322 Recovery of Functional Status After Right Hemisphere Stroke: Relationship With Unilateral Neglect Leora R. Cherney, PhD, BC-NCD, Anita S. Halper, MA, BC-NCD, Christina M. Kwasnica, MD, Richard L. Harvey, MD, Ming Zhang, PhD ABSTRACT. Cherney LR, Halper AS, Kwasnica CM, Harvey RL, Zhang M. Recovery of functional status after right hemisphere stroke: relationship with unilateral neglect. Arch Phys Med Rehabil 2001;82:322-8. Objective: To evaluate relationships between unilateral spatial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke. Design: Assessment of overall and cognitive-communicative function was conducted on admission to acute rehabilitation, at discharge, and at 3-month follow-up. Setting: Urban, acute inpatient rehabilitation facility. Patients: Fifty-two consecutive admissions of adult righthanded patients with a single, right hemispheric stroke, confirmed by computed tomography scan. Main Outcome Measures: The FIM instrument and reading comprehension and written expression items of the Rehabilitation Institute of Chicago Functional Assessment Scale. Results: Patients made significant functional gains between admission and discharge, and between discharge and follow-up on the FIM. Severity of neglect was correlated with total, motor, and cognitive FIM scores at admission, discharge, and follow-up. Subjects with neglect had significantly more days from onset to admission and a longer length of rehabilitation stay than subjects without neglect. FIM outcomes were significantly different for subject groups with more severe neglect. Both the presence of neglect and its severity were significantly related to functional outcomes for reading and writing. Conclusions: Patients with neglect show reduced overall and cognitive-communicative functional performance and outcome than patients without neglect. Further studies are needed to explore causal relationships between these factors. Key Words: Cerebrovascular accident; Communication disorders; Rehabilitation; Unilateral neglect. 2001 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation MEASUREMENT OF FUNCTIONAL ABILITIES is an essential part of the assessment process in rehabilitation. Clinicians use functional measures to develop goals and treatment plans, to facilitate interdisciplinary team communication, From the Rehabilitation Institute of Chicago (Cherney, Halper, Kwasnica, Harvey, Zhang); and Physical Medicine and Rehabilitation, Northwestern University Medical School (Cherney, Halper, Kwasnica, Harvey), Chicago, IL. Accepted in revised form July 10, 2000. Supported in part by the Rehabilitation Research and Training Center, National Institute on Disability and Rehabilitation Research, US Department of Education (grant no. H133B30024). No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the author(s) is/are associated. Reprint requests to Leora R. Cherney, PhD, BC-NCD, Rehabilitation Institute of Chicago, 345 E Superior St, Chicago, IL 60611, e-mail: lcherney@rehabchicago.org. 0003-9993/01/8203-6017$35.00/0 doi:10.1053/apmr.2001.21511 and to document functional gains. Payers and regulators use functional measurement data to determine levels of independence and to make fiscal decisions about patient care. Functional measurement data are also used to select providers, to set payment rates, to determine eligibility for service, to determine treatment cutoffs, and to judge the quality of care. 1 One of the most widely used functional outcome measures in rehabilitation facilities is the FIM instrument, 2 which measures degree of disability and burden of care. It consists of 18 items that cover a range of functional activities. Each item is rated on a 7-point ordinal scale along a continuum from complete independence to total assistance. The 18 FIM items define 2 statistically and clinically different indicators. 3-5 Thirteen of the items are considered to be motor, and include functions related to locomotion, transfers, and activities of daily living (ADLs). The other 5 items are cognitive, and include memory, problem solving, social interaction, comprehension, and expression. Thus, the FIM yields a total score as well as 2 subscores motor and cognitive. The FIM motor score may be a more robust measure than the FIM cognitive score because it includes more items. 4 Although the FIM addresses comprehension and expression, it is limited in measuring the complete range of language areas. Comprehension and expression are rated according to the mode of communication typically used by the patient (auditory vs visual, vocal vs nonvocal). Because auditory and vocal are the usual modes for most individuals, reading and writing are typically not rated. Heinemann et al 4 have suggested that the FIM cognitive scale could be enhanced by rating modes of comprehension and expression separately. This would permit ratings of reading and writing and provide 4 communication ratings rather than 2. Information is limited about the overall functional outcomes, and more specifically about the cognitive-communicative outcomes of patients with right hemisphere stroke. One hallmark characteristic of patients with right hemisphere damage is unilateral spatial neglect. 6-8 Unilateral or hemispatial neglect is a complex disorder in which patients ignore, or do not respond or orient to, stimuli on the contralateral side to the lesion, despite the motor and sensory capacity to do so. 9 Neglect may occur in any modality, but it is most common in the visual modality. Mesulam 10 noted that when the neglect is severe, it is obvious in functional activities like shaving, grooming, and dressing only the right side of the body. Further, patients may read only the right side of the page or omit the left side of words regardless of where they are located on the page. When the neglect is more subtle, it may only be noted on specific tasks (eg, line bisection, cancellation tasks), and may not be observable during functional activities. Unilateral spatial neglect has consistently been identified as a negative predictor for a patient s recovery of independence in daily living. 8,11-13 However, none of these studies used the FIM instrument as a measure of functional status. Furthermore, the focus of these studies was primarily on ADLs and motor aspects of recovery, with little emphasis on cognition and communication.
