Treatment of visual neglect in elderly patients with stroke: a single-subject series using either a scanning and cueing strategy or a left-limb activation strategy

BACKGROUND AND PURPOSE: The presence of unilateral visual neglect (UVN) may adversely affect functional recovery, and rehabilitation strategies that are practical for use in clinical settings are needed. The purpose of this study was to evaluate the use of 2 approaches to reduce UVN in people who have had strokes. SUBJECTS: Seven elderly patients with stroke and severe left UVN, aged 60 to 85 years, were recruited from a stroke rehabilitation unit. METHODS: A nonconcurrent, multiple-baselines-across-subjects approach, with an A-B-A treatment-withdrawal single-subject experimental design, was used. Five subjects received a scanning and cueing approach, and 2 subjects received a contralesional limb activation approach, for 10 one-hour sessions. In the former approach, active scanning to the left was encouraged by the therapist, using visual and verbal cues and a mental imagery technique, during reading and copying tasks and simple board games. In the latter approach, functional and goal-oriented left upper-limb activities in neglected hemispace were encouraged. Unilateral visual neglect was examined by a masked (blinded) examiner throughout all phases using the Star Cancellation Test, the Line Bisection Test, and the Baking Tray Task. Data were analyzed using visual and inferential statistical techniques. RESULTS: Both subjects who received limb activation and 3 of the 5 subjects who received scanning and cueing showed a reduction in UVN in one or more tests. This improvement was maintained during the withdrawal phase. DISCUSSION AND CONCLUSION: Both approaches had a positive effect of reducing aspects of UVN in some subjects relative to no-treatment baselines. However, causality cannot be assured in the absence of controls. The approaches are practical for use in rehabilitation settings. These procedures warrant further replication across subjects, settings, and therapists.     

Recovery from unilateral neglect after right-hemisphere stroke

Purpose:?To show the recovery process for different forms of unilateral neglect (UN)—including personal neglect and neglect of far space—in relationship to impairment, disability, cognition and mood.

Method:?Patients were tested at 2?–?4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

Results:?Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

Conclusions:?For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.     

Development of a behavioral test of visuospatial neglect

The Rivermead Behavioral Inattention Test (RBIT), consisting of nine items sampling activities of daily living, was administered to 28 patients after unilateral right (20) or left (8) cerebrovascular accidents, and to 14 non-brain-damaged controls. All patients were tested on two parallel forms of the RBIT with order of presentation balanced and on at least two of six conventional tests of visual neglect. Control subjects were tested on either form 1 or form 2 of the RBIT. Interrater reliability of scoring was tested on seven subjects chosen at random. Using control scores to determine the cutoff point between visual inattention and noninattention, 14 patients (50%) showed evidence of visuospatial neglect on the RBIT. Correlation between the two forms of the test was 0.83. The RBIT also correlated well with five of the conventional tests. Interrater reliability was 100%. The RBIT appears to be a valid and reliable test of visuospatial neglect and one which is likely to provide more information about everyday problems than existing measures of neglect.     

Recovery from unilateral neglect after right-hemisphere stroke

Purpose: To show the recovery process for different forms of unilateral neglect (UN)—including personal neglect and neglect of far space—in relationship to impairment, disability, cognition and mood.

Method: Patients were tested at 2 - 4 weeks, at 6 months and at 1 year. We used the Behaviour Inattention Test and a test for personal neglect. We also used the NIH Stroke Scale, the Functional Independence Measure (FIM), the Mini-Mental State Evaluation and the Geriatric Depression Scale.

Results: Peripersonal neglect diminishes within 6 months, but complete recovery occurred in only 13%. The prognosis for personal neglect and neglect of far space is better, with a recovery ratio at 6 months of 52% and 46%, respective. The correlations between UN and FIM are high. A few patients deteriorate in the absence of recurrent stroke.

Conclusions: For clinical purposes, it is practical to postpone UN evaluation until a couple of weeks after a stroke. Many of the patients who then have UN are likely to retain their UN, although many will improve. Patients with UN should receive special attention in the rehabilitation phase, as well as at discharge. One explanation of the worsening of UN seen in some patients, may be continuing cerebral atherosclerosis.     

