The scope of this Practice Portal page is right hemisphere disorder (RHD)—a unique constellation of deficits associated with acquired right-side brain injury in adults.
See ASHA’s Right Hemisphere Disorder Evidence Map for summaries of the available research on this topic. See also ASHA’s Evidence Maps on Stroke and Traumatic Brain Injury for research related to right hemisphere damage in these populations.
RHD is most commonly caused by a stroke or other acquired brain injury (e.g., stroke, tumor) that impacts the right hemisphere of the brain. RHD is a constellation of changes in
Communication deficits caused by brain injury often co-occur with other cognitive deficits. These include the following:
Word retrieval, syntax, morphology, and phonological processing are not typically affected by injury to the right hemisphere. However, these deficits occur with right hemisphere stroke in a small percentage of patients. This phenomenon is called crossed aphasia. This condition may occur in people with language dominance in the right hemisphere at baseline. Most people are left hemisphere dominant for language, so crossed aphasia is rare.
Although the deficits associated with RHD may be subtle in highly structured contexts, they are often more apparent during dynamic and/or complex tasks such as conversation (Ferré et al., 2011). These deficits can significantly impact functional performance in social and vocational settings (Blake, 2006; Lehman & Tompkins, 2000).
Realizing the potential impact of RHD on daily functioning is particularly important, as the deficits experienced by people with acute RHD often go unrecognized and undiagnosed (Edwards et al., 2006). This may lead to reduced referrals for speech-language pathology or other rehabilitation services and prolonged, negative impacts for people with RHD. In addition, RHD can lead to disrupted social relationships (Hewetson et al., 2021) and difficulty maintaining jobs and other social activities (Tompkins, 2012).
Incidence is the number of new cases of a disorder or condition identified in a specific time period.
Prevalence is the number of individuals who are living with a disorder or condition in a given time period.
There are no population-level statistics on the incidence and prevalence of RHD. Therefore, the following estimates should be interpreted with caution. Statistics are most often reported within stroke populations because of the localized nature of RHD.
Hospital-based studies have reported that 42.3%–47.2% of people presenting with stroke have right hemisphere strokes (Deb-Chatterji et al., 2022; Hedna et al., 2013; Portegies et al., 2015). However, these statistics may be an underestimate. Patients may be less likely to seek medical attention with right hemisphere stroke due to diminished insight into their new deficits and the reduced recognizability of RHD symptoms (e.g., visual or cognitive-communication deficits) when compared to those of the left hemisphere (e.g., aphasia; Deb-Chatterji et al., 2022; Foerch et al., 2005).
The reported rates of disorders of the right hemisphere are as follows:
RHD results in a collection of symptoms that vary in severity and in domains affected depending on the site and extent of injury. For a detailed discussion of signs and symptoms associated with RHD, see Blake (2018).
Below are examples of symptoms grouped by domain. Individuals may not present with all symptoms.
Apragmatism is when a person has difficulty conveying or comprehending the meaning or intent of a message within a specific context. Contexts can include the conversational partner(s), environment, culture, or goals of the interaction. Apragmatism is a primary communication impairment in RHD (Minga et al., 2023).
Apragmatism can be divided into three areas: Linguistic, paralinguistic, and extralinguistic.
RHD affects aspects of cognitive communication that impact how the person interacts with others and with their environment. Common areas of impairment include
For more information about the executive functioning deficits that occur across brain injuries of varying etiologies, please see ASHA’s Practice Portal page on Executive Function Deficits.
RHD also affects discourse—language units larger than a sentence that have a specific purpose and meaning together.
Discourse-level communication involves cognition and language—both of which are commonly impaired in RHD. As such, subtle deficits in cognition and/or language may be more apparent in discourse-level tasks than in discrete tasks.
Cognitive deficits in RHD may make efficient and appropriate discourse management challenging. However, healthy aging can also contribute to changes in discourse over time. Clinicians can determine if there are any baseline or age-related factors that may influence a patient’s discourse-level communication to understand the true impact of RHD.
