Unilateral Spatial Neglect

Note: When reviewing the findings, it is important to note that they are always made according to randomized clinical trial (RCT) criteria – specifically as compared to a control group. To clarify, if a treatment is “effective” it implies that it is more effective than the control treatment to which it was compared. Non-randomized studies are no longer included when there is sufficient research to indicate strong evidence (level 1a) for an outcome.

The effectiveness of the various interventions in the management of unilateral spatial neglect (USN) has been examined with individuals post-stroke. This review presents 16 high quality RCTs, 14 fair quality RCTs, 4 poor quality RCTs and several non-randomized studies that evaluate the benefits of different treatment interventions for USN. 

Please click here to see the Authors’ Results Table.

Acute phase

Eye patchingNot effective1b

One high quality RCT (Ianes et al., 2012) examined the effects of right hemifield eye patching on USN symptoms in patients with acute stroke. This high quality RCT randomized patients with acute stroke and left USN to receive right half-field patching or visual scanning training over a 15 day period. There were no significant between-group differences in USN (Line Crossing Test, Bells Test, Line Bisection Test) at post-treatment. At one-week follow-up there was a significant between-group difference in Line Crossing Test scores only, in favor of half-field patching compared to visual scanning training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that eye patching is not more effective than comparative interventions (visual scanning training) for improving USN among patients with acute stroke. However, note that one high quality RCT found a significant between group difference in favour of eye patching for one measure of USN at follow up.

Family participationEffective2b

One quasi-experimental study (Osawa & Maeshima, 2010) examined the effects of family participation on USN in patients with acute stroke. This quasi-experimental study allocated patients with acute stroke and left USN to receive conventional rehabilitation with family participation or conventional rehabilitation alone. There were significant between-group differences in USN (Behavioral Inattention Test- BIT) at post-treatment (3 weeks), favoring family participation compared to the control group.
Note: There was no significant between-group difference reported for a measure of hemispheric dominance (Laterality Index). 

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that conventional rehabilitation with family participation is more effective than conventional rehabilitation alone for improving USN in patients with acute stroke.

Limb ActivationEffective1b

One high quality RCT (Kalra et al., 1997) investigated the impact of a limb activation intervention on USN among patients with acute stroke. This high  quality RCT  randomly assigned patients with acute stroke and visual neglect to receive spatiomotor cueing based on the ‘attentional motor integration’ model or conventional rehabilitation. At 12 weeks there were significant between-group differences in visual perceptual abilities (Rivermead Perceptual Assessment Battery – Body Image and Cancellation subtests only), in favour of spatiomotor cueing intervention compared to conventional rehabilitation.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that limb activation interventions (spatiomotor cueing) are more effective than conventional rehabilitation for improving USN in patients with acute stroke.

Mirror TherapyEffective1b

One high quality RCT (Pandian et al., 2014) investigated the effect of mirror therapy on hemineglect in patients with acute stroke. This high quality RCT  randomized patients with acute stroke to an intervention group that received mirror therapy or a control group that performed the same exercises using a nonreflecting mirror. There was a significant between-group difference in USN (Star Cancellation Test, Line Bisection Test, Picture Identification Task) at 1, 3, and 6 months, in favor of mirror therapy compared to the control group.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mirror therapy is more effective than a control intervention for improving USN in patients with acute stroke.

Prism adaptationEffective1b

One high quality RCT (Nys et al., 2008) investigated the effect of prism adaptation on USN among patients with acute stroke. This high quality RCT  randomized patients with acute stroke to wear prism goggles with 10° rightward deviation or neutral goggles with 0° deviation while performing pointing exercises for 30 minutes/day for 4 consecutive days. At 4 days (post- treatment) there was a significant between-group difference in USN (Schenkenberg Line Bisection Task, BIT Letter Cancellation Task, Scene Copying Task), in favour of prism goggles compared to neutral goggles.
Note: No significant between-group differences were observed on four subscales of the BIT (Star Cancellation, Figure Copying, Representational Drawing, and Line Bisection) at 1-month follow-up.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT (Nys et al, 2008) that prisms are more effective than neutral glasses in improving USN in patients with acute stroke, in the short term.

Repetitive Transcranial Magnetic Stimulation (rTMS)Not effective1b

One high quality RCT (Kim et al., 2013) investigated the effect of repetitive transcranial magnetic stimulation (rTMS) on USN among patients with acute stroke. This high quality RCT randomly assigned patients with acute stroke and visuospatial neglect to receive low frequency (1Hz) repetitive transcranial magnetic stimulation (rTMS) to the non-affected posterior parietal cortex (PPC), high frequency (10Hz) rTMS to the affected PPC, or sham stimulation. Patients received their respective intervention for 10 sessions over 2 weeks. At post-treatment (2 weeks) there was a significant between-group difference on only one measure of USN (Line Bisection Test), in favour of high frequency rTMS compared to sham stimulation. There were no significant between-group differences on other measures of USN (Motor-Free Visual Perception Test, Star Cancellation Test, Catherine Bergego Scale).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that rTMS is not more effective than sham stimulation for improving USN among patients with acute stroke.
Note: High frequency rTMS was more effective than sham stimulation on one measure of USN (Line Bisection Test).

