0 A COMPARISON OF THE CATHERINE BERGEGO SCALE AND THE SEMI- STRUCTURED SCALES FOR FUNCTIONAL EVALUATION OF HEMI-INATTENTION IN PATIENTS WITH STROKE Kara Vorster Student Number 1105652 A Dissertation submitted to the Faculty of Health Sciences, University of the Witwatersrand, in fulfilment of the requirements for the degree of Master of Science in Physiotherapy Johannesburg, 2022 i DECLARATION I, Kara Vorster, declare that the work contained in this dissertation is my own work, except to the extent indicated in the acknowledgement sections. This dissertation is being submitted for a degree of Masters of Science in Physiotherapy, at the University of the Witwatersrand, Johannesburg, South Africa. This work has not been submitted for any other degree or examination in this or any other university. Kara Vorster Date ii ABSTRACT Background It is common to experience unilateral neglect after suffering from a stroke. This can have an effect on the patient’s activities of daily living, the rehabilitation process and the length of stay in hospital. There are many different outcome measures that can be used to measure unilateral neglect. It is therefore important to determine which outcome measure is best used in a South African in-patient rehabilitation hospital. The aim of this study was to compare the responsiveness of the CBS via the KF-NAP to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention when measuring unilateral neglect in adult patients following a stroke in a neurological rehabilitation unit. Method Forty-one patients from Witrand Hospital Rehabilitation unit were recruited to participate in this study. All of the participants included in this study experienced a first-ever stroke and they were excluded if they had severe speech impairments, were confused or had impairments or activity limitations that are not related to stroke. All participants gave informed consent and thereafter the Catherine Bergego Scale (CBS) and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention was then administered. The scores were calculated for the CBS & the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention by adding the results of each item for each patient. The different categories were also scored individually. Frequencies and percentages for the CBS via KF- NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention were calculated. Results It was determined that the majority of study participants experienced neglect on admission at the Rehabilitation unit. The unilateral neglect mean score during admission was higher than the score on discharge with the CBS and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. The p-value comparing mean scores of the two methods, was 0,308 which showed that statistically there was no difference when comparing the two outcome measures. iii Conclusion This study found that either the CBS via the KF-NAP or the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention are responsive when measuring unilateral neglect in a rehabilitation setting. Keywords Unilateral neglect; spacial neglect; rehabilitation unit; stroke; outcome measure; Catherine Bergego Scale; Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention iv ACKNOWLEDGEMENTS This study would not have been possible without the unending support and assistance of certain people. I would like to thank them for their time and expertise on both personal and professional level. To Professor Veronica Ntsiea, my main supervisor for always putting so much time and dedication into guiding my research, and above all for your friendship which has made this process much more enjoyable. To Doctor Shawn Liebenberg, for all their assistance with the statistical analysis of this research report. To Ludwig Fechter, for all his assistance in correcting my wording and grammar. To the Physiotherapy Department at the University of the Witwatersrand for the loan of the equipment needed for my research. To all the staff members of Witrand Specialised Hospital for allowing me to conduct the research at their clubs and for their willingness to assist me, and their continued support to accommodate the research in their busy schedules. To all the participants for making my data collection so smooth and easy, and for volunteering your precious time to my research. To my family and friends for their faith in me and for all their support and encouragement through this process. v Table of Contents LIST OF TABLES .................................................................................................................. vi LIST OF FIGURES ............................................................................................................... vi LIST OF APPENDICES ....................................................................................................... vii LIST OF ABBREVIATIONS .................................................................................................. vii CHAPTER 1: INTRODUCTION AND SCOPE OF THE RESEARCH REPORT ..................... 1 1.1 Introduction ............................................................................................................. 1 1.2 Problem Statement ................................................................................................. 3 1.3 Research Question ................................................................................................. 3 1.4 Aim of the Study ..................................................................................................... 3 1.5 Objectives of the Study ........................................................................................... 3 1.6 Significance of the Study......................................................................................... 4 1.7 Organisation of the research report ......................................................................... 4 CHAPTER 2: LITERATURE REVIEW ................................................................................... 5 2.1 Introduction ............................................................................................................. 5 2.2 Stroke ..................................................................................................................... 5 2.3 Unilateral neglect .................................................................................................... 7 2.4 Outcome measures used to assess post stroke unilateral neglect .......................... 9 2.5 Catherine Bergego Scale via KF-NAP ................................................................... 11 2.6 Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention .......... 12 2.7 Conclusion of literature review .............................................................................. 13 CHAPTER 3: METHODOLOGY .......................................................................................... 15 3.1 Type of Study ........................................................................................................ 15 3.2 Participants ........................................................................................................... 15 3.3 Instrumentation and Outcome Measures .............................................................. 16 3.4 Procedure ............................................................................................................. 16 3.5 Ethical Considerations .......................................................................................... 17 3.6 Data Analysis ........................................................................................................ 18 3.7 Conclusion of the methodology ............................................................................. 19 CHAPTER 4: RESULTS ..................................................................................................... 20 4.1 Study Participants ................................................................................................. 20 4.1.1 Age of the study participants ................................................................................. 21 4.1.2 Gender .................................................................................................................. 21 4.1.3 Type and side of stroke ......................................................................................... 22 4. 2. Catherine Bergego Scale via the KF-NAP ............................................................. 22 vi 4.3 The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention ... 25 4.4 Comparison between the two outcome measures: ................................................ 27 4.5 Challenges of data collection ................................................................................ 28 4.6 Conclusion of the results ....................................................................................... 29 CHAPTER 5: DISCUSSION ................................................................................................ 30 5.1 Participants ........................................................................................................... 30 5.2. Unilateral neglect scores of study participants ...................................................... 31 5.3 Conclusion of the discussion ................................................................................ 33 CHAPTER 6: CONCLUSION AND RECOMMENDATIONS FOR FUTURE RESEARCH .... 35 6.1 Conclusions .......................................................................................................... 35 6.2 Strengths of this study .......................................................................................... 36 6.3 Limitations of this study ......................................................................................... 36 6.4 Clinical Recommendations .................................................................................... 36 6.5 Recommendations for Future Studies ................................................................... 37 LIST OF TABLES Table 3-1 Sample size ........................................................................................................ 15 Table 3-2 Data analysis ...................................................................................................... 18 Table 4-1 Unilateral neglect scores of participants when using the CBS via the KF-NAP…. 22 Table 4-2 The subcategory scores of the CBS via the KF-NAP………………………………. 24 Table 4-3 Unilateral neglect scores of participants by using the Semi-Structured Scales…. 25 Table 4-4 Subcategories of the Two-Semi-Structured Scales…………………………………. 26 Table 4-5 The mean scores of the outcome measures over the four-week period…………. 27 LIST OF FIGURES Figure 1-1 Organisation of the research report ...................................................................... 4 Figure 2-1 Potential impairments from stroke according to brain areas ................................. 6 Figure 2-2 Blood supply to the brain ...................................................................................... 6 Figure 4-1 Participants of the study ..................................................................................... 20 Figure 4-2 Age of participants (n=41) .................................................................................. 21 Figure 4-3 Gender distribution (n=41) ................................................................................. 21 Figure 4-4 Type and side of stroke (n=41) .......................................................................... 22 vii Figure 4-5 The mean scores of the outcome measures over the four-week time period ...... 