients with unilateral neglect: crossing the virtual street. CyberPsychology & Behavior, 10(1), 7-15.
Reason for exclusion: feasibility study.

Tham, K. & Tegner, R. (1997). Video feedback in the rehabilitation of patients with unilateral neglect. Archives of Physical Medicine and Rehabilitation, 78, 410-413.
Reason for exclusion: Both groups received sensory feedback (verbal feedback vs. visual feedback)

Trislin, I., Dupierriz, E., Chokron, S., Coquillart, S., & Ohlmann, T. (2009). Uses of virtual reality for diagnosis, rehabilitation and study of unilateral spatial neglect: review and analysis. CyberPsychology & Behavior, 12(2), 175-81.
Reason for exclusion: review article.

Walker, R., Young, A.W., & Lincoln, N.B. (1996). Eye patching and the rehabilitation of visual neglect. Neuropsychological Rehabilitation, 6(3), 219-231.
Reason for exclusion: no control group.

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