379 A/&/J 3C3i

THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS

WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF

FIELD OF PRESENTATION AND CUEING

DISSERTATION

Presented to the Graduate Council of the

University of North Texas in Partial

Fulfillment of the Requirements

For the Degree of

DOCTOR OF PHILOSOPHY

By

Vicki Marlene Soukup

Denton, Texas

August, 1992

379 A/&/J 3C3i

THE ASSESSMENT OF COGNITIVE FUNCTIONING AMONG PATIENTS

WITH UNILATERAL VISUAL NEGLECT: EFFECTS OF

FIELD OF PRESENTATION AND CUEING

DISSERTATION

Presented to the Graduate Council of the

University of North Texas in Partial

Fulfillment of the Requirements

For the Degree of

DOCTOR OF PHILOSOPHY

By

Vicki Marlene Soukup

Denton, Texas

August, 1992

Soukup, Vicki Marlene, The Assessment of Cognitive

Functioning among Patients with Unilateral Visual Neglect:

Effects of Field of Presentation and Cueing. Doctor of

Philosophy (Clinical Psychology), August, 1992, 122 pp.,

11 tables, 3 illustrations, references, 122 titles.

Prior evidence has shown a reduction of neglect on line

bisection tasks as a function of altered hemispace

presentation and left cueing. The present study was

conducted to examine the effect of these factors in reducing

symptoms of neglect on measures of general cognitive

functioning.

To examine proposed changes, revised versions of the

Raven's Coloured Progressive Matrices and the Memory-for-

Designs (MFD) Test were constructed by placing the target

stimuli in the right hemifield. Two experimental

presentations, a right hemispace condition and a right

hemispace plus left cue prompt condition, were compared to

the standard presentation format. The primary hypotheses

predicted that RBD neglect patients would reveal enhanced

performance on the criterion measures as a result of these

manipulations. Significant correlations were predicted

between the neglect measures and between the two scoring

systems for the MFD.

The sample was comprised of 54 hospitalized patients,

assigned to either a RBD neglect group (N = 18), a RBD

nonneglect group (N = 18) , or an orthopedic control group (N

= 18) . Both RBD groups were administered the Mini Inventory

of Right Brain Injury, to document the presence and severity

of right brain injury. Presence of neglect was assessed via

the Schenkenberg Line Bisection Task and the Bells Test for

Visual Neglect. Subjects were examined under all three

conditions by administering one third of the items for each

condition.

Neglect subjects demonstrated significantly poorer

performance on both criterion measures than the two

comparison groups. However, no significant improvement in

performance was revealed with right hemispace presentation

of stimuli or left cue prompts combined with the right

hemispace version. Ancillary predictions concerning

correlations for the neglect measures and MFD scoring

systems were confirmed.

Results are interpreted in terms of increased

attentional demands and task complexity. These results

suggest that, despite the frequent clinical use of these

manipulations in the cognitive assessment of this

population, support for the efficacy of these procedures is

lacking.

TABLE OF CONTENTS

Page

LIST OF TABLES iv

LIST OF ILLUSTRATIONS V

Chapter

I. INTRODUCTION 1

Anatomical Correlates Animal Literature Theories of Neglect Incidence of Neglect Recovery of Function Assessment of Neglect Factors Affecting the Manifestation of Neglect Independent Deficit or Global Cognitive

Deterioration Defective Performance on the Raven's Coloured

Matrices Memory-for-Designs Test Summary and Statement of Hypotheses

II. METHOD 4 0

Subjects Procedure Instruments

III. RESULTS 50

IV. DISCUSSION 59

APPENDICES 68

REFERENCES 107

i l l

LIST OF TABLES

Table Page

1. Sample Characteristics and Group Performance

on Screening Measures 72

2. Clinical Data for Neglect Subjects 74

3. Clinical Data for RBD W/0 Neglect Subjects . . 75 4. Correlation Matrix for Subject Characteristics,

Screening Measures, and Dependent Variables . . 76

5. Group Means and Standard Deviations for the Raven's Coloured Progressive Matrices (RCPM) and the Memory-for-Designs (MFD) Tests . . . . 79

6. Tests for Equality and Compound Symmetry for the Dependent Variables 80

7. Analysis of Variance with Repeated Measures on One Factor for Raven's Coloured Progressive Matrices (RCPM) Scores 81

8. Analysis of Variance with Repeated Measures on One Factor for Memory-for-Designs (MFD) Test (Graham-Kendall Scoring) 82

9. Analysis of Variance with Repeated Measures on One Factor for Memory-for-Designs (MFD) Test (Modified Taylor Scoring System) 83

10. Components Found to Influence the Expression of Neglect 84

11. Comparison of RCPM Group Performance for RBD Patients and Controls 87

IV

LIST OF ILLUSTRATIONS

Figure Page

1. Raven's Coloured Progressive Matrices Group Means for Each Presentation 55

2. Memory-for-Designs Mean Error Scores (Graham-Kendall Scoring System) 56

3. Memory-for-Designs Mean Error Scores (Modified Taylor Scoring System 57

CHAPTER I

INTRODUCTION

Converging evidence from neurophysiological and

clinical studies points to the presence of a neuronal

apparatus in each hemisphere which functionally mediates the

shift of attention and of head and eye movements to the

contralateral space. This mechanism implements its scanning

as soon as a novel stimulus appears; however, if this

mechanism is disrupted by a unilateral lesion, the patient

is no longer aroused by events occurring in that space and

will not respond to them (De Renzi, Gentilini, Faglioni, &

Barbieri, 1989). This phenomenon is known as unilateral

neglect, but has also been referred to in the literature as

unilateral spatial neglect, hemispatial agnosia,

hemi-inattention or hemi-neglect (Fox, 1983).

Initially described by Oppenheimer (1883) and by Holmes

(1919), and then discussed in detail by Brain (1941),

unilateral spatial neglect was regarded as a disorder of

attention confined to one-half of space. In Brain's three

patients, large right parietal lesions were present. Brain

(1941) concluded that visual neglect was usually seen after

damage to the right hemisphere, and was thus encountered as

left visual neglect. He indicated that the symptom was not

due to visual-field or oculomotor abnormalities.

1

Brain damaged patients demonstrating neglect are

unaware of body side or extrapersonal space contralateral to

the site of the lesion. In severe cases, the affected

individual persistently lacks awareness of sensory stimuli

in the affected hemifield (Critchley, 1966). In other

cases, lack of awareness is manifest episodically, only when

there are simultaneous competing sensory stimuli in the

normal hemifield (eg., Heilman & Valenstein, 1972b).

Typical behavioral manifestations have been described in

terms of failure to complete the left side of drawings

(Colombo, De Renzi, & Faglioni, 197 6), to respond to oral

commands from the left side of space (Heilman & Valenstein,

1979), to eat food from the left side of the plate, and to

recognize the limbs on the left side as his/her own

(Friedland & Weinstein, 1977).

Neglect can occur for stimuli presented in the visual,

auditory, or tactile modalities, but Riddoch and Humphreys

(1983) contend that patients rarely demonstrate neglect in

all of these modalities. Conceptual neglect has been

documented in the studies by Bisiach and Luzzatti (1978) and

a distinct, nonsensory form of motor neglect has been

described by Laplane and Degos (1983). Halsband, Gruhn, and

Ettlinger (1985) identified 30 individuals as having neglect

from a sample of 84 unilaterally injured patients, with 20

of these patients showing only one form of neglect and 10

subjects revealing various combinations of neglect.

Analysis of patient performance indicated that mixed neglect

seems to differ qualitatively from unimodal neglect. Mixed

neglect, tactile, and motor neglect were reported as easy to

discriminate from other kinds of neglect; whereas, visual

and auditory neglect were less easy to discriminate,

particularly from patients without neglect.

Anatomical Correlates

Instances of neglect have traditionally been considered

to occur following lesions in the right parietal lobe

(Brain, 1941; Critchley, 1966). More recent case studies,

however, have reported virtually identical and in certain

instances, more persistent and severe inattention to the

left extrapersonal space after right hemisphere lesions in

the frontal lobe (Heilman & Valenstein, 1972b; Stein &

Volpe, 1983), the thalamus (Watson & Heilman, 1979; Watson,

Valenstein, & Heilman, 1981) and the basal ganglia (Damasio,

Damasio, & Chui, 1980). These findings are consistent with

models that propose multiple cerebral structures, including

the posterior parietal and the frontal cortex, are involved

in a neural network responsible for the modulation of

directed spatial attention (Mesulam, 1981).

The data presented by Vallar and Perani (1986), using

CT-scans of 110 right hemisphere stroke patients, has

provided support for the traditional view that neglect is

more frequently associated with retrorolandic damage. Their

results indicated that the inferior parietal lobule was the

area most frequently involved in patients with cortical

lesions showing signs of neglect. In their analysis,

frontal lesions and damage confined to the subcortical white

matter were rarely found to be associated with neglect.

When the lesion was confined to deep structures, neglect

occurred much more frequently when grey nuclei such as the

thalamus and basal ganglia were damaged.

On the other hand, evidence presented by Spiers and

colleagues (1990) lends support for the role of frontal

activity in neglect symptomatology. These researchers

examined hemispheric asymmetries in the spatial distribution

of attention using a rather unique paradigm involving the

artificial induction of neglect via intracarotid sodium

amobarbital tests. Scanning performance was correlated with

EEG activity, in an effort to identify the anatomic locus of

control for directed attention to extrapersonal space. The

results indicated that disruption of scanning and

contralateral neglect occurred only after right hemisphere

suppression and seemed specifically related to changes in

right frontal lobe EEG activity. The resolution of neglect

appeared to coincide most closely with the resumption of

normal electrophysiological activity in the frontal areas.

This pattern of performance was revealed for right handed

and left handed subjects, as well as those who had right

hemisphere language dominance. While this study provides

strong support for the presence of a lateralized attentional

network, further investigation with a nonCNS impaired

sample, as opposed to epileptic patients, is warranted.

Also, consistent findings revealed via PET neuroimaging

would provide strong confirmatory evidence to resolve these

anatomical foci disputes.

Animal Literature

The experimental evidence provided by ablation studies

in animals has yielded some interesting findings concerning

the lesion site controversy. In monkeys, contralateral

multimodal sensory neglect has often been produced by

unilateral dorsolateral frontal damage (Bianchi, 1895;

Kennard & Ectors, 1938). Acutely, animals demonstrate

spontaneous circling to the side of the lesion, with disuse

of the contralateral upper extremity and face. They do not

orient to visual or somatosensory stimuli contralateral to

the lesion. Recovery from neglect proceeds spontaneously.

After small removals in the superior limb of the arcuate

sulcus, recovery is complete within two weeks (Welsh &

Stuteville, 1958); whereas, larger lesions comprising

frontal "polysensory" associative cortex show recovery in 4-

10 weeks (Deuel & Dunlop, 1979; Deuel, Collins, & Caston,

1980).

Despite various implications to the contrary, visual

neglect has never been observed as a consequence of parietal

ablations in monkeys. The report by Heilman and colleagues

(1970), often cited as evidence for neglect in parietal

monkeys, in reality describes extinction, i.e., failure to

respond to a unilateral stimulus exclusively in the

condition of bilateral simultaneous stimulation. Other

reports have documented neglect in animals as a result of

lesions in the anterior cingulate gyrus (Watson, Heilman,

Cauthen, & King, 1973), the lateral hypothalamus (Deuel,

1980), superior colliculus (Flandrin & Jeannerod, 1981), and

mesencephalic reticular formation (Watson, Heilman, Miller,

& King, 1974) .

