Cognitive rehabilitation for spatial neglect following stroke neglect 2007.pdf · Cognitive rehabilitation for spatial neglect following stroke (Review) Bowen A, Lincoln NB This record

Cognitive rehabilitation for spatial neglect following stroke

(Review)

Bowen A, Lincoln NB

This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2007, Issue 3

http://www.thecochranelibrary.com

1Cognitive rehabilitation for spatial neglect following stroke (Review)

Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd

http://www.thecochranelibrary.com

T A B L E O F C O N T E N T S

1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

3CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .

3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .

6METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

7DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

8METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

9RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

10DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

11POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .

12ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

12REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

15Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

25Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

26Characteristics of ongoing studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

28Comparison 01. Cognitive rehabilitation versus any control: immediate effects . . . . . . . . . . . . .

28Comparison 02. Cognitive rehabilitation versus any control: persisting effects . . . . . . . . . . . . . .

29Comparison 03. One type of cognitive rehabilitation versus standard care or attention control: persisting effects . .

29Comparison 04. One cognitive rehabilitation approach versus another: persisting effects . . . . . . . . . .

29Comparison 05. Bottom-up processing approaches versus any control: persisting effects . . . . . . . . . .

29Comparison 06. Top-down processing rehabilitation approaches versus any control: persisting effects . . . . . .

29INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

29COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

30GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

31Analysis 01.01. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 01 Activities of

Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

32Analysis 01.02. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 02 Cancellation:

numbers correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33Analysis 01.03. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 03 Cancellation:

numbers of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

33Analysis 01.04. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 04 Line

bisection: error scores/right deviation . . . . . . . . . . . . . . . . . . . . . . . . . .

34Analysis 01.05. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 05 BIT

behavioural subtests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

34Analysis 01.06. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 06 Discharge

destination (home) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

35Analysis 01.07. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 07 A-rated

studies only: Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . .


studies only: cancellation number correct (single letter task) . . . . . . . . . . . . . . . . . .


studies only: cancellation errors . . . . . . . . . . . . . . . . . . . . . . . . . . . .


studies only: BIT behavioural subtests . . . . . . . . . . . . . . . . . . . . . . . . .

iCognitive rehabilitation for spatial neglect following stroke (Review)


37Analysis 02.01. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 01 Activities of

Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38Analysis 02.02. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 02 Cancellation:

number correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

38Analysis 02.03. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 03 Cancellation:

number of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

39Analysis 02.04. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 04 Line

Bisection: error scores or right deviation . . . . . . . . . . . . . . . . . . . . . . . . .

39Analysis 02.05. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 05 BIT

behavioural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

40Analysis 02.06. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 06 A-rated

studies: Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . .


studies only: cancellation number of errors . . . . . . . . . . . . . . . . . . . . . . . .


studies only: BIT behavioural . . . . . . . . . . . . . . . . . . . . . . . . . . . .

41Analysis 03.01. Comparison 03 One type of cognitive rehabilitation versus standard care or attention control: persisting

effects, Outcome 01 Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . .

42Analysis 04.01. Comparison 04 One cognitive rehabilitation approach versus another: persisting effects, Outcome 01

Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

42Analysis 05.01. Comparison 05 Bottom-up processing approaches versus any control: persisting effects, Outcome 01

Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

43Analysis 06.01. Comparison 06 Top-down processing rehabilitation approaches versus any control: persisting effects,

Outcome 01 Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . .

iiCognitive rehabilitation for spatial neglect following stroke (Review)


Cognitive rehabilitation for spatial neglect following stroke

(Review)

Bowen A, Lincoln NB

This record should be cited as:

Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews 2007,

Issue 2. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586.pub2.

This version first published online: 18 April 2007 in Issue 2, 2007.

Date of most recent substantive amendment: 19 January 2007

A B S T R A C T

Background

Unilateral spatial neglect causes difficulty attending to one side of space. Various rehabilitation strategies have been used but evidence

of their benefit is lacking.

Objectives

To determine the persisting effects of cognitive rehabilitation specifically aimed at spatial neglect following stroke, as measured on

impairment and disability level outcome assessments and on destination on discharge from hospital.

Search strategy

We searched the Cochrane Stroke Group Trials Register (last searched 4 July 2005), MEDLINE (1966 to July 2005), EMBASE

(1980 to July 2005), CINAHL (1983 to July 2005), PsycINFO (1974 to July 2005), UK National Research Register (July 2005). We

handsearched relevant journals, screened reference lists, and tracked citations using SCISEARCH.

Selection criteria

We included randomised controlled trials of cognitive rehabilitation specifically aimed at spatial neglect. We excluded studies of general

stroke rehabilitation and studies with mixed patient groups, unless more than 75% of their sample were stroke patients or separate

stroke data were available.

Data collection and analysis

Two review authors independently selected trials, extracted data, and assessed trial quality.

Main results

We included 12 RCTs with 306 participants. Only four had adequate allocation concealment, that is a low risk of selection bias. A large

number of outcome measures were reported. Only six studies measured disability and two investigated whether the effects persisted.

The overall effect (standardised mean difference) on disability had a wide confidence interval that included zero and was not statistically

significant. For discharge destination there were clinically significant effects but in both directions and the confidence interval of the

odds ratio included one. In contrast, cognitive rehabilitation did improve performance on some, but not all, standardised neglect tests.

The number of cancellation errors made was reduced and the ability to find the midpoint of a line improved immediately and persisted

at follow up. These effects appeared likely to generalise from the samples studied to the target population, but were based on a small

number of studies.

Authors’ conclusions

Several types of neglect specific approaches are now described but there is insufficient evidence to support or refute their effectiveness

at reducing disability and improving independence. They can alter test performance and warrant further investigation in high quality

randomised controlled trials. As we did not review whether patients with neglect benefit from rehabilitation input in general, such

patients should continue to receive general stroke rehabilitation services.



P L A I N L A N G U A G E S U M M A R Y

The benefit of cognitive rehabilitation for unilateral spatial neglect, a condition that can affect stroke survivors, is unclear

Unilateral spatial neglect is a condition which reduces a person’s ability to look, listen or make movements in one half of their

environment. This can affect their ability to carry out many everyday tasks such as eating, reading and getting dressed, and restricts

a person’s independence. Our review found that rehabilitation specifically targeted at neglect appeared to improve a person’s ability

to complete tests such as finding visual targets and marking the mid-point of a line. However, its effect on their ability to carry out

a meaningful everyday task or to live independently was not clear. Patients with neglect should continue to receive general stroke

rehabilitation services but better quality research is needed to identify optimal treatments.

B A C K G R O U N D

Stroke can affect cognitive as well as physical and sensory abili-

ties (Wade 1985). Cognitive deficits include a disorder of spatial

awareness known as unilateral spatial neglect. The most widely

quoted definition of neglect is a description of the resulting be-

havioural disabilities: ’fails to report, respond, or orient to novel

or meaningful stimuli presented to the side opposite a brain le-

sion’ (Heilman 1993). This definition does not describe the causal

mechanism of neglect but indicates that it is not simply due to

sensory or motor defects. Neglect is a disorder which can reduce a

person’s ability to look, listen or make movements towards one half

of their environment. This can also affect their ability to carry out

many everyday tasks, such as eating, reading and getting dressed

(Katz 1999). Stroke may differentially affect our ability to direct

our attention in the visual, auditory or tactile modalities. Since dif-

ferent types of neglect can occur, several terms are used in clinical

practice, such as visual neglect, motor neglect, hemineglect, and

inattention (Bailey 1999). Although people do sometimes neglect

their ipsilesional (same) side, most researchers and clinicians focus

on the far more common neglect of contralesional space.

The reported incidence of neglect in stroke patients has varied

from as high as 90% (Massironi 1988) to as low as 8% (Sunder-

land 1987). The figures depend on the operational definition, se-

lection criteria for patients and method of assessment employed

(Bailey 1999; Bowen 1999; Ferro 1999). A previous systematic

review found that, in 16 of the 17 studies making the comparison,

contralesional neglect occurred more often after right than left

hemisphere stroke (Bowen 1999). Cognitive dysfunction, such as

neglect, can determine the outcome of rehabilitation by adversely

affecting mobility, discharge destination, length of hospital stay,

meal preparation and independence in self-care skills (Barer 1990;

Bernspang 1987; Neistadt 1993). In the light of these functional

implications, it is not surprising that the rehabilitation of neglect

is an important aim in stroke rehabilitation.

Several investigators (Calvanio 1993; Gianutsos 1991; Robertson

1990) have reviewed interventions that have been designed specif-

ically to improve cognitive functioning following stroke and other

forms of neurological damage. They concluded that there is now

growing evidence that such interventions may produce a benefi-

cial effect across a variety of cognitive deficits. Cognitive rehabil-

itation includes training procedure(s) to improve cognitive func-

tions such as perception, memory and attention (Berrol 1990;

Levin 1990). These procedures sometimes aim to reduce the level

of impairment. Within rehabilitation there is a conceptual dis-

tinction between the effects a disease may have at different levels

(WHO 2001): impairment, activity (disability) and participation

(handicap). Therapists’ provision of aids and environmental adap-

tations aim to help the person adapt to their impairment rather

than change the underlying impairment itself. Other cognitive re-

habilitation approaches have been aimed at the level of activity

(disability). Loverro et al repositioned stroke patients’ beds with

the aim that improvements in spatial awareness would lead to less

disability as measured on the Barthel Index (Loverro 1988).

Most reports of the effectiveness of rehabilitation techniques have

been based on single case experimental designs rather than ran-

domised controlled trials (RCTs) (Lincoln 1995). Neglect reha-

bilitation is probably the cognitive area in which most RCTs have

been conducted and contains some of the oldest rehabilitation

RCTs (Weinberg 1977). Some trials have shown positive results of

their efficacy although generalisation of training to untrained sit-

uations is rarely examined, nor is the maintenance of any immedi-

ate benefits. Thus, it is currently difficult to draw definite conclu-

sions regarding whether or not stroke patients benefit from neglect

rehabilitation or whether such impairment specific rehabilitation

facilitates independence in activities of daily living (ADLs). This

review aimed to systematically consider the evidence from RCTs

on the effectiveness of cognitive rehabilitation specifically aimed at

spatial neglect. It is not a review of whether the subgroup of stroke

patients with neglect benefit from general rehabilitation such as

physiotherapy or occupational therapy. Whatever the findings of

this review of cognitive rehabilitation specifically for neglect it is

essential that patients with neglect are included in general stroke

rehabilitation services.

O B J E C T I V E S

To assess whether cognitive rehabilitation improves functional in-



dependence, performance on conventional and behavioural tests

of neglect, and destination on discharge in stroke patients with

neglect; to determine which types of interventions are effective;

and whether cognitive rehabilitation is more effective than stan-

dard care or an attention control.

C R I T E R I A F O R C O N S I D E R I N G

S T U D I E S F O R T H I S R E V I E W

Types of studies

In the first version of this review we sought all controlled trials

in which cognitive rehabilitation was compared to a control treat-

ment. In addition to well designed randomised controlled trials

(RCTs), other trials (such as those described as quasi-random) were

considered for inclusion but, if selected, were assigned a lower

methodological quality score. However, in this updated version

of the review we excluded all non-randomised trials to reduce se-

lection bias. These are listed in the ’Characteristics of excluded

studies ’ table.

Types of participants

This review was confined to trials which included patients with

neglect following stroke. Stroke was confirmed by neurological

examination or computerised tomography (CT) scan, or both,

and neglect by neuropsychological examination. Thus, trials that

included participants whose deficits were the result of head trauma,

brain tumour or any other brain damage were excluded unless a

subgroup of stroke patients could be identified for which there

were separate results or more than 75% of patients in the sample

were stroke patients. We excluded trials of patients with general

perceptual problems unless a subgroup of patients with neglect

could be identified.

Types of intervention

To be included in the review, a clinical trial had to report a com-

parison between an active treatment group that received one of

various cognitive rehabilitation programmes for neglect versus a

control group that received either an alternative form of treatment

or none. Cognitive rehabilitation was broadly defined to include

therapy activities designed to directly reduce the level of the neglect

impairment or the resulting disability. Drug treatments were not

included. Cognitive rehabilitation could include structured ther-

apy sessions, computerised therapy, prescription of aids and mod-

ification of the patients’ environment as long as these were specific

to neglect. The aim was to directly target the neglect rather than to

examine whether patients with neglect happened to benefit from

general rehabilitation services. This is an important distinction.

When planning this updated version of the review, we became

aware that authors were categorising their neglect interventions

as either bottom-up or top-down processing (Parton 2004). Top-

down approaches aim to train the patient to voluntarily compen-

sate for their neglect and require awareness of the disorder. Meth-

ods include training in scanning and usually provide feedback

(Pizzamiglio 2004). Top-down approaches focus at the level of

disability rather than impairment. Bottom-up approaches do not

require awareness of the disorder. They aim to modify underlying

factors, that is to alter the impaired representation of space. Prism

adaptation is the most popular and recent example of a bottom-up

approach (Rossetti 1998). We included both approaches in this

updated review.

Types of outcome measures

Primary outcome

(1) Ratings on measures of functional disability: activities of daily

living (ADL) scales: Barthel Index (BI), Functional Independence

Measure (FIM), Frenchay Activities Index (FAI), or neglect specific

ADL measures.

Secondary outcomes

(1) Performance on standardised neglect assessments: target can-

cellation (single letter, double letter, line, shape), line bisection.