Virtual RealityEffective2b

One poor quality RCT (Kim et al., 2011) investigated the effect of virtual reality training on USN among patients with acute stroke. This poor quality RCT randomized patients with acute stroke to receive virtual reality (VR) USN training or conventional USN training. Both groups showed a significant improvement in USN (Star Cancellation Test, Line Bisection Test, Catherine Bergego Scale) at 3 weeks (post-treatment); the VR USN group demonstrated significantly greater improvement than the control group on the Star Cancellation Test and Catherine Bergego Scale from baseline to post-treatment. 

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that virtual reality training is more effective than conventional rehabilitation for improving USN among patients with acute stroke.

Visual imageryNot effective2b

One quasi-experimental study (Niemeier et al., 2001) investigated the effect of visual imagery on USN among patients with stroke. This pre-post repeated measures study assigned patients with acute stroke to receive visual imagery training and conventional rehabilitation or conventional rehabilitation alone. Visual imagery training promoted visual scanning. There were no significant between-group differences in USN (Mesulam Verbal Cancellation Test, Rancho Los Amigos Cognitive and Behavioural Scale) at post-treatment. However, there was a significant between-group difference on the Functional Independence Measure (FIM) for the subscales Walking/Wheelchair Task and Problem-Solving Task as well as for a Route-Finding Task at discharge.
Note: There were no reported differences on the FIM grooming, dressing upper body, dressing lower body, feeding, toileting, safety judgement, attention, bathing, reading or writing subtests.

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that visual imagery to promote visual scanning is not more effective than conventional rehabilitation alone for improving USN among patients with acute stroke.

Visual scanningNot effective1b

One high quality RCT (Ianes et al., 2012) investigated the effect of visual scanning training on USN among patients with acute stroke. This high quality RCT randomized patients with acute stroke and left USN to receive right half-field patching or visual scanning training over a 15 day period. There were no significant between-group differences in USN (Line Crossing Test, Bells Test, Line Bisection Test) at post-treatment. At one-week follow-up there was a significant between-group difference in Line Crossing Test scores only, in favor of half-field patching compared to visual scanning training.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that visual scanning training is not more effective than a comparative intervention (half-field patching) for improving USN among patients with acute stroke.
Note: in fact, half-field patching was more effective than visual scanning training on one measure of USN.

Subacute phase

Computer trainingNot effective2a

One fair quality RCT (Modden et al., 2012) has investigated the effect of computer training on USN among patients with subacute stroke. This fair quality  RCT randomly assigned patients with subacute stroke  and homonomous hemianopia to receive Restorative Computerized Training (RT), Compensatory Therapy (CT) or conventional occupational therapy (OT) in addition to standard inpatient rehabilitation. Participants in the RT group were required to respond to stimuli as they appeared on the computer screen, and eye movements were not permitted. Participants in the CT group performed an ‘exploration task’ that promoted visual exploration in the hemianopic field. At post-treatment (3 weeks) there were no significant between-group differences on measures of USN (Test of Attentional Performance (TAP) Visual Field Test, Phasic Alertness and visual scanning tests; Behavioral Inattention Test (BIT) Line Cancellation, Star Cancellation and Letter Cancellation Tasks; Weschler Memory Test standardized reading texts).

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that computer training is not more effective than conventional occupational therapy for improving USN among patients with subacute stroke.
Note: Results from one fair quality RCT also indicate no significant difference in efficacy between two types of computer training.

Limb activationInsufficient evidence5

No known RCTs have investigated the effect of limb activation interventions on USN among patients with subacute stroke. One non-randomized study (Bailey et al., 2002) is reviewed. This non-randomized study assigned 2 patients with subacute stroke and USN to perform contralesional  limb activation training using functional, goal-oriented upper limb activities in the neglected hemispace, for ten 1-hour sessions conducted over approximately 3 weeks. Both patients demonstrated a significant improvement on one or more tests of USN (measured using the BIT Star Cancellation Test, Line Bisection Test and the Baking Tray Task) at post-treatment, and maintained results at follow-up (approximately three weeks later).

Conclusion: There is insufficient evidence (level 5) regarding the effect of limb activation interventions on USN among patients with subacute stroke. However, one non-randomized study reported improvement on one or more tests of USN following limb activation interventions.

Mirror TherapyEffective1b

One high quality RCT (Dohle et al., 2009) investigated the effect of mirror therapy on USN in patients with stroke. This high quality RCT randomized patients with subacute stroke to a mirror therapy group that performed upper limb exercises while watching the unaffected limb in a mirror, or a control group that performed the same exercises while watching the affected limb. There was a significant between-group difference in hemineglect (measured using a 5-point rating scale derived from the Behavioural Inattention Test and the Test of Attentional Performance), in favour of the mirror therapy group compared to the control group.

 Conclusion: There is moderate evidence (level 1b) from one high quality RCT that mirror therapy is more effective than a control therapy in improving USN in patients with subacute stroke.

