Unilateral Spatial Neglect May Not Be Detected by Performance-Based Functional Neglect Assessment.

IMPORTANCE: Unilateral spatial neglect (neglect) poststroke is disabling. It is critical that people with neglect are identified so that treatment can be provided to maximize independence. However, there is some evidence to suggest that existing assessments may not adequately measure neglect. It is unclear whether assessments also fail to identify people with neglect entirely. OBJECTIVE: To determine whether there are stroke survivors who self-report neglect symptoms that are not detected by therapist-rated assessments and to compare self-report and therapist-ratings. DESIGN: Cross-sectional study. SETTING: U.S. university research center. PARTICIPANTS: Unilateral stroke survivors (N = 133). INTERVENTION: Not applicable. OUTCOMES AND MEASURES: The Catherine Bergego Scale (CBS) was administered to participants and scored by a trained occupational therapist. The parallel self-evaluation anosognosia form was also administered to participants to self-report and rate neglect symptoms. RESULTS: Forty-eight participants (36.1%) were classified as without neglect on the basis of therapist-rated total CBS scores, yet 30 (62.5%) of these 48 participants reported symptoms of neglect on the CBS self-evaluation anosognosia form. There was a significant difference (p < .001) between therapist-rated and self-rated total CBS scores. CONCLUSIONS AND RELEVANCE: Our results indicate that many stroke survivors report some level of disability associated with neglect yet do not meet the criteria to be classified as having neglect according to a commonly used therapist-rated performance-based measure. Plain-Language Summary: The findings of this study contribute to the evidence that existing assessments used by occupational therapists to measure performance-based neglect may not always detect neglect symptoms comprehensively in people poststroke. The finding also suggest that we may be missing neglect symptoms entirely. Occupational therapists should consider using various methods to assess for neglect, including patient self-report and comprehensive occupational profiles. Clinicians should also thoroughly screen all clients with stroke for neglect, regardless of lesion location.

Development of a Short Form Assessment Combining the Fugl-Meyer Assessment-Upper Extremity and the Wolf Motor Function Test for Evaluating Stroke Recovery.

OBJECTIVE: To use Rasch methodologies to combine the items of the Fugl-Meyer Assessment-Upper Extremity (FMA-UE, motor skill) and the Wolf Motor Function Test (WMFT, motor function) onto a single measurement metric and create an FMA-UE+WMFT short form. DESIGN: Secondary analysis of preintervention data from 2 upper extremity stroke rehabilitation trials. Confirmatory factor analysis and Rasch rating scale analysis were first applied to examine the properties of the pooled item bank and then item response theory methodologies were used to develop the short form. Confirmatory factor analysis and Rasch analysis were then applied to the short form to examine the dimensionality and measurement properties. SETTING: Outpatient academic medical research center. PARTICIPANTS: Data from 167 participants who completed the FMA-UE and WMFT (rating scale score) were pooled (N=167). Participants were eligible if they had a stroke ≥3 months prior and had upper extremity (UE) hemiparesis and excluded if they had severe UE hemiparesis, severe UE spasticity, or UE pain. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: The dimensionality and measurement properties of the pooled 30-item FMA-UE and the 15-item WMFT and short form were examined. RESULTS: Five items from the pool of 45 items were misfit and were removed. The 40-item pool demonstrated adequate measurement properties. A 15-item short form was then developed and met rating diagnostic scale criteria. All items on the 15-item short form met the Rasch fit criteria, and the assessment met criteria for reliability (Cronbach alpha=.94), separation (person separation = 3.7), and strata (number of strata = 5). CONCLUSIONS: Items from the FMA-UE and WMFT can be pooled to create a psychometrically sound 15-item short form.

Do Neglect Assessments Detect Neglect Differently?

OBJECTIVE: We determined whether various assessment tools detect neglect differently by administering a battery of assessments to people with stroke. METHOD: We conducted a case series study and administered five neglect assessments (paper-and-pencil, functional, virtual reality) to participants poststroke. RESULTS: Twelve participants (6 men, 6 women) with stroke completed the assessment battery, which required approximately 2 hr to administer (over one to two sessions). All participants demonstrated neglect on three or more assessments. Functional assessments and the virtual reality assessment detected neglect more frequently than the paper-and-pencil assessments. Participants performed differently on the paper-and-pencil assessments and functional assessments. CONCLUSION: Because neglect is complex, detection may depend largely on the assessment administered.

Examining the Feasibility, Tolerability, and Preliminary Efficacy of Repetitive Task-Specific Practice for People With Unilateral Spatial Neglect.

