Treatment Strategies for Unilateral Visuospatial Neglect and Anosognosia

Unilateral visuospatial neglect is an attentional disorder in which a patient does not fully process visual stimuli and images in a region of space contralateral to the brain lesion. It most often occurs after right hemisphere strokes, resulting in neglect of the left region of space. There are different types of visuospatial neglect:

• Personal neglect: Patients neglect half of their body and will fail to completely dress or groom the left side.
• Peri-personal neglect: Patients have the most difficulty with reading and writing tasks and processing items within an arm’s reach.
• Extra-personal neglect: Patients do not fully process things beyond an arm’s reach.

To make things even more complicated, some patients will have combinations of the three types.

Clinically, the biggest issue impacting treatment for neglect is anosognosia, or reduced awareness of deficits. Anosognosia and neglect are separate disorders, but they often co-occur. Patients with both deficits will show the typical neglect signs of missing items on the left side of space, and not be aware that anything is wrong or that what they’re “seeing” is incomplete. Unfortunately, research on neglect treatments rarely addresses the issue of anosognosia and how it impacts treatment outcomes.

Treatment for unilateral neglect

Reviews of treatment studies suggest that the most effective treatment for peri-personal neglect is visual scanning. This treatment involves finding the left-most side of a page, scanning all the way to the right, and returning to the left side to begin the process again. The tasks and stimuli used should be designed to be functional for each patient. If your patient wants to be able to read the newspaper, then reading newspapers should be targeted in therapy.

External cues

In clinical practice, external cues such as visual and tactile anchors commonly are used. These most often include putting a highlighted line along the left margin. Line guides can be used to minimize the stimuli visible at any one time, to enhance scanning ability. And then there’s the ubiquitous verbal cue to “look to the left.” Although external cues are a mainstay of clinical practice, there is no research specifically on the effectiveness of such cues. No one yet has studied how well they work.

The critical problems with external cues are just that – they’re external and they’re cues. As soon as the clinician leaves the room, the cue disappears. The process of transitioning from external to internal cues can be long and tedious; even more so for patients with anosognosia, because they’re not fully aware of their deficits or the need for the cues.

Cues as a stepping stone

The cues should be used only as a stepping stone in the development of strategies, or plans that are implemented to improve performance. There is good evidence that adults with cognitive deficits can learn to use strategies with extensive, functional practice. This could involve teaching a patient:

• to find and then highlight the left margin
• to use a line guide
• to self-initiate whatever external cue was the most effective

But the battle isn’t won when the patient can recite their strategy. The difference between knowing and doing can be huge for patients with cognitive deficits. Even if they get to the point at which they can tell you “I need to find the left side and start on the left,” they may be unable to carry out that strategy when they need it.

Treatment for anosognosia

Treatment for neglect should incorporate treatment for anosognosia. Unfortunately, there isn’t much research on anosognosia to guide treatment.

• Some suggestions are to provide education and facilitate discussion about the problem, and provide verbal and visual feedback to increase awareness of errors.
• In some cases, awareness can develop by comparing performance while using a cue or strategy with performance without it. This may not only enhance awareness of the deficit, but also the usefulness of a specific strategy.
• Some patients can begin to develop awareness and identify their own errors when watching a video of their performance.

If a patient has a breakthrough in awareness, and really knows and understands that she misses things on the left – or that she misses fewer things on the left when using a cue or strategy – then she may be able to internalize the strategies and use them spontaneously.

If that breakthrough doesn’t happen, it may be possible to teach the patient to use a strategy habitually, no matter what, even if they don’t feel they need it. However, the habituation usually takes many, many hours of treatment and lots of patience on the part of both the clinician and patient.