Atlas›Domain IX · Biomedical, neuro & digital›Guide 073
Guide IX-073

Prism adaptation for spatial neglect

Rossetti1998
A 24 · L 68 · M 816 interventions in the Trinity explorer
Client cardCompare
[source: …] where a claim comes from[uncertain] not confirmed in a primary source[synthesis] the writer's reconstruction

1. Introduction

Version followed: prism adaptation (PA) for spatial neglect as introduced by Rossetti and colleagues (Nature, 1998) and as delivered in routine inpatient rehabilitation through the Kessler Foundation Prism Adaptation Treatment (KF-PAT) protocol (Chen, Hreha, Barrett and colleagues); evidence status per the Cochrane review CD003586.pub4 (Longley et al., 2021), the Canadian Stroke Best Practice Recommendations and the Italian recommendations (Mancuso et al., 2026).

Who this guide is for. PA is not a psychotherapy. It is a sensorimotor rehabilitation treatment delivered by occupational therapists (OTs), neuropsychologists and other members of stroke and neurorehabilitation teams. This guide describes the treatment at a descriptive level, as research and guidelines publish it, and then sets out what a psychotherapist working alongside the team does. It gives no treatment schedules, prism strengths or session counts as instructions: those belong to the trained team and the protocol manual. For the wider psychological rehabilitation framework (holistic programmes, awareness, goal setting, family work), see 065 Neuropsychological rehabilitation (Wilson).

What it is. Spatial neglect is a syndrome, most often after right-hemisphere stroke, in which a person fails to notice, attend to, represent or act in one side of space, usually the left, and often does not realise this [source: Rossetti et al. 1998 abstract; Kessler Foundation guide]. In PA the person wears goggles fitted with prism lenses that shift the visual field to one side (rightward for left neglect), and makes a series of pointing or reaching movements to targets. At first the movements miss in the direction of the shift; with repetition the brain corrects for the error. When the goggles come off, movements are briefly displaced the other way, towards the neglected side: the "after-effect", which is the measurable sign that adaptation happened [source: medRxiv 2025 meta-analysis; Chen et al. 2025].

Core idea of change. Adapting to the optical shift is thought to recalibrate the person's internal spatial reference and shift attention towards the neglected side. Rossetti et al. reported that the benefit extended beyond the pointing task to a body-midline test and standard neglect tests, and outlasted the prism exposure, which is why they proposed it for rehabilitation [source: Rossetti et al. 1998 abstract]. Later authors describe the effect as a rebalancing of activity within and between the hemispheres, with cerebellar-parietal involvement, rather than a simple visual correction [source: medRxiv 2025 meta-analysis]. A therapist-guided, brief, repetitive reaching task is the usual clinical form [source: Chen et al. 2025].

2. Framework

PA is delivered as part of a rehabilitation programme, not as a stand-alone therapy. The phases below are how the published clinical pathway is organised; the session format and course length are set by the protocol and the treating team [source: Hreha et al. 2022; Chen et al. 2025].

Who delivers it and regulatory context. In the KF-PAT implementation network, OTs delivered both the neglect assessment and the treatment after a formal training course run by the protocol developers, with a mandatory manual, video tutorials and graded competency levels, the highest of which qualified a therapist to train colleagues [source: Hreha et al. 2022]. The Italian recommendations name neurologists, physiatrists, neuropsychologists and rehabilitation therapists as the professionals in stroke pathways who would implement neglect treatment [source: Mancuso et al. 2026]. OTs are a registered profession: in the UK they are regulated by the Health and Care Professions Council (HCPC); in the US they hold state licensure with national certification through NBCOT, and the professional body is AOTA [uncertain: not verified]. Clinical neuropsychologists in the UK are regulated by the HCPC as practitioner psychologists [uncertain: not verified]. Prism goggles are rehabilitation equipment; no drug-style approval pathway applies, and their status as a device should be checked locally [uncertain: not verified].

Phase 1: Screening and assessment (rehabilitation team).