Cancellation studies reporting number correct were analysed sepa-

rately from those reporting number of errors. In addition to a con-

ventional subtest score (such as letter cancellation) the behavioural

summary score from the Behavioural Inattention Test (BIT) was

used when available. In this updated review we removed outcomes

of attention and drawing tests to reduce the number of outcomes

being reviewed and to concentrate on those most relevant to ne-

glect.

(2) Discharge destination: whether a person was discharged to

live in their own home or to a care facility was included where

available, with deaths before discharge treated as not discharged

to their own home.

We did not specify a primary outcome in the first version of this

review. In this update, we decided that the primary outcome should

be the persistence of functional recovery, that is ADL benefits that

are maintained beyond the end of the intervention.

S E A R C H M E T H O D S F O R

I D E N T I F I C A T I O N O F S T U D I E S

See: Cochrane Stroke Group methods used in reviews.

(1) We searched the Cochrane Stroke Group Trials Register,

which was last searched by the Review Group Co-ordinator on

4 July 2005. In addition, we searched the following electronic

databases: MEDLINE (1998 to July 2005), EMBASE (1998 to

July 2005), CINAHL (1998 to July 2005), PsycINFO (1998 to

July 2005) and the National Research Register (July 2005). The

following search strategies were used:

Database MEDLINE (Ovid)

1. exp cerebrovascular disorders/

2. (stroke$ or poststroke$ or cva$).tw.



3. (cerebrovascular$ or cerebral vascular).tw.

4. ((cerebral or cerebellar or brainstem or vertebrobasilar) adj5

(infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$)).tw.

5. ((cerebral or intracerebral or intracranial or parenchymal

or brain or intraventricular or brainstem or cerebellar

or infratentorial or supratentorial or subarachnoid) adj

(haemorrhage or hemorrhage or haematoma or hematoma or

bleeding or aneurysm)).tw.

6. 1 or 2 or 3 or 4 or 5

7. exp Perceptual disorders/

8. exp perception/

9. Attention/

10. “Extinction (psychology)”/

11. (hemineglect or hemi-neglect).tw.

12. ((unilateral or spatial) adj5 neglect).tw.

13. (perception or inattention or hemi-inattention or attention

or extinction).tw.

14. ((perceptual or visuo?spatial or visuo?perceptual or

attentional) adj5 (disorder$ or deficit$ or impairment$ or

abilit$)).tw.

15. ((perceptual or visuo?spatial or visuo?perceptual or attention$

or cognit$ or scanning$) adj5 (training or re-training or

rehabilitation or intervention or therapy)).tw.

16. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15

17. Randomized Controlled Trials/

18. random allocation/

19. Controlled Clinical Trials/

20. control groups/

21. clinical trials/

22. double-blind method/

23. single-blind method/

24. Placebos/

25. placebo effect/

26. cross-over studies/

27. Research Design/

28. evaluation studies/

29. randomized controlled trial.pt.

30. controlled clinical trial.pt.

31. clinical trial.pt.

32. evaluation studies.pt.

33. random$.tw.

34. (controlled adj5 (trial$ or stud$)).tw.

35. (clinical$ adj5 trial$).tw.

36. ((control or treatment or experiment$ or intervention) adj5

(group$ or subject$ or patient$)).tw.

37. (quasi-random$ or quasi random$ or pseudo-random$ or

pseudo random$).tw.

38. ((control or experiment$ or conservative) adj5 (treatment or

therapy or procedure or manage$)).tw.

39. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or

mask$)).tw.

40. (coin adj5 (flip or flipped or toss$)).tw.

41. latin square.tw.

42. (cross-over or cross over or crossover).tw.

43. placebo$.tw.

44. sham.tw.

45. (assign$ or alternate or allocat$ or counterbalance$ or

multiple baseline).tw.

46. controls.tw.

47. or/17-46

48. 6 and 16 and 47

Database EMBASE (Ovid)

1. exp cerebrovascular disease/

2. (stroke$ or cva$ or poststroke).tw.

3. (cerebrovasc$ or cerebral vascular).tw.








6. 1 or 2 or 3 or 4 or 5

7. exp perception disorder/

8. exp perception/

9. exp attention/

10. visual deprivation/


12. ((unilateral or spatial or hemi?spatial) adj5 neglect).tw.


or extinction).tw.


attentional) adj5 (disorder$ or deficit$ or impairment$ or abilit$

or dysfunction)).tw.


or cognit$ or scanning$) adj5 (training or retraining or


16. or/7-15

17. clinical trial/

18. randomized controlled trial/

19. controlled study/

20. double blind procedure/

21. single blind procedure/

22. randomization/

23. placebo/

24. prospective study/

25. types of study/

26. methodology/

27. comparative study/

28. parallel design/

29. crossover procedure/ or intermethod comparison/

30. clinical study/

31. random$.tw.

32. (controlled adj5 (trial$ or stud$)).tw.

33. (clinical$ adj5 trial$).tw.



34. ((control or treatment or experiment$ or intervention) adj5

(group$ or subject$ or patient$)).tw.

35. (quasi-random$ or quasi random$ or pseudo-random$ or

pseudo random$).tw.

36. ((control or experiment$ or conservative) adj5 (treatment or

therapy or procedure or manage$)).tw.


mask$)).tw.

38. (coin adj5 (flip or flipped or toss$)).tw.

39. latin square.tw.

40. (cross-over or cross over or crossover).tw.

41. placebo$.tw.

42. sham.tw.

43. (assign$ or alternate or allocat$ or counterbalance$ or

multiple baseline).tw.

44. controls.tw.

45. or/17-44

46. 6 and 16 and 45

Database CINAHL (Ovid)











6. 1 or 2 or 3 or 4 or 5

7. exp Perceptual disorders/

8. exp perception/

9. Attention/




or extinction).tw.



abilit$)).tw.




15. or/7-14

16. random assignment/

17. random sample/

18. convenience sample/

19. Crossover design/

20. exp Clinical trials/

21. Comparative studies/

22. “control (research)”/

23. Control group/

24. Factorial design/

25. quasi-experimental studies/

26. Nonrandomized trials/

27. Placebos/

28. Community trials/ or Experimental studies/ or One-shot case

study/ or Pretest-posttest design/ or Solomon four-group design/

or Static group comparison/ or Study design/

29. Research question/

30. Research methodology/

31. exp Evaluation research/

32. Evaluation/mt [Methods]

33. (“clinical trial” or “systematic review”).pt.

34. random$.tw.


mask$)).tw.

36. (cross?over or placebo$ or control$ or factorial or sham?).tw.

37. ((clin$ or intervention$ or compar$ or experiment$ or

preventive or therapeutic) adj10 trial$).tw.

38. (counterbalance$ or multiple baseline$ or ABAB design$).tw.

39. or/16-38

40. 6 and 15 and 39

Database PsycINFO (Ovid)











6. 1 or 2 or 3 or 4 or 5

7. exp perceptual disturbances/

8. exp perception/

9. sensory neglect/

10. exp attention/

11. “extinction (learning)”/




or extinction).tw.



abilit$)).tw.




17. or/7-16

18. 6 and 17

19. (random$ or quasi-random$ or control$ or trial$ or blind$

or cross?over or experiment$ or compar$ or prospective).tw.



20. 18 and 19

(2) For the purpose of this and other reviews (Lincoln 2001;

Majid 2001), trials in four areas of stroke rehabilitation

(cognitive rehabilitation, occupational therapy, speech

therapy, and treatment for mood disorders) were searched

for simultaneously using on-line computerised bibliographic

databases: MEDLINE (1966 to 1998), BIDS EMBASE (1980 to

1998), CINAHL (1983 to 1998), PSYCLIT (1974 to 1998) and

CLINPSYCH (1980 to November 1994). These computerised

searches were conducted using combinations of the following

descriptors/key words: stroke/cerebrovascular accidents/

neurological disability and randomised controlled/clinical trials/

random allocation/double blind method and rehabilitation/

remedial therapy/treatment/intervention and cognitive/unilateral

neglect/visuospatial/visuoperceptual/memory/attention span/

concentration/hemianopia/attentional deficits/activities of daily

living/occupational therapy/leisure/dressing/self-care/domiciliary

rehabilitation.

(3) To ensure that trials not listed in the above databases were

not overlooked, in 1999 we handsearched all volumes of the

following journals.

• American Journal of Occupational Therapy (1947 to 1998)

• Aphasiology (1987 to 1998)

• Australian Occupational Therapy Journal (1965 to 1998)

• British Journal of Occupational Therapy (1950 to 1998)

• British Journal of Therapy and Rehabilitation (1994 to 1998)

• Canadian Journal of Occupational Therapy (1970 to 1998)

• Clinical Rehabilitation (1987 to 1998)

• Disability Rehabilitation (1992 to 1998), formerly InternationalDisability Studies (1987 to 1991), formerly InternationalRehabilitation Medicine (1979 to 1986)

• International Journal of Language & CommunicationDisorders (1998), formerly European Journal of Disorders ofCommunication (1985 to 1997), formerly British Journal ofDisorders of Communication (1977 to 1984)

• Journal of Clinical Psychology in Medical Settings (1994 to

1998), formerly Journal of Clinical Psychology (1944 to 1994)

• Journal of Developmental and Physical Disabilities (1992 to

1998), formerly Journal of the Multihandicapped Person (1989

to 1991)

• Journal of Rehabilitation (1963 to 1998)

• International Journal of Rehabilitation Research (1977 to 1998)

• Journal of Rehabilitation Science (1989 to 1996)

• Neuropsychological Rehabilitation (1987 to 1998)

• Neurorehabilitation (1991 to 1998)

• Occupational Therapy International (1994 to 1998)

• Physiotherapy Theory and Practice (1990 to 1998), formerly

Physiotherapy Practice (1985 to 1989)

• Physical Therapy (1988 to 1998)

• Rehabilitation Psychology (1982 to 1998)

• The Journal of Cognitive Rehabilitation (1988 to 1998),

formerly Cognitive Rehabilitation (1983 to 1987)

The 1999 handsearch included a broad range of journals as it

covered trials in four areas of rehabilitation, only one of which

(neglect) was relevant to this specific review. Therefore for this

update we checked the Master List of journals that is searched

by The Cochrane Collaboration (http://www.cochrane.us/

masterlist.asp). We found that the journals relevant to neglect

had been handsearched. The resulting trials would be found

from the search of the Cochrane Central Register of Controlled

Trials (CENTRAL) carried out quarterly by the Cochrane Stroke

Group and we did not wish to duplicate effort.

(4) We screened reference lists of all relevant articles

(5) We used the three citation index databases, Science Citation

Index (SCI), Social Sciences Citation Index (SSCI) and Arts and

Humanities Citation Index (A&HCI) for citation tracking of

relevant included studies.

M E T H O D S O F T H E R E V I E W

As previously mentioned, the pre-1999 searching and selection

was carried out simultaneously for four reviews, two of which have

been published in The Cochrane Library (Lincoln 2001; Majid

2001). Updated searches specific to this present review were carried

out in July 2005.

Two review authors (NBL, AB) independently selected trials to

be included in this review using the four inclusion criteria (types

of trials, participants, interventions and outcome measures). We

independently assessed the methodological quality of the trials,

with reference to the Cochrane Handbook for Systematic Reviews ofInterventions (Higgins 2005), selected, entered, and cross-checked

data for analysis. Differences were resolved by discussion.

Study characteristics and outcomes were abstracted. The following

information was recorded: method of participant assignment,

adequacy of concealment, adequacy of matching at baseline,

description of intervention, sample size, numbers lost to follow up,

types of dependent variable(s), blinding at outcome assessment,

reported results and publication details. Where these data were

not available or unclear from the reports then they were sought

or confirmed by correspondence with the first author of the



publication or both. Intention-to-treat analyses were used where

possible.

Where a crossover design was used (for example Schindler 2002)

only data from the first treatment period were used. Where initial

participants were randomised but later allocations were non-

randomised (for example Schindler 2002; Zeloni 2002) we only

included the study if we could extract the data on those randomised

(Zeloni 2002). If not we excluded the trial (Schindler 2002).

The left and right labels on the graphs were set according to the

method of scoring used on each outcome measure. For example,

a high score on the Barthel Index (BI) indicates a good outcome

and so the BI graph was set with the right label favouring the

experimental group. However, on the ’cancellation: number of

errors’ and ’line bisection’ outcomes a low score (that is fewer

errors) is better and so the left label of the graph was set to favour

the experimental group.

Activities of daily living (ADL) data, such as the BI, were treated as

continuous outcomes and mean and standard deviation data were

requested or calculated. We are aware that there is a difference

of opinion over how to deal with BI data. We have treated it

as an interval measurement whereas other people prefer to treat

it as ordinal. It is our view that, although from a theoretical

viewpoint there is an issue here, in practice it makes relatively

little difference. This is supported by a recent statistical study of

parametric versus nonparametric methods of BI data in stroke

trials, which recommended that means and standard deviations

(SDs) should be reported (Song 2005). Outcomes were analysed

as the standardised mean difference (SMD) and 95% confidence

intervals (CI). Random-effects models were used.

Odds ratios (OR) were selected for the outcome ’discharge

destination’ comparing the numbers discharged to their own

home. Deaths before discharge were treated in this review as not

discharged to their own home. In this way those discharged home

were compared to everyone who was not discharged home.

Meta-analyses were conducted for studies of spatial neglect. To

reduce selection bias only those studies with adequate allocation

concealment were rated as ’A’. A separate sensitivity analysis of

only the ’A’-rated studies was conducted where there was more

than one ’A’ rated study.

