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Kathleen B Kortte†1 & Argye E Hillis1,2,3
Johns Hopkins University School of Medicine, Department of Physical Medicine & Rehabilitation, 600 North
Wolfe Street, Phipps 174, Baltimore, MD 21205, USA
2
Johns Hopkins University School of Medicine, Department of Neurology, Baltimore, MD, USA
3
Johns Hopkins University, Department of Cognitive Science, Baltimore, MD, USA

Author for correspondence: Tel.: +1 410 502 5357 n Fax: +1 410 614 4033 n kortte@jhmi.edu
1

This article highlights the most recent findings regarding the rehabilitation
interventions for the syndromes of visual neglect and anosognosia for hemiplegia
that occur following right hemisphere stroke. We review papers published in the
past 4 years pertaining to therapeutic approaches for these two syndromes in
order to identify the trends in the development of effective interventions. Overall,
it appears well recognized that visual neglect syndromes and awareness
syndromes frequently co-occur and both include complex, multifaceted
impairments leading to significant difficulties in daily life functioning following
stroke. Thus, the interventions for these syndromes must be multifaceted in order
to address the complex interplay of cognitive–behavioral–emotional components.
There appears to be a trend for using combination therapeutic interventions that
address these components.

Neglect and anosognosia for hemiplegia (AHP)
are two neuropsychological syndromes that occur
following right hemisphere stroke with regular
frequency [1,2] . Neglect is an impairment in attention or response to stimuli in the hemispace contralateral to the lesion not attributable to a primary
sensory or motor deficit [3] , whereas AHP is an
unawareness of motor impairment and the changes
in functioning that result from that motor impairment. Incidence rates range from 13 to 85% of cases
of right hemisphere stroke for neglect syndromes
and 17–28% for AHP [4] . Notably, hemispatial
neglect has been found to occur after left hemisphere stroke, but is often under-recognized and
has drawn less clinical and research attention [5] .
There is a high co-occurrence of neglect and
AHP, which has been suggested to be the product
of neuroanatomical contiguity rather than functional contiguity per se [6,7] . The presence of AHP
in patients with neglect has been found to be associated with a worse rehabilitation prognosis [8] . In
addition, AHP and neglect have been found to be
associated with safety concerns such as falls [9,10] ,
longer rehabilitation stays [8,11,12] , poorer functional outcomes following stroke  [10,12,13] and
poorer quality of life [13] . Despite the strong
association between these two syndromes, it is
agreed that neglect and AHP are distinguishable syndromes with unique clinical characteristics and implications for the rehabilitation
interventions [6,12,14] .
10.2217/FNL.10.79 © 2011 Future Medicine Ltd

Review

Future Neurology

Recent trends in rehabilitation
interventions for visual neglect and
anosognosia for hemiplegia
following right hemisphere stroke

Given the prevalence of these two syndromes
co-occurring and the combined negative impact
on the rehabilitation process and outcomes, interventions to address each of them will need to be
considered simultaneously within the clinical setting. New interventions have been emerging to
facilitate recovery of functioning, and this article
summarizes the recent approaches and the known
efficacy to impact functioning or reduce morbidity. This is not meant to be an exhaustive review of
the literature, but rather a summary of the recent
research findings and past literature as is needed to
capture the current trends and the potential areas
for future research. We will not review all of the
therapies shown to be effective prior to 2006. The
reader is directed to past comprehensive reviews
for a more historical perspective on the range of
interventions that have been developed and tested
over time [15] .
Interventions for neglect

As noted earlier, neglect is considered to involve
impairments in attention and/or sensory processing. However, neglect is not one unitary syndrome.
There are actually a variety of neglect syndromes
that can be distinguished on the basis of the
regions of space affected, reference frame or mode
of output, as well as the sensory modality  [16] .
Neglect affecting the contralesional side of space
defined by the viewer-centered frame of reference
(i.e., according to the midline of the body, head or
Future Neurol. (2011) 6(1), 33–43

