Assessment Of Unilateral Spatial Neglect Research Articles

Ecological assessment of unilateral spatial neglect in immersive virtual reality: A multiple-case study to assess the feasibility and relevance of a Baking Tray Task

ABSTRACT The assessment of unilateral spatial neglect (USN) primarily relies on paper-and-pencil tests, which do not fully represent daily life difficulties. To address this limitation, ecological tests, like the Baking Tray Test (BTT), have been developed. However, the original BTT identifies the presence of USN without providing information on its severity. In this aim, a new severity measure, the Centre of Mass (CoM), has been proposed, but its calculation in real environments poses challenges. Immersive virtual reality (VR) offers a promising solution for implementing a BTT in which measures are automatically calculated. This study aimed to assess the feasibility and relevance of an immersive VR BTT. Nineteen right brain-damaged patients with and without USN and 25 healthy participants were included. Group analyses showed an equivalence between the two BTT versions. Individual analyses revealed that all USN patients, except one, had pathological results in both versions. They also underlined pathological scores in patients without USN signs on paper-and-pencil tests. Finally, the CoM strongly correlated with paper-and-pencil tests and appeared to be a good indicator of USN severity. These findings support the relevance of implementing the BTT in an immersive VR version, suggesting its potential to enhance USN assessment.

The Application of Immersive Virtual Reality and Machine Learning for the Assessment of Unilateral Spatial Neglect

Abstract Even subtle forms of hemispatial neglect after stroke negatively affect the performance of daily life tasks, increase the risk of injury, and are associated with poor rehabilitation outcomes. Conventional paper-and-pencil tests, however, often underestimate the symptoms. We aimed to identify relevant neglect-specific measures and clinical decision rules based on machine learning techniques on behavioral data generated in a new Virtual Reality (VR) application, the immersive virtual road-crossing task. In total, 59 participants were included in our study: two right-hemispheric stroke groups with left neglect (N = 20) or no neglect (N = 19), classified based on conventional tests and medical diagnosis, and healthy controls (N = 20). A neuropsychological test battery and the VR task were administered to all participants. We applied decision trees and random forest models to predict the respective groups based on the results of the VR task. Our feature selection procedure yielded six features as suitable predictors, most of which involved lateral time-related measures, particularly reaction times, and head movements. Our model achieved a high training accuracy of 96.6% and estimated test accuracy of 76.8%. These results confirm previous reports that temporal behavioral patterns are key to detecting subtle neglect in patients with chronic stroke. Our results indicate that VR combined with machine learning has the potential to achieve higher test accuracies while being highly applicable to clinical practice.

Validation of "Neurit.Space": Three Digital Tests for the Neuropsychological Evaluation of Unilateral Spatial Neglect.

Patients suffering from Unilateral Spatial Neglect (USN) fail to pay attention to, respond to, and report sensory events occurring in the contralesional side of space. The traditional neuropsychological assessment of USN is based on paper-and-pencil tests, whose data recording and scoring may be subjected to human error. The utilization of technological devices can be expected to improve the assessment of USN. Therefore, we built Neurit.Space, a modified digital version of three paper-and-pencil tests, widely used to detect signs of USN, namely: Bells Cancellation, Line Bisection and Five Elements Drawing Test. Administration and data processing is fully automatic. Twelve right brain-damaged patients (six with and six without USN) and 12 age- and education-balanced healthy participants were enrolled in the study. All participants were administered both the computerized and the paper-and-pencil versions of the tests. The results of this preliminary study showed good sensitivity, specificity, and usability of Neurit.Space, suggesting that these digital tests are a promising tool for the evaluation of USN, both in clinical and in research settings.

Virtual reality for the assessment and rehabilitation of neglect: where are we now? A 6-year review update

Unilateral spatial neglect (USN) is a frequent repercussion of a cerebrovascular accident, typically a stroke. USN patients fail to orient their attention to the contralesional side to detect auditory, visual, and somatosensory stimuli, as well as to collect and purposely use this information. Traditional methods for USN assessment and rehabilitation include paper-and-pencil procedures, which address cognitive functions as isolated from other aspects of patients’ functioning within a real-life context. This might compromise the ecological validity of these procedures and limit their generalizability; moreover, USN evaluation and treatment currently lacks a gold standard. The field of technology has provided several promising tools that have been integrated within the clinical practice; over the years, a “first wave” has promoted computerized methods, which cannot provide an ecological and realistic environment and tasks. Thus, a “second wave” has fostered the implementation of virtual reality (VR) devices that, with different degrees of immersiveness, induce a sense of presence and allow patients to actively interact within the life-like setting. The present paper provides an updated, comprehensive picture of VR devices in the assessment and rehabilitation of USN, building on the review of Pedroli et al. (2015). The present paper analyzes the methodological and technological aspects of the studies selected, considering the issue of usability and ecological validity of virtual environments and tasks. Despite the technological advancement, the studies in this field lack methodological rigor as well as a proper evaluation of VR usability and should improve the ecological validity of VR-based assessment and rehabilitation of USN.

