The right hemisphere of the brain participates in many communication skills, primarily at the semantic (word and discourse) and pragmatic levels.
Right hemisphere damage (RHD; also known as “right hemisphere disorder” and “right hemisphere brain damage”) is an acquired brain injury—usually secondary to stroke or TBI—that causes impairments in language and other cognitive domains that affect communication.
Syntax, grammar, phonological processing, and word retrieval typically are not affected. However, RHD can affect
RHD can also cause impairments in other cognitive domains—including attention, memory, and executive functioning—that can interfere with communication abilities. Impairments can include anosagnosia (reduced awareness of deficits) and visual neglect (aspects of visual stimulus are ignored), both of which can significantly affect spoken and written language.
Deficits associated with RHD may be more evident during the performance of multidimensional, complex tasks such as conversation (Ferré, Ska, Lajoie, Bleau, & Joanette, 2011) and can have a significant impact on functional performance in social and vocational settings (Blake, 2006; Lehman & Tompkins, 2000).
In a very small proportion of right-handed individuals, the language centers are located in the right hemisphere of the brain, rather than in the left hemisphere. In these individuals, damage to the right hemisphere may result in symptoms of aphasia similar to those normally associated with a left hemisphere lesion. This condition is known as crossed aphasia (e.g., Coppens, Hungerford, Yamaguchi, & Yamadori, 2002).
The incidence of RHD has been reported most frequently following strokes. Several hospital-based studies have reported frequency of right hemisphere strokes ranging from 42% to 49% (Foerch et al., 2005; Hedna et al., 2013; Portegies et al., 2015). In addition, studies have reported that approximately 50%–78% of individuals with RHD exhibit one or more cognitive deficits that affect communication (Benton & Bryan, 1996; Blake, Duffy, Myers, & Tompkins, 2002; Ferré et al., 2009; Heweston, Cornwell & Shum, 2017; Joanette & Goulet, 1994; Nys et al., 2007).
RHD results in a collection of symptoms that vary in severity and in domains affected, depending on the site and extent of injury to the underlying neural substrate. For a detailed discussion of signs and symptoms associated with RHD, see, for example, Blake (2018). Below are examples of symptoms grouped by domain. Individuals may not present with all symptoms.
RHD does not typically affect word retrieval, syntax, and/or repetition, as seen in aphasia. However, if the left hemisphere language centers are also damaged (e.g., in TBI), RHD symptoms can co-occur with classic aphasia symptoms. Occasionally, RHD may result in the classic aphasia subtypes [PDF] in individuals with crossed hemispheric dominance.
Language deficits typically affected by RHD include the following:
Cognitive impairments are not exclusive to RHD. For example, memory deficits are often associated with any injury to the brain, including stroke and TBI.
Cognitive deficits typically associated with RHD that can affect communication include
Other deficits that may be associated with RHD include
RHD may result from a variety of causes, including but not limited to
Speech-language pathologists (SLPs) play a central role in the screening, assessment, diagnosis, and treatment of persons with RHD. The professional roles and activities in speech-language pathology include clinical/educational services (diagnosis, assessment, planning, and treatment); prevention, counseling, and advocacy; and education, administration, and research. See ASHA's Scope of Practice in Speech-Language Pathology (ASHA, 2016b).
Appropriate roles for SLPs include, but are not limited to, the following:
As indicated in the Code of Ethics (ASHA, 2016a), individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.
The clinician considers the following factors that may have an impact on screening and comprehensive assessment:
If the individual with RHD wears prescription glasses and/or hearing aids, these should be worn during assessment.
If additional hearing and/or visual deficits resulted from the neurological event—and physical or environmental modifications (e.g., large-print material, attention to placement of test stimuli, modified lighting, amplification devices) are not sufficient to compensate for these changes—then the individual should be referred for complete audiologic and/or vision assessments prior to testing. If there are signs or reports of depression, then the individual should be referred for a psychological or psychiatric evaluation.
Screening does not provide a detailed description of the severity and characteristics associated with RHD but, rather, identifies the need for further assessment. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity.
