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SPECIAL COMMUNICATION
Rehabilitation for Cognitive-Communication Disorders in
Right Hemisphere Brain Damage
Connie A. Tompkins, PhD
ABSTRACT. Tompkins CA. Rehabilitation for cognitive-
communication disorders in right hemisphere brain damage.
Arch Phys Med Rehabil 2012;93(1 Suppl 1):S61-9.
Although the left hemisphere of the brain has long been
linked with language, the right cerebral hemisphere also con-
tributes importantly to cognitive operations that underlie lan-
guage processing and communicative performance. Adults
with right hemisphere damage (RHD) typically do not have
aphasia, but they often have communication disorders that may
have a substantial impact on their social functioning. After a
brief summary of communicative and cognitive characteristics
of RHD in adults and of extant theoretical accounts of common
communicative difficulties, this article discusses rehabilitation
issues, approaches, evidence, and needs.
Key Word: Cerebral infarction; Communication disorders;
Delirium, dementia, amnestic, cognitive disorders; Language
disorders; Rehabilitation.
2012 by the American Congress of Rehabilitation
Medicine
T ANGENTIAL, LITERAL, aprosodic, verbose, socially
inappropriate, anosognosic, with unilateral neglect: these are
some of the communicative and cognitive characteristics that
typically come to mind for adults with brain damage restricted to
the right cerebral hemisphere (RHD). The primary goal of this
article is to describe rehabilitation issues, approaches, evidence,
and needs relevant to the communicative difficulties of this clin-
ical population. The discussion incorporates nonlanguage cogni-
tion and its treatment (eg, aspects of attention, memory, and
executive functioning), because nonlanguage cognitive perfor-
mance has been hypothesized and demonstrated to underlie, co-
vary with, or otherwise modulate communication in adults with
RHD.1,2 As such, rehabilitation approaches can and do focus on
nonlanguage cognition with the goal of effecting change in com-
munication. In fact, in light of these close links between cognitive
and communicative impairments, the constellations of communi-
cation deficits that emerge after RHD have been described as
cognitive-communication disorders.
To preface this discussion, the material below briefly defines
communication and cognition, summarizes communicative and
cognitive sequelae of RHD in adults, and reviews current
From the Department of Communication Science and Disorders and Center for the
Neural Basis of Cognition, University of Pittsburgh, Pittsburgh, PA.
Portions of this material were presented at the 2010 Clinical Aphasiology Confer-
ence, May 2327, 2010, Isle of Palms, SC.
Supported in part by the National Institute on Deafness and Other Communication
Disorders (grant no. DC010182).
No commercial party having a direct financial interest in the results of the research
supporting this article has or will confer a benefit on the authors or on any organi-
zation with which the authors are associated.
Correspondence to Connie A. Tompkins, PhD, Communication Science and Dis-
orders, University of Pittsburgh, 4033 Forbes Tower, Pittsburgh, PA 15260, e-mail:
tompkins@pitt.edu. Reprints are not available from the author.
0003-9993/12/9301S-00703$36.00/0
doi:10.1016/j.apmr.2011.10.015
theoretical accounts of common cognitive-communication dif-
ficulties.
COMMUNICATION AND COGNITION DEFINED
The term communication refers to the interpersonal ex-
change of ideas, information, needs, mutual understanding, and
the like. Communication can be intentional or unintentional,
and does not need to involve language (eg, may occur via facial
expression or tone of voice), though language is 1 form of
communication. Cognition can be defined as the collection of
mental processes and activities used in perceiving, remember-
ing, and thinking, and the act of using those processes.3(p10)
COGNITIVE-COMMUNICATION
DISORDERS IN RHD
This article opened with a list of characteristics that actually
are stereotypes of cognitive-communication impairments in
RHD. In fact, there is great diversity in this populations
presentation of cognitive-communication problems. Many in-
dividuals with RHD stay on track when they talk, are not
overly literal, have good intonational variation, and so on. This
diversity derives from many factors, no doubt including lesion
site and premorbid individual differences. The stereotypical
view of the patient with RHD probably results in part from
sampling bias: patients in research studies often are, or have
been, receiving rehabilitation services. As a result, these indi-
viduals are likely more impaired than the population as a
whole. In addition, many of the studies use metalinguistic or
metacognitive tasks, such as defining metaphors or idioms,
matching pictured facial expressions with vocal intonations, or
solving hypothetical, what would you do if . . . problems.
Such tasks, which require participants to consciously reflect on
or make judgments about communication or cognition, do not
reflect natural language, communicative, or cognitive process-
ing and may overestimate deficits.
