Category Archives: Visual Spatial and Left Neglect

Signs of Left Neglect

Left neglect is one of the more curious symptoms of brain injury.  Briefly, left neglect is an attention deficit in which a patient’s brain essentially tells that patient to ignore the left side of his or her world.  For that individual, it is almost as if the left side of the world does not exist.  It is most commonly observed when a patient ignores items in the left visual field (even when visual acuity is perfect) but can also involve hearing and sensation on the left side.  Left neglect is due to an injury to the right side of the brain.  Different techniques (such as practicing scanning skills) are used to help manage left neglect.  For more general information on left neglect, please see these previous posts on the topic:

What is Left Neglect?

Left Neglect vs. Field Cut

What I would like to do with this post is to give a few signs that rehabilitation professionals commonly observe when diagnosing cases of left neglect.  Below is a list of these common indicators of left neglect.

1. The patient only eats food on the right side of plates and does not notice food on the left side.  Often the patient will complain that he or she is not being fed enough because the patient believes that he or she is only being offered half-sized portions (since food to the left is necessarily ignored).

2. The patient bumps against objects with the left side of the body or wheelchair.  For instance, the patient may catch the left side of a door frame as he or she attempts to enter or exit a room.  Typically, patients who are just beginning to understand their left neglect and have yet to become proficient in scanning techniques will have bruising visible along the left arm or leg.  Staff often have to monitor patients in wheelchairs who have left neglect to ensure that the patients’ left arms do not fall down and get caught in the wheels of their wheelchairs.

3. The patient does not face people to his or her left, even when talking with these people.  Many times the patient may begin a conversation face to face, but slowly during that conversation his or her gaze can be observed to drift to the right.

4. The patient only shaves the right side of the face, only washes the right side of the face or only puts make-up on the right side of the face.

5. The patient misses words on the left side of the page.  This can cause a patient to complain that the reading material he or she is given does not make sense because the patient does not realize that he or she is only reading words on the right side of the page.

6. The patient is unable to find rooms located on the left side of a hallway.  Sometimes a patient will claim that a room has “moved” or “disappeared” since the patient cannot find the room in question.

7. The patient will start all activities on the right side and not make it all the way to the left. As example, a patient may play Connect 4 and only place chips on the right half of the board.  The patient may also be seen squeezing all his or her writing onto the right side of a page while leaving the left side of the page entirely blank.  When drawing a picture, the patient may leave a similarly barren left side of the page upon completion.

8. The patient complains that he or she is losing hearing in a left ear even though audiological testing shows no hearing loss.

9. In extreme cases, a patient may not recognize a left arm or leg as being his or her own body part.  When the patient sees this limb but does not recognize it, he or she may even make a complaint such as that a stranger has joined him or her in bed.

I hope this post helps everyone understand some of the more common signs of left neglect that rehabilitation professionals often observe!

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Left Neglect vs. Field Cut

It is possible for multiple distinct symptoms of an acquired brain injury to present in remarkably similar fashions.  For instance, a brain-injured survivor’s failure to take medication could be due to a memory deficit leading that survivor to simply forget his or her medication or it could be due to an attention deficit leading the survivor to be too distracted to take the medication in question.  In each case the medication was missed, but for acutely separate reasons.  A similar issue comes to light in observation of post-injury visual deficits.  Did a survivor fail to notice information to his or her left due to left neglect or due to a field cut?

Let’s start off with outlining precisely what a field cut is, as it is the simpler of the two to understand.  Under the effects of a field cut, the survivor has actually permanently lost the ability to perceive a portion of the field of vision.  That area of the field formerly available has now been “cut” away.  Due to his or her injury, the survivor is now in effect partially blind.  In medical terms, this loss of vision is often called “hemianopsia.”  So a survivor contending with a field cut has had actual visual loss  in his or her left visual field and thereby misses seeing information on his or her left side.

Left neglect is an attention issue which often manifests in the visual attention domain.  It is associated with an injury to the right side of the brain.  With left neglect, the brain fails to pay attention to information to the left side of the survivor.  If you ask a survivor with left neglect to turn his or her head all the way to the right, he or she will generally turn until the chin reaches the right shoulder.  However if you ask the same survivor to turn to the left, he or she may only bring the chin half-way to the the left shoulder despite fully understanding the request and giving a best effort to fulfill it.  It is almost as if the survivor’s brain is saying, “the left side of the world does not exist.”  The survivor’s eyesight can be perfectly intact, yet his or her brain is ignoring information generated from the left side.  This ignoring is not voluntary; as far as the survivor is consciously aware, he or she did look all the way to the left even though an outside observer can clearly see that the survivor did not make it all the way over.  Again, though it appears functionally as if the survivor has lost vision, the underlying issue is one of attention.

