The Speed of Trust Advances Treatments

Spatial neglect and resulting problems with managing 3-dimensional space adaptively are more disabling than paralysis or language and speech disabilities. The problem occurs in over 50% of patients hospitalized for stroke and impairs simple and complex functions, including the critical activities of daily living required to drive, work, and even manage personal finances. When writing numbers on a page, a patient with spatial neglect will often leave out digits on the far left, for example, reading “$1,506” as “$6.” Patients with spatial neglect have difficulty standing straight, failing to notice what happens with one side of the body, which makes standing, sitting, and walking all safety concerns (Box 1). These patients have longer stays in rehabilitation hospitals, yet do not make as much progress in rehabilitation as patients without spatial neglect. They experience twice as many falls during stays in rehabilitation hospitals and are less likely to return home.

However, spatial neglect is usually not diagnosed or treated. What the patient described in Box 1 experienced was a step forward from what most of the 300,000 people with spatial neglect on US stroke units every year go through. She was fortunate to be at one of two places at the time that were actively diagnosing and prescribing visual-motor training with off-the-shelf optical prisms as part of her rehabilitation.

A Paradigm Shift in Treatment of Spatial Neglect

There is a treatment for spatial neglect that uniquely targets spatial aiming and visual-motor rehabilitation through the use of prism lenses (Figure 1), but it has been appreciably underutilized. Abnormally directed movements in spatial neglect account for specific disability in the hospital setting; that is, our understanding of the 3-dimensional world affects how we move. Yet, because doctors and therapists were taught that spatial neglect was a visual problem, they did not utilize tools identifying and treating spatial movements. Instead, most stroke, brain injury, and rehabilitation practitioners used tools they identified with improving vision and were familiar with, such as verbal cuing methods.

At the Kessler Foundation and the Kessler Institute for Rehabilitation, our research on spatial neglect care introduced a paradigm shift. Instead of treating spatial neglect as something that could not be changed and which clinical staff, patient, and family had simply to accept, clinicians began to present it as a problem of movements that could recover with spatial retraining. This included several steps and changes in clinical perspective (Table).

Some of these tools were last formally investigated in the 1970s; some of them have never been formally evaluated (Table).

We, and others in France, Germany, Switzerland, Italy, Japan, and many other countries demonstrated that spatial retraining with prism adaptation helped people with spatial neglect to become independent by starting to use a wheelchair, dress themselves, and return to their routine. It wasn’t, however, until the therapists working with us started to see the gains patients were making that we earned their trust, and the paradigm shift took hold.

Spread Paradigm Shifts with the Speed of Trust

The American Academy of Neurology Transforming Leaders Program

In 2016-2017, I was honored to be selected as part of a group of mid-career leaders supported by the American Academy of Neurology, the Transforming Leaders Program (https://www.aan.com/conferences-community/leadership-programs/transforming-leaders/). As our group project, my colleagues and I worked to address how the American Academy of Neurology could expand the scope of neurologic practice to include a greater emphasis on preventive, interventional, and regenerative care. Each of the team members also developed an individual project, expanding the scope and impact of neurologic care in their subspecialty, discipline, region, and institutions.

It is said that new work processes move forward at the speed of trust. The spatial systems in the right brain tell us continuously where our bodies are in the 3-dimensional world. With our spatial system, we can accomplish goals as challenging as steering a car at 60 miles per hour on a rainy highway, or as straightforward as maneuvering around a conference table while greeting a colleague, holding a cup of coffee, and wearing new high heels.

As part of our training in the Transforming Leaders Program 2016-2017 American Academy of Neurology group, we focused on how a system of communication, practice, monitoring, and trust can also change the paradigm of neurological care. A new-rologist leads and facilitates clinical teams, builds tools to implement new therapies, and communicates the vision and purpose of team-based care.

Neurologist-Led Team-Based Care Pathways

The 2016-2017 Transforming Leaders also identified neurologist-led team-care pathways as essential to achieving the triple aim of new-rology: improving functional outcomes, cost effectiveness, and the patient experience. The care pathway from diagnosis to treatment for spatial neglect, using prism adaptation, traverses this new territory (Figure 2).

We recommended that neurologists can become active change agents to develop, recommend and guide national policy and our field. In this new role, we can introduce work processes into practice that are required as new, evidence-based treatments emerge for previously untreatable neurological disorders. Organizations like the American Academy of Neurology will be invaluable allies that may serve as catalysts for change. They can provide endorsement, infrastructure, and encouragement to neurologists and their teams. However, the process will always require a neurologist at the bedside, whose belief in the possibility of rehabilitation inspires the team to action.

We presented that neurologist-led care pathways could extend to rehabilitation and enhance recovery. Neurologists can lead this process, reminding our colleagues, patients, their families, and the public that our purpose is to improve rehabilitation so that we can serve all of society (Box 2). I emphasized the need to inspire practitioners to try the spatial neglect care pathway in a 2016 TEDx lecture in Herndon, Virginia.

Barrett AM, Goedert KM, Basso JC. Prism adaptation for spatial neglect after stroke: translational practice gaps. Nature Reviews Neurol. 2012;8:567-577

Champod AS, Frank RC, Taylor K, Eskes GA. The effects of prism adaptation on daily life activities in patients with visuospatial neglect: a systematic review. Neuropsychol Rehabil. 2016:published online May 18.

Chen P, Hreha K, Kong, YK, Barrett, AM. Impact of spatial neglect in stroke rehabilitation: evidence from the setting of an inpatient rehabilitation facility. Arch Phys Med Rehabil. 2015 Aug;96(8):1458-66.

Goedert KM, Chen P, Boston RC, Foundas AL, Barrett AM. Presence of motor-intentional aiming deficit predicts functional improvement of spatial neglect with prism adaptation. Neurorehabil Neural Rep. 2013;28(5):483-493.

Shigaki CL, Frey SH, Barrett, AM. Rehabilitation of post-stroke cognition. Semin Neurol. 2014 Nov;34(5):496-503.

A. M. Barrett, MD, FAAN, FANA, FASNR

Director, Stroke Rehabilitation Research
Kessler Foundation
Professor, Physical Medicine and Rehabilitation
Rutgers New Jersey Medical School
West Orange, NJ

Jennifer Bickel, MD, FAAN

Assistant Professor, Pediatric Neurology
Children’s Mercy Hospital Neurology
Kansas City, MO

Daniela Bota, MD, PhD

Associate Professor, Neurology
University of California Irvine Medical School
Irvine, CA

Anil Dhuna, MD, FAASM, FAAN

Clinical Adjunct Assistant Professor
University of Iowa School of Medicine
Burlington Neurology & Sleep Clinic
West Burlington, IA

Richard Ferguson, MD, MBA, FACP

Chief, Neurology
Erie County Medical Center
Buffalo, NY

Charlene Gamaldo, MD, FAASM, FAAN

Associate Professor, Neurology
John Hopkins University School of Medicine
Baltimore, MD

Susan T. Herman, MD, FAAN

Assistant Professor, Neurology
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA

Barbara C. Jobst, MD, FAAN

Professor, Neurology
Dartmouth Geisel School of Medicine
Hanover, NH

J. Kirk Roberts, MD, FAAN

Associate Professor, Neurology
Columbia University Medical Center
New York, NY

Michael Waters, MD, PhD, FAAN

Professor, Neurology
Barrows Neurological Institute
Scottsdale, AZ