Interventions for Neglect With Stroke: A Systematic Review

PURPOSE AND BACKGROUND: The aim of this study was to investigate interventions for neglect with stroke. Unilateral neglect is a syndrome that commonly follows hemisphere brain injury, especially the right hemisphere. Neglect is one of the major factors associated with poor functional outcome. For example, stroke patients with neglect may wash their face and body on the right side, eat food on the right side of the mouth, and bump into obstacles on the left side. Intervention approaches for neglect have been divided into top-down approaches and bottom-up approaches. Recently, new approaches that combine top-down approaches with bottom-up approaches, different top-down approaches, and top-down approaches with occupational therapy have been applied in studies. We examined trends in intervention to improve neglect symptoms for stroke patients over the past 10 years and discuss the evidence and implications for occupational therapy practice addressing neglect in stroke patients.

DESIGN AND METHOD: We systematically reviewed articles published in English located using Scopus, PubMed Central, and MEDLINE. The literature search focused on Level I and II studies published between January 2005 and December 2015. The following key terms were used: Stroke AND Neglect AND Intervention. A total of 1,496 articles were found through a database search. After careful review by three reviewers, 14 articles were included for analysis. All articles reviewed provided Level I evidence. The 14 articles were analyzed using the hierarchy of levels of evidence for evidence-based practice. The details of each study were classified and analyzed according to intervention type.

RESULTS: The results were analyzed for level of quality and trend of each study, type of approach, type of intervention, stroke patients’ recovery stage, and dependent variables measured with neglect. The 14 articles were Level I randomized controlled trials. Three studies were published between 2005 and 2010; one study used one intervention and two studies used a combination of interventions. Eleven studies were published between 2011 and 2015; six studies used one intervention and five studies used a combination of interventions. The combination interventions included a top-down approach and bottom-up approach in one study, a bottom-up approach in two studies, occupational therapy and a bottom-up approach in one study, and physiotherapy and a top-down approach in one study. Six approaches to neglect were classified consisting of 16 interventions. Top-down approaches, the most frequently used, consisted of six interventions provided to chronic stroke patients. Functional independence in ADLs was most commonly measured with neglect in all studies, followed by eye movement.

CONCLUSION: We systematically analyzed 14 articles about interventions for stroke with neglect. The 14 articles described randomized controlled trials; the quantity of such studies is increasing. Combination interventions are also increasing; combined interventions are needed to treat neglect with stroke. The interventions were mostly provided to chronic stroke patients; neglect with stroke decreases until 6–8 mo after onset, so interventions for neglect with stroke are needed in the chronic stage. Eye patching and star cancellation were the most frequently used interventions. This systematic review expands the understanding of trends in intervention for neglect and can help occupational therapists select interventions, including frequency and intensity, and assessments according to the stage of stroke of individual patients.

IMPACT STATEMENT: We analyzed the occupational therapy interventions being applied to stroke patients with neglect. This review provides direction and evidence for occupational therapy in hospital settings.

References

Kortte, K. B., & Hillis, A. E. (2011). Recent trends in rehabilitation interventions for visual neglect and anosognosia for hemiplegia following right hemisphere stroke. Future Neurology, 6, 33–43. https://doi.org/10.2217/fnl.10.79

Luauté, J., Halligan, P., Rode, G., Rossetti, Y., & Boisson, D. (2006). Visuo-spatial neglect: A systematic review of current interventions and their effectiveness. Neuroscience and Biobehavioral Reviews, 30, 961–982. https://doi.org/10.1016/j.neubiorev.2006.03.001