The original analyses compared a rehabilitation approach with

any other control. The controls used were standard care, attention

control (where the control group were given extra hours of contact

in addition to their standard care to ensure the experimental and

control groups had similar amounts of contact or attention from

a therapist), and a control alternative neglect therapy. In this

update we kept the ’any control’ general comparison. However,

we added comparisons to separate out studies comparing two

equally feasible rehabilitation approaches (for example Edmans

2000; Robertson 2002) from those comparing one rehabilitation

approach with a control that was less likely to improve outcome

(for example Kalra 1997; Rossi 1990). This was done for the

primary outcome only, that is persisting functional or ADL data,

and was considered necessary as the different comparators answer

different rehabilitation questions.

In this update we also added a subgroup comparison by type of

intervention (grouped as bottom-up or top-down processing) to

reduce the main limitation of the original review design, which

was that it was not set up to test which of several rehabilitation

approaches was effective. This subgroup analysis was for the

primary outcome only, that is persisting functional or ADL data.

D E S C R I P T I O N O F S T U D I E S

Data from 306 participants in 12 RCTs were included (Cherney

2002; Cottam 1987; Edmans 2000; Fanthome 1995; Kalra 1997;

Robertson 1990; Robertson 2002; Rossi 1990; Rusconi 2002;

Weinberg 1977; Wiart 1997; Zeloni 2002). Trials had small sam-

ple sizes. The smallest trials recruited and followed up four and

eight participants respectively (Cherney 2002; Zeloni 2002) and

the largest had a sample size of 50 (Kalra 1997). Statistical power

was rarely commented on, however some (such as Cherney 2002

and Kalra 1997) did explicitly state that they were intended as

pilot or feasibility studies.

All trials were of patients with neglect. In one trial (Rossi 1990)

some of the participants may have had visual sensory deficits (visual

field or scanning) as well as or instead of neglect. There were 12

people with a visual sensory deficit in the experimental group and

15 in the control group. However, the review authors do not ex-

pect that their inclusion would bias the results. The majority of tri-

als only included patients with right hemisphere stroke (Cherney

2002; Cottam 1987; Fanthome 1995; Robertson 1990; Robertson

2002; Rusconi 2002; Weinberg 1977; Wiart 1997; Zeloni 2002).

The others included those with either left or right hemisphere le-

sions, although in each trial there were more patients with right

hemisphere lesions.

Five of the centres contributing the 12 RCTs were based in the UK

(Edmans 2000; Fanthome 1995; Kalra 1997; Robertson 1990;

Robertson 2002), four were based in North America (Cherney

2002; Cottam 1987; Rossi 1990; Weinberg 1977), two in Italy

(Rusconi 2002; Zeloni 2002), and one in France (Wiart 1997).

Many trials recruited from in-patient rehabilitation hospitals (such

as Cottam 1987; Rusconi 2002) or specialist in-patient stroke

services (for example Edmans 2000; Kalra 1997). As expected

in a stroke population, the average age of participants was over

60 years. Only one trial explicitly mentioned an age exclusion

criterion, that was aged over 80 years (Robertson 2002). Many

trials excluded participants on the basis of progressive dementia,

previous stroke, current cognitive or communication problems,

on the grounds that these would adversely affect responsiveness to

therapy. Occasionally the neglect data were extracted as part of a

larger study (Edmans 2000).



A broad range of interventions was used (for full details see ’Char-

acteristics of included studies’ table). The included trials used both

top-down (Cherney 2002; Cottam 1987; Edmans 2000; Fan-

thome 1995; Robertson 2002; Rusconi 2002; Weinberg 1977;

Wiart 1997) and bottom-up (Kalra 1997; Robertson 1990; Rossi

1990; Zeloni 2002) approaches to rehabilitation. Several trials

provided equipment such as: fitting prisms to spectacles in order

to shift the image seen by the participant towards the neglected

side (Rossi 1990), or blinding the right side of goggles (Zeloni

2002), or specially adapted glasses which gave auditory feedback if

the participant failed to scan the neglected side (Fanthome 1995).

Wiart 1997 fitted participants with a ’vest’ with a metal pointer

attached. Robertson 2002 provided a ’limb activation device’ fit-

ted to the wrist, leg or shoulder.

Other interventions involved training with a therapist. For ex-

ample, various scanning tasks were used to demonstrate the pa-

tient’s deficit and show how a strategy could improve performance

(Cherney 2002). Another example of therapy-directed interven-

tion was spatio-motor cueing aimed at integrating attention and

limb movement (Kalra 1997). The principle behind this approach

is that movements of the affected limb in the neglected part of

space will result in improvements in attention skills and apprecia-

tion of spatial relationships on the affected side. Some approaches

involved multiple strategies, for example in the Wiart 1997 study

a therapist participated actively guiding and giving feedback while

the participant used the fitted pointer. A therapist was present in

both arms of the Rusconi 2002 trial but only provided cueing

and feedback in the ’experimental’ arm. This latter study is an

example of cognitive rehabilitation versus an attention control as

participants in both arms received equal amounts of time (that is

attention) from a therapist. What differed was the nature of the

therapy itself, that is whether or not cueing and feedback were

provided by the therapist.

The nature of the interventions was usually well described as were

the number, frequency and duration of therapy sessions. The num-

ber of sessions varied from 12 (Robertson 2002) to 40 (Rusconi

2002) over a duration of 3 to 12 weeks. Sessions ranged from

daily to once a week and lasted from 30 to 75 minutes each. The

Rossi trial probably provided the highest ’dose’ of rehabilitation as

participants in the experimental arm wore their prisms during all

daytime activities for four weeks (Rossi 1990).

This updated review found that more trials included functional

outcome data, that is using measure of activities of daily living.

However few trials measured outcomes beyond the end of therapy

and so very few data existed on the persistence or maintenance of

functional recovery. This limited the comparisons that could be

made of one type of cognitive rehabilitation with any other and the

subgroup analyses of the top-down and bottom-up approaches.

In this updated review we only included the 12 trials that had

randomised participants. The search identified studies that were

published as randomised but the authors later confirmed that non-

random allocation had been used. These were then excluded. Ex-

amples of popular non-random methods were: allocating the first

set to one arm and the second to the other (Rossetti 1998; Tham

1997); alternate allocation (Pizzamiglio 2004), allocating by bed

number (Paolucci 1996), bed availability (Loverro 1988) or date

of admission (Harvey 2003). In total 22 studies were excluded.

The reasons for exclusion are detailed in the ’Characteristics of

excluded studies’ table.

One further RCT of spatial neglect was identified and is awaiting

assessment and data from the authors (Cubelli 1993). We are aware

of several ongoing RCTs which will be considered for inclusion in

the next update (Kerkhoff 2005; Rossetti 2005; Turton 2005).

M E T H O D O L O G I C A L Q U A L I T Y

Of the 12 included RCTs four did not provide further detail on

the randomisation method used (Cherney 2002; Cottam 1987;

Rossi 1990; Weinberg 1977) or the method of ensuring allocation

concealment. As they were published as RCTs we included them

but assigned a ’B’ rating meaning allocation concealment was un-

clear.

The other eight RCTs confirmed that they used external ran-

domisation (Kalra 1997; Robertson 1990), random number ta-

bles (Edmans 2000; Fanthome 1995; Wiart 1997), drawing pre-

labelled allocations from an envelope (Zeloni 2002) or, in the case

of Robertson 2002 and Rusconi 2002, the authors confirmed ran-

domisation but did not specify the method used. The methods

used by Kalra 1997 and Robertson 1990 provided a good guar-

antee of concealment of allocation and they were both given an

’A’ rating. Edmans 2000 and Robertson 2002 were also given ’A’

ratings on the grounds that concealment was highly likely to have

been achieved, although it could not be guaranteed. For example,

in Edmans 2000 the researcher used random number tables to pre-

pare sequentially numbered opaque sealed envelopes. The random

number tables were then returned and due to the large number

randomised (80 to the full perception trial) it was unlikely that the

sequence would be remembered. The envelopes were only opened

in the presence of a witness. Robertson 2002 confirmed that the

recruiters were unaware of and unable to predict allocation con-

cealment. The other four trials (Fanthome 1995; Rusconi 2002;

Wiart 1997; Zeloni 2002) were rated as ’B’ as the information on

allocation concealment was unclear. For example, the combina-

tion of a small sample size with no external randomisation meant

that there was a potential risk to concealment (Fanthome 1995).

Edmans 2000, Fanthome 1995, Kalra 1997, Robertson 1990,

Robertson 2002, Rusconi 2002 and Zeloni 2002 used blinded

outcome assessors. Cherney 2002, Cottam 1987, Weinberg 1977

and Wiart 1997 provided no information suggesting that blinding

was used. Rossi 1990 did not use blinded outcome assessors.



In summary there were four ’A’ rated trials, that is with adequate

allocation concealment (Edmans 2000; Kalra 1997; Robertson

1990; Robertson 2002). Blinded assessment was reported in seven

trials (Edmans 2000; Fanthome 1995; Kalra 1997; Robertson

1990; Robertson 2002; Rusconi 2002; Zeloni 2002).

R E S U L T S

Outcome data were available on 306 participants from 12 trials.

A large number of outcome measures were reported within single

studies, especially using standardised neglect tests, but not all par-

ticipants completed all outcomes. At times the number of outcome

measures used within a trial limited the analyses (for example, seecancellation below). With the exception of ’discharge destination’

for which we used an odds ratio all other results refer to standard-

ised mean difference (SMD) and 95% confidence intervals (CI)

using random-effects models. The comparison numbers referred

to in this section (for example 01.01) refer to the numbered graphs.

Ratings on measures of functional disability: activities of daily

living (ADL) scales: Barthel Index (BI) at discharge, Functional

Independence Measure (FIM)

Immediate

Six studies (206 participants) included a measure of disability im-

mediately after the end of rehabilitation or on discharge, five with

the BI (Edmans 2000; Kalra 1997; Robertson 2002; Rossi 1990;

Rusconi 2002) and one with the FIM (Wiart 1997). A seventh

(Robertson 1990) collected similar disability data on the Frenchay

Activities Index but these data were not available for the review. As

shown in the graph for comparison 01.01, the individual results

of two of these studies (rated A and B respectively for adequacy of

allocation concealment) favoured the experimental group (Kalra

1997; Wiart 1997). None favoured the control group. However,

the overall effect for the six studies measuring immediate effect

on disability was small, with a wide confidence interval that in-

cluded zero and was not statistically significant, SMD 0.26 (95%

CI -0.16 to 0.67), P = 0.23.

Persisting

The primary outcome for this review was whether effects on dis-

ability persisted over time. Only two studies, rated A and B respec-

tively, examined this (Robertson 2002; Wiart 1997). Outcome on

the FIM favoured the experimental group SMD 1.17 (95% CI

0.25 to 2.08), P = 0.01, which received one hour of specialised

neglect therapy for 20 days (Wiart 1997). However, the groups

were not well matched. The experimental group was younger and

had a higher baseline FIM score (66) than the control group (54).

Outcome on the BI favoured neither group (Robertson 2002). As

shown in the graph for comparison 02.01 there is no overall evi-

dence for a persisting effect on ADL functioning from these two

studies 0.61 (95% CI -0.42 to 1.63), P = 0.24.

The same two studies were the only data available for comparison

03.01, persisting effects on ADL of one type of cognitive reha-

bilitation versus standard care or attention control. There are no

studies of comparison 04.01 persisting effects on ADL of one type

of cognitive rehabilitation versus another type.

The paucity of good functional data also restricted the planned

subgroup analyses of the persisting benefits of two rehabilitation

approaches, top-down and bottom-up. Comparison 06.01 is re-

stricted to the single B-rated top-down study by Wiart 1997, the

results which favoured the experimental group are described pre-

viously. The effects of the bottom-up approach are shown in com-

parison 05.01. This A-rated study (Robertson 2002) did not find

evidence to support or refute bottom-up approaches SMD 0.12

(95% CI -0.62 to 0.86), P = 0.75.

Sensitivity analyses

Sensitivity analyses (A-rated studies only) of the ADL outcome,

conducted on three studies of immediate effect on the BI (Edmans

2000; Kalra 1997; Robertson 2002) resulted in a reduced effect

size and wider confidence interval SMD 0.16 (95% CI -0.36 to

0.68) but did not alter the overall result of no significant effect,

P = 0.54. Sensitivity analysis of a persisting effect could not be

reliably determined as there was only one small study (Robertson

2002).

Performance on standardised neglect assessments

Immediate

Almost all of the studies (11) provided data on standardised tests

of neglect, although there was no one measure common to all and

some studies used more than one measure. There was evidence

that cognitive rehabilitation improved immediate performance al-

though this varied depending on the test used, as described in de-

tail below. In summary, outcome favoured the experimental group

on: one of the four cancellation targets that were scored for number

correct (double letter), cancellation scored for number of errors,

and line bisection. There was no evidence in favour of either group

on single letter, line or shape cancellation targets (although only

one study used the latter two outcomes) or the BIT behavioural

subtest score (three studies).