Deuel and Collins (1983) have provided direct evidence

that a network of specific foci, rather than a single center

or wide expanses of heterogeneous neural tissue, undergoes

metabolic depression in neglect. Differences in 2-deoxyl

14C glucose (DG autoradiography) utilization were reported

following removal of the right frontal associative cortex of

the macaque monkeys. During the acute phase, utilization

was selectively decreased in the damaged hemisphere;

specifically, in the striatum, motor nuclei of the thalamus,

nucleus medialis dorsalis, and the deep layers of the

superior colliculus (i.e., in subcortical structures rather

than in cortical regions to which frontal cortex projects).

After recovery, there was decreased metabolic activity only

in the nucleus medialis dorsalis. No consistent glucose

utilization changes appeared in cortex or in primary motor

or sensory pathways. Brains from unoperated control animals

did not exhibit these changes, nor did brains from operated

animals with behavioral recovery from neglect. These

findings suggest that in frontal monkeys, neglect is based

on depression of neuronal activity in widespread uninjured

subcortical structures with synaptic relations to the

ablated cortex; return of neuronal activity in these

structures parallels recovery from manifestations of

neglect.

Theories of Neglect

The cerebral mechanisms underlying neglect and

hemi-inattention have been the subject of intense

speculation. Early theories revolved largely around

afferent sensory defects, including altered sensation

(Battersby, Bender, Pollack, & Kahn, 1956), impaired sensory

integration (Denny-Brown, Meyers, & Horenstein, 1952), or

disordered body schema.

Denny-Brown and colleagues (1952) related neglect to

poor integration of sensory information from the

contralateral side of the body, a function deranged by a

lesion of either parietal lobe. Battersby et al., (1956)

argued that neglect stems from decreased sensory input in

patients with generally impaired mental function. Eidelberg

and Schwartz (1971) hypothesized that neglect is a result of

quantitatively asymmetrical input to the two cerebral

hemispheres.

Pure sensory theories of neglect, however, have had

difficulty accounting for other symptomatology observed in

these patients; specifically, the impaired motor acts (e.g.,

the omission of the left side of a drawing) and denial of

hemiparesis (Kirshner, 1986). Furthermore, since neglect

can be demonstrated in the absence of any sensory impairment

(Albert, 1973; Ettlinger, Warrington, & Zangwill, 1957) and

because there is no one-to-one relationship between neglect

and sensory deficit (Costa, Vaughn, Horwitz, & Ritter, 1969;

Gainotti, 1968), alternative theories have been proposed.

De Renzi, Faglioni, and Scotti (1970) suggested that

neglect may be the result of a "mutilated representation of

space". They suggested that patients with right-hemispheric

lesions who could not find a marble when it was in the

contralateral corner of a tactile finger maze, appeared to

be unaware that the left side of space existed. This idea

has been supported by Bisiach and colleagues who found that

patients with right-hemispheric lesions and left

visuospatial neglect omitted the left sides of images

retrieved from long-term memory (Bisiach, Capitani,

Luzzatti, & Perani, 1981; Bisiach & Luzzatti, 1978) and the

left sides of images mentally constructed from immediate

external input (Bisiach, Luzzatti, & Perani, 1979). The

notion that contralateral neglect also occurs in internally

generated representations implies that at some level of

processing in the intact brain, images are represented

analogically in the two hemispheres, at least with respect

to their left and right sides. More recent findings from a

visual imagery task described by Ogden (1987) provide

support for the idea that deficits in the processing of

visuospatial mental images underlie some forms of neglect.

Given that neglect has been observed in all modalities, but

few if any patients have demonstrated a generalized neglect

that encompasses all modalities, Ogden (1987) suggests that

the term unilateral spatial neglect covers a number of

neglect disorders, each of which conceivably results from

one or more deficits at different levels of perceptual and

cognitive processing.

More recent theories have conceptualized the neglect

phenomenon in terms of an attentional disorder, resulting

from unilaterally defective arousal. Although the

importance of right hemisphere function in maintaining

attention has been cited among early investigators (eg.,

Brain, 1941; Critchley, 1966), Heilman and colleagues, in a

series of animal and human studies, extended this theory

into an attention-arousal hypothesis. From their

perspective, the arousal mechanisms constitute the

dysfunctional component in unilateral neglect patients.

According to their theory, each side of the brain contains

its own activating system, a cortico-limbic-reticular loop

which mediates orientation (Heilman & Watson, 1977a, 1977b).

When this system is destroyed, half of the brain cannot

properly process the incoming sensory information and

organize the appropriate motor responses to it. Such a

10

unilateral decrease in arousal is thought to result in the

selective loss of the orienting response to the space

contralateral to the lesion, since it is assumed that each

cerebral hemisphere subserves orienting responses to the

opposite half space. However, in order to explain the fact

that neglect occurs more frequently following right than

left hemisphere lesions (Ogden, 1987), Heilman and Van Den

Abell (1979, 1980) further assume that the left hemisphere

only controls orienting to the right side of space, whereas

the right hemisphere can produce orienting to both sides

(Ladavas, Del Pesce, & Provinciali, 1989).

Anatomically, the frontal and inferior parietal

cortical areas associated with neglect have abundant

connections both to each other and to the reticular

activating system (i.e., the ascending system of neurons in

the brainstem and thalamus which alerts the brain). Lesions

anywhere in this circuit may impair the alerting or

orienting responses to contralateral stimuli. Damage to

this ascending system may explain the neglect seen with

thalamic and other subcortical lesions (Watson & Heilman,

1979; Watson, Valenstein, & Heilman, 1981).

Heilman, Schwartz, and Watson (1978) presented

experimental evidence for this decreased arousal in right

hemisphere lesions by recording the galvanic skin response

(GSR) in the hand ipsilateral to the lesion after

stimulation of this same hand. GSRs were less in patients

11

with right hemisphere lesions and neglect than in either

normal controls or patients with left hemisphere lesions and

aphasia. Similarly, electroencephalographic (EEG)

desynchronization in the parietal lobe of normal subjects,

another measure of arousal, occurred in the right parietal

lobe after stimulation of either side of the body, whereas

the left parietal lobe desynchronized only after right-sided

stimulation (Heilman & Van Den Abell, 1980).

Another cerebral mechanism related to neglect is

unilateral hypokinesia, or decreased spontaneous motor use

of either the left limbs or of all limbs in the left side of

space. This mechanism can be thought of as the motor aspect

of neglect. Valenstein and Heilman (1981) indicated that

even in the absence of weakness or sensory extinction,

occasional patients with neglect have clinically evident

hypokinesia of the left limbs. Hemiakinesia may also

explain the omission of left-sided details in the

spontaneous drawings of patients with right hemisphere

lesions. Experimental evidence from monkeys with either

right frontal or right temporoparietal cortex also favors

motor akinesia as a factor in neglect behavior (Watson,

Miller, & Heilman, 1978; Valenstein, Van Den Abell, Watson,

& Heilman, 1982).

Mesulam (1981) has attempted to synthesize the

behavioral and neuroanatomical data on neglect in a

"network" approach. In this model, the right inferior

12

parietal region contains the sensory schema for the

contralateral body, and hence right parietal lesions produce

sensory inattention, extinction, and abnormalities of

spatial and topographical function. The frontal lobe

subserves movement and exploration in contralateral space,

and hence, right frontal lesions produce inattention and

hypokinesia. The cingulate gyrus, a limbic structure also

implicated in neglect (Heilman & Valenstein, 1972b), relates

to the motivation to explore or attend to contralateral

space. The cingulate gyrus has extensive connections to

other limbic structures thought to be related to motivation

and rewards. Finally, the reticular activating system in

the brainstem and thalamus is necessary for arousal,

vigilance, and attention, especially as direct to the

contralateral body and space. This "network" theory brings

together the three mechanisms of sensory alteration,

inattention, and hypokinesia, and takes into account much of

the clinical and experimental evidence relating to neglect.

Incidence of Neglect

There is considerable discrepancy in the literature

concerning the incidence and severity of neglect exhibited

by brain damaged patients, especially with respect to the

involved hemisphere (Friedland & Weinstein, 1977). Numerous

studies have found hemineglect to be more frequent and more

severe in right than in left hemisphere lesions (Brain,

1941; Critchley, 1966; Battersby, et al., 1956; Denes,

13

Semenza, Stoppa, & Lis, 1982? Gainotti, 1968; Costa et al.,

1969; Colombo, De Renzi, & Faglioni, 1976; Schenkenberg,

Bradford, & Ajax, 1980). Others have suggested that the

apparent association of neglect with right hemisphere

lesions is artifactual in that aphasic deficits caused by

left hemisphere lesions prevent detection of the neglect

syndrome (e.g., Ogden, 1987).

Studies to ascertain the extent of unilateral neglect

in right versus left hemisphere lesions have generally

reported a milder form (if found at all) in left side damage

(Colombo et al., 1976; Gainotti, Messerli, & Tissot, 1972;

Gainotti & Tiacci, 1971; Oxbury, Campbell, & Oxbury, 1974,

Schenkenberg et al., 1980). Colombo et al., (1976) reported

that no left brain damaged subject failed to complete the

right side of drawings in the way many right brain damaged

subjects omitted the entire left side; however, mild but

significant neglect was observed for the former on some

tasks relative to controls. Gainotti et al., (1972) also

reported drawing asymmetries as definitely more severe in

right than left hemisphere involvement. Oxbury et al.,

(1974) found unilateral neglect exclusively in their right

brain damaged subjects.

Schenkenberg, Bradford, and Ajax's study (1980) showed

as many as 90% of right brain damaged subjects exhibited

unilateral neglect, depending on the evaluation procedure;

whereas, only an occasional person with other lesion sites

14

manifested symptoms of neglect. Early estimates of the

incidence of neglect among right brain damaged patients

range from 33% (Benton, 1969) to 66% (McFie & Zangwill,

1960). With Albert's (1973) test, Fullerton, McSherry, and

Stout (1986) observed neglect in 49% of patients with

nondominant hemisphere lesions and 25% of patients with

dominant hemisphere lesions. Observations reported by Wade,

Wood, and Hewer (1988) on stroke patients from a community

register indicated that 11% of their sample had some visual

neglect, with neglect being more frequent (14%) in patients

with right sided symptoms. Similar results were reported in

a study restricted to patients with right hemisphere stroke

(Meerwaldt, 1983).

In a review of studies of spatial neglect, Ogden (1987)

proposed several factors to account for the wide variation

in incidence of right and left-sided neglect. In addition

to the methodological argument of excluding many left

hemisphere lesioned patients due to aphasia, Ogden (1987)

cites definitional issues of neglect and the varying

sensitivities of tests used to assess neglect as

contributing to differential frequencies observed in these

studies. Furthermore, the etiology of the lesions and the

recency of the lesions may be different. Given that the

more striking symptoms of hemineglect often diminish in the

weeks directly following a brain lesion (Campbell & Oxbury,

197 6; Gainotti, 1968) and assuming that neglect following

15

left-hemispheric lesions tends to be less severe anyway than

that following right-hemisphere lesions (Vallar & Perani,

1986), then one might expect a greater right-left difference

in incidence as the time interval between the sustaining of

the lesion and the assessment of neglect increases.

Recovery of Function

A number of authors have reported that the

manifestations of neglect tend to be transitory, with the

acute and more obvious neglect of contralateral information

being most pronounced in the first few weeks post injury (De

Renzi, 1982; Heilman, Valenstein, & Watson, 1985). Although

asymmetries in reading and drawing may persist (Friedland &

Weinstein, 1977), recovery is relatively rapid, compared to

other behavioral abnormalities observed in right hemisphere

injury (Hier, Mondlock, & Caplan, 1983). A recent study of

recovery of function among right hemisphere stroke patients

indicated that 85% of the sample manifested unilateral

spatial neglect on drawing and 46% showed visual and

auditory neglect of left hemispace (Hier et al., 1983).

