Journal of Rehabilitation Medicine 51-1CompleteIssue | Page 33

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Y. Kimura et al.
These results showed that USN was not significantly
associated with recovery of independent gait in stroke
survivors without other CIs. This result is consistent
with some previous studies, which showed that USN
had no negative prognostic influence on gait ability
and ADL ability (12, 30). Several previous studies
have investigated the time course of USN recovery and
shown that the severity of neglect greatly improved
until about 12 weeks after the onset of stroke (31–33).
Another recent study reported that the improvement
in the severity of neglect significantly correlated with
increased MMSE scores in subacute stroke survivors
(34). In our results also, neglect symptoms disappea-
red at discharge in approximately half of the stroke
survivors in group 2. Therefore, the influence of the
presence of USN at admission on independent gait
recovery might be limited in stroke survivors with
relatively good other cognitive functions. In contrast,
approximately 75% of stroke survivors in group 1 still
had neglect symptoms at discharge and were signifi-
cantly inhibited from regaining independent gait.
Several studies have concluded that USN is a nega-
tive predictive factor of functional outcome in stroke
survivors (7–10, 34, 35). Unlike these previous studies,
our results showed that USN was not significantly asso-
ciated with recovery of independent gait in stroke sur-
vivors without other CIs. Stroke survivors with USN
often have other cognitive dysfunctions that negatively
influence functional recovery. However, some of the
previous studies that concluded USN as a negative pre-
dictive factor of functional outcome did not consider
other cognitive functions (7, 34, 35), in other words,
whether USN itself or its combination with other CIs
played a crucial role in functional recovery is unclear.
The influence of USN may be overestimated unless
other cognitive functions are considered.
The main finding of this study is that the presence
of USN with other CIs had a strong negative impact
on recovery of independent gait. Stroke survivors with
USN are unable to orient their attention toward the left
hemi-space and often are not aware of the left side of
their body while performing everyday tasks. These
neglect symptoms could lead to unstable walking, for
instance, because stroke survivors with spatial neglect
tend to bump into objects (36). Awareness regarding
disability is a key determinant to overcoming these
neglect symptoms in stroke survivors with USN (37).
Cognitive skills, such as short-term verbal memory,
non-spatial attention, comprehension, and orientation,
are fundamental to the awareness and understanding
of the impairments, as well as understanding the re-
lationship between insight and the capacity to learn.
Deficits in these cognitive skills could interfere with
stroke survivors’ awareness of neglect symptoms
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and inhibit learning of compensatory strategies to
overcome disabilities in the rehabilitation and ADL
settings. Therefore, the presence of USN with a low
MMSE score may have a strongly negative impact on
recovery of independent gait in stroke survivors.
Study limitations
This study has several limitations. First, the subtypes
of USN were not considered. A previous study reported
that the improvement in ADL differed depending on the
subtypes of USN (38), and that it could also be associa-
ted with gait independence. Therefore, it is necessary
to consider a more nuanced definition of USN in future
studies. Secondly, the sample size was relatively small;
in particular, only 3 participants in group 1 regained
independent gait. Further studies will require a larger
cohort and the inclusion of stroke survivors with various
severities. Thirdly, we did not examine the more detailed
domains of cognitive functions, such as memory, langu-
age, attention, and executive function. Further studies
are warranted to investigate the relationships between
specific domains of cognitive impairment and functional
outcomes. Finally, we did not investigate information
regarding apathy and anosognosia for hemiplegia. Apa-
thy and anosognosia are often found in stroke survivors
and are known to have a negative effect on functional
outcome (30, 39, 40). Further studies should investigate
these symptoms and take into account their influence on
the recovery of gait ability in stroke survivors.
Conclusion
The presence of USN in subacute stroke survivors with
relatively good other cognitive functions was not sig-
nificantly associated with recovery of independent gait
during hospitalization in the convalescent rehabilitation
ward. In contrast, stroke survivors with USN and other
CIs were significantly inhibited from regaining indepen-
dent gait even after controlling for covariates such as
ADL ability at admission, and severity of hemiplegia.
These findings indicated that USN became a strong
negative predictor when combined with other cognitive
dysfunctions, and that only 10% of the stroke survivors
with both USN and other CIs regained independent gait
during hospitalization. These results may be helpful in
accurate prediction of the prognosis of subacute stroke
and decisions regarding interventions required for reco-
very of independent gait in subacute stroke survivors.
ACKNOWLEDGEMENTS
We thank the nursing staff and rehabilitation therapists of JCHO
Tokyo Shinjuku Medical Center for their contributions to the
data collection.