This document outlines the identification, assessment, and treatment of unilateral spatial neglect (USN) during stroke rehabilitation. It begins with an introduction that defines USN as the inability to respond to stimuli on the side opposite a brain lesion. It then covers the epidemiology, types, mechanisms, identification, assessment tools, prognosis, and treatment techniques for USN, including visual scanning, sensory stimulation, video feedback, and pharmacological therapy. The conclusion emphasizes that understanding and treating USN beyond the acute period is important for functional recovery in stroke patients.

1. IDENTIFICATION,
ASSESSMENT AND
TREATMENT OF UNILATERAL
SPATIAL NEGLECT (USN)
DURING STROKE
REHABILITATION.
BY
ADEAGBO, CALEB ADEWUMI

2. OUTLINE
• Introduction
• Definition of USN
• Epidemiology
• Types of USN
• Mechanism of USN
• Identification of USN
• Assessment of USN
• Prognosis
• Treatment and Rehabilitation
• References
2

3. Introduction
• Unilateral Spatial Neglect
(USN) is a disabling feature and
a common behavioural
syndrome in patients following
stroke (Swan, 2001; Parton et al, 2004;
Menon-Nair et al, 2007).
3

4. Introduction cont
• It is a neuropsychological
disorder and characterized by the
inability to orient or respond to
stimuli appearing on the side
contralateral to the brain lesion
(Bowen et al, 1999; Gbiri et al, 2014).
4

5. Introduction cont
• The presence of USN may be
determined on the basis of a left-right
asymmetry in performance
of a variety of measures such as
line and letter cancellation,
reading, drawing, mental imagery,
attention to the body and
naturalistic action tasks (Pierce and
Buxbaum, 2002).
5

6. Introduction cont
• USN is associated with a greater
risk for falls, longer rehabilitation,
poor functional recovery and
degrading Quality of Life (QoL)
(Paolucci et al, 2001; Hamzat et al, 2012; Choi et al,
2013).
6

7. Introduction cont
• To counteract the disabling effects
of USN it is critical that
rehabilitation professionals be
astute at identifying the impairment,
assessing the patients by using
tools with strong psychometric
properties and providing
interventions aimed at reducing the
impairment and functional sequelae
(Parton et al, 2004; Menon-Nair et al, 2007).
7

8. Definition of USN
• USN has been defined as a failure
to report, respond or orient to
stimuli in the contralesional
hemispace of the brain lesion and
the failure cannot be attributed to
sensory or motor impairments
(Heilman et al, 1993).
8

9. Epidemiology
• The reported prevalence of USN
varies widely from 10% to 82%
following right-hemisphere stroke
and from 15% to 65% following
left-hemisphere stroke (Swan, 2001;
Plummer et al, 2003).
• USN was observed in about a
third of the participants in the
study conducted by Hamzat et al,
(2012).
9

10. Epidemiology cont
• The clinical impression that USN
occurs more frequently following
right brain damage than left brain
damage has been supported in
many systematic review of
published data, some authors have
however documented a mild and
sometimes non-significant
difference between right and left
brain damaged patients (Bowen et al,
1999; Plummer et al, 2003; Gbiri et al, 2014).
10

11. Types of USN
• There are two main classification
systems for USN. It can be
described in terms of the modality
in which the behaviour is elicited
(representational (Fig 1), motor, or
sensory (Fig 2)) or by the
distribution of the abnormal
behaviour (personal or spatial)
(Heilman et al, 1994; Plummer et al, 2003).
11

12. Fig 1: Representational neglect in a patient with USN
(Chatterjee, 2003; Bartolomeo et al, 2012).
12

13. Fig 2: A picture showing patients with sensory
neglect
13

14. Mechanism of USN
• USN can occur as a result of
lesions at different anatomical
sites (such as posterior parietal
cortex, frontal lobe, cingulate
gyrus, striatum and thalamus) and
varies in its presentation (Swan, 2001;
Kim et al, 2011).
14

15. Identification of USN
• Patients with USN only
• Patients with USN and
hemianopia
• Patients with extinction
• Patients that are anosognosic
15

16. Assessment of USN
• Cancellation Tests
• Bells Test (Fig 2)
• Line Bisection test
• Albert's test
• Copying and Drawing Tests
• Figure copying
• Clock drawing
16

17. Fig 3: Bells test for assessing Unilateral Spatial Neglect (USN)
(Zeltzer and Menon, 2014).
17

18. Assessment of USN cont
• Reading
• Writing
• Comb and Razor Test
• The Behavioural Inattention Test
• Semi-structured Scale for
Functional Evaluation of USN
• The Catherine Bergego Scale
18

19. Prognosis
• The rate of recovery from USN
is greatest in the first month
post stroke and recovery can
range from a persistent USN to
complete recovery (Cassidy et al, 1998;
Swan, 2001; Gbiri et al, 2014).
19

20. Prognosis cont
• USN has been associated with
poor outcome measures on
functional activities and thus
patients require more assistance
at discharge than patients without
USN (Katz et al, 1999; Swan, 2001; Hamzat et al,
2012, Bowen et al, 2013).
20

21. Treatment and Rehabilitation
• Visual Scanning
Patients with USN are encouraged
to explore the neglected visual
field by performing tasks on
neglected visual field side. The
treatment often includes visual
target that the patient uses as an
anchor while scanning.
21

