Treatment of Visual Perceptual Disorders Post Stroke

Abstract

Visual perceptual disorders are a common clinical consequence of stroke. They include unilateral neglect, which has a major impact on rehabilitation outcome. The nature of the behavioral deficits associated with neglect has suggested that behavioral modification strategies may improve performance. This article presents a critical review and synthesis of published research evidence for the effectiveness of treatments for visual perceptual disorders after stroke. The strongest evidence for rehabilitation effectiveness was for the following: (a) specific treatment for perceptual disorders; and (b) specific training for neglect (including visual scanning). Findings also suggest that more research is needed into how the assessment of specific features of visual perceptual disorders might lead to improved methods for rehabilitation, including the use of assistive devices for mobility and activities of daily living.

Full text

77
Visual perceptual disorders are a com-
mon clinical consequence of stroke
and occur when there has been injury
to the cortical (especially parietal or occipital
lobe) or midbrain areas.1Hemianopsia refers to
blindness in one half of the visual field of one
or both eyes.2There can also be disorders of
body scheme and higher level visual perceptu-
al skills such as discrimination and spatial rela-
tions. The major forms of visual perceptual
deficit (and their clinical manifestations) are as
follows: agnosia (inability to recognize an
object by sight despite adequate cognition, lan-
guage skills, and visual acuity/field; may
include denial of illness); alexia (inability to
recognize or comprehend written or printed
words); apraxia (inability to execute purposeful
movement, leading to dressing difficulty); atax-
ia (inability to visually guide limbs; mislocal-
ization when reaching or pointing for objects);
depth perception (inability to judge depths and
distances); figure-ground discrimination
(inability to distinguish foreground from back-
ground); form perception/constancy (inability
Jeffrey W. Jutai, PhD, CPsych, is Associate
Professor, Department of Physical Medicine and
Rehabilitation, University of Western Ontario,
London, Ontario, Canada
Sanjit K. Bhogal, BA (Hon), is Research Associate,
St. Joseph’s Health Care London, Parkwood Site,
London, Ontario, Canada.
Norine C. Foley, BASc, is Research Associate,
St. Joseph’s Health Care London, Parkwood Site,
London, Ontario, Canada.
Mark Bayley, MD, FRCPC, is Medical Director,
NeuroRehabilitation Program, Toronto
Rehabilitation Institute, Toronto, Ontario, Canada
Robert W. Teasell, MD, FRCPC, is Professor and
Chair/Chief, Department of Physical Medicine and
Rehabilitation, St. Joseph’s Health Care London and
University of Western Ontario, London, Ontario,
Canada.
Mark R. Speechley, PhD, is Associate Professor,
Department of Epidemiology and Biostatistics,
University of Western Ontario, London, Ontario,
Canada.
Top Stroke Rehabil 2003;10(2):77–106
© 2003 Thomas Land Publishers, Inc.
www.thomasland.com
Visual perceptual disorders are a common clinical consequence of stroke. They include unilateral neglect,
which has a major impact on rehabilitation outcome. The nature of the behavioral deficits associated with
neglect has suggested that behavioral modification strategies may improve performance. This article pres-
ents a critical review and synthesis of published research evidence for the effectiveness of treatments for
visual perceptual disorders after stroke. The strongest evidence for rehabilitation effectiveness was for the
following: (a) specific treatment for perceptual disorders; and (b) specific training for neglect (including
visual scanning). Findings also suggest that more research is needed into how the assessment of specific
features of visual perceptual disorders might lead to improved methods for rehabilitation, including the use
of assistive devices for mobility and activities of daily living. Key words: evidence-based medicine, neg-
lect, perceptual disorder, rehabilitation, stroke
Treatment of Visual Perceptual
Disorders Post Stroke
Jeffrey W. Jutai, Sanjit K. Bhogal, Norine C. Foley, Mark Bayley,
Robert W. Teasell, and Mark R. Speechley

to judge variations in form); spatial relations
(inability to perceive the position of two or
more objects in relation to self and to each oth-
er); unilateral spatial neglect (inability to attend
to or respond to meaningful sensory stimuli
presented in the affected hemisphere, also
known as hemi-inattention and hemispatial
neglect).2,3 It is estimated that as many as 30%
of stroke patients may have either homony-
mous hemianopsia or unilateral visual neglect.4
Studies have reported incidence rates
from 23% to 46% for unilateral neglect; uni-
lateral neglect also negatively impacts func-
tional recovery and long-term outcomes.5–11
Neglect is more common and more severe in
patients with lesions in the right side of the
brain, and it is recognized as a complex phe-
nomenon with perceptual, motor, and moti-
vational components.12 The patient appears
to have lost awareness of sensory events
within the left extrapersonal space, especial-
ly when there is competing stimulation in
the right half of the extrapersonal world.13 In
those cases in which unilateral neglect is the
outcome of stroke, 70% of patients usually
recover by 3 months (median time for 50%
of patients to recover varies from 9 to 43
weeks).14 Patients with severe neglect on ini-
tial presentation have the worst prognosis.14
The most persistent cases seem to occur
with subcortical lesions in the basal ganglia,
thalamus, or white matter.12 Unilateral neg-
lect commonly occurs in conjunction with
other behavioral features that are typically
associated with right-hemisphere damage,
such as denial of illness, constructional
deficits, and apraxia.5The nature of the
behavioral deficits has suggested that behav-
ioral modification strategies may improve
performance.15,16
Unilateral neglect has a major impact on
rehabilitation outcome. Studies have shown
that patients who have neglect of the left
hemispace have longer hospital stays,17
more difficulty resuming activities of daily
living,18 and more frequent falls during their
hospital stays than do other patients.19 There
is evidence indicating that use of ipsilesion-
al limbs may exacerbate neglect symp-
toms.20,21 Neglect is important in the reha-
bilitation for mobility; a crucial factor in the
risk for falls is the patient’s inclination
toward initiating behaviors that place the
patient in danger.22
Method
A comprehensive search of five electron-
ic databases (MEDLINE, EMBASE, MAN-
TIS, PASCAL, and Sci Search) was con-
ducted from 1995 to June 2002 to identify
published literature evaluating the efficacy
of stroke rehabilitation therapies. From
1970 to 1994, a single database (MED-
LINE) was searched. Additional references
were also obtained from the bibliographies
of selected articles. Search terms included
cerebrovascular disorders and perceptual
disorders or neglect and treatment and ran-
domized controlled trial or controlled study
or quantitative or methodological overview.
Unpublished data were not included.
Abstracts of 2,500 studies were reviewed,
and all randomized controlled trials (RCTs)
that evaluated perceptual disorders were
identified. An RCT was defined as a com-
parative trial that included at least one inter-
vention group and a control group and
where group assignments took place
through a formal randomization process.
The studies reviewed included those with
patients who had experienced a radiologi-
cally confirmed ischemic or hemorrhagic
cerebrovascular accident.
78 TOPICS IN STROKE REHABILITATION/SUMMER 2003

