Visual neglect

Visual neglect was assessed by the version of the B e h a ­ vioural Inattention Test (Wilson et al 1987) that had been m o d i f i e d and sho r t e n e d for use on p a t i e n t s w i t h i n a few days of their stroke (Stone et al 1987). This consists of eight simple and sensitive tests. Four of the tests simu­

late everyday activities and are intended to help t h e r a ­

pists select areas for treatment (eating a meal, reading a menu, r e a d i n g a new s p a p e r a r t i c l e and s e l e c t i n g c o i n s ) . Three of the tests are paper and pencil tasks, two of which are used frequently by clinicians (line cancellation and figure copying). The other (star cancellation) was said to b e p a r t i c u l a r l y s e n s i t i v e t o v i s u a l n e g l e c t

( P .H a l l i g a n - - p e r s o n a l c o m m u n i c a t i o n ) . T h e f i n a l t e s t (Pointing to objects in a room) was included because, if found to have particular diagnostic or prognostic value, it would provide clinicians with a simple bedside test that requires no additional equipment.

All tests were presented in front of the subject's m i d ­

line with the examiner seated directly opposite. No time limit was imposed. Aft e r a p a t i e n t had c o m p l e t e d a test

they w ere ask e d to check that t h e y w e r e finished. Some p a t i e n t s w e r e u n a b l e to a t t e m p t t e s t s due to l a n g u a g e difficulties, the level of consciousness, fatigue, c o n f u ­ sion, p e r s e v eration, poor eyesight, or p a r a l y s i s of the dominant hand. The tests were administered in the following o r der.

(appointing to objects located about the ward (Fig 2.2) The p a t i e n t was asked to p o i n t to a n d / o r n a m e all the objects that they could see on both sides scattered about their hospital room or ward (Patterson + Zangwill 1944). The examiner always stood directly behind the pat i e n t and made sure that there was an approximately equal d i s t r i b u ­ tion of o bjects located on the left and the r i g h t hand sides.

Using a photocopy of a closed semicircle , with the posi­ tion of the patients head marked at the centre of the base and w i t h m a r k s on the c i r c u m f e r e n c e at 45, 90 and 135 degrees,the examiner noted which objects were situated at 0,45,90,135 and 180 degrees and used these as landmarks. When the patient pointed to or named objects in the room the examiner marked their position relative to the land­ marks. W h e n the p a t i e n t f i n i s h e d pointing, the e x a m i n e r measured the approximate number of degrees omitted on the circumference of the semi-circle.

(bP Food on a plate (Wilson et al 1987) (Fig 2.3)

A life size colour p h o t o g r a p h of a p l a t e c o n t a i n i n g 8 items of food was placed in front of the patient who was asked to point or name each item of food. Where necessary the e x a m i n e r d e m o n s t r a t e d w h a t was required. T h e total number of items omitted was recorded. Correct i d e n tifica­

tion of the food items was not required.

fc)Reading a menu (Wilson et al 1987) (Fig 2.4)

The patient was asked to open and read aloud from a menu that listed 12 items of food on the left page and 12 on the right. The number of words omitted on the left, right, and in total was recorded. Aphasies were allowed to poi n t to words. If the patient did not begin reading in the first left hand column, this was noted as a sign of left visual neglect (Mesulam 1983; Holmes 1918) and referred to as a Right Hand Start (cf. arrow on Fig 2.4).

fd)Reading a newspaper article (adapted from Wilson et al 198 7 ) (fig 2.5)

Pat i e n t s w e r e asked to r ead the "newspaper" e x t r a c t aloud. The examiner marked any words omitted on a p h o t o ­ copy. Some patients were unable to read small print and in o r d e r to c o n t r o l for the e f f e c t s of p o o r e y e s i g h t the number of w o r d s o m itted from the H e a d l i n e s (10 w o r d s in b o l d p r i n t ) , the P a r a g r a p h (5 w o r d s in s m aller, f i n e r capitals) and the Article (117 words in small newsprint) were recorded separately. If the patient began reading any where but at the top left hand corner a Right Hand Start was recorded. This test was not given to patients w ith a left h e m i s p h e r e stroke b e c a u s e in the p i l o t s t u d y tha t modified the BIT (Stone et al 1987) it was found that few of these patients were able to read well enough to attempt this t est and that few of those t hat c o u l d d e m o n s t r a t e d neglect on this test.

