Purpose

Albert’s Test is a screeningTesting for disease in people without symptoms.
tool used to detect the presence of unilateral spatial neglect (USN) in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. In this test, patients must cross out lines that are placed in random orientations on a piece of paper. USN is indicated when lines are left uncrossed on the same side of the page as the patients motor deficit or brain lesion is located.

In-Depth Review

Purpose of the measure

Albert’s Test is a screeningTesting for disease in people without symptoms.
tool used to detect the presence of unilateral spatial neglect (USN) in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. In this test, patients must cross out lines that are placed in random orientations on a piece of paper. USN is indicated when lines are left uncrossed on the same side of the page as the patients motor deficit or brain lesion is located.

Available versions

The original Albert’s Test was published by Albert in 1973.

Features of the measure

Items:
The modified Albert’s Test is the preferred version of the test and varies only slightly from the original description in which 41 lines were placed on slightly smaller sheet of paper. In the modified version, a series of 40 black lines, each about 2 cm long, are randomly oriented on a sheet of white 11 x 8.6-inch size paper in 6 rows. The test sheet is presented to the patient at their midline. Some of the lines are pointed out to him/her, including those to the extreme right and extreme left. The examiner asks the patient to cross out all of the lines, and demonstrates what is required by crossing out the 5 central lines him/herself. The patient is encouraged to cross out all the lines until he/she is satisfied that they have all been crossed.

Scoring:
The presence or absence of USN is based on the number of lines left uncrossed on each side of the test sheet. If any lines are left uncrossed, and more than 70% of uncrossed lines are on the same side as motor deficit, USN is indicated. This may be quantified in terms of the percentage of lines left uncrossed (Fullerton, McSherry, & Stout, 1986).

Time:
Less than 5 minutes.

Training:
None typically reported.

Subscales:
None.

Equipment:

• 11x 8.5-inch page of paper with 41 lines 2 cm in length each.
• Pencil

Alternative forms of the Albert’s Test

Modified version of Albert’s Test. This version varies only slightly from the original version and consists of 40 black lines (25 mm long, 0.5 or 1.2 mm thick) of various orientations dispersed randomly on a 297 x 210 mm sheet of white paper. Each side of the stimulus sheet contains 18 lines divided into 3 columns of 6 lines. The columns are numbered as 1 to 6 from left to right.

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
• Patients must be able to hold a pencil to complete the test (the presence of apraxia may impair this ability).

Should not be used with:

• Albert’s Test should be used with caution in the clinical diagnosis of spatial neglect. Performance on Albert’s Test may be influenced by or may be indicative of other syndromes besides spatial neglect, such as hemianopia (damage of optic pathways that result in loss of vision in half of the visual field) (Ferber & Karnath, 2001). The use of a clinical expert system for assessment of perceptual disorders may be useful for interpreting results and forming a diagnosis (e.g. McSherry & Fullerton, 1985).

In what languages is the measure available?

Not applicable.

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN).
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	Modified version of Albert’s Test.
Other Languages	Not applicable.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Test-retest: One study examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of Albert’s Test and reported excellent test-retest.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Predictive: Albert’s Test significantly predicted functional outcome at 6 months post-stroke. Construct: Convergent: Excellent correlations reported between Albert’s Test and the Line Bisection Test, the Wundt-Jastrow Area Illusion test, and the Catherine Bergego Scale. An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. has been reported between Albert’s Test and the Star Cancellation Test. Known groups: Albert’s Test can distinguish between patients with neglect from patients without neglect.
Does the tool detect change in patients?	Not applicable.
Acceptability	Albert’s Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Performance may be influenced by or may be indicative of other syndromes besides spatial neglect, such as hemianopia. This test cannot be completed by proxy.
Feasibility	Albert’s Test requires no specialized training to administer and only simple equipment is required (an 11x 8.5-inch page of paper with 41 lines 2 cm in length each and a pencil). The clinician must present the test sheet to the patient at their midline. Some of the lines are pointed out to him/her, including those to the extreme right and extreme left. The clinician asks the patient to cross out all of the lines, and demonstrates what is required by crossing out the 5 central lines him/herself. The patient is encouraged to cross out all the lines until he/she is satisfied that they have all been crossed.
How to obtain the tool?	Please click here.

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of Albert’s Test.

Reliability

Test-retest:
Chen-Sea and Henderson (1994) reported that Albert’s Test has an excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of r = 0.79.

Validity

Criterion:
Predictive:
Fullerton, McSherry, and Stout (1986) found that test scores on Albert’s Test administered to 205 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. within 48 hours of hospital admission significantly predicted functional outcome at 6 months post-stroke (as measured by a 4-point crude scale). This study specifically found that 56.8% of individuals identified with visual neglect using the Albert’s Test were true cases of neglect (true positives). Approximately 4.3% of individuals without neglect were also screened negative on the Albert’s Test (true negatives). However, more than 35% of the individuals were unable to comply with the test because of an altered state of consciousness or dysphasiaImpaired speech with difficulty or inability to put words in their proper order. This disorder affects the power of expression (speech, writing or signs) or loss of the power of comprehension (spoken or written language). More severe forms of dysphasia are called aphasia.
during this early phase of recovery.

Construct:
Convergent:
Agrell, Dehlin, and Dahlgren (1997) compared the performance of 57 elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. on 5 different tests for visuo-spatial neglect (Star Cancellation, Line Crossing, Line Bisection, Clock Drawing Task and Copy A Cross). Albert’s Test had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Line Bisection Test (r = 0.85) and correlated adequately with the Star Cancellation Test (r = 0.63).

Massironi, Antonucci, Pizzamiglio, Vitale, Zoccolotti (1988) found an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the Wundt-Jastrow Area Illusion test and Albert’s Test (r = 0.64).

Deloche et al. (1996) reported an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the Catherine Bergego Scale and Albert’s Test (Spearman’s r = 0.73).

Known groups:
Potter, Deighton, Patel, Fairhurst, Guest, and Donnelly (2000) examined a computer-based method of administering the Albert’s Test in 30 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and neglect, 57 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and without neglect, and 13 age-matched control subjects. Significant differences were found between subjects with neglect and those without neglect, as well as subjects with neglect and age-matched controls. No difference between patients without neglect and age-matched controls was observed.

Responsiveness

Not applicable.

References

• Agrell, B. M., Dehlin, O. I., Dahlgren, C. J. (1997). Neglect in elderly stroke patients: a comparison of five tests.Psychiatry Clin Neurosci, 51(5), 295-300.
• Albert, M. L. (1973). A simple test of visual neglect.Neurology, 23, 658 664.
• Chen-Sea, M. J., Henderson, A. (1994). The reliability and validity of visuospatial inattention tests with stroke patients.Occup Ther Int, 1, 36-48.
• Deloche, G., Azouvi, P., Bergego, C., Marchal, F., Samuel, C., Morin, L., Renard, C., Louis-Dreyfus, A., Jokic, C., Wiart, L., Pradat-Diehl, P. (1996). Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychol Rehabil, 6, 133 150.
• Fullerton, K. J., McSherry, D., Stout, R. W. (1986). Albert’s Test: A neglected test of perceptual neglect. The Lancet,1(8478), 430-432.
• Massironi, M., Antonucci, G., Pizzamiglio, L., Vitale, M. V., Zoccolotti, P. (1988). The Wundt-Jastrow illusion in the study of spatial hemi-inattention. Neuropsychologia, 26(1), 161-166.
• McSherry, D., Fullerton, K. (1985). Preceptor: A shell for medical expert systems and its applications in a study of prognostic indices in stroke. Expert Systems, 2, 140-145.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Plummer, P., Morris, M. E., Dunai, J. (2003). Assessment of unilateral neglect. Phys Ther, 83(8), 732-740.
• Potter, J., Deighton, T., Patel, M., Fairhurst, M., Guest, R., Donnelly, N. (2000). Computer recording of standard tests of visual neglect in stroke patients. Clinical Rehabilitation, 14(4), 441-446.
• Na, D. L., Adair, J. C., Kang, Y., Chung, C. S., Lee, K. H., Heilman, K. M. (1999). Motor perseverative behavior on a line cancellation task. Neurology, 52, 1569-1576

See the measure

How to obtain Albert’s Test

Click here to get a copy of Albert’s test.

Purpose

The Arnadottir OT-ADL Neurobehavioural Evaluation (A-One) evaluates the impact of neurobehavioural impairment on functional performance of activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis..

In-Depth Review

Purpose of the measure

The Arnadottir OT-ADL Neurobehavioural Evaluation (A-One) is a standardized, performance-based measure that identifies the impact of neurobehavioural impairment on functional performance of ADL. The measure allows observation of ADL and evaluation of the level of assistance required for ADL performance (Arnadottir et al., 2009). Accordingly, the A-ONE provides the therapist with an ecologically-relevant assessment of the consequences of neurobehavioural impairments through clinical observation of ADL tasks using a ‘top-down’ (occupation-based) approach (Arnadottir et al., 2009; Bottari et al., 2006; Carswell et al., 1992; Cooke et al., 2006).

The A-ONE is comprised of two parts: (a) assessment of the individual’s independence in ADL tasks and the type of assistance required; and (b) identification of the type and severity of neurobehavioural impairment that is limiting the individual’s independence in these tasks (Gardarsdottir & Kaplan, 2002).

The A-ONE can be used to assist therapists in goal setting and treatment planningPlanning ability involves anticipating future events, formulating a goal or endpoint, and devising a sequence of steps or actions that will achieve the goal or endpoint" (Anderson, 2008, p. 17)
(Gardarsdottir & Kaplan, 2002).

Available versions

The A-ONE was previously named the Arnadottir Occupational Therapy – ADL (OT-ADL) Neurobehavioural Evaluation.

Features of the measure

Items:
The A-ONE is comprised of 2 scales: the Functional Independence scale, more commonly referred to as the ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living Scale (ADL scale), and the Neurobehavioural Impairment scale (NBI scale).

The ADL scale measures 5 ADL domains (dressing; grooming and hygiene; transfers and mobility; feeding; and communication) using 20 everyday tasks.

1. Dressing

• i. Put on shirt
• ii. Put on pants
• iii. Put on socks
• iv. Put on shoes
• v. Manipulate fastenings

2. Grooming and hygiene

• i. Wash face
• ii. Comb hair
• iii. Brush teeth
• iv. Shave beard/apply cosmetics
• v. Perform toilet hygiene
• vi. Bathe

3. Transfers and mobility

• i. Sit up in bed
• ii. Transfer from sitting
• iii. Maneuver around
• iv. Transfer to toilet
• v. Transfer to tub

4. Feeding

• i. Drink from glass/cup
• ii. Use fingers to bring food to mouth
• iii. Bring food to mouth by fork or spoon
• iv. Use knife to cut and spread

5. Communication

The NBI scale consists of items to assist the therapist in identifying the probable site of cortical dysfunction based on the observed neurological behaviours. The NBI scale is comprised of 2 subscales:

1. The Specific SubscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
Impairment (NBSIS) subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).

• i. Motor apraxia
• ii. Ideational apraxia
• iii. Unilateral body neglect
• iv. Spatial relations
• v. Unilateral spatial neglect
• vi. Organization and sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
  
• vii. Perseveration
• viii. Topographical disorientation (transfers and mobility)
• ix. Sensory aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) (communication)
• x. Anomia (communication)
• xi. Paraphasia (communication)
• xii. Expressive aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) (communication)

2. The Pervasive SubscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
Impairment (NBPSI) subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).

• i. Lability
• ii. Apathy
• iii. DepressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
  
• iv. Irritability
• v. Frustration
• vi. Restlessness
• vii. Insight
• viii. Judgement
• ix. Confusion
• x. Attention
• xi. Distraction
• xii. Initiative
• xiii. Motivation
• xiv. Performance latency
• xv. Working memoryExecutive process responsible for the temporary storage and manipulation of information in both simple (e.g. recalling a series of digits such as a phone number) and complex cognitive tasks (e.g. coordinating two tasks simultaneously) (Van der Linden, 2007)
  
• xvi. Confabulation

Description of tasks:
The therapist observes the patient performing the listed ADL tasks and determines the level of assistance required to complete the tasks (see scoring below). Errors in task performance are an indication of underlying neurobehavioural impairments. Different neurobehavioural impairments manifest as different errors or difficulties in ADL task performance. The therapist observes for the presence and severity of neurobehavioural impairments, according to how much the impairment impacts on the individual’s ability to perform the ADL task independently (Gardarsdottir & Kaplan, 2002; Arnadottir et al., 2009).

What to consider before beginning:
The A-ONE should be performed in the clinical setting (Bottari et al., 2006).

Scoring and Score Interpretation:
The ADL and the Neurobehavioural linear scales were developed as criterion-referenced rating scales of the ordinal type by application of Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute – such as upper limb function – independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
(Arnadottir & Fisher, 2008; Arnadottir et al., 2010).

The ADL scale measures the individual’s need for assistance to overcome neurobehavioural impairments during ADL task performance. Arnadottir et al. (2008) examined the original 5-point rating scale structure and noted that thresholds were disordered. This disorder was eliminated when score 2 (verbal assistance) and score 3 (supervision) were combined, resulting in a 4-point rating scale:

0 = Full assistance needed
1 = Minimum to considerable physical assistance needed
2 = Verbal assistance/supervision needed
3 = Independent

Scores can be added within each ADL domain, but total ADL scores should not be added. Individuals are not penalized for using assistive devicesAssistive devices are any piece of equipment that you use to make your daily activities easier to perform.
when performing ADL tasks (Arnadottir et al., 2008).

Scoring of the NBI scale is based on the extent to which the neurobehavioural impairment interferes with ADL task performance, not the severity of the impairment. Most items of the NBSIS are rated several times:

1. Motor apraxia*
2. Ideational apraxia*
3. Unilateral body neglect*
4. Spatial relations*
5. Unilateral spatial neglect*
6. Organization and sequencing“The coordination and proper ordering of the steps that comprise the task, requiring a proper allotment of attention to each step” (Lezak, 1989; as cited in (Baum, Morrison, Hahn & Edwards, 2007))
   *
7. Perseveration^
8. Topographical disorientation (transfers and mobility)
9. Sensory aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
   An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) (communication)
10. Anomia (communication)
11. Paraphasia (communication)
12. Expressive aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
    An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada) (communication)

* scored 4 times (during dressing; grooming and hygiene; transfers and mobility; and feeding ADL tasks)

^ scored 5 times (during all ADL tasks)

Items that are rated more than once are scored using a 5-point ordinal rating scale, from 0 = the particular neurobehavioural impairment is not observed, to 4 = the patient is unable to perform the task due to the neurobehavoural impairment. All other items (including communication items from the NBSIS and all items from the NBPSI are rated dichotomously: 0 = absent or 1 = present during ADL task performance (Arnadottir et al., 2009).

The manual includes conceptual and operational definitions for all items as well as standardized instruction and detailed criteria for administration and scoring of the instrument.

Time:
Time taken to administer the A-ONE has not been reported.

Equipment:
Not reported

Alternative forms of the assessment

The author has developed several variations of the NBI scale including 2 global scales and 4 psychometrically-sound diagnostic-specific scales (Arnadottir, 2010):

• Common global scale (NBI-CVA, 53 items)
• NBI common short form scale (29 items)
• Left-hemisphere CVA (NBI-LCVA, 42 items)
• Right-hemisphere CVA (NBI-RCVA, 51 items)
• Dementia Alzheimers Type (NBI-DAT, 49 items)
• Dementia Unspecified (NBI-DU, 40 items).

The scales contain different items and hierarchical structure. These versions can be used across diagnostic groups but should not be used to compare different diagnostic groups (Arnadottir, 2010).

Client suitability

Can be used with:

• The A-ONE can be used with patients with dementia and other neurological disorders (Gardarsdottir & Kaplan, 2002).

Should not be used with:

• As the A-ONE has been designed for use with adults with neurobehavioural disorders, it is not recommended for use with individuals with other diagnoses or disorders.

Languages of the measure

English, Dutch

Summary

What does the tool measure?	The Arnadottir OT-ADL Neurobehavioural Evaluation (A-One) measures the impact of neurobehavioural impairment on functional performance of ADLs. The A-ONE is used to assess (a) independence in ADL tasks and (b) neurobehavioural impairments that limit the individual’s independence in ADL tasks.
What types of clients can the tool be used for?	The A-ONE is designed for use with adults with neurological dysfunction of cortical origin, including strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., dementia, Alzheimer’s disease and other neurological disorders.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment tool.
Time to administer	The A-ONE ADL scale takes approximately 25 minutes to administer.
Versions	There is only 1 version of the ADL scale but there are several versions of the neurobehavioural scale: Common global scale (NBI-CVA) NBI common short form scale Left-hemisphere CVA (NBI-LCVA) Right-hemisphere CVA (NBI-RCVA) Dementia Alzheimers Type (NBI-DAT) Dementia Unspecified (NBI-DU). There is a Dutch version of the A-ONE.
Other Languages	English and Dutch.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: – One study reported adequate internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ADL scale (α = 0.75 – 0.79), poor to adequate internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the NBSIS scale (α= 0.69 – 0.75), and poor internal consistence of the NBPIS scale (α= 0.59 – 0.63) using Cronbach’s alpha. – One study reported excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (item separation reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . coefficient = 0.98, item separation index = 8.02; person separation reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest . coefficient = 0.90, person separation index = 2.93) using Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute – such as upper limb function – independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model. . Test-retest: One study reported excellent one-week test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the A-ONE (agreement of 0.85 or higher for all items). Intra-rater: No studies have reported on intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the A-ONE. Inter-rater: Two studies have reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. for the A-ONE ADL scale (kappa = 0.83; weighted kappa=0.90; ICC=0.98; Kendall’s r=0.92), the NB scale (kappa = 0.85) or the NBSIS scale (ICC=0.93, weighted kappa=0.74).
ValidityThe degree to which an assessment measures what it is supposed to measure.	– One study reported logical ordering of ADL items according to difficulty, but noted large gaps in the hierarchy of item difficulty in some NBI scales. – One study reported that the ADL scale may not be well targeted to higher functioning individuals. – One study reported a moderate inverse relationship between ADL and neurobehavioural impairment scales, using Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson’s r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship (r=-0.57). Content: – Content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the A-ONE is based on literature review and expert opinion. – Internal validityThe degree to which an assessment measures what it is supposed to measure. of the A-ONE is determined by examination of goodness of fit for items, logical hierarchical ordering of items, targeting, and PCA analysis. – One study reported unidimensionality of the ADL scale and logical hierarchical ordering of ADL items. – One study reported unidimensionality of the NBI scales. Criterion: Concurrent: One study reporConted excellent correlations between the A-ONE ADL scale and the Barthel Index (r=0.70), and between the A-ONE and the MMSE (r=0.85). Predictive: No studies have reported on the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the A-ONE. Construct: One study reported that the ADL scale has three factors and the NBSIS scale has 2 factors. A later study reported that the NBSIS scale has a third factor. Convergent/Discriminant: No studies have reported on the convergent or discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess. of the A-ONE. Known Groups: – One study reported no significant difference in the extent of the impact of neurobehavioural impairment on ADL between patients with right CVA and left CVA. – One study reported significant differences between adults with right and left CVA on the ADL scale and the NBSIS scale.
Floor/Ceiling Effects	The A-ONE ADL scale and neurobehavioural scales demonstrate potential floor/ceiling effects. The ADL scale should be restricted to individuals who are not independent in ADLs. The NBI-CVA should be used clinically with patients with LCVA due to ceiling effects of the NBI-LCVA scale.
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” /Specificity	No studies have reported on the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” /specificity of the A-ONE.
Does the tool detect change in patients?	The ADL ordinal rating scale can be used as an interval scale, which allows measurement of change in ADL task performance over time.
Acceptability	No studies have reported on the acceptability of the A-ONE.
Feasibility	No studies have reported on the feasibility of the A-ONE.
How to obtain the tool?	The A-ONE can be found in the textbook The Brain and Behavior: Assessing Cortical Dysfunction Through ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. of Daily Living For more information email: a-one@islandia.is

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Arnadottir OT-ADL Neurobehavioural Evaluation (A-ONE). Nine articles were reviewed.