In the case of a field cut, most survivors do reasonably well after becoming sufficiently aware of their field cuts.  They will after enough practice naturally turn and make that extra effort to look for the information in their blind spots.  For a survivor with left neglect, improvement requires not just awareness but also daily repetition of scanning exercises and consistent use of visual aids.  As example, a survivor with left neglect may practice scanning techniques by slowly looking for information on a piece of paper being sure to start all the way on the left of that page before scanning across.  It can also be helpful to put a brightly colored highlighter mark on the paper to identify the far left of the page.  Sadly, in some cases a survivor will suffer from both left neglect and a field cut.  This combination can of course make successful functioning especially difficult, but with appropriate dedication and determined effort most any such goal gains entrance into the realm of the attainable.

I hope this clarifies the differences between left neglect and a field cut.  Please leave me a comment below with any questions, thoughts or ideas!

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What is Left Neglect?

Left neglect, also known as unilateral neglect or hemispatial neglect, is one of the oddest symptoms of a brain injury.  It can also be one of the most troublesome symptoms.  Left neglect is a term describing a deficit in awareness that occurs following an injury to the right side of the brain.  Due to the injury, the brain has difficulty paying attention to items falling into the left hemisphere of an individual’s awareness.  This generally sees its clearest expression in difficulties with visually noticing items  on the left side.  For instance, a survivor with left neglect may bump into frames of doors on his or her left side or routinely miss eating food sitting on the left side of a plate.  It often appears as if he or she is blind to items on the left, but this is not a true vision issue.  It is an attention issue.  The brain is not attending to information generated from the individual’s left side.  The survivor can have perfect visual skills, but the message that the survivor’s brain is providing is that the left side of his or her world for all intents and purposes does not exist.

Left neglect does not only involve visual components, but can also manifest as a lack of attention to sound or touch on the left-hand side.  For example, survivors may report that they cannot hear as well from their left ears despite audiological testing demonstrating perfect hearing.  Survivors may fail to notice left hands getting stuck in the wheels of their wheelchairs, potentially injuring those hands.  In the most severe of cases, survivors may not recognize their own left arms or legs as being parts of their bodies.  They may find cause to ask something like, “Whose arm is this in my bed?”  Fine variations in damage suffered to slightly different parts of the right side of the brain lead to notably distinct manifestations of left neglect, making each survivor’s experiences differ in some regard to that of the next.

Left neglect difficulties can cause many serious safety problems.  For instance, a survivor may not notice a boiling pot of water sitting upon the stove on his or her left side and bump into that pot’s handle.  This could then cause that pot to spill and lead to serious burns.  Similarly, a survivor may not sufficiently attend to cars on his or her left and attempt to cross a busy street at an inopportune moment, risking being hit by a car.  It is not uncommon for survivors with left neglect to have ever-present bruising on the left side of their bodies due to bumping into items.  To make the issue even more complex, many survivors with left neglect may also have issues with impulse control or now be much more easily distracted.  This then substantially compounds the danger and difficulties confronted by survivors contending with left neglect.  Some survivors may also be outright missing vision on the left side (a condition known as a field cut), adding an actual visual problem on top of these attentional issues.  Even when survivors are equipped with a complete awareness of their left neglect, in the absence of treatment the difficulties and errors unfortunately will still persist.  Remember, the brain is unconsciously telling the survivors to ignore the left side.  The neglect is not an intentional act by the survivors.  Since the brain is creating this false message, the survivors feel like everything is normal and that they are attending to the left just as well as they would have prior to the injury.
Though left neglect is most certainly an issue of attention, it cannot be treated with stimulant medications like Ritalin (which can generally be relied upon to improve more typical attention deficits).  The survivor must engage in specific therapies and learn compensatory techniques to help make more manageable these attentional deficits.  Even with treatment, left neglect strategies must be practiced and carried over into life at home in order to avoid seeing a regression in a survivor’s performance.

Left neglect can affect a survivor’s ability to engage in activities requiring both tabletop scanning and environmental scanning.  Examples of left neglect effects on tabletop tasks can be observed when survivors with left neglect miss words on the left side of a page or overlook numbers on the left side of a bill.  Some examples of left neglect effects as related to environmental scanning would be survivors missing potholes on the left side of a street or failure to locate a car parked on the left side of a parking lot.

There are a number of methods to help survivors compensate for left neglect.  One such method is known as prism adaptation.  This is a method used by rehabilitation professionals in which patients engage in an activity while wearing strong prism glasses which pull visual items from the left into a more central attentional domain.  This visual change forces the patients to compensate for the effects of the prism in order to accurately complete the activity.  After the activity, some patients with left neglect notice an aftereffect in which the brain will continue to pull visual items from the left more into their attention even when the glasses are no longer being worn.

