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Neglect syndrome in post-stroke conditions: Assessment and treatment

(scoping review)

Article  in  International journal of rehabilitation research. Internationale Zeitschrift fur Rehabilitationsforschung. Revue internationale de recherches de readaptation · September 2020
DOI: 10.1097/MRR.0000000000000438

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Neglect syndrome in post-stroke conditions: assessment and
treatment (scoping review)
Ibolya Tavaszia, Alexandra Szilvia Nagya, Gabor Szaboa and Gabor Fazekasa,b
There is no consensus about the definition or most
effective treatment for neglect syndrome. The aim of
this review was therefore to evaluate the results of trials
that investigated different treatment methods for neglect
syndrome. A systematic literature search in PubMed and
Web of Science databases was performed to identify
studies that investigated the effects of neglect therapies.
Authors followed Preferred Reporting Items for Systematic
Reviews and Meta-Analyses statement. Studies were
selected by two assayers, and disagreement was resolved
by a third reviewer. The literature search identified 202
articles: 19 met the inclusion criteria and were included for
data extraction. Thirty-five different kinds of assessments
were used in these studies, and 17 treatment methods
were applied. Successful treatments were reported at
least in some parts of the assessments in 12 studies:
mirror therapy (in two trials), transcranial magnetic
stimulation, street crossing test in virtual reality, smooth
pursuit eye movement training, saccadic eye movement
therapy, direct current stimulation, eye patching therapy,
prism adaptation treatment, socially assistive pet-type
therapeutic robot (PARO), Kinesiological Instrument for
Introduction
Neglect syndrome was first described in case studies in
the late 1800s [1]. In this syndrome, attention is impaired
as a consequence of stroke, and as it is associated mostly
with lesions in the right hemisphere, although most left-
handed people could be an exception to that rule. There
has been no consensus about the definition of the syn-
drome till now because hemineglect is a multi-modular
deficit. It can affect one or more sensory modalities, man-
ifesting as visuo-spatial neglect. The most widely used
definition of neglect ‘is a description of the resulting
behavioural disabilities: fails to report or orient to novel
or meaningful stimuli presented to the side opposite a
brain lesion’ [2]. It is neither sole sensory disability nor
sole motor impairment. Visual, auditory, or tactile modal-
ities may also be affected. Several names have been used
to describe this syndrome, such as hemineglect, hemi-in-
attention, and unilateral spatial neglect. Some categories
have also been described, including visual neglect, motor
neglect, and tactile neglect.
‘Neglect is a condition that reduces a person’s ability to
look’ [2]. This has a negative impact, associated with ano-
sognosia and compound disabling effects of motor and
0342-5282 Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.
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Review article  1
Normal and Altered Reaching Movement robotic device
therapy, transcutaneous electrical nerve stimulation,
and optokinetic stimulation (the last two methods in the
same trial). No success was shown in seven trials, which
contained not only single treatments but combined ones
also. Authors concluded that there are no convincing
results for or against any of the different therapies
used for neglect syndrome. The quality of the trials is
questionable, and the numbers of included patients are
small in the trials. International Journal of Rehabilitation
Research XXX: 000–000 Copyright © 2020 Wolters Kluwer
Health, Inc. All rights reserved.
International Journal of Rehabilitation Research 2020, XXX:000–000
Keywords: assessment, neglect, neglect therapy, stroke
a
Department of Rehabilitation Post-Stroke, National Institute for Medical
Rehabilitation, Budapest and  bDepartment of Rehabilitation Medicine, University
of Szeged, Szeged, Hungary
Correspondence to Ibolya Tavaszi, MD, National Institute for Medical
Rehabilitation, Szanatorium str.19, H-1121 Budapest, Hungary
Tel: +36204985262; e-mail: tavaszi.ibolya@gmail.com
Received 27 April 2020 Accepted 18 August 2020
cognitive functions, thus limiting certain activities (lis-
tening, looking, and movement). Functional outcomes
affect activities of daily living, and because of that, qual-
ity of life could also be affected [3].
It is not easy to detect and describe the symptoms of
hemineglect, and this accounts for the equivocal inci-
dence in reporting (ranging from 8 to 90%). The reason
for underdiagnosis could be long-term outcome of these
symptoms, the type of assessments used, the rigour of
using them, the lack of strict definition of neglect, and
non-uniform standardisation of assessments. The varying
classification of these disabilities ‘increases the length of
hospital stay’, and it is a barrier to positive outcome [1].
Augmenting and prolonging neuroplasticity are central to
Coleman et al.’s view about management during the early
dynamic phase of stroke [4]. Rehabilitation programme
can be commenced immediately even if there is no
apperception, but it could be annoying for the patient. Is
there evidence for the commencement of rehabilitation?
[4] Can A Very Early Rehabilitation Trial, which tested
