Right Hemisphere Brain Damage

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Differences in cognitive styles between right and left hemisphere:

Back 1

- both hemispheres participate in most intellectual functions but make separate contributions to final cognitive accomplishments

- each hemisphere has unique capacities and functions but acts in concert with the other hemisphere under normal circumstances.
Each hemisphere produces a unique pattern of deficits/preserved abilities when damaged.

Front 2

Anatomical differences between RH and LH

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Gross anatomical asymmetries between hemispheres

· -configuration of Sylvian fissures:

· -fissure divides temporal lobe from frontal lobe.

· -On LH, fissure continues smoothly posteriorly, whereas on RH, fissure angulates superiorly in posterior region, creating larger planum temporale on left and larger inferior parietal region on right

· -asymmetries in cerebral ventricles:

-larger left-sided lateral ventricles in most people [larger third frontal convolution on LH than RH (Broca's area)]

** -Right hemisphere has a larger frontal lobe than the left hemisphere

· -Gross differences between LH and RH are visible in 30 week old fetuses

· -Most asymmetries involve regions of brain concerned with language with bias toward increased size of left temporal and inferior frontal regions.

· -RH posterior regions are larger than left as these are areas concerned with visuo-spatial functions.

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Behavioral Characteristics Associated with RHBD Syndromes

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RH lesions typically do not produce aphasia and/or linguistically-based symptoms whereas LH lesions do.Most of the communicative problems associated with RH brain-damage are a product of concomitant cognitive deficits (Individuals with RH BD typically have cognitive-communicative disorders). These individuals can vary significantly relative to the nature and severity of their cognitive-communicative disorder. These varying problems arise from a variety of deficits including impairments in perception, attention, memory, and executive functioning.

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Perceptual Disorders

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Deficits in perceiving visual or auditory information frequently occurs following RH BD. Sometimes these are the underlying basis of language symptoms.

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Visual Perceptual Disorders:
Hemi-spatial Neglect

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o failure of patients to detect/report/orient to stimuli in one hemisphere usually following damage to RH structures.

o We do still have neglect following LH structures, however, it’s difficult to identify because they are linguistically impaired due to aphasia; they do not have the ability to tell us they are having negthe neglect is low on the list of important in these individuals

o Disorder of directed attention.

o Neglected hemi-space is contra-lateral to lesion side occurring with parietal, frontal, and/or sub-cortical lesions but it is more severe and long-lasting with parietal lesions.

o Patients may fail to attend to auditory, somato-sensory, and visual stimuli on one side, typically the left side of space.

o Although neglect is most obvious when it affects attention to visual information, it can negatively affect processing in auditory and somato-sensory modalities.

o If defect is mild, neglect is only evident where both sides are stimulated simultaneously (sensory extinction to simultaneous stimulation).

o With more severe cases, all lateralized stimuli go undetected

o fails to orient to stimuli originating in neglected hemi-space.

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Symptoms of Hemi-Spatial Neglect:
Hemi-Inattention is...

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a symptom of neglect in which there is poor response to or report of stimuli presented contra-laterally in the absence of sensory impairments or poor performance of tasks/activities in the contra-lateral hemi-space that cannot be attributed to motor impairments.

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symptoms of hemi-spatial neglect:
this spatial problem can result in...

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may copy only one half of model or omitting details from left side of drawings, will cross out lines only in non-neglected hemi-space (visual cancellation task); may read only one half of words/sentences (hemi-alexia or neglect dyslexia).

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Symptoms of Hemi-Spatial Neglect:
Neglect dysgraphia...

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Neglect dysgraphia refers to writing problems related to neglect

o (failing to cross or dot letters, etc., leaving large left side margin on page which increases as patient progresses writing down page).

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Symptoms of Hemi-Spatial Neglect:
Hemi-akinesia & Allesthesia...

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Hemi-akinesia is another symptom of neglect (sometimes referred to as motor extinction or impersistence):

o person under uses or never uses left side of body even in absence of hemi-paresis.

o Signs include poor balance, failing to evade painful stimuli, difficulties completing bilateral tasks, and minimal exploration of the left hemi-space with left hand or limb.

· Allesthesia:

o another neglect symptom when patients report being stimulated on their right side when they were actually stimulated on their left side.

