Topics in Stroke Rehabilitation

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Cognitive-Communication Problems after Right

Hemisphere Stroke: A Review of Intervention
Studies

Anita S. Halper & Leora R. Cherney

To cite this article: Anita S. Halper & Leora R. Cherney (1998) Cognitive-Communication
Problems after Right Hemisphere Stroke: A Review of Intervention Studies, Topics in Stroke
Rehabilitation, 5:1, 1-10, DOI: 10.1310/R9C8-23C6-34V7-MB2H

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 Cognitive-Communication Problems after Right Hemisphere Stroke 1

Cognitive-Communication Problems
after Right Hemisphere Stroke: A Review
of Intervention Studies

This article addresses the history of interventions for visual attention/neglect and communication problems
in patients with right hemisphere damage. Several key studies that are representative of the types of
interventions that have been researched in the area of visual attention and perception are presented. In
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addition, clinical studies directed toward the nature of the communication deficits and their implications for
rehabilitation are summarized. For the most part, the procedures in these latter studies have been clinically
used but not empirically tested for their effectiveness. Key words: communication, intervention, right
hemisphere damage, visual attention/neglect

Anita S. Halper, MA, CCC-SLP, BC-NCD

Associate Professor
Physical Medicine and Rehabilitation
Northwestern University Medical School
Clinical Associate Professor
Communication Sciences and Disorders
Northwestern University
Reengineering Project Specialist
Rehabilitation Institute of Chicago
Leora R. Cherney, PhD, CCC-SLP,
BC-NCD
Associate Professor
Physical Medicine and Rehabilitation
Northwestern University Medical School
Clinical Educator/Researcher
Center for Clinical Excellence
Rehabilitation Institute of Chicago
Chicago, Illinois
T HE MANAGEMENT of cognitive-
communicative problems in patients
with right hemisphere stroke presents a chal-
lenge to the clinician. For many years, these
problems were virtually ignored and went
untreated. In the 1950s and 1960s, prelimi-
nary studies describing the various charac-
teristics of patients with right hemisphere
damage (RHD) began to emerge, but these
studies did not focus on intervention or man-
agement (Arrigoni & DeRenzi, 1964;
DeRenzi & Spinnler, 1966, 1967; McFie,
Piercy, & Zangwill, 1950; Milner, 1968;
Warrington & James, 1967; Weinstein &
Kahn, 1950). Rather, they focused on trying
to understand and describe the characteris-
tics of this population. It was not until later
that attempts to remediate some of these
problems were initiated. This article ad-
dresses the history of intervention in the two
areas most relevant to speech-language pa-
thologists: (1) visual attention/neglect and
(2) communication. Studies on intervention
strategies for communication problems and
the assessment of their effectiveness are

