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January2008 Vol.45 Issue:      1 Table of Contents
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Compromised Quality of Life in 1st- Ever Cerebral Stroke with Rt Hemisphere Ischemic Lesion. In Right-Hemisphere Ischemic Stroke Patients With Unilateral Visual Neglect: Are We Neglecting Neglect?

M.F. El-Shater 1, A.I. Yassin2
Departments of Neuropsychiatry1, Public Health2, Tanta University

ABSTRACT

Background: Unilateral Visual Neglect (UVN) is a common disabling consequence after right-hemisphere stroke that can disrupt many aspects of daily living and quality of life. It involves the inability to report, respond, or orient to visual stimuli, generally in the hemispace contra lateral to cerebral lesion. Objectives: The present study was designed to evaluate the effect of persistent UVN on disability status and quality of life in patients with first-ever right-hemisphere ischemic stroke. Patients and Methods: A total of 45 patients with cerebral  stroke with lesion, at least 6-months after stroke onset, were included in this cross-sectional study. The patients were subdivided according to the presence of UVN into 2 groups: (i) patients with UVN, and (ii) patients without UVN. Neurocognitive test battery was done including the following: the Line Bisection Test (LBT), Letter Cancellation Test (LCT) and Catherine Bergego Scale (CBS) for UVN ,NIHS scale for stroke severity, Barthel index (BI) for disability and activities of daily living (ADL) ,Rivermead Mobility Index (RMI) for physical mobility, and Health Related Quality of Life Short Form-36 (HRQOL-SF-36). Results: Unilateral visual neglect was diagnosed in 21 (46.7%), out of 45 stroke patients. It was observed that the BI and RMI scores in UVN patients were significantly lower than the non-UVN patients (p<0.05). In patients with UVN, the SF-36 subgroups physical functioning (PF), general health (GH), vitality (V), and social functioning (SF) were negatively influenced significantly compared with those patients without UVN (p<0.05). There was a statistically significant correlation between the BI and the general health perception at last year in the non- UVN group (p<0.05). Conclusion: The present study concluded that the disability was higher in the stroke patients with UVN which has a negative impact on many subscales of HRQOL. As a consequence, it is recommended to do screening and behavioral battery for early detection and proper rehabilitation of disabling UVN.

(Egypt J. Neurol. Psychiat. Neurosurg., 2008, 45(1): 161-173)

 




INTRODUCTION

 

Unilateral Visual Neglect (UVN) is a common feature and an important predictor of poor functional outcome after right hemisphere stroke1-4. It involves the inability to report, respond, or orient to visual stimuli, generally in the contralesional space. The deficit must not be fully attributable to primary sensory deficits (eg, hemianopia) or motor disturbance (eg, hemiparesis). Cerebral infarct is the most common cause of UVN5.

Spatial neglect also encompasses a cluster of symptoms, affecting several areas of vital importance in daily life, and is associated with other cognitive dysfunction such as emotional processing dysfunction and abnormal awareness of deficits (anosognosia and anosodiaphoria), which may affect independence6. People with injury to either side of the brain may experience spatial neglect, but neglect occurs more commonly in those with brain injury affecting the right cortical hemisphere, often causing left hemiparesis7.

Spatial neglect is more commonly associated with lesions of the inferior parietal lobule or temporoparietal region, superior temporal cortex, or frontal lobe. Less common are lesions of the subcortical regions, including the basal ganglia, thalamus, and cingulate cortex8. Spatial neglect may be more common and persistent after cortical than subcortical lesions7. These areas produce the neural network which is responsible for the visuo-spatial attention. Hemineglect is more severe and longer lasting following right-sided as opposed to left-sided brain damage. This has led to the right hemisphere being attributed with playing the primary role in spatial processing9–12.

The reported overall frequency is estimated to be anywhere from 13-81% in people who have had a right-hemisphere stroke. The frequency of spatial neglect may increase with the size of the lesion at presentation and at 3 months after injury13.

The presence of UVN may adversely affect functional recovery. In addition, it is associated with rehabilitation taking longer and being less complete than in patients without UVN14-16. Patients with UVN are faced with a long term rehabilitation process to regain a normal or near to normal life as they had previously. Recently, it has been suggested that assessments of neurological function and disability are insufficient to evaluate the total influence of a stroke on the well being of a patient. QOL related to strokes and life satisfactions after a stroke are important healthcare issues that have not received sufficient attention in the literature. Therefore, QOL has been put forward as an important index of outcome after a stroke as it is likely to be more relevant to the patient than impairment or disability. Treatment for spatial neglect focuses on cognitive rehabilitation that uses specific exercises and alterations to the patient's environment.17

This study aims to investigate the impact of persistent UVN on disability status and QOL in first-ever stroke patients, 6 months after stoke onset.

