Body Neglect in Stroke Patients

Body neglect in stroke recovery can be challenging for rehab professionals to address. Below are suggestions to facilitate patient awareness of the affected side.

Body neglect in stroke patients is a neuropsychological condition that occurs due to damage in one hemisphere of the brain. Body neglect occurs when there is a deficit in attention or awareness to one side of the field of vision or to the affected limb. Body neglect in stroke recovery can also be referred to as:

• Hemispatial neglect (hemiagnosia)
• Hemineglect
• Unilateral neglect
• Spatial neglect
• Contralateral neglect
• Unilateral visual inattention
• Hemi-inattention
• Neglect syndrome
• Contralateral hemispatialagnosia

Signs and Symptoms of Body Neglect

The signs and symptoms of body neglect in stroke patients can vary, but primarily occurs when patients fail to report, respond, or orient to meaningful stimuli presented on the affected side. Examples of body neglect in a stroke survivor include:

• leaving food on half of their dinner plate
• bumping into the wall or a door with the affected side
• avoiding turning to look at you when you are speaking or failing to recall auditory information presented on the affected side after distraction
• shaving or grooming unaffected side only
• forgetting to cover their affected arm in a shirt sleeve
• ignoring objects placed on the affected side of their body

Stroke patients may also experience anosognosia, a lack of awareness or the underestimation of a specific deficit in sensory, perceptual, motor, affective or cognitive functioning.

Incidence Rate of Body Neglect in Stroke Patients

The incidence rate for unilateral spatial neglect following stroke in the U.S. is upwards of 80% in right-sided stroke patients. Right-sided unilateral neglect resulting from left hemisphere damage is found (at least to some degree) in about 44% of stroke patients. Research demonstrates that improvement in upper extremity strength is associated with severity of neglect. Moreover, visuospatial neglect is also associated with poor motor recovery, higher disability, and poor responses to rehabilitation services.

How to Avoid Body Neglect

Body neglect after stroke can be very frustrating for the patient. It is more than “not being able to use” one side; it is actually a complete lack of awareness of the affected side. This can reduce the possibility of independent living and increase the potential of painful injury. Therefore, it is crucial to improve body awareness. With proper positioning and therapeutic communication techniques, rehab professionals can encourage a patient to use the affected (neglected) arm or leg. But, it is important to note that a patient should be ready to use the paretic limb both during rehab and non-rehab hours. Otherwise, the patient may experience aggression, depression, and decreased motivation when attempting to use the paretic limb inconsistently i.e. only during treatment periods. (In acute cases, you can encourage the use of the affected limb only in rehab. Once the patient is able to use the affected limb for 50% of the time, then incorporate the strategies described below during non-rehab periods.)

Strategies to Encourage Use of the Affected Side During Non-Rehab Time

There are several things that you can do to help a patient improve awareness of their neglected side. The best way to encourage use is to make environmental changes:

• Place the television, remote control, glass of water, etc. on the neglected side
• Place the nightstand on the neglected side
• Stand on the paretic side and encourage conversation with the patient
• Put wall decorations with family pictures on the neglected side
• Sometimes, setting handwritten instructions on the non-affected side will remind patients to use and look at the other side
• Play video games with the affected side, when appropriate

Note: Make sure equipment such as the call bell or phone is placed on the non-affected side so the patient is able to reach them in an emergency. Also, family and caregivers should be educated to aid the stroke survivor in “tuning in” to the neglected side. Small actions can make a big difference. Encourage the family to sit beside the patient on the affected side, gently hold or rub the affected hand/arm, or engage in conversation on the affected side. Last, educate non-rehab professionals as well as the family about proper communication in stroke patients. You will only add to the patient’s frustration by making comments such as, “Did you forget that again?” or talking in a scolding manner. Rather, encourage the patient to locate an item from the neglected side by saying, “Here is your spoon, remote control, etc.” Proper therapeutic communication is a must to facilitate recovery.

References:

1. Klinke ME, Hafsteinsdottir TB, Hjaltason H, Jonsdottir H. Ward-based interventions for patients with hemispatial neglect in stroke rehabilitation: A systematic literature International Journal Of Nursing Students. 215; 52 (8): 1375-1403.
2. Pierce SR, Buxbaum Treatments of unilateral neglect: A review. Archives of Physical Medicine and Rehabilitation. 2002; 83 (2): 256-268.
3. Winstein CJ, Stein J, Arena R, Bates B, Cherney LR, Cramer SC, Deruyter F, Eng JJ, Fisher B, Harvey RL, Lang CE, MacKay-Lyons M, Ottenbacher KJ, Pugh S, Reeves MJ, Richards LG, Stiers W, Zorowitz RD; on behalf of the American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. 2016;47:e98–e169. DOI: 10.1161/STR.0000000000000098.
4. Nijboer TCW, Kollen BJ, Kwakkel G (2014) The Impact of Recovery of Visuo-Spatial Neglect on Motor Recovery of the Upper Paretic Limb after Stroke. PLoS ONE 9(6): e100584. https://doi.org/10.1371/journal.pone.0100584.
5. Pierce SR, Buxbaum Treatments of Unilateral Neglect: A Review. Arch Phys MEd Rehabilitation. 2002; 83: 256-268.