Ep. 11 - A Conversation with Margaret Blake - Right Hemisphere Damage and Disorders

Welcome to the Academy of Neurologic Communication Disorders and Sciences podcast. My name is Michael Beal, I'm an Assistant Professor at California State University in Northridge and a speech-language pathologist at UCLA Medical Center. In this episode of the ANCDS podcast, I talked to Dr. Margaret Blake about communication and cognitive difficulties after right hemisphere damage. Dr. Blake is an associate professor in the Department of Communication, Sciences, and Disorders at the University of Houston. Her research focuses on understanding and treating cognitive communication disorders after right hemisphere brain damage and mild traumatic brain injury. She's also the author of a recently published book titled the right hemisphere and Disorders of Cognition and Communication. To begin our conversation, I asked Dr. Blake how she became interested in communication disorders and in doing research. So when I started my undergraduate degree, I really wanted, I thought I wanted to go into deaf education pretty much for the sole reason that sign language was cool, not much more than that. And so the closest thing to that at Colorado State University where I went was communication disorders. So once I got into those classes, I found that I really liked communication and language and the tiny bit that we talked about cognition was really interesting also. So I went in thinking that I wanted to work with kids, but then once I took a class in the neurogenic disorders and learned more about the brain, then I was kind of hooked on neurogenics. So as I moved on to my master's program at Arizona State, I worked with Chick La Point there. He was my advisor. And I just kind of assumed that I would go into aphasia because that seemed like the, the only, almost, the only neurogenic disorder. And in one of my conversations with him, we were talking about a potential thesis topic. And he said, well, I had a student a couple years ago who did a project looking at right hemisphere communication. And you know, why don't you look into that and see if you'd be interested in doing a follow up to her study. And once I started looking into right hemisphere, I was just totally hooked. And pretty much haven't looked back since then. So I really like the communication aspect, but that it's broader and brings in more cognition than kind of standard, the standard take on aphasia. And in all honesty, grammar puts me to sleep. You know, you get too far into this. Yes. Yes. You know, I kind of want to start beating my head on the wall. So I really like the more cognitive take on communication. You know, we were talking at the clinical aphasiology conference about just general practice issues when it comes to working with persons with right hemisphere damage. And right now, I'm, I'm thinking about my experience with that population. And I can kind of sum, sum it up in this way. And that is that I rarely, if ever, get a consult, outpatient consult to see somebody with right hemisphere damage. And in the acute setting, I only seem to have gotten those individuals with right hemisphere damage who had noticeable left and black. But certainly not, not, it's not 100%, but infrequently, giving any kind of, I actually can't remember a consult where it was for communication issues. If it's not left neglect, it's made me, you know, some cognitive, cognitive stuff, memory issues. That seems to be common, I think maybe because family members and clients themselves, it's easier for them to kind of notice or conceptualize or talk about having memory problems rather than some of this other issues in right hemisphere damage. Is my experience typical? I think it probably is. I think that in the acute setting, physicians, neurologists, other medical professionals, they have a sense of what aphasia is. And they could recognize when someone has a distinct problem with comprehension or being able to put words into a sentence. I think they have a sense of what dysarthria is when they can't understand what a patient is saying. And they know about neglect because I think it part because it's so striking. And you know, very interesting, fascinating disorder. But the communication problems that we see after right hemisphere of brain damage tend to be more pragmatic and they can be more subtle. And I think you, if you don't know to look for that and that that could be a consequence of stroke, then you know, what I envision is, is the neurologist goes in and talks to the patient and the patient might be, you know, not quite on topic or, you know, make some oblique references to things and the neurologist walks out and says, "Oh, that person's a little odd." And goes on with this day. Not having a sense that, you know, that may not be who that person was before the stroke, but it's a consequence of the brain injury. And I don't know how much about right hemisphere is actually taught in medical school or in neurology specialty beyond neglect and intentional problems. So I think that's, you know, what, maybe what they're trained to notice or what is most striking. And the other things they don't know to look for. You sent me a copy of the first chapter of your book to help me prepare for this podcast interview and I just want to say that yesterday I got an email announcing that your new book on right hemisphere disorders is published. What's the title of the book? I'm trying to remember. It's called the right hemisphere and disorders of cognition and communication, theory and clinical practice. There's not a lot of competition out there for books on right hemisphere disorder is there. No, that made it quite an easy sell to the publisher. You know, I, you know, go ahead. The comprehensive books, more like mine, that are out there at Connie Tompkins book, came out in 1995. And Penny Meyer's book came out in 1999. And that's, those are pretty much the last two. You know, what made me think about your book is you were talking about physicians and maybe their lack of understanding