1931
ORIGINAL ARTICLE
Hemispatial Neglect and Rehabilitation in Acute Stroke
Toby B. Cumming, PhD, Prudence Plummer-D’Amato, PhD, Thomas Linden, PhD, Julie Bernhardt, PhD
ABSTRACT. Cumming TB, Plummer-D’Amato P, Linden
T, Bernhardt J. Hemispatial neglect and rehabilitation in acute
stroke. Arch Phys Med Rehabil 2009;90:1931-6.
Objectives: To compare 2 methods for determining neglect
in patients within 2 days of stroke, and to investigate whether
early neglect was related to rehabilitation practice, and whether
this relationship was affected by an early, intensive mobiliza-
tion intervention.
Design: Data were collected from patients participating in a
phase II randomized controlled trial of early rehabilitation after
stroke.
Setting: Acute hospital stroke unit.
Participants: Stroke patients (N⫽71).
Intervention: The 2 arms of the trial were very early mo-
bilization (VEM) and standard care (SC).
Main Outcome Measures: Neglect was assessed using the
Star Cancellation Test and the National Institutes of Health
Stroke Scale (NIHSS) inattention item within 48 hours of
stroke onset, and therapy details were recorded during the
hospital stay.
Results: Assessing neglect so acutely after stroke was dif-
ficult: 29 of the 71 patients were unable to complete the Star
Cancellation Test, and agreement between this test and the
NIHSS measure was only .42. Presence of neglect did not
preclude early mobilization. SC group patients with neglect
had longer hospital stays (median, 11d) than those without
neglect (median, 4d); there was no difference in length of stay
between patients with and without neglect in the VEM group
(median, 6d in both).
Conclusion: Early mobilization of patients with neglect was
feasible and may contribute to a shorter acute hospital stay.
Key Words: Perceptual disorders; Rehabilitation; Stroke.
© 2009 by the American Congress of Rehabilitation
Medicine
ANY FACTORS INFLUENCE physical recovery after
M stroke. One prominent prognostic factor is hemispatial
neglect (referred to hereafter simply as neglect). Up to three
quarters of patients with acute stroke have signs of neglect,
with a greater incidence after right hemisphere stroke.1 Neglect
persists in a substantial proportion of people with stroke. For
example, Linden et al2 reported that 15% of stroke patients had
From the National Stroke Research Institute (Cumming, Linden, Bernhardt), La
Trobe University (Bernhardt), Melbourne, Australia; and Department of Physical
Therapy, Northeastern University, Boston, MA (Plummer-D’Amato).
Supported by the National Heart Foundation of Australia (grant no. G 04M 1571),
Affinity Health, an equipment grant from the Austin Health Medical Research Fund,
and by a National Health and Medical Research Council (Australia) fellowship (no.
157305).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Correspondence to Toby B. Cumming, PhD, NSRI, 300 Waterdale Rd, Heidelberg
Heights, Victoria, Australia, 3081, e-mail: tcumming@nsri.org.au. Reprints are not
available from the author.
0003-9993/09/9011-00271$36.00/0
doi:10.1016/j.apmr.2009.04.022
neglect at 20 months poststroke. It is often associated with a
lesion of the parietal lobe (particularly on the right), but neglect
can occur after a unilateral lesion to any one of a diverse range
of brain structures.3-5 Behaviorally, neglect is characterized by
a failure to report, orient to, or respond to events in the
contralesional side of space (more often the left side).
Neglect after stroke has a significant negative impact on
functional outcome, both as an independent factor and in
connection with other variables.6 For example, Nys et al7 found
that neglect in the first 3 weeks after stroke was an important
predictor of functional impairment at 8 months poststroke.
Poor functional recovery in stroke patients with neglect may be
at least partially explained by suboptimal management and
reduced opportunities for rehabilitation. Kalra et al8 reported
that patients with neglect took longer to recover than other
stroke patients with comparable stroke pathology and severity
of motor impairment. Patients with neglect had more therapy
input and stayed longer in the rehabilitation unit than patients
without neglect. These comparisons, however, were not ad-
justed for important confounding variables such as stroke se-
verity. The influence of neglect on stroke rehabilitation prac-
tices, particularly in the acute setting, is yet to be determined.
