functional assessment of spatial neglect: a review of the...

423

Top Stroke Rehabil 2012;19(5):423–435© 2012 Thomas Land Publishers, Inc.www.thomasland.com

doi: 10.1310/tsr1905-423

Grand Rounds

Functional Assessment of Spatial Neglect: A Review of the Catherine Bergego

Scale and an Introduction of the Kessler Foundation Neglect Assessment Process

Peii Chen, PhD,1–3 Kimberly Hreha, OTR,4–6 Paola Fortis, PhD,7,8 Kelly M. Goedert, PhD,9 and Anna M. Barrett, MD1–4

1Kessler Foundation Research Center, West Orange, New Jersey; 2Department of Physical Medicine & Rehabilitation, University of Medicine and Dentistry of New Jersey – New Jersey Medical School (UMDNJ-NJMS), Newark, New Jersey; 3Graduate School of

Biomedical Sciences, UMDNJ-NJMS, Newark, New Jersey; 4Kessler Institute for Rehabilitation, West Orange, New Jersey; 5Department of Occupational Therapy, Columbia University, New York, New York; 6Movement Science and Education/Kinesiology Program, Teachers College, Columbia University, New York, New York; 7Center for Neurocognitive Rehabilitation, University of Trento, Rovereto, Trentino, Italy; 8Department of Psychology, University of Milano-Bicocca, Milano, Italy; 9Department of Psychology, Seton Hall University, South

Orange, New Jersey

Spatial neglect is a debilitating poststroke neurocognitive disorder associated with prolonged hospitalization and poor rehabilitation outcomes. The literature suggests a high prevalence of this disorder, but clinicians have diffi culty reliably identifying affected survivors. This discrepancy may result from suboptimal use of validated neglect assessment procedures. In this article, we suggest use of a validated assessment tool that is sensitive to identifi cation of neglect and its functional consequences – the Catherine Bergego Scale (CBS). We provide detailed item-by-item instructions for observation and scoring – the Kessler Foundation Neglect Assessment Process (KF-NAP). Rehabilitation researchers may be able to use the CBS via the KF-NAP to measure ecological outcomes and specifi c, separable perceptual-attentional and motor-exploratory spatial behaviors. Key words: Catherine Bergego Scale, neglect assessment, spatial neglect

Practical Problem of Spatial Neglect

Spatial neglect is a debilitating neurocognitive disorder associated with prolonged hospitalization,1 poor rehabilitation outcomes in stroke survivors,2–4 increased risk of falls,5 and unsafe navigation while walking6 and using a wheelchair.7 This disorder is characterized by a failure or slowness to respond, orient, or initiate action toward contralesional stimuli8; consequently, spatial neglect is accompanied by functional disability.9 Literature suggests that between 30% and 70% of right brain–damaged stroke survivors present with spatial neglect and that 20% to 60% of left brain–damaged stroke survivors have this disorder.10–14 This large variance in the estimates of prevalence suggests a problem in the assessment and diagnosis of this disorder.

Diffi culty in diagnosing spatial neglect derives from several sources. First, there is large variability in the assessments used in its diagnosis. Menon and Korner-Bitensky15 identifi ed 28 standardized

and 34 nonstandardized neglect assessment tools, including behavioral tests and functional assessments. Second, neglect is a heterogeneous disorder.16 Thus, some assessments may fail to detect specifi c aspects or subtypes of neglect. As a result, research suggests that assessment with more than one behavioral test is helpful to detect the disorder,17 to investigate subtypes,18 to differentiate various mechanisms of spatial neglect,19 and to assess both clinical signs and real-world function, especially treatment outcomes.20,21 Last, in some contexts, neglect assessment may not be employed at all,22 perhaps because of perceived barriers in the implementation of the assessment. In sum, clinical practice has not followed a consistent standard: some practitioners use behavioral tests

424 TOPICS IN STROKE REHABILITATION/SEPT-OCT 2012

(eg, target cancellation, fi gure copying), some document clinical observations, and others make judgments about the presence and treatment of neglect based on a general evaluation rather than results of any specifi c cognitive testing.22–24 This inconsistent practice standard may contribute to the low detection rate of spatial neglect in medical and rehabilitation settings,25 and it hampers efforts to optimize stroke management and rehabilitation through neglect-specifi c therapeutic interventions.26,27

Possible Solution: Catherine Bergego Scale

To bridge the gap between the actual and best clinical practices, rehabilitation clinicians need successful strategies for knowledge translation28 and practice reform.29 With the goal of increasing the clinical use of neglect assessments, we advocate for the use of a functional assessment for spatial neglect — the Catherine Bergego Scale (CBS).30,31 Of the existing 28 standardized assessments,15 the CBS is the only one that assesses performance in personal (body parts or on the body surface), peri-personal (within arm’s reach), and extra-personal spaces (beyond arm’s reach), as well as in perceptual, representational, and motor domains. Thus, the CBS captures the heterogeneity of the neglect disorder. Additionally, the CBS assesses function by direct observation of spontaneous (ie, self-initiated) behaviors in 10 everyday activities, such as brushing hair on both left and right sides and remembering to take care of the left limb, which may be weaker and hanging outside the wheelchair. In contrast, a laboratory-based or paper-and-pencil behavioral examination usually requires patients to follow instructions to perform a task seldom encountered in daily life, which may be sensitive in detecting lateralized bias but is not directly translatable to functional disabilities. Commonly used measures of activities of daily living (ADLs), such as the Barthel Index (BI)32 and the FIM,33 do not directly assess the impact of spatial neglect versus other disabling impairments. Even though the presence of spatial neglect, detected by behavioral tests, is significantly correlated with the BI34,35 or the FIM,3,4 the CBS directly measures neglect-related limitation on activity and participation.36 Therefore, the CBS can

be used to assess ADLs with a precise description of a patient’s ability and disability directly related to spatial neglect, and the CBS is a useful and effi cient tool for evaluating rehabilitation effi cacy.