  • Goal: detect neglect and establish its type and severity in daily life.
  • Format: all stroke patients screened for visual and visual-perceptual deficits as part of routine rehabilitation assessment, with validated tools for suspected deficits (Canadian guideline, Evidence Level C) [source: Canadian Stroke Best Practices]. Tools named include the Behavioural Inattention Test, line bisection and the Comb and Razor test [source: Canadian Stroke Best Practices]; KF-PAT pairs treatment with an assessment protocol (KF-NAP) that uses the Catherine Bergego Scale, an observation of neglect during everyday activities [source: Hreha et al. 2022].
  • Criterion to move on: neglect confirmed on assessment [source: Hreha et al. 2022].

Phase 2: Prism adaptation course (OT or trained therapist).

  • Goal: produce repeated adaptation and after-effects so that attention and action shift towards the neglected side.
  • Format: brief, therapist-guided sessions on consecutive days during inpatient rehabilitation, in which the person wears the goggles for a short period and performs a set of pointing movements; the prism strength is standard rather than individually tailored in KF-PAT [source: Chen et al. 2025]. Course length is protocol-defined; total amount of exposure is the most promising predictor of benefit in a 2025 meta-analysis [source: medRxiv 2025 meta-analysis].
  • Criterion to continue: in KF-PAT, if a person shows no after-effect on either pointing measure, continuing PA is not recommended [source: Chen et al. 2025].

Phase 3: Integration into function and re-assessment.

  • Goal: carry gains into self-care, mobility, reading and safety, alongside other neglect treatments (scanning training, limb activation, mirror therapy and others; see section 4).
  • Format: re-assessment after treatment or before discharge [source: Hreha et al. 2022]; education of the person and family about neglect and treatment recommendations (Canadian guideline, Evidence Level C) [source: Canadian Stroke Best Practices].

Phase 4: Discharge and community. Neglect may persist; families need guidance on home hazards, cueing and their own wellbeing [source: Kessler Foundation guide]. Driving after stroke with perceptual deficits is handled under separate guideline sections and licensing rules [source: Canadian Stroke Best Practices].

Where the psychotherapist fits across phases [synthesis]: Phase 1, notice and report possible neglect, assess mood and adjustment; Phase 2, support consent, engagement and tolerance of the treatment, and report adverse reactions; Phase 3, work on awareness, adjustment and family strain; Phase 4, continue adjustment work and carer support after the rehabilitation course ends.

Evidence status (attributed).

  • Cochrane (Longley et al. 2021): 65 small RCTs, 1,951 participants, eight intervention types; for PA, no evidence of an effect on activities of daily living (ADL) in the trials that could be pooled; all evidence very low certainty; "No rehabilitation approach can be supported or refuted over any other based on current evidence"; clinicians should follow national guidelines and are encouraged to take part in trials [source: Cochrane Corner summary of CD003586].
  • Canadian Stroke Best Practice Recommendations: visual scanning recommended (Evidence Level B); virtual reality or computer-based interventions recommended; mirror therapy may be considered; limb activation alone insufficient evidence; evidence on prism glasses and eye patches described as conflicting [source: Canadian Stroke Best Practices].
  • Italian recommendations (Mancuso et al. 2026): conditional recommendation in favour of PA for peri-personal neglect as part of the rehabilitation programme, very low certainty; effects small and short-term; patients should be told benefits are expected but not firmly established [source: Mancuso et al. 2026].
  • 2025 meta-analysis (preprint): short-term benefit on the Catherine Bergego Scale, no significant long-term effect on it [source: medRxiv 2025 meta-analysis].
  • Kessler Foundation clinical data: treated inpatients had higher total and cognitive FIM scores than untreated patients, with no significant difference in discharge home [source: Rehab Management 2021, reporting Chen et al.].
  • UK National Clinical Guideline for Stroke (2023) and AHA/ASA 2016 rehabilitation guideline: both address neglect; their exact wording and strength for PA [uncertain: not verified]. Check the current version before quoting either to clients or colleagues.

