Validity of the rnadttir OT-ADL Neurobehavioral

Evaluation (A-ONE): Performance in Activities of Daily Living

and Neurobehavioral Impairments of Persons With
Left and Right Hemisphere Damage
Sigrn Gardarsdttir,
Susan Kaplan
KEY WORDS
clinical reasoning
intervention
occupational performance assessment

OBJECTIVE. The rnadttir OT-ADL Neurobehavioral Evaluation (A-ONE) is a standardized assessment that
links performance in activities of daily living (ADL) to neurobehavioral impairments. This study tested the construct validity of the A-ONE.

METHOD. From two hospitals in Iceland, 42 patients between 45 and 87 years of age who had sustained
either a right or a left cerebrovascular accident (CVA) were evaluated on the Functional Independence Scale
(FIS) and Neurobehavioral Specific Impairment Subscale (NSIS) of the A-ONE. The Mann Whitney U test and
chi-square test were used to explore possible differences between the performance of participants with left and
right CVA. Descriptive statistics were calculated for demographic data and for items on the FIS and NSIS. The
level of significance was set at p < .05.
RESULTS. Three of 18 ADL items observed on the FIS and 13 of 46 items on the NSIS discriminated at a
statistically significant level between the left and right CVA groups.

CONCLUSION. The results provide minimal support for the construct validity of the A-ONE related to differentiating between ADL performance of persons with left and right CVA. However, results regarding the ability of the A-ONE to detect and lateralize impairments agreed with literature regarding lesion sites for the impairments.
Gardarsdttir, S., & Kaplan, S. (2002). Validity of the rnadttir OT-ADL Neurobehavioral Evaluation (A-ONE): Performance
in activities of daily living and neurobehavioral impairments of persons with left and right hemisphere damage.
American Journal of Occupational Therapy, 56, 499508.

Sigrn Gardarsdttir, OT, MS, is Director of Occupational

Therapy, Department of Rehabilitation and Neurology,
LandsptaliThe National University Hospital, Reykjavk,
Iceland, and is Assistant Professor, Department of
Occupational Therapy, University of Akureyri, Slborg,
600 Akureyri, Iceland. (Mailing address: Tmasarhagi 17,
107 Reykjavk, Iceland; sigrgard@landspitali.is)
Susan Kaplan, PhD, MBA, OTR, is Associate Professor,
Occupational Therapy Department, College of Health
Sciences, Florida International University, Miami, Florida.

troke is a leading cause of disability in older persons. The incidence of stroke

increases with advancing age, doubling with every decade after 55. The percentage of persons surviving stroke has increased with improved acute care. In general, roughly 80% of persons who have had a stroke are able to attain independence
in mobility, whereas 67% gain independence in activities of daily living (ADL)
(National Stroke Association, 1991; Trombly, 1995; U.S. Department of Health
and Human Services, 1995). According to Mauthe, Haaf, Hayn, and Krall (1996),
70% of the variance in discharge destination after stroke rehabilitation is determined by the patients ability to perform self-care tasks independently.
A cerebrovascular accident (CVA) can result in a variety of cognitive, perceptual, and motor deficits, which hereafter will be referred to as neurobehavioral
impairments. Neurobehavioral impairments caused by a CVA may result in
impaired performance of specific aspects of ADL. The types of neurobehavioral
impairments present after a CVA largely depend on which areas of the brain have
been injured. rnadttir (1990) defined a neurobehavioral impairment or dysfunction as

a functional impairment of an individual manifested in defective skill performance

due to a neurological processing deficit that affects any of the following performance
components: affect, body scheme, cognition, emotion, gnosis, language, memory,
personality, praxis, or spatial relations, and visuospatial skills. (p. 313)
The American Journal of Occupational Therapy

499

According to Llorens (1986), neurobehavioral theory is

concerned with how environmental stimuli are processed
within the central nervous system to affect behavioral and
emotional responses. Task performance in daily activities is
one type of behavioral response (rnadttir, 1990, 1998a).
Further, neurobehavior is considered the basis of task performance.
Adults who have had a CVA are among the patients
most commonly evaluated and treated by occupational
therapists (Trombly, 1995). Occupational therapy in stroke
rehabilitation is aimed at improvement of the persons maximal level of independence in occupational performance
areas and resumption of meaningful occupational roles in
order to regain quality of life. The key element in stroke
rehabilitation occupational therapy is independence in the
areas of self-care (i.e., dressing, grooming, hygiene, feeding
and eating, functional mobility), leisure, and work
(rnadttir, 1990, 1998a; Trombly 1995).
Despite the importance of neurobehavior to occupational performance, the rnadttir OT-ADL Neurobehavioral Evaluation (A-ONE) is the only standardized assessment that occupational therapists use to specifically identify
neurobehavioral deficits by observation of occupational
performance (rnadttir, 1990; Rubio & Van Deusen,
1995) and level of task performance. The A-ONE was
designed for use with adults with central nervous system
dysfunctions of cortical origin. It simultaneously (a) assesses independence in selected ADL tasks and the type of assistance needed to complete them and (b) identifies the types
and severity of neurobehavioral impairments. The information gathered from the A-ONE assists occupational therapists in goal setting and treatment planning.1