Neck/Hand VibrationEffective2b

One quasi-experimental study (Kamada et al.,2011) has investigated the effect of neck/hand vibration on USN among patients with subacute stroke. This multiple-baselines study assigned patients with subacute stroke  and USN to receive neck-muscle vibration before occupational therapy (OT) in an A1-B-A2 format. Neck vibration treatment (session B) consisted of left posterior neck muscle vibration for 5 minutes using a handheld vibrator; and conventional OT (sessions A1 and A2) consisted of ADLs, vocational, perceptual and functional activities. Significant improvements in USN (BIT conventional and behavioral scores) were noted compared to baseline after sessions B and A2.
Note: Significant improvements in USN (not compared to baseline) were noted after session B (BIT conventional and behavioral scores) and after sessions A2 (BIT behavioral scores).

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that the use of neck vibration stimulation with conventional occupational therapy may improve USN symptoms in patients with subacute stroke shortly following treatment.

Optokinetic stimulationEffective1b

One high quality RCT (Kerkhoff et al., 2012) investigated the effect of optokinetic stimulation on USN among patients with subacute stroke. This high  quality  RCT  randomly assigned patients with subacute stroke and left visual neglect and left auditory neglect to receive  optokinetic stimulation (OKS) or conventional visual scanning training. At post-treatment (4 weeks) there was a significant between-group difference in visual neglect (horizontal line bisection task, number cancellation task, reading task), in favour of OKS compared to visual scanning training. Between-group differences did not remain significant at follow-up (2 months later).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that optokinetic stimulation is more effective than a comparison intervention (conventional visual scanning training) for improving USN among patients with subacute stroke, in the short term.

Prism AdaptationNot effective1a

Two high quality RCTs (Turton et al., 2010Mizuno et al., 2011), one fair quality RCT (Rossi et al., 1990) and a single subject repeated measures study (Pisella et al., 2002) have investigated the effect of prism adaptation interventions on USN among patients with subacute stroke.

The first high quality RCT (Turton et al., 2010) randomized patients with subacute stroke and left USN to receive prism adaptation training using prismatic lenses of 6° or sham treatment using neutral glasses. There were no significant between-group differences in USN (BIT) at post treatment (2 weeks) or follow-up (8 weeks).

The second high quality RCT (Mizuno et al., 2011) randomized patients with subacute stroke and left USN to a prism adaptation group or a control group that wore neutral glasses. Prism glasses shifted the visual field 12 degrees to the right. Patients were also grouped according to mild or severe USN. There were no significant between-group differences in USN (Catherine Bergego Scale, BIT-B, BIT-C) at post-treatment (2 weeks) or on discharge from hospital.

The fair-quality RCT (Rossi et al., 1990) randomly assigned patients with subacute stroke and homonymous hemianopia or unilateral visual neglect to an intervention group that received treatment using Fresnel prisms or a control group that received no additional treatment. Fresnel prisms were 15-diopter plastic press-on prisms that were worn during all daytime activities. There were significant between-group differences in measures of USN (Motor Free Visual Perception Test, Line Bisection Task, Line Cancellation Task, Harrington Flocks Visual Field Screener, Tangent Screen Examination) at 4 weeks, in favour of the intervention group compared to the control group. 

A single subject repeated measures study (Pisella et al., 2002) assigned two patients with subacute stroke and USN to receive one session of prism adaptation treatment. One patient demonstrated improved USN (Line Bisection Test) at post-treatment, and sustained improvements up to 4 days post-treatment.

Conclusion: There is strong evidence (level 1a) from two high quality RCTs that prisms are not more effective than neutral glasses in improving USN symptoms in patients with subacute stroke. However, one fair quality RCT noted an improvement in USN using Fresnel prisms and a single subject repeated measures study noted improvement in USN for one patient following prism adaptation treatment.

Transcranial Magnetic Stimulation - Theta-burst Stimulation (TBS)Effective1a

Two high quality RCTs (Cazzoli et al., 2012Koch et al., 2012) examined the effects of theta-burst stimulation (TBS) transcranial magnetic stimulation (TMS) over the left posterior parietal cortex on unilateral spatial neglect (USN) symptoms in patients with subacute stroke and left USN.

The first high quality RCT (Cazzoli et al., 2012) randomly assigned patients with subacute stroke and left spatial neglect to receive continuous theta burst stimulation followed by sham stimulation (TBS1), sham stimulation followed by continuous theta burst stimulation (TBS2), or no stimulation (control). There were significant between-group differences in USN (Catherine Bergego Scale, Vienna Test System, Random Shape Cancellation Test, Two-Part Picture Test) between groups that received cTBS and the group that received no stimulation immediately following stimulation and at follow-up (1-2 weeks later).
Note: There were no differences between groups on another measure of USN (Munich Reading Texts) at either time point. This study did not compare cTBS and sham stimulation.

The second high quality RCT (Koch et al., 2012) randomized patients to receive real continuous (cTBS) or sham TBS over the left posterior parietal cortex in addition to conventional therapy. There was a significant between-group difference in USN symptoms (Behavioral Inattention Test) at post-treatment (2 weeks) and at follow-up (4 weeks) in favour of real cTBS compared to sham TBS.