 

SUBJECTS AND METHODS

 

Subjects

Subjects were identified from records of consecutive discharges of 476 stroke survivors during a 2-year period from stroke unit, Tanta University Hospital, Egypt. Recruitment and assessment were carried out at Neurology Department, Tanta University Hospital, during the period between 1 May, 2007 to 30 July, 2007. The study sample consisted of 45 patients who had had a first-ever Rt-hemisphere ischemic stroke at least six months 18 prior to study entry to investigate the impact of persistent UVN on QOL of these patients in this cross-sectional study. The patients were sub classified according to the presence of UVN into 2 groups: (i) 21 patients with UVN (46.7%), and (ii) 24 patients without UVN (53.3%). The diagnosis of ischemic stroke patients was done on the basis of The World Health Organization’s definition of stroke and brain computed tomography scan or magnetic resonance imaging. The mean age was 61.3±11.5 (41-73) years. The lesion sites of the patients were frontal (n= 9); parietal (n=27); parietotemporal (n=7) and frontotemporal (n=2).

Patients were included in this study according to the following criteria: (1) First-ever right ischemic stroke patients of at least 6-month duration, (2) right-handed (according to the Edinburgh Handedness Inventory), (3) literate and achieving 23 or more on the Mini Mental State Examination (MMSE), (4) sufficiently healthy to participate in the evaluation, (5) absence of other neuromusculoskeletal condition that interfered with activities of daily living, (6) living with their family, (7) joining the study voluntarily. Exclusion criteria were the following: (1) transient ischemic attack, (2) subarachnoid or intracerebral hemorrhage, (3) recurrent ischemic stroke, (4) posterior cerebral artery and basal ganglia infarct or hemorrhage, (5) morbid obesity according to body mass index, (6) homonymous hemianopia, (7) perception or cooperation problem, (8) history of neuropsychiatric disorder, (9) depression (according to the Hamilton Depression Scale). Written consent was received from all subjects.

 

Methods and Measurements

History: Data were collected including patients' demographic characteristics. Individuals with visuo-spatial neglect usually do not report attention or perceptual problems, because of the usually associated abnormal self-monitoring (anosognosia).Thus; the disorder is usually detected via clinical observation and testing. Spatial neglect symptoms are often first observed by caregivers or therapists, who may note personal neglect (failure to groom or clothe the contralesional side) or motor neglect (may not use the contralesional limb despite adequate motor strength or may not explore left space).

Neurological Examination: The most severe cases of spatial neglect may be diagnosed by simple bedside observation, and more moderate cases may be diagnosed based on findings from a complete neurological examination that includes neurobehavioral testing. Preliminary assessment of related disorders included the following: (1) awareness of motor and visual deficits was assessed using a methodology described by Bisiach et al.19. The examiner asked "Why are you now in the hospital? What are your current problems?" If the patient did not spontaneously mention a left sided problem, more direct questions were given. A four level scale was used, both for motor and visual impairments, ranging from 0: perfect awareness of the deficit, to 3: the patient never admitted having some impairment despite its demonstration by the examiner, (2) the presence of extinction or of hemianopia was tested clinically by wiggling fingers for two seconds in one or both visual fields. Central gaze fixation was controlled by the examiner. Six trials were given, in a fixed pseudo-random sequence including four unilateral trials (two on each side), and two simultaneous bilateral trials. Extinction was considered as present when a patient failed at least once to report a contralesional stimulus during bilateral simultaneous presentation, while accurately detecting unilateral stimuli 3.

 

Neurocognitive Test Battery:

Testing conditions

The tasks were always given in the same order within one session of one hour or less. Patients were in a quiet environment, seated in a chair (not in their bed). The examiner sat in front of the patient and presented the test material centrally. Patients were asked not to move the material, nor their trunk, while performing the tasks. At the end of each task, the examiner asked only once "are you finished?", but gave no feedback to the patient20. A sample size of 200 healthy controls was taken to determine normal values of neurocognitive tests.