Floor/Ceiling Effects

In a study of the psychometric properties of the ADL scale Arnadottir et al. (2008) reported that 9 of 209 participants with left hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (LHS) reached maximum scores on all items, indicating possible ceiling effects of the scale. The authors concluded that use of the A-ONE should be restricted to individuals who are not independent in ADLs (where maximum scores indicate independence in ADLs). However, while a patient may achieve maximum scores on the ADL scale, they may demonstrate neurobehavioural impairments that can be detected using the NBI scale (Arnadottir, 2010).

In a study of the psychometric properties of the neurobehavioural scales Arnadottir et al. (2009) reported potential floor/ceiling effects of the measure. Two patients with LCVA and 6 patients with RCVA attained extreme (minimum) scores. Extreme (maximum) measures were seen on 10 items when used with patients with LCVA and on 4 items when used with patients with RCVA.

Following refinement of the NBI scales and development of additional versions of the scale, further analysis was conducted using Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
(Arnadottir, 2010). Results indicated that 30 of 422 patients with CVA or dementia achieved maximum or minimum scores on the 29-item NBI-Common scale; 6 of 215 patients with left-hemisphere or right-hemisphere CVA achieved maximum or minimum scores on the 53-item NBI-CVA scale; 9 of 114 patients with LCVA achieved maximum or minimum scores on the 42-item NBI-LCVA scale; and 0 of 108 patients with RCVA achieved maximum or minimum scores on the 51-item NBI-RCVA scale. Arnadottir (2010) recommended the NBI-CVA for clinical use with patients with LCVA due to the possible ceiling effectA ceiling effect occurs when test items aren't challenging enough for a group of individuals. Thus, the test score will not increase for a subsample of people who may have clinically improved because they have already reached the highest score that can be achieved on that test. In other words, because the test has a limited number of difficult items, the most highly functioning individuals will score at the highest possible score. This becomes a measurement problem when you are trying to identify changes - the person may continue to improve but the test does not capture that improvement. Example: A memory test that assesses how many words a participant can recall has a total of five words that each participant is asked to remember. Because most individuals can remember all five words, this measure has a ceiling effect. See also "floor effect." when using the NBI-LCVA scale.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Arnadottir (1990) investigated the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the A-ONE and reported adequate internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the ADL scale (α= 0.75 – 0.79), poor to adequate internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the NBSIS scale (α= 0.69 – 0.75), and poor internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the NBPIS scale (α= 0.59 – 0.63).

Arnadottir et al. (2008) examined the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of the ADL scale by performing a Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute – such as upper limb function – independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
with retrospective data from 209 patients with neurological conditions (dementia, n=111; CVA, n=95, other, n=3). Item separation reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
was 0.98 and the item separation index was 8.02, indicating reliable differentiation of items into at least 9 strata of difficulty. A separation reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
coefficient of 0.90 and person separation index of 2.93 was found, indicating reliable differentiation of the sample into at least 3 statistically distinct strata of ADL ability.
Note: Item separation reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
is the ratio of the “true” (observed minus error) variance to the obtained variation. The smaller the error, the higher the ratio will be. It ranges from 0.00 to 1.00 and is interpreted the same as the Cronbach’s alpha. A separation index > 2.00 is equivalent to a Cronbach’s alpha of 0.80 or greater (excellent).

Test-retest:
Gardarsdottir & Kaplan (2002) reported that one-week test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the A-ONE was excellent (agreement of 0.85 or higher for all items).

Intra-rater:
No studies have reported on intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
of the A-ONE.

Inter-rater:
Arnadottir (1990) reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the A-ONE ADL scale (average kappa coefficient = 0.83) and the NB scale (kappa = 0.85).

Further analysis by Arnadottir (2008) reiterated excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the A-ONE ADL scale (ICC=0.98; Kendall’s r=0.92, weighted kappa=0.90) and the NBSIS scale (ICC=0.93, weighted kappa=0.74).

Validity

Content:
Internal validation of the A-ONE was performed by examination of goodness of fit for items, logical hierarchical ordering of items, targeting, and PCA analysis (Arnadottir, 2010).

Arnadottir et al. (2008) performed factor analysis of the A-ONE ADL scale using retrospective data from 209 patients with neurological conditions (CVA, n= 95; dementia, n= 111, other diagnosis, n=3). Analysis of all 22 ADL items revealed that the two communication items (expression, comprehension) and one feeding item (‘use knife’) did not demonstrate acceptable goodness of fit (total of 13.6% item misfit). Following removal of the two communication items, the item ‘use knife’ demonstrated substantially reduced misfit to an acceptable rate (≤ 5%), and as such was maintained. With removal of the two communication items, 84% of total variance was explained by the measures, with 3.6% of the unexplained variance accounted for by first contrast. These results support unidimensionality of the ADL scale.

Arnadottir et al. (2009) performed factor analysis of nomotor neurobehavioural items (34 NBSIS items and 16 NBPIS items) using retrospective data from 206 patients with CVA and dementia. After four items (anomia, expressive aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada), working memoryExecutive process responsible for the temporary storage and manipulation of information in both simple (e.g. recalling a series of digits such as a phone number) and complex cognitive tasks (e.g. coordinating two tasks simultaneously) (Van der Linden, 2007)
, motivation) were removed due to outfit misfit, 56.8% of variance was explained by the Rasch factor (global measure of neurobehavioural impairments), with 4.9% of the unexplained variance accounted for by the first contrast. These results indicate that the neurobehavioural impairment items can be viewed as unidimensional – i.e. belonging to the same construct. The authors proceeded to conduct a principal component analysis (PCA) of global hierarchies according to diagnosis (LCVA, n=36; RCVA, n=37; dementia, n=111). After removal of misfit items (LCVA group – 2 items; RCVA and dementia groups – 3 items), improved results were seen for all diagnostic groups (Rasch factors: LCVA group = 85.5%, RCVA group = 83.3%, dementia group = 79.2%; unexplained variance in first contrast: LCVA group = 2.4%, RCVA group = 3.4%, dementia group = 1.7%). These results indicate that the hierarchical structure of the dimension varies across diagnostic groups.

Arnadottir (2010) reported on factor analysis conducted in development of the NBI common short form scale. All diagnosis-specific versions of the NBI scales demonstrate unidimensionality, as confirmed by PCA analysis (Arnadottir, 2010). The original NBSIS scale included neurobehavioural motor items that measured left- and right-sided performance, which were collapsed to a singular motor item. A resulting 33 neurobehavoural motor items were common to all 4 diagnostic groups (LCVA, RCVA, Dementia Alzheimers type, Dementia). Four of the 33 items were omitted due to misfit by Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute – such as upper limb function – independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
and the remaining 29 items demonstrated acceptable goodness of fit. PCA analysis revealed 72.8% of variance was explained by Rasch factor, supporting unidimensionality.

Arnadottir et al. (2008) examined the hierarchical ordering of difficulty of ADL items using retrospective data from individuals with dementia (n=111), CVA (n=95), or other neurological conditions (n=3) and reported logical ordering according to item difficulty. However, Arnadottir (2010) conducted an evaluation of the targeting of person ability to item difficulty and identified that the ADL scale may not be well targeted to higher functioning individuals (discrepancy between mean measures = 1.61 logits).

Arnadottir (2010) reported that some NBI scales have large gaps in the hierarchy of item difficulty as there are few items that evaluate neurobehavioural impairments of higher-functioning individuals (mean person measure = -1.74, SD = 1.34).

Arnadottir et al. (2010) examined the relationship between ADL ability and the impact of neurobehavioural impairments on ADL using retrospective data from 215 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. A moderate inverse relationship was found between ADL ability and the extent of neurobehavioural impairment impacting ADL, using Pearson product moment correlationThe most commonly used method of computing a correlation coefficient between variables that are linearly related. Pearson’s r is a measure of association which varies from -1 to +1, with 0 indicating no relationship (random pairing of values) and 1 indicating perfect relationship
(r=-0.57).

Arnadottir (2010) reported that the NBI-CVA scale demonstrates acceptable goodness of fit statistics for all retained items (MnSq ≤1.4, z < 2) and acceptable PCA.

Criterion:
Concurrent:
Steultjens (1998) examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the A-ONE. Comparison of the A-ONE ADL scale with the Barthel Index and comparison of NB scores with the MMSE revealed excellent correlations (r=0.70 and r=0.85 respectively).

Predictive:
No studies have reported on the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the A-ONE.

Construct:
Convergent/Discriminant:
No studies have reported on the convergent or discriminant validityMeasures that should not be related are not. Discriminant validity examines the extent to which a measure correlates with measures of attributes that are different from the attribute the measure is intended to assess.
of the A-ONE.

Arnadottir (1990) conducted exploratory factor analysis and reported that the ADL scale has 3 factors and the NBSIS scale has 2 factors.

Arnadottir et al. (2009) performance factor analysis of the A-ONE neurobehavioural items and reported an additional factor is formed by neurobehavioural impairments that reflect occupational errors representative of lateralized motor impairments (e.g. tone).

Known Group:
Arnadottir et al. (2010) examined whether patients with right or left CVA differ in the extent to which their neurobehavioural impairments impact performance of ADLs, using retrospective data from 215 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. No significant difference in the extent of the impact of neurobehavioural impairment on ADL was seen between patients with right CVA (n=103) and patients with left CVA (n=112).

Gardarsdottir & Kaplan (2002) examined the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the A-ONE ADL scale and Neurobehavioural Specific Impairment Scale (NBSIS) in adults with right CVA (n=19) and left CVA (n=23). Mann-Whitney U tests identified significant differences between the groups for only 3 of 18 ADL tasks: shave/makeup (p=0.013), comprehension (p=0.005), and speech (p=0.001), whereby patients with left CVA were more dependent than patients with right CVA for these tasks. Mann-Whitney U and chi-square tests revealed significant between-group differences for 13 of 46 neurobehavioural impairments, all within the three NSIS categories of motor apraxia, unilateral body neglect and abnormal tone. Results indicated that patients with left CVA demonstrated greater severity of motor apraxia in dressing (p=0.022), grooming and hygiene (p=0.001) and feeding (p=0.002) than patients with right CVA. Patients with left CVA also demonstrated greater severity of abnormal tone on both sides of the body in grooming and hygiene tasks (p=0.001) than patients with right CVA, whereas patient with right CVA demonstrated greater severity of abnormal tone on both sides of the body during performance of dressing (p=0.001), transfers and mobility (p=0.001) and feeding (p=0.001). Patients with right CVA also demonstrated greater severity of unilateral body neglect in grooming and hygiene tasks (p=0.002) than patients with left CVA.

Responsiveness

Principal component analysis of the ADL domain supported unidimensionality, enabling conversion of the ordinal rating scale to an interval scale, which would allow measurement of change in ADL task performance over time (Arnadottir, 1990).

References

• Arnadottir, G. (2010). Measuring the impact of body functions on occupational performance: Validation of the ADL-focused Occupation-based Neurobehavioural Evaluation (A-ONE). (Doctoral dissertation). Retrieved from Swedish Dissertations database.
• Arnadottir, G. (1990). The brain and behavior: Assessing cortical dysfunction through activities of daily living. St. Louis, MO: Mosby.
• Arnadottir, G. & Fisher, A.G. (2008). Rasch analysis of the ADL scale of the A-ONE. The American Journal of Occupational Therapy, 62, 51-60
• Arnadottir, G., Fisher, A.G., & Löfgren, B. (2009). Dimensionality of nonmotor neurobehavioural impairments when observed in the natural contexts of ADL task performance. Neurorehabilitation and Neural Repair, 23(6), 579-86.
• Arnadottir, G., Löfgren, B., & Fisher, A.G. (2010). Difference in impact of neurobehavioural dysfunction on activities of daily living performance between right and left hemisphere stroke. Journal of Rehabilitation Medicine, 42, 903-7.
• Bottari, C., Dutil, É., Dassa, C., & Rainville, C. (2006). Choosing the most appropriate environment to evaluation independence in everyday activities: Home or clinic? Australian Occupational Therapy Journal, 53, 98-106.
• Carswell, A., Carson, L.J., Walop, W. & Zgola, J. (1992). A theoretical model of functional performance in persons with Alzheimer disease. Canadian Journal of Occupational Therapy, 59(3), 132-40.
• Cooke, D.M., McKenna, K. & Fleming, J. (2005). Development of a standardized occupational therapy screening tool for visual perception in adults. Scandinavian Journal of Occupational Therapy, 12, 59-71.
• Gardarsdottir, S. & Kaplan, S. (2002). Validity of the Árnadottir OT-ADL Neurobehavioral Evaluation (A-ONE): Performance in activities of daily living and neurobehavioural impairments of persons with left and right hemisphere damage. American Journal of Occupational Therapy, 56, 499-508.
• Steultjens, E.M. (1998). A-ONE: De Nederlands Versie [A-ONE: The Dutch version]. Nederlands Tidskrift for Ergoterapie, 26, 100-4.

See the measure

How to obtain the assessment?

The A-ONE assessment is in the textbook: The Brain and Behavior: Assessing Cortical Dysfunction Through ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living.

For more information email: a-one@islandia.is

Purpose

The Behavioral Inattention Test (BIT), initially called as Rivermead Behavioral Inattention Test, is a short screeningTesting for disease in people without symptoms.
battery of tests to assess the presence and the extent of visual neglect on a sample of everyday problems faced by patients with visual inattention (Wilson, Cockburn, & Halligan, 1987).

In-Depth Review

Purpose of the measure

The Behavioral Inattention Test (BIT), initially called as Rivermead Behavioral Inattention Test, is a short screening battery of tests to assess the presence and the extent of visual neglect on a sample of everyday problems faced by patients with visual inattention (Wilson, Cockburn, & Halligan, 1987).

Available versions

The BIT was developed in 1987 by Barbara Wilson, Janet Cockburn and Peter Halligan.

Features of the measure

Items:
The BIT is divided into two subtests: Conventional and Behavioral. The BIT Conventional subtest (BITC) consists of 6 items: line crossing, letter cancelation, star cancellation, figure and shape copying, line bisection, and representational drawing. The BIT Behavioral subtest (BITB) consists of 9 items: pre-scanning, phone dialing, menu reading, article reading, telling and setting the time, coin sorting, address and sentence copying, map navigation, and card sorting. To minimize practice and learning effects upon re-testing, parallel versions of the test were created (Wilson et al., 1987).

A client will be diagnosed as being visual neglect if they failure to attend the target stimuli and based on the relative spatial location of targets omitted (Wilson et al., 1987).

The BIT items are as follow (Halligan, Cockburn, & Wilsom, 1991):

• BITC subtest

Item	Test description
Line crossing	Patients are required to detect and cross out all target lines on a page. When administering the test, the examiner demonstrates the nature of the task to the patient by crossing out two of four lines located in a central column, and then instructing them to cross out all lines they can see on the page.
Letter Cancellation	Paper and pencil test in which patients are required to scan, locate, and cross out designated targets from a background of distractor letters. The test consists of 5 rows of 34 upper case letters presented on a rectangular page. Forty target stimuli are positioned such that each appears in equal number on both sides of the page. Each letter is 6 mm high and positioned 2 mm apart.
Star Cancellation	This test consists of a random array of verbal and non-verbal stimuli. The stimuli are 52 large stars (14 mm), 13 randomly positioned letters and 19 short (3-4 letters) words are interspersed with 56 smaller stars (8mm) which comprise the target stimuli. The patient is instructed to cancel all the small stars.
Figure and Shape copying	In this test, the patient is required to copy three separate, simple drawings from the left side of the page. The three drawings (a four pointed star, a cube, and a daisy) are arranged vertically and are clearly indicated to the patient. The second part of the test requires the patient to copy a group of three geometric shapes presented on a separate stimulus sheet. Unlike the previous items, the contents of the page are not pointed out to the patient.
Line Bisection	Patients are required to estimate and indicate the midpoint of a horizontal line. The expectation is that the patient with left neglect will choose a midpoint to the right of true center. Each patient is presented with three horizontal, 8-inch black lines, 1- mm thick, displayed in a staircase fashion across the page. The extent of each line is clearly pointed out to the patient who is then instructed to mark the center.
Representational Drawing	Patient is asked to draw pictures of a clock face, together with the numbers and a setting of the hands; a man or a woman; and a simple outline drawing of a butterfly. The task is designed to assess patient’s visual imagery independent of sensory input. Patients with left sided neglect typically use the right side of the page and their drawings after contain major omissions of features on the left hand side. Drawings of a clock face, the human form and a butterfly have shown themselves to be clinically sensitive.

• BITB subtest

Item	Test description
Picture Scanning	Three large photographs (a meal, a wash basin and toiletries, and a large room flanked by various pieces of furniture and hospital aids), each measuring 357 x 278 mm are presented one at a time. Each photograph is placed in front of the seated patient who is not permitted to move it. The patient is instructed to name and or point the main items in each picture.
Telephone Dialing	A telephone with a numbered dial or a push-button keyboard is presented. Each number is placed directly in front of the telephone and patient is instructed to dial the number sequence presented.
Menu reading	A menu “open-out” page (420 x 297 mm) containing 18 common food items arranged in 4 adjacent columns (2 on the left and 2 on the right) is presented. The food items are presented in 6 mm high letters. Patient is instructed to open the menu and read out all the items. Language-impaired patients are permitted to point to all the words they can see.
Article Reading	Three short columns of text are presented, which patients are then instructed to read.
Telling and Setting the time	This test has three parts. First, the patient is required to read the time from photographed settings on a digital clock face. Second, the patient is required to read the time from three settings on an analogue clock face. Finally, the patient is instructed to set times on the analogue clock face as they are called out by the examiner.
Coin Sorting	An array of familiar coins is presented. The client is the asked to indicate the locations of the coin type called out by the examiner. This task requires selective scanning of the coin array in order to not miss any instance of the named denomination.
Address and Sentence copying	Patient is required to copy an address and a sentence on separate pages.
Map Navigation	Patient is required to follow and locate spatial points (letters) positioned on a network of pathways located on a sheet of paper. More specifically, after having been shown the junctions of each pathway, patients are instructed to use their fingers to trace out the sequence of the letters said by the examiner
Card Sorting	Sixteen playing cards are presented in a 4×4 matrix. Initially, each card is pointed out to the patient, who is then required to point to each of the cards types present as the examiner calls them out.

Scoring:
The BIT total score, as well as the sub-scores for the BITC and BITB are obtained by adding the subtests scores together. Maximum scores fort the BIT, BITC and BITB are respectively 227, 146, and 81. Higher scores are indicative of more severe visual impairment (Menon & Korner-Bitensky, 2004).

• BITC subtest

Item	Scoring
Line crossing	The four central lines are not included and neglect is diagnosed in any lines are missed by the patient. A score sheet is provided to notate the nature of the neglect.
Letter Cancellation	The maximum score is 40, and a scoring template allows scorer to divide the total array into four columns, two on the left and two on the right. On completion of the task, the total number of omitted target letters is calculated, and the location of the omissions is noted.
Star Cancellation	As with the letter cancellation task, the test sheet can be subdivided into columns to calculate the number and location of errors.
Figure and Shape copying	Scoring is based on completeness of each drawing. Neglect is defined as an omission or gross distortion of any major contralesional component of the drawing.
Line Bisection	The test is scored by measuring deviations from the true mid-point. Deviations to left scored as negative; to the right as positive. Deviation score is calculated using the normative data obtained from the age-matched controls. Each of the three lines is scored out of a maximum of three. Using data from the control sample, score values between o and 3 are assigned to the patient’s performance.
Representational Drawing	Scoring is similar to copying tasks, where neglect is defined as the omission or gross distortion of any major contralesional component of the drawing.

• BITB subtest

Item	Scoring
Picture Scanning	Only omissions are scored, though errors of identification are also noted. Scoring of this and all other BITB testes is out of a total of nine and is calculated from the total number of omission recorded.
Telephone Dialing	Dialing sequence is recorded, together with number and location of omissions or substitutions.
Menu reading	Each of 18 items is scored as correct or incorrect, where incorrect response refers to partial entire word substitutions or omission.
Article Reading	Scoring is based on the percentage of words omitted across all three columns. Word omissions and partial or entire word substitutions are scored as errors.
Telling and Setting the time	All three parts are scored according to the numbers of omissions or substitutions made.
Coin Sorting	Scoring is based on the number of omissions
Address and Sentence copying	Score is calculated from the number of letters omitted or substituted from each side of the page
Map Navigation	Failure to complete any segment of the route sequence incurs a penalty deduction of one point down to a minimum of zero for each trial
Card Sorting	To score, the position and total number of omissions are recorded.