FUNCTIONAL STATUS AND UNILATERAL NEGLECT, Cherney 323 More recently, Katz et al 14 assessed the impact of unilateral visual neglect on the rehabilitation outcome of a group of 40 patients with right hemisphere stroke. They found that individuals with unilateral neglect performed significantly worse on several measures, including the FIM, at both admission and discharge. Furthermore, their preliminary analysis indicated that unilateral neglect is a major predictor of rehabilitation outcome from admission to follow-up at 6 months postdischarge. In addition, patients with neglect had a significantly longer stay in the rehabilitation hospital than patients without neglect. Katz 14 did address some cognitive aspects of performance but did not examine functional communication outcomes. Studies of functional communication in patients with neglect should include measures of reading and writing, 2 communication areas in which neglect is commonly observed. For example, patients with neglect may ignore the left half of compound words, the left half of sentences, the left half of a paragraph, or the entire left page of a book. Their writing may be characterized by excessive left-hand margins and extraneous perseverative strokes on the right. 15 As a result, they may have difficulty reading and writing functionally in such activities as reading signs and newspapers and writing lists and personal letters. Therefore, studies that investigate functional communication in patients with neglect must consider reading and writing as well as auditory comprehension and oral expression. This study examined the overall and cognitive-communicative functional outcomes of a group of patients with right hemisphere stroke who were admitted to an acute inpatient rehabilitation facility. Its purpose was: (1) to evaluate the relation between functional status and rehabilitation outcome (as measured with the FIM) and the presence and severity of unilateral neglect; (2) to assess the impact of severity of neglect on length of rehabilitation hospital stay; and (3) to assess the relation between unilateral neglect and functional communication outcome, including reading and writing. Table 1: Demographic Subject Data for a Group* With Right Hemisphere Stroke Mean SD METHOD Range Age (yr) 66.19 13.46 25 89 Education (yr) 12.77 2.25 8 18 Time from onset 33.13 68.40 3 378 to admission (d) Total FIM score at 53.63 18.13 25 103 admission LOS (d) 35.79 10.04 11 56 * Fifty-two patients (33 men, 19 women). Abbreviation: SD, standard deviation. Subjects We report outcome results for 52 consecutive patients who were admitted between October 1993 and March 1998 to a free-standing urban, acute inpatient rehabilitation facility after having a unilateral right hemisphere stroke as confirmed by computed tomography scan. During this period, all consecutive admissions were screened, but only 52 patients met the study criteria and agreed to participate in this study. All subjects were right handed, spoke English as their primary language, were premorbidly literate, and had no history of neurologic or psychiatric disorders or drug and alcohol abuse. All subjects had sufficient corrected visual acuity to read the visual items on the assessment tasks. Table 1 provides the mean, standard deviation, and range of pertinent data for 33 men and 19 women, including age and length of time between onset and admission. The wide range of days between onset and date of admission was due largely to the inclusion in this sample of 2 outliers with Table 2: The RIC-FAS: Reading Comprehension 19 Domain Communication Item Name Reading comprehension Definition Includes understanding linguistic information via the written word. Reasons for difficulty in reading comprehension will vary depending on communication diagnosis. May be due to a symbolic linguistic disorder, reduced processing rate, and/or deficits in underlying cognitive processes such as attention, perception, memory, and reasoning. Scale Points 7 Normal Subject understands a variety of complex or abstract written materials. 6 Minimal Impairment Subject understands complex or abstract written material with the use of self-initiated compensatory strategies (eg, re-reading), or reading rate may be slightly slow. 5 Mild Impairment Subject reads average adult reading material (eg, newspaper articles) more than 90% of the time; breakdown may occur when content is complex, abstract, inferential, or lengthy. 4 Mild to Moderate Impairment Subject reads several (more than 2) simple related paragraphs; comprehension decreases if material is syntactically complex or inferential. May require some cueing (eg, directed reading) to aid comprehension. 3 Moderate Impairment Subject reads 1 to 2 simple paragraphs more than 50% of the time. 2 Moderate to Severe Impairment Subject reads single words, phrases, and/or sentence level material more than 25% of the time. 1 Severe Impairment Subject may not understand any written stimuli or reads single words, phrases, and/or sentences inconsistently (less than 25% of the time). 0 Not Applicable or Not Assessed (eg, non-english speaking, decreased visual acuity)