• The number of targets correctly cancelled was measured using

four types of targets (comparison 01.02): single letter, double

letter, line and shape. Analysis beyond the subgroup level was

not valid as three studies used more than one type of target (Fan-

thome 1995; Weinberg 1977; Zeloni 2002). Subgroup analysis

by target type suggested that outcomes for one of these targets

favoured the experimental group: double letter SMD 1.8 (95%

CI 0.85 to 2.76), P = 0.0002. However, this was based on data

from only 25 participants in a single B-rated study (Weinberg

1977). Single letter cancellation was the most frequently used

cancellation measure (Edmans 2000; Fanthome 1995; Kalra

1997; Rusconi 2002; Weinberg 1977; Zeloni 2002). With the

exception of Edmans 2000 (an A-rated study which favoured

the control group) the other five studies all favoured the ex-

perimental group, although many of the confidence intervals

included zero and only Kalra 1997 was A rated. The overall



subgroup effect for single letter cancellation was small and not

significant SMD 0.39 (95% CI -0.13 to 0.92), P = 0.14. Sensi-

tivity analyses conducted on the two A-rated studies (Edmans

2000; Kalra 1997) suggested a smaller effect and remained non-

significant SMD 0.01 (95% CI -0.84 to 0.86], P = 0.98 (com-

parison 01.08). Line (SMD 0.56, 95% CI -0.15 to 1.26, P =

0.12) and shape (SMD 0.09, 95% CI -0.69 to 0.88, P = 0.81)

cancellation data were provided by two B-rated studies (Fan-

thome 1995; Zeloni 2002). Neither were significant.

• Four studies using the number of errors made cancelling tar-

gets (Cottam 1987; Robertson 1990; Rossi 1990; Wiart 1997)

reported a small effect favouring the experimental group which

was of borderline statistical significance, SMD -0.65 (95% CI

-1.28 to -0.01), P = 0.05. These were based on 103 participants

and shown in the graph depicting comparison 01.03. Only one

(Robertson 1990) was A rated.

• Four studies (89 participants) reporting line bisection perfor-

mance (Rossi 1990; Rusconi 2002; Wiart 1997; Zeloni 2002)

suggested a favourable outcome for the experimental group

SMD -0.84 (95% CI -1.36 to -0.33), P = 0.001. However, none

of these studies, shown in comparison 01.04, were A rated.

• There was no evidence of an overall effect on the three stud-

ies using the BIT behavioural summary score (Cherney 2002;

Fanthome 1995; Robertson 1990) SMD -0.27 (95% CI -0.84

to 0.3), P = 0.35. As the graph for comparison 01.05 shows,

none of the individual studies showed an effect favouring the

experimental group. Only one study was A rated (Robertson

1990).

Persisting

The data available on whether beneficial effects on neglect assess-

ments persisted at follow up were limited to four studies (Cot-

tam 1987; Fanthome 1995; Robertson 1990; Wiart 1997), only

one of which was A rated (Robertson 1990). There were no long-

term studies of number of targets correctly cancelled, comparison

02.02. Analyses were possible on: cancellation errors (02.03), line

bisection (02.04) and the BIT behavioural summary score (02.05).

The detailed results are as follows.

• Three studies provided data on 52 participants on the can-

cellation number of errors outcome (Cottam 1987; Robertson

1990; Wiart 1997). A persisting effect favouring the experi-

mental group was found SMD -0.76 (95% CI -1.39 to -0.13),

P = 0.02.

• Only Wiart 1997 provided data on persisting effects on line bi-

section but these favoured the experimental group, SMD -1.09

(95% CI -2.0 to -0.18), P = 0.02.

• Two studies (Fanthome 1995; Robertson 1990) of 31 partici-

pants did not find a persisting effect favouring the experimental

group on the BIT behavioural summary summary score, SMD

0.06 (95% CI -0.66 to 0.78], P = 0.87.

Sensitivity analyses

Sensitivity analyses of only the A-rated studies could only be con-

ducted in the one outcome area that contained more than one A-

rated study (comparison 01.08). The results are described above.

Discharge destination (comparison 01.06)

The information regarding whether a person was discharged to

live in their own home or to a care facility, was included if avail-

able. One RCT, rated A, investigated discharge destination as an

outcome (Kalra 1997). The odds of being discharged home had

a confidence interval that included one and were not significantly

higher for the experimental group OR 1.4 (95% CI 0.45 to 4.35),

P = 0.56.

Statistical heterogeneity

The variability among studies was found to be higher than ex-

pected by chance in a few of the outcome areas. The I-squared

test suggested substantial heterogeneity (greater than 50%) for

the primary outcome ’persisting effects on functional disability’

and when taken immediately after intervention. The other area

with substantial heterogeneity was the immediate post-interven-

tion cancellation test (when scored as ’number of errors’ and ’sin-

gle letter cancelled correctly’) although the heterogeneity on the

persisting effects of ’number of errors’ was only 13% (no persisting

data on ’correct’). We used SMD and random-effects meta-analy-

sis. As discussed in the Cochrane Handbook for Systematic Reviewsof Interventions (Higgins 2005), random-effects analysis incorpo-

rates heterogeneity among trials although it is not a substitute for

thorough investigation. Given the small number of studies and

the small sample sizes in this review further investigation would

be of questionable value and was not carried out.

D I S C U S S I O N

In this updated review we excluded several previously included

non-randomised trials to reduce bias. We added several new, or

newly found, randomised controlled trials resulting in a review of

306 participants from 12 RCTs. We also re-examined the quality of

the allocation concealment and re-graded several trials, resulting in

only four A-rated trials. The method of randomisation was gener-

ally poorly described and the published papers were often not suf-

ficiently methodologically detailed to determine whether conceal-

ment of group allocation or outcome assessor blinding was likely.

Both included and excluded trial authors were extremely helpful

in providing unpublished data. Therefore this review presents a

considerable amount of unpublished data and previously unpub-

lished clarification of the methods used by the original authors.

In contrast to the problems of methodological reporting, the re-

porting quality of the rehabilitation approach used has generally

improved. We also added comparisons to examine the two main

theoretical approaches to cognitive rehabilitation, bottom up and

top down.



We found that outcome, following cognitive rehabilitation,

favoured the experimental group on several measures including

functional disability. However the effect sizes in these samples were

small and statistical analysis suggested they would not generalise

beyond the samples studied to the target population of people with

neglect after stroke. The results of sensitivity analyses of A-rated

studies that could be carried out supported the main analyses and

suggested an even smaller effect size and wider confidence inter-

vals. In contrast there was some generalisable evidence for both a

short-term and persisting effect on standardised neglect tests, such

as a reduction in errors cancelling targets and better line bisection

performance. However the validity of these measures (that is pa-

per-and-pencil tasks) is questionable. They may provide a useful

indication of changes in the underlying impairment but say little

of the person’s ability to function in the complex everyday activ-

ities that are relevant to their life. Selection bias cannot be ruled

out in these studies with low quality concealment ratings, and in

fact the only A-rated study suggested a small effect favouring the

control group. Furthermore, the evidence for persisting effects is

restricted to three and one studies respectively for cancellation and

line bisection.

In conclusion, there is a growing number of cognitive rehabilita-

tion approaches that show promise on standardised neglect tests.

However, there is insufficient unbiased evidence to support or re-

fute the effectiveness of either bottom-up or top-down approaches.

Although there has been a steady rise in the number of neglect

rehabilitation trials we do not yet have sufficient high quality

RCTs with appropriate functional outcome measures with which

to make confident recommendations for clinical practice.

A U T H O R S ’ C O N C L U S I O N S

Implications for practice

The effectiveness of cognitive rehabilitation strategies for reduc-

ing the disabling effects of neglect and increasing independence

remains unproven. No rehabilitation approach can at present be

supported or challenged by information from randomised trials.

Implications for research

There is sufficiently compelling evidence, from standardised ne-

glect tests, to encourage further trials of cognitive rehabilitation

for neglect. However, future studies need to improve on method-

ological and reporting issues and should define and distinguish

between different types of neglect. Key procedural aspects, such

as randomisation, concealment, completeness of follow up, and

blinding of assessors, must be sufficiently described. In fact the

process of random allocation appears to be misunderstood. Sev-

eral studies which described themselves as randomised were found

instead to use alternate allocation or other methods which risk

selection bias. Trialists are referred to the Cochrane Handbook for

Systematic Review of Interventions (Higgins 2005) for a descrip-

tion of acceptable methods of randomisation. Concealment and

blinding appear to be confused with each other but again are well

described in the Handbook (Higgins 2005). By its nature cog-

nitive rehabilitation is likely to be restricted to single blind trials

(of outcome assessors) as blinding of participants and therapists

is not realistic. Crossover trials are not appropriate for cognitive

rehabilitation as the effects of one approach may well contaminate

the next, which invalidates long-term outcome measurements. As

rehabilitation aims to promote independence and maintenance of

effects it is not logical to expect the ’washout’ effect that is possible

in some drug therapies.

Furthermore, trials need to have adequate statistical power to de-

tect a clinically meaningful difference. Power is very rarely men-

tioned in neglect trials and the small sample sizes used are unlikely

to be adequate. Sample specification and selection methods could

also be improved on. Neglect is a heterogeneous condition and it is

unlikely that a single rehabilitation approach would be appropri-

ate for all types and severity and co-morbidity. Future trials should

provide adequate sample description, theoretical justification and

consider using stratified randomisation to avoid imbalance of any

factors likely to confound the trial. Future studies must avoid using

non-random allocation methods (such as matching) to deal with

imbalance of known factors as this risks imbalance of potentially

important unknown factors by introducing selection bias.

There is scope for both pragmatic and explanatory RCTs. Explana-

tory trials provide evidence on efficacy, examining whether a single

rehabilitation approach (such as prism adaptation) can work in

an optimum situation (that is a more homogeneous sample with

little co-morbidity, treated by research therapists with protected

time in a controlled environment). There is also a need for prag-

matic RCTs to provide evidence on effectiveness and ideally cost

effectiveness. Pragmatic trials examine whether rehabilitation does

work in a realistic clinical setting with all of the pressures that places

on busy clinicians and examines the generalisability of findings

to the heterogeneous clinical populations likely to be referred for

rehabilitation. Finally completeness of follow up (and intention-

to-treat analysis) must be adequately conducted in future neglect

trials. Previous analyses tended to be per protocol and therefore

say little about the acceptability of rehabilitation to service users.

High drop out may well be an important measure of effectiveness

and future neglect trialists are recommended to consult the hand-

book (Higgins 2005) for a good discussion of intention to treat.

This review is ongoing and the authors would be grateful to receive

information on ongoing trials for a future update.

P O T E N T I A L C O N F L I C T O F

I N T E R E S T

Nadina Lincoln has been involved in trials included in and ex-

cluded from this review (Edmans 2000; Fanthome 1995; Lincoln



1985).

A C K N O W L E D G E M E N T S

We would like to thank the principal investigators of many of

the included and excluded trials who provided additional infor-

mation to that published and to Clare Starmer for helping with

the searches. We are especially indebted to Brenda Thomas and

Hazel Fraser at the Cochrane Stroke Group for their continued

support and specialist guidance. Thanks also to the Editorial team

and external peer reviewer who provided useful suggestions for

improving the clarity and focus of this review. The initial searches

were funded by grants to Nadina Lincoln from The Stroke Asso-

ciation and the UK NHS Research and Development Programme

for Physical and Complex Disabilities. Michael Dewey provided

statistical input to the first published version of this review, for

which we are very grateful.

S O U R C E S O F S U P P O R T

External sources of support

• The Stroke Association UK

• NHS Executive Research and Development Programme Phys-

ical and Complex Disabilities UK

Internal sources of support

• No sources of support supplied

R E F E R E N C E S

References to studies included in this review

Cherney 2002 {published data only}

Cherney LR, Halper AS, Papachronis D. Two approaches to treating

unilateral neglect after right hemisphere stroke: a preliminary inves-

tigation. Topics in Stroke Rehabilitation 2003;9(4):22–33.

Cottam 1987 {published data only}

Cottam GL. Visual scanning training for right hemispheric stroke pa-

tients exhibiting hemispatial neglect [Dissertation]. Mississippi: Uni-

versity of Mississippi, 1987.

Edmans 2000 {published and unpublished data}

Edmans JA, Webster J, Lincoln NB. A comparison of two approaches

in the treatment of perceptual problems after stroke. Clinical Reha-

bilitation 2000;14(3):230–43.

Fanthome 1995 {published and unpublished data}

Fanthome Y, Lincoln N, Drummond A, Walker M. The treatment

of visual neglect using feedback of eye movements: a pilot study.

Disability Rehabilitation 1995;17(8):413–7.

Kalra 1997 {published and unpublished data}

Kalra L, Perez I, Gupta S, Whittink M. Effects of visual neglect

on stroke rehabilitation [Abstract]. Proceedings of the Challenge of

Stroke. The Lancet Conference. 15-16 October 1998; Vol. 71 [Abst

92].

∗ Kalra L, Perez I, Gupta S, Wittink M. The influence of visual

neglect on stroke rehabilitation. Stroke 1997;28(7):1386–91.

Robertson 1990 {published and unpublished data}

Robertson I, Gray J, Pentland B, Waite L. Microcomputer-based re-

habilitation for unilateral left visual neglect: a randomised controlled

trial. Archives of Physical Medicine and Rehabilitation 1990;71:663–8.

Robertson 2002 {published data only}

Robertson IH, McMillan TM, MacLeod E, Edgeworth J, Brock D.

Rehabilitation by limb activation training reduces left-sided motor

impairment in unilateral neglect patients: a single-blind randomised

control trial. Neuropsychological Rehabilitation 2002;12(5):439–54.

Rossi 1990 {published data only}

Rossi P, Kheyfets S, Reding M. Fresnel prisms improve visual percep-

tion in stroke patients with homonymous hemianopia or unilateral



visual neglect. Neurology 1990;40:1597–9.

Rusconi 2002 {published data only}

Rusconi ML, Meinecke C, Sbrissa P, Bernardini B. Different cog-

nitive trainings in the rehabilitation of visuo-spatial neglect. Europa

Medicophysica 2002;38:159–66.

