Rehabilitation in practice- hemispatial neglect: approaches to rehabilitation, by Singh-Curry
Introduction:
- hemispatial neglect: syndrome caused by unilateral brain injury, especially RH stroke. Its an inability of the
pt to orient toward and attend to stimuli. Even their own body parts in contralesional space. Ex/ left side for pts
w/RH damage.
- they also have anosognosia: unaware of their deficit
The heterogeneity of neglect makes rehab a complex challenge:
- the syndrome isn’t caused by a disruption in just 1 cog process.
- some common tests to assess neglect are:
1.) Star cancellation: circle all the small stars. Ex/ they can only circle the ones on the right side of the page
2.) Copying scenes/objects: can only draw the things on the right side of the drawing
3.) Writing/copying from memory: they start writing at the left hand margin but subsequent lines move more
rightward. Draw only the right side of the flower
4.) Naming objects in a room: only items on the right side of space are identified
5.) Line bisection: asked to mark in the middle of a horizontal line, they always deviate to the right
**some pts show deficits on all the tasks but many are only impaired on some. Thus a single therapy wont wrk
on all the individuals
- common cortical areas associated with neglect are: right inferior partial lobe (IPL), inferior frontal gyrus
(IFG), and temporoparietal junction (TPJ). Sometimes damange to the analogous LH regions are implicated too.
Subcortical strokes can lead to neglect too becaz remote effects such as hypoperfusion of overylying cortical
regions or disconnection of fronto-parietal circuits.
- other studies suggest materal or medial temporal damage in the RH.
- broadly speaking, the cognitive deficits in neglect are divided into 2 types of deficits...
a.) Spatial: bias in spatial attention towards the ipsilateral (same side) of space, difficulty in disengaging
attention from ipsilateral side to the contralateral side, a pathological spatial bias (contralesional items lose
attention to the ipsilateral side), directional motor deficits (difficulty directing movements to the contralesional
side), spatial working memory problems (cant keep track of spatial locations over time), and a disordered
egocentric representation of space.
b.) non-spatial: more extensive and delibitating as they can exacerbate spatial deficits. Ex/ difficulty sustaining
attention even when items are presented in a central location, selective attention impairment (can demonstrate
bilateral attentional impairments even tho theres a bias toward their ipsilateral side)
- a full neurospcyh (including physical) is need to examine all stroke pts, especially those w/RH lesions. Thus a
battery of standardized measures, an exam for visual/somatosensory extinction and assessment of functional
activities is needed for these pts.
Techniques used to rehabilitate neglect:
-few techniques that are derived from understanding the underlying cognitive deficits have proven useful in
treating neglect pts. This could be because: few RCTs, heterogeneity in the syndrome, and they might rely on
particular brain regions being intact.
---Treatment used to rehabiliate neglect can be divided 3 broad categories:
A/ Behavioral strategies:
- help facilitate the orientation of attention into the contralesional, neglected side of space. Help provide
compensation strategies for functional impairment. More research needs to done to determine functional
efficacy over time. Ex/
1.) Visual scanning or visuospatial training- cueing the RH pts to make leftward eye or head movements with
explicit instructions. Most common method however lacks RCT studies to determine its short/long term efficacy
and where improvements are seen.And generalization might be low.
2.) Sustained attention tasks: sorting objects such as coins. Ex/ the experimenter wud intermittently prompt
ppl to pay attention, making them aware of their spatial/attention deficit and gradually trained to subvocally prompt themselves. Thus involves a self alerting process.This is limited to the degree that pts can appreciate
their deficits and situation that need their attention, thus their general applicability.
3.) Limb activation therapy: ppl with left sided neglect are forced to make leftward movements with their left
arm, thus activating poorly attended areas in extra-personal space.
- such spatiomotor cueing is effective even if te person cant see the moving limb. However constrained by the
fact that some control over the hemipar
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