Revising the Kessler Foundation Neglect Assessment Process Manual: A Guidebook to Assessing Spatial Neglect

Abstract

Background

Spatial neglect, a disorder of lateralized spatial attention, is often considered to be a hidden condition because symptoms do not appear unless comprehensive assessment is completed. The Kessler Foundation Neglect Assessment Process (KF-NAP®) is a standardized method using the Catherine Bergego Scale (CBS) to detect and measure spatial neglect during daily activities. It is a frequently used tool because it assesses spatial neglect during functional activities, meaning it is comprehensive and applied. Since it was introduced in 2012, the KF-NAP has been adopted in numerous inpatient and outpatient settings and gone through several revisions. The latest and most used version is the 2015 edition.

Methods

Users have been providing the developers of the assessment informal feedback and suggestions during training sessions, lectures, and professional conferences. In addition, as part of a multisite implementation project, the developers asked KF-NAP users to provide their comments about the tool.

Results

Using this qualitative information, the developers made changes to the KF-NAP Manual by adding detail to the observation and scoring procedures, a “questions to consider” section to each item-specific instruction, and highlighted instructions based on practice setting. For example, clarification about how to assess the personal belongings category in an outpatient setting is provided, which includes more details on what items to ask and directions about setup.

Conclusions

This article aims to inform health professionals working with the neurological population about the KF-NAP 2023 Manual. The goal is to help users improve their experience and consequently improve practice.

Introduction

Spatial neglect is a neurological disorder that is often caused by damage to the ventral attention network (He et al., 2007; Karnath & Rorden, 2012; Toba et al., 2018), dorsal attention network, or subcortical structures in the brain (Fruhmann Berger et al., 2009; Ptak & Schnider, 2010; Ten Brink et al., 2019). Spatial neglect is described as a failure or slowness to respond, report, orient, or initiate action towards stimuli that occurs contralateral to the brain lesion, which then affects spatial perception and representation, mental imagery, and motor action planning (Esposito et al., 2021; Heilman et al., 2000).

Overall when not considering time post stroke or injured hemisphere, spatial neglect is prevalent in approximately 30% of stroke survivors (Esposito et al., 2021). Although it is more common to have left-sided neglect as a result of a right hemisphere lesion, individuals with left hemisphere lesions also experience right-sided neglect. For example, in inpatient rehabilitation, 64% of 4,454 people with acquired brain injury had left-sided neglect and 36% had right-sided neglect, measured via Kessler Foundation Neglect Assessment Process (KF-NAP®) (Hreha et al., 2022).

Spatial neglect is one of the strongest predictors of poor recovery. It negatively impacts activities of daily living, increases burden on caregivers, increases risk of falls, and prolongs hospital stays (Chen et al., 2015, 2016, 2017; Oh-Park et al., 2014; Wee & Hopman, 2008; Yoshida et al., 2022). In order to provide treatments to help individuals with spatial neglect return to independent living, it is important that their symptoms are detected effectively, especially symptoms demonstrated in real-life situations.

Functional or ecological assessment for spatial neglect is available. One assessment is the KF-NAP, which standardizes the way to use the Catherine Bergego Scale (CBS), and measures the severity of the spatial neglect behaviors in 10 categories (Chen et al., 2012). The scores range from 0-3 for each category, with the final score ranging between 0-30. The greater severity of spatial neglect, the higher the CBS score. Since it was introduced in 2012, it’s been adopted by other research teams worldwide in numerous inpatient (Nishida et al., 2021; Pitteri et al., 2018; Vilimovsky et al., 2021) and outpatient settings (Hreha et al., 2017) and gone through several revisions. The latest and most used version is the 2015 edition (Chen & Hreha, 2015). This version has been translated into 6 other languages and we estimate that it is being used in about 15 countries.

The KF-NAP Manual is a separate document that includes specific directions for how to deliver the assessment and how to score each category, to help make the subjective assessment more systematic. The KF-NAP was originally designed for inpatient rehabilitation (Chen et al., 2012), and therefore the information and tips in the Manual are tailored to that practice setting. It also wasn’t very detailed because it was created at the same time the assessment was developed, and we therefore did not have as much practical experience using the tool.

This commentary aims to describe the process of revising the KF-NAP 2015 Manual and to highlight the importance of using the KF-NAP assessment and Manual in clinical practice across practice settings. The updated KF-NAP 2023 Manual is the result of a quality improvement project. This project integrated the developers’ clinical and expert experience, along with user feedback, which is described as well as how these considerations were incorporated into the revised Manual.

The Quality Improvement Process to Revising the Manual

Over 11 years, we (the KF-NAP developers) have collaborated with clinicians, researchers and students worldwide through training and ongoing dialogue about the KF-NAP. These engagements created opportunities for users to offer informal feedback and specific suggestions for improving the KF-NAP Manual. In addition, as part of an implementation research project (Hreha et al., 2022), qualitative information were collected via a survey to better understand KF-NAP administration at admission and discharge from inpatient rehabilitation.

To revise the Manual, we completed a multi-step process. First, we used the “frequently asked questions” and informal feedback provided to us during the events noted above to start modifications. This information was compiled into one document and was tallied, with final changes being agreed upon by the original developers. Second, we considered feedback provided by individuals who achieved “Master Trainer” or “Level-3” certification status during the implementation projects (Hreha et al., 2020, 2022). This feedback was collected but not included in previous publications. Through the implementation project alone, five people reached Master Trainers and more than 81 became Level-3 KF-NAP users (Hreha et al., 2022). Table 1 describes the eligibility criteria and then the training completed to become certified. To showcase examples of the feedback being provided, Table 2 selectively highlights quotes from a subset of occupational therapists—either Level-3 certified or Master Trainers.

