Limb Activation Effects in Hemispatial Neglect Gail A. Eskes, PhD, Beverly Butler, BSc, Alison McDonald, BScPT, Edmund R. Harrison, MD, Stephen J. Phillips, MB ABSTRACT. Eskes GA, Butler B, McDonald A, Harrison ER, Phillips SJ. Limb activation effects in hemispatial neglect. Arch Phys Med Rehabil 2003;84:323-8. Objective: To assess the efficacy of passive and active limb movement to improve visual scanning in patients with hemi- spatial neglect. Design: Before-after trial: behavioral analyses of a case series. Setting: Stroke rehabilitation unit in a tertiary care hospital. Participants: Nine individuals with right-hemisphere stroke (mean time poststroke, 19.5mo) and left-sided neglect, as as- sessed by the Sunnybrook Bedside Neglect Battery. Intervention: Active left limb movement (button push; n=3) or passive left limb movement (n=8) with functional electric stimulation (FES) administered during visual scanning testing. Main Outcome Measures: Performance on visual scanning tests involving naming of letters and numbers. Results: Both active and passive movement significantly improved target detection on the left side, but not on the right side, on the visual scanning task. Positive results were seen in 2 of 3 active movement patients and 6 of 8 passive movement patients. Conclusions: Both active and FES-stimulated passive movements are potential techniques for the treatment of hemi- spatial neglect. Key Words: Hemispatial neglect; Neuropsychology; Per- ceptual disorders; Rehabilitation. © 2003 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation H EMISPATIAL NEGLECT (or neglect) is a failure to respond, orient, or attend to, contralesional stimuli after brain damage (eg, stroke, head injury), despite adequate sen- sorimotor ability to do so. 1 Neglect is a frequent disorder after stroke, and appears more common after right-hemisphere brain damage 2 (with consequent left-sided neglect). In 1 study, the frequency of neglect 2 months poststroke was estimated as 48% in a right brain– damaged group and was only 15% in a left brain– damaged group. 3,4 Although the severity of the ne- glect may lessen with time, patients with acute or chronic left-sided neglect show a similar pattern of failures in process- ing information on the contralesional left side. This deficit often results in significant difficulty with everyday activities, such as failure to eat food on the left side of a plate, to shave the left side of the face, or to avoid objects on the left side when walking or navigating in a wheelchair. 5 Chronic neglect after stroke is postulated to be associated with the involvement of other spatial or attentional circuits that reduce the possibility of functional adaptation. 6 Neglect is of clinical importance in that it is associated with poor reintegration into everyday life tasks. 4,7,8 In the long term, the neglect syndrome has been associated with reduced independence and impaired mobil- ity. 9-11 Given the poor prognosis of patients with left-sided neglect, the need for research into rehabilitation strategies to ameliorate this condition is critical. To date, much research has concen- trated on techniques that use behavioral and computerized training programs to teach visual scanning to the unattended left side, but these programs have had mixed results. One group of researchers has reported positive effects, 12,13 but other at- tempts to replicate these findings have met with negative 14 or mixed results (eg, with poor generalization to other tasks or no maintenance over time, 15-17 as reviewed by Robertson 18 ). Al- though visual scanning training has received much attention in the rehabilitation literature, its inconsistent results suggest that alternative approaches are needed. Investigations of techniques to improve neglect have included visual imagery, 19 voluntary trunk rotation, 20 prism adaptation, 21 eye patching, 22 and con- tralesional limb activation. 23-25 Contralesional limb activation was based on early observa- tions that use of the left limb in performing standard tests of neglect (eg, line bisection) resulted in improved perfor- mance. 26,27 Robertson and North 23,28 and Robertson et al 24 extended these findings by using a procedure that required subjects to move a finger or push a button in response to a verbal command every 8 to 10 seconds while they were scan- ning for targets on a page. Using single case studies, the researchers showed that active left limb movement in the left hemispace (left side of the body) significantly reduced neglect, compared with no movement or right-sided movement, as measured by performance on visual scanning tasks. Improve- ment in walking trajectory with left hand movements was also found in a group study. 29 Importantly, a case study 24 showed that left limb activation resulted in increased functional perfor- mance in everyday life for several weeks after training ended. These effects were not dependent on visual cueing, because left hand movements out of sight of the subject had the same beneficial effect 23 ; therefore, they were hypothesized to result from changes in lateral attention or spatial representation be- cause of activation of the contralesional hemisphere by left limb movement in the left hemispace. Passive left limb movement by the experimenter was not effective in improving neglect, 30 suggesting that the intentional motor programming aspects of the procedure were more im- portant than any potential sensory cueing. Recent work by From the Department of Physiotherapy, Queen Elizabeth II Health Sciences Centre (McDonald); and the Departments of Psychology, Psychiatry, and Medicine (Neu- rology) (Eskes) and Psychology (Butler), Divisions of Physical Medicine & Reha- bilitation (Harrison) and Neurology (Phillips), Dalhousie University, Halifax, NS, Canada. Supported in part by the Heart & Stroke Foundation of Nova Scotia, the QEII Health Sciences Centre Research Fund, the Nova Scotia Department of Health Designated Mental Health Research fund, and the National Sciences and Engineering Research Council of Canada (predoctoral fellowship). Presented as an abstract at the Canadian Psychological Association’s Annual Meeting, May 1999, Halifax, NS. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the author(s) or upon any organization with which the author(s) is/are associated. Reprint requests to Gail Eskes, PhD, Dept of Psychiatry, Room 9216 AJLB, QEII HSC, 5909 Veterans Memorial Lane, Halifax, NS B3H 2E2, Canada, e-mail: gail.eskes@dal.ca. 0003-9993/03/8403-7514$30.00/0 doi:10.1053/apmr.2003.50012 323 Arch Phys Med Rehabil Vol 84, March 2003