Rehabilitation in practice:

Hemispatial neglect:
Approaches to rehabilitation

Clin Rehabil August 2010 24: 675-

684,

Victoria Singh-Curry and Masud Husain

What is Hemispatial Neglect?
 Hemispatial Neglect
• Syndrome commonly follows unilateral brain
injury, especially RIGHT hemisphere stroke.
• Inability to orient towards and attend to
stimuli in the contralesional space (Left side if
right hemisphere lesions)
• Anosognosia
– Difficult to rehabilitate
 Contributing Factors
Spatial Non - Spatial
• A bias in the gradient of spatial attention • Difficulties in sustaining attention over time,
towards the ipsilesional (towards the right in even when items are presented at a central
patients with right hemisphere lesions) side of location
space • Impairments in selective attention, which may
• Difficulty disengaging attention from occur in both left and right sides of space and at
ipsilesional (right-sided) and shifting it to central locations.
contralesional (left-sided) locations • Neglect patients can demonstrate bilateral
• A pathological spatial bias, in which attentional impairments, even though the most
contralesional (left-sided) items lose in the obvious abnormality is a bias towards
competition for attention to ipsilesional (right- ipsilesional (usually right-sided) space
sided) stimuli
• Directional motor deficits in which patients
have difficulty directing movements into the
contralesional (left) side of space
• Problems with spatial working memory,i.e.
keeping track of spatial locations over time
• A disordered egocentric representation of
space
 What test/s to do?
• A full neuropsychological (as well as physical) examination would
ideally be required in all stroke patients, particularly those with
right hemisphere lesions.
• No single test provides an adequate screening tool. Instead a
battery of standardized measures (such as from the Behavioural
Inattention Test)
• Examination for visual and somatosensory extinction
• Assessment of functional activities (for example the Barthel Index
or Functional Independence Measure) are needed to fully evaluate
the syndrome in an individual patient.

This information, along with an appreciation of the underlying lesion

anatomy, could be used to guide attempts at effective
rehabilitation
Rehabilitation Technique
 Three Categories
1. Purely behavioural strategies;

2. Techniques employing devices or specialized

equipment; and

3. Pharmacological manipulations.
 Behavioural Strategies
• Most Common
1. Visual scanning or visuospatial training
– cueing right-hemisphere patients to make
leftward eye or head movements
– facilitate the orientation of attention into the
contralesional, neglected side of space
Example:
asking the subject to locate the left hand margin of the page before
reading the next line.
 Behavioural Strategies
2. Sustained Attention
– sorting of objects such as coins
– intermittently verbally prompt patients to attend
during the task
– gradually pt were trained to prompt themselves
subvocally
 Behavioural Strategies
3. Limb activation therapy
– making leftward movements with the left arm can
activate poorly attended areas in extrapersonal
space and thereby improve neglect
– constrained by the fact that some control over the
often hemiparetic arm is required
– passive movements if large enough can lead to
some improvement of neglect
Therapies that use specialized devices
1. neglect alerting device
2. functional electrical stimulation(FES)
3. computerized training tasks
4. Rotation of the head or trunk
5. Neck muscle vibration (NMV)
6. Optokinetic stimulation
7. Prism adaptation
 Pharmacological Therapies
• Dopaminergic drugs
– Bromocriptine given daily for 3–4 weeks, levodopa
and the other apomorphine has been found to effect
an improvement in measures of neglect
– some reports have failed to demonstrate any benefit
• Noradrenergic compounds (Guanfacine)
– improves planning and working memory performance
in healthy human participants
– sustain attention for longer periods of time on the
visual exploration task
Thank You

Questions??