MODIFIED REY-OSTERRIETH COMPLEX FIGURE COPYING TASK … · Rey-Osterrieth Complex Figure copying is a method of assessment of visuoconstructional skills and is sensitive to pathology

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MODIFIED REY-OSTERRIETH COMPLEX FIGURE COPYING TASK

DIFFERENTIATES FRONTAL AND POSTERIOR LESIONS OF BRAIN

Working Paper · October 2007

DOI: 10.13140/RG.2.2.12885.22242

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MODIFIED REY-OSTERRIETH COMPLEX

FIGURE COPYING TASK DIFFERENTIATES

FRONTAL AND POSTERIOR LESIONS OF BRAIN

ABSTRACT:

Rey-Osterrieth Complex Figure copying is a method of assessment of visuoconstructional

skills and is sensitive to pathology of posterior cortices. However, poor copy score might also

reflect executive dysfunctions following frontal lobe lesion. Thus far there has been no meth-

od allowing accurate differentiation between these two difficulties. In current study a proce-

dure is introduced based on providing an organizational aid and observation of changes in

copy. Two groups were examined: 1) people with posterior lesions of brain; 2) people with

prefrontal lesions. Results showed that the method differentiate accurately between these

groups, and as a result between the mechanisms of discussed disorders.

KEYWORDS: visual perception; visuospatial; visuoconstructional; planning impairment; ex-

ecutive functions; neuropsychological diagnosis

INTRODUCTION

Copying of the the Rey-Osterrieth Complex Figure (R-OCF) is a widely known method of

neuropsychological assessment of visual perception and organization as well as visuospatial

and visuoconstructional skills (Spreen & Strauss, 1998; Fisher & Loring, 2004; Strauss et al.,

2006). As the standardized tool of examining the latest it has remarkable, empirically proven,

diagnostic accuracy. Klitzke (1997) examined a group of posteriorly lesioned subjects suffer-

ing from visuospatial dysfunctions with R-OCF and the subtest “Block Designs” from WAIS

battery. In the first task all subjects scored below fifth cumulative percent according to norms

for healthy people while in the second task such a low result was achieved only by 5 out of 20

people.

On the other hand, Luria and Tswietkowa (after: Pillon, 1981) noticed that there are

two kinds of problems appearing in complex visuoconstructional tasks. They called them two

kinds of visuoconstructional difficulties, although this term does not seem to be adequate with

reference to both of the deficits in question. The first kind encompasses troubles resulting

from inability to perceive correctly the stimulus set or to utilize created percept for the pur-

pose of constructional behavior. These arise due to the disintegration of visual and

visuospatial processing and result from the damage to the posterior parts of brain, mainly oc-

cipital lobe and parieto-occipital junction (Luria, 1973; Lindsay & Norman, 1977; Walsh,

1991; Girkin & Miller, 2000).

Second kind of problems arises due to inability to develop and implement an appropriate plan

of action. Inertness and impulsiveness, lack of capacity or motivation to predict the outcomes

of successively taken steps or inability to take advantage of feedback are the basis of troubles

of this kind (Lhermitte et al., 1972; Pillon, 1981: Shorr et al., 1992; Walsh, 1994; 1991). Such

dysfunctions are usually an effect of prefrontal lesion and they can be seen not only in con-

structional tasks. They can manifest in virtually any kind of cognitive activity (Owen, 1997;

Della Sala et al., 1998; Miyake et al., 2000; Goldberg, 2001; Stuss & Knight, 2002; Hommel,

2003; Wood & Grafman, 2003).

Differentiating the reasons of patient’s difficulties in the test is necessary in the pro-

cess of neuropsychological diagnosis from the prognostic point of view or for the sake of con-

structing adequate compensation.