Discourse-level changes may impact the following:
Other deficits that may be associated with RHD include
See ASHA’s Practice Portal pages on Adult Dysphagia and Dysarthria in Adults.
RHD may result from a variety of changes in the structure or function of the right hemisphere of the brain. These can range in severity and may result in chronic or acute deficits. Changes in the brain include tumors, surgery, infection, stroke, seizure, neurodegenerative conditions, and traumatic brain injury.
Please see the following Practice Portal pages for further information: Head and Neck Cancer and Traumatic Brain Injury in Adults.
SLPs play a central role in the screening, assessment, diagnosis, and treatment of persons with RHD. The professional roles and activities in speech-language pathology include
See ASHA’s Scope of Practice in Speech-Language Pathology (ASHA, 2016).
Appropriate roles for SLPs include, but are not limited to, the following:
Assessment
Counseling and Education
Treatment
Other
As indicated in the ASHA Code of Ethics (ASHA, 2023), individuals who hold the Certificate of Clinical Competence shall engage in only those aspects of the professions that are within the scope of their professional practice and competence, considering their certification status, education, training, and experience.
See ASHA’s Right Hemisphere Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. See also ASHA’s Evidence Maps on Stroke and Traumatic Brain Injury for information related to right hemisphere brain damage in these populations.
The clinician considers the following factors that may have an impact on screening and comprehensive assessment:
If the individual with RHD wears prescription glasses and/or hearing aids, then they should wear these items during assessment.
If additional hearing and/or visual deficits resulted from the neurological event—and physical or environmental modifications (e.g., large-print material, attention to placement of test stimuli, modified lighting, amplification devices) are not sufficient to compensate for these changes—then the individual should be referred for complete audiologic and/or vision assessments prior to testing. The individual should be referred to psychology, psychiatry, and/or neuropsychiatry if there are signs or reports of depression, emotional lability, or other psychological issues.
Screening is a procedure for identifying the need for further assessment and does not provide a detailed description of the severity and nature of the deficits associated with RHD. Screening is conducted in the language(s) used by the person, with sensitivity to cultural and linguistic diversity. Screening may be completed by the SLP or another appropriately trained professional. Standardized and nonstandardized methods are used to screen oral motor functions, speech production skills, comprehension and production of spoken and written language, pragmatic language skills, and other cognitive skills (attention, memory, and executive function) as they relate to communication, swallowing, unilateral neglect, and hearing. Deficits in these skills may be related to RHD.
Screening often incorporates the use of targeted questionnaires with the individual and family members. Keep in mind that changes after RHD are not always recognized by the individual or family members.
Screening may result in
Effective RHD assessment relies on patient and care partner interviews to establish baseline communication function and to highlight behavioral changes. Assessment also considers normal age-related changes in cognitive-communication skills when gauging baseline function.
There are few standardized assessments for use with patients with RHD (see, e.g., Joanette et al., 2015). Functional assessment may more accurately predict performance on activities of daily living than standardized assessment and is particularly valuable for individuals with RHD. Assessment considers the impact of RHD on a patient’s quality of life. Appropriate treatment goals target the patient’s cognitive-communication deficits in an effort to restore that person to their maximum functional capacity and quality of life.
Typical components of a comprehensive assessment of deficits associated with RHD include the following:
See Minga et al. (2023) for further information.
Areas that are assessed in terms of cognitive communication include the following:
Deficits that frequently occur with RHD impact feeding and swallowing. These deficits include
See the Assessment section of ASHA’s Practice Portal page on Adult Dysphagia.
Hearing and vestibular testing may be indicated, depending on the individual’s presenting needs. SLPs make referrals to audiologists as appropriate. For details, see the Assessment sections of ASHA’s Practice Portal pages on Hearing Loss in Adults, Balance System Disorders, and Tinnitus and Hyperacusis.
Assessment may result in one or more of the following:
Pragmatic and social norms (e.g., eye contact, turn-taking, nonverbal cues) vary among different cultures. Cultural differences should not be interpreted as pragmatic deficits. See ASHA’s Practice Portal page on Cultural Responsiveness for more information.