CBS validity

The strength of the CBS is not only in its direct observation of ADLs, but is also in its validity. Table 1 summarizes the 8 studies30,37–43 verifying and confi rming the validity of the CBS since the original English publication by Azouvi et al30 in 1996. This summary is a result of our systematic review of literature covering the period from 1996 to August 2011 using electronic databases (PubMed, PubMed Central, MEDLINE, and ISI Web of Science) to search for articles written in English with the key word “Catherine Bergego Scale” in “all fi elds” or “topic.” It is reported that the CBS is signifi cantly correlated with behavioral paper-and-pencil tests for detecting spatial neglect, especially bell cancellation,30,38 but that the CBS may be even more sensitive to neglect symptoms than paper-and-pencil tests.30,38,40 Luukkainen-Markkula et al39 and Goedert et al41 also found signifi cant correlations between items of the CBS and the conventional subtest of the Behavioral Inattention Test (BIT),44 which includes the following widely used paper-and-pencil tasks: line crossing,45 letter cancellation, star cancellation, fi gure and shape copying, line bisection, and representational drawing. Among CBS items, internal consistency was verifi ed such that all items were correlated with one another.38,41 The CBS correlates with other functional assessments such as the BI,41,46 the FIM,37,42 the Postural Assessment for Stroke Scale,37 and wheelchair collisions.42

In addition to its apparent validity in the detection of spatial neglect and problems with ADLs, the CBS may also be used to identify the presence of pathological unawareness of defi cits, that is, anosognosia. Azouvi et al38 rephrased the CBS items into a questionnaire given to patients to self-evaluate their behavior. The difference between the self-assessed and therapist-assessed CBS scores serves as a tool for detecting anosognosia. Anosognosia strongly correlates with the therapist-assessed CBS score, supporting a strong relationship between neglect and

Functional Assessment of Spatial Neglect 425

Tab

le 1

. V

alid

atio

n s

tudi

es o

n t

he

Cat

her

ine

Ber

gego

Sca

le (

CB

S)

Stu

dy

Ch

arac

teri

stic

s of

str

oke

surv

ivor

s

CB

S co

rrel

atio

ns

wit

h o

ther

n

egle

ct a

sses

smen

ts (

un

corr

ecte

d

sign

ifi c

ance

lev

el: P

< .0

5)

CB

S as

soci

atio

ns

wit

h A

DL

or

clin

ical

ass

essm

ents

(u

nco

rrec

ted

si

gnifi

can

ce l

evel

: P <

.05)

CB

S se

nsi

tivi

ty i

n d

etec

tin

g sp

atia

l n

egle

ct

Azo

uvi e

t al

, 199

630•

50 R

BD s

trok

e su

rviv

ors

• A

ge: 2

0 to

79

(57.

1 ±

14.2

) yr

• T

PS: 3

wk

to 6

yr

(18.

9 ±

44.3

wk)

• C

BS-t

otal

cor

rela

ted

wit

h sc

ores

in

dai

sy d

raw

ing,

Ogd

en s

cene

co

pyin

g, li

ne c

ance

llati

on, b

ell

canc

ella

tion

, and

rea

ding

.

• Se

lf-as

sess

ed C

BS s

igni

fi can

tly

low

er t

han

OT-

asse

ssed

C

BS, s

ugge

stin

g pr

esen

ce o

f an

osog

nosi

a.•

CBS

-tot

al c

orre

late

d w

ith

anos

ogno

sia

scor

e.•

CBS

-tot

al c

orre

late

d w

ith

BI.

How

ever

, 1 p

atie

nt w

ith

perf

ect

scor

e on

BI

had

mod

erat

e ne

glec

t on

CBS

.

94%

Top

3 se

nsit

ive

item

s:•

Lim

b aw

aren

ess

(66%

)•

Dre

ssin

g (6

0%)

• C

ollis

ions

(50

%)

Azo

uvi e

t al

, 200

240•

69 o

f the

206

RBD

str

oke

surv

ivor

s w

ere

eval

uate

d w

ith

CBS

.•

TPS

(n=

206)

: 11.

1 ±

13.8

wk

• C

BS-t

otal

cor

rela

ted

wit

h sc

ores

in

bell

canc

ella

tion

, fi g

ure

copy

ing,

cl

ock

draw

ing,

20-

cm li

ne

bise

ctio

n, o

verl

appi

ng fi

gure

s te

st,

read

ing,

and

wri

ting

.

• C

BS-t

otal

cor

rela

ted

wit

h an

osog

nosi

a sc

ore.

76.8

%To

p 3

sens

itiv

e it

ems:

• Li

mb

awar

enes

s (6

8.3%

)•

Col

lisio

ns (

59.3

%)

• D

ress

ing

(57.

9%)

Azo

uvi e

t al

, 200

338•

83 R

BD s

trok

e su

rviv

ors

• A

ge: 5

4.5

± 14

.1 y

r•

TPS

: 3 t

o 64

(15

.9 ±

15.

2) w

k

• C

BS it

ems

all c

orre

late

d w

ith

each

ot

her.

• C

BS-t

otal

cor

rela

ted

wit

h sc

ores

in

bell

canc

ella

tion

, fi g

ure

copy

ing,

an

d te

xt r

eadi

ng.

• C

BS-t

otal

cor

rela

ted

wit

h an

osog

nosi

a sc

ore.

96.4

%To

p 3

sens

itiv

e it

ems:

• D

ress

ing

(79.

5%)

• Li

mb

awar

enes

s (7

4.5%

)•

Col

lisio

ns (

69.1

%)

Azo

uvi e

t al

, 200

637•

78 L

BD s

trok

e su

rviv

ors

• A

ge: 5

4.6

± 15

.7 y

r•

TPS

: 10.

8 ±

12.4

wk

• R

esul

ts fo

r R

BD s

trok

e su

rviv

ors

wer

e du

plic

ated

from

the

ir

prev

ious

stu

dies

.•

LBD

str

oke

surv

ivor

s’ C

BS-t

otal

co

rrel

ated

wit

h be

ll ca

ncel

lati

on,

but

the

corr

elat

ion

coef

fi cie

nts

wer

e of

low

er m

agni

tude

tha

n th

ose

in R

BD s

trok

e su

rviv

ors.

• LB

D s

trok

e su

rviv

ors’

CBS

-tot

al

corr

elat

ed w

ith

FIM

and

PA

SS.

77.3

%In

com

pari

son

wit

h th

e 36

%

mod

erat

e an

d se

vere

neg

lect

in R

BD

stro

ke s

urvi

vors

, onl

y 5.

4% L

BD

stro

ke s

urvi

vors

had

a C

BS s

core

hi

gher

tha

n 10

.

Qia

ng e

t al

, 200

542•

19 s

trok

e su

rviv

ors

wit

h le

ft

hem

iple

gia

• A

ge: 6

5.2

± 10

.9 y

r•

TPS

: 23

to 1

15 (

61.9

± 2

5.8)

day

s

No

info

rmat

ion

• C

BS-t

otal

cor

rela

ted

wit

h nu

mbe

r of

whe

elch

air

colli

sion

s, F

IM

mot

or, F

IM c

ogni

tion

, and

FIM

to

tal s

core

s.

