Network for Spatial Neglect

Spatial neglect is a debilitating neurocognitive disorder that frequently occurs after a stroke with unilateral brain damage. About 50% of right-brain-damaged stroke survivors and about 30% of left-brain-damaged stroke survivors present spatial neglect in the inpatient rehabilitation setting. This disorder is manifested with a failure to attend to, perceive, and/or respond to stimuli presented on the contralesional side of personal (body parts or on the body surface), peri-personal (within arm’s reach) and extra-personal spaces (beyond arm’s reach). Individuals with spatial neglect may also fail to generate or maintain a normal representation of the contralesional side of mental images.

Therefore, individuals with right-brain damage may leave their left limb hanging off of the wheelchair, forget personal belongings to the left of their current position, fail to dress themselves appropriately on the left side, care relatively less about their appearance on the left side, show gaze preference to the right side, present slowed or no reaction to sudden noises from the left, ignore food on the left side of the plate, and/or collide into furniture or a wall on the left side. Unfortunately, stroke survivors with spatial neglect are more likely to stay hospitalized longer and have worse rehabilitation outcomes than those without spatial neglect.

Watch an introduction of spatial neglect

The Network for Spatial Neglect is an initiative developed by Dr. A. M. Barrett, Dr. Peii Chen, Dr. Kimberly Hreha, and Ms. Robin Hedeman, first presented in the 2011 annual joint meetings of the American Congress of Rehabilitation Medicine – American Society for Neurorehabilitation (ACRM-ASNR). We aim to advocate the need for accurate detection of spatial neglect, for direct translation of research to practices, and for effective treatments tailored to people with various types of spatial neglect. In September 2012, our Kessler Foundation Neglect Assessment Process (KF-NAP) was published in Topics in Stroke Rehabilitation. Since then, we have continued working on refining the assessment. And Kessler Foundation now makes the KF-NAP™ manuals free. The KF-NAP™ 2015 tutorial is online at Kessler Foundation Learning Center.

NOTE: It is recommended that the KF-NAP™ be administered by trained individuals only. The KF-NAP™ may help clinicians to make a diagnosis related to spatial neglect. Kessler Foundation is not responsible for a clinical diagnosis.

In addition, we have established the manual and devices for Kessler Foundation Prism Adaptation Treatment (KF-PAT™).  Kessler Foundation also makes the KF-PAT™ available to order for use in your facility or organization. 

NOTE: It is recommended that the KF-PAT™ be administered by trained individuals only. The KF-PAT™ may help reducing symptoms of spatial neglect. Kessler Foundation is not responsible for clinical outcomes. Click here to watch a video clip of the KF-PAT™ demonstration.

Frequently asked questions

Q1: How do I join the Network for Spatial Neglect?

Fill out the Network for Spacial Neglect application. We will contact you once or twice a year with updates of our research and related activities.

Q2: What is the KF-NAP™?

We have been using the Catherine Bergego Scale (CBS) since 2008 when Dr. Paola Fortis visited Kessler Foundation for her doctoral project. However, we encountered a number of obstacles using the CBS.  In order to overcome these obstacles, researchers at Kessler Foundation have been working very closely with therapy clinicians at Kessler Institute for Rehabilitation, and have developed a process for administering the CBS, named Kessler Foundation Neglect Assessment Process (KF-NAP™).

The KF-NAP™ entails the use of a scoring sheet and a manual. The KF-NAP™ scoring sheet contains a table of the scale with instructions for calculating the final score, which indicates the severity of spatial neglect.  In 2012, we published the first edition of the KF-NAP™ manual in an article titled “Functional assessment of spatial neglect: A review of the Catherine Bergego Scale and an introduction of Kessler Foundation Neglect Assessment Process” (Chen et al., Topics in Stroke Rehabilitation. 2012; 19: 423-435.)  In this article, we reviewed the importance of assessing spatial neglect during activities of daily living and included a one-page KF-NAP™ instruction sheet describing how to score each category.  In addition, the labels of several CBS categories were changed in order to better convey the purpose of an observation, to include the assessment for right-sided neglect symptoms, or to shorten the wording for simplification.  For example, “knowledge of left limbs” on the CBS is revised to “limb awareness” on the KF-NAP™. 