Their results revealed that half of these patients recovered

in 8-9 weeks with a 90% probability of recovery 20 weeks

post-stroke. Similarly, Wade, Wood, and Hewer's (1988)

study of recovery of cognitive function following stroke

indicated that 24% of their sample who survived three months

showed more or less rapid recovery to normal function within

10 weeks.

16

Levine, Warach, Benowitz and Calvanio's (1986) analysis

of 29 left neglect patients showed that both size of the

infarct and degree of premorbid cortical atrophy were

important determinants of severity and improvement of left

spatial neglect after stroke. In general, severity was not

found to be related to damage in any single area of the

right hemisphere. However, in patients with moderate to

severe neglect, there was a higher incidence of

frontotemporal (FT) lesions and tempoparietal (TP) lesions

than in patients with mild to no neglect. Lesion location

was confounded by lesion size, since FT and TP patients had

medium to large infarcts whereas central gyri lesion size

was more uniformly distributed. More importantly, premorbid

diffuse cortical atrophy acted independently of lesion size

to influence severity and persistence of neglect. In the

presence of a right cerebral infarct, cortical atrophy

augmented left neglect and retarded recovery. These

findings strongly support the notion that amount of reserve

brain tissue is critical in determining the course of left

neglect.

Assessment of Neglect

Currently, there is no single, standard test used by

all researchers who investigate visual hemi-neglect

(Johnston & Diller, 1986), and few studies have attempted to

quantify the severity of this symptom. Consequently, the

nature and subtlety of the tasks presented to the patient

17

and the degree of asymmetry in the patient's performance

required to diagnose neglect have contributed to discrepant

findings regarding the incidence and prevalence of neglect

associated with right versus left hemisphere lesions.

Copying and spontaneous drawings of houses, stars,

geometric figures, human figures, clocks, wagonwheels and

daisies have been used (Campbell & Oxbury, 1976; Colombo et

al., 1976; Lezak, 1983), with omissions or incomplete

representations of the figures indicative of neglect.

Simple line bisection tests (e.g., Schenkenberg et al.,

1980) have been used to indicate neglect when patients show

a tendency to incorrectly estimate the center of the line to

the right of true center, neglecting the left end of the

line.

Cancellation exercises are perhaps more commonly used,

and reveal neglect when performance yields relatively more

omissions on the side of the page contralateral to the

lesion than on the side which is ipsilateral. Such

exercises have included crossing out lines according to the

method of Albert (197 3), or specific letters (or numbers,

words, or geometric figures) from an array of distractors

(Diller et al., 1974).

To eliminate the strong praxic effort required by

patients in these tasks, Massironi, Antonucci, Pizzamiglio,

Vitale, and Zoccolotti (1988) developed a diagnostic test of

hemi-inattention using a modified version of the

18

Wundt-Jastrow area illusion. They reported that 40.4% of

RBD patients showed responses inconsistent with the visual

illusion when the determinant features of the illusion

pointed to the left visual field. No LBD patients or

controls showed unexpected responses to the stimuli. The

Wundt-Jastrow test scores correlated with clinical ratings

of neglect severity, (yielding a Spearman correlation

coefficient of .83), and demonstrated a .64 correlation with

the Albert test.

Weinberg and co-workers (1977) have used a number of

reading and writing tasks for evaluation of neglect. More

recently, Caplan's (1987) Indented Paragraph Reading Test

has been designed to detect left-sided visual neglect. The

task not only provides a measure of "real world" relevance,

but also revealed instances of neglect that visual

perceptual tests failed to identify.

To provide more information about everyday problems

than existing measures of neglect, Wilson, Cockburn, and

Halligan (1987) developed a behavioral test of visuospatial

neglect. The Rivermead Behavioral Inattention Test (RBIT),

consisting of nine items sampling activities of daily

living, has been found to correlate well with conventional

tests of copying, drawing, cancellation, reading, and

arithmetic but was not significantly correlated with line

bisection tasks.

19

Several researchers have employed observation of

patients' scanning behavior to evaluate evidence of neglect.

The rationale for recording ocular movement is that it

allows a precise measurement of the time devoted to the

exploration of the right and left halves of space.

Proponents of this technique contend that the degree of

asymmetry in exploration provides a direct measure of

unilateral inattention.

The electro-oculographic recordings reported by Chedru,

Leblanc, and Lhermitte (1973) yielded the following results

among their brain damaged subjects: (1) longer search times

than that of normal subjects, especially for images situated

contralateral to the lesion, (2) abnormal ocular movements,

(3) unsystematic, irregular exploration patterns, and (4) a

unilateral defect of ocular exploration. Specifically, in

the case of right hemisphere lesions, the left side of space

is explored for a shorter period than the right side. In

contrast, Locher and Bigelow (1983) found that neither right

nor left brain damaged patients in their sample exhibited an

asymmetry of visual exploration as they viewed visual

perception cards. However, irregular scanning strategies

and increased scanning time were reported. These

researchers interpreted their results in accord with other

research demonstrating that various conditions influence the

occurrence of neglect (Colombo et al., 1976).

20

Johnston and Diller (1986) compared eye movement

behavior to severity of visual hemineglect among right

hemisphere stroke patients and age-matched normal controls.

A severity index was obtained from scores on letter

cancellation and visual matching tests. A strong negative

correlation was obtained between the severity index and eye

movement exploration time of the left visuospatial field for

stroke patients, but not for controls. These findings

support Chedru's et al. (197 3) conclusions that exploration

time does not distinguish brain lesioned individuals with

mild neglect from individuals who do not manifest this

symptom.

Analyses of the performance of patients with unilateral

cerebral lesions on the Raven Coloured Progressive Matrices

(RCPM) (Raven, 1965) have revealed that in addition to

providing an index of cognitive reasoning capacity, the

format of the RCPM provides an opportunity to assess

specific spatial factors which may contribute to impaired

performance (Piercy & Smyth, 1962; Gainotti, 1968). The

test not only requires discrimination of forms of varying

complexity, but because of the spatial arrangement of the

response alternatives (on the left, center and right of the

page below the stimulus pattern), it permits identification

of response position preference as a behavioral index of

unilateral neglect.

21

Raven (19 65) reported that normal subjects do not

prefer response alternatives on either the left or right

side, but may tend to respond slightly more frequently to

the center alternatives on the RCPM. Piercy and Smyth

(1962) observed that patients with right cerebral lesions

showed a preference for response alternatives in the right

positions. Gainotti (1968) subsequently developed the

initial system for identification of neglect on the basis of

position preference, but Costa et al., (1969) refined the

technique to provide an improved, empirically derived

response position preference score to measure visual spatial

neglect. Costa's et al., (1969) results revealed that right

cerebral lesioned patients showed poorer RCPM performance

and a higher incidence of response position preference for

the side ipsilateral to their lesions than did patients with

left lesions. While these findings provided support for the

measure's usefulness as an index of neglect, Caltagirone,

Gainotti, and Miceli (1977) showed that this tendency to

neglect the response alternatives lying on the half sheet

contralateral to the damaged hemisphere is an important

factor in lowering the scores of both right and left brain

damaged patients. Essentially, these findings suggest that

the assessment of global cognitive functioning among these

patients becomes obscured by the influence of unilateral

neglect.

22

Factors Affecting Manifestations of Neglect

It would appear then, that unilateral neglect is a

heterogeneous syndrome. Indeed, several researchers have

shown variability in the expression of a neglect syndrome

when the nature of the stimuli, or strategy induced by a

task, chang€is.

For excimple, Heilman and Watson (1978) reported changes

in the symptoms of neglect as a function of varying task

strategy. Six male right hemisphere damaged subjects with

left side unilateral neglect were presented with

visuospatial and verbal cancellation tasks. Results

revealed that the symptoms of neglect were less severe with

the visuospatial than with the verbal tasks; i.e., subjects

displayed a smaller degree of neglect when the task required

them to cross out lines than when the targets were words.

The authors reported clinical observations that neglect can

be improved by manually turning a patient's head and eyes to

the neglected side or by moving a stimulus card from the

neglected field to the normal field, but did not provide

experimental data to support this claim.

Caplan (1985) extended and refined Heilman and Watson's

(1978) approach by equating the verbal and visuospatial

cancellation tasks and comparing performance on single and

double target tasks. Contrary to Heilman and Watson's

(1978) finding that degree of neglect varied as a function

of stimulus characteristics, Caplan's (1985) neglect

23

subjects omitted targets to a comparable degree on both

verbal and nonverbal tasks. The greatest amount of neglect

was seen on the single-target verbal tasks. These results

raised a question concerning the robustness of the

stimulus-specific effect reported by Heilman and Watson.

Under conditions in which stimuli and task-induced

strategy remained the same, Joanette, Brouchon, Gauthier,

and Samson (1986) examined the visual detection capacities

of three left neglect subjects, using a visual pointing task

to elicit differences in the expression of a hemispatial

neglect syndrome. The hypothesis was based on the postulate

that the use of a given hand will enhance (or activate) the

right hemisphere's readiness to respond to incoming stimuli.

Results showed better detection performances when manual

pointing was executed with the left hand (i.e. contralateral

to the lesion) than when made with the right hand. These

results demonstrate that the manifestation of a neglect

syndrome may differ, not only according to the nature of the

task and/or stimuli employed, but also according to the

laterality of the motor response. This finding coincides

with the literature demonstrating that selective attention

for each hemifield can be manipulated by a variety of

peripheral maneuvers that affect activation balance between

the two hemispheres (Kinsbourne, 1977). Furthermore, these

results suggest that studies which use a motor response

24

paradigm in evaluating the expression of neglect will have

to control for the laterality of a motor response.

Mark, Kooistra and Heilman (1988) examined the

proposition that the deficit in neglect occurs as a result

of difficulties in disengagement from the right hemispace

and that the manifestations of neglect are influenced by the

presence of stimuli in the nonneglected hemispace. In their

paradigm, the standard version of line cancellation was

contrasted with one that required erasing lines rather than

marking over them. Performance dramatically improved with

line removal, supporting hypotheses related to an impaired

disengagement process.

Ishiai and colleagues (1990) suggested that

insufficient motivation for visuospatial searching may be a

factor in deficient performance on line cancellation tasks.

In their sample of eight CVA neglect patients, a significant

reduction of neglect occurred as a function of numbering

rather than crossing-out the lines. The beneficial effect

of numbering was interpreted as a process which enhanced the

general level of attention or arousal and activation.

Additional support for the defective arousal and

activation model was presented by Fleet and Heilman (1986).

Fatigue resulting from repetitive trials was found to

exacerbate symptoms of neglect on a letter cancellation

task; whereas, when patients were provided with knowledge of

errors, performance improved. These results suggest that

25

procedures that increase arousal reduce the symptoms of

neglect.

In a line bisection task, Heilman and Valenstein (1979)

evaluated performance changes associated with forced

reporting of endpoints and altered hemispatial field of

presentation. Prior to bisecting the line, RBD subjects

were required to identify a letter at either end of the line

to ensure their seeing the left/right side of the line. The

task was given with the lines placed at either the right,

center, or left of the body midline. Performance in trials

when subjects were required to look to the left did not

differ from when they were required to report letters at the

right end of the line. However, line bisection performance

was significantly better when the line was placed to the

right side of the body than to the left.

Similar observations were reported by Samuels, Butters,

and Goodglass (1971) in a study of visual memory deficits

among right parietal and Korsakoff patients. The

researchers reported that field of presentation was a

critical variable in the visual deficits exhibited by right

parietal lesioned patients. Specifically, poor performance

was due to rapid decay for items presented to the left

visual field. Normal subjects showed fast decay for items

presented to the right visual field, but little loss for

material presented to the left visual field, indicating

26

better retention for visual material transmitted directly to

the right than the left hemisphere.

