Occupational Therapy Interventions for Unilateral Neglect

I was first inspired to write this post about interventions for unilateral neglect as I was remembering my first evaluation with this condition on my own after I was working at my first job out of OT school.

I  realized that it was much more of a challenge for me to figure out on-the-spot optimal interventions for my patient experiencing visual neglect/inattention, especially since I didn’t have a CI to bounce ideas off of.

If I’d done some planning beforehand, it would have made me feel a bit more prepared for my first treatment with this patient without rummaging through my textbooks frantically my first day with them.

To help you avoid this similar stress, I’ve included current evidence-based interventions that I studied in detail for this article. I hope this article helps you when you’re new and out in the field treating on your own (or in your Level II Fieldwork).

We’ll first go over what unilateral neglect actually is, followed by several treatment ideas. 

Other Names for Unilateral Neglect:

Unilateral neglect can be referred to as many different things, for example:

• Hemi-neglect
• Hemispatial neglect
• One-side neglect
• Left- right-side neglect
• Visual neglect
• Unilateral neglect syndrome
• Unilateral spatial neglect
• Hemi-inattention

For the sake of clarity, I’ll stick to the term “unilateral neglect.”

The definition of unilateral neglect is that it is a condition, after damage to one brain hemisphere occurs, where the person becomes unaware of and inattentive to one side of the body. This is usually the side opposite to the half of the brain that was damaged, i.e. a right CVA (stroke) causing left neglect.

Characterizing Unilateral Neglect

The defining characteristics are:

• Consistent inattention to stimuli on the affected side (Mosby’s, 2006)
• Inadequate self-care
• Lack of looking toward the affected side
• Leaving food on the plate of the affected side

Essentially, after the injury or stroke, the person cannot process or perceive stimuli on the affected side of the body and/or environment (again, usually the side opposite of the injury).

You may find that the person will walk or propel their wheelchair into walls or door frames on the neglected side, lean towards their unaffected side, keep their head turned away from the neglected side, forget to put their affected arm into a shirt sleeve, or only shave half of their face, among other behaviors.

Effects of Unilateral Neglect

Unilateral neglect is potentially dangerous for the patient due to impaired mid-line orientation and postural control during mobility. For example, wheelchair collisions and falls may occur toward the affected side.

Not only is it dangerous, the neglect itself can also be detrimental to the recovery of the affected side if nothing is done to help train the patient to acknowledge the affected side.

Motor recovery in a hemiparetic arm is much more likely to occur when the patient can attempt to use that side. If they are completely ignoring that arm and only using the unaffected arm, chances for regaining movement of the affected side are low.

Because of this, patients are also more likely to experience a debilitating loss of independence in ADLs (Jehkonen and Colleagues, 2006), which makes treating this aspect of the patient’s condition post-injury even more important.

5 Interventions for Treating Unilateral Neglect

First, it’s important to know the biggest mistake to avoid which is just repeating to the patient, “Look to your left” over and over (and over!). It’s just not going to be that effective. (Note: If I keep referring to the “left” side, this is because left neglect is much more common than right neglect. If your patient has right neglect, you’ll have the same effect.)

There are quite a few interventions to do with your patient experiencing unilateral neglect. The ones I use most commonly are listed here. If you have any other interventions you like to use, be sure to leave them in the comments at the end!

1. Encourage Use of Affected Side

Encourage using the affected hand during ADLs as much as possible if your patient has movement in that extremity. You can do this by using hand over hand guiding to help your patient use their fork, wash their face and body with the affected hand, squeeze toothpaste, or brush their hair.

If they have enough movement in their affected hand to pick up and drop a washcloth, consider making this an activity. Have the patient pick up small items incorporating reaching and keeping it functional and not too difficult for the patient.

Try to only use the patient’s affected hand during your session (which is basically a form of constraint-induced movement therapy). This intervention is kind of a “double whammy” and is really beneficial not only because it has the patient use the affected extremity, but also it encourages the person to look/scan to their affected side.

If your patient’s affected arm is flaccid (not able to move), you can use hand over hand guiding so they use their hand passively. This could be to hold an item or use it as a stabilizer during ADLs.

2. Anchoring

Instruct the patient to scan to the affected side by providing visual cues like a bright post-it note or colored tape and train the patient to scan using the mental imagery “Lighthouse strategy” looking all the way to the anchor and back (like a light from a lighthouse).

Sit at the patient’s affected side at all times as well, as this can help to cue the individual to look more towards their affected side.

 3. Visual Scanning

Incorporate visual scanning activities like letter cancellation worksheets or word finds, and even consider adding in vibration to the affected side during rest breaks to provide more sensory input.

4. ADLs with a Mirror

Perform ADLs in front of a mirror in addition to practicing transfers and mobility to draw attention to the affected side (Reed, 2014). This will really help to provide visual feedback to your patient and can aid in mid-line orientation as the person can help to correct their leaning posture.

5. Eye Patch/Partial Visual Occlusion

This technique uses standard eyeglasses that have half of both lenses taped or blacked out on the same side of each lens. This aids in training the person to look through the side of the lens being ignored. This technique can be used during performance of activities to assist in attending to the neglected side (Unsworth, 2007).

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I hope this helps give you a starter guide of interventions to help your patients experiencing neglect or inattention using either compensatory or remedial strategies, depending on what you feel will work best for your patient.

I also urge you to do a little homework of your own if you have a patient with this condition. There are multiple ways to approach unilateral neglect, and reading up all you can on it can really help you to understand the neurological aspects of it.

Also, if you have any questions or other evidence-based interventions that you’ve found to be effective in your practice, please don’t hesitate to add them to comments for more tips and ideas.

Lastly, be sure to check out these additional vision resources here:

Unilateral Spatial Neglect: New Treatment Approaches With Potential Application to Occupational Therapy (AOTA)

Treatment Strategies for Unilateral Visuospatial Neglect and Anosognosia (MedBridge)

Finding Your Passion For All Things Vision in Occupational Therapy (My OT Spot)

Vision Assessment and Treatment: Your One-Stop Shop (My OT Spot)

This post was originally published on April 18, 2016 and updated on June 10, 2020.