of right hemisphere disorders. And there's, you have a quote in your book. I wrote it down because it's great. And it's a quote from an author named Virtasic was written in 96 talking, you know, the book was about this person's life as a neurosurgery resident. And this author said, to a brain surgeon, there are two cerebral hemispheres, the left one and the one that isn't the left one. Yes, I love that quote. And I cringe every time I hear it. Yeah. Yeah. Well, I don't remember actually ever having a conversation with a neurologist specifically about their training related to right hemisphere damage. Although I can remember having conversations about how much they learned about a fadizia and blood or speech disorders. So these, these communication issues that persons with right hemisphere damage, as you mentioned, can be subtle in the sense that the symptoms aren't as overt, let's say, as a person with the phasia, who's having pronounced word finding difficulty producing paraphysics, speech, etc. But does that mean that it's less disruptive to a person's life? I don't think it is. And in some cases, it potentially could be more disruptive. So I said I don't think so because we don't have any data to look at that. There aren't any studies that have looked at the social and vocational consequences and you know it's something that that really needs to be done to help show how important these things really are. But I think in a way some of it may be analogous to what some people with traumatic brain injury report that you know cognitively they're not at the same place but if they can walk and they can talk okay then it's this hidden problem that people don't expect and it's hard for other people to understand that you know they're they're not functioning at the same level. So I think that's part of it and then the other part is if the the person who had the stroke also has reduced awareness of their deficits then you know they may try to go back to work they may try to go back to their social activities or whatever it was they used to do and may fail miserably at that and not really have a good understanding why things aren't working the way they should and because they're not aware that they're not communicating as well or that they're missing social cues then they don't they can't change their behavior to accommodate that or ask for help or you know tell people you know I have a little bit of trouble with this so bear with me you know whereas someone with aphasia if they can communicate well enough you know can say I need you to slow down or something like that so that you know they can adapt to themselves better to a situation and I think those things would be really difficult for someone with right hemisphere brain damage who really isn't fully aware of the deficits that here she has. Yeah you know and as I was saying I don't get a lot of consults for communication issues for persons with right hemisphere disorder and so my my experience is much more limited with that population but the experience that I do have is that it can be really disruptive and there's a certain kind of suffering that happens when people both the person with right hemisphere damage and those individuals family and friends around them certain men a suffering that happens from not understanding. Sure and and and from not understanding from misinterpretation so thinking a person has changed as a person in a way rather than this is an expression of or consequence of their stroke that they've had let's say and that a number of the kind of the affective processing problems that persons with right hemisphere damage along with some of the communication issues have really puts a strain on on close relationships is that is that here is that the feedback that you've gotten from subjects you've worked with patients etc. It is and you know it's it's in some ways I think this disorder may be more difficult for spouses and families than it is for the patient you know especially if there is a reduced awareness going on and one of the things that really struck me was the the change in empathy that can happen and it's we think that this may be tied into theory of mind where you know you have a someone with good theory of mind understands that another person has different thoughts and beliefs and feelings and things like that that may be different from your own but then you you use that when you're communicating with them when you're interacting with them you know to get a sense of how they're doing you know and that helps with empathy you know understanding their feelings or being able to empathize you know when they're sad or happy about something and there was a a study a couple of years ago by R. G. Hillis and her group from Johns Hopkins and it was a very small study but they looked at 14 couples about two years after one of them had a right hemisphere stroke and they asked both the patient and their spouse to rate a big list of different signs and symptoms related to stroke the typical hemiparesis and you know reduced mobility attention was on their prosperity was on their but they also included empathy you know along with some of these others and then they had the patients in their spouses rate how important are these deficits to you at this point in time and 50% of the caregivers said empathy was very important and it was as much or more important than physical mobility to them and there wasn't any other disorder that was rated more important by more people than empathy was and so you know you get this sense that that can really alter kind of who a person is you know if your spouse used to be fairly empathetic and could you know read your moods and you know change behavior appropriately and and now they can't very well you know that that could have a really dramatic effect on the family or spouse a relationship how would we as an SLP I'm sorry go ahead no go ahead with your questions well I was just wondering is an SLP how would we suspect or know that there was an issue with empathy going on I think that's really hard and