With this in mind, table 1 summarizes some commonly
observed language, communication, and cognitive difficulties
in adults with RHD (Tompkins et al1 provides a detailed
discussion of these and other characteristics). There is very
little information on the prevalence of most of these difficul-
ties, in part because the research area is quite new. Estimates
suggest impairment in at least 1 aspect of communication and
social interaction in somewhere between 50%4 and 78%5 of
adults with RHD. There are almost no good estimates for
specific communication impairments. Aprosodia was recorded
in about 25% of charts for a sizeable inpatient rehabilitation
sample,6,7 but this estimate may be low, because many in the
List of Abbreviations
MSI metacognitive strategy instruction
RHD right hemisphere damage
ToM theory of mind
VST visual scanning training
WMCL working memory capacity for language
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S62 REHABILITATION FOR RIGHT BRAIN DISORDERS, Tompkins

Table 1: Some Commonly Observed Language, Communicative, and Cognitive Difficulties in Adults With RHD

Language
Discourse production
-Produce stories or explanations go off topic and/or end abruptly
-Supply vague referents, or none at all (eg, You look just like her, you know?)
Discourse comprehension
-Draw incorrect inferences/conclusions from what they read or are told, especially when there is some ambiguity in the
information
Conveying or interpreting intent (pragmatics)
-Have difficulty catching on to hints from others (eg, Im trying to concentrate here . . .; or comments that signal an end to a
conversation)
-May not soften requests of others by, for example, providing a reason or an apologetic opening (eg, Im sorry to bother you,
but do you have change for a dollar?)
General
-Have difficulty determining or designating relevant information
Communication
Expressive aprosodia
-Exhibit little modulation of vocal intonation
Receptive aprosodia
-Have difficulty interpreting emotions or intentions from other peoples voices
Social communication
-Exhibit communication that is inappropriate for the situation and/or communication partner (eg, telling off-color jokes in church)
Cognition
Attention
-Look around during conversation or testing
-Orient toward extraneous sights or sounds
-Interrupt others
-Appear to talk/act without thinking
-Have difficulty following lengthy instructions or conversations
-Exhibit uniliateral neglect (a constellation of disorders of spatial exploration and selective attention, that manifests primarily in a
directional bias for perception, attention, and/or action, and that cannot be explained by sensory or motor impairments)
-For example, bump into doorframes; have rightward gaze bias; crowd writing/drawing/copying onto right side of a page; lack
left-sided detail in copying/drawing from memory; omit left side of words, or of lines of text, when reading aloud; rarely
choose left-side response options, even with material placed rightward; leave food on left side of plate
Visual processing
-Have difficulty interpreting emotional facial expressions
-Have difficulty reading signs in the environment
-Have difficulty finding way to unfamiliar location
Memory
-Have difficulty recalling information recently heard or read
-Have difficulty drawing a complex figure recently copied
-Have difficulty following multiple directions
-Have difficulty remembering to bring belongings (eg, memory notebook, hearing aids)
-Have difficulty remembering to take medications
-Do not use memory strategies
Executive functioning
-Exhibit anosognosia (impaired awareness of deficits and/or reduced insight into how those deficits affect daily functioning)
-For example, statements appear to contradict physical/cognitive/emotional abilities, obvious changes in function are denied,
little attempt is made to self-correct, appear to lack awareness of social consequences of behavior
-Appear unmotivated
-Exhibit discrepancy between knowing (or saying) and doing
-For example, can explain steps in safe wheelchair transfer but do not apply them, and/or cannot describe a solution for a
hypothetical problem but act appropriately when actually confronted with that problem
-Have difficulty planning daily activities, organizing materials or activities, keeping records, adhering to checklists, organizing
schedules, keeping track of belongings, managing time
-Have difficulty monitoring behavior, sustaining appropriate behavior, adjusting behavior

sample were not referred for evaluation of cognitive-commu-
nicative difficulties. The same study reported, unsurprisingly,
that speech-language pathologists more often diagnose diffi-
culties in communication and interpersonal interaction than do
neurologists, neuropsychologists, and occupational therapists.
In terms of RHD cognitive deficits, estimates suggest a con-
siderable prevalence of difficulties in attention, neglect, per-
ception, learning and memory, and reasoning and problem-
solving (all affecting at least 50%8 and up to 68%6) of patients
evaluated.
Some of the problems in table 1 may have several roots. For
example, difficulty following multiple directions (eg, fold the

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 REHABILITATION FOR RIGHT BRAIN DISORDERS, Tompkins
paper in half and seal it in the envelope) could be due to
deficits in sustained attention rather than in memory or lan-
guage comprehension, and difficulty interpreting emotions
from voices may reflect problems with perceiving emotion
rather than impairments in decoding intonational cues. One
primary job of the clinician is to discern the underlying nature
of observed behaviors, to help shape behavioral treatment.
Given the vast range of normal in communication, another
crucial diagnostic task is to determine whether observed be-
haviors are significantly different from premorbid functioning.
Poor functional outcomes in the RHD population are clearly
associated with unilateral neglect9 and anosognosia.10 Other-
wise there is little literature linking RHD impairments to
broader outcomes. Nonetheless, many of these impairments
could be quite socially debilitating. For example, adults with
RHD may alienate or embarrass friends and family; experience
diminished participation in jobs or hobbies that require con-
centration or visual perception/construction; or lose indepen-
dence due to other peoples concerns about awareness and
safety.