Screenings may be completed by the SLP or another appropriately trained professional. Standardized and nonstandardized methods are used to screen oral motor functions, speech production skills, comprehension and production of spoken and written language, pragmatic language skills, and other cognitive skills (attention, memory, and executive function) as they relate to communication, swallowing, unilateral visual neglect, and hearing.
Screening often incorporates the use of targeted questionnaires with the individual and family members. Keep in mind, however, that changes post RHD are not always recognized by the individual or family members.
Screening may result in
Consistent with the World Health Organization's (WHO) International Classification of Functioning, Disability and Health (ICF) framework (ASHA, 2016b; WHO, 2001), comprehensive assessment is conducted to identify and describe
See the ASHA resource titled Person-Centered Focus on Function: Traumatic Brain Injury [PDF] for an example of assessment data consistent with ICF.
Assessment can be static (i.e., using procedures designed to describe current levels of functioning within relevant domains) and/or dynamic (i.e., an ongoing process using hypothesis-testing procedures to identify potentially successful interventions and supports).
Assessment protocols can include both standardized and nonstandardized tools and data sources. The choice of assessment tools and procedures is based on a variety of factors, including the needs of the person with RHD, the clinician's professional judgment, the complexity of impairment, payer guidelines, and facility policy. See ASHA's resource on assessment tools, techniques, and data sources for additional information.
There are few standardized communication assessments for use with patients with RHD (see, e.g., Joanette et al., 2015) and few standardized assessments of cognition normed on individuals with RHD. Functional nonstandardized assessments are particularly valuable for individuals with RHD, whose performance on activities of daily living (ADLs) and more complex tasks may be disproportionately better or worse than their performance as predicted by standardized test scores.
Typical components of a comprehensive assessment of deficits associated with RHD include following:
The focus of the cognitive assessment is to determine the impact of cognitive deficits on communication (e.g., Blake, 2018). SLPs may conduct these assessments in collaboration with neuropsychologists. Areas assessed include the following:
See assessment section of ASHA's Practice Portal page on Adult Dysphagia.
Factors affecting the assessment of neurogenic dysphagia following RHD include
If the RHD is a result of TBI, then hearing and vestibular testing may be indicated, depending on the individual's presenting needs. Referral to an audiologist is made, as appropriate. For details, see the Assessment sections of ASHA's Practice Portal pages on Hearing Loss – Beyond Early Childhood, Balance System Disorders, and Tinnitus and Hyperacusis.
Assessment may result in one or more of the following:
When selecting the language of assessment for individuals who speak more than one language, it is important to consider the languages spoken, age of acquisition of each language, premorbid use of each language, and language(s) needed for return to daily activities. Clinicians should gather data in all languages used in order to determine degree of impact.
Pragmatic and social norms (e.g., eye contact, turn taking, nonverbal cues, etc.) vary from culture to culture. Cultural differences should not be interpreted as pragmatic deficits. See ASHA's Practice Portal page on Cultural Competence for more information.
Appropriate accommodations and modifications can be made to the testing process to reconcile cultural and linguistic variations. Documentation should include descriptions of these accommodations and modifications. Scores from standardized tests should be interpreted and reported with caution in these cases. See ASHA's Practice Portal pages on Bilingual Service Delivery; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Competence.
Treatment for RHD is individualized to address areas of need identified in the assessment, taking into account the goals identified by the individual and his or her family.
Treatment occurs in the language(s) used by the individual with RHD—either by a bilingual SLP or with the use of trained interpreters, when necessary. See ASHA's Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.
Consistent with the WHO (2001) ICF framework, the goal of intervention is to help the individual with RHD achieve the highest level of independent function for participation in daily living.
Intervention is designed to
See the ASHA resource titled Person-Centered Focus on Function: Traumatic Brain Injury [PDF] for an example of functional goals consistent with ICF.
Treatment can be restorative (i.e., aimed at improving or restoring impaired function) and/or compensatory (i.e., aimed at compensating for deficits not amenable to retraining).
Treatment approaches—whether restorative or compensatory—can focus on specific functional skills (e.g., composing and sending emails) or underlying processes (e.g., attention, memory, executive function) that affect a range of skills.