Literature Review
Neurobehavioral impairments have been shown to be associated with decreased or limited ability to perform ADL
tasks (Jesshope, Clark, & Smith, 1991; Titus, Gall, Yerxa,
Roberson, & Mack, 1991; Walker & Lincoln, 1991). Most
of these studies correlated scores on cognitive-perceptual
measurements with scores on ADL instruments and found
a relationship between perceptual abilities and performance
in daily living skills, revealing decreased independence in
ADL due to cognitive-perceptual deficits. Titus et al.
(1991) concluded that not just one factor, but many factors
probably contribute to both ADL performance and perceptual skills in individuals who had a stroke.

G. rnadttir can be contacted regarding the A-ONE instrument at

a-one@islandia.is.

500

Many studies have focused on the correlation between

neurobehavioral impairments and specific ADL skills
(Carter, Oliveira, Duponte, & Lynch, 1988; Chen-Sea,
2000; Chen-Sea, Henderson, & Cermak, 1993; Denes,
Semenza, Stoppa, & Lis, 1982; Kinsella & Ford, 1980;
Kinsella, Olver, Ng, Packer, & Stark, 1993; Kotila, Niemi,
& Laaksonen, 1986). All reported that persons with unilateral neglect or visual-spatial inattention remain more
dependent in ADL tasks than persons without neglect or
attention deficits. Wade, Hewer, David, and Enderby
(1986) found that aphasia was associated with more severe
disabilities (i.e., degree of motor function, loss of function
and mental function) and less recovery of social activities
poststroke.
Many studies have identified motor status as one of a
number of predictors of poststroke function (Bernspng,
Viitanen, & Eriksson, 1989; Chae, Johnston, Kim, &
Zorowitz, 1995; Eriksson, Bernspng, & Fugl-Meyer,
1988; Filiatrault, Arsenault, Dutil, & Bourbonnais, 1991).
Eriksson et al. (1988) and Chae et al. (1995) found that
dependency in ADL tasks after stroke is primarily determined by the degree of motor impairment. However,
Filiatrault et al. (1991) and Chae et al. (1995) stated that
although motor function is important as a predictor of
independence, variables such as cognition, visual-spatial
orientation, learning of compensatory techniques, and
hand dominance also play important roles. Bernspng et al.
(1989) studied the effects of motor versus perceptual
deficits on the ability to perform ADL tasks 4 to 6 years
after stroke in response to Eriksson et al. (1988). Results
indicated that visual-perceptual deficits remain for many
years after stroke and appear to significantly impair performance in ADL more than motor impairment. Kotila et al.
(1986) reported similar results.
A few studies have not supported a statistically significant relationship between neurobehavioral impairments
and ADL skills. One such study found no relationship
between ADL performance and visual neglect (Edmans &
Lincoln, 1990). Another found no relationships between
muscle tone and the ability to perform daily activities
(Spaulding, Strachota, McPherson, Kuphal, & Ramponi,
1989).
The relationship between lesion site and perceptual
performance has stronger indications for some impairments
than others. Patients who had a stroke due to right hemispheric lesions often do less well poststroke in achieving levels of independence in self-care activities than do patients
with left hemispheric lesions (Denes et al., 1982;
Johansson, Jadbck, Norrving, & Widner, 1992; Kalra,
Smith, & Crome, 1993; Ween, Alexander, DEsposito, &
Roberts, 1996). This difference is supported by findings
September/October 2002, Volume 56, Number 5

that symptoms such as neglect and reduced spatial awareness are more frequent and severe after right hemisphere
lesions (Denes et al., 1982; Edmans & Lincoln, 1990;
Johansson et al., 1992; Ween et al., 1996). On the other
hand, Mills and DiGenio (1983) found no significant difference in recovery of mobility and ADL performance,
except in language, between persons with left or right hemispheric lesions. Another study confirmed that language
deficits were more common in persons with left hemispheric lesions and that individuals with right hemispheric
lesions were more likely to have spatial disorders (Wade,
Hewer, & Wood, 1984). Rubio (1994) found an association between spatial neglect and grooming tasks in persons
with right hemisphere CVA and between grooming tasks
and both motor and ideational apraxia in persons with left
hemisphere CVA.

