Cognitive rehabilitation for spatial neglect following stroke neglect 2007.pdf · Cognitive...
Transcript of Cognitive rehabilitation for spatial neglect following stroke neglect 2007.pdf · Cognitive...
Cognitive rehabilitation for spatial neglect following stroke
(Review)
Bowen A, Lincoln NB
This is a reprint of a Cochrane review, prepared and maintained by The Cochrane Collaboration and published in The Cochrane Library2007, Issue 3
http://www.thecochranelibrary.com
1Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
T A B L E O F C O N T E N T S
1ABSTRACT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2PLAIN LANGUAGE SUMMARY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2BACKGROUND . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
2OBJECTIVES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3CRITERIA FOR CONSIDERING STUDIES FOR THIS REVIEW . . . . . . . . . . . . . . . . . .
3SEARCH METHODS FOR IDENTIFICATION OF STUDIES . . . . . . . . . . . . . . . . . . .
6METHODS OF THE REVIEW . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
7DESCRIPTION OF STUDIES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8METHODOLOGICAL QUALITY . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
9RESULTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
10DISCUSSION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11AUTHORS’ CONCLUSIONS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
11POTENTIAL CONFLICT OF INTEREST . . . . . . . . . . . . . . . . . . . . . . . . . . .
12ACKNOWLEDGEMENTS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12SOURCES OF SUPPORT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
12REFERENCES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
15Characteristics of included studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
25Characteristics of excluded studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
26Characteristics of ongoing studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28ANALYSES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
28Comparison 01. Cognitive rehabilitation versus any control: immediate effects . . . . . . . . . . . . .
28Comparison 02. Cognitive rehabilitation versus any control: persisting effects . . . . . . . . . . . . . .
29Comparison 03. One type of cognitive rehabilitation versus standard care or attention control: persisting effects . .
29Comparison 04. One cognitive rehabilitation approach versus another: persisting effects . . . . . . . . . .
29Comparison 05. Bottom-up processing approaches versus any control: persisting effects . . . . . . . . . .
29Comparison 06. Top-down processing rehabilitation approaches versus any control: persisting effects . . . . . .
29INDEX TERMS . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
29COVER SHEET . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
30GRAPHS AND OTHER TABLES . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
31Analysis 01.01. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 01 Activities of
Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
32Analysis 01.02. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 02 Cancellation:
numbers correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33Analysis 01.03. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 03 Cancellation:
numbers of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
33Analysis 01.04. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 04 Line
bisection: error scores/right deviation . . . . . . . . . . . . . . . . . . . . . . . . . .
34Analysis 01.05. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 05 BIT
behavioural subtests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
34Analysis 01.06. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 06 Discharge
destination (home) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
35Analysis 01.07. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 07 A-rated
studies only: Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . .
35Analysis 01.08. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 08 A-rated
studies only: cancellation number correct (single letter task) . . . . . . . . . . . . . . . . . .
36Analysis 01.09. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 09 A-rated
studies only: cancellation errors . . . . . . . . . . . . . . . . . . . . . . . . . . . .
36Analysis 01.10. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 10 A-rated
studies only: BIT behavioural subtests . . . . . . . . . . . . . . . . . . . . . . . . .
iCognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
37Analysis 02.01. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 01 Activities of
Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38Analysis 02.02. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 02 Cancellation:
number correct . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
38Analysis 02.03. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 03 Cancellation:
number of errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
39Analysis 02.04. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 04 Line
Bisection: error scores or right deviation . . . . . . . . . . . . . . . . . . . . . . . . .
39Analysis 02.05. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 05 BIT
behavioural . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
40Analysis 02.06. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 06 A-rated
studies: Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . .
40Analysis 02.07. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 07 A-rated
studies only: cancellation number of errors . . . . . . . . . . . . . . . . . . . . . . . .
41Analysis 02.08. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 08 A-rated
studies only: BIT behavioural . . . . . . . . . . . . . . . . . . . . . . . . . . . .
41Analysis 03.01. Comparison 03 One type of cognitive rehabilitation versus standard care or attention control: persisting
effects, Outcome 01 Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . .
42Analysis 04.01. Comparison 04 One cognitive rehabilitation approach versus another: persisting effects, Outcome 01
Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
42Analysis 05.01. Comparison 05 Bottom-up processing approaches versus any control: persisting effects, Outcome 01
Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
43Analysis 06.01. Comparison 06 Top-down processing rehabilitation approaches versus any control: persisting effects,
Outcome 01 Activities of Daily Living . . . . . . . . . . . . . . . . . . . . . . . . .
iiCognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Cognitive rehabilitation for spatial neglect following stroke
(Review)
Bowen A, Lincoln NB
This record should be cited as:
Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews 2007,
Issue 2. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586.pub2.
This version first published online: 18 April 2007 in Issue 2, 2007.
Date of most recent substantive amendment: 19 January 2007
A B S T R A C T
Background
Unilateral spatial neglect causes difficulty attending to one side of space. Various rehabilitation strategies have been used but evidence
of their benefit is lacking.
Objectives
To determine the persisting effects of cognitive rehabilitation specifically aimed at spatial neglect following stroke, as measured on
impairment and disability level outcome assessments and on destination on discharge from hospital.
Search strategy
We searched the Cochrane Stroke Group Trials Register (last searched 4 July 2005), MEDLINE (1966 to July 2005), EMBASE
(1980 to July 2005), CINAHL (1983 to July 2005), PsycINFO (1974 to July 2005), UK National Research Register (July 2005). We
handsearched relevant journals, screened reference lists, and tracked citations using SCISEARCH.
Selection criteria
We included randomised controlled trials of cognitive rehabilitation specifically aimed at spatial neglect. We excluded studies of general
stroke rehabilitation and studies with mixed patient groups, unless more than 75% of their sample were stroke patients or separate
stroke data were available.
Data collection and analysis
Two review authors independently selected trials, extracted data, and assessed trial quality.
Main results
We included 12 RCTs with 306 participants. Only four had adequate allocation concealment, that is a low risk of selection bias. A large
number of outcome measures were reported. Only six studies measured disability and two investigated whether the effects persisted.
The overall effect (standardised mean difference) on disability had a wide confidence interval that included zero and was not statistically
significant. For discharge destination there were clinically significant effects but in both directions and the confidence interval of the
odds ratio included one. In contrast, cognitive rehabilitation did improve performance on some, but not all, standardised neglect tests.
The number of cancellation errors made was reduced and the ability to find the midpoint of a line improved immediately and persisted
at follow up. These effects appeared likely to generalise from the samples studied to the target population, but were based on a small
number of studies.
Authors’ conclusions
Several types of neglect specific approaches are now described but there is insufficient evidence to support or refute their effectiveness
at reducing disability and improving independence. They can alter test performance and warrant further investigation in high quality
randomised controlled trials. As we did not review whether patients with neglect benefit from rehabilitation input in general, such
patients should continue to receive general stroke rehabilitation services.
1Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
P L A I N L A N G U A G E S U M M A R Y
The benefit of cognitive rehabilitation for unilateral spatial neglect, a condition that can affect stroke survivors, is unclear
Unilateral spatial neglect is a condition which reduces a person’s ability to look, listen or make movements in one half of their
environment. This can affect their ability to carry out many everyday tasks such as eating, reading and getting dressed, and restricts
a person’s independence. Our review found that rehabilitation specifically targeted at neglect appeared to improve a person’s ability
to complete tests such as finding visual targets and marking the mid-point of a line. However, its effect on their ability to carry out
a meaningful everyday task or to live independently was not clear. Patients with neglect should continue to receive general stroke
rehabilitation services but better quality research is needed to identify optimal treatments.
B A C K G R O U N D
Stroke can affect cognitive as well as physical and sensory abili-
ties (Wade 1985). Cognitive deficits include a disorder of spatial
awareness known as unilateral spatial neglect. The most widely
quoted definition of neglect is a description of the resulting be-
havioural disabilities: ’fails to report, respond, or orient to novel
or meaningful stimuli presented to the side opposite a brain le-
sion’ (Heilman 1993). This definition does not describe the causal
mechanism of neglect but indicates that it is not simply due to
sensory or motor defects. Neglect is a disorder which can reduce a
person’s ability to look, listen or make movements towards one half
of their environment. This can also affect their ability to carry out
many everyday tasks, such as eating, reading and getting dressed
(Katz 1999). Stroke may differentially affect our ability to direct
our attention in the visual, auditory or tactile modalities. Since dif-
ferent types of neglect can occur, several terms are used in clinical
practice, such as visual neglect, motor neglect, hemineglect, and
inattention (Bailey 1999). Although people do sometimes neglect
their ipsilesional (same) side, most researchers and clinicians focus
on the far more common neglect of contralesional space.
The reported incidence of neglect in stroke patients has varied
from as high as 90% (Massironi 1988) to as low as 8% (Sunder-
land 1987). The figures depend on the operational definition, se-
lection criteria for patients and method of assessment employed
(Bailey 1999; Bowen 1999; Ferro 1999). A previous systematic
review found that, in 16 of the 17 studies making the comparison,
contralesional neglect occurred more often after right than left
hemisphere stroke (Bowen 1999). Cognitive dysfunction, such as
neglect, can determine the outcome of rehabilitation by adversely
affecting mobility, discharge destination, length of hospital stay,
meal preparation and independence in self-care skills (Barer 1990;
Bernspang 1987; Neistadt 1993). In the light of these functional
implications, it is not surprising that the rehabilitation of neglect
is an important aim in stroke rehabilitation.
Several investigators (Calvanio 1993; Gianutsos 1991; Robertson
1990) have reviewed interventions that have been designed specif-
ically to improve cognitive functioning following stroke and other
forms of neurological damage. They concluded that there is now
growing evidence that such interventions may produce a benefi-
cial effect across a variety of cognitive deficits. Cognitive rehabil-
itation includes training procedure(s) to improve cognitive func-
tions such as perception, memory and attention (Berrol 1990;
Levin 1990). These procedures sometimes aim to reduce the level
of impairment. Within rehabilitation there is a conceptual dis-
tinction between the effects a disease may have at different levels
(WHO 2001): impairment, activity (disability) and participation
(handicap). Therapists’ provision of aids and environmental adap-
tations aim to help the person adapt to their impairment rather
than change the underlying impairment itself. Other cognitive re-
habilitation approaches have been aimed at the level of activity
(disability). Loverro et al repositioned stroke patients’ beds with
the aim that improvements in spatial awareness would lead to less
disability as measured on the Barthel Index (Loverro 1988).
Most reports of the effectiveness of rehabilitation techniques have
been based on single case experimental designs rather than ran-
domised controlled trials (RCTs) (Lincoln 1995). Neglect reha-
bilitation is probably the cognitive area in which most RCTs have
been conducted and contains some of the oldest rehabilitation
RCTs (Weinberg 1977). Some trials have shown positive results of
their efficacy although generalisation of training to untrained sit-
uations is rarely examined, nor is the maintenance of any immedi-
ate benefits. Thus, it is currently difficult to draw definite conclu-
sions regarding whether or not stroke patients benefit from neglect
rehabilitation or whether such impairment specific rehabilitation
facilitates independence in activities of daily living (ADLs). This
review aimed to systematically consider the evidence from RCTs
on the effectiveness of cognitive rehabilitation specifically aimed at
spatial neglect. It is not a review of whether the subgroup of stroke
patients with neglect benefit from general rehabilitation such as
physiotherapy or occupational therapy. Whatever the findings of
this review of cognitive rehabilitation specifically for neglect it is
essential that patients with neglect are included in general stroke
rehabilitation services.
O B J E C T I V E S
To assess whether cognitive rehabilitation improves functional in-
2Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
dependence, performance on conventional and behavioural tests
of neglect, and destination on discharge in stroke patients with
neglect; to determine which types of interventions are effective;
and whether cognitive rehabilitation is more effective than stan-
dard care or an attention control.
C R I T E R I A F O R C O N S I D E R I N G
S T U D I E S F O R T H I S R E V I E W
Types of studies
In the first version of this review we sought all controlled trials
in which cognitive rehabilitation was compared to a control treat-
ment. In addition to well designed randomised controlled trials
(RCTs), other trials (such as those described as quasi-random) were
considered for inclusion but, if selected, were assigned a lower
methodological quality score. However, in this updated version
of the review we excluded all non-randomised trials to reduce se-
lection bias. These are listed in the ’Characteristics of excluded
studies ’ table.
Types of participants
This review was confined to trials which included patients with
neglect following stroke. Stroke was confirmed by neurological
examination or computerised tomography (CT) scan, or both,
and neglect by neuropsychological examination. Thus, trials that
included participants whose deficits were the result of head trauma,
brain tumour or any other brain damage were excluded unless a
subgroup of stroke patients could be identified for which there
were separate results or more than 75% of patients in the sample
were stroke patients. We excluded trials of patients with general
perceptual problems unless a subgroup of patients with neglect
could be identified.
Types of intervention
To be included in the review, a clinical trial had to report a com-
parison between an active treatment group that received one of
various cognitive rehabilitation programmes for neglect versus a
control group that received either an alternative form of treatment
or none. Cognitive rehabilitation was broadly defined to include
therapy activities designed to directly reduce the level of the neglect
impairment or the resulting disability. Drug treatments were not
included. Cognitive rehabilitation could include structured ther-
apy sessions, computerised therapy, prescription of aids and mod-
ification of the patients’ environment as long as these were specific
to neglect. The aim was to directly target the neglect rather than to
examine whether patients with neglect happened to benefit from
general rehabilitation services. This is an important distinction.
When planning this updated version of the review, we became
aware that authors were categorising their neglect interventions
as either bottom-up or top-down processing (Parton 2004). Top-
down approaches aim to train the patient to voluntarily compen-
sate for their neglect and require awareness of the disorder. Meth-
ods include training in scanning and usually provide feedback
(Pizzamiglio 2004). Top-down approaches focus at the level of
disability rather than impairment. Bottom-up approaches do not
require awareness of the disorder. They aim to modify underlying
factors, that is to alter the impaired representation of space. Prism
adaptation is the most popular and recent example of a bottom-up
approach (Rossetti 1998). We included both approaches in this
updated review.
