The CBS is a short scale designed to assess the existence and extent of unilateral neglect during observations of the patient. It has both an observational component and a self-report questionnaire of the same items to compare the therapists’ perspective and the patient’s awareness (P. Azouvi et al., 1996).
10 categories
15-45 minutes
Depends on severity of neglect
Adult
18 - 64
yearsElderly Adult
+
yearsInitial instrument review completed by Kimberly Hreha, MS, OTR/L, EdD(c). Stroke Clinical Research Coordinator, and Peii Chen, PhD. Research Scientist.
Reviewed and revised by Allison Peipert, 2017.
Updated by Bridget Hahn, OTD, OTR/L, Baylee Cawley, OTS; Samantha Conrad, OTS; Alexandra Wasko, OTS; Rush University in 2019
In the most severe cases, some items may not be able to be scored due to confounding factors, such as apraxia or severity of hemiplegia. In these cases, only score the items the patient is able to perform. The sum of the items scored should then be divided by the number of items scored and multiplied by 10 to give a final score (Azouvi, 1996).
Anosognosia score can be obtained by comparing the patient’s self report with the therapist scored test. In the self-report questionnaire, the patient rates themselves in the same 10 areas on the assessment. They score if they have difficulty in each area, and if they find it mild, moderate, or severe. An anosognosia score can be obtained from subtracting the patient’s score from the therapists score (Azouvi, 2003).
The ME subscale of the CBS may describe spatial neglect after acute stroke and recognize functional dependence, however, future research is needed to evaluate the validity of the ME component of the CBS by including measures of whole-body spatial bias (such as postural measures) (Goedert, 2012).
The authors of the KF-NAP suggest the following: Take the entire session as a continuous time period. If the patient shows left-right asymmetric performance in two thirds of the session, you rate a given category with a score of 2; if the left-right asymmetric performance occurs one third of the session, the patient receives a score of 1. This principle can be helpful in observing Gaze Orientation and Limb Awareness.
When having doubt, you may ask yourself if “ineffective and incomplete” describes the patient’s performance. If so, you should probably give him/her a score of 2 rather than 1 in a given category. This could be helpful in observing Dressing, Grooming, Meals, or Cleaning after Meals.
No lateralized cue: Being a rehabilitation clinician, such as an occupational therapist, you may often give your patients verbal instructions to initiate, or try to initiate, certain behaviors or engage them in a task during a therapy session. During the KF-NAP, however, it is extremely important that the verbal instructions should not involve spatial cues and not give any type of cue to elicit a response that will help improve spatial attention. For example, phrases like: “look more to the left” or “what is on the left of the tray?” may prompt false responses to what should be an observed presentation. To avoid this, allow time for the patient to spontaneously explore the environment, and permit them to freely use their limbs and move their eyes.
Look for lateralized or asymmetrical behavior. You must look for patient behavior that is biased toward one side of space. That is, whether their eyes, limbs, or body often move toward one side but pay less attention to the other side. It is important that both the left and right sides are equally assessed before you come to the conclusion that the patient shows left-sided or right-sided spatial neglect.
The KF-NAP has been translated into Italian and Korean.
This assessment can be used during all stages of recovery from a stroke or traumatic brain injury. Even if the person has cognitive deficits or aphasia, aspects of the assessment can be observed and scored appropriately. There is a column (on the scoring sheet) for not applicable. If, for example, the person is not medically stable enough to eat by mouth, the Meals item would not be able to be scored at that time and “not applicable” would need to be used.
