Revising the Kessler Foundation Neglect Assessment Process Manual: A Guidebook to Assessing Spatial Neglect.

Background: Spatial neglect (SN) is present in about 20% patients in acute stroke units. If left unidentified SN may obstruct rehabilitation. The 10-item Catherine Bergego Scale (CBS) is increasingly recommended for SN assessment and has excellent psychometric properties. However, a standardized assessment with the CBS takes around 30-40 minutes to complete, making it rather unrealistic for nurses and physicians to use in the fast pace of the stroke unit. Objectives: To test a revised protocol for the CBS to make its routine use feasible in acute stroke units. We will: a). Compare the time used to administer the original version of the CBS with the simplified version of the CBS (sCBS), b). evaluate the agreement between the results of the CBS and sCBS, c). establish the interrater agreement between two rates, R1+R2, when scoring the sCBS, and d). correlate the sCBS with stroke severity and disability. Methods: Out of 98 consecutive stroke patients from the stroke units in Kaunas and Reykjavik, 15 with right-sided SN were included within five days following stroke. A structured assessment with the CBS established the presence and severity of SN. Patients identified with SN using the original structured assessment underwent a replicated evaluation with a simplified version of the sCBS. Two raters assessed the participants with the sCBS while they were blinded to the other rater’s scores. Stroke severity was assessed with NIHSS and disability with smRS. Results: There was a positive correlation between the NIHSS and the severity of SN r(13) = .78, p = .001. and the smRS and SN r(13) = .72, p =.002. On average it took 42 minutes to assess patients with mild/moderate SN with the CBS versus 14 minutes with the sCBS. Patients with very severe SN took <10 minutes to assess, both with the CBS and sCBS, because many scale items were impossible to score. A total of 54 items were impossible to score across patients with the CBS. Significantly more items could be scored using the sCBS (p< .05; 39 items, r1 and 40 items, r2). Conclusions: In contrast to the original CBS, the sCBS is more assessment-friendly for application in bedridden acute SN patients. We expect that the shortening of the assessment time may enhance SN screening in stroke units.

Objective: To introduce the Kessler-CBS Process, a detailed item-by-item instruction for reliably administering a validated functional neglect assessment to stroke survivors. Background Spatial neglect is a debilitating post-stroke neurocognitive disorder, associated with longer hospitalization and worse rehabilitation outcomes. However, clinicians have difficulty reliably identifying affected survivors, even when using validated neglect assessment procedures. CBS is the only published tool assessing performance in personal, peri-personal (within arm9s reach) and extra-personal spaces, as well as in both perceptual and motor domains. Our team at the Kessler Foundation Research Center has used the CBS in our rehabilitation research on spatial neglect since 2008. However, we encountered implementation obstacles in reliably administering and scoring this instrument, and thus developed the K-CBS Process to standardize spatial neglect diagnosis and enhance stroke care. Design/Methods: Rehabilitation researchers, physiatrists, and occupational therapists (OTs) drafted a detailed manual for using and scoring the CBS, reviewed videos of the actual CBS administration by OTs, and refined the manual in four iterative cycles over three years. The K-CBS Process constrained key features of examiners9 structured observations. Results: The K-CBS Process uses two forms: Form A contains the table of the scale and instructions for calculating the final score and assigning the severity of spatial neglect; Form B provides item by item instructions for how to make observations. Conclusions: Research confirms the validity and value of the CBS as an outcome measure, and it has the unique attribute of potentially separating function in different brain-behavior networks supporting different spatial processing stages. The Kessler-CBS Process may improve the CBS, making it more reliable for detecting spatial neglect and its functional consequences, and may help clinicians to assign neglect treatments. Routinely identifying post-stroke spatial neglect fulfills national post-stroke rehabilitation guidelines and may enhance the quality of care and improve rehabilitation outcomes for these patients. Supported by: The Kessler Foundation and the NIH/NINDS (K02 NS 047099-05, R01 NS 055808-02, PI: Barrett). Disclosure: Dr. Chen has nothing to disclose. Dr. Hreha has nothing to disclose. Dr. Fortis has nothing to disclose. Dr. Goedert has nothing to disclose. Dr. Barrett has received personal compensation for activities with WebMD. Dr. Barrett has received research support from the Kessler Foundation, NIH, O9Brien Technologies, Pfizer/Eisai, and the Wallerstein Foundation for Geriatric Improvement.