very early mobilisation, be useful for every patient at the
same period after stroke? These are pertinent questions
DOI: 10.1097/MRR.0000000000000438
2  International Journal of Rehabilitation Research  2020, Vol XXX No XXX
in the management of neglect also. Moreover, multiple
treatments are available, and researchers can make proto-
cols for using treatment combinations as a strategy, but no
protocol is better than others [1]. Probably these different
strategies can be useful in different phases of neglect and
for awareness of inattention.
Since the early 2000s, new methods have been developed
with the aim of improving the management of patients
post-stroke [5]. A group of these methods includes the
application of latest technology and uses sensory stimu-
lation to induce subjects to pay more attention. It helps
in reducing impairment and reaching better cognitive
rehabilitation. The numbers of such devices have been
growing [6].
The aim of this review was to identify the most fre-
quently used assessment tools and to evaluate the results
of trials that investigated different treatment methods for
neglect syndrome.
Methods
Databases and search strategy
A literature search was performed in the PubMed and
Web of Science databases on 13 January 2020.
The following four combinations of keywords were used
as inclusion criteria to extract data: stroke, neglect, robot;
stroke, neglect, physiotherapy; stroke, neglect, occupa-
tional therapy; stroke, neglect, mirror therapy. Articles
published between 1 January 2005 and 31 December
2019 in English were included. Eight exclusion crite-
ria were determined: not an original article (review, let-
ter, etc.), not aimed at neglect therapy, treatment done
in children (under the age of 18), drug trial, participants
were not only stroke patients, the number of subjects
in the experimental group was under 10, neglect was
an exclusion criterion in the trial, and lack of control
group. Authors applied Preferred Reporting Items for
Systematic Reviews and Meta-Analyses (PRISMA)
statement. The PRISMA flowchart (Fig. 1) was followed
for study selection.
PubMed had 130 such articles, and Web of Science had
114. After merging the two databases and excluding
duplications, 202 articles remained.
Study selection
In the first step, only the titles of the articles were exam-
ined by two reviewers (I.T. and A.S.N.) according to the
exclusion criteria. Disagreements were resolved by the
third reviewer (G.F.), and 112 articles were thus elimi-
nated. Then the abstracts of the remaining 90 articles
were screened using the same method, and 52 articles
were excluded. In the last step, the full texts of the
remaining 38 articles were screened in the same way, in
two rounds. On the basis of the full-text analysis, 19 pub-
lications remained altogether and were evaluated in the
Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
review (Table 1). PICO [P – Populations/People/Patient/
Problem, I – Intervention(s), C – Comparison and O –
Outcome] was applied to report the results of the studies
included in the scoping review (Table 1): involving post-
stroke Patients with neglect syndrome (time since onset,
number of subjects in different groups), Interventions
(treatments, duration of trial, assessments), Comparison
(study design), and Outcomes (results, follow up).
Results
Study characteristics
After the above described systematic selection pro-
cedure, 19 trials remained. All trials were prospective
except two that had a retrospective part as well. Most of
the studies were randomized controlled trial (RCT) (n
= 15), one was controlled but group allocation designed
trial, one was controlled with no described randomiza-
tion, one was a randomized trial with sham-controlled,
and one was a crossover variant. Four double-blind and
eight single-blind studies were detected. Blinding was
not defined in seven cases. The phase of stroke was dif-
ferent across studies. Most of the studies were done in
the acute or subacute phase (n = 17), in one case chronic
stroke patients were treated. One study did not strictly
identify time since stroke onset (time onset = more than
1 month) [21]. The experimental group was formed by
385 participants with neglect.
Thirty-five different kinds of assessments were used
altogether: neglect-specific assessments (n = 16), motor
functional assessments (n = 11), and the rest (n = 8). Ten
tools were used more than in only one study (Fig. 2). The
most relevant assessments of neglect seemed to be Star
Cancellation Test (SCT), Line Bisection Test (LBT),
and whole Behavioural Inattention Test (BIT): at least
one of them was measured in each audited/monitored
trial. Part of the BIT was measured in some studies, and
the incidence of these subtests was more than one in
some cases.
Duration of the treatment showed distinctness.
Widespread solutions were interpreted. Most of the tri-
als were 4–6 weeks long, and the therapy sessions lasted
20–60 minutes.
Results of individual studies
The most common types of the treatments used in these
studies are robotic and virtual reality (VR) training, elec-
trical stimulation, and visual scanning. Only two–two
studies were based on mirror therapy and transcranial
magnetic stimulation (rTMS).
Among 19 articles, 17 different types of treatment were
analysed. Totally successful treatments were found in
seven cases while partially successful results were found
in five trials. In these cases, only a part of the applied
assessment scales showed significant improvement in