Conclusion: There is strong evidence (level 1a) from two high-quality RCTs that theta-burst stimulation over the left posterior parietal cortex is more effective than comparison interventions (no stimulation, sham stimulation) for improving USN symptoms on the left visual field in patients with subacute stroke and USN.

Virtual RealityNot effective2b

No RCTs have investigated the use of virtual reality in the management of USN among patients with subacute stroke. A quasi-experimental study (Katz et al., 2005) is reviewed. This quasi-experimental study allocated patients with subacute stroke to received computer-based virtual reality street crossing USN training or computer-based visual scanning USN training. There were no significant between-group differences in USN measures (BIT Star Cancellation Test, Mesulam Symbol Cancellation Test) at 4 weeks (post-treatment). 
Note: At post-treatment the control group demonstrated a significant improvement in BIT Star Cancellation Test scores, whereas no significant improvement was seen in the VR group. Both groups demonstrated a significant improvement in scores on the Mesulam Symbol Cancellation Test at post-treatment.

Conclusion: There is limited evidence (level 2b) that virtual reality is not more effective than comparison interventions (computer-based visual scanning training) for improving USN among patients with subacute stroke.
Note: The virtual reality treatment group presented with more severe USN at baseline than the computer-based visual scanning group, which might have contributed to the lack of significant between-group findings at post-treatment.

Visual scanningConflicting evidence4

Two high quality RCTs (Fanthome et al., 1995Kerkhoff et al., 2012), three fair quality RCTs (Weinberg et al., 1977Weinberg et al., 1979Antonucci et al., 1995), one poor quality RCT(Paolucci et al., 1996) and one non-randomized study (Bailey et al., 2002) have investigated the effect of visual scanning training on USN among patients with subacute stroke.

The first high quality RCT (Fanthome et al., 1995) randomly assigned patients with subacute stroke and USN to receive auditory feedback of eye movements or no treatment for visual inattention. The intervention group were required to wear glasses that provided an auditory reminder beep if the patient failed to move their eyes to the left in a 15 second interval. There were no significant between-group differences in eye movements or USN (measured using the Behavioural Inattention Test) at post-treatment (4 weeks) or follow-up (8 weeks).

The second high quality RCT (Kerkhoff et al., 2012) randomly assigned patients with subacute stroke and left visual neglect and left auditory neglect to receive visual scanning training or optokinetic stimulation. At post-treatment (4 weeks) there was a significant between-group difference in visual neglect (Horizontal Line Bisection Task, Number Cancellation Task, Reading Task), in favour of optokinetic stimulation compared to visual scanning training. Between-group differences did not remain significant at follow-up (2 months later).

The first fair quality RCT (Weinberg et al., 1977) randomly assigned patients with subacute stroke and left USN to receive visual scanning training or conventional therapy. There were significant between-group differences in improvements on a comprehensive neuropsychological battery (including the Wide Range Reading Achievement Test, Paragraph Reading, Wide Range Arithmetic, Single Letter Cancellation Test, Double Letter Cancellation Test) at post-treatment (4 weeks), in favour of visual scanning training compared to conventional therapy

The second fair quality RCT (Weinberg et al., 1979) randomly assigned patients with subacute stroke and left USN to receive visual scanning training with spatial and sensory awareness or conventional therapy. There were significant between-group differences in improvements on a comprehensive neuropsychological battery (including the Wide Range Reading Achievement Test, Paragraph Reading, Wide Range Arithmetic, Single Letter Cancellation Test, Double Letter Cancellation Test) at post-treatment (4 weeks), in favour of visual scanning training compared to conventional therapy. 
Note: Further analysis revealed that participants in the experimental group with severe impairments had significantly greater improvements following treatment as compared to those with mild impairments.

The third fair quality RCT (Antonucci et al., 1995) randomized patients with subacute stroke to receive immediate or delayed specific neglect training that included visual scanning, reading and copying, drawing and figure description tasks. There were significant within-group improvements in neglect (measured by the Letter Cancellation test, Albert’s Barrage Test, Sentence Reading Test, Wundt-Jastrow Area Illusion Test and Functional Neglect Scale) following specific neglect training. 
Note: The study did not report between-group differences. The delayed training group received nonspecific cognitive training while waiting for specific training; no significant improvements in measures of neglect were reported following nonspecific cognitive training.

The poor quality cross-over study (Paolucci et al., 1996) randomly assigned patients with subacute stroke and left USN to receive immediate specific neglect training (visual scanning exercises, reading and copying tasks, copying line drawings and description of scene tasks) or delayed specific neglect training, during which time participants received general cognitive training. There was a significant between-group difference in measures of USN (Letter Cancellation Test, Wundt-Jastrow Area Illusion Test and the Sentence Reading Test) at 8 weeks (post-treatment 1), in favour of the group that received immediate specific neglect training compared to those who received general cognitive training. At 16 weeks (post-treatment 2), by which time the second group had also received specific neglect training, there were no longer any significant between-group differences in USN.
Note: However, there were no significant between-group differences in a fourth measure of USN (Barrage Test) at both measurement times.