especially if we see them only in the acute care setting because they happen to have neglect you know because I think that if I saw somebody in acute care who didn't who seemed to be a bit egocentric who didn't seem to have empathy for other people within the first week or two of a stroke this major life-changing event I don't think I would think there was anything wrong with that right because I think anybody may become more egocentric more tuned to themselves and less attuned to other people you know as they're going through that kind of a medical crisis and so one of the things that RG had said in it in a group discussion we were having a few years ago was that some of these communication issues that we see with right hemisphere aren't necessarily apparent until that person goes home and they go back to their kind of normal life as much as possible and then their family starts noticing you know what you know he he doesn't seem to care about people as much as he used to or you know maybe he doesn't get jokes the way he used to or he doesn't tell jokes the way he used to and you know those kinds of things that you may not notice in an acute care setting or possibly not in a rehab setting either when they're not around their their close social network as much and so I think that's one of the challenges that that we face is that some of these problems are subtle and they are personality they get into personality characteristics that you may not be able to notice as an outsider when you see them acutely and as far as management that these issues is an SLK so we we don't have anything specifically for this population probably the closest that we have is what we know about autism spectrum disorders although you obviously have to look at those things really carefully because we're dealing with stroke survivors who had those abilities before and now they have lost some of those whereas with people with autism that's a developmental issue that they have had all their life and so you know you you would have to address it differently than in teaching somebody for the first time about other people's thoughts and feelings and and that kind of stuff so I I don't know right now Christine Lundgren and Hiram Brown now have one study that they have done looking at a theory of mind treatment for people with right hemisphere disorder order intro. brain injury. And as far as I know, it's still in the early phases. I haven't looked to see if they have a more recent publication on that. But that's probably the first step that we have at this point in terms of knowing how to address this clinically. Yeah, and given what you mentioned about surveys of family members and the importance they put on empathy, if speech pathologists don't address this, who will? Right. But the other catch to this is that if spouse notices that, you know, her husband isn't really that empathetic anymore, doesn't seem to care as much about other people. I don't think that she would think, I think I need to talk to a speech languageologist. And I'm not sure how many neurologists would be able to say, oh, okay, let's send you to a speech pathologist because they may be able to address that for you. You know, and so I wrote an article for plural publishing for it for their newsletter this summer. And suggested that maybe as speech language pathologist, one of the most important things we can do is talk to the families when they're in acute care, give them information that they can look at later to say, you know, there may be issues with interpersonal interactions or social interactions or empathy or use of humor or, you know, these, these subtle things that when you get home, you think, she's not quite the same as he used to be. And let them know that speech language pathologists are the people best prepared to help them with those kinds of things and just, you know, provide them with that education and information initially because I'm once they get out of the system, I'm not sure where they would be able to find that. And the adult speech rehab group on Facebook, I mentioned that I was going to be doing a podcast with you and asked if anybody in that group had any questions and one of the questions that came up was around resources for education, material for the family. Is there anything like that out there or do speech pathologists have to kind of create their own. I think at this point, creating their own is what's needed. I was asked many years ago, probably almost 10 years ago to to write a description of handout for families about right hemisphere. And I believe the the editor of that was Ed Hardy. And so he he published a set of handouts, you know, providing information. I think it's I haven't read what I wrote for him in very, very long time and it's probably only partially accurate and useful at this point. But that's the only one I know of. And when you mentioned that question to me the other day, I went to the American Stroke Association website and pretty much all they have for right hemisphere is linked to neglect and attention. And I think there was a little bit better information, but it wasn't easy to find on that website. And I should I couldn't find anything specific and easy to find on the asha website either. So, you know, I and there's no right hemisphere damage association or nonprofit organization is there, which that's kind of interesting. I mean, even from the the public's perspective, this is not an easy to recognize or maybe even conceptualize group of problems. You know, I I don't want to put you on the spot here, but for those SLPs out there who might want to create their own education material, could you provide like maybe just a broad, super broad outline of the topics that you think should be covered in in material like that. Oh, that's a good question. I think you know, some of the things that we've just talked about about subtle changes in social interaction. And it could be linked to things like, you know, misunderstanding what somebody means misunderstanding when someone was trying to tell a joke or