For the most part, the literature examining the effect

of cueing in altering symptoms of neglect has been

inconsistent. An effect of cueing would suggest that some

processes governing the conscious orienting of visual

attention are intact, and that neglect is due to a more

specific impairment in automatically orienting to stimuli on

the side of space contralateral to the site of lesion.

Posner, Cohen, and Rafel (1982) used a simple reaction time

task in which patients were cued to attend to the probable

spatial location of the stimulus prior to its presentation.

On 80% of the trials, the stimulus appeared in the cued

location while on 20% of the trials, it appeared in the

opposite location. For valid trials (when the target

appeared in the cued location), there was a small but

consistent advantage for targets occurring on the side

ipsilateral to the lesion over those occurring contralateral

to the lesion. In contrast, on the invalid trials, there

were marked differences to stimuli occurring ipsilaterally

and contralaterally to the lesion. For stimuli occurring

ipsilaterally, responses were slightly slower on the invalid

trials than on the valid ones. For stimuli occurring

contralaterally, however, there was a marked effect of

validity, with responses being very substantially slower on

the invalid trials than in any of the other conditions.

27

Indeed, in this instance, when the cue preceded the target

stimulus by a short interval, patients usually failed to

detect the target stimulus. Thus, for this study, there was

a large effect of cueing, demonstrating that patients with

neglect can attend to stimuli contralateral to the side of

lesion.

Riddoch and Humphreys (1983) speculated that Heilman

and Valenstein's failure to reduce neglect by cueing

occurred because patients were presented with competing

stimuli in their neglected and nonneglected fields. Since

two cues were available at either end of the line, attention

would most likely have been drawn to the right hemisphere by

the presence of a right side cue, even if subjects had to

report only one of the stimuli. This may have interfered

with attention being allocated to the left side cue,

minimizing any effect of cueing on the line bisection task.

Consequently, Riddoch and Humphreys (1983) investigated

single cue effects and hemispace effects on a line bisection

task with neglect patients. A "no cue" condition and a dual

cue condition were included for baseline in order to assess

the differential effects of single left or right side cues.

Their results indicated that cueing to the left hand side

produced a marked decrease in neglect. In contrast, the

effect of forcing subjects to report only a right side cue

was to increase neglect relative to when no cues were

present. Although there was no effect of hemispace of

28

stimulus presentation, the authors reported that there was a

trend for patients to neglect the left ends of the lines

more when the stimuli were in the left hemispace than when

they were in the middle hemispace, and more in the middle

hemispace than when they were in the right hemispace.

Somewhat different results were obtained by Robertson

(1989), using a computer task requiring recognition of

geometric stimuli and word reading. Among 10 neglect

patients, an increase in right sided omissions was observed

as a function of (1) double, but not single stimulus

conditions and (2) cueing to the left.

In an effort to resolve some of the empirical and

theoretical controversies about the efficacy of cueing in

left neglect, Halligan and Marshall (1989) sought to "glue"

the spatial cue to the line bisection task by use of a

"mouse", attached to a computer display of lines for

bisection. A small bisection arrow is under the motor

control of the subject and thus, cue and bisection are

merged into one task. With the methodology deployed in this

study and N = 1, the results showed that left perceptual

cueing was efficacious in reducing (but not eliminating)

left neglect on line bisection.

In a more extensive analysis of hemispace, cueing, and

motor components, Reuter-Lorenz and Posner (1990) examined

two versions of the line bisection task in nine posterior

CVA patients. The traditional line bisection task (directed

29

manual version) was compared to an altered version (directed

visual task), in which subjects observed the experimenter

move the pen along the line and verbally indicated the

subjective midpoint. Patients only showed significant left

neglect in the manual task and visual scanning towards the

left. When the manual response was eliminated, scan

direction determined the presence or absence of neglect on

bisection. In contrast, controls showed no consistent

biases or influence of scanning direction. No effect of

hemispace wcis observed, but right and left cues biased line

bisection for both groups. Specifically, greater right

deviation was observed with a right cue and greater left

deviation was revealed with a left cue. The results are

consistent with the attentional and visual orienting

deficits ascribed to neglect.

Independent Deficit or Global Cognitive Deterioration

Taking into consideration data regarding the recovery

course of nejglect, the functional mechanism proposed to

account for the symptoms, and the variability in the

expression of neglect (as a function of the nature of the

stimuli and strategy changes), the evidence has theoretical

as well as practical implications in the assessment of

cognitive functioning of RBD patients. Specifically, the

data lend support to the controversial issue that unilateral

visual neglect is an independent deficit not uniquely

associated with general mental deterioration. From a

30

practical standpoint, if various mechanisms could be

identified as reducing the deleterious effects of neglect on

measures of global intellectual functioning, the results

would yield a more accurate, undiluted measure of residual

cognitive reasoning capacity.

In a recent study to determine whether hemi-inattention

is an independent deficit or associated with general or

specific cognitive deficits, Vilkki (1989) observed that the

degree of inattention was unrelated to other cognitive

deficits among left-hemisphere damaged patients. However,

in the right-hemisphere damaged group, the degree of

inattention to the left side was significantly correlated

with inaccurate line orientation perception and slowness of

simple verbal performances. These results do not support

prior contentions that hemi-inattention is associated with

general mental deterioration (Battersby et al., 1956;

Weinstein & Friedland, 1977). Rather, these findings

suggest that left hemisphere lesions result in discrete and

dissociated defects with associated hemi-inattention being

unrelated to other cognitive deficits; whereas, right

hemisphere lesions reveal diffuse deficits with

hemi-inattention being related to generalized attentional

deficits such as slowness and inaccuracy in simple spatial

and verbal functioning.

31

Defective Performance on RCPM

Although evidence is conflicting and inconclusive (eg.,

Gainotti, D'Erme, Villa, & Caltagirone, 1986), numerous

investigations using the RCPM to obtain estimates of

residual intellectual capacity have revealed substantially

lower scores among right brain damaged individuals (Piercy &

Smyth, 1962; Gainotti, 1968; Costa et al., 1969). The poor

performance of RBD patients on the RCPM has raised concerns

as to whether the relative deficit is due to general

intellectual deterioration or more specific defects, such as

defective discrimination of visual patterns and/or a

defective exploration of space. Both Gainotti (1968) and

Costa et al., (1969) have provided evidence that a certain

number of brain-damaged patients, particularly those with

right hemisphere injury, neglect the alternatives on the

side of the page contralateral to the lesion as a

consequence of their spatial hemi-inattention. This finding

emphasizes the need for controlling the degree of impairment

in visual perception and space exploration, when the RCPM

test is used to evaluate intelligence in brain damaged

patients.

In a series of classical papers, Zangwill and

co-workers (Paterson & Zangwill, 1944; McFie, Piercy, &

Zangwill, 1950; Ettlinger et al., 1957) proposed that

patients with posterior lesions of the right hemisphere may

present signs of visual spatial agnosia at every level of

32

psychological response, in absence of defects of general

intelligence. Gainotti and Tiacci (1971) reported that

patients with unilateral spatial neglect perform worse than

nonneglecting RBD subjects on tasks of visual spatial

analysis. With similar findings revealing defects of

spatial analysis and visual perception occurring

predominantly among right hemisphere damaged patients with

left neglect, the Oxbury, Campbell, and Oxbury (1974) report

concluded that this disability could not be attributed to

general intellectual deterioration.

In a. subsequent study examining performance changes on

various cognitive tasks, Campbell and Oxbury (197 6) revealed

additional support for the notion that defective performance

among neglect patients reflects specific deficits rather

than global decline in higher level cognitive processes.

Patients who had demonstrated neglect via drawing and

copying tasks at three to four weeks post-stroke were

reassessed five months later on various measures of spatial

analysis, visual perception, and verbal cognitive abilities.

On re-examination, even though drawings were more complete,

neglect patients still performed significantly worse than

non-neglecting RBD subjects on Block Design, cube counting,

incomplete figures, visual recognition, and the Raven's

Matrices. Only the Matrices scores and verbal fluency tasks

revealed significant improvement over time. The remaining

tests of verbal cognitive abilities revealed no significant

33

changes for either groups. Position preference for right

sided responses on the visual recognition test remained

unaltered. The authors concluded that the improved

performance on the Matrices and drawings could not be

attributed to a recovery of general cognitive functioning,

given the stability over time of six out of the seven verbal

measures.

Gainotti, Caltagirone, and Miceli's (1977)

investigation revealed that right hemisphere-damaged

patients obtain significantly lower scores on the RCPM than

patients with damage restricted to the left hemisphere. The

tendency to neglect information on the half sheet

contralateral to the damaged hemisphere was dramatically

more evident in right hemisphere damaged cases. As with

prior studies, their data suggested that the poor

performances obtained on the RCPM by right brain-damaged

patients seemed due to the detrimental effect of unilateral

spatial neglect rather than indicative of a general

intellectual impairment.

In a subsequent project, Gainotti and associates (1979)

further explored the meaning of poor RCPM performance by

patients with posterior right hemisphere lesions. Using two

verbal tests and a test of visual-spatial analysis in

addition to the RCPM, these investigators concluded that the

deficits found with RBD patients with unilateral spatial

34

neglect were found to be related more to specific

disabilities than to a general intellectual deterioration.

Consequently, Gainotti, D'Erme, Villa, and Caltagirone

(1986) constructed a new version of the Matrices,

purportedly to minimize the influence of spatial neglect

without changing the essential features of the original

task. Their new format consisted of (1) arranging all the

response alternatives in a single column below the stimulus

pattern in the center of the response plate and (2)

orienting the stimulus pattern so that the space to be

filled would always be placed in the half space

contralateral to the damaged hemisphere. Although their

rationale weis not explicated, the authors noted that the

structure of the original stimulus pattern appears to favor

inattention to the left side of the pattern since the space

to be filled in with the response alternative is always on

the lower right hand portion of the design and as such, RBD

patients are not induced to thoroughly explore the stimulus

pattern. Unfortunately, their design did not include a

comparison between the standard and revised versions with

brain damaged patients to ascertain if indeed, the changes

yielded the expected improved performance that would be

predicted by minimizing the effects of unilateral neglect.

Furthermore, while their approach represents a reasonable

attempt to expand visual exploration of the stimulus field,

their strategy is not consistent with evidence presented

35

earlier in this review concerning a reduction in the

expression of neglect as a result of field of presentation

and left side cueing.

In view of these concerns, the present study

constructed a revised version of the RCPM and examined

whether these changes reduced the deleterious effects of

neglect with results of higher estimates of general

cognitive capacity among neglect patients. In accordance

with prior evidence of a reduction in neglect as a function

of hemispace manipulations, the current revision placed the

response alternatives in a column located in the right

hemispace of the stimulus field. Additionally, since left

sided cueing has yielded contradictory results in terms of

efficacy among this population, the effects of left sided

cueing, employed in conjunction with the right hemispace

version, were also examined.

Memorv-for-Desiqns (MFD) Test

A second measure, characterized as one of the most

widely used of any single psychological test for the

diagnosis of perceptual, motor and memory deficits (Dustman

& Beck, 1980), was also investigated in the context of

changes in hemispace presentation and left sided cueing.

Specifically, as with the RCPM, this study constructed a

revised version of the Memory-for-Designs (MFD) Test (Graham

& Kendall, 1960) by placing each design in the right

hemifield (RH condition) to examine proposed performance

36

changes. A second experimental condition, a left cue prompt

employed with the right hemispace version (RH + L) was also

investigated. For this condition, the patient was shown the

RH version and reminded on each item, to look to the left.

The MFD is credited as a short, easily administered,

highly reliable measure to assess impaired cognitive

functioning (Dustman & Beck, 1980). The task requisites,

such as visual functioning, nonverbal memory, and nonverbal

visual constructive skills, make the MFD a particularly

suitable comparison measure, since the primary functions

tapped by the measure are those considered sensitive to

impairment of the nondominant hemisphere and the posterior

cortex (Webster, Scott, Nunn, McNeer, & Varnell, 1984).

