Journal of Clinical and Experimental Neuropsychology

ISSN: 0168-8634 (Print) (Online) Journal homepage: http://www.tandfonline.com/loi/ncen19

Neurorehabilitation following right thalamic
infarct: Effects of cognitive retraining on functional
performance
Robert E. Hanlon , Bruce H. Dobkin , Bette Hadler , Shari Ramirez & Yana
Cheska
To cite this article: Robert E. Hanlon , Bruce H. Dobkin , Bette Hadler , Shari Ramirez &
Yana Cheska (1992) Neurorehabilitation following right thalamic infarct: Effects of cognitive
retraining on functional performance, Journal of Clinical and Experimental Neuropsychology,
14:4, 433-447, DOI: 10.1080/01688639208402836
To link to this article: http://dx.doi.org/10.1080/01688639208402836

Published online: 04 Jan 2008.

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Journal of Clinical and Experimental Neuropsychology
1992, Vol. 14, No. 4, pp. 433447

0168-8634/92/1404-0433$3.00
Q Swets & Zeitlinger

Neurorehabilitation Following Right Thalamic Infarct:
Effects of Cognitive Retraining
on Functional Performance*

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Robert E. Hanlon, Bruce H. Dobkin, Bette Hadler, Shari Ramirez,
and Yana Cheska
Neurologic Rehabilitation Service
University of California at Los Angeles School of Medicine

ABSTRACT
We treated the cognitive impairments of a 69-year-old male, that persisted 7 months
after an infarction in the distribution of the right posterior cerebral artery. The
infarct produced a 20% reduction in right cerebral blood flow, established by positron emission tomography (PET). Neuropsychological status was characterized by
marked hemivisuospatial inattention, visuoperceptual and perceptuomotor dysfunction, and impaired visual memory. A multiple-baselines across behaviors design was utilized to assess effects of specific interventions on targeted cognitive
functions. We found significant improvement in attention to left hemispace in
response to directed interventions. Considerable gains were also realized in
perceptuomotor abilities, mobility, and activities of daily living. Results indicated
process-specific effects of strategic cognitive interventions, initiated 7 months
postonset.

Neurorehabilitation services have proliferated over the past 20 years and the
interdisciplinary team approach to rehabilitation has become the standard model
of service delivery. However, when patients make functional gains, it is unclear
just how improvement emerged. Whether or not the outcome could have been
facilitated by any physical or behavioral intervention, spurred by spontaneous
recovery remains unanswered (Dobkin, 1989). Cognitive retraining has more
recently become a major component of rehabilitation following neurological
insult. Here too, efficacy studies are generally unavailable and it is unclear whether

* The authors wish to thank Dr. Joseph VickRoy, Nancy Sedat, and Elise Herlihy for their
invaluable assistance in the treatment of this patient. We would also like to express our
appreciation to Dr. Scott Grafton for completion of the PET study. Finally, we would
especially like to thank Drs. D. Zaidel and T. Wickens, Dept. of Psychology, UCLA, and
two anonymous reviewers for their comments and suggestions.
Requests for reprints should be addressed to: Robert Hanlon, Ph.D., Neuropsychology
Department, Baylor Institute for Rehabilitation, 3505 Gaston Avenue, Dallas, TX 75246,
USA.
Accepted for publication: June 30, 1991.

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434

RE.HANLON ET AL.

