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Rehabilitation intervention for unilateral spatial neglect in post-stroke subjects with hemiparesis
*Corresponding author: Kamal Narayan Arya, Department of Occupational Therapy, Pandit Deendayal Upadhyaya National Institute for Persons with Physical Disabilities, New Delhi, India. kamalnarya@yahoo.com
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Received: ,
Accepted: ,
How to cite this article: Pandey D, Arya KN, Pandian S. Rehabilitation intervention for unilateral spatial neglect in post-stroke subjects with hemiparesis. J Neurosci Rural Pract. doi: 10.25259/JNRP_37_2025
Abstract
Unilateral spatial neglect (USN) is a common condition observed in up to 70% of stroke survivors, primarily affecting attention to the contralesional side of the body or visual space. It is associated with significant functional impairments, including poor motor recovery, balance issues, and increased risk of falls. Although USN occurs widely after the brain insult, the impairment is usually underdiagnosed, and as a result, it is poorly focused in stroke rehabilitation. Typical stroke rehabilitation emphasizes on motor paresis. Further, the USN is exhibited in various complex forms, leading to its challenging assessment and management. The purpose of this study was to review and describe the current rehabilitative therapies available for treating USN in stroke survivors, with a focus on their efficacy, challenges, and the necessity for a multimodal therapy approach. The impact of various interventions, including virtual reality, mental imagery, prism adaptation therapy, mirror therapy, visual scanning, and transcranial direct current stimulation (tDCS), on enhancing spatial awareness, attention, and motor recovery in people with USN was assessed through a critical review of the literature. Interventions such as virtual reality, mirror therapy, and prism adaptation have exhibited favorable effects on motor recovery. These regimens increase the use of the neglected side and, thus, enhance spatial awareness. In addition to this, the method such as mental imagery activates certain brain areas, enhancing neural recovery. Although tDCS promotes brain plasticity, which enhances motor control and spatial awareness, visual scanning techniques help people become more conscious of the affected side. However, each patient responds differently to various approaches, and no single treatment has proven to be successful in all cases. USN is still a major challenge to stroke recovery, even after improvements in rehabilitation methods. A more specific approach to rehabilitation is necessary due to the variety of neglect symptoms and the unique characteristics of treatment responses. To improve the overall recovery and functional results, future research should focus on creating complete protocols that incorporate a variety of therapies that are specific to each patient’s USN type and severity. Several interventions have shown promise in managing USN; no single approach is ideal for all stroke patients. When treating USN, a multimodal, individualized approach combining therapy is most likely to provide the best outcomes. In addition, the identification and categorization of USN in clinical practice is still a challenge.
Keywords
Cerebrovascular accident
Cognition
Disability
Functional impairment
Motor control
Perception
INTRODUCTION
Unilateral spatial neglect (USN) is a condition that usually occurs in up to 70% of cases after a stroke.[1] It is defined as a negligence to attend to or make a response to the stimuli on the side of the body opposite to the brain lesion. It is more common on the left side of the body. USN is also referred to as hemineglect, hemispatial neglect, spatial neglect, visual neglect, visual-spatial neglect, and inattention.[2]
In addition to the motor manifestation, this non-motor deficit increases the post-stroke disability by many folds. In spite of the motor abilities, a post-stroke survivor experiences challenges in functional performance due to hemispace neglect. USN leads to consequences such as poor motor recovery, poor functional outcome, impaired balance, and risk of falls.[3] USN hampers the overall recovery, including motor and functional recovery, of a post-stroke individual. However, the major focus of stroke rehabilitation is usually on motor impairment. In addition to this, the identification, assessment, and intervention of the USN have always been a challenge in clinical practice.[4]
The objective of this review was to provide an overview of rehabilitation methods for the management of USN among stroke survivors.