3. Guiding principles

  1. Stay in your lane, actively. The OT or neuropsychology team owns the assessment, the prism protocol and its decisions; you own the psychological work and the communication around it. Practical meaning: never suggest starting, stopping or changing the prism course; route questions to the treating therapist [synthesis].
  2. Neglect is a syndrome of attention, not of eyesight or effort. Practical meaning: explain and respond to omissions as brain-based, never as laziness or stubbornness; families who think it is vision loss need correcting [source: Kessler Foundation guide; Hreha et al. 2022 on confusion with visual problems].
  3. Expect reduced awareness. A majority of people with neglect have poor self-awareness of their symptoms, which limits engagement in strategy training [source: Chen et al. 2025]. Practical meaning: work with what the person can notice now; avoid confrontation and build awareness gradually and collaboratively [synthesis, consistent with Freer et al. 2016].
  4. Honest expectations. Benefits are expected but not firmly established, and effects may be short-term [source: Mancuso et al. 2026; Cochrane Corner]. Practical meaning: help the person and family hold hope without over-promising, and frame PA as one component of a programme.
  5. Function and safety first. Neglect raises the risk of bumping into objects, spills, falls and less favourable rehabilitation outcomes [source: Kessler Foundation guide]. Practical meaning: every conversation about progress also checks safety at home and on the ward.
  6. Fatigue and environment change the picture. Symptoms can worsen with tiredness and busy surroundings [source: Kessler Foundation guide]. Practical meaning: schedule psychological sessions when the person is alert, keep rooms quiet, and do not interpret a bad day as a relapse.
  7. Knowing is not doing. A person may state a strategy yet fail to use it when needed [source: Freer et al. 2016]. Practical meaning: test change in real tasks reported by the team, not by what the person says.
  8. The family is part of the treatment system. Carers of people with neglect report more stress and burden [source: Kessler Foundation guide]. Practical meaning: offer carers their own space, information and signposting.
  9. Integrate, do not duplicate. Psychological work on mood, identity and adjustment sits inside the holistic rehabilitation model described in 065 [synthesis]. Practical meaning: share goals with the team and use the same language about neglect as they do.

4. Intervention inventory

Part A describes how the rehabilitation team delivers the treatment, so you can explain it accurately and recognise problems. It is descriptive only: you do not deliver these components. Part B is the psychotherapist's own work.

Part A. How the treatment is delivered (descriptive)

A1. Neglect assessment by the team

  • Purpose: confirm neglect, gauge how it shows up in daily life and decide whether PA is indicated.
  • What happens (description): the OT or neuropsychologist uses validated tests and observation. Pen-and-paper tests such as the Behavioural Inattention Test, line bisection and cancellation or scanning tasks show omissions on one side; the Comb and Razor test looks at personal (body) neglect [source: Canadian Stroke Best Practices; Dawson 2017 ACRM slides]. In KF-PAT the KF-NAP protocol scores the Catherine Bergego Scale while the person carries out everyday activities such as grooming, dressing, eating and moving around [source: Hreha et al. 2022]. Re-assessment follows treatment or comes before discharge [source: Hreha et al. 2022].
  • Example language (illustrative): "The OT will watch you do some everyday things, like eating and getting around, and give you a few paper tasks. It isn't a test you can pass or fail. It shows the team how your brain is handling space on each side."
  • Watch for: distress or shame at being observed; some patients felt uncomfortable being watched during meals [source: Hreha et al. 2022]. Pass this on so the team can adjust.

A2. The prism adaptation session

  • Purpose: produce adaptation to an optical shift so that, once the goggles come off, attention and action are pulled towards the neglected side.
  • What happens (description): the person sits at a table and wears goggles with prism lenses that shift what they see to one side (rightward in left neglect). Guided by the therapist, they point or reach to targets. In many protocols a shelf or occluder hides the start of the arm's path, so only the end of the movement is seen (terminal feedback); others allow the whole movement to be seen (concurrent feedback) [source: medRxiv 2025 meta-analysis; Hreha et al. 2022 on the wearable shelf]. Early movements miss in the direction of the shift; over repeated trials the errors shrink. The exposure is brief, and in KF-PAT the prism strength is the same for everyone [source: Chen et al. 2025]. The session uses a portable kit, stimulus sheets and set verbal commands, and the therapist can skip a task and move on when needed [source: Hreha et al. 2022]. Session length, repetitions and course length are set by the protocol manual and are not given here.
  • Example language (illustrative): "The glasses bend what you see a little to one side. At first your hand will land off target, and that's expected. Your brain corrects for it. When the glasses come off, that correction carries over for a while and nudges your attention towards the side that's harder to notice."
  • Watch for: dizziness or seeing double ("unable to tolerate the prism goggles"); pressure from the goggles for people who wear a protective helmet; fit problems with existing spectacles, which may need an optometry consult; reading glasses can sometimes be worn underneath [source: Hreha et al. 2022]. Severe neglect, language barriers and physical limitations can stop people following commands or using the equipment [source: Hreha et al. 2022]. Report any of these to the treating therapist.