Patients with RHD have cognitive-communication strengths,
as well (see, eg, Tompkins et al2). They have few if any
problems in comprehending or expressing language syntax
(grammar), morphology (eg, word endings), and/or phonology
(speech sounds), and as such do not have a classical aphasia.
Their lexical retrieval ability (eg, coming up with words they
want to use in conversation) is like that of age-matched healthy
individuals. If they have trouble naming pictures or objects it
may be due to visual-perceptual or visuospatial difficulties
rather than language problems. Among the other strengths of
the RHD population is an ability to profit from semantically
consistent information, as when an interaction sticks to a single
theme or topic, and to benefit from redundant input. Adults
with RHD also comprehend better when expressions that may
be difficult for them, such as metaphors (eg, the man is a
mule), are preceded by moderately-to-strongly biased linguis-
tic context (The man is stubborn. He never quits. The man is
a mule). Other cognitive-communication strengths are intro-
duced in the material below.
THEORETICAL ACCOUNTS OF COMMON RHD
COGNITIVE-COMMUNICATION DIFFICULTIES
This section briefly describes some current proposals about
the nature of RHD cognitive-communication deficits. These
proposals, which vary widely in scope, are not mutually ex-
clusive. The more general accounts are addressed first, 3 fo-
cusing primarily on language comprehension and 2 that are
more broadly based. This section ends with a brief discussion
of current thinking about the bases of expressive aprosodia.
Interactions and contrasts between accounts are also consid-
ered.
Cognitive Resources Hypothesis
Early accounts of RHD cognitive-communication disorders
emphasized domain-specific difficulties. That is, these disor-
ders were attributed to impairments in processing discrete
aspects of communication, such as figurative language, jokes,
prosody (intonation patterns), or inferential or emotional ele-
ments of incoming messages. The limited utility of this view
has been well-documented over the past 20 years. Patients with
RHD perform well in these problem domains when tested
indirectly or implicitly, using priming or word-monitoring
methods that require little or no meta-language or metacogni-
tion (see summary in Tompkins2). In addition, performance in
cognitively-demanding discourse conditions is predicted by
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interindividual differences in working memory capacity for
language (WMCL) (see summary in Tompkins2), a system
engaged in the simultaneous processing and storage of incom-
ing language information.
Together, these results underpin the first domain-general
account of typical language comprehension difficulties in
adults with RHD (see Tompkins2 for summary), a view dubbed
the cognitive resources hypothesis. More recent work from
other labs continues to support this view.11 This account spec-
ifies that in domains historically considered problematic for the
RHD population, comprehension varies substantially with the
attentional or working memory demands of a language task. In
addition, these results suggest that the right hemisphere con-
tributes mental resources to perform demanding language
tasks.
Coarse Coding Deficit Hypothesis
The right cerebral hemisphere is involved in mentally rep-
resenting and accessing word meanings to a greater degree than
originally thought. In a seminal study,12 young adults without
brain damage were briefly presented with ambiguous words
(eg, bank) that have more than 1 meaning. Visual targets, some
real words and some nonwords, were subsequently projected to
each visual field to assess how the brain hemispheres contribute
to processing word meaning. Participants decided whether or
not each target was a real word. The critical targets were either
related to the most frequent meaning of the ambiguous word
(money) or to a less frequent meaning (river). These same
targets also occurred in an unrelated condition, after a seman-
tically unrelated word. Measures of priming were calculated by
subtracting target response times in the unrelated condition
from those obtained for either related condition. These priming
effects reflect how readily the word meanings are mentally
activated in the brain.
When critical targets very rapidly followed the ambiguous
words, both frequent and less frequent meanings were primed
in both visual fields/cerebral hemispheres.12 However, with a
longer delay between ambiguous words and targets, the less
frequent meanings were primed only in the left visual field/
right hemisphere. This suggested that the right hemisphere
serves an important maintenance function for secondary mean-
ings of words.
More recently, this approach has been extended to examine
more distant features or meanings of words (eg, rotten as a
semantically distant feature of an apple,13 or more generally,
the connotative meanings of ambiguous words, if those mean-
ings are sufficiently distant from the dominant interpretation of
the word). This and other work (summarized in Beeman,14 and
Jung-Beeman15) highlights the role of the intact right hemi-
sphere in mentally activating and maintaining activation of
distant meanings or features of words, regardless of the larger
linguistic context. Beeman14,15 called this activation process
coarse semantic coding. He further proposed that figurative
language interpretation, some kinds of inference generation,
and other aspects of narrative (story) comprehension are sup-
ported by the overlapping mental activations that result from
coarse semantic coding. For example, a scenario like when
Sue called the lifeguard for help, he saw the broken glass can
yield the inference Sue cut her foot, due to remote associa-
tions between lifeguard (swim, bare feet) and broken glass.
