We are pleased to welcome Celia R. Hooper, Ph.D., CCC-SLP, as our
guest host for the SLP chat tonight, Monday, January 31, 2005.
Dr. Hooper will be addressing the topic of Right Hemisphere Disorder.

Celia R. Hooper, Ph.D., CCC-SLP is  Professor and Department Head in
the Department of Communication Sciences and Disorders at the University
of North Carolina-Greensboro.  Her professional interests are adult
neurogenic speech and language disorders (especially older adults),
voice disorders, and innovative teaching in speech-language pathology.
Dr. Hooper is currently ASHA Vice President for Professional Practices
in Speech-Language Pathology. Her responsibilities include identifying
issues, forecasting needs and trends, recommending policies, and, where
necessary, initiating appropriate action to enhance practice content
areas in speech-language pathology for persons with communication
disorders; () monitoring the emergence of new areas of practice and
the application of new knowle<dg>e and research data to the practice of
the profession of speech-language pathology as it pertains to the
identification, diagnosis and treatment of communication disorders;
() addressing unique issues and concerns of specific work settings in
which the profession of speech-language pathology is practiced; and
() monitoring and facilitating Association activities designed to
promote and enhance professional practices and service delivery in
speech-language pathology to persons with communication disorders in
all work settings, including persons from culturally diverse backgrounds.

<Robin> Welcome!  We are chatting tonight about Right Hemisphere Disorder with Celia R. Hooper, Ph.D., CCC-SLP.
<Robin> Thank you all for being here!  Dr. Hooper, please give us some background information about Right
          Hemisphere Disorder.
<Celia Hooper> Most Right Hemisphere Disorders (RHD) are related to stroke.  A small number are related to post
          tumor...when we use the term RHD, we usually do NOT refer to Traumatic Brain Injury (TBI).
<Celia Hooper> The disorder, as a cognitive linguistic disorder, has only been described well in the past 25 years.
<Celia Hooper> Unlike left hemisphere stroke, it cannot be divided into syndromes, although in the 1970's some
          folks (Ross and Heilman) tried to do that.
<Celia Hooper> A better way to start is to think about WHAT the right hemisphere does.
<Celia Hooper> Basically, think of the right hemisphere with these functions...get ready for a long list:
          Primary Sensory Functions, Sensation of left body Perception, of left visual field; Appreciation of sound
          from left ear and cognitive functions: spacial recognition, orientation, comp of faces, timing, music,
          emotional communication, emotional functions, arousal functions, humor, wit, and then many "frontal"
          functions that you might associate with "executive function."
<Robin> What do you mean by executive function?
<AdrienneFSU> attention, sequencing, planning
<Celia Hooper> So you see, if someone has a stroke in the right hemisphere, any of these can be impaired
<Robin> Thank you
<Robin> Is memory affected?
<Celia Hooper> Yes, memory, but usually short term memory.
<Celia Hooper> WE like to say, "if you've seen one, you've seen one."
<AdrienneFSU> lol
<masha> lol...totally true Celia!
<Celia Hooper> In the past many people who were post stroke RHD were not referred to SLPS...they were not
          considered "language impaired."
<Celia Hooper> My first patient, years ago, was referred because of reading (really visual comprehension
          problems) and I got here by accident.  She had a stroke during surgery.
<Robin> Interesting..what is the incidence of right hemisphere strokes compared to the incidence of Left CVAs?
<Celia Hooper> No one really knows...the identification is not as good, but probably several million a year.
<Celia Hooper> The same rules hold true...the golden three hours for care after a "brain attack."
<Robin> Tell us what a typical patient with RHD (Right Hemisphere Disorder) presents like.
<Celia Hooper> There is not really a typical patient, since we can't classify by syndrome, but the current
          thinking now is that it is good to group patients according to intrahemispheric site of lesions...
          for example, some patients will have discourse problems...verbose production, etc.  while others will
          have mainly visual comprehension problems..others executive function, etc.
<Celia Hooper> Which is why I like students to learn right hemisphere functions in the normal brain.
