Chapter 13 - Perceptual Disorders - With Appendix

EBRSR
[Evidence-Based Review of Stroke Rehabilitation]
13
Perceptual Disorders
Robert Teasell MD, Katherine Salter PhD (cand.), Andreea Cotoi MSc, Jashan Brar BSc, Janet Donais OT
Last Updated: September 2016
Abstract
This review examines the treatment perceptual disorders following stroke focussing primarily on
unilateral spatial neglect (USN). Unilateral spatial neglect is reported in about 25% of stroke patients
referred for rehabilitation and is more commonly associated with right parietal lesions. Unilateral
spatial neglect has been reported to have a negative impact on functional recovery, length of
rehabilitation stay, and need for assistance after discharge. In general, rehabilitation interventions to
improve neglect may be classified into a) those which attempt to increase the stroke patient's
awareness of or attention to the neglected space or b) those which focus on the remediation of deficits
of position sense or body orientation. Interventions of the first type included in the present review are:
visual scanning retraining, arousal or activation strategies and feedback to increase awareness of
neglect behaviours. Identified interventions that attempt to improve neglect by targeting deficits
associated with position sense and spatial representation include the use of prisms, eyepatching and
hemispatial glasses, caloric stimulation, optokinetic stimulation, TENS and neck vibration. The use of
dopaminergic medication therapy and music therapy is also discussed.
13. Perceptual Disorders pg. 1 of 66

www.ebrsr.com
Key Points
Perceptual Deficits
 Perceptual training interventions appear to be effective for improving perceptual impairment
post stroke.
 The additional benefit of family participation in the rehabilitation of neglect is unclear relative to
conventional rehabilitation.
Treatment of Neglect
 Visual scanning training may be effective for alleviating perceptual impairment and improving
functional ability post-stroke.
 Computer-based visual scanning therapy and virtual reality treatment for neglect appears to be
effective in improving visual perception.
 Limb activation appears to have a positive effect on neglect and motor function.
 The use of external sensory stimulation in the treatment of neglect may be beneficial, although
evidence is limited.
 Electrical somatosensory stimulation may be a useful supplement to visual scanning training.
 Visuomotor feedback strategies appear to be beneficial in the treatment of neglect.
 Prismatic adaptation with a significant rightward shift appears to be beneficial for neglect;
however, the long-term effect is unclear.
 The evidence for the use of eye patching and hemispatial glasses for improving neglect is
currently unclear.
 The effectiveness of caloric stimulation as part of a treatment intervention for unilateral spatial
neglect has not been well evaluated.
 Vestibular galvanic stimulation appears to have a positive effect on visuospatial neglect. Further
study is required to determine polarity specific effects.
 Although optokinetic stimulation appears to have a positive effect on neglect, it is uncertain

whether the addition of optokinetic stimulation to a program of rehabilitation for neglect would
be of benefit.
 Trunk rotation may not be an effective treatment for unilateral spatial neglect post-stroke
although evidence is limited and conflicting.
 Neck muscle vibration therapy used in combination with visual exploration training may result in
a reduction in the symptoms of neglect and increased performance of activities of daily living.
 There is little evidence to support the use of music therapy for neglect rehabilitation.

www.ebrsr.com
 Transcutaneous electrical nerve stimulation treatment appears to have a positive effect on
neglect post-stroke.
 Overall, transcranial magnetic stimulation has been found to be beneficial in the treatment of
neglect.
 Transcranial direct current stimulation may be beneficial in the treatment of neglect.
 More research is needed to determine if dopamine may be useful for improving post-stroke
neglect.
 More research is needed to determine the effectiveness of rivastigmine at improving post-

stroke neglect.
 There is limited evidence regarding the effect of nicotine on unilateral neglect. Further studies
are needed.
Dr. Robert Teasell

Parkwood Institute, 550 Wellington Road, London, Ontario, Canada, N6C 0A7
Phone: 519.685.4000 ● Web: www.ebrsr.com ● Email: Robert.Teasell@sjhc.london.on.ca
www.ebrsr.com
Table of Contents
Abstract .............................................................................................................................................1
Key Points..........................................................................................................................................2
Table of Contents ...............................................................................................................................4
13.1 Perceptual Deficits ......................................................................................................... 5
13.1.1 Treatment of Perceptual Disorders ............................................................................................. 5
13.1.2 Family Participation..................................................................................................................... 7
13.2 Neglect ......................................................................................................................... 8
13.2.1 Defining Neglect .......................................................................................................................... 8
13.2.2 The Incidence of Neglect Post Stroke.......................................................................................... 8
13.2.3 Anatomical Substrates of Neglect ............................................................................................... 9
13.2.4 Spontaneous Recovery and Neglect ......................................................................................... 10
13.2.5 The Impact of Neglect Post-Stroke............................................................................................ 10
13.2.6 Screening and Assessments for Neglect ................................................................................... 11
13.3 Treatment of Neglect .................................................................................................... 12
13.3.1 Visual Scanning .......................................................................................................................... 13
13.3.2 Computer-Based Rehabilitation ................................................................................................ 17
13.3.3 Activation Strategies ................................................................................................................. 19
13.3.4 Limb Activation.......................................................................................................................... 19
13.3.5 Sensory Stimulation Interventions ............................................................................................ 21
13.3.6 Feedback Strategies .................................................................................................................. 23
13.3.7 Prism Treatment........................................................................................................................ 24
13.3.8 Eye-Patching and Hemispatial Glasses ...................................................................................... 28
13.3.9 Caloric Stimulation .................................................................................................................... 30
13.3.10. Vestibular Galvanic Stimulation ............................................................................................. 31
13.3.11 Optokinetic Stimulation .......................................................................................................... 33
13.3.12 Trunk Rotation Therapy .......................................................................................................... 35
13.3.13 Neck Muscle Vibration ............................................................................................................ 36
13.3.14 Music Therapy ......................................................................................................................... 37
13.3.15 Transcutaneous Electrical Nerve Stimulation ......................................................................... 37
13.3.16 Repetitive Transcranial Magnetic Stimulation ........................................................................ 39
13.3.17 Transcranial Direct Current Stimulation ................................................................................. 40
13.3.18 Pharmacological Interventions ............................................................................................... 41
13.3.18.1 Dopaminergic Medication Therapy ...................................................................................... 41
13.3.18.2 Acetylcholinesterase Inhibitors Therapy .............................................................................. 42
13.3.18.3 Nicotine Therapy .................................................................................................................. 43
Summary ......................................................................................................................................... 45
References....................................................................................................................................... 48
Appendix ......................................................................................................................................... 64

www.ebrsr.com
13.1 Perceptual Deficits
In 1991, Titus and colleagues defined perceptual performance as “the ability to organize, process and
interpret incoming visual information, tactile-kinesthetic information, or both, and to act appropriately
on the basis of the information received,” (Titus et al. 1991). Using this definition, Titus et al. (1991)
examined the relationship between perceptual performance and activities of daily living (ADLs). The
authors observed that perceptual deficits, in particular constructional praxes and visual discrimination,
were related to performance of activities of daily living.
Unilateral spatial neglect is found in about 23% of stroke patients. It is more common in patients with
right sided lesions (42%) than left sided lesions (8%) and is more persistent with right sided strokes.
Neuroanatomical studies found left hemisphere modulated arousal and attention for right visual field
but right hemisphere controlled process for both right and left visual fields so intact right hemisphere is
able to compensate.
13.1.1 Treatment of Perceptual Disorders

There are two main approaches to the treatment of perceptual disorders: a transfer of training
approach and the functional approach (Edmans et al. 2000). The transfer of training approach assumes
that practice on a particular perceptual task will improve performance on similar perceptual tasks. The
functional approach strives to promote functional independence through the repetitive practice of
particular tasks, usually ADLs. When occupational therapists treat stroke patients having cognitive
impairments, they often use a functional approach in ADL re-training to reduce the consequences of
cognitive-perceptual impairments such as visual-spatial neglect (Steultjens et al. 2003).
Individual studies examining these approaches to the rehabilitation of perceptual disorders post-stroke
are summarized in Table 13.1.1.1.
Table 13.1.1.1 Summary of Studies Evaluating Treatments of Perceptual Deficits Post Stroke
Author, Year
Study Design (PEDro Score) Intervention Main Outcome(s)
Sample Size Result
Edmans et al.(2000) E1: Transfer of training approach  Barthel Index (-)
RCT (6) E2: Functional Approach  Rivermead Perceptual Assessment Battery
N=80 (-)
 Edmans Activity of Daily Living Index (-)
Lincoln et al. (1997) E: Rehabilitation for neglect on stroke unit  Rey Complex Figure Copy (+)
RCT (6) C: Conventional ward treatment
N=315
Lincoln et al. (1985) E: Perceptual retraining  Rivermead Perceptual Assessment Battery
RCT (6) C: Conventional therapy (-)
N=33  Rivermead Activities of Daily Living (-)
Carter et al.(1983) E: Cognitive Skill remediation + specific task  Letter Cancellation (+)
RCT (5) training  Visual-spatial task (+)
N=33 C: Conventional rehabilitation  Time-judgement task (+)
Weinberg et al.(1982) E: Perceptual retraining + rehabilitation  Wechsler Adult Intelligence Scale: Digit
RCT (5) therapy Symbol (-); Picture Completion (-); Block
N=33 C: Conventional rehabilitation therapy Design (-); Object Assembly (-); Arithmetic
(-); Similarities (-)
 Metropolitan Achievement Test:
Comprehension (-)

www.ebrsr.com
 Embedded Figures (-)
 Visual Simultaneity (+)
 Conditional Cancellation (-)
 Knox Cubes (-)
 Goldstein Object Sort (-)
Gordon et al.(1985) E: Perceptual remediation  Wechsler Adult Intelligence Scale (-)
PCT C: Conventional rehabilitation without  Cancellation Tasks: Post (+); 4mo Post (-)
N=77 perceptual remediation  Wide Range Achievement Test (-)
 Address Copying (-)
 Arithmetic: Post (+); 4mo Post (-)
 Metropolitan Achievement Test: Post (+);
4mo Post (-)
 Double Simultaneous Stimulation: Post (+);
4mo Post (-)
 Line Bisection Test: Post (+); 4mo Post (-)
 Midline to side sensation (-)
 Raven’s Coloured Progressive Matrices:
Post (+); 4mo Post (-)
 Lateral Asymmetry and Visual-Spatial
Attention: Post: Structured (+),
Unstructured (-); 4mo Post (-)
 Embedded Figures Task (-)
 Facial Recognition Task (-)
 Purdue Pegboard Test (-)
 Weschler Bellevue: Post: Similarities (-),
Comprehension (+)
 Multiple Affect Adjective Checklist:
Depression (-); Anxiety: Post (-), 4mo Post
(+); Hostility: Post (+), 4mo Post (+)
- Indicates no statistically significant differences between treatment groups
+ Indicates statistically significant differences between treatment groups
Discussion
Overall, the majority of studies demonstrated a positive effect associated with the remediation of
perceptual deficits following stroke. In a study comparing cognitive skill remediation training for neglect
to no treatment, Carter et al. (1983) found significantly greater improvement with cognitive
remediation on all measures of visuospatial perception. Similar results were also observed in Gordon et
al.’s (1985) comparison of a comprehensive perceptual remediation therapy with conventional
rehabilitation. The comprehensive rehabilitation program was based on three previously reported,
successful treatments of visual scanning training, somatosensory training and complex visual perceptual
training. After a maximum of 35 hours of training, the authors found significantly greater improvements
in favour of the experimental group on mostly scanning and visual perception tasks. However, the
authors failed to notice a significant difference on the majority of the somatosensory and non-specific
generalization tasks. Additionally, these improvements were not maintained at the four month follow-
up compared to the control.
Only one other study assessed the durability of the treatment effect. In order to investigate the effect of
perceptual impairment on rehabilitation outcome, Lincoln et al. (1997) randomized patients to receive
either intensive care where perceptual impairments were routinely screened and the rehabilitation
program was continuously adjusted, or to a conventional care ward (see insert above). Significantly
greater improvement in the perceptual impairment focused group was found on measures of neglect
persisting up to 12 months post-randomization. One study compared a transfer of training approach to a
www.ebrsr.com
functional approach for perceptual retraining. Although Edmans et al. (2000) found significant
improvements within each group on the majority of outcomes, they noted no differences between
groups. The authors suggest that this lack of difference may be due to the use of similar strategies in
each intervention (i.e. imitation, mental stimulation, repetition) or the low sensitivity of measures such
as the Rivermead Perceptual Assessment Battery.
Conclusions Regarding Treatment of Perceptual Disorders Post-Stroke
There is conflicting level 1a and level 2 regarding the evidence for perceptual training interventions
on perceptual functioning.
There is level 1b evidence that a transfer of training approach may not produce different results on
measures of neglect and functional ability when compared to a functional approach to perceptual
training.
Perceptual training interventions appear to be effective for improving perceptual impairment post-
stroke.
13.1.2 Family Participation

Only two studies were identified that examined the impact of family participation on the rehabilitation
outcomes of individuals with perceptual deficits (i.e. unilateral spatial neglect) following stroke. (Table
13.1.2.1).
Table 13.1.2.1 Summary Studies Evaluating of Family Participation in Rehabilitation

Author, Year
Sample Size Result
Dai et al. (2013) E: Vestibular rehabilitation with a caregiver +  Rivermead Behavioural Inattention Test
RCT (5) conventional rehabilitation Conventional subtest (-)
N=48 C: Conventional rehabilitation  Functional Independence Measure (-)
 Postural Assessment Scale for Stroke (-)
Osawa & Maeshima (2010) E: Structured mobility exercises + usual  Behavioural Inattention Test Conventional
PCT therapy subtests (+)
N=34 C: Usual therapy  Rivermead Mobility Index (-)
 Barthel Index (-)
Discussion
One study examined the impact of family participation in delivering a program of structured exercises
with increasing intensity to improve mobility (Osawa & Maeshima 2010). The authors compared this
group to a group that did not receive structured exercises and found significant improvement associated
with unilateral neglect in the family participation group. Given that increased intensity of therapy may
be associated with improvement in mobility outcomes, it is not possible to assume that the
improvements reported by Osawa and Maeshima (2010) were attributable to family participation alone
(Klinke et al. 2015). One RCT trained caregivers in the experimental group to provide vestibular
rehabilitation to patients with unilateral neglect (Dai et al. 2013). Patients in all groups improved on
measures of neglect, activities of daily living and balance. Yet, no differences were seen between

www.ebrsr.com
groups. This may be partially attributed to the short duration of the study with caregivers only guiding
vestibular rehabilitation for two weeks. Further study is necessary to determine the full range of
potential improvements that could be attributed to caregivers.
Conclusions Regarding Family Participation
There is limited level 2 evidence that family participation in rehabilitation may not be associated
with additional improvements in perceptual impairment and functional ability when compared to
The additional benefit of family participation in the rehabilitation of neglect is unclear relative to
13.2 Neglect
13.2.1 Defining Neglect

Unilateral spatial neglect (USN) is one of the disabling features of a stroke, and is defined as a failure to
report, respond, or orient to sensory stimuli presented to the side contralateral to the stroke lesion site
(Heilman & Watson 1985). Many terms are used interchangeably in the literature to describe USN,
including unilateral neglect, hemi-inattention, visual neglect and hemi spatial neglect. Clinically, the
presence of severe USN is apparent when a patient often collides into his/her surroundings, ignores
food on one side of the plate, and attends to only one side of his/her body (Wyness 1985). However,
symptoms of USN have to be quite severe for this impairment to be observed easily during the
performance of functional activities (Cherney et al. 2001; Mesulam 2000) and are more obvious when
present during the early stages post stroke. More subtle forms of USN may go undetected in a hospital
setting but are a major concern for client function and safety upon discharge. Mild symptoms of USN
become apparent during high-level activities such as driving, working or while interacting with others.
Neglect is a complex combination of clinical presentation that differs from patient to patient. Unilateral
spatial neglect can be classified into egocentric and allocentric.
 Egocentric neglect: Neglect of the own body or personal space, tendency to neglect the
opposite side of the lesion, in reference to the midline the body.
 Allocentric neglect: Can present in 2 ways, either peripersonal neglect or extrapersonal neglect.
o Peripersonal neglect refers to neglect towards the contralesional side of
object/environment within the patient's normal reach (within reaching space).
o Extrapersonal neglect refers to neglect towards the contralesional side of each
object/environment beyond the patient's normal reach (beyond reaching space).
13.2.2 The Incidence of Neglect Post Stroke

Reported incidence of USN ranges from 8% to 95%, however, sample selection, definitions of USN and
methods used to assess USN are not consistent in all studies that report its incidence (Bowen et al.
1999). Pedersen et al. suggested that the 23% rate of occurrence found in the Copenhagen stroke study
is a more reasonable estimate (Pedersen et al. 1997). More recently, Appelros et al. (2002) reported
23% of patients included in a stroke incidence study to have visual-spatial neglect while 8% were
reported to have personal neglect. The presence of neglect has been associated with both severity of
stroke and age of the individual (Appelros et al. 2002; Pedersen et al. 1997; Ringman et al. 2004), but

www.ebrsr.com
not with gender, prior stroke, comorbidities or handedness (Pedersen et al. 1997; Ringman et al. 2004).
Linden et al. (2005) reported that elderly stroke patients with persistent neglect 20 months following
the stroke event demonstrated more visual field impairments, cognitive impairments and dementia than
stroke patients with no neglect. The frequency of these impairments was associated with the severity of
neglect. The most common cognitive impairment among stroke patients with neglect was reported to
be apraxia, either constructional or ideational-instrumental (Linden et al. 2005).
13.2.3 Anatomical Substrates of Neglect

Unilateral spatial neglect (USN) is more common in patients with right-sided lesions than left. In the
Copenhagen Stroke Study (Pedersen et al. 1997), 42% of individuals with a right-sided lesion were
reported to have USN compared to only 8% of patients with a left hemisphere lesion. A study of 1,282
acute stroke patients (Ringman et al. 2004) revealed that 43% of patients with right-sided lesions
experienced neglect compared to 20% of patients with left-sided lesions (p<0.001). At 3 months
following stroke onset, 17% of patients with right-sided lesions continued to suffer from neglect
compared to only 5% of patients with left-sided lesions.
There is evidence from positron emission tomographic (PET) scan analyses (Corbetta et al. 1993) and a
systematic review of 17 studies (Bowen et al. 1999) that the right hemisphere regulates attention.
Neuroanatomical findings have identified that the left hemisphere is responsible for modulating arousal
and attention for the right visual field, whereas the right hemisphere controls these processes in both
right and left visual fields (Feinberg et al. 1990). This may explain why USN is not typical for those with
left hemisphere damage (LHD) post-stroke because the intact right hemisphere is capable of
compensating for perceptual deficits that result from LHD (Feinberg et al. 1990) (See Figure 13.2.3.1 for
an illustration of visual neglect and the compensatory action of the right hemisphere).
Figure 13.2.3.1 Lesion location and the resulting neglect.
In a review of the literature, Ferro et al. (1999) reported that more severe and more stable neglect has
been associated with parietal and frontoparietal lesions. Paolucci et al. (2001) reported USN in right
brain damaged individuals post stroke to be more frequently associated with MCA territory infarcts with

www.ebrsr.com
large, cortical frontal temporoparietal lesions (p<0.001) and with cortical parietotemporal lesions
(p<0.05). A study of 1,282 patients with acute stroke reported that unilateral neglect was most
frequently associated with cortical lesions and in the temporal, parietal, and frontal lobes (Ringman et
al. 2004).
13.2.4 Spontaneous Recovery and Neglect

It has been reported that incidence of USN declines one month or more following the stroke event (Katz
et al. 1999; Paolucci et al. 2001). In their 1999 review, Ferro and colleagues reported that, in many
cases, the most conspicuous manifestations of hemi-spatial neglect resolved spontaneously within the
first 4 weeks following a stroke event (Ferro et al. 1999). While further recovery may continue over the
period of one year, it is not as significant as the recovery seen in the acute phase post stroke.
The degree of recovery may vary according to type of neglect. Appelros and colleagues demonstrated
that patients experiencing neglect of peripersonal space experienced complete recovery less often than
those patients experiencing either neglect of far space or of personal space (Appelros et al. 2004). In the
latter cases, complete recovery was seen by 6 months post stroke in 52% and 46% of cases, respectively
compared with 13% of patients experiencing neglect of peripersonal space. For all three types of
neglect, there were no further significant improvements seen from 6 months to one year post stroke
(Appelros et al. 2004).
13.2.5 The Impact of Neglect Post-Stroke

Unilateral spatial neglect has been reported to have a negative impact on functional recovery, length of
rehabilitation stay, and need for assistance after discharge. While the majority of patients diagnosed
with visuospatial inattention post-stroke recover by three months, those with severe visuospatial
inattention on initial presentation have the worst prognosis (Diamond 2001). Paolucci et al. (2001)
reported USN to be a clearly negative prognostic factor. The presence of USN was associated with
poorer functional outcome, poorer mobility, longer length of stay in rehabilitation and a greater chance
of institutionalization upon discharge from rehabilitation. A 2005 study reported the presence of USN to
be a significant predictor of length of stay (Gillen et al. 2005). In that study, patients with right-sided
stroke and USN were matched for severity of functional deficits (FIM scores) at admission to
rehabilitation with patients with right-sided stroke and no USN. It was determined that among patients
with similar functional deficits, the presence of USN was associated with longer lengths of stay and
slower rates of improvement (Gillen et al. 2005).
Patients with USN may be more impaired at the beginning of rehabilitation than patients without USN
(Katz et al. 1999), particularly if they are experiencing both spatial and personal neglect (Wee & Hopman
2008). While significant gains may be made throughout the course of rehabilitation, patients with
unilateral neglect, whether left or right, spatial or personal, tend to be more functionally disabled at
discharge (Wee & Hopman 2008). Wee and Hopman (2008) reported that the presence of both
unilateral spatial neglect and unilateral personal neglect was associated with increased safety risk (e.g.
collisions with objects or people, risk to unattended side of the body, lack of insight regarding cause of
injury), decreased likelihood of discharge home, longer lengths of stay in rehabilitation, increased
incidence of shoulder or hand complications and lower FIM scores at admission and discharge from
stroke rehabilitation (Wee & Hopman 2008). Similar results were also observed in a more recent study
conducted by Timbeck et al. (2013). The authors found that visuospatial neglect was significantly
associated with worse admission and discharge FIM scores and found that all six individuals with neglect
were discharged to a supportive living environment.

