Comparison of Evaluation Methods for Unilateral Spatial Neglect

1. Comparison of Evaluation Methods for Unilateral Spatial Neglect Lana Watson, MHS, OTR/L

3. Objectives • Understand clinical presentations of unilateral spatial neglect (USN) • Compare assessments for sensitivity in evaluating USN • Discuss most effective administration of USN assessments • Understand most common paper/pencil tasks and behavioral tasks for evaluating USN

4. About the project… • Literature review on assessment only • Articles from PubMed, CINAHL and WebMD • Focused on left USN • Two major questions: • Sensitivity comparison of line bisection and cancellation tasks in assessment of unilateral spatial neglect. • Are paper and pencil tasks as sensitive as behavioral tasks in assessing spatial neglect?

5. What is neglect? • Defined as a cluster of symptoms characterized by a failure to orient, or react to stimuli located predominantly on the contralesional side (Keller, 2005) • More common in left hemisphere • Often associated with anosognosia • Poorer prognosis for recovery

6. Other Names • Unilateral Spatial Neglect • Neglect • Left Side Inattention • Unilateral Neglect • Hemi-Inattention

7. Types of Neglect • Sensory and motor aspects • Personal (body) • Peri-personal (reaching) • Most common • Extra-personal (beyond reaching) • Viewer-centered neglect • Stimulus-centered neglect (Hillis, 2006)

10. Because neglect has a wide variety of clinical presentations, no single test can be used to identify the disorder in all patients (Plummer, 2003) • There are over 60 assessments tools for neglect (Robertson, 1999)

11. Types of Assessments:Paper/Pencil • Line Bisection • Cancellation Tasks • Line, Bells, Star, Letter • Clock Drawing • Copy a Person/Daisy

15. Types of Assessments:Behavioral • Baking Tray Task • Catherine Bergego Scale (CBS) • Behavioral Inattention Test (BIT)

16. Baking Tray Task • Simple behavioral assessment • Test materials can easily be collected • Peri-personal neglect

17. Catherine Bergego Scale (Azouvi, 2003) • Direct observation of patient functioning in 10 real-life tasks • Same questions given to patients in questionnaire format to measure anosognosia (only tool available) • Indicated for inpatient rehabilitation facilities for patients with severe neglect

19. Behavior Inattention Test (Appelros, 2004) • One hour to administer • Peri-personal neglect • 6 paper/pencil tasks, 9 behavioral tasks • 3 item version, 8 item version • Subtests: • Figure and shape copying • Picture Scanning • Card Sorting • Article Reading • Line Bisection • Time Telling

20. Sensitivity comparison of line bisection and cancellation tasks (Ferber, 2001) • Line bisection compared to four different cancellation tasks (line, letter, stars, bell) • Line bisection missed 40% of neglect patients while bells only missed 13% and letter missed 6% • Overall, every cancellation task performed better than the simple line bisection test.

21. Comparison Continued (Bailey, 2000) • The following tests were used in a neglect battery with the first two being the most sensitive (identifying 69% of patients): • Star cancellation • Line bisection • Copy-a-daisy • Baking tray task • Clock drawing • Exploratory motor task • Personal neglect test

22. Comparison Continued (Maeshima, 2001) • The following tests were used in a neglect battery with the first being the most sensitive (identifying 80% of patients): • Line cancellation • Line bisection • Complex figure, flower and cube copying • Person drawing • Clock drawing

23. Comparison Continued (Azouvi, 2002) • The following tests were used in a neglect battery: • Gaze and head orientation • Bells test (51% identified) • Figure copying • Clock drawing • Line bisection (38% w/ long line, 19% w/ short line) • Overlapping figures test • Reading and writing • Catherine Bergego Scale • The complete battery was more sensitive than any one single test with identifying 86% of patients

24. Assessment of Evidence • Recommend use of both line bisection and star cancellation task due to double dissociations (meaning the patient was normal on one but not the other) • Therefore neglect is multi-factorial! • Or more severe neglect for those with errors in both rather than error in just one test

26. Assessment Continued(Plummer, 2003) • Bells and letter cancellation most sensitive • Starting point on Bells test • Higher demand on selective attention • Forces the patient to segregate distractors from target stimuli • Increase the sensitivity of tests by: • Unstructured stimulus arrangement • Locating two targets instead of one

28. Application of Evidence: Line Bisection • The longer the line, the more sensitive the test is (20 cm vs. 5 cm) • Standard cut-off of 1 cm is used for longer line in control groups • Better to use this assessment in battery of tests rather than on an individual basis