or not patients benefit from cognitive rehabilitation, particularly with regard to
significant changes in quality of living (Berrol, 1990; Levin, 1990).
The published studies in the neurology, neuropsychology, and rehabilitation
literature that describe the effectiveness of a specific cognitive intervention or
cognitive rehabilitation program (e.g., Ben-Yishay, Silver, Rasetsky, & Rattok,
1987; Hanlon, Brown, & Gersrman, 1990; Prigatano et al., 1984; Schacter. Rich,
& Stampp, 1985; Sparks & Holland, 1976; Weinberg et al., 1977) seem
underrepresented, given the time spent in a proliferating number of programs.
Randomized, controlled trials of a specific treatment are nearly nonexistent. In
addition to ethical concerns about witholding a treatment program,confounding
variables that might preclude such studies include the heterogeneity of patients
and spontaneous recovery.
Single-case designs, which can include multiple-baselines and alternating
treatment, are clinically well established and accepted in, for example, behavioral
modification studies (Wood, 1987). As a result of growing frustration with group
studies in cognitiverehabilitation and advancesin&e methodological sophistication
of single-case experimental designs (Barlow & Hersen, 1984; Kazdin, 1982), Nof-1 designs have recently met with increased acceptability and popularity in
neuropsychological rehabilitation (e.g., Gianutsos & Gianutsos, 1979; Soblberg
& Mateer, 1987; Wilson, 1987).
The neurological and neuropsychological sequelae associated with righthemisphere lesions are well documented. These include impairments in left spatial
attention (Costa, Vaughan, Horwitz, & Ritter, 1969; Heilman, Watson, &
Valenstein. 1985; Mesulam, 1981; Weintraub & Mesulam, 1987). visuoperception
and perceptuomotor function (Benton, 1985; DeRenzi, 1982; McFie & Zangwill,
1960), visual memory (Milner, 1968; Speedie & Heilman 1983), left hemiplegia
(Brodal, 1973), and left-sided unimodal or multimodal sensory loss (Hier,
Mondlock, & Caplan. 1983a). They may, singularly or collectively, produce
severe functional disability.
Recovery of function following a right-hemisphere lesion has also been well
documented for cognitive impainnents, sensory loss, and motoric dysfunction
(Hier, Mondlock, & Caplan, 1983b), as well as for affective disorders (Egelko et
al., 1989). Hier et al. (1983b) found that spontaneous recovery from unilateral
spatial neglect and visuoconstructional impairment steadily progressed during
the first 5 months postonset, followed by a plateau with negligible probablity of
further recovery.
The time required for maximal recovery from neuropsychologicalimpairments
following neurological insult, and particularly clinical estimations of duration of
recovery, remains a controversial issue in neurorehabilitation. Recovery of language and motor functions in aphasic patients following left hemisphere lesions
has received considerable attention (e.g., Basso, Capitani, Della Sala, Laiacona,
& Spinnler, 1987; Kertesz & McCabe, 1977; Lendrem & Lincoln, 1985; Sarno &
Levita, 1971). Kertesz (1985) has noted that, although recovery from aphasia
may continue during the f i s t year post-stroke, the greatest amount of recovery

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RIGHT THALAMIC INFARCT

435

occurs during the first three months and “after six months, the rate of recovery
significantly drops” (p. 492). This appears t o be essentially the same pattern for
impairments commonly associated with right hemisphere lesions (Hier et al.,
1983b).
W e present a single-case design for treatment of cognitive impairments secondary to the patient’s right cerebral infarct. Cognitive rehabilitation was initiated
7 months postonset, thereby minimizing the confounding influence of spontaneous
recovery on the effect o f cognitive retraining. The interventions were administered by all members of an interdisciplinary rehabilitation team as part of discipline-specific tasks and objectives. In addition to determining the effect of processspecific cognitive interventions on neuropsychological test performance, the influence of cognitive retraining on functional performance in specified areas of
physical functioning and activities of daily living (ADL) was examined pre and
posttreatment.