Effects of visual-motor illusion in stroke hemiplegic patients with left-side personal neglect: A report of two cases

ABSTRACT Personal neglect is the neglect of self-body space, which often occurs in patients with unilateral spatial neglect (USN), but lacks a dedicated rehabilitation. The purpose of this study was to investigate the effects of visual-motor illusion (VMI) on two-stroke hemiplegic patients with left-side personal neglect. Case 1 was a 53-year-old man diagnosed with a right lenticulostriate artery infarction. Case 2 was a 76-year-old woman diagnosed with a right middle cerebral artery infarction. USN symptoms were not observed in either patient in the desk USN assessment, but personal neglect and USN symptoms in daily life were observed in both patients. Intervention effects were verified using an ABA design, comprising a 5-day three-phase (A1, B, A2). In phase B, VMI was performed on the paralyzed upper limb for 10 min in addition to conventional physical therapy. Outcomes measures were the Fluff test, Catherine Bergego Scale (CBS), Fugl-Meyer Assessment (FMA), and Functional Independence Measure (FIM). In both patients, no improvements were noted in FMA, but improvements were observed in the Fluff test, CBS, and FIM in phase B; these effects were retained in phase A2. Therefore, VMI may have contributed to improvements in Personal neglect and USN symptoms in daily life.

Effects of standing and walking training using a laser pointer based on stimulus-driven attention for behavioural outcome in spatial neglect: A single-case study

ABSTRACT The therapy for unilateral spatial neglect (USN) is unclear. This case report investigated the effect of standing and walking training using a laser pointer based on stimulus-driven attention for USN. The patient was a right-handed 79-year-old man with cardiogenic cerebral embolism in the right middle and posterior cerebral arteries. Initially, we evaluated the absence of hemiparalysis in the lower limb and sensory disorder; almost all daily activities were performed independently. Intervention effects were verified using the BABA method. The course of the four phases (B1, A1, B2, A2) was conducted for 5 days. In the B1 and B2 phases, standing and walking training using a laser pointer was performed additionally to conventional physical therapy. Outcomes were measured using the Behavioural Inattention Test conventional subtest (BIT-c), Catherine Bergego Scale (CBS), and modified Posner task (MPT). The BIT-c remained unchanged in each phase. CBS scores improved after B1 and B2. In the MPT, the reaction time in the left space reduced after B1 and B2 compared with those in the A1 and A2 control phases. In this case, training may have contributed to the improvement in the response to the neglected space and behavioural assessment of USN.

Behavioral Assessment of Unilateral Spatial Neglect with the Catherine Bergego Scale (CBS) Using the Kessler Foundation Neglect Assessment Process (KF-NAP) in Patients with Subacute Stroke during Rehabilitation in Japan.

The Kessler Foundation Neglect Assessment Process (KF-NAP) is an assessment tool for unilateral spatial neglect (USN), which is the scoring method for the Catherine Bergego Scale (CBS) based on detailed instructions. This study is aimed at determining the reliability and validity of the Japanese version of the KF-NAP (KF-NAP-J), evaluating the improvement of neglect assessment with KF-NAP-J, and comparing it with the original CBS for subacute stroke patients. We assessed subacute stroke patients admitted to our intensive rehabilitation hospital. Two KF-NAP-trained occupational therapists (OTs) assessed 22 patients. Before implementing the KF-NAP at the hospital, two other OTs assessed the other 23 patients using the CBS. We evaluated the interrater reliability of the KF-NAP and CBS using intraclass correlation coefficients (ICC) for the total scores, weighted kappa statistics for each subscale, and internal consistency using Cronbach's alpha. We assessed the validity of the KF-NAP against the Behavioral Inattention Test (BIT) and Functional Independence Measure (FIM) using Spearman's correlation coefficient. The reliability of both the KF-NAP and CBS was excellent. The weighted kappa results demonstrated that each subscale was in better agreement with the KF-NAP than with the CBS. In the KF-NAP, all eight subscales in which weighted kappa could be calculated were in significant agreement, and two were almost in perfect agreement. The KF-NAP moderately correlated with the subscales of BIT and FIM representing USN and activities of daily living. The USN detection rates of KF-NAP and BIT in the KF-NAP group were 63.6% and 22.7%, respectively. These results suggest that the KF-NAP, as well as the CBS, is useful to assess USN, which strongly impacts the rehabilitation outcomes in subacute stroke patients.