Validating the Draw-A-Man Test as a personal neglect test.

OBJECTIVES: The purpose of this study was to determine the reliability and validity of a Draw-A-Man Test in measuring personal neglect in patients with right brain stroke. METHOD: Draw-A-Man Test was administered to 51 persons with right cerebrovascular accident (CVA) and 110 age-matched persons without brain insult. A categorical classification was developed based on the man drawn in the test. Participants who showed homogeneous bilateral representation of body parts were considered to not have personal neglect, whereas those who showed unilateral body parts were considered to have personal neglect. The completed tests were used to blindly categorize the persons with and without personal neglect according to the above definition by two raters for calculating interrater reliability. The Klein-Bell ADL (Activities of Daily Living) Scale was also administered to the participants with right CVA to validate the Draw-A-Man Test. RESULTS: This dichotomy--bilateral representation versus unilateral representation--showed a high percentage of agreement between two raters. Rater A classified all 110 "normal" participants as being without personal neglect and classified 13 of the 51 participants with stroke as having personal neglect. Participants demonstrating personal neglect showed significantly poorer ADL performance than did those without personal neglect. ADL performance was also found to be significantly related to somatosensation, motor status of the impaired limbs, and muscle strength of the sound limbs. However, even after controlling the effect of these variables by partial correlation, personal neglect was still highly related to ADL performance. CONCLUSION: The Draw-A-Man Test is a reliable and valid tool for discriminating clients with personal neglect from those without.     

Visuospatial inattention and daily life performance in people with Alzheimer's disease.

OBJECTIVE: The purpose of this study was to examine the relationship between visual inattention and daily life performance in people with Alzheimer's disease. METHODS: Twenty persons with Alzheimer's disease (Mini Mental Status Exam [MMSE] > 20) and 21 community dwelling persons (MMSE > 26) voluntarily participated in this study. One line bisection test and two cancellation tests were used for testing attention abilities. The Functional Spatial Abilities Questionnaire (FSAQ), the Disability Assessment for Dementia (DAD), and the behavioral subtests of the Behavioral Inattention Test (BIT) were used to assess daily functioning. The presence of visuospatial neglect in people with Alzheimer's disease was determined by comparing performance on the three attention tests with the control group. RESULTS: People with Alzheimer's disease who omitted more targets on the symbol cancellation test showed more deficits on the behavioral subtests of the BIT (p = .02). They also used less systematic searching strategies (p = .001), spent more time looking for targets (p = .001), and made more commission errors (p = .007) than controls on the cancellation test. However, those with Alzheimer's disease who had visuospatial neglect did not differ from those without neglect on the FSAQ, DAD, and most of the BIT behavioral subtests. CONCLUSION: People with Alzheimer's disease have visual inattention problems; however, visuospatial neglect did not interfere with their performance in daily activities as measured in this study. Further research focusing on the relationship between visual attention and daily life function as the disease progresses is suggested.     

Long-term effect of low-frequency repetitive transcranial magnetic stimulation over the unaffected posterior parietal cortex in patients with unilateral spatial neglect.

OBJECTIVE: To explore long-term effects on unilateral spatial neglect of low-frequency repetitive transcranial magnetic stimulation (rTMS) over the unaffected posterior parietal cortex.DESIGN: Uncontrolled pilot study.SUBJECTS: Two chronic-phase patients with left-sided unilateral spatial neglect from cerebral infarction.METHODS: Six rTMS sessions were undertaken for 2 weeks. Each session included 900 stimuli applied over P5 at an intensity of 95% motor thresholds and a frequency of 0.9 Hz. The Behavioural Inattention Test, either the Mini-Mental State Examination or the Revised Hasegawa Dementia Scale, Brunnstrom Recovery Stage, and Barthel Index were evaluated at 2-week intervals until 6 weeks after rTMS sessions. Single-photon emission computed tomography was performed 2 weeks before and after rTMS.RESULTS: Behavioural Inattention Test scores improved remarkably, especially from 2 to 4 weeks after rTMS sessions. At 6 weeks, Behavioural Inattention Test scores still remained above pre-rTMS levels. Other clinical evaluations as well as single-photon emission computed tomography showed no significant change during the study.CONCLUSION: In this small pilot study, low-frequency rTMS over the unaffected posterior parietal cortex decreased unilateral spatial neglect for at least 6 weeks.     