www.ebrsr.com
The presence of USN has been identified as a significant predictor of functional dependence in ADLs
(Appelros et al. 2002; Katz et al. 1999) and poorer performance in IADLs at six months (Katz et al. 1999)
and one year post discharge from rehabilitation (Jehkonen et al. 2000). The presence of USN explained
73% of the total variance in IADL at a three-month follow up, 64% at six months and 61% at one-year in
57 subjects post stroke (Jehkonen et al. 2000). Appelros et al. (2003) reported USN to be a significant
predictor of both mortality (OR=2.7) and dependency (OR=4.0) one year after the stroke event. In
addition, substantial proportions of individuals (79 – 82%) with neglect require home assistance
following discharge (Appelros et al. 2003; Katz et al. 1999) or may be discharged to nursing home care
(Appelros et al. 2003; Paolucci et al. 2001).
It should be noted that not all authors report strong associations between neglect and functional
outcome. Pedersen et al. (1997) found hemi-neglect to have no influence on functional prognosis,
length of rehabilitation or mortality. A review of studies evaluating the impact of neglect on functional
outcomes following stroke found that, in 25 of 26 studies from 1996 – 2005, neglect was reported to be
a significant predictor of poorer functional outcome either alone or in combination with one or more
variables such as age, hemiparesis, severity of stroke, anosognosia or other cognitive impairments
(Jehkonen et al. 2006). The authors note that the reported relationship between neglect and functional
outcome is dependent upon both how and when variables are assessed, which potential predictors are
included in the analysis and how patients are selected for study inclusion. Definitions of neglect were
inconsistent and few studies provided detailed operational definitions of the construct (Jehkonen et al.
2006).
13.2.6 Screening and Assessments for Neglect

Language impairments reported in those with LHD post-stroke can influence the validity of assessments
requiring receptive and expressive speech, such that this population is frequently excluded in studies
evaluating USN. For example, when assessed with the Rivermead Perceptual Assessment Battery
(Whiting et al. 1985), 47% of non-dysphasic subjects with LHD post stroke were identified as having USN
(Barer et al. 1990). When individuals with language deficits were included in the sample, almost every
dysphasic subject (97%) with LHD screened positive for USN within 48 hours post-stroke (Barer et al.
1990), suggesting that the lack of assessment of patients with aphasia may account, in part, for the low
incidence of USN reported in those with LHD. While USN is commonly associated with a right-sided
stroke, evidence from the literature suggests that all patients with stroke might benefit from USN
screening.
Clinicians are responsible to systematically screen all stroke patients for USN as a routine part of clinical
examination. The Canadian Best Practice Recommendations for Stroke Care 2013 emphasize the all
patients with stroke should be screened for perceptual deficits as part of the broader rehabilitation
assessment process. Clinical Guidelines for Stroke have recommended that it is “best practice” for acute
care clinicians to screen for cognitive deficits, which include visual perception and USN, during routine
neurological examination within 48 hours of the client regaining consciousness post-stroke (Royal
College of Physicians 2012). Clinicians have the responsibility to systematically screen all clients for
cognitive impairments and disabilities post stroke, including USN, with the use of standardized
assessment tools and stroke scales (Agency for Health care Policy and Research (AHCPR) 1994; Kelly-
Hayes et al. 1998; Royal College of Physicians 2012; VA DoD Clinical Practice Guideline 2010).
Screening and assessment can be performed via pen & paper test, observation of behaviour/activity or a
combination of both. As USN is a complex disorder with both an egocentric and allocentric component,

www.ebrsr.com
it is important to note that a single test may detect a specific type of neglect, thus a battery of tests are
often more sensitive that single test (Parton et al. 2004).
A literature review reported that there are currently 61 standardized and non-standardized assessment
tools available to assess USN in each of the hemispaces at both impairment and disability levels (Menon
& Korner-Bitensky 2004). Common pen and paper tests for screening are the Line Bisection Test (Figure
13.2.6.1) and Cancellation Tests (Figure 13.2.6.2). There are various versions of cancellation tests which
require the patient to mark/cancel target items printed on a paper placed directly in front. The target
items for cancellation may be single target items (without distractors) e.g. Line Cancellation Test; target
items (with distractors) e.g. Bells Test, Star Cancellation Test and Mesulam shape cancellation test
(Parton et al. 2004).
Figure 13.2.6.1 Line Bisection Test.
Figure 13.2.6.2 Cancellation Test
Behavioural/activity observations are also used to assess client's personal space by assessing their
performance in functional activities, such as using a comb or applying makeup as in Comb and Razor
Test and Catherine-Bergego Scale which is comprised of 10 different daily activities including grooming
and eating (Azouvi et al. 2003). A combination of pen and paper tests and observation of behavioural/
activity e.g. Behavioural Inattention Test is used to assess USN in more detail, though it is more time
consuming.
13.3 Treatment of Neglect

It has been suggested that consistent and specific strategies, such as forced awareness of neglected
space and task-specific practice, improve cognitive-perceptual abilities after stroke (Ma & Trombly
2002). A Cochrane review (Bowen et al. 2007) reported that “cognitive rehabilitation” for spatial neglect
resulted in improved performance on some standardised measures of neglect and functional ability.
Overall, the effect of cognitive rehabilitation on disability was not significant and the authors concluded

www.ebrsr.com
that there was insufficient evidence to either Table 13.3.1 Studies included in Bowen et al. 2007 &
support or refute the effectiveness of 2013 review
cognitive rehabilitation in improving functional Cherney et al. 2002 Polanowska et al. 2009
ability. However, cognitive rehabilitation was Cottam 1987 Robertson et al. 1990,2002
very broadly defined to include “therapy Edmans et al. 2000 Rossi et al. 1990
activities designed to directly reduce the level Fanthome et al. 1995 Rusconi et al. 2002
of cognitive deficits or the resulting disability” Ferreia et al., 2011 Schroeder et al. 2008 a,b,c
and, as a result, interventions included in the Fong et al. 2007 Tsang et al. 2009
review varied substantially (Bowen et al. 2007)
Kalra et al. 1997, 1998 Turton et al. 2010
Kerkhoff et al., 2012a Weinberg et al. 1977
In 2001, Paolucci and colleagues pointed out
Luukkainen-Markkula et al. 2009 Welfringer et al. 2011
that despite positive results being reported,
Mizuno et al. 2011 Wiart et al. 1997
there are problems associated with most
Nys et al. 2008 Zeloni et al. 2002
studies including very small sample sizes,
inconsistent assessment methods and reporting, and lack of randomised controlled trials (Paolucci et al.
2001). It has been suggested that these shortcomings limit our ability to generalize findings from
individual studies to the target population of individuals with post-stroke neglect (Bowen et al. 2013). It
was also noted that patients’ and carers’ views on acceptability of interventions is strikingly absent from
the literature as well (Bowen et al. 2013). Unfortunately, the methodological quality of studies
examining rehabilitation of neglect does not appear to be improving over time (Paci et al. 2010). Further
research of improved methodological quality is required in order to develop optimal treatments.
In general, rehabilitation interventions to improve neglect may be classified into those which attempt to
increase the stroke patient’s awareness of or attention to the neglected space and those which focus on
the remediation of deficits of position sense or body orientation (Butter et al. 1990; Pierce & Buxbaum
2002). Examples of interventions that attempt to improve awareness of or attention to the neglected
space include the use of visual scanning retraining, arousal or activation strategies and feedback to
increase awareness of neglect behaviours (Butter et al. 1990). Interventions that attempt to improve
neglect by targeting deficits associated with position sense and spatial representation include the use of
prisms, eye-patching and hemispatial glasses, caloric stimulation, optokinetic stimulation, TENS and neck
vibration.
13.3.1 Visual Scanning

It has been reported that individuals with neglect do Table 13.3.1.1 Class 1 Studies included by
not visually scan their whole environment (Weinberg Cicerone et al. (2000)
et al. 1977), paying no attention to their left-sided Weinberg et al. 1977 Gordon et al. 1985
space (Ladavas et al. 1994). Visuoperceptual or Weinberg et al. 1979 Carter et al. 1983
visuospatial training, including training of visual Young et al. 1983 Weinberg et al. 1982
scanning, attempts to improve the deficits of visual Robertson et al. 1990 Taylor et al. 1971
attention associated with neglect (Pierce & Buxbaum Wiart et al. 1997 Lincoln et al. 1985
2002). Cicerone et al. noted that the research Kalra et al. 1997 Neistadt 1992
literature concerning remediation of visuospatial deficits encompassed two basic approaches (Cicerone
et al. 2000). One group of studies addressed the remediation of basic abilities and behaviour such as
visual scanning or visual perception while the second focussed on the remediation of functional or
constructional activities requiring spatial ability.
Cicerone et al. (2000) undertook a review of evidence-based cognitive rehabilitation to make

recommendations for clinical practice. Forty articles were considered for review in the area of

www.ebrsr.com
remediation of visuospatial deficits. Of these, 9 were considered Class I, or prospective, randomized
controlled trial and trials with “quasi-randomized assignment to treatment conditions”. The 12 Class I
studies included for review appear in Table 13.3.1.1 (Cicerone et al. 2000). A later review by Cicerone et
al. (2005) added two Class I studies (Antonucci et al. 1995; Cicerone et al. 2005; Kasten et al. 1998;
Niemeier 1998).
Eight of the Class I studies identified by Cicerone et al. (2000; 2005) demonstrated a positive effect
associated with visuospatial rehabilitation that included visual scanning. One study failed to support this
conclusion. Three studies demonstrated that additional training on complex tasks enhanced the positive
effects of visual scanning. However, only one Class I study reported effects on activities of daily living or
over a longer period of time (Cicerone et al. 2000). Based on the results of their reviews, the authors
recommended that visuospatial rehabilitation with training in visuospatial scanning should be standard
practice for patients affected by visuoperceptual deficits associated with visual neglect after right
hemispheric stroke (Cicerone et al. 2000; Cicerone et al. 2005). Furthermore, Cicerone et al. noted that
training of complex visuospatial tasks seemed to augment treatment effects and aid in generalization to
other activities of daily living requiring visual scanning (Cicerone et al. 2000). EFNS guidelines on
cognitive rehabilitation give a Level A recommendation to the use of visual scanning training for
remediation of unilateral spatial neglect based on a review of published evidence (Cappa et al. 2005).
A systematic review of occupational therapy for stroke patients (Steultjens et al. 2003) included four
studies in an assessment of the efficacy of visual perception training; one RCT (Carter et al. 1983), two
case-controlled trials (Gordon et al. 1985; Young et al. 1983) and one non-controlled trial (Carter et al.
1988). The authors concluded that while visual scanning and visual-spatial ability may improve after
treatment, visual perception training does not significantly affect activities of daily living.
Controlled trials examining the use of visual scanning treatment for neglect are summarized in Table
13.3.1.2.
Table 13.3.1.2 Summary of Studies Evaluating Visual Scanning for Neglect

Author, Year
Sample Size Result
van Wyk et al. (2014) E: Saccadic eye movement training + visual  King-Devick Test Subtest 3 (+)
RCT (8) scanning exercises + task-specific activities  Barthel Index (+)
NStart=24 C: Only task-specific activities  Star Cancellation Test (-)
NEnd=24
Chan & Man (2013) E: Visual scanning training + conventional  Catherine Bergego Scale (+)
RCT (6) rehabilitation  Mini Mental State Examination (-)
NStart=40 C: Conventional rehabilitation only  Modified Barthel Index (-)
NEnd=40  Behavioural Inattention Test Conventional
Subtest (-)
van Kessel et al. (2013) E: Dual task visual scanning training  Behavioural Inattention Test Conventional
RCT (6) C: Single task visual scanning training Subtest (-)
NStart=29  Bell’s Cancellation Test (-)
NEnd=29  Grey Scales Index (-)
 Word reading task (-)
 Semi-structured neglect questionnaire (-)
 Subjective neglect questionnaire (-)
 Single and dual lane tracking (-)
Paolucci et al. (1996) E: Conventional rehabilitation + cross-over of  Rivermead Mobility Index : Post-phase 1

www.ebrsr.com
Cross-over RCT (6) neglect treatment (+); Post-phase 2 (-)
N=59 C: General cognitive treatment  Barthel Index: Post-phase 1 (+); Post-phase
2 (-)
 Canadian Neurological Scale: Post-phase 1
(-); Post-phase 2 (-)
 Letter Cancellation Test: Post-phase 1 (+);
Post-phase 2 (-)
 Barrage Test: Post-phase 1 (-); Post-phase
2 (-)
 Wundt-Jastrow Area Illusion Test: Post-
phase 1 (+); Post-phase 2 (-)
 Sentence Reading Test: Post-phase 1 (+);
Post-phase 2 (-)
Priftis et al. (2013) E1: Visual scanning training  Fluff Test (-)
RCT (5) E2: Limb activation treatment  Comb and Razor Test (-)
NStart=33 E3: Prism adaptation  Semi-structured ecological scale (-)
NEnd=31  Room description (-)
 Catherine Bergego Scale (-)
Ferreira et al. (2011) E1: Visual scanning training + physical therapy  Behaviour Inattention Test : Overall (+); E1
RCT (5) (PT) vs. C (+); E1 vs. E2 (-); E2 vs. C (-)
N=10 E2: Mental practice training + PT  Functional Independence Measure: Total
C: PT only score (-); Self-care: E1 vs. C (+), E1 vs. E2 (-
), E2 vs. C (-)
Niemeier et al. (2001) E: Lighthouse strategy training + usual  Route-Finding Task (+)
RCT (5) rehabilitation  Cognitive and Behavioural Scale (-)
N=19 C: Waiting list with no treatment  Functional Independence Measure:
Walking/Wheelchair (+); Problem Solving
(+); Attention (-); Safety Judgement (-);
Grooming (-); Feeding (-); Bathing (-);
Dressing (-); Toileting (-); Reading (-);
Writing (-); Community Re-entry (-)
 Rancho Los Amigos Scale (-)
 Mesulam Verbal Cancellation Test (-)
Wiart et al. (1997) E: Bon Saint Come scanning training +  Behavioural Inattention Test Conventional
RCT (4) traditional rehabilitation Subtest: Line bisection (+); Line
N=22 C: Traditional rehabilitation cancellation (+)
 Bell’s Cancellation Test (+)
 Functional Independence Measure (+)
Antonucci et al. (1995) E: Immediate visual scanning treatment +  Letter Cancellation Test (+)
RCT (4) conventional rehabilitation  Barrage Test (-)
N=20 C: General cognitive intervention +  Sentence Reading Test (+)
conventional rehabilitation  Wundt-Jastrow Area Illusion Test (+)
Gordon et al. (1985) E: Perceptual remediation treatment  Wechsler Adult Intelligence Scale (-)
PCT C: Conventional rehabilitation  Cancellation Tasks: Post (+); 4mo Post (-)
N=77  Wide Range Achievement Test (-)
 Address Copying (-)
 Arithmetic: Post (+); 4mo Post (-)
 Metropolitan Achievement Test: Post (+);
4mo Post (-)
 Double Simultaneous Stimulation: Post (+);
4mo Post (-)
 Line Bisection Test: Post (+); 4mo Post (-)
 Midline to side sensation (-)

www.ebrsr.com
 Raven’s Coloured Progressive Matrices:
Post (+); 4mo Post (-)
 Lateral Asymmetry and Visual-Spatial
Attention: Post: Structured (+),
Unstructured (-); 4mo Post (-)
 Embedded Figures Task (-)
 Facial Recognition Task (-)
 Purdue Pegboard Test (-)
 Weschler Bellevue: Post: Similarities (-),
Comprehension (+)
Multiple Affect Adjective Checklist:
Depression (-); Anxiety: Post (-), 4mo Post
(+); Hostility: Post (+), 4mo Post (+)
Young et al. (1983) E1: Routine occupational therapy (OT)  Letter Cancellation Task (+)
PCT E2: Routine OT + cancellation training + visual  Wechsler Adult Intelligence Scale: Block
N=27 scanning training Design: Overall (-), E1 vs. E3 (+), E2 vs. E3 (-
E3: Block design training + cancellation ); Digit Symbol (-); Picture Completion (-);
training + visual scanning training Picture Arrangement (-); Object Assembly
(-)
 Wide Range Achievement Test: Reading (+)
 Copying Address Task (-)
 Counting Faces Task (-)
Discussion
Overall, the impact of visual scanning procedures on neglect has tended to be positive. Two studies
compared a visual scanning program to no treatment and found visual scanning to significantly improve
performance on tasks assessing visual perception (Antonucci et al. 1995; Niemeier et al. 2001). Similar
results were also observed in seven studies that contrasted visual scanning therapy to a form of
conventional rehabilitation therapy. In one of those studies, Chan and Man (2013) found significantly
greater reductions of unilateral neglect in the visual scanning group and a significant improvement in
activities of daily living. The authors also observed a generalization effect where strategies used during
visual scanning (eg. identifying an anchor on the left-hand side at all times) led to improvements in self-
care tasks. Van Wyk et al.(2014) compared a group of patients receiving saccadic eye movement training
with visual scanning exercises to a group practicing task-specific activities. Although the groups did not
show significant differences in visual perception measured by the Star Cancellation Test, the visual
scanning group was associated with greater improvements in oculomotor function and ADLs. The
authors proposed that through training perceptual processing, the patients were able to improve their
visual function and thus their ability to perform visually guided ADLs.
In addition to measuring the impact of treatment on perceptual ability, six studies (five of which were
RCTs) assessed the impact of visual scanning training on functional ability. In all six, participation in the
treatment condition was associated with improved functional ability. However, it is unclear whether
treatment effects are sustained. Gordon et al. (1985) demonstrated no effect in terms of perceptual
gains associated with treatment at four months and suggested that treatment may influence the
individual’s ability to learn compensatory strategies rather than the eventual, overall, level of
performance. In one study conducted by van Kessel et al. (2013), the authors attempted to improve
upon traditional visual scanning training by incorporating a second task (dual task training). The use of
dual tasks was hypothesized to increase recovery through increasing the attentional load, or by further
associating spatial and non-spatial processes (van Kessel et al. 2013). Despite the additional task, the

www.ebrsr.com
authors failed to find a significant difference in visual neglect between the two groups. Further study is
required to assess the effectiveness of dual task visual scanning training.
Conclusion Regarding Visual Scanning for Neglect
There is level 1a and level 2 evidence that treatment utilizing primarily visual scanning techniques
may improve perceptual impairment post-stroke with associated improvements in function.
Visual scanning training may be effective for alleviating perceptual impairment and improving
functional ability post-stroke.
13.3.2 Computer-Based Rehabilitation

Computerized versions of tasks associated with visual scanning training have been developed and their
use evaluated. Studies assessing the use of computer-based visual training techniques are summarized
in Table 13.3.2.1.
Table 13.3.2.1 Summary of Studies Evaluating Computer-based Rehabilitation

Author, Year
Sample Size Result
Modden et, al. (2012) E1: Computerized compensatory therapy  Testing Battery for Attentional
RCT (7) E2: Restorative Computerized Training Performance: Visual field (-); Phasic
N=45 C: Standard occupational therapy alertness (-); Visual scanning (-)
 Behavioural Inattention Test: Cancellation
tasks (-)
 Reading performance: Errors (-); Speed (-)
 Barthel Index (-)
Jo et. al. (2012) E: Virtual Reality training  Motor-Free Visual Perception Test: Total
RCT (6) C: No intervention score (+); Response time (+); Visual
N=29 difference (+); Figure ground (+)
 Wolf Motor Function Test (-)
Robertson et al. (1990) E: Computer scanning + attentional training  Behavioural Inattention Test (-)
RCT (6) C: Recreational computing  Wechsler Adult Intelligence Scale (-)
N=36  Neale Reading Test (-)
 Letter Cancellation Test (-)
 Rey-Osterreith Test (-)
Kim et al. (2011) E: Virtual reality training  Star Cancellation Test (+)
RCT (4) C: Conventional rehabilitation (visual  Line Bisection Test (+)
N=24 tracking, reading, etc.)  Catherine Bergego Scale (+)
 Korean-Modified Barthel Index (+)
Van Vleet and DeGutis (2014) E: Tonic and phasic alertness computer based  Visual conjunction search task (+)
PCT auditory discrimination training  Spatial and non-spatial selective attention
NStart=16 C: No treatment wait list task (+)
NEnd=16  Subjective midpoint estimation task (-)
DeGutis and Van Vleet (2010) E: Tonic and phasic alertness computer based  Visual conjunction search task (+)
PCT auditory discrimination training  Spatial and non-spatial selective attention
NStart=24 C: No treatment wait list task (+)
NEnd=24  Subjective midpoint estimation task (+)
Katz et al. (2005) E: Computer-based virtual reality training  Mesulam Symbol cancellation test (-)

www.ebrsr.com
PCT C: Computerized visual scanning training  Star cancellation test (-)
N=19  Activities of Daily Living checklist (+)
 Virtual reality street crossing: Looking left
(-); Number of accidents (+)
Webster et al. (2001) E: Computer-assisted training  Wheelchair obstacle course track: Left
PCT C: Conventional rehabilitation sided collisions (+); Right sided collisions (-)
N=40  Falls during hospitalization (+)
Discussion
Overall, the majority of studies that used computer-based or virtual reality techniques for neglect
treatment reported a positive effect on patients’ awareness of the neglected space. Most of the
interventions included made use of visual perception therapies; however, two studies also assessed the
effectiveness of auditory alertness training for neglect (Degutis & Van Vleet 2010; Van Vleet et al. 2014).
These studies trained the auditory discrimination of centrally presented tones and found significant
alleviation of spatial bias and neglect symptoms; although no differences were found when comparing
auditory training to a similar visual training protocol. Two studies provided information with regard to
the durability of the training effect. Kim et al. (2007) suggested that decreased asymmetry for neglect
was persevered at the three month follow-up. Additionally, Funk et al. (2013) found improvements in
spatial orientation were maintained at eight week follow-up.
In the study by Webster et al. (2001), computer-based training appeared to transfer to a real world
environment and may have had additional beneficial effect on the frequency of recorded falling
incidents during acute rehabilitation. Similarly, Katz et al. (2005) observed that virtual reality training
was associated with an increase in behaviours that may result in improved safety in real life street
crossing. However, in a study conducted by Edmans et al. (2006), patients found the virtual task more
difficult and committed different errors when performing virtual and real world tasks. The authors
suggested that this could be due to technical and interface difficulties as well as lack of patient
familiarity with computers. Technologies using mixed environments in which real objects are
manipulated to control a virtual counterpart may improve the similarity between real and virtual
environments while maintaining advantages associated with computer-assisted or virtual environment
training (Edmans et al. 2006).
Several studies have examined the potential of using virtual environments for the assessment of extra-
personal neglect (Baheux et al. 2005; Jannink et al. 2009; Tsirlin et al. 2009). Conventional paper and
pencil tests are administered within the reaching or peri-personal space of an individual and, therefore,
may not be indicative of functioning within a larger environment. Virtual reality may provide the
opportunity to examine exploration and orientation tasks in extrapersonal space. For example, Jannink
et al. (2009) described a system based on the use of head-mounted display and a 3D orientation tracker
which could differentiate between healthy participants and patients with visual neglect on several
parameters.
It should be noted that the use of virtual reality technology, as an intervention or assessment tool, may
be associated with significant resource expenditures in terms of either equipment requirements such as
specialized interfaces: data gloves (Ansuini et al. 2006; Castiello et al. 2004; Kim et al. 2004; Kim et al.
2011) or head-mounted display (Kim et al. 2007), computer projection capability or physical space
requirements (Webster et al. 2001). The study by Katz et al. (2005) utilized less expensive, simpler,
desktop equipment that provides a less immersive virtual reality environment.