Beeman14 (Jung-Beeman15) and others reasoned that RHD
would yield a coarse semantic coding deficit. Several recent
studies have documented this difficulty for some individuals
with RHD,16 manifest in reduced speed or accuracy to activate
or maintain particularly peripheral features or meanings of
words. In addition, this coarse coding deficit has been linked
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S64 REHABILITATION FOR RIGHT BRAIN DISORDERS, Tompkins
with poor comprehension of implied information in narratives
by adults with RHD, even after accounting for vocabulary
knowledge and WMCL.17 A majority of the patients who
displayed the coarse coding deficit had lesions that involved the
posterior parietal lobe, though this result is based on a small
sample.
Suppression Deficit Hypothesis
The suppression deficit hypothesis (see Tompkins1,2) is a
proposal about the nature of narrative comprehension difficul-
ties after RHD, extrapolated from work on normal language
comprehension across input media and modalities.18 During an
initial phase of normal comprehension, a wide range of inter-
pretive possibilities is mentally activatedfrom coarse coding
processes, linguistic knowledge, and knowledge of the world.
Shortly afterwards, a suppression mechanism18 dampens acti-
vation that is incompatible with the broader context (eg, for
The farmers pigs were crowded. He built a pen, the contex-
tually-inappropriate ink meaning of pen is initially active
but quickly suppressed). Suppression is often assessed in a
relatedness judgment task, in which participants indicate
whether a target word (ink) is related to its prior context. The
example above illustrates an assessment of suppression in the
case of lexical-level ambiguity (pen), but suppression function
has been examined in a variety of language forms and func-
tions, including ambiguous inferences and nonliteral language.
The suppression deficit hypothesis has 2 premises: (1) when
processing material that supports or induces competing inter-
pretations, some adults with RHD who activate those interpre-
tations will be delayed in suppressing whichever is contextu-
ally inappropriate, and (2) interindividual differences in
suppression function for such interpretations will predict com-
prehension of narratives by adults with RHD. Both premises
were borne out in a series of studies assessing lexical- and
inference-level interpretations (see Tompkins19 for summary).
In addition, the link between story comprehension and suppres-
sion function (which ranges from unaffected to quite delayed
for individual patients) is significant even after controlling for
vocabulary knowledge, WMCL, and age. These results impli-
cate the right cerebral hemisphere in processes of timely se-
lection from among competing interpretations.
Theoretically, coarse coding and suppression deficits could
co-occur in adults with RHD. The former would reduce or
delay the activation of meanings and features that are particu-
larly distant from the dominant meaning or image of encoun-
tered words (eg, rotten for apple). The latter would slow the
comprehension mechanism that dampens contextually irrele-
vant mental activation, regardless of considerations like seman-
tic distance. The suppression deficit hypothesis also intersects
with the cognitive resources view, in that effective suppression
requires attention (as summarized in Tompkins2).
Although the suppression deficit hypothesis derives from the
psycholinguistic realm, we20 have argued that ineffective sup-
pression could underlie a variety of the other difficulties in
table 1, such as incorrect inferences (eg, being led astray by the
ink meaning of the word pen in the example above) or
difficulty being relevant. Tompkins et al20 provides an ex-
tended discussion of the potential breadth of this account,
including its possible relevance for language production tasks
and other situations that engender multiple, competing mental
activations (eg, when different peoples points-of-view must be
considered and reconciled, to understand an action).
Pragmatic Deficits Hypothesis
The fourth, broader-based account centers on right brain
contributions to pragmatics.21,22 Pragmatics refers to the con-
Arch Phys Med Rehabil Vol 93, Suppl 1, January 2012
text-appropriate, social interpretation and use of language, and
many of the communication difficulties exhibited by patients
with RHD can be situated under this umbrella. Pragmatic
deficits may be less apparent in natural situations than research
suggests, because pragmatic difficulties usually have been doc-
umented with contrived, metalinguistic or metacognitive tasks.
For example, Tompkins described a group of patients with
RHD who failed on a task of talking about how they would
initiate a conversation with someone they did not know, just
after welcoming a newcomer with questions and conversa-
tion.23 Another example concerns the processing of indirect
requests, which are questions that serve as requests for action
(eg, Can you pass the salt?), but that when taken literally
require a yes or no answer. Metacognitive measures have
documented a deficit in this area, but adults with RHD re-
sponded appropriately when such requests were used as they
would be in a clinical setting (eg, Can you sign your name on
this sheet?24). The pragmatic deficits account intersects with
those described above, in that behavior that is pragmatically
deficient could be due to deficits in cognitive resource capacity
or its allocation, in coarse semantic coding, or in the suppres-
sion mechanism.
Social Cognition Deficit Hypothesis
A related account emphasizes deficits in social cognition.25
According to this view, RHD can impair broad cortical net-
works involved in empathy, the understanding of social infor-
mation, and the conduct of social relationships. This account
focuses on, for example, difficulty using contextually appro-
priate politeness conventions, or shaping communication based
on information about interpersonal relationships (eg, friends vs
boss vs family). Impaired reasoning based on a theory of mind
(ToM) also has been attributed to adults with RHD,26 though a
study with improved stimulus controls and lower metalinguis-
tic demand did not replicate a ToM deficit.27 ToM refers to an
ability to understand and interpret thoughts, beliefs, feelings,
and intentions both our own and those of othersto predict
and account for behavior.