Objective: To examine whether the CBS or BIT is potentially more sensitive to spatial disability, and whether the CBS better identifies spatial-motor exploratory symptoms. Background Spatial neglect, common after right stroke, is a failure to perceive or respond to contralesional stimuli, causing functional disability. It is strongly linked to adverse hospitalization and rehabilitation outcomes. Consistent assessment to identify survivors with spatial neglect for early treatment might reduce the cost of care, but it is unclear whether widely-used diagnostic tests such as the Catherine Bergego Scale (CBS) or the Behavioural Inattention Test (BIT) differ in identifying patients for treatment. We previously suggested that the CBS may be more sensitive to spatial-motor exploratory network dysfunction (Verdon et al., 2010) and disability (Goedert et al., in press). Design/Methods: We performed a retrospective analysis of eighty-seven consecutive patients (mean age 65) screened for spatial neglect using conventional cut-off scores (BIT 11). Results: The CBS and BIT were very consistent in quantifying spatial neglect with a linear regression r = 0.7. After excluding patients falling within 5% of the cut-off to account for random variability, 64 survivors fell into three groups: those demonstrating neglect on BIT-only (n=7), CBS-only (n=1), or on both (n=56). We expected spatial motor-exploratory deficits may be more identified by the CBS, and more disabling. Indeed, patients in the BIT-only group were less disabled, with higher Barthel scores, and had less tactile extinction, consistent with previous characterization of “where” perceptual-attentional bias (Goedert et al., in press). Conclusions: Overall, the CBS and BIT were consistent and correlated when identifying spatial neglect. However, our data suggests that patients identified on the BIT alone may have primarily “where” perceptual-attentional symptoms, and may be less disabled. This may be important to assign treatments or predict recovery of specific tasks (e.g. driving). Supported by: Kessler Foundation, National Institutes of Health, Wallerstein Foundation for Geriatric Improvement. Disclosure: Dr. Chaudhari has nothing to disclose. Dr. Chen has nothing to disclose. Dr. Goedert has nothing to disclose. Dr. Barrett has received personal compensation for activities with WebMD. Dr. Barrett has received research support from the Kessler Foundation, NIH, O9Brien Technologies, Pfizer/Eisai, and the Wallerstein Foundation for Geriatric Improvement.

Robotic Rehabilitation Effect on Unilateral Spatial Neglect in Patients With Acute Stroke

The aim of this study was to determine the prevalence and functional impact of unilateral spatial neglect on right hemisphere stroke patients in an inpatient rehabilitation facility using a multidimensional, functionally based behavioral measure (Catherine Bergego Scale [CBS]). This was a retrospective cohort study of 742 consecutive admissions of patients with right hemispheric stroke to an inpatient rehabilitation facility. Spatial neglect was assessed using the CBS. Functional impact of neglect was measured by hospital length of stay, Functional Independence Measure change per day, discharge destination, and number of falls. As measured by the CBS, 86% of the right hemisphere stroke patients had symptoms of spatial neglect. Moderate and severe neglect was associated with less Functional Independence Measure change per day and lower rates of community discharge. The presence of neglect was not significantly associated with fall rate or length of hospital stay after controlling for admission Functional Independence Measure scores and age. The "difficulty looking left" CBS item had the strongest relationship with total CBS scores and effectively predicted Functional Independence Measure change per day and discharge destination. Using a sensitive measure, the CBS, rates of spatial neglect are extremely high in right hemisphere stroke patients entering inpatient rehabilitation. Both identification and determination of neglect severity are extremely important given their significant relationship to rehabilitation outcomes and discharge destinations. Complete the self-assessment activity and evaluation online at http://www.physiatry.org/JournalCME. Upon completion of this article, the reader should be able to (1) describe why carefully assessing spatial neglect in right hemisphere stroke patients is important; (2) identify multiple dimensions of spatial neglect assessed by the Catherine Bergego Scale and how this approach differs from traditional paper and pencil assessment methods; and (3) describe the relationship between spatial neglect as measured by the Catherine Bergego Scale and functional outcomes of right hemisphere stroke patients in inpatient rehabilitation settings. Advanced. The Association of Academic Physiatrists is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.The Association of Academic Physiatrists designates this journal-based CME activity for a maximum of 1.0 AMA PRA Category 1 Credit(s)™. Physicians should only claim credit commensurate with the extent of their participation in the activity.