A short screening test for visual neglect in stroke patients

Objective: to extend a preliminary study²² of the internal structure of six measures comprising the ‘conventional’ subtests of the Behavioural Inattention Test (BIT)²³ in order to develop a short screening test for visual neglect. Design: discriminant function analysis of the 15 tests constituting BIT. Setting: rehabilitation centre. Patients: 59 selected from consecutive stroke patients entering the centre. Selection criteria: absent prior history of major CNS disorder, at least 1 week post-stroke, right-handed for writing, absent significant visual impairment other than visual field deficit, no psychiatric overlay or generalized intellectual deterioration, and ability to comprehend and respond to the visuomotor tasks administered. Comparison group: 50 non-brain-damaged subjects (hospital employees, members of University subject panel, and local community volunteers). Assessments: the 15 tests constituting the BIT. Results: two subtests, letter cancellation and star cancellation, were the most sensitive measure, identifying 74% of neglect patients with no false positives. Conclusions: letter and star cancellation offer an adequate yet brief screening test for determining which patients might benefit from administration of the complete neglect test battery.     

Sustained attention in patients with mild traumatic brain injury

OBJECTIVE: To demonstrate that two tests of sustained attention were sensitive to attention deficits in patients with mild traumatic brain injury (TBI). DESIGN: A cross-sectional study recruiting 51 patients with TBI and 51 matched controls. OUTCOME MEASURES: The Sustained Attention to Response Task (SART) and Monotone Counting Test. RESULTS: The patient groups performed significantly worse than the normal controls in both sustained attention tests. The SART performance was also correlated with pathology severity in the patient group in terms of loss of consciousness (r = 0.247, p = 0.05). A cut-off of less than 1 standard deviation (SD) gives optimal diagnostic information in terms of sensitivity in the present sample (0.61 for Monotone Counting Test; 0.75 for SART). CONCLUSION: These findings suggest that the SART and Monotone Counting Test are sensitive to patients with mild TBI. The SART-assessed sustained attention is also sensitive enough to detect attention impairment in this clinical group regardless of diagnosis and may provide clinicians with an alternative method of assessing sustained attention in these clinical groups.     

Dopaminergic therapy with carbidopa L-dopa for left neglect after stroke: a case series

OBJECTIVE: To evaluate the efficacy of carbidopa L-dopa (Sinemet) in reducing left spatial neglect after stroke. DESIGN: Case series. SETTING: Inpatient neurorehabilitation unit in a regional rehabilitation center. PARTICIPANTS: A convenience sample of 4 women with right brain strokes and left neglect. INTERVENTION: A trial of carbidopa L-dopa to treat left neglect, if indicated by selected subtests of the Behavioral Inattention Test (BIT). MAIN OUTCOME MEASURES: Baseline and posttreatment evaluation with the modified BIT and the FIM instrument. RESULTS: Three of 4 subjects had significant improvements in their modified BIT scores (8%, 12%, 27%, respectively) and their functional status on the FIM. CONCLUSION: With further study, carbidopa L-dopa may be shown to reduce unilateral spatial neglect and thereby improve rehabilitation outcomes.     

Is the Posner Reaction Time Test More Accurate Than Clinical Tests in Detecting Left Neglect in Acute and Chronic Stroke?