Fig. 1
PRISMA flow diagram. PRISMA, preferred reporting items for systematic reviews and meta-analyses.
comparison with the other group(s). There was no dif-
ference between the control and experimental groups in
seven trials.
Six trials, which are approximately 30% of the total exam-
ined studies, had scheduled follow-up. Follow-up was
not scheduled in 14 cases, even though neglect has an
effect on long-term outcome.
In two studies, authors found significant improvement:
after 6 months’ follow-up in mirror therapy and after 1
month in left-hand somatosensory electrical stimulation
combined with visual scanning training (VST).
There was no difference in test results at the end of the
treatment and at 1 or 2 weeks or a month after follow-up
test in four of six follow-up sessions. Five kinds of exper-
imental groups were recorded in these four trials. At
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Neglect post-stroke Tavaszi et al. 3
follow-up, two of them showed significant improvement
from the baseline assessment, and both studies were
conducted in the acute phase of stroke. Another study
described a short-term follow-up.
At follow-up assessments, 11 neglect tools were used:
SCT, picture identification task, auditory midline, para-
graph reading, single-digit cancellation and double-digit
cancellation post-test, Line Crossing tests, the task of
reading letters aloud, figure copy, freehand drawing, and
LBT (in one article, perceptual line bisection and motor
line bisection were measured apart, but only that study
made this kind of distinction between them).
Synthesis and analysis of results
In 12 trials, one kind of therapy was compared to the
control group receiving conventional treatment or sham
 Table 1  Characteristics of reviews (n = 19)

Number of subjects
First author with neglect in Number of subjects in control
(publication experimental group(s)/task(s) for control
year) Design Time since onset group(s) group(s) Duration of trial Assessments Results Follow-up

Cha and Kim RCT Experimental group: 4.4 n = 10 n = 10; sham magnetic 5 days/week for 4 weeks MVPT, LBT, AT, SCT Experimental group significant No
(2015) [7] ± 0.2 weeks; Control stimulation and comprehensive increase: MVPT, LBT, AT, and
group: 4.9 ± 0.3 weeks rehabilitation therapy SCT compared with the preinter-
vention values
rTMS (10 minutes) and Control group significant increase:
conventional rehabilita- MVPT, LBT, and AT compared
tion therapy (30 minutes) with the preintervention results
with 10-minute rest
A significant difference in the
post-training: MVPT; LBT, AT,
and SCT between the experi-
mental group and the control
group
Chan and RCT Experimental group: mean, n = 20 n = 20; standard rehabilitation 3 days/week for 4 weeks Modified Barthel Index, Experimental group: no significant No
Man 20.10 day; SD, 15.77. services only: General physical MMSE, BIT-CT, CBS difference: MMSE
(2013) [8] Control group: mean, training (preservation and res-
11.90 day; SD, 6.36. toration of range of motion and
the rehabilitation of functions in
the upper extremities) and self-
care and cognitive training
Visual scanning program Significant in MBI, CBS, BIT-CT
(45 minutes/day) and between the pre-test and
occupational therapy (60 posttest phases
minutes) and physical
4  International Journal of Rehabilitation Research  2020, Vol XXX No XXX

therapy (60 minutes)