Purpose
The purpose of this study was to test the construct validity
of the A-ONE by determining whether differences exist in
ADL performance and neurobehavioral impairment
between persons with left and right hemisphere damage (a
measure of construct). A further purpose was to contribute
to the ongoing investigation of the relationship between
lesion site and perceptual performance. We predicted that
scores on the two communication items on the Functional
Independence Scale (FIS), because of their nature, and the
items on the Neurobehavioral Specific Impairment Subscale
(NSIS) (component scale of the A-ONE) would demonstrate significant differences between persons with right versus left hemisphere lesions.

Method
A methodological nonexperimental research design (Bailey,
1997) intended to validate a standardized instrument was
used. The study can be related further to the fourth phase
of instrument development described by Benson and Clark
(1982), as one of its purposes was to support construct
validity of the A-ONE.
Participants
A convenience sample of 42 adult patients (18 women, 24
men) from two hospitals in Iceland were recruited for the
study. Participants met the following inclusion criteria: (a)
primary diagnosis of right or left CVA; (b) no history of
peripheral nerve injury or injury to the central nervous system, including a previous CVA, head injury, or dementia;
(c) at least 1 week post-CVA and medically stable; (d) no
previous occupational therapy intervention; and (e) a conThe American Journal of Occupational Therapy

Table 1. Participant Characteristics

Demographic
Gender
Male
Female
Age (years)
M
Range
SD
Days from onset of CVA
M
Range
SD

Entire Groupa

Left CVAb

Right CVAc

24
18

13
10

11
8

70.64
4587
9.05

72
5187
7.62

69
4583
10.51

23.67
774
16.67

23.09
774
19

24.37
749
13.82

Note. CVA = cerebrovascular accident.

an = 42. bn = 23. cn = 19.

sent to participate in the study. Twenty-three participants

had left hemispheric lesions (20 due to cerebral infarct, 3
due to hemorrhage), and 19 had right hemispheric lesions
(14 due to cerebral infarct, 5 due to hemorrhage). With the
exception of one left-handed participant (with a right hemispheric lesion), all participants were right-handed. Table 1
summarizes the demographic characteristics of all the participants.
Instrument
The A-ONE is a standardized assessment (rnadttir,
1990, 1998a, 1999) that detects neurobehavioral impairments in adults with cortical central nervous system dysfunction by observing ADL performance. The A-ONE is
composed of two parts.
Part I includes the FIS and the Neurobehavioral
Impairment Scale (NIS) (see Table 2). The FIS covers five
ADL domains: dressing, grooming and hygiene, transfers
and mobility, feeding, and communication. Each domain is
broken down further into specific tasks. For example, the
ADL domain of dressing includes such tasks as putting on
a shirt or dress, pants, socks, and shoes and manipulating
fastenings. Although the ADL tasks of bathing, continence
and toilet hygiene, and toilet and tub transfers are included
on the FIS, these items are not required for the neurobehavioral evaluation.
The NIS is composed of two subscales: the NSIS
(Neurobehavioral Specific Impairment Subscale) and the
NPIS (Neurobehavioral Pervasive Impairment Subscale).
The NSIS has 10 neurobehavioral items (motor apraxia,
ideational apraxia, unilateral body neglect, somatoagnosia,
spatial relations, unilateral spatial neglect, abnormal tone
left and right, perseveration, and organization/sequencing)
that relate to four of the five ADL domains in the FIS. For
the communication domain, which comprises speech and
comprehension, items such as sensory and expressive aphasia, dysarthria, jargon aphasia, paraphasia, perseveration,
and anomia are observed.
501

Table 2. Items on the Functional Independence Scale (FIS) and the

Neurobehavioral Specific Impairment Subscale (NSIS)
FIS Domain and Tasks

NSIS Neurobehavioral Impairment

Dressing
Shirt (or dress)
Pants
Socks
Shoes
Fastenings
Grooming and hygiene
Wash face and upper body
Comb hair
Brush teeth
Shave/make-up
Continence/toilet hygieneb
Bathingb
Transfers
Sitting up in bed
Transfers to/from bed (chair)
Maneuver around
Toilet transfersb
Tub transfersb
Feeding
Drink from a mug
Use fingers/sandwich
Use fork or spoon
Use knife
Communication
Comprehension
Speech

Motor apraxia, ideational apraxia, unilateral

body neglect, somatoagnosiaa, spatial relations, unilateral spatial neglect, abnormal
tone right, abnormal tone left, perseveration, organization/sequencing
Motor apraxia, ideational apraxia, unilateral
body neglect, somatoagnosiaa, spatial relations, unilateral spatial neglect, abnormal
tone right, abnormal tone left, perseveration, organization/sequencing