Given the well-documented impact of neglect on functional
recovery after stroke, it is important, from both a clinical and
a research perspective, to assess neglect in stroke survivors.
Assessment, however, is not straightforward: because neglect
has a wide range of clinical presentations, no single test can be
used to identify it in all patients.9 There are at least 28 stan-
dardized tools to evaluate unilateral spatial neglect,10 including
traditional “pencil and paper” tests as well as a range of
standardized functional assessments of neglect behavior, such
as the Behavioral Inattention Test,11 the Semi-structured Scale
for Functional Evaluation of Hemi-inattention,12 and the
Catherine Bergego Scale.13 One of the major issues with cur-
rent test procedures is their inability to differentiate between
sensory and motor neglect.14 Evaluating neglect in the first few
days after a stroke presents its own difficulties, including
problems with aphasia (inability to comprehend the task) and
apraxia (inability to use a pen or pencil), and some tests may be
more appropriate than others in this setting.
Our research group is interested in studying the effect that
commencing physical rehabilitation very early (⬍24h) after
stroke has on functional outcome. The challenge for our team
was to identify a simple and valid measure of neglect that could
be used in the acute stage of stroke, and thus provide a
preintervention baseline measure. Our first aim was to evaluate,
in the context of a phase II randomized controlled trial, the
feasibility of using the Star Cancellation Test11 and an obser-
vational assessment of inattention from the NIHSS15 to identify
List of Abbreviations
AVERT A Very Early Rehabilitation Trial
mRS modified Rankin Scale
NIHSS National Institutes of Health Stroke Scale
SC standard care
VEM very early mobilization
Arch Phys Med Rehabil Vol 90, November 2009
1932 NEGLECT IN ACUTE STROKE REHABILITATION, Cumming
people with neglect in the first 48 hours after stroke, and to
investigate the agreement between these 2 assessments. The
NIHSS is widely used in the acute setting to characterize stroke
severity. It is not known whether neglect diagnosed using this
assessment scale is in accord with a more traditional and
sensitive measure of neglect, such as the Star Cancellation
Test. A second aim was to investigate whether neglect in the
acute phase of stroke was related to rehabilitation practice and
outcomes, including measures of time to first out-of-bed epi-
sode (mobilization), minutes of therapy per day, and length of
hospital stay. The third aim was to determine whether early
neglect was associated with longer-term outcome: death and
disability at 12 months poststroke. We hypothesized that (1)
agreement between the 2 assessments of neglect would be
good; (2) patients with neglect in the SC group would have a
longer delay to first mobilization, less therapy, and a longer
hospital stay than those without neglect, but that no such
differences would be found in the group managed using a
specified early and intensive rehabilitation protocol; and (3)
early neglect would be related to 12-month death and disabil-
ity. This study was not designed to test the effect of rehabili-
tation on neglect or to evaluate change in neglect over time.
Neglect was assessed at a single time point only to allow us to
adjust for this important prognostic factor within the phase II
trial.
METHODS
Data reported in this study were collected as part of AVERT.
This was a prospective, phase II, randomized controlled trial
that included blinded outcome assessment and intention-to-
treat analysis. AVERT was designed to test the safety and
feasibility of initiating out-of-bed activity very early after
stroke. Methods have been reported in detail elsewhere16 and
are summarized below.
Participants
Patients were included if they were older than 18 years, had
a confirmed stroke, satisfied physiologic limits (blood pressure,
heart rate, oxygen saturation, temperature), and arrived at the
hospital and consented within 24 hours of symptom onset.
Patients were excluded if they had a premorbid mRS score
greater than 3 (indicating disability), deteriorated within the
first hour of admission, required palliative care, had a concur-
rent, progressive neurologic disorder, or had an acute coronary
syndrome, severe heart failure, or lower limb fracture that
prevented mobilization. Of the 315 stroke patients screened
during open recruitment, 56 (18%) were recruited, 180 (57%)
failed to meet the inclusion criteria (most of these patients
reached the hospital more than 24 hours after stroke symptom
onset), and 79 (25%) arrived outside recruitment hours or were
enrolled in another clinical trial. To limit imbalance in stroke
severity, open recruitment was stopped, and only patients with
moderate or severe stroke were recruited (the final 15 patients).
A participant flowchart is shown in figure 1.