Control group significant increase:
MMSE, MBI, and BIT
Significant decrease: CBS
Between groups: no significant
improvement: CBS, BIT-CT, MBI,
MMSE
Choi et al. RCT Experimental group: mean, n = 20 n = 18 5 days/week for 3 weeks MVPT-3, LBT, SCT, AT, CBS, Both groups showed significant No
(2016) [9] 37.4 days. Control group: MMSE, K-MBI improvements in: MVPT-3, LBT,
mean, 37.9 days SCT, AT, the CBS, MMSE, and
the K-MBI
VST and range of motion Left upper limb training The changes in all measure-
exercises with upper limb rehabili- ments showed no significant
tation robot (NEURO-X) differences between the two
(30 minutes) groupsThe changes in all meas-
urements showed no significant
differences between the two
groups
continue

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 Table 1 (Continued)

Number of subjects
First author with neglect in Number of subjects in control
(publication experimental group(s)/task(s) for control
year) Design Time since onset group(s) group(s) Duration of trial Assessments Results Follow-up

Dohle et al. RCT Not more than 8 weeks n = 11 n = 9; patients had direct view 5 days/week for 6 weeks Fugl–Meyer subscores for the Not significant: any of the 3 motor No
(2009) after stroke of the affected arm. They had upper extremity, ARAT, FIM subscores, across all patients
[10] to move their affected limb ‘as
well as possible’
Mirror therapy (30 minutes) Significant: nonmotor symptoms,
surface sensibility (light touch)
difference between the 2 treat-
ment groups
Significant improvement in neglect
score: greater in MT group than
in CT group
Fong et al. RCT sin- Within 8 weeks post-stroke. n = 39; two types n = 15; conventional occupational5 days/week for 30 days MMSE, BIT, CDT, FIM-MM No significant differences Insignificant:
(2007) gle-blinded Average (SD) time: 11.9 of experimental therapy (training in ADL (15 between groups in functional the results of
[11] (7.3) days groups: TR group minutes) and in hemiplegic performance and neglect comparison
(n = 19); TR + EP upper extremity (45 minutes) measures at day 30 for all groups
group (n = 20) with the same contact time
during the intervention period)
TR group: daily experimen-
tal training in voluntary
trunk rotation (60
minutes)
TR + EP group: voluntary
trunk rotation with half-
field eye-patching (60
minutes)
Hreha et al. RCT, time ran-Time b/w stroke and n = 13 n = 13; standard occupational 5 days/week for 2 weeks CBS via KF-NAP, 2 subtest of Both groups: improved spatial no
(2018) domization: admission (median days; therapy (not including PAT) BIT: SCT, LBT. FIM, WMFT, neglect and motor function (FIM)
[12] prospective inter quartile range): MAL. GENEActiv Original
intervention treatment group, 6 days accelero-meter
-retrospek- (4–14); control group, 5
tive control days (4–5)
Prism adaptation treatment Treatment group: greater improve-
(60 times or until 20 ment on two subtests of spatial
minutes) function (BIT)
PAT improve spatial neglect func-
tion more in paper and pencil
measure
Significance depends on the
assessment
Karner et al. RCT Within the previous 3 n = 21 n = 18. A book was given to the 3 days/week for 2 weeks Cancellation test, Cats test, B/w 2 groups significant improve- 2-week
(2019) months. Time after stroke: patient to see and grasp. The LBT, SINGER ment in: Cats test in PARO follow-up:
[13] PARO group, mean = patient then read aloud from group at the follow up too. T1 may be too
49.24 (SD 29.12); con- the book and T2: improved hemineglect: short to see
trol group, mean = 55.17 and subcategory of cognitive any further
(SD 22.75) abilities in the PARO group. effects
No significant difference: LBT
and subcategories of self-care,

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mobility, and communication
PARO robot device therapy Significance depends on the
(30 minutes) assessment
continue
Neglect post-stroke Tavaszi et al. 5
 Table 1 (Continued)

Number of subjects
First author with neglect in Number of subjects in control
(publication experimental group(s)/task(s) for control
year) Design Time since onset group(s) group(s) Duration of trial Assessments Results Follow-up