A non-randomized study (Bailey et al., 2002) assigned 5 patients with subacute stroke and USN to perform scanning and cueing training during reading and copying tasks and games. Three of the five patients demonstrated a significant improvement on one or more tests of USN (measured using the BIT Star Cancellation Test, the Line Bisection Test and the Baking Tray Task) at post-treatment (3 weeks), and maintained results at follow-up (approximately three weeks later).

Conclusion: There is conflicting evidence (level 4) regarding the effect of visual scanning training on USN among patients with subacute stroke. Differences in the type and duration of visual scanning training, comparison treatments, and USN measures used, are likely to account for discrepancies among studies.

Visual scanning with trunk rotationEffective2a

One fair quality RCT (Wiart et al., 1997) examined the use of trunk rotation to encourage visual scanning of the neglected hemispace in patients with subacute stroke and USN. This  fair  quality RCT  randomized patients with subacute stroke and USN to receive visual scanning training with voluntary trunk rotation using the Bon Saint Come method or conventional neurorehabilitation. There were significant between-group differences in improvements on measures of USN (Line Bisection Test, Line Cancellation Test, Bell Test) at post-treatment (day 30) and follow-up (day 60), in favour of the experimental group compared to the control group.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that visual scanning training using trunk rotation is more effective than conventional rehabilitation for improving USN among patients with subacute stroke.

Chronic phase

Virtual RealityEffective2b

Two non-randomised studies (Webster et al., 2001Sedda et al., 2013) have investigated the effect of virtual reality on USN among patients with chronic stroke.

quasi-experimental study (Webster et al., 2001) allocated patients with chronic stroke to receive virtual reality (VR) USN training focusing on wheelchair navigation/obstacle avoidance course tasks or conventional USN intervention. Significant between-group differences were found on all measures of USN (number of errors in real and virtual wheelchair obstacle crossing tasks, fall reports during hospitalization, obstacle hits on a video obstacle course task) at post-treatment, in favour of VR USN training compared to conventional USN intervention.

A pre-post single design study (Sedda et al., 2013) assigned one patient with chronic stroke and left USN to receive VR training using the Sony PS3 “EyeToy” to grasp virtual objects among distractors using the unaffected hand. Significant* improvements on measures of USN (Line Bisection Test, Albert’s Cancellation Test) at post-treatment (4 weeks) and gains were maintained at follow-up (5 months).
*Note: Statistical data was not provided. 

Conclusion: There is limited evidence (level 2b) from one quasi-experimental study that virtual reality USN training is more effective than conventional USN intervention for improving USN among patients with chronic stroke. Also, a pre-post single design study noted improvements on USN measures after a VR training.

Visual scanningInsufficient evidence5

One non-randomized study (Ladavas et al., 1994) has examined the effect of visual scanning intervention on USN among patients with chronic stroke. This non-randomized study assigned patients with chronic stroke and left USN to receive covert computerized visual scanning and attention training, overt computerized visual scanning and attention training, or no computerized visual scanning and attention training. Both training groups demonstrated significant improvements in measures of USN (Letter Cancellation Test, Line Cancellation Test, Bells Test, Object Pointing Task) and a non-standardized measure of visual extinction and neglect at post-treatment (6 weeks). 
Note: Improvements in detecting targets were specific to the left space; there was no significant improvement in a test of tactile extinction and neglect within any group at post-treatment.

Conclusion: There is insufficient evidence (level 5) regarding the effect visual scanning on USN among patients with chronic stroke. However, a non-randomized study reported significant improvements in measures of USN after computerized visual scanning and attention training.

Phase of stroke recovery not specific to one period

Eye patchingEffective2b

One poor quality RCT (Zeloni et al., 2002) has investigated the effect of eye patching on USN among patients with stroke (time since stroke not specific to one period). This poor quality RCT randomized patients with subacute or chronic stroke and left USN to receive hemiblinding using goggles or no hemiblinding. A significant between group difference was found in favour of the goggles group for the Albert’s Test at at 1 week (post-treatment) or 2 weeks (follow-up). However, there were no significant between-group differences in other measures of USN (Line Cancellation Test, Letter Cancellation Test, Bell’s Test, Copying A Drawing, Line Bisection Test) at both measurement times.

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that eye patching is more effective than a control intervention (no eye patching) for improving USN among patients with stroke.

Limb activationConflicting evidence4

Two high quality RCTs (Robertson et al., 2002Luukkainen-Markkula et al., 2009) and one fair quality RCT (Harvey et al., 2003) investigated the effect of limb activation exercises on USN among patients with stroke (time since stroke not specific).

The first high quality RCT (Robertson et al., 2002) randomised patients with subacute to chronic stroke and left unilateral visual neglect to receive perceptual training + limb activation treatment or perceptual training alone. There were no significant between-group differences in unilateral neglect (Behavioural Inattention Test – BIT, Comb and Razor Test, Landmark Test) at 12 weeks (post-treatment) or at 3 months, 6 months or 18-24 months (follow-up).