Top Stroke Rehabil 1998;5(1):1–10

© 1998 Aspen Publishers, Inc.
1
 2 TOPICS IN STROKE REHABILITATION/SPRING 1998
sparse. However, the literature is more re-
plete with intervention studies on visual at-
tention/neglect and perceptual deficits.
VISUAL ATTENTION AND
PERCEPTION
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This section discusses several key studies
that are representative of the types of inter-
ventions that have been researched with pa-
tients with right hemisphere stroke in the area
of visual attention and perception. One of the
earliest studies involved the treatment of
only two patients with neglect (Lawson,
1962). Patients were reminded to “look to the
left” and to use their fingers as a guide during
reading. In addition, they were instructed to
use touch to find the center of a book or food
tray and then to systematically explore the
page or tray using their finger position as a
reference point. Although patients improved
on the trained tasks, generalization to un-
trained tasks was poor.
A series of intervention studies using gen-
eral principles and procedures developed by
Diller and colleagues (1974) is also impor-
tant to review when discussing rehabilitation
of visual attention and perception. The box,
“Principles of Scanning Training,” presents
the basic principles of scanning training on
which these early studies were based. The
studies used a scanning machine consisting
of a board with a target that could be moved
around the periphery. The patient was re-
quired to point to the target as it moved.
Cancellation tasks were also used as a pri-
mary tool for training.
Weinberg and colleagues (1977) imple-
mented a training program using the prin-
ciples described in the box, “Principles of
Scanning Training,” and a specially de-
signed scanning machine. Graded visual
Principles of Scanning Training
1. Anchoring: placing a strong cue at the
point where scanning begins. Anchor-
ing might be needed for the end of one
line and the beginning of the next line.
2. Pacing: providing a mechanism for
keeping a steady rate (e.g., reciting tar-
gets aloud slows impulsive behavior).
3. Feedback: confirming correct or incor-
rect responses.
4. Density: manipulating the distance be-
tween targets and the size of the targets
to reduce error.
5. Arousing and maintaining awareness:
stimulating involvement in the task.
6. Repetition: practicing to transfer new
strategies into habits.
7. Platforms: building new skills based on
achievement of previous skills.
Source: Diller, L., & Riley, E. (1993). The
behavioural management of neglect. In I.H.
Robertson & J.C. Marshall (Eds.), Unilateral
neglect: Clinical and experimental studies. East
Sussex, England: Lawrence Erlbaum Associ-
ates Limited.
materials, interesting enough to facilitate
head turning to the left so that a target is
viewed in the right visual field, were used to
train patients to compensate for their im-
paired visual scanning. The patients received
20 hr of treatment, 1 hr daily for 4 weeks. The
stimuli consisted of single letters, numbers,
letters and numbers, nonsense syllables,
words, and paragraphs. Maximum cueing
was provided initially and gradually de-
creased, as depicted in Table 1. The 25 pa-
tients who received the specific scanning
treatment programs showed superior perfor-
mance as compared to the 32 patients who
received traditional rehabilitation. Results
 Cognitive-Communication Problems after Right Hemisphere Stroke 3

further indicated that when patients were
taught to scan the visual environment, per-
formance improved on a number of visual
tasks, particularly those that are related to
academic performance (reading, writing,
and paper and pencil arithmetic tasks). Train-
ing also generalized to pictorial tasks such as
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training programs focusing on sensory
awareness and spatial organization (Wein-
berg et al., 1979).
Thirty experimental subjects received this
revised training program, which included 5
hr of sensory awareness and spatial organiza-
tion in addition to 15 hr of the previously

counting faces, matching faces, and picture
completion. However, improvement was not
found on other tasks, such as location of the
midline of the body and line bisection. As a
result, the authors developed additional
described scanning program (Weinberg et
al., 1979). In the sensory awareness program,
the patient was touched on the back and had
to identify on a manikin’s back the same
locus of touch. In the spatial organization

Table 1. Sequence of training materials

Sequence of cueing Stimulus material Task demand

1. A vertical anchoring line
on left side
1- The Treasury Secretary is not now a -1 Patient is asked to look at the
2- member of the National Security -2 anchoring line and the
3- Council but is occasionally invited to -3 number at the beginning
4- participate in its deliberations. -4 and end of the line. He or
she uses the vertical line to
find the beginning of the
paragraph, and the
numbers so that lines are
not skipped. Patient also is
asked to copy the para-
graph.

2. A vertical anchoring line 1- A growth of 6 percent in the nation’s Patient uses only anchoring
Beginning of line 2- output of goods and services next year line and number at the
sequentially numbered 3- would be higher than what is now being beginning of paragraph.
4- forecast by most economists. In the third

3. A vertical anchoring line Among the subjects discussed in the series Patient uses only the
of meetings, most of them an hour long, anchoring line.
were foreign policy, the international
economic situation, governmental reor-

4. No cues provided At a meeting with the Senate Foreign Patient reads without any
Relations and House International lines.
Relations Committees, Mr. Carter said that
he would cooperate and consult closely

