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Neglect rehabilitation in stroke: not to be neglected

The rehabilitation of disorders of cognitive functions, following acquired neurological damage of different aetiology (in particular, stroke and traumatic brain injury), is an important area of neurological rehabilitation. Unfortunately, it is generally agreed that the present status of studies on the effectiveness of cognitive rehabilitation is fair from satisfactory. In particular, there are not many randomized clinical trials (RCT) in this area, and they are often of poor methodological quality. Insufficient sample size, failures to assess the outcome at the disability level or to compare intervention with placebo or sham treatment are amongst the problems which plague this area [1]. Whilst most practitioners in the field are convinced that the same standards required for the evaluation of pharmacological and surgical interventions are mandatory also in the case of rehabilitation treatments, it is clearly necessary to acknowledge that there are a number of problematic issues related to the application of the RCT model to cognitive rehabilitation. These include the highly heterogeneous nature of cognitive deficits, and the inherent difficulty in defining standardized treatment approaches, which may be expected to be effective in large patient samples. In recent years, the cognitive neuropsychological approach to rehabilitation has focused on the assessment of specific, theoretically driven treatments on well-defined area of impairment, usually by means of single-case studies. When conducted with a rigorous methodology, including appropriate statistical evaluation, these studies may be useful for the preliminary evaluation of promising rehabilitation methods to be assessed in large scale investigations. From the methodological standpoint, the rehabilitation of UN may be considered as a relatively privileged area, as compared to, for example, the rehabilitation of language or memory disorders. Whilst also UN is a complex clinical syndrome, associated with a number of possible physiopathological mechanisms [2], many of the treatment approaches are based on interventions amenable to adequate standardization [3,4]. The clinical justification of an active interventional approach is the observation that the presence of UN beyond the acute stage is associated with poor outcome in terms of independence [4,5]. Several theoretically founded methods of neglect rehabilitation have been investigated in clinical trials [3]. These include visual scanning training, visuospatio-motor training, trunk orientation, neck vibration, the use of prism goggles as well as transcutaneous electrical stimulation of neck muscles. There is convincing evidence of effectiveness for several of these approaches (in particular for programmes based on the training of visual scanning) as assessed at the impairment level [1,6], even if conclusive evidence for the impact of UN rehabilitation at the functional level is still lacking. The paper by Wist et al. ([7], pp 922–927, this issue) provides additional evidence for the effectiveness of different forms of rehabilitation of UN after stroke. The comparison was between a control group, receiving only exploration training and two experimental groups, in which exploration training was combined with either contralateral transcutaneous electrical nerve stimulation or optokinetic stimulation. The treatment outcome was measured both using standard impairment measures (UN tests), as well as on measures of reading and writing performance, which may reflect ecologically relevant changes. Both experimental treatments resulted in an improvement of reading and writing abilities, which was persistent 1 week after the end of therapy. The results are remarkable, considering that they were obtained with a relatively modest amount of training (20 sessions in 4 weeks). This kind of programmemight thus prove to be more practical, and feasible in a variety of clinical settings, than the very intensive approaches applied in other investigations, and has the additional advantage of being based on relatively simple procedures. The widespread adoption of UN training procedures in association with motor rehabilitation outside specialized research centers can be expected to provide definitive evidence about the relevance of this important area of neuropsychological rehabilitation on the functional recovery of stroke patients.