28 LIST OF APPENDICES Appendix i: KF-NAP ................................................................................................................ Appendix ii: Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention ......... Appendix iii: Permission letter to conduct research and approval letters ................................. Appendix iv: Information sheet ................................................................................................ Appendix v: Informed consent ................................................................................................. Appendix vi: Data Collection ................................................................................................... Appendix vii: Change of title letter…………………………………………………………………… Appendix viii: Plagiarism declaration………………………………………………………………… Appendix ix: Certificate of submission for examination signed by student………………………. Appendix x: Certificate of submission for examination signed by supervisor…………………… Appendix xi: Acknowledgement of Research Submission for Examination……………………… LIST OF ABBREVIATIONS ADLs Activities of daily living ACA Anterior Cerebral Artery BIT Behavioural Inattention Test CBS Catherine Bergego Scale DALY Disability-adjusted life years EBP Evidence based practice IRF In-patient Rehabilitation Facility KF-NAP Kessler Foundation Neglect Assessment Process MCA Middle cerebral artery PCA Posterior cerebral artery viii 1 CHAPTER 1: INTRODUCTION AND SCOPE OF THE RESEARCH REPORT 1.1 Introduction Unilateral neglect is defined as the failure to report or respond to stimuli such as people or objects presented to the side opposite a brain lesion, when this failure cannot be attributed to either sensory or motor defects (Plummer et al., 2003). This disorder can have an effect on many activities of daily living. Unilateral neglect can be divided into different patterns of impairment according to the specific frame of reference (personal, extra-personal, peri-personal) that can be selectively affected according to distinct coordinates (Vallar, 1998). Personal neglect implies a general inattention for the contralesional side of the body (Caggiano & Jehkonen, 2018). Extra-personal neglect refers to a form of unilateral neglect where patients fail to acknowledge and respond to stimuli in their extra-personal space (Yang et al., 2013). Peri- personal space refers to a space immediately surrounding our bodies, where objects can easily be grasped or manipulated (de Pellegrino & Làdavas, 2015). Unilateral neglect may be multimodal, including sensory and motor neglect. Motor neglect refers to patients that show a considerable reduction in spontaneous use of the contralesional limbs, which is not explained by their associated motor impairments (Punt & Riddoch, 2006; Sampanis & Rinoch, 2013). Sensory neglect is an inability to attend to sensory information on one side of the body due to a brain injury (American Psychological Association, 2018). In South Africa, stroke is responsible for roughly 25000 deaths annually and 95000 people live with disabilities due to stroke (Taylor, 2019). In the United States the incidence rate for unilateral spatial neglect is upwards of 80% in patients with right-sided stroke (Barrett et al., 2017). Right-sided unilateral neglect resulting from left hemisphere damage was found at least to some degree in 43.5% of patients with stroke (Beis et al., 2004). There are many different outcome measures that can be used to measure extra-personal unilateral neglect and these include figure copying, clock drawing and paper-and-pencil tests, such as the bells test and the line bisection test. A normal performance on one test alone is not sufficient to rule out the presence of neglect in a given patient (Beis et al., 2004). Examples of measures of personal unilateral neglect include the Behavioural Inattention Test (BIT), the Catherine Bergego Scale (CBS) and the Two Semi-structured Scales for Hemi-inattention (Plummer et al., 2003). Azouvi et al. (2017) mentioned that conventional paper-and-pencil tests of unilateral neglect are of limited ecological validity. Therefore, the issue was addressed by proposing a number of assessment procedures to provide clinicians and researchers with more ecologically valid assessments of unilateral neglect. In a study by Azouvi et al. (2017) the Behavioural Inattention Test (BIT), the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention, The Subjective Neglect Questionnaire, The Baking Tray Task, Wheelchair 2 Obstacle Course, Standardised Activities of Daily Living Testing and the Catherine Bergego Scale (CBS) were compared. They found that the choice of measure depends on the moment and the time available to do the tests as well as the setting. Another study compared a wide variety of different assessment methods, including: line bisection tests, cancellation tests, copying and drawing tests, Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention, BIT and CBS (Plummer et al., 2003). It was found that all these tests can provide the administrator with an indication of whether the patient has unilateral neglect and it can be used as an evaluation tool to determine how the patient responds to changes in task demands (Plummer et al., 2003). After reading through the previously mentioned studies, it was evident that the most frequently used outcome measures in recent times were the CBS, BIT and the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention. The BIT only tests the patient in a peri-personal space, but it can evaluate the impact of neglect in visually based function tests (Plummer et al., 2003). Goedert et al. (2012) determined that the BIT showed good reliability. The once off purchase cost of using the BIT is $280.00, which is roughly about R4200.00, which is expensive, making it difficult to use all over South Africa, as some of the clinics and smaller hospitals will not have the finances to pay this amount for a measure that might not be used often. The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention can differentiate between personal and extra-personal neglect, but does not differentiate between sensory or motor neglect (Plummer et al., 2003). The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention consists of two scales, namely the Personal and the Extra-personal scales. The Extra-personal scale detected asymmetry in most neglect. The Personal Scale measures a different dimension than both the Extra-personal Scale and standard tests for neglect. The Extra-personal Scale was correlated with standard tests of neglect, but not the Personal scale (Zoccolotti et al., 1992). The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention is easy and quick to use, but requires some effort to set up all of the different tests. The CBS is a functional scale where the administrator uses direct observation of the patient’s functioning during activities of daily living (Azouvi et al., 1996). The CBS uniquely predicted deficits in activities of daily living (ADLs) assessed by using the Barthel Index, but did not predict clinical and laboratory assessments of motor-intentional bias. The results indicated that assessments of unilateral neglect may be used to detect specific motor-exploratory deficits in unilateral neglect. The study also determined that by obtaining CBS scores frequently, it might improve the detection of acute-stage patients with unilateral deficits who require more assistance that may be prolonged to the chronic stage of recovery (Goedert et al., 2012). The CBS provides a way of distinguishing personal or unilateral neglect, but does not discriminate between sensory and motor neglect (Plummer et al., 2003). Azouvi et al. (2017) did however indicate that if the patient 3 is still in a rehabilitation facility, the CBS is possibly the best suited measure, due to the fact that it looks at ADLs such as grooming, eating, dressing, which are functional. The CBS however had no formal description on how it must be used and additional instructions were needed for reliable CBS administration, which is why the Kessler Foundation Neglect Assessment Process (KF-NAP) was developed. The KF-NAP provides detailed administration instructions and a scoring chart for the 10 original CBS categories of behaviour (Chen et al., 2015). The KF-NAP is a comprehensive explanation of how the CBS can be administered. By using the KF-NAP to administer the CBS it standardises the administration (Shirley Ryan Ability Lab, 2019). Rehabilitation researchers may be able to use the CBS via the KF-NAP to measure ecological outcomes and specific, separable perceptual-attentional and motor- exploratory spatial behaviours (Chen et al., 2012). The CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention will be compared in this study. 1.2 Problem Statement It is important to find valid outcome measures that can be used to measure unilateral neglect. These valid and reliable outcome measures should then be compared and it is also important to see whether the patients and administrators understand them. The ability of the outcome measures to identify impairments should also be determined. It is important to compare outcome measures in South Africa, because some of them cannot be used due to the financial implications thereof, like the BIT. Some of the outcome measures, like the figure copying, clock drawing and paper-and-pencil tests are very easy to use, but are of limited ecological validity. Other tests like the CBS and the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention are more complex to use, but are more valid and reliable than the previously mentioned tests. Comparison of the responsiveness of the CBS and the Two Semi-structured Scales for Functional Evaluation of Hemi- inattention will give an indication of which of these two tests if not both, can be considered for use in a South African stroke rehabilitation setting. 1.3 Research Question What is the most responsive outcome measure to use when testing unilateral neglect in a South African stroke rehabilitation context between the CBS and the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention? 1.4 Aim of the Study To compare the responsiveness of the CBS to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention when measuring unilateral neglect in adult patients following a stroke in a neurological rehabilitation unit. 1.5 Objectives of the Study 1.5.1 To assess unilateral neglect in adult patients following a stroke by using the CBS via the KF-NAP 1.5.2 To assess unilateral neglect in adult patients following a stroke by using the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention 4 1.5.3 To determine the responsiveness of the CBS in measuring unilateral neglect in an inpatient rehabilitation unit 1.5.4 To determine the responsiveness of the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention in measuring unilateral neglect in an inpatient rehabilitation unit 1.5.5 To compare the responsiveness of the CBS via the KF-NAP to the responsiveness of the Two Semi- Structured Scales for Functional Evaluation of Hemi-inattention 1.6 Significance of the Study Many different outcome measures are being used to test unilateral neglect all over the world, some are however more expensive and others are less efficient to use. To the researcher’s knowledge, there are no commonly used tests for unilateral neglect following stroke in South Africa. It is therefore important to determine which outcome measure is best suited to use in a South African setting. It is important to know whether a patient has unilateral neglect, because it slows down the rehabilitation process and my result in a longer length of stay in the rehabilitation unit (Chen et al., 2015). Patients with unilateral neglect also require different treatment modalities than those without neglect. This is why it should be known if unilateral neglect is present and whether it is improving or not. This study will hopefully be able to determine the best suited outcome measure to test unilateral neglect that can be used in a South African in-patient hospital setting and hopefully many healthcare providers will then routinely test for unilateral neglect to take the neglect into consideration when planning the treatment programme. 