Source: Weinberg, J., Diller, L., Gordon, W.A., Gerstmann, L.J., Lieberman, A., Lain, P., Hodges, G., & Ezrachi, O. (1977).
Visual scanning training effect on reading-related tasks in acquired right brain damage. Archives of Physical Medicine and
Rehabilitation, 58, 479–486.
 4 TOPICS IN STROKE REHABILITATION/SPRING 1998
task, the patient had to place cylinders on a
board such that the distance between the
cylinders approximated the length of a given
rod. Performance of the patients in the ex-
perimental group exceeded that of the 23
control subjects. In addition, those patients in
the experimental group with severe impair-
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ments improved more than those patients
with mild impairments. The authors con-
cluded that this modified combined program
produced greater improvement on all tasks
than the original single treatment program.
There have been several more recent at-
tempts at replicating the training procedures
developed and evaluated by Diller,
Weinberg, and their colleagues (Gordon et
al., 1985; Gouvier, Bua, Blanton, & Urey,
1987; Webster et al., 1984; Young, Collins,
& Hren, 1983).
Gordon and colleagues (1985) integrated
the previously discussed training modules
into a comprehensive visual/perceptual reha-
bilitation program. In addition to the basic
scanning training (Weinberg et al., 1977) and
somatosensory awareness and size estima-
tion (Weinberg et al., 1979), a third module
of complex visual perceptual training was
included (Weinberg, Piasetsky, Diller, &
Gordon, 1982). In this module, training goals
were accomplished by incorporating left to
right scanning within cognitively more com-
plex spatial tasks requiring organization and
sequential analysis of spatial information.
The 48 experimental subjects received 35
hours of the treatment program. The 29 con-
trol subjects participated in leisure activities
A major issue with these studies is the
question of generalization of the
training to other more functional tasks.
or traditional treatment for visual/perceptual
problems. There were consistent improve-
ments in the experimental group compared to
the control group in basic scanning and com-
plex visual/perceptual skills.
A major issue with these studies is the
question of generalization of the training to
other more functional tasks. For example,
Gouvier and colleagues (1987) found that
training effects for visual attention were con-
sistently evident only on tests that were simi-
lar to the training procedure. Light board
training of the type developed by Weinberg
and colleagues (1977, 1979) produced im-
provements on this measure but not on the
cancellation tasks; similarly, training on can-
cellation tasks improved performance on this
task but not on light board performance.
The problem of generalization is one that
is present in other treatment approaches.
Stanton, Flowers, Kuhl, Miller, and Smith
(1979) presented a language-oriented pro-
gram to help patients compensate for left
neglect. The training program had seven hi-
erarchical steps in which subjects were told
of the deficits and verbally reminded to com-
pensate. The goal was to verbally self-cue
themselves on a task of naming two objects,
one presented simultaneously to each visual
field. Results indicated that patients were
able to verbally instruct themselves on this
task, but there was no evidence that generali-
zation occurred to other tasks.
Myers and Mackisack (1990) have de-
scribed a different approach to the treatment
of directed attention and perception. Their
techniques of Edgeness and Bookness are
based on the premise that neglect affects an
individual’s capacity to explore space as well
as respond to sensory input within that space.
In the Edgeness program, patients are asked
to find colored cues placed in varying loca-
 Cognitive-Communication Problems after Right Hemisphere Stroke
tions on a flat board that has been divided into
segments. The purpose of the task is to estab-
lish boundaries of relevant space and explore
within the boundaries. The authors describe
a step-by-step procedure with criteria for
moving from one step to the next. In the
Bookness program, patients use verbal de-
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scriptions and touch to explore the character-
istics of a closed and open book. Both of
these techniques have been used clinically,
but no data regarding their efficacy or gener-
alization are available.
With improvements in technology, com-
puterized training for visual attention and
perception problems is another viable ap-
proach. Robertson, Gray, Pentland, and
Waite (1990) conducted one of the first ran-