www.ebrsr.com
Of the 15 studies reviewed, four of these were RCTs (Jo et al. 2012; Kim et al. 2011; Modden et al. 2012;
Robertson et al. 1994). Six additional studies (Ansuini et al. 2006; Katz et al. 2005; Kim et al. 2011;
Webster et al. 2001) reported between group comparisons relevant to the intervention studied. Two
further studies reported the use of control groups but reported only single group effects with regard to
treatment (Kim et al. 2007; Kim et al. 2004) and the remaining three studies were of single group design
(Castiello et al. 2004; Fanthome et al. 1995). The RCTs and studies reporting between group
comparisons are summarized below.
Conclusions Regarding Computer-Based Rehabilitation in Neglect
There is level 1b and level 2 evidence that computer-based or virtual reality treatment for neglect
may improve visual perception and alleviate right-hemisphere bias when compared to conventional
rehabilitation or no treatment.
There is limited level 2 evidence that computerized visual perception training may be no more
effective than occupational therapy for patients with hemianopia.
Computer-based visual scanning therapy and virtual reality treatment for neglect appears to be
effective in improving visual perception.
13.3.3 Activation Strategies

Activation strategies are intended to increase orientation and attention to the neglected hemi-space. A
stimulus, either a motor stimulus or externally applied sensory stimulus, to the affected side is thought
to “activate” the right hemisphere. The mechanism by which this might improve neglect is still under
debate. The activation may be a general activation of the right hemisphere (Robertson et al. 1994),
which improves attention control in the neglected space (Bailey et al. 2002). Others postulate a personal
space system that, when activated, improves the representation of the left-sided personal space (Pierce
& Buxbaum 2002). Activation strategies include limb activation as well as the application of a sensory
stimulus.
13.3.4 Limb Activation

Limb activation is based on the idea that any movement of the contralesional side may function as a
motor stimulus activating the right hemisphere and improving neglect as described above.
Robertson and North (1992) demonstrated, via a series of single patient experiments, that left hand
finger movements made in left hemi-space were associated with a decrease in neglect as assessed by
letter cancellation tests. This decrease was independent of visual scanning in that the subject did not
need to see the left limb for the effect on neglect to occur. Verbal cuing to anchor visual perception,
passive visual cueing, movement of the right hand in the left hemi-space, and movement of the left
hand in right hemi-space had no significant effect on neglect (Robertson & North 1992). The authors
proposed that neither cueing nor personal spatial system theories when considered independently offer
adequate explanations of the effect of contra-lesional limb movement on neglect (Robertson & North
1992). The effect of spatial-motor cueing for neglect rehabilitation was also assessed by Kalra et al.
(1997) which is described below.

www.ebrsr.com
The duration of hospitalization was significantly less in patients assigned to receive spatial cueing during
treatment (42 vs. 66 days, p=0.001). In addition, the authors reported that on average, patients in the
intervention group spent less time in physiotherapy compared to the control group (17.1±4.9 vs.
22.6±8.0 hours in the control group, p=0.01).
Studies examining the efficacy of limb activation strategies are summarized in Table 13.3.4.1.
Table 13.3.4.1 Summary of Studies Evaluating Limb Activation Interventions

Author, Year
Sample Size Result
Wu et al. (2013) E1: Constraint induced therapy + eye  Catherine Bergego Scale: E1 vs. C (+); E2 v.
RCT (7) patching C (+)
NStart=27 E2: Constraint induced therapy  Left fixation points: E1 vs. E2 (+); C vs. E1 (+)
NEnd=24 C: Conventional rehabilitation  Fixation amplitude (-)
 Left fixation time (-)
 Reaction time: E2 vs. C (+)
 Preplanned control of reaching movement:
E1 vs. E2 (+); E1 vs. C (+)
 Trunk lateral shift: E1 vs. E2 (+); E2 vs. C (-)
Kalra et al.(1997) E: Spatiomotor cueing of affected limb in  Rivermead Perceptual Assessment Battery:
RCT (7) deficit hemispace Cancellation (+); Body image (+); Picture
N=50 C: Conventional therapy matching (-); Object matching (-); Size
recognition (-); Series (-); Missing article (-);
Sequencing-pictures (-); Right/Left copying
(-); Word colour matching (-); 3 dimensional
copying (-); Figure ground discrimination (-);
Animal halves (-)
Reinhart et. al. (2012) E1: Passive left limb activation  Hand judgement task (-)
RCT Cross-over (6) E2: Alertness cueing  Left-hand judgement (+)
N=8  Right-hand judgement (-)
Robertson et al. (2002) E: Limb activation treatment + perceptual  Motricity Index (+)
RCT (6) training  Barthel Index (-)
N=40 C: Perceptual training  Catherine Bergego Scale (-)
Discussion
From the above table, it would appear that left limb activation has some positive impact on visual
neglect. However, some studies report conflicting results for the effectiveness of this intervention,
especially when comparing it to other forms of neglect rehabilitation. Additionally, these studies were
all quite small and little data is available with regard to the effect of treatment on functional activities or
the duration of effect. In one study, Kalra et al. (1997) compared limb activation to a conventional
therapy protocol and found significantly greater improvement associated with limb activation on two
subtests of the Rivermead Perceptual Assessment Battery (RPAB). Despite this, no significant differences
were found between interventions on the other 14 subtests of the RPAB or on functional activities

www.ebrsr.com
measured by the Barthel Index. In an RCT conducted by Robertson et al. (2002), the authors found that
the addition of limb activation to perceptual training had no significant effect on functional activities or
neglect measured by the Catherine Bergego Scale. In contrast, Wu et al. (2013) found significant
improvements on the Catherine Bergego Scale and alleviation of rightward bias when comparing
constraint induced therapy to conventional rehabilitation. There is also uncertainty regarding the
effectiveness of limb activation when compared to other neglect rehabilitation interventions. For
example, Priftis et al. (2013) compared visual scanning therapy to limb activation and prism adaptation
and found no significant differences between groups on any measure. Similar results were also observed
in a comparison of optokinetic stimulation with limb activation to visual scanning treatment (Keller et al.
2009)
There is some concern with regard to the requirement for movement of the contra-lesion limb in that
hemiplegic patients may not be able to move the left limb (Pierce & Buxbaum 2002). In the studies
conducted by Eskes and colleagues, relatively few (4/16) individuals with neglect were able to produce
the active limb movements required such as pressing a mouse button (Eskes & Butler 2006; Eskes et al.
2003). This concern may be alleviated by further study of passive movement through FES stimulation
(Eskes & Butler 2006; Eskes et al. 2003). In addition, it is not yet clear that ipsilateral movements
through the neglected space are ineffective. While Robertson & North (1992) reported that movement
of the right hand in the left hemispace was not associated with improvements on cancellations and
reading tasks, conflicting results have been noted. Lin et al. (1996) undertook a small study to
demonstrate that the right hand and both circling the digit and tracing the line (again with the right
hand) from the left end toward its midpoint. While all testing conditions resulted in improvement on
line bisection, the circling plus tracing condition was associated with the greatest gains over baseline
(p<0.0001). It is suggested that activation is not determined by which hand performs the movement, but
rather it is the movement itself, either within or toward the neglected hemi-space that results in an
activation effect (Lin et al. 1996). Movement through the left or neglected space with the ipsilesional
limb may also serve to improve neglect. Participants completed line bisection tasks during 3 testing
conditions and one neutral condition. Testing conditions included visual cueing requiring the subject to
report a number placed at the left end of the line, circling the number at the left end of the line using
Conclusion Regarding Limb Activation Treatment for Neglect
There is level 1a and level 2 evidence that limb activation may alleviate rightward bias and improve
motricity when compared to conventional rehabilitation.
Limb activation appears to have a positive effect on neglect and motor function.
13.3.5 Sensory Stimulation Interventions

Increased awareness of the neglected space may also be achieved by the application of an external
stimulus, which may function as cue similar to the spatial motor cueing associated with limb activation.
Studies examining this mode of intervention are summarized in Table 13.3.5.1.
Table 13.3.5.1 Summary of Studies Evaluating Activation Interventions using External Stimuli
Author, Year
Sample Size Result
Fong et al. (2013) E: Conventional rehabilitation + cued arm  Behavioural Inattention Test Conventional
RCT (9) movements subtest: Cancellation tasks (-); Drawing

www.ebrsr.com
NStart=40 C: Conventional rehabilitation + instructions tasks (+)
NEnd=35 to move as much as possible  Fugl-Meyer Assessment: Upper Extremity
Motor subscore (-); Hand subscore (-)
 Functional Test for Hemiplegic Upper
Extremity (-)
 Functional Independence Measure Motor
subscale (-)
Polanowska et al. (2009) E: Computerized visual scanning training +  Barthel Index (-)
RCT (7) electrical somatosensory stimulation  Visual scanning accuracy (+)
N=40 C: Computerized visual scanning training +  Visual scanning range (+)
sham stimulation
Discussion
The studies summarized above present a conflicting view of the efficacy of external stimulation in
increasing orientation and attention to the neglected space. Visual, tactile and auditory stimulation have
all been assessed. One RCT compared sensory modalities and found improvements on a drawing task
associated with only nonverbal auditory stimulation (Hommel et al. 1990); however, this has not been
confirmed (or assessed) by subsequent studies. In another RCT conducted by Fong et al. (2013), the
authors compared a cued limb activation protocol to instructions to move as much as possible and
found rightward bias to be significantly alleviated with cued activation. Although this suggests
improvements in the patients’ awareness of their hemiplegic field, the authors failed to find the same
benefit for visual target detection and functional ability when compared to the control intervention.
Overall, while some modest improvements were demonstrated, further investigation is required to
clarify the effectiveness of sensory stimulation on multiple measures of neglect and the duration of
treatment effects.
A single, recent RCT examined the impact of supplementing visual scanning training with electrical
somatosensory stimulation (Menon & Korner-Bitensky 2004) applied to the left hand of patients with
left-sided visual neglect (Polanowska et al. 2009). While all study participants demonstrated significant
gains over the course of the 1-month-long treatment, individuals who received the supplementary
stimulation demonstrated greater improvement on measures of neglect. Unfortunately, there was no
similar improvement in functional ability associated with treatment allocation.
Conclusions Regarding Sensory Stimulation Interventions
There is level 1b evidence that sensory cues for movement may have a positive effect on neglect,
although evidence is inconclusive.
There is level 1b evidence that use of electrical somatosensory stimulation as a supplement to visual
scanning training is associated with greater benefit than visual scanning training alone.
The use of external sensory stimulation in the treatment of neglect may be beneficial, although
evidence is limited.
Electrical somatosensory stimulation may be a useful supplement to visual scanning training.

www.ebrsr.com
13.3.6 Feedback Strategies
Feedback strategies are intended to improve awareness of and attention to the neglected space (Pierce
& Buxbaum 2002). Typical methods of feedback used include auditory and visual. All function to make
the patient aware of his/her neglect behaviours and may assist in learning ways to remediate neglect
(Soderback et al. 1992). Studies examining the use of feedback are summarized in Table 13.3.6.1.
Table 13.3.6.1 Summary of Studies Evaluating Feedback Strategies in Treatment of Neglect

Author, Year
Sample Size Result
Pandian et al. (2014) E: Mirror training  Star Cancellation Test (+)
RCT (8) C: Sham mirror training  Line Bisection Test (+)
NStart=48  Picture identification task (+)
NEnd=46  Functional Independence Measure: 1mo (-);
3mo (+); 6mo (+)
 Modified Rankin Scale: 1mo (-); 3mo (+); 6mo (+)
Fanthome et al. (1995) E: Treatment with auditory feedback  Behaviour Inattention Test: Conventional
RCT (5) glasses subtest (-); Behavioural subtest (-)
N=18 C: No neglect treatment  Eye movement (-)
Harvey et al. (2003) E: Rod lifting and balancing at central  Landmark test (+)
RCT (4) point  Line Bisection Test (-)
N=14 C: Rod lifting and balancing at right side  Real objects test (-)
 6wk follow-up: Behavioural Inattention Test
Conventional subtest (+); Balloons test (-); Test
of Everyday Attention (-); Barthel Index (-);
Neglect rating scores (-)
Discussion
Overall, the reported results of feedback strategies are encouraging. Provision of visual or visuomotor
feedback appears to have a beneficial effect on the performance of various neglect behaviours. This was
clearly demonstrated in a RCT conducted by Pandian et al. (2014) investigating the effectiveness of
mirror therapy for visual neglect. The authors used a sham mirror therapy condition as a comparison
and found significantly greater improvements in measures of neglect and disability associated with
mirror therapy. In contrast, Fanthome et al. (1995) found no benefit associated with auditory feedback
on measures of visual attention or eye movement when compared to treatment with no auditory
feedback. All other studies reported some positive effect associated with feedback strategies. However,
as is the case for many intervention strategies for neglect, evaluations were generally undertaken with a
very limited number of participants.
There is little data available with regard to the duration of effect in the long term and the generalization
of effect has not been demonstrated. While the study by Soderback et al. (1992) demonstrated an
improvement in household tasks, the tasks that improved are the same used in the video feedback
intervention. Harvey et al. (2003) attempted to demonstrate a generalization of the rod lifting feedback
technique to independence in activities of daily living as assessed by the Barthel Index, but
unfortunately, no significant effect was demonstrated. Only Pandian et al. (2014) found significant
improvements in functional ability measured by the Functional Independence Measure at two and five
months following mirror therapy.

www.ebrsr.com
Conclusions Regarding Feedback Strategies
There is level 1b and limited level 2 evidence that visuomotor feedback may be beneficial in the
treatment of neglect. Further study is required to establish the degree to which treatment effects
generalize to other behaviours and to determine the durability of effect.
There is limited level 2 evidence that the auditory feedback for left eye movement may not improve
visual inattention or bias in eye movement.
Visuomotor feedback strategies appear to be beneficial in the treatment of neglect.
13.3.7 Prism Treatment

Visual neglect can have an adverse effect on functional outcomes even in the presence of adequate
strength and coordination. As noted by Rossi et al. (1990), a variety of optical aids have been used to
help patients compensate for their visual difficulties.
Prisms affect spatial representation by causing an optical deviation of the visual field to either the left or
the right. One of the most common low vision interventions for stroke induced hemianopia is the
incorporation of binocular sector prisms in the person's habitual spectacle lenses. These may be Fresnel
membrane lenses or prisms that are cemented onto the lens surface. The prism is located so that it
remains outside the residual field of view when the person if looking straight ahead. When gaze is
shifted in the direction of the non-seeing hemi-field, the prismatic effect gives a more peripheral view to
the side (6 - 9 deg.) than would otherwise be possible without a larger magnitude eye movement. In
addition to prisms, other optical aids have been used to achieve a similar effect including wide-angle
lenses (Drasdo 1976; Weiss 1969), mirrors attached to the spectacle frame (Duszynski 1955; Nerenberg
1980; Nooney 1986) and closed circuit TV monitor systems (Turner 1976).
Another approach proposed by Peli (2000) in patients with homonymous field defects (including
homonymous hemianopia post stroke) but no neglect, relies on spatial multiplexing wherein prisms are
mounted superiorly above the line of sight in one eye to induce peripheral diplopia. The diplopic image
contains information relocated from the unseen hemi-field superimposed on information from the
straight ahead environment. In a small study of this novel approach, most patients (11 of 12)
demonstrated an expanded field of view. Most reported quick adaptation to the prisms and a subjective
benefit associated with the prism correction (Peli 2000).
Studies examining the effectiveness of prisms in the treatment of neglect are summarized in Table
13.3.7.1.
Table 13.3.7.1 Summary of Studies Evaluating Prismatic Adaptation

Author, Year
Sample Size Result
Mancuso et al. (2012b) E: Pointing intervention with prismatic  Albert Test (-)
RCT (7) goggles with a rightward shift of 5°  Bell’s Cancellation Test (-)
N=29 C: Pointing intervention with neutral goggles  Orientation Lines Test (-)
 Bit Drawing Test (-)
 Line Bisection Test (-)
 Dealing playing card test (-)

www.ebrsr.com
 Objects searching test (-)
Mizuno et al. (2011) E: Pointing intervention with prismatic  Functional Independence Measure (-)
RCT (7) goggles  Behavioural Inattention Test: Conventional
N=34 C: Pointing intervention with neutral goggles subtest (-); Behavioural subtest (-)
Serino et al. (2009) E: Pointing intervention with prismatic  Behavioural Inattention Test: Post-intervention
RCT (7) goggles (+); 1mo-post (-)
N=20 C: Pointing intervention with neutral goggles  Pointing accuracy (-)
 Cancellation tasks (Bell’s cancellation, Star
cancellation, Letter cancellation): Post-
intervention (+); 1mo-post (-)
 Reading accuracy: Post-intervention (+); 1mo-
post (-)
Jacquin-Courtois et al. (2010) E: Prism adaptation treatment  Dichotic listening task: Number of correct
C: Sham prism adaptation responses (-); Lateralization (+); Number of
RCT (6) fusion errors (-)
NStart=12
NEnd=12
Turton et al. (2010) E: Pointing intervention with prismatic  Behavioural Inattention Test: Post-intervention
RCT (6) goggles (-); 2mo-post (-)
N=36 C: Pointing intervention with neutral goggles  Catherine Bergego Scale: Post-intervention (-);
2mo-post (-)
 Rate of change in pointing bias: Post-week 1
(+); Post-week 2 (-)
Nys et al. (2008) E: Prismatic adaptation treatment  Line Bisection Test (-)
RCT (6) C: Sham prismatic adaptation treatment  Letter Cancellation (+)
N=16  Scene Copying task (+)
 1mo post-intervention: Star Cancellation (-);
Representational Drawing (-); Line Bisection (-);
Figure Copying (-); Behavioural Inattention Test
(-)
Rossetti et al. (1998) E: Prismatic adaptation  Standard neuropsychological procedure (Line
RCT (5) C: Sham prismatic adaptation bisection, Line cancellation, Simple figure
N=16 copying, Drawing, Reading) (+)
Rossi et al. (1990) E: Prismatic adaptation treatment  Barthel Index (-)
RCT (4) C: No treatment  Motor-free Visual Perceptual Test (+)
N=39  Line Bisection Test (+)
 Line Cancellation Test (+)
 Tangent Screen Examination (+)
 Harrington Flocks Visual Screener (+)
Ladavas et al.(2011) E1: Terminal prismatic adaptation  Visual target pointing accuracy: E1 vs. E2 (+)
PCT E2: Concurrent prismatic adaptation  Behavioural Inattention Test: Conventional
NStart=30 C: Sham prism adaptation subtest: E1 vs. E2 (+), E1 vs. C (+), E2 vs. CG (-);
NEnd=30 Behavioural subtest: E1 vs. E2 (+), E1 vs. C (+),
E2 vs. C (-)
 Reading accuracy: E1 vs. E2 (-)
 First saccadic endpoint: E1 vs. E2 (+)

www.ebrsr.com
Serino et al. (2006) E: Prismatic adaptation treatment  Behavioural Inattention Test: Conventional
PCT C: General cognitive stimulation + motor subtest (+); Behavioural subtest (+)
N=24 treatments  Reading accuracy (+)
 Amplitude of first saccade (+)
 Left-right exploration time (+)
Angeli et al. (2004) E: Prism adaptation  Reading task accuracy (+)
PCT C: Sham prism adaptation  Endpoint of first saccade (+)
NStart=13  Fixation time (+)
NEnd=13
Discussion
Overall, a general positive effect of treatment is observed with prism adaptation in patients with neglect
and homonymous hemianopsia (Rossi et al. 1990). In two RCTs, the authors found no differences in
measures of neglect between patients using rightward shifted goggles compared to neutral goggles
(Mancuso et al. 2012a; Turton et al. 2010). However, these studies only used a prismatic shift of 5° and
6° while other successful prismatic interventions generally used a shift of 10° or greater (Barrett et al.
2012). Most of the included studies incorporated target pointing during prism adaptation and used a
concurrent adaptation protocol, allowing the patient to view their limb during the reaching movement
and make changes before completing the movement (Ladavas et al. 2011) This method is thought to
involve primarily the proprioceptive system while the terminal exposure condition, where the patient
can only view the limb at the final part of the movement, is thought to involve primarily the visual
system. In a comparison of these two methods, Ladavas et al. (2011) found significantly greater leftward
deviation of hand and eye-movements with terminal exposure along with greater scores on the
Behavioural Inattention Test when compared to concurrent adaptation. Previous studies using terminal
exposure for prism adaptation have also reported similar results and a longer lasting amelioration of
neglect (Angeli et al. 2004; Frassinetti et al. 2002b; Serino et al. 2006; Serino et al. 2009).
Prism adaptation appears to be effective in improving various aspects of perceptual performance and
may also be associated with long-lasting effects, even after a single, short session (Farne et al. 2002;
Frassinetti et al. 2002a; Rode et al. 2003; Rossetti et al. 1998). One study, though very small,
demonstrated that prism adaptation might have a positive effect on tactile extinction in addition to
visuospatial neglect. The authors suggest that the benefit of prism treatments may extend beyond
visual-motor or spatial orientation tasks to tasks operating in nonvisual modalities (Maravita et al. 2003).
In a review of prism adaptation, Rode et al. (2006) suggested that the varying effects on cognition
(mental imagery, sensory cross-modal, visual-constructive) associated with prism adaptation may be
indicative of a general rehabilitative effect on visual-spatial functions of the right cortical hemisphere.
A single study examined the impact of yoked prisms on subjectively assessed visual midline shift and
postural lean (Padula et al. 2009). Following a single exposure, the authors report positive results for a
majority of participants with either right or left CVA and Visual Midline Shift Syndrome. Results are,
however, expressed as a proportion of participants with CVA meeting subjective standards for
improvement. Between group comparisons are limited to proportions of individuals in the CVA group
who respond as expected versus the proportion of control participants (with no neurological
impairment) who do not respond (or are put off balance). Further study using objective evaluations to
assess the effect of intervention over time are required.
Several studies have examined the stability of treatment effects following prism adaptation (Frassinetti
et al. 2002a; Nys et al. 2008; Serino et al. 2006; Serino et al. 2009; Shiraishi et al. 2008; Turton et al.