When selecting the language of assessment, it is important to consider the patient’s preference, language(s) spoken, age of acquisition of each language, premorbid use of each language, and language(s) needed for return to daily activities. Clinicians should gather data in all languages used by the client and their care partners to determine the degree of impact.
Prompts and cues used in assessment may not carry the same meaning for individuals from one culture to another. Any accommodations and/or modifications to the testing process to reconcile cultural and linguistic variations should be documented. Scores from standardized tests should be interpreted and reported with caution in these cases. See ASHA’s Practice Portal pages on Multilingual Service Delivery in Audiology and Speech-Language Pathology; Collaborating With Interpreters, Transliterators, and Translators; and Cultural Responsiveness.
See ASHA’s Right Hemisphere Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. See also ASHA’s Evidence Maps on Stroke and Traumatic Brain Injury for information related to right hemisphere brain damage in this population.
Treatment for RHD is individualized to address areas of need identified in the assessment, considering the goals identified by the individual and their care partners.
Treatment is provided in the language(s) used by the individual with RHD. Services may be provided either by a multilingual SLP or in collaboration with trained interpreters. See ASHA’s Practice Portal page on Collaborating With Interpreters, Transliterators, and Translators.
For a detailed discussion of RHD treatment, see, for example, Blake (2018) and Myers (1999, 2001).
Treatment approaches can be restorative, compensatory, or a combination of the two.
People with RHD often have limited insight into their deficits. This can decrease participation in either therapeutic approach and can limit an individual’s ability to generalize compensatory strategies taught in treatment sessions.
Treatment selection depends on the person’s communication and activity participation needs, the preferences of the person and their care partners, and the presence of co-occurring conditions. See ASHA’s Practice Portal page on Cultural Responsiveness for more information.
Below are descriptions of treatment options for addressing RHD, although there are few published treatment approaches available.
Treatment for apragmatism and discourse focus on improving communication skills across a variety of settings. Treatment often involves making implicit communication practices explicit. SLPs typically work to increase the individual’s awareness of their pragmatic deficits when compared to social norms. The clinician asks questions to better understand the person’s norms and premorbid communication behaviors. Techniques used to practice these skills include coaching, one-on-one rehearsal, role play, group practice, visual and verbal feedback, and video modeling. There are four aspects of apragmatism and discourse:
Each of these four aspects is discussed in the subsections below.
Treatment considers the person’s language use including appropriateness to context, if they can clearly communicate, and if they can correctly interpret the meaning of others’ language. This includes (a) using conversational skills, (b) applying inference and using global meanings of discourse, and (c) understanding and using alternate meanings.
Conversational Skills
Treatment considers the person’s premorbid behaviors and cultural norms and includes explicit instruction on how to use and monitor strategies for successful conversation—for example:
Conversational skills may also be supported by providing direct instruction on theory of mind—which is the ability to understand the mental states of others and how their mental states may differ from your own. It includes
Inference and Global Meanings of Discourse (Topic, Gist, Big Picture)
People with RHD may have difficulty understanding the key points or the core message or topic of conversation.
Treatment includes
Understanding and Using Alternate Meanings
People with RHD may have trouble understanding ambiguities and nonliteral language as well as recognizing multiple meanings of words.
Treatment includes
Paralinguistic apragmatism, or prosody, is the set of variations in the suprasegmental aspects of language (e.g., rate, pitch or intonation, and intensity).
Prosody can convey linguistic content such as rising intonation for a yes/no question or part of speech (e.g., “PREsent” vs. “present”). Prosody also can convey emotional or affective information (e.g., anger, happiness). Deficits in prosody (aprosodia) can be expressive and/or receptive.
For examples of prosodic treatments, see Leon et al. (2005), Rosenbek et al. (2004, 2006), and Durfee et al. (2021).
Restorative treatment of prosody may include the following:
Treatment can also use compensatory strategies, including
Prosodic features—and how people use them to convey meaning—vary across languages, and goals may need to be language specific. See ASHA’s page on Phonemic Inventories and Cultural and Linguistic Information Across Languages for more information.