There are two ways of examining reasons for diminished quality of the copy of R-

OCF described in the literature. The first way is based on description of planned approach to

copying process regardless of copy quality. A classic example is the categorization of copying

strategies proposed by Osterrieth (Fisher & Loring, 2004). Other methods of this kind include

subjective assessment of observed copying strategy adequacy (Hamby et al.; Anderson et al.;

Waber & Holmes; Boston Qualitative Scoring System after: Fisher & Loring, 2004), or ob-

jective measurement of systematic approach to copying based on continuity and order of pro-

duction of specific figure’s elements (Binder after: Fisher & Loring, 2004; Bennett-Levy,

1984; Shorr et al., 1992).

Unfortunately, methods of this kind are not suitable for differentiation between

mechanisms of difficulties in copying. Planned approach to copying are reflected in the copy

quality and perceptual difficulties always lead to chaotic copying. In a study by Przybylski,

(2006) a group of people with perceptual or visuoconstructional deficits after a damage to

posterior regions of brain achieved mean perceptual clustering ratio – an index created by

Shorr et al., (1992) – as low as the frontally lesioned group did, and this measure is hard to

interpret in terms of quality of the plan. Frequencies of copying strategies also did not differ-

entiate significantly between compared groups (Przybylski, 2006).

Second group of procedures is based on providing an external structure of the copy-

ing process. Examiner imposes a framework that diminishes or eliminates a chaos in copying.

The extent to which such help is efficient can be a subject of qualitative or quantitative as-

sessment. Two such methods have been described in literature and in both cases organization-

al help consisted in splitting a process of copying into some stages. For the first time

Lhermitte et al. (1972) used it on patient with extensive frontal damage whose planning im-

pairments caused substantial distortion of the copy. There were six stages of copying and their

employment resulted in equally substantial improvement in the quality of the copy. However,

this study has a casuistic character therefore the range of generalization is limited. Besides,

this result was not compared to a result of patient with posterior lesion, so it is impossible to

tell whether this kind of help would not have been efficient as well.

Pillon (1981) used similar idea and employed similar organizational help on a group

of patients with frontal lesions and a group of patients with lesions of posterior regions (oc-

cipital lobes and their junctions). The procedure he applied was efficient, but unfortunately in

both groups. This means that it was nonspecific, so it cannot be used in differentiating the

reasons of diminished copy quality. Thereby the problem of differentiating between mecha-

nisms of difficulties in copying remained unresolved.

Basing on the results of studies by Lhermitte et al. (1972) and Pillon (1981) an as-

sumption was made that copying of R-OCF may be employed for differentiating between

frontal and posterior pathology, but it requires introducing such a modification of the proce-

dure that would minimize the engagement of executive functions and, at the same time, would

not facilitate the task perceptually. In other words the help has to be specific towards plan-

ning impairment. This hypothesis has been verified with the help of the procedure described

below in details.

Analyzing the method used by K.W. Walsh (1991) in the “Block Designs” task from

WAIS battery, conclusion was formulated that organizational help in R-OCF copying has to

be based on inserting additional visual material without splitting copying into stages. We con-

sider that such splitting of copying process would simplify the stimulus set at initial stages of

performance, and consequently makes it less demanding to visual perception. This, in turn,

causes undesirable improvement within a group of patients with posterior lesions.

In this study a method has been introduced consisting in drawing lacking elements

of the figure onto already provided frame and observing to what degree the copy improved

after introducing such an aid. Frame provides defined and outlined edges and geometrical

middle point of the figure. Thus participants are given spatial points of reference in copying.

Defining these points is thought to be the greatest organizational problem in the process of

copying. At the same time, such an aid not only does not cause a simplification of stimulus set

at any stage, but actually can make the task more demanding to visual perception. This should

guarantee specificity of the aid towards planning impairment.

It was expected that standard copy score would not differentiate sufficiently between

these clinical groups. Introducing the aid should cause significant increase in copy quality

within the frontal group, but not within the posterior group and finally, level of copy im-

provement should accurately differentiate between the groups.