www.ebrsr.com
2010). Of these eight studies, five were non-RCTs and demonstrated a durable effect in that
improvements appeared to be sustained for four to six weeks following the end of the prism treatment
(Frassinetti et al. 2002a; Serino et al. 2006; Serino et al. 2009; Shiraishi et al. 2008). In one study of pre-
post design, positive effects of prism adaptation on binocular vision were found up to six months post-
intervention (Schaadt et al. 2014). Nys et al. (2008) assessed the impact of treatment at a one-month
follow-up and Turton et al. (2010) conducted a two month follow-up. Neither of these RCTs reported
significant between-group differences on assessments for neglect at that time. Likewise, Serino et al.
(2009) found no differences on measures of neglect between sham and actual prismatic adaptation at a
one-month follow-up. Although the prism-based intervention described in Nys et al. (2008) was
provided for a very short period of time, the interventions described in Turton et al. (2010) and Serino et
al. (2009) were provided over a two week period. Treatments described in the non-RCTs were provided
for two to eight weeks with the number of individual treatment sessions ranging from four to ten per
week.
The majority of studies that have assessed functional ability have reported no significant changes in
function associated with prism adaptation (Mizuno et al. 2011; Rossi et al. 1990; Turton et al. 2010).
However, recent reports (Mizuno et al. 2011; Shiraishi et al. 2010) have provided some conflicting
evidence suggesting that the use of prisms may be associated with improvements in the performance of
activities of daily living, particularly in individuals with mild neglect (Mizuno et al. 2011). In addition, in
the Mizuno et al. (2011) study, differences in function were reported for assessments on the FIM, but
not the Catherine Bergego Scale (CBS).
A review completed by Newport & Schenk (2012) studying prism adaptation as a tool for neglect
rehabilitation looked at 41 original studies. Overall, they found that more than 90% of the studies
reported positive effects of prism adaptation on symptoms of neglect (all but (Rousseaux et al. 2006;
Turton et al. 2010)). After considering both positive and negative findings of prism adaptations this
review concluded that at the moment, prism adaptation seems to be an effective treatment yet, it is
unknown if this is superior to other treatments (Newport & Schenk 2012). In contrast, a review
conducted by Barrett et al. (2012) of 48 studies concluded that patients undergoing prism adaptation do
not consistently improve. The authors suggested that prism adaptation may target spatial aiming output
processing and not the earlier perceptual or representational spatial processing, which may impact
patients differently based on their level of neglect. Further research should investigate prism adaptation
within certain classifications of neglect in addition to comparing treatments such as prism adaptation,
neck vibration and optokinetic stimulation directly with each other (Newport & Schenk 2012).
Conclusions Regarding Prisms for Neglect
There is level 1a and level 2 evidence that the use of rightward shifted prisms may be effective for
neglect and hemianopia.
There is level 1a evidence that any improvements seen in visual-spatial tasks may not be sustained
over time.
There is level 1b and limited level 2 evidence that improvements in visual-spatial tasks following
prism treatment are not associated with improvement in functional ability.
There is limited level 2 evidence that terminal prismatic adaptation may alleviate rightward bias and
improve visual perception to a greater degree than concurrent prismatic adaptation.

www.ebrsr.com
Prismatic adaptation with a significant rightward shift appears to be beneficial for neglect;
however, the long-term effect is unclear.
13.3.8 Eye-Patching and Hemispatial Glasses

Eye-patching is an interesting approach to hemispatial neglect rehabilitation that has been proposed
since the early 1990s as a method to improve visual-scanning and attend to the neglected field (Butter &
Kirsch 1992). Beis et al. (1999) stated that their “hypothesis was that eye patches can be used to alter
the processing of visual information by affecting the information processing structures of the central
nervous system”. Shulman noted that in healthy subjects, eye patches should increase eye movements
towards the contralateral space (Shulman 1984). Thus, eye patching of the eye ipsilateral to the lesion
causes patients to look toward contralateral space by either moving their eye or by movement of the
head. In turn these effects, as cited by Beis et al. (1999), “encourage the development of voluntary,
deliberate control of attention in the short term and the development of automatic shifts of attention
over the longer term,” (Beis, et al. 1999; Seron et al. 1989).
Smania et al. (2013b) reviewed 13 intervention studies which involved right or left monocular eye-
patching for individuals who previously had a stroke and had hemi-spatial neglect. This review included
five case-series/case-control studies, two single-case studies and six randomized controlled trials. This
review concluded that eye-patching is a promising procedure in rehabilitation for those with hemi-
spatial neglect (Smania et al. 2013b).
Individual studies are summarized in Table 13.3.8.1.
Table 13.3.8.1 Summary of Eye-Patching and Hemispatial Glasses for Neglect

Author, Year
Sample Size Result
Wu et al. (2013) E1: Constraint induced therapy + right  Catherine Bergego Scale: E1 vs. C (+); E2 vs. C
RCT (7) monocular occlusion (+)
NStart=27 E2: Constraint induced therapy  Eye movement variables: Number of left
NEnd=24 C: Conventional rehabilitation fixation points E2 vs. E1 (+), C vs. E2 (+);
Fixation amplitude (-); Left fixation time (-)
 Arm-trunk movement variables: Reaction
time E2 vs. C (+); Time of peak velocity E1 vs.
E2 (+), E1 vs. C (+); Movement time (-); Total
distance (-)
 Trunk lateral shift: E1 vs. E2 (+); E2 vs. C (-)
Ianes et al. (2012) E: Right half-field eye patching  Line Bisection Test (-)
RCT (7) C: Visual scanning training  Line Crossing Test (-)
N=18  Bell’s Cancellation Test (-)
Tsang et al. (2009) E: Conventional occupational therapy + right  Behavioural Inattention Test: Conventional
RCT (7) half-field eye patching subtest (+)
N=35 C: Occupational therapy  Functional Independence Measure (-)
Aparicio-Lopez et al. (2015) E: Cognitive rehabilitation + right hemifield  Line Bisection Test (-)
RCT (6) eye-patching  Bell’s Cancellation Test (-)
NStart=12 C: Cognitive rehabilitation  Figure Copying of Ogden (-)
NEnd=12  Baking tray task (-)
 Reading test (+)

www.ebrsr.com
Fong et al. (2007) E1: Voluntary trunk rotation + right hemifield  Behavioural Inattention Test: Conventional (-
RCT (6) eye patching ); Behavioural (-)
N=19 E2: Voluntary trunk rotation  Clock Drawing Test (-)
C: Conventional rehabilitation  Functional Independence Measure Motor
Measure: Total (-); Self-care (-); Sphincter (-);
Transfer (-); Locomotion (+)
Machner et al. (2014) E: Hemifield eye patching and repetitive  Catherine Bergego Scale (-)
RCT (5) optokinetics simulation + usual care  Barthel Index (-)
NStart=23 C: Usual care  Modified Rankin scale (-)
NEnd=21  National Institutes of Health Stroke Scale (-)
 Bell’s Cancellations Test (-)
 Star Cancellation Test (-)
 Ogden Figure Copying Task (-)
 Reading errors (-)
Beis et al.(1999) E1: right monocular patch  Functional Independence Measure: Overall
Cross-over RCT (5) E2: right half-field patches over both eyes (+); E2 vs E3 (+)
N=22 C: no patch  Eye movement: Time in right hemifield (-);
Time in left hemifield (-); Rightward eye
movements (-); Leftward eye movements:
Overall (+), E2 vs E3 (+)
Zeloni et al. (2002) E: Goggles with right hemisphere occlusion  Albert’s Test (+)
RCT (3) C: Standard rehabilitation  Letter Cancellation (-)
N=11  Bell’s Cancellation (-)
 Line Bisection (-)
 Figure drawing 1 (-)
 Figure drawing 2 (-)
Discussion
Eye-patching is a promising intervention for neglect because of its high feasibility and low cost (Smania
et al. 2013b). Of the studies included in this review, five used right hemi-field eye-patching as a stand-
alone intervention or with conventional rehabilitation, four used monocular occlusion of the left or right
eye and three combined right hemi-field eye-patching with another neglect intervention (eg. repetitive
optokinetic stimulation). Generally, studies reported some positive effect with right hemi-field eye-
patching, although evidence for the use of monocular occlusion is lacking. In a review of eye-patching
interventions, Smania et al. (2013b) supported the use of right hemi-field eye patching as an effective
intervention for neglect, but confirmed the need for additional research directed at investigating the
effects of eye-patching and reducing hemi-spatial neglect severity, disability and improving patient
independence. The authors also found little supporting evidence for monocular occlusion. Three of the
studies in their review that used monocular occlusion showed improvement in neglect even after left
monocular occlusion, which suggests that the rationale of monocular occlusion for hemi-spatial neglect
is unclear (Smania et al. 2013a; Soroker et al. 1994; Walker 1996). Right hemi-field eye-patching was
shown to significantly improve preplanned control and trunk lateral shift when combined with
constraint induced therapy (Wu et al. 2013); however, no effects of eye-patching on measures of
neglect were found for this intervention or when it was combined with repetitive optokinetic
stimulation and voluntary trunk rotation (Fong et al. 2007; Machner et al. 2014). Studies have also
provided conflicting reports regarding the generalizability of eye-patching to functional ability (Beis et al.
1999; Tsang et al. 2009).

www.ebrsr.com
Conclusions Regarding Eye-Patching and Hemispatial Glasses for Neglect
There is conflicting level 1b and level 2 evidence regarding the use of right half-field eye patches for
left visual neglect.
There is limited level 2 evidence that monocular occlusion may not improve visual neglect or
alleviate rightward bias.
There is conflicting level 1b and level 2 evidence with regards to the effect of bilateral half-field eye
patches on functional ability.
The evidence for the use of eye patching and hemi-spatial glasses for improving neglect is currently
unclear.
13.3.9 Caloric Stimulation

Rubens noted that visual neglect could be caused partly by bias of gaze and postural turning (Rubens
1985). It has been noted that when cold water is funnelled into the external ear canal, the vestibular-
ocular reflex induces the slow phase of nystagmus toward the stimulated ear (Pierce & Buxbaum 2002).
If warm water is used, this slow phase is directed away from the stimulation. Accordingly, Rubens
suggested that caloric vestibular stimulation to produce eye deviation in the direction opposite the
pathologically acquired bias might reduce visual neglect (Rubens 1985). As proposed by Cappa et al.
(1987) and Vallar et al. (1993), caloric stimulation consisting of cold water on the contralateral side of
the lesion or warm water ipsilateral to the lesion may improve visual neglect by influencing vestibular
system involvement with the eye.
Individual studies examining the effects of caloric or vestibular stimulation are summarized in Table
13.3.9.1.
Table 13.3.9.1 Summary of Studies Evaluating Caloric Stimulation in Neglect

Author, Year
Sample Size Result
Sturt & Punt (2013) Caloric stimulation to the contralesional ear in  Star Cancellation Test (+)
PCT patients with right brain damage with neglect,  Postural Assessment Scale (-)
N=18 right brain damage with no neglect, left brain
damage with no neglect
Adair et al. (2003) Cold caloric stimulation in patients with  Line Bisection Test (+)
PCT attentional or intentional neglect  Target Cancellation (+)
NStart=16
NEnd=16
Discussion
Although the studies summarized in this review demonstrated a positive effect on some aspects of
visual-spatial neglect, none of them were able to provide evidence of effectiveness in comparison with
control interventions. No clinical trials assessing its efficacy as a treatment intervention were identified.

www.ebrsr.com
There has been no evaluation of its effect over multiple sessions. Further study using more rigorous
methods of investigation are required.
The clinical usefulness of this technique is also unclear. Apart from the reported discomfort associated
with the procedure (Cappa et al. 1987; Vallar et al. 1993), all effects examined were transient and
dissipated quickly following treatment. While caloric stimulation may be a useful tool in developing an
understanding of the mechanisms underlying neglect as it affects one’s personal representation of
space, it appears to have little utility as a treatment on its own.
Conclusions Regarding Caloric Stimulation in Neglect
At present, there is little evidence regarding the effectiveness of caloric stimulation as a treatment
intervention for visuospatial neglect post-stroke.
The effectiveness of caloric stimulation as part of a treatment intervention for unilateral spatial
neglect has not been well studied.
13.3.10. Vestibular Galvanic Stimulation

Caloric stimulation, while producing some transient, beneficial effect on neglect, has been criticised for
being relatively impractical for use in applications outside of research (Rorsman et al. 1999). Rorsman et
al. (1999) pointed out that it is uncomfortable for the patient and propose that stimulation of the
vestibular system is possible without the discomfort and inconvenience associated with irrigation.
Galvanic stimulation involves electrical stimulation of the vestibular nerves at a very low level (Rorsman
et al. 1999).
Studies examining the effectiveness of galvanic stimulation are summarized in Table 13.3.10.1.
Table 13.3.10.1 Summary Studies Evaluating of Vestibular Galvanic Stimulation (GVS)

Author, Year
Sample Size Result
Nakamura et al. (2015) E1: right cathodal GVS  Line Cancellation Test (+)
Cross-over RCT (7) E2: left cathodal GVS
NStart=7 C: sham GVS
NEnd=7
Schmidt et al. (2013) E1: right cathodal GVS  Arm Position Sense : Right arm (-); Left
Cross-over RCT (7) E2: left cathodal GVS arm: E2 vs. C (+), E1 vs. E2 (-); E1 vs. C (-)
NEnd=32
Utz et al. (2011) E1: right cathodal GVS  Line Bisection Test-Rightward deviation: E1
Cross-over RCT (7) E2: left cathodal GVS vs. C (+); E1 vs. E2 (+); E2 vs. C (-)
NEnd=17
Ruet et al. (2014) E1: right cathodal GVS  Line Bisection Test (-)
Cross-over RCT (6) E2: left cathodal GVS  Star Cancellation Test (-)
NEnd=4

www.ebrsr.com
Wilkinson et al. (2014) E1: Active right GVS only  Behavioural Inattention Test Conventional
RCT (6) E2: 1 active + 9 sham vestibular galvanic subtest (-)
NStart=52 stimulations
NEnd=49 E3: 5 active + 5 sham vestibular galvanic
stimulations
Oppenländer et al.(2015) E1: right cathodal GVS  Number Cancellation: E1 vs. C (+); E1 vs. E2
PCT E2: left cathodal GVS (-); E2 vs. C (-)
NStart=24 C: sham GVS  Copy of symmetrical figures: E1 vs. C (+);
NEnd=24 E1 vs. E2 (-); E2 vs. C (-)
 Line Bisection Test: E2 vs. C (+); E1 vs. E2 (-
); E1 vs. C (-)
 Text copying: E2 vs. C (+); E1 vs. E2 (-); E1
vs. C (-)
Discussion
The first study assessing galvanic vestibular stimulation (GVS) demonstrated that this method of
stimulating the vestibular system was capable of reducing the effects of left visuospatial neglect
assessed via performance on a line-crossing task (Rorsman et al. 1999). In addition, effects
demonstrated did not appear to be quite as transient as those associated with caloric stimulation in that
a significant improvement was identified from the initial no stimulation condition to the final no
stimulation condition of the first experimental condition. This benefit was reported to be in excess of
improvements associated with spontaneous recovery (Rorsman et al. 1999). In more recent years,
several RCTs have been conducted further investigating the effectiveness of GVS. Similar to (Rorsman et
al. 1999), most of these studies found significant improvements in unilateral spatial neglect even after
only one session of GVS (Wilkinson et al. 2014) However, one study conducted by Ruet et al.(2014)
found no differences between active and sham GVS. The authors suggested that this absence of
difference may have been due to insensitive measures or a low intensity of stimulation (1.5mA),
although successful interventions have used an intensity ranging from 0.7-2.0 mA (Nakamura et al.
2015; Oppenlander et al. 2015). Several studies have also assessed the polarity effect by crossing over
treatments of left cathodal GVS and right cathodal GVS. Results for these comparisons are conflicting,
although this may be due to differences in lesion location among patients (Nakamura et al. 2015).
Further study is required to elucidate the polarity effect of GVS.
In an attempt to investigate the safety and adverse effect of this technique, Utz and colleagues analyzed
data from 255 sessions of vestibular galvanic stimulation (Utz et al. 2011). Out of 85 participants, 53
(62.2%) reported no adverse effects. The most common adverse effects reported by the remaining
participants were slight itching (mean: 10.2%) and tingling (mean: 10.7%) under the electrodes. Healthy
individuals and persons with stroke did not differ in their incidence and rated intensity of adverse
effects, nor did persons with or without unilateral spatial neglect. Adverse effects were found more
frequently with GVS with 1.45 mA as with sub-sensory GVS. Participants were unable to differentiate
real from sham conditions during sub-sensory GVS. Therefore, Utz et al. (2011) suggested that the use of
galvanic stimulation in individuals with stroke when safety guidelines are followed.
Conclusions Regarding Vestibular Galvanic Stimulation
There is level 1a evidence that galvanic vestibular stimulation may improve unilateral spatial
neglect.

www.ebrsr.com
There is conflicting level 1a evidence with regards to the effect of right cathodal versus left cathodal
galvanic vestibular stimulation on unilateral spatial neglect.
Vestibular galvanic stimulation appears to have a positive effect on visuospatial neglect. Further
study is required to determine polarity specific effects.
13.3.11 Optokinetic Stimulation

Optokinetic stimulation functions in a fashion similar to vestibular stimulation in that it is based on the
induction of nystagmus by exposure to a stimulus. Optokinetic stimulation uses a visual stimulus moving
linearly from right to left (Pierce & Buxbaum 2002). Like vestibular stimulation, optokinetic stimulation is
believed to function by impacting position sense or the representation of personal space (Karnath 1996).
Studies examining the effects of optokinetic stimulation on visuospatial neglect are summarized in Table
13.3.11.1.
Table 13.3.11.1 Summary of Optokinetic Stimulation

