Neglect is a disorder of spatial awareness characterized by the failure to react to stimuli presented to the side opposite to a brain lesion. Neglect may affect one or more senses involving visual, auditory, and tactile modalities.

This disorder decreases a person’s independence in activities of daily living (ADLs), such as dressing or eating, and this negatively affects their quality of life and increases caregiver burden.

In this scenario, rehabilitation aims to reduce the impact of this disorder on a patient’s functional independence, social activities, and quality of life. In particular, individuals are trained to voluntarily compensate for their neglect.

This review investigated the effects of different non-pharmacological interventions for people with spatial neglect following a stroke and other brain injuries.

This review is important for

People with neglect due to an acquired brain lesion, their loved ones/caregivers, health professionals caring for this population, general practitioners, researchers, and policymakers.

Outcomes of this review

This is an update of Cochrane Systematic Reviews (CSRs) published in 2002, 2006, and 2013. The outcomes analysed were functional ability in ADLs; a specific measure of performance on a standardised test for neglect, balance, and a number of falls; psychological symptoms like depression and anxiety; quality of life; social isolation; adverse events; and destination after discharge.

The CSR included 65 randomised controlled trials published and/or registered from 1966 to October 2020, with 1,951 participants. The types of treatment analysed were visual treatment, prismatic lens adaptation, treatments on body-awareness mental function and movements, noninvasive brain stimulation, electrical stimulation, and acupuncture. Overall results showed that for each type of treatment there was no significant difference or a small possible benefit from interventions compared to controls, with very low-quality evidence.

These results must be interpreted with caution since (i) study samples were small; (ii) the applicability of evidence was limited because most of the cases of neglect were caused by right-hemisphere stroke; and (iii) no data on different stroke severity were extracted. Moreover, (iv) a lack of follow-up data limited the evaluation of long-term effects; (v) most of the studies had insufficient evidence on blinding of outcome assessment; and (vi) variations in studies’ design limited the combination of a large pool of data.

Author’s conclusion of the review

The effect of non-pharmacological interventions for people who had acquired a brain lesion and experienced neglect remains yet to be proved. No specific rehabilitation protocol can be defined and supported; therefore, current clinical practise should be guided by national guidelines, when present, and by individual evaluation.

Usual stroke or neurological rehabilitation interventions should be delivered to people with neglect, and they should take part in high-quality research to improve clinical practice.

Future recommendations

The authors recommended that large-scale, multi-centre studies are needed, particularly to find out (a) the role of different types of non-pharmacological interventions to improve ADLs in patients with neglect. The studies should (b) improve the current methodology; (c) properly describe all of the procedures; (d) employ only random allocation methods; (e) attempt blinding of assessors; (f) provide an adequate description of the study samples; and (g) include follow-up data after the intervention, particularly data assessing functional ADLs and neglect.

Sara Liguori