Comparison of Evaluation Methods for Unilateral Spatial Neglect Lana Watson, MHS, OTR/L 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 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? 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 Other Names Unilateral Spatial Neglect Neglect Left Side Inattention Unilateral Neglect Hemi-Inattention 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) 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) Types of Assessments: Paper/Pencil Line Bisection Cancellation Tasks Line, Bells, Star, Letter Clock Drawing Copy a Person/Daisy Types of Assessments: Behavioral Baking Tray Task Catherine Bergego Scale (CBS) Behavioral Inattention Test (BIT) Baking Tray Task Simple behavioral assessment Test materials can easily be collected Peri-personal neglect 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 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 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. 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 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 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 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 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 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 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 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 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 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 Application of Evidence: CBS Evaluates personal, peri-personal and extrapersonal 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 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! 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. 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 neglectline 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. 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.