Rehabilitation for Spatial Neglect Improves Test Performance but Not Disability
Graeme J. Hankey MD, FRCP Section Editor
Unilateral spatial neglect causes difficulty attending to one side of space and adversely affects activities of daily living.
This updated systematic review examined the effectiveness of cognitive rehabilitation aimed at spatial neglect after stroke. The primary outcome was at the level of disability (restricted activity), specifically whether any benefits were maintained beyond the end of the intervention. Immediate effects, impairment measures and discharge destination were also investigated.
Materials and Methods
We searched the Cochrane Stroke Group Trials Register (last searched July 4, 2005), MEDLINE (1966 to July 2005), EMBASE (1980 to July 2005), CINAHL (1983 to July 2005), PsycINFO (1974 to July 2005), UK National Research Register (July 2005). We hand-searched relevant journals, screened reference lists, and tracked citations using SCISEARCH. Two reviewers independently selected trials, extracted data, and assessed trial quality. To reduce bias we included only randomized controlled trials (RCT) of neglect rehabilitation. We excluded studies of general stroke rehabilitation and those with mixed patient groups, unless >75% of their sample were stroke patients, or separate stroke data were available.
There were 12 eligible RCTs with 306 participants. Only 4 had adequate allocation concealment, ie, low risk of selection bias. A large number of outcome measures were reported. Only 6 studies measured disability and 2 investigated whether the effects persisted (the primary outcome). The overall effect was not statistically significant (SMD 0.61, 95% CI, −0.42, 1.63).
In contrast, there was improved performance on some, but not all of the secondary outcomes (impairment measures). As shown in the Figure, there was a reduction in the number of errors made on cancellation tests (immediate, 4 studies: SMD, −0.65; 95% CI, −1.28, −0.01; follow up, 3 studies: SMD, −0.76; 95% CI, −1.39, −0.13) and on line bisection (immediate, 4 studies, SMD, −0.84; 95% CI, −1.36, −0.33; follow up, 1 study: SMD, −1.09; 95% CI, −2.0, −0.18). Discharge destination (1 study) was not significant (odds ratio, 1.4; 95% CI, 0.45, 4.35).
Several types of neglect specific approaches are now described in the literature. They can alter performance on impairment measures and warrant further investigation in high quality randomized controlled trials. Training in visual scanning was the approach most often related to improving performance detecting and cancelling visual targets or bisecting lines. Prism use (simply wearing prisms rather than prism adaptation training) was also successfully used in 1 study but outcome was not measured after the intervention ended, so we do not know whether prism effects persist. However, there is insufficient evidence to support or refute the effectiveness of any of these approaches at reducing disability, the main aim of rehabilitation. It is essential that future trials are adequately powered and choose outcome measures that determine effects on disability that persist beyond the end of the intervention. Because we did not review whether patients with neglect benefited from rehabilitation input in general, patients with neglect should continue to receive general stroke rehabilitation services. This Cochrane review is ongoing and the authors would be grateful to receive information about on-going trials.
Note: The full text of this review should be cited as: Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews. 2007; Issue 2. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586.pub2.
- Received April 4, 2007.
- Accepted April 11, 2007.