Limb activation therapy is another method used by professionals to aid with left neglect.  The focus in this method is to get the patient to actively use his or her left limbs in the space surrounding the left side of his or her body in order to engage the brain’s spatial and motor maps for those domains.  This has been found to be very helpful to patients, but unfortunately substantial difficulties are all too often encountered.  As it’s common for survivors contending with left neglect to also have difficulty moving anything on the left side of their bodies (such targeted paralysis or semi-paralysis is itself one of the most common symptoms of a stroke or brain injury), the limits inherent in attempting to apply such a method become apparent.  However, some research shows that even passive movement of the left side can help improve issues stemming from left neglect.

Working at honing scanning techniques is one of the most frequently utilized methods in treating patients with left neglect.  Patients are taught by therapists methods by which to ensure that they have scanned the entire visual field.  To do so, patients are often instructed to pretend as if the head is a lighthouse.  Patients will be directed to turn their heads all of the way from one side to the other while scanning an environment just as a lighthouse will turn it’s light fully from one side to the other in order to effectively scan the seas.  As a general rule of thumb, patients are taught that if they are scanning their environments and they have not seen their left shoulders, then they probably have not scanned as far to the left as needed.  When involved in tabletop activities, patients are taught to scan to their left hands or left elbows.  Practicing this type of scanning can be done in multiple ways.  Patients may be asked to scan for and then identify letters or lights spread out upon a board or asked to scan and then find features in a parking lot.  Often, therapists teach patients to highlight the left side of a page or place a bright bookmark next to the left side of a page so as to institute a cue to help recognize when they have scanned all the way to the left.  If the patients have not seen the highlighted area or bookmark, then they know they have not made it as far to the left as they should.  Patients are taught to always start their scanning from the left and then move slowly to the right.  Patients with left neglect are less likely to miss items if they begin the scanning process on the left and proceed to the right than if they do the reverse.
Therapists may also deliberately place items on the left side of patients in order to force those patients to move, scan and utilize their left sides.  A glass of water with dinner may be placed to the left of a plate.  The therapist may pass a pen to the patient’s left hand.  All of these seemingly small acts contribute to improving scanning to the left and to using the left side of the body in the left hemisphere of the space occupied by the patient.  The ultimate goal is for robust scanning and increased use of the left side to become part of daily habit in the patients’ lives.  Therapists also may use other cues to help a patient better attend to the left.  For instance, they may put bells on a patient’s left hand so that he or she will hear the bells every time that left hand falls from the wheelchair (and then know to pick the hand back up).

Scanning skills can often be easily taught to family and friends, which can be of great help to the survivor in extending use of these techniques beyond an environment explicitly dedicated to therapy.  Family and friends can also help by identifying situations in which the survivor may be having a difficulty related to left neglect of which he or she is not aware.  All involved can then apply this knowledge so as to aid in identifying how left neglect could impact future situations.  For example, a family member may help a survivor in an airport recognize that he or she has knocked over a fellow traveler’s bag and then also help the survivor prepare to enter the plane without bumping into the left aisle seats.  This manner of aided behavior reinforced over time will do much to improve that survivor’s solo interactions with his or her world.

Hopefully this post has provided an amount of useful guidance on the road to a wider, more complete understanding of left neglect.  Feel free to leave comments below with any questions!

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Visual Scanning with Telephone Books and Circulars

As I have talked about previously in this blog, many brain injury survivors recovering from traumatic brain injuries will experience visual scanning difficulties as a result of those injuries.  This can be due to a direct loss of visual ability (often called a visual field cut) or due to an attentional issue such as left neglect.  One convenient and practical way to work on scanning is for the survivor to practice with a telephone book or supermarket circular.

The idea is pretty straightforward:  the survivor is tasked with locating various items found in the advertisements of the telephone book’s yellow pages or in a supermarket circular.  You’ll want to pick items in a random order so as to prevent the survivor from figuring out where each correct item is without really working on the skills.  For example, if you are using restaurant ads in the yellow pages, you may first have the survivor find the hours of operation from an Arby’s ad in the top left corner, then the address of a Taco Bell advertised on the bottom left of the page, followed by the Domino’s Pizza fax number down at the bottom right. The supermarket circular can be used in the exact same manner.  As example, you could ask the survivor for the cost of the Oscar Meyer bologna in the top right corner of the page, then the size packaging of the Frosted Flakes cereal in the bottom left corner, followed by having the survivor point to the Hebrew National hot dogs back up towards the top right.