Types of outcome measures
Primary outcome
(1) Ratings on measures of functional disability: activities of daily
living (ADL) scales: Barthel Index (BI), Functional Independence
Measure (FIM), Frenchay Activities Index (FAI), or neglect specific
ADL measures.
Secondary outcomes
(1) Performance on standardised neglect assessments: target can-
cellation (single letter, double letter, line, shape), line bisection.
Cancellation studies reporting number correct were analysed sepa-
rately from those reporting number of errors. In addition to a con-
ventional subtest score (such as letter cancellation) the behavioural
summary score from the Behavioural Inattention Test (BIT) was
used when available. In this updated review we removed outcomes
of attention and drawing tests to reduce the number of outcomes
being reviewed and to concentrate on those most relevant to ne-
glect.
(2) Discharge destination: whether a person was discharged to
live in their own home or to a care facility was included where
available, with deaths before discharge treated as not discharged
to their own home.
We did not specify a primary outcome in the first version of this
review. In this update, we decided that the primary outcome should
be the persistence of functional recovery, that is ADL benefits that
are maintained beyond the end of the intervention.
S E A R C H M E T H O D S F O R
I D E N T I F I C A T I O N O F S T U D I E S
See: Cochrane Stroke Group methods used in reviews.
(1) We searched the Cochrane Stroke Group Trials Register,
which was last searched by the Review Group Co-ordinator on
4 July 2005. In addition, we searched the following electronic
databases: MEDLINE (1998 to July 2005), EMBASE (1998 to
July 2005), CINAHL (1998 to July 2005), PsycINFO (1998 to
July 2005) and the National Research Register (July 2005). The
following search strategies were used:
Database MEDLINE (Ovid)
1. exp cerebrovascular disorders/
2. (stroke$ or poststroke$ or cva$).tw.
3Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
3. (cerebrovascular$ or cerebral vascular).tw.
4. ((cerebral or cerebellar or brainstem or vertebrobasilar) adj5
(infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$)).tw.
5. ((cerebral or intracerebral or intracranial or parenchymal
or brain or intraventricular or brainstem or cerebellar
or infratentorial or supratentorial or subarachnoid) adj
(haemorrhage or hemorrhage or haematoma or hematoma or
bleeding or aneurysm)).tw.
6. 1 or 2 or 3 or 4 or 5
7. exp Perceptual disorders/
8. exp perception/
9. Attention/
10. “Extinction (psychology)”/
11. (hemineglect or hemi-neglect).tw.
12. ((unilateral or spatial) adj5 neglect).tw.
13. (perception or inattention or hemi-inattention or attention
or extinction).tw.
14. ((perceptual or visuo?spatial or visuo?perceptual or
attentional) adj5 (disorder$ or deficit$ or impairment$ or
abilit$)).tw.
15. ((perceptual or visuo?spatial or visuo?perceptual or attention$
or cognit$ or scanning$) adj5 (training or re-training or
rehabilitation or intervention or therapy)).tw.
16. 7 or 8 or 9 or 10 or 11 or 12 or 13 or 14 or 15
17. Randomized Controlled Trials/
18. random allocation/
19. Controlled Clinical Trials/
20. control groups/
21. clinical trials/
22. double-blind method/
23. single-blind method/
24. Placebos/
25. placebo effect/
26. cross-over studies/
27. Research Design/
28. evaluation studies/
29. randomized controlled trial.pt.
30. controlled clinical trial.pt.
31. clinical trial.pt.
32. evaluation studies.pt.
33. random$.tw.
34. (controlled adj5 (trial$ or stud$)).tw.
35. (clinical$ adj5 trial$).tw.
36. ((control or treatment or experiment$ or intervention) adj5
(group$ or subject$ or patient$)).tw.
37. (quasi-random$ or quasi random$ or pseudo-random$ or
pseudo random$).tw.
38. ((control or experiment$ or conservative) adj5 (treatment or
therapy or procedure or manage$)).tw.
39. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or
mask$)).tw.
40. (coin adj5 (flip or flipped or toss$)).tw.
41. latin square.tw.
42. (cross-over or cross over or crossover).tw.
43. placebo$.tw.
44. sham.tw.
45. (assign$ or alternate or allocat$ or counterbalance$ or
multiple baseline).tw.
46. controls.tw.
47. or/17-46
48. 6 and 16 and 47
Database EMBASE (Ovid)
1. exp cerebrovascular disease/
2. (stroke$ or cva$ or poststroke).tw.
3. (cerebrovasc$ or cerebral vascular).tw.
4. ((cerebral or cerebellar or brainstem or vertebrobasilar) adj5
(infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$)).tw.
5. ((cerebral or intracerebral or intracranial or parenchymal
or brain or intraventricular or brainstem or cerebellar
or infratentorial or supratentorial or subarachnoid) adj
(haemorrhage or hemorrhage or haematoma or hematoma or
bleeding or aneurysm)).tw.
6. 1 or 2 or 3 or 4 or 5
7. exp perception disorder/
8. exp perception/
9. exp attention/
10. visual deprivation/
11. (hemineglect or hemi-neglect).tw.
12. ((unilateral or spatial or hemi?spatial) adj5 neglect).tw.
13. (perception or inattention or hemi-inattention or attention
or extinction).tw.
14. ((perceptual or visuo?spatial or visuo?perceptual or
attentional) adj5 (disorder$ or deficit$ or impairment$ or abilit$
or dysfunction)).tw.
15. ((perceptual or visuo?spatial or visuo?perceptual or attention$
or cognit$ or scanning$) adj5 (training or retraining or
rehabilitation or intervention or therapy)).tw.
16. or/7-15
17. clinical trial/
18. randomized controlled trial/
19. controlled study/
20. double blind procedure/
21. single blind procedure/
22. randomization/
23. placebo/
24. prospective study/
25. types of study/
26. methodology/
27. comparative study/
28. parallel design/
29. crossover procedure/ or intermethod comparison/
30. clinical study/
31. random$.tw.
32. (controlled adj5 (trial$ or stud$)).tw.
33. (clinical$ adj5 trial$).tw.
4Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
34. ((control or treatment or experiment$ or intervention) adj5
(group$ or subject$ or patient$)).tw.
35. (quasi-random$ or quasi random$ or pseudo-random$ or
pseudo random$).tw.
36. ((control or experiment$ or conservative) adj5 (treatment or
therapy or procedure or manage$)).tw.
37. ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or
mask$)).tw.
38. (coin adj5 (flip or flipped or toss$)).tw.
39. latin square.tw.
40. (cross-over or cross over or crossover).tw.
41. placebo$.tw.
42. sham.tw.
43. (assign$ or alternate or allocat$ or counterbalance$ or
multiple baseline).tw.
44. controls.tw.
45. or/17-44
46. 6 and 16 and 45
Database CINAHL (Ovid)
1. exp cerebrovascular disorders/
2. (stroke$ or poststroke$ or cva$).tw.
3. (cerebrovascular$ or cerebral vascular).tw.
4. ((cerebral or cerebellar or brainstem or vertebrobasilar) adj5
(infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$)).tw.
5. ((cerebral or intracerebral or intracranial or parenchymal
or brain or intraventricular or brainstem or cerebellar
or infratentorial or supratentorial or subarachnoid) adj
(haemorrhage or hemorrhage or haematoma or hematoma or
bleeding or aneurysm)).tw.
6. 1 or 2 or 3 or 4 or 5
7. exp Perceptual disorders/
8. exp perception/
9. Attention/
10. (hemineglect or hemi-neglect).tw.
11. ((unilateral or spatial) adj5 neglect).tw.
12. (perception or inattention or hemi-inattention or attention
or extinction).tw.
13. ((perceptual or visuo?spatial or visuo?perceptual or
attentional) adj5 (disorder$ or deficit$ or impairment$ or
abilit$)).tw.
14. ((perceptual or visuo?spatial or visuo?perceptual or attention$
or cognit$ or scanning$) adj5 (training or re-training or
rehabilitation or intervention or therapy)).tw.
15. or/7-14
16. random assignment/
17. random sample/
18. convenience sample/
19. Crossover design/
20. exp Clinical trials/
21. Comparative studies/
22. “control (research)”/
23. Control group/
24. Factorial design/
25. quasi-experimental studies/
26. Nonrandomized trials/
27. Placebos/
28. Community trials/ or Experimental studies/ or One-shot case
study/ or Pretest-posttest design/ or Solomon four-group design/
or Static group comparison/ or Study design/
29. Research question/
30. Research methodology/
31. exp Evaluation research/
32. Evaluation/mt [Methods]
33. (“clinical trial” or “systematic review”).pt.
34. random$.tw.
35. ((singl$ or doubl$ or tripl$ or trebl$) adj25 (blind$ or
mask$)).tw.
36. (cross?over or placebo$ or control$ or factorial or sham?).tw.
37. ((clin$ or intervention$ or compar$ or experiment$ or
preventive or therapeutic) adj10 trial$).tw.
38. (counterbalance$ or multiple baseline$ or ABAB design$).tw.
39. or/16-38
40. 6 and 15 and 39
Database PsycINFO (Ovid)
1. exp cerebrovascular disorders/
2. (stroke$ or poststroke$ or cva$).tw.
3. (cerebrovascular$ or cerebral vascular).tw.
4. ((cerebral or cerebellar or brainstem or vertebrobasilar) adj5
(infarct$ or isch?emi$ or thrombo$ or apoplexy or emboli$)).tw.
5. ((cerebral or intracerebral or intracranial or parenchymal
or brain or intraventricular or brainstem or cerebellar
or infratentorial or supratentorial or subarachnoid) adj
(haemorrhage or hemorrhage or haematoma or hematoma or
bleeding or aneurysm)).tw.
6. 1 or 2 or 3 or 4 or 5
7. exp perceptual disturbances/
8. exp perception/
9. sensory neglect/
10. exp attention/
11. “extinction (learning)”/
12. (hemineglect or hemi-neglect).tw.
13. ((unilateral or spatial) adj5 neglect).tw.
14. (perception or inattention or hemi-inattention or attention
or extinction).tw.
15. ((perceptual or visuo?spatial or visuo?perceptual or
attentional) adj5 (disorder$ or deficit$ or impairment$ or
abilit$)).tw.
16. ((perceptual or visuo?spatial or visuo?perceptual or attention$
or cognit$ or scanning$) adj5 (training or re-training or
rehabilitation or intervention or therapy)).tw.
17. or/7-16
18. 6 and 17
19. (random$ or quasi-random$ or control$ or trial$ or blind$
or cross?over or experiment$ or compar$ or prospective).tw.
5Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
20. 18 and 19
(2) For the purpose of this and other reviews (Lincoln 2001;
Majid 2001), trials in four areas of stroke rehabilitation
(cognitive rehabilitation, occupational therapy, speech
therapy, and treatment for mood disorders) were searched
for simultaneously using on-line computerised bibliographic
databases: MEDLINE (1966 to 1998), BIDS EMBASE (1980 to
1998), CINAHL (1983 to 1998), PSYCLIT (1974 to 1998) and
CLINPSYCH (1980 to November 1994). These computerised
searches were conducted using combinations of the following
descriptors/key words: stroke/cerebrovascular accidents/
neurological disability and randomised controlled/clinical trials/
random allocation/double blind method and rehabilitation/
remedial therapy/treatment/intervention and cognitive/unilateral
neglect/visuospatial/visuoperceptual/memory/attention span/
concentration/hemianopia/attentional deficits/activities of daily
living/occupational therapy/leisure/dressing/self-care/domiciliary
rehabilitation.
(3) To ensure that trials not listed in the above databases were
not overlooked, in 1999 we handsearched all volumes of the
following journals.
• American Journal of Occupational Therapy (1947 to 1998)
• Aphasiology (1987 to 1998)
• Australian Occupational Therapy Journal (1965 to 1998)
• British Journal of Occupational Therapy (1950 to 1998)
• British Journal of Therapy and Rehabilitation (1994 to 1998)
• Canadian Journal of Occupational Therapy (1970 to 1998)
• Clinical Rehabilitation (1987 to 1998)
• Disability Rehabilitation (1992 to 1998), formerly InternationalDisability Studies (1987 to 1991), formerly InternationalRehabilitation Medicine (1979 to 1986)
• International Journal of Language & CommunicationDisorders (1998), formerly European Journal of Disorders ofCommunication (1985 to 1997), formerly British Journal ofDisorders of Communication (1977 to 1984)
• Journal of Clinical Psychology in Medical Settings (1994 to
1998), formerly Journal of Clinical Psychology (1944 to 1994)
• Journal of Developmental and Physical Disabilities (1992 to
1998), formerly Journal of the Multihandicapped Person (1989
to 1991)
• Journal of Rehabilitation (1963 to 1998)
• International Journal of Rehabilitation Research (1977 to 1998)
• Journal of Rehabilitation Science (1989 to 1996)
• Neuropsychological Rehabilitation (1987 to 1998)
• Neurorehabilitation (1991 to 1998)
• Occupational Therapy International (1994 to 1998)
• Physiotherapy Theory and Practice (1990 to 1998), formerly
Physiotherapy Practice (1985 to 1989)
• Physical Therapy (1988 to 1998)
• Rehabilitation Psychology (1982 to 1998)
• The Journal of Cognitive Rehabilitation (1988 to 1998),
formerly Cognitive Rehabilitation (1983 to 1987)
The 1999 handsearch included a broad range of journals as it
covered trials in four areas of rehabilitation, only one of which
(neglect) was relevant to this specific review. Therefore for this
update we checked the Master List of journals that is searched
by The Cochrane Collaboration (http://www.cochrane.us/
masterlist.asp). We found that the journals relevant to neglect
had been handsearched. The resulting trials would be found
from the search of the Cochrane Central Register of Controlled
Trials (CENTRAL) carried out quarterly by the Cochrane Stroke
Group and we did not wish to duplicate effort.
(4) We screened reference lists of all relevant articles
(5) We used the three citation index databases, Science Citation
Index (SCI), Social Sciences Citation Index (SSCI) and Arts and
Humanities Citation Index (A&HCI) for citation tracking of
relevant included studies.
M E T H O D S O F T H E R E V I E W
As previously mentioned, the pre-1999 searching and selection
was carried out simultaneously for four reviews, two of which have
been published in The Cochrane Library (Lincoln 2001; Majid
2001). Updated searches specific to this present review were carried
out in July 2005.