 

Occupational Therapy-Adult Perceptual Screening Test (OT-APST)

The OT-APST is a standardized screening measure that enables occupational therapists to test for the presence of impairment in visual perception across each of the major constructs of visual perception and praxis, including the problems most frequently occurring after stroke. The OT-APST has 25 items in 7 subtest areas (Agnosia; Visuospatial Relations; Unilateral neglect; Body scheme; Apraxia; Acalculia; Functional Skills). Several of the items contribute to assessment of more than one area and are only performed once. Scores for items in each construct or subtest area are summed to allow interpretation of patterns of impairments and to compare with normative data, but not to produce a total score for the OT-APST. The length of time taken to complete the OT-APST in its entirety is recorded as a general indicator of the information-processing speed of the client and to reflect the client's perceptual processing ability. The cutoff scores indicating impairment for each of the subscales of the OT-APST, stratified by age group (16-74 years) are: agnosia ≤ 24, body scheme ≤ 21, neglect ≤ 12, constructional apraxia ≤ 51, apraxia ≤ 9, acalculia ≤ 2, and functional skills ≤ 9 21.

 

Personal neglect

Following Bisiach et al.19 methodology, patients were asked to reach their left hand with the right hand, first with eyes open, then with eyes closed. A four level scale was used, ranging from 0: normal performance, to 3: no attempt to reach the target.

 

Paper and pencil tests of extrapersonal neglect

The following tests were selected because they had previously been found sensitive to the presence of unilateral neglect and because they are easy to perform and to score in a clinical setting. UVN was diagnosed using the Line Bisection Test, Letter Cancellation Test, Catherine Bergego Scale2,5,9. All patients were given 2 paper and pencil tests that were previously found highly sensitive to neglect (1) the Line Bisection Test consisted of 20 horizontal black lines of three different line lengths on an A4 sheet. The patient was asked to mark the centre of each line. Scoring involves the number of omitted lines as well as the deviations from the true midpoint The deviation from the true centers of the lines and the numbers of omissions were scored. Following the literature, a deviation of 10% or an omission of more than two lines, were used as cut-off scores indicating the presence of neglect6; (2) the Letter Cancellation Test is a set of four cancellation tests, two of that involve letters (verbal stimuli), other two symbols (non-verbal stimuli). A structured and a randomized array are presented to the subjects and asked to circle the letter A and O on an A4 horizontal piece of paper using for every 10 items different colored pencils. The score is the total number of omissions. The healthy adults less than 50 years could complete each of the four tests without error in less than two minutes, older than 50 years old not more than one error per array22.

 

Behavioral assessment of neglect and anosognosia

Behavioral assessment of unilateral neglect and anosognosia in daily living activities was performed, using the Catherine Bergego Scale3 .Previous studies found that the scale had a good inter-rater reliability and concurrent validity, was more sensitive to neglect than paper and pencil tests, and was sensitive to change during rehabilitation. The scale was completed by an occupational therapist, based on a direct observation of the patient's behavior in 10 everyday life situations, such as grooming and shaving the left part of the face, wearing the left sleeve or slipper, eating food on the left side of the plate, cleaning the left side of the mouth after eating, spontaneous leftward gaze orientation, "knowledge" of the left part of the body, auditory attention to stimuli from the left, collisions with objects on the left, leftward navigation in familiar places, and locating familiar items on the left. It was performed within the same week as conventional assessment, blindly to the results of paper and pencil tests. For each item, a four point scale was used, ranging from 0 (no neglect) to 3 (severe neglect). A total score is then calculated (range: 0–30).Arbitrary cut-off points were drawn in the CBS, to distinguish different levels of impairment. Patients with a total score of 0 were considered as having no UN, a score ranging from 1 to 10 was considered as mild behavioral UN, a score 11–20 as a moderate UN and a score 21–30 as a severe UN. Anosognosia was assessed by comparing the examiner's score with the patient's rating on a self assessment version of the scale.3  As a consequence, 21 subjects showed left hemispatial neglect during pencil and-paper activities and the CBS.

 

NIHSS for Stroke Severity

The National Institute of Health Stroke Scale (NIHSS) is a 15-item impairment scale, intended to evaluate neurologic outcome and degree of recovery for patients with stroke. The scale assesses level of consciousness, extraocular movements, visual fields, facial muscle function, extremity strength, sensory function, coordination (ataxia), language (aphasia), speech (dysarthria), and hemi-inattention (neglect). Each item is scored from 0 - 2, 0 - 3, or 0 - 4, and untestable items are scored as "UN". A score of 0 indicates normal performance. Total scores on the NIHSS range from 0 - 42, with higher values reflecting more severe cerebral infarcts. Stroke severity is further stratified in the following way: ≥ 25 Very severe neurological impairment, 5-14 Mild to adequately severe neurological impairment, < 5 Mild impairment. The motor function part of NIHSS was used to establish the stroke severity on motor functions. Hemiparesis severity was calculated in the upper and lower limbs separately (0=normal, 4=severe hemiparesis). These scores were summarized and patients were classified according to the hemiparesis severity between 0 to 8 points (0=no motor defect, 1-2=mild hemiparesis, 3-5=moderate hemiparesis, 6-8= severe hemiparesis)23.

