Occupational Therapists’ Identification, Assessment, and Treatment of Unilateral Spatial Neglect During Stroke Rehabilitation in Canada
Background and Purpose— Unilateral spatial neglect (USN) is a disabling feature of stroke, and its identification and management are critical for optimizing patient outcomes. This study examined USN problem identification, assessment, and treatment among clinicians working in stroke rehabilitation.
Methods— This report was based on a Canada-wide survey of 253 occupational therapists providing inpatient stroke rehabilitation.
Results— Eighty percent (n=202) recognized USN as a potential problem, 27% (n=67) reported using standardized USN assessment tools, and 58% (n=147) indicated using USN interventions. Working on a stroke unit and younger age were among the variables explaining 7% to 19% of the variability in USN problem identification, assessment, and intervention use.
Conclusions— Although USN problem identification was high, clinicians were unlikely to use standardized assessment tools or evidence-based interventions to effectively manage this serious impairment.
Unilateral spatial neglect (USN) is a disabling feature of stroke, with an estimated prevalence of 40% or greater.1 It is characterized by the inability to orient or respond to stimuli appearing on the side contralateral to the brain lesion. USN is associated with a greater risk for falls, longer rehabilitation stays, and poor functional recovery.1 To counteract these disabling effects, it is critical that rehabilitation professionals be astute at (1) identifying the impairment, (2) assessing patients by using tools with strong psychometric properties, and (3) providing interventions aimed at reducing the impairment and functional sequelae.
Although numerous standardized tools are available to identify USN after stroke,2 a study in acute care hospitals in Ontario, Canada, suggests a low prevalence of their use.3 Of 248 subjects, only 13% were assessed with a standardized assessment, and of these, only 4% were assessed within 48 hours after stroke, as recommended by practice guidelines.4 Typically, occupational therapists (OTs) were responsible for USN assessment once the Emergency Department screening by the neurologist was completed.3
It is important to understand the management of USN beyond the acute care period. Indeed, it might be argued that the rehabilitation phase provides the ideal opportunity for in-depth assessment and treatment. Effective management of USN is particularly important, given its negative impact on long-term functional outcomes.5
Thus, the objectives of this study were to identify the extent to which OTs working in inpatient stroke rehabilitation (1) recognize USN as a potential problem when it exists, (2) actually use USN-related assessments and interventions, (3) desire the use of assessments and interventions, and (4) recognize clinician and environmental factors associated with being a “USN problem identifier,” “best-practice USN assessment user,” or “USN intervention user.”
Subjects and Methods
A Canada-wide survey investigated the stroke rehabilitation practices of 1755 stroke rehabilitation professionals. This report focuses on the findings related to USN management by OTs providing inpatient stroke rehabilitation. Prompted by a vignette depicting a typical patient, therapists were asked to identify problems, as well as to specify assessments and interventions they would use for this patient in their actual practice. Research ethics approval was attained from the Faculty of Medicine, McGill University, Montreal, Quebec, Canada.
Sample Size Considerations
Sample size was based on the estimate that 20% of clinicians would use USN assessments.3 With a 2-sided confidence interval of 95% and a desired precision of 5%, ≈246 therapists were required to allow stable estimates.6
The Canadian Association of Occupational Therapists and the provincial licensing bodies provided lists of clinicians working in adult neurology. In smaller provinces without lists, the orders provided names of sites. Disproportional random sampling was used to ensure sufficient numbers by province.
Clinicians were eligible if they (1) were registered with the licensing body, (2) had provided stroke rehabilitation for ≥3 months during the year and treated ≥2 adult inpatients with a primary diagnosis of stroke per month, (3) worked in a setting for ≥6 months in the past year, (4) spoke English or French, and (5) provided consent.
Development of the Case Vignette
Previous work has demonstrated that case studies are a valid form of treatment ascertainment.7 Using focus-group methodology, expert clinicians and researchers developed a case representing a typical patient with stroke receiving inpatient rehabilitation. Next, the vignette’s contents were refined, and team members reviewed the final version for readability. It was translated into French with rigorous procedures and pilot-tested on 3 clinicians to verify clarity and coherence.