22. Treatment and
Rehabilitation cont
• Sensory Stimulation
Visual/Verbal/Auditory Cues
Limb Activation
Caloric Stimulation
Eye Patching/Hemiglasses
22

23. Treatment and
Rehabilitation cont
• Sensory Stimulation cont
Neck/Hand Vibration or
Stimulation
Trunk Rotation
Visuo-motor Imagery
Constraint-Induced Therapy
Optokinetic Stimulation
23

24. Treatment and
Rehabilitation cont
• Video Feedback
This treatment involves filming
the patient while he does
specific activities. The
Physiotherapist and patient
then watch the video together.
The Physiotherapist points out
to the patient how they are
neglecting their body and
discuss strategies use the
part.
24

25. Treatment and
Rehabilitation cont
• Pharmacological Therapy
This involves the use of specific
medications (dopamine-agonist
drugs) to improve visual attention
skills. A physician must prescribe
these medications.
25

26. Conclusion
• The presence of USN has been
said to be one of the major
factors that affect the Activities
of Daily Living (ADL) most
especially the self-care activities
and it is considered to be a major
cause of disability in post-stroke
patients
26

27. Conclusion cont
• Therefore it is important to
understand the management of
USN beyond the acute care
period. Indeed, it might be argued
that the rehabilitation phase
provides the ideal opportunity for
in-depth assessment and
treatment
27

28. 28

29. References
• Bowen A, Hazelton C, Pollock A, Lincoln NB (2013). Cognitive
rehabilitation for spatial neglect following stroke (Review). In: The
Cochrane Collaboration. Pp 1-24. John Wiley & Sons, Ltd.
• Bowen A, McKenna K, Tallis RC (1999). Reasons for variability in the
reported rate of occurrence of Unilateral Spatial Neglect after Stroke.
Stroke 30: 1196-1202.
• Cassidy TP, Lewis S, Gray CS (1998). Recovery from visuospatial neglect
in stroke patients. Journal of Neurology, Neurosurgery and Psychiatry
64:555–557.
• Chatterjee A (2003). Neglect: A Disorder of Spatial Attention. In
Neurological Foundations of Cognitive Neuroscience. Pp 1-26. The MIT
Press Cambridge, Massachusetts, London, England
• Choi Y, Lee S, Kim E (2013). Awareness, Assessment, and Intervention of
Unilateral Neglect: A Survey of Korean Occupational Therapists. Journal
of Next Generation Information Technology (JNIT) 4(8): 245-250.
• Gbiri CA, Akinpelu AO, Odole AC, Adejare OA (2014). Assessment of
Unilateral Spatial Neglect in People Post-Stroke: Development of Gbiri
Distracter Test. Scottish Journal of Arts, Social Sciences and Scientific
Studies 19:2 114-122.
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30. References cont
• Hamzat TK, Oyedele SY, Peters GO (2012). Clinical and demographic
correlates of unilateral spatial neglect among Community-dwelling Nigerian
stroke survivors. African Journal of Neurological Sciences 23(1): 3-7.
• Heilman KM, Valenstein E, Watson RT (1994). The what and how of neglect.
Neuropsychological Rehabilitation 4: 133–139.
• Heilman KM, Watson RT, Valenstein E (1993). Neglect and related disorders.
In: Clinical Neuropsychology. 2nd Edition Pp 243–294. New York, NY: Oxford
University Press.
• Katz N, Hartman-Maeir A, Ring H, Soroker N (1999). Functional disability and
rehabilitation outcome in right hemisphere damaged patients with and
without unilateral spatial neglect. Archives of Physical Medical and
Rehabilitation 80: 379 –384.
• Kim YM, Chun MH, Yun GJ, Song YJ, Young HE(2011). The Effect of Virtual
Reality Training on Unilateral Spatial Neglect in Stroke Patients. Annals of
Rehabilitation Medicine 35: 309-315
• Menon-Nair A, Korner-Bitensky N, Ogourtsova T (2007). Occupational
Therapists’ Identification, Assessment, and Treatment of Unilateral Spatial
neglect during Stroke Rehabilitation in Canada Stroke 38: 2556-2562. 30

31. References cont
• Paolucci S, Antonucci G, Grasso G, Pizzamiglio L (2001). The role of
unilateral spatial neglect in rehabilitation of right brain-damaged
ischemic stroke patients: a matched comparison. Archives of Physical
Medical and Rehabilitation 82: 743–749.
• Parton A, Malhotra P, Husain M (2004). Hemispatial neglect. Journal of
Neurology, Neurosurgery and Psychiatry 75: 13–21.
• Plummer P, Morris ME, Dunai J (2003). Assessment of unilateral neglect.
Physical Therapy. 83: 732–740.
• Pierce SR, Buxbaum LJ (2002). Treatment of Unilateral Neglect: A review.
Archives of Physical Medical and Rehabilitation 83: 256-268.
• Swan L (2001). Unilateral Spatial Neglect. Physical Therapy 81: 1572-
1580.
• Zeltzer L, Menon A (2014). Bells test. Available @
http://strokengine.ca/assess/module_bt_intro-en.html Retrieved on June
10, 2014.
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