324 FUNCTIONAL STATUS AND UNILATERAL NEGLECT, Cherney Table 3: The RIC-FAS: Written Expression 19 Domain Communication Item Name Written expression Definition Includes expressing linguistic information graphically with appropriate and accurate semantics (meaning), syntax (grammar), and spelling. Scale Points 7 Normal Subject writes complex or abstract ideas accurately. 6 Minimal Impairment In most situations, subject writes complex or abstract ideas accurately. May self-monitor, self-correct, self-cue, and self-initiate compensatory strategies. 5 Mild Impairment Subject writes about daily activities and ideas about a variety of topics. Writing is more than 90% accurate but may be simple (eg, limited syntactic complexity), contain some spelling errors, and/or be slow. Occasionally cueing (less than 10% of the time) may be required. 4 Mild to Moderate Impairment Subject writes several related sentences (more than 2) about daily activities and ideas. Writing is 75% to 90% accurate but may be simple (eg, limited syntactic complexity), contain some spelling and organizational errors, and/or be slow. Some cueing may be required. 3 Moderate Impairment Subject writes about basic needs and simple ideas. Writing is 50% to 74% accurate but may be incomplete (eg, limited syntactic complexity or errors), contain some spelling and organizational errors, and/or be slow. Moderate cueing may be required. 2 Moderate to Severe Impairment Subject inconsistently writes about basic daily needs. Writing is 25% to 49% accurate but may be incomplete (eg, words, phrases, sentence fragments) or syntactically incorrect or disorganized. 1 Severe Impairment Subject writes basic daily needs less than 25% of the time or does not write appropriately or consistently despite prompting. 0 Not Applicable or Not Assessed (eg, upper extremity involvement, decreased visual acuity, non- English speaking) time between onset and admission of greater than 100 days. The median length of time since onset, however, was 12.5 days. Overall severity ratings of patients on admission was based on the total FIM score obtained within 72 hours of admission. It ranged from 25 to 103 (max score 126), with a mean of 53.63. According to the Uniform Data System for Medical Rehabilitation (UDSMR), a patient with a score of less than 76 is considered severely impaired. 16 Therefore, 44 (84.6%) of the patients were severely impaired. Procedures The outcome measures used were the FIM 2 and the reading comprehension and written expression items on the Rehabilitation Institute of Chicago Functional Assessment Scale (RIC-FAS). 17-19 Initial FIM scores were obtained within 72 hours of admission to the acute inpatient rehabilitation facility. Discharge FIM scores were obtained at the time of discharge. Both the admission and discharge FIM items were rated by individuals trained in the administration and scoring of the FIM instrument and credentialed by the UDSMR; therefore, these ratings are considered to be reliable. Follow-up FIM ratings were obtained by personnel from the outcomes management department of the rehabilitation facility, 3 months postdischarge by telephone interview with the patient and/or caregiver. Telephone raters were blind to the purpose of the study. The RIC-FAS was developed as a supplement to the FIM to evaluate more completely patient function in several areas, including communication. Speech-language pathologists who were trained in its use scored the RIC-FAS reading comprehension and written expression items at the initial evaluation of the patient and at discharge. Tables 2 and 3 show the 7-point RIC-FAS items for reading comprehension and written expression. Assessment of interrater reliability was conducted during the first year of RIC-FAS implementation. Reliability of 99% and 96% were obtained, respectively, for reading comprehension and written expression. 18 Therefore, the ratings achieved in this study were considered to be reliable. Table 4: FIM Obtained at Admission, Discharge, and 3-Month Follow-Up for Patients With Right Hemisphere Stroke Maximum Possible Score Admission* (n 52) Discharge* (n 48) Follow-Up* (n 40) Total FIM 126 53.63 18.13 82.44 19.38 100.53 22.94 FIM motor 91 34.73 12.96 56.65 15.26 70.35 19.20 FIM cognitive 35 18.90 7.04 25.79 6.19 30.18 5.13 NOTE. Values presented as mean SD. * p.001 for all analyses from admission to discharge, and from discharge to follow-up.
