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

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 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 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.

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 subscale.

  • Personal neglect subscale: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 subscale: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 subscale 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 stroke.

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 stroke to perform these high-level activities soon after stroke, 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 validity 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 stroke.
Is this a screening or assessment tool? Screening.
Time to administer It takes approximately 5 minutes to complete the personal neglect subscale and 15 minutes to complete the extra personal neglect subscale.
Versions None.
Other Languages Not applicable.
Measurement Properties
Reliability
  • One study examined the internal consistency of the Semi-Structured Scale and found adequate internal consistency.
  • No studies have examined the test-retest reliability of the Semi-Structured Scale.
  • One study examined the inter-rater reliability of the Semi-Structured Scale and reported excellent inter-rater reliability.
Validity

Construct:

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 subscale 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 screening measure, one study examined the responsiveness of the scale and found that the personal neglect subscale was not responsive to clinical change following rehabilitation; however the extra personal subscale 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 subscale 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 activities soon after their stroke, 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 validity 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 subscale 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 subscale 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 subscale, 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. 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 reliability and validity of the scale.

Reliability

Internal consistency (inter-item correlations):

Zoccolotti et al. (1992) assessed the inter-item correlations of the scale and found that items within the personal subscale had adequate correlations ranging from r = 0.57 to r = 0.62, and items within the extra personal subscale 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 reliability 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

Construct:

Concurrent:

Zoccolotti et al. (1992) assessed the concurrent validity 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 subscale to correlate with conventional tests suggests that conventional and personal tests measure different dimensions of neglect. The personal subscale requires further validation.

Criterion:

No evidence.

Responsiveness

Zoccolotti et al. (1992) examined the responsiveness of the scale and found that the personal neglect subscale was not responsive to clinical change following rehabilitation; however the extra personal subscale 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.

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