TYPES OF USN
Neglect is a diverse condition with different types. It can be divided into three dimensions: (1) Reference frame (egocentric or allocentric);[5] (2) processing stage – perceptual subtypes (visual, tactile, or auditory),[6] representational,[7] and motor; and (3) spatial sector (personal, peripersonal, or extrapersonal).[8,9]
Neglect symptoms are described as occurring at various stages of information processing: (1) Perceptual neglect – patients find it harder to notice or pay attention to stimuli on the left side and (2) pre-motor neglect – patients find it more challenging to respond to or plan movements toward stimuli on the left side.[10] Table 1 shows the various types/subtypes of the USN.
| Types | Definition | Example |
|---|---|---|
| Reference frame | ||
| Egocentric | Neglect related to the individual’s own body midline | An individual ignores food on the left side of their plate |
| Allocentric | Neglect of one side of objects, irrespective of their position relative to the individual | An individual might ignore the left half of an object, even if the object is on the right side |
| Processing stage | ||
| Perceptual subtypes | ||
| Visual neglect | Lack of awareness or response to visual stimuli on the contralesional side of the space | The individual misses keys on the left side of a table |
| Tactile neglect | Lack of awareness of tactile stimuli on the contralesional side of the body | The individual puts a sleeve only on the right arm, leaving the left arm undressed |
| Auditory neglect | Failure to notice or to respond to sounds coming from the side opposite the brain lesion | The individual only responds to people speaking on the right side. |
| Representational neglect | Refers to a failure to attend to the contralesional side of mental representations, visualizing a place or object from the memory | The individual only draws an element on the right side, a clock drawing |
| Motor neglect | Also known as intentional neglect, refers to the lack of spontaneous use of the limbs on the contralesional side | The individual fails to use their left hand to grasp an object |
| Spatial sector | ||
| Personal (own body) | Difficulty responding to stimuli on one side of the body | The individual fails to dress or groom the left side of their body |
| Peripersonal (within arm’s reach) | Difficulty noticing or responding to the stimuli within arm’s reach on the affected side | The individual ignores an object on the left side of a table, failing to pick up a cup placed to their left |
| Extrapersonal (distant space) | Difficulty noticing or responding to the stimuli in the space beyond arm’s reach on the affected side | The individual ignores objects or events occurring on their left side in the environment; cars approaching from the left when crossing the street |
ASSESSMENT OF USN
There are various assessment tools used to identify and quantify USN in clinical and research practice. Some of the tools are summarized in Table 2.[6,11-22]
| Category | Assessment tools | Description | Type of neglect | Psychometric properties |
|---|---|---|---|---|
| Functional assessments | CBS | Evaluates neglect in real-world tasks like dressing, eating, and mobility | Personal, peripersonal, and extrapersonal neglect | Reliability: 0.98 Concurrent validity: 0.70–0.76 Predictive validity: −0.58 Construct validity: −0.67 |
| Comb and Razor test | Assesses personal grooming on both sides of the face/head | Personal neglect | Test-retest reliability: 0.94 | |
| Fluff test | Patients remove objects (e.g., paper pieces) attached to their body, focusing on body neglect | Personal neglect | Test-retest reliability: 0.89 | |
| Paper-and-pencil tests | Line bisection test | Patients mark the midpoint of a line; misplacements indicate neglect | Peripersonal neglect | Reliability: 0.97 Validity: 0.48 |
| Star cancellation test | Patients find and cancel stars among distractor symbols on a page. | Peripersonal neglect | Reliability: 0.89 Validity: 0.63 |
|
| Letter cancellation test | Patients locate and cancel specific target letters among a field of distractors. | Peripersonal neglect | Reliability: 0.93 | |
| Clock drawing test/copying and drawing tasks | Patients draw a clock; neglect is seen if one side is omitted or clustered. | Peripersonal neglect | Reliability: 0.88–0.96 Validity: 0.51–0.59 |
|
| Standardized battery tests | BIT | A battery of six conventional subtests and nine functional subtests that assess various aspects of neglect. | Peripersonal neglect | Interrater/intrarater reliability: 0.99 Validity: 0.64 |
| Body-centered neglect tests | Comb and Razor test | Focuses on personal grooming, particularly face and neck | Personal neglect | Test-retest reliability: 0.94 |
| Fluff test | Patients remove fluff from their bodies, focusing on their awareness of both sides | Personal neglect | Test-retest reliability: 0.89 |
USN: Unilateral spatial neglect, CBS: Catherine Bergego Scale, BIT: Behavioral inattention test.