domized, controlled trials of computerized
training of left unilateral neglect. Twenty
subjects received computerized scanning
and attention training, while 16 subjects re-
ceived recreational computing activities that
minimized scanning and timed attentional
tasks. At the end of training and at 6 months,
no large improvements in neglect were ob-
served in either group, with no statistically or
clinically significant difference between the
groups. Therefore, the authors argued
against routine use of computerized training
until further studies establish what type, fre-
quency, and duration of training produced
clinically significant changes, if any.
Careful review of the studies described
previously reveals that, while training effects
are evident, they tend to be restricted to
measures that share stimulus characteristics
with the training materials and do not gener-
alize to more functional tasks. In this regard,
Robertson, Halligan, and Marshall (1993),
discussing the prospects for the rehabilita-
tion of unilateral neglect, stated that “gener-
alized scanning improvements in unilateral
5
neglect as a result of training remain elusive”
(p. 284).
COMMUNICATION
The study of interventions directed toward
the communication problems of patients
with right hemisphere damage is still emerg-
ing. As recently as 1976, Collins summa-
rized the status of clinical practice with this
population at that time:
Speech pathologists interested in the treatment
of deficits associated with right hemisphere dam-
age receive little succor or guidance from the
literature or from their peers. While we show a
willingness to study these patients’ deficits
(Bonkowski, 1969; Boone, 1959; Boone &
Landis, 1968) only a few elect to treat them or
choose to report the results of that treatment
(LaPointe & Culton, 1969; Leutenegger, 1975).
This unwillingness may be due to several factors:
an uncertainty of our territorial imperatives, a
lack of expertise, or the patient’s concomitant
behavior deficits. (p. 342)
This quote, from a round-table discussion
at the 1976 Clinical Aphasiology Confer-
ence, may be considered representative of
the beginning of interest in the recognition,
assessment, and rehabilitation of specific
deficits for patients with cognitive-commu-
nicative problems resulting from right hemi-
sphere stroke. At subsequent Clinical
Aphasiology Conferences, a number of stud-
ies that are important milestones in describ-
ing the cognitive-communicative deficits
associated with RHD were presented.
Metzler and Jelinek discussed writing distur-
bances (1977); Myers (1978, 1979) de-
scribed the perceptual and cognitive deficits
seen, their impact on communication skills,
and the nature of their verbal output; and
 6 TOPICS IN STROKE REHABILITATION/SPRING 1998
Deal, Deal, Wertz, Kiteselman, and Dwyer
(1979) collected some preliminary norma-
tive data about right hemisphere patient per-
formance on the speech and language tasks
of the Porch Index of Communicative Abil-
ity (PICA; Porch, 1967). At about the same
time, a group of researchers (Gardner &
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Denes, 1973; Gardner, Ling, Flamm, &
Silverman, 1975; Winner & Gardner, 1977)
also was investigating the comprehension of
humorous or figurative material by patients
with RHD. Although none of these studies
focused on intervention, careful analysis of
each of them yields valuable information that
can be incorporated into the assessment and
treatment of these patients.
Myers (1978) presented a case study of a
patient with RHD and identified four catego-
ries as the key areas of communication defi-
cits: (1) visual imagery, (2) figurative lan-
guage, (3) affect, and (4) sense of humor. In
addition, she discussed the subtle shifts in
cognitive style that alter communication.
She concluded that the first step for the pro-
fession of speech-language pathology is to
identify the specific communication deficits
that characterize patients with RHD.
Myers (1979) subsequently focused on the
nature of the verbal expression of eight sub-
jects with RHD and eight normal controls.
She hypothesized that the inappropriate ver-
bal output might reflect a deficit in percep-
tual integration. From subjects’ performance
on the Hooper Test of Visual Organization
(Hooper, 1958) and the Boston Diagnostic
Aphasia Examination (Goodglass & Kaplan,
1972), she concluded that patients with RHD
have difficulty integrating information on a
perceptual level and that this deficit is re-
flected in their verbal output. For example,
on a picture description task, patients with
RHD tended to itemize rather than interpret
information. In developing an assessment