In the spring of 2014, we released the KF-NAP™ 2014 Manual, which was much more than a “one-pager." Dr. Marco Pitteri encouraged us to refine the instructions so that the assessment process and scoring criteria were very detailed.  In this manual we described how to assign a score of 0, 1, 2, or 3 for observation of each category.  We also provided general principles across all categories.  In addition, the KF-NAP™ 2014 Manual specified the environment where the observation takes place and how to observe left vs. right asymmetric performance in a given category.

Even though the 2014 Manual is detailed, hands-on training programs on how to use assessments can be more effective. However, they can also be costly and time consuming.  Thus, we produced a series of training videos to use in conjunction with the Manual.  Again, during this time of detailed attentiveness to the process, we found the Manual could be refined even further.  We decided to make four major changes: 1) the order of the categories, 2) the presentation of the scoring sheet, 3) the organization of scoring criteria in each category, and 4) we renamed “Eating” as “Meals” because during this observation, you are not assessing the ability to chew or swallow (which also may be impaired).  We hope you find the KF-NAP 2015 Manual and its Video Tutorial helpful in your assessment of spatial neglect during activities of daily living.

The License Agreement is no longer required for the KF-NAP™ 2015 Manual.

It is recommended that the KF-NAP™ be administered by trained individuals only. The KF-NAP™ may help clinicians to make a diagnosis related to spatial neglect. Kessler Foundation is not responsible for a clinical diagnosis.

Q3: Is the KF-NAP™ an alternative to the CBS?

The KF-NAP™ is not an alternative to the CBS; rather, it is a detailed description of how to administer the CBS.  One may question whether using the KF-NAP™ is better than the original method for the CBS. However, the difficulty in comparing the KF-NAP™ and other administration methods lies in the fact that there is no detailed description (at least not publicly available) on how the CBS was administered in other studies or the original study. Using the KF-NAP™ to administer the CBS may standardize the administration and strengthen the CBS as the most-recommended functional assessment for spatial neglect.

We presented the inter-rater reliability at the 2012 ACRM-ASNR conference.  For the raw scores, there was a high linear correlation (r = 0.86) and high intraclass correlation between the two independent raters. For the categorical severity of spatial neglect, the raters agreed exactly 87.9% of the time with k = 0.76, indicating a substantial level of agreement. 

Q4: What is the KF-PAT™?

Since the seminal reports by Peter W. Rossi and colleagues (Neurology, 1990; 40: 1597-1599) and Yves Rossetti and colleagues (Nature, 1998; 395: 166-169), many researchers and clinicians have studied prism adaptation for treating spatial neglect. Prism adaptation treatment is a visuomotor training process, involving goal-directed arm movement to visual targets. The adaptation itself occurs naturally, requiring no insight, top-down strategy, or conscious self-monitoring.

Kessler Foundation Prism Adaptation Treatment (KF-PAT™) is the result of the collaboration between Kessler Foundation and Kessler Institute for Rehabilitation. We provide detailed instructions and devices for the treatment. Unlike the apparatus used by most of the published work, the KF-PAT™ is portable with all the materials fitted in a 46 ᵡ 16 ᵡ 6 in. (LxHxW) bag that can be easily carried to patients. We use wedged 20-diopter prism lenses in an opaque rubber goggle, which is large enough such that patients can have their own reading glasses inside the goggle.

It is recommended that the KF-PAT™ be administered by trained individuals only. The KF-PAT™ may help reducing symptoms of spatial neglect. Kessler Foundation is not responsible for clinical outcomes.

The KF-PAT™ is available to order for use in your facility or organization.

Q5: May I translate KF-NAP™ or KF-PAT™ Manual to a different language?

Yes, we welcome you to do so! You must contact us for legal agreements. The translated version will be the property of Kessler Foundation and will be posted here acknowledging the translators.

Research work leading to the KF-NAP™ and KF-PAT™ is supported by the National Institutes of Health (NIH/NINDS, R01NS055808; NIH/NICHD/NCMRR, K24HD062647) and the Department of Health & Human Services/ National Institute on Disability, Independent Living and Rehabilitation Research and Rehabilitation Research (NIDILRR, 901F0037; previously H133G120203 Department of Education/ NIDRR). Contents in the manual do not necessarily represent the policy of the Department of Education, and one should not assume endorsement by the federal government.