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Hemispatial Neglect:

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Neglect also can occur with LH Brain Damage but neglect associated with RH BD is much more severe and enduring because of the RH’s relative dominance for allocating attention to both hemi-spaces.

· Neglect usually resolves over time but is still detected years later

· Neglect is independent of visual field deficit which is an acuity problem.

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Visual Perceptual Disorders:
Anosognosia

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may minimize deficits/joke about them (anosodiaphoria), ownership of limbs to someone else (somatophrenia), hatred of limb (misoplegia). Anosognosia is related to depressed executive functioning and often accompanies neglect. It is more common for patients to have limited awareness of their cognitive rather than motor or sensory impairments.

o denial of illness.

o Most commonly occurs with right parietal lesions

o usually involves contra-lateral hemi-paresis

o Visual field deficit

o may vary from underestimation of deficit degree or denial of abnormality.

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Associated with Anosognosia

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In general, executive function deficits following RH BD are more common in patients with damage to the frontal lobe or to connections between the right frontal lobe and sub-cortical structures such as the thalamus. They can include deficits in planning, cognitive flexibility, problem solving, and inhibition.

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Visual Perceptual Disorders

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1. Achromatopsia
2. Environmental Agnosia
3. Facial recognition defects

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achromatopsia

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loss of color vision limited to hemi-field contra-lateral to lesion. Result of anterior occipital lesion (RH PCA)

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Environmental Agnosia

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loss of environmental familiarity, inability to become oriented topographically even in familiar surroundings. Patient can see/describe environment accurately, and intellect and memory are intact. Deficit due to inability to match intact perceptions with preserved memory stores (percept stripped of meaning); usually due to temporo-occipital lesions.

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Facial Recognition Defects

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problems with recognition of famous faces, matching identical faces. These problems occur with posterior RH lesions. Prosopagnosia: failure to recognize familiar faces attributable to bilateral posterior lesions or RH parietal occipital lesions.

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Visual Motor Diorders:

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1. Constructional disability
2. Dressing disturbance

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Constructional Disability

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difficulty in drawing spontaneously, copy figures, assemble block models, reproduce geometric patterns. Usually due to posterior lesions; can occur with both RH or LH lesions:but RH damage results in tendency to neglect left half of models, add materials, and/or make errors in spatial relationsLH lesions result in simplified drawings.

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Dressing Disturbance

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failure to dress one half of body and/or patient has difficulty aligning body and clothes appropriately. Due to right parietal lesions.

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Affective Emotional Disorders:

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aprosody: anterior lesions may result in impaired prosody without affecting propositional verbal output.impaired affective auditory comprehension: comprehension of prosodic/affective elements of speech (have no impairment in propositional language comprehension; therefore, this disorder may contribute to patients’ literalness; due to parietal lesions. disturbances of emotional facial recognition: difficulty recognizing/interpreting emotional expressions; altered emotional facial expression: RH lesions may impair facial display of emotional expression.

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Attention Disorders

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Already discussed neglect which is a disorder of directed attention. All aspects of attention including sustained attention, focused attention, attention-switching, and divided attention may be impaired. They are often the source of many communicative symptoms in RH BD.

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Memory Disorders:

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RH BD has been associated with impaired temporary and long-term recall of nonverbal more so than verbal material. Difficulty encoding and remembering visual information such as complex designs, faces and facial expressions, and spatial locations and route. Also, auditory information such as rhythm or tune of a song or information presented in other sensory modalities. Patients with RH frontal lobe damage may show problems remembering the temporal order of the to-be-recalled nonverbal information or show a source memory deficit. Some verbal memory deficits have been noted in auditory-verbal working memory correlates with poor performances on discourse comprehension tasks involving contextual discrepancies or revising linguistic inferences.

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Memory Disorders (2):

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nonverbal amnesia: temporal lobe lesions may affect recall of nonverbal visual material.paramnesia: disorder of spatial orientation. Substitution of people and places for real situation. Confabulation syndrome: combination of impaired spatial perception, poor visual memory due to parietal lesions.

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Overall Impairment in RH brain damage

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1) RH damage does not disrupt a set of symbolic behaviors

2) Adequate linguistic system with phonology, syntax, and lexical choice intact

3) RH damage interferes with a more general response to experience

4) That is, RH patients have some specific linguistic deficits but are overly dependent on their linguistic system, using it to respond based on faulty/inadequate perceptions.