tool for this population, both the inappropri-
ate verbal output and the underlying deficits
in perceptual integration should then be in-
cluded in a diagnostic protocol and ad-
dressed in treatment.
Gardner and his colleagues focused on a
related communication deficit in patients
with RHD, the ability to comprehend and
interpret nonliteral, figurative language.
They found that patients with RHD had dif-
ficulty comprehending metaphors and chose
a literal interpretation of the metaphor more
often than normal controls or even aphasic
patients (Winner & Gardner, 1977). They
had difficulty matching nonliteral phrases
(e.g., heavy heart) to pictorial representa-
tions of their connotative or metaphorical
meanings (Gardner & Denes, 1973). In addi-
tion, they found that patients could not appre-
ciate the point of a cartoon when no caption
was provided (Gardner et al., 1975).
In a study of differences in writing between
20 subjects with right hemisphere lesions and
20 normal controls, Metzler and Jelinek (1977)
administered the following five subtests: lis-
tening to a paragraph and writing what the
subject recalled; writing a sentence describing
the function of 10 common objects; writing 10
sentences to dictation describing the function
of the 10 objects; writing the name of 10
common objects to dictation; and copying the
names of 10 common objects. Significant dif-
ferences between the two groups were found in
length of time required to complete the
subtests, total number of spelling errors,
perseveration of strokes and syllables, omis-
sion of strokes and words, and undotted i’s and
uncrossed t’s. In view of these findings, a
comprehensive management program should
consider the assessment and treatment of writ-
ing skills.
Deal and colleagues (1979) studied the
performance of 111 patients with RHD on
 Cognitive-Communication Problems after Right Hemisphere Stroke
the PICA (Porch, 1967). Deficits in speech
and language occurred on this measure, with
PICA percentiles representing a range of
severity. They speculated coexisting defi-
cits, such as visual-spatial impairment, may
mask communication problems in some pa-
tients. They also concluded that the PICA
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may not be the best instrument for evaluating
these patients and that descriptions of speech
and language impairment in RHD might
have to come from using other measures.
The studies described above pointed to the
necessity for developing a tool tailored to
identifying the cognitive-communicative
problems of this population. In the 1970s,
clinicians were typically using tests devel-
oped for the diagnosis and management of
the language disorder of aphasia (Goodglass
& Kaplan, 1972; Schuell, 1955). It was not
until the 1980s that tests designed for this
population emerged (Burns, Halper, &
Mogil, 1985; Pimental & Kingsbury, 1989).
The first author’s interest in this popula-
tion also began in the mid 1970s. By this
time, it had become increasingly clear that
these individuals were having problems that
affected their overall cognitive-communica-
tive functioning for social and vocational
purposes. They complained of having one or
more of the following problems: having
trouble remembering what they heard and
read, having trouble organizing what they
needed to do in a day, missing words on the
left side of the page as they read, not under-
standing the subtleties of a conversation, and
missing the humor in jokes. The families of
The studies pointed to the necessity for
developing a tool tailored to identifying
the cognitive-communicative problems
of this population.
7
these patients complained of inappropriate
affect and communication behaviors in so-
cial situations.
While there had been an emerging body of
information on the characteristics of patients
with RHD and the role of this hemisphere in
language, studies on intervention ap-
proaches for the cognitive-communicative
deficits were lacking.
Based on clinical experience, Glista,
Halper, and Nowikowski (1977) presented a
case study that included the treatment pro-
gram of a patient with nondominant right
hemisphere stroke. The therapy program was
divided into tasks designed to improve five
major areas: (1) visual attention, (2) orienta-
tion, (3) verbal organization, (4) judgment,
and (5) concretism. See the box, “Early Prin-
ciples of Rehabilitation,” for specific inter-
vention procedures suggested at that time.
While many of these suggestions are still
being used clinically, they have not been
empirically tested.
The lack of intervention studies for com-
munication problems of patients with RHD
has persisted. As recently as l994, Myers
stated that “there are no published studies on