To assess the methodological quality of
the articles, the PEDro scoring system was
used. PEDro was developed for the purpose
of accessing bibliographic details and
abstracts of RCTs, quasi-randomized stud-
ies, and systematic reviews in the physio-
therapy literature.23 The PEDro Scale con-
sists of 10 quality criteria each receiving
either a yes or no score. A single point is
awarded for each of the following items:
randomization; concealment of allocation;
comparison of baseline characteristics;
blinding of patient, therapist, and assessor;
adequacy of follow-up; intention-to-treat
analysis; and between-group statistical
comparisons using point estimates and
measures of variability. Studies using a
nonrandomized design or quasi-randomiza-
tion techniques were not scored or included
in this review. Two reviewers independent-
ly assessed each article and assigned a qual-
ity score. Scoring discrepancies were
resolved by a third person, whose scoring
decision was final.
The levels of evidence used to summarize
the findings were based, in part, on the levels
of evidence used by the US Agency for
Health Care Policy and Research’s (AHCPR)
guidelines for stroke rehabilitation.24 Levels
of evidence considered were strong (two
RCTs), moderate (one RCT), limited (cohort
or case-control studies), consensus (panel of
experts), and conflicting (diverging RCTs).
Perceptual deficits
Titus et al.,25 by combining the working
definition of several authors, defined per-
ceptual performance as “the ability to
organize, process and interpret incoming
visual information, tactile-kinesthetic infor-
mation, or both, and to act appropriately on
the basis of the information received.”(p410)
Using this definition, Titus et al.25 examined
the relationship between perceptual per-
formance and activities of daily living
(ADLs). The authors observed that percep-
tual deficits, in particular constructional
praxes and haptic visual discrimination,
were related to performance of ADLs.
Two main approaches to the treatment of
perceptual disorders have received the most
attention from researchers.26 The transfer of
training approach assumes that practice on a
particular perceptual task will improve per-
formance on similar perceptual tasks. The
functional approach strives to promote func-
tional independence through the repetitive
practice of particular tasks, usually ADLs.
Six RCTs, one single group intervention
study, and one comparative cohort study
that addressed the treatment of perceptual
deficits post stroke were identified (see
Table 1).
Four of the reviewed RCTs were of good
quality while the remaining two RCTs were
of fair quality. The one comparative cohort
study and one single group intervention
study identified were not of appropriate
design to be assigned a PEDro score. Of the
six RCTs, three demonstrated positive
results, two resulted in nonsignificant find-
ings, and one demonstrated mixed results.
A summary of treatments of perceptual
deficits post stroke is presented in Table 2.
Conclusions regarding treatment of percep-
tual disorders post stroke
There is strong evidence (3 positive, 1
negative, and 1 mixed study) that specific
treatment of perceptual disorders (i.e.,
transfer of training approach) improves per-
ceptual functioning. One additional RCT,
Treatment of Visual Perceptual Disorders 79

80 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 1. Treatments of perceptual deficits post stroke
Weinberg et al.
197760
United States
Right brain-damaged
(RBD) patients due to
stroke
Inclusion: Unilateral
brain damage; absence of
severe organic mental
syndrome; no history of
prior stroke; at least 4 wk
after onset of CVA
57
Treatment
n= 25
Control
n= 32
Patients randomly
assigned to the experi-
mental group receiving
20 hr of testing (1
hr/day for 4 wk in read-
ing, writing and calcu-
lation) or the control
group that received no
testing between evalua-
tions. In each group,
patients were divided
into severe and mild
visual perceptual
deficits. Both groups
received OT as part of
general rehabilitation.
Wide Range Achievement
Test (WRAT);
cancellation H and can-
cellation C & E;
counting faces,
matching faces;
Digit Span;
object assembly; picture
completion;
WAIS test and DSS
RBD severe experimental
patients improved on WRAT,
p= .01; paragraph, p= .01;
arithmetic, p = .01;
copying, p= .01;
H cancellation, p= .01;
C&E cancellation, p= .05;
picture completion, p= .01;
Digit Span, p= .01;
DSS, p= .05;
and confront, p= .01.
RBD mild experimental
patients improved on
WRAT, p= .05;
H cancellation, p= .01;
C&E cancellation, p= .01;
face matching, p= .05;
Digit Span, p= .01;
impersistence, p= .05.
RBD mild control improved
on face counting, picture
completion, and object
assembly, p= .05.
Experimental group improved
significantly more than the
control group.
6
(RCT)
Weinberg et al.
197961
United States
Stroke patients with right
brain damage
Inclusion: Right brain
damage; CVA at least 4
wk previous; unilateral
brain damage; absence of
severe organic mental
syndrome; and negative
history of prior stroke
53
Treatment
n= 53
Control
n= 23
Patients randomly
assigned to receive
either 1 hr treatment, 5
days/wk for 4 wk of
occupational and physi-
cal therapy (C) or to
receive 15 hr of track-
ing target practice and 5
hr of training in sensory
awareness.
Wide Range Reading
Achievement Test; para-
graph reading; Wide
Range Arithmetic; copy-
ing a paragraph; cancella-
tion H; cancellation C
and E; counting faces,
matching faces; picture
completion; object assem-
bly; Digit Span; pace-
hand test; visual con-
frontation; motor
impersistence; body mid-
line;bisecting lines;
shoulder; midline
In RBD severe treatment
group demonstrated signifi-
cant improvement in 24 or 26
scores, .01 < p < .05.
Mild experimental exceeded
controls on 3 of 26 scores.
Severe subgroup exceeded
controls on 15 of 26 scores.
6
(RCT)

Treatment of Visual Perceptual Disorders 81
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 1. (continued)
Weinberg et al.
198262
United States
Right brain-damaged
stroke patients.
Inclusion: At least 4 wk
post onset of CVA; > 45
years; rendered RBD
secondary to stroke with
no clinical neurologic
signs of bilateral involve-
ment; no significant local
impairment of vision; no
severe impairment of
general mentation
Exclusion: Length of
stay not sufficient to
guarantee completion of
20 hr of training; patients
scheduled for an unrelat-
ed experimental training
program; patients with
manifested gross unilat-
eral neglect of space
35
Treatment
n= 17
Control
n= 18
Patients randomly
assigned to control or
treatment group.
Treatment group
received training in
using paragraphs of
varying length; training
localizing individual
dots and organizing
dots into Gestalts; and
training in
observing/describing
irregular perimeters of
stimulus figures.
Training was given 1
hr/day, 5 days/wk, for 4
wks.
9 verbal-cognitive test
battery; 12 visuocognitive
battery
Treatment group improved on
10 of the 21 tests tapping
visuocognitive abilities
(8/12 visuocognitive test,
2/0 verbal cognitive tests),
.01 < ps < .05.
Controls improved on
1 visuocognitive test and
2 verbal-cognitive tests,
ps < .05.
5
(RCT)
Carter et al.
198363
United States
Acute stroke patients 33
Treatment
n= 16
Control
n= 17
Patients were randomly
assigned to either treat-
ment group receiving
cognitive skill remedia-
tion training adminis-
tered on a 1- to-1 basis
for 30 to 40 min, 3x/wk
and only for those skill
areas that needed
improvement (visual
scanning, visual-spatial,
and time judgment
skills) for 3 to 4 wk, or
patients were random-
ized to the control
group that did not
receive training but
were included in other
stroke program activi-
ties.
Letter cancellation;
visual-spatial matching to
sample;
time estimation
Overall mean improvement
score was significantly
greater for experimental than
for control group,
32.2 vs. 4.9, p< .005.
For each of the specific tasks,
improvement was significant-
ly greater for the experimen-
tal group than for the control
group on scanning,
35.9 vs. 3.8, p< .005;
visual-spatial, 31.0 vs. 3.3,
p< .005; time-judgment,
24.8 vs. 7.8, p< .05.
5