FUNCTIONAL STATUS AND UNILATERAL NEGLECT, Cherney 325 Table 5: Means and SDs Obtained on the BIT 12 by 52 Patients With Right Hemisphere Stroke Cutoff Score The presence and severity of neglect was assessed with the Behavioural Inattention Test (BIT), 20 a standardized test of unilateral visual neglect. The test includes 6 conventional paper-and-pencil measures of neglect (line crossing, letter cancellation, star cancellation, figure and shape copying, line bisection, representational drawing), and 9 behavioral subtests reflecting aspects of daily life (picture scanning, telephone dialing, menu reading, article reading, telling and setting the time, coin sorting, address and sentence copying, map navigation, card sorting). Scores from each subtest are summed to provide a score for the total test, as well as overall scores for the conventional and for the behavioral groups of subtests. For each of these, the normal range of performance is provided, as well as cutoff scores below which problems in unilateral neglect are suspected. 20 The BIT was administered to subjects on their admission to the rehabilitation facility by a speech pathologist or a trained research assistant. RESULTS Mean SD Conventional subtests 129 88.78 46.44 Behavioral subtests 67 41.26 27.97 Total test 196 128.02 74.22 Functional Outcomes The means and standard deviations (SDs) of the total FIM scores for the 52 subjects, obtained at admission, discharge, and follow-up, are listed in table 4. Discharge FIM scores were obtained on 48 subjects because of incomplete documentation on 4 subjects at the time of discharge. Follow-up total FIM scores were obtained on the 40 patients who could be contacted by telephone at 3 months postdischarge. Of these 40 interviews, 19 (47.5%) were conducted with the patient, 18 (45%) with a family member, and 3 (7.5%) with an attendant. Analysis of variance (ANOVA) showed significant differences between all these measures (p.001), indicating that the improvements in patient ratings as a group between admission, discharge, and follow-up were statistically significant. Table 4 also includes the means and SDs of the admission, discharge, and follow-up FIM scores for the motor and cognitive groups of items. ANOVA showed statistically significant differences between all these measures (p.001), indicating that the patients ratings as a group showed functional gains between admission, discharge, and follow-up for both the motor and cognitive groups of items. Of the 52 subjects evaluated at admission, there was complete FIM documentation at all 3 data collection points on 36 Table 6: Pearson s Product Moment Correlations and Significance Levels Obtained Between BIT 12 Conventional Subtest Score and FIM Measures at Admission, Discharge, and Follow-Up Admission (n 52) Discharge (n 48) Follow-up (n 40) * p.01. p.05. Total FIM (18 Items) FIM Motor (13 Items) FIM Cognitive (5 Items).54*.55*.39*.51*.48*.42*.36.33.40* subjects. Data were missing because of incomplete documentation at the time of discharge or inability to contact the patient at follow-up. Analyses of the FIM data on the subgroup of 36 subjects with completed scores were statistically similar to that of the larger sample. Therefore, all further analyses were conducted on the larger sample presented in table 4. (Specific information regarding the subgroup of 36 subjects is available from the authors.) Unilateral Visual Neglect Table 5 includes the means and SDs for the total BIT, as well as for the conventional and functional groups of subtests. As a group, performance fell below the cutoff scores, indicating unilateral visual neglect. Two subjects completed only the conventional subtests of the BIT. In view of the high correlation between performance on the conventional and the behavioral subtests (r.89, p.001) and between the conventional subtests and total BIT (r.98, p.001), only scores on the conventional subtests were used in the following correlation analyses with the FIM scores so that the maximum number of subjects could be included in the analyses. Relation Between FIM and BIT Scores To assess the relation between unilateral neglect and functional performance, the BIT conventional score was correlated with the total FIM score and the FIM motor and cognitive scores at