Functioning and Disability
Yuji Fujino, PhD
Associate Professor
Juntendo University
Bunkyo-ku, Tokyo, Japan
Toshiya Nezu, MS
Physical Therapist
Juntendo University
Kasukabe City, Saitama, Japan
Tadamitsu Matsuda, PhD
professor
Department of Physical Therapy, Faculty of Health and Medical Sciences, Juntendo University
Bunkyo-ku, Tokyo, Japan
A woman in her 70s had a right subcortical hemorrhage causing severe left hemiparesis. Neuropsychological assessment showed crossed aphasia (Western Aphasia Battery score 51) and left unilateral spatial neglect (Behavioral Inattention Test conventional subtest 37). She exhibited marked postural imbalance with lateropulsion and active pushing toward the paretic side (LP), scoring 6 on the Scale for Contraversive Pushing (SCP).
Case Description:
Anosognosia for spatial neglect was quantified using the Catherine Bergego Scale (CBS) as the discrepancy between observer- and self-rated scores. On day 6, she showed severe LP and marked anosognosia (CBS anosognosia 22; observer 24, self 2) but reported minimal fear of falling during 30° sitting tilts (NRS 0–1). By day 30, SCP slightly improved to 5.5 and the anosognosia score decreased to 8 (observer 14, self 6), indicating greater awareness; concurrently, fear of falling increased (NRS 5 for paretic-side tilts, 3 for non-paretic-side tilts).
Discussions:
Previous work suggests that directional fear of falling toward the non-paretic side is a specific marker of LP. Our case indicates that anosognosia for neglect can initially suppress this pattern: severe anosognosia coexisted with minimal reported fear, whereas improvement in anosognosia paralleled the emergence of direction-specific fear. This temporal coupling may reflect recovery of right-hemisphere networks supporting spatial awareness and emotion. Objective physiological indices could help detect fear-related responses when subjective fear is blunted.
Conclusions:
Direction-specific fear of falling has been proposed as a diagnostic marker of LP. This case suggests that when anosognosia for neglect is present, awareness of fear may be diminished and the marker becomes unreliable. As anosognosia improved, fear of falling aligned with patterns seen in stroke patients without LP. Consequently, clinical evaluations of LP using subjective fear responses should consider the presence of anosognosia for neglect to ensure diagnostic accuracy.