Weinberg 1977 {published data only}

Weinberg J, Diller L, Gordon W, Gerstman L, Lieberman A, Lakin

P, et al. Visual scanning training effect on reading-related tasks in

acquired right brain damage. Archives of Physical Medicine and Reha-

bilitation 1977;58:479–86.

Wiart 1997 {published and unpublished data}

Wiart L, Bon Saint Come A, Debellaix X, Petit H, Joseph PA, Mazaux

JM, et al. Unilateral neglect syndrome rehabilitation by trunk rota-

tion and scanning training. Archives of Physical Medicine and Reha-

bilitation 1997;78:424–9.

Zeloni 2002 {published data only}

Zeloni G, Farne A, Baccini M. Viewing less to see better. Journal of

Neurology Neurosurgery and Psychiatry 2002;73:195–8.

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glect in right hemisphere stroke patients [Dissertation]. University

of Michigan 1991.

Beis 1999

Beis J-M, Andre JM, Baumgarten A, Challier B. Eye patching in

unilateral spatial neglect : efficacy of two methods. Archives of Physical

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in patients with right brain damage: a comprehensive programme.

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Harvey M, Hood B, North A, Robertson IH. The effects of visuomo-

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Niemeier 1998

Niemeier JP. The Lighthouse Strategy: use of a visual imagery tech-

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∗ Paolucci S, Antonucci G, Guariglia C, Magnotti L, Pizzamiglio

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Rossetti Y. Personal communication 2005.

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Turton A. Personal communication 2005.

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Levin HS. Cogntive rehabilitation - unproved but promising. Archives

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Lincoln NB. The assessment and treatment of disorders of visual

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Massironi M, Antonucci G, Pizzamiglio L, Vitale M, Zoccolotti P.

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K. Can parametric statistical methods be used to analyse and present

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Sunderland A, Wade D, Langton-Hewer R. The natural history of

visual neglect after stroke: indications from two assessment methods.

International Disability Studies 1987;9:55–61.

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Wade D, Skilbeck C, David R, Langton-Hewer R. Stroke: a critical

approach to diagnosis, treatment and management. London: Chapman

and Hall, 1985.



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WHO 2001

World Health Organization. International Classification of Function-

ing, Disability and Health (ICF). Geneva: World Health Organiza-

tion, 2001.

∗Indicates the major publication for the study

T A B L E S

Characteristics of included studies

Study Cherney 2002

Methods RCT: no further information provided. No mention of blinded outcome assessments.

Quality of allocation concealment rated as B/C: unclear/inadequate.

Participants USA.

Four right hemisphere stroke patients with clinical evidence of neglect at least six months post onset.

Exptl n = 2, cntrl n = 2.

Mean age (SD): exptl 69.5 yrs (23.3), cntrl 62.0 yrs (5.7).

Sex (m): exptl 2, cntrl 1.

Side of damage (RBD): exptl 2, cntrl 2.

Mean months post-onset (SD): exptl 16 (12.7), cntrl 7.5 (0.7).

Inclusion: right-handed, right hemisphere stroke, persisting neglect after six months, spoke English as a

primary language, passed pure tone audiometry in their better ear, corrected visual acuity was sufficient to

read newsprint.

Interventions Visual scanning training, practising letter and word cancellation tasks (to address the assumed underlying

impairment of selective visual attention)

versus

repetitive practice of a functional task: oral reading (to represent an approach commonly used in rehabilita-

tion).

Both groups received 20 sessions. The frequency of sessions is not known.

Both scanning and reading training included the use of visual, verbal and tactile cues to attend to the left. In

both training the task difficulty gradually increased if the patient achieved 90% success (scanning) or 100%

success (reading). In reading training the cues were gradually removed. (NB. Scanning is coded as exptl in

this review.)

For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-

dition as top down.

Outcomes The study collected four types of outcomes, pre and post training:

(1) the MMSE;

(2) the Stroop Neuropsychological Screening Test;

(3) the BIT;

(4) a functional reading test devised for this study.

The latter was to identify five names from a local telephone book; there was a time limit of three minutes per

name. The BIT was scored in three ways: conventional subtests; behavioural subtests; and total. It is assumed

this was measured immediately post training.

For comparability with other studies this review used only the BIT behavioural subtests post training.

Notes A comparison of two treatments. Intended as a small preliminary study.

Allocation concealment B – Unclear



Characteristics of included studies (Continued )

Study Cottam 1987

Methods RCT: no further information provided.


Participants USA.

12 stroke rehabilitation in-patients with left hemispatial neglect.

Exptl n = 6, cntrl = 6.

Mean age: exptl 66.2 yrs, ctrl 71.3 yrs.

Sex (m/f ): 7/5.

Side of damage: all had right middle cerebral artery lesions.

Time post-onset (mean weeks): exptl 6, cntrl 16.3.

Inclusion: right-handed, visual acuity > 20/100 corrected on Snellen’s, orientated in person, place and time,

evidence of left hemispatial neglect on at least three of the tests used, either WAIS-R VIQ > 80 or minimum

scaled score of 8 on 4/6 verbal subtests, arm and leg able to propel wheelchair.

Interventions Three-phase intervention, each phase consisted of five half-hour sessions per day:

(1) visually scanning a lightboard when stationary, taught to verbally self-prompt to start on left and scan

from left to right;

(2) same activity but while self propelling;

(3) did not use the lightboard but participants named objects presented on both sides while self-propelling

versus

no information other than participants were in-patients at a rehabilitation facility and were assessed after

same periods as experimental group.


dition as top down.

Outcomes The study collected three types of outcomes:

(1) data scanning and attention skills: single target cancellation (three minutes letter H) and double target

cancellation (three minutes letters C & E), scores are average number of far left-sided omissions;

(2) Lightboard: point at light and say the colour, allowed 10 seconds, scores are average number of left-sided

omissions;

(3) ADL: avoidance of obstacles on wheelchair course, rated by two observers.

Assessed pre-intervention, after each phase (five days) and at follow up six weeks post discharge from hospital.

This review used only the cancellation data, immediate and persisting effects.

Notes NB. Single letter cancellation outcome data are entered as left-sided omissions (i.e. low score is better outcome)


Study Edmans 2000

Methods RCT: the recruiter used random number tables to prepare the group allocations for the 80 patients (see

Notes) in advance. They did not keep the random number tables, did not have access to them at the time of

recruitment and were highly unlikely to have been able to remember the allocations. Allocations were stored

in sealed, opaque, numbered envelopes, only opened at the time of recruitment in the presence of a witness.

Concealment of allocation is likely but cannot be guaranteed in the absence of third party randomisation.

The post-treatment assessor was blinded to allocation.

Quality of allocation concealment rated as A: adequate.

Participants UK.

42 (see Notes) stroke patients with visual neglect from those with general perceptual problems admitted to

an in-patient SU.


Mean age (SD): exptl 69.17 yrs (11.35), cntrl 66.61yrs (14.5).

Sex (m/f ): exptl 10/14, cntrl 8/10.

Mean time post-onset: 37 days.




Inclusion: a subset of those with neglect from those with general perceptual problems from those consecutive

admissions to a stroke unit trial. SU trial criteria were: medically stable, able to transfer with maximum two

nurses, no discharge date planned, able to tolerate 30 minute treatments, able to carry out some independent

ADLs pre-stroke.

Interventions ToT approach to treat the ’cause of the perceptual problem’. The underlying assumption is that practising

a perceptual task will treat the underlying impairment and if successful will improve performance of other

tasks which depend on the skills. Personal communication suggested that cueing and feedback were used to

teach participants to compensate

versus

FA to treat the ’symptom rather than the cause’ and involved practising ADL tasks.

Both groups received 2.5 hrs per week for six weeks in addition to standard OT.

(NB. ToT is coded as exptl in this review.)


dition as top down.

Outcomes The broader study of perceptual problems completed the following measures by different assessors immedi-

ately after the six weeks treatment: an independent blinded assessor completed the BI, Edmans ADL Scale,

and RPAB. This assessor completed the ADL scales following interviews with unblinded nursing staff. The

unblinded ward OT also completed the BI and Edmans ADL Scale. An unblinded physiotherapist com-

pleted the RMA gross motor score. Additionally assessments by other clinical staff were analysed: speech and

language therapists, psychologists, physiotherapists.

For comparability with other studies this review used only the RPAB letter cancellation subtest score (number

correctly cancelled) and the blinded assessor’s BI.

Notes Personal communication supplied further data and clarification of method. Authors provided unpublished

data on 42 neglect patients from a larger RCT of 80 left and right (35) hemisphere strokes with perceptual

problems which was itself taken from the stroke unit admission arm (n = 158) of a RCT of stroke unit versus

general medical care. No pre-randomisation differences between groups except that the ToT group were a

little longer post stroke (40/33 days) than the FA group.

Allocation concealment A – Adequate

Study Fanthome 1995

Methods RCT: sealed opaque envelopes prepared from random number tables. Concealment of allocation is unclear.

It cannot be guaranteed as randomisation was not done by a third party and may have been predictable given

the small numbers involved. Blinded assessor.


Participants UK.

18 (see Notes) RH stroke patients admitted to hospital.


(The following data describe the 18 initial participants: see Notes.)



Time post-onset (mean months): exptl 1.0, cntrl 0.6.

Inclusion: not blind; < 80 yrs of age; no history of dementia or psychiatric problems; not ill; right-handedness;

score > 6 on Abbreviated Mental Test; RH stroke; score < 130 on BIT.

Interventions Four weeks (2 hrs 40 mins/wk) feedback of eye movements (wearing specially adapted glasses with auditory

signal)

versus

four weeks no treatment.


dition as top down.




Outcomes The study collected three types of outcomes: eye movements, conventional BIT subtests and behavioural

BIT subtests, immediately post treatment (four weeks) and four weeks later (eight weeks).

For comparability with other studies this review used only the four week star, single letter and line cancellation

from the conventional BIT subtests, and the four and eight week BIT summary behavioural subtest scores.

Notes Personal communication supplied group data on BIT subtests for all but one control participant at four weeks

(missing data, therefore n = 18 - 1), and the information that assessor blinded to allocation. BIT behavioural

data are for all 18 at four weeks but only 13 at eight weeks. Eight weeks = post start of treatment, i.e. is a

four week follow up post end of treatment.

Single letter cancellation data are for number cancelled, i.e. higher numbers indicate better outcome.

Exptl and cntrl groups appeared adequately matched on demographic and clinical data although cntrl group

slightly older than exptl, no baseline BIT data.


Study Kalra 1997

Methods RCT: random permuted block technique in groups of 10 for pragmatic reasons of service and workload con-

siderations, allocation by telephone by clerical staff using computer generated random numbers, assessments

by blinded observer.


Participants UK.

50 (see Notes) stroke patients with visual neglect admitted to a SU.

The following data are for the 47 surviving patients.


Mean age (SD): exptl 78 yrs (9), cntrl 76 yrs (10).

Sex (m): exptl 11, cntrl 9.

Side of damage (RBD): exptl 16, cntrl 17.

Median time post-onset (range): 6 days (2 to 14).

Inclusion: infarcts partial anterior circulation, known to be sensitive to rehabilitation on basis of impairments

of power, balance, proprioception and cognition at one to two weeks after stroke.

Exclusion: TIAs, reversible neurological deficits, hemianopsia or severe dysphasia.

Interventions Spatio-motor cueing based on ’attentional-motor integration’ model and early emphasis on restoration of

function

versus

conventional therapy input concentrating on restoration of tone, movement pattern and motor activity before

addressing skilled functional activity.


dition as bottom up.

Outcomes The study collected six types of outcomes:

(1) mortality;

(2) BI at discharge;

(3) discharge destination;

(4) length of hospital stay;

(5) duration of therapy input;

(6) RPAB after 12 weeks.

This review used only the BI, RPAB letter cancellation subtest, and discharge home. These were all analysed

as immediate effects.

Notes Principle behind approach: movements of affected limb in the deficit hemispace led to summation of acti-

vation of affected receptive fields of two distinct but linked spatial systems for personal and extrapersonal

space resulting in improvements in attentional skills and appreciation of spatial relationships on the affected

side. Personal communication supplied further data and clarification of method.

No difference between groups on demographic variables or initial impairment or disability including BI.




Outcome data on 47 of 50 stroke patients with visual neglect admitted to a SU: exptl n = 24 (+1 died), cntrl

n = 23 (+2 died). For the ’destination discharge’ outcome the total figure of 50 was used in this review as

deaths were entered as not going home.


Study Robertson 1990

Methods RCT: random allocation of patients to conditions with blocks of severe versus mild neglect patients. Ran-

domisation was carried out by a third party. The authors confirmed that outcome assessors were blinded to

allocation.


Participants UK.

30 (see Notes) in-patients of Edinburgh hospitals who showed left visual field neglect on BIT.





Onset of neglect (SD): exptl 19.2 wks (21.1), cntrl 10.8 wks (6.3).

Inclusion: presence of neglect (failure on at least 3/9 behavioural tests), oriented for time and place, ability

to consent, ability to concentrate sufficiently to sit at computer-based task for at least 15 mins.

Interventions 15.5 hrs (14 sessions of 75 mins each, 2 x wk for 7 wks) computerised scanning and attentional training

(intensive briefing about nature of participants problems, feedback on left and right latencies, trainer rein-

forcement and encouragement

versus

11.4 hrs recreational computing (to minimise scanning and timed attentional tasks, without any potential

neuropsychological mechanism to improve cognitive function, but exposed to computer activities such as

games, quizzes and simple logical games).


dition as top down.