Motor apraxia, ideational apraxia, unilateral

body neglect, spatial relations, unilateral
spatial neglect, abnormal tone right, abnormal tone left, perseveration, organization/
sequencing, topographical disorientationc
Motor apraxia, ideational apraxia, unilateral
body neglect, spatial relations, unilateral
spatial neglect, abnormal tone right, abnormal tone left, perseveration, organization/
sequencing
Sensory aphasia, jargon aphasia, anomia,
paraphasia, perseveration, expressive aphasia, dysarthria

Note. Activities of daily living (ADL) tasks as measured by the FIS and
neurobehavioral items as measured by the NSIS; both scales are part of the
rnadttir OT-ADL Neurobehavioral Evaluation (A-ONE) instrument.
a
Somatoagnosia is only observed in the domains of dressing and grooming
and hygiene. bADL tasks of continence/toilet hygiene, bathing, and toilet and
tub transfers are included on the FIS; these items are not required for the
neurobehavioral evaluation. cTopographical disorientation is observed in only
the transfers and mobility domain.

The ADL tasks and neurobehavioral impairments are

rated on a 5-point ordinal scale. The FIS measures level of
independence from 4 (functionally independent) to 0
(unable to perform and totally dependent on assistance),
with a total of 22 items. According to research results
(rnadttir, 1990), it is possible to add up independence
scores within each ADL domain on the FIS, but total scores
should not be added because the categories are not additive.
For such exceptions, the total scores for dressing (20),
grooming and hygiene (24), transfers (20), feeding (16),
and communication (8) would be obtained.
The NSIS is used to rate the severity of impairments
noted during performance of ADL (including communication activities) based on how much the impairment interferes with activity performance, not on how severe the
impairment looks as is common on deficit-specific tests.
The items are scored from 0 (the particular neurobehavioral
impairment is not observed) to 4 (unable to perform due to
the particular neurobehavioral impairment), except for
communication for which impairments are either scored
present (1) or absent (0). Therefore, the scores on the FIS
502

and NSIS are inversely related. Each neurobehavioral

impairment is identified, and its severity is evaluated and
reported independently in the different ADL domains.
More than one type of neurobehavioral impairment can
interfere with function, with a total of 39 items scored 0 to
4 and 7 items scored 1 or 0. The scores on the NSIS are not
additive. The most frequent score across domains for a particular impairment indicating type of assistance needed
(i.e., verbal, physical) due to the impairment is much more
informative in terms of treatment consideration and planning than a total neurobehavioral score (rnadttir, 1990).
The A-ONE allows the therapist, through clinical reasoning, to identify neurobehavioral impairments that interfere with task performance and to understand factors that
underlie functional dependence. The therapists clinical reasoning performed during A-ONE administration and scoring can be described in the following way (rnadttir,
1990, 1998b, 1999, 2000). Critical cues are observed during task performance of specific tasks. These cues would be
like those in the following example:
The client holds a piece of bread in the left hand and starts
eating it. Simultaneously, a glass is held in the right hand.
After a while, the left hand with the bread slides under the
table and the person grabs another piece of bread with the
right hand and continues eating the bread from that one,
not noticing the bread in the left hand.

Subsequently, the therapist interprets these cues and forms

a hypothesis regarding the nature of problems that interfere
with occupational performance, using conceptual and operational definitions from the A-ONE terminology. Cue
interpretation is based on the performance component dysfunction of unilateral body neglect, somesthetic dysfunction, possibility of motoric problems, other attentional
deficits, and unilateral visual neglect. Further, the pattern of
observed impairments is considered, as are processing sites
in the central nervous system based on the neurological
background of the instrument, and other indications of
component dysfunction during performance of other tasks.
After having reasoned through the definitions of all possible
deficits and comparing them with the observed performance, a hypothesis based on one performance component
dysfunction, such as unilateral body neglect, is chosen for
an impairment or as the reason for the particular performance dysfunction. This method allows therapists to analyze the nature or cause of functional problems that require
occupational therapy intervention so that the analysis is
made with the framework of occupational performance.
Therapists are trained in this type of reasoning during specific A-ONE training courses. The courses include 40 hours
of training and are intended to increase the reliability of
scoring.
September/October 2002, Volume 56, Number 5