Procedure
Patients were recruited from the acute stroke units of 2 large
hospitals in Melbourne, Australia. The ethics committees of
both hospitals approved the study. If a patient agreed to par-
ticipate, informed consent was obtained from them or from
their representative. Patients were told they would be given 1
of 2 different types of rehabilitation—A or B. Computer-
generated blocked randomization procedures (block size 6) and
concealment with opaque envelopes were used to allocate
patients to either the VEM group or the SC group. Random-
Arch Phys Med Rehabil Vol 90, November 2009
Fig 1. Participant flowchart (*315 stroke patients were screened
during open recruitment; open recruitment was then stopped to
limit imbalance in stroke severity, and only patients with moderate
or severe stroke were recruited [the final 15 patients]).
ization was stratified by stroke severity on the NIHSS to help
balance mild (0 –7), moderate (8 –16), and severe (⬎16) pa-
tients across the VEM and SC groups within each site.
Intervention
Both VEM and SC groups received standard care from ward
therapists and nursing staff in the stroke unit (for more details,
see Bernhardt et al16). Patients randomly assigned to the VEM
group began mobilization as soon as practical after recruitment,
with the goal of first mobilization within 24 hours of stroke
symptom onset. The VEM group received additional mobili-
zation with the aim of assisting patients to be upright and out
of bed at least twice a day, thereby doubling the standard dose
previously identified.17 VEM was delivered by a nurse and
physiotherapist team for the first 14 days poststroke or until
discharge (whichever was sooner). The amount and timing of
all therapy delivered, to both SC and intervention groups, was
recorded on personal digital assistants. Occupational health and
safety procedures for manual handling of patients were main-
tained at all times. The intervention protocol included physio-
logic monitoring of blood pressure, heart rate, oxygen satura-
tion, and temperature before each mobilization in the first 3
days poststroke.
Neglect
Neglect within the first 48 hours of stroke was identified
using 2 methods: (1) the inattention item of the NIHSS and (2)
the Star Cancellation Test. Instructions for the NIHSS state that
“neglect can often best be detected by general observation
throughout the examination. In addition to general observation,
the patient is tested with visual double simultaneous stimula-
tion (performed during the visual field item of the NIHSS) and
double simultaneous cutaneous stimulation of both upper limbs
and lower limbs.” A trained and accredited clinician performed
all testing using the NIHSS. Patients were assigned a score
from 0 to 2: 0 for no abnormality; 1 for visual, tactile, auditory,
spatial, or personal inattention or extinction to bilateral simul-
taneous stimulation in one of the sensory modalities; and 2 for
profound hemi-inattention or extinction to more than one mo-
dality, does not recognize own hand, or orients to only one side
 NEGLECT IN ACUTE STROKE REHABILITATION, Cumming 1933

Table 1: Baseline Characteristics for Patients in the VEM and Mann-Whitney U tests were used to test for within-group
SC Groups differences on each of the rehabilitation practice and outcome
Characteristics VEM (n⫽38) SC (n⫽33) variables: time to first out-of-bed episode (mobilization), min-
utes of therapy per day, and length of hospital stay. Z tests were
Age (y) 74.6⫾14.6 74.9⫾9.8
used to test interactions between neglect status and group on
Sex (M) 22 (58) 16 (48)
each of these variables (analogous to Altman and Bland19).
Previous stroke 11 (29) 7 (21)
Logistic regression analyses were used to determine whether
Diabetes 11 (29) 4 (12)
neglect was an important prognostic factor for discharge des-
Stroke type*
tination and for functional outcome (mRS) at 12 months.
TACI 10 (26) 6 (18)
PACI 13 (34) 10 (30) RESULTS
POCI 7 (18) 5 (15)
LACI 5 (13) 6 (18) Baseline Characteristics
ICH 3 (8) 6 (18)
NIHSS 9.5 (5–18) 8 (4–12)
Baseline characteristics for the 71 stroke patients are pre-
Mild 15 (39) 15 (45)
sented in table 1. None of the differences between groups were
Moderate 13 (34) 11 (33)
statistically significant.