METHOD
Subject
The subject, a 69-year-old male, was bilingual and functionally right-handed, although he
was reported to be a natural left-hander who was forced to develop a right-handed preference as a child. Six months after onset of his stroke, an MRI revealed an infarction in the
distribution of the right posterior cerebral artery, involving the right thalamus, posterior
limb of the internal capsule, and mesial occipital lobe (Figure 1). Eight months after
onset, positron emission tomography (PET) revealed a 20% decrease in right cerebral
blood flow, relative to the left hemisphere, on an Oxygen-15 cerebral blood flow study
(Figure 2).
Previous treatment had not included cognitive rehabilitation therapy and had focused
exclusively on physical rehabilitation, with an emphasis on right-sided compensation for
left-sided motoric dysfunction. He had achieved ambulation with moderate assistance. At
approximately 7 months postonset, he was transferred to UCLA Medical Center and
began a 3-month course of daily neurorehabilitation; this included physical, occupational,
and speech/language therapy, and neuropsychological services.
The patient manifested a left hemiparesis with mostly patterned strength graded 3/5,
left hemianesthesia with absent proprioception, and a left homonymous hemianopsia.
Neuropsychological findings included marked left spatial inattention, impaired visuoperceptual and perceptuomotor functions, (e.g., WAIS- R Performance IQ = 68), and
defective visual-nonverbal memory. Speech/language assessment of reading on the Reading Comprehension Battery For Aphasia (LaPointe & Homer, 1979) revealed deficient
reading accuracy and comprehension, primarily due to neglect of left hemispace in visual
scanning.
Physical and occupational therapy evaluations utilized a standard 5-point clinical rating scale, based on the amount (%) of assistance required in functional performance.
Functional status was scored as follows: 5 = Dependent (76-100%assistance), 4 =Maximal
assist (51-75% assistance), 3 = Moderate assist (26- 50% assistance), 2 = Minimal assist
(1-25% assistance), 1 = Independent (0% assistance). His unsteady asymmetrical gait
required moderate assistance for ambulation. Standing balance and transfers to and from a
wheelchair also required moderate assistance. Occupational therapy evaluation of activities of daily living (ADL) revealed the following: dressing, bathing, and toileting required
maximal assistance, and grooming and feeding required moderate assistance.

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RE.HANLON ET AL.

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Examples of the effect of hemivisuospatial inattention and neglect of the hemiparetic
side on functional performance included the following: he would M into furniture and
doorways with the left side of his wheelchair. when unsupervised. his left arm would hang
over the left side of his bed or wheelchair; in assisted but unguided ambulation, he
demonstrated a 3-foot deviation to the right per 30 feet of walldng distance;he demonstrat
ed variable neglect of the left side in grooming and dressing; when eating, he was unaware
of food or utensils placed beyond 8 inches to the left of midline.
Procedure
A multiple-baselines across behaviors design was implemented to assess the effect of
structured interventions on specific cognitive functions across consecutive treatment intervals (Barlow & Hersen, 1984). This required an initial baseline evaluation (Week l),
followed by the first treatment interval (Weeks 2-6),the focus of which was on a previously
selected deficit. After completion of the first treatment interval, a second baseline evaluation was conducted (Week 7). Following this, the second treatment interval was completed
(Weeks 8-12), the focus of which was on another deficit, A third baseline evaluation was
conducted at Week 13.
Four cognitive functions (hemivisuospatial attention, visuoperceptual processing.
visuoconstruction, and visual-nonverbal memory) were established as dependent variables
and were assessed at Weeks 1, 7, and 13. The four functions were operationalized as
follows: Hemivisuospatial attention was assessed on the four forms of the Cancellation
Test (Weintraub & Mesulam, 1985); Visuoperceptual capacity was assessed on the Visual
Form Discrimination Test (Benton, Hamsher. Vamey, & Spreen. 1983) and the Hooper
Visual Organization Test (Hooper, 1958); Visuoconstructional ability was assessed on the
Revised Visual Retention Test (Copy Administration) (Benton, 1974) and the Complex
Figure Test (Copy Administration) (Rey. 1941); Visual Memory was assessed on the
Revised Visual Retention Test (immediate recall) (Benton, 1974) and the Complex Figure
Test (immediate recall) (Rey, 1941). The influence of cognitive interventions on functional performance in mobility and activities of daily living (ADL) was also monitored in
nine specified areas: functional use of the left arm and hand, ambulation, transfers, postural
control, dressing, bathing, toileting, grooming, and feeding.
The focus of the first 5-week treatment interval was conditioning of responsive and
spontaneous visual scanning of left hemispace. A multisensory cueing strategy (i.e.. visual,
auditory, proprioceptive, and tactile) involving explicit left-sided cueing was employed
by all members of the neurorehabilitation treatment team. Cues included auditory-verbal
commands and auditory-nonverbal stimuli to direct and orient the subject to left hemispace,
visual cues (such as salient peripheral left visual field stimuli and gestures redirecting the
subject to left-sided scanning) as well as therapeutic positioning, placement, and touching
of the left upper and lower limbs.
These interventions were progressively refined according to the saturation cueing
technique (Diller & Gordon, 1981). The saturation cueing technique involves the systematic reduction in cues required for successful task completion. For example, once the
subject began to search spontaneously for and locate the left visual field anchor (i.e.. left
peripheral visual stimulus), verbal commands to initiate left-sided scanning were progressive
ly withdrawn. Similarly, once he began to use his left arm spontaneously in a stabilizing
or supportive manner in paper-and- pencil and ADL tasks, strategic placement and tactile
stimulation of the limb were progressively reduced.
We employed paper-and-pencil tasks, such as copying sentences and paragraphs and
reading newspaper articles and other written materials; environmental visual search tasks,
involving counting and identification of specified stimuli (e.g.. money, people, windows,
buildings, etc.); physical activities utilizing a mirror for visual feedback; and functional
engagement of the left upper extremity (LUE) in ADL tasks to increase left-sided awareness/
attention. A comprehensive and detailed description of the therapeutic tasks is available