 

Barthel Index for Activities of Daily Living

Measures of disability in basic ADL are used to determine the impact of impairments, establish therapeutic goals, and monitor progress in rehabilitation. They reflect both the impact of neurological impairments and the ability to compensate for losses. They focus on actual task accomplishment rather than on the theoretic ability to perform a task. Disability status on ADL was evaluated with the Barthel Index (BI), which gives a score ranging from 0 to 100 (100= physical independence, 75-95= mild disability, 50-70= moderate disability, 25-45= severe disability, 0-20= very severe disability). The top score implies full functional independence, but not necessarily normal status. BI comprises 10 items measuring feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair/bed transfer, ambulation and stair climbing. Original BI scoring varies between the ranges of 0-5, 1-10 and 0-15 points to this title. The BI score is highly correlated with independent functional ability and the ability to return home. Additionally, the BI score before the start of rehabilitation gives an indication as to the expected rate/duration of the patient’s recovery24.

 

Rivermead Mobility Index for Mobility Status

Physical performance measures provide insights into a patient's ability to perform basic mobility functions. They may be used for screening to determine the need for treatment, for measuring responses to treatment, and for discharge planning. The Rivermead Mobility Index is recommended because it has been tested and used in stroke patients and is simple and reliable. Timed functional movements (e.g., time to walk 10 meters or the distance that can be walked in 6 minutes) should also be considered. Mobility status was measured by the Rivermead Mobility Index (RMI), a simple scale that assesses disability status in mobility through questions about 14 activities and direct observation of 1. These activities range from turning over in bed, standing unsupported, walking inside and outside (with and without an aid), going up stairs and picking up something from the floor to running. Scale scoring ranges from 0 to 15, with 0 indicating complete inability. Mobility disorder is classified into groups as follows: 0-6 points = severe, 7-11= moderate, 12-15= mild11.

 

Health-related quality of life-Short Form-36 (HRQOL-SF-36)

Quality of life includes the ability to engage in life's activities, the satisfaction derived from them, and overall perceptions of health status and well-being. The person's wishes and expectations, limitations in achieving these, and value system are all important factors. Health-related quality of life (HRQOL) was assessed by means of The Medical Outcomes Study Short-Form Health Survey Scale-36 (SF-36) which is a generic, subjective, valid measure for the assessment of HRQOL after a stroke. The SF-36 is the most commonly used generic instrument for measuring quality of life. Moreover, it is the most widely used measure to assess HRQOL in patients with stroke. It facilitates assessment across 8 health domains: physical functioning (PF), role limitations due to physical problems-physical role (PR), bodily pain (BP), general health (GH), vitality (V), social functioning (SF), role limitations due to emotional problems-emotional role (ER) and mental health (MH). Scores were assessed for these 8 domains and general health perception of last year. The SF-36 does not lend itself to the generation of an overall summary score. This is because information within the individual responses is lost in the total scale score (since the total score can be achieved in a variety of ways from individual item responses. The recommended scoring system for the SF-36 is a weighted Likert system for each item. Items within subscales are totaled to provide a summed score for each subscale or dimension. Each of the 8 summed scores is linearly transformed onto a scale from 0 (negative health) to 100 (positive health) to provide a score for each subscale17.

 

Statistical Analysis

Statistical analysis was performed using SPSS software, Version 12. Quantitative variables were expressed as mean±SD; qualitative variables were expressed as number and percent. Comparing parametric variables was done using Student t-test, while non-parametric variables were compared using Mann-Whitney test & Chi-square test. Pearson linear correlation coefficient was calculated to measure correlation between parametric variables & Spearman rank correlation for non-parametric variables. The significance level was 5%.

 

RESULTS

 

Forty-five patients were included in the study. The sample comprised 21 patients UVN and 24 patients without UVN (control patients). The means and standard deviations of age, body weight, body length and BMI in the UVN group and control group (Patients without UVN) are summarized in Table 1. There was not a statistically significant difference between the groups in demographic variables (p>0.05).