Assessment of Unilateral Spatial Neglect Using a Free Mobile Application for Italian Clinicians.

Background: Unilateral Spatial Neglect (USN) is traditionally assessed with paper-and-pencil tests or computer-based tests. Thanks to the wide-spreading of mobile devices, and the extensive capabilities that they have in dealing complex elements, it is possible to provide clinicians with tools for cognitive assessment. Contemporary 3D engine is, in general generally, able to deploy complex 3D environments for iOS, Android and Windows mobile, i.e., most of the mobile phone and tablet operative systems.Results: This brand-new scenario and pressing requests from professionals, pushed us to build an application for the assessment of USN. Our first attempt was to replicate the classic cognitive tests, traditionally used at this purpose. Ecological assessment is difficult in real scenarios so we implemented virtual environments to assess patients’ abilities in realistic situations. At the moment, the application is available only for iPad and iPhone for free, from the Apple Store, under the name of “Neglect App.” The App contains traditional tests (e.g., barrage with and without distractors) and ecological tests (e.g., to distribute the tea in a table to close people). Scoring of each test is available to the clinicians through a database with the executed ecological tasks, that are stored locally.Conclusion: In conclusion, Neglect App is an advanced mobile platform for the assessment of Neglect.

Use of immersive virtual reality to detect unilateral spatial neglect in chronic stroke

Unilateral spatial neglect (USN) is a neuropsychological syndrome in which patients fail to pay attention to and represent the contralesional part of the space. Standard assessment of USN is carried out with paper-and-pencil tests, which do not capture the full range of deficits (i.e., not sensitive enough; no evaluation of “far” space) or detect compensatory learning effects in chronic patients. Here we explore interactive and ecological assessments within immersive virtual reality (IVR) to overcome these limitations. Twelve chronic stroke patients (58 ± 9.4 years; 5 female; time from stroke: 15.8 ± 7.7 months) completed a battery of paper-and-pencil neuropsychological tests (line bisection, cancellation, reading, drawing, functional scales) and a IVR-based assessment for extra-personal USN. In the IVR tasks, participants were presented with a virtual environment representing a forest, via head-mounted display ( Fig. 1 ). The tasks consisted of finding static objects (level 1) or moving rabbits (levels 2–4) in the scene. Difficulty was modulated with the presence of distractors and an additional auditory dual task. Participants used the embedded head tracker in the HMD to control a pointer to select the targets in the scene, and the space bar of the computer to validate the selected item. Four patients presented USN in both paper-and-pencil and IVR tasks. Interestingly, two other participants showed signs of neglect in the IVR assessment without being classified as neglect patients in the paper-and-pencil tests. These patients did not show signs of USN in the items of the Catherine Bergego Scale that assesses their ability to explore the extra-personal space. This preliminary data suggests that IVR-based assessments represent an easy-to-use and consistent tool to investigate USN, can extend its evaluation to the far space, and can detect USN in chronic patients who do not show sign of neglect in standard assessments.

Post-stroke visual neglect affects goal-directed locomotion in different perceptuo-cognitive conditions and on a wide visual spectrum.