<Celia Hooper> But stay tuned...I will describe a patient now
<Celia Hooper> A "typical" patient presents with post stroke and left neglect...before I go on do you know what
          neglect means?
<Robin> Please define just in case.
<cynbitt> I'm actually working with a patient now who has left side neglect and it's very interesting.
<Celia Hooper> OK!  neglect can have many forms/levels, but in a nutshell the patient is unaware of "something"
          on the left side of space...it can be an arm, leg or it can be all of space...example ...he eats only
          the food on the right side of the plate, then his wife turns the plate around and he says "seconds!"
<Celia Hooper> This patient may be unaware of his neglect, but it usually subsides in about 6 months.
<AdrienneFSU> So the RIGHT hemisphere damage would cause this LEFT neglect.
<Celia Hooper> Yes
<Celia Hooper> On to communication...
<Celia Hooper> A patient may not be able to understand emotional content (again, depends on site of lesion). 
          This patient may see his wife cry and just think she has a wet face.
<Celia Hooper> Another problem this patient may have would be appropriate use of humor, organizational skills,
          I can go on and on, but the "handout" I have on my web page, with links will help.
<Robin> Great...lets move on to assessment.
<Celia Hooper> OK assessment
<Celia Hooper> If you look at the great book, Right Hemisphere Damage, by Penny Myers, she outlines some good
          tests.  First you would want to do a cognitive-linguistic screening or quick test.
<Celia Hooper> My current favorite is Nancy Helms Estabrooks' test, The Cognitive Linguistic Quick Test (CLQT).
<Celia Hooper> This looks at older and younger patients and yields severity ratings for 5 cognitive domains...
          It has 10 tasks.
<AdrienneFSU> Do you find that it's too hard for some low-level patients?
<Celia Hooper> Yes..
<Celia Hooper> In the appendix of the Myers book are some good tasks that are more simple, but they are not
          standardized in any way...
<Robin> What do you suggest for the low level patients?
<Celia Hooper> A good way to go is to try to give the The Cognitive Linguistic Quick Test (criterion references)
          or choose the behaviors of interest and, sometimes with the help of a psychologist, give a more
          standardized subtest, such as the Florida Affective Battery.
<Celia Hooper> If you can give a shorter screening test, then you can work your way through behaviors with more
          standardized tests.
<Celia Hooper> Nancy Helms Estabrooks' is working on a simple version of the CLQT.
<Celia Hooper> I still like the RIC (Rehab Institute of Chicago) test, but it is not well standardized.
<Celia Hooper> If you look at the standardization of many of our adult tests, there are very few that look at
          RHD or even normal, age matched controls.
<Celia Hooper> And, for some reason, RHD patients tend to be a tad younger than left..isn't that interesting?
<Robin> that is interesting....so after using the cognitive-linguistic screen what do you do next?
<allysonmsu> Can you give an example of an assessment item that might be found on the CLQT?
<Celia Hooper> CLQT items include personal facts, symbol cancellation (for neglect), confrontation naming,
          clock drawing, story retelling, generative naming, design memory, mazes and design generation.
<Celia Hooper> It's purpose is quick screening.
<allysonmsu> Oh, I see, thank you.
<masha> What is design memory?
<Celia Hooper> You are shown a design, it is taken away, you have to remember it.  Some psychologists like to
          give patients different colored pens to see in what order they remember the design.
<masha> aahh...I see. Thanks!
<jennye> Would the CLQT be useful for use in skilled nursing residents?
<Celia Hooper> Yes, it would be...you can be very basic with this.
<Celia Hooper> It is also standardized in Spanish
<jennye> Thanks!
<Celia Hooper> Do any of you work in a clinic where your RHD folks get a good neuropsychological evaluation?
<Celia Hooper> I think that is critical.
<Robin> Lets move on to treatment!
<Celia Hooper> Wanna move on to treatment?
<Celia Hooper> First, like left stroke, we think about treatment as task oriented or process oriented...
