1. SSNP Stroke Conference
Manchester 2010
Workshop on Neglect
Ailie Turton
ailie.turton@uw e.ac.uk

2. Overview
What is Neglect? The state of the evidence
Neglect is a syndrome Interventions - their basis
in cognitive psychology
Anatomy
Building a f ramework for
Assessment
clinical reasoning of
Recovery treatment options
Ideas for treatment

3. A chaotic w orld Findings from a Sw edish 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

4. A chaotic w orld
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

5. 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 alw ays 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

6. 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

7. Neglect is not a disorder of low-level visual perception
Neglect patients have specif ic problem with voluntarily
orienting 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 often be
detected if attention is first cued to that side of space
(Riddoch & Humphreys, 1983).
Rees et al. Brain 2000; 123: 1624 -33
Riddoch & Humphrey s, Neuropsychologia 1983; 21:589-599

8. Neglect is not a disorder of low-level visual perception
Neglect patients have specif ic problem with voluntarily
orienting to neglected side
It can be object based rather
than related to side of space
Halligan P W, Marshall J C, Perception 1993; 22(3): 309 312

9. Representational neglect - Imagining a place, giving directions,
imaging arm position when putting on a jumper
visual memory for two ends of a piazza.
(Bisiach and Luzzatti 1978)

10. Anatomy
MRI scan of a single
patient with neglect
a) Neglect patients
(n = 14)
b) Patients without negl ect
(n = 10)
c) Relative involvement in the
lesions of the negl ect
group compared with the
non-neglect pt group
(red most frequent)
Mort et al. The anatomy of visual neglect. Brain (2003), 126, 1986 -1997

11. 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). Parton & Husain
JNPP 2004; 75: 13 21
Subcortical lesions involving
basal ganglia or thalamus, (may
be due to disconnection with
parietal and frontal regions).
% MCA RBD stroke patients with
neglect

12. Dissociations Reaching space:
Guariglia C, Antonucci G (1992) finding things
Halligan PW, Marshall JC (1991) eating
Avoiding collisions
reading
Personal Space
washing, shaving,
navigation/route finding dressing
finding things in a room awareness of body parts
Schematic from Roberts on et al. Neuropsychol. Rehabil. 2002;12(5) p442
Photo from New Sc ientist

13. Representative lesion sites computed for awareness of
extrapersonal & personal space in R brain-damaged patients.
Committeri, G. et al. Brain 2007 130:431-441;
doi:10.1093/brain/aw l265

14. Given the diversity of brain regions that may lead to
neglect, it may be better understood as a cluster of
lateralised spatial problems that can
arise following damage to or dysfunction in a
network of brain regions and normal psychological
functions involved in the allocation of attention and
representation of space
Tom Manley, Neurops ychol 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

15. Assessment
What methods do you use?
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)
What is the best way?
Observation ADL

16. Catherine Bergego Behavioural Assessment (unidimensional 4 pt scale)
Azouvi et al. Arch Phys Med Rehabil 2003; 84: 51-7
Personal space tasks Extra-personal space
(n=4) tasks (n=6)
Forgets to clean the left Has difficulty in paying Experiences difficulty
side of his/her mouth after attention to noise or people finding his/her personal
eating addressing him/her from belongings in the room or
the left. bathroom when they are on
the left side
Forgets to groom or shave Forgets to eat food on left Experiences difficulty
the left part of his/her face side of plate finding his/her personal
belongings in the room or
bathroom when they are on
the left side.
Forgets about a left part of Experiences difficulty in Collides with people or
his/her body finding his/her way towards objects on the left side,
(e.g. forgets to put his/her the left when travelling in such as doors or furniture
upper limb on the armrest, familiar places or in the (either while walking or
or forgets to use left arm). rehabilitation unit. driving a wheelchair).
Experiences difficulty in
adjusting his/her left sleeve
or slipper

17. Sensitivity of tests for neglect
206 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 deg ree 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

18. Recovery
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

19. Recovery
Mean Visual Neglect Recovery Index at different time
intervals up to 6 months patients with R (n=34) and L
(n=34) hemisphere stroke.
Stone et al. J. Neurol, Neurosurg & Psychiatry 1992; 55: 431-436

20. The state of the evidence for effective treatment
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
Follow up,
how long is
Cochrane Database Systematic Reviews,
Issue 2. Art. No.: CD003586. realistic?
DOI:10.1002/14651858.CD003586.pub2.

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

22. Interventions and their basis in cognitive psycholog y
Theory: Neglect is.... Treatment
a deficit in disengaging attention Cueing/Priming
1 from ipsilesional objects
motor system can increase Limb activation (proprioceptive
2 salience of affected hemispace cueing)
a lateralised bias or gradient of Transcranial magnetic
3 attention, due to disruption of stimulation
normal balance between
hemispheres in directing
attention
4 An impaired representation of prism adaptation, vestibular
space stimulation, neck vibration
5 Non-spatially lateralised deficits: Sustained attention training
Reduced alertness

23. DECISION TREE FOR MANAGING NEGLECT
Mobility problem Mobility problem Mobility Problem
unable find way/route bumps into things Balance when walking
Space/modality of neglect Extrapersonal Personal space
space
Representational
Far space
Motor neglect
Other neglect related issues: Somatosensory
vision Arousal, spatial memory
Considerations/ assessments
Mobility? Motor activity
Cognitive load available?
needed to walk/
drive chair
Memory will
person
Vision? remember to
Visual fields,
do limb
Eye movements activation
Treatment strategy/activity
Limb activation
Find post its en
open/ close
route
fingers when
walking