The assessment of USN is difficult because it is usually present in any or all of the three dimensions. The occurrence and intensity of neglect are influenced by multiple factors. Several factors, including the site of injury, cognitive reserves, and the rehabilitation setting, affect the level and presentation of neglect. USN is assessed by clinical observations and common neuropsychological tests. Some of the activities of daily living scales are used to assess a patient’s awareness of the condition.[23] However, after a stroke, complete neglect symptoms may not always be identified by functional neglect evaluations.[24] In clinical settings, simple pen-and-paper tests like line bisection, clock drawing, and cancellation assessment are commonly used to measure neglect. As of now, there is no standardized assessment that exists to evaluate neglect in the extra personal space.[3] Paperand-pencil assessments are not able to provide insight into how neglect impacts day-to-day functioning.[23] The only performance-based neglect assessment with items addressing extrapersonal, peripersonal, and personal neglect is the Catherine Bergego Scale (CBS).[24] Its use is not widespread, and its performance-based nature may not always be practical in clinical settings.[3] A variation in line bisection does not always indicate the direction-specific deficit. The impairment is prevalent in the clinical behavior of neglect patients. The severity of the neglect increases with the distance in the line bisection test.[25] For primary use, a cancellation test was suggested in situations where there is not enough time for more than one neglect evaluation. The baking tray task, figure copy, and line bisection were suggested for secondary use when time allowed. Finally, continuous observation using the CBS was suggested for a functional or ecological assessment, ideally by an expert observer like a therapist, when more time is available and when the patient’s physical condition has adequately improved.[26] The patient’s awareness of the disorder is assessed by the ADL scale or ecological scales. Patients may perform well on structured tests yet demonstrate severe neglect in unstructured, real-world settings, leading to underdiagnosis and missed opportunities for intervention.[23] The development of tools that combine results from neuropsychological testing with performance evaluations in the actual world is an important unmet need in the assessment of spatial neglect. A significant unmet need in spatial neglect assessment is the development of tools that integrate findings from neuropsychological tests with real-world performance assessments. Many patients find difficulty in doing activities of daily living but still do better in neuropsychological tests. Computerized tests provide more precise information, such as accuracy and response time, as the task is completed.[27] With the one single assessment, neglect should not be assessed. In the post-acute and chronic stages, computer-based tasks do not generally place a significant pressure on stroke patients. Further, such tests do not lead to any boredom, fatigue, or headache. The digital tests have been found to be safer and easier than the traditional paper-and-pencil tests.
INVESTIGATED INTERVENTION
Prism adaptation therapy
Prism adaptation utilizes optical prisms to shift the visual field laterally, usually to the left or right. For a long time, prism adaptation was considered a pure sensory-motor adaptation task.[28] Now, it is considered to be a visuomotor phenomenon and a “bottom-up” approach. When an individual wears prism glasses, the visual input being received is displaced from its actual location.[29] This process engages the brain’s neuroplasticity, particularly in the parietal cortex, which plays a crucial role in spatial awareness.
For prism adaptation therapy, patients should be aware of their neglect and pay proper attention to the affected side, which may be challenging for them.[30] Prism adaptation primarily focuses on pre-motor neglect.
Prism adaptation works in many steps:
Initial displacement: While wearing the prism glasses, it causes a shift in a person’s visual field, leading to an inability to reach the target.
Prism adaptation effect: After a few attempts, the accuracy of reaching the target returns to normal.
After-effect: Subjects usually misjudge the direction of reaching the target after removing the prisms, which is the opposite of the original deviance.[31]
Prism therapy can increase clear information of the contralesional side of neglected imaginary visual objects (stimuli that connect the left and right sides of several recognizable items) and increase perceptual awareness.[32] Its effects are often short-term. Several studies have demonstrated that prism adaptation significantly improves symptoms of neglect, particularly in tasks measuring visual scanning, line bisection, and cancellation tasks.[33] A study showed that prism adaptation training significantly improved line bisection tasks in patients with left hemispatial neglect. Prism adaptation provides instant advantages in clinical measurements of neglect by facilitating the realignment of attention toward the neglected side.[28] Prism adaptation primarily benefits individuals with pre-motor neglect.[31]
Mirror therapy
Ramachandran and Roger-Ramachandran initially developed mirror therapy to treat phantom limb sensation in individuals who have undergone unilateral amputation.[34] Mirror therapy is a type of rehabilitation where a mirror is positioned between the arms or legs to create the illusion of normal movement in the impaired limb by reflecting the image of a non-affected limb in motion. Mirror therapy can also be applied using various tasks. In this, the patient performs specific motor activities using objects such as balls, blocks, and a piece of cloth in conjunction with the mirror therapy.[35,36]
Mirror therapy stimulates the mirror neuron system using visual information through mirror visual feedback.[37] Mirror feedback increased the excitability in the ipsilateral hemisphere (as determined by transcranial magnetic stimulation-induced motor evoked potentials during task execution) when the motor task was performed in conjunction with motor imagery.[38] Mirror therapy improves attention, conscious awareness of sensory feedback, and the avoidance of learned non-use of the affected limb by increasing activity in primary and secondary visual and somatosensory areas.[35] In mirror therapy, the size of a mirror may be considered an important factor. A mirror of large size provides enhanced perception of the image leading to a favorable results in comparison to a mirror of small size.[39] Mirror therapy showed moderate to large effect size for improving upper limb recovery when compared with traditional motor interventions.