Treatment for extralinguistic apragmatism considers the person’s premorbid behaviors and cultural norms and includes explicit instruction on how to use and monitor the following behaviors:
Attention, memory, and executive functions (discussed in the subsections below) are common targets for treatment in people with RHD (see, e.g., Tompkins, 2012). These skills influence the dynamic aspects of communication and functional independence.
Attention
Restorative approaches are aimed at improving one or more types of attention (e.g., sustained, selective, alternating, divided). Restorative approaches include tasks that require the person to keep a target action or response in mind in the presence of confounding variables—variables such as competing distractors, dual-task training, and task shifting. Treatment options include
Task complexity can be varied by the amount of material presented, the rate of presentation, the number of targets, or the relationship between targets (e.g., “Tell me if the next number in the sequence is higher than the one before it”).
Compensatory and metacognitive approaches help the person attend to a task until they complete it. These approaches include the following:
People with RHD may experience three types of attention disorders: unilateral neglect, left-sided neglect, and neglect dyslexia.
Unilateral Neglect
Unilateral neglect is an attention disorder that frequently occurs with anosognosia—reduced insight into one’s own deficits. People with RHD may experience the neglect of visual, auditory, and/or tactile stimuli from one side of their body and/or the environment. This includes proprioceptive feedback—or information sent to the brain that allows an individual to know where their body is in space.
Left-Sided Neglect
Left-sided neglect, is common in people with RHD. This section focuses on one particular subtype—called left visual neglect—particularly as it affects communication and functional independence.
It is important to understand the person’s visual acuity (i.e., how sharp someone's vision is at a distance), and the presence of a visual field cut (i.e., missing a part of the area a person can typically see) before selecting treatment strategies. Clinicians may consult with or refer to neuro-optometry or neuro-ophthalmology as appropriate.
Treatment approaches include the following:
Neglect Dyslexia
Neglect dyslexia is a reading impairment that can occur in people with RHD wherein they omit or misread text on the left side of the page or on the left side of individual words. Treatment can include compensatory strategies designed to draw attention to the left side of the text (e.g., a bold, red line down the left side of the page). Other treatment approaches have been trialed, although there is no consensus as to the best method for treating this disorder (see, e.g., Gordon et al., 1985; Reinhart et al., 2011).
Memory
Compensatory treatment is often used to address memory deficits in people with RHD. This includes the use of external aids and internal strategies.
External aids include
Internal strategies include
Restorative treatment is also used to treat memory deficits. Treatment may include
Please see ASHA’s Practice Portal page on Traumatic Brain Injury for further information.
Executive Functions
Executive functions are also common treatment targets for people with RHD. Please see ASHA’s Practice Portal page on Executive Function Deficits for further information.
Awareness of Deficits
Treatment to increase awareness of deficits and their functional impact include the following:
The goal of treatments that address anosognosia and that involve increasing one’s awareness is to teach an individual how to use metacognitive skills to reflect on their own performance, challenges, and safety. This can drive the use of compensatory strategies, encourage participation in therapy, and limit risk (e.g., fall risk).
See ASHA’s Right Hemisphere Disorder Evidence Map for pertinent scientific evidence, expert opinion, and client/caregiver perspective. See also ASHA’s Evidence Maps on Stroke and Traumatic Brain Injury for information related to right hemisphere brain damage in these populations.
In addition to determining the optimal treatment approach for individuals with RHD, other factors include the availability of specific types of services in a particular region, insurance coverage, pattern of recovery, potential for returning to school or work, and service delivery options, including the following:
This list of resources is not exhaustive, and the inclusion of any specific resource does not imply endorsement from ASHA.
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Content for ASHA’s Practice Portal is developed through a comprehensive process that includes multiple rounds of subject-matter expert input and review. ASHA extends its gratitude to the following subject-matter experts who were involved in the development of the Right Hemisphere Disorder page:
The recommended citation for this Practice Portal page is:
American Speech-Language-Hearing Association. (n.d.). Right hemisphere Disorder [Practice portal]. https://www.asha.org/Practice-Portal/Clinical-Topics/Right-Hemisphere-Disorder/
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