Keywords
anosognosia n awareness
neglect
n rehabilitation n stroke
n

n intervention n

part of

ISSN 1479-6708

33

for some paradigms. however. In bottom-up mechanistic interventions. auditory neglect or somatosensory neglect). the researchers found no overall effect of the treatment on self-care or even on a standardized measure of inattention. (2011) 6(1) Prism adaptation Prism adaptation through the use of rightward prism glasses has received the most scientific scrutiny.e. Right half-field patching By occluding the right visual field with specialized glasses. the visual scanning training generalized to an eye-tracking communication strategy. a single case study showed the intriguing finding of the effect persisting for up to 1 year post-training [33] . but not to other daily life functional tasks [23] . However. tactile stimulation via arm activation and transcranial stimulation. Further research is needed to determine the specific mechanisms at play.32] . a recent study suggests that the mechanism for improvement of neglect may be due at least in part to an allevia­tion of the local processing bias  [25] . including postural stability [26] and wheelchair navigation [27. right half-field eye patching. Visual neglect is the most well-known type of neglect and thus has received more clinical and research attention historically than other modalities of neglect (i. For example. By contrast. These types of interventions have received some support as being effective  [19–22] .28] . it is not a viable intervention for some individuals with more severe cognitive impairments. Thus. in a blinded randomized control trial. More recently. the findings for generalization are controversial. but this did not generalize to self-care tasks [29] . We briefly review some of these techniques in the following sections. reaching movements or eye movements toward targets) may be characterized as ‘egocentric’ [17] . the beneficial effects of prism adaptation in pointing behavior have been shown to be effective when applied in the postacute phases of recovery [30. 36 individuals with neglect following right hemisphere stroke were randomized into either prism adaptation or a sham treatment (using plain glasses) [29] . the authors found that only the prism-treated group showed increased leftward bias in pointing behavior.Review Kortte & Hillis retina and is required for gait direction. However. Finally. These limitations have recently spurred researchers to investigate ‘bottom-up’ mechanistic approaches for neglect interventions (Table 1) . Specifically. there is concern that such training only generalizes to very similar tasks. the individual’s attention to the contralesional space can be concentrated. stimulation is used to enhance perception of the contralesional space. In a recent randomized future science group . There is some evidence that prism adaptation is an effective intervention for visual neglect with generalization of the effect to functional tasks. but not to other functional tasks [24] . Such techniques are particularly problematic for individuals who have comorbid awareness problems as they will not understand the need to learn a strategy for a deficit of which they are not aware. However. Individuals receive training to make visually guided pointing movements to specific targets while wearing prism glasses that induce a rightward shift in the visual field. regardless of the location of the stimulus with respect to the viewer (stimulus-centered neglect). Across studies. this singular result needs to be replicated in a larger sample. This technique is hypothesized to change the interhemispheric imbalance by reducing the disinhibition of the orienting mechanism of the ipsilesional side [34] . these are more passive approaches in which the patient is the recipient of the stimulation and. called right half-field patching. After 2 weeks of treatment (5 days per week). 34 Future Neurol. neglect of the contralesional side of the physical stimulus. as a recent study of prism adaptation suggested that the intervention was effective in increasing the hypothesized leftward bias. However.31] and were found to last from days to weeks. or neglect of the contralesional side of the abstract representations of the object (irrespective of its orientation or modality) may be categorized as ‘allocentric’ [18] . in the recent case study of an individual with locked-in syndrome and neglect. a variety of stimulation methods have been investigated in terms of their efficacy in improving neglect symptoms. Explanations for the clinical benefits induced by prism adaptation have generally focused on a leftward re­alignment of attention. optokinetic stimulation (OKS). Very recently.20] . This type of ‘top-down’ mechanistic approach relies on the patient learning a new skill to overcome or compensate for the impairment. including the use of prism glasses. The most recent study findings suggest that sustained effects can last up to 6 weeks post-treatment depending upon the length of stimulation training [30. because they rely on the patient learning a technique to compensate for neglect.. Early interventions focused on addressing the apparent deficit in scanning to the left hemispace by training patients to orient to the neglected side [19. can perform tasks while being stimulated or after receiving stimulation training rather than actively learning a compensatory strategy or technique.