Not

app

licab

le

(con

tinu

ed)


Stu

dy

Ch

arac

teri

stic

s of

str

oke

surv

ivor

s

CB

S co

rrel

atio

ns

wit

h o

ther

n

egle

ct a

sses

smen

ts (

un

corr

ecte

d

sign

ifi c

ance

lev

el: P

< .0

5)

CB

S as

soci

atio

ns

wit

h A

DL

or

clin

ical

ass

essm

ents

(u

nco

rrec

ted

si

gnifi

can

ce l

evel

: P <

.05)

CB

S se

nsi

tivi

ty i

n d

etec

tin

g sp

atia

l n

egle

ct

Wan

g et

al,

2005

43•

30 s

trok

e su

rviv

ors

wit

h le

ft

hem

iple

gia

• A

ge: 6

4.1

± 12

.7 y

r•

TPS

: 23

to 1

15 (

61.6

± 2

2.8)

day

s

• C

BS-t

otal

cor

rela

ted

wit

h ri

ghtw

ard

erro

r in

bis

ecti

ng li

nes

alig

ned

wit

h bo

dy c

ente

r or

line

s pl

aced

on

the

left

sid

e.•

Pati

ents

wit

h se

vere

neg

lect

(C

BS >

20)

mad

e m

ore

left

war

d er

rors

in b

isec

ting

line

s pl

aced

on

the

righ

t si

de.

No

info

rmat

ion

Not

app

licab

le

Luuk

kain

en-M

arkk

ula

et a

l, 20

1139

• 17

RBD

str

oke

surv

ivor

s w

ith

left

-sid

ed n

egle

ct (

BIT

< 1

31 o

r C

BS >

4).

• A

ge: 4

0 to

74

(57

± 8)

yr

• T

PS: 0

to

131

(20

± 32

) m

o

• 17

pai

rs o

f CBS

item

s co

rrel

ated

w

ith

each

oth

er.

• C

BS-e

atin

g co

rrel

ated

wit

h BI

T-lin

e cr

ossi

ng, l

ette

r ca

ncel

lati

on, a

nd

star

can

cella

tion

.•

BIT-

line

bise

ctio

n co

rrel

ated

wit

h C

BS-g

room

ing,

gaz

e or

ient

atio

n,

audi

tory

att

enti

on, a

nd n

avig

atio

n.

• D

iffer

ence

s in

CBS

-tot

al a

nd

navi

gati

on b

etw

een

thos

e id

enti

fi ed

wit

h an

d w

itho

ut V

FD.

• N

umbe

r of

mon

ths

from

str

oke

corr

elat

ed w

ith

limb

awar

enes

s,

colli

sion

s, n

avig

atio

n, a

nd p

erso

nal

belo

ngin

gs.

• N

umbe

r of

lesi

on a

reas

cor

rela

ted

wit

h ga

ze o

rien

tati

on.

• V

FD c

orre

late

d w

ith

audi

tory

at

tent

ion,

nav

igat

ion,

and

C

BS-t

otal

.

Not

app

licab

le

Goe

dert

et

al, 2

01241

• 51

RBD

str

oke

surv

ivor

s w

ith

left

-sid

ed n

egle

ct (

BIT

< 1

29 o

r C

BS >

11)

• A

ge: 2

8 to

90

(66.

9 ±

15.9

) yr

• T

PS: 9

to

61 (

22.3

± 1

0.9)

day

s

• Tw

o gr

oups

of C

BS it

ems

emer

ged

from

PC

A, a

nd t

hen

cate

gori

zed

as

CBS

-PA

and

CBS

-ME

item

s.

CBS

-PA

: per

sona

l bel

ongi

ngs,

ea

ting

, cle

anin

g af

ter

mea

l, au

dito

ry a

tten

tion

, gaz

e or

ient

atio

n, a

nd g

room

ing.

C

BS-M

E: c

ollis

ions

, dre

ssin

g,

limb

awar

enes

s, a

nd n

avig

atio

n.•

CBS

-PA

and

CBS

-ME

cor

rela

ted

wit

h ea

ch o

ther

.•

CBS

-PA

cor

rela

ted

wit

h BI

T t

otal

sc

ore,

DSS

-vis

ual,

DSS

-tac

tile

, and

“w

here

” sp

atia

l bia

s.•

CBS

-ME

cor

rela

ted

wit

h BI

T t

otal

sc

ore

and

DSS

-tac

tile

.

• Bo

th C

BS-P

A a

nd C

BS-M

E

corr

elat

ed w

ith

BI.

Not

app

licab

le

Not

e: A

DL

= ac

tivi

ties

of d

aily

livi

ng; B

I =

Bart

hel I

ndex

; BIT

= B

ehav

iora

l Ina

tten

tion

Tes

t; C

BS-t

otal

= C

BS t

otal

sco

re; C

BS-M

E =

mot

or-e

xplo

rato

ry C

BS it

ems;

CBS

-PA

= p

erce

ptua

l-at

tent

iona

l CBS

item

s; D

SS =

dou

ble

sim

ulta

neou

s st

imul

atio

n; L

BD =

left

bra

in–d

amag

ed; O

T =

occ

upat

iona

l the

rapi

st; P

ASS

= P

ostu

ral A

sses

smen

t fo

r St

roke

Sca

le; P

CA

= p

rinc

ipal

com

pone

nts

anal

ysis

; RBD

= r

ight

bra

in–d

amag

ed; T

PS =

tim

e po

st s

trok

e; V

FD =

vis

ual fi

eld

defi

cit

.

Tab

le 1

. (c

onti

nued

)


anosognosia severity.40 Therefore, as an assessment highly sensitive to spatial neglect, carrying fi ne psychometric properties, and directly informative of functional disability, the CBS is a valuable tool for detecting and evaluating severity of spatial neglect in terms of its manifestation in functional activities.36