A3. After-effect check and continuation decision

  • Purpose: confirm that adaptation occurred and decide whether to continue.
  • What happens (description): after the goggles come off, the therapist measures pointing (for example with the eyes closed, or without seeing the arm) to see whether movements are displaced towards the neglected side. In KF-PAT, if neither pointing measure shows an after-effect, continuing PA is not recommended [source: Chen et al. 2025; medRxiv 2025 meta-analysis].
  • Example language (illustrative): "The OT checks after each session whether your brain picked up the shift. If it isn't picking it up, they'll talk to you about other ways to work on the neglect. That wouldn't be your failure. It just tells them which tool suits your brain."
  • Watch for: the person or family reading a stopped course as personal failure or as being "given up on"; address this in Part B.

A4. Other neglect treatments the team may combine or use instead (brief)

  • Purpose: know the alternatives the team may offer, so you can explain them consistently.
  • What they are (description):
    • Visual scanning training: structured, functional practice in starting from the neglected edge and searching systematically, for example reading the newspaper from the left margin. Recommended in the Canadian guideline (Evidence Level B) and as a practice standard in Azouvi et al. 2017 as cited by Dawson [source: Canadian Stroke Best Practices; Dawson 2017; Freer et al. 2016]. Cues such as a highlighted left margin or a line guide are common, though their effectiveness has not been researched [source: Freer et al. 2016].
    • Limb activation: moving the affected-side limb within the neglected space. Insufficient evidence alone (Canadian guideline); may be combined with scanning (Azouvi et al. as cited) [source: Canadian Stroke Best Practices; Dawson 2017].
    • Mirror therapy: may be considered; with limb activation it was more effective than limb activation alone [source: Canadian Stroke Best Practices].
    • Virtual reality and computer-based training: recommended in the Canadian guideline; isolated computer exercises are not recommended (Azouvi et al. as cited) [source: Canadian Stroke Best Practices; Dawson 2017].
    • Body awareness approaches: very low certainty evidence of possible benefit on ADL in the Cochrane review [source: Cochrane Corner].
    • Eye patching: conflicting evidence [source: Canadian Stroke Best Practices].
    • Non-invasive brain stimulation, electrical stimulation, mental function training, movement interventions, acupuncture: reviewed by Cochrane with no evidence of an effect on ADL, or no longer-term ADL data [source: Cochrane Corner]. Brain stimulation is a medical-team treatment; parameters are outside this guide.
    • Self-instruction strategies: the "Lighthouse Strategy" was reported to improve safety in rehabilitation and at home (Niemeier 1998, as cited by Dawson) [source: Dawson 2017].
  • Example language (illustrative): "There isn't one proven best treatment for neglect yet, so teams use a mix: scanning practice, moving your arm on that side, mirror work, the prism glasses. Different people respond to different ones."
  • Watch for: families chasing a single cure or unregulated programmes; bring questions back to the team.

Part B. The psychotherapist's interventions

Unless tagged otherwise, Part B is [synthesis]: good practice for a psychotherapist working alongside a stroke or neurorehabilitation team, informed by the sources cited. For the overall holistic model (awareness, goals, identity, family), see 065.

B1. Recognising possible neglect and asking for a team review

  • Purpose: neglect is common after stroke (Chen's group estimates about 30% [source: Rehab Management 2021]) and can be missed in outpatient or community psychotherapy.
  • Steps: (1) notice everyday signs: rarely turning the head to one side, missing food or objects on one side, bumping into things, shaving or making up one side of the face, missing words on one side of a page, not using a limb that has regained strength [source: Kessler Foundation guide]; (2) ask the client and family, descriptively, about such events; (3) with consent, write to the stroke team, GP or rehabilitation service asking for a perceptual assessment; do not test or diagnose it yourself.
  • Example language (illustrative): "You mentioned you keep finding food left on one side of the plate, and you bumped the door frame twice today. After a stroke that can happen when the brain pays less attention to one side. I'd like to ask the rehab team to look at it. Is that okay with you?"
  • Watch for: the client dismissing the signs (possible reduced awareness; see B4); new or sudden neurological symptoms, which need emergency services, not a routine referral [synthesis].