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RIGHT THALAMIC INFARCT

437

upon request from the authors (also see Diller & Gordon, 1981; Weinberg et al., 1977).
In Week 7, a second cognitive treatment interval was initiated. This focused on
visuospatial analysis and perceptuomotor integration. Treatment was directed toward the
acquisition and utilization of a systematic approach to detailed visual analysis, requiring
verbal elaboration and description of visual elements and spatial relations. This approach
involved training in sequential,unidirectional visual analysis/synthesisincorporating verbal
mediation. We used single and multiple-element configura tions. including drawings,
geometric forms, objects, routes, floor plans, and relatively complex scenes depicting
social situations. For example, the subject was required to provide detailed verbal descriptions
of the visuospatial attributes of the objects, people, and other environmental stimuli that
he confronted during therapy sessions. This approach emphasized active and independent
incorporation of the hemiparetic limb, but did not involve explicit cueing directed toward
scanning of the left visual field. Following the second treatment interval, the third baseline
evaluation was completed (Week 13).
Statistical Analysis
The use of statistics in single-case studies is a controversial issue (Wilson, 1987). The
conventional method of data analysis in single-case designs is visual inspection of graphic
display (Kazdin, 1984).Due to the fact that there is no inter-subject variability, generalization
from single-case studies is limited. However, since the essential issue in single-case
designs involves the observation of processes rather than static relationships, replication
is crucial to the determination of the generalizability of effects (Yule & Hemsley, 1977).
As a result, statistical effects in single-case studies address the variability of replication
rather than intersubject variability. Statistical analysis in intrasubject designs is generally

Fig. 1. MRI completed 6 months post-onset, revealing an infarction in the dismbution of
the right posterior cerebral artery.

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438

R.E. HANLON ET A L

Fig. 2. Positron Emission Tomography (Oxygen-15 Study), revealing a 20% reduction in
right cerebral blood flow.

used to provide further support for treatment effects evident on graphic display (e.g.,
Gentile, Roden, & Klein, 1972; Epstein, Herson, & Hemphill, 1974; Wood, 1987).
Following Gentile et al. (1972), the degree of change in the two target functions (i.e.,
hemivisuospatial attention and visuoperceptual processing) was assessed by repeated
measures analysis of variance. The indirect effect of the targeted treatments on
visuoconstructional ability and visual-nonverbal memory was assessed in the same manner. Following the repeated measures ANOVA, protected r tests were conducted to determine the specificity of effect. The influence of cognitive rehabilitation on functional
performance in the two domains of physicaVmotoric function and activities of daily living
was examined by visual inspection of graphic display.

