Unilateral spatial neglect after stroke: assessment and rehabilitation

Neglect most often follows damage to the right side of the brain, so the left side of space is ignored, although it can occur in either direction. NICE defines visual inattention as an inability to orient towards and attend to stimuli, including body parts, on the side of the body affected by stroke. The person may eat food from only one half of the plate, shave or apply make-up to one side of the face, bump into door frames, leave one sleeve undone or miss words at the start of each line when reading.

It differs from hemianopia, which is loss of half the visual field caused by damage to the visual pathways. In hemianopia the person usually knows something is missing and learns to turn the head. In neglect the awareness is the thing that is lost, which is why safety advice sometimes feels baffling to the person concerned.

NICE recommends standardised assessments combined with behavioural observation. Therapists may ask the person to cross out items on a page, copy a drawing or bisect a line, then watch how they perform when dressing, moving around a ward or using a wheelchair. Observation across the day often reveals more than a single test, because neglect fluctuates with tiredness and distraction.

Occupational therapists, physiotherapists, nurses and speech and language therapists each see different parts of the picture. Relatives can report things such as missing half the meal at home, so they are usually asked for their observations.

NICE guidance on stroke rehabilitation says interventions should focus on the relevant functional tasks and take into account the underlying impairment. It gives several examples that teams use.

• Scanning training, with brightly coloured lines or highlighter at the edge of the page so the person learns to look to the neglected side before starting to read.

• Sounds used to alert the person to the neglected side.

• Repeating tasks such as dressing, so that a routine replaces reliance on awareness.

• Prism glasses to broaden the field of view.

The occupational therapy section of the same guideline describes restorative strategies, such as encouraging people with hemisensory inattention to attend to the neglected side, and establishing a dressing routine for people whose concentration, inattention or dyspraxia makes dressing difficult. Compensatory strategies include one-handed dressing and the use of bathing and dressing aids.

Environmental changes also help. Therapists may place the bedside table, call bell and television on the side where the person can see them, then gradually move them toward the neglected side as awareness improves. Family are usually taught to approach from the neglected side when possible, to avoid cluttered walkways and to prompt gently rather than correcting repeatedly.

Neglect often improves in the first weeks as swelling around the injury settles and the brain reorganises, and for some people it fades almost completely. For others subtle forms persist, which can show up in busy environments, when tired or when doing two things at once. The NHS describes stroke recovery as depending on how much the stroke has affected someone physically and mentally and on the rehabilitation plan, with a review of progress after about six months.

Because progress is uneven, teams reassess regularly and adjust cues. Rehabilitation is more effective when the person can practise with a goal that matters to them, such as making a hot drink safely or finding their way to the shops.

Neglect increases the risk of falls, injuries to the neglected arm, scalds and road accidents. NICE tells clinicians who advise about visual problems after stroke to consult the DVLA regulations. DVLA guidance says that anyone who still has problems with eyesight, balance, memory or understanding one month after a stroke must tell the DVLA, and ordinary car drivers must stop driving for at least one month and restart only when a doctor or healthcare professional says it is safe.