<Celia Hooper> We think of compensation and facilitation....the longer since the stroke, the more likely
          compensation will be the way.
<Celia Hooper> You can divide treatment into:  treatment of deficits of attention, treatment of neglect,
          treatment of prosodic deficits, treatment of affective comm deficits, discourse and social disconnection.
<Celia Hooper> If the patient is early post stroke, neglect is important...for those in rehab or hospitals
<Celia Hooper> I mostly work in outpatient....group and individual therapy and neglect has resolved. 
<Robin> Isn't the neglect often addressed by OT or PT?
<Celia Hooper> Sometimes a team approach. For example...we teach verbal cues and can help restructure the
          communication environment.
<Celia Hooper> If you work in a nursing home or home health, you may be IT!
<Celia Hooper> Once I saw a man with neglect in a nursing home and they had everything...pictures, all stimulus
          items on the LEFT side of his room...
<masha> At my hospital, we often place a sign above the bed for the doctors, nurses, etc. if there is a neglect...
          it seems to be helpful.
<Celia Hooper> That is great.
<jennye>I have a great rehab team and they each value my role as I do theirs; Seems I need to do more
          training/suggestions with my PT's in neglect; is that unusal?
<Celia Hooper> I have worked for years in rural NC....new topic: the PTs....they sometimes don't think to tie
          VERBAL cues to the physical work that they do.
<masha> yes...I agree Celia
<hollanderj> Isn't it usually a team approach?
<Celia Hooper> YES!!  If you work in a rehab setting it is.
<jennye>Yes, that is it exactly! However I learn much from them also as we team approach our residents in my SNF.
<Robin> Can you give an example of verbal cues that a PT should use?
<Celia Hooper> Yes, you can always say "go left" in any activity...put that on the wall. If you are working on
          reading you can put go left cues and borders.
<Celia Hooper> You can add tactile reminders (OT is good at this) to go left and you can use conversational
          partners as reminders.
<masha> Can we discuss short term memory? 
<Celia Hooper> Sure! Short term memory next!
<jennye> My favorite topic!!
<Celia Hooper> Mine too
<Celia Hooper> OK, before I launch into something, can anyone out there give me a favorite short term memory
          task or hint?
<jennye> I use lots of written short phrases for cues for one.
<masha> rehearsal
<masha> using pneumonics
<jennye> spaced retrieval works with some
<masha> Please give an example, jennye.
<jennye> I ask a question; they may not get the answer; then I say "good try, yes the toothbrush is in the
           bathroom" does that make sense?
<masha> What are a few efficacious compensatory memory strategies you have found?
<Celia Hooper> Well, I have found that REALLY structuring the environment...using lists, Palms, date books that
          are HUGE..on the wall, some of the computerized drill work, photo albums..the sky is the limit.
<masha> So drill work is beneficial?
<Celia Hooper> I hate the word drill...repeating practice is better.
<masha> I thought that the research indicated this type of practice was really not beneficial.
<Celia Hooper> Not the same thing over and over with no comprehension, but
<Celia Hooper> The ACTIVITY...for example, remembering to LOOK at the date book each morning, or having an
          auditory cue to do it each hour, etc.
<masha> Ok...I agree with that.
<robynsing> Does that incorporate procedural memory skills?
<Celia Hooper> I once had a client who wanted to work on writing skills...he began with some software and then
          graduated to his own work (former professor).
<masha> nice
<Celia Hooper> I would say that his initial writing work was somewhat "drilllike".
<jennye> Celia, I have this problem with lots of my residents that I create strategies and then they forget to
          look at their calendar, written cues,pics,etc. any suggestions?
<Celia Hooper> Yes..they need communication partners...even volunteers can help...or, if possible, some auditory
          signal, for example...
<Celia Hooper> I had one man who lived at home and his wife set the beeper on his Palm to remind him of things
          throughout the day...of course in a nursing home, that's hard.
<AdrienneFSU> Maybe spaced retrieval could help ... "After breakfast, check your calendar", etc.
<jennye>Thanks Adrienne!