misunderstanding when someone was being sarcastic or misunderstanding someone's emotion or mood. I think those things should be in there. I think neglect needs to be in there because it obviously is is an issue that can have lots of different consequences related to it. Things like prosperity should be in there also, you know, not only the productive expressive a person where they sound flat and monotone. So that they may have difficulty interpreting, prostitue and some of the misinterpretations may be because they're not interpreting tone of voice as well as they used to. I think things like the more cognitive parts with problem solving and reasoning and judgment, those can be affected and in turn can affect communication that they don't necessarily notice when they say something that is inappropriate for the context or the people they're talking with or that, you know, they're going off on a tangent and, you know, somebody is trying to close up the conversation. And they're not noticing the cues that the listener is giving that, you know, looking at their watch or trying to interrupt or things like that. I think those kinds of things would be really good to find a hard it's kind of a hard task in the sense of being able to do it in a really clear way because so many of these issues are seem interrelated. Definitely. And in a way that kind of goes back to something that you mentioned in this introduction to your book, which was that compared to left hemisphere damage, in right hemisphere damage, we don't really have like these identified syndromes. Right. Like a broken suffrage, etc, etc. Is that because of simply the lack of attention in being paid to this population, or is it kind of a reflection of the kind of processing that happens in the right hemisphere and the way processing happens in the right hemisphere. I think it has more to do with the way processing occurs. I think that if there were subtypes or patterns of deficits, like, you know, you can see in the left hemisphere, you know, you can very basically see fluent versus non fluent forms of aphasia based on anterior versus posterior lesions. And I think if if you could identify those, it would have been done by now. You know, if you think about broke and dax and verna key, we're able to divide those up, you know, over 100 years ago. And. But we haven't been able to do that with right hemisphere. Part of it definitely is linked to the fact that there are fewer people working on the problem. But I think still, you know, if there were easy subdivisions, we would have found them by now. But I there's evidence that the right hemisphere is more just the neurons are more interconnected. And it seems like it works more like a network compared to the left side of the brain, where you do have a little bit more modular organization. And I say that very loosely because some of the people who educated me would squirm if they hear me talking about modular or. But the fact that you can identify. Areas in the left hemisphere that are more specialized for comprehension versus production and things like that. Whereas on the right side of the brain, we haven't identified specific areas linked directly linked to specific abilities. You know, with the studies that have been done with some of the language processing, the semantic processing in the right hemisphere. You can get deficits similar deficits from lesions in the frontal, parietal, temporal lobes, some cortical structures. And it isn't as easy to identify those. So I think it's in part due to the way the right hemisphere is organized and networked. And I also think it's because we're looking at a different level of processing. you said about these different areas being, these different processes being interconnected. You know, some of the cognitive problem solving and reasoning directly affects how you interpret somebody's facial expression and what that might mean linked to the, what they actually say. And that it's a different level, I think, then putting words into a syntactic order to convey a certain meaning. So I think, you know, not only the organization, but the kinds of processes that are going on, you need a network to integrate all of those different areas that makes it hard to identify specific lesion locations that will cause a specific deficit. You know, and in kind of the popular culture to the extent to which people do talk about the right hemisphere, it always seems to be in the context of the right hemisphere is where creativity is. - You're right. - Like the book, drawing from the right side of the brain. - Uh-huh. - Why is that? - I don't really know. I think part of it comes from the finding that artists of any type, they can be visual artist, musical artist, more artists are left handed than you would expect in the general population. And so I think that was one really basic link. Oh, if the right side of the brain controls the left side of the body, then these artists must be more right-brained and that's what contributes to their artistry. The other may be linked to the right hemisphere, having a greater role in visual perception and visual spatial skills. And that can be linked more to at least visual artistry. But that's my guess where those things came from. You know, this kind of, I don't know, for lack of a better term holistic processing. I was reading one of your papers on, get the title of the treatment, right? Contextual constraint treatment, which I'll let you describe what it is in just a second on your own, I'm afraid I might butcher it. But one of the things that was interesting to me, and this was a treatment that was helping discourse comprehension, I believe, in people with right hemisphere damage. One of the things I found interesting about that was that you clearly chose kind of a, the treatment was domain-wide in the sense that what was being measured wasn't like, you know, phasor, you know, people pretty much get better at oftentimes just what they practice, the vocabulary they practice. And there isn't a great deal of generalization. In your study, in this