IDENTIFICATION, ASSESSMENT AND

TREATMENT OF UNILATERAL SPATIAL NEGLECT (USN)

DURING STROKE REHABILITATION.

BY

ADEAGBO, CALEB ADEWUMI

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OUTLINE

• Introduction• Definition of USN• Epidemiology• Types of USN• Mechanism of USN• Identification of USN • Assessment of USN• Prognosis• Treatment and Rehabilitation• References

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Introduction• Unilateral Spatial Neglect (USN) is

a disabling feature and a common behavioural syndrome in patients following stroke (Swan, 2001; Parton et al,

2004; Menon-Nair et al, 2007).

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Introduction cont

• It is a neuropsychological disorder and characterized by the inability to orient or respond to stimuli appearing on the side contralateral to the brain lesion (Bowen et al, 1999; Gbiri et

al, 2014).

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Introduction cont• The presence of USN may be

determined on the basis of a left-right asymmetry in performance of a variety of measures such as line and letter cancellation, reading, drawing, mental imagery, attention to the body and naturalistic action tasks (Pierce and Buxbaum, 2002).

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Introduction cont

• USN is associated with a greater risk for falls, longer rehabilitation, poor functional recovery and degrading Quality of Life (QoL) (Paolucci et al, 2001; Hamzat et al, 2012; Choi et al, 2013).

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Introduction cont• To counteract the disabling effects of

USN it is critical that rehabilitation professionals be astute at identifying the impairment, assessing the patients by using tools with strong psychometric properties and providing interventions aimed at reducing the impairment and functional sequelae (Parton et al, 2004; Menon-Nair et al, 2007).

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Definition of USN• USN has been defined as a failure to

report, respond or orient to stimuli in the contralesional hemispace of the brain lesion and the failure cannot be attributed to sensory or motor impairments (Heilman et al, 1993).

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Epidemiology• The reported prevalence of USN

varies widely from 10% to 82% following right-hemisphere stroke and from 15% to 65% following left-hemisphere stroke (Swan, 2001; Plummer et al, 2003).

• USN was observed in about a third of the participants in the study conducted by Hamzat et al, (2012).

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Epidemiology cont• The clinical impression that USN

occurs more frequently following right brain damage than left brain damage has been supported in many systematic review of published data, some authors have however documented a mild and sometimes non-significant difference between right and left brain damaged patients (Bowen et al, 1999; Plummer et al, 2003; Gbiri et al, 2014).

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Types of USN• There are two main classification

systems for USN. It can be described in terms of the modality in which the behaviour is elicited (representational (Fig 1), motor, or sensory (Fig 2)) or by the distribution of the abnormal behaviour (personal or spatial) (Heilman et al, 1994; Plummer et al, 2003).

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Fig 1: Representational neglect in a patient with USN (Chatterjee, 2003; Bartolomeo et al, 2012).

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Fig 2: A picture showing patients with sensory neglect

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Mechanism of USN• USN can occur as a result of lesions

at different anatomical sites (such as posterior parietal cortex, frontal lobe, cingulate gyrus, striatum and thalamus) and varies in its presentation (Swan, 2001; Kim et al, 2011).

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Identification of USN • Patients with USN only• Patients with USN and

hemianopia • Patients with extinction• Patients that are anosognosic

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Assessment of USN

• Cancellation Tests• Bells Test (Fig 2)• Line Bisection test• Albert's test• Copying and Drawing Tests• Figure copying• Clock drawing

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Fig 3: Bells test for assessing Unilateral Spatial Neglect (USN) (Zeltzer and Menon, 2014).

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Assessment of USN cont

• Reading• Writing• Comb and Razor Test• The Behavioural Inattention Test• Semi-structured Scale for

Functional Evaluation of USN• The Catherine Bergego Scale

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Prognosis• The rate of recovery from USN is

greatest in the first month post stroke and recovery can range from a persistent USN to complete recovery (Cassidy et al, 1998; Swan, 2001; Gbiri et al, 2014).

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Prognosis cont

• USN has been associated with poor outcome measures on functional activities and thus patients require more assistance at discharge than patients without USN (Katz et al, 1999; Swan, 2001; Hamzat et al, 2012, Bowen et al, 2013).

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Treatment and Rehabilitation

• Visual ScanningPatients with USN are encouraged to explore the neglected visual field by performing tasks on neglected visual field side. The treatment often includes visual target that the patient uses as an anchor while scanning.