5) RH patients show a breakdown in comprehension/expression of complex contextually based communicative events

6) Use of contextual cues is not intact

7) synthesis of verbal information is impaired

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Linguistic/Communicative Impairments in Right Hemisphere Brain-Damage

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· SO, their communication problems are sort of the INVERSE of what you see in aphasia

· Whereas aphasia is associated with impaired phonological, lexical, and morpho-syntactic processing but relatively preserved pragmatic abilities, RH BD is associated with relatively intact phonological, lexical-semantic, and morpho-syntactic processing but show compromised pragmatic skills

· RH BD patients are typically capable of communicating breakdowns in more complex, less structured and abstract communicative situations

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Linguistic Disorders of RHBD:

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1) May make straightforward errors on expressive/receptive language tasks such as naming, word discrimination, following simple commands, word/sentence reading, writing

2) These deficits are not major source of RH communicative impairment

3) on aphasia batteries, deficits on these types of tasks have been found due to visuo-spatial defects, neglect, and attention disorders

4) Picture stimuli used to assess naming, word discrimination may place burden on visual perceptual system

5) reading/writing deficits are clearly due to perceptual disturbances and neglect.

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Pragmatic Disorders in RHBD:

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1) Refers to use of language in linguistic and situational context

2) understanding what is meant from what is said based on contextual framework of words and the actual communicative exchange itself.

3) attention and perceptual deficits associated with RH damage affect all levels of experiential processing

4) (BASIS of PRAGMATIC DEFICIT) Patient's failure to use contextual cues stems from:

a) Difficulty in evaluating the significance of sensory input

b) In associating it with prior knowledge, and

c) integrating multiple features of experience into a meaningful pattern

5) patient tends to react to literal rather than intended meaning (due to intact linguistic system)

6) That is, reacts to what is said rather than what is meant.

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Pragmatic Disorders in RHBD cont.:

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4) Patient confabulates to make sense out of experience/perception of the world

5) may fail to recognize critical information and include tangential detail

6) deficits in integrating information may result in impaired ability to create an organizational framework for the messages patients sends or receives (they miss the point or get main ideas in conversation)

7) they miss the point or get main ideas in conversation.

8) literal interpretations of words/actions occurs when stimuli are taken out of context

9) failure to appreciate context inhibits ability to draw inference or get intended meaning

10) RH patients have been observed to demonstrate impaired performance in interpreting metaphors, to interpret story outcomes, particularly when based on idiomatic expressions, or to infer moral of a story.

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Pragmatic Disorders in RHBD cont:

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4) these patients tend to itemize bits of information and fail to distinguish their relative importance or recognize relationships among bits of information.

5) also have impaired sense of humor

a) Again approaching experience in most literal manner

b) straightforward explanations of figurative, humorous and affective material.

16) (PRAGMATIC IMPAIRMENT AFFECTING SEMANTIC FUNCTIONING) RH patients rely on denotative aspects of words when putting them in clusters whereas aphasic patients have been found to rely on connotative meaning of words at expense of denotative meaning

a) therefore, literalness of RH patients may also be due to an inadequate sense of the connotative meanings of individual words

b) connotation implies several meanings, denotation refers to a single meaning

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Pragmatic Disorders in RHBD cont:

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15) RH patients can often give accurate verbal explanations of idioms but fail to appreciate/apply meaning in actual communicative events.

16) (PRAGMATIC IMPAIRMENT AFFECTING DISCOURSE FUNCTIONING) appreciation of context deficits

a) related to an impairment in ability to determine relationships and stimulus significance

b) therefore, they focus on detail and miss the point.

17) deficits in generating an overall structure for discourse

a) due to failure to integrate information and extract an interpretation of events

b) leads to inclusion of tangential and irrelevant information in verbal expression of RH patients.