Outcomes The study collected several types of outcomes:

(1) BIT;

(2) WAIS-R subtests (Picture Completion and Block Design);

(3) Neale Reading test;

(4) letter cancellation;

(5) observer’s report of neglect;

(6) Rey CFT (copy only).

The BIT was the principal outcome measure. (Although not explicitly stated it is assumed from the description

on page 664 and the low scores in Table 2 that only the BIT behavioural subtests were given.) The outcomes

were given immediately after training and after six months. The study also collected data on several other

tests including the GHQ and the FAI to ensure matching of groups (see Notes).These were collected at each

timepoint.

This review used only the letter cancellation (error score), and BIT, immediately and after six months.

Notes This review entered n = 30 of initial 36 (33 with CVA, 2 HI, 1 had surgery for excision of meningioma). 3/36

not followed up immediately and 9/36 not seen at six months but no information on which group these were

from so data entered to this review subtracted three and nine from each group at first (n = 30) and second

assessments respectively. Information on allocation concealment provided by personal communication. Six

months follow up.

Exclusion: patients with BIT score > 70.

Cancellation data reported as errors rather than correct performance.

The review could not include the FAI data as these were not reported.





Study Robertson 2002

Methods RCT: 1:1 randomisation. Author confirmed recruiters could not have been aware of likely allocations but

concealment of allocation cannot be guaranteed as randomisation was not done externally. Outcome assessors

were blinded.


Participants UK.

40 randomised but 36 seen for immediate outcome assessment (see Notes), recruited from London hospital

and community rehabilitation teams, had left visual neglect on cancellation or bisection tests.

(The following data describe the initial 40 participants: see Notes.)


Mean age (SD): exptl 69.3 yrs (9), cntrl 67 yrs (9.4).


Onset of neglect (SD): exptl 152.8 days (142.4), cntrl 152.1 days (117.9).

Inclusion: right hemisphere stroke, aged under 80, right-handed, no history of major psychiatric/disease/

disability that would prevent participation or contaminate results.

Interventions LAT wearing (on the wrist/leg/shoulder) an active limb activation device during perceptual training. The

device emitted an auditory tone if no left-sided movement was made

versus

perceptual training wearing an inactive (no tone) limb activation device.

Both groups received training at their residence (usually own home) for 12 weeks for approximately 45

mins/wk.

The perceptual training for both groups involved working on visuoperceptual puzzles and reading tasks

which implicitly but not explicitly involved advice to scan to the left.




(1) BI/Nottingham EADL;

(2) Bergego rating scale of neglect;

(3) Motricity index (total left body side) at four time points: immediately post-training, three months, six

months, 18 to 24 months. In addition the BIT, Comb and Razor personal neglect test, and the modified

Landmark test were given at the first three timepoints.

For comparability with other studies this review used only the following outcome/timepoints: BI immediate

and six months.

Notes Attrition: 36/40 followed up immediately (exptl 17, cntrl 19); 32 at 6 months, 26 at 18 to 24 months.

Groups appeared appropriately matched for demographic and clinical baseline variables.

No information on n per group at six months. Know four lost but not whether all were from a single group

so assumed worst case and subtracted four per group, i.e. conservative sample estimate of 28 not 32.


Study Rossi 1990

Methods RCT: no further information provided. Only the Tangent Screen Examination outcomes were assessed

blinded.


Participants USA.

39 stroke patients from an in-patient stroke rehabilitation unit with HHA or VN.


Mean age: exptl 72.6 yrs, cntrl 63.3 yrs.


Mean weeks post-stroke: exptl 4.4, cntrl 4.7.

Side of stroke (right/left): exptl 16/2, cntrl 13/8.




Lesion type (infarct/haemorrhage): exptl 15/3, cntrl 18/3.

Inclusion: patients free of disabling cardiac pulmonary or rheumatological problems, HHA determined by

inability to detect 1 cm red target on tangent screen examination, VN defined as inability to detect bilateral

tachistoscopically presented targets using HFVS.

HHA/VN: exptl 12/6, cntrl 15/6.

Exclusion: patients with best-corrected visual acuity worse than 20/200; inability to comprehend and co-

operate with assessments.

Interventions 15-diopter plastic press-on fresnel prisms (cut to a half circle, to fit on the inside of spectacle lenses, overlaying

the affected hemi-field with the base of the prism towards the affected field to produce an intended effect of

shifting a peripheral image more towards the centre) worn for all daytime activities

versus

no prism treatment.

Both groups received routine rehabilitation programmes including ADL training and table-top visual per-

ception retraining tasks.



Outcomes The study collected eight types of outcomes:

(1) Modified MMSE;

(2) MVPT;

(3) Line bisection;

(4) Line cancellation;

(5) HFVS;

(6) Tangent Screen Examination;

(7) BI;

(8) frequency of falls.

Outcomes were assessed at baseline, two weeks and four weeks. This review used only line bisection, line

cancellation and the BI. The four week outcome data were used. However, as prisms were still being used at

that time this review analysed them as ’immediate’ rather than ’persisting’ effects.

Notes Clarification of randomisation procedure sought but not obtained.

Cntrl group younger but otherwise groups were similar on demographic and clinical background factors

including BI.

Data for VN subgroup not reported separately to HHA subgroup therefore all outcome data in this review

are for VN and HHA combined. The authors report that the HHA diagnosis precluded a diagnosis of neglect

and that patients with either HHA or VN who were treated with prisms showed equal improvement.

The prism group wore their prisms during outcome assessments.

Cancellation data reported as errors rather than correct performance. Line bisection scores are errors in cms

from the middle.

SEM data converted to SD for analysis.


Study Rusconi 2002

Methods RCT: randomised into Type 1 or Type 2, stratified by TENS or no TENS. Randomisation performed by

researcher. Allocations stored in sequentially numbered, sealed, opaque, envelopes. The outcome assessor

was blinded to allocation. Concealment of allocation is unlikely. It cannot be guaranteed as randomisation

was not done by a third party and may have been predictable given the small numbers involved.


Participants Italy.

24 randomised (see Notes) but outcome data collected on 20.

(The following data describe the 20 participants.)

Exptl n = 12, cntrl n = 8 (exptl = Type 1 and cntrl is Type 2: see Interventions).






Mean weeks post-stroke: exptl 6.92, cntrl 8.38.

Inclusion: unilateral right hemisphere stroke assessed by CT scan, right-handed, symptoms of unilateral

neglect, admitted to hospital for rehabilitation five weeks post-stroke.

Exclusion: dementia.

Interventions The study compared more than two interventions. First there is a comparison of two types of cognitive

training: Type 1 versus Type 2. Each ’type’ is then subdivided into whether or not TENS is added (see Notes).

Type 1 versus Type 2: both consist of five one hour sessions per week for two consecutive months (40 sessions)

using four procedures requiring the patient to actively scan the visual field (reading sentences and stories, line

drawing on a dot matrix, assembling 3D cubes, matching cards containing the name and the visual image

of an object. Type 1 and 2 differed in that only Type 1 involved verbal and visuo-spatial cueing and verbal

feedback. Although Type 2 used the same four procedures it did not involve cueing or feedback, i.e. the

aspects of the training designed to improve awareness and encourage compensation.

For this review Type 1 was classed as a top-down approach and Type 2 as an attention control.

Outcomes Assessments were classified as ’functional and neurological’ (i.e. BI, standard clinical neurological exami-

nation) or ’neuropsychological’ (i.e. line cancellation, letter cancellation, line bisection, sentence reading,

O’clock test, judgement of drawings, anosognosia, RCPM, facial recognition, position deficit).

These were taken at four timepoints: on admission for neurorehabilitation at least five weeks post-stroke

(T0), one month later (T1) after which eligibility was determined and participants were randomised, after

one month of intervention (T2) and after two months of intervention (T3).

For comparability with other studies this review used only the T3 letter cancellation, line bisection and BI.

As intervention continued for two months T3 is coded in this review as ’immediate’ effects.

Notes Author provided clarification and raw data by personal communication.

24 people were randomised: 12 to Type 1 and 12 to Type 2. The authors excluded four from the final

evaluation because of a ’clinical worsening that prevented the conclusion of the treatment’. These four were

all allocated to Type 2.

Cancellation scores were for the number correctly cancelled. Separate scores were given for left and right

space but this review used the total score. Line bisection data were for mean deviation in mm left (negative)

or right (positive) or the midpoint. Line cancellation data could not be used as the exptl group’s SD was zero.


Study Weinberg 1977

Methods RCT: no further information provided.


Participants USA.

25 (see Notes) stroke rehabilitation in-patients.




Onset of testing (wks): exptl 9.9, cntrl 10.53.

Interventions 20 hrs visual training (1 hr each day for 4 wks in reading, writing and calculation)

versus

no visual training (but received OT as part of general rehab program).


dition as top down.


(1) closest to the area being trained (WRAT, simple arithmetic, paragraph reading, copying a name & address);

(2) training related tasks (single and double letter cancellation H & C-E);

(3) related tasks (counting faces, matching faces, WAIS Digit Span, Object Assembly, Picture Completion,

confrontation, motor impersistence and simultaneous stimulation). Outcomes assessed after one month, i.e.

immediate effects.




This review used only the single and double letter cancellation.

Notes Hypothesises that neglect underlies visual perceptual problems.

Exptl and cntrl groups appeared similar in age, two of exptl group had ’aberrantly long times since onset’.

Groups divided into RBD severe and RBD mild.

No reply to request for clarification of randomisation procedure and other outcome measures.

57 patients reported but outcome data reported separately for severe and mild RBD groups and only severe

data (n = 25) entered in this review, exptl 14 and cntrl 11.

Cntrl group better than exptl on single letter cancellation at baseline. No difference in double letter cancel-

lation or digit span.


Study Wiart 1997

Methods RCT: randomisation table, no further information on concealment.


Participants France.

22 people within three months onset of stroke and severe left unilateral neglect, hospitalised in two neurore-

habilitation hospitals, positive for neglect on three tests (see Outcomes).


Mean age: exptl 66 yrs, cntrl 72 yrs.


Time post onset (mean days): exptl 35, cntrl 30.

Exclusions: history of stroke, alteration of general status, or cognitive difficulties incompatible with rehabil-

itation.

Interventions One hr per day for 20 days of experimental treatment followed by traditional rehabilitation (one to two

hrs physiotherapy and one hr OT). Experimental treatment is Bon Saint Come method: patient wears a

thoracolumbar vest with attached metal pointer above head, patient points to target on mobile wooden panel,

audible and luminous signals provide biofeedback effect when targets are touched. Initially conducted when

sitting, this progresses to standing, the therapist participates actively during the session, stimulating, guiding

and correcting

versus

three to four hrs traditional rehabilitation per day.


dition as top-down.

Outcomes The study collected two types of outcomes:

(1) quantitative assessment of neglect (line bisection, line cancellation, bell cancellation);

(2) autonomy (FIM).

These assessments were conducted three times: day 0, day 30 (after therapy) and day 60.

This review used only the data from line cancellation, line bisection and FIM. Both the 30 day (immediate)

and 60 day (persisting) data were used in this review.

Notes The paper consists of two studies. These data refer to Study 1 only.

The exptl group were younger and had a higher initial FIM score (66) than the cntrl group (54).

Cancellation data reported as errors rather than correct performance. Only one set of cancellation data (lines

not bells) were entered in this review to avoid entering the same group of patients twice into the meta analysis.

Line bisection scores are % deviation to right.

Cntrl group had more, but not significantly so, omissions on line cancellation (cntrl 16, exptl 14) and right

deviations on line bisection (cntrl 53%, exptl 50%) at baseline compared with exptl group.


Study Zeloni 2002

Methods RCT: for the first eight participants group allocation was performed by randomly selecting a label from a

pre-printed set of eight (see Notes). The label preparation was performed by a member of the trial team but




the selection was performed by a student who had no previous or later involvement in the trial. Although

the allocation was done externally the method used did not permit verification. The post-treatment assessor

was blinded to allocation.


Participants Italy.

8 randomised (see Notes).




Mean months post stroke: exptl 11.25, cntrl 4.5.

Inclusion: ’post-acute’ patients with right hemisphere vascular lesions and neglect, admitted to hospital,

right-handed, left hemiplegic.

Exclusions: normally wore glasses.

Interventions Wearing plastic goggles for one week, only removing them to go to sleep. The right side of each lens was

blinded

versus

no goggles.

All eight participants were involved in the hospital’s daily activities including the hospital’s usual treatment

for neglect, tasks to train compensation for faulty scanning.



Outcomes Participants were assessed on three occasions: at recruitment, after the experimental group had received one

week of hemiblinding goggles, and again one week after the goggle treatment ended. Controls were assessed

at the same timepoints but never wore the hemiblinding goggles. Testing was performed without goggles.

The outcomes used were: line, letter and bell cancellation, copy drawing, line bisection.

For comparability with other studies this review used: line, letter and bell cancellation, line bisection and

line bisection scores at the third timepoint. As this was only one week after intervention it is coded in this

review as ’immediate’ effects. Letter cancellation data were analysed as single letter cancellation.

Notes Personal communication from the authors confirmed the methods used and provided data. The eight ran-

domised participants are numbers 1 to 4 in the treatment and control group as listed in the authors’ Table

1, page 196. The original study recruited eleven participants. The first eight were randomised as described

above. The other three were non-randomly added to the groups (one to treatment and two to control). This

review only used the eight randomised participants.

Cancellation tests were scored as number correct. Line bisection was scored as percent correct decreasing for

rightward deviation. Authors provided raw data (percentages) for the eight participants on line bisection.

The mean (SD) were: exptl 62.5 (35.2), cntrl 73.8 (22.2). For comparability with other studies this review

reversed the line bisection scoring so that a low score favours the experimental group.


