Comparison of Evaluation
Methods for Unilateral
Spatial Neglect
Lana Watson, MHS, OTR/L
Objectives
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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…
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Literature review on assessment only
Articles from PubMed, CINAHL and WebMD
Focused on left USN
Two major questions:
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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?
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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
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Unilateral Spatial Neglect
Neglect
Left Side Inattention
Unilateral Neglect
Hemi-Inattention
Types of Neglect
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Sensory and motor aspects
Personal (body)
Peri-personal (reaching)
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Most common
Extra-personal (beyond reaching)
Viewer-centered neglect
Stimulus-centered neglect (Hillis, 2006)
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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
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Line Bisection
Cancellation Tasks
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Line, Bells, Star, Letter
Clock Drawing
Copy a Person/Daisy
Types of Assessments:
Behavioral
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Baking Tray Task
Catherine Bergego Scale (CBS)
Behavioral Inattention Test (BIT)
Baking Tray Task
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Simple behavioral assessment
Test materials can easily be collected
Peri-personal neglect
Catherine Bergego Scale
(Azouvi, 2003)
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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)
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One hour to administer
Peri-personal neglect
6 paper/pencil tasks, 9 behavioral tasks
3 item version, 8 item version
Subtests:
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Figure and shape copying
Picture Scanning
Card Sorting
Article Reading
Line Bisection
Time Telling
Sensitivity comparison of line
bisection and cancellation tasks
(Ferber, 2001)
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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)
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The following tests were used in a neglect
battery with the first two being the most
sensitive (identifying 69% of patients):
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Star cancellation
Line bisection
Copy-a-daisy
Baking tray task
Clock drawing
Exploratory motor task
Personal neglect test
Comparison Continued
(Maeshima, 2001)
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The following tests were used in a neglect
battery with the first being the most sensitive
(identifying 80% of patients):
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Line cancellation
Line bisection
Complex figure, flower and cube copying
Person drawing
Clock drawing
Comparison Continued (Azouvi, 2002)
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The following tests were used in a neglect battery:
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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
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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
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(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:
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Unstructured stimulus arrangement
Locating two targets instead of one
Application of Evidence:
Line Bisection
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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.