admission, discharge, and follow-up (table 6). All correlations were statistically significant, suggesting an association between unilateral neglect and functional performance as measured by the FIM. Presence and Severity of Neglect To investigate this relationship further, the 52 patients were subdivided into 2 groups based on the BIT scores. One group of 36 patients who had BIT scores less than the cutoff score of 129 was considered to have unilateral neglect; the other group Table 7: Mean Performance on the FIM by 2 Patient Groups Differentiated by the Presence and Absence of Unilateral Neglect Group 1: Neglect (n 36) Admission Discharge Follow-Up Group 2: No Neglect (n 16) Group 1: Neglect (n 32) Group 2: No Neglect (n 16) Group 1: Neglect (n 30) Group 2: No Neglect (n 10) Total FIM 50.61 18.07 60.44* 16.82 78.40 17.19 90.50* 21.52 97.93 23.17 108.30 21.48 FIM motor 32.14 12.61 40.56* 12.14 53.41 13.31 63.13* 17.21 68.37 18.97 76.30 19.63 FIM cognitive 18.47 7.06 19.88 7.14 25.00 6.23 27.38 5.99 29.57 5.58 32.00 3.02 NOTE. Values presented as mean SD. Group 1: Presence of neglect (range BIT score, 1 128); Group 2: Absence of neglect (range BIT score, 129 ). * p.05.
326 FUNCTIONAL STATUS AND UNILATERAL NEGLECT, Cherney Table 8: Mean Performance on the FIM by 2 Patient Groups Differentiated by the Severity of Unilateral Neglect Group 1: More (n 19) Admission Discharge Follow-Up Group 2: Less (n 17) Group 1: More (n 18) Group 2: Less (n 14) Group 1: More (n 16) Group 2: Less (n 14) Total FIM 42.42 10.06 59.76 20.80* 71.67 15.76 87.07 15.35* 94.81 22.08 101.50 24.68 FIM motor 26.68 7.91 38.24 14.24* 48.94 12.40 59.14 12.60 66.63 18.07 70.36 20.44 FIM cognitive 15.74 5.14 21.53 7.78 22.72 6.35 27.93 4.84 28.19 5.94 31.14 4.87 NOTE. Values presented as mean SD. Group 1: More severe unilateral neglect (range BIT score, 1 65); Group 2: Less severe unilateral neglect (range BIT score, 66 128). * p.01. p.05. of 16 patients who scored within the normal range ( 129) presented with no neglect. Independent t tests indicated that the groups did not differ significantly in terms of age, education, and length of time since onset (p.05). Because of small group size, the Mann-Whitney U test was conducted to compare FIM scores (table 7). Patients with neglect showed significantly lower scores than those without neglect on the total FIM scores obtained at admission (U 186, p.05) and discharge (U 154.5, p.05) and the FIM motor scores obtained at admission (U 170.5, p.05) and discharge (U 153.5, p.05). Follow-up scores and the FIM cognitive scores obtained at all times were not significantly different. We also tested whether the severity of the neglect was related to functional outcome by further dividing the group with neglect into 2 subgroups based on their BIT conventional scores. A score of 65 was selected to differentiate between less severe and more severe neglect because it represents the midpoint score that could be achieved by patients with neglect (min score 1, max score 129). One group of 19 patients with a BIT score of less than 65 was considered to have more severe neglect; the other group of 17 patients with a BIT score between 65 and 129 was considered to have less severe neglect. These groups did not differ significantly in terms of age, education, and length of time since stroke onset on independent t tests (p.05). Table 8 shows that the group with more severe neglect differed significantly at admission from the group with less severe neglect on the total FIM scores (U 69.5, p.01), as well as the FIM motor (U 80, p.01) and cognitive (U 84, p.05) scores. Furthermore at discharge, the severe neglect group had significantly lower FIM total (U 59, p.01), motor (U 71.5, p.05), and cognitive (U 62.5, p.05) scores than the group with less severe neglect. Length of Stay The patient s length of stay (LOS) is a variable that is often used as an indicator of resource utilization. When patients were subdivided into 2 groups based on whether they did or did not have neglect, LOS was significantly different (t 2.49, p.05). Patients with neglect had a mean LOS SD of 38.03 9.39 days, whereas patients without neglect had a mean LOS of 30.75 9.89 days. In contrast, there was no significant difference in LOS when the subjects with neglect were