The social cognition account is most easily distinguished
from the coarse coding deficit hypothesis, because the latter
emphasizes consequences of impaired word-level process-
ing. The cognitive resources or suppression deficit views,
however, may intersect with the social cognition account.
For example, reasoning based on ToM requires the activa-
tion and then reconciliation of multiple individuals knowl-
edge and perspectives. Thus poor performance on the ToM
assessment tasks may reflect a limitation in the availability
of cognitive resources to handle so much processing. Alter-
natively, difficulty reconciling the competing mental activa-
tions in such tasks may reflect a deficit in suppressing
activation that becomes less compatible with a final, inte-
grated interpretation.2,20 Nonetheless, the broader view of
potential social impacts of RHD is an important one that
merits further investigation.
Accounts of Expressive Aprosodia
As summarized by Rosenbek et al,28 the 2 major theories
of expressive aprosodia emphasize either a motor impair-
ment or a deficit in a modality-specific nonverbal affect
lexicon.28(p787) The motor deficit may reflect a difficulty
programming the movements of the speech mechanism that
are needed to produce gradations in pitch, loudness, and
duration, or in the actual execution of those movements. The
affect lexicon is conceptualized as a right hemisphere coun-
terpart to the left hemisphere verbal lexicon, as a vocabulary
 REHABILITATION FOR RIGHT BRAIN DISORDERS, Tompkins
of affective indicators that is presumably crucial for inter-
preting social signals.29 With its emphasis on social signals,
this theory may be at least partly subsumable under the
social cognition account.
REHABILITATION ISSUES, APPROACHES,
EVIDENCE, AND NEEDS
Rehabilitation Issues
As previously noted, the area of RHD cognitive-communi-
cation disorders is quite new, with the earliest systematic
research only about 30 years old. As such, there continue to be
a variety of challenges to research and rehabilitation. One is the
heterogeneity of symptom presentation. This problem interacts
with the lack of a sound definition of the disorders, to make it
difficult at times to know what characterizes the patients in
research studies. Other difficulties include a dearth of explicit,
testable models of the domains and systems that support inter-
personal communication; the vast range of normal in these
domains and systems, that can make it difficult to discern what
is disordered; and the still preliminary understanding of the
nature of these disorders, that creates a challenge for tailoring
treatments with the best chance of extra-clinic generalization
and important daily life outcomes.
Rehabilitation Approaches
In most clinical situations, the medical model still prevails:
clinicians identify and try to fix impairments. Increasingly,
however, skilled clinicians think beyond the level of the deficit.
The International Classification of Functioning, Disability and
Health30 reminds us to consider how health conditions limit
everyday activities and restrict habitual roles, and to take into
account relevant contextual factors. Similarly, a multidimen-
sional applied cognitive rehabilitation approach points us away
from the mere existence of deficits and toward the functional
impact of those deficits.31 This approach conceptualizes treat-
ment as a process of addressing obstacles to patients attain-
ment of their own goals. In this view, deficits are appropriate
for direct treatment only when they create meaningful obstacles
to goal attainment. Other obstacles may be factors outside of
the patients themselves.
Behavioral rehabilitation often has a restorative bent, aiming
to improve the underpinnings of deficient performance. A
renewed emphasis on restorative treatments has stemmed from
increasing evidence of brain plasticity, which seems to be
potentiated by intensive rehabilitation, even long postonset of
stroke (eg, Cornelissen,32 Meinzer,33 and colleagues). Treat-
ment also can take a compensatory focus, to work around
existing deficits.
Evidence
Evidence-based practice has been defined in various ways,
but in general involves applying the best available evidence to
solve clinical problems.34 Evidence-based practitioners select
treatments by considering research evidence, clinical expertise,
and patient preferences.34
There is extensive research evidence on treatments for uni-
lateral neglect, but otherwise, the evidence base for the RHD
population is just emerging. This section summarizes the best
available research evidence for difficulties associated with cog-
nitive-communication disorders in RHD. Treatments specifi-
cally tested on RHD samples are considered first in each
subsection. Evidence also is discussed briefly, when applicable,
for patients with behavioral similarities to the RHD population,
but due to other etiologies, most notably traumatic brain inju-
S65
ries. Most of the treatments investigated thus far have a restor-
ative orientation, aimed at alleviating deficits. In this work,
expectations vary for generalization to untreated behaviors,
domains, or situations.
Expert clinical opinion is available in a number of sources
(eg, Blake,21 Mackenzie and Brady,35 Tompkins and Gibbs
Scott36). In a few of the subsections below, expert clinical
opinion is integrated with research evidence. A preliminary
exploration of patient preference is reported in a recent study of
a treatment for self-awareness and self-regulation37; results of
this exploration also are described briefly.