B2. Psychoeducation about neglect and prism adaptation

  • Purpose: give the person and family a shared, accurate model that cuts blame and confusion.
  • Steps: (1) find out what they have been told; (2) explain neglect as a change in the brain's spatial attention networks, not an eye problem or a lack of effort [source: Kessler Foundation guide]; (3) explain PA in plain terms (A2), using the team's own wording; (4) explain why "look left" often doesn't help, because the person's sense of left has changed [source: Kessler Foundation guide]; (5) give written material in a layout the person can read (B10), such as the team's or the Kessler Foundation's family brochure [source: Hreha et al. 2022; Kessler Foundation guide].
  • Example language (illustrative): "Your eyes are working. It's more that the part of the brain that points your attention around the room is lopsided at the moment. The prism glasses are one way the OT tries to rebalance it."
  • Watch for: the family still calling it "not trying" after the explanation; a person who hears "brain damage" as a final verdict. Check what they took away by asking them to explain it back.

B3. Supporting informed consent and realistic expectations

  • Purpose: help the person take part in decisions about PA with an accurate picture.
  • Steps: (1) check whether they know what the treatment involves, what it is for, and that they can ask questions or decline; (2) reflect the published position: benefits are expected but not firmly established, effects may be short-term, and no neglect treatment is proven superior [source: Mancuso et al. 2026; Cochrane Corner]; (3) help them write down questions for the OT, such as tolerability, how progress will be judged, and what happens if there's no after-effect; (4) where capacity is in doubt, flag it to the team, who assess capacity under local law [synthesis].
  • Example language (illustrative): "The research says this can help some people, especially in the short term, but it isn't a guarantee. It's one piece of the programme. What would you want to ask the OT before you start?"
  • Watch for: consent that is really just compliance; over-hope ("the glasses will fix me"); hopelessness ("nothing works anyway").

B4. Working with reduced awareness (anosognosia)

  • Purpose: many people with neglect underestimate or don't recognise their symptoms, which limits engagement and safety [source: Chen et al. 2025; Kessler Foundation guide].
  • Steps: (1) assess awareness with the team, comparing the person's account with observed performance; (2) don't argue or confront; take a curious, collaborative stance; (3) support the team's methods: education and discussion, verbal and visual feedback on errors, comparing performance with and without a cue, and video feedback of the person's own performance [source: Freer et al. 2016]; (4) in psychotherapy, explore what admitting a deficit would mean for the person (identity, independence, driving, work); (5) as awareness grows, expect grief, anxiety or low mood, and plan for them (B5); (6) where awareness stays limited, back the team's switch to habitual, routine-based strategies, which can take many hours of practice [source: Freer et al. 2016]. A secondary analysis suggests PA itself may improve awareness of neglect [source: Mancuso et al. 2026, citing Mizuno et al.].
  • Example language (illustrative): "You feel you're managing fine, and your OT is seeing some things on the left get missed. Could we look at the video from this morning together and see what you make of it?"
  • Watch for: distinguish brain-based unawareness from psychological denial or defensive minimisation. Both can be present. Confronting the first causes distress without insight; with the second, work on what makes the facts too hard to accept [synthesis].

B5. Adjustment, mood and identity work

  • Purpose: address the emotional effects of stroke, disability and slow, uncertain recovery.
  • Steps: (1) screen for depression, anxiety and adjustment problems with validated tools suitable for stroke survivors, and pass positive screens to the team or medical lead; (2) offer adjustment-focused work within the holistic rehabilitation framework (065): grief for lost abilities, a changed sense of self, roles, hope; (3) link therapy goals to rehabilitation goals (for example, reading the paper again, safe cooking); (4) assess suicide risk in line with standard practice when mood is low.
  • Example language (illustrative): "A lot of people find the hardest part isn't the exercises. It's the feeling of not being the same person. What's that been like for you?"
  • Watch for: low mood showing up as "not engaging" in therapy; frustration after sessions with no visible gain; caregiver-patient conflict.

