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Rehab Measures

Catherine Bergego Scale

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Purpose

The CBS is a short scale designed to assess the existence and extent of unilateral neglect during observations of the patient. It has both an observational component and a self-report questionnaire of the same items to compare the therapists’ perspective and the patient’s awareness (P. Azouvi et al., 1996).

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instrument details

Acronym CBS (via KF-NAP)

Area of Assessment

Activities of Daily Living

Assessment Type

Performance Measure

Administration Mode

Paper & Pencil

Cost

Free

Cost Description

Cost of equipment

Populations

Key Descriptions

  • The CBS is an observational, functional, performance based assessment.
  • There are 10 items, Each item is scored from 0-3.

    0= no neglect
    1=mild (patient will cross midline after right side is attended to first)
    2= moderate (with clear and consistent left side omissions)
    3=severe

    The minimum total score is 0 (indicating no neglect), and the maximum total score is 30 (indicating severe neglect).
  • The total score is derived through the addition of the individual items (which can either be scored 0, 1, 2, or 3). Giving a score of 3 or 0 is usually easier than 2 or 1. Many times, the difference between 2 and 1 is a matter of degree in the presentation of a specific symptom.
  • Kessler Foundation Neglect Assessment Process (KF-NAP™) is a detailed description of how to administer the CBS.
  • The KF-NAP™ was developed because there was not a detailed description (at least not publicly available) on how the CBS was to be administered or used.

    Using the KF-NAP™ to administer the CBS standardizes the administration and strengthens the CBS as the most-recommended functional assessment for spatial neglect.
  • All 10 categories of the CBS should be observed during one session. It is suggested that you score the categories in the order found on the scoring sheet. Although this is not absolutely critical, the order follows a natural progression.

    For instance, the category that takes the most amount of time is Meals, and so the authors suggest you observe it at the end of the assessment.
  • If the KF-NAP™ is used in follow-up assessments, the recommendation is that you observe the patient at the same time of the day and in the same location as that first session. By doing so, you will reduce the effect of wakefulness, mood, or motivation, all factors that may fluctuate throughout the day and influence the accuracy of the assessment.
  • In the manual, the authors provide instructions for assessing left-sided spatial neglect, commonly occurring after right brain damage. However, you may use the same principles to assess right-sided neglect, commonly occurring after left brain damage. The scoring sheet is applicable to both left and right-sided spatial neglect.

Number of Items

10 categories

Equipment Required

  • If administration is taking place in acute care or an outpatient clinic, the authors suggest having a “kit” with these items:
  • Lab coat or a large button-down shirt, plastic basin, mirror with stand, hair brush, soap, paper towel
  • Empty garbage can or anything safe to drop on the floor for making unexpected loud noise, food tray, utensils, water and food for observing the meal

Time to Administer

15-45 minutes

Depends on severity of neglect

Required Training

No Training

Age Ranges

Adult

18 - 64

years

Elderly Adult

+

years

Instrument Reviewers

Initial instrument review completed by Kimberly Hreha, MS, OTR/L, EdD(c). Stroke Clinical Research Coordinator, and Peii Chen, PhD. Research Scientist.

Reviewed and revised by Allison Peipert, 2017.

Updated by Bridget Hahn, OTD, OTR/L, Baylee Cawley, OTS; Samantha Conrad, OTS; Alexandra Wasko, OTS; Rush University in 2019

ICF Domain

Participation
Body Function

Measurement Domain

Activities of Daily Living

Considerations

In the most severe cases, some items may not be able to be scored due to confounding factors, such as apraxia or severity of hemiplegia.  In these cases, only score the items the patient is able to perform.  The sum of the items scored should then be divided by the number of items scored and multiplied by 10 to give a final score (Azouvi, 1996).

Anosognosia score can be obtained by comparing the patient’s self report with the therapist scored test.  In the self-report questionnaire, the patient rates themselves in the same 10 areas on the assessment.  They score if they have difficulty in each area, and if they find it mild, moderate, or severe.  An anosognosia score can be obtained from subtracting the patient’s score from the therapists score  (Azouvi, 2003).