Severe 10 (26) 7 (21)
Neglect
Neglect 20 (53) 19 (58)
Of the 71 patients, 70 were assigned a score for unilateral
NOTE. Values are mean ⫾ SD, n (%), or median (IQR). neglect on the NIHSS item (missing data for 1 subject), and 42
Abbreviations: ICH, intracerebral hemorrhage; IQR, interquartile were assessed using the Star Cancellation Test. Twenty-nine
range; LACI, lacunar infarct; M, male; PACI, partial anterior circula-
tion infarct; POCI, posterior circulation infarct; TACI, total anterior
patients were unable to complete the Star Cancellation Test
circulation infarct. because of stroke severity, low level of cognition, aphasia, or
*Oxfordshire classifications. the need for repeated stimulation to maintain arousal. All 17
patients who had a severe stroke (NIHSS total score ⬎16) were
not testable on Star Cancellation. Of the testable patients, 31
of space. For the purposes of the current study, patients were (44%) of 70 had neglect on the NIHSS item, and 17 (41%) of
identified as having neglect if they were scored as either 1 or 2 42 had neglect on Star Cancellation. Despite the similar prev-
on this inattention item. The second method used to identify alence of neglect as indicated by the 2 measures, there was
patients with neglect was the Star Cancellation Test, a valid considerable disagreement (table 2).
and sensitive test18 that requires the patient to cross out all the Eight patients identified as having neglect on Star Cancella-
small stars in an array of larger stars and other items. A trained tion were “missed” on the inattention item of the NIHSS, and
assessor administered this test. A score of less than 51 out of 54 3 patients who were rated as having neglect on the NIHSS item
was taken to indicate neglect on the Star Cancellation Test.11 performed within normal range on Star Cancellation. Level of
Patients were classified as having neglect if they had a positive agreement between the NIHSS item and Star Cancellation was
result on either test (ie, scoring 1 or 2 on NIHSS inattention .42 for all 3 correlation coefficients, which is considered to be
item or scoring ⬍51 on Star Cancellation, or both). on the border between “fair” and “moderate” agreement.20
Using our classification (a positive result on either test indi-
Outcome Measures cates neglect), 55% (39/71) of patients had neglect at baseline.
Patients with neglect were equally distributed between the
Patient characteristics collected at baseline included sex, VEM group (20/38, 53%) and the SC group (19/33, 58%). In
age, stroke severity (NIHSS total score), and previous stroke keeping with previous findings, neglect was more common
history. There were 3 primary outcome measures in the current after right hemisphere (24/35, 69%) than left hemisphere (15/
study: time to first mobilization (measured in hours), amount of 36, 42%) stroke, as established through cerebral imaging (com-
therapy (measured in minutes per day), and length of acute puted tomography or magnetic resonance imaging) in all cases.
hospital stay (measured in days). Secondary outcome measures
were discharge destination from the acute hospital and 12- Time to First Mobilization
month death and disability (measured using the mRS).
Number of hours to first mobilization was compared be-
Blinding tween groups in patients with and without neglect (fig 2). Three
Patients consented to undergo randomization to 1 of 2 reha-
bilitation styles (A or B) and were blind to group allocation.
Blinding was possible because the rehabilitation styles differed Table 2: Agreement Between Measures of Neglect
only in their timing (the intervention group received mobiliza-
NIHSS Item
tion sooner and more often) and not in their content. Although
trial therapists and nursing staff could not be blinded to inter- Variables Neglect No Neglect Missing
vention group, the importance of maintaining blinding of pa- Star Cancellation Test
tients and assessors was stressed to them. Intervention sessions Neglect 9 8 0
were not documented in the medical record and were con- No neglect 3 21 1
ducted behind closed curtains where possible. Unable 19 10 0
Stroke severity (unable)
Statistical Analyses
Mild 0 3
All analyses were performed using SPSS version 14.0.a The Moderate 5 4
level of agreement between the 2 methods of identifying ne- Severe 14 3
glect (NIHSS item and Star Cancellation) was analyzed using
kappa, intraclass, and concordance correlation coefficients. NOTE. Values are number of patients.

Arch Phys Med Rehabil Vol 90, November 2009

1934 NEGLECT IN ACUTE STROKE REHABILITATION, Cumming
Fig 2. Time to first mobilization (hours) in SC (nⴝ32) and VEM
(nⴝ36) patients. Boxes represent interquartile range with horizontal
line at the median, vertical whiskers identify smallest and largest
values (that are not outliers), open circles and stars (*) represent
mild and extreme outliers.
of the 71 patients were not mobilized at all and were not
included in this analysis.