The second high quality RCT (Luukkainen-Markkula et al., 2009) randomly assigned patients with acute or subacute stroke and left hemispatial neglect to receive left arm activation therapy or visual scanning training, in addition to conventional rehabilitation. The arm activation therapy group demonstrated significant improvements in visual neglect (BIT conventional subtest) at 3 weeks (post-treatment) and 6 months later (follow-up). There was no significant improvement in behavioural neglect (Catherine Bergego Scale) at either time point. 
Note: Between-group differences were not reported.

The fair quality RCT (Harvey et al., 2003) pseudorandomly assigned patients with subacute or chonic stroke and USN to an intervention group that performed centre-lifting rod exercises or a control group that performed right-lifting rod exercises. There was a significant between-group difference in one measure of USN (Landmark Test) at 3 days (post-treatment stage 1), in favour of the intervention group compared to the control group. There were no significant between-group differences in other measures of USN (Line Bisection Test, Real Objects Test, BIT, Balloons Test) at 10 days (post-treatment stage 2) or 1 month (follow-up).

Conclusion: There is conflicting evidence (level 4) from 2 high quality RCTs and one fair quality RCT regarding the effect of limb activation on USN. A first, high quality  RCT found no significant between-group differences on USN when comparing a perceptual training + limb activation treatment and perceptual training alone. On the other hand, a second high quality  RCT found significant improvements in USN after an arm activation therapy group as compared to a visual scanning training. Finally, a fair quality RCT noted a significant improvement in one measure of USN post-treatment but not on the other three measures at post-treatment and follow up.

Mental practiceNot effective2a

One fair quality RCT (Ferreira et al., 2011) investigated the effect of mental practice on USN among patients with stroke (time since stroke not specific to one period). This fair quality RCT randomly assigned patients with subacute or chronic stroke and left hemispatial neglect to receive mental practice training, visual scanning training, or physiotherapy alone (control). There were no significant differences in neglect (BIT conventional scores) between mental practice and visual scanning, or between mental practice and the control group, at post-treatment (5 weeks) or follow-up (3 months later).

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that mental practice is not more effective than comparison interventions (visual scanning training, conventional rehabilitation) for improving USN among patients with subacute or chronic stroke.

Optokinetic stimulationConflicting evidence4

One fair quality RCT (Schroder et al., 2008) and one poor quality RCT (Pizzamiglio et al., 2004) examined the use of optokinetic stimulation in patients with stroke and USN (time since stroke not specific).

The fair quality RCT (Schroder et al., 2008) randomly assigned patients with acute to subacute stroke and left neglect to receive optokinetic stimulation + exploration (scanning) training, TENS + exploration training, or exploration training alone. There were significant between-group differences in neglect (measured using the NET Line Cancellation, Star Cancellation, Line Bisection, Figure Copying and Freehand Drawing Subtests and the Test of Attentional Performance (TAP) Neglect Subtest) and reading and writing skills (measured using reading test A from the ELEX manual and a writing dictation task) after 10 sessions (mid-treatment), 20 sessions (post-treatment) and 1 week post-treatment (follow-up), in favour of optokinetic stimulation + exploration training compared to exploration training alone. There were no significant differences between optokinetic stimulation + exploration training or TENS + exploration training at any time point.

The poor quality RCT (Pizzamiglio et al., 2004) randomized patients with subacute or chronic stroke to receive specific USN training and optokinetic stimulation (a leftward-moving background of black dots on a computer screen) or specific USN training alone. At post-treatment (6 weeks) there were no significant between-group differences in measures of USN (Albert’s Test, Letter Cancellation Test, Reading Task, Wundt-Jastrow Area Illusion Test, BIT Line Cancellation Test), the functional impact of USN (Semi-structured Scale for the Functional Evaluation of Personal Neglect, Semi-structured Scale for the Functional Evaluation of Extrapersonal Neglect), or functional independence (Barthel Index).

Conclusion: There is conflicting evidence (level 4) between studies regarding the effectiveness of optokinetic stimulation on neglect among patients with stroke. Discrepancies in results arise from differences in control treatments and stage of stroke of study participants.

Prism adaptationEffective1b

One high quality RCT (Serino et al., 2009), two fair quality RCTs (Rossetti et al., 1998Mancuso et al., 2012) and one non-randomized study (Frassinetti et al., 2002) investigated the effect of prism adaptation on USN among patients with stroke (time since stroke not specific to one period).

The high quality RCT (Serino et al., 2009) pseudorandomized patients with acute to chronic stroke and left USN to an intervention group that performed scanning treatment wearing prismatic goggles deviating the visual field 10 degrees to the right, or a control group that performed scanning treatment with neutral goggles. At post-treatment (2 weeks) there was a significant between-group difference* on measures of USN (BIT, BIT Star and Letter Cancellation subtests, Bell Cancellation Test, Reading Test), in favour of prismatic goggles compared to neutral goggles. At the end of treatment the control group also received 2 weeks of prismatic adaptation training. This group demonstrated significant improvement on measures of USN (BIT, Cancellation Tests, Reading Task). At follow-up (1 month post-treatment), both groups demonstrated significant improvements compared to baseline (but not compared to post-treatment) on measures of USN (BIT, Cancellation Tests, Reading Task). There were no significant between-group differences at follow-up. 
*differences reflect change in scores from baseline to post-treatment.