Rengachary J, d'Avossa G, Sapir A, Shulman GL, Corbetta M. Is the Posner Reaction Time Test more accurate than clinical tests in detecting left neglect in acute and chronic stroke?ObjectiveTo compare the accuracy of common clinical tests for left neglect with that of a computerized reaction time Posner test in a stroke population.DesignNeglect measures were collected longitudinally in patients with stroke at the acute (≈2wk) and chronic (≈9mo) stages. Identical measures were collected in a healthy control group.SettingInpatient and outpatient rehabilitation.ParticipantsPatients with acute stroke (n=59) with left neglect, 30 of whom were tested longitudinally; healthy age-matched controls (n=30).InterventionsNot applicable.Main Outcome MeasuresA receiver operating characteristic analysis ranking the measures' sensitivity and specificity using a single summary statistic.ResultsMost clinical tests were adequately accurate at the acute stage, but many were near chance at the chronic stage. The Posner test was the most sensitive test at both stages. The most sensitive variable was the reaction time difference for detecting targets appearing on the left compared with the right side.ConclusionsComputerized reaction time tests can be used to screen for subtle but potentially clinically relevant left neglect, which may not be detectable by conventional clinical tests, especially at the chronic stage. Such tests may be useful to assess the severity of the patients' deficits and provide more accurate measures of the degree of recovery in clinical trials than established clinical measures.     

A Comparison of Three Measures of Elder Abuse

PURPOSE: To present a comparison of three measures for assessing elder abuse. DESIGN AND METHODS: Three measures for assessing elder abuse were identified through a literature review. The characteristics and uses of each measure were reviewed and evaluated. FINDINGS: The Indicators of Abuse (IOA) is a 22-item tool for discriminating abuse and nonabuse cases; it is completed by a health care professional after a home assessment is conducted. The Elder Abuse and Neglect Assessment (EAI) is a 44-item scale comprised of seven sections to review signs, symptoms, and subjective complaints of elder abuse, neglect, exploitation, and abandonment; it can be used by health care providers in all clinical settings. The Elder Abuse Screening Test (EAST) is a 15-item tool to be completed by a health care provider based on the patient's responses. This screening tool is limited because of the small unrepresentative samples used to test it, the low internal consistency, and a relatively high false-negative rate. CONCLUSIONS: An instrument to accurately assess elder abuse in long-term care is needed. Proper identification of elder abuse is the first step in assisting victims in dealing with abusive situations.     

Assessing unilateral neglect: shortcomings of standard test methods

INTRODUCTION: When investigating the incidence of unilateral neglect in a first-ever stroke population, we found that some patients showed clinical signs of neglect, but managed to pass our tests. The purpose of this paper is to describe the nature of such signs, and analyse why test instruments were insufficiently corresponding to those signs. METHOD: One hundred and thirty-one consecutive patients with first-ever stroke in a community-based sample were evaluated for the presence of unilateral neglect. We used a test battery consisting of tests for visuo-spatial neglect, personal neglect, and anosognosia. Twenty cases of neglect were discovered by standard methods. We asked our collaborators at the wards to report any behavioural abnormality reminiscent of neglect present in patients who had normal test results. Such patients were evaluated clinically. RESULTS: Nine cases with neglect-like symptoms were discovered. Our clinical evaluation of the nine patients indicated several possible explanations for their behavioural abnormalities, including motor neglect, neglect for far extrapersonal space, disturbances of proprioception, and spatial disturbances other than neglect. CONCLUSION: Standard neglect tests do not cover all clinical forms of neglect. It is therefore important not to rely completely on test instruments when diagnosing neglect. More versatile test instruments are desired.     

The treatment of visual neglect using feedback of eye movements: A pilot study

Feedback of eye movements was evaluated as a treatment for visual neglect in right hemisphere stroke patients. Patients with visual neglect identified on the Behavioural Inattention Test (BIT) were randomly allocated to two groups. One group (n = 9) was treated for 2 h 40 min a week for 4 weeks, by wearing glasses which provided a reminder bleep if patients failed to move their eyes to the left in a 15 s interval. The control group (n = 9) received no treatment for their visual inattention. Comparison of the groups after 4 weeks treatment and a further 4 weeks follow-up showed no significant difference either in eye movements or on the BIT. However, there was a trend towards a difference between eye movements in the two groups at 8 weeks, suggesting treatment may have influenced eye movements without changing neglect.     