Aside from reports concerning age effects in the MFD or

its utility as a screening measure, much of the recent

literature has evaluated the two scoring procedures

developed for the MFD. The original scoring procedure

(i.e., the Graham-Kendall (GK) system) has incurred

criticism for the severe penalties associated with reversals

and rotations, yielding less than adequate separation of

normal and brain damaged groups (Grundvig, Needham, & Ajax,

1970). Although Kendall (1966) proposed modifications, no

change was initiated by the test developers in the scoring

procedures. Taylor (1961) developed a system consisting of

six error categories for each design and one for the entire

group. He found this system to provide more effective

37

discrimination between normal and brain impaired groups than

the GK method. A modified version of Taylor's method (MT),

incorporating the GK method of grading distortion from zero

to three, was also suggested. Subsequent research has since

confirmed that the Taylor (T) and Modified Taylor (MT)

scoring methods are essentially comparable in ability to

discriminate, while the GK system is somewhat less effective

(Grundvig et al., 1970; Grundvig et al., 1973; Bradford,

1978) . Therefore, as a secondary focus of the study, the

relationship between the two scoring procedures for this

population was investigated.

Summary and Statement of Hypotheses

The studies reviewed thus far have indicated that

neglect RBD patients exhibit significantly poorer

performance on various cognitive measures. These

performance decrements have been ascribed to the deleterious

effects of visual neglect, rather than to a global

deterioration of cognitive functioning. A related body of

research in the neurology literature has revealed that the

manifestations of neglect are influenced by a variety of

external factors, such as the nature of the stimuli, task

strategy, hemispace presentation, and cueing. However, the

methodology to examine changes in symptoms of neglect has

been confined to visual detection paradigms or tasks

requiring line bisection or cancellation. The current

investigation sought to examine whether performance changes

38

are revealed on general cognitive measures when hemispace

manipulations and verbal prompts to "look to the left" are

employed. Specifically, this study examined whether right

hemispace presentation of stimuli and left side cues in

conjunction with right hemifield presentations reveal

improved performance on two general cognitive indices, the

RCPM and the MFD. These criterion measures were selected

because of their reported sensitivity to the effects of

neglect and frequent use with this population. Revised

versions of these measures were constructed to examine the

proposed performance changes. The following hypotheses were

examined:

(1) RBD patients with neglect will exhibit

significantly poorer performance on the criterion measures

(i.e., the RCPM and the MFD) than RBD patients without

neglect and hospitalized control subjects.

(2) Neglect subjects will show significantly higher

RCPM scores when response alternatives are aligned in the

right hemifield of the stimulus array (Right Hemifield

condition) than when response alternatives are placed below

the stimulus in the standard version (Standard presentation

condition).

(3) Neglect subjects will demonstrate significantly

higher scores on the RCPM when left side cueing is employed

with the right hemifield version (RH + L condition) than

under standard administration conditions.

39

(4) Neglect subjects will reveal significantly lower

mean error scores on the MFD when examined under the two

experimental conditions (i.e., the RH condition and RH + L

condition) than when examined under the standard

presentation condition.

In addition to these primary predictions, several

ancillary hypotheses were formulated and examined within the

context of this study:

(1) Neglect patients will demonstrate greater

impairment on a measure of right brain injury than RBD

patients without neglect, as evidenced by significantly

higher scores on the Mini Inventory for Right Brain Injury

(MIRBI).

(2) Significant correlations will be observed between

measures of neglect (i.e., for the Bells Test of Visual

Neglect and the Schenkenberg Line Bisection Task) across all

groups.

(3) Significant correlations will be revealed between

the two scoring systems of the MFD Test.

CHAPTER II

METHOD

Subjects

The sample was comprised of 54 hospitalized patients,

recruited from the rehabilitation units of two area

hospitals. The criterion group of neglect subjects (RBD-N)

consisted of seventeen right cerebral vascular accident

(CVA) patients, ranging in age from 4 6 to 84 years, and one

37 year old right parietal tumor patient. The criteria for

inclusion in this group consisted of defective scores on two

out of the three indices of neglect, a current diagnosis of

right brain injury, and impaired performance on the

screening assessment for right brain injury. Scores on the

indices of neglect were rated as defective if patient

performance revealed 6 or more omissions on the Bells Test,

two or more omissions on the Schenkenberg Line Bisection

(SLB) Task, or line bisection scores greater than +/- 10%

average deviation from midpoint on the SLB.

The RBD without neglect (RBD-NN) group consisted of 17

right CVA patients, ranging in age from 55 to 87 years, and

one 33 year old patient, hospitalized for a hematoma

evacuation. Patients assigned to this group had a current

diagnosis of right brain injury and exhibited impaired

40

41

performance on the right brain injury screening measure.

However, in contrast to the criterion group, the RBD-NN

group displayed negative results on two out of the three

indices for neglect. In this study, negative results were

operationalized as protocols exhibiting fewer than six

omissions on the Bells Test, less than two omissions on the

SLB, or line bisection scores less than +/- 10% average

deviation on the SLB. These scores are in accordance with

the respective authors' recommendations and validation data.

A second comparison group consisted of 18 patients

(ranging from 65-90 years of age), who had been hospitalized

for orthopedic conditions and presented with no reported

history of focal central nervous system (CNS) injury or

disorder. Thirteen of these individuals had undergone hip

replacements and five were hospitalized for knee surgery.

Patients in this group exhibited no abnormal performance on

the Bells Tests for neglect or revealed any SLB omissions.

All subjects were right-handed. Individuals presenting

a history of alcoholism or psychiatric treatment and persons

unable to provide informed consent, due to severe dementia

or language deficits, were excluded from participation.

Procedure

All subjects were advised of the nature of the study

prior to securing written consent (Appendix A).

Specifically, each patient was asked to participate in a

research project designed to identify the instrument that

42

most accurately depicted their current level of functioning.

In exchange for their voluntary participation, the

information obtained in the study was included in the

patient's medical record to assist in treatment planning.

Upon securing consent, participants completed a series of

neuropsychological screening instruments, a nonverbal,

visuospatial measure of global cognitive functioning, and a

memory-drawing task. Subjects were assessed individually

and administered the instruments described below in the

order listed. Except for the initial screening instrument

designed to identify prospective RBD subjects, all measures

were administered by the author, a clinical psychology Ph.D.

doctoral candidate, under the supervision of a licensed

clinical neuropsychologist. Total testing time ranged from

60-90 minutes.

For the criterion instruments, all subjects were

examined under each of the three conditions. For the

standard presentation condition, target items were presented

at the midline. In contrast, for the right hemifield

condition, target items were presented along the right side

of the page. For the right hemifield plus left cue

condition, the right hemifield version of the stimuli was

presented and the patient was reminded to "look to the left"

when shown each item.

43

Instruments

Mini-inventory of Right Brain Injury (MIRBI)• The

MIRBI (Pigmental & Kingsbury, 1989) was developed for the

purpose of identifying adults who exhibit deficits in areas

known to be compromised in right hemisphere brain injury and

to determine the relative severity of right brain injury.

This screening measure was used to identify potential

participants in the RBD groups. By adding the total number

of points received on the 27 item inventory, a total MIRBI

score is obtained. According to the standardization data,

scores of 38-43 are within normal limits and scores of 37

and below are considered brain injured. The total MIRBI

score can also be converted to a seven-scale severity rating

provided in the summary and profile sheet of the test

booklet. After correcting for age effects, the test

publishers report an alpha reliability coefficient of .92,

indicating a high level of internal consistency. Interrater

reliability estimates range from .65 to .87 and the standard

error of estimate is small (0 to 5.5 SEm), providing further

support of satisfactory reliability. Concurrent validity

studies using CT scan results have yielded a diagnostic

accuracy of 99.97% in differentiating normals, left, and

right brain injured groups.

Schenkenberq Line Bisection Test (SLB). As one of the

most common methods used to identify the presence and

severity of neglect, the bisection of horizontal lines was

44

formally evaluated by Schenkenberg and colleagues (1980) to

provide systematic normative data. The task requires the

patient to bisect a total of twenty lines (2 sample lines

and 18 scored lines) that are represented on a 21.5 x 28 cm

white sheet of paper, parallel to the long axis. Line

lengths of 100 - 200 mm are organized in three sets of six

lines, with each set positioned on the left, center, and

right side of the page. Scoring involves two components:

(1) noting the number and position of unmarked or omitted

lines and (2) measuring the deviation of the attempted

bisection of each of the marked lines from the true center.

Average percent deviation scores were computed according to

the method described by Schenkenberg et al.,(1980).

Test-retest correlations have yielded reliability

coefficients in the range of .84 to .93. Total neglect of

more than two lines has been found to discriminate between

RBD patients and patients with left or diffuse damage as

well as hospital controls. Additional normative data with

an elderly nonbrain damaged population has been presented by

Van Deusen (1983). In this study, defective performance

indicative of visual neglect on this measure was

operationalized as either two or more line omissions and/or

line bisection scores greater than +/- 10% average deviation

from line midpoint. A sample is provided in Appendix C.

The Bells Test. This measure, developed by Gauthier,

Dehaut, and Joanette (1989), was devised to provide a

45

quantitative and qualitative evaluation of visual neglect.

It is a cancellation task that allows a rapid visualization

of the location of omissions as well as of the scanning

pattern used by subjects, permitting the detection of mild

and moderate visual neglect. Prior to administration of the

actual test, the subject is presented with a sheet

containing an oversized version of the target (bell) and

each of the distractor items, and is asked to name the

elements to ensure proper object recognition. Instructions

are given to the subject to circle all the bells, and then

the task sheet is placed in front of the subject. On the

score sheet, the examiner marks the order of circling the

bells by successive numbering as the subject encircles the

bells. The maximum score is 35. In the preliminary

normative study, half of the normal controls obtained a

perfect score, with a maximum number of 3 omissions in this

group. Omissions of six or more bells in the contralateral

half of the test is suggestive of visual neglect. A sample

of the demonstration sheet, Bells Test, and examiner's

scoring sheet is provided in Appendix D.

Raven's Coloured Progressive Matrices (RCPM). This

measure was administered to provide an index of an ability

that has been alternately described as "clear thinking",

11 intellectual capacity", and "reasoning" (Raven, 1962,

1965). Developed initially as a children's version of a

culturally-reduced measure of intellectual functioning, the

46

RCPM is considered the best of all the nonverbal tests of

"g", i.e., the superordinate ability which, according to the

hierarchical theory of intelligence (Spearman, 1946), enters

into all intellectual performances (Burke & Bingham, 1969;

Jensen, 1982) . The test provides a measure of what Cattell

(1971) called fluid intelligence, i.e., the ability to make

inferences, draw relations, and develop hypotheses. In view

of the relative ease of administration and minimal

requirements for overt verbalization, the RCPM has been

described as the test of choice for the assessment of

intellectual disorders among brain damaged individuals

(Gainotti et al., 1986).

The test consists of 3 6 geometric designs in which

there is a missing piece. Six alternative pieces are

located below the design, one of which correctly completes

the design. The subject's task is to point to or verbalize

the correct response alternative for each test item.

Although the common practice is to administer all 36 items,

a modification in standardized administration procedures was

necessary in the present study in order to obtain RCPM

scores for each subject across all three experimental

conditions. Specifically, to avoid practice effects

associated with repeated administration of the test, three

sets of stimulus cards (i.e., 12 cards per set) were

selected for use in the standard administration condition

(Std), the right hemifield condition (RH), and the right

47

hemifield plus left cue condition (RHL). Every third card

was selected for each set, such that Set 1 consisted of Al,

A4, A7, A10, AB1, AB4, AB7, AB10, Bl, B4, B7, BIO; Set 2

consisted of A2, A5, A8, All, AB2, AB5, AB8, AB11, B2, B5,

B8, Bll; Set 3 consisted of A3, A6, A9, A12, AB3, AB6, AB9,

AB12, B3, B6, B9, B12. The order of presentation for the

experimental conditions and card sets was counterbalanced

across groups to eliminate practice or sequencing effects

and control for item difficulty level. A sample of the

standard version and the modified version for the RH and RHL

conditions can be found in Appendix E.