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Pragmatics & Discourse in RHBD: Comprehension

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· so, relatively to pragmatic and discourse levels of processing, there are deficits in comprehension and expression

· in terms of comprehension, difficulties are observed in:

o appreciating humor

o comprehending non-literal language

o sensitivity to and interpretation of cues related to communicative context and partners

o resolving lexical ambiguity based on previous world knowledge or current communicative content and context

o inferencing/revising of preliminary inferences

o differentiating between relevant and irrelevant information

o identifying the moral or theme of a story

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Pragmatics & Discourse in RHBD: Expression

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· in terms of language expressing, informativeness and efficiency of spoken and written output may be affected by deficits such as:

o inefficient organization and summarization of information

o inclusion of tangential or irrelevant details

o problems with the cohesion and/or coherence of their discourse

o confabulation or inclusion of fabricated verbal information

o inaccurate or incomplete discourse framework or macrostructure

· all of these comprehension and production symptoms are increased as the cognitive demands of the communicative task or context increase

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Processing Deficits Affecting Pragmatics & Discourse in RHBD

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· the processing deficits underlying the pragmatic and discourse level problems observed with RH BD patients have been varied

· some researchers suggest that other cognitive deficits in attention and working memory cause or contribute to these problems

· another hypothesis is that RBH BD patients have difficulty suppressing word meanings or discourse interpretations that are irrelevant to incompatible with the communicative context

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Assessment of Impairment in RHBD:

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a. Right hemisphere lesions interfere with general processing capacities

b. Attention, perception, organization, orientation, memory, and integration

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Observational Assessment:

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1. Initially, make some summary regarding behavioral observations, possibly in a one-t-one interview in a quiet environment as well as distracting environment

2. Also 3-way interview with family member or other professional

3. Scale behaviors on a rating scale or describe behaviors

4. Focus on attention

A. Look at patients’ ability to focus/sustain attention

B. Also can patient effectively shift attention or impulsively responds to stimuli

5. Focus on eye contact

A. Patients’ ability to focus initially on speaker

B. Use appropriate eye contact

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Observational Assessment cont:

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1. Focus on awareness of illness – patients’ reaction to/awareness of illness/specific deficits

2. Focus on orientation to place

A. Investigate presence of paramnesia, environmental agnosia

B. Use map reading task, maze-solving task

3. Focus on orientation to time: knowledge of time concepts as well as ability to monitor passage of time should be investigated

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Observational Assessment cont:

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1. Focus on orientation to person

A. Ability to recognize persons/familiar faces

B. May also rely on family/hospital reports

C. Also can have patient identify pictures of familiar people (family, friends, staff, etc.)

D. Attending neurologist will usually diagnose prosopagnosia

2. Focus on facial expression: can individual appropriately display positive/negative emotion

3. Focus on intonation

4. Focus on topic maintenance: can patient maintain topic during dialogue

5. Most of these behaviors examined in more depth through more formal testing: RICE/RICE-R (has a rating scale and interview format that can be used to assess some of the behaviors)

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Audiological Assessment

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1. Pure-tone evaluation

2. Also have more extensive assessment looking at auditory attention and perception

3. Also conversational word discrimination tests

4. Auditory localization and tracking tests

5. Auditory recognition for verbal and nonverbal stimuli (sound/picture, sound/object association tasks)

6. Ability to discriminate pitch, intensity, and temporal patterning

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Visuo-perceptual testing

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1. VFD by neurologist

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Visual Neglect of LH assessment

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a. Usually carried out by neurologist (involves testing for extinction to stimultaneous stimulation)

b. Also speech/language pathologist, OT, and neuropsychologist collect additional data through copying or drawing symmetrical objects (clock, flower, man)

c. Also having patient perform visual scanning tasks (some on RICE-R)

d. Visual cancellation tasks

e. Line bisection tasks (line is anchored at each end by letter which patient is asked to read aloung before bisecting line. Patients with neglect will tend to mark midline to right of true midline)

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Examine visuo-spatial deficits or tasks that do not require motoric response.

