Update on the Clinical Approach to Spatial Neglect
Purpose of Review
Spatial neglect is asymmetric orienting and action after a brain lesion, causing functional disability. It is common after a stroke; however, it is vastly underdocumented and undertreated. This article addresses the implementation gap in identifying and treating spatial neglect, to reduce disability and improve healthcare costs and burden.
Professional organizations published recommendations to implement spatial neglect care. Physicians can lead an interdisciplinary team: functionally relevant spatial neglect assessment, evidence-based spatial retraining, and integrated spatial and vision interventions can optimize outcomes. Research also strongly suggests spatial neglect adversely affects motor systems. Spatial neglect therapy might thus “kick-start” rehabilitation and improve paralysis recovery.
Clinicians can implement new techniques to detect spatial neglect and lead interdisciplinary teams to promote better, integrated spatial neglect care. Future studies of brain imaging biomarkers to detect spatial neglect, and real-world applicability of prism adaptation treatment, are needed.
KeywordsSpatial neglect Right brain Cognitive rehabilitation Prism adaptation treatment Implementation science Functional brain imaging Brain network activation
Compliance with Ethical Standards
Conflict of Interest
A.M. Barrett is an employee of the Kessler Foundation and also reports grants from Dart Neuroscience LLC, grants from National Institutes of Health, others from eMedicine/WebMD, grants from Bright Cloud International Corp., outside the submitted work. Kevin Houston declares no potential conflict of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors.
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 5.Barrett AM. Perceptual-attentional “where” and motor-intentional “aiming” spatial bias. In: Chatterjee A, Coslett HB, editors. The roots of cognitive neuroscience: behavioral neurology and neuropsychology. New York: Oxford University Press; 2013.Google Scholar
- 8.Loetscher T, Nicholls MER, Brodtmann A, Thomas NA, Brugger P. Disentangling input and output-related components of spatial neglect. Front Hum Neurosci. 2012;6.Google Scholar
- 9.Smith GA, Heuer A. 6-OHDA toxin models of PD in the mouse. In: Lane EL, Dunnett SB, editors. Animal models of movement disorders: Vol 1. NY: Springer/Humana; 2012. p. 281–97.Google Scholar
- 10.Dunnett SB, Torres EM. Rotation in the 6-OHDA-lesioned rat. In: Lane E, , Dunnett, S.B., editor. Animal models of movement disorders: volume 1. Neuromethods: Springer Science and Business Media; 2011. p. 299–315.Google Scholar
- 17.•• Chen P, Ward I, Khan U, Liu Y, Hreha K. Spatial neglect hinders success of inpatient rehabilitation in individuals with traumatic brain injury: a retrospective study. Neurorehabil Neural Repair. 2016;30(5):451–60. The syndrome of spatial neglect affects people with many kinds of right brain disorders, adversely affecting outcomes.PubMedGoogle Scholar
- 22.Bender MB. Disorders in perception: with particular reference to the phenomena of extinction and displacement. Aring CD, editor. Springfield, IL: Charles C. Thomas; 1952.Google Scholar
- 23.Heilman KM, Watson RT, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E, editors. Clinical neuropsychology. 5th ed. New York: Oxford University; 2012. p. 296–348.Google Scholar
- 26.Glymour MM, Berkman LF, Ertel KA, Fay ME, Glass TA, Furie KL. Lesion characteristics, NIH stroke scale, and functional recovery after stroke. Am J Phys Med Rehab. 2007;86(9):725–33.Google Scholar
- 27.•• Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, et al. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2016;47(6):e98–e169. This is a required reading for clinicians caring for stroke patients as they transition to the community, for appropriate assignment of evidence-based care.PubMedGoogle Scholar
- 28.Management of Stroke Rehabilitation Working Group. VA/DOD clinical practice guideline for the management of stroke rehabilitation. J Rehabil Res Dev. 2010;47(9):1–43.Google Scholar