(2006) Schroder et al. however. the investigators aimed to demonstrate that left arm activation alone could result in a positive www. suggesting that the effect does not generalize to these functions. which was shorter than in previous studies of right half-field patching  [35] .Rehabilitation for neglect & anosognosia controlled trial. this study demonstrated that the improvements in neglect symptoms were associated with: Increases of neural activity during a functional MRI spatial attention task in areas normally involved in spatial attention. (2008) Visual scanning training Prism adaptation Ref. This result contrasts with previous findings that did support that right half-field patching is related to generalization to functional skills [36] . visual scanning training. (2008) Nijboer et al. the use of a global measure of functioning (overall gain on the Functional Independence Measure) and the duration of the training sessions. n A compensatory recruitment of left hemisphere areas [37] . or transcutaneous nerve stimulation (TENS) [41] . Optokinetic stimulation In OKS.com 35 . no difference was found between the groups on a measure of functional skills. (2009) George et al. A very recent study of the behavioral and neural effects of a 3-week OKS training in seven patients with chronic neglect showed that the training led to improvements of performance on standard measures of neglect that persisted for up to 4 weeks after training [37] . (2009) Shiraishi et al. (2008) Tsang et al. (2009) Thimm et al. In a recent randomized control study of future science group Review Table 1. (2008) Jacquin-Courtois et al. In addition. Further research is needed to determine the potential for this stimulation technique to generalize to functional tasks. (2009) Kerkhoff et al.futuremedicine. the OKS and the TENS groups showed significant improvements in reading and writing compared with the visual scanning training group that were still present upon retesting 1 week after the end of therapy [41] . Past research has demonstrated that such stimulation training leads to improvements in neglect on standard measures of spatial judgments and orientation [38. Typically. (2010) Bultitude et al. the subjects received one of the following interventions: OKS. n There is some burgeoning evidence the OKS training generalizes to daily life functional tasks. (2009) Ko et al.39] . including low power secondary to a small sample size. (2008) Keller et al. (2010) Watanabe and Amimoto (2010) Turton et al. this stimulation is combined with visual scanning training to reach its clinical effect. (2009) Saevarsson et al. The authors note that the null finding may be due to multiple factors. [24] [33] [28] [29] [25] [32] [56] [30] [27] Right half-field eye patching Optokinetic stimulation training [35] [37] [40] Motor activation Transcranial stimulation [44] [48] [49] Virtual reality Electrical stimulation/scanning training Combination treatments [52] [41] [55] [56] [57] [58] 30 individuals with at least moderately severe left-side neglect. TENS has been argued in the past to lead to improvement in neglect through a nonspecific activation of the right hemisphere or a directional effect on the egocentric co­ordinates of extrapersonal space [42] . Motor activation There is evidence to suggest that activation of the contralesional limb within the left hemispace can lead to improvements in neglect symptoms [43] . After receiving 20 therapy sessions across a 4‑week period of time. These results provide some preliminary support that OKS may be an intervention that can generalize to daily functional skills such as reading and writing. and more recent evidence has shown that this effect is heightened when patients are told to actively pursue the moving targets on the screen [40] . (2009) Saevarsson et al. an exogenously triggered directing of spatial attention to the neglected side is caused by the patient performing smooth-pursuit eye movements in response to visual stimuli that move coherently from the ipsilesional to the contra­ lesional side across a screen [37] . The researchers found a greater improvement on standardized neglect measures for the experimental group than for the control group [35] . Study (year) Interventions for neglect Trojano et al. (2010) Nijboer et al. Recent evidence for the efficacy of interventions for neglect syndromes. (2009) Serino et al. However. (2009) Ansuini et al. in a recent study by Luukainen‑Markkula and colleagues. 35 patients with neglect received either 4 weeks of standard stroke rehabilitation care or 4 weeks of right half-field eye-patching in addition to the standard rehabilitation care. (2009) Song et al. at least within the early phases of recovery from stroke. (2006) Luukainen-Markkula et al.