CBS implementation in rehabilitation

In rehabilitation research, an improvement in functional outcome is the gold standard supporting effi cacy of an experimental treatment. Bowen and Lincoln47 state, in a Cochrane review, that insuffi cient evidence is available to support the effi cacy of neglect rehabilitation at reducing real-world disability. Although implementing more treatment studies with functional outcomes will be helpful to address this goal, improved identifi cation and assessment of spatial neglect will optimize opportunities to manage symptoms in the hospital and at home. Rehabilitation studies have used the CBS to quantify the functional outcome. As summarized in Table 2 (resulting from the database search described earlier), improvement in the CBS total score was observed after the treatment in all of the studies.46,48–54 In 2 of the studies that included a no-treatment control group,51,52 investigators found equivalent changes in CBS total scores in both treatment and no-treatment groups, which could potentially refl ect a failure of the treatment or a lack of sensitivity of the CBS to those changes. Consistent with the studies in which signifi cant psychometric values in the CBS are reported (Table 1), treatment outcomes measured with the CBS are correlated with those measured with the behavioral tests in the studies reviewed in Table 2.48–53 This indicates that functional abilities (measured with the CBS) improve with the improvement of perceptual-attentional or motor-intentional abilities (measured with behavioral tests such as the BIT). However, if the behavioral tests were used without the CBS for the outcome measure, it may have been diffi cult for clinicians to translate the treatment effect into functional outcome, and thus clinicians may underestimate the clinical signifi cance of the studied treatment specifi cally for spatial neglect. In addition, using other conventional ADL outcome

measures (eg, FIM or BI), clinicians may not obtain direct information on neglect recovery. Therefore, the CBS score may improve with other measures after a treatment (see the last column in Table 2), but the information provided by the CBS is unique such that improvement quantifi ed in the CBS score over time may suggest functional neglect recovery.

Changes in the CBS total score may conceal changes in individual items that receive benefi ts specifi cally from the treatment. Because ADLs are not unidimensional but involve many brain networks and systems, an ADL/functional assessment should be multidimensional. Clinicians may wish to review patients’ scores on individual CBS items to explore their individual symptom profile.55 Goedert et al41 suggested that specifi c CBS items may support 2 distinct underlying constructs, potentially corresponding to impairment in different brain-behavior spatial systems: perceptual-attentional versus motor-exploratory components (CBS-PA and CBS-ME, respectively; see Table 1). In addition, Goedert et al41 found that poor performance on motor-exploratory items predicted a proportion of disability not correlated with performance on other, conventional impairment measures. These fi ndings are consistent with independent manifestation of spatial dysfunction in perceptual-attentional versus motor-intentional systems, induced by damage to distinct brain networks,8,56–60 and are also consistent with the idea that the CBS captures the heterogeneity of spatial neglect.15 Further research is needed to focus on brain-behavior neurocognitive relations of individual CBS items and to use the CBS as an outcome measure to investigate effective treatments targeting the perceptual-attentional or motor-intentional neglect (eg, determine whether patients with motor-exploratory defi cits may respond better to targeted defi cits such as limb activation therapy).

Kessler Foundation Neglect Assessment Process

Since 2008, our team at the Kessler Foundation Research Center has used the CBS in our rehabilitation research on spatial neglect. However, we found limitations in administering the CBS. The original English publication of


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• 5

sess

ions

(1

per

day)

of t

arge

t po

inti

ng

(30

tria

ls p

er s

essi

on)

whi

le w

eari

ng F

resn

el

lens

es o

ver

12 t

o 17

day

s

• Le

tter

can

cella

tion

, lin

e bi

sect

ion,

CBS

, and

FI

M im

prov

ed.

Ert

ekin

et

al, 2

00946

• Su

perv

ised

exe

rcis

e gr

oup

(n=1

0) a

ged

63.3

± 1

0.5

yr•

Hom

e ex

erci

se g

roup

(n=

10)

aged

61

.8 ±

9.0

yr

• T

PS: ≥

3 m

o an

d ≤

24 m

o

• Su

perv

ised

exe

rcis

e gr

oup:

PT-

supe

rvis

ed

exer

cise

pro

gram

for

12 w

k•

Hom

e ex

erci

se g

roup

: uns

uper

vise

d ex

erci

se p

rogr

am fo

r 12

wk

wit

h a

wri

tten

in

stru

ctio

n. P

T p

hone

d th

e pa

tien

ts o

nce

a w

eek.

• BI

, PA

SS, R

MI,

BBS

, and

CBS

impr

oved

in

bot

h gr

oups

aft

er t

he t

reat

men

t an

d at

1-

year

follo

w-u

p.

Luuk

kain

en-M

arkk

ula

et a

l, 20

0949

• A

rm-a

ctiv

atio

n gr

oup

(n=6

) ag

ed

59.5

± 8

.4 y

r; T

PS 8

1.0

± 64

.6 d

ays

• V

isua

l-sc

anni

ng g

roup

(n=

6) a

ged

57.8

± 1

1.8

yr; T

PS 9

5.5

± 63

.2 d

ays

• A

rm-a

ctiv

atio

n gr

oup:

sup

ervi

sed

left

arm

m

ovem

ent

in t

he le

ft s

pace

for

20–3

0 hr

du

ring

hos

pita

lizat

ion

• V

isua

l-sc

anni

ng g

roup

: vis

ual s

cann

ing

inte

grat

ed w

ith

OT

and

PT

ses

sion

s du

ring

ho

spit

aliz

atio

n

• BI

T, C

BS, a

nd F

IM im

prov

ed in

bot

h gr

oups

.

Stau

bli e

t al

, 200

954•

4 pa

tien

ts a

ged

39–6

0 yr

• T

PS: 1

2 to

131

mo

• A

rob

otic

dev

ice

appl

ied

arou

nd t

he le

ft

arm

for

mov

ing

the

arm

pas

sive

ly a

nd fo

r su

ppor

ting

the

arm

to

mov

e ac

tive

ly•

8 w

eeks

of t

rain

ing

(3 t

o 4

sess

ions

per

w

eek;

1 h

r pe

r se

ssio

n)

• FM

A, W

MFT

, MV

T, a

nd C

BS im

prov

ed

afte

r th

e tr

eatm

ent.

Tab

le 2

. N

egle

ct r

ehab

ilit

atio

n s

tudi

es u

sin

g th

e C

ath

erin

e B

erge

go S

cale

(C

BS)

as

an o

utc

ome

mea

sure


Fort

is e

t al

, 201

048•

10 p

atie

nts

aged

72.

7 ±

5.2

yr•

TPS

: 1 t

o 10

mo

• W

edge

pri

sm g

lass

es w

ith

10°

righ

twar

d vi

sual

shi

ft•

Cro

ssov

er d

esig

n: A

ll th

e pa

tien

ts

expe

rien

ced

both

tre

atm

ents

. Ord

er o

f tr

eatm

ents

alt

erna

ted

betw

een

pati

ents

.•

Poin

ting

tre

atm

ent:

10

sess

ions

(2

per

day)

of

tar

get

poin

ting

(90

tri

als

or 2

0 m

in)

• E

colo

gica

l act

ivit

y tr

eatm

ent:

10

sess

ions

(2

per

day

) of

per

form

ing

visu

al-g

uide

d m

anua

l tas

ks w

ith

AD

L va

lidit

y (1

2 ac

tivi

ties

or

20

min

)

• Le

tter

can

cella

tion

, bel

l can

cella

tion

, sta

r ca

ncel

lati

on, c

ompl

ex d

raw

ing,

wor

d an

d se

nten

ce r

eadi

ng, F

IM, a

nd C

BS im

prov

ed

afte

r th

e fi r

st t

reat

men

t an

d co

ntin

ued

impr

ovin

g af

ter

the

seco

nd, i

ndep

ende

nt o

f th

e or

der

of t

reat

men

ts.