METHODS

SUBJECTS

Adult patients took part in current research. Selection of subjects for the research was carried

out according to the localization of the lesion of central nervous system. Patients with lesions

limited to either frontal lobe (frontal group – FG) or occipital lobe, parieto-occipital junction

and temporo-occipital junction (posterior group – PG) were included in the sample. Subjects

were recruited from among patients of neurological, neurosurgical and rehabilitation wards of

public hospitals from Lublin, Sosnowiec and Katowice, Poland.

Aetiology of lesions was varying and encompassed: cerebral ischaemiae (6 sub-

jects), cerebral haemorrhages (8 subjects), intracranial tumors (7 subjects), neurosurgical re-

sections of tumors (7 subjects), closed head injuries (6 subjects), frontotemporal dementia (2

subjects), 1 subject with brain abscess and 1 subject with lesion of mixed aetiology. 38 sub-

jects were examined, among them 21 with frontal lesions and 17 with posterior brain patholo-

gy. Distribution of lateralization of damage is presented in table 1. As one can see, there is

more subjects with bilateral damage in the frontal group. Significance of the difference as

measured with Pearson χ2 test is p = 0,153. It will be controlled in further analyzes.

Right-sided Left-sided Bilateral

FG 7 (33,3%) 4 (19%) 10 (47,7%)

PG 9 (52,9%) 5 (29,45%) 3 (17,65%) Table 1 Distribution of lesion lateralization.

Percent of males is higher in the frontal group (66,7%) than in the posterior group

(47,1%), but the difference as measured with Pearson χ2 test is statistically insignificant (p =

0,224). Means and standard deviations of age and years of formal education in both groups

are presented in table 2.

Age M(SD) Years of education M(SD)

FG 48,24(15,937) 12,43(3,25)

PG 51,88(17,776) 10,71(3,6)

Sign. level p = 0,515 p = 0,135 Table 2 Means and standard deviations of side variables in each of compared group with the statistical

significance of differences as measured with t test.

Because compared groups differed significantly in education, this variable will be

included in statistical analyzes.

PROCEDURES

Subjects were asked to make a copy of the figure with a pencil on an A5 sheet of paper as

carefully as possible. Subjects were allowed to rotate their drawings, which was aimed at

maximizing the quality of their copies, but they were not allowed to rotate the figure. Ferraro

et al. (2002) showed that the position of the figure and the paper had no influence on the qual-

ity of the produced copies. Erasing was allowed – pencils were fit with an eraser. So far only

Meyers & Meyers after: Spreen & Strauss (1998) have expressed their opinion about this is-

sue and they allowed it. We assume that this helps to differentiate better between groups.

Next, subjects produced another (assisted) copy, this time with an external aid. They

were asked to draw lacking details of the figure into the frame consisting of: a large main rec-

tangle (element 2 according to Osterrieth's numeration), the diagonals of the large main rec-

tangle (element 3) and a large triangle on the right (element 13) as carefully as possible – to

produce possibly accurate copy. Other conditions remained unchanged. Stimulus set – R-OCF

as well as the help – the frame is presented in the figure 1.

Rysunek Fig. 1. Stimulus set – Rey-Osterrieth Coplex Figure (left) and the aid – frame (right)

Both copies were scored according to L. Taylor’s criteria (Spreen & Strauss, 1998).

The use of these strict criteria is crucial for the described method because using more lenient

ones could have resulted in overlooking some of the subtle errors. The score in the first copy

was converted into proportion of maximum score (36 points) according to the formula: %C =

C / 36; where: C – raw standard copy score; %C – percent of maximum score in standard

copy. An analogical method was employed in computing a proportion of maximum score in

the assisted copy. Maximum score this time is 30 (3 elements worth 2 points each were al-

ready provided as a frame), so the formula looks as follows: %CH = CH / 30; where: CH –

raw score in copy with help; %CH – percent of maximum score in copy with help. Next, the

first proportion has to be subtracted from the second, which gives Copy Change Ratio (CCR):

%CH – % C = CCR. This index theoretically ranges from -1 (negative values mean that the

aid actually increased the distortion of the copy) through 0 (the help had no influence on copy

quality) to 1 (positive values mean that the help improved copy quality), but practically ex-

treme values (especially negative) are highly unlikely.