Two review authors (NBL, AB) independently selected trials to
be included in this review using the four inclusion criteria (types
of trials, participants, interventions and outcome measures). We
independently assessed the methodological quality of the trials,
with reference to the Cochrane Handbook for Systematic Reviews ofInterventions (Higgins 2005), selected, entered, and cross-checked
data for analysis. Differences were resolved by discussion.
Study characteristics and outcomes were abstracted. The following
information was recorded: method of participant assignment,
adequacy of concealment, adequacy of matching at baseline,
description of intervention, sample size, numbers lost to follow up,
types of dependent variable(s), blinding at outcome assessment,
reported results and publication details. Where these data were
not available or unclear from the reports then they were sought
or confirmed by correspondence with the first author of the
6Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
publication or both. Intention-to-treat analyses were used where
possible.
Where a crossover design was used (for example Schindler 2002)
only data from the first treatment period were used. Where initial
participants were randomised but later allocations were non-
randomised (for example Schindler 2002; Zeloni 2002) we only
included the study if we could extract the data on those randomised
(Zeloni 2002). If not we excluded the trial (Schindler 2002).
The left and right labels on the graphs were set according to the
method of scoring used on each outcome measure. For example,
a high score on the Barthel Index (BI) indicates a good outcome
and so the BI graph was set with the right label favouring the
experimental group. However, on the ’cancellation: number of
errors’ and ’line bisection’ outcomes a low score (that is fewer
errors) is better and so the left label of the graph was set to favour
the experimental group.
Activities of daily living (ADL) data, such as the BI, were treated as
continuous outcomes and mean and standard deviation data were
requested or calculated. We are aware that there is a difference
of opinion over how to deal with BI data. We have treated it
as an interval measurement whereas other people prefer to treat
it as ordinal. It is our view that, although from a theoretical
viewpoint there is an issue here, in practice it makes relatively
little difference. This is supported by a recent statistical study of
parametric versus nonparametric methods of BI data in stroke
trials, which recommended that means and standard deviations
(SDs) should be reported (Song 2005). Outcomes were analysed
as the standardised mean difference (SMD) and 95% confidence
intervals (CI). Random-effects models were used.
Odds ratios (OR) were selected for the outcome ’discharge
destination’ comparing the numbers discharged to their own
home. Deaths before discharge were treated in this review as not
discharged to their own home. In this way those discharged home
were compared to everyone who was not discharged home.
Meta-analyses were conducted for studies of spatial neglect. To
reduce selection bias only those studies with adequate allocation
concealment were rated as ’A’. A separate sensitivity analysis of
only the ’A’-rated studies was conducted where there was more
than one ’A’ rated study.
The original analyses compared a rehabilitation approach with
any other control. The controls used were standard care, attention
control (where the control group were given extra hours of contact
in addition to their standard care to ensure the experimental and
control groups had similar amounts of contact or attention from
a therapist), and a control alternative neglect therapy. In this
update we kept the ’any control’ general comparison. However,
we added comparisons to separate out studies comparing two
equally feasible rehabilitation approaches (for example Edmans
2000; Robertson 2002) from those comparing one rehabilitation
approach with a control that was less likely to improve outcome
(for example Kalra 1997; Rossi 1990). This was done for the
primary outcome only, that is persisting functional or ADL data,
and was considered necessary as the different comparators answer
different rehabilitation questions.
In this update we also added a subgroup comparison by type of
intervention (grouped as bottom-up or top-down processing) to
reduce the main limitation of the original review design, which
was that it was not set up to test which of several rehabilitation
approaches was effective. This subgroup analysis was for the
primary outcome only, that is persisting functional or ADL data.
D E S C R I P T I O N O F S T U D I E S
Data from 306 participants in 12 RCTs were included (Cherney
2002; Cottam 1987; Edmans 2000; Fanthome 1995; Kalra 1997;
Robertson 1990; Robertson 2002; Rossi 1990; Rusconi 2002;
Weinberg 1977; Wiart 1997; Zeloni 2002). Trials had small sam-
ple sizes. The smallest trials recruited and followed up four and
eight participants respectively (Cherney 2002; Zeloni 2002) and
the largest had a sample size of 50 (Kalra 1997). Statistical power
was rarely commented on, however some (such as Cherney 2002
and Kalra 1997) did explicitly state that they were intended as
pilot or feasibility studies.
All trials were of patients with neglect. In one trial (Rossi 1990)
some of the participants may have had visual sensory deficits (visual
field or scanning) as well as or instead of neglect. There were 12
people with a visual sensory deficit in the experimental group and
15 in the control group. However, the review authors do not ex-
pect that their inclusion would bias the results. The majority of tri-
als only included patients with right hemisphere stroke (Cherney
2002; Cottam 1987; Fanthome 1995; Robertson 1990; Robertson
2002; Rusconi 2002; Weinberg 1977; Wiart 1997; Zeloni 2002).
The others included those with either left or right hemisphere le-
sions, although in each trial there were more patients with right
hemisphere lesions.
Five of the centres contributing the 12 RCTs were based in the UK
(Edmans 2000; Fanthome 1995; Kalra 1997; Robertson 1990;
Robertson 2002), four were based in North America (Cherney
2002; Cottam 1987; Rossi 1990; Weinberg 1977), two in Italy
(Rusconi 2002; Zeloni 2002), and one in France (Wiart 1997).
Many trials recruited from in-patient rehabilitation hospitals (such
as Cottam 1987; Rusconi 2002) or specialist in-patient stroke
services (for example Edmans 2000; Kalra 1997). As expected
in a stroke population, the average age of participants was over
60 years. Only one trial explicitly mentioned an age exclusion
criterion, that was aged over 80 years (Robertson 2002). Many
trials excluded participants on the basis of progressive dementia,
previous stroke, current cognitive or communication problems,
on the grounds that these would adversely affect responsiveness to
therapy. Occasionally the neglect data were extracted as part of a
larger study (Edmans 2000).
7Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
A broad range of interventions was used (for full details see ’Char-
acteristics of included studies’ table). The included trials used both
top-down (Cherney 2002; Cottam 1987; Edmans 2000; Fan-
thome 1995; Robertson 2002; Rusconi 2002; Weinberg 1977;
Wiart 1997) and bottom-up (Kalra 1997; Robertson 1990; Rossi
1990; Zeloni 2002) approaches to rehabilitation. Several trials
provided equipment such as: fitting prisms to spectacles in order
to shift the image seen by the participant towards the neglected
side (Rossi 1990), or blinding the right side of goggles (Zeloni
2002), or specially adapted glasses which gave auditory feedback if
the participant failed to scan the neglected side (Fanthome 1995).
Wiart 1997 fitted participants with a ’vest’ with a metal pointer
attached. Robertson 2002 provided a ’limb activation device’ fit-
ted to the wrist, leg or shoulder.
Other interventions involved training with a therapist. For ex-
ample, various scanning tasks were used to demonstrate the pa-
tient’s deficit and show how a strategy could improve performance
(Cherney 2002). Another example of therapy-directed interven-
tion was spatio-motor cueing aimed at integrating attention and
limb movement (Kalra 1997). The principle behind this approach
is that movements of the affected limb in the neglected part of
space will result in improvements in attention skills and apprecia-
tion of spatial relationships on the affected side. Some approaches
involved multiple strategies, for example in the Wiart 1997 study
a therapist participated actively guiding and giving feedback while
the participant used the fitted pointer. A therapist was present in
both arms of the Rusconi 2002 trial but only provided cueing
and feedback in the ’experimental’ arm. This latter study is an
example of cognitive rehabilitation versus an attention control as
participants in both arms received equal amounts of time (that is
attention) from a therapist. What differed was the nature of the
therapy itself, that is whether or not cueing and feedback were
provided by the therapist.
The nature of the interventions was usually well described as were
the number, frequency and duration of therapy sessions. The num-
ber of sessions varied from 12 (Robertson 2002) to 40 (Rusconi
2002) over a duration of 3 to 12 weeks. Sessions ranged from
daily to once a week and lasted from 30 to 75 minutes each. The
Rossi trial probably provided the highest ’dose’ of rehabilitation as
participants in the experimental arm wore their prisms during all
daytime activities for four weeks (Rossi 1990).
This updated review found that more trials included functional
outcome data, that is using measure of activities of daily living.
However few trials measured outcomes beyond the end of therapy
and so very few data existed on the persistence or maintenance of
functional recovery. This limited the comparisons that could be
made of one type of cognitive rehabilitation with any other and the
subgroup analyses of the top-down and bottom-up approaches.
In this updated review we only included the 12 trials that had
randomised participants. The search identified studies that were
published as randomised but the authors later confirmed that non-
random allocation had been used. These were then excluded. Ex-
amples of popular non-random methods were: allocating the first
set to one arm and the second to the other (Rossetti 1998; Tham
1997); alternate allocation (Pizzamiglio 2004), allocating by bed
number (Paolucci 1996), bed availability (Loverro 1988) or date
of admission (Harvey 2003). In total 22 studies were excluded.
The reasons for exclusion are detailed in the ’Characteristics of
excluded studies’ table.
One further RCT of spatial neglect was identified and is awaiting
assessment and data from the authors (Cubelli 1993). We are aware
of several ongoing RCTs which will be considered for inclusion in
the next update (Kerkhoff 2005; Rossetti 2005; Turton 2005).
M E T H O D O L O G I C A L Q U A L I T Y
Of the 12 included RCTs four did not provide further detail on
the randomisation method used (Cherney 2002; Cottam 1987;
Rossi 1990; Weinberg 1977) or the method of ensuring allocation
concealment. As they were published as RCTs we included them
but assigned a ’B’ rating meaning allocation concealment was un-
clear.
The other eight RCTs confirmed that they used external ran-
domisation (Kalra 1997; Robertson 1990), random number ta-
bles (Edmans 2000; Fanthome 1995; Wiart 1997), drawing pre-
labelled allocations from an envelope (Zeloni 2002) or, in the case
of Robertson 2002 and Rusconi 2002, the authors confirmed ran-
domisation but did not specify the method used. The methods
used by Kalra 1997 and Robertson 1990 provided a good guar-
antee of concealment of allocation and they were both given an
’A’ rating. Edmans 2000 and Robertson 2002 were also given ’A’
ratings on the grounds that concealment was highly likely to have
been achieved, although it could not be guaranteed. For example,
in Edmans 2000 the researcher used random number tables to pre-
pare sequentially numbered opaque sealed envelopes. The random
number tables were then returned and due to the large number
randomised (80 to the full perception trial) it was unlikely that the
sequence would be remembered. The envelopes were only opened
in the presence of a witness. Robertson 2002 confirmed that the
recruiters were unaware of and unable to predict allocation con-
cealment. The other four trials (Fanthome 1995; Rusconi 2002;
Wiart 1997; Zeloni 2002) were rated as ’B’ as the information on
allocation concealment was unclear. For example, the combina-
tion of a small sample size with no external randomisation meant
that there was a potential risk to concealment (Fanthome 1995).
Edmans 2000, Fanthome 1995, Kalra 1997, Robertson 1990,
Robertson 2002, Rusconi 2002 and Zeloni 2002 used blinded
outcome assessors. Cherney 2002, Cottam 1987, Weinberg 1977
and Wiart 1997 provided no information suggesting that blinding
was used. Rossi 1990 did not use blinded outcome assessors.
8Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
In summary there were four ’A’ rated trials, that is with adequate
allocation concealment (Edmans 2000; Kalra 1997; Robertson
1990; Robertson 2002). Blinded assessment was reported in seven
trials (Edmans 2000; Fanthome 1995; Kalra 1997; Robertson
1990; Robertson 2002; Rusconi 2002; Zeloni 2002).
R E S U L T S
Outcome data were available on 306 participants from 12 trials.
A large number of outcome measures were reported within single
studies, especially using standardised neglect tests, but not all par-
ticipants completed all outcomes. At times the number of outcome
measures used within a trial limited the analyses (for example, seecancellation below). With the exception of ’discharge destination’
for which we used an odds ratio all other results refer to standard-
ised mean difference (SMD) and 95% confidence intervals (CI)
using random-effects models. The comparison numbers referred
to in this section (for example 01.01) refer to the numbered graphs.
Ratings on measures of functional disability: activities of daily
living (ADL) scales: Barthel Index (BI) at discharge, Functional
Independence Measure (FIM)
Immediate
Six studies (206 participants) included a measure of disability im-
mediately after the end of rehabilitation or on discharge, five with
the BI (Edmans 2000; Kalra 1997; Robertson 2002; Rossi 1990;
Rusconi 2002) and one with the FIM (Wiart 1997). A seventh
(Robertson 1990) collected similar disability data on the Frenchay
Activities Index but these data were not available for the review. As
shown in the graph for comparison 01.01, the individual results
of two of these studies (rated A and B respectively for adequacy of
allocation concealment) favoured the experimental group (Kalra
1997; Wiart 1997). None favoured the control group. However,
the overall effect for the six studies measuring immediate effect
on disability was small, with a wide confidence interval that in-
cluded zero and was not statistically significant, SMD 0.26 (95%
CI -0.16 to 0.67), P = 0.23.
Persisting
The primary outcome for this review was whether effects on dis-
ability persisted over time. Only two studies, rated A and B respec-
tively, examined this (Robertson 2002; Wiart 1997). Outcome on
the FIM favoured the experimental group SMD 1.17 (95% CI
0.25 to 2.08), P = 0.01, which received one hour of specialised
neglect therapy for 20 days (Wiart 1997). However, the groups
were not well matched. The experimental group was younger and
had a higher baseline FIM score (66) than the control group (54).
Outcome on the BI favoured neither group (Robertson 2002). As
shown in the graph for comparison 02.01 there is no overall evi-
dence for a persisting effect on ADL functioning from these two
studies 0.61 (95% CI -0.42 to 1.63), P = 0.24.
The same two studies were the only data available for comparison
03.01, persisting effects on ADL of one type of cognitive reha-
bilitation versus standard care or attention control. There are no
studies of comparison 04.01 persisting effects on ADL of one type
of cognitive rehabilitation versus another type.
