Synonyms for neglect are: to ignore, to overlook or to pay no attention to. That pretty much summarises the obscure and sometimes almost comically complex symptoms of hemispatial neglect after stroke. 

When the world gets smaller

Neglect is primarily a disorder of attention. Between 50 and  80% of stroke survivors suffer from neglect after stroke. It is usually caused by a large stroke more likely in the right hemisphere and is heterogeneous, which means that most patients do not exhibit all syndromes. 

Neglect is marked by the inattention to one side of the body or space.

The most typical aspect is the failure to orientate or respond to stimuli such as visual, somatosensory, auditory and kinaesthetic stimuli to or on the paretic side. 

Due to the neglect, independency and the rehabilitation process can be critically in danger.  (1,2)

The background of neglect

Especially in the early phase after stroke, patients present a wide variety of symptoms that can be connected to neglect. Some of the obvious signs of neglect can spontaneously improve within the first few weeks. Other more severe neglect patients need various treatments to overcome or cope with the remaining symptoms. (2,3)

The core deficit of neglect is attentional bias. Contributory deficits are lack of arousal, vigilance, visuospatial working memory and a reduced capacity of attention resources. (3)

How does neglect effects a life?

  • Here is a list of behavioral patterns that are noticeable in therapy or at home.
  • Failure to notice external stimuli on one side of the room
  • Failure to notice external stimuli on one side of the body
  • Failure to explore or recognize multiple objects on the table or in the room especially on one side
  • Failing to complete daily activities
    • Eating only half of the food on a plate
    • Grooming only half of the face
  • Unable to read or tell time because they can’t find one side of the page or clock (4)

Patients with neglect usually have a decreased awareness of there deficits, this can increase the complexity and time of rehabilitation. It may also hinder the therapy response and produces a risk of accidents. A lot of patients recover spontaneously from the more noticeable syndromes, but evidence shows, that remaining cognitive impairments related to attention may stay forever. (2, 3, 5)
Although neglect is primarily a cognitive deficit, it can affect functional performance in a negative way and can interfere with mobility activities such as gait and balance. Measured with assessments for daily activities like the Barthel Index, patients with neglect score significantly lower. (2, 5, 6)

How to test for neglect?
There are approximately 28 standardized tests for predicting neglect after stroke. None of them really encompass the whole picture. The problem with testing neglect is the complexity of it. The tests range from classic pencil-and-paper- tests to “the backing tray task” as well as questionaries and wheelchair obstacle courses.
Until now, there is no test available that can assess all aspects of neglect. However, behavioral assessments can be used for detecting otherwise unnoticed deficits. (7)

Can neglect be cured?
According to studies neglect can not be fully cured. In a stressful situation, the attention deficit will always be noticeable in some form. However, it can be trained.

Coping with known and learned strategies, such as exploring combined with the awareness of the deficit can enable normal life.

Accompanying symptoms

Neglect and extinction

A related phenomenon to neglect is extinction.
Extinction is the failure to report a stimulus on one body side in the presence of a competing stimulus on the other side. That means that when both hands are being touched only the less effected hand feels the touch. Or two cars are passing, one on either side, only the car on the less affected side will be noticed. Neglect and extinction often coexist and extinction symptoms can still be present after the main recovery of neglect. (3)

Anosognosia and awareness

Anosognosia is the lack of insights or awareness of impairment. This means that the patients are totally unaware of their deficits, going so far as even denying them when directly confronted. For stroke patients, it is commonly combined with neglect. As neglect affects the ability to perform daily tasks, anosognosia can hinder the progress of rehabilitation and is a safety concern due to the lack of awareness. Similar to neglect, a patient with anosognosia can partly recover, but it still has an effect on their daily life and can become chronic. (1, 8)

Hemianopsia

Hemianopsia or quadrantanopsia is unlike neglect, not an attention deficit, but a visual deficit. Hemianopsia obeys the vertical meridian and presents certain patterns. Another distinction is that they are fully aware of the deficit and thereby poses the ability to learn to cope with it. However, in the case of severe neglect, it can be difficult to detect additional hemianopsia. (3)

Rehabilitation

As said before, some signs of neglect might spontaneously improve within a few weeks after a stroke, but most patients will need treatment in some form. Knowing that neglect is heterogeneous in its symptoms, different approaches have been tried. So far there is no “most effective” concept of rehabilitation.
One aspect that is difficult in treating anosognosia is in combination with neglect. The unawareness of the deficits negatively affects the final outcome.