Katz et al. Controlled The mean time since stroke n = 11 n = 8; computer-based VST. The 3 days/week for 4 weeks FIM, Star cancellation from USN: Star cancellation: not sig- no
(2005) trial; rand- onset until beginning of timing of the control group (BIT), Mesulam Symbol nificant. Mesulam Cancellation:
[14] omization the intervention were 47.9 computer scanning training Cancellation test, VR street mean difference not significant
was not days (SD: 21.3) and 35.6 protocol was identical crossing test, Real street b/w groups. The percent twice
described days (SD: 10.0) days in crossing test as large for the VR group than
the experimental and con- in control group. ADL significant
trol groups, respectively improvement: both groups pre-
to post-test and difference b/w
groups
Computer desktop-based VR street crossing significant
VR street crossing improvement: VR group and
training (45 minutes for a difference b/w 2 group’s mean
total of 9 h)
Real street-crossing: no significant
difference
Significance depends on the
assessment and therapy
Kerkhoff et RCT ≥1 month. Months since n = 24 n = 21 VST group: systematically Consecutive 5 days/week Single and Double Cancellation The SPT group: significant No significant
al. (2013) stroke (mean, median): scanning static stimuli with for 6 weeks tasks, Paragraph reading, improvements in all visual meas- difference 2
[15] VST, mean = 5.24 eyes visuoperceptual and Motor ures and normal performance in weeks after
(1–34), Mdn=3; SPT: LBT, Auditory midline the auditory midline post-test to
mean = 3.58 (1–10), follow up.
Mdn = 3 Significant
difference
b/w baseline
6  International Journal of Rehabilitation Research  2020, Vol XXX No XXX

and follow up
in all tests
SPT: smooth pursuit eye Visual and auditory neglect impair-
movements (60 minutes) ments: no significant change
and occupational therapy after VST
and physiotherapy
Kim et al. Randomized rTMS group: 7–45 days; n = 30; three types Three experimental groups were 5 days/week for 2 weeks MVPT-3, LBT, SCT, AT, CBS, All groups significant improve- No
(2018) trial Robot group: 7–55 days; of experimental compared; each group received MMSE, K-MBI ment: MVPT-3, LBT, SCT, CBS,
[16] Combined group: 6–35 groups: rTMS some kind of experimental MMSE, and K-MBI
days. (n = 10); Robot treatment
group (NEURO-X
system) (n = 10);
Combined group
(n = 10)
rTMS group: rTMS (30 No significant difference among
minutes) and conven- groups
tional neglect therapy
Robot group: robot therapy
(30 minutes) and con-
ventional neglect therapy
Combined group: robot
and rTMS therapy (30
minutes) and conven-
tional neglect therapy

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continue
 Table 1 (Continued)

Number of subjects
First author with neglect in Number of subjects in control
(publication experimental group(s)/task(s) for control
year) Design Time since onset group(s) group(s) Duration of trial Assessments Results Follow-up

Pandian et RCT inter- <48 h of stroke onset n = 27 n = 21; Similar exercises for the 5 days/week for 4 weeks SCT, LBT, PIT, FIM, mRS Improvement was seen in the MT group:
al. (2014) ventional, same time period as treatment primary outcome measures Improvement
[17] PROBE group, but they used the during follow-up in patients who in SCT over
non-reflecting side of the mirror received MT compared to the 6 months
control group was greater.
Similarly, in
PIT and LBT
Mirror therapy (60 minutes) The overall differences were also
seen in the SCT, LBT, and PIT in
the treatment group
Park et al. RCT <6 months. Experimental n = 16 n = 17; cyclic electrical stimula- 5 days/week for 6 weeks LBT, SCT, CBS Experimental group showed a sig- No
(2015) single-blind group: 3.3 ± 1.3 months tion on the neglect side plus nificant improvement in the LBT,
[18] after stroke; Control conventionnal occupationnal CBS, and SCT scores
group: 3.5 ± 1.6 months and physical therapy
after stroke
Mental practice combined Control group: no significant differ-
with electro-myo- ence, except in the LBT score
gram-triggered electrical
stimulation on the
neglected side (2 × 30
minutes); plus conven-
tional occupational and
physical therapy
No significant differences: LBT,
CBS, and SCT scores between
the two groups after treatment
Polanowska RCT dou- The time b/w stroke and n = 20 n = 20; VST with sham 5 days/week for 4 weeks From BIT test: Line crossing Group C had significantly better Significant
et al. ble-blind enrolment in the study stimulation and SCT. Task of reading performance than group E in improvement
(2009) trial ranged from 2 to 12 letters aloud scanning accuracy. The differ- in group E
[19] weeks (average = 45.5 ence in scanning range was not than in
days) significant group C
Group E received
conventional VST with
electrostimulation (45
minutes)
Schröder et RCT Less than 90 days n = 20 n = 10 5 days/week for 4 weeks NET: LCT, SCT, LBT, figure Control group: no improvement on No signify-cant
al. (2008) copy, freehand drawing both NTs in reading and writing change in
[20] performance all groups
b/w the end
of therapy
and 1-week
follow-up
Two types of exper- Received only standard TENS group: TENS TENS and OKS: significant TENS and OKS
iment-tal groups: exploration training (100 Hz) and exploration improvements in both sets group had
TENS group (n = training (25–40 minutes) significant
10); OKS group improvement
(n = 10) from the