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Treatment and Rehabilitation cont

• Sensory StimulationVisual/Verbal/Auditory CuesLimb ActivationCaloric StimulationEye Patching/Hemiglasses

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Treatment and Rehabilitation cont

• Sensory Stimulation contNeck/Hand Vibration or

StimulationTrunk RotationVisuo-motor ImageryConstraint-Induced TherapyOptokinetic Stimulation

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Treatment and Rehabilitation cont

• Video FeedbackThis treatment involves filming the patient while he does specific activities. The Physiotherapist and patient then watch the video together. The Physiotherapist points out to the patient how they are neglecting their body and discuss strategies use the part.

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Treatment and Rehabilitation cont

• Pharmacological TherapyThis involves the use of specific medications (dopamine-agonist drugs) to improve visual attention skills. A physician must prescribe these medications.

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Conclusion

• The presence of USN has been said to be one of the major factors that affect the Activities of Daily Living (ADL) most especially the self-care activities and it is considered to be a major cause of disability in post-stroke patients

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Conclusion cont

• Therefore it is important to understand the management of USN beyond the acute care period. Indeed, it might be argued that the rehabilitation phase provides the ideal opportunity for in-depth assessment and treatment

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References• Bowen A, Hazelton C, Pollock A, Lincoln NB (2013). Cognitive rehabilitation for

spatial neglect following stroke (Review). In: The Cochrane Collaboration. Pp 1-24. John Wiley & Sons, Ltd.

• Bowen A, McKenna K, Tallis RC (1999). Reasons for variability in the reported rate of occurrence of Unilateral Spatial Neglect after Stroke. Stroke 30: 1196-1202.

• Cassidy TP, Lewis S, Gray CS (1998). Recovery from visuospatial neglect in stroke patients. Journal of Neurology, Neurosurgery and Psychiatry 64:555–557.

• Chatterjee A (2003). Neglect: A Disorder of Spatial Attention. In Neurological Foundations of Cognitive Neuroscience. Pp 1-26. The MIT Press Cambridge, Massachusetts, London, England

• Choi Y, Lee S, Kim E (2013). Awareness, Assessment, and Intervention of Unilateral Neglect: A Survey of Korean Occupational Therapists. Journal of Next Generation Information Technology (JNIT) 4(8): 245-250.

• Gbiri CA, Akinpelu AO, Odole AC, Adejare OA (2014). Assessment of Unilateral Spatial Neglect in People Post-Stroke: Development of Gbiri Distracter Test. Scottish Journal of Arts, Social Sciences and Scientific Studies 19:2 114-122.

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References cont• Hamzat TK, Oyedele SY, Peters GO (2012). Clinical and demographic correlates of

unilateral spatial neglect among Community-dwelling Nigerian stroke survivors. African Journal of Neurological Sciences 23(1): 3-7.

• Heilman KM, Valenstein E, Watson RT (1994). The what and how of neglect. Neuropsychological Rehabilitation 4: 133–139.

• Heilman KM, Watson RT, Valenstein E (1993). Neglect and related disorders. In: Clinical Neuropsychology. 2nd Edition Pp 243–294. New York, NY: Oxford University Press.

• Katz N, Hartman-Maeir A, Ring H, Soroker N (1999). Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect. Archives of Physical Medical and Rehabilitation 80: 379 –384.

• Kim YM, Chun MH, Yun GJ, Song YJ, Young HE(2011). The Effect of Virtual Reality Training on Unilateral Spatial Neglect in Stroke Patients. Annals of Rehabilitation Medicine 35: 309-315

• Menon-Nair A, Korner-Bitensky N, Ogourtsova T (2007). Occupational Therapists’ Identification, Assessment, and Treatment of Unilateral Spatial neglect during Stroke Rehabilitation in Canada Stroke 38: 2556-2562.

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References cont• Paolucci S, Antonucci G, Grasso G, Pizzamiglio L (2001). The role of

unilateral spatial neglect in rehabilitation of right brain-damaged ischemic stroke patients: a matched comparison. Archives of Physical Medical and Rehabilitation 82: 743–749.

• Parton A, Malhotra P, Husain M (2004). Hemispatial neglect. Journal of Neurology, Neurosurgery and Psychiatry 75: 13–21.

• Plummer P, Morris ME, Dunai J (2003). Assessment of unilateral neglect. Physical Therapy. 83: 732–740.

• Pierce SR, Buxbaum LJ (2002). Treatment of Unilateral Neglect: A review. Archives of Physical Medical and Rehabilitation 83: 256-268.

• Swan L (2001). Unilateral Spatial Neglect. Physical Therapy 81: 1572-1580.

• Zeltzer L, Menon A (2014). Bells test. Available @ http://strokengine.ca/assess/module_bt_intro-en.html Retrieved on June 10, 2014.

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