The paucity of good functional data also restricted the planned
subgroup analyses of the persisting benefits of two rehabilitation
approaches, top-down and bottom-up. Comparison 06.01 is re-
stricted to the single B-rated top-down study by Wiart 1997, the
results which favoured the experimental group are described pre-
viously. The effects of the bottom-up approach are shown in com-
parison 05.01. This A-rated study (Robertson 2002) did not find
evidence to support or refute bottom-up approaches SMD 0.12
(95% CI -0.62 to 0.86), P = 0.75.
Sensitivity analyses
Sensitivity analyses (A-rated studies only) of the ADL outcome,
conducted on three studies of immediate effect on the BI (Edmans
2000; Kalra 1997; Robertson 2002) resulted in a reduced effect
size and wider confidence interval SMD 0.16 (95% CI -0.36 to
0.68) but did not alter the overall result of no significant effect,
P = 0.54. Sensitivity analysis of a persisting effect could not be
reliably determined as there was only one small study (Robertson
2002).
Performance on standardised neglect assessments
Immediate
Almost all of the studies (11) provided data on standardised tests
of neglect, although there was no one measure common to all and
some studies used more than one measure. There was evidence
that cognitive rehabilitation improved immediate performance al-
though this varied depending on the test used, as described in de-
tail below. In summary, outcome favoured the experimental group
on: one of the four cancellation targets that were scored for number
correct (double letter), cancellation scored for number of errors,
and line bisection. There was no evidence in favour of either group
on single letter, line or shape cancellation targets (although only
one study used the latter two outcomes) or the BIT behavioural
subtest score (three studies).
• The number of targets correctly cancelled was measured using
four types of targets (comparison 01.02): single letter, double
letter, line and shape. Analysis beyond the subgroup level was
not valid as three studies used more than one type of target (Fan-
thome 1995; Weinberg 1977; Zeloni 2002). Subgroup analysis
by target type suggested that outcomes for one of these targets
favoured the experimental group: double letter SMD 1.8 (95%
CI 0.85 to 2.76), P = 0.0002. However, this was based on data
from only 25 participants in a single B-rated study (Weinberg
1977). Single letter cancellation was the most frequently used
cancellation measure (Edmans 2000; Fanthome 1995; Kalra
1997; Rusconi 2002; Weinberg 1977; Zeloni 2002). With the
exception of Edmans 2000 (an A-rated study which favoured
the control group) the other five studies all favoured the ex-
perimental group, although many of the confidence intervals
included zero and only Kalra 1997 was A rated. The overall
9Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
subgroup effect for single letter cancellation was small and not
significant SMD 0.39 (95% CI -0.13 to 0.92), P = 0.14. Sensi-
tivity analyses conducted on the two A-rated studies (Edmans
2000; Kalra 1997) suggested a smaller effect and remained non-
significant SMD 0.01 (95% CI -0.84 to 0.86], P = 0.98 (com-
parison 01.08). Line (SMD 0.56, 95% CI -0.15 to 1.26, P =
0.12) and shape (SMD 0.09, 95% CI -0.69 to 0.88, P = 0.81)
cancellation data were provided by two B-rated studies (Fan-
thome 1995; Zeloni 2002). Neither were significant.
• Four studies using the number of errors made cancelling tar-
gets (Cottam 1987; Robertson 1990; Rossi 1990; Wiart 1997)
reported a small effect favouring the experimental group which
was of borderline statistical significance, SMD -0.65 (95% CI
-1.28 to -0.01), P = 0.05. These were based on 103 participants
and shown in the graph depicting comparison 01.03. Only one
(Robertson 1990) was A rated.
• Four studies (89 participants) reporting line bisection perfor-
mance (Rossi 1990; Rusconi 2002; Wiart 1997; Zeloni 2002)
suggested a favourable outcome for the experimental group
SMD -0.84 (95% CI -1.36 to -0.33), P = 0.001. However, none
of these studies, shown in comparison 01.04, were A rated.
• There was no evidence of an overall effect on the three stud-
ies using the BIT behavioural summary score (Cherney 2002;
Fanthome 1995; Robertson 1990) SMD -0.27 (95% CI -0.84
to 0.3), P = 0.35. As the graph for comparison 01.05 shows,
none of the individual studies showed an effect favouring the
experimental group. Only one study was A rated (Robertson
1990).
Persisting
The data available on whether beneficial effects on neglect assess-
ments persisted at follow up were limited to four studies (Cot-
tam 1987; Fanthome 1995; Robertson 1990; Wiart 1997), only
one of which was A rated (Robertson 1990). There were no long-
term studies of number of targets correctly cancelled, comparison
02.02. Analyses were possible on: cancellation errors (02.03), line
bisection (02.04) and the BIT behavioural summary score (02.05).
The detailed results are as follows.
• Three studies provided data on 52 participants on the can-
cellation number of errors outcome (Cottam 1987; Robertson
1990; Wiart 1997). A persisting effect favouring the experi-
mental group was found SMD -0.76 (95% CI -1.39 to -0.13),
P = 0.02.
• Only Wiart 1997 provided data on persisting effects on line bi-
section but these favoured the experimental group, SMD -1.09
(95% CI -2.0 to -0.18), P = 0.02.
• Two studies (Fanthome 1995; Robertson 1990) of 31 partici-
pants did not find a persisting effect favouring the experimental
group on the BIT behavioural summary summary score, SMD
0.06 (95% CI -0.66 to 0.78], P = 0.87.
Sensitivity analyses
Sensitivity analyses of only the A-rated studies could only be con-
ducted in the one outcome area that contained more than one A-
rated study (comparison 01.08). The results are described above.
Discharge destination (comparison 01.06)
The information regarding whether a person was discharged to
live in their own home or to a care facility, was included if avail-
able. One RCT, rated A, investigated discharge destination as an
outcome (Kalra 1997). The odds of being discharged home had
a confidence interval that included one and were not significantly
higher for the experimental group OR 1.4 (95% CI 0.45 to 4.35),
P = 0.56.
Statistical heterogeneity
The variability among studies was found to be higher than ex-
pected by chance in a few of the outcome areas. The I-squared
test suggested substantial heterogeneity (greater than 50%) for
the primary outcome ’persisting effects on functional disability’
and when taken immediately after intervention. The other area
with substantial heterogeneity was the immediate post-interven-
tion cancellation test (when scored as ’number of errors’ and ’sin-
gle letter cancelled correctly’) although the heterogeneity on the
persisting effects of ’number of errors’ was only 13% (no persisting
data on ’correct’). We used SMD and random-effects meta-analy-
sis. As discussed in the Cochrane Handbook for Systematic Reviewsof Interventions (Higgins 2005), random-effects analysis incorpo-
rates heterogeneity among trials although it is not a substitute for
thorough investigation. Given the small number of studies and
the small sample sizes in this review further investigation would
be of questionable value and was not carried out.
D I S C U S S I O N
In this updated review we excluded several previously included
non-randomised trials to reduce bias. We added several new, or
newly found, randomised controlled trials resulting in a review of
306 participants from 12 RCTs. We also re-examined the quality of
the allocation concealment and re-graded several trials, resulting in
only four A-rated trials. The method of randomisation was gener-
ally poorly described and the published papers were often not suf-
ficiently methodologically detailed to determine whether conceal-
ment of group allocation or outcome assessor blinding was likely.
Both included and excluded trial authors were extremely helpful
in providing unpublished data. Therefore this review presents a
considerable amount of unpublished data and previously unpub-
lished clarification of the methods used by the original authors.
In contrast to the problems of methodological reporting, the re-
porting quality of the rehabilitation approach used has generally
improved. We also added comparisons to examine the two main
theoretical approaches to cognitive rehabilitation, bottom up and
top down.
10Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
We found that outcome, following cognitive rehabilitation,
favoured the experimental group on several measures including
functional disability. However the effect sizes in these samples were
small and statistical analysis suggested they would not generalise
beyond the samples studied to the target population of people with
neglect after stroke. The results of sensitivity analyses of A-rated
studies that could be carried out supported the main analyses and
suggested an even smaller effect size and wider confidence inter-
vals. In contrast there was some generalisable evidence for both a
short-term and persisting effect on standardised neglect tests, such
as a reduction in errors cancelling targets and better line bisection
performance. However the validity of these measures (that is pa-
per-and-pencil tasks) is questionable. They may provide a useful
indication of changes in the underlying impairment but say little
of the person’s ability to function in the complex everyday activ-
ities that are relevant to their life. Selection bias cannot be ruled
out in these studies with low quality concealment ratings, and in
fact the only A-rated study suggested a small effect favouring the
control group. Furthermore, the evidence for persisting effects is
restricted to three and one studies respectively for cancellation and
line bisection.
In conclusion, there is a growing number of cognitive rehabilita-
tion approaches that show promise on standardised neglect tests.
However, there is insufficient unbiased evidence to support or re-
fute the effectiveness of either bottom-up or top-down approaches.
Although there has been a steady rise in the number of neglect
rehabilitation trials we do not yet have sufficient high quality
RCTs with appropriate functional outcome measures with which
to make confident recommendations for clinical practice.
A U T H O R S ’ C O N C L U S I O N S
Implications for practice
The effectiveness of cognitive rehabilitation strategies for reduc-
ing the disabling effects of neglect and increasing independence
remains unproven. No rehabilitation approach can at present be
supported or challenged by information from randomised trials.
Implications for research
There is sufficiently compelling evidence, from standardised ne-
glect tests, to encourage further trials of cognitive rehabilitation
for neglect. However, future studies need to improve on method-
ological and reporting issues and should define and distinguish
between different types of neglect. Key procedural aspects, such
as randomisation, concealment, completeness of follow up, and
blinding of assessors, must be sufficiently described. In fact the
process of random allocation appears to be misunderstood. Sev-
eral studies which described themselves as randomised were found
instead to use alternate allocation or other methods which risk
selection bias. Trialists are referred to the Cochrane Handbook for
Systematic Review of Interventions (Higgins 2005) for a descrip-
tion of acceptable methods of randomisation. Concealment and
blinding appear to be confused with each other but again are well
described in the Handbook (Higgins 2005). By its nature cog-
nitive rehabilitation is likely to be restricted to single blind trials
(of outcome assessors) as blinding of participants and therapists
is not realistic. Crossover trials are not appropriate for cognitive
rehabilitation as the effects of one approach may well contaminate
the next, which invalidates long-term outcome measurements. As
rehabilitation aims to promote independence and maintenance of
effects it is not logical to expect the ’washout’ effect that is possible
in some drug therapies.
Furthermore, trials need to have adequate statistical power to de-
tect a clinically meaningful difference. Power is very rarely men-
tioned in neglect trials and the small sample sizes used are unlikely
to be adequate. Sample specification and selection methods could
also be improved on. Neglect is a heterogeneous condition and it is
unlikely that a single rehabilitation approach would be appropri-
ate for all types and severity and co-morbidity. Future trials should
provide adequate sample description, theoretical justification and
consider using stratified randomisation to avoid imbalance of any
factors likely to confound the trial. Future studies must avoid using
non-random allocation methods (such as matching) to deal with
imbalance of known factors as this risks imbalance of potentially
important unknown factors by introducing selection bias.
There is scope for both pragmatic and explanatory RCTs. Explana-
tory trials provide evidence on efficacy, examining whether a single
rehabilitation approach (such as prism adaptation) can work in
an optimum situation (that is a more homogeneous sample with
little co-morbidity, treated by research therapists with protected
time in a controlled environment). There is also a need for prag-
matic RCTs to provide evidence on effectiveness and ideally cost
effectiveness. Pragmatic trials examine whether rehabilitation does
work in a realistic clinical setting with all of the pressures that places
on busy clinicians and examines the generalisability of findings
to the heterogeneous clinical populations likely to be referred for
rehabilitation. Finally completeness of follow up (and intention-
to-treat analysis) must be adequately conducted in future neglect
trials. Previous analyses tended to be per protocol and therefore
say little about the acceptability of rehabilitation to service users.
High drop out may well be an important measure of effectiveness
and future neglect trialists are recommended to consult the hand-
book (Higgins 2005) for a good discussion of intention to treat.
This review is ongoing and the authors would be grateful to receive
information on ongoing trials for a future update.
P O T E N T I A L C O N F L I C T O F
I N T E R E S T
Nadina Lincoln has been involved in trials included in and ex-
cluded from this review (Edmans 2000; Fanthome 1995; Lincoln
11Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
1985).
A C K N O W L E D G E M E N T S
We would like to thank the principal investigators of many of
the included and excluded trials who provided additional infor-
mation to that published and to Clare Starmer for helping with
the searches. We are especially indebted to Brenda Thomas and
Hazel Fraser at the Cochrane Stroke Group for their continued
support and specialist guidance. Thanks also to the Editorial team
and external peer reviewer who provided useful suggestions for
improving the clarity and focus of this review. The initial searches
were funded by grants to Nadina Lincoln from The Stroke Asso-
ciation and the UK NHS Research and Development Programme
for Physical and Complex Disabilities. Michael Dewey provided
statistical input to the first published version of this review, for
which we are very grateful.
S O U R C E S O F S U P P O R T
External sources of support
• The Stroke Association UK
• NHS Executive Research and Development Programme Phys-
ical and Complex Disabilities UK
Internal sources of support
• No sources of support supplied
R E F E R E N C E S
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L, Zoccolotti P. Facilitatory effect of neglect rehabilitation on the
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13Cognitive rehabilitation for spatial neglect following stroke (Review)
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reported rate of occurrence of unilateral spatial neglect following
stroke. Stroke 1999;30(6):1196–202.
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Calvanio R, Levine D, Petrone P. Elements of cognitive rehabilitation
after right hemisphere stroke. Behavioural Neurology 1993;11(1):25–
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Lincoln NB. The assessment and treatment of disorders of visual
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and Hall, 1985.
14Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
WHO 2001
World Health Organization. International Classification of Function-
ing, Disability and Health (ICF). Geneva: World Health Organiza-
tion, 2001.
∗Indicates the major publication for the study
T A B L E S
Characteristics of included studies
Study Cherney 2002
Methods RCT: no further information provided. No mention of blinded outcome assessments.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants USA.
Four right hemisphere stroke patients with clinical evidence of neglect at least six months post onset.
Exptl n = 2, cntrl n = 2.
Mean age (SD): exptl 69.5 yrs (23.3), cntrl 62.0 yrs (5.7).
Sex (m): exptl 2, cntrl 1.