Table (2) showed a statistically significant differences between UVN patients with and without anosognosia with regard to severity of neglect (p<0.05), NIHSS motor subscale (p<0.05), BI (p<0.05), RMI (p<0.05), and HRQOL-SF36 (p<0.05).Furthermore, UVN patients with anosognosia exhibited more severe degree of neglect than UVN patients with anosognosia.

It was found that BI and RMI scores of the UVN group were lower (BI: 81.34±13.14; RMI: 8.63±3.47) compared with the non- UVN control group patients' scores (BI: 97.65±4.32; RMI: 12.97±2.04). There was statistically significant difference between BI and RMI scores of the UVN group and control group (p<0.05).It was observed that in patients with UVN, all subgroups scores of the SF-36 Scale were lower than the SF-36 scores of the control group. However, when the SF-36 scores of the UVN group were compared with the control group, there was a significant difference in PF, GH, V, and SF (p<0.05). Conversely, mean scores of PR, BP, ER, MH and the general health perception of last year were not statistically significant (p>0.05) as shown in Table (3) and Fig. (1).

According to NIHS- motor Subscale, the UVN group patients' scores are higher than the control group patients which mean severe motor disability in UVN patients (Table 4).

The stroke patients with and without neglect were then correlated with regard to their disability scores (BI and RMI) and QOL scores (SF-36).  In UVN group, a strong correlation was found between BI and PF (rho= +0.675, p=0.005), SF (rho= +0.625, p=0.01), and MH(+0.78, p=0.04). It was found that there was a positive and very strong correlation between RMI and PF(rho=+.0.753, p=0.001), PR (rho=+.0.651, p=0.008). Additionally, the correlation of RMI and SF (rho=+0.593, p=0.02), ER (rho=+0.563, p<0.05), MH (rho=+0.521, p<0.05) were positively strong. In the same group, a weak correlation between BI and SF-36 subgroups BP, GH, V, and general health perception of last year (question 2) was observed (p>0.05).In the non-UVN group, based on Pearson correlation coefficient analysis for BI and SF-36 subgroups, a strong-positive correlation was indicated only between BI and the general health perception of last year (question 2) (rho=+0.551, p<0.05). There was a weak correlation between BI and the other SF-36 subgroups (PR, V, ER) (p>0.05). In addition, it was found that the correlation between RMI and all subgroups of SF-36 was weak (p>0.05) as shown in Table (5).


 

Table 1. Demographic Data among Study Groups.

 

p-value

Patients without UVN

N=24

Patients with UVN

N=21

Parameter

>0.05

62.9±12.8

61.3±11.5

Age in years

>0.05

17/7

15/6

Sex (M/F)

>0.05

67.51±13.42

65.23±12.53

Body Weight (kg)

>0.05

167.85±11.18

166.17±10.13

Length (cm)

>0.05

24.32±2.54

22.71±3.98

BMI (kg/m2 )

 

 

>0.05

 

13

9

2

 

11

7

3

Educational  Level

≤ 6 yrs

7-12 yrs.

13-16 yrs.

N=Number, BMI=Body Mass Index

 

 

Table 2. Clinical and Neurocognitive Characteristics in Patients with UVN.

 

P value

Patients without UVN (N=21)

Parameter

Without  Anosognosia

N= 6 (28.6%)

With  Anosognosia

N=15 (71.4%)

 

<0.05*

 

2 (33.3%)

3 (50.0%)

1 (16.7%)

 

0

5 (33.3%)

10 (66.7%)

Neglect (CBS)

Mild (1-10)

Moderate (11-20)

Severe (21-30)

 

<0.05*

 

1 (14.3%)

2 (42.9%)

3 (42.9%)

 

2 (13.3%)

5 (33.3%)

8 (53.3%)

NIHSS (motor subscale)

1-2

3-5

6-8

 

<0.05*

 

87.32±5.64

(90-100)

 

80.15±11.79

(50-100)

Barthel Index (BI)

Mean ± SD

Range (0-100)

 

<0.05*

 

 

10.35±3.78

(11-15)

 

8.12±3.56

(1-13)

Rivermead Mobility Index (RMI)

Mean±SD

Range  (0-15)

 

 

 

HRQOL-SF36 Subscales (0-100)