Part II of the A-ONE includes items to assist therapists

in identifying the most likely site of cortical dysfunction on
the basis of the identified neurobehavioral impairments. In
this study, 18 of the 22 possible ADL items (bathing, continence and toilet hygiene, toilet and tub transfers tasks
were excluded) on the FIS and all 46 neurobehavioral items
on the NSIS from Part I were used to gather data.
Good interrater reliability has been established for the
A-ONE (Kappa = .84) (rnadttir, 1990). A pilot study of
testretest reliability with a 1-week interval showed agreement of .85 or higher for all items. Content validity for
Parts I and II is based on literature review and expert opinion. Concurrent validity has been established with healthy
persons, comparing scores for individuals who had experienced a CVA or individuals who had dementia (rnadttir,
1990, 1992), and with other instruments measuring ADL
and cognitive aspects (Steultjens, 1998). Contribution to
construct validity has been initiated through exploratory
factor analysis (rnadttir, 1990). Studies also have reported the sensitivity of the A-ONE to progress in ADL performance over time, thus demonstrating that the instrument is
useful for research in occupational therapy (rnadttir,
1990, 1998a; Ross & Sageby, 1997).
Procedure
Four occupational therapists plus the investigator collected
data for this study. All had completed an A-ONE training
course. The time since the therapists had completed the AONE training course ranged from 5 years to 7 years. To
promote interrater reliability, a 3-hour review course on
administering, interpreting, and scoring was held before the
study and led by the developer of the assessment.
In all instances, the A-ONE instrument was administered by the participants therapists as a part of the regular
occupational therapy evaluation for persons who had a
stroke in the two hospitals represented in this study. The
ADL assessments were performed at the participants bedside on the hospital ward in the morning and at normal
times for the activities. The therapists informed the participants about the procedure (i.e., what the participant would
be asked to do) and obtained written consent from each
before administering the ADL assessment. All the participants were volunteers and free to withdraw from the study
at any time. Diagnosis and site of lesion were determined by
reviewing the participants medical charts.

right and left CVAs in 18 out of 22 ADL tasks on the FIS

and 39 neurobehavioral impairments on the NSIS, except
for communication. The chi-square test was performed to
determine whether a difference existed between the left and
right hemisphere CVA groups in the domain of communication because impairments are either scored present (1) or
absent (0) on the NSIS. These statistical tests were used
because the data were nonparametric (Bailey, 1997).
Descriptive statistics, such as frequencies, percentages,
means, and standard deviations, were calculated for demographic data and for items on the FIS and NSIS. The level
of significance was set at p < .05.

Results
Results of the Mann Whitney U test indicated a significant
difference in scores between the right and left CVA groups
for 3 ADL tasks out of the 18 observed on the FIS and 13
neurobehavioral impairments out of 39 on the NSIS.
Participants in the left CVA group depended more on the
shave/make-up, comprehension, and speech tasks than
those in the right CVA group (see Table 3).
The neurobehavioral impairments of motor apraxia,
unilateral body neglect, and abnormal tone on either side of
the body discriminated significantly between the left and
right CVA groups. Participants in the left CVA group
demonstrated a higher level of severity of motor apraxia in
the dressing, grooming and hygiene, and feeding tasks than
those in the right CVA group. Conversely, participants in
the right CVA group demonstrated a higher level of severity of unilateral body neglect in dressing and grooming and
hygiene tasks. Participants in the left CVA group had a
higher level of abnormal tone in the grooming and hygiene
tasks than those in the right CVA group. On the other
hand, participants in the right CVA group had a higher
level of abnormal tone in the dressing, transfers and mobility, and feeding tasks (see Table 4).
The chi-square test revealed no significant differences
between the left and right CVA groups on the NSIS for
communication (i.e., 7 neurobehavioral impairments)
because the values in the cells were too small (expected
counts < 5), thus p > .05. Only participants in the left CVA
group demonstrated sensory aphasia, anomia, and expressive aphasia. Dysarthria affected speech in both groups.

Data Analysis

Discussion

All analyses were conducted using the Statistical Package for

the Social Sciences (SPSS, 1997).
The Mann Whitney U test was used to test for possible
differences between the performance of participants with

The purpose of this study was to test the construct validity

of the A-ONE by determining whether a difference in ADL
performance and neurobehavioral impairment existed
between persons with left and right hemisphere damage

The American Journal of Occupational Therapy

503

Table 3. Mann Whitney U Tests on FIS by Side of CVA

Left CVAa
FIS
Dressing
Shirt
Pants
Socks
Shoes
Fastenings
Grooming and hygiene
Wash face
Comb hair
Brush teeth
Shave/make-up
Transfers and mobility
Sit up in bed
Out of bed
Maneuver
Feeding
Drink
Finger feeding
Use fork or spoon
Use knife
Communication
Comprehension
Speech

