Neglect Syndrome in Paralyzed Patients

Brain injuries can lead to the neglect syndrome, which is difficult to understand at first glance in patients. Neglect syndrome can affect the right or left side. The word “side” used when describing the neglect syndrome refers to the body and the environment to the right and left of the line passing through the middle of the body. The patient may have difficulty perceiving and responding to stimuli on the affected side or may act as if that side does not exist.

Who is it seen in? Why does it happen?

Stroke, traumatic conditions, tumors that cause brain damage can lead to neglect syndrome.

Neglect syndrome is seen in up to 70% of patients with paralysis after stroke in which the right brain hemisphere is affected (1). Neglect of the right side occurs around 40% in strokes in which the left hemisphere is affected (2).

Anatomy of the disease and how it occurs

The part of the brain’s shell called the parietal lobe (lateral head lobe) allows us to perceive the environment and pay attention. In general, the right parietal lobe provides attention to both the right and left sides, while the left parietal lobe provides attention only to the right side. Therefore, in brain damage in the right parietal lobe, the left side of the body is neglected. However, damage to the left brain leads to neglect syndrome less frequently, as the right brain can pay attention to both sides.

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In brain injuries such as stroke, aphasia (speech and comprehension disorder) is more common if the left side of the brain is affected, and neglect syndrome is more common if the right side is affected.

What complaints does it cause? How is it recognized?

Neglect syndrome can be classified according to neglected perception (sensation, movement or representation) and neglected area (bodily or spatial) (3). Accordingly, the effects that may occur on the patient can be exemplified as follows:

Sensory neglect: The patient neglects sensory stimuli in the body or environment area on the opposite side of the brain damage. There may be visual, auditory, or tactile neglect.

Movement (motor) neglect: The person perceives the sensation on that side, but there is a problem with the movement response. Movement may be less than expected (hypometry), late onset (hypokinesia), or unexplained slow (bradykinesia). Movement disorder may be within the affected side (hemispasial hypometry) or oriented towards the affected side (directive hypometry).

Representational neglect: The patient neglects one side while envisioning a movement, task, or environment. For example, the patient is asked to describe a familiar place by imagining that he is looking at it from a certain position. The patient neglects the features on the left while describing the space.

Personal neglect: Neglects the body part on the opposite side of the brain injury. For example, he only takes one sleeve of his shirt and shaves only half of his face.

Spatial neglect: The patient neglects his environment on the opposite side of the brain injury. For example, he eats only the right side of the food on his plate, leaving the left side.

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There are standard tests (eg Catherine Bergago scale, Weintraub and Mesulam’s marking test, copying and drawing test, etc.) prepared for the diagnosis and classification of neglect syndrome.

What other situations can it interfere with?

Neglect syndrome can be confused with true muscle weakness, loss of vision, loss of sensation. They can also be found together with neglect syndrome. The use of tests to help differentiate the neglect syndrome is required for accurate identification.

How is neglect syndrome treated?

In some of the patients diagnosed with neglect syndrome immediately after the stroke, the symptoms improve in a few days. However, symptoms persist in 2/3 of patients with spatial neglect. Many physical therapy and rehabilitation applications can be used for the treatment of these patients (4). Neglect syndrome remains a difficult condition to treat.

  • Visual scanning training
  • Eye patch (visual-environmental neglect of the other side can be reduced by closing the eye on the healthy side.)
  • Attention span extension training
  • Neck muscle vibration therapy (5)
  • Transcranial magnetic stimulation (6)
  • optokinetic stimulation
  • Vestibular stimulation with cold water (The balance organ in the ear is stimulated with cold water)
  • Galvanic-vestibular stimulation (The balance organ in the ear is stimulated by electrical stimulation)
  • Prism adaptation
  • Arm-leg activation training
  • mental image training
  • Virtual reality training
  • trunk rotation training
  • TENS to neck muscles (back edge of sternocleidomastoid muscle)
  • mirror therapy
  • Biofeedback training

What is the course of the disease?

Neglect syndrome in patients who have had a stroke due to damage to the right cerebral hemisphere adversely affects the overall success of treatment. Hospitalization of neglected patients is prolonged and their recovery is delayed. These patients need more attention and care than non-neglect paralyzed patients.

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