82 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 1. (continued)
Gordon et al.
198564
United States
Stroke patients with (R)
brain damage undergoing
active rehabilitation
Inclusion: at least 4 wk
post onset CVA; age
40–85 years; right hand-
ed; no significant local
impairment in visual acu-
ity; inattention as deter-
mined by neuropsych
testing
Exclusion: bilateral cere-
bral involvement; history
of alcoholism; major psy-
chiatric disturbance; those
not needing perceptual
remediation
77
Treatment
n= 48
Control
n= 29
Experimental group:
maximum 35 hrs of
perceptual remediation.
Control group: partici-
pated in leisure or con-
ventional rehab pro-
gram minus perceptual
remediation.
Basic scanning
somatosensory awareness
and size estimation
complex visual perceptual
organization as deter-
mined by a battery
of tests
At discharge, the experimen-
tal group showed a greater
improvement in 3 types of
perceptual functioning.
At 4 mo post discharge, the
control group continued to
show perceptual gains while
the experimental group
plateaued; perceptual per-
formance was equal.
Experimental group had a
long-term reduction in anxi-
ety but not depression.
At discharge, experimental
group showed an increase in
recreational reading; no dif-
ference by 4 mo.
ns
(quasi-
random-
ized
trial)
Lincoln et al.
198565
United Kingdom
Head injury and stroke
patients with impairments
of visual perception
Inclusion: Visual impair-
ment on Rivermead
Perceptual Assessment
Battery with a score
more than 2 SD below
the mean normal score
33
Treatment
n= 17
Control
n= 16
Patients were randomly
assigned to receive
either perceptual
retraining or to receive
conventional therapy
for 4 hr/wk for 4 wk.
Rivermead Perceptual
Assessment Battery
(RPAB);
Rivermead Activities of
Daily Living Scale
(RADL)
Both groups showed
improvements on RPAB
and RADL; however, no
significant differences were
observed between the
two groups.
6
(RCT)
Wagenaar et al.
199266
The Netherlands
Right-handed and brain-
damaged stroke patients
with visual inattention
5 Treated according to
B-C-B-D design;
patients received physi-
cal therapy in all phas-
es. Occupational thera-
py was applied during
phase B, training of
scanning apparatus was
given during phase C,
and training on reading
task was given during
phase D.
Visual scanning;
transfer effect
4 out of 5 patients demon-
strated a significant positive
effect of visual scanning
training on visual scanning
behavior.
No evidence for any transfer
of visual scanning training
effect to other domains of
gross motor skills
ns

Treatment of Visual Perceptual Disorders 83
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 1. (continued)
Edmans et al.
200026
United Kingdom
Inpatients on the
Nottingham Stroke Unit
Inclusion: Perceptual
problems; functional use
of one hand; able to give
consent; able to tolerate
30-min treatment ses-
sions; suitable for assess-
ment with the Rivermead
Perceptual Ax Battery.
Exclusion: Unable to
complete assessments
because of decreased
seeing, hearing, English
fluency, psychiatric
problems
80 (79)
Transfer of training
n= 40
Functional approach
n= 40 (39)
Baseline measure of
perception and func-
tion, followed by ran-
dom assignment to
either the transfer of
training approach
group, emphasizing
practice of specific per-
ceptual tasks, or to the
functional approach
group focusing on a
specific ADL task; both
groups received 2.5
hr/wk of perceptual
treatment for 6 wk in
addition to general OT
treatment.
Barthel Index;
Rivermead Perceptual
Assessment Battery;
Edmans ADL Index
Both groups showed signifi-
cant improvement on percep-
tual and functional abilities
post treatment.
There was no significant dif-
ference between groups on
initial demographics and ini-
tial scores or at 6 wk on final
scores.
6
(RCT)

84 TOPICS IN STROKE REHABILITATION/SUMMER 2003
PEDro Sample
Study score size Treatment Outcome
Edmans et al.
200026
680 –Transfer of training vs. functional approach
Table 2. Summary of treatments of perceptual deficits post stroke
Weinberg et al.
197760
657 +Testing of reading, writing, and calculation abilities
Weinberg et al.
197961
653 +Tracing target practice, light searching, cancellation of stimulation,
reading and sensory awareness, and spatial organization training
Lincoln et al.
198565
633 –Perceptual retraining
Weinberg et al.
198262
533 +/–Perceptual retraining
Carter et al.
198363
533 +Cognitive skill remediation and specific task training
Gordon et al.
198564
No
score
77 + at discharge
– at 4 months
Perceptual remediation
Wagenaar et al.
199266
No
score
5 + visual scanning
– for transfer effect
Visual scanning
which also included a small number of head
injury patients, did not show a significant
difference with perceptual training,
although there was a trend in that direction.
There is moderate evidence that transfer of
training approach is no more effective than a
functional approach to perceptual training.26
Neglect
Cicerone et al.27 noted that the research lit-
erature concerning remediation of visual per-
ceptual deficits encompassed two different
issues. The first group of studies addressed
the remediation of basic abilities and behav-
ior such as visual scanning or visual percep-
tion. The second group of studies focused on
remediation of complex, high-level skills
involved in construction or functional activi-
ties requiring spatial relationships for assem-
bly, arrangement, or mobile interaction with
the environment.
Cicerone et al.27 suggest that visuospatial
rehabilitation involving practice in visual
scanning improves compensation for visual
neglect after a right hemisphere stroke. In
addition, it was found to be superior to con-
ventional occupational or physical therapies.
Accordingly, the authors recommended that
visuospatial rehabilitation with training in
visuospatial scanning should be standard
practice for patients suffering visuoperceptu-
al deficits associated with visual neglect after
right hemispheric stroke. Furthermore,
Cicerone et al.27 noted that training of com-
plex visuospatial task seems to augment
treatment and generalizes to other visuospa-
tial tasks, academic tasks, and ADLs that
require visual scanning.
Specific training for neglect
Nine studies on specific training for neg-
lect (including visual scanning) post stroke
that met inclusion criteria were identified.
Two studies were RCTs, one was a ran-
domized crossover study, three were com-
parative cohort studies, and two were single
group intervention studies (see Table 3)
Of the nine studies reviewed, two were of

good quality, one was of fair quality, and six
studies were not eligible to receive a PEDro
quality score.
Conclusion regarding specific training for
neglect
There is strong evidence that treatment
utilizing primarily enhanced visual scan-
ning techniques improves visual neglect
post stroke with associated improvements
in function. However, neglect appears to be
a negative prognostic factor even after
focused treatment (Table 4).
Activation treatments
Five studies that examined activation
treatments for neglect post stroke were
identified. Four studies were RCTs, and one
study was a single group intervention study
(see Table 5).
Conclusion regarding activation treatment
for neglect
There is conflicting evidence that activa-
tion treatments benefit neglect.
Prism treatment
Homonymous hemianopsia and unilateral
visual neglect can have an adverse effect on
functional outcomes even in the presence of
adequate strength and coordination. As noted
by Rossi et al.,4a variety of optical aids have
been used to help patients compensate for
their visual difficulties. These aids include
the Fresnel prism,28–30 wide-angle lens,31,32
mirrors attached to the spectacle frame,33–35
and closed circuit TV monitor systems.36
Held37 and Ferraro et al.38 observed (as
cited by Rossi et al.4) that study participants
adapt to the use of prisms within a day or
two. A steady improvement in perceptual
task performance over 4 weeks demonstrat-
ed by the study patients suggested that a
more complex adaptation to the prisms
occurred. There was a suggestion that such
an approach may be useful for hemianopic
field cuts where loss of vision may not be as
absolute as originally thought.39
Conclusions regarding prism for neglect
There is moderate evidence, based on one
positive RCT, that use of Fresnel prisms
improves visual perception scores in stroke
patients with homonymous hemianopsia and
visual neglect but is not associated with
improvement in ADL scores. Prisms were
more effective for patients who had neglect
than those who had hemianopsia. Given that
the study was only a fair quality study (PEDro
= 4), further research is necessary (Table 6).
Eye-patching and hemispatial glasses
Beis et al.40 stated that their “hypothesis
was that eye patches can be used to alter the
processing of visual information by affect-
ing the information processing structures of
the central nervous system.”(p71) Shulman41
noted that in healthy participants, eye
patches should increase eye movements
toward the contralateral space. Thus, eye
patching of the right eye causes patients to
look toward the left by either moving their
eye or by moving their head. These effects,
as cited by Beis et al., “encourage the devel-
opment of voluntary, deliberate control of
attention in the short term and the develop-
ment of automatic shifts of attention over
the longer term.”40(p71)
Treatment of Visual Perceptual Disorders 85