Author, Year
Sample Size Result
Kerkhoff et al. (2014) E: Smooth pursuit eye movement training  Functional Neglect Index (+)
RCT (8) C: Visual scanning training  Unawareness and Behavioural Neglect
NStart=24 Index (+)
NEnd=24  Barthel Index (-)
 Help Index (-)
Kerkhoff et al. (2012) E: Optokinetic stimulation through the  Peripheral hearing sensitivity (-)
RCT (7) movement of a yellow square pattern  Auditory subjective median plane: Mean
N=20 C: Stimulation with a stationary pattern deviation (+), Standard deviation (-)
Kerkhoff et al. (2013) E: Smooth pursuit eye movement training  Auditory Subjective Midline Test (+)
RCT (6) C: Visual scanning training  Paragraph reading task (-)
NStart=50  Line Bisection: Perceptual (-); Motor (-)
NEnd=45  Single Digit Cancellation (+)
 Double Digit Cancellation (+)
Machner et al. (2014) E: Hemifield eye patching and repetitive  Catherine Bergego Scale (-)
RCT (5) optokinetics simulation + usual care  Barthel Index (-)
NStart=23 C: Usual care (physiotherapy, occupational  Modified Rankin scale (-)
NEnd=21 therapy, speech therapy)  National Institutes of Health Stroke Scale (-)
 Bell’s Cancellations Test (-)
 Star Cancellation Test (-)
 Ogden Figure Copying Task (-)
 Reading errors (-)
Pizzamiglio et al. (2004) E: Optokinetic simulation + standard neglect  Screening tests (Line cancellation, Letter
RCT (5) rehabilitation cancellation, Wundt-Jastrow Illusion,
N=22 C: Standard neglect rehabilitation (Visual Reading) (-)
scanning training + practice of tasks)  Semi-structured Scale for the Functional
Evaluation of Extrapersonal Neglect (-)
 Scale for Personal Neglect (-)

www.ebrsr.com
Schroder et al. (2008) E1: Transcutaneous electrical nerve  Reading and writing tasks: Post-
RCT (4) stimulation + computerized scanning training intervention E1 vs. C (+), E2 vs. C (+), E1 vs.
N=30 E2: Optokinetic stimulation + computerized E2 (-); 1wk post-intervention E1 vs. C (+), E2
scanning training vs. C (+), E1 vs. E2 (-)
C: Computerized scanning training only  Neglect tests (Line Bisection, Figure
Copying, Free drawing, Star Cancellation,
Line Cancellation, Test Battery of
Attentional Performance): Post-
intervention E1 vs. C (+), E2 vs. C (+), E1 vs.
E2 (-); 1wk post-intervention E1 vs. C (-), E2
vs. C (+), E1 vs. E2 (-)
Discussion
It has been demonstrated in the studies reported above that the linear leftward movement of a visual
pattern can alleviate unilateral neglect, whereas a rightward movement tends to have little effect. The
majority of studies administered optokinetic stimulation for several sessions, although positive effects
were found after only one session (Kerkhoff et al. 2012). Several studies also conducted follow-up
evaluations to assess the longevity of the effect and found significant improvement on measures of
neglect lasting up to 30 days post-intervention (Machner et al. 2014). Two studies also examined the
change in functional ability as a result of optokinetic stimulation and found no additional benefit when
compared to visual scanning training or conventional rehabilitation (Kerkhoff et al. 2014; Machner et al.
2014).
Based on the six randomized controlled trials identified above, evidence regarding the use of optokinetic
stimulation in rehabilitation of neglect is conflicting. In two studies (Kerkhoff et al. 2014; Kerkhoff et al.
2013), the authors compared following leftward moving stimuli to traditional visual scanning training
and found optokinetic stimulation to significantly improve measures of unilateral neglect. Similar
improvements were also found in Schroder et al.’s (2008) comparison of optokineitc stimulation and
computerized scanning training. However, Pizzamiglio et al. reported that, when added to a program
consisting of visual scanning training, reading and copying training, copying line drawings and figure
description, optokinetic stimulation resulted in no additional improvements on measures of neglect and
functional ability (Pizzamiglio et al. 2004). Likewise, when comparing conventional rehabilitation to a
program of hemi-field eye patching and optokinetic stimulation, Machner et al. (2014) found no benefit
associated with the additional treatment. The authors hypothesized that the spontaneous remission of
neglect accounted for this lack of difference since the patients were in the acute stage of recovery
(mean of five days post-stroke), although other studies including patients in the acute stage have found
a positive effect of optokinetic stimulation (Kerkhoff et al. 2014). Two studies of pre-post design that
administered optokinetic stimulation in addition to visual alertness training found little benefit of
optokinetic stimulation.
Conclusions with Regard to Optokinetic Stimulation
There is level 1a evidence that optokinetic stimulation may have a positive impact on unilateral
neglect when compared to scanning or alertness training; however, level 2 evidence suggests that
optokinetic stimulation may not have additional benefit.
There is level 1a evidence that optokinetic stimulation may not have an effect on functional
outcome.

www.ebrsr.com
There is level 2 evidence that optokinetic stimulation may not improve neglect when compared to
standard rehabilitation.
Although optokinetic stimulation appears to have a positive effect on neglect, it is uncertain

whether the addition of optokinetic stimulation to a program of rehabilitation for neglect would be
of benefit.
13.3.12 Trunk Rotation Therapy

It has been proposed that the orientation of the trunk midline in space functions as the dividing line
between our personal representation of left versus right space and acts as an anchor for the calculation
of body position (Karnath et al. 1991). Karnath et al. (1993) demonstrated that turning only the trunk of
the patient to the left such that both right and left stimuli were projected to the right side of the trunk
could compensate for deficits in reaction times to stimuli in the left visual field.
Further studies examining the effect of trunk rotation on body position and neglect are summarized in
Table 13.3.12.1.
Table 13.3.12.1 Summary Studies Evaluating of Trunk Rotation Therapy

Author, Year
Sample Size Result
Fong et al. (2007) E1: Trunk rotation training + activities of daily  Behavioural Inattention Test: Conventional
RCT (6) living (ADL) training subtest (-); Behavioural subtest (-)
N=54 E2: Trunk rotation training + ADL training +  Functional Independence Measure (-)
half-field eye patching  Clock drawing test (-)
C: Occupational therapy
Wiart et al. (1997) E: Bon Saint Come trunk rotation training +  Line Bisection Test (+)
RCT (4) traditional rehabilitation  Bell’s Cancellation Test (+)
N=22 C: Traditional rehabilitation  Functional Independence Measure (+)

Discussion
Rotation of the trunk to the left is associated with an improvement of neglect as assessed by the
detection and identification of stimuli in the left visual field (or the visual evoked potentials associated
with the presentation of stimuli). It has been proposed that this effect is based on the relationship of the
trunk position to the neck position. The lengthening of the left posterior neck muscles associated with
trunk rotation contributes to compensation in personal space representation by altering information
about the position of the body relative to the straight/forward position of the head (Karnath et al. 1993;
Karnath et al. 1991).
A single RCT has examined the use of trunk rotation as part of a treatment intervention to improve
neglect. The Bon Saint Come method, which incorporates trunk rotation with visual scanning,
demonstrated positive effects on spatial neglect and functional ability (Wiart et al. 1997). Similarly, Fong
et al. examined the effects of trunk rotation in combination with half-field eye patching (Fong et al.
2007). In this study, neither trunk rotation alone nor combined therapy resulted in improvement in

www.ebrsr.com
either unilateral spatial neglect or performance of activities of daily living when compared to
conventional occupational therapy.
Conclusions Regarding Trunk Rotation
There is level 1b evidence that trunk rotation therapy may not have a positive effect on unilateral
spatial neglect or performance of activities of daily living.
There is level 1b evidence that trunk rotation in combination with half-field eye-patching is similarly
ineffective.
There is level 2 evidence that trunk rotation when combined with visual scanning is of benefit in the
treatment of spatial neglect. Further study of trunk rotation therapy is indicated.
Trunk rotation may not be an effective treatment for unilateral spatial neglect post-stroke
although evidence is limited and conflicting.
13.3.13 Neck Muscle Vibration

Karnath et al. (1993) demonstrated that the detection and identification of stimuli in the left visual field
in patients with neglect could be improved by trunk rotation, resulting in the lengthening of left
posterior neck muscles, or by somatosensory stimulation applied to the left posterior neck muscles in
the form of neck muscle vibration. Neck muscle vibration is thought to improve neglect by creating a
kinaesthetic illusion and is non-invasive, has no side-effects and is easy to apply (Schindler et al. 2002).
Studies examining the use of neck muscle vibration in the treatment of neglect are summarized in Table
13.3.13.1.
Table 13.3.13.1 Summary of Studies Evaluating Neck Muscle Vibration Therapy

Author, Year
Sample Size Result
Schindler et al. (2002) E: visual exploration training + neck muscle  Visual subjective straight ahead
Cross-over RCT (5) vibration judgements (+)
NStart=20 C: visual exploration training only  Cancellation test (+)
NEnd=20  Tactile search (+)
 Indented text reading (+)
 Visual size discrimination (-)
 Activities of daily living questionnaire:
Personal care (+); Reaching and grasping
(+); Spatial orientation (+); Time
orientation (-); Awareness of deficit (-)
Discussion
The study summarized in Table 13.3.13.1 demonstrates a positive effect of neck muscle vibration on
neglect when used alone or in combination with visual exploration training. This supplements an earlier
report by Ferber et al. (1998), as cited in Johannsen et al. (2003), which demonstrated a reduction in the
symptoms of neglect in a single patient. Neck muscle vibration therapy has been associated with

www.ebrsr.com
sustained improvement in neglect symptoms and performance of ADLs (Johannsen et al. 2003; Schindler
et al. 2002). The simplicity of treatment together with promising results that translate into improved
functional ability over the long-term indicate a need for further study of muscle vibration therapy.
Conclusions Regarding Neck Muscle Vibration Therapy
There is level 1b evidence that neck muscle vibration therapy in association with visual exploration
training may be effective in improving both symptoms of neglect and performance of activities of
daily living.
Neck muscle vibration therapy used in combination with visual exploration training may result in a
reduction in the symptoms of neglect and increased performance of activities of daily living.
13.3.14 Music Therapy

Music therapy has been proposed to be beneficial in patients with unilateral neglect post stroke. Several
preliminary studies were performed in a within-subject design.
Discussion
There appears to be some benefit associated with music therapy for neglect, although evidence is
limited and of poor methodological quality. Two within-subject studies found positive improvement in
patients with unilateral neglect post-stroke during assessment with the use of music compared to other
conditions which include white noise, unpleasant music or nothing (Chen et al. 2013; Tsai et al. 2013). A
single subject study by the same author group investigated the effect of music therapy in the chronic
stroke with encouraging results (Tsai et al. 2013).
Conclusions Regarding Music Therapy
Presently, there is little evidence to support the use of music as treatment for unilateral spatial
neglect in right hemispheric patients. Further investigations are required.
There is little evidence to support the use of music therapy for neglect rehabilitation.
13.3.15 Transcutaneous Electrical Nerve Stimulation

Transcutaneous electrical nerve stimulation (Menon & Korner-Bitensky 2004) is an alternate form of
somatosensory stimulation thought to be capable of reducing neglect in a fashion somewhat similar to
that of neck muscle vibration (Vallar et al. 1995). In TENS therapy, stimulation of nerve fibers is achieved
by means of an electrical current. Studies examining the effect of TENS therapy on neglect are
summarized in Table 13.3.15.1
Table 13.3.15.1 Summary of Studies Evaluating Transcutaneous Electrical Nerve Stimulation Therapy
for Neglect
Author, Year
Sample Size Result
Schroder et al. (2008) E1: Transcutaneous electrical nerve  Reading and writing tasks: Post-
RCT (4) stimulation + computerized scanning training intervention E1 vs. C (+), E2 vs. C (+), E1 vs.

www.ebrsr.com
N=30 E2: Optokinetic stimulation + computerized E2 (-); 1wk post-intervention E1 vs. C (+),
scanning training E2 vs. C (+), E1 vs. E2 (-)
C: Computerized scanning training only  Neglect tests (Line Bisection, Figure
Copying, Free drawing, Star Cancellation,
Line Cancellation, Test Battery of
Attentional Performance): Post-
intervention EG1 vs. C (+), E2 vs. C (+), E1
vs. E2 (-); 1wk post-intervention E1 vs. C (-
), E2 vs. C (+), E1 vs. E2 (-)
Rusconi et al. (2002) E1: Cognitive rehabilitation + cueing and  Line Cancellation Test (-)
RCT (3) feedback  Letter Cancellation Test: Left (-); Right: E1
N=20 E2: Cognitive rehabilitation with feedback + vs. E2 (+); E2 vs. E3 (+); E2 vs. E4 (+); E4 vs.
transcutaneous electrical nerve stimulation E1 (+); E3 vs. E4 (+); E1 vs. E3 (-)
(Menon, #40)  Line Bisection Test (-)
E3: Cognitive rehabilitation + TENS with no  Sentence reading (-)
feedback  O’ Clock test (-)
E4: Cognitive rehabilitation with no feedback  Drawing of 2 houses (-)
 Raven’s Coloured Matrices (-)
 Facial recognition test: E1 vs. E3 (+); E1 vs.
E4 (+); All other comparisons (-)
 Position sense deficit: E2 vs. E4 (+); E3 vs.
E4 (+); All other comparisons (-)
Discussion
Based on the results of small, non-randomized studies, stimulation via TENS appears to be associated
with an improvement in symptoms of neglect (Guariglia et al. 1998; Vallar et al. 1995). This stimulation
has shown to be effective when applied to the left neck or the left hand, suggesting a non-specific effect
in terms of the anatomical site, but a specific effect in terms of laterality (van Dijk et al. 2002). In
addition, stimulation of the neck may result in some improvement in the manifestations of neglect
possibly related to the postural control system (Vallar et al. 1995).
Although a single, small RCT (Rusconi et al. 2002) demonstrated little benefit associated with the
addition of TENS to cognitive rehabilitation based on visuo-spatial scanning training, it was of poor
methodological quality. A more recent RCT, of moderate quality, examined TENS applied during
exploration/scanning training and reported significant gains compared to exploration training alone by
session 10 of a 20-session intervention (Schroder et al. 2008). Gains appeared to be maintained at one-
week, post-treatment follow-up. No information was identified with regard to the long-term durability
of treatment effects produced by TENS therapy.
Conclusions Regarding TENS in Neglect
There is level 2 evidence that transcutaneous electrical nerve stimulation may result in
improvements on tests of neglect, reading and writing post-stroke.
Transcutaneous electrical nerve stimulation treatment appears to have a positive effect on neglect
post-stroke.

www.ebrsr.com
13.3.16 Repetitive Transcranial Magnetic Stimulation
Transcranial magnetic stimulation is a non-invasive procedure that uses a rapidly fluctuating magnetic
field to “create electrical currents in discrete areas of the brain” (Martin et al. 2004). Multiple stimuli can
be used to increase or decrease the excitability of the affected cortex temporarily. Theta burst
stimulation, a pattern of transcranial magnetic stimulation delivered in three bursts of pulses, is a
relatively new treatment that has also been shown to produce an effect on the affected cortex (Fu et al.
2015).
Repetitive transcranial magnetic stimulation, or rTMS, has been used to create “virtual lesions” in
normal, healthy individuals. Fierro et al. demonstrated that stimulation of the posterior parietal areas
(areas P5 and P6), unilaterally, resulted in transient, contralateral neglect (Fierro et al. 2000). It has been
suggested that spatial neglect following unilateral brain damage may arise from an imbalance in
hemispheric activation in those areas involved in spatial attention (Oliveri et al. 2001). Several studies
have examined the possibility that stimulation of the same areas in the unaffected hemisphere of
individuals experiencing unilateral spatial neglect might result in improved attention to the neglected
space. Individual studies are summarized below in Table 13.3.16.1.
Table 13.3.16.1 Summary of rTMS for Unilateral Neglect Post Stroke

Author, Year
Sample Size Result
Koch et al. (2012) E: Real TBS + conventional therapy  Behavioural Inattention Test: Total score
RCT (9) C: Sham TBS + conventional therapy (+)
N=20
Fu et al. (2015) E: Continuous TBS  Star Cancellation Test: Post-intervention
RCT (8) C: Sham stimulation (+); 4wk follow-up (+)
NStart=22  Line Bisection Test: Post-intervention (-);
NEnd=20 4wk follow-up (+)
Cazzoli et al.,(2012) E1: Sham stimulation then TBS  Catherine Bergego Scale: Post-intervention
RCT (8) E2: TBS then sham stimulation E1 vs. C (+), E2 vs. C (+); Follow-up E1 vs. C
Nstart=24 C: No stimulation (+), E2 vs. C (+)
Nend=24  Vienna Test System : Post-intervention E1
vs. C (+), E2 vs. C (+); Follow-up E1 vs. C (+),
E2 vs. C (+)
 Random Shape Cancellation Test: Post-
intervention E1 vs. C (+), E2 vs. C (+);
Follow-up E1 vs. C (+), E2 vs. C (-)
 Two Part Picture Test: Post-intervention E1
vs. C (+), E2 vs. C (+); Follow-up E1 vs. C (+),
E2 vs. C (-)
 Munich Reading Texts: Post-intervention
E1 vs. C (-), E2 vs. C (-); Follow-up E1 vs. C (-
); E2 vs. C (-)
Kim et al. (2013) E1: High frequency rTMS  Line Bisection Test: E1 vs. C (+); E2 vs. C (+);
RCT (7) E2: Low frequency rTMS E1 vs. E2 (-)
N=27 C: Sham stimulation  Korean-Modified Barthel Index: E1 vs. C
(+); E2 vs. C (+); E1 vs. E2 (-)
Lim et al. (2010) E: rTMS + standard neglect therapy  Line Bisection Test (-)
PCT C: Standard neglect therapy  Albert’s Test (+)
N=14

www.ebrsr.com
Discussion
rTMS is a new approach to treat spatial neglect (Utz et al. 2011). Preliminary studies demonstrated a
positive treatment effect associated with rTMS and four RCTs also demonstrated improvement in
neglect symptoms and performance of activities of daily living when compared to sham rTMS (Cazzoli et
al. 2012; Kim et al. 2013; Koch et al. 2012). In addition, positive effects of rTMS have been found after
both the inhibition and excitation of the lesioned hemisphere (Agosta et al. 2014; Kim et al. 2013). These
results suggest that rTMS, specifically theta burst rTMS, is a promising viable add-on therapy in neglect
rehabilitation that facilitates recovery in neglect symptoms and everyday behaviour. Improvements
found in three studies also noted continued persistence of positive effects still present after three and
four weeks at follow-up (Cazzoli et al. 2012; Koch et al. 2012).
Conclusions Regarding the Repetitive Transcranial Magnetic Stimulation
There is level 1b and limited level 2 evidence that both the inhibition and excitation of the lesioned
hemisphere through rTMS may improve neglect and functional ability.
There is level 1a evidence that theta burst stimulation may improve neglect with positive effects
lasting up to four weeks post-intervention.
Overall, transcranial magnetic stimulation has been found to be beneficial in the treatment of
neglect.
13.3.17 Transcranial Direct Current Stimulation

Like transcranial magnetic stimulation, transcranial direct current stimulation (tDCS) is used to provoke
changes in excitability in the brain. In tDCS, a weak DC current is applied continuously to the scalp. The
polarity of the current flow determines whether excitability is increased (anodal tDCS) or decreased
(cathodal tDCS). Three studies examining the impact of tDCS on neglect post stroke were identified
(Table 13.3.17.1).
Table 13.3.17.1 Summary of Studies Evaluating Transcranial Direct Current Stimulation (tDCS)
Author, Year
Sample Size Result
Ko et al. (2008) E: Active tDCS  Line Bisection Test (+)
Cross-over RCT (8) C: Sham stimulation  Shape Cancellation Test (+)
N=15  Letter Cancellation Test (-)
Smit et al. (2015) E: Active tDCS  Star Cancellation Test: intermediate, post-
Cross-over PCT C: sham stimulation intervention or at 3wk follow-up (-)
NStart=5  Letter Cancellation Test: intermediate,
NEnd=5 post-intervention or at 3wk follow-up (-)
 Line Cancellation Test: intermediate, post-
intervention or at 3wk follow-up (-)
 Line Bisection Test: intermediate, post-
 Figure and Shape Copying Test:
intermediate, post-intervention or at 3wk
follow-up (-)

www.ebrsr.com
 Representational Drawing: intermediate,
post-intervention or at 3wk follow-up (-)
 Center of Cancellation: intermediate, post-
Discussion
The evidence for tDCS as a treatment for neglect is limited. A single, small RCT examining the impact of
anodal DC stimulation over the right posterior parietal cortex was identified. Positive results were
reported after just one session of tDCS for tests of neglect administered before and after the treatment
(Ko et al. 2008). In contrast, a prospective cross-over study conducted by Smit et al. (2015) found no
differences between tDCS and sham stimulation on any measure of neglect post-intervention or at the
three weeks follow-up after 20 sessions of tDCS. In a study of poor methodological quality, Sparring et
al. (2009) found some benefit associated with tDCS; however, this improvement was limited to the line
bisection test and not found on the Test Battery of Attentional Performance. No adverse side-effects
were reported with tDCS application (Smit et al. 2015). Further study is required to determine if tDCS is
an effective method of neglect rehabilitation.
Conclusions Regarding Transcranial Direct Current Stimulation
There is level 1b evidence that transcranial direct current stimulation is associated with
improvement on tests of neglect; however, limited Level 2 and Level 4 evidence suggests that
transcranial direct current stimulation may not be beneficial for neglect.
Transcranial direct current stimulation may be beneficial in the treatment of neglect.
13.3.18 Pharmacological Interventions
13.3.18.1 Dopaminergic Medication Therapy

Marshall & Gotthelf (1979), as cited in (Pierce & Buxbaum 2002), reported that a reduced level of
dopamine, a neurotransmitter, has been identified as playing a role in the arousal and orientation to
stimuli. Hurford et al. (1998) reported a single case study of a patient with unilateral spatial neglect who
received two consecutive treatments; methylphenidate followed by bromocriptine. While treatment
with methylphenidate resulted in some improvement of neglect symptoms, bromocriptine, a dopamine
agonist, was associated with greater improvement. While being treated with bromocriptine (5 mg 3
times daily), performance on line bisection, letter cancellation and star cancellation tests improved such
that results fell within the range of normal scores (Hurford et al. 1998). Improvements in performance
were sustained or increased following cessation the medication regime and anecdotal reports were
provided of improvements in everyday function (Hurford et al. 1998).
Individual studies examining the effects of dopaminergic medications on neglect are summarized in
Table 13.3.18.1.1.
Table 13.3.18.1.1 Summary of Studies Evaluating Dopaminergic Medications for Neglect After Stroke
Author, Year
Sample Size Result

www.ebrsr.com
Gorgoraptis et al. (2012) E: rotigotine  Mesulam cancellation task: Right targets (-); Left targets (+)
RCT (9) C: placebo  Bell’s cancellation test (-)
NStart=16  Line bisection test (-)
NEnd=16  Touch screen visual search task (-)
 Corsi vertical task (-)
 Visual vigilance and salience task (-)
 Motricity Index (-)
Discussion
Most early reports concerning dopamine agonists in hemi-spatial neglect in stroke were performed in
very small, single group studies which showed a general positive effect associated with the use of
dopaminergic medications on symptoms of neglect. In a recent double blinded, placebo controlled RCT,
Gorgoraptis et al. (2012) provided higher level of evidence on the use of rotigotine on hemi-spatial
neglect following stroke. This proof-of -concept study suggests that dopaminergic medication used for
neglect in stroke patients can be beneficial.
Based on the information presented above, the use of a dopamine agonist, such as bromocriptine, may
be associated with a reduction in symptoms of neglect, although there is little evidence apart from a
single case report that treatment effects could be sustained beyond withdrawal of the drug (Hurford et
al. 1998). In fact, Fleet et al. (1987) reported a significant decline in performance associated with
withdrawal of therapy. However, only two subjects were included in the analysis (Fleet et al. 1987).
Mukand et al. (2001) reported on an alternative to dopamine agonists. Levodopa is a metabolic

precursor to dopamine. Typically, used in the treatment of Parkinson’s disease, it is associated with
increased dopamine levels in the brain (Mukand et al. 2001). When used in the treatment of unilateral
spatial neglect, it may be associated with improvements in neglect and in functional ability (Mukand et
al. 2001).
Conclusion Regarding Dopaminergic Medications
There is level 1b evidence that the dopamine agonist rotigotine may not improve perceptual
impairment or motor function.
More research is needed to determine if dopamine may be useful for improving post-stroke
neglect.
13.3.18.2 Acetylcholinesterase Inhibitors Therapy