The ME subscale of the CBS may describe spatial neglect after acute stroke and recognize functional dependence, however, future research is needed to evaluate the validity of the ME component of the CBS by including measures of whole-body spatial bias (such as postural measures) (Goedert, 2012).

The authors of the KF-NAP suggest the following: Take the entire session as a continuous time period. If the patient shows left-right asymmetric performance in two thirds of the session, you rate a given category with a score of 2; if the left-right asymmetric performance occurs one third of the session, the patient receives a score of 1. This principle can be helpful in observing Gaze Orientation and Limb Awareness.

When having doubt, you may ask yourself if “ineffective and incomplete” describes the patient’s performance. If so, you should probably give him/her a score of 2 rather than 1 in a given category. This could be helpful in observing Dressing, Grooming, Meals, or Cleaning after Meals.

No lateralized cue: Being a rehabilitation clinician, such as an occupational therapist, you may often give your patients verbal instructions to initiate, or try to initiate, certain behaviors or engage them in a task during a therapy session. During the KF-NAP, however, it is extremely important that the verbal instructions should not involve spatial cues and not give any type of cue to elicit a response that will help improve spatial attention. For example, phrases like: “look more to the left” or “what is on the left of the tray?” may prompt false responses to what should be an observed presentation. To avoid this, allow time for the patient to spontaneously explore the environment, and permit them to freely use their limbs and move their eyes.

Look for lateralized or asymmetrical behavior. You must look for patient behavior that is biased toward one side of space. That is, whether their eyes, limbs, or body often move toward one side but pay less attention to the other side. It is important that both the left and right sides are equally assessed before you come to the conclusion that the patient shows left-sided or right-sided spatial neglect.

The KF-NAP has been translated into Italian and Korean.

This assessment can be used during all stages of recovery from a stroke or traumatic brain injury. Even if the person has cognitive deficits or aphasia, aspects of the assessment can be observed and scored appropriately. There is a column (on the scoring sheet) for not applicable. If, for example, the person is not medically stable enough to eat by mouth, the Meals item would not be able to be scored at that time and “not applicable” would need to be used.

Stroke

back to Populations

Cut-Off Scores

Stroke: (Azouvi, 2003; n =83; mean age = 54.5 (14.1) years, mean time post stroke = 15.9 (15.2) weeks)

  • Score of 1-10=Mild Behavioral Neglect
  • Score of 11-20=Moderate Behavioral Neglect
  • Score of 21-30=Severe Behavioral Neglect

Normative Data

Acute stroke, right hemisphere: (Goedert, 2012; n = 51; mean age = 66.9 (15.9) years; mean time post stroke = 22.3 (10.9) days)

  • Mean (SD) Catherine Bergego Scale (CBS) score; 19.3 (6.7), range = 2-30
  • Mean (SD) CBS score for perceptual-attentional items (CBS-PA subscale) 1.7 (.08), range = 0.17-3.0
  • Mean (SD) CBS score for embodied motor-exploratory items (CBS-ME subscale); 2.3 (0.7), range = 0-3.0

Acute Stroke: (Marques et al, 2019; n = 22; Mean Age = 62.7(12.6); Mean CBS scores = 11.41 and 11.55 from evaluators)

Variable N Mean SD Min Max Median
Age (years) 22 62.73 12.63 23.00 85.00 64.00
Weight (kg) 22 68.26 18.75 51.60 90.00 69.50
BMI (kg/m2) 22 27.66 4.00 18.50 35.90 27.05
Education (years) 22 4.63 1.94 1.00 7.00 5.00
Time since stroke (days) 22 37.36 6.10 30.00 50.00 38.00
NIHSS admission 22 10.59 5.46 0.00 23.00 11.00
NIHSS current 22 4.77 3.10 0.00 11.00 4.50
mRS 22 1.77 1.34 0.00 4.00 1.50
Barthel index 22 61.59 33.07 15.00 100.00 60.00
BIT 22 80.23 37.50 13.00 125.00 89.00
Evaluator 1 CBS 22 11.41 9.40 0.00 30.00 10.00
Evaluator 2 CBS 22 11.55 9.16 0.00 29.00 12.00

BMI: Body mass index; NIHSS: National Institute of Health Stroke Scale; mRS: modified Rankin scale; BIT: Behavioural Inattention Test; CBS: Catherine Bergego Scale.