86 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 3. Specific training (including visual scanning) for neglect
Weinberg et al.
197760
United States
Right brain-damaged
patients due to stroke
Inclusion: Unilateral
brain damage; absence of
severe organic mental
syndrome; no history of
prior stroke; at least 4 wk
after onset of CVA
57
Treatment
n= 25
Control
n= 32
Patients were randomly
assigned to the experi-
mental group that
received 20 hr of test-
ing (1 hr/day for 4 wk
in reading, writing, and
calculation) or to the
control group that
received no testing
between evaluations. In
each group, patients
were divided into
severe and mild visual
perceptual deficits.
Both groups received
OT as part of general
rehabilitation.
Wide Range Achievement
Test (WRAT); cancella-
tion H and cancellation
C & E; counting faces,
matching faces;
Digit Span; object
assembly; picture com-
pletion; WAIS test and
DSS
RBD severe experimental
patients improved on WRAT,
p= .01; paragraph, p= .01;
arithmetic, p= .01;
copying, p= .01;
H cancellation, p= .01;
C&E cancellation, p= .05;
picture completion, p= .01;
Digit Span, p= .01;
DSS, p= .05;
and confront, p= .01.
RBD mild experimental
patients improved on
WRAT, p= .05;
H cancellation, p= .01;
C&E cancellation, p= .01;
face matching, p= .05;
Digit Span, p= .01;
impersistence, p= .05.
RBD mild control improved
on face counting, picture
completion, and object
assembly, p= .05.
Experimental group improved
significantly more than the
control group.
6
(RCT)
Weinberg et al.
197961
United States
Stroke patients with right
brain damage
Inclusion: Right brain
damage; CVA at least 4
wk previous; unilateral
brain damage; absence of
severe organic mental
syndrome; and negative
history of prior stroke
53
Treatment
n= 53
Control
n= 23
Patients randomly
assigned to receive
either 1 hr treatment, 5
days/wk for 4 wk of
occupational and physi-
cal therapy (C) or to
receive 15 hr of track-
ing target practice and 5
hr of training in sensory
awareness.
Wide Range Reading
Achievement Test;
paragraph reading;
Wide Range Arithmetic;
copying a paragraph;
cancellation H;
cancellation C and E;
counting faces, matching
faces; picture completion;
object assembly;
Digit Span;
pace-hand test;
visual confrontation;
motor impersistence;
body midline bisecting
lines; shoulder midline
In RBD severe treatment
group demonstrated signifi-
cant improvement in 24 or 26
scores, .01 < p< .05.
Mild experimental exceeded
controls on 3 of 26 scores.
Severe subgroup exceeded
controls on 15 of 26 scores.
6
(RCT)

Treatment of Visual Perceptual Disorders 87
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 3. (continued)
Gordon et al.
198564
United States
Stroke patients with right
brain damage undergoing
active rehabilitation.
Inclusion: at least 4 wk
post onset CVA; aged
40–85 years; right hand-
ed; no significant local
impairment in visual acu-
ity; inattention as deter-
mined by neuropsych
testing
Exclusion: bilateral cere-
bral involvement; history
of alcoholism; major
psychiatric disturbance;
not needing perceptual
remediation
77
Treatment n= 48
Control n= 29
Experimental group:
maximum 35 hr of per-
ceptual remediation
Control group: partici-
pated in leisure or con-
ventional rehab pro-
gram minus perceptual
remediation
Basic scanning
somatosensory awareness
and size estimation
complex visual perceptual
organization as deter-
mined by a battery of
tests
At discharge, the experimen-
tal group showed a greater
improvement in 3 types of
perceptual functioning.
At 4 mo post discharge, the
control group continued to
show perceptual gains while
the experimental group
plateaued; perceptual per-
formance was equal.
Experimental group had a
long-term reduction in anxi-
ety but not depression.
At discharge, experimental
group showed an increase in
recreational reading; no dif-
ference by 4 mo.
ns
(quasi-
randomized
trial)
Young et al.
198367
Canada
Hemiplegic stroke
patients who had signifi-
cant neglect and/or visual
scanning deficits
27 Group 1 received rou-
tine occupational thera-
py; Group 2 received 20
min of routine occupa-
tional therapy, 20 min
of cancellation training,
and 20 minutes of visu-
al scanning training;
Group 3 received 20
min of block design
training, 20 min of can-
cellation training, and
20 min of visual scan-
ning training.
WAIS Digit Symbol;
picture completion;
block design;
picture arrangement;
object assembly;
letter cancellation task;
Wide Range Achievement
Test; copying on address;
counting faces
Group 2 and Group 3
improved significantly more
on measures of visual scan-
ning, reading, and writing
compared to Group 1, and
Group 3 improved to a signif-
icantly greater extent when
compared to Group 2.
ns
Pizzamiglio et al.
199268
Italy
Patients with stabilized
hemineglect
symptomology due to
right-hemisphere lesions
13 Rehabilitation training
specifically aimed at
reducing scanning
deficits. The training
procedure consisted of
visual-spatial scanning,
reading and copying
training, copying of line
drawings on a dot
matrix, and figure
description.
Semi-structured Scale for
the Functional Evaluation
of Hemineglect;
Barrage Test;
letter cancellation;
Sentence Reading Test;
Wundt-Jastrow Area
Illusion Test
End of therapy patients as a
group showed significant
improvement on several stan-
dard test of hemineglect,
however, patients improved
only slightly on standard
visual-spatial tests thereby
indicating a specificity of
training in reducing the scan-
ning defect.
ns

88 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 3. (continued)
Ladavas69 et al.
1994
Italy
Patients with lesions in
the right parietal lobes
were selected for the
study. Stroke onset was
at least 6 mo prior to
study. All patients
demonstrated visual
and tactile neglect as
well as visual and tactile
extinction and all
patients had hemiplegia
or hemiparesis.
12 Patients were assigned
to either the covert ori-
enting intervention
group, the overt orien-
tating group, or to the
control group (tactile
modality). In the covert
attention condition,
patients were instructed
to keep fixating the
central point while
directing attention to
the cued box; in the
overt attention condi-
tion, patients were
instructed to look
directly at the cued box
and to keep fixating the
central point. Eye
movement was moni-
tored through 2 mirrors
fastened at the two
sides of the screen.
Treatment was given
for 1 hr/day, 5 days/wk
for 6 wks.
Ladavas Tests Both overt and covert orient-
ing treatments were equally
effective in improving visual
extinction and neglect. No
improvement was noted for
those tests that involved the
tactile modality.
ns
Antonucci et al.
199570
Italy
Stroke patients admitted
to rehab clinic
Inclusion: Univascular
right hemisphere lesion
on MRI; no previous
CVA or contralateral
lesions; hemi-inattention
≥2 mo post CVA
N= 20
Immediate treatment
n= 10
Delayed treatment
n= 10
8 wk training in visual
scanning, reading, and
copying; copying line
drawings; figure
description
Changes in scores
on Barrage Test;
Letter Cancellation Test;
Sentence Reading Test;
Wundt-Jastow Area
Illusion Test
Significant improvement in
both delayed & immediate
treatment groups
(all ps < .01)
4
(crossover
randomized
controlled
trial)