Memory for Designs (MFD). The MFD, developed by Graham

and Kendall (1960), is a neuropsychological instrument,

consisting of 15 geometric designs that vary in complexity

from an equilateral triangle to complicated, unfamiliar

designs. Individual designs are shown to the subject for 5

seconds and after each presentation, the subject is asked to

draw the design from memory.

The MFD was originally developed as a screening

instrument for discriminating brain impairment among

psychiatric populations, but in more recent years, has been

widely used to assess functions sensitive to impairment in

the nondominant, posterior cortex. The measure evaluates

several cognitive skills; specifically, visual functioning,

nonverbal memory, and nonverbal visual constructive skills.

The MFD was selected as a second criterion measure not only

48

for its sensitivity to RBD, but also because it evaluates a

compendium of cognitive functions similar to and yet

slightly different from the RCPM. Both measures require

visual perceptual skills and associative functions; however,

the MFD entails an additional nonverbal memory factor and a

constructional-motor component as well.

Two scoring methods have been developed for use with

the MFD, both of which were evaluated in the present study.

The original methodology (GK), proposed by Graham and

Kendall (1960), assigns each design a score of 0, 1, 2, or

3, which are then summed for a total score. Faults which

are more frequently observed in brain impaired populations,

such as rotations, are given an error score of 3; whereas,

incomplete items are not penalized. Detailed scoring

instructions and scoring samples are described in Graham and

Kendall's (1960) manual.

The alternative scoring system, the Modified Taylor

method (MT) (Bradford, 1978), entails scoring each design

for the presence or absence of each of six errors (i.e.,

embellishment, perseveration, reversal, rotation,

distortion, and omission). The omission category is scored

0, 1, or 2, depending on the proportion of the design which

is omitted. A seventh error category, organization, is

scored 0, 3, or 6, according to how disorganized the entire

set of figures appears on the page. The scores for each

49

design are summated to yield a total score. More explicit

instructions for MT scoring are detailed in Appendix F.

Interrater agreement for these two methods is commonly

found to be greater than .90. For example, independent

scoring of individual designs by Howard and Shoemaker

(1954), using the GK method, resulted in a 93% agreement,

lending favorable support to Graham and Kendall's (1960)

correlation of .99 between independent ratings of total

scores. Bradford (1978) reported estimates of .97 for the

GK method and .99 for the MT system. Similarly, Grundvig,

Needham, and Ajax (1970) indicated Pearson correlations

ranged from .90 to .98 for interscorer performance with both

scoring systems.

For this study, the same procedures employed with the

RCPM were applied to the MFD; i.e., the 15 geometric designs

were subdivided into 3 card sets, with one card set

administered to the subject for each of the three

experimental conditions. Set 1 consisted of MFD designs 1,

4, 7, 10, and 13. Set 2 was composed of MFD designs 2, 5,

8, 11, and 14 and Set 3 included MFD designs 3, 6, 9, 12,

and 15. As with the RCPM, the order of presentation for the

experimental conditions and card sets was counterbalanced

across groups to eliminate practice or sequencing effects

and control for item difficulty level. A sample of the

standard presentation and Right Hemispace revision of the

MFD are displayed in Appendix G.

CHAPTER III

RESULTS

The primary hypotheses of the study proposed improved

cognitive performance among neglect subjects as a result of

right hemispace presentation and left cue prompts. Neglect

subject performance was contrasted with two comparison

groups: right brain damaged patients without neglect and

hospitalized orthopedic controls. Two measures of cognitive

functioning, the Raven's Coloured Progressive Matrices

(RCPM, Raven, 1962) and the Memory-for-Designs (MFD, Graham

& Kendall, 1960), were employed as dependent variables.

Scoring of the MFD yielded two separate scores; one score

reflecting the criteria defined by the Graham and Kendall

methodology (MFD-GK) and the other score representing the

more recent Modified Taylor scoring revisions (MFD-MT).

Thus, for the primary analyses of the study, a 3 x 3 ANOVA

with repeated measures on one factor was conducted for the

RCPM scores, the MFD-GK scores, and the MFD-MT scores.

A preliminary analysis of the demographic data revealed

significant age effects (F (2,51) = 5.71, p < .01). Post

hoc comparisons, using the Newman Keuls procedure, indicated

that orthopedic controls were significantly older than

neglect patients. However, no significant age differences

50

51

were obtained between neglect and nonneglecting RBD subjects

or between nonneglecting RBD subjects and hospitalized

orthopedic patients. A significant sex difference between

the groups was observed (Chi square likelihood ratio =

12.56, p = .002). The table indicated a higher frequency of

males in the neglect group and a greater number of females

in the orthopedic group. Table 1 (Appendix B) displays

relevant sample characteristics and group performance on the

various screening measures. Specific clinical data for

individual neglect and nonneglecting RBD patients are listed

in Tables 2 and 3 (Appendix B), respectively.

Screening Measures for RBD and Neglect

A comparison to assess differences in severity between

the two RBD groups on the Mini Inventory of Right Brain

Injury (MIRBI) yielded significant differences (t = 3.04, df

=34, g < .01). As predicted, the neglect group revealed

significantly greater impairment than the nonneglecting RBD

subjects on the screening measure for right brain injury.

Correlations between subject characteristics, screening

measures and dependent variables are shown in Table 4

(Appendix B). As predicted, significant correlations were

obtained between the two measures of neglect. The Bells

Test correlated .90 with left side omissions on the SLB and

.68 with SLB center omissions. The Bells showed a .79

correlation with the average percent deviation (APD) score

of left lines on the SLB and a .65 correlation with the SLB

52

APD score for center lines. Total APD score on the SLB

yielded a .72 correlation with the Bells Test.

The neglect group omitted a mean number of 17.94 (SD =

8.56) bells (out of a possible 35) on the cancellation task.

In contrast, the nonneglect RBD individuals and orthopedic

controls omitted an average of 2.28 (SD = 1.53) bells and

1.0 (SD = .84) bell, respectively. With a ceiling of 6

lines per hemifield on the SLB task, the neglect group

averaged 2.83 (SD = 1.86) omissions for left lines and 1.28

(SD = 1.71) omissions for center lines. In contrast, the

nonneglect RBD group omitted a mean of .06 (SD = .23) left

lines and no center line omissions. Only one neglect

patient failed to cross lines in the right hemifield, no

nonneglecting RBD patients omitted lines in the right

portion of the SLB, and all orthopedic patients bisected all

18 lines.

To adjust for variations in line length on the SLB, all

scores for each bisected line were converted to a

standardized score, using Schenkenberg's et al., (1980)

formula. Specifically, a percent deviation score was

obtained for each line by subtracting the true midpoint

distance from the subject's mark (measured to the nearest

millimeter), dividing by the true midpoint distance, and

multiplying by 100. This transformation yielded positive

numbers for marks placed to the right of center and negative

numbers for marks placed to the left of center. Average

53

percent deviation (APD) scores were computed for the 6 left,

center, and right lines on the page and for the entire 18-

line page.

As expected, neglect subjects demonstrated marked right

biases with a mean APD of 34.91 (SD = 26.19) for left lines,

a mean APD of 21.94 (SD = 27.82) for center lines, and a

mean APD of 2.47 (SD = 26.79) for right lines. In contrast,

both comparison groups revealed mean APDs ranging from .37

to 4.10 (SD = 4.73 to 8.78).

Analyses of Criterion Measures

Group means and standard deviations for the dependent

variables are provided in Table 5 (Appendix B). Prior to

conducting the primary analyses, tests for equality and

compound symmetry of the variance-covariance matrices were

performed to ensure that the data satisfied the assumptions

for factorial repeated measures analyses (Winer, 1971). Chi

square values, computed for each of the dependent measures,

are shown in Table 6 (Appendix B). Results reveal

nonsignificant chi square values, indicating that the data

conform to the assumptions necessary for the repeated

measures analysis and that subsequent ANOVAs are justified.

The repeated measures ANOVA on RCPM scores demonstrated

a main effect for group, F(2,51) = 18.29, p < .001 (Table 7,

Appendix B). Subsequent comparison of the group means,

using the Newman Keuls procedure, showed that neglect

subjects scored significantly lower across all treatment

54

conditions than nonneglecting RBD patients or hospitalized

controls. Contrary to expectations, however, no significant

condition effect, F(2,102) = .22, p = .80, or group by

condition interaction, F(4,102) = .39, p = .82, was

obtained. Figure 1 presents a graphic display of the group

means across the three presentation conditions.

The second dependent variable under investigation, the

Memory-for-Designs (MFD) Test, revealed similar results.

The repeated measures ANOVA on the MFD scores, using the

Graham-Kendall scoring (MFD-GK), yielded a main effect for

group, F(2,51) = 11.82, p < .001 (Table 8, Appendix B). A

Newman Keuls comparison indicated that neglect subjects

demonstrated significantly higher errors than either of the

two comparison groups. No significant condition effect,

F(2,102) = .03, p = .97, or significant group by condition

interaction, F(4,102) = .66, p = .62, was obtained. The

repeated measures ANOVA on the MFD scores, according to the

Modified Taylor scoring system, revealed a main effect for

group, F(2,51) = 20.15, p < .001, but no significant

condition effect, F(2,102) = .08, p = .93, or significant

group by condition interaction, F(4,102) = .73, p = .57

(Table 9, Appendix B). The MFD group means, scored

according to the GK method, are graphically presented in

Figure 2 and the MFD group means using the MT scoring system

are displayed in Figure 3.

55

9.5

Legend

- Neglect - RBD w/o Neglect • Controls

C cd <D

<D > *</) CO o k. O) O l .

CL

<D L» D O O O c <D > CO (X

8.5

8

7.5

7

6.5 H

5.5

4 . 5 -

Standard Presentation

Right Hemispace

Method of Presentation

Right Hemispace + Left Cue

Figure 1. Raven's Coloured Progressive Matrices Group Means for each Presentation.

56

8

Legend

- Neglect - RBD w/o Neglect - Controls

1 7.5 "o c CD *

I

E CO jc CO V-0

w V-o v_

HI c CO a>

7 -

6.5-

6 -

5.5

(0 c D) "(0 <1> Q I

4.5

o E 0

3.5 J

3 -I

2.5

Standard Presentation

Right Hemispace

Right Hemispace + Left Cue

Method of Presentation Figure 2. Memory-for-Designs Mean Error Scores

(Graham-Kendall Scoring System)

57

9 i

8.5-

"U o

sz

8 -

0 2

7.5-

o >1 CO h-

7 -

l CO

6.5-

o u. L.

Lil 6 -

c CO o 5.5-

co c U) 5 -CO 0 Q i

4.5-i*. o M— 1 >* IL

4 -o e CD

2 3.5-

2.5

Legend

- Neglect - RBD w/o Neglect - Controls

Standard Presentation

Right Hemispace

Right Hemispace + Left Cue

Method of Presentation Figure 3. Memory-for-Designs Mean Error Scores

(Taylor Scoring System)

58

As predicted, the two scoring systems revealed significant

correlations, ranging from .68 to .90 (e < .01). The

correlation matrix in Table 4 (Appendix B) displays the R

values for the various conditions and scoring systems.