Visual neglect and extinction: a new test

A new computerized test for visual neglect and extinction was developed and evaluated by testing twenty-five patients with right-hemisphere cerebrovascular accidents. The test consisted of a series of unilateral or bilateral lights on a semicircular array to which the subject responded by pushing a button. A computer controlled the sequence of stimuli and stored the responses. Results of the computer test were compared to conventional occupational therapy and beside clinical tests. Extinction was present in 16 subjects on the computerized test, and in 11 on the clinical test. Neglect was present in 13 subjects on the computerized test, in seven subjects on the occupational therapy test, and in five subjects on the clinical test. The computerized test was more sensitive than the other tests. On both computerized and clinical testing, all subjects with left-sided neglect also had left-sided extinction, but not all subjects with extinction had neglect. Neglect may represent a more severe manifestation of an underlying perceptual defect that produces both neglect and extinction.     

Developing a short form of the Berg Balance Scale for people with stroke

BACKGROUND AND PURPOSE: To improve the utility of the Berg Balance Scale (BBS), the aim of this study was to develop a short form of the BBS (SFBBS) that was psychometrically similar (including test reliability, validity, and responsiveness) to the original BBS for people with stroke. SUBJECTS AND METHODS: A total of 226 subjects with stroke participated in this prospective study at 14 days after their stroke; 167 of these subjects also were examined at 90 days after their stroke. The BBS, Barthel Index, and Fugl-Meyer Motor Test were administered at these 2 time points. By reducing the number of tested items by more than half the number of items in the original BBS (ie, making 4-, 5-, 6-, and 7-item tests) and simplifying the scoring system of the original BBS (ie, collapsing the 5-level scale into a 3-level scale [BBS-3P]), we generated a total of 8 SFBBSs. RESULTS: The distributions of scores for all 8 SFBBSs were acceptable but featured notable floor effects. The 4-item BBS, 5-item BBS, 5-item BBS-3P, and 7-item BBS-3P demonstrated good reliability. The subjects' scores on the 6-item BBS, 6-item BBS-3P, 7-item BBS, and 7-item BBS-3P showed excellent agreement with those on the original BBS. The 6-item BBS-3P and 7-item BBS-3P exhibited great responsiveness. Only the 7-item BBS-3P demonstrated both satisfactory and psychometric properties similar to those of the original BBS. DISCUSSION AND CONCLUSION: The 7-item BBS-3P was found to be psychometrically similar to the original BBS. The 7-item BBS-3P, compared with the original BBS, is simpler and faster to complete in either a clinical or a research setting and is recommended.     

The Behavioral Inattention Test for Unilateral Visual Neglect:

The Behavioral Inattention Test (BIT) which was designed to measure unilateral visual neglect (UVN) consists of two parts: six conventional subtests which have commonly been used to detect UVN and nine behavioral subtests which were developed to simulate activities of daily living. The test was standardized on 50 normal subjects and was administered to 80 CVA patients in Great Britain. The test appears to have high inter-rater (.99), test-retest (.99), and parallel from reliability (.91). Validity of the conventional subtests has been examined, but the validity of the behavioral subtests has not. The test appears to be useful to clinicians because it is relatively simple to administer, is standardized, and is intended to identify problems that patients will demonstrate in daily life. However to improve its usefulness, further studies should address a normative sample in the U.S. with greater attention to age and sex distribution, I.Q., and educational level. The relationship between performance on the behavioral subtests and functional task performance needs to be examined.     