Turt

on e

t al

, 201

052•

Inte

rven

tion

gro

up (

n=16

) ag

ed 7

2 ±

14 y

r;

TPS

45

± 23

day

s.•

Con

trol

gro

up (

n=18

) ag

ed 7

1 ±

14 y

r;

TPS

47

± 39

day

s.

• W

edge

pri

sm g

lass

es w

ith

6° r

ight

war

d vi

sual

shi

ft•

10 s

essi

ons

(1 s

essi

on a

day

) of

tar

get

poin

ting

(30

tri

als

per

sess

ion)

whi

le w

eari

ng

pris

m g

lass

es (

inte

rven

tion

gro

up)

or s

ham

(c

ontr

ol g

roup

) ov

er 2

wk

• BI

T a

nd C

BS im

prov

ed in

bot

h gr

oups

.

Miz

uno

et a

l, 20

1151

• In

terv

enti

on g

roup

(n=

20)

aged

66

± 1

1.5

yr; T

PS 6

7.1

± 18

.4 d

ays.

• C

ontr

ol g

roup

(n=

18)

aged

66.

6 ±

7.7

yr;

TPS

64.

4 ±

20.9

day

s

• Fr

esne

l len

ses

wit

h 12

° ri

ghtw

ard

visu

al s

hift

• 20

ses

sion

s (2

ses

sion

s a

day)

of t

arge

t po

inti

ng (

90 t

rial

s pe

r se

ssio

n) w

hile

wea

ring

Fr

esne

l len

ses

(int

erve

ntio

n gr

oup)

or

sham

(c

ontr

ol g

roup

) ov

er 2

wk.

• BI

T, C

BS, a

nd F

IM im

prov

ed in

bot

h gr

oups

af

ter

trea

tmen

t an

d at

hos

pita

l dis

char

ge

(97.

5 ±

45.3

day

s po

st s

trok

e).

• Pa

tien

ts w

ith

mild

er n

egle

ct h

ad

grea

ter

FIM

cha

nge

if th

ey r

ecei

ved

the

inte

rven

tion

.

Not

e: B

BS =

Ber

g Ba

lanc

e Sc

ale;

BI

= Ba

rthe

l Ind

ex; B

IT =

Beh

avio

ral I

natt

enti

on T

est;

FM

A =

Fug

l-M

eyer

Sco

re o

f the

upp

er e

xtre

mit

y A

sses

smen

t; M

VT

= m

axim

al v

olun

tary

tor

ques

; O

T =

occ

upat

iona

l the

rapi

st; P

ASS

= P

ostu

ral A

sses

smen

t fo

r St

roke

Sca

le; P

T =

phy

sica

l the

rapi

st; R

BD =

rig

ht b

rain

–dam

aged

; RM

I =

Riv

erm

ead

Mob

ility

Ind

ex; S

T =

spe

ech

ther

apis

t;

TPS

= t

ime

post

str

oke;

WM

FT =

Wol

f Mot

or F

unct

ion

Test

.


with clinicians, who on occasion had diffi culty reliably distinguishing how to assign a score of 1 for mild neglect or 2 for moderate neglect. Therefore, the KF-NAP follows and clarifies the guidelines from Azouvi et al30 and includes additional instructions for calculating the fi nal score. In addition, the description of each item is shortened (in comparison with Azouvi et al’s description30) for the convenience of potentially computerizing the database, but the instruction for each observation item is much more detailed (Form B).

Because the CBS is designed to measure neglect-related ADLs in an ecological environment, the observation needs to be based on the fact that the new normal in the daily life of inpatients occurs in their ward. This fact created diffi culties in scoring certain CBS items. Form B, that is, the instruction for administering the CBS, is the result of a constant refi nement by means of frequent communication with inpatient occupational therapists over the past 3 years. Items with longer instructions reflect greater confusion when therapists used the CBS at the beginning of our researcher-clinician collaboration. For example, item 2 “personal belongings” is not a visual search task (eg, looking for a particular book on a packed multilayer shelf); rather, it is a visuospatial memory task for patients to demonstrate whether they are able to locate familiar objects that they use frequently in daily life with all the cues and contexts available (ie, therapists are instructed not to hide objects from the patient). Because patients may not have many personal belongings brought to the hospital to allow at least 3 questions on each of the hemispaces, therapists may ask for the same objects later in the session when the patient is facing the opposite direction. This example represents our efforts in developing the KF-NAP to ensure that the observation score assigned to each CBS item is based on similar situations across different patients and examiners.

The KF-NAP is not an alternative to the CBS; rather, it is a detailed description of how to administer the CBS. One may question whether using the KF-NAP is better than the original method for using the CBS. However, the diffi culty in comparing the KF-NAP and other

the CBS by Azouvi et al30 does not specify the observational context of each item. Thus, administration of the assessment might vary significantly among clinicians. Specifically, their CBS instructions do not specify whether performance is assessed at one time point or over a multisession observation period. If performance is assessed at one time point, is it based on one or multiple instructions/tasks/observations? If performance is assessed at one time point based on one observation, is it based on a scripted task set or specifi ed testing context? For example, when grooming is assessed, are toiletries provided, where are they placed, and how is the patient positioned?