ADL: activities of daily living

BI: Barthel Index

BIT: Behavioural Inattention Test

cm: centimetre

Cntrl: control

CT: computerised tomography

CVA: cerebrovascular accident

Exptl: experimental

FA: functional approach

FAI: Frenchay Activities Index

FIM: Functional Independence Measure

GHQ: General Health Questionnaire

HFVS: Harrington Flocks Visual Screener

HHA: homonymous hemianopia



HI: head injury

hrs: hours

LAT: limb activation training

mins: minutes

mm: millimetre

MMSE: Mini Mental Status Exam

MVPT: Motor Free Visual Perception Test

Nottingham EADL: extended ADL index

OT: occupational therapy/therapist

RBD: right brain damage

RCPM: Raven’s Coloured Progressive Matrices

RCT: randomised controlled trial

Rey CFT: Rey Osterreith Complex Figure Test

RH: right hemisphere

RMA: Rivermead Motor Assessment

RPAB: Rivermead Perceptual Assessment Battery

SD: standard deviation

SU: stroke unit

TENS: transcutaneous electrical nerve stimulation

TIA: transient ischaemic attack

ToT: transfer of training

VN: visual neglect

WAIS-R: Revised Weschler Adult Intelligence Scale

wk: week

WRAT: Wide Range Achievement Test

yrs: years

Characteristics of excluded studies

Study Reason for exclusion

Al Mahasneh 1991 Extreme difficulties with recruitment and participant attrition. 14 participants with neglect consented. These

were unevenly assigned to the experimental (9) and control (5) groups. Only five participants completed three

weeks of treatment. Reviewers did not feel the data were adequate for meta-analysis, e.g. missing data and no

SDs.

Beis 1999 Controlled trial but not RCT: allocation by fixed order of presentation of participants i.e. first to group 1, second

to group 2, etc. Outcome assessors were blinded to allocation. Personal communication provided FIM data,

confirmed allocation method, and that assessments were carried out by two blinded researchers.

Butter 1992 Clarification of randomisation sought but not obtained. Appropriate results (means and SDs) not reported.

Review authors were not sure that the trial was actually evaluating a treatment for spatial neglect.

Carter 1980 Clarification of randomisation sought but not obtained. Separate data for stroke patients also requested but not

obtained. Appropriate data (means, SDs) not reported.

Diller 1974 Reported data inadequate for review. No reply to our letter of 9 February 1999 asking for difficult-to-extract data.

Frassinetti 2002 Controlled clinical trial: non-random allocation (n = 13). Controls at different hospital. Assessment of outcome

not clear (probably non-blind).

Gordon 1985 Controlled trial: quasi-randomisation based on rehabilitation service to which patient was assigned. Experimental

and control conditions alternated every six months between the two services. Not randomised.

Harvey 2003 Controlled trial: non-randomised, initial recruits allocated by date of admission to hospital ward, later recruits

allocated by attempting to match the groups on their scores on pre-intervention neglect assessments. Author

provided clarification and unpublished data by personal communication.



Characteristics of excluded studies (Continued )

Klos 2005 Personal communication from an expert in the field reported that Klos had completed an unpublished RCT of

prism adaptation therapy for neglect. Excluded from review as no reply to request for clarification of methods

and data. Will reconsider for inclusion in next update if further information becomes available.

Lincoln 1985 RCT of patients with general perceptual problems. Problems likely to have included neglect but this subgroup

could not be separately identified.

Loverro 1988 Controlled trial: reported as randomly assigned but allocation based on bed availability; outcome assessors blinded

to purpose of the study.

Niemeier 1998 Controlled trial: not randomised, selected in order of consecutive admissions and on documented left or right

neglect. No information on concealment.

Paolucci 1996 Controlled trial: abstract states randomly assigned but allocated on the basis of bed number (odd or even), bed

number had been assigned by Hospital Administration, odd numbers got immediate training, even numbers got

training after two months (delayed training), neglect screening assessment done after allocation by psychologist

unaware of purpose of study, outcome assessor blinded to the purpose of the study, after eight weeks the delayed

group received the training and the immediate group received the control treatment (broad cognitive stimulation).

Pizzamiglio 2004 Non-random controlled trial (n = 22): alternate allocation. Blind assessment of outcome on Barthel (functional

outcome).

Not clear if outcome assessed blind on impairment measures.

Rossetti 1998 Controlled trial: further data from author confirms it was not randomised. First six consecutive cases were allocated

to experimental group and next six to control. Outcome assessors were not blinded. The trial is the second of two

experiments reported in the paper.

Schindler 2002 Non-randomised cross-over controlled trial. First 10 patients were randomised to one of two groups but the data

on these 10 were not available at the time of this version of this review. It would be considered for inclusion at

the next update if the authors could provide the randomised data.

Tham 1997 Non-random controlled trial. First seven patients assigned to novel treatment group, second seven patients to

conventional treatment group.

Trudell 2003 A published abstract suggested this may be an eligible study. Excluded from review as no information with which

to confirm methods. Will re-consider for inclusion in next update if further information becomes available.

Webster 2001 Controlled clinical trial: 40 assigned, one excluded and matched patient excluded, n = 38. Twenty controls were

from a previous study, not simultaneous. Non-blind assessment of outcome. Wheelchair navigation (functional

measure) as outcome, no impairment measures.

Weinberg 1979 Clarification of randomisation procedure sought but not obtained, and unlikely to be given the age of this paper.

The timescale of publication (and a statement in the results) suggests the participants in this study were not in

the Weinberg 1977 study, however, this has not been confirmed by the authors. On the other hand the 1979

paper does not explicitly mention ’neglect’ and may instead be a trial of visual perception. Given the amount of

uncertainty about this study’s fit to the inclusion criteria, inability to obtain confirmation and clarification about

this old study, lack of detail on randomisation and concern to avoid duplicating data by including this and the

1977 paper we decided to exclude the 1979 paper from this version of the review.

Weinberg 1982 Confirmation regarding randomisation sought from trialist but not obtained. No SD reported.

Young 1983 Controlled trial: not randomised. Divided into three groups matched for age, education, time since onset and

degree of deficit: no further information provided other than assessor blinded to group’s membership.

FIM: Functional Independence Measure


SD: standard deviation

Characteristics of ongoing studies

Study Kerkhoff 2005

Trial name or title Optokinetic rehabilitation of multimodal neglect



Characteristics of ongoing studies (Continued )

Participants 32 patients between 1 and 34 months post-stroke, with left-sided multimodal neglect.

Interventions Optokinetic stimulation for five one-hour sessions

versus

’conventional’ visual scanning training with static stimuli.

Outcomes Digit cancellation, paragraph reading, visuoperceptual and motor line bisection > outcomes assessed twice

immediately after the fifth treatment and at a three week follow up.

Starting date Unknown

Contact information [email protected]

Notes Personal communication

Study Rossetti 2005

Trial name or title Unknown

Participants Unknown

Interventions Prism adaptation

Outcomes Unknown

Starting date Unknown

Contact information Yves Rossetti

[email protected]

Notes Author reported is currently running a double blind RCT.

Study Turton 2005

Trial name or title The effect of using prism adaptation treatment on performance of self care and mobility tasks in patients with

unilateral inattention following stroke

Participants Intended sample size of 40.

Interventions Prism goggles and adaptation training

versus

sham goggles.

Outcomes ADL task

Starting date 2004

Contact information Dr Ailie Turton

Dept of Experimental Psychology, University of Bristol, Bristol UK.

Notes Summary on funder’s website www.stroke.org.uk

ADL: activities of daily living




A N A L Y S E S

Comparison 01. Cognitive rehabilitation versus any control: immediate effects

Outcome titleNo. of

studies

No. of

participants Statistical method Effect size

01 Activities of Daily Living 6 206 Standardised Mean Difference (Random) 95%

CI

0.26 [-0.16, 0.67]

02 Cancellation: numbers correct Standardised Mean Difference (Random) 95%

CI

Subtotals only

03 Cancellation: numbers of errors 4 103 Standardised Mean Difference (Random) 95%

CI

-0.65 [-1.28, -0.01]

04 Line bisection: error scores/

right deviation

4 89 Standardised Mean Difference (Random) 95%

CI

-0.84 [-1.36, -0.33]

05 BIT behavioural subtests 3 52 Standardised Mean Difference (Random) 95%

CI

-0.27 [-0.84, 0.30]

06 Discharge destination (home) 1 50 Odds Ratio (Random) 95% CI 1.40 [0.45, 4.35]

07 A-rated studies only: Activities

of Daily Living


CI

0.16 [-0.36, 0.68]

08 A-rated studies only:

cancellation number correct

(single letter task)


CI

0.01 [-0.84, 0.86]


cancellation errors


CI

0.01 [-0.72, 0.73]

10 A-rated studies only: BIT

behavioural subtests


CI

-0.34 [-1.07, 0.39]

Comparison 02. Cognitive rehabilitation versus any control: persisting effects

Outcome titleNo. of

studies

No. of



CI

0.61 [-0.42, 1.63]

02 Cancellation: number correct Standardised Mean Difference (Random) 95%

CI

Subtotals only

03 Cancellation: number of errors 3 52 Standardised Mean Difference (Random) 95%

CI

-0.76 [-1.39, -0.13]

04 Line Bisection: error scores or

right deviation


CI

-1.09 [-2.00, -0.18]

05 BIT behavioural 2 31 Standardised Mean Difference (Random) 95%

CI

0.06 [-0.66, 0.78]

06 A-rated studies: Activities of

Daily Living


CI

0.12 [-0.62, 0.86]


cancellation number of errors


CI

-0.19 [-1.14, 0.76]

08 A-rated studies only: BIT

behavioural


CI

-0.08 [-1.03, 0.87]



Comparison 03. One type of cognitive rehabilitation versus standard care or attention control: persisting effects

Outcome titleNo. of

studies

No. of



CI

0.61 [-0.42, 1.63]

Comparison 04. One cognitive rehabilitation approach versus another: persisting effects

Outcome titleNo. of

studies

No. of



CI

Not estimable

Comparison 05. Bottom-up processing approaches versus any control: persisting effects

Outcome titleNo. of

studies

No. of



CI

0.12 [-0.62, 0.86]

Comparison 06. Top-down processing rehabilitation approaches versus any control: persisting effects

Outcome titleNo. of

studies

No. of



CI

1.17 [0.25, 2.08]

I N D E X T E R M S

Medical Subject Headings (MeSH)

Cerebrovascular Accident [∗complications; rehabilitation]; ∗Cognitive Therapy; Perceptual Disorders [etiology; ∗rehabilitation]; Ran-

domized Controlled Trials; Sensation Disorders [etiology; rehabilitation]; ∗Space Perception

MeSH check words

Humans

C O V E R S H E E T

Title Cognitive rehabilitation for spatial neglect following stroke

Authors Bowen A, Lincoln NB

Contribution of author(s) Audrey Bowen designed the updated review, conducted the data collection and analysis and

prepared the final report.

Nadina Lincoln initiated and co-ordinated the review project, was the principal grant holder,

conducted data collection, confirmed the analysis and contributed to the final report.

Issue protocol first published 2002/2

Review first published 2002/2

Date of most recent amendment 19 January 2007

Date of most recent

SUBSTANTIVE amendment

19 January 2007



What’s New In this updated review we excluded several previously included non-randomised trials to

reduce bias. We added several new, or newly identified, randomised controlled trials resulting

in a review of 306 participants from 12 RCTs.

Date new studies sought but

none found

Information not supplied by author

Date new studies found but not

yet included/excluded


Date new studies found and

included/excluded

04 July 2005

Date authors’ conclusions

section amended


Contact address Dr Audrey Bowen

Senior Lecturer in Psychology (Speech & Language Therapy)

HCD, School of Psychological Sciences, Humanities Devas Street

University of Manchester

Oxford Road

Manchester

M13 9PL

UK

E-mail: [email protected]

Tel: +44 161 275 3401

Fax: +44 161 275 3373

DOI 10.1002/14651858.CD003586.pub2

Cochrane Library number CD003586

Editorial group Cochrane Stroke Group

Editorial group code HM-STROKE

G R A P H S A N D O T H E R T A B L E S



Analysis 01.01. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 01

Activities of Daily Living

Review: Cognitive rehabilitation for spatial neglect following stroke

Comparison: 01 Cognitive rehabilitation versus any control: immediate effects

Outcome: 01 Activities of Daily Living

Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)

N Mean(SD) N Mean(SD) 95% CI (%) 95% CI

01 Barthel Index

Edmans 2000 24 11.13 (3.95) 18 12.28 (4.11) 18.9 -0.28 [ -0.90, 0.33 ]

Kalra 1997 24 14.20 (3.70) 23 11.70 (4.20) 19.6 0.62 [ 0.04, 1.21 ]

Robertson 2002 17 13.10 (5.50) 19 12.60 (5.10) 17.9 0.09 [ -0.56, 0.75 ]

Rossi 1990 18 50.00 (21.20) 21 54.00 (22.91) 18.5 -0.18 [ -0.81, 0.45 ]

Rusconi 2002 12 56.58 (18.70) 8 48.25 (18.69) 12.7 0.43 [ -0.48, 1.33 ]

Subtotal (95% CI) 95 89 87.6 0.12 [ -0.24, 0.47 ]

Test for heterogeneity chi-square=5.74 df=4 p=0.22 I² =30.3%

Test for overall effect z=0.65 p=0.5

02 FIM

Wiart 1997 11 86.00 (23.00) 11 62.00 (14.00) 12.4 1.21 [ 0.29, 2.14 ]