CHAPTER IV

DISCUSSION

In view of prior research which has demonstrated that

various strategies can reduce the deleterious effects of

neglect (see Table 10 for a review), the current

investigation was conducted to determine if such changes in

performance would be manifested on measures of cognitive

functioning. Specifically, the primary question was whether

changes in hemispace presentation of stimuli as well as left

sided cueing served to reduce the cognitive performance

decrement frequently observed in the RBD neglect population.

The initial hypothesis predicted that RBD neglect

individuals would demonstrate significantly lower scores on

the RCPM and MFD than nonneglect RBD patient's and orthopedic

control subjects. The results indicated a significant

performance decrement among the criterion group on both

measures of cognitive functioning relative to the comparison

group. These findings are consistent with prior evidence

that has revealed greater cognitive impairment among this

group (Piercy & Smyth, 1962; Gainotti, 1968; Costa et al.,

1969; Campbell & Oxbury, 1976). Contrary to expectations,

however, the present study failed to reveal any significant

improvement in neglect performance as a result of right

59

60

hemispace presentation of stimuli or left sided cueing.

This evidence was consistent for both measures. These

results suggest that, in contrast to the reported changes

observed in line bisection or cancellation task performance,

hemispace manipulations and cueing do not provide the

compensatory assistance needed for improved performance on

these measures.

One explanation that could account for this finding is

the notion that perhaps some improvement occurs, but is

mediated by neglect severity. It may be that performance

improves as a function of hemispace manipulation and cueing

among neglect subjects with mild to moderate levels of

severity, whereas a negligible change or performance

decrement is observed among the more severely impaired

neglect subjects. Since the current neglect sample was

primarily comprised of moderate to severe levels of

impairment, minimal improvement would be predicted to occur.

Indirect support for this idea is provided in studies that

have revealed the size of the infarct and integrity of

residual brain tissue to be important determinants of

recovery (Levine et al., 1986; Hier et al., 1983). Prior

research provides little assistance in addressing this issue

since few studies have differentiated samples in terms of

severity of neglect. Furthermore, the available data are

characterized by small samples with divergent operational

measures of neglect, which make comparisons difficult.

61

Unfortunately, the counterbalancing paradigm of the current

study does not permit such an analysis and further research

is needed to confirm this relationship.

A more parsimonious explanation for the results centers

on the nature of the criterion stimulus. A synthesis of

existing findings and evidence from recent sources suggest

that these strategies are not sufficient to promote enhanced

performance, particularly as task complexity is increased.

Rapcsak, Verfaellie, Fleet, and Heilman (1989) have recently

demonstrated that increased demands on visual selective

attention adversely affected both exploration of the left

side of space and visual discrimination. In a geometric

figure cancellation task that systematically varied the

level of selective attention, results indicated that left

neglect was more severe with complex visual tasks than with

targets that required minimal perceptual discrimination.

Under conditions of greater focusing of attention, incorrect

responses were equally likely in both hemispaces. From this

perspective, the argument can be made that the stimulus

features in the current study reflected an increased number

of distractors and higher demands for selective visual

attention, relative to the demands of line bisection and

cancellation tasks.

On another note, the failure to obtain significant

improvement in performance does not necessarily confirm that

such differences do not exist. Indeed, certain design

62

characteristics may obscure the detection of changes in

performance as a function of the experimental manipulations.

However, close examination of these factors does not provide

strong support for such a conclusion. The sample size in

the current study is considerably larger than previous

studies which have demonstrated significant improvement via

these manipulations (as shown in Table 10). The data

conform to the assumptions of equality and symmetry,

indicating no evidence of gross violations with respect to

sample variances. Concerns about the power of the measures

in detecting significant differences are not appertaining,

given that overall group differences were obtained between

neglect subjects and the comparison groups. In effect,

there is minimal evidence to argue for a Type II error.

The consistency of the results from both measures

provides additional confirmatory evidence to argue against

spurious findings. The data obtained in the present sample

are, for the most part, relatively consistent with prior

research findings. That is, the neglect RBD patients

exhibited significantly more impairment on criterion

measures than the nonneglecting RBD patients and the

orthopedic controls.

One anomalous result that has been difficult to

reconcile is the relatively high level of performance

exhibited by the nonneglecting RBD subjects. Their

performance was not significantly different from the

63

hospitalized orthopedic controls in this study.

Furthermore, when compared to undifferentiated RBD group

means reported by prior investigators, the current sample of

nonneglecting RBD patients exhibited substantially higher

performance. One plausible explanation that may be inferred

from these results is that when neglect is ruled out as a

component in the manifestation of right brain injury, the

cognitive performance associated with lateralized

dysfunction more closely approximates the cognitive

efficiency of cortical functions exposed to diffuse aging

effects. Further research is warranted, however, to confirm

this hypothesis.

The current findings are not entirely unexpected, given

the conflicting outcomes reported for rudimentary line

bisection and cancellation tasks. To date, such mediating

factors as the presence of double cues (Heilman &

Valenstein, 1979; Riddoch & Humphreys, 1983; Robertson,

1989), involvement of a motor response (Joanette et al.,

1986; Reuter-Lorenz & Posner, 1990; Bisiach et al., 1990),

the nature of the task (Heilman & Watson, 1978; Caplan,

1985; Rapcsak et al., 1989), the direction of visual scan

(Reuter-Lorenz & Posner, 1990; Mark et al., 1988), cognitive

load capacity (Rapcsak et al., 1989), and motivational or

conversely, fatigue effects (Ishiai, et al., 1990; Fleet &

Heilman, 1986) have been implicated as potential influences

which alter performance on measures of neglect.

64

These results suggest implications on several levels.

Clearly, the finding that no discernable performance changes

emerge as a function of stimulus modifications and verbal

prompts to explore the contralesional space is of practical

importance. These manipulations are frequently employed in

a clinical context to maximize patient performance, although

empirical support for such procedures is lacking. While the

present study does not presume to prove the null,

replication of these results would provide substantive

evidence for the utility or futility of these tactics. From

a psychometric standpoint, these results underscore the

importance of multiple measures in the assessment of

neglect. And with the multiple factors that have been

delineated as impacting neglect, studies utilizing larger

sample sizes will be necessary to evaluate how these factors

interact to change or improve the symptom picture of

unilateral visual neglect.

Theoretically, the results suggest that while the

phenomenon of neglect may be manifested as a visual

perceptual disorder or directed attentional deficit, the

deficit appears to impact multiple cognitive systems,

limiting the capacity for processing. The implication is

that if general cognitive functioning is defined as multiple

cognitive systems and encompasses processing capacity, then

these results would lend support to theories that relate

65

neglect to a generalized cognitive decline, rather than a

specific deficit.

Although the primary focus of the study examined

proposed cognitive changes among neglect patients as a

function of hemispace and cue manipulations, several

ancillary findings merit review. Specifically, predictions

concerning the screening measures and the relationship

between the two scoring systems for the MFD were

investigated. The two measures employed for detection of

neglect (i.e., the Bells Test and the SLB) yielded

substantial correlations, ranging from .65 to .90. These

results not only confirm the predictions generated in this

study, but also provide additional validation data for the

recently introduced Bells Test. According to the test

developers, this measure is sensitive for detection of mild

and moderate neglect and is more suitable for use during the

rehabilitation period of recovery (Gauthier et al., 1989).

In contrast, the less complex visual scene, like Albert's

Test (Albert, 1973) is routinely used to elicit striking

neglect in severe cases and more commonly employed during

acute stage assessment. Results from the present study

suggest that, in spite of apparent differences in task

requirements or level of perceived difficulty, the two

measures demonstrate marked agreement in their ability to

tap manifestations of neglect. Furthermore, the congruence

between the two instruments exists not only for those

66

patients examined at different stages of recovery, but also

for those patients exhibiting varying degrees of severity.

Similarly, a secondary concern of this study predicted

significant correlations between the two MFD scoring

systems. The findings support the proposed relationship,

revealing correlations ranging from .68 to 90. Contrary to

speculations concerning the deficiencies of the initial

system, these results suggest that the two scoring systems

provide a relatively consistent picture of the perceptual,

motor, and memory deficits associated with brain

dysfunction. Furthermore, these similarities are revealed

in samples that have traditionally been characterized as

exhibiting inconsistent performance (i.e., the RBD

patients), pronounced variability within the sample (i.e.,

the elderly control subjects), and substantial dysfunction

in this cognitive domain (i.e., the neglect group).

There are several limitations of the study that deserve

mention. Due to time constraints, no formal estimates of

premorbid IQ were obtained. More importantly, considerable

neglect group variability characterized the current neglect

sample. While the overall RBD severity level of the neglect

sample was in the moderate to severe range of impairment,

all levels of severity were represented in the neglect

group. On the other hand, the nonneglecting group revealed

an average RBD impairment rating of mild to moderate, and by

definition, represented a less impaired RBD group. The

67

failure to equate the RBD groups on degree of impairment and

premorbid intellectual factors may have posed limitations in

interpretation. Also, since admissions were screened for

participation in the study, there may have been a selection

factor in operation. Attempts were made, however, to

procure a representative sample, since patients were

selected from both a full-service medical facility as well

as a rehabilitation hospital. Finally, data pertaining to

lesion location and extent of damage were relatively crude

and nonspecific, restricting speculations about anatomical

correlates.

At the present time, replication studies designed to

confirm these initial findings are warranted. Future

studies that address the extent and course of recovery

following stroke, according to levels of severity, are

recommended.

APPENDIX A

INFORMED CONSENT

68

69

Informed Consent Form

I, , agree to participate in a study designed to identify the test instrument which most accurately identifies my current level of functioning. The information obtained in this study will be used to improve current assessment devices that fail to compensate for various brain traumas.

I understand that I will be given a series of paper and pencil tasks and shown various geometric designs to complete. Total participation time should be approximately 60-90 minutes. I understand that the information obtained from this study can be used to supplement my medical records and that there will be no charges or additional fees incurred as a result of patient involvement in this study. Further, I understand that this information may be added to my medical records to assist the treatment team in rehabilitation planning, pending patient consent.

I have been informed that any information obtained in this study will be recorded with a code number to ensure that all information remains anonymous. At the completion of the study, the key that relates to the identity of each participant will be destroyed to safeguard confidentiality concerns. Under this condition, I agree that any information obtained from this research may be used in any way thought best for publication and education.

I understand that there are no personal risks or discomfort directly involved with this research and that I am free to withdraw my consent at any time. A decision to withdraw from the study will not affect the services available to me on the rehabilitation unit at St. Joseph's Hospital.

If I have any questions or problems that arise in connection with my participation in this study, I should contact Vicki Soukup or the project director, Dr. Ernest Harrell, at 336-9371 (ext. 6577).

Date Participant

Date Investigator

Date Witness

THIS PROJECT HAS BEEN REVIEWED BY THE UNIVERSITY OF NORTH TEXAS COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS.

70

Informed Consent Form

I, , agree to participate in a study designed to identify the test instrument which most accurately identifies my current level of functioning. The information obtained in this study will be used to improve current assessment devices that fail to compensate for various brain traumas.

I understand that I will be given a series of paper and pencil tasks and shown various geometric designs to complete. Total participation time should be approximately 60-90 minutes. I understand that the information obtained from this study can be used to supplement my medical records and that there will be no charges or additional fees incurred as a result of patient involvement in this study. Further, I understand that this information may be added to my medical records to assist the treatment team in rehabilitation planning, pending patient consent.

I have been informed that any information obtained in this study will be recorded with a code number to ensure that all infprmation remains anonymous. At the completion of the study;, the key that relates to the identity of each participant will be destroyed to safeguard confidentiality concerns. U;nder this condition, I agree that any information obtained from this research may be used in any way thought best for publication and education.

I understand that there are no personal risks or discomfort directly involved with this research and that I am free to withdraw my consent at any time. A decision to withdraw from the study will not affect the services available to( me at the Baylor Institute for Rehabilitation.