study, that the only real measure of any meaning was generalization and the only thing you were really targeting was this domain level kind of processing. I'm kind of taking a long way of asking, maybe a simple question, but does this kind of more holistic processing in the right hemisphere, in a way kind of having it is an advantage for us as a therapist, in the sense that it's much easier for us to target treatments that are domain-wide and have generalization, whereas with our left hemisphere damage patients who tend to kind of get better at what they practice, we have to really be concerned about the items we choose to practice and things like that. Do you see where I'm going with that question? - I do, I do. I think it, in part, depends on how the treatment is structured and if you're trying to improve a language process versus trying to improve the accuracy of production. If that makes sense. So with the contextual constraint therapy, we developed that to help immediate two different language processing problems that have been reported after right brain damage. One of them is suppression and the suppression deficit hypothesis we developed through Connie Tompkins lab. There was a group of us that worked on this for many years with her and what happens with the suppression deficit is that when normal comprehenders hear a word or a sentence that could be ambiguous, our brains generally activate multiple potential meanings. So when you hear the word spade, you're in your brain, you automatically activate a playing card, meaning as well as a small gardening shovel, meaning. But when that word appears in context, even though those meanings are both activated, the less appropriate one, the one that's not appropriate for the context is very quickly suppressed or inhibited so that then comprehension can proceed with the most appropriate meaning, remaining active. And what we found is that some people with right hemisphere damage were slower to suppress the meaning that wasn't appropriate for the context. So if you just looked at accuracy, so we'd give them a sentence such as she dug with the spade and then they had to respond to a word that came after that like cards and it just had to respond yes or no if that was related to the context. And in that case, it would be no because if you're digging with the spade, then it indicates it's the shoveled meaning of that word. So we did this through precisely timed response times and we found that many people, or at least a subset of people with right hemisphere damage, were just as accurate, but they were a little bit slower to reject that word as being not related. And the people who tended to be slower have this inefficiency also tended to have general comprehension deficits. Suggesting that this inefficiency along the way was interfering with their comprehension on a broader level. So that was the one deficit and then the other was a course coding deficit and that term came from Mark Beeman who proposed that the two hemispheres of the brain do language processing a little bit differently. So when you hear an ambiguous word or a word with multiple meanings, in the left hemisphere, the left hemisphere is very good at very rapidly selecting either the dominant meaning or the most likely meaning given the context. Whereas in the right hemisphere, some of those extraneous meanings can stay active for longer and that becomes beneficial when the interpretation changes. And then you have to go back and revise your interpretation. So if you have, over on the right side of your brain, some of these other meanings or features of a word activated, then you can return to those. And so Mark Beeman suggested that some of the deficits that we see after right hemisphere damage like difficulty with inferencing, for example, was due to the fact that the right hemisphere was no longer maintaining some of those either less common meanings or features. And that was part of the problem. And so with this contextual constraint therapy, we were trying to improve the efficiency of these processes, the course coding process and the suppression process. With the idea that if we could improve these inefficiencies, then you would see the gains more broadly in terms of general comprehension. And so with the treatment itself, as we were doing the probes and having them respond to different stimuli like the, she dug with the spade and responding to the word cards, we expected them to get faster at those things, the more they heard them, just pretty much a simple practice effect, which is not very interesting and not very useful. But what we were hoping is that you would see generalization to general comprehension that by going over these items and through the way we created the treatment to have this hierarchy of contextual support, aiding in the process, processing that those suppression and course coding processes themselves would become more efficient. And so we were really working at targeting the processing, which, as you said, would help more broadly than just a stimulus-specific effect. Yeah, and I, and I, to the listeners, I don't mean to suggest that I don't think that generalization doesn't occur in aphasia treatment. It's just that as a therapist, I don't feel like there's evidence that it does so enough that we can rely on, and plan for it in a way. But because the left hemisphere is, does tend to process communication-related information language in very kind of, we'll just say modular ways or in discrete ways, whereas the right hemisphere is more networked that, you know, we can't really have narrow practice-oriented targets in right hemisphere damage anyone's. What would we narrowly target? Right. So I think perhaps one way to think about it is the treatments that have been suggested for difficulty with non-literal language, figurative language, such as metaphors and idioms and things like that. I think in that case, you could, depending on how you set up the treatment, you could end up really treating specific stimuli as opposed to the process of interpreting non-literal