What is the treatment for hemi-neglect syndrome?

Treatment for Hemi-Neglect Syndrome

The most effective treatment approach for hemi-neglect syndrome involves a combination of top-down and bottom-up rehabilitation strategies, with visual scanning training, limb activation, and prism adaptation therapy showing the strongest evidence for improving neglect symptoms.1

Understanding Hemi-Neglect Syndrome

Hemi-neglect (also called hemispatial neglect, unilateral neglect, or spatial neglect) is a neuropsychological condition that typically occurs after damage to one hemisphere of the brain, most commonly the right hemisphere. It results in a deficit in attention to and awareness of one side of space, usually the left side, which cannot be attributed to primary sensory or motor deficits 1.

Key characteristics include:

• Difficulty attending to stimuli on the contralesional side
• Impaired daily functioning and rehabilitation outcomes
• Often co-occurs with anosognosia (lack of awareness of deficits)
• Significant impact on quality of life and functional recovery

Evidence-Based Treatment Approaches

Top-Down Approaches (Requiring Active Patient Participation)

1. Visual Scanning Training

   • Involves teaching patients to systematically scan the neglected side of space
   • Consistently identified as one of the most effective and widely used interventions 1
   • Implementation: Structured exercises requiring leftward eye movements, often with visual cues or markers

2. Mental Imagery Training

   • Helps patients develop internal representations of neglected space
   • Shows improvement on standard neglect tests 1

Bottom-Up Approaches (Manipulating Sensory Input)

1. Limb Activation

   • Involves movement of the contralesional limb in the neglected space
   • Effective in improving neglect symptoms on standard tests 1
   • Implementation: Structured exercises requiring left limb movement in left hemispace

2. Prism Adaptation

   • Patients wear prism glasses that shift visual field, requiring adaptation
   • Strong evidence for effectiveness in multiple studies 1
   • Implementation: 10-20 minute sessions of reaching tasks while wearing prism glasses

3. Non-Invasive Brain Stimulation

   • Includes repetitive transcranial magnetic stimulation (rTMS) and transcranial direct current stimulation (tDCS)
   • Based on interhemispheric inhibition model 2
   • Implementation: Can inhibit the contralesional (typically left) hemisphere or stimulate the lesioned (typically right) hemisphere

4. Optokinetic Stimulation

   • Uses moving visual stimuli to shift attention
   • Shows improvement on standard neglect tests 1

5. Half-Field Eye Patching

   • Evidence is mixed; some studies show no significant functional improvement 1

Treatment Algorithm

1. Initial Assessment

   • Use multiple tests to identify neglect subtypes and severity 1
   • Assess impact on daily functioning using measures like the Catherine Bergego Scale

2. Early Phase (First 2 Weeks Post-Stroke)

   • Begin with visual scanning training and limb activation exercises
   • Implement these techniques during all rehabilitation activities

3. Acute/Subacute Phase (2-12 Weeks)

   • Add prism adaptation therapy (most effective during this period) 3
   • Continue visual scanning and limb activation
   • Consider non-invasive brain stimulation if available

4. Chronic Phase (>12 Weeks)

   • Continue effective interventions from earlier phases
   • Focus on functional tasks and real-world applications
   • Consider maintenance therapy to prevent regression

Implementation Considerations

• Intensity and Frequency: Higher intensity interventions (>8 hours/week) show better outcomes than lower intensity interventions 1
• Combination Approaches: Using multiple techniques simultaneously appears more effective than single interventions 2
• Duration: Treatment should continue throughout rehabilitation, as neglect symptoms can persist long-term 1
• Multidisciplinary Approach: Coordination between rehabilitation professionals is essential to avoid duplication or omission of cognitive tests and treatments 1

Common Pitfalls and Limitations

1. Task-Specific Effects: Improvements often don't generalize to untrained tasks or daily activities 1
2. Heterogeneous Response: Patients respond differently to treatments based on lesion location and neglect subtype 2
3. Treatment Barriers: Time constraints and equipment shortages are common obstacles to implementing optimal treatment 3
4. Limited Evidence: While promising, many interventions lack large-scale randomized controlled trials 4
5. Awareness Issues: Patients with poor awareness of neglect may show less improvement with scanning protocols 1

Monitoring Progress

• Regular reassessment using standardized neglect tests
• Evaluation of functional improvements in daily activities
• Adjustment of treatment plan based on response

The evidence suggests that a structured rehabilitation program combining visual scanning training, limb activation, and prism adaptation therapy offers the best chance for improving neglect symptoms and functional outcomes in patients with hemi-neglect syndrome.