RESULTS

RESULTS OF COPYING

Table 3 shows means and standard deviations of “Raw Copy Score” in frontal and posterior

group, together with the level of statistical significance of differences between groups as well

as between-subjects effects in ANOVA analysis. The analysis was conducted with lesion site,

lesion hemisphere and their interaction as factors and years of education as covariate. As one

can see intergroup differences did not reach the level of significance and after controlling for

influence of education this effect becomes even weaker. Simple and interactive influence of

lesion hemisphere on copy quality was insignificant.

FG

M

(SD)

PG

M

(SD)

Significance

of differences in

means: t test

Significance of Between-Subject Effects: ANOVA

A(ANOVA) Lesion

Site

Lesion

Hemisphere

Interaction:

S*H

Years of

education

Raw

copy

26,238

(5,137)

21,588

(9,707)

p = 0,088 p = 0,121 p = 0,508 p = 0,637 p = 0,088

Table 3. Means and standard deviations of standard copy raw score with statistical

analysis of the results.

COPY CHANGE WITH EXTERNAL AID

Mean and standard deviations of CCR in each group together with the results of statistical an-

alyzes are presented in table 4. For this variable an analysis of variance was conducted with

the same factorial model as previously. As one can see in table 4 intergroup differences in

CCR are much more pronounced than for raw copy score. Moreover, controlling for the side

effects of education did not decrease significantly the strength of the relationship.

In figure 2 and in table 5 means and standard deviations of percent of maximum

score in standard and helped copy in each group are presented. Table 5 presents also the re-

sults of the analyzes concerning significance of change in means and variances in copying

after applying the help within each of the lesion site groups. To estimate significance of dif-

ferences in variances the formula for dependent groups based on t-distribution was used (Fer-

guson & Takane, 1989, formula 12.6).

FG

M

(SD)

PG

M

(SD)

Significance

of differences in

means: t test

Significance of Between-Subject Effects (ANOVA)

Lesion

Site

Lesion

Hemisphere

Interaction

S*H

Years of

education

CCR 0,164

(0,102)

0,016

(0,113)

p = 0,00015** p = 0,001** p = 0,867 p = 0,997 p = 0,946

Table 4. Copy change ratios in both groups together with results of statistical analyses.

** - sinificant at a level p = 0,01

Fig. 2. Results in copying of R-OCF in each group before and after providing the aid. The graph shows

means (bars) and standard deviations (whiskers) of scores expressed in the percent of maximum score.

%C

M(SD)

%CH

M(SD)

Significance of

differences in means:

t test for dependent groups

Significance of

differences in variances:

t test for dependent groups

FG 0,7288(0,1427) 0,892(0,0844) p < 0,001** p = 0,0015**

PG 0,599(0,269) 0,615(0,271) p = 0,567 p = 0,4696

Table 5. Means and standard deviations of results in standard copy and assisted copy

expressed as a proportion of maximum score, together with levels of significance of

changes. ** - significant at p = 0,01.

Data presented in table 5 show two important results: First, the mean result in copy-

ing rose significantly after applying the aid for frontal lesions, but did not rise for posterior

lesions. Second, in FG applying the help caused significant decrease in variance of results –

so to speak, leveling it – which did not happen within PG. It is worth noticing that in terms of

either means or variances the results within FG nearly equaled the results of the group of neu-

rologically healthy controls (Przybylski, 2006).

In the frontal group 14 subjects achieved CCR ≥ 0,1277 (the same proportion was

with cut-point at 0,10). In the posterior group CCR ≥ 0,1277 was achieved only by 2 subjects,

3 subjects had CCR ≥ 0,11 and 4 of them had CCR ≥ 0,10.

However, in patients from posterior group with highest CCR's some specific mecha-

nism occurred. All 3 subjects from PG with highest CCRs suffered from either unilateral

hemianopsia or hemispherical neglect, which resulted in dramatic decrease in copy score.