language. So with idioms, I know there are-- it's always a common thing to have in workbooks designed more for right hemisphere, where you have people interpret idioms. They just get an idiom usually with no context and say, well, what does this mean? And same thing with metaphors. And I think that that can be really problematic, and doesn't necessarily get to the underlying problem. So what I have suggested is that if you want to address difficulties with interpreting non-literal or figurative language, that you shouldn't do it without some sort of context to help support the meaning. And I think this is especially true for idioms. And idioms are always fun and interesting, because there are these phrases that don't seem to have any connection to their actual meaning, or a very loose connection. And they're always really fun. And it's fun to find idioms from other languages, because you just wonder how the heck did that ever get to mean what it does. So one of the examples I use is-- I believe it's an Italian idiom-- that the idiom is to sew on a button. And when you ask people, if you gave them the idiom, so what does to sew on a button mean? Most of the people will say, well, put the finishing touches on something, or put your personal touch on something, or finish something. And in actuality, the meaning is to talk too much, which you could never get by trying to derive it from any of the words in there, or the combination. It's kind of like the American idiom to kick the bucket. There's nothing in kicking a bucket, except that maybe it happens suddenly, that would get you to the meaning to die suddenly. And so for idioms like that that really have no connection between semantics and the meaning, the semantics of the words and the meaning, I think the only way to help them interpret it is by putting it into a context. And then working on the process of using contextual cues to determine the intended meaning. And I think that kind of process can be useful for a lot of different things with this population, because you have the potential for misunderstandings of emotion and sarcasm and jokes and non-literal language and all of these kinds of things. And if you put the focus on using the cues that you have in the context to figure out the intended meaning, then that can be generalizable to lots of different settings and people and environments as opposed to teaching them the meanings of idioms, which are only going to be useful if they happen to hear that particular idiom. Right. Some more of a strategy-based training, in a way, or metacognitive training. It would be more similar to that, yes. Yes. There were a few other questions from Facebook. I'm going to take a look here real quick. So related to what we were just talking about, one of SLPs said that she'd seen you at a conference in 2007 or 2008. And at that time, you had said that there wasn't any evidence-based practice for right hemisphere cognitive treatments. She's wondered if it's changed much recently or since then. And where are we at with the state of evidence-based right hemisphere practice? Sure. For the cognitive deficits, if you're thinking more attention, executive function, and those kinds of things, there isn't anything new for right hemisphere. But I think that there is some good evidence for treatments if you look in the traumatic brain injury literature. And there's not-- do you think you can translate that over to right hemisphere? I think you can. And there's-- again, we don't have a lot of evidence to show that an intentional disorder after right brain damage is the same as an attention disorder after TBI. And you'd actually expected that there should be some differences. But I think the way they approach treatment is a good place to start. And if we don't have any evidence for right hemisphere, you have to start somewhere. And so if you look at the TBI literature, and some of the findings that they've been reporting is that metacognitive strategies can be really useful and really beneficial for attention problems, for some executive function, problems for awareness deficits. And I think that might be a place to start for the right hemisphere population. Yeah, particularly with the awareness deficit issues, if that's a problem. Right. Right. Let's see. Another question. Another question is, I'd be interested in Dr. Blake's talk, the take on the difference between cognitive disorders and cognitive communication disorders in our role with regards to each of these. So I think of cognitive disorders as disorders of memory, you know, executives functioning, the organizing, planning, problem solving, reasoning, and attention. But for me, the reason why I find those interesting and important in patients with right hemisphere damage is because they impact communication. So, you know, if someone just had a memory deficit, so just has amnesia of some sort, to me, that's less interesting than someone who has maybe a working memory deficit that affects how they're able to comprehend and then put together their thoughts to tell a coherent story. So when I'm thinking of the cognitive deficits, it's always in relation to communication. So with organization and planning, how are people able to organize their thoughts to plan how they're going to tell a story, to convey what they really want to convey? How are they able to problem solve when they're in a conversation with somebody? And, you know, the other person is providing good, nonverbal cues as to whether not they're interested or bored or if they need to. to end the conversation and how can you help the person recognize those cues, recognize what they mean and then change your behavior to facilitate communication. So I tend to refer to them as cognitive dash communication deficits because I think as a speech language pathologist that's why I'm really interested in them because they do affect how people interact. Yeah, yeah. Staying on with the cognitive problems, another question was assessment and treatment of left field cut versus a left neglect. Treatment issues there. I