1.7 Organisation of the research report Figure 1-1 Organisation of the research report Chapter 1 • An introduction to the research topic is given in this chapter. The problem of hemi-inattention in patients following a stroke is presented. The research question, the aims and objectives and the significance of the research report are laid out. Chapter 2 • This chapter presents a review of the literature and includes the following aspects : the definition and prevelance of stroke, unilateral neglect and outcome measure to measure unilateral neglect Chapter 3 • The methodology of the study is presented in this chapter. It includes the sample population and size as well as the inclusion and exclusion criteria. The measuring instruments and the physical assessment used for data collection are discussed. Ethical consideration and statistical analysis are also covered. Chapter 4 • This chapter presents the results of the study. Chapter 5 • This chapter presents discussion of the main findings of the study in relation to the existing literature. Chapter 6 • The conclusion of the study is presented in this chapter, as well as recommendations for future research and practice. 5 CHAPTER 2: LITERATURE REVIEW 2.1 Introduction This chapter reviews the current available literature documenting unilateral neglect following a stroke. The term stroke will be defined and there will be an overview of the anatomy of the blood supply to the brain and the different areas of the brain with their functions. The anatomy of the areas mostly responsible for unilateral neglect will be presented. Unilateral neglect will be discussed in terms of the effect it has on patients and the functional limitations thereof. Different outcome measures to test whether unilateral neglect is present will be presented. There is no standard protocol to measure unilateral neglect in South Africa and thus two of the best suited measures will be reviewed: CBS and the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention. Literature was sourced from online medicine and science literature databases, including PubMed, CINAHL, PEDro, Elsevier and Google Scholar, and included English articles published between 2001 and December 2021. Search words used in the search were stroke, isch(a)emic stroke, intracerebral h(a)emorrage, h(a)emorrhagic stroke, unilateral neglect, spatial neglect, hemineglect, spatial cognition, KFNAP, CBS. 2.2 Stroke A stroke occurs when the blood vessel that carries oxygen and nutrients to the brain is either blocked by a clot or ruptures. When that happens, part of the brain is deprived of sufficient blood, so that part of the brain and brain cells die (American Heart association, 2021). Statistics noted in the Global Burden of Diseases, Injuries and Risk Factors Study determined that in 2019 stroke was the second-leading cause of death and the third-leading cause of death and disability combined in the world. From 1990 to 2019 the burden of stroke in terms of the absolute number of cases increased significantly (Global Burden of Diseases, Injuries and Risk Factors Study, 2021). The findings indicate that the bulk of the global stroke burden (86.0% of deaths and 89.0% of disability adjusted life years (DALYs)) is in lower-income and lower-middle-income countries (Global Burden of Diseases, Injuries and Risk Factors Study, 2021). A stroke is generally divided into subcategories, such as: Ischaemic, intracerebral haemorrhagic and a subarachnoid haemorrhagic stroke. An ischaemic stroke is an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction. An intracerebral haemorrhagic stroke is defined as: “rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma”. Subarachnoid haemorrhagic stroke is a “rapidly developing signs of neurological dysfunction and/ or headache because of bleeding into the subarachnoid space (the space between the arachnoid membrane and the pia mater of the brain or spinal cord), which is not caused by trauma” (Sacco et al., 2013 p.2066). Statistics indicate that ischaemic stroke constitutes the largest proportion of all new strokes (comprising 62.4% of all incident strokes in 2019), followed by intracerebral haemorrhage (27.9%), and subarachnoid haemorrhage (9.7%) (Global Burden of Diseases, Injuries and Risk Factors Study, 2021). 6 Stroke can affect different areas of the brain such as the frontal lobe, temporal lobe, parietal lobe, occipital lobe, cerebellum and brain stem. Injury to these different areas can cause different impairments of function as seen in figure 2-1. (Puthenpurakal & Crussell, 2017). Figure 2-1 Potential impairments from stroke according to brain areas (Puthenpurakai & Crussel, 2017) These different lobes are supplied by the anterior cerebral artery (ACA), middle cerebral artery (MCA) and posterior cerebral artery (PCA) as seen in figure 2.2. The anterior cerebral artery supplies most of the medial and superior surfaces of the brain as well as the frontal pole. The middle cerebral artery supplies the lateral surface of the brain and the temporal pole. The posterior cerebral artery supplies the inferior surface of the brain and the occipital pole (Moore et al., 2014). Figure 2-2 Blood supply to the brain (https://memorang.com/flashcards/155064/Neurology+Anatomy+and+Physiology) 7 Yee Sing Ng et al. (2007) reported that the MCA stroke was the most common stroke (50.8%) followed by small-vessel stroke (12.8%) and brain stem stroke (11.4%). An MCA stroke is the most common stroke due to the size of the territory and the direct flow from the internal carotid artery into the MCA which provides the easiest path for an embolus (Nogles & Galuska, 2021). The parietal lobe is supplied by the MCA and ACA and thus a stroke in one of these arteries can lead to unilateral neglect. 2.3 Unilateral neglect 2.3.1 Definition Unilateral neglect is a syndrome that frequently happens after a stroke (Appelros et al., 2002), it is not just a single condition, but a complex syndrome (Vallar, 2001). It can be defined as a multifaceted and incapacitating cognitive syndrome frequently occurring after a stroke, other brain injury or neurodegenerative disease (Andrade et al., 2010; Bender, 2011). Unilateral neglect has multiple subcategories depending on the specific networks that are damaged (Husain & Nachev, 2007; Harvey & Rossit, 2011). Unilateral neglect may be divided into subcategories such as sensory modality (Jacobs et al., 2012), sectors of space (Van der Stoep et al., 2013), and spatial frame of reference (Chechlacz et al., 2010). Patients with unilateral neglect tend to be oblivious of half of the space around them as well as half of their own body. Patients tend to present with a permanent deviation of their head and gaze towards the right, in the most severe cases. The patient also ignores inputs from the side opposite to the brain lesion (Azouvi, 2017). 2.3.2. Types of unilateral neglect Neglect can be egocentric or allocentric. Egocentric neglect is apparent when objects are neglected relative to the person’s own position, whereas allocentric neglect involves neglect occurring in relation to the object itself, regardless of its position relative to the person experiencing neglect (Jang & Jang, 2018). Previous studies have investigated the neuroanatomical correlates of unilateral neglect related to spatial frames of reference. These studies have determined that egocentric neglect was associated with injury to the premotor cortex, right angular and supramarginal gyrus and that allocentric neglect is associated with damage to the inferior temporal gyrus and superior temporal cortex (Grimsen et al., 2008; Hillis et al., 2005). However structural damage to the interparietal sulcus and the tempero-parietal cortex appears to be related to both forms of neglect (Chechlacz et al., 2010). Other studies that were done on right-hemisphere stroke patients reported that a shortfall in target-directed tasks, such as reaching, was associated with lesions in basal ganglia nuclei and frontal regions (pre-central and inferior frontal gyri) (Rossit et al., 2009; Vossel et al., 2010). Increased difficulty with target directing reaching tasks was associated with lateral and medial parieto- occipital regions (Rossit et al., 2009; Vossel et al., 2010). 2.3.3 Prevalence of unilateral neglect According to Antonia et al. (2017) left and right sided unilateral neglect are both common after stroke. It is estimated that unilateral neglect occurs in 50% of patients after a right sided hemisphere stroke and in 30% of patients after a left-sided hemisphere stroke (Chen, Chen, et al., 2015). Most studies report that unilateral neglect is more persistent and severe after right sided hemisphere injury compared to left sided hemisphere damage (Chen et al., 2015; Gainotti et al., 1972; Ogden, 1985; Ringman et al., 2004). 8 2.3.4. Effect of unilateral neglect on functional outcomes Unilateral neglect has a substantial effect on inpatient rehabilitation outcomes (Chen, Chen et al., 2015; Chen, Hreha et al., 2015; Chen et al., 2021). Some barriers affecting rehabilitation outcomes in patients with unilateral neglect include: Symptoms of unilateral neglect, unilateral related self-awareness problems, decreased motivation or poor therapy engagement, physical weakness, other co-morbidities and poor treatment efficiency due to previously mentioned barriers (Chen et al., 2021). Unilateral neglect can decrease independence in ADLs and has a negative impact on the patient’s quality of life (Bowen et al., 2013; Chen et al., 2015; Chen et al., 2021). When the patient is eating, they might neglect plates located to their left or only eat half of the food located on the plate. They omit the left sided page in a book or will neglect details on the left of pictures (Azouvi et al., 2017). There can also be deficits when reading or with appropriate social interactions (Chen, Hrera et al., 2015) which affects memory retrieval and mental imagery (Chen et al., 2021). Unilateral neglect also affects the patient’s movement and balance (Shiraishi et al., 2010; Ten Brink et al., 2017) and appears to impair paralysis recovery (Nijboer et al., 2014). This influences the patient’s mobility such as walking, using a wheelchair, driving and overall community mobility (Oh-Park et al., 2014; Chen et al., 2015). The patient will also be a higher fall risk due to the above-mentioned impairments (Chen et al., 2021). If unilateral neglect is present, it is associated with prolonged hospitalisation and poorer functional outcomes (Chen, Hreha, et al., 2015; Nijboer et al., 2013; Wilkinson et al., 2012). In a study done by Hammerbeck, et al. (2019) data was collected from 88,000 UK hospital admissions, the study concluded that those with neglect had an increased length of stay (27 vs. 10 days) and on discharge they were still “dependent” on the modified Rankin scale (76% vs. 57%). In general, unilateral neglect is also linked to higher disability (Appelros et al., 2002; Chen, Chen, et al., 2015; Nijboer, et al., 2013). Many individuals with unilateral