fe)Line cancellation(adapted from Wilson et al 1987; Albert 1973) (Fig 2.6)

The patient was presented with a sheet of paper on which 40 one inch lines had been marked in 7 columns. The patient

was required to cross out all the lines on the pag e after the examiner had demonstrated what was required by crossing out the 4 lines in the centre of the page. The place where the patient started to cancel the lines was noted because initiation of tasks on the right hand side is a fundamental feature of p a t i e n t s w i t h v i s u a l neg l e c t due to a r i ght

hemisphere lesion (Chedru et al 1973; Weinburg et al 1977;

Mesulam 1985). A Right Hand Start was considered present if the first lines to be c a n c e l l e d w e r e in the 6th or 7th column located on the right side of the page (cf. arrow in Fig 2.6). The number of lines o m i t t e d on the right, the left and in total was recorded. If the patient's dominant hand was too weak to cross out lines and they w e r e unable to use the other hand, they were allowed to point to each line, which the examiner would then cross out.

ff)Star cancellation(Wilson et al 1987) (Fig 2.7)

The p a t i e n t was p r e s e n t e d w i t h 56 small stars m i x e d up with many large stars and capital letters. They w ere in­ structed to cross out the small stars after the examiner had demonstrated this by crossing out two of the centrally positioned stars. The number of small stars omitted on the

left, the right and in total was recorded. A Right Hand

Start was considered present if the patient began cancel­ ling stars in the 5th or 6th column located on the right side of the page. Where their hemiparesis made it difficult to cross out stars, they w ere aga i n all o w e d to p o i n t to them.

(g)Coin selection (Wilson et al 1987) (Fig 2.8)

A large card (32x21cm) with three coins of each of the following values (2p, 5p, lOp, 20p, 5Op, £1) was presented

to the patient with the three five pence coins on the side opposite their cerebral lesion. The patient was asked to point to each of the coins called out in turn. The examiner ma r k e d the resu l t s on a p h o t o c o p y of the test c a r d . T h e number of o m i s s i o n s on the left, r i g h t and in t o t a l was recorded. O c c a s i o n a l l y the e x a m i n e r w o u l d p l a c e a loose coin of the value required in front of the patient in order to help an aphasie patient understand which coin they were being asked to find. An alternative strategy was to write the value of the coin requested on a piece of paper,

fh) Figure coovina from the left (Wilson et al 1987) (Fig 2.9)

The patient was presented with a piece of paper divided

into six squares. In the 3 squares on the left were fig­

ures of a four p o i n t e d star (Oxbury et al 1974), a cube (Gainotti et al 1972) and a daisy (Gregory + Aitken 1971) . These were to be copied into the e m p t y 3 spaces on the

right side. The number of m a j o r o m i s s i o n s (e.g.half a

cube) and the number of minor omissions (e.g. a leaf) was

recorded for each object. Each major omission was given an arbitrary score of 2 and each minor omission a score of 1 (Ogden 1985). Other difficulties in spatial exploration on construction e.g.closing figures in a rough undifferentiat­ ed manner, were not regarded as a sign of visual neglect

(Gainotti + al 1972).

This test was not given to t h o s e p a t i e n t s w i t h a right hemisphere stroke as the pilot study that modified the BIT (Stone et al 1987) indicated that this test was less sensi­ t i v e to n e g l e c t t h a n m a n y o t h e r t e s t s in the b a t t e r y . However it was found to be useful for those patients with LH stroke. Those patients with neglect often ignored the

empty right spaces and "crowded” their copies into the left hand side of the page. This Crowding had also been observed in patients with a right hemisphere lesion when they were p r e s e n t e d w i t h f i gures on the r i g h t to be c o p i e d into spaces on the left.