B6. Engagement and ambivalence about the treatment

  • Purpose: help the person find their own reasons to take part, or voice concerns to the team, without you advising on the treatment.
  • Steps: (1) explore what makes sessions hard: fatigue, dizziness, boredom, feeling watched, doubting the point; (2) reflect both sides; (3) encourage them to raise tolerability and doubts directly with the OT; (4) never advise them to stop or continue; route decisions to the treating therapist.
  • Example language (illustrative): "Part of you wants to give the glasses a fair go, and part of you feels sick and fed up after each session. That's worth telling the OT about. They can tell you what can be adjusted."
  • Watch for: missed sessions linked to low mood; an early discharge cutting the course short [source: Hreha et al. 2022 on early discharge].

B7. Monitoring and passing on adverse reactions and warning signs

  • Purpose: make sure problems you hear about reach the people who can act.
  • Steps: (1) ask briefly after PA sessions about dizziness, double vision, discomfort from the goggles or spectacles, and nausea [source: Hreha et al. 2022 for dizziness, double vision and fit; nausea is synthesis]; (2) ask about falls, near misses, spills and injuries [source: Kessler Foundation guide]; (3) with consent, pass these on to the OT or nurse the same day; (4) sudden new weakness, speech change, facial droop, severe headache or confusion means urgent medical help or emergency services [synthesis].
  • Example language (illustrative): "How did you feel after the session today, any dizziness or seeing double? I'd like to let the OT know so they can check."
  • Watch for: under-reporting because of reduced awareness. Ask carers and staff too.

B8. Family and carer work

  • Purpose: carers of people with neglect report more stress and burden [source: Kessler Foundation guide].
  • Steps: (1) offer carers psychoeducation (B2); (2) go over home strategies that the team endorses: check the neglected side for hazards; place stimulating things (TV, photos, flowers) on the affected side but essentials (glasses, call button, emergency information) on the unaffected side; reduce noise and crowding before important tasks; time key activities for when the person is most alert; help with detail-heavy tasks such as finances; avoid "look left" and use other cues [source: Kessler Foundation guide]; (3) attend to the carer's own wellbeing: respite, social contact, support groups [source: Kessler Foundation guide]; (4) refer carers for their own support where needed.
  • Example language (illustrative): "When he says he's fine and you can see he isn't, that's exhausting. Let's think about what you need, as well as what he needs."
  • Watch for: carer burnout, critical or blaming comments, conflict over safety (driving, cooking), and the carer taking over in ways that reduce the person's rehabilitation practice.

B9. Safety planning

  • Purpose: reduce harm from neglect-related accidents.
  • Steps: (1) review daily risks with the person and carer: hot drinks, cooking, wheelchair brakes on the neglected side, crossing roads, stairs [source: Kessler Foundation guide]; (2) encourage use of the team's strategies; (3) refer driving questions to the team and the licensing authority; do not judge fitness to drive yourself [source: Canadian Stroke Best Practices cross-reference to driving]; (4) record and share agreed safety steps with the team.
  • Example language (illustrative): "Let's go through a normal day and spot the moments where missing something on the left could be risky, then decide what would help."
  • Watch for: the person resisting restrictions (often linked to reduced awareness or loss of independence); work with the meaning, not just the rule.

B10. Adapting your own sessions for neglect

  • Purpose: make sure psychotherapy itself is accessible.
  • Steps: (1) ask the OT how to position yourself and materials for this person; (2) keep handouts short, with a clear anchor at the left margin, and check that the person has read the whole line; (3) use a quiet room and schedule sessions for alert times [source: Kessler Foundation guide on fatigue and noise]; (4) give summaries out loud and check understanding.
  • Example language (illustrative): "Could you read me the first line back? I want to check the sheet works for you."
  • Watch for: missed items in questionnaires or written homework that look like low engagement but are neglect-related omissions.