Cut-offs scores for the BIT, BITC, and BITB are respectively 196 out of 227, 129 out of 146 and 67 out of 81 (Halligan et al., 1991; Menon & Korner-Bitensky, 2004).

To score the relative spatial location component, the number of screeningTesting for disease in people without symptoms.
tests that demonstrated an overall lateralized performance is calculated. If half of the tests show lateralized performance and half do not, the index of lateralized performance is then determined by the total number of omissions/errors made on each side. The severity of visual negligence can be calculated based on the client’s performance on the 6 BITC tests. This score is determined by the number of conventional tests on which a given client demonstrates visual negligence. Severity scores range from 1 to 6, with higher scores indicating more severe visual negligence (Halligan et al., 1991).

Time:
The BIT takes approximately 30 to 40 minutes to administer (Menon & Korner-Bitensky, 2004).

Subscales:
BITC – BIT Conventional subtest

BITB – BIT Behavioral subtest

Equipment:

• Forms for the BITC and BTIB;
• Photographs of 1) a meal, 2) wash-basin and toiletries, 3) a large room with pieces of furniture and hospital aids and 4) different settings of a digital clock;
• Open-out menu;
• Analogue clock;
• Six different types of coins;
• Playing cards;
• Paper and pencil.

Training:
Not required.

Alternative forms of the BIT

• BIT – shortened version: Developed by Stone, Wilsom, & Rose in 1987, the test is comprised of three Conventional (BITC) subtests (line crossing, star cancelation tests, figure copying) and five Behavioral (BITB) subtests (scanning a picture, reading a menu, eating a meal, reading an article, sorting coins). This version takes, on average, 10 to 15 minutes to administer (Menon & Korner-Bitensky, 2004).

Client suitability

Can be used with:

• Clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.

Should not be used with:

• The BIT should not be used with clients who have difficulty communicating (e.g. apraxia or aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada)).

In what languages is the measure available?

English, Chinese.

Summary

What does the tool measure?	The BIT estimates the presence and the extent of visual neglect.
What types of clients can the tool be used for?	The BIT can be used with, but is not limited to clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment.
Time to administer	The BIT takes 30 to 40 minutes to administer.
Versions	BIT; BIT shortened version
Other Languages	English, Chinese
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the BIT. Test-retest: Two studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the BIT. All reported excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficient. Intra-rater: No studies have examined the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the BIT. Inter-rater: Two studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the BIT and reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. using Pearson correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficient.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Content: One study examined the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the BIT and reported the item generation process when creating the measure. Criterion: Concurrent: No studies have reported the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the BIT in clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Predictive: One study examined the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the BITB and reported that BITB scores measured at 10 days post-stroke is an excellent predictor of poor functional outcome at 3, 6 and 12 months post-stroke. Construct: Convergent/Divergent: Three studies have examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the BIT and reported excellent correlations between the BIT, the Occupational Therapy Checklist and the Barthel Index, along with adequate correlations with the Rivermead ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. of Daily Living Assessment. Known Groups: One study reported that BITC scores were able to distinguish between those with and without visual neglect.
Floor/Ceiling Effects	No studies have reported floor/ceiling effects of the BIT in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” /Specificity	One study examined the specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). and sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” of the BIT and reported that both subtests are able to accurately identify individuals with visual neglect.
Does the tool detect change in patients?	No studies have reported the responsivenessThe ability of an instrument to detect clinically important change over time. of the BIT in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Acceptability	The tests are easy and simple to administer.
Feasibility	The tests are easy to administer, simple and relatively unambiguous to score, and are sufficiently wide ranging to detect different forms of visual neglect.
How to obtain the tool?	The BIT can be obtained from on the website: http://www.pearsonclinical.com/psychology/products/100000138/behavioral-inattention-test-bit.html?Pid=015-8054-628&Mode=summary

Psychometric Properties

Overview

We conducted a literature search to identify all relevant publications on the psychometric properties of the Behavioral Inattention Test (BIT) in individuals with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. We identified 5 studies.

Floor/Ceiling Effects

No studies have reported floor/ceiling effects of the BIT in clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Reliability

Internal ConsistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No studies have reported the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the BIT in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Test-retest:
Wilson, Cockburn, and Halligan (1987) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the BIT in 28 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and 14 healthy individuals. Participants were re-assessed within 1 week. The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for the BIT, as calculated using Pearson CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficient, was excellent (r = 0.83).

Halligan, Cockburn, and Wilsom (1991) estimated the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the BIT conventional subtest (BITC) and the BIT behavioral subtest (BITB) in 10 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Participants were re-assessed within 15 days. The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was excellent for both BITC and BITB (r = 0.89; r = 0.97, respectively).

Intra-rater:
No studies have reported the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the BIT in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Inter-rater:
Wilson et al. (1987) assessed the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the BIT in 7 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Two raters assessed participants simultaneously. 100% agreement level was found between raters.

Halligan et al. (1991) verified the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the BIT conventional subtest (BITC) and the BIT behavioral subtest (BITB) in 13 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Two independent raters scored participants separately but simultaneously. CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between raters mean scores, as calculated using Pearson CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
Coefficient, was excellent (r = 0.99) for both BITC and BITB.

Validity

Content:
Wilson et al. (1987) obtained information about client’s everyday difficulties in order to construct a brief battery of tests that included real world’ experiences of patients recovering from strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Information was retrieved from published cases, behavioral observation of patients with neglect, as well as from discussions with occupational therapists, physiotherapists, clinical psychologists, and neurologists, all of whom had worked with patients with visual neglect. The final selection of items was determined based on results of a pilot study.

Criterion:
Concurrent:
The concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the BIT has not been examined in clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Predictive:
Jehkonen, Ahonen, Dastidar, Koivisto, Laippala, Vilkki et al. (2000) examined in 50 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. to determine if visual neglect measured 10 days post strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. was predictive of poor functional outcomes at 3, 6 and 12 months post stroke. Visual neglect was measured with the BIT and functional outcomes with the Frenchay ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
Index (FAI) (Holbrook & Skilbeck, 1983). Linear regression analysis indicated that the BIT is an excellent predictor of poor functional outcomes, accounting for 73%, 64% and 61% of the total variance of the FAI at 3, 6 and 12 months respectively.

Halligan et al. (1991) analyzed the percentage of people that were correctly classified as having visual neglect using the BITC and the BITB. This study included 80 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Results were as follows:

• BITC

	Right brain damaged clients (n = 26)		Left brain damaged clients (n = 54)
	SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”	SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”	SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
Line crossing	65%	76%	75%	96%
Letter cancelation	77%	82%	100%	95%
Star cancelation	100%	64%	100%	77%
Figure copying	96%	97%	100%	91%
Line bisection	65%	76%	75%	96%
Representational drawing	42%	64%	0%	85%

• BITB

	Right brain damaged clients (n = 26)		Left brain damaged clients (n = 54)
	SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”	SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”	SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
Picture scanning	65%	76%	25%	88%
Telephone dialing	57%	72%	25%	88%
Menu reading	65%	76%	75%	96%
Article reading	38%	64%	50%	92%
Telling time	69%	78%	100%	100%
Coin sorting	100%	100%	100%	95%
Address and sentence copying	65%	76%	50%	92%
Map navigation	46%	67%	100%	95%
Card sorting	54%	70%	25%	88%

Construct:
Convergent/Divergent:
Halligan et al. (1991) examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the BIT by comparing it to the Occupational TherapistIn charge of the “assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education.”(Suggested by Philips et al, 2002)
Checklist and the Rivermead ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living Assessment (Whiting & Lincoln, 1980) in 80 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent correlations were found between the BIT and the Occupational TherapistIn charge of the “assessment of personal and domestic care activities; evaluation and treatment of functional impairments related to change in sensorimotor, cognitive and perceptual abilities; prescription of wheelchairs and bathroom appliances; home visits; patient and family education.”(Suggested by Philips et al, 2002)
Checklist (r = -0.65); adequate correlations between the BIT and the Rivermead ActivitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
of Daily Living Assessment (r = 0.55).

Hartman-Maier and Katz (1995) verified the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the BIT Behavioral subtest by comparing it to a checklist of activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis.. Correlations, as calculated using Pearson Coefficient CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
, were excellent (r = 0.77).

Cassidy, Bruce, Lewis, and Gray (1999) evaluated the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the BIT by comparing it to the Barthel Index (Mahoney & Barthel, 1965) in 44 clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Correlations between both measures were excellent (r = 0.64).

Known Groups:
Halligan et al. (1991) studied 80 clients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. to determine if the BITC subtest was able to distinguish between persons with visual neglect from those healthy ones. Individuals with visual neglect performed significantly worse on the BITC as compared to healthy ones (p<0.001; calculated using Kruskal-Wallis test). Therefore, the BITC is capable of discriminating between known groups.

Responsiveness

No studies have reported the responsivenessThe ability of an instrument to detect clinically important change over time.
of the BIT in clients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

References

• Albert, M. L. (1973). A simple test of visual neglect. Neurology, 23, 658-664.
• Beschin, N., Robertson, I. H. (1997). Personal versus extrapersonal neglect: a group study of their dissociation using a reliable clinical test. Cortex. 33, 379-384.
• Brunila, T., Jalas, M., Lindell, J.A., Tenovuo, O., Hamalainen, H. The two part picture in detection of visuospatial neglect. Clin Neuropsychol 2003;17:45-53.
• Cassidy, T.P., Bruce, D.W., Lewis, S., & Gray, S.G. (1999). The association of visual field deficits and visuospatial neglect in acute right hemisphere stroke patients. Age Ageing, 28, 257-260
• Diller, L., Ben-Yishay, Y., Gerstman, L. J., Goodin, R., Gordon, W., Weinberg, J. (1974). Studies in scanning behavior in hemiplegia. Rehabilitation Monograph No. 50, Studies in cognition and rehabilitation in hemiplegia. New York: New York University Medical Center, Institute of Rehabilitation Medicine.
• Goodenough, F. L. (1926). The measurement of intelligence by drawing. New York: World Books.
• Halligan, P., Cockburn, J., Wilson, B. (1991). The Behavioural Assessment of Visual Neglect. Neuropsychological Rehabilitation 1, 5-32.
• Hartman-Maeir, A., Katz, N. (1995). Validity of the Behavioral Inattention Test: relationship with functional tasks. Am J Occup Therapy, 49, 507-516.
• Holbrook, M., Skilbeck, C. E. (1983). An activities index for use with stroke patients. Age and Ageing, 12(2), 166-170.
• Jehkonen, M., Ahonen, J.P., Dastidar, P., et al. (2000). Visual neglect as a predictor of functional outcome one year after stroke. Acta Neurol Scand, 101, 195-201.
• Mahoney, F. I., Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Md State Med J, 14, 61-5.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: working your way through the maze of assessment choices. Top Stroke Rehabil 11, 41-66.
• Zoccolotti, P., Antonucci, G., Judica, A. (1992). Psychometric characteristics of two semi-structured scales for the functional evaluation of hemi-inattention in extrapersonal and personal space. Neuropsychological Rehabilitation, 2, 179-191.
• Whiting, S. & Lincoln, N. (1980). An A.D.L. assessment for stroke patients. British Journal of Occupational Therapy, 43, 44-46.
• Wilson, B., Cockburn, J., Halligan, P. (1987) Development of a behavioral test of visuospatial neglect. Arch Phys Med Rehabil 68, 98-102.

See the measure

How to obtain the BIT

The BIT can be obtained from on the website:
http://www.pearsonclinical.com/psychology/products/100000138/behavioral-inattention-test-bit.html?Pid=015-8054-628&Mode=summary

The BIT Complete Kit, including manual, 25 record forms, various stimulus, test and playing cards, and clock face costs US$ 339.00. A package including only the record forms (n = 25) costs US$42.00.

Purpose

The Catherine Bergego Scale is a standardized checklist to detect presence and degree of unilateral neglect during observation of everyday life situations. The scale also measures self-awareness of behavioral neglect (anosognosia).

In-Depth Review

Purpose of the measure

The Catherine Bergego Scale is a standardized checklist to detect presence and degree of neglect during observation of everyday life situations. The scale also provides a measure of neglect self-awareness (anosognosia).

Available versions

There is only one version of the CBS. The CBS is comprised of a 10-item checklist for use by clinicians, and a corresponding patient-administered questionnaire that can be used to measure self-awareness of neglect (anosognosia).

Features of the measure

Items:
The CBS is comprised of 10 everyday tasks that the therapist observes during performance of self-care activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
. The therapist scores the patient on the following items:

1. Forgets to groom or shave the left part of his/her face
2. Experiences difficulty in adjusting his/her left sleeve or slipper
3. Forgets to eat food on the left side of his/her plate
4. Forgets to clean the left side of his/her mouth after eating
5. Experiences difficulty in looking towards the left
6. Forgets about a left part of his/her body (e.g. forgets to put his/her upper limb on the armrest, or his/her left foot on the wheelchair rest, or forgets to use his/her left harm when he/she needs to)
7. Has difficulty in paying attention to noise or people addressing him/her from the left
8. Collides with people or objects on the left side, such as doors or furniture (either while walking or driving a wheelchair)
9. Experiences difficulty in finding his/her way towards the left when traveling in familiar places or in the rehabilitation unit
10. Experiences difficulty finding his/her personal belongings in the room or bathroom when they are on the left side

There is a corresponding patient/carer questionnaire that can be used to assess anosognosia (i.e. self-awareness of neglect). The questionnaire is comprised of 10 questions that correspond with CBS items. For instance, in accordance with the first item the clinician would ask the patient: “do you sometimes forget to groom or shave the left side of your face?” If the patient identifies that the difficulty is present, the clinician asks: “do you find this difficulty mild, moderate or severe?”

Scoring:
The CBS uses a 4-point rating scale to indicate the severity of neglect for each item:

0 = no neglect
1 = mild neglect (patient always explores the right hemispace first and slowly or hesitantly explores the left side)
2 = moderate neglect (patient demonstrates constant and clear left-sided omissions or collisions)
3 = severe neglect (patient is only able to explore the right hemispace)

This results in a total score out of 30.

Azouvi et al. (2002, 2003) have reported arbitrary ratings of neglect severity according to total scores:

0 = No behavioral neglect
1-10 = Mild behavioral neglect
11-20 = Moderate behavioral neglect
21-30 = Severe behavioral neglect

In cases of severe impairment the patient may not able to perform an item of the CBS. In these instances the item is considered invalid, is not scored, and is not included in the final score. As such, the total score would be a calculation of the average score of the valid questions (i.e. sum of individual scores divided by number of valid questions x 10).

The patient questionnaire also uses a 4-point rating scale according to the following levels of difficulty experienced by the patient:

0 = no difficulty
1 = mild difficulty
2 = moderate difficulty
3 = severe difficulty

The anosognosia score is then calculated as the difference between the clinician’s total score and the patient’s self-assessment score (Azouvi et al., 2003):

Anosognosia score = clinician’s CBS score – patient’s self-assessment score

Description of tasks:
The clinician observes the patient performing self-care activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
and provides a score for each of the 10 items according to observations of neglect behaviors (Plummer et al., 2003).

What to consider before beginning:
The items of the CBS vary in their degree of difficulty (tasks listed from least difficult to most difficult, with item numbers indicated in parentheses): cleaning mouth after a meal (item 4); grooming (1) / auditory attention (7); eating (3); spatial orientation (9); gaze orientation (5); finding personal belongings (10); collides when moving (8); left limb knowledge (6); dressing (2). Note that two items (grooming, auditory attention) share the same level of difficulty (Azouvi et al., 2003).

Time:
The CBS takes approximately 30 minutes to administer.

Training requirements:
There are no formal training requirements for administration of the CBS.

Equipment:
The clinician requires the form, a pen and household equipment used to perform the tasks (e.g. razor, brush, toothbrush, clothing, mealtime utensils, serviette). The test can be administered in the patient’s own environment or in the rehabilitation setting.

Alternative forms of the assessment

There are no alternative forms of the CBS.

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and hemispatial neglect. While the authors specify use of the CBS with patients with right hemispatial neglect, it may be modified for use with individuals with left hemispatial neglect (Plummer et al., 2003).

Should not be used with:

• The CBS requires patients to perform upper limb and lower limb movements in various testing positions for approximately 30 minutes (Menon & Korner-Bitensky, 2004). While scoring can be adjusted for patients who are not able to perform all tasks, the clinician must consider whether these difficulties are due to neglect or other neurological deficits such as apraxia (Azouvi et al., 1996; Menon & Korner-Bitensky, 2004).

Languages of the measure

English, French, Portuguese

Summary

What does the tool measure?	The CBS measures unilateral behavioural neglect.
What types of clients can the tool be used for?	The CBS is designed for use with individuals with stroke who have hemispatial neglect.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	Assessment.
Time to administer	The CBS takes approximately 30 minutes to administer.
Versions	There is one version of the CBS checklist for use by clinicians. There is also a patient-administered questionnaire that can be used to measure self-awareness of neglect (anosognosia).
Languages	English, French, Portuguese
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: Five studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the CBS and have reported adequate to excellent internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency., using Spearman rank. Test-retest: No studies have reported on the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the CBS. Intra-rater: No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings. of the CBS. Inter-rater: One study examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the CBS and reported adequate to excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. , using kappa and correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficients.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Internal validityThe degree to which an assessment measures what it is supposed to measure. : One study has examined the internal validityThe degree to which an assessment measures what it is supposed to measure. of the CBS and found unidimensionality of items by Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model. . Content: No studies have reported on the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension. of the CBS. Criterion: Concurrent: – Five studies has examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the CBS with other neglect tasks in patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and reported excellent correlations with Albert’s Test, Behavioral Inattention Test subtests, the Bells test, a reading task and a writing task. Adequate to excellent correlations were reported with Ogden’s scene drawing task, overlapping figures and a daisy drawing task. Poor to adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. were reported with Bisiach et al.’s (1986) scale of awareness of visual and motor neglect. – One study has examined the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.” of the CBS with other neglect tasks in patients with left hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and reported adequate correlations with the Bells test, but no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with a line bisection test. Predictive: No studies have reported on the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks. of the CBS. Construct: One study conducted a factor analysis and revealed one underlying factor. Convergent/Discriminant: Two studies have examined the convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other. of the CBS and reported an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Barthel Index and an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Functional Independence Measure and the Postural Assessment for StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Scale, using Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. coefficient. Known Groups: Two studies have examined the known groups validityKnown groups validity is a form of construct validation in which the validity is determined by the degree to which an instrument can demonstate different scores for groups know to vary on the variables being measured. of the CBS and reported that the CBS is able to distinguish between patients with/without neglect and patients with/without visual field deficits. The CBS does not differentiate between patients with/without depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely “pull themselves together” and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression. .
Floor/Ceiling Effects	One study reported adequate floor/ceiling effects.
Does the tool detect change in patients?	Two studies have reported that the CBS can detect change in neglect.
Acceptability	Not reported
Feasibility	The CBS is straightforward and easy to administer. While there is no formal training, administration of the CBS requires clinicians to possess a sound understanding of neglect and its behavioral manifestations. There is no manual to aide administration or scoring.
How to obtain the tool?	The CBS can be accessed in the article by Azouvi et al. (1995).

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Catherine Bergego Scale (CBS). Eight articles were reviewed.

Floor/Ceiling Effects

Azouvi et al. (2003) reported that 3.6% of patients with right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. achieved a total CBS score of 0 (no neglect), indicating an adequate floor/ceiling effect.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Bergego et al. (1995) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the CBS with 18 patients with right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and reported adequate to excellent correlations between the total score and all items (rho range = 0.48 – 0.87, p<0.05).