Stroke: (Azouvi, 2003; n =83; mean age = 54.5 (14.1) years, mean time post stroke = 15.9 (15.2) weeks)
Acute stroke, right hemisphere: (Goedert, 2012; n = 51; mean age = 66.9 (15.9) years; mean time post stroke = 22.3 (10.9) days)
Acute Stroke: (Marques et al, 2019; n = 22; Mean Age = 62.7(12.6); Mean CBS scores = 11.41 and 11.55 from evaluators)
| Variable | N | Mean | SD | Min | Max | Median |
|---|---|---|---|---|---|---|
| Age (years) | 22 | 62.73 | 12.63 | 23.00 | 85.00 | 64.00 |
| Weight (kg) | 22 | 68.26 | 18.75 | 51.60 | 90.00 | 69.50 |
| BMI (kg/m2) | 22 | 27.66 | 4.00 | 18.50 | 35.90 | 27.05 |
| Education (years) | 22 | 4.63 | 1.94 | 1.00 | 7.00 | 5.00 |
| Time since stroke (days) | 22 | 37.36 | 6.10 | 30.00 | 50.00 | 38.00 |
| NIHSS admission | 22 | 10.59 | 5.46 | 0.00 | 23.00 | 11.00 |
| NIHSS current | 22 | 4.77 | 3.10 | 0.00 | 11.00 | 4.50 |
| mRS | 22 | 1.77 | 1.34 | 0.00 | 4.00 | 1.50 |
| Barthel index | 22 | 61.59 | 33.07 | 15.00 | 100.00 | 60.00 |
| BIT | 22 | 80.23 | 37.50 | 13.00 | 125.00 | 89.00 |
| Evaluator 1 CBS | 22 | 11.41 | 9.40 | 0.00 | 30.00 | 10.00 |
| Evaluator 2 CBS | 22 | 11.55 | 9.16 | 0.00 | 29.00 | 12.00 |
BMI: Body mass index; NIHSS: National Institute of Health Stroke Scale; mRS: modified Rankin scale; BIT: Behavioural Inattention Test; CBS: Catherine Bergego Scale.
Acute Stroke: : (Azouvi, 2003; n =83; mean age = 54.5 (14.1) years, mean time post stroke = 15.9 (15.2) weeks)
Stroke: (Marques et al, 2019)
Stroke: (Azouvi, 1996)
Acute Stroke: (Azouvi, 1996)
Acute Stroke: (Azouvi, 2003)
Acute Stroke: (Luukkainen-Markkula, 2011; n = 17; mean age = 57 (8) years; time since stroke = 20 (32) months)
Normative Sample: (Marques et al, 2019)
Concurrent validity:
Acute Stroke, Right Hemisphere: (Azouvi, 1996)
Acute Stroke: (Azouvi, 2003)
Acute Stroke, Left Hemisphere: (Azouvi, 2006; Right hemisphere stroke: n = 206; mean age = 55.9 (15.3); mean time post stroke 11.1 (13.8) weeks; Left hemisphere stroke: n = 78; mean age = 54.6 (15.7); mean time post stroke: 10.8 (12.4) weeks.
Acute Stroke: (Qiang, 2005; n = 19; mean age = 62.5 (10.9), mean time post stroke: 61.9 (25.8) days)
Subacute Stroke, Right Hemisphere: (Azouvi, 2002; n = 206; mean age = 55.9 (15.3); mean time post stroke 11.1 (13.8) weeks)
Predictive Validity:
Acute Stroke: (Qiang, 2005)
Acute Stroke, Left Hemisphere: (Goedert, 2012)
Subacute Stroke: (Oh-Park, 2014; n = 21; mean age = 60.0 (11.5) years; mean time post stroke = 20.8 (10.1) months)
Predictive validity:
Stroke: (Azouvi, 1996)
Convergent Validity:
Acute Stroke: (Azouvi, 1996)
Acute Stroke: (Azouvi, 2006)
Stroke: (Pitteri et al., 2018; n = 14; Mean Age = 61.3 (15); Right CVA)
Pearson correlation of CBS scale scores with NIHSS, BIT, mRS and Barthel.
|
|
NIHSS |
mRS |
Barthel |
NIHSS |
BIT |
Evaluator 1 |
Evaluator 2 |
|
NIHSS admission |
1 |
-0.24037 |
-0.29128 |
0.67149 |
-0.31804 |
-0.21905 |
-0.22637 |
|
mRS |
|
1 |
-0.05581 |
-0.17313 |
0.32732 |
0.03413 |
-0.00880 |
|
Barthel index |
|
|
1 |
-0.41195 |
0.47041 |
-0.28712 |
-0.32825 |
|
NIHSS current |
|
|
|
1 |
-0.19694 |
0.03276 |
-0.00381 |
|
BIT |
|
|
|
|
1 |
-0.45891 |
-0.46222 |
|
Evaluator 1 |
|
|
|
|
|
1 |
0.97804 |
|
Evaluator 2 |
|
|
|
|
|
|
1 |
NIHSS: National Institute of Health Stroke Scale; mRS: modified Rankin scale; BIT: Behavioural Inattention Test.
Acute Stroke: (Azouvi, 2003)
For two patients with chronic stroke, the CBS was responsive to a visuo-spatial-motor cueing program, scores decreasing from 21/30 to 15/30 and 23/30 to 12/30 (Samuel et al., 2000).