The focus-group members generated cues of clear and persistent symptoms of USN and its effects on functional performance: “J was transferred to the rehabilitation inpatient facility where you work, 14 days after experiencing an ischemic, right middle cerebral artery stroke”; “By discharge, J was participating in 45 minutes of daily therapy and had progressed to wheeling the chair for short distances but tended to bump into obstacles on the left”; “J is sitting slumped in a wheelchair with the left arm dangling over the sidearm”.
The questionnaire was designed according to Dillman’s guidelines.8 It was reviewed for face validity and pretested in English before translation into French. The first section elicited information on the clinician, work environment, and client characteristics (see Tables 1 and 2⇓). The next series of questions focused on management of the patient depicted in the vignette and included open-ended questions regarding potential problems, as well as the assessments and interventions that the clinician would typically use. Finally, questions were included regarding the use of desired assessments and interventions in an “ideal” world. Lists of potential assessments and interventions were not provided. We have used a similar version of this questionnaire with high participation rates.9
Trained interviewers traced potential participants according to rigorous procedures. Once contacted, the clinician was screened for eligibility. Those who agreed were scheduled for a 25-minute telephone interview. The vignette was forwarded 24 to 48 hours before the interview to allow the clinician time to become familiar with the case. The interviewer used a standard script when administering the questionnaire and when responding to queries. To avoid contamination, respondents were asked to refrain from discussing the survey with their peers. Their responses to the questions were recorded by hand onto the questionnaire forms.
Two research assistants coded clinicians’ responses. Two authors (A.M.-N. and N.K.-B.) reviewed the codes for accuracy and consistency. Data were entered into a database and each entry was verified. A clinician was considered a “USN problem identifier” if he or she used any of the following terms to denote a problem: unilateral spatial neglect, neglect, visual perception (VP), perception, hemianopsia, anosognosia, or lack of body awareness. We used these inclusion criteria because it was likely that a clinician who mentioned hemianopsia, for example, would be doing so to differentiate between USN and visual field impairment.10
A clinician was classified as a “best-practice USN assessment user” if he or she indicated the use of tool(s) 1 or more times (initial, interim, discharge, follow-up) that has procedures for administration and scoring, as well as reliability and validity for USN evaluation after stroke, as identified from a systematic review2 (Table 3). A clinician was classified as a “VP assessment user” if he or she reported the use of tool(s) classified as general assessments of VP (see Table 3). A clinician who used terms such as visual-perception assessment was also included in this category (Table 3). A clinician was categorized as a “USN intervention user” if he or she indicated the use of any intervention that has been indicated in the scientific literature for the treatment of USN (Table 4). “Best-practice USN management” was defined for the clinician who identified USN as a potential problem, used 1 or more standardized USN-specific tools at any point during rehabilitation, and used 1 or more USN-related interventions.
Descriptive statistics were used to indicate the prevalence of USN problem identification, use of USN specific and general VP assessments, and USN interventions. Additionally, the prevalence of desired use of USN assessments and interventions was calculated.
To study the contribution of potential explanatory variables for each of the 3 dichotomous outcomes, “USN problem identifier” (yes/no), “best-practice USN assessment user” (yes/no), or “USN intervention user” (yes/no), univariate analyses were performed on the 18 clinician and environmental factors (described in Tables 1 and 2⇑). χ2 analyses were used for categorical variables and ANOVA, for continuous variables. Because numerous comparisons were performed, the threshold for significance was set at 0.01 with a Bonferroni correction.
Next, 3 separate logistic-regression analyses were performed to investigate the contribution of potential explanatory variables that were univariately associated at P<0.10 (Tables 1 and 2⇑ indicate these variables) with the same 3 dichotomous outcomes. With stepwise backward elimination along with forward model building, the most parsimonious models were identified. To identify multicolinearity, 3 aspects were used: the presence of high correlation coefficients (0.8 or more) between independent variables, the percentage of variation of the regression coefficients from 1 step to the next in the backward elimination or forward inclusion of variables, and the presence of unacceptably large standard errors for those coefficients.