Azouvi et al. (1996) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the CBS with 50 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the CBS total score and the “mouth cleaning” item (rho=0.58, p<0.0001). An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the total score and all other items (rho range from 0.69 – 0.88, p<0.0001). An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the therapist’s score and the patient’s self-evaluation (rho = 0.52, p<0.001). There was an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the therapist’s score and the anosognosia score (i.e. therapist’s total score – patient’s self-evaluation score) (rho = 0.75, p<0.0001).

Azouvi et al. (2002) examined the anosognosia component of the CBS in 69 patients with subacute right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Patients’ self-assessment score was significantly lower than the examiner’s score (p<0.0001). There was an excellent correlation between the therapist’s score (neglect severity) and the anosognosia score (r=0.82, p<0.0001).

Azouvi et al. (2003) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the CBS with 83 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and reported adequate to excellent correlations between items (correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient range = 0.48 – 0.73, p<0.0001). Patients’ self-assessment scores were significantly lower than examiners’ total CBS scores (p<0.0001). An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the therapist’s score (neglect severity) and the anosognosia score (r=0.79, p<0.0001). Patients with moderate or severe neglect achieved high anosognosia scores, whereas patients with mild or no neglect achieved negative scores, indicating higher self-rating of severity than scores attributed by the therapist.

Luukkainen-Markkula et al. (2011) examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the CBS using Spearman correlations. There were adequate< to excellent correlations between the CBS total score and all item scores, except for the “eating” item (grooming: r=0.64, p<0.05; mouth cleaning: r=0.73, p<0.05; gaze orientation: r=0.80, p<0.01; knowledge of left limbs: r=0.61, p<0.05; auditory attention: r=0.89, p<0.01; collisions when moving: r=0.89, p<0.01; spatial orientation: r=0.89, p<0.01; dressing: r=0.51, p<0.05; finding personal belongings: r=-0.66, p<0.05). Adequate to excellent correlations were also reported between many CBS items (r range from 0.51 to 0.94, p<0.05 to p<0.01).

Azouvi et al. (2003) examined the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of the CBS. The item reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
index was 0.93, resulting in 3.5 strata of significantly different difficulty (p<0.05). Although most items vary in their degree of difficulty, 2 items (grooming, auditory attention), share the same level of difficulty. The person reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
index was 0.88, resulting in 2.7 statistically different levels of ability (p<0.05).

Azouvi et al. (2003) examined the internal structure of the CBS by Rasch analysisRasch analysis is a statistical measurement method that allows the measurement of an attribute - such as upper limb function - independently of particular tests or indices.   It creates a linear representation using many individual items, ranked by item difficulty (e.g. picking up a very small item, versus a task requiring a very gross grasp) and person ability.   A well performing Rasch model will have items hierarchically placed from simple to more difficult, and individuals with high abilities should be able to perform all the items below a level of difficulty.  The Rasch model is statistically strong because it enables ordinal measures to be converted into meaningful interval measures. It also allows information from various tests or tools with different scoring systems to be applied using the Rasch model.
. Item 2 (dressing) obtained an outlier outfit value (mnsq = 0.58), indicating potential redundancy of this item due to too little variance. Overall mean fit scores were very close to 1.00, supporting unidimensionality. This is further supported by high positive-point biserial correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients (i.e. the extent to which the items correlate with the linear measure) between each item score, and cumulative scores obtained across the whole sample.

Test-retest:
No studies have reported on the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the CBS.

Intra-rater:
No studies have reported on the intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater’s subsequent ratings are contaminated by knowledge of earlier ratings.
of the CBS.

Inter-rater :
Bergego et al. (1995) examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the CBS among 18 patients and found adequate to excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for the 10 items (kappa coefficient range = 0.59 – 0.99). CorrelationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the two examiners’ total scores, measured by Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient, was excellent (rho = 0.96, p<0.0001).

Validity

Content:
No studies have reported on the content validityRefers to the extent to which a measure represents all aspects of a given social concept. Example: A depression scale may lack content validity if it only assesses the affective dimension of depression but fails to take into account the behavioral dimension.
of the CBS.

Criterion:
Concurrent:
Bergego et al. (1995) compared the CBS total score with other conventional neglect tests in 18 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Excellent correlations were reported between the CBS and the Bells test, Ogden’s scene drawing task, writing task, reading task and Albert’s Test (rho = 0.72, 0.72, 0.72, 0.70 and 0.67 respectively, p<0.01). There was no statistically significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with a flower drawing task.

Azouvi et al. (1996) compared the CBS total score with other conventional neglect tests among 50 patients with right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients. Excellent correlations were found between the CBS and the Bells test (rho = 0.74, p<0.0001), Albert’s Test (line cancellation) (rho = 0.73, p<0.0001) and a reading task (rho = 0.61, p<0.0001). Adequate correlations were found with the Ogden’s scene drawing task (rho = 0.56, p<0.001) and a daisy drawing task (rho = 0.50, p<0.001). Adequate correlations were found between the CBS anosognosia score and conventional tests of neglect (rho range = 0.45 – .58, p<0.01). A weak correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between the CBS anosognosia score and Bisiach et al.’s (1986) scale of patients’ awareness of neurological deficit (rho = 0.31, p<0.05).

Azouvi et al. (2002) compared the CBS with a battery of conventional pen and paper neglect tasks among 69 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Conventional neglect tasks included the Bells test, a figure-copying task, clock drawing, line bisection tasks (5cm, 20cm), overlapping figures test, reading task and a writing task. There were adequate to excellent correlations between the CBS and all conventional neglect tasks (r range = 0.49 – 0.77, p<0.0001), except for the short (5cm) line bisection task. The strongest correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was seen with the Bells test (total number of omissions). Further stepwise multiple regression analysis revealed that four conventional neglect tasks – the total number of omissions in the Bells test, starting point in the Bells test, figure copying task and the clock drawing task – significantly predict behavioral neglect. Moderate to excellent correlations were found between the CBS anosognosia score and all conventional neglect tasks (r range = 0.47 – 0.70, p<0.0001), except the short (5cm) line bisection task. Comparison with Bisiach et al.’s (1986) scale of visual and motor anosognosia found a moderate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with visual anosognosia (r=0.37, p<0.05), but a poor correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with motor anosognosia (r=0.29, p<0.05).

Azouvi et al. (2003) compared the CBS total score with three conventional neglect tasks in 83 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent correlations were found with the Bells test (number of omissions) (r=0.76, p<0.0001) and a figure-copying task (r=0.70, p<0.0001), and an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found with a short reading task (number of omissions) (r=0.54, p<0.0001). Comparison of the CBS anosognosia scores with conventional neglect tasks revealed adequate to excellent correlations (r range = 0.43 – 0.72, p<0.01).

Azouvi et al. (2006) reported on unpublished data from 54 patients with left hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. There was an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the CBS score and the Bells test – total omissions (r=0.41, p<0.01) and right minus left omissions (r=0.34, p<0.01). There was no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with a line bisection test.

Luukkainen-Markkula et al. (2011) compared the CBS with the conventional subtests of the Behavioral Inattention Test (BIT C) among 17 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and hemispatial neglect. Only the BIT C line bisection subtest showed statistically significant correlations with the CBS, demonstrating excellent correlations with the grooming (r=-0.64, p≤0.01) and gaze orientation (-0.61, p≤0.01) subtests, and adequate correlations with the auditory attention (r=-0.56, p≤0.05) and spatial orientation (r=-0.54, p≤0.05) subtests and the CBS total score (r=-0.54, p≤0.05). Conversely, the CBS eating item was the only item to demonstrate statistically significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the BIT C, revealing excellent correlations with the line crossing (r=-0.95, p≤0.01), letter cancellation (r=0.83, p≤0.01) and star cancellation (r=-0.83, p≤0.01) subtests and the BIT C total score (r=-0.83, p≤0.01).

Despite significant correlations between the CBS and traditional visual neglect tests, individual patients can demonstrate dissociations between visual and behavioral neglect (Azouvi et al., 1995, 2002, 2006; Luukkainen-Markkula et al., 2011).

Predictive:
No studies have reported on the predictive ability of the CBS.

Construct:
Azouvi et al. (2003) conducted a conventional factor analysis on raw scores, revealing a single underlying factor that explained 65.8% of total variance. The factor matrix showed that all 10 items obtained a high loading on this factor (range = 0.77 – 0.84). Further, principal component analysis on standardized residuals after the linear method was extracted showed that no strong factors remained hidden in the residuals between observed and expected scores.

Convergent/Discriminant :
Azouvi et al. (1996) examined the ability of the CBS to measure aspects of daily functioning related to neglect by comparing CBS and Barthel Index scores of 50 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman’s rank correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. An excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found between CBS total score and the Barthel Index (rho = -0.63, p<0.0001).

Azouvi et al. (2006) reported on unpublished data from 54 patients with left hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. There was an adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the CBS score and the Functional Independence Measure (r=-0.48, p<0.01), and the Postural Assessment for StrokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. Scale (r=-0.55, p<0.001).

Known Group:
Azouvi et al. (1996) compared behavioral neglect in patients with neglect on conventional tests and patients with no neglect, using Mann Whitney tests. There was a significant difference in total CBS scores between the two groups (p<0.0001). Comparison of anosognosia revealed a significant difference between groups (p<0.001), whereby patients with no neglect tended to overestimate their difficulties (compared to the difficulties reported by the therapist) and patients with neglect tended to underestimate their neglect difficulties.

Azouvi et al. (1996) reported no significant difference in CBS anosognosia scores between patients with depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
and patients without depressionIllness involving the body, mood, and thoughts, that affects the way a person eats and sleeps, the way one feels about oneself, and the way one thinks about things. A depressive disorder is not the same as a passing blue mood or a sign of personal weakness or a condition that can be wished away. People with a depressive disease cannot merely "pull themselves together" and get better. Without treatment, symptoms can last for weeks, months, or years. Appropriate treatment, however, can help most people with depression.
.

Luukkainen-Markkula et al. (2011) compared behavioral neglect in patients with right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and hemispatial neglect with visual field deficits (n=8) and patients with intact visual fields (n=9), using Mann Whitney tests. Patients with visual field deficits demonstrated significantly more severe behavioral neglect (i.e. higher CBS total score) than patients with intact visual fields (p=0.03).

Responsiveness

Samuel et al. (2000) reported that the CBS is responsive to clinical change following visuo-spatio-motor cueing intervention in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. and unilateral spatial neglect.

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
:
Azouvi et al (1995) examined the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of the CBS by determining the ability of each CBS item to detect the presence of neglect (i.e. a score of 1 or more) in a group of 50 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. The most sensitive items at detecting neglect were items 2 (dressing), 4 (knowledge of left limbs) and 8 (collisions while moving), which all demonstrated neglect in more than 50% of patients. SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of other items in descending order was as follows: item 1 (grooming), 3 (eating), 10 (personal belongings), 5 (gaze orientation), 7 (auditory attention), 9 (spatial orientation) and 4 (mouth cleaning). The CBS was more sensitive to neglect than conventional neglect tasks (Bells test, reading task, line cancellation test), which were found to detect neglect in 42 – 49% of patients.

Azouvi et al. (2002) examined the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of the CBS among 69 patients with right hemisphere neglect. Similar to their earlier study (Azouvi et al., 1995), the most sensitive items were item 4 (knowledge of left limbs), item 8 (collisions) and item 2 (dressing). The authors compared the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of the CBS with a battery of conventional neglect tasks that comprised the Bells test, a figure copying task, clock drawing, line bisection task, overlapping figures test, reading task and a writing task. Stepwise multiple regression analysis revealed that four conventional neglect tasks – the total number of omissions in the Bells test, starting point in the Bells test, figure copying task and the clock drawing task – significantly predict behavioral neglect. These tasks revealed neglect in 71.84% of patients, but did not indicate neglect in 16.38% of patients who demonstrated neglect on the CBS. The highest incidence of neglect in conventional tests was 50%, whereas neglect was seen on at least 1 of the 10 CBS items in 76% of patients. This indicates that the CBS was more sensitive to neglect, although the difference in sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
between the CBS and the battery of conventional neglect tasks was not statistically significant.

Azouvi et al. (2003) compared the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of the CBS to three conventional neglect tasks in 83 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Incidence of neglect on individual conventional tasks was 44.3% on a figure copying task, 53.8% on the Bells Test and 64.2% on a reading task; 65.4% of participants showed neglect on at least one conventional neglect task and 32.7% of participants showed neglect on all three tasks. By comparison, 96.4% of participants demonstrated neglect based on total CBS score. SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
of individual CBS items ranged from 49.5% (auditory attention, spatial orientation) to 79.5% (dressing).

Azouvi et al. (2006) reported on unpublished data from 54 patients with left hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., which showed that 77.3% of patients showed neglect on one item of the CBS scale. Only 5.4% of patients showed clinically significant neglect, compared to 36% of patients with right hemisphere neglect reported in an earlier study by Azouvi et al. (2002). The three items “neglect of right limbs’, “dressing” and “mouth cleaning after eating” showed higher incidence of neglect among patients with left hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., whereas the item “collisions while moving” obtained lower neglect scores. This is in contrast to earlier studies with patients with right hemisphere neglect (Azouvi et al., 1996, 2002).

References

• Azouvi, P., Bartolomeo, P., Beis, J-M., Perennou, D., Pradat-Diehl, P., & Rousseaux, M. (2006). A battery of tests for the quantitative assessment of unilateral neglect. Restorative Neurology and Neuroscience, 24, 273-85.
• Azouvi, P., Marchal, F., Samuel, C., Morin, L., Renard, C., Louis-Dreyfus, A., Jokie, C., Wiart, L., Pradat-Diehl, P., Deloche, G., & Bergego, C. (1996). Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychological Rehabilitation, 6(2), 133-150.
• Azouvi, P., Olivier, S., de Montety, G., Samuel, C., Louis-Dreyfus, A., & Tesio, L. (2003). Behavioral assessment of unilateral neglect: Study of the psychometric properties of the Catherine Bergego Scale. Archives of Physical Medicine and Rehabilitation, 84, 51-7.
• Azouvi, P., Samuel, C., Louis-Dreyfus, A., Bernati, T., Bartolomeo, P., Beis, J-M., Chokron, S., Leclercq, M., Marchal, F., Martin, Y., de Montety, G., Olivier, S., Perennou, D., Pradat-Diehl, P., Prairial, C., Rode, G., Siéroff, E., Wiart, L., Rousseaux, M. for the French Collaborative Study Group on Assessment of Unilateral Neglect (GEREN/GRECO). (2002). Sensitivity of clinical and behavioral tests of spatial neglect after right hemisphere stroke. Journal of Neurology, Neurosurgery and Psychiatry, 73, 160-6.
• Bergego, C., Azouvi, P., Samuel, C., Marchal, F., Louis-Dreyfus, A., Jokie, C., Morin, L., Renard, C., Pradat-Diehl, P., & Deloche, G. (1995). Validation d’une échelle d’évaluation fonctionnelle de l’héminegligence dans la vie quotidienne: l’échelle CB. Annales de Readaptation et de Medecine Physique, 38, 183-9.
• Luukkainen-Markkula, R., Tarkka, I.M., Pitkänen, K., Sivenius, J., & Hämäläinen, H. (2011). Comparison of the Behavioral Inattention Test and the Catherine Bergego Scale in assessment of hemispatial neglect. Neuropsychological Rehabilitation, 21(1), 103-116.
• Menon, A. & Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Plummer, P., Morris, M. E., & Dunai, J. (2003). Assessment of unilateral neglect. Physical Therapy, 83, 732-40.
• Samuel, C., Louis-Dreyfus, A., Kaschel, R., Makiela, E., Troubat, M., Anselmi, N., Cannizzo, V., & Azouvi, P. (2000). Rehabilitation of very severe unilateral neglect by visuo-spatio-motor cueing: Two single case studies. Neuropsychological Rehabilitation, 10(4), 385-99.

See the measure

How to obtain the CBS

The Catherine Bergego Scale (CBS) can be viewed in the journal article:
Azouvi, P., Marchal, F., Samuel, C., Morin, L., Renard, C., Louis-Dreyfus, A., Jokie, C., Wiart, L., Pradat-Diehl, P., Deloche, G., & Bergego, C. (1996). Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychological Rehabilitation, 6(2), 133-150.

Purpose

The Comb and Razor Test screens for unilateral spatial neglect (USN) in the client’s personal space by assessing their performance in functional activities, such as using a comb or applying makeup.

In-Depth Review

Purpose of the measure

The Comb and Razor Test screens for unilateral spatial neglect (USN) in the client’s personal space by assessing their performance in functional activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
, such as using a comb or applying makeup.

Available versions

The Comb and Razor Test was published by Beschin and Robertson in 1997 and was developed from a test by Zoccolotti and Judica (1991) (Beschin & Robertson, 1997), which comprised of three tasks: hair combing, pretend shaving (men) or facial compact use (women) and putting on glasses.

Features of the measure

Items:
There are no actual items for the Comb and Razor Test. The patient is asked to demonstrate the use of two common objects for 30 seconds each: 1. comb and 2. razor or powder compact case. Each object is placed at the patient’s midline.

Comb (Males and Females)

• Examiner sits opposite to the patient and holds the comb up saying: “I would like you to comb your hair, and continue combing until I tell you to stop. Do you understand that? O.K., now begin”.
• Examiner activates the stopwatch as soon as the patient takes the comb.
• Examiner observes and records the number of moves on the left side and right side of the head. Any moves that are difficult to categorize are classified as ambiguous.
• At the end of 30 seconds, the examiner asks the patient to stop, and takes the comb from him or her.

Razor (Males)

• Examiner sits opposite to the patient and holds the razor up saying: “I am going to give you a razor, and I want you to pretend that you are shaving (razor with shield). I want you to continue shaving until I say stop. Do you understand?”
• Examiner activates the stopwatch as soon as the patient takes the razor.
• Examiner observes and records the number of moves on the left side and right side of the head. Any moves that are difficult to categorize are classified as ambiguous.
• At the end of 30 seconds, the examiner asks the patient to stop, and takes the razor from him.

Powder Compact Case (Females)

• Examiner sits opposite to the patient and holds the open powder compact case up saying: “I am going to give you a powder compact case and I want you to pretend that you are putting powder on your face. I want you to continue putting powder until I say stop. Do you understand?”
• Examiner activates the stopwatch as soon as the patient takes the powder compact case.
• Examiner observes and records the number of touches on the left side and right side of the head. Any touches that are difficult to categorize are classified as ambiguous.
• At the end of 30 seconds, the examiner asks the patient to stop, and takes the powder compact case from her.

Scoring:
There are two scoring methods available, the original Beschin and Robertson (1997) method and the preferred reformulated McIntosh et al. (2000) scoring method:

Beschin and Robertson (1997) scoring method:

The number of moves with the razor, comb or powder compact that are made to the left, right or ambiguously are recorded to calculate an average percentage for all three categories.

% left = (left moves) / (left + ambiguous + right moves)

The % left is calculated for the comb and razor/powder compact case, and the scores are combined in the formula below as the index for left personal neglect:

(razor/compact case % left) + (comb % left) / 2

A score < 0.35 indicates the presence of left personal neglect. A score > 0.35 indicates the absence of left personal neglect.

McIntosh et al. (2000) scoring method:

McIntosh, Brodie, Beschin, and Robertson (2000) developed a reformulated scoring method for the Comb and Razor Test, which is considered the preferred method:

% bias = (left – right moves) / (left + ambiguous + right moves)

The % bias formula yields a score between -1 (total left neglect) and +1 (total right neglect), with symmetrical performance at 0.

Time:
The Comb and Razor Test takes around 5 minutes to complete.

Training:
No training required.

Subscales:
None.

Equipment:

• One comb
• One razor with shield
• One powder compact case
• Stopwatch

Alternative forms of the Comb and Razor Test

Reformulated Comb and Razor Test (McIntosh, Brodie, Beschin, & Robertson, 2000).