- 29.National Institute for Health and Care Excellence. Stroke rehabilitation: long term rehabilitation after stroke. National Institute for Health and Care Excellence: clinical guidelines. London 2013.Google Scholar
- 30.•• Intercollegiate Stroke Working Party. National Clinical Guidelines for Stroke. London: Royal College of Physicians; 2016. These British guidelines complement the 2016 AHA/ASA publication, with staffing recommendations in stroke care (e.g., for clinical neuropsychology) and information on specific rehabilitation interventions. Google Scholar
- 31.Azouvi P The ecological assessment of unilateral neglect. Ann Phys Rehabil Med 2016.Google Scholar
- 33.Barrett AM, Diaz-Segarra N, Patel K, Gillen R, Kaplan EL, Masmela JR, Gonzalez-Snyder C, for the Practice-RRuN network,. A care pathway for post-stroke spatial neglect: initial analysis of a practice-based rehabilitation research network (abstract). Neurology. 2019.Google Scholar
- 34.•• Pitteri M, Chen P, Passarini L, Albanese S, Meneghello F, Barrett AM. Conventional and functional assessment of spatial neglect: clinical practice suggestions. Neuropsychology. 2018. Clinicians need to use functional performance—not just paper-and-pencil testing—to reliably identify spatial neglect. Google Scholar
- 36.Wilson B, Cockburn J, Halligan P. Behavioural Inattention Test. Titchfield: Thames Valley Test Company; 1987.Google Scholar
- 37.Halligan PW, Cockburn J, Wilson BA. The behavioural assessment of visual neglect. Neuropsychol Rehabil 1991;1(1):5–32.Google Scholar
- 41.Chen P, Pitteri M, Gillen G, Ayyala H Ask the experts how to treat individuals with spatial neglect: a survey study. Disabil Rehabil 2017:1–15.Google Scholar
- 45.•• Goedert KM, Chen P, Foundas AL, Barrett AM. Frontal lesions predict response to prism adaptation treatment in spatial neglect: a randomised controlled study. Neuropsychol Rehabil. 2018:1–22. Prism adaptation treatment can improve spatial neglect, especially after a frontal stroke. Google Scholar
- 47.Jung JH, Peli E. Impact of high power and angle of incidence on prism corrections for visual field loss. Opt Eng. 2014;53(6):061707.Google Scholar
- 49.•• Champod AS, Frank RC, Taylor K, Eskes GA. The effects of prism adaptation on daily life activities in patients with visuospatial neglect: a systematic review. Neuropsychological Rehabilitation. 2016:1-24. Spatial neglect rehabilitation reduces functional disability and improves daily life. We need to use it. Google Scholar
- 50.Bowen A, Hazelton C, Pollock A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev. 2013:7, CD003586.Google Scholar
- 58.•• Houston KE, Bowers AR, Peli E, Woods RL. Peripheral prisms improve obstacle detection during simulated walking for patients with left hemispatial neglect and hemianopia. Optom Vis Sci. 2018;95(9):795–804. Optometric low vision care and assistive devices may improve spatial neglect.PubMedGoogle Scholar
- 59.Rowe F, UK VISg. The profile of strabismus in stroke survivors. Eye (Lond). 2010;24(4):682–5.Google Scholar
- 60.Rowe F, UK VISg. Prevalence of ocular motor cranial nerve palsy and associations following stroke. Eye (Lond). 2011;25(7):881–7.Google Scholar
- 61.Houston KE, Keilty M. Initial response to prism treatment in an inpatient rehabilitation hospital setting: preliminary results (abstract). Arch Phys Med Rehabil. 2015;96(10):e73.Google Scholar
- 68.Flanders M, Sarkis N. Fresnel membrane prisms: clinical experience. Can J Ophthalmol. 1999;34(6):335–40.Google Scholar
- 70.Chen P, Goedert KM, Shah P, Foundas AL, Barrett AM. Integrity of medial temporal structures may predict better improvement of spatial neglect with prism adaptation treatment. Brain Imaging Behav 2014;8(3):346–58.Google Scholar
- 76.•• Ramsey LE, Siegel JS, Baldassarre A, Metcalf NV, Zinn K, Shulman GL, et al. Normalization of network connectivity in hemispatial neglect recovery. Ann Neurol. 2016;80(1):127–41. Interaction of the coordinated brain activity that defines functional systems may be a key biomarker of disability.PubMedPubMedCentralGoogle Scholar