The first fair quality RCT (Rossetti et al., 1998) randomized patients with acute to chronic stroke and left hemispatial neglect to an intervention group that received prism adaptation training using goggles with wedge prisms with 10-degree optical deviation to the right or a control group that wore neutral goggles. Immediately post-treatment (5 minutes) and at follow-up (2 hours later), there were significant between-group differences on all measures of USN (Line Bisection Task, Line Cancellation Task, Copying A Drawing, Drawing From Memory, Reading Simple Text) in favour of the prism adaptation training group.

The second fair quality RCT (Mancuso et al., 2012) randomized patients with subacute or chronic stroke and left USN to an intervention group that performed pointing exercises wearing prismatic lenses deviating the visual field 5 degrees to the right or a control group that performed pointing exercises with neutral lenses. There were no significant between-group differences on measures of USN (Albert Test, Bells Cancellation Test, Line Orientation Test, and four BIT subtests: line bisection, copying drawings, finding objects, dealing playing cards) at post-treatment (1 week).

A non-randomized study (Frassinetti et al., 2002) provided patients with subacute or chronic stroke and left USN with prism adaptation training during pointing tasks. Participants demonstrated significant improvements on measures of USN (BIT, Bell’s Test, Reading Test, Objects Reaching Test and Room Description Test) at post-treatment (2 days) and follow-up (1 week post-treatment, 5 weeks post-treatment).
Note: there was no significant improvement in performance on a modified version of the Fluff Test at any time point.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT, one fair quality RCTs and one non randomized study that training with prism adaptation is more effective than control interventions (neutral glasses) for improving USN among patients with stroke . However, another fair quality RCT did not find any significant difference on USN after wearing prismatic lenses while performing pointing exercises.

Sensory cueingNot effective1b

One high quality RCT (Fong et al., 2013) has investigated the use of sensory cueing in the treatment of USN among patients with stroke (time since stroke not specific to one period). This high quality RCT randomly assigned patients with acute or subacute stroke and left USN to receive contralesional sensory cueing and limb activation or sham cueing. There was a significant between-group difference in one measure of USN (BIT Drawing Tasks) overall (i.e. from measures taken at post-treatment and follow-up), in favour of the intervention group compared to the control group. There were no significant between-group differences in other measures of USN (BIT Cancellation Tasks) at post-treatment (3 weeks) or follow-up (6 weeks).

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that sensory cueing and limb activation training is not more effective than a control intervention (sham cueing) for improving USN among patients with stroke.
Note: Significant between-group differences were found on one measure of USN.

Sensory stimulationEffective1b

One high quality RCT (Polanowska et al., 2009) investigated the effect of sensory stimulation to the affected arm on USN among patients with stroke (time since stroke not specific to one period). This high  quality  RCT  randomised patients with acute to subacute stroke  and left visual hemineglect to receive visual scanning training with somatosensory electrical stimulation or visual scanning training with sham stimulation. Stimulation comprised 30 minutes of transcutaneous electrical stimulation to the left hand in the experimental group and sham (no current) stimulation in the control group. At post-treatment (4 weeks) there was a significant between-group difference in scanning accuracy and scanning range (measured using the BIT Line Crossing and Star Cancellation Tests and a Letter Reading Task), in favour of electrical stimulation compared to sham stimulation.

Conclusion: There is moderate evidence (level 1b) from one high quality RCT that somatosensory electrical stimulation is more effective than sham stimulation for improving USN among patients with acute/subacute stroke.

Transcutaneous Electrical Nerve Stimulation (TENS)Effective2a

One fair quality RCT (Schroder et al., 2008) investigated the effect of TENS on neglect among patients with stroke (time since stroke not specific to one period). This fair quality RCT randomly assigned patients with acute to subacute stroke and left neglect to receive  TENS + exploration (scanning) training, optokinetic stimulation + exploration training, or exploration training alone. Compared to the control group, the TENS group demonstrated significantly better improvement in neglect (measured using the NET Line Cancellation, Star Cancellation, Line Bisection, Figure Copying and Freehand Drawing subtests and the Test of Attentional Performance (TAP) neglect subtest) after 20 sessions (post-treatment), and in reading/writing (measured using reading test A from the ELEX manual and a writing dictation task) at 10 sessions (mid-treatment), 20 sessions (post-treatment) and 1 week post-treatment (follow-up). There were no significant differences between TENS + exploration training or optokinetic stimulation + exploration training at any time point.

Conclusion: There is limited evidence (level 2a) from one fair quality RCT that TENS + exploration (scanning) training is more effective than conventional scanning training for improving neglect among patients with acute to subacute stroke.