OBJECTIVE: We examined the feasibility, tolerability, and preliminary efficacy of repetitive task-specific practice for people with unilateral spatial neglect (USN). METHOD: People with USN ≥6 mo poststroke participated in a single-group, repeated-measures study. Attendance, total repetitions, and satisfaction indicated feasibility and pain indicated tolerability. Paired t tests and effect sizes were used to estimate changes in upper-extremity use (Motor Activity Log), function (Action Research Arm Test), and attention (Catherine Bergego Scale). RESULTS: Twenty participants attended 99.4% of sessions and completed a high number of repetitions. Participants reported high satisfaction and low pain, and they demonstrated small, significant improvements in upper-extremity use (before Bonferroni corrections; t = -2.1, p = .04, d = .30), function (t = -3.0, p < .01, d = .20), and attention (t = -3.4, p < .01, d = -.44). CONCLUSION: Repetitive task-specific practice is feasible and tolerable for people with USN. Improvements in upper-extremity use, function, and attention may be attainable.

Developing complex interventions: lessons learned from a pilot study examining strategy training in acute stroke rehabilitation.

OBJECTIVE: To examine the feasibility of a strategy training clinical trial in a small group of adults with stroke-related cognitive impairments in inpatient rehabilitation, and to explore the impact of strategy training on disability. DESIGN: Non-randomized two-group intervention pilot study. SETTING: Two inpatient rehabilitation units within an academic health centre. PARTICIPANTS: Individuals with a primary diagnosis of acute stroke, who were admitted to inpatient rehabilitation and demonstrated cognitive impairments were included. Individuals with severe aphasia; dementia; major depressive disorder, bipolar, or psychotic disorder; recent drug or alcohol abuse; and anticipated length of stay less than five days were excluded. INTERVENTION: Participants received strategy training or an attention control session in addition to usual rehabilitation care. Sessions in both groups were 30-40 minutes daily, five days per week, for the duration of inpatient rehabilitation. MAIN OUTCOME MEASURES: We assessed feasibility through participants' recruitment and retention; research intervention session number and duration; participants' comprehension and engagement; intervention fidelity; and participants' satisfaction. We assessed disability at study admission, inpatient rehabilitation discharge, 3 and 6 months using the Functional Independence Measure. RESULTS: Participants in both groups (5 per group) received the assigned intervention (>92% planned sessions; >94% fidelity) and completed follow-up testing. Strategy training participants in this small sample demonstrated significantly less disability at six months (M (SE) = 117 (3)) than attention control participants (M(SE) = 96 (14); t 8 = 7.87, P = 0.02). CONCLUSIONS: It is feasible and acceptable to administer both intervention protocols as an adjunct to acute inpatient rehabilitation, and strategy training shows promise for reducing disability.

Impact of Spatial Neglect on Activity and Participation: A Mixed-Methods Study.

Post-stroke neglect is disabling, yet it is unclear whether existing assessments capture the extent neglect affects activity and participation. The objective of the study is to explore stroke survivor and caregiver perspectives on how neglect affects activity and participation and to compare their experiences to neglect assessments items. We conducted an explanatory sequential mixed-methods study by conducting semi-structured interviews with stroke survivors (n = 7) and caregivers (n = 7) analyzed using thematic analysis. Stroke survivors completed the Catherine Bergego Scale (CBS) and Behavioral Inattention Test (BIT). Descriptive analyses characterized participant's neglect. The standardized CBS and BIT tests indicated that stroke survivors demonstrated mild-to-moderate (CBS) or no-to-mild (BIT) neglect. In contrast, the qualitative data revealed serious safety concerns and significant ongoing difficulties participating in school, work, and family activities because of neglect. Current assessments may not measure the impact of neglect on activity or participation in life for stroke survivors.

Individuals with neglect after stroke experience disability. This study interviewed individuals with neglect and their caregivers to understand whether clinical assessments capture the impact that neglect has on their daily life. Results show that existing assessments may not fully measure the challenges that individuals experience.

Detection of Stroke-Induced Visual Neglect and Target Response Prediction Using Augmented Reality and Electroencephalography.

We aim to build a system incorporating electroencephalography (EEG) and augmented reality (AR) that is capable of identifying the presence of visual spatial neglect (SN) and mapping the estimated neglected visual field. An EEG-based brain-computer interface (BCI) was used to identify those spatiospectral features that best detect participants with SN among stroke survivors using their EEG responses to ipsilesional and contralesional visual stimuli. Frontal-central delta and alpha, frontal-parietal theta, Fp1 beta, and left frontal gamma were found to be important features for neglect detection. Additionally, temporal analysis of the responses shows that the proposed model is accurate in detecting potentially neglected targets. These targets were predicted using common spatial patterns as the feature extraction algorithm and regularized discriminant analysis combined with kernel density estimation for classification. With our preliminary results, our system shows promise for reliably detecting the presence of SN and predicting visual target responses in stroke patients with SN.

Interpreting Action Research Arm Test Assessment Scores to Plan Treatment.