Acetylcholinesterase inhibitors, (rivastigmine, donepezil and galantamine) which have been used in the
treatment of Alzheimer’s disease, act by allowing acetylcholine levels to increase (Narasimhalu et al.
2010). These drugs have been used in association with treatments for cognitive disorders and may help
improve cognitive functioning (Narasimhalu et al. 2010; Whyte et al. 2008). A single study was identified
examining the effects of acetylcholinesterase inhibitors (specifically rivastigmine) on neglect (Table
13.3.18.2.1).
Treatment with the acetylcholinesterase inhibitor rivastigmine in conjunction with cognitive training was
associated with significant improvement on assessments of unilateral spatial neglect (Paolucci et al.

www.ebrsr.com
2010). Gains appeared to be maintained one-month following treatment, while individuals in the control
group continued to improve over time to reach comparable levels. Further study is required to
determine if acetylcholinesterase inhibitors are an effective method of rehabilitation for neglect.
Table 13.3.18.2.1 Summary of Studies Evaluating Acetylcholinesterase Inhibitors for Neglect after
Stroke
Author, Year
Sample Size Result
Paolucci et al. (2010) E: Rivastigmine therapy + physical therapy +  Letter Cancellation Test: Discharge (+);
RCT (7) cognitive training 1mo follow-up (-)
N=20 C: Cognitive training  Wundt-Jastrow Area Illusion Test:
Discharge (+); 1mo follow-up (-)
 Barrage Test (-)
 Sentence reading test (-)
Conclusions Regarding Acetylcholinesterase Inhibitors for Neglect
There is level 1b evidence that the use of rivastigmine in conjunction with cognitive training may
accelerate the rate of improvement of unilateral spatial neglect associated with therapy.
More research is needed to determine the effectiveness of rivastigmine at improving post-stroke

neglect.
13.3.18.3 Nicotine Therapy

Findings from neuroimaging and behavioural studies in animals and healthy humans suggest that the
cholinergic system may be involved in selective and focused attention (Lucas et al. 2013). Nicotine, a
powerful cholinergic agonist, could potentially modulate activity in frontal and parietal areas and lead to
improvements in unilateral spatial neglect. Two studies investigating the effects of nicotine in neglect
are summarized below (Table 13.3.18.3.1).
Table 13.3.18.3.1 Summary of Studies Evaluating Nicotine for Neglect after Stroke
Author, Year
Sample Size Result
Lucas et al. (2013) E: nicotine  Letter Cancellation Test (+)
Cross-over RCT (7) C: placebo  Shape Cancellation Test (+)
NStart=10  Bell’s Cancellation Test (+)
NEnd=10  Cued Detection Task (Posner’s paradigm) (+)
 Quadruplet Detection Task (-)
Discussion
Treatment with nicotine was found to have some positive effect on unilateral neglect. In a study of poor
methodological design, Vossel et al. (2010) found nicotine to decrease the reaction time of locating
www.ebrsr.com
targets in a location cueing paradigm when compared to placebo. However, the authors found that
nicotine did not have a significant effect on spatial attention measured by accuracy on the location
cueing task. In a RCT of fair quality, Lucas et al. (2013) found nicotine to significantly improve
performance on cancellation tasks and cued target detection when compared to placebo, although no
positive effect was found on other measures of neglect. Further study is required to assess the
effectiveness of nicotine as a treatment for neglect.
Conclusions Regarding Nicotine Therapy for Neglect
There is level 1b evidence that nicotine may improve unilateral neglect and target information
processing when compared to placebo treatment.
There is limited evidence regarding the effect of nicotine on unilateral neglect. Further studies are
needed.

www.ebrsr.com
Summary
1. There is conflicting level 1a and level 2 regarding the evidence for perceptual training
interventions on perceptual functioning.
2. There is level 1b evidence that a transfer of training approach may not produce different results
on measures of neglect and functional ability when compared to a functional approach to
perceptual training.
3. There is limited level 2 evidence that family participation in rehabilitation may not be associated
with additional improvements in perceptual impairment and functional ability when compared to
4. There is level 1a and level 2 evidence that treatment utilizing primarily visual scanning techniques
may improve perceptual impairment post-stroke with associated improvements in function.
5. There is level 1b and level 2 evidence that computer-based or virtual reality treatment for neglect
may improve visual perception and alleviate right-hemisphere bias when compared to
conventional rehabilitation or no treatment.
6. There is limited level 2 evidence that computerized visual perception training may be no more
effective than occupational therapy for patients with hemianopia.
7. There is level 1a and level 2 evidence that limb activation may alleviate rightward bias and
improve motricity when compared to conventional rehabilitation.
8. There is level 1b evidence that sensory cues for movement may have a positive effect on neglect,
although evidence is inconclusive.
9. There is level 1b evidence that use of electrical somatosensory stimulation as a supplement to

visual scanning training is associated with greater benefit than visual scanning training alone.
10. There is level 1b and limited level 2 evidence that visuomotor feedback may be beneficial in the
treatment of neglect. Further study is required to establish the degree to which treatment effects
generalize to other behaviours and to determine the durability of effect.
11. There is limited level 2 evidence that the auditory feedback for left eye movement may not
improve visual inattention or bias in eye movement.
12. There is level 1a and level 2 evidence that the use of rightward shifted prisms may be effective for
neglect and hemianopia.
13. There is level 1a evidence that any improvements seen in visual-spatial tasks may not be
sustained over time.
14. There is level 1b and limited level 2 evidence that improvements in visual-spatial tasks following
prism treatment are not associated with improvement in functional ability.
15. There is limited level 2 evidence that terminal prismatic adaptation may alleviate rightward bias
and improve visual perception to a greater degree than concurrent prismatic adaptation.

www.ebrsr.com
16. There is conflicting level 1b and level 2 evidence regarding the use of right half-field eye patches
for left visual neglect.
17. There is limited level 2 evidence that monocular occlusion may not improve visual neglect or
alleviate rightward bias.
18. There is conflicting level 1b and level 2 evidence with regards to the effect of bilateral half-field
eye patches on functional ability.
19. At present, there is little evidence regarding the effectiveness of caloric stimulation as a
treatment intervention for visuospatial neglect post-stroke.
20. There is level 1a evidence that galvanic vestibular stimulation may improve unilateral spatial
neglect.
21. There is conflicting level 1a evidence with regards to the effect of right cathodal versus left
cathodal
22. There is level 1a evidence that optokinetic stimulation may have a positive impact on unilateral
neglect when compared to scanning or alertness training; however, level 2 evidence suggests that
optokinetic stimulation may not have additional benefit.
23. There is level 1a evidence that optokinetic stimulation may not have an effect on functional
outcome.
24. There is level 2 evidence that optokinetic stimulation may not improve neglect when compared to
standard rehabilitation.
25. There is level 1b evidence that trunk rotation therapy may not have a positive effect on unilateral
spatial neglect or performance of activities of daily living.
26. There is level 1b evidence that trunk rotation in combination with half-field eye-patching is
similarly ineffective.
27. There is level 2 evidence that trunk rotation when combined with visual scanning is of benefit in
the treatment of spatial neglect. Further study of trunk rotation therapy is indicated.
28. There is level 1b evidence that neck muscle vibration therapy in association with visual
exploration training may be effective in improving both symptoms of neglect and performance of
activities of daily living.
29. Presently, there is little evidence to support the use of music as treatment for unilateral spatial
neglect in right hemispheric patients. Further investigations are required.
30. There is level 2 evidence that transcutaneous electrical nerve stimulation may result in
improvements on tests of neglect, reading and writing post-stroke.
31. There is level 1b and limited level 2 evidence that both the inhibition and excitation of the
lesioned hemisphere through rTMS may improve neglect and functional ability.

www.ebrsr.com
32. There is level 1a evidence that theta burst stimulation may improve neglect with positive effects
lasting up to four weeks post-intervention.
33. There is level 1b evidence that transcranial direct current stimulation is associated with
improvement on tests of neglect; however, limited Level 2 and Level 4 evidence suggests that
transcranial direct current stimulation may not be beneficial for neglect.
34. There is level 1b evidence that the dopamine agonist rotigotine may not improve perceptual
impairment or motor function.
35. There is level 1b evidence that the use of rivastigmine in conjunction with cognitive training may
accelerate the rate of improvement of unilateral spatial neglect associated with therapy.
36. There is level 1b evidence that nicotine may improve unilateral neglect and target information
processing when compared to placebo treatment.

www.ebrsr.com
References
Adair, J. C., Na, D. L., Schwartz, R. L., Heilman, K. M. (2003). Caloric stimulation in neglect: evaluation of
response as a function of neglect type. J Int Neuropsychol Soc, 9(7), 983-988.
Agency for Health care Policy and Research (AHCPR). (1994). Health Services/Technology Assessment
Texts (HSTAT). Bethesda (MD).
Agosta, S., Herpich, F., Miceli, G., Ferraro, F., Battelli, L. (2014). Contralesional rTMS relieves visual
extinction in chronic stroke. Neuropsychologia, 62, 269-276.
Angeli, V., Benassi, M. G., Ladavas, E. (2004). Recovery of oculo-motor bias in neglect patients after
prism adaptation. Neuropsychologia, 42(9), 1223-1234.
Ansuini, C., Pierno, A. C., Lusher, D., Castiello, U. (2006). Virtual reality applications for the remapping of
space in neglect patients. Restor.Neurol.Neurosci., 24(4-6), 431-441.
Antonucci, G., Guariglia, C., Judica, A., Magnotti, L., Paolucci, S., Pizzamiglio, L., Zoccolotti, P. (1995).
Effectiveness of neglect rehabilitation in a randomized group study. J.Clin.Exp.Neuropsychol.,
17(3), 383-389.
Aparicio-Lopez, C., Garcia-Molina, A., Garcia-Fernandez, J., Lopez-Blazquez, R., Ensenat-Cantallops, A.,
Sanchez-Carrion, R., Muriel, V., Tormos, J. M., Roig-Rovira, T. (2015). Cognitive rehabilitation
with right hemifield eye-patching for patients with sub-acute stroke and visuo-spatial neglect: a
randomized controlled trial. Brain Injury, 29(4), 501-507.
Appelros, P., Karlsson, G. M., Seiger, A., Nydevik, I. (2002). Neglect and anosognosia after first-ever
stroke: incidence and relationship to disability. J.Rehabil.Med., 34(5), 215-220.
Appelros, P., Karlsson, G. M., Seiger, A., Nydevik, I. (2003). Prognosis for patients with neglect and
anosognosia with special reference to cognitive impairment. J.Rehabil.Med., 35(6), 254-258.
Appelros, P., Nydevik, I., Karlsson, G. M., Thorwalls, A., Seiger, A. (2004). Recovery from unilateral
neglect after right-hemisphere stroke. Disabil.Rehabil., 26(8), 471-477.
Azouvi, P., Olivier, S., de Montety, G., Samuel, C., Louis-Dreyfus, A., Tesio, L. (2003). Behavioral
assessment of unilateral neglect: study of the psychometric properties of the Catherine Bergego
Scale. Arch Phys Med Rehabil, 84(1), 51-57.
Baheux, K., Yoshizawa, M., Tanaka, A., Seki, K., Handa, Y. (2005). Diagnosis and rehabilitation of
hemispatial neglect patients with virtual reality technology. Technol.Health Care, 13(4), 245-260.
Bailey, M. J., Riddoch, M. J., Crome, P. (2002). Treatment of visual neglect in elderly patients with stroke:
a single-subject series using either a scanning and cueing strategy or a left-limb activation
strategy. Phys.Ther., 82(8), 782-797.

www.ebrsr.com
Barer, D. H., Edmans, J. A., Lincoln, N. B. (1990). Screening for perceptual problems in acute stroke
patients. Clinical Rehabilitation, 4(1), 1-11.
Barrett, A. M., Goedert, K. M., Basso, J. C. (2012). Prism adaptation for spatial neglect after stroke:
translational practice gaps. Nat Rev Neurol, 8(10), 567-577.
Beis, J. M., Andre, J. M., Baumgarten, A., Challier, B. (1999). Eye patching in unilateral spatial neglect:
efficacy of two methods. Arch.Phys.Med.Rehabil., 80(1), 71-76.
Beis, J. M., André, J. M., Baumgarten, A., Challier, B. (1999). Eye patching in unilateral spatial neglect:
efficacy of two methods. Arch Phys Med Rehabil., 80(1), 71-76.
Bowen, A., Hazelton, C., Pollock, A., Lincoln, N. B. (2013). Cognitive rehabilitation for spatial neglect
following stroke. Cochrane Database Syst Rev, 7, Cd003586.
Bowen, A., Lincoln, N. B., Dewey, M. (2007). Cognitive rehabilitation for spatial neglect following stroke.
Cochrane Database Syst Rev, 2.
Bowen, A., McKenna, K., Tallis, R. C. (1999). Reasons for variability in the reported rate of occurrence of
unilateral spatial neglect after stroke. Stroke, 30(6), 1196-1202.
Butter, C. M., Kirsch, N. (1992). Combined and separate effects of eye patching and visual stimulation on
unilateral neglect following stroke. Arch.Phys.Med.Rehabil., 73(12), 1133-1139.
Butter, C. M., Kirsch, N. L., Reeves, G. (1990). The effect of lateralized dynamic stimuli on unilateral
spatial neglect following right hemisphere lesions. Restorative Neurology and Neuroscience,
2(1), 39-46.
Cappa, S., Sterzi, R., Vallar, G., Bisiach, E. (1987). Remission of hemineglect and anosognosia during
vestibular stimulation. Neuropsychologia, 25(5), 775-782.
Cappa, S. F., Benke, T., Clarke, S., Rossi, B., Stemmer, B., van Heugten, C. M. (2005). EFNS guidelines on
cognitive rehabilitation: report of an EFNS task force. Eur.J.Neurol., 12(9), 665-680.
Carter, L. T., Howard, B. E., O'Neil, W. A. (1983). Effectiveness of cognitive skill remediation in acute
stroke patients. Am.J.Occup.Ther., 37(5), 320-326.
Carter, L. T., Oliveira, D. O., Duponte, J., Lynch, S. V. (1988). The relationship of cognitive skills
performance to activities of daily living in stroke patients. Am.J.Occup.Ther., 42(7), 449-455.
Castiello, U., Lusher, D., Burton, C., Glover, S., Disler, P. (2004). Improving left hemispatial neglect using
virtual reality. Neurology, 62(11), 1958-1962.

www.ebrsr.com
Cazzoli, D., Muri, R. M., Schumacher, R., Von Arx, S., Chaves, S., Gutbrod, K., Bohlhalter, S., Bauer, D.,
Vanbellingen, T., Bertschi, M., Kipfer, S., Rosenthal, C. R., Kennard, C., Bassetti, C. L., Nyffeler, T.
(2012). Theta burst stimulation reduces disability during the activities of daily living in spatial
neglect. Brain, 135(11), 3426-3439.
Chan, D. Y. W., Man, D. W. K. (2013). Unilateral neglect in stroke a comparative study. Topics in Geriatric
Rehabilitation, 29(2), 126-134.
Chen, M. C., Tsai, P. L., Huang, Y. T., Lin, K. C. (2013). Pleasant music improves visual attention in patients
with unilateral neglect after stroke. Brain Inj., 27(1), 75-82.
Cherney, L. R., Halper, A. S., Kwasnica, C. M., Harvey, R. L., Zhang, M. (2001). Recovery of functional
status after right hemisphere stroke: relationship with unilateral neglect.
Arch.Phys.Med.Rehabil., 82(3), 322-328.
Cicerone, K. D., Dahlberg, C., Kalmar, K., Langenbahn, D. M., Malec, J. F., Bergquist, T. F., Felicetti, T.,
Giacino, J. T., Harley, J. P., Harrington, D. E., Herzog, J., Kneipp, S., Laatsch, L., Morse, P. A.
(2000). Evidence-based cognitive rehabilitation: recommendations for clinical practice.
Cicerone, K. D., Dahlberg, C., Malec, J. F., Langenbahn, D. M., Felicetti, T., Kneipp, S., Ellmo, W., Kalmar,
K., Giacino, J. T., Harley, J. P., Laatsch, L., Morse, P. A., Catanese, J. (2005). Evidence-based
cognitive rehabilitation: updated review of the literature from 1998 through 2002.
Corbetta, M., Miezin, F. M., Shulman, G. L., Petersen, S. E. (1993). A PET study of visuospatial attention.
J.Neurosci., 13(3), 1202-1226.
Dai, C. Y., Huang, Y. H., Chou, L. W., Wu, S. C., Wang, R. Y., Lin, L. C. (2013). Effects of primary caregiver
participation in vestibular rehabilitation for unilateral neglect patients with right hemispheric
stroke: a randomized controlled trial. Neuropsychiatr.Dis.Treat., 9, 477-484.
Degutis, J. M., Van Vleet, T. M. (2010). Tonic and phasic alertness training: a novel behavioral therapy to
improve spatial and non-spatial attention in patients with hemispatial neglect. Front Hum
Neurosci, 4.
Diamond, P. T. (2001). Rehabilitative management of post-stroke visuospatial inattention.

Disabil.Rehabil., 23(10), 407-412.
Drasdo, N. (1976). Visual field expanders. Am.J.Optom.Physiol Opt., 53(9 Pt 1), 464-467.
Duszynski, L. (1955). Hemianopsia dichroic mirror device. Am J Ophthalmol, 39(6), 876-878.
Edmans, J. A., Gladman, J. R., Cobb, S., Sunderland, A., Pridmore, T., Hilton, D., Walker, M. F. (2006).
Validity of a virtual environment for stroke rehabilitation. Stroke, 37(11), 2770-2775.

www.ebrsr.com
Edmans, J. A., Webster, J., Lincoln, N. B. (2000). A comparison of two approaches in the treatment of
perceptual problems after stroke. Clin.Rehabil., 14(3), 230-243.
Eskes, G. A., Butler, B. (2006). Using limb movements to improve spatial neglect: the role of functional
electrical stimulation. Restor.Neurol.Neurosci., 24(4-6), 385-398.
Eskes, G. A., Butler, B., McDonald, A., Harrison, E. R., Phillips, S. J. (2003). Limb activation effects in
hemispatial neglect. Arch Phys Med Rehabil, 84(3), 323-328.
Fanthome, Y., Lincoln, N. B., Drummond, A., Walker, M. F. (1995). The treatment of visual neglect using
feedback of eye movements: a pilot study. Disabil.Rehabil., 17(8), 413-417.
Farne, A., Rossetti, Y., Toniolo, S., Ladavas, E. (2002). Ameliorating neglect with prism adaptation: visuo-
manual and visuo-verbal measures. Neuropsychologia, 40(7), 718-729.
Feinberg, T. E., Haber, L. D., Stacy, C. B. (1990). Ipsilateral extinction in the hemineglect syndrome.
Arch.Neurol., 47(7), 802-804.
Ferreira, H. P., Leite Lopes, M. A., Luiz, R. R., Cardoso, L., Andre, C. (2011). Is visual scanning better than
mental practice in hemispatial neglect? Results from a pilot study. Top Stroke Rehabil., 18(2),
155-161.
Ferro, J. M., Mariano, G., Madureira, S. (1999). Recovery from aphasia and neglect. Cerebrovasc.Dis., 9
Suppl 5, 6-22.
Fierro, B., Brighina, F., Oliveri, M., Piazza, A., La, B., V, Buffa, D., Bisiach, E. (2000). Contralateral neglect
induced by right posterior parietal rTMS in healthy subjects. NeuroReport, 11(7), 1519-1521.
Fleet, W. S., Valenstein, E., Watson, R. T., Heilman, K. M. (1987). Dopamine agonist therapy for neglect
in humans. Neurology, 37(11), 1765-1770.
Fong, K. N., Chan, M. K., Ng, P. P., Tsang, M. H., Chow, K. K., Lau, C. W., Chan, F. S., Wong, I. P., Chan, D.
Y., Chan, C. (2007). The effect of voluntary trunk rotation and half-field eye-patching for patients
with unilateral neglect in stroke: a randomized controlled trial. Clin Rehabil, 21(8), 729-741.
Fong, K. N. K., Yang, N. Y. H., Chan, M. K. L., Chan, D. Y. L., Lau, A. F. C., Chan, D. Y. W., Cheung, J. T. Y.,
Cheung, H. K. Y., Chung, R. C. K., Chan, C. C. H. (2013). Combined effects of sensory cueing and
limb activation on unilateral neglect in subacute left hemiplegic stroke patients: a randomized
controlled pilot study. Clinical Rehabilitation, 27(7), 628-637.
Frassinetti, F., Angeli, V., Meneghello, F., Avanzi, S., Ladavas, E. (2002a). Long-lasting amelioration of
visuospatial neglect by prism adaptation. Brain, 125(Pt 3), 608-623.
Frassinetti, F., Angeli, V., Meneghello, F., Avanzi, S., Ladavas, E. (2002b). Long-lasting amelioration of
visuospatial neglect by prism adaptation. Brain, 125(Pt 3), 608-623.