McIntosh et al. (2000) examined a new method for scoring the Comb and Razor Test, which characterizes personal neglect as a lateral bias of behavior without further assumptions about the direction of bias, rather than as a lateralized deficit. The original % left formula of Beschin and Robertson (1997) (see scoring), characterizes personal grooming behavior according to the proportion of the total activity that is directed to the left side of the body. Conversely, the proposed %bias formula of McIntosh et al. (2000) yields a score between -1 (total left neglect) and +1 (total right neglect), with symmetrical performance at 0. The reformulated version of the Comb and Razor Test was able to discriminate between 17 right brain damaged patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and extra personal neglect from 14 right brain damaged patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. without extra personal neglect as well as both of these groups from left brain damaged patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and healthy controls. This version was also found to be more sensitive to the behavioral abnormalities of patients with brain damage than the original. In the %left index, 11 patients performed below cut-off, however with the %bias cut-off, 20 patients performed below cut-off. Further, all cases of personal neglect that were diagnosed using the %left index were also diagnosed using the %bias index. The test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for 40 patients tested twice was excellent (r = 0.95).

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Should not be used with:

• Patients who do not have unilateral voluntary movement and control of the shoulder, elbow, and fingers.
• Need to rule out the presence of apraxia, given that this may impact the validityThe degree to which an assessment measures what it is supposed to measure.
  of testing results.

In what languages is the measure available?

Not applicable.

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in personal space
What types of clients can the tool be used for?	Patients with stroke
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	Reformulated Comb and Razor Test
Other Languages	Not applicable.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Comb and Razor Test. Test-retest: Two studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Comb and Razor Test and both studies reported excellent test-retest. Inter-rater: No studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Comb and Razor Test.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Construct: Known groups: The Comb and Razor Test is able to discriminate between different groups of subjects (i.e. patients with right brain strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., with or without extra personal neglect, patients with left brain strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., as well as healthy individuals).
Does the tool detect change in patients?	Not applicable.
Acceptability	The Comb and Razor Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients who do not have unilateral voluntary movement and control of the shoulder, elbow, and fingers cannot complete the test.
Feasibility	The Comb and Razor Test requires no specialized training to administer and only simple equipment is required (a razor with shield, a compact case, a comb, and a stopwatch). The test is fairly simple to score and interpret, calculated using a mathematical equation. Cutoff scores for the presence of left or right neglect are provided.
How to obtain the tool?	Not applicable. To conduct the Comb and Razor Test, the clinician asks the patient to demonstrate the use of two common objects for 30 seconds each: 1. comb and 2. razor or powder compact case. Each object is placed at the patient’s midline. A dialogue has been created for administering the Comb and Razor Test. See Features of the measures in the in-depth review section.

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Comb and Razor Test as a measure of USN. Although easy to use, this tool has only minimal evidence of reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and validityThe degree to which an assessment measures what it is supposed to measure.
(Menon & Korner-Bitensky, 2004). Further studies examining the psychometric properties of the test have had small sample sizes. More testing is required prior to clinical use.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Comb and Razor Test.

Test-retest:
Beschin and Robertson (1997) examined the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of the Comb and Razor Test. Forty-three patients with stroke were assessed twice. In this study, the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Comb and Razor Test was excellent (r = 0.94).

McIntosh et al. (2000) examined the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of a reformulated version of the Comb and Razor Test and compared it to the original version by Beschin and Robertson (1997). Forty patients who were administered the test were reassessed at a later time. The original Comb and Razor Test had excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(r = 0.94).

Inter-rater:
No studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
of the Comb and Razor Test.

Validity

Construct:
Known groups:
Beschin and Robertson (1997) examined the psychometric properties of the Comb and Razor Test in 17 patients with right brain strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and extra personal neglect, 14 without unilateral extra personal neglect, 13 patients with left brain strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 17 age-matched controls. An analysis of variance (ANOVA) by group shows that the four samples of subjects significantly differed in their performance [F (3, 57) = 18.0; p < 0.0001]. A series of Fisher’s post hoc exact tests showed significant differences between all the pairs of groups, with the exception of the left brain damage group who did not differ significantly from the control group. Therefore, this tool is able to discriminate between different groups of subjects (i.e. patients with right brain strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., with or without extra personal neglect, patients with left brain stroke, as well as healthy individuals).

McIntosh et al. (2000) examined the validityThe degree to which an assessment measures what it is supposed to measure.
of a reformulated version of the Comb and Razor Test in 88 patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.: 17 with right brain damage and extra personal neglect, 14 with right brain damage and no extra personal neglect, 13 with left brain damage, and 44 age-matched controls. Mean scores for each group were as follows: patients with right brain damage and extra personal neglect scored 0.25, patients with right brain damage and no extra personal neglect scored 0.37, patients with left brain damage scored 0.46, and controls scored 0.43. An ANOVA by group performed upon the % left scores was highly significant [F (3, 84) = 27.54; p < 0.0001] and Fisher’s post-hoc exact tests found significant differences between all pairs of groups. Therefore, this tool is able to discriminate between different groups of subjects (i.e. patients with right brain strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., with or without extra personal neglect, patients with left brain strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., as well as healthy individuals).

Criterion;
No studies have examined the criterion validityExamines the extent to which a measure provides results that are consistent with a gold standard . It is typically divided into concurrent validity and predictive validity .
of the Comb and Razor Test.

Responsiveness

No studies have examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the Comb and Razor Test.

References

• Beschin, N., Robertson, I. H. (1997). Personal versusextrapersonal neglect: a group study of their dissociation using areliable clinical test. Cortex. 33, 379-384.
• McIntosh, R. D., Brodie, E. E., Beschin, N., et al. (2000). Improving the clinical diagnosis of personal neglect: a reformulated comb and razor test. Cortex, 36,
  289-292.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Zoccolotti, P., Judica, A. (1991). Functional evaluation of hemineglect by means of a semistructured scale: Personal extrapersonal differentiation. Neuropsychological Rehabilitation, 1, 33-34.
• Zoccolotti, P., Antonucci, G., Judica, A. (1992). Psychometric characteristics of two semi-structured scales for the functional evaluation of hemi-inattention in extrapersonal and personal Space. Neuropsychological Rehabil, 2, 179-191.

See the measure

To complete the comb and razor test, one simply requires a comb, razor, and powder compact case.

Purpose

The Double Letter Cancellation Test (DLCT) is used to evaluate the presence and severity of visual scanning deficits, and is used to evaluate unilateral spatial neglect (USN) in the near extrapersonal space (Diller, Ben-Yishay, Gertsman, Goodkin, Gordon, & Weinberg, 1974).

In-Depth Review

Purpose of the measure

The Double Letter Cancellation Test (DLCT) is used to evaluate the presence and severity of visual scanningDuring this intervention the person with USN is encouraged to conduct voluntary eye movements toward the neglected visual field (usually the left side) by performing a task in that hemispace. The treatment often includes a visual target that the patient uses as an anchor to direct voluntary gaze control while scanning.
deficits, and is used to evaluate unilateral spatial neglect (USN) in the near extrapersonal space (Diller, Ben-Yishay, Gertsman, Goodkin, Gordon, & Weinberg, 1974).

Available versions

The DLCT was published by Diller et al. in 1974.

Features of the measure

Items:
There are no actual items for the DLCT.

The patient is asked to look at an 8.5″x11″ sheet of paper containing 6 lines with 52 letters per line. Together, the stimuli letters C and E are presented 105 times. The patient is instructed to put a mark through all the letters C and E. The time taken to complete the test is recorded.

This test may be more challenging than cancellation of shapes or colours, since it requires the discrimination of 2 letters (C and E) from the rows of letters. The letters are arranged in structured rows and thus require less organizational skills than when the forms are randomly scattered on the page. This enables the therapist to examine more closely the issue of attention without the confounding factor of visual organization.

To begin the DLCT, the therapist places the test sheet at the patient’s midline and secures it with tape, and points to the trial line, asking the patient to mark the Cs and Es. If the patient is unable to perform the trial, further instruction is given. If the trial is correctly performed, the therapist will then proceed to give instructions as follows: “Look at the letters on this page. Put one line through each C and E. Ready, begin here”. The therapist points to the first letter in the first row and begins timing the patient.

Scoring:
The score is calculated by subtracting the number of omissions (Cs and Es that were not crossed out) from the possible perfect score of 105. Higher scores indicate better performance. The timing and total number of errors should be noted. According to Diller et al. (1974) 13 control subjects had a median error of 1 with a performance time of 100 seconds. Errors on the right with those on the left side of the page should be compared. Randomly scattered errors indicate poor sustained attention. Errors concentrated on one half of the page (either left or right) indicate USN. Commissions are rarely seen and are therefore not included in the analyses.

The patient’s general approach to the task should be observed (i.e. does the patient work from left to right or move randomly over the page; is their response time slowed; does the patient selectively choose the correct response or frequently mark non-target letters).

Normative data has been published by sex and age, based on the results from 241 patients with lesions of the right hemisphere (Gordon, Ruckdeschel-Hibbard, Egelko, Diller, Simmens, & Langer, 1984).

Time:
Less than 5 minutes.

Training:
None typically reported.

Subscales:
None.

Equipment:

• 11x 8.5-inch page of paper containing 6 lines with 52 letters per line and the stimulus letters C and E presented 105 times.
• Pencil
• Stopwatch

Alternative Forms of the DLCT

• Number version of the DLCT (Wade, Wood, & Hewer, 1988).p>A test similar to the DLCT has been created using numbers instead of letters. The patient is asked to cancel all the 1s and 4s from the rows of numbers. Normative data for this form of the DLCT was gathered from 51 elderly individuals (Wade et al., 1988).
• Letter cancellation subtest of the Behavioural Inattention Test (Wilson, Cockburn, & Halligan, 1987).
  The patient is presented with a sheet of paper with five lines of letters (34 per line). The patient is instructed to put a mark through all the letters E and R. The maximum score is 40 (20 left, 20 right).

Client suitability

Can be used with:

Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

• Patients must be able to hold a pencil to complete the test (the presence of apraxia may impair this ability).
• Patients must be able to recognize letters of the alphabet to complete the test.

Should not be used with:

• The DLCT requires language skills sufficient to identify letters. Therefore the DLCT may not be appropriate for patients with receptive aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury.
  An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada).
• The DLCT may not be appropriate for patients with poor vision as the letters may appear too small.
• The DLCT cannot be used to differentiate between sensory neglect and motor neglect because it requires both visual search and manual exploration (Ladavas, 1994).
• The DLCT cannot be completed by proxy.

In what languages is the measure available?

The DLCT has been used with English and French-speak patients.

A Hebrew version of the DLCT has been used in some studies as part of the Behavioral Inattention Test (e.g. Friedman & Nachman-Katz, 2004).

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the near extrapersonal space.
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	None.
Other Languages	The DLCT has been used with English and French-speak patients. A Hebrew version of the DLCT has been used in some studies as part of the Behavioural Inattention Test.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the DLCT. Test-retest: One study has examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the DLCT and reported adequate test-retest.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Construct: Adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with mean CT-scan damage.
Does the tool detect change in patients?	Not applicable.
Acceptability	The DLCT should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. – This test cannot be completed by proxy. The DLCT is known to be a more taxing measure of USN than the Single Letter Cancellation Test. Patients must be able to hold a pencil. The DLCT requires language skills sufficient to identify letters, and therefore may not be suitable for patients with receptive aphasiaAphasia is an acquired disorder caused by an injury to the brain and affects a person’s ability to communicate. It is most often the result of stroke or head injury. An individual with aphasia may experience difficulty expressing themselves when speaking, difficulty understanding the speech of others, and difficulty reading and writing. Sadly, aphasia can mask a person’s intelligence and ability to communicate feelings, thoughts and emotions. (The Aphasia Institute, Canada). Patients with poor vision may not be able to complete the DLCT as the letters may appear too small. The DLCT cannot be used to differentiate between sensory neglect and motor neglect.
Feasibility	The DLCT requires no specialized training to administer and only minimal equipment is required (a pencil, a stopwatch, and the test paper). The test is simple to score and interpret. No suggested cutoff score for the presence of USN is provided for the DLCT, however normative data has been published (see Gordon, Ruckdeschel-Hibbard, Egelko, Diller, Simmens, & Langer, 1984). The test is placed at the patient’s midline and is secured with tape. The time it takes for the patient to complete the test is recorded.
How to obtain the tool?	Please click here to see a copy of the DLCT.

Psychometric Properties

Overview

In general, cancellation tests are believed to have greater test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
than line bisection tests and are often more sensitive for detecting USN than line bisection tests (Marsh & Kersel, 1993; Azouvi et al., 2002). The DLCT has been reported to have adequate psychometric properties, including some evidence of reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and validity, in identifying USN in the near extrapersonal space (Menon & Korner-Bitensky, 2004). For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the DLCT.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No evidence.

Test-retest.:
Gordon et al. (1984) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the DLCT using a group of 31 subjects and found adequate test-retest (r = 0.62).

Validity

Construct:
Egelko et al. (1988) found that the DLCT correlated adequately with mean CT-scan damage (r = -0.35).

Note: This correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
is negative because a high score on the DLCT indicates better performance, whereas a high CT-scan score indicates more brain damage.

Criterion:
No evidence.

Responsiveness

No evidence.

References

• Azouvi, P., Samuel, C., Louis-Dreyfus, A., et al. (2002). Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. J Neurol Neurosurg Psychiatry, 73, 160 -166.
• Diller, L., Ben-Yishay, Y., Gerstman, L. J., Goodin, R., Gordon, W., Weinberg, J. (1974). Studies in scanning behavior in hemiplegia. Rehabilitation Monograph No. 50, Studies in cognition and rehabilitation in hemiplegia. New York: New York University Medical Center, Institute of Rehabilitation Medicine.
• Egelko, S., Gordon, W. A., Hibbard, M. R., Diller, L., Lieberman, A., Holliday, R., Ragnarsson, K., Shaver, M. S., Orazem, J. (1988). Relationship among CT scans, neurological exam, and neuropsychological test performance in right-brain-damaged stroke patients. J Clin Exp Neuropsychol, 10, 539-564.
• Friedmann, N., Nachman-Katz, I. (2004). Developmental neglect dyslexia in a hebrew-reading child. Cortex, 40(2), 301-313.
• Gordon, W. A., Ruckdeschel-Hibbard, M., Egelko, S., Diller, L., Simmens, S., Langer, K., Sano, M., Orazem, J., Weinberg, J. (1984). Single Letter Cancellation Test in Evaluation of the Deficits Associated with Right Brain Damage: Normative Data on the Institute of Rehabilitation Medicine Test Battery. pp1-7, New York: New York University Medical Center.
• Ladavas, E. (1994). The role of visual attention in neglect: A dissociation between perceptual and directional motor neglect. Neuropsychological Rehabilitation, 4, 155-159.
• Marsh, N. V., Kersel, D. A. (1993). Screening tests for visual neglect following stroke. Neuropsychological Rehabilitation, 3, 245-257.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Wade, D. T., Wood, V. A., Hewer, R. L. (1988). Recovery of cognitive function soon after stroke: A study of visual neglect, attention span and verbal recall. Journal of Neurology, Neurosurgery ,and Psychiatry, 51, 10-13.
• Wilson, B., Cockburn, J., Halligan, P. (1987). Development of a behavioural test of visuospatial neglect. Archives of Physical Medicine and Rehabilitation, 68, 98-102.

See the measure

How to obtain the DLCT?

The DLCT can be purchased as part of the Behavioral Inattention Test from Harcourt Assessment by clicking on the following link: http://www.harcourt-uk.com/product.aspx?skey=2906
Click here to view a copy of the DLCT as it appears in the Behavioral Inattention Test.

Purpose

The Draw-A-Man Test (Goodenough, 1926) has been widely used as a measure of intellectual maturation in children, to elicit personality type and unconscious material, and as part of neuropsychologic test batteries. The test has also been used to identify the presence of unilateral spatial neglect (USN) in adult patients post-stroke.

In-Depth Review

Purpose of the measure

The Draw-A-Man Test (Goodenough, 1926) has been widely used as a measure of intellectual maturation in children, to elicit personality type and unconscious material, and as part of neuropsychologic test batteries. The test has also been used to identify the presence of unilateral spatial neglect (USN) in adult patients post-stroke.

Available versions

The Draw-A-Man test was published by Goodenough in 1926.

Features of the measure

Items:
There are no actual items in the Draw-A-Man Test. Patients are given a blank piece of paper (8.5 x11) entitled “Draw an Entire Man” and pencil, and are asked to draw an entire man from memory.

Scoring:
Chen-Sea (2000) developed a new scoring method for the Draw-A-Man Test specifically for examining the presence of USN. Rather than use the original quantitative 10-point scoring method that was not able to distinguish patients with personal neglect from healthy controls, this new method scores drawings that show only homogenous unilateral body parts as having USN and those with homogenous bilateral body parts as normal. This scoring system was found to have a high inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
. Agreement between two raters was 95.45% for the participants without brain insult and 100% for the participants with stroke, demonstrating the ability for this scoring method to discriminate patients with personal neglect from those without personal neglect.

Time:
It takes less than 5 minutes to complete the Draw-A-Man Test.

Training:
The examiner must be able to distinguish homogenous unilateral body parts (indicates presence of USN) from homogenous bilateral body parts (indicates normal functioning), as drawn by the patient.

Subscales:
None.

Equipment:
A pencil and a blank piece of paper (8.5 x11) entitled “Draw an Entire Man”.

Alternative Forms of the Draw-A-Man Test

Quantitative 10-point scoring method of the Draw-A-Man Test.

• Using a blank piece of paper and a pencil, the seated patient must draw an entire man. The picture is scored by giving one point for the presence of each of the following body parts: head, trunk, right arm, left arm, right hand, left hand, right leg, left leg, right foot, and left foot. The total score of this version of the test is 10 (see Figure 1). This method has not been found to be able to distinguish patients with personal neglect from healthy controls (Chen-Sea, 1995b).

Figure 1. Perfect score of 10 points.

(Source: Chen-Sea, 2000)

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
• Patients must be able to hold a pencil to complete the test.

Should not be used with:

• Patients who have had a left stroke and patients who are left handed.
• Need to rule out the presence of apraxia, given that this may impact the validityThe degree to which an assessment measures what it is supposed to measure.
  of testing results.

In what languages is the measure available?

Not applicable.

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the personal and extrapersonal space (as well as the presence of anosagnosia). Other constructs: intellectual ability/cognitive function/body image.
What types of clients can the tool be used for?	Adults with stroke.
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	Quantitative 10-point scoring method of the Draw-A-Man Test
Other Languages	Not applicable.
Measurement Properties
Reliability	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Draw-A-Man Test. Test-retest: Two studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Draw-A-Man Test and both reported adequate test-retest. Inter-rater: One study examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Draw-A-Man Test and reported excellent inter-rater.
Validity	Construct: Convergent: Correlated with activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. performance measured by the Klein-Bell ADL Scale. Known groups: The Draw-A-Man Test was able to discriminate patients with personal neglect from those without personal neglect.
Does the tool detect change in patients?	Not applicable.
Acceptability	The Draw-A-Man Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients must be able to hold a pencil. Patients with hemiparesis on their dominant side may have difficulty completing the test.
Feasibility	The Draw-A-Man Test takes only 5 minutes to complete and requires minimal training to score (must be able to distinguish homogenous unilateral body parts from homogenous bilateral body parts). Only simple equipment is required (a pencil and paper).
How to obtain the tool?	All that is required is a blank piece of paper (8.5×11) entitled “Draw an Entire Man”, and a pencil. The patient is asked to draw an entire man from memory.

Psychometric Properties

Overview

The Draw-A-Man Test has rarely been used with patients with stroke in the right hemisphere to determine USN. For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Draw-A-Man Test as a measure of USN.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No evidence.

Test-retest:
Chen-Sea (1995, reported in Chen-Sea, 2000) administered the Draw-A-Man Test to 19 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. in a pilot study, and found that the test showed adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
(r = 0.50).

Gordon et al. (1984) also reported an adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for the Draw-A-Man Test (r= 0.62) in patients with right brain damage.

Inter-rater:
Chen-Sea (1995, reported in Chen-Sea, 2000) administered the Draw-A-Man Test to 19 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. in a pilot study, and found that the test showed excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
(r = 0.96).

Chen-Sea (2000) administered the Draw-A-Man Test to 51 patients with stroke and 110 age-matched controls without brain injury. The test had a high inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
, as two blinded raters had 96% agreement for the patients with neglect and 100% for those without neglect.