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baseline
OKS group: OKS by Significant improvement in both
computer program and treatments: reading and writing
exploration training (still present upon retesting 1
Neglect post-stroke Tavaszi et al. 7

(25–40 minutes) week after the end of therapy)

continue
 Table 1 (Continued)

Number of subjects
First author with neglect in Number of subjects in control
(publication experimental group(s)/task(s) for control
year) Design Time since onset group(s) group(s) Duration of trial Assessments Results Follow-up

Semrau et Controlled, Average of 18 days after n = 35. n = 84 from community. Same task as control BIT, Robotic measure of kin- Neglect group significantly No
al. (2015) group stroke. Median = 10 Participants completed 6 group but KINARM aesthetic function (KINARM different from S3 group and S2
[21] allocation days; range = 1–112 movements in 6 possible moved the affected robotic exoskeleton), FIM, group on the majority of clinical
design days after stroke pseudo-randomized directions arm, and participants CMSA-Arm and Hand measures (S2: stroke partici-
for 36 trials with KINARM matched with their less Impairment Inventory, PPB pants who scored 136–140 of
affected/unaffected arm BIT = passing with some errors;
S3: stroke participants who
scored 141–146 of BIT = pass-
ing score with few or no errors)
Seniów et RCT: 3 weeks to 6 months n = 14 n = 15 5 days/week for 3 weeks Screening test (Addenbrooke’s Study did not provide evidence of No
al. (2016) sham-con- Cognitive Examination the effectiveness of TENS plus
[22] trolled – Revised) Barthel Index, VST during early rehabilitation
study, BIT, Line Crossing, Letter
double-blind Cancellation, SCT, Figure
and Shape Copying, LBT,
Representational Drawing
VST and sham electric stimulation VST (45min.) and in the Patients achieved significant
first 30 minutes of VST+ improvement in neglect signs
TENS. post-treatment versus at base-
line, but this can be attributed to
early stage of recovery
Differences b/w control and experi-
mental groups: not significant
Sunwoo et Crossover The mean length of time n = 10 n = 10 3 tDCS sessions rand- LBT, SCT Significant interaction b/w time No
8  International Journal of Rehabilitation Research  2020, Vol XXX No XXX

al. (2013) dou- since stroke was 27.8 ±
[23] ble-blind 60.4 months
study
Tsang et al. RCT sin- The average time between
(2009) gle-blind, stroke onset and admis-
[24] with a sion to the programme:
pre-test- Control group, 21.50
post-test (SD = 21.67) days;
control and intervention group, 22.18
intervention (SD = 15.87) days
omized order: and tDCS mode: dual tDCS had
a stronger effect than the single
or sham stimulation modes. SCT
did not show any significant
change. LBT: significant improve-
ments were observed after both
dual- and the single-mode tDCS
but not after sham stimulation
Self-control I. Dual-mode (anodal tDCS Significance depends on
posterior parietal cortex assessments
and cathodal over the
left PPC) (20 minutes)
II. Single-mode (anodal
tDCS over the right
PPC) (20 minutes)
III. Sham mode (20
minutes)
n = 17 n = 17 5 days/week for 4 weeks BIT, FIM Right half-field EP group had No
significantly higher BIT than
those treated with conventional
treatment

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group
design

continue
 Table 1 (Continued)