In the SC group, patients without neglect were mobilized
earlier than patients with neglect, but this difference was not
significant (z⫽1.2, P⫽.22). There was no significant interac-
tion between group and neglect status for time to first mobili-
zation (z⫽0.6, P⫽.56).
Amount of Therapy
There was no significant difference in the amount of therapy
received per day in the acute hospital setting between patients with
Fig 3. Length of acute hospital stay (days) in SC (nⴝ33) and VEM
(nⴝ38) patients. Boxes represent interquartile range with horizontal
line at the median, vertical whiskers identify smallest and largest
values (that are not outliers), open circles and stars (*) represent
mild and extreme outliers.
Arch Phys Med Rehabil Vol 90, November 2009
Table 3: Discharge Destination
Variables Home Not Home
SC
No neglect 6 8
Neglect 2 17
VEM
No neglect 7 11
Neglect 5 15
NOTE. N⫽71. Values are number of patients.
neglect and without neglect in the SC group (median: 16min and
12min, respectively; z⫽0.2, P⫽.87) or the VEM group (median:
33min and 46min, respectively; z⫽1.1, P⫽.28). There was no
significant interaction between group and neglect status in minutes
of therapy per day (z⫽1.3, P⫽.18).
Length of Stay in Acute Hospital
Length of stay, measured in days, was compared between
groups in patients with and without neglect (fig 3). Patients
who died during acute care were included in this analysis, even
though their “true” length of stay was potentially cut short by
their death.
In the SC group, patients with neglect had a longer acute
hospital stay than patients with no neglect (Mann-Whitney U
test: z⫽2.4, P⫽.016). However, there was no significant inter-
action between group and neglect status in length of stay
(z⫽1.3, P⫽.19).
Discharge Destination (From Acute Hospital)
The discharge destination (home or not home) was compared
between groups in patients with and without neglect (table 3).
Patients with neglect were less likely to be discharged home
from acute hospital care, as indicated by univariate logistic
regression (␤⫽1.14, SE⫽.55, P⫽.039). Multivariate logistic
regression, however, indicated the strong effects of stroke
severity (␤⫽.42, SE⫽.13, P⫽.001) and age (␤⫽.07, SE⫽.03,
P⫽.013) on discharge destination, and the effect of neglect was
diminished (␤⫽.37, SE⫽.75, P⫽.619).
Long-term Outcome
The score on the mRS at the 12-month follow-up was used
to investigate whether neglect in the acute phase was associated
with poor recovery (fig 4). Scores were dichotomized into
Fig 4. mRS score (good outcome: 0 –2, no symptoms to slight dis-
ability; poor outcome: 3– 6, moderate disability to dead) at 12
months for patients with and without neglect at baseline.
 NEGLECT IN ACUTE STROKE REHABILITATION, Cumming
“good outcome” (mRS 0 –2) and “poor outcome” (mRS ⬎2); 2
patients had missing data. Of the 38 patients identified with
neglect, 33 (87%) had a poor outcome at 12 months. Of the 31
without neglect, only 14 (45%) had a poor outcome at 12
months. Multivariate logistic regression was performed on
mRS outcome at 12 months. All variables included in the
model were associated with poor mRS outcome: greater
stroke severity (␤⫽.34, SE⫽.12, P⫽.007), older age
(␤⫽.08, SE⫽.04, P⫽.030), and female sex (␤⫽1.72,
SE⫽.82, P⫽.035) were significantly related, while neglect
neared significance (␤⫽–1.57, SE⫽.83, P⫽.060).
DISCUSSION
This is the first study to describe the relationship between
neglect and rehabilitation practices in acute stroke, and it has
yielded 3 notable findings. First, agreement between the
NIHSS inattention item and the Star Cancellation Test was
only fair to moderate (.42), illustrating the difficulty of assess-
ing neglect early after stroke. Second, the introduction of a
protocol promoting early and frequent mobilization was found
to be feasible in stroke patients with neglect. Third, patients
with neglect in the SC group had longer hospital stays than
those without neglect, but this was not the case in the inter-
vention group.