However. the reader is encouraged to read Utz et al. findings that need further replication in a larger sample.53] and on ‘real-life’ virtual tasks [54] . future science group . As the authors noted. there is research to suggest that application of virtual reality techniques does lead to improvements in performance for individuals with neglect on standard measures of neglect [52. did not find support for this treatment [46] . In addition. with parameters and applications within the environment that are easily controlled. Using a randomized controlled trial format comparing trunk rotation training with the combined treatments of trunk rotation training and right half-field eye patching and with standard treatment (with no specific neglect interventions). Ko and colleagues applied 20 min of anodal tDCS (stimulation. with previous studies suggesting that therapy that includes 15 degrees of voluntary trunk rotation to the left leads to improvements in neglect symptoms [45] . these findings can only be concluded to be preliminary until this effect is replicated with a larger sample. Nonetheless. which may have led to this intervention being less effective [46] . A recent randomized controlled pilot study of 14 individuals with a recent history of right hemisphere stroke demonstrated that low-frequency repetitive transcranial magnetic stimulation over the left parietal cortex 36 Future Neurol. With virtual reality technology. 3D world. Computer-generated virtual reality environments are interactive and realistic. They noted that in order for the subjects to complete the trunk rotation. A recent review by Tsirlin and colleagues provides a thorough discussion of the potential uses of virtual reality in neglect assessment and intervention in the hope of spurring more research in this area [51] . Although the findings are preliminary. and the effect is found to generalize to functional daily life skill use. researchers have begun to investigate the effectiveness of left hemisphere inhibition to reduce neglect. Another study of transcranial stimulation using transcranial direct current stimulation (tDCS) showed complementary results. In addition. a more recent study of 60 patients with neglect by Fong et al. the user is immersed in a rich. They found that performance on standard measures of neglect improved immediately after the transcranial stimulation compared with the stimulation testing. these are preliminary. (2011) 6(1) led to improvements on standard measures of neglect for the seven individuals who received this intervention [48] . it appears that transcranial stimulation deserves further scientific exploration as a potential intervention technique for neglect. Another motor activation approach is trunk rotation. For a review of the potential utility of transcranial stimulation (parti­c ularly tDCS and galvanic vestibular stimulation) for neglect and other neuropsychological impairments. multimodal. Overall. Virtual reality A relatively new tool being explored for the assessment and intervention of neglect is virtual reality [51] . Specifically. suggesting that arm activation training alone has beneficial effects on neglect symptoms. it remains to be shown whether a lasting effect on neglect can be maintained after repetitive transcranial magnetic stimulation and whether that effect generalizes to daily life functioning. they needed to cross over their right arm to compensate for their impairments in left-side motor functioning. However. but more research is needed to determine the mechanisms and the parameters of when such interventions are truly effective. it appears that motor activation may have some utility as an intervention for neglect in patients who do not have comorbid motor impairments. given that the majority of individuals with neglect also have paresis of their contra­ lesional arm. these researchers found no group differences on measures of neglect or on measures of functioning. Again. although intriguing. [50] .Review Kortte & Hillis therapeutic effect on neglect symptoms [44] . the researchers found that both the arm activation group and the visual scanning group showed better performance on traditional neglect measures at the 6‑month follow-up timepoint. this method of intervention is only applicable to a small subgroup of patients. which does not tap into the left limb activation that has been shown to be key for the stimulation effect to occur [43] . the results are found to be maintained for longer periods of time after discontinuation of the stimulation. Transcranial stimulation Based on the recent hypothesis that the cerebral dysfunction underlying neglect is related to a relative hyperactivity of the unaffected hemisphere secondary to release from reciprocal inhibition [47] . In a randomized controlled study of 12 patients with neglect. the subjects were noted to have difficulty tolerating the eye-patching while performing the trunk rotation. rather than inhibition) over the right posterior parietal cortex of 15 individuals who were at least 1 month postright hemisphere stroke and had neglect  [49] .