www.ebrsr.com
Fu, W., Song, W. Q., Zhang, Y. M., Yang, Y. B., Huo, S., Zhang, R., Wang, M. B. (2015). Long-term effects
of continuous theta-burst stimulation in visuospatial neglect. Journal of International Medical
Research, 43(2), 196-203.
Funk, J., Finke, K., Reinhart, S., Kardinal, M., Utz, K. S., Rosenthal, A., Kuhn, C., MÃ¼ller, H., Kerkhoff, G.
(2013). Effects of feedback-based visual line-orientation discrimination training for visuospatial
disorders after stroke. Neurorehabilitation and Neural Repair, 27(2), 142-152.
Gillen, R., Tennen, H., McKee, T. (2005). Unilateral spatial neglect: relation to rehabilitation outcomes in
patients with right hemisphere stroke. Arch.Phys.Med.Rehabil., 86(4), 763-767.
Gordon, W. A., Hibbard, M. R., Egelko, S., Diller, L., Shaver, M. S., Lieberman, A., Ragnarsson, K. (1985).
Perceptual remediation in patients with right brain damage: a comprehensive program.
Gorgoraptis, N., Mah, Y. H., Machner, B., Singh-Curry, V., Malhotra, P., Hadji-Michael, M., Cohen, D.,
Simister, R., Nair, A., Kulinskaya, E., Ward, N., Greenwood, R., Husain, M. (2012). The effects of
the dopamine agonist rotigotine on hemispatial neglect following stroke. Brain, 135(Pt 8), 2478-
2491.
Guariglia, C., Lippolis, G., Pizzamiglio, L. (1998). Somatosensory stimulation improves imagery disorders
in neglect. Cortex, 34(2), 233-241.
Harvey, M., Hood, B., North, A., Robertson, I. H. (2003). The effects of visuomotor feedback training on
the recovery of hemispatial neglect symptoms: assessment of a 2-week and follow-up
intervention. Neuropsychologia, 41(8), 886-893.
Heilman, K. M., Watson, R. T. (1985). Neglect and related disorders. In (KM Heilman & E. Valenstein, ed.)
Clinical Neuropsychology: Oxford: OUP.
Hommel, M., Peres, B., Pollak, P., Memin, B., Besson, G., Gaio, J. M., Perret, J. (1990). Effects of passive
tactile and auditory stimuli on left visual neglect. Arch.Neurol., 47(5), 573-576.
Hurford, P., Stringer, A. Y., Jann, B. (1998). Neuropharmacologic treatment of hemineglect: a case report
comparing bromocriptine and methylphenidate. Arch.Phys.Med.Rehabil., 79(3), 346-349.
Ianes, P., Varalta, V., Gandolfi, M., Picelli, A., Corno, M., Di Matteo, A., Fiaschi, A., Smania, N. (2012).
Stimulating visual exploration of the neglected space in the early stage of stroke by hemifield
eye-patching: A randomized controlled trial in patients with right brain damage. European
Journal of Physical and Rehabilitation Medicine, 48(2), 189-196.
Jacquin-Courtois, S., Rode, G., Pavani, F., O'Shea, J., Giard, M. H., Boisson, D., Rossetti, Y. (2010). Effect
of prism adaptation on left dichotic listening deficit in neglect patients: glasses to hear better?
Brain, 133(Pt 3), 895-908.

www.ebrsr.com
Jannink, M. J., Aznar, M., de Kort, A. C., van de Vis, W., Veltink, P., van der Kooij, H. (2009). Assessment
of visuospatial neglect in stroke patients using virtual reality: a pilot study. International Journal
of Rehabilitation Research, 32(4), 280-286.
Jehkonen, M., Ahonen, J. P., Dastidar, P., Koivisto, A. M., Laippala, P., Vilkki, J., Molnar, G. (2000). Visual
neglect as a predictor of functional outcome one year after stroke. Acta Neurol.Scand., 101(3),
195-201.
Jehkonen, M., Laihosalo, M., Kettunen, J. E. (2006). Impact of neglect on functional outcome after
stroke: a review of methodological issues and recent research findings. Restor.Neurol.Neurosci.,
24(4-6), 209-215.
Jo, K., Yu, J., Jung, J. (2012). Effects of virtual reality-based rehabilitation on upper extremity function
and visual perception in stroke patients: A randomized control trial. Journal of Physical Therapy
Science, 24(11), 1205-1208.
Johannsen, L., Ackermann, H., Karnath, H. O. (2003). Lasting amelioration of spatial neglect by treatment
with neck muscle vibration even without concurrent training. J.Rehabil.Med., 35(6), 249-253.
Kalra, L., Perez, I., Gupta, S., Wittink, M. (1997). The influence of visual neglect on stroke rehabilitation.
Stroke, 28(7), 1386-1391.
Karnath, H. O. (1996). Optokinetic stimulation influences the disturbed perception of body orientation in
spatial neglect. J.Neurol.Neurosurg.Psychiatry, 60(2), 217-220.
Karnath, H. O., Christ, K., Hartje, W. (1993). Decrease of contralateral neglect by neck muscle vibration
and spatial orientation of trunk midline. Brain, 116(2), 383-396.
Karnath, H. O., Schenkel, P., Fischer, B. (1991). Trunk orientation as the determining factor of the
'contralateral' deficit in the neglect syndrome and as the physical anchor of the internal
representation of body orientation in space. Brain, 114 ( Pt 4), 1997-2014.
Kasten, E., Wust, S., Behrens-Baumann, W., Sabel, B. A. (1998). Computer-based training for the
treatment of partial blindness. Nat.Med., 4(9), 1083-1087.
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.
Katz, N., Ring, H., Naveh, Y., Kizony, R., Feintuch, U., Weiss, P. L. (2005). Interactive virtual environment
training for safe street crossing of right hemisphere stroke patients with unilateral spatial
neglect. Disabil Rehabil., 27(20), 1235-1243.

www.ebrsr.com
Keller, I., Lefin-Rank, G., Losch, J., Kerkhoff, G. (2009). Combination of pursuit eye movement training
with prism adaptation and arm movements in neglect therapy: a pilot study. Neurorehabil
Neural Repair, 23(1), 58-66.
Kelly-Hayes, M., Robertson, J. T., Broderick, J. P., Duncan, P. W., Hershey, L. A., Roth, E. J., Thies, W. H.,
Trombly, C. A. (1998). The American Heart Association Stroke Outcome Classification. Stroke,
29(6), 1274-1280.
Kerkhoff, G., Bucher, L., Brasse, M., Leonhart, E., Holzgraefe, M., Volzke, V., Keller, I., Reinhart, S. (2014).
Smooth pursuit "Bedside" training reduces disability and unawareness during the activities of
daily living in neglect: a randomized controlled trial. Neurorehabilitation and Neural Repair,
28(6), 554-563.
Kerkhoff, G., Keller, I., Artinger, F., Hildebrandt, H., Marquardt, C., Reinhart, S., Ziegler, W. (2012).
Recovery from auditory and visual neglect after optokinetic stimulation with pursuit eye
movements--transient modulation and enduring treatment effects. Neuropsychologia., 50(6),
1164-1177.
Kerkhoff, G., Reinhart, S., Ziegler, W., Artinger, F., Marquardt, C., Keller, I. (2013). Smooth pursuit eye
movement training promotes recovery from auditory and visual neglect: a randomized
controlled study. Neurorehabilitation and Neural Repair, 27(9), 789-798.
Kim, B. R., Chun, M. H., Kim, D. Y., Lee, S. J. (2013). Effect of High- and Low-Frequency Repetitive
Transcranial Magnetic Stimulation on Visuospatial Neglect in Patients With Acute Stroke: A
Double-Blind, Sham-Controlled Trial. Archives of Physical Medicine & Rehabilitation, 94(5), 803-
807.
Kim, J., Kim, K., Kim, D. Y., Chang, W. H., Park, C. I., Ohn, S. H., Han, K., Ku, J., Nam, S. W., Kim, I. Y., Kim,
S. I. (2007). Virtual environment training system for rehabilitation of stroke patients with
unilateral neglect: crossing the virtual street. Cyberpsychol.Behav., 10(1), 7-15.
Kim, K., Kim, J., Ku, J., Kim, D. Y., Chang, W. H., Shin, D. I., Lee, J. H., Kim, I. Y., Kim, S. I. (2004). A virtual
reality assessment and training system for unilateral neglect. Cyberpsychol.Behav., 7(6), 742-
749.
Kim, Y. M., Chun, M. H., Yun, G. J., Song, Y. J., Young, H. E. (2011). The Effect of Virtual Reality Training
on Unilateral Spatial Neglect in Stroke Patients. Annals of rehabilitation medicine, 35(3), 309-
315.
Klinke, M. E., Hafsteinsdóttir, T. B., Hjaltason, H., Jónsdóttir, H. (2015). Ward-based interventions for
patients with hemispatial neglect in stroke rehabilitation: A systematic literature review.
International Journal of Nursing Studies, 52(8), 1375-1403.
Ko, M. H., Han, S. H., Park, S. H., Seo, J. H., Kim, Y. H. (2008). Improvement of visual scanning after DC
brain polarization of parietal cortex in stroke patients with spatial neglect. Neurosci.Lett., 448(2),
171-174.

www.ebrsr.com
Koch, G., Bonni, S., Giacobbe, V., Bucchi, G., Basile, B., Lupo, F., Versace, V., Bozzali, M., Caltagirone, C.
(2012). Theta-burst stimulation of the left hemisphere accelerates recovery of hemispatial
neglect. Neurology, 78(1), 24-30.
Ladavas, E., Bonifazi, S., Catena, L., Serino, A. (2011). Neglect rehabilitation by prism adaptation:
different procedures have different impacts. Neuropsychologia, 49(5), 1136-1145.
Ladavas, E., Menghini, G., Umilta , C. (1994). A rehabilitation study of hemispatial neglect. Cognitive
Neuropsychology, 11(1), 75-95.
Lim, J. Y., Kang, E. K., Paik, N. J. (2010). Repetitive transcranial magnetic stimulation to hemispatial
neglect in patients after stroke: an open-label pilot study. J.Rehabil.Med., 42(5), 447-452.
Lin, K. C., Cermak, S. A., Kinsbourne, M., Trombly, C. A. (1996). Effects of left-sided movements on line
bisection in unilateral neglect. J.Int.Neuropsychol.Soc., 2(5), 404-411.
Lincoln, N. B., Drummond, A. E., Berman, P. (1997). Perceptual impairment and its impact on
rehabilitation outcome. SUE Study Group. Disabil.Rehabil., 19(6), 231-234.
Lincoln, N. B., Whiting, S. E., Cockburn, J., Bhavnani, G. (1985). An evaluation of perceptual retraining.
Int.Rehabil.Med., 7(3), 99-101.
Linden, T., Samuelsson, H., Skoog, I., Blomstrand, C. (2005). Visual neglect and cognitive impairment in
elderly patients late after stroke. Acta Neurol.Scand., 111(3), 163-168.
Lucas, N., Saj, A., Schwartz, S., Ptak, R., Schnider, A., Thomas, C., Conne, P., Leroy, R., Pavin, S., Diserens,
K., Vuilleumier, P. (2013). Effects of pro-cholinergic treatment in patients suffering from spatial
neglect. Frontiers in Human Neuroscience, 7.
Ma, H. I., Trombly, C. A. (2002). A synthesis of the effects of occupational therapy for persons with
stroke, Part II: Remediation of impairments. Am.J.Occup.Ther., 56(3), 260-274.
Machner, B., Konemund, I., Sprenger, A., von der Gablentz, J., Helmchen, C. (2014). Randomized
controlled trial on hemifield eye patching and optokinetic stimulation in acute spatial neglect.
Stroke, 45(8), 2465-2468.
Mancuso, M., Pacini, M., Gemignani, P., Bartalini, B., Agostini, B., Ferroni, L., Caputo, M., Capitani, D.,
Mondin, E., Cantagallo, A. (2012a). Clinical application of prismatic lenses in the rehabilitation of
neglect patients. A randomized controlled trial. Eur J Phys Rehabil Med, 48(2), 197-208.
Mancuso, M., Pacini, M., Gemignani, P., Bartalini, B., Agostini, B., Ferroni, L., Caputo, M., Capitani, D.,
Mondin, E., Cantagallo, A. (2012b). Clinical application of prismatic lenses in the rehabilitation of
neglect patients. A randomized controlled trial. Eur J Phys Rehabil Med., 48(2), 197-208.

www.ebrsr.com
Maravita, A., McNeil, J., Malhotra, P., Greenwood, R., Husain, M., Driver, J. (2003). Prism adaptation can
improve contralesional tactile perception in neglect. Neurology, 60(11), 1829-1831.
Martin, P. I., Naeser, M. A., Theoret, H., Tormos, J. M., Nicholas, M., Kurland, J., Fregni, F., Seekins, H.,
Doron, K., Pascual-Leone, A. (2004). Transcranial magnetic stimulation as a complementary
treatment for aphasia. Semin.Speech Lang, 25(2), 181-191.
Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: working your
way through the maze of assessment choices. Top.Stroke Rehabil., 11(3), 41-66.
Mesulam, M. M. (2000). Attentional networks, confused states and neglect syndromes. In M. M.

Mesulam (Ed.), Principles of behavioral and cognitive neurology (pp. 173-256). New York: Oxford
University Press, USA. (Reprinted from: Not in File).
Mizuno, K., Tsuji, T., Takebayashi, T., Fujiwara, T., Hase, K., Liu, M. (2011). Prism adaptation therapy
enhances rehabilitation of stroke patients with unilateral spatial neglect: a randomized,
controlled trial. Neurorehabil.Neural Repair, 25(8), 711-720.
Modden, C., Behrens, M., Damke, I., Eilers, N., Kastrup, A., Hildebrandt, H. (2012). A randomized
controlled trial comparing 2 interventions for visual field loss with standard occupational
therapy during inpatient stroke rehabilitation. Neurorehabil.Neural Repair., 26(5), 463-469.
Mukand, J. A., Guilmette, T. J., Allen, D. G., Brown, L. K., Brown, S. L., Tober, K. L., Vandyck, W. R. (2001).
Dopaminergic therapy with carbidopa L-dopa for left neglect after stroke: a case series.
Nakamura, J., Kita, Y., Ikuno, K., Kojima, K., Okada, Y., Shomoto, K. (2015). Influence of the stimulus
parameters of galvanic vestibular stimulation on unilateral spatial neglect. NeuroReport: For
Rapid Communication of Neuroscience Research, 26(8), 462-466.
Narasimhalu, K., Effendy, S., Sim, C. H., Lee, J. M., Chen, I., Hia, S. B., Xue, H. L., Corrales, M. P., Chang, H.
M., Wong, M. C., Chen, C. P., Tan, E. K. (2010). A randomized controlled trial of rivastigmine in
patients with cognitive impairment no dementia because of cerebrovascular disease. Acta
Neurol.Scand., 121(4), 217-224.
Nerenberg, B. (1980). A new mirror design for hemianopia. Am.J.Optom.Physiol Opt., 57(3), 183-186.
Newport, R., Schenk, T. (2012). Prisms and neglect: What have we learned? Neuropsychologia, 50(6),
1080-1091.
Niemeier, J. P. (1998). The Lighthouse Strategy: use of a visual imagery technique to treat visual
inattention in stroke patients. Brain Inj., 12(5), 399-406.

www.ebrsr.com
Niemeier, J. P., Cifu, D. X., Kishore, R. (2001). The lighthouse strategy: Improving the functional status of
patients with unilateral neglect after stroke and brain injury using a visual imagery intervention.
Top.Stroke Rehabil., 8(2), 10-18.
Nooney, T. W., Jr. (1986). Partial visual rehabilitation of hemianopic patients. Am.J.Optom.Physiol Opt.,
63(5), 382-386.
Nys, G. M., de Haan, E. H., Kunneman, A., de Kort, P. L., Dijkerman, H. C. (2008). Acute neglect
rehabilitation using repetitive prism adaptation: a randomized placebo-controlled trial.
Restor.Neurol.Neurosci., 26(1), 1-12.
Oliveri, M., Bisiach, E., Brighina, F., Piazza, A., La, B., V, Buffa, D., Fierro, B. (2001). rTMS of the
unaffected hemisphere transiently reduces contralesional visuospatial hemineglect. Neurology,
57(7), 1338-1340.
Oppenlander, K., Utz, K. S., Reinhart, S., Keller, I., Kerkhoff, G., Schaadt, A. K. (2015). Subliminal galvanic-
vestibular stimulation recalibrates the distorted visual and tactile subjective vertical in right-
sided stroke. Neuropsychologia, 74, 178-183.
Osawa, A., Maeshima, S. (2010). Family participation can improve unilateral spatial neglect in patients
with acute right hemispheric stroke. Eur.Neurol., 63(3), 170-175.
Paci, M., Matulli, G., Baccini, M., Rinaldi, L. A., Baldassi, S. (2010). Reported quality of randomized
controlled trials in neglect rehabilitation. Neurol.Sci., 31(2), 159-163.
Padula, W. V., Nelson, C. A., Padula, W. V., Benabib, R., Yilmaz, T., Krevisky, S. (2009). Modifying postural
adaptation following a CVA through prismatic shift of visuo-spatial egocenter. Brain Inj., 23(6),
566-576.
Pandian, J. D., Arora, R., Kaur, P., Sharma, D., Vishwambaran, D. K., Arima, H. (2014). Mirror therapy in
unilateral neglect after stroke (MUST trial): a randomized controlled trial. Neurology, 83(11),
1012-1017.
Paolucci, S., Antonucci, G., Grasso, M. G., Pizzamiglio, L. (2001). The role of unilateral spatial neglect in
rehabilitation of right brain-damaged ischemic stroke patients: a matched comparison.
Paolucci, S., Antonucci, G., Guariglia, C., Magnotti, L., Pizzamiglio, L., Zoccolotti, P. (1996). Facilitatory
effect of neglect rehabilitation on the recovery of left hemiplegic stroke patients: a cross-over
study. J.Neurol., 243(4), 308-314.
Paolucci, S., Bureca, I., Multari, M., Nocentini, U., Matano, A. (2010). An open-label pilot study of the use
of rivastigmine to promote functional recovery in patients with unilateral spatial neglect due to
first ischemic stroke. Funct.Neurol., 25(4), 195-200.

www.ebrsr.com
Parton, A., Malhotra, P., Husain, M. (2004). Hemispatial neglect. J Neurol Neurosurg Psychiatry, 75(1),
13-21.
Peli, E. (2000). Field expansion for homonymous hemianopia by optically induced peripheral exotropia.
Optom.Vis.Sci., 77(9), 453-464.
Pierce, S. R., Buxbaum, L. J. (2002). Treatments of unilateral neglect: a review. Arch.Phys.Med.Rehabil.,

83(2), 256-268.
Pizzamiglio, L., Fasotti, L., Jehkonen, M., Antonucci, G., Magnotti, L., Boelen, D., Asa, S. (2004). The use
of optokinetic stimulation in rehabilitation of the hemineglect disorder. Cortex, 40(3), 441-450.
Polanowska, K., Seniow, J., Paprot, E., Lesniak, M., Czlonkowska, A. (2009). Left-hand somatosensory
stimulation combined with visual scanning training in rehabilitation for post-stroke hemineglect:
a randomised, double-blind study. Neuropsychol.Rehabil., 19(3), 364-382.
Priftis, K., Passarini, L., Pilosio, C., Meneghello, F., Pitteri, M. (2013). Visual scanning training, limb
activation treatment, and prism adaptation for rehabilitating left neglect: who is the winner?
Frontiers in Human Neuroscience, 7.
Reinhart, S., Schmidt, L., Kuhn, C., Rosenthal, A., Schenk, T., Keller, I., Kerkhoff, G. (2012). Limb activation
ameliorates body-related deficits in spatial neglect. Frontiers in Human Neuroscience, 6.
Ringman, J. M., Saver, J. L., Woolson, R. F., Clarke, W. R., Adams, H. P. (2004). Frequency, risk factors,
anatomy, and course of unilateral neglect in an acute stroke cohort. Neurology, 63(3), 468-474.
Robertson, I. H., Gray, J. M., Pentland, B., Waite, L. J. (1990). Microcomputer-based rehabilitation for
unilateral left visual neglect: a randomized controlled trial. Arch.Phys.Med.Rehabil., 71(9), 663-
668.
Robertson, I. H., McMillan, T. M., MacLeod, E., Edgeworth, J., Brock, D. (2002). Rehabilitation by limb
activation training reduces left-sided motor impairment in unilateral neglect patients: A single-
blind randomised control trial. Neuropsychological Rehabilitation, 12(5), 439-454.
Robertson, I. H., North, N. (1992). Spatio-motor cueing in unilateral left neglect: the role of hemispace,
hand and motor activation. Neuropsychologia, 30(6), 553-563.
Robertson, I. H., Tegner, R., Goodrich, S. J., Wilson, C. (1994). Walking trajectory and hand movements in
unilateral left neglect: a vestibular hypothesis. Neuropsychologia, 32(12), 1495-1502.
Rode, G., Klos, T., Courtois-Jacquin, S., Rossetti, Y., Pisella, L. (2006). Neglect and prism adaptation: a
new therapeutic tool for spatial cognition disorders. Restorative Neurology and Neuroscience,
24(4), 347-356.

