Research Article: The Impact of Recovery of Visuo-Spatial Neglect on Motor Recovery of the Upper Paretic Limb after Stroke

Date Published: June 20, 2014

Publisher: Public Library of Science

Author(s): Tanja C. W. Nijboer, Boudewijn J. Kollen, Gert Kwakkel, Francesco Di Russo.


The aim of the current study was to investigate the longitudinal relationship between improvements of synergism and strength of the upper paretic limb and severity of visuo-spatial neglect during the first 52 weeks post-stroke. The longitudinal association between severity of VSN and motor impairment using Fugl Meyer motor score and Motricity Index of the arm was measured in an intensive repeated measurement design including 18 measurement sessions for each subject. Neglect was assessed using the letter cancellation test applied in a prospective cohort of 101 ischemic, first-ever, hemispheric stroke patients. All time-dependent measures were taken weekly, starting within 14 days post-stroke. From week 10 to 20 biweekly measurements are obtained. The longitudinal relationship of (bi)weekly time on improvement of motor functions and severity of neglect was investigated using random coefficient analysis and trend analyses. Fifty-one of the 101 stroke patients showed neglect at stroke onset. Less improvement of synergism and strength of the upper paretic limb was associated with more severe neglect. This association was most pronounced in the first 10 weeks post-stroke. The seemingly suppressive effect of neglect on upper-limb motor recovery appears to take place mainly during spontaneous neurological recovery of first 10 weeks post-stroke. This finding suggests that damage to large-scale white matter tracts of especially the perceptual-attention networks suppress recovery of other networks at distance in the brain suggesting a common underlying mechanism.

Partial Text

Visuospatial neglect (VSN) is a frequent post-stroke disorder [1], [2], where patients demonstrate impaired awareness for contralesional stimuli. VSN is linked to poor motor recovery, higher disability, poor responses to rehabilitation services [3], yet the time course of suppressive effects of VSN are largely unknown [4] due to lack of prospective cohort studies satisfying the key methodological criteria for prognostic research according to the STROBE statement [5].

During repeated assessments, 12 out of 101 stroke patients withdrew (six had recurrent stroke, two cancer, one carotid endarterectomy, two refused control treatment, and one died from a heart attack). Therefore, 1670 (92.3%) of the planned 1818 measurements were made in the present cohort. Mean time interval between stroke assessments was approximately 8 days.

Currently, the critical period of spontaneous neurological change that contributes to observed cognitive, motor and activity recovery in the first months post-stroke is largely ignored in rehabilitation medicine [6], [7], [15], [30], [31], [32], [33]. The aim of the current study was to investigate the assumed remote, suppressive effects of VSN on the pattern of motor recovery of the upper paretic limb, as reflected by the Fugl-Meyer-arm score, during the first 52 weeks post-stroke. The focus was on FM-arm scores as they are often interpreted as a reflection of ‘true neurological repair’ by which patients regain their ability to control the different degrees of freedom in the paretic upper limb [11], [12]. Additionally, the impact of VSN on severity at stroke onset and recovery profiles was validated with Motricity Index of the arm (strength). Overall, the results suggested that more severe VSN is associated with more suppression on the pattern of recovery in synergism and strength from stroke-onset onwards resulting in slower improvements in time. However this association tapered off with each subsequent measurement in time. Trend analyses indicated that VSN patients not only have a significantly more severe impairment in strength at stroke onset, but also show less improvement in the first 10 weeks post-stroke when compared to non-VSN patients. Beyond this time window, further motor recovery was hampered in those with VSN when compared to non-VSN patients. With that, the suppressive effect of VSN on the pattern of motor recovery was mainly restricted to the same time-window in which spontaneous neurological recovery occurs [6]. Interestingly, not only the magnitude of motor recovery is much lower, the time course of recovery is also delayed and even becomes almost invariant after 10 weeks post-stroke onset.

This study is the first to disentangle the unique longitudinal courses of impaired motor functions patients with and without VSN as a function of progress of time. In the acute phase, VSN patients show more severe impairment of motor function and time-dependent recovery follows a different pattern with less improvement. Importantly, a suppressive, probably inhibitory effect of VSN on the pattern of improvement of motor impairment appears take place mainly within the first 10 weeks post-stroke, which is the exact same time-window in which spontaneous neurological recovery emerges.