Interrater/Intrarater Reliability

Acute Stroke: : (Azouvi, 2003; n =83; mean age = 54.5 (14.1) years, mean time post stroke = 15.9 (15.2) weeks)

  • Adequate to excellent interrater reliability was found for each question (ICC= .59-.99)

Stroke:  (Marques et al, 2019)

  • Excellent Interrater/Intrarater Reliability: (ICC = 0.98 )

Stroke: (Azouvi, 1996)

  • Excellent Interrater/Intrarater Reliability: (ICC = 0.96)

Internal Consistency

Acute Stroke: (Azouvi, 1996)

  • Adequate correlation was found between cleaning the mouth after eating and the total score of the CBS (r=0.58)
  • Excellent correlation was found between the other items and the total score of the CBS (r=0.69-0.88)

Acute Stroke: (Azouvi, 2003)

  • Excellent correlation was found between total score of the CBS grooming (0.81), dressing (0.84), Eating (0.80), knowledge of left limbs (0.80), auditory attention (0.82), spatial orientation (0.83), and finding personal belongings (0.85).
  • Adequate correlation was found between total score of the CBS mouth cleaning (0.78), gaze orientation (0.79), and moving (0.77)

Acute Stroke: (Luukkainen-Markkula, 2011; n = 17; mean age = 57 (8) years; time since stroke = 20 (32) months)

  • Excellent correlation was found between total score of the CBS grooming (r=0.64), mouth cleaning (r=0.73), gaze orientation (r=0.73), knowledge of left limbs (r=0.80), auditory attention (r=0.61), collisions (r=0.89), and spatial orientation (r=0.89)
  • Adequate correlation was found between total score of the CBS and dressing (r=0.51) and finding personal belongings (r=0.58)
  • Poor correlation was found between the total CBS score and eating (r=0.32)

Normative Sample: (Marques et al, 2019)

  • Excellent: Cronbach's alpha coefficient = 0.913

Criterion Validity (Predictive/Concurrent)

Concurrent validity:

Acute Stroke, Right Hemisphere: (Azouvi, 1996)

  • Excellent concurrent validity was found when comparing the total CBS score and Bells test (r=0.74), Line cancellation (r=0.73), and reading task (r=0.61)
  •  Adequate concurrent validity was found for the CBS with Daisy drawing (r=0.50) and Ogden’s Scene (r=0.56)
  • Adequate concurrent validity was found when scoring the self -report questionnaire with conventional neglect assessments (r=0.45-0.58).

Acute Stroke: (Azouvi, 2003)

  • Excellent concurrent validity was found for the CBS with Bells test (r=0.76) and figure copying (r=0.70)
  • Adequate concurrent validity was found between the CBS and text reading (r=0.54)

Acute Stroke, Left Hemisphere: (Azouvi, 2006; Right hemisphere stroke: n = 206; mean age = 55.9 (15.3); mean time post stroke 11.1 (13.8) weeks; Left hemisphere stroke: n = 78; mean age = 54.6 (15.7); mean time post stroke: 10.8 (12.4) weeks.

  • Adequate concurrent validity was found between the CBS and Bells test (r=0.41)

Acute Stroke: (Qiang, 2005; n = 19; mean age = 62.5 (10.9), mean time post stroke: 61.9 (25.8) days)

  • Excellent concurrent validity was found between the Wheelchair Collision Test and the CBS ( r =0.72) if the distance between the chairs was 120 cm and (r = 0.75) if the distance was 140 cm

 Subacute Stroke, Right Hemisphere: (Azouvi, 2002; n = 206; mean age = 55.9 (15.3); mean time post stroke 11.1 (13.8) weeks)