Issues arising from the assessment of neglect are considered
first. Catchment with the NIHSS item was almost complete,
with missing data for 1 patient only. The Star Cancellation
Test, however, could not be completed by 29 patients (includ-
ing all 17 with severe stroke). Eight patients with neglect
identified on the Star Cancellation Test were “missed” on the
NIHSS. This is not altogether surprising; the Star Cancellation
Test is one of the most sensitive tests of neglect,18 and mild
symptoms may have been missed by the examiner. Although
raters in this study had completed training and accreditation for
the NIHSS, the inattention item does rely on clinical judgment.
Examiners with limited experience of neglect may be less
likely to detect the clinical signs. This is a problem because
mild neglect can still have a considerable impact on functional
tasks, including gait. In clinical practice, to ensure mild neglect
does not go undetected, one approach might be to routinely
administer a more sensitive test of neglect when a person
scores 0 (no abnormality) on the NIHSS inattention item. Three
patients with neglect on the NIHSS item performed within
normal limits on the Star Cancellation Test, and this finding
may be related to the spatial constraints of the Star Cancellation
Test. Cancellation tests examine neglect only in peripersonal
(reaching) space, whereas the NIHSS item is based on general
observation and is not limited to one spatial domain. A further
consideration is that the NIHSS inattention item involves bi-
lateral simultaneous stimulation testing, which is the classic
test for extinction. Since extinction can occur in the absence of
neglect,21 this may explain why some subjects would be as-
signed “neglect” on the NIHSS but show no impairment on the
Star Cancellation Test. Collectively, these findings highlight
the need for valid measures of neglect in multiple spatial and
sensory domains that are simple to administer in the acute care
setting.
Our second interesting finding was the association between
neglect and rehabilitation practice during the acute hospital
stay. Patients in the SC group with neglect had a longer wait
until first mobilization (median, 33h) than those without ne-
glect (median, 28h). In the VEM group, the median time until
first mobilization was 18 hours, irrespective of neglect status.
Importantly, this illustrated that it was feasible to mobilize
people with neglect sooner than current conventional practice
(for more details on what conventional practice involves, see
1935
Bernhardt et al17). Furthermore, early and more frequent mo-
bilization may have contributed to a shorter length of stay. In
the VEM group, patients with and without neglect both had a
median length of stay of 6 days, whereas patients with neglect
in the SC group stayed in the hospital longer (median, 11d).
However, we also found that people with neglect were less
likely (regardless of group) to return home after their acute
hospital episode of care.
It is well established that neglect after stroke has a strong
negative impact on functional outcome,6,7 and our results are
consistent with this finding. Of the patients who had neglect in
the acute phase, 87% had a poor outcome at 12 months,
whereas only 45% of the patients without neglect in the acute
phase had a poor outcome. Even after accounting for other
relevant factors (age, sex, stroke severity), the impact of early
neglect on poor 12-month outcome neared significance.
There were many strengths of this study, including a ran-
domized design, broad inclusion criteria, and a blinded out-
come assessment. Neglect was assessed very early after stroke
and was measured using 2 different methods. Extensive data
were collected on rehabilitation practices.
The small sample size was a limiting factor. Given the lack
of statistical power, the interesting trends identified should be
seen as hypothesis-generating and need to be confirmed in a
larger study.
CONCLUSIONS
In terms of therapy and rehabilitation, we found no evidence
that neglect was a barrier to early and frequent mobilization of
stroke patients in the acute hospital setting. There was some
indication that patients with neglect who received this rehabil-
itation intervention had a shorter hospital stay than those who
received SC. Given that agreement between our 2 neglect
assessments was only fair to moderate and the Star Cancella-
tion completion rate was far from 100%, there remains scope to
identify a practical and valid measure (or combination of
measures) for neglect in acute stroke. Nevertheless, the assess-
ments used here can be seen as useful screening tools that can
guide the introduction of interventions to remediate neglect
early in recovery.
A large, multicenter phase III trial to test the efficacy and
cost-effectiveness of VEM is currently underway. In AVERT
phase III, we will continue to assess neglect using both the
NIHSS and Star Cancellation Test. In addition, a clock-draw-
ing task, part of the Montreal Cognitive Assessment cognitive
screening tool,22 has been included in the 3-month follow-up
assessment. This should allow further study of neglect as a
prognostic factor in the context of a larger rehabilitation trial
and permit us to determine whether neglect in the first days
persists at 3 months.