divided into 2 groups based on the severity of their neglect (tables 9, 10). Unilateral Visual Neglect and Cognitive-Communicative Outcome Significant correlations have been noted between the FIM cognitive and BIT scores for all the subjects. Furthermore, when the subjects were divided into 2 groups based on the severity of the neglect, FIM cognitive scores differed significantly at admission and discharge. These results support a relation between cognitive-communicative outcome and neglect. However, FIM cognitive includes only 5 items; 3 reflect communicative interaction, rated in the auditory/vocal mode on all patients. It was anticipated that unilateral visual neglect would impact communication that relied more on the visual modality. Therefore, we examined the relation between neglect and functional reading and writing skills by assessing the association between the RIC-FAS reading comprehension and written expression ratings and the presence of neglect. Table 11 shows the reading and writing ratings obtained at admission and discharge for the entire group of patients. Significant improvements were made between admission and discharge in both reading (t 3.82, p.01) and writing (t 3.47, p.01). When the group was divided into groups with and without neglect, the former group scored significantly worse than did Table 9: LOS and Mean Functional Reading and Writing Performance by 2 Patient Groups Differentiated by the Presence and Absence of Unilateral Neglect Group 1: Neglect Group 2: No Neglect Significance Testing Time from onset to admission (d) 31.78 56.08 (n 36) 36.19 92.49 (n 16) U 175.5; p.05 LOS (d) 38.03 9.39 (n 36) 30.75 9.89 (n 16) U 171.5; p.05 RIC-FAS reading at admission 2.72 1.46 (n 32) 4.19 1.56 (n 16) U 111.5; p.01 RIC-FAS reading at discharge 3.24 1.18 (n 21) 5.08 1.44 (n 12) U 41.5; p.01 RIC-FAS writing at admission 2.59 1.58 (n 32) 3.06 1.81 (n 16) U 194.5; p.05 RIC-FAS writing at discharge 3.24 1.61 (n 21) 4.42 1.08 (n 12) U 65.5; p.05 NOTE. Values presented as mean SD. Group 1: Presence of neglect (range BIT score, 1 128); Group 2: Absence of neglect (range BIT score, 129 ).
FUNCTIONAL STATUS AND UNILATERAL NEGLECT, Cherney 327 Table 10: LOS and Mean Functional Reading and Writing Performance by 2 Patient Groups Differentiated by the Severity of Unilateral Neglect Group 1: More Severe Neglect Group 2: Less Severe Neglect Significance Testing Time from onset to admission (d) 40.84 73.67 (n 19) 21.65 23.85 (n 17) U 114; p.05 LOS (d) 39.05 7.49 (n 19) 36.88 1.28 (n 17) U 144; p.05 RIC-FAS reading at admission 1.94 0.66 (n 17) 3.60 1.64 (n 15) U 41; p.01 RIC-FAS reading at discharge 2.73 0.90 (n 11) 3.80 1.23 (n 10) U 27.05; p.05 RIC-FAS writing at admission 1.82 1.07 (n 17) 3.47 1.64 (n 15) U 44.5; p.01 RIC-FAS writing at discharge 2.73 1.19 (n 11) 3.80 1.87 (n 10) U 31; p.05 NOTE. Values presented as mean SD. Group 1: More severe unilateral neglect (range BIT score, 1 65); Group 2: Less severe unilateral neglect (range BIT score, 66 128). the group without neglect on reading at admission (t 3.14, p.01) and discharge (t 3.77, p.01), and on writing at discharge (t 2.51, p.05) (table 9). When the groups were divided according to patients with more severe and less severe neglect, patients with more severe neglect scored significantly worse on reading at both admission (t 3.67, p.01) and discharge (t 2.26, p.05) and on writing at admission (t 3.30, p.05) (table 10). DISCUSSION The results of this study indicate that patients with right hemisphere stroke in an acute rehabilitation hospital made significant overall functional changes from admission to discharge and from discharge to follow-up. The changes, as measured by the FIM, were significant for both motor and cognitive-communicative functions in this cohort of patients considered to have severe disability at admission. Because this study sought to describe changes in functional status, information about the amount or type of treatment that each patient received was not collected. Furthermore, most of the patients were seen early in their recovery (average, 33d postonset), and therefore the effects of spontaneous recovery cannot be separated from the effects of treatment. Therefore, we cannot interpret the effects of rehabilitation. The results confirm previous findings that indicate functional performance at admission and functional outcome at discharge and follow-up are related to the severity of neglect. 