Research on Treatment of Cognitive-Communication
Disorders in RHD
Evidence has begun to emerge for treatment of coarse coding
and suppression deficits, spoken interpretation of metaphor,
and expressive aprosodia (diminished vocal intonation). Read-
ing and writing outcomes are included in some of the treat-
ments for neglect, which are addressed under research for
treatment of cognition, below.
For inefficient coarse coding and suppression, preliminary
effects have been reported for 2 versions of a contextual
constraint treatment.38 The treatment addresses (the speed of)
these general comprehension processes, that, as described
above, may underlie many aspects of performance in adults
with RHD (eg, drawing and revising inferences, interpreting
figurative language, comprehending narratives). As such, the
effects of treatment are proposed to generalize more broadly
than treatments that target specific language forms, like meta-
phor.
The treatment is novel in being applied implicitly, for coarse
coding, or with little demand on cognitive resources, for sup-
pression. As such, it builds on well-documented strengths of
the RHD population.1,2 Treatment tasks replicate the research
tasks used to document the deficits, and differ slightly in the 2
versions of treatment. In the coarse coding version, the task is
simply to decide as quickly as possible whether a target string
of phonemes (speech sounds) is a real word or not. In the
suppression version, the task is to decide as quickly as possible
whether a target word fits with the meaning of a prior sentence.
There are 2 primary reasons to emphasize speed of response.
The first is because coarse coding and suppression deficits in
RHD typically reflect delays or inefficiencies, rather than out-
right failure of these processes. The second is to tap processing
that is relatively unaffected by metalinguistic strategies.
The treatment involves presenting simple context sentences
before a target word occurs, to bias or constrain the intended
meaning or feature of another word to the meaning or feature
represented by the target. To illustrate for coarse coding treat-
ment, consider the target rotten. To facilitate activation of
this distant feature of the word apple, a strongly constraining
context is first presented: The fruit smelled awful. It had
turned very soft. After this, the patient hears the experimental
stimulus There was an applerotten, and responds to indi-
cate that rotten is indeed a real word. (The task also includes
items with nonword targets). Similarly, for suppression treat-
ment, the biasing context He looked at his pigs. They were too
crowded is presented prior to the experimental stimulus He
built a penink. This context facilitates the context-appro-
priate interpretation of the ambiguous word pen and bolsters
suppression of the context-inappropriate, ink meaning.
This contextual prestimulation or priming sped target re-
sponses of 3 participants with RHD, a result proposed to reflect
the facilitation of coarse semantic coding and suppression
processes. While these initial data suggest that contextual con-
straint treatment may have promise, the true test of its value
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S66 REHABILITATION FOR RIGHT BRAIN DISORDERS, Tompkins
will come from data currently being collected on generalization
of treatment effects38 to the previously noted comprehension
consequences of coarse coding and suppression deficits (im-
provements in certain types of inferencing, interpreting nonlit-
eral language, and comprehending narratives) and to functional
reasoning tasks that involve competing options.
A highly metalinguistic treatment for novel metaphor (eg,
A family is a cradle) also has demonstrated preliminary
effects.39 Treatment activities include judging connotations of
the word-level concepts represented in the metaphors (Is a
family protective? Comfortable?); judging associations be-
tween these concepts (Are both families and cradles protec-
tive?); and generating associations between concepts (What
else do families and cradles have in common?). Spoken inter-
pretation of novel metaphors improved in quality for all 5
participants with RHD, with 3 maintaining their gains for 3
months. Nonliteral language comprehension improved in 1
patient.
Turning to expressive aprosodia, preliminary evidence is
available for 2 treatments targeting production of emotional
prosody. One is cognitive-linguistic in nature and the other has
a motor-imitative focus.40 The cognitive-linguistic approach,
derived from the affective nonverbal lexicon theory, involves
associating representations of emotion with one another (writ-
ten label, facial expression, prosody). The motor-imitative
treatment moves from maximal to minimal support in produc-
ing prosodic patterns (from clinician modeling to independent
production). Effects for 14 participants have ranged from slight
to sizeable, with no generalization to untrained emotions. The
same research group has combined the treatments and is eval-
uating the effects of adding knowledge of performance or
knowledge of results.41 Knowledge of performance is provided
by an auditory signal, a visual display, and discussion to
compare the display of the patients production with a target.
Knowledge of results involves telling the patient only whether
the production is correct or incorrect.
Research on Treatment of Cognition in RHD
Relevant treatment evidence is available for the areas of
attention, including neglect, memory, and executive function-
ing. A survey of this evidence base is highly pertinent to this
review, because, as described above, these cognitive deficits
have been demonstrated or hypothesized to predict, influence,
or underlie many of the communicative difficulties in adults
with RHD. As such, treatments for cognitive deficits hold
promise for improving language and communication in this
population. Communicative outcomes have been targeted in
some of these cognitive treatments, and in the future, should be
so targeted more often.
