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

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 activities, 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 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.

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 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).

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 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). .
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 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). 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 validityThe degree to which an assessment measures what it is supposed to measure.
(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 validityThe degree to which an assessment measures what it is supposed to measure.
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 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).
correlated with each conventional test (kendall tau = -0.60; -0.52; 0.20; and -0.40, respectively). Performance on 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 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 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.

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.