Number of subjects
First author with neglect in Number of subjects in control
(publication experimental group(s)/task(s) for control
year) Design Time since onset group(s) group(s) Duration of trial Assessments Results Follow-up
Conventional occupational ther- Conventional occupational No significant difference: FIM b/w
apy training without EP therapy (60 min)) with patients in both groups
modified right half-field
EP
Significance depends on the
assessment
van Wyk et RCT, Within 1 and 3 weeks n = 12 n = 12 5 days/week for 4 consec- King-Devick Test, SCT, Significant difference: King-Devick No
al. (2014) matched- post-stroke utive weeks Barthel Index Test, SCT and Barthel Index.
[25] pair Therefore intensive saccadic
eye movement training with
VSE integrated with task-
specific activities has a signifi-
cant effect on USN in patients
post-stroke
Task-specific activities Saccadic eye movement
training with VSE
integrated with task-
specific activities (45
minutes)
ADL, activities of daily living; ARAT, Action Research Arm Test; AT, Albert Test; b/w, between; BIT, Behavioural Inattention Test; BIT-CT, Behavioural Inattention Test – Conventional subtest; CBS, Catherine Bergego Scale; CDT,
Clock Drawing Test; CMSA, Chedoke-McMaster Stroke Assessment; CT, control therapy; EP, eye-patching; FIM, Functional Independence Measure; FIM-MM, Functional Independence Measure – Motor Measure; HC, healthy
control; KF-NAP, Kessler foundation neglect assessment process; KINARM, Kinesiological Instrument for Normal and Altered Reaching Movement; K-MBI, Korean version of Modified Barthel Index; LBT, Line Bisection Test;
LCT, line cancellation test; MAL, motor activity log; Mdn, median; MMSE, Mini-Mental State Examination; mRS, modified Rankin Scale; MT, mirror therapy; MVPT, Motor-Free Visual Perception Test; MVPT-3, Motor-Free Visual
Perception Test 3rd edition; OKS, optokinetic stimulation; PAT, Prism adaptation treatment; PIT, picture identification task; PPB, Purdue Peg Board; PPC, posterior parietal cortex; PROBE, prospective, open, blinded endpoint;
RCT, randomized controlled trial; rTMS, repetitive transcranial magnetic stimulation; SCT, Star Cancellation Test; SINGER, Scores of Independence Index for Neurological and Geriatric Rehabilitation; SPT, smooth pursuit
training; tDCS, transcranial direct current stimulation; TENS, transcutaneous electrical nerve stimulation; TLT, Thumb Localizing Test; TR, trunk rotation; USN, Unilateral Spatial Neglect; VR, Virtual Reality; VSE, visual scanning
exercise; VST, visual scanning training; WMFT, Wolf motor function test.

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Neglect post-stroke Tavaszi et al. 9
10  International Journal of Rehabilitation Research  2020, Vol XXX No XXX

Fig. 2

The most frequently used assessments in neglect trials.

therapy. Significant improvement was detected with the other trials, there was no significant difference between
following treatments: rTMS, mirror therapy (in two tri- the groups.
als), transcutaneous electrical nerve stimulation (TENS)
and optokinetic stimulation (OKS) (in the same trial), Discussion
Kinesiological Instrument for Normal and Altered This review included neglect-specific studies done in the
Reaching Movement robotic device treatment, and sac- last 15 years, comparing several types of neglect treat-
cadic eye movement. Two of these trials also showed ments. Generally, authors came to similar conclusions as
significant improvement after follow-up: mirror therapy other reviews in this field [1,2,4].
and TENS plus OKS. Four studies showed partially suc-
The number of subjects who were involved in the trials
cessful results: prism adaptation treatment, PARO robotic
was mostly small: close to half of the studies had less than
device therapy, transcranial direct current stimulation
20 patients in the experimental groups, and the highest
(tDCS), and eye-patching treatment (used alone). In two
number was only 35. This is similar to what was observed
trials, no success was reported with VST and voluntary
by Coleman et al. in 2017. Most studies were pilot studies
trunk rotation.
or single-centre trials.
In seven articles, different types of treatments were com-
To give an overview of cognitive rehabilitation, authors ana-
pared. Different experimental groups (somatosensory
lysed a study designed by Lee and Cha, which recruited an
electrostimulation, smooth pursuit eye movements, VR
acceptable number of subjects in every respect. However,
street crossing training, Neuro-X robotic training, and
inclusion and exclusion criteria were not very well defined.
TENS) were compared with VST five times. In one
Assessments were also not very objective because the
case, cyclic electrical stimulation versus mental practice
authors considered only cognitive functions, only motor
plus electromyogram-triggered electric stimulation were
functional tests and Mini-Mental State were used.
investigated. In another case, repetitive rTMS versus
However, studying a subgroup of patients with neglect
Upper Limb Rehabilitation Robot (Neuro-X) System
could be useful for adumbrating the broader subject of cog-
were compared to each other and to combination treat-
nitive rehabilitation because this kind of cognitive condi-
ment involving the two. Successful results were reported
tion can reduce the ability of the participant [26].
only in one trial: smooth pursuit eye movement proved to
be superior to VST, and the results were maintained also The quality of the studies is important because it deter-
at follow-up. In another trial, VR was reported partially mines the reliability of a piece of evidence, but most of
(not in all assessments) more successful than VST. In the the studies were not classified.