RESULTS
On a repeated measures ANOVA, we found a significant increase in compensation for left visuospatial inattention through responsive and spontaneous scanning
of left hemispace ( F = 77.4, p < .OOl). A protected t test comparison between
Baseline 1 and Baseline 2 revealed a significant increase in attention to left
hemispace (t = 18.34, p < .001) as a result of directed therapeutic intervention,
involving explicit multisensory cueing. Additionally, a t test comparison between Baseline 1 and Baseline 3 was also significant, ( t = 8.1, p < .Ol), reflecting
maintenance of the increased tendency for attending to left hemispace, despite
withdrawal of explicit cueing for left visual field scanning and a shift to another
treatment. Figure 3 represents the degree of change in four cognitive functions

439

RIGHT T H A L M C INFARCT

Percent Accuracy
80

__

60 I50,
40

- --

-

___

-

---

10

.-

~

I

0,
1

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__

-

2

I

3

I

4

5

6

7

8

9

I

I

1

0

I

1

I

1

1

I

2

1

3

Weeks
Cognitive Measures
+

+

Spatial Attention

+

Visuoconstruction

Visuoperception

-S

Visual Memory

Fig. 3. Changes in selected functions resulting from cognitive rehabilitation (three
neuropsychological baselines)

(Weemaseline 1)
Fig. 4. Performance on one of the four forms of the Cancellation Test (Weintraub &
Mesulam, 1985), from each of the three baseline evaluations (i.e., Weeks 1,7, and
13).

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440
RE. HANLON

AL..

441

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RIGHT THALAMIC INFARCT

across three baseline evaluations. Figure 4 is a sample performance on one of the
four forms of the Cancellation Test from each of the three baseline evaluations.
Although the functional improvement noted in visuoperceptual processing is
evident on visual inspection of the graphic display (Figure 3), this increase was
not statistically significant ( F = 4.6, p = .18). However, notable improvements
were revealed in both PIQ and reading performance, as assessed on the RCBA,
from admission (Baseline 1) to discharge (Baseline 3). It should be noted that a
practice effect may have contributed to the increases in PIQ and RCBA scores.
However, given the defective level of performance on both of these measures at
Baseline 1, it seems unlikely that a single exposure to these measures would have
significantly increased performance 3 months later. Table 1 presents the test
scores from the measures completed at each of the three neuropsychological
baseline evaluations. Table 2 presents the WAIS-R Performance Scale scores
and the RCBA subtests scores.
Considerable improvement was noted in visuoconstructional ability and this

Table 1. Test Performance from Three Neuropsychological Baseline Evaluations.
Test

Baseline 1
Pretreatment
Week 1

Baseline 2
Treatment #1
Week 7

Baseline 3
Treatment #2
Week 13

Cancellation
Test
Form 1
Form 2
Form 3
Form 4

41/60 (68%)
43/60 (72%)
41/60 (68%)
37/60 (62%)

57/60 (95%)
57/60 (95%)
59/60 (98%)
54/60 (90%)

53/60 (88%)
54/60 (90%)
53/60 (88%)
55/60 (92%)

VRT(C0PY1
Score
Errors

4/10 (40%)
10

7/10 (70%)
3

7/10 (70%)
5

ReY (COPY)

25.5/36 (71%)

30.5/36 (85%)

28.5/36 (79%)

VRT (Recall)
Score
Errors

2/10 (20%)
15

3/10 (30%)
9

3/10 (30%)
9

Rey (Recall)

8.5/36 (24%)

8/36 ( 2 2 4 )

8/36 (22%)

VFDT

25/32 (78%)

27/32 (84%)

28/32 (88%)

HVOT

7/30 (23%)

7/30 (23%)

1 1 3 3 0 (38%)

Note. Tests have been abbreviated as follows: VRT = Visual Retention Test, Rey = Rey
Complex Figure, VFDT = Visual Form Discrimination Test, HVOT = Hooper Visual
Organization Test.