Mirror therapy is a promising intervention for improving motor function and rehabilitation outcomes in stroke patients. The integration of mirror therapy into standard rehabilitation protocols may enhance recovery and quality of life for post-stroke survivors. Significant improvements were observed following MT therapies in functional neglect evaluation utilizing measures such as CBS.[24]
Virtual reality
Virtual reality is characterized as a real-time, computer-based, multimodal, engaging, and interactive environment. The user is involved in activities that mimic real life situations.[40] Virtual reality offers an innovative approach, allowing patients to engage in realistic, interactive environments that can encourage attention and movements toward the neglected side. Using gaming techniques, virtual reality protocols provide an excellent opportunity to develop innovative, fulfilling, and sustainable environments that enhance patient’s motivation, engagement, and adherence to therapy.[40] It is safe and cost-effective. Virtual reality is used as an assessment and treatment for patients with USN. Virtual reality helps in the detection of visual impairments, such as visual extinction and gaze asymmetries.[41] Many studies have shown virtual reality to be effective in improving USN by creating interacting environments that engage patients in spatial tasks. Virtual reality combined with integrated eye tracking is a useful technique for evaluating stroke patients who have mild USN.[41] Virtual reality is also effective in post-traumatic stress disorder, panic disorder, or attention deficit hyperactivity disorder. Many studies reported significant improvements in visual scanning behaviors and attention toward the neglected side.[42] A considerable time, financial and other resource commitment is necessary for the development of the virtual reality. Further, the advancement of software increases the cost of equipment.
Types of virtual reality:
Immersive: It contains a head-mounted display (HMD) and a 3D device. Immersive VR differs from other virtual reality technologies in that the user is completely submerged in the virtual environment (VE) they may interact with.
Semi-immersive: It usually comprises a big screen that projects the virtual reality onto, as well as specialized infrared devices (cyber gloves, haptic feedback devices, or infrared cameras) that allow an individual to interact with the VE when still seeing the outside world. This allows for partial immersion and a strong sense of presence.[43,44]
Non-immersive: Non-immersive virtual reality environments are the least interactive virtual reality implementations, allowing users to interact with the world using two-dimensional interface tools like keyboards and mice without completely submerging themselves in them. Nausea, motion sickness, and cybersickness are the side effects of virtual reality.[40]
Mental imagery
The mental imagery technique is initially developed to improve the performance of athletes. It is a top-down technique for USN treatment, which requires voluntary efforts by the patients followed by the therapist’s instructions.[45,46] In the mental imagery process, an experience (visual, tactile, auditory, and kinesthetic) is created that is actually not present.[47] It refers to the cognitive process of imagining and rehearsing actions without any physical movements. Mental imagery can either be visual (i.e., visualizing shapes of objects, color, or brightness) or motor (the simulation of physical activity without any actual movement). Mental imagery has a positive impact on memorization.[48] A review found that mental imagery training in neglected patients is able to activate the relevant brain areas.[49] Mental imagery may have therapeutic benefits for the USN.[50]
Visual scanning
Visual scanning was originally introduced by Diller and Weinburg and further developed by Pizzamiglio et al.[51] Visual scanning treatment uses the top-down approach to the treatment. Visual scanning treatment includes repeat practice of scanning in different types of situations to promote spontaneous and generalization of skills.[52] Patients with neglect are encouraged to actively pay attention to stimuli on the affected side using visual scanning activities, which increase visual scanning behavior.[53] The visual scanning program is based on the principles of “anchoring, pacing, density, and feedback.”[54] Visual scanning improves visual perception processing and reduces the symptoms of USN in post-stroke patients. Adding the dual task to visual scanning training may improve spatial awareness and attention more effectively than visual scanning training alone. In evaluating recovery from and rehabilitation from neglect, dual task may then be more instructive than the single ones.[55] Using visual scanning training when patients notice improvements in their respective skills, they become more aware of their deficit, which assists them in their ability to create compensatory skills.[52]
Transcranial direct current stimulation (tDCS)
