Ailie Turton

ailie.turton@uw e.ac.uk

SSNP Stroke ConferenceManchester 2010

Workshop on Neglect

Overview

What is Neglect?

Neglect is a syndrome

Anatomy

Assessment

Recovery

Ideas for treatment

The state of the evidence

Interventions - their basis in cognitive psychology

Building a f ramework for clinical reasoning of treatment options

‘A chaotic world’ – Findings from a Swedish study of the experience of unilateral neglect

� The 4 participants experienced objects and people as disappearing and reappearing as they passed in and out of the left ‘unperceived ’ world.

� Such experiences were unsettling.

“It is very unpleasant when [new] things suddenly materialise despite you thinking you knew what was there”.

Lampinen & Tham, Scandinavian Journal of OT 2003; 10 (4): 147 - 156

A chaotic world

When manoeuvring their wheelchairs, the women sometimes bumped into furniture that did not exist for them. They did not experience these collisions as their mistakes.

Instead of noticing an object into which they accidentally bumped, they heard a banging sound that “came from nowhere” and felt the chair had stopped suddenly “for no reason”

Lampinen & Tham, Scandinavian Journal of OT 2003; 10 (4): 147 - 156

Estrangement from the left half of their bodies

� Participants felt as though the left half of their bodies did not belong to them

� Sometimes they had to locate where the left half was.

“When I can’t find my bad arm in the bed I call for the nurses and ask them if they can find my arm and I am so satisfied because they can always find it in the bed. Usually, they find it on the pillow , otherwise we continue our search together ”.

Lampinen & Tham, Scandinavian Journal of OT 2003; 10 (4): 147 - 156

What is Unilateral spatial neglect?

Terms.....Types......

� ‘fails to report or orient to novel or meaningf ul stimuli presented to the side opposite a brain lesion. ’ Heilman (1993)

Neglect and related disorders. in Clinical Neurospsychology. eds Heilman KM, Valenstein E (OUP, New York), pp 243–293.

� A syndrome of disorders of attention or of representation of space that manifests as an inability to detect stimuli on the side contralateral to the lesion

Neglect is not a disorder of low-level visual perception

Neglect patients have specif ic problem with voluntarilyorienting to neglected side

• The syndrome can have non -visual components

• FMRI shows objects in neglected visual field still activate regions in the occipital cortex (Rees et al, 2000)

• Stimuli presented in the neglected f ield can of ten be detected if attention is first cued to that side of space (Riddoch & Humphreys, 1983).

Rees et al. Brain 2000; 123: 1624-33Riddoch & Humphreys, Neuropsychologia 1983; 21:589-599

It can be object based rather than related to side of space

Halligan P W, Marshall J C, Perception 1993; 22(3): 309 – 312

Neglect is not a disorder of low-level visual perception

Neglect patients have specif ic problem with voluntarilyorienting to neglected side

visual memory for two ends of a piazza.(Bisiach and Luzzatti 1978)

Representational neglect - Imagining a place, giving directions, imaging arm position when putting on a jumper

Mort et al. The anatomy of visual neglect. Brain (2003), 126, 1986-1997

Anatomy

a) Neglect patients (n = 14)

b) Patients without neglect (n = 10)

c) Relative involvement in the lesions of the neglect group compared with the non-neglect pt group(red most frequent)

MRI scan of a single patient with neglect

% MCA RBD stroke patients with neglect

Parton & HusainJNPP 2004; 75: 13–21

Neglect syndrome specifically associated with damage to:

•R inferior parietal lobe (IPL), temporo-parietal junction (TPJ), (the ‘classical’ cortical sites).

•R inferior frontal lobe, more transient neglect, (motor exploration).

• Subcortical lesions involving basal ganglia or thalamus, (may be due to disconnect ion with parietal and frontal regions).

navigation/route findingfinding things in a room

Reaching space:finding thingseatingAvoiding collisionsreading

Personal Spacewashing, shaving, dressingawareness of body parts

Schematic from Roberts on et al. Neuropsychol. Rehabil. 2002;12(5) p442Photo from New Sc ientist

DissociationsGuariglia C, Antonucci G (1992) Halligan PW, Marshall JC (1991)

Committeri, G. et al. Brain 2007 130:431-441; doi:10.1093/brain/aw l265

Representative lesion sites computed for awareness of extrapersonal & personal space in R brain-damaged patients.

