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PURPOSE: To investigate the frequency of unawareness of disabilities after stroke during the rehabilitation stage, the relationship of unawareness with neuroanatomical variables, and the impact of unawareness on functional outcomes. METHOD: Sixty consecutive patients (36 with right, 24 with left hemisphere damage) admitted to rehabilitation hospital with a first, single, unilateral stroke were evaluated at admission, discharge and at 1-year post onset of stroke. Unawareness of disabilities was operationally defined as the discrepancy between therapist and patient's rating on the motor scale of the functional independence measure (FIM). Functional outcomes included FIM, instrumental activities of daily living (IADL) scale, activity card sort (ACS) and safety rating scale. RESULTS: Unawareness of disabilities was found in 44/60 patients at admission and 24/57 at discharge. There was no significant difference between the hemisphere groups in the frequency of unawareness at both times. Discharge unawareness in the right hemisphere group was significantly associated with lesions in the frontal and temporal lobes, and with lesion size. Unawareness in the left hemisphere damaged group was not associated with any neuroanatomical variables. A negative impact of unawareness at admission on functional outcomes was not found, but it was found that unawareness at discharge was a negative predictor of activity level (ACS score) at follow up, after controlling for the severity of initial disability level. CONCLUSIONS: Unawareness of disabilities is a significant issue in stroke rehabilitation. Unawareness that persists to discharge from rehabilitation correlates with neuroanatomical variables in right hemisphere damaged patients, and is a negative predictor for some rehabilitation outcomes at follow-up.

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OBJECTIVE: The purpose of this study was to investigate anosognosia for hemiplegia (AHP) in the rehabilitation phase after onset of stroke. METHODS: Forty-six hemiplegic stroke patients, 29 with right hemisphere damage (RHD) and 17 with left hemisphere damage (LHD) were evaluated approximately 1 month after onset of stroke. Anosognosia was evaluated with an implicit measure designed to assess anosognosic behaviors (choosing between unimanual and bimanual tasks), in addition to a traditional explicit verbal measure. RESULTS: AHP was found in 28% of the RHD and 24% of the LHD group. The majority of patients with AHP in the RHD group had large lesions involving the frontal, parietal, or temporal lobes and had coexisting sensory deficits and unilateral spatial neglect, whereas the LHD patients with AHP had predominantly small subcortical lesions and no sensory or attentional deficits. The functional outcomes of AHP patients in both hemisphere groups revealed their inability to retain safety measures at discharge from rehabilitation (p < 0.036) and their need for assistance in basic and instrumental activities of daily living at follow-up. CONCLUSIONS: AHP presents a significant risk for negative functional outcome in stroke rehabilitation. The underlying mechanisms of AHP may be different for left and right hemisphere patients, therefore requiring different intervention approaches.

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OBJECTIVE: To evaluate the impact of unilateral spatial neglect (USN) on the rehabilitation outcome and long-term functioning in activities of daily living (ADL) and instrumental ADL (IADL) of right hemisphere damaged (RHD) stroke patients. DESIGN: Assessments of sensory-motor and cognitive impairment and of functional disability were conducted upon admission to rehabilitation, upon discharge from the rehabilitation hospital, and 6 months after discharge, up to a year postonset. SETTING: The Loewenstein Rehabilitation Hospital, which receives patients from all general hospitals in Israel. PATIENTS: Forty consecutive admissions of adult right-handed patients with a first, single, right hemispheric stroke proven by computed tomography. Based on their total score in the Behavioral Inattention Test for neglect, patients were divided into two groups: 19 with neglect (USN+) and 21 without neglect (USN-). OUTCOME MEASURES: Functional Independence Measure, for ADL; The Rabideau Kitchen Evaluation, for IADL. RESULTS: Impairment and disability levels of RHD patients with and without USN were clearly differentiated. Neglect is associated with lower performance on measures of impairment (sensory-motor and cognitive), as well as on measures of disability in ADL and IADL. Differences were significant in all testing periods. The recovery pattern of USN+ patients is slower and more attenuated. In both groups, most improvement occurs in the first 5 months after onset. USN is the major predictor of rehabilitation outcome from admission to follow-up. CONCLUSIONS: The significance of neglect as a major source of stroke-related long-term disability justifies further research efforts to develop appropriate therapeutic modalities for this complex, multifactorial syndrome.

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The purpose of this study was to examine and compare the cognitive profiles of three groups of Israeli individuals who exhibit cognitive deficits for diverse reasons, using the Neurobehavioural Cognitive Status Examination (Cognistat, former name NCSE). The test is a standardized cognitive screening instrument which includes general areas of alertness, attention, orientation, language (comprehension, repetition, naming), construction, memory, calculations and reasoning (similarities, judgement). Assessment results are provided as a profile of the different domains and graded on four performance levels (average, mild, moderate, severe). Subjects included 47 healthy independent elderly subjects, 47 neurosurgical patients and 42 persons suffering from dementia. Supporting the hypothesized direction, statistically significant differences were found among the three groups on raw scores of all individual subtests and on the four performance levels with the healthy elderly subjects showing the highest performance and persons with dementia the lowest. Construction subtest scores were low for all groups and seemed to detect the aging process as well as disease-related dysfunction. The mean scores and standard deviations of all groups for most subtests were similar or a little lower to those reported in the American standardization data suggesting the test's cross-cultural applicability. In conclusion, the Cognistat was found to be a useful screening test for clinical and research purposes, however, further research is required.

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OBJECTIVES: The Behavioral Inattention Test (BIT) is a standardized assessment for unilateral visual neglect. It comprises six conventional and nine behavioral subtests. The purpose of this study was to add to the validation of the behavioral subtests. METHOD: Forty Israeli subjects with right cerebrovascular accident (CVA), from both day center and hospital settings, were evaluated on three measures: the BIT, performance tasks, and a checklist of activities of daily living (ADL). RESULTS: Seven of the nine BIT behavioral subtests differentiated significantly between subjects with visual neglect and those without neglect; six of the nine subtests correlated significantly with parallel performance tasks or ADL checklist items. CONCLUSION: These results support the construct and predictive validity of most of the BIT behavioral subtests as functional measures of unilateral neglect, thus, the BIT is recommended for use by occupational therapists. Inclusion of a relative score for right and left omissions within the BIT is recommended.

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