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

Neural Mechanisms of Prism Adaptation in Healthy Adults and Individuals with Spatial Neglect after Unilateral Stroke: A Review of fMRI Studies

Functional disability due to spatial neglect hinders recovery in up to 30% of stroke survivors. Prism adaptation treatment (PAT) may alleviate the disabling consequences of spatial neglect, but we do not yet know why some individuals show much better outcomes following PAT than others. The goal of this scoping review and meta-analysis was to investigate the neural mechanisms underlying prism adaptation (PA). We conducted both quantitative and qualitative analyses across fMRI studies investigating brain activity before, during, and after PA, in healthy individuals and patients with right or left brain damage (RBD or LBD) due to stroke. In healthy adults, PA was linked with activity in posterior parietal and cerebellar clusters, reduced bilateral parieto-frontal connectivity, and increased fronto-limbic and sensorimotor network connectivity. In contrast, RBD individuals with spatial neglect relied on different circuits, including an activity cluster in the intact left occipital cortex. This finding is consistent with a shift in hemispheric dominance in spatial processing to the left hemisphere. However, more studies are needed to clarify the contribution of lesion location and load on the circuits involved in PA after unilateral brain damage. Future studies are also needed to clarify the relationship of decreasing resting state functional connectivity (rsFC) to visuomotor function

A special issue on cognitive rehabilitation

International audienc

Kessler Foundation Neglect Assessment Process (KF-NAP™) 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\u27 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\u3e0) 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

Prism Adaptation Treatment Predicts Improved Rehabilitation Responses in Stroke Patients with Spatial Neglect

Spatial neglect (SN) impedes functional recovery after stroke, leading to reduced rehabilitation gains and slowed recovery. The objective of the present study was to investigate whether integrating prism adaptation treatment (PAT) into a highly intensive rehabilitation program eliminates the negative impact of spatial neglect on functional and motor recovery. We examined clinical data of the 355 consecutive first-time stroke patients admitted to a sub-acute inpatient neurorehabilitation program that integrated PAT. The 7-item Motor Functional Independence Measure, Berg Balance Scale, and Motor Activity Log were used as main outcome measures. We found that 84 patients (23.7%) had SN, as defined by a positive score on the Catherine Bergego Scale via the Kessler Foundation Neglect Assessment Process (KF-NAP®). Although 71 patients (85%) received PAT, the presence of SN at baseline, regardless of PAT completion, was associated with lower functional independence, higher risk of falls, and a lower functional level of the affected upper limb both at admission and at discharge. The severity of SN was associated with inferior rehabilitation outcomes. Nonetheless, patients with SN who received PAT had similar rehabilitation gains compared to patients without SN. Thus, the present study suggests that integrating PAT in an intensive rehabilitation program will result in improved responses to regular therapies in patients with SN

Prism adaptation treatment to address spatial neglect in an intensive rehabilitation program: A randomized pilot and feasibility trial.

Spatial neglect (SN) is a common cognitive disorder after brain injury. Prism adaptation treatment (PAT) is one of the promising interventions for SN albeit inconsistent results from previous studies. We carried out a comparison intervention (PAT vs. Sham) and aimed to evaluate the efficacy of PAT on visuospatial symptoms of SN in an inpatient rehabilitation setting that offered a highly intensive comprehensive brain injury rehabilitation program. A total of 34 patients with moderate-to-severe SN secondary to stroke or traumatic brain injury were randomized to the PAT group and the Sham group (an active control group). Both groups received 10 sessions of treatment, over two weeks, in addition to the rehabilitation therapies provided by their rehabilitation care teams. Outcomes were measured using an ecological instrument (the Catherine Bergego Scale) and paper-and-pencil tests (the Bells Test, the Line Bisection Test and the Scene Copying Test). Patients were assessed at baseline, immediately after treatment, two weeks after treatment, and four weeks after treatment. 23 (67.6%) patients completed treatment and all the assessment sessions and were included in the final analyses using mixed linear modeling. While SN symptoms reduced in both groups, we found no difference between the two groups in the degree of improvement. In addition, the average SN recovery rates were 39.1% and 28.6% in the PAT and Sham groups, respectively, but this discrepancy did not reach statistical significance. Thus, the present study suggests that PAT may contribute little to SN care in the context of a highly intensive inpatient rehabilitation program. Further large-scale investigation is required to uncover the mechanisms underlying PAT and Sham in order to refine the treatment or create new interventions