researchers have begun to investigate the combined effects of neglect interventions and modifications of the testing parameters. In a case study of two individuals with neglect secondary to right hemisphere stroke. Thus. but not for the exogenous cue trials. In another study of prism adaptation training. This study. Finally. investigated four treatments (OKS with pursuit eye movements. Toglia and Cermak found that a group of 20 individuals with neglect that received the dynamic assessment approach showed greater improvement on measures of neglect than the control group [59] . Keller et al. OKS with pursuit eye movements in conjunction with wearing baseleft prisms and OKS with pursuit eye movements in conjunction with following the visual stimuli by arm movements from the right to the left side) [55] . the small sample sizes of these studies do limit the conclusions that can be drawn. In addition. visual scanning training. This finding was concluded to suggest that the time pressure provided an increased subjective arousal and thus possibly increased alertness. the intervention is embedded within the assessment pro­ cedure with the goal of positively impacting the patient’s performance. throughout the assessment the degree of change that occurs in response to cues. feedback or task conditions are systematically and objectively measured [59] . For example. It is unclear whether the combined effects of OKS and prism adaptation training offers benefits above and beyond OKS alone. they found that these effects transferred to nontrained tasks through improved use of a left-side search strategy.com 37 . However.Rehabilitation for neglect & anosognosia Combination treatments It appears to be well recognized that neglect is a complex syndrome with multiple underlying mechanisms. In a randomized controlled trial of prism adaptation. the authors found a leftward reorienting of attention for the endogenous cue trials. The results suggest that visual scanning training showed a positive but modest improvement on neglect symptoms. whereas OKS with pursuit eye movements led to significant improvements in all measures of neglect. However. In an attempt to address these complexities with effective therapeutic interventions. Each of the nonpatients received all four different single-session treatments. strategies. When the researchers removed the time restrictions and feedback. each on a different day. so further research is warranted. These results provide further support for OKS with pursuit eye movements being a viable intervention for visual neglect. Dynamic assessment is an approach in which. Nijboer and colleagues manipulated the typical training paradigm by adding conditions of exogenous (peripheral) and endogenous (central) visual cueing on a computer screen for locating a target [58] . Saevarsson and colleagues investigated the effects of time restrictions and visual and auditory feedback for task completion in eight individuals who had neglect [56] . the prism adaptation intervention was ineffective for improving performance on neglect measures. resulting in improvements in overall brain functioning. another study found that a time pressure component positively affected performance of individuals with neglect on a spatial cancellation task [57] . are further attempts to elucidate the underlying mechanisms of neglect and to develop interventions that address the multifaceted nature of neglect syndromes. These two studies may be tapping into two separate mechanisms and two separate endogenous means for positively affecting spatial neglect. In this study. Future research should strive to evaluate these combination interventions in larger samples. and the studies of other combination treatments outlined earlier. In contrast to these findings. with a pre-test and post-test of standard neglect measures. a combination of OKS with pursuit eye movements in conjunction with prism adaptation showed no additional effect on test performance. These researchers found that when they placed restrictions on visual search time and provided feedback for correct and incorrect responses. in an attempt to apply a dynamic teaching–learning approach to a comprehensive rehabilitation intervention for neglect. Thus. the future science group Review five participants were asked to complete the task with and without instructions regarding a time limit. prism adaptation was once again effective for improving symptoms of neglect. They concluded that these findings suggest that prism adaptation improves neglect by a compensatory process of leftward voluntary orienting.futuremedicine. and the ipsilesional arm movements in conjunction with OKS appeared to aggravate the neglect symptoms. rather than by a fundamental change in attentional bias [58] . but it has been widely demonstrated that prism adaption training requires a longer duration of treatment than the one session offered in the current study. patients are able to successfully attend to the left with conscious effort even though the automatic orienting reflex remains biased to the right [58] . It could be argued that dynamic assessment relies upon a ‘top-down’ www.