don't really remember much treating field cuts other than simply kind of providing people within the information they may not have figured out themselves how to get around it. Right. So with a visual field cut, that's going to interrupt the sensory pathways, the pathway from the eye back to the occipital lobe. And with that, there's, I don't know of any way that can be treated. And for us, if if a patient has just a visual field cut, they should be very aware of it and they should be able to compensate for that. You know, if if they're not actually perceiving the things over on the left side, they're going to turn their head to find things and they're going to know that something is missing. The explanation from someone who had a small visual field cut, it wasn't quite quadrant in Opsia, it wasn't a whole quadrant of her visual field, but a little bit is that she said, well, it's a little grayed out area. You know, and if I focus on it, I can see the grayed out area. And over time, her brain just adapted to it and learns to ignore it. And you know, she learns to compensate fairly quickly for that. So if it's just a visual field cut, there's less that we can do, but I think there's less that we would need to do. If you can get a visual field cut that co-occurs with neglect, and that's just going to complicate the treatment for neglect, because not only are they not attending to that, but they're actually not seeing it. So it may be more difficult to train some of the compensatory strategies, you know, turning your head and beginning over on the left margin, because they're not even getting the sensory, you know, an initial perception of that. Whereas we know if someone has just neglect, the things over on the left side are processed to some extent at an unconscious level. But if someone has a visual field cut also, then you're not getting that unconscious perception because of the sensory deficit. I'm curious, in your experience of individuals who have some degree of neglect, maybe a mild left neglect, do they ever get back to driving? I mean, that's a main concern for a lot of my clients. They want to drive again. I don't remember someone with left neglect. My experience with left neglect has almost exclusively been in the acute settings. I never really found out how well people ended up doing in the long term and what they were able to do. Right. I do not know. I don't work with enough clients directly to be able to say. Two that I've worked with most recently both have a fairly mild neglect and they receive lots of treatment for that. I don't think either one is driving at this point because of other physical issues with hemiparesis that helps prevent that. But I think in those two cases, these gentlemen are both aware that they have neglect. They can't compensate for it all the time. One of the examples that I use and that I put in my book is this gentleman who knows he has neglect, can tell you he has neglect, can tell you some of the strategies that he needs to use. Yet he routinely can't find his socks when he gets dressed in the morning. Most of the time his wife says they just got moved over to the left side of his drawer. And so even though he has this kind of academic knowledge of his neglect and he can describe experiences of it, he can't compensate for it all the time which would make it, which would make me very uncomfortable with him getting in a car. One of the ways neglect is described in the research is that there can be an orientation bias to the right side. In some cases, this is described as a magnetic attraction to things on the right side so that they can't, they have difficulty moving their attention away from things over on the right side to be able to shift the attention over to the left. And I think when you're in a complex activity like driving where you can't predict what the other cars are going to do, you know, and even if it's driving in your neighborhood, you know, somebody rides by on the bike over on the right side. And if your attention is drawn over there and you lose the attention over to the left, then, you know, I think it would be very dangerous. Yeah. One other question was standardized assessments for right hemisphere disorders. You know, what's the state of affairs there? I think this person on Facebook mentioned the Mirby trying to remember what the acronym stands for exactly. That one's the mini inventory of right brain injury. Right. Yeah. Let's let's say you're an SLP, you're starting a clinic and you're going to do some work to try and drum up some referrals for patients with right hemisphere damage. You've got a limited budget, right? You're going to buy every test in the world. What would be your core assessment package? Sure. Specifically for right hemisphere, one of the newest assessments that's available is the Montreal evaluation of communication. And that was created by Eve's Joannette and Herrine Fere and their group up in Montreal, obviously. They just came out last year with the English version of their test. And as the name suggests, it really focuses on communication. So there are subtests looking at inferencing and interpretation of idioms and metaphors. And there's some prosody in there, a little conversational sample. I think there's some verbal fluency subtests. So it's really focused on communication. That test is again, the newest and probably one of the better ones that we have. It doesn't cover anything related to the cognitive aspects. So you need to supplement if you want to look at that. One of the tests that I tend to use for that is the favors, the functional assessment of verbal reasoning and executive strategies. Yeah, that sounds right. I've mcdonald. And that one looks more at reasoning and problem solving in more functional tasks. Right. I like that one. And then there is, there's a test called the tacit, T-A-S-I-T, which I believe is the assessment of social inferencing. I don't remember the acronym specifically. See if I can find it and put a reference to it in the show notes. Oh, that would be great. That one