Side of damage (RBD): exptl 2, cntrl 2.
Mean months post-onset (SD): exptl 16 (12.7), cntrl 7.5 (0.7).
Inclusion: right-handed, right hemisphere stroke, persisting neglect after six months, spoke English as a
primary language, passed pure tone audiometry in their better ear, corrected visual acuity was sufficient to
read newsprint.
Interventions Visual scanning training, practising letter and word cancellation tasks (to address the assumed underlying
impairment of selective visual attention)
versus
repetitive practice of a functional task: oral reading (to represent an approach commonly used in rehabilita-
tion).
Both groups received 20 sessions. The frequency of sessions is not known.
Both scanning and reading training included the use of visual, verbal and tactile cues to attend to the left. In
both training the task difficulty gradually increased if the patient achieved 90% success (scanning) or 100%
success (reading). In reading training the cues were gradually removed. (NB. Scanning is coded as exptl in
this review.)
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top down.
Outcomes The study collected four types of outcomes, pre and post training:
(1) the MMSE;
(2) the Stroop Neuropsychological Screening Test;
(3) the BIT;
(4) a functional reading test devised for this study.
The latter was to identify five names from a local telephone book; there was a time limit of three minutes per
name. The BIT was scored in three ways: conventional subtests; behavioural subtests; and total. It is assumed
this was measured immediately post training.
For comparability with other studies this review used only the BIT behavioural subtests post training.
Notes A comparison of two treatments. Intended as a small preliminary study.
Allocation concealment B – Unclear
15Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Study Cottam 1987
Methods RCT: no further information provided.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants USA.
12 stroke rehabilitation in-patients with left hemispatial neglect.
Exptl n = 6, cntrl = 6.
Mean age: exptl 66.2 yrs, ctrl 71.3 yrs.
Sex (m/f ): 7/5.
Side of damage: all had right middle cerebral artery lesions.
Time post-onset (mean weeks): exptl 6, cntrl 16.3.
Inclusion: right-handed, visual acuity > 20/100 corrected on Snellen’s, orientated in person, place and time,
evidence of left hemispatial neglect on at least three of the tests used, either WAIS-R VIQ > 80 or minimum
scaled score of 8 on 4/6 verbal subtests, arm and leg able to propel wheelchair.
Interventions Three-phase intervention, each phase consisted of five half-hour sessions per day:
(1) visually scanning a lightboard when stationary, taught to verbally self-prompt to start on left and scan
from left to right;
(2) same activity but while self propelling;
(3) did not use the lightboard but participants named objects presented on both sides while self-propelling
versus
no information other than participants were in-patients at a rehabilitation facility and were assessed after
same periods as experimental group.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top down.
Outcomes The study collected three types of outcomes:
(1) data scanning and attention skills: single target cancellation (three minutes letter H) and double target
cancellation (three minutes letters C & E), scores are average number of far left-sided omissions;
(2) Lightboard: point at light and say the colour, allowed 10 seconds, scores are average number of left-sided
omissions;
(3) ADL: avoidance of obstacles on wheelchair course, rated by two observers.
Assessed pre-intervention, after each phase (five days) and at follow up six weeks post discharge from hospital.
This review used only the cancellation data, immediate and persisting effects.
Notes NB. Single letter cancellation outcome data are entered as left-sided omissions (i.e. low score is better outcome)
Allocation concealment B – Unclear
Study Edmans 2000
Methods RCT: the recruiter used random number tables to prepare the group allocations for the 80 patients (see
Notes) in advance. They did not keep the random number tables, did not have access to them at the time of
recruitment and were highly unlikely to have been able to remember the allocations. Allocations were stored
in sealed, opaque, numbered envelopes, only opened at the time of recruitment in the presence of a witness.
Concealment of allocation is likely but cannot be guaranteed in the absence of third party randomisation.
The post-treatment assessor was blinded to allocation.
Quality of allocation concealment rated as A: adequate.
Participants UK.
42 (see Notes) stroke patients with visual neglect from those with general perceptual problems admitted to
an in-patient SU.
Exptl n = 24, cntrl n = 18.
Mean age (SD): exptl 69.17 yrs (11.35), cntrl 66.61yrs (14.5).
Sex (m/f ): exptl 10/14, cntrl 8/10.
Mean time post-onset: 37 days.
16Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Inclusion: a subset of those with neglect from those with general perceptual problems from those consecutive
admissions to a stroke unit trial. SU trial criteria were: medically stable, able to transfer with maximum two
nurses, no discharge date planned, able to tolerate 30 minute treatments, able to carry out some independent
ADLs pre-stroke.
Interventions ToT approach to treat the ’cause of the perceptual problem’. The underlying assumption is that practising
a perceptual task will treat the underlying impairment and if successful will improve performance of other
tasks which depend on the skills. Personal communication suggested that cueing and feedback were used to
teach participants to compensate
versus
FA to treat the ’symptom rather than the cause’ and involved practising ADL tasks.
Both groups received 2.5 hrs per week for six weeks in addition to standard OT.
(NB. ToT is coded as exptl in this review.)
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top down.
Outcomes The broader study of perceptual problems completed the following measures by different assessors immedi-
ately after the six weeks treatment: an independent blinded assessor completed the BI, Edmans ADL Scale,
and RPAB. This assessor completed the ADL scales following interviews with unblinded nursing staff. The
unblinded ward OT also completed the BI and Edmans ADL Scale. An unblinded physiotherapist com-
pleted the RMA gross motor score. Additionally assessments by other clinical staff were analysed: speech and
language therapists, psychologists, physiotherapists.
For comparability with other studies this review used only the RPAB letter cancellation subtest score (number
correctly cancelled) and the blinded assessor’s BI.
Notes Personal communication supplied further data and clarification of method. Authors provided unpublished
data on 42 neglect patients from a larger RCT of 80 left and right (35) hemisphere strokes with perceptual
problems which was itself taken from the stroke unit admission arm (n = 158) of a RCT of stroke unit versus
general medical care. No pre-randomisation differences between groups except that the ToT group were a
little longer post stroke (40/33 days) than the FA group.
Allocation concealment A – Adequate
Study Fanthome 1995
Methods RCT: sealed opaque envelopes prepared from random number tables. Concealment of allocation is unclear.
It cannot be guaranteed as randomisation was not done by a third party and may have been predictable given
the small numbers involved. Blinded assessor.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants UK.
18 (see Notes) RH stroke patients admitted to hospital.
Exptl n = 9, cntrl n = 9.
(The following data describe the 18 initial participants: see Notes.)
Mean age (SD): exptl 66.3 yrs (10.7), cntrl 71.1 yrs (7.6).
Sex (m/f ): exptl 6/3, cntrl 6/3.
Time post-onset (mean months): exptl 1.0, cntrl 0.6.
Inclusion: not blind; < 80 yrs of age; no history of dementia or psychiatric problems; not ill; right-handedness;
score > 6 on Abbreviated Mental Test; RH stroke; score < 130 on BIT.
Interventions Four weeks (2 hrs 40 mins/wk) feedback of eye movements (wearing specially adapted glasses with auditory
signal)
versus
four weeks no treatment.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top down.
17Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Outcomes The study collected three types of outcomes: eye movements, conventional BIT subtests and behavioural
BIT subtests, immediately post treatment (four weeks) and four weeks later (eight weeks).
For comparability with other studies this review used only the four week star, single letter and line cancellation
from the conventional BIT subtests, and the four and eight week BIT summary behavioural subtest scores.
Notes Personal communication supplied group data on BIT subtests for all but one control participant at four weeks
(missing data, therefore n = 18 - 1), and the information that assessor blinded to allocation. BIT behavioural
data are for all 18 at four weeks but only 13 at eight weeks. Eight weeks = post start of treatment, i.e. is a
four week follow up post end of treatment.
Single letter cancellation data are for number cancelled, i.e. higher numbers indicate better outcome.
Exptl and cntrl groups appeared adequately matched on demographic and clinical data although cntrl group
slightly older than exptl, no baseline BIT data.
Allocation concealment B – Unclear
Study Kalra 1997
Methods RCT: random permuted block technique in groups of 10 for pragmatic reasons of service and workload con-
siderations, allocation by telephone by clerical staff using computer generated random numbers, assessments
by blinded observer.
Quality of allocation concealment rated as A: adequate.
Participants UK.
50 (see Notes) stroke patients with visual neglect admitted to a SU.
The following data are for the 47 surviving patients.
Exptl n = 24, cntrl n = 23.
Mean age (SD): exptl 78 yrs (9), cntrl 76 yrs (10).
Sex (m): exptl 11, cntrl 9.
Side of damage (RBD): exptl 16, cntrl 17.
Median time post-onset (range): 6 days (2 to 14).
Inclusion: infarcts partial anterior circulation, known to be sensitive to rehabilitation on basis of impairments
of power, balance, proprioception and cognition at one to two weeks after stroke.
Exclusion: TIAs, reversible neurological deficits, hemianopsia or severe dysphasia.
Interventions Spatio-motor cueing based on ’attentional-motor integration’ model and early emphasis on restoration of
function
versus
conventional therapy input concentrating on restoration of tone, movement pattern and motor activity before
addressing skilled functional activity.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as bottom up.
Outcomes The study collected six types of outcomes:
(1) mortality;
(2) BI at discharge;
(3) discharge destination;
(4) length of hospital stay;
(5) duration of therapy input;
(6) RPAB after 12 weeks.
This review used only the BI, RPAB letter cancellation subtest, and discharge home. These were all analysed
as immediate effects.
Notes Principle behind approach: movements of affected limb in the deficit hemispace led to summation of acti-
vation of affected receptive fields of two distinct but linked spatial systems for personal and extrapersonal
space resulting in improvements in attentional skills and appreciation of spatial relationships on the affected
side. Personal communication supplied further data and clarification of method.
No difference between groups on demographic variables or initial impairment or disability including BI.
18Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Outcome data on 47 of 50 stroke patients with visual neglect admitted to a SU: exptl n = 24 (+1 died), cntrl
n = 23 (+2 died). For the ’destination discharge’ outcome the total figure of 50 was used in this review as
deaths were entered as not going home.
Allocation concealment A – Adequate
Study Robertson 1990
Methods RCT: random allocation of patients to conditions with blocks of severe versus mild neglect patients. Ran-
domisation was carried out by a third party. The authors confirmed that outcome assessors were blinded to
allocation.
Quality of allocation concealment rated as A: adequate.
Participants UK.
30 (see Notes) in-patients of Edinburgh hospitals who showed left visual field neglect on BIT.
Exptl n = 17, cntrl n = 13.
(The following data describe the 36 initial participants: see Notes.)
Mean age (SD): exptl 64.2 yrs (12.6), cntrl 63.1 yrs (9.6).
Sex (m/f ): exptl 9/11, cntrl 10/6.
Onset of neglect (SD): exptl 19.2 wks (21.1), cntrl 10.8 wks (6.3).
Inclusion: presence of neglect (failure on at least 3/9 behavioural tests), oriented for time and place, ability
to consent, ability to concentrate sufficiently to sit at computer-based task for at least 15 mins.
Interventions 15.5 hrs (14 sessions of 75 mins each, 2 x wk for 7 wks) computerised scanning and attentional training
(intensive briefing about nature of participants problems, feedback on left and right latencies, trainer rein-
forcement and encouragement
versus
11.4 hrs recreational computing (to minimise scanning and timed attentional tasks, without any potential
neuropsychological mechanism to improve cognitive function, but exposed to computer activities such as
games, quizzes and simple logical games).
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top down.
Outcomes The study collected several types of outcomes:
(1) BIT;
(2) WAIS-R subtests (Picture Completion and Block Design);
(3) Neale Reading test;
(4) letter cancellation;
(5) observer’s report of neglect;
(6) Rey CFT (copy only).
The BIT was the principal outcome measure. (Although not explicitly stated it is assumed from the description
on page 664 and the low scores in Table 2 that only the BIT behavioural subtests were given.) The outcomes
were given immediately after training and after six months. The study also collected data on several other
tests including the GHQ and the FAI to ensure matching of groups (see Notes).These were collected at each
timepoint.
This review used only the letter cancellation (error score), and BIT, immediately and after six months.
Notes This review entered n = 30 of initial 36 (33 with CVA, 2 HI, 1 had surgery for excision of meningioma). 3/36
not followed up immediately and 9/36 not seen at six months but no information on which group these were
from so data entered to this review subtracted three and nine from each group at first (n = 30) and second
assessments respectively. Information on allocation concealment provided by personal communication. Six
months follow up.
Exclusion: patients with BIT score > 70.
Cancellation data reported as errors rather than correct performance.
The review could not include the FAI data as these were not reported.
Allocation concealment A – Adequate
19Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Study Robertson 2002
Methods RCT: 1:1 randomisation. Author confirmed recruiters could not have been aware of likely allocations but
concealment of allocation cannot be guaranteed as randomisation was not done externally. Outcome assessors
were blinded.
Quality of allocation concealment rated as A: adequate.
Participants UK.
40 randomised but 36 seen for immediate outcome assessment (see Notes), recruited from London hospital
and community rehabilitation teams, had left visual neglect on cancellation or bisection tests.
(The following data describe the initial 40 participants: see Notes.)
Exptl n = 19, cntrl n = 21.
Mean age (SD): exptl 69.3 yrs (9), cntrl 67 yrs (9.4).
Sex (m/f ): exptl 13/6, cntrl 16/5.
Onset of neglect (SD): exptl 152.8 days (142.4), cntrl 152.1 days (117.9).
Inclusion: right hemisphere stroke, aged under 80, right-handed, no history of major psychiatric/disease/
disability that would prevent participation or contaminate results.
Interventions LAT wearing (on the wrist/leg/shoulder) an active limb activation device during perceptual training. The
device emitted an auditory tone if no left-sided movement was made
versus
perceptual training wearing an inactive (no tone) limb activation device.
Both groups received training at their residence (usually own home) for 12 weeks for approximately 45
mins/wk.
The perceptual training for both groups involved working on visuoperceptual puzzles and reading tasks
which implicitly but not explicitly involved advice to scan to the left.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as bottom up.
Outcomes The study collected three types of outcomes:
(1) BI/Nottingham EADL;
(2) Bergego rating scale of neglect;
(3) Motricity index (total left body side) at four time points: immediately post-training, three months, six
months, 18 to 24 months. In addition the BIT, Comb and Razor personal neglect test, and the modified
Landmark test were given at the first three timepoints.