In the attention domain, a systematic review endorsed early
treatment of attention deficits as a practice guideline for stroke
patients; this review also cautioned against computerized drills
without a clinician.42 Unfortunately, this review and most other
relevant literature do not address right hemisphere stroke spe-
cifically. An exception is a small, single-blind randomized
trial43 investigating Attention Process Training44 in patients
with RHD. Attention Process Training is a comprehensive,
theoretically based treatment that targets sustained, selective,
alternating, and divided attention. Five weeks after treatment
ended, the experimental group performed better than a non-
treatment control group on tests of subtle selective attention.
Neglect, as noted previously, is the subject of many pub-
lished reviews and treatment studies, including a number of
controlled trials (for reviews, see Arene and Hillis,45 Bowen
and Lincoln46). One problem is that extant neglect treatment
studies likely mixed participants with various forms of neglect
Arch Phys Med Rehabil Vol 93, Suppl 1, January 2012
(viewer-centered vs stimulus-centered spatial neglect, spatial
vs motor neglect, combinations), necessitating cautious inter-
pretation of results and recommendations.
Visual scanning training (VST), targeting mainly viewer-
centered spatial neglect, has been endorsed as a practice stan-
dard.42 VST has many variants, but in general, requires patients
to consciously distribute their attention broadly, to targets that
appear in both visual fields. Improvement has been reported to
generalize to functional reading, writing, and motor tasks, with
long-lasting gains in some cases. Using more complex stimuli
seems to improve generalization effects.
The same systematic review42 recommended as a practice
option VST with electronic adjuncts (eg, a buzzer) or combined
with forced limb activation (typically provided for motor ne-
glect). Limb activation treatments generally involve initiating
movements of a left-sided limb, usually the arm, into left
hemispace. This active form of limb activation appears to yield
greater benefits than a passive version, in which the affected
limb is moved, by the patient or the clinician, into left space.
Substantial and durable gains have been reported even for a
patient with severe neglect.47 A randomized controlled trial
documented improvements from training that requires a patient
to use the left arm to deactivate a loudly buzzing alerting
device,48 though evidence of functional gains remains elusive.
Other approaches to the treatment of neglect use bottom-up
stimulation (eg, see Arene and Hillis,49 Luaut et al50) to target
patients who cannot voluntarily engage attention to treatment
tasks. Treatment effects are generally transitory, with prism
adaptation the potential exception. In prism adaptation, a sen-
sorimotor approach that induces procedural learning, the pa-
tient wears prism glasses or goggles that shift the left visual
field to the right. One study reported gains that lasted out to 6
months postonset.51 As noted by Arene and Hillis,49 patients
with right cerebellar damage may not be good candidates for
this treatment.
In a recent randomized controlled trial,52 a spatial explora-
tion treatment was combined with either of 2 bottom-up ap-
proaches: transcutaneous electrical nerve stimulation to left-
sided neck muscles, or optokinetic stimulation, using visual
stimuli that slowly moved to the left without eliciting nystag-
mus. A control group did only the spatial exploration. Greater
effects were reported for both combined treatments than for
spatial exploration alone, with generalization to simple reading
and writing tasks that maintained for a week posttreatment.
Several aspects of this study make it difficult to interpret the
results, however. For example, pretreatment reading and writ-
ing performance was significantly worse in the control group
than the other 2 groups. The control group also was potentially
more neurologically stable (mean, 44d) when treatment was
initiated (transcutaneous electrical nerve stimulation group
mean, 25d; optokinetic group mean, 36d), calling into question
contributions of spontaneous recovery. Finally, the spatial ex-
ploration treatment did not include complex scanning tasks of
the kind associated with better generalization in VST. Thus, the
jury remains out on the relative effectiveness of these treatment
approaches.
Exciting developments in neglect treatment are proliferating,
and initial evidence exists for constraint-induced movement
therapy53 and treatment via transcranial direct current54 or
repetitive transcranial magnetic stimulation.55,56 Dopamine and
norepinephrine agonists are also being examined as adjuncts, to
treat sustained attention, alerting, and arousal in patients with
neglect.57
Turning to memory and learning, a systematic review42
endorsed the training of external memory aids as a practice
standard for individuals with relatively mild impairments due
 REHABILITATION FOR RIGHT BRAIN DISORDERS, Tompkins
to stroke or traumatic brain injury. This approach probably
works best when focused on patient-identified needs with a
socially acceptable aid. One recent example is a text messaging
system57; more traditional are various kinds of memory note-
books, which are often used to support communication. It must
be emphasized that patients need to be trained to use these
notebooks, sometimes extensively. The amount of training
typically provided in clinics in the United States may be
woefully inadequate, in part due to restrictions on insurance
coverage for treatment and in part due to the uninformed
opinion that little training is necessary.