Treatment of Visual Perceptual Disorders 89
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 3. (continued)
Paolucci et al.
199671
Italy
Right dominant, right
strokes admitted over 3 yr
Inclusion: Single CVA 2
to 6 mo prior
Exclusion: >78 yrs old;
multiple lesions, neo-
plasmic or hemorrhagic
etiology; other CNS
pathology
N= 59
Nonneglect
n= 36
Neglect
n= 23
Treatment for neglect in
5 X 1-hr sessions per
week over 8 wk
General cognitive treat-
ment 3 X 1 hr sessions
per week over 8 wk
Changes in scores on
Rivermead Mobility
Index; Barthel Index;
Canadian Neurology
Scale
Neglect tests: Letter
Cancellation Test;
Barrage Test; Wundt-
Jastow Area Illusion Test;
Sentence Reading Test
Improvement in both delayed
and immediate treatment
groups (p≤.05)
6
(crossover
randomized
controlled
trial)
Niemeier
199872
United States
Stroke patients undergo-
ing comprehensive day
rehabilitation
31
Treatment group
n= 16
Control group
n=15
All patients received
comprehensive
multidisciplinary
rehabilitation.
Treatment group
received in addition the
“lighthouse strategy.”
Outcome measures were
assessed at admission and
discharge from program.
Sheltering Arms
Functional Autonomy
Rating Scale (FARS) –
score of Attention;
Mesulam Verbal
Cancellation Test (only
experimental group)
A significant (F= 8.389,
p> .007) main effect for the
treatment procedure was
obtained on the FARS
Attention rating.
Mesulam Verbal Cancellation
Test was significantly
improved between admission
and discharge for experimen-
tal group (p> .002).
NS
(pre-test/
post-test)

The present review identified one ran-
domized controlled trial, one randomized
crossover study, and one single group inter-
vention study (see Table 7).
The Walker et al.42 and Beis et al.40 studies
were fair quality studies, both receiving a
PEDro score of 4. The Arai et al.43 study was
not an RCT, therefore, it was not eligible for
PEDro scoring.
Conclusions regarding eye-patching and
hemispatial glasses for neglect
There is moderate evidence (one positive
study) that bilateral half visual field eye patch-
es improve visual neglect and function. Given
that the Beis et al.40 study had only a PEDro
score of 4, further research is necessary.
Mirror treatment
This treatment involves using a parasagi-
tally placed mirror propped vertically on the
nonneglect side so that the neglected side is
reflected back to the patient (see Table 8).
In the Ramachandran et al.44 study, patients
were asked to reach for an object on the neg-
lected side. Patients responded to the task in
one of two ways. For some of the patients, the
presence of the mirror helped them overcome
the neglect, that is, when they were asked to
retrieve the article they reached correctly for
the object in the left visual field. In the second
subgroup, even though the patient was look-
ing into a mirror, the patient kept reaching for
the mirror reflection of the object, confusing
the mirror reflection for the real object.
90 TOPICS IN STROKE REHABILITATION/SUMMER 2003
PEDro Sample
Study score size Treatment Outcome
Weinberg et al.
197761
657 +Testing in reading, writing, and calculation
Table 4. Summary of specific training for neglect
Weinberg et al.
197962
653 +Tracing practice, searching for lights on a board, cancellation of
stimuli and practice in reading, and sensory awareness and spatial
organization training
Paolucci et al.
199671
659 +Specific treatment for neglect
Antonucci
et al. 199571
420 +Training in visual scanning, reading and copying, copying line
drawings, and figure description
Gordon et al.
198565
No
score
77 + at discharge
– at 4 months
Perceptual remediation
Niemeier
199873
No
score
31 +Comprehensive multidisciplinary rehabilitation plus training
in the “lighthouse strategy”
Young et al.
198368
No
score
27 +
block design train-
ing, cancellation
training, and visual
scanning training
Routine OT vs. OT, cancellation training and visual scanning
training vs. block design training, cancellation training and
visual scanning training
Pizzamiglio
et al. 199269
No
score
13 + hemineglect
– visual-spatial
The training procedure consisted of visual-spatial scanning, reading
and copying training, copying of line drawings on a dot matrix, and
figure description.
Ladavas et al.
199470
No
score
12 + for covert and
overt condition
Covert vs. overt orienting vs. tactile modality

Treatment of Visual Perceptual Disorders 91
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 5. Activation treatments for neglect
Butter et al.
199073
United States
Inclusion: left neglect on
≥1 scanning test; right
cerebral infarct on CT;
initial symptoms ≥10
days before testing.
Exclusion: Other neuro-
logical disease; psychi-
atric disease; alcohol or
drug abuse
N= 26 (20)
Treatment
n= 18 (12)
Control
n= 8
1 session of dynamic
left visual stimulation
Static left visual
stimulation
Dynamic visual
stimulation in
subjective center
Mean % error to right
of true center on line
bisection
Error size reduced with
dynamic left or static left
stimuli (p< .0005)
Fewer errors with left dynam-
ic stimuli vs. left static
stimuli (p≤.0005)
ns
(pre-test/
post-test)
Hommel et al.
199074
France
Patients with left-sided
visual neglect after right
hemispheric stroke
14 Patients randomly
received no stimulation
at all, tactile unilateral
and bilateral, binaural
auditory verbal, and
nonverbal stimuli dur-
ing tests consisting of
copying 6 drawings: a
flower, a cube, a bicy-
cle, a clock, a house,
and three men.
Copying 6 drawings –
flower, cube, bicycle,
clock, house, and 3 men
Severity of neglect
Only the nonverbal auditory
simulation (music or white
noise) significantly improved
drawing performance of the
patients.
4
(RCT)
Fanthome et al.
199575
United Kingdom
Inpatient CVA patients
Inclusion: Not blind;
< 80 yrs old;
no dementia;
no psychiatric problems;
not too ill to be assessed;
right dominant;
> 6 on Abbreviated
Mental Test;
right hemispheric CVA;
score < 130 on
Behavioural Inattention
Test (BIT)
N= 18
Treatment
n= 9
Control
n= 9
Patients wore glasses
that beeped if patient
failed to move eyes to
left in 15 seconds.
Eye movements recorded
while looking at slides
after 4 wk and 8 wk.
BIT at 4 wks and 8 wks
No differences were reported
at 4 or 8 wk.
1 patient was lost to follow-
up (moved) and data was
incomplete for 1 patient.
5
(RCT)

92 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 5. (continued)
Cubelli et al.
199976
Italy
Patients with clinical evi-
dence of left neglect after
stroke and had the pre-
served ability to move the
left hand
10 All patients participated
in 3 different experi-
ments given to them in
randomized order: 2
reading conditions and
1 target cancellation
condition.
Number of omissions In only 1 patient did they
find that on reading and can-
cellation the total number of
omissions were significantly
decreased when irrelevant
movements were performed
with the left hand in the left
space.
4
(RCT)
Robertson et al.
200277
Ireland
Patients with right
hemisphere strokes
40 Randomly allocated to
perceptual training
group (PT) or limb acti-
vation treatment with
PT (LAT+PT). The PT
group received percep-
tual training on visuo-
perceptual puzzles that
required scanning to the
left. LAT+PT: Received
the same training as PT
but also had timer that
emitted tone when a left
movement was not per-
formed by left wrists,
leg, or shoulder within
a set time period. Both
groups received 12 ses-
sions of 45-min dura-
tion over a 12-wk peri-
od. Patients were
assessed at intake, post
training, and 3, 6, and
18–24 mo post training.
Barthel Scale;
Nottingham Extended
ADL Scale; CB rating
scale of unilateral neglect;
Motricity Index of Limb
Function; Behavioural
Inattention Test; Comb
and Razor Test of person-
al neglect
Time by treatment condition
interaction significant for
Motricity Index.
Improvement up to 24 mo in
LAT+OT group with little
change in PT group over
time.
6
(RCT)

