Albert’s Test

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

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