www.ebrsr.com
Rode, G., Pisella, L., Rossetti, Y., Farne, A., Boisson, D. (2003). Bottom-up transfer of sensory-motor
plasticity to recovery of spatial cognition: visuomotor adaptation and spatial neglect. Prog.Brain
Res., 142, 273-287.
Rorsman, I., Magnusson, M., Johansson, B. B. (1999). Reduction of visuo-spatial neglect with vestibular
galvanic stimulation. Scand.J.Rehabil.Med., 31(2), 117-124.
Rossetti, Y., Rode, G., Pisella, L., Farne, A., Li, L., Boisson, D., Perenin, M. T. (1998). Prism adaptation to a
rightward optical deviation rehabilitates left hemispatial neglect. Nature, 395(6698), 166-169.
Rossi, P. W., Kheyfets, S., Reding, M. J. (1990). Fresnel prisms improve visual perception in stroke
patients with homonymous hemianopia or unilateral visual neglect. Neurology, 40(10), 1597-
1599.
Rousseaux, M., Bernati, T., Saj, A., Kozlowski, O. (2006). Ineffectiveness of prism adaptation on spatial
neglect signs. Stroke, 37(2), 542-543.
Royal College of Physicians. (2012) National Clinical Guideline for Stroke. London.
Rubens, A. B. (1985). Caloric stimulation and unilateral visual neglect. Neurology, 35(7), 1019-1024.
Ruet, A., Jokic, C., Denise, P., Leroy, F., Azouvi, P. (2014). Does galvanic vestibular stimulation reduce
spatial neglect? A negative study. Ann Phys Rehabil Med, 57(9-10), 570-577.
Rusconi, M. L., Meinecke, C., Sbrissa, P., Bernardini, B. (2002). Different cognitive trainings in the
rehabilitation of visuo-spatial neglect. Europa Medicophysica, 38(4), 159-166.
Schaadt, A. K., Schmidt, L., Reinhart, S., Adams, M., Garbacenkaite, R., Leonhardt, E., Kuhn, C., Kerkhoff,
G. (2014). Perceptual relearning of binocular fusion and stereoacuity after brain injury.
Neurorehabilitation and Neural Repair, 28(5), 462-471.
Schindler, I., Kerkhoff, G., Karnath, H. O., Keller, I., Goldenberg, G. (2002). Neck muscle vibration induces
lasting recovery in spatial neglect. J.Neurol.Neurosurg.Psychiatry, 73(4), 412-419.
Schmidt, L., Keller, I., Utz, K. S., Artinger, F., Stumpf, O., Kerkhoff, G. (2013). Galvanic vestibular
stimulation improves arm position sense in spatial neglect: a sham-stimulation-controlled study.
Neurorehabilitation and Neural Repair, 27(6), 497-506.
Schroder, A., Wist, E. R., Homberg, V. (2008). TENS and optokinetic stimulation in neglect therapy after
cerebrovascular accident: a randomized controlled study. Eur.J.Neurol., 15(9), 922-927.
Serino, A., Angeli, V., Frassinetti, F., Ladavas, E. (2006). Mechanisms underlying neglect recovery after
prism adaptation. Neuropsychologia, 44(7), 1068-1078.

www.ebrsr.com
Serino, A., Barbiani, M., Rinaldesi, M. L., Ladavas, E. (2009). Effectiveness of prism adaptation in neglect
rehabilitation: a controlled trial study. Stroke, 40(4), 1392-1398.
Seron, X., Deloche, G., Coyette, F. (1989). A retrospective analysis of a single case neglect therapy: a
point of theroy. In X. Seron, G. Deloche (Eds.), Cognitive Approaches in Neuropsychological
Rehabilitation (pp. 289-316). Hillsdae (NJ): Laurence Erlbaum Associates. (Reprinted from: Not in
File).
Shiraishi, H., Muraki, T., Ayaka Itou, Y. S., Hirayama, K. (2010). Prism intervention helped sustainability of
effects and ADL performances in chronic hemispatial neglect: a follow-up study.
NeuroRehabilitation., 27(2), 165-172.
Shiraishi, H., Yamakawa, Y., Itou, A., Muraki, T., Asada, T. (2008). Long-term effects of prism adaptation
on chronic neglect after stroke. NeuroRehabilitation., 23(2), 137-151.
Shulman, G. L. (1984). An asymmetry in the control of eye movements and shifts of attention. Acta
Psychol.(Amst), 55(1), 53-69.
Smania, N., Fonte, C., Picelli, A., Gandolfi, M., Varalta, V. (2013a). Effect of eye patching in rehabilitation
of hemispatial neglect. Frontiers in Human Neuroscience, 7.
Smania, N., Fonte, C., Picelli, A., Gandolfi, M., Varalta, V. (2013b). Effect of Eye Patching in Rehabilitation
of Hemispatial Neglect. Front Hum.Neurosci., 7, 527.
Smit, M., Schutter, D. J. L. G., Nijboer, T. C. W., Visser-Meily, J. M. A., Kappelle, L. J., Kant, N., Penninx, J.,
Dijkerman, H. C. (2015). Transcranial direct current stimulation to the parietal cortex in
hemispatial neglect: A feasibility study. Neuropsychologia.
Soderback, I., Bengtsson, I., Ginsburg, E., Ekholm, J. (1992). Video feedback in occupational therapy: its
effects in patients with neglect syndrome. Arch.Phys.Med.Rehabil., 73(12), 1140-1146.
Soroker, N., Cohen, T., Baratz, C., Glicksohn, J., Myslobodsky, M. S. (1994). Is there a place for
ipsilesional eye patching in neglect rehabilitation? Behav Neurol, 7(3), 159-164.
Steultjens, E. M., Dekker, J., Bouter, L. M., van de Nes, J. C., Cup, E. H., van den Ende, C. H. (2003).
Occupational therapy for stroke patients: a systematic review. Stroke, 34(3), 676-687.
Sturt, R., Punt, T. D. (2013). Caloric vestibular stimulation and postural control in patients with spatial
neglect following stroke. Neuropsychological Rehabilitation, 23(2), 299-316.
Titus, M. N., Gall, N. G., Yerxa, E. J., Roberson, T. A., Mack, W. (1991). Correlation of perceptual
performance and activities of daily living in stroke patients. Am J Occup Ther., 45(5), 410-418.
Tsai, P. L., Chen, M. C., Huang, Y. T., Lin, K. C. (2013). Effects of listening to pleasant music on chronic
unilateral neglect: A single-subject study. NeuroRehabilitation, 32(1), 33-42.

www.ebrsr.com
Tsai, P. L., Chen, M. C., Huang, Y. T., Lin, K. C., Chen, K. L., Hsu, Y. W. (2013). Listening to classical music
ameliorates unilateral neglect after stroke. Am J Occup Ther, 67(3), 328-335.
Tsang, M. H., Sze, K. H., Fong, K. N. (2009). Occupational therapy treatment with right half-field eye-
patching for patients with subacute stroke and unilateral neglect: a randomised controlled trial.
Disabil.Rehabil., 31(8), 630-637.
Tsirlin, I., Dupierrix, E., Chokron, S., Coquillart, S., Ohlmann, T. (2009). Uses of virtual reality for
diagnosis, rehabilitation and study of unilateral spatial neglect: review and analysis.
Cyberpsychol.Behav., 12(2), 175-181.
Turner, P. J. (1976). The Place of CCTV in the Rehabilitation of the Low Vision Patient. New Outlook for
the Blind, 70(5), 206-214.
Turton, A. J., O'Leary, K., Gabb, J., Woodward, R., Gilchrist, I. D. (2010). A single blinded randomised
controlled pilot trial of prism adaptation for improving self-care in stroke patients with neglect.
Neuropsychol.Rehabil., 20(2), 180-196.
Utz, K. S., Korluss, K., Schmidt, L., Rosenthal, A., Oppenlander, K., Keller, I., Kerkhoff, G. (2011). Minor
adverse effects of galvanic vestibular stimulation in persons with stroke and healthy individuals.
Brain Inj., 25(11), 1058-1069.
VA DoD Clinical Practice Guideline. (2010). Management of Stroke Rehabilitation.
Vallar, G., Bottini, G., Rusconi, M. L., Sterzi, R. (1993). Exploring somatosensory hemineglect by
vestibular stimulation. Brain, 116 ( Pt 1), 71-86.
Vallar, G., Rusconi, M. L., Barozzi, S., Bernardini, B., Ovadia, D., Papagno, C., Cesarani, A. (1995).
Improvement of left visuo-spatial hemineglect by left-sided transcutaneous electrical
stimulation. Neuropsychologia, 33(1), 73-82.
van Kessel, M. E., Geurts, A. C. H., Brouwer, W. H., Fasotti, L. (2013). Visual scanning training for neglect
after stroke with and without a computerized lane tracking dual task. Frontiers in Human
Neuroscience, 7.
Van Vleet, T., DeGutis, J., Dabit, S., Chiu, C. (2014). Randomized control trial of computer-based
rehabilitation of spatial neglect syndrome: the RESPONSE trial protocol. BMC Neurology, 14.
van Wyk, A., Eksteen, C. A., Rheeder, P. (2014). The effect of visual scanning exercises integrated into
physiotherapy in patients with unilateral spatial neglect poststroke: a matched-pair randomized
control trial. Neurorehabilitation and Neural Repair, 28(9), 856-873.
Vossel, S., Kukolja, J., Thimm, M., Thiel, C. M., Fink, G. R. (2010). The effect of nicotine on visuospatial
attention in chronic spatial neglect depends upon lesion location. J Psychopharmacol, 24(9),
1357-1365.

www.ebrsr.com
Walker, R. (1996). Eye patching and the rehabilitation of visual neglect. Neuropsychological
Rehabilitation, 6(3), 219-232.
Webster, J. S., McFarland, P. T., Rapport, L. J., Morrill, B., Roades, L. A., Abadee, P. S. (2001). Computer-
assisted training for improving wheelchair mobility in unilateral neglect patients.
Wee, J. Y., Hopman, W. M. (2008). Comparing consequences of right and left unilateral neglect in a
stroke rehabilitation population. Am.J.Phys.Med.Rehabil., 87(11), 910-920.
Weinberg, J., Diller, L., Gordon, W. A., Gerstman, L. J., Lieberman, A., Lakin, P., Hodges, G., Ezrachi, O.
(1977). Visual scanning training effect on reading-related tasks in acquired right brain damage.
Weinberg, J., Piasetsky, E., Diller, L., Gordon, W. (1982). Treating perceptual organization deficits in
nonneglecting RBD stroke patients. J.Clin.Neuropsychol., 4(1), 59-75.
Weiss, N. J. (1969). Management of the low vision patient with peripheral field loss. J.Am.Optom.Assoc.,
40(8), 830-832.
Whiting, S. E., Lincoln, N. B., Bhavnani, G., Cockburn, J. (1985). Rivermead Perceptual Assessment
Battery. Windsor: NFER-Nelson.
Whyte, E. M., Lenze, E. J., Butters, M., Skidmore, E., Koenig, K., Dew, M. A., Penrod, L., Mulsant, B. H.,
Pollock, B. G., Cabacungan, L. (2008). An open-label pilot study of acetylcholinesterase inhibitors
to promote functional recovery in elderly cognitively impaired stroke patients. Cerebrovascular
Diseases, 26(3), 317-321.
Wiart, L., Come, A. B., Debelleix, X., Petit, H., Joseph, P. A., Mazaux, J. M., Barat, M. (1997). Unilateral
neglect syndrome rehabilitation by trunk rotation and scanning training. Arch Phys Med
Rehabil., 78(4), 424-429.
Wilkinson, D., Zubko, O., Sakel, M., Coulton, S., Higgins, T., Pullicino, P. (2014). Galvanic vestibular
stimulation in hemi-spatial neglect. Frontiers in Integrative Neuroscience, 8.
Wu, C., Wang, T., Chen, Y., Lin, K., Chen, Y., Li, H., Tsai, P. (2013). Effects of constraint-induced therapy
combined with eye patching on functional outcomes and movement kinematics in poststroke
neglect. American Journal of Occupational Therapy, 67(2), 236-245.
Wyness, A. M. (1985). Perceptual Dysfunction: nursing assessment and management. Journal of

Neuroscience Nursing, 17(2), 105-110.
Young, G. C., Collins, D., Hren, M. (1983). Effect of pairing scanning training with block design training in
the remediation of perceptual problems in left hemiplegics. J.Clin.Neuropsychol., 5(3), 201-212.

www.ebrsr.com
Zeloni, G., Farne, A., Baccini, M. (2002). Viewing less to see better. J.Neurol.Neurosurg.Psychiatry, 73(2),
195-198.

www.ebrsr.com
Appendix
Acute Stroke
1. There is level 1b and level 2 evidence that perceptual retraining improves visuospatial perception
when compared to conventional rehabilitation.
2. There is level 1a evidence that visual scanning training for neglect improves visuospatial perception
when compared to conventional rehabilitation.
3. There is level 1b and level 2 evidence that virtual reality training for neglect improves visuospatial
perception and rightward bias when compared to conventional rehabilitation.
4. There is level 1b evidence that computer-based compensatory therapy for neglect improves
visuospatial perception and rightward bias when compared to restorative computer-based training
and conventional rehabilitation.
5. There is level 1b evidence that computer-based training for neglect does not improve visuospatial
perception or rightward bias when compared to recreational computing.
6. There is level 1b evidence that limb activation for neglect improves visuospatial perception and
rightward bias when compared to conventional rehabilitation.
7. There is level 1b evidence that cued movements for neglect do not improve visuospatial perception
or motor function when compared to conventional rehabilitation.
8. There is level 1b evidence that visuomotor feedback for neglect improves visuospatial perception,
rightward bias, and functional ability when compared to control.
9. There is level 2 evidence that auditory feedback for neglect does not improve visuospatial
perception, rightward bias, or functional ability when compared to control.
10. There is level 1b and level 2 evidence that prismatic adaptation for neglect improves visuospatial
perception and rightward bias when compared to sham treatment; however these improvements
are not sustained over time nor associated with improvements in functional ability.
11. There is level 1a and level 2 evidence that hemifield occlusion does not improve visuospatial
perception, rightward bias, or functional ability when compared to conventional rehabilitation.
12. There is level 1b evidence that right cathodal VGS for neglect, but not left cathodal VGS, improves
visuospatial perception when compared to sham VGS.
13. There is level 2 evidence that optokinetic stimulation for neglect combined with hemifield occlusion
does not improve visuospatial perception or functional ability when compared to conventional
rehabilitation.
14. There is level 1b evidence that trunk rotation training for neglect does not improve visuospatial
perception or functional ability when compared to conventional rehabilitation.
15. There is level 1b evidence that low- and high-frequency rTMS improve visuospatial perception and
functional ability in neglect when compared to sham stimulation; however there is no difference in
improvement between frequencies.
16. There is level 1b evidence that theta burst rTMS improves visuospatial perception and functional
ability in neglect for up to 3 weeks when compared to sham stimulation.
Subacute Stroke

www.ebrsr.com
1. There is level 1a and level 2 evidence that perceptual retraining does not improve visuospatial
2. There is level 2 evidence that caregiver participation in rehabilitation does not improve visuospatial
3. There is level 1b and level 2 evidence that visual scanning training for neglect improves visuospatial
perception and functional ability when compared to conventional rehabilitation.
4. There is level 1b evidence that dual-task and single-task visual scanning training do not differ at
improving visuospatial perception or functional ability in neglect.
5. There is level 2 evidence that visual scanning, limb activation, and prismatic adaptation do not differ
at improving visuospatial perception or functional ability in neglect.
6. There is level 1a evidence that limb activation for neglect improves visuospatial perception,
rightward bias, and motor function when compared to conventional rehabilitation.
7. There is level 2 evidence that limb activation, visual scanning, and prismatic adaptation do not differ
8. There is level 1b evidence that electrical somatosensory stimulation in combination with visual
scanning training for neglect improves visuospatial perception when compared to visual scanning
training alone.
9. There is conflicting level 1a and level 2 evidence as to whether prismatic adaptation for neglect
improves visuospatial perception, rightward bias, and functional ability when compared to sham
treatment.
10. There is level 2 evidence that prismatic adaptation, visual scanning, and limb activation do not differ
11. There is conflicting level 1b and level 2 evidence as to whether hemifield or monocular occlusion
improve visuospatial perception, rightward bias, and functional ability when compared to
12. There is level 1a evidence that VGS for neglect improves visuospatial perception when compared to
sham VGS; however the effect of right versus left cathode is conflicting.
13. There is level 1a and level 2 evidence that optokinetic stimulation for neglect, with or without visual
scanning training, improves visuospatial perception and functional ability when compared to visual
scanning training alone; however level 2 evidence suggests otherwise.
14. There is level 2 evidence that optokinetic stimulation and TENSdo not differ at improving
visuospatial perception or functional ability in neglect.
15. There is level 2 evidence that trunk rotation training for neglect improves visuospatial perception
and functional ability when compared to conventional rehabilitation.
16. There is level 2 evidence that neck muscle vibration combined with visual exploration training
improves visuospatial perception and functional ability when compared visual exploration training
alone.
17. There is level 2 evidence that TENS, with or without feedback, improves visuospatial perception and
functional ability when compared to conventional rehabilitation.
18. There is level 2 evidence that TENS combined with visual scanning training improves visuospatial
perception and functional ability when compared to visual scanning training alone.

www.ebrsr.com
19. There is level 2 evidence that TENS and optokinetic stimulation do not differ at improving
visuospatial perception or functional ability in neglect.
20. There is level 1a evidence that theta burst rTMS improves visuospatial perception and functional
ability in neglect for up to 4 weeks when compared to sham stimulation.
21. There is level 1b evidence that tDCS improves visuospatial perception in neglect when compared to
sham stimulation.
Chronic Stroke
1. There is level 2 evidence that visual scanning training for neglect improves visuospatial perception
and functional ability when compared to conventional rehabilitation but not mental practice
training.
2. There is level 1b evidence that limb activation for neglect improves visuospatial perception,
rightward bias, and motor function when compared to conventional rehabilitation.
3. There is level 2 evidence that visuomotor feedback for neglect improves visuospatial perception,
rightward bias, and functional ability when compared to control.
4. There is conflicting level 1a evidence as to whether prismatic adaptation for neglect improves
visuospatial perception, rightward bias, and functional ability when compared to sham treatment.
5. There is level 1b evidence that monocular occlusion in combination with constraint-induced therapy
improves visuospatial perception, rightward bias, and motor function when compared to constraint-
induced therapy alone and conventional rehabilitation.
6. There is level 1b evidence that right and left cathodal VGS for neglect improve visuospatial
perception when compared to sham VGS.
7. There is level 1b evidence that rotigotine does not improve visuospatial perception in neglect when
compared to placebo; however it may alleviate rightward bias.
8. There is level 1b evidence that rivastigmine in combination with cognitive training improves
visuospatial perception in neglect when compared to cognitive training alone; however these
improvements are not sustained over time.
9. There is level 1b evidence that nicotine therapy improves visuospatial perception in neglect when
compared to placebo.

www.ebrsr.com

Chapter 13 - Perceptual Disorders - With Appendix

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

Chapter 13 - Perceptual Disorders - With Appendix

Uploaded by

Copyright:

Available Formats

EBRSR

[Evidence-Based Review of Stroke Rehabilitation]

Last Updated: September 2016

13. Perceptual Disorders pg. 1 of 66

 Electrical somatosensory stimulation may be a useful supplement to visual scanning training.

 Visuomotor feedback strategies appear to be beneficial in the treatment of neglect.

 Although optokinetic stimulation appears to have a positive effect on neglect, it is uncertain

13. Perceptual Disorders pg. 2 of 66

 Transcranial direct current stimulation may be beneficial in the treatment of neglect.

 More research is needed to determine the effectiveness of rivastigmine at improving post-

Dr. Robert Teasell

13. Perceptual Disorders pg. 4 of 66

13.1.1 Treatment of Perceptual Disorders

13. Perceptual Disorders pg. 5 of 66

Conclusions Regarding Treatment of Perceptual Disorders Post-Stroke

13.1.2 Family Participation

Table 13.1.2.1 Summary Studies Evaluating of Family Participation in Rehabilitation

13. Perceptual Disorders pg. 7 of 66

Conclusions Regarding Family Participation

13.2.1 Defining Neglect

13.2.2 The Incidence of Neglect Post Stroke

13. Perceptual Disorders pg. 8 of 66

13.2.3 Anatomical Substrates of Neglect

Figure 13.2.3.1 Lesion location and the resulting neglect.

13. Perceptual Disorders pg. 9 of 66

13.2.4 Spontaneous Recovery and Neglect

13.2.5 The Impact of Neglect Post-Stroke

13. Perceptual Disorders pg. 10 of 66

13.2.6 Screening and Assessments for Neglect

13. Perceptual Disorders pg. 11 of 66

Figure 13.2.6.1 Line Bisection Test.

Figure 13.2.6.2 Cancellation Test

13.3 Treatment of Neglect

13. Perceptual Disorders pg. 12 of 66

13.3.1 Visual Scanning

Cicerone et al. (2000) undertook a review of evidence-based cognitive rehabilitation to make

13. Perceptual Disorders pg. 13 of 66

Table 13.3.1.2 Summary of Studies Evaluating Visual Scanning for Neglect

13. Perceptual Disorders pg. 14 of 66

13. Perceptual Disorders pg. 15 of 66

13. Perceptual Disorders pg. 16 of 66

Conclusion Regarding Visual Scanning for Neglect

13.3.2 Computer-Based Rehabilitation

Table 13.3.2.1 Summary of Studies Evaluating Computer-based Rehabilitation

13. Perceptual Disorders pg. 17 of 66

13. Perceptual Disorders pg. 18 of 66

Conclusions Regarding Computer-Based Rehabilitation in Neglect

13.3.3 Activation Strategies

13.3.4 Limb Activation

13. Perceptual Disorders pg. 19 of 66

Table 13.3.4.1 Summary of Studies Evaluating Limb Activation Interventions

13. Perceptual Disorders pg. 20 of 66

Conclusion Regarding Limb Activation Treatment for Neglect

13.3.5 Sensory Stimulation Interventions

13. Perceptual Disorders pg. 21 of 66

Conclusions Regarding Sensory Stimulation Interventions

Electrical somatosensory stimulation may be a useful supplement to visual scanning training.

13. Perceptual Disorders pg. 22 of 66

Table 13.3.6.1 Summary of Studies Evaluating Feedback Strategies in Treatment of Neglect

13. Perceptual Disorders pg. 23 of 66

Visuomotor feedback strategies appear to be beneficial in the treatment of neglect.

13.3.7 Prism Treatment

Table 13.3.7.1 Summary of Studies Evaluating Prismatic Adaptation