Subsequent providing an organizational aid had significant positive influence on copy quality

although mechanisms were clearly distinct (it helped them focus on previously neglected parts

of the figure) and easily distinguishable from that observed in subjects with frontal damage.

Moreover, in the frontal group among 7 subjects with the CCR < 0,1277 as many as

5 of them achieved raw copy score ≥ 30. Such copy is considered correct, and in such case

there is little room for improvement an no need for differentiation.

Considering these two facts we can cautiously assume that high CCR can be regard-

ed as an indicator of distortion resulting from impaired planning / dysexecutive symptoms,

although improvement of copy quality should always be assessed individually.

DISCUSSION

An analysis of results of the current research gave a strong support for hypotheses stated.

Standard copy score poorly differentiated between the lesion sites. Although generally pa-

tients with frontal damage achieved slightly higher scores than those with posterior pathology,

the difference did not reach the level of statistical significance. In other words data has con-

firmed the hypothesis that low score in copy of the R-OCF can be the result of disorders of

perceptual functions specific for this task, which are common consequence of posterior le-

sions, as well as the result of disorders of non-specific executive functions due to damage to

frontal lobes. It was also demonstrated that copy score alone is insufficient to distinguish be-

tween these mechanisms. It is worth noticing that both groups have significantly lower stand-

ard copy scores than neurologically healthy controls (Przybylski, 2006).

Much more useful differentiating measure was the level of disintegration or serious

structural distortions of the copy. In the current study, patients with frontal damage rarely

produced copies so distorted that some structural elements were unrecognizable. Mechanisms

to a greatest extent responsible for lower copy scores within the frontal group were major

sloppiness, askewness and lack of symmetry – mainly due to badly defined midpoint. In the

posterior group poor quality of the copy was related to its disintegration and incompleteness.

Errors occurring in such cases were glaring.

Figures 3 and 4 show copies drawn by two female patients with frontal lobe pathol-

ogy. The first patient – E.G. was 56 years old and sustained right frontal ischemia as a result

of ruptured aneurysm 1,5 year before the examination. The second – A.K. was 28 years old at

the moment of examination and sustained bilateral anterior and orbital frontal damage due to

TBI. In case of A.K. it is clearly visible that serious decrease in copy quality may take place

even though the copy is complete.

Fig. 3. Copies of R-OCF made by patient E.G. Standard copy (left) was scored 15 points while assisted

copy (right) 25 points. Copy Change Ratio = 0,41666.

Fig. 4. Copies of R-OCF made by patient A.K. Standard copy (left) was scored 19,5 points while assisted

copy (right) 25 points. Copy Change Ratio = 0,29166.

Figures 5 and 6 present copies drawn by two male patients (S.Z. and M.B.) with oc-

cipital damage. They were 69 and 62 years old. In both cases there had taken place surgical

resection of tumors in occipital lobes, however, in case of S.Z. it was right-sided and in case

of M.B. it was bilateral. In both copies one can see serious distortions of form, missing of

some details, and in case of M.B. severe disintegration of the drawing.

Fig. 5. Copies of R-OCF made by patient S.Z. Standard copy (left) was scored 12,5 points while c assisted

copy (right) 11 points. Copy Change Ratio = 0,01944.

Fig. 6. Copies of R-OCF made by patient M.B. Standard copy (left) was scored 9 points, while assisted

copy (right) 6,5 points. Copy Change Ratio = -0,03333.

Most promising measure enabling to differentiate between dysfunctions that cause

poor copy quality is CCR. In cases of distorted standard copies (scored

As one can see, providing an aid allowed to compensate for at least some of the difficulties.

PRACTICAL IMPLICATIONS

The procedure described in this paper may find application in neuropsychological diagnosis

as an improvement of methods of assessment of visual perception and visuoconstructional

functions as well as features of disorganization of behaviour as an element of dysexecutive

syndrome. The results of this study indicate that employment of copy with help as a supple-

ment of the R-OCF test may be very advantageous in clinical practice due to the significant

increase of informative value carried by the small modification of the current procedure.

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