Visuomotor misalignment induced through immersive virtual reality to improve spatial neglect: a case-series study.

One evidence-based treatment for spatial neglect is prism adaptation (PA) treatment. PA after-effects, i.e., the implicit shifts in the arm reaching position toward the neglected side of space after prism removal, are considered fundamental to PA treatment effects. In the present study, the arm reaching position was shifted through a visuomotor misalignment procedure using immersive virtual reality (VR). To examine whether this procedure might have a beneficial impact on spatial neglect, we conducted a multi-baseline experiment in three individuals with chronic left-sided neglect post stroke. Improved spatial neglect was observed in all participants immediately after 5 sessions with two rounds in each. Two participants demonstrated lasting or continuous improvement two weeks later. Participants' pattern of brain lesions did not appear to clearly explain performance differences. The findings suggest that VR-induced visuomotor misalignment may improve spatial neglect immediately after a multi-session treatment course. The optimal number of sessions will be determined by future studies with a larger sample size, which may also elucidate the number of sessions sufficient for sustained improvement in most patients. Further investigations will identify the neural mechanisms underlying VR-induced visuomotor misalignment, which may or may not be identical to PA after-effects.

Effect of Missed Items on the Reliability of the Kessler Foundation Neglect Assessment Process.

OBJECTIVE: To determine the maximum permissible number of missed items on the 10-item Catherine Bergego Scale administered after the Kessler Foundation Neglect Assessment Process (KF-NAP). Secondary objectives were to determine the frequency, characteristics, and most commonly cited reasons reported for missed items. DESIGN: Retrospective diagnostic accuracy study. SETTING: Sixteen inpatient rehabilitation facilities in the United States. PARTICIPANTS: A consecutive clinical sample of 4256 patients (N=4256) with stroke or other neurologic deficits who were assessed for spatial neglect with the KF-NAP. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: Catherine Bergego Scale via KF-NAP. RESULTS: The majority (69.7%) of patients had at least 1 missed item on their KF-NAP. Among those with missed items, it was most common to have 2 missed items (51.4%), and few had more than 3 missed items (11.3%). The most commonly missed items were Collisions (37.2%), Cleaning After Meals (36.1%), Meals (34.0%), and Navigation (19.7%). The most commonly reported reasons for missed items included time constraints, cognitive or communication deficits, and behavior or refusal of the therapy session. These reasons were reported for nearly all item types. Item-specific reasons were also commonly reported, such as a lack of a needed resource for task completion or low functional status of the patient. Prorated scoring of measures with up to 3 missed items maintained an acceptable level of concordance with complete measures (Lin's Concordance Correlation Coefficient=0.96, 95% CI, 0.9478-0.9626) for the combination of 3 missed items with lowest concordance. CONCLUSIONS: Clinicians should make every effort to capture all items on the KF-NAP. However, missed items occur in the majority of cases because of patient factors and barriers inherent to the inpatient hospital setting. When missed items are necessary, clinicians can confidently interpret a prorated score when 7 or more items are scored.

Spatial exploration strategy training for spatial neglect: A pilot study.

Spatial neglect is a syndrome due to impaired neural networks critical for spatial attention and related cognitive and motor functions. Affected individuals also have impaired self-awareness of their own neglect symptoms. The present randomized controlled study was the first proof-of-concept pilot examining the multi-context treatment approach using a protocol of spatial exploration strategy training in one brief session (20-30 minutes). The therapist provided supportive feedback and semi-structured guidance to promote strategy learning and self-discovery of omission errors. 40 patients with left-sided neglect after right brain stroke were included. The results showed that the treatment reduced lateralized bias toward the ipsilesional side of space but did not improve overall detection performance. Impaired general self-awareness of daily-life spatial difficulties was found independent of treatment outcome. This implies that judgment regarding responsiveness to treatment should not be made based on an awareness interview or the severity of neglect symptoms. Lastly, the treatment showed the potential of improving online contextual self-awareness of spatial abilities. A collaborative and interactive approach that focuses on helping the patient self-discover, monitor and self-manage their errors, appears to have a potential for decreasing neglect symptoms. Future studies are required to examine additional aspects of the multi-context treatment approach.

Editorial for special issue on neglect rehabilitation.

It is clear already that in current and future years more people will suffer from stroke, whether related to COVID-19 or not, and given its prevalence, many more people's lives will be affected by neglect. Here we hope to have contributed to its possible amelioration with highlights of the latest thinking on neglect diagnosis, prevalence and treatment.