After providing her with video feedback of herself performing the awareness assessment. very recently. behavioral and physical disturbances that are direct threats to safety and medical stability. Because individuals with AHP believe there is nothing wrong with their motor functioning. This limitation of previous studies might account for the inconsistent results across studies with respect to the effectiveness and generalization of various approaches.69] . AHP has received the most attention and scientific scrutiny [60] . few advances have been made in treatment approaches. these authors presented the case of a 67-year-old individual with a left-sided hemiplegia and AHP that persisted 3 weeks after onset.. leading to refusals to participate in rehabilitation.e. Since that time. future science group . Although AHP is a specific type of awareness syndrome. Fotopoulou and colleagues provided preliminary evidence that self-observation of motor behavior from the third-person perspective may lead to permanent recovery from AHP [64] . interventions are aimed at the myriad of cognitive. it is essential to replicate this singular finding. they do not understand the need for therapeutic interventions. That impaired recognition may be for the actual change in motor. a set of theoretical models have emerged to provide a structure on which to approach interventions for various awareness syndromes. but most treatment studies have failed to individualize the intervention to the underlying cognitive disorder (i.Review Kortte & Hillis approach to impact the symptoms of neglect. longer rehabilitation stays and poorer outcomes [8. In recognition of these commonalities.16] . structuring the environment and providing greater levels of supervision appear warranted in order to reduce the risk of falls and other safety risks associated with motor impairments of which the individual is not completely aware [10] . It is also well recognized that the unawareness presentation is complex. there is the potential of gleaning important information regarding intervention strategies that could be helpful for AHP. Over the last 20–25 years.10. Although several anosognostic syndromes following right hemisphere stroke have been identified. From the literature. the self­-determination approach to enhance selfawareness [71] and the Comprehensive Dynamic Interactional Model (CDIM) of awareness [72] . When there are many treatments for the same condition. very few studies have been conducted investigating interventions for AHP and so to date. As such. a substantial amount of attention has been given to awareness syndromes that present after the onset of brain injury given the negative impact that such syndromes can have on the rehabilitation process and outcomes [65–67] . Neglect is a heterogeneous disorder. Specifically. However.12] . many of which have shown some effectiveness. all awareness syndromes are marked by an impaired recognition for the presence of some impairment in functioning. they may not follow appropriate precautions. which included questions and execution of motor movements. or it is a heterogeneous disorder requiring individualized treatment. this generally suggests that there is not a single very effective intervention. little is known about interventions that have a direct impact on AHP. Interventions for anosognosia for hemiplegia Anosognosia for hemiplegia is characterized by an unawareness of motor impairment and the changes in functioning that result from that motor impairment. During the very acute stages of recovery following stroke. In addition. (2011) 6(1) Initial studies from 20 years ago demonstrated that temporary remission of AHP symptoms can be initiated by vestibular stimulation [62. its characteristics parallel those of other awareness syndromes. however. emotional and physical sequelae. In summary. she demonstrated signs of spontaneous recovery from AHP. consisting of neural and cognitive processes as well as psychological factors [68. However. including unawareness of cognitive. but some of which have not. For a review of these models and discussion of awareness interventions in greater detail. see Fleming and Ownsworth [73] . The resolution of the unawareness persisted through the next day. 38 Future Neurol. Although these results are intriguing. Given the paucity of research investigating potential interventions for AHP. no single method of treatment or rehabilitation has emerged [61] . visuomotor/exploratory. These include the pyramid model of awareness [70] .63] . there have been various treatment strategies described for neglect. it may be beneficial to consider the evidence supporting interventions for awareness syndromes more generally. Specifically. perceptive/visuospatial or allocentric/object-centered) [3. However. further research is needed to determine whether there is some stimulation component of this intervention that would also constitute a ‘bottom-up’ approach. sensory or cognitive functioning and/or the impact of that deficit on life functioning. which may result in safety risks [10] .