neglect are unaware of their own symptoms or the consequences of their deficits and this causes delays in seeking suitable treatment or learning compensatory strategies (Chen, et al., 2021). Despite breakthroughs in rehabilitation research on unilateral neglect interventions and known barriers to evidence based practice (EBP), recent reports have shown the same poor outcomes associated with unilateral neglect as reports published years ago (Chen et al., 2021). Generally, the lateralized attention deficit is better in right unilateral neglect than in left unilateral neglect, although the consequences at the level of physical functioning and physical independence are largely similar. The deficit in lateralized attention is more severe with respect to the neuropsychological outcomes and observations of unilateral neglect in ADL (Antonia et al., 2017). Antonia et al. (2017) mentioned that even though left unilateral neglect is more frequent, from a clinical perspective, it is important to screen for unilateral neglect after right- and left hemisphere damage. There are national clinical guidelines which recommend the thorough and timely screening and diagnosis of neglect as an essential part of post-stroke clinical care planning, e.g., the Royal College of Physicians London, the 9 Canadian Stroke Association (Hebert et al., 2016), the American Heart Association, and the National Stroke Foundation of Australia’s clinical guidelines for stroke management. These guidelines lack specific guidance on which of the many neglect tests would be best suited, for which subtypes of neglect and at which timepoints. There are various standardized outcome measures of neglect, or of functions that could be affected by neglect. There are tentative signs of an emerging consensus, an identified need for a combined approach to screening and diagnosis, and for further training (Checketts et al., 2021). 2.4 Outcome measures used to assess post stroke unilateral neglect Different outcome measures for unilateral neglect mostly fall into four broad categories: cognitive assessment, functional assessment, neurological assessment, and neuroimaging. Currently it is unknown how various clinical professional groups screen, assess, or diagnose unilateral neglect and whether they use any or all of the four categories (Checketts et al., 2021). A cognitive assessment for unilateral neglect refers to the measurement of skills and processes like attention and memory by means of standardised tests (Checketts et al., 2021). Examples of such a standardised test are: • The behavioural inattention test (BIT): This test is made up of 15 subtests involving target cancellation, drawing, line bisection, text reading, clock reading, and visual description (Wilson et al., 1987). The BIT only tests the patient in a peri-personal space, but it can evaluate the impact of neglect in visually based function tests (Plummer et al., 2003). Goedert et al. (2012) determined that the BIT showed good reliability. Disadvantages of the BIT include, all tests are performed only in the peri-personal space, it requires fluency in English and it is time-consuming (Plummer et al., 2003). • Cancellation tests are also examples of cognitive assessments. When performing cancellation tests, a sheet of paper with different targets is placed before the patient, and the patient is asked to cross out or cancel all the targets. Increasing the number of targets, placing them randomly on the sheet, and using foils that are difficult to discriminate from the targets are methods that can be used to increase the sensitivity of the task. It is important to note the manner in which the patient explores the sheet the patient is performing the task. The sensitivity of the task can be increased by increasing the amount of target on the sheet or by placing them in no particular order (Heilman et al., 2000). Disadvantages of cancellation tests are that they are not testing an individual in a functional capacity and if not administered correctly the sensitivity is questionable (Plummer et al., 2003). • Drawing can also be used to measure intentional or representational deficits such as the memory of one side of the objects. Drawing can be tested by letting a patient copy an examiner’s drawing or letting the patient draw spontaneously. The sensitivity of this task can be increased by using a more detailed drawing or asking the patient to copy an asymmetric figure for neglect. The more detailed the drawing, the more sensitive the task (Heilman et al., 2000). Disadvantages of these tests include that they are insensitive, difficult to interpret and have questionable validity which is why these tests are not recommended to measure unilateral neglect (Plummer et al., 2003). 10 The problem with using conventional methods of assessing unilateral neglect as mentioned above, such as the paper-and-pencil or computerised tasks, is that they are not easily translatable to functional outcome (Chen et al., 2015). A functional assessment of unilateral neglect refers to structured appraisal of a patient’s ability to perform ADLs (Checketts et al., 2021). Examples of functional unilateral neglect measures include: • The BIT as mentioned above. • The CBS is a 10-item structured functional assessment, which focuses on personal space and performance of ADLs in extra-personal space. Each item is scored by direct observation from 0-3, giving a maximum total score of 30 (Bergego et al., 1995). This standardised test can be used to diagnose personal, peri-personal and extra-personal neglect and it indicates the severity of the unilateral neglect (Plummer et al., 2003). Disadvantages of the CBS include that the score does not differentiate between personal and spatial behaviours and there is no formal description on how to administer the CBS (Plummer et al., 2003). This is why the CBS via the KF-NAP will be used in this study, which is also an example of a functional assessment (Checketts et al., 2021) and will be discussed later in this chapter. • The Two Semi-Structured Scales for the Evaluation of Hemi-inattention consists of the extra-personal hemi-neglect scale and the personal hemi-neglect scale. The extra-personal scale looks at items such as serving tea, dealing cards to four people sitting round a square table, describing three complex pictures, and describing a room. The personal scale consists of ADLs such as hair combing, shaving and putting glasses on. (Zoccolotti et al., 1992). It is also scored from a 0-3. Interrater reliability is good. A statistical analysis of the internal validity of the test showed a differentiation between extra- personal and personal items (Azouvi et al., 2017). Disadvantages of this measure includes that the personal scale still requires validation, it requires that the therapist who will administer the measure will have to be trained in rating scale and the extra-personal scale does not differentiate between peri- personal and far space (Plummer et al., 2003). Neurological assessment of unilateral neglect refers to the clinical examination of signs and symptoms including, but not specific to, those indicative of neglect (Checketts et al., 2021). In an acute phase after a stroke the National Institutes of Health Stroke Scale (Brott et al., 1989) is primarily used, this determines immediate treatment and subsequent rehabilitation and some subscales can screen for neglect. Visual field testing and extinction tests can also be used in neurological assessment (Checketts et al., 2021). Neuroimaging is used in an acute phase to determine the type of lesion, the location and the extent of the lesion, which could also foreshadow neglect (Checketts et al., 2021). These findings are then used to guide the assessment. Some professionals use these findings for a first prediction of cognitive and functional deficits by determining the lesion location and/or damage to distributed neural networks (Vuilleumier, 2013). The selection of neglect assessments varies widely across different research studies (Chen, Chen et al., 2015). This emphasises the wide variety of assessments available. A Cochrane review of cognitive 11 rehabilitation for stroke mentioned that there was no specific neglect outcome measure that was common across included studies (Bowen et al., 2013). In literature it was also determined that there were also modest differences between countries. It was also found that individual neglect-specific outcome measures generally chosen based on professional choice rather than institutional policy (Checketts et al., 2021). 2.5 Catherine Bergego Scale via KF-NAP 2.5.1 Description of the CBS via the KF-NAP The CBS is a functional scale that thoroughly assesses the functional performance in personal, peri-personal, and extra-personal spaces, as well as performance in perceptual, mental imagery and motor domains. Thus, the CBS can capture the heterogeneity of spatial neglect and is more sensitive than paper-and-pencil tests to problems in ADLs (Chen et al., 2012; Azouvi et al., 2003). Assessing spatial neglect during ADLs instead of using paper-and-pencil or computerized tasks may enable clinicians to better understand the impact of spatial neglect (Chen et al., 2014; Chen, Chen et al., 2015). The CBS takes approximately 30 minutes to administer (Plummer et al., 2003) The CBS however had no formal description on how it must be used and the additional instructions were needed for reliable CBS administration, thus the KF-NAP was created. The authors of the KF-NAP modified some of the CBS category labels to shorten some of the wording and to better explain the purpose of the observation. The KF-NAP manual also provides more information regarding observation and a more detailed scoring sheet. In the manual, the examinator is also instructed to provide the patients with verbal cuing to initiate or perform certain actions (Chen, Chen et al., 2015). The KF-NAP also specifies the environment where the observations should take place and also includes the observation of left and right asymmetry when performing tasks. The KF-NAP also focuses on observing spontaneous behaviour of participants, rather than functional ability in a certain situation. This is to enable the patients to explore their environment spontaneously. The reason why it is also important to measure right and left asymmetry, is for the examiner to have something to compare the findings to. Another description that was added, was to observe all 10 categories in one session. Scoring the patients during or immediately after a session leads to direct observation, not just summarised impressions of their behaviour (Chen, Chen et al., 2015). The KF-NAP can be seen as a process to measure unilateral neglect using the CBS. It can easily form part of the clinical assessment of ADLs and it can uniquely measure some deficits which cannot be assessed by other functional outcome measures. 2.5.2. Psychometric properties of the KF-NAP The KF-NAP provides detailed instructions for administering the tests and it includes a scoring chart for the CBS categories (Chen et al., 2014). The KF-NAP was developed to reduce ambiguity and to increase the reliability of the outcome measure (Chen et al., 2012). Reliability and Factor Structure of KF-NAP 12 Cronbach's alpha was .96, indicating excellent internal consistency. Thus, the process of the KFNAP may increase consistency among the observational categories (Chen, Chen et al., 2015). 