Mean±SD

<0.05

69.2±4.98

47.8±7.14

PF

>0.05

59.3±5.43

56.3±531

PR

>0.05

62.3±6.68

61.7±6.65

BP

<0.05*

47.4±4.67

39.5±5.32

GH

<0.05*

62.3±4.93

49.6±7.81

V

<0.05*

52.7±3.45

39.9±3.47

SF

>0.05

60.5±4.37

56.2±5.71

ER

>0.05

58.2±5.76

55.4±6.42

MH

*= Significant, CBS= Catherine Bergego Scale, Health Related Quality of Life Short Form-36(HRQOL-SF-36), PF=Physical Functioning, PR=Physical Role, BP=Body Pain, GH=General Health, V=Vitality, SF=Social Functioning, ER=Emotional Role, MH=Mental Health.

 

Table 3. Comparison between patients with UVN and patients without UVN regarding BI, RMI, and HRQOL-SF 36.

 

p-value

Patients without UVN

N=24

Patients with UVN

N= 21

Parameter

 

<0.05*

 

97.65±4.32

(90-100)

 

81.34±13.14

(50-100)

BI

Mean ± SD

Range (0-100)

<0.05*

 

12.97±2.04

(11-15)

 

8.63±3.47

(1-13)

RMI

Mean±SD

Range  (0-15)

 

 

 

HRQOL-SF36 Subscales (0-100)

Mean±SD

<0.05*

79.8±5.37

49.7±8.53

PF

>0.05

60.5±6.85

57.3±6.34

PR

>0.05

63.7±6.94

61.2±7.53

BP

<0.05*

67.4±4.85

39.5±5.67

GH

<0.05*

82.3±5.03

49.6±7.81

V

<0.05*

72.6±3.65

37.1±2.11

SF

>0.05

61.3±4.32

57.3±5.64

ER

>0.05

60.2±5.98

57.9±6.42

MH

 RMI= Rivermead Mobility Index, BI=Barthel Index.

 

Fig. (1): Comparison between patients with and without UVN regarding BI, RMI, and HRQOL-SF 36.

 

Table 4. NIHSS (motor subscale) Scores of patients with and without UVN.

 

NIHS Scale

Motor Subscale

Patients with UVN       (N=21)

Patients without UVN (N=24)

P

N

%

N

%

0

1

4.76

14

58.33

<0.05*

1-2

2

9.52

7

29.17

3-5

13

61.90

2

8.33

6-8

5

23.81

1

4.17

 

Table 5. Correlations between mobility status and ADLs with HRQOL-SF 36 and Q. 2 in patients with UVN versus patients without UVN.

HRQOL  Subscales

PF

PR

BP

GH

V

SF

ER

MH

Q.2

 

Patients with

UVN

BI

r

P

0.675

0.005*

0.289

0.300

0.175

0.553

0.398

0.137

0.452

0.090

0.625

0.012*

0.147

0.680

0.780

0.04*

0.171

0.593

RMI

r

P

0.753

0.001*

0.651

0.008*

0.147

0.615

0.532

0.043

0.479

0.069

0.593

0.02*

0.563

0.03*

0.521

0.043*

0.587

0.05

 

Patients without

UVN

BI

r

P

0.375

0.107

 -0.27

0.397

0.259

0.275

0.201

0.417

-0.05

0.883

-0.305

0.047

-0.07

0.815

0.125

0.597

0.551

0.03*

RMI

r

P

0.379

0.061

-0.054

0.805

0.412

0.125

0.047

0.843

0.089

0.721

-0.293

0.264

0.127

0.581

0.045

0.863

0.432

0.65

DISCUSSION

 

The interest in human conscious awareness has increasingly propelled the study of neglect, the most striking occurrence of an acquired lack of conscious experience of space. Neglect syndromes commonly arise after unilateral brain damage that spares primary sensory areas nonetheless leading to a lack of conscious stimulus perception. Because of the central role of vision in our everyday life and motor behavior, most research on neglect has been carried out in the visual domain25. Unilateral spatial neglect is a disorder that has, for many years, intrigued and frustrated researchers and clinicians working in the area of stroke rehabilitation. More recently, research has focused on evaluation of rehabilitation strategies to reduce the disabling effects of neglect26.

Improving the QOL of stroke patients has received increasing attention in the development of therapeutic strategies. In many studies, unilateral spatial neglect has consistently been identified as a negative predictor for a patient’s recovery of independence in daily living. However, the focus of these studies was primarily on ADLs and the motor aspects of recovery with little emphasis on the effect of disability on QOL in neglected stroke patients27-30.