Treatment of Visual Perceptual Disorders 93
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 6. Prism treatment for visual neglect
Rossi et al.
19904
United States
Patients with homony-
mous hemianopsia (HHA)
or unilateral visual neglect
(UVN) in an inpatient
stroke rehab unit.
Inclusion: CVA with
HHA or UVN; able to
give consent; best cor-
rected visual acuity
>20/200; able to compre-
hend and cooperate with
visual field assessment.
Exclusion: Disabling car-
diac, pulmonary, or
rheumatologic problem
N=39
Treatment
n= 18
Control
n= 21
Special glasses with 15
diopter plastic press on
Fresnel prisms
Assessed visual percep-
tion and ADLs at base-
line (similar results)
and at 2 wk and 4 wk
MMSE;
Barthel ADL;
Motor Free Visual
Perceptual Test (MVPT);
line bisection;
line cancellation;
Harrington Flocks Visual
Screen (HFVS);
Tangent Screen Exam
(TSE)
At 4 wk, the prism group had
significant improvement in
MVPT scores, line bisection,
line cancellation, and the TSE
relative to baseline and control.
At 4 wk, prism group had
significant greater improve-
ment in the HFVS relative to
baseline compared to controls.
There was no significant dif-
ference between the two
groups in Barthel ADL index.
Treatment with Fresnel
prisms improves visual per-
ception test scores but not
ADL function in CVA
patients with HHA and UVN.
4
(RCT)
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 7. Eye-patching and hemispatial glasses for neglect
Walker et al.
199642
United Kingdom
Patients who had suffered
a unilateral stroke affect-
ing the right cerebral
hemisphere and exhibited
symptoms of unilateral
neglect
9 Each patient was tested
under 3 conditions in
randomized order: nor-
mal binocular vision,
with the left eye
patched, and with the
right eye patched.
Letter cancellation;
line bisection;
letter string reading;
text reading;
chimaeric face
recognition
Right eye patching did not pro-
duce a consistent reduction in
the severity of neglect. 3
patients demonstrated a
decrease in neglect after right
eye patching on one or more of
the tests. 4 patients experi-
enced increased neglect after
right eye patching. Left eye
patching had a similar trend.
4
(RCT)

94 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 7. (continued)
Arai et al.
199743
Japan
Hemiplegic patients show-
ing left unilateral neglect
during pencil-and-paper
activities
10 Patients used glasses in
which the right half of
each lens was shaded
by a darker lens like
those used in sunglass-
es. Patients were meas-
ured for unilateral neg-
lect: (1) deviation from
marking the middle of a
20-cm horizontal line;
(2) number of lines left
unmarked on the left-
hand portion of a page
of 40 randomly orient-
ed lines; (3) degree of
failure to copy a repre-
sentation of a cube.
Functional activities Among the 10 patients,
improvement was mixed for
each of the 3 outcome meas-
ures. 1 patient, however,
demonstrated dramatic and
lasting improvement in func-
tional activities by wearing the
hemispatial sunglasses.
Hemispatial sunglasses
appeared to have a potentially
specific effect on visual neglect
in certain patients with right
hemispheric lesions.
ns
(descrip-
tive study)
Beis et al.
199940
France
Patients with left unilater-
al spatial neglect in a
rehab program in an
urban general hospital
Inclusion: Left unilateral
neglect; right CVA; right
handed
Exclusion: Older than 70
years; history of psychi-
atric or neurological dis-
order
22
Right 1⁄2field patches
N= 7
Right monocular patch
n= 7
Control
n= 8
Patients given standard
spectacle frames with a
right monocular patch,
right half field patches
over both eyes, or no
patch. Refractive prob-
lems were solved using
the patch and patient’s
corrective lenses.
Patches were worn
through the day
(~12 hrs) from
admission to 3 mo.
Assessment was
performed without
patches on.
FIM;
right eye movement;
photo occulography
At 3 mo, there was a signifi-
cant difference in the FIM
score and displacement of the
right eye in the (L) field
between the control group
and the half eye patches.
At 3 mo, there was no signifi-
cant difference between the
control group and the right
monocular patch.
Half field patches affect eye
movement and improve gen-
eral everyday function.
4
(RCT)

Treatment of Visual Perceptual Disorders 95
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 8. Mirror treatment for visual neglect
Ramachandran
et al. 199944
United States
Patient with visual
hemineglect caused
by right CVA
12
In addition, 6 control
patients of comparable
mental status with a left
CVA
Use of mirror The reaching pattern of
the patient
In one group of patients, the
presence of the mirror seemed
to help them overcome the
neglect.
For the other group, they kept
reaching for the mirror reflec-
tion of the object (mirror
agnosia or looking-glass syn-
drome). This was not seen with
the control patients.
ns
(descrip-
tive pilot
study)
Conclusions regarding mirror treatment for
neglect
There is limited evidence that some
patients with neglect respond to mirror ther-
apy. Its impact on functional outcomes has
yet to be tested.
Caloric stimulation
Rubens45 noted that visual neglect could
be caused partly by bias of gaze and postur-
al turning. It has been noted that when cold
water is funnelled into the right external ear
canal, the vestibular-ocular reflex induces
nystagmus toward the stimulated ear. If
warm water is used, nystagmus is directed
away from the stimulation. Accordingly,
Rubens45 suggested that caloric vestibular
stimulation to produce eye deviation and
past-pointing the direction opposite the
pathologically acquired bias may reduce
visual neglect. As proposed by Cappa et
al.46 and Vallar et al.,47 caloric stimulation
consisting of cold water on the contralateral
side of the lesion and warm water ipsilater-
al to the lesion may improve visual neglect
by influencing vestibular system involve-
ment with the eye (see Table 9).
Conclusions regarding caloric stimulation in
neglect
There is limited evidence that caloric
stimulation temporarily improves neglect.
Computer-based rehabilitation
Only one RCT investigating computer-
based rehabilitation for the treatment of
visual perceptual disorders was retrieved
(see Table 10)

96 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 9. Caloric stimulation in neglect
Right-handed patients
with left-sided visual neg-
lect in the first 2 wk after
an acute right hemisphere
stroke were studied.
18 Caloric testing was car-
ried out with 20 cc of
warm or ice water slowly
instilled in to the exter-
nal ear canal over 1 min.
Testing with ice water in
the left ear was followed
30 min later by testing
with warm water in the
right. The next day, ice
water stimulation of the
right ear and warm water
stimulation of the left ear
were carried out.
Point and count;
reading 1-inch-high mul-
tisyballabic words printed
on cards held at distance;
line cancellation
All patients improved during
caloric stimulation on the left
by cold water or on the right
by warm water. Improvement
seemed to be dependent on the
facilitation of left lateral gaze
and on past-pointing to the left.
ns
Rubens
198545
United States
Cappa et al.
198746
Italy
Stroke patients 4 In 3 patients, the left
external canal was irri-
gated with 20 cc of ice
water for 1 min; in 1
patient, the right ear
was irrigated with 20 cc
of warm water. Patients
were retested on base-
line measures (extraper-
sonal neglect assess-
ment and personal
neglect assessment)
before and then 15 min
after caloric stimulation.
Circle crossing test;
personal neglect
All patients demonstrated a
temporary reduction of
extrapersonal neglect after
caloric stimulation followed
by a return to base level after
15 min. Personal neglect
improved in all 4 patients.
ns
Vallar et al.
199078
Italy
Right-handed patients
who had suffered a recent
ischemic stroke in the
right hemisphere
3Patients were tested on
extrapersonal and personal
neglect, anosognosia, and
somatosensory deficits.
All patients received cold
water stimulation in the
left external ear canal,
which was irrigated with
20 cc of iced water for 1
min. One patient also
received warm stimulation
of the right external ear
canal, which was irrigated
with 20 cc of warm water
for 1 min.
Identification of tactile
stimulation
Treatment induced a tempo-
rary remission of extraper-
sonal neglect. 2 patients had
severe anosognosia; 1 patient
was unaffected by vestibular
stimulation while it produced
a temporary complete remis-
sion in another. Personal neg-
lect was transiently abolished
in both these cases.
Hemianethesia in the left
hand was temporally but sig-
nificantly reduced by vestibu-
lar stimulation.
ns