The main approach at the moment is to address the core deficit and reorient the attention to the neglected side. Exploring objects on the neglected side and visual scanning therapy is a known strategy. Brain stimulation techniques, optical prisms therapy, vestibular stimulation and vibration on the less affected side on the neck combined with other technics can be effective.  (2, 3, 9)

Mirror therapy is another promising therapy attempt regarding neglect, as is patching the less affected eye to increase attention on the neglected side. Overall there are three things to say. First, a combination of therapy strategies regarding all aspects of the complex syndrome of neglect may be more effective than only one strategy. Second, due to the complexity of neglect, individual therapy is needed in any case. And third, as all attention strategies are linked to motivation, neglect therapy should focus on that aspect as well. (10, 11, 12)

What’s new?

New technology can and will change at least the exploring therapy. Assessments and therapies on computers and tablets already include multiple aspects of neglect and attention therapy.

If you want to read up on some other articles about neglect!

What are your thoughts on the complex syndrome of neglect?

What is your approach of choice?

Bibliography

  1. Grattan, E. S., Skidmore, E. R., & Woodbury, M. L. (2018). Examining Anosognosia of Neglect. OTJR: Occupation, Participation and Health, 38(2), 113–120. https://doi.org/10.1177/1539449217747586
  2. Kutlay, S., Genç, A., Gök, H., Öztuna, D., & Küçükdeveci, A. (2018). Kinaesthetic ability training improves unilateral neglect and functional outcome in patients with stroke: A randomized control trial. Journal of Rehabilitation Medicine, 50(2), 159–164. https://doi.org/10.2340/16501977-2301
  3.  Li, K., & Malhotra, P. A. (2015). Spatial neglect. Practical Neurology, 15(5), 333–339. https://doi.org/10.1136/practneurol-2015-001115
  4. Caggiano, P., & Jehkonen, M. (2018). The ‘Neglected’ Personal Neglect. Neuropsychology Review, 28(4), 417–435. https://doi.org/10.1007/s11065-018-9394-4
  5. Meyer, S., De Bruyn, N., Lafosse, C., Van Dijk, M., Michielsen, M., Thijs, L., … Verheyden, G. (2016). Somatosensory Impairments in the Upper Limb Poststroke. Neurorehabilitation and Neural Repair, 30(8), 731–742. https://doi.org/10.1177/1545968315624779
  6. Aravind, G., & Lamontagne, A. (2018). Effect of visuospatial neglect on spatial navigation and heading after stroke. Annals of Physical and Rehabilitation Medicine, 61(4), 197–206. https://doi.org/10.1016/j.rehab.2017.05.002
  7. Azouvi, P. (2017). The ecological assessment of unilateral neglect. Annals of Physical and Rehabilitation Medicine, 60(3), 186–190. https://doi.org/10.1016/j.rehab.2015.12.005
  8. Nurmi (née Laihosalo), M. E., & Jehkonen, M. (2014). Assessing anosognosias after stroke: A review of the methods used and developed over the past 35 years. Cortex, 61, 43–63. https://doi.org/10.1016/j.cortex.2014.04.008
  9.  Kwon, J.-S. (2018). Therapeutic Intervention for Visuo-Spatial Neglect after Stroke: A Meta-Analysis of Randomized Controlled Trials. Osong Public Health and Research Perspectives, 9(2), 59–65. https://doi.org/10.24171/j.phrp.2018.9.2.04
  10. Coleman, E. R., Moudgal, R., Lang, K., Hyacinth, H. I., Awosika, O. O., Kissela, B. M., & Feng, W. (2017). Early Rehabilitation After Stroke: a Narrative Review. Current Atherosclerosis Reports, 19(12), 59. https://doi.org/10.1007/s11883-017-0686-6
  11. Azouvi, P., Jacquin-Courtois, S., & Luauté, J. (2017). Rehabilitation of unilateral neglect: Evidence-based medicine. Annals of Physical and Rehabilitation Medicine, 60(3), 191–197. https://doi.org/10.1016/j.rehab.2016.10.006
  12. Spaccavento, S., Cellamare, F., Falcone, R., Loverre, A., & Nardulli, R. (2017). Effect of subtypes of neglect on functional outcome in stroke patients. Annals of Physical and Rehabilitation Medicine, 60(6), 376–381. https://doi.org/10.1016/j.rehab.2017.07.245