The present study aimed to investigate the effect of persistent UVN on disability status and QOL in first-ever ischemic stroke patients.

The present study has detected persistent UVN in 21 (46.7%) out of 45 patients with first-ever supratentorial ischemic stroke, 6-months after stroke onset. This high figure of neglect is in accordance with many studies, for example Halligan et al.31, reported that 48% of right hemisphere stroke patients in rehabilitation suffered from neglect. Zoccolotti et al.32 found that estimates of the disorder in rehabilitation patients varied with the test used from 26.7% to 52.0%, but only 20% of patients had very severe neglect on the basis of overall clinical judgment. Özge et al.22 found UVN in 19 (55.9 %) out of 34 subacute-chronic ischemic stroke patients. A higher incidence (75%) was reported by Stone et al,33 in non-selected right hemisphere stroke patient three months after stroke. In the context of neglect severity, our results showed clinically significant neglect, moderate (38.1%) to severe (52.4%) out of 21 patients with UVN. Clinically important issue was the detection of neglect by behavioral assessment of activities of daily living in those patients who did not exhibit abnormality with paper and pencil tests of neglect.  Moreover, anosognosia was detected in 15 (71.4 %) out of 21 patients with UVN, representing an additional overload on disability status and QOL of patients with neglect. The syndrome of unawareness (anosognosia) for sensory and motor neurological deficits (hemiplegia, hemianaesthesia, and hemianopia), contralateral to the side of a hemispheric lesion, is of paramount importance and major concern in poor functional outcome and QOL in Rt-hemishere stroke patients.

Although paper and pencil tests are useful for rapid clinical screening, they fail to consider the patient’s actual performance in his everyday life. Some patients obtain a normal performance on conventional tests, while showing a directional bias in daily life skills. Such dissociations have been attributed to the relative sparing of voluntary orientation of attention (involved in conventional tests) contrasting with an impairment of automatic orienting which allows attention to be automatically captured by relevant stimuli in everyday life34. This underlines the necessity to use a behavioral assessment of UN. Neglect should be assessed with a standardized test battery rather than a single test, and functional outcome should be measured with scales consisting of cognitive, social and motor items35.

It was found that the disability status of the UVN group patients was higher than the non-UVN group patients. Similarly, the QOL level of the UVN group patients was lower than the QOL level of the non-UVN group. The present study goes in harmony with the most of research results of UVN after ischemic stroke. Indeed, UN may affect many daily living skills and has been found associated with poor functional recovery from stroke36-38. Denes et al.39, found that neglect was the worst prognostic factor for functional recovery in hemiplegia, when compared to other cognitive disorders, such as aphasia, intellectual deterioration, or disturbed emotional reactions. These findings have been subsequently largely reproduced by other authors, who showed that neglect had an adverse influence upon functional outcome, improvement on rehabilitation, length of hospital stay and discharge to home 36-38, although contradictory results have been reported40. 

It was found that neglect patients showed poorer outcomes in the four subgroups of QOL (physical function, general health, vitality and social functioning) when compared with non UVN patients. It is thought that these outcomes may be influenced by a decrease in the activity level and difficulties in ADLs and mobility which may originate from a tendency to social isolation.

In the UVN group, there was a strong correlation between BI and physical function, social function, and mental health subgroups of HRQOL, SF-36. Additionally, it was observed that there was a strong correlation between RMI and PF, PR, SF, ER and MH subscales of HRQOL, SF-36. On the other side, in the non-UVN group, the dependency level in ADLs, according to the Barthel Index, was associated only with the general health perception of the last year score of SF-36.QOL was affected in stroke patients with UVN negatively because of the poor disability status. However, this negative influence was not seen in all subgroups of QOL.

UVN represents an alteration in the construction of the bodily and/or the nonbodily space in non-dominant right hemisphere located lesions. As the left side of the body is often underused in patients with left neglect, it is not surprising that spatial neglect has been found to be among the most important factors influencing postural ability in hemiplegic patients41. In addition to these results of the syndrome, automatically diminished visual field, hypokinesia and fear of falling result in a decrease in mobility and are other co-factors enhancing the disability status in ADLs. Hence, there is a resemblance of some aspects of the hemispatial neglect syndrome (hypokinesia, decreased arousal) to aspects of Parkinsonian syndromes. The present study revealed that UVN group patients had severe motor involvement. This finding is in parallel with the results of Özge et al.22, who found severe motor involvement only in the UVN group and no motor or mild motor deficits in their control patients (non-UVN group).Therefore, disability status in ADLs and mobility activities may have been influenced by aspects of the neglect syndrome.