To overcome the obstacles using the CBS, we worked with a therapy clinician collaborator (K.H.)61 and the Kessler Institute for Rehabilitation to develop a Kessler process for administering the CBS – the Kessler Foundation Neglect Assessment Process (the KF-NAP). The KF-NAP entails the use of 2 forms (see Appendix): Form A contains the table of the scale and the instructions for calculating the fi nal score and suggesting the severity of spatial neglect; Form B provides item-by-item instructions for making observations. Completion of all the observations in one visit takes approximately 20 to 40 minutes, depending on a patient’s condition. Most of the time may be spent in observing the patient eat (item 9); thus, we suggest that the assessment start 20 minutes before a predetermined meal time so the examiner may observe the patient eating and cleaning after a meal at the end of the visit (items 9 and 10, respectively). The order of items, which is different from that described in the original publication by Azouvi et al,30 suggests the actual sequence of observations during a single session, although it is not necessary to perform observations in a particular order. If the CBS is used for multiple follow-up assessments, it is preferable to observe the patient at the same time of the day to reduce the effect of wakefulness, mood, or motivation that may fl uctuate throughout the day and infl uence the accuracy of the assessment.37

On the scoring sheet (Form A), the examiner is reminded of how to assign a score to each item. This reminder is based on our working experience


administration methods lies in the fact that there is no detailed description (at least not publicly available) on how the CBS was administered in other studies or in the original study.30 Using the KF-NAP to administer the CBS may standardize the administration and strengthen the CBS as the most recommended functional assessment for spatial neglect.15,36

Conclusion

As rehabilitation researchers, we have a signifi cant responsibility to assist clinicians in assessing spatial neglect after stroke. Research confi rms the validity and value of the CBS as an outcome measure, and it has the unique attribute of potentially separating function in different brain-behavior networks supporting different

spatial processing stages. The KF-NAP may make the CBS more useful for detecting spatial neglect and its functional consequences, enable clinicians and researchers to agree more on assigned scores, and help clinicians to assign neglect treatments. Routine identification of poststroke spatial neglect fulfi lls national poststroke rehabilitation guidelines62 and may enhance the quality of care and improve rehabilitation outcomes for these patients.25

Acknowledgments

The authors thank Giuseppe Vallar for suggestions at the project development stage. Research activities are supported by the Kessler Foundation and the NIH/NINDS (K02 NS 047099–05, R01 NS 055808–02; PI: Barrett).

REFERENCES

1. Appelros P. Prediction of length of stay for stroke patients. Acta Neurol Scand. 2007;116(1):15–19.

2. Jehkonen M, Laihosalo M, Kettunen JE. Impact of neglect on functional outcome after stroke: a review of methodological issues and recent research findings. Restor Neurol Neurosci. 2006;24(4–6):209–215.

3. Gillen R, Tennen H, McKee T. Unilateral spatial neglect: relation to rehabilitation outcomes in patients with right hemisphere stroke. Arch Phys Med Rehabil. 2005;86(4):763–767.

4. Katz N, Hartman-Maeir A, Ring H, Soroker N. Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect. Arch Phys Med Rehabil. 1999;80(4):379–384.

5. Ugur C, Gucuyener D, Uzuner N, Ozkan S, Ozdemir G. Characteristics of falling in patients with stroke. J Neurol Neurosurg Psychiatr. 2000;69(5):649–651.

6. Tromp E, Dinkla A, Mulder T. Walking through doorways: an analysis of navigation skills in patients with neglect. Neuropsychol Rehabil. 1995;5(4):319–331.

7. Webster JS, Roades LA, Morrill B, et al. Rightward orienting bias, wheelchair maneuvering, and fall risk. Arch Phys Med Rehabil. 1995;76(10):924–928.

8. Heilman KM, Watson RT, Valenstein E. Neglect and related disorders. In: Heilman KM, Valenstein E, eds. Clinical Neuropsychology. 4th ed. New York: Oxford University; 2003:296–346.

9. Barrett AM, Burkholder S. Monocular patching in subjects with right-hemisphere stroke affects perceptual-attentional bias. J Rehabil Res Dev. 2006;43(3):337–345.

10. Fullerton KJ, McSherry D, Stout RW. Albert test: a neglected test of perceptual neglect. Lancet. 1986;1(8478):430–432.

11. McGlone J, Losier BJ, Black SE. Are there sex differences in hemispatial visual neglect after unilateral stroke? Neuropsychiatry Neuropsychol Behav Neurol. 1997;10(2):125–134.

12. Ringman JM, Saver JL, Woolson RF, Clarke WR, Adams HP. Frequency, risk factors, anatomy, and course of unilateral neglect in an acute stroke cohort. Neurology. 2004;63(3):468–474.

13. Wee JYM, Hopman WM. Comparing consequences of right and left unilateral neglect in a stroke rehabilitation population. Am J Phys Med Rehabil. 2008;87(11):910–920.

14. Stone SP, Wilson B, Wroot A, et al. The assessment of visuospatial neglect after acute stroke. J Neurol Neurosurg Psychiatr. 1991;54(4):345–350.

15. Menon A, Korner-Bitensky N. Evaluating unilateral spatial neglect post stroke: working your way through the maze of assessment choices. Top Stroke Rehabil. 2004;11(3):41–66.

16. Adair JC, Barrett AM. Spatial neglect: clinical and neuroscience review a wealth of information on the poverty of spatial attention. Ann N Y Acad Sci. 2008;1142:21–43.

17. Karnath HO, Rennig J, Johannsen L, Rorden C. The anatomy underlying acute versus chronic spatial neglect: a longitudinal study. Brain. 2011;134:903–912.

18. Marsh EB, Hillis AE. Dissociation between egocentric and allocentric visuospatial and tactile neglect in acute stroke. Cortex. 2008;44(9):1215–1220.


19. Buxbaum LJ, Ferraro MK, Veramonti T, et al. Hemispatial neglect: subtypes, neuroanatomy, and disability. Neurology. 2004;62(5):749–756.

20. Vangkilde S, Habekost T. Finding Wally: prism adaptation improves visual search in chronic neglect . Neuropsycholog ia. 2010;48(7) :1994–2004.

21. Pizzamiglio L, Fasotti L, Jehkonen M, et al. The use of optokinetic stimulation in rehabilitation of the hemineglect disorder. Cortex. 2004;40(3):441–450.

22. Menon-Nair A, Korner-Bitensky N, Ogourtsova T. Occupational therapists’ identifi cation, assessment, and treatment of unilateral spatial neglect during stroke rehabilitation in Canada. Stroke. 2007;38(9):2556–2562.

23. Menon-Nair A, Korner-Bitensky N, Wood-Dauphinee S, Robertson E. Assessment of unilateral spatial neglect post stroke in Canadian acute care hospitals: are we neglecting neglect? Clin Rehabil. 2006;20(7):623–634.

24. Chen P, McKenna C, Kutlik AM, Frisina PG. Interdisciplinary communication in inpatient rehabilitation facility: evidence of under-documentation of spatial neglect after stroke. Disabil Rehabil. In press.

25. Edwards DF, Hahn MG, Baum CM, Perlmutter MS, Sheedy C, Dromerick AW. Screening patients with stroke for rehabilitation needs: validation of the post-stroke rehabilitation guidelines. Neurorehabil Neural Repair. 2006;20(1):42–48.