Rasch keyforms can help interpret clinical assessment scores. The Action Research Arm Test (ARAT) is a commonly used assessment, yet no keyform currently exists. The aim is to provide a keyform for the ARAT and demonstrate how a clinician can use the keyform to design optimally challenging rehabilitation sessions. Secondary analysis of ARAT data ( n = 122) using confirmatory factor and Rasch analyses were used to examine the measurement properties and generate a keyform. The item standardized factor loadings were >0.40 (range = 0.82-0.96) and R2 values were >.60 (range = .65-.96). All items exhibited adequate infit statistics with point measure correlations >.60 (range = .72-.97). Person reliability was .98, and person separation was 7.07. Item-difficulty measures ranged from -2.78 logits to 2.64 logits. The ARAT has strong measurement properties, and a keyform was provided. We showed how the keyform can be utilized by clinicians to interpret scores, set goals, and plan treatment.

Examining Anosognosia of Neglect.

Unilateral neglect (neglect) and anosognosia often co-occur post stroke. It is unknown whether anosognosia of neglect varies for different types of daily activities. The objective is to examine the frequency of anosognosia of neglect for items on the Catherine Bergego Scale (CBS) and to determine the level of agreement between participant/assessor item ratings and total scores. Secondary analysis of data was carried out. We conducted descriptive analyses and interrater reliability analyses (Cohen's kappa) to determine the level of agreement between assessor and participant item ratings. A paired t test was conducted to compare assessor and participant total scores. The frequency of anosognosia among items varied (29.2%-83.3%) and Kappa statistics ranged from -0.07 (no agreement) to 0.23 (fair agreement) for item ratings. There was a significant difference- t(36) = 3.02, p ≤ .01)-between assessor ( M = 8.0, SD = 5.2) and participant-rated ( M = 5.3, SD = 4.5) total CBS scores. Anosognosia is prevalent among those with neglect. Findings highlight the importance of assessing for anosognosia.

Strategy Training Shows Promise for Addressing Disability in the First 6 Months After Stroke.

BACKGROUND: Cognitive impairments occur frequently after stroke and contribute to significant disability. Strategy training shows promise but has not been examined in the acute phase of recovery. OBJECTIVE: We conducted a single-blind randomized pilot study estimating the effect of strategy training, relative to reflective listening (attention control), for reducing disability and executive cognitive impairments. METHODS: Thirty participants with acute stroke who were enrolled in inpatient rehabilitation and had cognitive impairments were randomized to receive strategy training (n = 15, 10 sessions as adjunct to usual inpatient rehabilitation) or reflective listening (n = 15, same dose). The Functional Independence Measure assessed disability at baseline, rehabilitation discharge, 3, and 6 months. The Color Word Interference Test of the Delis-Kaplan Executive Function System assessed selected executive cognitive impairments (inhibition, flexibility) at baseline, 3, and 6 months. RESULTS: Changes in Functional Independence Measure scores for the 2 groups over 6 months showed significant effects of group (F1,27 = 9.25, P = .005), time (F3,74 = 96.00, P < .001), and group * time interactions (F3,74 = 4.37, P < .007) after controlling for baseline differences in stroke severity (F1,27 = 6.74, P = .015). Color Word Interference Inhibition scores showed significant effects of group (F1,26 = 6.50, P = .017) and time (F2,34 = 4.74, P = .015), but the group * time interaction was not significant (F2,34 = 2.55, P = .093). Color Word Interference Cognitive Flexibility scores showed significant effects of group (F1,26 = 23.41, P < .001), time (F2,34 = 12.77, P < .001), and group * time interactions (F2,34 = 7.83, P < .002). Interaction effects suggested greater improvements were associated with strategy training. CONCLUSIONS: Strategy training shows promise for addressing disability in the first 6 months after stroke. Lessons from this pilot study may inform future clinical trials.

Cognitive impairments and depressive symptoms did not impede upper limb recovery in a clinical repetitive task practice program after stroke: a pilot study.

OBJECTIVE: We examined whether cognitive impairments or depressive symptoms impeded improvement in upper limb function in a clinical repetitive task practice program. DESIGN: Participants had mild to moderate upper limb impairment after stroke (n = 20). We characterized baseline cognitive function and depressive symptoms using the Repeatable Battery of Neuropsychological Status and the Hamilton Rating Scale for Depression. We measured upper limb function at baseline, week 4, and week 24 using the Action Research Arm Test. RESULTS: Participants with and without cognitive impairments improved significantly over time (F(1,17) = 84.48, P < 0.001) regardless of cognitive status (t(31) = 1.42, P = 0.16) or time since stroke (t(17) = 0.07, P = 0.95). Participants with and without depressive symptoms improved significantly over time (F(1,18) = 86.29, P < 0.001), but participants with depressive symptoms demonstrated greater improvement than did participants with no depressive symptoms (t(31) = 3.19, P = 0.003), regardless of time since stroke (t(17) = 0.06, P = 0.95). CONCLUSIONS: Preliminary findings suggest that cognitive impairments and depressive symptoms may not impede benefit from repetitive task practice after stroke.