the efficacy of a given treatment technique
for RHD communication deficits. There is
hardly agreement about the nature of the
deficits themselves, thus, clinicians must be
creative in designing tasks and evaluating
their impact on communication.” (p. 528)
Recently, Halper, Cherney, and Burns
(1996) presented guidelines and a variety of
tasks for treating the patient with RHD. They
organized their discussion around the areas
of attention, perception, memory, orienta-
tion, pragmatics, and higher level cognition
(organization, reasoning, and problem solv-
ing/judgment). Within each area, long-term,
functionally based objectives, short-term
clinical objectives, procedures to achieve the
 8 TOPICS IN STROKE REHABILITATION/SPRING 1998
Early Principles of Rehabilitation
Visual Attention
• Begin with a relatively simple and
nonfrustrating task so that complexity of
task does not interfere with primary goal of
increasing attention span.
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• Increase gradually length and complexity.
• Decrease external stimuli (e.g., close door,
have patient face a blank wall).
• Progress from nonlinguistic to linguistic
materials.
• Use compensatory cues such as verbal in-
struction, physical manipulation of
patient’s head and hand, placement of thick
red vertical line on left margin.
• Increase gradually distractions into the
therapy environment (e.g., turn the patient
toward a wall with a picture on it, open the
door by inches every day, play music and
gradually increase its volume, move therapy
into hall or family room on unit).
Orientation
• Present orientation information several
times during the treatment session.
• Review patient’s schedule, and ask ques-
tions about its content.
• Train strategy of self-cueing of commonly
asked questions (e.g., in response to the
Source: Glista, S., Halper, A.S., & Nowikowski, K. (1977, April). Language rehabilitation in patients with
non-dominant hemisphere lesions. Paper presented at the annual meeting of the Illinois Speech and Hearing
Association Convention, Chicago, IL.
short-term objectives, and a variety of mea-
sures of performance on the procedure were
provided. While the guidelines presented are
helpful to the practicing clinician, the proce-
dures and the evaluation of their effective-
ness are derived from clinical experience
rather than empirical studies.
Although treatment may focus on the im-
paired cognitive areas, Halper and col-
leagues (1996) emphasize the importance of
question “What time is it?” a sequence of
questions to be answered might be: How do
I tell time? Do I have a watch? Look at it,
what does it say? What time is it?).
• Involve other nurses and other therapists in
reviewing orientation information.
Verbal Organization of Daily Activities
• Sequence picture cards of activities of daily
living in order of occurrence.
• Describe the action orally.
• Write a sentence describing each isolated
picture.
• Describe the activity while performing it in
occupational therapy.
Problem Solving
• Identify a problem situation from a picture.
• Select one of three possible solutions that
are provided.
• Explain the reason for the choice.
• Predict what would happen depending upon
the decision.
Concretism
• Use articles with controversial information.
• Discuss the facts of the article.
• Introduce questions that require making in-
ferences and giving opinions.
the speech-language pathologist document-
ing their relevancy to communication. They
suggest that both long- and short-term objec-
tives/goals be written using terminology
consistent with improving communication.
For example, a memory objective written in
cognitive terminology as “consistent recall
of a three-part message after 15 minutes
using compensatory strategies” might be
rewritten as “accurate expression of a three-
 Cognitive-Communication Problems after Right Hemisphere Stroke
part message after 15 minutes using compen-
satory strategies.” This type of documenta-
tion is in keeping with third-party payer de-
mands and falls within the areas of expertise
of communication specialists.
● ● ● mal treatment? What is the clinical signifi-
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Tompkins (1995) also discusses a variety
of treatment approaches and strategies, many
of which have been derived from treatment
with other populations, such as aphasia and
traumatic brain injury. She delineates several
issues that need to be addressed in the treat-
ment of patients with RHD. These issues
include the following: Which patients are
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9
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