B11. Collaboration and integration with the team

  • Purpose: keep psychological and rehabilitation work aligned.
  • Steps: (1) agree with the client what you'll share; (2) join team meetings or goal-setting where possible (see 065); (3) use the team's terms for neglect and strategies; (4) feed back mood, awareness, engagement and carer issues; (5) ask the team for task-based observations to judge change ("knowing is not doing" [source: Freer et al. 2016]).
  • Example language (illustrative, to the OT): "Mrs B finds the post-session dizziness frightening and has started dreading the mornings. Could we think together about how to frame it, and whether anything can be adjusted?"
  • Watch for: splitting (the client telling different professionals different things); duplicated or contradictory advice.

B12. After the rehabilitation course ends

  • Purpose: neglect and its consequences often continue after discharge [source: Kessler Foundation guide].
  • Steps: (1) continue adjustment and carer work; (2) check for longer-term mood problems and social isolation; (3) signpost community stroke services, support groups and carer organisations [source: Kessler Foundation guide]; (4) re-refer to rehabilitation if function or safety gets worse.
  • Example language (illustrative): "The glasses sessions have finished, but the adjusting goes on. What feels hardest now you're home?"
  • Watch for: a drop in hope once formal therapy stops; carer exhaustion; new safety incidents.

5. Handling problems

The published sources on PA cover implementation and tolerability problems. They say little about psychological difficulties, so most responses below are [synthesis] unless a source is given.

  • "There's nothing wrong with my left side." (reduced awareness): don't argue. Use the team's observations, video or with-and-without-cue comparisons [source: Freer et al. 2016], and explore what accepting the deficit would mean. If awareness doesn't shift, support routine-based strategies and carer-led safety measures [synthesis].
  • Goggle intolerance (dizziness, double vision, fit, helmet pressure): validate it, record it and pass it to the OT the same day. Optometry input may be needed for spectacle wearers [source: Hreha et al. 2022]. Don't advise stopping; the team decides.
  • No after-effect, so PA is stopped: reframe this as information that redirects the team, not failure. In KF-PAT, absent after-effects are a reason not to continue [source: Chen et al. 2025]. Help the person stay engaged with the alternatives (A4) [synthesis].
  • Hope collapses after small or short-lived gains: acknowledge the evidence honestly (effects are often small and short-term [source: Mancuso et al. 2026; medRxiv 2025 meta-analysis]), shift focus to functional goals and adjustment, and screen for depression [synthesis].
  • Over-hope or a search for a cure: gently align expectations with the published position that no neglect treatment is proven superior [source: Cochrane Corner]. Bring questions about private or unregulated programmes back to the team [synthesis].
  • Overwhelm and fatigue: shorten sessions, schedule for alert times, cut noise [source: Kessler Foundation guide], and coordinate with the timetable so psychotherapy doesn't directly follow demanding rehabilitation sessions [synthesis].
  • Non-adherence to strategies at home: expect a gap between knowing and doing [source: Freer et al. 2016]. Work with the carer on environmental set-up rather than relying on the person remembering [source: Kessler Foundation guide; synthesis].
  • Shame at being observed (meals, self-care): voice it, normalise it, and ask the team about privacy or alternatives [source: Hreha et al. 2022 for the problem; synthesis for the response].
  • Carer conflict and burnout: offer the carer separate time and refer them for their own support; address blaming beliefs with psychoeducation [source: Kessler Foundation guide; synthesis].
  • Ruptures ("you're on their side"): acknowledge the client's experience of the team, clarify your separate role and what you share, and repair through collaboration rather than defending the team [synthesis].
  • Language barriers or severe neglect stop the client following instructions: ask for interpreters and simplified materials, and recognise that PA may not be feasible; the team decides [source: Hreha et al. 2022; synthesis].
  • Early discharge cuts the course short: help the person and family understand the change, and make sure community rehabilitation and carer support are arranged [source: Hreha et al. 2022 for the problem; synthesis for the response].
  • Professional disagreement about scope (for example OT vs optometry): this is documented in implementation [source: Hreha et al. 2022]. Stay out of it and keep the focus on the client's experience [synthesis].
  • Safety disputes (driving, cooking alone): refer driving to the team and licensing authority, explore what losing independence means, and record agreed measures [synthesis; source: Canadian Stroke Best Practices on driving cross-reference].
  • Low mood or suicidal thoughts: assess risk following standard practice, involve the medical team, and build a safety plan with the person and carer [synthesis].
  • New neurological symptoms: urgent medical help or emergency services [synthesis].

Sources

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