Validity

Criterion:
No evidence.

Construct:
Convergent:
Chen-Sea (2000) reported significant correlations of the Draw-A-Man Test with activities of daily living (ADL)Basic tasks that involve bodily issues (bathing, dressing, toileting, transferring, continence, eating and walking) that are done on a daily basis. performance measured by the Klein-Bell ADL Scale (Klein & Bell, 1979). Subjects with personal neglect had lower scores in five areas of ADL as compared to those without personal neglect.

Known groups:
Chen-Sea (2000) administered the Draw-A-Man Test to 51 patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 110 age-matched controls without brain injury and found that all of the controls were correctly classified as normal, and 13 of the 51 strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. patients were categorized as having USN. The results of this study demonstrate the ability of the Draw-A-Man Test to discriminate patients with personal neglect from those without personal neglect.

Responsiveness

No evidence.

References

• Chen-Sea, M-J. (1995a). Test-retest reliability of Draw-A-Man Test. Unpublished manuscript, National Cheng Kung University, Tainan, Taiwan.
• Chen-Sea, M-J. (1995b). Performance of normal and right CVA patients on Draw-A-Man Test. Unpublished manuscript, National Cheng Kung University, Tainan, Taiwan.
• Chen-Sea, MJ. (2000). Validating the Draw-A-Man Test as a personal neglect test. Am J Occup Therap, 54, 391-397.
• Goodenough, F. L. (1926). The measurement of intelligence by drawing. New York: World Books.
• Gordon, W. A., Ruckdeschel-Hibbard, M., Egelko, S., Diller, L., Simmens, S., Langer, K. (1984). Single Letter Cancellation Test in Evaluation of the Deficits Associated with Right Brain Damage: Normative Data on the Institute of Rehabilitation Medicine Test Battery. New York: New York University Medical Center.
• Klein, R. M., Bell, B. J. (1979). Klein-Bell Activity of Daily Living Scale: Manual. Seattle: Division of Occupational Therapy, University of Washington.

See the measure

How to obtain the Draw-A-Man Test?

All that is required is a blank piece of paper (8.5 x11) entitled “Draw an Entire Man”.

Purpose

The Line Bisection Test is a test is a quick measure to detect the presence of unilateral spatial neglect (USN). To complete the test, one must place a mark with a pencil through the center of a series of horizontal lines. Usually, a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect.

In-Depth Review

Purpose of the measure

The Line Bisection Test is a test is a quick measure to detect the presence of unilateral spatial neglect (USN). To complete the test, one must place a mark with a pencil through the center of a series of horizontal lines. Usually, a displacement of the bisection mark towards the side of the brain lesion is interpreted as a symptom of neglect.

Available versions

There are many versions of the Line Bisection Test, and the procedures are rarely standardized, with the exception of when the Line Bisection Test is used as an item within a standardized test battery (Plummer, Morris, & Dunai, 2003).

The relationship between abnormal line bisection and visual neglect has been observed for over a century (e.g. Axenfeld, 1894; Liepmann & Kalmus, 1900). In 1980, Schenkenberg, Bradford, and Ajax formally evaluated this method of detecting the presence of visual neglect in patients with lesions of the non-dominant hemisphere, and are thought to be the first to statistically evaluate this method.

Features of the measure

Items:
Patients are asked to place a mark with a pencil (with their preferred or unaffected hand) through the center of a series of 18 horizontal lines on an 11x 8.5-inch page.

Scoring:
The test is scored by measuring the deviation of the bisection from the true center of the line. A deviation of more than 6 mm from the midpoint indicates USN. Omission of two or more lines on one half of the page indicates USN.

Time:
The test takes less than 5 minutes to complete.

Training:
None typically reported.

Subscales:
None.

Equipment:

• 11x 8.5-inch page of paper with 18 horizontal lines
• Pencil

Alternative form of the Line Bisection Test

The Line Bisection Test can be presented in various forms. Some studies use 18 horizontal lines, while others have used a single line (Parton, Malhotra & Husain, 2004), or a series of 10 lines (Ferber & Karnath, 2001). The Line Bisection Test is also offered as part of some standardized test batteries such as within the Behavioural Inattention Test (Wilson, Cockburn, Halligan, 1987; Schubert & Spatt, 2001).

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
• Patients must be able to hold a pencil in order to complete the task (the presence of apraxia may impair this ability).

Should not be used with:

• The Line Bisection Test should be used with caution in the clinical diagnosis of spatial neglect:
  Ferber and Karnath (2001) found that deviation in line bisection was not apparent in 40% of the patients in their sample that had severe neglect. In comparison, each of the four cancellation tests administered in this study (Line Crossing, Letter Cancellation, Star Cancellation Test and Bells Test) missed 6% of the subjects and may be preferred over the Line Bisection Test for diagnosing USN.
• Performance on the Line Bisection Test may be influenced by or may be indicative of other syndromes besides spatial neglect, such as hemianopia (damage of optic pathways that result in loss of vision in half of the visual field) (Ferber & Karnath, 2001). Consequently, the Line Bisection Test is not a highly specific measure of USN.

In what languages is the measure available?

Not applicable.

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the extrapersonal space
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	There are many versions of the Line Bisection Test, and the procedures are rarely standardized, with the exception of when the Line Bisection Test is used as an item within a standardized test battery such as in the Behavioural Inattention Test.
Other Languages	Not applicable.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Test-retest: Four studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Line Bisection Test. Three studies reported excellent test-retest and one study reported adequate test-retest.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: One study reported that when the Line Bisection Test was compared to other cancellation tests, the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” of the test for detecting visuo-spatial neglect in elderly patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. was 76.4%. Construct: Convergent: Excellent correlations with Albert’s Test and the Baking Tray Task. Adequate correlations with the Star Cancellation Test and with mean CT-scan damage. Poor correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Clock Drawing Test.
Does the tool detect change in patients?	Not applicable.
Acceptability	The Line Bisection Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Performance on the Line Bisection Test may be influenced by or may be indicative of other syndromes besides spatial neglect, such as hemianopia. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients must be able to hold a pencil to complete.
Feasibility	The Line Bisection Test takes only 5 minutes to complete and is simple to score. Only simple equipment is required (a pencil and paper with 18 horizontal lines).
How to obtain the tool?	The Line Bisection Test can be purchased as part of the Behavioural Inattention Test from Pearson Assessment by clicking on the following link:http://pearsonassess.ca/haiweb/Cultures/en-CA/Products/Product+Detail.htm?CS_Category=&CS_Catalog=TPC-CACatalog&CS_ProductID=749129972

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Line Bisection Test. The test has been evaluated in many studies for its criterion validityExamines the extent to which a measure provides results that are consistent with a gold standard . It is typically divided into concurrent validity and predictive validity .
, resulting in evidence of its strong psychometric properties in comparison to other paper-and-pencil tests (Menon & Korner-Bitensky, 2004).

Reliability

Test-retest:
Schenkenberg et al. (1980) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Line Bisection Test in patients with right-hemisphere lesions, diffuse lesions, left-hemisphere lesions, and hospital controls, and found that it had excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
, ranging from r = 0.84 to r = 0.93.

Similarly, Chen-Sea and Henderson (1994) reported an excellent test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of r = 0.93 for the Line Bisection Test.

Kinsella, Packer, Ng, Olver, and Stark (1995) found adequate test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
for the Line Bisection Test (Pearson r = 0.64).

Bailey, Riddoch and Crome (2004) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Line Bisection Test in elderly patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (85 patients with neglect and 83 patients without neglect). Patients repeated the test within the hour. The intraclass correlation coefficient (ICC)Intraclass correlation (ICC) is used to measure inter-rater reliability for two or more raters. It may also be used to assess test-retest reliability. ICC may be conceptualized as the ratio of between-groups variance to total variance. was excellent for patients with neglect (ICC = 0.97).

Validity

Criterion:
Bailey, Riddoch, and Crome (2000) found that when the Line Bisection Test was compared to other cancellation tests, the sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of the test for detecting visuo-spatial neglect in elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. was 76.4%.

Construct:
Marsh and Kersel (1993) examined the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the Line Bisection Test by correlating the test with the Star Cancellation Test using Pearson’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
in a sample of 27 rehabilitation patients with a history of stroke. The two measures were found to have an adequate negative correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r = -0.40). The correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
is negative because a high score on the Line Bisection Test indicates USN, however a score close to 0 on the Star Cancellation Test indicates the absence of USN.

Egelko et al. (1988) correlated Line Bisection Test scores with mean CT-scan damage, and CT-scan damage of temporal lobe, parietal lobe, and occipital lobe. All correlations were found to be adequate (r = -0.44, -0.59,-0.37, and -0.42, respectively).

Friedman (1990) examined whether the Line Bisection Test correlated with functional outcome in 82 elderly patients within 14 days of a non-lacunar strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. At discharge assessment, patients with impaired line bisection had poorer functional outcome than those with normal line bisection as measured by Barthel Index scores, walking speed and discharge destination. When subjects with impaired line bisection were divided into two groups according to line bisection score, the severely impaired had worse functional outcome than the mildly impaired.

Convergent:
Agrell, Dehlin, and Dahlgren (1997) compared the performance of 57 elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. on 5 different tests for visuo-spatial neglect (Star Cancellation Test, Line Crossing-Albert’s Test, Line Bisection, Clock Drawing Test and Copy A Cross). The Line Bisection Test had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with Line Crossing-Albert’s Test (r = 0.85) and correlated adequately with the Star Cancellation Test (r = -0.33).

Bailey, Riddoch, and Crome (2000) administered the Line Bisection Test and the Baking Tray Task to 107 patients with right or left sided brain damage and 43 age-matched controls. The Baking Tray Task had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Line Bisection Test (r = -0.66). This correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
is negative because a high score on the Line Bisection Test indicates the presence of USN, whereas a high score on the Baking Tray Task indicates normal performance.

Binder, Marshall, Lazer, Benjamin, and Mohr (1992) compared the performance on line bisection with that on Letter Cancellation in a group of 34 patients with right-sided brain damage. They found no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
(r = 0.39) between the scores in the two tests.

Similarly, Schubert and Spatt (2001) found that in 20 patients with right hemisphere strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., no significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between the Line Bisection Test and the Star Cancellation Test were found (r = 0.48). Furthermore, five patients with impaired performance on one of the tests were within the normal range on the other one.

Ishiai, Sugishita, Ichikawa, Gono, and Watabiki (1993) examined the construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the Clock Drawing Test and found that it had a poor correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Line Bisection Test (r = 0.05).

Known groups:
Schenkenberg et al. (1980) reported that Line Bisection Test performance can discriminate between patients with right-hemisphere lesions and patients with diffuse lesions, patients with left-hemisphere lesions, and hospital controls.

Responsiveness

No evidence.

References

• Agrell, B. M., Dehlin, O. I., Dahlgren, C. J. (1997). Neglect in elderly stroke patients: a comparison of five tests. Psychiatry Clin Neurosci, 51(5), 295-300.
• Axenfeld, D. (1894). Eine einfache Methode Hemianopsie zu constatiren. Neurol Centralbl, 437-438.
• Bailey, M. J., 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.
• Bailey, M. J., Riddoch, M. J., Crome, P. (2004). Test-retest stability of three tests for unilateral visual neglect in patients with stroke: Star Cancellation, Line Bisection, and the Baking Tray Task. Neurophsychological Rehabilitation, 14(4), 403-419.
• Barton, J. J. S., Black, S. E. (1998). Line bisection in hemianopia. J Neurol Neurosurg Psychiatry, 64, 660-662.
• Binder, J., Marshall, R., Lazar, R., Benjamin, J., Mohr, J. P. (1992). Distinct syndromes of hemineglect. Archiv Neurology, 49, 1187-1194.
• Chen-Sea, M. J., Henderson, A. (1994). The reliability and validity of visuospatial inattention tests with stroke patients. Occup Ther Int, 1, 36-48.
• Egelko, S., Gordon, W. A., Hibbard, M. R., Diller, L., Lieberman, A., Holliday, R., Ragnarsson, K., Shaver, M. S., Orazem, J. (1988). Relationship among CT scans, neurological exam, and neuropsychological test performance in right-brain-damaged stroke patients. J Clin Exp Neuropsychol, 10, 539-564.
• Ferber, S., Karnath, H. O. (2001). How to assess spatial neglect–Line Bisection or Cancellation Tests? J Clin Expl Neuropsychol, 23, 599-607.
• Friedman, P. J. (1990). Spatial neglect in acute stroke: the Line Bisection Test. Scand J Rehabil Med, 22, 101-106.
• Ishiai,S., Sugishita, M., Ichikawa, T., Gono, S., Watabiki, S. (1993). Clock-drawing test and unilateral spatial neglect. Neurology. 43, 106-110.
• Kinsella, G., Packer, S., Ng, K., Olver, J., Stark, R. (1995). Continuing issues in the assessment of neglect. Neuropsychological Rehabilitation, 5(3), 239-258.
• Liepmann, H., Kalmus, E. (1900). Ãœber einer Augenma beta störung beu Hemianopikern. Berlin Klin Wochenschr, 38, 838-842.
• Marsh, N. V., Kersel, D. A. (1993). Screening tests for visual neglect following stroke. Neuropsychological Rehabilitation, 3, 245-257.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Parton, A., Malhotra, P., Husain, M. (2004). Hemispatial neglect. J Neurol Neurosurg Psychiatry, 75, 13-21.
• Plummer, P., Morris, M. E., Dunai, J. (2003). Assessment of unilateral neglect. Phys Ther, 83(8), 732-740.
• Schenkenberg, T., Bradford, D. C., Ajax, E. T. (1980). Line bisection and unilateral visual neglect in patients with neurological impairment. Neurology. 30, 509-517.
• Schubert, F., Spatt, J. (2001). Double dissociations between neglect tests: Possible relation to lesion site. Eur Neurol, 45, 160-164.
• Wilson, B. A., Cockburn, J., Halligan, P. W. (1987). Behavioural Inattention Test. Titchfield, Hants, England: Thames Valley Test Company Ltd.

See the measure

How to obtain the Line Bisection Test?

Click here to obtain a copy of the Line Bisection Test

The Line Bisection Test can be purchased as part of the Behavioural Inattention Test from Pearson Assessment by clicking on the following link: Pearson Assessment

Purpose

The Semi-Structured Scale for the Functional Evaluation of Hemi-inattention is a screening tool used to detect the presence of unilateral spatial neglect (USN) in both the personal and extra personal space. In this scale, patients must perform functional activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
, such as using a comb or serving tea.

In-Depth Review

Purpose of the measure

The Semi-Structured Scale for the Functional Evaluation of Hemi-inattention is a screeningTesting for disease in people without symptoms.
tool used to detect the presence of unilateral spatial neglect (USN) in both the personal and extra personal space. In this scale, patients must perform functional activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
, such as using a comb or serving tea.

Available versions

The Semi-Structured Scale for the Functional Evaluation of Hemi-inattention was published by Zoccolotti, Antonucci, and Judica in 1992.

Features of the measure

Items:
Patients are asked to perform different tasks with real objects.

To assess personal neglect, patients must demonstrate the use of three common objects: comb, razor/powder compact, and eyeglasses. The objects are placed at the patient’s midline one at a time and is asked:

• “Show me how you comb your hair?”
• “Show me how to use the razor?” (male) or “Show me how to powder yourself?” (female)
• “Show me how to put the eyeglasses on?”

To assess extra personal neglect, patients must serve tea, deal cards, describe a picture, and describe an environment. The patient is asked to perform these activities with objects that are provided on a table.

1. Serving tea.
   The patient is brought to a table with a tray containing 4 cups and saucers, a teapot, a sugar bowl, teaspoons, and paper napkins. Examiners are seated on the right, in front, and to the left of the patient who is asked to serve tea for him/herself and for those who are with him/her, to distribute napkins and teaspoons, and also to serve the sugar. The examiner, who is seated in front of the patient asks: “Would you like to serve the tea?”. If the patient serves the tea but not the napkins and/or teaspoons, the examiner asks: “Would you like to give us the teaspoons (napkins)?”.
2. Card dealing.
   The examiners and the patient are seated the same way as they were for the tea-serving situation. The patient is asked if he/she knows how to play “Scopa”. If necessary, he/she is reminded of the basic rules (3 cards for each player and 4 in the middle of the table).
   Note: As Scopa is an Italian card game, as an alternative, other card games featuring four players can be used. The examiner seated in front of the patient asks: “Would you like to deal the cards for a game of Scopa?”.
3. Picture description.
   A picture is placed in front of the patient and he/she is asked: “Will you describe everything you see in this picture?”. Three pictures are used. Two are cards 3 and 6 (45 x 32 cm) of Set 1 of the Progressive Picture Compositions by Byrne (1967); one is Tissot’s painting ‘The dance on the ship’ (60 x 100 cm). The examiner indicates the persons and objects pointed out by the patient with progressive numbers on a photocopy of the stimulus figure in the order in which they are reported, without soliciting in any way. When the description is finished, the patient is asked: “Well, what does this picture represent?”. The patients’ response is transcribed but it does not contribute to the score.
4. Description of an environment.
   The patient is placed in a room full of objects on both sides (arm chairs, pictures, lamps) and is asked to describe it. The patient is told: “Will you describe everything you see in this room?”. To facilitate scoring, it is useful to record the elements described by the patient on a schematic drawing of the environment.

Scoring:
Patients receive a score ranging from 0 to 3 for each item based on the symmetry of his or her performance. A total score is calculated for each subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
.

• Personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
  : A score of 0 indicates normal performance, 1 indicates slight asymmetry, 2 indicates clear omissions, and 3 indicates significant reduction in space explored. The maximum score that can be achieved is 9. A total score greater than the cutoff of 1 indicates the presence of personal neglect.
• Extra personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
  : A score of 0 indicates normal performance, 1 indicates slight asymmetries, uncertainty, or slowness in space explored, 2 indicates clear omissions, and 3 indicates significant reduction in space explored. The maximum score that can be achieved is 12. A total score greater than the cutoff of 3 indicates the presence of extra personal

Time:
It takes approximately 5 minutes to complete the personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
and 15 minutes to complete the extra personal neglect subscale

Training:
The therapist must be trained on how to use the rating scale.

Subscales:
Personal neglect and extra personal (spatial) neglect.

Equipment:

• Comb
• Razor/Powder compact
• Eyeglasses
• Tea set
• Playing cards
• Picture

Alternative forms of the Semi-Structured Scale for the Functional Evaluation of Hemi-inattention

None.

Client suitability

Can be used with:

• Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

Should not be used with:

• Patients who do not have unilateral voluntary movement and control of the shoulder, elbow, and fingers cannot be assessed for the presence of personal neglect.
• Patients who do not have unilateral voluntary movement and control of shoulder, elbow, and fingers, language, cognition, or visual perceptual skills cannot be assessed for the presence of extra personal It may be challenging for patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. to perform these high-level activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function.
  soon after strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., however this scale may become more useful as the patient approaches discharge from acute care (Menon & Korner-Bitensky, 2004).
• Need to rule out the presence of apraxia, given that this may impact the validityThe degree to which an assessment measures what it is supposed to measure.
  of testing results.
• A proxy respondent cannot be used because the measure is dependent on observed completion of each task.

In what languages is the measure available?

Not applicable.