26. Foerch C, Misselwitz B, Sitzer M, Berger K, Steinmetz H, Neumann-Haefelin T. Difference in recognition of right and left hemispheric stroke. Lancet. 2005;366(9483):392–393.

27. Yoo AJ, Romero J, Hakimelahi R, et al. Predictors of functional outcome vary by the hemisphere of involvement in major ischemic stroke treated with intra-arterial therapy: a retrospective cohort study. BMC Neurol. 2010;10:25.

28. Davis D, Evans M, Jadad A, et al. The case for knowledge translation: shortening the journey from evidence to effect. BMJ. 2003;327(7405):33–35.

29. Rochette A, Korner-Bitensky N, Thomas A. Changing clinicians’ habits: Is this the hidden challenge to increasing best practices? Disabil Rehabil. 2009;31(21):1790–1794.

30. Azouvi P, Marchal F, Samuel C, et al. Functional consequences and awareness of unilateral neglect: study of an evaluation scale. Neuropsychol Rehabil. 1996;6(2):133–150.

31. Bergego C, Azouvi P, Samuel C, et al. Validation d’une echelle d’evaluation fonctionnelle de l’heminegligence dance la vie quotidienne: l’echelle C.B. Ann Readapt Med Phys. 1995;38:183–189.

32. Mahoney FI, Barthel D. Functional evaluation: the Barthel Index. Md State Med J. 1965;14:56–61.

33. Granger C, Hamilton BB, Keith RA, Zielezny M, Sherwin F. Advances in functional assessment for medical rehabilitation. Top Geriatr Rehabil. 1986;1:59–74.

34. Paolucci S, Antonucci G, Grasso MG, Pizzamiglio L. The role of unilateral spatial neglect in rehabilitation of right brain-damaged ischemic stroke patients: a matched comparison. Arch Phys Med Rehabil. 2001;82(6):743–749.

35. Jehkonen M, Laihosalo M, Koivisto AM, Dastidar P, Ahonen JP. Fluctuation in spontaneous recovery of left visual neglect: a 1-year follow-up. Eur Neurol. 2007;58(4):210–214.

36. Ting DSJ, Pollock A, Dutton GN, et al. Visual neglect following stroke: current concepts and future focus. Surv Ophthalmol. 2011;56(2):114–134.

37. Azouvi P, Bartolomeo P, Beis JM, Perennou D, Pradat-Diehl P, Rousseaux M. A battery of tests for the quantitative assessment of unilateral neglect. Restor Neurol Neurosci. 2006;24(4–6):273–285.

38. Azouvi P, Olivier S, de Montety G, Samuel C, Louis-Dreyfus A, Tesio L. Behavioral assessment of unilateral neglect: study of the psychometric properties of the Catherine Bergego Scale. Arch Phys Med Rehabil. 2003;84(1):51–57.

39. Luukkainen-Markkula R, Tarkka IM, Pitkanen K, Sivenius J, Hamalainen H. Comparison of the Behavioural Inattention Test and the Catherine Bergego Scale in assessment of hemispatial neglect. Neuropsychol Rehabil. 2011;21(1):103–116.

40. Azouvi P, Samuel C, Louis-Dreyfus A, et al. Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. J Neurol Neurosurg Psychiaty. 2002;73(2):160–166.

41. Goedert KM, Chen P, Botticello A, Masmela JR, Adler U, Barrett AM. Psychometric evaluation of neglect assessment reveals motor-exploratory predictor of functional disability in acute-stage spatial neglect. Arch Med Phys Rehabil. 2012;93(1):137–142.

42. Qiang W, Sonoda S, Suzuki M, Okamoto S, Saitoh E. Reliability and validity of a wheelchair collision test for screening behavioral assessment of unilateral neglect after stroke. Am J Phys Med Rehabil. 2005;84(3):161–166.

43. Wang Q, Sonoda S, Hanamura M, Okazaki H, Saitoh E. Line bisection and rebisection: the crossover effect of space location. Neurorehabil Neural Repair. 2005;19(2):84–92.

44. Wilson B, Cockburn J, Halligan P. Behavioural Inattention Test. London: Thames Valley Test Company; 1987.

45. Albert ML. A simple test of visual neglect. Neurology. 1973;23(6):658–664.

46. Ertekin OA, Gelecek N, Yildirim Y, Akdal G. Supervised versus home physiotherapy outcomes in stroke patients with unilateral visual neglect: a randomized controlled follow-up study. J Neurol Sci Turk. 2009;26(3):325–334.

47. Bowen A, Lincoln NB. Cognitive rehabilitation for spatial neglect following stroke. Cochrane Database Syst Rev. 2007(2):CD003586.

48. Fortis P, Maravita A, Gallucci M, et al. Rehabilitating patients with left spatial neglect by prism exposure during a visuomotor activity. Neuropsychology. 2010;24(6):681–697.


49. Luukkainen-Markkula R, Tarkka IM, Pitkanen K, Sivenius J, Hamalainen H. Rehabilitation of hemispatial neglect: a randomized study using either arm activation or visual scanning training. Restor Neurol Neurosci. 2009;27(6):663–672.

50. Samuel C, Louis-Dreyfus A, Kaschel R, et al. Rehabilitation of very severe unilateral neglect by visuo-spatio-motor cueing: two single case studies. Neuropsychol Rehabil. 2000;10(4):385–399.

51. Mizuno K, Tsuji T, Takebayashi T, Fujiwara T, Hase K, Liu M. Prism adaptation therapy enhances rehabilitation of stroke patients with unilateral spatial neglect: a randomized, controlled trial. Neurorehabil Neural Repair. 2011;25(8):711–720.

52. Turton AJ, O’Leary K, Gabb J, Woodward R, Gilchrist ID. A single blinded randomised controlled pilot trial of prism adaptation for improving self-care in stroke patients with neglect. Neuropsychol Rehabil. 2010;20(2):180–196.

53. Keane S, Turner C, Sherrington C, Beard JR. Use of Fresnel prism glasses to treat stroke patients with hemispatial neglect. Arch Phys Med Rehabil. 2006;87(12):1668–1672.

54. Staubli P, Nef T, Klamroth-Marganska V, Riener R. Effects of intensive arm training with the rehabilitation robot ARMin II in chronic stroke patients: four single-cases. J Neuroengineering Rehabil. 2009;6:46.

55. Plummer P, Morris ME, Dunai J. Assessment of unilateral neglect. Phys Ther. 2003;83(8):732–740.

56. Verdon V, Schwartz S, Lovblad KO, Hauert CA, Vuilleumier P. Neuroanatomy of hemispatial

neglect and its functional components: a study using voxel-based lesion-symptom mapping. Brain. 2010;133:880–894.