442

RE. HANLON ET AL.

Table 2. WAIS-R Performance Scores and Reading Comprehension Battery (RCBA)
Scores at Pre (Baseline 1) and Post-treatment (Baseline3).
Test
PIQ:

Pre-treatment
(Baseline 1)
7 Months Poststroke

Post-treatment
(Baseline3)
10 Months Poststroke

68

78

RCBA Overall Score:

45

83

Word-Visual
Word-Auditory
Word-Semantic
Functional Reading
Synonyms
Sentence-Picture
Paragraph-Picture
Paragraph-Factual
Paragraph-Inferential
Morpho-Syntax

7

10
10
8
7
10
6
8

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(Age-Corrected
Subtest Scores)
Picture Completion
Picture Arrangement
Block Design
Object Assembly
Digit Symbol

8
8
3
9
7

3
0
0
0

9
8

7

increase in accuracy of copy drawing approximated the trend which characterized the change in hemivisuospatial attention (See Figure 3). As a result, we
believe that the improvement in visuoconstructionalperformance was secondary
to the increased tendency for left visuospatial attention. However, this increase
in accuracy of copy drawing did not reach commonly accepted levels of statistical
significance (F = 4.5, p = .18). Finally, no notable indirect change was revealed
in visual-nonverbal memory capacity as a result of interventions directed toward
hemivisuospatial attention and visuoperceptual processing.
Functional capacity in the two domains of physical function and activities of
daily living (ADL) was evaluated on the previously described 5-point scale. This
scale was based on the percentage of assistance required for task completion
upon admis sion (Baseline 1) and at time of discharge (Baseline 3). These ratings
were completed according to standard procedure in physical and occupational
therapy assessments of functional performance. In an attempt to control for rater
bias, these ratings were completed independently by three different therapists,
both upon admission and at discharge; mean ratings in each of the nine areas of
functional performance were computed therefrom.

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RIGHT THALAMIC INFARCT

In the assessment of physical functioning, these ratings were based on the
following: initiation of movement, extent of volitional movement, support/assistance
required to achieve and maintain standing balance, support/assistance required
to transfer from wheelchair to bed and wheelchair to toilet, support/assistance
required for ambulation across a flat surface and up/down stairs. Changes in the
four subcomponentsof physical function, including functional use of the hemiparetic
limb (LUE), ambulation, transfers, and postural control are displayed in Figure
5 . Although the patient demonstrated modest improvement in ambulation, transfers, and postural control, functional use of the hemiparetic LUE increased considerably. This increase in LUE function was presumably due to the treatment
focus on left-sided awareness/attention and conditioning in the incorporation of
the LUE in functional tasks.
Changes in ADL function were more pronounced, relative to improvements
in physical/motoric function. Ratings completed by the occupational therapy
staff at admission (Baseline 1) and discharge (Baseline 3) revealed notable improvement in all five subcomponentsof ADL dressing, bathing, toileting, grooming,
and feeding. In the assessment of performance in ADL these ratings were based
on the following: task initiation, task set-up requirements, sequencing, perseverance, and degree of physical assistance required. Changes in ADL status at preand post-treatment are presented in Figure 6. Apparently, this improvement in
overall ADL status was due to a number of factors, including increased physical
functions (particularly transfers and use of the hemiparetic limb), increased attention
to left hemispace, and increased capacity for perceptuomotor integration.

70

60

t

Motor Functions
LUE Function

50

Postural Control

40

Transfers

30

Ambulation

20
10

n
1

13

Weeks
Fig. 5 . Changes in physical function resulting from neurorehabilitation(based on 5-pobt
rating scale).

444

R.E. HANLON ET AL.
Level of Independence (XI
100

I

90

80
ADL

70

Droaaing

60

Emthing

50

TOllOtlnp

40

Qroorning

30

Feeding

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20
10
0

13

1

Weeks
Fig. 6. Changes in ADL function resulting from neurorehabilitation (based on s-poht

rating scale).