Conclusions regarding computer-based
rehabilitation in neglect
There is moderate evidence that comput-
er-based rehabilitation of left neglect does
not influence outcomes.
General treatment of neglect following stroke
Three of the reviewed studies were of
good quality and two were of fair quality.
One study was not eligible for PEDro scor-
ing. With the exception of one mixed result
study, four RCTs demonstrated positive
outcomes (see Table 11).
Conclusions regarding general treatment of
neglect post stroke
There is strong evidence that rehabilita-
tion therapies specifically designed to treat
neglect result in significant improvements
in neglect scores (see Table 12).
There is considerable overlap among
visual neglect, perceptual disorders, and
even attentional disorders. Strong evi-
dence exists that specific treatment of
visual neglect and perceptual disorders
results in significant improvements of
those disorders and, where studied, func-
tional outcomes.
Transcutaneous electrical nerve stimulation
(TENS)
Two studies examined TENS treatment
for neglect (see Table 13)
Conclusions regarding TENS in neglect
There is limited evidence that TENS
treatments improve neglect post stroke.
Dopaminergic medications for neglect
Mukand et al.48 cited a study by Geminiani
et al.49 in which apomorphine, which tem-
porarily reverses the off state in Parkinson’s
disease (Stibe et al.50), produced a signifi-
cant, albeit a transient, improvement in the
perceptual-motor and perceptual functions
of four patients with left neglect following a
right ischemic lesion. Levodopa is a meta-
bolic precursor of dompamine that is used to
treat Parkinson’s disease by increasing
dopamine levels in the brain. Mukand et al.48
hypothesized that “increased dopaminergic
activity in the brain would also reduce uni-
lateral spatial neglect.”(p1279)
Conclusion regarding dopaminergic medica-
tions
There is limited evidence, based on one
study with a sample size of four, that
dopaminergic therapy improves neglect
(see Table 14).
Summary
1. There is strong evidence that specific
treatment of perceptual disorders
improves perceptual functioning.
2. There is moderate evidence that a
transfer of training approach is no
more effective than a functional
approach to perceptual training.
3. There is strong evidence that treat-
ment utilizing primarily enhanced
visual scanning techniques improves
visual neglect post stroke with associ-
ated improvements in function.
4 There is conflicting evidence that
activation treatments benefit neglect.
5. There is moderate evidence that Fresnel
Treatment of Visual Perceptual Disorders 97

98 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 10. Computer-based rehabilitation in neglect
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 11. General treatment of neglect post stroke
Stroke patients with uni-
lateral left visual field
neglect
36 Randomized to 1 of 2
groups: Computer scan-
ning and attention train-
ing (Group 1) or recre-
ational computing
(Group 2). Group 1
received an average of
15.5 hr of training, and
the control group
received an average of
11.4 hr of control com-
puter use.
Behavioural Inattention
Test; WAIS-R;
Neale Reading Test;
Letter Cancellation Test;
Rey-Osterreith Test;
an observers’ report of
neglect
No significant differences were
noted between the groups on
any outcome measure.
6
(RCT)
Robertson et al.
199079
Scotland
Carter et al.
198363
United States
Acute stroke patients 33
Treatment
n= 16
Control
n= 17
Patients were randomly
assigned to either treat-
ment group receiving cog-
nitive skill remediation
training administered on a
1- to-1 basis for 30 to 40
min, 3x/wk and only for
those skill areas that need-
ed improvement (visual
scanning, visual-spatial,
and time judgement skills)
for 3 to 4 wk, or patients
were randomized to the
control group that did not
receive training but were
included in other stroke
program activities.
Letter cancellation;
visual-spatial matching
to sample;
time estimation
Overall mean improvement
score was significantly
greater for experimental than
for control group,
32.2 vs. 4.9, p< .005.
For each of the specific tasks,
improvement was significant-
ly greater for the experimen-
tal group than for the control
group on scanning,
35.9 vs. 3.8, p< .005;
visual-spatial, 31.0 vs. 3.3,
p< .005; time judgment,
24.8 vs. 7.8, p< .05.
5
(RCT)

Treatment of Visual Perceptual Disorders 99
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 11. (continued)
Right hemisphere stroke
and hemineglect
4The study included four phas-
es (A1, B, A2, A3). Phases
A1 and A2 included 4 obser-
vation times and phase A3
included 3 observation times
over 12 wk for each patient.
Three household tasks were
assessed (finding the pastry in
the refrigerator, cutting the
pastry, arranging the cakes on
an oven tray) and the
patients’ neglect behavior
while performing; the tasks
were video recorded. A modi-
fied Albert’s test was used but
not filmed. In the intervention
program, the patients watched
the film that was stopped by
the occupational therapist
where the neglect behavior
was significant. Through dia-
logue, the patients were led to
perceive and interpret their
neglect behavior, and strate-
gies for relearning and reme-
diation were recommended.
Modified Albert’s test; 3
household tasks – finding
pastry in the refrigerator,
cutting the pastry, arrang-
ing the cakes on an oven
tray
All the patients exhibited an
improvement in their neglect
behavior in the task of finding
the pastry in the refrigerator
and in the Albert test. On the
task of cutting the dough and
arranging the cake on the tray,
3 patients showed improve-
ment and the results were
maintained in the follow-up
measurement for finding the
pastry and arranging the cakes
on the tray for all 4 patients.
nsSoderback et al.
199280
Sweden
Kalra et al.
19977
United Kingdom
Stroke patients with par-
tial anterior circulation
infarction and visual neg-
lect.
Inclusion: Visual neglect
identity by comprehen-
sive multidisciplinary
assessment – visual and
sensory confrontation test,
line bisection test, and
observation of patients
during activities using a
structured observational
test for function.
Exclusion: Hemianopsia
or severe dysphasia
restricting communica-
tion; TIA during assess-
ment period
50
Motor activity (CT)
n= 25
Spatial cueing (SC)
n= 25
Randomly assigned to
receive either therapy
aimed to restore normal
tone, movement pat-
terns, and motor activi-
ty (CT) or to receive
therapy aimed to inte-
grate attentional and
motor functions (SC)
Mortality;
discharge;
length of hospital stay;
duration of therapy input;
Rivermead Perceptual
Assessment Battery
(RPAB)
Significant improvement on
body image and cancellation
subtest of RPAB at 12 wk in
favor of SC, p= .01
7
(RCT)