“Given the diversity of brain regions that may lead to neglect, it may be better understood as a cluster of lateralised spatial problems that canarise following damage to—or dysfunction in—a network of brain regions and normal psychological functions involved in the allocation of attention andrepresentation of space”

Tom Manley, Neuropsychol Rehabil. 2002; 12 (4), 289–310 2002

Most neglect patients have suffered large middle cerebral artery strokes –

unlikely to be dealing w ith single symptoms

Finger wiggling

Pencil and paper tests

Behavioural inattention test battery

Baking tray test (Tham and Tegner 1996)

Scored functional assessment, Catherine Bergego scale (Azouvi et al. 2003)

Observation – ADL

AssessmentWhat methods do you use?

What is the best way?

Personal space tasks(n=4)

Extra-personal space tasks (n=6)

Forgets to clean the left side of his/her mouth after eating

Has difficulty in paying attention to noise or people addressing him/her from the left.

Experiences difficulty finding his/her personal belongings in the room or bathroom when they are on the left side

Forgets to groom or shave the left part of his/her face

Forgets to eat food on left side of plate

Experiences difficulty finding his/her personal belongings in the room or bathroom when they are on the left side.

Forgets about a left part of his/her body(e.g. forgets to put his/her upper limb on the armrest, or forgets to use left arm).

Experiences difficulty in finding his/her way towards the left when travelling in familiar places or in the rehabilitation unit.

Collides with people or objects on the left side, such as doors or furniture (either while walking or driving a wheelchair).

Experiences difficulty in adjusting his/her left sleeve or slipper

Catherine Bergego Behavioural Assessment (unidimensional 4 pt scale)Azouvi et al. Arch Phys Med Rehabil 2003; 84: 51-7

Sensitivity of tests for neglect206 sub-acute R hemisphere stroke patients given a test battery.Subgroup (n=69) received CBS

• The most sensitive paper and pencil measure was the starting point in the cancellation task.

• Whole battery was more sensitive than any single test alone.

• About 85% of patients presented some degree of neglect on at least one measure.

• (CBS) Behavioural assessment of neglect in daily life was more sensitive than any other single measure.

Azouvi et al. J Neurol Neurosurg Psychiatry 2002;73:160 -166

• N=66, right hemisphere stroke patients admitted to medical and elderly care wards of DGH

• tested with Behavioural Inattention test

• Week 1: 27 patients (40%) tested had signs of neglect.

• At 3 months: 6/66 (9%) patients had signs of neglect

Cassidy, Lewis & Gray, J. Neurol Neurosurg Psychiatry 1998;64:555 -557

Recovery

Recovery

Stone et al. J. Neurol, Neurosurg & Psychiatry 1992; 55: 431-436

Mean Visual Neglect Recovery Index at different time intervals up to 6 months patients with R (n=34) and L (n=34) hemisphere stroke.

Bowen & Lincoln, Cognitive rehabilitation f or spatial neglect following stroke 2007.

� Included 12 RCTs with 306 participants

� Only 6 studies included a measure of disability

� Only 2 of these investigated persisting eff ects of treatment

The state of the evidence for effective treatment

Cochrane Database Systematic Reviews, Issue 2. Art. No.: CD003586. DOI:10.1002/14651858.CD003586.pub2.

Follow up, how long is realistic?

Conclusion

“Several types of neglect specif ic approaches are now described but there is insufficient evidence to support or refute their effectiveness at reducing disability and improving independence.

They can alter test perf ormance and warrant further investigation in high quality randomised controlled trials ”.

Bowen & Lincoln, Cognitive rehabilitation f or spatial neglect following stroke 2007.

Interventions and their basis in cognitive psycholog y

Theory: Neglect is.... Treatmenta deficit in disengaging attentionfrom ipsilesional objects

Cueing/Priming

motor system can increase salience of affected hemispace

Limb activation (proprioceptive cueing)

a lateralised bias or gradient of attention, due to disruption of normal balance between hemispheres in directing attention

Transcranial magnetic stimulation

An impaired representation of space

prism adaptation, vestibular stimulation, neck vibration

Non-spatially lateralised deficits: Reduced alertness

Sustained attention training

1

2

3

4

5

Personal spaceExtrapersonal spaceRepresentational

SomatosensoryMotor neglect

Space/modality of neglect

vision

Far space

Find post its en route

Limb activation – open/ close fingers when

walking

Mobility?Cognitive load needed to walk/ drive chair

Vision?Visual fields,Eye movements

Motor activity available?

Memory – will person

remember to do limb

activation

Considerations/ assessments

Treatment strategy/activity

DECISION TREE FOR MANAGING NEGLECTMobility problem

bumps into things

Other neglect related issues:Arousal, spatial memory

Mobility problemunable find way/route

Mobility ProblemBalance when walking