The survey was completed in 2004 to 2005: 1072 OTs from acute care, rehabilitation, and community practices were contacted: 290 were ineligible; 71 were untraceable; and 48 (7%) refused, with the remaining 663 participating. Of these, 253 OTs worked in inpatient rehabilitation settings and thus completed the interview related to the inpatient rehabilitation vignette describing a patient with poststroke USN. The mean±SD age of the participants was 36.7±9.2 years, and 91% were female. The majority had a bachelor’s degree (Table 1).
Of the 253 clinicians, 80% (n=202) recognized USN as a potential problem or used a term that potentially indicated an attempt to establish a differential diagnosis. Specific key words included USN/neglect (152/253, 60%), perception (73/253, 29%), VP (21/253, 8%), lack of body awareness (16/253, 6%), hemianopsia (7/253, 3%), and anosognosia (3/253, 1%).
Table 3 describes the prevalence and timing of use of assessments. Twenty-seven percent of clinicians were identified as “best-practice USN assessment users.” Four clinicians had unclear responses: each indicated using the Rivermead assessment but did not clarify whether it was specific to USN2,11 or the Rivermead Motor Assessment.12 One of these clinicians was already using standardized USN assessments; the other 3 were not counted. A high proportion (85%) reported using some form of USN/VP assessment. When asked about the timing of use of assessments, clinicians rarely indicated performing a repeat assessment of USN with standardized tools: 10% at interim, 17% at discharge, and 1% at follow-up. Although few (2%) clinicians indicated a desire to introduce a USN-specific assessment into their practice, one fifth indicated a desire to change their current VP assessment practices by introducing a new assessment or evaluating patients more frequently.
More than half of clinicians indicated using a USN intervention, with the 3 most common being perceptual retraining, visual scanning, and activation treatment (Table 4). Six percent indicated a desire to introduce a USN intervention into their practice.
Best-Practice USN Management
Sixteen percent of OTs (40/253) were classified as providing “best-practice USN management.” Specifically, of 202 clinicians who indicated a problem, 58 indicated using a “best-practice USN assessment” at some point during rehabilitation, and of these, 40 indicated using a USN intervention.
Clinician/Environmental Factors Associated With USN Management
Tables 1 and 2⇑ indicate the clinician and environmental factors and their univariate associations with USN problem identification, assessment, and intervention. Multivariate analysis including the variables significant at P<0.10 (see Tables 1 and 2⇑) showed that degree and specialty certification explained 7.2% of the variability in USN problem identification (Table 5). Univariate analyses of factors associated with being a “best-practice USN assessment user” showed a significant effect of age (Table 1): 41% of therapists age 20 to 30 years were users versus 11.5% of those older than 50 (F=11.691, P=0.001). There was a significant interaction between age and degree (χ2=71.554, P=0.000): 0% of those with a diploma were <40 years old compared with 68% with a bachelor’s degree. Multivariate analysis including the variables significant at P<0.10 (Tables 1 and 2⇑) and the interaction term (age×degree) found that the most parsimonious model that best explained being a “best-practice USN assessment user” included younger age, urban location, presence of a stroke unit, and the availability of funds for education. Together these variables explained 19.4% of the variability in the outcome (Table 5). The model that best explained being a “USN intervention user” included degree (bachelor’s versus diploma or master’s), presence of a stroke unit, and research conducted in the work setting, explaining 16.0% of the variability in USN intervention use (Table 5).
