Cognitive rehabilitation for spatial neglect following stroke
Editorial Group: Cochrane Stroke Group
Published Online: 1 JUL 2013
Assessed as up-to-date: 17 APR 2013
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Bowen A, Hazelton C, Pollock A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD003586. DOI: 10.1002/14651858.CD003586.pub3.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 1 JUL 2013
Unilateral spatial neglect causes difficulty attending to one side of space. Various rehabilitation interventions have been used but evidence of their benefit is lacking.
To assess whether cognitive rehabilitation improves functional independence, neglect (as measured using standardised assessments), destination on discharge, falls, balance, depression/anxiety and quality of life in stroke patients with neglect measured immediately post-intervention and at longer-term follow-up; and to determine which types of interventions are effective and whether cognitive rehabilitation is more effective than standard care or an attention control.
We searched the Cochrane Stroke Group Trials Register (last searched June 2012), MEDLINE (1966 to June 2011), EMBASE (1980 to June 2011), CINAHL (1983 to June 2011), PsycINFO (1974 to June 2011), UK National Research Register (June 2011). We handsearched relevant journals (up to 1998), screened reference lists, and tracked citations using SCISEARCH.
We included randomised controlled trials (RCTs) of cognitive rehabilitation specifically aimed at spatial neglect. We excluded studies of general stroke rehabilitation and studies with mixed participant 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 studies, extracted data, and assessed study quality. For subgroup analyses, review authors independently categorised the approach underlying the cognitive intervention as either 'top-down' (interventions that encourage awareness of the disability and potential compensatory strategies) or 'bottom-up' (interventions directed at the impairment but not requiring awareness or behavioural change, e.g. wearing prisms or patches).
We included 23 RCTs with 628 participants (adding 11 new RCTs involving 322 new participants for this update). Only 11 studies were assessed to have adequate allocation concealment, and only four studies to have a low risk of bias in all categories assessed. Most studies measured outcomes using standardised neglect assessments: 15 studies measured effect on activities of daily living (ADL) immediately after the end of the intervention period, but only six reported persisting effects on ADL. One study (30 participants) reported discharge destination and one study (eight participants) reported the number of falls.
Eighteen of the 23 included RCTs compared cognitive rehabilitation with any control intervention (placebo, attention or no treatment). Meta-analyses demonstrated no statistically significant effect of cognitive rehabilitation, compared with control, for persisting effects on either ADL (five studies, 143 participants) or standardised neglect assessments (eight studies, 172 participants), or for immediate effects on ADL (10 studies, 343 participants). In contrast, we found a statistically significant effect in favour of cognitive rehabilitation compared with control, for immediate effects on standardised neglect assessments (16 studies, 437 participants, standardised mean difference (SMD) 0.35, 95% confidence interval (CI) 0.09 to 0.62). However, sensitivity analyses including only studies of high methodological quality removed evidence of a significant effect of cognitive rehabilitation.
Additionally, five of the 23 included RCTs compared one cognitive rehabilitation intervention with another. These included three studies comparing a visual scanning intervention with another cognitive rehabilitation intervention, and two studies (three comparison groups) comparing a visual scanning intervention plus another cognitive rehabilitation intervention with a visual scanning intervention alone. Only two small studies reported a measure of functional disability and there was considerable heterogeneity within these subgroups (I² > 40%) when we pooled standardised neglect assessment data, limiting the ability to draw generalised conclusions.
Subgroup analyses exploring the effect of having an attention control demonstrated some evidence of a statistically significant difference between those comparing rehabilitation with attention control and those with another control or no treatment group, for immediate effects on standardised neglect assessments (test for subgroup differences, P = 0.04).
The effectiveness of cognitive rehabilitation interventions for reducing the disabling effects of neglect and increasing independence remains unproven. As a consequence, no rehabilitation approach can be supported or refuted based on current evidence from RCTs. However, there is some very limited evidence that cognitive rehabilitation may have an immediate beneficial effect on tests of neglect. This emerging evidence justifies further clinical trials of cognitive rehabilitation for neglect. However, future studies need to have appropriate high quality methodological design and reporting, to examine persisting effects of treatment and to include an attention control comparator.
Plain language summary
Cognitive rehabilitation for spatial neglect following stroke
The benefit of cognitive rehabilitation (therapy) for unilateral spatial neglect, a condition that can affect stroke survivors, is unclear. Unilateral spatial neglect is a condition that 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 of 23 studies involving 628 participants with stroke found insufficient high quality evidence to tell us the effect of therapy designed for treating neglect. We did find some limited evidence which suggested that such therapy might be helpful, but the quality of this evidence was poor and more research is needed to confirm this finding. People with neglect should continue to receive general stroke rehabilitation services and to have the opportunity to take part in high-quality research.
我們搜尋Cochrane Stroke Group Trials Register (搜尋至2005年7月4日)，MEDLINE (1966年至2005年7月)，EMBASE (1980年至2005年7月)，CINAHL (1983至2005年7月)，PsycINFO (1974年至2005年7月)，UK National Research Register (至2005年7月)。我們查閱相關的期刊，篩選參考索引並用SCISEARCH來追蹤文獻。
我們納入特別以空間忽略症為目標的智能復健所做的隨機對照試驗(randomised controlled trial)。我們排除一般性中風復健的研究以及混合病人的研究，除非它們的對象有超過75%是中風病人或是能夠取得單獨的中風資料。
我們納入了12個隨機對執照試驗，共囊括306位參與者。只有4個試驗有適當的分組隱匿(allocation concealment)，亦即有低度的選擇性誤差(selection bias)風險。有很多的預後評量項目被報告出來。只有6個研究評量了失能，兩個研究該效果是否持續。整體的效果(標準平均差，standardised mean difference)在失能方面擁有寬的信賴區間(confidence interval)，包括了0，因此不是統計上顯著的。在出院的最終狀況方面有臨床上顯著的效果，但在兩方面，且勝算比(odds ratio)的信賴區間包括1。相對地，智能復健確實改善了部分，但非全部的，標準化忽略測試的成績。在消去測驗裡犯的錯誤數減少了，並且一條線取中點的能力立即得到改善而且持續到再追蹤時。這些效果似乎可以從研究樣本普遍化到目標族群，但只是根據少數的一些研究。
此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。