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1. One test is Motor-Free Visual Perception Test (Hammill): looks at visual discrimination, visual memory, visual closure, figure ground spatial relationships

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Examining Visual Motor Disturbances

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a. Use Dvelopmental Test of Visual Motor Integration (Beery): looks at integration between visual perception and motor behavior

b. Developmental Tests of Visual Perception (Frostig): looks at eye-motor coordination, figure-ground perception, constancy of shape, position in space, and spatial relationships

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Assess spatial orientation and organization

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a. Spatial Orientation memory Test (Wepman): looks at retention and recall of spatial orientation of forms

b. Hooper Test of Visual Organization

c. Revised Visual Retention Test (Benton): uses reproduction of designs to assess visual perception, memory, and visuo-contructive abilities

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Language Testing

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1. To look at what we truly consider language functions, may want to do full language assessment

2. Administration of BDAE, Token Test, Reporters Test, WAB, BNT

3. These tasks are context-free and assess straightforward language processing

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Reading Skills

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1. Do not want to administer standard reading test until patient shows the appropriate visuo-spatial and perceptual prerequisites

2. Woodcock Reading Mastery Tests (letter/word identification, word attack, word/passage comprehension)

3. Gates-Macginitie Reading Tests (reading vocabulary and comprehension)

4. Nelson Reading Tests

5. Also Gray Oral Reading Test (GORT-4) and Grady Silent Reading Test (GSRT) or the newer Gray Diagnostic Reading Tests (GDRT-s)

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Writing Skills

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1. Most standard aphasia tests will address

2. Copying sentences containing all letters of alphabet (identify any poorly formed letters)

3. Spelling words to dictation (include words of varying length, familiarity, control degree of phonetic spelling correspondence)

4. Writing short narrative through story or picture description (assess spatial organization on page, legibility, sentence composition skills)

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. Assessing prosodic/nonprosodic affective disturbances

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1. Nonprosodic

2. Prosodic production

3. Prosodic comprehension

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Prosodic Comprehension

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a. Have patient judge mood or discriminate moods from other heard on tape

b. Also have patients indicate sentence types (questions vs. statements)

c. Have patients point to pictures which vary in meaning according to syllabic stress

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Prosodic production

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a. Have patient produce a particular mood while producing neutral sentences

b. Also have patients produce different types of sentences using same format

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Nonprosodic

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a. Have patient name emotions conveyed in picture stimuli

b. Have them match emotions (use situations as well as facial expressions)

c. Also ask patients to produce expressions on command

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Assessing Pragmatics

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1. Want to assess ability to integrate/assosciate verbal/nonverbal information

2. Categorize/organize information

3. Use of contextual cues

4. Interpret beyond literal expression

5. Examine spontaneous discourse to look at pragmatic conversational rules

6. RICE-R has a scale of pragmatic communication skills that examines:

a. Nonverbal communicative behaviors (gesture, intonation)

b. Conversational skills (turn-taking, initiating conversation, examining patient’s ability to use different speech acts, also assess length of patient’s turn in conversation)

c. Ability to use linguistic context to maintain a topic and sensitivity to given/new distinction (use of shared knowledge between speaker and listener: presupposition)

d. Referencing (referring to objects and actions clearly)

e. Ability to organizae narrative in retelling story or joke

f. Completeness of details required to make a point (can give patient sentences to arrange into paragraphs, picture cards in sequence, solve problematic situations)

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Integrative Skills

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1. Ross Test of Higher Cognitive Processes: which examines abstract and critical thinking

2. DTLA: especially pictorial absurdities, verbal absurdities, likenesses/differences

3. Also explaining idioms, proverbs, metaphors (on RICE-R)

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Assessment of calculation skills

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1. Want to examine integration skills required for verbal problem-solving

2. Math subtests on BDAE or Woodcock Johnson Psycho-educational

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Battery Achievement Tests:
Specific Formal Tests

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1. Mini Inventory of Right Brain Injury
2. Ravens Coloured Progressive Matrices
3. Right Hemisphere Language Battery - 2
4. Western Aphasia Battery
5. New York University Battery
6. Discourse Comprehension Test
7. Hooper Visual Organization Test
8. Rivermead Behavioral Memory Test
9. Memory Assessment Clinics Self-Rating Scale
10. Behavioral Inattention Test
11. Test of Everyday Attention

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Mini Inventory of Right Brain Injury

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a. Mini Inventory of Right Brain Injury (MIRBI) (Pimental & Kingsbury): this is a standardized quick screening for right brain injury that provides a severity index and deficit profile

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Ravens Coloured Progressive Matrices

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a. Ravens Coloured Progressive Matrices (RCPM) (or Standard Progressive Matrices) (Raven)