Selected publications from our research team since 2010 (in reverse chronological order):

  • Goedert, K. M., Chen, P., Foundas, A. L., & Barrett, A. M. (2018). Frontal lesions predict response to prism adaptation treatment in spatial neglect: A randomised controlled study. Neuropsychological Rehabilitation. doi:10.1080/09602011.2018.1448287
  • Pitteri, M., Chen, P., Passarini, L., Albanese, S., Meneghello, F., & Barrett, A. M. (2018). Conventional and functional assessment of spatial neglect: Clinical practice suggestions. Neuropsychology. doi:10.1037/neu0000469
  • Chen, P., & Toglia, J. (2018). Online and offline awareness deficits: Anosognosia for spatial neglect. Rehabilitation Psychology. doi:10.1037/rep0000207
  • Chen, P., Pitteri, M., Gillen, G., & Ayyala, H. (2017). Ask the experts how to treat individuals with spatial neglect: A survey study. Disability and Rehabilitation. doi:10.1080/09638288.2017.1347720
  • Caulfield, M. D., Chen, P., Barry, M. M., & Barrett, A. M. (2017). Which perseverative behaviors are symptoms of spatial neglect? Brain and Cognition, 113, 93-101. doi:
  • Chen, P., Caulfield, M. D., Hartman, A. J., O'Rourke, J., & Toglia, J. (2016). Assessing viewer-centered and stimulus-centered spatial bias: The 3s Spreadsheet Test version 1. Applied Neuropsychology: Adult, 24(6), 532-539. doi:10.1080/23279095.2016.1220382
  • Chen, P., Fyffe, D. C., & Hreha, K. (2017). Informal caregivers’ burden and stress in caring for stroke survivors with spatial neglect: An exploratory mixed-method study. Topics in Stroke Rehabilitation, 24(1), 24-33. doi: 10.1080/10749357.2016.1186373
  • Chen, P., Ward, I., Khan, U., Liu, Y., & Hreha, K. (2016). Spatial neglect hinders success of inpatient rehabilitation in individuals with traumatic brain injury: A retrospective study. Neurorehabilitation and Neural Repair, 30(5), 451-460. doi: 10.1177/1545968315604397 
  • Chen, P., Hreha, K., Kong, Y., & Barrett, A. M. (2015). Impact of spatial neglect in stroke rehabilitation: Evidence from the setting of an inpatient rehabilitation facility. Archives of Physical Medicine and Rehabilitation, 96(8), 1458-1466. doi: 10.1016/j.apmr.2015.03.019
  • Chen, P., Chen, C. C., Hreha, K., Goedert, K. M., & Barrett, A. M. (2015). Kessler Foundation Neglect Assessment Process uniquely measures spatial neglect during activities of daily living. Archives of Physical Medicine and Rehabilitation, 96(5), 869-876. doi: 10.1016/j.apmr.2014.10.023
  • Chaudhari, A., Pigott, K., & Barrett, A. M. (2015). Midline body actions and leftward spatial "aiming" in patients with spatial neglect. Frontiers in Human Neuroscience, 9, 393. doi: 10.3389/fnhum.2015.00393
  • Goedert, K. M., Zhang, J. Y., & Barrett, A. M. (2015). Prism adaptation and spatial neglect: The need for dose-finding studies. Frontiers in Human Neuroscience, 9, 243. doi: 10.3389/fnhum.2015.00243
  • Barrett, A. M., & Muzaffar, T. (2014). Spatial cognitive rehabilitation and motor recovery after stroke. Current Opinion in Neurology, 27(6), 653-658. doi: 10.1097/wco.0000000000000148
  • Chen, P., Goedert, K. M., Shah, P., Foundas, A. L., & Barrett, A. M. (2014). Integrity of medial temporal structures may predict better improvement of spatial neglect with prism adaptation treatment. Brain Imaging and Behavior, 8(3), 346-358. doi: 10.1007/s11682-012-9200-5
  • Oh-Park, M., Hung, C., Chen, P., & Barrett, A. M. (2014). Severity of spatial neglect during acute inpatient rehabilitation predicts community mobility post stroke. PM&R, 6(8), 716-722. doi: 10.1016/j.pmrj.2014.01.002