The Kessler Foundation Neglect Assessment Process (KF-NAP) is an assessment tool for unilateral spatial neglect (USN), which is the scoring method for the Catherine Bergego Scale (CBS) based on detailed instructions. This study is aimed at determining the reliability and validity of the Japanese version of the KF-NAP (KF-NAP-J), evaluating the improvement of neglect assessment with KF-NAP-J, and comparing it with the original CBS for subacute stroke patients. We assessed subacute stroke patients admitted to our intensive rehabilitation hospital. Two KF-NAP-trained occupational therapists (OTs) assessed 22 patients. Before implementing the KF-NAP at the hospital, two other OTs assessed the other 23 patients using the CBS. We evaluated the interrater reliability of the KF-NAP and CBS using intraclass correlation coefficients (ICC) for the total scores, weighted kappa statistics for each subscale, and internal consistency using Cronbach's alpha. We assessed the validity of the KF-NAP against the Behavioral Inattention Test (BIT) and Functional Independence Measure (FIM) using Spearman's correlation coefficient. The reliability of both the KF-NAP and CBS was excellent. The weighted kappa results demonstrated that each subscale was in better agreement with the KF-NAP than with the CBS. In the KF-NAP, all eight subscales in which weighted kappa could be calculated were in significant agreement, and two were almost in perfect agreement. The KF-NAP moderately correlated with the subscales of BIT and FIM representing USN and activities of daily living. The USN detection rates of KF-NAP and BIT in the KF-NAP group were 63.6% and 22.7%, respectively. These results suggest that the KF-NAP, as well as the CBS, is useful to assess USN, which strongly impacts the rehabilitation outcomes in subacute stroke patients.

We developed Stimulus-driven Attention Tests (SAT) for a patient with unilateral spatial neglect (USN) and longitudinally investigated the results and compared them to two conventional assessments. The patient suffered a right putaminal hemorrhage resulting in left-side USN. On the 12th, 22nd, and 28th days from the onset, the Behavioral Inattention Test (BIT) and the Catherine Bergego Scale (CBS), which are conventional USN assessments, and our two Stimulus-driven Attention Tests (SAT-1 and SAT-2) were performed. Our assessment tests comprise two tasks in which participants respond to suddenly appearing stimuli and to a target stimulus among distractors. A longitudinal comparison of all assessments was performed to observe the clinical course of the USN. On the 12th day, scores were low on the BIT, CBS, and both SATs, but on the 22nd day, BIT improved above the cutoff; however, the CBS and SATs did not improve. On the 28th day, response to a target stimulus among distractors in the SAT remained low, and CBS scores did not change significantly. We were able to detect USN with the SAT when the participant showed improvement on the paper-and-pencil tests. Moreover, the number of distractors in the SAT was thought to reveal covert USN.