Problem Detection and Assessment
Encouragingly, this study indicated a high level of problem identification in response to persistent USN symptoms embedded in a patient vignette.13 In terms of assessment, whereas three quarters of clinicians indicated that they would use some form of USN or VP assessment, only one quarter indicated a USN-specific assessment. A similarly low prevalence has been documented in the United States, where 61% of positive cases of USN had not been detected during admission assessment.14 At the time of our survey, there were 28 standardized USN assessments2; clinicians used 7. Accurate assessment is a vital component of best practice. Moreover, because USN can occur in 3 hemispaces (personal, near extrapersonal, far extrapersonal), it is critical that clinicians use a tool that will identify impairments in each.2 No respondent assessed all 3 hemispaces, even though the vignette’s cues indicated a need to do so. This lack of identification is serious for both the patient and society and raises concern that most patients return home to resume activities, such as community mobility or driving, without having been alerted to the potential dangers. Repeat assessment is also important, given that the rate of recovery from neglect is greatest within the first month after stroke15 and that interventions should be adjusted or eliminated as the patient’s status changes.16 Repeat assessment was rare in this study.
Prevalence of USN-Related Interventions
More than half of clinicians provided interventions. A systematic review concluded that treatments exist to effectively remediate USN symptoms in subacute stroke.17,18 Specifically, visual scanning training, trunk rotation, neck muscle vibration, mental imagery training, video feedback training, and prism therapy result in short-term (4 to 6 weeks) improvements in visual scanning and functional performance.18 Less than one quarter of clinicians provided scanning training, and rarely did therapists use any other effective treatments.
Prevalence of Best-Practice Management
Best-practice management of USN was low. Notably, those who did identify a USN problem were more likely to indicate a best-practice assessment and intervention. This provides an important focus for knowledge translation strategies19 aimed at enhancing problem detection, which in turn is likely to heighten awareness of the need for assessment and treatment.
Desired Use of USN-Related Assessments and Interventions in an Ideal World
In Canada’s busy health care system, it is important to understand the gap between actual and desired practices. Respondents rarely indicated a desire to introduce a USN-specific assessment or intervention, suggesting that gaps in management are not necessarily associated with a perceived lack of resources, equipment, or time.
Clinician/Environmental Factors Associated With Best Practices
Overall, the 18 potential explanatory variables were only minimally successful in identifying USN problem identifiers and assessment and intervention users. Those with diploma-level training were less likely to identify a USN problem. Diploma-level training has been replaced by bachelor’s/master’s entry to practice in Canada. In each of the 3 logistic models, either age or degree was significant, and the interaction between these 2 variables was clear—younger clinicians all have bachelor’s or master’s training.
The presence of a stroke unit increased USN assessment and intervention. A Cochrane Review concluded that patients receiving organized stroke unit care compared with medical care were more likely to experience increased survival, functional independence, and return home.20 Our findings add new support to substantiate the beneficial effects of stroke units.
A study using vignettes may overestimate or underestimate USN management. However, vignettes have been shown to be a valid means of determining actual practice because they provide a consistent case on which to base practice variations.7 Also, given the random sampling and high rate of participation, it is likely these study findings can be generalized across Canada.
This survey found that USN problem identification was high, but evidence-based assessment and intervention use were less than optimal. Given that USN is a highly disabling feature of stroke, it is important that rehabilitation professionals become more astute at identifying, assessing, and treating patients with the aim of reducing both the impairment and serious functional sequelae. Overall, it appears that there is a need for effective knowledge translation19 aimed at improving USN management after stroke.
We acknowledge the support of Dr Julie Lamoureux for statistical analysis, our large and dedicated team of interviewers, and the clinicians who participated. We also acknowledge the investigators of this project for their collaboration: S. Wood-Dauphinee, R. Teasell, J. Hanley, J. Desrosiers, F. Malouin, A. Thomas, M. Harrison, F. Kaizer, and E. Kehayia.
Sources of Funding
A. Menon-Nair was funded by a doctoral award from the CIHR program (Innovations in Patient Safety and Knowledge Translation) at the Faculty of Medicine, University of Toronto, and N. Korner-Bitensky was funded by a senior career award from the Fond de la recherche en santé du Québec.
This project was funded by the Canadian Stroke Network, the Réseau provincial de recherche en adaptation réadaptation, and the Centre de recherche interdisciplinaire en réadaptation du Montréal Métropolitain.
- Received February 7, 2007.
- Accepted February 26, 2007.
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