1. Nonverbal test of reasoning, visual spatial functioning, and intellectual capacity

2. Complexity of solving and/or completing each matrix or figure sequentially increasing in difficulty throughout the test

3. Correlates highly with Test of Intelligence

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Right Hemisphere Language Battery

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a. Right Hemisphere Language Battery – 2 (RHLB) (Bryan): a generalized measure of right hemisphere function examining discourse production, humor appreciation, lexical/semantic recognition, and inferred meaning

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Western Aphasia Battery

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a. Western Aphasia Battery (WAB) (Kertesz)

1. A comprehensive standardized test of aphasia, discussed last semester

2. The broader measure used on this test, referred to as the Cortical Quotient (CG) may be used as an overall measure of cognitive ability in regard to right hemisphere functioning

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New York University Battery

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a. New York University Battery (Gordon)

1. A series of normative data on a variety of standardized and experimental tools with right hemisphere brain-damaged adults

2. Areas investigated include visual scanning deficits and visual inattention, basic activities of daily living, sensory-motor integration, perceptual/visual integration, higher cognitive functions, linguistic and cognitive flexibility, and evaluation of affect stat

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Discourse Comprehension Test

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a. Discourse Comprehension Test (BRookeshire & Nicholas)

1. Test assesses comprehension and retnention of spoken narrative discourse

2. The test examines comprehension regarding stated and implied main ideas and details

3. Designed to identify problems that may affect daily life function

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Hooper Visual Organization Test

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a. Hooper Visual Organization Test (Hooper)

1. A measure examining visual perception and integration of disarranged line drawings

2. The individual is responsible for labeling the overall drawing

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Rivermead Behavioral Memory Test

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a. Rivermead Behavioral Memory Test

1. Quick measure of everyday memory abilitiles which includes items such recalling a route, or remembering a name

2. Also explores prospective memory: patient’s ability to remember to do something after varying amounts of time have passed or when a specific cue occurs. It also looks at a topographical memory along with other aspects of everyday memory

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Memory Assessment Clinics Self-Rating Scale

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a. Memory Assessment Clinics Self-Rating Scale

1. Measure that evaluates meta-memory or one’s insight into one’s own memory function

2. This is a questionnaire about the nature and frequency of memory failures experienced in daily life

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Behavioral Inattention Test

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a. Behavioral Inattention Test

1. Comprehensive standardized measure for assessing unilateral visual neglect

2. Includes conventional subtests to evaluate neglect as well as other subtests that examine the types of everyday problems that are likely to occur as a result of varying degrees of neglect

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Test of Everyday Attention

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a. Test of Everyday Attention:

1. Standardized test that assess selective and sustained attention and alternating attention via use of map, telephone lottery, and elevator counting

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Nonverbal Memory Tests:

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1. Rey's Visual Design Learning Test
2. Rey-Osterrieth Complex Figure Test
3. Continuous Visual Memory Test

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Rey Visual Design Learning Test

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A. Rey’s Visual Design Learning Test:

i. Requires patients to learn a series of 15 visual designs over several trials, thus assessing visual learning and recall

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Rey-Ossterrieth Complex Figure Test

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A. Rey-Osterrieth Complex Figure Test:

i. Copying (examining visuo-perceptual and construction skill) and then recalling after various delays, a complex abstract design (assessing immediate and delayed visual memory abilities)

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Continuous Visual Memory Test

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A. Continuous Visual Memory Test

i. Examines immediate and delayed visual memory by requiring patients to view a series of complex abstract designs

ii. Indicates whether designs are “new” or “old” (previously seen, some after a delay)

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Education of Family and Staff

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Should be instructed about nature of patient's limitations and expected course of recovery.Prior to enrolling patient in treatment program, patient should be medically stable, physically able to tolerate sitting upright, aware of external environment, and responsive to external stimuli.

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Overview of Treatment

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At all levels of treatment, clinician will need to control patient's impulsivity and control therapeutic environment through manipulating amount of competing stimuli. Prior to initiating any new phase of treatment, clinician should objectively measure change in a way that the patient can understand.