Table 1.

Requirements of Master Trainers and Level 3 KF-NAP Competency

	Master trainer	KF-NAP level 3 certification
Hours	Approximately 32 hours	Approximately 18 hours
Eligibility requirements	(1) Level 3 certified, (2) administered the KF-NAP for at least a year with approximately 5 patients per month	Participation in the 1.5-day course, meaning at the end of the course they obtain
		Level 1 and 2 competencies
Additional requirements	(1) Gives a didactic training lecture, (2) completes pre- and post-training quizzes, (3) shadows course director during a training session to learn process of training and completing course	Assess and score at least 10 patients independently using the KF-NAP.

Table 2.

Quotes From Users on Dislikes and Suggested Revisions

Therapist ID	Years using the KF-NAP	Practice setting	Exemplary quote on dis-likes	Exemplary quote on suggested changes for manual
1	1.5	Outpatient	“Personal belongings is challenging because the rooms are not familiar [to patients, and] we work in different spaces every time a patient comes [to therapy]”	“I would suggest modifying the meals directions so we know how to observe that better”
2	11	Inpatient	“It is occasionally hard to use with aphasic patients”	“I would change it by adding alternative suggestions for example what to do if someone can’t communicate”
3	1	Inpatient	“I don’t like how the same therapist has to complete the pre and then post assessment, this makes it challenging to schedule”	“I think more information about the difference between a [score of] 2 and 3 would be helpful to have in the manual”
4	5	Acute care	“[It is] very time sensitive in this setting, so it is hard to get all items completed. Also, we don’t have wheelchairs here. It would be good to know how many missed items is OK.”	“I would clarify more about the cleaning after meals category, is it really cleaning during and after meals?”
5	3	Outpatient	“It is hard to do meals during therapy, there are environmental and time constraints”	“More detail in the manual would be helpful, especially for personal belongings in the outpatient clinic setting”
6	3	Inpatient	“[Regarding navigation, I see that culture plays into why many of my patients don’t know their way around the hospital…their family members push them to and from therapy and anywhere else they want to go”	“What do I do if someone really doesn’t have a familiar place to go to”

Note. KF-NAP categories, when mentioned in a quote, are italic.

The therapists represented a range of practice settings and had an average of 3.5 years using the CBS via the KF-NAP (Table 2). For example, a therapist, working in an acute care setting, reported the Navigation category difficult to observe because of two reasons. First, wheelchairs are not readily available for rehabilitation purposes in the acute care hospital and therefore are not easily obtainable for assessment purposes. In the United States, patients rarely get assigned a personal wheelchair to use for mobility in acute care settings; if they need transportation, they will be pushed in their bed or on a stretcher. Therapy staff typically see patients in their rooms and complete assessment and intervention bedside or in the bed. This is unlike an inpatient rehabilitation setting where each person has their personal wheelchair and will transition from their room to a therapy gym multiple times per day. Second, most patients in acute care are unable to walk independently yet, and therefore other devices such as walkers are also not available on the acute wards either. Specifying what to do in a situation where mobility devices are not accessible and how that may impact how to administer and score both the Navigation and the Collisions categories, is written out in the revised Manual.

In addition to setting-specific instructions, the revised Manual provides detailed suggestions on what to do if someone has multiple competing conditions such as communication problems (e.g., aphasia) or visual impairment in addition to spatial neglect. For example, if someone has expressive aphasia, it is appropriate to allow them to point during the Personal Belongings question instead of verbally explaining the location of the object. Now we have created a “questions to consider” section for each category, which provides this level of detail.

There are also more details in the scoring section. For example, if an entire meal isn’t available, we explain that it isn’t appropriate to observe a snack or dessert. This is because you won’t be able to see the person attempting to navigate the peri-personal space if their only food option is located in one location on a tray. It is key that there are enough options (e.g., coffee, utensils, bowl of cereal, fruit) that the person will then demonstrate behaviors that can be recognizable as normal or a lateralized bias. We explain how this would then impact both the observation and scoring of the Cleaning after Meals category. As shown in Table 2, Therapist 4 inquired about having more clarity around the scoring of the Cleaning after Meals category. Specifically, it wasn’t clear prior if the observation of “cleaning” throughout the meal impacts the scoring after the meal, which it does. We provide these details in the revised Manual.

The revised Manual also includes updated research conducted by our team and others, addressing common questions raised by therapists during certification trainings and lectures. For example, one question asked frequently is “How many missed items is OK?”. We conducted a diagnostic accuracy study using Lin’s Concordance Correlation Coefficient analysis, to determine that up to three items could be missed while still allowing for a reliable prorated score (Rich et al., 2022).

As this commentary describes, the revision of the KF-NAP 2015 Manual reflects almost a decade of clinical use, interdisciplinary collaboration, and valuable feedback from certified users across diverse practice settings. The updated KF-NAP 2023 Manual offers enhanced clarity, practical guidance, and evidence-informed updates that support more consistent and confident administration. We have always recommended the KF-NAP to be used to screen for spatial neglect after any neurological event, and at any timepoint. Now, the revised Manual has additional details to remove the guesswork in specific situations, and support consistent assessment administration and scoring.