If I haye any questions or problems that arise in connection with my participation in this study, I should contact Vicki Soukup or the project director, Dr. Ernest Harrell, at 336-9371 (ext. 6577).

Date ; Participant

Date Investigator

Date ; Witness

THIS PROJECT! HAS BEEN REVIEWED BY THE UNIVERSITY OF NORTH TEXAS COMMITTEE FOR THE PROTECTION OF HUMAN SUBJECTS.

APPENDIX B

TABLES

71

72

Table 1

Sample Characteristics and Group Performance on Screening

Measures

Neglect RBD w/o Neglect

Controls

Age

(range)

64.39

37-84

69.33

33-93

76.33

65-90

Sex Male

Female

13

5

10

8

3

15

Mean Days Post Onset 3 5.44

(range) (9-108)

18.39

(3-39)

16.83

(5-31)

Admission Diagnosis 17 CVA 17 CVA 13 Hip

1 Tumor 1 Hema Evac 5 Knee

Mini Inventory of Right Brain Injury (MIRBI)

Total Score 19.22

(5.56)

26. 56

(8.60)

Severity Rating 3.94 2.50

(1.06) (1-54)

Bells Test

Mean Number of Omissions 17.94

(8.56)

2 . 2 8

(1.53)

1.0

(.84)

73

Neglect RBD w/o Controls Neglect

Schenkenberq Line Bisection (SLB)

Left Omissions 2.83 .06 -0-

(1.86) (.23)

Center Omissions 1.28 -0- -0-

(1.71)

Right Omissions .06 -0- -0-

(.24)

Average Percent Deviation (APD)

Left Lines 34.91 4.10 1.39

(26.19) (8.78) (5.18)

Center Lines 21.94 2.68 .37

(27.82) (5.02) (4.72)

Right Lines 2.47 3.69 .48

(26.79) (6.96) (5.56)

Total APD 20.93 3.59 .74

(24.17) (4.79) (4.75)

74

Table 2

Clinical Data for Neglect Subjects

Pt. Age Sex Post Onset (days)

Source of

Lesion

Location b RBDC

Severity Omissions

Bells Line Bisection

1 63 F 11 k

CVA OP, BG 2 23 5

2 67 M 14 CVA 3 11 0

3 58 M 11 CVA 4 5 3

4 76 F 31 *k

CVA BG 4 27 4

5 69 M 16 •k

CVA T 4 29 5

6 76 F 27 •k

CVA MCA 5 27 9

7 66 M 28 CVA* F 2 16 3

8 46 F 64 CVA* MCA 4 6 3

9 66 M 53 -k

CVA FP 4 24 5

10 67 M 9 k

CVA MCA 4 17 1

11 65 M 22 CVA* MCA 4 6 2

12 58 M 32 CVA 5 23 9

13 56 M 56 CVA* FP 3 13 1

14 56 M 66 CVA* MCA 4 11 2

15 79 M 13 CVA 5 30 12

16 70 M 41 CVA * MCA 6 26 7

17 84 M 36 CVA* FP 5 20 2

18 37 F 108 k

G1ioma FT 3 9 2

Confirmed via CAT Scan. •jjf

Location: BG = Basal Ganglia; F = Frontal; FP = Frontoparietal;

FT = Frontotemporal; MCA = Middle Cerebral Artery;

OP = Occipitoparietal; T = Temporal.

Severity rankings according to MIRBI: 1 = Mild; 2 = Mild-

Moderate; 3 = Moderate; 4 = Moderate-Severe; 5 = Severe;

6 = Profound.

75

Table 3

Clinical Data for RBD Without Neglect Sub.iects

Pt. Age Sex Post Onset (days)

Source of

Lesion

Location b RBDC

Severity Omissions

Bells Line Bisection

1 67 F 21 CVA* U 2 2 0

2 69 M 9 CVA U 3 0 0

3 33 F 11 1 HemaEvac P 1 1 0

4 74 M 8 *

CVA Pons 3 2 0

5 71 F 20 CVA BG,Th 1 2 0

6 55 M 19 *

CVA P 1 2 1

7 72 M 19 *

CVA P 5 1 0

8 67 M 15 CVA Pons 1 1 0

9 77 F 21 CVA U 2 2 0

10 80 F 13 CVA 1 1 0

11 69 F 12 CVA 5 5 0

12 60 M 15 CVA P,T 5 3 0

13 62 M 36 CVA* BG 3 1 0

14 87 M 3 *

CVA U 4 4 0

15 80 F 19 CVA 1 1 0

16 64 M 38 CVA* FTP 2 4 0

17 68 M 13 CVA 1 5 0

18 93 F 39 CVA 4 4 0

•jjjf

Confirmed via CAT Scan. *$c 'jt

Location: BG = Basal Ganglia; FTP = Frontotempoparietal;

P = Parietal; T = Temporal; Th = Thalamic; U = Unspecified. icitjc

Severity rankings according to MIRBI: 1 = Mild; 2 = Mild-

Moderate; 3 = Moderate; 4 = Moderate-Severe; 5 = Severe;

6 = Profound.

76

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Table 5

Group Means and Standard Deviations for the Raven's Coloured

Progressive Matrices (RCPM^ and the Memorv-for-Desian fMFDl

Tests

Neglect RBD w/o Neglect

Controls

RCPM (Mean number correct on 12 items)

Standard* M 4.67 7.89 8. 06

SD 1.41 2 . 63 2 . 01

RH** M 5. 39 7.72 8.11

SD 2 .17 1.96 2.25

RH + L*** M 5.11 7.94 8 . 00

SD 1.78 2.46 2 . 28

MFD Errors (Graham-Kendall Scoring)

Standard* M 6.83 2.83 2 . 61

SD 3.31 3.15 2 . 09

RH** M 6.72 3 . 11 2.67

SD 3.46 2.85 2.77

RH + L*** M 6.33 3 .72 2.50

SD 4.23 3.49 2 . 01

MFD Errors (Modified Taylor Scoring)

Standard* M 8 .17 3 . 83 3.44

SD 3.11 2.46 2 . 01

RH M 8.28 3.56 3.22

SD 3 . 08 2.73 2.37

RH + L M 7.78 4.44 3 .17

SD 4 .49 3 .11 1.72

Note. =

Condition;

Standard Presentation; ***

* * = Right Hemispace

Right Hemispace Plus Left Cue Condition,

80

Table 6

Tests for Equality and Compound Symmetry for the Dependent

Variables

Dependent Variables

RCPM MFD-GK MFD-MT"

Test for Equality

Chi Square* 9.07

df 12

Test for Compound Symmetry

Chi Square** 4.31

df 4

24.75

12

2 .18

4

18 . 61

12

6.83

4

1

Raven's Coloured Progressive Matrices

^Memory-for-Designs Test (Graham-Kendall Scoring)

3Memory-for-Designs Test (Modified Taylor Scoring) *Critical value (.99) = 26.2 ** Critical value (.99) = 13.3

81

Table 7

Analysis of Variance with Repeated Measures on One Factor

for Raven's Coloured Progressive Matrices (RCPM} Scores

Source Sum of Squares

df MS F E

A (group) 303.49 2 151.75 18.29* <.001

Subjects Within Group 423.15 51 8.30

B (condition) o CM •

rH 2 . 60 . 22 .80

AB 4 .17 4 1. 04 . 39 .82

B X Subjects Within Group 273.96 102 2 . 69

82

Table 8

Analysis of Vciriance with Repeated Measures on One Factor

for Memory-for-Designs CMFD) Test (Graham-Kendall Scoring)

Source Sum of Squares

df MS F E

A (group) 509.48 2 254.74 11.82* <.001

Subjects Within Group 1098.96 51 21. 55

B (condition) .26 2 . 13 . 03 .97

AB 9.93 4 2.48 . 66 . 62

B X Subjects Within Group 381.81 102 3 . 74

83

Table 9

Analysis of Variance with Repeated Measures on One Factor

for Memory-for—Designs (MFD) Test (Modified Tavlor Scoring

System

Source Sum of Squares

df MS £ P

A (group) 729.05 2 364.52 20.15* <.001

Subjects Within Group 922.70 51 18.09

B (condition) .53 2 .27 . 08 .93

AB 10.17 4 2 . 54 . 73 . 57

B X Subjects Within Group 353.96 102 3 . 47

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SCHENKENBERG LINE BISECTION TEST

88

89

APPENDIX D

THE BELLS TEST

90

91

4

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92

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APPENDIX E

RAVEN'S COLOURED PROGRESSIVE MATRICES (RCPM)

SAMPLE ITEM FROM ORIGINAL VERSION AND REVISED VERSION

94

B 8 95

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96

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APPENDIX F

MODIFIED TAYLOR SCORING INSTRUCTIONS

MEMORY-FOR-DESIGNS (MFD) TEST

97

98

Memory-for Designs Test

(Modified Taylor Scoring System)

General Instructions

Judging the figures one at a time, tally the appropriate

number of points for each error. Note that any individual

figure may score in several of the error categories. Points

may be given to a single figure for errors of rotation and

omission and distortion, etc., or any figure may be found to

score in only one category, or in no category.

After scoring all figures for each of the first six

categories, then score for Organization.

Total the number of tallies in each of the seven

categories and sum them. This grand total is the subject's

Total score.

Omission:

Distortion:

Scoring Categories Defined

If half or more of the figure is omitted,

score 2 points. If any part or line (but

less than half the figure) is omitted,

score 1 point.

If the overall gestalt of the figure does

not agree with the stimulus figure, or if

any portion of a figure is out of

proportion by more than about 50%, score

1 point. Do not score this category if

the discrepancy between reproduction and

99

3. Rotation:

4. Reversal:

Perseveration:

stimulus is caused solely by omission,

rotation, or reversal, etc.

Score 1 point in this category when the

figure as it is reproduced represents the

stimulus as though it were rotated about

its central axis. Rotation must be 45

degrees or more to be scored.

Score 1 point for reversal if the figure

or a proportion of the figure is drawn as

though the stimulus had been "flopped

over," either horizontally or vertically.

Note. Rotation represents the

figure as having been "spun around"—

reversal as though it had been "flopped

over." Generally there are fewer

possibilities of reversal, and reversal

must not be scored on Figures 1, 2, 7, or

8. When in doubt, check the illustrated

sample errors, and remember that the same

reproduction may contain both rotation

and reversal errors.

This might be called "carry-over effect"

and is scored for uncalled for

reproduction or partial reproduction of

any previous stimulus figure. No

perseveration score may be given on Figure

100

#1, as it represents the initial

stimulus.

6. Embellishment: Score 1 point for any addition of

uncalled for lines, loops, flags, boxes,

etc. to the figure, except where such

additions are clearly preservations from

previous figures.

Note. Distortion changes the

gestalt of the figure from that of the

stimulus; Embellishment maintains the

general gestalt, but adds extra frills or

adornments.

7. Organization: This category is based on the arrangement

of the figures on the paper relative to

numerical order of presentation. Only

scores of 0, 3, or 6 may be given in this

category.

For figures in orderly column or row

sequence with no more than one deviation,

score zero (0) points. For irregular

arrangement in which there is some order

but the figures do deviate more than once

from sequential column or row

presentation, score three (3) points.

For confused presentation score six (6)

points. This is for helter-skelter

101

distribution in which there appears no

pattern or sequential order of

presentation.

8. Total: This is the grand total of all points

scored in each of the preceeding seven

categories.

Bradford, D. C. (1978). Differences between groups of brain

damaged patients on the Memory-for-Designs test: A

comparison of two scoring systems. Unpublished doctoral

dissertation, University of Utah.

APPENDIX G

MEMORY-FOR-DESIGNS (MFD) TEST

SAMPLE ITEM FROM ORIGINAL VERSION AND REVISED VERSION

102

103

104

APPENDIX H

RAW DATA

105

106

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