Most recently. with some components remaining the same with each approach. Goverover and colleagues demonstrated that multicontext­ ual treatment results in improved self-­regulation and functional performance on instrumental activities of daily living after brain injury [79] . In a randomized clinical trial. such as denial and avoidance.futuremedicine. both individuals demonstrated improvements in selfcare. The interventions. emergent awareness and anticipatory awareness). on his/her own. anticipate challenges and identify errors.74] .e. Thus. more recently there have several studies of the multicontextual treatment approach [78] . which is based on the CDIM of awareness [72] .. selfappraisal and/or timing feedback) in order to improve emergent awareness. It is assumed that the patient cannot glean. may show resistance to participating in rehabilitation interventions and so respond more poorly  [69] . It has been proposed that individuals that employ more defensive coping strategies. but no improvements in general awareness of deficits (self-knowledge/intellectual www.76] . Using the terminology proposed by Crosson and colleagues. The assumption is that the patient does not have information about themselves due to a lack of access and/or understanding of the problem. emergent awareness in which the individual can recognize the impact of the deficits while performing a task and anticipatory awareness in which the individual is able to predict how they will perform on a particular task and/or whether a problem will occur given the deficits [70] . This approach targets self-­k nowledge (intellectual awareness) and online awareness (emergent and predictive awareness) and is based upon the assumption that self-knowledge emerges slowly over time with experience. the key components for complete awareness include an intellectual awareness in which the individual has a basic knowledge of the deficits and the implications. In order to facilitate the development of complete awareness (intellectual awareness. Although there is limited research of interventions to target these components. Another example of this type of intervention for more general awareness of deficits is the study by Roberts and colleagues [77] . there has been recognition of the role that psycho­logical adjustment and coping can play in the complete awareness presentation [68. specific interventions have been developed to address the specific area of unawareness (Table 2) . observer feedback. Such psychological coping reactions have been labeled ‘denial of illness’ and can be differentiated from anosognosia  [75. Educational approaches are aimed at patients learning about the types of deficits that they have following brain injury and how they impact daily life functioning in order to increase intellectual awareness. taking into consideration all of his/her strengths and weaknesses in order to develop anticipatory awareness. The authors reported improvements on measures of unawareness postfeedback that were maintained 2 weeks later. They reviewed brain future science group Review imaging findings to provide feedback to 16 individuals with brain injury about the presence of neuropathology and possible neurobehavioral outcomes. The study by Fotopoulou and colleagues mentioned earlier is an example of using a feedback approach for AHP [64] . Feedback approaches are aimed at provision of cues and tangible feedback regarding performance on tasks (i. In addition. videotaped. In addition to these three main components. mobility and graphomotor abilities. Zlotnik and colleagues presented two case examples in which the individuals had impaired awareness of their cognitive and motor impairments post-brain injury [80] .Rehabilitation for neglect & anosognosia These three approaches build on one another. as well as being able to identify deficits in these functional activities. were found to be related to improvements in speci­fic awareness in order to recognize and verbalize errors (online awareness/predictive awareness). there have been two studies that investigated the effectiveness of multi­contextual treatment approach. These examples can easily be applied to individuals with AHP to determine if these types of multicontextual treatment could improve self-knowledge regarding the impaired motor functioning and begin to get individuals with AHP to predict what types of tasks will be more difficult secondary to their impairments. most approaches incorporate psychological interventions to address the coping reactions. prediction approaches are aimed at the patient predicting his/her performance on a task. the implications of the information about his/her deficits. which included provision of feedback and assisting patients to self-cue. along with intervention approaches to address one or more of the key components of complete awareness.com 39 . After several weeks of multicontextual treatment. Toglia and colleagues investigated whether the multicontextual treatment could promote transfer of strategy use and self-regulation in four individuals with brain injury  [81] . whereas online awareness potentially changes from activity to activity depending on the task demands and task context. Finally.