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General Guidelines for Communication Management

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Emphasis on communication; routinize daily schedules; organize home/therapeutic environment to aid memory; use verbal mediation to compensate for visual impairments; supplement direction with repeated verbal cues; establish attention before giving directions to patient; encourage individual to plan out a task (breaking it up into smaller steps); encourage patient to slow down to decrease impulsivity; Draw attention to visual reference points in a room; redirect attention to other activity when patient has negative outbursts

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Areas of Emphasis: Attention
Increase Attention Skills

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begin with an easy non-frustrating task increase complexity slowly while maintaining achieved level of attentionIncrease patient's ability to focus attention to taskShift attention set from one modality to another from task to taskSustain attention for longer periods of time

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Treatment: Attention

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Incorporate functional attention tasks that resemble patient’s everyday communicative and cognitive activities into treatment.To improve eye contact and visual gaze, emphasis should be placed on physical manipulation of patient's head, use of gestural cues, use of verbal cues. To focus the patient's attention to task in environment with competing stimuli, use variety of simple pointing tasks with auditory (opening door to hall, radio background noise, etc.) and/or visual competing stimuli (pictures on wall, etc.).

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Shifting Attention

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To shift attention set, vary input modes for same task, vary stimulus materials, vary response requirements. To shift attention from speaker to speaker, bring second person into session. To shift attention from task to non-task, introduce controlled interruptions.

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Directed Attention as a result of Neglect

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Environmental or task modifications: Drawing a red line down the neglected side of a page to assist reading, placing a brightly colored bracelet or sweatband on the patient’s neglected wrist to encourage visual attention to that side of the body, putting a flashing light on the neglected side of a clothes closet. These may all be helpful for individuals who have little awareness of their neglect.

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Treatment: Neglect

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Other approaches that provide the patient with the impression that their environment has been shifted towards their neglected side include: Monocular eye patching: blocking or shading the lens of the non-neglected side. Hemi-spatial sunglasses: shading the lens of the non-neglected side. Prism lenses: with wearing, cause a natural adjustment of eyes in which visual focus shifts toward the neglected side. Exciting vestibular organs on neglected side via ear irrigation or visual motion stimulation.

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Neglect/Directed Attention

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Neglect improvement may dissipate after these devices or stimulation have been removed unless the patient has had intensive and prolonged exposure to device/stimulation. This is expected as these adaptations do not fix the patient’s neglect but instead change variables in the environment, modify task demands, or alter visual input. These modifications are most appropriate for patients not responding to other treatments, those with severe deficits who are not candidates for other treatments, or reducing the effect of neglect while patient is undergoing treatment for other cognitive or linguistic impairments. Neglect treatment also involves remediating cognitive problems that contribute to the neglect. Treatment aims to increase their active attention to the neglected side. Patients practice activities in which they demonstrate neglect and during the practice, clinicians provide cues (verbal, visual, auditory, tactile) to encourage attention to their neglected side. Over time, clinician cuing can be faded as performance improves. Patients should also be taught to cue themselves; this can be implemented as long as patients are sufficiently aware of their neglect and the consequences of their neglect.

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Neglect/Limb Activation

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Limb activation is a technique that patients can learn as a self-cue/strategy to help decrease neglect symptoms. Patients are trained to move some part of the neglected side of their body in the neglected hemi-space while they complete daily activities that are negatively affected by their neglect. The limb movement is proposed to decrease neglect symptoms by increasing activation within neural areas of the damaged hemisphere that contribute to attention. As this is a cueing approach, training proceeds with the clinician initially reminding patients to use limb activation while they complete their therapy activities; when performance improves, clinician cueing is faded. Obviously, this technique is inappropriate for patients with dense hemi-plegia.

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Treatment: Orientation

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initially work on passive orientation, such as recognition of time of day, own belongings. Instruct patient to scan entire environment for relevant details. Then work on active orientation, using orientation skills to regain independence in the environment. Patient needs to be reminded to examine environment passively before initiating activities. To establish knowledge of basic biographical information, use visual supplements to aid patient in retaining facts as well as using repetition and manipulation of delays to retain the information.

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Treatment: Orientation cont

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To establish orientation to person, present audio recordings and photographs simultaneously of significant others. Then build visual self-cuing techniques. To establish passive orientation to place, present familiar objects, etc. in environment using verbal association cues. To establish passive orientation to time, use temporal aids to cue recognition of time factors. To establish active orientation to place, make a verbal plan to move around in environment. Use schematic representations with patient. To establish active orientation to time, estimate time of routine activities and move from simple to complex activities.