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in both the personal and extra personal space.
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screeningTesting for disease in people without symptoms. or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	It takes approximately 5 minutes to complete the personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). and 15 minutes to complete the extra personal neglect subscale.
Versions	None.
Other Languages	Not applicable.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: One study examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Semi-Structured Scale and found adequate internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.. Test-retest: No studies have examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Semi-Structured Scale. Inter-rater: One study examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Semi-Structured Scale and reported excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. .
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: The extra personal subscale correlated with the Line Cancellation Test, Letter Cancellation Test, Wundt-Jastrow Area Illusion Test, and Sentence Reading Test. The personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). did not correlated with these conventional diagnostic tests and requires further validation.
Does the tool detect change in patients?	Although the scale is typically used as a screeningTesting for disease in people without symptoms. measure, one study examined the responsivenessThe ability of an instrument to detect clinically important change over time. of the scale and found that the personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). was not responsive to clinical change following rehabilitation; however the extra personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). was responsive to clinical change after rehabilitative treatment.
Acceptability	Both subscales cannot be completed by patients who do not have unilateral voluntary movement and control of the shoulder, elbow, and fingers. Furthermore, the extra personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). cannot be completed by patients with deficits in language, cognition, or visual perception. Although it may be challenging for patients to perform these high-level activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. soon after their strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., this scale may become more useful to screen patients before they are discharged home from acute care or rehabilitation. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy.
Feasibility	The Semi-Structured Scale is one of the longer scales used to detect USN, and the personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). requires further validation. The scale is simple to score, however training is required regarding how to use the rating scale. Simple and readily accessible equipment is required to complete the scale (Comb, Razor/Powder compact, Eyeglasses, Tea set, Playing cards, Picture).
How to obtain the tool?	Not applicable. To administer the personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). of the Semi-Structured Scale, the clinician asks the patient to demonstrate the use of 3 common objects: comb, razor/powder compact, and eyeglasses. The objects are placed at the patient’s midline one at a time. To administer the extra personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society). , patients must serve tea, deal cards, describe a picture, and describe an environment. The patient is asked to perform these activitiesAs defined by the International Classification of Functioning, Disability and Health, activity is the performance of a task or action by an individual. Activity limitations are difficulties in performance of activities. These are also referred to as function. with objects that are provided on a table. A dialogue has been created for administering the Semi-Structured Scale and can be found under the tab ‘in-depth review – features of the measure’.

Psychometric Properties

Overview

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Semi-Structured Scale for the Functional Evaluation of Hemi-inattention as a measure of USN. Although easy to use, this tool has only minimal evidence of validity (Menon & Korner-Bitensky, 2004). More testing is required regarding the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and validity of the scale.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. (inter-item correlations):
Zoccolotti et al. (1992) assessed the inter-item correlations of the scale and found that items within the personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
had adequate correlations ranging from r = 0.57 to r = 0.62, and items within the extra personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
had adequate correlations ranging from r = 0.44 to r = 0.71.

Test-retest:
No evidence.

Inter-rater:
Zoccolotti et al. (1992) found excellent inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
for both the personal neglect items and extra personal neglect items of the scale (r = 0.88 and r = 0.96, respectively). However, in this study, raters underwent intense training, which may limit the generalizability of these findings.

Validity

Criterion:
Concurrent:
Zoccolotti et al. (1992) assessed the concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard."
of the scale by comparing correlations of the personal and extra personal subscales with performance on four standard diagnostic tests for USN: Line Cancellation Test, Letter Cancellation Test, Wundt-Jastrow Area Illusion Test, and Sentence Reading Test. The extra personal subscale correlated with each conventional test (kendall tau = -0.60; -0.52; 0.20; and -0.40, respectively). Performance on the personal subscale did not correlate with performance on these conventional tests. According to the authors, the failure of the personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
to correlate with conventional tests suggests that conventional and personal tests measure different dimensions of neglect. The personal subscale requires further validation.

Responsiveness

Zoccolotti et al. (1992) examined the responsivenessThe ability of an instrument to detect clinically important change over time.
of the scale and found that the personal neglect subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
was not responsive to clinical change following rehabilitation; however the extra personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
was responsive to clinical change after rehabilitative treatment.

References

• Byrne, D. (1967). Progressive Picture Compositions. Picture Set 1. Burn Mill, Harlow: Longman.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Plummer, P., Morris, M. E., Dunai, J. (2003). Assessment of unilateral neglect. Phys Ther, 83(8), 732-740.
• Tissot, J. il ballo sulla nave. Reproduction on canvas. Series: Maestri della Tavolozza, n. 1295 HH, Milano: Amilcare Pizzi.
• Zoccolotti, P, Judica, A. (1991). Functional evaluation of hemineglect by means of a semistructured scale: personal extrapersonal differentiation. Neuropsychological Rehabilitation, 1, 33-44.
• Zoccolotti, P., Antonucci, G., Judica, A. (1992). Psychometric characteristics of two semi-structured scales for the functional evaluation of hemi-inattention in extrapersonal and personal space. Neuropsychological Rehabilitation, 2, 179-191.

See the measure

How to obtain the Semi-Structured Scale for the Functional Evaluation of Hemi-inattention?

Not applicable.

Purpose

The Single Letter Cancellation Test (SLCT) is used to evaluate the presence and severity of visual scanning deficits, and is used to evaluate unilateral spatial neglect (USN) in the near extra personal space (Diller, Ben-Yishay, Gertsman, Goodkin, Gordon, & Weinberg, 1974).

In-Depth Review

Purpose of the measure

The Single Letter Cancellation Test (SLCT) is used to evaluate the presence and severity of visual scanning deficits, and is used to evaluate unilateral spatial neglect (USN) in the near extra personal space (Diller, Ben-Yishay, Gertsman, Goodkin, Gordon, & Weinberg, 1974).

Available versions

The SLCT was published by Diller et al. in 1974.

Features of the measure

Items:
There are no actual items for the SLCT.

The test consists of one 8.5 x 11 sheet of paper containing 6 lines with 52 letters per line. The stimulus letter H is presented 104 times. The page is placed at the patient’s midline. The patient is told to put a line through each H that is found on the page. The time taken to complete the test is recorded.

Scoring:
The score is calculated by subtracting the number of omissions (H’s that were not crossed out) from the possible perfect score of 104 (0 to 53 on the left and 0 to 51 on the right). Higher scores indicate better performance. Presence of USN can be inferred by calculating the frequency of errors to the left or to the right from the center of the page. Omissions of 4 or more have been found to be pathological (Zoccolotti, Antonucci, Judica, Montenero, Pizzamiglio, & Razzano, 1989). Commissions are rarely seen and are therefore not included in the analyses.

Normative data has been published by sex and age, based on the results from 341 patients with lesions of the right hemisphere (Gordon, Ruckdeschel-Hibbard, Egelko, Diller, Simmens, & Langer, 1984).

Normative data has been published by sex and age, based on the results from 341 patients with lesions of the right hemisphere (Gordon, Ruckdeschel-Hibbard, Egelko, Diller, Simmens, & Langer, 1984).

Time:
Less than 5 minutes.

Training:
None typically reported.

Subscales:
None.

Equipment:

• 11x 8-inch page of paper containing 6 lines with 52 letters per line and the stimulus letter H presented 104 times (53 times on left, 51 on right).
• Pencil
• Stopwatch

Alternative forms of the SLCT

None typically reported.

Client suitability

Can be used with: Patients with stroke.

• Patients must be able to hold a pencil to complete the test (the presence of apraxia may impair this ability).
• Patients must be able to recognize letters of the alphabet to complete the test.

Should not be used with:

• The SLCT cannot be used to differentiate between sensory neglect and motor neglect because it requires both visual search and manual exploration (Ladavas, 1994).
• The SLCT cannot be completed by proxy.

In what languages is the measure available?

The SLCT has been used with English and French-speak patients.

A Hebrew version of the SLCT has been used in some studies as part of the Behavioral Inattention Test (e.g. Friedman & Nachman-Katz, 2004).

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the near extra personal space.
What types of clients can the tool be used for?	Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..
Is this a screening or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Less than 5 minutes.
Versions	None.
Other Languages	The SLCT has been used with English and French-speak patients. A Hebrew version of the SLCT has been used in some studies as part of the Behavioral Inattention Test.
Measurement Properties
Reliability	Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the SLCT. Test-retest: One study has examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the SLCT and reported adequate test-retest.
Validity	Construct: Adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with mean CT-scan damage; adequate to excellent correlations with Albert’s Test , Sentence Reading Test, and the Wundt-Jastrow Area Illusion Test; significant correlation with the Semi-Structured Scale for the Functional Evaluation of Hemi-inattention.
Does the tool detect change in patients?	Not applicable.
Acceptability	The SLCT should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients must be able to hold a pencil and recognize letters of the alphabet to complete. The SLCT cannot be used to differentiate between sensory neglect and motor neglect.
Feasibility	The SLCT requires no specialized training to administer and only minimal equipment is required (a pencil, a stopwatch, and the test paper). The test is simple to score and interpret. A suggested cutoff score for the presence of USN is provided (omissions of 4 or more). The test is placed at the patient’s midline and the time it takes for the patient to complete the test is recorded.
How to obtain the tool?	Please click here to see a copy of the SLCT.

Psychometric Properties

Overview

In general, cancellation tests are believed to have greater test-retest reliability than line bisection tests and are often more sensitive for detecting USN than line bisection tests (Marsh & Kersel, 1993; Azouvi et al., 2002). The SLCT has been reported to have strong psychometric properties, including reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
and validity, in identifying USN in the near extra personal space (Menon & Korner-Bitensky, 2004). For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of SLCT.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No evidence.

Test-retest:
Gordon, Ruckdeschel-Hibbard, Egelko, Diller, Simmens, and Langer (1984) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the SLCT using a group of 31 subjects and found adequate test-retest (r = 0.63).

Validity

Construct:
Egelko et al. (1988) found that the SLCT correlated adequately with mean CT-scan damage (r = -0.35).
Note: This correlation is negative because a high score on the SLCT indicates better performance, whereas a high CT-scan score indicates more damage.

Zoccolotti, Antonucci, Judica, Montenero, Pizzamiglio, and Razzano (1989) found that correlations between the SLCT and other visuo-spatial tests (Albert’s Test , Sentence Reading Test, and the Wundt-Jastrow Area Illusion Test) ranged from adequate to excellent (ranging from r = 0.36 to r = 0.69). The SLCT was found to be the most sensitive among these tests in detecting USN (from 4.1% to 25%), which may be due to the high density of stimuli used.

Zoccolotti, Antonucci, and Judica (1992) found that the SLCT correlated with the Extra personal subscaleMany measurement instruments are multidimensional and are designed to measure more than one construct or more than one domain of a single construct. In such instances subscales can be constructed in which the various items from a scale are grouped into subscales. Although a subscale could consist of a single item, in most cases subscales consist of multiple individual items that have been combined into a composite score (National Multiple Sclerosis Society).
of Semi-Structured Scale for the Functional Evaluation of Hemi-inattention (Kendal’s tau = -0.52).
Note: This correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
is negative because a high score on the SLCT indicates better performance, whereas a high score on the Semi-Structured Scale indicates the presence of USN.

Criterion:
No evidence.

Responsiveness

No evidence.

References

• Azouvi, P., Samuel, C., Louis-Dreyfus, A., et al. (2002). Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. J Neurol Neurosurg Psychiatry, 73, 160 -166.
• Diller, L., Ben-Yishay, Y., Gerstman, L. J., Goodin, R., Gordon, W., Weinberg, J. (1974). Studies in scanning behavior in hemiplegia. Rehabilitation Monograph No. 50, Studies in cognition and rehabilitation in hemiplegia. New York: New York University Medical Center, Institute of Rehabilitation Medicine.
• Egelko, S., Gordon, W. A., Hibbard, M. R., Diller, L., Lieberman, A., Holliday, R., Ragnarsson, K., Shaver, M. S., Orazem, J. (1988). Relationship among CT scans, neurological exam, and neuropsychological test performance in right-brain-damaged stroke patients. J Clin Exp Neuropsychol, 10, 539-564.
• Friedman, N., Nachman-Katz, I. (2004). Developmental neglect dyslexia in a hebrew-reading child. Cortex, 40(2), 301-313.
• Gordon, W.A., Ruckdeschel-Hibbard, M., Egelko, S., Diller, L., Simmens, S., Langer, K. (1984). Single Letter Cancellation Test in Evaluation of the Deficits Associated with Right Brain Damage: Normative Data on the Institute of Rehabilitation Medicine Test Battery. New York: New York University Medical Center.
• Ladavas, E. (1994). The role of visual attention in neglect: A dissociation between perceptual and directional motor neglect. Neuropsychological Rehabilitation, 4, 155-159.
• Marsh, N. V., Kersel, D. A. (1993). Screening tests for visual neglect following stroke. Neuropsychological Rehabilitation, 3, 245-257.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Zoccolotti, P., Antonucci, G., Judica, A., Montenero, P., Pizzamiglio, L., Razzano, C. (1989). Incidence and evoluation of the hemi-negelct disorder in chronic patients with unilateral right brain damage. Int J Neurosci, 47, 209-216.

See the measure

How to obtain the Single Letter Cancellation Test?

Please click here to see a copy of the SLCT.

Purpose

The Star Cancellation Test is a screeningTesting for disease in people without symptoms.
tool that was developed to detect the presence of unilateral spatial neglect (USN) in the near extra personal space in patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

In-Depth Review

Purpose of the measure

The Star Cancellation Test is a screeningTesting for disease in people without symptoms.
tool that was developed to detect the presence of unilateral spatial neglect (USN) in the near extra personal space in patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Available versions

The Star Cancellation Test was developed by Wilson, Cockburn, and Halligan in 1987.

Features of the measure

Items:
There are no actual items to the Star Cancellation Test. In the Star Cancellation Test, the stimuli are 52 large stars, 13 letters, and 10 short words interspersed with 56 smaller stars (see figure below). The patient must cross out with a pencil all the small stars on an 8.5″ x 11″ piece of paper. Two small stars in the centre are used for demonstration. The page is placed at the patient’s midline.

Scoring:
The maximum score that can be achieved on the test is 54 points (56 small stars in total minus the 2 used for demonstration). A cutoff of < 44 indicates the presence of USN. A Laterality Index or Star Ratio can be calculated from the ratio of stars cancelled on the left of the page to the total number of stars cancelled. Scores between 0 and 0.46 indicate USN in the left hemispace. Scores between 0.54 and 1 indicate USN in the right hemispace

Time:
Less than 5 minutes.

Training:
None typically reported.

Subscales:
None.

Equipment:

• The test paper (8.5″x11″ page with 52 large stars, 13 letters, and 10 short words interspersed with 56 smaller stars).
• Pencil

Alternative forms of the Star Cancellation Test

Laterally extended version of the Star Cancellation Test (Small, Cowey, & Ellis, 1994). In this version of the test, the section in the traditional version of the Star Cancellation Test extending from the midline to the right side of the page is duplicated at the right end (i.e. the display area is extended twice as far to the right of midline as to the left). The dimensions of the test paper in this version are 41 cm x 21 cm.

Client suitability

Can be used with: Patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain..

• Patients must be able to hold a pencil to complete the test (the presence of apraxia may impair this ability).
• Patients must be able to visually discriminate between distractor items such as the words and big stars, and the small stars that are to be cancelled.

Should not be used with:

• As with other cancellation tests, the Star Cancellation Test cannot be used to differentiate between sensory neglect and motor neglect because it requires both visual search and manual exploration (Ladavas, 1994).
• The Star Cancellation Test cannot be completed by proxy.

In what languages is the measure available?

The words included in the Star Cancellation Test can be translated into the patients’ native language (Linden, Samuellson, Skoog, & Blomstrand, 2005).

Summary

What does the tool measure?	Unilateral Spatial Neglect (USN) in the near extra personal space.
What types of clients can the tool be used for?	Patients with stroke.
Is this a screening or assessment tool?	Screening.
Time to administer	Less than 5 minutes.
Versions	Laterally extended version of the Star Cancellation Test
Other Languages	The words can be translated into the patients’ native language.
Measurement Properties
Reliability	Internal consistency: No studies have examined the internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the Star Cancellation Test. Test-retest: One study has examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). of the Star Cancellation Test and reported excellent test-retest. Inter-rater: No studies have examined the inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept. of the Star Cancellation Test.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Predictive: One study reported that out of 4 different measures of USN (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph), the Star Cancellation Test was the best predictor of functional outcome. Construct: Convergent: The Star Cancellation Test correlated adequately with the Barthel Index, the Line Bisection Test, the Clock Drawing Test, and the Copy A Cross Test. The test had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. with the Line Crossing Test and with the Indented Paragraph test.
Does the tool detect change in patients?	Not applicable.
Acceptability	The Star Cancellation Test should be used as a screeningTesting for disease in people without symptoms. tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validityThe degree to which an assessment measures what it is supposed to measure. of test results. This test cannot be completed by proxy. Patients must be able to hold a pencil and visually discriminate between distractor items to complete. The measure cannot be used to differentiate between sensory neglect and motor neglect.
Feasibility	The Star Cancellation Test requires no specialized training to administer and only minimal equipment is required (a pencil and the test paper). The test is simple to score and interpret (counting the number of small stars cancelled by patient out of a total of 54). A suggested cutoff score for the presence of USN is provided (< 44 indicates the presence of USN). The test is placed at the patient’s midline and the 2 small stars in the middle are used for demonstration.
How to obtain the tool?	Please click here to see a copy of the Star Cancellation Test.

Psychometric Properties

Overview

A review of the Star Cancellation Test reported that the measure has excellent construct and criterion validityExamines the extent to which a measure provides results that are consistent with a gold standard . It is typically divided into concurrent validity and predictive validity .
, however, little published data exist on the reliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
of this measure (Menon & Korner-Bitensky, 2004). In general, cancellation tests with distractors (e.g. the big stars in the Star Cancellation Test) are thought to be more sensitive measures of USN than cancellation tests without distractors (e.g. Albert’s Test), and are believed to have greater test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
than line bisection tests (Marsh & Kersel, 1993; Azouvi et al., 2002).

For the purposes of this review, we conducted a literature search to identify all relevant publications on the psychometric properties of the Star Cancellation Test.

Reliability

Internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
No evidence.

Test-retest:
Bailey, Riddoch, and Crome (2004) examined the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the Star Cancellation Test in elderly patients post-stroke (85 with neglect, 83 without neglect). For patients with neglect, the test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
was excellent (Intraclass Correlation Coefficient = 0.89).

Intra-rater:
No evidence.

Inter-rater:
No evidence.

Validity

Criterion :
Marsh and Kersel (1993) examined the sensitivity of four different measures of visual neglect (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph) in a sample of elderly patients with stroke. The Star Cancellation Test was found to be the most sensitive measure of visual neglect (100%) when compared with the other tests.

Bailey, Riddoch, and Crome (2000) compared cancellation measures of USN (Star Cancellation Test, Line Bisection Test, Baking Tray Task, Exploratory Motor Task, Copying a Daisy and Clock Drawing Task) that were administered to 107 patients with right or left sided brain damage and 43 age-matched controls. In this study, the Star Cancellation Test and Line Bisection Test had the highest relative sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
for visuo-spatial neglect (76.4%) when compared to the other cancellation tests.

Halligan, Wilson, and Cockburn (1990) examined the internal structure of the measures that comprise the Behavioural Inattention Test (BIT). Out of the 15 tests that comprise the BIT, the Letter Cancellation Test and Star Cancellation Test were the most sensitive measures, identifying 74% of patients with neglect.

Predictive :
Marsh and Kersel (1993) examined the predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of four different measures of visual neglect (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph) in a sample of elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. In this study, the Star Cancellation Test was found to be the best predictor of functional outcome (r = 0.55) as measured by the modified Barthel Index of Self-Care (Mahoney & Barthel, 1965).

Construct:
Convergent:
Agrell, Dehlin, and Dahlgren (1997) compared five tests of visuo-spatial neglect (Star Cancellation Test, Line Crossing Test, Line Bisection Test, Clock Drawing Test, and Copy A Cross Test) and the Barthel Index in 57 elderly patients using Spearman’s correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. In this study, the Star Cancellation Test correlated adequately with the Barthel Index (r = 0.48), the Line Bisection Test (r = -0.33), the Clock Drawing Test (r = -0.47) and the Copy A Cross Test (r = -0.47). The test had an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the Line Crossing Test score (r = 0.63).
Note: Some correlations are negative because a high score on the Star Cancellation Test indicates normal performance, whereas a high score on some other measures of visual neglect indicates the presence of USN.

Marsh and Kersel (1993) examined correlations between four measures of visual neglect (Line Crossing Test, Line Bisection Test, Star Cancellation Test, and Indented Paragraph) in a sample of elderly patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Excellent correlations were found between the Star Cancellation Test and the Line Crossing Test (r = 0.68) and with the Indented Paragraph test (r = -0.60). An adequate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
was found with the Line Bisection Test (r = -0.40).
Note: Some correlations are negative because a high score on the Star Cancellation Test indicates normal performance, whereas a high score on some other measures of visual neglect indicates the presence of USN.