Unilateral spatial neglect (USN), a highly prevalent and disabling post-stroke deficit, has been shown to affect the recovery of locomotion. However, our current understanding of USN role in goal-directed locomotion control, and this, in different cognitive/perceptual conditions tapping into daily life demands, is limited. To examine goal-directed locomotion abilities in individuals with and without post-stroke USN vs. healthy controls. Participants (n = 45, n = 15 per group) performed goal-directed locomotion trials to actual, remembered and shifting targets located 7 m away at 0° and 15° right/left while immersed in a 3-D virtual environment. Greater end-point mediolateral displacement and heading errors (end-point accuracy measures) were found for the actual and the remembered left and right targets among those with post-stroke USN compared to the two other groups (p < 0.05). A delayed onset of reorientation to the left and right shifting targets was also observed in USN+ participants vs. the other two groups (p < 0.05). Results on clinical near space USN assessment and walking speed explained only a third of the variance in goal-directed walking performance. Post-stroke USN was found to affect goal-directed locomotion in different perceptuo-cognitive conditions, both to contralesional and ipsilesional targets, demonstrating the presence of lateralized and non-lateralized deficits. Beyond neglect severity and walking capacity, other factors related to attention, executive functioning and higher-order visual perceptual abilities (e.g. optic flow perception) may account for the goal-directed walking deficits observed in post-stroke USN+. Goal-directed locomotion can be explored in the design of future VR-based evaluation and training tools for USN to improve the currently used conventional methods.

Persistent neglect in everyday life

Unilateral Spatial Neglect (USN) is a multifarious syndrome ( Cubelli, 2017 ), aspects of which could be long lasting either as poor performance on individual diagnostic tests ( Farne et al., 2004 ), in subclinical forms ( Colombo et al., 1982 ) or as a marked preference for the ipsilesional side even in the absence of overt omissions ( Mattingley, et al., 1994 ). The assessment of USN, both when first diagnosed and in the follow-ups, is carried out by means of standard tests. However, these tests are not equipoise in detecting USN ( Halligan et al., 1989 ); they can present double dissociations ( Halligan and Marshall, 1992 ) and can be differentially sensitive to compensation strategies ( Campbell and Oxbury, 1976 ). Therefore, it is widely assumed that the more tests are used, the higher is the probability of detecting signs of initial or residual USN ( Azouvi et al., 2006 ). Nevertheless, we have observed a dissociation between normal performance on all formal tests of a very large battery and clear signs of USN in everyday tasks and actions.

Towards a Dynamic Assessment of Unilateral Spatial Neglect

Background: The traditional paper and pencil tests are often inadequate to detect the mild forms of Unilateral Spatial Neglect (USN). Objective: To verify the effectiveness of a touchscreen-based cancellation test in assessing individuals with USN. Methods: Seven individuals, six with right and one with left brain damage, who showed moderate to severe USN at admission, were involved in the study. Besides classic paper and pencil tests, participants were presented with a new, “user-friendly”, device consisting of an interactive “table” that integrates the principles of ecologic interaction and sophisticated technology. Such a touch screen table made possible to analyse the spatial and temporal evolution of the participants’ performance, providing a set of indices related to “how” the different tasks have been fulfilled, rather than simple raw scores. Results: This new technological approach turned out to be much more sensitive than the classic paper and pencil tests to detect the slightest forms of USN. In particular, while four out of the seven participants, performed flawless on the papery version of the Albert’s test, all of them made errors on the technological versions of the same Albert’s test. Finally, under all the different experimental conditions, participants achieved always a better performance when asked to erase rather than mark stimuli. Conclusion: Such a device has a potential in the ecological assessment of USN as well as in monitoring its evolution. Although in need of further substantiation, our findings further support the need to go beyond the traditional paper and pencil tests in the assessment of USN. The information provided by a more dynamic approach seems to be relevant for both clinical and research purposes.

A case study of new assessment and training of unilateral spatial neglect in stroke patients: effect of visual image transformation and visual stimulation by using a head mounted display system (HMD)

BackgroundUnilateral spatial neglect (USN) is most damaging to an older stroke patient who also has a lower performance in their activities of daily living or those elderly who are still working. The purpose of this study was to understand more accurately pathology of USN using a new HMD system.MethodsTwo stroke patients (Subject A and B) participated in this study after gaining their informed consent and they all had Left USN as determined by clinical tests. Assessments of USN were performed by using the common clinical test (the line cancellation test) and six special tests by using HMD system in the object-centered coordinates (OC) condition and the egocentric coordinates (EC) condition. OC condition focused the test sheet only by a CCD. EC condition was that CCD can always follow the subject's movement. Moreover, the study focused on the effect of the reduced image condition of real image and the arrows.ResultsIn Patient A who performed the common test and special tests of OC and EC conditions, the results showed that for the line cancellation test under the common condition, both of the percentage of the correct answers at the right and left sides in the test sheet was 100 percent. However, in the OC condition, the percentage of the correct answers at the left side in the test sheet was 44 percent and the right side was 94 percent. In the EC condition, the left side was 61 percent and the right side was 67 percent. In Patient B, according to the result of the use of reduced image condition and the arrows condition by HMD system, these line cancellation scores more increased than the score of the common test.ConclusionsThe results showed that the assessment of USN using an HMD system may clarify the left neglect area which cannot be easily observed in the clinical evaluation for USN. HMD may be able to produce an artificially versatile environment as compared to the common clinical evaluation and treatment.

