Patients with unilateral spatial neglect have greater impairment and disability, and poorer functional outcome

SUMMARY

Objective: To explore the relationship between unilateral spatial neglect and levels of sensorimotor and cognitive impairment and functional ability in patients with right hemisphere lesions.

Design: Cohort study. Patients assessed at admission, discharge and 6 months post discharge.

Setting: Rehabilitation Hospital, Israel.

Patients: 40 consecutively admitted patients with first stroke, divided into a ‘neglect’ and ‘no-neglect’ group based on Behavioural Inattention Test for Neglect Scores. Neglect group: n=19, time between onset and first assessment = 34.5 ± 10.9 days. No-neglect group: n=21, time between onset and first assessment = 25.4 ± 9.0 days.

Main outcome measures: Sensorimotor Assessment of upper limb; Behavioral Inattention Test; ADL checklist for Neglect; Loewenstein OT cognitive assessment; FIM; Rabideau Kitchen Evaluation to assess instrumental activity of daily living (IADL).

Main results: Neglect group significantly more impaired in sensorimotor assessment; cognitive performance (Behavioral Inattention Test and ‘perception’, ‘visuomotor organisation’ and ‘thinking operations’ from the Loewenstein OT cognitive assessment); FIM; and IADL. Performance at all assessments improved with time, but a significant difference was maintained between groups at admission, discharge and 6-month follow-up. The length of stay was significantly longer for patients with neglect, and these patients needed significantly more support from carers to perform basic ADL. The Behavioral Inattention Test score was a predictor of functional outcome (FIM and IADL) at 6 month follow-up.

Conclusions: Unilateral neglect appears to be strongly related to levels of impairment and functional ability in patients with stroke. Further research is essential to determine appropriate treatment strategies for this patient group.

DEBATE: WHAT DO WE THINK OF IT?

Introduction: Do we know the key aim of the study? And why/how this was formed?

Definitions and reports of incidence of unilateral spatial neglect are provided. No data is provided from other studies comparing the relationship of neglect to functional outcome: it is not clear whether such data has not previously been collected or whether there is data available in the literature.

Useful descriptors, and references, for each of the assessments used are provided, given information on the scoring of the tests and whether their validity and reliability has been established. However the authors fail to identify who performed the assessments for this study, what their experience was, whether their reliability was assessed, and whether the assessor was blinded to either the "group" of the patient (i.e. ’neglect’ or ‘no neglect’) or to previous assessments. It is difficult to assess whether or not the assessor could have introduced bias without having this information.

The score from the Behavioural Inattention Test was used to categorise patients as having or not having neglect. However the score at which "neglect" was defined as being present is not provided. This makes it difficult to assess the validity of the categorisation, and prevents repetition of this study by other researchers.

The results are clearly presented, with means and standard deviations and significant levels displayed in tables.

This study has demonstrated that the functional outcome of patients with unilateral spatial neglect is generally poorer than that of patients without neglect. However it is likely that this study has just confirmed what many health professional working in stroke may well have predicted from clinical experience. These results serve to emphasise the need for research into possible treatment interventions for patients with neglect (as the authors of the paper identify), but will have little clinical implication for therapists at the present time.