For comparability with other studies this review used only the following outcome/timepoints: BI immediate
and six months.
Notes Attrition: 36/40 followed up immediately (exptl 17, cntrl 19); 32 at 6 months, 26 at 18 to 24 months.
Groups appeared appropriately matched for demographic and clinical baseline variables.
No information on n per group at six months. Know four lost but not whether all were from a single group
so assumed worst case and subtracted four per group, i.e. conservative sample estimate of 28 not 32.
Allocation concealment A – Adequate
Study Rossi 1990
Methods RCT: no further information provided. Only the Tangent Screen Examination outcomes were assessed
blinded.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants USA.
39 stroke patients from an in-patient stroke rehabilitation unit with HHA or VN.
Exptl n = 18, cntrl n = 21.
Mean age: exptl 72.6 yrs, cntrl 63.3 yrs.
Sex (m/f ): exptl 10/8, cntrl 9/12.
Mean weeks post-stroke: exptl 4.4, cntrl 4.7.
Side of stroke (right/left): exptl 16/2, cntrl 13/8.
20Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Lesion type (infarct/haemorrhage): exptl 15/3, cntrl 18/3.
Inclusion: patients free of disabling cardiac pulmonary or rheumatological problems, HHA determined by
inability to detect 1 cm red target on tangent screen examination, VN defined as inability to detect bilateral
tachistoscopically presented targets using HFVS.
HHA/VN: exptl 12/6, cntrl 15/6.
Exclusion: patients with best-corrected visual acuity worse than 20/200; inability to comprehend and co-
operate with assessments.
Interventions 15-diopter plastic press-on fresnel prisms (cut to a half circle, to fit on the inside of spectacle lenses, overlaying
the affected hemi-field with the base of the prism towards the affected field to produce an intended effect of
shifting a peripheral image more towards the centre) worn for all daytime activities
versus
no prism treatment.
Both groups received routine rehabilitation programmes including ADL training and table-top visual per-
ception retraining tasks.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as bottom up.
Outcomes The study collected eight types of outcomes:
(1) Modified MMSE;
(2) MVPT;
(3) Line bisection;
(4) Line cancellation;
(5) HFVS;
(6) Tangent Screen Examination;
(7) BI;
(8) frequency of falls.
Outcomes were assessed at baseline, two weeks and four weeks. This review used only line bisection, line
cancellation and the BI. The four week outcome data were used. However, as prisms were still being used at
that time this review analysed them as ’immediate’ rather than ’persisting’ effects.
Notes Clarification of randomisation procedure sought but not obtained.
Cntrl group younger but otherwise groups were similar on demographic and clinical background factors
including BI.
Data for VN subgroup not reported separately to HHA subgroup therefore all outcome data in this review
are for VN and HHA combined. The authors report that the HHA diagnosis precluded a diagnosis of neglect
and that patients with either HHA or VN who were treated with prisms showed equal improvement.
The prism group wore their prisms during outcome assessments.
Cancellation data reported as errors rather than correct performance. Line bisection scores are errors in cms
from the middle.
SEM data converted to SD for analysis.
Allocation concealment B – Unclear
Study Rusconi 2002
Methods RCT: randomised into Type 1 or Type 2, stratified by TENS or no TENS. Randomisation performed by
researcher. Allocations stored in sequentially numbered, sealed, opaque, envelopes. The outcome assessor
was blinded to allocation. Concealment of allocation is unlikely. It cannot be guaranteed as randomisation
was not done by a third party and may have been predictable given the small numbers involved.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants Italy.
24 randomised (see Notes) but outcome data collected on 20.
(The following data describe the 20 participants.)
Exptl n = 12, cntrl n = 8 (exptl = Type 1 and cntrl is Type 2: see Interventions).
Mean age: exptl 69.8 yrs, cntrl 65.1 yrs.
21Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
Sex (m/f ): exptl 5/7, cntrl 3/5.
Mean weeks post-stroke: exptl 6.92, cntrl 8.38.
Inclusion: unilateral right hemisphere stroke assessed by CT scan, right-handed, symptoms of unilateral
neglect, admitted to hospital for rehabilitation five weeks post-stroke.
Exclusion: dementia.
Interventions The study compared more than two interventions. First there is a comparison of two types of cognitive
training: Type 1 versus Type 2. Each ’type’ is then subdivided into whether or not TENS is added (see Notes).
Type 1 versus Type 2: both consist of five one hour sessions per week for two consecutive months (40 sessions)
using four procedures requiring the patient to actively scan the visual field (reading sentences and stories, line
drawing on a dot matrix, assembling 3D cubes, matching cards containing the name and the visual image
of an object. Type 1 and 2 differed in that only Type 1 involved verbal and visuo-spatial cueing and verbal
feedback. Although Type 2 used the same four procedures it did not involve cueing or feedback, i.e. the
aspects of the training designed to improve awareness and encourage compensation.
For this review Type 1 was classed as a top-down approach and Type 2 as an attention control.
Outcomes Assessments were classified as ’functional and neurological’ (i.e. BI, standard clinical neurological exami-
nation) or ’neuropsychological’ (i.e. line cancellation, letter cancellation, line bisection, sentence reading,
O’clock test, judgement of drawings, anosognosia, RCPM, facial recognition, position deficit).
These were taken at four timepoints: on admission for neurorehabilitation at least five weeks post-stroke
(T0), one month later (T1) after which eligibility was determined and participants were randomised, after
one month of intervention (T2) and after two months of intervention (T3).
For comparability with other studies this review used only the T3 letter cancellation, line bisection and BI.
As intervention continued for two months T3 is coded in this review as ’immediate’ effects.
Notes Author provided clarification and raw data by personal communication.
24 people were randomised: 12 to Type 1 and 12 to Type 2. The authors excluded four from the final
evaluation because of a ’clinical worsening that prevented the conclusion of the treatment’. These four were
all allocated to Type 2.
Cancellation scores were for the number correctly cancelled. Separate scores were given for left and right
space but this review used the total score. Line bisection data were for mean deviation in mm left (negative)
or right (positive) or the midpoint. Line cancellation data could not be used as the exptl group’s SD was zero.
Allocation concealment B – Unclear
Study Weinberg 1977
Methods RCT: no further information provided.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants USA.
25 (see Notes) stroke rehabilitation in-patients.
Exptl n = 14, cntrl n = 11.
(The following data describe the 57 initial participants: see Notes.)
Mean age (SD): exptl 61.5 yrs (9.84), cntrl 65.7 yrs (10.92).
Onset of testing (wks): exptl 9.9, cntrl 10.53.
Interventions 20 hrs visual training (1 hr each day for 4 wks in reading, writing and calculation)
versus
no visual training (but received OT as part of general rehab program).
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top down.
Outcomes The study collected three types of outcomes:
(1) closest to the area being trained (WRAT, simple arithmetic, paragraph reading, copying a name & address);
(2) training related tasks (single and double letter cancellation H & C-E);
(3) related tasks (counting faces, matching faces, WAIS Digit Span, Object Assembly, Picture Completion,
confrontation, motor impersistence and simultaneous stimulation). Outcomes assessed after one month, i.e.
immediate effects.
22Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
This review used only the single and double letter cancellation.
Notes Hypothesises that neglect underlies visual perceptual problems.
Exptl and cntrl groups appeared similar in age, two of exptl group had ’aberrantly long times since onset’.
Groups divided into RBD severe and RBD mild.
No reply to request for clarification of randomisation procedure and other outcome measures.
57 patients reported but outcome data reported separately for severe and mild RBD groups and only severe
data (n = 25) entered in this review, exptl 14 and cntrl 11.
Cntrl group better than exptl on single letter cancellation at baseline. No difference in double letter cancel-
lation or digit span.
Allocation concealment B – Unclear
Study Wiart 1997
Methods RCT: randomisation table, no further information on concealment.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants France.
22 people within three months onset of stroke and severe left unilateral neglect, hospitalised in two neurore-
habilitation hospitals, positive for neglect on three tests (see Outcomes).
Exptl n = 11, cntrl n = 11.
Mean age: exptl 66 yrs, cntrl 72 yrs.
Sex (m/f ): exptl 6/5, cntrl 6/5.
Time post onset (mean days): exptl 35, cntrl 30.
Exclusions: history of stroke, alteration of general status, or cognitive difficulties incompatible with rehabil-
itation.
Interventions One hr per day for 20 days of experimental treatment followed by traditional rehabilitation (one to two
hrs physiotherapy and one hr OT). Experimental treatment is Bon Saint Come method: patient wears a
thoracolumbar vest with attached metal pointer above head, patient points to target on mobile wooden panel,
audible and luminous signals provide biofeedback effect when targets are touched. Initially conducted when
sitting, this progresses to standing, the therapist participates actively during the session, stimulating, guiding
and correcting
versus
three to four hrs traditional rehabilitation per day.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as top-down.
Outcomes The study collected two types of outcomes:
(1) quantitative assessment of neglect (line bisection, line cancellation, bell cancellation);
(2) autonomy (FIM).
These assessments were conducted three times: day 0, day 30 (after therapy) and day 60.
This review used only the data from line cancellation, line bisection and FIM. Both the 30 day (immediate)
and 60 day (persisting) data were used in this review.
Notes The paper consists of two studies. These data refer to Study 1 only.
The exptl group were younger and had a higher initial FIM score (66) than the cntrl group (54).
Cancellation data reported as errors rather than correct performance. Only one set of cancellation data (lines
not bells) were entered in this review to avoid entering the same group of patients twice into the meta analysis.
Line bisection scores are % deviation to right.
Cntrl group had more, but not significantly so, omissions on line cancellation (cntrl 16, exptl 14) and right
deviations on line bisection (cntrl 53%, exptl 50%) at baseline compared with exptl group.
Allocation concealment B – Unclear
Study Zeloni 2002
Methods RCT: for the first eight participants group allocation was performed by randomly selecting a label from a
pre-printed set of eight (see Notes). The label preparation was performed by a member of the trial team but
23Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of included studies (Continued )
the selection was performed by a student who had no previous or later involvement in the trial. Although
the allocation was done externally the method used did not permit verification. The post-treatment assessor
was blinded to allocation.
Quality of allocation concealment rated as B/C: unclear/inadequate.
Participants Italy.
8 randomised (see Notes).
Exptl n = 4, cntrl n = 4.
Mean age: exptl 68.8 yrs, cntrl 76.3 yrs.
Sex (m/f ): exptl 4/0, cntrl 2/2.
Mean months post stroke: exptl 11.25, cntrl 4.5.
Inclusion: ’post-acute’ patients with right hemisphere vascular lesions and neglect, admitted to hospital,
right-handed, left hemiplegic.
Exclusions: normally wore glasses.
Interventions Wearing plastic goggles for one week, only removing them to go to sleep. The right side of each lens was
blinded
versus
no goggles.
All eight participants were involved in the hospital’s daily activities including the hospital’s usual treatment
for neglect, tasks to train compensation for faulty scanning.
For analysis of bottom-up and top-down rehabilitation approaches this review coded the experimental con-
dition as bottom up.
Outcomes Participants were assessed on three occasions: at recruitment, after the experimental group had received one
week of hemiblinding goggles, and again one week after the goggle treatment ended. Controls were assessed
at the same timepoints but never wore the hemiblinding goggles. Testing was performed without goggles.
The outcomes used were: line, letter and bell cancellation, copy drawing, line bisection.
For comparability with other studies this review used: line, letter and bell cancellation, line bisection and
line bisection scores at the third timepoint. As this was only one week after intervention it is coded in this
review as ’immediate’ effects. Letter cancellation data were analysed as single letter cancellation.
Notes Personal communication from the authors confirmed the methods used and provided data. The eight ran-
domised participants are numbers 1 to 4 in the treatment and control group as listed in the authors’ Table
1, page 196. The original study recruited eleven participants. The first eight were randomised as described
above. The other three were non-randomly added to the groups (one to treatment and two to control). This
review only used the eight randomised participants.
Cancellation tests were scored as number correct. Line bisection was scored as percent correct decreasing for
rightward deviation. Authors provided raw data (percentages) for the eight participants on line bisection.
The mean (SD) were: exptl 62.5 (35.2), cntrl 73.8 (22.2). For comparability with other studies this review
reversed the line bisection scoring so that a low score favours the experimental group.
Allocation concealment B – Unclear
ADL: activities of daily living
BI: Barthel Index
BIT: Behavioural Inattention Test
cm: centimetre
Cntrl: control
CT: computerised tomography
CVA: cerebrovascular accident
Exptl: experimental
FA: functional approach
FAI: Frenchay Activities Index
FIM: Functional Independence Measure
GHQ: General Health Questionnaire
HFVS: Harrington Flocks Visual Screener
HHA: homonymous hemianopia
24Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
HI: head injury
hrs: hours
LAT: limb activation training
mins: minutes
mm: millimetre
MMSE: Mini Mental Status Exam
MVPT: Motor Free Visual Perception Test
Nottingham EADL: extended ADL index
OT: occupational therapy/therapist
RBD: right brain damage
RCPM: Raven’s Coloured Progressive Matrices
RCT: randomised controlled trial
Rey CFT: Rey Osterreith Complex Figure Test
RH: right hemisphere
RMA: Rivermead Motor Assessment
RPAB: Rivermead Perceptual Assessment Battery
SD: standard deviation
SU: stroke unit
TENS: transcutaneous electrical nerve stimulation
TIA: transient ischaemic attack
ToT: transfer of training
VN: visual neglect
WAIS-R: Revised Weschler Adult Intelligence Scale
wk: week
WRAT: Wide Range Achievement Test
yrs: years
Characteristics of excluded studies
Study Reason for exclusion
Al Mahasneh 1991 Extreme difficulties with recruitment and participant attrition. 14 participants with neglect consented. These
were unevenly assigned to the experimental (9) and control (5) groups. Only five participants completed three
weeks of treatment. Reviewers did not feel the data were adequate for meta-analysis, e.g. missing data and no
SDs.
Beis 1999 Controlled trial but not RCT: allocation by fixed order of presentation of participants i.e. first to group 1, second
to group 2, etc. Outcome assessors were blinded to allocation. Personal communication provided FIM data,
confirmed allocation method, and that assessments were carried out by two blinded researchers.