References
1. Stone SP, Halligan PW, Greenwood RJ. The incidence of neglect
phenomena and related disorders in patients with an acute right or
left hemisphere stroke. Age Ageing 1993;22:46-52.
2. Linden T, Samuelsson H, Skoog I, Blomstrand C. Visual neglect
and cognitive impairment in elderly patients late after stroke. Acta
Neurol Scand 2005;111:163-8.
3. Desimone R, Duncan J. Neural mechanisms of selective visual
attention. Annu Rev Neurosci 1995;18:193-222.
4. Karnath H-O, Ferber S, Himmelbach M. Spatial awareness is a
function of the temporal not the posterior parietal lobe. Nature
2001;411:950-3.
5. Karnath H-O, Himmelbach M, Rorden C. The subcortical anat-
omy of human spatial neglect: Putamen, caudate nucleus, and
pulvinar. Brain 2002;125:350-60.
Arch Phys Med Rehabil Vol 90, November 2009
1936 NEGLECT IN ACUTE STROKE REHABILITATION, Cumming
6. Jehkonen M, Laihosalo M, Kettunen JE. Impact of neglect on
functional outcome after stroke: a review of methodological issues
and recent research findings. Restor Neurol Neurosci 2006;
24:209-15.
7. Nys GM, van Zandvoort MJ, de Kort PL, et al. The prognostic
value of domain-specific cognitive abilities in acute first-ever
stroke. Neurology 2005;64:821-7.
8. Kalra L, Perez I, Gupta S, Wittink M. The influence of visual
neglect on stroke rehabilitation. Stroke 1997;28:1386-91.
9. Bailey MJ, Riddoch MJ, Crome P. Evaluation of a test battery for
hemineglect in elderly stroke patients for use by therapists in
clinical practice. NeuroRehabilitation 2000;14:139-150.
10. Menon A, Korner-Bitensky N. Evaluating unilateral spatial ne-
glect post stroke: working your way through the maze of assess-
ment choices. Top Stroke Rehabil 2004;11:41-66.
11. Wilson B, Cockburn J, Halligan P. Development of a behavioral test
of visuospatial neglect. Arch Phys Med Rehabil 1987;68:98-102.
12. Zoccolatti P, Judica A. Functional evaluation of hemineglect by
means of a semistructured scale: personal extrapersonal differen-
tiation. Neuropsychol Rehabil 1991;1:33-44.
13. Azouvi P, Marchal F, Samuel C, et al. Functional consequences
and awareness of unilateral neglect: study of an evaluation scale.
Neuropsychol Rehabil 1996;6:133-50.
14. Plummer P, Morris ME, Dunai J. Assessment of unilateral neglect.
Phys Ther 2003;83:732-40.
Arch Phys Med Rehabil Vol 90, November 2009
15. Brott T, Adams HP, Olinger CP, et al. Measurements of acute
cerebral infarction: a clinical examination scale. Stroke 1989;20:
864-70.
16. Bernhardt J, Dewey H, Thrift A, Collier J, Donnan G. A Very
Early Rehabilitation Trial for Stroke (AVERT): phase II safety
and feasibility. Stroke 2008;39:390-6.
17. Bernhardt J, Dewey H, Thrift A, Donnan G. Inactive and alone:
physical activity within the first 14 days of acute stroke unit care.
Stroke 2004;35:1005-9.
18. Azouvi P, Samuel C, Louis-Dreyfus A, et al. Sensitivity of clinical
and behavioural tests of spatial neglect after right hemisphere
stroke. J Neurol Neurosurg Psychiatry 2002;73:160-6.
19. Altman DG, Bland JM. Interaction revisited: the difference be-
tween two estimates. BMJ 2003;326:219.
20. Altman DG. Practical statistics for medical research. London:
Chapman & Hall; 1991.
21. Robertson I, Halligan P. Spatial neglect: a clinical handbook for
diagnosis and treatment. East Sussex, UK: Psychology Press;
1999.
22. Nasreddine ZS, Phillips NA, Bedirian V, et al. The Montreal
Cognitive Assessment, MoCA: a brief screening tool for mild
cognitive impairment. J Am Geriatr Soc 2005;53:695-9.
Supplier
a. SPSS Inc, 233 S Wacker Dr, 11th Fl, Chicago, IL 60606.