You do not want to tell the survivor where on the page each item is located, but allow the survivor to naturally search on his or her own.  All parts of the page, including the center, should be used during this activity.  If the survivor cannot find the material, the survivor (often with the help of a loved one) should be prompted to conduct a slow, organized search for the item in question.  If the survivor has left neglect, such a search should always begin on the left side, using a slow up-down search rather than side to side.  If the survivor has a visual field cut, the search should always begin on whichever side has suffered the cut, again using an up-down search.  If the survivor is missing the right visual field in both eyes, the search should always begin on the right side and if he or she is missing the left visual field in both eyes, the search should always begin on the left. Missing both the right or both the left visual fields is known as homonymous hemianopsia.

There are a few things you want to keep in mind to help this task go smoothly.  You will want to check and ensure that the information can be easily seen by the survivor.  Sometimes the writing in phone books and circulars may be quite small and the survivor may need to use reading glasses or perhaps need only to work with the bigger items on the page.  When working with the yellow pages, it is generally better to pick pages with lots of display ads rather than just listings.  I do not advise using the white pages since the writing is small, placed very close together and is always in an obvious alphabetical order.  Supermarket circulars are generally much better for this task than department store circulars since they will tend to list more items.  If the survivor has left neglect, it may be helpful to highlight the left side of the page or put a bright object (such as a strip of paper) on the left side.  Additionally, some survivors benefit from the use of a line reader (such as ruler) to help with their ability to focus on one section of information at a time.

Here are a few previous blog posts on home-based visual scanning activities:

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Visual and Verbal Memory

Most information that we try to remember usually comes through only two of our five senses, vision and hearing.  Interestingly, the memories we make for this information is generally stored in two separate parts of our brain.  We tend to store verbal memories from the information that we heard in the left side of the brain.  We tend to store visual memories from the information that we saw in the right side of the brain.  One way that we can help our memory is by using both sides of our brain during memory tasks.

We can help our verbal memory by taking the information that we hear and creating pictures in our mind  of the information.  For instance, you might be told three items you need to buy in the store.  While trying to remember the words, you can imagine what those three items look like while sitting in your shopping cart.  In this way you both have verbal memories from when you heard the items told to you and visual memories from imagining yourself with those items in your cart.  Similarly, you can bolster your visual memory with your verbal memory.  For instance, you could try to remember where you parked your car at a store and at the same time you were visually looking at the parking spot, you could also verbally describe to yourself where you were parked.  In this example, you might look at the spot while telling yourself, “I am parked by the red pole, two spaces from the large concrete block.”  Your sight would provide the visual memory and the words would add  the verbal memory.  In these ways, both sides of your brain can be involved in helping you to remember information.  The more places you have information stored in your brain, the more easily you can later access that information.

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Visual Scanning Skills With I Spy

As I stated in a previous post, many people with brain injuries have visual scanning deficits.  Often this is due to an injury to the right side of the brain.  An easy (and free) way to practice visual scanning skills is through an adaptation of the game I Spy.

The adapted version of I Spy is a very simple game to play.  At least two people are needed to play.  To start, pick a location or room with lots of items to see but which is not so familiar that everyone knows the location of all the items by heart.  One person is the “spy” and has to find an item that is visible to everyone.  The spy then says “I spy with my little eye ____ (the item).”  It is the job of the other players to point to the item to show that they have found it.

When I Spy is used to practice scanning skills after a brain injury, it is important to vary the location of the items that are being “spied.”  For instance, you may first want to “spy” an item on the right side and then an item on the left side.  Varying locations forces a person to scan the entire visual field.  If this game is being played with someone in a wheelchair, make sure that each item can be seen from his or her visual perspective.  Often items that are easy to see when standing are obstructed when sitting.  Also, make sure that the item is big enough to be clearly seen by all the players.  Sometimes a person with a brain injury loses some of their visual acuity due to the effects of the injury and may not be able to clearly see  small items.  If the person playing has left neglect, they will likely need extra help and direction to scan the left side of the visual field.

I Spy is an easy, portable method to practice visual scanning skills while still having fun!

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Visual Scanning Practice With Hidden Pictures

Many brain injured patients have difficulty with scanning skills.  This can be due to many problems such as partial loss of vision, left neglect  or visual-spatial deficits.  Often, but not exclusively, these problems are associated with an injury to the right side of the brain.

One way to practice scanning skills is by using hidden pictures puzzles.  Many people are familiar with hidden pictures puzzles from children’s magazines.  They involve a larger picture having many smaller items hidden within it.  The goal is to locate the smaller hidden items.   Highlights magazine has a number of free hidden pictures puzzles that can be printed from their online website:

Although this is a fun way to practice scanning skills, it can be quite difficult and some individuals may need help from loved ones to work on these puzzles.

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