Butter 1992 Clarification of randomisation sought but not obtained. Appropriate results (means and SDs) not reported.
Review authors were not sure that the trial was actually evaluating a treatment for spatial neglect.
Carter 1980 Clarification of randomisation sought but not obtained. Separate data for stroke patients also requested but not
obtained. Appropriate data (means, SDs) not reported.
Diller 1974 Reported data inadequate for review. No reply to our letter of 9 February 1999 asking for difficult-to-extract data.
Frassinetti 2002 Controlled clinical trial: non-random allocation (n = 13). Controls at different hospital. Assessment of outcome
not clear (probably non-blind).
Gordon 1985 Controlled trial: quasi-randomisation based on rehabilitation service to which patient was assigned. Experimental
and control conditions alternated every six months between the two services. Not randomised.
Harvey 2003 Controlled trial: non-randomised, initial recruits allocated by date of admission to hospital ward, later recruits
allocated by attempting to match the groups on their scores on pre-intervention neglect assessments. Author
provided clarification and unpublished data by personal communication.
25Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of excluded studies (Continued )
Klos 2005 Personal communication from an expert in the field reported that Klos had completed an unpublished RCT of
prism adaptation therapy for neglect. Excluded from review as no reply to request for clarification of methods
and data. Will reconsider for inclusion in next update if further information becomes available.
Lincoln 1985 RCT of patients with general perceptual problems. Problems likely to have included neglect but this subgroup
could not be separately identified.
Loverro 1988 Controlled trial: reported as randomly assigned but allocation based on bed availability; outcome assessors blinded
to purpose of the study.
Niemeier 1998 Controlled trial: not randomised, selected in order of consecutive admissions and on documented left or right
neglect. No information on concealment.
Paolucci 1996 Controlled trial: abstract states randomly assigned but allocated on the basis of bed number (odd or even), bed
number had been assigned by Hospital Administration, odd numbers got immediate training, even numbers got
training after two months (delayed training), neglect screening assessment done after allocation by psychologist
unaware of purpose of study, outcome assessor blinded to the purpose of the study, after eight weeks the delayed
group received the training and the immediate group received the control treatment (broad cognitive stimulation).
Pizzamiglio 2004 Non-random controlled trial (n = 22): alternate allocation. Blind assessment of outcome on Barthel (functional
outcome).
Not clear if outcome assessed blind on impairment measures.
Rossetti 1998 Controlled trial: further data from author confirms it was not randomised. First six consecutive cases were allocated
to experimental group and next six to control. Outcome assessors were not blinded. The trial is the second of two
experiments reported in the paper.
Schindler 2002 Non-randomised cross-over controlled trial. First 10 patients were randomised to one of two groups but the data
on these 10 were not available at the time of this version of this review. It would be considered for inclusion at
the next update if the authors could provide the randomised data.
Tham 1997 Non-random controlled trial. First seven patients assigned to novel treatment group, second seven patients to
conventional treatment group.
Trudell 2003 A published abstract suggested this may be an eligible study. Excluded from review as no information with which
to confirm methods. Will re-consider for inclusion in next update if further information becomes available.
Webster 2001 Controlled clinical trial: 40 assigned, one excluded and matched patient excluded, n = 38. Twenty controls were
from a previous study, not simultaneous. Non-blind assessment of outcome. Wheelchair navigation (functional
measure) as outcome, no impairment measures.
Weinberg 1979 Clarification of randomisation procedure sought but not obtained, and unlikely to be given the age of this paper.
The timescale of publication (and a statement in the results) suggests the participants in this study were not in
the Weinberg 1977 study, however, this has not been confirmed by the authors. On the other hand the 1979
paper does not explicitly mention ’neglect’ and may instead be a trial of visual perception. Given the amount of
uncertainty about this study’s fit to the inclusion criteria, inability to obtain confirmation and clarification about
this old study, lack of detail on randomisation and concern to avoid duplicating data by including this and the
1977 paper we decided to exclude the 1979 paper from this version of the review.
Weinberg 1982 Confirmation regarding randomisation sought from trialist but not obtained. No SD reported.
Young 1983 Controlled trial: not randomised. Divided into three groups matched for age, education, time since onset and
degree of deficit: no further information provided other than assessor blinded to group’s membership.
FIM: Functional Independence Measure
RCT: randomised controlled trial
SD: standard deviation
Characteristics of ongoing studies
Study Kerkhoff 2005
Trial name or title Optokinetic rehabilitation of multimodal neglect
26Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Characteristics of ongoing studies (Continued )
Participants 32 patients between 1 and 34 months post-stroke, with left-sided multimodal neglect.
Interventions Optokinetic stimulation for five one-hour sessions
versus
’conventional’ visual scanning training with static stimuli.
Outcomes Digit cancellation, paragraph reading, visuoperceptual and motor line bisection > outcomes assessed twice
immediately after the fifth treatment and at a three week follow up.
Starting date Unknown
Contact information [email protected]
Notes Personal communication
Study Rossetti 2005
Trial name or title Unknown
Participants Unknown
Interventions Prism adaptation
Outcomes Unknown
Starting date Unknown
Contact information Yves Rossetti
Notes Author reported is currently running a double blind RCT.
Study Turton 2005
Trial name or title The effect of using prism adaptation treatment on performance of self care and mobility tasks in patients with
unilateral inattention following stroke
Participants Intended sample size of 40.
Interventions Prism goggles and adaptation training
versus
sham goggles.
Outcomes ADL task
Starting date 2004
Contact information Dr Ailie Turton
Dept of Experimental Psychology, University of Bristol, Bristol UK.
Notes Summary on funder’s website www.stroke.org.uk
ADL: activities of daily living
RCT: randomised controlled trial
27Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
A N A L Y S E S
Comparison 01. Cognitive rehabilitation versus any control: immediate effects
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Activities of Daily Living 6 206 Standardised Mean Difference (Random) 95%
CI
0.26 [-0.16, 0.67]
02 Cancellation: numbers correct Standardised Mean Difference (Random) 95%
CI
Subtotals only
03 Cancellation: numbers of errors 4 103 Standardised Mean Difference (Random) 95%
CI
-0.65 [-1.28, -0.01]
04 Line bisection: error scores/
right deviation
4 89 Standardised Mean Difference (Random) 95%
CI
-0.84 [-1.36, -0.33]
05 BIT behavioural subtests 3 52 Standardised Mean Difference (Random) 95%
CI
-0.27 [-0.84, 0.30]
06 Discharge destination (home) 1 50 Odds Ratio (Random) 95% CI 1.40 [0.45, 4.35]
07 A-rated studies only: Activities
of Daily Living
3 125 Standardised Mean Difference (Random) 95%
CI
0.16 [-0.36, 0.68]
08 A-rated studies only:
cancellation number correct
(single letter task)
2 89 Standardised Mean Difference (Random) 95%
CI
0.01 [-0.84, 0.86]
09 A-rated studies only:
cancellation errors
1 30 Standardised Mean Difference (Random) 95%
CI
0.01 [-0.72, 0.73]
10 A-rated studies only: BIT
behavioural subtests
1 30 Standardised Mean Difference (Random) 95%
CI
-0.34 [-1.07, 0.39]
Comparison 02. Cognitive rehabilitation versus any control: persisting effects
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Activities of Daily Living 2 50 Standardised Mean Difference (Random) 95%
CI
0.61 [-0.42, 1.63]
02 Cancellation: number correct Standardised Mean Difference (Random) 95%
CI
Subtotals only
03 Cancellation: number of errors 3 52 Standardised Mean Difference (Random) 95%
CI
-0.76 [-1.39, -0.13]
04 Line Bisection: error scores or
right deviation
1 22 Standardised Mean Difference (Random) 95%
CI
-1.09 [-2.00, -0.18]
05 BIT behavioural 2 31 Standardised Mean Difference (Random) 95%
CI
0.06 [-0.66, 0.78]
06 A-rated studies: Activities of
Daily Living
1 28 Standardised Mean Difference (Random) 95%
CI
0.12 [-0.62, 0.86]
07 A-rated studies only:
cancellation number of errors
1 18 Standardised Mean Difference (Random) 95%
CI
-0.19 [-1.14, 0.76]
08 A-rated studies only: BIT
behavioural
1 18 Standardised Mean Difference (Random) 95%
CI
-0.08 [-1.03, 0.87]
28Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Comparison 03. One type of cognitive rehabilitation versus standard care or attention control: persisting effects
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Activities of Daily Living 2 50 Standardised Mean Difference (Random) 95%
CI
0.61 [-0.42, 1.63]
Comparison 04. One cognitive rehabilitation approach versus another: persisting effects
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Activities of Daily Living 0 0 Standardised Mean Difference (Random) 95%
CI
Not estimable
Comparison 05. Bottom-up processing approaches versus any control: persisting effects
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Activities of Daily Living 1 28 Standardised Mean Difference (Random) 95%
CI
0.12 [-0.62, 0.86]
Comparison 06. Top-down processing rehabilitation approaches versus any control: persisting effects
Outcome titleNo. of
studies
No. of
participants Statistical method Effect size
01 Activities of Daily Living 1 22 Standardised Mean Difference (Random) 95%
CI
1.17 [0.25, 2.08]
I N D E X T E R M S
Medical Subject Headings (MeSH)
Cerebrovascular Accident [∗complications; rehabilitation]; ∗Cognitive Therapy; Perceptual Disorders [etiology; ∗rehabilitation]; Ran-
domized Controlled Trials; Sensation Disorders [etiology; rehabilitation]; ∗Space Perception
MeSH check words
Humans
C O V E R S H E E T
Title Cognitive rehabilitation for spatial neglect following stroke
Authors Bowen A, Lincoln NB
Contribution of author(s) Audrey Bowen designed the updated review, conducted the data collection and analysis and
prepared the final report.
Nadina Lincoln initiated and co-ordinated the review project, was the principal grant holder,
conducted data collection, confirmed the analysis and contributed to the final report.
Issue protocol first published 2002/2
Review first published 2002/2
Date of most recent amendment 19 January 2007
Date of most recent
SUBSTANTIVE amendment
19 January 2007
29Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
What’s New In this updated review we excluded several previously included non-randomised trials to
reduce bias. We added several new, or newly identified, randomised controlled trials resulting
in a review of 306 participants from 12 RCTs.