2.5.3. Advantages and Disadvantages of the CBS via the KF-NAP The CBS via KF-NAP is highly sensitive in detecting signs of unilateral neglect, especially in those patients with mild severity, because it covers several aspects of unilateral neglect manifestations (Pitteri et al., 2018). The CBS is the only outcome measure that assesses performance in all the different spatial areas such as personal, peri-personal and also extra-personal space, as well as assessing spatial errors in various processing stages (Barrett, 2013). A disadvantage of the CBS via the KF-NAP is that even though there are personal and spatial tasks included in this measure, the score does not differentiate between whether it is personal, peri-personal or extra-personal neglect (Plummer et al., 2003). 2.5.4. Why this measure can be used in a South African setting The measure is easy to use and needs no formal instructions as the test already includes instructions and a scoring chart. There are no costs to using this outcome measure and it can be performed on patients with speech impairments since instructions are given and no questions need to be answered. There was no literature found regarding the use of the CBS via the KF-NAP in the South-African setting. 2.6 Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention 2.6.1. Description of Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention: The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention can be used as a screening tool to determine whether unilateral neglect is present in a personal or extra-personal space (Zeltzer & Menon, 2008). The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention screen patients while performing functional tasks, such as some ADLs. Menon & Korner-Bitensky (2004) reported that these subscales test some high-level activities which may be challenging for patient to perform soon-after a stroke, therefore this outcome measure is better used if the patient approaches discharge from the acute setting or when entering the sub-acute setting. It takes approximately 5 minutes to complete the Personal neglect subscale and 15 minutes to complete the Extra-personal neglect subscale (Plummer et al., 2003). 2.6.2. The Psychometric properties of Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention Zoccolotti et al. (1992) assessed the inter-item correlations of the scale and found that items within the personal subscale had adequate correlations ranging from r = 0.57 to r = 0.62, and items within the extra personal subscale had adequate correlations ranging from r = 0.44 to r = 0.71. Zoccolotti et al. (1992) also found excellent inter-rater reliability for both the personal neglect items and extra personal neglect items of the scale (r = 0.88 and r = 0.96, respectively). However, it is important to note in this study, raters underwent intense training, which may limit the generalizability of these findings (Zeltzer & Menon, 2008). 13 In a study by Zoccolotti et al. (1992) the responsiveness of the subscales was examined and the study determined that the personal neglect subscale was not responsive to clinical change following rehabilitation, but the extra personal subscale was responsive to clinical change after rehabilitative treatment. The study also determined the concurrent validity of the subscales by comparing the personal and extra-personal subscales with the patient’s performance in four other standard diagnostic tests (Line Cancellation Test, Letter Cancellation Test, Wundt-Jastrow Area Illusion Test, and Sentence Reading Test). The extra personal subscale correlated with each conventional test. However, performance on the personal subscale did not correlate with performance on these conventional tests. The authors attributed the failure of the personal scale to correlate with the conventional tests to the fact that the personal scale measures different dimensions of neglect, therefore, personal subscale requires further validation. 2.6.3. Advantages and Disadvantages of the Two Semi-Structured Scales for the Evaluation of Hemi- inattention Plummer et al. (2003) mentioned that some of the advantages of the Two Semi-Structured Scales for the Evaluation of Hemi-inattention include that it differentiates between whether personal and extra-personal neglect is present and also indicates the severity of unilateral neglect during functional tasks. Disadvantages according to Menon & Korner-Bitensky (2004) are that although this scale is quick and easy to use, it has minimal evidence of validity and thus further testing is required regarding the validity and reliability of these Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. Plummer et al. (2003) also mentioned that therapists need to be trained in the rating scale and that the extra-personal scale does not differentiate whether peri-personal or far space neglect is present. 2.6.4. Why the Two Semi-Structured Scales for the Evaluation of Hemi-inattention can be used in a South African setting The Two Semi-Structured Scales for the Evaluation of Hemi-inattention is quick and easy to use. This scale is free to use to the public. There was no literature found regarding the use of the Two Semi-Structured Scales for the Evaluation of Hemi-inattention in the South-African setting. 2.7 Conclusion of literature review The literature review was presented in this chapter and it was established that no studies mentioned unilateral neglect testing specific to South African setting taking into consideration the contextual factors such as resources (staffing and equipment). The measures that were compared in the literature review, were the BIT, cancellation tests, copying and drawing tests, the CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. The disadvantages of the BIT were that it only tests the patient in the peri-personal space, it required fluency in English, so patients with speech impairments cannot use this outcome measure and it is time consuming, taking about 40 minutes to administer (Menon & Korner-Bitensky, 2004). Cancellation tests do not functionally test impairments caused by unilateral neglect and the sensitivity is questionable, if 14 t\not administered in a specific manner. Drawing can also be used, but these tests are insensitive, difficult to interpret and the validity is questionable. After comparing the different outcome measures it was determined that the two that would be best suited for this study will be the CBS via the KF-NAP as well as Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. The main reasons for choosing these two outcome measures are that both are able to measure neglect in different spatial areas, both are functional assessments, these measures are free to use to the general public, have definite instructions on how to administer them and are also relatively quick to use. Some of the biggest differences between the CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention include that the CBS via the KF-NAP is scored out of 30 with 10 sub-categories and definite explanations of the scores with regards to severity, where the Two Semi- Structured Scales for Functional Evaluation of Hemi-inattention is scored out of a possible 27 with nine sub- categories. This CBS via the KF-NAP requires no formal training and can also be used on patients who have speech difficulties and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention requires some setup, but cannot be used for participants with severe speech impairments. It is beneficial to determine which one of these outcome measure would be better to use in South Africa to make sure there is a certain standardised test that is used throughout South Africa. This would lead to a better carry-over of patients between hospitals or clinics. It is time-consuming to administer both the CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention and more materials are required if both are to be performed. 15 CHAPTER 3: METHODOLOGY 3.1 Type of Study This study is a longitudinal quantitative descriptive study design. 3.2 Participants 3.2.1 Study Setting This study was conducted at Witrand Hospital in Potchefstroom, North West, South Africa. The rehabilitation unit is a 15-bed unit and is the only rehabilitation unit of its kind in North West. This unit caters for all sub- acute neurologically impaired rehabilitation patients in North West. It has a fully equipped gym, an indoor pool, offices for speech therapists, medical doctors and psychologists and a room including a biodex machine. This is a multi-professional unit and includes physiotherapists, occupational therapists, speech and language therapists, psychologists, social workers, dieticians, nursing staff, medical doctors and a unit manager. The unit caters to patients who have neurological conditions, such as stroke, spinal cord injuries and traumatic brain injuries. The unit caters for all age groups; however, the majority of patients are adults. Patients at the Witrand Hospital are evaluated on admission and discharge with outcome measures such as the Oxford Muscle Testing Scale, the Modified Ashworth Scale, the Berg Balance scale and Range of Motion. Patients are also scored weekly using the Functional Independence Measure (FIM) in order to give feedback of the patient to the medical aid regarding their progress within the unit during their stay. 3.2.2 Source of Participants A consecutive sampling method was used to ensure that the maximum sample size is attained. The study required the use of patient data in real time, which is why sample size determined how many patients we needed to collect the data from. The sample size was calculated using the Raosoft sample size online calculator (http://www.raosoft.com/samplesize.html) and are shown in table 3-1 below: Table 3-1 Sample size Parameters Sample size for research Margin of error Level of confidence Response distribution Population size (number of patients with stroke that the rehab unit usually has in 3 months’ time) 5% 95% 50% 45 patients 41 patients 3.2.3 Sample Selection Inclusion Criteria Participants were included in this study if they: • presented with a first-ever unilateral stroke in Witrand Hospital during the duration of the data collection. http://www.raosoft.com/samplesize.html 16 Exclusion Criteria Participants were excluded from the study if they: • had severe speech problems • were confused • had impairments or activity limitations that are not related to stroke 3.3 Instrumentation and Outcome Measures The CBS is a scale that evaluates the impact of unilateral neglect on everyday life of patients after stroke. It is a functional scale where the administrator uses direct observation of the patient’s functioning in 10 activities of daily living, such as grooming, eating, dressing, wheelchair driving, mouth cleaning, gaze orientation, left limb knowledge, auditory attention, spatial orientation and finding personal belongings (Azouvi et al., 2017). The CBS is scored from a 0-3, 0 being no neglect and 3 being severe neglect. The total score is then calculated by adding all of the scores. This then determines whether the patient has mild, moderate or severe behavioural neglect. The CBS has excellent interrater and intrarater reliability (Marques et al., 2019). The KF-NAP (Appendix I) gives a detailed description of how to use the CBS. It is used to standardise the use of the CBS which makes the results more reliable. The KF-NAP is free to use and can be obtained by anyone online and will be used accordingly. No permission is required to use this scale. The Two Semi-Structured Scales for the Functional Evaluation of Personal Neglect (Appendix II) consists of the extra-personal hemi-neglect scale and the personal hemi-neglect scale. The extra-personal scale looks at items such as serving tea, dealing cards to four people sitting round a square table, describing three complex pictures, and describing a room. The personal scale consists of ADLs such as hair combing, shaving and putting glasses on. (Zoccolotti et al., 1992). It is also scored from a 0-3. Interrater reliability is good. A statistical analysis of the internal validity of the test showed a differentiation between extra-personal and personal items (Azouvi et al., 2017). This scale is available online and is free to use by the public, no permission is required to use this scale. 3.4 Procedure 3.4.1 Pilot Study A pilot study was performed to identify potential sources of problems early on. It was done to establish responsiveness by looking at the understanding of the tests, the duration it takes and logistics in terms of booking assessment time and space as well as data capturing. Two patients participated in the pilot study and no major changes were made to the methodology; thus, these participants were also included in the final data. Patients were admitted to the rehabilitation unit on Mondays and Tuesdays. One day after the admission the researcher went to the rehabilitation unit and determined who of the patients had a stroke. The patients who 17 had a stroke and met the inclusion criteria were then recruited and informed consent was obtained. Written informed consent or verbal informed consent was given, but in some cases where the patient was unable to give the informed consent themselves the next of kin was contacted to ask for informed consent. Just before lunch the patients were taken into the rehabilitation gym. In the gym, the setup needed for the tests was already done. The researcher then conducted the study as described in the CBS via the KF-NAP. Just before dinner, the researcher conducted the study as described in the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. The CBS via the KF-NAP was administered first for the first patient, followed by the Two Semi-Structured Scales for functional evaluation of hemi-inattention. Thereafter the Two Semi- Structured Scales for Functional Evaluation of Hemi-inattention was administered first for the next patient, followed by the CBS via the KF-NAP. The tests were re-administered on a weekly basis and again on discharge. The results of these tests were noted and kept locked in a safe space, where only the researcher had access to. The information was then entered into an excel spreadsheet and a data analysis was done. 3.4.2 Main Study The procedure for the main study was the same as the procedure for the pilot study. The only difference was that the outcome measure that was used first will switch after two patients. This was done to make the setup and transitioning between the two outcome measures easier for the researcher. This means the KF-NAP was administered first for the first two patients, followed by the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. Thereafter the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention was administered first for the next two patients, followed by the KF-NAP. Then the KF-NAP was used first for the next two patients followed by the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention after which the outcome measures were switched again. This was done to ensure that the participants do not perform better in the first test and then worse in the second test due to fatigue for example. The results of these tests were noted and kept locked in a safe space, where only the researcher had access to. The information was entered into an excel spreadsheet until data analysis was done. 3.5 Ethical Considerations Ethical clearance was obtained from the University of the Witwatersrand Human Research Ethics Committee. Permission to access the patients was obtained from Witrand Hospital and the Department of health in North West (Appendix III). Patients received an information sheet and informed written consent was obtained from patients (Appendices IV & V) and in some cases where the participant was unable to give informed consent, the participant’s family were contacted. Participants were informed that they can withdraw from the study at any time without suffering any repercussions. Participants were not exposed to any risks. Information was only used for the purpose intended for this study and will only be released to the participants. All participants were assigned a number. The key to the numbers assigned will be kept in the possession of the researcher only. 18 3.6 Data Analysis A summary of the Data analysis is done in table 3-2 below. Table 3-2 Data analysis Objective Outcome measure Type of data Statistical test To assess the existence and the extent of unilateral neglect during observations of the patient CBS via KF-NAP Categorical data (total scores) Continuous data (Age of patient) Frequencies and percentages Mean and standard deviation To assess the existence of unilateral neglect during observations by means of a personal and extra- personal scale Semi-structured Scales for Functional Evaluation of hemi- inattention Categorical data (total scores) Continuous data (Age of patient) Frequencies and percentages Mean and standard deviation The data was collected, captured, coded and edited using STATA version 16 by entering the collected data into an electronic data file and creating a data set. In this study, descriptive statistical techniques were used to describe the gathered data and to provide more insight into the demographic profile of the participants. For the purpose of this study, the internal consistency reliability of the outcome measures was assessed by calculating the Cronbach’s α coefficient. This measures the average covariance between item-pairs and the variance of the total score. When a Cronbach’s alpha coefficient is greater than 0.70 or more, the measure can be considered reliable. Frequencies and percentages for qualitative variables such as the total score and the subscales of each of the CBS via KF-NAP questionnaire and the Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention were obtained. The scores were calculated for the CBS & the Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention by adding the results of each item for each patient. The different categories were also scored individually. The Pearson correlation coefficients between the CBS and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention were also calculated. In all tests, a p-value of p<0.05 was considered significant. Mean scores were determined for the participants’ ages and for the outcome measures. These different scores were retested weekly and the scores of each patient was compared to determine the responsiveness of the tests. 19 3.7 Conclusion of the methodology The study design, aims, sample size and inclusion and exclusion criteria have been presented in this chapter. The procedure and method of the study have been described, as well as the data collection, data recording and statistical analysis. The results of the study are presented in Chapter 4. 20 CHAPTER 4: RESULTS The aims of this study were to assess unilateral neglect in adult patients following a stroke using the CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. Thereafter the responsiveness of the CBS and the Two Semi-structured Scales for Functional Evaluation of Hemi- inattention in measuring unilateral neglect in an inpatient rehabilitation unit was determined. The CBS and the Two Semi-Structured Scales for Functional Evaluation were then compared with regards to the responsiveness. Results of the study are reported in this chapter, starting with the characteristics of study participants, followed by the results of the CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation for Hemi-inattention. The results of comparison of the CBS and the Two Semi-structured Scales for Functional Evaluation are also presented in this chapter. 4.1 Study Participants The number of participants admitted into Witrand Hospital during the period September 2021 until December 2021 and the recruitment of participants to the study is summarised in the flow diagram in Figure 4-1. Figure 4-1 Participants of the study Participants recruited for study n=44 Participants included in the study n=41 Participants for 1 week follow-up n=41 Participants for 2 week follow-up n=19 Participants for 3 week follow-up n=9 Participants discharged from Hospital n=10 Participants discharged from Hospital n=22 Participants excluded from the study due to severe speech impairments n=3 21 Forty-four participants that had a stroke were recruited for this study. Three participants were excluded due to severe speech impairments and no patients dropped out of this study. Forty-one participants were in hospital for the one-week follow-up. During the two-week and third week follow-up 22 and 10 of the participants (respectively) were discharged from the hospital and only patients who remained in hospital (19 and 9 participants) took part in this study. 4.1.1 Age of the study participants The age of the participants recruited in this study is summarized in Figure 4-2. Figure 4-2 Age of participants (n=41) Most of the study participants were within the age group of 60-69 years old (n=14; 34,1%). The mean age for the participants was 54 (±15.5) years with the minimum age being 18 years, and the maximum age being 83 years. 4.1.2 Gender The participant population will be discussed in the figure below (Figure 4-3). Figure 4-3 Gender distribution (n=41) 3 2 7 10 14 4 1 0 2 4 6 8 10 12 14 16 Age 18-29 Years Age 30-39 Years Age 40-49 Years Age 50-59 Years Age 60-69 Years Age 70-79 Years Age 80-89 Years Age of patients 68,3 31,7 Female Male 22 Most of the participants in the study were females (n=28; 68,3%). 4.1.3 Type and side of stroke Figure 4-4 summarizes the most common type of stroke as the side of the brain that was most affected. Figure 4-4 Type and side of stroke (n=41) The most common type of stroke was an ischaemic stroke affecting 31 participants of the study (75,6%). The most common hemisphere that was affected by a stroke in this study population was a stroke in the left hemisphere, affecting 20 of the participants (49%). 4. 2. Catherine Bergego Scale via the KF-NAP The results of the CBS via the KF-NAP are presented in Table 4-1. Table 4-1 Unilateral neglect scores of participants when using the CBS via the KF-NAP Baseline scores (n=41) One-week follow-up (n=41) Two-week follow-up (n=19) Three-week follow-up (n=9) No neglect 7 (17,1%) 10 (24,4%) 4 (21,0%) 0 (0%) Neglect 34 (82.9%) 31 (75,6%) 15 (79,0%) 9 (100%) Mild severity of neglect 22 (53,7%) 19 (46,3%) 12 (63,2%) 8 (88,9%) Moderate severity of neglect 9 (21,9%) 9 (21,9%) 3 (15,8%) 1 (11,1%) Severe neglect 3 (7,3%) 3 (7,3%) 0 (0%) 0 (0%) When administering the Catherine Bergego Scale via the KF-NAP it was determined that 82,9% (n=34) of the participants experienced unilateral neglect to some degree and 17,1% of the participants (n=7) experienced no neglect during admission to the Rehabilitation unit. Most of the participants in this study experienced mild severity of neglect (n=22, 53,7%) at baseline. There were no patients with severe neglect during the two- and three-week follow-up. There is a decrease in the CBS via the KF-NAP scores from baseline to the two-week follow-up. 75% 15% 10% Ischaemic Haemorrhagic Other 41% 49% 10% Right hemisphere stroke Left hemisphere stroke Other 23 The sub-categories results of the CBS via the KF-NAP are presented in Table 4-2. 24 Table 4-2 The subcategory scores of the CBS via the KF-NAP over the course of the study Absent (0) Mild (1) Moderate (2) Severe (3) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Gaze orientation 18 (43,9%) 19 (46,3%) 8 (42,1%) 4 (44,4%) 11 (26,8%) 18 (43,9%) 10 (52,6%) 5 (55,5%) 10 (24,4%.) 