For patients with more severe memory and planning diffi-
culties, treatment to achieve functional outcomes with external
compensations has been recommended as a clinical practice
guideline.42,58 Again, extensive training is required to use these
compensations, and in the case of assistive devices, training
may be needed first just to get the patient to bring the device to
treatment sessions. Treatment to acquire particularized infor-
mation or skills, such as touch typing59 or adapted email,60 is
endorsed as a practice option.42
A recent systematic review of instructional methods61 rec-
ommended an errorless learning approach for memory deficits
of diverse causes and severities, as well as for varying memory
targets (eg, declarative information, procedural skills) and
tasks. Errorless learning aims to minimize errors during acqui-
sition. This approach often involves modeling before a patient
attempts a response, with clinician support carefully faded
while maintaining accuracy. If an error occurs, the clinician
immediately provides the correct response and has the patient
try again. Expanded rehearsal, or spaced retrieval practice, was
recommended in the same review for declarative memory
training. In this approach, patients practice recalling specific
target information over systematically increasing time delays.
Working memory has been addressed in a randomized pilot
study of young, chronic stroke patients.62 Improvements in
neuropsychologic test performance and self-rated cognitive
function were reported after 5 weeks of computerized training
on various working memory tasks. Unfortunately, the sample
size was small, and the randomization resulted in some poten-
tially important differences between the experimental group
and the no-treatment control group, in terms of lesion location
and etiology (hemorrhage vs infarct).
Finally, some progress has been made in treatment of exec-
utive functioning. For example, substantial gains in self-aware-
ness and self-regulation were reported for a young patient with
a right thalamic hemorrhage, after 12 weeks of comprehensive
training for self-knowledge, self-perception, self-evaluation,
self-prediction, self-reflection, self-monitoring, self-correction,
goal identification, and on-the-job training.37 The patient was
also able to get and keep a job, something he had not been
successful at before treatment. Generalization of these results is
of course limited by the N of 1, and by characteristics of the
patient. For example, he did not have neglect, and had good
metacognition. More importantly, it is hard to discern the
mechanism(s) of reported improvements. The patient was re-
ceiving concurrent counseling/psychotherapy, had access to a
disability employment service that offered on-the-job support,
and participated in a unique partnership with the clinician.
Specifically, he was interviewed for 10 to 15 minutes after each
session to provide his perspectives about the treatment. He
articulated several recurring themes, related to the importance
of understanding social performance standards, learning
through meaningful experiences, and individuated examples
and exercises. He also commented about the confidence-build-
ing aspects of the treatment experience.
S67
Many of the techniques used to treat this young man are part
of metacognitive strategy instruction (MSI). A recent system-
atic review and meta-analysis has endorsed MSI as a practice
standard for patients with traumatic brain injuries who have
difficulties with daily life planning, organization, problem-
solving, and multitasking63; these problems can characterize
patients with RHD, as well.64 MSI also includes time pressure
management (eg, planning ahead, adjusting environment when
possible, practicing a few times) and strategic thinking training
(eg, clinician models problem-solving strategies, explaining
decisions). MSI often incorporates external organizers and
prompts, such as charts, notebooks, checklists, and cue cards.
It is important to note, particularly for patients who cannot
engage in such highly metalinguistic activities, that behavior
can be changed without the patients explicit acknowledgment
of awareness (eg, Cicerone et al42). To accomplish this, treat-
ment should tap implicit learning of a procedure, as described
above for patients with severe memory and planning abilities.
Rehabilitation professionals and family members alike may
need to be counseled that it is not necessary for patients to
admit their deficits in order to make progress in treatment.
Expert clinical opinion on awareness training also recom-
mends experiential exercises.31,65 Rather than contradicting
patients clearly unrealistic goals, members of the rehabilita-
tion team engage patients in supported exploration and expe-
rience of subgoals. The aim of this approach is to improve
patients awareness of gaps between their conditions or expe-
riences and their goals, and to help them discard those goals,
implicitly or explicitly, for alternatives. This approach must be
used with caution, in an empathetic and supportive manner, as
it may yield strong emotional responses in patients who begin
to realize the extent and implications of their difficulties.
Rehabilitation Needs
The rehabilitation needs in the area of RHD cognitive-
communication disorders are many and varied. Clearly, more
treatment evidence is essential, of every kind. But in particular,
evidence is lacking for approaches that focus on obstacles to
goal attainment other than patients deficits. Among these
obstacles might be the expectations or misattributions of oth-
ersthe patient is rude, lazy, not suited for treatmentwhich
could be addressed by demonstration and training. Communi-
cation partners could be trained to interact in ways that reduce
obstacles (eg, provide contextual constraint; supply and guide
use of cue cards and other prompts or organizers; learn to elicit
appropriate responses, reduce and simplify input, identify trig-
gers and reinforcers of desired and undesirable behaviors). It is
both legitimate and necessary to target clinical interventions in
these ways, but in the United States, at least, insurance cover-
age is limited or unavailable for work with people other than
the patient. In addition, treatment research going forward needs
to specify clearly the theoretical underpinnings of rehabilitation
approaches, and to explicitly program for and assess general-
ization to daily life activities and participation. Finally, and
fundamentally, progress in this area will require a good defi-
nition of RHD cognitive-communication disorders, which in-
corporates inclusion and exclusion criteria, potential bases of
common patterns of impairments, and factors likely to affect
the expression or nature of strengths and weaknesses in indi-
vidual subsets of patients.
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