<Celia Hooper> YES!!!!
<Celia Hooper> And, these folks GET BETTER...very rewarding...on to affective communication disorders.
<Celia Hooper> This is very hard on families.
<Celia Hooper> Some clinicians have success in using verbal information in mildly impaired clients for example...
<Celia Hooper> You might show pictures of emotions and set the scene....
<Celia Hooper> "When your wife's face is wet, she is sad. Let's talk about what SAD means...
<hollanderj> Do some families go into family therapy?
<Celia Hooper> YES...and if you are lucky you will work with a psychologist or psychiatrist willing to learn
          about RHD.
<masha> Is this uncommon because I have never really seen this?
<Celia Hooper> Some people take years to develop or improve in nonverbal or verbal affective communication.
<masha> aahhh...I see
<Celia Hooper> I have found it somewhat common...maybe half of the patients I have seen in 25 years...maybe it's
          a southern thing!  There are no good national data.
<Jdyann> Does it help for the spouse, for example, to say "I am sad." ?  What about writing it down?
<Celia Hooper> YES YES..both
<Celia Hooper> And I can't stress enough..you can work on these skills for a short time, and the conversation
          partner can continue..the client improves.
<Celia Hooper> And you will need to check out depression, particularly in right frontal patients, just like in
          left stroke...
<AdrienneFSU> Even if the patient learns that crying = sad, can they understand what is sad, what causes sadness,
          what to do when someone's sad...?
<masha> But crying doesn't always mean sad...that's the tough part.
<AdrienneFSU> good point!
<Celia Hooper> Sometimes the patient doesn't understand..you are right.
<Celia Hooper> I think it helps the patient and the spouse/friend for you just to explain this...many think they
          have lost their minds
<AdrienneFSU> So would that lead to pragmatic skills?
<Celia Hooper> Yes, pragmatic skills can be very impaired.
<jennye>I also am thinking of my residents' spouses who have poor communication skills with the resident and
          that adds to the communication issues; that is frustrating for everyone, including me.
<masha> I think family education is the toughest and MOST important part of therapy especially in the rehab setting.
<Celia Hooper> YES!   Do any of you work in outpatient, group therapy...much like the aphasia center model?
<masha> I do outpatient therapy but not group therapy.
<Celia Hooper> I have found that a group of RHD patients needs to be smaller than left.
<hollanderj> Are most families cooperative?
<Celia Hooper> Yes, but some patients have no families OR any problems that existed before the event can be worsened.
<Celia Hooper> I like to have community volunteers--retired people or college undergrads as communication partners.
          Even one hour a week helps.
<Jdyann> What is the optimal size for group therapy for RHD?
<Celia Hooper> There is no research...the Chapey book has good info on left.  I find that I can handle 8-9 left
          folks, but 3-4 RHD is the limit for good progress, but this isn't research, just clinical report!
<masha> What about impulsivity...any tips?
<Celia Hooper> Impulsivity...labeling helps.  Hand signals, reminders, usually it is repetitive.
<masha> Labeling where?
<Celia Hooper> Verbal labeling...people don't always know they are impulsive (like some "normals" you know)!
<Celia Hooper> A good book to read is Right Hemisphere Stroke, a Victim Reflects, by FK JOHNSON.
<masha> thanks!
<Celia Hooper> A good text book: RHD by Penelope Myers.
<Celia Hooper> Good thought questions...would you rather have a left or right stroke?
<masha> NEITHER!
<Robin> This is such an interesting topic!  Dr. Hooper, thank you so much for sharing your expertise with us!
<Jdyann> Thank you Dr. Hooper!
<uri_speech> Thank you, Dr. Hooper.
<allysonmsu> Thank you Dr. Hooper!
<robynsing> Thank you
<AdrienneFSU> Thank you so much!!
<masha> Thank you...very informative!
<Celia Hooper> You are welcome!  North Carolina hugs to you all!
<msusham> Thank you very much. Have a nice night.
<dg> Thank you Dr. Hooper!
<Robin> Thank you all for joining us!