4 (9,8%) 1 (5,3%) 0 (0%) 2 (4,9%) 2 (4,9%) 0 (0%) 0 (0%) Limb awareness 9 (21,9%) 15 (36,6%) 7 (36,9%) 3 (33,3%) 21 (51,2%) 18 (43,9%) 11 (57,9%) 5 (55,5%) 9 (21,9%) 8 (19,5%) 1 (5,3%) 1 (11,1%) 2 (4,9%) 0 (0%) 0 (0%) 0 (0%) Auditory attention 28 (68,3%) 29 (70,7%) 16 (84,2%) 7 (77,8%) 9 (21,9%) 8 (19,5%) 2 (4,9%) 2 (22,2%) 3 (7,3%) 4 (9,8%) 1 (5,3%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Personal belongings 22 (53,7%) 24 (58,5%) 12 (63,2%) 6 (66,7%) 11 (26,8%) 10 (24,4%) 6 (31,6%) 2 (22,2%) 7 (17,1%) 5 (12,2%) 1 (5,3%) 1 (11,1%) 2 (4,9%) 2 (4,9%) 0 (0%) 0 (0%) Dressing 12 (29,3%) 18 (43,9%) 8 (42,1%) 4 (44,4%) 18 (43,9%) 13 (31,7%) 9 (47,4%) 4 (44,4%) 7 (17,1%) 10 (24,4%) 2 (10,5%) 1 (11,1%) 4 (9,8%) 4 (9,8%) 0 (0%) 0 (0%) Grooming 15 (36,6%) 19 (46,3%) 8 (42,1%) 3 (33,3%) 18 (43,9%) 17 (41,5%) 10 (52,6%) 5 (55,6%) 8 (19,5%) 5 (12,2%) 1 (5,3%) 1 (11,1%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) Navigation 18 (43,9%) 20 (48,8%) 9 (47,4%) 4 (44,4%) 15 (36,6%) 14 (34,1%) 9 (47,4%) 4 (44,4%) 7 (17,1%) 6 (14,6%) 1 (5,3%) 1 (11,1%) 1 (2,4%) 0 (0%) 0 (0%) 0 (0%) Collisions 19 (46,3%) 21 (51,2%) 6 (31,6%) 3 (33,3%) 12 (29,3%) 11 (26,8%) 10 (52,6%) 5 (55,6%) 9 (21,9%) 8 (19,5%) 3 (15,8%) 1 (11,1%) 1 (2,4%) 1 (2,4%) 0 (0%) 0 (0%) Meals 17 (41,5%) 21 (51,2%) 10 (52,6%) 2 (22,2%) 11 (26,8%) 9 (21,9%) 6 (31,6%) 6 (66,7%) 11 (26,8%) 10 (24,4%) 3 (15,8%) 1 (11,1%) 2 (4,9%) 1 (2,4%) 0 (0% 0 (0%) Cleaning after meals 16 (39,0%) 20 (48,8%) 10 (52,6%) 2 (22,2%) 12 (29,3%) 9 (21,9%) 5 (26,3%) 6 (66,7%) 9 (21,9%) 10 (24,4%) 4 (21,1%) 1 (11,1%) 4 (9,8%) 2 (4,9%) 0 (0%) 0 (0%) 25 When comparing the CBS via the KF-NAP scores as seen above during the two-week follow-up and the three-week follow-up there were no participants with severe neglect sub-category scores. During admission most of the participants with neglect (n=21 ;51,2%) experienced mild severity of neglect in the category of limb awareness and the second highest scoring categories were dressing and grooming (n=18; 43,9%). With the one-week follow-up, limb awareness was still the highest scoring sub category (n=18; 43,9%), followed by grooming (n=17; 41,5%). The two-week follow-up had less participants (n=19), but also showed limb awareness as the highest scoring subcategory (n=11; 57,9%), followed by gaze orientation, grooming and collisions (n=10; 52,6%). There were nine participants during the third-week follow-up, which showed the highest scoring subcategory as meals and cleaning after meals (n=6; 66,7%). 4.3 The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention The results of the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention are presented in Table 4-3 below. Table 4-3 Unilateral neglect scores of participants by using the Two Semi-Structured Scales Baseline (n=41) One-week (n=41) Two-week (n=19) Three-week (n=9) No neglect 11(26,8%) 13 (31,7%) 6 (31,6%) 0 (0%) Neglect 30 (73,2%) 28 (68,3%) 13 (68,4%) 9 (100%) Mild severity of neglect (1-10) 17 (41,5%) 18 (43,0%) 12 (63,2%) 8 (88,9%) Moderate severity of neglect (11-20 11 (26,8%) 9 (21,9%) 1 (5,3,8%) 1 (11,1%) Severe neglect (21-27) 2 (4,9%) 1 (2,4%) 0 (0%) 0 (0%) When using the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention 30 participants (73,2%) experienced unilateral neglect to some degree and 11 participants (26,8%) experienced no neglect during admission to the Rehabilitation unit. Most of the participants in this study experienced mild severity of neglect (n=17, 41,5%) at baseline. There were no patients with severe neglect during the two- and three- week follow-up. There is a steady decrease in the scores of the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention over the course of the one- and two-week follow-up. The subcategory scores of the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention are presented in Table 4-4. 26 Table 4-4 Subcategories of the Two Semi-Structured Scales for the duration of this study Absent (0) Mild (1) Moderate (2) Severe (3) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Baseline (n=41) One- week (n=41) Two- week (n=19) Three- week (n=9) Tea Serving 19 (46,3%) 19 (46,3%) 7 (36,8%) 3 (33,3%) 13 (31,7%) 14 (34,1%) 11 (57,9%) 5 (55,6%) 7 (17,1%) 7 (17,1%) 1 (5,3%) 1 (11,1%) 2 (4,9%) 1 (2,4%) 0 (0%) 0 (0%) Card dealing 19 (46,3%) 21 (51,2%) 8 (41,1%) 3 (33,3%) 11 (26,8%) 11 (26,8%) 10 (52,7%) 5 (55,6%) 10 (24,4%) 8 (19,5%) 1 (5,3%) 1 (11,1%) 1 (2,4%) 1 (2,4%) 0 (0%) 0 (0%) Picture description 1 17 (41,5%) 20 (48,8%) 12 (63,2%) 5 (55,6%) 14 (34,1%) 15 (36,6%) 6 (31,6%) 3 (33,3%) 9 (21,9%) 5 (12,1%) 1 (5,3%) 1 (11,1%) 1 (2,4%) 1 (2,4%) 0 (0%) 0 (0%) Picture description 2 15 (36,6%) 17 (41,5%) 12 (63,2%) 4 (44,4%) 14 (34,1%) 17 (41,5%) 6 (31,6%) 4 (44,4%) 10 (24,4%) 5 (12,1%) 1 (5,3%) 1 (11,1%) 2 (4,9%) 2 (4,9%) 0 (0%) 0 (0%) Picture description 3 13 (31,7%) 14 (34,1%) 7 (36,8%) 1 (11,1%) 12 (29,3%) 14 (34,1%) 11 (57,9%) 7 (77,8%) 10 (24,4%) 8 (19,5%) 1 (5,3%) 1 (11,1%) 6 (14,6%) 5 (12,1%) 0 (0%) 0 (0%) Environmental description 14 (34,1%) 15 (36,6%) 8 (42,1%) 3 (33,3%) 18 (43,9%) 21 (51,2%) 10 (52,7%) 4 (44,4%) 6 (14,6%) 3 (7,3%) 1 (5,3%) 2 (22,2%) 3 (7,3%) 2 (4,9%) 0 (0%) 0 (0%) Comb hair 16 (39,0%) 18 (43,9%) 9 (47,4%) 3 (33,3%) 16 (39,0%) 18 (43,9%) 9 (47,4%) 5 (55,6%) 8 (19,5%) 5 (12,1%) 1 (5,3%) 1 (11,1%) 1 (2,4%) 0 (0%) 0 (0%) 0 (0%) Groom 14 (34,1%) 17 (41,5%) 8 (42,1%) 2 (22,2%) 17 (41,5%) 17 (41,5%) 10 (52,7%) 6 (66,7%) 9 (21,9%) 6 (14,6%) 1 (5,3%) 1 (11,1%) 1 (2,4%) 0 (0%) 0 (0%) 0 (0%) Glasses 26 (63,4%) 27 (65,8%) 13 (68,4%) 5 (55,6%) 9 (21,9%) 10 (24,4%) 5 (26,3%) 3 (33,3%) 6 (14,6%) 4 (9,8%) 1 (5,3%) 1 (11,1%) 0 (0%) 0 (0%) 0 (0% 0 (0%) 27 On admission and during the one-week follow-up there were participants who experienced severe neglect, however there were no participants who experienced severe neglect during the two-week and three-week follow-up. The highest scoring subcategory for participants experiencing neglect during admission was the environmental description (n=18; 43,9%), followed by grooming (n=17; 41,5%). During the one-week follow- up the highest scoring category was also the environmental description (n=21; 51,2%), followed by hair combing (n=18; 43,9%). During the two-week follow-up the highest scoring subcategories were tea serving and picture description (n=10; 52,7%) and with the three-week follow-up the highest scoring subcategory was picture description (n=7; 77,8%), followed by grooming (n=6; 66,7%). 4.4 Comparison between the two outcome measures: The mean scores of the two outcome measures over the four-week period are presented in Table 4-5. Table 4-5 The mean scores of the outcome measures over the four-week period Baseline Mean (SD) One-week follow-up Mean (SD) Two-week follow-up Mean (SD) Three-week follow-up Mean (SD) CBS via the KF-NAP/30 8,5 (±7.5) 7,1 (±7,0) 5,9 (±5.3) 6,6 (±4,5) Two Semi-Structured Scales/27 8,0 (±7,1) 6,9 (±6,5) 5,1 (±4,7) 6,7 (±4,5) SD: Standard deviation As seen in the table above there was a steady decrease in mean scores of the CBS via the KF-NAP as well as the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention from baseline to the two- week follow-up. Table 4-5 is put into a graph in Figure 4-5, to show how the mean score of the two outcome measures has changed over the duration of the study. 28 Figure 4-5 The mean scores of the outcome measures over the four-week time period When comparing the CBS via the KF-NAP to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention it can be seen that both scales show a steady decrease in scores from the first week to the third week, with a slight increase toward week four. The CBS via the KF-NAP, as shown by the light blue line, starts slightly higher, where the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention, shown by the darker blue line, is slightly lower. This graph shows that the unilateral neglect detection rate is slightly higher in the CBS via the KF-NAP, compared to the Two Semi-Structured Scales. The two lines show the same trajectory when using the mixed model, when comparing the mean score over the four-week hospital stay (Figure 4-5). The p-value comparing mean scores of the two outcome measures is 0,308 which shows that statistically there was no difference when comparing the two outcome measures. The p-value for the time period of the 4 weeks was <0,001, which shows that there was a statistically significant change in the scores over the course of the study. 4.5 Differences in data collection process between The CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention Some of the differences while comparing the two outcome measures were that the Two Semi-structured Scales for Functional Evaluation of Hemi-inattention took about 20 minutes to be administered compared to the CBS via the KF-NAP which took 10-15 minutes. The patients struggled more with the Two Semi- Structured Scales for Functional Evaluation of Hemi-inattention with regards to the picture description category. The participants found it difficult to describe Tissot’s painting titled: The dance on the ship, which could be because this painting is quite far from this population’s frame of reference. It was slightly easier to administer the CBS via the KF-NAP and there was less setup required. The CBS via the KF-NAP also had specific instructions with regards to the implementation and interpretation of findings. The CBS via the KF- NAP could be used on all patients, even the patients with severe speech impairments, as the patients do not have to describe any content, whereas due to the Two Semi-Structured Scales for Functional Evaluation of 0 1 2 3 4 5 6 7 8 9 Baseline One-week Two-week Three-week M ea n Sc or es CBS via KF-NAP Two Semi-Structured Scales 29 Hemi-inattention some patients could not be used in this study as they had to describe different pictures as well as the environment surrounding them. 4.6 Conclusion of the results The CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention were able to determine that hemi-neglect was present in patients in the Rehabilitation unit. Over the period of admission to the Rehabilitation unit, there were definite changes in the scores of the severity of hemi- neglect from admission to discharge with a decrease of neglect over time. The CBS and the Two Semi- Structured Scales for Functional Evaluation of Hemi-inattention were able to detect these changes over time and were both seen as responsive outcome measures. There were no statistically significant differences when comparing the responsiveness of the two outcome measures: the p-value was 0,308 (which is >0,05) which shows that statistically there was no differences when comparing the two scales. The CBS via the KF- NAP was however easier and quicker to administer compared to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. 30 CHAPTER 5: DISCUSSION The aim of this study was to compare the CBS via the KF-NAP to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention when measuring unilateral neglect in adult patients following a stroke in a neurological rehabilitation unit. Chapter 5 will discuss the main findings of the research and the comparison between the different outcome measures. 