Hemispatial Neglect LDH

8/10/2019 Hemispatial Neglect LDH

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Hemispatial Neglect The prognosis for recovery of independent function in

patients with persisting spatial neglect is worse than inthose with seemingly more disabling deficits (e.g.hemiparesis)

Although patients may recover from spatial neglect,

they often remain severely disabled.

Linked to longer hospitalisation and worse rehaboutcomes


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Incidence Reported incidence of neglect in stroke patients has varied

from as low as 8% of patients to as high as 90%.

Luukainen-Makkula report 30% of all acute stroke patients

suffer from neglect, while 2% suffer chronically More common in injuries affecting right cortical

hemisphere

Causes of spatial neglect include stroke, traumatic brain

injury, brain tumors, and aneurysm. Rarely,neurodegenerative diseases can cause neglect symptoms

This disorder is under-recognized in clinical practices,which may result from the failure to document its presence(Chen et al 2013)


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Mechanisms Many different cognitive deficits have been identified

in patients with neglect.

Led to a range of hypotheses about the mechanismsunderlying the condition


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Mechanisms

attention Perception Attention disordered awareness

(Heilman 2003)

Deficit in directing spatial attention, specificallyin disengaging attention from ipsilesional objects andshifting it contralesionally towards the neglected sideof space

Cueing attention towards the neglected side of spacecan help to reduce spatial biases


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Mechanisms - Spatial working

memory Imagery/representation unable to maintain an

internal map or spatial knowledge of the environment

Patients have difficulty in keeping track of spatiallocations across saccadic eye movements

Suggests limitations in visual short term memory(Malholtra et al 2004)


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Symptoms Deficits in attention to the area within reaching space

(peripersonal neglect) and beyond (extrapersonal neglect)

Personal neglect- deficit in grooming or dressing thecontralesional side.

Anosognosia- unaware of the deficit that is present (Occursin 20-58% of patients)

Deficits in attending to or perceiving contralesional space.

Motor neglect fail to use contralesional limbs even ifthere is little weakness


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Neglect vs. hemianopia Hemianopia primary sensory deficit visual field

loss, pt is aware of deficit will turn head to see

Patients with neglect are unaware of their deficit ofthe missing information on one side. Vision is intact,attention is disrupted.

Once their attention is drawn to the missinginformation, they become aware of it.


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Prognosis Most patients with neglect show early recovery, particularly

within the first month,and marked improvement may beseen within 3 months.

Patients with neglect need to be monitored because theymay be more prone to falls or left-sided wheelchaircollisions.Patients may require sitters, vest restraints, gaitbelts, or other interventions to prevent falling out of bed,for which they are at high risk.

Spatial neglect may greatly increase morbidity and the riskof acute and chronic complications of stroke (eg, hipfracture). It is associated with a longer acute hospital stay.

Neglect patients who were not detected clinically stayed inrehab longer than those who were (Chen et al 2013)


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Copying


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Catherine Bergego Scale


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Rx Prism Adaptation

Motor bias rehabilitation/Constraint-induced therapy

Visual Scanning Cueing

Trunk rotation

Vibration of contralesional neck muscles

Bed Placement/ Room rearrangement

Caloric stimulation


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Rx Interventions which simply attempt to improve

exploration of contralesional space (e.g. directinggaze) are effective in reducing neglect on those tasks,but have little transfer to functional benefits ineveryday life

However when combined with vibration ofcontralateral neck muscles, there is evidence forsignificant improvement in functional outcomemeasures at 2 months follow up (Schindler et al., 2002)


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Prism Adaptation Prism adaptation causes an optical deviation of the visual field

to the Right, so objects appear farther to the subjects right thanis actually the case.

After repeated exposure, it forces patients to correct their reachtrajectory to accurately grasp objects, thus overriding the visualimpairment. (A recalibration of visuomotor hand-eyecoordination.)

Significant improvements in neglect tests, but not functionalperformance.

Some have reported improvements in representational neglect,haptic neglect, neglect dyslexia, postural imbalance inhemiparesis

Mcintosh et al reported benefits for chronic neglect patients


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Contralesional Limb ActivationActive and passive movement to reduce visual and

behavioural neglect

Passive movement was also induced by functionalelectrical stimulation

Experimental groups appeared to have statisticallysignificant improvements on BIT, CBS and FIMmeasures during rehabilitation, however had ratherlarge standard deviations


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Constraint-Induced Therapy Based on principle of learned non-use - Causes reduced

neural representation of that limb, diminishing theirpotential to return to function

Mechanically forces patient to use their affected limb

van de Lee et al. (1999) compared CIT againsttraditional therapy

66 Stroke patients 7 with neglect

Showed significant improvements vs normal rehab

But no proper neglect measures used!

Requires active + functional wrist and hand movement


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Conclusion There have been numerous studies on various treatments

for neglect that have shown statistically significantimprovements both immediately and in the long-term.

Daily life functions are often performed under morechallenging conditions than is the case for formalneuropsychological testing/treatment environments

According to Cochrane review by Bowen and Lincoln(2007) it is difficult to correlate an improvement instandardised neglect tests, as they say little about thepersons ability to function in complex everyday activitiesthat are relevant to their life

More research is required on the various techniques andthe long-term effects


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References Luukkainen-Markkula, I.M. Tarkka, K. Pitkanen, J. Sivenius, and H. Hamalainen. Rehabilitation ofhemispatial neglect: A randomized study using either arm activation or visual scanning training.Restorative Neurology and Neuroscience.(2009); 27: 665-674.

Schindler I, Kerkhoff G, Karnath HO, Keller I, Goldenberg G. Neck muscle vibration induces lastingrecovery in spatial neglect. J Neurol Neurosurg Psychiatry 2002;73(4):412-9.

Nicole Y. H. Yang, Dong Zhou, Raymond C. K. Chung, Cecilia W. P. Li-Tsang, and Kenneth N. K.

Fong. Rehabilitation interventions for Unilateral Negelct after stroke: A systematic review from 1997through 2012. Frontiers in Human Neuroscience. (2013); 7: 187. van de Lee, J., Wagenaar, R., Lankhorst, G., Vogelaar, T., Deville, W., Bouter, L. Forced Use of the

Upper Extremity in Chronic Stoke Patients. Stroke. (1999); 30: 2369-2375. Bowen, A. & Lincoln, N. Cognitive Rehabilitation for Spatial Neglect Following Stroke. Cochrane

Database of Systematic Reviews. (2007); 2. Heilman KM, Watson RW, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E,

eds. Clinical neuropsychology. 4thed. New York, NY: 2003:296-346. Ringman JM, Saver JL, Woolson RF, Clarke WR, Adams HP. Frequency, risk factors, anatomy, and course of

unilateral neglect in an acute stroke cohort. Neurology. Aug 10 2004;63(3):468-74. Malhotra, P., Jager, H.R., Parton, A., Greenwood, R., Playford, E.D., Brown, M., Driver, J., and Husain, M. (2005). Spatial

working memory capacity in unilateral neglect. Brain 128, 424-435.

Chen, P., Pasquale, G.F. & Barret, A.M. Evidence of under-documentation of spatial neglect after stroke. DisabilRehabil. 2013 Jun;35(12):1033-8

Hemispatial Neglect LDH

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