  • Excellent concurrent validity was found with the CBS and the Bells test (r=0.77), Figure copying (r=0.66), and Writing tests (r=0.62)
  • Adequate concurrent validity was found between CBS with Clock drawing (r=0.55), Bisection 20 cm lines (r=0,49), and Reading tests (r=0.53)(P Azouvi et al., 2002)
  • Poor concurrent validity was found the CBS and Line bisection 5 cm lines (r=0.16)

Predictive Validity:

Acute Stroke: (Qiang, 2005)

  • Excellent predictive validity of the CBS at 61.9 (25.8) days post onset at predicting deficits in activities of daily living (ADLs) assessed by the FIM (r =-0.70)

Acute Stroke, Left Hemisphere: (Goedert, 2012)

  • Adequate predictive validity of the CBS-ME at 22.3 days post lesion at predicting deficits in activities of daily living (ADLs) using the Barthel index (r = -0.43)

Subacute Stroke: (Oh-Park, 2014; n = 21; mean age = 60.0 (11.5) years; mean time post stroke = 20.8 (10.1) months)

  • Adequate predictive validity of the CBS in predicting deficits with community mobility assessed with the University of Alabama at Birmingham Study of Aging Life-Space Involvement (LSA) (r = -0.58)

Predictive validity:

Stroke: (Azouvi, 1996)

  • Excellent correlations with the Barthel activities of daily living index (r = .63)

Construct Validity

Convergent Validity:

Acute Stroke: (Azouvi, 1996)

  • Excellent convergent validity was found when the CBS score was compared to the Barthel index as a measure of functional independence (r=-0.63)

Acute Stroke: (Azouvi, 2006)

  • Adequate convergent validity was found between the CBS independence in activities of daily living as measured by the Functional Independence Measure (r=-0.48)
  • Adequate convergent validity was found between the CBS and posture and balance as measured by the Postural Assessment for Stroke Scale (r=-0.55)

Stroke:  (Pitteri et al., 2018; n = 14; Mean Age = 61.3 (15); Right CVA)

  • Excellent correlations with the Behavioral Inattention Test- Conventional (r = -.668)
  • Excellent correlations with the Barthel Index (r = -.700)
  • Excellent correlations with the Functional Independence Measure (r = -.662)

 

Pearson correlation of CBS scale scores with NIHSS, BIT, mRS and Barthel.

 

NIHSS
admission

mRS

Barthel
index

NIHSS
current

BIT

Evaluator 1

Evaluator 2

NIHSS admission

1

-0.24037
0.2812

-0.29128
0.1884

0.67149
0.0006

-0.31804
0.1492

-0.21905
0.3274

-0.22637
0.3111

mRS

 

1

-0.05581
0.8052

-0.17313
0.4410

0.32732
0.1370

0.03413
0.8802

-0.00880
0.9690

Barthel index

 

 

1

-0.41195
0.0568

0.47041
0.0271

-0.28712
0.1951

-0.32825
0.1358

NIHSS current

 

 

 

1

-0.19694
0.3797

0.03276
0.8849

-0.00381
0.9866

BIT

 

 

 

 

1

-0.45891
0.0317

-0.46222
0.0303

Evaluator 1

 

 

 

 

 

1

0.97804
<.0001

Evaluator 2

 

 

 

 

 

 

1

NIHSS: National Institute of Health Stroke Scale; mRS: modified Rankin scale; BIT: Behavioural Inattention Test.

 

 

Floor/Ceiling Effects

Acute Stroke: (Azouvi, 2003)

  • Adequate floor effects 3/83 (3.6%) of acute stroke patients achieved a score of 0

Responsiveness

For two patients with chronic stroke, the CBS was responsive to a visuo-spatial-motor cueing program, scores decreasing from 21/30 to 15/30 and 23/30 to 12/30 (Samuel et al., 2000).

Bibliography

Azouvi P, Bartolomeo P, Beis J-M, Perennou D, Pradat-Diehl P, Rousseaux M. A battery of tests for the quantitative assessment of unilateral neglect. Restorative Neurology & Neuroscience. 2006;24(4/6):273-85.