Azouvi P, Bartolomeo P, Beis J-M, Perennou D, Pradat-Diehl P, Rousseaux M. A battery of tests for the quantitative assessment of unilateral neglect. Restorative Neurology & Neuroscience. 2006;24(4/6):273-85.
Azouvi P, Olivier S, de Montety G, Samuel C, Louis-Dreyfus A, Tesio L. Behavioral assessment of unilateral neglect: Study of the psychometric properties of the Catherine Bergego Scale. Archives of Physical Medicine and Rehabilitation. 2003;84(1):51-7.
Azouvi P, Samuel C, Louis-Dreyfus A, et al. Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. Journal of Neurology, Neurosurgery & Psychiatry. 2002 August 1, 2002;73(2):160-6.
Azouvi P, Marchal F, Samuel C, et al. Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychol. Rehabil. Apr 1996;6(2):133-150.
Bercot, H. (2018). Inpatient rehabilitation for a patient with a right posterior cerebral artery stroke, unilateral neglect syndrome, and homonymous hemianopia. Retrieved from DSpace
Chen, P., & Hreha, K. (2015). KF-NAP 2015 Manual Retrieved from https://kesslerfoundation.org/researchcenter/stroke/networkforspatialneglect.php
Chen, P., Chen, C. C., Hreha, K., Goedert, K. M., & Barrett, A. M. (2015). Kessler Foundation Neglect Assessment Process uniquely measures spatial neglect during activities of daily living. Archives of Physical Medicine and Rehabilitation, 96(5), 869-876. doi: 10.1016/j.apmr.2014.10.023
Chen, P., Hreha, K., Fortis, P., Goedert, K. M., & Barrett, A. M. (2012). Functional assessment of spatial neglect: A review of the Catherine Bergego Scale and an introduction of the Kessler Foundation Neglect Assessment Process. Topics in Stroke Rehabilitation, 19(5), 423-435. doi: 10.1310/tsr1905-423
Goedert KM, Chen P, Botticello A, Masmela JR, Adler U, Barrett AM. Psychometric Evaluation of Neglect Assessment Reveals Motor-Exploratory Predictor of Functional Disability in Acute-Stage Spatial Neglect. Archives of Physical Medicine and Rehabilitation. 2012 1//;93(1):137-42.
Luukkainen-Markkula R, Tarkka IM, Pitkänen K, Sivenius J, Hämäläinen H. Comparison of the Behavioural Inattention Test and the Catherine Bergego Scale in assessment of hemispatial neglect. Neuropsychological Rehabilitation. 2011;21(1):103-16.
Marques, C. L. S., Souza, J. T. D., Gonçalves, M. G., Silva, T. R. D., Costa, R. D. M. D., Modolo, G. P., & Luvizutto, G. J. (2019). Validation of the Catherine Bergego Scale in patients with unilateral spatial neglect after stroke. Dementia & neuropsychologia, 13(1), 82-88. Find on PubMed
Oh-Park M, Hung C, Chen P, Barrett AM. Severity of spatial neglect during acute inpatient rehabilitation predicts community mobility after stroke. PM & R: The Journal Of Injury, Function, And Rehabilitation. 2014;6(8):716-22.
Pitteri, M., Chen, P., Passarini, L., Albanese, S., Meneghello, F., & Barrett, A. M. (2018). Conventional and functional assessment of spatial neglect: Clinical practice suggestions. Neuropsychology, 32(7), 835-842. http://dx.doi.org/10.1037/neu0000469. Find on PubMed
Qiang W, Sonoda S, Suzuki M, Okamoto S, Saitoh E. Reliability and validity of a wheelchair collision test for screening behavioral assessment of unilateral neglect after stroke. American Journal of Physical Medicine & Rehabilitation. 2005;84(3):161-6 6p.
Samuel C, Louis-Dreyfus A, Kaschel R, et al. Rehabilitation of very severe unilateral neglect by visuo-spatio-motor cueing: Two single case studies. Neuropsychological Rehabilitation. 2000;10(4):385-99.
Shah, P., Hreha, K., & Chen, P. (2012). Evidence of inter-rater reliability in scoring the Kessler Foundation Neglect Assessment Process. Paper presented at the American Congress of Rehabilitation Medicine – American Society for Neurorehabilitation, Vancouver, Canada.
We have reviewed more than 500 instruments for use with a number of diagnoses including stroke, spinal cord injury and traumatic brain injury among several others.