Family Participation Can Improve Unilateral Spatial Neglect in Patients with Acute Right Hemispheric Stroke

Objective: Unilateral spatial neglect (USN) is one of the major behavioral disturbances in patients with cerebral lesions and often impairs the patients’ independence in activities of daily living (ADL). Although many studies have addressed the mechanism and assessment of USN, there have been only few reports on rehabilitation strategies for patients with USN. The present study examined whether family participation can contribute to an improvement in USN following an acute stroke. Design: This study compared the improvement at 3 weeks among patients treated with conventional exercise sessions and a program including the participation of family members. The study followed 34 stroke patients with hemiparesis and USN. Twenty had family participation in their therapy. The severity of USN was measured using the Behavioral Inattention Test (BIT) and a laterality index (LI). Mobility was assessed using the Rivermead Mobility Index (RMI), and ADL were assessed using the Barthel index. Results: The results showed a relationship between BIT score improvement and family participation, and the BIT score improvement reflected the LI improvement. The RMI and BIT scores showed that ADL improved more with than without family participation. Conclusion: Family participation improved not only the mobility but also USN, suggesting that it can make important contributions to acute stroke rehabilitation.

Assessment of unilateral spatial neglect: Scoring star cancellation performance from video recordings—method, reliability, benefits, and normative data.

Unilateral spatial neglect, a debilitating condition affecting awareness of one side of space, is commonly assessed using cancellation tasks in which patients cross out targets distributed over a sheet. Standard scores emphasize the left-right distribution of omissions. Here, the additional value of extracting temporal as well as spatial aspects of performance from video recordings was examined. Videos from 18 patients with left neglect and 19 healthy age-matched control participants were obtained. Interrater reliability of the video analysis was high. In addition to overall differences in target detection and bias, patients significantly differed from the control group in terms of the location of first cancellation, overall slowness, greater variability in speed, systematic slowing with time on task and as a function of target location, less coherent search organization, and a sharply increased tendency to recancel targets. Considering a subset of patients whose scores, by standard criteria, were at or near the normal range indicated that these additional variables indeed increased the sensitivity of the task as well as allowed the simultaneous assessment of spatial and nonspatial aspects of the disorder.

Intérêt de la thérapie par contrainte induite chez l’enfant hémiplégique après lésion cérébrale acquise

Constraint-induced movement therapy is a promising technique for improving upper limb function in adults with hemiplegia. It involves restraint of the non-involved limb and intensive movement practice with the paretic limb. Although the technique has been applied successfully to children with cerebral palsy, only two studies have used it in children with acquired brain injury. ObjectiveTo assess the feasibility and efficacy of constraint-induced movement therapy in children with acquired brain injury. MethodsWe used a single-subject experimental design in three children (aged five at the time of the intervention) with hemiplegia in the chronic phase following acquired brain injury. The intervention involved restraint of the unaffected arm with a Mayo Clinic elbow brace for seven hours a day in a hospital setting, together with three hours a day of physical and occupational therapy rehabilitation for five days a week for two weeks. The children were assessed twice at baseline and then once immediately post-treatment and again two months post-treatment. Assessment included a range of timed, quantitative measures of upper limb use, assessment of unilateral spatial neglect and qualitative assessment by therapists and parents in terms of activities of daily living. ResultsThe three children completed the full protocol and improved significantly in all timed, quantitative tests of motor function. These improvements were partially maintained at two months. No improvement in unilateral spatial neglect was found in the paper-and-pencil tasks, although less spatial neglect was observed in activities of daily living such as eating and walking. ConclusionConstraint-induced movement therapy appears to be both feasible and efficient in children with acquired brain injury.

