Star Cancellation 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 Star Cancellation Test is a screening tool that was developed to detect the presence of unilateral spatial neglect (USN) in the near extra personal space in patients with stroke.

In-Depth Review

Purpose of the measure

The Star Cancellation Test is a screening tool that was developed to detect the presence of unilateral spatial neglect (USN) in the near extra personal space in patients with stroke.

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 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 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
  • No studies have examined the internal consistency of the Star Cancellation Test.
  • One study has examined the test-retest reliability of the Star Cancellation Test and reported excellent test-retest.
  • No studies have examined the inter-rater reliability of the Star Cancellation Test.
Validity

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 correlation with the Line Crossing Test and with the Indented Paragraph test.

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.

Does the tool detect change in patients? Not applicable.
Acceptability The Star Cancellation 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 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 validity, however, little published data exist on the reliability 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 reliability 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 consistency:

No evidence.

Test-retest:

Bailey, Riddoch, and Crome (2004) examined the test-retest reliability of the Star Cancellation Test in elderly patients post-stroke (85 with neglect, 83 without neglect). For patients with neglect, the test-retest reliability was excellent (Intraclass Correlation Coefficient = 0.89).

Intra-rater:

No evidence.

Inter-rater:

No evidence.

Validity

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 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 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 stroke. 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 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.

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 sensitivity 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 validity 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. 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).

Sensitivity and Specificity:

Jehkonen et al. (1998) examined the specificity of the Star Cancellation Test in 52 patients with a first-ever single acute right hemisphere stroke. In this study, using the specific cutoff score for detecting the presence of USN, the Star Cancellation test had a diagnostic sensitivity of 80% and a diagnostic specificity 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. 

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