  • Goedert, K. M., Chen, P., Boston, R., Foundas, A. L., & Barrett, A. M. (2014). Presence of motor-intentional aiming deficit predicts functional improvement of spatial neglect with prism adaptation. Neurorehabilitation and Neural Repair, 28(5), 483-492. doi: 10.1177/1545968313516872
  • Galletta, E. E., Campanelli, L., Maul, K. K., & Barrett, A. M. (2014). Assessment of neglect dyslexia with functional reading materials. Topics in Stroke Rehabilitation, 21(1), 75-86. doi: 10.1310/tsr2101-75
  • Chen, P., McKenna, C., Kutlik, A. M., & Frisina, P. G. (2013). Interdisciplinary communication in inpatient rehabilitation facility: Evidence of under-documentation of spatial neglect after stroke. Disability and Rehabilitation, 35(12), 1033-1038. doi: 10.3109/09638288.2012.717585
  • Barrett, A. M. (2013). Picturing the body in spatial neglect: descending a staircase. Neurology, 81(15), 1280-1281. doi: 10.1212/WNL.0b013e3182a82571
  • Shah, P., Spaldo, N., Barrett, A. M., & Chen, P. (2013). Assessment and functional impact of allocentric neglect: A reminder from a case study. The Clinical Neuropsychologist, 27(5), 840-863. doi: 10.1080/13854046.2013.783120
  • Barrett, A. M., Goedert, K. M., & Basso, J. C. (2012). Prism adaptation for spatial neglect after stroke: translational practice gaps. Nature Reviews Neurology, 8(10), 567-577. doi: 10.1038/nrneurol.2012.170
  • Chen, P., & Goedert, K. M. (2012). Clock drawing in spatial neglect: A comprehensive analysis of clock perimeter, placement, and accuracy. Journal of Neuropsychology, 6, 270-289. doi: 10.1111/j.1748-6653.2012.02028.x
  • Chen, P., Hreha, K., Fortis, P., Goedert, K. M., & Barrett, A. M. (2012). Functional assessment of spatial neglect: A review of the Catherine Bergego Scale and an introduction of  Kessler Foundation Neglect Assessment Process. Topics in Stroke Rehabilitation, 19(5), 423-435. doi: 10.1310/tsr1905-423
  • Das, A., & Chen, P. (2012). The eyes in the scanner: Latent conjugate eye deviation. Neurology India, 60(3), 343-344. doi: 10.4103/0028-3886.98536
  • Goedert, K., Chen, P., Botticello, A., Masmela, J. R., Adler, U., & Barrett, A. M. (2012). Psychometric evaluation of neglect assessment reveals motor-exploratory predictor of functional disability in acute-stage spatial neglect. Archives of Physical Medicine and Rehabilitation, 93, 137-142. doi: 10.1016/j.apmr.2011.06.036
  • Fortis, P., Chen, P., Goedert, K. M., & Barrett, A. M. (2011). Effects of prism adaptation on motor-intentional spatial bias in neglect. Neuroreport, 22(14), 700-705. doi: 10.1097/WNR.0b013e32834a3e20
  • Fortis, P., Goedert, K. M., & Barrett, A. M. (2011). Prism adaptation differently affects motor-intentional and perceptual-attentional biases in healthy individuals. Neuropsychologia, 49(9), 2718-2727. doi: 10.1016/j.neuropsychologia.2011.05.020
  • Goedert, K. M., Leblanc, A., Tsai, S. W., & Barrett, A. M. (2010). Asymmetrical effects of adaptation to left- and right-shifting prisms depends on pre-existing attentional biases. Journal Of The International Neuropsychological Society, 16(5), 795-804. doi: 10.1017/s1355617710000597
  • Hreha, K., Eller, M., & Barrett, A. M. (2010). Treating post-stroke spatial neglect: Establishing a clinical research-clinical partnership program.ADVANCE for Occupational Therapy Practitioners, 26(7), 16.


Updated by Peii Chen, PhD, September 17, 2018