Occupational Therapists’ Identification, Assessment, and Treatment of Unilateral Spatial Neglect During Stroke Rehabilitation in Canada

Unilateral spatial neglect (USN) is a disabling feature of stroke, and its identification and management are critical for optimizing patient outcomes. This study examined USN problem identification, assessment, and treatment among clinicians working in stroke rehabilitation. This report was based on a Canada-wide survey of 253 occupational therapists providing inpatient stroke rehabilitation. Eighty percent (n=202) recognized USN as a potential problem, 27% (n=67) reported using standardized USN assessment tools, and 58% (n=147) indicated using USN interventions. Working on a stroke unit and younger age were among the variables explaining 7% to 19% of the variability in USN problem identification, assessment, and intervention use. Although USN problem identification was high, clinicians were unlikely to use standardized assessment tools or evidence-based interventions to effectively manage this serious impairment.

Assessment of unilateral spatial neglect post stroke in Canadian acute care hospitals: are we neglecting neglect?

Objective: To estimate the prevalence, timing and frequency of use of standardized and non-standardized assessments to detect unilateral spatial neglect in acute care patients post stroke. Design and setting: Multicentred, retrospective study on medical charts from 10 randomly selected acute care hospitals in Ontario, Canada. Subjects: Three hundred and twenty-four randomly selected medical charts of adult subjects with a primary diagnosis of stroke admitted in 2002 to the participating acute care hospitals. Results: Out of 248 subjects who should have been assessed, 38% received some form of unilateral spatial neglect assessment. Only 13% were assessed with a standardized assessment and of these, 4% within 48 h post stroke or within 48 h of the patient regaining consciousness as recommended by clinical practice guidelines for stroke. Bivariate analysis found significant associations between severity of cognitive impairment and being ever assessed, as well as between the severity of motor deficits of the upper extremity and being ever assessed. Conclusion: Routine standardized assessment of unilateral spatial neglect during the acute care phase post stroke was not incorporated into daily practice in this study sample.

Assessment of unilateral spatial neglect in children using the Teddy Bear Cancellation Test

The purpose of the study was to provide normative data for the Teddy Bear Cancellation Test (TBCT) and to evaluate prospectively the frequency of unilateral spatial neglect (USN) in children with acquired brain injury (ABI). In the control group (n = 419; 218 males, 201 females; mean age 5y 1mo [SD 1y 4mo]; range 3 to 8y) omissions were rare and decreased with age. A left displacement of the first three teddy bears cancelled was observed with increasing age. This preferential left-to-right cancelling strategy was interpreted as learned under the influence of reading habits. The same test was used prospectively in 41 children with ABI (24 males, 17 females; mean age 5y 5mo [SD 2y]; range 3 to 8y) admitted to a paediatric rehabilitation department specializing in acquired brain lesions. In patients and controls, children under 6 years of age omitted more items than older children. The localization of omissions was skewed significantly to the left in children with right-sided lesions compared with children with left-sided lesions. USN was observed in seven patients with ABI. Left USN was found in three of the 10 patients with right-sided ABI. Right USN was present in two of the patients with 15 left-sided ABI and two of the 16 patients with non-lateralized ABI. Left USN is frequent in children after right-sided brain injury. The relatively high incidence of right spatial neglect in children is discussed in relation to the development of hemispheric specialization.

Unilateral spatial neglect: Relation to rehabilitation outcomes in patients with right hemisphere stroke

Gillen R, Tennen H, McKee T. Unilateral spatial neglect: relation to rehabilitation outcomes in patients with right hemisphere stroke. Arch Phys Med Rehabil 2005;86: 763–7. Objective To examine the relation between left unilateral spatial neglect (USN) and rehabilitation outcomes in patients with right hemisphere stroke. Design A retrospective analysis of a database of right hemisphere stroke patients. Setting Acute inpatient rehabilitation hospital. Participants Patients (N=175) with a diagnosis of right hemisphere stroke who had undergone a neuropsychologic screening including assessment of USN and depressive symptoms at time of admission to an inpatient rehabilitation program. Interventions Not applicable. Main outcome measures Functional status was evaluated with the FIM instrument at admission and discharge. The relationship between USN, depressive symptoms, cognitive functioning, length of stay (LOS), and rate of progress in rehabilitation was examined via univariate (correlational) and multivariate (Cox regression) analyses. Results Patients with USN had longer LOS and progressed more slowly compared with those without USN. When matched against patients with equally poor functional status at admission, USN patients still had longer admissions and progressed more slowly. Conclusions USN is a unique predictor of rehabilitation outcomes in patients with right hemisphere stroke. Identification of those specific functional skill areas most affected by USN may make possible the development of targeted interventions aimed at these key areas.