Comb and Razor Test

Evidence Reviewed as of before: 19-08-2008
Author(s): Lisa Zeltzer, MSc OT; Anita Menon, MSc
Editor(s): Nicol Korner-Bitensky, PhD OT; Elissa Sitcoff, BA BSc

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 activities, 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) x 100

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 stroke and extra personal neglect from 14 right brain damaged patients with stroke without extra personal neglect as well as both of these groups from left brain damaged patients with stroke 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 reliability for 40 patients tested twice was excellent (r = 0.95).

Client suitability

Can be used with:

Patients with stroke.

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 validity 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 screening or assessment tool? Screening.
Time to administer Less than 5 minutes.
Versions Reformulated Comb and Razor Test
Other Languages Not applicable.
Measurement Properties
Reliability
  • No studies have examined the internal consistency of the Comb and Razor Test.
  • Two studies have examined the test-retest reliability of the Comb and Razor Test and both studies reported excellent test-retest.
  • No studies have examined the inter-rater reliability of the Comb and Razor Test.
Validity

Construct:

Known groups:

The Comb and Razor Test is able to discriminate between different groups of subjects (i.e. patients with right brain stroke, with or without extra personal neglect, patients with left brain stroke, 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 screening tool rather than for clinical diagnosis of USN. Apraxia must be ruled out as this may affect the validity 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 reliability and validity (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 consistency:

No studies have examined the internal consistency of the Comb and Razor Test.

Test-retest:

Beschin and Robertson (1997) examined the reliability of the Comb and Razor Test. Forty-three patients with stroke were assessed twice. In this study, the test-retest reliability of the Comb and Razor Test was excellent (r = 0.94).

McIntosh et al. (2000) examined the reliability 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 reliability (r = 0.94).

Inter-rater:

No studies have examined the inter-rater reliability 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 stroke and extra personal neglect, 14 without unilateral extra personal neglect, 13 patients with left brain stroke 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 stroke, with or without extra personal neglect, patients with left brain stroke, as well as healthy individuals).

McIntosh et al. (2000) examined the validity of a reformulated version of the Comb and Razor Test in 88 patients with stroke: 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 stroke, with or without extra personal neglect, patients with left brain stroke, as well as healthy individuals).

Criterion;

No studies have examined the criterion validity of the Comb and Razor Test.

Responsiveness

No studies have examined the responsiveness 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.

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