5.1 Participants The sample size for this study was 41 patients who were admitted to Witrand Hospital over the data collection period. Forty-four participants were originally recruited, but 3 participants were not included in this study due to severe speech impairments. The participants had a mean age of 54 years (±15,5 years), this is similar to a study done by Azouvi et al. (2003) where 83 participants were recruited with a mean age of 54,5 years (±15,9). Goedert et al. (2012) recruited 51 patients and the mean age of participants in this study was 57 years (±8) and in a study by Beis, et al. (2004) 78 participants were recruited, and the mean age was 54,6 years (±15,7). Kenneth et al. (2007) recruited 54 participants; the mean age of the participants was 69.7 (±10.5) years. Nishida et al. (2021) recruited 23 patients for the CBS group and 22 participants for the KF- NAP group, the mean age of the CBS group was 64,4 years (±12,2) and the mean age of the KF-NAP group was 65,4 years (±13,5). The participants in the current study are thus comparable to these other studies in sample size and age. The participants in this study were predominantly female (n=28, 68,3%) and when comparing these findings to other studies, Beis et al. (2004) had 58.9% male participants and Kenneth et al. (2007) had thirty-four (63%) male participants. Nishida et al. (2021) recruited 17 male participants (73,9%) and six female participants (26,1%) in the CBS group and there were 17 males (77,3%) and five females (22,7%) in the KF- NAP group. The reason why the study participants were predominantly female in this study, could be due to the fact that more females are affected by stroke in South Africa. According to the Southern Africa Stroke Prevention Initiative (2004) 66 of their participants were female stroke survivors compared to only 37 males. Participants in this study diagnosed with right hemisphere stroke made up 41,4% (n=17) of the population and 49% (n=20) of the participants were diagnosed with strokes affecting the left hemisphere of the brain. These findings are in line with the literature which showed left-hemispheric strokes were more common (54%) than right-hemispheric strokes (46%) (Hedna et al., 2013). In this study the most common stroke was an ischaemic stroke (n= 31; 75,6%) compared to 14,6% (n=6) of participants experiencing haemorrhagic stroke. When comparing these findings to previous studies, Beis et al. (2004) reported 69,3% of their population had ischaemic stroke, Azouvi et al. (2003) reported that 55,4% of their cases were ischaemic stroke and Nishida et al. (2021) mentioned that 65,2% of their participants had ischaemic stroke. When looking at global statistics, it is indicated that ischaemic stroke constitutes the largest proportion of all new strokes, followed by intracerebral haemorrhage and subarachnoid haemorrhage (Global 31 Burden of Diseases, Injuries and Risk Factors Study, 2021). This comparison between these studies indicates that ischaemic stroke is the most common type of stroke and the participants in this study are thus a reflection of a typical stroke population. 5.2. Unilateral neglect scores of study participants 5.2.1. The CBS via the KF-NAP The Catherine Bergego Scale via the KF-NAP was used to determine presence of unilateral neglect and it was established that on admission the majority of the participants experienced neglect (n=34, 82,9%). The neglect varied in severity and most of the participants experienced only a mild severity of neglect (n=22, 53,7%), followed by moderate severity of neglect (n=9, 21,9%). Nishida et al. (2021) determined that the KF- NAP diagnosed neglect in 63,6% of their participants and Chen et al. (2015) reported that 67,8% of their participants had spatial neglect when using the KF-NAP. Thus, in this study, the percentage of patients who experienced neglect, was slightly higher when being compared to other studies that were previously done. This could be due to the fact that the other studies had participants scoring higher in the moderate to severe categories, compared to the participants in this study that have mostly mild severity of neglect. Limb awareness was the highest scoring sub-category on admission (n=21; 51,2%) and throughout the study. The reason for the limb awareness scoring the highest could be because it was observed that a considerable number of patients will forget about their limb throughout the session, whether it was during ADLs, eating or with propelling the wheelchair. 5.2.2. The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention determined that 30 of the participants (73,2%) experienced hemi-neglect to some degree on admission to Witrand Hospital. The total mean score on admission was 8,0 (±7,1) and this score is comparable to scores mentioned by van Kessel, et al. (2013). The highest scoring sub-categories of the Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention was the environmental description (n=18; 43,9%) and grooming (n=17; 41,5%). reason the participants scored high in the environmental description could be due to the fact that it is an unknown environment for them in the hospital, the grooming could have scored high due to the fact that they did not always understand what the instrument is that is given to them and the picture description scored high, because some of the pictures used in this scale are outdated and not used frequently in their frame of reference. 5.2.3 Comparing the CBS to the Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention As seen in this study, the unilateral neglect scores were lower at discharge compared to higher scores during admission. More participants experienced severe neglect during admission, these scores decreased weekly and by the last week 0 participants (0%) experienced severe neglect. Chen et al. (2015) also reported a 32 decrease in neglect scores from admission to discharge. This study seems to follow the same trend as Chen et al. (2015). The CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention were both able to determine whether hemi-neglect is present in an individual. The CBS via the KF-NAP has a slightly higher unilateral neglect detection rate when compared to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention. This could also be due to the CBS via the KF-NAP being scored out of a possible 30 points and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention having a total score of 27. Both of these outcome measures also test neglect in special areas, such as personal or extra-personal space and both these outcome measures do not differentiate whether neglect is due to sensory or motor neglect. The CBS via the KF-NAP measures the participant’s functioning in 10 activities of daily living, such as grooming, eating, dressing, wheelchair driving, mouth cleaning, gaze orientation, limb awareness, auditory attention, spatial orientation and finding personal belongings. The Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention looked at items such as serving tea, dealing cards to four people sitting round a square table, describing three complex pictures, and describing a room, as well as ADLs such as hair combing, shaving and putting glasses on. In this study there was also a steady decrease in the mean score values from baseline to the two-week follow- up, with a slight increase at the three-week follow-up, but this score was still lower than on admission. In a study done by van Kessel et al. (2013) the mean scores for admission were higher than the scores on discharge. This study is thus comparable to other studies when looking at the downward trend of the mean scores from admission to discharge. The unilateral neglect detection rate of the CBS via the KF-NAP was slightly higher than that of the Two Semi-Structured Scales for Hemi-inattention as seen in Figure 4-5. In the study by Nishida et al. (2021) the KF-NAP detection rate was also higher than the measure they compared it against, the BIT. The BIT measured in neglect in 22,7% of the participants in the study compared to the CBS that measured neglect to some extent in 63,6% of the participants. The CBS via the KF-NAP has a lot of functional items and also requires a lot of observation when the participants are performing ADLs (Chen et al., 2012), this could be the reason for the higher detection rate. When looking at the sub-categories, one of the categories of the CBS via the KF-NAP that the participants scored higher in during admission, was the limb awareness, with 32 participants (78,0%) forgetting about their limbs at some time during a session, which could be due to sensory or motor impairment. This limb awareness category continued to score slightly higher compared to the others throughout the study. With the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention, the sub-categories that participants scored higher in, were the picture descriptive categories. This could be because the participants 33 struggled to understand some of the pictures such as Tissot’s painting titled: The dance on the ship. This could be due to the painting being outdated and not fitting in to this patient population’s frame of reference. In this study, as mentioned above, there was a difference in the weekly unilateral neglect scores when looking at the CBS via the KF-NAP as well as the Two Semi-Structured Scales for Functional Evaluation of Hemi- inattention. These scores showed a definite change and steady decrease, with this it is seen that both outcome measures were able to detect change in unilateral neglect over a period of time, making both these outcome measures responsive when testing unilateral neglect. When comparing these two outcome measures in terms of responsiveness, there was no statistically significant differences between the two outcome measures, thus concluding that either of these outcome measures are responsive when measuring unilateral neglect in patients following a stroke in an in-patient rehabilitation setting. The CBS via the KF-NAP scores were however slightly higher compared to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention, which indicated that the CBS via the KF-NAP detected more people with unilateral neglect. There was a slight increase in participants experiencing neglect compared to those experiencing no neglect by week-four. This is because all of the participants who were in hospital by week four experienced neglect, which increased the mean scores. This could be due to the fact that the participants who were kept in hospital so long had more severe neglect compared to those who were discharged sooner. These participants have significant impairments and decreased functionality and are therefore kept longer to attempt to improve their functionality, since unilateral neglect increases length of stay in hospital. Chen, Hrera et al. (2015) mentions that average length of stay were ten days longer in participants with unilateral neglect. Both of these outcome measures can be used in a rehabilitation setting in South Africa, however the CBS via the KF-NAP is the recommended outcome measure. The CBS via the KF-NAP was easier to administer and easier for the patients to understand. The CBS via the KF-NAP provided less challenges with regards to the patient understanding and if the patient had speech impairments if compared to the Two Semi-Structured Scales for Hemi-inattention. 5.3 Conclusion of the discussion The study has compared the responsiveness of the CBS via the KF-NAP to the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention and found no statistically significant difference between the two outcome measures with regards to the responsiveness. This means that either of these scales can be effectively used to determine changes in unilateral neglect in patients over a period of time. There was a steady decrease in the mean scores of both the CBS via the KF-NAP and the Two Semi-Structured Scales for Functional Evaluation of Hemi-inattention from admission to discharge. Both the different outcome measures followed this trend. 34 The recommended outcome measure to use is the CBS via the KF-NAP. This