Date new studies sought but
none found
Information not supplied by author
Date new studies found but not
yet included/excluded
Information not supplied by author
Date new studies found and
included/excluded
04 July 2005
Date authors’ conclusions
section amended
Information not supplied by author
Contact address Dr Audrey Bowen
Senior Lecturer in Psychology (Speech & Language Therapy)
HCD, School of Psychological Sciences, Humanities Devas Street
University of Manchester
Oxford Road
Manchester
M13 9PL
UK
E-mail: [email protected]
Tel: +44 161 275 3401
Fax: +44 161 275 3373
DOI 10.1002/14651858.CD003586.pub2
Cochrane Library number CD003586
Editorial group Cochrane Stroke Group
Editorial group code HM-STROKE
G R A P H S A N D O T H E R T A B L E S
30Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.01. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 01
Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 01 Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Barthel Index
Edmans 2000 24 11.13 (3.95) 18 12.28 (4.11) 18.9 -0.28 [ -0.90, 0.33 ]
Kalra 1997 24 14.20 (3.70) 23 11.70 (4.20) 19.6 0.62 [ 0.04, 1.21 ]
Robertson 2002 17 13.10 (5.50) 19 12.60 (5.10) 17.9 0.09 [ -0.56, 0.75 ]
Rossi 1990 18 50.00 (21.20) 21 54.00 (22.91) 18.5 -0.18 [ -0.81, 0.45 ]
Rusconi 2002 12 56.58 (18.70) 8 48.25 (18.69) 12.7 0.43 [ -0.48, 1.33 ]
Subtotal (95% CI) 95 89 87.6 0.12 [ -0.24, 0.47 ]
Test for heterogeneity chi-square=5.74 df=4 p=0.22 I² =30.3%
Test for overall effect z=0.65 p=0.5
02 FIM
Wiart 1997 11 86.00 (23.00) 11 62.00 (14.00) 12.4 1.21 [ 0.29, 2.14 ]
Subtotal (95% CI) 11 11 12.4 1.21 [ 0.29, 2.14 ]
Test for heterogeneity: not applicable
Test for overall effect z=2.57 p=0.01
03 Other
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 106 100 100.0 0.26 [ -0.16, 0.67 ]
Test for heterogeneity chi-square=10.65 df=5 p=0.06 I² =53.0%
Test for overall effect z=1.21 p=0.2
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
31Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.02. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 02
Cancellation: numbers correct
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 02 Cancellation: numbers correct
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Single letter cancellation
Edmans 2000 24 23.08 (13.58) 18 28.83 (12.43) 21.5 -0.43 [ -1.05, 0.19 ]
Fanthome 1995 9 24.00 (12.09) 8 22.90 (14.30) 15.3 0.08 [ -0.87, 1.03 ]
Kalra 1997 24 37.20 (13.10) 23 30.10 (18.50) 22.3 0.44 [ -0.14, 1.02 ]
Rusconi 2002 12 95.00 (8.38) 8 86.63 (23.65) 16.0 0.50 [ -0.41, 1.41 ]
Weinberg 1977 14 92.21 (15.06) 11 50.75 (41.70) 16.3 1.35 [ 0.46, 2.24 ]
Zeloni 2002 4 16.90 (11.80) 4 7.50 (6.10) 8.7 0.87 [ -0.64, 2.38 ]
Subtotal (95% CI) 87 72 100.0 0.39 [ -0.13, 0.92 ]
Test for heterogeneity chi-square=11.85 df=5 p=0.04 I² =57.8%
Test for overall effect z=1.46 p=0.1
02 Double letter cancellation
Weinberg 1977 14 84.07 (17.81) 11 40.67 (28.84) 100.0 1.80 [ 0.85, 2.76 ]
Subtotal (95% CI) 14 11 100.0 1.80 [ 0.85, 2.76 ]
Test for heterogeneity: not applicable
Test for overall effect z=3.69 p=0.0002
03 Line cancellation
Fanthome 1995 9 28.90 (9.30) 8 26.30 (12.00) 54.5 0.23 [ -0.72, 1.19 ]
Zeloni 2002 4 32.00 (8.50) 41 20.30 (12.40) 45.5 0.94 [ -0.10, 1.99 ]
Subtotal (95% CI) 13 49 100.0 0.56 [ -0.15, 1.26 ]
Test for heterogeneity chi-square=0.97 df=1 p=0.32 I² =0.0%
Test for overall effect z=1.54 p=0.1
04 Shape cancellation (stars)
Fanthome 1995 9 33.60 (17.40) 8 34.30 (21.00) 68.7 -0.03 [ -0.99, 0.92 ]
Zeloni 2002 4 11.20 (8.90) 4 7.30 (9.00) 31.3 0.38 [ -1.03, 1.79 ]
Subtotal (95% CI) 13 12 100.0 0.09 [ -0.69, 0.88 ]
Test for heterogeneity chi-square=0.23 df=1 p=0.63 I² =0.0%
Test for overall effect z=0.24 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
32Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.03. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 03
Cancellation: numbers of errors
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 03 Cancellation: numbers of errors
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Cottam 1987 6 28.50 (28.20) 6 34.00 (10.80) 18.5 -0.24 [ -1.38, 0.90 ]
Robertson 1990 17 43.40 (30.40) 13 43.20 (28.30) 28.7 0.01 [ -0.72, 0.73 ]
Rossi 1990 18 2.40 (4.24) 21 9.80 (9.16) 30.2 -0.99 [ -1.66, -0.32 ]
Wiart 1997 11 4.00 (4.00) 11 12.00 (7.00) 22.7 -1.35 [ -2.29, -0.41 ]
Total (95% CI) 52 51 100.0 -0.65 [ -1.28, -0.01 ]
Test for heterogeneity chi-square=6.78 df=3 p=0.08 I² =55.7%
Test for overall effect z=2.00 p=0.05
-10.0 -5.0 0 5.0 10.0
Favours experimental Favours control
Analysis 01.04. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 04
Line bisection: error scores/right deviation
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 04 Line bisection: error scores/right deviation
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Rossi 1990 18 0.68 (0.85) 21 2.20 (2.29) 40.5 -0.84 [ -1.50, -0.18 ]
Rusconi 2002 12 4.27 (8.94) 8 17.87 (18.90) 23.5 -0.95 [ -1.90, 0.00 ]
Wiart 1997 11 17.00 (14.00) 11 45.00 (25.00) 23.9 -1.33 [ -2.27, -0.39 ]
Zeloni 2002 4 37.50 (35.20) 4 26.30 (22.25) 12.1 0.33 [ -1.07, 1.74 ]
Total (95% CI) 45 44 100.0 -0.84 [ -1.36, -0.33 ]
Test for heterogeneity chi-square=3.76 df=3 p=0.29 I² =20.1%
Test for overall effect z=3.20 p=0.001
-10.0 -5.0 0 5.0 10.0
Favours experimental Favours control
33Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.05. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 05
BIT behavioural subtests
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 05 BIT behavioural subtests
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Cherney 2002 2 59.00 (9.90) 2 41.00 (12.73) 1.1 0.90 [ -4.56, 6.37 ]
Fanthome 1995 9 37.60 (21.30) 9 42.90 (29.30) 37.7 -0.20 [ -1.12, 0.73 ]
Robertson 1990 17 52.00 (24.00) 13 59.90 (20.20) 61.2 -0.34 [ -1.07, 0.39 ]
Total (95% CI) 28 24 100.0 -0.27 [ -0.84, 0.30 ]
Test for heterogeneity chi-square=0.24 df=2 p=0.89 I² =0.0%
Test for overall effect z=0.94 p=0.3
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
Analysis 01.06. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 06
Discharge destination (home)
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 06 Discharge destination (home)
Study Experimental Control Odds Ratio (Random) Weight Odds Ratio (Random)
n/N n/N 95% CI (%) 95% CI
Kalra 1997 16/25 14/25 100.0 1.40 [ 0.45, 4.35 ]
Total (95% CI) 25 25 100.0 1.40 [ 0.45, 4.35 ]
Total events: 16 (Experimental), 14 (Control)
Test for heterogeneity: not applicable
Test for overall effect z=0.58 p=0.6
0.1 0.2 0.5 1 2 5 10
Favours control Favours experimental
34Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.07. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 07
A-rated studies only: Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 07 A-rated studies only: Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Barthel Index
Edmans 2000 24 11.13 (3.95) 18 12.18 (4.11) 33.5 -0.26 [ -0.87, 0.36 ]
Kalra 1997 24 14.20 (3.70) 23 11.70 (4.20) 35.0 0.62 [ 0.04, 1.21 ]
Robertson 2002 17 13.10 (5.50) 19 12.60 (5.10) 31.5 0.09 [ -0.56, 0.75 ]
Subtotal (95% CI) 65 60 100.0 0.16 [ -0.36, 0.68 ]
Test for heterogeneity chi-square=4.19 df=2 p=0.12 I² =52.2%
Test for overall effect z=0.61 p=0.5
02 FIM
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
03 Other
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 65 60 100.0 0.16 [ -0.36, 0.68 ]
Test for heterogeneity chi-square=4.19 df=2 p=0.12 I² =52.2%
Test for overall effect z=0.61 p=0.5
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
Analysis 01.08. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 08
A-rated studies only: cancellation number correct (single letter task)
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 08 A-rated studies only: cancellation number correct (single letter task)
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Edmans 2000 24 23.08 (13.58) 18 28.83 (12.43) 49.2 -0.43 [ -1.05, 0.19 ]
Kalra 1997 24 37.20 (13.10) 23 30.10 (18.50) 50.8 0.44 [ -0.14, 1.02 ]
Total (95% CI) 48 41 100.0 0.01 [ -0.84, 0.86 ]
Test for heterogeneity chi-square=4.03 df=1 p=0.04 I² =75.2%
Test for overall effect z=0.02 p=1
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
35Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 01.09. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 09
A-rated studies only: cancellation errors
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 09 A-rated studies only: cancellation errors
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Robertson 1990 17 43.40 (30.40) 13 43.20 (28.30) 100.0 0.01 [ -0.72, 0.73 ]
Total (95% CI) 17 13 100.0 0.01 [ -0.72, 0.73 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.02 p=1
-10.0 -5.0 0 5.0 10.0
Favours experimental Favours control
Analysis 01.10. Comparison 01 Cognitive rehabilitation versus any control: immediate effects, Outcome 10
A-rated studies only: BIT behavioural subtests
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 01 Cognitive rehabilitation versus any control: immediate effects
Outcome: 10 A-rated studies only: BIT behavioural subtests
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Robertson 1990 17 52.00 (24.00) 13 59.90 (20.20) 100.0 -0.34 [ -1.07, 0.39 ]
Total (95% CI) 17 13 100.0 -0.34 [ -1.07, 0.39 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.92 p=0.4
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
36Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 02.01. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 01
Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 01 Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Barthel Index
Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 53.5 0.12 [ -0.62, 0.86 ]
Subtotal (95% CI) 13 15 53.5 0.12 [ -0.62, 0.86 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.32 p=0.8
02 FIM
Wiart 1997 11 93.00 (23.00) 11 69.00 (16.00) 46.5 1.17 [ 0.25, 2.08 ]
Subtotal (95% CI) 11 11 46.5 1.17 [ 0.25, 2.08 ]
Test for heterogeneity: not applicable
Test for overall effect z=2.49 p=0.01
03 Other
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 24 26 100.0 0.61 [ -0.42, 1.63 ]
Test for heterogeneity chi-square=3.01 df=1 p=0.08 I² =66.8%
Test for overall effect z=1.16 p=0.2
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
37Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 02.02. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 02
Cancellation: number correct
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 02 Cancellation: number correct
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N
Mean(SD) N
Mean(SD) 95% CI (%) 95% CI
01 Single letter cancellation
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
02 Double letter cancellation
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
03 Line cancellation
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
04 Shape cancellation (stars)
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
Analysis 02.03. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 03
Cancellation: number of errors
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 03 Cancellation: number of errors
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Cottam 1987 6 23.30 (17.70) 6 44.80 (23.40) 23.7 -0.96 [ -2.18, 0.27 ]
Robertson 1990 11 20.00 (16.40) 7 23.10 (14.50) 37.1 -0.19 [ -1.14, 0.76 ]
Wiart 1997 11 3.00 (4.00) 11 10.00 (7.00) 39.2 -1.18 [ -2.10, -0.26 ]
Total (95% CI) 28 24 100.0 -0.76 [ -1.39, -0.13 ]
Test for heterogeneity chi-square=2.30 df=2 p=0.32 I² =12.9%
Test for overall effect z=2.38 p=0.02
-10.0 -5.0 0 5.0 10.0
Favours experimental Favours control
38Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 02.04. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 04
Line Bisection: error scores or right deviation
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 04 Line Bisection: error scores or right deviation
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Wiart 1997 11 16.00 (14.00) 11 39.00 (25.00) 100.0 -1.09 [ -2.00, -0.18 ]
Total (95% CI) 11 11 100.0 -1.09 [ -2.00, -0.18 ]
Test for heterogeneity: not applicable
Test for overall effect z=2.36 p=0.02
-10.0 -5.0 0 5.0 10.0
Favours experimental Favours control
Analysis 02.05. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 05
BIT behavioural
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 05 BIT behavioural
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Fanthome 1995 7 45.10 (19.00) 6 39.00 (26.00) 42.8 0.25 [ -0.84, 1.35 ]
Robertson 1990 11 60.10 (18.60) 7 61.80 (21.50) 57.2 -0.08 [ -1.03, 0.87 ]
Total (95% CI) 18 13 100.0 0.06 [ -0.66, 0.78 ]
Test for heterogeneity chi-square=0.20 df=1 p=0.65 I² =0.0%
Test for overall effect z=0.17 p=0.9
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
39Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 02.06. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 06 A-
rated studies: Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 06 A-rated studies: Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Barthel index
Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 100.0 0.12 [ -0.62, 0.86 ]
Subtotal (95% CI) 13 15 100.0 0.12 [ -0.62, 0.86 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.32 p=0.8
02 FIM
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
03 Other
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 13 15 100.0 0.12 [ -0.62, 0.86 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.32 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
Analysis 02.07. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 07 A-
rated studies only: cancellation number of errors
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 07 A-rated studies only: cancellation number of errors
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Robertson 1990 11 20.00 (16.40) 7 23.10 (14.50) 100.0 -0.19 [ -1.14, 0.76 ]
Total (95% CI) 11 7 100.0 -0.19 [ -1.14, 0.76 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.39 p=0.7
-10.0 -5.0 0 5.0 10.0
Favours experimental Favours control
40Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 02.08. Comparison 02 Cognitive rehabilitation versus any control: persisting effects, Outcome 08 A-
rated studies only: BIT behavioural
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 02 Cognitive rehabilitation versus any control: persisting effects
Outcome: 08 A-rated studies only: BIT behavioural
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
Robertson 1990 11 60.10 (18.60) 7 61.80 (21.50) 100.0 -0.08 [ -1.03, 0.87 ]
Total (95% CI) 11 7 100.0 -0.08 [ -1.03, 0.87 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.17 p=0.9
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
Analysis 03.01. Comparison 03 One type of cognitive rehabilitation versus standard care or attention control:
persisting effects, Outcome 01 Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 03 One type of cognitive rehabilitation versus standard care or attention control: persisting effects
Outcome: 01 Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Barthel Index
Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 53.5 0.12 [ -0.62, 0.86 ]
Subtotal (95% CI) 13 15 53.5 0.12 [ -0.62, 0.86 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.32 p=0.8
02 FIM
Wiart 1997 11 93.00 (23.00) 11 69.00 (16.00) 46.5 1.17 [ 0.25, 2.08 ]
Subtotal (95% CI) 11 11 46.5 1.17 [ 0.25, 2.08 ]
Test for heterogeneity: not applicable
Test for overall effect z=2.49 p=0.01
Total (95% CI) 24 26 100.0 0.61 [ -0.42, 1.63 ]
Test for heterogeneity chi-square=3.01 df=1 p=0.08 I² =66.8%
Test for overall effect z=1.16 p=0.2
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
41Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 04.01. Comparison 04 One cognitive rehabilitation approach versus another: persisting effects,
Outcome 01 Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 04 One cognitive rehabilitation approach versus another: persisting effects
Outcome: 01 Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N
Mean(SD) N
Mean(SD) 95% CI (%) 95% CI
01 Barthel Index
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
02 FIM
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
03 Other
Subtotal (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
Total (95% CI) 0 0 0.0 Not estimable
Test for heterogeneity: not applicable
Test for overall effect: not applicable
-10.0 -5.0 0 5.0 10.0
Favours control Favours experiment
Analysis 05.01. Comparison 05 Bottom-up processing approaches versus any control: persisting effects,
Outcome 01 Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 05 Bottom-up processing approaches versus any control: persisting effects
Outcome: 01 Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
01 Barthel Index
Robertson 2002 13 13.60 (14.50) 15 12.30 (5.10) 100.0 0.12 [ -0.62, 0.86 ]
Total (95% CI) 13 15 100.0 0.12 [ -0.62, 0.86 ]
Test for heterogeneity: not applicable
Test for overall effect z=0.32 p=0.8
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
42Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd
Analysis 06.01. Comparison 06 Top-down processing rehabilitation approaches versus any control: persisting
effects, Outcome 01 Activities of Daily Living
Review: Cognitive rehabilitation for spatial neglect following stroke
Comparison: 06 Top-down processing rehabilitation approaches versus any control: persisting effects
Outcome: 01 Activities of Daily Living
Study Experimental Control Standardised Mean Difference (Random) Weight Standardised Mean Difference (Random)
N Mean(SD) N Mean(SD) 95% CI (%) 95% CI
02 FIM
Wiart 1997 11 93.00 (23.00) 11 69.00 (16.00) 100.0 1.17 [ 0.25, 2.08 ]
Total (95% CI) 11 11 100.0 1.17 [ 0.25, 2.08 ]
Test for heterogeneity: not applicable
Test for overall effect z=2.49 p=0.01
-10.0 -5.0 0 5.0 10.0
Favours control Favours experimental
43Cognitive rehabilitation for spatial neglect following stroke (Review)
Copyright © 2007 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd