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, Har- vey 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 spa- tial neglect and both overall and cognitive-communicative functional outcomes in patients with right hemisphere stroke. Design: Assessment of overall and cognitive-communica- tive function was conducted on admission to acute rehabilita- tion, at discharge, and at 3-month follow-up. Setting: Urban, acute inpatient rehabilitation facility. Patients: Fifty-two consecutive admissions of adult right- handed patients with a single, right hemispheric stroke, con- firmed by computed tomography scan. Main Outcome Measures: The FIM ™ instrument and read- ing comprehension and written expression items of the Reha- bilitation 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 signif- icantly 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 out- come than patients without neglect. Further studies are needed to explore causal relationships between these factors. Key Words: Cerebrovascular accident; Communication dis- orders; Rehabilitation; Unilateral neglect. © 2001 by the American Congress of Rehabilitation Medi- cine and the American Academy of Physical Medicine and Rehabilitation M EASUREMENT OF FUNCTIONAL ABILITIES is an essential part of the assessment process in rehabilitation. Clinicians use functional measures to develop goals and treat- ment plans, to facilitate interdisciplinary team communication, and to document functional gains. Payers and regulators use functional measurement data to determine levels of indepen- dence and to make fiscal decisions about patient care. Func- tional 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 mea- sures 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 com- plete 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 ex- pression. 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 out- comes 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. 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 322 Arch Phys Med Rehabil Vol 82, March 2001