Comparison of Evaluation Methods for Unilateral Spatial Neglect

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Comparison of Evaluation Methods for Unilateral
Spatial Neglect

• Lana Watson, MHS, OTR/L

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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

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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?

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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

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Other Names

• Unilateral Spatial Neglect
• Neglect
• Left Side Inattention
• Unilateral Neglect
• Hemi-Inattention

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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)

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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)

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Types of AssessmentsPaper/Pencil

• Line Bisection
• Cancellation Tasks
• Line, Bells, Star, Letter
• Clock Drawing
• Copy a Person/Daisy

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Types of AssessmentsBehavioral

• Baking Tray Task
• Catherine Bergego Scale (CBS)
• Behavioral Inattention Test (BIT)

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Baking Tray Task

• Simple behavioral assessment
• Test materials can easily be collected
• Peri-personal neglect

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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

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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

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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.

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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

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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

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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

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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

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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

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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

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Application of EvidenceCancellation 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

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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

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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

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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

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Application of EvidenceCBS

• 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

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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!

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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.

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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.

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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.