Effect of Missed Items on the Reliability of the Kessler Foundation Neglect Assessment Process

  • Timothy J. Rich
    Corresponding author Timothy Rich, PhD, OTR/L, Kessler Foundation, 1199 Pleasant Valley Way, West Orange, New Jersey 07052.
    Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey

    Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, New Jersey
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  • Kimberly P. Hreha
    Department of Orthopedic Surgery, Duke University School of Medicine, Durham, North Carolina

    Department of Ophthalmology, Duke University School of Medicine, Durham, North Carolina
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  • A.M. Barrett
    Department of Neurology, Emory University School of Medicine, Atlanta, Georgia

    Center for Visual and Neurocognitive Rehabilitation, Atlanta VA Health Care System, US Department of Veterans Affairs, Decatur, Georgia
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  • Devan Parrott
    Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Indianapolis, Indiana

    Research, Training, and Outcome Center for Brain Injury, Rehabilitation Hospital of Indiana, Indianapolis, Indiana
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  • Peii Chen
    Center for Stroke Rehabilitation Research, Kessler Foundation, West Orange, New Jersey

    Department of Physical Medicine and Rehabilitation, New Jersey Medical School, Rutgers University, Newark, New Jersey
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Published:March 16, 2022DOI:



      To determine the maximum permissible number of missed items on the 10-item Catherine Bergego Scale administered after the Kessler Foundation Neglect Assessment Process (KF-NAP). Secondary objectives were to determine the frequency, characteristics, and most commonly cited reasons reported for missed items.


      Retrospective diagnostic accuracy study.


      Sixteen inpatient rehabilitation facilities in the United States.


      A consecutive clinical sample of 4256 patients (N=4256) with stroke or other neurologic deficits who were assessed for spatial neglect with the KF-NAP.


      Not applicable.

      Main Outcome Measures

      Catherine Bergego Scale via KF-NAP.


      The majority (69.7%) of patients had at least 1 missed item on their KF-NAP. Among those with missed items, it was most common to have 2 missed items (51.4%), and few had more than 3 missed items (11.3%). The most commonly missed items were Collisions (37.2%), Cleaning After Meals (36.1%), Meals (34.0%), and Navigation (19.7%). The most commonly reported reasons for missed items included time constraints, cognitive or communication deficits, and behavior or refusal of the therapy session. These reasons were reported for nearly all item types. Item-specific reasons were also commonly reported, such as a lack of a needed resource for task completion or low functional status of the patient. Prorated scoring of measures with up to 3 missed items maintained an acceptable level of concordance with complete measures (Lin's Concordance Correlation Coefficient=0.96, 95% CI, 0.9478-0.9626) for the combination of 3 missed items with lowest concordance.


      Clinicians should make every effort to capture all items on the KF-NAP. However, missed items occur in the majority of cases because of patient factors and barriers inherent to the inpatient hospital setting. When missed items are necessary, clinicians can confidently interpret a prorated score when 7 or more items are scored.


      List of abbreviations:

      CBS (Catherine Bergego Scale), CCC (concordance correlation coefficient), IQR (interquartile range), KF-NAP (Kessler Foundation Neglect Assessment Process), PEG (percutaneous endoscopic gastrostomy), SN (spatial neglect)
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        • Esposito E
        • Shekhtman G
        • Chen P
        Prevalence of spatial neglect post-stroke: a systematic review.
        Ann Phys Rehabil Med. 2021; 64101459
        • Heilman KM
        • Valenstein E
        Mechanisms underlying hemispatial neglect.
        Ann Neurol. 1979; 5: 166-170
        • Heilman KM
        • Watson RT
        • Valenstein E
        • Heilman KM
        • Valenstein E
        Neglect and related disorders.
        Clinical neuropsychology. Oxford University Press, New York2012: 296-348
        • Halligan PW
        • Fink GR
        • Marshall JC
        • Vallar G
        Spatial cognition: evidence from visual neglect.
        Trends Cogn Sci. 2003; 7: 125-133
        • Adair JC
        • Barrett AM
        Spatial neglect: clinical and neuroscience review: a wealth of information on the poverty of spatial attention.
        Ann N Y Acad Sci. 2008; 1142: 21-43
        • Buxbaum LJ
        • Ferraro MK
        • Veramonti T
        • et al.
        Hemispatial neglect subtypes, neuroanatomy, and disability.
        Neurology. 2004; 62: 749-756
        • Jehkonen M
        • Laihosalo M
        • Kettunen JE
        Impact of neglect on functional outcome after stroke: a review of methodological issues and recent research findings.
        Restor Neurol Neurosci. 2006; 24: 209-215
        • Katz N
        • Hartman-Maeir A
        • Ring H
        • Soroker N
        Functional disability and rehabilitation outcome in right hemisphere damaged patients with and without unilateral spatial neglect.
        Arch Phys Med Rehabil. 1999; 80: 379-384
        • Chen P
        • Hreha K
        • Kong Y
        • Barrett AM
        Impact of spatial neglect on stroke rehabilitation: evidence from the setting of an inpatient rehabilitation facility.
        Arch Phys Med Rehabil. 2015; 96: 1458-1466
        • Ugur C
        • Gücüyener D
        • Uzuner N
        • Özkan S
        • Özdemir G.
        Characteristics of falling in patients with stroke.
        J Neurol Neurosurg Psychiatry. 2000; 69: 649-651
        • Appelros P
        Prediction of length of stay for stroke patients.
        Acta Neurol Scand. 2007; 116: 15-19
        • Chen P
        • Fyffe DC
        • Hreha K
        Informal caregivers’ burden and stress in caring for stroke survivors with spatial neglect: an exploratory mixed-method study.
        Top Stroke Rehabil. 2017; 24: 24-33
        • Appelros P
        • Karlsson GM
        • Hennerdal S
        Anosognosia versus unilateral neglect. Coexistence and their relations to age, stroke severity, lesion site and cognition.
        Eur J Neurol. 2007; 14: 54-59
        • Langer KG
        • Bogousslavsky J
        The merging tracks of anosognosia and neglect.
        Eur Neurol. 2020; 83: 438-446
        • Vuilleumier P
        Anosognosia: the neurology of beliefs and uncertainties.
        Cortex. 2004; 40: 9-17
        • Chen P
        • Toglia J
        Online and offline awareness deficits: anosognosia for spatial neglect.
        Rehabil Psychol. 2019; 64: 50-64
        • Ekstam L
        • Uppgard B
        • Kottorp A
        • Tham K
        Relationship between awareness of disability and occupational performance during the first year after a stroke.
        Am J Occup Ther. 2007; 61: 503-511
        • Jehkonen M
        • Laihosalo M
        • Kettunen J
        Anosognosia after stroke: assessment, occurrence, subtypes and impact on functional outcome reviewed.
        Acta Neurol Scand. 2006; 114: 293-306
        • Schenkenberg T
        • Bradford DC
        • Ajax ET
        Line bisection and unilateral visual neglect in patients with neurologic impairment.
        Neurology. 1980; 30: 509-517
        • Urbanski M
        • Bartolomeo P
        Line bisection in left neglect: the importance of starting right.
        Cortex. 2008; 44: 782-793
        • Vallar G
        • Daini R
        • Antonucci G
        Processing of illusion of length in spatial hemineglect: a study of line bisection.
        Neuropsychologia. 2000; 38: 1087-1097
        • Albert ML
        A simple test of visual neglect.
        Neurology. 1973; 23: 658-664
        • Gauthier L
        • Dehaut F
        • Joanette Y
        The Bells Test: a quantitative and qualitative test for visual neglect.
        Int J Clin Neuropsychol. 1989; 11: 49-54
        • Wilson B
        • Cockburn J
        • Halligan P
        Development of a behavioral test of visuospatial neglect.
        Arch Phys Med Rehabil. 1987; 68: 98-102
        • Azouvi P
        • Olivier S
        • de Montety G
        • et al.
        Behavioral assessment of unilateral neglect: study of the psychometric properties of the Catherine Bergego Scale.
        Arch Phys Med Rehabil. 2003; 84: 51-57
        • Goedert KM
        • Chen P
        • Botticello A
        • et al.
        Psychometric evaluation of neglect assessment reveals motor-exploratory predictor of functional disability in acute-stage spatial neglect.
        Arch Phys Med Rehabil. 2012; 93: 137-142
        • Chen P
        • Chen CC
        • Hreha K
        • Goedert KM
        • Barrett AM
        Kessler Foundation Neglect Assessment Process uniquely measures spatial neglect during activities of daily living.
        Arch Phys Med Rehabil. 2015; 96: 869-876
        • Azouvi P
        • Marchal F
        • Samuel C
        • et al.
        Functional consequences and awareness of unilateral neglect: study of an evaluation scale.
        Neuropsychol Rehabil. 1996; 6: 133-150
        • Chen P
        • Hreha K
        • Fortis P
        • Goedert K
        • Barrett AM
        Functional assessment of spatial neglect: a review of the Catherine Bergego Scale and an introduction of the Kessler Foundation Neglect Assessment Process.
        Top Stroke Rehabil. 2012; 19: 423-435
        • Chen P
        • Hreha K
        Kessler Foundation Neglect Assessment Process: KF-NAP 2015 manual.
        Kessler Foundation, East Hanover, New Jersey2015
        • Nishida D
        • Mizuno K
        • Tahara M
        • et al.
        Behavioral assessment of unilateral spatial neglect with the Catherine Bergego Scale (CBS) using the Kessler Foundation Neglect Assessment Process (KF-NAP) in patients with subacute stroke during rehabilitation in Japan.
        Behav Neurol. 2021; 20218825192
        • Pitteri M
        • Chen P
        • Passarini L
        • et al.
        Conventional and functional assessment of spatial neglect: clinical practice suggestions.
        Neuropsychology. 2018; 32: 835-842
        • Shah PP
        • Hreha K
        • Chen P
        Evidence of inter-rater reliability in scoring the Kessler Foundation Neglect Assessment Process (poster abstract).
        Arch Phys Med Rehabil. 2012; 93: e33
        • Checketts M
        • Mancuso M
        • Fordell H
        • et al.
        Current clinical practice in the screening and diagnosis of spatial neglect post-stroke: findings from a multidisciplinary international survey.
        Neuropsychol Rehabil. 2021; 31: 1495-1526
        • Chen P
        • Diaz-Segarra N
        • Hreha K
        • Kaplan E
        • Barrett AM
        Prism adaptation treatment improves inpatient rehabilitation outcome in individuals with spatial neglect: a retrospective matched control study.
        Arch Rehabil Res Clin Transl. 2021; 3100130
        • Lin LI
        A concordance correlation coefficient to evaluate reproducibility.
        Biometrics. 1989; 45: 255-268
        • Hreha K
        • Chen P
        • LaRosa J
        • et al.
        Implementing a rehabilitation protocol for spatial neglect assessment and treatment in an acute care hospital.
        J Acute Care Phys Ther. 2020; 11: 59-69