Subjects
The study was carried out on 34 ischemic stroke patients diagnosed on the basis of The World Health Organization’s definition of stroke and brain computed tomography scan or magnetic resonance imaging. The mean age was 60.5 ± 10.6 (32-79) years. The UVN group consisted of 19 patients and the control group consisted of 15 patients. The lesion sites of the patients were frontal (n= 7); parietal (n=22); parietotemporal (n=4) and frontotemporal (n=1).
Patients were admitted onto the study if they satisfied the following criteria: (1) right-handed (according to the Edinburgh Handedness Inventory) (2) subacute-chronic state right ischemic stroke patients (3) literate and achieving 23 or more on the Mini Mental State Examination (MMSE) (4) sufficiently healthy to participate in the evaluation (5) living with their family (6) joining the study voluntarily.
Exclusion criteria were as follows (1) transient ischemic attack or subarachnoid hemorrhage (2) posterior cerebral arteria and basal ganglia infarct or hemorrhage (3) homonymous hemianopsia (4) perception or cooperation problem and history of neuropsychiatric disorder (5) depression (according to the Hamilton Depression Scale).
Approval was obtained from the University of Dokuz Eylul, Human Ethics Committee before commencing this study. Written consent was received from all subjects (approval number 05/01/04, date 8 Jan 2004).
Measurements
Data were collected including patient demographic characteristics.
UVN was diagnosed by a neurologist and physical therapist using the Line Bisection Test, Letter Cancellation Test, Catherine Bergego Scale (1,4,5,9,11,28). All patients were given 2 paper and pencil tests that were previously found highly sensitive to neglect (1) the Line Bisection Test consisted of 20 horizontal black lines of three different line lenghts on an A4 sheet. The patient was asked to mark the centre of each line. Scoring involves the number of omitted lines as well as the deviations from the true midpoint; (2) the Letter Cancellation Test is a set of four cancellation tests, two of that involve letters (verbal stimuli), other two symbols (non-verbal stimuli). A structured and a randomised array are presented to the subjects and asked to circle the letter A and Ø on an A4 horizontal piece of paper using for every 10 items different coloured pencils. The score is the total number of omissions. The healthy adults less than 50 years could complete each of the four tests without error in less than two minutes, older than 50 years old not more than one error per array 3) the Catherine Bergego Scale (CBS) was performed at the same day with paper-pencil tests. The CBS was scored by the physical therapist’s observation of the patient. The CBS includes 10 common everyday life items. For each item, a 4-point scale was used, ranging from 0 (no neglect) to 3 (severe neglect). A total score was calculated (range, 0–30). As a consequence, 19 subjects showed left hemispatial neglect during pencil and-paper activities and the CBS.
The motor function part of the National Institute of Health Stroke Scale (NIHSS) was used to establish the stroke severity on motor functions. Hemiparesis severity was calculated in the upper and lower limbs separately (0=normal, 4=severe hemiparesis). These scores were summarized and patients were classified according to the hemiparesis severity between 0 to 8 points (0=no motor defect, 1-2=mild hemiparesis, 3-5=moderate hemiparesis, 6-8=severe hemiparesis) (7).
Disability status on ADL was evaluated with the Barthel Index (BI), which gives a score ranging from 0 to 100 (100= physical independence, 75-95= mild disability, 50-70= moderate disability, 25-45= severe disability, 0-20= very severe disability). The top score implies full functional independence, but not necessarily normal status. BI comprises 10 items measuring feeding, bathing, grooming, dressing, bowel control, bladder control, toileting, chair/bed transfer, ambulation and stair climbing. Original BI scoring vary between the ranges of 0-5, 1-10 and 0-15 points to this titles. The BI score is highly correlated with independent functional ability and and the ability to return home. Additionally, the BI score before the start of rehabilitation gives an indication as to the expected rate / duration of the patient’s recovery (18).
Mobility status was measured by the Rivermead Mobility Index (RMI), a simple scale that assesses disability status in mobility through questions about 14 activities and direct observation of 1. These activities range from turning over in bed, standing unsupported, walking inside and outside (with and without an aid), going up stairs and picking up something from the floor to running. Scale scoring ranges from 0 to 15, with 0 indicating complete inability. Mobility disorder is classified into groups as follows: 0-6 points = severe, 7-11= moderate, 12-15= mild (6,9,19,26).
Health-related quality of life (HRQOL) was assessed by means of The Medical Outcomes Study Short-Form Health Survey Scale-36 (SF-36) which is a generic, subjective, valid measure for the assessment of HRQOL after a stroke (3,8,12,13,15,20). It facilitates assessment across 8 health domains: physical functioning (PF), role limitations due to physical problems-physical role (PR), bodily pain (BP), general health (GH), vitality (V), social functioning (SF), role limitations due to emotional problems-emotional role (ER) and mental health (MH). Scores were assessed for these 8 domains and general health perception of last year. Each health domain was scored from 0 to 100.
Statistical Analysis
The statistical package SPSS, Version 11, was used to analyze the results. All data is expressed as mean ± standard deviation (SD) and a 2-tailed probability value of p less than .05 was the criteria for statistical significance.
Mann-Whitney U Test were used to compare means of demographic characteristics, disability status (in ADLs and mobility) and HRQOL of both groups. The relationships in disability index scores (BI and RMI) and HRQOL (SF-36) score between UVN and control groups were examined using Spearman Correlation Analysis.
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