Right CVAb

SD

SD

2.48
1.83
1.73
1.87
2.60

1.34
1.53
1.49
1.42
1.50

2.05
1.83
2.00
1.83
1.82

1.35
1.50
1.81
1.82
1.63

1.04
0.085
0.199
0.041
1.48

.300
.932
.842
.968
.139

2.87
2.86
2.78
2.32

1.25
1.25
1.35
1.46

2.68
3.53
3.26
3.44

1.29
0.77
1.19
0.92

0.361
1.78
1.18
2.48

.718
.075
.237
.013*

2.52
2.35
2.65

1.50
1.47
1.40

2.16
2.26
2.84

1.54
1.52
1.46

0.703
0.136
0.586

.482
.892
.558

3.59
3.57
3.57
2.05

0.96
1.08
1.04
1.54

4.00
3.89
3.79
2.26

0.00
0.46
0.63
1.52

1.93
1.02
0.706
0.618

.054
.310
.480
.536

3.13
2.74

1.29
1.14

4.00
3.89

0.00
0.32

2.81
3.70

.005*
.001*

Note. CVA = cerebrovascular accident; FIS = Functional Independence Scale.

a
n = 23. bn = 19.
*p < .05.

and, thereby, further contribute to the ongoing investigation of the relationship between lesion site and perceptual
performance. Only scores on 3 of the 18 ADL items
observed on the FIS discriminated between participants in
the left and right CVA groups (shave/make-up, comprehension, speech), supporting the hypothesis that only the
communication items on the FIS would provide such difference. The inability of scores on the other ADL items on
the FIS to discriminate between the two groups could indicate that both hemispheres contribute important and necessary functions to behavior at the ADL level. This finding
agrees with rnadttir (1990, 1998a) that although certain
functions can be assigned to specific cortical lobes, several
functional areas in different lobes may contribute to a particular function, and therefore, a variety of cortical areas
may be responsible for processing particular functions. In
relation to the development of the A-ONE, rnadttir constructed different processing models that indicate processing sites of different functions in the cortex. Fiber connections in a single hemisphere, between hemispheres, and
between cortex and other central nervous system structures
play important roles in these models during occupational
performance. This finding further supports previous findings that many factors probably contribute to both ADL
performance and perceptual skills in persons who had a
stroke (Titus et al., 1991).
The ability of the A-ONE instrument to differentiate
between the performance of participants with left CVA and
504

right CVA in the domain of functional communication on

the FIS (i.e., comprehension, speech) was to be expected, as
the left hemisphere is considered to play a primary role in
language functions (rnadttir, 1990, 1998a; McKeough,
1996). Participants with communication problems in the
left CVA group had relatively lower independence scores on
the FIS in the other four ADL domains than those in the
right CVA group. This finding supports that of Wade et al.
(1986), who reported that persons with aphasia tended to
have had more severe strokes when measured in terms of
motor loss or impaired performance in ADL.
On the NSIS, 13 of the possible 39 neurobehavioral
impairments discriminated between participants in the two
groups. Motor apraxia, unilateral body neglect, and abnormal tone on either side of the body differentiated between
the two groups in the domains of dressing, grooming and
hygiene, transfers and mobility, and feeding. Participants in
the right CVA group were more impaired because of unilateral body neglect in dressing, grooming and hygiene, and
feeding tasks. These results reflect current knowledge on
hemispheric specialization of the brain (rnadttir, 1990,
1998a; Heilman, Watson, & Valenstein, 1993; McKeough,
1996). Abnormal tone in the right and left sides also
impaired participants in both groups.
Heilman et al. (1993) defined unilateral neglect as the
inability to perceive, respond to, or orient to stimuli in the
space contralateral to a brain lesion. Unilateral neglect is
most common after injury to the right parietal lobe and
September/October 2002, Volume 56, Number 5

Table 4. Mann Whitney U Tests on NSIS by Side of CVA

Left CVAa
NSIS
Dressing
Motor apraxia
Ideational apraxia
Unilateral body neglect
Somatoagnosia
Spatial relations
Unilateral spatial neglect
Abnormal tone right
Abnormal tone left
Perseveration
Organization/sequencing
Grooming and hygiene
Motor apraxia
Ideational apraxia
Unilateral body neglect
Somatoagnosia
Spatial relations
Unilateral spatial neglect
Abnormal tone right
Abnormal tone left
Perseveration
Organization/sequencing
Transfers and mobility
Motor apraxia
Ideational apraxia
Unilateral body neglect
Spatial relations
Unilateral spatial neglect
Abnormal tone right
Abnormal tone left
Perseveration
Organization/sequencing
Topographic disorientation
Feeding
Motor apraxia
Ideational apraxia
Unilateral body neglect
Spatial relations
Unilateral spatial neglect
Abnormal tone right
Abnormal tone left
Perseveration
Organization/sequencing