has very short videos of people interacting, either two or three people interacting. And the tacit, T-A-S-I-T, and the test. Asuka's to look and see what the person was communicating. And it can be the emotion, it can be if they were being serious, if they were joking around, if they were telling a white lie, those kinds of things. And I like it because you get not only the language that's used, but also the facial expressions, body language, prosody, all of those other cues that we use every day to help interpret what people are saying. And I haven't seen the newest version of it, and I'm not sure if they have data from, specifically from a right hemisphere sample, but they have norms from traumatic brain injury populations. And so that may be useful to have that. So that will help get you social interpretations, cognitive processes and reasoning and more language-based. So I think those would be tests that I would want to have at my disposal. If you wanted to know if your client had a suppression deficit or course coding deficit, or first of all, can they exist independently? Yes. They can. In, let's say through our work and jointly here at the University of Houston and then Connie Tomkins Lab at University of Pittsburgh, we tested, gosh, almost 50 people for these two deficits, the course coding and suppression. And what we found was that it was quite rare to have course coding deficit in isolation. Suppression deficit in isolation was a lot more common and there were, there was a good number of people who had the two combined. And so they, they definitely can co-occur and that's more common than, especially course coding on its own. For those deficits because they're inefficiencies in processing, you can't really assess them without some type of response time measure. If you gave them this stimuli and just asked them to respond yes or no, most of them would be pretty accurate and you couldn't detect whether or not the efficiency was underlying the problem. Yeah. Are we, when we talk about timing, are we talking about fine differences or gross enough that a SLP might be able to make a subjective judgment? No, the distinctions are, are pretty fine, you know, less than a second delay. And so it wouldn't be possible to identify that without some type of timing measure. And so the, the problem occurs when these very brief inefficiencies get compounded where, you know, in an ongoing conversation, if you're delayed by half of a second trying to interpret what one of the words may have meant, then you're going to lose what comes next because you're thinking of what the person previously said and not keeping up with what they're currently saying. And so I think that's where we see the problem in the general comprehension. But right now, unless we build a software system or an app or something to help detect those, it's not something that you can really assess for clinically. Yeah. Yeah. I think that's it for the questions from Facebook. I feel like we could keep going for quite a while talking about these issues. And there are a lot of issues to talk about, I think, with regards to write hemisphere damage and disorders. Thank you so much for coming on the podcast and talking to us. What, what, what, what's in your future? What, what are you working on now or have plans for? So right now, I have a study ongoing where I'm looking at unilateral neglect, visual spatial, unilateral neglect. And looking to see what effect there may be in using the, an anchor over on the left side of the page, or red line over on the left side. And trying to explore a couple different things. One is that if such an anchor might work and why it might work, you know, it could be that it is salient enough that it helps attract the attention over to the left side. But the other explanation for why it may help is that it's a strategy tool where, you know, through therapy, you help the patient learn the strategy of returning their attention all the way over to some sort of anchor over on the left side. So I think we, we need a better sense of whether or not that anchor really can attract attention over to the left side or not. And if it doesn't, then if you use that type of anchor in treatment, then it has to be treated more like a metacognitive strategy where you have to have repeated practice with it and train it to the point where it's almost habitual. Otherwise I don't think it's going to be useful once the patient leaves therapy. And so that's one of the things I'm looking at with this study. And that's a very common way of treating. I'm left with like for speech pathologists in my experience. So it seems like a pretty relevant question. Right. And I, for years when I teach about right hemisphere, I say I don't think that that's going to be helpful. Having just an anchor, unless it's really taught as a strategy. But, you know, we don't know if that visual stimulus is salient enough to actually shift attention to aid in the shifting of attention. And if it's not, then, you know, we need to think about what we're doing in therapy. So that's one of the projects I'm working on right now. And then another one I've just started collaborating with Tatiana Schner, who's a cognitive psychologist at Baylor College of Medicine here in Houston. And we are going to start looking acutely at patients with right hemisphere stroke and look at the presentation more acutely. The only other person who's doing this that I know of is Argyllis at Johns Hopkins. She's done some acute work. But looking to see if there's anything that we can do to help increase the identification of communication or cognitive deficits acutely so that we can get these patients into the pipeline to receive the services that they need. Well, Dr. Blake, thank you again. Oh, you're welcome. This was a lot of fun. Thank you for listening to this episode of the ANCDS podcast. To learn more about the Academy of Neurologic Communication Disorders and Sciences, you can go to ANCDS.ORG. You can also find our podcast there, or you can find the podcast on iTunes and SoundCloud.