29. Application of Evidence:Cancellation Tasks • Distractors and unorganized arrangement is best to use • Cut-off score for star cancellation is 51 out of 54 in a control group • Search pattern more important than omissions • Recommend therapist chart search pattern of patient

31. Are paper/pencil tasks as sensitive as behavioral tasks in assessing spatial neglect? • The CBS was compared to three highly sensitive tests of neglect including bells test, copying a picture and reading a short text • The CBS was more sensitive than these tests • The 3 most sensitive items of the scale were neglect in dressing, knowledge of left limbs and collisions while moving

32. Continued • The CBS was compared to sensitive tests of neglect including bells test, figure copying, clock drawing, and line bisection task • CBS identified 76.8% of neglect patients while the complete battery of paper/pencil tasks identified 85.9% of patients. • CBS more sensitive than any one paper/pencil test of neglect

33. Assessment of Evidence • CBS requires automatic orienting of attention rather than voluntary attention used during paper/pencil tasks • Therefore a patient may perform fine on paper/pencil task, but still have functional deficits

34. Application of Evidence:CBS • Evaluates personal, peri-personal and extra-personal aspects of neglect • Paper/pencil tasks only assess peri-personal • Good assessment for patients who are apraxic, aphasic and those unable to complete paper/pencil tasks

35. Conclusion • No gold standard • Neglect battery should include both behavioral and paper/pencil • Cancellation tasks appear most sensitive paper/pencil tasks including bells, star and letter • Other behavioral test: key removing, grocery naming, face washing, and tray wiping • Everyone understands function!!! • Need more research!

36. References • Appelros, P., Karlsson, G., Thorwalls, A., Tham, K., & Nydevik, I. (2004). Unilateral neglect: further validation of the baking tray task. Journal of Rehabilitation Medicine. 36: 258-262. • Appelros, P., Nydevik, I., Karlsson, G., Thorwalls, A., & Seiger, A. (2003). Assessing unilateral neglect: shortcomings of standard test methods. Disability and Rehabilitation. 25 (9): 473-479. • Azouvi, P., Olivier, S., de Montety, G., Samuel, C., Louis-Dreyfus, A., & Tesio, L. (2003). Behavioral assessment of unilateral neglect: study of psychometric properties of the catherine bergego scale. Archives of Physical Medicine & Rehabilitation. 84: 51-57. • Azouvi, P., Samuel, C., Louis-Dreyfus, A., Bernati, T., Bartolomeo, P., Beis, J., Chokron, S., Leclercq, M., Marchal, F., Martin, Y., de Montety, G., Olivier, S., Perennou, D., Pradat-Diehl, P., Prarial, C., Rode, G., Sieroff, E., Wiart, L., & Rousseaux, M., ((2002). Sensitivity of clinical and behavioral tests of spatial neglect after right hemispheric stroke. Journal of Neurology, Neurosurgery & Psychiatry. 73: 160-166.

37. References continued • Bailey, M., Riddoch, M. J., & Crome, P. (2000). Evaluation of a test battery for hemineglect in elderly stroke patients for use by therapists in clinical practice. Neurorehabilitation. 14; 139-150. • Bowen, A., & Graham, J. (2005). Developing functional outcomes measures for unilateral neglect: a pilot study. Neuropsychological Rehabilitation. 15 (2); 97-113. • Ferber, S., & Karnath, H. (2001). How to assess spatial neglect-line bisection or cancellation tasks? Journal of Clinical and Experimental Neuropsychology. 23 (5): 599-607. • Hillis, A. ((2006). Neurobiology of unilateral spatial neglect. The Neuroscientist. 12 (2): 153-163. • Keller, I., Schindler, I., Kerkhoff, G., von Rosen, F., & Golz, D. (2005). Visuospatial neglect in near and far space: dissociation between line bisection and letter cancellation. Neuropsychologia. 43; 724-731.

38. References continued • Maeshima, S., Truman, G., Smith, D., Dohi, N., Shigeno, K., Itakura, T., & Koma, N. (2001). Factor analysis of the components of 12 standard test batteries, for unilateral spatial neglect, reveals that they contain a number of discrete and important clinical variables. Brain Injury. 15 (2): 125-137. • Plummer, P., Morris, M., & Dunai, J. (2003). Assessment of unilateral spatial neglect. Physical Therapy. 83: 732-740. • Robertson, I. & Halligan, P. (1999). Spatial neglect: a clinical handbook for diagnosis and treatment. Psychology Press: Hove, England.