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Treatment: Perception

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use of multiple visual and verbal cues to orient to left, etc. Discrimination of environmental noises. Use visual and tactile markers to establish orientation to left. To develop visual scanning and tracking skills, use cancellation tasks and computer programs. To improve writing in regard to spatial orientation, use visual guides with eventual elimination of cues. To improve writing in regard to spelling errors, use visual closure tasks.

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Treatment: Pragmatics

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consider communication deficits at all treatment levels: to improve perception and use of prosody in regard to stress, identify/produce different words by syllabic stress patterns, use stress patterns to break words into syllables, identify and produce different rhythmic patterns. Specifically, for improvement in intonation and rate, show how these variables can be varied to convey different emotional states, interest levels, communicative intent, turn-taking signals, attention-getting signals, grammatical clarity. To improve perception of non-vocal cues, have patients identify/interpret negative/positive emotions in photographs, etc. To improve the use of contextual cues, teach situational context cues, such as various social constraints: different communication styles in different social situations.

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Treatment: Pragmatics cont.

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Use of role-playing, perspective taking, and group treatment incorporate meaningful contextual cues. Teach other situational context cues such as the use of deixis (sensitivity to speaker versus listener role) and sensitivity to shared knowledge between speaker and listener. Identify to patient violations in use of linguistic contextual cues (ambiguities in conversation, topic digression). Difficulties with figurative language and other forms of alternate or ambiguous meanings should be remediated by assuring appropriate awareness of linguistic ambiguity: clinician can identify examples of homographs, idioms, and metaphors, especially including consideration of the contexts in which each meaning is most likely to apply.

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Treatment: Pragmatics cont.

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Furthermore, the clinician can devise scenarios and have the patient determine the most appropriate interpretation of messages within a given context. Patients with discourse deficits will benefit from treatment activities that facilitate awareness of their coherence and cohesion errors (abrupt shifts in topic, vague use of reference, etc.) as well as understanding of strategies to enhance their coherence (topic introduction, topic maintenance) and teach cohesion devices in conversation (use of feedback, reference, contingent queries -- asking for clarification). Practice dialogue skills in regard to turn-taking, information gathering. Treating inference involves helping the patient become aware of implied meanings, similar to ambiguity.

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Pragmatics & Culture

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It is important to remember that pragmatic aspects of communication also are influenced by cultural norms and individual subjectivity. Cultural variations need to be considered when selecting treatment goals, activities, and stimuli. Pragmatic conventions of some cultures are sensitive to age or class differences between communication participants; some cultures may be more or less accepting of irony or sarcasm as acceptable communication styles. Furthermore, the nature of prosodic markings also differs across cultures and dialects.

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Treatment: Memory

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Focus on developing conscious awareness of the need to use strategies, identifying strategies useful to patient, and facilitating use of strategies. To develop facilitative/compensatory strategies, use memory book for retrieval of general information including information of daily schedule, personal events, significant others. Also use rehearsal and association strategies for remembering this information, particularly in meaningful contexts. In generalizing memory strategies, have patient use specific strategies in different settings, at different times, and with familiar as well as new people.

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Treatment: Integration

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To aid judgment and problem-solving, have patient plan how to carry out everyday tasks, formulate alternative solutions to single problem, anticipate responses to problem situations, identify inconsistencies (verbal and pictorial absurdities), role-playing of functional situations.

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Treatment: Organization

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To improve organizational skills in regard to sequencing, sequence words into sentences, letters into words, alphabet, sequence sentences into paragraphs and paragraphs into short stories, with familiar and unfamiliar activities. Also have patient prioritize specific items within activities of daily living, shopping list, things to do list, budget. Have patient learn to outline for specific professional functions.

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Treatment: Reasoning

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To improve abstract reasoning skills, practice deductive and inductive reasoning tasks (cause and effect relationships, analogies, drawing conclusions). Work on perceiving relationships (similarities/differences, categorizing, part-whole relationships), imagery tasks (interpreting visual symbolic materials, metaphors, similes, idioms), interpreting/appreciating humor (puns, anecdotes, double meanings).