tDCS is a portable, low–cost, and non-invasive technique. tDCS is a non-invasive brain stimulation technique that involves applying a low electric current to the scalp by using two or more electrodes. A low-intensity direct current stimulator are used to provide transcranial current direct current stimulation.[56] The anodal stimulation (positive electrode) enhances the cortical excitability, while the cathodal stimulation (negative stimulation) decreases the excitability. There are three possible applications: (1) The cathodal electrode may be positioned over the contralateral orbit (anodal stimulation) and the anodal electrode over the brain’s assumed region of interest, anodal-tDCS; (2) the anodal electrode may be positioned on the contralateral orbit (cathodal stimulation) and the cathodal electrode over the brain’s assumed region of interest, cathodaltDCS;[57] (3) anodal and cathodal stimulation may be applied simultaneously, dual-tDCS. Anodal stimulation typically corresponds to the excitement at rest, evidenced by a common increase in motor-evoked potentials following tDCS, whereas cathodal stimulation causes inhibition.[58] These differences in electrode polarity lead to the tDCS-induced polarization in the cortex.[59] tDCS may enhance cortical reorganization and may enhance spatial awareness and motor control.[10]
DISCUSSION
Post-stroke subjects usually experience USN, which is a major disabling condition affecting their recovery and quality of life. The neglect is typically exhibited in the form of a lack of awareness or attention to the contralesional side of the body or visual space. USN affects the rehabilitation process and undoubtedly interferes with motor recovery. Further, the USN is experienced in various domains such as motor, sensory, perception, and visuospatial. The condition manifests across various dimensions, including perceptual, motor, and representational neglect, which can affect different sensory and spatial domains. While the assessment of USN remains challenging due to its complex nature, existing assessment tools like CBS and various pen-and-paper tests provide some insight into the severity and types of neglect.
Prism adaptation therapy, in particular, has collected significant attention for its ability to rapidly shift attentional focus toward the neglected side.[30,60]
Mirror therapy and virtual reality stimulate both sensory and motor systems. Through the use of the brain’s mirror neuron system, mirror therapy improves motor function and spatial awareness by providing visual feedback about movement in the impaired limb. On the other hand, virtual reality provides an immersive, interactive environment that provides engagement and enables patients to practice intentional tasks in dynamic, controlled environments.[36,61]
REDESIGN THE RECENT INTERVENTION
There is no individualized approach for treating USN, despite the potential of contemporary therapies like prism adaption, mirror therapy, virtual reality, and tDCS. Each treatment has its advantages and limitations, and patients respond differently based on the severity and type of neglect they experience.[62] To optimize rehabilitation outcomes, a multimodal, individualized approach combining these therapies may be most effective. As of now, there is no ideal cure for USN.[63] Although various interventions exist, no single therapy has been proven effective for all individuals. In mirror therapy, the illusion of the right hemispace (created by the unaffected limb) can be perceived as the illusion of the left hemispace. The illusion may activate multiple brain areas, inducing cortical reorganization leading to motor and perceptual recovery.[64]
CONCLUSION
While significant studies have been made in understanding and treating USN, there remains a need for continued innovation and enhancement in both assessment and treatment methods. The assessment methods need to be more sensitive to discern the minute impairment related to USN. Further, no single therapy has proven universally effective for all patients, and the variability in treatment responses necessitates the development of personalized, multimodal rehabilitation protocols. Simple and economical management needs to be further expanded for substantial benefits in all aspects of post-stroke disability. In addition, the identification and categorization of USN in clinical practice is still a challenge. Comprehensive and valid tools to discern subtypes of neglect are warranted.
Ethical approval:
Institutional Review Board approval is not required.
Declaration of patient consent:
Patient’s consent is not required, as there are no patients in this study.
Conflicts of interest:
There are no conflicts of interest.
Use of artificial intelligence (AI)-assisted technology for manuscript preparation:
The authors confirm that there was no use of artificial intelligence (AI)-assisted technology for assisting in the writing or editing of the manuscript and no images were manipulated using AI.
Financial support and sponsorship: Indian Council of Medical Research, New Delhi, India, 5/4-5/3/202/Neuro/2020-NCD-I.
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