Spatial neglect (SN) constitutes a substantial barrier to functional recovery after acquired brain injury. However, because of its multimodal nature, no single test can capture all the signs of SN. To provide a clinically feasible solution, we used conventional neuropsychological tests as well as the Catherine Bergego Scale (CBS) via the Kessler Foundation Neglect Assessment Process (KF-NAP). The goal was to add evidence that a global approach should detect better even subtle signs of SN. Fourteen individuals with lesions located in the right cerebral hemisphere participated in the study. Participants were assessed with a comprehensive battery of neuropsychological tests, comprising a set of visuospatial tests to evaluate several spatial domains. In addition, patients underwent functional assessment with the Barthel Index, the Functional Independence Measure (FIM), and the CBS via KF-NAP. The CBS via KF-NAP was associated with the visuospatial paper-based tests (p = .004) as well as the Motor FIM (p = .003), and was more sensitive than the Behavioral Inattention Test-Conventional in detecting SN (p = .014). We showed that the CBS via KF-NAP was able: (a) to detect functional impairment, especially motor, related to SN; (b) to selectively measures spatial rather than nonspatial dysfunctions; and (c) to be highly sensitive in detecting SN signs especially in those patients with mild severity, covering several aspects of SN manifestations. The patient's SN diagnosis based on the CBS via KF-NAP is clinically important and directly relevant to care planning and goal setting. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

ABSTRACT.The Catherine Bergego Scale (CBS) is a scale to evaluates the impact of unilateral spatial neglect (USN) on everyday life of patients after stroke.Objective:The aim of this study was to evaluate the reliability and comprehension of the Portuguese version of the CBS for patients with USN after stroke.Methods:This was a cross-sectional study in patients with stroke and USN. The CBS was translated, culturally adapted and applied by two independent investigators. The patients were also evaluated by the Behavioural Inattention Test (BIT), NIHSS, mRS and Barthel scale to assess USN severity, neurological function, disability and autonomy consecutively. Consistency and coherence were analysed using Cronbach’s α, inter-observer reliability by Kappa, and the correlation between the CBS, BIT, NIHSS, mRS, and Barthel was determined using Pearson correlation.Results:Twenty-two patients were evaluated and the observed Cronbach’s α=0.913. For intra-observer reproducibility, the 10 items showed a reasonable and high reliability between evaluators. The CBS showed a negative correlation with the BIT. There was a low correlation between the BIT and NIHSS, mRS and Barthel index.Conclusion:The CBS is an adequate and validated scale for assessing patients with USN after stroke in a Brazilian population.

Implementing Prism Adaptation Treatment for Spatial Neglect in the Outpatient Setting

Background: Stroke is the second cause of mortality in the general population, and its incidence tends to increase because of population aging. The blood vessel territory most affected in the stroke is the middle cerebral artery (MCA). A frequent complication of stroke in the right MCA territory is the hemispatial neglect (HN), which can be defined as a disorder characterized by an unconscious attention deficit expressed in the patient’s behaviors in relation to the space contralateral to the lesions. The most common presentation is unilateral neglect, related to lesions in the right cerebral hemisphere with deficits in spatial perception on the left. HN correlates with poor prognosis, longer hospitalization and greater acute-phase complications. From clinical practice, some patients who suffered a stroke tend to lie in an oblique decubitus (OD) in the stretcher (diagonal position on the stretcher). Objective: Herein, we attempt to relate OD in the stretcher with HN. Methods: We performed a clinical prospective cohort study. The sample consisted of 17 individuals and the participants were recruited from the Dom José Maria Pires Hospital Metropolitano, in Paraíba, Brazil. The sample was divided into two groups: case (12) and control (5). The instruments used for data analysis were Star Cancellation Task (SCT), Bcos Apples Cancellation Task (BACT) and Catherine Bergego Scale (CBS) itens 2,5,6,7,9,10 and a Sociodemographic Questionnaire was used to identify the patient’s profile. Results: 17 individuals were included in the study. Out of 17, 10 (59%) were female, 70% had a right MCA stroke. The average age was 54.8. All participants were right-handed and in the acute phase of the stroke; 29% were in OD; 23% drink; 35.2% smoke; 58% have high blood pressure; 23% have diabetes. The mean NIHSS score was 7; 23% had HN on physical examination and 41% had HN on SCT, of which 28% were in OD. In the BACT 58% presented HN, with 20% in OD. On CBS, 29% presented HN, with 60% found in OD. A correlation was found between right MCA stroke and SCT (p value 0.02) and a positive correlation between CBS items and SCT (p value 0.01). There was no correlation between the other variables. Conclusion: Data analysis showed no correlation between OD and HN. However, there was a good result between CBS and SCT, indicating a good choice for testing HN in the acute phase of stroke. Due to the low sample number, further study is needed in the future. This information contributes to neurological semiology when seeking to confirm OD related to HN in patients presented with acute stroke considering that this type of information does not exist in the current literature.