Clinical significance of an easy-to-use dual task for assessing inattention

Purpose To investigate clinical significance of a newly developed paper-and-pencil type dual-task (Oiso-DT) for assessing inattention of brain-damaged patients. Methods A total of 134 healthy individuals and 44 patients with traumatic brain injury (TBI) were the subjects. Oiso-DT combined a cancelation sub-task and a written calculation sub-task on paper. The performance was scored based on the correct rate (CR) and success rate in the cancelation sub-task, and the number of correct answers and CR in the calculation sub-task for three minutes. Performances of Clinical Assessment for Attention (CAT) developed by The Japan Society for Higher Brain Dysfunction were also measured in TBI patients. Results Based on a simple and unique definition of cutoff values, abnormal performance was detected more often in the Oiso-DT than in any sub-task of CAT including Symbol Digit Modalities Test, The Memory Updating Test and Paced Auditory Serial Addition Task, etc. although the specificity was comparable. Conclusion This easy-to-use Oiso-DT might be valuable and sensitive for detecting inattention including mild deficit.

• Implications for Rehabilitation

• The Oiso-DT, a paper-and-pencil clinical test for assessing inattention demonstrates higher sensitivity for traumatic-brain-injury patients than standard neuropsychological tests.

• The task performance is evaluated by a simple and unique method without specific equipment or even a personal computer.

• The Oiso-DT might be valuable for detecting inattention including mild deficit.

• The Oiso-DT is easily applicable to patients with severe inattention who failed to complete complex tasks like paced auditory serial addition task.

     

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

OBJECTIVE: To investigate the effectiveness of voluntary trunk rotation and half-field eye-patching to treat patients with unilateral neglect in stroke. DESIGN: Pre-post, day 60 follow-up, single-blinded randomized controlled trial. SETTING: Single-centre inpatient rehabilitation hospital. SUBJECTS: Sixty subacute patients with right hemisphere stroke having unilateral neglect within eight weeks post stroke consented to participate between November 2003 and July 2005. They were randomly assigned to three comparison groups. INTERVENTIONS: Nineteen patients received daily experimental training in voluntary trunk rotation (TR) for 1 hour five times a week for 30 days. Twenty patients received the same kind of treatment together with half-field eye-patching (TR + EP). Fifteen patients in the control group received conventional training with the same contact time. MAIN OUTCOME MEASURES: Patients were assessed on days 0, 30 and 60 using the Behavioural Inattention Test, the Clock Drawing Test, and the Functional Independence Measure. RESULTS: No significant differences between voluntary trunk rotation (TR), voluntary trunk rotation and half-field eye-patching (TR + EP) and controls were found in functional performance and neglect measures at day 30 (P = 0.042-0.994) and follow-up (P = 0.052-0.911) at P = 0.005 using Bonferroni correction. CONCLUSIONS: The results of this study do not support the use of voluntary trunk rotation alone or with half-field eye-patching to improve functional performance or reduce unilateral neglect in subacute patients with stroke.     

Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect

OBJECTIVE: To evaluate the impact of unilateral spatial neglect (USN) on the rehabilitation outcome and long-term functioning in activities of daily living (ADL) and instrumental ADL (IADL) of right hemisphere damaged (RHD) stroke patients. DESIGN: Assessments of sensory-motor and cognitive impairment and of functional disability were conducted upon admission to rehabilitation, upon discharge from the rehabilitation hospital, and 6 months after discharge, up to a year postonset. SETTING: The Loewenstein Rehabilitation Hospital, which receives patients from all general hospitals in Israel. PATIENTS: Forty consecutive admissions of adult right-handed patients with a first, single, right hemispheric stroke proven by computed tomography. Based on their total score in the Behavioral Inattention Test for neglect, patients were divided into two groups: 19 with neglect (USN+) and 21 without neglect (USN-). OUTCOME MEASURES: Functional Independence Measure, for ADL; The Rabideau Kitchen Evaluation, for IADL. RESULTS: Impairment and disability levels of RHD patients with and without USN were clearly differentiated. Neglect is associated with lower performance on measures of impairment (sensory-motor and cognitive), as well as on measures of disability in ADL and IADL. Differences were significant in all testing periods. The recovery pattern of USN+ patients is slower and more attenuated. In both groups, most improvement occurs in the first 5 months after onset. USN is the major predictor of rehabilitation outcome from admission to follow-up. CONCLUSIONS: The significance of neglect as a major source of stroke-related long-term disability justifies further research efforts to develop appropriate therapeutic modalities for this complex, multifactorial syndrome.