Azouvi P, Olivier S, de Montety G, Samuel C, Louis-Dreyfus A, Tesio L. Behavioral assessment of unilateral neglect: Study of the psychometric properties of the Catherine Bergego Scale. Archives of Physical Medicine and Rehabilitation. 2003;84(1):51-7.

Azouvi P, Samuel C, Louis-Dreyfus A, et al. Sensitivity of clinical and behavioural tests of spatial neglect after right hemisphere stroke. Journal of Neurology, Neurosurgery & Psychiatry. 2002 August 1, 2002;73(2):160-6.

Azouvi P, Marchal F, Samuel C, et al. Functional consequences and awareness of unilateral neglect: Study of an evaluation scale. Neuropsychol. Rehabil. Apr 1996;6(2):133-150.

Bercot, H. (2018). Inpatient rehabilitation for a patient with a right posterior cerebral artery stroke, unilateral neglect syndrome, and homonymous hemianopia. Retrieved from DSpace

Chen, P., & Hreha, K. (2015). KF-NAP 2015 Manual Retrieved from https://kesslerfoundation.org/researchcenter/stroke/networkforspatialneglect.php

Chen, P., Chen, C. C., Hreha, K., Goedert, K. M., & Barrett, A. M. (2015). Kessler Foundation Neglect Assessment Process uniquely measures spatial neglect during activities of daily living. Archives of Physical Medicine and Rehabilitation, 96(5), 869-876. doi: 10.1016/j.apmr.2014.10.023

Chen, P., Hreha, K., Fortis, P., Goedert, K. M., & Barrett, A. M. (2012). Functional assessment of spatial neglect: A review of the Catherine Bergego Scale and an introduction of the Kessler Foundation Neglect Assessment Process. Topics in Stroke Rehabilitation, 19(5), 423-435. doi: 10.1310/tsr1905-423

Goedert KM, Chen P, Botticello A, Masmela JR, Adler U, Barrett AM. Psychometric Evaluation of Neglect Assessment Reveals Motor-Exploratory Predictor of Functional Disability in Acute-Stage Spatial Neglect. Archives of Physical Medicine and Rehabilitation. 2012 1//;93(1):137-42.

Luukkainen-Markkula R, Tarkka IM, Pitkänen K, Sivenius J, Hämäläinen H. Comparison of the Behavioural Inattention Test and the Catherine Bergego Scale in assessment of hemispatial neglect. Neuropsychological Rehabilitation. 2011;21(1):103-16.

Marques, C. L. S., Souza, J. T. D., Gonçalves, M. G., Silva, T. R. D., Costa, R. D. M. D., Modolo, G. P., & Luvizutto, G. J. (2019). Validation of the Catherine Bergego Scale in patients with unilateral spatial neglect after stroke. Dementia & neuropsychologia, 13(1), 82-88. Find on PubMed

Oh-Park M, Hung C, Chen P, Barrett AM. Severity of spatial neglect during acute inpatient rehabilitation predicts community mobility after stroke. PM & R: The Journal Of Injury, Function, And Rehabilitation. 2014;6(8):716-22.

Pitteri, M., Chen, P., Passarini, L., Albanese, S., Meneghello, F., & Barrett, A. M. (2018). Conventional and functional assessment of spatial neglect: Clinical practice suggestions. Neuropsychology, 32(7), 835-842. http://dx.doi.org/10.1037/neu0000469. Find on PubMed

Qiang W, Sonoda S, Suzuki M, Okamoto S, Saitoh E. Reliability and validity of a wheelchair collision test for screening behavioral assessment of unilateral neglect after stroke. American Journal of Physical Medicine & Rehabilitation. 2005;84(3):161-6 6p.

Samuel C, Louis-Dreyfus A, Kaschel R, et al. Rehabilitation of very severe unilateral neglect by visuo-spatio-motor cueing: Two single case studies. Neuropsychological Rehabilitation. 2000;10(4):385-99.

Shah, P., Hreha, K., & Chen, P. (2012). Evidence of inter-rater reliability in scoring the Kessler Foundation Neglect Assessment Process. Paper presented at the American Congress of Rehabilitation Medicine – American Society for Neurorehabilitation, Vancouver, Canada.

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