Ask the experts how to treat individuals with spatial neglect: a survey study

<p><b>Purpose:</b> Spatial neglect (SN) impedes rehabilitation success and leaves long-term consequences. We asked experts to provide their opinions in addressing SN by scenario (ideal vs. reality) and by recovery phase (earliest, acute, subacute, and chronic). Experts were individuals who have assessed or treated patients with SN clinically.</p> <p><b>Materials and methods:</b> This study was conducted using an anonymous survey on the Internet with 189 responders over 3 months. Located in 23 different countries, 127 experts of seven disciplines were included (occupational therapy, physical therapy, nursing, speech and language pathology or therapy, neurology, physical medicine and rehabilitation, and psychology or neuropsychology).</p> <p><b>Results:</b> Comparing the two scenarios, more treatments were selected in the ideal than in the reality scenario for all recovery phases except for the chronic phase. In both scenarios, (1) more treatments were selected in acute and subacute phases than in earliest or chronic phases, (2) less experienced experts selected diverse treatment options more often, and (3) highly experienced experts were more likely to provide their reasons of treatment selection, suggestions of treatment delivery methods, and other insights. Finally, 83.7% reported obstacles in treating SN.</p> <p><b>Conclusions:</b> Experts’ treatment selections are consistent with current evidence and practice guidelines. Recognizing the limitation of evidence, their opinions may help generate ideas in various topics (e.g., dosing, integrative intervention, and treatment implementation) to be examined in future studies.Implications for Rehabilitation</p><p>Clinicians with experience in treating people with spatial neglect (i.e., experts as defined in the present study) recognized the limitation of evidence but nonetheless suggested specific treatments by recovery phase.</p><p>In both the reality and ideal scenarios, experts included visual scanning, active limb activation, and sustained attention training in the top-five selections. Prism adaptation was in the top-five selections in the ideal scenario, while in the reality scenario, it was in the top-five in all phases except for the earliest phase where it was the sixth most selected.</p><p>They also shared their valuable opinions in when to use which treatment to address spatial neglect and how to deliver certain interventions, which may help to generate ideas in various topics (e.g., dosing, integrative intervention, knowledge dissemination, and treatment implementation) that can be examined in future studies.</p><p>We suggest that (1) clinicians consider collective expert opinions reported here to enhance their clinical judgment and practices, (2) researchers develop studies focused on treatments with limited evidence but selected here by experts, and (3) funding agencies provide the means to research and implementation projects that will generate rich information for improving practice guidelines and rehabilitation outcomes for patients with spatial neglect.</p><p>The majority of the experts reported some obstacles in providing treatment for spatial neglect, and time and equipment shortages were the most common barriers, which should be addressed at the system level to determine whether removing those barriers have long-term beneficial impacts on both patients and healthcare systems.</p><p></p> <p>Clinicians with experience in treating people with spatial neglect (i.e., experts as defined in the present study) recognized the limitation of evidence but nonetheless suggested specific treatments by recovery phase.</p> <p>In both the reality and ideal scenarios, experts included visual scanning, active limb activation, and sustained attention training in the top-five selections. Prism adaptation was in the top-five selections in the ideal scenario, while in the reality scenario, it was in the top-five in all phases except for the earliest phase where it was the sixth most selected.</p> <p>They also shared their valuable opinions in when to use which treatment to address spatial neglect and how to deliver certain interventions, which may help to generate ideas in various topics (e.g., dosing, integrative intervention, knowledge dissemination, and treatment implementation) that can be examined in future studies.</p> <p>We suggest that (1) clinicians consider collective expert opinions reported here to enhance their clinical judgment and practices, (2) researchers develop studies focused on treatments with limited evidence but selected here by experts, and (3) funding agencies provide the means to research and implementation projects that will generate rich information for improving practice guidelines and rehabilitation outcomes for patients with spatial neglect.</p> <p>The majority of the experts reported some obstacles in providing treatment for spatial neglect, and time and equipment shortages were the most common barriers, which should be addressed at the system level to determine whether removing those barriers have long-term beneficial impacts on both patients and healthcare systems.</p

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

Conventional and functional assessment of spatial neglect: clinical practice suggestions

OBJECTIVE: Spatial neglect (SN) constitutes a substantial barrier to functional recovery after acquired brain injury. However, because of its multimodal nature, no single test can capture all the signs of SN. To provide a clinically feasible solution, we used conventional neuropsychological tests as well as the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP). The goal was to add evidence that a global approach should detect better even subtle signs of SN. METHOD: Fourteen individuals with lesions located in the right cerebral hemisphere participated in the study. Participants were assessed with a comprehensive battery of neuropsychological tests, comprising a set of visuospatial tests to evaluate several spatial domains. In addition, patients underwent functional assessment with the Barthel Index, the Functional Independence Measure (FIM), and the CBS via KF-NAP. RESULTS: The CBS via KF-NAP was associated with the visuospatial paper-based tests (p = .004) as well as the Motor FIM (p = .003), and was more sensitive than the Behavioral Inattention Test-Conventional in detecting SN (p = .014). CONCLUSIONS: We showed that the CBS via KF-NAP was able: (a) to detect functional impairment, especially motor, related to SN; (b) to selectively measures spatial rather than nonspatial dysfunctions; and (c) to be highly sensitive in detecting SN signs especially in those patients with mild severity, covering several aspects of SN manifestations. The patient's SN diagnosis based on the CBS via KF-NAP is clinically important and directly relevant to care planning and goal setting