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Rehabilitation in practice:
Hemispatial neglect:
Approaches to rehabilitation
Clin RehabilAugust 2010 24: 675-
684,
Victoria Singh-Curry and Masud Husain
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What is Hemispatial Neglect?
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Hemispatial Neglect
Syndrome commonly follows unilateral brain
injury, especially RIGHT hemisphere stroke.
Inability to orient towards and attend tostimuli in the contralesional space (Left side if
right hemisphere lesions)
Anosognosia
Difficult to rehabilitate
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Contributing Factors
Spatial A bias in the gradient of spatial attention
towards the ipsilesional (towards the right in
patients with right hemisphere lesions) side of
space
Difficulty disengaging attention fromipsilesional (right-sided) and shifting it to
contralesional (left-sided) locations
A pathological spatial bias, in which
contralesional (left-sided) items lose in the
competition for attention to ipsilesional (right-
sided) stimuli
Directional motor deficits in which patientshave difficulty directing movements into the
contralesional (left) side of space
Problems with spatial working memory,i.e.
keeping track of spatial locations over time
A disordered egocentric representation of
space
Non - Spatial Difficulties in sustaining attention over time,
even when items are presented at a central
location
Impairments in selective attention, which may
occur in both left and right sides of space and atcentral locations.
Neglect patients can demonstrate bilateral
attentional impairments, even though the most
obvious abnormality is a bias towards
ipsilesional (usually right-sided) space
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What test/s to do?
A full neuropsychological (as well as physical) examination wouldideally be required in all stroke patients, particularly those withright hemisphere lesions.
No single test provides an adequate screening tool. Instead abattery of standardized measures (such as from the Behavioural
Inattention Test) Examination for visual and somatosensory extinction
Assessment of functional activities (for example the Barthel Indexor Functional Independence Measure) are needed to fully evaluatethe syndrome in an individual patient.
This information, along with an appreciation of the underlying lesionanatomy, could be used to guide attempts at effective rehabilitation
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Rehabilitation Technique
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Three Categories
1. Purely behavioural strategies;
2. Techniques employing devices or specializedequipment; and
3. Pharmacological manipulations.
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Behavioural Strategies
Most Common
1. Visual scanning or visuospatial training
cueing right-hemisphere patients to makeleftward eye or head movements
facilitate the orientation of attention into the
contralesional, neglected side of space
Example:
asking the subject to locate the left hand margin of the page before
reading the next line.
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Behavioural Strategies
2. Sustained Attention
sorting of objects such as coins
intermittently verbally prompt patients to attendduring the task
gradually pt were trained to prompt themselves
subvocally
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Behavioural Strategies
3. Limb activation therapy
making leftward movements with the left arm can
activate poorly attended areas in extrapersonal
space and thereby improve neglect
constrained by the fact that some control over the
often hemiparetic arm is required
passive movements if large enough can lead tosome improvement of neglect
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Therapies that use specialized devices
1. neglect alerting device
2. functional electrical stimulation(FES)
3. computerized training tasks4. Rotation of the head or trunk
5. Neck muscle vibration (NMV)
6. Optokinetic stimulation7. Prism adaptation
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Pharmacological Therapies
Dopaminergic drugs
Bromocriptine given daily for 34 weeks, levodopaand the other apomorphine has been found to effect
an improvement in measures of neglect some reports have failed to demonstrate any benefit
Noradrenergic compounds (Guanfacine)
improves planning and working memory performance
in healthy human participants sustain attention for longer periods of time on the
visual exploration task
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Thank You
Questions??