Below are brief descriptions of treatment options for addressing RHD, grouped into broad categories. This list is not exhaustive, and the inclusion of any specific treatment does not imply endorsement from ASHA. The majority of the treatments below are based on theories of RHD and treatments designed for disorders caused by brain injury.
Treatment selection depends on the communication needs of the individual, the preferences of the individual and his or her family, and the presence of co-occurring conditions that might affect the individual's insight into limitations or ability to implement some compensatory strategies.
For a detailed discussion of treatment of RHD, see, for example, Blake (2018), Myers (1999), and Myers (2001).
Treatment for language deficits associated with RHD typically focuses on narrative and conversational discourse, understanding and managing alternate meanings, and pragmatics.
Narrative and conversational discourse skills include the ability to make inferences and understand global meanings of discourse (e.g., topic, gist, big picture). Treatments that target these skills include the following:
Understanding and managing alternate meanings involves the ability to understand lexical ambiguities, generate alternate meanings, and understand nonliteral language. Treatments that target these skills include
Treatment for pragmatic deficits focuses on improving skills to support successful social communication in a variety of settings. Techniques used to practice these skills include coaching, one-on-one rehearsal, role play, group practice, visual and verbal feedback, and video modeling.
Some approaches focus specifically on conversational skills and include
Other approaches target the skills that underlie and support all social communication. These skills include the ability to
Pragmatic and social norms (e.g., eye contact, turn taking, nonverbal cues, etc.) vary from culture to culture. It is important to consider the individual's background and cultural needs when determining deficits and addressing goals related to pragmatics. See ASHA's Practice Portal page on Cultural Competence for more information. See also ASHA's Practice Portal page on Social Communication Disorder.
Treatment for prosodic deficits focuses on variations in pitch, loudness, and rhythm—the suprasegmental features of communication that convey meaning. Treatment may address expressive deficits (i.e., difficulty using prosody to express feelings, emotion, and tone) or receptive deficits (i.e., difficulty interpreting prosodic features in the speech of others). See, for example, Leon et al. (2005), Rosenbek et al. (2004), and Rosenbek et al. (2006).
Direct treatment approaches to improve prosody include
Treatment can also involve the use of compensatory strategies, including
Treatment for cognitive deficits that have an impact on language following a right hemisphere injury focuses on attention, memory, and executive functioning (see, e.g., Tompkins, 2012).
SLPs engage in professional practice in all areas that impact communication, including cognition (ASHA, 2016b). The cognitive treatments listed in this section utilize language-based materials and tasks and focus on the ultimate goal of improving communication.
Direct approaches are aimed at improving one or more types of attention (sustained, selective, alternating, and divided). These approaches include
Metacognitive and compensatory strategies help the person sustain attention to a task or goal until it is completed. They include
Environmental modifications are changes to the environment aimed at minimizing distraction. They include
Treatment for memory deficits typically are compensatory in nature. They include the use of external reminders and internal strategies.
External reminders include
Internal strategies include
Treatments for executive functioning deficits are functional in nature and typically focus on skills like solving problems, thinking flexibly, setting and completing goals, staying on task, and keeping organized. They include the use of metacognitive and compensatory strategies (see, e.g., Sohlberg & Turkstra, 2011) and environmental modification.
Metacognitive and compensatory strategies include
Environmental modifications to facilitate organization include
Unilateral neglect is considered to be an attention disorder, and it frequently occurs with anosagnosia. Unilateral neglect can affect visual, auditory, tactile, and olfactory modalities as well as movement. This treatment section focuses on left visual neglect, particularly as it affects language processing and communication.
Treatments to increase awareness and consequences of deficits include
In addition to determining the optimal treatment approach for individuals with RHD, other factors include the availability of specific types of services in a particular region, insurance coverage, pattern of recovery, potential for returning to school or work, and service delivery options, including the following:
This list of resources is not exhaustive and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA's Practice Portal is developed through a comprehensive process that includes multiple rounds of subject matter expert input and review. ASHA extends its gratitude to the following subject matter experts who were involved in the development of the Right Hemisphere Damage page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association (n.d). Right Hemisphere Damage. (Practice Portal). Retrieved month, day, year, from www.asha.org/Practice-Portal/Clinical-Topics/Right-Hemisphere-Damage/.