Subtotal (95% CI) 11 11 12.4 1.21 [ 0.29, 2.14 ]

Test for heterogeneity: not applicable


03 Other

Subtotal (95% CI) 0 0 0.0 Not estimable


Test for overall effect: not applicable

Total (95% CI) 106 100 100.0 0.26 [ -0.16, 0.67 ]



-10.0 -5.0 0 5.0 10.0

Favours control Favours experimental




Cancellation: numbers correct



Outcome: 02 Cancellation: numbers correct



01 Single letter cancellation

Edmans 2000 24 23.08 (13.58) 18 28.83 (12.43) 21.5 -0.43 [ -1.05, 0.19 ]

Fanthome 1995 9 24.00 (12.09) 8 22.90 (14.30) 15.3 0.08 [ -0.87, 1.03 ]

Kalra 1997 24 37.20 (13.10) 23 30.10 (18.50) 22.3 0.44 [ -0.14, 1.02 ]

Rusconi 2002 12 95.00 (8.38) 8 86.63 (23.65) 16.0 0.50 [ -0.41, 1.41 ]

Weinberg 1977 14 92.21 (15.06) 11 50.75 (41.70) 16.3 1.35 [ 0.46, 2.24 ]

Zeloni 2002 4 16.90 (11.80) 4 7.50 (6.10) 8.7 0.87 [ -0.64, 2.38 ]

Subtotal (95% CI) 87 72 100.0 0.39 [ -0.13, 0.92 ]



02 Double letter cancellation

Weinberg 1977 14 84.07 (17.81) 11 40.67 (28.84) 100.0 1.80 [ 0.85, 2.76 ]

Subtotal (95% CI) 14 11 100.0 1.80 [ 0.85, 2.76 ]



03 Line cancellation

Fanthome 1995 9 28.90 (9.30) 8 26.30 (12.00) 54.5 0.23 [ -0.72, 1.19 ]

Zeloni 2002 4 32.00 (8.50) 41 20.30 (12.40) 45.5 0.94 [ -0.10, 1.99 ]

Subtotal (95% CI) 13 49 100.0 0.56 [ -0.15, 1.26 ]



04 Shape cancellation (stars)

Fanthome 1995 9 33.60 (17.40) 8 34.30 (21.00) 68.7 -0.03 [ -0.99, 0.92 ]

Zeloni 2002 4 11.20 (8.90) 4 7.30 (9.00) 31.3 0.38 [ -1.03, 1.79 ]

Subtotal (95% CI) 13 12 100.0 0.09 [ -0.69, 0.88 ]



-10.0 -5.0 0 5.0 10.0





Cancellation: numbers of errors



Outcome: 03 Cancellation: numbers of errors



Cottam 1987 6 28.50 (28.20) 6 34.00 (10.80) 18.5 -0.24 [ -1.38, 0.90 ]

Robertson 1990 17 43.40 (30.40) 13 43.20 (28.30) 28.7 0.01 [ -0.72, 0.73 ]

Rossi 1990 18 2.40 (4.24) 21 9.80 (9.16) 30.2 -0.99 [ -1.66, -0.32 ]

Wiart 1997 11 4.00 (4.00) 11 12.00 (7.00) 22.7 -1.35 [ -2.29, -0.41 ]

Total (95% CI) 52 51 100.0 -0.65 [ -1.28, -0.01 ]



-10.0 -5.0 0 5.0 10.0

Favours experimental Favours control


Line bisection: error scores/right deviation



Outcome: 04 Line bisection: error scores/right deviation



Rossi 1990 18 0.68 (0.85) 21 2.20 (2.29) 40.5 -0.84 [ -1.50, -0.18 ]

Rusconi 2002 12 4.27 (8.94) 8 17.87 (18.90) 23.5 -0.95 [ -1.90, 0.00 ]

Wiart 1997 11 17.00 (14.00) 11 45.00 (25.00) 23.9 -1.33 [ -2.27, -0.39 ]

Zeloni 2002 4 37.50 (35.20) 4 26.30 (22.25) 12.1 0.33 [ -1.07, 1.74 ]

Total (95% CI) 45 44 100.0 -0.84 [ -1.36, -0.33 ]



-10.0 -5.0 0 5.0 10.0





BIT behavioural subtests



Outcome: 05 BIT behavioural subtests



Cherney 2002 2 59.00 (9.90) 2 41.00 (12.73) 1.1 0.90 [ -4.56, 6.37 ]

Fanthome 1995 9 37.60 (21.30) 9 42.90 (29.30) 37.7 -0.20 [ -1.12, 0.73 ]

Robertson 1990 17 52.00 (24.00) 13 59.90 (20.20) 61.2 -0.34 [ -1.07, 0.39 ]

Total (95% CI) 28 24 100.0 -0.27 [ -0.84, 0.30 ]



-10.0 -5.0 0 5.0 10.0



Discharge destination (home)



Outcome: 06 Discharge destination (home)

Study Experimental Control Odds Ratio (Random) Weight Odds Ratio (Random)

n/N n/N 95% CI (%) 95% CI

Kalra 1997 16/25 14/25 100.0 1.40 [ 0.45, 4.35 ]

Total (95% CI) 25 25 100.0 1.40 [ 0.45, 4.35 ]

Total events: 16 (Experimental), 14 (Control)



0.1 0.2 0.5 1 2 5 10





A-rated studies only: Activities of Daily Living



Outcome: 07 A-rated studies only: Activities of Daily Living



01 Barthel Index

Edmans 2000 24 11.13 (3.95) 18 12.18 (4.11) 33.5 -0.26 [ -0.87, 0.36 ]

Kalra 1997 24 14.20 (3.70) 23 11.70 (4.20) 35.0 0.62 [ 0.04, 1.21 ]

Robertson 2002 17 13.10 (5.50) 19 12.60 (5.10) 31.5 0.09 [ -0.56, 0.75 ]

Subtotal (95% CI) 65 60 100.0 0.16 [ -0.36, 0.68 ]



02 FIM




03 Other




Total (95% CI) 65 60 100.0 0.16 [ -0.36, 0.68 ]



-10.0 -5.0 0 5.0 10.0



A-rated studies only: cancellation number correct (single letter task)



Outcome: 08 A-rated studies only: cancellation number correct (single letter task)



Edmans 2000 24 23.08 (13.58) 18 28.83 (12.43) 49.2 -0.43 [ -1.05, 0.19 ]

Kalra 1997 24 37.20 (13.10) 23 30.10 (18.50) 50.8 0.44 [ -0.14, 1.02 ]

Total (95% CI) 48 41 100.0 0.01 [ -0.84, 0.86 ]


Test for overall effect z=0.02 p=1

-10.0 -5.0 0 5.0 10.0





A-rated studies only: cancellation errors



Outcome: 09 A-rated studies only: cancellation errors



Robertson 1990 17 43.40 (30.40) 13 43.20 (28.30) 100.0 0.01 [ -0.72, 0.73 ]

Total (95% CI) 17 13 100.0 0.01 [ -0.72, 0.73 ]


Test for overall effect z=0.02 p=1

-10.0 -5.0 0 5.0 10.0



A-rated studies only: BIT behavioural subtests



Outcome: 10 A-rated studies only: BIT behavioural subtests



Robertson 1990 17 52.00 (24.00) 13 59.90 (20.20) 100.0 -0.34 [ -1.07, 0.39 ]

Total (95% CI) 17 13 100.0 -0.34 [ -1.07, 0.39 ]



-10.0 -5.0 0 5.0 10.0




Analysis 02.01. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 01

Activities of Daily Living


Comparison: 02 Cognitive rehabilitation versus any control: persisting effects




01 Barthel Index

Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 53.5 0.12 [ -0.62, 0.86 ]

Subtotal (95% CI) 13 15 53.5 0.12 [ -0.62, 0.86 ]



02 FIM

Wiart 1997 11 93.00 (23.00) 11 69.00 (16.00) 46.5 1.17 [ 0.25, 2.08 ]

Subtotal (95% CI) 11 11 46.5 1.17 [ 0.25, 2.08 ]



03 Other




Total (95% CI) 24 26 100.0 0.61 [ -0.42, 1.63 ]



-10.0 -5.0 0 5.0 10.0





Cancellation: number correct



Outcome: 02 Cancellation: number correct


N

Mean(SD) N

Mean(SD) 95% CI (%) 95% CI

01 Single letter cancellation




02 Double letter cancellation




03 Line cancellation




04 Shape cancellation (stars)




-10.0 -5.0 0 5.0 10.0



Cancellation: number of errors



Outcome: 03 Cancellation: number of errors



Cottam 1987 6 23.30 (17.70) 6 44.80 (23.40) 23.7 -0.96 [ -2.18, 0.27 ]

Robertson 1990 11 20.00 (16.40) 7 23.10 (14.50) 37.1 -0.19 [ -1.14, 0.76 ]

Wiart 1997 11 3.00 (4.00) 11 10.00 (7.00) 39.2 -1.18 [ -2.10, -0.26 ]

Total (95% CI) 28 24 100.0 -0.76 [ -1.39, -0.13 ]



-10.0 -5.0 0 5.0 10.0





Line Bisection: error scores or right deviation



Outcome: 04 Line Bisection: error scores or right deviation



Wiart 1997 11 16.00 (14.00) 11 39.00 (25.00) 100.0 -1.09 [ -2.00, -0.18 ]

Total (95% CI) 11 11 100.0 -1.09 [ -2.00, -0.18 ]



-10.0 -5.0 0 5.0 10.0



BIT behavioural



Outcome: 05 BIT behavioural



Fanthome 1995 7 45.10 (19.00) 6 39.00 (26.00) 42.8 0.25 [ -0.84, 1.35 ]

Robertson 1990 11 60.10 (18.60) 7 61.80 (21.50) 57.2 -0.08 [ -1.03, 0.87 ]

Total (95% CI) 18 13 100.0 0.06 [ -0.66, 0.78 ]



-10.0 -5.0 0 5.0 10.0




Analysis 02.06. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 06 A-

rated studies: Activities of Daily Living



Outcome: 06 A-rated studies: Activities of Daily Living



01 Barthel index

Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 100.0 0.12 [ -0.62, 0.86 ]

Subtotal (95% CI) 13 15 100.0 0.12 [ -0.62, 0.86 ]



02 FIM




03 Other




Total (95% CI) 13 15 100.0 0.12 [ -0.62, 0.86 ]



-10.0 -5.0 0 5.0 10.0



rated studies only: cancellation number of errors



Outcome: 07 A-rated studies only: cancellation number of errors



Robertson 1990 11 20.00 (16.40) 7 23.10 (14.50) 100.0 -0.19 [ -1.14, 0.76 ]

Total (95% CI) 11 7 100.0 -0.19 [ -1.14, 0.76 ]



-10.0 -5.0 0 5.0 10.0





rated studies only: BIT behavioural



Outcome: 08 A-rated studies only: BIT behavioural



Robertson 1990 11 60.10 (18.60) 7 61.80 (21.50) 100.0 -0.08 [ -1.03, 0.87 ]

Total (95% CI) 11 7 100.0 -0.08 [ -1.03, 0.87 ]



-10.0 -5.0 0 5.0 10.0


Analysis 03.01. Comparison 03 One type of cognitive rehabilitation versus standard care or attention control:

persisting effects, Outcome 01 Activities of Daily Living


Comparison: 03 One type of cognitive rehabilitation versus standard care or attention control: persisting effects




01 Barthel Index

Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 53.5 0.12 [ -0.62, 0.86 ]

Subtotal (95% CI) 13 15 53.5 0.12 [ -0.62, 0.86 ]



02 FIM

Wiart 1997 11 93.00 (23.00) 11 69.00 (16.00) 46.5 1.17 [ 0.25, 2.08 ]

Subtotal (95% CI) 11 11 46.5 1.17 [ 0.25, 2.08 ]



Total (95% CI) 24 26 100.0 0.61 [ -0.42, 1.63 ]



-10.0 -5.0 0 5.0 10.0




Analysis 04.01. Comparison 04 One cognitive rehabilitation approach versus another: persisting effects,

Outcome 01 Activities of Daily Living


Comparison: 04 One cognitive rehabilitation approach versus another: persisting effects



N

Mean(SD) N

Mean(SD) 95% CI (%) 95% CI

01 Barthel Index




02 FIM




03 Other




Total (95% CI) 0 0 0.0 Not estimable



-10.0 -5.0 0 5.0 10.0

Favours control Favours experiment

Analysis 05.01. Comparison 05 Bottom-up processing approaches versus any control: persisting effects,

Outcome 01 Activities of Daily Living


Comparison: 05 Bottom-up processing approaches versus any control: persisting effects




01 Barthel Index

Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 100.0 0.12 [ -0.62, 0.86 ]

Total (95% CI) 13 15 100.0 0.12 [ -0.62, 0.86 ]



-10.0 -5.0 0 5.0 10.0




Analysis 06.01. Comparison 06 Top-down processing rehabilitation approaches versus any control: persisting

effects, Outcome 01 Activities of Daily Living


Comparison: 06 Top-down processing rehabilitation approaches versus any control: persisting effects




02 FIM

Wiart 1997 11 93.00 (23.00) 11 69.00 (16.00) 100.0 1.17 [ 0.25, 2.08 ]

Total (95% CI) 11 11 100.0 1.17 [ 0.25, 2.08 ]



-10.0 -5.0 0 5.0 10.0




Documents

Cognitive rehabilitation for spatial neglect following stroke neglect 2007.pdf · Cognitive rehabilitation for spatial neglect following stroke (Review) Bowen A, Lincoln NB This record