57. Mesulam MM. Spatial attention and neglect: parietal, frontal and cingulate contributions to the mental representation and attentional targeting of salient extrapersonal events. Philos Trans R Soc Lond Series B Biol Sci. 1999;354(1387):1325–1346.

58. Barrett AM. Perceptual-attentional “where” and motor-intentional “aiming” spatial bias. In: Chatterjee A, Coslett HB, eds. The Roots of Cognitive Neuroscience: Behavioral Neurology and Neuropsychology. New York: Oxford University Press. In press.

59. Na DL, Adair JC, Williamson DJG, Schwartz RL, Haws B, Heilman KM. Dissociation of sensory-attentional from motor-intentional neglect. J Neurol Neurosurg Psychiatr. 1998;64(3):331–338.

60. Fortis P, Chen P, Goedert KM, Barrett AM. Effects of prism adaptation on motor-intentional spatial bias in neglect. Neuroreport. 2011;22(14):700–705.

61. Hreha K, Eller M, Barrett AM. Treating post-stroke spatial neglect: establishing a clinical research-clinical care partnership program. Adv Occup Ther Pract. 2010;26(7):16.

62. Gresham GE, Duncan PW, Stason WB, et al. Post-Stroke Rehabilitation: Clinical Practice Guideline. Vol. 16. Rockville, MD: US Department of Health and Human Services. Public Health Service, Agency for Health Care Policy and Research; 1995.


APPENDIX

Date:______________ Name of Examinee:_________________________

Time:_________ am/pm Examiner(s):_______________________________

Kessler Foundation Neglect Assessment Process (Form A)

How to use the Catherine Bergego Scale to assess left-sided spatial neglect

Item # Item description0 no left neglect 1 mild neglect

2 moderate neglect

3 severe neglect

NA (provide reasons)

1 Limb awareness

2 Personal belongings

3 Dressing

4 Grooming

5 Gaze orientation

6 Auditory attention

7 Navigation

8 Collisions

9 Eating

10 Cleaning after meal

Number of scored items = ______ Sum of the score = ______ Final Score = _______Neglect classifi cation (circle one): Absent (0); Mild (1–10); Moderate (11–20); Severe (21–30)

• See KF-NAP Form B for detailed instructions to have standardized observations for each item.• A score of 0 is given if no left-sided spatial neglect is observed.• A score of 1 is given if a mild neglect is observed, with the patient always exploring right hemi-space fi rst, and going

slowly and hesitating towards the left. At this level, left-sided omissions or collisions are rare and inconsistent, and fl uctuations are observed, with fatigue and emotions.

• A score of 2 is given in case of moderate neglect, with constant and clear left-sided omissions or collisions; at this level, patients are still able to cross the midline, but performance in the left hemi-space is incomplete and ineffective.

• A score of 3, severe neglect is given if the patient is only able to explore the right hemi-space.• The fi nal score is calculated by adding up all the item scores, ranging from 0 – 30.• If an item is impossible to score even under the circumstance where the examiner creates the best possible scenario

for observation (i.e., operating the wheelchair by foot for the “collisions” item), it is not included in the fi nal score. The fi nal score is then calculated from the average score of the valid items, using the following formula:

Sum of the individual scores × 10 = fi nal score

Number of scored items

• Based on the fi nal score, classify neglect severity by circling either “absent” (fi nal score = 0), “mild” (fi nal score = 1–10), “moderate” (fi nal score = 11–20), or “severe” (fi nal score = 21–30).

• The KF-NAP is provided under license and is strictly limited for administration by trained and certifi ed individuals only.


Kessler Foundation Neglect Assessment Process (Form B)

How to administer each item for the Catherine Bergego Scale

The 10-item scale is based on observations, not tests, of patients’ everyday life activities. It is suggested the examiner follow this order of the items, but some items are evaluated during the entire session. If the scale is used for multiple follow-up assessments, it is preferable to observe the patient at the same time of the day to reduce the effect of wakefulness, mood, or motivation that may fl uctuate throughout the day and infl uence the accuracy of the assessment. See KF-NAP Form A for scoring.

1. Limb awareness: Observe the patient during the entire session. See if he/she remembers to care for the left arm or leg that may be paralyzed or is much weaker than the right.

2. Personal belongings: Observe the patient in his/her room. See if he/she can fi nd objects on the left side relative to the right side. “Personal belongings” are objects that will most likely stay in the same place throughout the patient’s stay in the facility. Ask the patient to locate three objects to his/her right and three objects to his/her left. If the number of objects is limited, you may ask for the same objects later in the session. For example, when he/she faces the other direction after navigating in the room (Item 7). Do not hide objects for him/her to fi nd. Simply ask questions such as “I cannot fi nd your reading glasses. Can you show me where they are?” Objects may include his/her glasses, handbag, toothbrush, picture frames, cell phone, clothing, greeting cards, etc.

3. Dressing: Provide the patient an open-front shirt or coat (e.g., a cloth examination gown or an item from their closet) and say “Would you please put this on?” Observe his/her spontaneous behavior for the entire session, observing for different performances on the left compared to the right side.

4. Grooming: Take the patient to the sink in his/her room or home. Alternatively, if the bathroom is inaccessible, you can set up a desk mirror, a comb, and a wet paper towel in front of the patient. Observe how he/she spontaneously combs his/her hair and wipes his/her face. You may say “Show me how you brush your hair.”

5. Gaze orientation: Observe the patient during the entire session. 6. Auditory attention: Make a loud noise close to the left side of the patient (e.g., drop a heavy object or clap) and

observe the directional reaction of the patient. For example, the patient may immediately turn his/her head or body toward the noise, or simply shift his/her gaze.

7. Navigation: Ask the patient to indicate directions while going with him/her to fi nd a familiar place (e.g., cafeteria, therapy gym). The directions must have an equal amount of “right-turn” and “left-turn” answers. You may say “Show me how to get to the therapy gym.”

8. Collisions: This can be observed with “navigation” (Item 7), or when the patient is walking or completing wheelchair trajectory in his/her room. Use verbal cues only if he/she is in harm’s way.

9. Eating: Observe the patient while he/she is having a meal or snack. All the related items (food, utensils, spice, creamer, etc.) should be prepared and placed on the tray in an organized manner.

10. Cleaning after meal: Observe the patient whether he/she cleans both sides of the mouth after the meal.

functional assessment of spatial neglect: a review of the...

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