DISCUSSION
The purpose of this study was to determine the effect of process-specific cognitive interventions on cognitive-behavioral performance and to assess the impact
of cognitive retrainii.2 on functionally oriented tasks. The subject had received
extensive physical rehabilitation throughout the first 6 months poststroke, but
remained markedly disabled due to both physical and cognitive dysfunction. He
was probably beyond the stage of spontaneous recovery from cognitive deficits
(Hier et al., 1983b), although subtle changes due to ongoing recovery could not
be ruled out. Nevertheless, since he remained highly motivated to continue his
rehabilitation and did not manifest a mood disorder, he was an ideal candidate
for cognitive rehabilitation.
The findings provide support for the contention that process-specific effects
of cognitive intervention may be achieved through strategic interdisciplinary
treatment paradigms, and that a cognitive emphasis in neurorehabilitation may
have a positive influence on functional performance. Furthermore, such effects
may be achieved when treatment is initiated following plateau in the spontaneous
recovery process (i.e., beyond 6 months postonset) (Hier et al., 1983b).
The finding of a significant increase in compensation for hemivisuospatial
inattention in response to structured interventionsaimed at conditioning of scanning
of left visual space provides support for earlier findings on the effect of this
technique (Weinberg et al., 1977). This finding is also extended to the postrecovery stage. That maintenance of this compensatory tendency was demon-

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RIGHT THALAMIC INFARCT

445

strated following withdrawal of explicit cueing seems to strengthen the inference
regarding the effect of the intervention. Although maintenance of increased visual
attention to left hemispace was demonstrated, it is evident on visual inspection of
the graphic display that, relative to Baseline 2, hemivisuospatial attention at
Baseline 3 was slightly decreased. The indirect effect of increased compensation
for left spatial inattention on visuoconstructional ability was an interesting finding, but was not terribly surprising, given the interrelatedness of the two functions.
Although the effect of the second treatment focus (i.e., training in a sequential approach to visuospatial analysis involving extensive verbal mediation) was
statistically insignificant, improvement was noted in both the psychometric and
functional spheres. No indirect effect on visual memory function was expected in
response to either treatment focus.
Although the findings discussed above are encouraging, it is equally important
to consider the confounding influences that may have contributed in some part to
the observed effects. As previously mentioned, it is possible, despite the fact that
the patient had probably experienced maximal benefit from the spontaneous
recovery process during the first 6 months postonset, that ongoing change, albeit
subtle, may have contributed to his improved performance. Another confound
inherent in many repeated measures designs, and particularly multiple-baseline
designs, is the effect of practice. As noted previously, the increase in PIQ from
Baseline 1 to Baseline 3 may have been partially due to a practice effect. However,
given the defective nature of his original performance and the fact that he did not
demonstrate such an effect on visual memory tests suggests that the contribution
of practice to the increase in his test performance was, at most, modest. Conversely,
practice and learning were crucial components of the treatments aimed at improving
his functional performance (i.e., physical and occupational therapy), and the
gains he demonstrated in the functional realm were to a large degree dependent
on his capacity to learn to compensate for his left hemivisuospatial inattention.
The demonstrated increase in compensation for left hemivisuospatial inattention and visuoconstructional ability are particularly striking in light of the 20%
reduction in right cerebral blood flow (Figure 2), which suggests a comparable
reduction in right cortical metabolism. It is important to note that the patient
improved significantly in selective areas of cognitive processing and realized
considerable gains in functional performance, despite ongoing thalamocortical
hypometabolism. However, it is equally important to note that impairments in
other functions, both treated (i.e., visuoperceptual processing) and untreated
(e.g., visual memory) persisted. Overall, these findings suggest that even severely impaired patients with right hemisphere stroke may benefit from structured cognitive intervention directed toward the compensation for left
hemivisuospatial inattention, and that this benefit can be demonstrated 6 months
after onset.

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