Virtual RealityNot effective2b

One poor quality RCT  (van Kessel et al., 2013) investigated the effect of virtual reality on USN among patients with stroke (time since stroke not specific to one period). This poor quality RCT semi-randomized patients with subacute or chronic stroke and left USN to receive dual task virtual reality (VR) training (driving simulation and response to visual scanning task) or single task VR training. There were no significant between-group differences in USN measure (Line Cancellation Test, Letter Cancellation Test, Bells Test, Line Bisection Test, Word Reading task, Grey Scales, Baking Tray Task, Semi-Structured Scale for the Evaluation of Extrapersonal and Personal Neglect, Subjective Neglect Questionnaire) at post-treatment (6 weeks).

Conclusion: There is limited evidence (level 2b) from one poor quality RCT that dual task VR training is not more effective than single task VR training for improving USN among patients with stroke.

Visual scanningNot effective1a

Two high quality RCTs (Roberston et al., 1990Luukkainen-Markkula et al., 2009) and one fair quality RCT (Ferreira et al., 2011) examined the effect of visual scanning on USN among patients with stroke  (time since stroke not specific).

The first high quality RCT (Robertson et al., 1990) randomly assigned patients with acquired head injury (n=33 subacute/chronic stroke) and left USN to receive computerized scanning and attentional training or recreational computing. There were no significant between-group differences on measures of USN (BIT, Rey-Osterreith Complex Figure Copy Test, Neale Reading Test Accuracy Score, Letter Cancellation Test, WAIS-R Block Design Subtest, an observer’s report of neglect) at post-treatment (approximately 9 weeks) or follow-up (6 months later). There was a significant between-group difference on one measure of USN (WAIS-R Picture Completion Subtest) at post-treatment but this was not maintained at follow-up.

The second high quality RCT (Luukkainen-Markkula et al., 2009) randomly assigned patients with acute or subacute stroke and left hemispatial neglect to receive left arm activation therapy or visual scanning training, in addition to conventional rehabilitation. The visual scanning group demonstrated no significant improvement in visual neglect (BIT conventional scores) at 3 weeks (post-treatment), but improvements were significant 6 months later (follow-up). There was no significant improvement in behavioural neglect (Catherine Bergego Scale) at either time point. 
Note: Between-group differences were not reported.

The fair quality RCT (Ferreira et al., 2011) randomly assigned patients with subacute or chronic stroke and left hemispatial neglect to receive visual scanning training, mental practice training, or physiotherapy alone (control). There were significant between-group differences in neglect (BIT conventional scores) at post-treatment (5 weeks), in favour of visual scanning training compared to the control group. Differences did not remain significant at follow-up (3 months later). There were no significant differences in neglect between visual scanning training and mental practice training at either time point.

Conclusion: There is moderate evidence (level 1a) from two high quality RCTs that visual scanning  is not more effective than a control intervention (recreational computing or conventional rehabilitation) for improving USN among patients with stroke . However, one fair quality RCT noted improvements in neglect at post-treatment but that difference did not remain significant at follow up.


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Excluded Studies:

Castiello, U., Lusher, D., Burton, C., et al. (2004). Improving left hemispatial neglect using virtual reality. Neurology, 62, 1958-62.
Reason for exclusion: feasibility study.

Dick, A. S., Raja Beharelle, A., Solodkin, A., & Small, S. L. (2013). Interhemispheric functional connectivity following prenatal or perinatal brain injury predicts receptive language outcome. J Neurosci., 33(13), 5612-5625.
Reason for exclusion: study participants were children.

Ertekin, A., Gelecek, N., Yildirim, Y., & Akdal, G. (2009). Supervised versus home physiotherapy outcomes in stroke patients with unilateral visual neglect: a randomized controlled follow-up study. Journal of Neurological Sciences, 26 (3), 325-34.
Reason for exclusion: Both groups were given the same exercise program to target USN, which was then performed under supervision or as a home program.

Hommel, M., Peres, B., Pollak, P., Memin, B., Besson, G., Gaio, J.M., & Perret, J. (1990). Effects of passive tactile and auditory stimuli on left visual neglect. Archives of Neurology, 47, 573-576.
Reason for exclusion: No control group.

Kim, J., Kim, K., Kim, D.Y., Chang, W.H., Park, C., Ohn, S.H., Han, K., Ku, J., Nam, S.W., Kim, I.Y., & Kim, S.I. (2007). Virtual reality training system for rehabilitation of stroke patients with unilateral neglect: crossing the virtual street. CyberPsychology & Behavior, 10(1), 7-15.
Reason for exclusion: feasibility study.

Tham, K. & Tegner, R. (1997). Video feedback in the rehabilitation of patients with unilateral neglect. Archives of Physical Medicine and Rehabilitation, 78, 410-413.
Reason for exclusion: Both groups received sensory feedback (verbal feedback vs. visual feedback)

Trislin, I., Dupierriz, E., Chokron, S., Coquillart, S., & Ohlmann, T. (2009). Uses of virtual reality for diagnosis, rehabilitation and study of unilateral spatial neglect: review and analysis. CyberPsychology & Behavior, 12(2), 175-81.
Reason for exclusion: review article.

Walker, R., Young, A.W., & Lincoln, N.B. (1996). Eye patching and the rehabilitation of visual neglect. Neuropsychological Rehabilitation, 6(3), 219-231.
Reason for exclusion: no control group.