such as trans­ cranial stimulation. (2010) Zlotnik et al. and can be tailored to the specific type of neglect. (2009) Toglia et al. Lundqvist and colleagues applied the multicontextual treatment within a group intervention with 21  individuals in order to improve emergent/online awareness  [82] . which can be tailored to the specific type of the syndrome that is present. firm conclusions cannot be made given the reliance on case reports and small sample sizes. Thus. but further research is needed. Although results from these studies provide preliminary support of the effectiveness of interventions structured after the CDIM [72] . However. including AHP. which may prove to be superior in effect. Study (year) Components of complete awareness Target of interventions Types of interventions Zlotnik et al.81] [79–82] evidence that having individuals put conscious effort into tracking a visual stimulus during the task may be particularly effective.Review Kortte & Hillis Table 2. Thus. However. the limited research on interventions for AHP that has been conducted is focused on a ‘bottom-up’ approach relying on stimulating the vestibular system with temporary resolution of the unawareness. noting that it ranges from low to moderate. the combination of ‘bottom-up’ and ‘top-down’ interventions may prove to be the most effective. new interventions are beginning to be investigated. [64. Summary of recent relevant research in relation to components of complete awareness. (2009) Goverover et al. However. future science group . The trend is for the use of combination therapeutic interventions that address these components from both ‘top-down’ and ‘bottom-up’ approaches. Emergent (2009) awareness Roberts et al. even within the last year. prism adaptation continues to be the most wellsupported intervention. As reviewed earlier. multifaceted impairments leading to significant difficulties in daily life functioning. It may be that application of the multicontextual approach to AHP will assist in the development of more comprehensive interventions that are maximally effective. the interventions for these syndromes must be multifaceted in order to address the complex interplay of cognitive–behavioral–emotional components. several studies have been published using randomized controlled trial methodologies in attempts to provide quality evidence along this line of research.80. Following treatment. This study’s findings fit within the overarching model of using feedback to impact emergent awareness.84] . (2006) Toglia et al. Taking all the recent findings together. (2007) awareness). patients demonstrated improved anticipatory awareness and use of coping strategies. it appears well recognized that both neglect syndromes and awareness syndromes include complex. Future research needs to expand upon these findings and replicate the results with larger sample sizes. (2010) Zlotnik et al. Conclusion & future perspective In summary. Interventions were provided during 11 group sessions across a 6-month period of time. It is likely that new approaches. (2010) Anticipatory awareness Lundqvist et al. The quality of studies in this line of research has been criticized recently  [83. All participants in the intervention had intellectual awareness as a prerequisite to participating in the study. there is mounting evidence supporting effective treatment options for visual neglect. this line of research suggests that a multicontextual approach that targets the three components of complete awareness may offer some avenues for intervention for awareness syndromes. Overall. will be most effective when used in combination with other ‘top-down’ approaches.77. and there is particular 40 Future Neurol. (2011) 6(1) [80] Video feedback Brain imaging findings feedback Multicontextual approach Prediction: having the patient predict Multicontextual his/her performance on a task taking into approach consideration all of his/her strengths and weaknesses Ref. but no change in emergent awareness. The trend is to augment the effect of prism adaptation by combining it with other treatments. whereas the recent study by Fotopoulou and colleagues uses a feedback paradigm resulting in resolution of the AHP [64] . (2009) Intellectual awareness Education: learning about the types of deficits following brain injury and how they impact daily life functioning Feedback: provision of cues and tangible feedback regarding performance on tasks Multicontextual approach Fotopoulou et al.

Keller C. emergent awareness and anticipatory awareness). 11. Papagno C. n Given the prevalence of these two syndromes co-occurring. n The combination of ‘bottom-up’ and ‘top-down’ interventions may prove to be the most effective. Acta Neurol. 471–482 (1986). 495–524 (1994). multifaceted impairments leading to significant difficulties in daily life functioning. Katz N: Anosognosia for hemiplegia in stroke rehabilitation. Kertesz A (Ed. Dauriac-Le Masson V. Louis‑Dreyfus A et al. Valenstein E: Localization of lesions in neglect and related disorders. 46(3). 114. 10. Stroke 36. 215–220 (2002). it may be beneficial to consider the evidence supporting interventions for awareness syndromes more generally. n Interventions for anosognosia for hemiplegia A recent case study provided intriguing but preliminary evidence that self-observation of motor behavior from the third-person perspective may lead to permanent recovery from AHP. J. 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