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
:
Jehkonen et al. (1998) examined the specificity of the Star Cancellation Test in 52 patients with a first-ever single acute right hemisphere strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. In this study, using the specific cutoff score for detecting the presence of USN, the Star Cancellation test had a diagnostic sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity."
of 80% and a diagnostic specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of 91%. Out of all of the USN measures examined in this study (Star Cancellation; Figure Copying; Letter Cancellation; Representational drawing; Line Crossing; Line Bisection), the Star Cancellation Test was the best single test for diagnosing USN, and misdiagnosed only 4 patients with neglect and 3 patients who did not have neglect.

Responsiveness

No evidence.

References

• Agrell, B. M., Dehlin, O. I., Dahlgren, C. J. (1997). Neglect in elderly stroke patients: a comparison of five tests. Psychiatry Clin Neurosci, 51(5), 295-300.
• Azouvi, P., Samuel, C., Louis-Dreyfus, A., et al. (2002). Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. J Neurol Neurosurg Psychiatry, 73, 160 -166.
• Bailey, M. J., 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.
• Bailey, M. J., Riddoch, M. J., Crome, P. (2004). Test-retest stability of three tests for unilateral visual neglect in patients with stroke: Star Cancellation, Line Bisection, and the Baking Tray Task. Neuropsychological Rehabilitation, 14(4), 403-419.
• Halligan, P., Wilson, B., Cockburn, J. (1990). A short screening test for visual neglect in stroke patients. Int Disabil Stud, 12(3), 95-99.
• Jehkonen, M., Ahonen, J. P., Dastidar, P., Koivisto, A. M., Laippala, P., Vilkki, J. (1998). How to detect visual neglect in acute stroke. The Lancet, 351, 727.
• Ladavas, E. (1994). The role of visual attention in neglect: A dissociation between perceptual and directional motor neglect. Neuropsychological Rehabilitation, 4, 155-159.
• Linden, T., Samuellson, H., Skoog, I., Blomstrand, C. (2005). Visual neglect and cognitive impairment in elderly patients late after stroke. Acta Neurol Scand, 111, 163-168.
• Mahoney, F. I., Barthel, D. W. (1965). Functional evaluation: The Barthel Index. Md State Med J, 14, 61-5.
• Mark, V. W., Woods, A. J., Ball, K. K., Roth, D. L., Mennemeier, M. (2004). Disorganized search on cancellation is not a consequence of neglect. Neurology, 63, 78-84.
• Marsh, N. V., Kersel, D. A. (1993). Screening tests for visual neglect following stroke. Neuropsychological Rehabilitation, 3, 245-257.
• Menon, A., Korner-Bitensky, N. (2004). Evaluating unilateral spatial neglect post stroke: Working your way through the maze of assessment choices. Topics in Stroke Rehabilitation, 11(3), 41-66.
• Small, M., Cowey, A., Ellis, S. (1994). How lateralized is visuospatial neglect? Neuropsychologia, 32(4), 449-464.
• Wilson, B., Cockburn, J., Halligan, P. (1987). Development of a behavioral test of visuospatial neglect. Arch Phys Med Rehabil, 68, 98-101.

See the measure

How to obtain the Star Cancellation Test?

Please click here to see a copy of the measure.

Purpose

The Sunnybrook Neglect Assessment Procedure (SNAP) is a test battery to screen for neglect in patients with acute stroke (Black et al., 2016).

In-Depth Review

Purpose of the measure

The Sunnybrook Neglect Assessment Procedure (SNAP) is a test battery for bedside screening of neglect. It is designed to assess neglect in patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and to monitor recovery of neglect at later stages of strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. recovery.

Available versions

There is one version of the SNAP.

Features of the measure

Items:
The SNAP is comprised of five paper-and-pencil items that are familiar measures of neglect. The items are administered to the patient in the following order:

1. Spontaneous drawing of clock and daisy
2. Line cancellation task
3. Line bisection task
4. Copying of clock and daisy
5. Shape cancellation

Description of tasks:
A1. Drawing task
The patient is asked to draw a clock face and a daisy on a blank piece of paper.

B. Line Cancellation Task
The patient is instructed to cross out all lines on a page.

C. Line Bisection Task
The patient is instructed to draw a mark on a line in order to bisect the line in half. This task is completed using 15cm and 20cm lines.

A2. Copying Tasks
The patient is asked to copy a picture of a clock and a daisy.
Note: The assessor does not identify that the pictures are a clock and a daisy.

D. Shape Cancellation Task
The patient is required to circle all the targets on a page.
Note: This is a timed task. The patient is given a different color pencil after every tenth target is circled, to determine the search pattern.

Scoring and score interpretation:
The scoring of the different SNAP subtests is based on omissions made on the contralateral side of the brain lesion. Left-side omissions are scored in patients in right hemisphere stroke and right-side omissions are scored in left hemisphere stroke.

A. Copying and drawing tasks
Drawings with a significant omission of details on the contralateral side are scored as having neglect.

B. Line Cancellation
Each omitted line on the contralateral side of the page is scored as neglect.

C. Line Bisection
The score for this task is based on the mean percent deviation of the patient’s mark from the true midpoint. Percent deviation and average deviation is calculated for the four lines of the task, according to the formula stipulated in the SNAP manual.

D.Shape cancellation task
All targets omitted on the contralateral side of the page are counted.

Total score interpretation:

Scores are calculated using the SNAP scoring manual. The patient is awarded a score for each subtest, resulting in a total score out of 100.

Leibovitch et al. (2012) recommended classifying severity of neglect according to performance on the SNAP as follows:

SNAP Score	Classification of Performance
0-5	Normal Performance
6-40	Mild Neglect
41-100	Severe Neglect

Please see the SNAP Administration and Scoring Manual for more details on scoring (Black et al., 2016).

What to consider before beginning:
SNAP test items should always be placed in the individual’s midline.

Time:
Time taken to administer the assessment has not been specified. Time will vary according to the patient’s attention and severity of neglect.

Training:
Training requirements have not been specified.

Subscales:
None.

Equipment:

• SNAP assessment package
• Two blank sheets of paper
• Coloured pens/pencils
• Stopwatch

Alternative forms of the SNAP

The original version of the Sunnybrook Neglect Assessment contained additional drawing tasks, a paragraph reading task, a writing task and additional visual search tasks. The four items that comprise the SNAP were deemed to be complementary and not redundant, so the additional items were eliminated (Leibovitch et al., 2012).

Client suitability

Can be used with:

• Patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..

Should not be used with:

• Not specified.

In what languages is the measure available?

English.

Summary

What does the tool measure?	Hemispatial neglect
What types of clients can the tool be used for?	Patients in the acute phase of stroke recovery.
What ICF domain is measured?	Impairment.
Is this a screening or assessment tool?	ScreeningTesting for disease in people without symptoms. .
Time to administer	Not specified.
Versions	There is one version of the SNAP.
Languages	English.
Measurement Properties
ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of “true” variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to “noise” in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .	Internal Consistency: One study reported moderate to excellent correlations between subtests and the total score. Test-retest: No studies have reported on test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society). among patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Intra-rater/inter-rater: One study reported adequate to excellent correlations for subtests and the total score.
ValidityThe degree to which an assessment measures what it is supposed to measure.	Criterion: Concurrent: No studies have reported on concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also "gold standard." of the SNAP among patients with strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain.. Predictive: One study reported that the SNAP significantly predicted neglect (present/absent) on the visual search board (VSB) visual search task. Construct: – One study reported a moderate correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. among SNAP subtests. – Two studies have conducted factor analysis and found that all subtests loaded on one factor that accounted for 69-72% of the variance. Convergent/Discriminant: – One study reported adequate correlations with the visual search board (VSB) visual search task. – One study reported a significant correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between neglect measured by the SNAP and parietal damage. – One study reported an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation. between the SNAP and a measure of generalized attentional capacity (digit span forward minus digit span backward). Known groups: One study reported significant differences in performance on the SNAP according to side of lesion.
Floor/Ceiling Effects	No studies have reported on floor/ceiling effects among patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain..
SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also "Specificity." / SpecificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).	– One study reported 68% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.” and 76% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). . – Two studies reported that the shape cancellation task was the most sensitive subtest; a third study reported that the line bisection task was the most sensitive subtest. – One study reported that the drawing/copying subtests showed highest specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative). .
Does the tool detect change in patients?	The tool does not detect or measure change but it can be used to monitor change in neglect over time.
Acceptability	The SNAP is simple to administer and can be used at the individual’s bedside.
Feasibility	The SNAP is portable, quick to administer and requires minimal equipment.
How to obtain the tool?	The SNAP administration and scoring manual and test booklet can be accessed here

Psychometric Properties

Overview

A literature search was conducted to identify all relevant publications on the psychometric properties of the Sunnybrook Neglect Assessment Procedure (SNAP) for use with patients with strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Five articles were reviewed.

Floor/Ceiling Effects

Leibovitch et al (2012) examined psychometric properties of the SNAP in a sample of 224 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. and 100 elderly individuals. Results from the population of elderly individuals without strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. showed no omissions of details on the drawing/copying subtests and no omissions on the line cancellation subtest.

Reliability

Internal ConsistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency.:
Leibovitch et al (2012) examined internal consistencyA method of measuring reliability . Internal consistency reflects the extent to which items of a test measure various aspects of the same characteristic and nothing else. Internal consistency coefficients can take on values from 0 to 1. Higher values represent higher levels of internal consistency. of the SNAP in a sample of 224 stroke patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using Cronbach’s coefficient alpha. All subtests showed an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
with the total neglect score (alpha = 0.84, p < 0.001) and correlations between subtests were moderate (alpha < 0.07, p < 0.0005). This indicates that subtests are measuring the same construct but are not redundant.

Test-retest:
There are no studies of test-retest reliabilityA way of estimating the reliability of a scale in which individuals are administered the same scale on two different occasions and then the two scores are assessed for consistency. This method of evaluating reliability is appropriate only if the phenomenon that the scale measures is known to be stable over the interval between assessments. If the phenomenon being measured fluctuates substantially over time, then the test-retest paradigm may significantly underestimate reliability. In using test-retest reliability, the investigator needs to take into account the possibility of practice effects, which can artificially inflate the estimate of reliability (National Multiple Sclerosis Society).
of the SNAP among patients with stroke.

Intra-rater/inter-rater:
Leibovitch et al (2012) examined intra-rater and inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
in a sample of 12 patients with acute stroke and 12 elderly individuals. Intra-rater reliabilityThis is a type of reliability assessment in which the same assessment is completed by the same rater on two or more occasions. These different ratings are then compared, generally by means of correlation. Since the same individual is completing both assessments, the rater's subsequent ratings are contaminated by knowledge of earlier ratings.
was measured with 1 rater and inter-rater reliabilityA method of measuring reliability . Inter-rater reliability determines the extent to which two or more raters obtain the same result when using the same instrument to measure a concept.
was measured between 2 raters. ReliabilityReliability can be defined in a variety of ways. It is generally understood to be the extent to which a measure is stable or consistent and produces similar results when administered repeatedly. A more technical definition of reliability is that it is the proportion of "true" variation in scores derived from a particular measure. The total variation in any given score may be thought of as consisting of true variation (the variation of interest) and error variation (which includes random error as well as systematic error). True variation is that variation which actually reflects differences in the construct under study, e.g., the actual severity of neurological impairment. Random error refers to "noise" in the scores due to chance factors, e.g., a loud noise distracts a patient thus affecting his performance, which, in turn, affects the score. Systematic error refers to bias that influences scores in a specific direction in a fairly consistent way, e.g., one neurologist in a group tends to rate all patients as being more disabled than do other neurologists in the group. There are many variations on the measurement of reliability including alternate-forms, internal consistency , inter-rater agreement , intra-rater agreement , and test-retest .
was measured using Kappa statistics for drawing/copying tasks and interclass correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases - for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases - for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficients for other scores. The authors reported adequate to excellent correlations for subtests and the total score (r = 0.73-0.99, p < 0.001); specific statistics were not provided.

Validity

Content:
Development of the SNAP is not reported.

Criterion:
Concurrent:
No studies have reported on concurrent validityTo validate a new measure, the results of the measure are compared to the results of the gold standard obtained at approximately the same point in time (concurrently), so they both reflect the same construct. This approach is useful in situations when a new or untested tool is potentially more efficient, easier to administer, more practical, or safer than another more established method and is being proposed as an alternative instrument. See also “gold standard.”
of the SNAP among patients with stroke.

Predictive:
Leibovitch et al (2012) examined predictive validityA form of criterion validity that examines a measure’s ability to predict some subsequent event. Example: can the Berg Balance Scale predict falls over the following 6 weeks? The criterion standard in this example would be whether the patient fell over the next 6 weeks.
of the SNAP by comparison with the visual search board (VSB) visual search task (Kimura, 1986) in a sample of 224 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using logistic regression. Comparison of test results showed that the SNAP significantly predicted neglect (present/absent) on the VSB.

Construct:
Black et al. (1995) examined construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the SNAP in a sample of 294 patients with acute stroke. SNAP subtest scores correlated significantly (r = 0.4-0.6, p = 0,0001). Initial factor analysis showed that all four tests contributed to a single factor which accounted for 72% of the information contained in the four subtests.

Leibovitch et al. (2012) examined construct validityReflects the ability of an instrument to measure an abstract concept, or construct. For some attributes, no gold standard exists. In the absence of a gold standard , construct validation occurs, where theories about the attribute of interest are formed, and then the extent to which the measure under investigation provides results that are consistent with these theories are assessed.
of the SNAP in a sample of 224 strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain. patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using factor analysis of subtest scores. Results revealed all subtests loaded equally on one factor that accounted for 69.4% of the total variance (eigenvalue = 2.8). Further factor analysis according to side of brain injury similarly showed that, among patients with right hemisphere damage, all four subtests loaded equally on one factor that accounted for 69% of the total variance. Results of patients with left hemisphere damage revealed two factors accounting for 62% of the total variance: the first factor comprised three subtests (drawing/copying, line cancellation and shape cancellation) and accounted for 37% of total variance; the second factor (line bisection) accounted for 25% of the total variance.

Convergent/Discriminant:
Leibovitch et al. (2012) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the SNAP by comparison with the visual search board (VSB) visual search task (Kimura, 1986) in a sample of 224 patients with acute stroke, using Receiver Operating Characteristic analysis. Results showed adequate validityThe degree to which an assessment measures what it is supposed to measure.
(area under curve = 0.78).

Leibovitch et al. (1998) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the SNAP by comparison with location and severity of brain damage on CT and SPECT scans in a sample of 120 patients with acute/subacute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using regression analysis. Results showed that damage to the parietal and anterior cingulate cortex was a significant predictor of neglect using CT data (p<0.05), whereas regional blood flow in the parietal cortex was the best predictor of neglect using SPECT data (p<0.05).

Eskes et al. (2003) examined convergent validityA type of validity that is determined by hypothesizing and examining the overlap between two or more tests that presumably measure the same construct. In other words, convergent validity is used to evaluate the degree to which two or more measures that theoretically should be related to each other are, in fact, observed to be related to each other.
of the SNAP by comparison with a measure of generalized attentional capacity (digit span forward minus digit span backward) in a sample of 9 patients with acute to chronic strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain., using Spearman correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
coefficient. Results showed an excellent correlationThe extent to which two or more variables are associated with one another. A correlation can be positive (as one variable increases, the other also increases – for example height and weight typically represent a positive correlation) or negative (as one variable increases, the other decreases – for example as the cost of gasoline goes higher, the number of miles driven decreases. There are a wide variety of methods for measuring correlation including: intraclass correlation coefficients (ICC), the Pearson product-moment correlation coefficient, and the Spearman rank-order correlation.
between measures (r=0.85, p<0.02).

Known groups:
Black et al. (1995) administered the SNAP to 294 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Comparison of incidence of neglect between patients with right hemisphere damage vs. patients with left hemisphere damage was 54% vs. 31% (respectively). Performance on SNAP subtests differed significantly between groups: Shape cancellation: 74% vs. 54% (respectively); Line bisection: 61% vs. 35 % (respectively); Line cancellation: 26% vs. 7% (respectively); and Drawing: 25% vs. 3% (respectively).

Responsiveness

SensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
/specificity:
Black et al. (1990) used a modified version of the SNAP in a sample of 41 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain. (n=21 with right hemisphere damage). The tool comprised the standard SNAP subtests as well as two additional tasks (designs cancellation, visual search). Results showed that the line bisection task was the most sensitive subtest, with neglect observed in 76% and 30% of individuals with right and left hemisphere damage respectively. While the line bisection subtest was most likely to detect mild impairment, the line drawing and line cancellation subtests indicated more severe impairment.

Black et al (1995) administered the SNAP to 294 patients with acute strokeAlso called a "brain attack" and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a "schemic stroke", or the formation of a blood clot in a vessel supplying blood to the brain.. Comparison of incidence of neglect between patients with right hemisphere damage vs. left hemisphere damage was 54% vs. 31% (respectively). Results indicate that the shape cancellation subtest was the most sensitive subtest, with neglect observed in 74% and 54% of individuals with right and left hemisphere damage respectively. The line bisection subtest revealed neglect in 61% and 35% of individuals with right and left hemisphere damage respectively.

Leibovitch et al. (2012) evaluated sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
of the SNAP in a sample of 224 patients with acute strokeAlso called a “brain attack” and happens when brain cells die because of inadequate blood flow. 20% of cases are a hemorrhage in the brain caused by a rupture or leakage from a blood vessel. 80% of cases are also know as a “schemic stroke”, or the formation of a blood clot in a vessel supplying blood to the brain., using the visual search board (VSB) visual search task (Kimura, 1986) to confirm neglect. Overall, the SNAP showed 68% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
and 76% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
. The shape cancellation task showed highest sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
(70% sensitivitySensitivity refers to the probability that a diagnostic technique will detect a particular disease or condition when it does indeed exist in a patient (National Multiple Sclerosis Society). See also “Specificity.”
); the drawing/copying tasks showed highest specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
(99% specificitySpecificity refers to the probability that a diagnostic technique will indicate a negative test result when the condition is absent (true negative).
).

References

• Black, S.E., Vu, B., Martin, D., & Szalai, J.P. (1990). Evaluation of a bedside battery for hemispatial neglect in acute stroke [Abstract]. Journal of Clinical and Experimental Neuropsychology, 12, 109.
• Black, S., Ebert, P. L., Leibovitch, F., Szalai, J. P., & Blair, N. (1995). Recovery in hemispatial neglect [Abstract]. Neurology, 45(suppl 4), A178.
• Black, S. E., Leibovitch, F. S., Ebert, P. L., & L., B. K. (2016). SNAP : Sunnybrook Neglect Assessment Procedure Administration and Scoring Manual.
• Eskes, G.A., Butler, B., McDonald, A., Harrison, E.R., & Phillips, S.J. (2003). Limb activation effects in hemispatial neglect. Archives of Physical Medicine and Rehabilitation, 84, 323-8.
• Leibovitch, F.S., Black, S.E., Caldwell, C.B., Ebert, P.L., Ehrlich, L.E., & Szalai, J.P. (1998). Brain-behaviour correlations in hemispatial neglect using CT and SPECT: the Sunnybrook stroke study. Neurology, 50, 901-8.
• Leibovitch, F. S., Vasquez, B. P., Ebert, P. L., Beresford, K. L., & Black, S. E. (2012). A short bedside battery for visuoconstructive hemispatial neglect: Sunnybrook Neglect Assessment Procedure (SNAP). Journal of Clinical and Experimental Neuropsychology, 34(4), 359-68. doi:10.1080/13803395.2011.645016
• Menon-Nair, A., Korner-Bitensky, N., & Ogourtsova, T. (2007). Occupational Therapists’ identification, assessment, and treatment of unilateral spatial neglect during stroke rehabilitation in Canada. Stroke, 38, 2556-62. DOI: 10.1161/STROKEAHA.107.484857

See the measure

How to obtain the SNAP

The SNAP administration and scoring manual and test booklet can be accessed here.