100 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 11. (continued)
Stroke patients
Inclusion: Able to transfer
with 2 nurses; able to toilet
themselves independently
prior to the stroke; able to
do 2 out of eat, drink, and
face washing; able to toler-
ate rehab for 2 hr a day; no
medical problems that
would prevent transfer to
the stroke unit; not due to
be discharged from hospi-
tal within 2 wks
315
Stroke unit
n= 176
General ward
n= 39
Patients randomly
assigned to receive rehab
on stroke unit or to
remain on a conventional
ward
Barthel Index;
Rivermead ADL Scale;
Rivermead Motor
Assessment;
Rey Figure Copy
Rey Figure Copy score signifi-
cantly better for stroke unit
patients at 3 mo, p= .01,
6 and 12 mo, p= .03.
6
(RCT)
Lincoln et al.
199781
United Kingdom
Wiart et al.
199782
France
Patients who were hospi-
talized in two neuro-reha-
bilitation units.
Inclusion: Recent stroke
(< 3 mo); severe unilater-
al neglect syndrome as
described when these 3
tests were positive: Line
bisection > 11% of right
deviation; line cancella-
tion > 2 left omission
(LO); Bell test > 6 LO
Exclusion: History of
stroke; alteration of gen-
eral status; cognitive diffi-
culties incompatible with
rehabilitation ( Mini
Mental Status Revised)
22 Experimental group:
received 1 hr a day for 20
days of the Bon Saint
Come method followed
by 2 to 3 hr of traditional
rehabilitation (1 to 2 hr of
PT and 1 hr of OT)
Control group: received
3 to 4 hr of traditional
rehabilitation
The following assess-
ments were done at day 0,
day 30, and day 60:
Line bisection
(Schekenberg test);
line cancellation
(Albert test);
Bell test; FIM
All 4 test results improved
significantly more in the
experimental group.
Day 30:
Line bisection (p< .01);
line cancellation (p< .02);
Bell test (p< .05);
change in FIM (p< .03)
Day 60:
Line bisection (p< .02);
line cancellation (p< .02);
Bell test (p< .05);
change in FIM (ns)
4
(RCT)

Treatment of Visual Perceptual Disorders 101
PEDro Sample
Study score size Treatment Outcome
Kalra et al. 19977750 +
body image and cancellation for SC
Restoration of normal tone, movement patterns and motor activity (CT) vs.
integration of attention and motor functions (SC)
Table 12. Summary of general treatment of neglect post stroke
Lincoln et al. 199781 6 315 + stroke unitRehabilitation for neglect on stroke unit vs. general medical ward
Carter et al. 198363 533 +Cognitive skill remediation training for those skill areas that needed
improvement
Wiart et al. 199782 422 +Bon Saint Come methods
Soderback et al. 199280 No score 4 +Video feedback
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 13. Transcutaneous electrical nerve stimulation treatment for neglect post stroke
Vallar et al.
199583
Italy
Right-handed patients
were studied. All patients
had a unilateral lesion in
the right hemisphere. 13
patients had suffered an
ischaemic or haemorrhag-
ic stroke with a mean
duration 2.8 mo, and 1
patient had an intracranial
neoplasm.
14 An AGAR 2000TM stimulator
with superficial electrodes
(diameter 30 mm) was used to
stimulate the posterior left or
right neck, below the occipital,
just lateral to the spine.
Visuospatial hemineglect was
assessed by the letter cancella-
tion task in three successive
conditions: (1) before stimula-
tion baseline; (2) after a 15-min
unilateral simulation of the pos-
terior neck: post stimulation
assessment; (3) 30 min after the
completion of the preceding
condition: 30-min delay assess-
ment. In experiment 2, effects
of stimulation of the left side of
the neck were assessed in two
conditions: (1) free: patients
were free to move their head
and trunk; (2) blocked: head
movement was prevented by a
chin rest and trunk rotation by
string fixed to the wheelchair. In
experiment 3, stimulation of the
left side of the neck and stimu-
lation of dorsal surface of the
left hand were assessed.
Nonspecific activation
of the right hemisphere,
contralateral to the
stimulation side; specific
directional effects of
left somatosensory
stimulation on the
egocentric coordinates
of extrapersonal space
The stimulation of the left
side of the neck improved
cancellation performance in
13 (93%) of the 14 patients.
Right-sided stimulation
improved performance in 9
(64%) patients, had a positive
effect in 4 (29%) patients,
and 1 patient was left unaf-
fected by the stimulation.
Left neck stimulation tem-
porarily improved neglect
when head movement was
prevented by chin-rest.
Stimulation of both the left
hand and left neck had com-
parable positive effects on
visuospatial hemineglect.
ns

102 TOPICS IN STROKE REHABILITATION/SUMMER 2003
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 13. (continued)
Stroke patients with
neglect
22 Patients sat for 8 sec on
a laterally rocking plat-
form and were asked to
maintain an actively
erect posture, sitting as
still as possible and
TENS was applied on
the contralesional side of
the neck during the pos-
tural task. An effective
stimulation (TENS) was
compared to placebo
stimulation (BASE).
Also, patients were com-
pared to 14 healthy-aged
matched controls.
Number of aborted trials
caused by loss of balance;
angular dispersion of the
support oscillations in roll
Aborted trials were more fre-
quent in patients than in
healthy participants. Angular
dispersion was smaller in
healthy adults than in patients.
Less balance loss was observed
during TENS condition than in
BASE condition for patients. A
significant TENS effect on
postural control was demon-
strated for neglect patients.
ns
Perennou et al.
200184
France
Author/year Eligibility Treatment group Main PEDro
Country criteria Start N(end N) Treatment outcome Results score
Table 14. Dopaminergic medications for neglect after stroke
Women with right brain
stem stroke and left
neglect
4Given a trial of car-
bidopa L-dopa to treat
left neglect
Behavioural Inattention
Test (BIT); FIM
3 of the 4 patients demonstrat-
ed significant improvements on
the modified BIT and FIM.
nsMukand et al.
200148
United States

prisms improve visual perceptual
scores in stroke patients with homony-
mous hemianopsia and visual neglect,
but use of the prisms is not associated
with improvement in ADL scores.
6. There is moderate evidence that bilat-
eral half visual field eye patches
improve visual neglect and function.
7. There is limited evidence that caloric
stimulation temporarily improves
neglect.
8. There is strong evidence that rehabil-
itation therapies specifically designed
to treat visual neglect and perceptual
disorders result in significant
improvements in these disorders and,
where studied, functional outcomes.
9. There is limited evidence that TENS
treatments improve neglect post stroke.
10. There is limited evidence that dopamin-
ergic therapy improves neglect.
Conclusion
In the treatment of visual perceptual dis-
orders, the strongest evidence for rehabilita-
tion effectiveness was found for the transfer
of training approach to perceptual disorders
(compared with the functional approach)
and for specific training for neglect (includ-
ing visual scanning).
Because many patients who present with
visual perceptual disorders have consider-
able overlap among visual neglect, percep-
tual disorders, and attentional disorders
(both auditory and visual),51,52 the mecha-
nisms for rehabilitation effectiveness have
not been clearly established. Apart from
the treatment strategies used, it is not yet
clear how perceptual improvement may be
affected by spontaneous recovery or by
treatment on a specialized stroke unit.26
Even with specialized treatment, including
training in visual scanning, unilateral neglect
seems to be incompatible with excellent func-
tional recovery for mobility and ADLs.53
Despite the apparent special needs of stroke
patients with unilateral neglect for mobility
aids, there is surprisingly little published
research on special methods for assessing and
designing mobility devices for them.54–57 For
example, features of neglect that seem to put
these patients at greatest risk for falls and relat-
ed injury include task initiation location56 and
pushing behavior.58 At the same time, use of a
tool may extend extrapersonal visual space in
patients with neglect and thereby improve per-
ceptual-motor performance,59 so that an assis-
tive device such as a cane, walker, or wheel-
chair might become a much more effective
rehabilitation aid for neglect patients than it is
at present. More research is needed into how
the assessment of specific features of visual
perceptual disorders might lead to improved
methods for rehabilitation, including the use of
assistive devices for mobility and ADLs.
Treatment of Visual Perceptual Disorders 103
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