 

Recommendation:

The present study recommends the following: (i) routine use of behavioral assessment of unilateral neglect in every stroke patient for early detection and proper neurorehabilitation of disabling neglect,(ii) prospective, longitudinal, follow-up study of early unilateral neglect after stroke to address the natural course of this common syndrome.

 

Acknowledgments

We are so grateful to Prof. Dr. M.Y. El-Senousy, Head of Neuropsychiatry Department, Faculty of Medicine, Tanta University, for his unlimited support and advice. We are also thanking all staff members of Neurology and Physical Medicine Departments, Tanta University for their genuine help. Our greet appreciation for patients participated in this study. 

 

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الملخــص العربـــى

 

تأثر الأداء الوظيفي ونوعية الحياة في مرضى جلطات النصف الأيمن للمخ المصحوب بالإهمال البصري النصفي

 

مرجعية البحث : يعتبر الإهمال البصرى النصفي من الإعاقات الشائعة الناتجة عن جلطات المخ  والذي يعني عدم القدرة على الإدراك والاستجابة للمؤثرات البصرية في نصف المجال البصري المعاكس لأصابه المخ وهو  يؤثر على الأداء الوظيفي ونوعية الحياة في مرضى جلطات النصف الأيمن للمخ   .  

أهداف البحث : تقييم مدى تأثير الإهمال البصرى النصفي على الأداء الوظيفي ونوعية الحياة في مرضى جلطات النصف الأيمن للمخ.

المرضى وطرق البحث : تكونت عينه البحث من45 مريض بجلطة النصف الأيمن للمخ للمرة الأولى فى حياة المرضى بعد 6 شهور من حدوث السكتة الدماغية وقد تم تقسيم هؤلاء المرضى إلى مجموعتين حسب وجود الإهمال البصرى النصفي الأيسر مع عمل قياسات الأداء الحركى والوظيفي لأنشطة الحياة اليومية وشدة السكتة الدماغية بالإضافة لمقياس جودة الحياة المرتبط بصحة هؤلاء المرضى.  وقد تم استخدام قياسات اختبار وظائف الأعصاب المعرفيه لتشخيص الإهمال البصري النصفي.

النتائج : أظهرت النتائج وجود  21 مريض (46%) مصابين بإهمال بصري نصفي أيسر من مجموع 45 مريض بجلطة النصف الأيمن للمخ وقد تبين انخفاض ذي دلاله احصائيه في مقياس مستوي الأداء الوظيفي لأنشطه الحياة اليومية- ومقياس مستوى الأداء الحركي في مرضى الإهمال البصري النصفي عنه في المرضى بدون إهمال نصفي بصري . في مرضى الإهمال البصري النصفي كانت نواحي الأداء الوظيفي {الوظائف العضوية - الصحة العامة الحيوية - الوظائف الاجتماعية} قد تأثرت سلبا بفروق ذات دلاله احصائيه مقارنه بالمرضى بدون إهمال بصري أيسر.  كما وجد ارتباط قوي بين مستوى الأداء الوظيفي لنوعيه الحياة ومستوى الإحساس بالصحة العامة خلال العام الأخير. ووجد ارتباط ذي دلاله احصائيه بين مستوى الأداء الحركي ومستوى الأداء الوظيفي لأنشطه الحياة في وجود الإهمال البصري النصفي فى المجال البصري الأيسر.

خلاصة البحث : أثبتت الدراسة زيادة درجه الاعاقه في مرضى جلطات النصف الأيمن للمخ مع وجود إهمال بصري نصفى أيسر مما يؤثر بصوره سلبية على العديد من جوانب الأداء الوظيفي وأثره على أنشطه الحياة اليومية و جودة الحياة المرتبط بصحة هؤلاء المرضى

التوصيات : يوصى بعمل القياسات المتخصصة للإهمال البصري والمرتبطة بأنشطه الحياة اليومية وذلك للكشف المبكر عن هذه الحالات مما يحسن من نتائج اعاده التأهيل لاعاقه الإهمال البصري النصفي بعد جلطات النصف الأيمن للمخ كما يوصى بعمل دراسة إكلينيكية لمتابعة المرضي فى الفترة المبكرة بعد حدوث الجلطة ولمدة سنتين لمعرفة مآل الإهمال البصرى النصفي وفعالية أعاده التأهيل.



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