Unilateral Neglect: A More Complete View
For my second Neuro Note assignment, I chose to listen to a podcast titled, Unilateral Neglect, by occupational therapists, Jessica Kersey and Natalie Barnes. The podcast gave insight into what unilateral neglect is, how it affects occupations, and how occupational therapists can help clients overcome the difficulties associated with unilateral neglect after stroke. I decided to dive deeper into this topic for a few reasons: (1) I recently participated in my first simulation experience via Telehealth with a patient who suffered from unilateral neglect post-stroke, (2) a family friend (of a friend) in his early 50's was impacted by a massive stroke 2 weeks ago, so I am currently following along with his journey on social media, and (3) stroke and unilateral neglect are topics covered on my upcoming Neuro-Aspects exam. Below is my take-away from the podcast, as well as the reference for others to listen and learn along with me, if interested.
Jess and Natalie defined unilateral neglect as, "the failure to report, respond to, or orient to contralateral stimuli that is not caused by a specific sensory or motor deficit." In lay terms, unilateral neglect is a disorder that impacts an individual's perception on one side of the body. Typically, this phenomenon occurs after a stroke, when there has been damage to the brain. The brain works in mysterious ways: one of these ways is that the right side of the brain controls what's happening on the left side of the body, and vice versa. So, if a person experiences brain damage on the right side, there is a possibility (approximately a 30% chance, according to the podcast) that the person will experience neglect on the left side. Neglect usually refers to a lack of sensation and attention. The individual may not notice a person standing to their left, may not eat the food on the left side of their plate, or may not even believe that their left arm belongs to them. The range of symptoms I've just described depends on the type of neglect experienced.
There are three types of neglect: personal neglect (failure to process sensory stimuli on the affected side of the body, like the patient's own arm), peri-personal neglect (failure to process stimuli in the near environment on the affected side, like the food on the left side of the dinner plate), and extra-personal neglect (failure to respond to stimuli in the larger surrounding environment on the affected side, like a person or wheelchair on that side of the hallway). It is possible to have one, two, or all three types of neglect. In any situation, neglect contributes to a high risk for injury and is associated with poor functional ability in ADLs, iADLs, and community mobility. In cases of extra-personal neglect, community mobility could be especially dangerous because of failure to process road signs, cars, people, or even various aisles at the grocery store.
Occupational therapy has an important role in rehabilitation and education of compensatory strategies in cases of unilateral neglect. Initially, the OT will do an assessment or screening to determine if the client is experiencing unilateral neglect. Often, this screening includes the client being instructed to draw a clock, a man, or another symmetrical object. If the drawing is incomplete or asymmetrical, neglect is likely an issue. This tool is helpful and quick, but it only tests for peri-personal neglect and gives limited information about the client's ability to perform functional skills. Of course, there are other tests that can be used, and more information about standardized assessments is available on the Glass Half Full website on the Unilateral Neglect podcast web page below.
After the screening has taken place, restorative approaches can be implemented in the acute phase of unilateral neglect. For example, the client can be referred to a neuro-optometrist who would prescribe prism glasses. The glasses have a prism on the non-neglect side to shift the client's attention to the neglected side. The client could also undergo visual scanning training, which involves repetitive scanning to the affected side that is targeted toward a specific object during a functional task. For example, the client could scan for forks on the left side of the silverware drawer.
Occupational therapists also provide the client with compensatory strategies for living with unilateral neglect. One example is teaching the client to have an "anchor," or a visual cue that lets them know when they have scanned completely. This may be the very far edge of their plate, or a red line on the far left side of the newspaper to facilitate attention to the whole page. Environmental modifications can also be implemented to support the client and facilitate attention on the neglected side. This could involve talking to the client on the affected side or placing his/her phone and television on the affected side. Hopefully, these stimuli would act as motivational cues to look and attend in the neglected direction. No matter what intervention is used, repetition is key for improvement in functional outcomes. It is vital for the care team and family to use a consistent approach.
I am thankful for the opportunity to learn from this podcast-- it has really helped me have a more complete view of unilateral neglect.
Jess and Natalie defined unilateral neglect as, "the failure to report, respond to, or orient to contralateral stimuli that is not caused by a specific sensory or motor deficit." In lay terms, unilateral neglect is a disorder that impacts an individual's perception on one side of the body. Typically, this phenomenon occurs after a stroke, when there has been damage to the brain. The brain works in mysterious ways: one of these ways is that the right side of the brain controls what's happening on the left side of the body, and vice versa. So, if a person experiences brain damage on the right side, there is a possibility (approximately a 30% chance, according to the podcast) that the person will experience neglect on the left side. Neglect usually refers to a lack of sensation and attention. The individual may not notice a person standing to their left, may not eat the food on the left side of their plate, or may not even believe that their left arm belongs to them. The range of symptoms I've just described depends on the type of neglect experienced.
There are three types of neglect: personal neglect (failure to process sensory stimuli on the affected side of the body, like the patient's own arm), peri-personal neglect (failure to process stimuli in the near environment on the affected side, like the food on the left side of the dinner plate), and extra-personal neglect (failure to respond to stimuli in the larger surrounding environment on the affected side, like a person or wheelchair on that side of the hallway). It is possible to have one, two, or all three types of neglect. In any situation, neglect contributes to a high risk for injury and is associated with poor functional ability in ADLs, iADLs, and community mobility. In cases of extra-personal neglect, community mobility could be especially dangerous because of failure to process road signs, cars, people, or even various aisles at the grocery store.
Occupational therapy has an important role in rehabilitation and education of compensatory strategies in cases of unilateral neglect. Initially, the OT will do an assessment or screening to determine if the client is experiencing unilateral neglect. Often, this screening includes the client being instructed to draw a clock, a man, or another symmetrical object. If the drawing is incomplete or asymmetrical, neglect is likely an issue. This tool is helpful and quick, but it only tests for peri-personal neglect and gives limited information about the client's ability to perform functional skills. Of course, there are other tests that can be used, and more information about standardized assessments is available on the Glass Half Full website on the Unilateral Neglect podcast web page below.
After the screening has taken place, restorative approaches can be implemented in the acute phase of unilateral neglect. For example, the client can be referred to a neuro-optometrist who would prescribe prism glasses. The glasses have a prism on the non-neglect side to shift the client's attention to the neglected side. The client could also undergo visual scanning training, which involves repetitive scanning to the affected side that is targeted toward a specific object during a functional task. For example, the client could scan for forks on the left side of the silverware drawer.
Occupational therapists also provide the client with compensatory strategies for living with unilateral neglect. One example is teaching the client to have an "anchor," or a visual cue that lets them know when they have scanned completely. This may be the very far edge of their plate, or a red line on the far left side of the newspaper to facilitate attention to the whole page. Environmental modifications can also be implemented to support the client and facilitate attention on the neglected side. This could involve talking to the client on the affected side or placing his/her phone and television on the affected side. Hopefully, these stimuli would act as motivational cues to look and attend in the neglected direction. No matter what intervention is used, repetition is key for improvement in functional outcomes. It is vital for the care team and family to use a consistent approach.
I am thankful for the opportunity to learn from this podcast-- it has really helped me have a more complete view of unilateral neglect.
Kersey, J. & Barnes, N. (2018, March 4). Unilateral Neglect [Audio Podcast]. Glass Half Full. https://glasshalffullot.com/podcast/unilateral-neglect/
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