Current clinical practice in the screening and diagnosis of spatial neglect post-stroke: Findings from a multidisciplinary international survey.

Spatial neglect has profound implications for quality of life after stroke, yet we lack consensus for screening/diagnosing this heterogeneous syndrome. Our first step in a multi-stage research programme aimed to determine which neglect tests are used (within four categories: cognitive, functional, neurological and neuroimaging/neuromodulation), by which stroke clinicians, in which countries, and whether choice is by professional autonomy or institutional policy. 454 clinicians responded to an online survey: 12 professions (e.g., 39% were occupational therapists) from 33 countries (e.g., 38% from the UK). Multifactorial logistic regression suggested inter-professional differences but fewer differences between countries (Italy was an outlier). Cognitive tests were used by 82% (particularly by psychologists, cancellation and drawing were most popular); 80% used functional assessments (physiotherapists were most likely). 20% (mainly physicians, from Italy) used neuroimaging/ neuromodulation. Professionals largely reported clinical autonomy in their choices. Respondents agreed on the need for a combined approach to screening and further training. This study raises awareness of the translation gap between theory and practice. These findings lay an important foundation to subsequent collaborative action between clinicians, researchers and stroke survivors to reach consensus on screening and diagnostic measures. The immediate next step is a review of the measures' psychometric properties.

Improved stability of long-duration sitting in spatial neglect after a single session of prism adaptation.

Spatial neglect after right brain stroke affects balance, and improvements in sitting balance after prism adaptation have been demonstrated using short-duration center of pressure (CoP) data. We present long-duration (5 min) CoP and trunk muscles electromyography recordings of a 61-year-old man with left-sided spatial neglect, before and after a single session of prism adaptation. His CoP-derived measures showed improved balance and postural stability in both the anterior-posterior and medial-lateral directions after prism adaptation. Concurrently, asymmetry in neuromuscular activations was reduced. The findings suggest that improved sitting balance may be associated with more symmetrical activation of trunk muscles after prism adaptation.

Frontal lesions predict response to prism adaptation treatment in spatial neglect: A randomised controlled study.

Spatial neglect commonly follows right hemisphere stroke. It is defined as impaired contralesional stimulus detection, response, or action, causing functional disability. While prism adaptation treatment is highly promising to promote functional recovery of spatial neglect, not all individuals respond. Consistent with a primary effect of prism adaptation on spatial movements, we previously demonstrated that functional improvement after prism adaptation treatment is linked to frontal lobe lesions. However, that study was a treatment-only study with no randomised control group. The current study randomised individuals with spatial neglect to receive 10 days of prism adaptation treatment or to receive only standard care (control group). Replicating our earlier results, we found that the presence of frontal lesions moderated response to prism adaptation treatment: among prism-treated patients, only those with frontal lesions demonstrated functional improvements in their neglect symptoms. Conversely, among individuals in the standard care control group, the presence of frontal lesions did not modify recovery. These results suggest that further research is needed on how frontal lesions may predict response to prism adaptation treatment. Additionally, the results help elucidate the neural network involved in spatial movement and could be used to aid decisions about treatment.

Which perseverative behaviors are symptoms of spatial neglect?

Spatial neglect is a characterized by a failure to attend or make movements towards left-sided stimuli. Common paper-and-pencil tasks to diagnose spatial neglect are sensitive to perseverative errors, including additional marks over already cancelled targets and "scribbling" out a target. Here, we examine whether functionally distinct perseverative behaviors are related to spatial neglect. Line cancellation tasks of 45 healthy controls and 220 right-hemisphere stroke survivors were examined for recurrent marks (RM) and continuous marks (CM) perseverations. We found that RM perseveration correlated with neglect severity, while CM perseveration did not. Examination of lesion profiles for the two groups indicated distinct anatomical correlates, with RM lesions overlapping regions implicated in spatial neglect including the rolandic operculum, superior temporal gyrus, and inferior parietal lobule.

Impact of spatial neglect on stroke rehabilitation: evidence from the setting of an inpatient rehabilitation facility.

OBJECTIVE: To examine the impact of spatial neglect on rehabilitation outcome, risk of falls, and discharge disposition in stroke survivors. DESIGN: Inception cohort. SETTING: Inpatient rehabilitation facility (IRF). PARTICIPANTS: Individuals with unilateral brain damage after their first stroke (N=108) were assessed at IRF admission and discharge. At admission, 74 of them (68.5%) demonstrated symptoms of spatial neglect as measured using the Kessler Foundation Neglect Assessment Process (KF-NAP). INTERVENTIONS: Usual and standard IRF care. MAIN OUTCOME MEASURES: The FIM, Conley Scale, number of falls, length of stay (LOS), and discharge disposition. RESULTS: The greater the severity of spatial neglect (higher KF-NAP scores) at IRF admission and the lower the FIM scores at admission as well as at discharge. Higher KF-NAP scores also correlated with greater LOS and lower FIM improvement rate. The presence of spatial neglect (KF-NAP score>0), but not Conley Scale scores, predicted falls such that participants with spatial neglect fell 6.5 times more often than those without symptoms. More severe neglect, indicated by KF-NAP scores at IRF admission, reduced the likelihood of returning home at discharge. A model that took spatial neglect and other demographic, socioeconomic, and clinical factors into account predicted home discharge. Rapid FIM improvement during IRF stay and lower annual income level were significant predictors of home discharge. CONCLUSIONS: Spatial neglect after a stroke is a prevalent problem and may negatively affect rehabilitation outcome, risk of falls, and LOS.

Kessler Foundation Neglect Assessment Process uniquely measures spatial neglect during activities of daily living.

OBJECTIVES: To explore the factor structure of the Kessler Foundation Neglect Assessment Process (KF-NAP), and evaluate the prevalence and clinical significance of spatial neglect among stroke survivors. DESIGN: Inception cohort. SETTING: Inpatient rehabilitation facility (IRF). PARTICIPANTS: Participants (N=121) with unilateral brain damage from their first stroke were assessed within 72 hours of admission to an IRF, and 108 were assessed again within 72 hours before IRF discharge. INTERVENTIONS: Usual and standard IRF care. MAIN OUTCOME MEASURES: During each assessment session, occupational therapists measured patients' functions with the KF-NAP, FIM, and Barthel Index (BI). RESULTS: The KF-NAP showed excellent internal consistency with a single-factor structure. The exploratory factor analysis revealed the KF-NAP to be unique from both the FIM and BI even though all 3 scales were correlated. Symptoms of spatial neglect (KF-NAP>0) were present in 67.8% of the participants at admission and 47.2% at discharge. Participants showing the disorder at IRF admission were hospitalized longer than those showing no symptoms. Among those presenting with symptoms, the regression analysis showed that the KF-NAP scores at admission negatively predicted FIM scores at discharge, after controlling for age, FIM at admission, and length of stay. CONCLUSIONS: The KF-NAP uniquely quantifies symptoms of spatial neglect by measuring functional difficulties that are not captured by the FIM or BI. Using the KF-NAP to measure spatial neglect, we found the disorder persistent after inpatient rehabilitation, and replicated previous findings showing that spatial neglect adversely affects rehabilitation outcome even after prolonged IRF care.

Identifying Spatial Neglect in Chronic Right Hemisphere Stroke Survivors Using the RHDBank Outcomes.

PURPOSE: The chronicity of spatial neglect (SN) and the utility of existing diagnostic measures used by speech-language pathologists remain poorly understood. In this retrospective study, we examined how the RHDBank test battery informs the identification of SN after right hemisphere brain damage (RHD) during the chronic phase of recovery. METHOD: Data from 29 right hemisphere stroke survivors were extracted from the RHDBank, including SN tests, for which we performed laterality index scoring: a 51-item demographic survey, the Apples Test, the Indented Paragraph Test, and the clock drawing task from the Cognitive Linguistic Quick Test (CLQT). Two groups (SN+ and SN-) were identified using the Apples Test. A hierarchical cluster analysis explored CLQT performance clusters in association with SN, and group comparisons of demographic variables and test scores were conducted. RESULTS: Ten patients were identified as having SN+ (34%) using the Apples Test. The Indented Paragraph Test and the CLQT's clock drawing test identified only two of the 20 stroke survivors with SN+. Cluster analyses showed that domain and task scores on the CLQT carried information to classify participants into SN+ and SN- in concordance with performance on the Apples Test. Participants in the SN+ cluster had moderately impaired attention and executive function skills and mildly impaired visuospatial skills. CONCLUSIONS: The Apples Test differentiated SN in a group of chronic right hemisphere stroke survivors. Using multiple measures from the CLQT seemed to capture a greater range of problems than clock drawing and paragraph reading tests alone. Therefore, the RHDBank test battery as a whole-and in part the CLQT, Apples Test, and Indented Paragraph Test-can detect certain subtypes of SN in the chronic deficit profile after RHD and is a starting point for diagnostic integration by speech-language pathologists.

An International and Multidisciplinary Consensus on the Labeling of Spatial Neglect Using a Modified Delphi Method.

Survivors of neurologic injury (most commonly stroke or traumatic brain injury) frequently experience a disorder in which contralesionally positioned objects or the contralesional features of individual objects are often left unattended or underappreciated. The disorder is known by >200 unique labels in the literature, which potentially causes confusion for patients and their families, complicates literature searches for researchers and clinicians, and promotes a fractionated conceptualization of the disorder. The objective of this Delphi was to determine if consensus (≥75% agreement) could be reached by an international and multidisciplinary panel of researchers and clinicians with expertise on the topic. To accomplish this aim, we used a modified Delphi method in which 66 researchers and/or clinicians with expertise on the topic completed at least 1 of 4 iterative rounds of surveys. Per the Delphi method, panelists were provided with results from each round prior to responding to the survey in the subsequent round with the explicit intention of achieving consensus. The panel ultimately reached consensus that the disorder should be consistently labeled spatial neglect. Based on the consensus reached by our expert panel, we recommend that researchers and clinicians use the label spatial neglect when describing the disorder in general and more specific labels pertaining to subtypes of the disorder when appropriate.

Spouses of stroke survivors may be at risk for poor cognitive functioning: a cross-sectional population-based study.

BACKGROUND: Stroke often results in chronic disability and the need for long-term assistance, which is provided in large part by spouses. Stroke caregivers experience poorer health and well-being compared with non-caregivers, but less is known about the specific toll that caregiving may exact on cognitive functioning. OBJECTIVE: To investigate whether persons caring for a spouse who experienced a recent stroke may be at risk for poor cognitive functioning compared with non-caregivers. METHODS: Existing data from the United States' Health and Retirement Study (HRS) were used to identify 146 caregivers from among couples in which 1 individual reported surviving a recent stroke and experiencing functional limitations. This cross-sectional population-based analysis compared the stroke caregivers with 3,416 non-caregivers in time orientation, working memory, semantic memory, learning, and episodic memory. RESULTS: Overall, the caregiver group was considerably more disadvantaged than the non-caregiver group in terms of background characteristics, socioeconomic status, health, and well-being. Results of weighted Poisson regression models indicated that stroke caregivers were at risk for poorer performance than non-caregivers in working memory, semantic memory, learning, and episodic memory. The gap between stroke caregivers and non-caregivers in episodic memory remained after adjusting for systematic differences between the 2 groups across an array of risk factors. CONCLUSIONS: Spousal caregivers of stroke survivors may be at risk for poor cognitive functioning. More work is needed to identify the processes that may contribute to the diminished cognitive capacity among these adults so that interventions may be developed to reduce caregiver burden and promote cognitive health.

Prism Adaptation Treatment for Right-Sided and Left-Sided Spatial Neglect: A Retrospective Case-Matched Study.

Objective: To compare the effectiveness of prism adaptation treatment (PAT) between patients with right- and left-sided spatial neglect (SN). Design: Retrospective case-matched design. Setting: Inpatient rehabilitation hospitals and facilities. Participants: A total of 118 participants were selected from a clinical dataset of 4256 patients from multiple facilities across the United States. Patients with right-sided SN (median age: 71.0 [63.5-78.5] years; 47.5% female; 84.8% stroke, 10.1% traumatic/nontraumatic brain injury) were matched 1:1 with patients with left-sided SN (median age: 70.0 [63.0-78.0] years; 49.2% female; 86.4% stroke, 11.8% traumatic/nontraumatic brain injury) based on age, neglect severity, overall functional ability at admission, and number of PAT sessions completed during their hospital stay. Intervention: Prism adaptation treatment. Main Outcome Measures: Primary outcomes were pre-post change on the Kessler Foundation Neglect Assessment Process (KF-NAP) and the Functional Independence Measure (FIM). Secondary outcomes were whether the minimal clinically important difference was achieved for pre-post change on the FIM. Results: We found greater KF-NAP gain for patients with right-sided SN than those with left-sided SN (Z = 2.38, P=.018). We found no differences between patients with right-sided and left-sided SN for Total FIM gain (Z=-0.204, P=.838), Motor FIM gain (Z=-0.331, P=.741), or Cognitive FIM gain (Z=-0.191, P=.849). Conclusions: Our findings suggest PAT is a viable treatment for patients with right-sided SN just as it is for patients with left-sided SN. Therefore, we suggest prioritizing PAT within the inpatient rehabilitation setting as a treatment to improve SN symptoms regardless of brain lesion side.

Psychometric evaluation of neglect assessment reveals motor-exploratory predictor of functional disability in acute-stage spatial neglect.

OBJECTIVE: To determine the psychometric properties of 2 neglect measures, the Behavioral Inattention Test (BIT)-conventional and the Catherine Bergego Scale (CBS), in acute spatial neglect. Spatial neglect is a failure or slowness to respond, orient, or initiate action toward contralesional stimuli, associated with functional disability that impedes stroke recovery. Early identification of specific neglect deficits may identify patients likely to experience chronic disability. However, psychometric evaluation of assessments has focused on subacute/chronic populations. DESIGN: Correlational/psychometric study. SETTING: Inpatient rehabilitation hospital. PARTICIPANTS: Screening identified 51 consecutive patients with a right-hemisphere stroke with left neglect (BIT score <129 or CBS score >11) tested an average of 22.3 days poststroke. INTERVENTIONS: Not applicable. MAIN OUTCOME MEASURES: We obtained BIT, CBS, and Barthel Index assessments for each participant and clinical and laboratory measures of perceptual-attentional and motor-intentional deficits. RESULTS: The BIT showed good reliability and loaded onto a single factor. Consistent with our theoretical prediction, principal components analysis of the CBS identified 2 underlying factors: Where perceptual-attentional items (CBS-PA) and embodied, motor-exploratory items (CBS-ME). The CBS-ME uniquely predicted deficits in activities of daily living (ADLs) assessed by using the Barthel Index, but did not predict clinical and laboratory assessments of motor-intentional bias. More severe neglect on the CBS-PA correlated with greater Where perceptual-attentional bias on clinical and laboratory tests, but did not uniquely predict deficits in ADLs. CONCLUSIONS: Our results indicate that assessments of spatial neglect may be used to detect specific motor-exploratory deficits in spatial neglect. Obtaining CBS-ME scores routinely might improve the detection of acute-stage patients with spatial action deficits requiring increased assistance that may persist to the chronic stage.

Functional assessment of spatial neglect: a review of the Catherine Bergego scale and an introduction of the Kessler foundation neglect assessment process.

Spatial neglect is a debilitating poststroke neurocognitive disorder associated with prolonged hospitalization and poor rehabilitation outcomes. The literature suggests a high prevalence of this disorder, but clinicians have difficulty reliably identifying affected survivors. This discrepancy may result from suboptimal use of validated neglect assessment procedures. In this article, we suggest use of a validated assessment tool that is sensitive to identification of neglect and its functional consequences - the Catherine Bergego Scale (CBS). We provide detailed item-by-item instructions for observation and scoring - the Kessler Foundation Neglect Assessment Process (KF-NAP). Rehabilitation researchers may be able to use the CBS via the KF-NAP to measure ecological outcomes and specific, separable perceptual-attentional and motor-exploratory spatial behaviors.

An apparent-motion confound causes the negative exogenous cuing effect at SOAs with larger numbers of target locations.

Salient but irrelevant stimuli seem to cause an automatic orienting of covert attention, facilitating the detection of targets at the cued location for a brief period of time. However, this finding is highly dependent on the number of possible target locations, at least when the simple detection of targets is all that the task requires. Whereas small numbers of possible target locations (e.g., 2 or 3) produce the well-known advantage in response time for valid cue trials (i.e., a positive cuing effect), larger numbers of possible target locations (e.g., 6 or 8) produce a negative cuing effect. If not explained in terms of a nonattentional mechanism, this latter finding raises serious questions about the standard interpretation of positive cuing effects. The present experiment tested a particular nonattentional mechanism: that a confound between target presence and apparent motion, which occurs only on invalid cue trials, is responsible for negative cuing effect. We reduced or eliminated this confound by the use of a new type of catch trial and eliminated the negative cuing effect with large numbers of target locations.