8,11-14 Patients with neglect are likely to have poorer functional outcome than patients without neglect on measures of FIM total and motor scores. Furthermore, patients with more severe neglect are likely to make less functional improvement than are patients with less severe neglect on measures of FIM total, motor, and cognitive scores. Although neglect patients had lower FIM cognitive scores at admission, discharge, and follow-up than nonneglect patients, these differences did not reach significance. Because fewer items are included in the FIM cognitive score, as compared with the FIM motor score, the cognitive score may be less reliable in its ability to detect associations with other variables. In addition, the small sample size might have been a factor in statistical significance not being reached. These results may also reflect the sensitivity of the BIT 20 and the reliability of the cutoff score of 129 that was used to differentiate neglect from nonneglect patients. It is possible that the BIT is not sensitive to mild neglect and that some of the patients included in the nonneglect group might actually have had subtle but clinically important neglect. Conversely, the cutoff score may be too high, and there may have been individuals without neglect who were erroneously included in the neglect group. Future research in this area should use a larger sample size and more than 1 measure to ascertain the presence or absence of neglect. LOS, a measure of resource utilization, significantly correlated to neglect. Patients with neglect stayed approximately 1 week longer in inpatient rehabilitation than did patients without neglect. Katz et al 14 also showed that patients with neglect had longer inpatient rehabilitation hospitalization (118d vs 78d). Furthermore, patients with neglect had a significantly longer time between onset and admission to rehabilitation, a finding that was confirmed in our study. However, the length of time from onset to admission was not significantly different for patients with more severe as compared with less severe neglect. Therefore, the presence or absence of neglect, rather than its severity, may be a factor that delays admission to rehabilitation and affects the LOS in the acute care hospital. The impact of neglect on functional outcome in reading and writing has not been considered in previous studies. Our results are consistent with what is anticipated clinically. Patients with neglect will have poorer functional performance in reading and writing than patients without neglect, and the more severe the neglect, the poorer the functional performance will be. For reading, both the presence and severity of neglect were associated with reading outcome. For writing, it was the presence of neglect rather than its initial severity that was associated with outcomes. Further studies are needed to replicate this finding, which may have important implications for rehabilitation outcome. At present, with the reliance on the FIM, reading and writing skills may be overlooked. Study results support the suggestion by Heinemann et al 4 that the inclusion of reading and writing in the FIM may enhance its performance in predicting patient outcomes. CONCLUSION The results of this study do not answer questions about causal relationships between the presence and severity of neglect and functional outcomes. The analyses also do not directly address whether neglect is an independent predictor of outcome because of the lack of adjustment for confounding variables, such as age, time since onset, and severity of motor impairment. Rather, the study highlights observations that are useful to the practicing clinician responsible for determining Table 11: Functional Reading and Writing as Measured by the RIC-FAS Obtained at Admission and Discharge for a Group of Patients With Right Hemisphere Stroke Maximum Possible Score Admission* (n 48) Discharge* (n 33) RIC-FAS reading 7 3.21 1.64 3.91 1.55 RIC-FAS writing 7 2.75 1.66 3.67 1.53 NOTE. Values presented as mean SD. * p.01 for all analyses from admission to discharge.
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