Right CVAb

SD

SD

1.17
0.43
0.39
0.09
0.52
0.26
2.22
0.00
0.09
1.48

1.27
0.90
1.08
0.29
1.16
0.86
1.38
0.00
0.42
1.41

0.47
0.16
1.37
0.00
0.68
0.37
0.00
2.53
0.00
1.26

1.12
0.69
1.42
0.00
1.29
0.96
0.00
1.61
0.00
1.24

2.29
1.41
2.57
1.30
0.618
0.270
5.23
5.11
0.909
0.531

.022*
.158
.010*
.193
.537
.787
.001*
.001*
.363
.596

1.61
0.61
0.13
0.17
0.39
0.22
2.09
0.00
0.30
1.52

1.41
1.12
0.63
0.65
1.03
0.74
1.24
0.00
0.88
1.20

0.11
0.05
0.84
0.00
0.05
0.21
0.00
1.53
0.26
0.95

0.32
0.23
0.96
0.00
0.23
0.63
0.00
1.26
0.73
1.03

3.76
1.87
3.04
1.30
0.918
0.149
5.27
5.12
0.187
1.56

.001*
.062
.002*
.193
.358
.882
.001*
.001*
.852
.118

0.78
0.30
0.35
0.30
0.35
2.09
0.00
0.04
1.09
0.45

1.28
0.88
0.98
1.02
0.98
1.35
0.00
0.21
1.47
1.01

0.32
0.00
0.84
0.37
0.58
0.00
2.16
0.11
1.05
0.37

0.95
0.00
1.34
1.12
1.22
0.00
1.42
0.46
1.43
0.90

1.47
1.61
1.45
0.199
0.701
4.88
5.14
0.171
0.043
0.240

.142
.107
.148
.843
.483
.001*
.001*
.864
.966
.811

0.91
0.30
0.22
0.22
0.22
1.78
0.00
0.30
0.48

1.20
1.02
0.74
0.67
0.74
1.24
0.00
1.02
1.16

0.05
0.00
0.16
0.00
0.11
0.00
1.89
0.11
0.11

0.23
0.00
0.50
0.00
0.46
0.00
1.37
0.46
0.32

3.04
1.30
.124
1.61
0.453
5.26
4.91
0.481
0.748

.002*
.193
.901
.107
.651
.001*
.001*
.631
.455

Note. CVA = cerebrovascular accident; NSIS = Neurobehavioral Specific Impairment Subscale.

a
n = 23. bn = 19.
*p < .05.

may affect an individuals perception of extrapersonal or

personal space (Vallar, 1993). According to Heilman and
Van Den Abel (1980), the right hemisphere is considered to
be dominant in mediating attention; therefore, left side
neglect resulting from a right hemisphere lesion is seen
more frequently than right side neglect. The impairments of
unilateral neglect and inattention also have been reported to
negatively affect performance in ADL and have been found
to be important predictors of functional ability (Carter et
al., 1988; Chen-Sea, 2000; Chen-Sea et al., 1993; Denes et
al., 1982; Kinsella et al., 1993; Kinsella & Ford, 1980;
Kotila et al., 1986). The present results as well indicate that
the A-ONE can detect unilateral body neglect at a statistiThe American Journal of Occupational Therapy

cally significant level as an impairment limiting performance in several tasks in patients with right CVA. These
results may be of further value regarding choice of intervention methods and could indicate a potential for predictive value of the A-ONE instrument for outcomes.
Participants in the left CVA group were more impaired
by motor apraxia in dressing, grooming and hygiene, and
feeding tasks than participants in the right CVA group.
Other researchers agree that motor apraxia results most frequently from lesions in the left, dominant hemisphere
(rnadttir, 1990; Heilman & Rothi, 1993). Heilman and
Rothi (1993) developed a schema that accounts for most of
the available evidence. They suggested that motor control
505