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Restrictions of the trials in this field
Rehabilitation is done in the acute–subacute phase of
stroke, and brain plasticity also is present at that time.
Rehabilitation programme could be started immediately
even if there is no apperception. If rehabilitation starts
too early (up to 2 weeks after stroke), it may be effective
according to Coleman et al. settled in 2017, but focussing
on the therapy may be difficult and too intensive for the
patient in that period.
Another reason for the lack of high-quality evidence
could be that in the chronic phase, brain plasticity is
complete or reaches a plateau. Researchers should bring
these categories closer for better results, and for better
cost-benefit ratios. Although the effectiveness of neglect
rehabilitation is unclear, paying attention could be the
key to those studies that have significant effect [2]. This
limitation was described 7 years before this review but
nothing has changed during this period and authors found
the same problem: for example, poor quality of evidence.
The main goals of neglect studies should be in reducing
disabilities and improving independence [2].
Authors could make proposals for conducting studies
in better ways but most of the suggestions had limita-
tions. For example, functional MRI and PET studies are
expensive, and they have a functional limitation as well.
Trials with EEG seem to be a promising alternative, but
the use of EEG for studying neglect is far away yet.
Limitations of this review
Conventional treatment did not have the same meaning
in all the trials. In Choi’s trial, VST was used as conven-
tional therapy, while Chan used this kind of treatment
in the experimental group. Authors resolved this dis-
crepancy by considering VST as an experimental ther-
apy. Similar solution was applied to Katz’s, Kerkhoff’s,
Polanowska’s, and Seniów’s studies.
There are too many unknown and individual factors in
the subject of neglect. Several types of disabilities could
appear (cognitive, behavioural, visual, sensory, and motor)
[1], and assessments are not standardised in any case. No
standardisation is available even now for the settings in
which trials are conducted, and this makes it hard to com-
pare them in authors’ opinion. This may be the reason
why some unusual assessments are not considered sensi-
tive enough for making objective comparison.
Follow-ups are essential, especially longer ones; how-
ever, most of the studies did not follow-up participants
for re-assessment. It is high time to adopt a policy for
high-quality methodological design.
The main limitation of this review is the quality of arti-
cles. Most studies were not classified, nor did they pro-
vide enough information for making the usually used
classifications of quality. The lack of systematic risk of
bias assessment made categorisation more difficult.
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Neglect post-stroke Tavaszi et al. 11
Conclusion
During analysis of the trials, the authors found certain
good ideas, but the selected participants, goals, and design
of some trials did not allow clear evidence; for example,
some trials used treatments that are not neglect-specific,
while others lost a lot of patients due to dropout.
Considering the heterogeneity of neglect trials, authors
consider that standardisation of assessments and pro-
cedures would be useful for facilitating comparisons
between studies and improving the quality of trials.
This kind of homogeneity would be useful for creating
high-quality scientific information in line with decreas-
ing the limitations of reviews, improving the submissions
of not only scoping reviews but also systematic reviews.
Thereby, improving the quality of future scientific stud-
ies [27].
The following are recommendations for methodology of
neglect studies:
(1) study design: prospective randomized control trial;
(2) time since onset of stroke: 2 weeks to 3 months;
(3) clarification of the control groups’ tasks (conventional
and sham therapy) – conventional here means that
the method was not used as treatment in the last
decade;
(4) one experimental group preferably;
(5) at least 20 patients with neglect syndrome in the
experimental group;
(6) duration of trial: 4–5 times per week for at least 4
weeks;
(7) strongly suggested neglect-specific assessments:
SCT, LBT, and BIT (because these are the most fre-
quently used ones—BIT would also be useful, but it
has a lot of parts);
(8) results should determine significance between the
control and experimental groups;
(9) follow-up is necessary after at least 3 months, but 6
months would be better.
Future studies are needed for effective application of
cognitive rehabilitation.
Acknowledgements
This work was supported by the Hungarian Scientific
Research Fund (OTKA) – 2017–2021 (Project No. K
125263).
Conflicts of interest
There are no conflicts of interest.
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