Cognitive rehabilitation for spatial neglect following stroke.
Level 1 - systematic review of randomized trials
Systematic review and meta-analysis of randomized controlled trials
PubMed 23813503 · doi:10.1002/14651858.CD003586.pub3
What was done
This Cochrane systematic review evaluated randomized controlled trials (RCTs) assessing cognitive rehabilitation specifically aimed at spatial neglect in stroke patients. Authors searched multiple databases through June 2012. Two authors independently selected trials, extracted data, and assessed methodological quality. Outcomes assessed included standardized neglect test scores, activities of daily living (ADL), discharge destination, falls, balance, depression/anxiety, and quality of life immediately post-intervention and at longer-term follow-up. Comparisons included cognitive rehabilitation versus control (placebo, attention control, or no treatment) and comparisons between different cognitive rehabilitation approaches (e.g., top-down vs. bottom-up).
What was found
Twenty-three RCTs with 628 participants were included. Only 4 studies had low risk of bias in all categories, and 11 had adequate allocation concealment. Meta-analysis of cognitive rehabilitation versus control showed no statistically significant differences for: - Persisting effects on ADL (5 studies, n = 143) - Persisting effects on standardized neglect tests (8 studies, n = 172) - Immediate effects on ADL (10 studies, n = 343) A statistically significant effect favoring cognitive rehabilitation was found for immediate performance on standardized neglect assessments (16 studies, n = 437; SMD 0.35, 95% CI 0.09 to 0.62). However, sensitivity analyses restricted to high-quality studies eliminated this effect. Direct comparisons between rehabilitation types were limited to 5 small studies with substantial heterogeneity (I² > 40%). Only one study reported discharge destination (n = 30) and one reported falls (n = 8).
Why it matters
Current trial evidence is insufficient to confirm or refute the effectiveness of cognitive rehabilitation for reducing functional disability or improving long-term outcomes in post-stroke spatial neglect.
Limits
The evidence base is limited by small sample sizes across included trials (total 628 participants across 23 RCTs), widespread risk of bias, and poor allocation concealment. Most studies did not measure long-term persistence of effects, and critical clinical outcomes like falls, discharge destination, balance, and mood were rarely evaluated.
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