Association of delirium and spatial neglect in patients with right-hemisphere stroke.

The relationship between fractional amplitude of low-frequency fluctuations (fALFF) and the severity of neglect in patients with unilateral spatial neglect (USN) after stroke: A functional near-infrared spectroscopy study.

Background: Robot-assisted arm training (RAT) is an innovative exercise-based therapy that provides highly intensive, adaptive, and task-specific training, yet its effects for stroke individuals with unilateral spatial neglect remain to be explored. The study was aimed to investigate the effects of RAT on unilateral spatial neglect, arm motor function, activities of daily living, and social participation after stroke.Methods: In a pilot randomized controlled trial, individuals with unilateral spatial neglect after right hemisphere stroke were equally allocated to intervention group and control group, 45-min training daily, 5 days/week, for 4 weeks. Outcome measures included the Behavioral Inattention Test-conventional section (BIT-C), Catherine Bergego Scale (CBS), Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Modified Barthel Index (MBI), and World Health Organization Disability Assessment Schedule Version 2.0 (WHODAS 2.0).Results: From November 2018 to February 2021, 20 stroke patients (mean age 47.40 ± 8.47) were enrolled in the study. Robot-assisted arm training was feasible and safe for individuals with unilateral spatial neglect. Both groups had significant improvements in all outcome measures. Participants assigned to RAT therapy had significantly greater improvements in BIT-C (difference, 7.70; 95% CI, 0.55–14.85, P = 0.04), FMA-UE (difference, 5.10; 95% CI, 1.52–8.68, P = 0.01), and WHODAS 2.0 (difference, −7.30; 95% CI, −12.50 to −2.10, P = 0.01). However, the change scores on CBS and MBI demonstrated no significance between the groups.Conclusion: Our findings provide preliminary support for introducing robot-assisted arm training to remediate unilateral spatial neglect after stroke. The training program focusing on neglect of contralateral space and affected upper extremity may be effective in neglect symptoms, motor function recovery, and social participation, while not generalizing into improvements in activities of daily living.Clinical Trial Registration: Chinese Clinical Trial Registry (http://www.chictr.org.cn/) on 17 October 2019, identifier: ChiCTR1900026656.

Background: Unilateral spatial neglect (USN) frequently occurs following a right hemisphere stroke, leading to impaired awareness of one side of the body. This condition affects daily activities despite intact motor and sensory functions. The Catherine Bergego Scale (CBS) and Albert's Test are tools used to assess USN severity, but their reliability needs further investigation. Objective: This study aimed to evaluate the intra-rater reliability of the Catherine Bergego Scale and Albert's Test in chronic stroke patients with unilateral spatial neglect. Methods: A cross-sectional study was conducted from November 2023 to March 2024 across three hospitals in Lahore, Pakistan. Using non-probability convenient sampling, 218 chronic stroke patients aged 50 to 80 years were recruited. Participants exhibited signs of USN but had no severe cognitive impairments or concurrent neurological conditions. The CBS and Albert's Test were administered by trained raters in controlled settings. The reliability of these assessments was evaluated using Cronbach's alpha coefficients, and statistical analysis was performed with SPSS version 25. Results: The CBS showed a Cronbach's alpha of 0.737, indicating acceptable reliability. Albert's Test demonstrated a Cronbach's alpha of 0.931, reflecting excellent reliability. These findings support the consistency and dependability of both assessment tools in evaluating USN severity. Conclusion: The study confirmed that the CBS and Albert's Test are reliable tools for assessing USN in chronic stroke patients, facilitating accurate diagnosis and tailored rehabilitation interventions.