formulas that coordinate movements in space and time are

located in the dominant parietal lobe. Lesions in this area or
in the connections of the area to the premotor cortex result
in apraxia. In right-handed persons, almost all cases of
motor apraxia are associated with left hemispheric damage.
Apraxia therefore often is associated with aphasia.
The results from this study demonstrated minimal support of the ability of the FIS of the A-ONE to differentiate
between ADL performance of right and left CVA groups,
except for the communication items. This finding is expected because both hemispheres are believed to contribute
important and necessary functions to behavior at the ADL
level. The theory behind the A-ONE does not propose a
difference in ADL performance between individuals with
right or left CVA, except for the aforementioned items. On
the contrary, the theory proposes that task performance
depends on combined activity of many different performance components as a result of cerebral function taking
place at different sites of the central nervous system
(rnadttir, 1990, 1998a). Earlier studies of the concurrent
type of criterion-related validity have indicated that all 22
ADL items on the FIS can discriminate significantly
between the performance of persons without neurological
conditions and those with CVA. Further, all but six items
on the NSIS discriminated significantly between the average performance of the two groups (rnadttir, 1990).
These results were supported by the findings of Steultjens
(1998). These previous studies thus support the theoretical
statements that the instrument is able to differentiate
between the average performance of persons with CVA and
persons without neurological conditions, thereby supporting the instruments construct validity.
The impairments of motor apraxia, unilateral body
neglect, and abnormal tone (motor impairment) on the
right and left sides of the body were found to differentiate
significantly between the left and right CVA groups on
selected test items. These aforementioned neurobehavioral
impairments are those most often referred to in the literature, and there is agreement about the lesion sites that cause
these impairments (rnadttir, 1990, 1998a; Heilman &
Rothi, 1993; Heilman et al., 1993; Heilman & Van Den
Abel, 1980; McKeough, 1996; Vallar, 1993).
On the other hand, impairments such as spatial relations deficits and ideational apraxia did not differentiate significantly between the two groups on any tasks. This finding could have several explanations. In the literature, spatial
relations deficits are most commonly associated with posterior lesions of the right or nondominant hemisphere
(rnadttir, 1990, 1998a, 1999; Walsh, 1999). However,
one must keep in mind that when a task requires verbal reasoning, it calls for neural processing in the left hemisphere.
506

Ideational apraxia has been associated with lesions of the

left parietal lobe or diffuse brain damage (rnadttir 1990,
1998a, 1999; Heilman & Rothi, 1985; Walsh, 1999).
Thus, the literature does not suggest an exact lateralization
for these impairments as it does for paresis of the right or
left side the body, unilateral neglect, or motor apraxia, and
this lack of lateralization could be mirrored by these results.
One could further speculate about whether the therapists
collecting the data had misinterpreted observed behavior
because no interrater reliability study was performed
(although all therapists had undergone appropriate training). The therapists may have had difficulties with the clinical reasoning aspects of interpreting observed behavioral
cues and selecting the appropriate hypothesis for differentiating between behavior resulting from spatial relations
deficits and ideational apraxia.
Limitations
A limitation of this study is that a sample of convenience
was used; thus, the sample may not be representative of all
persons who have had a stroke in Iceland. The use of five
raters could have increased variability of test administration
and lowered interrater reliability. Although a short-review
course was held for raters before the study, it could not be
expected to eliminate all possibilities of rater errors in using
the A-ONE.
Directions for Future Research
The results of the current study suggest replication on a
larger sample size and use of fewer raters. In addition, an
interrater reliability study among raters could be performed
before the study.

Conclusion
The results from this study demonstrated minimal support
for the construct validity of the A-ONE instrument in differentiating between task performance of persons with left
and right hemisphere damage, as was expected, because performance of most ADL tasks depend on bilateral hemispheric use by their nature. However, the results regarding
the ability of the A-ONE to detect and lateralize impairments supported literature regarding lesion sites for the
impairments. These findings added to the knowledge
obtained by previous studies on concurrent validity of the
A-ONE assessment for the CVA population, supporting its
continuing use in clinical evaluation and research.
The emphasis on cost-effective health care in recent
years has highlighted the need for valid and reliable outcome measures. Occupational therapists need to select both
valid and reliable assessments to demonstrate the efficacy of
September/October 2002, Volume 56, Number 5

their clinical interventions in comprehensive stroke rehabilitation. The A-ONE instrument may be of use in therapists
choice of effective intervention techniques because it is
intended to gather clinical information regarding individuals occupational performance and the neurobehavioral
impairments that limit performance. Research has supported its ability to detect progress in performance. The tool
therefore can be recommended as a component of a comprehensive occupational therapy evaluation of persons who
had a stroke.

Acknowledgments
This article is based on the first authors masters thesis in
the Department of Occupational Therapy, Florida
International University, Miami. I thank Susan Kaplan,
PhD, MBA, OTR, Gail Ann Hills, PhD, OTR/L, FAOTA,
and Paulette Johnson, PhD, for their support as thesis
committee members; Erna Magnsdttir, Kolbrn
Hdinsdttir, Lilly H. Sverrisdttir, and Sigrn lafsdttir
for assisting with the data collection; Anna Mara
Frmannsdttir for statistical consultation; and Gudrn
rnadttir, MA, BMROT, and Valerie Harris, OT, MS, for
their help and personal support. I also thank all the persons
who participated in this study, my coworkers, and my superiors. Portions of this article were presented at the 12th
International Congress of the World Federation of
Occupational Therapy in Montreal, Canada.

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